ࡱ> [^XYZ bjbj خee<<<<<PPP8,Px<$P0#(X#X#X#%%%+;-;-;-;-;-;-;$>NAQ;<%%%"%%Q;<<X#X#:2<`7`7`7%@<X#<X#+;`7%+;`7`799X#YjG+9;H<0x<9,A1A99JA<3:%%`7%%%%%Q;Q;`7%%%x<%%%%A%%%%%%%%% :  Complete this form if you received the NCCT mailing sent on April 16, 2012. When completing the form: Include all payer volume (Medicare, Medicaid, commercial, self-pay) for the previous 12 months Put N/A in the volume column if the procedure is not performed at your facility Return one form for each facility (do not combine facility data) Return the completed form by Tuesday, May 15, 2012 Email the completed form to: HYPERLINK "mailto:PremeraNCCT@premera.com"PremeraNCCT@premera.com or fax it to: 425-918-5185 Attn: PIMS For questions about this form or NCCT, call Physician and Provider Relations at 877-342-5258, option 4. Location Name:  FORMTEXT       Address:  FORMTEXT       Tax ID:  FORMTEXT       Contact name and phone number:  FORMTEXT       Inpatient Treatment CategoriesMS-DRGICD 9VolumeBariatric Surgery - Laparoscopic Gastric Bypass621 FORMTEXT      Cardiac Angioplasty - w/ Drug Eluting Stent247 FORMTEXT      Cardiac Defibrillator Implant w/o Cardiac Catheterization227 FORMTEXT      Coronary Bypass (CABG) w/o Cardiac Catheterization236 FORMTEXT      C-Section Delivery766 + 795 FORMTEXT      Vaginal Delivery775 + 795 FORMTEXT      Hip Replacement47081.51, 81.52 FORMTEXT      Hysterectomy743 FORMTEXT      Knee Replacement47081.54 FORMTEXT      Laminectomy - Inpatient491 FORMTEXT      Spinal Fusion (Anterior)473 FORMTEXT      Spinal Fusion (Posterior)460 FORMTEXT      Removal of Plaque Build-Up in the Major Neck (Carotid) Arteries39 FORMTEXT      Revision of Total Hip or Total Knee Replacement468 FORMTEXT      Removal of Prostate Gland and Surrounding Tissue708 FORMTEXT      Partial or Total Removal of Thyroid Gland627 FORMTEXT       Outpatient Treatment CategoriesCPT CodeVolumeACL Repair by Arthroscopy 29888 FORMTEXT      Back Surgery - Laminectomy 63030, 63047 FORMTEXT      Bariatric Surgery (Lap Band)43770 FORMTEXT      Bladder Repair For Incontinence (Sling)57288 FORMTEXT      Breast Biopsy Percutaneous w/Imaging19102 FORMTEXT      Breast Biopsy w/Device 19103 FORMTEXT      Breast Lumpectomy19301 FORMTEXT      Bunionectomy28296, 28292 FORMTEXT      Hammertoe Correction28285, 28270 FORMTEXT      Carpal Tunnel 64721 FORMTEXT      Cataract Removal 66984 FORMTEXT      Dilation & Curettage - D&C58120 FORMTEXT      Hernia Inguinal Repair (Age 5+)49505 FORMTEXT      Knee Arthroscopy with Cartilage Repair 29877, 29880, 29881, 29882 FORMTEXT      Laparoscopic Gall Bladder Removal 47562, 47563 FORMTEXT      Laparoscopic Removal of Ovaries and/or Fallopian Tubes58661 FORMTEXT      Laparoscopic Tubal Block or Tubal Ligation 58671 FORMTEXT      Left Heart Catheterization 93510, 93452, 93458, 93459 FORMTEXT      Lithotripsy - Fragmenting of Kidney Stones 50590 FORMTEXT      Nasal/Sinus - Corrective Surgery - Septoplasty30520 FORMTEXT      Nasal/Sinus - Endoscopy - Sinus Surgery31255, 31237, 31256, 31267, 31276 FORMTEXT      Shoulder Arthroscopy 29826, 29806, 29807, 29822, 29823, 29824 FORMTEXT      Shoulder Arthroscopy with Rotator Cuff Repair 29827 FORMTEXT      Tonsillectomy and/or Adenoidectomy, Under Age 1242820, 42825, 42830 FORMTEXT      Tonsillectomy and Adenoidectomy, Over Age 1242821, 42826, 42831 FORMTEXT      Tympanostomy and Myringotomy69420, 69421, 69433, 69436 FORMTEXT      Upper GI Endoscopy 43235 FORMTEXT      Upper GI Endoscopy with Biopsy 43239 FORMTEXT      Bronchoscopy31622, 31623, 31624, 31625, 31628, 31629 FORMTEXT      Urethra and Bladder Scope52000 FORMTEXT      Colonoscopy with Removal of Lesion(s)45385, 45383, 45384 FORMTEXT      Colonoscopy with Biopsy 45380 FORMTEXT      Screening Colonoscopy 45378 FORMTEXT      Hysteroscopy with Removal of Lesion(s) or Uterine Lining 58563 FORMTEXT      Uterine Tissue Sample (Biopsy)58558 FORMTEXT      Repair of Umbilical Hernia (Age 5+)49585 FORMTEXT      Spinal Fusion of Neck - Front22554 FORMTEXT      Bladder Scope with Stent52332 FORMTEXT       Diagnostic Treatment CategoriesCPT CodeVolumeCT Angiography, Abdomen w/o & w/ contrast74175 FORMTEXT      CT Angiography, Head w/o & w/ contrast70496 FORMTEXT      CT Angiography, Pelvis w/o & w/ contrast72191 FORMTEXTNghi  Z [ x  zzh`\`I$hshs0JCJOJQJ^JaJh jh U#hshsCJOJQJ\^JaJ#hnh=5CJOJQJ^JaJ#hnhs5CJOJQJ^JaJ#hsh=CJOJQJ\^JaJ hshGCJOJQJ^JaJhGCJOJQJ^JaJh/RCJOJQJ^JaJhsCJOJQJ^JaJ hsh=CJOJQJ^JaJhqUhi [ , .  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lBa_pyt(((^(p(~(xggg$d$Ifa$gd: dxgdM|kdQ$$IflF4&"*FAfxfv t/*6    44 lBa_pytp(~((((((())) )d)f)z)|)~)))))˶ra˶Ira/jTh;Fh CJOJQJU^JaJ!hMhMB*CJPJaJph4jh;FhGCJOJQJU^JaJmHnHu/jSh;Fh CJOJQJU^JaJ h;FhGCJOJQJ^JaJ)jh;Fh CJOJQJU^JaJ$hMhMCJOJPJQJ^JaJ h;FhM3hMhM5B*CJOJPJQJ\^JaJph~(((()m___d$Ifgd: kdR$$Ifl4,F4&0*FAFxf  t    44 lBa_pyt) )X)d))vvvd$Ifgd: {kdT$$IflF4&0*FAfxf t    44 lBa_pyt))))vvvd$Ifgd: {kdXU$$IflF4&0*FAfxf t    44 lBa_pyt))))*PnpŴngŴOngŴ/j\Wh;Fh CJOJQJU^JaJ h;FhM!hMhMB*CJPJaJph4jh;FhGCJOJQJU^JaJmHnHu/j'Vh;Fh CJOJQJU^JaJU h;FhGCJOJQJ^JaJ)jh;Fh CJOJQJU^JaJ$hMhMCJOJPJQJ^JaJ$hhMCJOJPJQJ^JaJ      Mammogram, Analog Unilateral77055 (77051) FORMTEXT      Mammogram, Analog Bilateral77056 (77051) FORMTEXT      Mammogram, Analog Bilateral 2 Views77057 (77052) FORMTEXT      Mammogram, Digital Screening BilateralG0202 (77052) FORMTEXT      Mammogram, Digital Diagnostic BilateralG0204 (77051) FORMTEXT      Mammogram, Digital Diagnostic UnilateralG0206 (77051) FORMTEXT      CT Scan Abdomen w/o contrast74150 FORMTEXT      CT Scan Abdomen w/ contrast74160 FORMTEXT      CT Scan Abdomen w/o & w/ contrast74170 FORMTEXT      CT Scan Head/Brain w/o contrast70450 FORMTEXT      CT Scan Head/Brain w/ contrast70460 FORMTEXT      CT Scan Head/Brain w/o & w/ contrast70470 FORMTEXT      CT Scan Pelvis w/o contrast72192 FORMTEXT      CT Scan Pelvis w/contrast72193 FORMTEXT      CT Scan Pelvis w/o & w/ contrast72194 FORMTEXT      MRI Brain w/o contrast70551 FORMTEXT      MRI Brain w/ contrast70552 FORMTEXT      MRI Brain w/o & w/ contrast70553 FORMTEXT      MRI Lumbar Spine w/ contrast72149 FORMTEXT      MRI Lumbar Spine w/o contrast72148 FORMTEXT      MRI Lumbar Spine w/o & w/ contrast72158 FORMTEXT      MRI Neck Spine w/ contrast72142 FORMTEXT      MRI Neck Spine w/o contrast72141 FORMTEXT      MRI Neck Spine w/o & w/ contrast72156 FORMTEXT      MRI Orbit/Face/Neck w/ contrast70542 FORMTEXT      MRI Orbit/Face/Neck w/o contrast70540 FORMTEXT      MRI Orbit/Face/Neck w/o & w/ contrast70543 FORMTEXT      MRI Spine w/o contrast72146 FORMTEXT      MRI Spine w/ contrast72147 FORMTEXT      MRI Spine w/o & w/ contrast72157 FORMTEXT      MRI Lower Limb w/o contrast73718 FORMTEXT      MRI Lower Limb w/ contrast73719 FORMTEXT      MRI Lower Limb w/o & w/ contrast73720 FORMTEXT      MRI Upper Limb (Other Than Joint) w/o contrast73218 FORMTEXT      MRI Upper Limb (Other Than Joint) w/ contrast73219 FORMTEXT      MRI Upper Limb (Other Than Joint) w/o contrast & w/contrast73220 FORMTEXT      MRI Lower Limb with Joint w/o contrast73721 FORMTEXT      MRI Lower Limb with Joint w/ contrast73722 FORMTEXT      MRI Lower Limb with Joint w/o & w/ contrast73723 FORMTEXT      CT Scan of Mouth, Jaw, and Neck w/o contrast70486 FORMTEXT      CT Scan of Mouth, Jaw, and Neck w/ contrast70487 FORMTEXT      CT Scan of Mouth, Jaw, and Neck w/o & w/ contrast70488 FORMTEXT      CT Scan Chest w/o contrast71250 FORMTEXT      CT Scan Chest w/ contrast71260 FORMTEXT      CT Scan Chest w/o & w/ contrast71270 FORMTEXT      CT Scan of Lumbar Lower Spine w/o contrast72131 FORMTEXT      CT Scan of Lumbar Lower Spine w/ contrast72132 FORMTEXT      CT Scan of Lumbar Lower Spine w/o & w/ contrast72133 FORMTEXT      Bone Density study of Spine or Pelvis77080 FORMTEXT      Ultrasound of Head and Neck (e.g. Thyroid, Parathyroid, Parotid)76536 FORMTEXT      Ultrasound of Breast(s)76645 FORMTEXT      Ultrasound of Abdomen76700 FORMTEXT      Ultrasound of Pelvis 76856 FORMTEXT      Bone and Joint Scan of Whole Body78306 FORMTEXT      PET Scan Image from Skull base to Mid-Thigh78815 FORMTEXT      PET Scan Image of Whole Body78816 FORMTEXT           National Consumer Cost Tool (NCCT) Procedure Volume Data Form Page  PAGE 1 of  NUMPAGES 3 019183 (04-16-2012) An Independent Licensee of the Blue Cross Blue Shield Association Pnvvvd$Ifgd: {kdV$$IflF4&0*FAfxf t    44 lBa_pytvvvd$Ifgd: {kdW$$IflF4&0*FAfxf t    44 lBa_pytJ`~*ҷҦ|iX@ҷҦ|iX/jYh;Fh CJOJQJU^JaJ 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