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# SBS
## Saudi Billing System
### Version 3

# Tabular List

ضمان
مجلس الضمان الصحي
Council of Health Insurance

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SBS V 3.0
TABULAR LIST OF
INTERVENTIONS

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# PREFACE

## ACKNOWLEDGMENTS INTRODUCTION

Conventions used in the SBS Tabular List of Interventions

Guidance in the use of SBS TABULAR LIST

1. Procedures on nervous system
2. Procedures on endocrine system
3. Procedures on eye and adnexa
4. Procedures on ear and mastoid process
5. Procedures on nose, mouth and pharynx
6. Dental services
7. Procedures on respiratory system
8. Procedures on cardiovascular system
9. Procedures on blood and blood-forming organs
10. Procedures on digestive system
11. Procedures on urinary system
12. Procedures on male genital organs
13. Gynaecological procedures
14. Obstetric procedures
15. Procedures on musculoskeletal system
16. Dermatological and plastic procedures
17. Procedures on breast
18. Radiation oncology procedures
19. Interventions not elsewhere classified
20. Imaging services
21. Laboratory and pathology
22. Ambulance and transport services
23. KSA service codes
24. Emergency medical services (EMS)
25. Mortuary services
26. Rehabilitation services

Appendix A: SBS Code List
Appendix B: Billing Instructions
Appendix C: Clinical Explanation

# PREFACE

The Saudi Billing System (SBS) has been developed by the Council of Health Insurance (CHI). Version 3 is a revision of Version 2 with input from Classification experts, clinicians, and industry bodies.

SBS extensions, interpretations, modifications, addenda, or errata other than those approved by CHI are not to be considered official and should not be utilised.

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# ACKNOWLEDGMENTS

Saudi Billing System (SBS) Version 3 has been developed by the Council of Health Insurance (CHI).

Assistance and support in preparing the Version 3 Saudi Billing System (SBS), including the Tabular List and Alphabetic Index, were provided to CHI by Selat Business Solutions, with contributions from 3M Health Information Systems and Accumed. CHI also acknowledges the clinical and technical advice contributed by ITG Information Technology Group Australia, CCAG Clinical Coding Advisory Group Australia members, and the practicing clinical coders and clinicians who support these groups.

The CHI management team, systems, and administrative staff are also acknowledged for their significant contributions.

## SPECIAL ACKNOWLEDGEMENT

Dr. Shabab Al Ghamdi - Secretary General - Council of Health Insurance

### PROJECT LEADS

* Dr. Wail Yar, CHI
* Susan E Young, CHI
* Nasser Albluwi, CHI
* Fawaz Al Omran, CHI
* Faizah Jamalallail, CHI

### CONSULTANTS

* Heather Grain, SELAT
* Anna Coote, SELAT

### CONTRIBUTORS

* Ahmed Alhamalawy, SELAT
* Radi Hamad, SELAT
* Safaa S. Eissa, SELAT
* Muath AlQasemy, SELAT
* Abdulaziz Ibrahim, SELAT
* Manal Ali, SELAT
* Rawan Faqiri, SELAT
* Shahad Almadani, SELAT
* Ebtehal Aldokhi, SELAT
* Latifah Alrzeen, SELAT
* Haytham Ibrahim, SELAT
* Ayman Magdi, SELAT
* Mohamed AbdelKhalek, SELAT
* Ahmed Moustafa, SELAT

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Ahmed Bakhshwin, Consultant Pathologist

* Michelle Badore, 3M HIS US
* Cecilia Charles, 3M HIS US
* Angela Dixon, 3M HIS US
* Felisha Bochantin, 3M HIS US
* Maarten Lambrecht, 3M HIS EMEA
* Kaycie LeSage, 3M HIS US
* Mireia López Salvà, 3M HIS EMEA
* Octavian Weiser, 3M HIS EMEA

* Anitha Kumari, ACCUMED
* James P. Katte, ACCUMED
* Sheeja Ramachandran, ACCUMED
* Sofia Christy Arivalagan, ACCUMED

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# INTRODUCTION

The development of the Saudi Billing System (SBS) has been a crucial initiative focused on improving the efficiency and accuracy of healthcare data management in Saudi Arabia. This initiative was driven by the need to align the SBS with DRG (Diagnosis-Related Groups) and other bundling systems, ensuring a cohesive and modern healthcare coding framework. The revision of Version 2 brought significant enhancements to the SBS maintenance framework, aligning it with international best practices and making it more adaptable to the changing needs of healthcare providers and systems.

A comprehensive governance framework and policy were established to maintain and update the SBS in harmony with DRG and other bundling systems. Additionally, a tabular list was developed to support this synchronization. The maintenance strategy was further refined to effectively address clinical and financial inconsistencies. SBS codes were mapped to relevant international terminologies and classifications, such as SNOMED CT and ACHI, ensuring interoperability with Electronic Health Records (EHRs) and other applications.

Specifications for the Saudi Billing System (SBS) are:

1. Saudi Billing System (SBS) published as the SBS Tabular List and the SBS Alphabetic Index in tandem with ACHI Standards and Saudi Coding Standards.
2. SBS classifies interventions performed in public and private hospitals, day centers, and ambulatory settings. Allied health interventions, dental services, and other interventions performed outside the operating theatre are also included.
3. The structure of the intervention classification is based on anatomy rather than surgical specialty. Chapters closely follow the chapter headings of the WHO ICD-10 to maintain parity with the disease classification.
4. Nonsurgical procedures are listed separately from the surgical procedures, whenever feasible.
5. The interventions in SBS are provider-neutral. That is, the same code should be assigned for a specific intervention regardless of which health professional performs the intervention.
6. An Electronic Code List (ECL) has been produced for implementation of the SBS V3 codes, their descriptions, and basic edits (system rules). This file and instructions for use have been published by CHI for software vendors.

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# CONTENT SUMMARY

**SBS Tabular List:** The SBS Tabular List contains the classification of the intervention.
Appendices included are:
* Appendix A: Clinical Explanation
* Appendix B: Billing Instructions
* Appendix C: SBS Code List

**SBS Alphabetic Index.** The SBS Alphabetic Index is used to locate interventional terms for coding. The SBS Alphabetic Index contains many interventional terms that do not appear in the SBS Tabular List.

**Australian and Saudi Coding Standards.** The Coding Standards contain the standards maintained by CHI, which guide the application of SBS.

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# CONVENTIONS IN THE SBS TABULAR LIST

## FORMAT

### First level – anatomical site axis

SBS is structured with a principal axis of anatomical site. Within each chapter the anatomical site is structured by a 'superior' to 'inferior' (head-to-toe) approach.

### Second level – procedural type axis

The secondary axis is intervention type, beginning with the least invasive intervention through to the most invasive intervention. Standardised interventional axes are:

* Examination
* Application, Insertion, Removal Incision
* Destruction Excision
* Reduction (only applicable in Chapter 15 Procedures on Musculoskeletal chapter)
* Repair Reconstruction Revision Reoperation Other procedures

### Third level – block axis

SBS is structured on an anatomical basis, therefore code numbers do not always appear in numerical order within the SBS Tabular List. Therefore, a third level axis, called a **block**, is utilised. Blocks are numbered sequentially in the SBS Tabular List to assist users in locating a specific code and have titles that relate specifically to the codes contained within the block.

Certain chapters are an exception to the general format:

* **Chapter 6 Dental services**
 This chapter is based on 'The Australian Schedule of Dental Services and Glossary, Twelfth Edition' (Australian Dental Association 2017, The Australian Schedule of Dental Services and Glossary, Australian Dental Association, Sydney, https://www.ada.org.au/Dental-Professionals/Publications/Schedule-and- Glossary/The-Australian-Schedule-of-Dental-Services-and-(1)/Australian_Schedule_and_Dental_Glossary_2015_FA2_W).
 This chapter is structured on a service basis (for example, diagnostic services, preventative services, periodontics, oral surgery). Secondary axes, in most instances, relate to the type of intervention.

* **Chapter 14 Obstetric procedures**
 This chapter has a principal axis relating to the pregnancy cycle, for example, antepartum procedures, procedures associated with labour, and delivery. Secondary axes relate to intervention type.

* **Chapter 18 Radiation oncology procedures**
 This chapter has a principal axis relating to radiation oncology interventions. Secondary axes relate to the type of radiation (for example, external beam therapy, brachytherapy, computerised planning).

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* **Chapter 19 Interventions not elsewhere classified**
 This chapter has a principal axis relating to the purpose of the intervention (for example, diagnostic, therapeutic, or administrative/clinical/client support and interventions not elsewhere classified). The secondary axis relates to the type of intervention or the body system. For example, in the primary axis of Diagnostic Interventions, the secondary axes include Assessment, Consultation, Interview, Examination, Evaluation, Diagnostic Tests, Measures, or Investigations Eye and Adnexa. In the primary axis of Therapeutic Interventions, secondary axes include Counselling, Education, or Nutritional Support Interventions, or Therapeutic Interventions for the Cardiovascular System.
* **Chapter 20 Imaging services**
 The principal axis within this chapter relates to the imaging service performed (for example, ultrasound, tomography, radiography). There is no secondary axis within this chapter.
 **Chapter 21 Laboratory and Pathology**
 The principal axis within this chapter relates to the laboratory or pathology service performed (for example, ultrasound, tomography, radiography). There is no secondary axis within this chapter.

**INCLUSION TERMS**
*Inclusion terms* are the interventional terms listed under a block heading, *Glossary* description/definition, or code.
Their purpose is to demonstrate examples of interventions that are classified to the block or code. They may refer to different interventions, or synonyms, but they are not a subclassification. *Inclusion* terms are listed primarily as a *guide to the content* of the block or code. Many of the items listed relate to important or common terms belonging to the block or code. Others are interventions or sites, listed to distinguish the boundary between one subcategory and another.
Inclusion terms are *not exhaustive*. NEVER code directly from the SBS Tabular List. Reference first the SBS Alphabetic Index, as it contains many more interventional terms than the SBS Tabular List.

**EXAMPLE 1:**
| Code | Description |
| :--------- | :---------------------------------------- |
| 90064-01-01 | Refractive keratoplasty Keratomileusis Thermokeratoplasty |

In some instances, it is necessary to read the *Inclusion* terms in conjunction with code titles. This usually occurs when the *Inclusion* terms are lists of sites or pharmaceutical products. Where appropriate, terms from the preceding code or category titles need to be read and understood.

**EXAMPLE 2:**

| Code | Description |
| :----- | :---------------------------------------- |
| 1920 | Administration of pharmacotherapy |
| -02-00 | Anti-infective agent |
| | Antibacterial |
| | Antibiotic Antifungal |
| | Antiprotozoal Antiviral |

In this example, the *Inclusion* terms represent the 'administration of those agents (e.g. administration of antibacterial agent).

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INSTRUCTIONAL NOTES/TERMS
Instructional notes/terms appear in certain locations throughout the ACHI Tabular List:
Chapter Applies to the codes classified to the chapter
First level - Anatomical site axis Applies to the codes classified to the site
Second level Interventional type axis Applies to the codes classified to the intervention
type
Third level - Block axis Applies to the codes grouped under the block heading
Fourth level-Code Applies to the code

Glossary Descriptions/Definitions
Glossary descriptions/definitions are formal statements of the meaning of a term or code. They
define the content of a chapter, anatomical site, intervention type, block or code. This
instruction is useful in standardising terminology and assisting with classification quality.
The Glossary descriptions/definitions are not intended for use by clinical coders.

Includes note
Includes notes further define the content of a chapter, site, intervention type, block or code.
They refer to intervention components or equipment used, that is inherent in a code or block.

EXAMPLE 3:
36503-00-00 Kidney transplantation
Includes: vascular anastomosis

In other instances, the Includes instructional note further defines the site.

EXAMPLE 4:
41867-01-00 Reoperation arytenoidectomy
Includes: that by laser

In other instances, the Includes instructional note further defines the site.

EXAMPLE 5:
306 Other procedures on external ear
Includes: auricle external
auditory canal

Note
The Note clarifies the use of a code or codes. In some instances, the Note provides an
example of a diagnostic term for which the intervention may be performed (the Note is not
exhaustive).

EXAMPLE 6:
39806-00-00 Clipping of intracranial proximal artery Note:
Performed for aneurysm or arteriovenous malformation

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The *Note* may also further define certain terms used in code or block descriptions within the block.

### EXAMPLE 7:
12 Arterial bypass graft using synthetic material
*Note:* Synthetic material can include polyester (woven or knitted) or polytetrafluoroethylene [PTFE] grafts

### See
The term *see* is listed within other *Instructional* notes/terms, as a cross-reference to another section of the classification. Follow the cross-references to ensure correct code selection.

### EXAMPLE 8:
90011-00-00 Other diagnostic procedures on spinal canal or spinal cord structures
*Note:* For nonsurgical diagnostic interventions see Chapter 19

### EXAMPLE 9:
43801-00-00 Correction of malrotation of intestine
Ladd operation
*Excludes:* that with resection of intestine — see Alphabetic Index

### Code first
The *Code first* instruction assists with the sequencing of codes. This instruction appears under codes that must never be assigned alone.

### EXAMPLE 10:
15012-00-01 Brachytherapy, eye, unilateral
*Code first:*
* implantation of brachytherapy applicator,1 eye (42801-00-01) [177])

### Code also/Code also when performed
These instructions indicate that an additional code is assigned when certain associated interventions are performed or equipment is used.

### EXAMPLE 11:
41548-00-01 Obliteration of mastoid cavity, unilateral
*Code also when performed:*
* meatoplasty, unilateral (41512-00-01 [305])

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Excludes note
*Excludes* notes are listed at the chapter, block, and code level. Interventions listed in
*Excludes* notes are classified elsewhere in ACHI.
*Note*: Codes are not listed within the *Excludes* note in numerical order; they are ordered
sequentially by block number.

EXAMPLE 12:
8 Intracranial drainage
*Excludes*: cerebrospinal fluid shunt (40003 [5], 40000-00, 40012 [19]):
Codes may be listed in *Excludes* notes with or without their extensions (see Example 12;
40003 [5] and 40012 [19]). When the extensions are not listed, the *Excludes* note applies to
all the four digit extensions of that code (i.e. in Example 12, there are four extensions to code
40012 [19] (see Example 13)

EXAMPLE 13:
40012-00-00 [19] Endoscopic third ventriculostomy
40012-01-00 [19] Third ventriculostomy

BLACK REVERSE TEXT BOXES
Black reverse text boxes are used for all block title numbers. They are NOT VALID codes and
CANNOT be assigned.

EXAMPLE 14:
1340 Caesarean delivery

TYPE FACE
**Bold** Bold type face is used for all block titles in the SBS Tabular List.
**_Bold, Italics_** Bold and italicised type face is used for Instructional notes/terms:
*Includes*, *Excludes* and *Note*.
_Italics_ Italicised type face is used for Instructional notes/terms: Code also..., Code also when
performed, and Code first.

PUNCTUATION
Parentheses ()
Parentheses are used to enclose:
1. nonessential modifiers (NEM) ie supplementary terms that follow an
interventional term, but do not affect the code number to which it is assigned.

EXAMPLE 15:
43912-02-01 Other open excision of bronchus, single
Excision of (lesion) (tissue) bronchus NEC

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2. the code(s) in Excludes notes and other Instructional notes/terms

### EXAMPLE 16:

| 5 shunt | Irrigation, insertion or removal of intracranial cerebrospinal fluid |
|---|---|

Code also when performed:
* neuroendoscopy (40903-00-00 [1])
Excludes: insertion of external ventricular drain (39015-00 [3]) revision of cerebrospinal fluid shunt (40009-00, 40009-01 [24])

3. the block ranges listed at the beginning of a chapter

### EXAMPLE 17:
CHAPTER 1
PROCEDURES ON NERVOUS SYSTEM (BLOCKS 1–86)

### SQUARE BRACKETS []

Square brackets are used to enclose:
1. synonyms or alternative terms

### EXAMPLE 18:
235 Canthoplasty

Includes: excision of tarsal cartilage [tarsectomy]

2. explanatory terms

### EXAMPLE 19:
90047-00-00 Aspiration of thyroid
Percutaneous [needle] drainage of thyroid

3. abbreviations

### EXAMPLE 20:
57362-00-00 Computerised tomography of temporomandibular joint [TMJ]

4. block numbers

### EXAMPLE 21:
37212-02-00 Incision of prostate
Excludes: Drainage of Abscess of Prostate (37212-01-00 [1161])

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COLON:
A colon is used in Inclusion terms and Excludes notes, when the terms preceding the colon require one or more modifiers (qualifying terms) for assignment to the code or block.

EXAMPLE 22:
90408-00-00 Destruction procedures on prostate
Includes: Destruction of (Lesion) (Tissue) Prostate:
* Endoscopic (37224-00-00 [1162])
* Percutaneous (90408-02-00 [1162])
In this example, the code classifies endoscopic and percutaneous destruction of lesion of prostate.
Colons are used in Includes notes to avoid repetition of terms.

EXAMPLE 23:
90408-00-00 Destruction procedures on prostate
Includes: Destruction of (Lesion) (Tissue) Prostate:
* Endoscopic (37224-00-00 [1162])
* Percutaneous (90408-02-00 [1162])
In this example, the colon is used here to avoid duplication of the terms Destruction of
Colons are also used to separate certain Instructional notes/terms (ie Includes, Note, Code also/Code first/Code also when performed, Excludes), and the Interventional terms that follow (see Examples 3–12).

NOT OTHERWISE SPECIFIED (NOS)
NOS is an abbreviation for 'not otherwise specified', meaning 'unspecified' or 'unqualified'.

EXAMPLE 24:
90468-06-00 Forceps delivery, unspecified
Forceps delivery NOS.

NOT ELSEWHERE CLASSIFIED (NEC)
The terms 'not elsewhere classified' indicate that certain specified variants of that intervention are classified in other parts of ACHI.

EXAMPLE 25:
43987-02-00 Excision of neuroblastoma, not elsewhere classified
Excludes: intraabdominal neuroblastoma (43987-01-00 [989])
intrathoracic neuroblastoma (43987-00-00 [563])
The abbreviation 'NEC' is used in the ACHI Tabular List in Inclusion terms and Excludes notes.
NEC code options are only assigned when there is insufficient information to assign the interventional term to a more specific code.

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EXAMPLE 26:
90319-04-00 Other closed procedures on liver
Percutaneous procedures on liver NEC
In this example, the code is assigned when there is insufficient information to permit
assignment of a more specific percutaneous/closed procedure on the liver.

AND/OR IN CODE TITLES
The term:
•'and' in code titles means 'and'
•'or' in code titles means 'or'.

EXAMPLE 27:
48224-00-01 [1435] Bone graft to radius or ulna, unilateral
47393-00-01 [1431] Open reduction of fracture of shaft of radius and ulna, unilateral

SPECIAL SIGNS/ANNOTATIONS
✔ This symbol denotes that an Australian Coding Standard applies to a particular code or
group of codes (category or block) and therefore reference to the standard is essential before
the code is assigned. The relevant standard number(s) is shown under or beside the symbol.

■ This symbol denotes that a Saudi Coding Standard applies to a particular code or group
of codes (category or block) and therefore reference to the standard is essential before the
code is assigned. The relevant standard number(s) is shown under or beside the symbol.

¢ This symbol denotes that a clinical explanation found in (Appendix A) to a particular code
and for further information on the code utilization refer to the (Appendix A).

β This symbol denotes that a billing instruction found in (Appendix B) to a particular code
and reference to the billing instruction is essential before the code is billed.

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# GUIDANCE IN THE USE OF SBS

The main aim of clinical coding (clinical classification) is:

*To classify clinical concepts into codes.*

Clinical concepts in SBS are interventions.

Originally designed to provide access to information contained in clinical records for research, education, and administration, clinical codes are now also utilised to facilitate payment of health services, determine utilisation patterns, and evaluate the appropriateness of health care costs. Coded data also provides the basis for epidemiological studies and research into the quality of health care.

The classification of clinical concepts and/or entities (i.e., an intervention or procedure) into code is a complex activity. Because coded data are used in so many areas, classification must be performed correctly and consistently in order to produce meaningful statistics to aid in the planning of health care needs.

In order to classify accurately, it is essential to have a working knowledge of medical science and to understand the characteristics, terminology, and conventions of SBS. The SBS Alphabetic Index contains many terms not included in the SBS Tabular List, and clinical classification requires that the Alphabetic Index, the Tabular List, and the *Australian and Saudi Coding Standards* be all consulted before a code is assigned.

There are several steps in classifying interventions, and the following is a simple guide intended to assist the occasional user of SBS.

1. Identify the clinical concept to be classified and refer to the appropriate section of the Alphabetic Index.

 Note: Avoid indiscriminate coding of irrelevant information, such as operative approach or procedural components.

2. Locate the lead term. For interventions, this is usually a noun identifying the type of intervention performed. However, some interventions expressed as adjectives or eponyms are included in the Alphabetic Index as lead terms.
3. Read and be guided by any Instructional note(s) that appear under the lead term.
4. Read any terms enclosed in parentheses after the lead term (these nonessential modifiers do not affect the code), as well as any terms indented under the lead term (these essential modifiers may affect the code), until the clinical concept has been accounted for.
5. Follow carefully any cross-references (see and see also) found in the Alphabetic Index.
6. Refer to the Tabular List to verify the suitability of the selected code. In the SBS Alphabetic Index, a code with five digits and a block number in parentheses (e.g., 92514 [1910]), requires the addition of a further four digits located in the Tabular List at the appropriate block.
7. Be guided by any Inclusion terms and Instructional notes under the selected code or under the chapter, block, or category heading.
8. Refer to both standards for interventions in the Australian Coding Standards, and the SBS Coding Standards as indicated by the (V) ACS symbol in the Tabular List and for SBS Coding Standards
9. Assign the code.

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# LIST OF SBS BLOCK NUMBERS

## TABULAR LIST

1. Procedures on nervous system
2. Procedures on endocrine system
3. Procedures on eye and adnexa
4. Procedures on ear and mastoid process
5. Procedures on nose, mouth and pharynx
6. Dental services
7. Procedures on respiratory system
8. Procedures on cardiovascular system
9. Procedures on blood and blood-forming organs
10. Procedures on digestive system
11. Procedures on urinary system
12. Procedures on male genital organs
13. Gynaecological procedures
14. Obstetric procedures
15. Procedures on musculoskeletal system
16. Dermatological and plastic procedures
17. Procedures on breast
18. Radiation oncology procedures
19. Non-invasive, cognitive and other interventions, not elsewhere classified
20. Imaging services
21. Laboratory and pathology
22. Ambulance and transport services
23. KSA service codes
24. Emergency Medical Services
25. Mortuary Services
26. Rehabilitation Services

## Appendix A: SBS Code List

## Appendix B: Billing Instructions

## Appendix C: Clinical Explanation

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# CHAPTER 1

## PROCEDURES ON NERVOUS SYSTEM (BLOCKS 1 - 86)

### SKULL, MENINGES AND BRAIN

#### EXAMINATION

| | Examination of skull, meninges or brain |
|---|---|
| 40803-00-00 | Intracranial stereotactic localisation |
| | Stereotactic localisation for: |
| | • brachytherapy |
| | • intracranial surgery |
| | • radiosurgery |
| V 0629 | Includes: |
| | - Angiography |
| | - Application of head frame |
| | - Computer assisted Coordinate Determination |
| | - Computerized Tomography [CT] |
| | - localisation |
| | - magnetic resonance imaging [MRI] |
| | - Targeting |
| | - Ventriculography |
| | Excludes: |
| | - Functional stereotactic procedure (40801-00-00 [27]) |
| | - Stereotactic: |
| | - Cingulotomy (40801-00-00 [27]) |
| | - Pallidotomy (40801-00-00 [27]) |
| | - Thalamotomy (40801-00-00 [27]) |
| | Code also when performed: |

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

- Brachytherapy (90764-00-00 [1791]) Burr holes (39012-00-00 [7]) Radiosurgery (15600-00-00, 15600-01-00 [1789], 90764-00-00 [1791])
Code also: surgical procedure(s) performed

40903-00-00 Neuroendoscopy
Intraventricular neuroendoscopy

V 0634

Excludes: that with biopsy (40903-01-00 [12])

Code also when performed:
- insertion of shunt (40003-00-00, 40003-01-00, 40003-02-00, 40003-03-00 [5])
- third ventriculostomy (40012-00-00, 40012-01-00 [19])

APPLICATION, INSERTION, REMOVAL

2 Cranial tap or puncture

39703-03-00 Aspiration of brain cyst ¢
Excludes: drainage of infected cyst (39900-00-00 [8])

39003-00-00 Cisternal puncture ¢

90000-00-00 Other cranial puncture
Aspiration of:
* subarachnoid space
* subdural space NOS
* Cranial aspiration NOS

39009-00-00 Tap for subdural haemorrhage
Tap through Fontanelle
Excludes: drainage via burr holes (39600-00-00 [8])

39006-00-00 Ventricular puncture
Ventricular puncture through previously implanted catheter

3 Insertion of intracranial cerebrospinal fluid devices

39015-02-00 Replacement of cerebrospinal fluid devices
Revision of cerebrospinal fluid devices
Insertion of intracranial pressure monitoring device, with monitoring

39015-00-00 Insertion of external ventricular drain

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V 0634

SBS TABULAR LIST - CHAPTER 1 (1 - 86)

Excludes: insertion of ventricular cerebrospinal fluid shunt (40003-00-00, 40003-01-00, 40003-02-00 [5])

39015-01-00
Insertion of ventricular reservoir
Insertion of reservoir:
* Ommaya
* Rickham's

4 Removal of intracranial cerebrospinal fluid devices

Excludes: that with replacement (39015 [3])

90001-00-00
Removal of external ventricular drain ¢
V 0634

90001-02-00
Removal of intracranial pressure monitoring device ¢

90001-01-00
Removal of ventricular reservoir
Removal of reservoir:
* Ommaya
* Rickham's

5 Irrigation, insertion or removal of intracranial cerebrospinal fluid shunt

Excludes:
* insertion of external ventricular drain (39015-00-00 [3])
* revision of cerebrospinal fluid shunt (40009-00-00, 40009-01-00 [24])

Code also when performed: neuroendoscopy (40903-00-00 [1])

90002-00-00
irrigation of cerebrospinal fluid shunt ¢

40003-03-00
Insertion of ventricular shunt to other extracranial site
A tube that is surgically placed in one of the fluid-filled chambers inside the brain (ventricles)

V 0634

40003-04-00
Insertion of cisternal shunt
Insertion of shunt:
* Cisterno-atrial
* Cisternoperitoneal
* Cisternopleural

40003-00-00
V 0634
Insertion of ventriculo-atrial shunt ¢

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

40003-02-00
Insertion of ventriculoperitoneal shunt
Ventriculoperitoneostomy

V 0634

40003-01-00
Insertion of ventriculopleural shunt ¢

V 0634

40009-04-00
Removal of cisternal shunt ¢
Excludes: that with replacement (40009-00-00 [24])

40009-03-00
Removal of ventricular shunt ¢

V 0634

Excludes: that with replacement (40009-00-00 [24])

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Other application, insertion or removal procedures on skull, meninges or brain

40709-02-00
Adjustment of intracranial electrodes via burr holes
Revision of intracranial electrodes via burr holes
Includes: revision of extension wire connecting electrodes to neurostimulator

40712-02-00
Adjustment of intracranial electrodes via craniotomy
Revision of intracranial electrodes via craniotomy
Includes:
* Revision of extension wire connecting electrodes to neurostimulator

40709-00-00
Insertion of intracranial electrode via burr holes
* Deep brain stimulation
* Implantation of intracranial electrode
Includes:
- Insertion of extension wire connecting electrodes to neurostimulator
Performed For: epilepsy multiple sclerosis pain control Parkinson's disease
Code also when performed:
- intracranial stereotactic localisation (40803-00-00 [1]) subcutaneous implantation of
neurostimulator (39134-01-00 [1604])

40712-00-00
Insertion of intracranial electrode via craniotomy
Deep brain stimulation
Includes:
- Insertion of extension wire connecting electrodes to neurostimulator

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

47705-00-00
Performed For: epilepsy multiple sclerosis pain control Parkinson's disease
Insertion of skull caliper
Insertion of skull tongs
Excludes: that for spinal fracture or dislocation (47684-00-00, 47687-00-00 [1381], 47690-00-00, 47693-00-00 [1387])

40709-01-00
Removal of intracranial electrode via burr holes
Includes: Removal of extension wire connecting electrodes to neurostimulator
Excludes: that with replacement (40709-03-00 [6])

40712-01-00
Removal of intracranial electrode via craniotomy
Includes: Removal of extension wire connecting electrodes to neurostimulator
Excludes: that with replacement (40709-03-00 [6])

40709-03-00
Replacement of intracranial electrodes via burr holes
Includes: Replacement of extension wire connecting electrodes to neurostimulator

40712-03-00
Replacement of intracranial electrodes via craniotomy
Includes: Replacement of extension wire connecting electrodes to neurostimulator

INCISION

7 Incisional exploration of meninges or brain

39012-00-00
Burr holes
Burr Holes for:
* Brachytherapy
* Inspection Purpose
* Intracranial exploration
Excludes: that as operative approach for surgery - omit code

8 Intracranial drainage

Includes: that via burr hole
Excludes: cerebrospinal fluid shunt (40003 [5], 40000-00-00, 40012 [19])

39600-00-00
Drainage of intracranial haemorrhage
Drainage of haemorrhage:
* extradural
* intracerebral
* subdural
Excludes:

5

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* Postoperative reopening of craniotomy or craniectomy site (39721-00-00 [10])
* Removal of intracranial haematoma:
 * via osteoplastic craniotomy (39603-00-00 [14])
 * with craniectomy (39603-01-00 [14])
* Tap of subdural haemorrhage through Fontanelle (39009-00-00 [2])

39900-00-00 Drainage of intracranial infection

Drainage of:
* Infected brain cyst
* intracranial abscess

*Excludes:*
* Postoperative reopening of craniotomy or craniectomy site (39721-00-00 [10])
* Removal of intracranial haematoma:
 * via osteoplastic craniotomy (39603-00-00 [14])
 * with craniectomy (39603-01-00 [14])
* Tap of subdural haemorrhage through fontanelle (39009-00-00 [2])

39703-01-00 Drainage of intracranial lesion or cyst
Intracranial drainage NOS

*Excludes:* that of infected cyst (39900-00-00 [8])

9 Intracranial decompression

39706-01-00 Decompression of intracranial tumour via osteoplastic craniotomy

*Includes:*
* osteoplastic flap

40106-00-00 Hind brain decompression

Decompression:
* of Arnold-Chiari malformation
* of Chiari malformation

*Includes:*
* Duraplasty

40106-01-00 Posterior cranial fossa decompression
Decompression for Syringomyelia

*Includes:*
* Duraplasty

40015-00-00 Subtemporal decompression ¢

6

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

## 10 Postoperative reopening of craniotomy or craniectomy site

### 39721-00-00 Postoperative re-opening of craniotomy or craniectomy site
Decompression of Oedema postoperative
* Drainage of:
 * haemorrhage postoperative
 * Infection postoperative
* Removal of:
 * abscess postoperative
 * haematoma postoperative

V 0039

Includes:
* Removal of skull flap
* That via osteoplastic flap

## DESTRUCTION

## 11 Destruction of intracranial aneurysm or other vascular lesion

### 39800-00-00 Clipping of cerebral aneurysm
A small metal clip is used to stop blood flow into the aneurysm

### 39806-00-00 Clipping of intracranial proximal artery
Temporary clip occlusion of the proximal artery

Performed For: aneurysm or arteriovenous malformation

### 35412-00-00 Endovascular occlusion of cerebral aneurysm or arteriovenous malformation
Transcatheter Embolisation of cerebral aneurysm or arteriovenous malformation

Includes: Administration of:
* Coils
* intracranial:
 * balloons
 * stents
* Catheterisation

### 39812-00-00 Ligation of cervical vessel for intracranial aneurysm
Simple surgical clipping refers to the practice of the exposure of the aneurysmal neck via craniotomy and the exclusion of the entire abnormal vascular wall from the circulation using single or multiple clips

### 39815-00-00 Obliteration of carotid cavernous fistula

Includes: Combined cervical and intracranial procedure

7

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

EXCISION

12 Biopsy of brain or meninges
39703-00-00
Biopsy of brain via burr holes
Closed biopsy of brain
Excludes: that with neuroendoscopy (40903-01-00 [12])
40903-01-00
Biopsy of brain via neuroendoscopy
Intraventricular neuroendoscopy with biopsy
Includes:
- Burr Holes
39706-02-00
Biopsy of cerebral meninges via osteoplastic craniotomy ¢
Open biopsy of cerebral Meninges
Includes:
- osteoplastic flap
39706-00-00
Biopsy of brain via osteoplastic craniotomy
Open biopsy of brain
Includes: osteoplastic flap
39703-02-00
Biopsy of cerebral meninges via burr holes
Closed biopsy of cerebral Meninges

13 Excision of lesion of skull
Includes: that for infection
39906-00-00
Craniectomy for infection of skull
* Craniectomy for Osteomyelitis
* Debridement of skull for Infection
* Removal of Infected skull flap
* Sequestrectomy of skull
39700-00-00
Excision of lesion of skull
Code also when performed: cranioplasty (40600 [23])

14 Removal of intracranial haematoma or abscess
Excludes:
- drainage via burr holes (39600, 39900 [8])

8

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

- postoperative reopening of craniotomy or craniectomy site (39721-00-00 [10])
39903-00-00 Removal of intracranial abscess ¢
39603-01-00 Removal of intracranial haematoma with craniectomy ¢
39603-00-00 Removal of intracranial haematoma via osteoplastic craniotomy
Removal of intracranial haematoma via osteoplastic flap

15 Removal of intracranial lesion

Excludes: that by skull base surgery (39640-00-00, 39642-00-00, 39646-00-00, 41581-00-00, 39650-00-00, 39653-00-00, 39658-00-00, 39660-02-00, 39662-02-00, 90032-00-00 [17])
39712-03-00 Removal of intraventricular lesion ¢
39709-01-00 Removal of lesion of brain stem ¢
39709-02-00 Removal of lesion of cerebellum ¢
39712-00-00 Removal of lesion of cerebral meninges ¢
39709-00-00 Removal of lesion of cerebrum ¢
Partial lobectomy of brain for tumour
41575-00-00 Removal of lesion of cerebellopontine angle
Removal of Acoustic neuroma
Includes: That via craniotomy
39712-04-00 Removal of other intracranial lesion
Removal of intracranial tumour NOS
Excludes:
- craniopharyngioma (39712-02-00 [125])
- intracranial neuroblastoma (43987-02-00 [80])
- that involving infratemporal fossa (41581-00-00 [17])
- that of pineal body (39712-01-00 [122])

16 Other intracranial excision

Excludes: excision by skull base surgery (39640-00-00, 39642-00-00, 39646-00-00, 41581-00-00, 39650-00-00, 39653-00-00, 39658-00-00, 39660-02-00, 39662-02-00, 90032-00-00 [17])
40700-00-00 Anterior section of corpus callosum
* Corpus Callosotomy
* Division of Corpus Callosum

9

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40703-00-00
Corticectomy of brain ¢
* Cortical resection of brain
Excludes: topectomy (40703-01-00 [16])

39803-00-00
Excision of intracranial arteriovenous malformation ¢

40706-00-00
Hemispherectomy ¢

40703-02-00
Partial lobectomy of brain
* Amygdala Hippocampectomy
* Hippocampectomy
Excludes: that for tumour (39709-00-00 [15])

39718-00-00
Removal of brain cyst
* Marsupialisation of brain cyst
* Removal of Arachnoidal cyst

40703-01-00
Topectomy ¢

17
Skull base surgery for lesion

39660-02-00
Includes:
* any associated reparative or reconstructive surgery
* that for vascular lesions
Excision of lesion of cavernous sinus
Includes:
* With intracranial carotid artery exposure.

39658-00-00
Excision of lesion of clivus
Includes: via:
* transmaxillary approach
* transoral approach

39662-02-00
Excision of lesion of foramen magnum
Includes: via:
* far lateral suboccipital approach
* transcondylar approach

39640-00-00
Removal of lesion involving anterior cranial fossa
Includes:

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* Craniotomy
* dural repair
* Radical excision of skull base

41581-00-00
Removal of lesion involving infratemporal fossa

90032-00-00
Removal of lesion involving posterior cranial fossa
 Includes: via:
 * translabyrinth approach
 * transmastoid approach
 * transoral approach

39653-00-00
Removal of lesion of petroclivus and clivus
 Includes: via:
 * infratentorial approach
 * supratentorial approach

39646-00-00
Removal of lesion involving anterior cranial fossa with radical clearance of paranasal sinus and orbital fossa extensions
 Includes:
 * decompression of optic nerve
 * dural repair
 * frontal craniotomy
 * lateral rhinotomy
 * radical excision of skull base

39642-00-00
Removal of lesion involving anterior cranial fossa with clearance of paranasal sinus extension
 Includes:
 * dural repair
 * frontal craniotomy
 * lateral rhinotomy
 * radical excision of skull base

39650-00-00
Removal of lesion involving middle cranial and infratemporal fossae
 Includes: division and reconstruction of zygomatic arch

REPAIR

11

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

## 19 Ventriculostomy

V 0634

### Excludes:

* cerebrospinal fluid shunt (40003 [5])
* insertion of external ventricular drain (39015-00-00 [3])

| Code | Description |
|---|---|
| 40012-00-00 | Endoscopic third ventriculostomy <br> *Includes:* Septum pellucidotomy |
| 40012-01-00 | Third ventriculostomy <br> *Includes:* Septum pellucidotomy |
| 40000-00-00 | Ventriculocisternostomy <br> Torkildsen's procedure |

## 20 Repair of dura of brain

* Dural (fat) graft
* Duraplasty
* Repair of cerebral meninges

### Excludes: that with:

* intracranial decompression (40106-00-00, 40106-01-00 [9])
* plugging of obex (40339-00-00 [22])
* reduction of skull fracture (39612 [25])
* skull base surgery for lesion involving anterior cranial fossa (39640-00-00, 39642-00-00, 39646-00-00 [17])

*Code also when performed:* procurement of fat for graft via separate incision (45018-04-00 [1666])

| Code | Description |
|---|---|
| 39615-01-00 | Repair of dura of brain via craniotomy with cranioplasty <br> Delayed repair of dura following fractured skull with cranioplasty |
| 39615-00-00 | Repair of dura of brain via craniotomy <br> Delayed repair of dura following fractured skull via craniotomy <br> *Excludes:* that with cranioplasty (39615-01-00-00 [20]) |

## 21 Extracranial to intracranial bypass

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90006-00-00 Extracranial to intracranial bypass with radial artery graft ¢
39821-00-00 Extracranial to intracranial bypass with saphenous vein graft ¢
39818-00-00 Extracranial to intracranial bypass with superficial temporal artery graft

**22 Other repair of meninges or brain**

40339-00-00 Plugging of obex
Includes: Duraplasty

39800-01-00 Reinforcement of cerebral aneurysm
40109-00-00 Repair of encephalocele
Excision and closure of Encephalocele
* Repair of:
* cerebral Meningocele
* Meningoencephalocele

**RECONSTRUCTION**

**23 Cranioplasty**

Reconstructive cranioplasty
Includes: fat graft

Excludes:
- that of skull fracture (39606, 39609-01, 39609-02-00, 39612 [25])
- that with intracranial procedure – omit cranioplasty code

Code also when performed:
- excision of skull lesion (39700-00-00 [13])
- procurement of fat for graft via separate incision (45018-04-00 [1666])

40600-00-00 Cranioplasty with insertion of skull plate
Replacement of skull plate

40600-01-00 Cranioplasty with bone graft
Bone graft to skull

40600-02-00 Cranioplasty with skull flap
* Repair of skull with bone flap
* Replacement of skull flap
* Revision of skull flap

40600-03-00 Other cranioplasty
* Cranial osteoplasty NOS

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* Cranioplasty NOS
* Repair of skull NOS

REVISION

**24 Revision of intracranial cerebrospinal fluid shunt**

V 0634

*Includes:*
- removal and reinsertion of cerebrospinal fluid shunt
- replacement of cerebrospinal fluid shunt

*Excludes:*
revision at distal site:
- atrial (90200-00-00 [605])
- peritoneal (90330-00-00 [1001])
- pleural (90174-00-00 [557])

40009-01-00 Revision of cisternal shunt
V 0634
40009-00-00 Revision of ventricular shunt

OTHER PROCEDURES

**25 Procedures for skull fracture**

Cranioplasty for skull fracture
39609-00-00 Debridement of compound skull fracture
39606-00-00 Elevation of closed skull fracture
Reduction of closed depressed skull fracture
39612-00-00 Elevation of compound skull fracture with repair of dura and brain
* Reduction of compound depressed skull fracture with repair of dura and brain
*Excludes:* Delayed repair of dura following fractured skull (39615 [20])
39609-01-00 Elevation of compound skull fracture
* Reduction of compound depressed skull fracture
39612-01-00 Reduction of compound skull fracture with repair of dura and brain
* Repair of compound comminuted skull fracture and dura and brain
*Includes:* Internal fixation
*Excludes:* delayed repair of dura following fractured skull (39615 [20])
39609-02-00 Reduction of compound skull fracture
Repair of compound Comminuted skull fracture
*Includes:*

14

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- Internal fixation
39606-01-00 Reduction of closed skull fracture
* Repair of closed comminuted skull fracture
Includes:
- Internal fixation

27 Functional intracranial stereotactic procedure
V 0633
40801-00-00 Functional intracranial stereotactic procedure
Stereotactic:
* cingulotomy
* pallidotomy
* thalamotomy
Includes:
- Angiography
- Application of head frame
- Computer assisted Coordinate Determination
- Computerized tomography [CT]
- Destruction of lesion
- magnetic resonance imaging [MRI]
- Physiological localisation
- Production of lesion
- Targeting
- Ventriculography

SBS TABULAR LIST - CHAPTER 1 (1 - 86)

28 Other procedures on skull, meninges or brain
90007-00-00 Unlisted diagnostic procedures on skull, brain or cerebral meninges ¢
for nonsurgical diagnostic interventions see Chapter 19
Excludes: Biopsy of skull (50200-00-01 [1560])
90007-02-00 Unlisted procedures on brain or cerebral meninges
Choroid Plexectomy
* Curettage of brain or cerebral Meninges

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* Debridement of brain or cerebral meninges
* Decortication of cerebral meninges
* Excision of:
 * brain or cerebral meningesNOS
 * lesion of brain NOS
 * Incision of brain NOS
 * Lobotomy of brain
 * Lysis of cortical adhesions
 * Repair of brain NOS
 * Tractotomy of brain

| | |
|---|---|
| 90007-01-00 | Unlisted procedure on skull |

* Craniectomy NOS
* Incision and drainage of cranial sinus
* Removal of skull Plate

Excludes: Removal of foreign body of skull (90569-00-01 [1556])

SPINAL CANAL AND SPINAL CORD STRUCTURES

EXAMINATION

| | |
|---|---|
| 29 | Examination of spinal canal and spinal cord structures |

∇ 0629

| | |
|---|---|
| 90011-05-00 | Spinal stereotactic localisation |

* Stereotactic localisaion for spinal surgery

Includes:
- Angiography
- Application of head frame
- Computer assisted Coordinate Determination
- Computerized tomography [CT]
- magnetic resonance imaging [MRI]
- Physiological localisation
- Targeting

Excludes: Functional stereotactic procedure (39121-00-00 [58])

16

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Code also: surgical procedure(s) performed

APPLICATION, INSERTION, REMOVAL

### 30 Lumbar puncture

* **39000-00-00** Lumbar puncture
 Spinal Tap

### 31 Application, insertion or removal procedures on vertebra or intervertebral disc

* **39013-01-00** Administration of agent into costotransverse joint
 Injection Into Costotransverse joint of:
 * Corticosteroid
 * Local anaesthetic
* **39013-00-00** Administration of agent into sygo-apophyseal (facet) joint
 Injection Into Zygo-Apophyseal (Facet) joint of:
 * Corticosteroid
 * Local anaesthetic
* **40336-00-00** Administration of chemonucleolytic agent into disc
 Injection of Chymopapain Into intervertebral space
* **90027-00-00** Intradiscal therapy
 Intradiscal electrothermal therapy [IDET]
 * Intradiscal therapy (Percutaneous) by:
 * electrothermal catheter
 * radiofrequency (thermocoagulation)

### 32 Epidural injection

* **V 0031**
 Performed for: pain management Includes: spinal catheterisation Excludes:
 * epidural infusion (see block [33])
 * that during labour and delivery procedure (see block [1333])
 * that for operative anaesthesia (92508 [1909])
* **18216-27-00** Epidural injection of local anaesthetic
* **18216-28-00** Epidural injection of opioid

17

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| Code | Description |
| --------- | ------------------------------------------------------------------------ |
| 90018-00-00 | Epidural injection of other or combined therapeutic substance(s) |
| 39140-00-00 | Epidural injection for lysis of adhesions Performed under imaging control |

* Epidural:
 * adhesiolysis
 * neuroplasty
 * epidurolysis
 * Epiduroplasty
 * peridural adhesiolysis
 * Racz (Catheter) procedure

Includes: Epidurogram

| Code | Description |
| --------- | ----------------------------------------- |
| 18230-00-00 | Epidural injection of neurolytic agent |
| 90028-00-00 | Epidural injection of steroid |

**33 Epidural infusion**

V 0031

Performed for: pain management Includes: spinal catheterisation Excludes:

* epidural injection (see block [32])
* that during labour and delivery procedure (see block [1333])
* that for operative anaesthesia (92508 [1909])

| Code | Description |
| --------- | ------------------------------------------------------------------------ |
| 18216-06-00 | Epidural infusion of other or combined therapeutic substance(s) |
| 18216-00-00 | Epidural infusion of local anaesthetic |
| 18216-03-00 | Epidural infusion of opioid |
| 90028-01-00 | Epidural infusion of steroid |

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### 34 Caudal injection

∇ 0031

Performed for: pain management Includes: spinal catheterisation Excludes:
* caudal infusion (see block [35])
* that during labour and delivery procedure (see block [1333])
* that for operative anaesthesia (92508 [1909])

18216-29-00 Caudal injection of local anaesthetic
90019-00-00 Caudal injection of other or combined therapeutic substance(s)
Excludes:
* Caudal infusion (See block [35])
* That during labour and delivery procedure (See block [1333])
* that for operative anaesthesia (92508-10-00 [1909])

18216-30-00 Caudal injection of opioid
Excludes:
* Caudal infusion (See block [35])
* That during labour and delivery procedure (See block [1333])
* that for operative anaesthesia (92508-10-00 [1909])

90028-02-00 Caudal injection of steroid
Excludes:
* Caudal infusion (See block [35])
* That during labour and delivery procedure (See block [1333])
* that for operative anaesthesia (92508-10-00 [1909])

### 35 Caudal infusion

∇ 0031

Performed for: pain management Includes: spinal catheterisation Excludes:
* caudal injection (see block [34])
* that during labour and delivery procedure (see block [1333])

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

- that for operative anaesthesia (92508 [1909])

18216-15-00 Caudal infusion of other or combined therapeutic substance(s)
18216-09-00 Caudal infusion of local anaesthetic
18216-12-00 Caudal infusion of opioid
90028-03-00 Caudal infusion of steroid

### 36 Spinal injection

Injection into:
* intrathecal space
* spinal subarachnoid space Performed for: pain
management Includes: spinal catheterisation
Excludes: caudal:
- infusion (see block [35])
- injection (see block [34])
 - spinal infusion (see block [37])
 - that during labour and delivery procedure (see block [1333])
 - that for operative anaesthesia (92508 [1909])

18216-31-00 Spinal injection of local anaesthetic
 Includes: intrathecal testing

90020-00-00 Spinal injection of other or combined therapeutic substance(s)
 Includes: intrathecal testing

18230-01-00 Spinal injection of neurolytic agent

18216-32-00 Spinal injection of opioid
 Includes: intrathecal testing

90028-04-00 Spinal injection of steroid
 Includes: intrathecal testing

∇ 0031

### 37 Spinal infusion

∇ 0031

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Infusion into:
* intrathecal space
* spinal subarachnoid space *Performed for:* pain
management *Includes:*
* intrathecal testing
* spinal catheterisation
*Excludes:* caudal:
* infusion (see block [35])
* injection (see block [34])
* spinal injection (see block [36])
* that during labour and delivery procedure (see block [1333])
* that for operative anaesthesia (92508 [1909])

| Code | Description |
|------------|------------------------------------------------------------|
| 18216-24-00 | Spinal infusion of other or combined therapeutic substance(s) |
| 18216-18-00 | Spinal infusion of local anaesthetic |
| 18216-21-00 | Spinal infusion of opioid |
| 90028-05-00 | Spinal infusion of steroid |

### 38 Spinal blood patch

| Code | Description |
|------------|-------------------------------------------|
| 18233-00-00 | Spinal blood patch |
| | Epidural injection of blood for blood patch |

### 39 Insertion of spinal catheter, infusion device or pump

*Performed for:* management of:
* chronic spasticity
* pain

| Code | Description |
|------------|------------------------------------------------------------|
| 39127-00-00 | Insertion of implantable spinal infusion device or pump |

*Includes:*
* Connection of pump to catheter
* Loading of reservoir
* Programming of pump
* Spinal catheterisation

21

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

Excludes: that with replacement (39126-00-00 [56])

39125-00-00
Insertion or replacement of spinal catheter
Insertion or replacement of catheter:
* Caudal
* epidural
* intrathecal
* subarachnoid

Excludes:
that with:
* administration of therapeutic agent (see alphabetic Index: administration/specified site/spinal)
* insertion of implantable spinal infusion device or pump (39127-00-00 [39])

**40 Removal of spinal catheter, infusion device or pump**

39133-02-00
Removal of implantable spinal infusion device or pump
Includes: Removal of catheter
Excludes: that with replacement (39126-00-00 [56])

39133-01-00
Removal of spinal catheter ¢
Excludes:
* That Connected to implantable spinal infusion device or pump (39133-02-00 [40])
* that with replacement (39125-00-00 [39])

**41 Insertion and removal of spinal cerebrospinal fluid drain**

∇ 0634

Excludes: cerebrospinal fluid shunt (40006-00-00, 40009-05-00 [42], 40009-02-00 [56])

40018-00-00
Insertion of lumbar cerebrospinal fluid (CSF) drain
* Insertion of external lumbar drain
* Replacement of lumbar cerebrospinal fluid drain
* Revision of lumbar cerebrospinal fluid drain

90008-00-00
Removal of lumbar cerebrospinal fluid drain
Removal of a small flexible tube that is placed in the lumbar spine
Excludes: that with replacement (40018-00-00 [41])

22

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

## 42 Insertion and removal of spinal cerebrospinal fluid shunt

**Excludes:**
* lumbar cerebrospinal fluid drain (40018-00-00, 90008-00-00 [41])
* revision of spinal shunt (40009-02-00 [56])

### 40342-00-00 Insertion of cerebrospinal fluid (CSF) shunt with laminectomy
* Procedure performed for syringomyelia and hydromyelia

**Includes:**
* Syringoperitoneal shunt
* Syringopleural shunt

### 40006-00-00 Insertion of spinal shunt
Insertion of Lumboperitoneal shunt

V 0634

**Excludes:** that with laminectomy (40342-00-00 [42])

### 40009-05-00 Removal of spinal shunt
Removal of Lumboperitoneal shunt

V 0634

**Excludes:** that with replacement (40009-02-00 [56])

## 43 Insertion, replacement or removal of epidural electrodes

### 39131-00-00 Adjust of epidural electrodes
Revision of epidural electrodes

### 39139-00-00 Insertion of epidural electrodes by laminectomy
* Replacement of epidural electrodes by open approach
* Revision of epidural electrodes by open approach

**Includes:** Intraoperative test stimulation

**Performed for:** pain relief

### 39130-00-00 Percutaneous insertion of epidural electrodes

Percutaneous:
* burying of epidural electrodes
* threading of epidural electrodes
* tunnelling of epidural electrodes

**Includes:** Intraoperative test stimulation

23

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

39136-01-00 Removal of epidural electrodes
Excludes:
- that with replacement:
- by laminectomy (39139-00-00 [43])
- NOS (39137-00-00 [43])

39137-00-00 Replacement of epidural electrodes ¢
Includes: Intraoperative test stimulation
Excludes: that with replacement of epidural electrodes by laminectomy (39139-00-00 [43])

INCISION

45 Cordotomy or myelotomy
Excludes: percutaneous spinal cordotomy (39121-00-00 [58])
39124-00-00 Cordotomy
spinal tractotomy
Includes: Laminectomy

39124-02-00 Dorsal root entry zone [DREZ] procedure
Procedure for DREZ lesions
Includes: Laminectomy

39124-01-00 Myelotomy
Includes: Laminectomy

46 Decompression of cervical spinal cord
Decompressive laminectomy of cervical spine
Includes:
- bone graft
- cervical discectomy
- fat graft
- laminoplasty (open door)
- that for spinal stenosis

24

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

Code also when performed:
* decompression of spinal nerve roots (rhizolysis) (40330-00-00 [49])
* procurement of:
 * bone graft material through separate incision (47726 [1563])
 * fat for graft via separate incision (45018-04-00 [1666])

40332-00-00 Decompression of cervical spinal cord with anterior fusion, 1 level
Code also when performed:
* internal fixation (48678-00-00, 48681-00-00, 48684-00-00 [1390])

40335-00-00 Decompression of cervical spinal cord with anterior fusion, 2 or more levels
Code also when performed:
* internal fixation (48678-00-00, 48681-00-00, 48684-00-00 [1390])

40334-00-00 Decompression of cervical spinal cord, 2 or more levels
40331-00-00 Decompression of cervical spinal cord, 1 level

47 Decompression of thoracic and thoracolumbar spinal cord

Includes:
* fat graft
* laminoplasty (open door)
* that for spinal stenosis

Code also when performed:
* decompression of spinal nerve roots (rhizolysis) (40330-00-00 [49])
* procurement of fat for graft via separate incision (45018-04-00 [1666])
* spinal fusion (48642-00-00, 48645-00-00, 48648-00-00, 48651-00-00, 48660-00-00, 48669-00-00 [1389])

40351-00-00 Anterior decompression of thoracolumbar spinal cord
Anterior decompression of high lumbar spinal cord
Includes: Discectomy:
* lumbar
* thoracic

40345-00-00 Decompression of thoracic spinal cord via costotransversectomy
Includes:

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

* Removal of rib
* Thoracic discectomy

40348-00-00 Decompression of thoracic spinal cord via thoracotomy

Includes:
* Removal of rib
* Thoracic:
 * discectomy
 * Vertebrectomy

48 Decompression of lumbar spinal canal

Includes: decompression:
* anterior
* posterior
* discectomy
* fat graft
* laminectomy
* laminoplasty (open door)
* that for spinal stenosis

Excludes: anterior decompression of thoracolumbar spinal cord (40351-00-00 [47])

Code also when performed:
* decompression of spinal nerve roots (rhizolysis) (40330-00-00 [49])
* procurement of fat for graft via separate incision (45018-04-00 [1666])

90024-01-00 Decompression of lumbar spinal canal, >= 2 levels
90024-00-00 Decompression of lumbar spinal canal, 1 level

49 Other incision procedures on spinal canal or spinal cord structures

Code also when performed: procurement of fat for graft via separate incision (45018-04-00 [1666])

40330-00-00 Decompression of spinal nerve roots
Spinal:

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

* facetectomy
* foramenotomy
* rhizolysis
* rhizotomy

Includes: Exposure of spinal nerve roots at 1 or more levels
Excludes: Decompression of spinal nerve (39330-00-00 [77])

90031-00-00
Incision and drainage of spinal canal or spinal cord structures
Drainage of spinal cord haematoma:
* epidural
* meninges
* subdural

90009-00-00
Postoperative re-opening of laminotomy or laminectomy site
Performed for:
* haemorrhage
* infection

V 0039
Includes: fat graft

40112-00-00
Release of congenital tethered spinal cord
Performed For: diastematomyelia lipomeningocele

EXCISION

50
Biopsy of spinal cord or spinal meninges

90010-00-00
Biopsy of spinal cord or spinal meninges ¢
Biopsy of spinal lesion:
* extradural
* intradural

51
Discectomy for recurrent disc lesion

Discectomy via:
* laminectomy for recurrent disc lesion
* laminotomy for recurrent disc lesion

Excision of intervertebral disc for recurrent disc lesion
Includes: fat graft
Excludes: that with intervertebral disc prosthesis (see block [59])
Code also when performed: procurement of fat for graft via separate incision (45018-04-00 [1666])

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SBS TABULAR LIST - CHAPTER 1 (1 - 86)

| Code | Description |
|---|---|
| 40303-01-00 | Discectomy for recurrent disc lesion, 2 or more levels |
| 40303-00-00 | Discectomy for recurrent disc lesion, 1 level |

**52 Other discectomy**

Excision of intervertebral disc

*Includes:* fat graft

*Excludes:*
* discectomy for recurrent disc lesion (40303 [51])
* laminectomy with insertion of cerebrospinal fluid shunt (40342-00-00 [42])
* that with intervertebral disc prosthesis (see block [59])

*Code also when performed:* procurement of fat for graft via separate incision (45018-04-00 [1666])

| Code | Description |
|---|---|
| 40333-01-00 | Cervical discectomy, 2 or more levels |
| | *Excludes:* that with decompression of cervical spinal cord (40334-00-00, 40335-00-00 [46]) |
| 40333-00-00 | Cervical discectomy, 1 level |
| | *Excludes:* that with decompression of cervical spinal cord (40331-00-00, 40332-00-00 [46]) |

| Code | Description |
|---|---|
| 

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