EFfective for Dates of Service April 1, 2013 - BlueCross BlueShield ...

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0019T 0019T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0042T 0042T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0051T 0051T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0052T 0052T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0053T 0053T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0054T 0054T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0055T 0055T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0058T 0058T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0059T 0059T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0071T 0071T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0072T 0072T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0073T 0073T A 3 XXX 0 0 0 0 0 0 0 0.00 11.91 11.91 0.01 11.92 11.92 10.700 10.700
0075T 0075T C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0075T 26 0075T26 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0075T TC 0075TTC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0076T 0076T C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0076T 26 0076T26 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0076T TC 0076TTC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0078T 0078T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0079T 0079T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0080T 0080T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
1 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0081T 0081T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0085T 0085T N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0092T 0092T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0095T 0095T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0098T 0098T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0099T 0099T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0100T 0100T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0101T 0101T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0102T 0102T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0103T 0103T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0106T 0106T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0107T 0107T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0108T 0108T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0109T 0109T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0110T 0110T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0111T 0111T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0123T 0123T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0124T 0124T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0126T 0126T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0159T 0159T C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0159T 26 0159T26 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
2 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0159T TC 0159TTC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0163T 0163T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0164T 0164T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0165T 0165T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0169T 0169T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0171T 0171T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0172T 0172T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0174T 0174T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0175T 0175T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0178T 0178T C 4 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0179T 0179T C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0180T 0180T C 2 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0181T 0181T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0182T 0182T C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0182T 26 0182T26 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0182T TC 0182TTC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0183T 0183T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0184T 0184T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0185T 0185T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0186T 0186T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0188T 0188T N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
3 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0189T 0189T N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0190T 0190T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0191T 0191T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0192T 0192T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0195T 0195T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0196T 0196T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0197T 0197T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0198T 0198T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0199T 0199T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0200T 0200T C 0 XXX 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0201T 0201T C 0 XXX 0 0 0 0 2 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0202T 0202T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0205T 0205T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0206T 0206T C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0207T 0207T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0208T 0208T C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0209T 0209T C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0210T 0210T C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0211T 0211T C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0212T 0212T C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0213T 0213T C 0 XXX 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
4 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0214T 0214T C 0 ZZZ 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0215T 0215T C 0 ZZZ 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0216T 0216T C 0 XXX 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0217T 0217T C 0 ZZZ 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0218T 0218T C 0 ZZZ 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0219T 0219T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0220T 0220T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0221T 0221T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0222T 0222T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0223T 0223T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0224T 0224T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0225T 0225T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0226T 0226T C 0 XXX 0 0 0 0 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0227T 0227T C 0 XXX 0 0 0 0 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0228T 0228T C 0 XXX 0 0 0 0 1 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0229T 0229T C 0 XXX 0 0 0 0 1 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0230T 0230T C 0 XXX 0 0 0 0 1 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0231T 0231T C 0 XXX 0 0 0 0 1 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0232T 0232T C 0 XXX 0 0 0 0 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0233T 0233T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0234T 0234T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
5 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0235T 0235T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0236T 0236T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0237T 0237T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0238T 0238T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0239T 0239T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0240T 0240T C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0240T 26 0240T26 C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0240T TC 0240TTC C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0241T 0241T C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0241T 26 0241T26 C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0241T TC 0241TTC C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0243T 0243T C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0243T 26 0243T26 C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0243T TC 0243TTC C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0244T 0244T C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0244T 26 0244T26 C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0244T TC 0244TTC C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0245T 0245T C 0 YYY 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0246T 0246T C 0 YYY 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0247T 0247T C 0 YYY 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0248T 0248T C 0 YYY 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
6 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0249T 0249T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0253T 0253T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0254T 0254T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0255T 0255T C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0255T 26 0255T26 C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0255T TC 0255TTC C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0260T 0260T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0261T 0261T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0262T 0262T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0263T 0263T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0264T 0264T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0265T 0265T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0266T 0266T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0267T 0267T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0268T 0268T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0269T 0269T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0270T 0270T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0271T 0271T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0272T 0272T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0273T 0273T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0274T 0274T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
7 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0275T 0275T C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0278T 0278T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0281T 0281T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0282T 0282T C 0 XXX 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0283T 0283T C 0 XXX 0 0 0 0 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0284T 0284T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0285T 0285T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0286T 0286T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0287T 0287T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0288T 0288T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0289T 0289T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0290T 0290T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0291T 0291T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0292T 0292T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0293T 0293T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0294T 0294T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0295T 0295T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0296T 0296T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0297T 0297T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0298T 0298T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0299T 0299T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
8 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0300T 0300T C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0301T 0301T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0302T 0302T C 0 YYY 0 0 0 2 0 1 2 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0303T 0303T C 0 YYY 0 0 0 2 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0304T 0304T C 0 YYY 0 0 0 2 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0305T 0305T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0306T 0306T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0307T 0307T C 0 YYY 0 0 0 2 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0308T 0308T C 0 YYY 0 0 0 2 1 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0309T 0309T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0310T 0310T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0311T 0311T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0312T 0312T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0313T 0313T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0314T 0314T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0315T 0315T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0316T 0316T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0317T 0317T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0318T 0318T C 0 YYY 0 0 0 2 0 0 2 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0319T 0319T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0320T 0320T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
9 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
0321T 0321T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0322T 0322T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0323T 0323T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0324T 0324T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0325T 0325T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0326T 0326T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0327T 0327T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
0328T 0328T C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
10021 10021 A 0 XXX 0 0 0 0 0 0 0 1.27 3.04 0.59 0.22 4.53 2.08 4.115 1.915
10022 10022 A 0 XXX 0 0 0 0 0 0 0 1.27 2.74 0.49 0.14 4.15 1.90 3.804 1.783
10040 10040 A 0 010 0 1 0 2 0 1 0 1.21 1.64 1.24 0.18 3.03 2.63 2.777 2.418
10060 10060 A 0 010 0 1 0 2 0 1 0 1.22 2.13 1.53 0.12 3.47 2.87 3.196 2.657
10061 10061 A 0 010 0 1 0 2 0 1 0 2.45 3.37 2.58 0.30 6.12 5.33 5.633 4.924
10080 10080 A 0 010 0 1 0 2 0 1 0 1.22 4.03 1.68 0.20 5.45 3.10 4.944 2.833
10081 10081 A 0 010 0 1 0 2 0 1 0 2.50 5.29 2.20 0.45 8.24 5.15 7.486 4.711
10120 10120 A 0 010 0 1 0 2 0 1 0 1.22 3.21 1.72 0.16 4.59 3.10 4.186 2.848
10121 10121 A 0 010 0 1 0 2 0 1 0 2.74 5.15 2.40 0.41 8.30 5.55 7.579 5.110
10140 10140 A 0 010 0 1 0 2 0 1 0 1.58 3.11 1.75 0.20 4.89 3.53 4.477 3.256
10160 10160 A 0 010 0 1 0 2 0 1 0 1.25 2.50 1.45 0.16 3.91 2.86 3.579 2.636
10180 10180 A 0 010 0 1 0 2 0 1 0 2.30 4.66 2.57 0.48 7.44 5.35 6.736 4.859
11000 11000 A 0 000 0 0 0 2 0 1 0 0.60 0.97 0.18 0.05 1.62 0.83 1.497 0.788
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
10 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
11001 11001 A 0 ZZZ 0 0 0 0 0 1 0 0.30 0.30 0.09 0.03 0.63 0.42 0.585 0.397
11004 11004 A 0 000 0 0 0 2 0 1 0 10.80 4.25 4.25 1.89 16.94 16.94 15.605 15.605
11005 11005 A 0 000 0 0 0 0 0 0 0 14.24 5.76 5.76 2.97 22.97 22.97 20.966 20.966
11006 11006 A 0 000 0 0 0 2 0 1 0 13.10 5.21 5.21 2.34 20.65 20.65 19.002 19.002
11008 11008 A 0 ZZZ 0 0 0 0 0 0 0 5.00 2.02 2.02 1.05 8.07 8.07 7.363 7.363
11010 11010 A 0 010 0 1 0 2 2 1 0 4.19 9.97 3.36 0.76 14.92 8.31 13.541 7.605
11011 11011 A 0 000 0 0 0 2 2 1 0 4.94 10.24 2.92 0.98 16.16 8.84 14.648 8.075
11012 11012 A 0 000 0 0 0 2 2 1 0 6.87 13.15 4.31 1.31 21.33 12.49 19.364 11.426
11042 11042 A 0 000 0 0 0 2 0 1 0 1.01 2.39 0.69 0.13 3.53 1.83 3.224 1.698
11043 11043 A 0 000 0 0 0 2 0 1 0 2.70 3.74 1.49 0.45 6.89 4.64 6.294 4.273
11044 11044 A 0 000 0 0 0 2 0 1 0 4.10 4.66 2.08 0.72 9.48 6.90 8.661 6.344
11045 11045 A 0 ZZZ 0 0 0 0 0 0 0 0.50 0.65 0.20 0.11 1.26 0.81 1.141 0.737
11046 11046 A 0 ZZZ 0 0 0 0 0 0 0 1.03 0.97 0.44 0.18 2.18 1.65 1.995 1.519
11047 11047 A 0 ZZZ 0 0 0 0 0 0 0 1.80 1.55 0.79 0.33 3.68 2.92 3.364 2.682
11055 11055 R 0 000 0 0 0 2 0 1 0 0.35 1.05 0.09 0.02 1.42 0.46 1.303 0.441
11056 11056 R 0 000 0 0 0 2 0 1 0 0.50 1.20 0.13 0.03 1.73 0.66 1.593 0.632
11057 11057 R 0 000 0 0 0 2 0 1 0 0.65 1.25 0.17 0.04 1.94 0.86 1.793 0.824
11100 11100 A 0 000 0 0 0 2 0 1 0 0.81 2.21 0.52 0.11 3.13 1.44 2.852 1.334
11101 11101 A 0 ZZZ 0 0 0 0 0 1 0 0.41 0.50 0.27 0.05 0.96 0.73 0.885 0.679
11200 11200 A 0 010 0 1 0 2 0 1 0 0.82 1.70 1.26 0.11 2.63 2.19 2.404 2.009
11201 11201 A 0 ZZZ 0 0 0 0 0 1 0 0.29 0.23 0.16 0.04 0.56 0.49 0.517 0.455
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
11 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
11300 11300 A 0 000 0 0 0 2 9 0 0 0.60 2.27 0.35 0.08 2.95 1.03 2.680 0.956
11301 11301 A 0 000 0 0 0 2 9 0 0 0.90 2.60 0.56 0.12 3.62 1.58 3.298 1.466
11302 11302 A 0 000 0 0 0 2 9 0 0 1.05 3.08 0.66 0.14 4.27 1.85 3.889 1.716
11303 11303 A 0 000 0 0 0 2 9 0 0 1.25 3.27 0.77 0.18 4.70 2.20 4.281 2.036
11305 11305 A 0 000 0 0 0 2 9 0 0 0.80 2.09 0.27 0.06 2.95 1.13 2.708 1.074
11306 11306 A 0 000 0 0 0 2 9 0 0 0.96 2.58 0.44 0.11 3.65 1.51 3.334 1.413
11307 11307 A 0 000 0 0 0 2 9 0 0 1.20 2.97 0.61 0.15 4.32 1.96 3.946 1.826
11308 11308 A 0 000 0 0 0 2 9 0 0 1.46 2.97 0.58 0.14 4.57 2.18 4.200 2.054
11310 11310 A 0 000 0 0 0 2 9 0 0 0.80 2.52 0.48 0.11 3.43 1.39 3.120 1.289
11311 11311 A 0 000 0 0 0 2 9 0 0 1.10 2.09 0.69 0.15 3.34 1.94 3.055 1.798
11312 11312 A 0 000 0 0 0 2 9 0 0 1.30 3.36 0.82 0.20 4.86 2.32 4.422 2.141
11313 11313 A 0 000 0 0 0 2 9 0 0 1.68 3.66 1.04 0.25 5.59 2.97 5.097 2.745
11400 11400 A 0 010 0 1 0 2 0 1 0 0.90 2.71 1.37 0.12 3.73 2.39 3.396 2.193
11401 11401 A 0 010 0 1 0 2 0 1 0 1.28 3.01 1.63 0.20 4.49 3.11 4.088 2.848
11402 11402 A 0 010 0 1 0 2 0 1 0 1.45 3.30 1.72 0.24 4.99 3.41 4.539 3.120
11403 11403 A 0 010 0 1 0 2 0 1 0 1.84 3.60 2.25 0.31 5.75 4.40 5.235 4.023
11404 11404 A 0 010 0 1 0 2 0 1 0 2.11 4.04 2.36 0.37 6.52 4.84 5.931 4.423
11406 11406 A 0 010 0 1 0 2 0 1 0 3.52 5.14 3.11 0.67 9.33 7.30 8.486 6.663
11420 11420 A 0 010 0 1 0 2 0 1 0 1.03 2.55 1.29 0.12 3.70 2.44 3.383 2.251
11421 11421 A 0 010 0 1 0 2 0 1 0 1.47 3.05 1.62 0.22 4.74 3.31 4.324 3.040
11422 11422 A 0 010 0 1 0 2 0 1 0 1.68 3.33 2.13 0.26 5.27 4.07 4.806 3.729
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
12 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
11423 11423 A 0 010 0 1 0 2 0 1 0 2.06 3.68 2.32 0.33 6.07 4.71 5.537 4.316
11424 11424 A 0 010 0 1 0 2 0 1 0 2.48 4.08 2.46 0.41 6.97 5.35 6.358 4.904
11426 11426 A 0 010 0 1 0 2 0 1 0 4.09 5.08 3.32 0.71 9.88 8.12 9.023 7.443
11440 11440 A 0 010 0 1 0 2 0 1 0 1.05 2.88 1.92 0.16 4.09 3.13 3.720 2.858
11441 11441 A 0 010 0 1 0 2 0 1 0 1.53 3.29 2.18 0.24 5.06 3.95 4.610 3.613
11442 11442 A 0 010 0 1 0 2 0 1 0 1.77 3.59 2.31 0.29 5.65 4.37 5.145 3.996
11443 11443 A 0 010 0 1 0 2 0 1 0 2.34 3.99 2.61 0.38 6.71 5.33 6.122 4.883
11444 11444 A 0 010 0 1 0 2 0 1 0 3.19 4.68 3.04 0.52 8.39 6.75 7.665 6.192
11446 11446 A 0 010 0 1 0 2 0 1 0 4.80 5.97 4.02 0.80 11.57 9.62 10.579 8.828
11450 11450 A 0 090 0 1 0 2 1 1 0 3.22 7.61 3.65 0.65 11.48 7.52 10.394 6.838
11451 11451 A 0 090 0 1 0 2 1 0 0 4.43 9.29 4.31 0.90 14.62 9.64 13.243 8.771
11462 11462 A 0 090 0 1 0 2 1 0 0 3.00 7.65 3.60 0.60 11.25 7.20 10.184 6.547
11463 11463 A 0 090 0 1 0 2 1 0 0 4.43 9.28 4.32 0.88 14.59 9.63 13.224 8.770
11470 11470 A 0 090 0 1 0 2 0 1 0 3.74 8.03 3.96 0.71 12.48 8.41 11.322 7.667
11471 11471 A 0 090 0 1 0 2 0 0 0 4.89 9.72 4.62 0.91 15.52 10.42 14.094 9.515
11600 11600 A 0 010 0 1 0 2 0 1 0 1.63 3.91 1.68 0.26 5.80 3.57 5.277 3.275
11601 11601 A 0 010 0 1 0 2 0 1 0 2.07 4.49 2.06 0.31 6.87 4.44 6.264 4.082
11602 11602 A 0 010 0 1 0 2 0 1 0 2.27 4.85 2.27 0.34 7.46 4.88 6.803 4.486
11603 11603 A 0 010 0 1 0 2 0 1 0 2.82 5.23 2.56 0.42 8.47 5.80 7.736 5.339
11604 11604 A 0 010 0 1 0 2 0 1 0 3.17 5.75 2.71 0.52 9.44 6.40 8.605 5.876
11606 11606 A 0 010 0 1 0 2 0 1 0 5.02 7.56 3.57 0.88 13.46 9.47 12.269 8.686
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
13 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
11620 11620 A 0 010 0 1 0 2 0 1 0 1.64 3.98 1.73 0.26 5.88 3.63 5.350 3.330
11621 11621 A 0 010 0 1 0 2 0 1 0 2.08 4.53 2.08 0.31 6.92 4.47 6.310 4.110
11622 11622 A 0 010 0 1 0 2 0 1 0 2.41 4.93 2.34 0.37 7.71 5.12 7.031 4.705
11623 11623 A 0 010 0 1 0 2 0 1 0 3.11 5.41 2.72 0.49 9.01 6.32 8.224 5.809
11624 11624 A 0 010 0 1 0 2 0 1 0 3.62 5.91 2.92 0.60 10.13 7.14 9.241 6.556
11626 11626 A 0 010 0 1 0 2 0 1 0 4.61 6.80 3.33 0.80 12.21 8.74 11.135 8.019
11640 11640 A 0 010 0 1 0 2 0 1 0 1.67 4.13 1.82 0.26 6.06 3.75 5.515 3.440
11641 11641 A 0 010 0 1 0 2 0 1 0 2.17 4.66 2.17 0.33 7.16 4.67 6.527 4.291
11642 11642 A 0 010 0 1 0 2 0 1 0 2.62 5.14 2.47 0.39 8.15 5.48 7.440 5.042
11643 11643 A 0 010 0 1 0 2 0 1 0 3.42 5.63 2.91 0.54 9.59 6.87 8.758 6.316
11644 11644 A 0 010 0 1 0 2 0 1 0 4.34 6.76 3.44 0.71 11.81 8.49 10.782 7.800
11646 11646 A 0 010 0 1 0 2 0 1 0 6.26 8.04 4.43 1.05 15.35 11.74 14.029 10.787
11719 11719 R 0 000 0 0 0 2 0 1 0 0.17 0.16 0.04 0.01 0.34 0.22 0.319 0.211
11720 11720 A 0 000 0 0 0 0 0 1 0 0.32 0.61 0.08 0.03 0.96 0.43 0.883 0.408
11721 11721 A 0 000 0 0 0 0 0 1 0 0.54 0.74 0.14 0.04 1.32 0.72 1.225 0.687
11730 11730 A 0 000 0 0 0 2 0 1 0 1.10 1.75 0.29 0.08 2.93 1.47 2.713 1.402
11732 11732 A 0 ZZZ 0 0 0 0 0 1 0 0.44 0.58 0.12 0.03 1.05 0.59 0.977 0.563
11740 11740 A 0 000 0 0 0 2 0 1 0 0.37 1.08 0.57 0.03 1.48 0.97 1.356 0.898
11750 11750 A 0 010 0 1 0 2 0 1 0 2.50 3.94 2.43 0.22 6.66 5.15 6.153 4.797
11752 11752 A 0 010 0 1 0 2 0 1 0 3.63 5.58 3.74 0.39 9.60 7.76 8.845 7.192
11755 11755 A 0 000 0 0 0 2 0 0 0 1.31 2.61 0.90 0.11 4.03 2.32 3.711 2.176
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
14 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
11760 11760 A 0 010 0 1 0 2 0 1 0 1.63 5.18 2.12 0.26 7.07 4.01 6.418 3.670
11762 11762 A 0 010 0 1 0 2 0 1 0 2.94 5.28 2.28 0.31 8.53 5.53 7.844 5.150
11765 11765 A 0 010 0 1 0 2 0 1 0 1.22 3.70 1.47 0.08 5.00 2.77 4.584 2.582
11770 11770 A 0 010 0 1 0 2 0 1 0 2.66 5.19 2.31 0.52 8.37 5.49 7.593 5.006
11771 11771 A 0 090 0 1 0 2 0 1 0 6.09 9.80 5.54 1.24 17.13 12.87 15.539 11.713
11772 11772 A 0 090 0 1 0 2 0 1 0 7.35 12.03 8.39 1.47 20.85 17.21 18.922 15.653
11900 11900 A 0 000 0 0 0 2 0 1 0 0.52 1.08 0.34 0.07 1.67 0.93 1.526 0.862
11901 11901 A 0 000 0 0 0 2 0 1 0 0.80 1.17 0.53 0.11 2.08 1.44 1.908 1.333
11920 11920 R 0 000 0 0 0 2 0 0 0 1.61 3.27 1.53 0.31 5.19 3.45 4.709 3.146
11921 11921 R 0 000 0 0 0 2 0 0 0 1.93 3.69 1.75 0.37 5.99 4.05 5.437 3.695
11922 11922 R 0 ZZZ 0 0 0 0 0 0 0 0.49 1.29 0.31 0.08 1.86 0.88 1.690 0.810
11950 11950 R 0 000 0 0 0 2 0 0 0 0.84 1.21 0.52 0.10 2.15 1.46 1.979 1.359
11951 11951 R 0 000 0 0 0 2 0 0 0 1.19 1.74 0.81 0.24 3.17 2.24 2.878 2.043
11952 11952 R 0 000 0 0 0 2 0 0 0 1.69 2.22 1.17 0.24 4.15 3.10 3.809 2.866
11954 11954 R 0 000 0 0 0 2 0 0 0 1.85 2.54 1.22 0.35 4.74 3.42 4.314 3.129
11960 11960 A 0 090 0 1 0 2 0 1 0 11.49 14.45 14.45 1.84 27.78 27.78 25.428 25.428
11970 11970 A 0 090 0 1 0 2 1 1 0 8.01 8.73 8.73 1.57 18.31 18.31 16.671 16.671
11971 11971 A 0 090 0 1 0 2 1 0 0 3.41 10.30 5.63 0.64 14.35 9.68 12.994 8.800
11976 11976 R 0 000 0 0 0 2 0 0 0 1.78 2.24 0.76 0.30 4.32 2.84 3.948 2.619
11980 11980 A 0 000 0 0 0 2 0 1 0 1.48 1.34 0.64 0.23 3.05 2.35 2.804 2.175
11981 11981 A 0 XXX 0 0 0 2 0 0 0 1.48 2.35 0.65 0.24 4.07 2.37 3.716 2.189
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
15 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
11982 11982 A 0 XXX 0 0 0 2 0 0 0 1.78 2.57 0.81 0.24 4.59 2.83 4.213 2.633
11983 11983 A 0 XXX 0 0 0 2 0 0 0 3.30 2.60 1.24 0.35 6.25 4.89 5.818 4.597
12001 12001 A 0 000 0 0 0 2 0 1 0 0.84 1.74 0.34 0.14 2.72 1.32 2.476 1.219
12002 12002 A 0 000 0 0 0 2 0 1 0 1.14 1.96 0.42 0.19 3.29 1.75 2.999 1.617
12004 12004 A 0 000 0 0 0 2 0 1 0 1.44 2.18 0.50 0.24 3.86 2.18 3.523 2.015
12005 12005 A 0 000 0 0 0 2 0 1 0 1.97 2.69 0.64 0.33 4.99 2.94 4.558 2.717
12006 12006 A 0 000 0 0 0 2 0 1 0 2.39 3.23 0.78 0.41 6.03 3.58 5.505 3.305
12007 12007 A 0 000 0 0 0 2 0 1 1 2.90 3.46 1.09 0.50 6.86 4.49 6.269 4.140
12011 12011 A 0 000 0 0 0 2 0 1 0 1.07 2.06 0.40 0.19 3.32 1.66 3.019 1.529
12013 12013 A 0 000 0 0 0 2 0 1 0 1.22 2.21 0.42 0.20 3.63 1.84 3.309 1.702
12014 12014 A 0 000 0 0 0 2 0 1 0 1.57 2.41 0.51 0.26 4.24 2.34 3.870 2.164
12015 12015 A 0 000 0 0 0 2 0 1 0 1.98 2.86 0.61 0.33 5.17 2.92 4.721 2.700
12016 12016 A 0 000 0 0 0 2 0 1 0 2.68 3.28 0.80 0.46 6.42 3.94 5.866 3.639
12017 12017 A 0 000 0 0 0 2 0 0 0 3.18 0.78 0.78 0.56 4.52 4.52 4.173 4.173
12018 12018 A 0 000 0 0 0 2 0 2 0 3.61 1.74 1.74 0.64 5.99 5.99 5.507 5.507
12020 12020 A 0 010 0 1 0 2 0 1 0 2.67 5.38 2.54 0.42 8.47 5.63 7.721 5.171
12021 12021 A 0 010 0 1 0 2 0 1 0 1.89 2.92 2.11 0.31 5.12 4.31 4.674 3.947
12031 12031 A 0 010 0 1 0 2 0 1 0 2.00 4.86 2.28 0.32 7.18 4.60 6.532 4.215
12032 12032 A 0 010 0 1 0 2 0 1 0 2.52 6.27 2.95 0.38 9.17 5.85 8.349 5.368
12034 12034 A 0 010 0 1 0 2 0 1 0 2.97 5.92 2.70 0.50 9.39 6.17 8.548 5.656
12035 12035 A 0 010 0 1 0 2 0 1 0 3.50 7.54 3.09 0.65 11.69 7.24 10.611 6.615
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
16 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
12036 12036 A 0 010 0 1 0 2 0 1 0 4.23 7.70 3.31 0.81 12.74 8.35 11.568 7.626
12037 12037 A 0 010 0 1 0 2 0 0 1 5.00 8.05 3.68 0.96 14.01 9.64 12.731 8.807
12041 12041 A 0 010 0 1 0 2 0 1 0 2.10 4.87 2.26 0.32 7.29 4.68 6.641 4.297
12042 12042 A 0 010 0 1 0 2 0 1 0 2.79 5.47 2.78 0.41 8.67 5.98 7.916 5.501
12044 12044 A 0 010 0 1 0 2 0 1 0 3.19 7.13 2.69 0.52 10.84 6.40 9.865 5.878
12045 12045 A 0 010 0 1 0 2 0 1 0 3.75 7.72 3.73 0.64 12.11 8.12 11.017 7.434
12046 12046 A 0 010 0 1 0 2 0 0 0 4.30 11.00 5.00 0.84 16.14 10.14 14.617 9.229
12047 12047 A 0 010 0 1 0 2 0 2 1 4.95 11.79 5.35 0.96 17.70 11.26 16.040 10.256
12051 12051 A 0 010 0 1 0 2 0 1 0 2.33 5.10 2.45 0.36 7.79 5.14 7.098 4.718
12052 12052 A 0 010 0 1 0 2 0 1 0 2.87 5.54 2.79 0.42 8.83 6.08 8.065 5.595
12053 12053 A 0 010 0 1 0 2 0 1 0 3.17 6.76 2.81 0.50 10.43 6.48 9.502 5.955
12054 12054 A 0 010 0 1 0 2 0 1 0 3.50 7.04 2.74 0.59 11.13 6.83 10.130 6.269
12055 12055 A 0 010 0 1 0 2 0 1 0 4.50 8.99 3.73 0.73 14.22 8.96 12.955 8.231
12056 12056 A 0 010 0 1 0 2 0 0 0 5.30 10.46 5.25 0.67 16.43 11.22 15.043 10.365
12057 12057 A 0 010 0 1 0 2 0 2 1 6.00 9.82 4.41 0.76 16.58 11.17 15.216 10.358
13100 13100 A 0 010 0 1 0 2 0 1 0 3.00 6.58 2.66 0.47 10.05 6.13 9.155 5.634
13101 13101 A 0 010 0 1 0 2 0 1 0 3.50 7.90 3.56 0.54 11.94 7.60 10.877 6.979
13102 13102 A 0 ZZZ 0 0 0 0 0 1 0 1.24 2.19 0.73 0.23 3.66 2.20 3.327 2.016
13120 13120 A 0 010 0 1 0 2 0 1 0 3.23 6.80 3.34 0.50 10.53 7.07 9.598 6.491
13121 13121 A 0 010 0 1 0 2 0 1 0 4.00 8.24 3.36 0.61 12.85 7.97 11.719 7.336
13122 13122 A 0 ZZZ 0 0 0 0 0 1 0 1.44 2.31 0.84 0.26 4.01 2.54 3.650 2.330
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
17 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
13131 13131 A 0 010 0 1 0 2 0 1 0 3.73 7.28 3.16 0.57 11.58 7.46 10.566 6.866
13132 13132 A 0 010 0 1 0 2 0 1 0 4.78 8.80 3.88 0.71 14.29 9.37 13.054 8.636
13133 13133 A 0 ZZZ 0 0 0 0 0 1 0 2.19 2.78 1.35 0.34 5.31 3.88 4.864 3.580
13150 13150 A 0 010 0 1 0 2 0 1 0 3.58 7.09 2.48 0.57 11.24 6.63 10.245 6.105
13151 13151 A 0 010 0 1 0 2 0 1 0 4.34 7.66 3.58 0.65 12.65 8.57 11.559 7.895
13152 13152 A 0 010 0 1 0 2 0 1 0 4.90 8.73 3.93 0.73 14.36 9.56 13.121 8.811
13153 13153 A 0 ZZZ 0 0 0 0 0 1 0 2.38 3.01 1.42 0.38 5.77 4.18 5.282 3.854
13160 13160 A 0 090 0 1 0 2 0 1 0 12.04 9.80 9.80 2.23 24.07 24.07 22.007 22.007
14000 14000 A 0 090 0 1 0 2 0 1 0 6.37 11.26 7.65 1.13 18.76 15.15 17.072 13.831
14001 14001 A 0 090 0 1 0 2 0 1 0 8.78 13.69 9.31 1.54 24.01 19.63 21.879 17.946
14020 14020 A 0 090 0 1 0 2 0 1 0 7.22 12.55 8.69 1.21 20.98 17.12 19.123 15.656
14021 14021 A 0 090 0 1 0 2 0 1 0 9.72 14.86 10.31 1.55 26.13 21.58 23.875 19.789
14040 14040 A 0 090 0 1 0 2 0 1 0 8.60 12.97 9.11 1.32 22.89 19.03 20.937 17.471
14041 14041 A 0 090 0 1 0 2 0 1 0 10.83 15.77 10.85 1.62 28.22 23.30 25.839 21.421
14060 14060 A 0 090 0 1 0 2 0 1 0 9.23 12.61 9.58 1.42 23.26 20.23 21.296 18.576
14061 14061 A 0 090 0 1 0 2 0 1 0 11.48 17.14 11.71 1.71 30.33 24.90 27.766 22.890
14301 14301 A 0 090 0 1 0 2 0 2 0 12.65 17.49 11.65 2.14 32.28 26.44 29.475 24.231
14302 14302 A 0 ZZZ 0 0 0 0 0 2 0 3.73 2.12 2.12 0.63 6.48 6.48 5.963 5.963
14350 14350 A 0 090 0 1 0 2 0 0 0 11.05 8.46 8.46 1.55 21.06 21.06 19.458 19.458
15002 15002 A 0 000 0 0 0 0 0 0 0 3.65 6.17 2.48 0.65 10.47 6.78 9.531 6.217
15003 15003 A 0 ZZZ 0 0 0 0 0 0 0 0.80 1.33 0.39 0.16 2.29 1.35 2.078 1.234
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
18 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
15004 15004 A 0 000 0 0 0 0 0 0 0 4.58 6.78 2.81 0.67 12.03 8.06 11.019 7.454
15005 15005 A 0 ZZZ 0 0 0 0 0 0 0 1.60 1.81 0.79 0.31 3.72 2.70 3.388 2.472
15040 15040 A 0 000 0 0 0 0 0 1 0 2.00 5.43 1.43 0.37 7.80 3.80 7.070 3.478
15050 15050 A 0 090 0 1 0 2 0 1 0 5.57 10.71 6.96 0.90 17.18 13.43 15.658 12.291
15100 15100 A 0 090 0 1 0 2 0 1 0 9.90 13.93 9.62 1.95 25.78 21.47 23.429 19.559
15101 15101 A 0 ZZZ 0 0 0 0 0 1 0 1.72 3.57 1.23 0.34 5.63 3.29 5.104 3.002
15110 15110 A 0 090 0 1 0 2 0 1 0 10.97 12.89 9.49 2.15 26.01 22.61 23.670 20.616
15111 15111 A 0 ZZZ 0 0 0 0 0 1 0 1.85 1.16 0.80 0.38 3.39 3.03 3.090 2.767
15115 15115 A 0 090 0 1 0 2 0 1 0 11.28 12.76 9.42 1.85 25.89 22.55 23.706 20.707
15116 15116 A 0 ZZZ 0 0 0 0 0 1 1 2.50 1.48 0.99 0.49 4.47 3.98 4.085 3.645
15120 15120 A 0 090 0 1 0 2 0 1 0 10.15 13.58 8.93 1.76 25.49 20.84 23.265 19.090
15121 15121 A 0 ZZZ 0 0 0 0 0 1 1 2.00 3.89 1.56 0.37 6.26 3.93 5.687 3.594
15130 15130 A 0 090 0 1 0 2 0 1 0 7.53 11.25 7.90 1.48 20.26 16.91 18.407 15.398
15131 15131 A 0 ZZZ 0 0 0 0 0 1 1 1.50 0.85 0.59 0.31 2.66 2.40 2.425 2.192
15135 15135 A 0 090 0 1 0 2 0 1 0 11.03 13.32 10.00 1.88 26.23 22.91 23.975 20.993
15136 15136 A 0 ZZZ 0 0 0 0 0 1 1 1.50 1.10 0.90 0.10 2.70 2.50 2.540 2.361
15150 15150 A 0 090 0 1 0 2 0 1 0 9.39 9.27 7.39 1.99 20.65 18.77 18.755 17.067
15151 15151 A 0 ZZZ 0 0 0 0 0 1 0 2.00 1.09 0.79 0.42 3.51 3.21 3.198 2.929
15152 15152 A 0 ZZZ 0 0 0 0 0 1 0 2.50 1.60 1.30 0.49 4.59 4.29 4.193 3.924
15155 15155 A 0 090 0 1 0 2 0 1 0 10.14 11.89 9.98 0.76 22.79 20.88 21.215 19.500
15156 15156 A 0 ZZZ 0 0 0 0 0 1 1 2.75 1.38 1.09 0.59 4.72 4.43 4.298 4.037
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
19 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
15157 15157 A 0 ZZZ 0 0 0 0 0 1 1 3.00 2.23 1.81 0.22 5.45 5.03 5.118 4.740
15200 15200 A 0 090 0 1 0 2 0 1 0 9.15 14.13 9.34 1.65 24.93 20.14 22.702 18.400
15201 15201 A 0 ZZZ 0 0 0 0 0 1 0 1.32 2.91 0.77 0.26 4.49 2.35 4.069 2.147
15220 15220 A 0 090 0 1 0 2 0 1 0 8.09 13.73 9.02 1.39 23.21 18.50 21.147 16.917
15221 15221 A 0 ZZZ 0 0 0 0 0 1 0 1.19 2.74 0.70 0.23 4.16 2.12 3.771 1.939
15240 15240 A 0 090 0 1 0 2 0 1 0 10.41 15.92 12.01 1.70 28.03 24.12 25.595 22.084
15241 15241 A 0 ZZZ 0 0 0 0 0 1 0 1.86 3.38 1.12 0.33 5.57 3.31 5.068 3.038
15260 15260 A 0 090 0 1 0 2 0 1 0 11.64 16.98 12.44 1.77 30.39 25.85 27.814 23.737
15261 15261 A 0 ZZZ 0 0 0 0 0 1 0 2.23 3.91 1.60 0.37 6.51 4.20 5.935 3.860
15271 15271 A 0 000 0 0 0 2 0 1 0 1.50 2.28 0.80 0.25 4.03 2.55 3.678 2.349
15272 15272 A 0 ZZZ 0 0 0 0 0 1 0 0.33 0.38 0.13 0.04 0.75 0.50 0.692 0.468
15273 15273 A 0 000 0 0 0 2 0 1 0 3.50 3.95 1.61 0.62 8.07 5.73 7.371 5.270
15274 15274 A 0 ZZZ 0 0 0 0 0 1 0 0.80 0.92 0.32 0.10 1.82 1.22 1.678 1.140
15275 15275 A 0 000 0 0 0 2 0 1 0 1.83 2.41 0.94 0.31 4.55 3.08 4.156 2.836
15276 15276 A 0 ZZZ 0 0 0 0 0 1 0 0.50 0.45 0.20 0.06 1.01 0.76 0.935 0.711
15277 15277 A 0 000 0 0 0 2 0 1 1 4.00 4.22 1.81 0.59 8.81 6.40 8.098 5.934
15278 15278 A 0 ZZZ 0 0 0 0 0 1 1 1.00 1.06 0.41 0.13 2.19 1.54 2.020 1.436
15570 15570 A 0 090 0 1 0 2 0 1 0 10.21 15.21 9.85 2.07 27.49 22.13 24.951 20.138
15572 15572 A 0 090 0 1 0 2 0 1 0 10.12 14.40 10.18 1.82 26.34 22.12 24.003 20.214
15574 15574 A 0 090 0 1 0 2 0 1 0 10.70 14.85 10.43 1.82 27.37 22.95 24.987 21.018
15576 15576 A 0 090 0 1 0 2 0 1 0 9.37 13.43 9.34 1.54 24.34 20.25 22.236 18.563
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
20 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
15600 15600 A 0 090 0 1 0 2 0 0 0 2.01 7.48 3.90 0.38 9.87 6.29 8.926 5.711
15610 15610 A 0 090 0 1 0 2 0 0 0 2.52 7.80 4.32 0.45 10.77 7.29 9.760 6.635
15620 15620 A 0 090 0 1 0 2 0 1 0 3.75 8.95 5.48 0.61 13.31 9.84 12.106 8.990
15630 15630 A 0 090 0 1 0 2 0 1 0 4.08 9.21 5.76 0.65 13.94 10.49 12.691 9.592
15650 15650 A 0 090 0 1 0 2 0 0 0 4.77 9.70 5.99 0.78 15.25 11.54 13.889 10.557
15731 15731 A 0 090 0 1 0 2 0 0 0 14.38 17.09 13.55 2.41 33.88 30.34 30.987 27.808
15732 15732 A 0 090 0 1 0 2 0 1 1 16.38 19.55 14.66 2.91 38.84 33.95 35.458 31.067
15734 15734 A 0 090 0 1 0 2 0 2 1 19.86 20.97 15.59 3.99 44.82 39.44 40.778 35.947
15736 15736 A 0 090 0 1 0 2 0 1 1 17.04 19.21 13.91 3.36 39.61 34.31 36.048 31.288
15738 15738 A 0 090 0 1 0 2 0 2 1 19.04 19.21 14.21 3.81 42.06 37.06 38.283 33.793
15740 15740 A 0 090 0 1 0 2 0 1 0 11.80 16.84 11.95 1.77 30.41 25.52 27.848 23.457
15750 15750 A 0 090 0 1 0 2 0 2 0 12.96 12.02 12.02 2.29 27.27 27.27 24.952 24.952
15756 15756 A 0 090 0 1 0 2 0 2 2 36.94 26.23 26.23 6.36 69.53 69.53 63.821 63.821
15757 15757 A 0 090 0 1 0 2 0 2 2 37.15 25.57 25.57 5.92 68.64 68.64 63.208 63.208
15758 15758 A 0 090 0 1 0 2 0 2 2 36.90 25.74 25.74 5.92 68.56 68.56 63.111 63.111
15760 15760 A 0 090 0 1 0 2 0 1 0 9.86 14.29 9.93 1.58 25.73 21.37 23.519 19.603
15770 15770 A 0 090 0 1 0 2 0 2 1 8.96 9.70 9.70 1.63 20.29 20.29 18.523 18.523
15775 15775 R 0 000 0 0 0 2 0 0 0 3.95 4.40 2.06 0.29 8.64 6.30 8.053 5.952
15776 15776 R 0 000 0 0 0 2 0 0 0 5.53 8.25 4.27 0.38 14.16 10.18 13.137 9.563
15777 15777 A 0 ZZZ 0 0 0 0 1 1 0 3.65 1.48 1.48 0.77 5.90 5.90 5.382 5.382
15780 15780 A 0 090 0 1 0 2 0 0 0 8.73 17.64 9.84 1.20 27.57 19.77 25.198 18.194
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
21 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
15781 15781 A 0 090 0 1 0 2 0 1 0 5.02 10.94 7.29 0.76 16.72 13.07 15.242 11.964
15782 15782 A 0 090 0 1 0 2 0 0 0 4.44 12.05 6.93 0.63 17.12 12.00 15.590 10.993
15783 15783 A 0 090 0 1 0 2 0 0 0 4.41 9.61 6.24 0.63 14.65 11.28 13.369 10.343
15786 15786 A 0 010 0 1 0 2 0 1 0 2.08 5.08 1.70 0.33 7.49 4.11 6.814 3.779
15787 15787 A 0 ZZZ 0 0 0 0 0 1 0 0.33 1.14 0.15 0.04 1.51 0.52 1.375 0.486
15788 15788 R 0 090 0 1 0 2 0 1 0 2.09 11.94 5.31 0.35 14.38 7.75 12.995 7.041
15789 15789 R 0 090 0 1 0 2 0 1 0 4.91 10.99 6.95 0.68 16.58 12.54 15.135 11.507
15792 15792 R 0 090 0 1 0 2 0 0 0 1.86 11.34 5.91 0.30 13.50 8.07 12.200 7.324
15793 15793 A 0 090 0 1 0 2 0 0 0 3.96 10.43 6.57 0.56 14.95 11.09 13.619 10.153
15819 15819 A 0 090 0 1 0 2 0 0 0 10.65 9.16 9.16 2.10 21.91 21.91 19.974 19.974
15820 15820 A 0 090 0 1 0 2 1 0 0 6.27 10.09 8.38 1.24 17.60 15.89 15.979 14.444
15821 15821 A 0 090 0 1 0 2 1 0 0 6.84 10.46 8.57 1.33 18.63 16.74 16.929 15.231
15822 15822 A 0 090 0 1 0 2 1 1 0 4.62 8.23 6.55 0.82 13.67 11.99 12.439 10.931
15823 15823 A 0 090 0 1 0 2 1 1 0 6.81 10.72 8.78 1.27 18.80 16.86 17.101 15.359
15824 15824 R 0 000 0 0 0 2 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15825 15825 R 0 000 0 0 0 2 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15826 15826 R 0 000 0 0 0 2 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15828 15828 R 0 000 0 0 0 2 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15829 15829 R 0 000 0 0 0 2 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15830 15830 R 0 090 0 1 0 2 0 2 1 17.11 14.42 14.42 3.39 34.92 34.92 31.832 31.832
15832 15832 A 0 090 0 1 0 2 1 2 1 12.85 12.57 12.57 2.57 27.99 27.99 25.482 25.482
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
22 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
15833 15833 A 0 090 0 1 0 2 1 0 0 11.90 11.97 11.97 2.33 26.20 26.20 23.868 23.868
15834 15834 A 0 090 0 1 0 2 1 0 0 12.17 12.14 12.14 2.40 26.71 26.71 24.327 24.327
15835 15835 A 0 090 0 1 0 2 0 0 0 12.99 12.63 12.63 2.56 28.18 28.18 25.671 25.671
15836 15836 A 0 090 0 1 0 2 1 0 0 10.61 11.05 11.05 2.08 23.74 23.74 21.621 21.621
15837 15837 A 0 090 0 1 0 2 0 0 0 9.55 15.11 10.05 2.01 26.67 21.61 24.170 19.626
15838 15838 A 0 090 0 1 0 2 0 0 0 8.25 7.76 7.76 1.06 17.07 17.07 15.773 15.773
15839 15839 A 0 090 0 1 0 2 0 0 0 10.50 13.70 9.39 1.93 26.13 21.82 23.812 19.942
15840 15840 A 0 090 0 1 0 2 0 1 0 14.99 13.02 13.02 2.40 30.41 30.41 27.937 27.937
15841 15841 A 0 090 0 1 0 2 0 2 1 25.99 18.25 18.25 3.36 47.60 47.60 44.136 44.136
15842 15842 A 0 090 0 1 0 2 0 2 1 41.01 32.36 32.36 5.28 78.65 78.65 72.831 72.831
15845 15845 A 0 090 0 1 0 2 0 2 0 14.32 14.27 14.27 1.84 30.43 30.43 28.097 28.097
15847 15847 C 0 YYY 0 0 0 0 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15850 15850 B 9 XXX 0 0 0 9 9 9 9 0.78 1.77 0.32 0.05 2.60 1.15 2.396 1.094
15851 15851 A 0 000 0 0 0 2 0 1 0 0.86 2.02 0.39 0.12 3.00 1.37 2.737 1.273
15852 15852 A 0 000 0 0 0 2 0 1 0 0.86 0.37 0.37 0.14 1.37 1.37 1.265 1.265
15860 15860 A 0 000 0 0 0 2 0 0 0 1.95 0.97 0.97 0.38 3.30 3.30 3.020 3.020
15876 15876 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15877 15877 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15878 15878 R 0 000 0 0 0 2 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15879 15879 R 0 000 0 0 0 2 1 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
15920 15920 A 0 090 0 1 0 2 0 0 0 8.29 8.21 8.21 1.71 18.21 18.21 16.557 16.557
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
23 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
15922 15922 A 0 090 0 1 0 2 0 2 1 10.38 11.09 11.09 2.03 23.50 23.50 21.401 21.401
15931 15931 A 0 090 0 1 0 2 0 1 0 10.07 8.17 8.17 2.07 20.31 20.31 18.489 18.489
15933 15933 A 0 090 0 1 0 2 0 0 0 11.77 11.20 11.20 2.41 25.38 25.38 23.088 23.088
15934 15934 A 0 090 0 1 0 2 0 1 0 13.68 11.07 11.07 2.78 27.53 27.53 25.075 25.075
15935 15935 A 0 090 0 1 0 2 0 2 1 15.78 14.03 14.03 3.18 32.99 32.99 30.042 30.042
15936 15936 A 0 090 0 1 0 2 0 1 1 13.16 10.86 10.86 2.67 26.69 26.69 24.309 24.309
15937 15937 A 0 090 0 1 0 2 0 1 1 15.14 12.83 12.83 3.06 31.03 31.03 28.262 28.262
15940 15940 A 0 090 0 1 0 2 0 1 0 10.20 8.49 8.49 2.07 20.76 20.76 18.907 18.907
15941 15941 A 0 090 0 1 0 2 0 0 0 12.41 12.31 12.31 2.48 27.20 27.20 24.761 24.761
15944 15944 A 0 090 0 1 0 2 0 0 0 12.44 12.09 12.09 2.50 27.03 27.03 24.604 24.604
15945 15945 A 0 090 0 1 0 2 0 0 0 13.75 13.14 13.14 2.74 29.63 29.63 26.983 26.983
15946 15946 A 0 090 0 1 0 2 0 1 1 24.12 19.94 19.94 4.82 48.88 48.88 44.547 44.547
15950 15950 A 0 090 0 1 0 2 0 1 0 8.03 7.84 7.84 1.59 17.46 17.46 15.902 15.902
15951 15951 A 0 090 0 1 0 2 0 0 1 11.58 10.00 10.00 2.27 23.85 23.85 21.747 21.747
15952 15952 A 0 090 0 1 0 2 0 2 1 12.31 12.43 12.43 2.63 27.37 27.37 24.848 24.848
15953 15953 A 0 090 0 1 0 2 0 1 1 13.57 13.66 13.66 2.67 29.90 29.90 27.233 27.233
15956 15956 A 0 090 0 1 0 2 0 1 1 16.79 14.29 14.29 3.42 34.50 34.50 31.411 31.411
15958 15958 A 0 090 0 1 0 2 0 1 1 16.75 15.03 15.03 3.39 35.17 35.17 32.020 32.020
15999 15999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
16000 16000 A 0 000 0 0 0 2 0 1 0 0.89 1.04 0.35 0.12 2.05 1.36 1.887 1.267
16020 16020 A 0 000 0 0 0 2 0 1 0 0.71 1.64 0.81 0.10 2.45 1.62 2.235 1.490
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
24 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
16025 16025 A 0 000 0 0 0 2 0 1 0 1.74 2.38 1.29 0.29 4.41 3.32 4.029 3.050
16030 16030 A 0 000 0 0 0 2 0 1 0 2.08 3.05 1.51 0.37 5.50 3.96 5.012 3.629
16035 16035 A 0 000 0 0 0 2 0 1 0 3.74 1.50 1.50 0.63 5.87 5.87 5.416 5.416
16036 16036 A 0 ZZZ 0 0 0 0 0 1 0 1.50 0.61 0.61 0.27 2.38 2.38 2.189 2.189
17000 17000 A 0 010 0 1 0 2 0 1 0 0.65 1.72 0.95 0.08 2.45 1.68 2.236 1.545
17003 17003 A 0 ZZZ 0 0 0 0 0 1 0 0.07 0.12 0.05 0.01 0.20 0.13 0.183 0.120
17004 17004 A 0 010 0 1 0 0 0 1 0 1.85 2.96 1.76 0.27 5.08 3.88 4.649 3.572
17106 17106 A 0 090 0 1 0 2 0 1 0 3.69 5.87 3.91 0.53 10.09 8.13 9.238 7.478
17107 17107 A 0 090 0 1 0 2 0 1 0 4.79 7.61 4.98 0.73 13.13 10.50 12.006 9.644
17108 17108 A 0 090 0 1 0 2 0 0 0 7.49 10.35 6.88 1.31 19.15 15.68 17.469 14.353
17110 17110 A 0 010 0 1 0 2 0 1 0 0.70 2.58 1.32 0.08 3.36 2.10 3.059 1.927
17111 17111 A 0 010 0 1 0 2 0 1 0 0.97 2.89 1.48 0.12 3.98 2.57 3.628 2.362
17250 17250 A 0 000 0 0 0 2 0 1 0 0.50 1.85 0.53 0.07 2.42 1.10 2.198 1.013
17260 17260 A 0 010 0 1 0 2 0 1 0 0.96 1.74 1.00 0.12 2.82 2.08 2.585 1.921
17261 17261 A 0 010 0 1 0 2 0 1 0 1.22 2.94 1.34 0.18 4.34 2.74 3.954 2.517
17262 17262 A 0 010 0 1 0 2 0 1 0 1.63 3.40 1.61 0.23 5.26 3.47 4.803 3.196
17263 17263 A 0 010 0 1 0 2 0 1 0 1.84 3.64 1.74 0.26 5.74 3.84 5.245 3.539
17264 17264 A 0 010 0 1 0 2 0 1 0 1.99 3.88 1.83 0.29 6.16 4.11 5.626 3.785
17266 17266 A 0 010 0 1 0 2 0 1 0 2.39 4.23 2.06 0.34 6.96 4.79 6.366 4.418
17270 17270 A 0 010 0 1 0 2 0 1 0 1.37 2.97 1.42 0.20 4.54 2.99 4.142 2.750
17271 17271 A 0 010 0 1 0 2 0 1 0 1.54 3.15 1.55 0.23 4.92 3.32 4.489 3.052
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
25 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
17272 17272 A 0 010 0 1 0 2 0 1 0 1.82 3.51 1.73 0.26 5.59 3.81 5.108 3.510
17273 17273 A 0 010 0 1 0 2 0 1 0 2.10 3.83 1.91 0.30 6.23 4.31 5.696 3.972
17274 17274 A 0 010 0 1 0 2 0 1 0 2.64 4.33 2.24 0.37 7.34 5.25 6.722 4.845
17276 17276 A 0 010 0 1 0 2 0 1 0 3.25 4.77 2.59 0.48 8.50 6.32 7.785 5.827
17280 17280 A 0 010 0 1 0 2 0 1 0 1.22 2.85 1.32 0.18 4.25 2.72 3.873 2.500
17281 17281 A 0 010 0 1 0 2 0 1 0 1.77 3.31 1.70 0.26 5.34 3.73 4.878 3.433
17282 17282 A 0 010 0 1 0 2 0 1 0 2.09 3.73 1.90 0.30 6.12 4.29 5.596 3.953
17283 17283 A 0 010 0 1 0 2 0 1 0 2.69 4.24 2.28 0.38 7.31 5.35 6.696 4.936
17284 17284 A 0 010 0 1 0 2 0 1 0 3.20 4.67 2.57 0.44 8.31 6.21 7.624 5.738
17286 17286 A 0 010 0 1 0 2 0 1 0 4.48 5.60 3.33 0.67 10.75 8.48 9.859 7.821
17311 17311 A 0 000 0 0 0 2 0 1 0 6.20 12.46 4.09 0.87 19.53 11.16 17.844 10.328
17312 17312 A 0 ZZZ 0 0 0 0 0 1 0 3.30 7.94 2.17 0.45 11.69 5.92 10.665 5.484
17313 17313 A 0 000 0 0 0 2 0 1 0 5.56 11.48 3.67 0.78 17.82 10.01 16.277 9.264
17314 17314 A 0 ZZZ 0 0 0 0 0 1 0 3.06 7.36 2.02 0.42 10.84 5.50 9.889 5.094
17315 17315 A 0 ZZZ 0 0 0 0 0 1 0 0.87 1.34 0.57 0.11 2.32 1.55 2.131 1.439
17340 17340 A 0 010 0 1 0 2 0 1 0 0.77 0.65 0.57 0.10 1.52 1.44 1.406 1.334
17360 17360 A 0 010 0 1 0 2 0 1 0 1.46 2.19 1.26 0.22 3.87 2.94 3.542 2.707
17380 17380 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
17999 17999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
19000 19000 A 0 000 0 0 0 2 0 1 0 0.84 2.40 0.31 0.11 3.35 1.26 3.053 1.176
19001 19001 A 0 ZZZ 0 0 0 0 0 1 0 0.42 0.31 0.16 0.05 0.78 0.63 0.725 0.590
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
26 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
19020 19020 A 0 090 0 1 0 2 1 1 0 3.83 9.77 4.54 0.78 14.38 9.15 13.011 8.315
19030 19030 A 0 000 0 0 0 2 1 1 0 1.53 3.10 0.56 0.14 4.77 2.23 4.387 2.106
19100 19100 A 0 000 0 0 0 2 1 1 0 1.27 3.04 0.50 0.26 4.57 2.03 4.136 1.855
19101 19101 A 0 010 0 1 0 2 1 1 0 3.23 6.43 2.66 0.67 10.33 6.56 9.355 5.969
19102 19102 A 0 000 0 0 0 2 1 1 0 2.00 4.17 0.73 0.22 6.39 2.95 5.860 2.771
19103 19103 A 0 000 0 0 0 2 1 1 0 3.69 12.45 1.36 0.48 16.62 5.53 15.121 5.162
19105 19105 A 0 000 0 0 0 2 1 1 0 3.69 55.44 1.51 0.39 59.52 5.59 53.679 5.250
19110 19110 A 0 090 0 1 0 2 1 1 0 4.44 9.44 4.87 0.93 14.81 10.24 13.404 9.300
19112 19112 A 0 090 0 1 0 2 1 0 0 3.81 9.48 4.78 0.80 14.09 9.39 12.741 8.521
19120 19120 A 0 090 0 1 0 2 1 1 0 5.92 7.57 5.08 1.25 14.74 12.25 13.372 11.136
19125 19125 A 0 090 0 1 0 2 1 1 1 6.69 8.25 5.49 1.42 16.36 13.60 14.841 12.363
19126 19126 A 0 ZZZ 0 0 0 0 0 1 1 2.93 1.16 1.16 0.63 4.72 4.72 4.301 4.301
19260 19260 A 0 090 0 1 0 2 0 2 1 17.78 14.49 14.49 3.96 36.23 36.23 32.863 32.863
19271 19271 A 0 090 0 1 0 2 0 2 1 22.19 21.67 21.67 5.05 48.91 48.91 44.291 44.291
19272 19272 A 0 090 0 1 0 2 0 2 1 25.17 22.97 22.97 5.96 54.10 54.10 48.914 48.914
19290 19290 A 0 000 0 0 0 2 1 1 0 1.27 3.31 0.46 0.12 4.70 1.85 4.305 1.746
19291 19291 A 0 ZZZ 0 0 0 0 0 1 0 0.63 1.33 0.23 0.05 2.01 0.91 1.850 0.863
19295 19295 A 3 ZZZ 0 0 0 0 0 0 0 0.00 2.80 2.80 0.01 2.81 2.81 2.520 2.520
19296 19296 A 0 000 0 0 0 2 1 0 0 3.63 122.53 1.79 0.73 126.89 6.15 114.044 5.619
19297 19297 A 0 ZZZ 0 0 0 0 0 0 0 1.72 0.68 0.68 0.35 2.75 2.75 2.514 2.514
19298 19298 A 0 000 0 0 0 2 1 0 0 6.00 27.61 2.67 0.76 34.37 9.43 31.191 8.795
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
27 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
19300 19300 A 0 090 0 1 0 2 1 1 0 5.31 9.24 5.82 1.13 15.68 12.26 14.199 11.127
19301 19301 A 0 090 0 1 0 2 1 0 0 10.13 6.98 6.98 2.15 19.26 19.26 17.522 17.522
19302 19302 A 0 090 0 1 0 2 1 2 1 13.99 9.57 9.57 2.98 26.54 26.54 24.142 24.142
19303 19303 A 0 090 0 1 0 2 1 2 1 15.85 10.59 10.59 3.38 29.82 29.82 27.128 27.128
19304 19304 A 0 090 0 1 0 2 1 2 1 7.95 7.49 7.49 1.67 17.11 17.11 15.549 15.549
19305 19305 A 0 090 0 1 0 2 1 2 1 17.46 12.21 12.21 3.73 33.40 33.40 30.375 30.375
19306 19306 A 0 090 0 1 0 2 1 2 1 18.13 13.52 13.52 3.87 35.52 35.52 32.295 32.295
19307 19307 A 0 090 0 1 0 2 1 2 1 18.23 13.27 13.27 3.87 35.37 35.37 32.170 32.170
19316 19316 A 0 090 0 1 0 2 1 2 1 11.09 9.68 9.68 2.19 22.96 22.96 20.928 20.928
19318 19318 A 0 090 0 1 0 2 1 2 1 16.03 13.93 13.93 3.16 33.12 33.12 30.192 30.192
19324 19324 A 0 090 0 1 0 2 1 0 0 6.80 6.35 6.35 1.46 14.61 14.61 13.266 13.266
19325 19325 A 0 090 0 1 0 2 1 0 0 8.64 9.07 9.07 1.69 19.40 19.40 17.669 17.669
19328 19328 A 0 090 0 1 0 2 1 1 0 6.48 7.14 7.14 1.28 14.90 14.90 13.561 13.561
19330 19330 A 0 090 0 1 0 2 1 1 0 8.54 8.81 8.81 1.66 19.01 19.01 17.320 17.320
19340 19340 A 0 090 0 1 0 2 1 1 1 13.99 13.42 13.42 2.75 30.16 30.16 27.479 27.479
19342 19342 A 0 090 0 1 0 2 1 0 1 12.63 12.67 12.67 2.44 27.74 27.74 25.284 25.284
19350 19350 A 0 090 0 1 0 2 1 1 0 9.11 13.96 9.36 1.78 24.85 20.25 22.577 18.446
19355 19355 A 0 090 0 1 0 2 1 0 0 8.52 10.69 6.57 1.82 21.03 16.91 19.071 15.372
19357 19357 A 0 090 0 1 0 2 1 2 1 18.50 23.37 23.37 3.62 45.49 45.49 41.380 41.380
19361 19361 A 0 090 0 1 0 2 1 2 1 23.36 19.37 19.37 4.60 47.33 47.33 43.160 43.160
19364 19364 A 0 090 0 1 0 2 1 2 1 42.58 31.69 31.69 8.25 82.52 82.52 75.352 75.352
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
28 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
19366 19366 A 0 090 0 1 0 2 1 2 1 21.84 15.17 15.17 4.46 41.47 41.47 37.795 37.795
19367 19367 A 0 090 0 1 0 2 1 2 1 26.80 21.61 21.61 5.27 53.68 53.68 48.962 48.962
19368 19368 A 0 090 0 1 0 2 1 2 1 33.90 25.44 25.44 6.67 66.01 66.01 60.234 60.234
19369 19369 A 0 090 0 1 0 2 1 2 1 31.31 23.81 23.81 6.15 61.27 61.27 55.908 55.908
19370 19370 A 0 090 0 1 0 2 1 1 0 9.17 9.65 9.65 1.80 20.62 20.62 18.777 18.777
19371 19371 A 0 090 0 1 0 2 1 1 0 10.62 10.90 10.90 2.07 23.59 23.59 21.491 21.491
19380 19380 A 0 090 0 1 0 2 1 1 0 10.41 10.81 10.81 2.03 23.25 23.25 21.179 21.179
19396 19396 A 0 000 0 0 0 2 1 0 0 2.17 6.32 1.79 0.45 8.94 4.41 8.081 4.013
19499 19499 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
20005 20005 A 0 010 0 1 0 2 0 1 0 3.58 5.14 2.81 0.59 9.31 6.98 8.504 6.412
20100 20100 A 0 010 0 1 0 2 1 2 0 10.38 5.41 5.41 1.96 17.75 17.75 16.263 16.263
20101 20101 A 0 010 0 1 0 2 0 1 0 3.23 9.99 2.26 0.69 13.91 6.18 12.562 5.620
20102 20102 A 0 010 0 1 0 2 0 1 0 3.98 10.16 2.75 0.80 14.94 7.53 13.522 6.868
20103 20103 A 0 010 0 1 0 2 0 0 0 5.34 11.30 4.02 0.99 17.63 10.35 16.005 9.468
20150 20150 A 0 090 0 1 0 2 1 2 1 14.75 12.19 12.19 2.93 29.87 29.87 27.229 27.229
20200 20200 A 0 000 0 0 0 2 0 1 0 1.46 4.50 1.02 0.33 6.29 2.81 5.674 2.549
20205 20205 A 0 000 0 0 0 2 0 1 0 2.35 5.87 1.67 0.56 8.78 4.58 7.914 4.143
20206 20206 A 0 000 0 0 0 2 0 1 0 0.99 5.98 0.64 0.10 7.07 1.73 6.412 1.617
20220 20220 A 0 000 0 0 0 2 0 1 0 1.27 3.62 0.74 0.11 5.00 2.12 4.578 1.992
20225 20225 A 0 000 0 0 0 2 0 1 0 1.87 13.97 1.14 0.23 16.07 3.24 14.535 3.014
20240 20240 A 0 010 0 1 0 2 0 1 0 3.28 2.80 2.80 0.52 6.60 6.60 6.066 6.066
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
29 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
20245 20245 A 0 010 0 1 0 2 0 1 0 8.95 7.97 7.97 1.65 18.57 18.57 16.970 16.970
20250 20250 A 0 010 0 1 0 2 0 1 0 5.19 5.15 5.15 1.22 11.56 11.56 10.453 10.453
20251 20251 A 0 010 0 1 0 2 0 2 0 5.72 5.42 5.42 1.32 12.46 12.46 11.278 11.278
20500 20500 A 0 010 0 1 0 2 0 1 0 1.28 1.75 1.13 0.12 3.15 2.53 2.914 2.358
20501 20501 A 0 000 0 0 0 2 0 1 0 0.76 2.65 0.27 0.07 3.48 1.10 3.176 1.039
20520 20520 A 0 010 0 1 0 2 0 1 0 1.90 3.92 2.17 0.30 6.12 4.37 5.577 4.006
20525 20525 A 0 010 0 1 0 2 0 1 0 3.54 10.49 3.24 0.64 14.67 7.42 13.295 6.784
20526 20526 A 0 000 0 0 0 2 1 1 0 0.94 1.17 0.59 0.14 2.25 1.67 2.064 1.543
20527 20527 A 0 000 0 0 0 2 1 1 0 1.00 1.10 0.63 0.15 2.25 1.78 2.066 1.644
20550 20550 A 0 000 0 0 0 2 1 1 0 0.75 0.89 0.38 0.08 1.72 1.21 1.591 1.133
20551 20551 A 0 000 0 0 0 2 0 1 0 0.75 0.95 0.42 0.08 1.78 1.25 1.645 1.169
20552 20552 A 0 000 0 0 0 2 0 1 0 0.66 0.91 0.39 0.07 1.64 1.12 1.514 1.047
20553 20553 A 0 000 0 0 0 2 0 1 0 0.75 1.09 0.44 0.07 1.91 1.26 1.765 1.182
20555 20555 A 0 000 0 0 0 2 0 0 0 6.00 2.89 2.89 0.86 9.75 9.75 9.045 9.045
20600 20600 A 0 000 0 0 0 2 1 1 0 0.66 0.66 0.30 0.07 1.39 1.03 1.289 0.966
20605 20605 A 0 000 0 0 0 2 1 1 0 0.98 0.83 0.45 0.12 1.93 1.55 1.788 1.447
20610 20610 A 0 000 0 0 0 2 1 1 0 0.79 0.87 0.44 0.12 1.78 1.35 1.634 1.248
20612 20612 A 0 000 0 0 0 2 0 1 0 0.70 1.01 0.44 0.08 1.79 1.22 1.649 1.137
20615 20615 A 0 010 0 1 0 2 0 1 0 2.33 4.65 2.19 0.29 7.27 4.81 6.657 4.448
20650 20650 A 0 010 0 1 0 2 0 1 1 2.28 3.59 2.04 0.29 6.16 4.61 5.655 4.264
20660 20660 A 0 000 0 0 0 2 0 1 0 4.00 2.05 2.05 1.10 7.15 7.15 6.416 6.416
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
30 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
20661 20661 A 0 090 0 1 0 2 0 1 0 5.26 8.30 8.30 1.65 15.21 15.21 13.576 13.576
20662 20662 A 0 090 0 1 0 2 0 0 0 6.38 5.60 5.60 0.61 12.59 12.59 11.728 11.728
20663 20663 A 0 090 0 1 0 2 1 0 0 5.74 7.11 7.11 1.14 13.99 13.99 12.721 12.721
20664 20664 A 0 090 0 1 0 2 0 1 0 10.06 12.42 12.42 3.61 26.09 26.09 23.101 23.101
20665 20665 A 0 010 0 1 0 2 0 0 0 1.36 1.59 1.15 0.11 3.06 2.62 2.845 2.450
20670 20670 A 0 010 0 1 0 2 0 1 0 1.79 9.63 2.35 0.30 11.72 4.44 10.595 4.057
20680 20680 A 0 090 0 1 0 2 0 0 0 5.96 11.77 5.68 1.06 18.79 12.70 17.084 11.615
20690 20690 A 0 090 0 1 0 2 0 1 0 8.78 7.11 7.11 1.62 17.51 17.51 16.012 16.012
20692 20692 A 0 090 0 1 0 2 0 2 1 16.27 14.11 14.11 2.80 33.18 33.18 30.405 30.405
20693 20693 A 0 090 0 1 0 2 0 1 0 6.06 6.41 6.41 1.08 13.55 13.55 12.381 12.381
20694 20694 A 0 090 0 1 0 2 0 1 0 4.28 7.72 5.04 0.76 12.76 10.08 11.610 9.203
20696 20696 A 0 090 0 1 0 2 0 2 1 17.56 15.25 15.25 1.25 34.06 34.06 31.908 31.908
20697 20697 A 3 000 0 0 0 0 0 2 1 0.00 64.55 64.55 0.01 64.56 64.56 57.971 57.971
20802 20802 A 0 090 0 1 0 2 1 2 1 42.62 22.22 22.22 3.05 67.89 67.89 64.169 64.169
20805 20805 A 0 090 0 1 0 2 1 2 1 51.46 29.22 29.22 10.14 90.82 90.82 83.003 83.003
20808 20808 A 0 090 0 1 0 2 1 2 1 63.09 31.69 31.69 12.43 107.21 107.21 98.049 98.049
20816 20816 A 0 090 0 1 0 2 0 2 1 31.95 22.72 22.72 3.99 58.66 58.66 54.439 54.439
20822 20822 A 0 090 0 1 0 2 0 2 1 26.66 22.21 22.21 5.27 54.14 54.14 49.361 49.361
20824 20824 A 0 090 0 1 0 2 1 2 1 31.95 25.09 25.09 6.29 63.33 63.33 57.770 57.770
20827 20827 A 0 090 0 1 0 2 1 2 1 27.48 22.73 22.73 5.42 55.63 55.63 50.726 50.726
20838 20838 A 0 090 0 1 0 2 1 2 1 42.88 31.00 31.00 3.06 76.94 76.94 72.318 72.318
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
31 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
20900 20900 A 0 000 0 0 0 2 0 2 1 3.00 9.27 2.71 0.56 12.83 6.27 11.617 5.726
20902 20902 A 0 000 0 0 0 2 0 2 1 4.58 3.64 3.64 0.87 9.09 9.09 8.304 8.304
20910 20910 A 0 090 0 1 0 2 0 0 0 5.53 7.24 7.24 0.71 13.48 13.48 12.403 12.403
20912 20912 A 0 090 0 1 0 2 0 0 0 6.54 6.92 6.92 0.99 14.45 14.45 13.272 13.272
20920 20920 A 0 090 0 1 0 2 0 1 1 5.51 5.63 5.63 0.69 11.83 11.83 10.927 10.927
20922 20922 A 0 090 0 1 0 2 0 2 1 6.93 10.16 6.67 1.28 18.37 14.88 16.723 13.589
20924 20924 A 0 090 0 1 0 2 0 2 1 6.68 7.17 7.17 1.20 15.05 15.05 13.746 13.746
20926 20926 A 0 090 0 1 0 2 0 1 0 5.79 6.20 6.20 1.17 13.16 13.16 11.970 11.970
20930 20930 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
20931 20931 A 0 ZZZ 0 0 0 0 0 1 1 1.81 0.93 0.93 0.56 3.30 3.30 2.938 2.938
20936 20936 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
20937 20937 A 0 ZZZ 0 0 0 0 0 2 1 2.79 1.46 1.46 0.68 4.93 4.93 4.457 4.457
20938 20938 A 0 ZZZ 0 0 0 0 0 2 1 3.02 1.57 1.57 0.83 5.42 5.42 4.864 4.864
20950 20950 A 0 000 0 0 0 2 0 0 0 1.26 6.32 1.25 0.23 7.81 2.74 7.056 2.503
20955 20955 A 0 090 0 1 0 2 0 2 1 40.26 27.57 27.57 6.67 74.50 74.50 68.506 68.506
20956 20956 A 0 090 0 1 0 2 0 2 1 41.18 28.92 28.92 8.13 78.23 78.23 71.402 71.402
20957 20957 A 0 090 0 1 0 2 0 2 1 42.61 15.93 15.93 8.41 66.95 66.95 61.314 61.314
20962 20962 A 0 090 0 1 0 2 0 2 1 39.21 17.44 17.44 7.73 64.38 64.38 58.914 58.914
20969 20969 A 0 090 0 1 0 2 0 2 1 45.43 30.80 30.80 6.67 82.90 82.90 76.577 76.577
20970 20970 A 0 090 0 1 0 2 0 2 1 44.58 27.82 27.82 8.81 81.21 81.21 74.170 74.170
20972 20972 A 0 090 0 1 0 2 0 2 0 44.51 16.27 16.27 3.43 64.21 64.21 60.914 60.914
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
32 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
20973 20973 A 0 090 0 1 0 2 1 2 1 47.27 32.55 32.55 3.38 83.20 83.20 78.268 78.268
20974 20974 A 0 000 0 0 0 0 0 1 0 0.62 1.56 0.75 0.12 2.30 1.49 2.084 1.356
20975 20975 A 0 000 0 0 0 0 0 2 1 2.60 2.05 2.05 0.59 5.24 5.24 4.749 4.749
20979 20979 A 0 000 0 0 0 0 0 1 0 0.62 0.87 0.25 0.08 1.57 0.95 1.443 0.886
20982 20982 A 0 000 0 0 0 2 1 1 0 7.27 98.45 2.93 0.80 106.52 11.00 96.097 10.320
20985 20985 A 0 ZZZ 0 0 0 0 0 0 0 2.50 1.34 1.34 0.49 4.33 4.33 3.960 3.960
20999 20999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21010 21010 A 0 090 0 1 0 2 1 0 0 11.04 10.25 10.25 1.42 22.71 22.71 20.987 20.987
21011 21011 A 0 090 0 1 0 2 0 2 0 2.99 7.08 4.31 0.45 10.52 7.75 9.583 7.096
21012 21012 A 0 090 0 1 0 2 0 2 0 4.45 4.85 4.85 0.72 10.02 10.02 9.182 9.182
21013 21013 A 0 090 0 1 0 2 0 2 0 5.42 9.37 5.67 0.82 15.61 11.91 14.263 10.941
21014 21014 A 0 090 0 1 0 2 0 2 0 7.13 7.19 7.19 1.16 15.48 15.48 14.193 14.193
21015 21015 A 0 090 0 1 0 2 0 1 0 9.89 9.39 9.39 1.86 21.14 21.14 19.295 19.295
21016 21016 A 0 090 0 1 0 2 0 2 0 15.26 12.59 12.59 2.91 30.76 30.76 28.088 28.088
21025 21025 A 0 090 0 1 0 2 0 1 0 10.03 15.23 10.93 1.44 26.70 22.40 24.460 20.598
21026 21026 A 0 090 0 1 0 2 0 1 0 5.70 12.22 8.51 0.83 18.75 15.04 17.108 13.776
21029 21029 A 0 090 0 1 0 2 0 0 0 8.39 13.51 9.44 1.65 23.55 19.48 21.385 17.730
21030 21030 A 0 090 0 1 0 2 1 1 0 4.91 10.03 6.89 0.76 15.70 12.56 14.314 11.495
21031 21031 A 0 090 0 1 0 2 1 1 0 3.30 8.13 5.08 0.41 11.84 8.79 10.815 8.076
21032 21032 A 0 090 0 1 0 2 0 1 0 3.34 8.33 4.95 0.42 12.09 8.71 11.040 8.005
21034 21034 A 0 090 0 1 0 2 0 2 1 17.38 19.86 14.93 2.44 39.68 34.75 36.490 32.063
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
33 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21040 21040 A 0 090 0 1 0 2 0 1 0 4.91 10.13 6.91 0.75 15.79 12.57 14.399 11.507
21044 21044 A 0 090 0 1 0 2 0 2 1 12.80 11.83 11.83 1.78 26.41 26.41 24.354 24.354
21045 21045 A 0 090 0 1 0 2 0 2 1 18.37 15.62 15.62 2.52 36.51 36.51 33.715 33.715
21046 21046 A 0 090 0 1 0 2 0 0 1 14.21 17.06 17.06 1.82 33.09 33.09 30.482 30.482
21047 21047 A 0 090 0 1 0 2 0 2 1 20.07 15.97 15.97 2.59 38.63 38.63 35.766 35.766
21048 21048 A 0 090 0 1 0 2 0 0 1 14.71 17.35 17.35 1.89 33.95 33.95 31.279 31.279
21049 21049 A 0 090 0 1 0 2 0 2 1 19.32 14.47 14.47 2.46 36.25 36.25 33.601 33.601
21050 21050 A 0 090 0 1 0 2 1 0 0 11.76 11.90 11.90 2.30 25.96 25.96 23.649 23.649
21060 21060 A 0 090 0 1 0 2 1 2 1 11.07 11.23 11.23 2.34 24.64 24.64 22.378 22.378
21070 21070 A 0 090 0 1 0 2 1 0 0 8.62 9.42 9.42 1.10 19.14 19.14 17.654 17.654
21073 21073 A 0 090 0 1 0 2 1 0 0 3.45 7.68 3.53 0.68 11.81 7.66 10.702 6.976
21076 21076 A 0 010 0 1 0 2 0 0 0 13.40 14.38 9.31 1.70 29.48 24.41 27.202 22.649
21077 21077 A 0 090 0 1 0 2 1 0 0 33.70 35.92 23.69 4.33 73.95 61.72 68.221 57.238
21079 21079 A 0 090 0 1 0 2 0 1 0 22.31 24.77 15.81 2.87 49.95 40.99 46.054 38.008
21080 21080 A 0 090 0 1 0 2 0 1 0 25.06 27.79 17.27 3.23 56.08 45.56 51.705 42.258
21081 21081 A 0 090 0 1 0 2 0 0 0 22.85 25.93 16.03 2.95 51.73 41.83 47.678 38.788
21082 21082 A 0 090 0 1 0 2 0 0 0 20.84 25.63 15.96 2.67 49.14 39.47 45.252 36.568
21083 21083 A 0 090 0 1 0 2 0 0 0 19.27 25.18 14.93 1.37 45.82 35.57 42.598 33.394
21084 21084 A 0 090 0 1 0 2 0 0 0 22.48 28.11 17.03 2.90 53.49 42.41 49.239 39.290
21085 21085 A 0 010 0 1 0 2 0 0 0 8.99 12.52 6.54 3.35 24.86 18.88 21.985 16.615
21086 21086 A 0 090 0 1 0 2 1 0 0 24.88 27.03 17.44 3.20 55.11 45.52 50.827 42.215
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
34 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21087 21087 A 0 090 0 1 0 2 0 0 0 24.88 26.49 16.53 3.20 54.57 44.61 50.342 41.398
21088 21088 C 0 090 0 1 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21089 21089 C 0 YYY 0 0 0 0 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21100 21100 A 0 090 0 1 0 2 0 0 0 4.73 12.96 4.90 0.64 18.33 10.27 16.703 9.465
21110 21110 A 0 090 0 1 0 2 0 1 0 5.99 17.65 13.60 0.76 24.40 20.35 22.237 18.600
21116 21116 A 0 000 0 0 0 2 1 1 0 0.81 3.74 0.40 0.05 4.60 1.26 4.195 1.195
21120 21120 A 0 090 0 1 0 2 0 1 1 5.10 12.91 8.98 1.01 19.02 15.09 17.221 13.692
21121 21121 A 0 090 0 1 0 2 0 2 0 7.81 14.83 10.74 0.54 23.18 19.09 21.410 17.737
21122 21122 A 0 090 0 1 0 2 0 2 0 8.71 11.61 11.61 0.61 20.93 20.93 19.455 19.455
21123 21123 A 0 090 0 1 0 2 0 2 1 11.34 13.94 13.94 0.80 26.08 26.08 24.277 24.277
21125 21125 A 0 090 0 1 0 2 0 2 0 10.80 92.91 10.42 2.14 105.85 23.36 95.352 21.276
21127 21127 A 0 090 0 1 0 2 0 2 1 12.44 105.70 12.59 1.59 119.73 26.62 108.190 24.577
21137 21137 A 0 090 0 1 0 2 0 2 0 10.24 8.62 8.62 2.00 20.86 20.86 19.027 19.027
21138 21138 A 0 090 0 1 0 2 0 2 1 12.87 10.11 10.11 1.82 24.80 24.80 22.901 22.901
21139 21139 A 0 090 0 1 0 2 0 2 1 15.02 13.31 13.31 1.06 29.39 29.39 27.527 27.527
21141 21141 A 0 090 0 1 0 2 0 2 1 19.57 17.15 17.15 3.85 40.57 40.57 36.984 36.984
21142 21142 A 0 090 0 1 0 2 0 2 1 20.28 17.42 17.42 4.00 41.70 41.70 38.015 38.015
21143 21143 A 0 090 0 1 0 2 0 2 1 21.05 18.59 18.59 4.49 44.13 44.13 40.092 40.092
21145 21145 A 0 090 0 1 0 2 0 2 0 23.94 18.89 18.89 1.69 44.52 44.52 41.787 41.787
21146 21146 A 0 090 0 1 0 2 0 2 1 24.87 18.17 18.17 4.90 47.94 47.94 43.749 43.749
21147 21147 A 0 090 0 1 0 2 0 2 0 26.47 23.13 23.13 1.88 51.48 51.48 48.224 48.224
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
35 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21150 21150 A 0 090 0 1 0 2 0 2 0 25.96 17.58 17.58 1.84 45.38 45.38 42.709 42.709
21151 21151 A 0 090 0 1 0 2 0 2 0 29.02 22.60 22.60 3.74 55.36 55.36 51.271 51.271
21154 21154 A 0 090 0 1 0 2 0 2 1 31.29 24.19 24.19 4.01 59.49 59.49 55.110 55.110
21155 21155 A 0 090 0 1 0 2 0 2 0 35.22 26.16 26.16 2.50 63.88 63.88 60.019 60.019
21159 21159 A 0 090 0 1 0 2 0 2 1 43.14 27.51 27.51 5.53 76.18 76.18 70.736 70.736
21160 21160 A 0 090 0 1 0 2 0 2 0 47.19 26.57 26.57 3.36 77.12 77.12 72.807 72.807
21172 21172 A 0 090 0 1 0 2 0 2 1 28.20 23.75 23.75 3.62 55.57 55.57 51.421 51.421
21175 21175 A 0 090 0 1 0 2 0 2 0 33.56 26.28 26.28 12.03 71.87 71.87 63.451 63.451
21179 21179 A 0 090 0 1 0 2 0 2 0 22.65 15.05 15.05 4.46 42.16 42.16 38.497 38.497
21180 21180 A 0 090 0 1 0 2 0 2 1 25.58 16.61 16.61 3.29 45.48 45.48 42.216 42.216
21181 21181 A 0 090 0 1 0 2 0 0 0 10.28 8.24 8.24 1.31 19.83 19.83 18.365 18.365
21182 21182 A 0 090 0 1 0 2 0 2 1 32.58 25.87 25.87 4.18 62.63 62.63 57.997 57.997
21183 21183 A 0 090 0 1 0 2 0 2 1 35.70 27.97 27.97 7.02 70.69 70.69 64.489 64.489
21184 21184 A 0 090 0 1 0 2 0 2 0 38.62 18.95 18.95 7.62 65.19 65.19 59.622 59.622
21188 21188 A 0 090 0 1 0 2 0 2 0 23.15 20.91 20.91 2.98 47.04 47.04 43.486 43.486
21193 21193 A 0 090 0 1 0 2 2 2 1 18.90 14.17 14.17 4.04 37.11 37.11 33.738 33.738
21194 21194 A 0 090 0 1 0 2 2 2 0 21.82 16.03 16.03 2.80 40.65 40.65 37.679 37.679
21195 21195 A 0 090 0 1 0 2 2 2 0 19.16 18.43 18.43 2.45 40.04 40.04 36.991 36.991
21196 21196 A 0 090 0 1 0 2 2 2 1 20.83 20.47 20.47 2.67 43.97 43.97 40.608 40.608
21198 21198 A 0 090 0 1 0 2 0 2 1 15.71 16.83 16.83 2.18 34.72 34.72 31.963 31.963
21199 21199 A 0 090 0 1 0 2 0 2 1 16.73 11.03 11.03 2.15 29.91 29.91 27.759 27.759
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
36 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21206 21206 A 0 090 0 1 0 2 0 2 1 15.59 19.04 19.04 3.09 37.72 37.72 34.304 34.304
21208 21208 A 0 090 0 1 0 2 0 0 0 11.42 45.30 12.15 2.25 58.97 25.82 53.276 23.507
21209 21209 A 0 090 0 1 0 2 0 2 0 7.82 16.11 9.91 1.54 25.47 19.27 23.092 17.525
21210 21210 A 0 090 0 1 0 2 0 1 0 11.69 57.10 12.39 1.51 70.30 25.59 63.756 23.606
21215 21215 A 0 090 0 1 0 2 0 1 1 12.23 111.40 12.76 2.40 126.03 27.39 113.522 24.944
21230 21230 A 0 090 0 1 0 2 0 0 0 11.17 8.61 8.61 2.19 21.97 21.97 20.047 20.047
21235 21235 A 0 090 0 1 0 2 0 1 0 7.50 13.58 8.56 1.10 22.18 17.16 20.270 15.762
21240 21240 A 0 090 0 1 0 2 1 2 1 16.07 14.67 14.67 2.04 32.78 32.78 30.311 30.311
21242 21242 A 0 090 0 1 0 2 1 2 1 14.59 13.51 13.51 1.88 29.98 29.98 27.705 27.705
21243 21243 A 0 090 0 1 0 2 1 2 1 24.53 21.93 21.93 3.16 49.62 49.62 45.876 45.876
21244 21244 A 0 090 0 1 0 2 0 2 1 13.62 16.53 16.53 1.93 32.08 32.08 29.473 29.473
21245 21245 A 0 090 0 1 0 2 0 2 0 13.12 18.92 11.79 1.67 33.71 26.58 30.984 24.581
21246 21246 A 0 090 0 1 0 2 0 2 0 12.92 9.92 9.92 1.65 24.49 24.49 22.691 22.691
21247 21247 A 0 090 0 1 0 2 1 2 1 24.37 18.04 18.04 4.82 47.23 47.23 43.091 43.091
21248 21248 A 0 090 0 1 0 2 0 1 0 12.74 18.73 12.42 1.63 33.10 26.79 30.412 24.746
21249 21249 A 0 090 0 1 0 2 0 0 0 18.77 23.91 15.45 2.40 45.08 36.62 41.496 33.899
21255 21255 A 0 090 0 1 0 2 1 2 1 18.46 18.95 18.95 2.35 39.76 39.76 36.706 36.706
21256 21256 A 0 090 0 1 0 2 1 2 1 17.66 16.70 16.70 2.26 36.62 36.62 33.839 33.839
21260 21260 A 0 090 0 1 0 2 0 2 1 17.90 17.65 17.65 1.27 36.82 36.82 34.414 34.414
21261 21261 A 0 090 0 1 0 2 0 2 1 34.07 23.66 23.66 6.72 64.45 64.45 58.831 58.831
21263 21263 A 0 090 0 1 0 2 0 2 1 31.01 22.42 22.42 2.20 55.63 55.63 52.294 52.294
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
37 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21267 21267 A 0 090 0 1 0 2 1 2 1 20.69 25.15 25.15 4.08 49.92 49.92 45.409 45.409
21268 21268 A 0 090 0 1 0 2 1 2 1 27.07 20.83 20.83 5.34 53.24 53.24 48.568 48.568
21270 21270 A 0 090 0 1 0 2 1 2 1 10.63 17.36 9.96 1.51 29.50 22.10 27.009 20.364
21275 21275 A 0 090 0 1 0 2 0 2 1 11.76 11.15 11.15 2.30 25.21 25.21 22.976 22.976
21280 21280 A 0 090 0 1 0 2 1 0 0 7.13 9.18 9.18 1.40 17.71 17.71 16.106 16.106
21282 21282 A 0 090 0 1 0 2 1 1 0 4.27 6.67 6.67 0.78 11.72 11.72 10.668 10.668
21295 21295 A 0 090 0 1 0 2 1 0 0 1.90 3.66 3.66 0.37 5.93 5.93 5.380 5.380
21296 21296 A 0 090 0 1 0 2 1 0 0 4.78 7.96 7.96 0.61 13.35 13.35 12.247 12.247
21299 21299 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21310 21310 A 0 000 0 0 0 2 0 1 0 0.58 3.42 0.13 0.10 4.10 0.81 3.703 0.749
21315 21315 A 0 010 0 1 0 2 0 1 0 1.83 6.55 2.51 0.29 8.67 4.63 7.864 4.236
21320 21320 A 0 010 0 1 0 2 0 1 0 1.88 5.77 1.91 0.27 7.92 4.06 7.203 3.736
21325 21325 A 0 090 0 1 0 2 0 0 0 4.18 9.41 9.41 0.67 14.26 14.26 12.981 12.981
21330 21330 A 0 090 0 1 0 2 0 0 0 5.79 10.62 10.62 0.73 17.14 17.14 15.709 15.709
21335 21335 A 0 090 0 1 0 2 0 1 0 9.02 11.67 11.67 1.22 21.91 21.91 20.138 20.138
21336 21336 A 0 090 0 1 0 2 0 0 0 6.77 11.92 11.92 0.91 19.60 19.60 17.950 17.950
21337 21337 A 0 090 0 1 0 2 0 0 0 3.39 8.54 5.07 0.52 12.45 8.98 11.331 8.215
21338 21338 A 0 090 0 1 0 2 0 0 0 6.87 14.65 14.65 1.36 22.88 22.88 20.737 20.737
21339 21339 A 0 090 0 1 0 2 0 2 1 8.50 15.67 15.67 1.66 25.83 25.83 23.440 23.440
21340 21340 A 0 090 0 1 0 2 0 0 0 11.49 11.57 11.57 1.48 24.54 24.54 22.654 22.654
21343 21343 A 0 090 0 1 0 2 0 2 1 14.32 19.70 19.70 2.83 36.85 36.85 33.491 33.491
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
38 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21344 21344 A 0 090 0 1 0 2 0 2 2 21.57 17.12 17.12 7.74 46.43 46.43 40.992 40.992
21345 21345 A 0 090 0 1 0 2 0 0 0 9.06 15.08 9.80 1.17 25.31 20.03 23.214 18.472
21346 21346 A 0 090 0 1 0 2 0 1 1 11.45 14.54 14.54 1.48 27.47 27.47 25.281 25.281
21347 21347 A 0 090 0 1 0 2 0 2 1 13.53 18.12 18.12 1.71 33.36 33.36 30.696 30.696
21348 21348 A 0 090 0 1 0 2 0 2 2 17.52 15.42 15.42 2.25 35.19 35.19 32.544 32.544
21355 21355 A 0 010 0 1 0 2 1 0 0 4.45 8.11 4.65 0.56 13.12 9.66 12.026 8.919
21356 21356 A 0 010 0 1 0 2 1 0 0 4.83 9.70 5.83 0.71 15.24 11.37 13.912 10.437
21360 21360 A 0 090 0 1 0 2 1 2 0 7.19 7.85 7.85 0.91 15.95 15.95 14.715 14.715
21365 21365 A 0 090 0 1 0 2 1 2 1 16.77 13.66 13.66 2.80 33.23 33.23 30.501 30.501
21366 21366 A 0 090 0 1 0 2 1 2 2 18.60 16.11 16.11 3.67 38.38 38.38 34.986 34.986
21385 21385 A 0 090 0 1 0 2 1 2 1 9.57 9.74 9.74 1.22 20.53 20.53 18.955 18.955
21386 21386 A 0 090 0 1 0 2 1 2 0 9.57 9.55 9.55 1.88 21.00 21.00 19.129 19.129
21387 21387 A 0 090 0 1 0 2 1 2 0 10.11 10.00 10.00 1.97 22.08 22.08 20.120 20.120
21390 21390 A 0 090 0 1 0 2 1 2 1 11.23 11.03 11.03 1.89 24.15 24.15 22.123 22.123
21395 21395 A 0 090 0 1 0 2 1 2 1 14.70 12.76 12.76 1.88 29.34 29.34 27.142 27.142
21400 21400 A 0 090 0 1 0 2 1 0 0 1.50 4.17 3.03 0.27 5.94 4.80 5.386 4.362
21401 21401 A 0 090 0 1 0 2 1 2 0 3.68 9.92 4.51 0.72 14.32 8.91 12.965 8.107
21406 21406 A 0 090 0 1 0 2 1 2 1 7.42 8.44 8.44 0.95 16.81 16.81 15.496 15.496
21407 21407 A 0 090 0 1 0 2 1 2 1 9.02 9.04 9.04 1.59 19.65 19.65 17.969 17.969
21408 21408 A 0 090 0 1 0 2 1 2 2 12.78 11.39 11.39 2.52 26.69 26.69 24.326 24.326
21421 21421 A 0 090 0 1 0 2 0 0 0 6.02 17.43 13.12 1.18 24.63 20.32 22.289 18.419
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
39 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21422 21422 A 0 090 0 1 0 2 0 2 1 8.73 10.07 10.07 1.13 19.93 19.93 18.364 18.364
21423 21423 A 0 090 0 1 0 2 0 2 2 10.85 11.93 11.93 2.14 24.92 24.92 22.682 22.682
21431 21431 A 0 090 0 1 0 2 0 2 0 7.90 12.97 12.97 1.55 22.42 22.42 20.358 20.358
21432 21432 A 0 090 0 1 0 2 0 2 0 8.82 11.06 11.06 1.71 21.59 21.59 19.646 19.646
21433 21433 A 0 090 0 1 0 2 0 2 1 26.29 20.87 20.87 5.19 52.35 52.35 47.746 47.746
21435 21435 A 0 090 0 1 0 2 0 2 0 20.26 18.06 18.06 2.60 40.92 40.92 37.838 37.838
21436 21436 A 0 090 0 1 0 2 0 2 2 30.30 16.94 16.94 5.97 53.21 53.21 48.634 48.634
21440 21440 A 0 090 0 1 0 2 0 0 0 3.44 13.77 10.36 0.67 17.88 14.47 16.156 13.094
21445 21445 A 0 090 0 1 0 2 0 2 0 6.26 16.27 11.78 0.80 23.33 18.84 21.289 17.257
21450 21450 A 0 090 0 1 0 2 0 0 0 3.71 14.55 10.75 0.65 18.91 15.11 17.116 13.703
21451 21451 A 0 090 0 1 0 2 0 0 0 5.65 16.85 13.00 0.72 23.22 19.37 21.158 17.701
21452 21452 A 0 090 0 1 0 2 0 0 0 2.40 14.48 7.58 0.48 17.36 10.46 15.654 9.458
21453 21453 A 0 090 0 1 0 2 0 0 0 6.64 20.34 16.23 1.05 28.03 23.92 25.454 21.764
21454 21454 A 0 090 0 1 0 2 0 0 1 7.36 7.92 7.92 0.93 16.21 16.21 14.959 14.959
21461 21461 A 0 090 0 1 0 2 0 1 1 9.31 55.62 17.95 1.40 66.33 28.66 59.989 26.161
21462 21462 A 0 090 0 1 0 2 0 2 1 11.01 57.28 19.06 1.42 69.71 31.49 63.190 28.869
21465 21465 A 0 090 0 1 0 2 1 2 1 13.12 12.42 12.42 2.59 28.13 28.13 25.628 25.628
21470 21470 A 0 090 0 1 0 2 0 2 1 17.54 15.60 15.60 2.90 36.04 36.04 33.066 33.066
21480 21480 A 0 000 0 0 0 2 1 1 0 0.61 2.30 0.24 0.10 3.01 0.95 2.728 0.878
21485 21485 A 0 090 0 1 0 2 1 0 0 4.77 16.04 12.43 0.61 21.42 17.81 19.493 16.251
21490 21490 A 0 090 0 1 0 2 1 2 1 12.95 12.26 12.26 2.56 27.77 27.77 25.298 25.298
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
40 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21495 21495 A 0 090 0 1 0 2 0 2 0 6.79 14.13 14.13 0.86 21.78 21.78 19.929 19.929
21497 21497 A 0 090 0 1 0 2 0 0 0 4.64 17.31 13.37 0.90 22.85 18.91 20.655 17.117
21499 21499 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21501 21501 A 0 090 0 1 0 2 0 1 0 3.98 9.18 4.99 0.75 13.91 9.72 12.616 8.853
21502 21502 A 0 090 0 1 0 2 0 2 0 7.55 5.85 5.85 1.61 15.01 15.01 13.645 13.645
21510 21510 A 0 090 0 1 0 2 0 0 0 6.20 5.71 5.71 1.46 13.37 13.37 12.091 12.091
21550 21550 A 0 010 0 1 0 2 0 1 0 2.11 5.54 2.30 0.30 7.95 4.71 7.242 4.332
21552 21552 A 0 090 0 1 0 2 0 2 0 6.49 5.50 5.50 1.28 13.27 13.27 12.098 12.098
21554 21554 A 0 090 0 1 0 2 0 2 0 11.13 8.43 8.43 2.08 21.64 21.64 19.788 19.788
21555 21555 A 0 090 0 1 0 2 0 1 0 3.96 7.92 4.48 0.78 12.66 9.22 11.480 8.391
21556 21556 A 0 090 0 1 0 2 0 1 0 7.66 6.83 6.83 1.44 15.93 15.93 14.546 14.546
21557 21557 A 0 090 0 1 0 2 0 2 1 14.75 11.02 11.02 2.79 28.56 28.56 26.105 26.105
21558 21558 A 0 090 0 1 0 2 0 2 1 21.58 14.09 14.09 4.08 39.75 39.75 36.367 36.367
21600 21600 A 0 090 0 1 0 2 0 2 1 7.26 8.10 8.10 1.57 16.93 16.93 15.355 15.355
21610 21610 A 0 090 0 1 0 2 0 2 0 15.91 12.11 12.11 5.72 33.74 33.74 29.776 29.776
21615 21615 A 0 090 0 1 0 2 1 2 1 10.45 6.23 6.23 2.46 19.14 19.14 17.331 17.331
21616 21616 A 0 090 0 1 0 2 1 2 0 12.69 9.29 9.29 3.04 25.02 25.02 22.622 22.622
21620 21620 A 0 090 0 1 0 2 0 2 1 7.28 6.44 6.44 1.62 15.34 15.34 13.910 13.910
21627 21627 A 0 090 0 1 0 2 0 2 0 7.30 7.45 7.45 1.65 16.40 16.40 14.853 14.853
21630 21630 A 0 090 0 1 0 2 0 2 1 19.18 13.22 13.22 4.04 36.44 36.44 33.164 33.164
21632 21632 A 0 090 0 1 0 2 0 2 1 19.68 11.83 11.83 4.94 36.45 36.45 32.887 32.887
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
41 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21685 21685 A 0 090 0 1 0 2 0 2 1 15.26 12.58 12.58 1.96 29.80 29.80 27.582 27.582
21700 21700 A 0 090 0 1 0 2 1 2 0 6.31 3.32 3.32 1.50 11.13 11.13 10.076 10.076
21705 21705 A 0 090 0 1 0 2 1 2 0 9.92 4.29 4.29 2.34 16.55 16.55 14.996 14.996
21720 21720 A 0 090 0 1 0 2 0 2 0 5.80 7.85 7.85 2.07 15.72 15.72 13.932 13.932
21725 21725 A 0 090 0 1 0 2 0 2 1 7.19 6.02 6.02 1.42 14.63 14.63 13.339 13.339
21740 21740 A 0 090 0 1 0 2 0 2 1 17.57 15.06 15.06 3.47 36.10 36.10 32.909 32.909
21742 21742 C 0 090 0 1 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21743 21743 C 0 090 0 1 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21750 21750 A 0 090 0 1 0 2 0 2 1 11.40 6.47 6.47 2.71 20.58 20.58 18.627 18.627
21800 21800 A 0 090 0 1 0 2 0 1 0 1.01 2.26 2.38 0.18 3.45 3.57 3.134 3.241
21805 21805 A 0 090 0 1 0 2 0 0 0 2.88 4.54 4.54 0.67 8.09 8.09 7.307 7.307
21810 21810 A 0 090 0 1 0 2 0 2 0 7.03 6.94 6.94 1.63 15.60 15.60 14.115 14.115
21820 21820 A 0 090 0 1 0 2 0 1 0 1.36 2.69 2.80 0.26 4.31 4.42 3.912 4.010
21825 21825 A 0 090 0 1 0 2 0 2 1 7.76 6.84 6.84 1.82 16.42 16.42 14.854 14.854
21899 21899 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
21920 21920 A 0 010 0 1 0 2 0 1 0 2.11 5.47 2.42 0.34 7.92 4.87 7.200 4.461
21925 21925 A 0 090 0 1 0 2 0 1 0 4.63 7.98 5.08 0.93 13.54 10.64 12.282 9.678
21930 21930 A 0 090 0 1 0 2 0 1 0 4.94 8.37 4.98 1.02 14.33 10.94 12.990 9.946
21931 21931 A 0 090 0 1 0 2 0 2 0 6.88 5.69 5.69 1.42 13.99 13.99 12.732 12.732
21932 21932 A 0 090 0 1 0 2 0 2 0 9.82 7.74 7.74 2.08 19.64 19.64 17.858 17.858
21933 21933 A 0 090 0 1 0 2 0 2 0 11.13 8.41 8.41 2.35 21.89 21.89 19.911 19.911
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
42 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
21935 21935 A 0 090 0 1 0 2 0 1 1 15.72 11.69 11.69 3.21 30.62 30.62 27.896 27.896
21936 21936 A 0 090 0 1 0 2 0 2 1 22.55 14.57 14.57 4.60 41.72 41.72 38.040 38.040
22010 22010 A 0 090 0 1 0 2 0 0 0 12.75 12.16 12.16 3.29 28.20 28.20 25.390 25.390
22015 22015 A 0 090 0 1 0 2 0 1 0 12.64 11.12 11.12 3.08 26.84 26.84 24.237 24.237
22100 22100 A 0 090 0 1 0 2 0 2 1 11.00 12.76 12.76 3.96 27.72 27.72 24.530 24.530
22101 22101 A 0 090 0 1 0 2 0 2 1 11.08 11.08 11.08 3.97 26.13 26.13 23.106 23.106
22102 22102 A 0 090 0 1 0 2 0 2 1 11.08 10.22 10.22 2.67 23.97 23.97 21.654 21.654
22103 22103 A 0 ZZZ 0 0 0 0 0 2 1 2.34 1.18 1.18 0.64 4.16 4.16 3.734 3.734
22110 22110 A 0 090 0 1 0 2 0 2 1 14.00 13.07 13.07 5.04 32.11 32.11 28.373 28.373
22112 22112 A 0 090 0 1 0 2 0 2 1 14.07 12.68 12.68 5.05 31.80 31.80 28.098 28.098
22114 22114 A 0 090 0 1 0 2 0 2 1 14.07 12.83 12.83 2.78 29.68 29.68 27.045 27.045
22116 22116 A 0 ZZZ 0 0 0 0 0 2 1 2.32 1.18 1.18 0.60 4.10 4.10 3.693 3.693
22206 22206 A 0 090 0 1 0 2 0 2 1 37.18 25.25 25.25 7.32 69.75 69.75 63.683 63.683
22207 22207 A 0 090 0 1 0 2 0 2 1 36.68 24.83 24.83 9.20 70.71 70.71 63.789 63.789
22208 22208 A 0 ZZZ 0 0 0 0 0 2 1 9.66 5.08 5.08 2.59 17.33 17.33 15.576 15.576
22210 22210 A 0 090 0 1 0 2 0 2 1 25.38 20.44 20.44 6.75 52.57 52.57 47.265 47.265
22212 22212 A 0 090 0 1 0 2 0 2 1 20.99 17.82 17.82 4.97 43.78 43.78 39.592 39.592
22214 22214 A 0 090 0 1 0 2 0 2 1 21.02 17.86 17.86 5.12 44.00 44.00 39.736 39.736
22216 22216 A 0 ZZZ 0 0 0 0 0 2 1 6.03 3.18 3.18 1.51 10.72 10.72 9.675 9.675
22220 22220 A 0 090 0 1 0 2 0 2 1 22.94 18.94 18.94 6.42 48.30 48.30 43.306 43.306
22222 22222 A 0 090 0 1 0 2 0 2 1 23.09 15.28 15.28 4.55 42.92 42.92 39.191 39.191
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
43 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
22224 22224 A 0 090 0 1 0 2 0 2 1 23.09 18.64 18.64 5.38 47.11 47.11 42.642 42.642
22226 22226 A 0 ZZZ 0 0 0 0 0 2 1 6.03 3.13 3.13 1.58 10.74 10.74 9.667 9.667
22305 22305 A 0 090 0 1 0 2 0 1 0 2.13 3.23 2.68 0.41 5.77 5.22 5.245 4.751
22310 22310 A 0 090 0 1 0 2 0 1 0 3.89 4.47 3.72 0.78 9.14 8.39 8.312 7.639
22315 22315 A 0 090 0 1 0 2 0 1 0 10.11 13.73 10.34 2.55 26.39 23.00 23.773 20.729
22318 22318 A 0 090 0 1 0 2 0 2 2 22.72 18.15 18.15 7.68 48.55 48.55 43.035 43.035
22319 22319 A 0 090 0 1 0 2 0 2 2 25.33 19.77 19.77 9.11 54.21 54.21 47.848 47.848
22325 22325 A 0 090 0 1 0 2 0 2 1 19.87 17.31 17.31 5.69 42.87 42.87 38.390 38.390
22326 22326 A 0 090 0 1 0 2 0 2 1 20.84 17.09 17.09 6.30 44.23 44.23 39.482 39.482
22327 22327 A 0 090 0 1 0 2 0 2 1 20.77 17.81 17.81 5.62 44.20 44.20 39.703 39.703
22328 22328 A 0 ZZZ 0 0 0 0 0 2 1 4.60 2.38 2.38 1.36 8.34 8.34 7.449 7.449
22505 22505 A 0 010 0 1 0 2 0 1 0 1.87 1.49 1.49 0.29 3.65 3.65 3.360 3.360
22520 22520 A 0 010 0 1 0 2 0 1 0 9.22 58.41 4.60 1.06 68.69 14.88 62.227 13.905
22521 22521 A 0 010 0 1 0 2 0 1 0 8.65 59.10 4.55 1.01 68.76 14.21 62.250 13.264
22522 22522 A 0 ZZZ 0 0 0 0 0 1 0 4.30 1.73 1.73 0.54 6.57 6.57 6.136 6.136
22523 22523 A 0 010 0 1 0 2 0 1 0 9.04 224.14 5.82 1.78 234.96 16.64 211.249 15.197
22524 22524 A 0 010 0 1 0 2 0 1 0 8.54 223.34 5.59 1.68 233.56 15.81 209.978 14.438
22525 22525 A 0 ZZZ 0 0 0 0 0 1 0 4.47 139.24 2.13 0.95 144.66 7.55 130.004 6.880
22526 22526 N 9 010 0 1 0 9 9 9 9 6.10 66.36 3.39 0.54 73.00 10.03 65.974 9.427
22527 22527 N 9 ZZZ 0 0 0 9 9 9 9 3.03 57.64 1.23 0.24 60.91 4.50 54.916 4.260
22532 22532 A 0 090 0 1 0 2 0 2 2 25.99 19.40 19.40 7.57 52.96 52.96 47.370 47.370
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
44 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
22533 22533 A 0 090 0 1 0 2 0 2 2 24.79 18.58 18.58 6.38 49.75 49.75 44.812 44.812
22534 22534 A 0 ZZZ 0 0 0 0 0 2 2 5.99 3.12 3.12 1.59 10.70 10.70 9.623 9.623
22548 22548 A 0 090 0 1 0 2 0 2 2 27.06 21.48 21.48 9.72 58.26 58.26 51.433 51.433
22551 22551 A 0 090 0 1 0 2 0 2 2 25.00 18.38 18.38 7.57 50.95 50.95 45.464 45.464
22552 22552 A 0 ZZZ 0 0 0 0 0 2 2 6.50 3.35 3.35 1.78 11.63 11.63 10.439 10.439
22554 22554 A 0 090 0 1 0 2 0 2 2 17.69 14.64 14.64 5.47 37.80 37.80 33.698 33.698
22556 22556 A 0 090 0 1 0 2 0 2 2 24.70 18.10 18.10 6.63 49.43 49.43 44.421 44.421
22558 22558 A 0 090 0 1 0 2 0 2 2 23.53 16.56 16.56 5.66 45.75 45.75 41.361 41.361
22585 22585 A 0 ZZZ 0 0 0 0 0 2 2 5.52 2.77 2.77 1.59 9.88 9.88 8.839 8.839
22586 22586 A 0 090 0 1 0 2 0 2 2 28.12 10.37 10.37 6.76 45.25 45.25 40.968 40.968
22590 22590 A 0 090 0 1 0 2 0 2 2 21.76 18.18 18.18 7.05 46.99 46.99 41.773 41.773
22595 22595 A 0 090 0 1 0 2 0 2 2 20.64 17.55 17.55 6.57 44.76 44.76 39.836 39.836
22600 22600 A 0 090 0 1 0 2 0 2 2 17.40 15.72 15.72 5.32 38.44 38.44 34.299 34.299
22610 22610 A 0 090 0 1 0 2 0 2 2 17.28 15.44 15.44 4.86 37.58 37.58 33.687 33.687
22612 22612 A 0 090 0 1 0 2 0 2 2 23.53 17.60 17.60 6.23 47.36 47.36 42.593 42.593
22614 22614 A 0 ZZZ 0 0 0 0 0 2 2 6.43 3.34 3.34 1.77 11.54 11.54 10.355 10.355
22630 22630 A 0 090 0 1 0 2 0 2 2 22.09 17.57 17.57 6.27 45.93 45.93 41.147 41.147
22632 22632 A 0 ZZZ 0 0 0 0 0 2 2 5.22 2.71 2.71 1.50 9.43 9.43 8.438 8.438
22633 22633 A 0 090 0 1 0 2 0 2 2 27.75 19.45 19.45 7.35 54.55 54.55 49.060 49.060
22634 22634 A 0 ZZZ 0 0 0 0 0 2 2 8.16 4.23 4.23 2.25 14.64 14.64 13.135 13.135
22800 22800 A 0 090 0 1 0 2 0 2 1 19.50 15.91 15.91 4.90 40.31 40.31 36.350 36.350
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
45 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
22802 22802 A 0 090 0 1 0 2 0 2 1 32.11 22.50 22.50 7.51 62.12 62.12 56.243 56.243
22804 22804 A 0 090 0 1 0 2 0 2 1 37.50 25.42 25.42 8.53 71.45 71.45 64.788 64.788
22808 22808 A 0 090 0 1 0 2 0 2 1 27.51 19.38 19.38 7.27 54.16 54.16 48.715 48.715
22810 22810 A 0 090 0 1 0 2 0 2 1 31.50 20.79 20.79 7.93 60.22 60.22 54.317 54.317
22812 22812 A 0 090 0 1 0 2 0 2 1 34.25 24.45 24.45 6.75 65.45 65.45 59.736 59.736
22818 22818 A 0 090 0 1 0 2 0 2 2 34.33 23.99 23.99 6.76 65.08 65.08 59.409 59.409
22819 22819 A 0 090 0 1 0 2 0 2 2 39.38 27.75 27.75 14.15 81.28 81.28 71.700 71.700
22830 22830 A 0 090 0 1 0 2 0 2 1 11.22 10.07 10.07 2.90 24.19 24.19 21.780 21.780
22840 22840 A 0 ZZZ 0 0 0 0 0 2 1 12.52 6.51 6.51 3.48 22.51 22.51 20.186 20.186
22841 22841 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
22842 22842 A 0 ZZZ 0 0 0 0 0 2 2 12.56 6.53 6.53 3.44 22.53 22.53 20.223 20.223
22843 22843 A 0 ZZZ 0 0 0 0 0 2 2 13.44 7.02 7.02 3.50 23.96 23.96 21.574 21.574
22844 22844 A 0 ZZZ 0 0 0 0 0 2 2 16.42 8.71 8.71 3.69 28.82 28.82 26.171 26.171
22845 22845 A 0 ZZZ 0 0 0 0 0 2 2 11.94 6.15 6.15 3.66 21.75 21.75 19.377 19.377
22846 22846 A 0 ZZZ 0 0 0 0 0 2 2 12.40 6.39 6.39 3.77 22.56 22.56 20.110 20.110
22847 22847 A 0 ZZZ 0 0 0 0 0 2 2 13.78 7.01 7.01 4.95 25.74 25.74 22.664 22.664
22848 22848 A 0 ZZZ 0 0 0 0 0 2 2 5.99 3.16 3.16 1.39 10.54 10.54 9.555 9.555
22849 22849 A 0 090 0 1 0 2 0 2 1 19.17 14.30 14.30 5.14 38.61 38.61 34.700 34.700
22850 22850 A 0 090 0 1 0 2 0 2 1 9.82 9.13 9.13 2.61 21.56 21.56 19.384 19.384
22851 22851 A 0 ZZZ 0 0 0 0 0 2 2 6.70 3.47 3.47 1.89 12.06 12.06 10.805 10.805
22852 22852 A 0 090 0 1 0 2 0 2 1 9.37 8.86 8.86 2.41 20.64 20.64 18.587 18.587
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
46 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
22855 22855 A 0 090 0 1 0 2 0 2 1 15.86 12.71 12.71 4.75 33.32 33.32 29.758 29.758
22856 22856 A 0 090 0 1 0 2 0 2 2 24.05 18.20 18.20 7.28 49.53 49.53 44.201 44.201
22857 22857 R 0 090 0 1 0 2 0 2 2 27.13 9.40 9.40 5.78 42.31 42.31 38.594 38.594
22861 22861 A 0 090 0 1 0 2 0 2 2 33.36 23.58 23.58 9.12 66.06 66.06 59.305 59.305
22862 22862 R 0 090 0 1 0 2 0 2 2 32.63 16.92 16.92 6.42 55.97 55.97 51.182 51.182
22864 22864 A 0 090 0 1 0 2 0 2 2 29.40 21.56 21.56 8.04 59.00 59.00 52.966 52.966
22865 22865 R 0 090 0 1 0 2 0 2 2 31.75 23.95 23.95 6.25 61.95 61.95 56.526 56.526
22899 22899 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
22900 22900 A 0 090 0 1 0 2 0 2 1 8.32 6.69 6.69 1.71 16.72 16.72 15.222 15.222
22901 22901 A 0 090 0 1 0 2 0 2 1 10.11 7.47 7.47 2.10 19.68 19.68 17.916 17.916
22902 22902 A 0 090 0 1 0 2 0 2 1 4.42 7.94 4.56 0.71 13.07 9.69 11.921 8.886
22903 22903 A 0 090 0 1 0 2 0 2 1 6.39 5.33 5.33 1.21 12.93 12.93 11.809 11.809
22904 22904 A 0 090 0 1 0 2 0 2 1 16.69 10.94 10.94 3.55 31.18 31.18 28.371 28.371
22905 22905 A 0 090 0 1 0 2 0 2 1 21.58 13.19 13.19 4.60 39.37 39.37 35.830 35.830
22999 22999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
23000 23000 A 0 090 0 1 0 2 0 2 1 4.48 12.47 5.76 0.86 17.81 11.10 16.128 10.102
23020 23020 A 0 090 0 1 0 2 1 2 0 9.36 9.32 9.32 1.80 20.48 20.48 18.671 18.671
23030 23030 A 0 010 0 1 0 2 0 1 0 3.47 9.30 3.47 0.68 13.45 7.62 12.177 6.942
23031 23031 A 0 010 0 1 0 2 1 1 0 2.79 9.58 3.20 0.53 12.90 6.52 11.670 5.941
23035 23035 A 0 090 0 1 0 2 1 2 0 9.16 9.27 9.27 1.80 20.23 20.23 18.426 18.426
23040 23040 A 0 090 0 1 0 2 1 2 1 9.75 9.72 9.72 1.91 21.38 21.38 19.477 19.477
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
47 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
23044 23044 A 0 090 0 1 0 2 1 1 1 7.59 7.82 7.82 1.50 16.91 16.91 15.397 15.397
23065 23065 A 0 010 0 1 0 2 1 1 0 2.30 3.91 2.38 0.38 6.59 5.06 6.010 4.636
23066 23066 A 0 090 0 1 0 2 1 1 0 4.30 11.52 5.39 0.84 16.66 10.53 15.084 9.580
23071 23071 A 0 090 0 1 0 2 1 2 0 5.91 5.36 5.36 1.21 12.48 12.48 11.356 11.356
23073 23073 A 0 090 0 1 0 2 1 2 0 10.13 8.35 8.35 2.04 20.52 20.52 18.695 18.695
23075 23075 A 0 090 0 1 0 2 1 1 0 4.21 9.17 4.71 0.86 14.24 9.78 12.894 8.889
23076 23076 A 0 090 0 1 0 2 1 1 0 7.41 7.11 7.11 1.51 16.03 16.03 14.585 14.585
23077 23077 A 0 090 0 1 0 2 1 2 1 17.66 12.47 12.47 3.59 33.72 33.72 30.736 30.736
23078 23078 A 0 090 0 1 0 2 1 2 1 22.55 15.21 15.21 4.82 42.58 42.58 38.729 38.729
23100 23100 A 0 090 0 1 0 2 1 2 1 6.20 7.49 7.49 1.22 14.91 14.91 13.564 13.564
23101 23101 A 0 090 0 1 0 2 1 1 1 5.72 6.40 6.40 1.13 13.25 13.25 12.058 12.058
23105 23105 A 0 090 0 1 0 2 1 2 1 8.48 8.85 8.85 1.66 18.99 18.99 17.295 17.295
23106 23106 A 0 090 0 1 0 2 1 1 1 6.13 7.45 7.45 1.21 14.79 14.79 13.453 13.453
23107 23107 A 0 090 0 1 0 2 1 2 1 8.87 9.08 9.08 1.71 19.66 19.66 17.918 17.918
23120 23120 A 0 090 0 1 0 2 1 2 1 7.39 8.62 8.62 1.46 17.47 17.47 15.894 15.894
23125 23125 A 0 090 0 1 0 2 1 2 1 9.64 9.49 9.49 1.89 21.02 21.02 19.150 19.150
23130 23130 A 0 090 0 1 0 2 1 1 1 7.77 8.84 8.84 1.52 18.13 18.13 16.503 16.503
23140 23140 A 0 090 0 1 0 2 1 1 0 7.12 7.26 7.26 1.42 15.80 15.80 14.382 14.382
23145 23145 A 0 090 0 1 0 2 1 2 1 9.40 9.36 9.36 1.85 20.61 20.61 18.773 18.773
23146 23146 A 0 090 0 1 0 2 1 0 0 8.08 8.78 8.78 1.59 18.45 18.45 16.796 16.796
23150 23150 A 0 090 0 1 0 2 1 2 1 8.91 9.01 9.01 1.71 19.63 19.63 17.895 17.895
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
48 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
23155 23155 A 0 090 0 1 0 2 1 2 1 10.86 10.52 10.52 2.14 23.52 23.52 21.426 21.426
23156 23156 A 0 090 0 1 0 2 1 2 0 9.11 9.21 9.21 1.80 20.12 20.12 18.322 18.322
23170 23170 A 0 090 0 1 0 2 1 1 0 7.21 8.03 8.03 1.42 16.66 16.66 15.164 15.164
23172 23172 A 0 090 0 1 0 2 1 2 0 7.31 8.08 8.08 1.46 16.85 16.85 15.329 15.329
23174 23174 A 0 090 0 1 0 2 1 2 1 10.05 10.50 10.50 1.97 22.52 22.52 20.509 20.509
23180 23180 A 0 090 0 1 0 2 1 1 1 8.99 9.09 9.09 1.81 19.89 19.89 18.099 18.099
23182 23182 A 0 090 0 1 0 2 1 2 0 8.61 9.40 9.40 1.69 19.70 19.70 17.935 17.935
23184 23184 A 0 090 0 1 0 2 1 2 1 9.90 10.01 10.01 1.91 21.82 21.82 19.888 19.888
23190 23190 A 0 090 0 1 0 2 1 2 1 7.47 7.99 7.99 1.48 16.94 16.94 15.419 15.419
23195 23195 A 0 090 0 1 0 2 1 2 1 10.36 10.01 10.01 2.03 22.40 22.40 20.411 20.411
23200 23200 A 0 090 0 1 0 2 1 2 1 22.71 17.66 17.66 4.48 44.85 44.85 40.912 40.912
23210 23210 A 0 090 0 1 0 2 1 2 1 27.21 20.07 20.07 5.36 52.64 52.64 48.036 48.036
23220 23220 A 0 090 0 1 0 2 1 2 1 30.21 21.64 21.64 5.96 57.81 57.81 52.760 52.760
23330 23330 A 0 010 0 1 0 2 1 0 0 1.90 5.99 2.72 0.35 8.24 4.97 7.462 4.526
23331 23331 A 0 090 0 1 0 2 1 0 0 7.63 8.48 8.48 1.50 17.61 17.61 16.030 16.030
23332 23332 A 0 090 0 1 0 2 1 2 1 12.37 11.43 11.43 2.40 26.20 26.20 23.889 23.889
23350 23350 A 0 000 0 0 0 2 1 1 0 1.00 2.74 0.38 0.10 3.84 1.48 3.513 1.394
23395 23395 A 0 090 0 1 0 2 0 2 1 18.54 16.04 16.04 3.59 38.17 38.17 34.821 34.821
23397 23397 A 0 090 0 1 0 2 0 2 1 16.76 13.69 13.69 3.31 33.76 33.76 30.785 30.785
23400 23400 A 0 090 0 1 0 2 1 2 1 13.87 12.14 12.14 2.74 28.75 28.75 26.205 26.205
23405 23405 A 0 090 0 1 0 2 0 2 1 8.54 8.45 8.45 1.66 18.65 18.65 16.996 16.996
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
49 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
23406 23406 A 0 090 0 1 0 2 0 2 0 11.01 9.72 9.72 2.16 22.89 22.89 20.868 20.868
23410 23410 A 0 090 0 1 0 2 1 2 1 11.39 10.81 10.81 2.22 24.42 24.42 22.258 22.258
23412 23412 A 0 090 0 1 0 2 1 2 1 11.93 11.09 11.09 2.31 25.33 25.33 23.097 23.097
23415 23415 A 0 090 0 1 0 2 1 1 1 9.23 9.66 9.66 1.81 20.70 20.70 18.851 18.851
23420 23420 A 0 090 0 1 0 2 1 2 1 13.54 12.61 12.61 2.65 28.80 28.80 26.250 26.250
23430 23430 A 0 090 0 1 0 2 1 2 1 10.17 10.14 10.14 1.97 22.28 22.28 20.306 20.306
23440 23440 A 0 090 0 1 0 2 1 2 1 10.64 9.73 9.73 2.07 22.44 22.44 20.460 20.460
23450 23450 A 0 090 0 1 0 2 1 2 1 13.70 11.68 11.68 2.71 28.09 28.09 25.606 25.606
23455 23455 A 0 090 0 1 0 2 1 2 1 14.67 12.18 12.18 2.86 29.71 29.71 27.103 27.103
23460 23460 A 0 090 0 1 0 2 1 2 1 15.82 13.31 13.31 3.13 32.26 32.26 29.409 29.409
23462 23462 A 0 090 0 1 0 2 1 2 1 15.72 12.78 12.78 3.12 31.62 31.62 28.828 28.828
23465 23465 A 0 090 0 1 0 2 1 2 1 16.30 13.61 13.61 3.21 33.12 33.12 30.201 30.201
23466 23466 A 0 090 0 1 0 2 1 2 1 15.80 14.44 14.44 3.12 33.36 33.36 30.399 30.399
23470 23470 A 0 090 0 1 0 2 1 2 1 17.89 14.34 14.34 3.51 35.74 35.74 32.603 32.603
23472 23472 A 0 090 0 1 0 2 1 2 1 22.13 16.89 16.89 4.32 43.34 43.34 39.557 39.557
23473 23473 A 0 090 0 1 0 2 1 2 1 25.00 18.39 18.39 4.88 48.27 48.27 44.066 44.066
23474 23474 A 0 090 0 1 0 2 1 2 1 27.21 19.58 19.58 5.36 52.15 52.15 47.596 47.596
23480 23480 A 0 090 0 1 0 2 1 1 1 11.54 10.51 10.51 2.26 24.31 24.31 22.160 22.160
23485 23485 A 0 090 0 1 0 2 1 2 1 13.91 11.77 11.77 2.72 28.40 28.40 25.902 25.902
23490 23490 A 0 090 0 1 0 2 1 2 0 12.16 10.98 10.98 2.40 25.54 25.54 23.275 23.275
23491 23491 A 0 090 0 1 0 2 1 2 1 14.54 12.63 12.63 2.87 30.04 30.04 27.383 27.383
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
50 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
23500 23500 A 0 090 0 1 0 2 1 1 0 2.21 3.98 4.09 0.41 6.60 6.71 5.998 6.097
23505 23505 A 0 090 0 1 0 2 1 1 0 3.83 6.02 5.41 0.72 10.57 9.96 9.613 9.065
23515 23515 A 0 090 0 1 0 2 1 2 1 9.69 9.88 9.88 1.89 21.46 21.46 19.551 19.551
23520 23520 A 0 090 0 1 0 2 1 0 0 2.29 4.19 4.31 0.44 6.92 7.04 6.283 6.391
23525 23525 A 0 090 0 1 0 2 1 0 0 3.79 6.80 5.94 0.73 11.32 10.46 10.278 9.506
23530 23530 A 0 090 0 1 0 2 1 2 0 7.48 8.05 8.05 1.48 17.01 17.01 15.483 15.483
23532 23532 A 0 090 0 1 0 2 1 2 0 8.20 8.72 8.72 1.61 18.53 18.53 16.873 16.873
23540 23540 A 0 090 0 1 0 2 1 1 0 2.36 3.97 4.09 0.42 6.75 6.87 6.145 6.252
23545 23545 A 0 090 0 1 0 2 1 0 0 3.43 6.45 5.45 0.60 10.48 9.48 9.536 8.638
23550 23550 A 0 090 0 1 0 2 1 2 1 7.59 7.89 7.89 1.47 16.95 16.95 15.444 15.444
23552 23552 A 0 090 0 1 0 2 1 2 1 8.82 9.02 9.02 1.70 19.54 19.54 17.809 17.809
23570 23570 A 0 090 0 1 0 2 1 1 0 2.36 4.17 4.40 0.44 6.97 7.20 6.335 6.541
23575 23575 A 0 090 0 1 0 2 1 0 0 4.23 6.93 6.15 0.83 11.99 11.21 10.887 10.187
23585 23585 A 0 090 0 1 0 2 1 2 1 14.23 12.18 12.18 2.76 29.17 29.17 26.611 26.611
23600 23600 A 0 090 0 1 0 2 1 1 0 3.00 6.30 5.71 0.58 9.88 9.29 8.961 8.431
23605 23605 A 0 090 0 1 0 2 1 1 0 5.06 7.90 6.69 0.98 13.94 12.73 12.667 11.580
23615 23615 A 0 090 0 1 0 2 1 2 1 12.30 11.62 11.62 2.40 26.32 26.32 23.990 23.990
23616 23616 A 0 090 0 1 0 2 1 2 2 18.37 14.87 14.87 3.58 36.82 36.82 33.596 33.596
23620 23620 A 0 090 0 1 0 2 1 1 0 2.55 5.10 4.70 0.49 8.14 7.74 7.386 7.027
23625 23625 A 0 090 0 1 0 2 1 1 0 4.10 6.53 5.72 0.78 11.41 10.60 10.372 9.645
23630 23630 A 0 090 0 1 0 2 1 2 1 10.57 10.67 10.67 2.07 23.31 23.31 21.234 21.234
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
51 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
23650 23650 A 0 090 0 1 0 2 1 1 0 3.53 5.34 4.54 0.61 9.48 8.68 8.644 7.926
23655 23655 A 0 090 0 1 0 2 1 1 0 4.76 6.31 6.31 0.88 11.95 11.95 10.887 10.887
23660 23660 A 0 090 0 1 0 2 1 2 1 7.66 8.22 8.22 1.50 17.38 17.38 15.826 15.826
23665 23665 A 0 090 0 1 0 2 1 1 0 4.66 7.20 6.30 0.88 12.74 11.84 11.586 10.778
23670 23670 A 0 090 0 1 0 2 1 2 1 12.28 11.42 11.42 2.40 26.10 26.10 23.790 23.790
23675 23675 A 0 090 0 1 0 2 1 1 0 6.27 8.94 7.43 1.20 16.41 14.90 14.926 13.570
23680 23680 A 0 090 0 1 0 2 1 2 1 13.15 11.86 11.86 2.57 27.58 27.58 25.144 25.144
23700 23700 A 0 010 0 1 0 2 1 1 0 2.57 2.76 2.76 0.49 5.82 5.82 5.305 5.305
23800 23800 A 0 090 0 1 0 2 1 2 1 14.73 12.72 12.72 2.93 30.38 30.38 27.685 27.685
23802 23802 A 0 090 0 1 0 2 1 2 1 18.42 15.99 15.99 3.62 38.03 38.03 34.672 34.672
23900 23900 A 0 090 0 1 0 2 0 2 0 20.72 16.23 16.23 4.10 41.05 41.05 37.439 37.439
23920 23920 A 0 090 0 1 0 2 1 2 1 16.23 13.95 13.95 3.20 33.38 33.38 30.431 30.431
23921 23921 A 0 090 0 1 0 2 1 1 0 5.72 7.10 7.10 1.36 14.18 14.18 12.807 12.807
23929 23929 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
23930 23930 A 0 010 0 1 0 2 1 1 0 2.99 7.17 2.85 0.61 10.77 6.45 9.748 5.868
23931 23931 A 0 010 0 1 0 2 1 1 0 1.84 6.53 2.60 0.34 8.71 4.78 7.882 4.353
23935 23935 A 0 090 0 1 0 2 1 0 0 6.38 7.51 7.51 1.24 15.13 15.13 13.773 13.773
24000 24000 A 0 090 0 1 0 2 1 0 1 6.08 6.93 6.93 1.17 14.18 14.18 12.915 12.915
24006 24006 A 0 090 0 1 0 2 1 2 2 9.74 9.57 9.57 1.82 21.13 21.13 19.286 19.286
24065 24065 A 0 010 0 1 0 2 1 1 0 2.13 5.36 2.57 0.34 7.83 5.04 7.121 4.616
24066 24066 A 0 090 0 1 0 2 1 1 0 5.35 12.44 5.91 1.08 18.87 12.34 17.086 11.222
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
52 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
24071 24071 A 0 090 0 1 0 2 1 2 0 5.70 5.22 5.22 1.16 12.08 12.08 10.994 10.994
24073 24073 A 0 090 0 1 0 2 1 2 0 10.13 8.31 8.31 2.01 20.45 20.45 18.644 18.644
24075 24075 A 0 090 0 1 0 2 1 1 0 4.24 9.86 4.80 0.84 14.94 9.88 13.534 8.990
24076 24076 A 0 090 0 1 0 2 1 1 0 7.41 7.27 7.27 1.48 16.16 16.16 14.713 14.713
24077 24077 A 0 090 0 1 0 2 1 1 1 15.72 11.88 11.88 3.18 30.78 30.78 28.051 28.051
24079 24079 A 0 090 0 1 0 2 1 2 1 20.61 14.26 14.26 4.38 39.25 39.25 35.706 35.706
24100 24100 A 0 090 0 1 0 2 1 2 1 5.07 6.38 6.38 1.01 12.46 12.46 11.327 11.327
24101 24101 A 0 090 0 1 0 2 1 2 0 6.30 7.37 7.37 1.21 14.88 14.88 13.551 13.551
24102 24102 A 0 090 0 1 0 2 1 2 1 8.26 8.46 8.46 1.55 18.27 18.27 16.668 16.668
24105 24105 A 0 090 0 1 0 2 1 1 0 3.78 5.99 5.99 0.72 10.49 10.49 9.536 9.536
24110 24110 A 0 090 0 1 0 2 1 1 1 7.58 8.39 8.39 1.50 17.47 17.47 15.899 15.899
24115 24115 A 0 090 0 1 0 2 1 2 1 10.12 9.75 9.75 1.99 21.86 21.86 19.916 19.916
24116 24116 A 0 090 0 1 0 2 1 2 0 12.23 10.88 10.88 2.41 25.52 25.52 23.261 23.261
24120 24120 A 0 090 0 1 0 2 1 0 0 6.82 7.63 7.63 1.29 15.74 15.74 14.346 14.346
24125 24125 A 0 090 0 1 0 2 1 2 1 8.14 8.69 8.69 1.59 18.42 18.42 16.775 16.775
24126 24126 A 0 090 0 1 0 2 1 2 0 8.62 8.95 8.95 1.69 19.26 19.26 17.541 17.541
24130 24130 A 0 090 0 1 0 2 1 1 1 6.42 7.46 7.46 1.20 15.08 15.08 13.747 13.747
24134 24134 A 0 090 0 1 0 2 1 2 0 10.22 9.93 9.93 2.00 22.15 22.15 20.183 20.183
24136 24136 A 0 090 0 1 0 2 1 1 0 8.40 8.67 8.67 1.65 18.72 18.72 17.049 17.049
24138 24138 A 0 090 0 1 0 2 1 2 0 8.50 9.92 9.92 1.66 20.08 20.08 18.276 18.276
24140 24140 A 0 090 0 1 0 2 1 2 0 9.55 9.48 9.48 1.78 20.81 20.81 18.994 18.994
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
53 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
24145 24145 A 0 090 0 1 0 2 1 1 1 7.81 8.22 8.22 1.54 17.57 17.57 15.997 15.997
24147 24147 A 0 090 0 1 0 2 1 1 1 7.84 9.15 9.15 1.51 18.50 18.50 16.846 16.846
24149 24149 A 0 090 0 1 0 2 1 2 1 16.22 15.54 15.54 2.98 34.74 34.74 31.733 31.733
24150 24150 A 0 090 0 1 0 2 1 2 1 23.46 17.93 17.93 4.63 46.02 46.02 41.983 41.983
24152 24152 A 0 090 0 1 0 2 1 2 1 19.99 16.07 16.07 3.93 39.99 39.99 36.476 36.476
24155 24155 A 0 090 0 1 0 2 1 2 1 12.09 10.80 10.80 2.38 25.27 25.27 23.033 23.033
24160 24160 A 0 090 0 1 0 2 1 1 1 8.00 8.48 8.48 1.50 17.98 17.98 16.400 16.400
24164 24164 A 0 090 0 1 0 2 1 1 1 6.43 7.09 7.09 1.27 14.79 14.79 13.461 13.461
24200 24200 A 0 010 0 1 0 2 1 0 0 1.81 4.07 2.05 0.31 6.19 4.17 5.627 3.813
24201 24201 A 0 090 0 1 0 2 1 1 0 4.70 11.29 5.27 0.93 16.92 10.90 15.325 9.919
24220 24220 A 0 000 0 0 0 2 1 0 0 1.31 3.37 0.56 0.12 4.80 1.99 4.399 1.876
24300 24300 A 0 090 0 1 0 2 1 1 0 4.04 7.68 7.68 0.72 12.44 12.44 11.313 11.313
24301 24301 A 0 090 0 1 0 2 0 2 1 10.38 9.74 9.74 2.03 22.15 22.15 20.188 20.188
24305 24305 A 0 090 0 1 0 2 0 0 0 7.62 8.14 8.14 1.36 17.12 17.12 15.641 15.641
24310 24310 A 0 090 0 1 0 2 0 0 0 6.12 6.91 6.91 1.18 14.21 14.21 12.942 12.942
24320 24320 A 0 090 0 1 0 2 0 2 1 10.86 10.14 10.14 2.14 23.14 23.14 21.085 21.085
24330 24330 A 0 090 0 1 0 2 1 2 0 9.79 9.57 9.57 1.92 21.28 21.28 19.388 19.388
24331 24331 A 0 090 0 1 0 2 1 2 0 10.95 10.19 10.19 2.16 23.30 23.30 21.230 21.230
24332 24332 A 0 090 0 1 0 2 1 1 0 7.91 8.74 8.74 1.55 18.20 18.20 16.569 16.569
24340 24340 A 0 090 0 1 0 2 1 2 1 8.08 8.63 8.63 1.58 18.29 18.29 16.656 16.656
24341 24341 A 0 090 0 1 0 2 1 2 1 9.49 10.97 10.97 1.85 22.31 22.31 20.309 20.309
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
54 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
24342 24342 A 0 090 0 1 0 2 1 2 1 10.86 10.13 10.13 2.07 23.06 23.06 21.039 21.039
24343 24343 A 0 090 0 1 0 2 1 2 1 9.16 10.13 10.13 1.67 20.96 20.96 19.130 19.130
24344 24344 A 0 090 0 1 0 2 1 2 1 15.21 14.33 14.33 3.01 32.55 32.55 29.653 29.653
24345 24345 A 0 090 0 1 0 2 1 2 1 9.16 10.02 10.02 1.67 20.85 20.85 19.031 19.031
24346 24346 A 0 090 0 1 0 2 1 2 1 15.21 14.37 14.37 3.01 32.59 32.59 29.688 29.688
24357 24357 A 0 090 0 1 0 2 1 0 0 5.44 6.66 6.66 1.03 13.13 13.13 11.959 11.959
24358 24358 A 0 090 0 1 0 2 1 0 0 6.66 7.66 7.66 1.25 15.57 15.57 14.192 14.192
24359 24359 A 0 090 0 1 0 2 1 0 0 8.98 8.91 8.91 1.67 19.56 19.56 17.855 17.855
24360 24360 A 0 090 0 1 0 2 1 2 1 12.67 11.47 11.47 2.48 26.62 26.62 24.267 24.267
24361 24361 A 0 090 0 1 0 2 1 2 1 14.41 12.53 12.53 2.84 29.78 29.78 27.147 27.147
24362 24362 A 0 090 0 1 0 2 1 2 0 15.32 13.02 13.02 3.04 31.38 31.38 28.602 28.602
24363 24363 A 0 090 0 1 0 2 1 2 0 22.00 16.97 16.97 4.09 43.06 43.06 39.378 39.378
24365 24365 A 0 090 0 1 0 2 1 2 1 8.62 8.64 8.64 1.69 18.95 18.95 17.263 17.263
24366 24366 A 0 090 0 1 0 2 1 2 1 9.36 9.02 9.02 1.77 20.15 20.15 18.386 18.386
24370 24370 A 0 090 0 1 0 2 1 2 0 23.55 17.69 17.69 4.38 45.62 45.62 41.726 41.726
24371 24371 A 0 090 0 1 0 2 1 2 0 27.50 19.95 19.95 5.11 52.56 52.56 48.088 48.088
24400 24400 A 0 090 0 1 0 2 1 2 1 11.33 10.88 10.88 2.19 24.40 24.40 22.246 22.246
24410 24410 A 0 090 0 1 0 2 1 2 1 15.11 13.94 13.94 2.99 32.04 32.04 29.192 29.192
24420 24420 A 0 090 0 1 0 2 1 2 1 13.73 13.01 13.01 2.71 29.45 29.45 26.830 26.830
24430 24430 A 0 090 0 1 0 2 1 2 1 15.25 13.17 13.17 2.95 31.37 31.37 28.620 28.620
24435 24435 A 0 090 0 1 0 2 1 2 1 14.99 14.06 14.06 2.93 31.98 31.98 29.148 29.148
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
55 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
24470 24470 A 0 090 0 1 0 2 1 2 0 8.93 6.56 6.56 1.77 17.26 17.26 15.747 15.747
24495 24495 A 0 090 0 1 0 2 1 0 0 8.41 8.96 8.96 1.80 19.17 19.17 17.397 17.397
24498 24498 A 0 090 0 1 0 2 1 2 1 12.28 11.03 11.03 2.41 25.72 25.72 23.445 23.445
24500 24500 A 0 090 0 1 0 2 1 1 0 3.41 6.73 5.74 0.64 10.78 9.79 9.788 8.899
24505 24505 A 0 090 0 1 0 2 1 1 0 5.39 8.58 7.10 1.05 15.02 13.54 13.644 12.315
24515 24515 A 0 090 0 1 0 2 1 2 1 12.12 11.57 11.57 2.34 26.03 26.03 23.734 23.734
24516 24516 A 0 090 0 1 0 2 1 2 2 12.19 10.95 10.95 2.38 25.52 25.52 23.268 23.268
24530 24530 A 0 090 0 1 0 2 1 1 0 3.69 7.05 5.94 0.69 11.43 10.32 10.382 9.385
24535 24535 A 0 090 0 1 0 2 1 1 0 7.11 9.90 8.46 1.37 18.38 16.94 16.717 15.424
24538 24538 A 0 090 0 1 0 2 1 1 0 9.77 10.43 10.43 1.92 22.12 22.12 20.140 20.140
24545 24545 A 0 090 0 1 0 2 1 2 1 13.15 11.87 11.87 2.56 27.58 27.58 25.148 25.148
24546 24546 A 0 090 0 1 0 2 1 2 2 14.91 13.05 13.05 2.90 30.86 30.86 28.146 28.146
24560 24560 A 0 090 0 1 0 2 1 1 0 2.98 6.19 5.14 0.56 9.73 8.68 8.832 7.889
24565 24565 A 0 090 0 1 0 2 1 1 0 5.78 9.01 7.65 1.14 15.93 14.57 14.467 13.246
24566 24566 A 0 090 0 1 0 2 1 1 0 9.06 10.51 10.51 1.80 21.37 21.37 19.439 19.439
24575 24575 A 0 090 0 1 0 2 1 2 1 9.71 10.24 10.24 1.88 21.83 21.83 19.889 19.889
24576 24576 A 0 090 0 1 0 2 1 1 0 3.06 6.64 5.56 0.59 10.29 9.21 9.331 8.361
24577 24577 A 0 090 0 1 0 2 1 1 0 6.01 9.20 7.77 1.18 16.39 14.96 14.889 13.605
24579 24579 A 0 090 0 1 0 2 1 2 1 11.44 11.19 11.19 2.20 24.83 24.83 22.639 22.639
24582 24582 A 0 090 0 1 0 2 1 1 0 10.14 11.95 11.95 1.99 24.08 24.08 21.912 21.912
24586 24586 A 0 090 0 1 0 2 1 2 1 15.78 13.22 13.22 3.05 32.05 32.05 29.247 29.247
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
56 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
24587 24587 A 0 090 0 1 0 2 1 2 1 15.79 13.38 13.38 2.93 32.10 32.10 29.338 29.338
24600 24600 A 0 090 0 1 0 2 1 1 0 4.37 5.87 4.91 0.76 11.00 10.04 10.039 9.177
24605 24605 A 0 090 0 1 0 2 1 1 0 5.64 7.30 7.30 1.09 14.03 14.03 12.765 12.765
24615 24615 A 0 090 0 1 0 2 1 2 1 9.83 9.45 9.45 1.84 21.12 21.12 19.278 19.278
24620 24620 A 0 090 0 1 0 2 1 0 0 7.22 7.91 7.91 1.36 16.49 16.49 15.034 15.034
24635 24635 A 0 090 0 1 0 2 1 2 1 8.80 9.53 9.53 1.67 20.00 20.00 18.231 18.231
24640 24640 A 0 010 0 1 0 2 1 0 0 1.25 2.83 1.39 0.23 4.31 2.87 3.912 2.619
24650 24650 A 0 090 0 1 0 2 1 1 0 2.31 5.18 4.51 0.42 7.91 7.24 7.181 6.580
24655 24655 A 0 090 0 1 0 2 1 1 0 4.62 7.69 6.48 0.86 13.17 11.96 11.975 10.889
24665 24665 A 0 090 0 1 0 2 1 2 1 8.36 9.44 9.44 1.59 19.39 19.39 17.669 17.669
24666 24666 A 0 090 0 1 0 2 1 2 1 9.86 10.05 10.05 1.86 21.77 21.77 19.858 19.858
24670 24670 A 0 090 0 1 0 2 1 1 0 2.69 5.60 4.72 0.50 8.79 7.91 7.980 7.190
24675 24675 A 0 090 0 1 0 2 1 1 0 4.91 7.85 6.61 0.93 13.69 12.45 12.446 11.332
24685 24685 A 0 090 0 1 0 2 1 2 1 8.37 9.51 9.51 1.62 19.50 19.50 17.757 17.757
24800 24800 A 0 090 0 1 0 2 1 2 1 11.41 10.93 10.93 2.25 24.59 24.59 22.402 22.402
24802 24802 A 0 090 0 1 0 2 1 2 0 14.32 12.50 12.50 2.83 29.65 29.65 27.025 27.025
24900 24900 A 0 090 0 1 0 2 1 2 1 10.18 9.58 9.58 2.01 21.77 21.77 19.834 19.834
24920 24920 A 0 090 0 1 0 2 1 2 1 10.13 7.68 7.68 1.99 19.80 19.80 18.067 18.067
24925 24925 A 0 090 0 1 0 2 1 2 0 7.30 8.07 8.07 1.44 16.81 16.81 15.300 15.300
24930 24930 A 0 090 0 1 0 2 1 2 0 10.83 9.96 9.96 2.14 22.93 22.93 20.893 20.893
24931 24931 A 0 090 0 1 0 2 1 2 0 13.44 8.30 8.30 0.95 22.69 22.69 21.390 21.390
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
57 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
24935 24935 A 0 090 0 1 0 2 1 0 0 16.45 11.46 11.46 3.24 31.15 31.15 28.436 28.436
24940 24940 C 0 090 0 1 0 2 1 2 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
24999 24999 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
25000 25000 A 0 090 0 1 0 2 1 1 0 3.55 5.86 5.86 0.64 10.05 10.05 9.147 9.147
25001 25001 A 0 090 0 1 0 2 1 1 0 3.79 5.81 5.81 0.67 10.27 10.27 9.358 9.358
25020 25020 A 0 090 0 1 0 2 1 1 0 6.06 10.09 10.09 1.06 17.21 17.21 15.675 15.675
25023 25023 A 0 090 0 1 0 2 1 0 0 13.83 16.54 16.54 2.74 33.11 33.11 30.116 30.116
25024 25024 A 0 090 0 1 0 2 1 1 0 10.79 10.44 10.44 2.12 23.35 23.35 21.274 21.274
25025 25025 A 0 090 0 1 0 2 1 0 0 17.94 14.80 14.80 3.54 36.28 36.28 33.082 33.082
25028 25028 A 0 090 0 1 0 2 1 1 0 5.39 9.33 9.33 1.03 15.75 15.75 14.307 14.307
25031 25031 A 0 090 0 1 0 2 1 0 0 4.26 5.30 5.30 0.83 10.39 10.39 9.453 9.453
25035 25035 A 0 090 0 1 0 2 1 0 0 7.65 8.21 8.21 1.48 17.34 17.34 15.797 15.797
25040 25040 A 0 090 0 1 0 2 1 0 0 7.50 7.80 7.80 1.36 16.66 16.66 15.216 15.216
25065 25065 A 0 010 0 1 0 2 1 1 0 2.04 5.40 2.57 0.33 7.77 4.94 7.062 4.520
25066 25066 A 0 090 0 1 0 2 1 1 0 4.27 5.59 5.59 0.80 10.66 10.66 9.708 9.708
25071 25071 A 0 090 0 1 0 2 1 2 0 5.91 5.58 5.58 1.17 12.66 12.66 11.533 11.533
25073 25073 A 0 090 0 1 0 2 1 2 0 7.13 7.30 7.30 1.36 15.79 15.79 14.397 14.397
25075 25075 A 0 090 0 1 0 2 1 1 0 3.96 9.85 4.76 0.76 14.57 9.48 13.203 8.632
25076 25076 A 0 090 0 1 0 2 1 1 0 6.74 7.32 7.32 1.28 15.34 15.34 13.983 13.983
25077 25077 A 0 090 0 1 0 2 1 1 0 12.93 10.67 10.67 2.61 26.21 26.21 23.877 23.877
25078 25078 A 0 090 0 1 0 2 1 2 0 17.69 13.19 13.19 3.78 34.66 34.66 31.512 31.512
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
58 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
25085 25085 A 0 090 0 1 0 2 1 2 0 5.64 6.67 6.67 1.10 13.41 13.41 12.205 12.205
25100 25100 A 0 090 0 1 0 2 1 0 0 4.02 5.52 5.52 0.78 10.32 10.32 9.385 9.385
25101 25101 A 0 090 0 1 0 2 1 0 0 4.83 6.32 6.32 0.90 12.05 12.05 10.976 10.976
25105 25105 A 0 090 0 1 0 2 1 0 1 6.02 7.23 7.23 1.10 14.35 14.35 13.088 13.088
25107 25107 A 0 090 0 1 0 2 1 2 1 7.70 9.20 9.20 1.36 18.26 18.26 16.673 16.673
25109 25109 A 0 090 0 1 0 2 1 1 0 6.94 7.75 7.75 1.24 15.93 15.93 14.548 14.548
25110 25110 A 0 090 0 1 0 2 1 1 0 4.04 5.33 5.33 0.75 10.12 10.12 9.219 9.219
25111 25111 A 0 090 0 1 0 2 1 1 0 3.53 5.36 5.36 0.67 9.56 9.56 8.694 8.694
25112 25112 A 0 090 0 1 0 2 1 1 0 4.67 5.97 5.97 0.87 11.51 11.51 10.486 10.486
25115 25115 A 0 090 0 1 0 2 1 1 0 10.09 10.56 10.56 1.80 22.45 22.45 20.514 20.514
25116 25116 A 0 090 0 1 0 2 1 0 1 7.56 8.94 8.94 1.33 17.83 17.83 16.284 16.284
25118 25118 A 0 090 0 1 0 2 1 1 0 4.51 6.02 6.02 0.80 11.33 11.33 10.334 10.334
25119 25119 A 0 090 0 1 0 2 1 2 1 6.21 7.33 7.33 1.22 14.76 14.76 13.430 13.430
25120 25120 A 0 090 0 1 0 2 1 0 1 6.27 7.35 7.35 1.17 14.79 14.79 13.482 13.482
25125 25125 A 0 090 0 1 0 2 1 0 0 7.67 8.51 8.51 1.51 17.69 17.69 16.102 16.102
25126 25126 A 0 090 0 1 0 2 1 2 0 7.74 8.47 8.47 1.52 17.73 17.73 16.141 16.141
25130 25130 A 0 090 0 1 0 2 1 0 0 5.43 6.88 6.88 0.99 13.30 13.30 12.126 12.126
25135 25135 A 0 090 0 1 0 2 1 2 1 7.08 8.11 8.11 1.39 16.58 16.58 15.090 15.090
25136 25136 A 0 090 0 1 0 2 1 2 1 6.14 7.32 7.32 1.21 14.67 14.67 13.346 13.346
25145 25145 A 0 090 0 1 0 2 1 2 0 6.54 7.54 7.54 1.28 15.36 15.36 13.980 13.980
25150 25150 A 0 090 0 1 0 2 1 1 1 7.38 8.01 8.01 1.36 16.75 16.75 15.284 15.284
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
59 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
25151 25151 A 0 090 0 1 0 2 1 2 1 7.68 8.18 8.18 1.51 17.37 17.37 15.815 15.815
25170 25170 A 0 090 0 1 0 2 1 2 1 22.21 17.14 17.14 4.37 43.72 43.72 39.887 39.887
25210 25210 A 0 090 0 1 0 2 0 0 1 6.12 7.29 7.29 1.08 14.49 14.49 13.231 13.231
25215 25215 A 0 090 0 1 0 2 1 2 1 8.14 8.69 8.69 1.40 18.23 18.23 16.676 16.676
25230 25230 A 0 090 0 1 0 2 1 1 1 5.37 6.50 6.50 0.90 12.77 12.77 11.678 11.678
25240 25240 A 0 090 0 1 0 2 1 0 1 5.31 6.49 6.49 0.91 12.71 12.71 11.614 11.614
25246 25246 A 0 000 0 0 0 2 1 1 0 1.45 3.19 0.58 0.14 4.78 2.17 4.388 2.044
25248 25248 A 0 090 0 1 0 2 1 1 0 5.31 5.92 5.92 1.05 12.28 12.28 11.175 11.175
25250 25250 A 0 090 0 1 0 2 1 2 0 6.77 7.65 7.65 1.32 15.74 15.74 14.330 14.330
25251 25251 A 0 090 0 1 0 2 1 2 0 9.82 9.57 9.57 1.93 21.32 21.32 19.423 19.423
25259 25259 A 0 090 0 1 0 2 1 1 0 4.04 7.69 7.69 0.72 12.45 12.45 11.322 11.322
25260 25260 A 0 090 0 1 0 2 0 1 0 8.04 9.21 9.21 1.48 18.73 18.73 17.085 17.085
25263 25263 A 0 090 0 1 0 2 0 2 0 8.04 9.08 9.08 1.58 18.70 18.70 17.020 17.020
25265 25265 A 0 090 0 1 0 2 0 2 0 10.10 10.11 10.11 1.97 22.18 22.18 20.209 20.209
25270 25270 A 0 090 0 1 0 2 0 0 0 6.17 7.24 7.24 1.16 14.57 14.57 13.278 13.278
25272 25272 A 0 090 0 1 0 2 0 0 0 7.21 7.91 7.91 1.32 16.44 16.44 15.004 15.004
25274 25274 A 0 090 0 1 0 2 0 0 1 8.94 9.12 9.12 1.77 19.83 19.83 18.055 18.055
25275 25275 A 0 090 0 1 0 2 1 0 1 8.96 9.31 9.31 1.77 20.04 20.04 18.246 18.246
25280 25280 A 0 090 0 1 0 2 0 0 1 7.39 8.04 8.04 1.28 16.71 16.71 15.279 15.279
25290 25290 A 0 090 0 1 0 2 0 1 0 5.43 6.54 6.54 0.98 12.95 12.95 11.815 11.815
25295 25295 A 0 090 0 1 0 2 0 1 0 6.72 7.57 7.57 1.18 15.47 15.47 14.135 14.135
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
60 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
25300 25300 A 0 090 0 1 0 2 1 2 0 9.02 9.65 9.65 1.78 20.45 20.45 18.617 18.617
25301 25301 A 0 090 0 1 0 2 1 2 0 8.59 8.90 8.90 1.57 19.06 19.06 17.403 17.403
25310 25310 A 0 090 0 1 0 2 0 2 1 8.08 8.84 8.84 1.39 18.31 18.31 16.745 16.745
25312 25312 A 0 090 0 1 0 2 0 2 1 9.82 9.68 9.68 1.78 21.28 21.28 19.444 19.444
25315 25315 A 0 090 0 1 0 2 1 2 0 10.68 10.04 10.04 2.10 22.82 22.82 20.794 20.794
25316 25316 A 0 090 0 1 0 2 1 2 0 12.90 11.94 11.94 1.61 26.45 26.45 24.464 24.464
25320 25320 A 0 090 0 1 0 2 1 2 0 12.75 14.29 14.29 2.26 29.30 29.30 26.764 26.764
25332 25332 A 0 090 0 1 0 2 1 2 0 11.74 11.08 11.08 2.18 25.00 25.00 22.830 22.830
25335 25335 A 0 090 0 1 0 2 1 2 0 13.39 12.50 12.50 0.95 26.84 26.84 25.112 25.112
25337 25337 A 0 090 0 1 0 2 1 1 0 11.73 12.59 12.59 2.01 26.33 26.33 24.087 24.087
25350 25350 A 0 090 0 1 0 2 1 2 0 9.09 9.23 9.23 1.61 19.93 19.93 18.221 18.221
25355 25355 A 0 090 0 1 0 2 1 2 0 10.53 10.10 10.10 2.07 22.70 22.70 20.682 20.682
25360 25360 A 0 090 0 1 0 2 1 2 1 8.74 9.02 9.02 1.65 19.41 19.41 17.703 17.703
25365 25365 A 0 090 0 1 0 2 1 2 0 12.91 11.62 11.62 2.55 27.08 27.08 24.678 24.678
25370 25370 A 0 090 0 1 0 2 1 2 0 14.10 12.92 12.92 2.78 29.80 29.80 27.156 27.156
25375 25375 A 0 090 0 1 0 2 1 2 1 13.55 12.33 12.33 0.95 26.83 26.83 25.119 25.119
25390 25390 A 0 090 0 1 0 2 1 2 1 10.70 10.14 10.14 1.88 22.72 22.72 20.789 20.789
25391 25391 A 0 090 0 1 0 2 1 2 1 14.28 12.36 12.36 2.83 29.47 29.47 26.859 26.859
25392 25392 A 0 090 0 1 0 2 1 2 0 14.58 12.52 12.52 2.90 30.00 30.00 27.340 27.340
25393 25393 A 0 090 0 1 0 2 1 2 0 16.56 13.58 13.58 3.28 33.42 33.42 30.470 30.470
25394 25394 A 0 090 0 1 0 2 1 2 1 10.85 10.23 10.23 2.14 23.22 23.22 21.156 21.156
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
61 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
25400 25400 A 0 090 0 1 0 2 1 2 1 11.28 10.40 10.40 2.07 23.75 23.75 21.702 21.702
25405 25405 A 0 090 0 1 0 2 1 2 1 15.01 12.85 12.85 2.74 30.60 30.60 27.982 27.982
25415 25415 A 0 090 0 1 0 2 1 2 1 13.80 12.10 12.10 2.72 28.62 28.62 26.088 26.088
25420 25420 A 0 090 0 1 0 2 1 2 1 17.04 14.13 14.13 3.38 34.55 34.55 31.496 31.496
25425 25425 A 0 090 0 1 0 2 1 2 1 13.72 12.06 12.06 2.71 28.49 28.49 25.967 25.967
25426 25426 A 0 090 0 1 0 2 1 2 1 16.45 13.52 13.52 3.24 33.21 33.21 30.285 30.285
25430 25430 A 0 090 0 1 0 2 1 1 0 9.71 10.09 10.09 1.21 21.01 21.01 19.404 19.404
25431 25431 A 0 090 0 1 0 2 1 2 1 10.89 10.34 10.34 2.15 23.38 23.38 21.300 21.300
25440 25440 A 0 090 0 1 0 2 1 2 1 10.68 10.15 10.15 1.89 22.72 22.72 20.783 20.783
25441 25441 A 0 090 0 1 0 2 1 2 1 13.29 12.15 12.15 1.65 27.09 27.09 25.064 25.064
25442 25442 A 0 090 0 1 0 2 1 2 1 11.12 10.72 10.72 1.39 23.23 23.23 21.474 21.474
25443 25443 A 0 090 0 1 0 2 1 2 1 10.66 10.39 10.39 2.10 23.15 23.15 21.089 21.089
25444 25444 A 0 090 0 1 0 2 1 2 0 11.42 11.05 11.05 0.80 23.27 23.27 21.761 21.761
25445 25445 A 0 090 0 1 0 2 1 1 1 9.88 9.64 9.64 1.80 21.32 21.32 19.478 19.478
25446 25446 A 0 090 0 1 0 2 1 2 1 17.30 14.14 14.14 2.95 34.39 34.39 31.541 31.541
25447 25447 A 0 090 0 1 0 2 1 2 1 11.14 11.37 11.37 1.96 24.47 24.47 22.375 22.375
25449 25449 A 0 090 0 1 0 2 1 2 1 14.94 12.88 12.88 2.95 30.77 30.77 28.049 28.049
25450 25450 A 0 090 0 1 0 2 1 1 0 8.06 8.64 8.64 1.58 18.28 18.28 16.645 16.645
25455 25455 A 0 090 0 1 0 2 1 1 0 9.71 7.04 7.04 0.68 17.43 17.43 16.388 16.388
25490 25490 A 0 090 0 1 0 2 1 2 0 9.73 9.67 9.67 1.25 20.65 20.65 19.067 19.067
25491 25491 A 0 090 0 1 0 2 1 2 0 10.15 9.77 9.77 1.99 21.91 21.91 19.964 19.964
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
62 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
25492 25492 A 0 090 0 1 0 2 1 2 0 12.66 8.32 8.32 2.48 23.46 23.46 21.428 21.428
25500 25500 A 0 090 0 1 0 2 1 1 0 2.60 5.14 4.45 0.45 8.19 7.50 7.451 6.831
25505 25505 A 0 090 0 1 0 2 1 1 0 5.45 8.61 7.30 1.03 15.09 13.78 13.720 12.544
25515 25515 A 0 090 0 1 0 2 1 2 1 8.80 9.43 9.43 1.67 19.90 19.90 18.142 18.142
25520 25520 A 0 090 0 1 0 2 1 1 0 6.50 9.14 8.24 1.28 16.92 16.02 15.377 14.569
25525 25525 A 0 090 0 1 0 2 1 2 2 10.55 10.64 10.64 2.01 23.20 23.20 21.156 21.156
25526 25526 A 0 090 0 1 0 2 1 2 2 13.15 12.57 12.57 2.60 28.32 28.32 25.798 25.798
25530 25530 A 0 090 0 1 0 2 1 1 0 2.24 5.27 4.49 0.41 7.92 7.14 7.187 6.486
25535 25535 A 0 090 0 1 0 2 1 1 0 5.36 8.29 7.17 1.02 14.67 13.55 13.338 12.332
25545 25545 A 0 090 0 1 0 2 1 2 1 7.94 9.08 9.08 1.51 18.53 18.53 16.884 16.884
25560 25560 A 0 090 0 1 0 2 1 1 0 2.59 5.34 4.51 0.48 8.41 7.58 7.636 6.891
25565 25565 A 0 090 0 1 0 2 1 1 0 5.85 8.69 7.17 1.10 15.64 14.12 14.229 12.864
25574 25574 A 0 090 0 1 0 2 1 2 2 8.80 9.54 9.54 1.70 20.04 20.04 18.256 18.256
25575 25575 A 0 090 0 1 0 2 1 2 1 12.29 12.08 12.08 2.34 26.71 26.71 24.362 24.362
25600 25600 A 0 090 0 1 0 2 1 1 0 2.78 6.62 6.08 0.52 9.92 9.38 8.997 8.512
25605 25605 A 0 090 0 1 0 2 1 1 0 6.25 9.00 7.99 1.20 16.45 15.44 14.960 14.053
25606 25606 A 0 090 0 1 0 2 1 1 0 8.31 9.78 9.78 1.61 19.70 19.70 17.934 17.934
25607 25607 A 0 090 0 1 0 2 1 2 0 9.56 10.47 10.47 1.82 21.85 21.85 19.914 19.914
25608 25608 A 0 090 0 1 0 2 1 2 0 11.07 11.29 11.29 2.07 24.43 24.43 22.291 22.291
25609 25609 A 0 090 0 1 0 2 1 2 0 14.38 13.96 13.96 2.69 31.03 31.03 28.323 28.323
25622 25622 A 0 090 0 1 0 2 1 1 0 2.79 5.89 5.05 0.52 9.20 8.36 8.351 7.597
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
63 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
25624 25624 A 0 090 0 1 0 2 1 0 0 4.77 8.63 7.31 0.88 14.28 12.96 12.980 11.795
25628 25628 A 0 090 0 1 0 2 1 2 0 9.67 9.88 9.88 1.74 21.29 21.29 19.452 19.452
25630 25630 A 0 090 0 1 0 2 1 1 0 3.03 5.59 4.82 0.56 9.18 8.41 8.343 7.651
25635 25635 A 0 090 0 1 0 2 1 0 0 4.61 8.11 6.54 0.90 13.62 12.05 12.363 10.954
25645 25645 A 0 090 0 1 0 2 1 2 0 7.42 8.01 8.01 1.47 16.90 16.90 15.382 15.382
25650 25650 A 0 090 0 1 0 2 1 1 0 3.23 5.82 5.20 0.60 9.65 9.03 8.770 8.213
25651 25651 A 0 090 0 1 0 2 1 0 0 5.82 7.51 7.51 1.10 14.43 14.43 13.139 13.139
25652 25652 A 0 090 0 1 0 2 1 1 1 8.06 8.92 8.92 1.47 18.45 18.45 16.839 16.839
25660 25660 A 0 090 0 1 0 2 1 0 0 4.98 6.37 6.37 0.90 12.25 12.25 11.171 11.171
25670 25670 A 0 090 0 1 0 2 1 2 1 8.09 8.30 8.30 1.50 17.89 17.89 16.328 16.328
25671 25671 A 0 090 0 1 0 2 1 1 0 6.46 8.09 8.09 1.27 15.82 15.82 14.389 14.389
25675 25675 A 0 090 0 1 0 2 1 0 0 4.89 7.54 6.36 0.87 13.30 12.12 12.116 11.056
25676 25676 A 0 090 0 1 0 2 1 2 0 8.29 8.86 8.86 1.54 18.69 18.69 17.052 17.052
25680 25680 A 0 090 0 1 0 2 1 0 0 6.23 6.97 6.97 1.08 14.28 14.28 13.054 13.054
25685 25685 A 0 090 0 1 0 2 1 2 0 10.09 9.73 9.73 1.97 21.79 21.79 19.858 19.858
25690 25690 A 0 090 0 1 0 2 1 0 0 5.72 7.48 7.48 1.14 14.34 14.34 13.033 13.033
25695 25695 A 0 090 0 1 0 2 1 2 1 8.51 8.59 8.59 1.66 18.76 18.76 17.092 17.092
25800 25800 A 0 090 0 1 0 2 1 2 1 10.07 9.77 9.77 1.81 21.65 21.65 19.790 19.790
25805 25805 A 0 090 0 1 0 2 1 2 1 11.73 10.98 10.98 2.30 25.01 25.01 22.793 22.793
25810 25810 A 0 090 0 1 0 2 1 2 1 11.95 11.59 11.59 2.12 25.66 25.66 23.467 23.467
25820 25820 A 0 090 0 1 0 2 1 2 1 7.64 9.28 9.28 1.37 18.29 18.29 16.690 16.690
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
64 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
25825 25825 A 0 090 0 1 0 2 1 2 1 9.69 11.06 11.06 1.69 22.44 22.44 20.506 20.506
25830 25830 A 0 090 0 1 0 2 1 2 1 10.88 15.50 15.50 2.15 28.53 28.53 25.923 25.923
25900 25900 A 0 090 0 1 0 2 1 0 0 9.61 9.62 9.62 1.82 21.05 21.05 19.201 19.201
25905 25905 A 0 090 0 1 0 2 1 2 0 9.59 9.30 9.30 1.89 20.78 20.78 18.930 18.930
25907 25907 A 0 090 0 1 0 2 1 2 0 8.09 8.50 8.50 1.59 18.18 18.18 16.555 16.555
25909 25909 A 0 090 0 1 0 2 1 2 0 9.31 9.15 9.15 1.84 20.30 20.30 18.489 18.489
25915 25915 A 0 090 0 1 0 2 1 2 0 17.52 9.90 9.90 3.10 30.52 30.52 28.032 28.032
25920 25920 A 0 090 0 1 0 2 1 0 0 9.03 9.89 9.89 1.78 20.70 20.70 18.842 18.842
25922 25922 A 0 090 0 1 0 2 1 2 0 7.65 9.03 9.03 0.53 17.21 17.21 16.036 16.036
25924 25924 A 0 090 0 1 0 2 1 2 0 8.81 9.81 9.81 1.71 20.33 20.33 18.514 18.514
25927 25927 A 0 090 0 1 0 2 1 0 0 9.09 13.39 13.39 1.80 24.28 24.28 22.056 22.056
25929 25929 A 0 090 0 1 0 2 1 2 0 7.82 8.35 8.35 1.54 17.71 17.71 16.124 16.124
25931 25931 A 0 090 0 1 0 2 1 1 0 8.04 12.30 12.30 1.70 22.04 22.04 19.975 19.975
25999 25999 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
26010 26010 A 0 010 0 1 0 2 0 1 0 1.59 6.21 2.30 0.27 8.07 4.16 7.308 3.797
26011 26011 A 0 010 0 1 0 2 0 1 0 2.24 9.23 2.88 0.39 11.86 5.51 10.733 5.030
26020 26020 A 0 090 0 1 0 2 0 1 0 5.08 6.93 6.93 0.93 12.94 12.94 11.790 11.790
26025 26025 A 0 090 0 1 0 2 1 0 0 5.08 6.59 6.59 0.91 12.58 12.58 11.474 11.474
26030 26030 A 0 090 0 1 0 2 1 0 0 6.25 7.21 7.21 1.16 14.62 14.62 13.331 13.331
26034 26034 A 0 090 0 1 0 2 0 1 0 6.63 8.18 8.18 1.22 16.03 16.03 14.614 14.614
26035 26035 A 0 090 0 1 0 2 0 0 0 11.37 11.86 11.86 2.23 25.46 25.46 23.187 23.187
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
65 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26037 26037 A 0 090 0 1 0 2 1 0 0 7.57 7.92 7.92 1.44 16.93 16.93 15.435 15.435
26040 26040 A 0 090 0 1 0 2 1 1 0 3.46 5.21 5.21 0.56 9.23 9.23 8.431 8.431
26045 26045 A 0 090 0 1 0 2 1 1 0 5.73 7.10 7.10 1.09 13.92 13.92 12.676 12.676
26055 26055 A 0 090 0 1 0 2 0 1 0 3.11 13.34 5.62 0.56 17.01 9.29 15.382 8.450
26060 26060 A 0 090 0 1 0 2 0 0 0 2.91 4.48 4.48 0.54 7.93 7.93 7.215 7.215
26070 26070 A 0 090 0 1 0 2 1 1 0 3.81 4.74 4.74 0.65 9.20 9.20 8.406 8.406
26075 26075 A 0 090 0 1 0 2 1 1 0 3.91 5.16 5.16 0.67 9.74 9.74 8.894 8.894
26080 26080 A 0 090 0 1 0 2 0 1 0 4.47 6.36 6.36 0.78 11.61 11.61 10.589 10.589
26100 26100 A 0 090 0 1 0 2 1 0 0 3.79 5.47 5.47 0.73 9.99 9.99 9.084 9.084
26105 26105 A 0 090 0 1 0 2 1 0 0 3.83 5.49 5.49 0.75 10.07 10.07 9.152 9.152
26110 26110 A 0 090 0 1 0 2 0 1 0 3.65 5.28 5.28 0.64 9.57 9.57 8.726 8.726
26111 26111 A 0 090 0 1 0 2 0 2 0 5.42 5.98 5.98 0.99 12.39 12.39 11.308 11.308
26113 26113 A 0 090 0 1 0 2 0 2 0 7.13 7.84 7.84 1.25 16.22 16.22 14.824 14.824
26115 26115 A 0 090 0 1 0 2 0 1 0 3.96 10.54 5.22 0.71 15.21 9.89 13.796 9.019
26116 26116 A 0 090 0 1 0 2 0 1 0 6.74 7.67 7.67 1.20 15.61 15.61 14.255 14.255
26117 26117 A 0 090 0 1 0 2 0 1 0 10.13 10.23 10.23 1.85 22.21 22.21 20.284 20.284
26118 26118 A 0 090 0 1 0 2 0 2 0 14.81 13.73 13.73 2.94 31.48 31.48 28.677 28.677
26121 26121 A 0 090 0 1 0 2 1 1 0 7.73 8.55 8.55 1.40 17.68 17.68 16.140 16.140
26123 26123 A 0 090 0 1 0 2 1 1 0 10.88 11.87 11.87 1.92 24.67 24.67 22.543 22.543
26125 26125 A 0 ZZZ 0 0 0 0 0 1 0 4.60 2.60 2.60 0.82 8.02 8.02 7.364 7.364
26130 26130 A 0 090 0 1 0 2 1 1 0 5.59 6.95 6.95 1.06 13.60 13.60 12.385 12.385
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
66 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26135 26135 A 0 090 0 1 0 2 0 0 0 7.13 7.90 7.90 1.27 16.30 16.30 14.888 14.888
26140 26140 A 0 090 0 1 0 2 0 1 0 6.34 7.48 7.48 1.14 14.96 14.96 13.653 13.653
26145 26145 A 0 090 0 1 0 2 0 1 0 6.49 7.50 7.50 1.18 15.17 15.17 13.842 13.842
26160 26160 A 0 090 0 1 0 2 0 1 0 3.57 13.20 5.75 0.65 17.42 9.97 15.764 9.073
26170 26170 A 0 090 0 1 0 2 0 0 0 4.91 6.27 6.27 0.86 12.04 12.04 10.990 10.990
26180 26180 A 0 090 0 1 0 2 0 0 0 5.35 6.90 6.90 0.90 13.15 13.15 12.017 12.017
26185 26185 A 0 090 0 1 0 2 1 2 1 6.52 8.58 8.58 1.28 16.38 16.38 14.894 14.894
26200 26200 A 0 090 0 1 0 2 0 0 0 5.65 6.67 6.67 1.03 13.35 13.35 12.178 12.178
26205 26205 A 0 090 0 1 0 2 0 1 0 7.93 8.37 8.37 1.57 17.87 17.87 16.267 16.267
26210 26210 A 0 090 0 1 0 2 0 1 0 5.32 6.85 6.85 0.95 13.12 13.12 11.968 11.968
26215 26215 A 0 090 0 1 0 2 0 1 0 7.27 8.09 8.09 1.44 16.80 16.80 15.288 15.288
26230 26230 A 0 090 0 1 0 2 0 0 0 6.47 7.19 7.19 1.13 14.79 14.79 13.518 13.518
26235 26235 A 0 090 0 1 0 2 0 0 0 6.33 7.14 7.14 1.10 14.57 14.57 13.317 13.317
26236 26236 A 0 090 0 1 0 2 0 1 0 5.46 6.64 6.64 0.98 13.08 13.08 11.935 11.935
26250 26250 A 0 090 0 1 0 2 0 0 0 15.21 13.51 13.51 3.01 31.73 31.73 28.916 28.916
26260 26260 A 0 090 0 1 0 2 0 2 0 11.16 10.46 10.46 2.19 23.81 23.81 21.698 21.698
26262 26262 A 0 090 0 1 0 2 0 2 0 8.29 8.92 8.92 1.62 18.83 18.83 17.147 17.147
26320 26320 A 0 090 0 1 0 2 0 1 0 4.10 5.47 5.47 0.71 10.28 10.28 9.383 9.383
26340 26340 A 0 090 0 1 0 2 1 1 0 2.80 6.78 6.78 0.52 10.10 10.10 9.160 9.160
26341 26341 A 0 010 0 1 0 2 1 1 0 0.91 1.89 1.15 0.14 2.94 2.20 2.680 2.016
26350 26350 A 0 090 0 1 0 2 0 1 0 6.21 13.87 13.87 1.13 21.21 21.21 19.256 19.256
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
67 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26352 26352 A 0 090 0 1 0 2 0 2 1 7.87 14.89 14.89 1.55 24.31 24.31 22.052 22.052
26356 26356 A 0 090 0 1 0 2 0 1 0 10.62 19.96 19.96 1.92 32.50 32.50 29.548 29.548
26357 26357 A 0 090 0 1 0 2 0 2 0 8.77 15.37 15.37 1.71 25.85 25.85 23.467 23.467
26358 26358 A 0 090 0 1 0 2 0 2 0 9.36 16.06 16.06 1.85 27.27 27.27 24.749 24.749
26370 26370 A 0 090 0 1 0 2 0 0 0 7.28 13.85 13.85 1.36 22.49 22.49 20.429 20.429
26372 26372 A 0 090 0 1 0 2 0 2 0 9.01 15.50 15.50 1.78 26.29 26.29 23.860 23.860
26373 26373 A 0 090 0 1 0 2 0 2 0 8.41 15.18 15.18 1.65 25.24 25.24 22.905 22.905
26390 26390 A 0 090 0 1 0 2 0 2 1 9.43 13.30 13.30 1.86 24.59 24.59 22.346 22.346
26392 26392 A 0 090 0 1 0 2 0 2 1 10.50 16.03 16.03 2.07 28.60 28.60 25.978 25.978
26410 26410 A 0 090 0 1 0 2 0 1 0 4.77 11.18 11.18 0.87 16.82 16.82 15.265 15.265
26412 26412 A 0 090 0 1 0 2 0 0 0 6.48 12.86 12.86 1.16 20.50 20.50 18.635 18.635
26415 26415 A 0 090 0 1 0 2 0 0 0 8.51 13.95 13.95 1.17 23.63 23.63 21.649 21.649
26416 26416 A 0 090 0 1 0 2 0 1 0 9.56 10.91 10.91 1.88 22.35 22.35 20.340 20.340
26418 26418 A 0 090 0 1 0 2 0 1 0 4.47 12.00 12.00 0.82 17.29 17.29 15.675 15.675
26420 26420 A 0 090 0 1 0 2 0 2 0 6.94 12.73 12.73 1.37 21.04 21.04 19.088 19.088
26426 26426 A 0 090 0 1 0 2 0 1 0 6.32 7.40 7.40 1.14 14.86 14.86 13.561 13.561
26428 26428 A 0 090 0 1 0 2 0 0 0 7.40 13.28 13.28 1.47 22.15 22.15 20.094 20.094
26432 26432 A 0 090 0 1 0 2 0 1 0 4.16 9.97 9.97 0.73 14.86 14.86 13.495 13.495
26433 26433 A 0 090 0 1 0 2 0 1 0 4.70 10.23 10.23 0.86 15.79 15.79 14.336 14.336
26434 26434 A 0 090 0 1 0 2 0 2 0 6.26 11.74 11.74 1.24 19.24 19.24 17.451 17.451
26437 26437 A 0 090 0 1 0 2 0 1 0 5.99 11.39 11.39 1.03 18.41 18.41 16.757 16.757
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
68 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26440 26440 A 0 090 0 1 0 2 0 1 0 5.16 12.31 12.31 0.90 18.37 18.37 16.685 16.685
26442 26442 A 0 090 0 1 0 2 0 1 0 9.75 17.07 17.07 1.74 28.56 28.56 25.989 25.989
26445 26445 A 0 090 0 1 0 2 0 1 0 4.45 11.95 11.95 0.78 17.18 17.18 15.589 15.589
26449 26449 A 0 090 0 1 0 2 0 0 0 8.59 10.53 10.53 1.51 20.63 20.63 18.836 18.836
26450 26450 A 0 090 0 1 0 2 0 0 0 3.79 7.44 7.44 0.68 11.91 11.91 10.827 10.827
26455 26455 A 0 090 0 1 0 2 0 0 0 3.76 7.60 7.60 0.69 12.05 12.05 10.946 10.946
26460 26460 A 0 090 0 1 0 2 0 1 0 3.58 7.48 7.48 0.63 11.69 11.69 10.627 10.627
26471 26471 A 0 090 0 1 0 2 0 0 0 5.90 11.27 11.27 1.03 18.20 18.20 16.559 16.559
26474 26474 A 0 090 0 1 0 2 0 2 0 5.49 10.97 10.97 1.08 17.54 17.54 15.906 15.906
26476 26476 A 0 090 0 1 0 2 0 1 0 5.35 10.89 10.89 1.06 17.30 17.30 15.684 15.684
26477 26477 A 0 090 0 1 0 2 0 1 1 5.32 10.89 10.89 1.02 17.23 17.23 15.633 15.633
26478 26478 A 0 090 0 1 0 2 0 0 0 5.97 11.37 11.37 1.09 18.43 18.43 16.750 16.750
26479 26479 A 0 090 0 1 0 2 0 2 0 5.91 11.22 11.22 1.17 18.30 18.30 16.597 16.597
26480 26480 A 0 090 0 1 0 2 0 0 0 6.90 14.24 14.24 1.21 22.35 22.35 20.320 20.320
26483 26483 A 0 090 0 1 0 2 0 2 1 8.48 14.90 14.90 1.57 24.95 24.95 22.681 22.681
26485 26485 A 0 090 0 1 0 2 0 2 1 7.89 14.62 14.62 1.40 23.91 23.91 21.751 21.751
26489 26489 A 0 090 0 1 0 2 0 0 0 9.86 15.96 15.96 1.93 27.75 27.75 25.201 25.201
26490 26490 A 0 090 0 1 0 2 0 0 0 8.60 13.13 13.13 1.69 23.42 23.42 21.275 21.275
26492 26492 A 0 090 0 1 0 2 0 2 1 9.84 14.33 14.33 1.93 26.10 26.10 23.718 23.718
26494 26494 A 0 090 0 1 0 2 0 2 1 8.66 13.32 13.32 1.69 23.67 23.67 21.505 21.505
26496 26496 A 0 090 0 1 0 2 0 0 0 9.78 13.77 13.77 1.65 25.20 25.20 23.008 23.008
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
69 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26497 26497 A 0 090 0 1 0 2 0 2 0 9.76 13.76 13.76 1.92 25.44 25.44 23.121 23.121
26498 26498 A 0 090 0 1 0 2 0 2 1 14.21 16.67 16.67 2.80 33.68 33.68 30.644 30.644
26499 26499 A 0 090 0 1 0 2 0 2 1 9.17 13.41 13.41 1.81 24.39 24.39 22.159 22.159
26500 26500 A 0 090 0 1 0 2 0 0 0 6.13 11.24 11.24 1.14 18.51 18.51 16.820 16.820
26502 26502 A 0 090 0 1 0 2 0 2 0 7.31 12.31 12.31 1.46 21.08 21.08 19.128 19.128
26508 26508 A 0 090 0 1 0 2 1 0 0 6.18 11.70 11.70 1.10 18.98 18.98 17.262 17.262
26510 26510 A 0 090 0 1 0 2 0 0 0 5.60 11.10 11.10 0.98 17.68 17.68 16.080 16.080
26516 26516 A 0 090 0 1 0 2 1 0 0 7.32 12.09 12.09 1.29 20.70 20.70 18.851 18.851
26517 26517 A 0 090 0 1 0 2 1 2 0 9.08 13.36 13.36 1.80 24.24 24.24 22.019 22.019
26518 26518 A 0 090 0 1 0 2 1 2 1 9.27 13.65 13.65 1.82 24.74 24.74 22.480 22.480
26520 26520 A 0 090 0 1 0 2 0 1 0 5.47 12.90 12.90 0.99 19.36 19.36 17.572 17.572
26525 26525 A 0 090 0 1 0 2 0 1 1 5.50 12.93 12.93 0.95 19.38 19.38 17.608 17.608
26530 26530 A 0 090 0 1 0 2 0 2 0 6.88 7.78 7.78 1.22 15.88 15.88 14.505 14.505
26531 26531 A 0 090 0 1 0 2 0 2 1 8.13 8.90 8.90 1.39 18.42 18.42 16.849 16.849
26535 26535 A 0 090 0 1 0 2 0 1 0 5.41 6.15 6.15 0.83 12.39 12.39 11.367 11.367
26536 26536 A 0 090 0 1 0 2 0 0 0 6.56 13.45 13.45 1.13 21.14 21.14 19.229 19.229
26540 26540 A 0 090 0 1 0 2 0 0 1 6.60 11.69 11.69 1.18 19.47 19.47 17.715 17.715
26541 26541 A 0 090 0 1 0 2 0 2 1 8.81 13.24 13.24 1.52 23.57 23.57 21.494 21.494
26542 26542 A 0 090 0 1 0 2 0 0 0 6.95 11.89 11.89 1.25 20.09 20.09 18.281 18.281
26545 26545 A 0 090 0 1 0 2 0 0 0 7.11 12.49 12.49 1.27 20.87 20.87 18.990 18.990
26546 26546 A 0 090 0 1 0 2 1 2 0 10.83 16.68 16.68 1.85 29.36 29.36 26.776 26.776
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
70 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26548 26548 A 0 090 0 1 0 2 0 0 0 8.22 12.80 12.80 1.50 22.52 22.52 20.499 20.499
26550 26550 A 0 090 0 1 0 2 1 2 0 21.68 22.81 22.81 4.26 48.75 48.75 44.391 44.391
26551 26551 A 0 090 0 1 0 2 1 2 0 48.48 28.26 28.26 9.55 86.29 86.29 78.852 78.852
26553 26553 A 0 090 0 1 0 2 1 2 1 48.17 28.05 28.05 3.43 79.65 79.65 75.153 75.153
26554 26554 A 0 090 0 1 0 2 1 2 1 57.01 32.07 32.07 4.06 93.14 93.14 87.932 87.932
26555 26555 A 0 090 0 1 0 2 0 2 0 17.08 20.03 20.03 3.38 40.49 40.49 36.835 36.835
26556 26556 A 0 090 0 1 0 2 0 2 1 49.75 32.03 32.03 3.96 85.74 85.74 80.584 80.584
26560 26560 A 0 090 0 1 0 2 0 2 0 5.52 10.97 10.97 1.09 17.58 17.58 15.941 15.941
26561 26561 A 0 090 0 1 0 2 0 2 1 11.10 14.48 14.48 2.35 27.93 27.93 25.332 25.332
26562 26562 A 0 090 0 1 0 2 0 2 0 16.68 19.66 19.66 1.18 37.52 37.52 34.952 34.952
26565 26565 A 0 090 0 1 0 2 0 2 0 6.91 11.88 11.88 1.36 20.15 20.15 18.290 18.290
26567 26567 A 0 090 0 1 0 2 0 0 0 6.99 11.87 11.87 1.24 20.10 20.10 18.298 18.298
26568 26568 A 0 090 0 1 0 2 0 2 0 9.27 15.64 15.64 1.82 26.73 26.73 24.267 24.267
26580 26580 A 0 090 0 1 0 2 1 2 0 19.75 20.93 20.93 3.89 44.57 44.57 40.580 40.580
26587 26587 A 0 090 0 1 0 2 0 2 0 14.50 13.40 13.40 3.10 31.00 31.00 28.155 28.155
26590 26590 A 0 090 0 1 0 2 0 2 0 18.67 15.42 15.42 3.70 37.79 37.79 34.452 34.452
26591 26591 A 0 090 0 1 0 2 0 0 0 3.38 9.08 9.08 0.61 13.07 13.07 11.853 11.853
26593 26593 A 0 090 0 1 0 2 0 1 0 5.50 11.29 11.29 0.93 17.72 17.72 16.125 16.125
26596 26596 A 0 090 0 1 0 2 0 2 0 9.14 11.56 11.56 1.81 22.51 22.51 20.468 20.468
26600 26600 A 0 090 0 1 0 2 0 1 0 2.60 5.81 5.28 0.48 8.89 8.36 8.068 7.592
26605 26605 A 0 090 0 1 0 2 0 1 0 3.03 6.10 5.22 0.56 9.69 8.81 8.801 8.010
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
71 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26607 26607 A 0 090 0 1 0 2 0 0 0 5.48 7.05 7.05 1.06 13.59 13.59 12.365 12.365
26608 26608 A 0 090 0 1 0 2 0 0 0 5.55 7.63 7.63 1.03 14.21 14.21 12.940 12.940
26615 26615 A 0 090 0 1 0 2 0 1 0 7.07 8.77 8.77 1.29 17.13 17.13 15.620 15.620
26641 26641 A 0 090 0 1 0 2 1 0 0 4.13 6.18 5.19 0.72 11.03 10.04 10.056 9.167
26645 26645 A 0 090 0 1 0 2 1 0 0 4.58 7.29 6.21 0.88 12.75 11.67 11.587 10.617
26650 26650 A 0 090 0 1 0 2 1 1 0 5.35 7.86 7.86 1.02 14.23 14.23 12.942 12.942
26665 26665 A 0 090 0 1 0 2 1 1 1 7.94 9.29 9.29 1.47 18.70 18.70 17.051 17.051
26670 26670 A 0 090 0 1 0 2 0 0 0 3.83 5.41 4.48 0.67 9.91 8.98 9.039 8.203
26675 26675 A 0 090 0 1 0 2 0 0 0 4.83 7.80 6.67 0.95 13.58 12.45 12.331 11.317
26676 26676 A 0 090 0 1 0 2 0 1 0 5.74 8.13 8.13 1.06 14.93 14.93 13.595 13.595
26685 26685 A 0 090 0 1 0 2 0 1 1 7.07 8.79 8.79 1.39 17.25 17.25 15.690 15.690
26686 26686 A 0 090 0 1 0 2 0 2 0 8.17 8.73 8.73 1.61 18.51 18.51 16.852 16.852
26700 26700 A 0 090 0 1 0 2 0 1 0 3.83 5.26 4.64 0.65 9.74 9.12 8.893 8.337
26705 26705 A 0 090 0 1 0 2 0 0 0 4.38 7.20 6.14 0.82 12.40 11.34 11.274 10.323
26706 26706 A 0 090 0 1 0 2 0 1 0 5.31 6.85 6.85 0.95 13.11 13.11 11.958 11.958
26715 26715 A 0 090 0 1 0 2 0 0 0 7.03 8.75 8.75 1.31 17.09 17.09 15.573 15.573
26720 26720 A 0 090 0 1 0 2 0 1 0 1.76 3.91 3.49 0.33 6.00 5.58 5.444 5.067
26725 26725 A 0 090 0 1 0 2 0 1 0 3.48 6.01 4.99 0.64 10.13 9.11 9.212 8.296
26727 26727 A 0 090 0 1 0 2 0 1 0 5.42 7.55 7.55 0.99 13.96 13.96 12.718 12.718
26735 26735 A 0 090 0 1 0 2 0 1 0 7.42 8.95 8.95 1.37 17.74 17.74 16.174 16.174
26740 26740 A 0 090 0 1 0 2 0 1 0 2.07 4.46 4.03 0.35 6.88 6.45 6.258 5.872
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
72 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26742 26742 A 0 090 0 1 0 2 0 1 0 3.99 6.28 5.22 0.72 10.99 9.93 10.006 9.054
26746 26746 A 0 090 0 1 0 2 0 1 0 9.80 10.37 10.37 1.78 21.95 21.95 20.043 20.043
26750 26750 A 0 090 0 1 0 2 0 1 0 1.80 3.43 3.45 0.33 5.56 5.58 5.053 5.071
26755 26755 A 0 090 0 1 0 2 0 1 0 3.23 5.65 4.39 0.59 9.47 8.21 8.612 7.481
26756 26756 A 0 090 0 1 0 2 0 0 0 4.58 7.08 7.08 0.83 12.49 12.49 11.372 11.372
26765 26765 A 0 090 0 1 0 2 0 1 0 5.86 8.00 8.00 1.09 14.95 14.95 13.614 13.614
26770 26770 A 0 090 0 1 0 2 0 1 0 3.15 4.64 4.01 0.54 8.33 7.70 7.599 7.033
26775 26775 A 0 090 0 1 0 2 0 1 0 3.90 6.97 5.84 0.69 11.56 10.43 10.520 9.505
26776 26776 A 0 090 0 1 0 2 0 1 0 4.99 7.28 7.28 0.91 13.18 13.18 12.003 12.003
26785 26785 A 0 090 0 1 0 2 0 1 0 6.60 8.46 8.46 1.21 16.27 16.27 14.830 14.830
26820 26820 A 0 090 0 1 0 2 1 2 1 8.45 13.21 13.21 1.66 23.32 23.32 21.181 21.181
26841 26841 A 0 090 0 1 0 2 1 0 1 7.35 12.86 12.86 1.39 21.60 21.60 19.625 19.625
26842 26842 A 0 090 0 1 0 2 1 2 1 8.49 13.10 13.10 1.66 23.25 23.25 21.122 21.122
26843 26843 A 0 090 0 1 0 2 0 2 1 7.78 12.56 12.56 1.54 21.88 21.88 19.864 19.864
26844 26844 A 0 090 0 1 0 2 0 2 1 8.98 13.30 13.30 1.78 24.06 24.06 21.854 21.854
26850 26850 A 0 090 0 1 0 2 0 0 0 7.14 12.03 12.03 1.24 20.41 20.41 18.591 18.591
26852 26852 A 0 090 0 1 0 2 0 2 1 8.71 13.18 13.18 1.47 23.36 23.36 21.314 21.314
26860 26860 A 0 090 0 1 0 2 0 1 0 4.88 11.01 11.01 0.84 16.73 16.73 15.206 15.206
26861 26861 A 0 ZZZ 0 0 0 0 0 1 0 1.74 0.98 0.98 0.31 3.03 3.03 2.782 2.782
26862 26862 A 0 090 0 1 0 2 0 2 1 7.56 12.51 12.51 1.31 21.38 21.38 19.479 19.479
26863 26863 A 0 ZZZ 0 0 0 0 0 2 0 3.89 2.30 2.30 0.75 6.94 6.94 6.348 6.348
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
73 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
26910 26910 A 0 090 0 1 0 2 0 1 0 7.79 11.86 11.86 1.50 21.15 21.15 19.225 19.225
26951 26951 A 0 090 0 1 0 2 0 1 0 6.04 12.22 12.22 1.14 19.40 19.40 17.610 17.610
26952 26952 A 0 090 0 1 0 2 0 1 0 6.48 11.40 11.40 1.21 19.09 19.09 17.350 17.350
26989 26989 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
26990 26990 A 0 090 0 1 0 2 0 1 0 7.95 9.11 9.11 1.58 18.64 18.64 16.957 16.957
26991 26991 A 0 090 0 1 0 2 0 0 0 7.06 12.84 7.15 1.39 21.29 15.60 19.317 14.208
26992 26992 A 0 090 0 1 0 2 0 0 0 13.48 12.39 12.39 2.67 28.54 28.54 26.003 26.003
27000 27000 A 0 090 0 1 0 2 1 1 1 5.74 5.78 5.78 1.08 12.60 12.60 11.495 11.495
27001 27001 A 0 090 0 1 0 2 1 2 1 7.14 7.61 7.61 1.40 16.15 16.15 14.706 14.706
27003 27003 A 0 090 0 1 0 2 1 2 1 7.81 8.35 8.35 1.54 17.70 17.70 16.114 16.114
27005 27005 A 0 090 0 1 0 2 1 2 1 10.07 9.52 9.52 1.97 21.56 21.56 19.649 19.649
27006 27006 A 0 090 0 1 0 2 1 2 1 10.11 9.85 9.85 1.96 21.92 21.92 19.980 19.980
27025 27025 A 0 090 0 1 0 2 1 0 1 12.89 11.90 11.90 2.57 27.36 27.36 24.920 24.920
27027 27027 A 0 090 0 1 0 2 1 0 0 13.04 11.14 11.14 0.91 25.09 25.09 23.520 23.520
27030 27030 A 0 090 0 1 0 2 1 2 1 13.65 10.48 10.48 2.67 26.80 26.80 24.457 24.457
27033 27033 A 0 090 0 1 0 2 1 2 1 14.11 11.95 11.95 2.78 28.84 28.84 26.295 26.295
27035 27035 A 0 090 0 1 0 2 1 2 1 17.37 8.90 8.90 3.43 29.70 29.70 27.156 27.156
27036 27036 A 0 090 0 1 0 2 1 2 1 14.38 12.77 12.77 2.79 29.94 29.94 27.307 27.307
27040 27040 A 0 010 0 1 0 2 1 1 0 2.92 6.82 2.45 0.48 10.22 5.85 9.295 5.371
27041 27041 A 0 090 0 1 0 2 1 1 0 10.18 8.27 8.27 1.81 20.26 20.26 18.553 18.553
27043 27043 A 0 090 0 1 0 2 1 1 0 6.88 5.70 5.70 1.42 14.00 14.00 12.741 12.741
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
74 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27045 27045 A 0 090 0 1 0 2 1 2 1 11.13 8.70 8.70 2.26 22.09 22.09 20.125 20.125
27047 27047 A 0 090 0 1 0 2 1 1 0 4.94 8.16 4.87 1.02 14.12 10.83 12.801 9.847
27048 27048 A 0 090 0 1 0 2 1 2 1 8.85 7.46 7.46 1.81 18.12 18.12 16.496 16.496
27049 27049 A 0 090 0 1 0 2 1 2 1 21.55 14.24 14.24 4.33 40.12 40.12 36.602 36.602
27050 27050 A 0 090 0 1 0 2 1 0 1 4.74 6.33 6.33 0.93 12.00 12.00 10.911 10.911
27052 27052 A 0 090 0 1 0 2 1 2 1 7.42 8.36 8.36 1.47 17.25 17.25 15.696 15.696
27054 27054 A 0 090 0 1 0 2 1 2 1 9.21 9.37 9.37 1.81 20.39 20.39 18.571 18.571
27057 27057 A 0 090 0 1 0 2 1 0 0 14.91 12.14 12.14 1.06 28.11 28.11 26.366 26.366
27059 27059 A 0 090 0 1 0 2 1 2 1 29.35 18.15 18.15 5.78 53.28 53.28 48.672 48.672
27060 27060 A 0 090 0 1 0 2 1 1 0 5.87 6.81 6.81 1.17 13.85 13.85 12.597 12.597
27062 27062 A 0 090 0 1 0 2 1 1 1 5.75 6.72 6.72 1.13 13.60 13.60 12.376 12.376
27065 27065 A 0 090 0 1 0 2 1 2 1 6.55 7.56 7.56 1.28 15.39 15.39 14.008 14.008
27066 27066 A 0 090 0 1 0 2 1 2 1 11.20 10.71 10.71 2.20 24.11 24.11 21.968 21.968
27067 27067 A 0 090 0 1 0 2 1 2 0 14.72 13.01 13.01 2.91 30.64 30.64 27.925 27.925
27070 27070 A 0 090 0 1 0 2 1 2 1 11.56 11.37 11.37 2.27 25.20 25.20 22.957 22.957
27071 27071 A 0 090 0 1 0 2 1 2 1 12.39 12.44 12.44 2.44 27.27 27.27 24.837 24.837
27075 27075 A 0 090 0 1 0 2 0 2 1 32.71 22.89 22.89 6.44 62.04 62.04 56.633 56.633
27076 27076 A 0 090 0 1 0 2 0 2 1 40.21 26.92 26.92 7.93 75.06 75.06 68.532 68.532
27077 27077 A 0 090 0 1 0 2 0 2 1 45.21 29.60 29.60 8.91 83.72 83.72 76.451 76.451
27078 27078 A 0 090 0 1 0 2 1 2 1 32.21 22.63 22.63 6.34 61.18 61.18 55.848 55.848
27080 27080 A 0 090 0 1 0 2 0 2 1 6.89 7.00 7.00 1.42 15.31 15.31 13.919 13.919
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
75 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27086 27086 A 0 010 0 1 0 2 1 0 0 1.92 5.58 2.30 0.31 7.81 4.53 7.093 4.148
27087 27087 A 0 090 0 1 0 2 1 2 1 8.83 8.16 8.16 1.70 18.69 18.69 17.047 17.047
27090 27090 A 0 090 0 1 0 2 1 2 1 11.69 10.67 10.67 2.29 24.65 24.65 22.469 22.469
27091 27091 A 0 090 0 1 0 2 1 2 1 24.35 18.22 18.22 4.80 47.37 47.37 43.222 43.222
27093 27093 A 0 000 0 0 0 2 1 1 0 1.30 4.31 0.62 0.14 5.75 2.06 5.244 1.930
27095 27095 A 0 000 0 0 0 2 1 1 0 1.50 5.53 0.73 0.18 7.21 2.41 6.560 2.250
27096 27096 A 0 000 0 0 0 2 1 1 0 1.48 3.41 0.92 0.13 5.02 2.53 4.610 2.374
27097 27097 A 0 090 0 1 0 2 1 2 0 9.27 9.03 9.03 1.82 20.12 20.12 18.331 18.331
27098 27098 A 0 090 0 1 0 2 1 2 0 9.32 9.44 9.44 1.84 20.60 20.60 18.759 18.759
27100 27100 A 0 090 0 1 0 2 1 2 1 11.35 10.90 10.90 2.23 24.48 24.48 22.304 22.304
27105 27105 A 0 090 0 1 0 2 1 2 0 12.04 11.27 11.27 2.35 25.66 25.66 23.390 23.390
27110 27110 A 0 090 0 1 0 2 1 2 1 13.77 12.20 12.20 2.72 28.69 28.69 26.148 26.148
27111 27111 A 0 090 0 1 0 2 1 2 1 12.60 11.57 11.57 2.46 26.63 26.63 24.276 24.276
27120 27120 A 0 090 0 1 0 2 1 2 1 19.25 15.17 15.17 3.80 38.22 38.22 34.860 34.860
27122 27122 A 0 090 0 1 0 2 1 2 1 16.09 13.36 13.36 3.16 32.61 32.61 29.740 29.740
27125 27125 A 0 090 0 1 0 2 1 2 1 16.64 13.70 13.70 3.28 33.62 33.62 30.658 30.658
27130 27130 A 0 090 0 1 0 2 1 2 1 21.79 16.67 16.67 4.29 42.75 42.75 39.003 39.003
27132 27132 A 0 090 0 1 0 2 1 2 1 25.69 18.95 18.95 5.06 49.70 49.70 45.353 45.353
27134 27134 A 0 090 0 1 0 2 1 2 1 30.28 20.53 20.53 5.96 56.77 56.77 51.833 51.833
27137 27137 A 0 090 0 1 0 2 1 2 1 22.70 16.52 16.52 4.46 43.68 43.68 39.868 39.868
27138 27138 A 0 090 0 1 0 2 1 2 1 23.70 17.04 17.04 4.67 45.41 45.41 41.444 41.444
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
76 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27140 27140 A 0 090 0 1 0 2 1 2 1 12.78 11.30 11.30 2.52 26.60 26.60 24.245 24.245
27146 27146 A 0 090 0 1 0 2 1 2 1 18.92 15.39 15.39 3.74 38.05 38.05 34.696 34.696
27147 27147 A 0 090 0 1 0 2 1 2 1 22.07 17.08 17.08 4.34 43.49 43.49 39.678 39.678
27151 27151 A 0 090 0 1 0 2 1 2 1 24.12 18.18 18.18 4.76 47.06 47.06 42.935 42.935
27156 27156 A 0 090 0 1 0 2 1 2 1 26.23 19.31 19.31 5.16 50.70 50.70 46.269 46.269
27158 27158 A 0 090 0 1 0 2 2 2 0 21.04 12.39 12.39 4.15 37.58 37.58 34.337 34.337
27161 27161 A 0 090 0 1 0 2 1 2 1 17.89 14.60 14.60 3.51 36.00 36.00 32.837 32.837
27165 27165 A 0 090 0 1 0 2 1 2 1 20.29 16.50 16.50 3.99 40.78 40.78 37.194 37.194
27170 27170 A 0 090 0 1 0 2 1 2 1 17.61 13.80 13.80 3.47 34.88 34.88 31.817 31.817
27175 27175 A 0 090 0 1 0 2 1 0 0 9.38 8.53 8.53 1.85 19.76 19.76 18.007 18.007
27176 27176 A 0 090 0 1 0 2 1 2 1 12.92 11.74 11.74 2.56 27.22 27.22 24.801 24.801
27177 27177 A 0 090 0 1 0 2 1 2 1 16.09 13.73 13.73 3.17 32.99 32.99 30.077 30.077
27178 27178 A 0 090 0 1 0 2 1 2 1 12.92 11.74 11.74 2.56 27.22 27.22 24.801 24.801
27179 27179 A 0 090 0 1 0 2 1 2 0 13.97 12.18 12.18 2.75 28.90 28.90 26.346 26.346
27181 27181 A 0 090 0 1 0 2 1 2 0 16.18 13.92 13.92 3.20 33.30 33.30 30.354 30.354
27185 27185 A 0 090 0 1 0 2 1 1 1 9.79 9.57 9.57 0.69 20.05 20.05 18.745 18.745
27187 27187 A 0 090 0 1 0 2 1 2 1 14.23 12.41 12.41 2.80 29.44 29.44 26.839 26.839
27193 27193 A 0 090 0 1 0 2 0 1 0 6.09 6.74 6.95 1.20 14.03 14.24 12.770 12.959
27194 27194 A 0 090 0 1 0 2 0 0 2 10.20 9.15 9.15 1.66 21.01 21.01 19.285 19.285
27200 27200 A 0 090 0 1 0 2 0 1 0 1.92 3.13 3.36 0.35 5.40 5.63 4.914 5.120
27202 27202 A 0 090 0 1 0 2 0 2 0 7.31 7.05 7.05 1.46 15.82 15.82 14.404 14.404
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
77 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27215 27215 I 9 090 0 1 0 9 9 9 9 10.45 6.50 6.50 0.73 17.68 17.68 16.669 16.669
27216 27216 I 9 090 0 1 0 9 9 9 9 15.73 9.34 9.34 1.13 26.20 26.20 24.708 24.708
27217 27217 I 9 090 0 1 0 9 9 9 9 14.65 8.90 8.90 1.05 24.60 24.60 23.191 23.191
27218 27218 I 9 090 0 1 0 9 9 9 9 20.93 11.44 11.44 1.50 33.87 33.87 31.988 31.988
27220 27220 A 0 090 0 1 0 2 1 1 0 6.83 7.63 7.49 1.33 15.79 15.65 14.377 14.252
27222 27222 A 0 090 0 1 0 2 1 1 0 14.11 11.79 11.79 2.76 28.66 28.66 26.141 26.141
27226 27226 A 0 090 0 1 0 2 1 2 2 15.57 12.67 12.67 3.08 31.32 31.32 28.559 28.559
27227 27227 A 0 090 0 1 0 2 1 2 2 25.41 18.74 18.74 5.01 49.16 49.16 44.859 44.859
27228 27228 A 0 090 0 1 0 2 1 2 2 29.33 20.81 20.81 5.78 55.92 55.92 51.040 51.040
27230 27230 A 0 090 0 1 0 2 1 1 0 5.81 7.26 7.16 1.14 14.21 14.11 12.926 12.836
27232 27232 A 0 090 0 1 0 2 1 1 0 11.72 8.61 8.61 2.25 22.58 22.58 20.629 20.629
27235 27235 A 0 090 0 1 0 2 1 1 1 13.00 11.40 11.40 2.56 26.96 26.96 24.576 24.576
27236 27236 A 0 090 0 1 0 2 1 2 1 17.61 14.44 14.44 3.47 35.52 35.52 32.392 32.392
27238 27238 A 0 090 0 1 0 2 1 1 0 5.75 6.89 6.89 1.13 13.77 13.77 12.528 12.528
27240 27240 A 0 090 0 1 0 2 1 1 0 13.81 12.02 12.02 2.69 28.52 28.52 26.011 26.011
27244 27244 A 0 090 0 1 0 2 1 2 1 18.18 14.76 14.76 3.57 36.51 36.51 33.302 33.302
27245 27245 A 0 090 0 1 0 2 1 2 2 18.18 14.77 14.77 3.57 36.52 36.52 33.311 33.311
27246 27246 A 0 090 0 1 0 2 1 1 0 4.83 5.71 5.77 0.93 11.47 11.53 10.444 10.498
27248 27248 A 0 090 0 1 0 2 1 2 1 10.78 9.14 9.14 2.12 22.04 22.04 20.096 20.096
27250 27250 A 0 000 0 0 0 2 1 1 0 3.82 0.88 0.88 0.67 5.37 5.37 4.961 4.961
27252 27252 A 0 090 0 1 0 2 1 1 0 11.03 9.37 9.37 2.14 22.54 22.54 20.563 20.563
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
78 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27253 27253 A 0 090 0 1 0 2 1 2 1 13.58 11.69 11.69 2.67 27.94 27.94 25.474 25.474
27254 27254 A 0 090 0 1 0 2 1 2 1 18.94 14.69 14.69 3.73 37.36 37.36 34.082 34.082
27256 27256 A 0 010 0 1 0 2 1 0 0 4.28 4.12 1.98 0.75 9.15 7.01 8.372 6.450
27257 27257 A 0 010 0 1 0 2 1 0 0 5.38 3.54 3.54 0.98 9.90 9.90 9.071 9.071
27258 27258 A 0 090 0 1 0 2 1 2 1 16.18 13.44 13.44 3.20 32.82 32.82 29.923 29.923
27259 27259 A 0 090 0 1 0 2 1 2 0 23.26 18.09 18.09 4.57 45.92 45.92 41.895 41.895
27265 27265 A 0 090 0 1 0 2 1 1 0 5.24 5.89 5.89 0.93 12.06 12.06 11.016 11.016
27266 27266 A 0 090 0 1 0 2 1 1 0 7.78 7.98 7.98 1.52 17.28 17.28 15.741 15.741
27267 27267 A 0 090 0 1 0 2 1 2 1 5.50 6.47 6.47 1.09 13.06 13.06 11.880 11.880
27268 27268 A 0 090 0 1 0 2 1 2 1 7.12 7.46 7.46 1.40 15.98 15.98 14.551 14.551
27269 27269 A 0 090 0 1 0 2 1 2 1 18.89 14.20 14.20 3.70 36.79 36.79 33.577 33.577
27275 27275 A 0 010 0 1 0 2 0 1 0 2.32 2.75 2.75 0.39 5.46 5.46 4.993 4.993
27280 27280 A 0 090 0 1 0 2 1 2 1 14.64 13.27 13.27 3.04 30.95 30.95 28.146 28.146
27282 27282 A 0 090 0 1 0 2 0 2 1 11.85 11.17 11.17 2.31 25.33 25.33 23.089 23.089
27284 27284 A 0 090 0 1 0 2 1 2 1 25.06 17.82 17.82 4.95 47.83 47.83 43.651 43.651
27286 27286 A 0 090 0 1 0 2 1 2 1 25.17 18.74 18.74 4.97 48.88 48.88 44.598 44.598
27290 27290 A 0 090 0 1 0 2 0 2 1 24.55 18.65 18.65 4.85 48.05 48.05 43.834 43.834
27295 27295 A 0 090 0 1 0 2 1 2 1 19.66 13.71 13.71 4.01 37.38 37.38 34.069 34.069
27299 27299 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
27301 27301 A 0 090 0 1 0 2 1 1 0 6.78 12.11 6.79 1.37 20.26 14.94 18.371 13.594
27303 27303 A 0 090 0 1 0 2 1 2 1 8.63 8.66 8.66 1.69 18.98 18.98 17.291 17.291
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
79 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27305 27305 A 0 090 0 1 0 2 1 2 1 6.18 7.00 7.00 1.22 14.40 14.40 13.104 13.104
27306 27306 A 0 090 0 1 0 2 1 2 0 4.74 5.16 5.16 0.93 10.83 10.83 9.860 9.860
27307 27307 A 0 090 0 1 0 2 1 0 1 6.06 7.03 7.03 1.20 14.29 14.29 13.001 13.001
27310 27310 A 0 090 0 1 0 2 1 2 1 10.00 9.77 9.77 1.96 21.73 21.73 19.799 19.799
27323 27323 A 0 010 0 1 0 2 1 1 0 2.33 5.54 2.62 0.41 8.28 5.36 7.519 4.897
27324 27324 A 0 090 0 1 0 2 1 1 0 5.04 5.68 5.68 1.05 11.77 11.77 10.690 10.690
27325 27325 A 0 090 0 1 0 2 1 2 0 7.20 7.94 7.94 1.42 16.56 16.56 15.073 15.073
27326 27326 A 0 090 0 1 0 2 1 2 1 6.47 7.55 7.55 1.27 15.29 15.29 13.914 13.914
27327 27327 A 0 090 0 1 0 2 1 1 0 3.96 9.20 4.61 0.80 13.96 9.37 12.640 8.518
27328 27328 A 0 090 0 1 0 2 1 1 0 8.85 7.86 7.86 1.81 18.52 18.52 16.855 16.855
27329 27329 A 0 090 0 1 0 2 1 2 1 15.72 11.75 11.75 3.18 30.65 30.65 27.935 27.935
27330 27330 A 0 090 0 1 0 2 1 1 1 5.11 6.27 6.27 0.95 12.33 12.33 11.237 11.237
27331 27331 A 0 090 0 1 0 2 1 2 1 6.02 7.00 7.00 1.18 14.20 14.20 12.923 12.923
27332 27332 A 0 090 0 1 0 2 1 2 1 8.46 8.95 8.95 1.65 19.06 19.06 17.360 17.360
27333 27333 A 0 090 0 1 0 2 1 2 1 7.55 8.37 8.37 1.50 17.42 17.42 15.851 15.851
27334 27334 A 0 090 0 1 0 2 1 2 1 9.19 9.36 9.36 1.81 20.36 20.36 18.542 18.542
27335 27335 A 0 090 0 1 0 2 1 2 1 10.55 10.09 10.09 2.07 22.71 22.71 20.693 20.693
27337 27337 A 0 090 0 1 0 2 1 2 0 5.91 5.37 5.37 1.21 12.49 12.49 11.365 11.365
27339 27339 A 0 090 0 1 0 2 1 2 0 11.13 8.91 8.91 2.26 22.30 22.30 20.313 20.313
27340 27340 A 0 090 0 1 0 2 1 1 0 4.32 5.95 5.95 0.84 11.11 11.11 10.102 10.102
27345 27345 A 0 090 0 1 0 2 1 2 1 6.09 7.03 7.03 1.20 14.32 14.32 13.031 13.031
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
80 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27347 27347 A 0 090 0 1 0 2 1 2 1 6.73 7.71 7.71 1.32 15.76 15.76 14.344 14.344
27350 27350 A 0 090 0 1 0 2 1 2 1 8.66 9.07 9.07 1.69 19.42 19.42 17.689 17.689
27355 27355 A 0 090 0 1 0 2 1 2 1 8.00 8.35 8.35 1.58 17.93 17.93 16.325 16.325
27356 27356 A 0 090 0 1 0 2 1 2 1 10.09 9.86 9.86 1.97 21.92 21.92 19.975 19.975
27357 27357 A 0 090 0 1 0 2 1 2 1 11.16 10.80 10.80 2.20 24.16 24.16 22.009 22.009
27358 27358 A 0 ZZZ 0 0 0 0 0 2 0 4.73 2.54 2.54 0.91 8.18 8.18 7.487 7.487
27360 27360 A 0 090 0 1 0 2 1 2 1 11.46 11.67 11.67 2.26 25.39 25.39 23.122 23.122
27364 27364 A 0 090 0 1 0 2 1 2 1 24.49 16.60 16.60 4.97 46.06 46.06 41.996 41.996
27365 27365 A 0 090 0 1 0 2 1 2 1 32.21 22.63 22.63 6.36 61.20 61.20 55.858 55.858
27370 27370 A 0 000 0 0 0 2 1 1 0 0.96 3.90 0.45 0.12 4.98 1.53 4.525 1.427
27372 27372 A 0 090 0 1 0 2 1 0 0 5.21 12.14 5.82 1.03 18.38 12.06 16.650 10.975
27380 27380 A 0 090 0 1 0 2 1 2 1 7.45 8.82 8.82 1.47 17.74 17.74 16.139 16.139
27381 27381 A 0 090 0 1 0 2 1 2 1 10.76 10.86 10.86 2.12 23.74 23.74 21.621 21.621
27385 27385 A 0 090 0 1 0 2 1 2 1 6.93 8.94 8.94 1.36 17.23 17.23 15.669 15.669
27386 27386 A 0 090 0 1 0 2 1 2 1 11.13 11.48 11.48 2.19 24.80 24.80 22.584 22.584
27390 27390 A 0 090 0 1 0 2 1 2 0 5.53 6.74 6.74 1.09 13.36 13.36 12.153 12.153
27391 27391 A 0 090 0 1 0 2 0 0 1 7.49 8.17 8.17 1.48 17.14 17.14 15.601 15.601
27392 27392 A 0 090 0 1 0 2 2 2 1 9.63 9.61 9.61 1.89 21.13 21.13 19.248 19.248
27393 27393 A 0 090 0 1 0 2 1 2 1 6.59 7.29 7.29 1.29 15.17 15.17 13.811 13.811
27394 27394 A 0 090 0 1 0 2 0 2 0 8.79 8.87 8.87 1.70 19.36 19.36 17.644 17.644
27395 27395 A 0 090 0 1 0 2 2 2 1 12.24 11.38 11.38 2.41 26.03 26.03 23.720 23.720
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
81 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27396 27396 A 0 090 0 1 0 2 1 2 1 8.15 8.52 8.52 1.61 18.28 18.28 16.643 16.643
27397 27397 A 0 090 0 1 0 2 1 2 0 12.66 12.03 12.03 2.48 27.17 27.17 24.760 24.760
27400 27400 A 0 090 0 1 0 2 1 2 1 9.33 9.44 9.44 1.84 20.61 20.61 18.769 18.769
27403 27403 A 0 090 0 1 0 2 1 2 1 8.62 8.75 8.75 1.67 19.04 19.04 17.351 17.351
27405 27405 A 0 090 0 1 0 2 1 2 1 9.08 9.28 9.28 1.80 20.16 20.16 18.355 18.355
27407 27407 A 0 090 0 1 0 2 1 2 1 10.85 10.51 10.51 2.14 23.50 23.50 21.407 21.407
27409 27409 A 0 090 0 1 0 2 1 2 1 13.71 12.17 12.17 2.71 28.59 28.59 26.056 26.056
27412 27412 A 0 090 0 1 0 2 1 2 1 24.74 19.33 19.33 4.89 48.96 48.96 44.656 44.656
27415 27415 A 0 090 0 1 0 2 1 2 1 20.00 16.78 16.78 3.93 40.71 40.71 37.124 37.124
27416 27416 A 0 090 0 1 0 2 1 0 0 14.16 12.08 12.08 2.79 29.03 29.03 26.467 26.467
27418 27418 A 0 090 0 1 0 2 1 2 1 11.60 10.86 10.86 2.26 24.72 24.72 22.534 22.534
27420 27420 A 0 090 0 1 0 2 1 2 1 10.26 9.36 9.36 2.00 21.62 21.62 19.711 19.711
27422 27422 A 0 090 0 1 0 2 1 2 1 10.21 9.90 9.90 1.99 22.10 22.10 20.141 20.141
27424 27424 A 0 090 0 1 0 2 1 2 1 10.24 9.93 9.93 2.00 22.17 22.17 20.203 20.203
27425 27425 A 0 090 0 1 0 2 1 1 1 5.39 6.92 6.92 1.06 13.37 13.37 12.159 12.159
27427 27427 A 0 090 0 1 0 2 1 2 1 9.79 9.60 9.60 1.92 21.31 21.31 19.415 19.415
27428 27428 A 0 090 0 1 0 2 1 2 1 15.58 14.40 14.40 3.09 33.07 33.07 30.127 30.127
27429 27429 A 0 090 0 1 0 2 1 2 1 17.54 16.06 16.06 3.47 37.07 37.07 33.777 33.777
27430 27430 A 0 090 0 1 0 2 1 2 1 10.16 9.88 9.88 1.99 22.03 22.03 20.073 20.073
27435 27435 A 0 090 0 1 0 2 1 2 1 10.88 11.07 11.07 2.15 24.10 24.10 21.945 21.945
27437 27437 A 0 090 0 1 0 2 1 1 1 8.93 8.91 8.91 1.77 19.61 19.61 17.857 17.857
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
82 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27438 27438 A 0 090 0 1 0 2 1 2 1 11.89 10.78 10.78 2.33 25.00 25.00 22.789 22.789
27440 27440 A 0 090 0 1 0 2 1 2 1 11.09 10.38 10.38 2.18 23.65 23.65 21.551 21.551
27441 27441 A 0 090 0 1 0 2 1 2 1 11.54 10.62 10.62 2.26 24.42 24.42 22.259 22.259
27442 27442 A 0 090 0 1 0 2 1 2 1 12.37 11.02 11.02 2.42 25.81 25.81 23.532 23.532
27443 27443 A 0 090 0 1 0 2 1 2 1 11.41 10.55 10.55 2.25 24.21 24.21 22.061 22.061
27445 27445 A 0 090 0 1 0 2 1 2 1 18.66 14.79 14.79 3.70 37.15 37.15 33.877 33.877
27446 27446 A 0 090 0 1 0 2 1 2 1 16.38 13.18 13.18 3.23 32.79 32.79 29.905 29.905
27447 27447 A 0 090 0 1 0 2 1 2 1 23.25 17.82 17.82 4.57 45.64 45.64 41.642 41.642
27448 27448 A 0 090 0 1 0 2 1 2 1 11.60 10.53 10.53 2.29 24.42 24.42 22.254 22.254
27450 27450 A 0 090 0 1 0 2 1 2 1 14.61 12.65 12.65 2.90 30.16 30.16 27.486 27.486
27454 27454 A 0 090 0 1 0 2 1 2 1 19.17 15.52 15.52 3.78 38.47 38.47 35.084 35.084
27455 27455 A 0 090 0 1 0 2 1 2 1 13.36 11.92 11.92 2.63 27.91 27.91 25.440 25.440
27457 27457 A 0 090 0 1 0 2 1 2 1 14.03 11.68 11.68 2.76 28.47 28.47 25.962 25.962
27465 27465 A 0 090 0 1 0 2 1 2 1 18.60 14.75 14.75 3.69 37.04 37.04 33.775 33.775
27466 27466 A 0 090 0 1 0 2 1 2 1 17.28 14.28 14.28 3.42 34.98 34.98 31.892 31.892
27468 27468 A 0 090 0 1 0 2 1 2 1 19.97 15.81 15.81 3.93 39.71 39.71 36.223 36.223
27470 27470 A 0 090 0 1 0 2 1 2 1 17.14 14.41 14.41 3.39 34.94 34.94 31.853 31.853
27472 27472 A 0 090 0 1 0 2 1 2 1 18.72 15.11 15.11 3.70 37.53 37.53 34.224 34.224
27475 27475 A 0 090 0 1 0 2 1 1 1 8.93 8.94 8.94 1.77 19.64 19.64 17.884 17.884
27477 27477 A 0 090 0 1 0 2 1 1 1 10.14 9.59 9.59 1.99 21.72 21.72 19.793 19.793
27479 27479 A 0 090 0 1 0 2 1 2 0 13.16 11.50 11.50 0.93 25.59 25.59 23.973 23.973
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
83 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27485 27485 A 0 090 0 1 0 2 1 1 0 9.13 8.96 8.96 1.81 19.90 19.90 18.123 18.123
27486 27486 A 0 090 0 1 0 2 1 2 1 21.12 16.50 16.50 4.15 41.77 41.77 38.107 38.107
27487 27487 A 0 090 0 1 0 2 1 2 1 27.11 19.70 19.70 5.34 52.15 52.15 47.593 47.593
27488 27488 A 0 090 0 1 0 2 1 2 1 17.60 14.62 14.62 3.47 35.69 35.69 32.544 32.544
27495 27495 A 0 090 0 1 0 2 1 2 1 16.54 13.68 13.68 3.25 33.47 33.47 30.524 30.524
27496 27496 A 0 090 0 1 0 2 1 1 0 6.78 8.08 8.08 1.33 16.19 16.19 14.731 14.731
27497 27497 A 0 090 0 1 0 2 1 0 2 7.79 7.96 7.96 1.54 17.29 17.29 15.744 15.744
27498 27498 A 0 090 0 1 0 2 1 2 2 8.66 9.08 9.08 1.69 19.43 19.43 17.698 17.698
27499 27499 A 0 090 0 1 0 2 1 2 2 9.43 9.50 9.50 1.86 20.79 20.79 18.934 18.934
27500 27500 A 0 090 0 1 0 2 1 1 0 6.30 7.90 6.71 1.22 15.42 14.23 14.032 12.964
27501 27501 A 0 090 0 1 0 2 1 0 0 6.45 7.28 7.16 1.27 15.00 14.88 13.652 13.544
27502 27502 A 0 090 0 1 0 2 1 1 0 11.36 9.34 9.34 2.19 22.89 22.89 20.893 20.893
27503 27503 A 0 090 0 1 0 2 1 0 0 11.27 10.39 10.39 2.20 23.86 23.86 21.751 21.751
27506 27506 A 0 090 0 1 0 2 1 2 1 19.65 16.20 16.20 3.87 39.72 39.72 36.222 36.222
27507 27507 A 0 090 0 1 0 2 1 2 2 14.48 11.51 11.51 2.86 28.85 28.85 26.312 26.312
27508 27508 A 0 090 0 1 0 2 1 1 0 6.20 8.35 7.38 1.20 15.75 14.78 14.326 13.455
27509 27509 A 0 090 0 1 0 2 1 0 0 8.14 9.53 9.53 1.59 19.26 19.26 17.530 17.530
27510 27510 A 0 090 0 1 0 2 1 1 0 9.80 8.72 8.72 1.88 20.40 20.40 18.614 18.614
27511 27511 A 0 090 0 1 0 2 1 2 2 15.11 11.45 11.45 2.98 29.54 29.54 26.951 26.951
27513 27513 A 0 090 0 1 0 2 1 2 2 19.25 13.68 13.68 3.80 36.73 36.73 33.522 33.522
27514 27514 A 0 090 0 1 0 2 1 2 1 14.60 11.19 11.19 2.87 28.66 28.66 26.150 26.150
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
84 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27516 27516 A 0 090 0 1 0 2 1 1 0 5.59 8.52 7.55 1.10 15.21 14.24 13.816 12.945
27517 27517 A 0 090 0 1 0 2 1 0 0 9.12 9.44 9.44 1.80 20.36 20.36 18.539 18.539
27519 27519 A 0 090 0 1 0 2 1 2 1 13.25 10.49 10.49 2.61 26.35 26.35 24.035 24.035
27520 27520 A 0 090 0 1 0 2 1 1 0 3.04 6.16 5.28 0.59 9.79 8.91 8.880 8.090
27524 27524 A 0 090 0 1 0 2 1 2 1 10.37 9.99 9.99 2.03 22.39 22.39 20.403 20.403
27530 27530 A 0 090 0 1 0 2 1 1 0 2.65 5.98 5.31 0.51 9.14 8.47 8.287 7.685
27532 27532 A 0 090 0 1 0 2 1 1 0 7.55 9.34 8.15 1.48 18.37 17.18 16.711 15.643
27535 27535 A 0 090 0 1 0 2 1 2 2 13.41 10.55 10.55 2.63 26.59 26.59 24.259 24.259
27536 27536 A 0 090 0 1 0 2 1 2 1 17.39 14.51 14.51 3.43 35.33 35.33 32.214 32.214
27538 27538 A 0 090 0 1 0 2 1 0 0 5.09 8.14 7.20 0.99 14.22 13.28 12.917 12.073
27540 27540 A 0 090 0 1 0 2 1 2 1 11.30 10.58 10.58 2.22 24.10 24.10 21.962 21.962
27550 27550 A 0 090 0 1 0 2 1 0 0 5.98 7.86 6.72 1.10 14.94 13.80 13.614 12.590
27552 27552 A 0 090 0 1 0 2 1 0 0 8.18 8.87 8.87 1.61 18.66 18.66 16.987 16.987
27556 27556 A 0 090 0 1 0 2 1 2 1 13.00 10.36 10.36 2.57 25.93 25.93 23.647 23.647
27557 27557 A 0 090 0 1 0 2 1 2 1 15.90 11.92 11.92 3.14 30.96 30.96 28.246 28.246
27558 27558 A 0 090 0 1 0 2 1 2 2 18.39 13.25 13.25 3.62 35.26 35.26 32.182 32.182
27560 27560 A 0 090 0 1 0 2 1 1 0 3.99 6.25 5.39 0.76 11.00 10.14 10.000 9.228
27562 27562 A 0 090 0 1 0 2 1 0 0 5.98 7.24 7.24 1.18 14.40 14.40 13.099 13.099
27566 27566 A 0 090 0 1 0 2 1 2 1 12.71 11.27 11.27 2.50 26.48 26.48 24.138 24.138
27570 27570 A 0 010 0 1 0 2 1 1 0 1.79 2.37 2.37 0.34 4.50 4.50 4.096 4.096
27580 27580 A 0 090 0 1 0 2 1 2 1 21.10 17.46 17.46 4.15 42.71 42.71 38.950 38.950
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
85 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27590 27590 A 0 090 0 1 0 2 1 2 1 13.47 7.88 7.88 2.95 24.30 24.30 22.089 22.089
27591 27591 A 0 090 0 1 0 2 1 2 1 13.94 11.93 11.93 2.91 28.78 28.78 26.175 26.175
27592 27592 A 0 090 0 1 0 2 1 2 1 10.98 7.46 7.46 2.34 20.78 20.78 18.903 18.903
27594 27594 A 0 090 0 1 0 2 1 1 0 7.29 6.42 6.42 1.55 15.26 15.26 13.866 13.866
27596 27596 A 0 090 0 1 0 2 1 1 1 11.29 8.23 8.23 2.40 21.92 21.92 19.936 19.936
27598 27598 A 0 090 0 1 0 2 1 2 1 11.22 8.41 8.41 2.33 21.96 21.96 19.991 19.991
27599 27599 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
27600 27600 A 0 090 0 1 0 2 1 1 1 6.03 5.16 5.16 1.27 12.46 12.46 11.328 11.328
27601 27601 A 0 090 0 1 0 2 1 1 0 6.05 5.94 5.94 1.27 13.26 13.26 12.048 12.048
27602 27602 A 0 090 0 1 0 2 1 2 1 7.82 5.43 5.43 1.74 14.99 14.99 13.606 13.606
27603 27603 A 0 090 0 1 0 2 1 1 0 5.23 10.05 5.50 1.01 16.29 11.74 14.783 10.697
27604 27604 A 0 090 0 1 0 2 1 0 0 4.59 9.28 4.77 0.78 14.65 10.14 13.331 9.281
27605 27605 A 0 010 0 1 0 2 1 0 0 2.92 7.15 2.26 0.34 10.41 5.52 9.519 5.127
27606 27606 A 0 010 0 1 0 2 1 1 1 4.18 3.61 3.61 0.72 8.51 8.51 7.798 7.798
27607 27607 A 0 090 0 1 0 2 1 1 0 8.62 7.91 7.91 1.58 18.11 18.11 16.550 16.550
27610 27610 A 0 090 0 1 0 2 1 1 0 9.13 8.59 8.59 1.63 19.35 19.35 17.696 17.696
27612 27612 A 0 090 0 1 0 2 1 2 1 8.15 7.31 7.31 1.16 16.62 16.62 15.321 15.321
27613 27613 A 0 010 0 1 0 2 1 1 0 2.22 5.22 2.40 0.31 7.75 4.93 7.070 4.537
27614 27614 A 0 090 0 1 0 2 1 1 0 5.80 10.85 5.38 1.03 17.68 12.21 16.082 11.170
27615 27615 A 0 090 0 1 0 2 1 0 1 15.72 11.55 11.55 3.14 30.41 30.41 27.734 27.734
27616 27616 A 0 090 0 1 0 2 1 0 1 19.63 13.74 13.74 3.91 37.28 37.28 34.013 34.013
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
86 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27618 27618 A 0 090 0 1 0 2 1 1 0 3.96 8.82 4.43 0.73 13.51 9.12 12.262 8.320
27619 27619 A 0 090 0 1 0 2 1 1 0 6.91 6.11 6.11 1.22 14.24 14.24 13.035 13.035
27620 27620 A 0 090 0 1 0 2 1 2 1 6.15 6.32 6.32 1.05 13.52 13.52 12.375 12.375
27625 27625 A 0 090 0 1 0 2 1 2 1 8.49 7.44 7.44 1.27 17.20 17.20 15.835 15.835
27626 27626 A 0 090 0 1 0 2 1 2 0 9.10 7.89 7.89 1.52 18.51 18.51 16.980 16.980
27630 27630 A 0 090 0 1 0 2 1 1 0 4.94 11.29 5.20 0.78 17.01 10.92 15.486 10.018
27632 27632 A 0 090 0 1 0 2 1 2 0 5.91 5.37 5.37 1.13 12.41 12.41 11.323 11.323
27634 27634 A 0 090 0 1 0 2 1 2 0 10.13 8.35 8.35 1.80 20.28 20.28 18.570 18.570
27635 27635 A 0 090 0 1 0 2 1 1 1 8.03 8.03 8.03 1.50 17.56 17.56 16.025 16.025
27637 27637 A 0 090 0 1 0 2 1 2 1 10.31 10.26 10.26 2.01 22.58 22.58 20.575 20.575
27638 27638 A 0 090 0 1 0 2 1 2 1 10.99 9.93 9.93 2.16 23.08 23.08 21.037 21.037
27640 27640 A 0 090 0 1 0 2 1 1 1 12.24 10.38 10.38 2.20 24.82 24.82 22.712 22.712
27641 27641 A 0 090 0 1 0 2 1 1 1 9.84 8.23 8.23 1.67 19.74 19.74 18.104 18.104
27645 27645 A 0 090 0 1 0 2 1 2 1 27.21 20.07 20.07 5.36 52.64 52.64 48.036 48.036
27646 27646 A 0 090 0 1 0 2 1 2 1 23.21 17.92 17.92 4.57 45.70 45.70 41.692 41.692
27647 27647 A 0 090 0 1 0 2 1 2 0 20.26 8.27 8.27 2.03 30.56 30.56 28.748 28.748
27648 27648 A 0 000 0 0 0 2 1 0 0 0.96 3.89 0.46 0.12 4.97 1.54 4.516 1.436
27650 27650 A 0 090 0 1 0 2 1 2 1 9.21 9.14 9.14 1.51 19.86 19.86 18.207 18.207
27652 27652 A 0 090 0 1 0 2 1 1 1 10.78 7.97 7.97 1.51 20.26 20.26 18.727 18.727
27654 27654 A 0 090 0 1 0 2 1 2 1 10.53 8.96 8.96 1.51 21.00 21.00 19.366 19.366
27656 27656 A 0 090 0 1 0 2 1 2 0 4.71 13.71 6.21 0.91 19.33 11.83 17.498 10.763
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
87 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27658 27658 A 0 090 0 1 0 2 0 2 1 5.12 5.39 5.39 0.78 11.29 11.29 10.368 10.368
27659 27659 A 0 090 0 1 0 2 0 2 1 7.10 6.42 6.42 0.99 14.51 14.51 13.383 13.383
27664 27664 A 0 090 0 1 0 2 0 0 0 4.73 5.41 5.41 0.75 10.89 10.89 9.980 9.980
27665 27665 A 0 090 0 1 0 2 0 2 1 5.57 5.97 5.97 0.88 12.42 12.42 11.391 11.391
27675 27675 A 0 090 0 1 0 2 1 2 1 7.35 6.24 6.24 1.02 14.61 14.61 13.487 13.487
27676 27676 A 0 090 0 1 0 2 1 2 0 8.73 8.15 8.15 1.70 18.58 18.58 16.938 16.938
27680 27680 A 0 090 0 1 0 2 0 1 1 5.88 6.08 6.08 0.98 12.94 12.94 11.852 11.852
27681 27681 A 0 090 0 1 0 2 1 1 1 7.05 7.82 7.82 1.39 16.26 16.26 14.799 14.799
27685 27685 A 0 090 0 1 0 2 1 2 1 6.69 12.48 6.23 0.91 20.08 13.83 18.373 12.760
27686 27686 A 0 090 0 1 0 2 1 1 1 7.75 7.39 7.39 1.29 16.43 16.43 15.061 15.061
27687 27687 A 0 090 0 1 0 2 1 2 1 6.41 6.26 6.26 0.99 13.66 13.66 12.549 12.549
27690 27690 A 0 090 0 1 0 2 1 2 1 9.17 8.35 8.35 1.32 18.84 18.84 17.359 17.359
27691 27691 A 0 090 0 1 0 2 1 2 1 10.49 10.13 10.13 1.82 22.44 22.44 20.539 20.539
27692 27692 A 0 ZZZ 0 0 0 0 0 2 1 1.87 0.93 0.93 0.34 3.14 3.14 2.883 2.883
27695 27695 A 0 090 0 1 0 2 1 1 1 6.70 6.59 6.59 1.08 14.37 14.37 13.183 13.183
27696 27696 A 0 090 0 1 0 2 1 1 1 8.58 6.94 6.94 1.16 16.68 16.68 15.419 15.419
27698 27698 A 0 090 0 1 0 2 1 2 1 9.61 8.03 8.03 1.51 19.15 19.15 17.611 17.611
27700 27700 A 0 090 0 1 0 2 1 2 1 9.66 6.71 6.71 1.20 17.57 17.57 16.313 16.313
27702 27702 A 0 090 0 1 0 2 1 2 1 14.42 11.84 11.84 2.65 28.91 28.91 26.438 26.438
27703 27703 A 0 090 0 1 0 2 1 2 0 16.94 13.49 13.49 3.18 33.61 33.61 30.717 30.717
27704 27704 A 0 090 0 1 0 2 1 1 1 7.81 8.24 8.24 1.42 17.47 17.47 15.952 15.952
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
88 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27705 27705 A 0 090 0 1 0 2 1 2 1 10.86 9.71 9.71 2.01 22.58 22.58 20.631 20.631
27707 27707 A 0 090 0 1 0 2 1 1 1 4.78 6.44 6.44 0.90 12.12 12.12 11.034 11.034
27709 27709 A 0 090 0 1 0 2 1 2 1 17.48 13.85 13.85 3.38 34.71 34.71 31.685 31.685
27712 27712 A 0 090 0 1 0 2 1 2 1 15.87 13.76 13.76 3.14 32.77 32.77 29.869 29.869
27715 27715 A 0 090 0 1 0 2 1 2 1 15.50 12.96 12.96 3.08 31.54 31.54 28.749 28.749
27720 27720 A 0 090 0 1 0 2 1 2 1 12.36 11.35 11.35 2.40 26.11 26.11 23.808 23.808
27722 27722 A 0 090 0 1 0 2 1 2 1 12.45 11.50 11.50 2.44 26.39 26.39 24.053 24.053
27724 27724 A 0 090 0 1 0 2 1 2 1 19.31 14.47 14.47 3.80 37.58 37.58 34.291 34.291
27725 27725 A 0 090 0 1 0 2 1 2 1 17.41 15.34 15.34 3.44 36.19 36.19 32.984 32.984
27726 27726 A 0 090 0 1 0 2 1 1 1 14.34 11.84 11.84 2.78 28.96 28.96 26.426 26.426
27727 27727 A 0 090 0 1 0 2 1 2 1 14.84 12.94 12.94 2.94 30.72 30.72 27.998 27.998
27730 27730 A 0 090 0 1 0 2 1 1 1 7.70 8.19 8.19 1.52 17.41 17.41 15.850 15.850
27732 27732 A 0 090 0 1 0 2 1 1 0 5.46 6.80 6.80 1.08 13.34 13.34 12.131 12.131
27734 27734 A 0 090 0 1 0 2 1 1 0 8.83 8.90 8.90 0.63 18.36 18.36 17.152 17.152
27740 27740 A 0 090 0 1 0 2 1 2 0 9.61 6.78 6.78 1.89 18.28 18.28 16.687 16.687
27742 27742 A 0 090 0 1 0 2 1 2 1 10.63 7.40 7.40 2.08 20.11 20.11 18.363 18.363
27745 27745 A 0 090 0 1 0 2 1 2 1 10.49 10.01 10.01 2.04 22.54 22.54 20.546 20.546
27750 27750 A 0 090 0 1 0 2 1 1 0 3.37 6.44 5.56 0.64 10.45 9.57 9.488 8.698
27752 27752 A 0 090 0 1 0 2 1 1 0 6.27 8.63 7.34 1.21 16.11 14.82 14.653 13.494
27756 27756 A 0 090 0 1 0 2 1 2 1 7.45 8.35 8.35 1.46 17.26 17.26 15.712 15.712
27758 27758 A 0 090 0 1 0 2 1 2 1 12.54 11.50 11.50 2.45 26.49 26.49 24.148 24.148
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
89 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27759 27759 A 0 090 0 1 0 2 1 2 2 14.45 12.35 12.35 2.84 29.64 29.64 27.026 27.026
27760 27760 A 0 090 0 1 0 2 1 1 0 3.21 6.33 5.41 0.59 10.13 9.21 9.203 8.377
27762 27762 A 0 090 0 1 0 2 1 1 0 5.47 7.84 6.54 1.01 14.32 13.02 13.039 11.871
27766 27766 A 0 090 0 1 0 2 1 1 1 7.89 8.81 8.81 1.51 18.21 18.21 16.591 16.591
27767 27767 A 0 090 0 1 0 2 1 1 0 2.64 5.38 5.43 0.50 8.52 8.57 7.733 7.778
27768 27768 A 0 090 0 1 0 2 1 1 0 5.14 7.00 7.00 1.02 13.16 13.16 11.959 11.959
27769 27769 A 0 090 0 1 0 2 1 1 0 10.14 9.69 9.69 1.99 21.82 21.82 19.882 19.882
27780 27780 A 0 090 0 1 0 2 1 1 0 2.83 5.93 5.07 0.53 9.29 8.43 8.432 7.660
27781 27781 A 0 090 0 1 0 2 1 1 0 4.59 7.09 6.15 0.87 12.55 11.61 11.412 10.568
27784 27784 A 0 090 0 1 0 2 1 1 1 9.67 9.78 9.78 1.88 21.33 21.33 19.436 19.436
27786 27786 A 0 090 0 1 0 2 1 1 0 3.02 6.03 5.09 0.54 9.59 8.65 8.717 7.873
27788 27788 A 0 090 0 1 0 2 1 1 0 4.64 7.23 6.10 0.84 12.71 11.58 11.572 10.557
27792 27792 A 0 090 0 1 0 2 1 1 1 8.75 9.13 9.13 1.66 19.54 19.54 17.817 17.817
27808 27808 A 0 090 0 1 0 2 1 1 0 3.03 6.55 5.50 0.56 10.14 9.09 9.205 8.262
27810 27810 A 0 090 0 1 0 2 1 1 0 5.32 7.83 6.49 1.01 14.16 12.82 12.880 11.676
27814 27814 A 0 090 0 1 0 2 1 2 1 10.62 10.36 10.36 2.04 23.02 23.02 20.990 20.990
27816 27816 A 0 090 0 1 0 2 1 1 0 3.07 6.02 4.99 0.54 9.63 8.60 8.758 7.833
27818 27818 A 0 090 0 1 0 2 1 1 0 5.69 7.84 6.30 1.05 14.58 13.04 13.279 11.897
27822 27822 A 0 090 0 1 0 2 1 2 1 11.21 11.75 11.75 2.16 25.12 25.12 22.891 22.891
27823 27823 A 0 090 0 1 0 2 1 2 1 13.16 12.73 12.73 2.55 28.44 28.44 25.925 25.925
27824 27824 A 0 090 0 1 0 2 1 1 0 3.31 5.48 5.21 0.61 9.40 9.13 8.550 8.308
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
90 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27825 27825 A 0 090 0 1 0 2 1 0 0 6.69 8.28 6.71 1.28 16.25 14.68 14.795 13.385
27826 27826 A 0 090 0 1 0 2 1 2 2 11.10 11.76 11.76 2.14 25.00 25.00 22.780 22.780
27827 27827 A 0 090 0 1 0 2 1 2 2 14.79 14.64 14.64 2.90 32.33 32.33 29.453 29.453
27828 27828 A 0 090 0 1 0 2 1 2 2 18.43 16.51 16.51 3.59 38.53 38.53 35.134 35.134
27829 27829 A 0 090 0 1 0 2 1 2 2 8.80 10.00 10.00 1.69 20.49 20.49 18.664 18.664
27830 27830 A 0 090 0 1 0 2 1 0 0 3.96 6.69 5.88 0.76 11.41 10.60 10.365 9.638
27831 27831 A 0 090 0 1 0 2 1 0 0 4.73 6.28 6.28 0.91 11.92 11.92 10.845 10.845
27832 27832 A 0 090 0 1 0 2 1 2 1 10.17 10.30 10.30 1.99 22.46 22.46 20.460 20.460
27840 27840 A 0 090 0 1 0 2 1 1 0 4.77 5.62 5.62 0.83 11.22 11.22 10.251 10.251
27842 27842 A 0 090 0 1 0 2 1 1 0 6.46 7.13 7.13 1.21 14.80 14.80 13.496 13.496
27846 27846 A 0 090 0 1 0 2 1 2 1 10.28 9.57 9.57 1.95 21.80 21.80 19.894 19.894
27848 27848 A 0 090 0 1 0 2 1 2 1 11.68 10.13 10.13 2.25 24.06 24.06 21.953 21.953
27860 27860 A 0 010 0 1 0 2 1 0 0 2.39 2.56 2.56 0.39 5.34 5.34 4.893 4.893
27870 27870 A 0 090 0 1 0 2 1 2 1 15.41 12.59 12.59 2.80 30.80 30.80 28.180 28.180
27871 27871 A 0 090 0 1 0 2 1 2 1 9.54 9.11 9.11 1.85 20.50 20.50 18.688 18.688
27880 27880 A 0 090 0 1 0 2 1 2 1 15.37 8.91 8.91 3.32 27.60 27.60 25.108 25.108
27881 27881 A 0 090 0 1 0 2 1 2 1 13.47 10.29 10.29 2.80 26.56 26.56 24.175 24.175
27882 27882 A 0 090 0 1 0 2 1 0 1 9.79 6.46 6.46 2.15 18.40 18.40 16.716 16.716
27884 27884 A 0 090 0 1 0 2 1 1 0 8.76 6.86 6.86 1.86 17.48 17.48 15.893 15.893
27886 27886 A 0 090 0 1 0 2 1 1 1 10.02 7.82 7.82 2.14 19.98 19.98 18.162 18.162
27888 27888 A 0 090 0 1 0 2 1 2 1 10.37 7.98 7.98 1.93 20.28 20.28 18.545 18.545
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
91 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
27889 27889 A 0 090 0 1 0 2 1 1 1 10.86 6.33 6.33 2.41 19.60 19.60 17.805 17.805
27892 27892 A 0 090 0 1 0 2 1 0 0 7.94 6.89 6.89 1.63 16.46 16.46 14.980 14.980
27893 27893 A 0 090 0 1 0 2 1 0 0 7.90 8.68 8.68 1.67 18.25 18.25 16.568 16.568
27894 27894 A 0 090 0 1 0 2 1 2 0 12.67 10.68 10.68 2.67 26.02 26.02 23.657 23.657
27899 27899 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
28001 28001 A 0 010 0 1 0 2 0 1 0 2.78 5.30 1.97 0.23 8.31 4.98 7.660 4.669
28002 28002 A 0 010 0 1 0 2 0 1 0 5.34 7.58 3.63 0.60 13.52 9.57 12.461 8.914
28003 28003 A 0 090 0 1 0 2 0 1 0 9.06 11.90 7.20 1.06 22.02 17.32 20.301 16.080
28005 28005 A 0 090 0 1 0 2 0 1 0 9.44 6.76 6.76 1.02 17.22 17.22 16.044 16.044
28008 28008 A 0 090 0 1 0 2 1 1 0 4.59 8.06 3.70 0.41 13.06 8.70 12.042 8.127
28010 28010 A 0 090 0 1 0 2 0 1 0 2.97 3.74 3.02 0.27 6.98 6.26 6.470 5.823
28011 28011 A 0 090 0 1 0 2 0 1 0 4.28 5.01 3.92 0.49 9.78 8.69 9.035 8.056
28020 28020 A 0 090 0 1 0 2 0 1 1 5.15 10.67 4.98 0.67 16.49 10.80 15.082 9.972
28022 28022 A 0 090 0 1 0 2 0 1 0 4.81 9.64 4.41 0.49 14.94 9.71 13.723 9.026
28024 28024 A 0 090 0 1 0 2 0 1 0 4.52 9.08 4.13 0.42 14.02 9.07 12.894 8.448
28035 28035 A 0 090 0 1 0 2 1 1 1 5.23 10.15 4.71 0.65 16.03 10.59 14.685 9.800
28039 28039 A 0 090 0 1 0 2 1 2 0 5.42 9.81 4.59 0.54 15.77 10.55 14.512 9.824
28041 28041 A 0 090 0 1 0 2 1 0 0 7.13 5.91 5.91 0.73 13.77 13.77 12.819 12.819
28043 28043 A 0 090 0 1 0 2 1 1 0 3.96 7.88 3.51 0.39 12.23 7.86 11.240 7.316
28045 28045 A 0 090 0 1 0 2 1 0 0 5.45 9.09 4.39 0.56 15.10 10.40 13.906 9.685
28046 28046 A 0 090 0 1 0 2 1 1 1 12.38 7.77 7.77 1.66 21.81 21.81 20.226 20.226
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
92 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28047 28047 A 0 090 0 1 0 2 1 2 1 17.45 11.32 11.32 1.33 30.10 30.10 28.311 28.311
28050 28050 A 0 090 0 1 0 2 1 1 1 4.39 8.16 3.60 0.39 12.94 8.38 11.922 7.827
28052 28052 A 0 090 0 1 0 2 1 1 1 4.06 8.96 3.90 0.49 13.51 8.45 12.362 7.818
28054 28054 A 0 090 0 1 0 2 1 0 0 3.57 7.58 3.17 0.27 11.42 7.01 10.518 6.558
28055 28055 A 0 090 0 1 0 2 1 0 0 6.29 4.33 4.33 0.53 11.15 11.15 10.456 10.456
28060 28060 A 0 090 0 1 0 2 1 1 0 5.40 9.81 4.67 0.54 15.75 10.61 14.492 9.876
28062 28062 A 0 090 0 1 0 2 1 1 1 6.69 10.43 4.78 0.60 17.72 12.07 16.370 11.296
28070 28070 A 0 090 0 1 0 2 0 1 0 5.24 10.44 4.78 0.56 16.24 10.58 14.908 9.825
28072 28072 A 0 090 0 1 0 2 0 1 0 4.72 10.19 4.62 0.64 15.55 9.98 14.205 9.203
28080 28080 A 0 090 0 1 0 2 0 0 0 4.86 10.73 5.70 0.48 16.07 11.04 14.747 10.230
28086 28086 A 0 090 0 1 0 2 1 2 1 4.92 11.09 5.16 0.72 16.73 10.80 15.255 9.930
28088 28088 A 0 090 0 1 0 2 1 0 0 3.98 10.36 4.57 0.54 14.88 9.09 13.566 8.366
28090 28090 A 0 090 0 1 0 2 1 1 0 4.55 9.34 4.18 0.48 14.37 9.21 13.188 8.555
28092 28092 A 0 090 0 1 0 2 0 1 0 3.78 8.87 3.93 0.39 13.04 8.10 11.949 7.513
28100 28100 A 0 090 0 1 0 2 1 2 1 5.83 12.08 5.76 0.76 18.67 12.35 17.075 11.400
28102 28102 A 0 090 0 1 0 2 1 2 0 7.92 8.56 8.56 0.61 17.09 17.09 15.926 15.926
28103 28103 A 0 090 0 1 0 2 1 2 0 6.67 4.42 4.42 0.50 11.59 11.59 10.901 10.901
28104 28104 A 0 090 0 1 0 2 0 2 1 5.26 10.00 4.55 0.54 15.80 10.35 14.522 9.628
28106 28106 A 0 090 0 1 0 2 0 2 1 7.35 5.57 5.57 0.56 13.48 13.48 12.645 12.645
28107 28107 A 0 090 0 1 0 2 0 2 0 5.73 9.46 4.18 0.42 15.61 10.33 14.445 9.703
28108 28108 A 0 090 0 1 0 2 0 1 0 4.30 8.69 3.89 0.38 13.37 8.57 12.302 7.992
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
93 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28110 28110 A 0 090 0 1 0 2 1 1 1 4.22 9.53 4.00 0.41 14.16 8.63 12.992 8.026
28111 28111 A 0 090 0 1 0 2 1 1 1 5.15 9.63 4.15 0.60 15.38 9.90 14.112 9.191
28112 28112 A 0 090 0 1 0 2 1 1 1 4.63 9.93 4.27 0.52 15.08 9.42 13.819 8.736
28113 28113 A 0 090 0 1 0 2 1 0 0 6.11 11.32 6.02 0.63 18.06 12.76 16.605 11.845
28114 28114 A 0 090 0 1 0 2 1 2 1 12.00 18.89 11.36 1.65 32.54 25.01 29.826 23.064
28116 28116 A 0 090 0 1 0 2 1 1 0 9.14 13.13 7.07 0.95 23.22 17.16 21.428 15.986
28118 28118 A 0 090 0 1 0 2 1 2 1 6.13 11.24 5.46 0.75 18.12 12.34 16.616 11.425
28119 28119 A 0 090 0 1 0 2 1 1 1 5.56 9.90 4.66 0.53 15.99 10.75 14.727 10.022
28120 28120 A 0 090 0 1 0 2 1 1 1 7.31 12.34 6.60 1.01 20.66 14.92 18.920 13.765
28122 28122 A 0 090 0 1 0 2 1 2 1 6.76 10.75 5.67 0.72 18.23 13.15 16.790 12.228
28124 28124 A 0 090 0 1 0 2 1 1 0 5.00 9.04 4.40 0.42 14.46 9.82 13.338 9.171
28126 28126 A 0 090 0 1 0 2 0 1 0 3.64 8.11 3.44 0.34 12.09 7.42 11.101 6.907
28130 28130 A 0 090 0 1 0 2 1 2 1 9.50 10.33 10.33 1.86 21.69 21.69 19.749 19.749
28140 28140 A 0 090 0 1 0 2 0 1 1 7.14 10.16 5.10 0.90 18.20 13.14 16.734 12.191
28150 28150 A 0 090 0 1 0 2 0 1 0 4.23 8.41 3.75 0.42 13.06 8.40 12.002 7.817
28153 28153 A 0 090 0 1 0 2 0 1 0 3.80 8.52 3.78 0.37 12.69 7.95 11.644 7.388
28160 28160 A 0 090 0 1 0 2 0 1 0 3.88 8.57 3.79 0.38 12.83 8.05 11.775 7.482
28171 28171 A 0 090 0 1 0 2 0 2 0 16.41 7.29 7.29 1.25 24.95 24.95 23.610 23.610
28173 28173 A 0 090 0 1 0 2 0 1 1 14.16 7.18 7.18 1.57 22.91 22.91 21.429 21.429
28175 28175 A 0 090 0 1 0 2 0 1 1 8.29 5.46 5.46 0.80 14.55 14.55 13.611 13.611
28190 28190 A 0 010 0 1 0 2 1 1 0 2.01 5.66 1.79 0.20 7.87 4.00 7.197 3.722
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
94 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28192 28192 A 0 090 0 1 0 2 1 1 0 4.78 9.16 4.15 0.49 14.43 9.42 13.262 8.763
28193 28193 A 0 090 0 1 0 2 1 1 0 5.90 9.79 4.59 0.56 16.25 11.05 14.984 10.315
28200 28200 A 0 090 0 1 0 2 0 1 1 4.74 9.57 4.27 0.45 14.76 9.46 13.569 8.810
28202 28202 A 0 090 0 1 0 2 0 2 1 7.07 10.25 4.87 0.64 17.96 12.58 16.609 11.778
28208 28208 A 0 090 0 1 0 2 0 1 1 4.51 9.28 4.20 0.49 14.28 9.20 13.100 8.538
28210 28210 A 0 090 0 1 0 2 0 2 0 6.52 10.40 5.08 0.64 17.56 12.24 16.194 11.417
28220 28220 A 0 090 0 1 0 2 1 1 0 4.67 8.53 3.87 0.41 13.61 8.95 12.544 8.360
28222 28222 A 0 090 0 1 0 2 1 1 0 5.76 9.22 4.17 0.50 15.48 10.43 14.301 9.766
28225 28225 A 0 090 0 1 0 2 1 1 1 3.78 8.44 3.63 0.35 12.57 7.76 11.542 7.223
28226 28226 A 0 090 0 1 0 2 1 1 0 4.67 13.14 6.19 0.35 18.16 11.21 16.653 10.412
28230 28230 A 0 090 0 1 0 2 1 1 0 4.36 8.36 3.62 0.39 13.11 8.37 12.071 7.815
28232 28232 A 0 090 0 1 0 2 0 1 0 3.51 8.08 3.47 0.34 11.93 7.32 10.944 6.804
28234 28234 A 0 090 0 1 0 2 0 1 0 3.54 8.68 4.06 0.35 12.57 7.95 11.518 7.369
28238 28238 A 0 090 0 1 0 2 1 2 1 7.96 11.35 5.56 0.86 20.17 14.38 18.602 13.403
28240 28240 A 0 090 0 1 0 2 1 1 0 4.48 8.35 3.64 0.44 13.27 8.56 12.208 7.979
28250 28250 A 0 090 0 1 0 2 1 2 1 6.06 10.77 5.19 0.76 17.59 12.01 16.129 11.118
28260 28260 A 0 090 0 1 0 2 1 2 1 8.19 11.21 5.76 1.03 20.43 14.98 18.795 13.901
28261 28261 A 0 090 0 1 0 2 1 0 0 13.11 14.55 8.17 1.28 28.94 22.56 26.845 21.116
28262 28262 A 0 090 0 1 0 2 1 2 1 17.21 23.63 14.47 3.01 43.85 34.69 40.004 31.778
28264 28264 A 0 090 0 1 0 2 1 2 0 10.65 17.75 10.07 0.82 29.22 21.54 27.018 20.122
28270 28270 A 0 090 0 1 0 2 1 1 0 4.93 9.59 4.55 0.50 15.02 9.98 13.803 9.277
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
95 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28272 28272 A 0 090 0 1 0 2 1 1 0 3.92 7.73 3.32 0.31 11.96 7.55 11.024 7.063
28280 28280 A 0 090 0 1 0 2 1 0 0 5.33 9.96 4.58 0.60 15.89 10.51 14.588 9.757
28285 28285 A 0 090 0 1 0 2 1 1 1 5.62 10.04 5.06 0.53 16.19 11.21 14.913 10.441
28286 28286 A 0 090 0 1 0 2 1 1 0 4.70 8.68 3.83 0.39 13.77 8.92 12.699 8.343
28288 28288 A 0 090 0 1 0 2 0 1 0 6.02 11.72 6.16 0.67 18.41 12.85 16.895 11.902
28289 28289 A 0 090 0 1 0 2 1 2 1 8.31 13.05 7.08 1.01 22.37 16.40 20.557 15.196
28290 28290 A 0 090 0 1 0 2 1 1 0 5.83 11.40 5.25 0.69 17.92 11.77 16.428 10.905
28292 28292 A 0 090 0 1 0 2 1 2 1 9.05 13.97 8.01 0.87 23.89 17.93 22.050 16.698
28293 28293 A 0 090 0 1 0 2 1 2 1 11.48 19.15 8.62 0.95 31.58 21.05 29.174 19.718
28294 28294 A 0 090 0 1 0 2 1 2 1 8.75 12.92 6.13 0.93 22.60 15.81 20.839 14.741
28296 28296 A 0 090 0 1 0 2 1 2 1 8.35 12.41 6.34 0.76 21.52 15.45 19.892 14.441
28297 28297 A 0 090 0 1 0 2 1 2 1 9.43 14.19 6.81 1.18 24.80 17.42 22.790 16.163
28298 28298 A 0 090 0 1 0 2 1 2 1 8.13 12.88 6.01 0.87 21.88 15.01 20.151 13.982
28299 28299 A 0 090 0 1 0 2 1 2 1 11.57 14.16 7.24 1.14 26.87 19.95 24.882 18.668
28300 28300 A 0 090 0 1 0 2 1 2 1 9.73 8.26 8.26 1.61 19.60 19.60 17.990 17.990
28302 28302 A 0 090 0 1 0 2 1 2 1 9.74 9.58 9.58 1.92 21.24 21.24 19.347 19.347
28304 28304 A 0 090 0 1 0 2 1 2 1 9.41 13.94 7.09 1.21 24.56 17.71 22.561 16.410
28305 28305 A 0 090 0 1 0 2 1 2 1 10.77 7.74 7.74 0.82 19.33 19.33 18.149 18.149
28306 28306 A 0 090 0 1 0 2 1 2 1 6.00 11.99 5.28 0.83 18.82 12.11 17.201 11.176
28307 28307 A 0 090 0 1 0 2 1 0 0 6.50 13.72 6.15 1.28 21.50 13.93 19.490 12.692
28308 28308 A 0 090 0 1 0 2 1 2 1 5.48 11.06 5.10 0.61 17.15 11.19 15.731 10.379
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
96 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28309 28309 A 0 090 0 1 0 2 1 0 0 14.16 10.26 10.26 2.10 26.52 26.52 24.472 24.472
28310 28310 A 0 090 0 1 0 2 1 1 1 5.57 10.44 4.47 0.54 16.55 10.58 15.228 9.866
28312 28312 A 0 090 0 1 0 2 0 1 1 4.69 10.41 4.35 0.50 15.60 9.54 14.300 8.858
28313 28313 A 0 090 0 1 0 2 0 1 0 5.15 10.16 4.80 0.69 16.00 10.64 14.635 9.821
28315 28315 A 0 090 0 1 0 2 1 1 1 5.00 9.15 4.19 0.49 14.64 9.68 13.473 9.019
28320 28320 A 0 090 0 1 0 2 1 2 1 9.37 7.52 7.52 1.39 18.28 18.28 16.850 16.850
28322 28322 A 0 090 0 1 0 2 0 2 1 8.53 14.11 7.39 1.31 23.95 17.23 21.886 15.851
28340 28340 A 0 090 0 1 0 2 0 1 0 7.15 9.78 4.54 0.54 17.47 12.23 16.215 11.509
28341 28341 A 0 090 0 1 0 2 0 1 0 8.72 10.84 5.16 0.67 20.23 14.55 18.805 13.704
28344 28344 A 0 090 0 1 0 2 1 1 1 4.40 8.25 3.60 0.34 12.99 8.34 11.986 7.811
28345 28345 A 0 090 0 1 0 2 0 0 0 6.09 9.25 4.27 0.45 15.79 10.81 14.632 10.160
28360 28360 A 0 090 0 1 0 2 1 2 0 14.92 14.36 14.36 3.18 32.46 32.46 29.478 29.478
28400 28400 A 0 090 0 1 0 2 1 1 0 2.31 4.94 4.26 0.37 7.62 6.94 6.940 6.329
28405 28405 A 0 090 0 1 0 2 1 0 0 4.74 6.00 4.92 0.65 11.39 10.31 10.468 9.498
28406 28406 A 0 090 0 1 0 2 1 0 0 6.56 8.03 8.03 1.17 15.76 15.76 14.383 14.383
28415 28415 A 0 090 0 1 0 2 1 2 1 16.19 14.06 14.06 2.83 33.08 33.08 30.296 30.296
28420 28420 A 0 090 0 1 0 2 1 2 1 17.52 16.27 16.27 3.46 37.25 37.25 33.940 33.940
28430 28430 A 0 090 0 1 0 2 1 1 0 2.22 4.59 3.77 0.35 7.16 6.34 6.525 5.789
28435 28435 A 0 090 0 1 0 2 1 0 0 3.54 6.62 5.43 0.69 10.85 9.66 9.846 8.777
28436 28436 A 0 090 0 1 0 2 1 1 0 4.90 7.63 7.63 0.98 13.51 13.51 12.264 12.264
28445 28445 A 0 090 0 1 0 2 1 2 1 15.76 13.15 13.15 2.78 31.69 31.69 29.023 29.023
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
97 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28446 28446 A 0 090 0 1 0 2 1 2 1 17.71 15.08 15.08 3.50 36.29 36.29 33.082 33.082
28450 28450 A 0 090 0 1 0 2 0 1 0 2.03 4.24 3.49 0.30 6.57 5.82 5.994 5.321
28455 28455 A 0 090 0 1 0 2 0 0 0 3.24 4.16 3.39 0.44 7.84 7.07 7.206 6.514
28456 28456 A 0 090 0 1 0 2 0 1 0 2.86 6.25 6.25 0.56 9.67 9.67 8.765 8.765
28465 28465 A 0 090 0 1 0 2 0 1 0 8.80 8.03 8.03 1.27 18.10 18.10 16.675 16.675
28470 28470 A 0 090 0 1 0 2 0 1 0 2.03 4.35 3.89 0.33 6.71 6.25 6.109 5.696
28475 28475 A 0 090 0 1 0 2 0 1 0 3.01 4.27 3.38 0.38 7.66 6.77 7.043 6.244
28476 28476 A 0 090 0 1 0 2 0 0 0 3.60 6.30 6.30 0.53 10.43 10.43 9.535 9.535
28485 28485 A 0 090 0 1 0 2 0 1 1 7.44 7.33 7.33 0.95 15.72 15.72 14.519 14.519
28490 28490 A 0 090 0 1 0 2 1 1 0 1.17 3.13 2.49 0.16 4.46 3.82 4.064 3.490
28495 28495 A 0 090 0 1 0 2 1 1 0 1.68 3.53 2.65 0.20 5.41 4.53 4.955 4.164
28496 28496 A 0 090 0 1 0 2 1 1 0 2.48 11.04 4.36 0.35 13.87 7.19 12.577 6.578
28505 28505 A 0 090 0 1 0 2 1 1 0 7.44 11.85 6.51 0.93 20.22 14.88 18.568 13.772
28510 28510 A 0 090 0 1 0 2 0 1 0 1.17 2.44 2.34 0.14 3.75 3.65 3.434 3.345
28515 28515 A 0 090 0 1 0 2 0 1 0 1.56 3.16 2.57 0.18 4.90 4.31 4.492 3.962
28525 28525 A 0 090 0 1 0 2 0 0 0 5.62 10.99 5.65 0.71 17.32 11.98 15.860 11.065
28530 28530 A 0 090 0 1 0 2 1 0 0 1.11 2.25 1.85 0.11 3.47 3.07 3.188 2.829
28531 28531 A 0 090 0 1 0 2 1 1 2 2.57 7.73 2.68 0.50 10.80 5.75 9.773 5.238
28540 28540 A 0 090 0 1 0 2 1 0 0 2.19 3.43 2.85 0.22 5.84 5.26 5.385 4.864
28545 28545 A 0 090 0 1 0 2 1 0 0 2.60 5.86 4.80 0.50 8.96 7.90 8.124 7.172
28546 28546 A 0 090 0 1 0 2 1 0 0 3.40 13.53 6.08 0.67 17.60 10.15 15.900 9.210
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
98 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28555 28555 A 0 090 0 1 0 2 1 2 1 9.65 15.46 8.71 1.61 26.72 19.97 24.375 18.314
28570 28570 A 0 090 0 1 0 2 1 0 0 1.76 3.01 2.29 0.12 4.89 4.17 4.526 3.879
28575 28575 A 0 090 0 1 0 2 1 0 0 3.49 6.85 5.75 0.68 11.02 9.92 9.997 9.009
28576 28576 A 0 090 0 1 0 2 1 0 0 4.60 6.35 6.35 0.90 11.85 11.85 10.773 10.773
28585 28585 A 0 090 0 1 0 2 1 2 1 11.13 13.69 7.76 1.65 26.47 20.54 24.287 18.961
28600 28600 A 0 090 0 1 0 2 0 0 0 2.02 3.35 2.59 0.29 5.66 4.90 5.180 4.497
28605 28605 A 0 090 0 1 0 2 0 0 0 2.89 6.46 5.43 0.56 9.91 8.88 8.984 8.059
28606 28606 A 0 090 0 1 0 2 0 1 0 5.09 5.93 5.93 0.84 11.86 11.86 10.854 10.854
28615 28615 A 0 090 0 1 0 2 0 2 1 10.70 11.11 11.11 1.77 23.58 23.58 21.602 21.602
28630 28630 A 0 010 0 1 0 2 0 0 0 1.75 2.78 1.29 0.23 4.76 3.27 4.367 3.029
28635 28635 A 0 010 0 1 0 2 0 0 0 1.96 3.05 1.71 0.22 5.23 3.89 4.814 3.611
28636 28636 A 0 010 0 1 0 2 0 1 2 2.77 6.00 2.66 0.39 9.16 5.82 8.362 5.363
28645 28645 A 0 090 0 1 0 2 0 1 1 7.44 11.70 6.21 0.80 19.94 14.45 18.365 13.435
28660 28660 A 0 010 0 1 0 2 0 1 0 1.28 2.06 1.19 0.20 3.54 2.67 3.234 2.453
28665 28665 A 0 010 0 1 0 2 0 0 0 1.97 2.47 1.75 0.24 4.68 3.96 4.314 3.667
28666 28666 A 0 010 0 1 0 2 0 1 2 2.66 2.61 2.61 0.52 5.79 5.79 5.276 5.276
28675 28675 A 0 090 0 1 0 2 0 1 0 5.62 11.25 5.85 0.75 17.62 12.22 16.115 11.266
28705 28705 A 0 090 0 1 0 2 1 2 1 20.33 14.41 14.41 3.46 38.20 38.20 35.080 35.080
28715 28715 A 0 090 0 1 0 2 1 2 1 13.42 12.17 12.17 2.28 27.87 27.87 25.541 25.541
28725 28725 A 0 090 0 1 0 2 1 2 1 11.22 10.16 10.16 1.73 23.11 23.11 21.248 21.248
28730 28730 A 0 090 0 1 0 2 1 2 1 10.70 9.55 9.55 1.65 21.90 21.90 20.139 20.139
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
99 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
28735 28735 A 0 090 0 1 0 2 1 2 1 12.23 9.28 9.28 1.78 23.29 23.29 21.494 21.494
28737 28737 A 0 090 0 1 0 2 1 2 1 11.03 8.23 8.23 1.28 20.54 20.54 19.090 19.090
28740 28740 A 0 090 0 1 0 2 0 2 1 9.29 15.12 8.00 1.36 25.77 18.65 23.579 17.185
28750 28750 A 0 090 0 1 0 2 1 0 0 8.57 15.14 7.97 1.31 25.02 17.85 22.851 16.412
28755 28755 A 0 090 0 1 0 2 1 1 1 4.88 10.09 4.44 0.52 15.49 9.84 14.213 9.139
28760 28760 A 0 090 0 1 0 2 1 2 1 9.14 13.47 6.84 1.05 23.66 17.03 21.785 15.831
28800 28800 A 0 090 0 1 0 2 1 2 1 8.79 6.32 6.32 1.31 16.42 16.42 15.150 15.150
28805 28805 A 0 090 0 1 0 2 1 0 0 12.71 7.34 7.34 2.14 22.19 22.19 20.421 20.421
28810 28810 A 0 090 0 1 0 2 0 0 0 6.64 5.32 5.32 1.18 13.14 13.14 12.035 12.035
28820 28820 A 0 090 0 1 0 2 0 1 0 5.82 10.83 5.36 0.85 17.50 12.03 15.990 11.078
28825 28825 A 0 090 0 1 0 2 0 1 0 5.37 10.51 5.11 0.75 16.63 11.23 15.200 10.351
28890 28890 A 0 090 0 1 0 2 1 1 1 3.45 6.10 2.96 0.35 9.90 6.76 9.111 6.291
28899 28899 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
29000 29000 A 0 000 0 0 0 2 0 0 0 2.25 5.96 2.46 0.18 8.39 4.89 7.696 4.553
29010 29010 A 0 000 0 0 0 2 0 0 0 2.06 4.79 1.97 0.39 7.24 4.42 6.565 4.033
29015 29015 A 0 000 0 0 0 2 0 0 0 2.41 6.05 2.54 0.41 8.87 5.36 8.057 4.905
29020 29020 A 0 000 0 0 0 2 0 0 0 2.11 4.00 1.68 0.08 6.19 3.87 5.744 3.660
29025 29025 A 0 000 0 0 0 2 0 0 0 2.40 6.03 2.54 0.48 8.91 5.42 8.066 4.932
29035 29035 A 0 000 0 0 0 2 0 0 0 1.77 4.65 1.84 0.34 6.76 3.95 6.124 3.600
29040 29040 A 0 000 0 0 0 2 0 0 0 2.22 4.27 1.80 0.42 6.91 4.44 6.274 4.056
29044 29044 A 0 000 0 0 0 2 0 0 0 2.12 6.22 2.50 0.41 8.75 5.03 7.920 4.579
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
100 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
29046 29046 A 0 000 0 0 0 2 0 0 0 2.41 5.15 2.19 0.48 8.04 5.08 7.286 4.628
29049 29049 A 0 000 0 0 0 2 0 0 0 0.89 1.93 1.03 0.18 3.00 2.10 2.717 1.909
29055 29055 A 0 000 0 0 0 2 0 0 0 1.78 4.64 2.01 0.35 6.77 4.14 6.130 3.768
29058 29058 A 0 000 0 0 0 2 0 0 0 1.31 2.16 1.25 0.23 3.70 2.79 3.370 2.553
29065 29065 A 0 000 0 0 0 2 1 1 0 0.87 1.89 1.02 0.16 2.92 2.05 2.651 1.870
29075 29075 A 0 000 0 0 0 2 1 1 0 0.77 1.72 0.96 0.14 2.63 1.87 2.388 1.705
29085 29085 A 0 000 0 0 0 2 1 1 0 0.87 1.87 1.00 0.14 2.88 2.01 2.622 1.841
29086 29086 A 0 000 0 0 0 2 1 1 0 0.62 1.69 0.85 0.08 2.39 1.55 2.179 1.425
29105 29105 A 0 000 0 0 0 2 1 1 0 0.87 1.65 0.77 0.14 2.66 1.78 2.425 1.635
29125 29125 A 0 000 0 0 0 2 1 1 0 0.50 1.40 0.61 0.08 1.98 1.19 1.799 1.090
29126 29126 A 0 000 0 0 0 2 1 1 0 0.68 1.56 0.68 0.10 2.34 1.46 2.133 1.343
29130 29130 A 0 000 0 0 0 2 1 1 0 0.50 0.66 0.27 0.07 1.23 0.84 1.129 0.779
29131 29131 A 0 000 0 0 0 2 1 1 0 0.55 0.94 0.37 0.08 1.57 1.00 1.436 0.924
29200 29200 A 0 000 0 0 0 2 0 1 0 0.65 0.89 0.48 0.05 1.59 1.18 1.475 1.107
29240 29240 A 0 000 0 0 0 2 1 1 0 0.71 0.96 0.54 0.05 1.72 1.30 1.598 1.221
29260 29260 A 0 000 0 0 0 2 1 1 0 0.55 0.96 0.52 0.05 1.56 1.12 1.438 1.043
29280 29280 A 0 000 0 0 0 2 1 1 0 0.51 0.98 0.53 0.04 1.53 1.08 1.411 1.007
29305 29305 A 0 000 0 0 0 2 0 0 0 2.03 5.09 2.34 0.39 7.51 4.76 6.805 4.335
29325 29325 A 0 000 0 0 0 2 0 0 0 2.32 5.53 2.56 0.45 8.30 5.33 7.521 4.854
29345 29345 A 0 000 0 0 0 2 1 1 0 1.40 2.46 1.35 0.27 4.13 3.02 3.750 2.754
29355 29355 A 0 000 0 0 0 2 1 1 0 1.53 2.47 1.38 0.29 4.29 3.20 3.900 2.921
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
101 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
29358 29358 A 0 000 0 0 0 2 1 1 0 1.43 3.15 1.38 0.29 4.87 3.10 4.410 2.821
29365 29365 A 0 000 0 0 0 2 1 1 0 1.18 2.33 1.22 0.23 3.74 2.63 3.393 2.396
29405 29405 A 0 000 0 0 0 2 1 1 0 0.80 1.56 0.88 0.11 2.47 1.79 2.258 1.648
29425 29425 A 0 000 0 0 0 2 1 1 0 0.80 1.47 0.79 0.10 2.37 1.69 2.172 1.562
29435 29435 A 0 000 0 0 0 2 1 1 0 1.18 2.22 1.13 0.23 3.63 2.54 3.294 2.315
29440 29440 A 0 000 0 0 0 2 1 1 0 0.57 0.69 0.23 0.08 1.34 0.88 1.231 0.818
29445 29445 A 0 000 0 0 0 2 1 1 0 1.78 2.08 1.11 0.24 4.10 3.13 3.773 2.902
29450 29450 A 0 000 0 0 0 2 1 1 0 2.08 2.02 1.06 0.22 4.32 3.36 4.009 3.147
29505 29505 A 0 000 0 0 0 2 1 1 0 0.69 1.74 0.70 0.11 2.54 1.50 2.310 1.376
29515 29515 A 0 000 0 0 0 2 1 1 0 0.73 1.35 0.66 0.10 2.18 1.49 1.995 1.375
29520 29520 A 0 000 0 0 0 2 1 0 0 0.54 0.88 0.47 0.04 1.46 1.05 1.351 0.983
29530 29530 A 0 000 0 0 0 2 1 1 0 0.57 0.96 0.51 0.05 1.58 1.13 1.458 1.054
29540 29540 A 0 000 0 0 0 2 1 1 0 0.39 0.69 0.35 0.03 1.11 0.77 1.025 0.720
29550 29550 A 0 000 0 0 0 2 1 1 0 0.25 0.69 0.32 0.01 0.95 0.58 0.875 0.543
29580 29580 A 0 000 0 0 0 2 1 1 0 0.55 0.97 0.44 0.07 1.59 1.06 1.458 0.982
29581 29581 A 0 000 0 0 0 2 1 0 0 0.25 1.63 0.11 0.01 1.89 0.37 1.719 0.354
29582 29582 A 0 000 0 0 0 2 1 0 0 0.35 1.78 0.09 0.01 2.14 0.45 1.954 0.436
29583 29583 A 0 000 0 0 0 2 1 0 0 0.25 1.07 0.07 0.01 1.33 0.33 1.216 0.318
29584 29584 A 0 000 0 0 0 2 1 0 0 0.35 1.78 0.09 0.01 2.14 0.45 1.954 0.436
29700 29700 A 0 000 0 0 0 2 0 1 0 0.57 1.33 0.33 0.10 2.00 1.00 1.817 0.919
29705 29705 A 0 000 0 0 0 2 1 1 0 0.76 1.12 0.50 0.12 2.00 1.38 1.829 1.272
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
102 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
29710 29710 A 0 000 0 0 0 2 1 0 0 1.34 2.11 0.86 0.27 3.72 2.47 3.376 2.253
29715 29715 A 0 000 0 0 0 2 0 0 0 0.94 1.36 0.49 0.12 2.42 1.55 2.224 1.443
29720 29720 A 0 000 0 0 0 2 0 1 0 0.68 1.73 0.48 0.12 2.53 1.28 2.296 1.174
29730 29730 A 0 000 0 0 0 2 0 1 0 0.75 1.10 0.47 0.11 1.96 1.33 1.795 1.230
29740 29740 A 0 000 0 0 0 2 0 1 0 1.12 1.51 0.65 0.18 2.81 1.95 2.570 1.798
29750 29750 A 0 000 0 0 0 2 1 0 0 1.26 1.71 0.80 0.26 3.23 2.32 2.932 2.114
29799 29799 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
29800 29800 A 0 090 0 1 0 2 1 0 0 6.84 7.14 7.14 1.33 15.31 15.31 13.947 13.947
29804 29804 A 0 090 0 1 0 2 1 2 1 8.87 8.78 8.78 1.74 19.39 19.39 17.664 17.664
29805 29805 A 0 090 0 1 0 2 1 1 1 6.03 6.88 6.88 1.18 14.09 14.09 12.825 12.825
29806 29806 A 0 090 0 1 0 3 1 1 1 15.14 13.42 13.42 2.98 31.54 31.54 28.750 28.750
29807 29807 A 0 090 0 1 0 3 1 1 1 14.67 13.21 13.21 2.87 30.75 30.75 28.034 28.034
29819 29819 A 0 090 0 1 0 3 1 1 1 7.79 8.17 8.17 1.52 17.48 17.48 15.922 15.922
29820 29820 A 0 090 0 1 0 3 1 2 1 7.21 7.49 7.49 1.40 16.10 16.10 14.668 14.668
29821 29821 A 0 090 0 1 0 3 1 2 1 7.89 8.12 8.12 1.55 17.56 17.56 15.992 15.992
29822 29822 A 0 090 0 1 0 3 1 2 0 7.60 8.06 8.06 1.50 17.16 17.16 15.622 15.622
29823 29823 A 0 090 0 1 0 3 1 2 1 8.36 8.73 8.73 1.63 18.72 18.72 17.052 17.052
29824 29824 A 0 090 0 1 0 3 1 2 1 8.98 9.47 9.47 1.77 20.22 20.22 18.410 18.410
29825 29825 A 0 090 0 1 0 3 1 2 1 7.79 8.16 8.16 1.52 17.47 17.47 15.913 15.913
29826 29826 A 0 ZZZ 0 0 0 0 1 2 1 3.00 1.60 1.60 0.59 5.19 5.19 4.745 4.745
29827 29827 A 0 090 0 1 0 3 1 2 1 15.59 13.26 13.26 3.08 31.93 31.93 29.108 29.108
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
103 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
29828 29828 A 0 090 0 1 0 3 1 2 1 13.16 11.73 11.73 2.59 27.48 27.48 25.048 25.048
29830 29830 A 0 090 0 1 0 2 1 1 0 5.88 6.50 6.50 1.17 13.55 13.55 12.329 12.329
29834 29834 A 0 090 0 1 0 3 1 2 1 6.42 6.99 6.99 1.22 14.63 14.63 13.335 13.335
29835 29835 A 0 090 0 1 0 3 1 2 1 6.62 7.20 7.20 1.29 15.11 15.11 13.760 13.760
29836 29836 A 0 090 0 1 0 3 1 2 1 7.72 7.91 7.91 1.52 17.15 17.15 15.618 15.618
29837 29837 A 0 090 0 1 0 3 1 2 1 7.01 7.41 7.41 1.36 15.78 15.78 14.375 14.375
29838 29838 A 0 090 0 1 0 3 1 0 0 7.88 8.20 8.20 1.50 17.58 17.58 16.028 16.028
29840 29840 A 0 090 0 1 0 2 1 0 0 5.68 6.69 6.69 1.13 13.50 13.50 12.279 12.279
29843 29843 A 0 090 0 1 0 3 1 2 1 6.15 7.07 7.07 1.21 14.43 14.43 13.132 13.132
29844 29844 A 0 090 0 1 0 3 1 2 0 6.51 7.12 7.12 1.18 14.81 14.81 13.521 13.521
29845 29845 A 0 090 0 1 0 3 1 2 1 7.69 8.15 8.15 1.37 17.21 17.21 15.725 15.725
29846 29846 A 0 090 0 1 0 3 1 0 0 6.89 7.35 7.35 1.22 15.46 15.46 14.128 14.128
29847 29847 A 0 090 0 1 0 3 1 2 0 7.22 7.53 7.53 1.42 16.17 16.17 14.725 14.725
29848 29848 A 0 090 0 1 0 2 1 1 0 6.39 7.64 7.64 1.17 15.20 15.20 13.863 13.863
29850 29850 A 0 090 0 1 0 2 1 0 2 8.27 8.67 8.67 1.62 18.56 18.56 16.903 16.903
29851 29851 A 0 090 0 1 0 2 1 2 2 13.26 11.78 11.78 2.61 27.65 27.65 25.203 25.203
29855 29855 A 0 090 0 1 0 2 1 2 2 10.76 10.53 10.53 2.12 23.41 23.41 21.325 21.325
29856 29856 A 0 090 0 1 0 2 1 2 2 14.28 12.45 12.45 2.83 29.56 29.56 26.940 26.940
29860 29860 A 0 090 0 1 0 2 1 2 1 9.00 9.07 9.07 1.78 19.85 19.85 18.076 18.076
29861 29861 A 0 090 0 1 0 3 1 2 1 10.10 9.57 9.57 1.97 21.64 21.64 19.724 19.724
29862 29862 A 0 090 0 1 0 3 1 2 1 11.17 11.02 11.02 2.19 24.38 24.38 22.211 22.211
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
104 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
29863 29863 A 0 090 0 1 0 3 1 2 1 11.17 11.03 11.03 2.20 24.40 24.40 22.226 22.226
29866 29866 A 0 090 0 1 0 2 1 0 0 14.67 13.60 13.60 2.91 31.18 31.18 28.405 28.405
29867 29867 A 0 090 0 1 0 2 1 0 0 18.39 15.92 15.92 3.62 37.93 37.93 34.579 34.579
29868 29868 A 0 090 0 1 0 2 1 0 0 25.10 19.52 19.52 4.95 49.57 49.57 45.218 45.218
29870 29870 A 0 090 0 1 0 2 1 1 1 5.19 11.52 6.12 1.02 17.73 12.33 16.068 11.219
29871 29871 A 0 090 0 1 0 3 1 1 0 6.69 7.34 7.34 1.31 15.34 15.34 13.966 13.966
29873 29873 A 0 090 0 1 0 3 1 1 1 6.24 8.25 8.25 1.22 15.71 15.71 14.287 14.287
29874 29874 A 0 090 0 1 0 3 1 0 0 7.19 7.46 7.46 1.40 16.05 16.05 14.621 14.621
29875 29875 A 0 090 0 1 0 3 1 0 0 6.45 7.08 7.08 1.27 14.80 14.80 13.472 13.472
29876 29876 A 0 090 0 1 0 3 1 1 0 8.87 8.96 8.96 1.74 19.57 19.57 17.826 17.826
29877 29877 A 0 090 0 1 0 3 1 0 0 8.30 8.67 8.67 1.62 18.59 18.59 16.933 16.933
29879 29879 A 0 090 0 1 0 3 1 0 0 8.99 9.03 9.03 1.77 19.79 19.79 18.025 18.025
29880 29880 A 0 090 0 1 0 3 1 0 1 7.39 8.00 8.00 1.45 16.84 16.84 15.332 15.332
29881 29881 A 0 090 0 1 0 3 1 0 0 7.03 7.81 7.81 1.37 16.21 16.21 14.760 14.760
29882 29882 A 0 090 0 1 0 3 1 1 0 9.60 9.37 9.37 1.89 20.86 20.86 19.003 19.003
29883 29883 A 0 090 0 1 0 3 1 0 0 11.77 10.93 10.93 2.30 25.00 25.00 22.788 22.788
29884 29884 A 0 090 0 1 0 3 1 2 1 8.28 8.63 8.63 1.62 18.53 18.53 16.877 16.877
29885 29885 A 0 090 0 1 0 3 1 2 1 10.21 10.17 10.17 2.00 22.38 22.38 20.389 20.389
29886 29886 A 0 090 0 1 0 3 1 1 0 8.49 8.78 8.78 1.66 18.93 18.93 17.243 17.243
29887 29887 A 0 090 0 1 0 3 1 2 1 10.16 10.15 10.15 1.99 22.30 22.30 20.315 20.315
29888 29888 A 0 090 0 1 0 2 1 2 1 14.30 12.30 12.30 2.80 29.40 29.40 26.810 26.810
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
105 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
29889 29889 A 0 090 0 1 0 2 1 2 1 17.41 15.45 15.45 3.42 36.28 36.28 33.073 33.073
29891 29891 A 0 090 0 1 0 2 1 2 0 9.67 8.95 8.95 1.65 20.27 20.27 18.570 18.570
29892 29892 A 0 090 0 1 0 2 1 2 0 10.27 6.05 6.05 2.01 18.33 18.33 16.754 16.754
29893 29893 A 0 090 0 1 0 2 1 1 1 6.32 11.71 5.93 0.50 18.53 12.75 17.097 11.907
29894 29894 A 0 090 0 1 0 2 1 2 1 7.35 6.91 6.91 1.22 15.48 15.48 14.193 14.193
29895 29895 A 0 090 0 1 0 2 1 2 1 7.13 6.10 6.10 1.13 14.36 14.36 13.199 13.199
29897 29897 A 0 090 0 1 0 2 1 2 0 7.32 6.77 6.77 1.24 15.33 15.33 14.048 14.048
29898 29898 A 0 090 0 1 0 2 1 2 1 8.49 7.09 7.09 1.29 16.87 16.87 15.531 15.531
29899 29899 A 0 090 0 1 0 2 1 2 1 15.41 12.97 12.97 2.87 31.25 31.25 28.558 28.558
29900 29900 A 0 090 0 1 0 2 1 0 0 5.88 7.11 7.11 0.41 13.40 13.40 12.479 12.479
29901 29901 A 0 090 0 1 0 2 1 0 0 6.59 8.04 8.04 1.29 15.92 15.92 14.485 14.485
29902 29902 A 0 090 0 1 0 2 1 0 0 7.16 8.34 8.34 2.57 18.07 18.07 15.993 15.993
29904 29904 A 0 090 0 1 0 2 1 2 0 8.65 8.62 8.62 1.69 18.96 18.96 17.275 17.275
29905 29905 A 0 090 0 1 0 2 1 2 0 9.18 9.57 9.57 1.81 20.56 20.56 18.720 18.720
29906 29906 A 0 090 0 1 0 2 1 2 0 9.65 9.49 9.49 1.89 21.03 21.03 19.160 19.160
29907 29907 A 0 090 0 1 0 2 1 2 0 12.18 11.45 11.45 2.40 26.03 26.03 23.717 23.717
29914 29914 A 0 090 0 1 0 3 1 2 1 14.67 12.45 12.45 2.91 30.03 30.03 27.372 27.372
29915 29915 A 0 090 0 1 0 3 1 2 1 15.00 12.68 12.68 2.95 30.63 30.63 27.929 27.929
29916 29916 A 0 090 0 1 0 3 1 2 1 15.00 12.71 12.71 2.95 30.66 30.66 27.956 27.956
29999 29999 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
30000 30000 A 0 010 0 1 0 2 0 0 0 1.48 5.45 1.89 0.22 7.15 3.59 6.489 3.292
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
106 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
30020 30020 A 0 010 0 1 0 2 0 1 0 1.48 5.58 1.92 0.20 7.26 3.60 6.595 3.309
30100 30100 A 0 000 0 0 0 2 0 1 0 0.94 3.34 1.03 0.11 4.39 2.08 3.997 1.922
30110 30110 A 0 010 0 1 0 2 1 1 0 1.68 5.22 2.02 0.23 7.13 3.93 6.488 3.614
30115 30115 A 0 090 0 1 0 2 1 1 0 4.44 8.08 8.08 0.56 13.08 13.08 11.989 11.989
30117 30117 A 0 090 0 1 0 2 0 1 0 3.26 23.78 6.62 0.41 27.45 10.29 24.829 9.419
30118 30118 A 0 090 0 1 0 2 0 1 1 9.92 11.69 11.69 1.31 22.92 22.92 21.103 21.103
30120 30120 A 0 090 0 1 0 2 0 1 0 5.39 9.53 6.98 0.84 15.76 13.21 14.387 12.097
30124 30124 A 0 090 0 1 0 2 0 1 0 3.20 5.05 5.05 0.41 8.66 8.66 7.949 7.949
30125 30125 A 0 090 0 1 0 2 0 2 0 7.30 10.11 10.11 0.93 18.34 18.34 16.865 16.865
30130 30130 A 0 090 0 1 0 2 1 1 0 3.47 7.66 7.66 0.44 11.57 11.57 10.579 10.579
30140 30140 A 0 090 0 1 0 2 1 1 0 3.57 9.49 9.49 0.45 13.51 13.51 12.327 12.327
30150 30150 A 0 090 0 1 0 2 0 1 1 9.55 12.12 12.12 1.42 23.09 23.09 21.176 21.176
30160 30160 A 0 090 0 1 0 2 0 2 1 9.99 11.97 11.97 1.28 23.24 23.24 21.409 21.409
30200 30200 A 0 000 0 0 0 2 0 1 0 0.78 2.66 0.92 0.10 3.54 1.80 3.221 1.658
30210 30210 A 0 010 0 1 0 2 0 1 0 1.13 3.36 1.75 0.14 4.63 3.02 4.221 2.775
30220 30220 A 0 010 0 1 0 2 0 1 0 1.59 7.70 1.98 0.22 9.51 3.79 8.620 3.483
30300 30300 A 0 010 0 1 0 2 0 1 0 1.09 6.02 2.67 0.14 7.25 3.90 6.569 3.561
30310 30310 A 0 010 0 1 0 2 0 0 0 2.01 4.02 4.02 0.26 6.29 6.29 5.756 5.756
30320 30320 A 0 090 0 1 0 2 0 0 0 4.64 8.48 8.48 0.60 13.72 13.72 12.569 12.569
30400 30400 R 0 090 0 1 0 2 0 0 0 10.86 18.33 18.33 1.39 30.58 30.58 28.047 28.047
30410 30410 R 0 090 0 1 0 2 0 2 0 14.00 19.90 19.90 1.80 35.70 35.70 32.812 32.812
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
107 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
30420 30420 R 0 090 0 1 0 2 0 1 0 16.90 21.97 21.97 2.40 41.27 41.27 37.884 37.884
30430 30430 R 0 090 0 1 0 2 0 2 0 8.24 17.02 17.02 1.62 26.88 26.88 24.371 24.371
30435 30435 R 0 090 0 1 0 2 0 2 0 12.73 19.26 19.26 1.63 33.62 33.62 30.878 30.878
30450 30450 R 0 090 0 1 0 2 0 2 0 19.66 22.72 22.72 2.52 44.90 44.90 41.381 41.381
30460 30460 A 0 090 0 1 0 2 0 2 2 10.32 12.15 12.15 2.01 24.48 24.48 22.282 22.282
30462 30462 A 0 090 0 1 0 2 0 2 2 20.28 18.85 18.85 4.00 43.13 43.13 39.299 39.299
30465 30465 A 0 090 0 1 0 2 0 0 0 12.36 15.45 15.45 1.74 29.55 29.55 27.144 27.144
30520 30520 A 0 090 0 1 0 2 0 1 0 7.01 11.00 11.00 0.90 18.91 18.91 17.359 17.359
30540 30540 A 0 090 0 1 0 2 0 2 0 7.92 11.83 11.83 1.02 20.77 20.77 19.077 19.077
30545 30545 A 0 090 0 1 0 2 0 2 0 11.62 12.89 12.89 0.82 25.33 25.33 23.624 23.624
30560 30560 A 0 010 0 1 0 2 0 1 0 1.31 6.93 2.72 0.18 8.42 4.21 7.627 3.847
30580 30580 A 0 090 0 1 0 2 0 1 0 6.88 11.62 7.24 0.87 19.37 14.99 17.770 13.837
30600 30600 A 0 090 0 1 0 2 0 0 0 6.16 10.41 5.85 0.78 17.35 12.79 15.916 11.821
30620 30620 A 0 090 0 1 0 2 0 1 0 6.16 12.08 12.08 0.88 19.12 19.12 17.468 17.468
30630 30630 A 0 090 0 1 0 2 0 0 0 7.29 10.66 10.66 0.99 18.94 18.94 17.380 17.380
30801 30801 A 0 010 0 1 0 2 2 1 0 1.14 5.86 2.95 0.14 7.14 4.23 6.476 3.862
30802 30802 A 0 010 0 1 0 2 2 1 0 2.08 6.59 3.43 0.27 8.94 5.78 8.139 5.301
30901 30901 A 0 000 0 0 0 2 1 1 0 1.10 1.63 0.40 0.16 2.89 1.66 2.647 1.543
30903 30903 A 0 000 0 0 0 2 1 1 0 1.54 4.59 0.58 0.23 6.36 2.35 5.782 2.181
30905 30905 A 0 000 0 0 0 2 2 1 0 1.97 5.64 0.70 0.30 7.91 2.97 7.192 2.756
30906 30906 A 0 000 0 0 0 2 2 1 0 2.45 5.86 1.08 0.33 8.64 3.86 7.885 3.592
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
108 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
30915 30915 A 0 090 0 1 0 2 0 1 0 7.44 8.92 8.92 0.99 17.35 17.35 15.968 15.968
30920 30920 A 0 090 0 1 0 2 0 1 0 11.14 12.47 12.47 1.46 25.07 25.07 23.102 23.102
30930 30930 A 0 010 0 1 0 2 1 1 0 1.31 2.28 2.28 0.18 3.77 3.77 3.452 3.452
30999 30999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
31000 31000 A 0 010 0 1 0 2 1 1 0 1.20 4.26 1.82 0.14 5.60 3.16 5.099 2.908
31002 31002 A 0 010 0 1 0 2 1 0 0 1.96 3.89 3.89 0.26 6.11 6.11 5.589 5.589
31020 31020 A 0 090 0 1 0 2 1 1 0 3.07 11.44 7.50 0.39 14.90 10.96 13.547 10.009
31030 31030 A 0 090 0 1 0 2 1 1 0 6.01 14.15 9.01 0.75 20.91 15.77 19.109 14.493
31032 31032 A 0 090 0 1 0 2 1 1 0 6.69 9.68 9.68 0.87 17.24 17.24 15.838 15.838
31040 31040 A 0 090 0 1 0 2 1 1 1 9.77 11.63 11.63 1.39 22.79 22.79 20.941 20.941
31050 31050 A 0 090 0 1 0 2 1 1 0 5.37 8.58 8.58 0.68 14.63 14.63 13.430 13.430
31051 31051 A 0 090 0 1 0 2 1 1 0 7.25 11.32 11.32 0.91 19.48 19.48 17.891 17.891
31070 31070 A 0 090 0 1 0 2 1 1 0 4.40 8.38 8.38 0.59 13.37 13.37 12.234 12.234
31075 31075 A 0 090 0 1 0 2 1 2 1 9.51 12.78 12.78 1.22 23.51 23.51 21.625 21.625
31080 31080 A 0 090 0 1 0 2 1 2 0 12.74 16.60 16.60 1.63 30.97 30.97 28.499 28.499
31081 31081 A 0 090 0 1 0 2 1 2 1 14.19 25.96 25.96 5.09 45.24 45.24 40.164 40.164
31084 31084 A 0 090 0 1 0 2 1 2 1 14.95 17.70 17.70 1.92 34.57 34.57 31.849 31.849
31085 31085 A 0 090 0 1 0 2 1 2 1 15.64 26.70 26.70 5.62 47.96 47.96 42.556 42.556
31086 31086 A 0 090 0 1 0 2 1 2 0 14.36 17.41 17.41 1.85 33.62 33.62 30.962 30.962
31087 31087 A 0 090 0 1 0 2 1 2 1 14.57 15.89 15.89 1.86 32.32 32.32 29.812 29.812
31090 31090 A 0 090 0 1 0 2 1 1 0 11.17 18.29 18.29 1.47 30.93 30.93 28.363 28.363
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
109 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
31200 31200 A 0 090 0 1 0 2 1 1 0 5.14 11.54 11.54 0.73 17.41 17.41 15.885 15.885
31201 31201 A 0 090 0 1 0 2 1 1 0 8.60 12.69 12.69 1.14 22.43 22.43 20.592 20.592
31205 31205 A 0 090 0 1 0 2 1 2 1 10.58 15.15 15.15 1.59 27.32 27.32 25.016 25.016
31225 31225 A 0 090 0 1 0 2 1 2 1 26.70 25.59 25.59 3.55 55.84 55.84 51.536 51.536
31230 31230 A 0 090 0 1 0 2 1 2 1 30.82 27.02 27.02 3.96 61.80 61.80 57.155 57.155
31231 31231 A 0 000 0 0 0 2 2 1 0 1.10 5.21 0.69 0.12 6.43 1.91 5.841 1.782
31233 31233 A 0 000 0 0 0 2 1 0 0 2.18 5.64 1.61 0.29 8.11 4.08 7.396 3.777
31235 31235 A 0 000 0 0 0 2 1 0 0 2.64 6.21 1.83 0.33 9.18 4.80 8.389 4.456
31237 31237 A 0 000 0 0 0 2 1 1 0 2.98 6.52 2.02 0.38 9.88 5.38 9.034 4.993
31238 31238 A 0 000 0 0 0 2 1 0 0 3.26 6.43 2.16 0.41 10.10 5.83 9.249 5.414
31239 31239 A 0 010 0 1 0 2 1 0 0 9.33 10.14 10.14 1.24 20.71 20.71 19.084 19.084
31240 31240 A 0 000 0 0 0 2 1 0 0 2.61 1.84 1.84 0.34 4.79 4.79 4.440 4.440
31254 31254 A 0 000 0 0 0 2 1 1 0 4.64 2.85 2.85 0.60 8.09 8.09 7.513 7.513
31255 31255 A 0 000 0 0 0 2 1 1 0 6.95 4.00 4.00 0.88 11.83 11.83 11.002 11.002
31256 31256 A 0 000 0 0 0 2 1 1 0 3.29 2.17 2.17 0.41 5.87 5.87 5.453 5.453
31267 31267 A 0 000 0 0 0 2 1 1 0 5.45 3.25 3.25 0.69 9.39 9.39 8.729 8.729
31276 31276 A 0 000 0 0 0 2 1 1 0 8.84 4.94 4.94 1.14 14.92 14.92 13.872 13.872
31287 31287 A 0 000 0 0 0 2 1 0 0 3.91 2.48 2.48 0.50 6.89 6.89 6.399 6.399
31288 31288 A 0 000 0 0 0 2 1 0 0 4.57 2.81 2.81 0.60 7.98 7.98 7.407 7.407
31290 31290 A 0 010 0 1 0 2 1 0 0 18.61 13.10 13.10 2.64 34.35 34.35 31.755 31.755
31291 31291 A 0 010 0 1 0 2 1 0 0 19.56 13.82 13.82 3.14 36.52 36.52 33.613 33.613
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
110 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
31292 31292 A 0 010 0 1 0 2 1 0 0 15.90 11.73 11.73 2.04 29.67 29.67 27.500 27.500
31293 31293 A 0 010 0 1 0 2 1 0 0 17.47 12.50 12.50 2.23 32.20 32.20 29.861 29.861
31294 31294 A 0 010 0 1 0 2 1 0 0 20.31 13.91 13.91 2.61 36.83 36.83 34.166 34.166
31295 31295 A 0 000 0 0 0 2 1 2 0 2.70 62.49 1.93 0.35 65.54 4.98 58.999 4.616
31296 31296 A 0 000 0 0 0 2 1 2 0 3.29 62.82 2.24 0.42 66.53 5.95 59.922 5.521
31297 31297 A 0 000 0 0 0 2 1 0 0 2.64 62.66 1.92 0.34 65.64 4.90 59.087 4.542
31299 31299 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
31300 31300 A 0 090 0 1 0 2 0 2 1 15.91 19.88 19.88 2.03 37.82 37.82 34.824 34.824
31320 31320 A 0 090 0 1 0 2 0 0 0 5.73 13.63 13.63 0.72 20.08 20.08 18.346 18.346
31360 31360 A 0 090 0 1 0 2 0 2 1 29.91 28.25 28.25 3.92 62.08 62.08 57.329 57.329
31365 31365 A 0 090 0 1 0 2 0 2 1 38.81 32.83 32.83 5.08 76.72 76.72 70.948 70.948
31367 31367 A 0 090 0 1 0 2 0 2 1 30.57 31.48 31.48 3.97 66.02 66.02 60.915 60.915
31368 31368 A 0 090 0 1 0 2 0 2 1 34.19 34.47 34.47 4.38 73.04 73.04 67.435 67.435
31370 31370 A 0 090 0 1 0 2 0 2 1 27.57 30.99 30.99 3.54 62.10 62.10 57.250 57.250
31375 31375 A 0 090 0 1 0 2 0 2 1 26.07 29.54 29.54 3.36 58.97 58.97 54.354 54.354
31380 31380 A 0 090 0 1 0 2 0 2 1 25.57 29.30 29.30 3.29 58.16 58.16 53.602 53.602
31382 31382 A 0 090 0 1 0 2 0 2 1 28.57 31.49 31.49 3.69 63.75 63.75 58.778 58.778
31390 31390 A 0 090 0 1 0 2 0 2 1 42.51 36.99 36.99 5.84 85.34 85.34 78.781 78.781
31395 31395 A 0 090 0 1 0 2 0 2 1 43.80 40.27 40.27 5.63 89.70 89.70 82.907 82.907
31400 31400 A 0 090 0 1 0 2 0 2 0 11.60 16.97 16.97 1.50 30.07 30.07 27.624 27.624
31420 31420 A 0 090 0 1 0 2 0 2 1 11.43 12.11 12.11 1.47 25.01 25.01 23.074 23.074
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
111 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
31500 31500 A 0 000 0 0 0 0 0 1 0 2.33 0.59 0.59 0.31 3.23 3.23 3.022 3.022
31502 31502 A 0 000 0 0 0 2 0 1 0 0.65 0.31 0.31 0.07 1.03 1.03 0.965 0.965
31505 31505 A 0 000 0 0 0 2 0 1 0 0.61 1.88 0.81 0.07 2.56 1.49 2.335 1.374
31510 31510 A 0 000 0 0 0 3 0 0 0 1.92 4.30 1.45 0.26 6.48 3.63 5.917 3.358
31511 31511 A 0 000 0 0 0 3 0 1 0 2.16 4.08 1.40 0.31 6.55 3.87 5.986 3.579
31512 31512 A 0 000 0 0 0 3 0 0 0 2.07 4.00 1.56 0.27 6.34 3.90 5.803 3.612
31513 31513 A 0 000 0 0 0 3 0 0 0 2.10 1.58 1.58 0.27 3.95 3.95 3.660 3.660
31515 31515 A 0 000 0 0 0 2 0 1 0 1.80 4.34 1.27 0.24 6.38 3.31 5.823 3.066
31520 31520 A 0 000 0 0 0 2 0 0 0 2.56 1.81 1.81 0.33 4.70 4.70 4.358 4.358
31525 31525 A 0 000 0 0 0 2 0 1 0 2.63 4.68 1.79 0.34 7.65 4.76 7.010 4.415
31526 31526 A 0 000 0 0 0 2 0 1 0 2.57 1.81 1.81 0.33 4.71 4.71 4.368 4.368
31527 31527 A 0 000 0 0 0 3 0 0 0 3.27 2.16 2.16 0.41 5.84 5.84 5.424 5.424
31528 31528 A 0 000 0 0 0 3 0 0 0 2.37 1.65 1.65 0.31 4.33 4.33 4.014 4.014
31529 31529 A 0 000 0 0 0 3 0 0 0 2.68 1.82 1.82 0.34 4.84 4.84 4.492 4.492
31530 31530 A 0 000 0 0 0 3 0 1 0 3.38 2.06 2.06 0.44 5.88 5.88 5.460 5.460
31531 31531 A 0 000 0 0 0 3 0 0 0 3.58 2.30 2.30 0.45 6.33 6.33 5.881 5.881
31535 31535 A 0 000 0 0 0 3 0 1 0 3.16 2.10 2.10 0.41 5.67 5.67 5.260 5.260
31536 31536 A 0 000 0 0 0 3 0 1 0 3.55 2.30 2.30 0.45 6.30 6.30 5.851 5.851
31540 31540 A 0 000 0 0 0 3 0 1 0 4.12 2.58 2.58 0.53 7.23 7.23 6.714 6.714
31541 31541 A 0 000 0 0 0 3 0 1 0 4.52 2.78 2.78 0.59 7.89 7.89 7.325 7.325
31545 31545 A 0 000 0 0 0 3 1 1 0 6.30 3.72 3.72 0.80 10.82 10.82 10.059 10.059
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
112 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
31546 31546 A 0 000 0 0 0 3 1 1 0 9.73 5.43 5.43 1.25 16.41 16.41 15.260 15.260
31560 31560 A 0 000 0 0 0 3 0 0 0 5.45 3.20 3.20 0.69 9.34 9.34 8.684 8.684
31561 31561 A 0 000 0 0 0 3 0 0 0 5.99 3.46 3.46 0.76 10.21 10.21 9.495 9.495
31570 31570 A 0 000 0 0 0 3 0 1 0 3.86 5.93 2.46 0.53 10.32 6.85 9.462 6.346
31571 31571 A 0 000 0 0 0 3 0 1 0 4.26 2.64 2.64 0.54 7.44 7.44 6.913 6.913
31575 31575 A 0 000 0 0 0 2 0 1 0 1.10 2.25 1.06 0.12 3.47 2.28 3.183 2.115
31576 31576 A 0 000 0 0 0 3 0 1 0 1.97 4.63 1.47 0.24 6.84 3.68 6.253 3.416
31577 31577 A 0 000 0 0 0 3 0 0 0 2.47 4.64 1.67 0.33 7.44 4.47 6.809 4.142
31578 31578 A 0 000 0 0 0 3 0 0 0 2.84 5.35 1.95 0.35 8.54 5.14 7.827 4.774
31579 31579 A 0 000 0 0 0 3 0 1 0 2.26 3.85 1.66 0.30 6.41 4.22 5.874 3.908
31580 31580 A 0 090 0 1 0 2 0 2 1 14.66 20.25 20.25 1.88 36.79 36.79 33.828 33.828
31582 31582 A 0 090 0 1 0 2 0 1 1 23.22 30.78 30.78 2.99 56.99 56.99 52.424 52.424
31584 31584 A 0 090 0 1 0 2 0 2 1 20.47 22.08 22.08 2.63 45.18 45.18 41.673 41.673
31587 31587 A 0 090 0 1 0 2 0 2 1 15.27 12.65 12.65 1.95 29.87 29.87 27.650 27.650
31588 31588 A 0 090 0 1 0 2 0 2 0 14.99 17.38 17.38 1.93 34.30 34.30 31.607 31.607
31590 31590 A 0 090 0 1 0 2 0 2 1 7.85 18.27 18.27 1.02 27.14 27.14 24.790 24.790
31595 31595 A 0 090 0 1 0 2 1 2 1 8.84 13.07 13.07 1.14 23.05 23.05 21.173 21.173
31599 31599 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
31600 31600 A 0 000 0 0 0 2 0 1 0 7.17 3.31 3.31 1.27 11.75 11.75 10.807 10.807
31601 31601 A 0 000 0 0 0 2 0 2 1 4.44 2.70 2.70 0.56 7.70 7.70 7.157 7.157
31603 31603 A 0 000 0 0 0 2 0 1 0 4.14 1.77 1.77 0.69 6.60 6.60 6.090 6.090
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
113 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
31605 31605 A 0 000 0 0 0 2 0 1 0 3.57 1.22 1.22 0.63 5.42 5.42 4.995 4.995
31610 31610 A 0 090 0 1 0 2 0 1 0 9.38 10.83 10.83 1.32 21.53 21.53 19.796 19.796
31611 31611 A 0 090 0 1 0 2 0 2 1 6.00 9.62 9.62 0.76 16.38 16.38 15.036 15.036
31612 31612 A 0 000 0 0 0 2 0 0 0 0.91 1.53 0.40 0.11 2.55 1.42 2.341 1.327
31613 31613 A 0 090 0 1 0 2 0 1 0 4.71 8.43 8.43 0.72 13.86 13.86 12.657 12.657
31614 31614 A 0 090 0 1 0 2 0 1 0 8.63 13.17 13.17 1.18 22.98 22.98 21.074 21.074
31615 31615 A 0 000 0 0 0 2 0 1 0 2.09 3.16 1.48 0.26 5.51 3.83 5.064 3.555
31620 31620 A 0 ZZZ 0 0 0 0 0 1 0 1.40 7.15 0.48 0.12 8.67 2.00 7.883 1.894
31622 31622 A 0 000 0 0 0 2 0 1 0 2.78 6.48 1.24 0.34 9.60 4.36 8.777 4.071
31623 31623 A 0 000 0 0 0 3 0 1 0 2.88 7.02 1.23 0.26 10.16 4.37 9.320 4.121
31624 31624 A 0 000 0 0 0 3 0 1 0 2.88 6.42 1.26 0.26 9.56 4.40 8.781 4.147
31625 31625 A 0 000 0 0 0 3 0 1 0 3.36 6.56 1.40 0.31 10.23 5.07 9.413 4.779
31626 31626 A 0 000 0 0 0 2 0 0 0 4.16 9.18 1.65 0.31 13.65 6.12 12.566 5.804
31627 31627 A 0 ZZZ 0 0 0 0 0 0 0 2.00 39.22 0.67 0.14 41.36 2.81 37.293 2.675
31628 31628 A 0 000 0 0 0 3 0 1 0 3.80 7.43 1.54 0.30 11.53 5.64 10.629 5.340
31629 31629 A 0 000 0 0 0 3 0 1 0 4.09 14.20 1.64 0.34 18.63 6.07 17.019 5.741
31630 31630 A 0 000 0 0 0 3 0 1 0 3.81 1.68 1.68 0.49 5.98 5.98 5.575 5.575
31631 31631 A 0 000 0 0 0 3 0 1 0 4.36 1.85 1.85 0.60 6.81 6.81 6.335 6.335
31632 31632 A 0 ZZZ 0 0 0 0 0 1 0 1.03 1.05 0.35 0.07 2.15 1.45 2.010 1.381
31633 31633 A 0 ZZZ 0 0 0 0 0 1 0 1.32 1.22 0.45 0.10 2.64 1.87 2.468 1.776
31634 31634 A 0 000 0 0 0 3 0 2 0 4.00 56.27 1.62 0.33 60.60 5.95 54.703 5.627
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
114 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
31635 31635 A 0 000 0 0 0 3 0 1 0 3.67 6.51 1.54 0.39 10.57 5.60 9.720 5.257
31636 31636 A 0 000 0 0 0 3 0 1 0 4.30 1.76 1.76 0.56 6.62 6.62 6.173 6.173
31637 31637 A 0 ZZZ 0 0 0 0 0 1 0 1.58 0.50 0.50 0.11 2.19 2.19 2.087 2.087
31638 31638 A 0 000 0 0 0 3 0 1 0 4.88 2.04 2.04 0.65 7.57 7.57 7.052 7.052
31640 31640 A 0 000 0 0 0 3 0 1 0 4.93 2.08 2.08 0.64 7.65 7.65 7.133 7.133
31641 31641 A 0 000 0 0 0 3 0 1 0 5.02 2.06 2.06 0.59 7.67 7.67 7.178 7.178
31643 31643 A 0 000 0 0 0 2 0 1 0 3.49 1.46 1.46 0.29 5.24 5.24 4.953 4.953
31645 31645 A 0 000 0 0 0 3 0 1 0 3.16 6.28 1.35 0.29 9.73 4.80 8.951 4.524
31646 31646 A 0 000 0 0 0 2 0 1 0 2.72 5.84 1.20 0.26 8.82 4.18 8.100 3.934
31647 31647 A 0 000 0 0 0 3 0 1 0 4.40 1.67 1.67 0.57 6.64 6.64 6.198 6.198
31648 31648 A 0 000 0 0 0 3 0 1 0 4.20 2.18 2.18 0.56 6.94 6.94 6.451 6.451
31649 31649 A 0 ZZZ 0 0 0 0 0 1 0 1.44 0.64 0.64 0.10 2.18 2.18 2.067 2.067
31651 31651 A 0 ZZZ 0 0 0 0 0 1 0 1.58 0.62 0.62 0.11 2.31 2.31 2.194 2.194
31660 31660 A 0 000 0 0 0 3 0 1 0 4.25 1.86 1.86 0.55 6.66 6.66 6.208 6.208
31661 31661 A 0 000 0 0 0 3 0 1 0 4.50 1.93 1.93 0.60 7.03 7.03 6.547 6.547
31717 31717 A 0 000 0 0 0 2 0 1 0 2.12 5.84 0.97 0.16 8.12 3.25 7.448 3.075
31720 31720 A 0 000 0 0 0 2 0 1 0 1.06 0.33 0.33 0.08 1.47 1.47 1.398 1.398
31725 31725 A 0 000 0 0 0 2 0 1 0 1.96 0.56 0.56 0.20 2.72 2.72 2.567 2.567
31730 31730 A 0 000 0 0 0 2 0 1 0 2.85 34.70 1.03 0.45 38.00 4.33 34.246 4.010
31750 31750 A 0 090 0 1 0 2 0 2 1 15.39 24.00 24.00 2.27 41.66 41.66 38.129 38.129
31755 31755 A 0 090 0 1 0 2 0 2 1 17.54 32.65 32.65 2.25 52.44 52.44 48.036 48.036
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
115 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
31760 31760 A 0 090 0 1 0 2 0 2 1 23.48 12.02 12.02 5.48 40.98 40.98 37.140 37.140
31766 31766 A 0 090 0 1 0 2 0 2 1 31.67 13.93 13.93 7.40 53.00 53.00 48.049 48.049
31770 31770 A 0 090 0 1 0 2 0 2 1 23.54 10.68 10.68 5.50 39.72 39.72 36.007 36.007
31775 31775 A 0 090 0 1 0 2 0 2 0 24.59 10.46 10.46 5.76 40.81 40.81 36.996 36.996
31780 31780 A 0 090 0 1 0 2 0 2 1 19.84 12.16 12.16 3.23 35.23 35.23 32.449 32.449
31781 31781 A 0 090 0 1 0 2 0 2 1 24.85 15.01 15.01 5.81 45.67 45.67 41.368 41.368
31785 31785 A 0 090 0 1 0 2 0 2 1 18.35 11.16 11.16 2.61 32.12 32.12 29.737 29.737
31786 31786 A 0 090 0 1 0 2 0 2 1 25.42 11.65 11.65 5.96 43.03 43.03 38.999 38.999
31800 31800 A 0 090 0 1 0 2 0 0 0 8.18 12.82 12.82 1.05 22.05 22.05 20.242 20.242
31805 31805 A 0 090 0 1 0 2 0 2 1 13.42 7.86 7.86 3.16 24.44 24.44 22.131 22.131
31820 31820 A 0 090 0 1 0 2 0 0 0 4.64 8.01 4.60 0.67 13.32 9.91 12.183 9.121
31825 31825 A 0 090 0 1 0 2 0 0 0 7.07 10.24 6.36 0.99 18.30 14.42 16.783 13.299
31830 31830 A 0 090 0 1 0 2 0 0 0 4.62 8.27 5.05 0.71 13.60 10.38 12.418 9.526
31899 31899 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
32035 32035 A 0 090 0 1 0 2 1 2 1 11.29 7.88 7.88 2.57 21.74 21.74 19.710 19.710
32036 32036 A 0 090 0 1 0 2 1 2 1 12.30 8.20 8.20 2.90 23.40 23.40 21.180 21.180
32096 32096 A 0 090 0 1 0 2 0 2 1 13.75 7.30 7.30 3.22 24.27 24.27 21.989 21.989
32097 32097 A 0 090 0 1 0 2 0 2 1 13.75 7.30 7.30 3.22 24.27 24.27 21.989 21.989
32098 32098 A 0 090 0 1 0 2 0 2 1 12.91 7.61 7.61 3.01 23.53 23.53 21.318 21.318
32100 32100 A 0 090 0 1 0 2 0 2 1 13.75 7.29 7.29 3.44 24.48 24.48 22.096 22.096
32110 32110 A 0 090 0 1 0 2 0 2 1 25.28 12.79 12.79 5.74 43.81 43.81 39.767 39.767
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
116 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
32120 32120 A 0 090 0 1 0 2 0 2 1 14.39 8.39 8.39 3.40 26.18 26.18 23.702 23.702
32124 32124 A 0 090 0 1 0 2 0 2 1 15.45 8.77 8.77 3.67 27.89 27.89 25.245 25.245
32140 32140 A 0 090 0 1 0 2 0 2 1 16.66 9.16 9.16 3.89 29.71 29.71 26.920 26.920
32141 32141 A 0 090 0 1 0 2 0 2 1 27.18 12.02 12.02 6.40 45.60 45.60 41.321 41.321
32150 32150 A 0 090 0 1 0 2 0 2 1 16.82 9.35 9.35 3.93 30.10 30.10 27.272 27.272
32151 32151 A 0 090 0 1 0 2 0 2 1 16.94 9.25 9.25 3.97 30.16 30.16 27.323 27.323
32160 32160 A 0 090 0 1 0 2 0 2 1 13.10 7.58 7.58 2.99 23.67 23.67 21.471 21.471
32200 32200 A 0 090 0 1 0 2 0 2 1 18.68 10.98 10.98 4.29 33.95 33.95 30.784 30.784
32201 32201 A 0 000 0 0 0 2 0 1 0 3.99 23.15 1.40 0.38 27.52 5.77 24.977 5.446
32215 32215 A 0 090 0 1 0 2 1 2 1 13.05 7.95 7.95 3.05 24.05 24.05 21.784 21.784
32220 32220 A 0 090 0 1 0 2 1 2 1 26.65 14.71 14.71 6.30 47.66 47.66 43.154 43.154
32225 32225 A 0 090 0 1 0 2 1 2 1 16.75 9.18 9.18 3.92 29.85 29.85 27.044 27.044
32310 32310 A 0 090 0 1 0 2 0 2 1 15.28 8.61 8.61 3.62 27.51 27.51 24.905 24.905
32320 32320 A 0 090 0 1 0 2 0 2 1 27.25 14.32 14.32 6.33 47.90 47.90 43.420 43.420
32400 32400 A 0 000 0 0 0 2 0 1 0 1.76 2.53 0.61 0.18 4.47 2.55 4.126 2.402
32405 32405 A 0 000 0 0 0 2 0 1 0 1.93 11.48 0.92 0.18 13.59 3.03 12.333 2.850
32440 32440 A 0 090 0 1 0 2 0 2 1 27.28 13.19 13.19 6.36 46.83 46.83 42.451 42.451
32442 32442 A 0 090 0 1 0 2 0 2 1 56.47 21.51 21.51 13.21 91.19 91.19 82.695 82.695
32445 32445 A 0 090 0 1 0 2 0 2 1 63.84 26.56 26.56 14.94 105.34 105.34 95.505 95.505
32480 32480 A 0 090 0 1 0 2 0 2 1 25.82 12.42 12.42 6.06 44.30 44.30 40.143 40.143
32482 32482 A 0 090 0 1 0 2 0 2 1 27.44 13.56 13.56 6.42 47.42 47.42 42.975 42.975
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
117 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
32484 32484 A 0 090 0 1 0 2 0 2 1 25.38 11.67 11.67 5.91 42.96 42.96 38.951 38.951
32486 32486 A 0 090 0 1 0 2 0 2 1 42.88 17.13 17.13 10.14 70.15 70.15 63.566 63.566
32488 32488 A 0 090 0 1 0 2 0 2 1 42.99 18.04 18.04 10.11 71.14 71.14 64.477 64.477
32491 32491 R 0 090 0 1 0 2 1 2 1 25.24 12.89 12.89 5.88 44.01 44.01 39.890 39.890
32501 32501 A 0 ZZZ 0 0 0 0 0 2 1 4.68 1.50 1.50 1.09 7.27 7.27 6.597 6.597
32503 32503 A 0 090 0 1 0 2 0 2 1 31.74 14.84 14.84 7.50 54.08 54.08 48.989 48.989
32504 32504 A 0 090 0 1 0 2 0 2 1 36.54 16.01 16.01 8.52 61.07 61.07 55.373 55.373
32505 32505 A 0 090 0 1 0 2 0 2 1 15.75 9.35 9.35 3.61 28.71 28.71 26.034 26.034
32506 32506 A 0 ZZZ 0 0 0 0 0 2 1 3.00 1.22 1.22 0.71 4.93 4.93 4.467 4.467
32507 32507 A 0 ZZZ 0 0 0 0 0 2 1 3.00 1.22 1.22 0.71 4.93 4.93 4.467 4.467
32540 32540 A 0 090 0 1 0 2 0 2 1 30.35 14.16 14.16 7.10 51.61 51.61 46.779 46.779
32550 32550 A 0 000 0 0 0 0 0 1 0 4.17 19.47 1.77 0.69 24.33 6.63 22.015 6.120
32551 32551 A 0 000 0 0 0 2 1 1 0 3.29 1.21 1.21 0.73 5.23 5.23 4.758 4.758
32552 32552 A 0 010 0 1 0 2 0 0 0 2.53 2.65 1.86 0.60 5.78 4.99 5.224 4.514
32553 32553 A 0 000 0 0 0 2 0 2 0 3.80 12.91 1.51 0.88 17.59 6.19 15.853 5.616
32554 32554 A 0 000 0 0 0 2 1 1 0 1.82 14.66 0.65 0.17 16.65 2.64 15.074 2.493
32555 32555 A 0 000 0 0 0 2 1 1 0 2.27 16.70 0.80 0.23 19.20 3.30 17.387 3.109
32556 32556 A 0 000 0 0 0 2 1 1 0 2.50 14.80 0.87 0.25 17.55 3.62 15.921 3.412
32557 32557 A 0 000 0 0 0 2 1 1 0 3.12 24.68 1.07 0.69 28.49 4.88 25.644 4.442
32560 32560 A 0 000 0 0 0 2 0 1 0 1.54 5.78 0.52 0.27 7.59 2.33 6.872 2.148
32561 32561 A 0 000 0 0 0 2 0 2 0 1.39 1.21 0.47 0.24 2.84 2.10 2.602 1.938
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
118 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
32562 32562 A 0 000 0 0 0 2 0 2 0 1.24 1.10 0.41 0.23 2.57 1.88 2.348 1.728
32601 32601 A 0 000 0 0 0 2 0 0 0 5.50 2.46 2.46 1.28 9.24 9.24 8.379 8.379
32604 32604 A 0 000 0 0 0 2 0 0 0 8.77 3.53 3.53 2.04 14.34 14.34 13.007 13.007
32606 32606 A 0 000 0 0 0 2 0 0 0 8.39 3.49 3.49 1.93 13.81 13.81 12.533 12.533
32607 32607 A 0 000 0 0 0 2 0 0 0 5.50 2.80 2.80 1.28 9.58 9.58 8.684 8.684
32608 32608 A 0 000 0 0 0 2 0 0 0 6.84 3.35 3.35 1.60 11.79 11.79 10.685 10.685
32609 32609 A 0 000 0 0 0 2 0 0 0 4.58 2.43 2.43 1.11 8.12 8.12 7.343 7.343
32650 32650 A 0 090 0 1 0 2 1 2 1 10.83 6.72 6.72 2.48 20.03 20.03 18.162 18.162
32651 32651 A 0 090 0 1 0 2 1 2 1 18.78 9.69 9.69 4.31 32.78 32.78 29.736 29.736
32652 32652 A 0 090 0 1 0 2 1 2 1 29.13 13.79 13.79 6.72 49.64 49.64 45.028 45.028
32653 32653 A 0 090 0 1 0 2 0 2 1 18.17 9.31 9.31 4.12 31.60 31.60 28.685 28.685
32654 32654 A 0 090 0 1 0 2 1 2 1 20.52 10.08 10.08 4.65 35.25 35.25 32.004 32.004
32655 32655 A 0 090 0 1 0 2 1 2 1 16.17 8.78 8.78 3.77 28.72 28.72 26.026 26.026
32656 32656 A 0 090 0 1 0 2 1 2 1 13.26 7.65 7.65 3.01 23.92 23.92 21.704 21.704
32658 32658 A 0 090 0 1 0 2 0 2 1 11.71 6.95 6.95 2.75 21.41 21.41 19.389 19.389
32659 32659 A 0 090 0 1 0 2 0 2 1 11.94 7.12 7.12 2.80 21.86 21.86 19.798 19.798
32661 32661 A 0 090 0 1 0 2 0 2 1 13.33 7.47 7.47 3.13 23.93 23.93 21.675 21.675
32662 32662 A 0 090 0 1 0 2 0 2 1 14.99 8.20 8.20 3.50 26.69 26.69 24.184 24.184
32663 32663 A 0 090 0 1 0 2 0 2 1 24.64 11.48 11.48 5.74 41.86 41.86 37.951 37.951
32664 32664 A 0 090 0 1 0 2 1 2 1 14.28 7.77 7.77 3.36 25.41 25.41 23.015 23.015
32665 32665 A 0 090 0 1 0 2 0 2 1 21.53 10.27 10.27 4.60 36.40 36.40 33.158 33.158
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
119 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
32666 32666 A 0 090 0 1 0 2 0 2 1 14.50 8.84 8.84 3.39 26.73 26.73 24.211 24.211
32667 32667 A 0 ZZZ 0 0 0 0 0 2 1 3.00 1.22 1.22 0.71 4.93 4.93 4.467 4.467
32668 32668 A 0 ZZZ 0 0 0 0 0 2 1 3.00 1.22 1.22 0.73 4.95 4.95 4.477 4.477
32669 32669 A 0 090 0 1 0 2 0 2 1 23.53 11.18 11.18 5.48 40.19 40.19 36.436 36.436
32670 32670 A 0 090 0 1 0 2 0 2 1 28.52 12.82 12.82 6.58 47.92 47.92 43.474 43.474
32671 32671 A 0 090 0 1 0 2 0 2 1 31.92 13.65 13.65 7.54 53.11 53.11 48.121 48.121
32672 32672 A 0 090 0 1 0 2 0 2 1 27.00 12.10 12.10 6.36 45.46 45.46 41.192 41.192
32673 32673 A 0 090 0 1 0 2 0 2 1 21.13 10.17 10.17 4.51 35.81 35.81 32.621 32.621
32674 32674 A 0 ZZZ 0 0 0 0 0 2 1 4.12 1.34 1.34 0.96 6.42 6.42 5.825 5.825
32701 32701 A 2 XXX 0 0 0 0 0 0 1 4.18 1.32 1.32 1.05 6.55 6.55 5.915 5.915
32800 32800 A 0 090 0 1 0 2 0 2 1 15.71 8.87 8.87 3.69 28.27 28.27 25.605 25.605
32810 32810 A 0 090 0 1 0 2 0 2 0 14.95 8.57 8.57 3.51 27.03 27.03 24.482 24.482
32815 32815 A 0 090 0 1 0 2 0 2 1 50.03 21.94 21.94 11.90 83.87 83.87 75.956 75.956
32820 32820 A 0 090 0 1 0 2 0 2 1 22.51 14.40 14.40 5.28 42.19 42.19 38.203 38.203
32850 32850 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
32851 32851 A 0 090 0 1 0 2 0 2 1 59.64 24.31 24.31 14.05 98.00 98.00 88.819 88.819
32852 32852 A 0 090 0 1 0 2 0 2 1 65.50 26.20 26.20 15.35 107.05 107.05 97.056 97.056
32853 32853 A 0 090 0 1 0 2 2 2 1 84.48 32.45 32.45 20.00 136.93 136.93 124.080 124.080
32854 32854 A 0 090 0 1 0 2 2 2 1 90.00 34.32 34.32 21.21 145.53 145.53 131.912 131.912
32855 32855 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
32856 32856 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
120 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
32900 32900 A 0 090 0 1 0 2 0 2 1 23.81 12.29 12.29 5.48 41.58 41.58 37.712 37.712
32905 32905 A 0 090 0 1 0 2 0 2 1 23.29 11.20 11.20 5.44 39.93 39.93 36.193 36.193
32906 32906 A 0 090 0 1 0 2 0 2 1 29.30 13.10 13.10 6.87 49.27 49.27 44.657 44.657
32940 32940 A 0 090 0 1 0 2 0 2 1 21.34 10.58 10.58 5.01 36.93 36.93 33.461 33.461
32960 32960 A 0 000 0 0 0 2 0 1 0 1.84 2.29 0.81 0.42 4.55 3.07 4.116 2.787
32997 32997 A 0 000 0 0 0 2 0 1 0 7.31 2.31 2.31 0.91 10.53 10.53 9.860 9.860
32998 32998 A 0 000 0 0 0 2 0 2 0 5.68 84.49 2.15 0.60 90.77 8.43 81.866 7.925
32999 32999 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
33010 33010 A 0 000 0 0 0 2 0 1 0 2.24 0.80 0.80 0.45 3.49 3.49 3.194 3.194
33011 33011 A 0 000 0 0 0 2 0 0 0 2.24 0.81 0.81 0.49 3.54 3.54 3.224 3.224
33015 33015 A 0 090 0 1 0 2 0 1 0 8.52 4.84 4.84 1.67 15.03 15.03 13.740 13.740
33020 33020 A 0 090 0 1 0 2 0 2 1 14.95 7.79 7.79 3.51 26.25 26.25 23.781 23.781
33025 33025 A 0 090 0 1 0 2 0 2 1 13.70 7.06 7.06 3.25 24.01 24.01 21.740 21.740
33030 33030 A 0 090 0 1 0 2 0 2 1 36.00 15.39 15.39 8.55 59.94 59.94 54.292 54.292
33031 33031 A 0 090 0 1 0 2 0 2 1 45.00 18.47 18.47 10.83 74.30 74.30 67.250 67.250
33050 33050 A 0 090 0 1 0 2 0 2 1 16.97 9.07 9.07 3.97 30.01 30.01 27.191 27.191
33120 33120 A 0 090 0 1 0 2 0 2 1 38.45 15.28 15.28 9.20 62.93 62.93 56.983 56.983
33130 33130 A 0 090 0 1 0 2 0 2 1 24.17 11.48 11.48 6.04 41.69 41.69 37.638 37.638
33140 33140 A 0 090 0 1 0 2 0 2 0 28.34 12.07 12.07 7.08 47.49 47.49 42.882 42.882
33141 33141 A 0 ZZZ 0 0 0 0 0 2 1 2.54 0.80 0.80 0.61 3.95 3.95 3.577 3.577
33202 33202 A 0 090 0 1 0 2 0 1 0 13.20 6.93 6.93 3.16 23.29 23.29 21.076 21.076
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
121 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33203 33203 A 0 090 0 1 0 2 0 1 0 13.97 6.82 6.82 3.28 24.07 24.07 21.810 21.810
33206 33206 A 0 090 0 1 0 2 0 1 2 7.39 4.49 4.49 1.62 13.50 13.50 12.269 12.269
33207 33207 A 0 090 0 1 0 2 0 1 2 8.05 4.48 4.48 1.77 14.30 14.30 12.999 12.999
33208 33208 A 0 090 0 1 0 2 0 1 2 8.77 4.76 4.76 1.92 15.45 15.45 14.049 14.049
33210 33210 A 0 000 0 0 0 2 0 1 0 3.30 1.22 1.22 0.71 5.23 5.23 4.767 4.767
33211 33211 A 0 000 0 0 0 2 0 1 0 3.39 1.20 1.20 0.75 5.34 5.34 4.860 4.860
33212 33212 A 0 090 0 1 0 2 0 1 0 5.26 3.42 3.42 1.15 9.83 9.83 8.933 8.933
33213 33213 A 0 090 0 1 0 2 0 1 0 5.53 3.51 3.51 1.22 10.26 10.26 9.320 9.320
33214 33214 A 0 090 0 1 0 2 0 0 2 7.84 4.72 4.72 1.70 14.26 14.26 12.968 12.968
33215 33215 A 0 090 0 1 0 2 0 1 0 4.92 2.98 2.98 1.08 8.98 8.98 8.161 8.161
33216 33216 A 0 090 0 1 0 2 0 1 0 5.87 3.93 3.93 1.28 11.08 11.08 10.069 10.069
33217 33217 A 0 090 0 1 0 2 0 1 0 5.84 3.90 3.90 1.28 11.02 11.02 10.012 10.012
33218 33218 A 0 090 0 1 0 2 0 1 0 6.07 4.23 4.23 1.32 11.62 11.62 10.559 10.559
33220 33220 A 0 090 0 1 0 2 0 1 0 6.15 4.23 4.23 1.33 11.71 11.71 10.644 10.644
33221 33221 A 0 090 0 1 0 2 0 1 0 5.80 3.61 3.61 1.29 10.70 10.70 9.716 9.716
33222 33222 A 0 090 0 1 0 2 0 1 0 5.10 4.01 4.01 1.14 10.25 10.25 9.297 9.297
33223 33223 A 0 090 0 1 0 2 0 0 0 6.55 4.23 4.23 1.46 12.24 12.24 11.112 11.112
33224 33224 A 0 000 0 0 0 2 0 1 0 9.04 3.87 3.87 1.99 14.90 14.90 13.556 13.556
33225 33225 A 0 ZZZ 0 0 0 0 0 1 0 8.33 3.26 3.26 1.82 13.41 13.41 12.209 12.209
33226 33226 A 0 000 0 0 0 2 0 1 0 8.68 3.74 3.74 1.91 14.33 14.33 13.037 13.037
33227 33227 A 0 090 0 1 0 2 0 1 0 5.50 3.50 3.50 1.23 10.23 10.23 9.286 9.286
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
122 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33228 33228 A 0 090 0 1 0 2 0 1 0 5.77 3.61 3.61 1.29 10.67 10.67 9.686 9.686
33229 33229 A 0 090 0 1 0 2 0 1 0 6.04 3.71 3.71 1.35 11.10 11.10 10.078 10.078
33230 33230 A 0 090 0 1 0 2 0 1 0 6.32 3.85 3.85 1.41 11.58 11.58 10.515 10.515
33231 33231 A 0 090 0 1 0 2 0 1 0 6.59 3.95 3.95 1.47 12.01 12.01 10.906 10.906
33233 33233 A 0 090 0 1 0 2 0 1 0 3.39 2.90 2.90 0.73 7.02 7.02 6.376 6.376
33234 33234 A 0 090 0 1 0 2 0 1 0 7.91 4.73 4.73 1.74 14.38 14.38 13.068 13.068
33235 33235 A 0 090 0 1 0 2 0 1 0 10.15 6.39 6.39 2.25 18.79 18.79 17.065 17.065
33236 33236 A 0 090 0 1 0 2 0 0 2 12.73 7.92 7.92 3.18 23.83 23.83 21.505 21.505
33237 33237 A 0 090 0 1 0 2 0 0 2 13.84 8.26 8.26 3.24 25.34 25.34 22.952 22.952
33238 33238 A 0 090 0 1 0 2 0 0 2 15.40 9.17 9.17 3.69 28.26 28.26 25.565 25.565
33240 33240 A 0 090 0 1 0 2 0 1 0 6.05 3.74 3.74 1.35 11.14 11.14 10.115 10.115
33241 33241 A 0 090 0 1 0 2 0 1 0 3.29 2.60 2.60 0.71 6.60 6.60 5.996 5.996
33243 33243 A 0 090 0 1 0 2 0 2 1 23.57 11.79 11.79 5.57 40.93 40.93 37.071 37.071
33244 33244 A 0 090 0 1 0 2 0 1 1 13.99 8.12 8.12 3.10 25.21 25.21 22.903 22.903
33249 33249 A 0 090 0 1 0 2 0 1 1 15.17 8.23 8.23 3.32 26.72 26.72 24.297 24.297
33250 33250 A 0 090 0 1 0 2 0 2 1 25.90 11.98 11.98 6.46 44.34 44.34 40.037 40.037
33251 33251 A 0 090 0 1 0 2 0 2 1 28.92 12.93 12.93 7.01 48.86 48.86 44.197 44.197
33254 33254 A 0 090 0 1 0 2 0 2 1 23.71 11.62 11.62 5.92 41.25 41.25 37.241 37.241
33255 33255 A 0 090 0 1 0 2 0 2 1 29.04 13.25 13.25 7.25 49.54 49.54 44.730 44.730
33256 33256 A 0 090 0 1 0 2 0 2 1 34.90 15.13 15.13 8.75 58.78 58.78 53.063 53.063
33257 33257 A 0 ZZZ 0 0 0 0 0 2 0 9.63 5.69 5.69 2.31 17.63 17.63 15.948 15.948
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
123 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33258 33258 A 0 ZZZ 0 0 0 0 0 2 0 11.00 6.21 6.21 2.63 19.84 19.84 17.952 17.952
33259 33259 A 0 ZZZ 0 0 0 0 0 2 0 14.14 8.02 8.02 3.43 25.59 25.59 23.136 23.136
33261 33261 A 0 090 0 1 0 2 0 2 1 28.92 12.93 12.93 7.23 49.08 49.08 44.312 44.312
33262 33262 A 0 090 0 1 0 2 0 1 0 6.06 3.75 3.75 1.35 11.16 11.16 10.134 10.134
33263 33263 A 0 090 0 1 0 2 0 1 0 6.33 3.86 3.86 1.41 11.60 11.60 10.534 10.534
33264 33264 A 0 090 0 1 0 2 0 1 0 6.60 3.96 3.96 1.47 12.03 12.03 10.925 10.925
33265 33265 A 0 090 0 1 0 2 0 2 1 23.71 11.51 11.51 5.65 40.87 40.87 37.001 37.001
33266 33266 A 0 090 0 1 0 2 0 2 1 33.04 14.71 14.71 7.98 55.73 55.73 50.423 50.423
33282 33282 A 0 090 0 1 0 2 0 1 0 4.80 3.63 3.63 1.05 9.48 9.48 8.609 8.609
33284 33284 A 0 090 0 1 0 2 0 1 0 3.14 3.01 3.01 0.68 6.83 6.83 6.199 6.199
33300 33300 A 0 090 0 1 0 2 0 2 1 44.97 17.71 17.71 10.74 73.42 73.42 66.491 66.491
33305 33305 A 0 090 0 1 0 2 0 2 1 76.93 27.48 27.48 18.43 122.84 122.84 111.246 111.246
33310 33310 A 0 090 0 1 0 2 0 2 1 20.34 10.27 10.27 4.49 35.10 35.10 31.911 31.911
33315 33315 A 0 090 0 1 0 2 0 2 1 35.00 14.18 14.18 8.41 57.59 57.59 52.132 52.132
33320 33320 A 0 090 0 1 0 2 0 2 1 18.54 8.81 8.81 4.30 31.65 31.65 28.700 28.700
33321 33321 A 0 090 0 1 0 2 0 2 1 20.81 10.24 10.24 4.87 35.92 35.92 32.553 32.553
33322 33322 A 0 090 0 1 0 2 0 2 1 24.42 11.62 11.62 5.87 41.91 41.91 37.925 37.925
33330 33330 A 0 090 0 1 0 2 0 2 1 25.29 14.28 14.28 6.33 45.90 45.90 41.424 41.424
33332 33332 A 0 090 0 1 0 2 0 2 1 24.56 11.42 11.42 6.12 42.10 42.10 38.016 38.016
33335 33335 A 0 090 0 1 0 2 0 2 1 33.91 14.48 14.48 8.18 56.57 56.57 51.191 51.191
33361 33361 A 0 000 0 0 0 2 0 0 2 25.13 9.01 9.01 5.61 39.75 39.75 36.155 36.155
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
124 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33362 33362 A 0 000 0 0 0 2 0 0 2 27.52 9.83 9.83 6.14 43.49 43.49 39.559 39.559
33363 33363 A 0 000 0 0 0 2 0 0 2 28.50 10.17 10.17 6.36 45.03 45.03 40.959 40.959
33364 33364 A 0 000 0 0 0 2 0 0 2 30.00 11.21 11.21 6.70 47.91 47.91 43.571 43.571
33365 33365 A 0 000 0 0 0 2 0 0 2 33.12 11.49 11.49 7.93 52.54 52.54 47.585 47.585
33367 33367 A 0 ZZZ 0 0 0 0 0 0 0 11.88 3.73 3.73 2.84 18.45 18.45 16.715 16.715
33368 33368 A 0 ZZZ 0 0 0 0 0 0 0 14.39 4.52 4.52 3.45 22.36 22.36 20.253 20.253
33369 33369 A 0 ZZZ 0 0 0 0 0 0 0 19.00 5.97 5.97 4.55 29.52 29.52 26.741 26.741
33400 33400 A 0 090 0 1 0 2 0 2 1 41.50 17.18 17.18 9.89 68.57 68.57 62.100 62.100
33401 33401 A 0 090 0 1 0 2 0 2 1 24.63 12.72 12.72 5.38 42.73 42.73 38.866 38.866
33403 33403 A 0 090 0 1 0 2 0 2 1 25.61 13.03 13.03 6.40 45.04 45.04 40.658 40.658
33404 33404 A 0 090 0 1 0 2 0 2 1 31.37 14.07 14.07 7.34 52.78 52.78 47.844 47.844
33405 33405 A 0 090 0 1 0 2 0 2 1 41.32 16.78 16.78 9.92 68.02 68.02 61.577 61.577
33406 33406 A 0 090 0 1 0 2 0 2 1 52.68 21.16 21.16 12.77 86.61 86.61 78.360 78.360
33410 33410 A 0 090 0 1 0 2 0 2 1 46.41 18.88 18.88 11.15 76.44 76.44 69.196 69.196
33411 33411 A 0 090 0 1 0 2 0 2 0 62.07 23.97 23.97 14.93 100.97 100.97 91.403 91.403
33412 33412 A 0 090 0 1 0 2 0 2 1 59.00 22.06 22.06 14.77 95.83 95.83 86.535 86.535
33413 33413 A 0 090 0 1 0 2 0 2 1 59.87 23.23 23.23 14.02 97.12 97.12 88.063 88.063
33414 33414 A 0 090 0 1 0 2 0 2 1 39.37 15.59 15.59 9.84 64.80 64.80 58.516 58.516
33415 33415 A 0 090 0 1 0 2 0 2 1 37.27 15.56 15.56 8.52 61.35 61.35 55.699 55.699
33416 33416 A 0 090 0 1 0 2 0 2 1 36.56 15.85 15.85 8.81 61.22 61.22 55.401 55.401
33417 33417 A 0 090 0 1 0 2 0 2 1 29.33 13.72 13.72 7.04 50.09 50.09 45.332 45.332
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
125 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33420 33420 A 0 090 0 1 0 2 0 1 1 25.79 13.74 13.74 3.54 43.07 43.07 39.980 39.980
33422 33422 A 0 090 0 1 0 2 0 2 1 29.73 13.63 13.63 7.42 50.78 50.78 45.850 45.850
33425 33425 A 0 090 0 1 0 2 0 2 1 49.96 20.42 20.42 11.99 82.37 82.37 74.568 74.568
33426 33426 A 0 090 0 1 0 2 0 2 1 43.28 18.10 18.10 10.41 71.79 71.79 64.978 64.978
33427 33427 A 0 090 0 1 0 2 0 2 1 44.83 17.95 17.95 10.78 73.56 73.56 66.587 66.587
33430 33430 A 0 090 0 1 0 2 0 2 1 50.93 20.72 20.72 12.26 83.91 83.91 75.949 75.949
33460 33460 A 0 090 0 1 0 2 0 2 1 44.70 17.21 17.21 11.17 73.08 73.08 65.996 65.996
33463 33463 A 0 090 0 1 0 2 0 2 1 57.08 22.01 22.01 13.79 92.88 92.88 84.057 84.057
33464 33464 A 0 090 0 1 0 2 0 2 1 44.62 18.30 18.30 10.74 73.66 73.66 66.670 66.670
33465 33465 A 0 090 0 1 0 2 0 2 1 50.72 20.02 20.02 12.29 83.03 83.03 75.126 75.126
33468 33468 A 0 090 0 1 0 2 0 2 1 45.13 17.43 17.43 11.30 73.86 73.86 66.692 66.692
33470 33470 A 0 090 0 1 0 2 0 2 0 21.54 12.57 12.57 5.05 39.16 39.16 35.469 35.469
33471 33471 A 0 090 0 1 0 2 0 2 1 22.96 12.71 12.71 5.76 41.43 41.43 37.386 37.386
33472 33472 A 0 090 0 1 0 2 0 2 0 23.06 10.56 10.56 5.80 39.42 39.42 35.576 35.576
33474 33474 A 0 090 0 1 0 2 0 2 1 39.40 16.43 16.43 9.23 65.06 65.06 58.981 58.981
33475 33475 A 0 090 0 1 0 2 0 2 1 42.40 17.77 17.77 10.60 70.77 70.77 63.901 63.901
33476 33476 A 0 090 0 1 0 2 0 2 1 26.57 12.79 12.79 6.64 46.00 46.00 41.528 41.528
33478 33478 A 0 090 0 1 0 2 0 2 1 27.54 13.09 13.09 6.89 47.52 47.52 42.898 42.898
33496 33496 A 0 090 0 1 0 2 0 2 1 29.84 13.47 13.47 6.98 50.29 50.29 45.587 45.587
33500 33500 A 0 090 0 1 0 2 0 2 1 27.94 12.62 12.62 6.98 47.54 47.54 42.923 42.923
33501 33501 A 0 090 0 1 0 2 0 2 2 19.51 9.64 9.64 4.89 34.04 34.04 30.724 30.724
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
126 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33502 33502 A 0 090 0 1 0 2 0 2 1 21.85 11.35 11.35 5.46 38.66 38.66 34.898 34.898
33503 33503 A 0 090 0 1 0 2 0 0 1 22.51 12.07 12.07 4.93 39.51 39.51 35.927 35.927
33504 33504 A 0 090 0 1 0 2 0 2 1 25.46 12.49 12.49 6.36 44.31 44.31 40.002 40.002
33505 33505 A 0 090 0 1 0 2 0 2 1 38.40 14.17 14.17 9.60 62.17 62.17 56.145 56.145
33506 33506 A 0 090 0 1 0 2 0 2 1 37.85 14.64 14.64 8.87 61.36 61.36 55.636 55.636
33507 33507 A 0 090 0 1 0 2 0 2 1 31.40 12.72 12.72 7.35 51.47 51.47 46.667 46.667
33508 33508 A 0 ZZZ 0 0 0 0 0 2 1 0.31 0.10 0.10 0.07 0.48 0.48 0.436 0.436
33510 33510 A 0 090 0 1 0 2 0 2 0 34.98 14.90 14.90 8.41 58.29 58.29 52.759 52.759
33511 33511 A 0 090 0 1 0 2 0 2 0 38.45 16.31 16.31 9.25 64.01 64.01 57.934 57.934
33512 33512 A 0 090 0 1 0 2 0 2 0 43.98 18.14 18.14 10.60 72.72 72.72 65.814 65.814
33513 33513 A 0 090 0 1 0 2 0 2 0 45.37 18.46 18.46 10.97 74.80 74.80 67.684 67.684
33514 33514 A 0 090 0 1 0 2 0 2 0 48.08 19.25 19.25 11.54 78.87 78.87 71.402 71.402
33516 33516 A 0 090 0 1 0 2 0 2 0 49.76 20.07 20.07 12.43 82.26 82.26 74.284 74.284
33517 33517 A 0 ZZZ 0 0 0 0 0 2 0 3.61 1.15 1.15 0.86 5.62 5.62 5.092 5.092
33518 33518 A 0 ZZZ 0 0 0 0 0 2 0 7.93 2.52 2.52 1.91 12.36 12.36 11.192 11.192
33519 33519 A 0 ZZZ 0 0 0 0 0 2 0 10.49 3.33 3.33 2.52 16.34 16.34 14.798 14.798
33521 33521 A 0 ZZZ 0 0 0 0 0 2 0 12.59 4.00 4.00 3.05 19.64 19.64 17.777 17.777
33522 33522 A 0 ZZZ 0 0 0 0 0 2 0 14.14 4.48 4.48 3.43 22.05 22.05 19.957 19.957
33523 33523 A 0 ZZZ 0 0 0 0 0 2 0 16.08 5.10 5.10 3.87 25.05 25.05 22.684 22.684
33530 33530 A 0 ZZZ 0 0 0 0 0 2 0 10.13 3.22 3.22 2.42 15.77 15.77 14.287 14.287
33533 33533 A 0 090 0 1 0 2 0 2 0 33.75 14.15 14.15 8.13 56.03 56.03 50.709 50.709
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
127 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33534 33534 A 0 090 0 1 0 2 0 2 0 39.88 16.78 16.78 9.58 66.24 66.24 59.959 59.959
33535 33535 A 0 090 0 1 0 2 0 2 0 44.75 18.30 18.30 10.75 73.80 73.80 66.806 66.806
33536 33536 A 0 090 0 1 0 2 0 2 0 48.43 18.89 18.89 11.70 79.02 79.02 71.512 71.512
33542 33542 A 0 090 0 1 0 2 0 2 1 48.21 19.30 19.30 11.64 79.15 79.15 71.629 71.629
33545 33545 A 0 090 0 1 0 2 0 2 1 57.06 22.10 22.10 13.68 92.84 92.84 84.060 84.060
33548 33548 A 0 090 0 1 0 2 0 2 1 54.14 22.06 22.06 13.11 89.31 89.31 80.806 80.806
33572 33572 A 0 ZZZ 0 0 0 0 0 2 0 4.44 1.41 1.41 1.08 6.93 6.93 6.271 6.271
33600 33600 A 0 090 0 1 0 2 0 2 1 30.31 14.07 14.07 7.08 51.46 51.46 46.648 46.648
33602 33602 A 0 090 0 1 0 2 0 2 1 29.34 13.77 13.77 6.25 49.36 49.36 44.974 44.974
33606 33606 A 0 090 0 1 0 2 0 2 1 31.53 14.27 14.27 6.72 52.52 52.52 47.859 47.859
33608 33608 A 0 090 0 1 0 2 0 2 1 31.88 14.57 14.57 7.46 53.91 53.91 48.865 48.865
33610 33610 A 0 090 0 1 0 2 0 2 1 31.40 16.46 16.46 7.35 55.21 55.21 50.025 50.025
33611 33611 A 0 090 0 1 0 2 0 2 1 35.57 14.39 14.39 8.90 58.86 58.86 53.147 53.147
33612 33612 A 0 090 0 1 0 2 0 2 1 36.57 14.71 14.71 7.98 59.26 59.26 53.953 53.953
33615 33615 A 0 090 0 1 0 2 0 2 1 35.89 15.38 15.38 8.41 59.68 59.68 54.100 54.100
33617 33617 A 0 090 0 1 0 2 0 2 1 39.09 16.38 16.38 9.16 64.63 64.63 58.590 58.590
33619 33619 A 0 090 0 1 0 2 0 2 1 48.76 21.32 21.32 11.42 81.50 81.50 73.878 73.878
33620 33620 A 0 090 0 1 0 2 0 2 1 30.00 5.97 5.97 7.50 43.47 43.47 39.284 39.284
33621 33621 A 0 090 0 1 0 2 0 2 1 16.18 6.11 6.11 3.76 26.05 26.05 23.633 23.633
33622 33622 A 0 090 0 1 0 2 0 2 1 64.00 23.47 23.47 14.98 102.45 102.45 92.911 92.911
33641 33641 A 0 090 0 1 0 2 0 2 1 29.58 12.57 12.57 7.12 49.27 49.27 44.592 44.592
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
128 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33645 33645 A 0 090 0 1 0 2 0 2 1 31.30 13.14 13.14 7.82 52.26 52.26 47.190 47.190
33647 33647 A 0 090 0 1 0 2 0 2 1 33.00 13.58 13.58 8.25 54.83 54.83 49.510 49.510
33660 33660 A 0 090 0 1 0 2 0 2 1 31.83 13.22 13.22 7.96 53.01 53.01 47.865 47.865
33665 33665 A 0 090 0 1 0 2 0 2 1 34.85 14.17 14.17 8.74 57.76 57.76 52.146 52.146
33670 33670 A 0 090 0 1 0 2 0 2 1 36.63 13.71 13.71 9.17 59.51 59.51 53.737 53.737
33675 33675 A 0 090 0 1 0 2 0 2 1 35.95 14.55 14.55 8.98 59.48 59.48 53.712 53.712
33676 33676 A 0 090 0 1 0 2 0 2 1 36.95 17.68 17.68 9.36 63.99 63.99 57.722 57.722
33677 33677 A 0 090 0 1 0 2 0 2 1 38.45 15.40 15.40 9.75 63.60 63.60 57.378 57.378
33681 33681 A 0 090 0 1 0 2 0 2 1 32.34 15.16 15.16 7.80 55.30 55.30 50.033 50.033
33684 33684 A 0 090 0 1 0 2 0 2 1 34.37 14.07 14.07 8.60 57.04 57.04 51.503 51.503
33688 33688 A 0 090 0 1 0 2 0 2 1 34.75 13.40 13.40 8.70 56.85 56.85 51.333 51.333
33690 33690 A 0 090 0 1 0 2 0 2 1 20.36 10.89 10.89 4.76 36.01 36.01 32.629 32.629
33692 33692 A 0 090 0 1 0 2 0 2 1 36.15 16.66 16.66 9.11 61.92 61.92 55.875 55.875
33694 33694 A 0 090 0 1 0 2 0 2 1 35.57 17.08 17.08 8.90 61.55 61.55 55.563 55.563
33697 33697 A 0 090 0 1 0 2 0 2 1 37.57 15.73 15.73 8.19 61.49 61.49 55.979 55.979
33702 33702 A 0 090 0 1 0 2 0 2 1 27.24 12.71 12.71 6.81 46.76 46.76 42.215 42.215
33710 33710 A 0 090 0 1 0 2 0 2 0 37.50 17.87 17.87 8.78 64.15 64.15 58.139 58.139
33720 33720 A 0 090 0 1 0 2 0 2 1 27.26 12.71 12.71 6.38 46.35 46.35 42.010 42.010
33722 33722 A 0 090 0 1 0 2 0 2 1 29.21 12.55 12.55 7.29 49.05 49.05 44.293 44.293
33724 33724 A 0 090 0 1 0 2 0 2 1 27.63 11.94 11.94 6.45 46.02 46.02 41.725 41.725
33726 33726 A 0 090 0 1 0 2 0 2 1 37.12 17.75 17.75 9.28 64.15 64.15 57.913 57.913
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
129 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33730 33730 A 0 090 0 1 0 2 0 2 1 36.14 15.32 15.32 9.05 60.51 60.51 54.631 54.631
33732 33732 A 0 090 0 1 0 2 0 2 1 28.96 13.65 13.65 7.24 49.85 49.85 45.004 45.004
33735 33735 A 0 090 0 1 0 2 0 2 0 22.20 10.98 10.98 5.57 38.75 38.75 34.973 34.973
33736 33736 A 0 090 0 1 0 2 0 2 1 24.32 12.13 12.13 6.07 42.52 42.52 38.387 38.387
33737 33737 A 0 090 0 1 0 2 0 2 1 22.47 12.52 12.52 5.27 40.26 40.26 36.469 36.469
33750 33750 A 0 090 0 1 0 2 0 2 1 22.22 12.54 12.54 7.98 42.74 42.74 37.654 37.654
33755 33755 A 0 090 0 1 0 2 0 2 1 22.60 12.90 12.90 4.94 40.44 40.44 36.768 36.768
33762 33762 A 0 090 0 1 0 2 0 2 1 22.60 11.96 11.96 5.73 40.29 40.29 36.337 36.337
33764 33764 A 0 090 0 1 0 2 0 2 1 22.60 11.59 11.59 4.83 39.02 39.02 35.534 35.534
33766 33766 A 0 090 0 1 0 2 0 2 1 23.57 12.35 12.35 5.13 41.05 41.05 37.343 37.343
33767 33767 A 0 090 0 1 0 2 0 2 1 25.30 11.32 11.32 6.33 42.95 42.95 38.776 38.776
33768 33768 A 0 ZZZ 0 0 0 0 0 2 2 8.00 3.17 3.17 1.99 13.16 13.16 11.887 11.887
33770 33770 A 0 090 0 1 0 2 0 2 1 39.07 18.06 18.06 9.16 66.29 66.29 60.079 60.079
33771 33771 A 0 090 0 1 0 2 0 2 1 40.63 18.15 18.15 10.32 69.10 69.10 62.326 62.326
33774 33774 A 0 090 0 1 0 2 0 2 1 31.73 14.75 14.75 7.93 54.41 54.41 49.123 49.123
33775 33775 A 0 090 0 1 0 2 0 2 0 32.99 16.99 16.99 8.29 58.27 58.27 52.583 52.583
33776 33776 A 0 090 0 1 0 2 0 2 1 34.75 18.09 18.09 8.72 61.56 61.56 55.555 55.555
33777 33777 A 0 090 0 1 0 2 0 2 0 34.17 16.84 16.84 8.61 59.62 59.62 53.795 53.795
33778 33778 A 0 090 0 1 0 2 0 2 1 42.75 17.47 17.47 10.85 71.07 71.07 64.113 64.113
33779 33779 A 0 090 0 1 0 2 0 2 1 43.23 19.53 19.53 10.99 73.75 73.75 66.516 66.516
33780 33780 A 0 090 0 1 0 2 0 2 1 43.90 20.01 20.01 11.14 75.05 75.05 67.695 67.695
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
130 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33781 33781 A 0 090 0 1 0 2 0 2 0 43.21 19.20 19.20 10.99 73.40 73.40 66.199 66.199
33782 33782 A 0 090 0 1 0 2 0 2 1 60.08 22.14 22.14 14.07 96.29 96.29 87.320 87.320
33783 33783 A 0 090 0 1 0 2 0 2 1 65.08 23.71 23.71 15.24 104.03 104.03 94.342 94.342
33786 33786 A 0 090 0 1 0 2 0 2 1 41.87 16.24 16.24 10.60 68.71 68.71 61.997 61.997
33788 33788 A 0 090 0 1 0 2 0 2 1 27.42 14.60 14.60 6.87 48.89 48.89 44.124 44.124
33800 33800 A 0 090 0 1 0 2 0 2 2 17.28 5.98 5.98 4.31 27.57 27.57 24.904 24.904
33802 33802 A 0 090 0 1 0 2 0 2 1 18.37 11.83 11.83 4.60 34.80 34.80 31.399 31.399
33803 33803 A 0 090 0 1 0 2 0 2 1 20.31 9.36 9.36 5.08 34.75 34.75 31.372 31.372
33813 33813 A 0 090 0 1 0 2 0 2 1 21.36 12.07 12.07 5.01 38.44 38.44 34.819 34.819
33814 33814 A 0 090 0 1 0 2 0 2 1 26.57 12.89 12.89 6.64 46.10 46.10 41.618 41.618
33820 33820 A 0 090 0 1 0 2 0 2 0 16.69 8.46 8.46 4.18 29.33 29.33 26.473 26.473
33822 33822 A 0 090 0 1 0 2 0 2 1 17.71 9.85 9.85 4.45 32.01 32.01 28.883 28.883
33824 33824 A 0 090 0 1 0 2 0 2 1 20.23 10.41 10.41 4.74 35.38 35.38 32.057 32.057
33840 33840 A 0 090 0 1 0 2 0 2 1 21.34 10.80 10.80 5.34 37.48 37.48 33.831 33.831
33845 33845 A 0 090 0 1 0 2 0 2 1 22.93 11.70 11.70 5.73 40.36 40.36 36.433 36.433
33851 33851 A 0 090 0 1 0 2 0 2 1 21.98 11.05 11.05 5.48 38.51 38.51 34.769 34.769
33852 33852 A 0 090 0 1 0 2 0 2 0 24.41 11.77 11.77 6.10 42.28 42.28 38.170 38.170
33853 33853 A 0 090 0 1 0 2 0 2 1 32.51 14.71 14.71 8.14 55.36 55.36 49.977 49.977
33860 33860 A 0 090 0 1 0 2 0 2 1 59.46 22.89 22.89 14.25 96.60 96.60 87.468 87.468
33863 33863 A 0 090 0 1 0 2 0 2 1 58.79 21.73 21.73 14.07 94.59 94.59 85.662 85.662
33864 33864 A 0 090 0 1 0 2 0 2 1 60.08 22.21 22.21 14.32 96.61 96.61 87.514 87.514
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
131 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33870 33870 A 0 090 0 1 0 2 0 2 1 46.06 18.68 18.68 11.00 75.74 75.74 68.588 68.588
33875 33875 A 0 090 0 1 0 2 0 2 1 50.72 19.79 19.79 12.12 82.63 82.63 74.830 74.830
33877 33877 A 0 090 0 1 0 2 0 2 1 69.03 24.35 24.35 16.35 109.73 109.73 99.447 99.447
33880 33880 A 0 090 0 1 0 2 2 2 2 34.58 12.32 12.32 7.72 54.62 54.62 49.681 49.681
33881 33881 A 0 090 0 1 0 2 2 2 2 29.58 10.71 10.71 6.60 46.89 46.89 42.649 42.649
33883 33883 A 0 090 0 1 0 2 0 2 2 21.09 8.17 8.17 4.70 33.96 33.96 30.885 30.885
33884 33884 A 0 ZZZ 0 0 0 0 0 2 2 8.20 2.34 2.34 1.84 12.38 12.38 11.264 11.264
33886 33886 A 0 090 0 1 0 2 0 2 2 18.09 7.21 7.21 4.30 29.60 29.60 26.813 26.813
33889 33889 A 0 000 0 0 0 2 1 2 2 15.92 4.34 4.34 3.78 24.04 24.04 21.794 21.794
33891 33891 A 0 000 0 0 0 2 1 2 2 20.00 4.82 4.82 4.75 29.57 29.57 26.813 26.813
33910 33910 A 0 090 0 1 0 2 0 2 1 48.21 19.21 19.21 12.04 79.46 79.46 71.758 71.758
33915 33915 A 0 090 0 1 0 2 0 2 1 24.95 10.77 10.77 5.44 41.16 41.16 37.467 37.467
33916 33916 A 0 090 0 1 0 2 0 2 1 78.00 28.73 28.73 19.49 126.22 126.22 113.993 113.993
33917 33917 A 0 090 0 1 0 2 0 2 1 25.30 12.49 12.49 5.92 43.71 43.71 39.612 39.612
33920 33920 A 0 090 0 1 0 2 0 2 1 32.74 13.66 13.66 8.18 54.58 54.58 49.285 49.285
33922 33922 A 0 090 0 1 0 2 0 2 1 24.22 11.75 11.75 6.06 42.03 42.03 37.941 37.941
33924 33924 A 0 ZZZ 0 0 0 0 0 2 1 5.49 1.73 1.73 1.28 8.50 8.50 7.713 7.713
33925 33925 A 0 090 0 1 0 2 0 2 1 31.30 12.74 12.74 7.32 51.36 51.36 46.569 46.569
33926 33926 A 0 090 0 1 0 2 0 2 1 44.73 16.91 16.91 11.17 72.81 72.81 65.757 65.757
33930 33930 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
33933 33933 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
132 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33935 33935 R 0 090 0 1 0 2 0 2 1 91.78 35.39 35.39 22.94 150.11 150.11 135.558 135.558
33940 33940 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
33944 33944 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
33945 33945 R 0 090 0 1 0 2 0 2 1 89.50 34.81 34.81 21.34 145.65 145.65 131.920 131.920
33960 33960 A 0 000 0 0 0 0 0 2 1 19.33 6.43 6.43 3.82 29.58 29.58 27.102 27.102
33961 33961 A 0 ZZZ 0 0 0 0 0 1 1 10.91 3.87 3.87 1.66 16.44 16.44 15.253 15.253
33967 33967 A 0 000 0 0 0 2 0 0 0 4.84 1.74 1.74 1.08 7.66 7.66 6.967 6.967
33968 33968 A 0 000 0 0 0 0 0 1 0 0.64 0.22 0.22 0.14 1.00 1.00 0.911 0.911
33970 33970 A 0 000 0 0 0 2 0 2 1 6.74 2.26 2.26 1.57 10.57 10.57 9.591 9.591
33971 33971 A 0 090 0 1 0 2 0 1 0 11.99 6.66 6.66 2.80 21.45 21.45 19.435 19.435
33973 33973 A 0 000 0 0 0 2 0 2 1 9.75 3.36 3.36 2.26 15.37 15.37 13.949 13.949
33974 33974 A 0 090 0 1 0 2 0 1 0 15.03 8.41 8.41 3.77 27.21 27.21 24.554 24.554
33975 33975 A 0 XXX 0 0 0 2 0 2 0 25.00 8.63 8.63 5.95 39.58 39.58 35.862 35.862
33976 33976 A 0 XXX 0 0 0 2 2 2 0 30.75 9.67 9.67 7.68 48.10 48.10 43.450 43.450
33977 33977 A 0 XXX 0 0 0 2 0 2 0 20.86 8.09 8.09 4.96 33.91 33.91 30.719 30.719
33978 33978 A 0 XXX 0 0 0 2 2 2 0 25.00 9.24 9.24 6.26 40.50 40.50 36.572 36.572
33979 33979 A 0 XXX 0 0 0 2 0 2 0 37.50 12.00 12.00 8.98 58.48 58.48 52.973 52.973
33980 33980 A 0 XXX 0 0 0 2 0 2 0 33.50 12.02 12.02 8.08 53.60 53.60 48.520 48.520
33981 33981 A 0 XXX 0 0 0 2 0 2 0 16.11 5.09 5.09 4.02 25.22 25.22 22.783 22.783
33982 33982 A 0 XXX 0 0 0 2 0 2 0 37.86 14.98 14.98 9.07 61.91 61.91 56.056 56.056
33983 33983 A 0 XXX 0 0 0 2 0 2 0 44.54 14.00 14.00 10.67 69.21 69.21 62.692 62.692
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
133 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
33990 33990 A 0 XXX 0 0 0 2 0 2 0 8.15 2.96 2.96 1.82 12.93 12.93 11.760 11.760
33991 33991 A 0 XXX 0 0 0 2 0 2 0 11.88 4.31 4.31 2.65 18.84 18.84 17.136 17.136
33992 33992 A 0 XXX 0 0 0 2 0 2 0 4.00 1.26 1.26 0.89 6.15 6.15 5.597 5.597
33993 33993 A 0 XXX 0 0 0 2 0 2 0 3.51 1.11 1.11 0.78 5.40 5.40 4.915 4.915
33999 33999 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
34001 34001 A 0 090 0 1 0 2 1 2 1 17.88 7.66 7.66 4.07 29.61 29.61 26.887 26.887
34051 34051 A 0 090 0 1 0 2 1 2 1 16.99 8.95 8.95 4.25 30.19 30.19 27.250 27.250
34101 34101 A 0 090 0 1 0 2 1 2 1 10.93 5.06 5.06 2.46 18.45 18.45 16.760 16.760
34111 34111 A 0 090 0 1 0 2 1 2 1 10.93 5.09 5.09 2.44 18.46 18.46 16.777 16.777
34151 34151 A 0 090 0 1 0 2 1 2 1 26.52 10.41 10.41 5.97 42.90 42.90 38.990 38.990
34201 34201 A 0 090 0 1 0 2 1 2 1 19.48 7.73 7.73 4.48 31.69 31.69 28.765 28.765
34203 34203 A 0 090 0 1 0 2 1 2 1 17.86 7.43 7.43 4.11 29.40 29.40 26.682 26.682
34401 34401 A 0 090 0 1 0 2 1 2 1 26.52 11.79 11.79 5.66 43.97 43.97 40.068 40.068
34421 34421 A 0 090 0 1 0 2 1 2 1 13.37 6.01 6.01 2.97 22.35 22.35 20.320 20.320
34451 34451 A 0 090 0 1 0 2 1 2 1 28.52 14.73 14.73 6.78 50.03 50.03 45.293 45.293
34471 34471 A 0 090 0 1 0 2 1 1 1 21.11 7.08 7.08 4.50 32.69 32.69 29.821 29.821
34490 34490 A 0 090 0 1 0 2 1 1 0 10.91 5.61 5.61 2.42 18.94 18.94 17.213 17.213
34501 34501 A 0 090 0 1 0 2 1 2 1 16.85 6.72 6.72 4.00 27.57 27.57 24.977 24.977
34502 34502 A 0 090 0 1 0 2 0 2 0 28.07 12.29 12.29 5.89 46.25 46.25 42.187 42.187
34510 34510 A 0 090 0 1 0 2 1 2 1 19.91 11.34 11.34 4.23 35.48 35.48 32.306 32.306
34520 34520 A 0 090 0 1 0 2 1 2 1 19.18 6.73 6.73 4.55 30.46 30.46 27.603 27.603
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
134 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
34530 34530 A 0 090 0 1 0 2 1 2 1 17.93 6.76 6.76 3.82 28.51 28.51 25.998 25.998
34800 34800 A 0 090 0 1 0 2 0 2 2 21.54 8.09 8.09 4.57 34.20 34.20 31.195 31.195
34802 34802 A 0 090 0 1 0 2 0 2 2 23.79 8.99 8.99 5.09 37.87 37.87 34.525 34.525
34803 34803 A 0 090 0 1 0 2 2 2 2 24.82 8.95 8.95 5.34 39.11 39.11 35.650 35.650
34804 34804 A 0 090 0 1 0 2 0 2 2 23.79 8.96 8.96 5.14 37.89 37.89 34.524 34.524
34805 34805 A 0 090 0 1 0 2 0 2 2 22.67 8.58 8.58 5.04 36.29 36.29 33.011 33.011
34806 34806 A 0 ZZZ 0 0 0 0 0 2 2 2.06 0.58 0.58 0.45 3.09 3.09 2.816 2.816
34808 34808 A 0 ZZZ 0 0 0 0 0 2 2 4.12 1.23 1.23 0.90 6.25 6.25 5.695 5.695
34812 34812 A 0 000 0 0 0 2 1 2 2 6.74 1.95 1.95 1.55 10.24 10.24 9.302 9.302
34813 34813 A 0 ZZZ 0 0 0 0 0 2 2 4.79 1.33 1.33 1.10 7.22 7.22 6.560 6.560
34820 34820 A 0 000 0 0 0 2 1 2 2 9.74 2.95 2.95 2.18 14.87 14.87 13.529 13.529
34825 34825 A 0 090 0 1 0 2 0 2 2 12.80 5.71 5.71 2.75 21.26 21.26 19.366 19.366
34826 34826 A 0 ZZZ 0 0 0 0 0 2 2 4.12 1.20 1.20 0.88 6.20 6.20 5.658 5.658
34830 34830 A 0 090 0 1 0 2 0 2 2 35.23 10.58 10.58 8.36 54.17 54.17 49.103 49.103
34831 34831 A 0 090 0 1 0 2 0 2 2 37.98 11.24 11.24 9.02 58.24 58.24 52.791 52.791
34832 34832 A 0 090 0 1 0 2 0 2 2 37.98 11.24 11.24 9.02 58.24 58.24 52.791 52.791
34833 34833 A 0 000 0 0 0 2 1 2 2 11.98 3.76 3.76 2.79 18.53 18.53 16.816 16.816
34834 34834 A 0 000 0 0 0 2 1 2 2 5.34 1.79 1.79 1.24 8.37 8.37 7.596 7.596
34900 34900 A 0 090 0 1 0 2 1 2 2 16.85 6.73 6.73 3.58 27.16 27.16 24.766 24.766
35001 35001 A 0 090 0 1 0 2 1 2 1 20.81 9.16 9.16 4.82 34.79 34.79 31.557 31.557
35002 35002 A 0 090 0 1 0 2 1 2 1 22.23 7.44 7.44 4.75 34.42 34.42 31.395 31.395
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
135 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35005 35005 A 0 090 0 1 0 2 1 2 1 19.29 11.23 11.23 4.57 35.09 35.09 31.765 31.765
35011 35011 A 0 090 0 1 0 2 1 2 1 18.58 7.74 7.74 4.22 30.54 30.54 27.738 27.738
35013 35013 A 0 090 0 1 0 2 1 2 1 23.23 9.70 9.70 5.28 38.21 38.21 34.702 34.702
35021 35021 A 0 090 0 1 0 2 1 2 1 22.17 10.62 10.62 5.20 37.99 37.99 34.426 34.426
35022 35022 A 0 090 0 1 0 2 1 2 1 25.70 11.69 11.69 6.02 43.41 43.41 39.346 39.346
35045 35045 A 0 090 0 1 0 2 1 2 1 18.01 8.18 8.18 4.00 30.19 30.19 27.448 27.448
35081 35081 A 0 090 0 1 0 2 0 2 1 33.53 12.45 12.45 7.77 53.75 53.75 48.774 48.774
35082 35082 A 0 090 0 1 0 2 0 2 1 42.09 15.20 15.20 9.66 66.95 66.95 60.792 60.792
35091 35091 A 0 090 0 1 0 2 1 2 1 35.35 11.30 11.30 8.19 54.84 54.84 49.781 49.781
35092 35092 A 0 090 0 1 0 2 1 2 1 50.97 16.88 16.88 11.79 79.64 79.64 72.294 72.294
35102 35102 A 0 090 0 1 0 2 1 2 1 36.53 13.08 13.08 8.45 58.06 58.06 52.695 52.695
35103 35103 A 0 090 0 1 0 2 1 2 1 43.62 15.10 15.10 9.99 68.71 68.71 62.405 62.405
35111 35111 A 0 090 0 1 0 2 1 2 1 26.28 8.33 8.33 5.61 40.22 40.22 36.694 36.694
35112 35112 A 0 090 0 1 0 2 1 2 1 32.57 16.51 16.51 6.94 56.02 56.02 51.026 51.026
35121 35121 A 0 090 0 1 0 2 1 2 0 31.52 11.53 11.53 7.25 50.30 50.30 45.666 45.666
35122 35122 A 0 090 0 1 0 2 1 2 1 37.89 18.61 18.61 8.08 64.58 64.58 58.828 58.828
35131 35131 A 0 090 0 1 0 2 1 2 1 26.40 10.00 10.00 6.10 42.50 42.50 38.570 38.570
35132 35132 A 0 090 0 1 0 2 1 2 1 32.57 9.94 9.94 7.44 49.95 49.95 45.387 45.387
35141 35141 A 0 090 0 1 0 2 1 2 1 20.91 8.34 8.34 4.83 34.08 34.08 30.925 30.925
35142 35142 A 0 090 0 1 0 2 1 2 1 25.16 9.71 9.71 5.78 40.65 40.65 36.903 36.903
35151 35151 A 0 090 0 1 0 2 1 2 1 23.72 9.03 9.03 5.47 38.22 38.22 34.690 34.690
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
136 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35152 35152 A 0 090 0 1 0 2 1 2 1 27.66 8.75 8.75 6.57 42.98 42.98 38.954 38.954
35180 35180 A 0 090 0 1 0 2 0 2 1 15.10 9.14 9.14 3.58 27.82 27.82 25.180 25.180
35182 35182 A 0 090 0 1 0 2 0 2 1 31.71 14.30 14.30 6.76 52.77 52.77 48.087 48.087
35184 35184 A 0 090 0 1 0 2 0 2 1 18.82 9.10 9.10 4.01 31.93 31.93 29.089 29.089
35188 35188 A 0 090 0 1 0 2 0 2 1 18.00 6.00 6.00 3.85 27.85 27.85 25.402 25.402
35189 35189 A 0 090 0 1 0 2 0 2 1 29.98 9.32 9.32 7.50 46.80 46.80 42.272 42.272
35190 35190 A 0 090 0 1 0 2 0 2 1 13.42 6.72 6.72 3.06 23.20 23.20 21.055 21.055
35201 35201 A 0 090 0 1 0 2 1 2 1 16.93 8.07 8.07 3.76 28.76 28.76 26.143 26.143
35206 35206 A 0 090 0 1 0 2 1 2 1 13.84 6.81 6.81 3.06 23.71 23.71 21.556 21.556
35207 35207 A 0 090 0 1 0 2 1 1 1 10.94 9.56 9.56 1.93 22.43 22.43 20.534 20.534
35211 35211 A 0 090 0 1 0 2 1 2 1 24.58 11.11 11.11 5.91 41.60 41.60 37.648 37.648
35216 35216 A 0 090 0 1 0 2 1 2 1 36.61 16.31 16.31 8.64 61.56 61.56 55.775 55.775
35221 35221 A 0 090 0 1 0 2 1 2 1 26.62 11.23 11.23 5.83 43.68 43.68 39.754 39.754
35226 35226 A 0 090 0 1 0 2 1 2 1 15.30 6.78 6.78 3.52 25.60 25.60 23.229 23.229
35231 35231 A 0 090 0 1 0 2 1 2 1 21.16 11.08 11.08 4.16 36.40 36.40 33.286 33.286
35236 35236 A 0 090 0 1 0 2 1 2 1 18.02 8.05 8.05 3.99 30.06 30.06 27.336 27.336
35241 35241 A 0 090 0 1 0 2 1 2 1 25.58 11.66 11.66 6.30 43.54 43.54 39.346 39.346
35246 35246 A 0 090 0 1 0 2 1 2 1 28.23 9.02 9.02 6.70 43.95 43.95 39.834 39.834
35251 35251 A 0 090 0 1 0 2 1 2 1 31.91 12.54 12.54 7.00 51.45 51.45 46.832 46.832
35256 35256 A 0 090 0 1 0 2 1 2 1 19.06 7.81 7.81 4.36 31.23 31.23 28.354 28.354
35261 35261 A 0 090 0 1 0 2 1 2 1 18.96 8.45 8.45 4.64 32.05 32.05 28.975 28.975
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
137 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35266 35266 A 0 090 0 1 0 2 1 2 1 15.83 6.84 6.84 3.62 26.29 26.29 23.866 23.866
35271 35271 A 0 090 0 1 0 2 1 2 1 24.58 11.21 11.21 6.14 41.93 41.93 37.858 37.858
35276 35276 A 0 090 0 1 0 2 1 2 1 25.83 12.08 12.08 6.04 43.95 43.95 39.837 39.837
35281 35281 A 0 090 0 1 0 2 1 2 1 30.06 12.72 12.72 6.79 49.57 49.57 45.034 45.034
35286 35286 A 0 090 0 1 0 2 1 2 1 17.19 7.45 7.45 3.96 28.60 28.60 25.951 25.951
35301 35301 A 0 090 0 1 0 2 1 2 1 19.61 8.05 8.05 4.56 32.22 32.22 29.224 29.224
35302 35302 A 0 090 0 1 0 2 1 2 1 21.35 8.37 8.37 4.93 34.65 34.65 31.445 31.445
35303 35303 A 0 090 0 1 0 2 1 2 1 23.60 9.21 9.21 5.43 38.24 38.24 34.710 34.710
35304 35304 A 0 090 0 1 0 2 1 2 1 24.60 9.14 9.14 5.65 39.39 39.39 35.763 35.763
35305 35305 A 0 090 0 1 0 2 1 2 1 23.60 8.83 8.83 5.43 37.86 37.86 34.369 34.369
35306 35306 A 0 ZZZ 0 0 0 0 0 2 1 9.25 2.23 2.23 2.19 13.67 13.67 12.398 12.398
35311 35311 A 0 090 0 1 0 2 1 2 1 28.60 11.58 11.58 6.70 46.88 46.88 42.503 42.503
35321 35321 A 0 090 0 1 0 2 1 2 1 16.59 6.92 6.92 3.77 27.28 27.28 24.776 24.776
35331 35331 A 0 090 0 1 0 2 1 2 1 27.72 10.57 10.57 6.44 44.73 44.73 40.580 40.580
35341 35341 A 0 090 0 1 0 2 1 2 1 26.21 9.95 9.95 6.06 42.22 42.22 38.314 38.314
35351 35351 A 0 090 0 1 0 2 1 2 1 24.61 9.06 9.06 5.65 39.32 39.32 35.701 35.701
35355 35355 A 0 090 0 1 0 2 1 2 1 19.86 7.41 7.41 4.56 31.83 31.83 28.899 28.899
35361 35361 A 0 090 0 1 0 2 1 2 1 30.24 9.38 9.38 7.19 46.81 46.81 42.424 42.424
35363 35363 A 0 090 0 1 0 2 1 2 1 32.35 12.75 12.75 7.57 52.67 52.67 47.759 47.759
35371 35371 A 0 090 0 1 0 2 1 2 1 15.31 6.40 6.40 3.52 25.23 25.23 22.898 22.898
35372 35372 A 0 090 0 1 0 2 1 2 1 18.58 7.30 7.30 4.26 30.14 30.14 27.363 27.363
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
138 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35390 35390 A 0 ZZZ 0 0 0 0 0 2 1 3.19 0.94 0.94 0.73 4.86 4.86 4.416 4.416
35400 35400 A 0 ZZZ 0 0 0 0 0 0 1 3.00 0.86 0.86 0.68 4.54 4.54 4.128 4.128
35450 35450 A 0 000 0 0 0 2 1 2 1 10.05 3.26 3.26 2.25 15.56 15.56 14.154 14.154
35452 35452 A 0 000 0 0 0 2 1 2 1 6.90 2.42 2.42 1.58 10.90 10.90 9.900 9.900
35458 35458 A 0 000 0 0 0 2 1 2 1 9.48 3.32 3.32 2.14 14.94 14.94 13.581 13.581
35460 35460 A 0 000 0 0 0 2 1 1 1 6.03 2.21 2.21 1.32 9.56 9.56 8.705 8.705
35471 35471 A 0 000 0 0 0 2 1 1 0 10.05 66.08 3.63 1.99 78.12 15.67 70.431 14.351
35472 35472 A 0 000 0 0 0 2 1 0 1 6.90 50.69 2.46 1.44 59.03 10.80 53.173 9.862
35475 35475 R 0 000 0 0 0 2 1 1 0 5.75 41.47 2.22 0.92 48.14 8.89 43.471 8.225
35476 35476 A 0 000 0 0 0 2 1 1 0 4.71 39.06 2.18 0.65 44.42 7.54 40.126 7.008
35500 35500 A 0 ZZZ 0 0 0 0 0 2 1 6.44 1.84 1.84 1.50 9.78 9.78 8.877 8.877
35501 35501 A 0 090 0 1 0 2 1 2 1 29.09 10.45 10.45 6.70 46.24 46.24 41.978 41.978
35506 35506 A 0 090 0 1 0 2 1 2 1 25.33 9.75 9.75 6.02 41.10 41.10 37.234 37.234
35508 35508 A 0 090 0 1 0 2 1 2 1 26.09 8.64 8.64 6.52 41.25 41.25 37.259 37.259
35509 35509 A 0 090 0 1 0 2 1 2 1 28.09 8.75 8.75 6.67 43.51 43.51 39.436 39.436
35510 35510 A 0 090 0 1 0 2 1 2 1 24.39 7.68 7.68 5.78 37.85 37.85 34.310 34.310
35511 35511 A 0 090 0 1 0 2 1 2 1 22.20 11.67 11.67 5.28 39.15 39.15 35.441 35.441
35512 35512 A 0 090 0 1 0 2 1 2 1 23.89 7.56 7.56 5.68 37.13 37.13 33.650 33.650
35515 35515 A 0 090 0 1 0 2 1 2 1 26.09 8.64 8.64 6.19 40.92 40.92 37.086 37.086
35516 35516 A 0 090 0 1 0 2 1 2 1 24.21 7.60 7.60 5.74 37.55 37.55 34.037 34.037
35518 35518 A 0 090 0 1 0 2 1 2 1 22.65 11.84 11.84 5.38 39.87 39.87 36.096 36.096
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
139 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35521 35521 A 0 090 0 1 0 2 1 2 1 24.13 13.17 13.17 5.73 43.03 43.03 38.953 38.953
35522 35522 A 0 090 0 1 0 2 1 2 1 23.15 9.49 9.49 5.48 38.12 38.12 34.538 34.538
35523 35523 A 0 090 0 1 0 2 1 2 1 24.13 9.58 9.58 5.48 39.19 39.19 35.599 35.599
35525 35525 A 0 090 0 1 0 2 1 2 1 21.69 8.48 8.48 4.83 35.00 35.00 31.831 31.831
35526 35526 A 0 090 0 1 0 2 1 2 1 31.55 13.27 13.27 7.89 52.71 52.71 47.593 47.593
35531 35531 A 0 090 0 1 0 2 1 2 1 39.11 13.94 13.94 8.91 61.96 61.96 56.288 56.288
35533 35533 A 0 090 0 1 0 2 1 2 1 29.92 9.30 9.30 7.10 46.32 46.32 41.985 41.985
35535 35535 A 0 090 0 1 0 2 1 2 1 38.13 11.32 11.32 2.71 52.16 52.16 49.713 49.713
35536 35536 A 0 090 0 1 0 2 1 2 1 33.73 19.95 19.95 8.02 61.70 61.70 55.840 55.840
35537 35537 A 0 090 0 1 0 2 0 2 1 41.88 12.26 12.26 9.94 64.08 64.08 58.088 58.088
35538 35538 A 0 090 0 1 0 2 0 2 1 47.03 13.54 13.54 11.16 71.73 71.73 65.026 65.026
35539 35539 A 0 090 0 1 0 2 1 2 1 44.11 12.80 12.80 10.48 67.39 67.39 61.085 61.085
35540 35540 A 0 090 0 1 0 2 1 1 1 49.33 17.93 17.93 11.35 78.61 78.61 71.367 71.367
35556 35556 A 0 090 0 1 0 2 1 2 1 26.75 10.27 10.27 6.14 43.16 43.16 39.184 39.184
35558 35558 A 0 090 0 1 0 2 1 2 1 23.13 9.63 9.63 5.34 38.10 38.10 34.571 34.571
35560 35560 A 0 090 0 1 0 2 1 2 1 34.03 10.29 10.29 8.08 52.40 52.40 47.496 47.496
35563 35563 A 0 090 0 1 0 2 1 2 1 26.12 8.39 8.39 6.19 40.70 40.70 36.892 36.892
35565 35565 A 0 090 0 1 0 2 1 2 1 25.13 9.61 9.61 5.74 40.48 40.48 36.762 36.762
35566 35566 A 0 090 0 1 0 2 1 2 1 32.35 11.61 11.61 7.50 51.46 51.46 46.698 46.698
35570 35570 A 0 090 0 1 0 2 1 2 1 29.15 10.60 10.60 2.07 41.82 41.82 39.751 39.751
35571 35571 A 0 090 0 1 0 2 1 2 1 25.52 9.46 9.46 5.89 40.87 40.87 37.096 37.096
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
140 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35572 35572 A 0 ZZZ 0 0 0 0 0 2 0 6.81 2.12 2.12 1.59 10.52 10.52 9.545 9.545
35583 35583 A 0 090 0 1 0 2 1 2 1 27.75 10.28 10.28 6.36 44.39 44.39 40.308 40.308
35585 35585 A 0 090 0 1 0 2 1 2 1 32.35 11.86 11.86 7.40 51.61 51.61 46.870 46.870
35587 35587 A 0 090 0 1 0 2 1 2 1 26.21 9.75 9.75 6.04 42.00 42.00 38.124 38.124
35600 35600 A 0 ZZZ 0 0 0 0 0 2 1 4.94 1.58 1.58 1.20 7.72 7.72 6.986 6.986
35601 35601 A 0 090 0 1 0 2 1 2 1 27.09 9.94 9.94 6.34 43.37 43.37 39.332 39.332
35606 35606 A 0 090 0 1 0 2 1 2 1 22.46 8.46 8.46 5.25 36.17 36.17 32.803 32.803
35612 35612 A 0 090 0 1 0 2 1 2 1 20.35 6.99 6.99 4.84 32.18 32.18 29.158 29.158
35616 35616 A 0 090 0 1 0 2 1 2 1 21.82 6.92 6.92 4.65 33.39 33.39 30.466 30.466
35621 35621 A 0 090 0 1 0 2 1 2 1 21.03 7.91 7.91 4.87 33.81 33.81 30.680 30.680
35623 35623 A 0 090 0 1 0 2 1 2 1 25.92 8.34 8.34 6.14 40.40 40.40 36.621 36.621
35626 35626 A 0 090 0 1 0 2 1 2 1 29.14 11.84 11.84 6.98 47.96 47.96 43.423 43.423
35631 35631 A 0 090 0 1 0 2 1 2 1 36.03 12.15 12.15 8.42 56.60 56.60 51.344 51.344
35632 35632 A 0 090 0 1 0 2 1 2 1 36.13 10.84 10.84 2.57 49.54 49.54 47.208 47.208
35633 35633 A 0 090 0 1 0 2 1 2 1 39.11 13.31 13.31 2.78 55.20 55.20 52.516 52.516
35634 35634 A 0 090 0 1 0 2 1 2 1 35.33 10.65 10.65 2.50 48.48 48.48 46.201 46.201
35636 35636 A 0 090 0 1 0 2 1 2 1 31.75 9.74 9.74 7.54 49.03 49.03 44.440 44.440
35637 35637 A 0 090 0 1 0 2 0 2 1 33.05 12.51 12.51 7.65 53.21 53.21 48.285 48.285
35638 35638 A 0 090 0 1 0 2 0 2 1 33.60 12.77 12.77 7.83 54.20 54.20 49.163 49.163
35642 35642 A 0 090 0 1 0 2 1 2 1 18.94 6.99 6.99 4.49 30.42 30.42 27.565 27.565
35645 35645 A 0 090 0 1 0 2 1 2 1 18.43 10.57 10.57 4.61 33.61 33.61 30.333 30.333
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
141 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35646 35646 A 0 090 0 1 0 2 0 2 1 32.98 12.16 12.16 7.59 52.73 52.73 47.869 47.869
35647 35647 A 0 090 0 1 0 2 1 2 1 29.73 11.25 11.25 6.90 47.88 47.88 43.441 43.441
35650 35650 A 0 090 0 1 0 2 1 2 1 20.16 7.94 7.94 4.60 32.70 32.70 29.696 29.696
35654 35654 A 0 090 0 1 0 2 0 2 1 26.28 9.61 9.61 6.07 41.96 41.96 38.084 38.084
35656 35656 A 0 090 0 1 0 2 1 2 1 20.47 8.17 8.17 4.71 33.35 33.35 30.270 30.270
35661 35661 A 0 090 0 1 0 2 1 2 1 20.35 8.42 8.42 4.70 33.47 33.47 30.369 30.369
35663 35663 A 0 090 0 1 0 2 1 2 1 23.93 9.34 9.34 5.47 38.74 38.74 35.178 35.178
35665 35665 A 0 090 0 1 0 2 1 2 1 22.35 8.69 8.69 5.12 36.16 36.16 32.831 32.831
35666 35666 A 0 090 0 1 0 2 1 2 1 23.66 10.08 10.08 5.44 39.18 39.18 35.557 35.557
35671 35671 A 0 090 0 1 0 2 1 2 1 20.77 9.07 9.07 4.78 34.62 34.62 31.415 31.415
35681 35681 A 0 ZZZ 0 0 0 0 0 2 1 1.60 0.47 0.47 0.37 2.44 2.44 2.216 2.216
35682 35682 A 0 ZZZ 0 0 0 0 0 0 1 7.19 1.93 1.93 1.66 10.78 10.78 9.791 9.791
35683 35683 A 0 ZZZ 0 0 0 0 0 0 1 8.49 2.04 2.04 2.00 12.53 12.53 11.368 11.368
35685 35685 A 0 ZZZ 0 0 0 0 0 2 1 4.04 1.13 1.13 0.93 6.10 6.10 5.541 5.541
35686 35686 A 0 ZZZ 0 0 0 0 0 2 1 3.34 0.95 0.95 0.75 5.04 5.04 4.585 4.585
35691 35691 A 0 090 0 1 0 2 1 2 1 18.41 6.33 6.33 4.37 29.11 29.11 26.380 26.380
35693 35693 A 0 090 0 1 0 2 1 2 1 15.73 6.31 6.31 3.74 25.78 25.78 23.352 23.352
35694 35694 A 0 090 0 1 0 2 1 2 1 19.28 6.54 6.54 4.57 30.39 30.39 27.543 27.543
35695 35695 A 0 090 0 1 0 2 1 2 1 20.06 6.73 6.73 4.76 31.55 31.55 28.593 28.593
35697 35697 A 0 ZZZ 0 0 0 0 0 2 2 3.00 0.83 0.83 0.69 4.52 4.52 4.106 4.106
35700 35700 A 0 ZZZ 0 0 0 0 0 2 1 3.08 0.89 0.89 0.71 4.68 4.68 4.251 4.251
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
142 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
35701 35701 A 0 090 0 1 0 2 1 2 1 9.19 6.28 6.28 1.80 17.27 17.27 15.771 15.771
35721 35721 A 0 090 0 1 0 2 1 2 1 7.72 4.48 4.48 1.74 13.94 13.94 12.653 12.653
35741 35741 A 0 090 0 1 0 2 1 2 1 8.69 5.06 5.06 1.93 15.68 15.68 14.243 14.243
35761 35761 A 0 090 0 1 0 2 1 2 1 5.93 4.68 4.68 1.29 11.90 11.90 10.807 10.807
35800 35800 A 0 090 0 1 0 2 0 2 1 12.00 7.20 7.20 2.53 21.73 21.73 19.789 19.789
35820 35820 A 0 090 0 1 0 2 0 2 1 36.89 14.78 14.78 8.83 60.50 60.50 54.781 54.781
35840 35840 A 0 090 0 1 0 2 0 2 1 20.75 10.41 10.41 4.45 35.61 35.61 32.426 32.426
35860 35860 A 0 090 0 1 0 2 0 2 1 15.25 7.02 7.02 3.48 25.75 25.75 23.374 23.374
35870 35870 A 0 090 0 1 0 2 0 2 1 24.50 7.99 7.99 5.81 38.30 38.30 34.714 34.714
35875 35875 A 0 090 0 1 0 2 0 1 1 10.72 5.20 5.20 2.44 18.36 18.36 16.666 16.666
35876 35876 A 0 090 0 1 0 2 0 2 1 17.82 7.22 7.22 4.08 29.12 29.12 26.437 26.437
35879 35879 A 0 090 0 1 0 2 1 2 1 17.41 7.14 7.14 4.01 28.56 28.56 25.919 25.919
35881 35881 A 0 090 0 1 0 2 1 2 1 19.35 7.65 7.65 4.49 31.49 31.49 28.568 28.568
35883 35883 A 0 090 0 1 0 2 1 2 1 23.15 8.72 8.72 5.34 37.21 37.21 33.773 33.773
35884 35884 A 0 090 0 1 0 2 1 2 1 24.65 7.67 7.67 5.84 38.16 38.16 34.592 34.592
35901 35901 A 0 090 0 1 0 2 0 2 1 8.38 5.08 5.08 1.91 15.37 15.37 13.941 13.941
35903 35903 A 0 090 0 1 0 2 0 2 1 9.53 5.82 5.82 2.15 17.50 17.50 15.881 15.881
35905 35905 A 0 090 0 1 0 2 0 2 1 33.52 10.17 10.17 7.96 51.65 51.65 46.816 46.816
35907 35907 A 0 090 0 1 0 2 0 2 1 37.27 12.84 12.84 8.59 58.70 58.70 53.293 53.293
36000 36000 B 9 XXX 0 0 0 9 9 9 9 0.18 0.57 0.07 0.03 0.78 0.28 0.708 0.259
36002 36002 A 0 000 0 0 0 2 1 1 0 1.96 2.61 0.92 0.30 4.87 3.18 4.461 2.943
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
143 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
36005 36005 A 0 000 0 0 0 2 1 0 0 0.95 8.83 0.33 0.14 9.92 1.42 8.953 1.320
36010 36010 A 0 XXX 0 0 0 2 1 1 0 2.43 12.62 0.81 0.35 15.40 3.59 13.946 3.340
36011 36011 A 0 XXX 0 0 0 2 1 1 0 3.14 22.39 1.08 0.44 25.97 4.66 23.476 4.340
36012 36012 A 0 XXX 0 0 0 2 1 1 0 3.51 22.58 1.21 0.52 26.61 5.24 24.059 4.869
36013 36013 A 0 XXX 0 0 0 2 0 1 0 2.52 22.04 0.94 0.45 25.01 3.91 22.547 3.599
36014 36014 A 0 XXX 0 0 0 2 1 1 0 3.02 21.69 1.06 0.33 25.04 4.41 22.670 4.144
36015 36015 A 0 XXX 0 0 0 2 1 1 0 3.51 23.06 1.24 0.37 26.94 5.12 24.411 4.817
36100 36100 A 0 XXX 0 0 0 2 1 1 0 3.02 12.13 1.10 0.67 15.82 4.79 14.263 4.358
36120 36120 A 0 XXX 0 0 0 2 0 1 0 2.01 11.07 0.63 0.33 13.41 2.97 12.123 2.748
36140 36140 A 0 XXX 0 0 0 2 0 1 0 2.01 11.22 0.66 0.39 13.62 3.06 12.290 2.807
36147 36147 A 0 XXX 0 0 0 2 0 2 0 3.72 21.76 1.33 0.50 25.98 5.55 23.522 5.176
36148 36148 A 0 ZZZ 0 0 0 0 0 2 0 1.00 6.98 0.34 0.12 8.10 1.46 7.331 1.368
36160 36160 A 0 XXX 0 0 0 2 0 1 0 2.52 12.86 0.90 0.38 15.76 3.80 14.267 3.527
36200 36200 A 0 000 0 0 0 2 1 1 0 3.02 15.89 0.93 0.60 19.51 4.55 17.603 4.169
36215 36215 A 0 XXX 0 0 0 2 0 1 0 4.67 28.47 1.70 0.82 33.96 7.19 30.665 6.625
36216 36216 A 0 XXX 0 0 0 2 0 1 0 5.27 31.64 1.98 0.93 37.84 8.18 34.169 7.534
36217 36217 A 0 XXX 0 0 0 2 0 1 0 6.29 57.76 2.44 1.06 65.11 9.79 58.713 9.036
36218 36218 A 0 ZZZ 0 0 0 0 0 1 0 1.01 4.85 0.39 0.16 6.02 1.56 5.449 1.444
36221 36221 A 0 000 0 0 0 2 2 1 0 4.17 29.27 1.39 0.83 34.27 6.39 30.889 5.852
36222 36222 A 0 000 0 0 0 2 0 1 0 5.53 35.93 2.13 0.98 42.44 8.64 38.308 7.955
36223 36223 A 0 000 0 0 0 2 0 1 0 6.00 39.37 2.28 1.06 46.43 9.34 41.909 8.602
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
144 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
36224 36224 A 0 000 0 0 0 2 0 1 0 6.50 42.83 2.57 1.10 50.43 10.17 45.537 9.383
36225 36225 A 0 000 0 0 0 2 0 1 0 6.00 39.04 2.25 1.05 46.09 9.30 41.607 8.570
36226 36226 A 0 000 0 0 0 2 0 1 0 6.50 43.81 2.59 1.10 51.41 10.19 46.417 9.401
36227 36227 A 0 ZZZ 0 0 0 0 0 1 0 2.09 4.98 0.80 0.33 7.40 3.22 6.735 2.981
36228 36228 A 0 ZZZ 0 0 0 0 0 1 0 4.25 30.37 1.64 0.67 35.29 6.56 31.873 6.073
36245 36245 A 0 XXX 0 0 0 2 1 1 0 4.67 25.06 1.65 0.87 30.60 7.19 27.629 6.607
36246 36246 A 0 000 0 0 0 2 1 1 0 5.27 21.22 1.73 0.98 27.47 7.98 24.838 7.336
36247 36247 A 0 000 0 0 0 2 1 1 0 6.29 41.58 2.07 1.18 49.05 9.54 44.246 8.766
36248 36248 A 0 ZZZ 0 0 0 0 0 1 0 1.01 3.52 0.34 0.16 4.69 1.51 4.255 1.399
36251 36251 A 0 000 0 0 0 2 0 1 0 5.35 38.35 1.95 1.00 44.70 8.30 40.311 7.624
36252 36252 A 0 000 0 0 0 2 2 1 0 6.99 40.59 2.51 1.30 48.88 10.80 44.120 9.924
36253 36253 A 0 000 0 0 0 2 0 1 0 7.55 59.20 2.55 1.41 68.16 11.51 61.449 10.577
36254 36254 A 0 000 0 0 0 2 2 1 0 8.15 61.11 2.75 1.52 70.78 12.42 63.822 11.414
36260 36260 A 0 090 0 1 0 2 0 1 0 9.91 7.21 7.21 2.12 19.24 19.24 17.493 17.493
36261 36261 A 0 090 0 1 0 2 0 2 0 5.63 5.15 5.15 1.33 12.11 12.11 10.950 10.950
36262 36262 A 0 090 0 1 0 2 0 1 0 4.11 4.23 4.23 0.87 9.21 9.21 8.364 8.364
36299 36299 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
36400 36400 A 0 XXX 0 0 0 2 0 1 0 0.38 0.44 0.15 0.05 0.87 0.58 0.801 0.541
36405 36405 A 0 XXX 0 0 0 2 0 1 0 0.31 0.43 0.13 0.05 0.79 0.49 0.722 0.453
36406 36406 A 0 XXX 0 0 0 2 0 1 0 0.18 0.38 0.08 0.03 0.59 0.29 0.537 0.268
36410 36410 A 0 XXX 0 0 0 2 0 1 0 0.18 0.30 0.07 0.03 0.51 0.28 0.465 0.259
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
145 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
36416 36416 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
36420 36420 A 0 XXX 0 0 0 2 0 0 0 1.01 0.41 0.41 0.12 1.54 1.54 1.441 1.441
36425 36425 A 0 XXX 0 0 0 2 0 1 0 0.76 0.31 0.31 0.11 1.18 1.18 1.096 1.096
36430 36430 A 5 XXX 0 0 0 0 0 1 0 0.00 1.01 1.01 0.01 1.02 1.02 0.912 0.912
36440 36440 A 0 XXX 0 0 0 2 0 0 0 1.03 0.47 0.47 0.24 1.74 1.74 1.578 1.578
36450 36450 A 0 XXX 0 0 0 2 0 0 0 2.23 0.81 0.81 0.11 3.15 3.15 3.015 3.015
36455 36455 A 0 XXX 0 0 0 2 0 1 0 2.43 0.76 0.76 0.14 3.33 3.33 3.186 3.186
36460 36460 A 0 XXX 0 0 0 2 0 2 0 6.58 2.81 2.81 1.40 10.79 10.79 9.836 9.836
36468 36468 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
36469 36469 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
36470 36470 A 0 010 0 1 0 2 1 1 0 1.10 3.36 1.27 0.22 4.68 2.59 4.232 2.356
36471 36471 A 0 010 0 1 0 2 1 1 0 1.65 3.35 1.06 0.33 5.33 3.04 4.831 2.774
36475 36475 A 0 000 0 0 0 2 1 1 0 6.72 45.13 2.47 1.42 53.27 10.61 47.989 9.681
36476 36476 A 0 ZZZ 0 0 0 0 1 1 0 3.38 7.74 1.11 0.72 11.84 5.21 10.707 4.753
36478 36478 A 0 000 0 0 0 2 1 1 0 6.72 33.68 2.47 1.32 41.72 10.51 37.655 9.628
36479 36479 A 0 ZZZ 0 0 0 0 1 1 0 3.38 7.99 1.15 0.65 12.02 5.18 10.895 4.753
36481 36481 A 0 000 0 0 0 2 0 1 0 6.98 56.55 2.73 0.88 64.41 10.59 58.222 9.892
36500 36500 A 0 000 0 0 0 2 0 1 0 3.51 1.27 1.27 0.53 5.31 5.31 4.928 4.928
36510 36510 A 0 000 0 0 0 2 0 0 0 1.09 1.54 0.46 0.24 2.87 1.79 2.598 1.629
36511 36511 A 0 000 0 0 0 2 0 1 0 1.74 0.83 0.83 0.27 2.84 2.84 2.627 2.627
36512 36512 A 0 000 0 0 0 2 0 1 0 1.74 0.84 0.84 0.16 2.74 2.74 2.578 2.578
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
146 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
36513 36513 A 0 000 0 0 0 2 0 1 0 1.74 0.84 0.84 0.34 2.92 2.92 2.672 2.672
36514 36514 A 0 000 0 0 0 2 0 1 0 1.74 14.21 0.77 0.27 16.22 2.78 14.642 2.573
36515 36515 A 0 000 0 0 0 2 0 1 0 1.74 63.62 0.60 0.24 65.60 2.58 58.996 2.404
36516 36516 A 0 000 0 0 0 2 0 1 0 1.22 62.41 0.53 0.35 63.98 2.10 57.447 1.879
36522 36522 A 0 000 0 0 0 2 0 1 0 1.67 40.98 1.21 0.16 42.81 3.04 38.554 2.840
36555 36555 A 0 000 0 0 0 0 0 1 0 2.68 4.89 0.56 0.22 7.79 3.46 7.186 3.298
36556 36556 A 0 000 0 0 0 0 0 1 0 2.50 4.27 0.76 0.31 7.08 3.57 6.497 3.345
36557 36557 A 0 010 0 1 0 2 1 0 0 5.14 17.46 2.90 1.09 23.69 9.13 21.389 8.314
36558 36558 A 0 010 0 1 0 2 1 0 0 4.84 18.52 2.76 0.72 24.08 8.32 21.848 7.695
36560 36560 A 0 010 0 1 0 2 1 0 0 6.29 35.56 4.04 0.59 42.44 10.92 38.531 10.226
36561 36561 A 0 010 0 1 0 2 1 0 0 6.04 29.67 3.52 1.10 36.81 10.66 33.259 9.776
36563 36563 A 0 010 0 1 0 2 0 0 0 6.24 34.34 3.84 1.31 41.89 11.39 37.762 10.373
36565 36565 A 0 010 0 1 0 2 1 0 0 6.04 23.70 3.22 1.29 31.03 10.55 27.997 9.606
36566 36566 A 0 010 0 1 0 2 1 0 0 6.54 165.47 3.70 1.27 173.28 11.51 155.796 10.527
36568 36568 A 0 000 0 0 0 0 0 1 0 1.92 6.76 0.74 0.18 8.86 2.84 8.085 2.679
36569 36569 A 0 000 0 0 0 0 0 1 0 1.82 5.44 0.68 0.18 7.44 2.68 6.799 2.525
36570 36570 A 0 010 0 1 0 2 1 0 0 5.36 30.66 3.34 0.49 36.51 9.19 33.149 8.616
36571 36571 A 0 010 0 1 0 2 1 0 0 5.34 34.12 3.31 1.02 40.48 9.67 36.513 8.846
36575 36575 A 0 000 0 0 0 2 0 0 0 0.67 4.43 0.28 0.10 5.20 1.05 4.700 0.974
36576 36576 A 0 010 0 1 0 2 0 0 0 3.24 8.02 2.07 0.56 11.82 5.87 10.735 5.392
36578 36578 A 0 010 0 1 0 2 0 0 0 3.54 11.95 2.42 0.53 16.02 6.49 14.548 5.990
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
147 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
36580 36580 A 0 000 0 0 0 0 0 1 0 1.31 5.07 0.51 0.16 6.54 1.98 5.947 1.852
36581 36581 A 0 010 0 1 0 2 0 0 0 3.48 19.70 1.96 0.44 23.62 5.88 21.401 5.470
36582 36582 A 0 010 0 1 0 2 0 0 0 5.24 28.13 3.04 0.88 34.25 9.16 30.961 8.430
36583 36583 A 0 010 0 1 0 2 0 0 0 5.29 36.58 3.66 1.14 43.01 10.09 38.735 9.173
36584 36584 A 0 000 0 0 0 0 0 1 0 1.20 4.82 0.64 0.11 6.13 1.95 5.586 1.832
36585 36585 A 0 010 0 1 0 2 0 0 0 4.84 31.94 3.04 0.67 37.45 8.55 33.873 7.920
36589 36589 A 0 010 0 1 0 2 0 0 0 2.28 2.35 1.54 0.37 5.00 4.19 4.584 3.856
36590 36590 A 0 010 0 1 0 2 0 0 0 3.35 4.94 2.19 0.63 8.92 6.17 8.116 5.646
36591 36591 T 3 XXX 0 0 0 0 0 0 0 0.00 0.69 0.69 0.01 0.70 0.70 0.625 0.625
36592 36592 T 3 XXX 0 0 0 0 0 0 0 0.00 0.80 0.80 0.01 0.81 0.81 0.724 0.724
36593 36593 A 3 XXX 0 0 0 0 0 0 0 0.00 0.92 0.92 0.01 0.93 0.93 0.831 0.831
36595 36595 A 0 000 0 0 0 2 0 1 0 3.59 13.28 1.48 0.39 17.26 5.46 15.719 5.123
36596 36596 A 0 000 0 0 0 2 0 1 0 0.75 3.24 0.49 0.10 4.09 1.34 3.712 1.242
36597 36597 A 0 000 0 0 0 2 0 1 0 1.21 2.45 0.47 0.11 3.77 1.79 3.468 1.690
36598 36598 T 9 000 0 0 0 2 1 0 0 0.74 2.50 0.26 0.07 3.31 1.07 3.022 1.010
36600 36600 A 0 XXX 0 0 0 2 0 1 0 0.32 0.59 0.11 0.03 0.94 0.46 0.866 0.434
36620 36620 A 0 000 0 0 0 0 0 1 0 1.15 0.24 0.24 0.10 1.49 1.49 1.418 1.418
36625 36625 A 0 000 0 0 0 0 0 1 0 2.11 0.61 0.61 0.42 3.14 3.14 2.877 2.877
36640 36640 A 0 000 0 0 0 2 0 1 0 2.10 1.39 1.39 0.42 3.91 3.91 3.568 3.568
36660 36660 A 0 000 0 0 0 2 0 0 0 1.40 0.44 0.44 0.34 2.18 2.18 1.973 1.973
36680 36680 A 0 000 0 0 0 2 0 0 0 1.20 0.34 0.34 0.22 1.76 1.76 1.620 1.620
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
148 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
36800 36800 A 0 000 0 0 0 2 0 1 0 2.43 2.09 2.09 0.42 4.94 4.94 4.526 4.526
36810 36810 A 0 000 0 0 0 2 0 1 0 3.96 1.72 1.72 0.73 6.41 6.41 5.886 5.886
36815 36815 A 0 000 0 0 0 2 0 1 0 2.62 1.32 1.32 0.56 4.50 4.50 4.098 4.098
36818 36818 A 0 090 0 1 0 2 0 2 1 11.89 5.91 5.91 2.65 20.45 20.45 18.583 18.583
36819 36819 A 0 090 0 1 0 2 0 2 1 13.29 6.19 6.19 2.98 22.46 22.46 20.407 20.407
36820 36820 A 0 090 0 1 0 2 1 2 1 14.47 6.87 6.87 3.24 24.58 24.58 22.334 22.334
36821 36821 A 0 090 0 1 0 2 0 2 1 12.11 6.33 6.33 2.71 21.15 21.15 19.212 19.212
36822 36822 A 0 090 0 1 0 2 0 1 0 5.57 4.87 4.87 1.29 11.73 11.73 10.618 10.618
36823 36823 A 0 090 0 1 0 2 0 1 0 22.98 12.03 12.03 5.01 40.02 40.02 36.403 36.403
36825 36825 A 0 090 0 1 0 2 0 2 1 14.17 6.91 6.91 3.17 24.25 24.25 22.033 22.033
36830 36830 A 0 090 0 1 0 2 0 2 1 12.03 5.24 5.24 2.71 19.98 19.98 18.153 18.153
36831 36831 A 0 090 0 1 0 2 0 2 1 8.04 4.04 4.04 1.80 13.88 13.88 12.609 12.609
36832 36832 A 0 090 0 1 0 2 0 2 1 10.53 4.76 4.76 2.34 17.63 17.63 16.028 16.028
36833 36833 A 0 090 0 1 0 2 0 2 1 11.98 5.26 5.26 2.69 19.93 19.93 18.110 18.110
36835 36835 A 0 090 0 1 0 2 0 1 0 7.51 3.57 3.57 1.78 12.86 12.86 11.647 11.647
36838 36838 A 0 090 0 1 0 2 1 2 1 21.69 8.43 8.43 4.94 35.06 35.06 31.844 31.844
36860 36860 A 0 000 0 0 0 2 0 1 0 2.01 4.02 1.03 0.26 6.29 3.30 5.756 3.071
36861 36861 A 0 000 0 0 0 2 0 1 0 2.52 1.78 1.78 0.48 4.78 4.78 4.369 4.369
36870 36870 A 0 090 0 1 0 2 1 1 2 5.20 51.38 3.16 0.68 57.26 9.04 51.695 8.393
37140 37140 A 0 090 0 1 0 2 0 1 1 40.00 19.65 19.65 8.53 68.18 68.18 62.107 62.107
37145 37145 A 0 090 0 1 0 2 0 2 0 37.00 18.36 18.36 8.07 63.43 63.43 57.708 57.708
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
149 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
37160 37160 A 0 090 0 1 0 2 0 2 1 38.00 18.86 18.86 8.13 64.99 64.99 59.188 59.188
37180 37180 A 0 090 0 1 0 2 0 2 1 36.50 18.23 18.23 7.80 62.53 62.53 56.950 56.950
37181 37181 A 0 090 0 1 0 2 0 2 1 40.00 19.65 19.65 8.52 68.17 68.17 62.102 62.102
37182 37182 A 0 000 0 0 0 2 0 0 0 16.97 6.09 6.09 1.62 24.68 24.68 23.286 23.286
37183 37183 A 0 000 0 0 0 2 0 0 0 7.99 172.52 2.89 0.73 181.24 11.61 163.295 10.967
37184 37184 A 0 000 0 0 0 2 1 1 2 8.66 60.41 3.39 1.51 70.58 13.56 63.698 12.494
37185 37185 A 0 ZZZ 0 0 0 0 2 1 2 3.28 18.60 1.08 0.61 22.49 4.97 20.302 4.569
37186 37186 A 0 ZZZ 0 0 0 0 2 1 2 4.92 37.56 1.66 0.95 43.43 7.53 39.146 6.908
37187 37187 A 0 000 0 0 0 2 1 1 2 8.03 56.07 2.94 1.13 65.23 12.10 58.972 11.261
37188 37188 A 0 000 0 0 0 2 1 1 2 5.71 48.31 2.20 0.69 54.71 8.60 49.453 8.046
37191 37191 A 0 000 0 0 0 2 0 1 0 4.71 76.78 1.68 0.69 82.18 7.08 74.019 6.580
37192 37192 A 0 000 0 0 0 2 0 1 0 7.35 45.16 2.46 1.08 53.59 10.89 48.469 10.124
37193 37193 A 0 000 0 0 0 2 0 1 0 7.35 42.74 2.48 1.08 51.17 10.91 46.295 10.142
37195 37195 C 5 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
37197 37197 A 0 000 0 0 0 2 0 1 0 6.29 39.71 2.16 0.57 46.57 9.02 42.248 8.528
37200 37200 A 0 000 0 0 0 2 0 1 0 4.55 1.55 1.55 0.42 6.52 6.52 6.162 6.162
37202 37202 A 0 000 0 0 0 2 0 1 0 5.67 2.94 2.94 1.18 9.79 9.79 8.927 8.927
37204 37204 A 0 000 0 0 0 2 0 1 0 18.11 6.05 6.05 2.22 26.38 26.38 24.704 24.704
37205 37205 A 0 000 0 0 0 2 0 0 0 8.27 124.29 2.80 1.57 134.13 12.64 120.704 11.606
37206 37206 A 0 ZZZ 0 0 0 0 0 0 0 4.12 74.38 1.35 0.82 79.32 6.29 71.342 5.761
37207 37207 A 0 000 0 0 0 2 1 2 2 8.27 2.81 2.81 1.86 12.94 12.94 11.766 11.766
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
150 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
37208 37208 A 0 ZZZ 0 0 0 0 0 2 2 4.12 1.15 1.15 0.93 6.20 6.20 5.639 5.639
37210 37210 A 0 000 0 0 0 2 0 1 0 10.60 99.69 3.85 1.02 111.31 15.47 100.655 14.591
37211 37211 A 0 000 0 0 0 2 0 1 0 8.00 2.56 2.56 1.39 11.95 11.95 11.026 11.026
37212 37212 A 0 000 0 0 0 2 0 1 0 7.06 2.26 2.26 1.23 10.55 10.55 9.733 9.733
37213 37213 A 0 000 0 0 0 2 0 1 0 5.00 1.50 1.50 0.87 7.37 7.37 6.802 6.802
37214 37214 A 0 000 0 0 0 2 0 1 0 2.74 1.11 1.11 0.48 4.33 4.33 3.988 3.988
37215 37215 R 0 090 0 1 0 2 1 0 0 19.68 8.42 8.42 4.19 32.29 32.29 29.433 29.433
37216 37216 N 9 090 0 1 0 9 9 9 9 18.95 9.69 9.69 1.33 29.97 29.97 28.347 28.347
37220 37220 A 0 000 0 0 0 2 1 1 0 8.15 90.85 2.65 1.67 100.67 12.47 90.607 11.403
37221 37221 A 0 000 0 0 0 2 1 0 0 10.00 135.36 3.29 1.89 147.25 15.18 132.542 13.943
37222 37222 A 0 ZZZ 0 0 0 0 1 0 0 3.73 23.83 1.13 0.76 28.32 5.62 25.527 5.142
37223 37223 A 0 ZZZ 0 0 0 0 1 0 0 4.25 77.08 1.34 0.84 82.17 6.43 73.907 5.893
37224 37224 A 0 000 0 0 0 2 1 0 0 9.00 110.44 2.95 1.81 121.25 13.76 109.122 12.596
37225 37225 A 0 000 0 0 0 2 1 0 0 12.00 333.59 4.07 2.52 348.11 18.59 312.882 16.973
37226 37226 A 0 000 0 0 0 2 1 0 0 10.49 274.30 3.45 1.29 286.08 15.23 257.486 14.263
37227 37227 A 0 000 0 0 0 2 1 0 0 14.50 452.78 4.87 3.05 470.33 22.42 422.692 20.468
37228 37228 A 0 000 0 0 0 2 1 0 0 11.00 159.64 3.54 2.26 172.90 16.80 155.539 15.361
37229 37229 A 0 000 0 0 0 2 1 0 0 14.05 325.83 4.67 2.98 342.86 21.70 308.204 19.802
37230 37230 A 0 000 0 0 0 2 1 0 0 13.80 244.93 4.61 2.61 261.34 21.02 235.112 19.305
37231 37231 A 0 000 0 0 0 2 1 0 0 15.00 399.37 5.02 2.84 417.21 22.86 375.120 20.993
37232 37232 A 0 ZZZ 0 0 0 0 1 0 0 4.00 33.54 1.27 0.82 38.36 6.09 34.548 5.569
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
151 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
37233 37233 A 0 ZZZ 0 0 0 0 1 0 0 6.50 38.01 2.07 1.37 45.88 9.94 41.349 9.075
37234 37234 A 0 ZZZ 0 0 0 0 1 0 0 5.50 117.54 1.81 1.09 124.13 8.40 111.621 7.695
37235 37235 A 0 ZZZ 0 0 0 0 1 0 0 7.80 117.25 2.26 1.55 126.60 11.61 113.901 10.640
37250 37250 A 0 ZZZ 0 0 0 0 0 0 1 2.10 0.65 0.65 0.45 3.20 3.20 2.919 2.919
37251 37251 A 0 ZZZ 0 0 0 0 0 0 1 1.60 0.45 0.45 0.35 2.40 2.40 2.187 2.187
37500 37500 A 0 090 0 1 0 2 1 1 1 11.67 5.28 5.28 2.63 19.58 19.58 17.787 17.787
37501 37501 C 0 YYY 0 0 0 2 1 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
37565 37565 A 0 090 0 1 0 2 1 0 1 12.05 8.49 8.49 2.57 23.11 23.11 21.018 21.018
37600 37600 A 0 090 0 1 0 2 0 2 1 12.42 6.37 6.37 2.55 21.34 21.34 19.474 19.474
37605 37605 A 0 090 0 1 0 2 0 2 1 14.28 6.88 6.88 3.39 24.55 24.55 22.231 22.231
37606 37606 A 0 090 0 1 0 2 0 2 0 8.81 6.65 6.65 1.88 17.34 17.34 15.765 15.765
37607 37607 A 0 090 0 1 0 2 0 1 1 6.25 3.93 3.93 1.37 11.55 11.55 10.496 10.496
37609 37609 A 0 010 0 1 0 2 1 1 0 3.05 5.94 2.65 0.64 9.63 6.34 8.719 5.764
37615 37615 A 0 090 0 1 0 2 0 2 1 7.80 6.12 6.12 1.65 15.57 15.57 14.159 14.159
37616 37616 A 0 090 0 1 0 2 0 2 1 18.97 9.72 9.72 4.06 32.75 32.75 29.822 29.822
37617 37617 A 0 090 0 1 0 2 0 2 1 23.79 11.38 11.38 5.02 40.19 40.19 36.635 36.635
37618 37618 A 0 090 0 1 0 2 0 2 1 6.03 4.45 4.45 1.32 11.80 11.80 10.716 10.716
37619 37619 A 0 090 0 1 0 2 0 2 0 30.00 13.95 13.95 6.89 50.84 50.84 46.131 46.131
37650 37650 A 0 090 0 1 0 2 1 1 1 8.49 3.71 3.71 1.88 14.08 14.08 12.805 12.805
37660 37660 A 0 090 0 1 0 2 1 2 1 22.28 7.04 7.04 4.75 34.07 34.07 31.086 31.086
37700 37700 A 0 090 0 1 0 2 1 1 0 3.82 3.05 3.05 0.84 7.71 7.71 6.998 6.998
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
152 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
37718 37718 A 0 090 0 1 0 2 1 1 1 7.13 4.74 4.74 1.57 13.44 13.44 12.208 12.208
37722 37722 A 0 090 0 1 0 2 1 1 1 8.16 4.75 4.75 1.81 14.72 14.72 13.372 13.372
37735 37735 A 0 090 0 1 0 2 1 1 1 10.90 6.21 6.21 2.40 19.51 19.51 17.732 17.732
37760 37760 A 0 090 0 1 0 2 1 1 1 10.78 5.40 5.40 2.29 18.47 18.47 16.827 16.827
37761 37761 A 0 090 0 1 0 2 1 2 1 9.13 5.63 5.63 1.96 16.72 16.72 15.211 15.211
37765 37765 A 0 090 0 1 0 2 1 1 1 7.71 10.94 4.41 1.57 20.22 13.69 18.355 12.491
37766 37766 A 0 090 0 1 0 2 1 1 1 9.66 12.37 5.17 2.01 24.04 16.84 21.819 15.354
37780 37780 A 0 090 0 1 0 2 1 1 1 3.93 2.99 2.99 0.86 7.78 7.78 7.065 7.065
37785 37785 A 0 090 0 1 0 2 1 1 0 3.93 6.23 3.26 0.86 11.02 8.05 9.974 7.307
37788 37788 A 0 090 0 1 0 2 0 2 1 23.33 13.19 13.19 4.98 41.50 41.50 37.779 37.779
37790 37790 A 0 090 0 1 0 2 0 0 0 8.43 4.86 4.86 0.82 14.11 14.11 13.223 13.223
37799 37799 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
38100 38100 A 0 090 0 1 0 2 0 2 1 19.55 10.38 10.38 4.08 34.01 34.01 31.005 31.005
38101 38101 A 0 090 0 1 0 2 0 2 1 19.55 10.63 10.63 4.16 34.34 34.34 31.271 31.271
38102 38102 A 0 ZZZ 0 0 0 0 0 2 1 4.79 1.89 1.89 0.99 7.67 7.67 7.005 7.005
38115 38115 A 0 090 0 1 0 2 0 2 1 21.88 11.31 11.31 4.29 37.48 37.48 34.280 34.280
38120 38120 A 0 090 0 1 0 2 0 2 1 17.07 10.47 10.47 3.61 31.15 31.15 28.360 28.360
38129 38129 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
38200 38200 A 0 000 0 0 0 2 0 0 0 2.64 0.96 0.96 0.63 4.23 4.23 3.832 3.832
38204 38204 B 9 XXX 0 0 0 9 9 9 9 2.00 0.81 0.81 0.14 2.95 2.95 2.801 2.801
38205 38205 R 0 000 0 0 0 2 0 0 0 1.50 0.78 0.78 0.08 2.36 2.36 2.242 2.242
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
153 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
38206 38206 R 0 000 0 0 0 2 0 0 0 1.50 0.80 0.80 0.11 2.41 2.41 2.276 2.276
38207 38207 I 9 XXX 0 0 0 9 9 9 9 0.89 0.36 0.36 0.05 1.30 1.30 1.239 1.239
38208 38208 I 9 XXX 0 0 0 9 9 9 9 0.56 0.23 0.23 0.04 0.83 0.83 0.787 0.787
38209 38209 I 9 XXX 0 0 0 9 9 9 9 0.24 0.10 0.10 0.01 0.35 0.35 0.335 0.335
38210 38210 I 9 XXX 0 0 0 9 9 9 9 1.57 0.64 0.64 0.10 2.31 2.31 2.197 2.197
38211 38211 I 9 XXX 0 0 0 9 9 9 9 1.42 0.58 0.58 0.10 2.10 2.10 1.993 1.993
38212 38212 I 9 XXX 0 0 0 9 9 9 9 0.94 0.38 0.38 0.05 1.37 1.37 1.307 1.307
38213 38213 I 9 XXX 0 0 0 9 9 9 9 0.24 0.10 0.10 0.01 0.35 0.35 0.335 0.335
38214 38214 I 9 XXX 0 0 0 9 9 9 9 0.81 0.33 0.33 0.05 1.19 1.19 1.132 1.132
38215 38215 I 9 XXX 0 0 0 9 9 9 9 0.94 0.38 0.38 0.05 1.37 1.37 1.307 1.307
38220 38220 A 0 XXX 0 0 0 2 1 0 0 1.08 3.66 0.57 0.11 4.85 1.76 4.424 1.649
38221 38221 A 0 XXX 0 0 0 2 1 0 0 1.37 3.48 0.72 0.08 4.93 2.17 4.537 2.058
38230 38230 A 0 000 0 0 0 2 0 0 0 3.50 1.83 1.83 0.79 6.12 6.12 5.557 5.557
38232 38232 A 0 000 0 0 0 2 0 0 0 3.50 1.83 1.83 0.79 6.12 6.12 5.557 5.557
38240 38240 R 0 XXX 0 0 0 2 0 0 0 3.00 1.65 1.65 0.21 4.86 4.86 4.592 4.592
38241 38241 R 0 XXX 0 0 0 2 0 0 0 3.00 1.64 1.64 0.19 4.83 4.83 4.572 4.572
38242 38242 A 0 000 0 0 0 2 0 0 0 2.11 1.15 1.15 0.12 3.38 3.38 3.205 3.205
38243 38243 A 0 000 0 0 0 2 0 0 0 2.13 1.17 1.17 0.12 3.42 3.42 3.243 3.243
38300 38300 A 0 010 0 1 0 2 0 1 0 2.36 5.84 2.84 0.41 8.61 5.61 7.819 5.125
38305 38305 A 0 090 0 1 0 2 0 1 0 6.68 5.84 5.84 1.33 13.85 13.85 12.620 12.620
38308 38308 A 0 090 0 1 0 2 0 2 1 6.81 5.21 5.21 1.46 13.48 13.48 12.252 12.252
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
154 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
38380 38380 A 0 090 0 1 0 2 0 2 1 8.46 7.60 7.60 1.09 17.15 17.15 15.855 15.855
38381 38381 A 0 090 0 1 0 2 0 2 1 13.38 7.45 7.45 3.14 23.97 23.97 21.712 21.712
38382 38382 A 0 090 0 1 0 2 0 2 1 10.65 7.11 7.11 2.26 20.02 20.02 18.217 18.217
38500 38500 A 0 010 0 1 0 2 1 1 0 3.79 5.43 2.99 0.78 10.00 7.56 9.074 6.883
38505 38505 A 0 000 0 0 0 2 1 1 0 1.14 2.53 0.86 0.12 3.79 2.12 3.475 1.975
38510 38510 A 0 010 0 1 0 2 1 1 0 6.74 7.70 4.56 1.21 15.65 12.51 14.287 11.468
38520 38520 A 0 090 0 1 0 2 1 1 0 7.03 5.43 5.43 1.42 13.88 13.88 12.649 12.649
38525 38525 A 0 090 0 1 0 2 1 1 0 6.43 5.20 5.20 1.36 12.99 12.99 11.811 11.811
38530 38530 A 0 090 0 1 0 2 1 2 1 8.34 6.25 6.25 1.82 16.41 16.41 14.904 14.904
38542 38542 A 0 090 0 1 0 2 1 2 1 7.95 6.21 6.21 1.33 15.49 15.49 14.222 14.222
38550 38550 A 0 090 0 1 0 2 0 0 0 7.11 6.57 6.57 1.52 15.20 15.20 13.805 13.805
38555 38555 A 0 090 0 1 0 2 0 2 1 15.59 9.20 9.20 3.35 28.14 28.14 25.604 25.604
38562 38562 A 0 090 0 1 0 2 2 2 1 11.06 7.68 7.68 1.96 20.70 20.70 18.982 18.982
38564 38564 A 0 090 0 1 0 2 0 2 1 11.38 7.07 7.07 2.25 20.70 20.70 18.906 18.906
38570 38570 A 0 010 0 1 0 3 0 2 2 9.34 4.88 4.88 1.37 15.59 15.59 14.439 14.439
38571 38571 A 0 010 0 1 0 2 2 2 2 14.76 6.57 6.57 1.48 22.81 22.81 21.434 21.434
38572 38572 A 0 010 0 1 0 2 2 2 2 16.94 8.64 8.64 2.40 27.98 27.98 25.954 25.954
38589 38589 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
38700 38700 A 0 090 0 1 0 2 1 2 1 12.81 9.52 9.52 1.77 24.10 24.10 22.285 22.285
38720 38720 A 0 090 0 1 0 2 1 2 1 21.95 14.75 14.75 3.39 40.09 40.09 36.968 36.968
38724 38724 A 0 090 0 1 0 2 1 2 1 23.95 16.06 16.06 3.35 43.36 43.36 40.124 40.124
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
155 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
38740 38740 A 0 090 0 1 0 2 1 2 1 10.70 7.57 7.57 2.26 20.53 20.53 18.680 18.680
38745 38745 A 0 090 0 1 0 2 1 2 1 13.87 9.14 9.14 2.95 25.96 25.96 23.621 23.621
38746 38746 A 0 ZZZ 0 0 0 0 0 2 1 4.12 1.34 1.34 0.96 6.42 6.42 5.825 5.825
38747 38747 A 0 ZZZ 0 0 0 0 0 2 1 4.88 1.90 1.90 1.03 7.81 7.81 7.125 7.125
38760 38760 A 0 090 0 1 0 2 1 2 1 13.62 8.50 8.50 2.79 24.91 24.91 22.712 22.712
38765 38765 A 0 090 0 1 0 2 1 2 1 21.91 11.79 11.79 4.23 37.93 37.93 34.710 34.710
38770 38770 A 0 090 0 1 0 2 1 2 1 14.06 7.57 7.57 1.77 23.40 23.40 21.784 21.784
38780 38780 A 0 090 0 1 0 2 0 2 1 17.70 9.76 9.76 2.56 30.02 30.02 27.803 27.803
38790 38790 A 0 000 0 0 0 2 1 1 0 1.29 0.94 0.94 0.24 2.47 2.47 2.260 2.260
38792 38792 A 0 000 0 0 0 2 1 1 0 0.52 0.61 0.61 0.08 1.21 1.21 1.110 1.110
38794 38794 A 0 090 0 1 0 2 0 0 0 4.62 3.66 3.66 0.42 8.70 8.70 8.126 8.126
38900 38900 A 0 ZZZ 0 0 0 0 1 2 1 2.50 1.00 1.00 0.53 4.03 4.03 3.675 3.675
38999 38999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
39000 39000 A 0 090 0 1 0 2 0 2 1 7.57 5.79 5.79 1.67 15.03 15.03 13.643 13.643
39010 39010 A 0 090 0 1 0 2 0 2 1 13.19 7.44 7.44 3.13 23.76 23.76 21.508 21.508
39200 39200 A 0 090 0 1 0 2 0 2 1 15.09 7.55 7.55 3.54 26.18 26.18 23.721 23.721
39220 39220 A 0 090 0 1 0 2 0 2 1 19.55 10.17 10.17 4.44 34.16 34.16 31.005 31.005
39400 39400 A 0 010 0 1 0 2 0 1 0 8.05 5.34 5.34 1.88 15.27 15.27 13.829 13.829
39499 39499 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
39501 39501 A 0 090 0 1 0 2 0 2 1 13.98 8.32 8.32 2.95 25.25 25.25 22.994 22.994
39503 39503 A 0 090 0 1 0 2 0 2 1 108.91 48.38 48.38 23.23 180.52 180.52 164.505 164.505
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
156 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
39540 39540 A 0 090 0 1 0 2 0 2 1 14.57 8.02 8.02 3.12 25.71 25.71 23.404 23.404
39541 39541 A 0 090 0 1 0 2 0 2 1 15.75 8.76 8.76 3.40 27.91 27.91 25.395 25.395
39545 39545 A 0 090 0 1 0 2 0 2 1 14.67 8.71 8.71 3.42 26.80 26.80 24.280 24.280
39560 39560 A 0 090 0 1 0 2 0 2 1 13.06 7.63 7.63 2.79 23.48 23.48 21.371 21.371
39561 39561 A 0 090 0 1 0 2 0 2 1 19.99 12.79 12.79 4.38 37.16 37.16 33.766 33.766
39599 39599 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
40490 40490 A 0 000 0 0 0 2 0 1 0 1.22 2.52 0.79 0.18 3.92 2.19 3.577 2.024
40500 40500 A 0 090 0 1 0 2 0 1 0 4.47 10.42 5.94 0.67 15.56 11.08 14.178 10.155
40510 40510 A 0 090 0 1 0 2 0 1 0 4.82 9.21 5.21 0.71 14.74 10.74 13.462 9.870
40520 40520 A 0 090 0 1 0 2 0 1 0 4.79 9.45 5.33 0.75 14.99 10.87 13.668 9.969
40525 40525 A 0 090 0 1 0 2 0 1 0 7.72 7.74 7.74 1.27 16.73 16.73 15.335 15.335
40527 40527 A 0 090 0 1 0 2 0 0 0 9.32 8.10 8.10 1.20 18.62 18.62 17.221 17.221
40530 40530 A 0 090 0 1 0 2 0 1 0 5.54 10.09 5.83 0.86 16.49 12.23 15.051 11.225
40650 40650 A 0 090 0 1 0 2 0 0 0 3.78 9.21 4.75 0.65 13.64 9.18 12.391 8.385
40652 40652 A 0 090 0 1 0 2 0 0 0 4.43 9.93 5.53 0.76 15.12 10.72 13.745 9.793
40654 40654 A 0 090 0 1 0 2 0 1 0 5.48 11.02 6.49 0.93 17.43 12.90 15.862 11.794
40700 40700 A 0 090 0 1 0 2 0 0 0 14.17 13.56 13.56 1.82 29.55 29.55 27.299 27.299
40701 40701 A 0 090 0 1 0 2 2 2 0 17.23 12.80 12.80 2.20 32.23 32.23 29.875 29.875
40702 40702 A 0 090 0 1 0 2 2 2 0 14.27 13.25 13.25 1.02 28.54 28.54 26.702 26.702
40720 40720 A 0 090 0 1 0 2 1 0 0 14.72 13.54 13.54 2.91 31.17 31.17 28.401 28.401
40761 40761 A 0 090 0 1 0 2 0 1 0 15.84 13.88 13.88 3.13 32.85 32.85 29.941 29.941
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
157 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
40799 40799 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
40800 40800 A 0 010 0 1 0 2 0 1 0 1.23 5.19 2.66 0.18 6.60 4.07 5.985 3.713
40801 40801 A 0 010 0 1 0 2 0 1 0 2.63 6.70 3.76 0.37 9.70 6.76 8.840 6.200
40804 40804 A 0 010 0 1 0 2 0 0 0 1.30 5.30 2.65 0.16 6.76 4.11 6.143 3.763
40805 40805 A 0 010 0 1 0 2 0 0 0 2.79 9.09 4.17 0.35 12.23 7.31 11.136 6.718
40806 40806 A 0 000 0 0 0 2 0 0 0 0.31 3.23 0.61 0.04 3.58 0.96 3.231 0.879
40808 40808 A 0 010 0 1 0 2 0 1 0 1.01 4.72 2.21 0.12 5.85 3.34 5.311 3.057
40810 40810 A 0 010 0 1 0 2 0 1 0 1.36 4.91 2.40 0.18 6.45 3.94 5.863 3.609
40812 40812 A 0 010 0 1 0 2 0 1 0 2.37 6.20 3.32 0.31 8.88 6.00 8.100 5.513
40814 40814 A 0 090 0 1 0 2 0 1 0 3.52 7.84 5.32 0.48 11.84 9.32 10.811 8.548
40816 40816 A 0 090 0 1 0 2 0 1 0 3.77 8.11 5.41 0.52 12.40 9.70 11.325 8.900
40818 40818 A 0 090 0 1 0 2 0 0 0 2.83 7.64 5.02 0.37 10.84 8.22 9.884 7.531
40819 40819 A 0 090 0 1 0 2 0 0 0 2.51 6.72 4.38 0.33 9.56 7.22 8.717 6.616
40820 40820 A 0 010 0 1 0 2 0 1 0 1.34 6.86 3.88 0.18 8.38 5.40 7.594 4.918
40830 40830 A 0 010 0 1 0 2 0 0 0 1.82 6.19 3.03 0.31 8.32 5.16 7.541 4.703
40831 40831 A 0 010 0 1 0 2 0 0 0 2.57 7.54 3.94 0.42 10.53 6.93 9.561 6.328
40840 40840 R 0 090 0 1 0 2 0 2 0 9.15 14.24 8.51 1.18 24.57 18.84 22.555 17.409
40842 40842 R 0 090 0 1 0 2 0 0 0 9.15 14.15 8.95 1.18 24.48 19.28 22.474 17.804
40843 40843 R 0 090 0 1 0 2 2 2 0 12.79 17.97 10.88 2.52 33.28 26.19 30.245 23.878
40844 40844 R 0 090 0 1 0 2 0 2 0 16.80 20.56 12.74 3.32 40.68 32.86 36.999 29.977
40845 40845 R 0 090 0 1 0 2 0 0 0 19.36 22.34 14.84 2.48 44.18 36.68 40.718 33.983
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
158 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
40899 40899 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
41000 41000 A 0 010 0 1 0 2 0 1 0 1.35 3.47 1.88 0.18 5.00 3.41 4.560 3.132
41005 41005 A 0 010 0 1 0 2 0 0 0 1.31 5.75 2.43 0.16 7.22 3.90 6.557 3.576
41006 41006 A 0 090 0 1 0 2 0 0 0 3.34 7.33 4.25 0.42 11.09 8.01 10.142 7.376
41007 41007 A 0 090 0 1 0 2 0 0 0 3.20 7.33 3.87 0.41 10.94 7.48 9.997 6.890
41008 41008 A 0 090 0 1 0 2 0 0 0 3.46 7.66 4.22 0.44 11.56 8.12 10.569 7.480
41009 41009 A 0 090 0 1 0 2 0 0 0 3.71 8.08 4.66 0.48 12.27 8.85 11.217 8.146
41010 41010 A 0 010 0 1 0 2 0 0 0 1.11 5.20 2.13 0.14 6.45 3.38 5.853 3.096
41015 41015 A 0 090 0 1 0 2 0 0 0 4.08 9.11 5.93 0.52 13.71 10.53 12.533 9.677
41016 41016 A 0 090 0 1 0 2 0 0 0 4.19 8.53 5.98 0.53 13.25 10.70 12.127 9.837
41017 41017 A 0 090 0 1 0 2 0 0 0 4.19 8.80 5.96 0.53 13.52 10.68 12.370 9.819
41018 41018 A 0 090 0 1 0 2 0 0 0 5.22 9.77 6.66 0.67 15.66 12.55 14.344 11.551
41019 41019 A 0 000 0 0 0 2 0 0 1 8.84 3.92 3.92 0.72 13.48 13.48 12.737 12.737
41100 41100 A 0 010 0 1 0 2 0 1 0 1.42 3.60 1.67 0.20 5.22 3.29 4.757 3.024
41105 41105 A 0 010 0 1 0 2 0 1 0 1.47 3.62 1.73 0.20 5.29 3.40 4.825 3.128
41108 41108 A 0 010 0 1 0 2 0 1 0 1.10 3.37 1.53 0.14 4.61 2.77 4.199 2.547
41110 41110 A 0 010 0 1 0 2 0 1 0 1.56 4.88 2.29 0.22 6.66 4.07 6.057 3.731
41112 41112 A 0 090 0 1 0 2 0 1 0 2.83 7.14 4.56 0.37 10.34 7.76 9.435 7.118
41113 41113 A 0 090 0 1 0 2 0 1 0 3.29 7.54 4.84 0.42 11.25 8.55 10.281 7.856
41114 41114 A 0 090 0 1 0 2 0 0 0 8.82 9.16 9.16 1.17 19.15 19.15 17.658 17.658
41115 41115 A 0 010 0 1 0 2 0 0 0 1.79 5.77 2.47 0.23 7.79 4.49 7.092 4.128
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
159 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
41116 41116 A 0 090 0 1 0 2 0 1 0 2.52 7.45 3.92 0.34 10.31 6.78 9.388 6.218
41120 41120 A 0 090 0 1 0 2 0 2 1 11.14 19.49 19.49 1.48 32.11 32.11 29.416 29.416
41130 41130 A 0 090 0 1 0 2 0 2 1 15.74 21.75 21.75 2.08 39.57 39.57 36.359 36.359
41135 41135 A 0 090 0 1 0 2 0 2 1 30.14 30.68 30.68 4.04 64.86 64.86 59.804 59.804
41140 41140 A 0 090 0 1 0 2 0 2 1 29.15 32.96 32.96 3.76 65.87 65.87 60.715 60.715
41145 41145 A 0 090 0 1 0 2 0 2 1 37.93 40.35 40.35 4.87 83.15 83.15 76.711 76.711
41150 41150 A 0 090 0 1 0 2 0 2 1 29.86 32.19 32.19 3.96 66.01 66.01 60.838 60.838
41153 41153 A 0 090 0 1 0 2 0 2 1 33.59 33.57 33.57 4.41 71.57 71.57 66.042 66.042
41155 41155 A 0 090 0 1 0 2 0 2 1 44.30 39.52 39.52 5.92 89.74 89.74 82.885 82.885
41250 41250 A 0 010 0 1 0 2 0 0 0 1.96 6.08 2.49 0.33 8.37 4.78 7.592 4.369
41251 41251 A 0 010 0 1 0 2 0 0 0 2.32 6.55 2.99 0.30 9.17 5.61 8.359 5.162
41252 41252 A 0 010 0 1 0 2 0 0 0 3.02 6.27 2.91 0.48 9.77 6.41 8.902 5.884
41500 41500 A 0 090 0 1 0 2 0 0 0 3.80 9.94 9.94 0.49 14.23 14.23 12.982 12.982
41510 41510 A 0 090 0 1 0 2 0 0 0 3.51 9.58 9.58 0.44 13.53 13.53 12.343 12.343
41512 41512 A 0 090 0 1 0 2 0 0 0 6.86 11.79 11.79 0.49 19.14 19.14 17.704 17.704
41520 41520 A 0 090 0 1 0 2 0 0 0 2.83 7.63 4.63 0.35 10.81 7.81 9.865 7.171
41530 41530 A 0 010 0 1 0 2 0 0 0 4.51 98.70 7.63 0.31 103.52 12.45 93.305 11.524
41599 41599 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
41800 41800 A 0 010 0 1 0 2 0 1 0 1.27 7.11 3.13 0.22 8.60 4.62 7.770 4.196
41805 41805 A 0 010 0 1 0 2 0 0 0 1.34 6.17 3.76 0.18 7.69 5.28 6.975 4.811
41806 41806 A 0 010 0 1 0 2 0 0 0 2.79 7.72 4.77 0.54 11.05 8.10 10.005 7.356
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
160 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
41820 41820 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
41821 41821 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
41822 41822 R 0 010 0 1 0 2 0 0 0 2.41 6.20 2.80 0.31 8.92 5.52 8.140 5.087
41823 41823 R 0 090 0 1 0 2 0 0 0 3.77 8.84 5.58 0.48 13.09 9.83 11.959 9.032
41825 41825 A 0 010 0 1 0 2 0 1 0 1.41 4.99 2.13 0.20 6.60 3.74 5.996 3.427
41826 41826 A 0 010 0 1 0 2 0 1 0 2.41 6.97 3.75 0.31 9.69 6.47 8.831 5.940
41827 41827 A 0 090 0 1 0 2 0 1 0 3.83 9.22 5.00 0.49 13.54 9.32 12.366 8.576
41828 41828 R 0 010 0 1 0 2 0 0 0 3.14 5.77 2.84 0.39 9.30 6.37 8.525 5.894
41830 41830 R 0 010 0 1 0 2 0 0 0 3.45 8.12 4.71 0.44 12.01 8.60 10.972 7.910
41850 41850 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
41870 41870 R 0 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
41872 41872 R 0 090 0 1 0 2 0 0 0 3.01 8.16 4.59 0.60 11.77 8.20 10.651 7.446
41874 41874 R 0 090 0 1 0 2 0 0 0 3.19 7.84 4.13 0.39 11.42 7.71 10.434 7.103
41899 41899 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
42000 42000 A 0 010 0 1 0 2 0 0 0 1.28 4.82 2.08 0.16 6.26 3.52 5.692 3.232
42100 42100 A 0 010 0 1 0 2 0 1 0 1.36 3.10 1.81 0.18 4.64 3.35 4.238 3.080
42104 42104 A 0 010 0 1 0 2 0 1 0 1.69 4.80 2.36 0.23 6.72 4.28 6.121 3.930
42106 42106 A 0 010 0 1 0 2 0 1 0 2.15 6.01 3.00 0.29 8.45 5.44 7.699 4.996
42107 42107 A 0 090 0 1 0 2 0 1 0 4.56 9.07 5.39 0.59 14.22 10.54 13.013 9.709
42120 42120 A 0 090 0 1 0 2 0 2 1 11.86 16.93 16.93 1.57 30.36 30.36 27.884 27.884
42140 42140 A 0 090 0 1 0 2 0 1 0 1.70 6.08 2.89 0.23 8.01 4.82 7.280 4.416
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
161 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
42145 42145 A 0 090 0 1 0 2 0 1 0 9.78 10.40 10.40 1.25 21.43 21.43 19.773 19.773
42160 42160 A 0 010 0 1 0 2 0 0 0 1.85 5.13 2.41 0.24 7.22 4.50 6.582 4.140
42180 42180 A 0 010 0 1 0 2 0 0 0 2.55 4.67 2.72 0.33 7.55 5.60 6.916 5.165
42182 42182 A 0 010 0 1 0 2 0 0 0 3.87 5.45 3.38 0.49 9.81 7.74 9.020 7.162
42200 42200 A 0 090 0 1 0 2 0 2 0 12.53 11.58 11.58 1.61 25.72 25.72 23.771 23.771
42205 42205 A 0 090 0 1 0 2 0 2 0 13.66 11.34 11.34 1.77 26.77 26.77 24.769 24.769
42210 42210 A 0 090 0 1 0 2 0 2 0 15.03 12.85 12.85 2.97 30.85 30.85 28.123 28.123
42215 42215 A 0 090 0 1 0 2 0 2 0 8.99 11.28 11.28 1.78 22.05 22.05 20.050 20.050
42220 42220 A 0 090 0 1 0 2 0 2 0 7.16 8.10 8.10 0.50 15.76 15.76 14.695 14.695
42225 42225 A 0 090 0 1 0 2 0 2 0 9.77 15.90 15.90 1.25 26.92 26.92 24.702 24.702
42226 42226 A 0 090 0 1 0 2 0 2 0 10.35 15.65 15.65 1.32 27.32 27.32 25.094 25.094
42227 42227 A 0 090 0 1 0 2 0 2 0 9.90 14.44 14.44 1.27 25.61 25.61 23.531 23.531
42235 42235 A 0 090 0 1 0 2 0 2 0 8.01 13.50 13.50 1.03 22.54 22.54 20.672 20.672
42260 42260 A 0 090 0 1 0 2 0 2 0 10.22 14.08 9.65 1.31 25.61 21.18 23.549 19.571
42280 42280 A 0 010 0 1 0 2 0 0 0 1.59 3.19 1.47 0.34 5.12 3.40 4.632 3.088
42281 42281 A 0 010 0 1 0 2 0 0 0 1.98 4.14 2.39 0.26 6.38 4.63 5.834 4.262
42299 42299 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
42300 42300 A 0 010 0 1 0 2 0 1 0 1.98 4.24 2.42 0.27 6.49 4.67 5.929 4.294
42305 42305 A 0 090 0 1 0 2 0 0 0 6.31 5.78 5.78 0.86 12.95 12.95 11.950 11.950
42310 42310 A 0 010 0 1 0 2 0 0 0 1.61 3.23 2.04 0.22 5.06 3.87 4.626 3.557
42320 42320 A 0 010 0 1 0 2 0 0 0 2.40 5.05 2.65 0.31 7.76 5.36 7.097 4.942
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
162 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
42330 42330 A 0 010 0 1 0 2 0 1 0 2.26 4.63 2.46 0.30 7.19 5.02 6.575 4.626
42335 42335 A 0 090 0 1 0 2 0 1 0 3.41 7.79 4.02 0.42 11.62 7.85 10.625 7.240
42340 42340 A 0 090 0 1 0 2 1 0 0 4.72 9.06 4.89 0.61 14.39 10.22 13.175 9.430
42400 42400 A 0 000 0 0 0 2 0 1 0 0.78 2.43 0.80 0.08 3.29 1.66 3.004 1.540
42405 42405 A 0 010 0 1 0 2 0 1 0 3.34 5.36 3.05 0.42 9.12 6.81 8.373 6.299
42408 42408 A 0 090 0 1 0 2 0 0 0 4.66 8.74 4.65 0.60 14.00 9.91 12.822 9.150
42409 42409 A 0 090 0 1 0 2 0 2 0 2.91 7.13 3.52 0.37 10.41 6.80 9.506 6.264
42410 42410 A 0 090 0 1 0 2 1 2 1 9.57 7.75 7.75 1.44 18.76 18.76 17.283 17.283
42415 42415 A 0 090 0 1 0 2 1 2 1 17.16 12.22 12.22 2.29 31.67 31.67 29.331 29.331
42420 42420 A 0 090 0 1 0 2 1 2 1 19.53 13.37 13.37 2.63 35.53 35.53 32.912 32.912
42425 42425 A 0 090 0 1 0 2 1 2 1 13.42 9.86 9.86 1.84 25.12 25.12 23.237 23.237
42426 42426 A 0 090 0 1 0 2 1 2 1 22.66 14.61 14.61 3.12 40.39 40.39 37.412 37.412
42440 42440 A 0 090 0 1 0 2 1 2 1 6.14 5.49 5.49 0.82 12.45 12.45 11.499 11.499
42450 42450 A 0 090 0 1 0 2 0 0 0 4.74 8.60 5.57 0.64 13.98 10.95 12.798 10.077
42500 42500 A 0 090 0 1 0 2 0 0 0 4.42 8.37 5.46 0.60 13.39 10.48 12.250 9.637
42505 42505 A 0 090 0 1 0 2 0 1 0 6.32 9.96 6.68 0.80 17.08 13.80 15.682 12.737
42507 42507 A 0 090 0 1 0 2 2 2 0 6.25 8.69 8.69 0.80 15.74 15.74 14.472 14.472
42508 42508 A 0 090 0 1 0 2 2 2 0 9.33 11.22 11.22 1.20 21.75 21.75 20.033 20.033
42509 42509 A 0 090 0 1 0 2 2 0 0 11.76 10.47 10.47 2.30 24.53 24.53 22.365 22.365
42510 42510 A 0 090 0 1 0 2 2 2 1 8.35 9.74 9.74 1.08 19.17 19.17 17.661 17.661
42550 42550 A 0 000 0 0 0 2 0 1 0 1.25 2.61 0.46 0.11 3.97 1.82 3.651 1.721
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
163 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
42600 42600 A 0 090 0 1 0 2 0 0 0 4.94 9.25 5.00 0.64 14.83 10.58 13.581 9.765
42650 42650 A 0 000 0 0 0 2 0 1 0 0.77 1.72 0.93 0.10 2.59 1.80 2.367 1.657
42660 42660 A 0 000 0 0 0 2 0 0 0 1.13 2.49 1.25 0.14 3.76 2.52 3.439 2.326
42665 42665 A 0 090 0 1 0 2 0 0 0 2.63 6.85 3.38 0.34 9.82 6.35 8.959 5.843
42699 42699 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
42700 42700 A 0 010 0 1 0 2 0 1 0 1.67 4.01 2.28 0.23 5.91 4.18 5.391 3.838
42720 42720 A 0 010 0 1 0 2 0 0 0 6.31 6.64 4.66 0.83 13.78 11.80 12.707 10.929
42725 42725 A 0 090 0 1 0 2 0 2 1 12.41 10.39 10.39 1.59 24.39 24.39 22.572 22.572
42800 42800 A 0 010 0 1 0 2 0 1 0 1.44 3.31 1.80 0.20 4.95 3.44 4.517 3.161
42802 42802 A 0 010 0 1 0 2 0 1 0 1.59 5.43 2.29 0.22 7.24 4.10 6.581 3.761
42804 42804 A 0 010 0 1 0 2 0 1 0 1.29 4.71 2.03 0.16 6.16 3.48 5.603 3.197
42806 42806 A 0 010 0 1 0 2 0 1 0 1.63 5.04 2.20 0.22 6.89 4.05 6.271 3.721
42808 42808 A 0 010 0 1 0 2 0 1 0 2.35 4.37 2.27 0.30 7.02 4.92 6.431 4.545
42809 42809 A 0 010 0 1 0 2 0 1 0 1.86 3.19 1.92 0.27 5.32 4.05 4.866 3.725
42810 42810 A 0 090 0 1 0 2 1 2 0 3.38 8.31 5.11 0.42 12.11 8.91 11.062 8.188
42815 42815 A 0 090 0 1 0 2 1 2 1 7.31 8.73 8.73 1.01 17.05 17.05 15.678 15.678
42820 42820 A 0 090 0 1 0 2 0 0 0 4.22 4.03 4.03 0.53 8.78 8.78 8.116 8.116
42821 42821 A 0 090 0 1 0 2 0 0 0 4.36 4.21 4.21 0.56 9.13 9.13 8.433 8.433
42825 42825 A 0 090 0 1 0 2 0 0 0 3.51 4.03 4.03 0.44 7.98 7.98 7.359 7.359
42826 42826 A 0 090 0 1 0 2 0 1 0 3.45 3.75 3.75 0.44 7.64 7.64 7.048 7.048
42830 42830 A 0 090 0 1 0 2 0 0 0 2.65 3.36 3.36 0.34 6.35 6.35 5.845 5.845
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
164 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
42831 42831 A 0 090 0 1 0 2 0 0 0 2.81 3.68 3.68 0.35 6.84 6.84 6.298 6.298
42835 42835 A 0 090 0 1 0 2 0 0 0 2.38 3.22 3.22 0.30 5.90 5.90 5.428 5.428
42836 42836 A 0 090 0 1 0 2 0 0 0 3.26 3.66 3.66 0.41 7.33 7.33 6.761 6.761
42842 42842 A 0 090 0 1 0 2 0 0 0 12.23 16.54 16.54 1.58 30.35 30.35 27.909 27.909
42844 42844 A 0 090 0 1 0 2 0 2 1 17.78 21.46 21.46 2.27 41.51 41.51 38.238 38.238
42845 42845 A 0 090 0 1 0 2 0 2 1 32.56 30.07 30.07 4.18 66.81 66.81 61.749 61.749
42860 42860 A 0 090 0 1 0 2 0 0 0 2.30 3.18 3.18 0.30 5.78 5.78 5.313 5.313
42870 42870 A 0 090 0 1 0 2 0 0 0 5.52 11.67 11.67 0.71 17.90 17.90 16.371 16.371
42890 42890 A 0 090 0 1 0 2 0 2 1 19.13 21.17 21.17 2.52 42.82 42.82 39.459 39.459
42892 42892 A 0 090 0 1 0 2 0 2 1 26.03 27.30 27.30 3.42 56.75 56.75 52.334 52.334
42894 42894 A 0 090 0 1 0 2 0 2 1 33.92 33.07 33.07 4.42 71.41 71.41 65.929 65.929
42900 42900 A 0 010 0 1 0 2 0 0 0 5.29 4.24 4.24 0.68 10.21 10.21 9.453 9.453
42950 42950 A 0 090 0 1 0 2 0 2 1 8.27 14.96 14.96 1.14 24.37 24.37 22.300 22.300
42953 42953 A 0 090 0 1 0 2 0 2 0 9.45 18.42 18.42 1.31 29.18 29.18 26.676 26.676
42955 42955 A 0 090 0 1 0 2 0 2 0 8.01 14.09 14.09 1.03 23.13 23.13 21.202 21.202
42960 42960 A 0 010 0 1 0 2 0 0 0 2.38 2.47 2.47 0.31 5.16 5.16 4.760 4.760
42961 42961 A 0 090 0 1 0 2 0 2 0 5.77 6.36 6.36 0.73 12.86 12.86 11.863 11.863
42962 42962 A 0 090 0 1 0 2 0 1 0 7.40 7.36 7.36 0.95 15.71 15.71 14.506 14.506
42970 42970 A 0 090 0 1 0 2 0 1 0 5.82 5.76 5.76 0.84 12.42 12.42 11.432 11.432
42971 42971 A 0 090 0 1 0 2 0 2 0 6.60 6.42 6.42 0.84 13.86 13.86 12.804 12.804
42972 42972 A 0 090 0 1 0 2 0 2 0 7.59 6.92 6.92 0.98 15.49 15.49 14.317 14.317
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
165 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
42999 42999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43020 43020 A 0 090 0 1 0 2 0 2 1 8.23 6.60 6.60 1.06 15.89 15.89 14.711 14.711
43030 43030 A 0 090 0 1 0 2 0 2 1 7.99 6.49 6.49 1.17 15.65 15.65 14.430 14.430
43045 43045 A 0 090 0 1 0 2 0 2 1 21.88 12.00 12.00 5.12 39.00 39.00 35.334 35.334
43100 43100 A 0 090 0 1 0 2 0 2 1 9.66 7.99 7.99 1.24 18.89 18.89 17.484 17.484
43101 43101 A 0 090 0 1 0 2 0 2 1 17.07 9.07 9.07 4.00 30.14 30.14 27.307 27.307
43107 43107 A 0 090 0 1 0 2 0 2 1 44.18 21.61 21.61 9.87 75.66 75.66 68.748 68.748
43108 43108 A 0 090 0 1 0 2 0 2 1 82.87 37.55 37.55 17.67 138.09 138.09 125.831 125.831
43112 43112 A 0 090 0 1 0 2 0 2 2 47.48 21.51 21.51 10.77 79.76 79.76 72.429 72.429
43113 43113 A 0 090 0 1 0 2 0 2 2 80.06 30.98 30.98 17.08 128.12 128.12 116.813 116.813
43116 43116 A 0 090 0 1 0 2 0 2 1 92.99 50.49 50.49 11.94 155.42 155.42 144.575 144.575
43117 43117 A 0 090 0 1 0 2 0 2 2 43.65 19.69 19.69 9.87 73.21 73.21 66.494 66.494
43118 43118 A 0 090 0 1 0 2 0 2 2 67.07 31.30 31.30 14.30 112.67 112.67 102.656 102.656
43121 43121 A 0 090 0 1 0 2 0 2 2 51.43 21.89 21.89 12.03 85.35 85.35 77.379 77.379
43122 43122 A 0 090 0 1 0 2 0 2 1 44.18 22.09 22.09 9.64 75.91 75.91 69.059 69.059
43123 43123 A 0 090 0 1 0 2 0 2 1 83.12 31.95 31.95 17.71 132.78 132.78 121.073 121.073
43124 43124 A 0 090 0 1 0 2 0 2 1 69.09 28.41 28.41 16.18 113.68 113.68 103.064 103.064
43130 43130 A 0 090 0 1 0 2 0 2 1 12.53 9.10 9.10 1.99 23.62 23.62 21.743 21.743
43135 43135 A 0 090 0 1 0 2 0 2 1 26.17 12.19 12.19 5.97 44.33 44.33 40.239 40.239
43200 43200 A 0 000 0 0 0 2 0 1 0 1.59 4.77 1.32 0.23 6.59 3.14 5.994 2.896
43201 43201 A 0 000 0 0 0 3 0 1 0 2.09 7.22 1.43 0.30 9.61 3.82 8.730 3.531
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
166 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43202 43202 A 0 000 0 0 0 3 0 1 0 1.89 6.68 1.29 0.29 8.86 3.47 8.040 3.200
43204 43204 A 0 000 0 0 0 3 0 1 0 3.76 2.37 2.37 0.59 6.72 6.72 6.197 6.197
43205 43205 A 0 000 0 0 0 3 0 0 0 3.78 2.34 2.34 0.56 6.68 6.68 6.174 6.174
43206 43206 C 0 YYY 0 0 0 2 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43215 43215 A 0 000 0 0 0 3 0 1 0 2.60 1.60 1.60 0.41 4.61 4.61 4.251 4.251
43216 43216 A 0 000 0 0 0 3 0 0 0 2.40 4.06 1.70 0.35 6.81 4.45 6.229 4.110
43217 43217 A 0 000 0 0 0 3 0 1 0 2.90 8.42 1.77 0.49 11.81 5.16 10.717 4.746
43219 43219 A 0 000 0 0 0 3 0 1 0 2.80 1.82 1.82 0.48 5.10 5.10 4.685 4.685
43220 43220 A 0 000 0 0 0 3 0 1 0 2.10 1.39 1.39 0.31 3.80 3.80 3.510 3.510
43226 43226 A 0 000 0 0 0 3 0 1 0 2.34 1.50 1.50 0.37 4.21 4.21 3.881 3.881
43227 43227 A 0 000 0 0 0 3 0 1 0 3.59 2.21 2.21 0.54 6.34 6.34 5.857 5.857
43228 43228 A 0 000 0 0 0 3 0 1 0 3.76 2.30 2.30 0.59 6.65 6.65 6.134 6.134
43231 43231 A 0 000 0 0 0 3 0 0 2 3.19 2.00 2.00 0.48 5.67 5.67 5.237 5.237
43232 43232 A 0 000 0 0 0 3 0 0 2 4.47 2.60 2.60 0.69 7.76 7.76 7.166 7.166
43235 43235 A 0 000 0 0 0 2 0 1 0 2.39 6.40 1.59 0.37 9.16 4.35 8.331 4.011
43236 43236 A 0 000 0 0 0 3 0 1 0 2.92 8.40 1.89 0.42 11.74 5.23 10.683 4.837
43237 43237 A 0 000 0 0 0 3 0 0 0 3.98 2.39 2.39 0.60 6.97 6.97 6.440 6.440
43238 43238 A 0 000 0 0 0 3 0 0 0 5.02 2.89 2.89 0.75 8.66 8.66 8.007 8.007
43239 43239 A 0 000 0 0 0 3 0 1 0 2.87 7.27 1.84 0.42 10.56 5.13 9.618 4.742
43240 43240 A 0 000 0 0 0 3 0 1 0 6.85 3.91 3.91 1.03 11.79 11.79 10.900 10.900
43241 43241 A 0 000 0 0 0 3 0 1 0 2.59 1.68 1.68 0.39 4.66 4.66 4.303 4.303
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
167 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43242 43242 A 0 000 0 0 0 3 0 0 0 7.30 4.20 4.20 1.08 12.58 12.58 11.636 11.636
43243 43243 A 0 000 0 0 0 3 0 1 0 4.56 2.72 2.72 0.68 7.96 7.96 7.358 7.358
43244 43244 A 0 000 0 0 0 3 0 0 0 5.04 3.00 3.00 0.73 8.77 8.77 8.116 8.116
43245 43245 A 0 000 0 0 0 3 0 1 0 3.18 1.93 1.93 0.50 5.61 5.61 5.175 5.175
43246 43246 A 0 000 0 0 0 3 0 0 2 4.32 2.49 2.49 0.69 7.50 7.50 6.917 6.917
43247 43247 A 0 000 0 0 0 3 0 1 0 3.38 2.08 2.08 0.52 5.98 5.98 5.520 5.520
43248 43248 A 0 000 0 0 0 3 0 1 0 3.15 2.01 2.01 0.45 5.61 5.61 5.190 5.190
43249 43249 A 0 000 0 0 0 3 0 1 0 2.90 1.86 1.86 0.42 5.18 5.18 4.790 4.790
43250 43250 A 0 000 0 0 0 3 0 1 0 3.20 1.93 1.93 0.52 5.65 5.65 5.205 5.205
43251 43251 A 0 000 0 0 0 3 0 1 0 3.69 2.26 2.26 0.56 6.51 6.51 6.012 6.012
43252 43252 C 0 YYY 0 0 0 2 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43255 43255 A 0 000 0 0 0 3 0 1 0 4.81 2.88 2.88 0.71 8.40 8.40 7.768 7.768
43256 43256 A 0 000 0 0 0 3 0 1 0 4.34 2.55 2.55 0.68 7.57 7.57 6.986 6.986
43257 43257 A 0 000 0 0 0 3 0 1 0 5.50 3.34 3.34 0.80 9.64 9.64 8.918 8.918
43258 43258 A 0 000 0 0 0 3 0 1 0 4.54 2.73 2.73 0.68 7.95 7.95 7.347 7.347
43259 43259 A 0 000 0 0 0 3 0 0 0 5.19 3.09 3.09 0.75 9.03 9.03 8.357 8.357
43260 43260 A 0 000 0 0 0 2 0 1 0 5.95 3.47 3.47 0.87 10.29 10.29 9.521 9.521
43261 43261 A 0 000 0 0 0 3 0 1 0 6.26 3.64 3.64 0.91 10.81 10.81 10.005 10.005
43262 43262 A 0 000 0 0 0 3 0 1 0 7.38 4.23 4.23 1.09 12.70 12.70 11.749 11.749
43263 43263 A 0 000 0 0 0 3 0 1 0 7.28 4.20 4.20 1.08 12.56 12.56 11.616 11.616
43264 43264 A 0 000 0 0 0 3 0 1 0 8.89 5.02 5.02 1.31 15.22 15.22 14.083 14.083
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
168 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43265 43265 A 0 000 0 0 0 3 0 1 0 10.00 5.60 5.60 1.48 17.08 17.08 15.803 15.803
43267 43267 A 0 000 0 0 0 3 0 1 0 7.38 4.13 4.13 1.09 12.60 12.60 11.659 11.659
43268 43268 A 0 000 0 0 0 3 0 1 0 7.38 4.42 4.42 1.09 12.89 12.89 11.919 11.919
43269 43269 A 0 000 0 0 0 3 0 1 0 8.20 4.65 4.65 1.21 14.06 14.06 13.009 13.009
43271 43271 A 0 000 0 0 0 3 0 1 0 7.38 4.22 4.22 1.09 12.69 12.69 11.740 11.740
43272 43272 A 0 000 0 0 0 3 0 0 0 7.38 4.25 4.25 1.09 12.72 12.72 11.767 11.767
43273 43273 A 0 ZZZ 0 0 0 0 0 0 0 2.24 1.17 1.17 0.33 3.74 3.74 3.463 3.463
43279 43279 A 0 090 0 1 0 2 0 2 1 22.10 11.34 11.34 4.71 38.15 38.15 34.747 34.747
43280 43280 A 0 090 0 1 0 2 0 2 1 18.10 10.04 10.04 3.85 31.99 31.99 29.129 29.129
43281 43281 A 0 090 0 1 0 2 0 2 1 26.60 13.32 13.32 5.66 45.58 45.58 41.522 41.522
43282 43282 A 0 090 0 1 0 2 0 2 1 30.10 14.74 14.74 6.38 51.22 51.22 46.673 46.673
43283 43283 A 0 ZZZ 0 0 0 0 0 2 1 2.95 1.07 1.07 0.60 4.62 4.62 4.225 4.225
43289 43289 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43300 43300 A 0 090 0 1 0 2 0 2 1 9.33 8.03 8.03 1.20 18.56 18.56 17.169 17.169
43305 43305 A 0 090 0 1 0 2 0 2 1 18.10 12.25 12.25 2.31 32.66 32.66 30.309 30.309
43310 43310 A 0 090 0 1 0 2 0 2 1 26.26 11.92 11.92 6.14 44.32 44.32 40.175 40.175
43312 43312 A 0 090 0 1 0 2 0 2 1 29.25 11.50 11.50 6.86 47.61 47.61 43.165 43.165
43313 43313 A 0 090 0 1 0 2 0 2 1 48.45 32.36 32.36 11.35 92.16 92.16 83.445 83.445
43314 43314 A 0 090 0 1 0 2 0 2 1 53.43 25.73 25.73 6.87 86.03 86.03 80.129 80.129
43320 43320 A 0 090 0 1 0 2 0 2 1 23.31 12.92 12.92 4.98 41.21 41.21 37.517 37.517
43325 43325 A 0 090 0 1 0 2 0 2 1 22.60 12.26 12.26 4.83 39.69 39.69 36.136 36.136
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
169 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43327 43327 A 0 090 0 1 0 2 0 2 1 13.35 7.96 7.96 2.84 24.15 24.15 21.983 21.983
43328 43328 A 0 090 0 1 0 2 0 2 1 19.91 9.60 9.60 4.98 34.49 34.49 31.135 31.135
43330 43330 A 0 090 0 1 0 2 0 2 1 22.19 12.48 12.48 4.78 39.45 39.45 35.897 35.897
43331 43331 A 0 090 0 1 0 2 0 2 1 23.06 11.69 11.69 5.40 40.15 40.15 36.382 36.382
43332 43332 A 0 090 0 1 0 2 0 2 1 19.62 10.58 10.58 4.18 34.38 34.38 31.307 31.307
43333 43333 A 0 090 0 1 0 2 0 2 1 21.46 11.36 11.36 4.55 37.37 37.37 34.041 34.041
43334 43334 A 0 090 0 1 0 2 0 2 1 22.12 10.22 10.22 4.71 37.05 37.05 33.761 33.761
43335 43335 A 0 090 0 1 0 2 0 2 1 23.97 10.44 10.44 5.08 39.49 39.49 36.002 36.002
43336 43336 A 0 090 0 1 0 2 0 2 1 25.81 13.50 13.50 5.85 45.16 45.16 40.993 40.993
43337 43337 A 0 090 0 1 0 2 0 2 1 27.65 14.73 14.73 6.27 48.65 48.65 44.157 44.157
43338 43338 A 0 ZZZ 0 0 0 0 0 2 1 2.21 0.73 0.73 0.50 3.44 3.44 3.127 3.127
43340 43340 A 0 090 0 1 0 2 0 2 1 22.99 12.79 12.79 4.90 40.68 40.68 37.038 37.038
43341 43341 A 0 090 0 1 0 2 0 2 1 24.23 14.49 14.49 5.68 44.40 44.40 40.213 40.213
43350 43350 A 0 090 0 1 0 2 0 2 1 19.49 12.15 12.15 4.15 35.79 35.79 32.571 32.571
43351 43351 A 0 090 0 1 0 2 0 2 1 22.05 12.22 12.22 5.16 39.43 39.43 35.722 35.722
43352 43352 A 0 090 0 1 0 2 0 2 1 17.81 10.03 10.03 4.16 32.00 32.00 28.993 28.993
43360 43360 A 0 090 0 1 0 2 0 2 1 40.11 17.87 17.87 9.40 67.38 67.38 61.073 61.073
43361 43361 A 0 090 0 1 0 2 0 2 1 45.68 19.73 19.73 9.74 75.15 75.15 68.492 68.492
43400 43400 A 0 090 0 1 0 2 0 2 1 25.60 16.94 16.94 3.77 46.31 46.31 42.784 42.784
43401 43401 A 0 090 0 1 0 2 0 2 1 26.49 14.18 14.18 5.65 46.32 46.32 42.179 42.179
43405 43405 A 0 090 0 1 0 2 0 2 1 24.73 13.11 13.11 5.28 43.12 43.12 39.264 39.264
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
170 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43410 43410 A 0 090 0 1 0 2 0 2 1 16.41 12.41 12.41 3.84 32.66 32.66 29.563 29.563
43415 43415 A 0 090 0 1 0 2 0 2 1 44.88 21.55 21.55 10.25 76.68 76.68 69.593 69.593
43420 43420 A 0 090 0 1 0 2 0 0 1 16.78 11.55 11.55 2.15 30.48 30.48 28.276 28.276
43425 43425 A 0 090 0 1 0 2 0 2 1 25.04 12.32 12.32 5.35 42.71 42.71 38.901 38.901
43450 43450 A 0 000 0 0 0 2 0 1 0 1.38 3.14 1.08 0.22 4.74 2.68 4.315 2.465
43453 43453 A 0 000 0 0 0 2 0 1 0 1.51 7.41 1.14 0.23 9.15 2.88 8.284 2.654
43456 43456 A 0 000 0 0 0 2 0 1 0 2.57 15.65 1.68 0.38 18.60 4.63 16.822 4.277
43458 43458 A 0 000 0 0 0 2 0 1 0 3.06 8.37 1.89 0.45 11.88 5.40 10.812 4.993
43460 43460 A 0 000 0 0 0 2 0 1 0 3.79 2.36 2.36 0.54 6.69 6.69 6.192 6.192
43496 43496 C 0 090 0 1 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43499 43499 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43500 43500 A 0 090 0 1 0 2 0 2 1 12.79 7.78 7.78 2.71 23.28 23.28 21.194 21.194
43501 43501 A 0 090 0 1 0 2 0 2 1 22.60 12.38 12.38 4.78 39.76 39.76 36.217 36.217
43502 43502 A 0 090 0 1 0 2 0 2 1 25.69 13.80 13.80 5.47 44.96 44.96 40.943 40.943
43510 43510 A 0 090 0 1 0 2 0 2 1 15.14 9.63 9.63 2.22 26.99 26.99 24.949 24.949
43520 43520 A 0 090 0 1 0 2 0 2 1 11.29 6.59 6.59 2.50 20.38 20.38 18.515 18.515
43605 43605 A 0 090 0 1 0 2 0 2 1 13.72 8.14 8.14 2.87 24.73 24.73 22.531 22.531
43610 43610 A 0 090 0 1 0 2 0 2 1 16.34 9.18 9.18 3.46 28.98 28.98 26.393 26.393
43611 43611 A 0 090 0 1 0 2 0 2 1 20.38 11.39 11.39 4.30 36.07 36.07 32.857 32.857
43620 43620 A 0 090 0 1 0 2 0 2 1 34.04 16.46 16.46 7.25 57.75 57.75 52.613 52.613
43621 43621 A 0 090 0 1 0 2 0 2 1 39.53 18.73 18.73 8.41 66.67 66.67 60.748 60.748
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
171 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43622 43622 A 0 090 0 1 0 2 0 2 1 40.03 19.02 19.02 8.55 67.60 67.60 61.582 61.582
43631 43631 A 0 090 0 1 0 2 0 2 1 24.51 13.12 13.12 5.20 42.83 42.83 39.011 39.011
43632 43632 A 0 090 0 1 0 2 0 2 1 35.14 17.23 17.23 7.42 59.79 59.79 54.493 54.493
43633 43633 A 0 090 0 1 0 2 0 2 1 33.14 16.46 16.46 7.00 56.60 56.60 51.582 51.582
43634 43634 A 0 090 0 1 0 2 0 2 1 36.64 18.13 18.13 7.81 62.58 62.58 57.005 57.005
43635 43635 A 0 ZZZ 0 0 0 0 0 2 1 2.06 0.81 0.81 0.42 3.29 3.29 3.007 3.007
43640 43640 A 0 090 0 1 0 2 0 2 1 19.56 11.16 11.16 4.12 34.84 34.84 31.736 31.736
43641 43641 A 0 090 0 1 0 2 0 2 1 19.81 11.47 11.47 4.22 35.50 35.50 32.317 32.317
43644 43644 A 0 090 0 1 0 2 0 2 1 29.40 15.49 15.49 6.22 51.11 51.11 46.563 46.563
43645 43645 A 0 090 0 1 0 2 0 2 1 31.53 16.24 16.24 6.74 54.51 54.51 49.639 49.639
43647 43647 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43648 43648 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43651 43651 A 0 090 0 1 0 2 0 2 1 10.13 7.15 7.15 2.16 19.44 19.44 17.680 17.680
43652 43652 A 0 090 0 1 0 2 0 2 1 12.13 7.94 7.94 2.59 22.66 22.66 20.615 20.615
43653 43653 A 0 090 0 1 0 2 0 2 1 8.48 6.82 6.82 1.81 17.11 17.11 15.551 15.551
43659 43659 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43752 43752 A 0 000 0 0 0 0 0 1 0 0.81 0.30 0.30 0.08 1.19 1.19 1.121 1.121
43753 43753 A 0 000 0 0 0 0 0 2 0 0.45 0.12 0.12 0.03 0.60 0.60 0.573 0.573
43754 43754 A 0 000 0 0 0 0 0 2 0 0.45 2.44 0.52 0.04 2.93 1.01 2.662 0.938
43755 43755 A 0 000 0 0 0 0 0 2 0 0.94 3.40 0.72 0.08 4.42 1.74 4.035 1.628
43756 43756 A 0 000 0 0 0 0 0 2 0 0.77 5.98 0.73 0.05 6.80 1.55 6.166 1.452
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
172 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43757 43757 A 0 000 0 0 0 0 0 2 0 1.26 8.20 0.99 0.08 9.54 2.33 8.665 2.191
43760 43760 A 0 000 0 0 0 2 0 1 0 0.90 14.59 0.39 0.14 15.63 1.43 14.075 1.323
43761 43761 A 0 000 0 0 0 2 0 1 0 2.01 1.18 0.78 0.24 3.43 3.03 3.195 2.836
43770 43770 A 0 090 0 1 0 2 0 2 1 18.00 11.32 11.32 3.81 33.13 33.13 30.158 30.158
43771 43771 A 0 090 0 1 0 2 0 2 1 20.79 12.39 12.39 4.44 37.62 37.62 34.238 34.238
43772 43772 A 0 090 0 1 0 2 0 2 1 15.70 9.13 9.13 3.36 28.19 28.19 25.656 25.656
43773 43773 A 0 090 0 1 0 2 0 2 1 20.79 12.35 12.35 4.44 37.58 37.58 34.202 34.202
43774 43774 A 0 090 0 1 0 2 0 2 1 15.76 9.30 9.30 3.36 28.42 28.42 25.869 25.869
43775 43775 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43800 43800 A 0 090 0 1 0 2 0 2 1 15.43 8.76 8.76 3.31 27.50 27.50 25.028 25.028
43810 43810 A 0 090 0 1 0 2 0 2 1 16.88 9.57 9.57 3.59 30.04 30.04 27.351 27.351
43820 43820 A 0 090 0 1 0 2 0 2 1 22.53 12.28 12.28 4.76 39.57 39.57 36.047 36.047
43825 43825 A 0 090 0 1 0 2 0 2 1 21.76 11.76 11.76 4.64 38.16 38.16 34.747 34.747
43830 43830 A 0 090 0 1 0 2 0 2 1 10.85 7.69 7.69 2.23 20.77 20.77 18.922 18.922
43831 43831 A 0 090 0 1 0 2 0 2 1 8.49 7.49 7.49 1.81 17.79 17.79 16.163 16.163
43832 43832 A 0 090 0 1 0 2 0 2 1 17.34 10.00 10.00 3.58 30.92 30.92 28.192 28.192
43840 43840 A 0 090 0 1 0 2 0 2 1 22.83 12.47 12.47 4.82 40.12 40.12 36.549 36.549
43842 43842 N 9 090 0 1 0 9 9 9 9 21.03 11.28 11.28 1.50 33.81 33.81 31.944 31.944
43843 43843 A 0 090 0 1 0 2 0 2 2 21.21 12.08 12.08 4.52 37.81 37.81 34.422 34.422
43845 43845 A 0 090 0 1 0 2 0 2 1 33.30 17.59 17.59 7.06 57.95 57.95 52.788 52.788
43846 43846 A 0 090 0 1 0 2 0 2 1 27.41 14.79 14.79 5.80 48.00 48.00 43.725 43.725
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
173 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
43847 43847 A 0 090 0 1 0 2 0 2 1 30.28 16.43 16.43 6.45 53.16 53.16 48.407 48.407
43848 43848 A 0 090 0 1 0 2 0 2 1 32.75 17.18 17.18 6.94 56.87 56.87 51.807 51.807
43850 43850 A 0 090 0 1 0 2 0 2 1 27.58 14.55 14.55 5.88 48.01 48.01 43.721 43.721
43855 43855 A 0 090 0 1 0 2 0 2 1 28.69 14.99 14.99 6.11 49.79 49.79 45.347 45.347
43860 43860 A 0 090 0 1 0 2 0 2 1 27.89 14.42 14.42 5.88 48.19 48.19 43.914 43.914
43865 43865 A 0 090 0 1 0 2 0 2 1 29.05 15.13 15.13 6.19 50.37 50.37 45.874 45.874
43870 43870 A 0 090 0 1 0 2 0 2 1 11.44 7.34 7.34 2.35 21.13 21.13 19.260 19.260
43880 43880 A 0 090 0 1 0 2 0 2 1 27.18 14.14 14.14 5.70 47.02 47.02 42.859 42.859
43881 43881 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43882 43882 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
43886 43886 A 0 090 0 1 0 2 0 2 1 4.64 5.30 5.30 0.99 10.93 10.93 9.917 9.917
43887 43887 A 0 090 0 1 0 2 0 2 1 4.32 4.60 4.60 0.91 9.83 9.83 8.927 8.927
43888 43888 A 0 090 0 1 0 2 0 2 1 6.44 5.93 5.93 1.37 13.74 13.74 12.482 12.482
43999 43999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44005 44005 A 0 090 0 1 0 2 0 2 1 18.46 10.02 10.02 3.84 32.32 32.32 29.466 29.466
44010 44010 A 0 090 0 1 0 2 0 2 1 14.26 8.49 8.49 3.01 25.76 25.76 23.458 23.458
44015 44015 A 0 ZZZ 0 0 0 0 0 2 1 2.62 1.00 1.00 0.56 4.18 4.18 3.811 3.811
44020 44020 A 0 090 0 1 0 2 0 2 1 16.22 9.18 9.18 3.40 28.80 28.80 26.242 26.242
44021 44021 A 0 090 0 1 0 2 0 2 1 16.31 9.12 9.12 3.44 28.87 28.87 26.299 26.299
44025 44025 A 0 090 0 1 0 2 0 2 1 16.51 9.34 9.34 3.43 29.28 29.28 26.691 26.691
44050 44050 A 0 090 0 1 0 2 0 2 1 15.52 8.90 8.90 3.24 27.66 27.66 25.207 25.207
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
174 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
44055 44055 A 0 090 0 1 0 2 0 2 1 25.63 13.13 13.13 5.42 44.18 44.18 40.255 40.255
44100 44100 A 0 000 0 0 0 2 0 1 0 2.01 1.04 1.04 0.31 3.36 3.36 3.106 3.106
44110 44110 A 0 090 0 1 0 2 0 2 1 14.04 8.23 8.23 2.90 25.17 25.17 22.947 22.947
44111 44111 A 0 090 0 1 0 2 0 2 1 16.52 9.22 9.22 3.44 29.18 29.18 26.599 26.599
44120 44120 A 0 090 0 1 0 2 0 2 1 20.82 10.96 10.96 4.33 36.11 36.11 32.927 32.927
44121 44121 A 0 ZZZ 0 0 0 0 0 2 1 4.44 1.75 1.75 0.90 7.09 7.09 6.482 6.482
44125 44125 A 0 090 0 1 0 2 0 2 1 20.03 10.83 10.83 4.07 34.93 34.93 31.884 31.884
44126 44126 A 0 090 0 1 0 2 0 2 1 42.23 21.41 21.41 9.00 72.64 72.64 66.163 66.163
44127 44127 A 0 090 0 1 0 2 0 2 1 49.30 24.10 24.10 10.51 83.91 83.91 76.439 76.439
44128 44128 A 0 ZZZ 0 0 0 0 0 2 1 4.44 1.76 1.76 0.93 7.13 7.13 6.507 6.507
44130 44130 A 0 090 0 1 0 2 0 2 1 22.11 12.18 12.18 4.56 38.85 38.85 35.433 35.433
44132 44132 R 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44133 44133 R 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44135 44135 R 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44136 44136 R 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44137 44137 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44139 44139 A 0 ZZZ 0 0 0 0 0 2 1 2.23 0.88 0.88 0.44 3.55 3.55 3.250 3.250
44140 44140 A 0 090 0 1 0 2 0 2 1 22.59 12.42 12.42 4.64 39.65 39.65 36.170 36.170
44141 44141 A 0 090 0 1 0 2 0 2 1 29.91 18.05 18.05 6.18 54.14 54.14 49.351 49.351
44143 44143 A 0 090 0 1 0 2 0 2 1 27.79 15.77 15.77 5.74 49.30 49.30 44.953 44.953
44144 44144 A 0 090 0 1 0 2 0 2 1 29.91 16.35 16.35 6.18 52.44 52.44 47.824 47.824
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
175 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
44145 44145 A 0 090 0 1 0 2 0 2 1 28.58 14.82 14.82 5.66 49.06 49.06 44.849 44.849
44146 44146 A 0 090 0 1 0 2 0 2 1 35.30 20.68 20.68 6.87 62.85 62.85 57.464 57.464
44147 44147 A 0 090 0 1 0 2 0 2 1 33.69 16.89 16.89 6.78 57.36 57.36 52.403 52.403
44150 44150 A 0 090 0 1 0 2 0 2 1 30.18 19.37 19.37 6.12 55.67 55.67 50.775 50.775
44151 44151 A 0 090 0 1 0 2 0 2 1 34.92 21.30 21.30 7.44 63.66 63.66 57.939 57.939
44155 44155 A 0 090 0 1 0 2 0 2 1 34.42 20.97 20.97 6.46 61.85 61.85 56.630 56.630
44156 44156 A 0 090 0 1 0 2 0 2 1 37.42 23.14 23.14 7.99 68.55 68.55 62.378 62.378
44157 44157 A 0 090 0 1 0 2 0 2 1 35.70 21.12 21.12 7.62 64.44 64.44 58.651 58.651
44158 44158 A 0 090 0 1 0 2 0 2 1 36.70 21.62 21.62 7.83 66.15 66.15 60.210 60.210
44160 44160 A 0 090 0 1 0 2 0 2 1 20.89 11.59 11.59 4.26 36.74 36.74 33.526 33.526
44180 44180 A 0 090 0 1 0 2 0 2 1 15.27 8.75 8.75 3.17 27.19 27.19 24.785 24.785
44186 44186 A 0 090 0 1 0 2 0 2 1 10.38 6.76 6.76 2.22 19.36 19.36 17.612 17.612
44187 44187 A 0 090 0 1 0 2 0 2 1 17.40 12.41 12.41 3.31 33.12 33.12 30.275 30.275
44188 44188 A 0 090 0 1 0 2 0 2 1 19.35 13.42 13.42 3.84 36.61 36.61 33.409 33.409
44202 44202 A 0 090 0 1 0 2 0 2 1 23.39 12.77 12.77 4.85 41.01 41.01 37.394 37.394
44203 44203 A 0 ZZZ 0 0 0 0 0 2 1 4.44 1.73 1.73 0.93 7.10 7.10 6.480 6.480
44204 44204 A 0 090 0 1 0 2 0 2 1 26.42 13.95 13.95 5.23 45.60 45.60 41.682 41.682
44205 44205 A 0 090 0 1 0 2 0 2 1 22.95 12.24 12.24 4.50 39.69 39.69 36.295 36.295
44206 44206 A 0 090 0 1 0 2 0 2 1 29.79 16.22 16.22 6.06 52.07 52.07 47.525 47.525
44207 44207 A 0 090 0 1 0 2 0 2 1 31.92 16.02 16.02 6.18 54.12 54.12 49.538 49.538
44208 44208 A 0 090 0 1 0 2 0 2 1 33.99 18.73 18.73 6.40 59.12 59.12 54.157 54.157
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
176 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
44210 44210 A 0 090 0 1 0 2 0 2 1 30.09 17.51 17.51 5.81 53.41 53.41 48.853 48.853
44211 44211 A 0 090 0 1 0 2 0 2 1 37.08 21.58 21.58 7.92 66.58 66.58 60.601 60.601
44212 44212 A 0 090 0 1 0 2 0 2 1 34.58 20.56 20.56 6.37 61.51 61.51 56.374 56.374
44213 44213 A 0 ZZZ 0 0 0 0 0 2 1 3.50 1.39 1.39 0.67 5.56 5.56 5.099 5.099
44227 44227 A 0 090 0 1 0 2 0 2 1 28.62 14.97 14.97 5.84 49.43 49.43 45.117 45.117
44238 44238 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44300 44300 A 0 090 0 1 0 2 0 2 1 13.75 8.33 8.33 2.91 24.99 24.99 22.752 22.752
44310 44310 A 0 090 0 1 0 2 0 2 1 17.59 9.90 9.90 3.46 30.95 30.95 28.290 28.290
44312 44312 A 0 090 0 1 0 2 0 0 0 9.43 6.40 6.40 1.71 17.54 17.54 16.072 16.072
44314 44314 A 0 090 0 1 0 2 0 2 1 16.74 9.99 9.99 3.16 29.89 29.89 27.364 27.364
44316 44316 A 0 090 0 1 0 2 0 2 1 23.59 13.11 13.11 5.04 41.74 41.74 37.999 37.999
44320 44320 A 0 090 0 1 0 2 0 2 1 19.91 11.69 11.69 4.07 35.67 35.67 32.536 32.536
44322 44322 A 0 090 0 1 0 2 0 2 1 13.32 13.97 13.97 2.84 30.13 30.13 27.350 27.350
44340 44340 A 0 090 0 1 0 2 0 1 1 9.28 7.52 7.52 1.88 18.68 18.68 17.016 17.016
44345 44345 A 0 090 0 1 0 2 0 2 1 17.22 10.63 10.63 3.44 31.29 31.29 28.565 28.565
44346 44346 A 0 090 0 1 0 2 0 2 1 19.63 11.65 11.65 3.88 35.16 35.16 32.121 32.121
44360 44360 A 0 000 0 0 0 2 0 1 0 2.59 1.72 1.72 0.38 4.69 4.69 4.333 4.333
44361 44361 A 0 000 0 0 0 3 0 1 0 2.87 1.87 1.87 0.41 5.15 5.15 4.764 4.764
44363 44363 A 0 000 0 0 0 3 0 0 0 3.49 2.14 2.14 0.52 6.15 6.15 5.684 5.684
44364 44364 A 0 000 0 0 0 3 0 0 0 3.73 2.29 2.29 0.54 6.56 6.56 6.069 6.069
44365 44365 A 0 000 0 0 0 3 0 0 0 3.31 2.05 2.05 0.49 5.85 5.85 5.407 5.407
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
177 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
44366 44366 A 0 000 0 0 0 3 0 1 0 4.40 2.69 2.69 0.64 7.73 7.73 7.150 7.150
44369 44369 A 0 000 0 0 0 3 0 0 0 4.51 2.74 2.74 0.65 7.90 7.90 7.310 7.310
44370 44370 A 0 000 0 0 0 3 0 0 0 4.79 3.07 3.07 0.69 8.55 8.55 7.908 7.908
44372 44372 A 0 000 0 0 0 3 0 1 0 4.40 2.58 2.58 0.69 7.67 7.67 7.078 7.078
44373 44373 A 0 000 0 0 0 3 0 1 0 3.49 2.12 2.12 0.53 6.14 6.14 5.671 5.671
44376 44376 A 0 000 0 0 0 2 0 0 0 5.25 2.95 2.95 0.82 9.02 9.02 8.328 8.328
44377 44377 A 0 000 0 0 0 3 0 0 0 5.52 3.21 3.21 0.82 9.55 9.55 8.831 8.831
44378 44378 A 0 000 0 0 0 3 0 0 0 7.12 4.08 4.08 1.05 12.25 12.25 11.333 11.333
44379 44379 A 0 000 0 0 0 3 0 0 0 7.46 4.51 4.51 1.09 13.06 13.06 12.080 12.080
44380 44380 A 0 000 0 0 0 2 0 1 0 1.05 0.84 0.84 0.14 2.03 2.03 1.878 1.878
44382 44382 A 0 000 0 0 0 2 0 1 0 1.27 0.97 0.97 0.20 2.44 2.44 2.246 2.246
44383 44383 A 0 000 0 0 0 2 0 1 0 2.94 1.51 1.51 0.33 4.78 4.78 4.469 4.469
44385 44385 A 0 000 0 0 0 2 0 1 0 1.82 6.06 1.11 0.26 8.14 3.19 7.398 2.953
44386 44386 A 0 000 0 0 0 2 0 0 0 2.12 8.66 1.38 0.33 11.11 3.83 10.069 3.532
44388 44388 A 0 000 0 0 0 2 0 1 0 2.82 7.69 1.71 0.45 10.96 4.98 9.961 4.591
44389 44389 A 0 000 0 0 0 3 0 1 0 3.13 8.76 1.92 0.49 12.38 5.54 11.253 5.110
44390 44390 A 0 000 0 0 0 3 0 0 0 3.82 10.21 2.40 0.56 14.59 6.78 13.281 6.268
44391 44391 A 0 000 0 0 0 3 0 0 0 4.31 10.59 2.56 0.65 15.55 7.52 14.160 6.949
44392 44392 A 0 000 0 0 0 3 0 1 0 3.81 9.26 2.16 0.63 13.70 6.60 12.455 6.079
44393 44393 A 0 000 0 0 0 3 0 1 0 4.83 10.09 2.70 0.76 15.68 8.29 14.288 7.652
44394 44394 A 0 000 0 0 0 3 0 1 0 4.42 10.33 2.54 0.69 15.44 7.65 14.057 7.062
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
178 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
44397 44397 A 0 000 0 0 0 3 0 1 0 4.70 2.83 2.83 0.68 8.21 8.21 7.597 7.597
44500 44500 A 0 000 0 0 0 0 0 0 0 0.49 0.18 0.18 0.04 0.71 0.71 0.673 0.673
44602 44602 A 0 090 0 1 0 2 0 2 1 24.72 11.74 11.74 5.10 41.56 41.56 37.930 37.930
44603 44603 A 0 090 0 1 0 2 0 2 1 28.16 13.84 13.84 5.76 47.76 47.76 43.601 43.601
44604 44604 A 0 090 0 1 0 2 0 2 1 18.16 9.32 9.32 3.72 31.20 31.20 28.475 28.475
44605 44605 A 0 090 0 1 0 2 0 2 1 22.08 11.91 11.91 4.56 38.55 38.55 35.160 35.160
44615 44615 A 0 090 0 1 0 2 0 2 1 18.16 9.93 9.93 3.73 31.82 31.82 29.028 29.028
44620 44620 A 0 090 0 1 0 2 0 2 1 14.43 8.48 8.48 2.83 25.74 25.74 23.525 23.525
44625 44625 A 0 090 0 1 0 2 0 2 1 17.28 9.63 9.63 3.36 30.27 30.27 27.685 27.685
44626 44626 A 0 090 0 1 0 2 0 2 1 27.90 13.81 13.81 5.70 47.41 47.41 43.282 43.282
44640 44640 A 0 090 0 1 0 2 0 2 1 24.20 12.37 12.37 4.89 41.46 41.46 37.866 37.866
44650 44650 A 0 090 0 1 0 2 0 2 1 25.12 12.73 12.73 5.06 42.91 42.91 39.198 39.198
44660 44660 A 0 090 0 1 0 2 0 2 1 23.91 11.43 11.43 3.85 39.19 39.19 36.188 36.188
44661 44661 A 0 090 0 1 0 2 0 2 1 27.35 13.26 13.26 5.10 45.71 45.71 41.925 41.925
44680 44680 A 0 090 0 1 0 2 0 2 1 17.96 9.84 9.84 3.84 31.64 31.64 28.805 28.805
44700 44700 A 0 090 0 1 0 2 0 2 1 17.48 9.72 9.72 3.04 30.24 30.24 27.798 27.798
44701 44701 A 0 ZZZ 0 0 0 0 0 2 1 3.10 1.23 1.23 0.59 4.92 4.92 4.513 4.513
44705 44705 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44715 44715 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44720 44720 A 0 XXX 0 0 0 2 0 2 1 5.00 2.03 2.03 0.35 7.38 7.38 7.006 7.006
44721 44721 A 0 XXX 0 0 0 2 0 2 1 7.00 2.77 2.77 1.50 11.27 11.27 10.272 10.272
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
179 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
44799 44799 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44800 44800 A 0 090 0 1 0 2 0 2 1 12.05 8.19 8.19 2.44 22.68 22.68 20.681 20.681
44820 44820 A 0 090 0 1 0 2 0 2 1 13.73 8.32 8.32 2.83 24.88 24.88 22.681 22.681
44850 44850 A 0 090 0 1 0 2 0 2 1 12.11 7.70 7.70 2.52 22.33 22.33 20.343 20.343
44899 44899 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
44900 44900 A 0 090 0 1 0 2 0 2 1 12.57 7.75 7.75 2.64 22.96 22.96 20.910 20.910
44901 44901 A 0 000 0 0 0 2 0 1 0 3.37 23.25 1.19 0.35 26.97 4.91 24.432 4.622
44950 44950 A 0 090 0 1 0 2 0 2 1 10.60 6.15 6.15 2.23 18.98 18.98 17.289 17.289
44955 44955 A 0 ZZZ 0 0 0 0 0 2 1 1.53 0.62 0.62 0.31 2.46 2.46 2.249 2.249
44960 44960 A 0 090 0 1 0 2 0 2 1 14.50 8.24 8.24 3.08 25.82 25.82 23.510 23.510
44970 44970 A 0 090 0 1 0 2 0 2 2 9.45 6.40 6.40 1.97 17.82 17.82 16.228 16.228
44979 44979 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
45000 45000 A 0 090 0 1 0 2 0 1 0 6.30 5.27 5.27 1.09 12.66 12.66 11.603 11.603
45005 45005 A 0 010 0 1 0 2 0 1 0 2.02 5.93 2.38 0.38 8.33 4.78 7.544 4.356
45020 45020 A 0 090 0 1 0 2 0 1 0 8.56 6.84 6.84 1.62 17.02 17.02 15.550 15.550
45100 45100 A 0 090 0 1 0 2 0 1 0 4.04 4.28 4.28 0.72 9.04 9.04 8.260 8.260
45108 45108 A 0 090 0 1 0 2 0 1 1 5.12 4.85 4.85 1.09 11.06 11.06 10.045 10.045
45110 45110 A 0 090 0 1 0 2 0 2 1 30.76 18.53 18.53 5.83 55.12 55.12 50.449 50.449
45111 45111 A 0 090 0 1 0 2 0 2 1 18.01 10.81 10.81 3.55 32.37 32.37 29.574 29.574
45112 45112 A 0 090 0 1 0 2 0 2 1 33.18 16.70 16.70 6.08 55.96 55.96 51.356 51.356
45113 45113 A 0 090 0 1 0 2 0 2 1 33.22 18.83 18.83 7.08 59.13 59.13 53.832 53.832
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
180 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
45114 45114 A 0 090 0 1 0 2 0 2 1 30.79 16.22 16.22 6.57 53.58 53.58 48.792 48.792
45116 45116 A 0 090 0 1 0 2 0 2 1 27.72 14.99 14.99 3.96 46.67 46.67 43.252 43.252
45119 45119 A 0 090 0 1 0 2 0 2 1 33.48 18.68 18.68 5.87 58.03 58.03 53.325 53.325
45120 45120 A 0 090 0 1 0 2 0 2 1 26.40 14.80 14.80 5.63 46.83 46.83 42.635 42.635
45121 45121 A 0 090 0 1 0 2 0 2 1 29.08 16.01 16.01 6.19 51.28 51.28 46.694 46.694
45123 45123 A 0 090 0 1 0 2 0 2 1 18.86 11.36 11.36 3.17 33.39 33.39 30.719 30.719
45126 45126 A 0 090 0 1 0 2 0 2 1 49.10 25.08 25.08 10.47 84.65 84.65 77.098 77.098
45130 45130 A 0 090 0 1 0 2 0 2 1 18.50 10.90 10.90 3.13 32.53 32.53 29.925 29.925
45135 45135 A 0 090 0 1 0 2 0 2 1 22.36 13.43 13.43 4.76 40.55 40.55 36.910 36.910
45136 45136 A 0 090 0 1 0 2 0 2 1 30.82 18.99 18.99 4.41 54.22 54.22 50.179 50.179
45150 45150 A 0 090 0 1 0 2 0 0 0 5.85 5.12 5.12 0.83 11.80 11.80 10.882 10.882
45160 45160 A 0 090 0 1 0 2 0 2 1 16.33 10.48 10.48 3.48 30.29 30.29 27.561 27.561
45171 45171 A 0 090 0 1 0 2 0 2 1 8.13 8.45 8.45 1.51 18.09 18.09 16.508 16.508
45172 45172 A 0 090 0 1 0 2 0 2 1 12.13 10.00 10.00 2.23 24.36 24.36 22.276 22.276
45190 45190 A 0 090 0 1 0 2 0 1 1 10.42 8.32 8.32 1.86 20.60 20.60 18.864 18.864
45300 45300 A 0 000 0 0 0 2 0 1 0 0.80 2.89 0.71 0.12 3.81 1.63 3.458 1.500
45303 45303 A 0 000 0 0 0 3 0 1 0 1.50 28.48 1.00 0.26 30.24 2.76 27.211 2.534
45305 45305 A 0 000 0 0 0 3 0 1 0 1.25 4.63 0.91 0.23 6.11 2.39 5.528 2.187
45307 45307 A 0 000 0 0 0 3 0 0 0 1.70 5.14 1.08 0.33 7.17 3.11 6.488 2.842
45308 45308 A 0 000 0 0 0 3 0 1 0 1.40 4.90 0.97 0.26 6.56 2.63 5.936 2.407
45309 45309 A 0 000 0 0 0 3 0 1 0 1.50 4.95 1.02 0.27 6.72 2.79 6.086 2.557
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
181 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
45315 45315 A 0 000 0 0 0 3 0 1 0 1.80 4.96 1.16 0.33 7.09 3.29 6.427 3.014
45317 45317 A 0 000 0 0 0 3 0 1 0 2.00 5.21 1.22 0.33 7.54 3.55 6.851 3.268
45320 45320 A 0 000 0 0 0 3 0 1 0 1.78 5.42 1.11 0.31 7.51 3.20 6.809 2.939
45321 45321 A 0 000 0 0 0 3 0 1 0 1.75 1.16 1.16 0.33 3.24 3.24 2.964 2.964
45327 45327 A 0 000 0 0 0 3 0 1 0 2.00 1.43 1.43 0.42 3.85 3.85 3.504 3.504
45330 45330 A 0 000 0 0 0 2 0 1 0 0.96 3.17 0.82 0.14 4.27 1.92 3.880 1.770
45331 45331 A 0 000 0 0 0 3 0 1 0 1.15 3.81 0.96 0.18 5.14 2.29 4.666 2.106
45332 45332 A 0 000 0 0 0 3 0 1 0 1.79 7.13 1.26 0.29 9.21 3.34 8.344 3.073
45333 45333 A 0 000 0 0 0 3 0 1 0 1.79 7.26 1.23 0.29 9.34 3.31 8.461 3.046
45334 45334 A 0 000 0 0 0 3 0 1 0 2.73 1.77 1.77 0.39 4.89 4.89 4.523 4.523
45335 45335 A 0 000 0 0 0 3 0 1 0 1.46 7.02 1.09 0.23 8.71 2.78 7.884 2.559
45337 45337 A 0 000 0 0 0 3 0 1 0 2.36 1.54 1.54 0.38 4.28 4.28 3.942 3.942
45338 45338 A 0 000 0 0 0 3 0 1 0 2.34 7.31 1.53 0.35 10.00 4.22 9.087 3.897
45339 45339 A 0 000 0 0 0 3 0 1 0 3.14 7.01 1.95 0.48 10.63 5.57 9.686 5.142
45340 45340 A 0 000 0 0 0 3 0 1 0 1.89 13.39 1.30 0.30 15.58 3.49 14.071 3.214
45341 45341 A 0 000 0 0 0 2 0 1 0 2.60 1.71 1.71 0.38 4.69 4.69 4.334 4.334
45342 45342 A 0 000 0 0 0 2 0 1 0 4.05 2.48 2.48 0.60 7.13 7.13 6.591 6.591
45345 45345 A 0 000 0 0 0 3 0 1 0 2.92 1.86 1.86 0.44 5.22 5.22 4.820 4.820
45355 45355 A 0 000 0 0 0 2 0 1 0 3.51 2.03 2.03 0.59 6.13 6.13 5.642 5.642
45378 45378 A 0 000 0 0 0 2 0 1 0 3.69 7.79 2.20 0.59 12.07 6.48 10.994 5.974
45378 53 4537853 A 0 000 0 0 0 2 0 1 0 0.96 3.17 0.82 0.14 4.27 1.92 3.880 1.770
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
182 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
45379 45379 A 0 000 0 0 0 3 0 1 0 4.68 10.12 2.71 0.72 15.52 8.11 14.144 7.490
45380 45380 A 0 000 0 0 0 3 0 1 0 4.43 9.28 2.63 0.67 14.38 7.73 13.114 7.142
45381 45381 A 0 000 0 0 0 3 0 1 0 4.19 9.67 2.52 0.63 14.49 7.34 13.203 6.782
45382 45382 A 0 000 0 0 0 3 0 1 0 5.68 12.21 3.31 0.84 18.73 9.83 17.084 9.092
45383 45383 A 0 000 0 0 0 3 0 1 0 5.86 10.59 3.26 0.91 17.36 10.03 15.846 9.263
45384 45384 A 0 000 0 0 0 3 0 1 0 4.69 8.88 2.65 0.73 14.30 8.07 13.046 7.451
45385 45385 A 0 000 0 0 0 3 0 1 0 5.30 10.08 3.07 0.80 16.18 9.17 14.770 8.475
45386 45386 A 0 000 0 0 0 3 0 1 0 4.57 15.70 2.66 0.72 20.99 7.95 19.045 7.335
45387 45387 A 0 000 0 0 0 3 0 1 0 5.90 3.51 3.51 0.88 10.29 10.29 9.512 9.512
45391 45391 A 0 000 0 0 0 3 0 1 0 5.09 2.99 2.99 0.73 8.81 8.81 8.157 8.157
45392 45392 A 0 000 0 0 0 3 0 1 0 6.54 3.74 3.74 1.02 11.30 11.30 10.432 10.432
45395 45395 A 0 090 0 1 0 2 0 2 1 33.00 20.15 20.15 5.99 59.14 59.14 54.227 54.227
45397 45397 A 0 090 0 1 0 2 0 2 1 36.50 21.59 21.59 6.02 64.11 64.11 59.036 59.036
45400 45400 A 0 090 0 1 0 2 0 2 1 19.44 11.36 11.36 3.57 34.37 34.37 31.508 31.508
45402 45402 A 0 090 0 1 0 2 0 2 1 26.51 14.16 14.16 4.82 45.49 45.49 41.747 41.747
45499 45499 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
45500 45500 A 0 090 0 1 0 2 0 0 0 7.73 6.90 6.90 1.21 15.84 15.84 14.559 14.559
45505 45505 A 0 090 0 1 0 2 0 1 0 8.36 7.92 7.92 1.51 17.79 17.79 16.262 16.262
45520 45520 A 0 000 0 0 0 2 0 1 0 0.55 4.31 0.60 0.07 4.93 1.22 4.457 1.125
45540 45540 A 0 090 0 1 0 2 0 2 1 18.12 10.23 10.23 3.12 31.47 31.47 28.938 28.938
45541 45541 A 0 090 0 1 0 2 0 2 1 14.85 10.27 10.27 2.59 27.71 27.71 25.427 25.427
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
183 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
45550 45550 A 0 090 0 1 0 2 0 2 1 24.80 14.28 14.28 4.48 43.56 43.56 39.966 39.966
45560 45560 A 0 090 0 1 0 2 0 2 1 11.50 7.40 7.40 1.80 20.70 20.70 19.087 19.087
45562 45562 A 0 090 0 1 0 2 0 2 1 17.98 11.83 11.83 3.38 33.19 33.19 30.371 30.371
45563 45563 A 0 090 0 1 0 2 0 2 1 26.38 16.77 16.77 5.63 48.78 48.78 44.384 44.384
45800 45800 A 0 090 0 1 0 2 0 2 1 20.31 11.55 11.55 3.39 35.25 35.25 32.455 32.455
45805 45805 A 0 090 0 1 0 2 0 2 1 23.32 14.98 14.98 4.98 43.28 43.28 39.377 39.377
45820 45820 A 0 090 0 1 0 2 0 2 1 20.37 10.21 10.21 1.96 32.54 32.54 30.564 30.564
45825 45825 A 0 090 0 1 0 2 0 2 1 24.17 15.89 15.89 3.46 43.52 43.52 40.249 40.249
45900 45900 A 0 010 0 1 0 2 0 0 0 2.99 2.55 2.55 0.56 6.10 6.10 5.573 5.573
45905 45905 A 0 010 0 1 0 2 0 1 0 2.35 2.31 2.31 0.41 5.07 5.07 4.639 4.639
45910 45910 A 0 010 0 1 0 2 0 1 0 2.85 2.53 2.53 0.48 5.86 5.86 5.373 5.373
45915 45915 A 0 010 0 1 0 2 0 1 0 3.19 6.31 3.07 0.52 10.02 6.78 9.128 6.219
45990 45990 A 0 000 0 0 0 2 0 0 1 1.80 1.06 1.06 0.31 3.17 3.17 2.914 2.914
45999 45999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
46020 46020 A 0 010 0 1 0 2 0 1 0 3.00 4.86 3.55 0.54 8.40 7.09 7.647 6.470
46030 46030 A 0 010 0 1 0 2 0 0 0 1.26 2.79 1.24 0.23 4.28 2.73 3.886 2.494
46040 46040 A 0 090 0 1 0 2 0 1 0 5.37 9.75 6.01 1.05 16.17 12.43 14.675 11.316
46045 46045 A 0 090 0 1 0 2 0 1 0 5.87 5.98 5.98 1.17 13.02 13.02 11.852 11.852
46050 46050 A 0 010 0 1 0 2 0 1 0 1.24 4.78 1.49 0.24 6.26 2.97 5.658 2.704
46060 46060 A 0 090 0 1 0 2 0 1 0 6.37 6.77 6.77 1.18 14.32 14.32 13.067 13.067
46070 46070 A 0 090 0 1 0 2 0 0 0 2.79 3.57 3.57 0.20 6.56 6.56 6.100 6.100
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
184 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
46080 46080 A 0 010 0 1 0 2 0 1 0 2.52 4.57 1.74 0.49 7.58 4.75 6.880 4.339
46083 46083 A 0 010 0 1 0 2 0 1 0 1.45 3.70 1.51 0.24 5.39 3.20 4.898 2.932
46200 46200 A 0 090 0 1 0 2 0 1 0 3.59 9.36 5.64 0.63 13.58 9.86 12.325 8.984
46220 46220 A 0 010 0 1 0 2 0 1 0 1.61 4.43 1.67 0.30 6.34 3.58 5.745 3.267
46221 46221 A 0 010 0 1 0 2 0 1 0 2.36 5.49 3.05 0.41 8.26 5.82 7.504 5.313
46230 46230 A 0 010 0 1 0 2 0 1 0 2.62 5.26 2.08 0.48 8.36 5.18 7.595 4.739
46250 46250 A 0 090 0 1 0 2 0 1 0 4.25 8.99 4.36 0.82 14.06 9.43 12.752 8.594
46255 46255 A 0 090 0 1 0 2 0 1 0 4.96 9.46 4.67 0.95 15.37 10.58 13.952 9.651
46257 46257 A 0 090 0 1 0 2 0 1 0 5.76 5.80 5.80 1.08 12.64 12.64 11.533 11.533
46258 46258 A 0 090 0 1 0 2 0 0 0 6.41 6.16 6.16 1.37 13.94 13.94 12.658 12.658
46260 46260 A 0 090 0 1 0 2 0 1 0 6.73 6.22 6.22 1.27 14.22 14.22 12.980 12.980
46261 46261 A 0 090 0 1 0 2 0 1 0 7.76 6.55 6.55 1.39 15.70 15.70 14.369 14.369
46262 46262 A 0 090 0 1 0 2 0 1 0 7.91 7.29 7.29 1.44 16.64 16.64 15.210 15.210
46270 46270 A 0 090 0 1 0 2 0 1 0 4.92 9.45 5.88 0.98 15.35 11.78 13.919 10.713
46275 46275 A 0 090 0 1 0 2 0 1 0 5.42 9.93 6.08 0.98 16.33 12.48 14.850 11.392
46280 46280 A 0 090 0 1 0 2 0 1 0 6.39 6.61 6.61 1.13 14.13 14.13 12.917 12.917
46285 46285 A 0 090 0 1 0 2 0 1 0 5.42 9.92 6.13 0.91 16.25 12.46 14.804 11.401
46288 46288 A 0 090 0 1 0 2 0 1 0 7.81 7.25 7.25 1.33 16.39 16.39 15.016 15.016
46320 46320 A 0 010 0 1 0 2 0 1 0 1.64 3.67 1.39 0.30 5.61 3.33 5.093 3.045
46500 46500 A 0 010 0 1 0 2 0 1 0 1.69 5.35 1.94 0.29 7.33 3.92 6.646 3.584
46505 46505 A 0 010 0 1 0 2 1 1 0 3.18 4.96 3.51 0.59 8.73 7.28 7.943 6.641
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
185 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
46600 46600 A 0 000 0 0 0 2 0 1 0 0.55 2.10 0.60 0.08 2.73 1.23 2.478 1.131
46604 46604 A 0 000 0 0 0 3 0 1 0 1.03 18.47 0.80 0.16 19.66 1.99 17.700 1.832
46606 46606 A 0 000 0 0 0 3 0 1 0 1.20 5.60 0.87 0.23 7.03 2.30 6.349 2.102
46608 46608 A 0 000 0 0 0 3 0 0 0 1.30 5.68 0.89 0.24 7.22 2.43 6.526 2.225
46610 46610 A 0 000 0 0 0 3 0 1 0 1.28 5.54 0.91 0.24 7.06 2.43 6.380 2.223
46611 46611 A 0 000 0 0 0 3 0 0 0 1.30 3.84 0.92 0.23 5.37 2.45 4.869 2.246
46612 46612 A 0 000 0 0 0 3 0 0 0 1.50 6.77 1.00 0.31 8.58 2.81 7.742 2.560
46614 46614 A 0 000 0 0 0 3 0 1 0 1.00 2.78 0.79 0.14 3.92 1.93 3.570 1.783
46615 46615 A 0 000 0 0 0 3 0 0 0 1.50 2.61 0.99 0.29 4.40 2.78 3.995 2.541
46700 46700 A 0 090 0 1 0 2 0 1 0 9.81 8.13 8.13 1.63 19.57 19.57 17.963 17.963
46705 46705 A 0 090 0 1 0 2 0 2 1 7.43 7.46 7.46 0.52 15.41 15.41 14.401 14.401
46706 46706 A 0 010 0 1 0 2 0 1 0 2.44 2.22 2.22 0.42 5.08 5.08 4.653 4.653
46707 46707 A 0 090 0 1 0 2 0 0 0 6.39 6.59 6.59 0.90 13.88 13.88 12.779 12.779
46710 46710 A 0 090 0 1 0 2 0 2 1 17.14 11.97 11.97 3.67 32.78 32.78 29.808 29.808
46712 46712 A 0 090 0 1 0 2 0 2 1 36.45 21.34 21.34 2.59 60.38 60.38 56.968 56.968
46715 46715 A 0 090 0 1 0 2 0 2 0 7.62 6.63 6.63 0.53 14.78 14.78 13.851 13.851
46716 46716 A 0 090 0 1 0 2 0 2 1 17.54 14.23 14.23 1.24 33.01 33.01 30.967 30.967
46730 46730 A 0 090 0 1 0 2 0 2 1 30.65 20.92 20.92 2.18 53.75 53.75 50.576 50.576
46735 46735 A 0 090 0 1 0 2 0 2 1 36.14 21.21 21.21 2.57 59.92 59.92 56.531 56.531
46740 46740 A 0 090 0 1 0 2 0 2 1 33.90 17.90 17.90 7.23 59.03 59.03 53.755 53.755
46742 46742 A 0 090 0 1 0 2 0 2 1 40.14 22.84 22.84 8.56 71.54 71.54 65.127 65.127
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
186 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
46744 46744 A 0 090 0 1 0 2 0 2 1 58.94 32.22 32.22 8.42 99.58 99.58 92.277 92.277
46746 46746 A 0 090 0 1 0 2 0 2 1 65.44 33.24 33.24 4.64 103.32 103.32 97.716 97.716
46748 46748 A 0 090 0 1 0 2 0 2 1 71.42 37.09 37.09 5.08 113.59 113.59 107.384 107.384
46750 46750 A 0 090 0 1 0 2 0 2 1 12.15 8.60 8.60 1.97 22.72 22.72 20.903 20.903
46751 46751 A 0 090 0 1 0 2 0 2 1 9.30 7.06 7.06 1.57 17.93 17.93 16.461 16.461
46753 46753 A 0 090 0 1 0 2 0 1 0 8.89 7.18 7.18 1.51 17.58 17.58 16.127 16.127
46754 46754 A 0 010 0 1 0 2 0 0 0 3.01 5.69 3.60 0.42 9.12 7.03 8.339 6.462
46760 46760 A 0 090 0 1 0 2 0 2 1 17.45 12.79 12.79 2.48 32.72 32.72 30.232 30.232
46761 46761 A 0 090 0 1 0 2 0 2 1 15.29 9.94 9.94 2.42 27.65 27.65 25.482 25.482
46762 46762 A 0 090 0 1 0 2 0 2 1 14.82 10.66 10.66 2.12 27.60 27.60 25.501 25.501
46900 46900 A 0 010 0 1 0 2 0 1 0 1.91 5.18 1.95 0.30 7.39 4.16 6.719 3.818
46910 46910 A 0 010 0 1 0 2 0 1 0 1.91 5.57 1.80 0.34 7.82 4.05 7.090 3.704
46916 46916 A 0 010 0 1 0 2 0 1 0 1.91 4.82 2.14 0.27 7.00 4.32 6.380 3.973
46917 46917 A 0 010 0 1 0 2 0 1 0 1.91 11.85 1.78 0.33 14.09 4.02 12.724 3.681
46922 46922 A 0 010 0 1 0 2 0 1 0 1.91 5.97 1.81 0.35 8.23 4.07 7.454 3.718
46924 46924 A 0 010 0 1 0 2 0 1 0 2.81 13.31 2.27 0.45 16.57 5.53 14.998 5.084
46930 46930 A 0 090 0 1 0 2 0 0 0 1.61 4.40 2.62 0.26 6.27 4.49 5.697 4.099
46940 46940 A 0 010 0 1 0 2 0 1 0 2.35 4.27 1.66 0.37 6.99 4.38 6.378 4.034
46942 46942 A 0 010 0 1 0 2 0 0 0 2.07 4.22 1.55 0.33 6.62 3.95 6.032 3.634
46945 46945 A 0 090 0 1 0 2 0 1 0 2.21 6.86 4.30 0.38 9.45 6.89 8.569 6.270
46946 46946 A 0 090 0 1 0 2 0 1 0 2.63 6.49 3.74 0.44 9.56 6.81 8.688 6.219
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
187 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
46947 46947 A 0 090 0 1 0 2 0 1 0 5.57 4.79 4.79 1.09 11.45 11.45 10.441 10.441
46999 46999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
47000 47000 A 0 000 0 0 0 2 0 1 0 1.90 8.93 0.95 0.20 11.03 3.05 10.024 2.858
47001 47001 A 0 ZZZ 0 0 0 0 0 1 1 1.90 0.74 0.74 0.38 3.02 3.02 2.763 2.763
47010 47010 A 0 090 0 1 0 2 0 2 1 19.40 12.24 12.24 3.96 35.60 35.60 32.463 32.463
47011 47011 A 0 000 0 0 0 2 0 1 0 3.69 1.29 1.29 0.35 5.33 5.33 5.031 5.031
47015 47015 A 0 090 0 1 0 2 0 2 1 18.50 12.00 12.00 3.93 34.43 34.43 31.331 31.331
47100 47100 A 0 090 0 1 0 2 0 2 1 12.91 9.51 9.51 2.69 25.11 25.11 22.857 22.857
47120 47120 A 0 090 0 1 0 2 0 2 1 39.01 21.36 21.36 8.26 68.63 68.63 62.511 62.511
47122 47122 A 0 090 0 1 0 2 0 2 1 59.48 28.52 28.52 12.64 100.64 100.64 91.702 91.702
47125 47125 A 0 090 0 1 0 2 0 2 1 53.04 26.17 26.17 11.20 90.41 90.41 82.398 82.398
47130 47130 A 0 090 0 1 0 2 0 2 1 57.19 27.63 27.63 12.04 96.86 96.86 88.299 88.299
47133 47133 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
47135 47135 R 0 090 0 1 0 2 0 2 1 83.64 42.85 42.85 17.71 144.20 144.20 131.382 131.382
47136 47136 R 0 090 0 1 0 2 0 2 1 70.74 37.87 37.87 15.09 123.70 123.70 112.639 112.639
47140 47140 A 0 090 0 1 0 2 0 2 1 59.40 33.24 33.24 12.67 105.31 105.31 95.876 95.876
47141 47141 A 0 090 0 1 0 2 0 2 1 71.50 39.02 39.02 5.08 115.60 115.60 109.197 109.197
47142 47142 A 0 090 0 1 0 2 0 2 1 79.44 42.16 42.16 16.93 138.53 138.53 126.154 126.154
47143 47143 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
47144 47144 C 0 090 0 1 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
47145 47145 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
188 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
47146 47146 A 0 XXX 0 0 0 2 0 2 1 6.00 2.37 2.37 1.28 9.65 9.65 8.798 8.798
47147 47147 A 0 XXX 0 0 0 2 0 2 1 7.00 2.78 2.78 1.48 11.26 11.26 10.270 10.270
47300 47300 A 0 090 0 1 0 2 0 2 1 18.14 11.60 11.60 3.84 33.58 33.58 30.565 30.565
47350 47350 A 0 090 0 1 0 2 0 2 1 22.49 13.33 13.33 4.70 40.52 40.52 36.918 36.918
47360 47360 A 0 090 0 1 0 2 0 2 1 31.31 17.40 17.40 6.67 55.38 55.38 50.424 50.424
47361 47361 A 0 090 0 1 0 2 0 2 1 52.60 25.70 25.70 10.70 89.00 89.00 81.275 81.275
47362 47362 A 0 090 0 1 0 2 0 2 1 23.54 14.33 14.33 4.94 42.81 42.81 38.992 38.992
47370 47370 A 0 090 0 1 0 2 0 2 1 20.80 11.53 11.53 4.22 36.55 36.55 33.361 33.361
47371 47371 A 0 090 0 1 0 2 0 2 1 20.80 11.85 11.85 4.44 37.09 37.09 33.763 33.763
47379 47379 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
47380 47380 A 0 090 0 1 0 2 0 2 1 24.56 12.81 12.81 4.95 42.32 42.32 38.652 38.652
47381 47381 A 0 090 0 1 0 2 0 2 1 24.88 13.47 13.47 5.31 43.66 43.66 39.753 39.753
47382 47382 A 0 010 0 1 0 2 0 1 0 15.22 135.85 5.99 1.48 152.55 22.69 137.987 21.373
47399 47399 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
47400 47400 A 0 090 0 1 0 2 0 2 1 36.36 19.40 19.40 7.74 63.50 63.50 57.829 57.829
47420 47420 A 0 090 0 1 0 2 0 2 1 22.03 13.10 13.10 4.67 39.80 39.80 36.236 36.236
47425 47425 A 0 090 0 1 0 2 0 2 1 22.31 13.34 13.34 4.76 40.41 40.41 36.779 36.779
47460 47460 A 0 090 0 1 0 2 0 2 1 20.52 12.63 12.63 4.37 37.52 37.52 34.147 34.147
47480 47480 A 0 090 0 1 0 2 0 2 1 13.25 10.07 10.07 2.75 26.07 26.07 23.731 23.731
47490 47490 A 0 010 0 1 0 2 0 1 0 4.76 4.64 4.64 0.44 9.84 9.84 9.157 9.157
47500 47500 A 0 000 0 0 0 2 0 1 0 1.96 0.68 0.68 0.20 2.84 2.84 2.675 2.675
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
189 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
47505 47505 A 0 000 0 0 0 2 0 0 0 0.76 0.26 0.26 0.07 1.09 1.09 1.030 1.030
47510 47510 A 0 090 0 1 0 2 0 1 0 8.03 5.02 5.02 0.80 13.85 13.85 12.956 12.956
47511 47511 A 0 090 0 1 0 2 1 1 0 10.77 5.17 5.17 1.02 16.96 16.96 15.946 15.946
47525 47525 A 0 000 0 0 0 2 1 1 0 1.54 13.35 0.81 0.14 15.03 2.49 13.602 2.341
47530 47530 A 0 090 0 1 0 2 0 1 0 6.05 35.28 3.72 0.61 41.94 10.38 38.050 9.710
47550 47550 A 0 ZZZ 0 0 0 0 0 2 1 3.02 1.20 1.20 0.63 4.85 4.85 4.427 4.427
47552 47552 A 0 000 0 0 0 2 0 1 1 6.03 2.53 2.53 0.63 9.19 9.19 8.631 8.631
47553 47553 A 0 000 0 0 0 3 0 1 0 6.34 2.20 2.20 0.63 9.17 9.17 8.645 8.645
47554 47554 A 0 000 0 0 0 3 0 1 1 9.05 3.81 3.81 1.51 14.37 14.37 13.261 13.261
47555 47555 A 0 000 0 0 0 3 0 1 0 7.55 2.59 2.59 0.71 10.85 10.85 10.247 10.247
47556 47556 A 0 000 0 0 0 3 0 1 0 8.55 2.98 2.98 0.80 12.33 12.33 11.644 11.644
47560 47560 A 0 000 0 0 0 2 0 0 0 4.88 1.93 1.93 1.05 7.86 7.86 7.162 7.162
47561 47561 A 0 000 0 0 0 2 0 0 0 5.17 2.38 2.38 1.10 8.65 8.65 7.883 7.883
47562 47562 A 0 090 0 1 0 2 0 2 1 10.47 6.81 6.81 2.21 19.49 19.49 17.741 17.741
47563 47563 A 0 090 0 1 0 2 0 2 1 11.47 7.26 7.26 2.43 21.16 21.16 19.260 19.260
47564 47564 A 0 090 0 1 0 2 0 2 1 18.00 11.13 11.13 3.84 32.97 32.97 30.003 30.003
47570 47570 A 0 090 0 1 0 2 0 2 1 12.56 7.69 7.69 2.67 22.92 22.92 20.862 20.862
47579 47579 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
47600 47600 A 0 090 0 1 0 2 0 2 1 17.48 10.42 10.42 3.70 31.60 31.60 28.772 28.772
47605 47605 A 0 090 0 1 0 2 0 2 1 18.48 10.84 10.84 3.93 33.25 33.25 30.270 30.270
47610 47610 A 0 090 0 1 0 2 0 2 1 20.92 11.69 11.69 4.45 37.06 37.06 33.745 33.745
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
190 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
47612 47612 A 0 090 0 1 0 2 0 2 1 21.21 11.70 11.70 4.50 37.41 37.41 34.070 34.070
47620 47620 A 0 090 0 1 0 2 0 2 1 23.07 12.68 12.68 4.94 40.69 40.69 37.040 37.040
47630 47630 A 0 090 0 1 0 2 0 1 1 9.65 5.30 5.30 1.21 16.16 16.16 15.042 15.042
47700 47700 A 0 090 0 1 0 2 0 2 1 16.50 11.19 11.19 3.52 31.21 31.21 28.390 28.390
47701 47701 A 0 090 0 1 0 2 0 0 0 28.73 16.36 16.36 6.11 51.20 51.20 46.617 46.617
47711 47711 A 0 090 0 1 0 2 0 2 1 25.90 14.39 14.39 5.48 45.77 45.77 41.688 41.688
47712 47712 A 0 090 0 1 0 2 0 2 1 33.72 18.03 18.03 7.20 58.95 58.95 53.677 53.677
47715 47715 A 0 090 0 1 0 2 0 2 1 21.55 13.21 13.21 4.60 39.36 39.36 35.818 35.818
47720 47720 A 0 090 0 1 0 2 0 2 1 18.34 11.94 11.94 3.88 34.16 34.16 31.091 31.091
47721 47721 A 0 090 0 1 0 2 0 2 1 21.99 13.38 13.38 4.70 40.07 40.07 36.463 36.463
47740 47740 A 0 090 0 1 0 2 0 2 1 21.23 13.08 13.08 4.52 38.83 38.83 35.340 35.340
47741 47741 A 0 090 0 1 0 2 0 2 1 24.21 14.26 14.26 5.16 43.63 43.63 39.714 39.714
47760 47760 A 0 090 0 1 0 2 0 2 1 38.32 19.95 19.95 8.11 66.38 66.38 60.477 60.477
47765 47765 A 0 090 0 1 0 2 0 2 1 52.19 26.16 26.16 11.13 89.48 89.48 81.503 81.503
47780 47780 A 0 090 0 1 0 2 0 2 1 42.32 21.50 21.50 8.98 72.80 72.80 66.324 66.324
47785 47785 A 0 090 0 1 0 2 0 2 1 56.19 27.19 27.19 11.99 95.37 95.37 86.877 86.877
47800 47800 A 0 090 0 1 0 2 0 2 1 26.17 14.96 14.96 5.59 46.72 46.72 42.528 42.528
47801 47801 A 0 090 0 1 0 2 0 2 1 17.60 9.96 9.96 2.44 30.00 30.00 27.820 27.820
47802 47802 A 0 090 0 1 0 2 0 2 1 24.93 14.88 14.88 5.32 45.13 45.13 41.075 41.075
47900 47900 A 0 090 0 1 0 2 0 2 1 22.44 13.52 13.52 4.72 40.68 40.68 37.050 37.050
47999 47999 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
191 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
48000 48000 A 0 090 0 1 0 2 0 2 1 31.95 16.45 16.45 6.18 54.58 54.58 49.954 49.954
48001 48001 A 0 090 0 1 0 2 0 2 1 39.69 19.82 19.82 8.48 67.99 67.99 61.923 61.923
48020 48020 A 0 090 0 1 0 2 0 2 1 19.09 11.67 11.67 4.08 34.84 34.84 31.704 31.704
48100 48100 A 0 090 0 1 0 2 0 2 1 14.46 8.76 8.76 2.99 26.21 26.21 23.890 23.890
48102 48102 A 0 010 0 1 0 2 0 1 0 4.70 10.65 1.94 0.44 15.79 7.08 14.494 6.672
48105 48105 A 0 090 0 1 0 2 0 2 1 49.26 24.42 24.42 10.30 83.98 83.98 76.576 76.576
48120 48120 A 0 090 0 1 0 2 0 2 1 18.41 10.47 10.47 3.91 32.79 32.79 29.857 29.857
48140 48140 A 0 090 0 1 0 2 0 2 1 26.32 14.14 14.14 5.58 46.04 46.04 41.936 41.936
48145 48145 A 0 090 0 1 0 2 0 2 1 27.39 14.95 14.95 5.83 48.17 48.17 43.864 43.864
48146 48146 A 0 090 0 1 0 2 0 2 1 30.60 18.05 18.05 6.52 55.17 55.17 50.219 50.219
48148 48148 A 0 090 0 1 0 2 0 2 1 20.39 12.18 12.18 4.34 36.91 36.91 33.597 33.597
48150 48150 A 0 090 0 1 0 2 0 2 1 52.84 27.35 27.35 11.23 91.42 91.42 83.274 83.274
48152 48152 A 0 090 0 1 0 2 0 2 1 48.65 26.10 26.10 10.38 85.13 85.13 77.517 77.517
48153 48153 A 0 090 0 1 0 2 0 2 1 52.79 27.09 27.09 11.21 91.09 91.09 82.980 82.980
48154 48154 A 0 090 0 1 0 2 0 2 1 48.88 26.19 26.19 10.43 85.50 85.50 77.854 77.854
48155 48155 A 0 090 0 1 0 2 0 2 1 29.45 18.02 18.02 6.27 53.74 53.74 48.911 48.911
48160 48160 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
48400 48400 A 0 ZZZ 0 0 0 0 0 0 0 1.95 1.03 1.03 0.29 3.27 3.27 3.027 3.027
48500 48500 A 0 090 0 1 0 2 0 2 1 18.16 12.10 12.10 3.87 34.13 34.13 31.050 31.050
48510 48510 A 0 090 0 1 0 2 0 2 1 17.19 11.29 11.29 3.59 32.07 32.07 29.206 29.206
48511 48511 A 0 000 0 0 0 2 0 1 0 3.99 23.64 1.39 0.38 28.01 5.76 25.417 5.437
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
192 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
48520 48520 A 0 090 0 1 0 2 0 2 1 18.15 10.33 10.33 3.84 32.32 32.32 29.435 29.435
48540 48540 A 0 090 0 1 0 2 0 2 1 21.94 12.05 12.05 4.67 38.66 38.66 35.203 35.203
48545 48545 A 0 090 0 1 0 2 0 2 1 22.23 12.77 12.77 4.75 39.75 39.75 36.182 36.182
48547 48547 A 0 090 0 1 0 2 0 2 1 30.38 15.99 15.99 6.46 52.83 52.83 48.118 48.118
48548 48548 A 0 090 0 1 0 2 0 2 1 28.09 14.99 14.99 5.97 49.05 49.05 44.673 44.673
48550 48550 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
48551 48551 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
48552 48552 A 0 XXX 0 0 0 2 0 2 1 4.30 1.70 1.70 0.90 6.90 6.90 6.297 6.297
48554 48554 R 0 090 0 1 0 2 0 2 2 37.80 30.60 30.60 7.89 76.29 76.29 69.405 69.405
48556 48556 A 0 090 0 1 0 2 0 2 2 19.47 14.27 14.27 4.15 37.89 37.89 34.455 34.455
48999 48999 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
49000 49000 A 0 090 0 1 0 2 0 2 1 12.54 7.69 7.69 2.57 22.80 22.80 20.790 20.790
49002 49002 A 0 090 0 1 0 2 0 2 1 17.63 9.60 9.60 3.66 30.89 30.89 28.165 28.165
49010 49010 A 0 090 0 1 0 2 0 2 1 16.06 8.38 8.38 3.20 27.64 27.64 25.259 25.259
49020 49020 A 0 090 0 1 0 2 0 2 0 26.67 14.88 14.88 5.42 46.97 46.97 42.867 42.867
49021 49021 A 0 000 0 0 0 2 0 1 0 3.37 22.80 1.18 0.31 26.48 4.86 24.007 4.592
49040 49040 A 0 090 0 1 0 2 0 2 1 16.52 9.80 9.80 3.39 29.71 29.71 27.093 27.093
49041 49041 A 0 000 0 0 0 2 0 1 0 3.99 23.22 1.40 0.38 27.59 5.77 25.040 5.446
49060 49060 A 0 090 0 1 0 2 0 1 1 18.53 10.23 10.23 3.69 32.45 32.45 29.646 29.646
49061 49061 A 0 000 0 0 0 2 0 1 0 3.69 22.92 1.29 0.34 26.95 5.32 24.450 5.026
49062 49062 A 0 090 0 1 0 2 0 2 1 12.22 7.16 7.16 2.46 21.84 21.84 19.936 19.936
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
193 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
49082 49082 A 0 000 0 0 0 2 0 1 0 1.24 3.96 0.78 0.11 5.31 2.13 4.854 1.998
49083 49083 A 0 000 0 0 0 2 0 1 0 2.00 7.39 1.11 0.18 9.57 3.29 8.730 3.091
49084 49084 A 0 000 0 0 0 2 0 1 0 2.00 0.81 0.81 0.18 2.99 2.99 2.822 2.822
49180 49180 A 0 000 0 0 0 2 0 1 0 1.73 2.93 0.61 0.16 4.82 2.50 4.445 2.361
49203 49203 A 0 090 0 1 0 2 0 2 1 20.13 11.13 11.13 3.93 35.19 35.19 32.180 32.180
49204 49204 A 0 090 0 1 0 2 0 2 1 26.13 13.66 13.66 5.08 44.87 44.87 41.054 41.054
49205 49205 A 0 090 0 1 0 2 0 2 1 30.13 15.37 15.37 6.03 51.53 51.53 47.086 47.086
49215 49215 A 0 090 0 1 0 2 0 2 1 37.81 19.69 19.69 7.54 65.04 65.04 59.435 59.435
49220 49220 A 0 090 0 1 0 2 0 2 1 15.79 8.89 8.89 3.39 28.07 28.07 25.546 25.546
49250 49250 A 0 090 0 1 0 2 0 1 1 9.01 6.50 6.50 1.84 17.35 17.35 15.809 15.809
49255 49255 A 0 090 0 1 0 2 0 2 1 12.56 8.39 8.39 2.55 23.50 23.50 21.428 21.428
49320 49320 A 0 010 0 1 0 2 0 2 0 5.14 3.56 3.56 1.03 9.73 9.73 8.876 8.876
49321 49321 A 0 010 0 1 0 3 0 2 2 5.44 3.74 3.74 1.13 10.31 10.31 9.390 9.390
49322 49322 A 0 010 0 1 0 3 0 2 2 6.01 3.84 3.84 1.16 11.01 11.01 10.065 10.065
49323 49323 A 0 090 0 1 0 3 0 2 2 10.23 6.85 6.85 2.14 19.22 19.22 17.501 17.501
49324 49324 A 0 010 0 1 0 3 0 2 2 6.32 4.04 4.04 1.33 11.69 11.69 10.644 10.644
49325 49325 A 0 010 0 1 0 3 0 2 2 6.82 4.19 4.19 1.47 12.48 12.48 11.351 11.351
49326 49326 A 0 ZZZ 0 0 0 0 0 2 1 3.50 1.31 1.31 0.73 5.54 5.54 5.058 5.058
49327 49327 A 0 ZZZ 0 0 0 0 0 2 1 2.38 0.94 0.94 0.48 3.80 3.80 3.475 3.475
49329 49329 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
49400 49400 A 0 000 0 0 0 2 0 1 0 1.88 1.91 0.66 0.24 4.03 2.78 3.721 2.598
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
194 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
49402 49402 A 0 090 0 1 0 2 0 1 1 14.09 8.31 8.31 2.90 25.30 25.30 23.069 23.069
49411 49411 A 0 000 0 0 0 2 0 0 0 3.82 12.07 1.58 0.35 16.24 5.75 14.842 5.422
49412 49412 A 0 ZZZ 0 0 0 0 0 0 1 1.50 0.59 0.59 0.30 2.39 2.39 2.187 2.187
49418 49418 A 0 000 0 0 0 2 0 0 0 4.21 39.30 1.79 0.63 44.14 6.63 39.831 6.147
49419 49419 A 0 090 0 1 0 2 0 1 0 7.08 4.65 4.65 1.22 12.95 12.95 11.894 11.894
49421 49421 A 0 000 0 0 0 2 0 1 0 4.21 1.73 1.73 0.83 6.77 6.77 6.198 6.198
49422 49422 A 0 010 0 1 0 2 0 1 0 6.29 3.74 3.74 1.29 11.32 11.32 10.323 10.323
49423 49423 A 0 000 0 0 0 2 0 0 0 1.46 15.16 0.54 0.12 16.74 2.12 15.136 2.008
49424 49424 A 0 000 0 0 0 2 0 0 0 0.76 3.59 0.30 0.07 4.42 1.13 4.020 1.066
49425 49425 A 0 090 0 1 0 2 0 2 1 12.22 7.44 7.44 2.67 22.33 22.33 20.298 20.298
49426 49426 A 0 090 0 1 0 2 0 1 0 10.41 6.09 6.09 2.07 18.57 18.57 16.961 16.961
49427 49427 A 0 000 0 0 0 2 0 0 0 0.89 0.33 0.33 0.10 1.32 1.32 1.239 1.239
49428 49428 A 0 010 0 1 0 2 0 1 0 6.87 4.46 4.46 1.47 12.80 12.80 11.644 11.644
49429 49429 A 0 010 0 1 0 2 0 1 0 7.44 4.06 4.06 1.59 13.09 13.09 11.917 11.917
49435 49435 A 0 ZZZ 0 0 0 0 0 2 1 2.25 0.81 0.81 0.45 3.51 3.51 3.213 3.213
49436 49436 A 0 010 0 1 0 2 0 2 1 2.72 2.29 2.29 0.59 5.60 5.60 5.085 5.085
49440 49440 A 0 010 0 1 0 2 0 0 0 4.18 27.42 1.97 0.48 32.08 6.63 29.054 6.200
49441 49441 A 0 010 0 1 0 2 0 0 0 4.77 30.72 2.24 0.54 36.03 7.55 32.639 7.064
49442 49442 A 0 010 0 1 0 2 0 0 0 4.00 24.26 2.06 0.37 28.63 6.43 25.979 6.043
49446 49446 A 0 000 0 0 0 2 0 0 0 3.31 26.84 1.16 0.31 30.46 4.78 27.574 4.514
49450 49450 A 0 000 0 0 0 2 0 0 0 1.36 19.04 0.48 0.12 20.52 1.96 18.521 1.854
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
195 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
49451 49451 A 0 000 0 0 0 2 0 0 0 1.84 20.34 0.65 0.20 22.38 2.69 20.210 2.528
49452 49452 A 0 000 0 0 0 2 0 0 0 2.86 24.35 1.00 0.27 27.48 4.13 24.868 3.899
49460 49460 A 0 000 0 0 0 2 0 0 0 0.96 21.57 0.35 0.10 22.63 1.41 20.382 1.327
49465 49465 A 0 000 0 0 0 2 0 0 0 0.62 4.37 0.22 0.05 5.04 0.89 4.570 0.844
49491 49491 A 0 090 0 1 0 2 1 2 1 12.53 8.30 8.30 2.67 23.50 23.50 21.380 21.380
49492 49492 A 0 090 0 1 0 2 1 2 1 15.43 8.83 8.83 3.29 27.55 27.55 25.080 25.080
49495 49495 A 0 090 0 1 0 2 1 2 1 6.20 4.17 4.17 1.32 11.69 11.69 10.635 10.635
49496 49496 A 0 090 0 1 0 2 1 2 1 9.42 5.32 5.32 2.20 16.94 16.94 15.348 15.348
49500 49500 A 0 090 0 1 0 2 1 2 1 5.84 4.01 4.01 1.24 11.09 11.09 10.090 10.090
49501 49501 A 0 090 0 1 0 2 1 2 1 9.36 6.60 6.60 1.99 17.95 17.95 16.328 16.328
49505 49505 A 0 090 0 1 0 2 1 2 1 7.96 5.83 5.83 1.66 15.45 15.45 14.064 14.064
49507 49507 A 0 090 0 1 0 2 1 2 1 9.09 6.36 6.36 1.92 17.37 17.37 15.805 15.805
49520 49520 A 0 090 0 1 0 2 1 2 1 9.99 6.62 6.62 2.10 18.71 18.71 17.033 17.033
49521 49521 A 0 090 0 1 0 2 1 2 1 11.48 7.29 7.29 2.41 21.18 21.18 19.287 19.287
49525 49525 A 0 090 0 1 0 2 1 2 1 8.93 6.18 6.18 1.86 16.97 16.97 15.452 15.452
49540 49540 A 0 090 0 1 0 2 1 2 1 10.74 7.01 7.01 2.26 20.01 20.01 18.217 18.217
49550 49550 A 0 090 0 1 0 2 1 2 1 8.99 6.20 6.20 1.89 17.08 17.08 15.546 15.546
49553 49553 A 0 090 0 1 0 2 1 2 1 9.92 6.68 6.68 2.10 18.70 18.70 17.017 17.017
49555 49555 A 0 090 0 1 0 2 1 2 1 9.39 6.32 6.32 1.97 17.68 17.68 16.096 16.096
49557 49557 A 0 090 0 1 0 2 1 2 1 11.62 7.30 7.30 2.45 21.37 21.37 19.457 19.457
49560 49560 A 0 090 0 1 0 2 1 2 1 11.92 7.40 7.40 2.48 21.80 21.80 19.862 19.862
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
196 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
49561 49561 A 0 090 0 1 0 2 1 2 1 15.38 8.85 8.85 3.24 27.47 27.47 25.022 25.022
49565 49565 A 0 090 0 1 0 2 1 2 1 12.37 7.75 7.75 2.60 22.72 22.72 20.689 20.689
49566 49566 A 0 090 0 1 0 2 1 2 1 15.53 8.94 8.94 3.29 27.76 27.76 25.279 25.279
49568 49568 A 0 ZZZ 0 0 0 0 0 2 1 4.88 1.93 1.93 1.03 7.84 7.84 7.152 7.152
49570 49570 A 0 090 0 1 0 2 1 2 1 6.05 5.10 5.10 1.28 12.43 12.43 11.299 11.299
49572 49572 A 0 090 0 1 0 2 1 2 1 7.87 5.80 5.80 1.65 15.32 15.32 13.941 13.941
49580 49580 A 0 090 0 1 0 2 0 2 1 4.47 4.55 4.55 0.95 9.97 9.97 9.053 9.053
49582 49582 A 0 090 0 1 0 2 0 2 1 7.13 5.72 5.72 1.52 14.37 14.37 13.062 13.062
49585 49585 A 0 090 0 1 0 2 0 2 1 6.59 5.26 5.26 1.37 13.22 13.22 12.030 12.030
49587 49587 A 0 090 0 1 0 2 0 2 1 7.08 5.58 5.58 1.49 14.15 14.15 12.870 12.870
49590 49590 A 0 090 0 1 0 2 1 2 1 8.90 6.21 6.21 1.88 16.99 16.99 15.460 15.460
49600 49600 A 0 090 0 1 0 2 0 2 1 11.55 7.62 7.62 2.45 21.62 21.62 19.674 19.674
49605 49605 A 0 090 0 1 0 2 0 2 1 87.09 39.23 39.23 18.58 144.90 144.90 132.036 132.036
49606 49606 A 0 090 0 1 0 2 0 2 1 19.00 10.32 10.32 4.06 33.38 33.38 30.391 30.391
49610 49610 A 0 090 0 1 0 2 0 2 1 10.91 5.08 5.08 2.31 18.30 18.30 16.680 16.680
49611 49611 A 0 090 0 1 0 2 0 2 1 9.34 5.26 5.26 0.65 15.25 15.25 14.403 14.403
49650 49650 A 0 090 0 1 0 2 1 2 1 6.36 5.05 5.05 1.33 12.74 12.74 11.590 11.590
49651 49651 A 0 090 0 1 0 2 1 2 1 8.38 6.42 6.42 1.78 16.58 16.58 15.076 15.076
49652 49652 A 0 090 0 1 0 2 1 2 1 11.92 7.61 7.61 0.83 20.36 20.36 19.188 19.188
49653 49653 A 0 090 0 1 0 2 1 2 1 14.94 9.38 9.38 1.07 25.39 25.39 23.923 23.923
49654 49654 A 0 090 0 1 0 2 1 2 1 13.76 8.35 8.35 0.97 23.08 23.08 21.766 21.766
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
197 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
49655 49655 A 0 090 0 1 0 2 1 2 1 16.84 10.13 10.13 1.19 28.16 28.16 26.559 26.559
49656 49656 A 0 090 0 1 0 2 1 2 1 15.08 8.86 8.86 1.08 25.02 25.02 23.601 23.601
49657 49657 A 0 090 0 1 0 2 1 2 1 22.11 12.22 12.22 1.57 35.90 35.90 33.905 33.905
49659 49659 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
49900 49900 A 0 090 0 1 0 2 0 2 1 12.41 9.30 9.30 2.55 24.26 24.26 22.095 22.095
49904 49904 A 0 090 0 1 0 2 0 1 1 22.35 16.12 16.12 4.75 43.22 43.22 39.310 39.310
49905 49905 A 0 ZZZ 0 0 0 0 0 2 2 6.54 2.56 2.56 1.24 10.34 10.34 9.487 9.487
49906 49906 C 0 090 0 1 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
49999 49999 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
50010 50010 A 0 090 0 1 0 2 1 2 1 12.28 7.45 7.45 1.80 21.53 21.53 19.912 19.912
50020 50020 A 0 090 0 1 0 2 0 1 1 18.08 10.66 10.66 2.41 31.15 31.15 28.913 28.913
50021 50021 A 0 000 0 0 0 2 0 1 0 3.37 24.47 1.17 0.31 28.15 4.85 25.506 4.583
50040 50040 A 0 090 0 1 0 2 1 1 1 16.68 8.42 8.42 1.69 26.79 26.79 25.125 25.125
50045 50045 A 0 090 0 1 0 2 1 2 1 16.82 8.47 8.47 1.62 26.91 26.91 25.273 25.273
50060 50060 A 0 090 0 1 0 2 1 2 1 20.95 9.91 9.91 2.01 32.87 32.87 30.900 30.900
50065 50065 A 0 090 0 1 0 2 1 2 0 22.32 10.39 10.39 2.16 34.87 34.87 32.780 32.780
50070 50070 A 0 090 0 1 0 2 1 2 1 21.85 10.23 10.23 2.12 34.20 34.20 32.145 32.145
50075 50075 A 0 090 0 1 0 2 1 2 1 27.09 12.31 12.31 2.63 42.03 42.03 39.520 39.520
50080 50080 A 0 090 0 1 0 2 1 1 0 15.74 7.84 7.84 1.55 25.13 25.13 23.591 23.591
50081 50081 A 0 090 0 1 0 2 1 2 1 23.50 11.06 11.06 2.31 36.87 36.87 34.640 34.640
50100 50100 A 0 090 0 1 0 2 1 2 1 17.45 8.69 8.69 3.73 29.87 29.87 27.204 27.204
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
198 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
50120 50120 A 0 090 0 1 0 2 1 2 1 17.21 8.53 8.53 1.66 27.40 27.40 25.738 25.738
50125 50125 A 0 090 0 1 0 2 1 2 1 17.82 10.86 10.86 1.71 30.39 30.39 28.467 28.467
50130 50130 A 0 090 0 1 0 2 1 2 1 18.82 9.17 9.17 1.82 29.81 29.81 28.007 28.007
50135 50135 A 0 090 0 1 0 2 1 2 1 20.59 9.79 9.79 1.99 32.37 32.37 30.422 30.422
50200 50200 A 0 000 0 0 0 2 1 1 0 2.63 14.90 1.28 0.31 17.84 4.22 16.172 3.942
50205 50205 A 0 090 0 1 0 2 1 2 1 12.29 7.49 7.49 2.40 22.18 22.18 20.271 20.271
50220 50220 A 0 090 0 1 0 2 1 2 1 18.68 9.38 9.38 2.25 30.31 30.31 28.280 28.280
50225 50225 A 0 090 0 1 0 2 1 2 1 21.88 10.43 10.43 2.38 34.69 34.69 32.491 32.491
50230 50230 A 0 090 0 1 0 2 1 2 2 23.81 10.71 10.71 2.45 36.97 36.97 34.709 34.709
50234 50234 A 0 090 0 1 0 2 1 2 1 24.05 11.05 11.05 2.44 37.54 37.54 35.249 35.249
50236 50236 A 0 090 0 1 0 2 1 2 1 26.94 12.72 12.72 2.64 42.30 42.30 39.743 39.743
50240 50240 A 0 090 0 1 0 2 1 2 1 24.21 11.60 11.60 2.42 38.23 38.23 35.892 35.892
50250 50250 A 0 090 0 1 0 2 0 2 1 22.22 10.80 10.80 2.18 35.20 35.20 33.059 33.059
50280 50280 A 0 090 0 1 0 2 1 2 1 17.09 8.76 8.76 1.86 27.71 27.71 25.929 25.929
50290 50290 A 0 090 0 1 0 2 0 2 1 16.15 8.23 8.23 1.57 25.95 25.95 24.362 24.362
50300 50300 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
50320 50320 A 0 090 0 1 0 2 1 2 1 22.43 16.29 16.29 3.88 42.60 42.60 39.088 39.088
50323 50323 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
50325 50325 C 0 XXX 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
50327 50327 A 0 XXX 0 0 0 2 0 2 1 4.00 1.54 1.54 0.78 6.32 6.32 5.791 5.791
50328 50328 A 0 XXX 0 0 0 2 0 2 1 3.50 1.35 1.35 0.67 5.52 5.52 5.063 5.063
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
199 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
50329 50329 A 0 XXX 0 0 0 2 0 2 1 3.34 1.27 1.27 0.48 5.09 5.09 4.732 4.732
50340 50340 A 0 090 0 1 0 2 1 2 1 14.04 11.19 11.19 3.01 28.24 28.24 25.663 25.663
50360 50360 A 0 090 0 1 0 2 0 2 2 40.90 26.87 26.87 8.30 76.07 76.07 69.370 69.370
50365 50365 A 0 090 0 1 0 2 1 2 2 46.13 28.53 28.53 9.84 84.50 84.50 76.896 76.896
50370 50370 A 0 090 0 1 0 2 0 2 1 18.88 12.89 12.89 3.76 35.53 35.53 32.422 32.422
50380 50380 A 0 090 0 1 0 2 0 2 1 30.11 23.01 23.01 6.41 59.53 59.53 54.125 54.125
50382 50382 A 0 000 0 0 0 2 1 1 0 5.50 29.92 1.94 0.52 35.94 7.96 32.640 7.514
50384 50384 A 0 000 0 0 0 2 1 1 0 5.00 23.30 1.76 0.48 28.78 7.24 26.174 6.832
50385 50385 A 0 000 0 0 0 2 1 0 0 4.44 29.76 1.88 0.42 34.62 6.74 31.384 6.348
50386 50386 A 0 000 0 0 0 2 1 0 0 3.30 18.80 1.49 0.31 22.41 5.10 20.345 4.800
50387 50387 A 0 000 0 0 0 2 1 0 0 2.00 14.58 0.68 0.20 16.78 2.88 15.197 2.715
50389 50389 A 0 000 0 0 0 2 1 1 0 1.10 7.89 0.39 0.10 9.09 1.59 8.238 1.503
50390 50390 A 0 000 0 0 0 2 1 1 0 1.96 0.68 0.68 0.18 2.82 2.82 2.665 2.665
50391 50391 A 0 000 0 0 0 2 1 1 0 1.96 1.39 0.69 0.20 3.55 2.85 3.313 2.684
50392 50392 A 0 000 0 0 0 2 1 1 0 3.37 1.55 1.55 0.31 5.23 5.23 4.924 4.924
50393 50393 A 0 000 0 0 0 2 1 1 0 4.15 1.82 1.82 0.38 6.35 6.35 5.983 5.983
50394 50394 A 0 000 0 0 0 2 1 1 0 0.76 2.22 0.64 0.07 3.05 1.47 2.790 1.371
50395 50395 A 0 000 0 0 0 2 1 1 0 3.37 1.54 1.54 0.33 5.24 5.24 4.926 4.926
50396 50396 A 0 000 0 0 0 2 1 0 0 2.09 0.99 0.99 0.20 3.28 3.28 3.084 3.084
50398 50398 A 0 000 0 0 0 2 1 1 0 1.46 13.54 0.54 0.12 15.12 2.12 13.682 2.008
50400 50400 A 0 090 0 1 0 2 1 2 1 21.27 10.07 10.07 2.10 33.44 33.44 31.411 31.411
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
200 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
50405 50405 A 0 090 0 1 0 2 1 2 1 25.86 11.89 11.89 2.50 40.25 40.25 37.845 37.845
50500 50500 A 0 090 0 1 0 2 0 2 1 21.22 11.56 11.56 4.52 37.30 37.30 33.965 33.965
50520 50520 A 0 090 0 1 0 2 0 2 1 18.88 9.19 9.19 1.84 29.91 29.91 28.095 28.095
50525 50525 A 0 090 0 1 0 2 0 2 1 24.39 13.71 13.71 5.20 43.30 43.30 39.421 39.421
50526 50526 A 0 090 0 1 0 2 0 2 0 26.31 13.70 13.70 1.86 41.87 41.87 39.585 39.585
50540 50540 A 0 090 0 1 0 2 2 2 1 21.10 9.97 9.97 2.03 33.10 33.10 31.115 31.115
50541 50541 A 0 090 0 1 0 2 1 2 1 16.86 8.01 8.01 1.70 26.57 26.57 24.942 24.942
50542 50542 A 0 090 0 1 0 2 1 2 1 21.36 10.22 10.22 2.10 33.68 33.68 31.636 31.636
50543 50543 A 0 090 0 1 0 2 1 2 1 27.41 12.87 12.87 2.72 43.00 43.00 40.390 40.390
50544 50544 A 0 090 0 1 0 2 1 2 1 23.37 10.28 10.28 2.31 35.96 35.96 33.810 33.810
50545 50545 A 0 090 0 1 0 2 1 2 1 25.06 11.11 11.11 2.55 38.72 38.72 36.370 36.370
50546 50546 A 0 090 0 1 0 2 1 2 1 21.87 10.58 10.58 2.30 34.75 34.75 32.574 32.574
50547 50547 A 0 090 0 1 0 2 1 2 1 26.34 16.15 16.15 4.83 47.32 47.32 43.369 43.369
50548 50548 A 0 090 0 1 0 2 1 2 1 25.36 10.98 10.98 2.50 38.84 38.84 36.528 36.528
50549 50549 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
50551 50551 A 0 000 0 0 0 2 1 0 0 5.59 4.27 2.38 0.54 10.40 8.51 9.707 8.010
50553 50553 A 0 000 0 0 0 2 1 1 0 5.98 4.58 2.49 0.65 11.21 9.12 10.433 8.556
50555 50555 A 0 000 0 0 0 3 1 0 0 6.52 4.76 2.71 0.63 11.91 9.86 11.124 9.283
50557 50557 A 0 000 0 0 0 3 1 0 0 6.61 4.87 2.74 0.64 12.12 9.99 11.318 9.405
50561 50561 A 0 000 0 0 0 3 1 0 0 7.58 5.42 3.06 0.75 13.75 11.39 12.839 10.720
50562 50562 A 0 090 0 1 0 2 0 2 1 10.90 4.82 4.82 1.06 16.78 16.78 15.783 15.783
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
201 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
50570 50570 A 0 000 0 0 0 2 1 0 0 9.53 3.71 3.71 0.91 14.15 14.15 13.338 13.338
50572 50572 A 0 000 0 0 0 3 1 0 0 10.33 3.99 3.99 1.01 15.33 15.33 14.441 14.441
50574 50574 A 0 000 0 0 0 3 1 0 0 11.00 4.23 4.23 1.08 16.31 16.31 15.363 15.363
50575 50575 A 0 000 0 0 0 3 1 1 0 13.96 5.27 5.27 1.36 20.59 20.59 19.404 19.404
50576 50576 A 0 000 0 0 0 3 1 0 0 10.97 4.22 4.22 1.06 16.25 16.25 15.314 15.314
50580 50580 A 0 000 0 0 0 3 1 0 0 11.84 4.52 4.52 1.16 17.52 17.52 16.506 16.506
50590 50590 A 0 090 0 1 0 2 1 1 0 9.77 10.27 5.73 0.95 20.99 16.45 19.489 15.412
50592 50592 A 0 010 0 1 0 2 1 1 0 6.80 87.17 3.13 0.64 94.61 10.57 85.413 9.945
50593 50593 A 0 010 0 1 0 2 1 2 0 9.13 129.85 4.11 0.86 139.84 14.10 126.185 13.271
50600 50600 A 0 090 0 1 0 2 1 2 1 17.17 8.26 8.26 1.66 27.09 27.09 25.456 25.456
50605 50605 A 0 090 0 1 0 2 1 2 1 16.79 9.18 9.18 2.65 28.62 28.62 26.420 26.420
50610 50610 A 0 090 0 1 0 2 1 2 1 17.25 8.37 8.37 1.66 27.28 27.28 25.634 25.634
50620 50620 A 0 090 0 1 0 2 1 2 1 16.43 8.08 8.08 1.59 26.10 26.10 24.517 24.517
50630 50630 A 0 090 0 1 0 2 1 2 1 16.21 8.00 8.00 1.57 25.78 25.78 24.215 24.215
50650 50650 A 0 090 0 1 0 2 1 2 1 18.82 9.23 9.23 1.89 29.94 29.94 28.097 28.097
50660 50660 A 0 090 0 1 0 2 0 2 1 21.02 9.94 9.94 2.03 32.99 32.99 31.008 31.008
50684 50684 A 0 000 0 0 0 2 1 1 0 0.76 2.32 0.64 0.07 3.15 1.47 2.880 1.371
50686 50686 A 0 000 0 0 0 2 0 0 0 1.51 2.70 1.02 0.22 4.43 2.75 4.050 2.541
50688 50688 A 0 010 0 1 0 2 0 1 0 1.20 1.04 1.04 0.11 2.35 2.35 2.191 2.191
50690 50690 A 0 000 0 0 0 2 0 1 0 1.16 1.61 0.79 0.10 2.87 2.05 2.658 1.922
50700 50700 A 0 090 0 1 0 2 1 2 1 16.69 8.42 8.42 1.62 26.73 26.73 25.098 25.098
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
202 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
50715 50715 A 0 090 0 1 0 2 1 2 1 20.64 11.49 11.49 3.01 35.14 35.14 32.532 32.532
50722 50722 A 0 090 0 1 0 2 0 2 1 17.95 10.14 10.14 3.05 31.14 31.14 28.651 28.651
50725 50725 A 0 090 0 1 0 2 0 2 1 20.20 9.65 9.65 1.95 31.80 31.80 29.886 29.886
50727 50727 A 0 090 0 1 0 2 0 2 2 8.28 5.58 5.58 0.84 14.70 14.70 13.730 13.730
50728 50728 A 0 090 0 1 0 2 0 2 2 12.18 6.84 6.84 1.18 20.20 20.20 18.939 18.939
50740 50740 A 0 090 0 1 0 2 1 2 1 20.07 11.75 11.75 4.29 36.11 36.11 32.865 32.865
50750 50750 A 0 090 0 1 0 2 1 2 0 21.22 10.01 10.01 2.04 33.27 33.27 31.276 31.276
50760 50760 A 0 090 0 1 0 2 1 2 1 20.07 10.13 10.13 2.67 32.87 32.87 30.563 30.563
50770 50770 A 0 090 0 1 0 2 0 2 1 21.22 10.01 10.01 2.04 33.27 33.27 31.276 31.276
50780 50780 A 0 090 0 1 0 2 1 2 1 19.95 9.83 9.83 2.31 32.09 32.09 29.985 29.985
50782 50782 A 0 090 0 1 0 2 1 2 2 19.66 11.58 11.58 4.19 35.43 35.43 32.250 32.250
50783 50783 A 0 090 0 1 0 2 1 2 2 20.70 9.83 9.83 2.00 32.53 32.53 30.573 30.573
50785 50785 A 0 090 0 1 0 2 1 2 1 22.23 10.47 10.47 2.25 34.95 34.95 32.809 32.809
50800 50800 A 0 090 0 1 0 2 1 2 1 16.41 8.75 8.75 1.74 26.90 26.90 25.178 25.178
50810 50810 A 0 090 0 1 0 2 0 2 1 22.61 11.25 11.25 4.83 38.69 38.69 35.239 35.239
50815 50815 A 0 090 0 1 0 2 1 2 1 22.26 10.87 10.87 2.16 35.29 35.29 33.151 33.151
50820 50820 A 0 090 0 1 0 2 1 2 1 24.07 11.44 11.44 2.65 38.16 38.16 35.729 35.729
50825 50825 A 0 090 0 1 0 2 0 2 1 30.68 14.08 14.08 3.17 47.93 47.93 44.982 44.982
50830 50830 A 0 090 0 1 0 2 0 2 1 33.77 14.90 14.90 3.29 51.96 51.96 48.871 48.871
50840 50840 A 0 090 0 1 0 2 1 2 1 22.39 10.92 10.92 2.18 35.49 35.49 33.336 33.336
50845 50845 A 0 090 0 1 0 2 0 2 1 22.46 11.56 11.56 2.18 36.20 36.20 33.981 33.981
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
203 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
50860 50860 A 0 090 0 1 0 2 1 2 1 17.08 8.56 8.56 1.65 27.29 27.29 25.630 25.630
50900 50900 A 0 090 0 1 0 2 1 2 1 15.04 8.10 8.10 1.47 24.61 24.61 23.083 23.083
50920 50920 A 0 090 0 1 0 2 0 2 1 15.81 8.11 8.11 1.54 25.46 25.46 23.898 23.898
50930 50930 A 0 090 0 1 0 2 0 2 1 20.19 9.65 9.65 4.30 34.14 34.14 31.105 31.105
50940 50940 A 0 090 0 1 0 2 1 2 1 15.93 8.16 8.16 1.55 25.64 25.64 24.068 24.068
50945 50945 A 0 090 0 1 0 2 1 2 1 17.97 8.37 8.37 1.74 28.08 28.08 26.396 26.396
50947 50947 A 0 090 0 1 0 2 1 2 1 25.78 11.68 11.68 2.50 39.96 39.96 37.576 37.576
50948 50948 A 0 090 0 1 0 2 1 2 1 23.82 10.64 10.64 2.30 36.76 36.76 34.578 34.578
50949 50949 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
50951 50951 A 0 000 0 0 0 2 1 0 0 5.83 4.46 2.46 0.56 10.85 8.85 10.128 8.332
50953 50953 A 0 000 0 0 0 3 1 0 0 6.23 4.68 2.98 0.61 11.52 9.82 10.752 9.225
50955 50955 A 0 000 0 0 0 3 1 0 0 6.74 4.90 3.16 0.65 12.29 10.55 11.480 9.918
50957 50957 A 0 000 0 0 0 3 1 0 0 6.78 4.97 2.80 0.65 12.40 10.23 11.583 9.634
50961 50961 A 0 000 0 0 0 3 1 0 0 6.04 4.54 2.53 0.59 11.17 9.16 10.425 8.621
50970 50970 A 0 000 0 0 0 2 1 0 0 7.13 2.87 2.87 0.68 10.68 10.68 10.063 10.063
50972 50972 A 0 000 0 0 0 2 1 0 0 6.88 2.79 2.79 0.67 10.34 10.34 9.736 9.736
50974 50974 A 0 000 0 0 0 3 1 0 0 9.16 3.59 3.59 0.88 13.63 13.63 12.844 12.844
50976 50976 A 0 000 0 0 0 3 1 0 0 9.03 3.54 3.54 0.87 13.44 13.44 12.664 12.664
50980 50980 A 0 000 0 0 0 2 1 0 0 6.84 2.77 2.77 0.65 10.26 10.26 9.667 9.667
51020 51020 A 0 090 0 1 0 2 0 2 1 7.69 5.16 5.16 0.78 13.63 13.63 12.732 12.732
51030 51030 A 0 090 0 1 0 2 0 0 0 7.81 5.08 5.08 0.75 13.64 13.64 12.764 12.764
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
204 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
51040 51040 A 0 090 0 1 0 2 0 2 1 4.49 3.49 3.49 0.44 8.42 8.42 7.854 7.854
51045 51045 A 0 090 0 1 0 2 0 2 0 7.81 5.47 5.47 1.06 14.34 14.34 13.276 13.276
51050 51050 A 0 090 0 1 0 2 0 2 1 7.97 4.94 4.94 0.78 13.69 13.69 12.814 12.814
51060 51060 A 0 090 0 1 0 2 0 2 1 9.95 5.91 5.91 0.98 16.84 16.84 15.770 15.770
51065 51065 A 0 090 0 1 0 2 0 0 0 9.95 5.83 5.83 0.98 16.76 16.76 15.698 15.698
51080 51080 A 0 090 0 1 0 2 0 2 1 6.71 4.50 4.50 0.65 11.86 11.86 11.091 11.091
51100 51100 A 0 000 0 0 0 2 0 1 0 0.78 0.96 0.26 0.08 1.82 1.12 1.684 1.055
51101 51101 A 0 000 0 0 0 2 0 1 0 1.02 2.60 0.39 0.12 3.74 1.53 3.418 1.433
51102 51102 A 0 000 0 0 0 2 0 1 0 2.70 3.70 1.23 0.29 6.69 4.22 6.174 3.956
51500 51500 A 0 090 0 1 0 2 0 2 1 11.05 6.29 6.29 1.08 18.42 18.42 17.263 17.263
51520 51520 A 0 090 0 1 0 2 0 2 1 10.21 6.00 6.00 0.99 17.20 17.20 16.116 16.116
51525 51525 A 0 090 0 1 0 2 0 2 1 15.42 7.88 7.88 1.57 24.87 24.87 23.317 23.317
51530 51530 A 0 090 0 1 0 2 0 2 1 13.71 7.61 7.61 1.65 22.97 22.97 21.407 21.407
51535 51535 A 0 090 0 1 0 2 1 2 1 13.90 7.27 7.27 1.33 22.50 22.50 21.124 21.124
51550 51550 A 0 090 0 1 0 2 0 2 1 17.23 8.74 8.74 2.14 28.11 28.11 26.198 26.198
51555 51555 A 0 090 0 1 0 2 0 2 1 23.18 11.03 11.03 2.60 36.81 36.81 34.445 34.445
51565 51565 A 0 090 0 1 0 2 0 2 1 23.68 11.37 11.37 2.42 37.47 37.47 35.156 35.156
51570 51570 A 0 090 0 1 0 2 0 2 1 27.46 12.43 12.43 2.80 42.69 42.69 40.087 40.087
51575 51575 A 0 090 0 1 0 2 2 2 1 34.18 14.94 14.94 3.35 52.47 52.47 49.348 49.348
51580 51580 A 0 090 0 1 0 2 0 2 1 35.37 15.85 15.85 3.44 54.66 54.66 51.402 51.402
51585 51585 A 0 090 0 1 0 2 2 2 1 39.64 17.35 17.35 3.85 60.84 60.84 57.234 57.234
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
205 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
51590 51590 A 0 090 0 1 0 2 0 2 1 36.33 15.74 15.74 3.67 55.74 55.74 52.384 52.384
51595 51595 A 0 090 0 1 0 2 2 2 1 41.32 17.71 17.71 4.11 63.14 63.14 59.373 59.373
51596 51596 A 0 090 0 1 0 2 0 2 1 44.26 19.24 19.24 4.34 67.84 67.84 63.807 63.807
51597 51597 A 0 090 0 1 0 2 0 2 1 42.86 18.83 18.83 4.53 66.22 66.22 62.139 62.139
51600 51600 A 0 000 0 0 0 2 0 1 0 0.88 4.47 0.31 0.08 5.43 1.27 4.936 1.200
51605 51605 A 0 000 0 0 0 2 0 1 0 0.64 0.42 0.42 0.05 1.11 1.11 1.043 1.043
51610 51610 A 0 000 0 0 0 2 0 1 0 1.05 1.98 0.72 0.10 3.13 1.87 2.880 1.749
51700 51700 A 0 000 0 0 0 2 0 1 0 0.88 1.48 0.32 0.08 2.44 1.28 2.251 1.209
51701 51701 A 0 000 0 0 0 2 0 1 0 0.50 1.07 0.25 0.05 1.62 0.80 1.487 0.751
51702 51702 A 0 000 0 0 0 2 0 1 0 0.50 1.55 0.33 0.05 2.10 0.88 1.918 0.822
51703 51703 A 0 000 0 0 0 2 0 1 0 1.47 2.19 0.74 0.14 3.80 2.35 3.510 2.208
51705 51705 A 0 000 0 0 0 2 0 1 0 0.90 1.69 0.52 0.09 2.68 1.51 2.465 1.414
51710 51710 A 0 000 0 0 0 2 0 1 0 1.35 1.26 0.85 0.12 2.73 2.32 2.544 2.176
51715 51715 A 0 000 0 0 0 2 0 0 0 3.73 4.35 1.68 0.39 8.47 5.80 7.840 5.443
51720 51720 A 0 000 0 0 0 2 0 1 0 1.50 1.52 0.67 0.14 3.16 2.31 2.938 2.175
51725 51725 A 1 000 0 0 0 2 0 0 0 1.51 3.95 3.95 0.13 5.59 5.59 5.125 5.125
51725 26 5172526 A 1 000 0 0 0 2 0 0 0 1.51 0.58 0.58 0.12 2.21 2.21 2.094 2.094
51725 TC 51725TC A 1 000 0 0 0 2 0 0 0 0.00 3.37 3.37 0.01 3.38 3.38 3.031 3.031
51726 51726 A 1 000 0 0 0 2 0 1 0 1.71 6.00 6.00 0.17 7.88 7.88 7.187 7.187
51726 26 5172626 A 1 000 0 0 0 2 0 1 0 1.71 0.62 0.62 0.14 2.47 2.47 2.340 2.340
51726 TC 51726TC A 1 000 0 0 0 2 0 1 0 0.00 5.38 5.38 0.03 5.41 5.41 4.847 4.847
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
206 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
51727 51727 A 1 000 0 0 0 2 0 0 0 2.11 7.09 7.09 0.23 9.43 9.43 8.597 8.597
51727 26 5172726 A 1 000 0 0 0 2 0 0 0 2.11 0.82 0.82 0.22 3.15 3.15 2.961 2.961
51727 TC 51727TC A 1 000 0 0 0 2 0 0 0 0.00 6.27 6.27 0.01 6.28 6.28 5.636 5.636
51728 51728 A 1 000 0 0 0 2 0 0 0 2.11 7.08 7.08 0.19 9.38 9.38 8.567 8.567
51728 26 5172826 A 1 000 0 0 0 2 0 0 0 2.11 0.75 0.75 0.18 3.04 3.04 2.878 2.878
51728 TC 51728TC A 1 000 0 0 0 2 0 0 0 0.00 6.33 6.33 0.01 6.34 6.34 5.690 5.690
51729 51729 A 1 000 0 0 0 2 0 0 0 2.51 7.45 7.45 0.25 10.21 10.21 9.331 9.331
51729 26 5172926 A 1 000 0 0 0 2 0 0 0 2.51 0.96 0.96 0.24 3.71 3.71 3.498 3.498
51729 TC 51729TC A 1 000 0 0 0 2 0 0 0 0.00 6.49 6.49 0.01 6.50 6.50 5.833 5.833
51736 51736 A 1 XXX 0 0 0 2 0 0 0 0.17 0.26 0.26 0.02 0.45 0.45 0.414 0.414
51736 26 5173626 A 1 XXX 0 0 0 2 0 0 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
51736 TC 51736TC A 1 XXX 0 0 0 2 0 0 0 0.00 0.20 0.20 0.01 0.21 0.21 0.185 0.185
51741 51741 A 1 XXX 0 0 0 2 0 1 0 0.17 0.27 0.27 0.02 0.46 0.46 0.423 0.423
51741 26 5174126 A 1 XXX 0 0 0 2 0 1 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
51741 TC 51741TC A 1 XXX 0 0 0 2 0 1 0 0.00 0.21 0.21 0.01 0.22 0.22 0.194 0.194
51784 51784 A 1 000 0 0 0 2 0 1 0 1.53 4.06 4.06 0.13 5.72 5.72 5.244 5.244
51784 26 5178426 A 1 000 0 0 0 2 0 1 0 1.53 0.57 0.57 0.12 2.22 2.22 2.105 2.105
51784 TC 51784TC A 1 000 0 0 0 2 0 1 0 0.00 3.49 3.49 0.01 3.50 3.50 3.139 3.139
51785 51785 A 1 000 0 0 0 2 0 0 0 1.53 5.97 5.97 0.13 7.63 7.63 6.959 6.959
51785 26 5178526 A 1 000 0 0 0 2 0 0 0 1.53 0.66 0.66 0.12 2.31 2.31 2.185 2.185
51785 TC 51785TC A 1 000 0 0 0 2 0 0 0 0.00 5.31 5.31 0.01 5.32 5.32 4.774 4.774
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
207 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
51792 51792 A 1 000 0 0 0 2 0 0 0 1.10 5.14 5.14 0.11 6.35 6.35 5.773 5.773
51792 26 5179226 A 1 000 0 0 0 2 0 0 0 1.10 0.41 0.41 0.10 1.61 1.61 1.520 1.520
51792 TC 51792TC A 1 000 0 0 0 2 0 0 0 0.00 4.73 4.73 0.01 4.74 4.74 4.253 4.253
51797 51797 A 1 ZZZ 0 0 0 0 0 0 0 0.80 2.48 2.48 0.06 3.34 3.34 3.058 3.058
51797 26 5179726 A 1 ZZZ 0 0 0 0 0 0 0 0.80 0.30 0.30 0.05 1.15 1.15 1.096 1.096
51797 TC 51797TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 2.18 2.18 0.01 2.19 2.19 1.963 1.963
51798 51798 A 3 XXX 0 0 0 0 0 0 0 0.00 0.57 0.57 0.01 0.58 0.58 0.517 0.517
51800 51800 A 0 090 0 1 0 2 0 2 1 18.89 9.36 9.36 1.95 30.20 30.20 28.315 28.315
51820 51820 A 0 090 0 1 0 2 2 2 1 19.59 9.79 9.79 1.89 31.27 31.27 29.370 29.370
51840 51840 A 0 090 0 1 0 2 0 2 1 11.36 6.57 6.57 1.50 19.43 19.43 18.044 18.044
51841 51841 A 0 090 0 1 0 2 0 2 1 13.68 7.57 7.57 1.84 23.09 23.09 21.440 21.440
51845 51845 A 0 090 0 1 0 2 0 2 1 10.15 5.79 5.79 1.20 17.14 17.14 15.977 15.977
51860 51860 A 0 090 0 1 0 2 0 2 1 12.60 7.44 7.44 1.85 21.89 21.89 20.249 20.249
51865 51865 A 0 090 0 1 0 2 0 2 1 15.80 8.40 8.40 1.92 26.12 26.12 24.347 24.347
51880 51880 A 0 090 0 1 0 2 0 2 1 7.87 4.82 4.82 0.99 13.68 13.68 12.716 12.716
51900 51900 A 0 090 0 1 0 2 0 2 1 14.63 8.01 8.01 1.42 24.06 24.06 22.566 22.566
51920 51920 A 0 090 0 1 0 2 0 2 1 13.41 9.23 9.23 1.29 23.93 23.93 22.373 22.373
51925 51925 A 0 090 0 1 0 2 0 2 1 17.53 10.48 10.48 2.97 30.98 30.98 28.494 28.494
51940 51940 A 0 090 0 1 0 2 0 2 1 30.66 13.80 13.80 2.98 47.44 47.44 44.611 44.611
51960 51960 A 0 090 0 1 0 2 0 2 1 25.40 12.19 12.19 2.65 40.24 40.24 37.733 37.733
51980 51980 A 0 090 0 1 0 2 0 2 1 12.57 6.82 6.82 1.22 20.61 20.61 19.332 19.332
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
208 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
51990 51990 A 0 090 0 1 0 2 0 2 1 13.36 7.13 7.13 1.77 22.26 22.26 20.688 20.688
51992 51992 A 0 090 0 1 0 2 0 2 1 14.87 8.18 8.18 2.23 25.28 25.28 23.382 23.382
51999 51999 C 0 YYY 0 0 0 0 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
52000 52000 A 0 000 0 0 0 2 0 1 0 2.23 3.49 1.20 0.23 5.95 3.66 5.484 3.428
52001 52001 A 0 000 0 0 0 3 0 1 0 5.44 4.76 2.32 0.53 10.73 8.29 9.992 7.801
52005 52005 A 0 000 0 0 0 3 0 1 0 2.37 5.17 1.25 0.24 7.78 3.86 7.138 3.618
52007 52007 A 0 000 0 0 0 3 1 1 0 3.02 9.80 1.48 0.30 13.12 4.80 11.977 4.506
52010 52010 A 0 000 0 0 0 3 0 1 0 3.02 7.46 1.47 0.30 10.78 4.79 9.876 4.497
52204 52204 A 0 000 0 0 0 3 0 1 0 2.59 8.03 1.25 0.26 10.88 4.10 9.937 3.848
52214 52214 A 0 000 0 0 0 3 0 1 0 3.50 15.75 1.23 0.33 19.58 5.06 17.816 4.777
52224 52224 A 0 000 0 0 0 3 0 1 0 4.05 16.00 1.42 0.40 20.45 5.87 18.627 5.534
52234 52234 A 0 000 0 0 0 3 0 1 0 4.62 2.03 2.03 0.44 7.09 7.09 6.673 6.673
52235 52235 A 0 000 0 0 0 3 0 1 0 5.44 2.36 2.36 0.53 8.33 8.33 7.836 7.836
52240 52240 A 0 000 0 0 0 3 0 1 0 7.50 3.08 3.08 0.73 11.31 11.31 10.648 10.648
52250 52250 A 0 000 0 0 0 3 0 1 0 4.49 2.08 2.08 0.45 7.02 7.02 6.593 6.593
52260 52260 A 0 000 0 0 0 3 0 1 0 3.91 1.79 1.79 0.39 6.09 6.09 5.721 5.721
52265 52265 A 0 000 0 0 0 3 0 1 0 2.94 7.57 1.49 0.35 10.86 4.78 9.921 4.461
52270 52270 A 0 000 0 0 0 3 0 1 0 3.36 6.71 1.57 0.33 10.40 5.26 9.558 4.942
52275 52275 A 0 000 0 0 0 3 0 1 0 4.69 8.89 2.03 0.45 14.03 7.17 12.909 6.748
52276 52276 A 0 000 0 0 0 3 0 1 0 4.99 2.19 2.19 0.49 7.67 7.67 7.213 7.213
52277 52277 A 0 000 0 0 0 3 0 0 0 6.16 2.66 2.66 0.60 9.42 9.42 8.862 8.862
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
209 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
52281 52281 A 0 000 0 0 0 3 0 1 0 2.75 4.92 1.38 0.29 7.96 4.42 7.320 4.141
52282 52282 A 0 000 0 0 0 3 0 1 0 6.39 2.69 2.69 0.65 9.73 9.73 9.146 9.146
52283 52283 A 0 000 0 0 0 3 0 1 0 3.73 3.90 1.73 0.37 8.00 5.83 7.426 5.477
52285 52285 A 0 000 0 0 0 3 0 1 0 3.60 4.15 1.72 0.37 8.12 5.69 7.520 5.338
52287 52287 A 0 000 0 0 0 3 0 1 0 3.20 5.56 1.35 0.33 9.09 4.88 8.365 4.585
52290 52290 A 0 000 0 0 0 3 2 1 0 4.58 2.04 2.04 0.44 7.06 7.06 6.642 6.642
52300 52300 A 0 000 0 0 0 3 2 0 0 5.30 2.40 2.40 0.56 8.26 8.26 7.748 7.748
52301 52301 A 0 000 0 0 0 3 2 0 0 5.50 2.42 2.42 0.53 8.45 8.45 7.950 7.950
52305 52305 A 0 000 0 0 0 3 0 1 0 5.30 2.22 2.22 0.52 8.04 8.04 7.566 7.566
52310 52310 A 0 000 0 0 0 3 0 1 0 2.81 3.97 1.29 0.29 7.07 4.39 6.527 4.120
52315 52315 A 0 000 0 0 0 3 0 1 0 5.20 6.27 2.21 0.50 11.97 7.91 11.092 7.446
52317 52317 A 0 000 0 0 0 3 0 1 0 6.71 16.29 2.65 0.65 23.65 10.01 21.678 9.430
52318 52318 A 0 000 0 0 0 3 0 1 0 9.18 3.58 3.58 0.88 13.64 13.64 12.855 12.855
52320 52320 A 0 000 0 0 0 3 1 1 0 4.69 1.97 1.97 0.45 7.11 7.11 6.694 6.694
52325 52325 A 0 000 0 0 0 3 1 1 0 6.15 2.51 2.51 0.60 9.26 9.26 8.718 8.718
52327 52327 A 0 000 0 0 0 3 1 1 0 5.18 1.87 1.87 0.52 7.57 7.57 7.131 7.131
52330 52330 A 0 000 0 0 0 3 1 1 0 5.03 8.91 2.09 0.49 14.43 7.61 13.287 7.163
52332 52332 A 0 000 0 0 0 3 1 1 0 2.82 11.97 1.40 0.28 15.07 4.50 13.716 4.224
52334 52334 A 0 000 0 0 0 3 1 1 0 4.82 2.12 2.12 0.48 7.42 7.42 6.975 6.975
52341 52341 A 0 000 0 0 0 3 1 1 0 5.35 2.48 2.48 0.52 8.35 8.35 7.849 7.849
52342 52342 A 0 000 0 0 0 3 1 1 0 5.85 2.66 2.66 0.56 9.07 9.07 8.532 8.532
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
210 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
52343 52343 A 0 000 0 0 0 3 1 1 0 6.55 2.90 2.90 0.64 10.09 10.09 9.489 9.489
52344 52344 A 0 000 0 0 0 3 1 1 0 7.05 3.24 3.24 0.68 10.97 10.97 10.315 10.315
52345 52345 A 0 000 0 0 0 3 1 0 0 7.55 3.42 3.42 0.72 11.69 11.69 10.998 10.998
52346 52346 A 0 000 0 0 0 3 1 0 0 8.58 3.80 3.80 0.83 13.21 13.21 12.426 12.426
52351 52351 A 0 000 0 0 0 2 0 1 0 5.75 2.62 2.62 0.55 8.92 8.92 8.390 8.390
52352 52352 A 0 000 0 0 0 3 1 1 0 6.75 3.07 3.07 0.66 10.48 10.48 9.852 9.852
52353 52353 A 0 000 0 0 0 3 1 1 0 7.50 3.33 3.33 0.72 11.55 11.55 10.867 10.867
52354 52354 A 0 000 0 0 0 3 1 1 0 8.00 3.51 3.51 0.77 12.28 12.28 11.555 11.555
52355 52355 A 0 000 0 0 0 3 1 1 0 9.00 3.86 3.86 0.88 13.74 13.74 12.927 12.927
52400 52400 A 0 090 0 1 0 3 0 1 0 8.69 4.28 4.28 0.84 13.81 13.81 12.973 12.973
52402 52402 A 0 000 0 0 0 3 0 0 0 5.27 1.90 1.90 0.50 7.67 7.67 7.238 7.238
52450 52450 A 0 090 0 1 0 2 0 1 0 7.78 5.10 5.10 0.75 13.63 13.63 12.752 12.752
52500 52500 A 0 090 0 1 0 2 0 1 0 8.14 5.22 5.22 0.78 14.14 14.14 13.236 13.236
52601 52601 A 0 090 0 1 0 2 0 1 0 15.26 7.67 7.67 1.50 24.43 24.43 22.932 22.932
52630 52630 A 0 090 0 1 0 2 0 1 0 6.55 4.43 4.43 0.64 11.62 11.62 10.863 10.863
52640 52640 A 0 090 0 1 0 2 0 1 0 4.79 3.93 3.93 0.45 9.17 9.17 8.554 8.554
52647 52647 A 0 090 0 1 0 2 0 1 0 11.30 40.39 6.33 1.10 52.79 18.73 48.146 17.560
52648 52648 A 0 090 0 1 0 2 0 1 0 12.15 40.98 6.63 1.20 54.33 19.98 49.578 18.731
52649 52649 A 0 090 0 1 0 2 0 0 0 14.56 7.59 7.59 1.41 23.56 23.56 22.113 22.113
52700 52700 A 0 090 0 1 0 2 0 0 0 7.49 4.55 4.55 0.72 12.76 12.76 11.952 11.952
53000 53000 A 0 010 0 1 0 2 0 1 0 2.33 1.75 1.75 0.24 4.32 4.32 4.027 4.027
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
211 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
53010 53010 A 0 090 0 1 0 2 0 1 0 4.45 3.69 3.69 0.42 8.56 8.56 7.983 7.983
53020 53020 A 0 000 0 0 0 2 0 1 0 1.77 0.86 0.86 0.18 2.81 2.81 2.636 2.636
53025 53025 A 0 000 0 0 0 2 0 0 0 1.13 0.97 0.97 0.07 2.17 2.17 2.038 2.038
53040 53040 A 0 090 0 1 0 2 0 0 0 6.55 4.20 4.20 0.64 11.39 11.39 10.656 10.656
53060 53060 A 0 010 0 1 0 2 0 1 0 2.68 2.31 1.71 0.44 5.43 4.83 4.985 4.446
53080 53080 A 0 090 0 1 0 2 0 1 0 6.92 4.60 4.60 0.67 12.19 12.19 11.401 11.401
53085 53085 A 0 090 0 1 0 2 0 2 1 11.18 6.52 6.52 1.46 19.16 19.16 17.799 17.799
53200 53200 A 0 000 0 0 0 2 0 1 0 2.59 1.66 1.25 0.27 4.52 4.11 4.222 3.854
53210 53210 A 0 090 0 1 0 2 0 2 1 13.72 7.43 7.43 1.32 22.47 22.47 21.083 21.083
53215 53215 A 0 090 0 1 0 2 0 2 1 16.85 8.29 8.29 1.63 26.77 26.77 25.147 25.147
53220 53220 A 0 090 0 1 0 2 0 0 0 7.63 4.82 4.82 0.73 13.18 13.18 12.340 12.340
53230 53230 A 0 090 0 1 0 2 0 2 1 10.44 6.10 6.10 1.17 17.71 17.71 16.530 16.530
53235 53235 A 0 090 0 1 0 2 0 2 1 10.99 6.25 6.25 1.06 18.30 18.30 17.157 17.157
53240 53240 A 0 090 0 1 0 2 0 1 0 7.08 4.55 4.55 0.68 12.31 12.31 11.522 11.522
53250 53250 A 0 090 0 1 0 2 0 1 0 6.52 4.33 4.33 1.42 12.27 12.27 11.151 11.151
53260 53260 A 0 010 0 1 0 2 0 1 0 3.03 2.53 1.90 0.35 5.91 5.28 5.485 4.919
53265 53265 A 0 010 0 1 0 2 0 1 0 3.17 2.86 1.91 0.34 6.37 5.42 5.916 5.063
53270 53270 A 0 010 0 1 0 2 0 1 0 3.14 2.52 1.87 0.53 6.19 5.54 5.680 5.096
53275 53275 A 0 010 0 1 0 2 0 1 0 4.57 2.59 2.59 0.45 7.61 7.61 7.131 7.131
53400 53400 A 0 090 0 1 0 2 0 2 1 14.13 7.74 7.74 1.42 23.29 23.29 21.823 21.823
53405 53405 A 0 090 0 1 0 2 0 2 1 15.66 8.05 8.05 1.52 25.23 25.23 23.684 23.684
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
212 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
53410 53410 A 0 090 0 1 0 2 0 2 1 17.68 8.92 8.92 1.71 28.31 28.31 26.584 26.584
53415 53415 A 0 090 0 1 0 2 0 2 1 20.70 9.90 9.90 2.04 32.64 32.64 30.657 30.657
53420 53420 A 0 090 0 1 0 2 0 1 1 15.17 7.64 7.64 1.48 24.29 24.29 22.805 22.805
53425 53425 A 0 090 0 1 0 2 0 2 1 17.07 8.31 8.31 1.65 27.03 27.03 25.395 25.395
53430 53430 A 0 090 0 1 0 2 0 2 1 17.43 8.73 8.73 1.97 28.13 28.13 26.300 26.300
53431 53431 A 0 090 0 1 0 2 0 2 1 21.18 10.07 10.07 2.04 33.29 33.29 31.290 31.290
53440 53440 A 0 090 0 1 0 2 0 2 1 13.36 7.11 7.11 1.31 21.78 21.78 20.430 20.430
53442 53442 A 0 090 0 1 0 2 0 2 0 13.49 7.86 7.86 1.31 22.66 22.66 21.233 21.233
53444 53444 A 0 090 0 1 0 2 0 2 1 14.19 7.36 7.36 1.37 22.92 22.92 21.516 21.516
53445 53445 A 0 090 0 1 0 2 0 2 1 13.00 7.52 7.52 1.28 21.80 21.80 20.422 20.422
53446 53446 A 0 090 0 1 0 2 0 2 1 11.02 6.50 6.50 1.09 18.61 18.61 17.427 17.427
53447 53447 A 0 090 0 1 0 2 0 2 1 14.28 7.70 7.70 1.40 23.38 23.38 21.927 21.927
53448 53448 A 0 090 0 1 0 2 0 2 1 23.44 11.24 11.24 2.26 36.94 36.94 34.716 34.716
53449 53449 A 0 090 0 1 0 2 0 2 1 10.56 6.10 6.10 1.05 17.71 17.71 16.587 16.587
53450 53450 A 0 090 0 1 0 2 0 1 0 6.77 4.41 4.41 0.65 11.83 11.83 11.070 11.070
53460 53460 A 0 090 0 1 0 2 0 0 0 7.75 4.76 4.76 0.73 13.24 13.24 12.406 12.406
53500 53500 A 0 090 0 1 0 2 0 2 1 13.00 7.37 7.37 1.50 21.87 21.87 20.403 20.403
53502 53502 A 0 090 0 1 0 2 0 1 0 8.26 5.03 5.03 0.80 14.09 14.09 13.195 13.195
53505 53505 A 0 090 0 1 0 2 0 2 0 8.26 5.02 5.02 0.80 14.08 14.08 13.186 13.186
53510 53510 A 0 090 0 1 0 2 0 2 1 10.96 6.24 6.24 1.06 18.26 18.26 17.118 17.118
53515 53515 A 0 090 0 1 0 2 0 2 1 14.22 7.38 7.38 1.37 22.97 22.97 21.564 21.564
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
213 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
53520 53520 A 0 090 0 1 0 2 0 1 0 9.48 5.72 5.72 0.91 16.11 16.11 15.092 15.092
53600 53600 A 0 000 0 0 0 2 0 1 0 1.21 1.09 0.51 0.11 2.41 1.83 2.246 1.726
53601 53601 A 0 000 0 0 0 2 0 1 0 0.98 1.29 0.47 0.08 2.35 1.53 2.180 1.444
53605 53605 A 0 000 0 0 0 2 0 1 0 1.28 0.45 0.45 0.12 1.85 1.85 1.747 1.747
53620 53620 A 0 000 0 0 0 2 0 1 0 1.62 1.59 0.74 0.16 3.37 2.52 3.132 2.368
53621 53621 A 0 000 0 0 0 2 0 1 0 1.35 1.71 0.60 0.12 3.18 2.07 2.948 1.952
53660 53660 A 0 000 0 0 0 2 0 1 0 0.71 1.29 0.43 0.07 2.07 1.21 1.905 1.133
53661 53661 A 0 000 0 0 0 2 0 1 0 0.72 1.24 0.38 0.07 2.03 1.17 1.870 1.098
53665 53665 A 0 000 0 0 0 2 0 1 0 0.76 0.28 0.28 0.08 1.12 1.12 1.053 1.053
53850 53850 A 0 090 0 1 0 2 0 1 0 10.08 50.70 6.55 0.99 61.77 17.62 56.126 16.480
53852 53852 A 0 090 0 1 0 2 0 1 0 10.83 44.91 6.13 1.06 56.80 18.02 51.714 16.889
53855 53855 A 0 000 0 0 0 2 0 0 0 1.64 21.56 0.58 0.16 23.36 2.38 21.085 2.245
53860 53860 A 0 090 0 1 0 2 0 0 0 3.97 42.73 2.21 0.68 47.38 6.86 42.697 6.310
53899 53899 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
54000 54000 A 0 010 0 1 0 2 0 0 0 1.59 2.60 1.41 0.14 4.33 3.14 3.998 2.929
54001 54001 A 0 010 0 1 0 2 0 1 0 2.24 2.94 1.57 0.23 5.41 4.04 5.000 3.770
54015 54015 A 0 010 0 1 0 2 0 0 0 5.36 3.03 3.03 0.56 8.95 8.95 8.374 8.374
54050 54050 A 0 010 0 1 0 2 0 1 0 1.29 2.50 1.68 0.16 3.95 3.13 3.619 2.882
54055 54055 A 0 010 0 1 0 2 0 1 0 1.25 2.14 1.35 0.14 3.53 2.74 3.245 2.536
54056 54056 A 0 010 0 1 0 2 0 1 0 1.29 2.82 1.87 0.18 4.29 3.34 3.917 3.063
54057 54057 A 0 010 0 1 0 2 0 1 0 1.29 2.59 1.36 0.12 4.00 2.77 3.679 2.574
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
214 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
54060 54060 A 0 010 0 1 0 2 0 1 0 1.98 3.07 1.61 0.22 5.27 3.81 4.852 3.541
54065 54065 A 0 010 0 1 0 2 0 1 0 2.47 3.76 2.37 0.31 6.54 5.15 6.009 4.760
54100 54100 A 0 000 0 0 0 2 0 1 0 1.90 3.76 1.60 0.24 5.90 3.74 5.402 3.462
54105 54105 A 0 010 0 1 0 2 0 1 0 3.54 3.77 2.26 0.35 7.66 6.15 7.109 5.753
54110 54110 A 0 090 0 1 0 2 0 2 0 10.92 6.08 6.08 1.06 18.06 18.06 16.934 16.934
54111 54111 A 0 090 0 1 0 2 0 2 1 14.42 7.30 7.30 1.40 23.12 23.12 21.708 21.708
54112 54112 A 0 090 0 1 0 2 0 2 1 16.98 8.45 8.45 1.63 27.06 27.06 25.421 25.421
54115 54115 A 0 090 0 1 0 2 0 2 0 6.95 5.50 4.69 0.67 13.12 12.31 12.239 11.512
54120 54120 A 0 090 0 1 0 2 0 2 1 11.01 6.19 6.19 1.09 18.29 18.29 17.139 17.139
54125 54125 A 0 090 0 1 0 2 0 2 1 14.56 7.47 7.47 1.48 23.51 23.51 22.042 22.042
54130 54130 A 0 090 0 1 0 2 2 2 1 21.84 10.48 10.48 2.12 34.44 34.44 32.360 32.360
54135 54135 A 0 090 0 1 0 2 2 2 0 28.17 12.69 12.69 2.74 43.60 43.60 40.999 40.999
54150 54150 A 0 000 0 0 0 2 0 0 0 1.90 2.42 0.72 0.23 4.55 2.85 4.193 2.667
54160 54160 A 0 010 0 1 0 2 0 1 0 2.53 3.65 1.39 0.24 6.42 4.16 5.933 3.904
54161 54161 A 0 010 0 1 0 2 0 1 0 3.32 2.06 2.06 0.34 5.72 5.72 5.348 5.348
54162 54162 A 0 010 0 1 0 2 0 1 0 3.32 3.87 2.14 0.33 7.52 5.79 6.968 5.414
54163 54163 A 0 010 0 1 0 2 0 1 0 3.32 2.71 2.71 0.33 6.36 6.36 5.926 5.926
54164 54164 A 0 010 0 1 0 2 0 1 0 2.82 2.54 2.54 0.29 5.65 5.65 5.253 5.253
54200 54200 A 0 010 0 1 0 2 0 1 0 1.11 1.94 1.24 0.10 3.15 2.45 2.904 2.276
54205 54205 A 0 090 0 1 0 2 0 2 0 8.97 5.59 5.59 0.86 15.42 15.42 14.440 14.440
54220 54220 A 0 000 0 0 0 2 0 1 0 2.42 3.27 1.23 0.26 5.95 3.91 5.492 3.661
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
215 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
54230 54230 A 0 000 0 0 0 2 0 1 0 1.34 1.34 0.85 0.12 2.80 2.31 2.606 2.166
54231 54231 A 0 000 0 0 0 2 0 1 0 2.04 1.83 1.13 0.20 4.07 3.37 3.788 3.159
54235 54235 A 0 000 0 0 0 2 0 1 0 1.19 1.33 0.84 0.11 2.63 2.14 2.442 2.002
54240 54240 A 1 000 0 0 0 0 0 0 0 1.31 1.51 1.51 0.09 2.91 2.91 2.713 2.713
54240 26 5424026 A 1 000 0 0 0 0 0 0 0 1.31 0.46 0.46 0.08 1.85 1.85 1.765 1.765
54240 TC 54240TC A 1 000 0 0 0 0 0 0 0 0.00 1.05 1.05 0.01 1.06 1.06 0.948 0.948
54250 54250 A 1 000 0 0 0 0 0 0 0 2.22 1.10 1.10 0.15 3.47 3.47 3.286 3.286
54250 26 5425026 A 1 000 0 0 0 0 0 0 0 2.22 0.78 0.78 0.14 3.14 3.14 2.994 2.994
54250 TC 54250TC A 1 000 0 0 0 0 0 0 0 0.00 0.32 0.32 0.01 0.33 0.33 0.293 0.293
54300 54300 A 0 090 0 1 0 2 0 2 1 11.20 6.26 6.26 1.09 18.55 18.55 17.392 17.392
54304 54304 A 0 090 0 1 0 2 0 2 0 13.28 7.11 7.11 1.28 21.67 21.67 20.334 20.334
54308 54308 A 0 090 0 1 0 2 0 2 1 12.62 6.84 6.84 1.22 20.68 20.68 19.400 19.400
54312 54312 A 0 090 0 1 0 2 0 2 1 14.51 7.74 7.74 1.40 23.65 23.65 22.193 22.193
54316 54316 A 0 090 0 1 0 2 0 2 1 18.05 9.02 9.02 1.74 28.81 28.81 27.060 27.060
54318 54318 A 0 090 0 1 0 2 0 2 1 12.43 6.93 6.93 0.87 20.23 20.23 19.108 19.108
54322 54322 A 0 090 0 1 0 2 0 2 0 13.98 7.22 7.22 1.36 22.56 22.56 21.175 21.175
54324 54324 A 0 090 0 1 0 2 0 2 1 17.55 8.72 8.72 1.69 27.96 27.96 26.264 26.264
54326 54326 A 0 090 0 1 0 2 0 2 1 17.02 8.65 8.65 1.65 27.32 27.32 25.651 25.651
54328 54328 A 0 090 0 1 0 2 0 2 1 16.89 8.61 8.61 1.63 27.13 27.13 25.474 25.474
54332 54332 A 0 090 0 1 0 2 0 2 1 18.37 9.13 9.13 1.78 29.28 29.28 27.500 27.500
54336 54336 A 0 090 0 1 0 2 0 2 1 21.62 12.13 12.13 2.10 35.85 35.85 33.611 33.611
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
216 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
54340 54340 A 0 090 0 1 0 2 0 2 1 9.71 5.86 5.86 0.93 16.50 16.50 15.459 15.459
54344 54344 A 0 090 0 1 0 2 0 2 1 17.06 8.67 8.67 1.65 27.38 27.38 25.709 25.709
54348 54348 A 0 090 0 1 0 2 0 2 1 18.32 9.19 9.19 1.29 28.80 28.80 27.247 27.247
54352 54352 A 0 090 0 1 0 2 0 2 1 26.13 12.21 12.21 2.55 40.89 40.89 38.428 38.428
54360 54360 A 0 090 0 1 0 2 0 2 1 12.78 6.82 6.82 1.24 20.84 20.84 19.553 19.553
54380 54380 A 0 090 0 1 0 2 0 2 1 14.18 11.00 11.00 1.37 26.55 26.55 24.775 24.775
54385 54385 A 0 090 0 1 0 2 0 2 1 16.56 9.86 9.86 2.42 28.84 28.84 26.680 26.680
54390 54390 A 0 090 0 1 0 2 0 2 1 22.77 12.38 12.38 2.20 37.35 37.35 35.038 35.038
54400 54400 A 0 090 0 1 0 2 0 1 1 9.17 5.27 5.27 0.88 15.32 15.32 14.363 14.363
54401 54401 A 0 090 0 1 0 2 0 1 1 10.44 7.60 7.60 1.03 19.07 19.07 17.803 17.803
54405 54405 A 0 090 0 1 0 2 0 2 1 14.52 7.42 7.42 1.42 23.36 23.36 21.926 21.926
54406 54406 A 0 090 0 1 0 2 0 2 1 12.89 6.97 6.97 1.25 21.11 21.11 19.803 19.803
54408 54408 A 0 090 0 1 0 2 0 2 1 13.91 7.58 7.58 1.37 22.86 22.86 21.433 21.433
54410 54410 A 0 090 0 1 0 2 0 2 1 15.18 8.19 8.19 1.48 24.85 24.85 23.309 23.309
54411 54411 A 0 090 0 1 0 2 0 2 1 18.35 9.52 9.52 1.78 29.65 29.65 27.830 27.830
54415 54415 A 0 090 0 1 0 2 0 2 1 8.88 5.58 5.58 0.86 15.32 15.32 14.341 14.341
54416 54416 A 0 090 0 1 0 2 0 2 1 12.08 7.35 7.35 1.18 20.61 20.61 19.297 19.297
54417 54417 A 0 090 0 1 0 2 0 2 1 16.10 8.31 8.31 1.57 25.98 25.98 24.383 24.383
54420 54420 A 0 090 0 1 0 2 0 2 0 12.39 6.79 6.79 1.21 20.39 20.39 19.120 19.120
54430 54430 A 0 090 0 1 0 2 2 2 0 11.06 6.40 6.40 1.08 18.54 18.54 17.372 17.372
54435 54435 A 0 090 0 1 0 2 0 1 0 6.81 4.63 4.63 0.65 12.09 12.09 11.308 11.308
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
217 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
54440 54440 C 0 090 0 1 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
54450 54450 A 0 000 0 0 0 2 0 1 0 1.12 0.79 0.43 0.10 2.01 1.65 1.882 1.558
54500 54500 A 0 000 0 0 0 2 1 0 0 1.31 0.72 0.72 0.12 2.15 2.15 2.019 2.019
54505 54505 A 0 010 0 1 0 2 1 0 0 3.50 2.25 2.25 0.34 6.09 6.09 5.698 5.698
54512 54512 A 0 090 0 1 0 2 1 1 1 9.33 5.36 5.36 0.93 15.62 15.62 14.630 14.630
54520 54520 A 0 090 0 1 0 2 1 1 0 5.30 3.62 3.62 0.61 9.53 9.53 8.870 8.870
54522 54522 A 0 090 0 1 0 2 1 2 1 10.25 6.25 6.25 1.01 17.51 17.51 16.391 16.391
54530 54530 A 0 090 0 1 0 2 1 2 1 8.46 5.36 5.36 0.87 14.69 14.69 13.728 13.728
54535 54535 A 0 090 0 1 0 2 1 2 0 13.19 7.04 7.04 1.28 21.51 21.51 20.181 20.181
54550 54550 A 0 090 0 1 0 2 1 2 0 8.41 5.03 5.03 0.82 14.26 14.26 13.356 13.356
54560 54560 A 0 090 0 1 0 2 1 2 1 12.10 6.58 6.58 1.18 19.86 19.86 18.626 18.626
54600 54600 A 0 090 0 1 0 2 1 1 0 7.64 4.75 4.75 0.73 13.12 13.12 12.287 12.287
54620 54620 A 0 010 0 1 0 2 1 1 0 5.21 2.96 2.96 0.50 8.67 8.67 8.130 8.130
54640 54640 A 0 090 0 1 0 2 1 0 0 7.73 5.43 5.43 0.87 14.03 14.03 13.061 13.061
54650 54650 A 0 090 0 1 0 2 1 2 0 12.39 7.00 7.00 1.21 20.60 20.60 19.309 19.309
54660 54660 A 0 090 0 1 0 2 1 0 0 5.74 4.09 4.09 0.54 10.37 10.37 9.695 9.695
54670 54670 A 0 090 0 1 0 2 1 0 0 6.65 4.47 4.47 0.64 11.76 11.76 10.999 10.999
54680 54680 A 0 090 0 1 0 2 1 2 1 14.04 7.35 7.35 1.36 22.75 22.75 21.352 21.352
54690 54690 A 0 090 0 1 0 2 1 2 1 11.70 7.69 7.69 2.48 21.87 21.87 19.903 19.903
54692 54692 A 0 090 0 1 0 2 1 1 0 13.74 8.45 8.45 1.32 23.51 23.51 22.018 22.018
54699 54699 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
218 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
54700 54700 A 0 010 0 1 0 2 1 1 0 3.47 2.39 2.39 0.39 6.25 6.25 5.820 5.820
54800 54800 A 0 000 0 0 0 2 1 0 0 2.33 1.08 1.08 0.33 3.74 3.74 3.472 3.472
54830 54830 A 0 090 0 1 0 2 1 0 0 6.01 4.23 4.23 0.63 10.87 10.87 10.138 10.138
54840 54840 A 0 090 0 1 0 2 1 1 0 5.27 3.54 3.54 0.52 9.33 9.33 8.721 8.721
54860 54860 A 0 090 0 1 0 2 0 1 0 6.95 4.53 4.53 0.68 12.16 12.16 11.374 11.374
54861 54861 A 0 090 0 1 0 2 0 0 0 9.70 5.75 5.75 0.93 16.38 16.38 15.350 15.350
54865 54865 A 0 090 0 1 0 2 0 0 0 5.77 4.10 4.10 0.56 10.43 10.43 9.745 9.745
54900 54900 A 0 090 0 1 0 2 0 0 0 14.20 7.56 7.56 1.02 22.78 22.78 21.522 21.522
54901 54901 A 0 090 0 1 0 2 2 0 0 19.10 9.55 9.55 1.36 30.01 30.01 28.387 28.387
55000 55000 A 0 000 0 0 0 2 1 1 0 1.43 1.86 0.90 0.14 3.43 2.47 3.174 2.311
55040 55040 A 0 090 0 1 0 2 0 1 0 5.45 3.83 3.83 0.61 9.89 9.89 9.208 9.208
55041 55041 A 0 090 0 1 0 2 2 1 0 8.54 5.40 5.40 0.90 14.84 14.84 13.860 13.860
55060 55060 A 0 090 0 1 0 2 1 0 0 6.15 4.29 4.29 0.67 11.11 11.11 10.353 10.353
55100 55100 A 0 010 0 1 0 2 0 1 0 2.45 3.64 2.16 0.30 6.39 4.91 5.876 4.547
55110 55110 A 0 090 0 1 0 2 0 1 0 6.33 4.29 4.29 0.68 11.30 11.30 10.538 10.538
55120 55120 A 0 090 0 1 0 2 0 0 0 5.72 4.16 4.16 0.61 10.49 10.49 9.775 9.775
55150 55150 A 0 090 0 1 0 2 0 2 1 8.14 5.31 5.31 0.86 14.31 14.31 13.358 13.358
55175 55175 A 0 090 0 1 0 2 0 0 0 5.87 4.11 4.11 0.60 10.58 10.58 9.875 9.875
55180 55180 A 0 090 0 1 0 2 0 0 0 11.78 6.99 6.99 1.29 20.06 20.06 18.732 18.732
55200 55200 A 0 090 0 1 0 2 2 0 0 4.55 7.82 3.09 0.44 12.81 8.08 11.802 7.555
55250 55250 A 0 090 0 1 0 2 2 1 0 3.37 7.64 2.93 0.33 11.34 6.63 10.403 6.174
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
219 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
55300 55300 A 0 000 0 0 0 2 2 0 0 3.50 1.57 1.57 0.34 5.41 5.41 5.088 5.088
55400 55400 A 0 090 0 1 0 2 1 2 1 8.61 4.98 4.98 0.83 14.42 14.42 13.516 13.516
55450 55450 A 0 010 0 1 0 2 2 0 0 4.43 5.62 2.59 0.42 10.47 7.44 9.696 6.975
55500 55500 A 0 090 0 1 0 2 1 0 0 6.22 4.58 4.58 0.88 11.68 11.68 10.793 10.793
55520 55520 A 0 090 0 1 0 2 1 2 1 6.66 5.47 5.47 1.36 13.49 13.49 12.283 12.283
55530 55530 A 0 090 0 1 0 2 1 1 1 5.75 3.90 3.90 0.63 10.28 10.28 9.582 9.582
55535 55535 A 0 090 0 1 0 2 1 2 1 7.19 4.60 4.60 0.69 12.48 12.48 11.682 11.682
55540 55540 A 0 090 0 1 0 2 1 1 1 8.30 6.04 6.04 1.65 15.99 15.99 14.587 14.587
55550 55550 A 0 090 0 1 0 2 1 2 1 7.20 4.53 4.53 0.69 12.42 12.42 11.629 11.629
55559 55559 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
55600 55600 A 0 090 0 1 0 2 1 0 0 7.01 4.54 4.54 0.68 12.23 12.23 11.443 11.443
55605 55605 A 0 090 0 1 0 2 1 0 0 8.76 5.50 5.50 0.84 15.10 15.10 14.138 14.138
55650 55650 A 0 090 0 1 0 2 1 2 1 12.65 6.91 6.91 1.22 20.78 20.78 19.493 19.493
55680 55680 A 0 090 0 1 0 2 1 0 0 5.67 3.83 3.83 0.54 10.04 10.04 9.392 9.392
55700 55700 A 0 000 0 0 0 2 0 1 0 2.58 3.53 1.19 0.26 6.37 4.03 5.886 3.785
55705 55705 A 0 010 0 1 0 2 0 1 1 4.61 2.65 2.65 0.45 7.71 7.71 7.225 7.225
55706 55706 A 0 010 0 1 0 2 0 2 1 6.28 3.91 3.91 0.44 10.63 10.63 10.021 10.021
55720 55720 A 0 090 0 1 0 2 0 2 1 7.73 4.62 4.62 0.73 13.08 13.08 12.261 12.261
55725 55725 A 0 090 0 1 0 2 0 2 1 10.05 6.17 6.17 0.98 17.20 17.20 16.103 16.103
55801 55801 A 0 090 0 1 0 2 0 2 1 19.80 9.86 9.86 1.92 31.58 31.58 29.658 29.658
55810 55810 A 0 090 0 1 0 2 0 2 1 24.29 11.28 11.28 2.48 38.05 38.05 35.716 35.716
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
220 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
55812 55812 A 0 090 0 1 0 2 0 2 1 29.89 13.62 13.62 2.91 46.42 46.42 43.643 43.643
55815 55815 A 0 090 0 1 0 2 2 2 1 32.95 14.69 14.69 3.20 50.84 50.84 47.815 47.815
55821 55821 A 0 090 0 1 0 2 0 2 1 15.76 7.94 7.94 1.55 25.25 25.25 23.701 23.701
55831 55831 A 0 090 0 1 0 2 0 2 1 17.19 8.44 8.44 1.66 27.29 27.29 25.637 25.637
55840 55840 A 0 090 0 1 0 2 0 2 1 24.63 11.56 11.56 2.41 38.60 38.60 36.271 36.271
55842 55842 A 0 090 0 1 0 2 0 2 1 26.49 12.25 12.25 2.60 41.34 41.34 38.850 38.850
55845 55845 A 0 090 0 1 0 2 2 2 1 30.67 13.45 13.45 3.04 47.16 47.16 44.338 44.338
55860 55860 A 0 090 0 1 0 2 0 1 1 15.84 7.93 7.93 1.52 25.29 25.29 23.756 23.756
55862 55862 A 0 090 0 1 0 2 0 2 1 20.04 9.68 9.68 1.93 31.65 31.65 29.742 29.742
55865 55865 A 0 090 0 1 0 2 2 2 1 24.57 11.54 11.54 2.38 38.49 38.49 36.178 36.178
55866 55866 A 0 090 0 1 0 2 0 2 1 32.06 14.88 14.88 3.18 50.12 50.12 47.085 47.085
55870 55870 A 0 000 0 0 0 2 0 1 1 2.58 2.27 1.28 0.26 5.11 4.12 4.754 3.865
55873 55873 A 0 090 0 1 0 2 0 1 0 13.60 192.13 7.17 1.36 207.09 22.13 186.844 20.750
55875 55875 A 0 090 0 1 0 2 0 0 0 13.46 7.30 7.30 1.29 22.05 22.05 20.690 20.690
55876 55876 A 0 000 0 0 0 2 0 1 1 1.73 2.06 1.02 0.16 3.95 2.91 3.664 2.730
55899 55899 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
55920 55920 A 0 000 0 0 0 2 0 0 0 8.31 3.78 3.78 0.80 12.89 12.89 12.123 12.123
55970 55970 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
55980 55980 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
56405 56405 A 0 010 0 1 0 2 0 1 2 1.49 1.55 1.53 0.26 3.30 3.28 3.018 3.000
56420 56420 A 0 010 0 1 0 2 0 1 0 1.44 2.00 1.07 0.24 3.68 2.75 3.362 2.526
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
221 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
56440 56440 A 0 010 0 1 0 2 0 1 0 2.89 2.10 2.10 0.49 5.48 5.48 5.032 5.032
56441 56441 A 0 010 0 1 0 2 0 0 0 2.02 1.97 1.81 0.29 4.28 4.12 3.941 3.797
56442 56442 A 0 000 0 0 0 2 0 0 0 0.68 0.65 0.65 0.11 1.44 1.44 1.321 1.321
56501 56501 A 0 010 0 1 0 2 0 1 0 1.58 2.09 1.61 0.27 3.94 3.46 3.598 3.167
56515 56515 A 0 010 0 1 0 2 0 1 0 3.08 3.14 2.39 0.50 6.72 5.97 6.161 5.488
56605 56605 A 0 000 0 0 0 2 0 1 2 1.10 1.19 0.52 0.18 2.47 1.80 2.263 1.661
56606 56606 A 0 ZZZ 0 0 0 0 0 1 2 0.55 0.48 0.24 0.08 1.11 0.87 1.023 0.807
56620 56620 A 0 090 0 1 0 2 0 2 1 7.53 6.45 6.45 1.27 15.25 15.25 13.986 13.986
56625 56625 A 0 090 0 1 0 2 0 2 1 9.68 6.92 6.92 1.62 18.22 18.22 16.741 16.741
56630 56630 A 0 090 0 1 0 2 0 2 1 14.80 9.40 9.40 2.56 26.76 26.76 24.580 24.580
56631 56631 A 0 090 0 1 0 2 0 2 2 18.99 11.74 11.74 3.21 33.94 33.94 31.211 31.211
56632 56632 A 0 090 0 1 0 2 2 2 2 21.86 14.02 14.02 3.70 39.58 39.58 36.385 36.385
56633 56633 A 0 090 0 1 0 2 0 2 2 19.62 11.83 11.83 3.32 34.77 34.77 31.980 31.980
56634 56634 A 0 090 0 1 0 2 0 2 2 20.66 12.79 12.79 3.50 36.95 36.95 33.976 33.976
56637 56637 A 0 090 0 1 0 2 0 2 2 24.75 14.11 14.11 4.18 43.04 43.04 39.607 39.607
56640 56640 A 0 090 0 1 0 2 1 2 1 24.78 13.03 13.03 4.18 41.99 41.99 38.667 38.667
56700 56700 A 0 010 0 1 0 2 0 2 1 2.84 2.31 2.31 0.48 5.63 5.63 5.165 5.165
56740 56740 A 0 010 0 1 0 2 1 1 0 4.88 3.22 3.22 0.83 8.93 8.93 8.206 8.206
56800 56800 A 0 010 0 1 0 2 0 2 1 3.93 2.61 2.61 0.64 7.18 7.18 6.609 6.609
56805 56805 A 0 090 0 1 0 2 0 2 1 19.88 11.06 11.06 3.38 34.32 34.32 31.580 31.580
56810 56810 A 0 010 0 1 0 2 0 2 2 4.29 2.78 2.78 0.69 7.76 7.76 7.147 7.147
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
222 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
56820 56820 A 0 000 0 0 0 2 0 1 0 1.50 1.57 0.80 0.26 3.33 2.56 3.046 2.354
56821 56821 A 0 000 0 0 0 2 0 1 0 2.05 2.01 1.03 0.34 4.40 3.42 4.033 3.153
57000 57000 A 0 010 0 1 0 2 0 0 0 3.02 2.16 2.16 0.50 5.68 5.68 5.221 5.221
57010 57010 A 0 090 0 1 0 2 0 0 0 6.84 5.06 5.06 1.16 13.06 13.06 11.991 11.991
57020 57020 A 0 000 0 0 0 2 0 0 0 1.50 1.05 0.68 0.26 2.81 2.44 2.579 2.247
57022 57022 A 0 010 0 1 0 2 0 0 0 2.73 1.86 1.86 0.45 5.04 5.04 4.636 4.636
57023 57023 A 0 010 0 1 0 2 0 0 0 5.18 3.27 3.27 0.87 9.32 9.32 8.571 8.571
57061 57061 A 0 010 0 1 0 2 0 1 0 1.30 1.91 1.44 0.22 3.43 2.96 3.130 2.708
57065 57065 A 0 010 0 1 0 2 0 1 0 2.66 2.68 2.05 0.44 5.78 5.15 5.297 4.731
57100 57100 A 0 000 0 0 0 2 0 1 0 1.20 1.24 0.57 0.20 2.64 1.97 2.418 1.816
57105 57105 A 0 010 0 1 0 2 0 1 0 1.74 2.04 1.74 0.29 4.07 3.77 3.724 3.454
57106 57106 A 0 090 0 1 0 2 0 2 1 7.50 5.80 5.80 1.21 14.51 14.51 13.341 13.341
57107 57107 A 0 090 0 1 0 2 0 2 1 24.56 13.41 13.41 4.15 42.12 42.12 38.773 38.773
57109 57109 A 0 090 0 1 0 2 2 2 1 28.40 16.12 16.12 4.80 49.32 49.32 45.386 45.386
57110 57110 A 0 090 0 1 0 2 0 2 1 15.48 8.77 8.77 2.59 26.84 26.84 24.710 24.710
57111 57111 A 0 090 0 1 0 2 2 2 1 28.40 14.82 14.82 4.80 48.02 48.02 44.219 44.219
57112 57112 A 0 090 0 1 0 2 2 2 1 30.52 15.73 15.73 2.42 48.67 48.67 45.911 45.911
57120 57120 A 0 090 0 1 0 2 0 2 1 8.28 5.64 5.64 1.36 15.28 15.28 14.056 14.056
57130 57130 A 0 010 0 1 0 2 0 2 1 2.46 2.46 1.91 0.41 5.33 4.78 4.884 4.390
57135 57135 A 0 010 0 1 0 2 0 1 0 2.70 2.60 2.02 0.44 5.74 5.16 5.265 4.744
57150 57150 A 0 000 0 0 0 2 0 1 0 0.55 0.73 0.23 0.08 1.36 0.86 1.247 0.798
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
223 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
57155 57155 A 0 000 0 0 0 2 0 1 2 5.40 7.18 2.41 0.48 13.06 8.29 12.099 7.815
57156 57156 A 0 000 0 0 0 2 0 0 0 2.69 2.78 1.27 0.23 5.70 4.19 5.307 3.951
57160 57160 A 0 000 0 0 0 2 0 1 0 0.89 1.27 0.37 0.14 2.30 1.40 2.104 1.295
57170 57170 A 0 000 0 0 0 2 0 0 0 0.91 0.76 0.39 0.14 1.81 1.44 1.666 1.333
57180 57180 A 0 010 0 1 0 2 0 1 0 1.63 2.35 1.26 0.27 4.25 3.16 3.882 2.903
57200 57200 A 0 090 0 1 0 2 0 2 1 4.42 3.84 3.84 0.71 8.97 8.97 8.240 8.240
57210 57210 A 0 090 0 1 0 2 0 2 1 5.71 4.34 4.34 0.91 10.96 10.96 10.083 10.083
57220 57220 A 0 090 0 1 0 2 0 2 1 4.85 3.95 3.95 0.80 9.60 9.60 8.816 8.816
57230 57230 A 0 090 0 1 0 2 0 2 1 6.30 4.51 4.51 1.06 11.87 11.87 10.904 10.904
57240 57240 A 0 090 0 1 0 2 0 2 1 11.50 6.67 6.67 1.63 19.80 19.80 18.342 18.342
57250 57250 A 0 090 0 1 0 2 0 2 1 11.50 6.85 6.85 1.86 20.21 20.21 18.624 18.624
57260 57260 A 0 090 0 1 0 2 0 2 1 14.44 8.08 8.08 2.34 24.86 24.86 22.920 22.920
57265 57265 A 0 090 0 1 0 2 0 2 1 15.94 8.71 8.71 2.57 27.22 27.22 25.106 25.106
57267 57267 A 0 ZZZ 0 0 0 0 0 2 1 4.88 1.98 1.98 0.72 7.58 7.58 7.035 7.035
57268 57268 A 0 090 0 1 0 2 0 2 1 7.57 5.66 5.66 1.22 14.45 14.45 13.291 13.291
57270 57270 A 0 090 0 1 0 2 0 2 1 13.67 7.95 7.95 2.25 23.87 23.87 21.986 21.986
57280 57280 A 0 090 0 1 0 2 0 2 1 16.72 9.03 9.03 2.60 28.35 28.35 26.189 26.189
57282 57282 A 0 090 0 1 0 2 0 2 1 7.97 5.73 5.73 1.24 14.94 14.94 13.764 13.764
57283 57283 A 0 090 0 1 0 2 0 2 1 11.66 7.03 7.03 1.92 20.61 20.61 18.977 18.977
57284 57284 A 0 090 0 1 0 2 0 2 2 14.33 7.71 7.71 2.16 24.20 24.20 22.383 22.383
57285 57285 A 0 090 0 1 0 2 0 2 2 11.60 6.64 6.64 1.80 20.04 20.04 18.504 18.504
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
224 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
57287 57287 A 0 090 0 1 0 2 0 2 1 11.15 7.42 7.42 1.47 20.04 20.04 18.582 18.582
57288 57288 A 0 090 0 1 0 2 0 2 1 12.13 7.28 7.28 1.59 21.00 21.00 19.499 19.499
57289 57289 A 0 090 0 1 0 2 0 2 1 12.80 7.03 7.03 1.24 21.07 21.07 19.761 19.761
57291 57291 A 0 090 0 1 0 2 0 2 0 8.64 5.82 5.82 1.47 15.93 15.93 14.635 14.635
57292 57292 A 0 090 0 1 0 2 0 2 1 14.01 8.11 8.11 2.34 24.46 24.46 22.517 22.517
57295 57295 A 0 090 0 1 0 2 0 2 1 7.82 5.21 5.21 1.20 14.23 14.23 13.126 13.126
57296 57296 A 0 090 0 1 0 2 0 2 1 16.56 9.07 9.07 2.79 28.42 28.42 26.164 26.164
57300 57300 A 0 090 0 1 0 2 0 2 1 8.71 6.49 6.49 1.52 16.72 16.72 15.333 15.333
57305 57305 A 0 090 0 1 0 2 0 2 1 15.35 9.45 9.45 2.97 27.77 27.77 25.389 25.389
57307 57307 A 0 090 0 1 0 2 0 2 1 17.17 10.84 10.84 3.67 31.68 31.68 28.824 28.824
57308 57308 A 0 090 0 1 0 2 0 2 1 10.59 6.82 6.82 1.80 19.21 19.21 17.656 17.656
57310 57310 A 0 090 0 1 0 2 0 2 1 7.65 4.96 4.96 0.73 13.34 13.34 12.486 12.486
57311 57311 A 0 090 0 1 0 2 0 2 1 8.91 5.40 5.40 0.86 15.17 15.17 14.209 14.209
57320 57320 A 0 090 0 1 0 2 0 2 1 8.88 5.59 5.59 1.05 15.52 15.52 14.449 14.449
57330 57330 A 0 090 0 1 0 2 0 2 1 13.21 6.86 6.86 1.28 21.35 21.35 20.040 20.040
57335 57335 A 0 090 0 1 0 2 0 2 1 20.02 11.25 11.25 3.39 34.66 34.66 31.895 31.895
57400 57400 A 0 000 0 0 0 2 0 0 0 2.27 1.32 1.32 0.38 3.97 3.97 3.654 3.654
57410 57410 A 0 000 0 0 0 2 0 1 0 1.75 1.17 1.17 0.29 3.21 3.21 2.952 2.952
57415 57415 A 0 010 0 1 0 2 0 0 0 2.49 1.90 1.90 0.37 4.76 4.76 4.390 4.390
57420 57420 A 0 000 0 0 0 2 0 1 0 1.60 1.62 0.83 0.26 3.48 2.69 3.191 2.481
57421 57421 A 0 000 0 0 0 2 0 1 0 2.20 2.11 1.10 0.37 4.68 3.67 4.288 3.381
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
225 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
57423 57423 A 0 090 0 1 0 2 0 2 2 16.08 8.61 8.61 2.72 27.41 27.41 25.234 25.234
57425 57425 A 0 090 0 1 0 2 0 2 1 17.03 9.19 9.19 2.67 28.89 28.89 26.679 26.679
57426 57426 A 0 090 0 1 0 2 0 2 1 14.30 8.65 8.65 2.41 25.36 25.36 23.328 23.328
57452 57452 A 0 000 0 0 0 2 0 1 0 1.50 1.52 1.01 0.24 3.26 2.75 2.990 2.533
57454 57454 A 0 000 0 0 0 3 0 1 0 2.33 1.88 1.36 0.38 4.59 4.07 4.217 3.750
57455 57455 A 0 000 0 0 0 3 0 1 0 1.99 1.97 0.99 0.33 4.29 3.31 3.932 3.052
57456 57456 A 0 000 0 0 0 3 0 1 0 1.85 1.89 0.93 0.31 4.05 3.09 3.709 2.847
57460 57460 A 0 000 0 0 0 3 0 1 0 2.83 5.28 1.58 0.48 8.59 4.89 7.822 4.500
57461 57461 A 0 000 0 0 0 3 0 1 0 3.43 5.67 1.61 0.59 9.69 5.63 8.830 5.184
57500 57500 A 0 000 0 0 0 2 0 1 0 1.20 2.48 0.88 0.20 3.88 2.28 3.532 2.095
57505 57505 A 0 010 0 1 0 2 0 1 0 1.19 1.69 1.39 0.20 3.08 2.78 2.812 2.543
57510 57510 A 0 010 0 1 0 2 0 1 0 1.90 1.73 1.26 0.31 3.94 3.47 3.616 3.194
57511 57511 A 0 010 0 1 0 2 0 1 0 1.95 2.10 1.71 0.33 4.38 3.99 4.008 3.658
57513 57513 A 0 010 0 1 0 2 0 1 0 1.95 2.05 1.72 0.33 4.33 4.00 3.963 3.667
57520 57520 A 0 090 0 1 0 2 0 1 0 4.11 4.37 3.40 0.68 9.16 8.19 8.390 7.519
57522 57522 A 0 090 0 1 0 2 0 1 0 3.67 3.62 3.02 0.63 7.92 7.32 7.250 6.711
57530 57530 A 0 090 0 1 0 2 0 2 1 5.27 4.20 4.20 0.87 10.34 10.34 9.497 9.497
57531 57531 A 0 090 0 1 0 2 2 2 1 29.95 17.07 17.07 5.06 52.08 52.08 47.925 47.925
57540 57540 A 0 090 0 1 0 2 0 2 1 13.29 7.82 7.82 2.23 23.34 23.34 21.479 21.479
57545 57545 A 0 090 0 1 0 2 0 2 1 14.10 8.16 8.16 2.35 24.61 24.61 22.657 22.657
57550 57550 A 0 090 0 1 0 2 0 2 1 6.34 4.84 4.84 1.08 12.26 12.26 11.251 11.251
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
226 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
57555 57555 A 0 090 0 1 0 2 0 2 1 9.94 6.42 6.42 1.66 18.02 18.02 16.573 16.573
57556 57556 A 0 090 0 1 0 2 0 2 1 9.36 6.08 6.08 1.46 16.90 16.90 15.583 15.583
57558 57558 A 0 010 0 1 0 2 0 1 0 1.72 1.75 1.41 0.29 3.76 3.42 3.443 3.138
57700 57700 A 0 090 0 1 0 2 0 0 0 4.35 4.30 4.30 0.72 9.37 9.37 8.588 8.588
57720 57720 A 0 090 0 1 0 2 0 2 0 4.61 3.87 3.87 0.76 9.24 9.24 8.483 8.483
57800 57800 A 0 000 0 0 0 2 0 1 0 0.77 0.92 0.56 0.12 1.81 1.45 1.659 1.336
58100 58100 A 0 000 0 0 0 2 0 1 0 1.53 1.49 0.84 0.26 3.28 2.63 3.004 2.420
58110 58110 A 0 ZZZ 0 0 0 0 0 0 0 0.77 0.54 0.33 0.12 1.43 1.22 1.318 1.129
58120 58120 A 0 010 0 1 0 2 0 1 0 3.59 3.55 2.34 0.61 7.75 6.54 7.097 6.010
58140 58140 A 0 090 0 1 0 2 0 2 1 15.79 8.92 8.92 2.80 27.51 27.51 25.265 25.265
58145 58145 A 0 090 0 1 0 2 0 2 1 8.91 5.90 5.90 1.50 16.31 16.31 14.993 14.993
58146 58146 A 0 090 0 1 0 2 0 2 1 20.34 10.75 10.75 3.44 34.53 34.53 31.793 31.793
58150 58150 A 0 090 0 1 0 2 0 2 1 17.31 9.64 9.64 2.94 29.89 29.89 27.504 27.504
58152 58152 A 0 090 0 1 0 2 0 2 1 21.86 11.67 11.67 3.74 37.27 37.27 34.296 34.296
58180 58180 A 0 090 0 1 0 2 0 2 1 16.60 9.26 9.26 2.80 28.66 28.66 26.380 26.380
58200 58200 A 0 090 0 1 0 2 0 2 1 23.10 12.54 12.54 3.89 39.53 39.53 36.395 36.395
58210 58210 A 0 090 0 1 0 2 2 2 1 30.91 16.79 16.79 5.27 52.97 52.97 48.744 48.744
58240 58240 A 0 090 0 1 0 2 0 2 1 49.33 26.56 26.56 8.33 84.22 84.22 77.537 77.537
58260 58260 A 0 090 0 1 0 2 0 2 1 14.15 8.23 8.23 2.38 24.76 24.76 22.785 22.785
58262 58262 A 0 090 0 1 0 2 0 2 2 15.94 8.97 8.97 2.69 27.60 27.60 25.402 25.402
58263 58263 A 0 090 0 1 0 2 0 2 2 17.23 9.49 9.49 2.91 29.63 29.63 27.274 27.274
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
227 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
58267 58267 A 0 090 0 1 0 2 0 2 1 18.36 10.08 10.08 3.12 31.56 31.56 29.044 29.044
58270 58270 A 0 090 0 1 0 2 0 2 1 15.30 8.49 8.49 2.57 26.36 26.36 24.268 24.268
58275 58275 A 0 090 0 1 0 2 0 2 1 17.03 9.53 9.53 2.90 29.46 29.46 27.105 27.105
58280 58280 A 0 090 0 1 0 2 0 2 1 18.33 10.13 10.13 3.08 31.54 31.54 29.038 29.038
58285 58285 A 0 090 0 1 0 2 0 2 1 23.38 11.88 11.88 3.93 39.19 39.19 36.104 36.104
58290 58290 A 0 090 0 1 0 2 0 2 1 20.27 10.58 10.58 3.43 34.28 34.28 31.565 31.565
58291 58291 A 0 090 0 1 0 2 0 2 2 22.06 11.50 11.50 3.73 37.29 37.29 34.338 34.338
58292 58292 A 0 090 0 1 0 2 0 2 2 23.35 12.03 12.03 3.93 39.31 39.31 36.208 36.208
58293 58293 A 0 090 0 1 0 2 0 2 1 24.33 12.45 12.45 4.11 40.89 40.89 37.660 37.660
58294 58294 A 0 090 0 1 0 2 0 2 1 21.55 11.26 11.26 3.66 36.47 36.47 33.576 33.576
58300 58300 N 9 XXX 0 0 0 9 9 9 9 1.01 0.98 0.41 0.07 2.06 1.49 1.927 1.415
58301 58301 A 0 000 0 0 0 2 0 0 0 1.27 1.38 0.54 0.22 2.87 2.03 2.624 1.870
58321 58321 A 0 000 0 0 0 2 0 0 0 0.92 1.25 0.39 0.05 2.22 1.36 2.069 1.296
58322 58322 A 0 000 0 0 0 2 0 0 0 1.10 1.30 0.47 0.18 2.58 1.75 2.362 1.616
58323 58323 A 0 000 0 0 0 2 0 0 0 0.23 0.20 0.10 0.04 0.47 0.37 0.431 0.341
58340 58340 A 0 000 0 0 0 2 0 1 0 0.88 2.58 0.73 0.12 3.58 1.73 3.260 1.598
58345 58345 A 0 010 0 1 0 2 1 2 2 4.70 2.87 2.87 0.78 8.35 8.35 7.685 7.685
58346 58346 A 0 090 0 1 0 2 0 1 0 7.56 4.60 4.60 0.63 12.79 12.79 12.020 12.020
58350 58350 A 0 010 0 1 0 2 1 1 0 1.06 1.68 1.14 0.18 2.92 2.38 2.663 2.178
58353 58353 A 0 010 0 1 0 2 0 1 2 3.60 26.74 2.37 0.61 30.95 6.58 27.932 6.047
58356 58356 A 0 010 0 1 0 2 0 2 2 6.41 50.29 2.84 1.08 57.78 10.33 52.135 9.525
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
228 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
58400 58400 A 0 090 0 1 0 2 0 2 1 7.14 4.86 4.86 1.08 13.08 13.08 12.069 12.069
58410 58410 A 0 090 0 1 0 2 0 2 1 13.80 7.96 7.96 2.31 24.07 24.07 22.156 22.156
58520 58520 A 0 090 0 1 0 2 0 2 1 13.48 7.82 7.82 2.90 24.20 24.20 22.019 22.019
58540 58540 A 0 090 0 1 0 2 0 2 0 15.71 8.85 8.85 2.65 27.21 27.21 25.043 25.043
58541 58541 A 0 090 0 1 0 3 0 2 2 14.70 8.72 8.72 2.46 25.88 25.88 23.817 23.817
58542 58542 A 0 090 0 1 0 2 0 2 2 16.56 9.55 9.55 2.80 28.91 28.91 26.600 26.600
58543 58543 A 0 090 0 1 0 2 0 2 2 16.87 9.64 9.64 2.86 29.37 29.37 27.023 27.023
58544 58544 A 0 090 0 1 0 2 0 2 2 18.37 10.32 10.32 3.12 31.81 31.81 29.269 29.269
58545 58545 A 0 090 0 1 0 2 0 2 2 15.55 8.57 8.57 2.67 26.79 26.79 24.642 24.642
58546 58546 A 0 090 0 1 0 2 0 2 2 19.94 10.37 10.37 3.39 33.70 33.70 31.025 31.025
58548 58548 A 0 090 0 1 0 2 2 2 2 31.63 17.48 17.48 5.32 54.43 54.43 50.109 50.109
58550 58550 A 0 090 0 1 0 3 0 2 2 15.10 8.77 8.77 2.56 26.43 26.43 24.314 24.314
58552 58552 A 0 090 0 1 0 2 0 2 2 16.91 9.59 9.59 2.87 29.37 29.37 27.023 27.023
58553 58553 A 0 090 0 1 0 2 0 2 2 20.06 10.49 10.49 3.40 33.95 33.95 31.258 31.258
58554 58554 A 0 090 0 1 0 2 0 2 2 23.11 12.34 12.34 3.93 39.38 39.38 36.247 36.247
58555 58555 A 0 000 0 0 0 2 0 0 2 3.33 5.26 1.79 0.56 9.15 5.68 8.346 5.230
58558 58558 A 0 000 0 0 0 3 0 1 2 4.74 6.39 2.43 0.80 11.93 7.97 10.897 7.341
58559 58559 A 0 000 0 0 0 3 0 1 2 6.16 3.04 3.04 1.05 10.25 10.25 9.439 9.439
58560 58560 A 0 000 0 0 0 3 0 2 2 6.99 3.39 3.39 1.18 11.56 11.56 10.651 10.651
58561 58561 A 0 000 0 0 0 3 0 0 2 9.99 4.68 4.68 1.67 16.34 16.34 15.066 15.066
58562 58562 A 0 000 0 0 0 3 0 1 2 5.20 6.27 2.59 0.87 12.34 8.66 11.285 7.981
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
229 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
58563 58563 A 0 000 0 0 0 3 0 0 2 6.16 43.80 3.03 1.05 51.01 10.24 46.042 9.430
58565 58565 A 0 090 0 1 0 3 2 1 2 7.12 49.41 4.70 1.20 57.73 13.02 52.118 11.968
58570 58570 A 0 090 0 1 0 2 0 2 2 15.88 9.26 9.26 2.69 27.83 27.83 25.602 25.602
58571 58571 A 0 090 0 1 0 2 0 2 2 17.69 10.35 10.35 3.01 31.05 31.05 28.559 28.559
58572 58572 A 0 090 0 1 0 2 0 2 2 20.09 11.13 11.13 3.40 34.62 34.62 31.863 31.863
58573 58573 A 0 090 0 1 0 2 0 2 2 23.11 12.73 12.73 3.89 39.73 39.73 36.576 36.576
58578 58578 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
58579 58579 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
58600 58600 A 0 090 0 1 0 2 2 2 1 5.91 4.03 4.03 1.01 10.95 10.95 10.057 10.057
58605 58605 A 0 090 0 1 0 2 2 2 0 5.28 3.72 3.72 0.88 9.88 9.88 9.081 9.081
58611 58611 A 0 ZZZ 0 0 0 0 0 2 0 1.45 0.62 0.62 0.24 2.31 2.31 2.132 2.132
58615 58615 A 0 010 0 1 0 2 0 2 0 3.94 2.71 2.71 0.67 7.32 7.32 6.724 6.724
58660 58660 A 0 090 0 1 0 3 0 2 2 11.59 6.49 6.49 2.04 20.12 20.12 18.485 18.485
58661 58661 A 0 010 0 1 0 3 1 2 2 11.35 5.95 5.95 1.93 19.23 19.23 17.702 17.702
58662 58662 A 0 090 0 1 0 3 0 2 2 12.15 6.88 6.88 2.07 21.10 21.10 19.411 19.411
58670 58670 A 0 090 0 1 0 3 0 1 2 5.91 4.05 4.05 1.01 10.97 10.97 10.075 10.075
58671 58671 A 0 090 0 1 0 3 0 1 2 5.91 4.05 4.05 1.01 10.97 10.97 10.075 10.075
58672 58672 A 0 090 0 1 0 3 1 2 0 12.91 6.92 6.92 2.18 22.01 22.01 20.264 20.264
58673 58673 A 0 090 0 1 0 3 1 2 0 14.04 7.52 7.52 2.35 23.91 23.91 22.022 22.022
58679 58679 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
58700 58700 A 0 090 0 1 0 2 2 2 1 12.95 7.92 7.92 2.41 23.28 23.28 21.323 21.323
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
230 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
58720 58720 A 0 090 0 1 0 2 2 2 1 12.16 7.38 7.38 2.15 21.69 21.69 19.912 19.912
58740 58740 A 0 090 0 1 0 2 0 2 1 14.90 8.74 8.74 2.64 26.28 26.28 24.129 24.129
58750 58750 A 0 090 0 1 0 2 1 2 1 15.64 9.30 9.30 2.64 27.58 27.58 25.372 25.372
58752 58752 A 0 090 0 1 0 2 1 2 0 15.64 8.58 8.58 1.10 25.32 25.32 23.920 23.920
58760 58760 A 0 090 0 1 0 2 1 2 1 13.93 7.97 7.97 2.34 24.24 24.24 22.311 22.311
58770 58770 A 0 090 0 1 0 2 1 2 0 14.77 8.26 8.26 2.48 25.51 25.51 23.485 23.485
58800 58800 A 0 090 0 1 0 2 2 1 0 4.62 4.17 3.57 0.76 9.55 8.95 8.762 8.223
58805 58805 A 0 090 0 1 0 2 2 2 1 6.42 4.59 4.59 1.09 12.10 12.10 11.112 11.112
58820 58820 A 0 090 0 1 0 2 1 2 0 4.70 3.91 3.91 0.78 9.39 9.39 8.619 8.619
58822 58822 A 0 090 0 1 0 2 1 2 1 11.81 7.97 7.97 2.52 22.30 22.30 20.285 20.285
58823 58823 A 0 000 0 0 0 2 0 1 0 3.37 23.33 1.19 0.38 27.08 4.94 24.519 4.637
58825 58825 A 0 090 0 1 0 2 0 2 1 11.78 7.05 7.05 1.97 20.80 20.80 19.141 19.141
58900 58900 A 0 090 0 1 0 2 2 2 1 6.59 4.72 4.72 1.40 12.71 12.71 11.561 11.561
58920 58920 A 0 090 0 1 0 2 2 2 1 11.95 7.01 7.01 2.00 20.96 20.96 19.291 19.291
58925 58925 A 0 090 0 1 0 2 2 2 1 12.43 7.52 7.52 2.23 22.18 22.18 20.349 20.349
58940 58940 A 0 090 0 1 0 2 2 2 1 8.22 5.84 5.84 1.54 15.60 15.60 14.270 14.270
58943 58943 A 0 090 0 1 0 2 0 2 1 19.52 10.94 10.94 3.52 33.98 33.98 31.185 31.185
58950 58950 A 0 090 0 1 0 2 2 2 1 18.37 10.98 10.98 3.25 32.60 32.60 29.930 29.930
58951 58951 A 0 090 0 1 0 2 2 2 1 24.26 13.35 13.35 4.18 41.79 41.79 38.434 38.434
58952 58952 A 0 090 0 1 0 2 2 2 1 27.29 15.16 15.16 4.74 47.19 47.19 43.383 43.383
58953 58953 A 0 090 0 1 0 2 2 2 1 34.13 18.38 18.38 5.88 58.39 58.39 53.710 53.710
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
231 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
58954 58954 A 0 090 0 1 0 2 2 2 1 37.13 19.77 19.77 6.36 63.26 63.26 58.210 58.210
58956 58956 A 0 090 0 1 0 2 2 2 1 22.80 13.07 13.07 3.99 39.86 39.86 36.624 36.624
58957 58957 A 0 090 0 1 0 2 2 2 1 26.22 14.72 14.72 4.80 45.74 45.74 41.949 41.949
58958 58958 A 0 090 0 1 0 2 2 2 1 29.22 16.00 16.00 4.94 50.16 50.16 46.172 46.172
58960 58960 A 0 090 0 1 0 2 0 2 1 15.79 9.46 9.46 2.76 28.01 28.01 25.729 25.729
58970 58970 A 0 000 0 0 0 2 0 0 0 3.52 2.56 1.90 0.26 6.34 5.68 5.955 5.362
58974 58974 C 0 000 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
58976 58976 A 0 000 0 0 0 2 0 2 1 3.82 3.06 2.01 0.27 7.15 6.10 6.709 5.766
58999 58999 C 0 YYY 0 0 0 2 0 1 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
59000 59000 A 0 000 0 0 0 2 0 1 0 1.30 2.15 0.77 0.37 3.82 2.44 3.424 2.185
59001 59001 A 0 000 0 0 0 2 0 1 0 3.00 1.56 1.56 0.86 5.42 5.42 4.851 4.851
59012 59012 A 0 000 0 0 0 2 0 0 0 3.44 1.69 1.69 0.99 6.12 6.12 5.475 5.475
59015 59015 A 0 000 0 0 0 2 0 0 0 2.20 1.88 1.16 0.63 4.71 3.99 4.218 3.571
59020 59020 A 1 000 0 0 0 0 0 0 0 0.66 1.32 1.32 0.17 2.15 2.15 1.934 1.934
59020 26 5902026 A 1 000 0 0 0 0 0 0 0 0.66 0.28 0.28 0.16 1.10 1.10 0.995 0.995
59020 TC 59020TC A 1 000 0 0 0 0 0 0 0 0.00 1.04 1.04 0.01 1.05 1.05 0.939 0.939
59025 59025 A 1 000 0 0 0 0 0 0 0 0.53 0.79 0.79 0.13 1.45 1.45 1.307 1.307
59025 26 5902526 A 1 000 0 0 0 0 0 0 0 0.53 0.23 0.23 0.12 0.88 0.88 0.799 0.799
59025 TC 59025TC A 1 000 0 0 0 0 0 0 0 0.00 0.56 0.56 0.01 0.57 0.57 0.508 0.508
59030 59030 A 0 000 0 0 0 2 0 0 0 1.99 1.06 1.06 0.12 3.17 3.17 3.005 3.005
59050 59050 A 0 XXX 0 0 0 0 0 0 0 0.89 0.38 0.38 0.26 1.53 1.53 1.367 1.367
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
232 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
59051 59051 A 0 XXX 0 0 0 0 0 0 0 0.74 0.32 0.32 0.22 1.28 1.28 1.142 1.142
59070 59070 A 0 000 0 0 0 2 0 2 0 5.24 5.67 2.61 1.51 12.42 9.36 11.121 8.374
59072 59072 A 0 000 0 0 0 2 0 1 0 8.99 4.10 4.10 2.59 15.68 15.68 14.026 14.026
59074 59074 A 0 000 0 0 0 2 0 2 0 5.24 5.37 2.58 1.51 12.12 9.33 10.852 8.347
59076 59076 A 0 000 0 0 0 2 0 2 0 8.99 4.10 4.10 2.59 15.68 15.68 14.026 14.026
59100 59100 A 0 090 0 1 0 2 0 2 1 13.37 8.00 8.00 3.84 25.21 25.21 22.562 22.562
59120 59120 A 0 090 0 1 0 2 0 2 1 12.67 7.65 7.65 3.66 23.98 23.98 21.454 21.454
59121 59121 A 0 090 0 1 0 2 0 2 1 12.74 7.58 7.58 3.67 23.99 23.99 21.466 21.466
59130 59130 A 0 090 0 1 0 2 0 0 0 15.08 8.58 8.58 1.08 24.74 24.74 23.350 23.350
59135 59135 A 0 090 0 1 0 2 0 0 0 14.92 8.42 8.42 1.06 24.40 24.40 23.036 23.036
59136 59136 A 0 090 0 1 0 2 0 2 0 14.25 9.21 9.21 4.10 27.56 27.56 24.665 24.665
59140 59140 A 0 090 0 1 0 2 0 2 0 5.94 4.47 4.47 0.41 10.82 10.82 10.168 10.168
59150 59150 A 0 090 0 1 0 2 0 2 0 12.29 7.39 7.39 3.54 23.22 23.22 20.778 20.778
59151 59151 A 0 090 0 1 0 2 0 2 0 12.11 6.97 6.97 3.48 22.56 22.56 20.189 20.189
59160 59160 A 0 010 0 1 0 2 0 0 0 2.76 2.61 1.67 0.78 6.15 5.21 5.512 4.668
59200 59200 A 0 000 0 0 0 2 0 1 0 0.79 1.17 0.34 0.23 2.19 1.36 1.961 1.216
59300 59300 A 0 000 0 0 0 2 0 0 0 2.41 2.76 1.39 0.68 5.85 4.48 5.244 4.014
59320 59320 A 0 000 0 0 0 2 0 0 0 2.48 1.42 1.42 0.69 4.59 4.59 4.116 4.116
59325 59325 A 0 000 0 0 0 2 0 0 0 4.06 2.10 2.10 0.29 6.45 6.45 6.097 6.097
59350 59350 A 0 000 0 0 0 2 0 2 0 4.94 2.11 2.11 1.42 8.47 8.47 7.577 7.577
59400 59400 A 0 MMM 0 0 0 2 0 1 0 32.16 22.09 22.09 8.96 63.21 63.21 56.683 56.683
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
233 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
59409 59409 A 0 MMM 0 0 0 2 0 0 0 14.37 6.23 6.23 3.98 24.58 24.58 22.046 22.046
59410 59410 A 0 MMM 0 0 0 2 0 1 0 18.01 8.34 8.34 4.99 31.34 31.34 28.109 28.109
59412 59412 A 0 MMM 0 0 0 0 0 0 0 1.71 0.92 0.92 0.49 3.12 3.12 2.792 2.792
59414 59414 A 0 MMM 0 0 0 2 0 0 0 1.61 0.69 0.69 0.46 2.76 2.76 2.470 2.470
59425 59425 A 0 MMM 0 0 0 0 0 0 0 6.31 5.75 2.70 1.74 13.80 10.75 12.384 9.645
59426 59426 A 0 MMM 0 0 0 0 0 0 0 11.16 10.52 4.78 3.01 24.69 18.95 22.181 17.027
59430 59430 A 0 MMM 0 0 0 2 0 1 0 2.47 2.46 1.06 0.67 5.60 4.20 5.029 3.772
59510 59510 A 0 MMM 0 0 0 2 0 1 0 35.64 24.08 24.08 10.15 69.87 69.87 62.572 62.572
59514 59514 A 0 MMM 0 0 0 2 0 2 1 16.13 6.96 6.96 4.57 27.66 27.66 24.770 24.770
59515 59515 A 0 MMM 0 0 0 2 0 1 0 21.47 10.45 10.45 6.09 38.01 38.01 34.039 34.039
59525 59525 A 0 ZZZ 0 0 0 0 0 2 1 8.53 3.65 3.65 2.44 14.62 14.62 13.084 13.084
59610 59610 A 0 MMM 0 0 0 2 0 0 0 33.87 22.63 22.63 9.75 66.25 66.25 59.291 59.291
59612 59612 A 0 MMM 0 0 0 2 0 0 0 16.09 6.88 6.88 4.62 27.59 27.59 24.685 24.685
59614 59614 A 0 MMM 0 0 0 2 0 0 0 19.73 8.94 8.94 5.66 34.33 34.33 30.718 30.718
59618 59618 A 0 MMM 0 0 0 2 0 0 0 36.16 24.25 24.25 10.40 70.81 70.81 63.376 63.376
59620 59620 A 0 MMM 0 0 0 2 0 2 0 16.66 7.12 7.12 4.79 28.57 28.57 25.559 25.559
59622 59622 A 0 MMM 0 0 0 2 0 0 0 22.00 10.72 10.72 6.33 39.05 39.05 34.937 34.937
59812 59812 A 0 090 0 1 0 2 0 1 0 4.44 3.92 3.22 1.25 9.61 8.91 8.614 7.985
59820 59820 A 0 090 0 1 0 2 0 1 0 4.84 5.28 4.57 1.39 11.51 10.80 10.308 9.671
59821 59821 A 0 090 0 1 0 2 0 0 0 5.09 5.02 4.25 1.47 11.58 10.81 10.367 9.675
59830 59830 A 0 090 0 1 0 2 0 0 0 6.59 4.70 4.70 1.89 13.18 13.18 11.799 11.799
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
234 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
59840 59840 R 0 010 0 1 0 2 0 0 0 3.01 2.71 2.43 0.80 6.52 6.24 5.862 5.611
59841 59841 R 0 010 0 1 0 2 0 0 0 5.65 4.27 3.61 1.62 11.54 10.88 10.332 9.739
59850 59850 R 0 090 0 1 0 2 0 0 0 5.90 3.87 3.87 0.41 10.18 10.18 9.590 9.590
59851 59851 R 0 090 0 1 0 2 0 0 0 5.92 4.43 4.43 1.69 12.04 12.04 10.782 10.782
59852 59852 R 0 090 0 1 0 2 0 0 0 8.23 6.07 6.07 0.59 14.89 14.89 13.989 13.989
59855 59855 R 0 090 0 1 0 2 0 0 0 6.43 4.26 4.26 1.85 12.54 12.54 11.223 11.223
59856 59856 R 0 090 0 1 0 2 0 0 0 7.79 4.68 4.68 2.23 14.70 14.70 13.159 13.159
59857 59857 R 0 090 0 1 0 2 0 0 0 9.33 5.20 5.20 0.65 15.18 15.18 14.340 14.340
59866 59866 R 0 000 0 0 0 2 0 2 1 3.99 2.08 2.08 0.29 6.36 6.36 6.010 6.010
59870 59870 A 0 090 0 1 0 2 0 2 0 6.57 5.83 5.83 1.89 14.29 14.29 12.794 12.794
59871 59871 A 0 000 0 0 0 2 0 0 0 2.13 1.31 1.31 0.61 4.05 4.05 3.625 3.625
59897 59897 C 0 YYY 0 0 0 2 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
59898 59898 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
59899 59899 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
60000 60000 A 0 010 0 1 0 2 0 0 0 1.81 3.20 2.64 0.24 5.25 4.69 4.809 4.306
60100 60100 A 0 000 0 0 0 2 0 1 0 1.56 1.58 0.58 0.16 3.30 2.30 3.063 2.165
60200 60200 A 0 090 0 1 0 2 0 2 1 10.02 8.01 8.01 1.70 19.73 19.73 18.102 18.102
60210 60210 A 0 090 0 1 0 2 0 2 1 11.23 7.81 7.81 2.07 21.11 21.11 19.326 19.326
60212 60212 A 0 090 0 1 0 2 0 2 1 16.43 10.52 10.52 3.06 30.01 30.01 27.477 27.477
60220 60220 A 0 090 0 1 0 2 0 2 1 11.19 7.97 7.97 1.94 21.10 21.10 19.362 19.362
60225 60225 A 0 090 0 1 0 2 0 2 1 14.79 10.32 10.32 2.64 27.75 27.75 25.438 25.438
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
235 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
60240 60240 A 0 090 0 1 0 2 0 2 1 15.04 9.54 9.54 2.74 27.32 27.32 25.040 25.040
60252 60252 A 0 090 0 1 0 2 0 2 1 22.01 13.26 13.26 3.88 39.15 39.15 35.947 35.947
60254 60254 A 0 090 0 1 0 2 0 2 1 28.42 16.55 16.55 4.53 49.50 49.50 45.651 45.651
60260 60260 A 0 090 0 1 0 2 1 2 1 18.26 11.04 11.04 3.13 32.43 32.43 29.811 29.811
60270 60270 A 0 090 0 1 0 2 0 2 1 23.20 13.11 13.11 4.38 40.69 40.69 37.264 37.264
60271 60271 A 0 090 0 1 0 2 0 2 1 17.62 10.73 10.73 3.01 31.36 31.36 28.830 28.830
60280 60280 A 0 090 0 1 0 2 0 2 1 6.16 6.34 6.34 0.84 13.34 13.34 12.293 12.293
60281 60281 A 0 090 0 1 0 2 0 2 1 8.82 7.70 7.70 1.14 17.66 17.66 16.331 16.331
60300 60300 A 0 000 0 0 0 2 0 1 0 0.97 2.46 0.37 0.11 3.54 1.45 3.237 1.360
60500 60500 A 0 090 0 1 0 2 0 2 1 15.60 10.07 10.07 3.01 28.68 28.68 26.217 26.217
60502 60502 A 0 090 0 1 0 2 0 2 1 21.15 12.90 12.90 4.15 38.20 38.20 34.905 34.905
60505 60505 A 0 090 0 1 0 2 0 2 1 23.06 14.11 14.11 4.33 41.50 41.50 37.995 37.995
60512 60512 A 0 ZZZ 0 0 0 0 0 2 1 4.44 1.88 1.88 0.83 7.15 7.15 6.562 6.562
60520 60520 A 0 090 0 1 0 2 0 2 1 17.16 10.17 10.17 3.47 30.80 30.80 28.107 28.107
60521 60521 A 0 090 0 1 0 2 0 2 1 19.18 9.88 9.88 4.53 33.59 33.59 30.421 30.421
60522 60522 A 0 090 0 1 0 2 0 2 1 23.48 11.95 11.95 5.46 40.89 40.89 37.067 37.067
60540 60540 A 0 090 0 1 0 2 1 2 1 18.02 10.01 10.01 3.04 31.07 31.07 28.599 28.599
60545 60545 A 0 090 0 1 0 2 1 2 1 20.93 11.06 11.06 3.69 35.68 35.68 32.792 32.792
60600 60600 A 0 090 0 1 0 2 0 2 1 25.09 10.88 10.88 5.31 41.28 41.28 37.637 37.637
60605 60605 A 0 090 0 1 0 2 0 2 1 31.96 18.17 18.17 4.11 54.24 54.24 50.426 50.426
60650 60650 A 0 090 0 1 0 2 1 2 1 20.73 10.50 10.50 3.74 34.97 34.97 32.115 32.115
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
236 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
60659 60659 C 0 YYY 0 0 0 2 1 2 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
60699 60699 C 0 YYY 0 0 0 2 0 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
61000 61000 A 0 000 0 0 0 2 2 1 0 1.58 1.74 1.74 0.14 3.46 3.46 3.216 3.216
61001 61001 A 0 000 0 0 0 2 2 1 0 1.49 1.32 1.32 0.53 3.34 3.34 2.953 2.953
61020 61020 A 0 000 0 0 0 2 0 1 0 1.51 2.17 2.17 0.50 4.18 4.18 3.720 3.720
61026 61026 A 0 000 0 0 0 2 0 1 0 1.69 1.81 1.81 0.38 3.88 3.88 3.514 3.514
61050 61050 A 0 000 0 0 0 2 0 0 0 1.51 1.57 1.57 0.12 3.20 3.20 2.983 2.983
61055 61055 A 0 000 0 0 0 0 0 1 0 2.10 1.66 1.66 0.29 4.05 4.05 3.742 3.742
61070 61070 A 0 000 0 0 0 2 0 1 0 0.89 1.50 1.50 0.20 2.59 2.59 2.342 2.342
61105 61105 A 0 090 0 1 0 2 0 0 0 5.45 6.57 6.57 1.92 13.94 13.94 12.354 12.354
61107 61107 A 0 000 0 0 0 0 0 1 0 4.99 2.52 2.52 1.78 9.29 9.29 8.184 8.184
61108 61108 A 0 090 0 1 0 2 0 1 0 11.64 11.44 11.44 4.14 27.22 27.22 24.078 24.078
61120 61120 A 0 090 0 1 0 2 0 0 0 9.60 9.32 9.32 3.46 22.38 22.38 19.779 19.779
61140 61140 A 0 090 0 1 0 2 0 2 0 17.23 14.32 14.32 6.11 37.66 37.66 33.285 33.285
61150 61150 A 0 090 0 1 0 2 0 1 1 18.90 14.60 14.60 6.78 40.28 40.28 35.557 35.557
61151 61151 A 0 090 0 1 0 2 0 1 0 13.49 11.30 11.30 4.85 29.64 29.64 26.174 26.174
61154 61154 A 0 090 0 1 0 2 1 2 1 17.07 14.77 14.77 6.10 37.94 37.94 33.524 33.524
61156 61156 A 0 090 0 1 0 2 0 2 1 17.45 13.28 13.28 6.26 36.99 36.99 32.649 32.649
61210 61210 A 0 000 0 0 0 2 0 1 0 5.83 2.95 2.95 2.08 10.86 10.86 9.567 9.567
61215 61215 A 0 090 0 1 0 2 0 1 1 5.85 7.29 7.29 2.07 15.21 15.21 13.479 13.479
61250 61250 A 0 090 0 1 0 2 1 2 1 11.49 10.28 10.28 4.12 25.89 25.89 22.876 22.876
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
237 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61253 61253 A 0 090 0 1 0 2 2 2 0 13.49 6.69 6.69 1.71 21.89 21.89 20.392 20.392
61304 61304 A 0 090 0 1 0 2 0 2 1 23.41 17.15 17.15 8.15 48.71 48.71 43.073 43.073
61305 61305 A 0 090 0 1 0 2 0 2 1 28.64 20.72 20.72 10.28 59.64 59.64 52.623 52.623
61312 61312 A 0 090 0 1 0 2 0 2 1 30.17 20.75 20.75 10.79 61.71 61.71 54.447 54.447
61313 61313 A 0 090 0 1 0 2 0 2 1 28.09 20.90 20.90 10.03 59.02 59.02 52.104 52.104
61314 61314 A 0 090 0 1 0 2 0 2 1 25.90 19.14 19.14 9.27 54.31 54.31 47.936 47.936
61315 61315 A 0 090 0 1 0 2 0 2 1 29.65 21.12 21.12 10.66 61.43 61.43 54.191 54.191
61316 61316 A 0 ZZZ 0 0 0 0 0 1 0 1.39 0.71 0.71 0.49 2.59 2.59 2.284 2.284
61320 61320 A 0 090 0 1 0 2 0 2 1 27.42 19.36 19.36 9.69 56.47 56.47 49.873 49.873
61321 61321 A 0 090 0 1 0 2 0 2 1 30.53 21.68 21.68 10.97 63.18 63.18 55.736 55.736
61322 61322 A 0 090 0 1 0 2 0 2 1 34.26 24.01 24.01 12.24 70.51 70.51 62.223 62.223
61323 61323 A 0 090 0 1 0 2 0 1 1 35.06 23.14 23.14 12.45 70.65 70.65 62.351 62.351
61330 61330 A 0 090 0 1 0 2 1 2 1 25.30 20.47 20.47 9.09 54.86 54.86 48.436 48.436
61332 61332 A 0 090 0 1 0 2 1 2 1 28.60 17.24 17.24 10.26 56.10 56.10 49.448 49.448
61333 61333 A 0 090 0 1 0 2 1 2 1 29.27 22.77 22.77 10.51 62.55 62.55 55.214 55.214
61334 61334 A 0 090 0 1 0 2 1 2 1 19.60 9.24 9.24 7.02 35.86 35.86 31.569 31.569
61340 61340 A 0 090 0 1 0 2 1 2 1 20.11 15.66 15.66 7.23 43.00 43.00 37.954 37.954
61343 61343 A 0 090 0 1 0 2 0 2 1 31.86 22.00 22.00 11.35 65.21 65.21 57.552 57.552
61345 61345 A 0 090 0 1 0 2 0 2 1 29.23 20.79 20.79 10.49 60.51 60.51 53.386 53.386
61440 61440 A 0 090 0 1 0 2 0 2 1 28.66 15.10 15.10 10.28 54.04 54.04 47.596 47.596
61450 61450 A 0 090 0 1 0 2 0 2 1 27.69 19.39 19.39 9.94 57.02 57.02 50.301 50.301
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
238 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61458 61458 A 0 090 0 1 0 2 0 2 1 28.84 20.51 20.51 10.25 59.60 59.60 52.619 52.619
61460 61460 A 0 090 0 1 0 2 0 2 2 30.24 21.31 21.31 10.85 62.40 62.40 55.051 55.051
61470 61470 A 0 090 0 1 0 2 0 2 1 27.62 13.71 13.71 9.91 51.24 51.24 45.115 45.115
61480 61480 A 0 090 0 1 0 2 0 2 1 28.05 19.39 19.39 1.97 49.41 49.41 46.493 46.493
61490 61490 A 0 090 0 1 0 2 1 2 1 27.22 19.15 19.15 9.79 56.16 56.16 49.537 49.537
61500 61500 A 0 090 0 1 0 2 0 2 1 19.18 14.69 14.69 5.78 39.65 39.65 35.395 35.395
61501 61501 A 0 090 0 1 0 2 0 2 1 16.35 13.14 13.14 4.67 34.16 34.16 30.592 30.592
61510 61510 A 0 090 0 1 0 2 0 2 1 30.83 23.16 23.16 11.01 65.00 65.00 57.386 57.386
61512 61512 A 0 090 0 1 0 2 0 2 1 37.14 25.25 25.25 13.28 75.67 75.67 66.760 66.760
61514 61514 A 0 090 0 1 0 2 0 2 1 27.23 19.67 19.67 9.72 56.62 56.62 49.977 49.977
61516 61516 A 0 090 0 1 0 2 0 2 1 26.58 19.28 19.28 9.23 55.09 55.09 48.721 48.721
61517 61517 A 0 ZZZ 0 0 0 0 0 1 0 1.38 0.70 0.70 0.49 2.57 2.57 2.265 2.265
61518 61518 A 0 090 0 1 0 2 0 2 1 39.89 27.78 27.78 14.30 81.97 81.97 72.315 72.315
61519 61519 A 0 090 0 1 0 2 0 2 1 43.43 28.42 28.42 15.49 87.34 87.34 77.052 77.052
61520 61520 A 0 090 0 1 0 2 0 2 2 57.09 35.62 35.62 17.97 110.68 110.68 98.475 98.475
61521 61521 A 0 090 0 1 0 2 0 2 1 46.99 30.36 30.36 16.86 94.21 94.21 83.071 83.071
61522 61522 A 0 090 0 1 0 2 0 2 1 31.54 21.97 21.97 11.32 64.83 64.83 57.189 57.189
61524 61524 A 0 090 0 1 0 2 0 2 1 29.89 21.13 21.13 10.74 61.76 61.76 54.482 54.482
61526 61526 A 0 090 0 1 0 2 0 1 2 54.08 34.47 34.47 19.41 107.96 107.96 95.185 95.185
61530 61530 A 0 090 0 1 0 2 0 1 2 45.56 29.10 29.10 16.37 91.03 91.03 80.253 80.253
61531 61531 A 0 090 0 1 0 2 0 2 2 16.41 14.15 14.15 5.89 36.45 36.45 32.197 32.197
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
239 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61533 61533 A 0 090 0 1 0 2 0 2 1 21.46 16.20 16.20 7.69 45.35 45.35 40.029 40.029
61534 61534 A 0 090 0 1 0 2 0 2 1 23.01 17.63 17.63 8.26 48.90 48.90 43.162 43.162
61535 61535 A 0 090 0 1 0 2 0 2 1 13.15 11.99 11.99 4.72 29.86 29.86 26.386 26.386
61536 61536 A 0 090 0 1 0 2 0 2 1 37.72 25.11 25.11 13.54 76.37 76.37 67.350 67.350
61537 61537 A 0 090 0 1 0 2 0 2 1 36.45 23.57 23.57 13.01 73.03 73.03 64.420 64.420
61538 61538 A 0 090 0 1 0 2 0 2 1 39.45 25.34 25.34 14.18 78.97 78.97 69.621 69.621
61539 61539 A 0 090 0 1 0 2 0 2 1 34.28 23.36 23.36 12.30 69.94 69.94 61.690 61.690
61540 61540 A 0 090 0 1 0 2 0 2 1 31.43 22.01 22.01 11.28 64.72 64.72 57.094 57.094
61541 61541 A 0 090 0 1 0 2 0 2 1 30.94 21.66 21.66 11.11 63.71 63.71 56.201 56.201
61542 61542 A 0 090 0 1 0 2 0 2 1 33.16 16.16 16.16 11.90 61.22 61.22 53.895 53.895
61543 61543 A 0 090 0 1 0 2 0 2 1 31.31 21.85 21.85 11.23 64.39 64.39 56.805 56.805
61544 61544 A 0 090 0 1 0 2 0 2 0 27.36 13.60 13.60 9.83 50.79 50.79 44.714 44.714
61545 61545 A 0 090 0 1 0 2 0 2 1 46.43 31.23 31.23 16.66 94.32 94.32 83.188 83.188
61546 61546 A 0 090 0 1 0 2 0 2 1 33.44 22.93 22.93 11.99 68.36 68.36 60.302 60.302
61548 61548 A 0 090 0 1 0 2 0 2 2 23.37 16.10 16.10 6.67 46.14 46.14 41.316 41.316
61550 61550 A 0 090 0 1 0 2 0 2 1 15.59 11.21 11.21 1.10 27.90 27.90 26.232 26.232
61552 61552 A 0 090 0 1 0 2 0 2 1 20.40 9.51 9.51 1.46 31.37 31.37 29.704 29.704
61556 61556 A 0 090 0 1 0 2 0 2 0 24.09 17.85 17.85 8.66 50.60 50.60 44.648 44.648
61557 61557 A 0 090 0 1 0 2 0 2 0 23.31 18.31 18.31 8.37 49.99 49.99 44.130 44.130
61558 61558 A 0 090 0 1 0 2 0 2 0 26.50 11.54 11.54 9.51 47.55 47.55 41.837 41.837
61559 61559 A 0 090 0 1 0 2 0 2 1 34.02 17.31 17.31 2.41 53.74 53.74 50.825 50.825
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
240 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61563 61563 A 0 090 0 1 0 2 0 2 1 28.44 20.07 20.07 10.21 58.72 58.72 51.803 51.803
61564 61564 A 0 090 0 1 0 2 1 2 1 34.74 17.14 17.14 12.45 64.33 64.33 56.643 56.643
61566 61566 A 0 090 0 1 0 2 0 2 1 32.45 22.53 22.53 11.64 66.62 66.62 58.770 58.770
61567 61567 A 0 090 0 1 0 2 0 2 1 37.00 25.68 25.68 13.30 75.98 75.98 67.017 67.017
61570 61570 A 0 090 0 1 0 2 0 2 1 26.51 19.41 19.41 9.51 55.43 55.43 48.914 48.914
61571 61571 A 0 090 0 1 0 2 0 2 1 28.42 20.38 20.38 10.19 58.99 58.99 52.051 52.051
61575 61575 A 0 090 0 1 0 2 0 2 1 36.56 24.52 24.52 13.12 74.20 74.20 65.441 65.441
61576 61576 A 0 090 0 1 0 2 0 2 1 55.31 39.67 39.67 7.10 102.08 102.08 94.647 94.647
61580 61580 A 0 090 0 1 0 2 1 1 1 34.51 33.76 33.76 5.89 74.16 74.16 67.907 67.907
61581 61581 A 0 090 0 1 0 2 1 1 2 39.13 36.29 36.29 5.04 80.46 80.46 74.354 74.354
61582 61582 A 0 090 0 1 0 2 0 2 1 35.14 44.17 44.17 12.62 91.93 91.93 81.405 81.405
61583 61583 A 0 090 0 1 0 2 0 2 1 38.50 35.19 35.19 12.94 86.63 86.63 76.868 76.868
61584 61584 A 0 090 0 1 0 2 1 2 1 37.70 34.88 34.88 12.70 85.28 85.28 75.664 75.664
61585 61585 A 0 090 0 1 0 2 1 2 1 42.57 38.87 38.87 15.28 96.72 96.72 85.467 85.467
61586 61586 A 0 090 0 1 0 2 0 2 1 27.48 36.60 36.60 9.87 73.95 73.95 65.509 65.509
61590 61590 A 0 090 0 1 0 2 1 2 1 47.04 35.65 35.65 8.45 91.14 91.14 83.473 83.473
61591 61591 A 0 090 0 1 0 2 1 2 1 47.02 35.76 35.76 9.60 92.38 92.38 84.153 84.153
61592 61592 A 0 090 0 1 0 2 1 2 1 43.08 37.21 37.21 14.51 94.80 94.80 84.083 84.083
61595 61595 A 0 090 0 1 0 2 1 1 1 33.74 29.96 29.96 7.15 70.85 70.85 64.384 64.384
61596 61596 A 0 090 0 1 0 2 1 2 1 39.43 28.76 28.76 5.06 73.25 73.25 67.903 67.903
61597 61597 A 0 090 0 1 0 2 1 2 1 40.82 30.67 30.67 14.66 86.15 86.15 76.029 76.029
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
241 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61598 61598 A 0 090 0 1 0 2 0 2 1 36.53 35.21 35.21 13.11 84.85 84.85 75.005 75.005
61600 61600 A 0 090 0 1 0 2 0 2 1 30.01 27.80 27.80 6.22 64.03 64.03 58.227 58.227
61601 61601 A 0 090 0 1 0 2 0 2 1 31.14 30.36 30.36 10.17 71.67 71.67 63.722 63.722
61605 61605 A 0 090 0 1 0 2 0 2 1 32.57 27.61 27.61 4.95 65.13 65.13 59.953 59.953
61606 61606 A 0 090 0 1 0 2 0 2 1 42.05 33.43 33.43 13.68 89.16 89.16 79.225 79.225
61607 61607 A 0 090 0 1 0 2 0 2 1 40.93 30.14 30.14 14.69 85.76 85.76 75.679 75.679
61608 61608 A 0 090 0 1 0 2 0 2 1 45.54 35.82 35.82 15.38 96.74 96.74 85.750 85.750
61609 61609 A 0 ZZZ 0 0 0 0 0 2 1 9.88 4.93 4.93 3.55 18.36 18.36 16.164 16.164
61610 61610 A 0 ZZZ 0 0 0 0 0 2 1 29.63 15.07 15.07 10.64 55.34 55.34 48.728 48.728
61611 61611 A 0 ZZZ 0 0 0 0 0 2 1 7.41 3.00 3.00 0.52 10.93 10.93 10.376 10.376
61612 61612 A 0 ZZZ 0 0 0 0 0 2 1 27.84 11.28 11.28 1.96 41.08 41.08 38.995 38.995
61613 61613 A 0 090 0 1 0 2 1 2 1 45.03 36.55 36.55 16.17 97.75 97.75 86.309 86.309
61615 61615 A 0 090 0 1 0 2 0 2 1 35.77 27.10 27.10 4.60 67.47 67.47 62.512 62.512
61616 61616 A 0 090 0 1 0 2 0 2 1 46.74 37.81 37.81 14.41 98.96 98.96 88.230 88.230
61618 61618 A 0 090 0 1 0 2 0 2 1 18.69 14.42 14.42 5.76 38.87 38.87 34.652 34.652
61619 61619 A 0 090 0 1 0 2 0 2 1 22.10 15.35 15.35 6.33 43.78 43.78 39.195 39.195
61623 61623 A 0 000 0 0 0 2 0 1 0 9.95 4.40 4.40 1.85 16.20 16.20 14.869 14.869
61624 61624 A 0 000 0 0 0 2 0 1 0 20.12 8.41 8.41 3.77 32.30 32.30 29.644 29.644
61626 61626 A 0 000 0 0 0 2 0 1 0 16.60 6.10 6.10 2.14 24.84 24.84 23.197 23.197
61630 61630 R 0 XXX 0 0 0 2 0 2 1 22.07 11.08 11.08 4.18 37.33 37.33 34.206 34.206
61635 61635 R 0 XXX 0 0 0 2 0 2 1 24.28 12.21 12.21 4.07 40.56 40.56 37.373 37.373
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
242 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61640 61640 N 9 000 0 0 0 9 9 9 9 12.32 4.99 4.99 0.87 18.18 18.18 17.256 17.256
61641 61641 N 9 ZZZ 0 0 0 9 9 9 9 4.33 1.75 1.75 0.31 6.39 6.39 6.064 6.064
61642 61642 N 9 ZZZ 0 0 0 9 9 9 9 8.66 3.51 3.51 0.61 12.78 12.78 12.131 12.131
61680 61680 A 0 090 0 1 0 2 0 2 1 32.55 22.91 22.91 11.68 67.14 67.14 59.232 59.232
61682 61682 A 0 090 0 1 0 2 0 2 1 63.41 37.48 37.48 22.76 123.65 123.65 108.971 108.971
61684 61684 A 0 090 0 1 0 2 0 2 1 41.64 27.64 27.64 14.94 84.22 84.22 74.274 74.274
61686 61686 A 0 090 0 1 0 2 0 2 1 67.50 41.29 41.29 24.24 133.03 133.03 117.256 117.256
61690 61690 A 0 090 0 1 0 2 0 2 1 31.34 22.25 22.25 11.26 64.85 64.85 57.209 57.209
61692 61692 A 0 090 0 1 0 2 0 2 1 54.59 34.07 34.07 19.60 108.26 108.26 95.436 95.436
61697 61697 A 0 090 0 1 0 2 0 2 1 63.40 38.99 38.99 22.52 124.91 124.91 110.191 110.191
61698 61698 A 0 090 0 1 0 2 0 2 1 69.63 42.37 42.37 24.99 136.99 136.99 120.748 120.748
61700 61700 A 0 090 0 1 0 2 0 2 1 50.62 32.44 32.44 18.06 101.12 101.12 89.197 89.197
61702 61702 A 0 090 0 1 0 2 0 2 1 60.04 37.50 37.50 21.54 119.08 119.08 104.980 104.980
61703 61703 A 0 090 0 1 0 2 0 2 1 18.80 14.87 14.87 6.75 40.42 40.42 35.684 35.684
61705 61705 A 0 090 0 1 0 2 0 2 1 38.10 25.30 25.30 13.68 77.08 77.08 67.974 67.974
61708 61708 A 0 090 0 1 0 2 0 2 0 37.20 23.89 23.89 3.08 64.17 64.17 60.264 60.264
61710 61710 A 0 090 0 1 0 2 0 0 0 31.29 11.03 11.03 6.52 48.84 48.84 44.605 44.605
61711 61711 A 0 090 0 1 0 2 0 2 1 38.23 25.37 25.37 13.72 77.32 77.32 68.188 68.188
61720 61720 A 0 090 0 1 0 2 0 1 0 17.62 13.83 13.83 6.33 37.78 37.78 33.350 33.350
61735 61735 A 0 090 0 1 0 2 0 1 1 22.35 16.85 16.85 8.02 47.22 47.22 41.676 41.676
61750 61750 A 0 090 0 1 0 2 0 1 1 19.83 14.89 14.89 7.06 41.78 41.78 36.894 36.894
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
243 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61751 61751 A 0 090 0 1 0 2 0 1 1 18.79 15.44 15.44 6.70 40.93 40.93 36.159 36.159
61760 61760 A 0 090 0 1 0 2 0 1 2 22.39 16.49 16.49 8.03 46.91 46.91 41.398 41.398
61770 61770 A 0 090 0 1 0 2 0 1 1 23.19 16.66 16.66 8.19 48.04 48.04 42.434 42.434
61781 61781 A 0 ZZZ 0 0 0 0 0 0 0 3.75 1.90 1.90 1.25 6.90 6.90 6.110 6.110
61782 61782 A 0 ZZZ 0 0 0 0 0 0 0 3.18 1.59 1.59 0.87 5.64 5.64 5.063 5.063
61783 61783 A 0 ZZZ 0 0 0 0 0 0 0 3.75 1.91 1.91 1.25 6.91 6.91 6.119 6.119
61790 61790 A 0 090 0 1 0 2 1 1 0 11.60 10.35 10.35 4.07 26.02 26.02 23.023 23.023
61791 61791 A 0 090 0 1 0 2 1 0 0 15.41 12.53 12.53 5.20 33.14 33.14 29.382 29.382
61796 61796 A 0 090 0 1 0 0 0 2 0 13.93 11.32 11.32 4.63 29.88 29.88 26.517 26.517
61797 61797 A 0 ZZZ 0 0 0 0 0 2 0 3.48 1.77 1.77 1.16 6.41 6.41 5.676 5.676
61798 61798 A 0 090 0 1 0 0 0 2 0 19.85 14.28 14.28 6.60 40.73 40.73 36.125 36.125
61799 61799 A 0 ZZZ 0 0 0 0 0 2 0 4.81 2.45 2.45 1.59 8.85 8.85 7.842 7.842
61800 61800 A 0 ZZZ 0 0 0 0 0 2 0 2.25 1.53 1.53 0.73 4.51 4.51 4.006 4.006
61850 61850 A 0 090 0 1 0 2 0 2 0 13.34 11.12 11.12 4.80 29.26 29.26 25.836 25.836
61860 61860 A 0 090 0 1 0 2 0 2 0 22.26 16.19 16.19 7.99 46.44 46.44 40.977 40.977
61863 61863 A 0 090 0 1 0 2 1 2 1 20.71 16.63 16.63 7.40 44.74 44.74 39.514 39.514
61864 61864 A 0 ZZZ 0 0 0 0 0 2 1 4.49 2.28 2.28 1.61 8.38 8.38 7.379 7.379
61867 61867 A 0 090 0 1 0 2 1 2 1 33.03 22.80 22.80 11.83 67.66 67.66 59.691 59.691
61868 61868 A 0 ZZZ 0 0 0 0 0 2 1 7.91 4.00 4.00 2.84 14.75 14.75 12.987 12.987
61870 61870 A 0 090 0 1 0 2 0 2 1 16.34 13.00 13.00 5.87 35.21 35.21 31.084 31.084
61875 61875 A 0 090 0 1 0 2 0 2 0 16.46 10.77 10.77 1.17 28.40 28.40 26.743 26.743
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
244 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
61880 61880 A 0 090 0 1 0 2 1 2 1 6.95 7.75 7.75 2.46 17.16 17.16 15.196 15.196
61885 61885 A 0 090 0 1 0 2 1 0 0 6.05 7.51 7.51 2.07 15.63 15.63 13.877 13.877
61886 61886 A 0 090 0 1 0 2 0 0 0 9.93 12.07 12.07 3.52 25.52 25.52 22.610 22.610
61888 61888 A 0 010 0 1 0 2 1 1 0 5.23 4.76 4.76 1.71 11.70 11.70 10.399 10.399
62000 62000 A 0 090 0 1 0 2 0 1 0 13.93 11.77 11.77 5.01 30.71 30.71 27.120 27.120
62005 62005 A 0 090 0 1 0 2 0 2 1 17.63 13.83 13.83 6.33 37.79 37.79 33.360 33.360
62010 62010 A 0 090 0 1 0 2 0 2 1 21.43 16.39 16.39 7.69 45.51 45.51 40.170 40.170
62100 62100 A 0 090 0 1 0 2 0 2 1 23.53 16.42 16.42 7.51 47.46 47.46 42.203 42.203
62115 62115 A 0 090 0 1 0 2 0 2 1 22.91 12.60 12.60 1.62 37.13 37.13 35.072 35.072
62116 62116 A 0 090 0 1 0 2 0 2 0 25.02 18.66 18.66 8.98 52.66 52.66 46.473 46.473
62117 62117 A 0 090 0 1 0 2 0 2 1 28.35 14.53 14.53 3.66 46.54 46.54 43.312 43.312
62120 62120 A 0 090 0 1 0 2 0 2 1 24.59 22.34 22.34 3.17 50.10 50.10 46.309 46.309
62121 62121 A 0 090 0 1 0 2 0 2 1 23.03 18.05 18.05 8.27 49.35 49.35 43.564 43.564
62140 62140 A 0 090 0 1 0 2 0 2 1 14.55 11.61 11.61 4.75 30.91 30.91 27.460 27.460
62141 62141 A 0 090 0 1 0 2 0 2 1 16.07 12.70 12.70 5.31 34.08 34.08 30.252 30.252
62142 62142 A 0 090 0 1 0 2 0 2 0 11.83 10.58 10.58 4.08 26.49 26.49 23.465 23.465
62143 62143 A 0 090 0 1 0 2 0 2 1 14.15 11.98 11.98 5.01 31.14 31.14 27.528 27.528
62145 62145 A 0 090 0 1 0 2 0 2 1 20.09 14.87 14.87 7.21 42.17 42.17 37.214 37.214
62146 62146 A 0 090 0 1 0 2 0 2 1 17.28 13.65 13.65 6.21 37.14 37.14 32.786 32.786
62147 62147 A 0 090 0 1 0 2 0 2 1 20.67 15.20 15.20 7.40 43.27 43.27 38.190 38.190
62148 62148 A 0 ZZZ 0 0 0 0 0 1 0 2.00 1.02 1.02 0.71 3.73 3.73 3.287 3.287
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
245 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
62160 62160 A 0 ZZZ 0 0 0 0 0 1 0 3.00 1.52 1.52 1.08 5.60 5.60 4.930 4.930
62161 62161 A 0 090 0 1 0 2 0 2 1 21.23 16.28 16.28 7.62 45.13 45.13 39.835 39.835
62162 62162 A 0 090 0 1 0 2 0 2 1 26.80 19.69 19.69 9.61 56.10 56.10 49.508 49.508
62163 62163 A 0 090 0 1 0 2 0 2 1 16.53 14.03 14.03 5.92 36.48 36.48 32.225 32.225
62164 62164 A 0 090 0 1 0 2 0 2 1 29.43 22.07 22.07 10.57 62.07 62.07 54.777 54.777
62165 62165 A 0 090 0 1 0 2 0 0 1 23.23 16.31 16.31 6.37 45.91 45.91 41.208 41.208
62180 62180 A 0 090 0 1 0 2 0 2 0 22.58 16.85 16.85 8.11 47.54 47.54 41.953 41.953
62190 62190 A 0 090 0 1 0 2 0 1 1 12.17 11.05 11.05 4.37 27.59 27.59 24.378 24.378
62192 62192 A 0 090 0 1 0 2 0 2 1 13.35 11.10 11.10 4.63 29.08 29.08 25.739 25.739
62194 62194 A 0 010 0 1 0 2 0 0 0 5.78 4.91 4.91 0.45 11.14 11.14 10.425 10.425
62200 62200 A 0 090 0 1 0 2 0 2 1 19.29 14.68 14.68 6.93 40.90 40.90 36.097 36.097
62201 62201 A 0 090 0 1 0 2 0 1 0 16.04 14.11 14.11 5.73 35.88 35.88 31.708 31.708
62220 62220 A 0 090 0 1 0 2 0 2 1 14.10 11.79 11.79 4.83 30.72 30.72 27.214 27.214
62223 62223 A 0 090 0 1 0 2 0 2 1 14.05 12.64 12.64 4.85 31.54 31.54 27.937 27.937
62225 62225 A 0 090 0 1 0 2 0 1 0 6.19 7.44 7.44 2.20 15.83 15.83 14.022 14.022
62230 62230 A 0 090 0 1 0 2 0 2 1 11.43 9.83 9.83 3.97 25.23 25.23 22.334 22.334
62252 62252 A 1 XXX 0 0 0 0 0 0 0 0.74 1.61 1.61 0.25 2.60 2.60 2.317 2.317
62252 26 6225226 A 1 XXX 0 0 0 0 0 0 0 0.74 0.37 0.37 0.24 1.35 1.35 1.198 1.198
62252 TC 62252TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.24 1.24 0.01 1.25 1.25 1.119 1.119
62256 62256 A 0 090 0 1 0 2 0 2 0 7.38 7.99 7.99 2.63 18.00 18.00 15.931 15.931
62258 62258 A 0 090 0 1 0 2 0 2 1 15.64 12.48 12.48 5.43 33.55 33.55 29.687 29.687
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
246 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
62263 62263 A 0 010 0 1 0 2 0 1 0 5.00 15.90 5.13 0.40 21.30 10.53 19.487 9.816
62264 62264 A 0 010 0 1 0 2 0 1 0 4.42 8.25 2.35 0.35 13.02 7.12 12.012 6.713
62267 62267 A 0 000 0 0 0 2 0 0 0 3.00 4.02 1.36 0.30 7.32 4.66 6.767 4.378
62268 62268 A 0 000 0 0 0 2 0 1 0 4.73 2.57 2.57 0.45 7.75 7.75 7.273 7.273
62269 62269 A 0 000 0 0 0 2 0 0 0 5.01 2.24 2.24 0.56 7.81 7.81 7.314 7.314
62270 62270 A 0 000 0 0 0 2 0 1 0 1.37 3.21 0.72 0.23 4.81 2.32 4.373 2.137
62272 62272 A 0 000 0 0 0 2 0 1 0 1.35 4.50 0.83 0.33 6.18 2.51 5.564 2.268
62273 62273 A 0 000 0 0 0 2 0 1 0 2.15 2.90 1.03 0.20 5.25 3.38 4.859 3.180
62280 62280 A 0 010 0 1 0 2 0 1 0 2.63 7.02 2.09 0.50 10.15 5.22 9.195 4.768
62281 62281 A 0 010 0 1 0 2 0 1 0 2.66 4.44 1.82 0.27 7.37 4.75 6.788 4.436
62282 62282 A 0 010 0 1 0 2 0 1 0 2.33 6.04 1.69 0.29 8.66 4.31 7.906 3.999
62284 62284 A 0 000 0 0 0 2 0 1 0 1.54 4.04 0.79 0.18 5.76 2.51 5.262 2.344
62287 62287 A 0 090 0 1 0 2 0 1 0 9.03 6.92 6.92 0.82 16.77 16.77 15.673 15.673
62290 62290 A 0 000 0 0 0 2 0 1 0 3.00 6.95 1.88 0.30 10.25 5.18 9.398 4.845
62291 62291 A 0 000 0 0 0 2 0 1 0 2.91 6.47 1.80 0.27 9.65 4.98 8.861 4.668
62292 62292 A 0 090 0 1 0 2 0 0 0 9.24 7.71 7.71 0.75 17.70 17.70 16.556 16.556
62294 62294 A 0 090 0 1 0 2 0 1 0 12.87 6.44 6.44 1.02 20.33 20.33 19.187 19.187
62310 62310 A 0 000 0 0 0 2 0 1 0 1.91 5.37 1.18 0.16 7.44 3.25 6.816 3.053
62311 62311 A 0 000 0 0 0 2 0 1 0 1.54 4.61 0.99 0.12 6.27 2.65 5.743 2.492
62318 62318 A 0 000 0 0 0 2 0 1 0 2.04 4.99 0.77 0.16 7.19 2.97 6.605 2.815
62319 62319 A 0 000 0 0 0 2 0 1 0 1.87 3.14 0.84 0.16 5.17 2.87 4.773 2.708
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
247 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
62350 62350 A 0 010 0 1 0 2 0 1 1 6.05 4.93 4.93 1.05 12.03 12.03 11.026 11.026
62351 62351 A 0 090 0 1 0 2 0 2 2 11.66 11.25 11.25 3.39 26.30 26.30 23.535 23.535
62355 62355 A 0 010 0 1 0 2 0 0 0 3.55 3.74 3.74 0.60 7.89 7.89 7.222 7.222
62360 62360 A 0 010 0 1 0 2 0 0 1 4.33 4.12 4.12 0.87 9.32 9.32 8.485 8.485
62361 62361 A 0 010 0 1 0 2 0 0 1 5.00 3.89 3.89 0.97 9.86 9.86 9.001 9.001
62362 62362 A 0 010 0 1 0 2 0 0 1 5.60 4.90 4.90 1.12 11.62 11.62 10.586 10.586
62365 62365 A 0 010 0 1 0 2 0 0 0 3.93 4.13 4.13 0.74 8.80 8.80 8.026 8.026
62367 62367 A 0 XXX 0 0 0 0 0 1 0 0.48 0.73 0.22 0.05 1.26 0.75 1.162 0.704
62368 62368 A 0 XXX 0 0 0 0 0 1 0 0.67 0.98 0.31 0.04 1.69 1.02 1.571 0.969
62369 62369 A 0 XXX 0 0 0 0 0 1 0 0.67 3.08 0.31 0.04 3.79 1.02 3.457 0.969
62370 62370 A 0 XXX 0 0 0 0 0 1 0 0.90 2.99 0.42 0.06 3.95 1.38 3.616 1.309
63001 63001 A 0 090 0 1 0 2 0 2 2 17.61 13.53 13.53 5.69 36.83 36.83 32.736 32.736
63003 63003 A 0 090 0 1 0 2 0 2 2 17.74 13.46 13.46 5.63 36.83 36.83 32.772 32.772
63005 63005 A 0 090 0 1 0 2 0 2 2 16.43 13.64 13.64 5.08 35.15 35.15 31.336 31.336
63011 63011 A 0 090 0 1 0 2 0 2 2 15.91 12.58 12.58 4.01 32.50 32.50 29.304 29.304
63012 63012 A 0 090 0 1 0 2 0 2 2 16.85 13.55 13.55 5.10 35.50 35.50 31.685 31.685
63015 63015 A 0 090 0 1 0 2 0 2 2 20.85 16.33 16.33 7.01 44.19 44.19 39.181 39.181
63016 63016 A 0 090 0 1 0 2 0 2 2 22.03 16.21 16.21 6.78 45.02 45.02 40.133 40.133
63017 63017 A 0 090 0 1 0 2 0 2 2 17.33 14.45 14.45 5.57 37.35 37.35 33.219 33.219
63020 63020 A 0 090 0 1 0 2 1 2 2 16.20 13.60 13.60 5.06 34.86 34.86 31.059 31.059
63030 63030 A 0 090 0 1 0 2 1 2 2 13.18 11.77 11.77 3.87 28.82 28.82 25.773 25.773
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
248 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
63035 63035 A 0 ZZZ 0 0 0 0 1 2 2 3.15 1.63 1.63 0.88 5.66 5.66 5.074 5.074
63040 63040 A 0 090 0 1 0 2 1 2 2 20.31 15.12 15.12 6.27 41.70 41.70 37.167 37.167
63042 63042 A 0 090 0 1 0 2 1 2 2 18.76 14.75 14.75 5.20 38.71 38.71 34.725 34.725
63043 63043 C 0 ZZZ 0 0 0 0 1 2 2 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
63044 63044 C 0 ZZZ 0 0 0 0 1 2 2 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
63045 63045 A 0 090 0 1 0 2 2 2 2 17.95 14.24 14.24 5.73 37.92 37.92 33.734 33.734
63046 63046 A 0 090 0 1 0 2 2 2 2 17.25 13.67 13.67 5.14 36.06 36.06 32.214 32.214
63047 63047 A 0 090 0 1 0 2 2 2 2 15.37 13.12 13.12 4.41 32.90 32.90 29.458 29.458
63048 63048 A 0 ZZZ 0 0 0 0 0 2 2 3.47 1.80 1.80 1.01 6.28 6.28 5.615 5.615
63050 63050 A 0 090 0 1 0 2 0 2 2 22.01 16.30 16.30 7.91 46.22 46.22 40.784 40.784
63051 63051 A 0 090 0 1 0 2 0 2 2 25.51 18.17 18.17 7.24 50.92 50.92 45.613 45.613
63055 63055 A 0 090 0 1 0 2 0 2 1 23.55 17.10 17.10 7.66 48.31 48.31 42.912 42.912
63056 63056 A 0 090 0 1 0 2 0 2 1 21.86 15.98 15.98 6.19 44.03 44.03 39.447 39.447
63057 63057 A 0 ZZZ 0 0 0 0 0 2 1 5.25 2.73 2.73 1.51 9.49 9.49 8.491 8.491
63064 63064 A 0 090 0 1 0 2 0 2 1 26.22 18.29 18.29 7.95 52.46 52.46 46.802 46.802
63066 63066 A 0 ZZZ 0 0 0 0 0 2 1 3.26 1.66 1.66 1.17 6.09 6.09 5.363 5.363
63075 63075 A 0 090 0 1 0 2 0 2 2 19.60 15.05 15.05 6.11 40.76 40.76 36.310 36.310
63076 63076 A 0 ZZZ 0 0 0 0 0 2 2 4.04 2.08 2.08 1.25 7.37 7.37 6.562 6.562
63077 63077 A 0 090 0 1 0 2 0 2 2 22.88 15.25 15.25 5.87 44.00 44.00 39.645 39.645
63078 63078 A 0 ZZZ 0 0 0 0 0 2 2 3.28 1.65 1.65 0.75 5.68 5.68 5.154 5.154
63081 63081 A 0 090 0 1 0 2 0 2 1 26.10 18.59 18.59 7.89 52.58 52.58 46.920 46.920
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
249 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
63082 63082 A 0 ZZZ 0 0 0 0 0 2 1 4.36 2.25 2.25 1.31 7.92 7.92 7.066 7.066
63085 63085 A 0 090 0 1 0 2 0 2 2 29.47 18.68 18.68 7.93 56.08 56.08 50.392 50.392
63086 63086 A 0 ZZZ 0 0 0 0 0 2 2 3.19 1.54 1.54 0.87 5.60 5.60 5.028 5.028
63087 63087 A 0 090 0 1 0 2 0 2 2 37.53 23.45 23.45 9.73 70.71 70.71 63.677 63.677
63088 63088 A 0 ZZZ 0 0 0 0 0 2 2 4.32 2.21 2.21 1.06 7.59 7.59 6.859 6.859
63090 63090 A 0 090 0 1 0 2 0 2 2 30.93 20.12 20.12 7.20 58.25 58.25 52.763 52.763
63091 63091 A 0 ZZZ 0 0 0 0 0 2 2 3.03 1.54 1.54 0.68 5.25 5.25 4.769 4.769
63101 63101 A 0 090 0 1 0 2 0 2 1 34.10 24.09 24.09 10.63 68.82 68.82 61.292 61.292
63102 63102 A 0 090 0 1 0 2 0 2 1 34.10 23.71 23.71 8.60 66.41 66.41 59.889 59.889
63103 63103 A 0 ZZZ 0 0 0 0 0 2 1 4.82 2.48 2.48 1.29 8.59 8.59 7.722 7.722
63170 63170 A 0 090 0 1 0 2 0 2 1 22.21 17.17 17.17 7.98 47.36 47.36 41.802 41.802
63172 63172 A 0 090 0 1 0 2 0 2 1 19.76 14.94 14.94 7.08 41.78 41.78 36.879 36.879
63173 63173 A 0 090 0 1 0 2 0 2 1 24.31 18.23 18.23 8.75 51.29 51.29 45.257 45.257
63180 63180 A 0 090 0 1 0 2 0 2 1 20.53 16.31 16.31 7.36 44.20 44.20 39.026 39.026
63182 63182 A 0 090 0 1 0 2 0 2 1 22.82 17.48 17.48 8.19 48.49 48.49 42.800 42.800
63185 63185 A 0 090 0 1 0 2 0 2 1 16.49 13.09 13.09 5.92 35.50 35.50 31.341 31.341
63190 63190 A 0 090 0 1 0 2 0 2 1 18.89 14.12 14.12 4.29 37.30 37.30 33.813 33.813
63191 63191 A 0 090 0 1 0 2 1 2 1 18.92 15.32 15.32 3.74 37.98 37.98 34.633 34.633
63194 63194 A 0 090 0 1 0 2 0 2 1 22.10 11.92 11.92 2.84 36.86 36.86 34.289 34.289
63195 63195 A 0 090 0 1 0 2 0 2 1 21.64 16.25 16.25 7.77 45.66 45.66 40.296 40.296
63196 63196 A 0 090 0 1 0 2 0 2 1 25.27 12.94 12.94 1.80 40.01 40.01 37.832 37.832
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
250 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
63197 63197 A 0 090 0 1 0 2 0 2 1 24.08 18.12 18.12 8.66 50.86 50.86 44.881 44.881
63198 63198 A 0 090 0 1 0 2 0 2 1 29.90 15.07 15.07 2.12 47.09 47.09 44.542 44.542
63199 63199 A 0 090 0 1 0 2 0 2 1 31.47 22.23 22.23 2.23 55.93 55.93 52.599 52.599
63200 63200 A 0 090 0 1 0 2 0 2 0 21.44 16.66 16.66 7.58 45.68 45.68 40.365 40.365
63250 63250 A 0 090 0 1 0 2 0 2 1 43.86 28.23 28.23 15.75 87.84 87.84 77.448 77.448
63251 63251 A 0 090 0 1 0 2 0 2 1 44.64 29.16 29.16 16.03 89.83 89.83 79.209 79.209
63252 63252 A 0 090 0 1 0 2 0 2 1 44.63 29.16 29.16 16.03 89.82 89.82 79.199 79.199
63265 63265 A 0 090 0 1 0 2 0 2 1 23.82 17.82 17.82 8.08 49.72 49.72 44.048 44.048
63266 63266 A 0 090 0 1 0 2 0 2 1 24.68 18.11 18.11 8.40 51.19 51.19 45.336 45.336
63267 63267 A 0 090 0 1 0 2 0 2 1 19.45 15.33 15.33 6.26 41.04 41.04 36.490 36.490
63268 63268 A 0 090 0 1 0 2 0 2 1 20.02 16.11 16.11 7.19 43.32 43.32 38.247 38.247
63270 63270 A 0 090 0 1 0 2 0 2 1 29.80 21.08 21.08 10.71 61.59 61.59 54.331 54.331
63271 63271 A 0 090 0 1 0 2 0 2 1 29.92 20.82 20.82 10.57 61.31 61.31 54.144 54.144
63272 63272 A 0 090 0 1 0 2 0 2 1 27.50 19.74 19.74 9.47 56.71 56.71 50.179 50.179
63273 63273 A 0 090 0 1 0 2 0 2 0 26.47 19.39 19.39 9.50 55.36 55.36 48.851 48.851
63275 63275 A 0 090 0 1 0 2 0 2 1 25.86 18.85 18.85 8.82 53.53 53.53 47.400 47.400
63276 63276 A 0 090 0 1 0 2 0 2 1 25.69 18.68 18.68 8.71 53.08 53.08 47.020 47.020
63277 63277 A 0 090 0 1 0 2 0 2 1 22.39 16.86 16.86 7.00 46.25 46.25 41.191 41.191
63278 63278 A 0 090 0 1 0 2 0 2 1 22.12 17.18 17.18 7.95 47.25 47.25 41.705 41.705
63280 63280 A 0 090 0 1 0 2 0 2 1 30.29 21.75 21.75 10.83 62.87 62.87 55.486 55.486
63281 63281 A 0 090 0 1 0 2 0 2 1 29.99 21.53 21.53 10.67 62.19 62.19 54.904 54.904
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
251 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
63282 63282 A 0 090 0 1 0 2 0 2 1 28.15 20.51 20.51 9.95 58.61 58.61 51.772 51.772
63283 63283 A 0 090 0 1 0 2 0 2 1 26.76 20.07 20.07 9.60 56.43 56.43 49.804 49.804
63285 63285 A 0 090 0 1 0 2 0 2 1 38.05 25.81 25.81 13.66 77.52 77.52 68.372 68.372
63286 63286 A 0 090 0 1 0 2 0 2 1 37.62 25.41 25.41 13.20 76.23 76.23 67.342 67.342
63287 63287 A 0 090 0 1 0 2 0 2 1 40.08 26.84 26.84 14.40 81.32 81.32 71.714 71.714
63290 63290 A 0 090 0 1 0 2 0 2 1 40.82 27.22 27.22 14.66 82.70 82.70 72.931 72.931
63295 63295 A 0 ZZZ 0 0 0 0 2 2 2 5.25 2.67 2.67 1.88 9.80 9.80 8.631 8.631
63300 63300 A 0 090 0 1 0 2 0 2 1 26.80 18.99 18.99 8.68 54.47 54.47 48.393 48.393
63301 63301 A 0 090 0 1 0 2 0 2 1 31.57 20.57 20.57 11.34 63.48 63.48 55.973 55.973
63302 63302 A 0 090 0 1 0 2 0 2 1 31.15 22.30 22.30 11.17 64.62 64.62 57.017 57.017
63303 63303 A 0 090 0 1 0 2 0 2 1 33.55 22.99 22.99 12.03 68.57 68.57 60.487 60.487
63304 63304 A 0 090 0 1 0 2 0 2 1 33.85 23.67 23.67 12.14 69.66 69.66 61.455 61.455
63305 63305 A 0 090 0 1 0 2 0 2 1 36.24 18.44 18.44 13.01 67.69 67.69 59.603 59.603
63306 63306 A 0 090 0 1 0 2 0 2 1 35.55 15.30 15.30 12.77 63.62 63.62 55.968 55.968
63307 63307 A 0 090 0 1 0 2 0 2 1 34.96 23.80 23.80 12.56 71.32 71.32 62.901 62.901
63308 63308 A 0 ZZZ 0 0 0 0 0 2 1 5.24 2.66 2.66 1.57 9.47 9.47 8.450 8.450
63600 63600 A 0 090 0 1 0 2 0 0 0 15.12 10.81 10.81 1.58 27.51 27.51 25.654 25.654
63610 63610 A 0 000 0 0 0 2 0 0 0 8.72 3.57 3.57 0.68 12.97 12.97 12.282 12.282
63615 63615 A 0 090 0 1 0 2 0 1 1 17.32 13.23 13.23 6.21 36.76 36.76 32.448 32.448
63620 63620 A 0 090 0 1 0 0 0 2 0 15.60 12.13 12.13 5.19 32.92 32.92 29.207 29.207
63621 63621 A 0 ZZZ 0 0 0 0 0 2 0 4.00 2.03 2.03 1.32 7.35 7.35 6.513 6.513
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
252 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
63650 63650 A 0 010 0 1 0 2 0 1 0 7.15 5.11 5.11 0.64 12.90 12.90 12.074 12.074
63655 63655 A 0 090 0 1 0 2 0 2 1 10.92 10.42 10.42 3.42 24.76 24.76 22.066 22.066
63661 63661 A 0 010 0 1 0 2 0 2 1 5.08 11.83 3.82 0.71 17.62 9.61 16.075 8.882
63662 63662 A 0 090 0 1 0 2 0 2 1 11.00 10.60 10.60 1.55 23.15 23.15 21.329 21.329
63663 63663 A 0 010 0 1 0 2 0 2 1 7.75 15.91 5.09 1.09 24.75 13.93 22.607 12.891
63664 63664 A 0 090 0 1 0 2 0 2 1 11.52 10.57 10.57 1.61 23.70 23.70 21.854 21.854
63685 63685 A 0 010 0 1 0 2 0 2 1 5.19 4.77 4.77 0.94 10.90 10.90 9.965 9.965
63688 63688 A 0 010 0 1 0 2 0 1 0 5.30 4.72 4.72 1.01 11.03 11.03 10.067 10.067
63700 63700 A 0 090 0 1 0 2 0 2 1 17.47 13.73 13.73 6.26 37.46 37.46 33.074 33.074
63702 63702 A 0 090 0 1 0 2 0 2 1 19.41 15.95 15.95 6.97 42.33 42.33 37.378 37.378
63704 63704 A 0 090 0 1 0 2 0 2 1 22.43 18.64 18.64 8.04 49.11 49.11 43.374 43.374
63706 63706 A 0 090 0 1 0 2 0 2 1 25.35 20.12 20.12 9.12 54.59 54.59 48.188 48.188
63707 63707 A 0 090 0 1 0 2 0 2 1 12.65 11.16 11.16 3.50 27.31 27.31 24.502 24.502
63709 63709 A 0 090 0 1 0 2 0 2 1 15.65 12.72 12.72 4.50 32.87 32.87 29.426 29.426
63710 63710 A 0 090 0 1 0 2 0 2 1 15.40 12.60 12.60 4.86 32.86 32.86 29.257 29.257
63740 63740 A 0 090 0 1 0 2 0 2 1 12.63 11.53 11.53 4.26 28.42 28.42 25.212 25.212
63741 63741 A 0 090 0 1 0 2 0 2 1 9.12 7.97 7.97 2.19 19.28 19.28 17.422 17.422
63744 63744 A 0 090 0 1 0 2 0 2 1 8.94 8.47 8.47 3.06 20.47 20.47 18.146 18.146
63746 63746 A 0 090 0 1 0 2 0 0 0 7.33 8.06 8.06 2.63 18.02 18.02 15.943 15.943
64400 64400 A 0 000 0 0 0 2 1 1 0 1.11 2.42 0.77 0.18 3.71 2.06 3.377 1.896
64402 64402 A 0 000 0 0 0 2 1 1 0 1.25 2.24 0.82 0.18 3.67 2.25 3.356 2.081
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
253 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64405 64405 A 0 000 0 0 0 2 1 1 0 0.94 1.92 0.75 0.19 3.05 1.88 2.764 1.713
64408 64408 A 0 000 0 0 0 2 1 0 0 1.41 1.41 0.61 0.16 2.98 2.18 2.760 2.041
64410 64410 A 0 000 0 0 0 2 1 0 0 1.43 2.10 0.48 0.33 3.86 2.24 3.488 2.034
64412 64412 A 0 000 0 0 0 2 1 1 0 1.18 2.83 0.78 0.20 4.21 2.16 3.826 1.985
64413 64413 A 0 000 0 0 0 2 1 1 0 1.40 2.18 0.81 0.20 3.78 2.41 3.462 2.232
64415 64415 A 0 000 0 0 0 2 1 1 0 1.48 1.97 0.30 0.11 3.56 1.89 3.307 1.807
64416 64416 A 0 000 0 0 0 2 1 1 0 1.81 0.35 0.35 0.14 2.30 2.30 2.198 2.198
64417 64417 A 0 000 0 0 0 2 1 1 0 1.44 2.34 0.52 0.11 3.89 2.07 3.599 1.964
64418 64418 A 0 000 0 0 0 2 1 1 0 1.32 2.83 0.79 0.12 4.27 2.23 3.924 2.092
64420 64420 A 0 000 0 0 0 2 0 1 0 1.18 2.15 0.76 0.12 3.45 2.06 3.173 1.925
64421 64421 A 0 000 0 0 0 2 1 1 0 1.68 2.80 0.94 0.20 4.68 2.82 4.299 2.629
64425 64425 A 0 000 0 0 0 2 1 1 0 1.75 2.12 0.88 0.20 4.07 2.83 3.758 2.645
64430 64430 A 0 000 0 0 0 2 1 1 0 1.46 2.51 0.81 0.14 4.11 2.41 3.787 2.261
64435 64435 A 0 000 0 0 0 2 1 1 0 1.45 2.40 0.81 0.24 4.09 2.50 3.731 2.303
64445 64445 A 0 000 0 0 0 2 1 1 0 1.48 2.45 0.48 0.16 4.09 2.12 3.764 1.995
64446 64446 A 0 000 0 0 0 2 1 1 0 1.81 0.36 0.36 0.14 2.31 2.31 2.207 2.207
64447 64447 A 0 000 0 0 0 2 1 1 0 1.50 1.96 0.30 0.11 3.57 1.91 3.318 1.827
64448 64448 A 0 000 0 0 0 2 1 1 0 1.63 0.32 0.32 0.12 2.07 2.07 1.980 1.980
64449 64449 A 0 000 0 0 0 2 1 1 0 1.81 0.47 0.47 0.14 2.42 2.42 2.305 2.305
64450 64450 A 0 000 0 0 0 2 1 1 0 0.75 1.58 0.52 0.06 2.39 1.33 2.200 1.248
64455 64455 A 0 000 0 0 0 2 1 0 0 0.75 0.59 0.20 0.08 1.42 1.03 1.322 0.971
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
254 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64479 64479 A 0 000 0 0 0 2 1 1 0 2.29 4.77 1.46 0.27 7.33 4.02 6.715 3.742
64480 64480 A 0 ZZZ 0 0 0 0 1 1 0 1.20 2.09 0.56 0.18 3.47 1.94 3.171 1.797
64483 64483 A 0 000 0 0 0 2 1 1 0 1.90 4.80 1.33 0.16 6.86 3.39 6.294 3.178
64484 64484 A 0 ZZZ 0 0 0 0 1 1 0 1.00 1.60 0.47 0.08 2.68 1.55 2.479 1.464
64490 64490 A 0 000 0 0 0 2 1 2 0 1.82 3.94 1.23 0.20 5.96 3.25 5.463 3.029
64491 64491 A 0 ZZZ 0 0 0 0 1 2 0 1.16 1.61 0.54 0.11 2.88 1.81 2.663 1.702
64492 64492 A 0 ZZZ 0 0 0 0 1 2 0 1.16 1.62 0.56 0.11 2.89 1.83 2.672 1.720
64493 64493 A 0 000 0 0 0 2 1 2 0 1.52 3.73 1.09 0.14 5.39 2.75 4.943 2.572
64494 64494 A 0 ZZZ 0 0 0 0 1 2 0 1.00 1.56 0.46 0.08 2.64 1.54 2.443 1.455
64495 64495 A 0 ZZZ 0 0 0 0 1 2 0 1.00 1.57 0.48 0.08 2.65 1.56 2.452 1.473
64505 64505 A 0 000 0 0 0 2 1 1 0 1.36 1.63 1.10 0.10 3.09 2.56 2.876 2.400
64508 64508 A 0 000 0 0 0 2 1 0 0 1.12 0.57 0.95 0.24 1.93 2.31 1.757 2.099
64510 64510 A 0 000 0 0 0 2 1 1 0 1.22 2.59 0.89 0.10 3.91 2.21 3.598 2.072
64517 64517 A 0 000 0 0 0 2 0 1 0 2.20 3.07 1.27 0.18 5.45 3.65 5.051 3.435
64520 64520 A 0 000 0 0 0 2 1 1 0 1.35 4.27 0.94 0.11 5.73 2.40 5.242 2.252
64530 64530 A 0 000 0 0 0 2 0 1 0 1.58 4.21 1.08 0.14 5.93 2.80 5.434 2.623
64550 64550 A 0 000 0 0 0 0 0 1 0 0.18 0.28 0.07 0.01 0.47 0.26 0.437 0.248
64553 64553 A 0 010 0 1 0 2 0 0 0 2.36 4.16 2.29 0.38 6.90 5.03 6.294 4.615
64555 64555 A 0 010 0 1 0 2 0 1 0 2.32 3.41 1.83 0.26 5.99 4.41 5.518 4.099
64561 64561 A 0 010 0 1 0 2 1 1 0 7.15 15.98 3.70 0.78 23.91 11.63 21.908 10.881
64565 64565 A 0 010 0 1 0 2 0 1 0 1.81 3.32 1.74 0.24 5.37 3.79 4.917 3.498
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
255 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64566 64566 A 0 000 0 0 0 2 0 0 0 0.60 2.99 0.22 0.05 3.64 0.87 3.311 0.824
64568 64568 A 0 090 0 1 0 2 1 0 0 9.00 8.01 8.01 1.25 18.26 18.26 16.847 16.847
64569 64569 A 0 090 0 1 0 2 1 0 1 11.00 9.03 9.03 3.16 23.19 23.19 20.762 20.762
64570 64570 A 0 090 0 1 0 2 1 0 1 9.10 8.10 8.10 3.27 20.47 20.47 18.084 18.084
64575 64575 A 0 090 0 1 0 2 0 1 0 4.42 4.53 4.53 0.44 9.39 9.39 8.718 8.718
64580 64580 A 0 090 0 1 0 2 0 2 0 4.19 4.05 4.05 0.88 9.12 9.12 8.287 8.287
64581 64581 A 0 090 0 1 0 2 0 1 0 12.20 5.69 5.69 1.58 19.47 19.47 18.136 18.136
64585 64585 A 0 010 0 1 0 2 0 1 0 2.11 5.07 1.92 0.27 7.45 4.30 6.804 3.975
64590 64590 A 0 010 0 1 0 2 0 1 1 2.45 5.12 1.98 0.29 7.86 4.72 7.199 4.380
64595 64595 A 0 010 0 1 0 2 0 1 0 1.78 5.45 1.76 0.22 7.45 3.76 6.789 3.476
64600 64600 A 0 010 0 1 0 2 2 1 0 3.49 7.85 2.45 0.53 11.87 6.47 10.816 5.967
64605 64605 A 0 010 0 1 0 2 1 0 0 5.65 10.40 3.88 0.44 16.49 9.97 15.219 9.364
64610 64610 A 0 010 0 1 0 2 1 1 0 7.20 12.96 5.03 2.15 22.31 14.38 19.963 12.841
64611 64611 A 0 010 0 1 0 2 2 0 0 1.03 2.05 1.61 0.29 3.37 2.93 3.023 2.627
64612 64612 A 0 010 0 1 0 2 1 1 0 1.41 2.24 1.80 0.46 4.11 3.67 3.662 3.267
64613 64613 A 0 010 0 1 0 2 1 1 0 2.01 2.55 2.10 0.59 5.15 4.70 4.608 4.204
64614 64614 A 0 010 0 1 0 2 1 1 0 2.20 2.91 2.28 0.42 5.53 4.90 5.033 4.467
64615 64615 A 0 010 0 1 0 2 2 1 0 1.85 1.78 1.36 0.60 4.23 3.81 3.762 3.385
64620 64620 A 0 010 0 1 0 2 0 1 0 2.89 3.08 2.05 0.29 6.26 5.23 5.808 4.883
64630 64630 A 0 010 0 1 0 2 0 0 0 3.05 2.88 1.90 0.34 6.27 5.29 5.814 4.934
64632 64632 A 0 010 0 1 0 2 1 0 0 1.23 1.20 0.70 0.10 2.53 2.03 2.360 1.911
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
256 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64633 64633 A 0 010 0 1 0 2 1 1 0 3.84 8.07 2.36 0.33 12.24 6.53 11.259 6.132
64634 64634 A 0 ZZZ 0 0 0 0 1 1 0 1.32 4.11 0.53 0.11 5.54 1.96 5.068 1.853
64635 64635 A 0 010 0 1 0 2 1 1 0 3.78 7.92 2.33 0.32 12.02 6.43 11.060 6.040
64636 64636 A 0 ZZZ 0 0 0 0 1 1 0 1.16 3.74 0.47 0.09 4.99 1.72 4.566 1.629
64640 64640 A 0 010 0 1 0 2 1 1 0 1.23 2.73 1.48 0.11 4.07 2.82 3.739 2.617
64650 64650 A 0 000 0 0 0 2 0 0 0 0.70 2.94 0.40 0.11 3.75 1.21 3.398 1.117
64653 64653 A 0 000 0 0 0 2 0 0 0 0.88 3.40 0.45 0.24 4.52 1.57 4.059 1.410
64680 64680 A 0 010 0 1 0 2 0 1 0 2.67 6.63 2.07 0.30 9.60 5.04 8.781 4.686
64681 64681 A 0 010 0 1 0 2 0 1 0 3.78 6.85 1.80 0.30 10.93 5.88 10.088 5.553
64702 64702 A 0 090 0 1 0 2 0 1 0 6.26 7.61 7.61 1.06 14.93 14.93 13.648 13.648
64704 64704 A 0 090 0 1 0 2 0 2 1 4.69 4.19 4.19 0.54 9.42 9.42 8.735 8.735
64708 64708 A 0 090 0 1 0 2 0 2 1 6.36 7.35 7.35 1.16 14.87 14.87 13.567 13.567
64712 64712 A 0 090 0 1 0 2 1 2 1 8.07 7.48 7.48 1.33 16.88 16.88 15.483 15.483
64713 64713 A 0 090 0 1 0 2 1 2 1 11.40 8.20 8.20 2.34 21.94 21.94 19.987 19.987
64714 64714 A 0 090 0 1 0 2 1 2 1 10.55 6.74 6.74 1.71 19.00 19.00 17.497 17.497
64716 64716 A 0 090 0 1 0 2 0 2 1 6.99 7.93 7.93 1.13 16.05 16.05 14.702 14.702
64718 64718 A 0 090 0 1 0 2 1 0 0 7.26 8.98 8.98 1.48 17.72 17.72 16.098 16.098
64719 64719 A 0 090 0 1 0 2 1 1 0 4.97 5.98 5.98 0.93 11.88 11.88 10.826 10.826
64721 64721 A 0 090 0 1 0 2 1 1 0 4.97 6.87 6.79 0.98 12.82 12.74 11.652 11.580
64722 64722 A 0 090 0 1 0 2 0 2 1 4.82 5.20 5.20 0.84 10.86 10.86 9.929 9.929
64726 64726 A 0 090 0 1 0 2 0 1 0 4.27 3.45 3.45 0.39 8.11 8.11 7.572 7.572
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
257 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64727 64727 A 0 ZZZ 0 0 0 0 0 1 0 3.10 1.70 1.70 0.60 5.40 5.40 4.940 4.940
64732 64732 A 0 090 0 1 0 2 1 2 0 4.89 6.64 6.64 1.77 13.30 13.30 11.778 11.778
64734 64734 A 0 090 0 1 0 2 1 0 0 5.55 5.33 5.33 0.71 11.59 11.59 10.708 10.708
64736 64736 A 0 090 0 1 0 2 1 2 0 5.23 5.75 5.75 1.88 12.86 12.86 11.377 11.377
64738 64738 A 0 090 0 1 0 2 1 2 0 6.36 6.21 6.21 2.27 14.84 14.84 13.124 13.124
64740 64740 A 0 090 0 1 0 2 1 2 0 6.22 6.75 6.75 0.80 13.77 13.77 12.700 12.700
64742 64742 A 0 090 0 1 0 2 1 2 0 6.85 7.28 7.28 0.87 15.00 15.00 13.842 13.842
64744 64744 A 0 090 0 1 0 2 1 0 0 5.72 7.07 7.07 2.04 14.83 14.83 13.136 13.136
64746 64746 A 0 090 0 1 0 2 1 2 1 6.56 4.85 4.85 1.54 12.95 12.95 11.721 11.721
64752 64752 A 0 090 0 1 0 2 0 2 1 7.69 5.19 5.19 1.81 14.69 14.69 13.297 13.297
64755 64755 A 0 090 0 1 0 2 0 2 1 15.05 8.87 8.87 3.21 27.13 27.13 24.694 24.694
64760 64760 A 0 090 0 1 0 2 0 2 1 7.59 6.09 6.09 1.61 15.29 15.29 13.901 13.901
64761 64761 A 0 090 0 1 0 2 1 2 0 7.04 5.76 5.76 1.01 13.81 13.81 12.741 12.741
64763 64763 A 0 090 0 1 0 2 1 2 1 7.56 7.42 7.42 1.61 16.59 16.59 15.065 15.065
64766 64766 A 0 090 0 1 0 2 1 2 0 9.47 7.12 7.12 0.91 17.50 17.50 16.340 16.340
64771 64771 A 0 090 0 1 0 2 0 2 0 8.15 7.95 7.95 1.05 17.15 17.15 15.838 15.838
64772 64772 A 0 090 0 1 0 2 0 2 1 7.84 7.56 7.56 1.81 17.21 17.21 15.576 15.576
64774 64774 A 0 090 0 1 0 2 0 1 0 5.80 5.67 5.67 1.05 12.52 12.52 11.441 11.441
64776 64776 A 0 090 0 1 0 2 0 0 0 5.60 5.08 5.08 0.84 11.52 11.52 10.601 10.601
64778 64778 A 0 ZZZ 0 0 0 0 0 1 0 3.11 0.80 0.80 0.61 4.52 4.52 4.147 4.147
64782 64782 A 0 090 0 1 0 2 0 1 1 6.86 5.60 5.60 0.91 13.37 13.37 12.365 12.365
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
258 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64783 64783 A 0 ZZZ 0 0 0 0 0 1 0 3.71 2.19 2.19 0.45 6.35 6.35 5.912 5.912
64784 64784 A 0 090 0 1 0 2 0 0 0 10.62 9.30 9.30 2.00 21.92 21.92 20.017 20.017
64786 64786 A 0 090 0 1 0 2 1 2 0 16.25 12.53 12.53 3.21 31.99 31.99 29.181 29.181
64787 64787 A 0 ZZZ 0 0 0 0 0 0 0 4.29 2.19 2.19 0.68 7.16 7.16 6.612 6.612
64788 64788 A 0 090 0 1 0 2 0 1 0 5.24 5.68 5.68 1.08 12.00 12.00 10.905 10.905
64790 64790 A 0 090 0 1 0 2 0 0 1 12.10 9.68 9.68 2.75 24.53 24.53 22.231 22.231
64792 64792 A 0 090 0 1 0 2 0 2 1 15.86 13.91 13.91 5.69 35.46 35.46 31.327 31.327
64795 64795 A 0 000 0 0 0 2 0 1 0 3.01 1.94 1.94 0.82 5.77 5.77 5.181 5.181
64802 64802 A 0 090 0 1 0 2 1 2 1 10.37 4.24 4.24 0.82 15.43 15.43 14.606 14.606
64804 64804 A 0 090 0 1 0 2 1 2 1 15.91 8.16 8.16 1.27 25.34 25.34 23.902 23.902
64809 64809 A 0 090 0 1 0 2 1 2 1 14.71 5.33 5.33 1.17 21.21 21.21 20.108 20.108
64818 64818 A 0 090 0 1 0 2 1 2 1 11.34 5.64 5.64 2.07 19.05 19.05 17.487 17.487
64820 64820 A 0 090 0 1 0 2 0 1 0 10.74 9.56 9.56 1.91 22.21 22.21 20.324 20.324
64821 64821 A 0 090 0 1 0 2 1 1 0 9.33 9.57 9.57 1.84 20.74 20.74 18.886 18.886
64822 64822 A 0 090 0 1 0 2 1 1 0 9.33 9.57 9.57 1.84 20.74 20.74 18.886 18.886
64823 64823 A 0 090 0 1 0 2 1 1 0 10.94 10.52 10.52 2.15 23.61 23.61 21.511 21.511
64831 64831 A 0 090 0 1 0 2 1 1 0 9.16 9.58 9.58 1.63 20.37 20.37 18.615 18.615
64832 64832 A 0 ZZZ 0 0 0 0 0 0 0 5.65 3.28 3.28 1.01 9.94 9.94 9.124 9.124
64834 64834 A 0 090 0 1 0 2 1 0 0 10.81 9.37 9.37 1.85 22.03 22.03 20.192 20.192
64835 64835 A 0 090 0 1 0 2 1 2 0 11.73 10.10 10.10 2.30 24.13 24.13 22.003 22.003
64836 64836 A 0 090 0 1 0 2 1 2 0 11.73 10.69 10.69 2.30 24.72 24.72 22.533 22.533
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
259 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64837 64837 A 0 ZZZ 0 0 0 0 0 2 0 6.25 3.95 3.95 0.76 10.96 10.96 10.195 10.195
64840 64840 A 0 090 0 1 0 2 1 2 0 14.02 12.39 12.39 1.08 27.49 27.49 25.711 25.711
64856 64856 A 0 090 0 1 0 2 0 1 1 15.07 12.16 12.16 2.84 30.07 30.07 27.475 27.475
64857 64857 A 0 090 0 1 0 2 0 2 1 15.82 12.49 12.49 2.91 31.22 31.22 28.558 28.558
64858 64858 A 0 090 0 1 0 2 1 2 1 17.82 14.55 14.55 3.51 35.88 35.88 32.722 32.722
64859 64859 A 0 ZZZ 0 0 0 0 0 2 1 4.25 2.51 2.51 0.83 7.59 7.59 6.938 6.938
64861 64861 A 0 090 0 1 0 2 1 2 1 20.89 13.71 13.71 4.12 38.72 38.72 35.356 35.356
64862 64862 A 0 090 0 1 0 2 1 2 0 21.09 12.05 12.05 7.57 40.71 40.71 35.870 35.870
64864 64864 A 0 090 0 1 0 2 0 2 1 13.41 10.95 10.95 1.70 26.06 26.06 24.132 24.132
64865 64865 A 0 090 0 1 0 2 0 2 1 16.09 15.26 15.26 2.04 33.39 33.39 30.860 30.860
64866 64866 A 0 090 0 1 0 2 0 2 1 16.83 15.63 15.63 2.16 34.62 34.62 31.995 31.995
64868 64868 A 0 090 0 1 0 2 0 2 1 14.90 13.76 13.76 1.91 30.57 30.57 28.255 28.255
64870 64870 A 0 090 0 1 0 2 0 2 1 17.08 11.42 11.42 4.00 32.50 32.50 29.427 29.427
64872 64872 A 0 ZZZ 0 0 0 0 0 2 1 1.99 1.17 1.17 0.26 3.42 3.42 3.177 3.177
64874 64874 A 0 ZZZ 0 0 0 0 0 2 1 2.98 1.88 1.88 0.37 5.23 5.23 4.862 4.862
64876 64876 A 0 ZZZ 0 0 0 0 0 2 1 3.37 1.36 1.36 0.65 5.38 5.38 4.931 4.931
64885 64885 A 0 090 0 1 0 2 0 2 1 17.60 13.88 13.88 2.25 33.73 33.73 31.241 31.241
64886 64886 A 0 090 0 1 0 2 0 2 1 20.82 15.18 15.18 2.67 38.67 38.67 35.848 35.848
64890 64890 A 0 090 0 1 0 2 0 2 0 16.24 12.52 12.52 3.20 31.96 31.96 29.157 29.157
64891 64891 A 0 090 0 1 0 2 0 2 0 17.35 14.35 14.35 3.43 35.13 35.13 32.030 32.030
64892 64892 A 0 090 0 1 0 2 0 2 1 15.74 13.22 13.22 3.12 32.08 32.08 29.243 29.243
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
260 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
64893 64893 A 0 090 0 1 0 2 0 2 0 16.87 12.98 12.98 3.35 33.20 33.20 30.278 30.278
64895 64895 A 0 090 0 1 0 2 0 2 1 20.39 15.66 15.66 4.01 40.06 40.06 36.550 36.550
64896 64896 A 0 090 0 1 0 2 0 2 1 21.96 14.24 14.24 7.89 44.09 44.09 38.874 38.874
64897 64897 A 0 090 0 1 0 2 0 2 0 19.38 15.07 15.07 3.82 38.27 38.27 34.911 34.911
64898 64898 A 0 090 0 1 0 2 0 2 1 20.97 16.96 16.96 4.14 42.07 42.07 38.365 38.365
64901 64901 A 0 ZZZ 0 0 0 0 0 2 1 10.20 6.44 6.44 2.00 18.64 18.64 17.029 17.029
64902 64902 A 0 ZZZ 0 0 0 0 0 2 0 11.81 5.89 5.89 2.31 20.01 20.01 18.307 18.307
64905 64905 A 0 090 0 1 0 2 0 2 1 15.11 12.82 12.82 2.98 30.91 30.91 28.181 28.181
64907 64907 A 0 090 0 1 0 2 0 2 1 20.03 15.50 15.50 1.42 36.95 36.95 34.692 34.692
64910 64910 A 0 090 0 1 0 2 0 2 1 11.39 11.06 11.06 1.97 24.42 24.42 22.352 22.352
64911 64911 A 0 090 0 1 0 2 0 2 1 14.39 13.44 13.44 2.84 30.67 30.67 27.944 27.944
64999 64999 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
65091 65091 A 0 090 0 1 0 2 1 0 1 7.26 11.09 11.09 1.44 19.79 19.79 17.972 17.972
65093 65093 A 0 090 0 1 0 2 1 1 1 7.04 11.12 11.12 1.39 19.55 19.55 17.753 17.753
65101 65101 A 0 090 0 1 0 2 1 1 0 8.30 13.05 13.05 1.63 22.98 22.98 20.871 20.871
65103 65103 A 0 090 0 1 0 2 1 1 1 8.84 13.41 13.41 1.74 23.99 23.99 21.792 21.792
65105 65105 A 0 090 0 1 0 2 1 2 1 9.93 14.55 14.55 1.95 26.43 26.43 24.016 24.016
65110 65110 A 0 090 0 1 0 2 1 2 1 15.70 19.26 19.26 2.00 36.96 36.96 34.041 34.041
65112 65112 A 0 090 0 1 0 2 1 2 1 18.51 21.97 21.97 2.35 42.83 42.83 39.468 39.468
65114 65114 A 0 090 0 1 0 2 1 2 1 19.65 22.74 22.74 2.52 44.91 44.91 41.388 41.388
65125 65125 A 0 090 0 1 0 2 1 1 1 3.27 10.32 5.21 0.64 14.23 9.12 12.872 8.283
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
261 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
65130 65130 A 0 090 0 1 0 2 1 1 1 8.42 12.71 12.71 1.65 22.78 22.78 20.697 20.697
65135 65135 A 0 090 0 1 0 2 1 1 0 8.60 12.83 12.83 1.67 23.10 23.10 20.995 20.995
65140 65140 A 0 090 0 1 0 2 1 1 0 9.46 13.82 13.82 1.22 24.50 24.50 22.508 22.508
65150 65150 A 0 090 0 1 0 2 1 0 0 6.43 10.29 10.29 0.45 17.17 17.17 15.906 15.906
65155 65155 A 0 090 0 1 0 2 1 1 0 10.10 14.25 14.25 1.97 26.32 26.32 23.927 23.927
65175 65175 A 0 090 0 1 0 2 1 1 1 7.40 11.58 11.58 0.95 19.93 19.93 18.296 18.296
65205 65205 A 0 000 0 0 0 2 1 1 0 0.71 0.89 0.53 0.10 1.70 1.34 1.562 1.238
65210 65210 A 0 000 0 0 0 2 1 1 0 0.84 1.14 0.66 0.12 2.10 1.62 1.926 1.495
65220 65220 A 0 000 0 0 0 2 1 1 0 0.71 0.93 0.45 0.11 1.75 1.27 1.603 1.172
65222 65222 A 0 000 0 0 0 2 1 1 0 0.84 1.09 0.64 0.13 2.06 1.61 1.887 1.483
65235 65235 A 0 090 0 1 0 2 1 0 0 9.01 11.40 11.40 1.24 21.65 21.65 19.896 19.896
65260 65260 A 0 090 0 1 0 2 1 2 0 12.54 14.86 14.86 0.88 28.28 28.28 26.345 26.345
65265 65265 A 0 090 0 1 0 2 1 2 1 14.34 16.48 16.48 3.08 33.90 33.90 30.750 30.750
65270 65270 A 0 010 0 1 0 2 1 0 0 1.95 5.98 2.07 0.27 8.20 4.29 7.461 3.950
65272 65272 A 0 090 0 1 0 2 1 1 0 4.62 10.11 5.42 0.33 15.06 10.37 13.871 9.660
65273 65273 A 0 090 0 1 0 2 1 1 1 5.16 5.71 5.71 0.37 11.24 11.24 10.481 10.481
65275 65275 A 0 090 0 1 0 2 1 0 0 6.29 9.99 6.47 0.86 17.14 13.62 15.711 12.550
65280 65280 A 0 090 0 1 0 2 1 0 0 9.10 10.05 10.05 1.80 20.95 20.95 19.066 19.066
65285 65285 A 0 090 0 1 0 2 1 1 0 15.36 16.19 16.19 2.71 34.26 34.26 31.316 31.316
65286 65286 A 0 090 0 1 0 2 1 1 0 6.63 13.99 7.53 0.90 21.52 15.06 19.664 13.863
65290 65290 A 0 090 0 1 0 2 1 1 1 6.53 7.48 7.48 1.28 15.29 15.29 13.916 13.916
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
262 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
65400 65400 A 0 090 0 1 0 2 1 1 0 7.50 12.20 9.84 1.03 20.73 18.37 18.994 16.875
65410 65410 A 0 000 0 0 0 2 1 0 0 1.47 2.68 1.49 0.31 4.46 3.27 4.039 2.970
65420 65420 A 0 090 0 1 0 2 1 1 0 4.36 10.75 6.49 0.56 15.67 11.41 14.306 10.481
65426 65426 A 0 090 0 1 0 2 1 1 0 6.05 13.07 7.69 0.83 19.95 14.57 18.221 13.390
65430 65430 A 0 000 0 0 0 2 1 1 0 1.47 1.82 1.48 0.22 3.51 3.17 3.219 2.914
65435 65435 A 0 000 0 0 0 2 1 1 0 0.92 1.39 1.08 0.16 2.47 2.16 2.252 1.974
65436 65436 A 0 090 0 1 0 2 1 1 0 4.82 6.31 5.83 0.84 11.97 11.49 10.926 10.495
65450 65450 A 0 090 0 1 0 2 1 1 0 3.47 5.98 5.88 0.48 9.93 9.83 9.091 9.001
65600 65600 A 0 090 0 1 0 2 1 1 0 4.20 7.27 5.73 0.60 12.07 10.53 11.042 9.659
65710 65710 A 0 090 0 1 0 2 1 2 1 14.45 17.21 17.21 1.97 33.63 33.63 30.935 30.935
65730 65730 A 0 090 0 1 0 2 1 2 1 16.35 18.70 18.70 2.23 37.28 37.28 34.309 34.309
65750 65750 A 0 090 0 1 0 2 1 2 1 16.90 18.24 18.24 2.16 37.30 37.30 34.409 34.409
65755 65755 A 0 090 0 1 0 2 1 2 1 16.79 18.18 18.18 2.29 37.26 37.26 34.313 34.313
65756 65756 A 0 090 0 1 0 2 1 2 1 16.84 16.79 16.79 1.20 34.83 34.83 32.545 32.545
65757 65757 C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
65760 65760 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
65765 65765 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
65767 65767 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
65770 65770 A 0 090 0 1 0 2 1 2 0 19.74 20.26 20.26 7.08 47.08 47.08 41.636 41.636
65771 65771 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
65772 65772 A 0 090 0 1 0 2 1 1 0 5.09 7.97 6.60 0.65 13.71 12.34 12.587 11.357
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
263 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
65775 65775 A 0 090 0 1 0 2 1 1 0 6.91 8.93 8.93 0.49 16.33 16.33 15.185 15.185
65778 65778 A 0 010 0 1 0 2 1 0 0 1.19 41.82 0.80 0.18 43.19 2.17 38.839 2.003
65779 65779 A 0 010 0 1 0 2 1 0 0 3.92 33.49 4.16 0.56 37.97 8.64 34.287 7.949
65780 65780 A 0 090 0 1 0 2 1 1 1 10.73 14.88 14.88 1.39 27.00 27.00 24.819 24.819
65781 65781 A 0 090 0 1 0 2 1 2 1 18.14 19.88 19.88 1.28 39.30 39.30 36.662 36.662
65782 65782 A 0 090 0 1 0 2 1 1 1 15.43 17.43 17.43 3.06 35.92 35.92 32.683 32.683
65800 65800 A 0 000 0 0 0 2 1 1 0 1.53 1.88 1.03 0.22 3.63 2.78 3.333 2.570
65810 65810 A 0 090 0 1 0 2 1 1 0 5.82 7.53 7.53 0.84 14.19 14.19 13.021 13.021
65815 65815 A 0 090 0 1 0 2 1 1 0 6.00 12.69 7.72 1.06 19.75 14.78 17.950 13.487
65820 65820 A 0 090 0 1 0 2 1 0 0 8.91 12.70 12.70 0.63 22.24 22.24 20.644 20.644
65850 65850 A 0 090 0 1 0 2 1 1 1 11.39 12.56 12.56 1.99 25.94 25.94 23.710 23.710
65855 65855 A 0 010 0 1 0 2 1 1 0 3.99 5.76 4.51 0.63 10.38 9.13 9.492 8.369
65860 65860 A 0 090 0 1 0 2 1 0 0 3.59 5.32 3.61 1.32 10.23 8.52 9.058 7.522
65865 65865 A 0 090 0 1 0 2 1 1 1 5.77 7.84 7.84 0.39 14.00 14.00 13.014 13.014
65870 65870 A 0 090 0 1 0 2 1 1 1 7.39 9.60 9.60 1.29 18.28 18.28 16.685 16.685
65875 65875 A 0 090 0 1 0 2 1 1 1 7.81 10.30 10.30 1.08 19.19 19.19 17.624 17.624
65880 65880 A 0 090 0 1 0 2 1 1 0 8.36 10.68 10.68 0.60 19.64 19.64 18.264 18.264
65900 65900 A 0 090 0 1 0 2 1 2 0 12.51 15.07 15.07 0.88 28.46 28.46 26.503 26.503
65920 65920 A 0 090 0 1 0 2 1 1 1 9.99 12.63 12.63 1.29 23.91 23.91 22.006 22.006
65930 65930 A 0 090 0 1 0 2 1 1 1 8.39 9.84 9.84 1.48 19.71 19.71 18.000 18.000
66020 66020 A 0 010 0 1 0 2 1 1 0 1.64 3.84 2.14 0.11 5.59 3.89 5.146 3.619
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
264 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
66030 66030 A 0 010 0 1 0 2 1 1 0 1.30 3.60 1.90 0.18 5.08 3.38 4.627 3.100
66130 66130 A 0 090 0 1 0 2 1 0 0 7.83 12.30 8.37 1.66 21.79 17.86 19.744 16.214
66150 66150 A 0 090 0 1 0 2 1 1 1 10.53 14.73 14.73 0.73 25.99 25.99 24.139 24.139
66155 66155 A 0 090 0 1 0 2 1 1 0 10.52 14.72 14.72 0.73 25.97 25.97 24.120 24.120
66160 66160 A 0 090 0 1 0 2 1 1 1 12.39 15.98 15.98 0.87 29.24 29.24 27.195 27.195
66165 66165 A 0 090 0 1 0 2 1 2 0 10.24 14.53 14.53 0.72 25.49 25.49 23.665 23.665
66170 66170 A 0 090 0 1 0 2 1 2 1 15.02 19.46 19.46 1.92 36.40 36.40 33.499 33.499
66172 66172 A 0 090 0 1 0 2 1 2 1 18.86 24.67 24.67 2.41 45.94 45.94 42.274 42.274
66174 66174 A 0 090 0 1 0 2 1 2 1 12.85 14.18 14.18 2.27 29.30 29.30 26.771 26.771
66175 66175 A 0 090 0 1 0 2 1 2 1 13.60 14.68 14.68 4.87 33.15 33.15 29.330 29.330
66180 66180 A 0 090 0 1 0 2 1 2 1 16.30 16.84 16.84 2.12 35.26 35.26 32.531 32.531
66185 66185 A 0 090 0 1 0 2 1 2 0 9.58 11.93 11.93 1.67 23.18 23.18 21.167 21.167
66220 66220 A 0 090 0 1 0 2 1 2 1 9.21 12.19 12.19 1.27 22.67 22.67 20.821 20.821
66225 66225 A 0 090 0 1 0 2 1 1 1 12.63 13.95 13.95 2.48 29.06 29.06 26.454 26.454
66250 66250 A 0 090 0 1 0 2 1 1 0 7.10 14.83 8.89 1.40 23.33 17.39 21.150 15.815
66500 66500 A 0 090 0 1 0 2 1 1 1 3.83 6.46 6.46 0.27 10.56 10.56 9.772 9.772
66505 66505 A 0 090 0 1 0 2 1 1 0 4.22 7.04 7.04 0.30 11.56 11.56 10.699 10.699
66600 66600 A 0 090 0 1 0 2 1 1 0 10.12 13.85 13.85 0.76 24.73 24.73 22.955 22.955
66605 66605 A 0 090 0 1 0 2 1 1 0 14.22 15.92 15.92 1.02 31.16 31.16 29.050 29.050
66625 66625 A 0 090 0 1 0 2 1 1 0 5.30 7.05 7.05 0.72 13.07 13.07 12.007 12.007
66630 66630 A 0 090 0 1 0 2 1 1 0 7.28 9.05 9.05 1.22 17.55 17.55 16.045 16.045
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
265 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
66635 66635 A 0 090 0 1 0 2 1 1 0 7.37 9.11 9.11 0.52 17.00 17.00 15.823 15.823
66680 66680 A 0 090 0 1 0 2 1 1 1 6.39 8.49 8.49 1.36 16.24 16.24 14.725 14.725
66682 66682 A 0 090 0 1 0 2 1 1 0 7.33 11.10 11.10 1.46 19.89 19.89 18.061 18.061
66700 66700 A 0 090 0 1 0 2 1 0 0 5.14 7.87 6.12 0.49 13.50 11.75 12.464 10.892
66710 66710 A 0 090 0 1 0 2 1 1 0 5.14 7.56 6.11 1.02 13.72 12.27 12.462 11.160
66711 66711 A 0 090 0 1 0 3 1 1 0 7.93 10.53 10.53 0.56 19.02 19.02 17.679 17.679
66720 66720 A 0 090 0 1 0 2 1 1 0 5.00 8.75 7.19 0.68 14.43 12.87 13.213 11.812
66740 66740 A 0 090 0 1 0 2 1 1 0 5.14 7.48 6.12 0.35 12.97 11.61 12.040 10.819
66761 66761 A 0 010 0 1 0 2 1 1 0 3.00 5.64 3.77 0.45 9.09 7.22 8.300 6.621
66762 66762 A 0 090 0 1 0 2 1 1 0 5.38 8.35 6.85 0.68 14.41 12.91 13.234 11.887
66770 66770 A 0 090 0 1 0 2 1 1 0 6.13 9.11 7.76 0.42 15.66 14.31 14.530 13.318
66820 66820 A 0 090 0 1 0 2 1 1 0 4.01 7.45 7.45 0.67 12.13 12.13 11.051 11.051
66821 66821 A 0 090 0 1 0 2 1 1 0 3.42 6.19 5.61 0.53 10.14 9.56 9.256 8.735
66825 66825 A 0 090 0 1 0 2 1 0 0 9.01 12.90 12.90 1.17 23.08 23.08 21.206 21.206
66830 66830 A 0 090 0 1 0 2 1 1 0 9.47 10.89 10.89 0.67 21.03 21.03 19.600 19.600
66840 66840 A 0 090 0 1 0 2 1 1 0 9.18 10.75 10.75 1.81 21.74 21.74 19.780 19.780
66850 66850 A 0 090 0 1 0 2 1 1 0 10.55 12.10 12.10 1.46 24.11 24.11 22.179 22.179
66852 66852 A 0 090 0 1 0 2 1 0 1 11.41 12.68 12.68 2.00 26.09 26.09 23.843 23.843
66920 66920 A 0 090 0 1 0 2 1 0 1 10.13 11.40 11.40 0.71 22.24 22.24 20.739 20.739
66930 66930 A 0 090 0 1 0 2 1 0 0 11.61 12.83 12.83 0.82 25.26 25.26 23.560 23.560
66940 66940 A 0 090 0 1 0 2 1 0 1 10.37 11.97 11.97 1.74 24.08 24.08 22.029 22.029
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
266 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
66982 66982 A 0 090 0 1 0 2 1 1 0 11.08 11.55 11.55 1.72 24.35 24.35 22.351 22.351
66983 66983 A 0 090 0 1 0 2 1 1 0 10.43 10.95 10.95 0.83 22.21 22.21 20.697 20.697
66984 66984 A 0 090 0 1 0 2 1 1 0 8.52 9.77 9.77 1.34 19.63 19.63 17.994 17.994
66985 66985 A 0 090 0 1 0 2 1 1 1 9.98 12.11 12.11 1.29 23.38 23.38 21.529 21.529
66986 66986 A 0 090 0 1 0 2 1 1 1 12.26 13.67 13.67 1.57 27.50 27.50 25.357 25.357
66990 66990 A 0 ZZZ 0 0 0 0 0 1 0 1.51 1.01 1.01 0.10 2.62 2.62 2.469 2.469
66999 66999 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
67005 67005 A 0 090 0 1 0 2 1 1 1 5.89 7.69 7.69 1.25 14.83 14.83 13.449 13.449
67010 67010 A 0 090 0 1 0 2 1 1 1 7.06 8.47 8.47 0.98 16.51 16.51 15.179 15.179
67015 67015 A 0 090 0 1 0 2 1 1 1 7.14 9.55 9.55 0.99 17.68 17.68 16.234 16.234
67025 67025 A 0 090 0 1 0 2 1 1 1 8.11 12.92 10.03 1.44 22.47 19.58 20.465 17.870
67027 67027 A 0 090 0 1 0 2 1 2 1 11.62 12.67 12.67 2.03 26.32 26.32 24.059 24.059
67028 67028 A 0 000 0 0 0 2 1 1 0 1.44 1.45 1.40 0.20 3.09 3.04 2.847 2.802
67030 67030 A 0 090 0 1 0 2 1 1 1 6.11 9.28 9.28 0.42 15.81 15.81 14.663 14.663
67031 67031 A 0 090 0 1 0 2 1 1 0 4.47 6.75 5.78 0.59 11.81 10.84 10.840 9.969
67036 67036 A 0 090 0 1 0 2 1 2 1 13.32 13.97 13.97 1.82 29.11 29.11 26.817 26.817
67039 67039 A 0 090 0 1 0 2 1 2 1 16.74 18.44 18.44 2.97 38.15 38.15 34.852 34.852
67040 67040 A 0 090 0 1 0 2 1 2 1 19.61 20.79 20.79 2.69 43.09 43.09 39.686 39.686
67041 67041 A 0 090 0 1 0 2 1 2 1 19.25 18.27 18.27 2.64 40.16 40.16 37.037 37.037
67042 67042 A 0 090 0 1 0 2 1 2 1 22.38 20.38 20.38 3.09 45.85 45.85 42.297 42.297
67043 67043 A 0 090 0 1 0 2 1 2 1 23.24 21.81 21.81 4.10 49.15 49.15 44.970 44.970
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
267 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
67101 67101 A 0 090 0 1 0 2 1 1 0 8.80 13.88 10.50 1.55 24.23 20.85 22.075 19.040
67105 67105 A 0 090 0 1 0 2 1 1 0 8.53 12.21 9.89 1.17 21.91 19.59 20.106 18.023
67107 67107 A 0 090 0 1 0 2 1 2 1 16.71 17.90 17.90 2.95 37.56 37.56 34.327 34.327
67108 67108 A 0 090 0 1 0 2 1 2 1 22.89 22.66 22.66 3.14 48.69 48.69 44.881 44.881
67110 67110 A 0 090 0 1 0 2 1 1 0 10.25 14.81 11.90 1.31 26.37 23.46 24.235 21.621
67112 67112 A 0 090 0 1 0 2 1 2 1 18.75 18.92 18.92 2.57 40.24 40.24 37.084 37.084
67113 67113 A 0 090 0 1 0 2 1 2 1 25.35 24.07 24.07 3.48 52.90 52.90 48.785 48.785
67115 67115 A 0 090 0 1 0 2 1 1 0 6.11 8.26 8.26 0.78 15.15 15.15 13.935 13.935
67120 67120 A 0 090 0 1 0 2 1 1 1 7.10 12.00 8.93 1.40 20.50 17.43 18.608 15.851
67121 67121 A 0 090 0 1 0 2 1 2 1 12.25 13.68 13.68 2.16 28.09 28.09 25.664 25.664
67141 67141 A 0 090 0 1 0 2 1 1 0 6.15 8.96 7.85 1.09 16.20 15.09 14.766 13.769
67145 67145 A 0 090 0 1 0 2 1 1 0 6.32 8.85 7.97 0.86 16.03 15.15 14.717 13.927
67208 67208 A 0 090 0 1 0 2 1 1 0 7.65 9.53 8.88 0.53 17.71 17.06 16.485 15.901
67210 67210 A 0 090 0 1 0 2 1 1 0 6.36 8.54 8.00 0.94 15.84 15.30 14.521 14.036
67218 67218 A 0 090 0 1 0 2 1 1 0 20.36 18.77 18.77 1.46 40.59 40.59 37.979 37.979
67220 67220 A 0 090 0 1 0 2 1 1 0 6.36 9.04 8.00 1.13 16.53 15.49 15.069 14.135
67221 67221 R 0 000 0 0 0 2 0 1 0 3.45 4.81 2.54 0.48 8.74 6.47 8.020 5.982
67225 67225 A 0 ZZZ 0 0 0 0 0 1 0 0.47 0.37 0.32 0.03 0.87 0.82 0.818 0.773
67227 67227 A 0 090 0 1 0 2 1 1 0 7.53 10.02 8.80 0.53 18.08 16.86 16.805 15.710
67228 67228 A 0 090 0 1 0 2 1 1 0 13.82 14.63 13.01 2.10 30.55 28.93 28.056 26.601
67229 67229 A 0 090 0 1 0 2 1 1 0 16.30 16.86 16.86 1.17 34.33 34.33 32.052 32.052
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
268 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
67250 67250 A 0 090 0 1 0 2 1 1 1 9.61 12.85 12.85 1.62 24.08 24.08 21.997 21.997
67255 67255 A 0 090 0 1 0 2 1 2 1 10.17 14.08 14.08 1.99 26.24 26.24 23.855 23.855
67299 67299 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
67311 67311 A 0 090 0 1 0 2 1 1 0 7.77 9.35 9.35 1.31 18.43 18.43 16.851 16.851
67312 67312 A 0 090 0 1 0 2 1 1 1 9.66 10.63 10.63 1.91 22.20 22.20 20.205 20.205
67314 67314 A 0 090 0 1 0 2 1 1 0 8.79 10.49 10.49 1.48 20.76 20.76 18.984 18.984
67316 67316 A 0 090 0 1 0 2 1 0 0 10.93 11.92 11.92 2.15 25.00 25.00 22.759 22.759
67318 67318 A 0 090 0 1 0 2 1 1 1 9.12 11.03 11.03 0.64 20.79 20.79 19.360 19.360
67320 67320 A 0 ZZZ 0 0 0 0 0 1 0 5.40 3.62 3.62 0.38 9.40 9.40 8.850 8.850
67331 67331 A 0 ZZZ 0 0 0 0 1 1 1 5.13 3.41 3.41 0.86 9.40 9.40 8.642 8.642
67332 67332 A 0 ZZZ 0 0 0 0 1 1 1 5.56 3.73 3.73 0.93 10.22 10.22 9.396 9.396
67334 67334 A 0 ZZZ 0 0 0 0 1 1 1 5.05 3.39 3.39 0.35 8.79 8.79 8.277 8.277
67335 67335 A 0 ZZZ 0 0 0 0 1 1 1 2.49 1.67 1.67 0.41 4.57 4.57 4.204 4.204
67340 67340 A 0 ZZZ 0 0 0 0 0 2 0 6.00 4.03 4.03 0.42 10.45 10.45 9.839 9.839
67343 67343 A 0 090 0 1 0 2 1 1 1 8.47 10.20 10.20 1.66 20.33 20.33 18.498 18.498
67345 67345 A 0 010 0 1 0 2 1 1 0 3.01 3.76 3.02 0.80 7.57 6.83 6.805 6.140
67346 67346 A 0 000 0 0 0 2 1 0 0 2.87 2.83 2.83 0.61 6.31 6.31 5.730 5.730
67399 67399 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
67400 67400 A 0 090 0 1 0 2 1 1 1 11.20 15.54 15.54 2.07 28.81 28.81 26.238 26.238
67405 67405 A 0 090 0 1 0 2 1 1 0 9.20 13.58 13.58 1.18 23.96 23.96 22.012 22.012
67412 67412 A 0 090 0 1 0 2 1 1 1 10.30 14.15 14.15 1.86 26.31 26.31 23.979 23.979
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
269 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
67413 67413 A 0 090 0 1 0 2 1 2 0 10.24 14.33 14.33 2.00 26.57 26.57 24.154 24.154
67414 67414 A 0 090 0 1 0 2 1 2 1 17.94 19.82 19.82 2.29 40.05 40.05 36.936 36.936
67415 67415 A 0 000 0 0 0 2 1 0 0 1.76 1.16 1.16 0.24 3.16 3.16 2.927 2.927
67420 67420 A 0 090 0 1 0 2 1 2 1 21.87 23.88 23.88 4.31 50.06 50.06 45.568 45.568
67430 67430 A 0 090 0 1 0 2 1 2 0 15.29 20.56 20.56 1.09 36.94 36.94 34.323 34.323
67440 67440 A 0 090 0 1 0 2 1 2 1 14.84 19.82 19.82 1.91 36.57 36.57 33.637 33.637
67445 67445 A 0 090 0 1 0 2 1 2 1 19.12 20.75 20.75 3.77 43.64 43.64 39.725 39.725
67450 67450 A 0 090 0 1 0 2 1 2 1 15.41 20.64 20.64 1.97 38.02 38.02 34.975 34.975
67500 67500 A 0 000 0 0 0 2 1 1 0 1.44 0.79 0.59 0.11 2.34 2.14 2.207 2.027
67505 67505 A 0 000 0 0 0 2 1 1 0 1.27 1.26 1.02 0.26 2.79 2.55 2.537 2.322
67515 67515 A 0 000 0 0 0 2 1 1 0 1.40 1.35 1.11 0.26 3.01 2.77 2.748 2.533
67550 67550 A 0 090 0 1 0 2 1 1 1 11.77 15.86 15.86 2.30 29.93 29.93 27.215 27.215
67560 67560 A 0 090 0 1 0 2 1 0 0 12.18 16.18 16.18 1.57 29.93 29.93 27.531 27.531
67570 67570 A 0 090 0 1 0 2 1 2 1 14.40 18.36 18.36 5.16 37.92 37.92 33.586 33.586
67599 67599 C 0 YYY 0 0 0 2 1 2 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
67700 67700 A 0 010 0 1 0 2 1 1 0 1.40 6.63 1.94 0.23 8.26 3.57 7.474 3.262
67710 67710 A 0 010 0 1 0 2 1 1 0 1.07 5.67 1.75 0.22 6.96 3.04 6.277 2.757
67715 67715 A 0 010 0 1 0 2 1 1 0 1.27 5.85 1.86 0.26 7.38 3.39 6.659 3.076
67800 67800 A 0 010 0 1 0 2 0 1 0 1.41 2.26 1.54 0.24 3.91 3.19 3.565 2.918
67801 67801 A 0 010 0 1 0 2 0 1 0 1.91 2.76 1.88 0.37 5.04 4.16 4.582 3.792
67805 67805 A 0 010 0 1 0 2 0 1 0 2.27 3.56 2.42 0.44 6.27 5.13 5.697 4.673
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
270 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
67808 67808 A 0 090 0 1 0 2 0 1 0 4.60 5.98 5.98 0.90 11.48 11.48 10.441 10.441
67810 67810 A 0 000 0 0 0 2 1 1 0 1.18 3.89 0.78 0.18 5.25 2.14 4.767 1.975
67820 67820 A 0 000 0 0 0 2 1 1 0 0.71 0.72 0.83 0.11 1.54 1.65 1.414 1.513
67825 67825 A 0 010 0 1 0 2 1 1 0 1.43 2.29 2.08 0.27 3.99 3.78 3.628 3.439
67830 67830 A 0 010 0 1 0 2 1 1 0 1.75 6.18 2.21 0.34 8.27 4.30 7.477 3.912
67835 67835 A 0 090 0 1 0 2 1 0 0 5.70 6.87 6.87 1.13 13.70 13.70 12.460 12.460
67840 67840 A 0 010 0 1 0 2 1 1 0 2.09 6.05 2.43 0.34 8.48 4.86 7.701 4.450
67850 67850 A 0 010 0 1 0 2 1 1 0 1.74 4.55 2.11 0.24 6.53 4.09 5.951 3.760
67875 67875 A 0 000 0 0 0 2 1 1 0 1.35 3.71 1.42 0.24 5.30 3.01 4.807 2.751
67880 67880 A 0 090 0 1 0 2 1 1 0 4.60 8.76 5.99 0.82 14.18 11.41 12.895 10.408
67882 67882 A 0 090 0 1 0 2 1 1 0 6.02 10.34 7.53 1.18 17.54 14.73 15.922 13.399
67900 67900 A 0 090 0 1 0 2 1 1 0 6.82 11.68 7.65 1.22 19.72 15.69 17.947 14.328
67901 67901 A 0 090 0 1 0 2 1 1 0 7.59 14.41 8.86 1.50 23.50 17.95 21.315 16.331
67902 67902 A 0 090 0 1 0 2 1 1 1 9.82 10.73 10.73 1.93 22.48 22.48 20.465 20.465
67903 67903 A 0 090 0 1 0 2 1 1 1 6.51 10.64 7.27 1.27 18.42 15.05 16.729 13.703
67904 67904 A 0 090 0 1 0 2 1 1 1 7.97 13.21 9.06 1.52 22.70 18.55 20.628 16.901
67906 67906 A 0 090 0 1 0 2 1 1 0 6.93 7.57 7.57 0.49 14.99 14.99 13.984 13.984
67908 67908 A 0 090 0 1 0 2 1 1 0 5.30 9.01 6.89 1.05 15.36 13.24 13.940 12.036
67909 67909 A 0 090 0 1 0 2 1 1 0 5.57 9.96 6.97 1.10 16.63 13.64 15.089 12.404
67911 67911 A 0 090 0 1 0 2 1 1 0 7.50 8.54 8.54 1.40 17.44 17.44 15.901 15.901
67912 67912 A 0 090 0 1 0 2 1 1 0 6.36 19.79 7.60 0.93 27.08 14.89 24.618 13.671
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
271 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
67914 67914 A 0 090 0 1 0 2 1 1 0 3.75 7.56 4.49 0.68 11.99 8.92 10.895 8.138
67915 67915 A 0 090 0 1 0 2 1 1 0 3.26 7.03 4.16 0.45 10.74 7.87 9.808 7.231
67916 67916 A 0 090 0 1 0 2 1 1 0 5.48 10.17 6.90 0.95 16.60 13.33 15.110 12.173
67917 67917 A 0 090 0 1 0 2 1 1 0 6.19 10.79 7.38 1.16 18.14 14.73 16.486 13.424
67921 67921 A 0 090 0 1 0 2 1 1 0 3.47 7.38 4.31 0.68 11.53 8.46 10.453 7.696
67922 67922 A 0 090 0 1 0 2 1 1 0 3.14 6.91 4.09 0.42 10.47 7.65 9.565 7.032
67923 67923 A 0 090 0 1 0 2 1 1 0 6.05 10.42 7.29 1.13 17.60 14.47 15.998 13.187
67924 67924 A 0 090 0 1 0 2 1 1 0 5.93 11.12 6.89 1.13 18.18 13.95 16.507 12.708
67930 67930 A 0 010 0 1 0 2 1 1 0 3.65 6.96 3.13 0.71 11.32 7.49 10.271 6.832
67935 67935 A 0 090 0 1 0 2 1 1 0 6.36 10.79 6.11 1.25 18.40 13.72 16.703 12.501
67938 67938 A 0 010 0 1 0 2 1 1 0 1.38 5.86 1.96 0.22 7.46 3.56 6.757 3.255
67950 67950 A 0 090 0 1 0 2 1 1 1 5.99 10.59 7.23 1.10 17.68 14.32 16.075 13.058
67961 67961 A 0 090 0 1 0 2 1 0 0 5.86 10.85 7.15 1.10 17.81 14.11 16.179 12.856
67966 67966 A 0 090 0 1 0 2 1 1 0 8.97 13.13 9.73 1.70 23.80 20.40 21.650 18.597
67971 67971 A 0 090 0 1 0 2 1 1 1 10.01 10.56 10.56 1.96 22.53 22.53 20.518 20.518
67973 67973 A 0 090 0 1 0 2 1 2 1 13.13 13.28 13.28 2.59 29.00 29.00 26.410 26.410
67974 67974 A 0 090 0 1 0 2 1 2 1 13.10 13.27 13.27 2.59 28.96 28.96 26.371 26.371
67975 67975 A 0 090 0 1 0 2 1 1 0 9.35 10.13 10.13 1.84 21.32 21.32 19.409 19.409
67999 67999 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
68020 68020 A 0 010 0 1 0 2 1 1 0 1.42 2.03 1.76 0.20 3.65 3.38 3.348 3.105
68040 68040 A 0 000 0 0 0 2 1 1 0 0.85 0.99 0.63 0.16 2.00 1.64 1.823 1.499
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
272 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
68100 68100 A 0 000 0 0 0 2 1 1 0 1.35 3.66 1.45 0.20 5.21 3.00 4.741 2.757
68110 68110 A 0 010 0 1 0 2 1 1 0 1.82 4.83 2.47 0.35 7.00 4.64 6.340 4.221
68115 68115 A 0 010 0 1 0 2 1 1 0 2.41 6.79 2.86 0.31 9.51 5.58 8.670 5.140
68130 68130 A 0 090 0 1 0 2 1 1 0 5.10 10.66 6.76 0.35 16.11 12.21 14.856 11.354
68135 68135 A 0 010 0 1 0 2 1 1 0 1.89 2.61 2.45 0.26 4.76 4.60 4.370 4.226
68200 68200 A 0 000 0 0 0 2 1 1 0 0.49 0.69 0.50 0.08 1.26 1.07 1.151 0.981
68320 68320 A 0 090 0 1 0 2 1 1 1 6.64 14.58 8.86 1.29 22.51 16.79 20.408 15.271
68325 68325 A 0 090 0 1 0 2 1 1 1 8.63 10.18 10.18 1.69 20.50 20.50 18.656 18.656
68326 68326 A 0 090 0 1 0 2 1 1 0 8.42 10.06 10.06 1.65 20.13 20.13 18.317 18.317
68328 68328 A 0 090 0 1 0 2 1 0 0 9.45 10.75 10.75 1.86 22.06 22.06 20.076 20.076
68330 68330 A 0 090 0 1 0 2 1 0 0 5.78 11.87 7.47 1.14 18.79 14.39 17.035 13.084
68335 68335 A 0 090 0 1 0 2 1 1 1 8.46 10.09 10.09 1.66 20.21 20.21 18.389 18.389
68340 68340 A 0 090 0 1 0 2 1 0 0 4.97 11.00 6.51 0.99 16.96 12.47 15.366 11.334
68360 68360 A 0 090 0 1 0 2 1 1 0 5.17 10.33 6.65 1.02 16.52 12.84 14.980 11.675
68362 68362 A 0 090 0 1 0 2 1 1 1 8.61 10.19 10.19 1.69 20.49 20.49 18.644 18.644
68371 68371 A 0 010 0 1 0 2 1 1 0 5.09 6.80 6.80 0.35 12.24 12.24 11.379 11.379
68399 68399 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
68400 68400 A 0 010 0 1 0 2 1 1 0 1.74 6.76 2.03 0.34 8.84 4.11 7.988 3.741
68420 68420 A 0 010 0 1 0 2 1 1 0 2.35 7.16 2.44 0.30 9.81 5.09 8.937 4.698
68440 68440 A 0 010 0 1 0 2 1 1 0 0.99 2.00 1.91 0.20 3.19 3.10 2.891 2.810
68500 68500 A 0 090 0 1 0 2 1 1 0 12.77 15.14 15.14 2.99 30.90 30.90 27.929 27.929
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
273 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
68505 68505 A 0 090 0 1 0 2 1 1 0 12.69 15.08 15.08 2.48 30.25 30.25 27.529 27.529
68510 68510 A 0 000 0 0 0 2 1 0 0 4.60 8.40 3.66 0.90 13.90 9.16 12.614 8.357
68520 68520 A 0 090 0 1 0 2 1 0 0 8.78 10.91 10.91 1.14 20.83 20.83 19.173 19.173
68525 68525 A 0 000 0 0 0 2 1 1 1 4.42 2.94 2.94 0.86 8.22 8.22 7.510 7.510
68530 68530 A 0 010 0 1 0 2 1 1 0 3.70 8.83 3.58 0.72 13.25 8.00 12.006 7.291
68540 68540 A 0 090 0 1 0 2 1 1 1 12.18 14.40 14.40 1.57 28.15 28.15 25.932 25.932
68550 68550 A 0 090 0 1 0 2 1 1 0 15.16 17.38 17.38 1.93 34.47 34.47 31.777 31.777
68700 68700 A 0 090 0 1 0 2 1 1 0 7.87 9.41 9.41 1.54 18.82 18.82 17.126 17.126
68705 68705 A 0 010 0 1 0 2 1 1 0 2.11 4.82 2.66 0.41 7.34 5.18 6.653 4.713
68720 68720 A 0 090 0 1 0 2 1 2 1 9.96 11.63 11.63 1.66 23.25 23.25 21.272 21.272
68745 68745 A 0 090 0 1 0 2 1 2 1 9.90 11.86 11.86 1.95 23.71 23.71 21.570 21.570
68750 68750 A 0 090 0 1 0 2 1 2 1 10.10 12.39 12.39 1.97 24.46 24.46 22.257 22.257
68760 68760 A 0 010 0 1 0 2 1 1 0 1.78 4.13 2.43 0.34 6.25 4.55 5.667 4.140
68761 68761 A 0 010 0 1 0 2 1 0 0 1.41 2.92 2.04 0.22 4.55 3.67 4.147 3.357
68770 68770 A 0 090 0 1 0 2 1 0 0 8.29 9.70 9.70 1.62 19.61 19.61 17.848 17.848
68801 68801 A 0 010 0 1 0 2 1 1 0 1.00 2.69 2.17 0.16 3.85 3.33 3.499 3.032
68810 68810 A 0 010 0 1 0 2 1 1 0 2.15 4.96 3.28 0.39 7.50 5.82 6.808 5.299
68811 68811 A 0 010 0 1 0 2 1 1 0 2.45 3.50 3.50 0.48 6.43 6.43 5.844 5.844
68815 68815 A 0 010 0 1 0 2 1 1 0 3.30 10.00 4.07 0.59 13.89 7.96 12.589 7.263
68816 68816 A 0 010 0 1 0 2 1 1 0 3.06 19.42 4.15 0.60 23.08 7.81 20.813 7.101
68840 68840 A 0 010 0 1 0 2 1 1 0 1.30 2.44 2.10 0.24 3.98 3.64 3.617 3.311
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
274 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
68850 68850 A 0 000 0 0 0 2 1 1 0 0.80 0.88 0.74 0.07 1.75 1.61 1.627 1.501
68899 68899 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
69000 69000 A 0 010 0 1 0 2 1 1 0 1.50 4.06 1.92 0.22 5.78 3.64 5.261 3.339
69005 69005 A 0 010 0 1 0 2 1 1 0 2.16 4.13 2.30 0.29 6.58 4.75 6.020 4.377
69020 69020 A 0 010 0 1 0 2 1 1 0 1.53 5.51 2.63 0.20 7.24 4.36 6.583 3.996
69090 69090 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
69100 69100 A 0 000 0 0 0 2 0 1 0 0.81 2.13 0.53 0.11 3.05 1.45 2.780 1.343
69105 69105 A 0 000 0 0 0 2 1 1 0 0.85 3.42 0.97 0.10 4.37 1.92 3.973 1.773
69110 69110 A 0 090 0 1 0 2 1 1 0 3.53 10.07 5.83 0.53 14.13 9.89 12.850 9.043
69120 69120 A 0 090 0 1 0 2 0 1 0 4.14 7.77 7.77 0.60 12.51 12.51 11.431 11.431
69140 69140 A 0 090 0 1 0 2 1 0 0 8.14 17.67 17.67 1.05 26.86 26.86 24.557 24.557
69145 69145 A 0 090 0 1 0 2 1 1 0 2.70 9.31 4.60 0.35 12.36 7.65 11.243 7.014
69150 69150 A 0 090 0 1 0 2 0 1 1 13.61 15.98 15.98 1.95 31.54 31.54 28.980 28.980
69155 69155 A 0 090 0 1 0 2 0 2 1 23.35 23.88 23.88 3.01 50.24 50.24 46.368 46.368
69200 69200 A 0 000 0 0 0 2 1 1 0 0.77 2.94 0.88 0.10 3.81 1.75 3.462 1.613
69205 69205 A 0 010 0 1 0 2 1 1 0 1.21 1.71 1.71 0.16 3.08 3.08 2.829 2.829
69210 69210 A 0 000 0 0 0 2 2 1 0 0.61 0.88 0.28 0.07 1.56 0.96 1.437 0.898
69220 69220 A 0 000 0 0 0 2 1 1 0 0.83 3.36 0.94 0.10 4.29 1.87 3.900 1.726
69222 69222 A 0 010 0 1 0 2 1 1 0 1.45 5.21 2.56 0.18 6.84 4.19 6.223 3.843
69300 69300 R 0 YYY 0 0 0 2 1 0 0 6.69 14.96 6.78 0.86 22.51 14.33 20.574 13.228
69310 69310 A 0 090 0 1 0 2 1 1 0 10.97 20.97 20.97 1.44 33.38 33.38 30.554 30.554
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
275 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
69320 69320 A 0 090 0 1 0 2 1 2 0 17.18 27.09 27.09 2.20 46.47 46.47 42.657 42.657
69399 69399 C 0 YYY 0 0 0 2 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
69400 69400 A 0 000 0 0 0 2 1 1 0 0.83 3.71 0.94 0.10 4.64 1.87 4.214 1.726
69401 69401 A 0 000 0 0 0 2 1 1 0 0.63 2.04 0.81 0.07 2.74 1.51 2.499 1.394
69405 69405 A 0 010 0 1 0 2 1 0 0 2.68 4.98 2.78 0.34 8.00 5.80 7.330 5.354
69420 69420 A 0 010 0 1 0 2 1 1 0 1.38 4.38 2.13 0.18 5.94 3.69 5.407 3.387
69421 69421 A 0 010 0 1 0 2 1 1 0 1.78 2.52 2.52 0.23 4.53 4.53 4.163 4.163
69424 69424 A 0 000 0 0 0 2 1 1 0 0.85 3.03 0.93 0.10 3.98 1.88 3.623 1.737
69433 69433 A 0 010 0 1 0 2 1 1 0 1.57 4.50 2.26 0.22 6.29 4.05 5.726 3.715
69436 69436 A 0 010 0 1 0 2 1 1 0 2.01 2.60 2.60 0.26 4.87 4.87 4.481 4.481
69440 69440 A 0 090 0 1 0 2 1 1 0 7.71 12.42 12.42 0.99 21.12 21.12 19.381 19.381
69450 69450 A 0 090 0 1 0 2 1 0 0 5.69 10.32 10.32 0.72 16.73 16.73 15.334 15.334
69501 69501 A 0 090 0 1 0 2 1 1 0 9.21 11.85 11.85 1.18 22.24 22.24 20.468 20.468
69502 69502 A 0 090 0 1 0 2 1 0 0 12.56 15.25 15.25 1.69 29.50 29.50 27.138 27.138
69505 69505 A 0 090 0 1 0 2 1 0 0 13.17 21.80 21.80 1.70 36.67 36.67 33.636 33.636
69511 69511 A 0 090 0 1 0 2 1 0 0 13.70 22.07 22.07 1.77 37.54 37.54 34.445 34.445
69530 69530 A 0 090 0 1 0 2 1 2 0 20.38 27.06 27.06 2.61 50.05 50.05 46.045 46.045
69535 69535 A 0 090 0 1 0 2 1 1 1 37.42 37.79 37.79 5.23 80.44 80.44 74.091 74.091
69540 69540 A 0 010 0 1 0 2 1 1 0 1.25 5.11 2.50 0.16 6.52 3.91 5.922 3.579
69550 69550 A 0 090 0 1 0 2 1 2 0 11.15 19.17 19.17 1.44 31.76 31.76 29.118 29.118
69552 69552 A 0 090 0 1 0 2 1 2 0 19.81 25.12 25.12 2.55 47.48 47.48 43.701 43.701
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
276 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
69554 69554 A 0 090 0 1 0 2 1 2 1 35.97 35.14 35.14 4.61 75.72 75.72 69.937 69.937
69601 69601 A 0 090 0 1 0 2 1 0 0 13.45 16.59 16.59 1.71 31.75 31.75 29.242 29.242
69602 69602 A 0 090 0 1 0 2 1 0 0 13.76 17.55 17.55 1.77 33.08 33.08 30.446 30.446
69603 69603 A 0 090 0 1 0 2 1 0 0 14.20 22.32 22.32 1.82 38.34 38.34 35.195 35.195
69604 69604 A 0 090 0 1 0 2 1 1 0 14.20 17.77 17.77 1.82 33.79 33.79 31.109 31.109
69605 69605 A 0 090 0 1 0 2 1 2 0 18.69 26.21 26.21 2.40 47.30 47.30 43.482 43.482
69610 69610 A 0 010 0 1 0 2 1 1 0 4.47 6.63 3.67 0.59 11.69 8.73 10.732 8.074
69620 69620 A 0 090 0 1 0 2 1 1 0 6.03 14.53 8.03 0.76 21.32 14.82 19.475 13.638
69631 69631 A 0 090 0 1 0 2 1 1 0 10.05 15.71 15.71 1.29 27.05 27.05 24.832 24.832
69632 69632 A 0 090 0 1 0 2 1 1 0 12.96 18.23 18.23 1.66 32.85 32.85 30.199 30.199
69633 69633 A 0 090 0 1 0 2 1 1 0 12.31 17.90 17.90 1.59 31.80 31.80 29.216 29.216
69635 69635 A 0 090 0 1 0 2 1 1 0 13.51 22.18 22.18 1.74 37.43 37.43 34.338 34.338
69636 69636 A 0 090 0 1 0 2 1 0 0 15.43 24.59 24.59 1.97 41.99 41.99 38.542 38.542
69637 69637 A 0 090 0 1 0 2 1 0 0 15.32 24.77 24.77 2.00 42.09 42.09 38.609 38.609
69641 69641 A 0 090 0 1 0 2 1 1 0 12.89 17.12 17.12 1.67 31.68 31.68 29.137 29.137
69642 69642 A 0 090 0 1 0 2 1 1 0 17.06 21.37 21.37 2.19 40.62 40.62 37.396 37.396
69643 69643 A 0 090 0 1 0 2 1 1 0 15.59 19.56 19.56 2.00 37.15 37.15 34.201 34.201
69644 69644 A 0 090 0 1 0 2 1 1 0 17.23 25.48 25.48 2.22 44.93 44.93 41.272 41.272
69645 69645 A 0 090 0 1 0 2 1 1 0 16.71 25.18 25.18 2.18 44.07 44.07 40.462 40.462
69646 69646 A 0 090 0 1 0 2 1 0 0 18.37 26.05 26.05 2.35 46.77 46.77 42.992 42.992
69650 69650 A 0 090 0 1 0 2 1 1 0 9.80 13.43 13.43 1.25 24.48 24.48 22.514 22.514
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
277 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
69660 69660 A 0 090 0 1 0 2 1 1 0 12.03 14.53 14.53 1.55 28.11 28.11 25.889 25.889
69661 69661 A 0 090 0 1 0 2 1 0 0 15.92 18.69 18.69 2.00 36.61 36.61 33.750 33.750
69662 69662 A 0 090 0 1 0 2 1 1 0 15.60 17.45 17.45 2.00 35.05 35.05 32.316 32.316
69666 69666 A 0 090 0 1 0 2 1 0 0 9.89 13.44 13.44 1.28 24.61 24.61 22.629 22.629
69667 69667 A 0 090 0 1 0 2 1 0 0 9.90 13.45 13.45 1.28 24.63 24.63 22.648 22.648
69670 69670 A 0 090 0 1 0 2 1 2 0 11.73 15.47 15.47 1.51 28.71 28.71 26.412 26.412
69676 69676 A 0 090 0 1 0 2 1 1 0 9.69 14.46 14.46 1.24 25.39 25.39 23.324 23.324
69700 69700 A 0 090 0 1 0 2 1 1 0 8.37 11.43 11.43 1.08 20.88 20.88 19.199 19.199
69710 69710 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
69711 69711 A 0 090 0 1 0 2 1 2 0 10.62 14.28 14.28 1.36 26.26 26.26 24.155 24.155
69714 69714 A 0 090 0 1 0 2 1 1 0 14.45 16.29 16.29 1.86 32.60 32.60 30.051 30.051
69715 69715 A 0 090 0 1 0 2 1 1 0 18.96 18.67 18.67 2.42 40.05 40.05 36.991 36.991
69717 69717 A 0 090 0 1 0 2 1 1 0 15.43 16.75 16.75 1.97 34.15 34.15 31.502 31.502
69718 69718 A 0 090 0 1 0 2 1 1 0 19.21 18.80 18.80 2.45 40.46 40.46 37.374 37.374
69720 69720 A 0 090 0 1 0 2 1 0 1 14.71 19.61 19.61 1.89 36.21 36.21 33.308 33.308
69725 69725 A 0 090 0 1 0 2 1 2 0 27.64 25.39 25.39 3.55 56.58 56.58 52.297 52.297
69740 69740 A 0 090 0 1 0 2 1 2 0 16.27 16.90 16.90 2.08 35.25 35.25 32.534 32.534
69745 69745 A 0 090 0 1 0 2 1 2 0 17.02 18.35 18.35 2.18 37.55 37.55 34.638 34.638
69799 69799 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
69801 69801 A 0 000 0 0 0 2 1 0 0 2.06 3.66 1.43 0.27 5.99 3.76 5.488 3.485
69805 69805 A 0 090 0 1 0 2 1 2 0 14.71 15.24 15.24 1.89 31.84 31.84 29.384 29.384
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
278 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
69806 69806 A 0 090 0 1 0 2 1 1 0 12.63 14.33 14.33 1.63 28.59 28.59 26.351 26.351
69820 69820 A 0 090 0 1 0 2 1 2 0 10.52 14.23 14.23 1.36 26.11 26.11 24.010 24.010
69840 69840 A 0 090 0 1 0 2 1 2 0 10.44 14.13 14.13 0.73 25.30 25.30 23.511 23.511
69905 69905 A 0 090 0 1 0 2 1 1 0 11.26 15.24 15.24 1.46 27.96 27.96 25.709 25.709
69910 69910 A 0 090 0 1 0 2 1 0 0 13.91 15.07 15.07 1.80 30.78 30.78 28.384 28.384
69915 69915 A 0 090 0 1 0 2 1 2 1 22.77 20.58 20.58 2.97 46.32 46.32 42.804 42.804
69930 69930 A 0 090 0 1 0 2 1 0 0 17.73 16.88 16.88 2.27 36.88 36.88 34.075 34.075
69949 69949 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
69950 69950 A 0 090 0 1 0 2 1 2 1 27.63 22.24 22.24 3.55 53.42 53.42 49.458 49.458
69955 69955 A 0 090 0 1 0 2 1 2 1 29.42 26.29 26.29 3.78 59.49 59.49 55.005 55.005
69960 69960 A 0 090 0 1 0 2 1 2 1 29.42 24.56 24.56 3.78 57.76 57.76 53.452 53.452
69970 69970 A 0 090 0 1 0 2 1 2 1 32.41 27.77 27.77 4.16 64.34 64.34 59.523 59.523
69979 69979 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
69990 69990 R 0 ZZZ 0 0 0 0 0 2 0 3.46 1.75 1.75 1.16 6.37 6.37 5.638 5.638
70010 70010 A 0 XXX 0 0 0 0 0 0 0 1.19 0.43 0.43 0.22 1.84 1.84 1.691 1.691
70015 70015 A 1 XXX 0 0 0 0 0 0 0 1.19 3.36 3.36 0.08 4.63 4.63 4.249 4.249
70015 26 7001526 A 1 XXX 0 0 0 0 0 0 0 1.19 0.45 0.45 0.07 1.71 1.71 1.631 1.631
70015 TC 70015TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.91 2.91 0.01 2.92 2.92 2.618 2.618
70030 70030 A 1 XXX 0 0 0 0 3 0 0 0.17 0.69 0.69 0.02 0.88 0.88 0.800 0.800
70030 26 7003026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
70030 TC 70030TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.63 0.63 0.01 0.64 0.64 0.571 0.571
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
279 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70100 70100 A 1 XXX 0 0 0 0 0 0 0 0.18 0.85 0.85 0.02 1.05 1.05 0.954 0.954
70100 26 7010026 A 1 XXX 0 0 0 0 0 0 0 0.18 0.07 0.07 0.01 0.26 0.26 0.248 0.248
70100 TC 70100TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.78 0.78 0.01 0.79 0.79 0.706 0.706
70110 70110 A 1 XXX 0 0 0 0 0 0 0 0.25 0.93 0.93 0.02 1.20 1.20 1.096 1.096
70110 26 7011026 A 1 XXX 0 0 0 0 0 0 0 0.25 0.10 0.10 0.01 0.36 0.36 0.345 0.345
70110 TC 70110TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.83 0.83 0.01 0.84 0.84 0.751 0.751
70120 70120 A 1 XXX 0 0 0 0 3 0 0 0.18 0.89 0.89 0.02 1.09 1.09 0.990 0.990
70120 26 7012026 A 1 XXX 0 0 0 0 3 0 0 0.18 0.07 0.07 0.01 0.26 0.26 0.248 0.248
70120 TC 70120TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.82 0.82 0.01 0.83 0.83 0.742 0.742
70130 70130 A 1 XXX 0 0 0 0 3 0 0 0.34 1.42 1.42 0.02 1.78 1.78 1.626 1.626
70130 26 7013026 A 1 XXX 0 0 0 0 3 0 0 0.34 0.14 0.14 0.01 0.49 0.49 0.471 0.471
70130 TC 70130TC A 1 XXX 0 0 0 0 3 0 0 0.00 1.28 1.28 0.01 1.29 1.29 1.155 1.155
70134 70134 A 1 XXX 0 0 0 0 0 0 0 0.34 1.03 1.03 0.02 1.39 1.39 1.275 1.275
70134 26 7013426 A 1 XXX 0 0 0 0 0 0 0 0.34 0.12 0.12 0.01 0.47 0.47 0.453 0.453
70134 TC 70134TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.91 0.91 0.01 0.92 0.92 0.822 0.822
70140 70140 A 1 XXX 0 0 0 0 0 0 0 0.19 0.70 0.70 0.02 0.91 0.91 0.829 0.829
70140 26 7014026 A 1 XXX 0 0 0 0 0 0 0 0.19 0.09 0.09 0.01 0.29 0.29 0.276 0.276
70140 TC 70140TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.61 0.61 0.01 0.62 0.62 0.553 0.553
70150 70150 A 1 XXX 0 0 0 0 0 0 0 0.26 1.01 1.01 0.02 1.29 1.29 1.177 1.177
70150 26 7015026 A 1 XXX 0 0 0 0 0 0 0 0.26 0.10 0.10 0.01 0.37 0.37 0.355 0.355
70150 TC 70150TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.91 0.91 0.01 0.92 0.92 0.822 0.822
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
280 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70160 70160 A 1 XXX 0 0 0 0 0 0 0 0.17 0.83 0.83 0.02 1.02 1.02 0.926 0.926
70160 26 7016026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
70160 TC 70160TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.76 0.76 0.01 0.77 0.77 0.688 0.688
70170 70170 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70170 26 7017026 A 1 XXX 0 0 0 0 0 0 0 0.30 0.11 0.11 0.03 0.44 0.44 0.414 0.414
70170 TC 70170TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70190 70190 A 1 XXX 0 0 0 0 3 0 0 0.21 0.87 0.87 0.02 1.10 1.10 1.002 1.002
70190 26 7019026 A 1 XXX 0 0 0 0 3 0 0 0.21 0.09 0.09 0.01 0.31 0.31 0.296 0.296
70190 TC 70190TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.78 0.78 0.01 0.79 0.79 0.706 0.706
70200 70200 A 1 XXX 0 0 0 0 0 0 0 0.28 1.02 1.02 0.02 1.32 1.32 1.206 1.206
70200 26 7020026 A 1 XXX 0 0 0 0 0 0 0 0.28 0.11 0.11 0.01 0.40 0.40 0.384 0.384
70200 TC 70200TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.91 0.91 0.01 0.92 0.92 0.822 0.822
70210 70210 A 1 XXX 0 0 0 0 0 0 0 0.17 0.75 0.75 0.02 0.94 0.94 0.854 0.854
70210 26 7021026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
70210 TC 70210TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.68 0.68 0.01 0.69 0.69 0.616 0.616
70220 70220 A 1 XXX 0 0 0 0 0 0 0 0.25 0.91 0.91 0.02 1.18 1.18 1.078 1.078
70220 26 7022026 A 1 XXX 0 0 0 0 0 0 0 0.25 0.10 0.10 0.01 0.36 0.36 0.345 0.345
70220 TC 70220TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.81 0.81 0.01 0.82 0.82 0.733 0.733
70240 70240 A 1 XXX 0 0 0 0 0 0 0 0.19 0.70 0.70 0.02 0.91 0.91 0.829 0.829
70240 26 7024026 A 1 XXX 0 0 0 0 0 0 0 0.19 0.08 0.08 0.01 0.28 0.28 0.267 0.267
70240 TC 70240TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.62 0.62 0.01 0.63 0.63 0.562 0.562
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
281 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70250 70250 A 1 XXX 0 0 0 0 0 0 0 0.24 0.87 0.87 0.02 1.13 1.13 1.032 1.032
70250 26 7025026 A 1 XXX 0 0 0 0 0 0 0 0.24 0.11 0.11 0.01 0.36 0.36 0.344 0.344
70250 TC 70250TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.76 0.76 0.01 0.77 0.77 0.688 0.688
70260 70260 A 1 XXX 0 0 0 0 0 0 0 0.34 1.06 1.06 0.02 1.42 1.42 1.302 1.302
70260 26 7026026 A 1 XXX 0 0 0 0 0 0 0 0.34 0.14 0.14 0.01 0.49 0.49 0.471 0.471
70260 TC 70260TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.92 0.92 0.01 0.93 0.93 0.831 0.831
70300 70300 A 1 XXX 0 0 0 0 0 0 0 0.10 0.33 0.33 0.02 0.45 0.45 0.407 0.407
70300 26 7030026 A 1 XXX 0 0 0 0 0 0 0 0.10 0.06 0.06 0.01 0.17 0.17 0.159 0.159
70300 TC 70300TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.27 0.27 0.01 0.28 0.28 0.248 0.248
70310 70310 A 1 XXX 0 0 0 0 0 0 0 0.16 0.99 0.99 0.02 1.17 1.17 1.059 1.059
70310 26 7031026 A 1 XXX 0 0 0 0 0 0 0 0.16 0.06 0.06 0.01 0.23 0.23 0.219 0.219
70310 TC 70310TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.93 0.93 0.01 0.94 0.94 0.840 0.840
70320 70320 A 1 XXX 0 0 0 0 0 0 0 0.22 1.40 1.40 0.02 1.64 1.64 1.488 1.488
70320 26 7032026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.11 0.11 0.01 0.34 0.34 0.324 0.324
70320 TC 70320TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.29 1.29 0.01 1.30 1.30 1.164 1.164
70328 70328 A 1 XXX 0 0 0 0 0 0 0 0.18 0.77 0.77 0.02 0.97 0.97 0.882 0.882
70328 26 7032826 A 1 XXX 0 0 0 0 0 0 0 0.18 0.08 0.08 0.01 0.27 0.27 0.257 0.257
70328 TC 70328TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.69 0.69 0.01 0.70 0.70 0.625 0.625
70330 70330 A 1 XXX 0 0 0 0 2 0 0 0.24 1.21 1.21 0.02 1.47 1.47 1.337 1.337
70330 26 7033026 A 1 XXX 0 0 0 0 2 0 0 0.24 0.11 0.11 0.01 0.36 0.36 0.344 0.344
70330 TC 70330TC A 1 XXX 0 0 0 0 2 0 0 0.00 1.10 1.10 0.01 1.11 1.11 0.993 0.993
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
282 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70332 70332 A 1 XXX 0 0 0 0 3 0 0 0.54 1.56 1.56 0.04 2.14 2.14 1.962 1.962
70332 26 7033226 A 1 XXX 0 0 0 0 3 0 0 0.54 0.20 0.20 0.03 0.77 0.77 0.735 0.735
70332 TC 70332TC A 1 XXX 0 0 0 0 3 0 0 0.00 1.36 1.36 0.01 1.37 1.37 1.227 1.227
70336 70336 A 1 XXX 0 0 0 4 0 0 0 1.48 9.20 9.20 0.09 10.77 10.77 9.789 9.789
70336 26 7033626 A 1 XXX 0 0 0 4 3 0 0 1.48 0.52 0.52 0.08 2.08 2.08 1.989 1.989
70336 TC 70336TC A 1 XXX 0 0 0 4 0 0 0 0.00 8.68 8.68 0.01 8.69 8.69 7.800 7.800
70350 70350 A 1 XXX 0 0 0 0 0 0 0 0.17 0.46 0.46 0.02 0.65 0.65 0.594 0.594
70350 26 7035026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.11 0.11 0.01 0.29 0.29 0.274 0.274
70350 TC 70350TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.35 0.35 0.01 0.36 0.36 0.320 0.320
70355 70355 A 1 XXX 0 0 0 0 0 0 0 0.20 0.41 0.41 0.02 0.63 0.63 0.579 0.579
70355 26 7035526 A 1 XXX 0 0 0 0 0 0 0 0.20 0.11 0.11 0.01 0.32 0.32 0.304 0.304
70355 TC 70355TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.30 0.30 0.01 0.31 0.31 0.275 0.275
70360 70360 A 1 XXX 0 0 0 0 0 0 0 0.17 0.65 0.65 0.02 0.84 0.84 0.764 0.764
70360 26 7036026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
70360 TC 70360TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.59 0.59 0.01 0.60 0.60 0.535 0.535
70370 70370 A 1 XXX 0 0 0 0 0 0 0 0.32 2.12 2.12 0.02 2.46 2.46 2.234 2.234
70370 26 7037026 A 1 XXX 0 0 0 0 0 0 0 0.32 0.12 0.12 0.01 0.45 0.45 0.433 0.433
70370 TC 70370TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.00 2.00 0.01 2.01 2.01 1.801 1.801
70371 70371 A 1 XXX 0 0 0 0 0 0 0 0.84 1.87 1.87 0.04 2.75 2.75 2.540 2.540
70371 26 7037126 A 1 XXX 0 0 0 0 0 0 0 0.84 0.33 0.33 0.03 1.20 1.20 1.152 1.152
70371 TC 70371TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.54 1.54 0.01 1.55 1.55 1.388 1.388
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
283 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70373 70373 A 1 XXX 0 0 0 0 0 0 0 0.44 1.94 1.94 0.02 2.40 2.40 2.193 2.193
70373 26 7037326 A 1 XXX 0 0 0 0 0 0 0 0.44 0.17 0.17 0.01 0.62 0.62 0.598 0.598
70373 TC 70373TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.77 1.77 0.01 1.78 1.78 1.595 1.595
70380 70380 A 1 XXX 0 0 0 0 0 0 0 0.17 1.00 1.00 0.02 1.19 1.19 1.078 1.078
70380 26 7038026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.09 0.09 0.01 0.27 0.27 0.256 0.256
70380 TC 70380TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.91 0.91 0.01 0.92 0.92 0.822 0.822
70390 70390 A 1 XXX 0 0 0 0 0 0 0 0.38 2.65 2.65 0.04 3.07 3.07 2.781 2.781
70390 26 7039026 A 1 XXX 0 0 0 0 0 0 0 0.38 0.14 0.14 0.03 0.55 0.55 0.521 0.521
70390 TC 70390TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.51 2.51 0.01 2.52 2.52 2.259 2.259
70450 70450 A 1 XXX 0 0 0 4 0 0 0 0.85 4.02 4.02 0.05 4.92 4.92 4.486 4.486
70450 26 7045026 A 1 XXX 0 0 0 4 0 0 0 0.85 0.31 0.31 0.04 1.20 1.20 1.149 1.149
70450 TC 70450TC A 1 XXX 0 0 0 4 0 0 0 0.00 3.71 3.71 0.01 3.72 3.72 3.337 3.337
70460 70460 A 1 XXX 0 0 0 4 0 0 0 1.13 5.26 5.26 0.06 6.45 6.45 5.885 5.885
70460 26 7046026 A 1 XXX 0 0 0 4 0 0 0 1.13 0.41 0.41 0.05 1.59 1.59 1.524 1.524
70460 TC 70460TC A 1 XXX 0 0 0 4 0 0 0 0.00 4.85 4.85 0.01 4.86 4.86 4.361 4.361
70470 70470 A 1 XXX 0 0 0 4 0 0 0 1.27 5.17 5.17 0.08 6.52 6.52 5.955 5.955
70470 26 7047026 A 1 XXX 0 0 0 4 0 0 0 1.27 0.46 0.46 0.07 1.80 1.80 1.720 1.720
70470 TC 70470TC A 1 XXX 0 0 0 4 0 0 0 0.00 4.71 4.71 0.01 4.72 4.72 4.235 4.235
70480 70480 A 1 XXX 0 0 0 4 0 0 0 1.28 6.91 6.91 0.08 8.27 8.27 7.527 7.527
70480 26 7048026 A 1 XXX 0 0 0 4 0 0 0 1.28 0.47 0.47 0.07 1.82 1.82 1.739 1.739
70480 TC 70480TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.44 6.44 0.01 6.45 6.45 5.788 5.788
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
284 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70481 70481 A 1 XXX 0 0 0 4 0 0 0 1.38 8.11 8.11 0.09 9.58 9.58 8.710 8.710
70481 26 7048126 A 1 XXX 0 0 0 4 0 0 0 1.38 0.50 0.50 0.08 1.96 1.96 1.871 1.871
70481 TC 70481TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.61 7.61 0.01 7.62 7.62 6.839 6.839
70482 70482 A 1 XXX 0 0 0 4 0 0 0 1.45 9.07 9.07 0.09 10.61 10.61 9.642 9.642
70482 26 7048226 A 1 XXX 0 0 0 4 0 0 0 1.45 0.52 0.52 0.08 2.05 2.05 1.959 1.959
70482 TC 70482TC A 1 XXX 0 0 0 4 0 0 0 0.00 8.55 8.55 0.01 8.56 8.56 7.683 7.683
70486 70486 A 1 XXX 0 0 0 4 0 0 0 1.14 5.60 5.60 0.06 6.80 6.80 6.200 6.200
70486 26 7048626 A 1 XXX 0 0 0 4 0 0 0 1.14 0.43 0.43 0.05 1.62 1.62 1.552 1.552
70486 TC 70486TC A 1 XXX 0 0 0 4 0 0 0 0.00 5.17 5.17 0.01 5.18 5.18 4.648 4.648
70487 70487 A 1 XXX 0 0 0 4 0 0 0 1.30 6.81 6.81 0.08 8.19 8.19 7.457 7.457
70487 26 7048726 A 1 XXX 0 0 0 4 0 0 0 1.30 0.47 0.47 0.07 1.84 1.84 1.759 1.759
70487 TC 70487TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.34 6.34 0.01 6.35 6.35 5.699 5.699
70488 70488 A 1 XXX 0 0 0 4 0 0 0 1.42 8.35 8.35 0.09 9.86 9.86 8.965 8.965
70488 26 7048826 A 1 XXX 0 0 0 4 0 0 0 1.42 0.51 0.51 0.08 2.01 2.01 1.920 1.920
70488 TC 70488TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.84 7.84 0.01 7.85 7.85 7.046 7.046
70490 70490 A 1 XXX 0 0 0 4 0 0 0 1.28 5.27 5.27 0.08 6.63 6.63 6.054 6.054
70490 26 7049026 A 1 XXX 0 0 0 4 0 0 0 1.28 0.47 0.47 0.07 1.82 1.82 1.739 1.739
70490 TC 70490TC A 1 XXX 0 0 0 4 0 0 0 0.00 4.80 4.80 0.01 4.81 4.81 4.316 4.316
70491 70491 A 1 XXX 0 0 0 4 0 0 0 1.38 6.53 6.53 0.08 7.99 7.99 7.286 7.286
70491 26 7049126 A 1 XXX 0 0 0 4 0 0 0 1.38 0.51 0.51 0.07 1.96 1.96 1.875 1.875
70491 TC 70491TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.02 6.02 0.01 6.03 6.03 5.411 5.411
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
285 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70492 70492 A 1 XXX 0 0 0 4 0 0 0 1.45 8.00 8.00 0.09 9.54 9.54 8.681 8.681
70492 26 7049226 A 1 XXX 0 0 0 4 0 0 0 1.45 0.52 0.52 0.08 2.05 2.05 1.959 1.959
70492 TC 70492TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.48 7.48 0.01 7.49 7.49 6.722 6.722
70496 70496 A 1 XXX 0 0 0 4 0 0 0 1.75 13.08 13.08 0.11 14.94 14.94 13.553 13.553
70496 26 7049626 A 1 XXX 0 0 0 4 0 0 0 1.75 0.63 0.63 0.10 2.48 2.48 2.368 2.368
70496 TC 70496TC A 1 XXX 0 0 0 4 0 0 0 0.00 12.45 12.45 0.01 12.46 12.46 11.185 11.185
70498 70498 A 1 XXX 0 0 0 4 0 0 0 1.75 13.59 13.59 0.11 15.45 15.45 14.011 14.011
70498 26 7049826 A 1 XXX 0 0 0 4 0 0 0 1.75 0.63 0.63 0.10 2.48 2.48 2.368 2.368
70498 TC 70498TC A 1 XXX 0 0 0 4 0 0 0 0.00 12.96 12.96 0.01 12.97 12.97 11.643 11.643
70540 70540 A 1 XXX 0 0 0 4 0 0 0 1.35 10.73 10.73 0.09 12.17 12.17 11.033 11.033
70540 26 7054026 A 1 XXX 0 0 0 4 0 0 0 1.35 0.48 0.48 0.08 1.91 1.91 1.823 1.823
70540 TC 70540TC A 1 XXX 0 0 0 4 0 0 0 0.00 10.25 10.25 0.01 10.26 10.26 9.210 9.210
70542 70542 A 1 XXX 0 0 0 4 0 0 0 1.62 11.98 11.98 0.11 13.71 13.71 12.436 12.436
70542 26 7054226 A 1 XXX 0 0 0 4 0 0 0 1.62 0.59 0.59 0.10 2.31 2.31 2.202 2.202
70542 TC 70542TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.39 11.39 0.01 11.40 11.40 10.233 10.233
70543 70543 A 1 XXX 0 0 0 4 0 0 0 2.15 14.55 14.55 0.13 16.83 16.83 15.284 15.284
70543 26 7054326 A 1 XXX 0 0 0 4 0 0 0 2.15 0.77 0.77 0.12 3.04 3.04 2.904 2.904
70543 TC 70543TC A 1 XXX 0 0 0 4 0 0 0 0.00 13.78 13.78 0.01 13.79 13.79 12.380 12.380
70544 70544 A 1 XXX 0 0 0 4 0 0 0 1.20 12.43 12.43 0.08 13.71 13.71 12.404 12.404
70544 26 7054426 A 1 XXX 0 0 0 4 0 0 0 1.20 0.43 0.43 0.07 1.70 1.70 1.623 1.623
70544 TC 70544TC A 1 XXX 0 0 0 4 0 0 0 0.00 12.00 12.00 0.01 12.01 12.01 10.781 10.781
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
286 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70545 70545 A 1 XXX 0 0 0 4 0 0 0 1.20 12.21 12.21 0.08 13.49 13.49 12.206 12.206
70545 26 7054526 A 1 XXX 0 0 0 4 0 0 0 1.20 0.43 0.43 0.07 1.70 1.70 1.623 1.623
70545 TC 70545TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.78 11.78 0.01 11.79 11.79 10.584 10.584
70546 70546 A 1 XXX 0 0 0 4 0 0 0 1.80 18.80 18.80 0.12 20.72 20.72 18.745 18.745
70546 26 7054626 A 1 XXX 0 0 0 4 0 0 0 1.80 0.65 0.65 0.11 2.56 2.56 2.441 2.441
70546 TC 70546TC A 1 XXX 0 0 0 4 0 0 0 0.00 18.15 18.15 0.01 18.16 18.16 16.304 16.304
70547 70547 A 1 XXX 0 0 0 4 0 0 0 1.20 12.45 12.45 0.08 13.73 13.73 12.422 12.422
70547 26 7054726 A 1 XXX 0 0 0 4 0 0 0 1.20 0.44 0.44 0.07 1.71 1.71 1.632 1.632
70547 TC 70547TC A 1 XXX 0 0 0 4 0 0 0 0.00 12.01 12.01 0.01 12.02 12.02 10.790 10.790
70548 70548 A 1 XXX 0 0 0 4 0 0 0 1.20 13.24 13.24 0.08 14.52 14.52 13.131 13.131
70548 26 7054826 A 1 XXX 0 0 0 4 0 0 0 1.20 0.44 0.44 0.07 1.71 1.71 1.632 1.632
70548 TC 70548TC A 1 XXX 0 0 0 4 0 0 0 0.00 12.80 12.80 0.01 12.81 12.81 11.500 11.500
70549 70549 A 1 XXX 0 0 0 4 0 0 0 1.80 18.84 18.84 0.11 20.75 20.75 18.776 18.776
70549 26 7054926 A 1 XXX 0 0 0 4 0 0 0 1.80 0.65 0.65 0.10 2.55 2.55 2.436 2.436
70549 TC 70549TC A 1 XXX 0 0 0 4 0 0 0 0.00 18.19 18.19 0.01 18.20 18.20 16.340 16.340
70551 70551 A 1 XXX 0 0 0 4 0 0 0 1.48 11.28 11.28 0.09 12.85 12.85 11.657 11.657
70551 26 7055126 A 1 XXX 0 0 0 4 0 0 0 1.48 0.54 0.54 0.08 2.10 2.10 2.007 2.007
70551 TC 70551TC A 1 XXX 0 0 0 4 0 0 0 0.00 10.74 10.74 0.01 10.75 10.75 9.650 9.650
70552 70552 A 1 XXX 0 0 0 4 0 0 0 1.78 12.45 12.45 0.12 14.35 14.35 13.023 13.023
70552 26 7055226 A 1 XXX 0 0 0 4 0 0 0 1.78 0.65 0.65 0.11 2.54 2.54 2.421 2.421
70552 TC 70552TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.80 11.80 0.01 11.81 11.81 10.602 10.602
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
287 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
70553 70553 A 1 XXX 0 0 0 4 0 0 0 2.36 14.30 14.30 0.15 16.81 16.81 15.280 15.280
70553 26 7055326 A 1 XXX 0 0 0 4 0 0 0 2.36 0.85 0.85 0.14 3.35 3.35 3.197 3.197
70553 TC 70553TC A 1 XXX 0 0 0 4 0 0 0 0.00 13.45 13.45 0.01 13.46 13.46 12.083 12.083
70554 70554 A 1 XXX 0 0 0 4 3 0 0 2.11 12.38 12.38 0.13 14.62 14.62 13.295 13.295
70554 26 7055426 A 1 XXX 0 0 0 4 3 0 0 2.11 0.78 0.78 0.12 3.01 3.01 2.873 2.873
70554 TC 70554TC A 1 XXX 0 0 0 4 3 0 0 0.00 11.60 11.60 0.01 11.61 11.61 10.422 10.422
70555 70555 C 1 XXX 0 0 0 0 3 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70555 26 7055526 A 1 XXX 0 0 0 0 3 0 0 2.54 0.93 0.93 0.24 3.71 3.71 3.501 3.501
70555 TC 70555TC C 1 XXX 0 0 0 0 3 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70557 70557 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70557 26 7055726 A 1 XXX 0 0 0 0 0 0 0 2.90 1.05 1.05 1.05 5.00 5.00 4.392 4.392
70557 TC 70557TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70558 70558 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70558 26 7055826 A 1 XXX 0 0 0 0 0 0 0 3.20 1.17 1.17 0.30 4.67 4.67 4.408 4.408
70558 TC 70558TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70559 70559 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
70559 26 7055926 A 1 XXX 0 0 0 0 0 0 0 3.20 1.18 1.18 0.30 4.68 4.68 4.417 4.417
70559 TC 70559TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
71010 71010 A 1 XXX 0 0 0 0 0 0 0 0.18 0.50 0.50 0.02 0.70 0.70 0.639 0.639
71010 26 7101026 A 1 XXX 0 0 0 0 0 0 0 0.18 0.07 0.07 0.01 0.26 0.26 0.248 0.248
71010 TC 71010TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.43 0.43 0.01 0.44 0.44 0.391 0.391
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
288 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
71015 71015 A 1 XXX 0 0 0 0 0 0 0 0.21 0.69 0.69 0.02 0.92 0.92 0.840 0.840
71015 26 7101526 A 1 XXX 0 0 0 0 0 0 0 0.21 0.08 0.08 0.01 0.30 0.30 0.287 0.287
71015 TC 71015TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.61 0.61 0.01 0.62 0.62 0.553 0.553
71020 71020 A 1 XXX 0 0 0 0 0 0 0 0.22 0.67 0.67 0.02 0.91 0.91 0.832 0.832
71020 26 7102026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.08 0.08 0.01 0.31 0.31 0.297 0.297
71020 TC 71020TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.59 0.59 0.01 0.60 0.60 0.535 0.535
71021 71021 A 1 XXX 0 0 0 0 0 0 0 0.27 0.84 0.84 0.02 1.13 1.13 1.035 1.035
71021 26 7102126 A 1 XXX 0 0 0 0 0 0 0 0.27 0.11 0.11 0.01 0.39 0.39 0.374 0.374
71021 TC 71021TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.73 0.73 0.01 0.74 0.74 0.661 0.661
71022 71022 A 1 XXX 0 0 0 0 0 0 0 0.31 1.11 1.11 0.02 1.44 1.44 1.317 1.317
71022 26 7102226 A 1 XXX 0 0 0 0 0 0 0 0.31 0.13 0.13 0.01 0.45 0.45 0.432 0.432
71022 TC 71022TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.98 0.98 0.01 0.99 0.99 0.885 0.885
71023 71023 A 1 XXX 0 0 0 0 0 0 0 0.38 1.58 1.58 0.02 1.98 1.98 1.809 1.809
71023 26 7102326 A 1 XXX 0 0 0 0 0 0 0 0.38 0.14 0.14 0.01 0.53 0.53 0.511 0.511
71023 TC 71023TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.44 1.44 0.01 1.45 1.45 1.298 1.298
71030 71030 A 1 XXX 0 0 0 0 0 0 0 0.31 1.05 1.05 0.02 1.38 1.38 1.263 1.263
71030 26 7103026 A 1 XXX 0 0 0 0 0 0 0 0.31 0.11 0.11 0.01 0.43 0.43 0.414 0.414
71030 TC 71030TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.94 0.94 0.01 0.95 0.95 0.849 0.849
71034 71034 A 1 XXX 0 0 0 0 0 0 0 0.46 2.10 2.10 0.02 2.58 2.58 2.356 2.356
71034 26 7103426 A 1 XXX 0 0 0 0 0 0 0 0.46 0.17 0.17 0.01 0.64 0.64 0.618 0.618
71034 TC 71034TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.93 1.93 0.01 1.94 1.94 1.738 1.738
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
289 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
71035 71035 A 1 XXX 0 0 0 0 0 0 0 0.18 0.88 0.88 0.02 1.08 1.08 0.981 0.981
71035 26 7103526 A 1 XXX 0 0 0 0 0 0 0 0.18 0.06 0.06 0.01 0.25 0.25 0.239 0.239
71035 TC 71035TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.82 0.82 0.01 0.83 0.83 0.742 0.742
71100 71100 A 1 XXX 0 0 0 0 0 0 0 0.22 0.74 0.74 0.02 0.98 0.98 0.895 0.895
71100 26 7110026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.01 0.32 0.32 0.306 0.306
71100 TC 71100TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.65 0.65 0.01 0.66 0.66 0.589 0.589
71101 71101 A 1 XXX 0 0 0 0 0 0 0 0.27 0.90 0.90 0.02 1.19 1.19 1.089 1.089
71101 26 7110126 A 1 XXX 0 0 0 0 0 0 0 0.27 0.10 0.10 0.01 0.38 0.38 0.365 0.365
71101 TC 71101TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.80 0.80 0.01 0.81 0.81 0.724 0.724
71110 71110 A 1 XXX 0 0 0 0 2 0 0 0.27 0.94 0.94 0.02 1.23 1.23 1.125 1.125
71110 26 7111026 A 1 XXX 0 0 0 0 2 0 0 0.27 0.11 0.11 0.01 0.39 0.39 0.374 0.374
71110 TC 71110TC A 1 XXX 0 0 0 0 2 0 0 0.00 0.83 0.83 0.01 0.84 0.84 0.751 0.751
71111 71111 A 1 XXX 0 0 0 0 2 0 0 0.32 1.27 1.27 0.02 1.61 1.61 1.471 1.471
71111 26 7111126 A 1 XXX 0 0 0 0 2 0 0 0.32 0.13 0.13 0.01 0.46 0.46 0.442 0.442
71111 TC 71111TC A 1 XXX 0 0 0 0 2 0 0 0.00 1.14 1.14 0.01 1.15 1.15 1.029 1.029
71120 71120 A 1 XXX 0 0 0 0 0 0 0 0.20 0.73 0.73 0.02 0.95 0.95 0.866 0.866
71120 26 7112026 A 1 XXX 0 0 0 0 0 0 0 0.20 0.07 0.07 0.01 0.28 0.28 0.268 0.268
71120 TC 71120TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.66 0.66 0.01 0.67 0.67 0.598 0.598
71130 71130 A 1 XXX 0 0 0 0 0 0 0 0.22 0.89 0.89 0.02 1.13 1.13 1.030 1.030
71130 26 7113026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.01 0.32 0.32 0.306 0.306
71130 TC 71130TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.80 0.80 0.01 0.81 0.81 0.724 0.724
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
290 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
71250 71250 A 1 XXX 0 0 0 4 0 0 0 1.02 5.18 5.18 0.06 6.26 6.26 5.703 5.703
71250 26 7125026 A 1 XXX 0 0 0 4 0 0 0 1.02 0.37 0.37 0.05 1.44 1.44 1.378 1.378
71250 TC 71250TC A 1 XXX 0 0 0 4 0 0 0 0.00 4.81 4.81 0.01 4.82 4.82 4.325 4.325
71260 71260 A 1 XXX 0 0 0 4 0 0 0 1.24 6.51 6.51 0.08 7.83 7.83 7.128 7.128
71260 26 7126026 A 1 XXX 0 0 0 4 0 0 0 1.24 0.46 0.46 0.07 1.77 1.77 1.690 1.690
71260 TC 71260TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.05 6.05 0.01 6.06 6.06 5.438 5.438
71270 71270 A 1 XXX 0 0 0 4 0 0 0 1.38 8.03 8.03 0.08 9.49 9.49 8.633 8.633
71270 26 7127026 A 1 XXX 0 0 0 4 0 0 0 1.38 0.50 0.50 0.07 1.95 1.95 1.866 1.866
71270 TC 71270TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.53 7.53 0.01 7.54 7.54 6.767 6.767
71275 71275 A 1 XXX 0 0 0 4 0 0 0 1.92 10.00 10.00 0.12 12.04 12.04 10.963 10.963
71275 26 7127526 A 1 XXX 0 0 0 4 0 0 0 1.92 0.69 0.69 0.11 2.72 2.72 2.597 2.597
71275 TC 71275TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.31 9.31 0.01 9.32 9.32 8.366 8.366
71550 71550 A 1 XXX 0 0 0 4 0 0 0 1.46 12.49 12.49 0.09 14.04 14.04 12.723 12.723
71550 26 7155026 A 1 XXX 0 0 0 4 0 0 0 1.46 0.52 0.52 0.08 2.06 2.06 1.969 1.969
71550 TC 71550TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.97 11.97 0.01 11.98 11.98 10.754 10.754
71551 71551 A 1 XXX 0 0 0 4 0 0 0 1.73 13.76 13.76 0.11 15.60 15.60 14.144 14.144
71551 26 7155126 A 1 XXX 0 0 0 4 0 0 0 1.73 0.62 0.62 0.10 2.45 2.45 2.339 2.339
71551 TC 71551TC A 1 XXX 0 0 0 4 0 0 0 0.00 13.14 13.14 0.01 13.15 13.15 11.805 11.805
71552 71552 A 1 XXX 0 0 0 4 0 0 0 2.26 17.45 17.45 0.13 19.84 19.84 17.998 17.998
71552 26 7155226 A 1 XXX 0 0 0 4 0 0 0 2.26 0.81 0.81 0.12 3.19 3.19 3.050 3.050
71552 TC 71552TC A 1 XXX 0 0 0 4 0 0 0 0.00 16.64 16.64 0.01 16.65 16.65 14.948 14.948
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
291 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
71555 71555 R 1 XXX 0 0 0 4 0 0 0 1.81 11.92 11.92 0.11 13.84 13.84 12.572 12.572
71555 26 7155526 R 1 XXX 0 0 0 4 0 0 0 1.81 0.65 0.65 0.10 2.56 2.56 2.446 2.446
71555 TC 71555TC R 1 XXX 0 0 0 4 0 0 0 0.00 11.27 11.27 0.01 11.28 11.28 10.126 10.126
72010 72010 A 1 XXX 0 0 0 0 0 0 0 0.45 1.91 1.91 0.04 2.40 2.40 2.186 2.186
72010 26 7201026 A 1 XXX 0 0 0 0 0 0 0 0.45 0.19 0.19 0.03 0.67 0.67 0.636 0.636
72010 TC 72010TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.72 1.72 0.01 1.73 1.73 1.550 1.550
72020 72020 A 1 XXX 0 0 0 0 0 0 0 0.15 0.54 0.54 0.02 0.71 0.71 0.645 0.645
72020 26 7202026 A 1 XXX 0 0 0 0 0 0 0 0.15 0.06 0.06 0.01 0.22 0.22 0.209 0.209
72020 TC 72020TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.48 0.48 0.01 0.49 0.49 0.436 0.436
72040 72040 A 1 XXX 0 0 0 0 0 0 0 0.22 0.82 0.82 0.04 1.08 1.08 0.977 0.977
72040 26 7204026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.03 0.34 0.34 0.317 0.317
72040 TC 72040TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.73 0.73 0.01 0.74 0.74 0.661 0.661
72050 72050 A 1 XXX 0 0 0 0 0 0 0 0.31 1.11 1.11 0.04 1.46 1.46 1.328 1.328
72050 26 7205026 A 1 XXX 0 0 0 0 0 0 0 0.31 0.12 0.12 0.03 0.46 0.46 0.433 0.433
72050 TC 72050TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.99 0.99 0.01 1.00 1.00 0.894 0.894
72052 72052 A 1 XXX 0 0 0 0 0 0 0 0.36 1.48 1.48 0.04 1.88 1.88 1.710 1.710
72052 26 7205226 A 1 XXX 0 0 0 0 0 0 0 0.36 0.14 0.14 0.03 0.53 0.53 0.501 0.501
72052 TC 72052TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.34 1.34 0.01 1.35 1.35 1.209 1.209
72069 72069 A 1 XXX 0 0 0 0 0 0 0 0.22 0.91 0.91 0.04 1.17 1.17 1.058 1.058
72069 26 7206926 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.03 0.34 0.34 0.317 0.317
72069 TC 72069TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.82 0.82 0.01 0.83 0.83 0.742 0.742
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
292 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72070 72070 A 1 XXX 0 0 0 0 0 0 0 0.22 0.78 0.78 0.02 1.02 1.02 0.931 0.931
72070 26 7207026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.01 0.32 0.32 0.306 0.306
72070 TC 72070TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.69 0.69 0.01 0.70 0.70 0.625 0.625
72072 72072 A 1 XXX 0 0 0 0 0 0 0 0.22 0.88 0.88 0.02 1.12 1.12 1.021 1.021
72072 26 7207226 A 1 XXX 0 0 0 0 0 0 0 0.22 0.08 0.08 0.01 0.31 0.31 0.297 0.297
72072 TC 72072TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.80 0.80 0.01 0.81 0.81 0.724 0.724
72074 72074 A 1 XXX 0 0 0 0 0 0 0 0.22 1.10 1.10 0.02 1.34 1.34 1.218 1.218
72074 26 7207426 A 1 XXX 0 0 0 0 0 0 0 0.22 0.08 0.08 0.01 0.31 0.31 0.297 0.297
72074 TC 72074TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.02 1.02 0.01 1.03 1.03 0.921 0.921
72080 72080 A 1 XXX 0 0 0 0 0 0 0 0.22 0.85 0.85 0.04 1.11 1.11 1.004 1.004
72080 26 7208026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.03 0.34 0.34 0.317 0.317
72080 TC 72080TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.76 0.76 0.01 0.77 0.77 0.688 0.688
72090 72090 A 1 XXX 0 0 0 0 0 0 0 0.28 1.25 1.25 0.05 1.58 1.58 1.429 1.429
72090 26 7209026 A 1 XXX 0 0 0 0 0 0 0 0.28 0.12 0.12 0.04 0.44 0.44 0.409 0.409
72090 TC 72090TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.13 1.13 0.01 1.14 1.14 1.020 1.020
72100 72100 A 1 XXX 0 0 0 0 0 0 0 0.22 0.83 0.83 0.04 1.09 1.09 0.986 0.986
72100 26 7210026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.03 0.34 0.34 0.317 0.317
72100 TC 72100TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.74 0.74 0.01 0.75 0.75 0.670 0.670
72110 72110 A 1 XXX 0 0 0 0 0 0 0 0.31 1.13 1.13 0.04 1.48 1.48 1.346 1.346
72110 26 7211026 A 1 XXX 0 0 0 0 0 0 0 0.31 0.12 0.12 0.03 0.46 0.46 0.433 0.433
72110 TC 72110TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.01 1.01 0.01 1.02 1.02 0.912 0.912
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
293 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72114 72114 A 1 XXX 0 0 0 0 0 0 0 0.32 1.57 1.57 0.05 1.94 1.94 1.756 1.756
72114 26 7211426 A 1 XXX 0 0 0 0 0 0 0 0.32 0.13 0.13 0.04 0.49 0.49 0.458 0.458
72114 TC 72114TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.44 1.44 0.01 1.45 1.45 1.298 1.298
72120 72120 A 1 XXX 0 0 0 0 0 0 0 0.22 1.03 1.03 0.04 1.29 1.29 1.166 1.166
72120 26 7212026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.10 0.10 0.03 0.35 0.35 0.325 0.325
72120 TC 72120TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.93 0.93 0.01 0.94 0.94 0.840 0.840
72125 72125 A 1 XXX 0 0 0 4 0 0 0 1.07 5.27 5.27 0.06 6.40 6.40 5.834 5.834
72125 26 7212526 A 1 XXX 0 0 0 4 0 0 0 1.07 0.39 0.39 0.05 1.51 1.51 1.446 1.446
72125 TC 72125TC A 1 XXX 0 0 0 4 0 0 0 0.00 4.88 4.88 0.01 4.89 4.89 4.387 4.387
72126 72126 A 1 XXX 0 0 0 4 0 0 0 1.22 6.52 6.52 0.08 7.82 7.82 7.117 7.117
72126 26 7212626 A 1 XXX 0 0 0 4 0 0 0 1.22 0.44 0.44 0.07 1.73 1.73 1.652 1.652
72126 TC 72126TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.08 6.08 0.01 6.09 6.09 5.465 5.465
72127 72127 A 1 XXX 0 0 0 4 0 0 0 1.27 8.01 8.01 0.08 9.36 9.36 8.505 8.505
72127 26 7212726 A 1 XXX 0 0 0 4 0 0 0 1.27 0.46 0.46 0.07 1.80 1.80 1.720 1.720
72127 TC 72127TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.55 7.55 0.01 7.56 7.56 6.785 6.785
72128 72128 A 1 XXX 0 0 0 4 0 0 0 1.00 5.21 5.21 0.06 6.27 6.27 5.710 5.710
72128 26 7212826 A 1 XXX 0 0 0 4 0 0 0 1.00 0.36 0.36 0.05 1.41 1.41 1.349 1.349
72128 TC 72128TC A 1 XXX 0 0 0 4 0 0 0 0.00 4.85 4.85 0.01 4.86 4.86 4.361 4.361
72129 72129 A 1 XXX 0 0 0 4 0 0 0 1.22 6.55 6.55 0.08 7.85 7.85 7.144 7.144
72129 26 7212926 A 1 XXX 0 0 0 4 0 0 0 1.22 0.44 0.44 0.07 1.73 1.73 1.652 1.652
72129 TC 72129TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.11 6.11 0.01 6.12 6.12 5.492 5.492
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
294 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72130 72130 A 1 XXX 0 0 0 4 0 0 0 1.27 8.06 8.06 0.08 9.41 9.41 8.550 8.550
72130 26 7213026 A 1 XXX 0 0 0 4 0 0 0 1.27 0.46 0.46 0.07 1.80 1.80 1.720 1.720
72130 TC 72130TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.60 7.60 0.01 7.61 7.61 6.830 6.830
72131 72131 A 1 XXX 0 0 0 4 0 0 0 1.00 5.19 5.19 0.06 6.25 6.25 5.692 5.692
72131 26 7213126 A 1 XXX 0 0 0 4 0 0 0 1.00 0.36 0.36 0.05 1.41 1.41 1.349 1.349
72131 TC 72131TC A 1 XXX 0 0 0 4 0 0 0 0.00 4.83 4.83 0.01 4.84 4.84 4.343 4.343
72132 72132 A 1 XXX 0 0 0 4 0 0 0 1.22 6.53 6.53 0.08 7.83 7.83 7.126 7.126
72132 26 7213226 A 1 XXX 0 0 0 4 0 0 0 1.22 0.44 0.44 0.07 1.73 1.73 1.652 1.652
72132 TC 72132TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.09 6.09 0.01 6.10 6.10 5.474 5.474
72133 72133 A 1 XXX 0 0 0 4 0 0 0 1.27 8.01 8.01 0.08 9.36 9.36 8.505 8.505
72133 26 7213326 A 1 XXX 0 0 0 4 0 0 0 1.27 0.45 0.45 0.07 1.79 1.79 1.711 1.711
72133 TC 72133TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.56 7.56 0.01 7.57 7.57 6.794 6.794
72141 72141 A 1 XXX 0 0 0 4 0 0 0 1.60 9.67 9.67 0.11 11.38 11.38 10.341 10.341
72141 26 7214126 A 1 XXX 0 0 0 4 0 0 0 1.60 0.58 0.58 0.10 2.28 2.28 2.173 2.173
72141 TC 72141TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.09 9.09 0.01 9.10 9.10 8.168 8.168
72142 72142 A 1 XXX 0 0 0 4 0 0 0 1.92 12.60 12.60 0.12 14.64 14.64 13.298 13.298
72142 26 7214226 A 1 XXX 0 0 0 4 0 0 0 1.92 0.71 0.71 0.11 2.74 2.74 2.615 2.615
72142 TC 72142TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.89 11.89 0.01 11.90 11.90 10.682 10.682
72146 72146 A 1 XXX 0 0 0 4 0 0 0 1.60 9.69 9.69 0.11 11.40 11.40 10.359 10.359
72146 26 7214626 A 1 XXX 0 0 0 4 0 0 0 1.60 0.58 0.58 0.10 2.28 2.28 2.173 2.173
72146 TC 72146TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.11 9.11 0.01 9.12 9.12 8.186 8.186
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
295 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72147 72147 A 1 XXX 0 0 0 4 0 0 0 1.92 10.89 10.89 0.12 12.93 12.93 11.762 11.762
72147 26 7214726 A 1 XXX 0 0 0 4 0 0 0 1.92 0.70 0.70 0.11 2.73 2.73 2.606 2.606
72147 TC 72147TC A 1 XXX 0 0 0 4 0 0 0 0.00 10.19 10.19 0.01 10.20 10.20 9.156 9.156
72148 72148 A 1 XXX 0 0 0 4 0 0 0 1.48 9.64 9.64 0.11 11.23 11.23 10.194 10.194
72148 26 7214826 A 1 XXX 0 0 0 4 0 0 0 1.48 0.54 0.54 0.10 2.12 2.12 2.017 2.017
72148 TC 72148TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.10 9.10 0.01 9.11 9.11 8.177 8.177
72149 72149 A 1 XXX 0 0 0 4 0 0 0 1.78 12.25 12.25 0.12 14.15 14.15 12.843 12.843
72149 26 7214926 A 1 XXX 0 0 0 4 0 0 0 1.78 0.65 0.65 0.11 2.54 2.54 2.421 2.421
72149 TC 72149TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.60 11.60 0.01 11.61 11.61 10.422 10.422
72156 72156 A 1 XXX 0 0 0 4 0 0 0 2.57 14.08 14.08 0.17 16.82 16.82 15.303 15.303
72156 26 7215626 A 1 XXX 0 0 0 4 0 0 0 2.57 0.93 0.93 0.16 3.66 3.66 3.489 3.489
72156 TC 72156TC A 1 XXX 0 0 0 4 0 0 0 0.00 13.15 13.15 0.01 13.16 13.16 11.814 11.814
72157 72157 A 1 XXX 0 0 0 4 0 0 0 2.57 12.89 12.89 0.17 15.63 15.63 14.234 14.234
72157 26 7215726 A 1 XXX 0 0 0 4 0 0 0 2.57 0.93 0.93 0.16 3.66 3.66 3.489 3.489
72157 TC 72157TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.96 11.96 0.01 11.97 11.97 10.745 10.745
72158 72158 A 1 XXX 0 0 0 4 0 0 0 2.36 13.93 13.93 0.17 16.46 16.46 14.958 14.958
72158 26 7215826 A 1 XXX 0 0 0 4 0 0 0 2.36 0.86 0.86 0.16 3.38 3.38 3.216 3.216
72158 TC 72158TC A 1 XXX 0 0 0 4 0 0 0 0.00 13.07 13.07 0.01 13.08 13.08 11.742 11.742
72159 72159 R 1 XXX 0 0 0 4 0 0 0 1.80 12.28 12.28 0.08 14.16 14.16 12.869 12.869
72159 26 7215926 R 1 XXX 0 0 0 4 0 0 0 1.80 0.65 0.65 0.07 2.52 2.52 2.420 2.420
72159 TC 72159TC R 1 XXX 0 0 0 4 0 9 0 0.00 11.63 11.63 0.01 11.64 11.64 10.449 10.449
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
296 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72170 72170 A 1 XXX 0 0 0 0 0 0 0 0.17 0.67 0.67 0.04 0.88 0.88 0.793 0.793
72170 26 7217026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.07 0.07 0.03 0.27 0.27 0.249 0.249
72170 TC 72170TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.60 0.60 0.01 0.61 0.61 0.544 0.544
72190 72190 A 1 XXX 0 0 0 0 0 0 0 0.21 1.07 1.07 0.04 1.32 1.32 1.192 1.192
72190 26 7219026 A 1 XXX 0 0 0 0 0 0 0 0.21 0.09 0.09 0.03 0.33 0.33 0.307 0.307
72190 TC 72190TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.98 0.98 0.01 0.99 0.99 0.885 0.885
72191 72191 A 1 XXX 0 0 0 4 0 0 0 1.81 10.02 10.02 0.13 11.96 11.96 10.876 10.876
72191 26 7219126 A 1 XXX 0 0 0 4 0 0 0 1.81 0.64 0.64 0.12 2.57 2.57 2.447 2.447
72191 TC 72191TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.38 9.38 0.01 9.39 9.39 8.428 8.428
72192 72192 A 1 XXX 0 0 0 4 0 0 0 1.09 4.03 4.03 0.06 5.18 5.18 4.740 4.740
72192 26 7219226 A 1 XXX 0 0 0 4 0 0 0 1.09 0.39 0.39 0.05 1.53 1.53 1.466 1.466
72192 TC 72192TC A 1 XXX 0 0 0 4 0 0 0 0.00 3.64 3.64 0.01 3.65 3.65 3.274 3.274
72193 72193 A 1 XXX 0 0 0 4 0 0 0 1.16 6.93 6.93 0.08 8.17 8.17 7.425 7.425
72193 26 7219326 A 1 XXX 0 0 0 4 0 0 0 1.16 0.42 0.42 0.07 1.65 1.65 1.574 1.574
72193 TC 72193TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.51 6.51 0.01 6.52 6.52 5.851 5.851
72194 72194 A 1 XXX 0 0 0 4 0 0 0 1.22 7.86 7.86 0.08 9.16 9.16 8.320 8.320
72194 26 7219426 A 1 XXX 0 0 0 4 0 0 0 1.22 0.44 0.44 0.07 1.73 1.73 1.652 1.652
72194 TC 72194TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.42 7.42 0.01 7.43 7.43 6.668 6.668
72195 72195 A 1 XXX 0 0 0 4 0 0 0 1.46 11.13 11.13 0.11 12.70 12.70 11.512 11.512
72195 26 7219526 A 1 XXX 0 0 0 4 0 0 0 1.46 0.53 0.53 0.10 2.09 2.09 1.988 1.988
72195 TC 72195TC A 1 XXX 0 0 0 4 0 0 0 0.00 10.60 10.60 0.01 10.61 10.61 9.524 9.524
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
297 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72196 72196 A 1 XXX 0 0 0 4 0 0 0 1.73 12.27 12.27 0.11 14.11 14.11 12.806 12.806
72196 26 7219626 A 1 XXX 0 0 0 4 0 0 0 1.73 0.63 0.63 0.10 2.46 2.46 2.348 2.348
72196 TC 72196TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.64 11.64 0.01 11.65 11.65 10.458 10.458
72197 72197 A 1 XXX 0 0 0 4 0 0 0 2.26 14.83 14.83 0.13 17.22 17.22 15.645 15.645
72197 26 7219726 A 1 XXX 0 0 0 4 0 0 0 2.26 0.81 0.81 0.12 3.19 3.19 3.050 3.050
72197 TC 72197TC A 1 XXX 0 0 0 4 0 0 0 0.00 14.02 14.02 0.01 14.03 14.03 12.595 12.595
72198 72198 A 1 XXX 0 0 0 4 0 0 0 1.80 12.05 12.05 0.11 13.96 13.96 12.678 12.678
72198 26 7219826 A 1 XXX 0 0 0 4 0 0 0 1.80 0.64 0.64 0.10 2.54 2.54 2.427 2.427
72198 TC 72198TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.41 11.41 0.01 11.42 11.42 10.251 10.251
72200 72200 A 1 XXX 0 0 0 0 0 0 0 0.17 0.71 0.71 0.02 0.90 0.90 0.818 0.818
72200 26 7220026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
72200 TC 72200TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.64 0.64 0.01 0.65 0.65 0.580 0.580
72202 72202 A 1 XXX 0 0 0 0 0 0 0 0.19 0.84 0.84 0.02 1.05 1.05 0.955 0.955
72202 26 7220226 A 1 XXX 0 0 0 0 0 0 0 0.19 0.07 0.07 0.01 0.27 0.27 0.258 0.258
72202 TC 72202TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.77 0.77 0.01 0.78 0.78 0.697 0.697
72220 72220 A 1 XXX 0 0 0 0 0 0 0 0.17 0.69 0.69 0.02 0.88 0.88 0.800 0.800
72220 26 7222026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
72220 TC 72220TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.62 0.62 0.01 0.63 0.63 0.562 0.562
72240 72240 A 1 XXX 0 0 0 0 0 0 0 0.91 2.89 2.89 0.06 3.86 3.86 3.537 3.537
72240 26 7224026 A 1 XXX 0 0 0 0 0 0 0 0.91 0.33 0.33 0.05 1.29 1.29 1.232 1.232
72240 TC 72240TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.56 2.56 0.01 2.57 2.57 2.304 2.304
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
298 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72255 72255 A 1 XXX 0 0 0 0 0 0 0 0.91 2.72 2.72 0.05 3.68 3.68 3.379 3.379
72255 26 7225526 A 1 XXX 0 0 0 0 0 0 0 0.91 0.35 0.35 0.04 1.30 1.30 1.245 1.245
72255 TC 72255TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.37 2.37 0.01 2.38 2.38 2.133 2.133
72265 72265 A 1 XXX 0 0 0 0 0 0 0 0.83 2.91 2.91 0.05 3.79 3.79 3.469 3.469
72265 26 7226526 A 1 XXX 0 0 0 0 0 0 0 0.83 0.31 0.31 0.04 1.18 1.18 1.129 1.129
72265 TC 72265TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.60 2.60 0.01 2.61 2.61 2.340 2.340
72270 72270 A 1 XXX 0 0 0 0 0 0 0 1.33 4.49 4.49 0.08 5.90 5.90 5.404 5.404
72270 26 7227026 A 1 XXX 0 0 0 0 0 0 0 1.33 0.49 0.49 0.07 1.89 1.89 1.807 1.807
72270 TC 72270TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.00 4.00 0.01 4.01 4.01 3.597 3.597
72275 72275 A 1 XXX 0 0 0 9 9 9 9 0.76 2.81 2.81 0.05 3.62 3.62 3.310 3.310
72275 26 7227526 A 1 XXX 0 0 0 9 9 9 9 0.76 0.35 0.35 0.04 1.15 1.15 1.095 1.095
72275 TC 72275TC A 1 XXX 0 0 0 9 9 9 9 0.00 2.46 2.46 0.01 2.47 2.47 2.214 2.214
72285 72285 A 1 XXX 0 0 0 0 0 0 0 1.16 2.28 2.28 0.06 3.50 3.50 3.239 3.239
72285 26 7228526 A 1 XXX 0 0 0 0 0 0 0 1.16 0.54 0.54 0.05 1.75 1.75 1.671 1.671
72285 TC 72285TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.74 1.74 0.01 1.75 1.75 1.568 1.568
72291 72291 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
72291 26 7229126 A 1 XXX 0 0 0 0 0 0 0 1.31 0.56 0.56 0.22 2.09 2.09 1.928 1.928
72291 TC 72291TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
72292 72292 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
72292 26 7229226 A 1 XXX 0 0 0 0 0 0 0 1.38 0.55 0.55 0.20 2.13 2.13 1.979 1.979
72292 TC 72292TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
299 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
72295 72295 A 1 XXX 0 0 0 0 0 0 0 0.83 2.19 2.19 0.05 3.07 3.07 2.823 2.823
72295 26 7229526 A 1 XXX 0 0 0 0 0 0 0 0.83 0.39 0.39 0.04 1.26 1.26 1.201 1.201
72295 TC 72295TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.80 1.80 0.01 1.81 1.81 1.622 1.622
73000 73000 A 1 XXX 0 0 0 0 3 0 0 0.16 0.70 0.70 0.02 0.88 0.88 0.799 0.799
73000 26 7300026 A 1 XXX 0 0 0 0 3 0 0 0.16 0.07 0.07 0.01 0.24 0.24 0.228 0.228
73000 TC 73000TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.63 0.63 0.01 0.64 0.64 0.571 0.571
73010 73010 A 1 XXX 0 0 0 0 3 0 0 0.17 0.77 0.77 0.04 0.98 0.98 0.882 0.882
73010 26 7301026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.08 0.08 0.03 0.28 0.28 0.258 0.258
73010 TC 73010TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.69 0.69 0.01 0.70 0.70 0.625 0.625
73020 73020 A 1 XXX 0 0 0 0 3 0 0 0.15 0.55 0.55 0.02 0.72 0.72 0.654 0.654
73020 26 7302026 A 1 XXX 0 0 0 0 3 0 0 0.15 0.06 0.06 0.01 0.22 0.22 0.209 0.209
73020 TC 73020TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.49 0.49 0.01 0.50 0.50 0.445 0.445
73030 73030 A 1 XXX 0 0 0 0 3 0 0 0.18 0.72 0.72 0.04 0.94 0.94 0.847 0.847
73030 26 7303026 A 1 XXX 0 0 0 0 3 0 0 0.18 0.08 0.08 0.03 0.29 0.29 0.268 0.268
73030 TC 73030TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.64 0.64 0.01 0.65 0.65 0.580 0.580
73040 73040 A 1 XXX 0 0 0 0 3 0 0 0.54 2.62 2.62 0.05 3.21 3.21 2.919 2.919
73040 26 7304026 A 1 XXX 0 0 0 0 3 0 0 0.54 0.21 0.21 0.04 0.79 0.79 0.750 0.750
73040 TC 73040TC A 1 XXX 0 0 0 0 3 0 0 0.00 2.41 2.41 0.01 2.42 2.42 2.169 2.169
73050 73050 A 1 XXX 0 0 0 0 2 0 0 0.20 0.99 0.99 0.04 1.23 1.23 1.110 1.110
73050 26 7305026 A 1 XXX 0 0 0 0 2 0 0 0.20 0.09 0.09 0.03 0.32 0.32 0.297 0.297
73050 TC 73050TC A 1 XXX 0 0 0 0 2 0 0 0.00 0.90 0.90 0.01 0.91 0.91 0.813 0.813
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
300 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73060 73060 A 1 XXX 0 0 0 0 3 0 0 0.17 0.69 0.69 0.02 0.88 0.88 0.800 0.800
73060 26 7306026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
73060 TC 73060TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.62 0.62 0.01 0.63 0.63 0.562 0.562
73070 73070 A 1 XXX 0 0 0 0 3 0 0 0.15 0.70 0.70 0.02 0.87 0.87 0.789 0.789
73070 26 7307026 A 1 XXX 0 0 0 0 3 0 0 0.15 0.07 0.07 0.01 0.23 0.23 0.218 0.218
73070 TC 73070TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.63 0.63 0.01 0.64 0.64 0.571 0.571
73080 73080 A 1 XXX 0 0 0 0 3 0 0 0.17 0.83 0.83 0.02 1.02 1.02 0.926 0.926
73080 26 7308026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
73080 TC 73080TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.76 0.76 0.01 0.77 0.77 0.688 0.688
73085 73085 A 1 XXX 0 0 0 0 3 0 0 0.54 2.51 2.51 0.04 3.09 3.09 2.815 2.815
73085 26 7308526 A 1 XXX 0 0 0 0 3 0 0 0.54 0.26 0.26 0.03 0.83 0.83 0.789 0.789
73085 TC 73085TC A 1 XXX 0 0 0 0 3 0 0 0.00 2.25 2.25 0.01 2.26 2.26 2.026 2.026
73090 73090 A 1 XXX 0 0 0 0 3 0 0 0.16 0.67 0.67 0.02 0.85 0.85 0.772 0.772
73090 26 7309026 A 1 XXX 0 0 0 0 3 0 0 0.16 0.07 0.07 0.01 0.24 0.24 0.228 0.228
73090 TC 73090TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.60 0.60 0.01 0.61 0.61 0.544 0.544
73092 73092 A 1 XXX 0 0 0 0 3 0 0 0.16 0.81 0.81 0.02 0.99 0.99 0.898 0.898
73092 26 7309226 A 1 XXX 0 0 0 0 3 0 0 0.16 0.07 0.07 0.01 0.24 0.24 0.228 0.228
73092 TC 73092TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.74 0.74 0.01 0.75 0.75 0.670 0.670
73100 73100 A 1 XXX 0 0 0 0 3 0 0 0.16 0.78 0.78 0.04 0.98 0.98 0.881 0.881
73100 26 7310026 A 1 XXX 0 0 0 0 3 0 0 0.16 0.08 0.08 0.03 0.27 0.27 0.248 0.248
73100 TC 73100TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.70 0.70 0.01 0.71 0.71 0.634 0.634
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
301 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73110 73110 A 1 XXX 0 0 0 0 3 0 0 0.17 0.96 0.96 0.02 1.15 1.15 1.043 1.043
73110 26 7311026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
73110 TC 73110TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.89 0.89 0.01 0.90 0.90 0.804 0.804
73115 73115 A 1 XXX 0 0 0 0 3 0 0 0.54 2.79 2.79 0.05 3.38 3.38 3.072 3.072
73115 26 7311526 A 1 XXX 0 0 0 0 3 0 0 0.54 0.23 0.23 0.04 0.81 0.81 0.767 0.767
73115 TC 73115TC A 1 XXX 0 0 0 0 3 0 0 0.00 2.56 2.56 0.01 2.57 2.57 2.304 2.304
73120 73120 A 1 XXX 0 0 0 0 3 0 0 0.16 0.66 0.66 0.02 0.84 0.84 0.763 0.763
73120 26 7312026 A 1 XXX 0 0 0 0 3 0 0 0.16 0.07 0.07 0.01 0.24 0.24 0.228 0.228
73120 TC 73120TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.59 0.59 0.01 0.60 0.60 0.535 0.535
73130 73130 A 1 XXX 0 0 0 0 3 0 0 0.17 0.80 0.80 0.02 0.99 0.99 0.899 0.899
73130 26 7313026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
73130 TC 73130TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.73 0.73 0.01 0.74 0.74 0.661 0.661
73140 73140 A 1 XXX 0 0 0 0 3 0 0 0.13 0.88 0.88 0.02 1.03 1.03 0.931 0.931
73140 26 7314026 A 1 XXX 0 0 0 0 3 0 0 0.13 0.06 0.06 0.01 0.20 0.20 0.189 0.189
73140 TC 73140TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.82 0.82 0.01 0.83 0.83 0.742 0.742
73200 73200 A 1 XXX 0 0 0 4 3 0 0 1.00 5.15 5.15 0.08 6.23 6.23 5.667 5.667
73200 26 7320026 A 1 XXX 0 0 0 4 3 0 0 1.00 0.36 0.36 0.07 1.43 1.43 1.360 1.360
73200 TC 73200TC A 1 XXX 0 0 0 4 3 0 0 0.00 4.79 4.79 0.01 4.80 4.80 4.307 4.307
73201 73201 A 1 XXX 0 0 0 4 3 0 0 1.16 6.41 6.41 0.08 7.65 7.65 6.958 6.958
73201 26 7320126 A 1 XXX 0 0 0 4 3 0 0 1.16 0.42 0.42 0.07 1.65 1.65 1.574 1.574
73201 TC 73201TC A 1 XXX 0 0 0 4 3 0 0 0.00 5.99 5.99 0.01 6.00 6.00 5.384 5.384
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
302 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73202 73202 A 1 XXX 0 0 0 4 3 0 0 1.22 8.44 8.44 0.08 9.74 9.74 8.841 8.841
73202 26 7320226 A 1 XXX 0 0 0 4 3 0 0 1.22 0.44 0.44 0.07 1.73 1.73 1.652 1.652
73202 TC 73202TC A 1 XXX 0 0 0 4 3 0 0 0.00 8.00 8.00 0.01 8.01 8.01 7.189 7.189
73206 73206 A 1 XXX 0 0 0 4 0 0 0 1.81 9.02 9.02 0.09 10.92 10.92 9.957 9.957
73206 26 7320626 A 1 XXX 0 0 0 4 0 0 0 1.81 0.65 0.65 0.08 2.54 2.54 2.436 2.436
73206 TC 73206TC A 1 XXX 0 0 0 4 0 0 0 0.00 8.37 8.37 0.01 8.38 8.38 7.521 7.521
73218 73218 A 1 XXX 0 0 0 4 3 0 0 1.35 11.06 11.06 0.08 12.49 12.49 11.324 11.324
73218 26 7321826 A 1 XXX 0 0 0 4 3 0 0 1.35 0.50 0.50 0.07 1.92 1.92 1.836 1.836
73218 TC 73218TC A 1 XXX 0 0 0 4 3 0 0 0.00 10.56 10.56 0.01 10.57 10.57 9.488 9.488
73219 73219 A 1 XXX 0 0 0 4 3 0 0 1.62 12.13 12.13 0.11 13.86 13.86 12.570 12.570
73219 26 7321926 A 1 XXX 0 0 0 4 3 0 0 1.62 0.59 0.59 0.10 2.31 2.31 2.202 2.202
73219 TC 73219TC A 1 XXX 0 0 0 4 3 0 0 0.00 11.54 11.54 0.01 11.55 11.55 10.368 10.368
73220 73220 A 1 XXX 0 0 0 4 3 0 0 2.15 14.81 14.81 0.13 17.09 17.09 15.517 15.517
73220 26 7322026 A 1 XXX 0 0 0 4 3 0 0 2.15 0.78 0.78 0.12 3.05 3.05 2.913 2.913
73220 TC 73220TC A 1 XXX 0 0 0 4 3 0 0 0.00 14.03 14.03 0.01 14.04 14.04 12.604 12.604
73221 73221 A 1 XXX 0 0 0 4 3 0 0 1.35 6.83 6.83 0.11 8.29 8.29 7.541 7.541
73221 26 7322126 A 1 XXX 0 0 0 4 3 0 0 1.35 0.51 0.51 0.10 1.96 1.96 1.860 1.860
73221 TC 73221TC A 1 XXX 0 0 0 4 3 0 0 0.00 6.32 6.32 0.01 6.33 6.33 5.681 5.681
73222 73222 A 1 XXX 0 0 0 4 3 0 0 1.62 11.28 11.28 0.11 13.01 13.01 11.807 11.807
73222 26 7322226 A 1 XXX 0 0 0 4 3 0 0 1.62 0.59 0.59 0.10 2.31 2.31 2.202 2.202
73222 TC 73222TC A 1 XXX 0 0 0 4 3 0 0 0.00 10.69 10.69 0.01 10.70 10.70 9.605 9.605
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
303 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73223 73223 A 1 XXX 0 0 0 4 3 0 0 2.15 13.83 13.83 0.13 16.11 16.11 14.637 14.637
73223 26 7322326 A 1 XXX 0 0 0 4 3 0 0 2.15 0.78 0.78 0.12 3.05 3.05 2.913 2.913
73223 TC 73223TC A 1 XXX 0 0 0 4 3 0 0 0.00 13.05 13.05 0.01 13.06 13.06 11.724 11.724
73225 73225 R 1 XXX 0 0 0 4 0 0 0 1.73 12.37 12.37 0.08 14.18 14.18 12.880 12.880
73225 26 7322526 R 1 XXX 0 0 0 4 0 0 0 1.73 0.61 0.61 0.07 2.41 2.41 2.314 2.314
73225 TC 73225TC R 1 XXX 0 0 0 4 0 9 0 0.00 11.76 11.76 0.01 11.77 11.77 10.566 10.566
73500 73500 A 1 XXX 0 0 0 0 0 0 0 0.17 0.63 0.63 0.04 0.84 0.84 0.757 0.757
73500 26 7350026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.08 0.08 0.03 0.28 0.28 0.258 0.258
73500 TC 73500TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.55 0.55 0.01 0.56 0.56 0.499 0.499
73510 73510 A 1 XXX 0 0 0 0 0 0 0 0.21 0.95 0.95 0.04 1.20 1.20 1.084 1.084
73510 26 7351026 A 1 XXX 0 0 0 0 0 0 0 0.21 0.09 0.09 0.03 0.33 0.33 0.307 0.307
73510 TC 73510TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.86 0.86 0.01 0.87 0.87 0.778 0.778
73520 73520 A 1 XXX 0 0 0 0 2 0 0 0.26 0.95 0.95 0.04 1.25 1.25 1.134 1.134
73520 26 7352026 A 1 XXX 0 0 0 0 2 0 0 0.26 0.11 0.11 0.03 0.40 0.40 0.374 0.374
73520 TC 73520TC A 1 XXX 0 0 0 0 2 0 0 0.00 0.84 0.84 0.01 0.85 0.85 0.760 0.760
73525 73525 A 1 XXX 0 0 0 0 3 0 0 0.54 2.61 2.61 0.05 3.20 3.20 2.910 2.910
73525 26 7352526 A 1 XXX 0 0 0 0 3 0 0 0.54 0.26 0.26 0.04 0.84 0.84 0.794 0.794
73525 TC 73525TC A 1 XXX 0 0 0 0 3 0 0 0.00 2.35 2.35 0.01 2.36 2.36 2.116 2.116
73530 73530 C 1 XXX 0 0 0 0 3 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
73530 26 7353026 A 1 XXX 0 0 0 0 3 0 0 0.29 0.10 0.10 0.03 0.42 0.42 0.395 0.395
73530 TC 73530TC C 1 XXX 0 0 0 0 3 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
304 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73540 73540 A 1 XXX 0 0 0 0 0 0 0 0.20 1.13 1.13 0.04 1.37 1.37 1.236 1.236
73540 26 7354026 A 1 XXX 0 0 0 0 0 0 0 0.20 0.09 0.09 0.03 0.32 0.32 0.297 0.297
73540 TC 73540TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.04 1.04 0.01 1.05 1.05 0.939 0.939
73550 73550 A 1 XXX 0 0 0 0 3 0 0 0.17 0.66 0.66 0.04 0.87 0.87 0.784 0.784
73550 26 7355026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.07 0.07 0.03 0.27 0.27 0.249 0.249
73550 TC 73550TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.59 0.59 0.01 0.60 0.60 0.535 0.535
73560 73560 A 1 XXX 0 0 0 0 3 0 0 0.17 0.74 0.74 0.04 0.95 0.95 0.855 0.855
73560 26 7356026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.08 0.08 0.03 0.28 0.28 0.258 0.258
73560 TC 73560TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.66 0.66 0.01 0.67 0.67 0.598 0.598
73562 73562 A 1 XXX 0 0 0 0 3 0 0 0.18 0.93 0.93 0.04 1.15 1.15 1.036 1.036
73562 26 7356226 A 1 XXX 0 0 0 0 3 0 0 0.18 0.08 0.08 0.03 0.29 0.29 0.268 0.268
73562 TC 73562TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.85 0.85 0.01 0.86 0.86 0.769 0.769
73564 73564 A 1 XXX 0 0 0 0 3 0 0 0.22 1.08 1.08 0.04 1.34 1.34 1.211 1.211
73564 26 7356426 A 1 XXX 0 0 0 0 3 0 0 0.22 0.10 0.10 0.03 0.35 0.35 0.325 0.325
73564 TC 73564TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.98 0.98 0.01 0.99 0.99 0.885 0.885
73565 73565 A 1 XXX 0 0 0 0 2 0 0 0.17 0.89 0.89 0.04 1.10 1.10 0.990 0.990
73565 26 7356526 A 1 XXX 0 0 0 0 2 0 0 0.17 0.09 0.09 0.03 0.29 0.29 0.267 0.267
73565 TC 73565TC A 1 XXX 0 0 0 0 2 0 0 0.00 0.80 0.80 0.01 0.81 0.81 0.724 0.724
73580 73580 A 1 XXX 0 0 0 0 3 0 0 0.54 3.37 3.37 0.06 3.97 3.97 3.598 3.598
73580 26 7358026 A 1 XXX 0 0 0 0 3 0 0 0.54 0.25 0.25 0.05 0.84 0.84 0.791 0.791
73580 TC 73580TC A 1 XXX 0 0 0 0 3 0 0 0.00 3.12 3.12 0.01 3.13 3.13 2.807 2.807
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
305 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73590 73590 A 1 XXX 0 0 0 0 3 0 0 0.17 0.65 0.65 0.02 0.84 0.84 0.764 0.764
73590 26 7359026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
73590 TC 73590TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.58 0.58 0.01 0.59 0.59 0.526 0.526
73592 73592 A 1 XXX 0 0 0 0 3 0 0 0.16 0.67 0.67 0.02 0.85 0.85 0.772 0.772
73592 26 7359226 A 1 XXX 0 0 0 0 3 0 0 0.16 0.06 0.06 0.01 0.23 0.23 0.219 0.219
73592 TC 73592TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.61 0.61 0.01 0.62 0.62 0.553 0.553
73600 73600 A 1 XXX 0 0 0 0 3 0 0 0.16 0.70 0.70 0.02 0.88 0.88 0.799 0.799
73600 26 7360026 A 1 XXX 0 0 0 0 3 0 0 0.16 0.07 0.07 0.01 0.24 0.24 0.228 0.228
73600 TC 73600TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.63 0.63 0.01 0.64 0.64 0.571 0.571
73610 73610 A 1 XXX 0 0 0 0 3 0 0 0.17 0.83 0.83 0.02 1.02 1.02 0.926 0.926
73610 26 7361026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
73610 TC 73610TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.76 0.76 0.01 0.77 0.77 0.688 0.688
73615 73615 A 1 XXX 0 0 0 0 3 0 0 0.54 2.61 2.61 0.05 3.20 3.20 2.910 2.910
73615 26 7361526 A 1 XXX 0 0 0 0 3 0 0 0.54 0.25 0.25 0.04 0.83 0.83 0.785 0.785
73615 TC 73615TC A 1 XXX 0 0 0 0 3 0 0 0.00 2.36 2.36 0.01 2.37 2.37 2.125 2.125
73620 73620 A 1 XXX 0 0 0 0 3 0 0 0.16 0.66 0.66 0.02 0.84 0.84 0.763 0.763
73620 26 7362026 A 1 XXX 0 0 0 0 3 0 0 0.16 0.05 0.05 0.01 0.22 0.22 0.210 0.210
73620 TC 73620TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.61 0.61 0.01 0.62 0.62 0.553 0.553
73630 73630 A 1 XXX 0 0 0 0 3 0 0 0.17 0.77 0.77 0.02 0.96 0.96 0.872 0.872
73630 26 7363026 A 1 XXX 0 0 0 0 3 0 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
73630 TC 73630TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.71 0.71 0.01 0.72 0.72 0.643 0.643
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
306 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73650 73650 A 1 XXX 0 0 0 0 3 0 0 0.16 0.69 0.69 0.02 0.87 0.87 0.790 0.790
73650 26 7365026 A 1 XXX 0 0 0 0 3 0 0 0.16 0.06 0.06 0.01 0.23 0.23 0.219 0.219
73650 TC 73650TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.63 0.63 0.01 0.64 0.64 0.571 0.571
73660 73660 A 1 XXX 0 0 0 0 3 0 0 0.13 0.78 0.78 0.02 0.93 0.93 0.841 0.841
73660 26 7366026 A 1 XXX 0 0 0 0 3 0 0 0.13 0.05 0.05 0.01 0.19 0.19 0.180 0.180
73660 TC 73660TC A 1 XXX 0 0 0 0 3 0 0 0.00 0.73 0.73 0.01 0.74 0.74 0.661 0.661
73700 73700 A 1 XXX 0 0 0 4 3 0 0 1.00 5.17 5.17 0.08 6.25 6.25 5.685 5.685
73700 26 7370026 A 1 XXX 0 0 0 4 3 0 0 1.00 0.36 0.36 0.07 1.43 1.43 1.360 1.360
73700 TC 73700TC A 1 XXX 0 0 0 4 3 0 0 0.00 4.81 4.81 0.01 4.82 4.82 4.325 4.325
73701 73701 A 1 XXX 0 0 0 4 3 0 0 1.16 6.52 6.52 0.08 7.76 7.76 7.057 7.057
73701 26 7370126 A 1 XXX 0 0 0 4 3 0 0 1.16 0.42 0.42 0.07 1.65 1.65 1.574 1.574
73701 TC 73701TC A 1 XXX 0 0 0 4 3 0 0 0.00 6.10 6.10 0.01 6.11 6.11 5.483 5.483
73702 73702 A 1 XXX 0 0 0 4 3 0 0 1.22 8.42 8.42 0.08 9.72 9.72 8.823 8.823
73702 26 7370226 A 1 XXX 0 0 0 4 3 0 0 1.22 0.44 0.44 0.07 1.73 1.73 1.652 1.652
73702 TC 73702TC A 1 XXX 0 0 0 4 3 0 0 0.00 7.98 7.98 0.01 7.99 7.99 7.171 7.171
73706 73706 A 1 XXX 0 0 0 4 3 0 0 1.90 10.07 10.07 0.12 12.09 12.09 11.006 11.006
73706 26 7370626 A 1 XXX 0 0 0 4 3 0 0 1.90 0.68 0.68 0.11 2.69 2.69 2.568 2.568
73706 TC 73706TC A 1 XXX 0 0 0 4 3 0 0 0.00 9.39 9.39 0.01 9.40 9.40 8.437 8.437
73718 73718 A 1 XXX 0 0 0 4 3 0 0 1.35 10.97 10.97 0.09 12.41 12.41 11.248 11.248
73718 26 7371826 A 1 XXX 0 0 0 4 3 0 0 1.35 0.49 0.49 0.08 1.92 1.92 1.832 1.832
73718 TC 73718TC A 1 XXX 0 0 0 4 3 0 0 0.00 10.48 10.48 0.01 10.49 10.49 9.416 9.416
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
307 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
73719 73719 A 1 XXX 0 0 0 4 3 0 0 1.62 12.36 12.36 0.11 14.09 14.09 12.777 12.777
73719 26 7371926 A 1 XXX 0 0 0 4 3 0 0 1.62 0.59 0.59 0.10 2.31 2.31 2.202 2.202
73719 TC 73719TC A 1 XXX 0 0 0 4 3 0 0 0.00 11.77 11.77 0.01 11.78 11.78 10.575 10.575
73720 73720 A 1 XXX 0 0 0 4 3 0 0 2.15 14.92 14.92 0.13 17.20 17.20 15.616 15.616
73720 26 7372026 A 1 XXX 0 0 0 4 3 0 0 2.15 0.77 0.77 0.12 3.04 3.04 2.904 2.904
73720 TC 73720TC A 1 XXX 0 0 0 4 3 0 0 0.00 14.15 14.15 0.01 14.16 14.16 12.712 12.712
73721 73721 A 1 XXX 0 0 0 4 3 0 0 1.35 6.83 6.83 0.11 8.29 8.29 7.541 7.541
73721 26 7372126 A 1 XXX 0 0 0 4 3 0 0 1.35 0.51 0.51 0.10 1.96 1.96 1.860 1.860
73721 TC 73721TC A 1 XXX 0 0 0 4 3 0 0 0.00 6.32 6.32 0.01 6.33 6.33 5.681 5.681
73722 73722 A 1 XXX 0 0 0 4 3 0 0 1.62 11.46 11.46 0.12 13.20 13.20 11.974 11.974
73722 26 7372226 A 1 XXX 0 0 0 4 3 0 0 1.62 0.60 0.60 0.11 2.33 2.33 2.216 2.216
73722 TC 73722TC A 1 XXX 0 0 0 4 3 0 0 0.00 10.86 10.86 0.01 10.87 10.87 9.758 9.758
73723 73723 A 1 XXX 0 0 0 4 3 0 0 2.15 13.82 13.82 0.13 16.10 16.10 14.628 14.628
73723 26 7372326 A 1 XXX 0 0 0 4 3 0 0 2.15 0.78 0.78 0.12 3.05 3.05 2.913 2.913
73723 TC 73723TC A 1 XXX 0 0 0 4 3 0 0 0.00 13.04 13.04 0.01 13.05 13.05 11.715 11.715
73725 73725 R 1 XXX 0 0 0 4 3 0 0 1.82 12.11 12.11 0.11 14.04 14.04 12.752 12.752
73725 26 7372526 R 1 XXX 0 0 0 4 3 0 0 1.82 0.64 0.64 0.10 2.56 2.56 2.447 2.447
73725 TC 73725TC R 1 XXX 0 0 0 4 3 0 0 0.00 11.47 11.47 0.01 11.48 11.48 10.305 10.305
74000 74000 A 1 XXX 0 0 0 0 0 0 0 0.18 0.53 0.53 0.02 0.73 0.73 0.666 0.666
74000 26 7400026 A 1 XXX 0 0 0 0 0 0 0 0.18 0.07 0.07 0.01 0.26 0.26 0.248 0.248
74000 TC 74000TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.46 0.46 0.01 0.47 0.47 0.418 0.418
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
308 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74010 74010 A 1 XXX 0 0 0 0 0 0 0 0.23 0.92 0.92 0.02 1.17 1.17 1.067 1.067
74010 26 7401026 A 1 XXX 0 0 0 0 0 0 0 0.23 0.09 0.09 0.01 0.33 0.33 0.316 0.316
74010 TC 74010TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.83 0.83 0.01 0.84 0.84 0.751 0.751
74020 74020 A 1 XXX 0 0 0 0 0 0 0 0.27 0.93 0.93 0.02 1.22 1.22 1.116 1.116
74020 26 7402026 A 1 XXX 0 0 0 0 0 0 0 0.27 0.10 0.10 0.01 0.38 0.38 0.365 0.365
74020 TC 74020TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.83 0.83 0.01 0.84 0.84 0.751 0.751
74022 74022 A 1 XXX 0 0 0 0 0 0 0 0.32 1.13 1.13 0.02 1.47 1.47 1.345 1.345
74022 26 7402226 A 1 XXX 0 0 0 0 0 0 0 0.32 0.12 0.12 0.01 0.45 0.45 0.433 0.433
74022 TC 74022TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.01 1.01 0.01 1.02 1.02 0.912 0.912
74150 74150 A 1 XXX 0 0 0 4 0 0 0 1.19 4.02 4.02 0.08 5.29 5.29 4.842 4.842
74150 26 7415026 A 1 XXX 0 0 0 4 0 0 0 1.19 0.43 0.43 0.07 1.69 1.69 1.613 1.613
74150 TC 74150TC A 1 XXX 0 0 0 4 0 0 0 0.00 3.59 3.59 0.01 3.60 3.60 3.229 3.229
74160 74160 A 1 XXX 0 0 0 4 0 0 0 1.27 6.96 6.96 0.08 8.31 8.31 7.562 7.562
74160 26 7416026 A 1 XXX 0 0 0 4 0 0 0 1.27 0.47 0.47 0.07 1.81 1.81 1.729 1.729
74160 TC 74160TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.49 6.49 0.01 6.50 6.50 5.833 5.833
74170 74170 A 1 XXX 0 0 0 4 0 0 0 1.40 8.08 8.08 0.09 9.57 9.57 8.703 8.703
74170 26 7417026 A 1 XXX 0 0 0 4 0 0 0 1.40 0.51 0.51 0.08 1.99 1.99 1.900 1.900
74170 TC 74170TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.57 7.57 0.01 7.58 7.58 6.803 6.803
74174 74174 A 1 XXX 0 0 0 4 0 0 0 2.20 12.55 12.55 0.15 14.90 14.90 13.548 13.548
74174 26 7417426 A 1 XXX 0 0 0 4 0 0 0 2.20 0.78 0.78 0.14 3.12 3.12 2.974 2.974
74174 TC 74174TC A 1 XXX 0 0 0 4 0 0 0 0.00 11.77 11.77 0.01 11.78 11.78 10.575 10.575
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
309 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74175 74175 A 1 XXX 0 0 0 4 0 0 0 1.90 10.08 10.08 0.13 12.11 12.11 11.020 11.020
74175 26 7417526 A 1 XXX 0 0 0 4 0 0 0 1.90 0.68 0.68 0.12 2.70 2.70 2.573 2.573
74175 TC 74175TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.40 9.40 0.01 9.41 9.41 8.446 8.446
74176 74176 A 1 XXX 0 0 0 4 0 9 0 1.74 4.98 4.98 0.11 6.83 6.83 6.270 6.270
74176 26 7417626 A 1 XXX 0 0 0 4 0 9 0 1.74 0.63 0.63 0.10 2.47 2.47 2.358 2.358
74176 TC 74176TC A 1 XXX 0 0 0 4 0 9 0 0.00 4.35 4.35 0.01 4.36 4.36 3.912 3.912
74177 74177 A 1 XXX 0 0 0 4 0 9 0 1.82 8.35 8.35 0.11 10.28 10.28 9.376 9.376
74177 26 7417726 A 1 XXX 0 0 0 4 0 9 0 1.82 0.66 0.66 0.10 2.58 2.58 2.465 2.465
74177 TC 74177TC A 1 XXX 0 0 0 4 0 9 0 0.00 7.69 7.69 0.01 7.70 7.70 6.911 6.911
74178 74178 A 1 XXX 0 0 0 4 0 9 0 2.01 9.90 9.90 0.13 12.04 12.04 10.968 10.968
74178 26 7417826 A 1 XXX 0 0 0 4 0 9 0 2.01 0.73 0.73 0.12 2.86 2.86 2.728 2.728
74178 TC 74178TC A 1 XXX 0 0 0 4 0 9 0 0.00 9.17 9.17 0.01 9.18 9.18 8.240 8.240
74181 74181 A 1 XXX 0 0 0 4 0 0 0 1.46 9.69 9.69 0.09 11.24 11.24 10.209 10.209
74181 26 7418126 A 1 XXX 0 0 0 4 0 0 0 1.46 0.52 0.52 0.08 2.06 2.06 1.969 1.969
74181 TC 74181TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.17 9.17 0.01 9.18 9.18 8.240 8.240
74182 74182 A 1 XXX 0 0 0 4 0 0 0 1.73 13.68 13.68 0.11 15.52 15.52 14.072 14.072
74182 26 7418226 A 1 XXX 0 0 0 4 0 0 0 1.73 0.62 0.62 0.10 2.45 2.45 2.339 2.339
74182 TC 74182TC A 1 XXX 0 0 0 4 0 0 0 0.00 13.06 13.06 0.01 13.07 13.07 11.733 11.733
74183 74183 A 1 XXX 0 0 0 4 0 0 0 2.26 14.89 14.89 0.13 17.28 17.28 15.699 15.699
74183 26 7418326 A 1 XXX 0 0 0 4 0 0 0 2.26 0.81 0.81 0.12 3.19 3.19 3.050 3.050
74183 TC 74183TC A 1 XXX 0 0 0 4 0 0 0 0.00 14.08 14.08 0.01 14.09 14.09 12.649 12.649
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
310 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74185 74185 R 1 XXX 0 0 0 4 0 0 0 1.80 12.04 12.04 0.11 13.95 13.95 12.669 12.669
74185 26 7418526 R 1 XXX 0 0 0 4 0 0 0 1.80 0.64 0.64 0.10 2.54 2.54 2.427 2.427
74185 TC 74185TC R 1 XXX 0 0 0 4 0 0 0 0.00 11.40 11.40 0.01 11.41 11.41 10.242 10.242
74190 74190 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74190 26 7419026 A 1 XXX 0 0 0 0 0 0 0 0.48 0.17 0.17 0.04 0.69 0.69 0.654 0.654
74190 TC 74190TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74210 74210 A 1 XXX 0 0 0 0 0 0 0 0.36 1.98 1.98 0.02 2.36 2.36 2.149 2.149
74210 26 7421026 A 1 XXX 0 0 0 0 0 0 0 0.36 0.13 0.13 0.01 0.50 0.50 0.482 0.482
74210 TC 74210TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.85 1.85 0.01 1.86 1.86 1.667 1.667
74220 74220 A 1 XXX 0 0 0 0 0 0 0 0.46 2.26 2.26 0.04 2.76 2.76 2.510 2.510
74220 26 7422026 A 1 XXX 0 0 0 0 0 0 0 0.46 0.17 0.17 0.03 0.66 0.66 0.628 0.628
74220 TC 74220TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.09 2.09 0.01 2.10 2.10 1.882 1.882
74230 74230 A 1 XXX 0 0 0 0 0 0 0 0.53 2.17 2.17 0.04 2.74 2.74 2.500 2.500
74230 26 7423026 A 1 XXX 0 0 0 0 0 0 0 0.53 0.19 0.19 0.03 0.75 0.75 0.716 0.716
74230 TC 74230TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.98 1.98 0.01 1.99 1.99 1.783 1.783
74235 74235 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74235 26 7423526 A 1 XXX 0 0 0 0 0 0 0 1.19 0.63 0.63 0.10 1.92 1.92 1.808 1.808
74235 TC 74235TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74240 74240 A 1 XXX 0 0 0 0 0 0 0 0.69 2.70 2.70 0.05 3.44 3.44 3.141 3.141
74240 26 7424026 A 1 XXX 0 0 0 0 0 0 0 0.69 0.26 0.26 0.04 0.99 0.99 0.944 0.944
74240 TC 74240TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.44 2.44 0.01 2.45 2.45 2.196 2.196
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
311 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74241 74241 A 1 XXX 0 0 0 0 0 0 0 0.69 2.87 2.87 0.04 3.60 3.60 3.288 3.288
74241 26 7424126 A 1 XXX 0 0 0 0 0 0 0 0.69 0.25 0.25 0.03 0.97 0.97 0.930 0.930
74241 TC 74241TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.62 2.62 0.01 2.63 2.63 2.358 2.358
74245 74245 A 1 XXX 0 0 0 0 0 0 0 0.91 4.40 4.40 0.06 5.37 5.37 4.893 4.893
74245 26 7424526 A 1 XXX 0 0 0 0 0 0 0 0.91 0.33 0.33 0.05 1.29 1.29 1.232 1.232
74245 TC 74245TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.07 4.07 0.01 4.08 4.08 3.660 3.660
74246 74246 A 1 XXX 0 0 0 0 0 0 0 0.69 3.14 3.14 0.05 3.88 3.88 3.536 3.536
74246 26 7424626 A 1 XXX 0 0 0 0 0 0 0 0.69 0.25 0.25 0.04 0.98 0.98 0.935 0.935
74246 TC 74246TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.89 2.89 0.01 2.90 2.90 2.600 2.600
74247 74247 A 1 XXX 0 0 0 0 0 0 0 0.69 3.58 3.58 0.05 4.32 4.32 3.931 3.931
74247 26 7424726 A 1 XXX 0 0 0 0 0 0 0 0.69 0.25 0.25 0.04 0.98 0.98 0.935 0.935
74247 TC 74247TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.33 3.33 0.01 3.34 3.34 2.996 2.996
74249 74249 A 1 XXX 0 0 0 0 0 0 0 0.91 4.83 4.83 0.06 5.80 5.80 5.279 5.279
74249 26 7424926 A 1 XXX 0 0 0 0 0 0 0 0.91 0.33 0.33 0.05 1.29 1.29 1.232 1.232
74249 TC 74249TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.50 4.50 0.01 4.51 4.51 4.046 4.046
74250 74250 A 1 XXX 0 0 0 0 0 0 0 0.47 2.77 2.77 0.04 3.28 3.28 2.978 2.978
74250 26 7425026 A 1 XXX 0 0 0 0 0 0 0 0.47 0.17 0.17 0.03 0.67 0.67 0.638 0.638
74250 TC 74250TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.60 2.60 0.01 2.61 2.61 2.340 2.340
74251 74251 A 1 XXX 0 0 0 0 0 0 0 0.69 11.93 11.93 0.05 12.67 12.67 11.429 11.429
74251 26 7425126 A 1 XXX 0 0 0 0 0 0 0 0.69 0.25 0.25 0.04 0.98 0.98 0.935 0.935
74251 TC 74251TC A 1 XXX 0 0 0 0 0 0 0 0.00 11.68 11.68 0.01 11.69 11.69 10.494 10.494
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
312 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74260 74260 A 1 XXX 0 0 0 0 0 0 0 0.50 9.90 9.90 0.04 10.44 10.44 9.411 9.411
74260 26 7426026 A 1 XXX 0 0 0 0 0 0 0 0.50 0.18 0.18 0.03 0.71 0.71 0.677 0.677
74260 TC 74260TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.72 9.72 0.01 9.73 9.73 8.734 8.734
74261 74261 A 1 XXX 0 0 0 4 0 0 0 2.40 13.41 13.41 0.13 15.94 15.94 14.510 14.510
74261 26 7426126 A 1 XXX 0 0 0 4 0 0 0 2.40 0.88 0.88 0.12 3.40 3.40 3.253 3.253
74261 TC 74261TC A 1 XXX 0 0 0 4 0 0 0 0.00 12.53 12.53 0.01 12.54 12.54 11.257 11.257
74262 74262 A 1 XXX 0 0 0 4 0 0 0 2.50 14.93 14.93 0.15 17.58 17.58 15.986 15.986
74262 26 7426226 A 1 XXX 0 0 0 4 0 0 0 2.50 0.89 0.89 0.14 3.53 3.53 3.372 3.372
74262 TC 74262TC A 1 XXX 0 0 0 4 0 0 0 0.00 14.04 14.04 0.01 14.05 14.05 12.613 12.613
74263 74263 N 1 XXX 0 0 0 9 9 9 9 2.28 20.72 20.72 0.13 23.13 23.13 20.955 20.955
74263 26 7426326 N 1 XXX 0 0 0 9 9 9 9 2.28 0.92 0.92 0.12 3.32 3.32 3.169 3.169
74263 TC 74263TC N 1 XXX 0 0 0 9 9 9 9 0.00 19.80 19.80 0.01 19.81 19.81 17.786 17.786
74270 74270 A 1 XXX 0 0 0 0 0 0 0 0.69 4.02 4.02 0.05 4.76 4.76 4.326 4.326
74270 26 7427026 A 1 XXX 0 0 0 0 0 0 0 0.69 0.25 0.25 0.04 0.98 0.98 0.935 0.935
74270 TC 74270TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.77 3.77 0.01 3.78 3.78 3.391 3.391
74280 74280 A 1 XXX 0 0 0 0 0 0 0 0.99 5.60 5.60 0.06 6.65 6.65 6.050 6.050
74280 26 7428026 A 1 XXX 0 0 0 0 0 0 0 0.99 0.36 0.36 0.05 1.40 1.40 1.339 1.339
74280 TC 74280TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.24 5.24 0.01 5.25 5.25 4.711 4.711
74283 74283 A 1 XXX 0 0 0 0 0 0 0 2.02 3.93 3.93 0.06 6.01 6.01 5.581 5.581
74283 26 7428326 A 1 XXX 0 0 0 0 0 0 0 2.02 0.74 0.74 0.05 2.81 2.81 2.711 2.711
74283 TC 74283TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.19 3.19 0.01 3.20 3.20 2.870 2.870
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
313 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74290 74290 A 1 XXX 0 0 0 0 0 0 0 0.32 1.77 1.77 0.02 2.11 2.11 1.920 1.920
74290 26 7429026 A 1 XXX 0 0 0 0 0 0 0 0.32 0.12 0.12 0.01 0.45 0.45 0.433 0.433
74290 TC 74290TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.65 1.65 0.01 1.66 1.66 1.487 1.487
74291 74291 A 1 XXX 0 0 0 0 0 0 0 0.20 1.85 1.85 0.02 2.07 2.07 1.872 1.872
74291 26 7429126 A 1 XXX 0 0 0 0 0 0 0 0.20 0.08 0.08 0.01 0.29 0.29 0.277 0.277
74291 TC 74291TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.77 1.77 0.01 1.78 1.78 1.595 1.595
74300 74300 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74300 26 7430026 A 1 XXX 0 0 0 0 0 0 0 0.36 0.13 0.13 0.03 0.52 0.52 0.492 0.492
74300 TC 74300TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74301 74301 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74301 26 7430126 A 1 ZZZ 0 0 0 0 0 0 0 0.21 0.07 0.07 0.03 0.31 0.31 0.289 0.289
74301 TC 74301TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74305 74305 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74305 26 7430526 A 1 XXX 0 0 0 0 0 0 0 0.42 0.15 0.15 0.04 0.61 0.61 0.576 0.576
74305 TC 74305TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74320 74320 A 1 XXX 0 0 0 0 0 0 0 0.54 2.38 2.38 0.04 2.96 2.96 2.698 2.698
74320 26 7432026 A 1 XXX 0 0 0 0 0 0 0 0.54 0.19 0.19 0.03 0.76 0.76 0.726 0.726
74320 TC 74320TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.19 2.19 0.01 2.20 2.20 1.972 1.972
74327 74327 A 1 XXX 0 0 0 0 0 0 0 0.70 3.40 3.40 0.13 4.23 4.23 3.821 3.821
74327 26 7432726 A 1 XXX 0 0 0 0 0 0 0 0.70 0.25 0.25 0.12 1.07 1.07 0.987 0.987
74327 TC 74327TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.15 3.15 0.01 3.16 3.16 2.834 2.834
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
314 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74328 74328 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74328 26 7432826 A 1 XXX 0 0 0 0 0 0 0 0.70 0.28 0.28 0.05 1.03 1.03 0.978 0.978
74328 TC 74328TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74329 74329 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74329 26 7432926 A 1 XXX 0 0 0 0 0 0 0 0.70 0.29 0.29 0.05 1.04 1.04 0.987 0.987
74329 TC 74329TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74330 74330 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74330 26 7433026 A 1 XXX 0 0 0 0 0 0 0 0.90 0.35 0.35 0.07 1.32 1.32 1.251 1.251
74330 TC 74330TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74340 74340 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74340 26 7434026 A 1 XXX 0 0 0 0 0 0 0 0.54 0.20 0.20 0.04 0.78 0.78 0.741 0.741
74340 TC 74340TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74355 74355 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74355 26 7435526 A 1 XXX 0 0 0 0 0 0 0 0.76 0.28 0.28 0.07 1.11 1.11 1.048 1.048
74355 TC 74355TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74360 74360 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74360 26 7436026 A 1 XXX 0 0 0 0 0 0 0 0.54 0.25 0.25 0.04 0.83 0.83 0.785 0.785
74360 TC 74360TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74363 74363 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74363 26 7436326 A 1 XXX 0 0 0 0 0 0 0 0.88 0.30 0.30 0.08 1.26 1.26 1.191 1.191
74363 TC 74363TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
315 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74400 74400 A 1 XXX 0 0 0 0 0 0 0 0.49 2.88 2.88 0.04 3.41 3.41 3.097 3.097
74400 26 7440026 A 1 XXX 0 0 0 0 0 0 0 0.49 0.18 0.18 0.03 0.70 0.70 0.667 0.667
74400 TC 74400TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.70 2.70 0.01 2.71 2.71 2.430 2.430
74410 74410 A 1 XXX 0 0 0 0 0 0 0 0.49 2.84 2.84 0.04 3.37 3.37 3.061 3.061
74410 26 7441026 A 1 XXX 0 0 0 0 0 0 0 0.49 0.17 0.17 0.03 0.69 0.69 0.658 0.658
74410 TC 74410TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.67 2.67 0.01 2.68 2.68 2.403 2.403
74415 74415 A 1 XXX 0 0 0 0 0 0 0 0.49 3.65 3.65 0.04 4.18 4.18 3.789 3.789
74415 26 7441526 A 1 XXX 0 0 0 0 0 0 0 0.49 0.18 0.18 0.03 0.70 0.70 0.667 0.667
74415 TC 74415TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.47 3.47 0.01 3.48 3.48 3.121 3.121
74420 74420 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74420 26 7442026 A 1 XXX 0 0 0 0 0 0 0 0.36 0.13 0.13 0.03 0.52 0.52 0.492 0.492
74420 TC 74420TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74425 74425 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74425 26 7442526 A 1 XXX 0 0 0 0 0 0 0 0.36 0.12 0.12 0.03 0.51 0.51 0.483 0.483
74425 TC 74425TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74430 74430 A 1 XXX 0 0 0 0 0 0 0 0.32 0.88 0.88 0.02 1.22 1.22 1.121 1.121
74430 26 7443026 A 1 XXX 0 0 0 0 0 0 0 0.32 0.11 0.11 0.01 0.44 0.44 0.424 0.424
74430 TC 74430TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.77 0.77 0.01 0.78 0.78 0.697 0.697
74440 74440 A 1 XXX 0 0 0 0 0 0 0 0.38 2.11 2.11 0.04 2.53 2.53 2.296 2.296
74440 26 7444026 A 1 XXX 0 0 0 0 0 0 0 0.38 0.14 0.14 0.03 0.55 0.55 0.521 0.521
74440 TC 74440TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.97 1.97 0.01 1.98 1.98 1.774 1.774
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
316 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74445 74445 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74445 26 7444526 A 1 XXX 0 0 0 0 0 0 0 1.14 0.40 0.40 0.10 1.64 1.64 1.552 1.552
74445 TC 74445TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74450 74450 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74450 26 7445026 A 1 XXX 0 0 0 0 0 0 0 0.33 0.12 0.12 0.03 0.48 0.48 0.453 0.453
74450 TC 74450TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74455 74455 A 1 XXX 0 0 0 0 0 0 0 0.33 2.20 2.20 0.02 2.55 2.55 2.316 2.316
74455 26 7445526 A 1 XXX 0 0 0 0 0 0 0 0.33 0.12 0.12 0.01 0.46 0.46 0.443 0.443
74455 TC 74455TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.08 2.08 0.01 2.09 2.09 1.873 1.873
74470 74470 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74470 26 7447026 A 1 XXX 0 0 0 0 0 0 0 0.54 0.19 0.19 0.04 0.77 0.77 0.732 0.732
74470 TC 74470TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74475 74475 A 1 XXX 0 0 0 0 0 0 0 0.54 2.34 2.34 0.04 2.92 2.92 2.662 2.662
74475 26 7447526 A 1 XXX 0 0 0 0 0 0 0 0.54 0.19 0.19 0.03 0.76 0.76 0.726 0.726
74475 TC 74475TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.15 2.15 0.01 2.16 2.16 1.936 1.936
74480 74480 A 1 XXX 0 0 0 0 0 0 0 0.54 2.34 2.34 0.04 2.92 2.92 2.662 2.662
74480 26 7448026 A 1 XXX 0 0 0 0 0 0 0 0.54 0.19 0.19 0.03 0.76 0.76 0.726 0.726
74480 TC 74480TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.15 2.15 0.01 2.16 2.16 1.936 1.936
74485 74485 A 1 XXX 0 0 0 0 0 0 0 0.54 2.35 2.35 0.04 2.93 2.93 2.671 2.671
74485 26 7448526 A 1 XXX 0 0 0 0 0 0 0 0.54 0.19 0.19 0.03 0.76 0.76 0.726 0.726
74485 TC 74485TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.16 2.16 0.01 2.17 2.17 1.945 1.945
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
317 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
74710 74710 A 1 XXX 0 0 0 0 0 0 0 0.34 0.63 0.63 0.02 0.99 0.99 0.916 0.916
74710 26 7471026 A 1 XXX 0 0 0 0 0 0 0 0.34 0.09 0.09 0.01 0.44 0.44 0.426 0.426
74710 TC 74710TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.54 0.54 0.01 0.55 0.55 0.490 0.490
74740 74740 A 1 XXX 0 0 0 0 0 0 0 0.38 1.93 1.93 0.02 2.33 2.33 2.124 2.124
74740 26 7474026 A 1 XXX 0 0 0 0 0 0 0 0.38 0.14 0.14 0.01 0.53 0.53 0.511 0.511
74740 TC 74740TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.79 1.79 0.01 1.80 1.80 1.613 1.613
74742 74742 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74742 26 7474226 A 1 XXX 0 0 0 0 0 0 0 0.61 0.23 0.23 0.05 0.89 0.89 0.843 0.843
74742 TC 74742TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74775 74775 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
74775 26 7477526 A 1 XXX 0 0 0 0 0 0 0 0.62 0.23 0.23 0.05 0.90 0.90 0.853 0.853
74775 TC 74775TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75557 75557 A 1 XXX 0 0 0 4 0 0 0 2.35 8.32 8.32 0.11 10.78 10.78 9.879 9.879
75557 26 7555726 A 1 XXX 0 0 0 4 0 0 0 2.35 0.86 0.86 0.10 3.31 3.31 3.175 3.175
75557 TC 75557TC A 1 XXX 0 0 0 4 0 0 0 0.00 7.46 7.46 0.01 7.47 7.47 6.704 6.704
75559 75559 A 1 XXX 0 0 0 4 0 0 0 2.95 11.68 11.68 0.13 14.76 14.76 13.507 13.507
75559 26 7555926 A 1 XXX 0 0 0 4 0 0 0 2.95 1.07 1.07 0.12 4.14 4.14 3.974 3.974
75559 TC 75559TC A 1 XXX 0 0 0 4 0 0 0 0.00 10.61 10.61 0.01 10.62 10.62 9.533 9.533
75561 75561 A 1 XXX 0 0 0 4 0 0 0 2.60 11.67 11.67 0.12 14.39 14.39 13.142 13.142
75561 26 7556126 A 1 XXX 0 0 0 4 0 0 0 2.60 0.94 0.94 0.11 3.65 3.65 3.502 3.502
75561 TC 75561TC A 1 XXX 0 0 0 4 0 0 0 0.00 10.73 10.73 0.01 10.74 10.74 9.641 9.641
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
318 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75563 75563 A 1 XXX 0 0 0 4 0 0 0 3.00 13.88 13.88 0.12 17.00 17.00 15.527 15.527
75563 26 7556326 A 1 XXX 0 0 0 4 0 0 0 3.00 1.09 1.09 0.11 4.20 4.20 4.036 4.036
75563 TC 75563TC A 1 XXX 0 0 0 4 0 0 0 0.00 12.79 12.79 0.01 12.80 12.80 11.491 11.491
75565 75565 A 1 ZZZ 0 0 0 0 0 0 0 0.25 1.61 1.61 0.02 1.88 1.88 1.706 1.706
75565 26 7556526 A 1 ZZZ 0 0 0 0 0 0 0 0.25 0.09 0.09 0.01 0.35 0.35 0.336 0.336
75565 TC 75565TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 1.52 1.52 0.01 1.53 1.53 1.370 1.370
75571 75571 A 1 XXX 0 0 0 4 0 0 0 0.58 2.76 2.76 0.02 3.36 3.36 3.069 3.069
75571 26 7557126 A 1 XXX 0 0 0 4 0 0 0 0.58 0.21 0.21 0.01 0.80 0.80 0.774 0.774
75571 TC 75571TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.55 2.55 0.01 2.56 2.56 2.295 2.295
75572 75572 A 1 XXX 0 0 0 4 0 0 0 1.75 7.41 7.41 0.06 9.22 9.22 8.436 8.436
75572 26 7557226 A 1 XXX 0 0 0 4 0 0 0 1.75 0.64 0.64 0.05 2.44 2.44 2.351 2.351
75572 TC 75572TC A 1 XXX 0 0 0 4 0 0 0 0.00 6.77 6.77 0.01 6.78 6.78 6.085 6.085
75573 75573 A 1 XXX 0 0 0 4 0 0 0 2.55 9.95 9.95 0.09 12.59 12.59 11.532 11.532
75573 26 7557326 A 1 XXX 0 0 0 4 0 0 0 2.55 0.92 0.92 0.08 3.55 3.55 3.418 3.418
75573 TC 75573TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.03 9.03 0.01 9.04 9.04 8.114 8.114
75574 75574 A 1 XXX 0 0 0 4 0 0 0 2.40 11.12 11.12 0.09 13.61 13.61 12.433 12.433
75574 26 7557426 A 1 XXX 0 0 0 4 0 0 0 2.40 0.87 0.87 0.08 3.35 3.35 3.223 3.223
75574 TC 75574TC A 1 XXX 0 0 0 4 0 0 0 0.00 10.25 10.25 0.01 10.26 10.26 9.210 9.210
75600 75600 A 1 XXX 0 0 0 6 0 0 0 0.49 5.85 5.85 0.04 6.38 6.38 5.764 5.764
75600 26 7560026 A 1 XXX 0 0 0 6 0 0 0 0.49 0.17 0.17 0.03 0.69 0.69 0.658 0.658
75600 TC 75600TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.68 5.68 0.01 5.69 5.69 5.106 5.106
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
319 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75605 75605 A 1 XXX 0 0 0 6 0 0 0 1.14 3.39 3.39 0.08 4.61 4.61 4.226 4.226
75605 26 7560526 A 1 XXX 0 0 0 6 0 0 0 1.14 0.39 0.39 0.07 1.60 1.60 1.527 1.527
75605 TC 75605TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.00 3.00 0.01 3.01 3.01 2.699 2.699
75625 75625 A 1 XXX 0 0 0 6 0 0 0 1.14 3.37 3.37 0.11 4.62 4.62 4.224 4.224
75625 26 7562526 A 1 XXX 0 0 0 6 0 0 0 1.14 0.36 0.36 0.10 1.60 1.60 1.516 1.516
75625 TC 75625TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.01 3.01 0.01 3.02 3.02 2.708 2.708
75630 75630 A 1 XXX 0 0 0 6 0 0 0 1.79 3.58 3.58 0.11 5.48 5.48 5.062 5.062
75630 26 7563026 A 1 XXX 0 0 0 6 0 0 0 1.79 0.60 0.60 0.10 2.49 2.49 2.381 2.381
75630 TC 75630TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.98 2.98 0.01 2.99 2.99 2.681 2.681
75635 75635 A 1 XXX 0 0 0 4 0 0 0 2.40 10.84 10.84 0.15 13.39 13.39 12.213 12.213
75635 26 7563526 A 1 XXX 0 0 0 4 0 0 0 2.40 0.86 0.86 0.12 3.38 3.38 3.235 3.235
75635 TC 75635TC A 1 XXX 0 0 0 4 0 0 0 0.00 9.98 9.98 0.03 10.01 10.01 8.978 8.978
75658 75658 A 1 XXX 0 0 0 6 0 0 0 1.31 4.06 4.06 0.09 5.46 5.46 5.003 5.003
75658 26 7565826 A 1 XXX 0 0 0 6 0 0 0 1.31 0.41 0.41 0.08 1.80 1.80 1.720 1.720
75658 TC 75658TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.65 3.65 0.01 3.66 3.66 3.283 3.283
75705 75705 A 1 XXX 0 0 0 6 0 0 0 2.18 5.08 5.08 0.08 7.34 7.34 6.784 6.784
75705 26 7570526 A 1 XXX 0 0 0 6 0 0 0 2.18 0.83 0.83 0.07 3.08 3.08 2.962 2.962
75705 TC 75705TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.25 4.25 0.01 4.26 4.26 3.822 3.822
75710 75710 A 1 XXX 0 0 0 6 0 0 0 1.14 4.16 4.16 0.06 5.36 5.36 4.907 4.907
75710 26 7571026 A 1 XXX 0 0 0 6 0 0 0 1.14 0.38 0.38 0.05 1.57 1.57 1.507 1.507
75710 TC 75710TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.78 3.78 0.01 3.79 3.79 3.400 3.400
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
320 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75716 75716 A 1 XXX 0 0 0 6 2 0 0 1.31 4.98 4.98 0.13 6.42 6.42 5.850 5.850
75716 26 7571626 A 1 XXX 0 0 0 6 2 0 0 1.31 0.43 0.43 0.10 1.84 1.84 1.748 1.748
75716 TC 75716TC A 1 XXX 0 0 0 6 2 0 0 0.00 4.55 4.55 0.03 4.58 4.58 4.102 4.102
75726 75726 A 1 XXX 0 0 0 6 0 0 0 1.14 4.15 4.15 0.09 5.38 5.38 4.914 4.914
75726 26 7572626 A 1 XXX 0 0 0 6 0 0 0 1.14 0.39 0.39 0.08 1.61 1.61 1.532 1.532
75726 TC 75726TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.76 3.76 0.01 3.77 3.77 3.382 3.382
75731 75731 A 1 XXX 0 0 0 6 0 0 0 1.14 3.79 3.79 0.05 4.98 4.98 4.570 4.570
75731 26 7573126 A 1 XXX 0 0 0 6 0 0 0 1.14 0.42 0.42 0.04 1.60 1.60 1.538 1.538
75731 TC 75731TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.37 3.37 0.01 3.38 3.38 3.031 3.031
75733 75733 A 1 XXX 0 0 0 6 2 0 0 1.31 4.81 4.81 0.07 6.19 6.19 5.666 5.666
75733 26 7573326 A 1 XXX 0 0 0 6 2 0 0 1.31 0.48 0.48 0.04 1.83 1.83 1.762 1.762
75733 TC 75733TC A 1 XXX 0 0 0 6 2 0 0 0.00 4.33 4.33 0.03 4.36 4.36 3.904 3.904
75736 75736 A 1 XXX 0 0 0 6 0 0 0 1.14 4.00 4.00 0.06 5.20 5.20 4.763 4.763
75736 26 7573626 A 1 XXX 0 0 0 6 0 0 0 1.14 0.37 0.37 0.05 1.56 1.56 1.498 1.498
75736 TC 75736TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.63 3.63 0.01 3.64 3.64 3.265 3.265
75741 75741 A 1 XXX 0 0 0 6 0 0 0 1.31 3.44 3.44 0.09 4.84 4.84 4.446 4.446
75741 26 7574126 A 1 XXX 0 0 0 6 0 0 0 1.31 0.45 0.45 0.08 1.84 1.84 1.756 1.756
75741 TC 75741TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.99 2.99 0.01 3.00 3.00 2.690 2.690
75743 75743 A 1 XXX 0 0 0 6 2 0 0 1.66 3.86 3.86 0.11 5.63 5.63 5.184 5.184
75743 26 7574326 A 1 XXX 0 0 0 6 2 0 0 1.66 0.56 0.56 0.10 2.32 2.32 2.215 2.215
75743 TC 75743TC A 1 XXX 0 0 0 6 2 0 0 0.00 3.30 3.30 0.01 3.31 3.31 2.969 2.969
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
321 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75746 75746 A 1 XXX 0 0 0 6 0 0 0 1.14 3.84 3.84 0.08 5.06 5.06 4.630 4.630
75746 26 7574626 A 1 XXX 0 0 0 6 0 0 0 1.14 0.41 0.41 0.07 1.62 1.62 1.545 1.545
75746 TC 75746TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.43 3.43 0.01 3.44 3.44 3.085 3.085
75756 75756 A 1 XXX 0 0 0 6 0 0 0 1.14 4.32 4.32 0.23 5.69 5.69 5.140 5.140
75756 26 7575626 A 1 XXX 0 0 0 6 0 0 0 1.14 0.37 0.37 0.22 1.73 1.73 1.587 1.587
75756 TC 75756TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.95 3.95 0.01 3.96 3.96 3.552 3.552
75774 75774 A 1 ZZZ 0 0 0 0 0 0 0 0.36 2.62 2.62 0.04 3.02 3.02 2.734 2.734
75774 26 7577426 A 1 ZZZ 0 0 0 0 0 0 0 0.36 0.12 0.12 0.03 0.51 0.51 0.483 0.483
75774 TC 75774TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 2.50 2.50 0.01 2.51 2.51 2.250 2.250
75791 75791 A 1 XXX 0 0 0 6 0 0 0 1.71 8.23 8.23 0.11 10.05 10.05 9.158 9.158
75791 26 7579126 A 1 XXX 0 0 0 6 0 0 0 1.71 0.56 0.56 0.10 2.37 2.37 2.265 2.265
75791 TC 75791TC A 1 XXX 0 0 0 6 0 0 0 0.00 7.67 7.67 0.01 7.68 7.68 6.893 6.893
75801 75801 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75801 26 7580126 A 1 XXX 0 0 0 0 0 0 0 0.81 0.32 0.32 0.18 1.31 1.31 1.192 1.192
75801 TC 75801TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75803 75803 C 1 XXX 0 0 0 0 2 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75803 26 7580326 A 1 XXX 0 0 0 0 2 0 0 1.17 0.43 0.43 0.10 1.70 1.70 1.608 1.608
75803 TC 75803TC C 1 XXX 0 0 0 0 2 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75805 75805 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75805 26 7580526 A 1 XXX 0 0 0 0 0 0 0 0.81 0.30 0.30 0.07 1.18 1.18 1.116 1.116
75805 TC 75805TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
322 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75807 75807 C 1 XXX 0 0 0 0 2 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75807 26 7580726 A 1 XXX 0 0 0 0 2 0 0 1.17 0.43 0.43 0.10 1.70 1.70 1.608 1.608
75807 TC 75807TC C 1 XXX 0 0 0 0 2 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75809 75809 A 1 XXX 0 0 0 6 0 0 0 0.47 2.61 2.61 0.04 3.12 3.12 2.835 2.835
75809 26 7580926 A 1 XXX 0 0 0 6 0 0 0 0.47 0.18 0.18 0.03 0.68 0.68 0.647 0.647
75809 TC 75809TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.43 2.43 0.01 2.44 2.44 2.187 2.187
75810 75810 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75810 26 7581026 A 1 XXX 0 0 0 0 0 0 0 1.14 0.41 0.41 0.10 1.65 1.65 1.560 1.560
75810 TC 75810TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75820 75820 A 1 XXX 0 0 0 6 0 0 0 0.70 3.03 3.03 0.05 3.78 3.78 3.447 3.447
75820 26 7582026 A 1 XXX 0 0 0 6 0 0 0 0.70 0.25 0.25 0.04 0.99 0.99 0.945 0.945
75820 TC 75820TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.78 2.78 0.01 2.79 2.79 2.502 2.502
75822 75822 A 1 XXX 0 0 0 6 2 0 0 1.06 3.56 3.56 0.08 4.70 4.70 4.299 4.299
75822 26 7582226 A 1 XXX 0 0 0 6 2 0 0 1.06 0.36 0.36 0.07 1.49 1.49 1.420 1.420
75822 TC 75822TC A 1 XXX 0 0 0 6 2 0 0 0.00 3.20 3.20 0.01 3.21 3.21 2.879 2.879
75825 75825 A 1 XXX 0 0 0 6 0 0 0 1.14 3.22 3.22 0.09 4.45 4.45 4.079 4.079
75825 26 7582526 A 1 XXX 0 0 0 6 0 0 0 1.14 0.37 0.37 0.08 1.59 1.59 1.514 1.514
75825 TC 75825TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.85 2.85 0.01 2.86 2.86 2.565 2.565
75827 75827 A 1 XXX 0 0 0 6 0 0 0 1.14 3.33 3.33 0.08 4.55 4.55 4.172 4.172
75827 26 7582726 A 1 XXX 0 0 0 6 0 0 0 1.14 0.37 0.37 0.07 1.58 1.58 1.509 1.509
75827 TC 75827TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.96 2.96 0.01 2.97 2.97 2.663 2.663
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
323 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75831 75831 A 1 XXX 0 0 0 6 0 0 0 1.14 3.40 3.40 0.25 4.79 4.79 4.324 4.324
75831 26 7583126 A 1 XXX 0 0 0 6 0 0 0 1.14 0.38 0.38 0.24 1.76 1.76 1.607 1.607
75831 TC 75831TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.02 3.02 0.01 3.03 3.03 2.717 2.717
75833 75833 A 1 XXX 0 0 0 6 2 0 0 1.49 3.98 3.98 0.09 5.56 5.56 5.111 5.111
75833 26 7583326 A 1 XXX 0 0 0 6 2 0 0 1.49 0.46 0.46 0.08 2.03 2.03 1.945 1.945
75833 TC 75833TC A 1 XXX 0 0 0 6 2 0 0 0.00 3.52 3.52 0.01 3.53 3.53 3.166 3.166
75840 75840 A 1 XXX 0 0 0 6 0 0 0 1.14 3.41 3.41 0.25 4.80 4.80 4.333 4.333
75840 26 7584026 A 1 XXX 0 0 0 6 0 0 0 1.14 0.42 0.42 0.24 1.80 1.80 1.643 1.643
75840 TC 75840TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.99 2.99 0.01 3.00 3.00 2.690 2.690
75842 75842 A 1 XXX 0 0 0 6 2 0 0 1.49 4.14 4.14 0.09 5.72 5.72 5.255 5.255
75842 26 7584226 A 1 XXX 0 0 0 6 2 0 0 1.49 0.55 0.55 0.08 2.12 2.12 2.026 2.026
75842 TC 75842TC A 1 XXX 0 0 0 6 2 0 0 0.00 3.59 3.59 0.01 3.60 3.60 3.229 3.229
75860 75860 A 1 XXX 0 0 0 6 0 0 0 1.14 3.39 3.39 0.09 4.62 4.62 4.231 4.231
75860 26 7586026 A 1 XXX 0 0 0 6 0 0 0 1.14 0.39 0.39 0.08 1.61 1.61 1.532 1.532
75860 TC 75860TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.00 3.00 0.01 3.01 3.01 2.699 2.699
75870 75870 A 1 XXX 0 0 0 6 0 0 0 1.14 3.39 3.39 0.08 4.61 4.61 4.226 4.226
75870 26 7587026 A 1 XXX 0 0 0 6 0 0 0 1.14 0.41 0.41 0.07 1.62 1.62 1.545 1.545
75870 TC 75870TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.98 2.98 0.01 2.99 2.99 2.681 2.681
75872 75872 A 1 XXX 0 0 0 6 0 0 0 1.14 3.39 3.39 0.08 4.61 4.61 4.226 4.226
75872 26 7587226 A 1 XXX 0 0 0 6 0 0 0 1.14 0.41 0.41 0.07 1.62 1.62 1.545 1.545
75872 TC 75872TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.98 2.98 0.01 2.99 2.99 2.681 2.681
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
324 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75880 75880 A 1 XXX 0 0 0 6 0 0 0 0.70 6.35 6.35 0.05 7.10 7.10 6.428 6.428
75880 26 7588026 A 1 XXX 0 0 0 6 0 0 0 0.70 0.34 0.34 0.04 1.08 1.08 1.026 1.026
75880 TC 75880TC A 1 XXX 0 0 0 6 0 0 0 0.00 6.01 6.01 0.01 6.02 6.02 5.402 5.402
75885 75885 A 1 XXX 0 0 0 6 0 0 0 1.44 3.52 3.52 0.09 5.05 5.05 4.648 4.648
75885 26 7588526 A 1 XXX 0 0 0 6 0 0 0 1.44 0.50 0.50 0.08 2.02 2.02 1.931 1.931
75885 TC 75885TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.02 3.02 0.01 3.03 3.03 2.717 2.717
75887 75887 A 1 XXX 0 0 0 6 0 0 0 1.44 3.50 3.50 0.06 5.00 5.00 4.614 4.614
75887 26 7588726 A 1 XXX 0 0 0 6 0 0 0 1.44 0.50 0.50 0.05 1.99 1.99 1.915 1.915
75887 TC 75887TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.00 3.00 0.01 3.01 3.01 2.699 2.699
75889 75889 A 1 XXX 0 0 0 6 0 0 0 1.14 3.43 3.43 0.08 4.65 4.65 4.262 4.262
75889 26 7588926 A 1 XXX 0 0 0 6 0 0 0 1.14 0.39 0.39 0.07 1.60 1.60 1.527 1.527
75889 TC 75889TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.04 3.04 0.01 3.05 3.05 2.735 2.735
75891 75891 A 1 XXX 0 0 0 6 0 0 0 1.14 3.43 3.43 0.08 4.65 4.65 4.262 4.262
75891 26 7589126 A 1 XXX 0 0 0 6 0 0 0 1.14 0.40 0.40 0.07 1.61 1.61 1.536 1.536
75891 TC 75891TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.03 3.03 0.01 3.04 3.04 2.726 2.726
75893 75893 A 1 XXX 0 0 0 6 0 0 0 0.54 3.22 3.22 0.02 3.78 3.78 3.442 3.442
75893 26 7589326 A 1 XXX 0 0 0 6 0 0 0 0.54 0.19 0.19 0.01 0.74 0.74 0.716 0.716
75893 TC 75893TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.03 3.03 0.01 3.04 3.04 2.726 2.726
75894 75894 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75894 26 7589426 A 1 XXX 0 0 0 0 0 0 0 1.31 0.45 0.45 0.16 1.92 1.92 1.798 1.798
75894 TC 75894TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
325 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75896 75896 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75896 26 7589626 A 1 XXX 0 0 0 0 0 0 0 1.31 0.44 0.44 0.16 1.91 1.91 1.789 1.789
75896 TC 75896TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75898 75898 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75898 26 7589826 A 1 XXX 0 0 0 0 0 0 0 1.65 0.59 0.59 0.20 2.44 2.44 2.284 2.284
75898 TC 75898TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75901 75901 A 1 XXX 0 0 0 0 0 0 0 0.49 4.72 4.72 0.04 5.25 5.25 4.749 4.749
75901 26 7590126 A 1 XXX 0 0 0 0 0 0 0 0.49 0.17 0.17 0.03 0.69 0.69 0.658 0.658
75901 TC 75901TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.55 4.55 0.01 4.56 4.56 4.091 4.091
75902 75902 A 1 XXX 0 0 0 0 0 0 0 0.39 1.83 1.83 0.05 2.27 2.27 2.059 2.059
75902 26 7590226 A 1 XXX 0 0 0 0 0 0 0 0.39 0.13 0.13 0.04 0.56 0.56 0.528 0.528
75902 TC 75902TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.70 1.70 0.01 1.71 1.71 1.532 1.532
75945 75945 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75945 26 7594526 A 1 XXX 0 0 0 0 0 0 0 0.40 0.12 0.12 0.05 0.57 0.57 0.534 0.534
75945 TC 75945TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75946 75946 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75946 26 7594626 A 1 ZZZ 0 0 0 0 0 0 0 0.40 0.11 0.11 0.07 0.58 0.58 0.535 0.535
75946 TC 75946TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75952 75952 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75952 26 7595226 A 1 XXX 0 0 0 0 0 0 0 4.49 1.32 1.32 0.86 6.67 6.67 6.125 6.125
75952 TC 75952TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
326 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75953 75953 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75953 26 7595326 A 1 XXX 0 0 0 0 0 0 0 1.36 0.40 0.40 0.27 2.03 2.03 1.860 1.860
75953 TC 75953TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75954 75954 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75954 26 7595426 A 1 XXX 0 0 0 0 0 0 0 2.25 0.67 0.67 0.41 3.33 3.33 3.066 3.066
75954 TC 75954TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75956 75956 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75956 26 7595626 A 1 XXX 0 0 0 0 0 0 0 7.00 2.04 2.04 1.44 10.48 10.48 9.585 9.585
75956 TC 75956TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75957 75957 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75957 26 7595726 A 1 XXX 0 0 0 0 0 0 0 6.00 1.73 1.73 1.21 8.94 8.94 8.186 8.186
75957 TC 75957TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75958 75958 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75958 26 7595826 A 1 XXX 0 0 0 0 0 0 0 4.00 1.14 1.14 0.82 5.96 5.96 5.453 5.453
75958 TC 75958TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75959 75959 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75959 26 7595926 A 1 XXX 0 0 0 0 0 0 0 3.50 0.85 0.85 0.83 5.18 5.18 4.697 4.697
75959 TC 75959TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75960 75960 A 1 XXX 0 0 0 0 0 0 0 0.82 2.85 2.85 0.06 3.73 3.73 3.411 3.411
75960 26 7596026 A 1 XXX 0 0 0 0 0 0 0 0.82 0.27 0.27 0.05 1.14 1.14 1.089 1.089
75960 TC 75960TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.58 2.58 0.01 2.59 2.59 2.322 2.322
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
327 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75962 75962 A 1 XXX 0 0 0 0 0 0 0 0.54 3.92 3.92 0.04 4.50 4.50 4.081 4.081
75962 26 7596226 A 1 XXX 0 0 0 0 0 0 0 0.54 0.18 0.18 0.03 0.75 0.75 0.717 0.717
75962 TC 75962TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.74 3.74 0.01 3.75 3.75 3.364 3.364
75964 75964 A 1 ZZZ 0 0 0 0 0 0 0 0.36 2.50 2.50 0.05 2.91 2.91 2.631 2.631
75964 26 7596426 A 1 ZZZ 0 0 0 0 0 0 0 0.36 0.12 0.12 0.04 0.52 0.52 0.489 0.489
75964 TC 75964TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 2.38 2.38 0.01 2.39 2.39 2.142 2.142
75966 75966 A 1 XXX 0 0 0 0 0 0 0 1.31 3.89 3.89 0.08 5.28 5.28 4.845 4.845
75966 26 7596626 A 1 XXX 0 0 0 0 0 0 0 1.31 0.43 0.43 0.07 1.81 1.81 1.733 1.733
75966 TC 75966TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.46 3.46 0.01 3.47 3.47 3.112 3.112
75968 75968 A 1 ZZZ 0 0 0 0 0 0 0 0.36 2.26 2.26 0.02 2.64 2.64 2.400 2.400
75968 26 7596826 A 1 ZZZ 0 0 0 0 0 0 0 0.36 0.12 0.12 0.01 0.49 0.49 0.473 0.473
75968 TC 75968TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 2.14 2.14 0.01 2.15 2.15 1.927 1.927
75970 75970 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75970 26 7597026 A 1 XXX 0 0 0 0 0 0 0 0.83 0.28 0.28 0.07 1.18 1.18 1.118 1.118
75970 TC 75970TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75978 75978 A 1 XXX 0 0 0 0 0 0 0 0.54 3.88 3.88 0.04 4.46 4.46 4.045 4.045
75978 26 7597826 A 1 XXX 0 0 0 0 0 0 0 0.54 0.18 0.18 0.03 0.75 0.75 0.717 0.717
75978 TC 75978TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.70 3.70 0.01 3.71 3.71 3.328 3.328
75980 75980 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75980 26 7598026 A 1 XXX 0 0 0 0 0 0 0 1.44 0.50 0.50 0.12 2.06 2.06 1.952 1.952
75980 TC 75980TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
328 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
75982 75982 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75982 26 7598226 A 1 XXX 0 0 0 0 0 0 0 1.44 0.50 0.50 0.12 2.06 2.06 1.952 1.952
75982 TC 75982TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
75984 75984 A 1 XXX 0 0 0 0 0 0 0 0.72 2.57 2.57 0.05 3.34 3.34 3.054 3.054
75984 26 7598426 A 1 XXX 0 0 0 0 0 0 0 0.72 0.25 0.25 0.04 1.01 1.01 0.965 0.965
75984 TC 75984TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.32 2.32 0.01 2.33 2.33 2.089 2.089
75989 75989 A 1 XXX 0 0 0 0 0 0 0 1.19 2.47 2.47 0.06 3.72 3.72 3.439 3.439
75989 26 7598926 A 1 XXX 0 0 0 0 0 0 0 1.19 0.42 0.42 0.05 1.66 1.66 1.593 1.593
75989 TC 75989TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.05 2.05 0.01 2.06 2.06 1.846 1.846
76000 76000 A 1 XXX 0 0 0 0 0 0 0 0.17 1.37 1.37 0.02 1.56 1.56 1.411 1.411
76000 26 7600026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
76000 TC 76000TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.30 1.30 0.01 1.31 1.31 1.173 1.173
76001 76001 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76001 26 7600126 A 1 XXX 0 0 0 0 0 0 0 0.67 0.28 0.28 0.08 1.03 1.03 0.963 0.963
76001 TC 76001TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76010 76010 A 1 XXX 0 0 0 0 0 0 0 0.18 0.61 0.61 0.02 0.81 0.81 0.738 0.738
76010 26 7601026 A 1 XXX 0 0 0 0 0 0 0 0.18 0.07 0.07 0.01 0.26 0.26 0.248 0.248
76010 TC 76010TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.54 0.54 0.01 0.55 0.55 0.490 0.490
76080 76080 A 1 XXX 0 0 0 0 0 0 0 0.54 1.23 1.23 0.04 1.81 1.81 1.665 1.665
76080 26 7608026 A 1 XXX 0 0 0 0 0 0 0 0.54 0.19 0.19 0.03 0.76 0.76 0.726 0.726
76080 TC 76080TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.04 1.04 0.01 1.05 1.05 0.939 0.939
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
329 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76098 76098 A 1 XXX 0 0 0 0 0 0 0 0.16 0.38 0.38 0.02 0.56 0.56 0.512 0.512
76098 26 7609826 A 1 XXX 0 0 0 0 0 0 0 0.16 0.06 0.06 0.01 0.23 0.23 0.219 0.219
76098 TC 76098TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.32 0.32 0.01 0.33 0.33 0.293 0.293
76100 76100 A 1 XXX 0 0 0 0 0 0 0 0.58 2.41 2.41 0.06 3.05 3.05 2.776 2.776
76100 26 7610026 A 1 XXX 0 0 0 0 0 0 0 0.58 0.28 0.28 0.05 0.91 0.91 0.858 0.858
76100 TC 76100TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.13 2.13 0.01 2.14 2.14 1.918 1.918
76101 76101 A 1 XXX 0 0 0 0 0 0 0 0.58 3.93 3.93 0.09 4.60 4.60 4.156 4.156
76101 26 7610126 A 1 XXX 0 0 0 0 0 0 0 0.58 0.37 0.37 0.08 1.03 1.03 0.954 0.954
76101 TC 76101TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.56 3.56 0.01 3.57 3.57 3.202 3.202
76102 76102 A 1 XXX 0 0 0 0 2 0 0 0.58 5.46 5.46 0.11 6.15 6.15 5.541 5.541
76102 26 7610226 A 1 XXX 0 0 0 0 2 0 0 0.58 0.37 0.37 0.10 1.05 1.05 0.965 0.965
76102 TC 76102TC A 1 XXX 0 0 0 0 2 0 0 0.00 5.09 5.09 0.01 5.10 5.10 4.576 4.576
76120 76120 A 1 XXX 0 0 0 0 0 0 0 0.38 1.85 1.85 0.04 2.27 2.27 2.062 2.062
76120 26 7612026 A 1 XXX 0 0 0 0 0 0 0 0.38 0.14 0.14 0.03 0.55 0.55 0.521 0.521
76120 TC 76120TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.71 1.71 0.01 1.72 1.72 1.541 1.541
76125 76125 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76125 26 7612526 A 1 ZZZ 0 0 0 0 0 0 0 0.27 0.11 0.11 0.03 0.41 0.41 0.384 0.384
76125 TC 76125TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76140 76140 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76376 76376 A 1 XXX 0 0 0 0 0 0 0 0.20 1.55 1.55 0.02 1.77 1.77 1.602 1.602
76376 26 7637626 A 1 XXX 0 0 0 0 0 0 0 0.20 0.07 0.07 0.01 0.28 0.28 0.268 0.268
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
330 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76376 TC 76376TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.48 1.48 0.01 1.49 1.49 1.334 1.334
76377 76377 A 1 XXX 0 0 0 0 0 0 0 0.79 1.59 1.59 0.05 2.43 2.43 2.244 2.244
76377 26 7637726 A 1 XXX 0 0 0 0 0 0 0 0.79 0.29 0.29 0.04 1.12 1.12 1.071 1.071
76377 TC 76377TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.30 1.30 0.01 1.31 1.31 1.173 1.173
76380 76380 A 1 XXX 0 0 0 0 0 0 0 0.98 3.90 3.90 0.05 4.93 4.93 4.508 4.508
76380 26 7638026 A 1 XXX 0 0 0 0 0 0 0 0.98 0.36 0.36 0.04 1.38 1.38 1.324 1.324
76380 TC 76380TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.54 3.54 0.01 3.55 3.55 3.184 3.184
76390 76390 N 1 XXX 0 0 0 9 9 9 9 1.40 12.22 12.22 0.06 13.68 13.68 12.405 12.405
76390 26 7639026 N 1 XXX 0 0 0 9 9 9 9 1.40 0.57 0.57 0.05 2.02 2.02 1.938 1.938
76390 TC 76390TC N 1 XXX 0 0 0 9 9 9 9 0.00 11.65 11.65 0.01 11.66 11.66 10.467 10.467
76496 76496 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76496 26 7649626 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76496 TC 76496TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76497 76497 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76497 26 7649726 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76497 TC 76497TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76498 76498 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76498 26 7649826 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76498 TC 76498TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76499 76499 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76499 26 7649926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
331 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76499 TC 76499TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76506 76506 A 1 XXX 0 0 0 0 0 0 0 0.63 3.09 3.09 0.05 3.77 3.77 3.431 3.431
76506 26 7650626 A 1 XXX 0 0 0 0 0 0 0 0.63 0.24 0.24 0.04 0.91 0.91 0.866 0.866
76506 TC 76506TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.85 2.85 0.01 2.86 2.86 2.565 2.565
76510 76510 A 1 XXX 0 0 0 7 3 0 0 1.55 3.54 3.54 0.27 5.36 5.36 4.870 4.870
76510 26 7651026 A 1 XXX 0 0 0 7 3 0 0 1.55 1.02 1.02 0.26 2.83 2.83 2.602 2.602
76510 TC 76510TC A 1 XXX 0 0 0 7 3 0 0 0.00 2.52 2.52 0.01 2.53 2.53 2.268 2.268
76511 76511 A 1 XXX 0 0 0 7 3 0 0 0.94 2.08 2.08 0.02 3.04 3.04 2.818 2.818
76511 26 7651126 A 1 XXX 0 0 0 7 3 0 0 0.94 0.59 0.59 0.01 1.54 1.54 1.475 1.475
76511 TC 76511TC A 1 XXX 0 0 0 7 3 0 0 0.00 1.49 1.49 0.01 1.50 1.50 1.343 1.343
76512 76512 A 1 XXX 0 0 0 7 3 0 0 0.94 1.83 1.83 0.05 2.82 2.82 2.609 2.609
76512 26 7651226 A 1 XXX 0 0 0 7 3 0 0 0.94 0.60 0.60 0.04 1.58 1.58 1.500 1.500
76512 TC 76512TC A 1 XXX 0 0 0 7 3 0 0 0.00 1.23 1.23 0.01 1.24 1.24 1.110 1.110
76513 76513 A 1 XXX 0 0 0 7 3 0 0 0.66 2.25 2.25 0.02 2.93 2.93 2.691 2.691
76513 26 7651326 A 1 XXX 0 0 0 7 3 0 0 0.66 0.38 0.38 0.01 1.05 1.05 1.006 1.006
76513 TC 76513TC A 1 XXX 0 0 0 7 3 0 0 0.00 1.87 1.87 0.01 1.88 1.88 1.684 1.684
76514 76514 A 1 XXX 0 0 0 7 2 0 0 0.17 0.26 0.26 0.02 0.45 0.45 0.414 0.414
76514 26 7651426 A 1 XXX 0 0 0 7 2 0 0 0.17 0.10 0.10 0.01 0.28 0.28 0.265 0.265
76514 TC 76514TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.16 0.16 0.01 0.17 0.17 0.149 0.149
76516 76516 A 1 XXX 0 0 0 7 2 0 0 0.54 1.82 1.82 0.02 2.38 2.38 2.185 2.185
76516 26 7651626 A 1 XXX 0 0 0 7 2 0 0 0.54 0.35 0.35 0.01 0.90 0.90 0.860 0.860
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
332 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76516 TC 76516TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.47 1.47 0.01 1.48 1.48 1.325 1.325
76519 76519 A 1 XXX 0 0 0 7 2 0 0 0.54 2.00 2.00 0.04 2.58 2.58 2.357 2.357
76519 26 7651926 A 1 XXX 0 0 0 7 3 0 0 0.54 0.36 0.36 0.03 0.93 0.93 0.879 0.879
76519 TC 76519TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.64 1.64 0.01 1.65 1.65 1.478 1.478
76529 76529 A 1 XXX 0 0 0 0 3 0 0 0.57 1.81 1.81 0.04 2.42 2.42 2.216 2.216
76529 26 7652926 A 1 XXX 0 0 0 0 3 0 0 0.57 0.37 0.37 0.03 0.97 0.97 0.918 0.918
76529 TC 76529TC A 1 XXX 0 0 0 0 3 0 0 0.00 1.44 1.44 0.01 1.45 1.45 1.298 1.298
76536 76536 A 1 XXX 0 0 0 0 0 0 0 0.56 3.07 3.07 0.04 3.67 3.67 3.338 3.338
76536 26 7653626 A 1 XXX 0 0 0 0 0 0 0 0.56 0.21 0.21 0.03 0.80 0.80 0.764 0.764
76536 TC 76536TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.86 2.86 0.01 2.87 2.87 2.574 2.574
76604 76604 A 1 XXX 0 0 0 4 0 0 0 0.55 2.05 2.05 0.04 2.64 2.64 2.412 2.412
76604 26 7660426 A 1 XXX 0 0 0 4 0 0 0 0.55 0.20 0.20 0.03 0.78 0.78 0.745 0.745
76604 TC 76604TC A 1 XXX 0 0 0 4 0 0 0 0.00 1.85 1.85 0.01 1.86 1.86 1.667 1.667
76645 76645 A 1 XXX 0 0 0 0 2 0 0 0.54 2.36 2.36 0.05 2.95 2.95 2.685 2.685
76645 26 7664526 A 1 XXX 0 0 0 0 2 0 0 0.54 0.20 0.20 0.04 0.78 0.78 0.741 0.741
76645 TC 76645TC A 1 XXX 0 0 0 0 2 0 0 0.00 2.16 2.16 0.01 2.17 2.17 1.945 1.945
76700 76700 A 1 XXX 0 0 0 4 0 0 0 0.81 3.35 3.35 0.05 4.21 4.21 3.844 3.844
76700 26 7670026 A 1 XXX 0 0 0 4 0 0 0 0.81 0.30 0.30 0.04 1.15 1.15 1.100 1.100
76700 TC 76700TC A 1 XXX 0 0 0 4 0 0 0 0.00 3.05 3.05 0.01 3.06 3.06 2.744 2.744
76705 76705 A 1 XXX 0 0 0 4 0 0 0 0.59 2.61 2.61 0.04 3.24 3.24 2.955 2.955
76705 26 7670526 A 1 XXX 0 0 0 4 0 0 0 0.59 0.21 0.21 0.03 0.83 0.83 0.794 0.794
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
333 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76705 TC 76705TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.40 2.40 0.01 2.41 2.41 2.160 2.160
76770 76770 A 1 XXX 0 0 0 4 0 0 0 0.74 3.18 3.18 0.05 3.97 3.97 3.622 3.622
76770 26 7677026 A 1 XXX 0 0 0 4 0 0 0 0.74 0.27 0.27 0.04 1.05 1.05 1.003 1.003
76770 TC 76770TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.91 2.91 0.01 2.92 2.92 2.618 2.618
76775 76775 A 1 XXX 0 0 0 4 0 0 0 0.58 2.64 2.64 0.04 3.26 3.26 2.972 2.972
76775 26 7677526 A 1 XXX 0 0 0 4 0 0 0 0.58 0.21 0.21 0.03 0.82 0.82 0.784 0.784
76775 TC 76775TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.43 2.43 0.01 2.44 2.44 2.187 2.187
76776 76776 A 1 XXX 0 0 0 4 0 0 0 0.76 3.79 3.79 0.05 4.60 4.60 4.190 4.190
76776 26 7677626 A 1 XXX 0 0 0 4 0 0 0 0.76 0.27 0.27 0.04 1.07 1.07 1.023 1.023
76776 TC 76776TC A 1 XXX 0 0 0 4 0 0 0 0.00 3.52 3.52 0.01 3.53 3.53 3.166 3.166
76800 76800 A 1 XXX 0 0 0 0 0 0 0 1.13 2.74 2.74 0.05 3.92 3.92 3.617 3.617
76800 26 7680026 A 1 XXX 0 0 0 0 0 0 0 1.13 0.43 0.43 0.04 1.60 1.60 1.537 1.537
76800 TC 76800TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.31 2.31 0.01 2.32 2.32 2.080 2.080
76801 76801 A 1 XXX 0 0 0 0 0 0 0 0.99 2.76 2.76 0.04 3.79 3.79 3.489 3.489
76801 26 7680126 A 1 XXX 0 0 0 0 0 0 0 0.99 0.39 0.39 0.03 1.41 1.41 1.356 1.356
76801 TC 76801TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.37 2.37 0.01 2.38 2.38 2.133 2.133
76802 76802 A 1 ZZZ 0 0 0 0 0 0 0 0.83 1.10 1.10 0.04 1.97 1.97 1.839 1.839
76802 26 7680226 A 1 ZZZ 0 0 0 0 0 0 0 0.83 0.33 0.33 0.03 1.19 1.19 1.142 1.142
76802 TC 76802TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.77 0.77 0.01 0.78 0.78 0.697 0.697
76805 76805 A 1 XXX 0 0 0 0 0 0 0 0.99 3.40 3.40 0.04 4.43 4.43 4.064 4.064
76805 26 7680526 A 1 XXX 0 0 0 0 0 0 0 0.99 0.40 0.40 0.03 1.42 1.42 1.365 1.365
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
334 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76805 TC 76805TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.00 3.00 0.01 3.01 3.01 2.699 2.699
76810 76810 A 1 ZZZ 0 0 0 0 0 0 0 0.98 1.87 1.87 0.04 2.89 2.89 2.680 2.680
76810 26 7681026 A 1 ZZZ 0 0 0 0 0 0 0 0.98 0.39 0.39 0.03 1.40 1.40 1.346 1.346
76810 TC 76810TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 1.48 1.48 0.01 1.49 1.49 1.334 1.334
76811 76811 A 1 XXX 0 0 0 0 0 0 0 1.90 3.61 3.61 0.06 5.57 5.57 5.173 5.173
76811 26 7681126 A 1 XXX 0 0 0 0 0 0 0 1.90 0.80 0.80 0.05 2.75 2.75 2.645 2.645
76811 TC 76811TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.81 2.81 0.01 2.82 2.82 2.529 2.529
76812 76812 A 1 ZZZ 0 0 0 0 0 0 0 1.78 4.52 4.52 0.06 6.36 6.36 5.870 5.870
76812 26 7681226 A 1 ZZZ 0 0 0 0 0 0 0 1.78 0.76 0.76 0.05 2.59 2.59 2.489 2.489
76812 TC 76812TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 3.76 3.76 0.01 3.77 3.77 3.382 3.382
76813 76813 A 1 XXX 0 0 0 0 0 0 0 1.18 2.42 2.42 0.05 3.65 3.65 3.379 3.379
76813 26 7681326 A 1 XXX 0 0 0 0 0 0 0 1.18 0.49 0.49 0.04 1.71 1.71 1.641 1.641
76813 TC 76813TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.93 1.93 0.01 1.94 1.94 1.738 1.738
76814 76814 A 1 XXX 0 0 0 0 0 0 0 0.99 1.34 1.34 0.04 2.37 2.37 2.214 2.214
76814 26 7681426 A 1 XXX 0 0 0 0 0 0 0 0.99 0.42 0.42 0.03 1.44 1.44 1.383 1.383
76814 TC 76814TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.92 0.92 0.01 0.93 0.93 0.831 0.831
76815 76815 A 1 XXX 0 0 0 0 0 0 0 0.65 2.03 2.03 0.02 2.70 2.70 2.483 2.483
76815 26 7681526 A 1 XXX 0 0 0 0 0 0 0 0.65 0.25 0.25 0.01 0.91 0.91 0.880 0.880
76815 TC 76815TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.78 1.78 0.01 1.79 1.79 1.604 1.604
76816 76816 A 1 XXX 0 0 0 0 0 0 0 0.85 2.66 2.66 0.04 3.55 3.55 3.260 3.260
76816 26 7681626 A 1 XXX 0 0 0 0 0 0 0 0.85 0.35 0.35 0.03 1.23 1.23 1.180 1.180
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
335 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76816 TC 76816TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.31 2.31 0.01 2.32 2.32 2.080 2.080
76817 76817 A 1 XXX 0 0 0 0 0 0 0 0.75 2.27 2.27 0.04 3.06 3.06 2.809 2.809
76817 26 7681726 A 1 XXX 0 0 0 0 0 0 0 0.75 0.30 0.30 0.03 1.08 1.08 1.035 1.035
76817 TC 76817TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.97 1.97 0.01 1.98 1.98 1.774 1.774
76818 76818 A 1 XXX 0 0 0 0 0 0 0 1.05 2.61 2.61 0.04 3.70 3.70 3.415 3.415
76818 26 7681826 A 1 XXX 0 0 0 0 0 0 0 1.05 0.44 0.44 0.03 1.52 1.52 1.461 1.461
76818 TC 76818TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.17 2.17 0.01 2.18 2.18 1.954 1.954
76819 76819 A 1 XXX 0 0 0 0 0 0 0 0.77 1.88 1.88 0.04 2.69 2.69 2.479 2.479
76819 26 7681926 A 1 XXX 0 0 0 0 0 0 0 0.77 0.31 0.31 0.03 1.11 1.11 1.064 1.064
76819 TC 76819TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.57 1.57 0.01 1.58 1.58 1.415 1.415
76820 76820 A 1 XXX 0 0 0 0 0 0 0 0.50 0.68 0.68 0.02 1.20 1.20 1.121 1.121
76820 26 7682026 A 1 XXX 0 0 0 0 0 0 0 0.50 0.21 0.21 0.01 0.72 0.72 0.694 0.694
76820 TC 76820TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.47 0.47 0.01 0.48 0.48 0.427 0.427
76821 76821 A 1 XXX 0 0 0 0 0 0 0 0.70 2.11 2.11 0.04 2.85 2.85 2.616 2.616
76821 26 7682126 A 1 XXX 0 0 0 0 0 0 0 0.70 0.29 0.29 0.03 1.02 1.02 0.976 0.976
76821 TC 76821TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.82 1.82 0.01 1.83 1.83 1.640 1.640
76825 76825 A 1 XXX 0 0 0 0 0 0 0 1.67 4.80 4.80 0.05 6.52 6.52 6.007 6.007
76825 26 7682526 A 1 XXX 0 0 0 0 0 0 0 1.67 0.67 0.67 0.04 2.38 2.38 2.293 2.293
76825 TC 76825TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.13 4.13 0.01 4.14 4.14 3.714 3.714
76826 76826 A 1 XXX 0 0 0 0 0 0 0 0.83 3.06 3.06 0.04 3.93 3.93 3.599 3.599
76826 26 7682626 A 1 XXX 0 0 0 0 0 0 0 0.83 0.33 0.33 0.03 1.19 1.19 1.142 1.142
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
336 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76826 TC 76826TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.73 2.73 0.01 2.74 2.74 2.457 2.457
76827 76827 A 1 XXX 0 0 0 0 0 0 0 0.58 1.18 1.18 0.02 1.78 1.78 1.650 1.650
76827 26 7682726 A 1 XXX 0 0 0 0 0 0 0 0.58 0.23 0.23 0.01 0.82 0.82 0.792 0.792
76827 TC 76827TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.95 0.95 0.01 0.96 0.96 0.858 0.858
76828 76828 A 1 XXX 0 0 0 0 0 0 0 0.56 0.74 0.74 0.02 1.32 1.32 1.235 1.235
76828 26 7682826 A 1 XXX 0 0 0 0 0 0 0 0.56 0.23 0.23 0.01 0.80 0.80 0.772 0.772
76828 TC 76828TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.51 0.51 0.01 0.52 0.52 0.463 0.463
76830 76830 A 1 XXX 0 0 0 0 0 0 0 0.69 1.51 1.51 0.04 2.24 2.24 2.067 2.067
76830 26 7683026 A 1 XXX 0 0 0 0 0 0 0 0.69 0.27 0.27 0.03 0.99 0.99 0.948 0.948
76830 TC 76830TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.24 1.24 0.01 1.25 1.25 1.119 1.119
76831 76831 A 1 XXX 0 0 0 4 0 0 0 0.72 3.03 3.03 0.04 3.79 3.79 3.462 3.462
76831 26 7683126 A 1 XXX 0 0 0 4 0 0 0 0.72 0.30 0.30 0.03 1.05 1.05 1.005 1.005
76831 TC 76831TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.73 2.73 0.01 2.74 2.74 2.457 2.457
76856 76856 A 1 XXX 0 0 0 4 0 0 0 0.69 3.00 3.00 0.04 3.73 3.73 3.405 3.405
76856 26 7685626 A 1 XXX 0 0 0 4 0 0 0 0.69 0.25 0.25 0.03 0.97 0.97 0.930 0.930
76856 TC 76856TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.75 2.75 0.01 2.76 2.76 2.475 2.475
76857 76857 A 1 XXX 0 0 0 4 0 0 0 0.38 2.44 2.44 0.04 2.86 2.86 2.592 2.592
76857 26 7685726 A 1 XXX 0 0 0 4 0 0 0 0.38 0.14 0.14 0.03 0.55 0.55 0.521 0.521
76857 TC 76857TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.30 2.30 0.01 2.31 2.31 2.071 2.071
76870 76870 A 1 XXX 0 0 0 4 0 0 0 0.64 3.04 3.04 0.05 3.73 3.73 3.396 3.396
76870 26 7687026 A 1 XXX 0 0 0 4 0 0 0 0.64 0.23 0.23 0.04 0.91 0.91 0.867 0.867
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
337 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76870 TC 76870TC A 1 XXX 0 0 0 4 0 0 0 0.00 2.81 2.81 0.01 2.82 2.82 2.529 2.529
76872 76872 A 1 XXX 0 0 0 0 0 0 0 0.69 1.42 1.42 0.05 2.16 2.16 1.991 1.991
76872 26 7687226 A 1 XXX 0 0 0 0 0 0 0 0.69 0.24 0.24 0.04 0.97 0.97 0.926 0.926
76872 TC 76872TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.18 1.18 0.01 1.19 1.19 1.065 1.065
76873 76873 A 1 XXX 0 0 0 9 9 9 9 1.55 3.45 3.45 0.09 5.09 5.09 4.695 4.695
76873 26 7687326 A 1 XXX 0 0 0 9 9 9 9 1.55 0.60 0.60 0.08 2.23 2.23 2.131 2.131
76873 TC 76873TC A 1 XXX 0 0 0 9 9 9 9 0.00 2.85 2.85 0.01 2.86 2.86 2.565 2.565
76881 76881 A 1 XXX 0 0 0 0 0 9 0 0.63 2.98 2.98 0.05 3.66 3.66 3.332 3.332
76881 26 7688126 A 1 XXX 0 0 0 0 0 9 0 0.63 0.24 0.24 0.04 0.91 0.91 0.866 0.866
76881 TC 76881TC A 1 XXX 0 0 0 0 0 9 0 0.00 2.74 2.74 0.01 2.75 2.75 2.466 2.466
76882 76882 A 1 XXX 0 0 0 0 0 9 0 0.49 0.50 0.50 0.05 1.04 1.04 0.965 0.965
76882 26 7688226 A 1 XXX 0 0 0 0 0 9 0 0.49 0.17 0.17 0.04 0.70 0.70 0.664 0.664
76882 TC 76882TC A 1 XXX 0 0 0 0 0 9 0 0.00 0.33 0.33 0.01 0.34 0.34 0.302 0.302
76885 76885 A 1 XXX 0 0 0 0 0 0 0 0.74 3.68 3.68 0.05 4.47 4.47 4.071 4.071
76885 26 7688526 A 1 XXX 0 0 0 0 0 0 0 0.74 0.27 0.27 0.04 1.05 1.05 1.003 1.003
76885 TC 76885TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.41 3.41 0.01 3.42 3.42 3.067 3.067
76886 76886 A 1 XXX 0 0 0 0 0 0 0 0.62 2.52 2.52 0.02 3.16 3.16 2.893 2.893
76886 26 7688626 A 1 XXX 0 0 0 0 0 0 0 0.62 0.23 0.23 0.01 0.86 0.86 0.832 0.832
76886 TC 76886TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.29 2.29 0.01 2.30 2.30 2.062 2.062
76930 76930 A 1 XXX 0 0 0 0 0 0 0 0.67 1.83 1.83 0.02 2.52 2.52 2.324 2.324
76930 26 7693026 A 1 XXX 0 0 0 0 0 0 0 0.67 0.24 0.24 0.01 0.92 0.92 0.891 0.891
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
338 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76930 TC 76930TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.59 1.59 0.01 1.60 1.60 1.433 1.433
76932 76932 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76932 26 7693226 A 1 XXX 0 0 0 0 0 0 0 0.67 0.24 0.24 0.04 0.95 0.95 0.906 0.906
76932 TC 76932TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76936 76936 A 1 XXX 0 0 0 0 0 0 0 1.99 6.20 6.20 0.24 8.43 8.43 7.683 7.683
76936 26 7693626 A 1 XXX 0 0 0 0 0 0 0 1.99 0.62 0.62 0.23 2.84 2.84 2.667 2.667
76936 TC 76936TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.58 5.58 0.01 5.59 5.59 5.016 5.016
76937 76937 A 1 ZZZ 0 0 0 0 0 0 0 0.30 0.73 0.73 0.04 1.07 1.07 0.976 0.976
76937 26 7693726 A 1 ZZZ 0 0 0 0 0 0 0 0.30 0.10 0.10 0.03 0.43 0.43 0.405 0.405
76937 TC 76937TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.63 0.63 0.01 0.64 0.64 0.571 0.571
76940 76940 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76940 26 7694026 A 1 XXX 0 0 0 0 0 0 0 2.00 0.73 0.73 0.29 3.02 3.02 2.807 2.807
76940 TC 76940TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76941 76941 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76941 26 7694126 A 1 XXX 0 0 0 0 0 0 0 1.34 0.57 0.57 0.11 2.02 2.02 1.909 1.909
76941 TC 76941TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76942 76942 A 1 XXX 0 0 0 0 0 0 0 0.67 5.41 5.41 0.05 6.13 6.13 5.554 5.554
76942 26 7694226 A 1 XXX 0 0 0 0 0 0 0 0.67 0.25 0.25 0.04 0.96 0.96 0.915 0.915
76942 TC 76942TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.16 5.16 0.01 5.17 5.17 4.639 4.639
76945 76945 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76945 26 7694526 A 1 XXX 0 0 0 0 0 0 0 0.67 0.29 0.29 0.04 1.00 1.00 0.951 0.951
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
339 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76945 TC 76945TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76946 76946 A 1 XXX 0 0 0 0 0 0 0 0.38 0.56 0.56 0.02 0.96 0.96 0.893 0.893
76946 26 7694626 A 1 XXX 0 0 0 0 0 0 0 0.38 0.16 0.16 0.01 0.55 0.55 0.529 0.529
76946 TC 76946TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.40 0.40 0.01 0.41 0.41 0.364 0.364
76948 76948 A 1 XXX 0 0 0 0 0 0 0 0.38 0.57 0.57 0.04 0.99 0.99 0.913 0.913
76948 26 7694826 A 1 XXX 0 0 0 0 0 0 0 0.38 0.16 0.16 0.03 0.57 0.57 0.539 0.539
76948 TC 76948TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.41 0.41 0.01 0.42 0.42 0.373 0.373
76950 76950 A 1 XXX 0 0 0 0 0 0 0 0.58 0.88 0.88 0.04 1.50 1.50 1.391 1.391
76950 26 7695026 A 1 XXX 0 0 0 0 0 0 0 0.58 0.24 0.24 0.03 0.85 0.85 0.811 0.811
76950 TC 76950TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.64 0.64 0.01 0.65 0.65 0.580 0.580
76965 76965 A 1 XXX 0 0 0 0 0 0 0 1.34 1.21 1.21 0.09 2.64 2.64 2.474 2.474
76965 26 7696526 A 1 XXX 0 0 0 0 0 0 0 1.34 0.50 0.50 0.08 1.92 1.92 1.831 1.831
76965 TC 76965TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.71 0.71 0.01 0.72 0.72 0.643 0.643
76970 76970 A 1 XXX 0 0 0 0 0 0 0 0.40 2.57 2.57 0.05 3.02 3.02 2.734 2.734
76970 26 7697026 A 1 XXX 0 0 0 0 0 0 0 0.40 0.15 0.15 0.04 0.59 0.59 0.556 0.556
76970 TC 76970TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.42 2.42 0.01 2.43 2.43 2.178 2.178
76975 76975 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76975 26 7697526 A 1 XXX 0 0 0 0 0 0 0 0.81 0.38 0.38 0.08 1.27 1.27 1.193 1.193
76975 TC 76975TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76977 76977 A 1 XXX 0 0 0 0 0 0 0 0.05 0.14 0.14 0.02 0.21 0.21 0.186 0.186
76977 26 7697726 A 1 XXX 0 0 0 0 0 0 0 0.05 0.02 0.02 0.01 0.08 0.08 0.073 0.073
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
340 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
76977 TC 76977TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.12 0.12 0.01 0.13 0.13 0.113 0.113
76998 76998 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76998 26 7699826 A 1 XXX 0 0 0 0 0 0 0 1.20 0.42 0.42 0.26 1.88 1.88 1.713 1.713
76998 TC 76998TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76999 76999 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76999 26 7699926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
76999 TC 76999TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77001 77001 A 1 ZZZ 0 0 0 0 0 9 0 0.38 3.14 3.14 0.04 3.56 3.56 3.221 3.221
77001 26 7700126 A 1 ZZZ 0 0 0 0 0 9 0 0.38 0.13 0.13 0.03 0.54 0.54 0.512 0.512
77001 TC 77001TC A 1 ZZZ 0 0 0 0 0 9 0 0.00 3.01 3.01 0.01 3.02 3.02 2.708 2.708
77002 77002 A 1 XXX 0 0 0 0 0 9 0 0.54 1.77 1.77 0.04 2.35 2.35 2.150 2.150
77002 26 7700226 A 1 XXX 0 0 0 0 0 9 0 0.54 0.23 0.23 0.03 0.80 0.80 0.762 0.762
77002 TC 77002TC A 1 XXX 0 0 0 0 0 9 0 0.00 1.54 1.54 0.01 1.55 1.55 1.388 1.388
77003 77003 A 1 XXX 0 0 0 9 9 9 9 0.60 2.18 2.18 0.04 2.82 2.82 2.579 2.579
77003 26 7700326 A 1 XXX 0 0 0 9 9 9 9 0.60 0.26 0.26 0.03 0.89 0.89 0.849 0.849
77003 TC 77003TC A 1 XXX 0 0 0 9 9 9 9 0.00 1.92 1.92 0.01 1.93 1.93 1.729 1.729
77011 77011 A 1 XXX 0 0 0 0 0 9 0 1.21 5.40 5.40 0.05 6.66 6.66 6.085 6.085
77011 26 7701126 A 1 XXX 0 0 0 0 0 9 0 1.21 0.51 0.51 0.04 1.76 1.76 1.689 1.689
77011 TC 77011TC A 1 XXX 0 0 0 0 0 9 0 0.00 4.89 4.89 0.01 4.90 4.90 4.396 4.396
77012 77012 A 1 XXX 0 0 0 0 0 9 0 1.16 2.57 2.57 0.05 3.78 3.78 3.494 3.494
77012 26 7701226 A 1 XXX 0 0 0 0 0 9 0 1.16 0.41 0.41 0.04 1.61 1.61 1.549 1.549
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
341 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77012 TC 77012TC A 1 XXX 0 0 0 0 0 9 0 0.00 2.16 2.16 0.01 2.17 2.17 1.945 1.945
77013 77013 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77013 26 7701326 A 1 XXX 0 0 0 0 0 9 0 3.99 1.38 1.38 0.37 5.74 5.74 5.423 5.423
77013 TC 77013TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77014 77014 A 1 XXX 0 0 0 0 0 9 0 0.85 2.76 2.76 0.05 3.66 3.66 3.355 3.355
77014 26 7701426 A 1 XXX 0 0 0 0 0 9 0 0.85 0.34 0.34 0.04 1.23 1.23 1.176 1.176
77014 TC 77014TC A 1 XXX 0 0 0 0 0 9 0 0.00 2.42 2.42 0.01 2.43 2.43 2.178 2.178
77021 77021 A 1 XXX 0 0 0 0 0 9 0 1.50 9.87 9.87 0.13 11.50 11.50 10.431 10.431
77021 26 7702126 A 1 XXX 0 0 0 0 0 9 0 1.50 0.53 0.53 0.12 2.15 2.15 2.039 2.039
77021 TC 77021TC A 1 XXX 0 0 0 0 0 9 0 0.00 9.34 9.34 0.01 9.35 9.35 8.393 8.393
77022 77022 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77022 26 7702226 A 1 XXX 0 0 0 0 0 9 0 4.24 1.45 1.45 0.38 6.07 6.07 5.741 5.741
77022 TC 77022TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77031 77031 A 1 XXX 0 0 0 0 0 9 0 1.59 2.10 2.10 0.13 3.82 3.82 3.544 3.544
77031 26 7703126 A 1 XXX 0 0 0 0 0 9 0 1.59 0.58 0.58 0.12 2.29 2.29 2.174 2.174
77031 TC 77031TC A 1 XXX 0 0 0 0 0 9 0 0.00 1.52 1.52 0.01 1.53 1.53 1.370 1.370
77032 77032 A 1 XXX 0 0 0 0 0 9 0 0.56 0.94 0.94 0.04 1.54 1.54 1.425 1.425
77032 26 7703226 A 1 XXX 0 0 0 0 0 9 0 0.56 0.20 0.20 0.03 0.79 0.79 0.755 0.755
77032 TC 77032TC A 1 XXX 0 0 0 0 0 9 0 0.00 0.74 0.74 0.01 0.75 0.75 0.670 0.670
77051 77051 A 1 ZZZ 0 0 0 0 0 9 0 0.06 0.22 0.22 0.02 0.30 0.30 0.268 0.268
77051 26 7705126 A 1 ZZZ 0 0 0 0 0 9 0 0.06 0.02 0.02 0.01 0.09 0.09 0.083 0.083
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
342 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77051 TC 77051TC A 1 ZZZ 0 0 0 0 0 9 0 0.00 0.20 0.20 0.01 0.21 0.21 0.185 0.185
77052 77052 A 1 ZZZ 0 0 0 0 0 9 0 0.06 0.22 0.22 0.02 0.30 0.30 0.268 0.268
77052 26 7705226 A 1 ZZZ 0 0 0 0 0 9 0 0.06 0.02 0.02 0.01 0.09 0.09 0.083 0.083
77052 TC 77052TC A 1 ZZZ 0 0 0 0 0 9 0 0.00 0.20 0.20 0.01 0.21 0.21 0.185 0.185
77053 77053 A 1 XXX 0 0 0 0 0 9 0 0.36 1.38 1.38 0.02 1.76 1.76 1.610 1.610
77053 26 7705326 A 1 XXX 0 0 0 0 0 9 0 0.36 0.13 0.13 0.01 0.50 0.50 0.482 0.482
77053 TC 77053TC A 1 XXX 0 0 0 0 0 9 0 0.00 1.25 1.25 0.01 1.26 1.26 1.128 1.128
77054 77054 A 1 XXX 0 0 0 0 0 9 0 0.45 1.88 1.88 0.04 2.37 2.37 2.159 2.159
77054 26 7705426 A 1 XXX 0 0 0 0 0 9 0 0.45 0.16 0.16 0.03 0.64 0.64 0.609 0.609
77054 TC 77054TC A 1 XXX 0 0 0 0 0 9 0 0.00 1.72 1.72 0.01 1.73 1.73 1.550 1.550
77055 77055 A 1 XXX 0 0 0 0 0 9 0 0.70 1.87 1.87 0.05 2.62 2.62 2.405 2.405
77055 26 7705526 A 1 XXX 0 0 0 0 0 9 0 0.70 0.25 0.25 0.04 0.99 0.99 0.945 0.945
77055 TC 77055TC A 1 XXX 0 0 0 0 0 9 0 0.00 1.62 1.62 0.01 1.63 1.63 1.460 1.460
77056 77056 A 1 XXX 0 0 0 0 0 9 0 0.87 2.44 2.44 0.06 3.37 3.37 3.093 3.093
77056 26 7705626 A 1 XXX 0 0 0 0 0 9 0 0.87 0.32 0.32 0.05 1.24 1.24 1.184 1.184
77056 TC 77056TC A 1 XXX 0 0 0 0 0 9 0 0.00 2.12 2.12 0.01 2.13 2.13 1.909 1.909
77057 77057 A 1 XXX 0 0 0 0 2 9 0 0.70 1.65 1.65 0.05 2.40 2.40 2.208 2.208
77057 26 7705726 A 1 XXX 0 0 0 0 2 9 0 0.70 0.26 0.26 0.04 1.00 1.00 0.954 0.954
77057 TC 77057TC A 1 XXX 0 0 0 0 2 9 0 0.00 1.39 1.39 0.01 1.40 1.40 1.253 1.253
77058 77058 A 1 XXX 0 0 0 4 0 9 0 1.63 16.80 16.80 0.11 18.54 18.54 16.774 16.774
77058 26 7705826 A 1 XXX 0 0 0 4 0 9 0 1.63 0.58 0.58 0.10 2.31 2.31 2.203 2.203
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
343 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77058 TC 77058TC A 1 XXX 0 0 0 4 0 9 0 0.00 16.22 16.22 0.01 16.23 16.23 14.571 14.571
77059 77059 A 1 XXX 0 0 0 4 2 9 0 1.63 16.66 16.66 0.11 18.40 18.40 16.648 16.648
77059 26 7705926 A 1 XXX 0 0 0 4 2 9 0 1.63 0.58 0.58 0.10 2.31 2.31 2.203 2.203
77059 TC 77059TC A 1 XXX 0 0 0 4 2 9 0 0.00 16.08 16.08 0.01 16.09 16.09 14.445 14.445
77071 77071 A 2 XXX 0 0 0 0 2 0 0 0.41 1.06 1.06 0.07 1.54 1.54 1.398 1.398
77072 77072 A 1 XXX 0 0 0 0 0 0 0 0.19 0.49 0.49 0.02 0.70 0.70 0.640 0.640
77072 26 7707226 A 1 XXX 0 0 0 0 0 0 0 0.19 0.07 0.07 0.01 0.27 0.27 0.258 0.258
77072 TC 77072TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.42 0.42 0.01 0.43 0.43 0.382 0.382
77073 77073 A 1 XXX 0 0 0 0 0 0 0 0.27 0.84 0.84 0.05 1.16 1.16 1.050 1.050
77073 26 7707326 A 1 XXX 0 0 0 0 0 0 0 0.27 0.12 0.12 0.04 0.43 0.43 0.399 0.399
77073 TC 77073TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.72 0.72 0.01 0.73 0.73 0.652 0.652
77074 77074 A 1 XXX 0 0 0 0 0 0 0 0.45 1.61 1.61 0.04 2.10 2.10 1.917 1.917
77074 26 7707426 A 1 XXX 0 0 0 0 0 0 0 0.45 0.16 0.16 0.03 0.64 0.64 0.609 0.609
77074 TC 77074TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.45 1.45 0.01 1.46 1.46 1.307 1.307
77075 77075 A 1 XXX 0 0 0 0 0 0 0 0.54 2.60 2.60 0.04 3.18 3.18 2.896 2.896
77075 26 7707526 A 1 XXX 0 0 0 0 0 0 0 0.54 0.20 0.20 0.03 0.77 0.77 0.735 0.735
77075 TC 77075TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.40 2.40 0.01 2.41 2.41 2.160 2.160
77076 77076 A 1 XXX 0 0 0 0 0 0 0 0.70 2.43 2.43 0.05 3.18 3.18 2.908 2.908
77076 26 7707626 A 1 XXX 0 0 0 0 0 0 0 0.70 0.25 0.25 0.04 0.99 0.99 0.945 0.945
77076 TC 77076TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.18 2.18 0.01 2.19 2.19 1.963 1.963
77077 77077 A 1 XXX 0 0 0 0 0 0 0 0.31 0.86 0.86 0.05 1.22 1.22 1.108 1.108
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
344 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77077 26 7707726 A 1 XXX 0 0 0 0 0 0 0 0.31 0.14 0.14 0.04 0.49 0.49 0.457 0.457
77077 TC 77077TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.72 0.72 0.01 0.73 0.73 0.652 0.652
77078 77078 A 1 XXX 0 0 0 0 0 0 0 0.25 3.66 3.66 0.02 3.93 3.93 3.547 3.547
77078 26 7707826 A 1 XXX 0 0 0 0 0 0 0 0.25 0.09 0.09 0.01 0.35 0.35 0.336 0.336
77078 TC 77078TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.57 3.57 0.01 3.58 3.58 3.211 3.211
77080 77080 A 1 XXX 0 0 0 0 0 0 0 0.20 1.26 1.26 0.02 1.48 1.48 1.342 1.342
77080 26 7708026 A 1 XXX 0 0 0 0 0 0 0 0.20 0.08 0.08 0.01 0.29 0.29 0.277 0.277
77080 TC 77080TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.18 1.18 0.01 1.19 1.19 1.065 1.065
77081 77081 A 1 XXX 0 0 0 0 0 0 0 0.22 0.60 0.60 0.02 0.84 0.84 0.769 0.769
77081 26 7708126 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.01 0.32 0.32 0.306 0.306
77081 TC 77081TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.51 0.51 0.01 0.52 0.52 0.463 0.463
77082 77082 A 1 XXX 0 0 0 0 0 0 0 0.17 0.65 0.65 0.02 0.84 0.84 0.764 0.764
77082 26 7708226 A 1 XXX 0 0 0 0 0 0 0 0.17 0.07 0.07 0.01 0.25 0.25 0.238 0.238
77082 TC 77082TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.58 0.58 0.01 0.59 0.59 0.526 0.526
77084 77084 A 1 XXX 0 0 0 0 0 0 0 1.60 11.42 11.42 0.11 13.13 13.13 11.913 11.913
77084 26 7708426 A 1 XXX 0 0 0 0 0 0 0 1.60 0.58 0.58 0.10 2.28 2.28 2.173 2.173
77084 TC 77084TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.84 10.84 0.01 10.85 10.85 9.740 9.740
77261 77261 A 2 XXX 0 0 0 0 0 0 0 1.39 0.61 0.61 0.10 2.10 2.10 1.990 1.990
77262 77262 A 2 XXX 0 0 0 0 0 0 0 2.11 0.87 0.87 0.18 3.16 3.16 2.985 2.985
77263 77263 A 2 XXX 0 0 0 0 0 0 0 3.14 1.27 1.27 0.26 4.67 4.67 4.416 4.416
77280 77280 A 1 XXX 0 0 0 0 0 0 0 0.70 4.58 4.58 0.04 5.32 5.32 4.834 4.834
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
345 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77280 26 7728026 A 1 XXX 0 0 0 0 0 0 0 0.70 0.28 0.28 0.03 1.01 1.01 0.967 0.967
77280 TC 77280TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.30 4.30 0.01 4.31 4.31 3.867 3.867
77285 77285 A 1 XXX 0 0 0 0 0 0 0 1.05 8.30 8.30 0.06 9.41 9.41 8.535 8.535
77285 26 7728526 A 1 XXX 0 0 0 0 0 0 0 1.05 0.42 0.42 0.05 1.52 1.52 1.453 1.453
77285 TC 77285TC A 1 XXX 0 0 0 0 0 0 0 0.00 7.88 7.88 0.01 7.89 7.89 7.081 7.081
77290 77290 A 1 XXX 0 0 0 0 0 0 0 1.56 13.98 13.98 0.08 15.62 15.62 14.156 14.156
77290 26 7729026 A 1 XXX 0 0 0 0 0 0 0 1.56 0.63 0.63 0.07 2.26 2.26 2.162 2.162
77290 TC 77290TC A 1 XXX 0 0 0 0 0 0 0 0.00 13.35 13.35 0.01 13.36 13.36 11.994 11.994
77295 77295 A 1 XXX 0 0 0 0 0 0 0 4.56 8.25 8.25 0.28 13.09 13.09 12.115 12.115
77295 26 7729526 A 1 XXX 0 0 0 0 0 0 0 4.56 1.85 1.85 0.24 6.65 6.65 6.347 6.347
77295 TC 77295TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.40 6.40 0.04 6.44 6.44 5.768 5.768
77299 77299 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77299 26 7729926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77299 TC 77299TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77300 77300 A 1 XXX 0 0 0 0 0 0 0 0.62 1.30 1.30 0.04 1.96 1.96 1.808 1.808
77300 26 7730026 A 1 XXX 0 0 0 0 0 0 0 0.62 0.25 0.25 0.03 0.90 0.90 0.860 0.860
77300 TC 77300TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.05 1.05 0.01 1.06 1.06 0.948 0.948
77301 77301 A 1 XXX 0 0 0 0 0 0 0 7.99 49.88 49.88 0.63 58.50 58.50 53.112 53.112
77301 26 7730126 A 1 XXX 0 0 0 0 0 0 0 7.99 3.24 3.24 0.41 11.64 11.64 11.114 11.114
77301 TC 77301TC A 1 XXX 0 0 0 0 0 0 0 0.00 46.64 46.64 0.22 46.86 46.86 41.998 41.998
77305 77305 A 1 XXX 0 0 0 0 0 0 0 0.70 0.98 0.98 0.04 1.72 1.72 1.601 1.601
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
346 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77305 26 7730526 A 1 XXX 0 0 0 0 0 0 0 0.70 0.28 0.28 0.03 1.01 1.01 0.967 0.967
77305 TC 77305TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.70 0.70 0.01 0.71 0.71 0.634 0.634
77310 77310 A 1 XXX 0 0 0 0 0 0 0 1.05 1.37 1.37 0.06 2.48 2.48 2.312 2.312
77310 26 7731026 A 1 XXX 0 0 0 0 0 0 0 1.05 0.42 0.42 0.05 1.52 1.52 1.453 1.453
77310 TC 77310TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.95 0.95 0.01 0.96 0.96 0.858 0.858
77315 77315 A 1 XXX 0 0 0 0 0 0 0 1.56 2.29 2.29 0.08 3.93 3.93 3.658 3.658
77315 26 7731526 A 1 XXX 0 0 0 0 0 0 0 1.56 0.63 0.63 0.07 2.26 2.26 2.162 2.162
77315 TC 77315TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.66 1.66 0.01 1.67 1.67 1.496 1.496
77321 77321 A 1 XXX 0 0 0 0 0 0 0 0.95 1.67 1.67 0.05 2.67 2.67 2.476 2.476
77321 26 7732126 A 1 XXX 0 0 0 0 0 0 0 0.95 0.39 0.39 0.04 1.38 1.38 1.321 1.321
77321 TC 77321TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.28 1.28 0.01 1.29 1.29 1.155 1.155
77326 77326 A 1 XXX 0 0 0 0 0 0 0 0.93 3.30 3.30 0.07 4.30 4.30 3.930 3.930
77326 26 7732626 A 1 XXX 0 0 0 0 0 0 0 0.93 0.38 0.38 0.04 1.35 1.35 1.292 1.292
77326 TC 77326TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.92 2.92 0.03 2.95 2.95 2.638 2.638
77327 77327 A 1 XXX 0 0 0 0 0 0 0 1.39 4.50 4.50 0.10 5.99 5.99 5.483 5.483
77327 26 7732726 A 1 XXX 0 0 0 0 0 0 0 1.39 0.56 0.56 0.07 2.02 2.02 1.929 1.929
77327 TC 77327TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.94 3.94 0.03 3.97 3.97 3.554 3.554
77328 77328 A 1 XXX 0 0 0 0 0 0 0 2.09 5.78 5.78 0.14 8.01 8.01 7.354 7.354
77328 26 7732826 A 1 XXX 0 0 0 0 0 0 0 2.09 0.85 0.85 0.10 3.04 3.04 2.906 2.906
77328 TC 77328TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.93 4.93 0.04 4.97 4.97 4.448 4.448
77331 77331 A 1 XXX 0 0 0 0 0 0 0 0.87 0.90 0.90 0.05 1.82 1.82 1.704 1.704
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
347 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77331 26 7733126 A 1 XXX 0 0 0 0 0 0 0 0.87 0.35 0.35 0.04 1.26 1.26 1.205 1.205
77331 TC 77331TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.55 0.55 0.01 0.56 0.56 0.499 0.499
77332 77332 A 1 XXX 0 0 0 0 0 0 0 0.54 1.78 1.78 0.04 2.36 2.36 2.159 2.159
77332 26 7733226 A 1 XXX 0 0 0 0 0 0 0 0.54 0.22 0.22 0.03 0.79 0.79 0.753 0.753
77332 TC 77332TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.56 1.56 0.01 1.57 1.57 1.406 1.406
77333 77333 A 1 XXX 0 0 0 0 0 0 0 0.84 0.61 0.61 0.05 1.50 1.50 1.414 1.414
77333 26 7733326 A 1 XXX 0 0 0 0 0 0 0 0.84 0.34 0.34 0.04 1.22 1.22 1.166 1.166
77333 TC 77333TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.27 0.27 0.01 0.28 0.28 0.248 0.248
77334 77334 A 1 XXX 0 0 0 0 0 0 0 1.24 3.11 3.11 0.06 4.41 4.41 4.064 4.064
77334 26 7733426 A 1 XXX 0 0 0 0 0 0 0 1.24 0.50 0.50 0.05 1.79 1.79 1.715 1.715
77334 TC 77334TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.61 2.61 0.01 2.62 2.62 2.349 2.349
77336 77336 A 3 XXX 0 0 0 0 0 0 0 0.00 1.28 1.28 0.01 1.29 1.29 1.155 1.155
77338 77338 A 1 XXX 0 0 0 0 0 0 0 4.29 10.17 10.17 0.27 14.73 14.73 13.564 13.564
77338 26 7733826 A 1 XXX 0 0 0 0 0 0 0 4.29 1.74 1.74 0.23 6.26 6.26 5.973 5.973
77338 TC 77338TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.43 8.43 0.04 8.47 8.47 7.591 7.591
77370 77370 A 3 XXX 0 0 0 0 0 0 0 0.00 3.43 3.43 0.04 3.47 3.47 3.101 3.101
77371 77371 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77372 77372 A 3 XXX 0 0 0 0 0 0 0 0.00 23.02 23.02 0.05 23.07 23.07 20.698 20.698
77373 77373 A 3 XXX 0 0 0 0 0 0 0 0.00 37.22 37.22 0.07 37.29 37.29 33.460 33.460
77399 77399 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77399 26 7739926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
348 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77399 TC 77399TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77401 77401 A 3 XXX 0 0 0 0 0 0 0 0.00 0.60 0.60 0.01 0.61 0.61 0.544 0.544
77402 77402 A 3 XXX 0 0 0 0 0 0 0 0.00 4.55 4.55 0.01 4.56 4.56 4.091 4.091
77403 77403 A 3 XXX 0 0 0 0 0 0 0 0.00 3.75 3.75 0.01 3.76 3.76 3.373 3.373
77404 77404 A 3 XXX 0 0 0 0 0 0 0 0.00 4.17 4.17 0.01 4.18 4.18 3.750 3.750
77406 77406 A 3 XXX 0 0 0 0 0 0 0 0.00 4.17 4.17 0.01 4.18 4.18 3.750 3.750
77407 77407 A 3 XXX 0 0 0 0 0 0 0 0.00 6.63 6.63 0.01 6.64 6.64 5.959 5.959
77408 77408 A 3 XXX 0 0 0 0 0 0 0 0.00 5.17 5.17 0.01 5.18 5.18 4.648 4.648
77409 77409 A 3 XXX 0 0 0 0 0 0 0 0.00 5.76 5.76 0.01 5.77 5.77 5.178 5.178
77411 77411 A 3 XXX 0 0 0 0 0 0 0 0.00 5.79 5.79 0.01 5.80 5.80 5.205 5.205
77412 77412 A 3 XXX 0 0 0 0 0 0 0 0.00 7.05 7.05 0.01 7.06 7.06 6.336 6.336
77413 77413 A 3 XXX 0 0 0 0 0 0 0 0.00 6.79 6.79 0.01 6.80 6.80 6.103 6.103
77414 77414 A 3 XXX 0 0 0 0 0 0 0 0.00 7.64 7.64 0.01 7.65 7.65 6.866 6.866
77416 77416 A 3 XXX 0 0 0 0 0 0 0 0.00 7.63 7.63 0.01 7.64 7.64 6.857 6.857
77417 77417 A 3 XXX 0 0 0 0 0 0 0 0.00 0.41 0.41 0.01 0.42 0.42 0.373 0.373
77418 77418 A 3 XXX 0 0 0 0 0 0 0 0.00 11.91 11.91 0.01 11.92 11.92 10.700 10.700
77421 77421 A 1 XXX 0 0 0 0 0 0 0 0.39 1.78 1.78 0.02 2.19 2.19 1.999 1.999
77421 26 7742126 A 1 XXX 0 0 0 0 0 0 0 0.39 0.16 0.16 0.01 0.56 0.56 0.539 0.539
77421 TC 77421TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.62 1.62 0.01 1.63 1.63 1.460 1.460
77422 77422 A 3 XXX 0 0 0 0 0 0 0 0.00 8.30 8.30 0.01 8.31 8.31 7.459 7.459
77423 77423 A 3 XXX 0 0 0 0 0 0 0 0.00 8.46 8.46 0.01 8.47 8.47 7.602 7.602
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
349 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77424 77424 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77425 77425 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77427 77427 A 2 XXX 0 0 0 9 9 9 9 3.37 1.60 1.60 0.27 5.24 5.24 4.948 4.948
77431 77431 A 2 XXX 0 0 0 0 0 0 0 1.81 0.93 0.93 0.14 2.88 2.88 2.718 2.718
77432 77432 A 2 XXX 0 0 0 0 0 0 0 7.92 3.22 3.22 0.65 11.79 11.79 11.152 11.152
77435 77435 A 2 XXX 0 0 0 0 0 0 0 11.87 4.94 4.94 0.99 17.80 17.80 16.824 16.824
77469 77469 A 0 XXX 0 0 0 0 0 0 0 5.75 2.63 2.63 0.47 8.85 8.85 8.358 8.358
77470 77470 A 1 XXX 0 0 0 0 0 0 0 2.09 2.25 2.25 0.11 4.45 4.45 4.168 4.168
77470 26 7747026 A 1 XXX 0 0 0 0 0 0 0 2.09 0.85 0.85 0.10 3.04 3.04 2.906 2.906
77470 TC 77470TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.40 1.40 0.01 1.41 1.41 1.262 1.262
77499 77499 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77499 26 7749926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77499 TC 77499TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77520 77520 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77522 77522 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77523 77523 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77525 77525 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77600 77600 R 1 XXX 0 0 0 0 0 0 0 1.56 11.02 11.02 0.10 12.68 12.68 11.508 11.508
77600 26 7760026 R 1 XXX 0 0 0 0 0 0 0 1.56 0.63 0.63 0.07 2.26 2.26 2.162 2.162
77600 TC 77600TC R 1 XXX 0 0 0 0 0 0 0 0.00 10.39 10.39 0.03 10.42 10.42 9.346 9.346
77605 77605 R 1 XXX 0 0 0 0 0 0 0 2.09 31.63 31.63 0.41 34.13 34.13 30.708 30.708
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
350 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77605 26 7760526 R 1 XXX 0 0 0 0 0 0 0 2.09 0.83 0.83 0.38 3.30 3.30 3.034 3.034
77605 TC 77605TC R 1 XXX 0 0 0 0 0 0 0 0.00 30.80 30.80 0.03 30.83 30.83 27.674 27.674
77610 77610 R 1 XXX 0 0 0 0 0 0 0 1.56 30.51 30.51 0.10 32.17 32.17 29.010 29.010
77610 26 7761026 R 1 XXX 0 0 0 0 0 0 0 1.56 0.62 0.62 0.07 2.25 2.25 2.153 2.153
77610 TC 77610TC R 1 XXX 0 0 0 0 0 0 0 0.00 29.89 29.89 0.03 29.92 29.92 26.857 26.857
77615 77615 R 1 XXX 0 0 0 0 0 0 0 2.09 27.69 27.69 0.17 29.95 29.95 27.045 27.045
77615 26 7761526 R 1 XXX 0 0 0 0 0 0 0 2.09 0.85 0.85 0.10 3.04 3.04 2.906 2.906
77615 TC 77615TC R 1 XXX 0 0 0 0 0 0 0 0.00 26.84 26.84 0.07 26.91 26.91 24.139 24.139
77620 77620 R 1 XXX 0 0 0 0 0 0 0 1.56 15.63 15.63 0.08 17.27 17.27 15.638 15.638
77620 26 7762026 R 1 XXX 0 0 0 0 0 0 0 1.56 0.62 0.62 0.04 2.22 2.22 2.138 2.138
77620 TC 77620TC R 1 XXX 0 0 0 0 0 0 0 0.00 15.01 15.01 0.04 15.05 15.05 13.500 13.500
77750 77750 A 1 090 0 0 0 0 0 0 0 5.00 5.31 5.31 0.29 10.60 10.60 9.920 9.920
77750 26 7775026 A 1 090 0 0 0 0 0 0 0 5.00 2.02 2.02 0.26 7.28 7.28 6.950 6.950
77750 TC 77750TC A 1 090 0 0 0 0 0 0 0 0.00 3.29 3.29 0.03 3.32 3.32 2.970 2.970
77761 77761 A 1 090 0 0 0 0 0 0 0 3.85 7.18 7.18 0.24 11.27 11.27 10.423 10.423
77761 26 7776126 A 1 090 0 0 0 0 0 0 0 3.85 1.53 1.53 0.20 5.58 5.58 5.329 5.329
77761 TC 77761TC A 1 090 0 0 0 0 0 0 0 0.00 5.65 5.65 0.04 5.69 5.69 5.095 5.095
77762 77762 A 1 090 0 0 0 0 0 0 0 5.76 8.80 8.80 0.35 14.91 14.91 13.845 13.845
77762 26 7776226 A 1 090 0 0 0 0 0 0 0 5.76 2.31 2.31 0.30 8.37 8.37 7.991 7.991
77762 TC 77762TC A 1 090 0 0 0 0 0 0 0 0.00 6.49 6.49 0.05 6.54 6.54 5.854 5.854
77763 77763 A 1 090 0 0 0 0 0 0 0 8.66 11.86 11.86 0.51 21.03 21.03 19.577 19.577
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
351 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77763 26 7776326 A 1 090 0 0 0 0 0 0 0 8.66 3.50 3.50 0.44 12.60 12.60 12.033 12.033
77763 TC 77763TC A 1 090 0 0 0 0 0 0 0 0.00 8.36 8.36 0.07 8.43 8.43 7.544 7.544
77776 77776 A 1 090 0 0 0 0 0 0 0 4.70 7.57 7.57 0.36 12.63 12.63 11.686 11.686
77776 26 7777626 A 1 090 0 0 0 0 0 0 2 4.70 1.91 1.91 0.31 6.92 6.92 6.577 6.577
77776 TC 77776TC A 1 090 0 0 0 0 0 0 0 0.00 5.66 5.66 0.05 5.71 5.71 5.109 5.109
77777 77777 A 1 090 0 0 0 0 0 0 0 7.52 9.04 9.04 0.54 17.10 17.10 15.920 15.920
77777 26 7777726 A 1 090 0 0 0 0 0 0 2 7.52 2.98 2.98 0.49 10.99 10.99 10.452 10.452
77777 TC 77777TC A 1 090 0 0 0 0 0 0 0 0.00 6.06 6.06 0.05 6.11 6.11 5.468 5.468
77778 77778 A 1 090 0 0 0 0 0 0 0 11.32 13.09 13.09 0.68 25.09 25.09 23.430 23.430
77778 26 7777826 A 1 090 0 0 0 0 0 0 2 11.32 4.55 4.55 0.60 16.47 16.47 15.720 15.720
77778 TC 77778TC A 1 090 0 0 0 0 0 0 0 0.00 8.54 8.54 0.08 8.62 8.62 7.711 7.711
77785 77785 A 1 XXX 0 0 0 0 0 0 0 1.42 5.85 5.85 0.10 7.37 7.37 6.726 6.726
77785 26 7778526 A 1 XXX 0 0 0 0 0 0 0 1.42 0.58 0.58 0.07 2.07 2.07 1.977 1.977
77785 TC 77785TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.27 5.27 0.03 5.30 5.30 4.748 4.748
77786 77786 A 1 XXX 0 0 0 0 0 0 0 3.25 12.91 12.91 0.21 16.37 16.37 14.953 14.953
77786 26 7778626 A 1 XXX 0 0 0 0 0 0 0 3.25 1.32 1.32 0.16 4.73 4.73 4.519 4.519
77786 TC 77786TC A 1 XXX 0 0 0 0 0 0 0 0.00 11.59 11.59 0.05 11.64 11.64 10.434 10.434
77787 77787 A 1 XXX 0 0 0 0 0 0 0 4.89 22.86 22.86 0.34 28.09 28.09 25.596 25.596
77787 26 7778726 A 1 XXX 0 0 0 0 0 0 0 4.89 1.99 1.99 0.26 7.14 7.14 6.813 6.813
77787 TC 77787TC A 1 XXX 0 0 0 0 0 0 0 0.00 20.87 20.87 0.08 20.95 20.95 18.783 18.783
77789 77789 A 1 000 0 0 0 0 0 0 0 1.14 2.27 2.27 0.06 3.47 3.47 3.210 3.210
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
352 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
77789 26 7778926 A 1 000 0 0 0 0 0 0 0 1.14 0.48 0.48 0.05 1.67 1.67 1.597 1.597
77789 TC 77789TC A 1 000 0 0 0 0 0 0 0 0.00 1.79 1.79 0.01 1.80 1.80 1.613 1.613
77790 77790 A 1 XXX 0 0 0 0 0 0 0 1.05 1.68 1.68 0.05 2.78 2.78 2.585 2.585
77790 26 7779026 A 1 XXX 0 0 0 0 0 0 0 1.05 0.42 0.42 0.04 1.51 1.51 1.448 1.448
77790 TC 77790TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.26 1.26 0.01 1.27 1.27 1.137 1.137
77799 77799 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77799 26 7779926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
77799 TC 77799TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78012 78012 A 1 XXX 0 0 0 0 0 0 0 0.19 2.23 2.23 0.02 2.44 2.44 2.203 2.203
78012 26 7801226 A 1 XXX 0 0 0 0 0 0 0 0.19 0.07 0.07 0.01 0.27 0.27 0.258 0.258
78012 TC 78012TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.16 2.16 0.01 2.17 2.17 1.945 1.945
78013 78013 A 1 XXX 0 0 0 0 0 0 0 0.37 5.76 5.76 0.04 6.17 6.17 5.563 5.563
78013 26 7801326 A 1 XXX 0 0 0 0 0 0 0 0.37 0.14 0.14 0.01 0.52 0.52 0.501 0.501
78013 TC 78013TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.62 5.62 0.03 5.65 5.65 5.062 5.062
78014 78014 A 1 XXX 0 0 0 0 0 0 0 0.50 6.57 6.57 0.06 7.13 7.13 6.431 6.431
78014 26 7801426 A 1 XXX 0 0 0 0 0 0 0 0.50 0.17 0.17 0.03 0.70 0.70 0.668 0.668
78014 TC 78014TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.40 6.40 0.03 6.43 6.43 5.763 5.763
78015 78015 A 1 XXX 0 0 0 0 0 0 0 0.67 5.81 5.81 0.07 6.55 6.55 5.924 5.924
78015 26 7801526 A 1 XXX 0 0 0 0 0 0 0 0.67 0.21 0.21 0.04 0.92 0.92 0.880 0.880
78015 TC 78015TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.60 5.60 0.03 5.63 5.63 5.044 5.044
78016 78016 A 1 XXX 0 0 0 0 0 0 0 0.82 7.62 7.62 0.06 8.50 8.50 7.694 7.694
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
353 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78016 26 7801626 A 1 XXX 0 0 0 0 0 0 0 0.82 0.14 0.14 0.03 0.99 0.99 0.961 0.961
78016 TC 78016TC A 1 XXX 0 0 0 0 0 0 0 0.00 7.48 7.48 0.03 7.51 7.51 6.733 6.733
78018 78018 A 1 XXX 0 0 0 0 0 0 0 0.86 8.54 8.54 0.07 9.47 9.47 8.566 8.566
78018 26 7801826 A 1 XXX 0 0 0 0 0 0 0 0.86 0.27 0.27 0.04 1.17 1.17 1.123 1.123
78018 TC 78018TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.27 8.27 0.03 8.30 8.30 7.442 7.442
78020 78020 A 1 ZZZ 0 0 0 0 0 0 0 0.60 1.85 1.85 0.04 2.49 2.49 2.282 2.282
78020 26 7802026 A 1 ZZZ 0 0 0 0 0 0 0 0.60 0.16 0.16 0.03 0.79 0.79 0.759 0.759
78020 TC 78020TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 1.69 1.69 0.01 1.70 1.70 1.523 1.523
78070 78070 A 1 XXX 0 0 0 0 0 0 0 0.80 8.15 8.15 0.07 9.02 9.02 8.155 8.155
78070 26 7807026 A 1 XXX 0 0 0 0 0 0 0 0.80 0.26 0.26 0.04 1.10 1.10 1.054 1.054
78070 TC 78070TC A 1 XXX 0 0 0 0 0 0 0 0.00 7.89 7.89 0.03 7.92 7.92 7.101 7.101
78071 78071 A 1 XXX 0 0 0 0 0 0 0 1.20 9.34 9.34 0.09 10.63 10.63 9.634 9.634
78071 26 7807126 A 1 XXX 0 0 0 0 0 0 0 1.20 0.40 0.40 0.06 1.66 1.66 1.591 1.591
78071 TC 78071TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.94 8.94 0.03 8.97 8.97 8.044 8.044
78072 78072 C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78072 26 7807226 A 1 XXX 0 0 0 0 0 0 0 1.60 0.65 0.65 0.05 2.30 2.30 2.210 2.210
78072 TC 78072TC C 1 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78075 78075 A 1 XXX 0 0 0 0 0 0 0 0.74 12.15 12.15 0.08 12.97 12.97 11.693 11.693
78075 26 7807526 A 1 XXX 0 0 0 0 0 0 0 0.74 0.21 0.21 0.04 0.99 0.99 0.950 0.950
78075 TC 78075TC A 1 XXX 0 0 0 0 0 0 0 0.00 11.94 11.94 0.04 11.98 11.98 10.743 10.743
78099 78099 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
354 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78099 26 7809926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78099 TC 78099TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78102 78102 A 1 XXX 0 0 0 0 0 0 0 0.55 4.52 4.52 0.06 5.13 5.13 4.640 4.640
78102 26 7810226 A 1 XXX 0 0 0 0 0 0 0 0.55 0.17 0.17 0.03 0.75 0.75 0.718 0.718
78102 TC 78102TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.35 4.35 0.03 4.38 4.38 3.922 3.922
78103 78103 A 1 XXX 0 0 0 0 0 0 0 0.75 5.73 5.73 0.07 6.55 6.55 5.932 5.932
78103 26 7810326 A 1 XXX 0 0 0 0 0 0 0 0.75 0.22 0.22 0.04 1.01 1.01 0.968 0.968
78103 TC 78103TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.51 5.51 0.03 5.54 5.54 4.964 4.964
78104 78104 A 1 XXX 0 0 0 0 0 0 0 0.80 6.64 6.64 0.07 7.51 7.51 6.799 6.799
78104 26 7810426 A 1 XXX 0 0 0 0 0 0 0 0.80 0.26 0.26 0.04 1.10 1.10 1.054 1.054
78104 TC 78104TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.38 6.38 0.03 6.41 6.41 5.745 5.745
78110 78110 A 1 XXX 0 0 0 0 0 0 0 0.19 2.56 2.56 0.04 2.79 2.79 2.510 2.510
78110 26 7811026 A 1 XXX 0 0 0 0 0 0 0 0.19 0.07 0.07 0.01 0.27 0.27 0.258 0.258
78110 TC 78110TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.49 2.49 0.03 2.52 2.52 2.252 2.252
78111 78111 A 1 XXX 0 0 0 0 0 0 0 0.22 2.29 2.29 0.04 2.55 2.55 2.297 2.297
78111 26 7811126 A 1 XXX 0 0 0 0 0 0 0 0.22 0.05 0.05 0.01 0.28 0.28 0.270 0.270
78111 TC 78111TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.24 2.24 0.03 2.27 2.27 2.027 2.027
78120 78120 A 1 XXX 0 0 0 0 0 0 0 0.23 2.48 2.48 0.04 2.75 2.75 2.478 2.478
78120 26 7812026 A 1 XXX 0 0 0 0 0 0 0 0.23 0.08 0.08 0.01 0.32 0.32 0.307 0.307
78120 TC 78120TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.40 2.40 0.03 2.43 2.43 2.171 2.171
78121 78121 A 1 XXX 0 0 0 0 0 0 0 0.32 1.97 1.97 0.04 2.33 2.33 2.110 2.110
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
355 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78121 26 7812126 A 1 XXX 0 0 0 0 0 0 0 0.32 0.05 0.05 0.01 0.38 0.38 0.370 0.370
78121 TC 78121TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.92 1.92 0.03 1.95 1.95 1.740 1.740
78122 78122 A 1 XXX 0 0 0 0 0 0 0 0.45 2.48 2.48 0.04 2.97 2.97 2.698 2.698
78122 26 7812226 A 1 XXX 0 0 0 0 0 0 0 0.45 0.14 0.14 0.01 0.60 0.60 0.581 0.581
78122 TC 78122TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.34 2.34 0.03 2.37 2.37 2.117 2.117
78130 78130 A 1 XXX 0 0 0 0 0 0 0 0.61 4.16 4.16 0.08 4.85 4.85 4.388 4.388
78130 26 7813026 A 1 XXX 0 0 0 0 0 0 0 0.61 0.23 0.23 0.04 0.88 0.88 0.837 0.837
78130 TC 78130TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.93 3.93 0.04 3.97 3.97 3.550 3.550
78135 78135 A 1 XXX 0 0 0 0 0 0 0 0.64 10.10 10.10 0.07 10.81 10.81 9.746 9.746
78135 26 7813526 A 1 XXX 0 0 0 0 0 0 0 0.64 0.24 0.24 0.04 0.92 0.92 0.876 0.876
78135 TC 78135TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.86 9.86 0.03 9.89 9.89 8.870 8.870
78140 78140 A 1 XXX 0 0 0 0 0 0 0 0.61 3.39 3.39 0.07 4.07 4.07 3.691 3.691
78140 26 7814026 A 1 XXX 0 0 0 0 0 0 0 0.61 0.22 0.22 0.04 0.87 0.87 0.828 0.828
78140 TC 78140TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.17 3.17 0.03 3.20 3.20 2.862 2.862
78185 78185 A 1 XXX 0 0 0 0 0 0 0 0.40 5.98 5.98 0.04 6.42 6.42 5.791 5.791
78185 26 7818526 A 1 XXX 0 0 0 0 0 0 0 0.40 0.15 0.15 0.01 0.56 0.56 0.540 0.540
78185 TC 78185TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.83 5.83 0.03 5.86 5.86 5.251 5.251
78190 78190 A 1 XXX 0 0 0 0 0 0 0 1.09 11.24 11.24 0.07 12.40 12.40 11.220 11.220
78190 26 7819026 A 1 XXX 0 0 0 0 0 0 0 1.09 0.44 0.44 0.04 1.57 1.57 1.506 1.506
78190 TC 78190TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.80 10.80 0.03 10.83 10.83 9.714 9.714
78191 78191 A 1 XXX 0 0 0 0 0 0 0 0.61 4.17 4.17 0.08 4.86 4.86 4.397 4.397
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
356 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78191 26 7819126 A 1 XXX 0 0 0 0 0 0 0 0.61 0.23 0.23 0.04 0.88 0.88 0.837 0.837
78191 TC 78191TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.94 3.94 0.04 3.98 3.98 3.559 3.559
78195 78195 A 1 XXX 0 0 0 0 0 0 0 1.20 9.51 9.51 0.10 10.81 10.81 9.792 9.792
78195 26 7819526 A 1 XXX 0 0 0 0 0 0 0 1.20 0.40 0.40 0.07 1.67 1.67 1.596 1.596
78195 TC 78195TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.11 9.11 0.03 9.14 9.14 8.196 8.196
78199 78199 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78199 26 7819926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78199 TC 78199TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78201 78201 A 1 XXX 0 0 0 0 0 0 0 0.44 5.13 5.13 0.07 5.64 5.64 5.083 5.083
78201 26 7820126 A 1 XXX 0 0 0 0 0 0 0 0.44 0.13 0.13 0.04 0.61 0.61 0.578 0.578
78201 TC 78201TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.00 5.00 0.03 5.03 5.03 4.506 4.506
78202 78202 A 1 XXX 0 0 0 0 0 0 0 0.51 5.64 5.64 0.04 6.19 6.19 5.596 5.596
78202 26 7820226 A 1 XXX 0 0 0 0 0 0 0 0.51 0.15 0.15 0.01 0.67 0.67 0.650 0.650
78202 TC 78202TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.49 5.49 0.03 5.52 5.52 4.946 4.946
78205 78205 A 1 XXX 0 0 0 0 0 0 0 0.71 5.65 5.65 0.07 6.43 6.43 5.820 5.820
78205 26 7820526 A 1 XXX 0 0 0 0 0 0 0 0.71 0.22 0.22 0.04 0.97 0.97 0.928 0.928
78205 TC 78205TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.43 5.43 0.03 5.46 5.46 4.892 4.892
78206 78206 A 1 XXX 0 0 0 0 0 0 0 0.96 9.24 9.24 0.07 10.27 10.27 9.294 9.294
78206 26 7820626 A 1 XXX 0 0 0 0 0 0 0 0.96 0.31 0.31 0.04 1.31 1.31 1.259 1.259
78206 TC 78206TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.93 8.93 0.03 8.96 8.96 8.035 8.035
78215 78215 A 1 XXX 0 0 0 0 0 0 0 0.49 5.36 5.36 0.06 5.91 5.91 5.335 5.335
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
357 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78215 26 7821526 A 1 XXX 0 0 0 0 0 0 0 0.49 0.17 0.17 0.03 0.69 0.69 0.658 0.658
78215 TC 78215TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.19 5.19 0.03 5.22 5.22 4.676 4.676
78216 78216 A 1 XXX 0 0 0 0 0 0 0 0.57 3.09 3.09 0.06 3.72 3.72 3.376 3.376
78216 26 7821626 A 1 XXX 0 0 0 0 0 0 0 0.57 0.17 0.17 0.03 0.77 0.77 0.738 0.738
78216 TC 78216TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.92 2.92 0.03 2.95 2.95 2.638 2.638
78226 78226 A 1 XXX 0 0 0 0 0 0 0 0.74 10.64 10.64 0.07 11.45 11.45 10.331 10.331
78226 26 7822626 A 1 XXX 0 0 0 0 0 0 0 0.74 0.30 0.30 0.04 1.08 1.08 1.030 1.030
78226 TC 78226TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.34 10.34 0.03 10.37 10.37 9.301 9.301
78227 78227 A 1 XXX 0 0 0 0 0 0 0 0.90 14.52 14.52 0.08 15.50 15.50 13.981 13.981
78227 26 7822726 A 1 XXX 0 0 0 0 0 0 0 0.90 0.36 0.36 0.04 1.30 1.30 1.244 1.244
78227 TC 78227TC A 1 XXX 0 0 0 0 0 0 0 0.00 14.16 14.16 0.04 14.20 14.20 12.737 12.737
78230 78230 A 1 XXX 0 0 0 0 0 0 0 0.45 4.73 4.73 0.06 5.24 5.24 4.729 4.729
78230 26 7823026 A 1 XXX 0 0 0 0 0 0 0 0.45 0.16 0.16 0.03 0.64 0.64 0.609 0.609
78230 TC 78230TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.57 4.57 0.03 4.60 4.60 4.120 4.120
78231 78231 A 1 XXX 0 0 0 0 0 0 0 0.52 3.33 3.33 0.04 3.89 3.89 3.531 3.531
78231 26 7823126 A 1 XXX 0 0 0 0 0 0 0 0.52 0.19 0.19 0.01 0.72 0.72 0.696 0.696
78231 TC 78231TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.14 3.14 0.03 3.17 3.17 2.835 2.835
78232 78232 A 1 XXX 0 0 0 0 0 0 0 0.47 2.40 2.40 0.06 2.93 2.93 2.657 2.657
78232 26 7823226 A 1 XXX 0 0 0 0 0 0 0 0.47 0.07 0.07 0.03 0.57 0.57 0.549 0.549
78232 TC 78232TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.33 2.33 0.03 2.36 2.36 2.108 2.108
78258 78258 A 1 XXX 0 0 0 0 0 0 0 0.74 5.99 5.99 0.06 6.79 6.79 6.150 6.150
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
358 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78258 26 7825826 A 1 XXX 0 0 0 0 0 0 0 0.74 0.25 0.25 0.03 1.02 1.02 0.980 0.980
78258 TC 78258TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.74 5.74 0.03 5.77 5.77 5.170 5.170
78261 78261 A 1 XXX 0 0 0 0 0 0 0 0.69 6.89 6.89 0.07 7.65 7.65 6.914 6.914
78261 26 7826126 A 1 XXX 0 0 0 0 0 0 0 0.69 0.25 0.25 0.04 0.98 0.98 0.935 0.935
78261 TC 78261TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.64 6.64 0.03 6.67 6.67 5.978 5.978
78262 78262 A 1 XXX 0 0 0 0 0 0 0 0.68 6.87 6.87 0.04 7.59 7.59 6.870 6.870
78262 26 7826226 A 1 XXX 0 0 0 0 0 0 0 0.68 0.25 0.25 0.01 0.94 0.94 0.910 0.910
78262 TC 78262TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.62 6.62 0.03 6.65 6.65 5.960 5.960
78264 78264 A 1 XXX 0 0 0 0 0 0 0 0.80 7.86 7.86 0.07 8.73 8.73 7.895 7.895
78264 26 7826426 A 1 XXX 0 0 0 0 0 0 0 0.80 0.27 0.27 0.04 1.11 1.11 1.063 1.063
78264 TC 78264TC A 1 XXX 0 0 0 0 0 0 0 0.00 7.59 7.59 0.03 7.62 7.62 6.832 6.832
78270 78270 A 1 XXX 0 0 0 0 0 0 0 0.20 2.36 2.36 0.02 2.58 2.58 2.330 2.330
78270 26 7827026 A 1 XXX 0 0 0 0 0 0 0 0.20 0.07 0.07 0.01 0.28 0.28 0.268 0.268
78270 TC 78270TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.29 2.29 0.01 2.30 2.30 2.062 2.062
78271 78271 A 1 XXX 0 0 0 0 0 0 0 0.20 2.60 2.60 0.02 2.82 2.82 2.545 2.545
78271 26 7827126 A 1 XXX 0 0 0 0 0 0 0 0.20 0.08 0.08 0.01 0.29 0.29 0.277 0.277
78271 TC 78271TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.52 2.52 0.01 2.53 2.53 2.268 2.268
78272 78272 A 1 XXX 0 0 0 0 0 0 0 0.27 2.53 2.53 0.04 2.84 2.84 2.563 2.563
78272 26 7827226 A 1 XXX 0 0 0 0 0 0 0 0.27 0.10 0.10 0.01 0.38 0.38 0.365 0.365
78272 TC 78272TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.43 2.43 0.03 2.46 2.46 2.198 2.198
78278 78278 A 1 XXX 0 0 0 0 0 0 0 0.99 9.49 9.49 0.08 10.56 10.56 9.554 9.554
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
359 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78278 26 7827826 A 1 XXX 0 0 0 0 0 0 0 0.99 0.34 0.34 0.05 1.38 1.38 1.321 1.321
78278 TC 78278TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.15 9.15 0.03 9.18 9.18 8.232 8.232
78282 78282 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78282 26 7828226 A 1 XXX 0 0 0 0 0 0 0 0.38 0.14 0.14 0.03 0.55 0.55 0.521 0.521
78282 TC 78282TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78290 78290 A 1 XXX 0 0 0 0 0 0 0 0.68 9.40 9.40 0.07 10.15 10.15 9.158 9.158
78290 26 7829026 A 1 XXX 0 0 0 0 0 0 0 0.68 0.23 0.23 0.04 0.95 0.95 0.907 0.907
78290 TC 78290TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.17 9.17 0.03 9.20 9.20 8.250 8.250
78291 78291 A 1 XXX 0 0 0 0 0 0 0 0.88 6.78 6.78 0.08 7.74 7.74 7.010 7.010
78291 26 7829126 A 1 XXX 0 0 0 0 0 0 0 0.88 0.29 0.29 0.05 1.22 1.22 1.167 1.167
78291 TC 78291TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.49 6.49 0.03 6.52 6.52 5.844 5.844
78299 78299 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78299 26 7829926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78299 TC 78299TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78300 78300 A 1 XXX 0 0 0 0 0 0 0 0.62 4.77 4.77 0.06 5.45 5.45 4.935 4.935
78300 26 7830026 A 1 XXX 0 0 0 0 0 0 0 0.62 0.22 0.22 0.03 0.87 0.87 0.833 0.833
78300 TC 78300TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.55 4.55 0.03 4.58 4.58 4.102 4.102
78305 78305 A 1 XXX 0 0 0 0 0 0 0 0.83 6.27 6.27 0.07 7.17 7.17 6.497 6.497
78305 26 7830526 A 1 XXX 0 0 0 0 0 0 0 0.83 0.29 0.29 0.04 1.16 1.16 1.111 1.111
78305 TC 78305TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.98 5.98 0.03 6.01 6.01 5.386 5.386
78306 78306 A 1 XXX 0 0 0 2 0 0 0 0.86 6.66 6.66 0.07 7.59 7.59 6.877 6.877
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
360 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78306 26 7830626 A 1 XXX 0 0 0 2 0 0 0 0.86 0.29 0.29 0.04 1.19 1.19 1.141 1.141
78306 TC 78306TC A 1 XXX 0 0 0 2 0 0 0 0.00 6.37 6.37 0.03 6.40 6.40 5.736 5.736
78315 78315 A 1 XXX 0 0 0 0 0 0 0 1.02 9.44 9.44 0.08 10.54 10.54 9.539 9.539
78315 26 7831526 A 1 XXX 0 0 0 0 0 0 0 1.02 0.35 0.35 0.05 1.42 1.42 1.360 1.360
78315 TC 78315TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.09 9.09 0.03 9.12 9.12 8.179 8.179
78320 78320 A 1 XXX 0 0 0 2 0 0 0 1.04 5.73 5.73 0.08 6.85 6.85 6.227 6.227
78320 26 7832026 A 1 XXX 0 0 0 2 0 0 0 1.04 0.33 0.33 0.05 1.42 1.42 1.362 1.362
78320 TC 78320TC A 1 XXX 0 0 0 2 0 0 0 0.00 5.40 5.40 0.03 5.43 5.43 4.865 4.865
78350 78350 N 1 XXX 0 0 0 9 9 9 9 0.22 0.75 0.75 0.02 0.99 0.99 0.904 0.904
78350 26 7835026 N 1 XXX 0 0 0 9 9 9 9 0.22 0.09 0.09 0.01 0.32 0.32 0.306 0.306
78350 TC 78350TC N 1 XXX 0 0 0 9 9 9 9 0.00 0.66 0.66 0.01 0.67 0.67 0.598 0.598
78351 78351 N 9 XXX 0 0 0 9 9 9 9 0.30 0.12 0.12 0.01 0.43 0.43 0.413 0.413
78399 78399 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78399 26 7839926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78399 TC 78399TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78414 78414 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78414 26 7841426 A 1 XXX 0 0 0 0 0 0 0 0.45 0.18 0.18 0.03 0.66 0.66 0.627 0.627
78414 TC 78414TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78428 78428 A 1 XXX 0 0 0 6 0 0 0 0.78 4.73 4.73 0.06 5.57 5.57 5.059 5.059
78428 26 7842826 A 1 XXX 0 0 0 6 0 0 0 0.78 0.26 0.26 0.03 1.07 1.07 1.029 1.029
78428 TC 78428TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.47 4.47 0.03 4.50 4.50 4.030 4.030
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
361 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78445 78445 A 1 XXX 0 0 0 6 0 0 0 0.49 4.69 4.69 0.04 5.22 5.22 4.723 4.723
78445 26 7844526 A 1 XXX 0 0 0 6 0 0 0 0.49 0.15 0.15 0.01 0.65 0.65 0.630 0.630
78445 TC 78445TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.54 4.54 0.03 4.57 4.57 4.093 4.093
78451 78451 A 1 XXX 0 0 0 6 0 0 0 1.38 9.13 9.13 0.08 10.59 10.59 9.621 9.621
78451 26 7845126 A 1 XXX 0 0 0 6 0 0 0 1.38 0.49 0.49 0.05 1.92 1.92 1.846 1.846
78451 TC 78451TC A 1 XXX 0 0 0 6 0 0 0 0.00 8.64 8.64 0.03 8.67 8.67 7.774 7.774
78452 78452 A 1 XXX 0 0 0 6 0 0 0 1.62 13.05 13.05 0.09 14.76 14.76 13.386 13.386
78452 26 7845226 A 1 XXX 0 0 0 6 0 0 0 1.62 0.58 0.58 0.05 2.25 2.25 2.167 2.167
78452 TC 78452TC A 1 XXX 0 0 0 6 0 0 0 0.00 12.47 12.47 0.04 12.51 12.51 11.219 11.219
78453 78453 A 1 XXX 0 0 0 6 0 0 0 1.00 8.12 8.12 0.08 9.20 9.20 8.334 8.334
78453 26 7845326 A 1 XXX 0 0 0 6 0 0 0 1.00 0.35 0.35 0.05 1.40 1.40 1.340 1.340
78453 TC 78453TC A 1 XXX 0 0 0 6 0 0 0 0.00 7.77 7.77 0.03 7.80 7.80 6.993 6.993
78454 78454 A 1 XXX 0 0 0 6 0 0 0 1.34 11.80 11.80 0.09 13.23 13.23 11.983 11.983
78454 26 7845426 A 1 XXX 0 0 0 6 0 0 0 1.34 0.48 0.48 0.05 1.87 1.87 1.797 1.797
78454 TC 78454TC A 1 XXX 0 0 0 6 0 0 0 0.00 11.32 11.32 0.04 11.36 11.36 10.186 10.186
78456 78456 A 1 XXX 0 0 0 6 9 9 9 1.00 9.68 9.68 0.06 10.74 10.74 9.724 9.724
78456 26 7845626 A 1 XXX 0 0 0 6 9 9 9 1.00 0.36 0.36 0.03 1.39 1.39 1.339 1.339
78456 TC 78456TC A 1 XXX 0 0 0 6 9 9 9 0.00 9.32 9.32 0.03 9.35 9.35 8.385 8.385
78457 78457 A 1 XXX 0 0 0 6 0 0 0 0.77 5.33 5.33 0.07 6.17 6.17 5.593 5.593
78457 26 7845726 A 1 XXX 0 0 0 6 0 0 0 0.77 0.27 0.27 0.04 1.08 1.08 1.033 1.033
78457 TC 78457TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.06 5.06 0.03 5.09 5.09 4.560 4.560
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
362 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78458 78458 A 1 XXX 0 0 0 6 2 0 0 0.90 4.68 4.68 0.08 5.66 5.66 5.144 5.144
78458 26 7845826 A 1 XXX 0 0 0 6 2 0 0 0.90 0.23 0.23 0.05 1.18 1.18 1.133 1.133
78458 TC 78458TC A 1 XXX 0 0 0 6 2 0 0 0.00 4.45 4.45 0.03 4.48 4.48 4.012 4.012
78459 78459 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78459 26 7845926 A 1 XXX 0 0 0 0 0 0 0 1.50 0.46 0.46 0.10 2.06 2.06 1.965 1.965
78459 TC 78459TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78466 78466 A 1 XXX 0 0 0 6 0 0 0 0.69 5.20 5.20 0.06 5.95 5.95 5.391 5.391
78466 26 7846626 A 1 XXX 0 0 0 6 0 0 0 0.69 0.28 0.28 0.03 1.00 1.00 0.957 0.957
78466 TC 78466TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.92 4.92 0.03 4.95 4.95 4.434 4.434
78468 78468 A 1 XXX 0 0 0 6 0 0 0 0.80 5.19 5.19 0.06 6.05 6.05 5.492 5.492
78468 26 7846826 A 1 XXX 0 0 0 6 0 0 0 0.80 0.29 0.29 0.03 1.12 1.12 1.076 1.076
78468 TC 78468TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.90 4.90 0.03 4.93 4.93 4.416 4.416
78469 78469 A 1 XXX 0 0 0 6 0 0 0 0.92 5.89 5.89 0.06 6.87 6.87 6.241 6.241
78469 26 7846926 A 1 XXX 0 0 0 6 0 0 0 0.92 0.35 0.35 0.03 1.30 1.30 1.250 1.250
78469 TC 78469TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.54 5.54 0.03 5.57 5.57 4.991 4.991
78472 78472 A 1 XXX 0 0 0 6 0 0 0 0.98 5.96 5.96 0.07 7.01 7.01 6.369 6.369
78472 26 7847226 A 1 XXX 0 0 0 6 0 0 0 0.98 0.34 0.34 0.04 1.36 1.36 1.306 1.306
78472 TC 78472TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.62 5.62 0.03 5.65 5.65 5.062 5.062
78473 78473 A 1 XXX 0 0 0 6 0 0 0 1.47 7.34 7.34 0.08 8.89 8.89 8.103 8.103
78473 26 7847326 A 1 XXX 0 0 0 6 0 0 0 1.47 0.52 0.52 0.05 2.04 2.04 1.963 1.963
78473 TC 78473TC A 1 XXX 0 0 0 6 0 0 0 0.00 6.82 6.82 0.03 6.85 6.85 6.140 6.140
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
363 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78481 78481 A 1 XXX 0 0 0 6 0 0 0 0.98 4.50 4.50 0.04 5.52 5.52 5.042 5.042
78481 26 7848126 A 1 XXX 0 0 0 6 0 0 0 0.98 0.35 0.35 0.03 1.36 1.36 1.310 1.310
78481 TC 78481TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.15 4.15 0.01 4.16 4.16 3.732 3.732
78483 78483 A 1 XXX 0 0 0 6 0 0 0 1.47 5.82 5.82 0.08 7.37 7.37 6.738 6.738
78483 26 7848326 A 1 XXX 0 0 0 6 0 0 0 1.47 0.53 0.53 0.05 2.05 2.05 1.972 1.972
78483 TC 78483TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.29 5.29 0.03 5.32 5.32 4.766 4.766
78491 78491 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78491 26 7849126 A 1 XXX 0 0 0 0 0 0 0 1.50 0.50 0.50 0.10 2.10 2.10 2.001 2.001
78491 TC 78491TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78492 78492 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78492 26 7849226 A 1 XXX 0 0 0 0 0 0 0 1.87 0.62 0.62 0.12 2.61 2.61 2.490 2.490
78492 TC 78492TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78494 78494 A 1 XXX 0 0 0 6 0 0 0 1.19 5.69 5.69 0.07 6.95 6.95 6.336 6.336
78494 26 7849426 A 1 XXX 0 0 0 6 0 0 0 1.19 0.42 0.42 0.04 1.65 1.65 1.588 1.588
78494 TC 78494TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.27 5.27 0.03 5.30 5.30 4.748 4.748
78496 78496 A 1 ZZZ 0 0 0 0 0 0 0 0.50 0.81 0.81 0.02 1.33 1.33 1.238 1.238
78496 26 7849626 A 1 ZZZ 0 0 0 0 0 0 0 0.50 0.18 0.18 0.01 0.69 0.69 0.667 0.667
78496 TC 78496TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.63 0.63 0.01 0.64 0.64 0.571 0.571
78499 78499 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78499 26 7849926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78499 TC 78499TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
364 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78579 78579 A 1 XXX 0 0 0 0 0 0 0 0.49 6.01 6.01 0.05 6.55 6.55 5.913 5.913
78579 26 7857926 A 1 XXX 0 0 0 0 0 0 0 0.49 0.20 0.20 0.03 0.72 0.72 0.685 0.685
78579 TC 78579TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.81 5.81 0.02 5.83 5.83 5.228 5.228
78580 78580 A 1 XXX 0 0 0 0 0 0 0 0.74 6.39 6.39 0.06 7.19 7.19 6.510 6.510
78580 26 7858026 A 1 XXX 0 0 0 0 0 0 0 0.74 0.25 0.25 0.03 1.02 1.02 0.980 0.980
78580 TC 78580TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.14 6.14 0.03 6.17 6.17 5.529 5.529
78582 78582 A 1 XXX 0 0 0 0 0 0 0 1.07 10.37 10.37 0.08 11.52 11.52 10.424 10.424
78582 26 7858226 A 1 XXX 0 0 0 0 0 0 0 1.07 0.43 0.43 0.05 1.55 1.55 1.482 1.482
78582 TC 78582TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.94 9.94 0.03 9.97 9.97 8.942 8.942
78597 78597 A 1 XXX 0 0 0 0 0 0 0 0.75 6.38 6.38 0.04 7.17 7.17 6.500 6.500
78597 26 7859726 A 1 XXX 0 0 0 0 0 0 0 0.75 0.30 0.30 0.02 1.07 1.07 1.030 1.030
78597 TC 78597TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.08 6.08 0.02 6.10 6.10 5.470 5.470
78598 78598 A 1 XXX 0 0 0 0 0 0 0 0.85 9.79 9.79 0.06 10.70 10.70 9.673 9.673
78598 26 7859826 A 1 XXX 0 0 0 0 0 0 0 0.85 0.34 0.34 0.03 1.22 1.22 1.171 1.171
78598 TC 78598TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.45 9.45 0.03 9.48 9.48 8.502 8.502
78599 78599 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78599 26 7859926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78599 TC 78599TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78600 78600 A 1 XXX 0 0 0 0 0 0 0 0.44 5.07 5.07 0.04 5.55 5.55 5.014 5.014
78600 26 7860026 A 1 XXX 0 0 0 0 0 0 0 0.44 0.16 0.16 0.01 0.61 0.61 0.589 0.589
78600 TC 78600TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.91 4.91 0.03 4.94 4.94 4.425 4.425
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
365 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78601 78601 A 1 XXX 0 0 0 0 0 0 0 0.51 5.98 5.98 0.06 6.55 6.55 5.911 5.911
78601 26 7860126 A 1 XXX 0 0 0 0 0 0 0 0.51 0.17 0.17 0.03 0.71 0.71 0.678 0.678
78601 TC 78601TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.81 5.81 0.03 5.84 5.84 5.233 5.233
78605 78605 A 1 XXX 0 0 0 0 0 0 0 0.53 5.39 5.39 0.06 5.98 5.98 5.402 5.402
78605 26 7860526 A 1 XXX 0 0 0 0 0 0 0 0.53 0.19 0.19 0.03 0.75 0.75 0.716 0.716
78605 TC 78605TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.20 5.20 0.03 5.23 5.23 4.685 4.685
78606 78606 A 1 XXX 0 0 0 0 0 0 0 0.64 9.39 9.39 0.04 10.07 10.07 9.093 9.093
78606 26 7860626 A 1 XXX 0 0 0 0 0 0 0 0.64 0.22 0.22 0.01 0.87 0.87 0.843 0.843
78606 TC 78606TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.17 9.17 0.03 9.20 9.20 8.250 8.250
78607 78607 A 1 XXX 0 0 0 0 0 0 0 1.23 9.33 9.33 0.08 10.64 10.64 9.650 9.650
78607 26 7860726 A 1 XXX 0 0 0 0 0 0 0 1.23 0.37 0.37 0.05 1.65 1.65 1.588 1.588
78607 TC 78607TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.96 8.96 0.03 8.99 8.99 8.062 8.062
78608 78608 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78608 26 7860826 A 1 XXX 0 0 0 0 0 0 0 1.50 0.46 0.46 0.11 2.07 2.07 1.971 1.971
78608 TC 78608TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78609 78609 N 1 XXX 0 0 0 9 9 9 9 1.50 0.61 0.61 0.10 2.21 2.21 2.100 2.100
78609 26 7860926 N 1 XXX 0 0 0 9 9 9 9 1.50 0.61 0.61 0.10 2.21 2.21 2.100 2.100
78609 TC 78609TC N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78610 78610 A 1 XXX 0 0 0 0 0 0 0 0.30 5.01 5.01 0.04 5.35 5.35 4.820 4.820
78610 26 7861026 A 1 XXX 0 0 0 0 0 0 0 0.30 0.11 0.11 0.01 0.42 0.42 0.404 0.404
78610 TC 78610TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.90 4.90 0.03 4.93 4.93 4.416 4.416
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
366 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78630 78630 A 1 XXX 0 0 0 0 0 0 0 0.68 9.72 9.72 0.06 10.46 10.46 9.440 9.440
78630 26 7863026 A 1 XXX 0 0 0 0 0 0 0 0.68 0.24 0.24 0.03 0.95 0.95 0.911 0.911
78630 TC 78630TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.48 9.48 0.03 9.51 9.51 8.529 8.529
78635 78635 A 1 XXX 0 0 0 0 0 0 0 0.61 9.60 9.60 0.04 10.25 10.25 9.252 9.252
78635 26 7863526 A 1 XXX 0 0 0 0 0 0 0 0.61 0.22 0.22 0.01 0.84 0.84 0.813 0.813
78635 TC 78635TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.38 9.38 0.03 9.41 9.41 8.439 8.439
78645 78645 A 1 XXX 0 0 0 0 0 0 0 0.57 9.11 9.11 0.06 9.74 9.74 8.782 8.782
78645 26 7864526 A 1 XXX 0 0 0 0 0 0 0 0.57 0.18 0.18 0.03 0.78 0.78 0.747 0.747
78645 TC 78645TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.93 8.93 0.03 8.96 8.96 8.035 8.035
78647 78647 A 1 XXX 0 0 0 0 0 0 0 0.90 10.11 10.11 0.08 11.09 11.09 10.021 10.021
78647 26 7864726 A 1 XXX 0 0 0 0 0 0 0 0.90 0.30 0.30 0.05 1.25 1.25 1.196 1.196
78647 TC 78647TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.81 9.81 0.03 9.84 9.84 8.825 8.825
78650 78650 A 1 XXX 0 0 0 0 0 0 0 0.61 9.43 9.43 0.07 10.11 10.11 9.115 9.115
78650 26 7865026 A 1 XXX 0 0 0 0 0 0 0 0.61 0.20 0.20 0.04 0.85 0.85 0.811 0.811
78650 TC 78650TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.23 9.23 0.03 9.26 9.26 8.304 8.304
78660 78660 A 1 XXX 0 0 0 0 0 0 0 0.53 5.13 5.13 0.06 5.72 5.72 5.168 5.168
78660 26 7866026 A 1 XXX 0 0 0 0 0 0 0 0.53 0.22 0.22 0.03 0.78 0.78 0.743 0.743
78660 TC 78660TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.91 4.91 0.03 4.94 4.94 4.425 4.425
78699 78699 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78699 26 7869926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78699 TC 78699TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
367 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78700 78700 A 1 XXX 0 0 0 0 0 0 0 0.45 4.85 4.85 0.06 5.36 5.36 4.837 4.837
78700 26 7870026 A 1 XXX 0 0 0 0 0 0 0 0.45 0.16 0.16 0.03 0.64 0.64 0.609 0.609
78700 TC 78700TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.69 4.69 0.03 4.72 4.72 4.227 4.227
78701 78701 A 1 XXX 0 0 0 0 0 0 0 0.49 5.91 5.91 0.06 6.46 6.46 5.829 5.829
78701 26 7870126 A 1 XXX 0 0 0 0 0 0 0 0.49 0.17 0.17 0.03 0.69 0.69 0.658 0.658
78701 TC 78701TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.74 5.74 0.03 5.77 5.77 5.170 5.170
78707 78707 A 1 XXX 0 0 0 0 0 0 0 0.96 5.94 5.94 0.07 6.97 6.97 6.331 6.331
78707 26 7870726 A 1 XXX 0 0 0 0 0 0 0 0.96 0.31 0.31 0.04 1.31 1.31 1.259 1.259
78707 TC 78707TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.63 5.63 0.03 5.66 5.66 5.071 5.071
78708 78708 A 1 XXX 0 0 0 0 0 0 0 1.21 3.86 3.86 0.08 5.15 5.15 4.718 4.718
78708 26 7870826 A 1 XXX 0 0 0 0 0 0 0 1.21 0.40 0.40 0.05 1.66 1.66 1.595 1.595
78708 TC 78708TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.46 3.46 0.03 3.49 3.49 3.123 3.123
78709 78709 A 1 XXX 0 0 0 0 0 0 0 1.41 9.61 9.61 0.10 11.12 11.12 10.092 10.092
78709 26 7870926 A 1 XXX 0 0 0 0 0 0 0 1.41 0.46 0.46 0.07 1.94 1.94 1.860 1.860
78709 TC 78709TC A 1 XXX 0 0 0 0 0 0 0 0.00 9.15 9.15 0.03 9.18 9.18 8.232 8.232
78710 78710 A 1 XXX 0 0 0 0 0 0 0 0.66 5.48 5.48 0.04 6.18 6.18 5.602 5.602
78710 26 7871026 A 1 XXX 0 0 0 0 0 0 0 0.66 0.18 0.18 0.01 0.85 0.85 0.827 0.827
78710 TC 78710TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.30 5.30 0.03 5.33 5.33 4.775 4.775
78725 78725 A 1 XXX 0 0 0 0 0 0 0 0.38 2.93 2.93 0.04 3.35 3.35 3.032 3.032
78725 26 7872526 A 1 XXX 0 0 0 0 0 0 0 0.38 0.13 0.13 0.01 0.52 0.52 0.502 0.502
78725 TC 78725TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.80 2.80 0.03 2.83 2.83 2.530 2.530
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
368 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78730 78730 A 1 ZZZ 0 0 0 0 0 0 0 0.15 1.83 1.83 0.02 2.00 2.00 1.804 1.804
78730 26 7873026 A 1 ZZZ 0 0 0 0 0 0 0 0.15 0.05 0.05 0.01 0.21 0.21 0.200 0.200
78730 TC 78730TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 1.78 1.78 0.01 1.79 1.79 1.604 1.604
78740 78740 A 1 XXX 0 0 0 0 0 0 0 0.57 6.38 6.38 0.06 7.01 7.01 6.331 6.331
78740 26 7874026 A 1 XXX 0 0 0 0 0 0 0 0.57 0.21 0.21 0.03 0.81 0.81 0.774 0.774
78740 TC 78740TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.17 6.17 0.03 6.20 6.20 5.556 5.556
78761 78761 A 1 XXX 0 0 0 0 0 0 0 0.71 5.75 5.75 0.07 6.53 6.53 5.910 5.910
78761 26 7876126 A 1 XXX 0 0 0 0 0 0 0 0.71 0.25 0.25 0.04 1.00 1.00 0.955 0.955
78761 TC 78761TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.50 5.50 0.03 5.53 5.53 4.955 4.955
78799 78799 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78799 26 7879926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78799 TC 78799TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78800 78800 A 1 XXX 0 0 0 0 0 0 0 0.66 5.01 5.01 0.07 5.74 5.74 5.196 5.196
78800 26 7880026 A 1 XXX 0 0 0 0 0 0 0 0.66 0.24 0.24 0.04 0.94 0.94 0.896 0.896
78800 TC 78800TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.77 4.77 0.03 4.80 4.80 4.299 4.299
78801 78801 A 1 XXX 0 0 0 0 0 0 0 0.79 6.51 6.51 0.07 7.37 7.37 6.673 6.673
78801 26 7880126 A 1 XXX 0 0 0 0 0 0 0 0.79 0.27 0.27 0.04 1.10 1.10 1.053 1.053
78801 TC 78801TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.24 6.24 0.03 6.27 6.27 5.619 5.619
78802 78802 A 1 XXX 0 0 0 2 0 0 0 0.86 8.85 8.85 0.07 9.78 9.78 8.844 8.844
78802 26 7880226 A 1 XXX 0 0 0 2 0 0 0 0.86 0.28 0.28 0.04 1.18 1.18 1.132 1.132
78802 TC 78802TC A 1 XXX 0 0 0 2 0 0 0 0.00 8.57 8.57 0.03 8.60 8.60 7.712 7.712
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
369 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78803 78803 A 1 XXX 0 0 0 2 0 0 0 1.09 9.13 9.13 0.08 10.30 10.30 9.331 9.331
78803 26 7880326 A 1 XXX 0 0 0 2 0 0 0 1.09 0.33 0.33 0.05 1.47 1.47 1.412 1.412
78803 TC 78803TC A 1 XXX 0 0 0 2 0 0 0 0.00 8.80 8.80 0.03 8.83 8.83 7.918 7.918
78804 78804 A 1 XXX 0 0 0 0 0 0 0 1.07 16.06 16.06 0.10 17.23 17.23 15.544 15.544
78804 26 7880426 A 1 XXX 0 0 0 0 0 0 0 1.07 0.35 0.35 0.05 1.47 1.47 1.410 1.410
78804 TC 78804TC A 1 XXX 0 0 0 0 0 0 0 0.00 15.71 15.71 0.05 15.76 15.76 14.134 14.134
78805 78805 A 1 XXX 0 0 0 0 0 0 0 0.73 4.72 4.72 0.07 5.52 5.52 5.005 5.005
78805 26 7880526 A 1 XXX 0 0 0 0 0 0 0 0.73 0.25 0.25 0.04 1.02 1.02 0.975 0.975
78805 TC 78805TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.47 4.47 0.03 4.50 4.50 4.030 4.030
78806 78806 A 1 XXX 0 0 0 2 0 0 0 0.86 9.10 9.10 0.07 10.03 10.03 9.068 9.068
78806 26 7880626 A 1 XXX 0 0 0 2 0 0 0 0.86 0.28 0.28 0.04 1.18 1.18 1.132 1.132
78806 TC 78806TC A 1 XXX 0 0 0 2 0 0 0 0.00 8.82 8.82 0.03 8.85 8.85 7.936 7.936
78807 78807 A 1 XXX 0 0 0 2 0 0 0 1.09 9.05 9.05 0.07 10.21 10.21 9.254 9.254
78807 26 7880726 A 1 XXX 0 0 0 2 0 0 0 1.09 0.32 0.32 0.04 1.45 1.45 1.398 1.398
78807 TC 78807TC A 1 XXX 0 0 0 2 0 0 0 0.00 8.73 8.73 0.03 8.76 8.76 7.855 7.855
78808 78808 A 5 XXX 0 0 0 0 0 0 0 0.18 1.14 1.14 0.03 1.35 1.35 1.219 1.219
78811 78811 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78811 26 7881126 A 1 XXX 0 0 0 0 0 0 0 1.54 0.53 0.53 0.18 2.25 2.25 2.110 2.110
78811 TC 78811TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78812 78812 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78812 26 7881226 A 1 XXX 0 0 0 0 0 0 0 1.93 0.64 0.64 0.16 2.73 2.73 2.588 2.588
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
370 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
78812 TC 78812TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78813 78813 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78813 26 7881326 A 1 XXX 0 0 0 0 0 0 0 2.00 0.66 0.66 0.18 2.84 2.84 2.687 2.687
78813 TC 78813TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78814 78814 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78814 26 7881426 A 1 XXX 0 0 0 0 0 0 0 2.20 0.74 0.74 0.20 3.14 3.14 2.969 2.969
78814 TC 78814TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78815 78815 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78815 26 7881526 A 1 XXX 0 0 0 0 0 0 0 2.44 0.81 0.81 0.22 3.47 3.47 3.282 3.282
78815 TC 78815TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78816 78816 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78816 26 7881626 A 1 XXX 0 0 0 0 0 0 0 2.50 0.78 0.78 0.22 3.50 3.50 3.316 3.316
78816 TC 78816TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78999 78999 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78999 26 7899926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
78999 TC 78999TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
79005 79005 A 1 XXX 0 0 0 0 0 0 0 1.80 2.06 2.06 0.08 3.94 3.94 3.692 3.692
79005 26 7900526 A 1 XXX 0 0 0 0 0 0 0 1.80 0.61 0.61 0.07 2.48 2.48 2.384 2.384
79005 TC 79005TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.45 1.45 0.01 1.46 1.46 1.307 1.307
79101 79101 A 1 XXX 0 0 0 0 0 0 0 1.96 2.16 2.16 0.08 4.20 4.20 3.942 3.942
79101 26 7910126 A 1 XXX 0 0 0 0 0 0 0 1.96 0.66 0.66 0.07 2.69 2.69 2.589 2.589
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
371 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
79101 TC 79101TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.50 1.50 0.01 1.51 1.51 1.352 1.352
79200 79200 A 1 XXX 0 0 0 0 0 0 0 1.99 2.47 2.47 0.12 4.58 4.58 4.271 4.271
79200 26 7920026 A 1 XXX 0 0 0 0 0 0 0 1.99 0.81 0.81 0.11 2.91 2.91 2.775 2.775
79200 TC 79200TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.66 1.66 0.01 1.67 1.67 1.496 1.496
79300 79300 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
79300 26 7930026 A 1 XXX 0 0 0 0 0 0 0 1.60 0.59 0.59 0.14 2.33 2.33 2.203 2.203
79300 TC 79300TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
79403 79403 A 1 XXX 0 0 0 0 0 0 0 2.25 3.19 3.19 0.14 5.58 5.58 5.188 5.188
79403 26 7940326 A 1 XXX 0 0 0 0 0 0 0 2.25 0.81 0.81 0.11 3.17 3.17 3.035 3.035
79403 TC 79403TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.38 2.38 0.03 2.41 2.41 2.153 2.153
79440 79440 A 1 XXX 0 0 0 0 0 0 0 1.99 2.15 2.15 0.06 4.20 4.20 3.952 3.952
79440 26 7944026 A 1 XXX 0 0 0 0 0 0 0 1.99 0.74 0.74 0.05 2.78 2.78 2.681 2.681
79440 TC 79440TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.41 1.41 0.01 1.42 1.42 1.271 1.271
79445 79445 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
79445 26 7944526 A 1 XXX 0 0 0 0 0 0 0 2.40 0.72 0.72 0.20 3.32 3.32 3.151 3.151
79445 TC 79445TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
79999 79999 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
79999 26 7999926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
79999 TC 79999TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
80050 80050 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
80055 80055 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
372 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
80101 80101 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
80103 80103 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
80104 80104 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
80500 80500 A 0 XXX 0 0 0 0 0 0 0 0.37 0.20 0.13 0.03 0.60 0.53 0.565 0.502
80502 80502 A 0 XXX 0 0 0 0 0 0 0 1.33 0.52 0.45 0.07 1.92 1.85 1.834 1.771
81099 81099 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81200 81200 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81205 81205 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81206 81206 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81207 81207 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81208 81208 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81209 81209 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81210 81210 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81211 81211 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81212 81212 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81213 81213 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81214 81214 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81215 81215 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81216 81216 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81217 81217 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81220 81220 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
373 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
81221 81221 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81222 81222 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81223 81223 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81224 81224 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81225 81225 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81226 81226 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81227 81227 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81228 81228 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81229 81229 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81240 81240 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81241 81241 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81242 81242 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81243 81243 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81244 81244 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81245 81245 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81250 81250 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81251 81251 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81255 81255 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81256 81256 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81257 81257 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81260 81260 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
374 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
81261 81261 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81262 81262 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81263 81263 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81264 81264 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81265 81265 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81266 81266 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81267 81267 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81268 81268 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81270 81270 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81275 81275 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81280 81280 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81281 81281 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81282 81282 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81290 81290 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81291 81291 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81292 81292 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81293 81293 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81294 81294 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81295 81295 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81296 81296 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81297 81297 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
375 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
81298 81298 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81299 81299 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81300 81300 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81301 81301 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81302 81302 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81303 81303 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81304 81304 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81310 81310 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81315 81315 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81316 81316 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81317 81317 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81318 81318 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81319 81319 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81330 81330 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81331 81331 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81332 81332 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81340 81340 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81341 81341 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81342 81342 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81350 81350 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81355 81355 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
376 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
81370 81370 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81371 81371 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81372 81372 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81373 81373 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81374 81374 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81375 81375 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81376 81376 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81377 81377 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81378 81378 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81379 81379 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81380 81380 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81381 81381 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81382 81382 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81383 81383 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81400 81400 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81401 81401 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81402 81402 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81403 81403 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81404 81404 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81405 81405 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81406 81406 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
377 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
81407 81407 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81408 81408 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81479 81479 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81500 81500 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81503 81503 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81506 81506 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81508 81508 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81509 81509 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81510 81510 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81511 81511 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81512 81512 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
81599 81599 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
83020 26 8302026 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
84165 26 8416526 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
84166 26 8416626 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
84181 26 8418126 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
84182 26 8418226 A 6 XXX 0 0 0 0 0 0 0 0.37 0.14 0.14 0.03 0.54 0.54 0.511 0.511
84999 84999 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
85060 85060 A 8 XXX 0 0 0 0 0 0 0 0.45 0.23 0.23 0.03 0.71 0.71 0.672 0.672
85097 85097 A 0 XXX 0 0 0 0 0 0 0 0.94 1.54 0.41 0.05 2.53 1.40 2.349 1.334
85390 26 8539026 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
378 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
85396 85396 A 0 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
85576 26 8557626 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
85999 85999 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86077 86077 A 0 XXX 0 0 0 0 0 0 0 0.94 0.58 0.47 0.05 1.57 1.46 1.487 1.388
86078 86078 A 0 XXX 0 0 0 0 0 0 0 0.94 0.59 0.47 0.05 1.58 1.46 1.496 1.388
86079 86079 A 0 XXX 0 0 0 0 0 0 0 0.94 0.58 0.47 0.05 1.57 1.46 1.487 1.388
86153 26 8615326 A 6 XXX 0 0 0 0 0 0 0 0.69 0.28 0.28 0.02 0.99 0.99 0.952 0.952
86255 26 8625526 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
86256 26 8625626 A 6 XXX 0 0 0 0 0 0 0 0.37 0.18 0.18 0.01 0.56 0.56 0.537 0.537
86320 26 8632026 A 6 XXX 0 0 0 0 0 0 0 0.37 0.16 0.16 0.01 0.54 0.54 0.519 0.519
86325 26 8632526 A 6 XXX 0 0 0 0 0 0 0 0.37 0.17 0.17 0.01 0.55 0.55 0.528 0.528
86327 26 8632726 A 6 XXX 0 0 0 0 0 0 0 0.42 0.22 0.22 0.03 0.67 0.67 0.633 0.633
86334 26 8633426 A 6 XXX 0 0 0 0 0 0 0 0.37 0.18 0.18 0.03 0.58 0.58 0.547 0.547
86335 26 8633526 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
86485 86485 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86486 86486 A 3 XXX 0 0 0 0 0 0 0 0.00 0.16 0.16 0.01 0.17 0.17 0.149 0.149
86490 86490 A 3 XXX 0 0 0 0 0 0 0 0.00 0.14 0.14 0.01 0.15 0.15 0.131 0.131
86510 86510 A 3 XXX 0 0 0 0 0 0 0 0.00 0.18 0.18 0.01 0.19 0.19 0.167 0.167
86580 86580 A 3 XXX 0 0 0 0 0 0 0 0.00 0.23 0.23 0.01 0.24 0.24 0.212 0.212
86849 86849 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86850 86850 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
379 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
86860 86860 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86870 86870 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86890 86890 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86891 86891 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86910 86910 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86911 86911 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86920 86920 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86921 86921 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86922 86922 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86923 86923 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86927 86927 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86930 86930 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86931 86931 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86932 86932 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86945 86945 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86950 86950 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86960 86960 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86965 86965 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86970 86970 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86971 86971 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86972 86972 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
380 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
86975 86975 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86976 86976 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86977 86977 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86978 86978 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86985 86985 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
86999 86999 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
87164 26 8716426 A 6 XXX 0 0 0 0 0 0 0 0.37 0.16 0.16 0.03 0.56 0.56 0.529 0.529
87207 26 8720726 A 6 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.03 0.59 0.59 0.556 0.556
87999 87999 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88000 88000 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88005 88005 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88007 88007 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88012 88012 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88014 88014 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88016 88016 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88020 88020 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88025 88025 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88027 88027 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88028 88028 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88029 88029 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88036 88036 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
381 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88037 88037 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88040 88040 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88045 88045 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88099 88099 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88104 88104 A 1 XXX 0 0 0 0 0 0 0 0.56 1.66 1.66 0.02 2.24 2.24 2.061 2.061
88104 26 8810426 A 1 XXX 0 0 0 0 0 0 0 0.56 0.27 0.27 0.01 0.84 0.84 0.808 0.808
88104 TC 88104TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.39 1.39 0.01 1.40 1.40 1.253 1.253
88106 88106 A 1 XXX 0 0 0 0 0 0 0 0.37 2.12 2.12 0.02 2.51 2.51 2.284 2.284
88106 26 8810626 A 1 XXX 0 0 0 0 0 0 0 0.37 0.18 0.18 0.01 0.56 0.56 0.537 0.537
88106 TC 88106TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.94 1.94 0.01 1.95 1.95 1.747 1.747
88108 88108 A 1 XXX 0 0 0 0 0 0 0 0.44 1.86 1.86 0.02 2.32 2.32 2.121 2.121
88108 26 8810826 A 1 XXX 0 0 0 0 0 0 0 0.44 0.20 0.20 0.01 0.65 0.65 0.625 0.625
88108 TC 88108TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.66 1.66 0.01 1.67 1.67 1.496 1.496
88112 88112 A 1 XXX 0 0 0 0 0 0 0 1.18 1.99 1.99 0.05 3.22 3.22 2.993 2.993
88112 26 8811226 A 1 XXX 0 0 0 0 0 0 0 1.18 0.49 0.49 0.04 1.71 1.71 1.641 1.641
88112 TC 88112TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.50 1.50 0.01 1.51 1.51 1.352 1.352
88120 88120 A 1 XXX 0 0 0 0 0 0 0 1.20 16.99 16.99 0.06 18.25 18.25 16.488 16.488
88120 26 8812026 A 1 XXX 0 0 0 0 0 0 0 1.20 0.43 0.43 0.03 1.66 1.66 1.602 1.602
88120 TC 88120TC A 1 XXX 0 0 0 0 0 0 0 0.00 16.56 16.56 0.03 16.59 16.59 14.887 14.887
88121 88121 A 1 XXX 0 0 0 0 0 0 0 1.00 15.36 15.36 0.04 16.40 16.40 14.814 14.814
88121 26 8812126 A 1 XXX 0 0 0 0 0 0 0 1.00 0.42 0.42 0.03 1.45 1.45 1.393 1.393
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
382 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88121 TC 88121TC A 1 XXX 0 0 0 0 0 0 0 0.00 14.94 14.94 0.01 14.95 14.95 13.421 13.421
88125 88125 A 1 XXX 0 0 0 0 0 0 0 0.26 0.38 0.38 0.02 0.66 0.66 0.612 0.612
88125 26 8812526 A 1 XXX 0 0 0 0 0 0 0 0.26 0.11 0.11 0.01 0.38 0.38 0.364 0.364
88125 TC 88125TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.27 0.27 0.01 0.28 0.28 0.248 0.248
88141 88141 A 2 XXX 0 0 0 0 0 0 0 0.42 0.48 0.48 0.03 0.93 0.93 0.867 0.867
88160 88160 A 1 XXX 0 0 0 0 0 0 0 0.50 1.35 1.35 0.02 1.87 1.87 1.723 1.723
88160 26 8816026 A 1 XXX 0 0 0 0 0 0 0 0.50 0.24 0.24 0.01 0.75 0.75 0.721 0.721
88160 TC 88160TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.11 1.11 0.01 1.12 1.12 1.002 1.002
88161 88161 A 1 XXX 0 0 0 0 0 0 0 0.50 1.26 1.26 0.02 1.78 1.78 1.642 1.642
88161 26 8816126 A 1 XXX 0 0 0 0 0 0 0 0.50 0.21 0.21 0.01 0.72 0.72 0.694 0.694
88161 TC 88161TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.05 1.05 0.01 1.06 1.06 0.948 0.948
88162 88162 A 1 XXX 0 0 0 0 0 0 0 0.76 2.03 2.03 0.04 2.83 2.83 2.604 2.604
88162 26 8816226 A 1 XXX 0 0 0 0 0 0 0 0.76 0.36 0.36 0.03 1.15 1.15 1.099 1.099
88162 TC 88162TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.67 1.67 0.01 1.68 1.68 1.505 1.505
88172 88172 A 1 XXX 0 0 0 0 0 0 0 0.69 0.90 0.90 0.02 1.61 1.61 1.509 1.509
88172 26 8817226 A 1 XXX 0 0 0 0 0 0 0 0.69 0.34 0.34 0.01 1.04 1.04 1.001 1.001
88172 TC 88172TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.56 0.56 0.01 0.57 0.57 0.508 0.508
88173 88173 A 1 XXX 0 0 0 0 0 0 0 1.39 2.97 2.97 0.05 4.41 4.41 4.083 4.083
88173 26 8817326 A 1 XXX 0 0 0 0 0 0 0 1.39 0.63 0.63 0.04 2.06 2.06 1.977 1.977
88173 TC 88173TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.34 2.34 0.01 2.35 2.35 2.107 2.107
88177 88177 A 1 ZZZ 0 0 0 0 0 0 0 0.42 0.43 0.43 0.02 0.87 0.87 0.817 0.817
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
383 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88177 26 8817726 A 1 ZZZ 0 0 0 0 0 0 0 0.42 0.21 0.21 0.01 0.64 0.64 0.614 0.614
88177 TC 88177TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.22 0.22 0.01 0.23 0.23 0.203 0.203
88182 88182 A 1 XXX 0 0 0 0 0 0 0 0.77 2.38 2.38 0.06 3.21 3.21 2.939 2.939
88182 26 8818226 A 1 XXX 0 0 0 0 0 0 0 0.77 0.23 0.23 0.03 1.03 1.03 0.992 0.992
88182 TC 88182TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.15 2.15 0.03 2.18 2.18 1.946 1.946
88184 88184 A 3 XXX 0 0 0 0 0 0 0 0.00 2.60 2.60 0.01 2.61 2.61 2.340 2.340
88185 88185 A 3 ZZZ 0 0 0 0 0 0 0 0.00 1.58 1.58 0.01 1.59 1.59 1.424 1.424
88187 88187 A 2 XXX 0 0 0 0 0 0 0 1.36 0.58 0.58 0.08 2.02 2.02 1.923 1.923
88188 88188 A 2 XXX 0 0 0 0 0 0 0 1.69 0.79 0.79 0.10 2.58 2.58 2.452 2.452
88189 88189 A 2 XXX 0 0 0 0 0 0 0 2.23 0.78 0.78 0.12 3.13 3.13 2.993 2.993
88199 88199 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88199 26 8819926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88199 TC 88199TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88291 88291 A 2 XXX 0 0 0 0 0 0 0 0.52 0.35 0.35 0.03 0.90 0.90 0.850 0.850
88299 88299 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88300 88300 A 1 XXX 0 0 0 0 0 0 0 0.08 0.33 0.33 0.02 0.43 0.43 0.387 0.387
88300 26 8830026 A 1 XXX 0 0 0 0 0 0 0 0.08 0.04 0.04 0.01 0.13 0.13 0.121 0.121
88300 TC 88300TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.29 0.29 0.01 0.30 0.30 0.266 0.266
88302 88302 A 1 XXX 0 0 0 0 0 0 0 0.13 0.76 0.76 0.02 0.91 0.91 0.823 0.823
88302 26 8830226 A 1 XXX 0 0 0 0 0 0 0 0.13 0.06 0.06 0.01 0.20 0.20 0.189 0.189
88302 TC 88302TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.70 0.70 0.01 0.71 0.71 0.634 0.634
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
384 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88304 88304 A 1 XXX 0 0 0 0 0 0 0 0.22 1.07 1.07 0.02 1.31 1.31 1.191 1.191
88304 26 8830426 A 1 XXX 0 0 0 0 0 0 0 0.22 0.10 0.10 0.01 0.33 0.33 0.315 0.315
88304 TC 88304TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.97 0.97 0.01 0.98 0.98 0.876 0.876
88305 88305 A 1 XXX 0 0 0 0 0 0 0 0.75 1.29 1.29 0.02 2.06 2.06 1.919 1.919
88305 26 8830526 A 1 XXX 0 0 0 0 0 0 0 0.75 0.32 0.32 0.01 1.08 1.08 1.043 1.043
88305 TC 88305TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.97 0.97 0.01 0.98 0.98 0.876 0.876
88307 88307 A 1 XXX 0 0 0 0 0 0 0 1.59 7.10 7.10 0.05 8.74 8.74 7.992 7.992
88307 26 8830726 A 1 XXX 0 0 0 0 0 0 0 1.59 0.78 0.78 0.04 2.41 2.41 2.311 2.311
88307 TC 88307TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.32 6.32 0.01 6.33 6.33 5.681 5.681
88309 88309 A 1 XXX 0 0 0 0 0 0 0 2.80 10.30 10.30 0.11 13.21 13.21 12.107 12.107
88309 26 8830926 A 1 XXX 0 0 0 0 0 0 0 2.80 1.38 1.38 0.08 4.26 4.26 4.081 4.081
88309 TC 88309TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.92 8.92 0.03 8.95 8.95 8.026 8.026
88311 88311 A 1 XXX 0 0 0 0 0 0 0 0.24 0.34 0.34 0.02 0.60 0.60 0.556 0.556
88311 26 8831126 A 1 XXX 0 0 0 0 0 0 0 0.24 0.11 0.11 0.01 0.36 0.36 0.344 0.344
88311 TC 88311TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.23 0.23 0.01 0.24 0.24 0.212 0.212
88312 88312 A 1 XXX 0 0 0 0 0 0 0 0.54 2.31 2.31 0.02 2.87 2.87 2.625 2.625
88312 26 8831226 A 1 XXX 0 0 0 0 0 0 0 0.54 0.23 0.23 0.01 0.78 0.78 0.752 0.752
88312 TC 88312TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.08 2.08 0.01 2.09 2.09 1.873 1.873
88313 88313 A 1 XXX 0 0 0 0 0 0 0 0.24 1.73 1.73 0.02 1.99 1.99 1.804 1.804
88313 26 8831326 A 1 XXX 0 0 0 0 0 0 0 0.24 0.10 0.10 0.01 0.35 0.35 0.335 0.335
88313 TC 88313TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.63 1.63 0.01 1.64 1.64 1.469 1.469
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
385 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88314 88314 A 1 XXX 0 0 0 0 0 0 0 0.45 1.91 1.91 0.02 2.38 2.38 2.176 2.176
88314 26 8831426 A 1 XXX 0 0 0 0 0 0 0 0.45 0.20 0.20 0.01 0.66 0.66 0.635 0.635
88314 TC 88314TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.71 1.71 0.01 1.72 1.72 1.541 1.541
88319 88319 A 1 XXX 0 0 0 0 0 0 0 0.53 2.00 2.00 0.04 2.57 2.57 2.347 2.347
88319 26 8831926 A 1 XXX 0 0 0 0 0 0 0 0.53 0.24 0.24 0.03 0.80 0.80 0.761 0.761
88319 TC 88319TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.76 1.76 0.01 1.77 1.77 1.586 1.586
88321 88321 A 0 XXX 0 0 0 0 0 0 0 1.63 1.01 0.72 0.10 2.74 2.45 2.589 2.329
88323 88323 A 1 XXX 0 0 0 0 0 0 0 1.83 2.28 2.28 0.05 4.16 4.16 3.904 3.904
88323 26 8832326 A 1 XXX 0 0 0 0 0 0 0 1.83 0.57 0.57 0.04 2.44 2.44 2.363 2.363
88323 TC 88323TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.71 1.71 0.01 1.72 1.72 1.541 1.541
88325 88325 A 0 XXX 0 0 0 0 0 0 0 2.50 3.56 1.17 0.12 6.18 3.79 5.760 3.613
88329 88329 A 0 XXX 0 0 0 0 0 0 0 0.67 0.98 0.34 0.04 1.69 1.05 1.571 0.996
88331 88331 A 1 XXX 0 0 0 0 0 0 0 1.19 1.72 1.72 0.02 2.93 2.93 2.745 2.745
88331 26 8833126 A 1 XXX 0 0 0 0 0 0 0 1.19 0.60 0.60 0.01 1.80 1.80 1.734 1.734
88331 TC 88331TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.12 1.12 0.01 1.13 1.13 1.011 1.011
88332 88332 A 1 XXX 0 0 0 0 0 0 0 0.59 0.67 0.67 0.02 1.28 1.28 1.202 1.202
88332 26 8833226 A 1 XXX 0 0 0 0 0 0 0 0.59 0.29 0.29 0.01 0.89 0.89 0.856 0.856
88332 TC 88332TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.38 0.38 0.01 0.39 0.39 0.346 0.346
88333 88333 A 1 XXX 0 0 0 0 0 0 0 1.20 1.84 1.84 0.05 3.09 3.09 2.878 2.878
88333 26 8833326 A 1 XXX 0 0 0 0 0 0 0 1.20 0.59 0.59 0.04 1.83 1.83 1.751 1.751
88333 TC 88333TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.25 1.25 0.01 1.26 1.26 1.128 1.128
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
386 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88334 88334 A 1 XXX 0 0 0 0 0 0 0 0.73 1.16 1.16 0.04 1.93 1.93 1.793 1.793
88334 26 8833426 A 1 XXX 0 0 0 0 0 0 0 0.73 0.37 0.37 0.03 1.13 1.13 1.078 1.078
88334 TC 88334TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.79 0.79 0.01 0.80 0.80 0.715 0.715
88342 88342 A 1 XXX 0 0 0 0 0 0 0 0.85 2.50 2.50 0.04 3.39 3.39 3.116 3.116
88342 26 8834226 A 1 XXX 0 0 0 0 0 0 0 0.85 0.36 0.36 0.03 1.24 1.24 1.189 1.189
88342 TC 88342TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.14 2.14 0.01 2.15 2.15 1.927 1.927
88346 88346 A 1 XXX 0 0 0 0 0 0 0 0.86 2.33 2.33 0.02 3.21 3.21 2.963 2.963
88346 26 8834626 A 1 XXX 0 0 0 0 0 0 0 0.86 0.36 0.36 0.01 1.23 1.23 1.189 1.189
88346 TC 88346TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.97 1.97 0.01 1.98 1.98 1.774 1.774
88347 88347 A 1 XXX 0 0 0 0 0 0 0 0.86 1.45 1.45 0.02 2.33 2.33 2.173 2.173
88347 26 8834726 A 1 XXX 0 0 0 0 0 0 0 0.86 0.25 0.25 0.01 1.12 1.12 1.090 1.090
88347 TC 88347TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.20 1.20 0.01 1.21 1.21 1.083 1.083
88348 88348 A 1 XXX 0 0 0 0 0 0 0 1.51 19.69 19.69 0.12 21.32 21.32 19.254 19.254
88348 26 8834826 A 1 XXX 0 0 0 0 0 0 0 1.51 0.63 0.63 0.04 2.18 2.18 2.097 2.097
88348 TC 88348TC A 1 XXX 0 0 0 0 0 0 0 0.00 19.06 19.06 0.08 19.14 19.14 17.158 17.158
88349 88349 A 1 XXX 0 0 0 0 0 0 0 0.76 12.03 12.03 0.07 12.86 12.86 11.600 11.600
88349 26 8834926 A 1 XXX 0 0 0 0 0 0 0 0.76 0.39 0.39 0.03 1.18 1.18 1.126 1.126
88349 TC 88349TC A 1 XXX 0 0 0 0 0 0 0 0.00 11.64 11.64 0.04 11.68 11.68 10.474 10.474
88355 88355 A 1 XXX 0 0 0 0 0 0 0 1.85 3.46 3.46 0.06 5.37 5.37 4.988 4.988
88355 26 8835526 A 1 XXX 0 0 0 0 0 0 0 1.85 0.53 0.53 0.05 2.43 2.43 2.352 2.352
88355 TC 88355TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.93 2.93 0.01 2.94 2.94 2.636 2.636
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
387 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88356 88356 A 1 XXX 0 0 0 0 0 0 0 3.02 4.96 4.96 0.18 8.16 8.16 7.568 7.568
88356 26 8835626 A 1 XXX 0 0 0 0 0 0 0 3.02 0.60 0.60 0.14 3.76 3.76 3.632 3.632
88356 TC 88356TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.36 4.36 0.04 4.40 4.40 3.936 3.936
88358 88358 A 1 XXX 0 0 0 0 0 0 0 0.95 1.42 1.42 0.04 2.41 2.41 2.246 2.246
88358 26 8835826 A 1 XXX 0 0 0 0 0 0 0 0.95 0.30 0.30 0.03 1.28 1.28 1.235 1.235
88358 TC 88358TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.12 1.12 0.01 1.13 1.13 1.011 1.011
88360 88360 A 1 XXX 0 0 0 0 0 0 0 1.10 2.60 2.60 0.04 3.74 3.74 3.456 3.456
88360 26 8836026 A 1 XXX 0 0 0 0 0 0 0 1.10 0.41 0.41 0.03 1.54 1.54 1.484 1.484
88360 TC 88360TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.19 2.19 0.01 2.20 2.20 1.972 1.972
88361 88361 A 1 XXX 0 0 0 0 0 0 0 1.18 3.37 3.37 0.05 4.60 4.60 4.232 4.232
88361 26 8836126 A 1 XXX 0 0 0 0 0 0 0 1.18 0.46 0.46 0.04 1.68 1.68 1.614 1.614
88361 TC 88361TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.91 2.91 0.01 2.92 2.92 2.618 2.618
88362 88362 A 1 XXX 0 0 0 0 0 0 0 2.17 6.86 6.86 0.14 9.17 9.17 8.404 8.404
88362 26 8836226 A 1 XXX 0 0 0 0 0 0 0 2.17 0.94 0.94 0.10 3.21 3.21 3.066 3.066
88362 TC 88362TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.92 5.92 0.04 5.96 5.96 5.337 5.337
88363 88363 A 0 XXX 0 0 0 0 0 0 0 0.37 1.27 0.17 0.03 1.67 0.57 1.526 0.538
88365 88365 A 1 XXX 0 0 0 0 0 0 0 1.20 4.01 4.01 0.04 5.25 5.25 4.822 4.822
88365 26 8836526 A 1 XXX 0 0 0 0 0 0 0 1.20 0.48 0.48 0.03 1.71 1.71 1.647 1.647
88365 TC 88365TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.53 3.53 0.01 3.54 3.54 3.175 3.175
88367 88367 A 1 XXX 0 0 0 0 0 0 0 1.30 6.23 6.23 0.06 7.59 7.59 6.926 6.926
88367 26 8836726 A 1 XXX 0 0 0 0 0 0 0 1.30 0.41 0.41 0.05 1.76 1.76 1.694 1.694
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
388 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88367 TC 88367TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.82 5.82 0.01 5.83 5.83 5.232 5.232
88368 88368 A 1 XXX 0 0 0 0 0 0 0 1.40 5.37 5.37 0.05 6.82 6.82 6.248 6.248
88368 26 8836826 A 1 XXX 0 0 0 0 0 0 0 1.40 0.37 0.37 0.04 1.81 1.81 1.753 1.753
88368 TC 88368TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.00 5.00 0.01 5.01 5.01 4.495 4.495
88371 26 8837126 A 6 XXX 0 0 0 0 0 0 0 0.37 0.17 0.17 0.03 0.57 0.57 0.538 0.538
88372 26 8837226 A 6 XXX 0 0 0 0 0 0 0 0.37 0.07 0.07 0.03 0.47 0.47 0.449 0.449
88375 88375 C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88380 88380 A 1 XXX 0 0 0 0 0 0 0 1.56 3.03 3.03 0.05 4.64 4.64 4.307 4.307
88380 26 8838026 A 1 XXX 0 0 0 0 0 0 0 1.56 0.51 0.51 0.04 2.11 2.11 2.039 2.039
88380 TC 88380TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.52 2.52 0.01 2.53 2.53 2.268 2.268
88381 88381 A 1 XXX 0 0 0 0 0 0 0 1.18 3.28 3.28 0.04 4.50 4.50 4.146 4.146
88381 26 8838126 A 1 XXX 0 0 0 0 0 0 0 1.18 0.29 0.29 0.03 1.50 1.50 1.456 1.456
88381 TC 88381TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.99 2.99 0.01 3.00 3.00 2.690 2.690
88387 88387 A 1 XXX 0 0 0 0 0 0 0 0.62 0.35 0.35 0.02 0.99 0.99 0.945 0.945
88387 26 8838726 A 1 XXX 0 0 0 0 0 0 0 0.62 0.18 0.18 0.01 0.81 0.81 0.787 0.787
88387 TC 88387TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.17 0.17 0.01 0.18 0.18 0.158 0.158
88388 88388 A 1 XXX 0 0 0 0 0 0 0 0.45 0.50 0.50 0.02 0.97 0.97 0.909 0.909
88388 26 8838826 A 1 XXX 0 0 0 0 0 0 0 0.45 0.23 0.23 0.01 0.69 0.69 0.662 0.662
88388 TC 88388TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.27 0.27 0.01 0.28 0.28 0.248 0.248
88399 88399 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88399 26 8839926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
389 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
88399 TC 88399TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
88749 88749 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89049 89049 A 0 XXX 0 0 0 0 0 0 0 1.40 6.62 0.42 0.10 8.12 1.92 7.397 1.829
89060 26 8906026 A 6 XXX 0 0 0 0 0 0 0 0.37 0.18 0.18 0.03 0.58 0.58 0.547 0.547
89220 89220 A 3 XXX 0 0 0 0 0 0 0 0.00 0.51 0.51 0.01 0.52 0.52 0.463 0.463
89230 89230 A 3 XXX 0 0 0 0 0 0 0 0.00 0.06 0.06 0.01 0.07 0.07 0.059 0.059
89240 89240 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89250 89250 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89251 89251 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89253 89253 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89254 89254 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89255 89255 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89257 89257 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89258 89258 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89259 89259 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89260 89260 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89261 89261 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89264 89264 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89268 89268 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89272 89272 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89280 89280 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
390 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
89281 89281 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89290 89290 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89291 89291 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89335 89335 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89342 89342 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89343 89343 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89344 89344 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89346 89346 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89352 89352 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89353 89353 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89354 89354 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89356 89356 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
89398 89398 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90460 90460 A 0 XXX 0 0 0 0 0 0 0 0.17 0.58 0.58 0.01 0.76 0.76 0.696 0.696
90461 90461 A 0 ZZZ 0 0 0 0 0 0 0 0.15 0.21 0.21 0.01 0.37 0.37 0.344 0.344
90471 90471 A 5 XXX 0 0 0 0 0 0 0 0.17 0.58 0.58 0.01 0.76 0.76 0.696 0.696
90472 90472 A 5 ZZZ 0 0 0 0 0 0 0 0.15 0.21 0.21 0.01 0.37 0.37 0.344 0.344
90473 90473 R 0 XXX 0 0 0 0 0 0 0 0.17 0.58 0.58 0.01 0.76 0.76 0.696 0.696
90474 90474 R 0 ZZZ 0 0 0 0 0 0 0 0.15 0.21 0.21 0.01 0.37 0.37 0.344 0.344
90785 90785 A 0 XXX 0 0 0 0 0 9 0 0.11 0.02 0.02 0.01 0.14 0.14 0.133 0.133
90791 90791 A 0 XXX 0 0 0 0 0 9 0 2.80 1.52 0.53 0.11 4.43 3.44 4.222 3.333
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
391 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
90792 90792 A 0 XXX 0 0 0 0 0 9 0 2.96 0.58 0.48 0.11 3.65 3.55 3.538 3.449
90832 90832 A 0 XXX 0 0 0 0 0 9 0 1.25 0.54 0.14 0.05 1.84 1.44 1.761 1.402
90833 90833 A 0 ZZZ 0 0 0 0 0 9 0 0.98 0.20 0.19 0.04 1.22 1.21 1.181 1.172
90834 90834 A 0 XXX 0 0 0 0 0 9 0 1.89 0.41 0.20 0.07 2.37 2.16 2.295 2.106
90836 90836 A 0 ZZZ 0 0 0 0 0 9 0 1.60 0.32 0.32 0.06 1.98 1.98 1.919 1.919
90837 90837 A 0 XXX 0 0 0 0 0 9 0 2.83 0.53 0.32 0.11 3.47 3.26 3.363 3.175
90838 90838 A 0 ZZZ 0 0 0 0 0 9 0 2.56 0.54 0.52 0.10 3.20 3.18 3.097 3.079
90839 90839 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90840 90840 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90845 90845 A 0 XXX 0 0 0 0 0 0 0 1.79 0.35 0.33 0.07 2.21 2.19 2.141 2.123
90846 90846 R 0 XXX 0 0 0 0 0 0 0 1.83 0.27 0.40 0.07 2.17 2.30 2.109 2.226
90847 90847 R 0 XXX 0 0 0 0 0 0 0 2.21 0.31 0.42 0.08 2.60 2.71 2.530 2.629
90849 90849 R 0 XXX 0 0 0 0 0 0 0 0.59 0.38 0.22 0.03 1.00 0.84 0.947 0.803
90853 90853 A 0 XXX 0 0 0 0 0 0 0 0.59 0.10 0.10 0.03 0.72 0.72 0.695 0.695
90863 90863 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90865 90865 A 0 XXX 0 0 0 0 0 0 0 2.84 1.99 0.71 0.11 4.94 3.66 4.685 3.535
90867 90867 C 0 000 0 0 0 0 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90868 90868 C 0 000 0 0 0 0 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90869 90869 C 0 000 0 0 0 0 0 1 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90870 90870 A 0 000 0 0 0 0 0 0 0 2.50 2.65 0.57 0.11 5.26 3.18 4.937 3.069
90875 90875 N 9 XXX 0 0 0 9 9 9 9 1.20 0.84 0.49 0.08 2.12 1.77 1.996 1.682
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
392 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
90876 90876 N 9 XXX 0 0 0 9 9 9 9 1.90 1.10 0.77 0.12 3.12 2.79 2.951 2.654
90880 90880 A 0 XXX 0 0 0 0 0 0 0 2.19 0.55 0.35 0.08 2.82 2.62 2.726 2.546
90882 90882 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90885 90885 B 9 XXX 0 0 0 9 9 9 9 0.97 0.39 0.39 0.07 1.43 1.43 1.357 1.357
90887 90887 B 9 XXX 0 0 0 9 9 9 9 1.48 0.99 0.60 0.10 2.57 2.18 2.421 2.071
90889 90889 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90899 90899 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90901 90901 A 0 000 0 0 0 0 0 0 0 0.41 0.75 0.17 0.01 1.17 0.59 1.089 0.568
90911 90911 A 0 000 0 0 0 0 0 0 0 0.89 1.54 0.33 0.07 2.50 1.29 2.310 1.223
90935 90935 A 0 000 0 0 0 0 0 0 0 1.48 0.53 0.53 0.08 2.09 2.09 1.998 1.998
90937 90937 A 0 000 0 0 0 0 0 0 0 2.11 0.77 0.77 0.11 2.99 2.99 2.859 2.859
90940 90940 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90945 90945 A 0 000 0 0 0 0 0 0 0 1.56 0.85 0.85 0.08 2.49 2.49 2.365 2.365
90947 90947 A 0 000 0 0 0 0 0 0 0 2.52 0.91 0.91 0.15 3.58 3.58 3.416 3.416
90951 90951 A 0 XXX 0 0 0 0 0 0 0 18.46 7.39 7.39 1.02 26.87 26.87 25.630 25.630
90952 90952 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90953 90953 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90954 90954 A 0 XXX 0 0 0 0 0 0 0 15.98 6.49 6.49 0.90 23.37 23.37 22.279 22.279
90955 90955 A 0 XXX 0 0 0 0 0 0 0 8.79 3.91 3.91 0.49 13.19 13.19 12.557 12.557
90956 90956 A 0 XXX 0 0 0 0 0 0 0 5.95 2.89 2.89 0.34 9.18 9.18 8.723 8.723
90957 90957 A 0 XXX 0 0 0 0 0 0 0 12.52 5.38 5.38 0.72 18.62 18.62 17.728 17.728
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
393 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
90958 90958 A 0 XXX 0 0 0 0 0 0 0 8.34 3.84 3.84 0.48 12.66 12.66 12.039 12.039
90959 90959 A 0 XXX 0 0 0 0 0 0 0 5.50 2.78 2.78 0.31 8.59 8.59 8.159 8.159
90960 90960 A 0 XXX 0 0 0 0 0 0 0 5.18 2.79 2.79 0.31 8.28 8.28 7.848 7.848
90961 90961 A 0 XXX 0 0 0 0 0 0 0 4.26 2.46 2.46 0.26 6.98 6.98 6.605 6.605
90962 90962 A 0 XXX 0 0 0 0 0 0 0 3.15 2.06 2.06 0.20 5.41 5.41 5.104 5.104
90963 90963 A 0 XXX 0 0 0 0 0 0 0 10.56 4.63 4.63 0.60 15.79 15.79 15.032 15.032
90964 90964 A 0 XXX 0 0 0 0 0 0 0 9.14 4.11 4.11 0.52 13.77 13.77 13.103 13.103
90965 90965 A 0 XXX 0 0 0 0 0 0 0 8.69 3.91 3.91 0.49 13.09 13.09 12.457 12.457
90966 90966 A 0 XXX 0 0 0 0 0 0 0 4.26 2.45 2.45 0.26 6.97 6.97 6.596 6.596
90967 90967 A 0 XXX 0 0 0 0 0 0 0 0.35 0.15 0.15 0.01 0.51 0.51 0.490 0.490
90968 90968 A 0 XXX 0 0 0 0 0 0 0 0.30 0.13 0.13 0.01 0.44 0.44 0.422 0.422
90969 90969 A 0 XXX 0 0 0 0 0 0 0 0.29 0.13 0.13 0.01 0.43 0.43 0.412 0.412
90970 90970 A 0 XXX 0 0 0 0 0 0 0 0.14 0.08 0.08 0.01 0.23 0.23 0.217 0.217
90989 90989 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90993 90993 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
90997 90997 A 0 000 0 0 0 0 0 0 0 1.84 0.66 0.66 0.10 2.60 2.60 2.485 2.485
90999 90999 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
91010 91010 A 1 000 0 0 0 0 0 0 0 1.28 4.16 4.16 0.08 5.52 5.52 5.058 5.058
91010 26 9101026 A 1 000 0 0 0 0 0 0 0 1.28 0.65 0.65 0.07 2.00 2.00 1.900 1.900
91010 TC 91010TC A 1 000 0 0 0 0 0 0 0 0.00 3.51 3.51 0.01 3.52 3.52 3.157 3.157
91013 91013 A 1 ZZZ 0 0 0 0 0 0 0 0.18 0.54 0.54 0.02 0.74 0.74 0.675 0.675
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
394 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
91013 26 9101326 A 1 ZZZ 0 0 0 0 0 0 0 0.18 0.09 0.09 0.01 0.28 0.28 0.266 0.266
91013 TC 91013TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.45 0.45 0.01 0.46 0.46 0.409 0.409
91020 91020 A 1 000 0 0 0 0 0 0 0 1.44 5.90 5.90 0.08 7.42 7.42 6.780 6.780
91020 26 9102026 A 1 000 0 0 0 0 0 0 0 1.44 0.75 0.75 0.07 2.26 2.26 2.150 2.150
91020 TC 91020TC A 1 000 0 0 0 0 0 0 0 0.00 5.15 5.15 0.01 5.16 5.16 4.630 4.630
91022 91022 A 1 000 0 0 0 0 0 0 0 1.44 3.84 3.84 0.06 5.34 5.34 4.920 4.920
91022 26 9102226 A 1 000 0 0 0 0 0 0 0 1.44 0.76 0.76 0.05 2.25 2.25 2.149 2.149
91022 TC 91022TC A 1 000 0 0 0 0 0 0 0 0.00 3.08 3.08 0.01 3.09 3.09 2.771 2.771
91030 91030 A 1 000 0 0 0 0 0 0 0 0.91 3.41 3.41 0.05 4.37 4.37 3.998 3.998
91030 26 9103026 A 1 000 0 0 0 0 0 0 0 0.91 0.48 0.48 0.04 1.43 1.43 1.362 1.362
91030 TC 91030TC A 1 000 0 0 0 0 0 0 0 0.00 2.93 2.93 0.01 2.94 2.94 2.636 2.636
91034 91034 A 1 000 0 0 0 0 0 0 0 0.97 4.91 4.91 0.05 5.93 5.93 5.405 5.405
91034 26 9103426 A 1 000 0 0 0 0 0 0 0 0.97 0.48 0.48 0.04 1.49 1.49 1.422 1.422
91034 TC 91034TC A 1 000 0 0 0 0 0 0 0 0.00 4.43 4.43 0.01 4.44 4.44 3.983 3.983
91035 91035 A 1 000 0 0 0 0 0 0 0 1.59 13.78 13.78 0.08 15.45 15.45 14.006 14.006
91035 26 9103526 A 1 000 0 0 0 0 0 0 0 1.59 0.80 0.80 0.07 2.46 2.46 2.345 2.345
91035 TC 91035TC A 1 000 0 0 0 0 0 0 0 0.00 12.98 12.98 0.01 12.99 12.99 11.661 11.661
91037 91037 A 1 000 0 0 0 0 0 0 0 0.97 4.02 4.02 0.08 5.07 5.07 4.622 4.622
91037 26 9103726 A 1 000 0 0 0 0 0 0 0 0.97 0.49 0.49 0.07 1.53 1.53 1.447 1.447
91037 TC 91037TC A 1 000 0 0 0 0 0 0 0 0.00 3.53 3.53 0.01 3.54 3.54 3.175 3.175
91038 91038 A 1 000 0 0 0 0 0 0 0 1.10 13.34 13.34 0.06 14.50 14.50 13.111 13.111
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
395 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
91038 26 9103826 A 1 000 0 0 0 0 0 0 0 1.10 0.56 0.56 0.05 1.71 1.71 1.629 1.629
91038 TC 91038TC A 1 000 0 0 0 0 0 0 0 0.00 12.78 12.78 0.01 12.79 12.79 11.482 11.482
91040 91040 A 1 000 0 0 0 0 0 0 0 0.97 8.00 8.00 0.04 9.01 9.01 8.175 8.175
91040 26 9104026 A 1 000 0 0 0 0 0 0 0 0.97 0.35 0.35 0.03 1.35 1.35 1.300 1.300
91040 TC 91040TC A 1 000 0 0 0 0 0 0 0 0.00 7.65 7.65 0.01 7.66 7.66 6.875 6.875
91065 91065 A 1 000 0 0 0 0 0 0 0 0.20 2.73 2.73 0.02 2.95 2.95 2.662 2.662
91065 26 9106526 A 1 000 0 0 0 0 0 0 0 0.20 0.10 0.10 0.01 0.31 0.31 0.295 0.295
91065 TC 91065TC A 1 000 0 0 0 0 0 0 0 0.00 2.63 2.63 0.01 2.64 2.64 2.367 2.367
91110 91110 A 1 XXX 0 0 0 0 0 0 0 3.64 24.71 24.71 0.17 28.52 28.52 25.918 25.918
91110 26 9111026 A 1 XXX 0 0 0 0 0 0 0 3.64 1.90 1.90 0.16 5.70 5.70 5.430 5.430
91110 TC 91110TC A 1 XXX 0 0 0 0 0 0 0 0.00 22.81 22.81 0.01 22.82 22.82 20.489 20.489
91111 91111 A 1 XXX 0 0 0 0 0 0 0 1.00 22.78 22.78 0.05 23.83 23.83 21.483 21.483
91111 26 9111126 A 1 XXX 0 0 0 0 0 0 0 1.00 0.52 0.52 0.04 1.56 1.56 1.488 1.488
91111 TC 91111TC A 1 XXX 0 0 0 0 0 0 0 0.00 22.26 22.26 0.01 22.27 22.27 19.995 19.995
91112 91112 A 1 XXX 0 0 0 0 0 0 0 2.10 32.69 32.69 0.10 34.89 34.89 31.508 31.508
91112 26 9111226 A 1 XXX 0 0 0 0 0 0 0 2.10 1.10 1.10 0.09 3.29 3.29 3.135 3.135
91112 TC 91112TC A 1 XXX 0 0 0 0 0 0 0 0.00 31.59 31.59 0.01 31.60 31.60 28.373 28.373
91117 91117 A 0 000 0 0 0 0 0 0 0 2.45 1.89 1.89 0.38 4.72 4.72 4.346 4.346
91120 91120 A 1 XXX 0 0 0 0 0 0 0 0.97 11.51 11.51 0.09 12.57 12.57 11.353 11.353
91120 26 9112026 A 1 XXX 0 0 0 0 0 0 0 0.97 0.43 0.43 0.08 1.48 1.48 1.398 1.398
91120 TC 91120TC A 1 XXX 0 0 0 0 0 0 0 0.00 11.08 11.08 0.01 11.09 11.09 9.955 9.955
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
396 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
91122 91122 A 1 000 0 0 0 0 0 0 0 1.77 4.84 4.84 0.11 6.72 6.72 6.174 6.174
91122 26 9112226 A 1 000 0 0 0 0 0 0 0 1.77 0.73 0.73 0.10 2.60 2.60 2.478 2.478
91122 TC 91122TC A 1 000 0 0 0 0 0 0 0 0.00 4.11 4.11 0.01 4.12 4.12 3.696 3.696
91132 91132 A 1 XXX 0 0 0 0 0 0 0 0.52 4.41 4.41 0.04 4.97 4.97 4.501 4.501
91132 26 9113226 A 1 XXX 0 0 0 0 0 0 0 0.52 0.27 0.27 0.03 0.82 0.82 0.778 0.778
91132 TC 91132TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.14 4.14 0.01 4.15 4.15 3.723 3.723
91133 91133 A 1 XXX 0 0 0 0 0 0 0 0.66 5.02 5.02 0.05 5.73 5.73 5.194 5.194
91133 26 9113326 A 1 XXX 0 0 0 0 0 0 0 0.66 0.35 0.35 0.04 1.05 1.05 0.995 0.995
91133 TC 91133TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.67 4.67 0.01 4.68 4.68 4.199 4.199
91299 91299 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
91299 26 9129926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
91299 TC 91299TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92002 92002 A 0 XXX 0 0 0 0 2 0 0 0.88 1.49 0.47 0.07 2.44 1.42 2.255 1.339
92004 92004 A 0 XXX 0 0 0 0 2 0 0 1.82 2.51 1.00 0.12 4.45 2.94 4.137 2.781
92012 92012 A 0 XXX 0 0 0 0 2 0 0 0.92 1.58 0.57 0.07 2.57 1.56 2.375 1.468
92014 92014 A 0 XXX 0 0 0 0 2 0 0 1.42 2.19 0.84 0.10 3.71 2.36 3.439 2.227
92015 92015 N 9 XXX 0 0 0 9 9 9 9 0.38 0.17 0.15 0.03 0.58 0.56 0.548 0.530
92018 92018 A 0 XXX 0 0 0 0 0 0 0 2.50 1.56 1.56 0.16 4.22 4.22 3.985 3.985
92019 92019 A 0 XXX 0 0 0 0 0 0 0 1.31 0.67 0.67 0.07 2.05 2.05 1.948 1.948
92020 92020 A 0 XXX 0 0 0 0 2 0 0 0.37 0.41 0.23 0.03 0.81 0.63 0.754 0.592
92025 92025 A 1 XXX 0 0 0 7 2 0 0 0.35 0.76 0.76 0.02 1.13 1.13 1.043 1.043
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
397 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92025 26 9202526 A 1 XXX 0 0 0 7 2 0 0 0.35 0.22 0.22 0.01 0.58 0.58 0.553 0.553
92025 TC 92025TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.54 0.54 0.01 0.55 0.55 0.490 0.490
92060 92060 A 1 XXX 0 0 0 7 2 0 0 0.69 1.23 1.23 0.04 1.96 1.96 1.815 1.815
92060 26 9206026 A 1 XXX 0 0 0 7 2 0 0 0.69 0.41 0.41 0.03 1.13 1.13 1.074 1.074
92060 TC 92060TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.82 0.82 0.01 0.83 0.83 0.742 0.742
92065 92065 A 1 XXX 0 0 0 0 2 0 0 0.37 1.24 1.24 0.02 1.63 1.63 1.494 1.494
92065 26 9206526 A 1 XXX 0 0 0 0 2 0 0 0.37 0.14 0.14 0.01 0.52 0.52 0.501 0.501
92065 TC 92065TC A 1 XXX 0 0 0 0 2 0 0 0.00 1.10 1.10 0.01 1.11 1.11 0.993 0.993
92071 92071 A 0 XXX 0 0 0 0 3 0 0 0.61 0.36 0.25 0.03 1.00 0.89 0.949 0.850
92072 92072 A 0 XXX 0 0 0 0 2 0 0 1.97 1.68 0.80 0.11 3.76 2.88 3.536 2.746
92081 92081 A 1 XXX 0 0 0 7 2 0 0 0.30 0.69 0.69 0.04 1.03 1.03 0.941 0.941
92081 26 9208126 A 1 XXX 0 0 0 7 2 0 0 0.30 0.16 0.16 0.03 0.49 0.49 0.459 0.459
92081 TC 92081TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.53 0.53 0.01 0.54 0.54 0.481 0.481
92082 92082 A 1 XXX 0 0 0 7 2 0 0 0.40 1.03 1.03 0.05 1.48 1.48 1.351 1.351
92082 26 9208226 A 1 XXX 0 0 0 7 2 0 0 0.40 0.22 0.22 0.04 0.66 0.66 0.618 0.618
92082 TC 92082TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.81 0.81 0.01 0.82 0.82 0.733 0.733
92083 92083 A 1 XXX 0 0 0 7 2 0 0 0.50 1.42 1.42 0.04 1.96 1.96 1.796 1.796
92083 26 9208326 A 1 XXX 0 0 0 7 2 0 0 0.50 0.30 0.30 0.03 0.83 0.83 0.785 0.785
92083 TC 92083TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.12 1.12 0.01 1.13 1.13 1.011 1.011
92100 92100 A 0 XXX 0 0 0 0 2 0 0 0.61 1.77 0.35 0.03 2.41 0.99 2.215 0.940
92132 92132 A 1 XXX 0 0 0 7 2 0 0 0.35 0.68 0.68 0.04 1.07 1.07 0.982 0.982
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
398 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92132 26 9213226 A 1 XXX 0 0 0 7 2 0 0 0.35 0.20 0.20 0.03 0.58 0.58 0.545 0.545
92132 TC 92132TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.48 0.48 0.01 0.49 0.49 0.436 0.436
92133 92133 A 1 XXX 0 0 0 7 2 0 0 0.50 0.79 0.79 0.04 1.33 1.33 1.230 1.230
92133 26 9213326 A 1 XXX 0 0 0 7 2 0 0 0.50 0.30 0.30 0.03 0.83 0.83 0.785 0.785
92133 TC 92133TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.49 0.49 0.01 0.50 0.50 0.445 0.445
92134 92134 A 1 XXX 0 0 0 7 2 0 0 0.50 0.82 0.82 0.04 1.36 1.36 1.257 1.257
92134 26 9213426 A 1 XXX 0 0 0 7 2 0 0 0.50 0.32 0.32 0.03 0.85 0.85 0.803 0.803
92134 TC 92134TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.50 0.50 0.01 0.51 0.51 0.454 0.454
92136 92136 A 1 XXX 0 0 0 7 2 0 0 0.54 2.18 2.18 0.02 2.74 2.74 2.508 2.508
92136 26 9213626 A 1 XXX 0 0 0 7 3 0 0 0.54 0.36 0.36 0.01 0.91 0.91 0.869 0.869
92136 TC 92136TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.82 1.82 0.01 1.83 1.83 1.640 1.640
92140 92140 A 0 XXX 0 0 0 0 2 0 0 0.50 1.38 0.25 0.03 1.91 0.78 1.755 0.740
92225 92225 A 0 XXX 0 0 0 0 3 0 0 0.38 0.40 0.23 0.03 0.81 0.64 0.755 0.602
92226 92226 A 0 XXX 0 0 0 0 3 0 0 0.33 0.39 0.22 0.01 0.73 0.56 0.685 0.533
92227 92227 A 3 XXX 0 0 0 0 2 0 0 0.00 0.40 0.40 0.01 0.41 0.41 0.364 0.364
92228 92228 A 1 XXX 0 0 0 7 2 0 0 0.37 0.67 0.67 0.02 1.06 1.06 0.982 0.982
92228 26 9222826 A 1 XXX 0 0 0 7 2 0 0 0.37 0.25 0.25 0.01 0.63 0.63 0.600 0.600
92228 TC 92228TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.42 0.42 0.01 0.43 0.43 0.382 0.382
92230 92230 A 0 XXX 0 0 0 0 3 0 0 0.60 1.12 0.36 0.04 1.76 1.00 1.627 0.944
92235 92235 A 1 XXX 0 0 0 7 3 0 0 0.81 2.48 2.48 0.04 3.33 3.33 3.058 3.058
92235 26 9223526 A 1 XXX 0 0 0 7 3 0 0 0.81 0.54 0.54 0.03 1.38 1.38 1.311 1.311
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
399 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92235 TC 92235TC A 1 XXX 0 0 0 7 3 0 0 0.00 1.94 1.94 0.01 1.95 1.95 1.747 1.747
92240 92240 A 1 XXX 0 0 0 7 3 0 0 1.10 6.68 6.68 0.04 7.82 7.82 7.120 7.120
92240 26 9224026 A 1 XXX 0 0 0 7 3 0 0 1.10 0.74 0.74 0.03 1.87 1.87 1.780 1.780
92240 TC 92240TC A 1 XXX 0 0 0 7 3 0 0 0.00 5.94 5.94 0.01 5.95 5.95 5.339 5.339
92250 92250 A 1 XXX 0 0 0 7 2 0 0 0.44 1.93 1.93 0.02 2.39 2.39 2.184 2.184
92250 26 9225026 A 1 XXX 0 0 0 7 2 0 0 0.44 0.24 0.24 0.01 0.69 0.69 0.661 0.661
92250 TC 92250TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.69 1.69 0.01 1.70 1.70 1.523 1.523
92260 92260 A 0 XXX 0 0 0 0 2 0 0 0.20 0.36 0.12 0.01 0.57 0.33 0.529 0.313
92265 92265 A 1 XXX 0 0 0 7 2 0 0 0.81 1.56 1.56 0.02 2.39 2.39 2.221 2.221
92265 26 9226526 A 1 XXX 0 0 0 7 2 0 0 0.81 0.43 0.43 0.01 1.25 1.25 1.201 1.201
92265 TC 92265TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.13 1.13 0.01 1.14 1.14 1.020 1.020
92270 92270 A 1 XXX 0 0 0 7 2 0 0 0.81 1.91 1.91 0.04 2.76 2.76 2.546 2.546
92270 26 9227026 A 1 XXX 0 0 0 7 2 0 0 0.81 0.36 0.36 0.03 1.20 1.20 1.149 1.149
92270 TC 92270TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.55 1.55 0.01 1.56 1.56 1.397 1.397
92275 92275 A 1 XXX 0 0 0 7 2 0 0 1.01 3.80 3.80 0.05 4.86 4.86 4.449 4.449
92275 26 9227526 A 1 XXX 0 0 0 7 2 0 0 1.01 0.67 0.67 0.04 1.72 1.72 1.633 1.633
92275 TC 92275TC A 1 XXX 0 0 0 7 2 0 0 0.00 3.13 3.13 0.01 3.14 3.14 2.816 2.816
92283 92283 A 1 XXX 0 0 0 7 2 0 0 0.17 1.50 1.50 0.02 1.69 1.69 1.527 1.527
92283 26 9228326 A 1 XXX 0 0 0 7 2 0 0 0.17 0.09 0.09 0.01 0.27 0.27 0.256 0.256
92283 TC 92283TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.41 1.41 0.01 1.42 1.42 1.271 1.271
92284 92284 A 1 XXX 0 0 0 7 2 0 0 0.24 1.62 1.62 0.02 1.88 1.88 1.705 1.705
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
400 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92284 26 9228426 A 1 XXX 0 0 0 7 2 0 0 0.24 0.11 0.11 0.01 0.36 0.36 0.344 0.344
92284 TC 92284TC A 1 XXX 0 0 0 7 2 0 0 0.00 1.51 1.51 0.01 1.52 1.52 1.361 1.361
92285 92285 A 1 XXX 0 0 0 7 2 0 0 0.05 0.56 0.56 0.02 0.63 0.63 0.563 0.563
92285 26 9228526 A 1 XXX 0 0 0 7 2 0 0 0.05 0.03 0.03 0.01 0.09 0.09 0.082 0.082
92285 TC 92285TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.53 0.53 0.01 0.54 0.54 0.481 0.481
92286 92286 A 1 XXX 0 0 0 7 2 0 0 0.40 0.72 0.72 0.02 1.14 1.14 1.057 1.057
92286 26 9228626 A 1 XXX 0 0 0 7 2 0 0 0.40 0.23 0.23 0.01 0.64 0.64 0.612 0.612
92286 TC 92286TC A 1 XXX 0 0 0 7 2 0 0 0.00 0.49 0.49 0.01 0.50 0.50 0.445 0.445
92287 92287 A 1 XXX 0 0 0 0 2 0 0 0.81 3.36 3.36 0.04 4.21 4.21 3.848 3.848
92287 26 9228726 A 1 XXX 0 0 0 0 2 0 0 0.81 0.54 0.54 0.03 1.38 1.38 1.311 1.311
92287 TC 92287TC A 1 XXX 0 0 0 0 2 0 0 0.00 2.82 2.82 0.01 2.83 2.83 2.538 2.538
92310 92310 N 9 XXX 0 0 0 9 9 9 9 1.17 1.58 0.47 0.08 2.83 1.72 2.631 1.634
92311 92311 A 0 XXX 0 0 0 0 0 0 0 1.08 1.94 0.51 0.08 3.10 1.67 2.864 1.580
92312 92312 A 0 XXX 0 0 0 0 2 0 0 1.26 2.17 0.55 0.05 3.48 1.86 3.235 1.780
92313 92313 A 0 XXX 0 0 0 0 0 0 0 0.92 2.09 0.50 0.05 3.06 1.47 2.823 1.395
92314 92314 N 9 XXX 0 0 0 9 9 9 9 0.69 1.64 0.28 0.04 2.37 1.01 2.184 0.962
92315 92315 A 0 XXX 0 0 0 0 0 0 0 0.45 2.00 0.24 0.04 2.49 0.73 2.267 0.686
92316 92316 A 0 XXX 0 0 0 0 2 0 0 0.68 2.57 0.46 0.04 3.29 1.18 3.009 1.114
92317 92317 A 0 XXX 0 0 0 0 0 0 0 0.45 1.85 0.17 0.01 2.31 0.63 2.117 0.608
92325 92325 A 5 XXX 0 0 0 0 0 0 0 0.00 1.26 1.26 0.01 1.27 1.27 1.137 1.137
92326 92326 A 5 XXX 0 0 0 0 0 0 0 0.00 1.07 1.07 0.01 1.08 1.08 0.966 0.966
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
401 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92340 92340 N 9 XXX 0 0 0 9 9 9 9 0.37 0.66 0.15 0.03 1.06 0.55 0.978 0.520
92341 92341 N 9 XXX 0 0 0 9 9 9 9 0.47 0.70 0.19 0.03 1.20 0.69 1.114 0.656
92342 92342 N 9 XXX 0 0 0 9 9 9 9 0.53 0.72 0.21 0.04 1.29 0.78 1.197 0.740
92352 92352 B 9 XXX 0 0 0 9 9 9 9 0.37 0.81 0.15 0.03 1.21 0.55 1.113 0.520
92353 92353 B 9 XXX 0 0 0 9 9 9 9 0.50 0.87 0.20 0.03 1.40 0.73 1.297 0.695
92354 92354 B 9 XXX 0 0 0 9 9 9 9 0.00 0.41 0.41 0.01 0.42 0.42 0.373 0.373
92355 92355 B 9 XXX 0 0 0 9 9 9 9 0.00 0.64 0.64 0.01 0.65 0.65 0.580 0.580
92358 92358 B 9 XXX 0 0 0 9 9 9 9 0.00 0.34 0.34 0.01 0.35 0.35 0.311 0.311
92370 92370 N 9 XXX 0 0 0 9 9 9 9 0.32 0.57 0.13 0.03 0.92 0.48 0.848 0.452
92371 92371 B 9 XXX 0 0 0 9 9 9 9 0.00 0.35 0.35 0.01 0.36 0.36 0.320 0.320
92499 92499 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92499 26 9249926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92499 TC 92499TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92502 92502 A 0 000 0 0 0 0 0 0 0 1.51 1.28 1.28 0.07 2.86 2.86 2.696 2.696
92504 92504 A 0 XXX 0 0 0 0 0 0 0 0.18 0.74 0.09 0.01 0.93 0.28 0.850 0.266
92506 92506 A 7 XXX 0 0 0 5 0 0 0 0.86 5.48 5.48 0.05 6.39 6.39 5.807 5.807
92507 92507 A 7 XXX 0 0 0 5 0 0 0 1.30 0.72 0.72 0.07 2.09 2.09 1.983 1.983
92508 92508 A 7 XXX 0 0 0 5 0 0 0 0.33 0.27 0.27 0.01 0.61 0.61 0.578 0.578
92511 92511 A 0 000 0 0 0 0 0 0 0 0.61 3.59 0.81 0.03 4.23 1.45 3.850 1.353
92512 92512 A 0 XXX 0 0 0 0 0 0 0 0.55 1.27 0.25 0.03 1.85 0.83 1.706 0.790
92516 92516 A 0 XXX 0 0 0 0 0 0 0 0.43 1.67 0.21 0.03 2.13 0.67 1.945 0.634
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
402 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92520 92520 A 0 XXX 0 0 0 0 0 0 0 0.75 1.42 0.40 0.04 2.21 1.19 2.046 1.130
92526 92526 A 7 XXX 0 0 0 5 0 0 0 1.34 0.86 0.86 0.07 2.27 2.27 2.149 2.149
92531 92531 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92532 92532 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92533 92533 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92534 92534 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92540 92540 A 1 XXX 0 0 0 0 0 0 0 1.50 1.41 1.41 0.05 2.96 2.96 2.792 2.792
92540 26 9254026 A 1 XXX 0 0 0 0 0 0 0 1.50 0.75 0.75 0.04 2.29 2.29 2.194 2.194
92540 TC 92540TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.66 0.66 0.01 0.67 0.67 0.598 0.598
92541 92541 A 1 XXX 0 0 0 0 0 0 0 0.40 0.47 0.47 0.02 0.89 0.89 0.833 0.833
92541 26 9254126 A 1 XXX 0 0 0 0 0 0 0 0.40 0.19 0.19 0.01 0.60 0.60 0.576 0.576
92541 TC 92541TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.28 0.28 0.01 0.29 0.29 0.257 0.257
92542 92542 A 1 XXX 0 0 0 0 0 0 0 0.33 0.44 0.44 0.02 0.79 0.79 0.736 0.736
92542 26 9254226 A 1 XXX 0 0 0 0 0 0 0 0.33 0.16 0.16 0.01 0.50 0.50 0.479 0.479
92542 TC 92542TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.28 0.28 0.01 0.29 0.29 0.257 0.257
92543 92543 A 1 XXX 0 0 0 0 0 0 0 0.10 0.36 0.36 0.02 0.48 0.48 0.434 0.434
92543 26 9254326 A 1 XXX 0 0 0 0 0 0 0 0.10 0.05 0.05 0.01 0.16 0.16 0.150 0.150
92543 TC 92543TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.31 0.31 0.01 0.32 0.32 0.284 0.284
92544 92544 A 1 XXX 0 0 0 0 0 0 0 0.26 0.41 0.41 0.02 0.69 0.69 0.639 0.639
92544 26 9254426 A 1 XXX 0 0 0 0 0 0 0 0.26 0.13 0.13 0.01 0.40 0.40 0.382 0.382
92544 TC 92544TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.28 0.28 0.01 0.29 0.29 0.257 0.257
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
403 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92545 92545 A 1 XXX 0 0 0 0 0 0 0 0.23 0.37 0.37 0.02 0.62 0.62 0.573 0.573
92545 26 9254526 A 1 XXX 0 0 0 0 0 0 0 0.23 0.11 0.11 0.01 0.35 0.35 0.334 0.334
92545 TC 92545TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.26 0.26 0.01 0.27 0.27 0.239 0.239
92546 92546 A 1 XXX 0 0 0 0 0 0 0 0.29 2.83 2.83 0.02 3.14 3.14 2.842 2.842
92546 26 9254626 A 1 XXX 0 0 0 0 0 0 0 0.29 0.13 0.13 0.01 0.43 0.43 0.412 0.412
92546 TC 92546TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.70 2.70 0.01 2.71 2.71 2.430 2.430
92547 92547 A 3 ZZZ 0 0 0 0 0 0 0 0.00 0.18 0.18 0.01 0.19 0.19 0.167 0.167
92548 92548 A 1 XXX 0 0 0 0 0 0 0 0.50 2.62 2.62 0.02 3.14 3.14 2.863 2.863
92548 26 9254826 A 1 XXX 0 0 0 0 0 0 0 0.50 0.23 0.23 0.01 0.74 0.74 0.712 0.712
92548 TC 92548TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.39 2.39 0.01 2.40 2.40 2.151 2.151
92550 92550 A 7 XXX 0 0 0 0 2 0 0 0.35 0.25 0.25 0.01 0.61 0.61 0.580 0.580
92551 92551 N 9 XXX 0 0 0 9 9 9 9 0.00 0.36 0.36 0.01 0.37 0.37 0.329 0.329
92552 92552 A 3 XXX 0 0 0 0 2 0 0 0.00 0.94 0.94 0.01 0.95 0.95 0.849 0.849
92553 92553 A 3 XXX 0 0 0 0 2 0 0 0.00 1.14 1.14 0.01 1.15 1.15 1.029 1.029
92555 92555 A 3 XXX 0 0 0 0 2 0 0 0.00 0.71 0.71 0.01 0.72 0.72 0.643 0.643
92556 92556 A 3 XXX 0 0 0 0 2 0 0 0.00 1.12 1.12 0.01 1.13 1.13 1.011 1.011
92557 92557 A 7 XXX 0 0 0 0 2 0 0 0.60 0.47 0.31 0.03 1.10 0.94 1.038 0.894
92558 92558 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92559 92559 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92560 92560 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92561 92561 A 3 XXX 0 0 0 0 2 0 0 0.00 1.15 1.15 0.01 1.16 1.16 1.038 1.038
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
404 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92562 92562 A 3 XXX 0 0 0 0 2 0 0 0.00 1.43 1.43 0.01 1.44 1.44 1.289 1.289
92563 92563 A 3 XXX 0 0 0 0 2 0 0 0.00 0.96 0.96 0.01 0.97 0.97 0.867 0.867
92564 92564 A 3 XXX 0 0 0 0 2 0 0 0.00 0.87 0.87 0.01 0.88 0.88 0.786 0.786
92565 92565 A 3 XXX 0 0 0 0 2 0 0 0.00 0.51 0.51 0.01 0.52 0.52 0.463 0.463
92567 92567 A 7 XXX 0 0 0 0 2 0 0 0.20 0.21 0.10 0.01 0.42 0.31 0.394 0.295
92568 92568 A 7 XXX 0 0 0 0 2 0 0 0.29 0.15 0.15 0.01 0.45 0.45 0.430 0.430
92570 92570 A 7 XXX 0 0 0 0 2 0 0 0.55 0.36 0.29 0.03 0.94 0.87 0.889 0.826
92571 92571 A 3 XXX 0 0 0 0 2 0 0 0.00 0.83 0.83 0.01 0.84 0.84 0.751 0.751
92572 92572 A 3 XXX 0 0 0 0 2 0 0 0.00 1.61 1.61 0.01 1.62 1.62 1.451 1.451
92575 92575 A 3 XXX 0 0 0 0 2 0 0 0.00 2.32 2.32 0.01 2.33 2.33 2.089 2.089
92576 92576 A 3 XXX 0 0 0 0 2 0 0 0.00 1.04 1.04 0.01 1.05 1.05 0.939 0.939
92577 92577 A 3 XXX 0 0 0 0 2 0 0 0.00 0.56 0.56 0.01 0.57 0.57 0.508 0.508
92579 92579 A 7 XXX 0 0 0 0 2 0 0 0.70 0.49 0.35 0.03 1.22 1.08 1.156 1.030
92582 92582 A 3 XXX 0 0 0 0 2 0 0 0.00 2.20 2.20 0.01 2.21 2.21 1.981 1.981
92583 92583 A 3 XXX 0 0 0 0 2 0 0 0.00 1.58 1.58 0.01 1.59 1.59 1.424 1.424
92584 92584 A 3 XXX 0 0 0 0 2 0 0 0.00 2.14 2.14 0.01 2.15 2.15 1.927 1.927
92585 92585 A 1 XXX 0 0 0 0 2 0 0 0.50 3.33 3.33 0.02 3.85 3.85 3.501 3.501
92585 26 9258526 A 1 XXX 0 0 0 0 2 0 0 0.50 0.25 0.25 0.01 0.76 0.76 0.730 0.730
92585 TC 92585TC A 1 XXX 0 0 0 0 2 0 0 0.00 3.08 3.08 0.01 3.09 3.09 2.771 2.771
92586 92586 A 3 XXX 0 0 0 0 2 0 0 0.00 2.62 2.62 0.01 2.63 2.63 2.358 2.358
92587 92587 A 1 XXX 0 0 0 0 2 0 0 0.35 0.25 0.25 0.04 0.64 0.64 0.595 0.595
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
405 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92587 26 9258726 A 1 XXX 0 0 0 0 2 0 0 0.35 0.17 0.17 0.03 0.55 0.55 0.518 0.518
92587 TC 92587TC A 1 XXX 0 0 0 0 2 0 0 0.00 0.08 0.08 0.01 0.09 0.09 0.077 0.077
92588 92588 A 1 XXX 0 0 0 0 2 0 0 0.55 0.39 0.39 0.03 0.97 0.97 0.916 0.916
92588 26 9258826 A 1 XXX 0 0 0 0 2 0 0 0.55 0.28 0.28 0.02 0.85 0.85 0.812 0.812
92588 TC 92588TC A 1 XXX 0 0 0 0 2 0 0 0.00 0.11 0.11 0.01 0.12 0.12 0.104 0.104
92590 92590 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92591 92591 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92592 92592 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92593 92593 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92594 92594 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92595 92595 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92596 92596 A 3 XXX 0 0 0 0 2 0 0 0.00 1.32 1.32 0.01 1.33 1.33 1.191 1.191
92597 92597 A 7 XXX 0 0 0 5 0 0 0 1.26 0.71 0.71 0.07 2.04 2.04 1.934 1.934
92601 92601 A 7 XXX 0 0 0 0 0 0 0 2.30 1.49 0.93 0.11 3.90 3.34 3.696 3.193
92602 92602 A 7 XXX 0 0 0 0 0 0 0 1.30 1.27 0.61 0.07 2.64 1.98 2.477 1.884
92603 92603 A 7 XXX 0 0 0 0 0 0 0 2.25 1.96 1.19 0.11 4.32 3.55 4.068 3.376
92604 92604 A 7 XXX 0 0 0 0 0 0 0 1.25 1.30 0.66 0.05 2.60 1.96 2.444 1.869
92605 92605 B 9 XXX 0 0 0 9 9 9 9 1.75 0.83 0.71 0.09 2.67 2.55 2.542 2.435
92606 92606 B 9 XXX 0 0 0 9 9 9 9 1.40 0.93 0.57 0.07 2.40 2.04 2.272 1.948
92607 92607 A 7 XXX 0 0 0 5 0 0 0 1.85 1.56 1.56 0.10 3.51 3.51 3.303 3.303
92608 92608 A 7 ZZZ 0 0 0 0 0 0 0 0.70 0.67 0.67 0.04 1.41 1.41 1.323 1.323
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
406 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92609 92609 A 7 XXX 0 0 0 5 0 0 0 1.50 1.32 1.32 0.07 2.89 2.89 2.722 2.722
92610 92610 A 7 XXX 0 0 0 0 0 0 0 1.30 0.92 0.60 0.07 2.29 1.97 2.163 1.875
92611 92611 A 7 XXX 0 0 0 0 0 0 0 1.34 1.15 1.15 0.08 2.57 2.57 2.415 2.415
92612 92612 A 0 XXX 0 0 0 0 0 0 0 1.27 3.95 0.61 0.07 5.29 1.95 4.854 1.854
92613 92613 A 0 XXX 0 0 0 0 0 0 0 0.71 0.37 0.37 0.04 1.12 1.12 1.063 1.063
92614 92614 A 0 XXX 0 0 0 0 0 0 0 1.27 3.21 0.63 0.07 4.55 1.97 4.189 1.872
92615 92615 A 0 XXX 0 0 0 0 0 0 0 0.63 0.32 0.31 0.03 0.98 0.97 0.933 0.924
92616 92616 A 0 XXX 0 0 0 0 0 0 0 1.88 4.26 0.92 0.10 6.24 2.90 5.758 2.758
92617 92617 A 0 XXX 0 0 0 0 0 0 0 0.79 0.39 0.38 0.04 1.22 1.21 1.161 1.152
92618 92618 B 9 ZZZ 0 0 0 9 9 9 9 0.65 0.28 0.26 0.03 0.96 0.94 0.917 0.899
92620 92620 A 9 XXX 0 0 0 0 2 0 0 1.50 1.15 0.85 0.07 2.72 2.42 2.569 2.300
92621 92621 A 9 ZZZ 0 0 0 0 0 0 0 0.35 0.29 0.19 0.01 0.65 0.55 0.616 0.526
92625 92625 A 9 XXX 0 0 0 0 2 0 0 1.15 0.82 0.60 0.05 2.02 1.80 1.913 1.715
92626 92626 A 9 XXX 0 0 0 0 2 0 0 1.40 1.16 0.75 0.07 2.63 2.22 2.478 2.110
92627 92627 A 9 ZZZ 0 0 0 0 0 0 0 0.33 0.29 0.17 0.01 0.63 0.51 0.596 0.488
92630 92630 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92633 92633 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92640 92640 A 9 XXX 0 0 0 0 2 0 0 1.76 1.49 0.95 0.37 3.62 3.08 3.292 2.807
92700 92700 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92920 92920 A 0 000 0 0 0 2 0 0 0 10.10 3.70 3.70 2.19 15.99 15.99 14.568 14.568
92921 92921 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
407 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92924 92924 A 0 000 0 0 0 2 0 0 0 11.99 4.41 4.41 2.61 19.01 19.01 17.315 17.315
92925 92925 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92928 92928 A 0 000 0 0 0 2 0 0 0 11.21 4.10 4.10 2.45 17.76 17.76 16.173 16.173
92929 92929 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92933 92933 A 0 000 0 0 0 2 0 0 0 12.54 4.58 4.58 2.74 19.86 19.86 18.086 18.086
92934 92934 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92937 92937 A 0 000 0 0 0 2 0 0 0 11.20 4.09 4.09 2.45 17.74 17.74 16.154 16.154
92938 92938 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92941 92941 A 0 000 0 0 0 2 0 0 0 12.56 4.59 4.59 2.75 19.90 19.90 18.120 18.120
92943 92943 A 0 000 0 0 0 2 0 0 0 12.56 4.59 4.59 2.75 19.90 19.90 18.120 18.120
92944 92944 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92950 92950 A 0 000 0 0 0 0 0 0 0 4.00 4.73 1.07 0.32 9.05 5.39 8.415 5.128
92953 92953 A 0 000 0 0 0 0 0 0 0 0.23 0.07 0.07 0.01 0.31 0.31 0.298 0.298
92960 92960 A 0 000 0 0 0 0 0 0 0 2.25 3.65 1.13 0.14 6.04 3.52 5.601 3.338
92961 92961 A 0 000 0 0 0 9 9 9 9 4.59 2.00 2.00 0.44 7.03 7.03 6.616 6.616
92970 92970 A 0 000 0 0 0 0 0 0 0 3.51 1.39 1.39 0.24 5.14 5.14 4.884 4.884
92971 92971 A 0 000 0 0 0 0 0 0 0 1.77 0.81 0.81 0.11 2.69 2.69 2.555 2.555
92973 92973 A 0 ZZZ 0 0 0 0 0 0 0 3.28 1.20 1.20 0.71 5.19 5.19 4.729 4.729
92974 92974 A 0 ZZZ 0 0 0 0 0 0 0 3.00 1.09 1.09 0.65 4.74 4.74 4.319 4.319
92975 92975 A 0 000 0 0 0 2 0 0 0 7.24 2.65 2.65 1.58 11.47 11.47 10.446 10.446
92977 92977 A 5 XXX 0 0 0 0 0 0 0 0.00 1.64 1.64 0.03 1.67 1.67 1.488 1.488
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
408 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
92978 92978 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92978 26 9297826 A 1 ZZZ 0 0 0 0 0 0 0 1.80 0.66 0.66 0.12 2.58 2.58 2.455 2.455
92978 TC 92978TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92979 92979 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92979 26 9297926 A 1 ZZZ 0 0 0 0 0 0 0 1.44 0.53 0.53 0.10 2.07 2.07 1.968 1.968
92979 TC 92979TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92986 92986 A 0 090 0 1 0 2 0 0 0 22.85 11.50 11.50 4.98 39.33 39.33 35.782 35.782
92987 92987 A 0 090 0 1 0 2 0 0 0 23.63 11.93 11.93 5.14 40.70 40.70 37.031 37.031
92990 92990 A 0 090 0 1 0 2 0 0 0 18.27 9.66 9.66 3.99 31.92 31.92 29.031 29.031
92992 92992 C 0 090 0 1 0 2 0 2 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92993 92993 C 0 090 0 1 0 2 0 2 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
92997 92997 A 0 000 0 0 0 2 0 0 0 11.98 4.55 4.55 2.61 19.14 19.14 17.431 17.431
92998 92998 A 0 ZZZ 0 0 0 0 0 0 0 5.99 2.17 2.17 1.31 9.47 9.47 8.624 8.624
93000 93000 A 4 XXX 0 0 0 6 0 0 0 0.17 0.35 0.35 0.02 0.54 0.54 0.495 0.495
93005 93005 A 3 XXX 0 0 0 6 0 0 0 0.00 0.29 0.29 0.01 0.30 0.30 0.266 0.266
93010 93010 A 2 XXX 0 0 0 0 0 0 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
93015 93015 A 4 XXX 0 0 0 6 0 0 0 0.75 1.56 1.56 0.03 2.34 2.34 2.167 2.167
93016 93016 A 2 XXX 0 0 0 0 0 0 0 0.45 0.17 0.17 0.01 0.63 0.63 0.608 0.608
93017 93017 A 3 XXX 0 0 0 6 0 0 0 0.00 1.28 1.28 0.01 1.29 1.29 1.155 1.155
93018 93018 A 2 XXX 0 0 0 0 0 0 0 0.30 0.11 0.11 0.01 0.42 0.42 0.404 0.404
93024 93024 A 1 XXX 0 0 0 6 0 0 0 1.17 2.09 2.09 0.05 3.31 3.31 3.073 3.073
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
409 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93024 26 9302426 A 1 XXX 0 0 0 6 0 0 0 1.17 0.43 0.43 0.04 1.64 1.64 1.577 1.577
93024 TC 93024TC A 1 XXX 0 0 0 6 0 0 0 0.00 1.66 1.66 0.01 1.67 1.67 1.496 1.496
93025 93025 A 1 XXX 0 0 0 6 0 0 0 0.75 4.24 4.24 0.04 5.03 5.03 4.578 4.578
93025 26 9302526 A 1 XXX 0 0 0 6 0 0 0 0.75 0.29 0.29 0.03 1.07 1.07 1.026 1.026
93025 TC 93025TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.95 3.95 0.01 3.96 3.96 3.552 3.552
93040 93040 A 4 XXX 0 0 0 6 0 0 0 0.15 0.22 0.22 0.02 0.39 0.39 0.358 0.358
93041 93041 A 3 XXX 0 0 0 6 0 0 0 0.00 0.17 0.17 0.01 0.18 0.18 0.158 0.158
93042 93042 A 2 XXX 0 0 0 0 0 0 0 0.15 0.05 0.05 0.01 0.21 0.21 0.200 0.200
93224 93224 A 4 XXX 0 0 0 6 0 0 0 0.52 2.21 2.21 0.03 2.76 2.76 2.520 2.520
93225 93225 A 3 XXX 0 0 0 6 0 0 0 0.00 0.82 0.82 0.01 0.83 0.83 0.742 0.742
93226 93226 A 3 XXX 0 0 0 6 0 0 0 0.00 1.16 1.16 0.01 1.17 1.17 1.047 1.047
93227 93227 A 2 XXX 0 0 0 0 0 0 0 0.52 0.23 0.23 0.01 0.76 0.76 0.732 0.732
93228 93228 A 2 XXX 0 0 0 0 0 0 0 0.52 0.19 0.19 0.03 0.74 0.74 0.706 0.706
93229 93229 A 3 XXX 0 0 0 6 0 0 0 0.00 21.62 21.62 0.01 21.63 21.63 19.420 19.420
93268 93268 A 4 XXX 0 0 0 6 0 0 0 0.52 5.95 5.95 0.03 6.50 6.50 5.879 5.879
93270 93270 A 3 XXX 0 0 0 6 0 0 0 0.00 0.27 0.27 0.01 0.28 0.28 0.248 0.248
93271 93271 A 3 XXX 0 0 0 6 0 0 0 0.00 5.50 5.50 0.01 5.51 5.51 4.944 4.944
93272 93272 A 2 XXX 0 0 0 0 0 0 0 0.52 0.18 0.18 0.01 0.71 0.71 0.687 0.687
93278 93278 A 1 XXX 0 0 0 6 0 0 0 0.25 0.64 0.64 0.02 0.91 0.91 0.835 0.835
93278 26 9327826 A 1 XXX 0 0 0 6 0 0 0 0.25 0.10 0.10 0.01 0.36 0.36 0.345 0.345
93278 TC 93278TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.54 0.54 0.01 0.55 0.55 0.490 0.490
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
410 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93279 93279 A 1 XXX 0 0 0 6 0 0 0 0.65 0.77 0.77 0.04 1.46 1.46 1.362 1.362
93279 26 9327926 A 1 XXX 0 0 0 6 0 0 0 0.65 0.25 0.25 0.03 0.93 0.93 0.890 0.890
93279 TC 93279TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.52 0.52 0.01 0.53 0.53 0.472 0.472
93280 93280 A 1 XXX 0 0 0 6 0 0 0 0.77 0.87 0.87 0.04 1.68 1.68 1.572 1.572
93280 26 9328026 A 1 XXX 0 0 0 6 0 0 0 0.77 0.29 0.29 0.03 1.09 1.09 1.046 1.046
93280 TC 93280TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.58 0.58 0.01 0.59 0.59 0.526 0.526
93281 93281 A 1 XXX 0 0 0 6 0 0 0 0.90 1.02 1.02 0.04 1.96 1.96 1.837 1.837
93281 26 9328126 A 1 XXX 0 0 0 6 0 0 0 0.90 0.34 0.34 0.03 1.27 1.27 1.221 1.221
93281 TC 93281TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.68 0.68 0.01 0.69 0.69 0.616 0.616
93282 93282 A 1 XXX 0 0 0 6 0 0 0 0.85 0.93 0.93 0.04 1.82 1.82 1.706 1.706
93282 26 9328226 A 1 XXX 0 0 0 6 0 0 0 0.85 0.33 0.33 0.03 1.21 1.21 1.162 1.162
93282 TC 93282TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.60 0.60 0.01 0.61 0.61 0.544 0.544
93283 93283 A 1 XXX 0 0 0 6 0 0 0 1.15 1.14 1.14 0.05 2.34 2.34 2.200 2.200
93283 26 9328326 A 1 XXX 0 0 0 6 0 0 0 1.15 0.44 0.44 0.04 1.63 1.63 1.566 1.566
93283 TC 93283TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.70 0.70 0.01 0.71 0.71 0.634 0.634
93284 93284 A 1 XXX 0 0 0 6 0 0 0 1.25 1.28 1.28 0.05 2.58 2.58 2.426 2.426
93284 26 9328426 A 1 XXX 0 0 0 6 0 0 0 1.25 0.48 0.48 0.04 1.77 1.77 1.702 1.702
93284 TC 93284TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.80 0.80 0.01 0.81 0.81 0.724 0.724
93285 93285 A 1 XXX 0 0 0 6 0 0 0 0.52 0.66 0.66 0.02 1.20 1.20 1.123 1.123
93285 26 9328526 A 1 XXX 0 0 0 6 0 0 0 0.52 0.20 0.20 0.01 0.73 0.73 0.705 0.705
93285 TC 93285TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.46 0.46 0.01 0.47 0.47 0.418 0.418
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
411 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93286 93286 A 1 XXX 0 0 0 6 0 0 0 0.30 0.46 0.46 0.02 0.78 0.78 0.724 0.724
93286 26 9328626 A 1 XXX 0 0 0 6 0 0 0 0.30 0.12 0.12 0.01 0.43 0.43 0.413 0.413
93286 TC 93286TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.34 0.34 0.01 0.35 0.35 0.311 0.311
93287 93287 A 1 XXX 0 0 0 6 0 0 0 0.45 0.55 0.55 0.02 1.02 1.02 0.954 0.954
93287 26 9328726 A 1 XXX 0 0 0 6 0 0 0 0.45 0.17 0.17 0.01 0.63 0.63 0.608 0.608
93287 TC 93287TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.38 0.38 0.01 0.39 0.39 0.346 0.346
93288 93288 A 1 XXX 0 0 0 6 0 0 0 0.43 0.63 0.63 0.02 1.08 1.08 1.006 1.006
93288 26 9328826 A 1 XXX 0 0 0 6 0 0 0 0.43 0.16 0.16 0.01 0.60 0.60 0.579 0.579
93288 TC 93288TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.47 0.47 0.01 0.48 0.48 0.427 0.427
93289 93289 A 1 XXX 0 0 0 6 0 0 0 0.92 0.93 0.93 0.04 1.89 1.89 1.776 1.776
93289 26 9328926 A 1 XXX 0 0 0 6 0 0 0 0.92 0.35 0.35 0.03 1.30 1.30 1.250 1.250
93289 TC 93289TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.58 0.58 0.01 0.59 0.59 0.526 0.526
93290 93290 A 1 XXX 0 0 0 6 0 0 0 0.43 0.44 0.44 0.02 0.89 0.89 0.836 0.836
93290 26 9329026 A 1 XXX 0 0 0 6 0 0 0 0.43 0.16 0.16 0.01 0.60 0.60 0.579 0.579
93290 TC 93290TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.28 0.28 0.01 0.29 0.29 0.257 0.257
93291 93291 A 1 XXX 0 0 0 6 0 0 0 0.43 0.59 0.59 0.02 1.04 1.04 0.970 0.970
93291 26 9329126 A 1 XXX 0 0 0 6 0 0 0 0.43 0.16 0.16 0.01 0.60 0.60 0.579 0.579
93291 TC 93291TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.43 0.43 0.01 0.44 0.44 0.391 0.391
93292 93292 A 1 XXX 0 0 0 6 0 0 0 0.43 0.49 0.49 0.02 0.94 0.94 0.880 0.880
93292 26 9329226 A 1 XXX 0 0 0 6 0 0 0 0.43 0.16 0.16 0.01 0.60 0.60 0.579 0.579
93292 TC 93292TC A 1 XXX 0 0 0 6 0 0 0 0.00 0.33 0.33 0.01 0.34 0.34 0.302 0.302
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
412 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93293 93293 A 1 XXX 0 0 0 0 0 0 0 0.32 1.22 1.22 0.02 1.56 1.56 1.426 1.426
93293 26 9329326 A 1 XXX 0 0 0 0 0 0 0 0.32 0.11 0.11 0.01 0.44 0.44 0.424 0.424
93293 TC 93293TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.11 1.11 0.01 1.12 1.12 1.002 1.002
93294 93294 A 2 XXX 0 0 0 0 0 0 0 0.65 0.27 0.27 0.04 0.96 0.96 0.913 0.913
93295 93295 A 2 XXX 0 0 0 0 0 0 0 1.29 0.52 0.52 0.08 1.89 1.89 1.799 1.799
93296 93296 A 3 XXX 0 0 0 0 0 0 0 0.00 0.76 0.76 0.01 0.77 0.77 0.688 0.688
93297 93297 A 2 XXX 0 0 0 0 0 0 0 0.52 0.20 0.20 0.03 0.75 0.75 0.715 0.715
93298 93298 A 2 XXX 0 0 0 0 0 0 0 0.52 0.20 0.20 0.03 0.75 0.75 0.715 0.715
93299 93299 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93303 93303 A 1 XXX 0 0 0 6 0 0 0 1.30 4.46 4.46 0.05 5.81 5.81 5.331 5.331
93303 26 9330326 A 1 XXX 0 0 0 6 0 0 0 1.30 0.49 0.49 0.04 1.83 1.83 1.761 1.761
93303 TC 93303TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.97 3.97 0.01 3.98 3.98 3.570 3.570
93304 93304 A 1 XXX 0 0 0 6 0 0 0 0.75 3.07 3.07 0.04 3.86 3.86 3.528 3.528
93304 26 9330426 A 1 XXX 0 0 0 6 0 0 0 0.75 0.28 0.28 0.03 1.06 1.06 1.017 1.017
93304 TC 93304TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.79 2.79 0.01 2.80 2.80 2.511 2.511
93306 93306 A 1 XXX 0 0 0 6 0 0 0 1.30 4.22 4.22 0.05 5.57 5.57 5.116 5.116
93306 26 9330626 A 1 XXX 0 0 0 6 0 0 0 1.30 0.48 0.48 0.04 1.82 1.82 1.752 1.752
93306 TC 93306TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.74 3.74 0.01 3.75 3.75 3.364 3.364
93307 93307 A 1 XXX 0 0 0 6 0 0 0 0.92 2.40 2.40 0.04 3.36 3.36 3.096 3.096
93307 26 9330726 A 1 XXX 0 0 0 6 0 0 0 0.92 0.35 0.35 0.03 1.30 1.30 1.250 1.250
93307 TC 93307TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.05 2.05 0.01 2.06 2.06 1.846 1.846
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
413 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93308 93308 A 1 XXX 0 0 0 6 0 0 0 0.53 2.40 2.40 0.02 2.95 2.95 2.696 2.696
93308 26 9330826 A 1 XXX 0 0 0 6 0 0 0 0.53 0.19 0.19 0.01 0.73 0.73 0.706 0.706
93308 TC 93308TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.21 2.21 0.01 2.22 2.22 1.990 1.990
93312 93312 A 1 XXX 0 0 0 6 0 0 0 2.20 6.69 6.69 0.10 8.99 8.99 8.260 8.260
93312 26 9331226 A 1 XXX 0 0 0 6 0 0 0 2.20 0.73 0.73 0.07 3.00 3.00 2.892 2.892
93312 TC 93312TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.96 5.96 0.03 5.99 5.99 5.368 5.368
93313 93313 A 0 XXX 0 0 0 0 0 0 0 0.95 0.19 0.19 0.07 1.21 1.21 1.157 1.157
93314 93314 A 1 XXX 0 0 0 6 0 0 0 1.25 7.06 7.06 0.07 8.38 8.38 7.626 7.626
93314 26 9331426 A 1 XXX 0 0 0 6 0 0 0 1.25 0.43 0.43 0.04 1.72 1.72 1.657 1.657
93314 TC 93314TC A 1 XXX 0 0 0 6 0 0 0 0.00 6.63 6.63 0.03 6.66 6.66 5.969 5.969
93315 93315 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93315 26 9331526 A 1 XXX 0 0 0 0 0 0 0 2.78 0.98 0.98 0.23 3.99 3.99 3.780 3.780
93315 TC 93315TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93316 93316 A 0 XXX 0 0 0 0 0 0 0 0.95 0.21 0.21 0.07 1.23 1.23 1.175 1.175
93317 93317 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93317 26 9331726 A 1 XXX 0 0 0 0 0 0 0 1.83 0.63 0.63 0.23 2.69 2.69 2.516 2.516
93317 TC 93317TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93318 93318 C 1 XXX 0 0 0 6 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93318 26 9331826 A 1 XXX 0 0 0 6 0 0 0 2.20 0.71 0.71 0.31 3.22 3.22 3.000 3.000
93318 TC 93318TC C 1 XXX 0 0 0 6 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93320 93320 A 1 ZZZ 0 0 0 0 0 0 0 0.38 0.92 0.92 0.02 1.32 1.32 1.217 1.217
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
414 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93320 26 9332026 A 1 ZZZ 0 0 0 0 0 0 0 0.38 0.14 0.14 0.01 0.53 0.53 0.511 0.511
93320 TC 93320TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.78 0.78 0.01 0.79 0.79 0.706 0.706
93321 93321 A 1 ZZZ 0 0 0 0 0 0 0 0.15 0.53 0.53 0.02 0.70 0.70 0.636 0.636
93321 26 9332126 A 1 ZZZ 0 0 0 0 0 0 0 0.15 0.05 0.05 0.01 0.21 0.21 0.200 0.200
93321 TC 93321TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.48 0.48 0.01 0.49 0.49 0.436 0.436
93325 93325 A 1 ZZZ 0 0 0 0 0 0 0 0.07 0.50 0.50 0.02 0.59 0.59 0.529 0.529
93325 26 9332526 A 1 ZZZ 0 0 0 0 0 0 0 0.07 0.03 0.03 0.01 0.11 0.11 0.102 0.102
93325 TC 93325TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 0.47 0.47 0.01 0.48 0.48 0.427 0.427
93350 93350 A 1 XXX 0 0 0 6 0 0 0 1.46 4.37 4.37 0.06 5.89 5.89 5.416 5.416
93350 26 9335026 A 1 XXX 0 0 0 6 0 0 0 1.46 0.54 0.54 0.05 2.05 2.05 1.971 1.971
93350 TC 93350TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.83 3.83 0.01 3.84 3.84 3.445 3.445
93351 93351 A 1 XXX 0 0 0 6 0 9 9 1.75 5.06 5.06 0.08 6.89 6.89 6.336 6.336
93351 26 9335126 A 1 XXX 0 0 0 6 0 9 9 1.75 0.65 0.65 0.05 2.45 2.45 2.360 2.360
93351 TC 93351TC A 1 XXX 0 0 0 6 0 9 9 0.00 4.41 4.41 0.03 4.44 4.44 3.976 3.976
93352 93352 A 0 ZZZ 0 0 0 0 0 0 0 0.19 0.82 0.82 0.01 1.02 1.02 0.932 0.932
93451 93451 A 1 000 0 0 0 2 0 0 0 2.72 20.72 20.72 0.62 24.06 24.06 21.651 21.651
93451 26 9345126 A 1 000 0 0 0 2 0 0 0 2.72 1.00 1.00 0.59 4.31 4.31 3.927 3.927
93451 TC 93451TC A 1 000 0 0 0 0 0 0 0 0.00 19.72 19.72 0.03 19.75 19.75 17.724 17.724
93452 93452 A 1 000 0 0 0 2 0 0 0 4.75 20.80 20.80 1.09 26.64 26.64 23.998 23.998
93452 26 9345226 A 1 000 0 0 0 2 0 0 0 4.75 1.74 1.74 1.06 7.55 7.55 6.867 6.867
93452 TC 93452TC A 1 000 0 0 0 0 0 0 0 0.00 19.06 19.06 0.03 19.09 19.09 17.132 17.132
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
415 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93453 93453 A 1 000 0 0 0 2 0 0 0 6.24 27.09 27.09 1.41 34.74 34.74 31.304 31.304
93453 26 9345326 A 1 000 0 0 0 2 0 0 0 6.24 2.30 2.30 1.37 9.91 9.91 9.022 9.022
93453 TC 93453TC A 1 000 0 0 0 0 0 0 0 0.00 24.79 24.79 0.04 24.83 24.83 22.282 22.282
93454 93454 A 1 000 0 0 0 2 0 0 0 4.79 21.40 21.40 1.09 27.28 27.28 24.577 24.577
93454 26 9345426 A 1 000 0 0 0 2 0 0 0 4.79 1.75 1.75 1.06 7.60 7.60 6.916 6.916
93454 TC 93454TC A 1 000 0 0 0 0 0 0 0 0.00 19.65 19.65 0.03 19.68 19.68 17.661 17.661
93455 93455 A 1 000 0 0 0 2 0 0 0 5.54 24.91 24.91 1.25 31.70 31.70 28.563 28.563
93455 26 9345526 A 1 000 0 0 0 2 0 0 0 5.54 2.02 2.02 1.21 8.77 8.77 7.987 7.987
93455 TC 93455TC A 1 000 0 0 0 0 0 0 0 0.00 22.89 22.89 0.04 22.93 22.93 20.576 20.576
93456 93456 A 1 000 0 0 0 2 0 0 0 6.15 26.67 26.67 1.37 34.19 34.19 30.816 30.816
93456 26 9345626 A 1 000 0 0 0 2 0 0 0 6.15 2.25 2.25 1.33 9.73 9.73 8.866 8.866
93456 TC 93456TC A 1 000 0 0 0 0 0 0 0 0.00 24.42 24.42 0.04 24.46 24.46 21.950 21.950
93457 93457 A 1 000 0 0 0 2 0 0 0 6.89 30.16 30.16 1.54 38.59 38.59 34.779 34.779
93457 26 9345726 A 1 000 0 0 0 2 0 0 0 6.89 2.52 2.52 1.50 10.91 10.91 9.937 9.937
93457 TC 93457TC A 1 000 0 0 0 0 0 0 0 0.00 27.64 27.64 0.04 27.68 27.68 24.842 24.842
93458 93458 A 1 000 0 0 0 2 0 0 0 5.85 25.49 25.49 1.33 32.67 32.67 29.436 29.436
93458 26 9345826 A 1 000 0 0 0 2 0 0 0 5.85 2.14 2.14 1.29 9.28 9.28 8.446 8.446
93458 TC 93458TC A 1 000 0 0 0 0 0 0 0 0.00 23.35 23.35 0.04 23.39 23.39 20.989 20.989
93459 93459 A 1 000 0 0 0 2 0 0 0 6.60 28.00 28.00 1.47 36.07 36.07 32.513 32.513
93459 26 9345926 A 1 000 0 0 0 2 0 0 0 6.60 2.41 2.41 1.43 10.44 10.44 9.512 9.512
93459 TC 93459TC A 1 000 0 0 0 0 0 0 0 0.00 25.59 25.59 0.04 25.63 25.63 23.001 23.001
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
416 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93460 93460 A 1 000 0 0 0 2 0 0 0 7.35 29.67 29.67 1.63 38.65 38.65 34.846 34.846
93460 26 9346026 A 1 000 0 0 0 2 0 0 0 7.35 2.69 2.69 1.59 11.63 11.63 10.597 10.597
93460 TC 93460TC A 1 000 0 0 0 0 0 0 0 0.00 26.98 26.98 0.04 27.02 27.02 24.249 24.249
93461 93461 A 1 000 0 0 0 2 0 0 0 8.10 34.36 34.36 1.82 44.28 44.28 39.907 39.907
93461 26 9346126 A 1 000 0 0 0 2 0 0 0 8.10 2.97 2.97 1.77 12.84 12.84 11.693 11.693
93461 TC 93461TC A 1 000 0 0 0 0 0 0 0 0.00 31.39 31.39 0.05 31.44 31.44 28.214 28.214
93462 93462 A 0 ZZZ 0 0 0 0 0 0 0 3.73 1.47 1.47 0.80 6.00 6.00 5.468 5.468
93463 93463 A 0 ZZZ 0 0 0 0 0 0 0 2.00 0.72 0.72 0.39 3.11 3.11 2.851 2.851
93464 93464 A 1 ZZZ 0 0 0 0 0 0 0 1.80 6.40 6.40 0.36 8.56 8.56 7.735 7.735
93464 26 9346426 A 1 ZZZ 0 0 0 0 0 0 0 1.80 0.66 0.66 0.35 2.81 2.81 2.576 2.576
93464 TC 93464TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 5.74 5.74 0.01 5.75 5.75 5.160 5.160
93503 93503 A 0 000 0 0 0 0 0 0 0 2.91 0.60 0.60 0.27 3.78 3.78 3.590 3.590
93505 93505 A 1 000 0 0 0 2 0 0 0 4.37 17.80 17.80 0.86 23.03 23.03 20.804 20.804
93505 26 9350526 A 1 000 0 0 0 2 0 0 0 4.37 1.59 1.59 0.83 6.79 6.79 6.232 6.232
93505 TC 93505TC A 1 000 0 0 0 0 0 0 0 0.00 16.21 16.21 0.03 16.24 16.24 14.572 14.572
93530 93530 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93530 26 9353026 A 1 000 0 0 0 2 0 0 0 4.22 1.54 1.54 0.91 6.67 6.67 6.079 6.079
93530 TC 93530TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93531 93531 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93531 26 9353126 A 1 000 0 0 0 2 0 0 0 8.34 3.04 3.04 1.82 13.20 13.20 12.022 12.022
93531 TC 93531TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
417 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93532 93532 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93532 26 9353226 A 1 000 0 0 0 2 0 0 0 9.99 3.63 3.63 2.18 15.80 15.80 14.390 14.390
93532 TC 93532TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93533 93533 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93533 26 9353326 A 1 000 0 0 0 2 0 0 0 6.69 2.43 2.43 1.47 10.59 10.59 9.641 9.641
93533 TC 93533TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93561 93561 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93561 26 9356126 A 1 000 0 0 0 0 0 0 0 0.50 0.16 0.16 0.04 0.70 0.70 0.665 0.665
93561 TC 93561TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93562 93562 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93562 26 9356226 A 1 000 0 0 0 0 0 0 0 0.16 0.05 0.05 0.01 0.22 0.22 0.210 0.210
93562 TC 93562TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93563 93563 A 0 ZZZ 0 0 0 0 0 0 0 1.11 0.40 0.40 0.10 1.61 1.61 1.522 1.522
93564 93564 A 0 ZZZ 0 0 0 0 0 0 0 1.13 0.41 0.41 0.11 1.65 1.65 1.556 1.556
93565 93565 A 0 ZZZ 0 0 0 0 0 0 0 0.86 0.31 0.31 0.08 1.25 1.25 1.180 1.180
93566 93566 A 0 ZZZ 0 0 0 0 0 0 0 0.86 4.26 0.31 0.08 5.20 1.25 4.727 1.180
93567 93567 A 0 ZZZ 0 0 0 0 0 0 0 0.97 3.21 0.36 0.08 4.26 1.41 3.894 1.335
93568 93568 A 0 ZZZ 0 0 0 0 0 0 0 0.88 3.69 0.32 0.08 4.65 1.28 4.235 1.209
93571 93571 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93571 26 9357126 A 1 ZZZ 0 0 0 0 0 0 0 1.80 0.66 0.66 0.11 2.57 2.57 2.450 2.450
93571 TC 93571TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
418 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93572 93572 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93572 26 9357226 A 1 ZZZ 0 0 0 0 0 0 0 1.44 0.53 0.53 0.11 2.08 2.08 1.973 1.973
93572 TC 93572TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93580 93580 A 0 000 0 0 0 2 0 0 0 17.97 7.01 7.01 3.92 28.90 28.90 26.315 26.315
93581 93581 A 0 000 0 0 0 2 0 0 0 24.39 9.27 9.27 5.32 38.98 38.98 35.497 35.497
93600 93600 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93600 26 9360026 A 1 000 0 0 0 0 0 0 0 2.12 0.84 0.84 0.45 3.41 3.41 3.110 3.110
93600 TC 93600TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93602 93602 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93602 26 9360226 A 1 000 0 0 0 0 0 0 0 2.12 0.83 0.83 0.45 3.40 3.40 3.101 3.101
93602 TC 93602TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93603 93603 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93603 26 9360326 A 1 000 0 0 0 0 0 0 0 2.12 0.82 0.82 0.45 3.39 3.39 3.092 3.092
93603 TC 93603TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93609 93609 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93609 26 9360926 A 1 ZZZ 0 0 0 0 0 0 0 4.99 1.95 1.95 1.09 8.03 8.03 7.311 7.311
93609 TC 93609TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93610 93610 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93610 26 9361026 A 1 000 0 0 0 0 0 0 0 3.02 1.16 1.16 0.65 4.83 4.83 4.402 4.402
93610 TC 93610TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93612 93612 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
419 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93612 26 9361226 A 1 000 0 0 0 0 0 0 0 3.02 1.13 1.13 0.65 4.80 4.80 4.375 4.375
93612 TC 93612TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93613 93613 A 0 ZZZ 0 0 0 0 0 0 0 6.99 2.77 2.77 1.52 11.28 11.28 10.272 10.272
93615 93615 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93615 26 9361526 A 1 000 0 0 0 0 0 0 0 0.99 0.36 0.36 0.05 1.40 1.40 1.339 1.339
93615 TC 93615TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93616 93616 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93616 26 9361626 A 1 000 0 0 0 0 0 0 0 1.49 0.29 0.29 0.11 1.89 1.89 1.808 1.808
93616 TC 93616TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93618 93618 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93618 26 9361826 A 1 000 0 0 0 0 0 0 0 4.25 1.68 1.68 0.91 6.84 6.84 6.235 6.235
93618 TC 93618TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93619 93619 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93619 26 9361926 A 1 000 0 0 0 2 0 0 0 7.31 2.85 2.85 1.59 11.75 11.75 10.701 10.701
93619 TC 93619TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93620 93620 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93620 26 9362026 A 1 000 0 0 0 2 0 0 0 11.57 4.54 4.54 2.52 18.63 18.63 16.965 16.965
93620 TC 93620TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93621 93621 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93621 26 9362126 A 1 ZZZ 0 0 0 0 0 0 0 2.10 0.83 0.83 0.45 3.38 3.38 3.081 3.081
93621 TC 93621TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
420 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93622 93622 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93622 26 9362226 A 1 ZZZ 0 0 0 0 0 0 0 3.10 1.22 1.22 0.67 4.99 4.99 4.546 4.546
93622 TC 93622TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93623 93623 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93623 26 9362326 A 1 ZZZ 0 0 0 0 0 0 0 2.85 1.12 1.12 0.63 4.60 4.60 4.185 4.185
93623 TC 93623TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93624 93624 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93624 26 9362426 A 1 000 0 0 0 2 0 0 0 4.80 1.82 1.82 1.05 7.67 7.67 6.984 6.984
93624 TC 93624TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93631 93631 C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93631 26 9363126 A 1 000 0 0 0 0 0 0 0 7.59 2.48 2.48 1.81 11.88 11.88 10.764 10.764
93631 TC 93631TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93640 93640 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93640 26 9364026 A 1 000 0 0 0 2 0 0 0 3.51 1.33 1.33 0.76 5.60 5.60 5.102 5.102
93640 TC 93640TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93641 93641 C 1 000 0 0 0 2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93641 26 9364126 A 1 000 0 0 0 2 0 0 0 5.92 2.29 2.29 1.29 9.50 9.50 8.651 8.651
93641 TC 93641TC C 1 000 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93642 93642 A 1 000 0 0 0 2 0 0 0 4.88 6.40 6.40 0.21 11.49 11.49 10.737 10.737
93642 26 9364226 A 1 000 0 0 0 2 0 0 0 4.88 1.91 1.91 0.18 6.97 6.97 6.689 6.689
93642 TC 93642TC A 1 000 0 0 0 0 0 0 0 0.00 4.49 4.49 0.03 4.52 4.52 4.048 4.048
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
421 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93650 93650 A 0 000 0 0 0 2 0 0 0 10.49 4.45 4.45 2.27 17.21 17.21 15.673 15.673
93653 93653 A 0 000 0 0 0 2 0 0 0 15.00 5.91 5.91 3.27 24.18 24.18 22.017 22.017
93654 93654 A 0 000 0 0 0 2 0 0 0 20.00 7.91 7.91 4.36 32.27 32.27 29.383 29.383
93655 93655 A 0 ZZZ 0 0 0 0 0 0 0 7.50 2.96 2.96 1.63 12.09 12.09 11.011 11.011
93656 93656 A 0 000 0 0 0 2 0 0 0 20.02 7.90 7.90 4.36 32.28 32.28 29.394 29.394
93657 93657 A 0 ZZZ 0 0 0 0 0 0 0 7.50 2.96 2.96 1.64 12.10 12.10 11.016 11.016
93660 93660 A 1 000 0 0 0 2 0 0 0 1.89 2.62 2.62 0.08 4.59 4.59 4.285 4.285
93660 26 9366026 A 1 000 0 0 0 2 0 0 0 1.89 0.73 0.73 0.07 2.69 2.69 2.582 2.582
93660 TC 93660TC A 1 000 0 0 0 0 0 0 0 0.00 1.89 1.89 0.01 1.90 1.90 1.702 1.702
93662 93662 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93662 26 9366226 A 1 ZZZ 0 0 0 0 0 0 0 2.80 1.10 1.10 0.20 4.10 4.10 3.892 3.892
93662 TC 93662TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93668 93668 N 9 XXX 0 0 0 9 9 9 9 0.00 0.58 0.58 0.01 0.59 0.59 0.526 0.526
93701 93701 A 3 XXX 0 0 0 6 0 0 0 0.00 0.73 0.73 0.01 0.74 0.74 0.661 0.661
93724 93724 A 1 000 0 0 0 6 0 0 0 4.88 2.70 2.70 0.19 7.77 7.77 7.404 7.404
93724 26 9372426 A 1 000 0 0 0 6 0 0 0 4.88 1.86 1.86 0.18 6.92 6.92 6.644 6.644
93724 TC 93724TC A 1 000 0 0 0 6 0 0 0 0.00 0.84 0.84 0.01 0.85 0.85 0.760 0.760
93740 93740 B 9 XXX 0 0 0 9 9 9 9 0.16 0.06 0.06 0.03 0.25 0.25 0.230 0.230
93745 93745 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93745 26 9374526 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93745 TC 93745TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
422 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93750 93750 A 0 XXX 0 0 0 0 0 0 0 0.92 0.61 0.32 0.05 1.58 1.29 1.494 1.234
93770 93770 B 9 XXX 0 0 0 9 9 9 9 0.16 0.06 0.06 0.03 0.25 0.25 0.230 0.230
93784 93784 A 4 XXX 0 0 0 6 0 0 0 0.38 1.23 1.23 0.03 1.64 1.64 1.500 1.500
93786 93786 A 3 XXX 0 0 0 6 0 0 0 0.00 0.92 0.92 0.01 0.93 0.93 0.831 0.831
93788 93788 A 3 XXX 0 0 0 6 0 0 0 0.00 0.16 0.16 0.01 0.17 0.17 0.149 0.149
93790 93790 A 2 XXX 0 0 0 0 0 0 0 0.38 0.15 0.15 0.01 0.54 0.54 0.520 0.520
93797 93797 A 0 000 0 0 0 0 0 0 0 0.18 0.30 0.07 0.01 0.49 0.26 0.455 0.248
93798 93798 A 0 000 0 0 0 0 0 0 0 0.28 0.44 0.11 0.01 0.73 0.40 0.680 0.384
93799 93799 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93799 26 9379926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93799 TC 93799TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
93880 93880 A 1 XXX 0 0 0 6 2 0 0 0.60 6.53 6.53 0.05 7.18 7.18 6.490 6.490
93880 26 9388026 A 1 XXX 0 0 0 6 2 0 0 0.60 0.21 0.21 0.04 0.85 0.85 0.810 0.810
93880 TC 93880TC A 1 XXX 0 0 0 6 2 0 0 0.00 6.32 6.32 0.01 6.33 6.33 5.681 5.681
93882 93882 A 1 XXX 0 0 0 6 0 0 0 0.40 4.71 4.71 0.06 5.17 5.17 4.661 4.661
93882 26 9388226 A 1 XXX 0 0 0 6 0 0 0 0.40 0.13 0.13 0.05 0.58 0.58 0.543 0.543
93882 TC 93882TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.58 4.58 0.01 4.59 4.59 4.118 4.118
93886 93886 A 1 XXX 0 0 0 6 0 0 0 0.94 10.20 10.20 0.05 11.19 11.19 10.126 10.126
93886 26 9388626 A 1 XXX 0 0 0 6 0 0 0 0.94 0.41 0.41 0.04 1.39 1.39 1.329 1.329
93886 TC 93886TC A 1 XXX 0 0 0 6 0 0 0 0.00 9.79 9.79 0.01 9.80 9.80 8.797 8.797
93888 93888 A 1 XXX 0 0 0 6 0 0 0 0.62 5.83 5.83 0.05 6.50 6.50 5.881 5.881
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
423 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93888 26 9388826 A 1 XXX 0 0 0 6 0 0 0 0.62 0.25 0.25 0.04 0.91 0.91 0.865 0.865
93888 TC 93888TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.58 5.58 0.01 5.59 5.59 5.016 5.016
93890 93890 A 1 XXX 0 0 0 6 0 0 0 1.00 7.75 7.75 0.05 8.80 8.80 7.986 7.986
93890 26 9389026 A 1 XXX 0 0 0 6 0 0 0 1.00 0.41 0.41 0.04 1.45 1.45 1.389 1.389
93890 TC 93890TC A 1 XXX 0 0 0 6 0 0 0 0.00 7.34 7.34 0.01 7.35 7.35 6.597 6.597
93892 93892 A 1 XXX 0 0 0 6 0 0 0 1.15 8.73 8.73 0.06 9.94 9.94 9.021 9.021
93892 26 9389226 A 1 XXX 0 0 0 6 0 0 0 1.15 0.48 0.48 0.05 1.68 1.68 1.607 1.607
93892 TC 93892TC A 1 XXX 0 0 0 6 0 0 0 0.00 8.25 8.25 0.01 8.26 8.26 7.414 7.414
93893 93893 A 1 XXX 0 0 0 6 0 0 0 1.15 9.40 9.40 0.06 10.61 10.61 9.623 9.623
93893 26 9389326 A 1 XXX 0 0 0 6 0 0 0 1.15 0.50 0.50 0.05 1.70 1.70 1.625 1.625
93893 TC 93893TC A 1 XXX 0 0 0 6 0 0 0 0.00 8.90 8.90 0.01 8.91 8.91 7.997 7.997
93922 93922 A 1 XXX 0 0 0 6 2 0 0 0.25 2.50 2.50 0.02 2.77 2.77 2.505 2.505
93922 26 9392226 A 1 XXX 0 0 0 6 2 0 0 0.25 0.09 0.09 0.01 0.35 0.35 0.336 0.336
93922 TC 93922TC A 1 XXX 0 0 0 6 2 0 0 0.00 2.41 2.41 0.01 2.42 2.42 2.169 2.169
93923 93923 A 1 XXX 0 0 0 6 2 0 0 0.45 3.80 3.80 0.05 4.30 4.30 3.889 3.889
93923 26 9392326 A 1 XXX 0 0 0 6 2 0 0 0.45 0.15 0.15 0.04 0.64 0.64 0.606 0.606
93923 TC 93923TC A 1 XXX 0 0 0 6 2 0 0 0.00 3.65 3.65 0.01 3.66 3.66 3.283 3.283
93924 93924 A 1 XXX 0 0 0 6 2 0 0 0.50 4.84 4.84 0.05 5.39 5.39 4.872 4.872
93924 26 9392426 A 1 XXX 0 0 0 6 2 0 0 0.50 0.17 0.17 0.04 0.71 0.71 0.674 0.674
93924 TC 93924TC A 1 XXX 0 0 0 6 2 0 0 0.00 4.67 4.67 0.01 4.68 4.68 4.199 4.199
93925 93925 A 1 XXX 0 0 0 6 2 0 0 0.80 6.66 6.66 0.09 7.55 7.55 6.828 6.828
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
424 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93925 26 9392526 A 1 XXX 0 0 0 6 2 0 0 0.80 0.28 0.28 0.06 1.14 1.14 1.083 1.083
93925 TC 93925TC A 1 XXX 0 0 0 6 2 0 0 0.00 6.38 6.38 0.03 6.41 6.41 5.745 5.745
93926 93926 A 1 XXX 0 0 0 6 0 0 0 0.50 3.77 3.77 0.07 4.34 4.34 3.922 3.922
93926 26 9392626 A 1 XXX 0 0 0 6 0 0 0 0.50 0.16 0.16 0.06 0.72 0.72 0.675 0.675
93926 TC 93926TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.61 3.61 0.01 3.62 3.62 3.247 3.247
93930 93930 A 1 XXX 0 0 0 6 2 0 0 0.46 6.70 6.70 0.05 7.21 7.21 6.503 6.503
93930 26 9393026 A 1 XXX 0 0 0 6 2 0 0 0.46 0.16 0.16 0.04 0.66 0.66 0.625 0.625
93930 TC 93930TC A 1 XXX 0 0 0 6 2 0 0 0.00 6.54 6.54 0.01 6.55 6.55 5.878 5.878
93931 93931 A 1 XXX 0 0 0 6 0 0 0 0.31 4.48 4.48 0.04 4.83 4.83 4.354 4.354
93931 26 9393126 A 1 XXX 0 0 0 6 0 0 0 0.31 0.10 0.10 0.03 0.44 0.44 0.415 0.415
93931 TC 93931TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.38 4.38 0.01 4.39 4.39 3.938 3.938
93965 93965 A 1 XXX 0 0 0 6 2 0 0 0.35 3.31 3.31 0.04 3.70 3.70 3.343 3.343
93965 26 9396526 A 1 XXX 0 0 0 6 2 0 0 0.35 0.12 0.12 0.03 0.50 0.50 0.473 0.473
93965 TC 93965TC A 1 XXX 0 0 0 6 2 0 0 0.00 3.19 3.19 0.01 3.20 3.20 2.870 2.870
93970 93970 A 1 XXX 0 0 0 6 2 0 0 0.70 4.91 4.91 0.08 5.69 5.69 5.151 5.151
93970 26 9397026 A 1 XXX 0 0 0 6 2 0 0 0.70 0.24 0.24 0.07 1.01 1.01 0.952 0.952
93970 TC 93970TC A 1 XXX 0 0 0 6 2 0 0 0.00 4.67 4.67 0.01 4.68 4.68 4.199 4.199
93971 93971 A 1 XXX 0 0 0 6 0 0 0 0.45 2.94 2.94 0.05 3.44 3.44 3.116 3.116
93971 26 9397126 A 1 XXX 0 0 0 6 0 0 0 0.45 0.15 0.15 0.04 0.64 0.64 0.606 0.606
93971 TC 93971TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.79 2.79 0.01 2.80 2.80 2.511 2.511
93975 93975 A 1 XXX 0 0 0 6 0 0 0 1.80 8.89 8.89 0.17 10.86 10.86 9.872 9.872
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
425 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93975 26 9397526 A 1 XXX 0 0 0 6 0 0 0 1.80 0.63 0.63 0.14 2.57 2.57 2.439 2.439
93975 TC 93975TC A 1 XXX 0 0 0 6 0 0 0 0.00 8.26 8.26 0.03 8.29 8.29 7.433 7.433
93976 93976 A 1 XXX 0 0 0 6 0 0 0 1.21 5.00 5.00 0.09 6.30 6.30 5.747 5.747
93976 26 9397626 A 1 XXX 0 0 0 6 0 0 0 1.21 0.43 0.43 0.08 1.72 1.72 1.638 1.638
93976 TC 93976TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.57 4.57 0.01 4.58 4.58 4.109 4.109
93978 93978 A 1 XXX 0 0 0 6 0 0 0 0.65 6.24 6.24 0.08 6.97 6.97 6.295 6.295
93978 26 9397826 A 1 XXX 0 0 0 6 0 0 0 0.65 0.22 0.22 0.07 0.94 0.94 0.884 0.884
93978 TC 93978TC A 1 XXX 0 0 0 6 0 0 0 0.00 6.02 6.02 0.01 6.03 6.03 5.411 5.411
93979 93979 A 1 XXX 0 0 0 6 0 0 0 0.44 4.33 4.33 0.05 4.82 4.82 4.354 4.354
93979 26 9397926 A 1 XXX 0 0 0 6 0 0 0 0.44 0.14 0.14 0.04 0.62 0.62 0.587 0.587
93979 TC 93979TC A 1 XXX 0 0 0 6 0 0 0 0.00 4.19 4.19 0.01 4.20 4.20 3.768 3.768
93980 93980 A 1 XXX 0 0 0 6 0 0 0 1.25 3.50 3.50 0.08 4.83 4.83 4.435 4.435
93980 26 9398026 A 1 XXX 0 0 0 6 0 0 0 1.25 0.45 0.45 0.07 1.77 1.77 1.691 1.691
93980 TC 93980TC A 1 XXX 0 0 0 6 0 0 0 0.00 3.05 3.05 0.01 3.06 3.06 2.744 2.744
93981 93981 A 1 XXX 0 0 0 6 0 0 0 0.44 2.83 2.83 0.04 3.31 3.31 3.002 3.002
93981 26 9398126 A 1 XXX 0 0 0 6 0 0 0 0.44 0.15 0.15 0.03 0.62 0.62 0.590 0.590
93981 TC 93981TC A 1 XXX 0 0 0 6 0 0 0 0.00 2.68 2.68 0.01 2.69 2.69 2.412 2.412
93982 93982 R 0 XXX 0 0 0 0 0 0 0 0.30 0.95 0.95 0.05 1.30 1.30 1.179 1.179
93990 93990 A 1 XXX 0 0 0 6 0 0 0 0.25 5.87 5.87 0.05 6.17 6.17 5.547 5.547
93990 26 9399026 A 1 XXX 0 0 0 6 0 0 0 0.25 0.07 0.07 0.04 0.36 0.36 0.334 0.334
93990 TC 93990TC A 1 XXX 0 0 0 6 0 0 0 0.00 5.80 5.80 0.01 5.81 5.81 5.214 5.214
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
426 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
93998 93998 C 0 XXX 0 0 0 0 0 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94002 94002 A 0 XXX 0 0 0 0 0 0 0 1.99 0.54 0.54 0.16 2.69 2.69 2.559 2.559
94003 94003 A 0 XXX 0 0 0 0 0 0 0 1.37 0.48 0.48 0.10 1.95 1.95 1.853 1.853
94004 94004 A 0 XXX 0 0 0 0 0 0 0 1.00 0.36 0.36 0.07 1.43 1.43 1.360 1.360
94005 94005 B 9 XXX 0 0 0 9 9 9 9 1.50 1.11 1.11 0.10 2.71 2.71 2.549 2.549
94010 94010 A 1 XXX 0 0 0 0 0 0 0 0.17 0.91 0.91 0.02 1.10 1.10 0.998 0.998
94010 26 9401026 A 1 XXX 0 0 0 0 0 0 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
94010 TC 94010TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.85 0.85 0.01 0.86 0.86 0.769 0.769
94011 94011 A 0 XXX 0 0 0 0 0 0 0 2.00 0.77 0.77 0.14 2.91 2.91 2.765 2.765
94012 94012 A 0 XXX 0 0 0 0 0 0 0 3.10 1.26 1.26 0.23 4.59 4.59 4.352 4.352
94013 94013 A 0 XXX 0 0 0 0 0 0 0 0.66 0.33 0.33 0.04 1.03 1.03 0.977 0.977
94014 94014 A 4 XXX 0 0 0 0 0 0 0 0.52 0.92 0.92 0.02 1.46 1.46 1.357 1.357
94015 94015 A 3 XXX 0 0 0 0 0 0 0 0.00 0.74 0.74 0.01 0.75 0.75 0.670 0.670
94016 94016 A 2 XXX 0 0 0 0 0 0 0 0.52 0.18 0.18 0.01 0.71 0.71 0.687 0.687
94060 94060 A 1 XXX 0 0 0 0 0 0 0 0.27 1.60 1.60 0.02 1.89 1.89 1.717 1.717
94060 26 9406026 A 1 XXX 0 0 0 0 0 0 0 0.27 0.10 0.10 0.01 0.38 0.38 0.365 0.365
94060 TC 94060TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.50 1.50 0.01 1.51 1.51 1.352 1.352
94070 94070 A 1 XXX 0 0 0 0 0 0 0 0.60 1.16 1.16 0.04 1.80 1.80 1.663 1.663
94070 26 9407026 A 1 XXX 0 0 0 0 0 0 0 0.60 0.21 0.21 0.03 0.84 0.84 0.804 0.804
94070 TC 94070TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.95 0.95 0.01 0.96 0.96 0.858 0.858
94150 94150 B 1 XXX 0 0 0 9 9 9 9 0.07 0.68 0.68 0.02 0.77 0.77 0.691 0.691
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
427 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
94150 26 9415026 B 1 XXX 0 0 0 9 9 9 9 0.07 0.03 0.03 0.01 0.11 0.11 0.102 0.102
94150 TC 94150TC B 1 XXX 0 0 0 9 9 9 9 0.00 0.65 0.65 0.01 0.66 0.66 0.589 0.589
94200 94200 A 1 XXX 0 0 0 0 0 0 0 0.11 0.64 0.64 0.02 0.77 0.77 0.695 0.695
94200 26 9420026 A 1 XXX 0 0 0 0 0 0 0 0.11 0.04 0.04 0.01 0.16 0.16 0.151 0.151
94200 TC 94200TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.60 0.60 0.01 0.61 0.61 0.544 0.544
94250 94250 A 1 XXX 0 0 0 0 0 0 0 0.11 0.65 0.65 0.02 0.78 0.78 0.704 0.704
94250 26 9425026 A 1 XXX 0 0 0 0 0 0 0 0.11 0.04 0.04 0.01 0.16 0.16 0.151 0.151
94250 TC 94250TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.61 0.61 0.01 0.62 0.62 0.553 0.553
94375 94375 A 1 XXX 0 0 0 0 0 0 0 0.31 0.86 0.86 0.02 1.19 1.19 1.093 1.093
94375 26 9437526 A 1 XXX 0 0 0 0 0 0 0 0.31 0.11 0.11 0.01 0.43 0.43 0.414 0.414
94375 TC 94375TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.75 0.75 0.01 0.76 0.76 0.679 0.679
94400 94400 A 1 XXX 0 0 0 0 0 0 0 0.40 1.34 1.34 0.02 1.76 1.76 1.614 1.614
94400 26 9440026 A 1 XXX 0 0 0 0 0 0 0 0.40 0.14 0.14 0.01 0.55 0.55 0.531 0.531
94400 TC 94400TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.20 1.20 0.01 1.21 1.21 1.083 1.083
94450 94450 A 1 XXX 0 0 0 0 0 0 0 0.40 1.65 1.65 0.02 2.07 2.07 1.892 1.892
94450 26 9445026 A 1 XXX 0 0 0 0 0 0 0 0.40 0.16 0.16 0.01 0.57 0.57 0.549 0.549
94450 TC 94450TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.49 1.49 0.01 1.50 1.50 1.343 1.343
94452 94452 A 1 XXX 0 0 0 0 0 0 0 0.31 1.48 1.48 0.02 1.81 1.81 1.650 1.650
94452 26 9445226 A 1 XXX 0 0 0 0 0 0 0 0.31 0.11 0.11 0.01 0.43 0.43 0.414 0.414
94452 TC 94452TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.37 1.37 0.01 1.38 1.38 1.235 1.235
94453 94453 A 1 XXX 0 0 0 0 0 0 0 0.40 2.12 2.12 0.02 2.54 2.54 2.314 2.314
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
428 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
94453 26 9445326 A 1 XXX 0 0 0 0 0 0 0 0.40 0.14 0.14 0.01 0.55 0.55 0.531 0.531
94453 TC 94453TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.98 1.98 0.01 1.99 1.99 1.783 1.783
94610 94610 A 0 XXX 0 0 0 0 0 0 0 1.16 0.53 0.53 0.07 1.76 1.76 1.673 1.673
94620 94620 A 1 XXX 0 0 0 0 0 0 0 0.64 1.00 1.00 0.04 1.68 1.68 1.559 1.559
94620 26 9462026 A 1 XXX 0 0 0 0 0 0 0 0.64 0.22 0.22 0.03 0.89 0.89 0.853 0.853
94620 TC 94620TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.78 0.78 0.01 0.79 0.79 0.706 0.706
94621 94621 A 1 XXX 0 0 0 0 0 0 0 1.42 3.44 3.44 0.06 4.92 4.92 4.541 4.541
94621 26 9462126 A 1 XXX 0 0 0 0 0 0 0 1.42 0.52 0.52 0.05 1.99 1.99 1.913 1.913
94621 TC 94621TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.92 2.92 0.01 2.93 2.93 2.627 2.627
94640 94640 A 5 XXX 0 0 0 0 0 0 0 0.00 0.56 0.56 0.01 0.57 0.57 0.508 0.508
94642 94642 C 5 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94644 94644 A 5 XXX 0 0 0 0 0 0 0 0.00 1.37 1.37 0.01 1.38 1.38 1.235 1.235
94645 94645 A 5 XXX 0 0 0 0 0 0 0 0.00 0.43 0.43 0.01 0.44 0.44 0.391 0.391
94660 94660 A 0 XXX 0 0 0 0 0 0 0 0.76 1.07 0.29 0.05 1.88 1.10 1.747 1.047
94662 94662 A 0 XXX 0 0 0 0 0 0 0 0.76 0.24 0.24 0.05 1.05 1.05 1.002 1.002
94664 94664 A 5 XXX 0 0 0 0 0 0 0 0.00 0.54 0.54 0.01 0.55 0.55 0.490 0.490
94667 94667 A 5 XXX 0 0 0 0 0 0 0 0.00 0.76 0.76 0.01 0.77 0.77 0.688 0.688
94668 94668 A 5 XXX 0 0 0 0 0 0 0 0.00 0.79 0.79 0.01 0.80 0.80 0.715 0.715
94680 94680 A 1 XXX 0 0 0 0 0 0 0 0.26 1.52 1.52 0.02 1.80 1.80 1.635 1.635
94680 26 9468026 A 1 XXX 0 0 0 0 0 0 0 0.26 0.10 0.10 0.01 0.37 0.37 0.355 0.355
94680 TC 94680TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.42 1.42 0.01 1.43 1.43 1.280 1.280
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
429 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
94681 94681 A 1 XXX 0 0 0 0 0 0 0 0.20 1.40 1.40 0.02 1.62 1.62 1.468 1.468
94681 26 9468126 A 1 XXX 0 0 0 0 0 0 0 0.20 0.08 0.08 0.01 0.29 0.29 0.277 0.277
94681 TC 94681TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.32 1.32 0.01 1.33 1.33 1.191 1.191
94690 94690 A 1 XXX 0 0 0 0 0 0 0 0.07 1.43 1.43 0.02 1.52 1.52 1.365 1.365
94690 26 9469026 A 1 XXX 0 0 0 0 0 0 0 0.07 0.03 0.03 0.01 0.11 0.11 0.102 0.102
94690 TC 94690TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.40 1.40 0.01 1.41 1.41 1.262 1.262
94726 94726 A 1 XXX 0 0 0 0 0 0 0 0.26 1.50 1.50 0.03 1.79 1.79 1.623 1.623
94726 26 9472626 A 1 XXX 0 0 0 0 0 0 0 0.26 0.11 0.11 0.01 0.38 0.38 0.364 0.364
94726 TC 94726TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.39 1.39 0.02 1.41 1.41 1.259 1.259
94727 94727 A 1 XXX 0 0 0 0 0 0 0 0.26 1.12 1.12 0.02 1.40 1.40 1.276 1.276
94727 26 9472726 A 1 XXX 0 0 0 0 0 0 0 0.26 0.11 0.11 0.01 0.38 0.38 0.364 0.364
94727 TC 94727TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.01 1.01 0.01 1.02 1.02 0.912 0.912
94728 94728 A 1 XXX 0 0 0 0 0 0 0 0.26 1.07 1.07 0.02 1.35 1.35 1.231 1.231
94728 26 9472826 A 1 XXX 0 0 0 0 0 0 0 0.26 0.11 0.11 0.01 0.38 0.38 0.364 0.364
94728 TC 94728TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.96 0.96 0.01 0.97 0.97 0.867 0.867
94729 94729 A 1 ZZZ 0 0 0 0 0 0 0 0.19 1.63 1.63 0.02 1.84 1.84 1.664 1.664
94729 26 9472926 A 1 ZZZ 0 0 0 0 0 0 0 0.19 0.08 0.08 0.01 0.28 0.28 0.267 0.267
94729 TC 94729TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 1.55 1.55 0.01 1.56 1.56 1.397 1.397
94750 94750 A 1 XXX 0 0 0 0 0 0 0 0.23 2.31 2.31 0.02 2.56 2.56 2.315 2.315
94750 26 9475026 A 1 XXX 0 0 0 0 0 0 0 0.23 0.08 0.08 0.01 0.32 0.32 0.307 0.307
94750 TC 94750TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.23 2.23 0.01 2.24 2.24 2.008 2.008
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
430 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
94760 94760 T 3 XXX 0 0 0 0 0 0 0 0.00 0.09 0.09 0.01 0.10 0.10 0.086 0.086
94761 94761 T 3 XXX 0 0 0 0 0 0 0 0.00 0.14 0.14 0.01 0.15 0.15 0.131 0.131
94762 94762 A 3 XXX 0 0 0 0 0 0 0 0.00 0.73 0.73 0.01 0.74 0.74 0.661 0.661
94770 94770 A 0 XXX 0 0 0 0 0 0 0 0.15 0.06 0.06 0.03 0.24 0.24 0.220 0.220
94772 94772 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94772 26 9477226 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94772 TC 94772TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94774 94774 C 4 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94775 94775 C 3 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94776 94776 C 3 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94777 94777 C 2 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94780 94780 A 0 XXX 0 0 0 0 0 1 0 0.48 1.03 0.17 0.03 1.54 0.68 1.421 0.648
94781 94781 A 0 ZZZ 0 0 0 0 0 1 0 0.17 0.43 0.06 0.01 0.61 0.24 0.561 0.229
94799 94799 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94799 26 9479926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
94799 TC 94799TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95004 95004 A 0 XXX 0 0 0 0 0 0 0 0.01 0.18 0.18 0.01 0.20 0.20 0.177 0.177
95012 95012 A 5 XXX 0 0 0 0 0 0 0 0.00 0.60 0.60 0.01 0.61 0.61 0.544 0.544
95017 95017 A 0 XXX 0 0 0 0 0 0 0 0.07 0.18 0.03 0.01 0.26 0.11 0.237 0.102
95018 95018 A 0 XXX 0 0 0 0 0 0 0 0.14 0.49 0.06 0.01 0.64 0.21 0.585 0.199
95024 95024 A 0 XXX 0 0 0 0 0 0 0 0.01 0.22 0.01 0.01 0.24 0.03 0.213 0.024
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
431 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95027 95027 A 0 XXX 0 0 0 0 0 0 0 0.01 0.13 0.13 0.01 0.15 0.15 0.132 0.132
95028 95028 A 3 XXX 0 0 0 0 0 0 0 0.00 0.42 0.42 0.01 0.43 0.43 0.382 0.382
95044 95044 A 5 XXX 0 0 0 0 0 0 0 0.00 0.16 0.16 0.01 0.17 0.17 0.149 0.149
95052 95052 A 5 XXX 0 0 0 0 0 0 0 0.00 0.20 0.20 0.01 0.21 0.21 0.185 0.185
95056 95056 A 5 XXX 0 0 0 0 0 0 0 0.00 1.38 1.38 0.01 1.39 1.39 1.244 1.244
95060 95060 A 3 XXX 0 0 0 0 0 0 0 0.00 1.03 1.03 0.01 1.04 1.04 0.930 0.930
95065 95065 A 3 XXX 0 0 0 0 0 0 0 0.00 0.80 0.80 0.01 0.81 0.81 0.724 0.724
95070 95070 A 3 XXX 0 0 0 0 0 0 0 0.00 0.92 0.92 0.01 0.93 0.93 0.831 0.831
95071 95071 A 3 XXX 0 0 0 0 0 0 0 0.00 1.05 1.05 0.01 1.06 1.06 0.948 0.948
95076 95076 A 0 XXX 0 0 0 0 0 0 0 1.50 1.89 0.56 0.05 3.44 2.11 3.223 2.029
95079 95079 A 0 ZZZ 0 0 0 0 0 0 0 1.38 0.99 0.51 0.05 2.42 1.94 2.295 1.864
95115 95115 A 5 XXX 0 0 0 0 0 0 0 0.00 0.27 0.27 0.01 0.28 0.28 0.248 0.248
95117 95117 A 5 XXX 0 0 0 0 0 0 0 0.00 0.31 0.31 0.01 0.32 0.32 0.284 0.284
95120 95120 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95125 95125 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95130 95130 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95131 95131 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95132 95132 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95133 95133 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95134 95134 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95144 95144 A 0 XXX 0 0 0 0 0 0 0 0.06 0.31 0.02 0.01 0.38 0.09 0.344 0.083
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
432 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95145 95145 A 0 XXX 0 0 0 0 0 0 0 0.06 0.60 0.02 0.01 0.67 0.09 0.604 0.083
95146 95146 A 0 XXX 0 0 0 0 0 0 0 0.06 1.12 0.02 0.01 1.19 0.09 1.071 0.083
95147 95147 A 0 XXX 0 0 0 0 0 0 0 0.06 1.01 0.02 0.01 1.08 0.09 0.972 0.083
95148 95148 A 0 XXX 0 0 0 0 0 0 0 0.06 1.54 0.02 0.01 1.61 0.09 1.448 0.083
95149 95149 A 0 XXX 0 0 0 0 0 0 0 0.06 2.10 0.02 0.01 2.17 0.09 1.951 0.083
95165 95165 A 0 XXX 0 0 0 0 0 0 0 0.06 0.32 0.03 0.01 0.39 0.10 0.353 0.092
95170 95170 A 0 XXX 0 0 0 0 0 0 0 0.06 0.22 0.02 0.01 0.29 0.09 0.263 0.083
95180 95180 A 0 XXX 0 0 0 0 0 0 0 2.01 1.83 0.84 0.07 3.91 2.92 3.690 2.801
95199 95199 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95250 95250 A 3 XXX 0 0 0 0 0 0 0 0.00 4.88 4.88 0.01 4.89 4.89 4.387 4.387
95251 95251 A 2 XXX 0 0 0 0 0 0 0 0.85 0.36 0.36 0.04 1.25 1.25 1.194 1.194
95782 95782 A 1 XXX 0 0 0 0 0 0 0 2.60 27.83 27.83 0.29 30.72 30.72 27.743 27.743
95782 26 9578226 A 1 XXX 0 0 0 0 0 0 0 2.60 1.05 1.05 0.10 3.75 3.75 3.595 3.595
95782 TC 95782TC A 1 XXX 0 0 0 0 0 0 0 0.00 26.78 26.78 0.19 26.97 26.97 24.148 24.148
95783 95783 A 1 XXX 0 0 0 0 0 0 0 2.83 29.63 29.63 0.33 32.79 32.79 29.610 29.610
95783 26 9578326 A 1 XXX 0 0 0 0 0 0 0 2.83 1.15 1.15 0.12 4.10 4.10 3.925 3.925
95783 TC 95783TC A 1 XXX 0 0 0 0 0 0 0 0.00 28.48 28.48 0.21 28.69 28.69 25.685 25.685
95800 95800 A 1 XXX 0 0 0 0 0 0 0 1.05 4.26 4.26 0.05 5.36 5.36 4.902 4.902
95800 26 9580026 A 1 XXX 0 0 0 0 0 0 0 1.05 0.41 0.41 0.04 1.50 1.50 1.439 1.439
95800 TC 95800TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.85 3.85 0.01 3.86 3.86 3.463 3.463
95801 95801 A 1 XXX 0 0 0 0 0 0 0 1.00 1.75 1.75 0.05 2.80 2.80 2.598 2.598
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
433 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95801 26 9580126 A 1 XXX 0 0 0 0 0 0 0 1.00 0.36 0.36 0.04 1.40 1.40 1.344 1.344
95801 TC 95801TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.39 1.39 0.01 1.40 1.40 1.253 1.253
95803 95803 A 1 XXX 0 0 0 0 0 0 0 0.90 3.53 3.53 0.05 4.48 4.48 4.096 4.096
95803 26 9580326 A 1 XXX 0 0 0 0 0 0 0 0.90 0.35 0.35 0.04 1.29 1.29 1.235 1.235
95803 TC 95803TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.18 3.18 0.01 3.19 3.19 2.861 2.861
95805 95805 A 1 XXX 0 0 0 0 0 0 0 1.20 11.34 11.34 0.08 12.62 12.62 11.425 11.425
95805 26 9580526 A 1 XXX 0 0 0 0 0 0 0 1.20 0.45 0.45 0.04 1.69 1.69 1.625 1.625
95805 TC 95805TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.89 10.89 0.04 10.93 10.93 9.800 9.800
95806 95806 A 1 XXX 0 0 0 0 0 0 0 1.25 4.06 4.06 0.08 5.39 5.39 4.938 4.938
95806 26 9580626 A 1 XXX 0 0 0 0 0 0 0 1.25 0.49 0.49 0.05 1.79 1.79 1.716 1.716
95806 TC 95806TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.57 3.57 0.03 3.60 3.60 3.222 3.222
95807 95807 A 1 XXX 0 0 0 0 0 0 0 1.28 13.26 13.26 0.15 14.69 14.69 13.266 13.266
95807 26 9580726 A 1 XXX 0 0 0 0 0 0 0 1.28 0.46 0.46 0.05 1.79 1.79 1.719 1.719
95807 TC 95807TC A 1 XXX 0 0 0 0 0 0 0 0.00 12.80 12.80 0.10 12.90 12.90 11.547 11.547
95808 95808 A 1 XXX 0 0 0 0 0 0 0 1.74 17.33 17.33 0.17 19.24 19.24 17.391 17.391
95808 26 9580826 A 1 XXX 0 0 0 0 0 0 0 1.74 0.69 0.69 0.07 2.50 2.50 2.396 2.396
95808 TC 95808TC A 1 XXX 0 0 0 0 0 0 0 0.00 16.64 16.64 0.10 16.74 16.74 14.995 14.995
95810 95810 A 1 XXX 0 0 0 0 0 0 0 2.50 16.27 16.27 0.21 18.98 18.98 17.220 17.220
95810 26 9581026 A 1 XXX 0 0 0 0 0 0 0 2.50 0.92 0.92 0.10 3.52 3.52 3.378 3.378
95810 TC 95810TC A 1 XXX 0 0 0 0 0 0 0 0.00 15.35 15.35 0.11 15.46 15.46 13.842 13.842
95811 95811 A 1 XXX 0 0 0 0 0 0 0 2.60 17.08 17.08 0.23 19.91 19.91 18.058 18.058
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
434 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95811 26 9581126 A 1 XXX 0 0 0 0 0 0 0 2.60 0.95 0.95 0.11 3.66 3.66 3.511 3.511
95811 TC 95811TC A 1 XXX 0 0 0 0 0 0 0 0.00 16.13 16.13 0.12 16.25 16.25 14.548 14.548
95812 95812 A 1 XXX 0 0 0 0 0 0 0 1.08 12.17 12.17 0.07 13.32 13.32 12.045 12.045
95812 26 9581226 A 1 XXX 0 0 0 0 0 0 0 1.08 0.52 0.52 0.04 1.64 1.64 1.568 1.568
95812 TC 95812TC A 1 XXX 0 0 0 0 0 0 0 0.00 11.65 11.65 0.03 11.68 11.68 10.477 10.477
95813 95813 A 1 XXX 0 0 0 0 0 0 0 1.73 13.47 13.47 0.11 15.31 15.31 13.884 13.884
95813 26 9581326 A 1 XXX 0 0 0 0 0 0 0 1.73 0.83 0.83 0.07 2.63 2.63 2.512 2.512
95813 TC 95813TC A 1 XXX 0 0 0 0 0 0 0 0.00 12.64 12.64 0.04 12.68 12.68 11.372 11.372
95816 95816 A 1 XXX 0 0 0 0 0 0 0 1.08 11.06 11.06 0.08 12.22 12.22 11.054 11.054
95816 26 9581626 A 1 XXX 0 0 0 0 0 0 0 1.08 0.53 0.53 0.05 1.66 1.66 1.582 1.582
95816 TC 95816TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.53 10.53 0.03 10.56 10.56 9.472 9.472
95819 95819 A 1 XXX 0 0 0 0 0 0 0 1.08 12.89 12.89 0.07 14.04 14.04 12.692 12.692
95819 26 9581926 A 1 XXX 0 0 0 0 0 0 0 1.08 0.53 0.53 0.04 1.65 1.65 1.577 1.577
95819 TC 95819TC A 1 XXX 0 0 0 0 0 0 0 0.00 12.36 12.36 0.03 12.39 12.39 11.115 11.115
95822 95822 A 1 XXX 0 0 0 0 0 0 0 1.08 11.40 11.40 0.07 12.55 12.55 11.354 11.354
95822 26 9582226 A 1 XXX 0 0 0 0 0 0 0 1.08 0.53 0.53 0.04 1.65 1.65 1.577 1.577
95822 TC 95822TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.87 10.87 0.03 10.90 10.90 9.777 9.777
95824 95824 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95824 26 9582426 A 1 XXX 0 0 0 0 0 0 0 0.74 0.36 0.36 0.05 1.15 1.15 1.089 1.089
95824 TC 95824TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95827 95827 A 1 XXX 0 0 0 0 0 0 0 1.08 22.67 22.67 0.13 23.88 23.88 21.506 21.506
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
435 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95827 26 9582726 A 1 XXX 0 0 0 0 0 0 0 1.08 0.52 0.52 0.05 1.65 1.65 1.573 1.573
95827 TC 95827TC A 1 XXX 0 0 0 0 0 0 0 0.00 22.15 22.15 0.08 22.23 22.23 19.933 19.933
95829 95829 A 1 XXX 0 0 0 0 0 0 0 6.20 51.57 51.57 0.21 57.98 57.98 52.620 52.620
95829 26 9582926 A 1 XXX 0 0 0 0 0 0 0 6.20 3.01 3.01 0.16 9.37 9.37 8.987 8.987
95829 TC 95829TC A 1 XXX 0 0 0 0 0 0 0 0.00 48.56 48.56 0.05 48.61 48.61 43.633 43.633
95830 95830 A 0 XXX 0 0 0 0 0 0 0 1.70 6.06 0.84 0.14 7.90 2.68 7.215 2.528
95831 95831 A 0 XXX 0 0 0 0 0 0 0 0.28 0.54 0.11 0.03 0.85 0.42 0.781 0.394
95832 95832 A 0 XXX 0 0 0 0 0 0 0 0.29 0.49 0.12 0.03 0.81 0.44 0.746 0.413
95833 95833 A 0 XXX 0 0 0 0 0 0 0 0.47 0.62 0.13 0.01 1.10 0.61 1.032 0.592
95834 95834 A 0 XXX 0 0 0 0 0 0 0 0.60 0.90 0.26 0.03 1.53 0.89 1.424 0.849
95851 95851 A 0 XXX 0 0 0 0 0 0 0 0.16 0.37 0.05 0.01 0.54 0.22 0.497 0.210
95852 95852 A 0 XXX 0 0 0 0 0 0 0 0.11 0.38 0.05 0.01 0.50 0.17 0.456 0.160
95857 95857 A 0 XXX 0 0 0 0 0 0 0 0.53 1.01 0.29 0.04 1.58 0.86 1.458 0.811
95860 95860 A 1 XXX 0 0 0 0 0 0 0 0.96 2.74 2.74 0.04 3.74 3.74 3.441 3.441
95860 26 9586026 A 1 XXX 0 0 0 0 0 0 0 0.96 0.50 0.50 0.03 1.49 1.49 1.425 1.425
95860 TC 95860TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.24 2.24 0.01 2.25 2.25 2.017 2.017
95861 95861 A 1 XXX 0 0 0 0 0 0 0 1.54 3.53 3.53 0.06 5.13 5.13 4.741 4.741
95861 26 9586126 A 1 XXX 0 0 0 0 0 0 0 1.54 0.79 0.79 0.05 2.38 2.38 2.276 2.276
95861 TC 95861TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.74 2.74 0.01 2.75 2.75 2.466 2.466
95863 95863 A 1 XXX 0 0 0 0 0 0 0 1.87 4.32 4.32 0.08 6.27 6.27 5.791 5.791
95863 26 9586326 A 1 XXX 0 0 0 0 0 0 0 1.87 0.93 0.93 0.07 2.87 2.87 2.742 2.742
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
436 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95863 TC 95863TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.39 3.39 0.01 3.40 3.40 3.049 3.049
95864 95864 A 1 XXX 0 0 0 0 0 0 0 1.99 5.12 5.12 0.08 7.19 7.19 6.630 6.630
95864 26 9586426 A 1 XXX 0 0 0 0 0 0 0 1.99 1.00 1.00 0.07 3.06 3.06 2.925 2.925
95864 TC 95864TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.12 4.12 0.01 4.13 4.13 3.705 3.705
95865 95865 A 1 XXX 0 0 0 0 2 0 0 1.57 2.39 2.39 0.05 4.01 4.01 3.742 3.742
95865 26 9586526 A 1 XXX 0 0 0 0 2 0 0 1.57 0.76 0.76 0.04 2.37 2.37 2.273 2.273
95865 TC 95865TC A 1 XXX 0 0 0 0 2 0 0 0.00 1.63 1.63 0.01 1.64 1.64 1.469 1.469
95866 95866 A 1 XXX 0 0 0 0 1 0 0 1.25 2.79 2.79 0.06 4.10 4.10 3.787 3.787
95866 26 9586626 A 1 XXX 0 0 0 0 1 0 0 1.25 0.64 0.64 0.05 1.94 1.94 1.851 1.851
95866 TC 95866TC A 1 XXX 0 0 0 0 1 0 0 0.00 2.15 2.15 0.01 2.16 2.16 1.936 1.936
95867 95867 A 1 XXX 0 0 0 0 0 0 0 0.79 2.56 2.56 0.04 3.39 3.39 3.110 3.110
95867 26 9586726 A 1 XXX 0 0 0 0 0 0 0 0.79 0.39 0.39 0.03 1.21 1.21 1.156 1.156
95867 TC 95867TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.17 2.17 0.01 2.18 2.18 1.954 1.954
95868 95868 A 1 XXX 0 0 0 0 2 0 0 1.18 3.02 3.02 0.05 4.25 4.25 3.918 3.918
95868 26 9586826 A 1 XXX 0 0 0 0 2 0 0 1.18 0.58 0.58 0.04 1.80 1.80 1.722 1.722
95868 TC 95868TC A 1 XXX 0 0 0 0 2 0 0 0.00 2.44 2.44 0.01 2.45 2.45 2.196 2.196
95869 95869 A 1 XXX 0 0 0 0 0 0 0 0.37 2.17 2.17 0.02 2.56 2.56 2.329 2.329
95869 26 9586926 A 1 XXX 0 0 0 0 0 0 0 0.37 0.18 0.18 0.01 0.56 0.56 0.537 0.537
95869 TC 95869TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.99 1.99 0.01 2.00 2.00 1.792 1.792
95870 95870 A 1 XXX 0 0 0 0 0 0 0 0.37 2.30 2.30 0.02 2.69 2.69 2.446 2.446
95870 26 9587026 A 1 XXX 0 0 0 0 0 0 0 0.37 0.19 0.19 0.01 0.57 0.57 0.546 0.546
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
437 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95870 TC 95870TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.11 2.11 0.01 2.12 2.12 1.900 1.900
95872 95872 A 1 XXX 0 0 0 0 0 0 0 2.88 2.97 2.97 0.12 5.97 5.97 5.610 5.610
95872 26 9587226 A 1 XXX 0 0 0 0 0 0 0 2.88 1.43 1.43 0.11 4.42 4.42 4.222 4.222
95872 TC 95872TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.54 1.54 0.01 1.55 1.55 1.388 1.388
95873 95873 A 1 ZZZ 0 0 0 0 0 0 0 0.37 1.91 1.91 0.02 2.30 2.30 2.096 2.096
95873 26 9587326 A 1 ZZZ 0 0 0 0 0 0 0 0.37 0.21 0.21 0.01 0.59 0.59 0.564 0.564
95873 TC 95873TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 1.70 1.70 0.01 1.71 1.71 1.532 1.532
95874 95874 A 1 ZZZ 0 0 0 0 0 0 0 0.37 1.82 1.82 0.02 2.21 2.21 2.015 2.015
95874 26 9587426 A 1 ZZZ 0 0 0 0 0 0 0 0.37 0.19 0.19 0.01 0.57 0.57 0.546 0.546
95874 TC 95874TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 1.63 1.63 0.01 1.64 1.64 1.469 1.469
95875 95875 A 1 XXX 0 0 0 0 0 0 0 1.10 2.61 2.61 0.06 3.77 3.77 3.475 3.475
95875 26 9587526 A 1 XXX 0 0 0 0 0 0 0 1.10 0.54 0.54 0.05 1.69 1.69 1.611 1.611
95875 TC 95875TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.07 2.07 0.01 2.08 2.08 1.864 1.864
95885 95885 A 1 ZZZ 0 0 0 0 3 0 0 0.35 1.43 1.43 0.02 1.80 1.80 1.645 1.645
95885 26 9588526 A 1 ZZZ 0 0 0 0 3 0 0 0.35 0.18 0.18 0.01 0.54 0.54 0.517 0.517
95885 TC 95885TC A 1 ZZZ 0 0 0 0 3 0 0 0.00 1.25 1.25 0.01 1.26 1.26 1.128 1.128
95886 95886 A 1 ZZZ 0 0 0 0 3 0 0 0.70 1.76 1.76 0.03 2.49 2.49 2.296 2.296
95886 26 9588626 A 1 ZZZ 0 0 0 0 3 0 0 0.70 0.36 0.36 0.02 1.08 1.08 1.034 1.034
95886 TC 95886TC A 1 ZZZ 0 0 0 0 3 0 0 0.00 1.40 1.40 0.01 1.41 1.41 1.262 1.262
95887 95887 A 1 ZZZ 0 0 0 0 3 0 0 0.47 1.61 1.61 0.02 2.10 2.10 1.926 1.926
95887 26 9588726 A 1 ZZZ 0 0 0 0 3 0 0 0.47 0.24 0.24 0.01 0.72 0.72 0.691 0.691
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
438 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95887 TC 95887TC A 1 ZZZ 0 0 0 0 3 0 0 0.00 1.37 1.37 0.01 1.38 1.38 1.235 1.235
95905 95905 A 1 XXX 0 0 0 0 0 0 0 0.05 2.02 2.02 0.02 2.09 2.09 1.874 1.874
95905 26 9590526 A 1 XXX 0 0 0 0 0 0 0 0.05 0.02 0.02 0.01 0.08 0.08 0.073 0.073
95905 TC 95905TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.00 2.00 0.01 2.01 2.01 1.801 1.801
95907 95907 A 1 XXX 0 0 0 0 0 0 0 1.00 1.72 1.72 0.06 2.78 2.78 2.576 2.576
95907 26 9590726 A 1 XXX 0 0 0 0 0 0 0 1.00 0.49 0.49 0.03 1.52 1.52 1.456 1.456
95907 TC 95907TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.23 1.23 0.03 1.26 1.26 1.120 1.120
95908 95908 A 1 XXX 0 0 0 0 0 0 0 1.25 2.11 2.11 0.07 3.43 3.43 3.181 3.181
95908 26 9590826 A 1 XXX 0 0 0 0 0 0 0 1.25 0.62 0.62 0.04 1.91 1.91 1.828 1.828
95908 TC 95908TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.49 1.49 0.03 1.52 1.52 1.354 1.354
95909 95909 A 1 XXX 0 0 0 0 0 0 0 1.50 2.52 2.52 0.09 4.11 4.11 3.810 3.810
95909 26 9590926 A 1 XXX 0 0 0 0 0 0 0 1.50 0.74 0.74 0.04 2.28 2.28 2.185 2.185
95909 TC 95909TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.78 1.78 0.05 1.83 1.83 1.625 1.625
95910 95910 A 1 XXX 0 0 0 0 0 0 0 2.00 3.29 3.29 0.12 5.41 5.41 5.017 5.017
95910 26 9591026 A 1 XXX 0 0 0 0 0 0 0 2.00 0.99 0.99 0.06 3.05 3.05 2.920 2.920
95910 TC 95910TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.30 2.30 0.06 2.36 2.36 2.097 2.097
95911 95911 A 1 XXX 0 0 0 0 0 0 0 2.50 3.90 3.90 0.15 6.55 6.55 6.081 6.081
95911 26 9591126 A 1 XXX 0 0 0 0 0 0 0 2.50 1.24 1.24 0.07 3.81 3.81 3.650 3.650
95911 TC 95911TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.66 2.66 0.08 2.74 2.74 2.431 2.431
95912 95912 A 1 XXX 0 0 0 0 0 0 0 3.00 4.49 4.49 0.18 7.67 7.67 7.126 7.126
95912 26 9591226 A 1 XXX 0 0 0 0 0 0 0 3.00 1.48 1.48 0.09 4.57 4.57 4.376 4.376
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
439 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95912 TC 95912TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.01 3.01 0.09 3.10 3.10 2.750 2.750
95913 95913 A 1 XXX 0 0 0 0 0 0 0 3.56 5.12 5.12 0.21 8.89 8.89 8.268 8.268
95913 26 9591326 A 1 XXX 0 0 0 0 0 0 0 3.56 1.76 1.76 0.10 5.42 5.42 5.193 5.193
95913 TC 95913TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.36 3.36 0.11 3.47 3.47 3.075 3.075
95921 95921 A 1 XXX 0 0 0 0 0 0 0 0.90 1.71 1.71 0.05 2.66 2.66 2.462 2.462
95921 26 9592126 A 1 XXX 0 0 0 0 0 0 0 0.90 0.38 0.38 0.04 1.32 1.32 1.262 1.262
95921 TC 95921TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.33 1.33 0.01 1.34 1.34 1.200 1.200
95922 95922 A 1 XXX 0 0 0 0 0 0 0 0.96 2.19 2.19 0.05 3.20 3.20 2.953 2.953
95922 26 9592226 A 1 XXX 0 0 0 0 0 0 0 0.96 0.42 0.42 0.04 1.42 1.42 1.358 1.358
95922 TC 95922TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.77 1.77 0.01 1.78 1.78 1.595 1.595
95923 95923 A 1 XXX 0 0 0 0 0 0 0 0.90 6.78 6.78 0.05 7.73 7.73 7.015 7.015
95923 26 9592326 A 1 XXX 0 0 0 0 0 0 0 0.90 0.43 0.43 0.04 1.37 1.37 1.307 1.307
95923 TC 95923TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.35 6.35 0.01 6.36 6.36 5.708 5.708
95924 95924 A 1 XXX 0 0 0 0 0 0 0 1.73 2.52 2.52 0.09 4.34 4.34 4.040 4.040
95924 26 9592426 A 1 XXX 0 0 0 0 0 0 0 1.73 0.74 0.74 0.08 2.55 2.55 2.436 2.436
95924 TC 95924TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.78 1.78 0.01 1.79 1.79 1.604 1.604
95925 95925 A 1 XXX 0 0 0 0 2 0 0 0.54 5.23 5.23 0.02 5.79 5.79 5.247 5.247
95925 26 9592526 A 1 XXX 0 0 0 0 2 0 0 0.54 0.26 0.26 0.01 0.81 0.81 0.779 0.779
95925 TC 95925TC A 1 XXX 0 0 0 0 2 0 0 0.00 4.97 4.97 0.01 4.98 4.98 4.468 4.468
95926 95926 A 1 XXX 0 0 0 0 2 0 0 0.54 5.02 5.02 0.04 5.60 5.60 5.069 5.069
95926 26 9592626 A 1 XXX 0 0 0 0 2 0 0 0.54 0.26 0.26 0.03 0.83 0.83 0.789 0.789
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
440 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95926 TC 95926TC A 1 XXX 0 0 0 0 2 0 0 0.00 4.76 4.76 0.01 4.77 4.77 4.280 4.280
95927 95927 A 1 XXX 0 0 0 0 0 0 0 0.54 4.52 4.52 0.02 5.08 5.08 4.609 4.609
95927 26 9592726 A 1 XXX 0 0 0 0 0 0 0 0.54 0.25 0.25 0.01 0.80 0.80 0.770 0.770
95927 TC 95927TC A 1 XXX 0 0 0 0 0 0 0 0.00 4.27 4.27 0.01 4.28 4.28 3.840 3.840
95928 95928 A 1 XXX 0 0 0 0 2 0 0 1.50 7.11 7.11 0.10 8.71 8.71 7.937 7.937
95928 26 9592826 A 1 XXX 0 0 0 0 2 0 0 1.50 0.73 0.73 0.07 2.30 2.30 2.192 2.192
95928 TC 95928TC A 1 XXX 0 0 0 0 2 0 0 0.00 6.38 6.38 0.03 6.41 6.41 5.745 5.745
95929 95929 A 1 XXX 0 0 0 0 2 0 0 1.50 7.16 7.16 0.10 8.76 8.76 7.982 7.982
95929 26 9592926 A 1 XXX 0 0 0 0 2 0 0 1.50 0.73 0.73 0.07 2.30 2.30 2.192 2.192
95929 TC 95929TC A 1 XXX 0 0 0 0 2 0 0 0.00 6.43 6.43 0.03 6.46 6.46 5.790 5.790
95930 95930 A 1 XXX 0 0 0 0 2 0 0 0.35 4.46 4.46 0.02 4.83 4.83 4.366 4.366
95930 26 9593026 A 1 XXX 0 0 0 0 2 0 0 0.35 0.17 0.17 0.01 0.53 0.53 0.508 0.508
95930 TC 95930TC A 1 XXX 0 0 0 0 2 0 0 0.00 4.29 4.29 0.01 4.30 4.30 3.858 3.858
95933 95933 A 1 XXX 0 0 0 0 0 0 0 0.59 2.08 2.08 0.04 2.71 2.71 2.479 2.479
95933 26 9593326 A 1 XXX 0 0 0 0 0 0 0 0.59 0.29 0.29 0.03 0.91 0.91 0.866 0.866
95933 TC 95933TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.79 1.79 0.01 1.80 1.80 1.613 1.613
95937 95937 A 1 XXX 0 0 0 0 0 0 0 0.65 1.63 1.63 0.05 2.33 2.33 2.140 2.140
95937 26 9593726 A 1 XXX 0 0 0 0 0 0 0 0.65 0.30 0.30 0.04 0.99 0.99 0.940 0.940
95937 TC 95937TC A 1 XXX 0 0 0 0 0 0 0 0.00 1.33 1.33 0.01 1.34 1.34 1.200 1.200
95938 95938 A 1 XXX 0 0 0 0 2 0 0 0.86 8.88 8.88 0.07 9.81 9.81 8.871 8.871
95938 26 9593826 A 1 XXX 0 0 0 0 2 0 0 0.86 0.42 0.42 0.04 1.32 1.32 1.258 1.258
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
441 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95938 TC 95938TC A 1 XXX 0 0 0 0 2 0 0 0.00 8.46 8.46 0.03 8.49 8.49 7.613 7.613
95939 95939 A 1 XXX 0 0 0 0 2 0 0 2.25 12.59 12.59 0.15 14.99 14.99 13.634 13.634
95939 26 9593926 A 1 XXX 0 0 0 0 2 0 0 2.25 1.10 1.10 0.11 3.46 3.46 3.295 3.295
95939 TC 95939TC A 1 XXX 0 0 0 0 2 0 0 0.00 11.49 11.49 0.04 11.53 11.53 10.339 10.339
95940 95940 A 0 XXX 0 0 0 0 0 0 0 0.60 0.31 0.31 0.03 0.94 0.94 0.894 0.894
95941 95941 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95943 95943 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95943 26 9594326 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95943 TC 95943TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95950 95950 A 1 XXX 0 0 0 0 0 0 0 1.51 8.67 8.67 0.10 10.28 10.28 9.348 9.348
95950 26 9595026 A 1 XXX 0 0 0 0 0 0 0 1.51 0.73 0.73 0.07 2.31 2.31 2.202 2.202
95950 TC 95950TC A 1 XXX 0 0 0 0 0 0 0 0.00 7.94 7.94 0.03 7.97 7.97 7.146 7.146
95951 95951 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95951 26 9595126 A 1 XXX 0 0 0 0 0 0 0 5.99 2.94 2.94 0.48 9.41 9.41 8.881 8.881
95951 TC 95951TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95953 95953 A 1 XXX 0 0 0 0 0 0 0 3.08 9.77 9.77 0.18 13.03 13.03 11.948 11.948
95953 26 9595326 A 1 XXX 0 0 0 0 0 0 0 3.08 1.48 1.48 0.15 4.71 4.71 4.487 4.487
95953 TC 95953TC A 1 XXX 0 0 0 0 0 0 0 0.00 8.29 8.29 0.03 8.32 8.32 7.460 7.460
95954 95954 A 1 XXX 0 0 0 0 0 0 0 2.45 11.48 11.48 0.15 14.08 14.08 12.837 12.837
95954 26 9595426 A 1 XXX 0 0 0 0 0 0 0 2.45 1.01 1.01 0.11 3.57 3.57 3.415 3.415
95954 TC 95954TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.47 10.47 0.04 10.51 10.51 9.423 9.423
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
442 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95955 95955 A 1 XXX 0 0 0 0 0 0 0 1.01 5.97 5.97 0.05 7.03 7.03 6.397 6.397
95955 26 9595526 A 1 XXX 0 0 0 0 0 0 0 1.01 0.50 0.50 0.04 1.55 1.55 1.480 1.480
95955 TC 95955TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.47 5.47 0.01 5.48 5.48 4.917 4.917
95956 95956 A 1 XXX 0 0 0 0 0 0 0 3.61 47.24 47.24 0.32 51.17 51.17 46.199 46.199
95956 26 9595626 A 1 XXX 0 0 0 0 0 0 0 3.61 1.73 1.73 0.16 5.50 5.50 5.247 5.247
95956 TC 95956TC A 1 XXX 0 0 0 0 0 0 0 0.00 45.51 45.51 0.16 45.67 45.67 40.952 40.952
95957 95957 A 1 XXX 0 0 0 0 0 0 0 1.98 11.60 11.60 0.11 13.69 13.69 12.454 12.454
95957 26 9595726 A 1 XXX 0 0 0 0 0 0 0 1.98 0.95 0.95 0.10 3.03 3.03 2.885 2.885
95957 TC 95957TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.65 10.65 0.01 10.66 10.66 9.569 9.569
95958 95958 A 1 XXX 0 0 0 0 0 0 0 4.24 12.75 12.75 0.26 17.25 17.25 15.825 15.825
95958 26 9595826 A 1 XXX 0 0 0 0 0 0 0 4.24 1.97 1.97 0.22 6.43 6.43 6.124 6.124
95958 TC 95958TC A 1 XXX 0 0 0 0 0 0 0 0.00 10.78 10.78 0.04 10.82 10.82 9.701 9.701
95961 95961 A 1 XXX 0 0 0 0 0 0 0 2.97 5.33 5.33 0.15 8.45 8.45 7.835 7.835
95961 26 9596126 A 1 XXX 0 0 0 0 0 0 0 2.97 1.43 1.43 0.14 4.54 4.54 4.327 4.327
95961 TC 95961TC A 1 XXX 0 0 0 0 0 0 0 0.00 3.90 3.90 0.01 3.91 3.91 3.507 3.507
95962 95962 A 1 ZZZ 0 0 0 0 0 0 0 3.21 3.96 3.96 0.15 7.32 7.32 6.845 6.845
95962 26 9596226 A 1 ZZZ 0 0 0 0 0 0 0 3.21 1.54 1.54 0.14 4.89 4.89 4.666 4.666
95962 TC 95962TC A 1 ZZZ 0 0 0 0 0 0 0 0.00 2.42 2.42 0.01 2.43 2.43 2.178 2.178
95965 95965 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95965 26 9596526 A 1 XXX 0 0 0 0 0 0 0 7.99 3.94 3.94 0.64 12.57 12.57 11.863 11.863
95965 TC 95965TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
443 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
95966 95966 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95966 26 9596626 A 1 XXX 0 0 0 0 0 0 0 3.99 1.45 1.45 0.31 5.75 5.75 5.454 5.454
95966 TC 95966TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95967 95967 C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95967 26 9596726 A 1 ZZZ 0 0 0 0 0 0 0 3.49 1.27 1.27 0.29 5.05 5.05 4.782 4.782
95967 TC 95967TC C 1 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
95970 95970 A 0 XXX 0 0 0 0 0 0 0 0.45 1.62 0.21 0.04 2.11 0.70 1.926 0.660
95971 95971 A 0 XXX 0 0 0 0 0 0 0 0.78 0.92 0.32 0.07 1.77 1.17 1.643 1.104
95972 95972 A 0 XXX 0 0 0 0 0 0 0 1.50 1.59 0.64 0.14 3.23 2.28 3.001 2.148
95973 95973 A 0 ZZZ 0 0 0 0 0 0 0 0.92 0.86 0.41 0.08 1.86 1.41 1.734 1.330
95974 95974 A 0 XXX 0 0 0 0 0 0 0 3.00 2.79 1.43 0.26 6.05 4.69 5.641 4.420
95975 95975 A 0 ZZZ 0 0 0 0 0 0 0 1.70 1.41 0.84 0.12 3.23 2.66 3.029 2.517
95978 95978 A 0 XXX 0 0 0 0 0 0 0 3.50 3.47 1.72 0.38 7.35 5.60 6.815 5.243
95979 95979 A 0 ZZZ 0 0 0 0 0 0 0 1.64 1.37 0.81 0.14 3.15 2.59 2.943 2.441
95980 95980 A 0 XXX 0 0 0 0 0 0 0 0.80 0.40 0.40 0.16 1.36 1.36 1.243 1.243
95981 95981 A 0 XXX 0 0 0 0 0 0 0 0.30 0.66 0.19 0.03 0.99 0.52 0.908 0.486
95982 95982 A 0 XXX 0 0 0 0 0 0 0 0.65 0.86 0.35 0.05 1.56 1.05 1.448 0.990
95990 95990 A 5 XXX 0 0 0 0 0 0 0 0.00 2.81 2.81 0.03 2.84 2.84 2.539 2.539
95991 95991 A 0 XXX 0 0 0 0 0 0 0 0.77 2.95 0.34 0.05 3.77 1.16 3.445 1.101
95992 95992 A 0 XXX 0 0 0 0 0 0 0 0.75 0.47 0.29 0.05 1.27 1.09 1.198 1.037
95999 95999 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
444 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
96000 96000 A 7 XXX 0 0 0 0 2 0 0 1.80 0.96 0.96 0.11 2.87 2.87 2.720 2.720
96001 96001 A 7 XXX 0 0 0 0 2 0 0 2.15 0.56 0.56 0.12 2.83 2.83 2.716 2.716
96002 96002 A 0 XXX 0 0 0 0 2 0 0 0.41 0.19 0.19 0.03 0.63 0.63 0.596 0.596
96003 96003 A 0 XXX 0 0 0 0 2 0 0 0.37 0.09 0.09 0.03 0.49 0.49 0.467 0.467
96004 96004 A 2 XXX 0 0 0 0 2 0 0 2.14 1.01 1.01 0.14 3.29 3.29 3.120 3.120
96020 96020 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
96020 26 9602026 A 1 XXX 0 0 0 0 0 0 0 3.43 1.09 1.09 0.31 4.83 4.83 4.571 4.571
96020 TC 96020TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
96040 96040 B 9 XXX 0 0 0 9 9 9 9 0.00 1.42 1.42 0.03 1.45 1.45 1.291 1.291
96101 96101 A 0 XXX 0 0 0 0 0 0 0 1.86 0.50 0.26 0.07 2.43 2.19 2.346 2.130
96102 96102 A 0 XXX 0 0 0 0 0 0 0 0.50 2.01 0.13 0.03 2.54 0.66 2.321 0.632
96103 96103 A 0 XXX 0 0 0 0 0 0 0 0.51 1.52 0.21 0.03 2.06 0.75 1.891 0.714
96105 96105 A 0 XXX 0 0 0 0 0 0 0 1.75 0.98 0.98 0.04 2.77 2.77 2.651 2.651
96110 96110 N 9 XXX 0 0 0 9 9 9 9 0.00 0.26 0.26 0.01 0.27 0.27 0.239 0.239
96111 96111 A 0 XXX 0 0 0 0 0 0 0 2.60 0.97 0.76 0.16 3.73 3.52 3.555 3.366
96116 96116 A 0 XXX 0 0 0 0 0 0 0 1.86 0.66 0.48 0.10 2.62 2.44 2.505 2.343
96118 96118 A 0 XXX 0 0 0 0 0 0 0 1.86 0.77 0.25 0.07 2.70 2.18 2.588 2.121
96119 96119 A 0 XXX 0 0 0 0 0 0 0 0.55 1.62 0.09 0.01 2.18 0.65 2.010 0.636
96120 96120 A 0 XXX 0 0 0 0 0 0 0 0.51 2.48 0.19 0.03 3.02 0.73 2.753 0.696
96125 96125 A 7 XXX 0 0 0 5 0 0 0 1.70 1.40 1.40 0.07 3.17 3.17 2.994 2.994
96150 96150 A 0 XXX 0 0 0 0 0 0 0 0.50 0.08 0.07 0.01 0.59 0.58 0.577 0.568
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
445 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
96151 96151 A 0 XXX 0 0 0 0 0 0 0 0.48 0.08 0.07 0.01 0.57 0.56 0.557 0.548
96152 96152 A 0 XXX 0 0 0 0 0 0 0 0.46 0.07 0.06 0.01 0.54 0.53 0.528 0.519
96153 96153 A 0 XXX 0 0 0 0 0 0 0 0.10 0.02 0.01 0.01 0.13 0.12 0.123 0.114
96154 96154 A 0 XXX 0 0 0 0 0 0 0 0.45 0.07 0.06 0.01 0.53 0.52 0.518 0.509
96155 96155 N 9 XXX 0 0 0 9 9 9 9 0.44 0.18 0.18 0.03 0.65 0.65 0.617 0.617
96360 96360 A 5 XXX 0 0 0 0 0 0 0 0.17 1.52 1.52 0.03 1.72 1.72 1.551 1.551
96361 96361 A 5 ZZZ 0 0 0 0 0 0 0 0.09 0.35 0.35 0.01 0.45 0.45 0.410 0.410
96365 96365 A 5 XXX 0 0 0 0 0 0 0 0.21 1.98 1.98 0.03 2.22 2.22 2.004 2.004
96366 96366 A 5 ZZZ 0 0 0 0 0 0 0 0.18 0.45 0.45 0.01 0.64 0.64 0.589 0.589
96367 96367 A 5 ZZZ 0 0 0 0 0 0 0 0.19 0.74 0.74 0.01 0.94 0.94 0.860 0.860
96368 96368 A 5 ZZZ 0 0 0 0 0 0 0 0.17 0.37 0.37 0.01 0.55 0.55 0.507 0.507
96369 96369 A 5 XXX 0 0 0 0 0 0 0 0.21 6.00 6.00 0.03 6.24 6.24 5.614 5.614
96370 96370 A 5 ZZZ 0 0 0 0 0 0 0 0.18 0.32 0.32 0.01 0.51 0.51 0.473 0.473
96371 96371 A 5 ZZZ 0 0 0 0 0 0 0 0.00 2.97 2.97 0.01 2.98 2.98 2.672 2.672
96372 96372 A 5 XXX 0 0 0 0 0 0 0 0.17 0.58 0.58 0.01 0.76 0.76 0.696 0.696
96373 96373 A 5 XXX 0 0 0 0 0 0 0 0.17 0.41 0.41 0.01 0.59 0.59 0.543 0.543
96374 96374 A 5 XXX 0 0 0 0 0 0 0 0.18 1.48 1.48 0.03 1.69 1.69 1.525 1.525
96375 96375 A 5 ZZZ 0 0 0 0 0 0 0 0.10 0.55 0.55 0.01 0.66 0.66 0.599 0.599
96376 96376 X 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
96379 96379 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
96401 96401 A 5 XXX 0 0 0 0 0 0 0 0.21 1.98 1.98 0.04 2.23 2.23 2.009 2.009
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
446 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
96402 96402 A 5 XXX 0 0 0 0 0 0 0 0.19 0.76 0.76 0.01 0.96 0.96 0.878 0.878
96405 96405 A 0 000 0 0 0 2 0 1 0 0.52 1.92 0.33 0.03 2.47 0.88 2.260 0.832
96406 96406 A 0 000 0 0 0 2 0 1 0 0.80 2.64 0.49 0.04 3.48 1.33 3.192 1.261
96409 96409 A 5 XXX 0 0 0 0 0 0 0 0.24 3.00 3.00 0.05 3.29 3.29 2.960 2.960
96411 96411 A 5 ZZZ 0 0 0 0 0 0 0 0.20 1.61 1.61 0.03 1.84 1.84 1.661 1.661
96413 96413 A 5 XXX 0 0 0 0 0 0 0 0.28 3.88 3.88 0.05 4.21 4.21 3.790 3.790
96415 96415 A 5 ZZZ 0 0 0 0 0 0 0 0.19 0.70 0.70 0.01 0.90 0.90 0.824 0.824
96416 96416 A 5 XXX 0 0 0 0 0 0 0 0.21 3.91 3.91 0.07 4.19 4.19 3.758 3.758
96417 96417 A 5 ZZZ 0 0 0 0 0 0 0 0.21 1.85 1.85 0.03 2.09 2.09 1.887 1.887
96420 96420 A 5 XXX 0 0 0 0 0 0 0 0.17 2.91 2.91 0.08 3.16 3.16 2.825 2.825
96422 96422 A 5 XXX 0 0 0 0 0 0 0 0.17 4.82 4.82 0.08 5.07 5.07 4.540 4.540
96423 96423 A 5 ZZZ 0 0 0 0 0 0 0 0.17 2.13 2.13 0.04 2.34 2.34 2.104 2.104
96425 96425 A 5 XXX 0 0 0 0 0 0 0 0.17 5.18 5.18 0.10 5.45 5.45 4.874 4.874
96440 96440 A 0 000 0 0 0 0 0 0 0 2.37 23.70 1.18 0.54 26.61 4.09 23.935 3.712
96446 96446 A 5 XXX 0 0 0 0 0 0 0 0.37 5.44 0.19 0.07 5.88 0.63 5.292 0.577
96450 96450 A 0 000 0 0 0 0 0 0 0 1.53 3.67 0.66 0.11 5.31 2.30 4.883 2.180
96521 96521 A 5 XXX 0 0 0 0 0 0 0 0.21 3.88 3.88 0.05 4.14 4.14 3.720 3.720
96522 96522 A 5 XXX 0 0 0 0 0 0 0 0.21 3.10 3.10 0.05 3.36 3.36 3.020 3.020
96523 96523 T 5 XXX 0 0 0 0 0 0 0 0.04 0.69 0.69 0.01 0.74 0.74 0.665 0.665
96542 96542 A 0 XXX 0 0 0 0 0 0 0 0.75 2.79 0.41 0.04 3.58 1.20 3.276 1.139
96549 96549 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
447 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
96567 96567 A 5 XXX 0 0 0 0 0 0 0 0.00 4.22 4.22 0.01 4.23 4.23 3.795 3.795
96570 96570 A 0 ZZZ 0 0 0 0 0 1 0 1.10 0.39 0.39 0.18 1.67 1.67 1.544 1.544
96571 96571 A 0 ZZZ 0 0 0 0 0 1 0 0.55 0.18 0.18 0.04 0.77 0.77 0.733 0.733
96900 96900 A 5 XXX 0 0 0 0 0 0 0 0.00 0.64 0.64 0.01 0.65 0.65 0.580 0.580
96902 96902 B 9 XXX 0 0 0 9 9 9 9 0.41 0.19 0.17 0.03 0.63 0.61 0.596 0.578
96904 96904 R 5 XXX 0 0 0 0 0 0 0 0.00 2.13 2.13 0.01 2.14 2.14 1.918 1.918
96910 96910 A 5 XXX 0 0 0 0 0 0 0 0.00 2.23 2.23 0.01 2.24 2.24 2.008 2.008
96912 96912 A 5 XXX 0 0 0 0 0 0 0 0.00 2.86 2.86 0.01 2.87 2.87 2.574 2.574
96913 96913 A 5 XXX 0 0 0 0 0 0 0 0.00 4.03 4.03 0.01 4.04 4.04 3.624 3.624
96920 96920 A 0 000 0 0 0 2 0 1 0 1.15 3.47 0.76 0.04 4.66 1.95 4.287 1.853
96921 96921 A 0 000 0 0 0 2 0 1 0 1.30 3.79 0.85 0.04 5.13 2.19 4.724 2.084
96922 96922 A 0 000 0 0 0 2 0 1 0 2.10 4.93 1.39 0.08 7.11 3.57 6.569 3.390
96999 96999 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97001 97001 A 7 XXX 0 0 0 5 0 0 0 1.20 0.95 0.95 0.05 2.20 2.20 2.079 2.079
97002 97002 A 7 XXX 0 0 0 5 0 0 0 0.60 0.61 0.61 0.03 1.24 1.24 1.163 1.163
97003 97003 A 7 XXX 0 0 0 5 0 0 0 1.20 1.24 1.24 0.05 2.49 2.49 2.340 2.340
97004 97004 A 7 XXX 0 0 0 5 0 0 0 0.60 0.94 0.94 0.03 1.57 1.57 1.460 1.460
97005 97005 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97006 97006 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97010 97010 B 9 XXX 0 0 0 9 9 9 9 0.06 0.11 0.11 0.01 0.18 0.18 0.164 0.164
97012 97012 A 7 XXX 0 0 0 5 0 0 0 0.25 0.21 0.21 0.01 0.47 0.47 0.444 0.444
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
448 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
97014 97014 I 9 XXX 0 0 0 9 9 9 9 0.18 0.28 0.28 0.01 0.47 0.47 0.437 0.437
97016 97016 A 7 XXX 0 0 0 5 0 0 0 0.18 0.39 0.39 0.01 0.58 0.58 0.535 0.535
97018 97018 A 7 XXX 0 0 0 5 0 0 0 0.06 0.26 0.26 0.01 0.33 0.33 0.299 0.299
97022 97022 A 7 XXX 0 0 0 5 0 0 0 0.17 0.52 0.52 0.01 0.70 0.70 0.642 0.642
97024 97024 A 7 XXX 0 0 0 5 0 0 0 0.06 0.12 0.12 0.01 0.19 0.19 0.173 0.173
97026 97026 R 7 XXX 0 0 0 5 0 0 0 0.06 0.11 0.11 0.01 0.18 0.18 0.164 0.164
97028 97028 A 7 XXX 0 0 0 5 0 0 0 0.08 0.13 0.13 0.01 0.22 0.22 0.202 0.202
97032 97032 A 7 XXX 0 0 0 5 0 0 0 0.25 0.30 0.30 0.01 0.56 0.56 0.525 0.525
97033 97033 A 7 XXX 0 0 0 5 0 0 0 0.26 0.70 0.70 0.01 0.97 0.97 0.894 0.894
97034 97034 A 7 XXX 0 0 0 5 0 0 0 0.21 0.31 0.31 0.01 0.53 0.53 0.494 0.494
97035 97035 A 7 XXX 0 0 0 5 0 0 0 0.21 0.15 0.15 0.01 0.37 0.37 0.350 0.350
97036 97036 A 7 XXX 0 0 0 5 0 0 0 0.28 0.69 0.69 0.01 0.98 0.98 0.905 0.905
97039 97039 C 7 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97110 97110 A 7 XXX 0 0 0 5 0 0 0 0.45 0.48 0.48 0.01 0.94 0.94 0.886 0.886
97112 97112 A 7 XXX 0 0 0 5 0 0 0 0.45 0.52 0.52 0.01 0.98 0.98 0.922 0.922
97113 97113 A 7 XXX 0 0 0 5 0 0 0 0.44 0.83 0.83 0.01 1.28 1.28 1.191 1.191
97116 97116 A 7 XXX 0 0 0 5 0 0 0 0.40 0.42 0.42 0.01 0.83 0.83 0.782 0.782
97124 97124 A 7 XXX 0 0 0 5 0 0 0 0.35 0.41 0.41 0.01 0.77 0.77 0.723 0.723
97139 97139 C 7 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97140 97140 A 7 XXX 0 0 0 5 0 0 0 0.43 0.44 0.44 0.01 0.88 0.88 0.830 0.830
97150 97150 A 7 XXX 0 0 0 5 0 0 0 0.29 0.21 0.21 0.01 0.51 0.51 0.484 0.484
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
449 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
97530 97530 A 7 XXX 0 0 0 5 0 0 0 0.44 0.58 0.58 0.01 1.03 1.03 0.966 0.966
97532 97532 A 7 XXX 0 0 0 0 0 0 0 0.44 0.32 0.32 0.01 0.77 0.77 0.733 0.733
97533 97533 A 7 XXX 0 0 0 5 0 0 0 0.44 0.40 0.40 0.01 0.85 0.85 0.804 0.804
97535 97535 A 7 XXX 0 0 0 5 0 0 0 0.45 0.56 0.56 0.01 1.02 1.02 0.958 0.958
97537 97537 A 7 XXX 0 0 0 5 0 0 0 0.45 0.42 0.42 0.01 0.88 0.88 0.832 0.832
97542 97542 A 7 XXX 0 0 0 5 0 0 0 0.45 0.43 0.43 0.01 0.89 0.89 0.841 0.841
97545 97545 R 7 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97546 97546 R 7 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97597 97597 A 0 000 0 0 0 0 0 0 0 0.51 1.74 0.13 0.05 2.30 0.69 2.099 0.653
97598 97598 A 0 ZZZ 0 0 0 0 0 0 0 0.24 0.48 0.06 0.03 0.75 0.33 0.687 0.310
97602 97602 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97605 97605 A 0 XXX 0 0 0 0 0 0 0 0.55 0.62 0.14 0.08 1.25 0.77 1.149 0.718
97606 97606 A 0 XXX 0 0 0 0 0 0 0 0.60 0.63 0.16 0.10 1.33 0.86 1.218 0.796
97750 97750 A 7 XXX 0 0 0 5 0 0 0 0.45 0.50 0.50 0.03 0.98 0.98 0.915 0.915
97755 97755 A 7 XXX 0 0 0 5 0 0 0 0.62 0.40 0.40 0.03 1.05 1.05 0.995 0.995
97760 97760 A 7 XXX 0 0 0 5 0 0 0 0.45 0.65 0.65 0.03 1.13 1.13 1.049 1.049
97761 97761 A 7 XXX 0 0 0 5 0 0 0 0.45 0.50 0.50 0.03 0.98 0.98 0.915 0.915
97762 97762 A 7 XXX 0 0 0 5 0 0 0 0.25 1.18 1.18 0.01 1.44 1.44 1.315 1.315
97799 97799 C 7 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
97802 97802 A 0 XXX 0 0 0 0 0 0 0 0.53 0.48 0.40 0.03 1.04 0.96 0.977 0.905
97803 97803 A 0 XXX 0 0 0 0 0 0 0 0.45 0.42 0.34 0.03 0.90 0.82 0.843 0.771
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
450 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
97804 97804 A 0 XXX 0 0 0 0 0 0 0 0.25 0.20 0.19 0.01 0.46 0.45 0.435 0.426
97810 97810 N 9 XXX 0 0 0 9 9 9 9 0.60 0.41 0.24 0.04 1.05 0.88 0.989 0.836
97811 97811 N 9 ZZZ 0 0 0 9 9 9 9 0.50 0.26 0.20 0.03 0.79 0.73 0.749 0.695
97813 97813 N 9 XXX 0 0 0 9 9 9 9 0.65 0.43 0.26 0.04 1.12 0.95 1.057 0.904
97814 97814 N 9 ZZZ 0 0 0 9 9 9 9 0.55 0.31 0.22 0.04 0.90 0.81 0.849 0.768
98925 98925 A 0 000 0 0 0 0 0 0 0 0.46 0.43 0.19 0.03 0.92 0.68 0.862 0.646
98926 98926 A 0 000 0 0 0 0 0 0 0 0.71 0.57 0.28 0.03 1.31 1.02 1.238 0.977
98927 98927 A 0 000 0 0 0 0 0 0 0 0.96 0.72 0.36 0.04 1.72 1.36 1.627 1.304
98928 98928 A 0 000 0 0 0 0 0 0 0 1.21 0.85 0.46 0.06 2.12 1.73 2.005 1.654
98929 98929 A 0 000 0 0 0 0 0 0 0 1.46 0.98 0.52 0.09 2.53 2.07 2.387 1.974
98940 98940 A 0 000 0 0 0 0 0 0 0 0.45 0.31 0.15 0.01 0.77 0.61 0.734 0.590
98941 98941 A 0 000 0 0 0 0 0 0 0 0.65 0.39 0.22 0.03 1.07 0.90 1.016 0.863
98942 98942 A 0 000 0 0 0 0 0 0 0 0.87 0.47 0.29 0.03 1.37 1.19 1.308 1.146
98943 98943 N 9 XXX 0 0 0 9 9 9 9 0.40 0.28 0.16 0.03 0.71 0.59 0.667 0.559
98960 98960 B 9 XXX 0 0 0 9 9 9 9 0.00 0.84 0.84 0.01 0.85 0.85 0.760 0.760
98961 98961 B 9 XXX 0 0 0 9 9 9 9 0.00 0.40 0.40 0.01 0.41 0.41 0.364 0.364
98962 98962 B 9 XXX 0 0 0 9 9 9 9 0.00 0.29 0.29 0.01 0.30 0.30 0.266 0.266
98966 98966 N 9 XXX 0 0 0 9 9 9 9 0.25 0.14 0.10 0.01 0.40 0.36 0.381 0.345
98967 98967 N 9 XXX 0 0 0 9 9 9 9 0.50 0.24 0.20 0.03 0.77 0.73 0.731 0.695
98968 98968 N 9 XXX 0 0 0 9 9 9 9 0.75 0.35 0.30 0.05 1.15 1.10 1.090 1.046
98969 98969 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
451 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99000 99000 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99001 99001 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99002 99002 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99024 99024 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99026 99026 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99027 99027 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99050 99050 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99051 99051 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99053 99053 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99056 99056 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99058 99058 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99060 99060 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99070 99070 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99071 99071 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99075 99075 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99078 99078 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99080 99080 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99082 99082 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99090 99090 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99091 99091 B 9 XXX 0 0 0 9 9 9 9 1.10 0.45 0.45 0.07 1.62 1.62 1.541 1.541
99100 99100 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
452 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99116 99116 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99135 99135 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99140 99140 B 9 ZZZ 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99143 99143 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99144 99144 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99145 99145 C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99148 99148 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99149 99149 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99150 99150 C 0 ZZZ 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99170 99170 A 0 000 0 0 0 2 0 1 0 1.75 1.83 0.69 0.12 3.70 2.56 3.456 2.432
99172 99172 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99173 99173 N 9 XXX 0 0 0 9 9 9 9 0.00 0.08 0.08 0.01 0.09 0.09 0.077 0.077
99174 99174 N 9 XXX 0 0 0 9 9 9 9 0.00 0.89 0.89 0.01 0.90 0.90 0.804 0.804
99175 99175 A 5 XXX 0 0 0 0 0 0 0 0.00 0.49 0.49 0.01 0.50 0.50 0.445 0.445
99183 99183 A 0 XXX 0 0 0 0 0 0 0 2.34 3.81 0.92 0.26 6.41 3.52 5.897 3.302
99190 99190 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99191 99191 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99192 99192 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99195 99195 A 5 XXX 0 0 0 0 0 0 0 0.00 2.97 2.97 0.05 3.02 3.02 2.693 2.693
99199 99199 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99201 99201 A 0 XXX 0 0 0 0 0 0 0 0.48 0.77 0.24 0.04 1.29 0.76 1.192 0.716
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
453 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99202 99202 A 0 XXX 0 0 0 0 0 0 0 0.93 1.19 0.44 0.07 2.19 1.44 2.035 1.362
99203 99203 A 0 XXX 0 0 0 0 0 0 0 1.42 1.62 0.65 0.14 3.18 2.21 2.948 2.077
99204 99204 A 0 XXX 0 0 0 0 0 0 0 2.43 2.18 1.11 0.23 4.84 3.77 4.508 3.547
99205 99205 A 0 XXX 0 0 0 0 0 0 0 3.17 2.55 1.40 0.27 5.99 4.84 5.601 4.568
99211 99211 A 0 XXX 0 0 0 0 0 0 0 0.18 0.41 0.07 0.01 0.60 0.26 0.553 0.248
99212 99212 A 0 XXX 0 0 0 0 0 0 0 0.48 0.77 0.20 0.04 1.29 0.72 1.192 0.681
99213 99213 A 0 XXX 0 0 0 0 0 0 0 0.97 1.10 0.42 0.07 2.14 1.46 1.994 1.384
99214 99214 A 0 XXX 0 0 0 0 0 0 0 1.50 1.54 0.65 0.10 3.14 2.25 2.935 2.136
99215 99215 A 0 XXX 0 0 0 0 0 0 0 2.11 1.95 0.92 0.14 4.20 3.17 3.934 3.009
99217 99217 A 0 XXX 0 0 0 0 0 0 0 1.28 0.72 0.72 0.08 2.08 2.08 1.968 1.968
99218 99218 A 0 XXX 0 0 0 0 0 0 0 1.92 0.80 0.80 0.12 2.84 2.84 2.701 2.701
99219 99219 A 0 XXX 0 0 0 0 0 0 0 2.60 1.10 1.10 0.17 3.87 3.87 3.677 3.677
99220 99220 A 0 XXX 0 0 0 0 0 0 0 3.56 1.51 1.51 0.24 5.31 5.31 5.042 5.042
99221 99221 A 0 XXX 0 0 0 0 0 0 0 1.92 0.82 0.82 0.18 2.92 2.92 2.751 2.751
99222 99222 A 0 XXX 0 0 0 0 0 0 0 2.61 1.13 1.13 0.22 3.96 3.96 3.740 3.740
99223 99223 A 0 XXX 0 0 0 0 0 0 0 3.86 1.67 1.67 0.29 5.82 5.82 5.511 5.511
99224 99224 A 0 XXX 0 0 0 0 0 0 0 0.76 0.32 0.32 0.06 1.14 1.14 1.079 1.079
99225 99225 A 0 XXX 0 0 0 0 0 0 0 1.39 0.60 0.60 0.07 2.06 2.06 1.965 1.965
99226 99226 A 0 XXX 0 0 0 0 0 0 0 2.00 0.87 0.87 0.11 2.98 2.98 2.839 2.839
99231 99231 A 0 XXX 0 0 0 0 0 0 0 0.76 0.31 0.31 0.05 1.12 1.12 1.065 1.065
99232 99232 A 0 XXX 0 0 0 0 0 0 0 1.39 0.59 0.59 0.08 2.06 2.06 1.962 1.962
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
454 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99233 99233 A 0 XXX 0 0 0 0 0 0 0 2.00 0.85 0.85 0.12 2.97 2.97 2.826 2.826
99234 99234 A 0 XXX 0 0 0 0 0 0 0 2.56 1.08 1.08 0.22 3.86 3.86 3.645 3.645
99235 99235 A 0 XXX 0 0 0 0 0 0 0 3.24 1.37 1.37 0.22 4.83 4.83 4.585 4.585
99236 99236 A 0 XXX 0 0 0 0 0 0 0 4.20 1.75 1.75 0.29 6.24 6.24 5.923 5.923
99238 99238 A 0 XXX 0 0 0 0 0 0 0 1.28 0.73 0.73 0.07 2.08 2.08 1.972 1.972
99239 99239 A 0 XXX 0 0 0 0 0 0 0 1.90 1.07 1.07 0.11 3.08 3.08 2.918 2.918
99241 99241 I 9 XXX 0 0 0 9 9 9 9 0.64 0.66 0.24 0.07 1.37 0.95 1.269 0.892
99242 99242 I 9 XXX 0 0 0 9 9 9 9 1.34 1.10 0.51 0.14 2.58 1.99 2.401 1.871
99243 99243 I 9 XXX 0 0 0 9 9 9 9 1.88 1.46 0.71 0.18 3.52 2.77 3.285 2.612
99244 99244 I 9 XXX 0 0 0 9 9 9 9 3.02 1.96 1.14 0.22 5.20 4.38 4.895 4.159
99245 99245 I 9 XXX 0 0 0 9 9 9 9 3.77 2.30 1.38 0.29 6.36 5.44 5.987 5.161
99251 99251 I 9 XXX 0 0 0 9 9 9 9 1.00 0.32 0.32 0.07 1.39 1.39 1.324 1.324
99252 99252 I 9 XXX 0 0 0 9 9 9 9 1.50 0.52 0.52 0.12 2.14 2.14 2.030 2.030
99253 99253 I 9 XXX 0 0 0 9 9 9 9 2.27 0.84 0.84 0.15 3.26 3.26 3.103 3.103
99254 99254 I 9 XXX 0 0 0 9 9 9 9 3.29 1.23 1.23 0.18 4.70 4.70 4.489 4.489
99255 99255 I 9 XXX 0 0 0 9 9 9 9 4.00 1.62 1.62 0.24 5.86 5.86 5.580 5.580
99281 99281 A 0 XXX 0 0 0 0 0 0 0 0.45 0.12 0.12 0.03 0.60 0.60 0.573 0.573
99282 99282 A 0 XXX 0 0 0 0 0 0 0 0.88 0.23 0.23 0.07 1.18 1.18 1.123 1.123
99283 99283 A 0 XXX 0 0 0 0 0 0 0 1.34 0.32 0.32 0.10 1.76 1.76 1.680 1.680
99284 99284 A 0 XXX 0 0 0 0 0 0 0 2.56 0.59 0.59 0.22 3.37 3.37 3.205 3.205
99285 99285 A 0 XXX 0 0 0 0 0 0 0 3.80 0.83 0.83 0.30 4.93 4.93 4.702 4.702
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
455 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99288 99288 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99291 99291 A 0 XXX 0 0 0 0 0 0 0 4.50 3.16 1.56 0.34 8.00 6.40 7.516 6.079
99292 99292 A 0 ZZZ 0 0 0 0 0 0 0 2.25 1.12 0.79 0.18 3.55 3.22 3.350 3.054
99304 99304 A 0 XXX 0 0 0 0 0 0 0 1.64 0.91 0.91 0.14 2.69 2.69 2.530 2.530
99305 99305 A 0 XXX 0 0 0 0 0 0 0 2.35 1.27 1.27 0.20 3.82 3.82 3.595 3.595
99306 99306 A 0 XXX 0 0 0 0 0 0 0 3.06 1.54 1.54 0.23 4.83 4.83 4.563 4.563
99307 99307 A 0 XXX 0 0 0 0 0 0 0 0.76 0.48 0.48 0.04 1.28 1.28 1.212 1.212
99308 99308 A 0 XXX 0 0 0 0 0 0 0 1.16 0.76 0.76 0.07 1.99 1.99 1.879 1.879
99309 99309 A 0 XXX 0 0 0 0 0 0 0 1.55 0.98 0.98 0.08 2.61 2.61 2.472 2.472
99310 99310 A 0 XXX 0 0 0 0 0 0 0 2.35 1.40 1.40 0.14 3.89 3.89 3.680 3.680
99315 99315 A 0 XXX 0 0 0 0 0 0 0 1.28 0.74 0.74 0.08 2.10 2.10 1.986 1.986
99316 99316 A 0 XXX 0 0 0 0 0 0 0 1.90 1.01 1.01 0.10 3.01 3.01 2.859 2.859
99318 99318 A 0 XXX 0 0 0 0 0 0 0 1.71 0.94 0.94 0.10 2.75 2.75 2.606 2.606
99324 99324 A 0 XXX 0 0 0 0 0 0 0 1.01 0.52 0.52 0.07 1.60 1.60 1.514 1.514
99325 99325 A 0 XXX 0 0 0 0 0 0 0 1.52 0.69 0.69 0.10 2.31 2.31 2.192 2.192
99326 99326 A 0 XXX 0 0 0 0 0 0 0 2.63 1.21 1.21 0.16 4.00 4.00 3.800 3.800
99327 99327 A 0 XXX 0 0 0 0 0 0 0 3.46 1.66 1.66 0.22 5.34 5.34 5.066 5.066
99328 99328 A 0 XXX 0 0 0 0 0 0 0 4.09 1.87 1.87 0.24 6.20 6.20 5.895 5.895
99334 99334 A 0 XXX 0 0 0 0 0 0 0 1.07 0.60 0.60 0.07 1.74 1.74 1.645 1.645
99335 99335 A 0 XXX 0 0 0 0 0 0 0 1.72 0.90 0.90 0.10 2.72 2.72 2.581 2.581
99336 99336 A 0 XXX 0 0 0 0 0 0 0 2.46 1.26 1.26 0.14 3.86 3.86 3.665 3.665
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
456 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99337 99337 A 0 XXX 0 0 0 0 0 0 0 3.58 1.72 1.72 0.23 5.53 5.53 5.245 5.245
99339 99339 B 9 XXX 0 0 0 9 9 9 9 1.25 0.92 0.92 0.08 2.25 2.25 2.118 2.118
99340 99340 B 9 XXX 0 0 0 9 9 9 9 1.80 1.23 1.23 0.12 3.15 3.15 2.967 2.967
99341 99341 A 0 XXX 0 0 0 0 0 0 0 1.01 0.51 0.51 0.07 1.59 1.59 1.505 1.505
99342 99342 A 0 XXX 0 0 0 0 0 0 0 1.52 0.66 0.66 0.11 2.29 2.29 2.170 2.170
99343 99343 A 0 XXX 0 0 0 0 0 0 0 2.53 1.05 1.05 0.18 3.76 3.76 3.567 3.567
99344 99344 A 0 XXX 0 0 0 0 0 0 0 3.38 1.63 1.63 0.22 5.23 5.23 4.959 4.959
99345 99345 A 0 XXX 0 0 0 0 0 0 0 4.09 1.95 1.95 0.26 6.30 6.30 5.977 5.977
99347 99347 A 0 XXX 0 0 0 0 0 0 0 1.00 0.53 0.53 0.07 1.60 1.60 1.513 1.513
99348 99348 A 0 XXX 0 0 0 0 0 0 0 1.56 0.76 0.76 0.10 2.42 2.42 2.295 2.295
99349 99349 A 0 XXX 0 0 0 0 0 0 0 2.33 1.20 1.20 0.14 3.67 3.67 3.481 3.481
99350 99350 A 0 XXX 0 0 0 0 0 0 0 3.28 1.60 1.60 0.22 5.10 5.10 4.832 4.832
99354 99354 A 0 ZZZ 0 0 0 0 0 0 0 1.77 0.98 0.77 0.11 2.86 2.65 2.708 2.519
99355 99355 A 0 ZZZ 0 0 0 0 0 0 0 1.77 0.92 0.69 0.11 2.80 2.57 2.654 2.447
99356 99356 A 0 ZZZ 0 0 0 0 0 0 0 1.71 0.81 0.81 0.11 2.63 2.63 2.495 2.495
99357 99357 A 0 ZZZ 0 0 0 0 0 0 0 1.71 0.80 0.80 0.11 2.62 2.62 2.486 2.486
99358 99358 B 9 XXX 0 0 0 9 9 9 9 2.10 0.89 0.89 0.14 3.13 3.13 2.972 2.972
99359 99359 B 9 ZZZ 0 0 0 9 9 9 9 1.00 0.45 0.45 0.07 1.52 1.52 1.441 1.441
99360 99360 X 9 XXX 0 0 0 9 9 9 9 1.20 0.49 0.49 0.08 1.77 1.77 1.682 1.682
99363 99363 B 9 XXX 0 0 0 9 9 9 9 1.65 1.98 0.67 0.11 3.74 2.43 3.486 2.309
99364 99364 B 9 XXX 0 0 0 9 9 9 9 0.63 0.59 0.26 0.04 1.26 0.93 1.181 0.884
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
457 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99366 99366 B 9 XXX 0 0 0 9 9 9 9 0.82 0.36 0.33 0.05 1.23 1.20 1.169 1.142
99367 99367 B 9 XXX 0 0 0 9 9 9 9 1.10 0.45 0.45 0.07 1.62 1.62 1.541 1.541
99368 99368 B 9 XXX 0 0 0 9 9 9 9 0.72 0.29 0.29 0.04 1.05 1.05 1.001 1.001
99374 99374 B 9 XXX 0 0 0 9 9 9 9 1.10 0.86 0.45 0.07 2.03 1.62 1.909 1.541
99375 99375 I 9 XXX 0 0 0 9 9 9 9 1.73 1.20 0.70 0.11 3.04 2.54 2.865 2.416
99377 99377 B 9 XXX 0 0 0 9 9 9 9 1.10 0.86 0.45 0.07 2.03 1.62 1.909 1.541
99378 99378 I 9 XXX 0 0 0 9 9 9 9 1.73 1.20 0.70 0.11 3.04 2.54 2.865 2.416
99379 99379 B 9 XXX 0 0 0 9 9 9 9 1.10 0.86 0.45 0.07 2.03 1.62 1.909 1.541
99380 99380 B 9 XXX 0 0 0 9 9 9 9 1.73 1.20 0.70 0.11 3.04 2.54 2.865 2.416
99381 99381 N 9 XXX 0 0 0 9 9 9 9 1.50 1.63 0.61 0.10 3.23 2.21 3.016 2.100
99382 99382 N 9 XXX 0 0 0 9 9 9 9 1.60 1.67 0.65 0.09 3.36 2.34 3.147 2.231
99383 99383 N 9 XXX 0 0 0 9 9 9 9 1.70 1.70 0.69 0.10 3.50 2.49 3.279 2.372
99384 99384 N 9 XXX 0 0 0 9 9 9 9 2.00 1.83 0.81 0.13 3.96 2.94 3.711 2.795
99385 99385 N 9 XXX 0 0 0 9 9 9 9 1.92 1.79 0.78 0.13 3.84 2.83 3.595 2.688
99386 99386 N 9 XXX 0 0 0 9 9 9 9 2.33 1.96 0.94 0.15 4.44 3.42 4.169 3.253
99387 99387 N 9 XXX 0 0 0 9 9 9 9 2.50 2.15 1.01 0.17 4.82 3.68 4.520 3.496
99391 99391 N 9 XXX 0 0 0 9 9 9 9 1.37 1.44 0.55 0.09 2.90 2.01 2.710 1.911
99392 99392 N 9 XXX 0 0 0 9 9 9 9 1.50 1.50 0.61 0.10 3.10 2.21 2.899 2.100
99393 99393 N 9 XXX 0 0 0 9 9 9 9 1.50 1.49 0.61 0.10 3.09 2.21 2.890 2.100
99394 99394 N 9 XXX 0 0 0 9 9 9 9 1.70 1.57 0.69 0.10 3.37 2.49 3.162 2.372
99395 99395 N 9 XXX 0 0 0 9 9 9 9 1.75 1.59 0.71 0.10 3.44 2.56 3.230 2.440
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
458 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99396 99396 N 9 XXX 0 0 0 9 9 9 9 1.90 1.65 0.77 0.12 3.67 2.79 3.444 2.654
99397 99397 N 9 XXX 0 0 0 9 9 9 9 2.00 1.83 0.81 0.13 3.96 2.94 3.711 2.795
99401 99401 N 9 XXX 0 0 0 9 9 9 9 0.48 0.55 0.19 0.03 1.06 0.70 0.990 0.666
99402 99402 N 9 XXX 0 0 0 9 9 9 9 0.98 0.75 0.40 0.07 1.80 1.45 1.690 1.376
99403 99403 N 9 XXX 0 0 0 9 9 9 9 1.46 0.95 0.59 0.10 2.51 2.15 2.365 2.042
99404 99404 N 9 XXX 0 0 0 9 9 9 9 1.95 1.14 0.79 0.12 3.21 2.86 3.036 2.722
99406 99406 A 0 XXX 0 0 0 0 0 0 0 0.24 0.16 0.10 0.01 0.41 0.35 0.389 0.335
99407 99407 A 0 XXX 0 0 0 0 0 0 0 0.50 0.26 0.20 0.03 0.79 0.73 0.749 0.695
99408 99408 N 9 XXX 0 0 0 9 9 9 9 0.65 0.32 0.26 0.04 1.01 0.95 0.958 0.904
99409 99409 N 9 XXX 0 0 0 9 9 9 9 1.30 0.58 0.53 0.08 1.96 1.91 1.863 1.818
99411 99411 N 9 XXX 0 0 0 9 9 9 9 0.15 0.33 0.06 0.01 0.49 0.22 0.452 0.209
99412 99412 N 9 XXX 0 0 0 9 9 9 9 0.25 0.37 0.10 0.01 0.63 0.36 0.587 0.345
99420 99420 N 9 XXX 0 0 0 9 9 9 9 0.00 0.32 0.32 0.01 0.33 0.33 0.293 0.293
99429 99429 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99441 99441 N 9 XXX 0 0 0 9 9 9 9 0.25 0.14 0.10 0.01 0.40 0.36 0.381 0.345
99442 99442 N 9 XXX 0 0 0 9 9 9 9 0.50 0.24 0.20 0.03 0.77 0.73 0.731 0.695
99443 99443 N 9 XXX 0 0 0 9 9 9 9 0.75 0.35 0.30 0.05 1.15 1.10 1.090 1.046
99444 99444 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99450 99450 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99455 99455 R 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99456 99456 R 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
459 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99460 99460 A 0 XXX 0 0 0 0 0 0 0 1.92 0.61 0.61 0.08 2.61 2.61 2.510 2.510
99461 99461 A 0 XXX 0 0 0 0 0 0 0 1.26 1.59 0.52 0.08 2.93 1.86 2.730 1.769
99462 99462 A 0 XXX 0 0 0 0 0 0 0 0.84 0.30 0.30 0.05 1.19 1.19 1.136 1.136
99463 99463 A 0 XXX 0 0 0 0 0 0 0 2.13 1.07 1.07 0.11 3.31 3.31 3.148 3.148
99464 99464 A 0 XXX 0 0 0 0 0 0 0 1.50 0.62 0.62 0.07 2.19 2.19 2.093 2.093
99465 99465 A 0 XXX 0 0 0 0 0 0 0 2.93 1.06 1.06 0.22 4.21 4.21 3.997 3.997
99466 99466 A 0 XXX 0 0 0 0 0 0 0 4.79 1.94 1.94 1.02 7.75 7.75 7.066 7.066
99467 99467 A 0 ZZZ 0 0 0 0 0 0 0 2.40 0.97 0.97 0.14 3.51 3.51 3.344 3.344
99468 99468 A 0 XXX 0 0 0 0 0 0 0 18.46 7.48 7.48 1.52 27.46 27.46 25.972 25.972
99469 99469 A 0 XXX 0 0 0 0 0 0 0 7.99 2.90 2.90 0.42 11.31 11.31 10.814 10.814
99471 99471 A 0 XXX 0 0 0 0 0 0 0 15.98 7.68 7.68 0.87 24.53 24.53 23.332 23.332
99472 99472 A 0 XXX 0 0 0 0 0 0 0 7.99 3.19 3.19 0.48 11.66 11.66 11.106 11.106
99475 99475 A 0 XXX 0 0 0 0 0 0 0 11.25 4.08 4.08 0.86 16.19 16.19 15.364 15.364
99476 99476 A 0 XXX 0 0 0 0 0 0 0 6.75 2.76 2.76 0.52 10.03 10.03 9.500 9.500
99477 99477 A 0 XXX 0 0 0 0 0 0 0 7.00 2.68 2.68 0.38 10.06 10.06 9.605 9.605
99478 99478 A 0 XXX 0 0 0 0 0 0 0 2.75 1.11 1.11 0.18 4.04 4.04 3.841 3.841
99479 99479 A 0 XXX 0 0 0 0 0 0 0 2.50 1.01 1.01 0.16 3.67 3.67 3.491 3.491
99480 99480 A 0 XXX 0 0 0 0 0 0 0 2.40 0.87 0.87 0.16 3.43 3.43 3.265 3.265
99485 99485 B 9 XXX 0 0 0 9 9 9 9 1.50 0.61 0.61 0.08 2.19 2.19 2.090 2.090
99486 99486 B 9 XXX 0 0 0 9 9 9 9 1.30 0.53 0.53 0.08 1.91 1.91 1.818 1.818
99487 99487 B 9 XXX 0 0 0 9 9 9 9 1.00 1.35 1.35 0.06 2.41 2.41 2.244 2.244
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
460 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
99488 99488 B 9 XXX 0 0 0 9 9 9 9 2.50 2.73 2.73 0.17 5.40 5.40 5.040 5.040
99489 99489 B 9 ZZZ 0 0 0 9 9 9 9 0.50 0.68 0.68 0.03 1.21 1.21 1.126 1.126
99495 99495 A 0 XXX 0 0 0 0 0 0 0 2.11 2.57 1.71 0.14 4.82 3.96 4.491 3.719
99496 99496 A 0 XXX 0 0 0 0 0 0 0 3.05 3.55 2.56 0.20 6.80 5.81 6.343 5.453
99499 99499 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99502 99502 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99605 99605 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99606 99606 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
99607 99607 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0008 G0008 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0009 G0009 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0010 G0010 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0101 G0101 A 0 XXX 0 0 0 0 0 0 0 0.45 0.64 0.32 0.03 1.12 0.80 1.040 0.753
G0102 G0102 A 0 XXX 0 0 0 9 9 9 9 0.17 0.41 0.07 0.01 0.59 0.25 0.543 0.238
G0104 G0104 A 0 000 0 0 0 2 0 1 0 0.96 3.17 0.82 0.14 4.27 1.92 3.880 1.770
G0105 G0105 A 0 000 0 0 0 2 0 1 0 3.69 7.79 2.20 0.59 12.07 6.48 10.994 5.974
G0105 53 G010553 A 0 000 0 0 0 2 0 1 0 0.96 3.17 0.82 0.14 4.27 1.92 3.880 1.770
G0106 G0106 A 1 XXX 0 0 0 0 0 0 0 0.99 5.60 5.60 0.04 6.63 6.63 6.040 6.040
G0106 26 G010626 A 1 XXX 0 0 0 0 0 0 0 0.99 0.36 0.36 0.03 1.38 1.38 1.329 1.329
G0106 TC G0106TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.24 5.24 0.01 5.25 5.25 4.711 4.711
G0108 G0108 A 0 XXX 0 0 0 0 0 0 0 0.90 0.58 0.58 0.05 1.53 1.53 1.447 1.447
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
461 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0109 G0109 A 0 XXX 0 0 0 0 0 0 0 0.25 0.15 0.15 0.01 0.41 0.41 0.390 0.390
G0117 G0117 T 0 XXX 0 0 0 0 0 0 0 0.45 1.15 1.15 0.03 1.63 1.63 1.498 1.498
G0118 G0118 T 0 XXX 0 0 0 0 0 0 0 0.17 0.98 0.98 0.01 1.16 1.16 1.055 1.055
G0120 G0120 A 1 XXX 0 0 0 0 0 0 0 0.99 5.60 5.60 0.04 6.63 6.63 6.040 6.040
G0120 26 G012026 A 1 XXX 0 0 0 0 0 0 0 0.99 0.36 0.36 0.03 1.38 1.38 1.329 1.329
G0120 TC G0120TC A 1 XXX 0 0 0 0 0 0 0 0.00 5.24 5.24 0.01 5.25 5.25 4.711 4.711
G0121 G0121 A 0 000 0 0 0 2 0 1 0 3.69 7.79 2.20 0.59 12.07 6.48 10.994 5.974
G0121 53 G012153 A 0 000 0 0 0 2 0 1 0 0.96 3.17 0.82 0.14 4.27 1.92 3.880 1.770
G0122 G0122 N 1 XXX 0 0 0 9 9 9 9 0.99 7.62 7.62 0.05 8.66 8.66 7.859 7.859
G0122 26 G012226 N 1 XXX 0 0 0 9 9 9 9 0.99 0.40 0.40 0.04 1.43 1.43 1.370 1.370
G0122 TC G0122TC N 1 XXX 0 0 0 9 9 9 9 0.00 7.22 7.22 0.01 7.23 7.23 6.489 6.489
G0124 G0124 A 0 XXX 0 0 0 0 0 0 0 0.42 0.48 0.48 0.03 0.93 0.93 0.867 0.867
G0127 G0127 R 0 000 0 0 0 2 0 1 0 0.17 0.51 0.04 0.01 0.69 0.22 0.633 0.211
G0128 G0128 R 3 XXX 0 0 0 0 0 0 0 0.00 0.23 0.23 0.01 0.24 0.24 0.212 0.212
G0130 G0130 A 1 XXX 0 0 0 0 0 0 0 0.22 0.78 0.78 0.02 1.02 1.02 0.931 0.931
G0130 26 G013026 A 1 XXX 0 0 0 0 0 0 0 0.22 0.09 0.09 0.01 0.32 0.32 0.306 0.306
G0130 TC G0130TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.69 0.69 0.01 0.70 0.70 0.625 0.625
G0141 G0141 A 0 XXX 0 0 0 0 0 0 0 0.42 0.48 0.48 0.03 0.93 0.93 0.867 0.867
G0166 G0166 A 0 XXX 0 0 0 9 9 9 9 0.07 4.13 4.13 0.03 4.23 4.23 3.794 3.794
G0168 G0168 A 0 000 0 0 0 2 0 1 0 0.45 2.64 0.32 0.03 3.12 0.80 2.836 0.753
G0173 G0173 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
462 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0175 G0175 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0176 G0176 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0177 G0177 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0179 G0179 A 0 XXX 0 0 0 0 0 0 0 0.45 0.74 0.74 0.03 1.22 1.22 1.130 1.130
G0180 G0180 A 0 XXX 0 0 0 0 0 0 0 0.67 0.85 0.85 0.04 1.56 1.56 1.454 1.454
G0181 G0181 A 0 XXX 0 0 0 0 0 0 0 1.73 1.28 1.28 0.10 3.11 3.11 2.932 2.932
G0182 G0182 A 0 XXX 0 0 0 0 0 0 0 1.73 1.30 1.30 0.10 3.13 3.13 2.950 2.950
G0186 G0186 C 0 YYY 0 0 0 2 1 0 1 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0202 G0202 A 1 XXX 0 0 0 0 2 0 0 0.70 3.33 3.33 0.05 4.08 4.08 3.716 3.716
G0202 26 G020226 A 1 XXX 0 0 0 0 2 0 0 0.70 0.28 0.28 0.04 1.02 1.02 0.972 0.972
G0202 TC G0202TC A 1 XXX 0 0 0 0 2 0 0 0.00 3.05 3.05 0.01 3.06 3.06 2.744 2.744
G0204 G0204 A 1 XXX 0 0 0 0 2 0 0 0.87 4.04 4.04 0.06 4.97 4.97 4.529 4.529
G0204 26 G020426 A 1 XXX 0 0 0 0 2 0 0 0.87 0.35 0.35 0.05 1.27 1.27 1.210 1.210
G0204 TC G0204TC A 1 XXX 0 0 0 0 2 0 0 0.00 3.69 3.69 0.01 3.70 3.70 3.319 3.319
G0206 G0206 A 1 XXX 0 0 0 0 0 0 0 0.70 3.17 3.17 0.05 3.92 3.92 3.573 3.573
G0206 26 G020626 A 1 XXX 0 0 0 0 0 0 0 0.70 0.28 0.28 0.04 1.02 1.02 0.972 0.972
G0206 TC G0206TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.89 2.89 0.01 2.90 2.90 2.600 2.600
G0219 G0219 N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0219 26 G021926 N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0219 TC G0219TC N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0235 G0235 N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
463 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0235 26 G023526 N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0235 TC G0235TC N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0237 G0237 A 5 XXX 0 0 0 0 0 0 0 0.00 0.31 0.31 0.01 0.32 0.32 0.284 0.284
G0238 G0238 A 5 XXX 0 0 0 0 0 0 0 0.00 0.33 0.33 0.01 0.34 0.34 0.302 0.302
G0239 G0239 A 5 XXX 0 0 0 0 0 0 0 0.00 0.37 0.37 0.01 0.38 0.38 0.337 0.337
G0245 G0245 R 0 XXX 0 0 0 0 0 0 0 0.88 0.98 0.30 0.05 1.91 1.23 1.786 1.176
G0246 G0246 R 0 XXX 0 0 0 0 0 0 0 0.45 0.64 0.13 0.03 1.12 0.61 1.040 0.582
G0247 G0247 R 0 ZZZ 0 0 0 0 0 0 0 0.50 1.66 0.14 0.04 2.20 0.68 2.012 0.647
G0248 G0248 R 3 XXX 0 0 0 0 0 0 0 0.00 3.34 3.34 0.01 3.35 3.35 3.005 3.005
G0249 G0249 R 3 XXX 0 0 0 0 0 0 0 0.00 3.29 3.29 0.01 3.30 3.30 2.960 2.960
G0250 G0250 R 2 XXX 0 0 0 0 0 0 0 0.18 0.07 0.07 0.01 0.26 0.26 0.248 0.248
G0251 G0251 E 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0252 G0252 N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0252 26 G025226 N 1 XXX 0 0 0 9 9 9 9 1.50 0.61 0.61 0.10 2.21 2.21 2.100 2.100
G0252 TC G0252TC N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0255 G0255 N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0255 26 G025526 N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0255 TC G0255TC N 1 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0257 G0257 E 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0259 G0259 E 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0260 G0260 E 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
464 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0268 G0268 A 0 000 0 0 0 2 2 1 0 0.61 0.91 0.30 0.03 1.55 0.94 1.443 0.895
G0269 G0269 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0270 G0270 A 0 XXX 0 0 0 0 0 0 0 0.45 0.42 0.34 0.03 0.90 0.82 0.843 0.771
G0271 G0271 A 0 XXX 0 0 0 0 0 0 0 0.25 0.20 0.19 0.01 0.46 0.45 0.435 0.426
G0275 G0275 A 0 ZZZ 0 0 0 0 0 0 0 0.25 0.09 0.09 0.01 0.35 0.35 0.336 0.336
G0278 G0278 A 0 ZZZ 0 0 0 0 0 0 0 0.25 0.09 0.09 0.01 0.35 0.35 0.336 0.336
G0281 G0281 A 7 XXX 0 0 0 5 0 0 0 0.18 0.21 0.21 0.01 0.40 0.40 0.374 0.374
G0282 G0282 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0283 G0283 A 7 XXX 0 0 0 5 0 0 0 0.18 0.21 0.21 0.01 0.40 0.40 0.374 0.374
G0288 G0288 A 3 XXX 0 0 0 0 0 0 0 0.00 1.14 1.14 0.01 1.15 1.15 1.029 1.029
G0289 G0289 A 0 ZZZ 0 0 0 0 1 0 0 1.48 0.79 0.79 0.29 2.56 2.56 2.341 2.341
G0302 G0302 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0303 G0303 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0304 G0304 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0305 G0305 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0329 G0329 A 7 XXX 0 0 0 5 0 0 0 0.06 0.23 0.23 0.01 0.30 0.30 0.272 0.272
G0337 G0337 X 9 XXX 0 0 0 9 9 9 9 1.42 0.58 0.58 0.10 2.10 2.10 1.993 1.993
G0339 G0339 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0340 G0340 C 0 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0341 G0341 A 0 000 0 0 0 2 0 0 1 6.98 59.88 3.07 0.49 67.35 10.54 61.009 9.993
G0342 G0342 A 0 090 0 1 0 2 0 2 1 11.92 7.08 7.08 0.84 19.84 19.84 18.717 18.717
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
465 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0343 G0343 A 0 090 0 1 0 2 0 2 1 19.85 11.73 11.73 1.40 32.98 32.98 31.116 31.116
G0364 G0364 A 0 ZZZ 0 0 0 0 0 0 0 0.16 0.19 0.08 0.01 0.36 0.25 0.336 0.237
G0365 G0365 A 1 XXX 0 0 0 0 0 0 0 0.25 6.21 6.21 0.04 6.50 6.50 5.848 5.848
G0365 26 G036526 A 1 XXX 0 0 0 0 0 0 0 0.25 0.08 0.08 0.03 0.36 0.36 0.338 0.338
G0365 TC G0365TC A 1 XXX 0 0 0 0 0 0 0 0.00 6.13 6.13 0.01 6.14 6.14 5.510 5.510
G0372 G0372 A 0 XXX 0 0 0 0 0 0 0 0.17 0.08 0.08 0.01 0.26 0.26 0.247 0.247
G0378 G0378 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0379 G0379 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0389 G0389 A 1 XXX 0 0 0 0 0 0 0 0.58 2.64 2.64 0.04 3.26 3.26 2.972 2.972
G0389 26 G038926 A 1 XXX 0 0 0 0 0 0 0 0.58 0.21 0.21 0.03 0.82 0.82 0.784 0.784
G0389 TC G0389TC A 1 XXX 0 0 0 0 0 0 0 0.00 2.43 2.43 0.01 2.44 2.44 2.187 2.187
G0396 G0396 A 0 XXX 0 0 0 0 0 0 0 0.65 0.38 0.31 0.04 1.07 1.00 1.012 0.949
G0397 G0397 A 0 XXX 0 0 0 0 0 0 0 1.30 0.65 0.58 0.08 2.03 1.96 1.926 1.863
G0398 G0398 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0398 26 G039826 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0398 TC G0398TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0399 G0399 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0399 26 G039926 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0399 TC G0399TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0400 G0400 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0400 26 G040026 C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
466 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0400 TC G0400TC C 1 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0402 G0402 A 0 XXX 0 0 0 0 0 0 0 2.43 2.26 1.06 0.12 4.81 3.61 4.522 3.445
G0403 G0403 A 4 XXX 0 0 0 0 0 0 0 0.17 0.35 0.35 0.02 0.54 0.54 0.495 0.495
G0404 G0404 A 3 XXX 0 0 0 0 0 0 0 0.00 0.29 0.29 0.01 0.30 0.30 0.266 0.266
G0405 G0405 A 2 XXX 0 0 0 0 0 0 0 0.17 0.06 0.06 0.01 0.24 0.24 0.229 0.229
G0406 G0406 A 0 XXX 0 0 0 0 0 0 0 0.76 0.31 0.31 0.05 1.12 1.12 1.065 1.065
G0407 G0407 A 0 XXX 0 0 0 0 0 0 0 1.39 0.59 0.59 0.08 2.06 2.06 1.962 1.962
G0408 G0408 A 0 XXX 0 0 0 0 0 0 0 2.00 0.85 0.85 0.12 2.97 2.97 2.826 2.826
G0409 G0409 R 9 XXX 0 0 0 0 0 0 0 0.00 0.55 0.55 0.01 0.56 0.56 0.499 0.499
G0412 G0412 A 0 090 0 1 0 2 0 2 2 10.45 9.02 9.02 2.04 21.51 21.51 19.617 19.617
G0413 G0413 A 0 090 0 1 0 2 0 2 2 15.73 12.80 12.80 3.06 31.59 31.59 28.825 28.825
G0414 G0414 A 0 090 0 1 0 2 0 2 2 14.65 12.06 12.06 2.86 29.57 29.57 26.976 26.976
G0415 G0415 A 0 090 0 1 0 2 0 2 2 20.93 15.47 15.47 4.21 40.61 40.61 37.024 37.024
G0416 G0416 A 1 XXX 0 0 0 0 0 0 0 3.09 16.51 16.51 0.12 19.72 19.72 17.979 17.979
G0416 26 G041626 A 1 XXX 0 0 0 0 0 0 0 3.09 2.15 2.15 0.11 5.35 5.35 5.078 5.078
G0416 TC G0416TC A 1 XXX 0 0 0 0 0 0 0 0.00 14.36 14.36 0.01 14.37 14.37 12.901 12.901
G0417 G0417 A 1 XXX 0 0 0 0 0 0 0 5.86 32.25 32.25 0.25 38.36 38.36 34.951 34.951
G0417 26 G041726 A 1 XXX 0 0 0 0 0 0 0 5.86 4.20 4.20 0.24 10.30 10.30 9.757 9.757
G0417 TC G0417TC A 1 XXX 0 0 0 0 0 0 0 0.00 28.05 28.05 0.01 28.06 28.06 25.194 25.194
G0418 G0418 A 1 XXX 0 0 0 0 0 0 0 10.30 55.07 55.07 0.42 65.79 65.79 59.973 59.973
G0418 26 G041826 A 1 XXX 0 0 0 0 0 0 0 10.30 7.17 7.17 0.41 17.88 17.88 16.953 16.953
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
467 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0418 TC G0418TC A 1 XXX 0 0 0 0 0 0 0 0.00 47.90 47.90 0.01 47.91 47.91 43.019 43.019
G0419 G0419 A 1 XXX 0 0 0 0 0 0 0 11.61 66.08 66.08 0.46 78.15 78.15 71.190 71.190
G0419 26 G041926 A 1 XXX 0 0 0 0 0 0 0 11.61 8.59 8.59 0.45 20.65 20.65 19.559 19.559
G0419 TC G0419TC A 1 XXX 0 0 0 0 0 0 0 0.00 57.49 57.49 0.01 57.50 57.50 51.631 51.631
G0422 G0422 A 0 XXX 0 0 0 0 0 0 0 1.20 1.08 1.08 0.07 2.35 2.35 2.206 2.206
G0423 G0423 A 0 XXX 0 0 0 0 0 0 0 1.20 1.20 1.20 0.07 2.47 2.47 2.314 2.314
G0424 G0424 A 0 XXX 0 0 0 0 0 0 0 0.28 0.60 0.10 0.03 0.91 0.41 0.834 0.385
G0425 G0425 A 0 XXX 0 0 0 0 0 0 0 1.92 0.82 0.82 0.18 2.92 2.92 2.751 2.751
G0426 G0426 A 0 XXX 0 0 0 0 0 0 0 2.61 1.13 1.13 0.22 3.96 3.96 3.740 3.740
G0427 G0427 A 0 XXX 0 0 0 0 0 0 0 3.86 1.67 1.67 0.29 5.82 5.82 5.511 5.511
G0428 G0428 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0429 G0429 A 0 000 0 0 0 2 0 0 0 1.19 1.52 0.69 0.24 2.95 2.12 2.680 1.935
G0436 G0436 A 0 XXX 0 0 0 0 0 0 0 0.24 0.16 0.10 0.01 0.41 0.35 0.389 0.335
G0437 G0437 A 0 XXX 0 0 0 0 0 0 0 0.50 0.27 0.21 0.03 0.80 0.74 0.758 0.704
G0438 G0438 A 0 XXX 0 0 0 0 0 0 0 2.43 2.43 2.43 0.12 4.98 4.98 4.675 4.675
G0439 G0439 A 0 XXX 0 0 0 0 0 0 0 1.50 1.76 1.76 0.03 3.29 3.29 3.096 3.096
G0442 G0442 A 0 XXX 0 0 0 0 0 0 0 0.18 0.35 0.08 0.01 0.54 0.27 0.500 0.257
G0443 G0443 A 0 XXX 0 0 0 0 0 0 0 0.45 0.27 0.20 0.03 0.75 0.68 0.708 0.645
G0444 G0444 A 0 XXX 0 0 0 0 0 0 0 0.18 0.35 0.08 0.01 0.54 0.27 0.500 0.257
G0445 G0445 A 0 XXX 0 0 0 0 0 0 0 0.45 0.29 0.19 0.03 0.77 0.67 0.726 0.636
G0446 G0446 A 0 XXX 0 0 0 0 0 0 0 0.45 0.27 0.20 0.03 0.75 0.68 0.708 0.645
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
468 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
G0447 G0447 A 0 XXX 0 0 0 0 0 0 0 0.45 0.27 0.21 0.03 0.75 0.69 0.708 0.654
G0448 G0448 E 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0451 G0451 A 5 XXX 0 0 0 0 0 0 0 0.00 0.26 0.26 0.01 0.27 0.27 0.239 0.239
G0452 26 G045226 A 6 XXX 0 0 0 0 0 0 0 0.37 0.15 0.15 0.03 0.55 0.55 0.520 0.520
G0453 G0453 A 0 XXX 0 0 0 0 0 0 0 0.50 0.24 0.24 0.03 0.77 0.77 0.731 0.731
G0454 G0454 A 0 XXX 0 0 0 0 0 0 0 0.18 0.07 0.07 0.01 0.26 0.26 0.248 0.248
G0455 G0455 A 0 000 0 0 0 0 0 0 0 0.97 2.23 0.47 0.10 3.30 1.54 3.025 1.444
G0456 G0456 C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0457 G0457 C 0 YYY 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G0458 G0458 E 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G9016 G9016 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
G9147 G9147 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
H1000 H1000 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
H1001 H1001 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
H1002 H1002 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
H1003 H1003 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
H1004 H1004 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
H1005 H1005 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
M0064 M0064 A 0 XXX 0 0 0 0 0 0 0 0.37 1.29 0.07 0.01 1.67 0.45 1.534 0.438
M0075 M0075 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
M0076 M0076 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
469 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
M0100 M0100 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
M0300 M0300 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
M0301 M0301 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
P2028 P2028 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
P2029 P2029 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
P2031 P2031 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
P2033 P2033 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
P3001 P3001 A 0 XXX 0 0 0 0 0 0 0 0.42 0.48 0.48 0.03 0.93 0.93 0.867 0.867
P7001 P7001 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
P9603 P9603 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
P9604 P9604 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
Q0035 Q0035 A 1 XXX 0 0 0 0 0 0 0 0.17 0.44 0.44 0.02 0.63 0.63 0.576 0.576
Q0035 26 Q003526 A 1 XXX 0 0 0 0 0 0 0 0.17 0.08 0.08 0.01 0.26 0.26 0.247 0.247
Q0035 TC Q0035TC A 1 XXX 0 0 0 0 0 0 0 0.00 0.36 0.36 0.01 0.37 0.37 0.329 0.329
Q0091 Q0091 A 0 XXX 0 0 0 0 0 0 0 0.37 0.95 0.16 0.03 1.35 0.56 1.239 0.529
Q0092 Q0092 A 3 XXX 0 0 0 0 0 0 0 0.00 0.73 0.73 0.01 0.74 0.74 0.661 0.661
Q3014 Q3014 X 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
R0070 R0070 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
R0075 R0075 C 3 XXX 0 0 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
R0076 R0076 B 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0199 S0199 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
470 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S0220 S0220 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0221 S0221 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0250 S0250 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0257 S0257 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0260 S0260 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0265 S0265 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0270 S0270 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0271 S0271 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0272 S0272 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0273 S0273 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0274 S0274 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0302 S0302 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0310 S0310 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0340 S0340 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0341 S0341 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0342 S0342 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0353 S0353 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0354 S0354 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0390 S0390 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0395 S0395 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0400 S0400 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
471 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S0601 S0601 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0610 S0610 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0612 S0612 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0613 S0613 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0618 S0618 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0620 S0620 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0621 S0621 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0622 S0622 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0630 S0630 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0800 S0800 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0810 S0810 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S0812 S0812 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2053 S2053 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2054 S2054 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2055 S2055 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2060 S2060 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2061 S2061 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2065 S2065 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2066 S2066 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2067 S2067 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2068 S2068 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
472 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S2070 S2070 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2079 S2079 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2080 S2080 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2083 S2083 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2095 S2095 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2102 S2102 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2103 S2103 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2107 S2107 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2112 S2112 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2115 S2115 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2117 S2117 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2118 S2118 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2120 S2120 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2140 S2140 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2142 S2142 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2150 S2150 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2202 S2202 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2205 S2205 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2206 S2206 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2207 S2207 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2208 S2208 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
473 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S2209 S2209 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2225 S2225 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2230 S2230 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2235 S2235 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2260 S2260 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2265 S2265 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2266 S2266 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2267 S2267 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2300 S2300 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2325 S2325 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2340 S2340 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2341 S2341 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2342 S2342 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2348 S2348 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2350 S2350 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2351 S2351 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2360 S2360 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2361 S2361 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2400 S2400 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2401 S2401 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2402 S2402 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
474 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S2403 S2403 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2404 S2404 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2405 S2405 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2409 S2409 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2411 S2411 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S2900 S2900 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3000 S3000 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3005 S3005 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3600 S3600 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3601 S3601 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3620 S3620 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3625 S3625 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3626 S3626 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3630 S3630 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3645 S3645 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3650 S3650 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3652 S3652 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3655 S3655 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3708 S3708 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3721 S3721 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3722 S3722 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
475 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S3800 S3800 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3833 S3833 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3834 S3834 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3840 S3840 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3841 S3841 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3842 S3842 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3844 S3844 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3845 S3845 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3846 S3846 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3849 S3849 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3850 S3850 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3852 S3852 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3853 S3853 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3854 S3854 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3861 S3861 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3865 S3865 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3866 S3866 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3870 S3870 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3890 S3890 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3900 S3900 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S3902 S3902 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
476 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S3904 S3904 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4011 S4011 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4013 S4013 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4014 S4014 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4015 S4015 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4016 S4016 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4017 S4017 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4018 S4018 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4020 S4020 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4021 S4021 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4022 S4022 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4023 S4023 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4025 S4025 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4026 S4026 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4027 S4027 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4028 S4028 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4030 S4030 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4031 S4031 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4035 S4035 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4037 S4037 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4040 S4040 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
477 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S4042 S4042 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S4981 S4981 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S5190 S5190 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8030 S8030 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8035 S8035 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8037 S8037 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8040 S8040 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8042 S8042 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8055 S8055 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8080 S8080 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8085 S8085 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8092 S8092 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8110 S8110 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8930 S8930 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8940 S8940 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8948 S8948 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8950 S8950 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S8990 S8990 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9001 S9001 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9015 S9015 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9024 S9024 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
478 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S9025 S9025 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9034 S9034 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9056 S9056 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9088 S9088 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9090 S9090 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9110 S9110 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9117 S9117 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9140 S9140 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9141 S9141 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9145 S9145 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9150 S9150 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9152 S9152 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9401 S9401 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9430 S9430 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9436 S9436 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9437 S9437 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9438 S9438 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9439 S9439 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9444 S9444 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9447 S9447 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9449 S9449 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
479 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
S9451 S9451 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9452 S9452 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9453 S9453 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9454 S9454 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9455 S9455 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9460 S9460 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9465 S9465 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9470 S9470 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9472 S9472 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9473 S9473 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9474 S9474 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9475 S9475 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9476 S9476 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9482 S9482 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9981 S9981 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
S9982 S9982 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1014 T1014 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1023 T1023 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1024 T1024 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1025 T1025 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1026 T1026 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
480 of 481

Code Mod Code_Mod
Status
Code
Effective Date of Service: 04/01/2013
BlueCross BlueShield of Tennessee
Commercial Professional Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs)
Reimbursement Rule Indicators (Note - Applicable to all commercial
networks
PCTC
IND
Global
DAYS
PRE
OP
INTRA
OP
POST
OP
MULT
PROC
BILAT
SURG
ASST
SURG
CO-
SURG
Work
RVU
RBRVS RVUs (Note - Only applicable when referenced in the provider's agreement)
NON-FAC
PE RVU
Facility
PE RVU MP RVU
Non-Facility
TOTAL
Facility
TOTAL
Rounded
Total Non-
Facility RVU
and GPCI
Component
Rounded
Total Facility
RVU and
GPCI
Component
T1027 T1027 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1028 T1028 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1502 T1502 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
T1503 T1503 I 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
V5008 V5008 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
V5010 V5010 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
V5011 V5011 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
V5014 V5014 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
V5020 V5020 N 9 XXX 0 0 0 9 9 9 9 0.00 0.00 0.00 0.00 0.00 0.00 0.000 0.000
CPT® is a registered trademark of the American Medical Association
Reimbursement rule indicators and RBRVS RVUs subject to additions, deletions, and/or revisions on a quarterly basis
Print Date: 3/13/2013
481 of 481