Actual CPT / HCPCS codes to pull before anyone talks leakage.

Office E/M — denominator, not an ancillary

Capture rates start from clinic volume.

Do not treat these as leakage lines.

• 99202New patient, straightforward
• 99203New patient, low
• 99204New patient, moderate
• 99205New patient, high
• 99211Established, minimal
• 99212Established, straightforward
• 99213Established, low
• 99214Established, moderate
• 99215Established, high

In-office radiography

Usually already captured. Pull so you do not waste the scan here.

Global or TC on POS 11.

• 73000Clavicle x-ray
• 73010Scapula x-ray
• 73020Shoulder, 1 view
• 73030Shoulder, complete ≥2 views
• 73050AC joints, bilateral
• 73060Humerus ≥2 views
• 73070Elbow, 2 views
• 73080Elbow, complete ≥3 views
• 73090Forearm, 2 views
• 73100Wrist, 2 views
• 73110Wrist, complete ≥3 views
• 73120Hand, 2 views
• 73130Hand, complete ≥3 views
• 73140Finger(s) ≥2 views
• 73501Hip unilateral, 1 view
• 73502Hip unilateral, 2–3 views
• 73503Hip unilateral ≥4 views
• 73521Hips bilateral, 2 views
• 73522Hips bilateral, 3–4 views
• 73523Hips bilateral ≥5 views
• 73551Femur, 1 view
• 73552Femur ≥2 views
• 73560Knee, 1–2 views
• 73562Knee, 3 views
• 73564Knee, complete ≥4 views
• 73565Knees both, standing AP
• 73590Tibia/fibula ≥2 views
• 73600Ankle, 2 views
• 73610Ankle, complete ≥3 views
• 73620Foot, 2 views
• 73630Foot, complete ≥3 views
• 73650Calcaneus ≥2 views
• 73660Toe(s) ≥2 views
• 72020Spine, single view
• 72040Cervical, 2–3 views
• 72050Cervical, 4–5 views
• 72052Cervical, complete ≥6 views
• 72070Thoracic, 2 views
• 72072Thoracic, 3 views
• 72074Thoracic, complete ≥4 views
• 72080Thoracolumbar, 2 views
• 72100Lumbosacral, 2–3 views
• 72110Lumbosacral, complete ≥4 views
• 72114Lumbosacral, complete with bending
• 72120Lumbosacral, bending only
• 72200SI joints ≤3 views
• 72202SI joints ≥4 views
• 72220Sacrum/coccyx ≥2 views
• 71100Ribs unilateral, 2 views
• 71101Ribs unilateral with PA chest
• 71110Ribs bilateral, 3 views
• 71111Ribs bilateral with PA chest
• 76000Fluoroscopy, up to 1 hour

MRI

Largest imaging dollar. Technical component is the leak.

Split 26 / TC / global. POS 11 vs 22 vs 24.

• 72141Cervical MRI without contrast
• 72142Cervical MRI with contrast
• 72156Cervical MRI without and with
• 72146Thoracic MRI without contrast
• 72147Thoracic MRI with contrast
• 72157Thoracic MRI without and with
• 72148Lumbar MRI without contrast
• 72149Lumbar MRI with contrast
• 72158Lumbar MRI without and with
• 72195Pelvis MRI without contrast
• 72196Pelvis MRI with contrast
• 72197Pelvis MRI without and with
• 73218Upper extremity MRI without contrast
• 73219Upper extremity MRI with contrast
• 73220Upper extremity MRI without and with
• 73221Upper extremity joint MRI without contrast
• 73222Upper extremity joint MRI with contrast
• 73223Upper extremity joint MRI without and with
• 73718Lower extremity MRI without contrast
• 73719Lower extremity MRI with contrast
• 73720Lower extremity MRI without and with
• 73721Lower extremity joint MRI without contrast
• 73722Lower extremity joint MRI with contrast
• 73723Lower extremity joint MRI without and with

73221 and 73721 (shoulder/knee without contrast) are the high-volume ortho magnets.

CT

Spine, trauma, and sinus-overlap. Same 26/TC split as MRI.

POS 11 vs 22.

• 72125Cervical CT without contrast
• 72126Cervical CT with contrast
• 72127Cervical CT without and with
• 72128Thoracic CT without contrast
• 72129Thoracic CT with contrast
• 72130Thoracic CT without and with
• 72131Lumbar CT without contrast
• 72132Lumbar CT with contrast
• 72133Lumbar CT without and with
• 72192Pelvis CT without contrast
• 72193Pelvis CT with contrast
• 72194Pelvis CT without and with
• 73200Upper extremity CT without contrast
• 73201Upper extremity CT with contrast
• 73202Upper extremity CT without and with
• 73700Lower extremity CT without contrast
• 73701Lower extremity CT with contrast
• 73702Lower extremity CT without and with
• 77002Fluoro guidance for needle
• 77003Fluoro guidance, spine
• 77012CT guidance for needle

Ultrasound

Office sports/hand. Often done and not billed.

POS 11, same-day as 20600–20611.

• 76881Complete joint ultrasound
• 76882Limited joint / focal ultrasound
• 76942Ultrasound guidance for needle
• 93922Limited extremity arterial study
• 93923Complete extremity arterial study
• 93925Lower extremity arterial duplex, bilateral
• 93926Lower extremity arterial duplex, unilateral
• 93970Extremity venous duplex, complete bilateral
• 93971Extremity venous duplex, unilateral / limited

DEXA

Standing order on arthroplasty and fragility.

On the practice TIN vs referred out.

• 77080DEXA axial (hips, pelvis, spine)
• 77081DEXA appendicular (wrist, heel)
• 77085DEXA axial with vertebral fracture assessment
• 77086Vertebral fracture assessment, stand-alone

Physical therapy / OT

Highest operational capture gap. Zero codes on the TIN = they do not own PT.

Episodes = evals (97161–97163), not 97110 units.

• 97161PT eval, low complexity
• 97162PT eval, moderate complexity
• 97163PT eval, high complexity
• 97164PT re-evaluation
• 97165OT eval, low complexity
• 97166OT eval, moderate complexity
• 97167OT eval, high complexity
• 97168OT re-evaluation
• 97110Therapeutic exercise
• 97112Neuromuscular re-education
• 97113Aquatic therapy
• 97116Gait training
• 97124Massage
• 97140Manual therapy
• 97150Group therapy
• 97530Therapeutic activities
• 97535Self-care / home management
• 97542Wheelchair management
• 97750Physical performance test
• 97760Orthotic management, initial
• 97761Prosthetic training, initial
• 97763Orthotic/prosthetic management, subsequent
• 97010Hot or cold packs
• 97012Traction, mechanical
• 97014Electrical stimulation, unattended
• 97016Vasopneumatic device
• 97018Paraffin bath
• 97022Whirlpool
• 97024Diathermy
• 97026Infrared
• 97028Ultraviolet
• 97032Electrical stimulation, attended
• 97033Iontophoresis
• 97034Contrast baths
• 97035Ultrasound
• 97036Hubbard tank
• G0283Medicare unattended e-stim (to one or more areas)

Bracing and DME

Enrolled ≠ capturing. L-codes on the group TIN vs outside supplier.

HCPCS L and E on practice NPI/PTAN.

• L1810Knee orthosis, elastic with joints
• L1812Knee orthosis, elastic with joints, prefab off-the-shelf
• L1820Knee orthosis, elastic with condylar pads and joints
• L1830Knee immobilizer, canvas longitudinal
• L1831Knee orthosis, locking knee joint(s)
• L1832Knee orthosis, adjustable flexion/extension, custom fitted
• L1833Knee orthosis, adjustable flexion/extension, off-the-shelf
• L1836Knee orthosis, rigid without joints
• L1843Knee orthosis, single upright, custom fitted
• L1844Knee orthosis, single upright, custom fabricated
• L1845Knee orthosis, double upright, custom fitted
• L1846Knee orthosis, double upright, custom fabricated
• L1851Knee orthosis, unloader, off-the-shelf
• L1852Knee orthosis, unloader, custom fitted
• L1860Knee orthosis, modification of supracondylar prosthetic
• L3650Shoulder orthosis, figure of eight, prefab
• L3660Shoulder orthosis, figure of eight, canvas
• L3670Shoulder orthosis, acromio/clavicular
• L3671Shoulder orthosis, shoulder cap design, prefab
• L3674Shoulder orthosis, abduction, airplane, custom
• L3675Shoulder orthosis, vest type, prefab
• L3677Shoulder orthosis, shoulder joint design, prefab
• L3678Shoulder orthosis, shoulder joint design, off-the-shelf
• L3807Wrist-hand-finger orthosis, without joints, prefab
• L3808Wrist-hand-finger orthosis, rigid without joints, custom
• L3809Wrist-hand-finger orthosis, without joints, off-the-shelf
• L3908Wrist-hand orthosis, wrist extension control, prefab
• L3912Hand-finger orthosis, flexion glove
• L3913Hand-finger orthosis, without joints, custom
• L3923Hand-finger orthosis, without joints, prefab
• L3924Hand-finger orthosis, without joints, off-the-shelf
• L3931Wrist-hand-finger orthosis, including one or more nontorsion joints, prefab
• L3933Finger orthosis, without joints, custom
• L3935Finger orthosis, nontorsion joint, custom
• L1902AFO, ankle gauntlet, prefab
• L1906AFO, ankle gauntlet, custom fitted
• L1930AFO, plastic or other material, prefab
• L1932AFO, rigid anterior tibial, prefab
• L1940AFO, plastic or other material, custom
• L1960AFO, posterior solid ankle, plastic, custom
• L1970AFO, plastic with ankle joint, custom
• L1971AFO, plastic with ankle joint, prefab
• L4350Ankle control orthosis, stirrup, prefab
• L4360Walking boot, pneumatic, prefab custom fitted
• L4361Walking boot, pneumatic, off-the-shelf
• L4370Pneumatic splint, prefab
• L4386Walking boot, non-pneumatic, custom fitted
• L4387Walking boot, non-pneumatic, off-the-shelf
• L4396Static or dynamic ankle-foot orthosis, prefab
• L4397Static or dynamic AFO, off-the-shelf
• L4398Foot drop splint, recumbent
• L0120Cervical, flexible, non-adjustable (foam collar)
• L0140Cervical, semi-rigid, adjustable (plastic collar)
• L0150Cervical, semi-rigid, adjustable molded chin cup
• L0160Cervical, semi-rigid, wire frame occipital/mandibular
• L0170Cervical, collar, molded to patient
• L0172Cervical, collar, semi-rigid thermoplastic foam, two-piece
• L0174Cervical, collar, semi-rigid, thermoplastic foam, two-piece with thoracic
• L0180Cervical, multiple post collar, occipital/mandibular supports
• L0190Cervical, multiple post collar, occipital/mandibular supports, adjustable
• L0200Cervical, multiple post collar, occipital/mandibular supports, adjustable, thoracic
• L0450TLSO, flexible, prefab
• L0456TLSO, flexible, custom fitted
• L0460TLSO, triplanar control, modular prefab
• L0480TLSO, triplanar control, custom fabricated
• L0625LSO, flexible, prefab
• L0627LSO, sagittal control, custom fitted
• L0631LSO, sagittal control, prefab
• L0637LSO, sagittal-coronal control, custom fitted
• L0642LSO, sagittal control, off-the-shelf
• L0648LSO, sagittal-coronal control, off-the-shelf
• L3000Foot insert, removable, formed to patient, UCB
• L3010Foot insert, removable, longitudinal arch
• L3020Foot insert, removable, longitudinal/metatarsal
• L3030Foot insert, removable, formed to patient, other
• L3031Foot, insert/plate, removable, addition to L3000–L3030
• E0100Cane, includes canes of all materials
• E0105Cane, quad or three-prong
• E0110Crutches, forearm, pair
• E0111Crutch, forearm, each
• E0112Crutches, underarm, wood, pair
• E0114Crutches, underarm, other than wood, pair
• E0116Crutch, underarm, other than wood, each
• E0118Crutch substitute, lower leg platform
• E0130Walker, rigid (pickup), adjustable or fixed height
• E0135Walker, folding (pickup), adjustable or fixed height
• E0141Walker, rigid, wheeled, adjustable or fixed height
• E0143Walker, folding, wheeled, adjustable or fixed height
• E0147Walker, heavy duty, multiple braking system
• E0148Walker, heavy duty, without braking, rigid or folding
• E0149Walker, heavy duty, wheeled
• E0154Platform attachment, walker, each
• E0155Wheel attachment, rigid pickup walker
• E0156Seat attachment, walker

Medicare DMEPOS accreditation and competitive bidding apply.

In-office injections

Confirm they bill what they already do. J-code leak to HOPD.

POS 11 vs 22.

• 20600Arthrocentesis, small joint
• 20604Arthrocentesis, small joint with US
• 20605Arthrocentesis, intermediate joint
• 20606Arthrocentesis, intermediate joint with US
• 20610Arthrocentesis, major joint
• 20611Arthrocentesis, major joint with US
• 20550Injection, tendon sheath / ligament
• 20551Injection, tendon origin/insertion
• 20552Injection, trigger point(s), 1–2 muscles
• 20553Injection, trigger point(s), 3+ muscles
• 27096SI joint injection with fluoro or CT
• 62321Cervical/thoracic epidural, with imaging
• 62323Lumbar/sacral epidural, with imaging
• 64483Transforaminal ESI, lumbar, single level
• 64484Transforaminal ESI, each additional level
• J3301Triamcinolone acetonide, 10 mg
• J1020Methylprednisolone, 20 mg
• J1030Methylprednisolone, 40 mg
• J1040Methylprednisolone, 80 mg
• J7321Hyaluronan, Hyalgan/Supartz, per dose
• J7323Hyaluronan, Euflexxa, per dose
• J7324Hyaluronan, Orthovisc, per dose
• J7325Hyaluronan, Synvisc/Synvisc-One, 1 mg
• J7326Hyaluronan, Gel-One, per dose
• J7327Hyaluronan, Monovisc, per dose
• J7328Hyaluronan, Gelsyn-3, 0.1 mg

EMG / NCS

Hand and spine often refer this out.

On group TIN vs neurology outside.

• 95885Needle EMG, each extremity, limited
• 95886Needle EMG, each extremity, complete
• 95887Needle EMG, non-extremity
• 95860Needle EMG, 1 extremity
• 95861Needle EMG, 2 extremities
• 95863Needle EMG, 3 extremities
• 95864Needle EMG, 4 extremities
• 95907NCS, 1–2 studies
• 95908NCS, 3–4 studies
• 95909NCS, 5–6 studies
• 95910NCS, 7–8 studies
• 95911NCS, 9–10 studies
• 95912NCS, 11–12 studies
• 95913NCS, 13 or more studies
• 95937Neuromuscular junction testing / H-reflex

ASC-eligible surgery (professional CPT, split by POS)

Same code, POS 24 = already in an ASC. POS 22 = HOPD leak. POS 21 + inpatient-only stay out.

Professional claims only. Drop CMS inpatient-only, hip fracture, most revisions.

• 27447Total knee arthroplasty
• 27446Unicompartmental knee
• 27130Total hip arthroplasty
• 23472Total shoulder arthroplasty
• 23470Shoulder hemiarthroplasty
• 23410Open rotator cuff, acute
• 23412Open rotator cuff, chronic
• 23420Open rotator cuff reconstruction
• 29806Shoulder arthroscopy, capsulorrhaphy
• 29807Shoulder arthroscopy, SLAP repair
• 29819Shoulder arthroscopy, remove loose/foreign body
• 29820Shoulder arthroscopy, partial synovectomy
• 29821Shoulder arthroscopy, complete synovectomy
• 29822Shoulder arthroscopy, limited debridement
• 29823Shoulder arthroscopy, extensive debridement
• 29824Shoulder arthroscopy, distal clavicle
• 29825Shoulder arthroscopy, lysis of adhesions
• 29826Shoulder arthroscopy, subacromial decompression
• 29827Shoulder arthroscopy, rotator cuff repair
• 29828Shoulder arthroscopy, biceps tenodesis
• 29870Knee arthroscopy, diagnostic
• 29871Knee arthroscopy, infection lavage
• 29873Knee arthroscopy, lateral release
• 29874Knee arthroscopy, remove loose/foreign body
• 29875Knee arthroscopy, limited synovectomy
• 29876Knee arthroscopy, major synovectomy
• 29877Knee arthroscopy, debridement/shaving
• 29879Knee arthroscopy, abrasion arthroplasty
• 29880Knee arthroscopy, meniscectomy medial AND lateral
• 29881Knee arthroscopy, meniscectomy medial OR lateral
• 29882Knee arthroscopy, meniscus repair medial OR lateral
• 29883Knee arthroscopy, meniscus repair medial AND lateral
• 29884Knee arthroscopy, lysis of adhesions
• 29888ACL reconstruction
• 29889PCL reconstruction
• 29848Endoscopic carpal tunnel
• 64721Open carpal tunnel
• 64718Ulnar nerve transposition at elbow
• 64719Ulnar nerve, wrist
• 26055Tendon sheath incision (trigger finger)
• 26160Excision of lesion tendon sheath (ganglion)
• 25000Incision, tendon sheath, wrist (DeQuervain)
• 25606Percutaneous skeletal fixation, distal radius
• 25607Open treatment extra-articular distal radius
• 25608Open treatment intra-articular distal radius, 2 fragments
• 25609Open treatment intra-articular distal radius, 3+ fragments
• 20680Removal of deep implant
• 29891Ankle arthroscopy, excision osteochondral
• 29892Ankle arthroscopy, repair osteochondral
• 29894Ankle arthroscopy, remove loose/foreign body
• 29895Ankle arthroscopy, partial synovectomy
• 29897Ankle arthroscopy, limited debridement
• 29898Ankle arthroscopy, extensive debridement
• 29899Ankle arthroscopy, arthrodesis
• 63030Lumbar laminotomy, single interspace
• 63042Lumbar laminotomy, re-exploration
• 63047Lumbar laminectomy, single segment
• 63048Lumbar laminectomy, each additional segment
• 22612Lumbar fusion, posterior, single level
• 22614Lumbar fusion, each additional level

Exclude 27236 / 27244 / 27245 (hip fracture) and CMS inpatient-only from applicable volume.