Thursday, September 22, 2016

CPT CODE 64483, 64479, 64484 - Anesthetic agent

CPT code and description


64479 - Injection, anesthetic agent and/or steroid, transforaminal epidural; Cervical or Thoracic, single level

64480 - Cervical or Thoracic, each additional level

64483 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level - average fee amount - $220 - $230

64484 – Lumbar or Sacral, each additional level

Billing and Coding Guidelines

 The CPT codes 64479-64484 (transforaminal epidurals) have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, file with modifier –50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier –LT or –RT.

Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.

Whether a transforaminal epidural injection is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

Whether a transforaminal epidural injection is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.


Explanation of Revision: Annual 2011 HCPCS Update. Revised descriptors for CPT codes 64479, 64480, 64483 and 64484 in LCD. The effective date of this revision is based on date of service.


For the medical record review component of the study, a random sample of 433 Medicare physician line item claims were selected from approximately 800,000 claims (amounting to $141 million in allowed physicians payments) consisting of all 2007 allowed physician services for transforaminal epidural injection CPT codes 64479 (Injection; anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level), 64480, (Injection; anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level), 64483 (Injection; anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level), and 64484 (Injection; anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level) for services billed in offices, Ambulatory Surgical Centers (ASCs), or hospital outpatient departments. The reviewers determined whether the service was adequately documented and medically necessary and whether the appropriate CPT code and modifier(s) were used.

The primary codes 64479, 64483, 64490 and 64493 are used for a single injection in the cervical/thoracic or lumbar/sacral areas of the spine, respectively. Each primary code has an associated add-on code, 64480, 64491, 64492 (cervical/thoracic) and 64484, 64494 and 64495 (lumbar/sacral) for use when injections are provided at multiple spinal levels. Unilateral injections are performed on one side of the joint level, while bilateral injections are performed on the right and left side of the joint level. The Centers for Medicare and Medicaid Services (CMS) requires physicians to indicate a bilateral injection by using billing modifier 50. Unilateral injections must be identified by an appropriate RT or LT.

Indications 

1. Pain associated with

Herpes Zoster and/or
Suspected radicular pain, based on radiation of pain along the dermatome (sensory distribution) of a nerve and/or

Neurogenic claudication and/or
Low back pain, NPRS = 3/10 (moderate to severe pain) associated with significant impairment of activities of daily living (ADLs) and one of the following:
a. substantial imaging abnormalityies such as a central disc herniation,
b. severe degenerative disc disease or central spinal stenosis.

2. Failure of four weeks (counting from onset of pain) of non-surgical, non-injection care, which includes appropriate oral medication(s) and physical therapy to the extent tolerated...

• Exceptions to the 4 week wait may include:
a. pain from Herpes Zoster
b. at least moderate pain with significant functional loss
at work or home.
c. severe pain unresponsive to outpatient medical management.
d. inability to tolerate non-surgical, non-injection care due to co-existing medical condition(s)
e. prior successful injections for same specific condition with relief of at least 3 months’ duration.

Procedure Requirements

1. An appropriately comprehensive evaluation of all potential contributing pain generators and treatment in accordance with an established and documented treatment plan.

2. Plain films to rule out red flag conditions may be appropriate if potential issues of trauma, osteomyelitis or malignancy are a concern.

3. Real-time imaging guidance, fluoroscopy or computed tomography, with the use of injectable radio-opaque contrast material is required for all steroid injections and all transforaminal injections. Its use is urged but not required for other epidural injections.

4. Contrast medium should be injected during epidural injection procedures unless patient has contraindication to injection. The reasons for not using contrast must be documented in the procedure report.

5. Films that adequately document final needle position and injectate flow must be retained and made available upon request.

6. For each session, no more than 80mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, 15 mg of dexamethasone or equivalent corticosteroid dosing may be used

7. When a diagnostic spinal nerve block is performed, post-block assessment of percentage pain relief must be documented.

8. Levels per session:

a. No more than two transforaminal injections may be performed at a single setting (e.g. single level bilaterally or two levels unilaterally)

b. One caudal or lumbar interlaminar injection per session and not in conjunction with a lumbar transforaminal injection.

9.Frequency:

a. No more than 3 epidurals may be performed in a 6-month period of time.

b. No more than 6 epidural injection sessions (therapeutic epidurals and/or diagnostic transforaminal injections) may be performed in a 12-month period of time regardless of the number of levels involved.

c. If a prior epidural provided no relief, a second epidural is allowed following reassessment of the patient and injection technique.

10. Local anesthesia or minimal conscious sedation may be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient.

Coverage Indications, Limitations, and/or Medical Necessity

    Epidural injections are used for the treatment of multiple different conditions in chronic and acute pain. Epidural injections may be used for therapeutic and/or diagnostic purposes. There are multiple approaches to epidural injections including caudal, translaminar, and transforaminal. These different approaches are used for different but specific indications. (In general it is felt that the closer the injection can be placed to the pathology the more likely to achieve a beneficial response). Correct placement is best confirmed by using fluoroscopic guidance and injection of contrast.

    Epidural injections and/or infusions will be considered medically reasonable and necessary for the following conditions:

    1. Management of pain caused by intervertebral disc disease with or without myelopathy.

    2. Management of pain caused by spinal stenosis.

    3. Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome.

    4. Management of intractable pain due to complex regional pain syndrome.

    5. Management of intractable pain due to post herpetic neuralgia and acute herpes zoster.

    6. Management of intractable pain due to traumatic neuropathy of the spinal nerve roots.

    7. Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or metabolic).

    8. Management of severe, intractable pain in patients with advanced stages of cancer with estimated life expectancy of 4 months or less.

    9. Management of pain caused by radiculitis (inflammation of the nerve roots).

    Low back pain may also be produced by “Myofascial Pain Syndrome” in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation.

    Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary.



CPT/HCPCS Codes
 
    For Single Injection     Group 1 Codes
    62310 Inject spine cerv/thoracic
    62311 Inject spine lumbar/sacral

    For Transforaminal Epidural Injections     Group 2 Codes

    64479 Inj foramen epidural c/t
    64480 Inj foramen epidural add-on
    64483 Inj foramen epidural l/s
    64484 Inj foramen epidural add-on


Epidural Injections

a. Lumbar–Transforaminal (CPT codes 64479, 64480, 64483 and 64484)

** Medicare does not have a National Coverage Determination (NCD) for the specific types of epidural injections for pain listed above.

** Local Coverage Determinations (LCDs) which address lumbar injections exist and compliance with these LCDs is required where applicable. For state-specific LCD, refer to the LCD Availability Grid (Attachment A).

Guideline 8 (Specific Type of Injections)

** Changed title to “Epidural Injections”

** Reformatted/re-organized to the following new sections:

o Guideline 8.a (Epidural Injections/Lumbar – Transforaminal (CPT codes 64479, 64480, 64483 & 64484)

o Guideline 8.b (Epidural Injection/Other Epidural Injections

o Guideline 9.a [Paravertebral Facet Joint/Nerve Blocks and Nerve Denervation/Diagnostic and Therapeutic (CPT codes 64490, 64491, 64492, 64493, 64494 & 64495)]

o Guideline 9.b [ Paravertebral Facet Joint /Paravertebral Joint/Nerve Denervation (CPT codes 64633, 64634, 64635, 64636 & 64999)]

o Guideline 10 [Trigger Point Injections (CPT Codes 20552 & 20553)]

o Guideline 11 [Sacroiliac (SI) Joint Injections (CPT codes 27096 & G0260)]

o Guideline 12 [Injections of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels and Morton’s Neuroma (CPT codes 20526, 20550, 20551,20612 & 28899)]

** Added “Injection, anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton's neuroma) (old Guideline 10)

** Updated title to Injections of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels and Morton’s Neuroma (CPT codes 20526, 20550, 20551,20612 & 28899)


Introduction/Injection of Anesthetic Agent (Nerve Bock), Diagnostic or Therapeutic


Fluoroscopic and computed tomographic (CT) guidance will be bundled into the 2011 editorially revised transforaminal epidural anesthetic and/or steroid injection codes 64479, 64480, 64483, 64484, as either fluoroscopic or CT guidance is required to perform these injections.

Note that ultrasound guidance is not included in the descriptor for codes 64479-64484; therefore, if ultrasound-guidance is used in place of fluoroscopic or CT guidance, one of the newly created Category III bundled ultrasound-guided transforaminal epidural injection procedure codes, 0228T-  0231T, should be reported as of January 1, 2011. Similar to the fluoroscopy and CT-guided paravertebral facet joint injection codes created in 2010, these codes are reported per level. If multiple injections are performed at a single level on the same side, the code should only be reported once.


Transforaminal Epidural Injection of Anesthetic Agent and/or Steroid (includes fluoroscopy or CT imaging guidance)*

Fluoroscopic or CT Guidance Ultrasound Guidance

Lumbar or Sacral 64483 0230T 


Bundling Issues with ESI Procedures

The 64479 code is Unbundled in the CCI Edits from code 62310 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Code 64483 is Unbundled from code 62311 (Regular ESI procedure) in the Mutually Exclusive Table of the CCI Unbundling Material. Therefore, for Medicare and other payors who observe the CCI edits, these codes are not billable together when they are performed at the SAME spinal area. If the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L4-5, the procedures are Unbundled and not both billable – only code 62311 would be billable in that case. However, if the physician does an ESI (62311) at level L5 and a Transforaminal ESI (64483) at area L3-4, then it is allowable to put a -59 Modifier on the 64483 code and bill it as the 2nd code following the 62311 ESI code on the claim form.


Coverage Indications, Limitations, and/or Medical Necessity

    Epidural injections are used for the treatment of multiple different conditions in chronic and acute pain. Epidural injections may be used for therapeutic and/or diagnostic purposes. There are multiple approaches to epidural injections including caudal, translaminar, and transforaminal. These different approaches are used for different but specific indications. (In general it is felt that the closer the injection can be placed to the pathology the more likely to achieve a beneficial response). Correct placement is best confirmed by using fluoroscopic guidance and injection of contrast.

    Epidural injections and/or infusions will be considered medically reasonable and necessary for the following conditions:

    1. Management of pain caused by intervertebral disc disease with or without myelopathy.

    2. Management of pain caused by spinal stenosis.

    3. Management of intractable radicular pain due to postlaminectomy syndrome/failed back syndrome.

    4. Management of intractable pain due to complex regional pain syndrome.

    5. Management of intractable pain due to post herpetic neuralgia and acute herpes zoster.

    6. Management of intractable pain due to traumatic neuropathy of the spinal nerve roots.

    7. Management of intractable and severe pain secondary to neuropathy from other causes (e.g., diabetic or metabolic).

    8. Management of severe, intractable pain in patients with advanced stages of cancer with estimated life expectancy of 4 months or less.

    9. Management of pain caused by radiculitis (inflammation of the nerve roots).

    Low back pain may also be produced by “Myofascial Pain Syndrome” in which case there is not nerve root pathology and epidural injections are not reasonable and necessary. If there is a doubt in the differential diagnosis, the diagnosis of radiculopathy can be confirmed by an EMG/nerve conduction/small fiber testing or appropriate radiological study. Degenerative Disk Disease without root compression has been shown to be a significant cause of low back and/or radicular pain; some patients will respond to Epidural Steroid Injection in this situation.

    Epidural injections, with the exception of interlaminar injections, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary.



Study Methodology

For the medical record review component of the study, a random sample of 433 Medicare physician line item claims were selected from approximately 800,000 claims (amounting to $141 million in allowed physicians payments) consisting of all 2007 allowed physician services for transforaminal epidural injection CPT codes 64479 (Injection; anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level), 64480, (Injection; anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level), 64483 (Injection; anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level), and 64484 (Injection; anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level) for services billed in offices, Ambulatory Surgical Centers (ASCs), or hospital outpatient departments. The reviewers determined whether the service was adequately documented and medically necessary and whether the appropriate CPT code and modifier(s) were used.

LCD number L27512 requires the following specific documentation requirements for Transforaminal Epidural and Paravertebral Facet Joint Injections:

 The patient’s medical record must indicate the medical necessity of services for each date of service billed and the frequency. This must include the patient’s history (complete pain history and inclusion of failed conservative measures), physical examination and adequate follow-up documentation specific to patient response to the nerve blocks.

• The pre-procedure evaluation leading to suspicion of the presence of the facet joint pathology must be explicitly documented in the patient’s medical record along with the post procedure conclusions or the reasoning behind the need for a transforaminal epidural injection must be explicitly documented in the patient’s medical record along with post procedure conclusions. Alldocumentation must be available to Medicare upon request.

• The primary codes 64479, 64483, 64490 and 64493 are used for a single injection in the cervical/thoracic or lumbar/sacral areas of the spine, respectively. Each primary code has an associated add-on code, 64480, 64491, 64492 (cervical/thoracic) and 64484, 64494 and 64495 (lumbar/sacral) for use when injections are provided at multiple spinal levels. Unilateral injections are performed on one side of the joint level, while bilateral injections are performed on the right and left side of the joint level. The Centers for Medicare and Medicaid Services (CMS) requires physicians to indicate a bilateral injection by using billing modifier 50. Unilateral injections must be identified by an appropriate RT or LT.

Medicare payment status

Medicare Part B physician payments for transforaminal epidural injections increased from $57 milion in 2003 to $141 milion to 2007. This represents an increase of almost 150 percent.

Transforaminal epidural injections are a type of inter ventiona i pain management technique used to diagnose or treat pain. Transforaminal epidural injections may be used to treat pain that starts in the back and radiates down the leg, such as that from a herniated disc pressing on a nerve.

Two primary codes, 64479 and 64483, are used to bil a single injection in the cervical/thoracic or lumbar/sacral areas of the spine, respectively. Each primary code has an associated add-on code for use when injections are provided at multiple spinal levels.

Medicare Part B contractors are responsible for implementing program safeguards to reduce payment error. To safeguard payments, contractors may create local coverage determinations (LCD), implement electronic edits (hereinafter referred to as edits), or conduct medical review.

We conducted a medical record review of a stratified random sample of 433 transforaminal epidural injection services performed in 2007. In addition, we reviewed documents and conducted structured interviews with contractor staff about program safeguards for transforaminal epidural injections.
Providers must use uniform procedure codes to report all services, including transforaminal injection services.19 The CPT codes and descriptions for transforaminal epidural injections are listed in Table 1,0 Two primary codes, 64479 and 64483, are used for a single injection in the cervical/thoracic or lumbar/sacral regions of the spine, respectively. Each primary code has an associated add-on code for use when more than one level is injected. The add -on codes are 64480 (cervical/thoracic) and 64484 (lumbar/sacral).

Reimbursements for primary codes 64479 and 64483 are higher because they include presurgical and postsurgical expenses related to the procedure that the add-on codes, 64480 and 64484, do not. Physician payments also vary based on the modifiers23 biled with the CPT. For example, bilateral transforaminal epidural injections, which are performed on both the right side and the left side of a vertebral level, should be biled using modifier 50, which increases reimbursement to 150 percent of the base rate.

Sample Selection

The population from which we sampled consisted of all 2007 allowed physician servces in the NCH physician/supplier file for transforaminal epidural injection CPT codes 64479,64480,64483, and 64484.

We restricted our population to Medicare physician services biled in offces, ASCs, or hospital outpatient departments as 99 percent oftransforaminal injection servces were biled in these settings,s1 We excluded claims that were less than $15 to avoid performing medical record review on low dollar claims,s2 The population consisted of approximately 800,000 claims and $141 milion in allowed physician payments.

From this population, we selected a stratified random sample of 440 Medicare physician line item claims,33 stratifying by place of service reported on the claim (offce or facility) and the Medicare-allowed amount. See Appendix A for further details on the sample selection, data collection, and data analysis.

Detailed Methodology

Sample Selection

The population from which we sampled consisted of all the allowed physician services in the Centers for Medicare & Medicaid Services National Claims History (NCH) file for Current Procedural Terminology (CPT) codes 64479, 64480, 64483, and 64484 performed in 2007. We stratified the sample by place of service and dollar amount. We stratified by place of service to compare rates by setting (office and facility).

Previous work found significantly different error rates between these two settings. We further stratified by the dollar amount of the claims to improve our ability to provide an overall estimate of the dollars in error with an acceptable confidence interval. We randomly selected 110 claims from each stratum for review, for a total of 440 claims. Table A I shows the sampling stratification and population of claims for CPT codes 64479, 64480, 64483, and 64484.


Modifier Reporting Examples

The following examples are provided to assist ASCs in correctly reporting services:

Bilateral Procedures

Bilateral procedures should be reported with modifier -50.

Example: Bilateral lumbar transforaminal epidural injections are administered. The correct way to bill this bilateral procedure is CPT code

64483 50. Do not bill CPT code
64483 and CPT code
64483 LT or
CPT code 64483 RT and CPT code 64483 LT.
    
    For procedures codes: 62310, 62311, 64479, 64480, 64483 and 64484

    A52.15 Late syphilitic neuropathy
    B02.0 Zoster encephalitis
    B02.23 Postherpetic polyneuropathy
    B02.24 Postherpetic myelitis
    B02.29 Other postherpetic nervous system involvement
    C30.0 Malignant neoplasm of nasal cavity
    C30.1 Malignant neoplasm of middle ear
    C31.0 Malignant neoplasm of maxillary sinus
    C31.1 Malignant neoplasm of ethmoidal sinus
    C31.2 Malignant neoplasm of frontal sinus
    C31.3 Malignant neoplasm of sphenoid sinus
    C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
    C31.9 Malignant neoplasm of accessory sinus, unspecified
    C32.0 Malignant neoplasm of glottis
    C32.1 Malignant neoplasm of supraglottis
    C32.2 Malignant neoplasm of subglottis
    C32.3 Malignant neoplasm of laryngeal cartilage
    C32.8 Malignant neoplasm of overlapping sites of larynx
    C32.9 Malignant neoplasm of larynx, unspecified
    C33 Malignant neoplasm of trachea
    C34.00 Malignant neoplasm of unspecified main bronchus
    C34.01 Malignant neoplasm of right main bronchus
    C34.02 Malignant neoplasm of left main bronchus
    C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
    C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
    C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
    C34.2 Malignant neoplasm of middle lobe, bronchus or lung
    C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
    C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
    C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
    C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
    C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
    C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
    C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
    C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
    C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
    C37 Malignant neoplasm of thymus
    C38.0 Malignant neoplasm of heart
    C38.1 Malignant neoplasm of anterior mediastinum
    C38.2 Malignant neoplasm of posterior mediastinum
    C38.3 Malignant neoplasm of mediastinum, part unspecified
    C38.4 Malignant neoplasm of pleura
    C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
    C39.0 Malignant neoplasm of upper respiratory tract, part unspecified
    C39.9 Malignant neoplasm of lower respiratory tract, part unspecified
    C40.00 Malignant neoplasm of scapula and long bones of unspecified upper limb
    C40.01 Malignant neoplasm of scapula and long bones of right upper limb
    C40.02 Malignant neoplasm of scapula and long bones of left upper limb
    C40.10 Malignant neoplasm of short bones of unspecified upper limb
    C40.11 Malignant neoplasm of short bones of right upper limb
    C40.12 Malignant neoplasm of short bones of left upper limb
    C40.20 Malignant neoplasm of long bones of unspecified lower limb
    C40.21 Malignant neoplasm of long bones of right lower limb
    C40.22 Malignant neoplasm of long bones of left lower limb
    C40.30 Malignant neoplasm of short bones of unspecified lower limb
    C40.31 Malignant neoplasm of short bones of right lower limb
    C40.32 Malignant neoplasm of short bones of left lower limb
    C40.80 Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb
    C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb
    C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
    C40.90 Malignant neoplasm of unspecified bones and articular cartilage of unspecified limb
    C40.91 Malignant neoplasm of unspecified bones and articular cartilage of right limb
    C40.92 Malignant neoplasm of unspecified bones and articular cartilage of left limb
    C41.0 Malignant neoplasm of bones of skull and face
    C41.1 Malignant neoplasm of mandible
    C41.2 Malignant neoplasm of vertebral column
    C41.3 Malignant neoplasm of ribs, sternum and clavicle
    C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx
    C41.9 Malignant neoplasm of bone and articular cartilage, unspecified
    C43.0 Malignant melanoma of lip
    C43.10 Malignant melanoma of unspecified eyelid, including canthus
    C43.11 Malignant melanoma of right eyelid, including canthus
    C43.12 Malignant melanoma of left eyelid, including canthus
    C43.20 Malignant melanoma of unspecified ear and external auricular canal
    C43.21 Malignant melanoma of right ear and external auricular canal
    C43.22 Malignant melanoma of left ear and external auricular canal
    C43.30 Malignant melanoma of unspecified part of face
    C43.31 Malignant melanoma of nose
    C43.39 Malignant melanoma of other parts of face
    C43.4 Malignant melanoma of scalp and neck
    C43.51 Malignant melanoma of anal skin
    C43.52 Malignant melanoma of skin of breast
    C43.59 Malignant melanoma of other part of trunk
    C43.60 Malignant melanoma of unspecified upper limb, including shoulder
    C43.61 Malignant melanoma of right upper limb, including shoulder
    C43.62 Malignant melanoma of left upper limb, including shoulder
    C43.70 Malignant melanoma of unspecified lower limb, including hip
    C43.71 Malignant melanoma of right lower limb, including hip
    C43.72 Malignant melanoma of left lower limb, including hip
    C43.8 Malignant melanoma of overlapping sites of skin
    C43.9 Malignant melanoma of skin, unspecified
    C44.00 Unspecified malignant neoplasm of skin of lip
    C44.01 Basal cell carcinoma of skin of lip
    C44.02 Squamous cell carcinoma of skin of lip
    C44.09 Other specified malignant neoplasm of skin of lip
    C44.101 Unspecified malignant neoplasm of skin of unspecified eyelid, including canthus
    C44.102 Unspecified malignant neoplasm of skin of right eyelid, including canthus
    C44.109 Unspecified malignant neoplasm of skin of left eyelid, including canthus
    C44.111 Basal cell carcinoma of skin of unspecified eyelid, including canthus
    C44.112 Basal cell carcinoma of skin of right eyelid, including canthus
    C44.119 Basal cell carcinoma of skin of left eyelid, including canthus
    C44.121 Squamous cell carcinoma of skin of unspecified eyelid, including canthus
    C44.122 Squamous cell carcinoma of skin of right eyelid, including canthus
    C44.129 Squamous cell carcinoma of skin of left eyelid, including canthus
    C44.191 Other specified malignant neoplasm of skin of unspecified eyelid, including canthus
    C44.192 Other specified malignant neoplasm of skin of right eyelid, including canthus
    C44.199 Other specified malignant neoplasm of skin of left eyelid, including canthus
    C44.201 Unspecified malignant neoplasm of skin of unspecified ear and 

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