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ANDHRA PRADESH - EHS PROCEDURES

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Code
Hospitals Hospitals Hospitals Hospitals
S1 GENERAL SUGERY
Routine Histopathological Examination, Clinical
1 04.06.1 S1 Excision of Ganglion - large Clinical Photograph, X-Ray 10280 10580 12850 13225
Photograph
Routine Histopathological Examination, Clinical
2 04.06.3 S1 Excision of Ganglion - Small Clinical Photograph, X-Ray 10600 11200 13250 14000
Photograph
3 04.92 S1 Ganglion Sclerotherapy Clinical Photograph Clinical Photograph 2000 2000 2500 2500
USG Abdomen,Chest X-Ray PA View(1 Routine Histopathological Examination, Doppler
4 05.23.2 S1 Laproscopic-Lumbar Sympathectomy Film),Doppler Scan Study Of Both Lower Limb Scan Study Of Both Lower Limb Arterial 26200 27400 32750 34250
Arterial System/Doppler, Clinical Photograph System/Doppler
T3, T4, TSH,USG Neck , Fine Needle
5 06.2.1 S1 Hemithyroidectomy Aspiration Cytology (FNAC),Clinical Routine Histopathological Examination 26200 27400 32750 34250
Photograph
T3, T4, TSH,USG Neck , Fine Needle
Routine Histopathological Examination,
6 06.2.2 S1 Laproscopic Hemi Thyroidectomy Aspiration Cytology (FNAC), Clinical 28930 29530 36163 36913
WEBEX
Photograph
T3, T4, TSH,USG Neck , Fine Needle
Routine Histopathological Examination, Scar
7 06.4.1 S1 Total Thyroidectomy Aspiration Cytology (FNAC), Clinical 31500 33000 39375 41250
Photo
Photograph
T3, T4, TSH,USG Neck , Fine Needle
Routine Histopathological Examination,
8 06.4.2 S1 Laproscopic Total Thyroidectomy Aspiration Cytology (FNAC), Clinical 29410 30010 36763 37513
WEBEX
Photograph
T3, T4, TSH,USG Neck / Thyroid Uptake
Measurements With 131-Iodine, Fine Needle
9 06.6 S1 Excision of Lingual Thyroid Routine Histopathological Examination 30900 31800 38625 39750
Aspiration Cytology (FNAC), Clinical
Photograph, Case sheet with clinical History
T3, T4, TSH,USG Neck , Fine Needle
Routine Histopathological Examination, Scar
10 06.7 S1 Excision of Thyroglossal Cyst Fistula Aspiration Cytology (FNAC), Clinical 30900 31800 38625 39750
Photo
Photograph, Fistulogram
USG Neck ,Serum Calcium Levels, P.T.H
Routine Histopathological Examination, Scar
11 06.8.1 S1 Parathyroidectomy -Non Malignant Assay (Parathyroid Assay), Fine Needle 31500 33000 39375 41250
Photo
Aspiration Cytology (FNAC)
T3, T4, TSH,USG Neck , Fine Needle Routine Histopathological Examination, Scar
12 06.31.1 S1 Resection Enucleation - Thyroid 26800 28600 33500 35750
Aspiration Cytology (FNAC) Photo
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T3, T4, TSH,USG Neck , Fine Needle
Routine Histopathological Examination, Scar
13 06.31.2 S1 Subtotal Thyroidectomy Aspiration Cytology (FNAC), Clinical 29200 30400 36500 38000
Photo
Photograph
Routine Histopathological Examination,
14 06.31.3 S1 Laproscopic Sub total Thyroidectomy T3, T4, TSH,USG Neck 28380 28980 35475 36225
WEBEX
Routine Histopathological Examination,
15 06.31.4 S1 Laproscopic Thyroid Nodule Excision T3, T4, TSH,USG Neck 28370 28970 35463 36213
WEBEX
T3, T4, TSH,USG Neck , Fine Needle
Routine Histopathological Examination, Intra OP
16 06.39.1 S1 Isthmectomy Aspiration Cytology (FNAC),Clinical 25500 26700 31875 33375
photo
Photograph
T3, T4, TSH,USG Neck , Fine Needle
Routine Histopathological Examination, Scar
17 06.39.2 S1 Partial Thyroidectomy Aspiration Cytology (FNAC), Clinical 25420 26620 31775 33275
Photo
Photograph
T3, T4, TSH,USG Neck , Fine Needle
18 06.39.3 S1 Laproscopic Isthmectomy Aspiration Cytology (FNAC), Clinical Routine Histopathological Examination 29270 29870 36588 37338
Photograph
Adrenal function test,Urinary VMA, Urinary
Metanephrine/Nor metanephrine,Urinary
Bilateral Adrenalectomy in nonmalignant Catecholamines,Aldosterone - Urine,24 hour USG Abdomen, Routine Histopathological
19 07.3.1 S1 43000 46000 53750 57500
conditions free cortisol,USG Abdomen / CT Scan Examination, Scar Photo
Abdomen With Contrast / MRI Abdomen With
Contrast
Adrenal function test,Urinary VMA, Urinary
Metanephrine/Nor metanephrine,Urinary
Unilateral Adrenelectopmy in Catecholamines,Aldosterone - Urine,24 hour USG Abdomen, Routine Histopathological
20 07.22.1 S1 37100 39200 46375 49000
nonmalignant conditions free cortisol,USG Abdomen / CT Scan Examination, Scar Photo
Abdomen With Contrast / MRI Abdomen With
Contrast
Laproscopic Right Hemi Colectomy in USG Abdomen/CT Scan Lower Abdomen With USG Abdomen, Routine Histopathological
21 17.33.1 S1 40300 40600 50375 50750
non malignant conditions Contrast,Colono Scopy, Biopsy report Examination , Scar Photo, WEBEX
USG Abdomen/CT Scan Lower Abdomen With USG Abdomen, Routine Histopathological
22 17.35.3 S1 Laproscopic Left Hemicolectomy 32960 34160 41200 42700
Contrast,Colono Scopy, Biopsy report Examination , WEBEX
Routine Histopathological Examination, Clinical
23 25.1.1 S1 Excision of large growth from Tongue Biopsy report, Clinical Photograph 20590 21490 25738 26863
Photograph
Routine Histopathological Examination, Clinical
24 25.1.2 S1 Excision of Small growth from Tongue Biopsy report, Clinical Photograph 17370 18270 21713 22838
Photograph
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Routine Histopathological Examination, Clinical
25 25.2.1 S1 Partial Glossectomy Biopsy report, Clinical Photograph 28450 30250 35563 37813
Photograph
26 26.4 S1 Parotid Duct Repair Silography Silography, Intra OP photo 28250 30350 35313 37938
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Intra OP
27 26.30.2 S1 Excision of Salivary Gland 23360 25460 29200 31825
Clinical Photograph, X-ray photo
Removal Of Submandibular Salivary Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Intra OP
28 26.30.3 S1 25680 26280 32100 32850
Gland Clinical Photograph photo
Superficial Parotoidectomy (Non- USG Neck, Fine Needle Aspiration Cytology Routine Histopathological Examination, Intra OP
29 26.31 S1 23360 25460 29200 31825
malignant) (FNAC), Clinical Photograph photo
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Intra OP
30 27.42.1 S1 Wedge Excision of Lip 15930 17130 19913 21413
Clinical Photograph photo
Wedge Excision of Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Intra OP
31 27.42.2 S1 19230 20730 24038 25913
Lip&Vermilionectomy(27.43) Clinical Photograph photo
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Intra OP
32 27.43.2 S1 Vermilionectomy 22370 23570 27963 29463
Clinical Photograph photo
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Clinical
33 27.54.2 S1 ABBE Operation 21800 23600 27250 29500
Clinical Photograph Photograph
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Scar
34 29.2 S1 Excision of Branchial Cyst 25500 27000 31875 33750
Clinical Photograph, X-ray Photo
X-ray, Clinical Photograph with IV canula in Routine Histopathological Examination, Clinical
35 29.52.1 S1 Excision of Branchial Sinus 24900 25800 31125 32250
situ Photograph
36 38.5 S1 Excision and Ligation of Varicose Veins Venous Doppler, Clinical Photograph Case Sheet with operation Notes 25620 27120 32025 33900
Upper GI endoscopy , USG Abdomen,
Color Doppler Sonography Single Study,USG
37 39.1.1 S1 Splenorenal Anastomosis Complete Haemogram, LFT(liver function 71500 73000 89375 91250
Abdomen
tests)
Upper GI endoscopy , USG Abdomen,
38 39.1.2 S1 Warren Shunt for Portal Hypertension Color Doppler Sonography Single Study 71200 72400 89000 90500
LFT(liver function tests)
Upper GI endoscopy , Procedure CD, USG USG Abdomen, Color Doppler Sonography
39 39.1.3 S1 Portocaval Anastomosis 81800 83600 102250 104500
Abdomen, LFT(liver function tests) Single Study
ACT Angiography Neck (Cartotid
Colour Doppler Study Of Neck Vessels, Routine
40 39.8.1 S1 Excision of Carotid Body Tumours Angiography)/ MRI Neck/Colour Doppler 36330 38730 45413 48413
Histopathological Examination
Study Of Neck Vessels
Routine Histopathological Examination, Clinical
41 39.92 S1 Hemangioma Scleotherapy USG local area, Clinical Photograph 9150 9150 11438 11438
Photograph
42 40.11 S1 Lymph Node Biopsy Fine Needle Aspiration Cytology (FNAC) Routine Histopathological Examination 8770 8770 10963 10963
Fine Needle Aspiration Cytology (FNAC),USG
43 40.23 S1 Axillary Lymph Node Dissection Routine Histopathological Examination 28420 29020 35525 36275
local area
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Fine Needle Aspiration Cytology (FNAC)//USG
44 40.29.1 S1 Excision of Cystic Hygroma -Extensive Routine Histopathological Examination 24740 26240 30925 32800
local area/ CT Local Area, Clinical Photograph

Fine Needle Aspiration Cytology (FNAC)/USG


45 40.29.2 S1 Excision of Cystic Hygroma -Major Routine Histopathological Examination 25500 27000 31875 33750
local area/ CT Local Area, Clinical Photograph

Fine Needle Aspiration Cytology (FNAC)/USG


46 40.29.3 S1 Cystic Hygroma Excision - Minor Routine Histopathological Examination 10900 11800 13625 14750
local area/ CT Local Area, Clinical Photograph
USG Abdomen,Complete Haemogram, Sickle USG Abdomen,Routine Histopathological
47 41.5.2 S1 Splenectomy For Hypersplenism 42100 44200 52625 55250
Cell Test Examination
Laproscopic Splenectomy - For other Chest X-Ray PA View(1 Film),USG Abdomen, USG Abdomen, Routine Histopathological
48 41.5.3 S1 55600 56200 69500 70250
Indications Complete Haemogram Examination , WEBEX
49 43.1.1 S1 Gastrostomy Lower GI Endoscopy / USG Abdomen Scar Photo 21200 22400 26500 28000
Routine Histopathological Examination, Intra OP
50 43.3.1 S1 Pyloromyotomy USG Abdomen 32100 34200 40125 42750
photo
Partial/Subtotal Gastrectomy with USG Abdomen/ CT Scan Abdomen With USG Abdomen, Routine Histopathological
51 43.5.1 S1 41200 42400 51500 53000
anastomosis to Esophagus for ulcer Contrast,Barium Studies,Upper GI endoscopy Examination, Scar Photo
USG Abdomen/ CT Scan Abdomen With USG Abdomen/ CT Scan Abdomen With
52 44.02 S1 Highly Selective Vagotomy 27100 29200 33875 36500
Contrast, Upper GI endoscopy Contrast
USG Abdomen/ CT Scan Abdomen With
53 44.2 S1 Pyloroplasty & Vagotomy USG Abdomen, HPE for Vagus 50100 52200 62625 65250
Contrast, Upper GI endoscopy
Upper GI endoscopy ,USG Abdomen, Upper GI endoscopy , USG Abdomen, WEBEX,
54 44.03 S1 Selective Vagotomy drainage 49200 50400 61500 63000
Endoscopic Dilatation-Video/Photo HPE for Vagus
USG Abdomen/ CT Scan Abdomen With
55 44.4 S1 Operation for bleeding peptic ulcer USG Abdomen, Intra OP photo 48900 49800 61125 62250
Contrast,Upper GI endoscopy
Surgical management For Haemorrhage USG Abdomen/ CT Scan Abdomen With Routine Histopathological Examination, Intra OP
56 44.4.1 S1 49800 51600 62250 64500
Of The Small Intestine Contrast /Triphasic, Upper GI endoscopy photo
USG Abdomen/ CT Scan Abdomen With USG Abdomen/ CT Scan Abdomen With
57 44.39.2 S1 Gastrojejunostomy & Vagotomy 40900 41800 51125 52250
Contrast, Upper GI endoscopy Contrast
USG Abdomen/Barium Studies/ CT Scan
Surgical management of Duodenal
58 44.42 S1 Abdomen With Contrast/Abdomen Radiograph Intra OP photo 50100 52200 62625 65250
perforation
Supine Or Erect(1 Film)
USG Abdomen/Barium Studies/ CT Scan
Laproscopic Surgical treatment for
59 44.42.1 S1 Abdomen With Contrast/Abdomen Radiograph WEBEX 48900 49800 61125 62250
Duodenal Perforation
Supine Or Erect(1 Film)
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USG Abdomen/ Barium Studies/ CT Scan
60 44.62 S1 Gastrostomy Closure Abdomen With Contrast/Abdomen Radiograph USG Abdomen, Scar Photo 23800 25600 29750 32000
Supine Or Erect(1 Film), Clinical Photograph

Resection & Anastomosis Of Small CT Scan Abdomen With Contrast, Abdomen USG Abdomen, CT Scan Abdomen With
61 45.3.2 S1 50100 52200 62625 65250
Intestine(45.9) Radiograph Supine Or Erect(1 Film) Contrast, Routine Histopathological Examination
Surgical treatment for Duodenal CT Scan Abdomen With Contrast,Upper GI Intra OP photo, Routine Histopathological
62 45.31 S1 32110 34210 40138 42763
Diverticulum endoscopy , Barium Meal Follow Through Examination, USG Abdomen
Abdomen Radiograph Supine Or Erect(1
63 45.33.1 S1 Excision of Meckel's Diverticulum Film),CT Scan Abdomen With Contrast/USG Routine Histopathological Examination 41500 43000 51875 53750
Abdomen
Abdomen Radiograph Supine Or Erect(1 USG Abdomen , Intra OP photo, Routine
Surgical treatment for Acute Intestinal
64 45.34.1 S1 Film),Barium Upper GI Study(Double Contrast) Histopathological Examination , Clinical 50100 52200 62625 65250
obstrucion
/ USG Abdomen, Clinical Photograph Photograph
Magnetic Resonance
Cholangiopancreatography (MRCP)/ERCP/ CT USG Abdomen, Intra OP photo, Routine
65 45.62 S1 Duodenectomy 40150 41650 50188 52063
Scan Abdomen With Contrast /USG Abdomen, Histopathological Examination
Biopsy
CT Scan Abdomen With Contrast/ USG
Surgical treatment for Duplication Of
66 45.63 S1 Abdomen, Abdomen Radiograph Supine Or Intra OP photo 50400 52800 63000 66000
Intestines
Erect(1 Film)
USG Abdomen, CT Scan Abdomen With
USG Abdomen , Routine Histopathological
67 45.73 S1,S6 Right Hemi Colectomy Contrast /Barium Studies/Lower GI Endoscopy, 40300 40600 50375 50750
Examination
Biopsy
USG Abdomen, CT Scan Abdomen With
USG Abdomen , Routine Histopathological
68 45.75 S1,S6 Left Hemi Colectomy Contrast /Barium Studies/Lower GI Endoscopy, 40900 41800 51125 52250
Examination
Biopsy
Barium Enema (Single Contrast\Double
Contrast), Colono Scopy, CT Scan Abdomen USG Abdomen , Routine Histopathological
69 45.81 S1 Laproscopic colectomy (Total Colectomy) 61200 62400 76500 78000
With Contrast, Chest X-Ray PA View(1 Film), Examination, WEBEX
Biopsy
USG Abdomen , CT Scan Abdomen With USG Abdomen , Routine Histopathological
70 45.82 S1 Total Colectomy 62100 64200 77625 80250
Contrast, Colonoscopy, Clinical Photograph Examination
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USG Abdomen, Barium Studies/CT Scan Clinical Photograph of Colostomy Along With
71 46.1.1 S1 Colostomy 20890 21790 26113 27238
Abdomen With Contrast /Lower GI Endoscopy Face
Lower GI Endoscopy/USG Abdomen,CT Scan Clinical Photograph of Ileostomy Along With
72 46.2.2 S1 Ileostomy 20900 21800 26125 27250
Abdomen With Contrast Face, Routine Histopathological Examination
CT Scan Abdomen With Contrast /Barium
Clinical Photograph, Routine Histopathological
73 46.03 S1 Loop Colostomy Sigmoid Studies,Colono Scopy, Abdomen Radiograph 22100 24200 27625 30250
Examination
Supine Or Erect(1 Film)
CT Scan Abdomen With Contrast,
CT Scan Abdomen With Contrast, Routine
74 46.23 S1 Illieo Sigmoidostomy Colonoscopy, Barium Enema (Single 50100 52200 62625 65250
Histopathological Examination
Contrast\Double Contrast)
USG Abdomen, Abdomen Radiograph Supine
75 46.51.2 S1 Ileostomy Closure Or Erect(1 Film), Clinical Photograph, Case Scar Photo 25890 26790 32363 33488
sheet with clinical History
USG Abdomen, Abdomen Radiograph Supine
76 46.52.2 S1 Colostomy Closure Scar Photo 25900 26800 32375 33500
Or Erect(1 Film), Clinical Photograph
Surgical treatment For Recurrent
CT Scan Abdomen With Contrast, Abdomen USG Abdomen, Intra OP photo, Routine
77 46.62 S1 Intestinal obstruction (Noble Plication 50100 52200 62625 65250
Radiograph Supine Or Erect(1 Film) Histopathological Examination
Other)
Barium Enema (Single Contrast\Double
78 46.64 S1 Cecopexy USG Abdomen, Intra OP photo 31800 33600 39750 42000
Contrast), Colonoscopy
Surgical treatment for Acute Intestinal Abdomen Radiograph Supine Or Erect(1
79 46.73 S1 Intra OP photo 50100 52200 62625 65250
perforation Film),USG Abdomen
Fistulogram, Barium Meal Follow Through,
80 46.74 S1 Excision Small Intestinal Fistula USG Abdomen 51500 53000 64375 66250
Clinical Photograph
USG Abdomen, Abdomen Radiograph Supine Scar Photo, Routine Histopathological
81 46.80.1 S1,S8 Surgical treatment for Intususception 50100 52200 62625 65250
Or Erect(1 Film) Examination
Surgical treatment for Mal-Rotation & CT Scan Abdomen With Contrast,Abdomen Abdomen Radiograph Supine Or Erect(1 Film),
82 46.81 S1 50100 52200 62625 65250
Volvulus Of The Midgut Radiograph Supine Or Erect(1 Film) USG Abdomen
CT Scan Abdomen With Contrast, Abdomen
Surgical treatment for Volvulus of Large CT Scan Abdomen With Contrast,Abdomen
83 46.82 S1 Radiograph Supine Or Erect(1 Film),USG 50100 52200 62625 65250
bowel Radiograph Supine Or Erect(1 Film)
Abdomen
USG Abdomen, WEBEX, Scar Photo,
USG Abdomen, Complete Blood Picture
84 47.01 S1,S8 Laproscopic Appendicectomy Specimen Photo, Routine Histopathological 22110 23310 27638 29138
[CBP], Case sheet with clinical History
Examination
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USG Abdomen, Abdomen Radiograph Supine
Clinical Photograph, Routine Histopathological
85 47.09.1 S1 Open Appendicectomy Or Erect(1 Film), Case sheet with clinical 18680 19880 23350 24850
Examination
History, Complete Blood Picture
Surgical treatment for Appendicular USG Abdomen, Scar Photo, Specimen Photo,
86 47.09.2 S1 USG Abdomen 27660 29460 34575 36825
Perforation Routine Histopathological Examination
Laproscopic Surgical treatment for USG Abdomen, Abdomen Radiograph Supine
87 47.19 S1 USG Abdomen, WEBEX 30900 31800 38625 39750
Appendicular Mass-Abscess Or Erect(1 Film)
Clinical Photograph, Routine Histopathological
88 48.3 S1 Excision of Prolapse of Rectal Mass Clinical Photograph 27170 28670 33963 35838
Examination
89 48.9 S1 Anorectoplasty USG Abdomen, Clinical Photograph Clinical Photograph 28150 30250 35188 37813
Clinical Photograph, Proctoscopy, USG Clinical Photograph, Routine Histopathological
90 48.35 S1 Excision of Papilloma Rectum 21160 22660 26450 28325
Abdomen, Colonoscopy Examination
Barium Enema (Single Contrast\Double
91 48.49 S1 Pull Through Abdominal Resection Contrast), Invertogram AP/ LAT, Clinical USG Abdomen, Clinical Photograph 52100 54200 65125 67750
Photograph
Colonoscopy/Barium Enema (Single
Routine Histopathological Examination, Intra OP
92 48.62.1 S1 Anterior Resection of Rectum Contrast\Double Contrast),Barium Studies, 52100 54200 65125 67750
photo
Clinical Photograph, Biopsy
Clinical Photograph, Routine Histopathological
93 48.73 S1 Fistulectomy Fistulogram, Clinical Photograph 15600 16200 19500 20250
Examination
Barium Enema (Single Contrast\Double
Rectopexy Open with Mesh for Rectal
94 48.75.1 S1,S6,S8 Contrast), Sigmoidoscopy (REGID), USG USG Abdomen 41800 43600 52250 54500
Prolapse
Abdomen, Clinical Photograph
Laproscopic Rectopexy With Mesh for Colonoscopy/Sigmoidoscopy (REGID), USG
95 48.75.2 S1,S6,S8 USG Abdomen, Clinical Photograph, WEBEX 51800 53600 64750 67000
Rectal Prolapse Abdomen, Clinical Photograph
Colonoscopy/Sigmoidoscopy (REGID) /
Rectopexy Open without Mesh for Rectal
96 48.75.3 S1,S6,S8 Defacogram, USG Abdomen, Clinical USG Abdomen, Clinical Photograph 31800 33600 39750 42000
Prolapse
Photograph
USG Abdomen, CT Pelvis ,Colonoscopy, Chest USG Abdomen, Clinical Photograph, WEBEX,
97 48.75.5 S1 Laproscopic Rectopexy With Repair 41200 42400 51500 53000
X-Ray PA View(1 Film) Routine Histopathological Examination
USG Abdomen, PUS Culture & Sensitivity,
98 49.01 S1 Drainage of Ischio Rectal Abscess Screening for Human Immunodeficiency Virus Intra OP photo 16500 18000 20625 22500
(HIV) 1 & 2, HBsAg
99 49.3 S1 Fissurectomy Proctosopy Routine Histopathological Examination 15600 16200 19500 20250
100 49.45 S1 Lord's Procedure for Haemorrhoids USG Abdomen, Proctoscopy,Colonoscopy Intra OP photo 10290 10590 12863 13238
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USG Abdomen, Routine Histopathological
101 49.46.1 S1 Haemorroidectomy Proctosopy, Clinical Photograph 22670 24170 28338 30213
Examination
Lower GI Endoscopy, Abdomen Radiograph
102 49.46.2 S1 Haemorroidectomy+ Fistulectomy(49.12) Routine Histopathological Examination 27640 30040 34550 37550
Supine Or Erect(1 Film),USG Abdomen
103 50.29.1 S1 Excision of liver Abscess USG Abdomen USG Abdomen 32100 34200 40125 42750
Surgical treatment For Hydatid cyst of Routine Histopathological Examination, USG
104 50.29.2 S1,S8 USG Abdomen, LFT(liver function tests) 40300 40600 50375 50750
Liver Abdomen
CT Scan Abdomen Without Contrast, USG Routine Histopathological Examination, CT
105 51.02 S1 Cholecystostomy 31760 33860 39700 42325
Abdomen, Chest X-Ray PA View(1 Film) Scan Abdomen Without Contrast
Magnetic Resonance
Cholangiopancreatography (MRCP) /USG
106 51.7 S1 Repair Of CBD USG Abdomen 49500 51000 61875 63750
Abdomen/CT scan Lower Abdomen Without
Contrast
USG Abdomen, MR Cholangiography, CT scan
USG Abdomen, CT scan Lower Abdomen
Cholecystectomy With CBD Exploration Lower Abdomen Without Contrast/CT Scan
107 51.22.1 S1 Without Contrast/CT Scan Abdomen Without 41800 43600 52250 54500
(51.41) Abdomen Without Contrast, Routine
Contrast, LFT(liver function tests)
Histopathological Examination
Routine Histopathological Examination, USG
USG Abdomen, CT scan Lower Abdomen
Laproscopic Cholecystectomy With CBD Abdomen/CT scan Lower Abdomen Without
108 51.22.2 S1 Without Contrast/CT Scan Abdomen Without 30600 31200 38250 39000
Exploration (51.41) Contrast/CT Scan Abdomen Without Contrast,
Contrast, LFT(liver function tests)
CT Scan Abdomen With Contrast , WEBEX
Routine Histopathological Examination, CT scan
USG Abdomen, CT scan Lower Abdomen
Lower Abdomen Without Contrast/CT Scan
109 51.22.3 S1,S6 Cholecystectomy Without Contrast/CT Scan Abdomen Without 25300 25600 31625 32000
Abdomen Without Contrast, CT Scan Abdomen
Contrast, LFT(liver function tests)
With Contrast ,
USG Abdomen, Showing Calculus, LFT(liver Routine Histopathological Examination, USG
110 51.22.4 S1,S6,S8 Laproscopic Cholecystectomy 30300 30600 37875 38250
function tests) Abdomen, WEBEX
Laproscopic Cholecystectomy With Routine Histopathological Examination, USG
111 51.22.5 S1 USG Abdomen, LFT(liver function tests) 30600 31200 38250 39000
Gargrene Abdomen, WEBEX
USG Abdomen/CT scan Lower Abdomen
Laproscopic Cholecystectomy For Without Contrast/CT Scan Abdomen Without Routine Histopathological Examination, USG
112 51.22.6 S1 30600 31200 38250 39000
Calculus Contrast, CT Scan Abdomen With Contrast , Abdomen
LFT(liver function tests)
USG Abdomen/CT scan Lower Abdomen
Laproscopic Cholecystectomy With CBD Without Contrast/CT Scan Abdomen Without Routine Histopathological Examination, USG
113 51.22.7 S1 40600 41200 50750 51500
Repair Contrast, CT Scan Abdomen With Contrast , Abdomen
LFT(liver function tests)
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CT scan Lower Abdomen Without Contrast/CT
Routine Histopathological Examination, CT scan
Scan Abdomen Without Contrast, ERCP, Upper
114 52.4.2 S1,S6 Pancreaticocystojejunostomy Lower Abdomen Without Contrast/CT Scan 51800 53600 64750 67000
GI endoscopy, USG Abdomen , LFT(liver
Abdomen With Contrast ,USG Abdomen,
function tests)
CT scan Lower Abdomen Without Contrast/CT
CT scan Lower Abdomen Without Contrast/CT
Scan Abdomen Without Contrast, USG
Scan Abdomen Without Contrast, CT Scan
115 52.4.4 S1,S6 Pancreaticocystogastrostomy Abdomen, Magnetic Resonance 43430 44930 54288 56163
Abdomen With Contrast, USG Abdomen ,
Cholangiopancreatography (MRCP), USG
Routine Histopathological Examination
Abdomen, LFT(liver function tests)
Herinoplasty without Mesh for Direct USG Abdomen,Chest X-Ray PA View(1 Film),
116 53.01 S1 Scar Photo 20900 21800 26125 27250
Inguinal Hernia Clinical Photograph
USG Abdomen/CT scan Lower Abdomen
Herinoplasty with Mesh Direct Inguinal USG Abdomen,Chest X-Ray PA View(1 Film), Without Contrast/CT Scan Abdomen Without
117 53.03 S1 25900 26800 32375 33500
Hernia Clinical Photograph Contrast/CT Scan Abdomen With Contrast,
Mesh Fixation Photo With Face
Routine Histopathological Examination, USG
Abdomen Radiograph Supine Or Erect(1 Film),
Abdomen/CT scan Lower Abdomen Without
Laproscopic Surgical treatment for USG Abdomen, CT scan Lower Abdomen
118 53.04 S1 Contrast/CT Scan Abdomen Without 30600 31200 38250 39000
Unilateral Femoral Hernia With Mesh Without Contrast, CT Scan Of Lower Abdomen
Contrast/CT Scan Abdomen With Contrast,
& Scrotum, USG Scrotum, Clinical Photograph
WEBEX
USG Abdomen, CT scan Lower Abdomen
Rare Hernias repair Without Contrast/CT Scan Abdomen Without
119 53.9.1 S1 USG Abdomen 21500 23000 26875 28750
(Spigalion,Obuturator,Sciatic) Contrast/CT Scan Abdomen With Contrast,
ECHO Cardiogram, Clinical Photograph
USG Abdomen/CT scan Lower Abdomen
USG Abdomen/CT scan Lower Abdomen
Laproscopic Surgical treatment for Without Contrast/CT Scan Abdomen Without
120 53.29.1 S1 Without Contrast, MRI Abdomen Without 40600 41200 50750 51500
Unilateral Femoral Hernia Without Mesh Contrast/CT Scan Abdomen With Contrast,
Contrast
WEBEX
USG Abdomen/CT Scan Abdomen With
121 53.29.2 S1 Unilateral Femoral Hernia repair USG Abdomen, Clinical Photograph 26500 28000 33125 35000
Contrast, Routine Histopathological Examination
USG Abdomen/CT scan Lower Abdomen USG Abdomen/CT scan Lower Abdomen
Without Contrast/CT Scan Abdomen Without Without Contrast/CT Scan Abdomen Without
122 53.41 S1 Umbilical Hernia repair with Mesh 31490 32990 39363 41238
Contrast/CT Scan Abdomen With Contrast, Contrast/CT Scan Abdomen With Contrast,
Clinical Photograph WEBEX
Price for Semi Price for Price for Semi Price for
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, CT scan Lower Abdomen Routine Histopathological Examination, USG
Laproscopic Surgical treatment for - Without Contrast/CT Scan Abdomen Without Abdomen/CT scan Lower Abdomen Without
123 53.42.1 S1 50600 51200 63250 64000
Umbilical Hernia With Mesh Contrast, ECHO Cardiogram, Clinical Contrast/CT Scan Abdomen With Contrast/CT
Photograph Scan Abdomen Without Contrast
USG Abdomen/CT scan Lower Abdomen
124 53.49.1 S1 Umbilical Hernia repair without Mesh USG Abdomen, Clinical Photograph Without Contrast/CT Scan Abdomen With 26490 27990 33113 34988
Contrast/CT Scan Abdomen Without Contrast
Routine Histopathological Examination, USG
Laproscopic Surgical treatment for USG Abdomen, ECHO Cardiogram, Clinical Abdomen/CT scan Lower Abdomen Without
125 53.51.1 S1 30600 31200 38250 39000
Incisional Hernia without Mesh Photograph Contrast/CT Scan Abdomen With Contrast/CT
Scan Abdomen Without Contrast, WEBEX
USG Abdomen/CT scan Lower Abdomen
126 53.59.1 S1 Epigastric Hernia repair without Mesh USG Abdomen, Clinical Photograph Without Contrast/CT Scan Abdomen With 26500 28000 33125 35000
Contrast/CT Scan Abdomen Without Contrast
USG Abdomen/CT scan Lower Abdomen
USG Abdomen/CT scan Lower Abdomen
Ventral And Scar Hernia repair without Without Contrast/CT Scan Abdomen With
127 53.59.2 S1 Without Contrast/CT Scan Abdomen With 31500 33000 39375 41250
Mesh Contrast/CT Scan Abdomen Without Contrast,
Contrast/CT Scan Abdomen Without Contrast
Clinical Photograph
USG Abdomen/CT scan Lower Abdomen USG Abdomen/CT scan Lower Abdomen
Laproscopic Surgical treatment for Without Contrast/CT Scan Abdomen Without Without Contrast/CT Scan Abdomen Without
128 53.62 S1 40600 41200 50750 51500
Incisional Hernia with Mesh Contrast, ECHO Cardiogram, Clinical Contrast/CT Scan Abdomen With Contrast,
Photograph WEBEX
Routine Histopathological Examination, USG
USG Abdomen/CT scan Lower Abdomen
Abdomen/CT scan Lower Abdomen Without
Laproscopic Surgical treatment for Without Contrast/CT Scan Abdomen Without
129 53.63 S1 Contrast/CT Scan Abdomen Without 50600 51200 63250 64000
Epigastric Hernia repair with Mesh Contrast, ECHO Cardiogram, Clinical
Contrast/CT Scan Abdomen With Contrast,
Photograph
WEBEX
USG Abdomen/CT scan Lower Abdomen
USG Abdomen/CT scan Lower Abdomen
Without Contrast/CT Scan Abdomen With
130 53.69.1 S1 Epigastric Hernia repair with Mesh Without Contrast/CT Scan Abdomen With 41490 42990 51863 53738
Contrast/CT Scan Abdomen Without Contrast,
Contrast/CT Scan Abdomen Without Contrast
Clinical Photograph
USG Abdomen/CT scan Lower Abdomen
USG Abdomen/CT scan Lower Abdomen
Ventral And Scar Hernia repair with Without Contrast/CT Scan Abdomen With
131 53.69.2 S1 Without Contrast/CT Scan Abdomen With 41500 43000 51875 53750
Mesh Contrast/CT Scan Abdomen Without Contrast,
Contrast/CT Scan Abdomen Without Contrast
Clinical Photograph
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, CT scan Lower Abdomen USG Abdomen/CT scan Lower Abdomen
Laproscopic Surgical treatment for Hiatus Without Contrast/CT Scan Abdomen Without Without Contrast/CT Scan Abdomen With
132 53.71.1 S1 50600 51200 63250 64000
Hernia With Mesh Contrast, ECHO Cardiogram, Clinical Contrast/CT Scan Abdomen Without Contrast,
Photograph WEBEX
USG Abdomen, CT scan Lower Abdomen USG Abdomen/CT scan Lower Abdomen
133 53.72 S1 Hiatus Hernia Repair - Abdominal Without Contrast/CT Scan Abdomen Without Without Contrast/CT Scan Abdomen Without 49800 51600 62250 64500
Contrast Contrast/CT Scan Abdomen With Contrast
Chest X-Ray PA View(1 Film), Abdomen
USG Abdomen/CT scan Lower Abdomen
Radiograph Supine Or Erect(1 Film)/USG
134 54.0.1 S1 Drainage of Perigastric Abscess Without Contrast/CT Scan Abdomen With 37230 39330 46538 49163
Abdomen/CT scan Lower Abdomen Without
Contrast, Routine Histopathological Examination
Contrast
Abdomen Radiograph Supine Or Erect(1 Film),
USG Abdomen, CT scan Lower Abdomen
135 54.0.2 S1 Drainage of Subdiaphragmatic Abscess USG Abdomen 31660 34060 39575 42575
Without Contrast/CT Scan Abdomen Without
Contrast , Chest X-Ray PA View(1 Film)
USG Abdomen, CT Pelvis, Abdomen
136 54.0.3 S1 Open Drainage of Pelvic Abscess Radiograph Supine Or Erect(1 Film), CT Scan USG Abdomen 30060 32760 37575 40950
Abdomen Without Contrast
USG Abdomen/CT scan Lower Abdomen
Laproscopic Surgical treatment for Intra USG Abdomen, Routine Histopathological
137 54.0.4 S1 Without Contrast/CT Scan Abdomen Without 35600 36200 44500 45250
Abdominal Abscess Examination, WEBEX
Contrast/CT Scan Abdomen With Contrast
USG Abdomen/CT scan Lower Abdomen
USG Abdomen, Fine Needle Aspiration
138 54.3.4 S1 Excision of Umbillical Sinus Without Contrast/CT Scan Abdomen Without 18200 19700 22750 24625
Cytology (FNAC)
Contrast, Routine Histopathological Examination
Routine Histopathological Examination, USG
USG Abdomen, CT scan Lower Abdomen
139 54.4.1 S1 Excision of Mesenteric Cyst Abdomen/CT scan Lower Abdomen Without 33660 36060 42075 45075
Without Contrast, Plain Abdomen X-Ray
Contrast/CT Scan Abdomen With Contrast
USG Abdomen/CT scan Lower Abdomen
Surgical treatment for Minor Abdominal Without Contrast/CT Scan Abdomen With
140 54.7.2 S1 USG Abdomen 21490 22690 26863 28363
Injuries Contrast/CT Scan Abdomen Without Contrast/
ECHO Cardiogram, Plain Abdomen X-Ray
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen/CT scan Lower Abdomen
Without Contrast/CT Scan Abdomen With
Surgical treatment for Major Abdominal
141 54.7.3 S1 Contrast/CT Scan Abdomen Without Contrast, USG Abdomen 52100 54200 65125 67750
Injuries
Abdomen Radiograph Supine Or Erect(1 Film),
Plain Abdomen X-Ray
USG Abdomen/CT scan Lower Abdomen Routine Histopathological Examination, USG
Without Contrast/CT Scan Abdomen With Abdomen/CT scan Lower Abdomen Without
142 54.7.4 S1 Surgical treatment for Burst Abdomen 51500 53000 64375 66250
Contrast/CT Scan Abdomen Without Contrast, Contrast/CT Scan Abdomen With Contrast/CT
Plain Abdomen X-Ray Scan Abdomen Without Contrast
Treatment with Self Expanding Metalic Venous Doppler, ECHO Cardiogram, High
143 54.99.1 S1 CT Scan Scan,USG, Biopsy report 21020 21620 26275 27025
Stent (SEMS) Resolution CT Chest
Surgical treatment for Unilateral USG Abdomen, CT Scan Of Lower Abdomen USG Abdomen, Routine Histopathological
144 61.2.1 S1 18410 19910 23013 24888
Hydrocoele & Scrotum, Clinical Photograph Examination
Surgical treatment for Bilateral USG Abdomen, CT Scan Of Lower Abdomen
145 61.2.2 S1 Routine Histopathological Examination 20140 21640 25175 27050
Hydrocoele & Scrotum, Clinical Photograph
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, Routine Histopathological
146 61.3.2 S1 Surgical treatment for Fourniers Gangrene 34190 38390 42738 47988
With Contrast, Clinical Photograph Examination
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, Routine Histopathological
147 61.3.3 S1 Surgical treatment for Filarial Scrotum 27100 29200 33875 36500
With Contrast, Clinical Photograph Examination
USG Abdomen, Routine Histopathological
148 61.3.4 S1 Excision of multiple Scrotal swellings USG Abdomen, Clinical Photograph 9130 9430 11413 11788
Examination
USG Abdomen, CT Scan Of Lower Abdomen USG Abdomen, CT Scan Of Lower Abdomen &
149 61.92 S1 Evacuation of Scrotal Hematoma 20660 22760 25825 28450
& Scrotum Scrotum
USG Abdomen, CT Scan Of Lower Abdomen
150 61.99 S1 Excision of multiple Scrotal Cysts Routine Histopathological Examination 8550 8850 10688 11063
& Scrotum, Clinical Photograph
USG-Doppler Abdomen, CT Scan Of Lower
Abdomen & Scrotum, Abdomen And Pelvis For USG Abdomen, Routine Histopathological
151 62.3.1 S1,S9 Orchidectomy -Unilateral 23500 25000 29375 31250
Kidneys, Ureters, And Bladder (KUB), Clinical Examination
Photograph
USG Abdomen, CT Scan Of Lower Abdomen USG Abdomen, Routine Histopathological
152 62.3.4 S1 Orchidectomy + Herniorraphy(53.00) 31500 33000 39375 41250
& Scrotum, Clinical Photograph Examination
USG-Doppler Abdomen, CT Scan Of Lower USG Abdomen, Routine Histopathological
153 62.5.1 S1 Orchidopexy with Eversion of Sac 27100 29200 33875 36500
Abdomen & Scrotum, Clinical Photograph Examination
USG Abdomen/ CT Scan Lower Abdomen USG Abdomen, Routine Histopathological
154 63.1.4 S1 Laproscopic Excision of Varicocele Cyst 41200 42400 51500 53000
With Contrast/ CT Pelvis, Clinical Photograph Examination, WEBEX
CT Scan Of Lower Abdomen & Scrotum, USG
155 63.2 S1 Excision of Epididymal Cyst Routine Histopathological Examination 16200 17400 20250 21750
Abdomen
Price for Semi Price for Price for Semi Price for
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Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Of Lower Abdomen & Scrotum, USG
CT Scan Of Lower Abdomen & Scrotum, USG
156 63.4 S1 Epididectomy Abdomen, Routine Histopathological 15900 16800 19875 21000
Abdomen
Examination
157 64.0 S1 Circumcision USG Abdomen, Clinical Photograph Routine Histopathological Examination 8500 8800 10625 11000
Dorsal Slit and Reduction of
158 64.91 S1 USG Penis, Clinical Photograph Routine Histopathological Examination 9440 10040 11800 12550
Paraphimosis
Rectovaginal fistula Management without CT scan Lower Abdomen Without Contrast/
159 70.73.2 S1,S4,S6 USG Abdomen 40900 43000 51125 53750
Colostomy USG Abdomen, Colonoscopy
X-Ray Facial Bones/ Routine Histopathological
160 76.31.1 S1 Hemimandibulectomy X-Ray Facial Bones 45780 48780 57225 60975
Examination
X-Ray Facial Bones, Orthopantomography X-Ray Facial Bones/ Routine Histopathological
161 76.31.4 S1,S11 Segmental Mandible Excision 37140 39540 46425 49425
(OPG) Examination
Surgical treatment for Infected Bunion
162 77.5 S1 X- Ray Foot, Clinical Photograph X- Ray Foot, Clinical Photograph 4800 5100 6000 6375
Foot
Color Doppler Sonography Single Study / X- Color Doppler Sonography Single Study / X-Ray
163 77.91 S1 Excision of Cervical Rib 28380 29880 35475 37350
Ray Thoracic inlet- AP view Dorso Lumbar Spine
X-Ray, X-Ray Dorso Lumbar Spine, USG Routine Histopathological Examination, Contrast
164 83.95.1 S1 Drainage of Psoas Abscess 19470 21570 24338 26963
Abdomen Enhanced USG
Routine Histopathological Examination, Clinical
165 85.21.1 S1 Excision of Mammary Fistula Fistulogram, Clinical Photograph 16140 18240 20175 22800
Photograph
Chest X-Ray PA View(1 Film), USG Breast,
166 85.21.2 S1 Wide Excision of Mammary Fistula Clinical Photograph 14020 15220 17525 19025
CT Local Area, Clinical Photograph
Fine Needle Aspiration Cytology (FNAC) ,
167 85.21.3 S1 Excision of Bilateral Fibroadenoma Chest X-Ray PA View(1 Film), USG Breast, Routine Histopathological Examination 15600 16200 19500 20250
Clinical Photograph
Fine Needle Aspiration Cytology (FNAC) ,
168 85.21.4 S1 Excision of Unilateral Fibroadenoma Routine Histopathological Examination 10300 10600 12875 13250
Clinical Photograph
Chest X-Ray PA View(1 Film)/ X- Ray
169 85.21.5 S1 Unilateral Lumpectomy Routine Histopathological Examination 10600 11200 13250 14000
Mammogram, Clinical Photograph
Chest X-Ray PA View(1 Film)/ X- Ray
170 85.21.6 S1 Bilateral Lumpectomy Routine Histopathological Examination 15900 16800 19875 21000
Mammogram, Clinical Photograph
Chest X-Ray PA View(1 Film), USG Breast,
171 85.21.7 S1 Breast Conservation Surgery Clinical Photograph 16200 17400 20250 21750
Clinical Photograph
Fine Needle Aspiration Cytology (FNAC), X-
172 85.22.2 S1 Segmental Resection of Breast Routine Histopathological Examination 15760 16660 19700 20825
Ray Mammogram, Clinical Photograph
X- Ray Mammogram / USG Breast, Fine
173 85.41.1 S1 Simple Mastectomy (Non Malignant) Routine Histopathological Examination 32100 34200 40125 42750
Needle Aspiration Cytology (FNAC)
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Fine Needle Aspiration Cytology (FNAC) ,
174 85.44 S1 Surgical repair of bilateral Gynaecomastia Clinical Photograph 12700 13600 15875 17000
USG Breast, Clinical Photograph
Fine Needle Aspiration Cytology (FNAC) ,
175 85.91 S1 I & D of Breast Abscess Clinical Photograph 9240 9540 11550 11925
USG Breast, Clinical Photograph
176 86.01.1 S1 Drainage of large Abscess Contrast Enhanced USG, Clinical Photograph Clinical Photograph 20120 21920 25150 27400
177 86.01.2 S1 Paronychia Drainage Clinical Photograph Clinical Photograph 6820 6820 8525 8525
Fine Needle Aspiration Cytology (FNAC), USG
178 86.3.3 S1 Excision of swelling Neck Routine Histopathological Examination 11430 11730 14288 14663
Neck, Clinical Photograph
179 86.3.5 S1 Excision of Granuloma Contrast Enhanced USG, Clinical Photograph Routine Histopathological Examination 10510 11110 13138 13888
Fine Needle Aspiration Cytology (FNAC),
180 86.3.6 S1 Surgical treatment for Carbuncle back Clinical Photograph 30490 34690 38113 43363
Clinical Photograph, RBS
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Clinical
181 86.3.7 S1 Excision of Sebaceous Cyst 9270 9570 11588 11963
Clinical Photograph, RBS Photograph
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Clinical
182 86.3.8 S1 Excision of Keloid 28000 30700 35000 38375
Clinical Photograph,RBS Photograph
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Clinical
183 86.3.9 S1 Excision of Pyogenic Granuloma 8310 8910 10388 11138
Clinical Photograph,RBS Photograph
Routine Histopathological Examination, Clinical
184 86.3.12 S1 Excision of Large Corn Clinical Photograph 5720 6020 7150 7525
Photograph
185 86.3.16 S1 Excision of Large Swelling in Hand X-Ray, Clinical Photograph Routine Histopathological Examination, X-Ray 15720 16020 19650 20025
186 86.3.17 S1 Excision of Small Swelling in Hand X-Ray, Clinical Photograph Routine Histopathological Examination, X-Ray 11070 11370 13838 14213
Contrast Enhanced USG, X-Ray, Clinical
187 86.3.18 S1 Excision of Fibro Lipoma Routine Histopathological Examination 9250 9550 11563 11938
Photograph
188 86.3.19 S1 Excision of Fibroma Contrast Enhanced USG, Clinical Photograph Routine Histopathological Examination 9180 9180 11475 11475
189 86.3.20 S1 Excision of Sinus Sinography, Clinical Photograph Routine Histopathological Examination 18050 19250 22563 24063
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Clinical
190 86.3.21 S1 Excision of Large Dermoid Cyst 11280 12180 14100 15225
Clinical Photograph Photograph
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Clinical
191 86.3.22 S1 Excision of Small Dermoid Cyst 7230 7530 9038 9413
Clinical Photograph Photograph
Fine Needle Aspiration Cytology (FNAC),
192 86.4.4 S1 Wide Local Excision (Non - malignant) Routine Histopathological Examination 36550 38650 45688 48313
Clinical Photograph, RBS
Contrast Enhanced USG, CT local Area,
193 86.05 S1 Foreign Body Removal in Deep Region Contrast Enhanced USG, CT local Area 30720 32820 38400 41025
Clinical Photograph
194 86.6 S1 Skin Grafting Clinical Photograph Clinical Photograph 18420 20520 23025 25650
Routine Histopathological Examination, Clinical
195 86.21.1 S1 Excision of Pilonidal Sinus Clinical Photograph 19250 21350 24063 26688
Photograph, Scar Photo
196 86.23 S1 Surgical treatment for Ingrowing Nail X-Ray, Clinical Photograph Clinical Photograph 6950 7250 8688 9063
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S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Contrast Enhanced USG, X-Ray, Clinical
197 86.89.1 S1 Surgical treatment for Cut Throat Injury Clinical Photograph 35380 37480 44225 46850
Photograph
S2 ENT SURGERY
198 04.42.2 S2 Facial Nerve Decompression 3D CT Facial Bones,Nerve conduction study Case Sheet with operation Notes 20590 21190 25738 26488
NLD probing(single eye), Endoscopic
199 09.53 S2 Endoscopic Surgery for Dacrocystitis NLD probing(single eye),Dacryocystography 10500 11100 13125 13875
Photograph, DNE Photo
200 18.21.1 S2 Surgical treatment for Preauricular sinus Clinical Photograph Scar Photo 18550 18550 23188 23188
201 18.29 S2 Cryosurgery Case sheet with clinical History Intra OP photo 11260 11560 14075 14450
Partial amputation of Pinna (malignancy
202 18.39 S2 CT Scan Ear Routine Histopathological Examination 19520 21620 24400 27025
perichondritis)
203 19.4.1 S2 Myringoplasty Pure Tone Audiometry Pure Tone Audiometry 16580 18080 20725 22600
Pure Tone Audiometry, Impedances
Audiometry(With Stepedeal Reflex) , X-Ray Of
204 19.4.2 S2 Myringoplasty with ossiculoplasty (19.3) X-Ray Of Both Mastoids 17300 17600 21625 22000
Both Mastoids, OTO endoscopy/ OTO
Endoscopy Photos
Pure Tone Audiometry, Impedances
Audiometry(With Stepedeal Reflex) , X-Ray Of
205 19.5 S2 Tympanoplasty Pure Tone Audiometry, Scar and Graft Photos 17400 18300 21750 22875
Both Mastoids, OTO endoscopy/ OTO
Endoscopy Photos
Impedances Audiometry(With Stepedeal
Pure Tone Audiometry After 3 Weeks, Clinical
206 19.11 S2 Stapedectomy - Veingraft Reflex), Pure Tone Audiometry, OTO 18890 19790 23613 24738
Photo With Piston + Vein Graft
endoscopy/ OTO Endoscopy Photos
Pure Tone Audiometry, Impedances Pure Tone Audiometry, Impedances
207 20.01.1 S2 Myringotomy with grommet for one ear Audiometry(With Stepedeal Reflex) ,OTO Audiometry(With Stepedeal Reflex) , Grommet 10300 10600 12875 13250
endoscopy/ OTO Endoscopy Photos in Positoin Photo.
Pure Tone Audiometry, Impedances Pure Tone Audiometry, Impedances
Myrinogotomy with-grommet for both
208 20.01.2 S2 Audiometry(With Stepedeal Reflex) ,OTO Audiometry(With Stepedeal Reflex) , Grommet 15600 16200 19500 20250
ears
endoscopy/ OTO Endoscopy Photos in Positoin Photo.
Pure Tone Audiometry, Impedances
Pure Tone Audiometry, Impedances
Audiometry(With Stepedeal Reflex) , X-Ray Of
209 20.4 S2 Mastoidectomy Audiometry(With Stepedeal Reflex) , X-Ray Of 18600 20700 23250 25875
Both Mastoids, OTO endoscopy/ OTO
Both Mastoids After 6 Weeks, Scar Photo.
Endoscopy Photos
Pure Tone Audiometry, OTO endoscopy/ OTO Routine Histopathological Examination, OTO
210 20.51 S2 Aural polypectomy 17400 18300 21750 22875
Endoscopy Photos endoscopy/ OTO Endoscopy Photos
Pure Tone Audiometry, MRI Scan Head &
211 20.79.1 S2 Labyrinthectomy Case Sheet with operation Notes 19990 19990 24988 24988
Neck Without Contrast
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Scar Photo, Routine Histopathological
212 21.1 S2 lateral Rhinotomy CT of Nose \ Nasopharynx 15600 16200 19500 20250
Examination
CT of Nose \ Nasopharynx, CT PNS With
Contrast9,DNL(Direct Nasal Laryngoscopy) \ Routine Histopathological Examination, DNE
213 21.3 S2 Excision of Benign tumours of Nose 17390 19790 21738 24738
DNE -Including Biopsy Under GI , Nasal Photo , WEBEX
Endoscopy
CT of Nose \ Nasopharynx, CT PNS With CT of Nose \ Nasopharynx, CT PNS With
214 21.32 S2 Surgery for Angiofibroma Contrast9,DNL(Direct Nasal Laryngoscopy) \ Contrast9,Routine Histopathological 42100 44200 52625 55250
DNE -Including Biopsy Under GI Examination , WEBEX
X-Ray Nasopharynx, DNE PHOTO 3 WEEKS
215 21.84 S2 Septo rhinoplasty X-Ray Nasopharynx, PRE DNE PHOTO 19090 19690 23863 24613
AFTER SURGERY , WEBEX Video.
216 21.88 S2 Youngs operation PRE DNE PHOTO Clinical Photograph 14600 15200 18250 19000
217 21.99 S2 Surgical treatment for Choanal atresia Nasal endoscopy Nasal endoscopy,WEBEX 15000 15000 18750 18750
CT Scan Of Nasal Sinus,CT PNS Without
218 22.5 S2 Endoscopic Sinus Surgery X-Ray PNS, WEBEX, Nasal endoscopy 18290 20090 22863 25113
Contrast, Nasal endoscopy
CT Scan Of Nasal Sinus,CT PNS Without Routine Histopathological Examination,
219 22.39 S2,S18 Caldwell-luc(unilateral) Contrast,DNL(Direct Nasal Laryngoscopy) DNL(Direct Nasal Laryngoscopy) \DNE - 18190 19390 22738 24238
\DNE -Including Biopsy Under GI Including Biopsy Under GI , WEBEX
220 22.71 S2 Surgical treatment for Oro antral fistula X-Ray Nasopharynx, PRE DNE PHOTO X-Ray Nasopharynx 15000 15000 18750 18750
Surgical treatment for release of tongue
221 25.93 S2,S8,S14 Clinical Photograph Clinical Photograph 9990 9990 12488 12488
tie
Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, Scar
222 26.2 S2 Excision of Benign Parotid gland tumor 20590 21190 25738 26488
Clinical Photograph Photo
X-Ray Nasopharynx, Clinical Photograph, PUS
223 27.0 S2 Drainage Parapharyngeal abscess X-Ray Nasopharynx 10300 10600 12875 13250
Culture & Sensitivity
Poly Somnograph, DNL(Direct Nasal
DNL(Direct Nasal Laryngoscopy) \ DNE -
224 27.7 S2 Uvulo ¿ Palato - Pharyngoplasty Laryngoscopy) \ DNE -Including Biopsy Under 26190 27390 32738 34238
Including Biopsy Under GI
GI
Surgical treatment for Pararetro X-Ray Nasopharynx, Clinical Photograph, PUS
225 27.49.1 S2 X-Ray Nasopharynx 9990 9990 12488 12488
pharyngeal abscess Culture & Sensitivity
226 28.3 S2 Adeno tonsillectomy Surgical profile report Clinical Photograph 12000 12000 15000 15000
Pure tone audiometry, Impedances audiometry, Pure tone audio metry, impedances audiometry,
227 28.6.1 S2 Adenoidectomy Gromet insertion 12100 14200 15125 17750
OTO endoscopy/ OTO Endoscopy Photos Post OP Grommet in Positoin Photo
Laryngoscopy, CT of Nose \ Nasopharynx, Routine Histopathological Examination, Scar
228 29.39.1 S2 Exision of Tumors In Pharynx 20890 21790 26113 27238
WEBEX Photo
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
DNL(Direct Nasal Laryngoscopy) \ DNE -
Laryngoscopy, CT of Nose \ Nasopharynx,
229 29.39.2 S2 Exision of Parapharyngeal Tumour Including Biopsy Under GI,Routine 21500 23000 26875 28750
WEBEX
Histopathological Examination
CT Scan Neck Includes Chest And Larynx
,DNL(Direct Nasal Laryngoscopy) / DNE -
230 30.3 S2 Laryngectomy in nonmalignant conditions Including Biopsy Under GI,DNL(Direct Nasal Routine Histopathological Examination 42990 45990 53738 57488
Laryngoscopy) / DNE -Including Biopsy Under
GI
CT Scan Neck Includes Chest And Larynx/
Dynamic MRI/Functional MRI, DNL(Direct
Nasal Laryngoscopy)/ DNE -Including Biopsy DNL(Direct Nasal Laryngoscopy) \ DNE -
231 30.22 S2 Phono Surgery For Vocal Cord Paralysis 27400 29800 34250 37250
Under GI, DNL(Direct Nasal Laryngoscopy)/ Including Biopsy Under GI, WEBEX
DNE -Including Biopsy Under GI, Nasal
Endoscopy . WEBEX
CT Scan Neck Includes Chest And Larynx,
DNL(Direct Nasal Laryngoscopy) \ DNE -
232 31.62 S2 Laryngo Fissurectomy DNL(Direct Nasal Laryngoscopy) / DNE - 27320 29720 34150 37150
Including Biopsy Under GI
Including Biopsy Under GI
DNL(Direct Nasal Laryngoscopy) \ DNE - DNL(Direct Nasal Laryngoscopy) \ DNE -
233 31.98.1 S2 Microlaryngeal Surgery 19440 20640 24300 25800
Including Biopsy Under GI, Nasal endoscopy Including Biopsy Under GI
CT Scan Neck Includes Chest And Larynx,
Surgical treatment for Laryngotracheal DNL(Direct Nasal Laryngoscopy) \ DNE -
234 31.98.2 S2 DNL(Direct Nasal Laryngoscopy) \ DNE - 20900 21800 26125 27250
stenosis Including Biopsy Under GI
Including Biopsy Under GI
3D CT Facial Bones/ MRI Local Area,Routine
235 76.5.1 S2 Bilateral Styloidectomy 3D CT Facial Bones. 15900 16800 19875 21000
Histopathological Examination.
236 76.45 S2 Temporal Bone Excision 3D CT Facial Bones 3D CT Facial Bones/MRI Local Area 52100 54200 65125 67750
237 76.79 S2 Exision of Maxilla 3D CT Facial Bones 3D CT Facial Bones 39490 42490 49363 53113
238 96.52 S2 Removal of Impacted Ear wax Clinical Photograph Clinical Photograph 9700 10300 12125 12875
239 96.53.1 S2 Rhinorrhoea- repair CT PNS Without Contrast, Clinical Photograph CT PNS Without Contrast, Clinical Photograph 25590 26190 31988 32738
240 96.53.2 S2 CSF rhinorrhoea - Endoscopic repair Clinical Photograph Clinical Photograph 25590 26190 31988 32738
Bronchoscopy Foreign Body Removal Routine Histopathological Examination, Clinical
241 98.02 S2 X-ray chest, Clinical Photograph 10600 11200 13250 14000
from Oesophagus Photograph, WEBEX
242 98.11 S2 Removal of foreign body in Ear Clinical Photograph Clinical Photograph 10590 11190 13238 13988
Bronchoscopy Foreign Body Removal
243 98.15.2 S2 X-ray chest, Clinical Photograph Clinical Photograph, WEBEX 24600 25200 30750 31500
from Bronchous
S3 OPHTHAMOLOGY
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Decompression/Excision Of Optic Nerve Visual field (Perimetry) Visual acuity,
244 04.42.1 S3,S10 Case Sheet with operation Notes 78900 79800 98625 99750
Lesions Fundoscopy
245 08.0 S3 Surgical treatment for Ankyloblepharon ICE Pack test with chin elevation Clinical Photograph 14370 14670 17963 18338
246 08.01 S3 Drainage of Lid Abscess Clinical Photograph Clinical Photograph 9460 10060 11825 12575
247 08.2.1 S3 Surgical treatment for disorders of Eyelid Clinical Photograph Clinical Photograph 11030 12530 13788 15663
248 08.2.2 S3 Exision of Small tumour of lid CT Orbits With Contrast Routine Histopathological Examination 10740 11640 13425 14550
249 08.3 S3 Surgical correction of Ptosis Clinical Photograph Clinical Photograph 30600 31200 38250 39000
250 08.4.1 S3 Ectropion correction Clinical Photograph Clinical Photograph 17700 20400 22125 25500
251 08.4.2 S3 Entropion correction Clinical Photograph Clinical Photograph 15300 15600 19125 19500
252 08.7 S3 Lid Reconstruction surgery Clinical Photograph Clinical Photograph 10350 10650 12938 13313
253 08.38 S3 Lagophthalmos correction T3, T4, TSH, Clinical Photograph Clinical Photograph 13210 13210 16513 16513
254 08.59 S3 Epicanthus repair Clinical Photograph Clinical Photograph 7110 7410 8888 9263
255 09.4 S3 Surgery for Congenital dacrocystitis NLD probing(single eye) ,Dacryocystography NLD probing(single eye) 10810 11710 13513 14638
256 09.21 S3 Dacrocystectomy Dacryocystography Case Sheet with operation Notes, Intra OP photo 8140 8440 10175 10550
257 09.43 S3 Congenital NLD probing NLD probing(single eye) NLD probing(single eye) 11010 11910 13763 14888
258 09.81 S3 External Dacryocysto rhinostomy NLD probing(single eye),Dacryocystography NLD probing(single eye) 14950 15850 18688 19813
Canaliculo/conjuctivo Dacryocysto
259 09.82 S3 X-Ray Orbit,Dacryocystography DNE Photo 13430 14030 16788 17538
rhinostomy
260 10.6 S3 Fornix forming sutures CT Orbits Without Contrast, X-Ray Orbit Clinical Photograph 11290 11890 14113 14863
261 10.41 S3 Surgical treatment for Symblepharon NLD probing(single eye) Swab Culture and Sensitivity 4760 5060 5950 6325
262 11.6 S3 Corneal Patch Graft Clinical Photograph Clinical Photograph 17720 18020 22150 22525
263 11.31 S3 Pterygium repair NLD probing(single eye) Intra OP photo 7600 7900 9500 9875
264 11.32 S3 Pterigium + conjunctival autograft NLD probing(single eye) Clinical Photograph 12080 12380 15100 15475
265 11.59.1 S3 Double Z-Plasty Clinical Photograph Clinical Photograph 4300 4600 5375 5750
266 11.61 S3 Lamellar Keratoplasty B-Scan Case Sheet with operation Notes 22790 23090 28488 28863
267 11.63 S3 Penetrating Keratoplasty Clinical Photograph Clinical Photograph 18650 19550 23313 24438
268 11.64 S3 Therapeutic Penetrating Keratoplasty B-Scan Swab Culture and Sensitivity 19800 20100 24750 25125
269 11.69 S3 Amniotic Membrane Graft for Cornea Clinical Photograph Clinical Photograph 11900 12800 14875 16000
270 12.0 S3 Intraocular foreign body removal Fundus floroscence Fundus floroscence 33730 34930 42163 43663
271 12.1 S3 Iridectomy-Iridotomy Fundus floroscence Fundus floroscence 7900 8800 9875 11000
Surgical treatment for Other disorders of
272 12.4 S3 Amplitude Modulation Scan (A-Scan) Fundus floroscence 7300 7600 9125 9500
iris and ciliary body
273 12.13 S3 Surgical treatment for Iris prolapse Fundus floroscence Fundus floroscence 7300 7600 9125 9500
274 12.41 S3 Exision of tumours of iris Fundus floroscence Fundus floroscence 21340 21640 26675 27050
275 12.54.1 S3 Glaucoma Surgery Fundus floroscence Fundus floroscence 9080 9980 11350 12475
276 12.72 S3 Cyclocryotherapy Fundus floroscence Fundus floroscence 12680 13280 15850 16600
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Glaucoma Filtering Surgery For Paediatric Fundus or Iris flouroscien angiography, Fundus
277 12.79 S3 Fundus floroscence 10190 11090 12738 13863
Glaucoma floroscence
278 12.81.1 S3 Surgical treatment for Scleral wound Fundus floroscence Fundus floroscence 11340 12240 14175 15300
Surgical treatment for Perforating scleral
279 12.81.2 S3 Fundus floroscence Fundus floroscence 23360 25460 29200 31825
injury
280 12.87.1 S3 Scleral Patch Graft Case sheet with clinical History Clinical Photograph 21540 23940 26925 29925
281 12.87.2 S3 Amniotic Membrane Graft for Sclera Clinical Photograph Clinical Photograph 18230 20330 22788 25413
282 12.89 S3 Removal of blood clot Fundus floroscence Fundus floroscence, Clinical Photograph 7500 7800 9375 9750
283 12.99 S3 Anterior chamber reconstruction USG local area, X-Ray Orbit Fundus floroscence 8590 9490 10738 11863
Bandage contact lens with glue
284 13.7 S3 USG local area, X-Ray Orbit Fundus floroscence 7080 7980 8850 9975
application
285 13.41 S3 Cataract surgery phacoemulsification Fundus floroscence Fundus floroscence 20000 20000 25000 25000
286 13.42 S3 Lensectomy Fundus floroscence Fundus floroscence, Clinical Photograph 12820 13720 16025 17150
287 13.64.1 S3 Posterior capsulotomy/polishing USG local area, X-Ray Orbit Fundus floroscence 11690 12590 14613 15738
288 13.64.2 S3 Yag laser capsulotomy USG local area, X-Ray Orbit Fundus floroscence 8190 9090 10238 11363
Cataract surgery phacoemulsification Amplitude Modulation Scan (A-Scan),B-Scan ,
289 13.71.1 S3 Fundus floroscence 22450 22750 28063 28438
+IOL Fundus floroscence
290 13.71.2 S3 Cataract surgery SICS + IOL(ECCE+IOL) Fundus floroscence Fundus floroscence 15300 15600 19125 19500
Paediatric Cataract Surgery
291 13.71.3 S3 Fundus floroscence Fundus floroscence 19150 20950 23938 26188
(Phacoemulsification IOL)
Secondary IOL-scleral fixation-sulcus X-Ray Orbit,Amplitude Modulation Scan (A-
292 13.72 S3 Fundus floroscence 22600 23200 28250 29000
fixation of lens ACIOL Scan)
Scleral buckle procedure for Retinal
293 14.4 S3 B-Scan, Fundus floroscence Fundus floroscence 30500 32900 38125 41125
detachment
294 14.25.1 S3 Photocoagulation for Retinopathy B-Scan, Fundus floroscence Fundus floroscence 2000 2000 2500 2500
Photocoagulation For Retinopathy Of
295 14.25.2 S3 Fundus floroscence Fundus floroscence 10330 10930 12913 13663
Prematurity
296 14.52.1 S3 Cryoretinopexy - closed Fundus floroscence Fundus floroscence 13150 14050 16438 17563
297 14.52.2 S3 Cryoretinopexy - open Fundus floroscence Fundus floroscence 11880 12180 14850 15225
Vitrectomy - Membrane Peeling-
298 14.72 S3 B-Scan, Fundus floroscence Fundus floroscence 21380 22580 26725 28225
Endolaser
299 14.74.1 S3 Vitrectomy B-Scan, Fundus floroscence Fundus floroscence 24220 25420 30275 31775
Vitrectomy Plus Silicon Oil Or Gas
300 14.74.2 S3 Fundus floroscence Fundus floroscence 24830 26330 31038 32913
(14.75)
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Vitrectomy -Membrane peeling -
301 14.74.3 S3 Endolaser _Silicon oil or Gas - with or Fundoscopy, Random Blood Sugar (RBS) Test Case Sheet with operation Notes 32400 34800 40500 43500
without belt bulking
Monthly Intravitreal Anti-Vegf For
Fundus floroscence,Fundus or Iris flouroscien
302 14.75 S3 Macular Degeneration - Per Injection Fundus floroscence 16390 18490 20488 23113
angiography,Optical coherence tomography
(Maximum - 6)
Removal Of Silicon Oil Or Gas post
303 14.79 S3 Fundus floroscence Fundus floroscence 10630 11530 13288 14413
Vitrectomy
304 15.2.1 S3 Rectus Muscle Surgery(Single) Clinical Photograph Clinical Photograph 8520 9120 10650 11400
305 15.2.2 S3 Oblique muscle surgery Clinical Photograph Clinical Photograph 8320 8920 10400 11150
306 15.4 S3 Rectus Muscle Surgery(Twohree) Clinical Photograph Clinical Photograph 11290 11890 14113 14863
307 16.0 S3 Orbitotomy CT Orbits Without Contrast ,3D CT Skull Clinical Photograph 27400 27700 34250 34625
Evisceration /Enucleation with Orbital
308 16.3 S3 CT Orbits With Contrast ,3D CT Skull Clinical Photograph 16110 16710 20138 20888
implant
CT Orbits With Contrast ,3D CT Skull/ MRI
309 16.5 S3 Exenteration of Orbit Routine Histopathological Examination 13480 14980 16850 18725
Orbits With Contrast
CT Orbits With Contrast /MRI Orbits With
310 16.63 S3 Dermis Fat Graft Routine Histopathological Examination 24090 25290 30113 31613
Contrast
311 16.64 S3 Socket Reconstruction Case sheet with clinical History Intra OP photo 26720 27920 33400 34900
CT Orbits Without Contrast / MRI Orbits
312 16.81 S3 Endoscopic orbital decompression Routine Histopathological Examination 9050 9050 11313 11313
Without Contrast
Excision of Benign neoplasm of Eye and CT Orbits With Contrast /MRI Orbits With
313 16.92 S3 Routine Histopathological Examination 10020 10320 12525 12900
Adnexa Contrast
CT Orbits Without Contrast, MRI Orbits
314 16.99 S3,S10 Surgical Management of Proptosis Clinical Photograph 60900 61800 76125 77250
Without Contrast, Clinical Photograph
Triple Markers/Immunohistochemistry (IHC)
Fine Needle Aspiration Cytology (FNAC), CT
315 86.3.11 S3 Dermoid cyst excision Three Markers, Routine Histopathological 14520 14820 18150 18525
local Area, Clinical Photograph
Examination, Clinical Photograph
S4 GYNAECOLOGY & OBSTETRICS
USG Abdomen,Bleeding Time And Clotting
Time,Platelet Count ,Blood Coagulation
316 38.86 S4 PPH-Conservative Surgical management USG Abdomen, Case Sheet with operation Notes 33100 35200 41375 44000
Analyzer (BCA) Or Coagulation Profile ,
Complete Blood Picture [CBP], HB%
Abdomen X-Ray (Lateral View), USG
317 54.03 S4 Surgical management of pelvic abscess Rapid AFB Culture, WEBEX 28240 30340 35300 37925
Abdomen
318 54.51 S4,S6 Laparoscopic Adhesiolysis USG Abdomen USG Abdomen 31800 33600 39750 42000
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, Papsmear, Endometrial Biopsy
319 59.4.3 S4 Purandares Sling operations - Open USG Abdomen, WEBEX 26050 26650 32563 33313
HPE
USG Abdomen, Papsmear, Endometrial Biopsy
320 59.4.4 S4 Laparoscopic Sling Operations USG Abdomen, WEBEX 33100 33700 41375 42125
HPE
USG Abdomen, CT scan Lower Abdomen
Without Contrast, CT Scan Abdomen With
Surgical Management of Ovarian Contrast/ Ca 125 (Cancer Antigen 125 Or USG Abdomen, Routine Histopathological
321 65.21 S4 33260 34760 41575 43450
Tumours Carbohydrate Antigen 125), Routine Examination, WEBEX
Histopathological Examination, USG-Doppler
Abdomen
USG Abdomen, CT scan Lower Abdomen
USG Abdomen, Routine Histopathological
Without Contrast, ECHO Cardiogram, CT
322 65.22 S4 Ovarian cystectomy Examination, Specimen Photo with face, 33260 34760 41575 43450
Scan Abdomen With Contrast, Ca 125 (Cancer
WEBEX
Antigen 125 Or Carbohydrate Antigen 125)

USG Abdomen, CT scan Lower Abdomen


USG Abdomen, Routine Histopathological
Without Contrast, ECHO Cardiogram, CT
323 65.23 S4 Laparoscopic Cystectomy Examination, Speciman photo along with the 25520 26120 31900 32650
Scan Abdomen With Contrast, Ca 125 (Cancer
patient's face, WEBEX
Antigen 125 Or Carbohydrate Antigen 125)
USG Abdomen, Routine Histopathological
Surgical Management of Tubal Ovarian USG Abdomen, CT scan Lower Abdomen
324 65.49 S4 Examination, Speciman photo along with the 30000 30600 37500 38250
mass Without Contrast
patient's face, WEBEX
USG Abdomen, Complete Blood Picture USG Abdomen, Routine Histopathological
325 66.62 S4 Laparoscopic Ectopic Resection [CBP], HB%, Blood Grouping And RH Typing, Examination, Speciman photo along with the 22740 23340 28425 29175
Pregnancy Test-Urine patient's face, WEBEX
HSG (Hysterosalpingography), Endometrial
326 66.73 S4 Laparoscopic Recanalisation WEBEX 33630 34530 42038 43163
Biopsy HPE
Serial USG Abdomen, Case sheet with clinical
327 67.5 S4 Encirclage Procedure Recording 11280 12180 14100 15225
History
328 67.33 S4 Cryo Surgery Papsmear, colposcopy, Clinical Photograph Clinical Photograph, WEBEX 3090 3090 3863 3863
329 67.61 S4 Surgical Management of Cervical Tears Clinical Photograph USG Abdomen 11600 12200 14500 15250
USG Abdomen, Routine Histopathological
330 68.4 S4 Hysterectomy - abdominal USG Abdomen, ECHO Cardiogram, Papsmear Examination, Speciman photo along with the 25420 26920 31775 33650
patient's face, WEBEX
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S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, Routine Histopathological
331 68.5.1 S4 Vaginal Hysterectomy USG Abdomen, ECHO Cardiogram, Papsmear Examination, Speciman photo along with the 26200 27400 32750 34250
patient's face, WEBEX
USG Abdomen, Routine Histopathological
Vaginal Hysterectomy With Pelvic Floor
332 68.5.2 S4 USG Abdomen,Papsmear Examination, Speciman photo along with the 31800 33600 39750 42000
Repair(70.79)
patient's face, WEBEX
333 68.21 S4 Hysteroscopic septal resection HSG (Hysterosalpingography), Hysteroscopy WEBEX 17490 17490 21863 21863
Papsmear, Routine Histopathological
334 68.23 S4 Ablation of Endometrium USG Abdomen, WEBEX 11280 11580 14100 14475
Examination
USG Abdomen,Papsmear, Complete Blood USG Abdomen, Routine Histopathological
335 68.29.1 S4 Laparoscopic Myomectomy Picture [CBP], HB%, Blood Grouping And RH Examination, Speciman photo along with the 30600 31200 38250 39000
Typing patient's face, WEBEX
USG Abdomen, Routine Histopathological
336 68.29.2 S4 Hysteroscopic submucus fibroid resection USG Abdomen, ECHO Cardiogram, Examination, Speciman photo along with the 15300 15600 19125 19500
patient's face, WEBEX
USG Abdomen, Routine Histopathological
USG Abdomen, ECHO Cardiogram, MRI
337 68.29.3 S4 Myomectomy Examination, Speciman photo along with the 27620 29420 34525 36775
Pelvis
patient's face, WEBEX
Routine Histopathological Examination,
338 68.29.4 S4 Polypectomy USG Abdomen, Speculum Examination Photo Speciman photo along with the patient's face, 13070 13970 16338 17463
WEBEX
USG Abdomen, Speciman photo along with the
339 68.51 S4 Laproscopic Vaginal Hysterectomy USG Abdomen,ECHO Cardiogram, Papsmear 30600 31200 38250 39000
patient's face, WEBEX
340 69.0 S4 D&C (Dilatation & Curettage) USG Abdomen, Papsmear Routine Histopathological Examination 6300 6600 7875 8250
USG Abdomen, Chest X-Ray PA View(1 Film),
Surgical Management of Endometriosis - USG Abdomen, Routine Histopathological
341 69.1 S4 ECHO Cardiogram, Ca125 (Cancer Antigen 23600 24200 29500 30250
Excision of Chocolate Cyst Examination
125 or Carbohydrate Antigen 125)
Incomplete Abortion + inevitable abortion USG Abdomen, Case sheet with clinical
342 69.02.1 S4 USG Abdomen 9150 9450 11438 11813
Management History
343 69.02.2 S4 Surgical Management of Missed abortion USG Abdomen, Serum Fibrinogen USG Abdomen 9910 10210 12388 12763
USG Abdomen, Abdomen X-Ray (Lateral
344 69.02.3 S4 Surgical Management of Septic Abortion View), Cervical and High Vaginal Swab, Sepsis Case Sheet with operation Notes 11400 12600 14250 15750
Profile
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S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, Beta HCG(Human Chorionic
USG Abdomen, Beta HCG(Human Chorionic
Surgical Management of Vesicular moles Gonadotropin) Levels, Routine
345 69.09 S4 Gonadotropin) Levels, T3, T4, TSH, Chest X- 14900 15800 18625 19750
(Benign GTD) D & C Histopathological Examination, Speciman photo
Ray PA View(1 Film)
along with the patient's face
USG Abdomen, Routine Histopathological
Manchesters Operation + Cervical
346 69.22 S4 USG Abdomen Examination, Speciman photo along with the 25600 26200 32000 32750
amputation(67.4)
patient's face
347 69.92 S4 Intra Uterine Insemination USG Abdomen, Semen Analysis Intra OP photo 10010 10010 12513 12513
Repair of Cystocele ,Rectocele
348 70.5 S4 USG Abdomen USG Abdomen 20900 21800 26125 27250
&Perineorraphy(71.71)
Haemato Colpo Surgical management or
349 70.31 S4 USG Abdomen, MRI Pelvis USG Abdomen 15600 16200 19500 20250
Hymenectomy
Surgical Management of Cystocoele -
350 70.51 S4 USG Abdomen USG Abdomen 14820 15420 18525 19275
Repair
351 70.61 S4 Mc Indoe's operation For Vaginal Atresia USG Abdomen, Double Stranded (DS) DNA USG Abdomen 41990 44990 52488 56238
352 70.71 S4 Surgical Management of Vaginal Tear Clinical Photograph Case Sheet with operation Notes 13600 14200 17000 17750
353 70.77.1 S4 Abdominal Repair for Vault Prolapse Clinical Photograph USG Abdomen 36200 37400 45250 46750
Laproscopic Sacrospinocolpopexy for USG Abdomen, Routine Histopathological
354 70.77.2 S4 USG Abdomen, ECHO Cardiogram 45900 46800 57375 58500
vault prolapse Examination, WEBEX
Abdominal Repair With Mesh for Vault
355 70.78 S4 USG Abdomen, Clinical Photograph USG Abdomen, WEBEX 41200 42400 51500 53000
Prolapse
USG Abdomen, 2D ECHO With Colour
356 71.6 S4 Vulvectomy for tumors USG Abdomen 22700 24200 28375 30250
Doppler
Surgical Treatment for Vulval
357 71.8 S4 Clinical Photograph Case Sheet with operation Notes 14100 14700 17625 18375
Heamatoma
Surgery for Bartholin
358 71.23 S4 USG Abdomen, PUS culture & sensitvity Routine Histopathological Examination 10300 10600 12875 13250
cyst(Marsupilasation,cyst removal)
USG Abdomen, Case sheet with clinical
359 72.0 S4 Instrumental Vaginal Delivery Case Sheet with operation Notes 15530 16430 19413 20538
History
Case Sheet with operation Notes, Mother &
360 73.59.1 S4 Normal Vaginal Delivery USG Abdomen, Bio-Physical Profile 15140 15740 18925 19675
Baby Photos
USG Abdomen, Bio-Physical Profile, CTG for
Normal Vaginal Delivery with Epidural Case Sheet with operation Notes, Mother &
361 73.59.2 S4 High risk factor/ Intermittant Fetal Heart 20600 21200 25750 26500
Anesthesia Baby Photos
monitoring
Normal Vaginal Delivery In Rh-Negative Non stress test, USG Abdomen, Bio-Physical Coomb s Test Direct, USG Abdomen, Blood
362 73.59.3 S4 18590 19190 23238 23988
Mother With Rh-Positive Baby Profile, Coomb s Test Indirect Grouping And RH Typing
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S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Normal Vaginal Delivery in Non stress test, USG Abdomen, Bio-Physical Case Sheet with operation Notes, Mother &
363 73.59.4 S4 16410 17010 20513 21263
Twins(Multiple pregnency) Profile Baby Photos
Normal Vaginal Delivery HIV +ve
364 73.59.5 S4 USG Abdomen, Bio-Physical Profile CD4 Absolute Count (of mother) 22100 24200 27625 30250
Mother
365 74.1.1 S4 Caesarean Section USG Abdomen, Bio-Physical Profile Case Sheet with operation Notes, Intra OP photo 15610 16510 19513 20638
USG Abdomen, Coomb s Test Direct, Cord
Blood for Investigations (Serum Bilirubin
Levels, Blood Culture & Sensitivity -
Caesarean Section In Rh-Negative Mother USG Abdomen, Bio-Physical Profile, Coomb s
366 74.1.2 S4 Automated, Arterial Blood Gas Analysis (ABG), 17400 18600 21750 23250
With Rh-Positive Baby Test Indirect
Random Blood Sugar (RBS) Test, Blood
Grouping And RH Typing, Complete Blood
Picture [CBP], Platelet Count)
Caesarean Section in Twins(Multiple
367 74.1.3 S4 USG Abdomen, Bio-Physical Profile Case Sheet with operation Notes 17400 18900 21750 23625
pregnency)
368 74.1.4 S4 Cesarean Section in HIV+ve Mother USG Abdomen, Bio-Physical Profile Case Sheet with operation Notes 21200 22400 26500 28000
Surgical Management of Ectopic
369 74.3 S4 USG Abdomen, Pregnancy Test-Urine Case Sheet with operation Notes, Intra OP photo 21820 22420 27275 28025
pregnancy
Routine Histopathological Examination,USG
Caesarean Hysterectomy with Bladder
370 74.91 S4 USG Abdomen Abdomen, WEBEX, Speciman photo along with 49180 51580 61475 64475
Repair
the patient's face
Surgery for Rupture Uterus with
371 74.99.1 S4 USG Abdomen , ECG (Electro Cardiogram) USG Abdomen, Intra OP photo 33700 34900 42125 43625
Tubectomy
Surgical Management of Abruptio- USG Abdomen, Blood Coagulation Analyzer USG Abdomen, Mother & Baby Photo With
372 74.99.2 S4 27730 28630 34663 35788
Placenta with Coagulation Defects(Dic) (BCA) Or Coagulation Profile, Renal Profile Retro Placental Clots
Obstetric Hysterectomy (Atonic USG Abdomen, Abdomen X-Ray (Lateral
373 74.99.3 S4 PPH,Traumatic PPH , Rupture-Rupture USG Abdomen, ECHO Cardiogram View), Intra OP photo/ Speciman photo along 32300 34400 40375 43000
Uterus,Abnormal Placentation) with the patient's face
USG Abdomen, Complete Blood Picture
First Trimester Medically Induced
374 75.0.1 S4 [CBP], Blood Grouping And RH Typing, Case Sheet with operation Notes 4350 4650 5438 5813
Abortion
Pregnancy Test-Urine
Termination of pregnancies for foetal USG Abdomen, Serum Fibrinogen, Anti Natal
375 75.0.2 S4 Case Sheet with operation Notes 9200 10100 11500 12625
anamolies + IUD Profile report
376 75.4 S4 Retained Placenta with Manual Removal USG Abdomen USG Abdomen 30910 32410 38638 40513
377 75.69 S4 Complete perineal tear repair USG Abdomen, Clinical Photograph USG Abdomen 19390 20590 24238 25738
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Arterial Blood Gas Analysis (ABG), Blood
Management of Eclampsia with
Coagulation Analyzer (BCA) Or Coagulation
378 93.9.1 S4 Complications Requiring Ventilatory ICU Photo on Ventilator 41200 42400 51500 53000
Profile, Renal Profile, LFT(liver function tests),
Support
Pulse Oxymetry Chart
Case sheet with clinical (obstetric & Past)
LNG-IUS (Levonorgestrene Intautrine
379 96.49 S4 USG Abdomen, Clinical Photograph History, Case Sheet with operation Notes, 14000 14000 17500 17500
system)
Clinical Photograph
Abdomen Radiograph Supine or Erect( 1 Film),
380 97.71.1 S4 Intra abdominal IUCD retrival - Open Clinical Photograph 21200 22400 26500 28000
USG Pelvis, Clinical Photograph
Abdomen Radiograph Supine or Erect( 1 Film),
381 97.71.2 S4 Intra abdominal IUCD retrival - Lap Clinical Photograph 25600 26200 32000 32750
USG Pelvis, Clinical Photograph
382 98.16 S4 Hysteroscopic FB removal Clinical Photograph Clinical Photograph 10560 10560 13200 13200
Complete Blood Picture [CBP], HB%,
,Bleeding Time And Clotting Time,Platelet Case Sheet with treatment details (with Blood
383 99.0.1 S4 Medical Management of PPH 11360 12260 14200 15325
Count ,Blood Coagulation Analyzer (BCA) Or Transfusion)
Coagulation Profile
Complete Haemogram/HB% USG Abdomen,
Medical Management of Haemorragic USG Abdomen, Case Sheet with treatment
384 99.0.2 S4 ECG (Electro Cardiogram), Chest X-Ray PA 37900 38800 47375 48500
shock in pregnancy details
View(1 Film)
385 D25 S4 Medical Management of Fibroids USG Abdomen, Papsmear Case Sheet with treatment details 8880 10080 11100 12600
Medical Management of Polycystic USG Abdomen, Serum Insulin, Glucose USG Abdomen, Case sheet with clinical
386 E28.2 S4 11630 11930 14538 14913
Ovarian Syndrome Tolerance Test (GTT), T3, T4, TSH improvement
Complete Blood Picture [CBP], CUE (pH ,
Specific Gravity , Sugar , Protein And
Microscopy),USG Abdomen, Urine Culture &
Medical Management of Pelvic
387 N73.9 S4 Sensitivity, Serum Creatinine Levelse, Spot Case sheet with clinical improvement 8890 10090 11113 12613
Inflammatory Disease
PR/CR (Protein-Creatinine) Ratio, T3, T4,
TSH, CT scan Lower Abdomen Without
Contrast
Complete Blood Picture [CBP], CUE (pH ,
Specific Gravity , Sugar , Protein And CUE (pH , Specific Gravity , Sugar , Protein And
388 N80 S4 Medical Management of Endometriosis Microscopy), USG Abdomen, Ca 125(Cancer Microscopy), Urine Culture & Sensitivity,USG 7990 8890 9988 11113
Antogen 125 or Carbohydrate Antigen 125), Abdomen, Case sheet with clinical improvement
Clinical Photograph
Complete Blood Picture [CBP], Papsmear,
389 N93.8 S4 Medical Management of DUB Urine Culture & Sensitivity, USG Abdomen, Endometrial Biopsy HPE 11210 12410 14013 15513
Renal Profile
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
ECHO Cardiogram, Antenatal,postnatal with
ECHO Cardiogram, ECG (Electro Cardiogram),
Heart disease complicating pregnancy baby photo, Case Sheet with operation
390 O10.1 S4 USG Abdomen, Biophysical profile, Case sheet 22100 24200 27625 30250
Management Notes,Babyphoto (dead /Alive), Case Sheet with
with clinical History
treatment details
Blood Urea,Serum Creatinine Levels, Serum
LFT(liver function tests), Urine Albumin Levels,
Uric Acid Levels, Random Blood Sugar (RBS)
Platelet Count, Renal Profile, Antenatal,postnatal
Test, Platelet Count, LFT(liver function tests),
391 O14.1 S4 Pre- eclampsia / PIH Management with baby photo, Case Sheet with operation 42370 44470 52963 55588
24 Hrs Urinary Protein, Fundus floroscence,
Notes, Babyphoto (dead /Alive), Case Sheet with
USG Abdomen, Non stress test, Biophysical
treatment details
profile
Blood Coagulation Analyzer (BCA) Or Bleeding Time And Clotting Time, Platelet
Coagulation Profile, Platelet Count, LFT(liver Count, LFT(liver function tests),
HELLP Syndrome Management in function tests), Bleeding Time And Clotting Antenatal,postnatal with baby photo, Case Sheet
392 O14.2 S4 22100 24200 27625 30250
pregnancy Time, Urine Albumin Levels, USG Abdomen, with operation Notes, Baby photo (dead /Alive),
Non stress test, Biophysical profile, Case sheet Birth / Death Certificate, Urine Albumin Levels,
with clinical History Case Sheet with treatment details

Blood Urea, Serum Creatinine Levels, Serum


Uric Acid Levels, Blood Coagulation Analyzer Renal Profile, Antenatal,postnatal with baby
Eclampsia Management without ventilator (BCA) Or Coagulation Profile, LFT(liver photo, Case Sheet with operation Notes,
393 O15.0 S4 32400 34800 40500 43500
support function tests), 24 Hrs Urinary Protein, Fundus Babyphoto (dead /Alive), Case Sheet with
floroscence, USG Abdomen, Case sheet with treatment details
clinical History, Babyphoto (dead /Alive)
Pregnancy Test-Urine, USG Abdomen, Blood
urea, Serum Creatinine Levels, Serum Serum electrolytes, Case Sheet with operation
394 O21 S4 Hyperemisis Gravidarum Management 9160 10060 11450 12575
electrolytes, Serum Bilirubin Levels, Vitamin Notes
B12, Case sheet with clinical History
FBS (Fasting Blood Sugar)/Post Lunch Blood
LFT(liver function tests), Renal Profile, FBS
Sugar (PLBS), LFT(liver function tests), HB
(Fasting Blood Sugar)/Post Lunch Blood Sugar
A1c(Glycosylated Hemoglobin)-, Blood Urea,
Diabetes complicating pregnancy (PLBS), Antenatal,postnatal with baby photo,
395 O24 S4 Serum Creatinine Levels, USG For Obstetrics - 22100 24200 27625 30250
Management Case Sheet with operation Notes, Babyphoto
Anomalies Scan (TIFFA), USG Abdomen,
(dead /Alive) , Birth / Death Certificate, Case
Biophysical profile,Non Stress Test, Case sheet
Sheet with treatment details
with clinical History
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Blood Coagulation Analyzer (BCA) Or
Blood Coagulation Analyzer (BCA) Or
Coagulation Profile, Platelet Count, LFT(liver
Coagulation Profile, Platelet Count, LFT(liver
Hepatic Disorder Management in function tests), Blood urea , Serum Creatinine
396 O26.6 S4 function tests), Urine Albumin Levels, USG 22100 24200 27625 30250
pregnancy Levels, Antenatal,postnatal with baby photo,
Abdomen, Non stress test, Biophysical profile,
Case Sheet with operation Notes, Babyphoto
Case sheet with clinical History
(dead /Alive), Case Sheet with treatment details
HB % , Serum Ferritin Levels, Complete Blood
Picture [CBP], UIBC (Unsaturated Iron Binding
Capacity Test / Total), PCV, USG Abdomen, HB %, Complete Blood Picture [CBP],
Moderate Anaemia Management in
397 O28.0.A S4 Non stress test, Biophysical profile, Complete Antenatal,postnatal with baby photo, Case Sheet 12280 14380 15350 17975
pregnancy
Haemogram, Perpheral Smear For Malarial with treatment details, Babyphoto (dead /Alive)
Parasites (MP), Urine Culture & Sensitivity,
Stool for Cysts & Ova
HB % , Folic Acid Levels , Vitamin B12,
Serum Ferritin Levels, UIBC (Unsaturated Iron
HB % ,PCV,Complete Blood Picture [CBP],
Binding Capacity Test / Total), PCV, USG
Antenatal,postnatal with baby photo, Case Sheet
398 O28.0.B S4 Severe Anemia Management in pregnancy Abdomen, Non stress test, Biophysical profile, 25860 26460 32325 33075
with operation Notes, Babyphoto (dead /Alive),
Urine Culture & Sensitivity, Stool for Cysts &
Blood Transfusion evidence(Photos)
Ova , Perpheral Smear For Malarial Parasites
(MP)
T3, T4, TSH, Venereal Disease Research
Laboratory (VDRL) Test, Acquired Immune
Deficiency Syndrome Serology (HIV 1&2 Anti
Body) - Elisa, CUE (pH , Specific Gravity ,
Intra Uterine Growth Retardation Sugar , Protein And Microscopy), FBS (Fasting USG Abdomen, Antenatal,postnatal with baby
399 O36.8 S4 23000 26000 28750 32500
Management Blood Sugar)/Post Lunch Blood Sugar (PLBS), photo, Casesheet, Babyphoto (dead /Alive)
USG-Doppler Abdomen , USG Abdomen, USG
For Obstetrics - Anomalies Scan (TIFFA), Non
stress test, Biophysical profile, Case sheet with
clinical History
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, FBS (Fasting Blood
Sugar)/Post Lunch Blood Sugar (PLBS), USG USG Abdomen, AMINIOTIC FLUID TAPPING
For Obstetrics - Anomalies Scan (TIFFA), Non PHOTOS, Antenatal,postnatal with baby photo,
400 O40 S4 Acute Poly Hydramnios Management 21500 23000 26875 28750
stress test, Biophysical profile,Glucose Case Sheet with operation Notes, Babyphoto
Tolerance Test (GTT), Case sheet with clinical (dead /Alive)
History
HB%, Antenatal,postnatal with baby photo, Case
Complete Blood Picture [CBP], USG-Doppler
Sheet with operation Notes, Babyphoto (dead
Placenta Previa-type III to IV Abdomen , USG Abdomen, HB% , Non stress
401 O44 S4 /Alive), Blood Transfusion evidence(Photos), 21200 22400 26500 28000
Management test, Biophysical profile, Case sheet with
Intra OP photo, Case Sheet with operation
clinical History
(Blood Transfusion) Notes
ORTHOPEDIC SURGERY AND
S5
PROCEDURES
Extremities , Bones & Joints AP & Lateral
Surgery for Brachial Plexus & Cervical View(2 Film),MRI Local Area,ENMG Extremities , Bones & Joints AP & Lateral
402 04.0 S5 46270 47770 57838 59713
Rib (Elektroneuromyography) ,Nerve conduction View(2 Film)
study
ENMG (Elektroneuromyography) ,Nerve
403 04.3.1 S5 Neurolysis / Nerve Suture Scar Photo 26510 28010 33138 35013
conduction study, Clinical Photograph
ENMG (Elektroneuromyography) ,Nerve
404 04.04 S5 Obturatorneurectomy Scar Photo 20600 21200 25750 26500
conduction study, Clinical Photograph
ENMG (Elektroneuromyography) ,Nerve
405 04.5.1 S5 Nerve Repair With Grafting Scar Photo 43130 44630 53913 55788
conduction study, Clinical Photograph
406 77.00.1 S5 Sequestrectomy&Saucerizations X-Ray X-Ray 40700 43400 50875 54250
407 77.00.2 S5 Sequestrectomy& bone grafting X-Ray X-Ray 40810 42610 51013 53263
408 77.1 S5 Excision of Accessory bone X-Ray X-Ray 21500 23000 26875 28750
Bone tumor surgery reconstruction with
409 77.8 S5 X-Ray , Clinical Photograph X-Ray 50420 52820 63025 66025
internal fixation(78.59)
Long bone osteotomy with POP
410 77.20.1 S5 X-Ray X-Ray 31810 33610 39763 42013
application & k-wires
Long bone osteotomy with internal
411 77.20.2 S5 X-Ray X-Ray 31500 33000 39375 41250
fixation
412 77.31 S5 Costo Transversectomy(77.39) X-Ray / MRI Local Area X-Ray / MRI Local Area 41620 43120 52025 53900
Extremities , Bones & Joints AP & Lateral
Extremities , Bones & Joints AP & Lateral
413 77.35 S5 Corrective osteotomy Acetabulum View(2 Film) / CT Scan Limbs Without 42400 44800 53000 56000
View(2 Film)
Contrast
414 77.37 S5 High tibial osteotomy X-Ray , Clinical Photograph X-Ray 33400 35800 41750 44750
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
415 77.39 S5 Anterolateral Clearance For Tuberculosis X-Ray / MRI Local Area X-Ray 61500 63000 76875 78750
Excision of deep Bone Tumours and Re-
CT Local Area Without Contrast / MRI Local
416 77.60.4 S5 Construction With Conventional X-Ray , Routine Histopathological Examination 51810 54810 64763 68513
Area
Prosthesis
Bone tumor curettage and bone X-Ray , MRI Local Area, Bone Marrow Biopsy
417 77.60.5 S5 X-Ray , Routine Histopathological Examination 31500 33000 39375 41250
graft(78.00) Needle
X-Ray , Routine Histopathological Examination,
418 77.60.6 S5 Bone tumor curettage X-Ray 25330 26230 31663 32788
Scar Photo
419 77.60.7 S5 Bone curettage and bone cement(84.56) X-Ray , Clinical Photograph X-Ray , Routine Histopathological Examination 31500 33000 39375 41250
Surgical Management of Exostosis of
420 77.60.8 S5 X-Ray , Clinical Photograph X-Ray , Routine Histopathological Examination 23500 25000 29375 31250
small joints
Surgical Management of Exostosis of
421 77.60.9 S5 X-Ray , Clinical Photograph X-Ray , Routine Histopathological Examination 28900 29800 36125 37250
long bones
422 77.60.10 S5 Excision of Fracture fragment X-Ray , Clinical Photograph X-Ray 87010 88510 108763 110638
423 77.61 S5 Excision of Scaphoid X-Ray , Clinical Photograph X-Ray 23900 24800 29875 31000
424 77.63.1 S5 Excision of Radial head X-Ray X-Ray 24500 26000 30625 32500
425 77.63.2 S5 Excision of Lower end Ulna X-Ray X-Ray 24500 26000 30625 32500
Excision Or Other Operations For
426 77.64 S5 X-Ray , Clinical Photograph X-Ray 16510 18010 20638 22513
Scaphoid Fractures
Spinal Ostectomy And Internal
427 77.89 S5 X-Ray , Clinical Photograph X-Ray Dorso Lumbar Spine 49410 51210 61763 64013
Fixations(78.59)
428 77.96 S5 Excision of Patella X-Ray X-Ray 17230 18130 21538 22663
429 78.00.1 S5 Bone Grafting As Exclusive Procedure X-Ray , Clinical Photograph X-Ray 20900 21800 26125 27250
430 78.00.2 S5 Phemister grafting X-Ray X-Ray 27500 29000 34375 36250
431 78.3 S5 Limb lengthening X-Ray X-Ray 43040 45140 53800 56425
432 78.10.1 S5 Neglected CTEV. Jess Fixator Clinical Photograph, X-Ray Clinical Photograph, X-Ray 37810 39610 47263 49513
433 78.10.2 S5 Tension band wirings X-Ray X-Ray 26200 27400 32750 34250
Cancecllous screw/pins fixations for
434 78.15 S5 X-Ray X-Ray 37100 39200 46375 49000
fracture neck of Femur
435 78.41.1 S5 Clavicle surgery X-ray X-Ray 25900 26800 32375 33500
Internal fixation lateral epicondyle for non
436 78.42 S5 X-Ray X-Ray 27960 29460 34950 36825
union Humerus
437 78.43 S5 Reconstruction around Radial head X-Ray X-Ray 33800 35600 42250 44500
438 78.60.1 S5 Removal of implants plates and nail X-Ray X-Ray 16200 17400 20250 21750
439 78.60.2 S5 Removal of implants wires and screws X-Ray X-Ray 15600 16200 19500 20250
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Surgery for Avascular Necrosis Of
440 78.95 S5 MRI Pelvis, X-Ray Pelvis (1 Film) MRI Pelvis, X-Ray Pelvis (1 Film) 30790 32290 38488 40363
Femoral Head (Core Decompression)
Reduction Of Compound Fractures &
441 79.0.1 S5 X-Ray , Clinical Photograph X-Ray 26500 28000 33125 35000
External Fixation(78.10)
Closed reduction with percutaneous k-
442 79.0.2 S5 X-Ray , Clinical Photograph X-Ray 16300 16600 20375 20750
wire fixation(78.10)
Closed reduction with percutaneous screw
443 79.0.3 S5 X-Ray , Clinical Photograph X-Ray 17600 18200 22000 22750
fixation(78.10)
Open reduction & Internal Fixation Of
444 79.3 S5 X-Ray , Clinical Photograph X-Ray 16390 17290 20488 21613
Fingers & Toes
445 79.8 S5 Open reduction of Deep dislocations X-Ray , Clinical Photograph X-Ray 32400 34800 40500 43500
446 79.71 S5 Closed reduction of Shoulder dislocation X-Ray , Clinical Photograph X-Ray 8100 8400 10125 10500
447 79.72 S5 Closed reduction of Elbow dislocation X-Ray Elbow, Clinical Photograph X-Ray 8400 9000 10500 11250
448 79.73 S5 Closed reduction of Wrist dislocation X-Ray , Clinical Photograph X-Ray 8100 8400 10125 10500
Closed reduction of fingers small joint
449 79.74 S5 X-Ray , Clinical Photograph X-Ray 8100 8400 10125 10500
dislocation
450 79.75 S5 Closed reduction of Hip dislocation X-Ray Hip Lateral View, Clinical Photograph X-Ray Hip Lateral View 8100 8400 10125 10500
451 79.76 S5 Closed reduction of Knee dislocation X-Ray , Clinical Photograph X-Ray 8400 9000 10500 11250
X-Ray Ankle - Lateral View/AP View, Clinical
452 79.77 S5 Closed reduction of Ankle dislocation X-Ray Ankle - Lateral View/AP View 8400 9000 10500 11250
Photograph
Acromioclavicular joint dislocation open
453 79.81.1 S5 X-Ray Intra OP photo 26670 27570 33338 34463
reconstruction
X-Ray , Clinical Photograph, Cbp ( HB %, TC ,
454 80.1 S5 Arthrotomy and joint lavage DC, WBC, Platelets), Complete Blood Count X-Ray , Routine Histopathological Examination 37110 39210 46388 49013
(CBC), Erythrocyte Sedimentation Rate (ESR)
455 80.2 S5 Diagnostic Arthroscopy MRI Local Area, Clinical Photograph MRI Local Area 24900 25800 31125 32250
CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)
456 80.6 S5 Arthroscopy . Operative Meniscectomy 25900 26800 32375 33500
Without Contrast /MRI Spine Without Contrast /MRI Spine,
457 80.21 S5 Subacromial decompression X-Ray X-Ray 31500 33000 39375 41250
458 80.42 S5 Release of Stiff Elbow X-Ray Elbow X-Ray Elbow, Scar Photo 31500 33000 39375 41250
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
459 80.70.1 S5 Synovectomy Without Contrast, X-Ray Dorso Lumbar Spine, 37100 39200 46375 49000
Without Contrast, X-Ray Dorso Lumbar Spine
Routine Histopathological Examination
CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)
Surgical management
460 80.70.2 S5 Without Contrast, X-Ray Dorso Lumbar Spine, Without Contrast, X-Ray Dorso Lumbar Spine, 6510 6510 8138 8138
Dequerenstenosynovities
Clinical Photograph Scar Photo
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Mossmiami instrumentation for vertebral CT Local Area Without Contrast, MRI Local
461 81.00.1 S5 X-Ray 51870 54870 64838 68588
fractures Area, X-Ray Ankle - Lateral View/AP View
462 81.1.1 S5 Arthrodesis of foot Small joints X- Ray Foot X- Ray Foot 15300 15600 19125 19500
X-Ray Ankle - Lateral View/AP View, Clinical
463 81.1.2 S5 Congenital ankle deformity correction X-Ray Ankle - Lateral View/AP View 54200 58400 67750 73000
Photograph
464 81.2.1 S5 Arthrodesis of major joints X-Ray X-Ray 30300 30600 37875 38250
465 81.4 S5 Flexion construction of hip release X-Ray Hip Lateral View, Clinical Photograph X-Ray Hip Lateral View 41500 43000 51875 53750
Scoliosis and kyphosis CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)
466 81.04 S5 97110 99210 121388 124013
correction(81.05+33.4) Without Contrast, X-Ray Dorso Lumbar Spine Without Contrast, X-Ray Dorso Lumbar Spine
467 81.7 S5 Excision arthroplasty(81.8) X-Ray CT local Area 31500 33000 39375 41250
468 81.8.2 S5 Shoulder replacement X-Ray X-Ray 41210 42410 51513 53013
CT Local Area Without Contrast, MRI Local CT Local Area Without Contrast, MRI Local
469 81.11 S5 Ankle arthrodesis 37100 39200 46375 49000
Area, X-Ray Ankle - Lateral View/AP View Area, X-Ray Ankle - Lateral View/AP View
CT Local Area Without Contrast, MRI Local CT Local Area Without Contrast, MRI Local
470 81.12 S5 Triple arthrodesis 36800 38600 46000 48250
Area, X-Ray Ankle - Lateral View/AP View Area, X-Ray Ankle - Lateral View/AP View
CT Local Area Without Contrast, MRI Local CT Local Area Without Contrast, MRI Local
471 81.18 S5 Subtalar arthrodesis 37400 39800 46750 49750
Area, X-Ray Ankle - Lateral View/AP View Area, X-Ray Ankle - Lateral View/AP View
472 81.21 S5 Arthrodesis of Hip X-Ray Hip Lateral View X-Ray Hip Lateral View 37100 39200 46375 49000
473 81.22 S5 Arthrodesis of Knee X-Ray X-Ray 36800 38600 46000 48250
474 81.23 S5 Arthrodesis of Shoulder X-Ray X-Ray 37400 39800 46750 49750
475 81.24 S5 Arthrodesis of Elbow X-Ray Elbow X-Ray Elbow 36800 38600 46000 48250
Arthrodesis of hand Small
476 81.26 S5 X-Ray X-Ray 15600 16200 19500 20250
joint(81.27/81.28)
477 81.27 S5 Arthrodesis of Wrist X-Ray X-Ray 36800 38600 46000 48250
478 81.43 S5 Release of Stiff knee X-Ray , Clinical Photograph X-Ray 36800 38600 46000 48250
MRI Knee Single Joint Without Contrast, X- CT Local Area Without Contrast/ MRI For
479 81.45.1 S5 Anterior cruciate ligamentl reconstruction 26500 28000 33125 35000
Ray Ligament Injuries
MRI Knee Single Joint Without Contrast, X- CT Local Area Without Contrast/ MRI For
480 81.45.2 S5 Posterior cruciate ligament reconstruction 26510 28010 33138 35013
Ray Ligament Injuries
481 81.51.1 S5 Total hip replacement cemented X-Ray Hip Lateral View X-Ray Hip Lateral View 79500 81000 99375 101250
482 81.51.2 S5 Total hip replacement uncemented X-Ray Hip Lateral View X-Ray Hip Lateral View 101200 102400 126500 128000
Bipolar hemiarthroplastyof Hip without
483 81.52.1 S5 X-Ray Hip Lateral View X-Ray Hip Lateral View 40400 42800 50500 53500
cement
484 81.52.2 S5 Hemiarthroplasty of Hip uncemented X-Ray Hip Lateral View X-Ray Hip Lateral View 36200 37400 45250 46750
Bipolar hemiarthroplasty of Hip with
485 81.52.3 S5 X-Ray Hip Lateral View X-Ray Hip Lateral View 44400 46800 55500 58500
cement
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
486 81.52.4 S5 Hemiarthroplasty of Hip cemented X-Ray Hip Lateral View X-Ray Hip Lateral View 36810 38610 46013 48263
487 81.54 S5 Total knee replacement X-Ray X-Ray 106800 108600 133500 135750
Reconstruction procedure for recurrent
488 81.82 S5 X-Ray , MRI Shoulder X-Ray 31210 32410 39013 40513
dislocation shoulder
489 81.83 S5 Arthroplasty of Shoulder X-Ray CT local Area 42400 44800 53000 56000
490 81.84 S5 Elbow replacement X-Ray Elbow X-Ray Elbow 41510 43010 51888 53763
Joint reconstruction/intraarticular
491 81.96 S5 X-Ray CT local Area 36800 38600 46000 48250
fractures
492 82.11 S5 Trigger Finger release Contrast Enhanced USG, Clinical Photograph X-Ray , Clinical Photograph 6500 6500 8125 8125
CT Local Area Without Contrast, Clinical
493 82.35 S5,S14 Dupuytrens contracture release Contrast Enhanced USG, Clinical Photograph 21200 22400 26500 28000
Photograph
494 82.56.2 S5 Tendon transfer procedure for claw hand Nerve conduction study, Clinical Photograph CT Local Area Without Contrast 33800 35600 42250 44500
495 82.99.2 S5 Maxpage release for Volkmann X-Ray , Clinical Photograph CT Local Area Without Contrast 31500 33000 39375 41250
Synovial cyst excision/ganglion/Bakers
496 83.3.2 S5 Contrast Enhanced USG, Clinical Photograph Contrast Enhanced USG 20090 20390 25113 25488
Cyst
497 83.5 S5 Excision of Retrocalcaneal bursa X-Ray , Clinical Photograph X-Ray 15910 16810 19888 21013
498 83.12 S5 Adductor release X-Ray , Clinical Photograph Case Sheet with operation Notes 15900 16800 19875 21000
499 83.13 S5 Tenotomy Nerve conduction study, Clinical Photograph Case Sheet with operation Notes 16510 18010 20638 22513
500 83.14.1 S5 Fasciotomy Clinical Photograph Clinical Photograph 21500 23000 26875 28750
501 83.14.2 S5 Fasciotomy with skin graft X-Ray , Clinical Photograph X-Ray , Scar Photo 25900 26800 32375 33500
X-Ray Ankle - Lateral View/AP View, Clinical
502 83.63 S5 Rotator cuff repair X-Ray Ankle - Lateral View/AP View 31200 32400 39000 40500
Photograph
X-Ray Ankle - Lateral View/AP View, Clinical
503 83.75 S5 Tendon transfer procedure around ankle X-Ray Ankle - Lateral View/AP View 34100 36200 42625 45250
Photograph
504 83.81 S5 Tendon transfer with graft X-Ray , Clinical Photograph X-Ray 33200 34400 41500 43000
CT Local Area Without Contrast, Clinical
505 83.84.1 S5 CTEV correction X-Ray , Clinical Photograph 50900 51800 63625 64750
Photograph
506 83.85 S5 Hamstrings release X-Ray , Clinical Photograph CT Local Area Without Contrast 16510 18010 20638 22513
507 83.86 S5 Quadricepsplasty X-Ray , Clinical Photograph CT Local Area Without Contrast 37100 39200 46375 49000
508 83.87 S5 Tricepsplasty X-Ray , Clinical Photograph CT Local Area Without Contrast 32100 34200 40125 42750
509 83.89 S5 Fasciotomy with skin graft with fixator X-Ray , Clinical Photograph X-Ray , CT Local Area Without Contrast 42700 45400 53375 56750
510 83.95.2 S5 Drainage of cold abscess X-Ray ,MRI Local Area, X-Ray ,MRI Local Area 31210 32410 39013 40513
CT Local Area Without Contrast/MRI Local
511 83.95.3 S5 Drainage of acute osteomyelitis X-Ray , MRI Local Area, Clinical Photograph 29500 31000 36875 38750
Area
CT Local Area Without Contrast/MRI Local
512 84.01.1 S5 Fingers amputations X-Ray , Clinical Photograph 10600 11200 13250 14000
Area, X-ray
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
X-Ray , Colour Doppler - Lower Limbs, CT Local Area Without Contrast/MRI Local
513 84.04 S5 Disarticulation at wrist level 24510 26010 30638 32513
Clinical Photograph Area, X-ray
514 84.4 S5 Orif-long bones with locking plates X-Ray X-Ray 36210 37410 45263 46763
X-Ray , Colour Doppler Of Specific Limb, CT Local Area Without Contrast/MRI Local
515 84.05 S5 Below Elbow amputations 24500 26000 30625 32500
Clinical Photograph Area, X-ray
X-Ray , Colour Doppler Of Specific Limb, CT Local Area Without Contrast/MRI Local
516 84.06 S5 Disarticulation at elbow level 25910 26810 32388 33513
Clinical Photograph Area, X-ray
X-Ray , Colour Doppler Of Specific Limb, CT Local Area Without Contrast/MRI Local
517 84.07 S5 Above Elbow amputations 26800 28600 33500 35750
Clinical Photograph Area, X-ray
Colour Doppler Of Specific Limb, Clinical CT Local Area Without Contrast/MRI Local
518 84.08.1 S5 Disarticulation at Shoulder level 41510 43010 51888 53763
Photograph Area, X-ray
CT Local Area Without Contrast/MRI Local
519 84.09.2 S5 Amputations - Forequarter X-Ray , Clinical Photograph 39470 41870 49338 52338
Area, X-ray
CT Local Area Without Contrast/MRI Local
520 84.11.1 S5 Disarticulations at small joints Foot X- Ray Foot, Clinical Photograph 10010 10010 12513 12513
Area, X-ray
X-Ray , Colour Doppler Of Specific Limb, CT Local Area Without Contrast/MRI Local
521 84.13 S5 Disarticulation at ankle level 26210 27410 32763 34263
Clinical Photograph Area, X-ray
X-Ray , Colour Doppler Of Specific Limb, CT Local Area Without Contrast/MRI Local
522 84.15 S5 Below Knee amputations 28660 30460 35825 38075
Clinical Photograph Area, X-ray
X-Ray , Colour Doppler Of Specific Limb, CT Local Area Without Contrast/MRI Local
523 84.16 S5 Disarticulations at knee level 27000 27000 33750 33750
Clinical Photograph Area, X-ray
CT Local Area Without Contrast/MRI Local
524 84.17.1 S5 Above Knee amputations X-Ray , Clinical Photograph 28800 30600 36000 38250
Area, X-ray
X-Ray Hip Lateral View, Colour Doppler Of CT Local Area Without Contrast/MRI Local
525 84.18 S5 Disarticulation at Hip level 42110 44210 52638 55263
Specific Limb, Clinical Photograph Area, X-ray
Amputations - Hind Quarter And CT Local Area Without Contrast/MRI Local
526 84.19.1 S5 X-Ray 52110 54210 65138 67763
Hemipelvectomy Area,
527 84.54 S5 Limb reconstruction system(lrs) X-Ray X-Ray 40400 42800 50500 53500
528 84.72.1 S5 Ilizarov Ring Fixator Application X-Ray X-Ray 46400 48800 58000 61000
529 84.72.2 S5 Ilizarov fixator with joint arthrolysis X-Ray X-Ray , Clinical Photograph 52100 54200 65125 67750
X-Ray Pelvis (1 Film)y, Sinography, Clinical
530 86.21.2 S5 Excision of Sinus over Sacrum CT Local Area Without Contrast 16300 16600 20375 20750
Photograph
Soft Tissue Reconstruction Procedures
531 86.89.3 S5 Clinical Photograph X-Ray 31510 33010 39388 41263
For Joints/Osteotomy
532 86.89.4 S5 CDH soft tissue reconstruction Contrast Enhanced USG, X-Ray Pelvis (1 Film) X-Ray, CT local Area 36500 38000 45625 47500
533 93.5 S5 Hip spica X-Ray, Clinical Photograph Physiotherapy Report 8600 9200 10750 11500
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Procedure private ward - Private ward - private ward - Private ward -
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Code
Hospitals Hospitals Hospitals Hospitals
Cervical spine injury(skull traction) CT Spine (Cervical,Dorsal,Lumbar,Sacral)
534 93.41 S5 X-Ray 21500 23000 26875 28750
treatment Without Contrast / X-Ray, MRI Local Area,
535 93.44 S5 Application of skeletal traction X-Ray X-Ray 6300 6600 7875 8250
536 93.46 S5 Application of skin traction X-Ray, Clinical Photograph Physiotherapy Report 4500 4500 5625 5625
537 93.53.1 S5 Application of functional cast brace X-Ray, Clinical Photograph Physiotherapy Report 2500 2500 3125 3125
538 93.53.2 S5 U-slab application X-Ray, Clinical Photograph Physiotherapy Report 7100 7700 8875 9625
539 93.53.3 S5 Synthetic cast application above Elbow X-Ray, Clinical Photograph Physiotherapy Report 5000 5000 6250 6250
540 93.53.4 S5 Synthetic cast application below Elbow X-Ray, Clinical Photograph Physiotherapy Report 5550 5550 6938 6938
541 93.53.5 S5 Synthetic cast application above Knee X-Ray, Clinical Photograph Physiotherapy Report 6500 6500 8125 8125
542 93.53.6 S5 Synthetic cast application below Knee X-Ray, Clinical Photograph Physiotherapy Report 5000 5000 6250 6250
543 93.53.7 S5 Synthetic cast cutting X-Ray, Clinical Photograph Physiotherapy Report 500 500 625 625
544 93.54.1 S5 POP application above Elbow Clinical Photograph Physiotherapy Report 4300 4600 5375 5750
545 93.54.2 S5 POP application below Elbow Clinical Photograph Physiotherapy Report 3300 3600 4125 4500
546 93.54.3 S5 POP application above Knee Clinical Photograph Physiotherapy Report 5300 5600 6625 7000
547 93.54.4 S5 POP application below Knee Clinical Photograph Physiotherapy Report 4300 4600 5375 5750
Bandages and strapping procedures for
548 93.56 S5 X-Ray X-Ray, Clinical Photograph 6800 7100 8500 8875
fractures
SURGICAL GASTROENTEROLOGY
S6
Upper GI endoscopy ,Complete Blood Picture
[CBP], USG Abdomen, Color Doppler
549 39.1.4 S6 Surgery For Portal Hypertension Bleed Upper GI endoscopy ,USG Abdomen 102100 104200 127625 130250
Sonography Single Study, LFT(liver function
tests)
CT Scan Abdomen Without Contrast, Perpheral
USG Abdomen, Routine Histopathological
550 41.5.1 S6 Splenectomy Smear For Malarial Parasites (MP), USG 36500 38000 45625 47500
Examination
Abdomen,Complete Haemogram
CT Scan Abdomen Without Contrast, USG
Splenectomy + Devascularisation + Color Doppler Sonography Single Study,
551 41.5.6 S6 Abdomen,Color Doppler Sonography Single 79260 81960 99075 102450
Spleno Renal Shunt(39.1) Routine Histopathological Examination
Study,Upper GI endoscopy
Spleenectomy For Space Occupying CT Scan Abdomen With Contrast, USG USG Abdomen , Routine Histopathological
552 41.42 S6 42290 42590 52863 53238
Lesion Abdomen Examination
Oesophageal manometry/ Barium Upper GI
553 42.7 S6 Open Hellers Myotomy USG Abdomen,Barium Studies 81200 82400 101500 103000
Study(Double Contrast),USG Abdomen
Barium Swallow, Oesophageal manometry,
554 42.7.1 S6 Laproscopic Hellers Myotomy WEBEX, Case Sheet with operation Notes 29610 31110 37013 38888
Upper GI endoscopy
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Procedure private ward - Private ward - private ward - Private ward -
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Surgery For Oesophageal Perforation
USG Abdomen, CT Scan Abdomen With
555 42.11 S6 Stage 1 Cervical Exclusion And Chest USG Abdomen 126800 128600 158500 160750
Contrast
Tube And Feeding Jejunostomy
Surgery For Oesophageal Perforation CT Scan Abdomen With Contrast,USG
556 42.32.1 S6 USG Abdomen 102400 104800 128000 131000
Stage 2 Definitive Surgery Abdomen, Case sheet with clinical History
Surgery For Oesophageal Perforation -
CT Scan Abdomen With Contrast,USG
557 42.32.2 S6 Single Staged Foreign Body, Iatrogenic & USG Abdomen 102400 104800 128000 131000
Abdomen
Spontaneous
CT Scan Abdomen With Contrast /Upper GI Upper GI endoscopy , Routine Histopathological
558 42.40.1 S6 Oesophagectomy 91200 92400 114000 115500
endoscopy , Biopsy Examination
Upper GI endoscopy / CT Scan Abdomen With
559 42.55 S6 Colonic Pull Up Routine Histopathological Examination 61500 63000 76875 78750
Contrast/ Colono Scopy, USG Abdomen
CT Scan Abdomen With Contrast,USG
560 43.4 S6 Surgery for Corrosive Injury Stomach Upper GI endoscopy 61200 62400 76500 78000
Abdomen
USG Abdomen/ CT Scan Abdomen With
Partial Gastrectomy with anastomosis to USG Abdomen, Routine Histopathological
561 43.5.2 S6 Contrast, Upper GI endoscopy , Case sheet with 41200 42400 51500 53000
esophagus Examination
clinical History
Partial Gastrectomy with anastomosis to USG Abdomen/ CT Scan Abdomen With USG Abdomen, Routine Histopathological
562 43.6.1 S6 41200 42400 51500 53000
duodenum Contrast, Upper GI endoscopy Examination
Distal Gastrectomy For Gastric Outlet USG Abdomen/ CT Scan Abdomen With USG Abdomen, Routine Histopathological
563 43.6.2 S6 41200 42400 51500 53000
Obstruction Contrast, Upper GI endoscopy , Biopsy Examination
USG Abdomen/ CT Scan Abdomen With
Partial/Subtotal Gastrectomy with Contrast,Barium Studies,Upper GI endoscopy , USG Abdomen, Scar Photo, Routine
564 43.7.1 S6 33180 34380 41475 42975
anastomosis to jejunum For Ulcer Routine Histopathological Examination , Histopathological Examination
Biopsy
CT Scan Abdomen With Contrast ,USG
565 43.9 S6 Total Gastrectomy Routine Histopathological Examination 41800 43600 52250 54500
Abdomen
CT Scan Abdomen With Contrast /Upper GI
566 43.99.1 S6 Oesophago-Gastrectomy endoscopy , Biopsy, Case sheet with clinical Routine Histopathological Examination 91200 92400 114000 115500
History
Truncal Vagotomy + Gastro USG Abdomen/ CT Scan Abdomen With
567 44 S6 USG Abdomen, Nerve Biopsy -HPE 48900 49800 61125 62250
Jejunostomy(44.3) Contrast
568 44.4.2 S6 Surgery For Bleeding Ulcers Upper GI endoscopy , USG Abdomen Upper GI endoscopy ,USG Abdomen 48900 49800 61125 62250
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Upper GI endoscopy , USG Abdomen, Color
Doppler Sonography Single Study/ CT Scan
Abdomen With Contrast/Abdomen Radiograph
569 44.43 S6 Surgery For Obscure Gi Bleed Supine Or Erect(1 Film),CT Angiogram Upper GI endoscopy , USG Abdomen, 72900 73800 91125 92250
Abdomen,Radionuclide scan(Obscure
Blood),Balloon enteroscopy ,99M TC Isotope
Gastric Bleed Scan
Upper GI endoscopy , Barium Studies, Clinical Barium Studies/CT Scan Abdomen With
Gastro Jejuno-Colic Fistula Surgical
570 44.63 S6 Photograph, CT Scan Abdomen With Contrast/ Contrast, Case Sheet with operation Notes, 62100 64200 77625 80250
Management
USG Abdomen Routine Histopathological Examination
CT Scan Abdomen With Contrast,Barium
571 44.67 S6 Lap Fundoplications Upper GI endoscopy 54300 54600 67875 68250
Studies/Upper GI endoscopy
Routine Histopathological Examination , USG
Abdomen, CT Scan Abdomen With Contrast USG Abdomen , Routine Histopathological
572 45.73.3 S6,S1 Extended Right Hemicolectomy 48300 48600 60375 60750
/Barium Studies/Lower GI Endoscopy,Colono Examination
Scopy
I Stage-Sub Total Colectomy + CT Scan Abdomen With Contrast ,Colono USG Abdomen , Routine Histopathological
573 45.8 S6 60300 60600 75375 75750
Ileostomy(46.2) Scopy,Lower GI Endoscopy, Biopsy Examination
I Stage- Sub Total Colectomy + Ileostomy CT Scan Abdomen With Contrast ,Colono USG Abdomen , Routine Histopathological
574 45.83 S6 96300 96600 120375 120750
+ J - Pouch Scopy,Lower GI Endoscopy, Biopsy Examination
USG Abdomen,Barium Studies, Routine
575 45.95.1 S6 II Stage-J - Pouch Colono Scopy 50300 50600 62875 63250
Histopathological Examination
Colono Scopy /Lower GI Endoscopy, Clinical
576 46.51.4 S6 II Stage- Ileostomy Closure Scar Photo 25900 26800 32375 33500
Photograph
Lower GI Endoscopy/CT Scan Abdomen With
577 46.51.5 S6 III Stage-Ileostomy Closure Scar Photo 26800 28600 33500 35750
Contrast, Clinical Photograph
USG Abdomen, CT Scan Abdomen With USG Abdomen, Routine Histopathological
578 46.80.2 S6 Surgical management of Volvulus 49200 50400 61500 63000
Contrast / Colono Scopy /Lower GI Endoscopy Examination

USG Abdomen, Abdomen Radiograph Supine


USG Abdomen, Routine Histopathological
579 46.80.3 S6 Surgical management of Malrotation Or Erect(1 Film),Lower GI Endoscopy / CT 49200 50400 61500 63000
Examination
Scan Abdomen With Contrast
Routine Histopathological Examination,Lower
GI Endoscopy, USG Abdomen /CT Scan USG Abdomen, Routine Histopathological
580 48.5 S6,S11 Abdomino Perineal Resection of rectum 53080 55480 66350 69350
Abdomen With Contrast/MRI Abdomen With Examination
Contrast
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Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, CT Scan Abdomen With
Contrast / Colono Scopy /Lower GI USG Abdomen, Routine Histopathological
581 48.62.2 S6 Hartman.S Procedure With Colostomy 54300 54600 67875 68250
Endoscopy,Routine Histopathological Examination
Examination
Routine Histopathological Examination, USG
USG Abdomen, Routine Histopathological
582 48.63.1 S6 Anterior Resection of Large Intestine Abdomen, CT Scan Abdomen With Contrast/ 40900 41800 51125 52250
Examination
Colono Scopy /Lower GI Endoscopy
Routine Histopathological Examination, USG
USG Abdomen, Routine Histopathological
583 48.93 S6 Anterior Resection With Ileostomy Abdomen, CT Scan Abdomen With Contrast / 60290 60590 75363 75738
Examination
Colono Scopy /Lower GI Endoscopy
Endo anal scan/ MRI Abdomen With
584 49.7.1 S6 Anal Sphincter Repair -With Colostomy Endo anal scan 35050 36250 43813 45313
Contrast,USG Abdomen
Anal Sphincter Repair -Without Endo anal scan/ MRI Abdomen With
585 49.7.2 S6 Endo anal scan 32520 33720 40650 42150
Colostomy Contrast,USG Abdomen
ERCP, CT Scan Abdomen Without
Routine Histopathological Examination, CT
586 50.3.1 S6 Rt.Hepatectomy Contrast/Lower GI Endoscopy, USG Abdomen, 86880 87180 108600 108975
Scan Abdomen Without Contrast
Alpha Feto Protiens Levels
ERCP, CT Scan Abdomen Without
Routine Histopathological Examination, CT
587 50.3.2 S6 Lt.Hepatectomy Contrast/Lower GI Endoscopy, USG Abdomen, 90300 90600 112875 113250
Scan Abdomen Without Contrast
Alpha Feto Protiens Levels
MR Cholangiography, CT Scan Abdomen USG Abdomen, Routine Histopathological
588 50.4 S6 Hepatectomy For Cholangiocarcinoma 151800 153600 189750 192000
Without Contrast/MRI Abdomen With Contrast Examination
USG Abdomen, Routine Histopathological
CT scan Lower Abdomen Without Contrast
589 50.21 S6 Hydatid Cyst-Marsupilisation Examination, Case sheet with clinical 40300 40600 50375 50750
/USG Abdomen
improvement
Lower GI Endoscopy, USG Abdomen, CT
Haemangioma Sol Liver Hepatectomy + USG Abdomen, Routine Histopathological
590 50.22 S6 Scan Abdomen With Contrast / MRI Abdomen 90300 90600 112875 113250
Wedge Resection Examination
With Contrast
CT scan Lower Abdomen Without Contrast,
Hepato Cellular Carcinoma(Advanced) Lower GI Endoscopy, USG Abdomen, Alpha
591 50.26 S6 USG Abdomen 72300 72600 90375 90750
Radio Frequency Ablation Feto Protiens Levels, Guided Fine Needle
Aspiration Cytology (FNAC)
ERCP, CT Scan Abdomen Without USG Abdomen, Routine Histopathological
592 50.29.3 S6 Segmentectomy 60300 60600 75375 75750
Contrast/Lower GI Endoscopy, USG Abdomen Examination
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Procedure private ward - Private ward - private ward - Private ward -
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT scan Lower Abdomen Without
Radical Extended Cholecystectomy For Routine Histopathological Examination, Clinical
593 51.2 S6 Contrast/MRI Abdomen With Contrast, Guided 102400 104800 128000 131000
Ca Gall Bladder Photograph
Fine Needle Aspiration Cytology (FNAC)
USG Abdomen, CT scan Lower Abdomen
Cyst Excision+Hepatic Without Contrast/CT Scan Abdomen Without USG Abdomen, Routine Histopathological
594 51.6 S6 56100 58200 70125 72750
Jejunostomy(51.37) Contrast/ Magnetic Resonance Examination
Cholangiopancreatography (MRCP)
USG Abdomen, CT Scan Lower Abdomen
With Contrast/ CT Scan Abdomen Without USG Abdomen, Routine Histopathological
595 51.37 S6 Hepatico Jejunostomy 67570 68170 84463 85213
Contrast/ Magnetic Resonance Examination
Cholangiopancreatography (MRCP)
USG Abdomen, CT Scan Lower Abdomen
Choledochoduodenostomy Or With Contrast/ CT Scan Abdomen Without USG Abdomen, Routine Histopathological
596 51.39 S6 42100 43600 52625 54500
Choledocho Jejunostomy Contrast/ Magnetic Resonance Examination
Cholangiopancreatography (MRCP)
USG Abdomen, Magnetic Resonance
GB+ Calculi CBD Stones Or Dilated Cholangiopancreatography (MRCP)/ERCP, CT USG Abdomen, Routine Histopathological
597 51.41 S6 50300 50600 62875 63250
CBD scan Lower Abdomen Without Contrast/ CT Examination
Scan Abdomen With Contrast
MR Cholangiography-, USG Abdomen, CT
scan Lower Abdomen Without Contrast/CT
598 51.98 S6 Benign Biliary Stricture Repair USG Abdomen 102100 104200 127625 130250
Scan Abdomen Without Contrast, CT Scan
Abdomen With Contrast
CT scan Lower Abdomen Without Contrast/CT
Scan Abdomen Without Contrast/ ERCP
USG Abdomen, Routine Histopathological
599 52.3 S6 Enucleation Of Cyst /Magnetic Resonance 91500 93000 114375 116250
Examination
Cholangiopancreatography (MRCP), USG
Abdomen
CT scan Lower Abdomen Without Contrast/CT
Scan Abdomen Without Contrast, ERCP, Upper
USG Abdomen, Routine Histopathological
600 52.4.1 S6,S11 Triple Bypass -Pancreas GI endoscopy, USG Abdomen, Magnetic 61500 63000 76875 78750
Examination
Resonance Cholangiopancreatography (MRCP)
, Biopsy
CT scan Lower Abdomen Without Contrast/CT
Lateral Pancreaticojejunostomy(Non- USG Abdomen, Routine Histopathological
601 52.4.3 S6 Scan Abdomen Without Contrast, ERCP, USG 103000 106000 128750 132500
Malignant) Examination
Abdomen
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT scan Lower Abdomen Without Contrast/CT
Scan Abdomen Without Contrast, USG
USG Abdomen, Routine Histopathological
602 52.4.5 S6 Other Bypasses -Pancreas Abdomen, Magnetic Resonance 40750 42250 50938 52813
Examination
Cholangiopancreatography (MRCP), USG
Abdomen
CT Scan Abdomen Without Contrast, ERCP
/Magnetic Resonance USG Abdomen, Routine Histopathological
603 52.7 S6,S11 Whipples Any Type 102710 105410 128388 131763
Cholangiopancreatography (MRCP), USG Examination
Abdomen
CT scan Lower Abdomen Without Contrast/CT
Scan Abdomen Without Contrast, ERCP, Upper USG Abdomen, Routine Histopathological
604 52.22.1 S6 Laproscopic Pancreatic Necrosectomy 114870 116970 143588 146213
GI endoscopy, USG Abdomen, Clinical Examination
Photograph
CT scan Lower Abdomen Without Contrast/CT
USG Abdomen, Routine Histopathological
605 52.22.2 S6 Open Pancreatic Necrosectomy Scan Abdomen Without Contrast, ERCP, Upper 123050 126050 153813 157563
Examination
GI endoscopy, USG Abdomen
CT scan Lower Abdomen Without Contrast/CT
Scan Abdomen Without Contrast, USG
USG Abdomen, Routine Histopathological
606 52.52.1 S6 Distal Pancreatectomy Abdomen, Magnetic Resonance 121500 123000 151875 153750
Examination
Cholangiopancreatography (MRCP), USG
Abdomen, ERCP
ERCP, Upper GI endoscopy, USG Abdomen,
Distal Pancreatectomy + CT scan Lower Abdomen Without Contrast/CT USG Abdomen, Routine Histopathological
607 52.52.2 S6 121500 123000 151875 153750
Splenectomy(41.5) Scan Abdomen Without Contrast/ Magnetic Examination
Resonance Cholangiopancreatography (MRCP)
Upper GI endoscopy, CT Scan Abdomen
Without Contrast/ ERCP /Magnetic Resonance USG Abdomen, Routine Histopathological
608 52.59 S6 Central Pancreatectomy 121500 123000 151875 153750
Cholangiopancreatography (MRCP), USG Examination
Abdomen
USG Abdomen, CT scan Lower Abdomen
Diaphragmatic Hernia (Gortex Mesh Without Contrast/CT Scan Abdomen Without
609 53.75 S6 USG Abdomen, Chest X-Ray PA View(1 Film) 49200 50400 61500 63000
Repair) Contrast/CT Scan Abdomen With Contrast,
ECHO Cardiogram
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Code
Hospitals Hospitals Hospitals Hospitals
CT scan Lower Abdomen Without Contrast,
Rectovaginal fistula Management with
610 70.73.1 S6,S1,S4 MRI Local Area, TRUS (Transrectal Scar Photo 41420 43520 51775 54400
Colostomy
Ultrasonography), Sigmoidoscopy (REGID)
S7 CARDIOTHORASIC SURGERY
Vertibral Arteries Angiography(CT Angio
Chest X-Ray PA View(1 Film), Doppler Of
Abdomen)/CT Scan Neck Includes Chest And
611 00.61 S7 Vertebral Angioplasty Peripheral Vessels, Stent bar code Details, 76200 77400 95250 96750
Larynx2 ,CT Angiography (Coronary
Procedure CD
Angiography)/Doppler Of Peripheral Vessels
Digital Subtraction Angiography(DSA
Peripheral Artery\Arteries) /CT Scan Chest Chest X-Ray PA View(1 Film), Doppler Of
Coronary Balloon Angioplasty with Bare
612 00.66.1 S7 Without Contrast , CT Angiography (Coronary Peripheral Vessels, Stent bar code Details, 55900 56800 69875 71000
Metal stent(00.45)
Angiography),Color Doppler Sonography Procedure CD
Single Study
Digital Subtraction Angiography(DSA
Peripheral Artery\Arteries) /CT Scan Chest Chest X-Ray PA View(1 Film), Doppler Of
PTCA Additional Bare Metal Stent
613 00.66.2 S7 Without Contrast , CT Angiography (Coronary Peripheral Vessels, Stent bar code Details, 10000 10000 12500 12500
(00.46)
Angiography),Color Doppler Sonography Procedure CD
Single Study, ECHO Cardiogram
Digital Subtraction Angiography(DSA
Peripheral Artery\Arteries) /CT Scan Chest Chest X-Ray PA View(1 Film), Doppler Of
Coronary Balloon Angioplasty with Drug
614 00.66.3 S7 Without Contrast , CT Angiography (Coronary Peripheral Vessels, Stent bar code Details, 65900 66800 82375 83500
eluting stent(00.45)
Angiography),Color Doppler Sonography Procedure CD
Single Study
Digital Subtraction Angiography(DSA
Peripheral Artery\Arteries) /CT Scan Chest Chest X-Ray PA View(1 Film), Doppler Of
PTCA Additional Drug eluting Stent
615 00.66.4 S7 Without Contrast , CT Angiography (Coronary Peripheral Vessels, Stent bar code Details, 20000 20000 25000 25000
(00.46)
Angiography),Color Doppler Sonography Procedure CD
Single Study, ECHO Cardiogram
CT Scan Chest With Contrast, Chest X-Ray PA Chest X-Ray PA View(1 Film), Routine
616 32.2.1 S7 Surgical management of lung cyst 40300 40600 50375 50750
View(1 Film), Pulmonary Function Test(Major) Histopathological Examination
CT Scan Chest With Contrast, Chest X-Ray PA
Chest X-Ray PA View(1 Film), Routine
617 32.4.2 S7 Lobectomy View(1 Film), ECHO Cardiogram, Pulmonary 60300 60600 75375 75750
Histopathological Examination
Function Test(Major)
CT Scan Chest With Contrast, Chest X-Ray PA
Chest X-Ray PA View(1 Film), Routine
618 32.5.1 S7 Pneumonectomy View(1 Film), ECHO Cardiogram, Pulmonary 60300 60600 75375 75750
Histopathological Examination
Function Test(Major)
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Chest With Contrast, Chest X-Ray PA
View(1 Film), PUS Culture & Sensitivity,
Chest X-Ray PA View(1 Film), Routine
619 32.9 S7 Surgical management of Lung Abcess Pulmonary Function Test(Major), ECHO 60900 61800 76125 77250
Histopathological Examination
Cardiogram, Aspirate For Culture/Acid-Fast
Bacilli (AFB) Culture
CT Scan Chest With Contrast, Chest X-Ray PA
Surgical management of Empyema View(1 Film), PUS Culture & Sensitivity,
620 33.32 S7 Chest X-Ray PA View(1 Film), 53340 54540 66675 68175
Thoracis Aspirate For Culture, Pulmonary Function
Test(Major)
Surgical management For Bronchial Bronchoscopy, CT Scan Chest Without
621 33.98 S7 Clinical Photograph, Bronchoscopy 63000 66000 78750 82500
Injuries due to foreign Body Contrast, Chest X-Ray PA View(1 Film)
CT Scan Chest With Contrast, Chest X-Ray PA
Surgical management of SolItary fibrous View(1 Film), Fine Needle Aspiration Cytology Chest X-Ray PA View(1 Film), Routine
622 34.3.1 S7 60900 61800 76125 77250
tumor- Mediastinum (FNAC), Pulmonary Function Test(Major), Histopathological Examination
ECHO Cardiogram
CT Scan Chest With Contrast, Chest X-Ray PA
Surgical Management Of Thymoma View(1 Film), Fine Needle Aspiration Cytology Chest X-Ray PA View(1 Film), Routine
623 34.3.5 S7 67980 69480 84975 86850
Mediastinum (FNAC), Pulmonary Function Test(Major), Histopathological Examination
ECHO Cardiogram
CT Scan Chest With Contrast, Chest X-Ray PA
624 34.51 S7,S11 Decortication of lung View(1 Film), Pulmonary Function Chest X-Ray PA View(1 Film) 60300 60600 75375 75750
Test(Major), ECHO Cardiogram
CT Scan Chest Without Contrast, Chest X-Ray
Surgical management of Bronchopleural
625 34.73.1 S7,S11 PA View(1 Film), Bronchoscopy, Pulmonary Chest X-Ray PA View(1 Film) 68740 69940 85925 87425
Fistula -Thorocoplasty
Function Test(Major), ECHO Cardiogram

CT Scan Chest Without Contrast, Chest X-Ray


Transpleural Bronchopleural Fistula
626 34.73.2 S7 PA View(1 Film), Bronchoscopy, Pulmonary Chest X-Ray PA View(1 Film) 65600 66200 82000 82750
closure
Function Test(Major), ECHO Cardiogram
Surgical management of Bronchopleural CT Scan Chest Without Contrast, Chest X-Ray
627 34.73.3 S7,S11 Chest X-Ray PA View(1 Film) 75450 75750 94313 94688
Fistula - Myoplasty PA View(1 Film), Bronchoscopy
Barium Studies,CT Scan Chest Without
Surgical management of Diaphragmatic
628 34.81 S7 Contrast,Chest X-Ray PA View(1 Film)/USG USG Abdomen, Chest X-Ray PA View(1 Film), 52700 55400 65875 69250
Eventeration
Abdomen,
Surgical management of Diaphragmatic CT Scan Chest Without Contrast, Chest X-Ray USG Abdomen, Chest X-Ray PA View(1 Film),
629 34.82 S7 57090 59190 71363 73988
injuries, Thoraco Abdominal approach PA View(1 Film), ECHO Cardiogram ECHO Cardiogram
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Procedure private ward - Private ward - private ward - Private ward -
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
ECHO Cardiogram ,TEE (Transesophageal
Chest X-Ray PA View(1 Film), ECHO
630 35.0 S7 Balloon Valvotomy Echocardiogram), Chest X-Ray PA View(1 26590 27190 33238 33988
Cardiogram , ECG (Electro Cardiogram)
Film), ECG (Electro Cardiogram)
ECHO Cardiogram , ECG (Electro
ECHO Cardiogram Showing Prosthetic Ring In
631 35.1 S7 Valve repair without Prosthetic Ring Cardiogram), TEE (Transesophageal 110600 111200 138250 139000
Situ, Chest X-Ray PA View(1 Film)
Echocardiogram)
ECHO Cardiogram , ECG (Electro ECHO Cardiogram , Chest X-Ray PA View(1
632 35.02 S7 Closed Mitral Valvotomy 40590 41190 50738 51488
Cardiogram), Chest X-Ray PA View(1 Film) Film)
Total Correction Of Complex Congenital ECHO Cardiogram , CT Scan Chest Without
ECHO Cardiogram , Chest X-Ray PA View(1
633 35.8 S7 Heart Disease With Special Conduits Contrast ,CT Angiography (Coronary 191500 193000 239375 241250
Film)
(Xeno Graft) Angiography), Chest X-Ray PA View(1 Film)
Ross procedure - Intracardiac repair of ECHO Cardiogram , ECG (Electro
634 35.11 S7 complex congenitalheart diseases without Cardiogram), CT Angiography (Coronary ECHO Cardiogram 111900 114300 139875 142875
Special Conduits Angiography)
ECHO Cardiogram , ECG (Electro ECG (Electro Cardiogram), ECHO Cardiogram ,
635 35.12 S7 Mitral valvotomy (Open) 110600 111200 138250 139000
Cardiogram), Chest X-Ray PA View(1 Film) Chest X-Ray PA View(1 Film), Procedure CD

ECHO Cardiogram , ECG (Electro ECG (Electro Cardiogram), ECHO Cardiogram ,


636 35.13 S7 Open Pulmonary Valvotomy 79690 82390 99613 102988
Cardiogram) Chest X-Ray PA View(1 Film), Procedure CD
ECHO Cardiogram , ECG (Electro
ECHO Cardiogram , Chest X-Ray PA View(1
637 35.20.1 S7 Valve repair with Prosthetic Ring Cardiogram), TEE (Transesophageal 140900 141800 176125 177250
Film), Procedure CD
Echocardiogram)
ECHO Cardiogram , ECG (Electro ECHO Cardiogram , Chest X-Ray PA View(1
638 35.20.2 S7 Double valve replacement (With Valve) 178590 179190 223238 223988
Cardiogram), Chest X-Ray PA View(1 Film) Film)
Double valve replacement With Bio ECHO Cardiogram , ECG (Electro ECHO Cardiogram Showing Prosthetic Ring In
639 35.20.3 S7 198600 199200 248250 249000
Prosthetic Valve Cardiogram), Chest X-Ray PA View(1 Film) Situ, Procedure CD
ECHO Cardiogram , ECG (Electro ECHO Cardiogram Showing Valve In Situ
640 35.21 S7 Aortic Valve Replacement (With Valve) 120590 121190 150738 151488
Cardiogram), Chest X-Ray PA View(1 Film) ,Chest X-Ray PA View(1 Film), Procedure CD
ECHO Cardiogram , ECG (Electro
Ross procedure - Intracardiac repair of
Cardiogram), CT Angiography (Coronary
641 35.22.1 S7 complex congenital heart diseases with ECHO Cardiogram Showing Conduits In Situ 151490 152990 189363 191238
Angiography), Chest X-Ray PA View(1 Film),
Special Conduits
MRI Angiogram
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
ECHO Cardiogram , CT Scan Chest Without
Contrast, CT Angiography (Coronary Chest X-Ray PA View(1 Film), ECHO
Surgical management of Annulus Aortic
642 35.22.2 S7 Angiography), CT Aortography, Chest X-Ray Cardiogram , CT Angiography (Coronary 168430 169030 210538 211288
Ectasia With Valved Conduits
PA View(1 Film), TEE (Transesophageal Angiography)
Echocardiogram), MRI Angiogram
ECHO Cardiogram , ECG (Electro
Arotic Valve Replacement With ECHO Cardiogram Showing Valve In Situ,
643 35.22.3 S7 Cardiogram), Chest X-Ray PA View(1 165600 166200 207000 207750
Bioprosthetic Valve Chest X-Ray PA View(1 Film), Procedure CD
Film),TEE (Transesophageal Echocardiogram)
ECHO Cardiogram , ECG (Electro
ECHO Cardiogram Showing Valve In Situ , X-
644 35.23 S7 Mitral Valve Replacement (With Valve) Cardiogram), Chest X-Ray PA View(1 Film), 146200 147400 182750 184250
ray, Procedure CD
TEE (Transesophageal Echocardiogram)
Replacement of Mitral valve with ECHO Cardiogram , ECG (Electro ECHO Cardiogram Showing Valve In Situ,
645 35.24 S7 160600 161200 200750 201500
Bioprosthetic valve low Profile Cardiogram), Chest X-Ray PA View(1 Film) Procedure CD
ECHO Cardiogram , ECG (Electro
Tricuspid valve Replacement (With ECHO Cardiogram Showing Valve In Situ , X-
646 35.27 S7 Cardiogram), Chest X-Ray PA View(1 Film), 144840 145440 181050 181800
Valve) ray, Procedure CD
TEE (Transesophageal Echocardiogram)
ECHO Cardiogram , ECG (Electro
Tricuspid valve Replacement with Bio ECHO Cardiogram Showing Valve In Situ, X-
647 35.28 S7 Cardiogram), Chest X-Ray PA View(1 Film), 160600 161200 200750 201500
Prosthetic ray, Procedure CD
TEE (Transesophageal Echocardiogram)
ECHO Cardiogram , ECG (Electro
ECHO Cardiogram , ECG (Electro Cardiogram),
648 35.41 S7 Balloon Atrial Septostomy Cardiogram), Chest X-Ray PA View(1 Film), 33970 34570 42463 43213
Procedure CD
TEE (Transesophageal Echocardiogram)
ECHO Cardiogram , ECG (Electro
Cardiogram), With Device QuantificatioN, ECHO Cardiogram Showing Device In Situ,
649 35.51 S7 ASD Device Closure 80590 81190 100738 101488
Chest X-Ray PA View(1 Film), TEE Chest X-Ray PA View(1 Film), Procedure CD
(Transesophageal Echocardiogram)
ECHO Cardiogram , ECG (Electro
ECHO Cardiogram Showing Device In Situ,
650 35.53 S7 VSD Device Closure Cardiogram), Cd With Device Quantification, 80600 81200 100750 101500
Chest X-Ray PA View(1 Film), Procedure CD
Chest X-Ray PA View(1 Film)
ECHO Cardiogram , ECG (Electro
Cardiogram), Chest X-Ray PA View(1 Film),
651 35.71 S7 Intra Cardiac Repair Of ASD ECHO Cardiogram 82100 84200 102625 105250
TEE (Transesophageal Echocardiogram), CT
Angiography (Coronary Angiography)
ECHO Cardiogram , ECG (Electro
652 35.72 S7 Intracardiac Repair Of VSD Cardiogram), Chest X-Ray PA View(1 Film), ECHO Cardiogram 87100 89200 108875 111500
CT Angiography (Coronary Angiography)
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
ECHO Cardiogram , ECG (Electro
Cardiogram), CT Angiography (Coronary ECHO Cardiogram , Chest X-Ray PA View(1
653 35.81 S7 Total Correction of Tetralogy of Fallot 105770 107270 132213 134088
Angiography), Chest X-Ray PA View(1 Film), Film)
MRI Angiogram
ECHO Cardiogram , ECG (Electro
surgical management (Correction) of ECHO Cardiogram , Chest X-Ray PA View(1
654 35.82 S7 Cardiogram), Chest X-Ray PA View(1 Film), 122530 125230 153163 156538
TAPVC Film)
TEE (Transesophageal Echocardiogram)
ECHO Cardiogram , ECG (Electro
ECHO Cardiogram Showing Stent In Situ, Chest
Cardiogram), Chest X-Ray PA View(1 Film),
655 35.83.1 S7 Patent Ductus Arterious - Stenting X-Ray PA View(1 Film), ECG (Electro 75600 76200 94500 95250
TEE (Transesophageal Echocardiogram), ECG
Cardiogram)
(Electro Cardiogram)
ECHO Cardiogram Showing Device In Situ
ECHO Cardiogram , ECG (Electro Chest X-Ray PA View(1 Film), ECG (Electro
656 35.83.2 S7 Patent Ductus Arterious - Device Closure 74410 76510 93013 95638
Cardiogram), With Device Quantification Cardiogram), Procedure CD, Device empty
pouch
ECHO Cardiogram Showing coil In Situ Chest
Patent Ductus Arterious - Single Coil ECHO Cardiogram , ECG (Electro X-Ray PA View(1 Film), ECG (Electro
657 35.83.3 S7 25600 26200 32000 32750
Closure Cardiogram), With Device Quantification Cardiogram), Procedure CD, Device empty
pouch
ECHO Cardiogram Showing coil In Situ Chest
Patent Ductus Arterious - Multiple Coils ECHO Cardiogram , ECG (Electro X-Ray PA View(1 Film), ECG (Electro
658 35.83.4 S7 35600 36200 44500 45250
Closrue Cardiogram), With Device Quantification Cardiogram), Procedure CD, Device empty
pouch
ECHO Cardiogram , ECG (Electro Scar Photo, ECHO Cardiogram , ECG (Electro
659 35.83.5 S7 Surgery for-PDA 41200 42400 51500 53000
Cardiogram), Chest X-Ray PA View(1 Film) Cardiogram), Chest X-Ray PA View(1 Film)

ECHO Cardiogram , CT Scan Chest Without


Chest X-Ray PA View(1 Film), ECHO
660 35.84 S7 TGA - Arterial Switch Contrast ,CT Angiography (Coronary 151500 153000 189375 191250
Cardiogram
Angiography), Chest X-Ray PA View(1 Film)
ECHO Cardiogram , CT Scan Chest Without
Chest X-Ray PA View(1 Film), ECHO
661 35.91 S7 TGA - Sennings Procedure Contrast ,CT Angiography (Coronary 151500 153000 189375 191250
Cardiogram
Angiography)
ECHO Cardiogram , CT Scan Chest Without
Contrast ,CT Angiography (Coronary Chest X-Ray PA View(1 Film), ECHO
662 36.1.1 S7 Coronary Bypass Surgery 116440 117040 145550 146300
Angiography), Chest X-Ray PA View(1 Film), Cardiogram
ECG (Electro Cardiogram)
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Post PTCA-CT Angiography (Coronary
Coronary Bypass Surgery-Post ECHO Cardiogram , Chest X-Ray PA View(1
663 36.1.2 S7 Angiography), Chest X-Ray PA View(1 Film), 120520 122320 150650 152900
Angioplasty Film), ECG (Electro Cardiogram), Scar Photo
ECG (Electro Cardiogram)
ECHO Cardiogram , ECG (Electro
664 36.1.3 S7 CABG With IABP Pump(37.61) Cardiogram), CT Angiography (Coronary Clinical Photograph With Iabp Along With Face 160480 163180 200600 203975
Angiography), Coronary Angiogram
ECHO Cardiogram , ECG (Electro
Cardiogram), CT Angiography (Coronary
ECHO Cardiogram , Chest X-Ray PA View(1
665 36.1.4 S7 CABG With Aneurysmal Repair(39.52) Angiography), MRI Chest Without Contrast, 156950 159650 196188 199563
Film)
CT Scan Chest With Contrast/CT Scan Chest
Without Contrast
Surgery For Anomalous left coronary ECHO Cardiogram , CT Scan Chest Without
ECHO Cardiogram , Chest X-Ray PA View(1
666 36.11 S7 artery from the pulmonary artery Contrast ,CT Angiography (Coronary 115980 116580 144975 145725
Film)
(ALCAPA) Angiography), Coronary Angiogram
ECHO Cardiogram , ECG (Electro ECHO Cardiogram , Chest X-Ray PA View(1
667 37.0 S7 Pericardiocentesis 16490 17990 20613 22488
Cardiogram), Chest X-Ray PA View(1 Film) Film), PUS Culture & Sensitivity
ECHO Cardiogram , ECG (Electro
ECG (Electro Cardiogram), Pacemaker Sticker
Cardiogram), CT Angiography (Coronary
668 37.8 S7 Permanent Pacemaker Implantation with bar Code, Chest X-Ray PA View(1 Film), 77090 79190 96363 98988
Angiography), Pacemaker Sticker with bar
Scar Photo
Code, Holter/24 Hr Ecg (Monitering)
ECHO Cardiogram , ECG (Electro ECHO Cardiogram , Chest X-Ray PA View(1
669 37.12 S7 Pericardiostomy 26190 27390 32738 34238
Cardiogram), Chest X-Ray PA View(1 Film) Film), PUS Culture & Sensitivity
Medical Management Of Valvular Heart
ECHO Cardiogram , ECG (Electro
670 37.23.1 S7 Diseases -Requiring Cardiac ECHO Cardiogram 18550 19450 23188 24313
Cardiogram)
Catheterization
Medical Management Of Congenital
ECHO Cardiogram , ECG (Electro
671 37.23.2 S7 Heart Diseases -Requiring Cardiac ECHO Cardiogram 18560 19460 23200 24325
Cardiogram)
Catheterization
ECHO Cardiogram CD, ECG (Electro
ECHO Cardiogram , Routine Histopathological
672 37.31 S7 Pericardiectomy Cardiogram), CT Scan Chest With Contrast/CT 50650 51850 63313 64813
Examination
Scan Chest Without Contrast/
ECHO Cardiogram , ECG (Electro
Surgical Treatment For MVR And Atrial Cardiogram),Holter/24 Hr Ecg (Monitering), Chest X-Ray PA View(1 Film), ECG (Electro
673 37.33.1 S7 170600 171200 213250 214000
Fibrillation- Maze Method Coronary Angiogram, Chest X-Ray PA View(1 Cardiogram)
Film)
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
ECHO Cardiogram , ECG (Electro
Surgical Treatment For MVR And Atrial ECG (Electro Cardiogram), Chest X-Ray PA
674 37.33.2 S7 Cardiogram),Holter/24 Hr Ecg (Monitering), 119480 120080 149350 150100
Fibrillation- Cryoablation Method View(1 Film)
Chest X-Ray PA View(1 Film)
Surgical Treatment For MVR And Atrial ECHO Cardiogram , ECG (Electro
675 37.33.3 S7 ECG (Electro Cardiogram) 169700 170300 212125 212875
Fibrillation- Hifu Method Cardiogram),Holter/24 Hr Ecg (Monitering)
ECHO Cardiogram , CT Angiography
(Coronary Angiography),MRI Chest With ECHO Cardiogram , Routine Histopathological
676 37.34 S7 Surgery For Intracardiac Tumors 102100 104200 127625 130250
Contrast ,CT Scan Chest With Contrast, Chest Examination, Chest X-Ray PA View(1 Film)
X-Ray PA View(1 Film)
ECHO Cardiogram , Chest X-Ray PA View(1 ECHO Cardiogram , Chest X-Ray PA View(1
677 37.49.1 S7 Surgery for Cardiac injuries Without CPB 72400 74800 90500 93500
Film) , ECG (Electro Cardiogram) Film)
ECHO Cardiogram , Chest X-Ray PA View(1 ECHO Cardiogram , Chest X-Ray PA View(1
678 37.49.2 S7 Surgery for Cardiac injuries With CPB 94360 96760 117950 120950
Film), ECG (Electro Cardiogram), Film)
ECHO Cardiogram , ECG (Electro
Cardiogram), CT Angiography (Coronary ECG (Electro Cardiogram), Pacemaker Sticker
679 37.78 S7 Temporary Pacemaker Implantation 13600 14200 17000 17750
Angiography), Pacemaker Sticker with bar with bar Code, Scar Photo
Code
CT Scan Limbs Without Contrast ,Digital
680 38.0 S7 Peripheral Embolectomy Without Graft Subtraction Angiography(DSA Peripheral Scar Photo, Colour Doppler - Lower Limbs 29990 29990 37488 37488
Artery\Arteries), Doppler Of Peripheral Vessels
CT Scan Limbs Without Contrast ,Digital
Subtraction Angiography(DSA Peripheral
681 38.1 S7 Arterial Embolectomy Scar Photo, Colour Doppler - Lower Limbs 29990 29990 37488 37488
Artery\Arteries),Colour Doppler - Lower Limbs
-
Digital Subtraction Angiography(DSA Scar Photo, Routine Histopathological
682 38.3 S7 Surgical management of Vascular Tumors Peripheral Artery\Arteries)/MRI Angiography Examination , Color Doppler Sonography Single 40890 41790 51113 52238
With Contrast Study
Venous Doppler , Lung Ventilation & Perfusion Abdomen Radiograph Supine Or Erect(1
683 38.7.1 S7 DVT - Ivc Filter implantation Scan, Clinical Photograph, USG Abdomen, Film),Venous Doppler, IVC Filter - 100590 101190 125738 126488
Procedure CD permanent/Pacemaker Sticker with bar Code
CT Local Area,CT Angiography
Colour Doppler Study Of Neck Vessels, Scar
684 38.12.1 S7 TGA - Carotid Embolectomy Neck\Chest(Cartotid Angiography), Colour 72100 74200 90125 92750
Photo
Doppler Study Of Neck Vessels
CT Scan Chest Without Contrast, Pulmonary
Color Doppler Sonography Single Study, Scar
685 38.15 S7 Pulmonary Thrombo Embolectomy Angiogram(CT Angio Chest), Color Doppler 149590 150190 186988 187738
Photo
Sonography Single Study
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Colour Doppler Study Abdominal Aorta And
ECHO Cardiogram , CT Angiography
686 38.34.1 S7 Coarctation-Arota Repair Without Graft Both Lower Limbs, Scar Photo, ECHO 70600 71200 88250 89000
(Coronary Angiography)
Cardiogram , Chest X-Ray PA View(1 Film)
ECHO Cardiogram , CT Angiography
Doppler Study Abdominal Aorta And Both
Coaractation of Aorta Repair Without (Coronary Angiography) With Doppler Study
687 38.34.2 S7 Lower Limbs, , ECHO Cardiogram , Case Sheet 30980 31580 38725 39475
Stent+ Aortoplasty(35.11) Abdominal Aorta And Both Lower Limbs,
with operation Notes, Aortogram, Scar Photo
Aortogram, Case sheet with clinical History
Pulmonary Angiogram(CT Angio Chest), Color
Colour Doppler Study Abdominal Aorta And
Intrathoracic Aneurysm -Aneurysm Not
688 38.35 S7 Doppler Sonography Single Study, CT Both Lower Limbs, Scar Photo, ECHO 100600 101200 125750 126500
Requiring Bypass
Aortography Cardiogram , Chest X-Ray PA View(1 Film)
Scar Photo, ECHO Cardiogram , Chest X-Ray
689 38.40.1 S7 Aneurysm Resection & Grafting ECHO Cardiogram , Angiography, Cd 184390 184990 230488 231238
PA View(1 Film)
Medium Size Arterial Aneurysms - Repair Color Doppler Sonography Single Study, Scar
690 38.40.2 S7 CT Angiogram Abdomen, Clinical Photograph 95600 96200 119500 120250
With Synthetic Graft Photo
Excision Of Vascular Tumors With Color Doppler Sonography Single Study, Color Doppler Sonography Single Study, Scar
691 38.40.3 S7 75890 76790 94863 95988
Prosthetic Graft Clinical Photograph Photo
Color Doppler Sonography Single Study, 2D
Coaractation of Aorta Repair With Stent ECHO With Colour Doppler, Case Sheet with
692 38.44.1 S7 ECHO Cardiogram , Angiography, CD 80600 81200 100750 101500
+ Aortoplasty(35.11) operation Notes, Aortogram With Stents
Demonstration, Scar Photo
ECHO Cardiogram , Angiography, CD, Chest Color Doppler Sonography Single Study, Scar
693 38.44.2 S7 Coarctation-Arota Repair With Graft 100600 101200 125750 126500
X-Ray PA View(1 Film) Photo
CT Scan Abdomen Without Contrast/MRI CT Scan Abdomen Without Contrast/MRI
Thoraco Abdominal Aneurysm Or
694 38.44.3 S7 Abdomen Without Contrast, Chest X-Ray PA Abdomen Without Contrast, Scar Photo, Chest 201500 203000 251875 253750
Dissection Repair With Graft(38.45)
View(1 Film), ECHO Cardiogram X-Ray PA View(1 Film), ECHO Cardiogram
Intrathoracic Aneurysm -Requiring ECHO Cardiogram , Pulmonary Color Doppler Sonography Single Study, Chest
695 38.45 S7 185600 186200 232000 232750
Bypass (With Graft) Angiogram(CT Angio Chest), CD X-Ray PA View(1 Film), Scar Photo
Excision Of Arterio Venous Color Doppler Sonography Single Study, Color Doppler Sonography Single Study,
696 38.60.1 S7 90740 91490 113425 114363
Malformation - Large Clinical Photograph Routine Histopathological Examination
Excision Of Arterio Venous Color Doppler Sonography Single Study, Color Doppler Sonography Single Study, Scar
697 38.60.2 S7 44590 45190 55738 56488
Malformation - Small Clinical Photograph Photo
ECHO Cardiogram Showing Graft In Situ,
Systemic Pulmonary Shunts With Graft ECG (Electro Cardiogram), ECHO Cardiogram
698 39.0.1 S7 Procedure CD, Scar Photo, Chest X-Ray PA 64800 66000 81000 82500
TOF , CT Angiography (Coronary Angiography)
View(1 Film)
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
ECG (Electro Cardiogram), ECHO Cardiogram
Systemic Pulmonary Shunts Without ECHO Cardiogram, Procedure CD, Scar Photo,
699 39.0.2 S7 , CT Angiography (Coronary Angiography), 56290 57190 70363 71488
Graft TOF Chest X-Ray PA View(1 Film)
Procedure CD
Surgery for Arterial Injuries, Venous Angiography, Color Doppler Sonography Color Doppler Sonography Single Study, Scar
700 39.3.1 S7 25290 25590 31613 31988
Injuries Without Graft Single Study, Clinical Photograph Photo
Digital Subtraction Angiography(DSA
Surgical Management of Major Vascular
701 39.3.2 S7 Peripheral Artery\Arteries), Colour Doppler - Colour Doppler - Lower Limbs, Scar Photo 30290 30590 37863 38238
Injury -In Lower Limbs
Lower Limbs, Clinical Photograph
Digital Subtraction Angiography(DSA
Surgical Management of Minor Vascular
702 39.3.3 S7 Peripheral Artery\Arteries), Colour Doppler - Colour Doppler - Lower Limbs, Scar Photo 19990 19990 24988 24988
Injury - Tibial Vessels In Leg
Lower Limbs, Clinical Photograph
Digital Subtraction Angiography(DSA
Surgical Management of Minor Vascular
703 39.3.4 S7 Peripheral Artery\Arteries), Colour Doppler - Colour Doppler - Lower Limbs, Scar Photo 19990 19990 24988 24988
Injury -Vessels In Foot
Lower Limbs, Clinical Photograph
CT Angiography Neck\Chest(Cartotid
Surgical Management of Neck Vascular
704 39.3.5 S7 Angiography) - , Colour Doppler Study Of Scar Photo 100300 100600 125375 125750
Injury - Carotid Vessels
Neck Vessels, Clinical Photograph
Surgical Management of Abdominal USG Abdomen, CT Angiogram Abdomen - , CT Angiogram Abdomen - , Colour Doppler
705 39.3.6 S7 Vascular Injuries - Aorta, Illac Arteries, Colour Doppler Study Abdominal Aorta And Study Abdominal Aorta And Both Lower Limbs, 100300 100600 125375 125750
Ivc, Iliac Veins Both Lower Limbs, Clinical Photograph Scar Photo
Surgical Management of Thoracic CT Scan Chest With Contrast ,Ultra Sound Color Doppler Sonography Single Study, CT
706 39.3.7 S7 150300 150600 187875 188250
Vascular Injuries Chest , Clinical Photograph Scan Chest With Contrast, Scar Photo
Surgical Management Of Abdominal CT Scan Abdomen With Contrast,Colour
CT Scan Abdomen With Contrast,USG
707 39.3.8 S7 Vascular Injuries - Aorta, Illac Arteries, Doppler Study Abdominal Aorta And Both 76500 78000 95625 97500
Abdomen, Clinical Photograph
Ivc, Iliac Veins Without Prosthetic Graft Lower Limbs, Scar Photo
Excicion Of Carotid Body Tumor With CT Angiography Neck\Chest(Cartotid Colour Doppler Study Of Neck Vessels, Routine
708 39.8.2 S7 80590 81190 100738 101488
Vascular Repair Angiography), Clinical Photograph Histopathological Examination
Excision Of Carotid Body Tumor With CT Angiography Neck\Chest(Cartotid Colour Doppler Study Of Neck Vessels, Routine
709 39.8.3 S7 100590 101190 125738 126488
Prosthetics Graft Repair Angiography), Clinical Photograph Histopathological Examination
CT Angiography Neck\Chest(Cartotid CT Angiography Neck\Chest(Cartotid
Carotid Artery Bypass With Synthetic
710 39.22 S7 Angiography), Colour Doppler Study Of Neck Angiography), Colour Doppler Study Of Neck 126090 128190 157613 160238
Graft
Vessels Vessels, Scar Photo
CT Angiogram Abdomen, Colour Doppler
Colour Doppler Study Abdominal Aorta And
711 39.23 S7 Aorto-Aorto Bypass With Graft Study Abdominal Aorta And Both Lower 102700 105400 128375 131750
Both Lower Limbs, Scar Photo
Limbs
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Digital Subtraction Angiography(DSA
712 39.25.1 S7 Femoro- Ileal Bypass With Graft Peripheral Artery\Arteries),Doppler Of Doppler Of Peripheral Vessels, Scar Photo 67100 69200 83875 86500
Peripheral Vessels
Digital Subtraction Angiography(DSA
713 39.25.2 S7 Femoro- Ileal Bypass Without Graft Peripheral Artery\Arteries),Doppler Of Doppler Of Peripheral Vessels, Scar Photo 47100 49200 58875 61500
Peripheral Vessels
CT Angiogram Abdomen, Colour Doppler
Aorto Billiac - Bifemoral Bypass With Colour Doppler Study Abdominal Aorta And
714 39.25.3 S7 Study Abdominal Aorta And Both Lower 128300 131600 160375 164500
Synthetic Graft Both Lower Limbs
Limbs, Clinical Photograph
Color Doppler Sonography Single Study, Scar
715 39.26 S7 Aorto-Aorto Bypass Without Graft CT Angiogram Abdomen 87100 89200 108875 111500
Photo
Colour Doppler Of Specific Limb, Renal
716 39.27.1 S7 A V Fistula surgery (creation) at Wrist Colour Doppler Of Specific Limb, Scar Photo 10590 11190 13238 13988
Profile, USG Abdomen,
Colour Doppler Of Specific Limb, Renal
717 39.27.2 S7 A. V Fistula surgery (creation) At Elbow Colour Doppler Of Specific Limb, Scar Photo 10590 11190 13238 13988
Profile, USG Abdomen
CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
718 39.29.1 S7 Femoro- Poplitial Bypass With Graft 67100 69200 83875 86500
Angiography, Clinical Photograph Photo
CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
719 39.29.2 S7 Femoro- Poplitial Bypass Without Graft 47100 49200 58875 61500
Angiography, Clinical Photograph Photo
CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
720 39.29.3 S7 Femoro-Femoral Bypass With Graft 67100 69200 83875 86500
Angiography, Clinical Photograph Photo
CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
721 39.29.4 S7 Femoro-Femoral Bypass Without Graft 47100 49200 58875 61500
Angiography, Clinical Photograph Photo
Axillo Bifemoral Bypass With Synthetic Color Doppler Sonography Single Study, Color Doppler Sonography Single Study, Scar
722 39.29.5 S7 100890 101790 126113 127238
Graft Clinical Photograph Photo
CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
723 39.29.6 S7 Femoro Distal Bypass With Vein Graft 60600 61200 75750 76500
Angiography, Clinical Photograph Photo
Femoro Distal Bypass With Synthetic CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
724 39.29.7 S7 80900 81800 101125 102250
Graft Angiography, Clinical Photograph Photo
Axillo Brachial Bypass Using With CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
725 39.29.8 S7 71800 73600 89750 92000
Synthetic Graft Angiography, Clinical Photograph Photo
Brachio - Radial Bypass With Synthetic CT Scan Limbs With Contrast Including CT Color Doppler Sonography Single Study, Scar
726 39.29.9 S7 59590 60190 74488 75238
Graft Angiography, Clinical Photograph Photo
Abdomen And Pelvis For Kidneys, Ureters,
Doppler Of Renal Arteries, CT Scan Abdomen
And Bladder (KUB) ,CT Scan Abdomen With
727 39.50.2 S7 Renal Angioplasty With Contrast, Stent bar code Details/Scar 60600 61200 75750 76500
Contrast,Renal Angiogram,Doppler Of Renal
Photo
Arteries, ECHO Cardiogram
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Digital Subtraction Angiography(DSA
Peripheral Artery\Arteries) / CT Angiography Doppler Of Peripheral Vessels, Stent bar code
728 39.50.3 S7 Peripheral Angioplasty 60590 61190 75738 76488
(Coronary Angiography)/ Doppler Of Details/Scar Photo
Peripheral Vessels
Digital Subtraction Angiography(DSA Doppler Of Peripheral Vessels, Digital
Perpheral Angioplasty - Additional Peripheral Artery\Arteries),Extremities , Bones Subtraction Angiography(DSA Peripheral
729 39.50.4 S7 9000 9000 11250 11250
Stent(00.46) & Joints AP & Lateral View(2 Film) ,CT Artery\Arteries), Stent bar code Details/Scar
Angiography (Coronary Angiography) Photo
Digital Subtraction Angiography(DSA
Peripheral Artery\Arteries),Extremities , Bones Color Doppler Sonography Single Study, CT
730 39.52.1 S7 Small Arterial Aneurysms - Repair 20590 21190 25738 26488
& Joints AP & Lateral View(2 Film) ,CT Angiogram Abdomen , Scar Photo
Angiography (Coronary Angiography)
Abdomen Radiograph Supine Or Erect(1
Color Doppler Sonography Single Study, CT
731 39.52.2 S7 Medium Size Arterial Aneurysms - Repair Film),CT Angiogram Abdomen , Clinical 25590 26190 31988 32738
Angiogram Abdomen , Scar Photo
Photograph
CT Angiography (Coronary Angiography),
surgical management of Ruptured Sinus
732 39.52.3 S7 ECHO Cardiogram ,CT Scan Chest With ECHO Cardiogram, Scar Photo 132690 135390 165863 169238
Of Valsalva
Contrast, ECHO CD
Surgical management of Dissecting ECHO Cardiogram ,CT Angiogram Abdomen, Color Doppler Sonography Single Study, Scar
733 39.54 S7 180590 181190 225738 226488
Aneurysms ECHO CD Photo
Surgical Management of Vascular Injury
Colour Doppler Of Specific Limb,CT Scan Colour Doppler Of Specific Limb,CT Scan
In Upper Limbs -
734 39.56.1 S7 Limbs With Contrast Including CT Limbs With Contrast Including CT Angiography, 20290 20590 25363 25738
Axillary,Branchial,Radial And Ulnar -
Angiography, Clinical Photograph Scar Photo
With Vein Graft
Surgical Management of Vascular Injury CT Angiography (Coronary Angiography), CT Angiography (Coronary Angiography), Scar
735 39.56.2 S7 30290 30590 37863 38238
With Vein Graft Clinical Photograph Photo
CT Angiography (Coronary Angiography), CT Angiography (Coronary Angiography),
Surgical Management of Vascular Injury
736 39.57.2 S7 Color Doppler Sonography Single Study, Color Doppler Sonography Single Study, Scar 40890 41790 51113 52238
With Prosthetic Graft
Clinical Photograph Photo
Surgical Management Of Neck Vascular CT Angiography Neck\Chest(Cartotid CT Angiography Neck\Chest(Cartotid
737 39.57.3 S7 Injury - Carotid Vessels - With Prosthetic Angiography),Colour Doppler Study Of Neck Angiography),Colour Doppler Study Of Neck 101200 102400 126500 128000
Graft Vessels, Clinical Photograph Vessels, Scar Photo
Surgical Management Of Major Vascular CT Scan Limbs With Contrast Including CT CT Scan Limbs With Contrast Including CT
738 39.57.4 S7 Injury -In Lower Limbs With Prosthetic Angiography,Colour Doppler Of Specific Limb, Angiography,Colour Doppler Of Specific Limb, 71490 72990 89363 91238
Graft Clinical Photograph Scar Photo
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Surgical Management Of Abdominal CT Angiogram Abdomen,Colour Doppler
CT Angiogram Abdomen,Colour Doppler Study
739 39.57.5 S7 Vascular Injuries - Aorta, Illac Arteries, Study Abdominal Aorta And Both Lower 70600 71200 88250 89000
Abdominal Aorta And Both Lower Limbs
Ivc, Iliac Veins With Prosthetic Graft Limbs, Clinical Photograph
Surgical Management Of Vascular Injury
CT Scan Limbs With Contrast Including CT CT Scan Limbs With Contrast Including CT
In Upper Limbs -
740 39.57.6 S7 Angiography,Colour Doppler Of Specific Limb, Angiography,Colour Doppler Of Specific Limb, 70300 70600 87875 88250
Axillary,Branchial,Radial And Ulnar -
Clinical Photograph Scar Photo
With Prosthetic Graft
Gastro Study Followed By Thoracotomy
CT Scan Abdomen With Contrast, Upper GI
741 42.9 S7 & Repairs For Oesophageal Injury For CT Scan Abdomen With Contrast, Scar Photo 67100 69200 83875 86500
endoscopy
Corrosive Injuries/Fb

Surgical Management of Oesophageal Barium Studies, CT Scan Abdomen With


742 42.31 S7 USG Abdomen, Scar Photo 52700 55400 65875 69250
Diverticula /Achalasia Cardia Contrast,USG Abdomen, Upper GI endoscopy
Routine Histopathological Examination, USG
USG Abdomen, CT scan Lower Abdomen Abdomen/CT scan Lower Abdomen Without
Surgical Management of Diaphragmatic
743 53.8 S7 Without Contrast/CT Scan Abdomen Without Contrast/CT Scan Abdomen Without 61800 63600 77250 79500
Hernia
Contrast Contrast/CT Scan Abdomen With Contrast, Scar
Photo
Clinical Photograph, Routine Histopathological
744 98.15.1 S7,S8 Bronchoscopic Foreign body removal Clinical Photograph, Procedure CD 20290 20590 25363 25738
Examination
S8 PAEDIATRIC SURGERIES
CT-Scan Brain Plain And Contrast, CT Angio Of
CT-Scan Brain Plain And Contrast, Clinical
745 02.1 S8 Surgical management of Encephalocele Brain(Head) /MRI Brain Without Contrast , Scar 42980 43880 53725 54850
Photograph
Photo
USG Abdomen/ CT Scan Abdomen Without Routine Histopathological Examination, Scar
746 05.2 S8 Surgical management of Neuroblastoma 48370 50470 60463 63088
Contrast/ CT Scan Abdomen With Contrast Photo
Urinary VMA, Urinary Metanephrine/Nor
metanephrine,Urinary
Adrenal Gland Surgeries In Paediatric USG Abdomen,Routine Histopathological
747 07.2 S8 Catecholamines,Aldosterone - Urine,24 hour 50330 53330 62913 66663
patients(07.3&07.4) Examination
free cortisol,USG Abdomen / CT Scan
Abdomen With Contrast
748 16.49.1 S8 Execision of pediatric tumors CT Local area , Bone scan Routine Histopathological Examination 53600 57200 67000 71500
Surgical treatment for Preauricular sinus Routine Histopathological Examination, Scar
749 18.21.2 S8 Clinical Photograph 10600 11200 13250 14000
in pediatric patient Photo
Surgical correction of Microtia/Anotia In
750 18.71 S8 Clinical Photograph Clinical Photograph 35840 38840 44800 48550
Paediatric Patient
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
751 27.43.1 S8 Excision of Retention Cyst Lip Clinical Photograph Routine Histopathological Examination 3060 3360 3825 4200
Surgical correction of Cleft Lip in
752 27.54.3 S8 Clinical Photograph Clinical Photograph 27090 29190 33863 36488
children
753 27.62 S8,S14 Surgical correction of Cleft Palate Clinical Photograph Clinical Photograph 28000 31000 35000 38750
Surgical corection of Velo-Pharyngeal
754 27.69 S8,S14 Upper GI endoscopy , Fluoroscopy Case Sheet with operation Notes, Intra OP photo 38940 42540 48675 53175
Incompetence
Surgical management of Sinuses & Routine Histopathological Examination , Scar
755 29.52.2 S8 Clinical Photograph 21770 22670 27213 28338
Fistula of the neck in Paediatric Patient Photo
CT Scan Chest With Contrast, Chest X-Ray PA Chest X-Ray PA View(1 Film), Routine
756 32.2 S8 Excision ofThoracoscopic cysts 41500 43000 51875 53750
View(1 Film) Histopathological Examination
Open excision of Lung cyst In Paediatric CT Scan Chest With Contrast, Chest X-Ray PA Chest X-Ray PA View(1 Film), Routine
757 32.2.2 S8 41200 42400 51500 53000
Patient View(1 Film) Histopathological Examination
Mediastinal Cyst Excision In Paediatric CT Scan Chest With Contrast, Chest X-Ray PA Chest X-Ray PA View(1 Film), Routine
758 34.3.3 S8 66900 67800 83625 84750
Patients View(1 Film) Histopathological Examination
CT Scan Chest With Contrast/CT Scan Chest
Empyema decortication In Paediatric Chest X-Ray PA View(1 Film), Routine
759 34.06 S8 Without Contrast, Chest X-Ray PA View(1 32130 33630 40163 42038
Patients Histopathological Examination
Film),
CT Scan Chest With Contrast/CT Scan Chest
Empyema-ICD drainage In Paediatric
760 34.09 S8 Without Contrast, Chest X-Ray PA View(1 Chest X-Ray PA View(1 Film) 10900 11800 13625 14750
Patients
Film)
CT Scan Chest With Contrast/CT Scan Chest
Thoracoscopic Decortication In Paediatric Chest X-Ray PA View(1 Film), Routine
761 34.52 S8 Without Contrast, Chest X-Ray PA View(1 49500 51000 61875 63750
Patients Histopathological Examination
Film)
Surgical Correction of Thoracic Wall CT Scan Chest Without Contrast, Chest X-Ray Chest X-Ray PA View(1 Film), Clinical
762 34.74 S8 65910 66810 82388 83513
Defects PA View(1 Film), Clinical Photograph Photograph
Clinical Photograph, Routine Histopathological
763 39.99 S8 Excision of Haemangioma USG local area, Clinical Photograph 19120 19420 23900 24275
Examination
Surgical management of Lymphangioma
764 40.29.4 S8 USG local area, Clinical Photograph Routine Histopathological Examination 49190 50390 61488 62988
In Paediatric Patients
USG Abdomen, Routine Histopathological
765 41.5.5 S8 Paediatric Splenectomy (Non Traumatic) Chest X-Ray PA View(1 Film),USG Abdomen 44700 47400 55875 59250
Examination
Surgical management of Oesophageal
766 42.12 S8 Chest X-Ray PA View(1 Film) / USG Abdomen Contrast Esophagogram, Scar Photo 64590 67290 80738 84113
Atresia In Paediatric Patients
Surgical Correction of Thoracic Chest X-Ray PA View(1 Film), CT Scan Chest Chest X-Ray PA View(1 Film), Routine
767 42.42.4 S8 47240 49940 59050 62425
Duplications In Paediatric Patients With Contrast ,Ultra Sound Chest Histopathological Examination
Surgical Correction of Esophageal Upper GI endoscopy /X-Ray/ Barium Meal
768 42.85 S8 Scar Photo 60000 61500 75000 76875
Obstructions In Paediatric Patients Follow Through
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Surgical Correction of Esophageal Upper GI endoscopy , Barium Meal Follow
769 42.89 S8 Scar Photo 76170 79170 95213 98963
Substitutions In Paediatric Patients Through
Surgical management of - Gastric Outlet
770 43.3.2 S8 USG Abdomen Scar Photo 31200 32400 39000 40500
Obstructions In Paediatric Patients
Surgical management of Gastro CT Scan Abdomen With Contrast /Barium
771 44.66 S8 Scar Photo 38210 40010 47763 50013
Esophageal Reflux In Paediatric Patients Upper GI Study(Double Contrast)
Surgical Management of Intestinal Abdomen Radiograph Supine Or Erect(1 Film) -
772 45.3.3 S8 Atresias & Obstructions In Paediatric ,/USG Abdomen , Upper GI endoscopy/ Lower Scar Photo 65900 66800 82375 83500
Patients GI endoscopy
Surgical management of Intestinal Colono Scopy,Barium Enema (Single
773 45.4 S8 Routine Histopathological Examination 61500 63000 76875 78750
Polyposis In Paediatric Patients Contrast\Double Contrast)
Meckel's Diverticulectomy In Paediatric USG Abdomen /Radio Scintography, Clinical Routine Histopathological Examination /Scar
774 45.33.2 S8 43000 46000 53750 57500
Patients Photograph Photo
Stage 2 procedure for Anorectal
775 45.95.2 S8 Distal Cologram, Clinical Photograph Clinical Photograph 62100 64200 77625 80250
Malformations In Paediatric Patients
Stage 1 procedure for Anorectal
776 46.11.1 S8 Invertogram AP/ LAT, Clinical Photograph Scar Photo 49500 51000 61875 63750
Malformations In Paediatric Patients
Stage 1 procedure for Hirschprungs Barium Enema (Single Contrast\Double Routine Histopathological Examination/Scar
777 46.11.2 S8 48600 49200 60750 61500
Disease In Paediatric Patients Contrast), Clinical Photograph Photo
Feeding Jejunostomy In Paediatric
778 46.32.1 S8 Clinical Photograph Clinical Photograph 30350 31850 37938 39813
Patients
Scar Photo, Routine Histopathological
779 46.51.3 S8 Ileostomy closure In Paediatric Patients Clinical Photograph 26790 28590 33488 35738
Examination
Stage 2 procedure for Hirschprungs Barium Enema (Single Contrast\Double Routine Histopathological Examination/Scar
780 46.52.3 S8 73500 75000 91875 93750
Disease In Paediatric Patients Contrast), Clinical Photograph Photo
781 46.52.4 S8 Colostomy closure In Paediatric Patients Clinical Photograph Scar Photo 25900 26800 32375 33500
Surgical mangement of Acute Intestinal USG Abdomen, Abdomen Radiograph Supine Routine Histopathological Examination/Scar
782 46.99 S8 51000 54000 63750 67500
Obstruction In Paediatric Patients Or Erect(1 Film) Photo
783 48.36 S8 Rectal polypectomy In Paediatric Patients Proctoscopy, Clinical Photograph Routine Histopathological Examination 8300 8600 10375 10750
Laparoscopic Pull Through For Ano
784 48.41.1 S8 Distal Cologram Scar Photo 73800 75600 92250 94500
Rectal Anomalies In Paediatric Patients
Laparoscopic Pull Through Surgeries For
Barium Enema (Single Contrast\Double
785 48.41.2 S8 Hirschprungs Disease In Paediatric Scar Photo 73500 75000 91875 93750
Contrast), Clinical Photograph
Patients
Surgical mangement of Anal Fissure and
786 49.12 S8 Clinical Photograph Scar Photo 24090 25590 30113 31988
Fistula In Paediatric Patients
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Surgical Management of Biliary Atresia CT Scan Abdomen Without Contrast USG Routine Histopathological Examination, Scar
787 51.63 S8 71860 74260 89825 92825
& Choledochal Cyst In Paediatric Patients Abdomen, Bulida Scan (Hepatobiliary Scan) Photo
Magnetic Resonance
Cholangiopancreatography
USG Abdomen, Routine Histopathological
788 52.9 S8 Pancreatic surgery in Paediatric Patients (MRCP)/ERCP/USG Abdomen/CT Scan 76500 78000 95625 97500
Examination
Abdomen Without Contrast/CT Scan Abdomen
With Contrast
Unilateral Inguinal Hernia repair In
789 53.0 S8 Clinical Photograph Scar Photo 15300 15600 19125 19500
Paediatric Patients
Bilateral Inguinal Hernia repair In
790 53.1 S8 Clinical Photograph Scar Photo 20300 20600 25375 25750
Paediatric Patients
Lumbar Hernia repair In Paediatric
791 53.9.2 S8 Clinical Photograph Scar Photo 16800 18600 21000 23250
Patients
Femoral Hernia repair In Paediatric
792 53.21 S8 Clinical Photograph Scar Photo 15300 15600 19125 19500
Patients
Umbilical Hernia repair In Paediatric
793 53.42.2 S8 USG Abdomen Scar Photo 20300 20600 25375 25750
Patients
Incisional Hernia repair In Paediatric
794 53.51.2 S8 Clinical Photograph Scar Photo 32700 35400 40875 44250
Patients
Open repair of diaphragmatic hernia in
795 53.72.1 S8 Chest X-Ray PA View(1 Film), X RAY Chest PA View, Scar Photo 75630 76530 94538 95663
Paediatric patients
Correction of Vitello intestinal duct
796 54.3.2 S8 USG Abdomen, Clinical Photograph Scar Photo 39960 41160 49950 51450
anomalies in Paediatric Patients
797 54.7 S8,S14 Repair of Abdominal wall defects USG Abdomen, Clinical Photograph Scar Photo 76500 78000 95625 97500
USG Abdomen/CT scan Lower Abdomen
Surgical management of Abdominal
798 54.9 S8 Without Contrast/CT Scan Abdomen Without USG Abdomen, Scar Photo 62400 64800 78000 81000
trauma in Paediatric Patients
Contrast,
Surgical management of peritonitis in Abdomen Radiograph Supine Or Erect(1 Film),
799 54.11 S8 Scar Photo 40900 41800 51125 52250
Paediatric Patients USG Abdomen
Correction of Duplications of alimentary Routine Histopathological Examination, Scar
800 54.99.2 S8 USG/,CT SCAN SCAN 48660 50160 60825 62700
tract in Paediatric Patients Photo
USG Abdomen / Abdomen And Pelvis For
Renal calculi-nephrolithotomy in X-Ray Abdomen And Pelvis For Kidneys,
801 55.03.1 S8 Kidneys, Ureters, And Bladder (KUB) / CT 34010 35810 42513 44763
Paediatric Patients Ureters, And Bladder (KUB), Scar Photo
Scan Lower Abdomen With Contrast
Intra Veneous Pyelogram, USG Abdomen/CT USG Abdomen/ Routine Histopathological
802 55.5.1 S8,S9 Simple Nephrectomy 41200 42400 51500 53000
Scan Lower Abdomen With Contrast Examination, Scar Photo
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Surgical Management of Congenital
803 55.8 S8 USG Abdomen / 99 TC Dtpa Renogram USG Abdomen, Scar Photo 56210 57710 70263 72138
Hydronephrosis in Paediatric Patients
804 56.2.1 S8,S9 Open ureterolithotomy USG Abdomen/Intra Veneous Pyelogram USG Abdomen, Scar Photo 30290 31790 37863 39738
805 56.6 S8 Ureterostomy in Paediatric Patients USG Abdomen/Intra Veneous Pyelogram Scar Photo 33850 35350 42313 44188
USG Abdomen / Micturating Cystourethrogram
806 56.74.1 S8,S9 Ureteric Reimplantations USG Abdomen, Scar Photo 36570 38370 45713 47963
(MCUG)
CT Scan Lower Abdomen With Contrast, USG
CT Scan Lower Abdomen With Contrast, USG
807 56.92 S8,S9 Ureteric Implantation with tailoring Abdomen, Intra Veneous Pyelogram, 43680 45480 54600 56850
Abdomen
Micturating Cystourethrogram (MCUG)
Vesical calculi-vesicolithotomy in USG Abdomen / X-Ray Kidneys, Ureters, And X-ray Kidneys, Ureters, And Bladder (KUB),
808 57.1 S8 25100 26600 31375 33250
Paediatric Patients Bladder (KUB) Scar Photo
Supra pubic drainage- open in Paediatric
809 57.17 S8 USG Abdomen Scar Photo 11200 12400 14000 15500
Patients
USG Abdomen/ Micturating Cystourethrogram
810 57.21.1 S8,S9 Vesicostomy Scar Photo 27260 28760 34075 35950
(MCUG)
811 57.22 S8 Vesicotomy closure in Paediatric Patients Clinical Photograph Clinical Photograph 28710 30510 35888 38138
Stage 1 procedure for Exstrophy Bladder
812 57.86.1 S8 USG Abdomen, Clinical Photograph Clinical Photograph 75310 77410 94138 96763
in Paediatric Patients
Stage 2 procedure for Exstrophy Bladder
813 57.86.2 S8 USG Abdomen, Clinical Photograph Clinical Photograph 71720 73220 89650 91525
in Paediatric Patients
USG Abdomen, Micturating Cystourethrogram
814 57.87 S8,S9 Bladder augmentation (MCUG)/Urodynamic Study(Cystometry), Clinical Photograph 54440 56240 68050 70300
Clinical Photograph
Repair of Urethral injuries in Paediatric
815 58.4 S8 USG Abdomen Clinical Photograph 27520 29020 34400 36275
Patients
Surgical Management of Posterior USG Abdomen/Micturating Cystourethrogram
816 58.39 S8 Clinical Photograph 32100 34200 40125 42750
Urethral Valves (MCUG)
817 58.45.1 S8,S9 Single Stage procedure for Hypospadiasis Clinical Photograph Clinical Photograph 43900 47800 54875 59750
818 58.45.2 S8,S9 Stage 1 procedure for Hypospadiasis Clinical Photograph Scar Photo 31450 33550 39313 41938
819 58.45.3 S8,S9 Stage 2 procedure for Hypospadiasis Clinical Photograph Scar Photo 31670 33470 39588 41838
820 58.45.4 S8,S9 Surgical Correction of Epispadiasis Clinical Photograph Clinical Photograph 43660 45460 54575 56825
Surgical Correction of Scrotal
821 61.49 S8 Clinical Photograph Scar Photo 20900 21800 26125 27250
Transposition In Paediatric Patients
Surgical management of Undescended
822 62.5.2 S8 USG Abdomen, Clinical Photograph Scar Photo 25900 26800 32375 33500
Testis In Paediatric Patients
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Laparoscopic Orchidopexy In Paediatric
823 62.5.3 S8 USG Abdomen, Clinical Photograph Scar Photo 27100 29200 33875 36500
Patients
USG Abdomen, CT Scan Lower Abdomen Routine Histopathological Examination, Scar
824 63.1.1 S8 Laparoscopic Varicocele Ligation 41200 42400 51500 53000
With Contrast, CT Pelvis Photo
Doppler And Scrotum & Testes, CT Scan Of
825 63.1.2 S8,S9 Open Varicocele ligation Scar Photo 32700 35400 40875 44250
Lower Abdomen & Scrotum, USG Abdomen
Hydrocele high ligation In Paediatric
826 63.1.3 S8 Clinical Photograph Scar Photo 15300 15600 19125 19500
Patients
Surgical Management for Torsion of
827 63.52 S8,S9 Doppler And Scrotum & Testes Scar Photo 27000 28800 33750 36000
Testis
Surgical Management of Phimosis and
828 64.4 S8,S9 Clinical Photograph Scar Photo 8600 9200 10750 11500
Paraphimosis
USG Abdomen/Genitogram, Karyo Typing -
829 64.5 S8 Intersex-Genitoplasty surgery(70.6) Clinical Photograph 47480 49580 59350 61975
Cytogenetics
Surgical Management of Tempero
830 76.5.2 S8,S14 3D CT Facial Bones X-Ray Facial Bones 47240 49940 59050 62425
mandibular Joint Ankylosis
Management Of Tmj Dysfunction
831 76.93.2 S8,S14 Orthopantomography (OPG) Orthopantomography (OPG) 1090 1090 1363 1363
Syndrome (76.94)
832 77.8.1 S8 Execision of cogental dermal sinus Clinical Photograph Intra OP photo 30590 31190 38238 38988
Surgical Management of Torticollis in
833 83.79 S8 X-Ray, Clinical Photograph Clinical Photograph, Scar Photo 16070 16670 20088 20838
Paediatric Patient
Excision of External angular dermoid in Routine Histopathological Examination, Scar
834 86.3.10 S8 X-Ray of part, Clinical Photograph 8350 8650 10438 10813
Paediatric Patient Photo
Surgical Management (excision) of Routine Histopathological Examination, Clinical
835 86.3.13 S8 Clinical Photograph 30600 31200 38250 39000
Congenital Dermal Sinus Photograph
Excision of Sebacencyst Lipoma in X-Ray of part, Clinical Photograph, [Contrast Routine Histopathological Examination, Clinical
836 86.3.15 S8 6140 6440 7675 8050
Paediatric Patient Enhanced USG for Eexcision of Lipoma] Photograph, Scar Photo
USG local area/ Color Doppler Sonography Routine Histopathological Examination, Clinical
837 86.04.1 S8 Excision of hamartoma 20600 21200 25750 26500
Single Study, Clinical Photograph Photograph
838 86.09.1 S8 Execision of cysti lesions of neck CT scan local / MRI Routine Histopathological Examination 27100 29200 33875 36500
Surgical correction of Syndactyly of
839 86.85.1 S8 X-Ray , Clinical Photograph Clinical Photograph 27090 29190 33863 36488
Hand For Each Hand in Paediatric Patient
Syndactoly correction-multiple correction
840 86.85.2 S8 X-Ray, Clinical Photograph Scar Photo 29500 31000 36875 38750
in Paediatric Patient
841 96.23 S8 Anal Dilatation Clinical Photograph Clinical Photograph 5300 5600 6625 7000
S9 GENITO URINARY SURGERIES
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Abdomen Without Contrast, Renal Doppler Of Renal Arteries, CT Scan Abdomen
842 38.17 S9 Renal angio embolization 36110 37910 45138 47388
Angiogram, Doppler Of Renal Arteries Without Contrast, USG Abdomen, WEBEX
A.V. Fistula surgery (creation) [Pre- Renal Profile, Serum Electrolytes, Color
843 39.27.3 S9 Scar Photo, Venous Doppler 10900 11800 13625 14750
Transplant Procedure Only] dopplar of limb vessels
Balloon dialatation of transplant Renal
844 39.50.1 S9 Renal Angiogram Renal Angiogram, WEBEX 34110 35610 42638 44513
Artery stenosis
Renal Profile, USG local area, Color dopplar of
845 39.53.1 S9 AV Fistula Scar Photo, Venous Doppler 12500 14000 15625 17500
limb vessels
846 40.9.1 S9 Open post transplant lymphocele USG Abdomen USG Abdomen 30830 32330 38538 40413
847 40.9.2 S9 Laproscopic post transplant lymphocele USG Abdomen USG Abdomen, WEBEX 32890 34390 41113 42988
Uni-lateral illioinguinal block dissection Fine Needle Aspiration Cytology (FNAC),USG
848 40.24.1 S9 Routine Histopathological Examination 31500 33000 39375 41250
in non malignant conditions local area, Biopsy
Bi-lateral illioinguinal block dissection Fine Needle Aspiration Cytology (FNAC),USG
849 40.24.2 S9 Routine Histopathological Examination 65350 66850 81688 83563
in non malignant conditions local area, Biopsy
Routine Histopathological Examination, USG
USG Abdomen, CT scan Lower Abdomen
Surgery for Retroperitoneal Fibrosis Abdomen/CT scan Lower Abdomen Without
850 54.0 S9 Without Contrast/CT Scan Abdomen Without 40930 42430 51163 53038
Open/Lap Contrast/CT Scan Abdomen With Contrast/CT
Contrast
Scan Abdomen Without Contrast
USG Abdomen/CT scan Lower Abdomen
USG Abdomen, Routine Histopathological
851 54.99 S9 Parapelvic Cyst Excision-Open/Lap Without Contrast/CT Scan Abdomen Without 33800 35600 42250 44500
Examination
Contrast
Intra Veneous Pyelogram, Abdomen And Pelvis
For Kidneys, Ureters, And Bladder (KUB), USG Abdomen, Abdomen And Pelvis For
852 55.01 S9 Open Nephrolithotomy 25900 27700 32375 34625
USG Abdomen/CT Scan Lower Abdomen With Kidneys, Ureters, And Bladder (KUB)
Contrast
Intra Veneous Pyelogram, USG Abdomen/CT
Scan Lower Abdomen With Contrast, Abdomen USG Abdomen, Abdomen And Pelvis For
853 55.02 S9 Nephrostomy - Renal 13900 14800 17375 18500
And Pelvis For Kidneys, Ureters, And Bladder Kidneys, Ureters, And Bladder (KUB), RFT
(KUB), RFT
Intra Veneous Pyelogram, USG Abdomen/CT
Scan Lower Abdomen With Contrast, Abdomen USG Abdomen, Abdomen And Pelvis For
854 55.04 S9 Percutaneous Nephrolithotomy 36380 38480 45475 48100
And Pelvis For Kidneys, Ureters, And Bladder Kidneys, Ureters, And Bladder (KUB), WEBEX
(KUB), RFT
Intra Veneous Pyelogram, USG Abdomen/CT USG Abdomen / CT Scan Lower Abdomen With
855 55.4.1 S9 Nephrectomy for Pyonephrosis/Xgp Scan Lower Abdomen With Contrast, 99 TC Contrast, Routine Histopathological 40900 41800 51125 52250
Dtpa Renogram Examination, WEBEX
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Lower Abdomen With Contrast, USG USG Abdomen, Routine Histopathological
856 55.4.3 S9 Laproscopic Partial Nephrectomy 62400 64800 78000 81000
Abdomen Examination, WEBEX
Intra Veneous Pyelogram, USG Abdomen/CT
USG Abdomen / CT Scan Lower Abdomen With
857 55.5.2 S9 Laproscopic Simple Nephrectomy Scan Lower Abdomen With Contrast, 99 TC 52400 54800 65500 68500
Contrast, Routine Histopathological Examination
Dtpa Renogram
Intra Veneous Pyelogram, USG Abdomen/CT
USG Abdomen / CT Scan Lower Abdomen With
858 55.5.3 S9 Laproscopic Radical Nephrectomy Scan Lower Abdomen With Contrast, 99 TC 63080 64280 78850 80350
Contrast, Routine Histopathological Examination
Dtpa Renogram
CT Scan Lower Abdomen With Contrast, USG
Abdomen, Abdomen And Pelvis For Kidneys, USG Abdomen / CT Scan Lower Abdomen With
859 55.6 S9 Renal Transplantation Surgery 167100 173100 208875 216375
Ureters, And Bladder (KUB), MRI Local Area, Contrast, Renal Profile
HLA Typing
USG Abdomen, CT Scan Lower Abdomen
860 55.7 S9 Nephropexy USG Abdomen, Scar Photo 37860 39960 47325 49950
With Contrast
Renal Profile, Complete Blood Count (CBC),
Erythrocyte Sedimentation Rate (ESR), 24 Hrs
Urine Analysis, Urine Culture & Sensitivity,
Serum Electrolytes, Blood Urea Nitrogen
Revascularization procedure for Case Sheet with operation Notes, Renal
861 55.7.0 S9 (BUN), plasma renin activity, Renal Angiogram 29930 31430 37413 39288
renovascular hypertension Angiogram , Renal Profile
/ Digital Subtraction Angiogram, 99 TC Dtpa
Renogram / Isotope Renogram/ Intra Veneous
Pyelogram, ECG (Electro Cardiogram)/ ECHO
Cardiogram, CT Aortography
Intra Veneous Pyelogram, USG Abdomen/CT
Scan Lower Abdomen With Contrast, Abdomen USG Abdomen, Abdomen And Pelvis For
862 55.11.1 S9 Open Pyelolithotomy 22960 24160 28700 30200
And Pelvis For Kidneys, Ureters, And Bladder Kidneys, Ureters, And Bladder (KUB)
(KUB)
Intra Veneous Pyelogram, USG Abdomen/CT
Abdomen And Pelvis For Kidneys, Ureters, And
Scan Lower Abdomen With Contrast, Abdomen
863 55.11.2 S9 Laparoscopic Pyelolithotomy Bladder (KUB), CT Scan Lower Abdomen With 43010 44210 53763 55263
And Pelvis For Kidneys, Ureters, And Bladder
Contrast, USG Abdomen
(KUB),
Intra Veneous Pyelogram, USG Abdomen/CT
CT Scan Lower Abdomen With Contrast, USG
Anatrophic Peylolithotomy For Staghorn Scan Lower Abdomen With Contrast, Abdomen
864 55.11.3 S9 Abdomen, Abdomen And Pelvis For Kidneys, 51800 53600 64750 67000
Caliculus And Pelvis For Kidneys, Ureters, And Bladder
Ureters, And Bladder (KUB)
(KUB)
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Intra Veneous Pyelogram, USG Abdomen/CT
CT Scan Lower Abdomen With Contrast, USG
Scan Lower Abdomen With Contrast, Abdomen
865 55.11.4 S9 Partial stag horn caluculi Abdomen, Abdomen And Pelvis For Kidneys, 35270 36770 44088 45963
And Pelvis For Kidneys, Ureters, And Bladder
Ureters, And Bladder (KUB)
(KUB)
Intra Veneous Pyelogram, USG Abdomen/CT
CT Scan Lower Abdomen With Contrast, USG
Scan Lower Abdomen With Contrast, Abdomen
866 55.11.5 S9 Complete stag horn caluculi Abdomen, Abdomen And Pelvis For Kidneys, 40060 42160 50075 52700
And Pelvis For Kidneys, Ureters, And Bladder
Ureters, And Bladder (KUB)
(KUB)
Intra Veneous Pyelogram, USG Abdomen/CT
USG Abdomen / CT Scan Lower Abdomen With
867 55.39 S9 Renal Cyst Excision Scan Lower Abdomen With Contrast, Fine 24720 26220 30900 32775
Contrast, Routine Histopathological Examination
Needle Aspiration Cytology (FNAC)
Intra Veneous Pyelogram, USG Abdomen/CT
USG Abdomen, CT Scan Lower Abdomen With
868 55.51.1 S9,S11 Radical Nephro-Ureterectomy Scan Lower Abdomen With Contrast, Renal 52100 54200 65125 67750
Contrast, Routine Histopathological Examination
biopsy
USG Abdomen/ CT Scan Lower Abdomen With
Intra Veneous Pyelogram, USG Abdomen/CT
Contrast, Routine Histopathological
869 55.51.2 S9 Bilateral Nephroureterectomy Scan Lower Abdomen With Contrast, Renal 82100 84200 102625 105250
Examination, Abdomen And Pelvis For Kidneys,
biopsy
Ureters, And Bladder (KUB)
USG Abdomen, CT Scan Lower Abdomen With
Laproscopic unilateral CT Scan Lower Abdomen With Contrast, USG
870 55.51.3 S9 Contrast, Routine Histopathological 50900 51800 63625 64750
Nephroureterectomy Abdomen, Renal biopsy
Examination, WEBEX
Intra Veneous Pyelogram/CT Scan Lower
USG Abdomen, CT Scan Lower Abdomen With
871 55.51.4 S9 Open unilateral Nephroureterectomy Abdomen With Contrast, USG Abdomen, 47390 49790 59238 62238
Contrast, Routine Histopathological Examination
Renal biopsy
USG Abdomen/ CT Scan Lower Abdomen With
Intra Veneous Pyelogram, USG Abdomen/CT
Contrast, Routine Histopathological
872 55.51.5 S9 Hemi- Nephroureterectomy Scan Lower Abdomen With Contrast, Renal 47100 49200 58875 61500
Examination, Abdomen And Pelvis For Kidneys,
biopsy
Ureters, And Bladder (KUB)
USG Abdomen, CT Scan Lower Abdomen
USG Abdomen / CT Scan Lower Abdomen With
873 55.53 S9 Post transplant graft Nephrectomy With Contrast, Abdomen And Pelvis For 37100 39200 46375 49000
Contrast, Routine Histopathological Examination
Kidneys, Ureters, And Bladder (KUB)
USG Abdomen, CT Scan Lower Abdomen With
Renal Angiogram, CT Scan Lower Abdomen
874 55.61 S9 Renal auto transplantation Contrast, Isotope Renogram, Colour Doppler - 61500 63000 76875 78750
With Contrast, USG Abdomen
Lower Limbs
USG Abdomen/Intra Veneous Pyelogram/99
Surgical Management of Congenital USG Abdomen,Intra Veneous Pyelogram, CT
875 55.87.1 S9 TC Dtpa Renogram-I36.001, CT Scan Lower 37100 39200 46375 49000
Hydronephrosis Scan Lower Abdomen With Contrast
Abdomen With Contrast, Renal Profile
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Abdomen X-Ray (Lateral View), ntra Veneous
USG Abdomen, CT Scan Lower Abdomen With
876 55.87.2 S9 Anderson Hynes Pyeloplasty Pyelogram/ USG Abdomen / CT Scan Lower 49500 51000 61875 63750
Contrast
Abdomen With Contrast, Renal Profile
Intra Veneous Pyelogram, USG Abdomen/CT
CT Scan Lower Abdomen With Contrast, USG
Scan Lower Abdomen With Contrast, Abdomen
877 55.87.3 S9 Retrograde Intrarenal Surgery(RIRS) Abdomen, Abdomen And Pelvis For Kidneys, 32480 33380 40600 41725
And Pelvis For Kidneys, Ureters, And Bladder
Ureters, And Bladder (KUB), WEBEX
(KUB), Renal Profile
USG Abdomen / CT Scan Lower Abdomen With
CT Scan Lower Abdomen With Contrast, USG
878 55.92 S9 Laparoscopic deroofing of Renal Cyst Contrast, Routine Histopathological 32980 34180 41225 42725
Abdomen
Examination, WEBEX
CT Scan Lower Abdomen With Contrast, USG
CT Scan Lower Abdomen With Contrast, USG
879 56.0 S9 URSL Abdomen, Abdomen And Pelvis For Kidneys, 26200 27400 32750 34250
Abdomen
Ureters, And Bladder (KUB), WEBEX
USG Abdomen / Abdomen And Pelvis For
Kidneys, Ureters, And Bladder (KUB) / Intra CT Scan Lower Abdomen With Contrast, USG
880 56.2.2 S9 Laparoscopic ureterolithotromy 31500 33000 39375 41250
Veneous Pyelogram,CT Scan Lower Abdomen Abdomen, WEBEX
With Contrast
Retrograde Urethrogram, Abdomen X-Ray
USG Abdomen, CT Scan Lower Abdomen With
881 56.4 S9 Surgical corrrection of Ureterocele (Lateral View), USG Abdomen/Intra Veneous 24560 25460 30700 31825
Contrast, Abdomen X-Ray (Lateral View)
Pyelogram
USG Abdomen, Intra Veneous Pyelogram, USG Abdomen, CT Scan Lower Abdomen With
Excision of Ureterocele with Ureteric
882 56.41 S9 Micturating Cystourethrogram (MCUG), CT Contrast, Routine Histopathological 43870 45370 54838 56713
Implantation
Scan Lower Abdomen With Contrast Examination, Abdomen X-Ray (Lateral View)
Surgical Procedure for Ileal Conduit CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
883 56.51 S9 42180 43680 52725 54600
Formation Abdomen/Intra Veneous Pyelogram Contrast, Abdomen X-Ray (Lateral View)
Post transplant revision Ureteroneo CT Scan Lower Abdomen With Contrast, USG CT Scan Lower Abdomen With Contrast, USG
884 56.74.2 S9 39360 41460 49200 51825
cystostomy/Pyelo Ureterostomy Abdomen Abdomen
CT Scan Lower Abdomen With Contrast, USG
CT Scan Lower Abdomen With Contrast, USG
885 56.74.3 S9 Ureteric replacement Abdomen, Abdomen And Pelvis For Kidneys, 46380 47880 57975 59850
Abdomen
Ureters, And Bladder (KUB)
USG Abdomen, CT Scan Lower Abdomen With
CT Scan Lower Abdomen With Contrast/Intra Contrast, Routine Histopathological
886 56.75 S9 Uretero ureterostomy 34030 35230 42538 44038
Veneous Pyelogram, USG Abdomen Examination, Abdomen And Pelvis For Kidneys,
Ureters, And Bladder (KUB)
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Lower Abdomen With Contrast, USG Fluoroscopy, CT Scan Lower Abdomen With
887 56.91 S9 Balloon dilatation of Ureteric stricture 20700 21300 25875 26625
Abdomen, Intra Veneous Pyelogram Contrast, USG Abdomen
Intra Veneous Pyelogram, Abdomen And Pelvis
For Kidneys, Ureters, And Bladder (KUB), CT USG Abdomen, Abdomen And Pelvis For
888 57.0 S9 Cystolithotripsy 14200 15400 17750 19250
Scan Lower Abdomen With Contrast, USG Kidneys, Ureters, And Bladder (KUB)
Abdomen
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
889 57.01 S9 Endoscope removel of stone in bladder 14900 15800 18625 19750
With Contrast, Cystoscopy Contrast
CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
890 57.6.1 S9 Partial Cystectomy 35350 36850 44188 46063
Abdomen, Cystoscopy, Renal biopsy/ Contrast, Routine Histopathological Examination
CT Scan Lower Abdomen With Contrast, USG
USG Abdomen, Cystoscopy, CT Scan Lower
891 57.7 S9 Total Cystectomy Abdomen, Routine Histopathological 47120 49220 58900 61525
Abdomen With Contrast, Biopsy
Examination
Intra Veneous Pyelogram, Abdomen And Pelvis
CT Scan Lower Abdomen With Contrast, USG
For Kidneys, Ureters, And Bladder (KUB), CT
892 57.19 S9 Open Cystolithotomy Abdomen, Abdomen And Pelvis For Kidneys, 20930 22730 26163 28413
Scan Lower Abdomen With Contrast, USG
Ureters, And Bladder (KUB)
Abdomen
CT Scan Lower Abdomen With Contrast, USG
CT Scan Lower Abdomen With Contrast, USG
893 57.21.2 S9 Mitrafanoff procedure Abdomen, Routine Histopathological 48950 51650 61188 64563
Abdomen
Examination
Transurethral resection of bladder tumour CT Scan Lower Abdomen With Contrast/USG USG Abdomen, CT Scan Lower Abdomen With
894 57.49.1 S9 39900 40800 49875 51000
(TURBT) Abdomen/Cystoscopy Contrast, Routine Histopathological Examination
Transurethral resection of bladder tumour
CT Scan Lower Abdomen With Contrast, USG Abdomen, CT Scan Lower Abdomen With
895 57.49.2 S9 (TURBT) with intravesical Mitomycin 35900 36800 44875 46000
Cystoscopy Contrast, Routine Histopathological Examination
instillation
CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
896 57.51 S9 Excision of Urachal cyst 36160 37660 45200 47075
Abdomen Contrast, Routine Histopathological Examination

USG Abdomen, Cystoscopy, CT Scan Lower CT Scan Lower Abdomen With Contrast, USG
897 57.59 S9 Bladder Diverticulectomy Abdomen With Contrast, Abdomen And Pelvis Abdomen, Cystoscopy, Routine 34000 35800 42500 44750
For Kidneys, Ureters, And Bladder (KUB) Histopathological Examination
USG Abdomen, CT Scan Lower Abdomen With
Laproscopic radical cystectomy with CT Scan Lower Abdomen With Contrast, USG
898 57.71.1 S9,S11 Contrast, Routine Histopathological 126500 128000 158125 160000
Ilealconduit diversion Abdomen
Examination, WEBEX
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, CT Scan Lower Abdomen With
Laproscopic radical cystectomy with CT Scan Lower Abdomen With Contrast, USG
899 57.71.3 S9 Contrast, Routine Histopathological 59670 62670 74588 78338
Ureterosigmoidostomy(57.88) Abdomen
Examination, WEBEX
Open radical cystectomy with CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
900 57.71.4 S9 48000 51000 60000 63750
Ureterosigmoidostomy (57.88) Abdomen, Cystoscopy, Biopsy Contrast, Routine Histopathological Examination
USG Abdomen, CT Scan Lower Abdomen With
Laproscopic radical cystectomy with CT Scan Lower Abdomen With Contrast, USG
901 57.71.5 S9 Contrast, Routine Histopathological 65560 66460 81950 83075
Continent Urinary diversion(56.7) Abdomen, Cystoscopy, Biopsy
Examination, WEBEX
Open radical cystectomy with Continent CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
902 57.71.6 S9 53000 56000 66250 70000
Urinary diversion Abdomen, Cystoscopy, Biopsy Contrast, Routine Histopathological Examination
Retrograde Urethrogram, USG Abdomen/ Intra USG Abdomen, CT Scan Lower Abdomen With
Surgical correction of Vesicovaginal
903 57.84.1 S9 Veneous Pyelogram, CT Scan Lower Abdomen Contrast, Routine Histopathological 45800 47600 57250 59500
Fistula
With Contrast, Cystoscopy Examination, WEBEX
Transvaginal repair of Vesicovaginal CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
904 57.84.2 S9 37930 40030 47413 50038
Fistula Abdomen Contrast
Trans abdominal repair of Vesicovaginal CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
905 57.84.4 S9 55800 59100 69750 73875
Fistula with omentoplasty Abdomen, Cystoscopy Contrast
USG Abdomen, Cystoscopy, CT Scan Lower CT Scan Lower Abdomen With Contrast, USG
906 57.88 S9 Caecocystoplasty 44840 47840 56050 59800
Abdomen With Contrast Abdomen, Scar Photo
CT Scan Lower Abdomen With Contrast, USG Abdomen, CT Scan Lower Abdomen With
907 57.91.1 S9 Bladder neck incision 25340 26540 31675 33175
Cystoscopy, USG Abdomen, Cystourethroscopy Contrast
Bladder neck reconstruction for USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
908 57.91.2 S9 62100 64200 77625 80250
Incontinence With Contrast, Case sheet with clinical History Contrast
Retrograde Urethrogram, Abdomen And Pelvis
For Kidneys, Ureters, And Bladder (KUB),
USG Abdomen, CT Scan Lower Abdomen With
909 58.0 S9 Perineal Urethrostomy USG Abdomen, Intra Veneous Pyelogram, CT 33150 34650 41438 43313
Contrast, Scar Photo
Scan Lower Abdomen With Contrast, Clinical
Photograph
Retrograde Urethrogram, USG Abdomen, CT USG Abdomen, CT Scan Lower Abdomen With
910 58.5.1 S9 Optical Urethrotomy Scan Lower Abdomen With Contrast/ Intra Contrast, Intra OP photo, Endoscopic 22430 23930 28038 29913
Veneous Pyelogram Photograph showing Receptoscope in situ
BMG Urethroplasty for pan Urethral Retrograde Urethrogram, USG Abdomen, CT USG Abdomen, CT Scan Lower Abdomen With
911 58.5.2 S9 66500 68000 83125 85000
stricture Scan Lower Abdomen With Contrast Contrast, Clinical Photograph
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
912 58.6 S9 Dilatation for Urethra stenosis 10870 11170 13588 13963
With Contrast Contrast
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
913 58.31 S9 Excision of Urethral Caruncle 16560 17160 20700 21450
With Contrast, Clinical Photograph Contrast
914 58.43 S9 Urethral Fistula closure Retrograde Urethrogram, Clinical Photograph Scar Photo 31500 33000 39375 41250
Retrograde Urethrogram, USG Abdomen, CT
USG Abdomen, CT Scan Lower Abdomen With
915 58.45.5 S9 Single stage- Urethroplasty for Stricture Scan Lower Abdomen With Contrast, Clinical 53300 56600 66625 70750
Contrast
Photograph
Double stage Urethroplasty Retrograde Urethrogram, USG Abdomen, CT
USG Abdomen, CT Scan Lower Abdomen With
916 58.46 S9 (Reconstruction Procedure) for stricture Scan Lower Abdomen With Contrast, Clinical 40200 42900 50250 53625
Contrast
Urethra. Photograph
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
917 58.47 S9 Meatoplasty 12580 12880 15725 16100
With Contrast, Clinical Photograph Contrast
Retrograde Urethrogram, USG Abdomen, CT
Transpubic Urethroplasty with USG Abdomen, CT Scan Lower Abdomen With
918 58.49 S9 Scan Lower Abdomen With Contrast, Clinical 68600 72200 85750 90250
Omentoplasty Contrast
Photograph
Retrograde Urethrogram, USG Abdomen, CT USG Abdomen, CT Scan Lower Abdomen With
919 58.49.1 S9 Urethroplasty doblestage stage I 40770 42870 50963 53588
Scan Lower Abdomen With Contrast Contrast
Retrograde Urethrogram, USG Abdomen, CT USG Abdomen, CT Scan Lower Abdomen With
920 58.49.2 S9 Urethroplasty doublestage stageII 40200 42900 50250 53625
Scan Lower Abdomen With Contrast Contrast
Nephrolysis/surgery for Chyluria USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
921 59.02 S9 41800 43600 52250 54500
Open/Lap With Contrast Contrast, WEBEX
Cystoscopy, USG Abdomen, CT Scan Lower
Surgical Management of Incontinence
922 59.4.1 S9 Abdomen With Contrast, Case sheet with USG Abdomen, Clinical Photograph 26800 28000 33500 35000
Urine (Male)
clinical History
Cystoscopy, USG Abdomen, CT Scan Lower
Surgical Management of Incontinence USG Abdomen, CT Scan Lower Abdomen With
923 59.4.2 S9 Abdomen With Contrast, Case sheet with 22900 23800 28625 29750
Urine (Female) Contrast
clinical History
MMK/birch colpo suspension for stress USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
924 59.5 S9 42100 44200 52625 55250
urinary Incontinence With Contrast, Case sheet with clinical History Contrast
USG Abdomen/CT Scan Lower Abdomen With USG Abdomen, CT Scan Lower Abdomen With
925 59.8.1 S9 Dj Stent (One Side) Contrast, Intra Veneous Pyelogram, Renal Contrast, Abdomen And Pelvis For Kidneys, 5300 5600 6625 7000
Profile Ureters, And Bladder (KUB), Renal Profile
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
926 59.8.2 S9 CAPD-Tenchkoff catheter insertion 38620 40720 48275 50900
With Contrast, Renal Profile Contrast
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, CT Scan Lower Abdomen
With Contrast, Renal Profile, Abdomen And USG Abdomen, CT Scan Lower Abdomen With
927 59.09 S9 Drainage of Perinephric Abscess 40060 42160 50075 52700
Pelvis For Kidneys, Ureters, And Bladder Contrast
(KUB)
Mid urethral sling procedure for stress USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
928 59.79 S9 31500 33000 39375 41250
urinary incontinence With Contrast, Case sheet with clinical History Contrast
USG Abdomen, CT Scan Lower Abdomen With
USG Abdomen, CT Scan Lower Abdomen
929 60.3 S9 Open Prostatectomy Contrast, Routine Histopathological 34500 36000 43125 45000
With Contrast, Cystoscopy, Cystouretroscopy
Examination, Scar Photo
USG Abdomen, CT Scan Lower Abdomen
With Contrast, Routine Histopathological USG Abdomen, CT Scan Lower Abdomen With
930 60.5.1 S9 Laproscopic radical Prostratectomy 57100 59200 71375 74000
Examination, Prostate-Specific Antigen (PSA), Contrast, Routine Histopathological Examination
Cystouretroscopy
USG Abdomen, CT Scan Lower Abdomen
USG Abdomen, CT Scan Lower Abdomen With
931 60.5.2 S9 Open radical Prostratectomy With Contrast, Prostate-Specific Antigen 50900 51800 63625 64750
Contrast, Routine Histopathological Examination
(PSA), Cystouretroscopy
Uroflowmetry, USG Abdomen, CT Scan Lower
USG Abdomen, CT Scan Lower Abdomen With
932 60.21 S9 Laser Prostatectomy Abdomen With Contrast, Cystoscopy, Prostate- 41500 43000 51875 53750
Contrast
Specific Antigen (PSA), Cystouretroscopy

Transurethral Resection of Prostate Cystoscopy, USG Abdomen, CT Scan Lower USG Abdomen, CT Scan Lower Abdomen With
933 60.29.1 S9 31500 33000 39375 41250
(TURP) Abdomen With Contrast, Cystouretroscopy Contrast, Routine Histopathological Examination
USG Abdomen, CT Scan Lower Abdomen
Transurethral Resection of Prostate USG Abdomen, CT Scan Lower Abdomen With
934 60.29.2 S9 With Contrast, Prostate-Specific Antigen 30900 31800 38625 39750
(TURP) Cyst Lithotripsy Contrast, Routine Histopathological Examination
(PSA), Cystouretroscopy
Uroflowmetry, USG Abdomen, CT Scan Lower
USG Abdomen, CT Scan Lower Abdomen With
935 60.29.3 S9 Bipolar TURP Abdomen With Contrast, Cystoscopy, 41500 43000 51875 53750
Contrast, Routine Histopathological Examination
Cystouretroscopy
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, CT Scan Lower Abdomen With
936 61.4 S9 Scrotal/Perineal Injuries 29560 31660 36950 39575
With Contrast, Clinical Photograph Contrast, Scar Photo
USG Abdomen, CT Scan Lower Abdomen With
USG Abdomen, CT Scan Lower Abdomen
937 62.5 S9 Orchidopexy Bilateral Contrast, Routine Histopathological 24670 26470 30838 33088
With Contrast, Clinical Photograph
Examination,
CT Scan Of Lower Abdomen & Scrotum, USG CT Scan Of Lower Abdomen & Scrotum, USG
938 63.92 S9 Vasectomy reversal 23910 24810 29888 31013
Abdomen, Semen Analysis Abdomen, Semen Analysis
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Penis,CT Scan Of Lower Abdomen & USG Penis,CT Scan Of Lower Abdomen &
939 64.3.1 S9,S11 Partial amputation of penis 38170 39670 47713 49588
Scrotum, Biopsy Scrotum, Routine Histopathological Examination
USG Penis,CT Scan Of Lower Abdomen & USG Penis,CT Scan Of Lower Abdomen &
940 64.42.1 S9 Surgical correction of Chordee 34660 36460 43325 45575
Scrotum, Clinical Photograph Scrotum
Surgical Correction of Chordee without USG Penis,CT Scan Of Lower Abdomen & USG Penis,CT Scan Of Lower Abdomen &
941 64.42.2 S9 34420 36520 43025 45650
Hypospadiasis Scrotum Scrotum
CT Scan Of Lower Abdomen &
CT Scan Of Lower Abdomen & Scrotum, USG
942 64.41 S9,S8 Surgical Management of Penile Injuries Scrotum/Doppler And Scrotum & Testes, USG 26200 27400 32750 34250
Penis
Penis, Clinical Photograph
CT Scan Of Lower Abdomen &
Plaque Excision/Plasty for Penile CT Scan Of Lower Abdomen & Scrotum, USG
943 64.43 S9 Scrotum/Doppler And Scrotum & Testes, USG 42100 44200 52625 55250
curvature/Peyronies disease Penis
Penis,
USG Penis,CT Scan Of Lower Abdomen & USG Penis,CT Scan Of Lower Abdomen &
944 64.98 S9 Surgery for Priapism 37100 39200 46375 49000
Scrotum Scrotum
Colour Doppler Of Specific Limb, Clinical
945 86.75 S9 Difficult vascular access/graft Colour Doppler Of Specific Limb 31500 33000 39375 41250
Photograph
Abdomen And Pelvis For Kidneys, Ureters,
Abdomen And Pelvis For Kidneys, Ureters, And
946 97.64 S9 CAPD-Tenchkoff catheter removal And Bladder (KUB), USG Abdomen, Clinical 36040 38140 45050 47675
Bladder (KUB), USG Abdomen, Scar Photo
Photograph
947 97.64.1 S9 CAPD bags per month Clinical Photograph CAPD bags Photo 8520 8520 10650 10650
Abdomen And Pelvis For Kidneys, Ureters, Abdomen And Pelvis For Kidneys, Ureters, And
948 97.65 S9 Cystoscopy/ Stent removal And Bladder (KUB), USG Abdomen, Clinical Bladder (KUB), USG Abdomen, Clinical 9400 9700 11750 12125
Photograph Photograph
Intra Veneous Pyelogram, Abdomen And Pelvis Abdomen And Pelvis For Kidneys, Ureters, And
Extracorporeal shockwave lithotripsy
949 98.51 S9 For Kidneys, Ureters, And Bladder (KUB), Bladder (KUB), USG Abdomen, Clinical 20600 21200 25750 26500
(ESWL)
Contrast Enhanced USG/ CT local Area Photograph
Post Renal Transplant
Renal Profile, USG Abdomen, Latest Color Renal Profile, Latest Color Dopplar of
950 99.23.1 S9 Immunosuppressive Treatment From 1st 91670 91670 114588 114588
Dopplar of Transplant Area Transplant Kidney
To 6th Months
Post Renal Transplant
Renal Profile, USG Abdomen, Latest Color Renal Profile, Latest Color Dopplar of
951 99.23.2 S9 Immunosuppressive Treatment From 7th 61200 61200 76500 76500
Dopplar of Transplant Area Transplant Kidney
To 12 Th Month.
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Urine Cytology For Malignant Cells , Urine
Culture & Sensitivity, Renal Profile, LFT(liver
function tests), Alkaline Phosphatase Levels,
952 99.28.1 S9 Intravesical BCG Induction therapy Cystoscopy, Case Sheet with operation Notes 10050 10350 12563 12938
Cystoscopy, Triple
Markers/Immunohistochemistry (IHC) Three
Markers
Urine Cytology For Malignant Cells , Urine
953 99.28.2 S9 Intravesical BCG maintenance Culture & Sensitivity, Cystoscopy, Case sheet Case Sheet with operation Notes, Intra OP photo 18120 19320 22650 24150
with clinical History
S10 NEURO SURGERY
CT Scan Head Without Contrast, CT Angio Of CT Scan Head Without Contrast, CT Angio Of
954 01.09.1 S10 Twist Drill Craniostomy 15600 16200 19500 20250
Brain(Head)/MRI Brain Without Contrast Brain(Head)/MRI Brain Without Contrast
CT Scan Head Without Contrast, CT Angio Of CT Scan Head Without Contrast, CT Angio Of
955 01.09.2 S10 Subdural Tapping 19510 19510 24388 24388
Brain(Head) /MRI Brain Without Contrast Brain(Head) /MRI Brain Without Contrast
CT Scan Head Without Contrast, CT Angio Of CT Scan Head Without Contrast, CT Angio Of
956 01.09.3 S10 Ventricular Tapping 15000 15000 18750 18750
Brain(Head) Brain(Head)
CT-Scan Brain Plain With Bone Window, CT
Burr Hole procedure for evacuation of PUS/Granulation For HPE - , Endoscopic
957 01.13 S10 Angio Of Brain(Head) /MRI Brain Without 32680 32680 40850 40850
Brain Abscess Photograph
Contrast
CT-Scan Brain Plain And Contrast ,CT Angio T-Scan Brain Plain And Contrast, CT Angio Of
958 01.18 S10 Endoscopy Procedures -Brain 79800 81600 99750 102000
Of Brain(Head) /MRI Brain Without Contrast Brain(Head)
Craniotomy And Evacuation of Subdural CT Scan Head Without Contrast, CT Angio Of CT Scan Head Without Contrast, CT Angio Of
959 01.24.1 S10 66000 66000 82500 82500
Haematoma Brain(Head) Brain(Head)
Craniotomy And Evacuation of CT Scan Head Without Contrast ,CT Angio Of CT Scan Head Without Contrast, CT Angio Of
960 01.24.2 S10 60000 60000 75000 75000
Extradural Haematoma Brain(Head) /MRI Brain Without Contrast Brain(Head)
CT Scan Head Without Contrast,CT Angio Of
De-Compressive Craniectomy (Non CT Scan Head Without Contrast,CT Angio Of
961 01.25 S10 Brain(Head) /MRI Brain Without Contrast After 80600 81200 100750 101500
Traumatic) Brain(Head) /MRI Brain Without Contrast
3 weeks
CT Scan Head Without Contrast, CT Angio Of CT Scan Head Without Contrast, CT Angio Of
962 01.31 S10 Tapping of Brain Abscess 40000 40000 50000 50000
Brain(Head) /MRI Brain Without Contrast Brain(Head) /MRI Brain Without Contrast
CT Scan Head Without Contrast, CT Angio Of
Brain(Head) /MRI Brain Without Contrast EEG (Electroencephalogram) \ Video
963 01.39 S10 Evacuation of Intra-Cerebral Hematoma 72000 72000 90000 90000
,EEG (Electroencephalogram) \ Video EEG, EEG,PUS/Granulation For HPE
Case sheet with clinical History
CT Scan Temporal Bones Without CT Scan Temporal Bones Without Contrast5,CT
Temporal Lobectomy Plus Depth
964 01.53.1 S10 Contrast5,CT Angio Of Brain(Head) /MRI Angio Of Brain(Head) /MRI Brain Without 140300 140600 175375 175750
Electrodes
Brain Without Contrast Contrast
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Temporal Bones Without CT Scan Temporal Bones Without Contrast5,CT
965 01.53.2 S10 Temporal Lobectomy Contrast5,CT Angio Of Brain(Head) /MRI Angio Of Brain(Head) /MRI Brain Without 75600 76200 94500 95250
Brain Without Contrast Contrast , Case Sheet with operation Notes
Excision of Lobe(frontal,temporal,cerebe CT-Scan Brain Plain And Contrast / MRI Brain CT-Scan Brain Plain And Contrast / MRI Brain
966 01.53.3 S10 40300 40600 50375 50750
llum Etc.) Without Contrast Without Contrast
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
967 01.59.1 S10 Excision of Parasagital Brain tumour Scan Brain Plain And Contrast, CT Angio Of 70390 71890 87988 89863
Of Brain(Head)/MRI Brain With Contrastt
Brain(Head)/MRI Brain With Contrast
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
968 01.59.2 S10 Excision of Basal Brain tumour Scan Brain Plain And Contrast, CT Angio Of 70300 70600 87875 88250
Of Brain(Head)/MRI Brain With Contrast
Brain(Head)/MRI Brain With Contrast
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
969 01.59.3 S10 Excision of Brain Stem Brain tumour Scan Brain Plain And Contrast, CT Angio Of 70900 71800 88625 89750
Of Brain(Head)/MRI Brain With Contrast
Brain(Head)/MRI Brain With Contrast
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
970 01.59.4 S10 Excision of C P Angle Brain tumour Scan Brain Plain And Contrast, CT Angio Of 80300 80600 100375 100750
Of Brain(Head)/MRI Brain With Contrast
Brain(Head)/MRI Brain With Contrast
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
971 01.59.5 S10 Excision of Other Brain tumours Scan Brain Plain And Contrast, CT Angio Of 48550 48850 60688 61063
Of Brain(Head)/MRI Brain With Contrast
Brain(Head)/MRI Brain With Contrast
CT-Scan Brain Plain And Contrast, CT Angio Intra EEG (Electroencephalogram) \ Video EEG
972 01.59.6 S10 Lesionectomy Type 1 57160 57460 71450 71825
Of Brain(Head)/MRI Brain With Contrast ,Routine Histopathological Examination
CT-Scan Brain Plain And Contrast, CT Angio Intra EEG (Electroencephalogram) \ Video EEG
973 01.59.7 S10 Lesionectomy Type 2 57350 57650 71688 72063
Of Brain(Head)/MRI Brain With Contrast ,Routine Histopathological Examination
CT-Scan Brain Plain And Contrast, CT Angio Routine Histopathological Examination, CT-
974 01.59.8 S10 Excision of Subtentorial Brain Tumours Of Brain(Head)/MRI Brain With Contrast, EEG Scan Brain Plain And Contrast, CT Angio Of 48550 48850 60688 61063
(Electroencephalogram) \ Video EEG Brain(Head)/MRI Brain With Contrast
CT-Scan Brain Plain And Contrast, CT Angio CT-Scan Brain Plain And Contrast, CT Angio Of
975 01.59.9 S10 Evacuation of Brain Abscess 60000 60000 75000 75000
Of Brain(Head)/MRI Brain With Contrast Brain(Head)/MRI Brain With Contrast
CT Scan Head Without Contrast, CT Angio Of
Surgical Management of CT Scan Head Without Contrast, CT Angio Of
976 01.59.10 S10 Brain(Head) /MRI Brain Without Contrast 40600 41200 50750 51500
Meningomyelocele Brain(Head) /MRI Brain Without Contrast
,Routine Histopathological Examination
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
977 01.59.11 S10 Intra Ventricular Tumours Scan Brain Plain And Contrast, CT Angio Of 60600 61200 75750 76500
Of Brain(Head)/MRI Brain With Contrast
Brain(Head)/MRI Brain With Contrast
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
978 01.59.12 S10 Meningocele Excision Scan Brain Plain And Contrast, CT Angio Of 40300 40600 50375 50750
Of Brain(Head) /MRI Brain Without Contrast
Brain(Head) /MRI Brain Without Contrast
Routine Histopathological Examination, CT-
CT-Scan Brain Plain And Contrast, CT Angio
979 01.59.13 S10 Excision of brain abscess Scan Brain Plain And Contrast, CT Angio Of 70300 70600 87875 88250
Of Brain(Head)/MRI Brain With Contrast
Brain(Head)/MRI Brain With Contrast
CT Scan Head Without Contrast,CT Angio Of CT Scan Head Without Contrast,CT Angio Of
980 02.0 S10 Cranioplasty Brain(Head), ECHO Cardiogram,ECG (Electro Brain(Head)/MRI Brain Without Contrast , X- 30300 30600 37875 38250
Cardiogram), ECHO CD Ray Skull
CT Scan Head Without Contrast, CT Angio Of X-Ray Skull/CT Scan Head Without Contrast,
981 02.02 S10 Depressed / Elevated Fracture 30300 30600 37875 38250
Brain(Head) /MRI Brain Without Contrast CT Angio Of Brain(Head)
CT-Scan Brain Plain And Contrast, CT Angio Of
CT-Scan Brain Plain And Contrast, CT Angio
982 02.2 S10 Endoscopic Third Ventriculostomy Brain(Head) /MRI Brain Without Contrast , 30900 31800 38625 39750
Of Brain(Head) /MRI Brain Without Contrast
Endoscopic Dilatation-Video/Photo
CT Scan Head Without Contrast, CT Angio Of
983 02.05 S10 Cranioplasty With Impants X-Ray Skull 30300 30600 37875 38250
Brain(Head)
CT-Scan Brain Plain With Bone Window, CT
X-Ray Skull/CT-Scan Brain Plain With Bone
984 02.06 S10 Cranioplasty With Titanium Mesh Angio Of Brain(Head) /MRI Brain Without 31930 32230 39913 40288
Window, CT Angio Of Brain(Head)
Contrast
Surgical Management of Meningo CT-Scan Brain Plain And Contrast, CT Angio CT-Scan Brain Plain And Contrast, CT Angio Of
985 02.12 S10 40600 41200 50750 51500
Encephalocele Of Brain(Head) /MRI Brain Without Contrast Brain(Head) /MRI Brain Without Contrast
CT Scan Head Without Contrast, CT Angio Of
Surgical Management of C.S.F. Brain(Head) /MRI Brain Without Contrast / CT Scan Head Without Contrast, CT Angio Of
986 02.31 S10 40600 41200 50750 51500
Rhinorrhoea Radionuclide Cisternography /Radio Brain(Head) /MRI Brain Without Contrast
Scintography
CT Scan Head Without Contrast, CT Angio Of
CT Scan Head Without Contrast, CT Angio Of
987 02.32 S10 Ventriculo Atrial Shunt Brain(Head) /MRI Brain Without Contrast / 21500 23000 26875 28750
Brain(Head) /MRI Brain Without Contrast
Neurosonogram(NSG)
CT Scan Head Without Contrast, CT Angio Of CT Scan Head Without Contrast, CT Angio Of
988 02.32.1 S10 Atrial shunt Brain(Head) /MRI Brain Without Contrast / Brain(Head) /MRI Brain Without Contrast , Case 20010 20010 25013 25013
Neurosonogram(NSG) Sheet with operation Notes
CT Scan Head Without Contrast, CT Angio Of Scan Head Without Contrast, CT Angio Of
989 02.34 S10 Ventriculo Peritoneal Shunt Brain(Head) /MRI Brain Without Contrast , X Brain(Head) /MRI Brain Without Contrast 30000 30000 37500 37500
Ray scull Cerebrospinal Fluid (CSF) Analysis Cell Count
CT Scan Head Without Contrast, CT Angio Of Scan Head Without Contrast, CT Angio Of
Ventriculoatrial / Ventriculoperitonial
990 02.34.1 S10 Brain(Head) /MRI Brain Without Contrast , X Brain(Head) /MRI Brain Without Contrast 20010 20010 25013 25013
shunt
Ray scull Cerebrospinal Fluid (CSF) Analysis Cell Count
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Head Without Contrast, CT Angio Of Scan Head Without Contrast, CT Angio Of
991 02.39 S10 External Ventricular Drainage (EVD) 40000 40000 50000 50000
Brain(Head) /MRI Brain Without Contrast Brain(Head) /MRI Brain Without Contrast
992 03.1 S10 Selective Posterior Rhizotomy Case sheet with clinical History Case Sheet with operation Notes 30300 30600 37875 38250
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
993 03.4.1 S10 Surgery for Cord Tumours Routine Histopathological Examination 38900 39800 48625 49750
Without Contrast /MRI Spine
Surgical Management of Intra Medullary CT Spine (Cervical,Dorsal,Lumbar,Sacral) Routine Histopathological Examination, X-Ray
994 03.4.2 S10 51200 52400 64000 65500
Spinal Tumours Without Contrast /MRI Local Area Dorso Lumbar Spine
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
995 03.4.3 S10 Surgical Management of Syringomyelia Without Contrast, Case Sheet with operation 60600 61200 75750 76500
Without Contrast /MRI Local Area
Notes
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
996 03.09.1 S10 Laminectomy Without Contrast /MRI Local Area,X-Ray X-Ray Dorso Lumbar Spine 27250 27850 34063 34813
Dorso Lumbar Spine
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
997 03.09.2 S10 Laminoplasty With Implants Without Contrast /MRI Local Area,X-Ray X-Ray Dorso Lumbar Spine 30780 31380 38475 39225
Dorso Lumbar Spine
998 03.39 S10 Endoscopy - Spinal Endoscopic Photograph Case Sheet with operation Notes 29900 30800 37375 38500
X-Ray Dorso Lumbar Spine,
999 03.52 S10 Meningo Myelocele Spinal Procedure Case Sheet with operation Notes 25600 26200 32000 32750
Neurosonogram(NSG), Clinical Photograph
X-Ray Dorso Lumbar Spine,CT Spine
Surgical Management of Spina Bifida
1000 03.59.1 S10 (Cervical,Dorsal,Lumbar,Sacral) Without X-Ray Dorso Lumbar Spine 35600 36200 44500 45250
Major
Contrast /MRI Local Area
X-Ray Dorso Lumbar Spine,CT Spine
Surgical Management of Spina Bifida
1001 03.59.2 S10 (Cervical,Dorsal,Lumbar,Sacral) Without X-Ray Dorso Lumbar Spine 30300 30600 37875 38250
Minor
Contrast /MRI Local Area
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1002 03.96 S10 Facet, Nerve Root Blocks Case Sheet with operation Notes 10000 10000 12500 12500
Without Contrast /MRI Local Area
ENMG (Elektroneuromyography) ,Nerve
Radiofrequency Ablation For Trigeminal ENMG (Elektroneuromyography) ,Nerve
1003 04.2 S10 conduction study, Case Sheet with operation 30600 31200 38250 39000
Neuralgia conduction study
Notes
Radio Surgery For Brain Tumours &
CT-Scan Brain Plain And Contrast/MRI Brain CT-Scan Brain Plain And Contrast/MRI Brain
1004 04.02 S10 Vascular Malformations/ Trigeminal 25300 25600 31625 32000
Without Contrast Without Contrast
Neuralgia
MRI Local Area/CT Scan Limbs Without ENMG (Elektroneuromyography) ,Nerve
Surgical treatment for brachial plexus
1005 04.5.2 S10 Contrast,ENMG (Elektroneuromyography) conduction study, Intra OP photo, Case Sheet 72900 73800 91125 92250
injuries
,Nerve conduction study, Clinical Photograph with operation Notes
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Microvascular Decompression For ENMG (Elektroneuromyography) ,Nerve
1006 04.41 S10 Nerve conduction study(NCS) 60300 60600 75375 75750
Trigeminal Neuralgia conduction study, MRI Local Area
CT Scan Limbs Without Contrast /MRI Of Both
Surgical management Carpal tunnel
1007 04.43 S10,S5 Hands,ENMG (Elektroneuromyography) ,Nerve Scar Photo, Case Sheet with operation Notes 10000 10000 12500 12500
syndrome
conduction study
ENMG (Elektroneuromyography) ,Nerve
ENMG (Elektroneuromyography) ,Nerve
1008 04.76.1 S10 Peripheral Nerve Injury Repair conduction study, Case Sheet with operation 40900 41800 51125 52250
conduction study
Notes
ENMG (Elektroneuromyography) , MRI
1009 05.22 S10 Cervical Sympathectomy Cervical Spine Without Contrast ,Nerve Routine Histopathological Examination 31200 32400 39000 40500
conduction study
ENMG (Elektroneuromyography) ,Nerve
1010 05.23.1 S10 Lumbar Sympathectomy Routine Histopathological Examination 31500 33000 39375 41250
conduction study,MRI Of Dorsolumbar Spine
CT-Scan Brain Plain And Contrast / MRI Brain Routine Histopathological Examination, X-Ray
1011 07.62 S10 Trans Sphenoidal Surgery 40300 40600 50375 50750
With Contrast Skull
CT Local Area,CT Angiography
1012 38.12.2 S10 Carotid Endarterectomy Neck\Chest(Cartotid Angiography), Colour Colour Doppler Study Of Neck Vessels 40600 41200 50750 51500
Doppler Study Of Neck Vessels
1013 39.28 S10 Intra Cranial Vascular Bypass CT Angio Of Brain(Head) CT-Scan Brain Plain And Contrast 100900 101800 126125 127250
CT Angio Of Brain(Head)/Dynamic
1014 39.51 S10 Aneurysm Clipping CT Angio Of Brain(Head) MRI/Functional MRI, X Ray scull with Marked 110000 110000 137500 137500
clips
Other Vascular Malformations (Other
Extremities , Bones & Joints AP & Lateral
1015 39.53.2 S10 Than AVM) - Cavernomas, AV Fistulas, Renal Profile, USG local area 60900 61800 76125 77250
View(2 Film), Scar Photo
Sinus Pericranii
CT Angio Of Brain(Head)/ MRI Angiography CT Angio Of Brain(Head)/ MRI Angiography
1016 39.72.1 S10 Embolization of Aneurysm 76500 78000 95625 97500
With Contrast With Contrast
1017 39.72.2 S10 Brain Tumour Embolisation MRI Brain With Contrast CT Angio Of Brain(Head) 28300 28600 35375 35750
Coil Embolization of Aneurysm (each coil CT Angio Of Brain(Head)/ MRI Brain With Color Doppler Sonography Single Study,
1018 39.79.1 S10 30000 30000 37500 37500
cost) Contrast Routine Histopathological Examination
Surgical Management of Vascular MRI Angiography With Contrast /Digital CT Local Area /Dynamic MRI/Functional MRI,
1019 39.79.2 S10 60600 61200 75750 76500
Malformations Subtraction Angiogram/CT Local Area Routine Histopathological Examination
Spinal Fixation Rods And Plates, CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1020 78.19 S10 X-Ray 85600 86200 107000 107750
Artificial Discs Without Contrast /MRI Spine
MRI Brain With Contrast/CT Scan Brain Plain X-Ray, Routine Histopathological Examination /
1021 80.5.1 S10 Anterior Lateral Decompression 31200 32400 39000 40500
and contrast Gram stain/ Zn stain Report
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1022 80.51.1 S10 Postirior cervical disectomy 27250 27850 34063 34813
Without Contrast, X-Ray Dorso Lumbar Spine Without Contrast, X-Ray Dorso Lumbar Spine

Excision Of Cervical Inter-Vertebral CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)


1023 80.51.2 S10 31200 32400 39000 40500
Discs Without Contrast, X-Ray Dorso Lumbar Spine Without Contrast, X-Ray Dorso Lumbar Spine
Orthopantomography (OPG), MRI Brain
1024 80.51.3 S10 Anterior Discectomy & Bone Grafting Orthopantomography (OPG), X Ray scull 41200 42400 51500 53000
without contrast
Orthopantomography (OPG), MRI Brain
1025 80.51.4 S10 Discectomy With Implants Orthopantomography (OPG), X Ray scull 65600 66200 82000 82750
without contrast
CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1026 80.51.5 S10 Anterior Cervical Discectomy 27550 28450 34438 35563
Without Contrast, X-Ray Dorso Lumbar Spine Without Contrast, X-Ray Dorso Lumbar Spine
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
Without Contrast/ MRI spine, X-Ray Dorso
X-Ray Dorso Lumbar Spine, Case Sheet with
1027 80.51.6 S10 Disectomy Lumbar Spine, ENMG 26950 27250 33688 34063
operation Notes, Intra-op photo
(Elektroneuromyography), Nerve conduction
study
CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1028 80.99 S10 Corpectomy For Spinal Fixation 75600 76200 94500 95250
Without Contrast, MRI Spine Without Contrast, X-Ray Dorso Lumbar Spine
CT Local Area Without Contrast, MRI Local
1029 81.00.2 S10 Spinal Fusion Procedure Area, X-Ray Ankle - Lateral View/AP View, X CT local Area,/MRI Local Area 50600 51200 63250 64000
Ray Dorso Lumbar Spine
CT Local Area Without Contrast/ MRI Local
1030 81.01.1 S10 Trans Oral Surgery Routine Histopathological Examination, X-Ray 40300 40600 50375 50750
Area
Combined Trans-Oral Surgery & Cv CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1031 81.01.2 S10 X-Ray 51790 52390 64738 65488
Junction Fusion Without Contrast, X-Ray Dorso Lumbar Spine

CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1032 81.01.3 S10 C.V. Junction Fusion X-Ray Dorso Lumbar Spine 40600 41200 50750 51500
Without Contrast, X-Ray Dorso Lumbar Spine

Anterior Cervical Spine Surgery With CT Spine (Cervical,Dorsal,Lumbar,Sacral) CT Spine (Cervical,Dorsal,Lumbar,Sacral)


1033 81.02 S10 45600 46200 57000 57750
Fusion Without Contrast, X-Ray Dorso Lumbar Spine Without Contrast, X-Ray Dorso Lumbar Spine
1034 86.3.14 S10 Excision Of Scalp Lesions Clinical Photograph Routine Histopathological Examination 10000 10000 12500 12500
1035 93.59 S10 Stereotactic Procedures Clinical Photograph Clinical Photograph 20600 21200 25750 26500
S11 SURGICAL ONCOLOGY
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
T3, T4, TSH,USG Neck / CT Scan Neck
Thyroidectomy any type in malignant (Thyroid,Parathyroid,Softtissues)With Contrast/
1036 06.4.3 S11 Routine Histopathological Examination 31200 32400 39000 40500
conditions MRI Neck, Fine Needle Aspiration Cytology
(FNAC), Clinical Photograph
USG Neck / MRI Neck,TC-99 Parathyroid
Parathyroidectomy in malignant
1037 06.8.2 S11 Scan, Serum Calcium Levels, P.T.H Assay Routine Histopathological Examination 36160 37360 45200 46700
conditions
(Parathyroid Assay),
T3, T4, TSH,USG Neck , Fine Needle
Excision of Solitory Thyroid nodule in
1038 06.31.5 S11 Aspiration Cytology (FNAC), Clinical Routine Histopathological Examination 37190 38690 46488 48363
malignant conditions
Photograph
T3, T4, TSH,USG Neck ,CT Scan Neck
Thyroidectomy for solitary nodule in (Thyroid,Parathyroid,Softtissues)With Contrast/
1039 06.39 S11 Routine Histopathological Examination 38840 40340 48550 50425
malignant conditions MRI Neck, Fine Needle Aspiration Cytology
(FNAC), Clinical Photograph
Adrenal function test,Urinary VMA, Urinary
Metanephrine/Nor metanephrine,Urinary
Laparoscopic Biilateral adrenalectomy in Catecholamines,Aldosterone - Urine,24 hour USG Abdomen,Routine Histopathological
1040 07.3.2 S11 41080 41080 51350 51350
malignant conditions free cortisol,USG Abdomen / CT Scan Examination
Abdomen With Contrast / MRI Abdomen With
Contrast
Adrenal function test,Urinary VMA, Urinary
Metanephrine/Nor metanephrine,Urinary
Unilateral Adrenalectomy in malignant Catecholamines,Aldosterone - Urine,24 hour
1041 07.22.2 S11 Routine Histopathological Examination 67140 68640 83925 85800
conditions free cortisol,USG Abdomen / CT Scan
Abdomen With Contrast / MRI Abdomen With
Contrast
Maxillectomy + Orbital Exenteration in CT of Zygoma And Maxilla / MRI Orbits With
1042 16.51 S11 Routine Histopathological Examination 55670 57470 69588 71838
malignant conditions Contrast, Biopsy
Orbital Exenteration in malignant CT Orbits With Contrast ,3D CT Skull/ MRI
1043 16.59 S11 Routine Histopathological Examination 44160 46260 55200 57825
conditions Orbits With Contrast
CEA(Carcino Embryonic Antigen) 125 ,Ca 19-
Laproscopic Right Hemicolectomy in 9 (Cancer Antigen 19-9 Or Carbohydrate USG Abdomen,Routine Histopathological
1044 17.33.2 S11 40000 40000 50000 50000
malignant conditions Antigen 19-9) , CT Scan Lower Abdomen With Examination , WEBEX
Contrast,Colono Scopy, Biopsy
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S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CEA(Carcino Embryonic Antigen) 125 ,Ca 19-
Hartman procedure in malignant 9 (Cancer Antigen 19-9 Or Carbohydrate USG Abdomen,Routine Histopathological
1045 17.35.1 S11 51290 52790 64113 65988
conditions Antigen 19-9) , CT Scan Lower Abdomen With Examination ,
Contrast,
Laparoscopic Left Hemicolectomy in USG Abdomen/CT Scan Lower Abdomen With USG Abdomen,Routine Histopathological
1046 17.35.2 S11 40000 40000 50000 50000
malignant conditions Contrast,Colono Scopy, Biopsy Examination , WEBEX
Sleeve Resection of Ear in malignant CT Scan EarMRI Local Area, Biopsy, Clinical
1047 18.3 S11 Routine Histopathological Examination 47310 50310 59138 62888
conditions Photograph
CT Local Area/Dynamic MRI/Functional MRI,
1048 25.2.2 S11 Hemiglossectomy in malignant conditions Routine Histopathological Examination 43370 45470 54213 56838
Biopsy, Clinical Photograph
Total Glossectomy + Reconstruction in CT Local Area/Dynamic MRI/Functional MRI,
1049 25.3 S11 Routine Histopathological Examination 59350 60850 74188 76063
malignant conditions(25.59) Biopsy, Clinical Photograph
USG Neck, Tmj-Open & Closed Mouth Views,
CT Scan Neck
Parotidectomy any type in malignant
1050 26.32.1 S11 (Thyroid,Parathyroid,Softtissues)With Routine Histopathological Examination 26210 27410 32763 34263
conditions
Contrast/MRI Neck, Fine Needle Aspiration
Cytology (FNAC), Clinical Photograph
CT Scan Neck
(Thyroid,Parathyroid,Softtissues)With
Excision of Submandibular gland in
1051 26.32.2 S11 Contrast0/MRI Neck, Fine Needle Aspiration Routine Histopathological Examination 26900 27800 33625 34750
malignant conditions
Cytology (FNAC), USG Neck , Clinical
Photograph
CT Scan Neck
Palatectomy any type in malignant (Thyroid,Parathyroid,Softtissues)Without
1052 27.32 S11 Routine Histopathological Examination 40980 42180 51225 52725
conditions Contrast/MRI Neck/Biopsy, Clinical
Photograph
Full Thickness Buccal Mucosal Resection
1053 27.49.2 S11 & Reconstruction in malignant USG Neck , Biopsy, Clinical Photograph Routine Histopathological Examination 65110 66910 81388 83638
conditions(27.59)
Excision of Parapharyngeal tumours in
1054 29.3.1 S11 CT of Nose \ Nasopharynx Routine Histopathological Examination 48930 50430 61163 63038
malignant conditions
Resection of Nasopharyngeal Tumor in
1055 29.3.2 S11 CT of Nose \ Nasopharynx, Biopsy Routine Histopathological Examination 79310 82010 99138 102513
malignant conditions
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Hospitals Hospitals Hospitals Hospitals
CT Scan Neck Includes Chest And Larynx2/
Dynamic MRI/Functional MRI,DNL(Direct
Laryngectomy Any Type in malignant
1056 30.4.1 S11 Nasal Laryngoscopy) / DNE -Including Biopsy Routine Histopathological Examination 69680 71180 87100 88975
conditions
Under GI, DNL(Direct Nasal Laryngoscopy) \
DNE -Including Biopsy Under GI
DNL(Direct Nasal Laryngoscopy) \ DNE -
Laryngopharyngo Oesophagectomy in Including Biopsy Under GI,Upper GI
1057 30.4.2 S11 Routine Histopathological Examination 99100 101200 123875 126500
malignant conditions endoscopy , CT Scan Neck Includes Chest And
Larynx2/MRI Local Area
Bronchoscopy, CT Scan Neck Includes Chest
Tracheal Resection in malignant
1058 31.5 S11 And Larynx2/MRI Neck , Routine Routine Histopathological Examination 66800 68600 83500 85750
conditions - CA Thyroid/CA Trachea
Histopathological Examination
Bronchoscopy, CT Scan Chest With Chest X-Ray PA View(1 Film), Routine
1059 32.4.1 S11 Sleeve Resection of Lung Cancer 110100 112200 137625 140250
Contrast/MRI Chest With Contrast -, Histopathological Examination
CT Scan Chest With Contrast, Chest X-Ray PA
Chest X-Ray PA View(1 Film), Routine
1060 32.4.3 S11 Lobectomy for Carcinoma Lung View(1 Film), Fine Needle Aspiration Cytology 77900 78800 97375 98500
Histopathological Examination
(FNAC)/ Truecut biopsy
CT Scan Chest With Contrast, Chest X-Ray PA
Chest X-Ray PA View(1 Film), Routine
1061 32.5.2 S11 Pneumonectomy for Carcinoma Lung View(1 Film), Fine Needle Aspiration Cytology 81190 82090 101488 102613
Histopathological Examination
(FNAC)/ Truecut biopsy
Chest X-Ray PA View(1 Film), CT Scan Chest Pulmonary Function Test(Major), Clinical
1062 32.9.0 S11 Icd + pleurodesis 21480 23580 26850 29475
With Contrast ,Ultra Sound Chest Photograph, Case Sheet with operation Notes
Solitary Lung Metastatectomy in CT Scan Chest With Contrast/MRI Chest With Chest X-Ray PA View(1 Film), Routine
1063 32.29.1 S11 69960 70860 87450 88575
malignant conditions Contrast Histopathological Examination
Lung Metastatectomy multiple in CT Scan Chest With Contrast/MRI Chest With Chest X-Ray PA View(1 Film), Routine
1064 32.29.2 S11 78900 79800 98625 99750
malignant conditions Contrast Histopathological Examination
Resection of mediastinal tumors in CT Scan Chest With Contrast, Chest X-Ray PA Chest X-Ray PA View(1 Film), Routine
1065 34.3.2 S11 64660 65560 80825 81950
malignant conditions View(1 Film) Histopathological Examination
Superior Mediastinal
CT Scan Chest With Contrast, Chest X-Ray PA Chest X-Ray PA View(1 Film), Routine
1066 34.3.4 S11 Dissection+Sternotomy in malignant 61650 62550 77063 78188
View(1 Film) Histopathological Examination
conditions(77.31)
Intercostal Drainage(Icd) in malignant CT Scan Chest With Contrast/ Chest X-Ray PA Chest X-Ray PA View(1 Film), Clinical
1067 34.04 S11 3300 3600 4125 4500
conditions View(1 Film) Photograph
CT Scan Chest With Contrast, Chest X-Ray PA
Surgical Resection of Soft tissue /Bone
1068 34.4.1 S11 View(1 Film), Fine Needle Aspiration Cytology Chest X-Ray PA View(1 Film) 31200 32400 39000 40500
tumors of Chest wall
(FNAC)/ Biopsy
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Surgical Resection and Reconstruction
CT Scan Chest With Contrast, Chest X-Ray PA
1069 34.4.2 S11 of Soft tissue /Bone tumors of Chest Chest X-Ray PA View(1 Film) 71200 72400 89000 90500
View(1 Film)
wall in malignant conditions
Surgical Correction of Bronchopleural
Bronchoscopy, CT Scan Chest Without Chest X-Ray PA View(1 Film), Routine
1070 34.73.4 S11 Fistula - Transpleural BPF Closure in 75940 76840 94925 96050
Contrast, Chest X-Ray PA View(1 Film) Histopathological Examination
malignant conditions
CT Scan Chest With Contrast ,Digital
IVC thrombectomy in malignant
1071 38.07 S11 Subtraction Angiography(DSA Peripheral Routine Histopathological Examination 54260 54860 67825 68575
conditions
Artery\Arteries)
IVC filters for tumour thrombus in Venous Doppler, Routine Histopathological
1072 38.7.2 S11 Venous Doppler 58460 59060 73075 73825
malignant conditions Examination
Vascular reconstruction with synthetic CT Angiography (Coronary Angiography),
1073 39.57.1 S11 CT Angiography (Coronary Angiography) 71850 72450 89813 90563
graft in malignant conditions Color Doppler Sonography Single Study
Vascular reconstruction with auto graft in CT Local Area / Color Doppler Sonography
1074 39.58 S11 Color Doppler Sonography Single Study 77960 80060 97450 100075
malignant conditions Single Study
CT Local Area/MRI Angiography With
1075 39.59 S11 Microvascular reconstruction CT Local Area 92800 97300 116000 121625
Contrast
Vascular isolation and perfusion in CT Scan Abdomen With Contrast/MRI USG-Doppler Abdomen , Routine
1076 39.97 S11 55440 57540 69300 71925
malignant conditions Abdomen With Contrast Histopathological Examination
USG Abdomen,CT Scan Abdomen With
Neck Dissection Any Type in malignant
1077 40.4 S11 Contrast/MRI Abdomen With Contrast,Fine Routine Histopathological Examination 34000 35500 42500 44375
conditions
Needle Aspiration Cytology (FNAC)
Retro Peritoneal Lymph Node Dissection
CT Scan Abdomen With Contrast/MRI
1078 40.5 S11 RPLND As Part Of Staging in malignant Routine Histopathological Examination 41800 43600 52250 54500
Abdomen With Contrast, Tumor marker
conditions
Uni-lateral Inguinal Block Dissection in Fine Needle Aspiration Cytology (FNAC),USG
1079 40.24 S11 Routine Histopathological Examination 31280 32780 39100 40975
malignant conditions local area, Clinical Photograph
Bi-lateral Ilioinguinal block disection in Fine Needle Aspiration Cytology (FNAC),USG
1080 40.24.3 S11 Routine Histopathological Examination 65350 66850 81688 83563
malignant conditions local area, Clinical Photograph
Axillary Dissection in malignant Fine Needle Aspiration Cytology (FNAC),CT
1081 40.51 S11 Routine Histopathological Examination 41320 43420 51650 54275
conditions Local Area,USG local area,
Bilateral Pelvic Lymph Node
1082 40.53 S11 Dissection(Bplnd) in malignant CT Pelvis/MRI Pelvis Routine Histopathological Examination 41800 43600 52250 54500
conditions
Bilateral pelvic lymph node CT Scan Abdomen With Contrast/MRI
1083 40.53.1 S11 dissection(bplnd)(CA. URINARY Abdomen With Contrast,Fine Needle Routine Histopathological Examination 41800 43600 52250 54500
BLADDER) Aspiration Cytology (FNAC)
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Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Abdomen With Contrast + CT Pelvis,
Retro Peritoneal Lymph Node
tumor Markers/Immunohistochemistry (IHC)
1084 40.59.1 S11 Dissection(Rplnd) (For Residual Disease) Routine Histopathological Examination 80100 82200 100125 102750
Three Markers,Fine Needle Aspiration Cytology
in malignant conditions
(FNAC)
Popliteal lymphadenectomy in malignant Fine Needle Aspiration Cytology (FNAC), USG
1085 40.59.2 S11 Routine Histopathological Examination 30900 31800 38625 39750
conditions Abdomen
CT Scan Abdomen With Contrast,USG USG Abdomen, Routine Histopathological
1086 41.5.7 S11 Splenectomy in malignant conditions 43710 44610 54638 55763
Abdomen, Examination
CT Scan Abdomen With Contrast,CT Scan
Oesophagectomy Any Type in malignant USG Abdomen, Routine Histopathological
1087 42.40.2 S11 Chest With Contrast, USG Abdomen, Upper GI 79800 81600 99750 102000
conditions Examination
endoscopy, Biopsy
Upper GI endoscopy , CT Scan Chest With
Transhiatal oesophagectomy in malignant
1088 42.42.1 S11 Contrast & USG Abdomen,CT Scan Upper Routine Histopathological Examination 82100 84200 102625 105250
conditions
Abdomen With Contrast6, Biopsy
CT Scan Abdomen With Contrast, CT Scan
Oesophagectomy With Two Field
Chest With Contrast/MRI Abdomen With
1089 42.42.2 S11 Lymphadenectomy in malignant Routine Histopathological Examination 118800 120600 148500 150750
Contrast,USG Abdomen, Upper GI endoscopy ,
conditions(40.59)
Biopsy
Oesophagectomy With Three Field CT Scan Abdomen With Contrast, CT Scan
1090 42.42.3 S11 Lymphadenectomy in malignant Chest With Contrast, USG Abdomen, Upper GI Routine Histopathological Examination 121500 123000 151875 153750
conditions(40.59) endoscopy , Biopsy
CT Scan Abdomen With Contrast/MRI
Substernal Gastric Bypass in malignant
1091 42.65 S11 Abdomen With Contrast, Upper GI endoscopy , Routine Histopathological Examination 51870 53970 64838 67463
conditions
Biopsy
CT Scan Abdomen With Contrast/MRI
Routine Histopathological Examination,
1092 43.1.2 S11 Gastrostomy in malignant conditions Abdomen With Contrast,USG Abdomen, Upper 20000 20000 25000 25000
WEBEX
GI endoscopy , Biopsy
Laparoscopic mobilization of stomach
CT Scan Abdomen With Contrast, Upper GI USG Abdomen, Routine Histopathological
1093 43.7.3 S11 with distal gastrectomy with billroth i/ii 101800 103600 127250 129500
endoscopy , Biopsy Examination
anastomosis in malignant conditions
Thoracoscopic Mobilization of
Oesophagus + Laparoscopic Mobilization USG Abdomen, CT Scan Abdomen With
1094 43.7.4 S11 Routine Histopathological Examination 120600 121200 150750 151500
of stomach + Gastric Pull-up in malignant Contrast, Upper GI endoscopy , Biopsy
conditions
Gastrectomy Any Type in malignant CT Scan Abdomen With Contrast ,USG USG Abdomen, Routine Histopathological
1095 43.89 S11 51200 52400 64000 65500
conditions Abdomen, Upper GI endoscopy , Biopsy Examination
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Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen/ CT Scan Abdomen With
Gastro Jejunostomy in malignant Contrast, Upper GI endoscopy , Cbp ( HB %, Routine Histopathological Examination, Case
1096 44.39.1 S11 50900 51800 63625 64750
conditions TC , DC, WBC, Platelets), Serum Electrolytes, Sheet with operation Notes
LFT(liver function tests), Biopsy
Barium Meal Follow Through CT Scan
Small Bowel Resection in malignant
1097 45.3.1 S11 Abdomen With Contrast/MRI Abdomen With Routine Histopathological Examination 49200 50400 61500 63000
conditions
Contrast
Routine Histopathological Examination ,Lower
GI Endoscopy, USG Abdomen, CT Scan
Colectomy Any Type in malignant USG Abdomen , Routine Histopathological
1098 45.7 S11 Abdomen With Contrast/MRI Abdomen With 54100 56200 67625 70250
conditions Examination
Contrast,CEA(Carcino Embryonic Antigen)
125
CT Scan Abdomen With Contrast/MRI
Ileotransverse Colostomy in malignant
1099 45.93 S11 Abdomen With Contrast, CEA(Carcino Routine Histopathological Examination 60910 61810 76138 77263
conditions
Embryonic Antigen) 125,Colono Scopy, Biopsy
CT Scan Abdomen With Contrast, /MRI
1100 46.1.2 S11 Colostomy in malignant conditions Abdomen With Contrast, Colono Scopy, Scar Photo 21200 22400 26500 28000
Biopsy
Lower GI Endoscopy/USG Abdomen,CT Scan Clinical Photograph of Ileostomy Along With
1101 46.2.1 S11 Ileostomy in malignant conditions 33210 33810 41513 42263
Abdomen With Contrast, Biopsy Face, Routine Histopathological Examination
CT Scan Abdomen With Contrast/MRI
1102 46.32.2 S11 Jejunostomy in malignant conditions Abdomen With Contrast, Upper GI endoscopy , Scar Photo 31850 31850 39813 39813
Biopsy
Routine Histopathological Examination
Laparoscopic anterior/low resection with
,Colono Scopy, CEA(Carcino Embryonic Routine Histopathological Examination,
1103 46.41 S11 stapplers with diversion covering 100000 100000 125000 125000
Antigen) 125 , CT Scan Abdomen With WEBEX
ileostomy in malignant conditions
Contrast
Ileostomy Closure in malignant
1104 46.51.1 S11 Colono Scopy/ Barium Meal Follow Through Clinical Photograph 25900 26800 32375 33500
conditions
Colostomy Closure in malignant Abdomen Radiograph Supine Or Erect(1 Film),
1105 46.52.1 S11 Clinical Photograph 25900 26800 32375 33500
conditions Clinical Photograph
Routine Histopathological Examination,Colono
Laparoscopic abdominoperineal resection Routine Histopathological Examination, Scar
1106 48.51 S11 Scopy, CEA(Carcino Embryonic Antigen) 125 , 100000 100000 125000 125000
in malignant conditions Photo, WEBEX
CT Scan Abdomen With Contrast
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Code
Hospitals Hospitals Hospitals Hospitals
Barium Meal Follow Through, CT Scan
Abdomino Perineal Resection (Apr) + Abdomen With Contrast, Colono Scopy /
USG Abdomen, Routine Histopathological
1107 48.52 S11 Sacrectomy in malignant Barium Enema (Single Contrast\Double 61500 63000 76875 78750
Examination
conditions(77.99) Contrast),Routine Histopathological
Examination
Colono Scopy/Barium Studies, Clinical
Anterior Resection of rectum in malignant USG Abdomen, Routine Histopathological
1108 48.63.2 S11 Photograph, CEA(Carcino Embryonic Antigen) 51500 53000 64375 66250
conditions Examination
125 , CT Scan Abdomen With Contrast, Biopsy
Barium Meal Follow Through, CT Scan
Abdomen With Contrast,Colono Scopy/ Barium
Posterior Exenteration for Carcinoma Enema (Single Contrast\Double
1109 48.64 S11 Routine Histopathological Examination 61500 63000 76875 78750
Rectum Contrast),Routine Histopathological
Examination, CEA(Carcino Embryonic
Antigen) 125
Barium Meal Follow Through, CT Scan
Abdomen With Contrast,Colono Scopy/ Barium
Enema (Single Contrast\Double
1110 48.69 S11 Total Exenteration for Carcinoma Rectum Routine Histopathological Examination 100100 102200 125125 127750
Contrast),Routine Histopathological
Examination, CEA(Carcino Embryonic
Antigen) 125
USG Abdomen , CT Scan Abdomen With Routine Histopathological Examination, USG
1111 50.2 S11 Hepatectomies in malignant conditions 101500 103000 126875 128750
Contrast, Alpha Feto Protiens Levels Abdomen
Radical Cholecystectomy in malignant CT scan Lower Abdomen Without Contrast/ CT Routine Histopathological Examination, CT
1112 51.22 S11 79800 81600 99750 102000
conditions Scan Abdomen With Contrast, USG Abdomen Scan Abdomen With Contrast, USG Abdomen
CT scan Lower Abdomen Without Contrast/CT
Scan Abdomen Without Contrast, CT Scan
Distal Pancreatectomy in malignant Routine Histopathological Examination, USG
1113 52.52 S11 Abdomen With Contrast, USG Abdomen, Ca 101800 103600 127250 129500
conditions Abdomen
19-9 (Cancer Antigen 19-9 Or Carbohydrate
Antigen 19-9)
Routine Histopathological Examination, Upper
GI endoscopy/CT scan Lower Abdomen
Other Bypasses-Pancreas in malignant Routine Histopathological Examination, USG
1114 52.96 S11 Without Contrast/CT Scan Abdomen Without 52320 54120 65400 67650
conditions Abdomen
Contrast/MRI Abdomen With Contrast, USG
Abdomen
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Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen/CT scan Lower Abdomen
Inoperable Laparotomy in malignant Routine Histopathological Examination, USG
1115 54.1 S11 Without Contrast/CT Scan Abdomen With 37770 39270 47213 49088
conditions Abdomen
Contrast/CT Scan Abdomen Without Contrast

Routine Histopathological Examination/Fine


Abdominal Wall Tumor Resection in Needle Aspiration Cytology (FNAC), USG Routine Histopathological Examination,USG
1116 54.3.1 S11 54280 56080 67850 70100
malignant conditions Abdomen, CT scan Lower Abdomen Without Abdomen
Contrast/CT Scan Abdomen Without Contrast

Resection With Reconstruction of Fine Needle Aspiration Cytology (FNAC), USG


1117 54.3.3 S11 Abdominal wall Tumors in malignant Abdomen, CT scan Lower Abdomen Without USG Abdomen 61100 63200 76375 79000
conditions Contrast/CT Scan Abdomen Without Contrast
USG Abdomen, Fine Needle Aspiration
Resection Of Retroperitoneal Tumors in Cytology (FNAC), CT scan Lower Abdomen
1118 54.4 S11 USG Abdomen 61500 63000 76875 78750
malignant conditions Without Contrast/CT Scan Abdomen Without
Contrast
USG Abdomen/CT scan Lower Abdomen
Diagnostic Laparoscopy in malignant
1119 54.21 S11 Without Contrast/CT Scan Abdomen With Routine Histopathological Examination 22740 23340 28425 29175
conditions
Contrast/CT Scan Abdomen Without Contrast
CT Scan Lower Abdomen With Contrast, USG
USG Abdomen / CT Scan Lower Abdomen With
1120 55.4.2 S11 Open Partial Nephrectomy Abdomen, Fine Needle Aspiration Cytology 42100 44200 52625 55250
Contrast, Routine Histopathological Examination
(FNAC)
Fine Needle Aspiration Cytology (FNAC), CT
Laproscopic radical nephrectomy in USG Abdomen / CT Scan Lower Abdomen With
1121 55.5 S11 Scan Lower Abdomen With Contrast, USG 100000 100000 125000 125000
malignant conditions Contrast, Routine Histopathological Examination
Abdomen, Bone Scan
CT Scan Lower Abdomen With Contrast, USG USG Abdomen, CT Scan Lower Abdomen With
1122 55.5.4 S11 Radical Nephrectomy Abdomen, Fine Needle Aspiration Cytology Contrast, Routine Histopathological 52110 54210 65138 67763
(FNAC),Bone Scan Examination,
USG Abdomen, CT Scan Lower Abdomen
Nephroureterectomy For Transitional Cell
With Contrast, Abdomen And Pelvis For USG Abdomen, Routine Histopathological
1123 55.51.6 S11 Carcinoma Of Renal Pelvis in malignant 66500 68000 83125 85000
Kidneys, Ureters, And Bladder (KUB), Fine Examination
conditions
Needle Aspiration Cytology (FNAC),Bone Scan
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Code
Hospitals Hospitals Hospitals Hospitals
Urinary Diversion in malignant CT Scan Lower Abdomen With Contrast/MRI USG Abdomen, Routine Histopathological
1124 56.5 S11 64750 66250 80938 82813
conditions(56.6/56.7) Local Area, USG Abdomen, Biopsy Examination
CT Scan Lower Abdomen With Contrast, USG
Other Cystectomies in malignant Abdomen, Intra Veneous Pyelogram, Abdomen USG Abdomen, Routine Histopathological
1125 57.6.2 S11 89140 90640 111425 113300
conditions And Pelvis For Kidneys, Ureters, And Bladder Examination
(KUB), Cystoscopy, Biopsy
USG Abdomen, CT Scan Lower Abdomen
1126 57.18 S11 Suprapubic cystostomy With Contrast, Abdomen And Pelvis For USG Abdomen 18490 19990 23113 24988
Kidneys, Ureters, And Bladder (KUB)
Open radical cystectomy with Ilealconduit CT Scan Lower Abdomen With Contrast, USG USG Abdomen, Routine Histopathological
1127 57.71.2 S11 102100 104200 127625 130250
diversion Abdomen, Cystoscopy, Biopsy Examination
Anterior Exenteration (CA. Urinary USG Abdomen, CT Scan Lower Abdomen USG Abdomen, Routine Histopathological
1128 57.79.2 S11 61500 63000 76875 78750
Bladder) With Contrast, Cystoscopy, Biopsy Examination
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, Routine Histopathological
1129 57.79.3 S11 Total Exenteration (CA. Urinary Bladder) 76800 78600 96000 98250
With Contrast, Cystoscopy, Biopsy Examination
USG Abdomen, CT Scan Lower Abdomen
With Contrast, Abdomen And Pelvis For
Radical Prostatectomy in malignant USG Abdomen, Routine Histopathological
1130 60.5.3 S11 Kidneys, Ureters, And Bladder (KUB), TRUS 89050 91450 111313 114313
conditions Examination
(Transrectal Ultrasonography) Biopsy, Prostate-
Specific Antigen (PSA)
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, Routine Histopathological
1131 60.29.4 S11 Channel TURP 41080 42880 51350 53600
With Contrast, Prostate-Specific Antigen (PSA) Examination
USG Abdomen, CT Scan Lower Abdomen USG Abdomen, Routine Histopathological
1132 61.3.1 S11 Scrotectomy in malignant conditions 41740 45040 52175 56300
With Contrast, Biopsy Examination
USG Abdomen, CT Scan Lower Abdomen
USG Abdomen, Routine Histopathological
1133 62.3.3 S11 High Orchidectomy With Contrast, Routine Histopathological 22900 23800 28625 29750
Examination
Examination, Tumor Marker
USG Abdomen, CT Scan Lower Abdomen
USG Abdomen, Routine Histopathological
1134 62.4 S11 Bilateral Orchidectomy With Contrast, Prostate-Specific Antigen 25150 26950 31438 33688
Examination
(PSA), Biopsy
CT Scan Of Lower Abdomen & Scrotum,
1135 64.3 S11 Emasculation in malignant conditions Doppler And Scrotum & Testes, USG Penis, Routine Histopathological Examination 41770 42970 52213 53713
Biopsy, Clinical Photograph
1136 64.3.2 S11,S9 Total Penectomy USG Abdomen, Biopsy, Clinical Photograph Routine Histopathological Examination 38770 40870 48463 51088
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
USG Abdomen, CT scan Lower Abdomen
Surgery For Carcinoma Ovary Early USG Abdomen,Routine Histopathological
1137 65.0 S11 Without Contrast, Ca 125 (Cancer Antigen 125 33860 35960 42325 44950
Stage Examination
Or Carbohydrate Antigen 125)
USG Abdomen, CT scan Lower Abdomen
Excision of Complex ovarian mass in USG Abdomen, Routine Histopathological
1138 65.2.1 S11 Without Contrast, Ca 125 (Cancer Antigen 125 53080 56080 66350 70100
malignant conditions Examination
Or Carbohydrate Antigen 125)
USG Abdomen, CT scan Lower Abdomen
Ovarian cystectomy in malignant USG Abdomen, Routine Histopathological
1139 65.2.2 S11 Without Contrast, Ca 125 (Cancer Antigen 125 53020 56020 66275 70025
conditions Examination
Or Carbohydrate Antigen 125)
USG Abdomen, CT scan Lower Abdomen
Unilateral Salpingo Oophorectomy in USG Abdomen, Routine Histopathological
1140 65.4 S11 Without Contrast, Ca 125 (Cancer Antigen 125 31500 33000 39375 41250
malignant conditions Examination
Or Carbohydrate Antigen 125)
USG Abdomen, CT scan Lower Abdomen
Surgery For Carcinoma Ovary Advance USG Abdomen, Routine Histopathological
1141 65.6 S11 Without Contrast, Ca 125 (Cancer Antigen 125 54100 56200 67625 70250
Stage Examination
Or Carbohydrate Antigen 125)
USG Abdomen, CT scan Lower Abdomen
Bilateral Salpingo Oophorectomy in USG Abdomen, Routine Histopathological
1142 65.6.1 S11 Without Contrast, Ca 125 (Cancer Antigen 125 30900 31800 38625 39750
malignant conditions Examination
Or Carbohydrate Antigen 125)
Radical Trachelectomy in malignant USG Abdomen, CT scan Lower Abdomen USG Abdomen, Routine Histopathological
1143 67.4 S11 52370 54170 65463 67713
conditions Without Contrast/MRI Abdomen With Contrast Examination
USG Abdomen, CT scan Lower Abdomen
Radical Hysterectomy in malignant CT scan Lower Abdomen Without Contrast,
1144 68.6 S11 Without Contrast, Routine Histopathological 59560 63460 74450 79325
conditions USG Abdomen, Biopsy
Examination
USG Abdomen, CT scan Lower Abdomen
Laparoscopic pelvic exenteration in CT scan Lower Abdomen Without
1145 68.8.1 S11 Without Contrast, Routine Histopathological 120000 120000 150000 150000
malignant conditions Contrast/MRI Pelvis, USG Abdomen, Biopsy
Examination
CT scan Lower Abdomen Without USG Abdomen, Routine Histopathological
1146 68.8.2 S11 Anterior Exenteration - Carcinoma Cervix 86860 88960 108575 111200
Contrast/MRI Pelvis, USG Abdomen, Biopsy Examination
Posterior Exenteration - Carcinoma CT scan Lower Abdomen Without USG Abdomen, Routine Histopathological
1147 68.8.3 S11 67100 69200 83875 86500
Cervix Contrast/MRI Pelvis, USG Abdomen, Biopsy Examination
Total Pelvic Exenteration - Carcinoma CT scan Lower Abdomen Without USG Abdomen, Routine Histopathological
1148 68.8.4 S11 100100 102200 125125 127750
Cervix Contrast/MRI Pelvis, USG Abdomen, Biopsy Examination
Supra Levator Exenteration - Carcinoma CT scan Lower Abdomen Without USG Abdomen, Routine Histopathological
1149 68.8.5 S11 92100 94200 115125 117750
Cervix Contrast/MRI Pelvis, USG Abdomen, Biopsy Examination
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Laparoscopic extraFACIAL hysterectomy CT scan Lower Abdomen Without Contrast, CT
USG Abdomen, Routine Histopathological
1150 68.41.1 S11 + multiple biopsies + omentectomy in Scan Abdomen With Contrast, USG Abdomen, 47550 47850 59438 59813
Examination
malignant conditions Biopsy
Laparoscopic ExtraFACIAL CT scan Lower Abdomen Without Contrast, CT
USG Abdomen, Routine Histopathological
1151 68.41.2 S11 Hysterectomy with Bilateral pelvic node Scan Abdomen With Contrast, USG Abdomen, 48270 49470 60338 61838
Examination
dissection in malignant conditions Biopsy
USG Abdomen, CT scan Lower Abdomen USG Abdomen, Routine Histopathological
1152 68.49 S11 Hysterectomy in malignant conditions 34000 35500 42500 44375
Without Contrast, Biopsy Examination
Total Abdominal Hysterectomy(Tah) +
Bilateral Salpingo Ophorectomy (Bso) +
USG Abdomen, CT scan Lower Abdomen USG Abdomen, Routine Histopathological
1153 68.69.1 S11 Bilateral Pelvic Lymph Node Dissection 64230 66330 80288 82913
Without Contrast/MRI Pelvis, Biopsy Examination
(Bplnd) + Omentectomy in malignant
conditions
Radical Hysterectomy +Bilateral Pelvic
Lymph Node Dissection (Bplnd) + USG Abdomen, Routine Histopathological
USG Abdomen, CT scan Lower Abdomen
1154 68.69.2 S11 Bilateral Salpingo Ophorectomy (Bso) / Examination, CT scan Lower Abdomen Without 52110 54210 65138 67763
Without Contrast/MRI Pelvis, Biopsy
Ovarian Transposition in malignant Contrast
conditions
Routine Histopathological Examination, Pap
Laparoscopic wertheim hysterectomy in USG Abdomen, Routine Histopathological
1155 68.69.3 S11 Smear, CT scan Lower Abdomen Without 56220 59220 70275 74025
malignant conditions Examination
Contrast, CT Scan Abdomen With Contrast
Radical Vaginectomy in malignant CT scan Lower Abdomen Without USG Abdomen, Routine Histopathological
1156 70.4.1 S11 55220 57320 69025 71650
conditions Contrast/USG Abdomen, Biopsy Examination
Radical Vaginectomy + CT scan Lower Abdomen Without USG Abdomen, Routine Histopathological
1157 70.4.2 S11 62640 64740 78300 80925
Reconstruction(70.62) Contrast/USG Abdomen, Biopsy Examination
CT scan Lower Abdomen Without Contrast,
USG Abdomen, Routine Histopathological
1158 71.5 S11 Vulvectomy in malignant conditions USG Abdomen, Routine Histopathological 47360 48860 59200 61075
Examination
Examination, Clinical Photograph
Cranio Facial Resection in malignant
1159 76.4 S11 3D CT Facial Bones, MRI Local Area Routine Histopathological Examination 93090 95190 116363 118988
conditions
Resection of Lateral Temporal Bone in 3D CT Facial Bones. / MRI Local Area / X-Ray Of Both Mastoids, Routine
1160 76.5.3 S11 69920 71720 87400 89650
malignant conditions Routine Histopathological Examination Histopathological Examination
Subtotal Resection of Temporal Bone in 3D CT Facial Bones. / MRI Local Area / X-Ray Of Both Mastoids, Routine
1161 76.5.4 S11 73480 74980 91850 93725
malignant conditions Routine Histopathological Examination Histopathological Examination
Total Resection of Temporal Bone in 3D CT Facial Bones. / MRI Local Area / X-Ray Of Both Mastoids, Routine
1162 76.5.5 S11 79500 81000 99375 101250
malignant conditions Routine Histopathological Examination Histopathological Examination
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination, 3D CT
Hemimandibulectomy in malignant Facial Bones/MRI Temporomandibular Single X-Ray Of Both Mastoids, Orthopantomography
1163 76.31 S11 39260 40760 49075 50950
conditions Joint With Contrast /Contrast Enhanced USG, (OPG), Routine Histopathological Examination
Clinical Photograph, OP4
Marginal Mandibulectomy in malignant Orthopantomography (OPG), Routine
1164 76.31.3 S11 Orthopantomography (OPG) 48020 51920 60025 64900
conditions Histopathological Examination
Routine Histopathological Examination,
Maxillectomy Any Type in malignant Contrast Enhanced USG, X-Ray Facial Bones, X-Ray Facial Bones, Routine Histopathological
1165 76.39 S11 32870 34970 41088 43713
conditions 3D CT Facial Bones/MRI Local Area, Clinical Examination
Photograph
Maxillectomy + Infratemporal Fossa X-Ray PNS, Routine Histopathological
1166 76.65.1 S11 3D CT Facial Bones, Biopsy, X-Ray PNS 67480 69280 84350 86600
Clearance in malignant conditions Examination
CT Local Area Without Contrast / MRI Local X-Ray,CT Local Area Without Contrast/MRI
1167 77.60.1 S11 Bone Resection in malignant conditions 44170 45370 55213 56713
Area Local Area
3D CT Skull/MRI Local Area, Routine
Scalp tumour with calvarial resection in Routine Histopathological Examination, Clinical
1168 77.60.2 S11 Histopathological Examination, Clinical 62760 64860 78450 81075
malignant conditions Photograph
Photograph
Bone and Soft TissueTumors Amputation Routine Histopathological Examination,
1169 77.60.3 S11 Routine Histopathological Examination 29800 31300 37250 39125
in malignant conditions(83.49) Clinical Photograph
Surgery (removal) for Bone/Soft tissue
Bone Scan, CT Local Area Without Contrast,
1170 77.60.11 S11 tumors-Without Prosthesis in malignant X-Ray, Routine Histopathological Examination 51270 53370 64088 66713
MRI Local Area, Clinical Photograph
conditions(83.49)
Surgery (removal) for Bone / Soft tissue
Bone Scan, CT Local Area Without Contrast,
1171 77.60.12 S11 tumors-With Custom Made Prosthesis in X-Ray, Routine Histopathological Examination 87610 89710 109513 112138
MRI Local Area, Clinical Photograph
malignant conditions(83.49+84.40)
Surgery (removal) for Bone / Soft tissue
Bone Scan, CT Local Area Without Contrast,
1172 77.60.13 S11 tumors-With Modular Prosthesis in X-Ray, Routine Histopathological Examination 99500 101000 124375 126250
MRI Local Area
malignant conditions(83.49+84.40)
Shoulder Girdle Resection in malignant Bone Scan, CT Local Area Without Contrast /
1173 77.81 S11 X-Ray, Routine Histopathological Examination 56290 57490 70363 71863
conditions MRI Shoulder
CT Spine (Cervical,Dorsal,Lumbar,Sacral)
1174 77.99 S11 Sacral Resection in malignant conditions X-Ray, Routine Histopathological Examination 61500 63000 76875 78750
Without Contrast /MRI Spine,
1175 83.49.1 S11 Soft tissue and bone tumour wide exision Clinical Photograph, X-Ray Routine Histopathological Examination 16800 18600 21000 23250
Soft tissue And Bone tumors wide CT Local Area Without Contrast, X-Ray,
1176 83.49.2 S11 X-Ray, Routine Histopathological Examination 26800 28600 33500 35750
excision reconstruction Clinical Photograph
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S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
MRI Local Area/CT Scan Head Without
Contrast,CT Scan Neck
(Thyroid,Parathyroid,Softtissues)With Contrast,
1177 83.49.3 S11 Head and Neck - Wide Excision Routine Histopathological Examination 41070 42570 51338 53213
X-Ray Dorso Lumbar Spine , Clinical
Photograph, Biopsy, Fine Needle Aspiration
Cytology (FNAC)
Bone Scan, CT Local Area Without
Forequarter Amputation in malignant Contrast/MRI Local Area, Clinical Photograph, Routine Histopathological Examination, Clinical
1178 84.09.1 S11 79140 80040 98925 100050
conditions Fine Needle Aspiration Cytology (FNAC), Photograph
Chest X-Ray PA View(1 Film)
CT Local Area Without Contrast, MRI Pelvis,
1179 84.19.2 S11 Hemipelvectomy in malignant conditions Fine Needle Aspiration Cytology (FNAC), CT Local Area Without Contrast, MRI Pelvis 80090 81290 100113 101613
Chest X-Ray PA View(1 Film)
CT Local Area Without Contrast, MRI Pelvis,
Internal Hemipelvectomy in malignant
1180 84.19.3 S11 Fine Needle Aspiration Cytology (FNAC), Routine Histopathological Examination, X-Ray 80840 82040 101050 102550
conditions
Chest X-Ray PA View(1 Film)
Curettage & Bone Cement in malignant X-Ray , CT Local Area Without Contrast/MRI
1181 84.56 S11 Routine Histopathological Examination, X-Ray 52630 54130 65788 67663
conditions Local Area
Fine Needle Aspiration Cytology (FNAC) ,
Mastectomy Any Type in malignant Chest X-Ray PA View(1 Film),X- Ray
1182 85.4 S11 Routine Histopathological Examination 30900 31800 38625 39750
conditions Mammogram, Clinical Photograph, USG
Abdomen
Routine Histopathological Examination,
1183 85.7.1 S11 Breast Reconstruction Surgery Routine Histopathological Examination 43320 44820 54150 56025
Clinical Photograph
Routine Histopathological Examination, X- Ray
Mammogram, Contrast Enhanced USG, CT
1184 85.21 S11 Lumpectomy Routine Histopathological Examination 3390 3690 4238 4613
Local Area Without Contrast , Clinical
Photograph
Routine Histopathological Examination, X- Ray
Wide Excision - Breast in malignant
1185 85.22.1 S11 Mammogram, Clinical Photograph, USG Routine Histopathological Examination 5750 6350 7188 7938
conditions
Abdomen
Skin Tumors Wide Excision in malignant Routine Histopathological Examination,
1186 86.4.1 S11 Routine Histopathological Examination 36550 38650 45688 48313
conditions Clinical Photograph
Skin Tumors wide Excision +
Routine Histopathological Examination,
1187 86.4.2 S11 Reconstruction in malignant Routine Histopathological Examination 41800 43600 52250 54500
Clinical Photograph
conditions(86.6/86.7)
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Wide local excision in malignant Routine Histopathological Examination,
1188 86.4.3 S11 Routine Histopathological Examination 64610 65810 80763 82263
conditions Clinical Photograph
Routine Histopathological Examination, Routine Histopathological Examination, Case
1189 86.4.5 S11 Wide local excision + reconstruction 67010 70610 83763 88263
Clinical Photograph Sheet with operation Notes
Skin Tumors amputation in malignant Routine Histopathological Examination,
1190 86.9 S11 Routine Histopathological Examination 26180 27980 32725 34975
conditions Clinical Photograph
Reconstructon with Myocutaneous / CT Local Area Without Contrast/MRI Local
1191 86.63 S11 Intra OP photo 39280 42880 49100 53600
Cutaneous Flap in malignant conditions Area, Clinical Photograph
Routine Histopathological Examination, USG
Composite Resection & Reconstruction - Routine Histopathological Examination, Intra
1192 86.89 S11 Neck, CT Local Area Without Contrast, MRI 68960 72860 86200 91075
Head & Neck in malignant conditions OP photo, Case Sheet with operation Notes
Neck, 3D CT Skull, Clinical Photograph
Biopsy, Clinical Photograph, CT Scan Chest
Isolated limb perfusion-hyperthermia in With Contrast/ CT Scan Chest Without
1193 99.85 S11 Case Sheet with operation Notes 62130 63330 77663 79163
malignant conditions Contrast, CT Scan Abdomen Without
Contrast/CT Scan Abdomen With Contrast
S12 MEDICAL ONCOLOGY
CT scan Abdomen With Contrast/ USG
Abdomen, Abdomen Prostate-Specific Antigen Case Sheet with treatment details, Clinical
1194 99.24 S12 Prostate Cancer with Hormonal Therapy 3700 3700 4625 4625
(PSA)-I02.056, Chest X-Ray PA View(1 Film), Photograph
Routine Histopathological Examination
Routine Histopathological Examination, Chest
X-Ray PA View(1 Film), USG Breast, Alkaline
Chemotherapy for Breast Cancer with Phosphatase Levels,Estrogen Case Sheet with treatment details, Clinical
1195 99.25.1 S12 4190 4790 5238 5988
Adriamycin / Cyclophosphamide (Ac) Receptor/Progesterone Receptor, Her-2eu - Photograph
Microscopy , Bone Scan, Case sheet with
clinical History
Routine Histopathological Examination, CT
Chemotherapy for Bladder Cancer with Scan Lower Abdomen With Contrast, USG Case Sheet with treatment details, Clinical
1196 99.25.2 S12 1990 1990 2488 2488
Weekly Cisplatin. Abdomen, Chest X-Ray PA view,Case sheet Photograph
with clinical History
USG Abdomen, Routine Histopathological
Chemotherapy for Bladder Cancer with
Examination, CT Scan Lower Abdomen With Case Sheet with treatment details, Clinical
1197 99.25.3 S12 Methotrexate Vinblastine Adriamycin 5990 5990 7488 7488
Contrast, Chest X-Ray PA View(1 Film), Case Photograph
Cyclophosphamide (Mvac)
sheet with clinical History
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S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination, X- Ray
Mammogram, USG Breast, Alkaline
Chemotherapy for Breast Cancer with 5- Case Sheet with treatment details, Clinical
1198 99.25.4 S12 Phosphatase Levels, Estrogen 4190 4790 5238 5988
Fluorouracil A-C (Fac) Photograph
Receptor/Progesterone Receptor, Case sheet
with clinical History
Routine Histopathological Examination, CT
Chemotherapy for Non SMAL cell Lung local area with contrast, Chest X-Ray PA Case Sheet with treatment details, Clinical
1199 99.25.5 S12 7900 8800 9875 11000
Cancer with Cisplatin/Etoposide (Iiib) View(1 Film), Alkaline Phosphatase Levels, Photograph
Bone scan, Case sheet with clinical History
Chest X-Ray PA View(1 Film), USG local area,
Chemotherapy for Non SMAL cell Lung CT local area without contrast, Routine Case Sheet with treatment details, Clinical
1200 99.25.6 S12 15000 15000 18750 18750
Cancer with Erlotinib histopathological examination, Clinical Photograph
Photograph
Routine Histopathological Examination, CT
Chemotherapy for Non SMAL cell Lung scan chest with contrast, USG local area, Case Sheet with treatment details, Clinical
1201 99.25.7 S12 7080 7080 8850 8850
Cancer with GEFITINIB Alkaline Phosphatase Levels, Case sheet with Photograph
clinical History
Routine Histopathological Examination, CT
chest with contrast/CT upper abdomen with
Chemotherapy for Non SMAL cell Lung Case Sheet with treatment details, Clinical
1202 99.25.8 S12 contrast6, Fine Needle Aspiration Cytology 10290 10590 12863 13238
Cancer with Paclitaxel /Carboplatin Photograph
(FNAC)/Routine histopathological examination
, Alkaline Phosphatase Levels
Routine Histopathological Examination, USG
Chemotherapy for Non SMAL cell Lung local area, SAlkaline Phosphatase Levels Bone
1203 99.25.9 S12 Case Sheet with treatment details 20290 20590 25363 25738
Cancer with PEM + Cisplatin Scan , CT local area with contrast, Clinical
Photograph
Routine Histopathological Examination, USG
Abdomen, Upper GI endoscopy,Chest X-Ray
Chemotherapy for Oesophageal Cancer Case Sheet with treatment details, Clinical
1204 99.25.10 S12 PA View(1 Film), CT chest with contrast/CT 7400 8300 9250 10375
with Cisplatin/5fu Photograph
upper abdomen with contrast, Case sheet with
clinical History
Routine Histopathological Examination, CT
Chemotherapy for Gastric Cancer with 5- Scan Abdomen With Contrast, Upper GI Case Sheet with treatment details, Clinical
1205 99.25.11 S12 5300 5600 6625 7000
Fu Leucovorin (Mcdonald Regimen) endoscopy,Chest X-Ray PA View(1 Film), Case Photograph
sheet with clinical History
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination, CT
Chemotherapy for Vulval Cancer with Case Sheet with treatment details, Clinical
1206 99.25.12 S12 Scan Lower Abdomen With Contrast, Upper GI 5890 6790 7363 8488
Cisplatin/5-Fu Photograph
endoscopy,Chest X-Ray PA View(1 Film)
Routine Histopathological Examination, CT
Chemotherapy for Gastric Cancer with Scan Abdomen With Contrast,Upper GI Case Sheet with treatment details, Clinical
1207 99.25.13 S12 15590 16190 19488 20238
EOX endoscopy,Chest X-Ray PA View(1 Film), Case Photograph
sheet with clinical History
Routine Histopathological Examination, CT
Chemotherapy for Gastric Cancer with Case Sheet with treatment details, Clinical
1208 99.25.14 S12 scan Lower Abdomen Without Contrast, Chest 16290 16590 20363 20738
Gemcitabine+Oxaliplatin Photograph
X-Ray PA View(1 Film)
Routine Histopathological Examination, CT
Chemotherapy for Gastric Cancer with Case Sheet with treatment details, Clinical
1209 99.25.15 S12 scan Lower Abdomen Without Contrast, Chest 12600 13200 15750 16500
Gemcitabine / Cisplatin Photograph
X-Ray PA View(1 Film)
Routine Histopathological Examination,
Case Sheet with treatment details, Clinical
1210 99.25.16 S12 Ac (Ac Then T) Alkaline Phosphatase Levels, CT scan Lower 4490 5390 5613 6738
Photograph
Abdomen Without Contrast
Routine Histopathological Examination, Upper
Chemotherapy for Gastric Cancer with GI endoscopy, Chest X-Ray PA View(1 Film), Case Sheet with treatment details, Clinical
1211 99.25.17 S12 5630 5630 7038 7038
Imatinib(CML) BCR-ABL1 Transcripts By Quantitative PCR, Photograph
Upper GI endoscopy
Routine Histopathological Examination, CT
Chemotherapy for Gastric Cancer with scan Abdomen With Contrast, Chest X-Ray PA Case Sheet with treatment details, Clinical
1212 99.25.18 S12 18290 18590 22863 23238
Dcf View(1 Film), Upper GI endoscopy, Case sheet Photograph
with clinical History
Routine Histopathological Examination,CT
Chemotherapy for Colorectal Cancer with Scan Abdomen With Contrast, Colono Scopy, Case Sheet with treatment details, Clinical
1213 99.25.19 S12 6390 7590 7988 9488
Monthly 5-Fu Chest X Ray PA View(1Film), Case sheet with Photograph
clinical History
Routine Histopathological Examination, CT
Chemotherapy for Colorectal Cancer with
scan Lower Abdomen With Contrast, Case Sheet with treatment details, Clinical
1214 99.25.20 S12 5-Fluorouracil-Oxaliplatin Leucovorin 12390 13290 15488 16613
Colonoscopy,Chest X Ray PA View(1Film), Photograph
(Folfox) (Stage III) Only
Case sheet with clinical History
Chest X-Ray PA View(1 Film), Colono Scopy,
Chemotherapy for Colorectal Cancer with CEA(Carcino Embryonic Antigen) 125, CT Case Sheet with treatment details, Clinical
1215 99.25.21 S12 8310 8910 10388 11138
Capecitabine + bevacizumab (metastatic) Scan Abdomen With Contrast Photograph
Abdomen(Whole)
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Chest X-Ray PA View(1 Film), Colono Scopy,
Chemotherapy for Colorectal Cancer with
CEA(Carcino Embryonic Antigen) 125, CT Case Sheet with treatment details, Clinical
1216 99.25.22 S12 Capecitabine + Oxalipantia (adjuvant) 12590 13190 15738 16488
Scan Abdomen With Contrast Photograph
and metastatic
Abdomen(Whole)
Routine Histopathological Examination, CT
Chemotherapy for Vaginal Cancer with Case Sheet with treatment details, Clinical
1217 99.25.23 S12 Scan Lower Abdomen With Contrast/MRI 6890 7790 8613 9738
Cisplatin/5-Fu Photograph
Abdomen Without Contrast (Pre Chemo)
Routine Histopathological Examination, CT
Chemotherapy for Colorectal Cancer with Scan Abdomen With Contrast, Chest X-Ray PA Case Sheet with treatment details, Clinical
1218 99.25.24 S12 7290 7590 9113 9488
Capacitabine View(1 Film), Colono Scopy, CEA(Carcino Photograph
Embryonic Antigen) 125
Routine Histopathological Examination, CT
Chemotherapy for Bone Tumors with Case Sheet with treatment details, Clinical
1219 99.25.25 S12 Scan Chest With Contrast, MRI Local area, 7590 8190 9488 10238
Cisplatin/Adriamycin Photograph
Case sheet with clinical History
Routine Histopathological Examination, CT
Chemotherapy for Bone Tumors - Scan Lower Abdomen With Contrast/ CT Scan
Hodgkin Lymphoma disease with Chest With Contrast, Chest X-Ray PA View(1 Routine Histopathological Examination, Case
1220 99.25.26 S12 5590 6190 6988 7738
Adriamycin Bleomycin Vinblastine Film), USG Abdomen, Bone Marrow Profile, Sheet with treatment details, Clinical Photograph
Dacarbazine (Abvd) ECHO Cardiogram, IHC, Case sheet with
clinical History
Routine Histopathological Examination, CT
Chemotherapy for Non Hodgkin Scan Chest With Contrast/CT Scan
Lymphoma with Cyclophosphamide neck(thyroid, para thyroid, soft tissues) with Routine Histopathological Examination, Case
1221 99.25.27 S12 5100 5700 6375 7125
Adriamycin Vincristine Prednisone contrast0/CT Scan with Abdomen with contrast, Sheet with treatment details, Clinical Photograph
(Chop) Chest X-Ray PA View(1 Film), Bone Marrow
Profile, Case sheet with clinical History
Routine Histopathological Examination, USG
Chemotherapy for Breast Cancer with Case Sheet with treatment details, Clinical
1222 99.25.28 S12 Breast, Alkaline Phosphatase Levels, Chest X- 7590 8190 9488 10238
Paclitaxel Photograph
Ray PA View(1 Film), , Breast IHC panel
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
CT Scan Lower Abdomen With Contrast, CT
local Area, CT Scan Neck
(Thyroid,Parathyroid,Softtissues)With
Contrast0/ PET Scan BEFORE TREATMENT
Chemotherapy for Non Hodgkin AFTER 4 CYCLES, END OF TREATMENT Case Sheet with treatment details, Clinical
1223 99.25.29 S12 45290 45590 56613 56988
Lymphoma with R - chop CT Scan Chest With Contrast, USG Abdomen, Photograph
Routine Histopathological Examination, Bone
Marrow Aspiration,Complete blood
picture(CBP), LFT(liver function tests) , Renal
Profile, IHC
Blood Grouping And RH Typing, Bone Marrow
Chemotherapy for Multiple Myeloma Biopsy, SR PROTEIN ELECTROPHOROSIS,
Case Sheet with treatment details, Clinical
1224 99.25.30 S12 with Vincristine, Complete blood picture(CBP), LFT(liver 4600 5200 5750 6500
Photograph
Adriamycin,Dexamethasone(Vad) function tests) , Renal Profile, Skeletal Survey ,
Case sheet with clinical History
Bone Marrow Biopsy, SERUM ELECTRO
Chemotherapy for Multiple Myeloma PHOROSIS, Serum Total Proteins Levels, Case Sheet with treatment details, Clinical
1225 99.25.31 S12 4990 4990 6238 6238
with Thalidomide+Dexamethasone(Oral) Skeletal Survey , Case sheet with clinical Photograph
History
Chemotherapy for Multiple Myeloma Complete Blood Picture [CBP], Bone Marrow Case Sheet with treatment details, Clinical
1226 99.25.32 S12 4790 5090 5988 6363
with Melphalan Prednisone (Oral) Profile, Skeletal Survey Photograph
Routine Histopathological Examination, CT
Scan Abdomen With Contrast/USG
Chemotherapy for Wilms Tumor with Clinical Photograph, Routine Histopathological
1227 99.25.33 S12 Abdomen,/CT Scan Chest With Contrast /Chest 7290 7590 9113 9488
Siopwts Regimen(Stages I-III) Examination
X-Ray PA View(1 Film)/Bone scan, Case sheet
with clinical History
Routine Histopathological Examination, CT
Scan Abdomen With Contrast, USG Abdomen,
Chemotherapy for Ovarian cancer with Clinical Photograph, Case Sheet with operation
1228 99.25.34 S12 Ca 125 (Cancer Antigen 125 Or Carbohydrate 11290 11590 14113 14488
Carboplatin / Paclitaxel Notes
Antigen 125) Chest X-Ray PA View(1 Film),
Case sheet with clinical History
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination, CT
Scan Abdomen With Contrast, USG Abdomen,
Chemotherapy for Hepatoblastoma
1229 99.25.35 S12 Alkaline Phosphatase Levels, Abdomen X-Ray Clinical Photograph 5300 5600 6625 7000
operable with Cisplatin -Adriamycin
(Lateral View), Chest X Ray PA View (1 Film),
Case sheet with clinical History
Complete Blood Picture [CBP], Chest X-Ray
PA View(1 Film), CT Scan Abdomen With
Chemotherapy for Childhood B cell
1230 99.25.36 S12 Contrast, Bone Marrow Profile, Triple Clinical Photograph 22090 24190 27613 30238
Lymphoma with variable regimen
Markers/Immunohistochemistry (IHC) Three
Markers , Case sheet with clinical History
Routine Histopathological Examination, CT
Scan Chest With Contrast/CT Scan
neck(thyroid, para thyroid, soft tissues) with
Chemotherapy for Neuroblastoma (Stages contrast/CT Scan with Abdomen with Clinical Photograph, Routine Histopathological
1231 99.25.37 S12 11490 12990 14363 16238
I-III ) with Variable Regimen contrast/Immunohistochemistry (IHC) Three Examination
Markers, USG local area, Bone Marrow Profile,
Chest X-Ray PA View(1 Film), Bone scan,
Case sheet with clinical History
Routine Histopathological Examination, CT
Chemotherapy for Neuroblastoma (Stages
1232 99.25.38 S12 Scan Head With Contrast, Chest X-Ray PA Case Sheet with operation Notes 5590 6190 6988 7738
I-III ) PCV (medulloblastoma)
View(1 Film), Case sheet with clinical History
Triple Markers/Immunohistochemistry (IHC)
Three Markers, Bone Marrow Profile, X-Ray
Chemotherapy for Retinoblastoma with Skull, CT Scan Chest With Contrast/CT Scan Clinical Photograph, Routine Histopathological
1233 99.25.39 S12 5590 6190 6988 7738
Carbo/Etoposide/Vincristine neck(thyroid, para thyroid, soft tissues) with Examination, Case Sheet with operation Notes
contrast/CT Scan with Abdomen with contrast,
Bone scan, Clinical Photograph
Routine Histopathological Examination, X- Ray
Chemotherapy for Breast Cancer with Mammogram, USG Breast, Alkaline
1234 99.25.40 S12 Cyclophosphamide/ Methotrexate / Phosphatase Levels, Estrogen Case Sheet with operation Notes 1990 1990 2488 2488
5fluorouracil (Cmf) Receptor/Progesterone Receptor, Clinical
Photograph
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ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination,
Complete Blood Picture [CBP], Cerebrospinal
Fluid (CSF) Analysis Cell Count, USG local
area, Triple Markers/Immunohistochemistry
Chemotherapy for Histiocytosis with (IHC) Three Markers, Bone Marrow Profile, Clinical Photograph, Case Sheet with operation
1235 99.25.41 S12 5290 5590 6613 6988
Variable Regimen Chest X-Ray PA View(1 Film), CT Scan Chest Notes, Routine Histopathological Examination
With Contrast/CT Scan neck(thyroid, para
thyroid, soft tissues) with contrast0/CT Scan
with Abdomen with contrast, Bone scan,
Clinical Photograph
Routine Histopathological Examination,
Cerebrospinal Fluid (CSF) Analysis Cell Count,
Bone Marrow Profile, Triple
Markers/Immunohistochemistry (IHC) Three
Chemotherapy for Rhabdomyosarcoma Markers, CT local area without contrast, CT
Clinical Photograph,Case sheet, Routine
1236 99.25.42 S12 with Vincristine-Actinomycin- Scan Chest With Contrast/CT Scan 9590 10190 11988 12738
Histopathological Examination
Cyclophosphamide(Vactc) Based Chemo neck(thyroid, para thyroid, soft tissues) with
contrast0/CT Scan with Abdomen with contrast,
Bone scan, Triple
Markers/Immunohistochemistry (IHC) Three
Markers , Clinical Photograph
Routine Histopathological Examination, CT
local area without contrast, Chest X-Ray PA
Chemotherapy for Ewings Sarcoma with View(1 Film), USG local area, Bone Marrow Clinical Photograph, Case Sheet with operation
1237 99.25.43 S12 5290 5590 6613 6988
Variable Regimen Profile, Bone scan, Triple Notes
Markers/Immunohistochemistry (IHC) Three
Markers , Clinical Photograph
Complete Blood Picture [CBP], Bone Marrow
Chemotherapy for Acute Myeloid
1238 99.25.44 S12 Profile, USG local area/CT local area without Clinical Photograph 68990 77990 86238 97488
Leukemia with Induction Phase
contrast, Case sheet with clinical History
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination, CT
local area without contrast, USG local area,
Chemotherapy for Ovarian cancer with Beta HCG(Human Chorionic Gonadotropin)
Clinical Photograph, Case Sheet with operation
1239 99.25.45 S12 Germ Cell Tumor Bleomycin-Etoposide- Levels, Alpha Feto Protiens Levels, Lactate 8590 9190 10738 11488
Notes
Cisplatin (Bep) Dehydrogenase (LDH), Chest X-Ray PA
View(1 Film)/CT Scan Chest With Contrast,
Clinical Photograph
Chemotherapy for Acute Myeloid Complete Blood Picture [CBP], BMA Clinical Photograph, Case Sheet with operation
1240 99.25.46 S12 66290 72590 82863 90738
Leukemia with Consolidation Phase Remission Report, Clinical Photograph Notes
Complete Blood Picture [CBP], BMA
Chemotherapy for Acute Myeloid Clinical Photograph, Case Sheet with operation
1241 99.25.47 S12 Remission Report, PMLRA Treatment Report , 2990 2990 3738 3738
Leukemia with Maintenance phase Notes
Clinical Photograph
Complete Blood Picture [CBP], Bone Marrow
Chemotherapy for Acute Lymphoblastic Profile, USG local area/CT local area without
Clinical Photograph, Case Sheet with operation
1242 99.25.48 S12 Leukemia with Induction 1st And 2nd contrast, Chest X-Ray PA View(1 Film), 108990 117990 136238 147488
Notes
Months Immuno pheno typing / Cytochemistry, Clinical
Photograph
Chemotherapy for Acute Lymphoblastic Complete Blood Picture [CBP], BMA Clinical Photograph, Case Sheet with operation
1243 99.25.49 S12 10900 11800 13625 14750
Leukemia with Induction 3rd, 4th, 5th Remission Report, Clinical Photograph Notes
Chemotherapy for Acute Lymphoblastic Complete Blood Picture [CBP], BMA Clinical Photograph, Case Sheet with operation
1244 99.25.50 S12 12290 12590 15363 15738
Leukemia with Induction Maintenance Remission Report, Clinical Photograph Notes
Palliative Chemotherapy for unlisted Routine Histopathological Examination, Clinical Photograph, Case Sheet with operation
1245 99.25.51 S12 5590 6190 6988 7738
Regimen Complete staging report Notes
Routine Histopathological Examination, Chest
X-Ray PA View(1 Film), USG local area,
Chemotherapy for Breast Cancer with Clinical Photograph, Case Sheet with operation
1246 99.25.52 S12 Alkaline Phosphatase Levels, Estrogen 490 490 613 613
Tamoxifen Tabs Notes
Receptor/Progesterone Receptor, Clinical
Photograph
Routine Histopathological Examination,
Palliative And Supportive Therapy for Clinical Photograph, Case Sheet with operation
1247 99.25.53 S12 Complete Blood Picture [CBP], Renal Profile, 3590 4190 4488 5238
terminally ill cancer patient Notes
LFT(liver function tests), Clinical Photograph
Chemotherapy for Acute Myeloid CT local area without contrast/USG local area,
1248 99.25.54 S12 Leukemia with Xelox Along With Routine Histopathological Examination, Chest Case Sheet with operation Notes 11990 11990 14988 14988
Adjuvant Chemotherapy Of As-I X-Ray PA View(1 Film)
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Chemotherapy for Multiple myeloma with Bone Marrow Profile, Chest X-Ray PA View(1
1249 99.25.55 S12 Zoledronic Acid Along With Adjuvant Film), Serum Calcium Levels, Serum Creatinine Case Sheet with operation Notes 3290 3590 4113 4488
Chemotherapy Of As-I Levels, Bone Scan, Clinical Photograph
Routine Histopathological Examination, CT
local area without contrast, USG local area,
Chemotherapy for low risk Gestational Beta HCG(Human Chorionic Gonadotropin)
1250 99.25.56 S12 Beta HCG(Human Chorionic Gonadotropin) 2290 2590 2863 3238
trophoblast DS with Weekly Methotrexate Levels, Case Sheet with operation Notes
Levels, Chest X-Ray PA View(1 Film), Clinical
Photograph
Bone Marrow Profile/Routine
Chemotherapy for Multiple myeloma with Histopathological Examination, Bence Jones
1251 99.25.57 S12 Case Sheet with operation Notes 9990 9990 12488 12488
Lenalidomide dexa Protein In Urine, Protein Electrophoresis,
Renal Profile, Complete Blood Picture [CBP]
Bone Marrow Profile/Routine
Chemotherapy for Multiple myeloma with Histopathological Examination, Bence Jones
1252 99.25.58 S12 Case Sheet with operation Notes 5360 5360 6700 6700
MPT(myeloma) Protein In Urine, Skeletal Survey , Protein
Electrophoresis
Chemotherapy for Multiple myeloma with
1253 99.25.59 S12 USG local area Case Sheet with operation Notes 6990 6990 8738 8738
Imatinib (GSIT)
Blood Culture & Sensitivity - Automated,
Chemotherapy for Febrile Neutropenia
Routine Histopathological Examination, Chest Routine Histopathological Examination,USG
with 1st Line Iv Antibiotics And Other
1254 99.25.60 S12 X-Ray PA View(1 Film), Renal Profile, local area, CT local area without contrast, Case 5290 5590 6613 6988
Supportive Therapy ( Third Generation
Complete Blood Picture [CBP], LFT(liver Sheet with operation Notes
Cephalosporin, Aminoglycoside Etc.,)
function tests), Clinical Photograph
Chemotherapy for Febrile Neutropenia Blood Culture & Sensitivity - Automated,
with 2nd Line Iv Antibiotics And Other Routine Histopathological Examination, Chest Routine Histopathological Examination, USG
1255 99.25.61 S12 Supportive Therapy(Carbapenems, Fourth X-Ray PA View(1 Film), Renal Profile, local area, CT local area without contrast, Case 44190 48390 55238 60488
Generation Cephalosporins, Piperacillin, Complete Blood Picture [CBP], LFT(liver Sheet with operation Notes
Anti-Fungal . Azoles Etc.,) function tests), Clinical Photograph
Bone Marrow Aspiration, Renal Profile,
Chemotherapy for Chronic lymphoid Complete Blood Picture [CBP], LFT(liver Clinical Photograph, Case Sheet with operation
1256 99.25.62 S12 16300 16600 20375 20750
leukemia with Benadamustine function tests), Abdomen X-Ray (Lateral Notes
View), USG Abdomen, Immuno pheno typing
Bone Marrow Aspiration, Renal Profile,
Chemotherapy for Chronic lymphoid Clinical Photograph, Case Sheet with operation
1257 99.25.63 S12 Complete Blood Picture [CBP], LFT(liver 2990 2990 3738 3738
leukemia with Chilorambucil Notes
function tests), Immuno pheno typing
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Chemotherapy for Breast Cancer with Estrogen Receptor/Progesterone Receptor, Clinical Photograph, Case Sheet with operation
1258 99.25.64 S12 1190 1190 1488 1488
Aromatase Inhibitors Routine Histopathological Examination Notes
LFT(liver function tests), Routine
Chemotherapy for Chronic lymphoid Histopathological Examination, CT local area Clinical Photograph, Case Sheet with operation
1259 99.25.65 S12 10600 11200 13250 14000
leukemia with IA without contrast, Chest X-Ray PA View(1 Notes
Film), Chest X-Ray Lateral View(1 Film)
Routine Histopathological Examination, CT
Chemotherapy for Chronic lymphoid Bone Marrow Aspiration/ Routine
1260 99.25.66 S12 local area without contrast, USG local area, Case 6990 6990 8738 8738
leukemia with Imatinib(CML) Histopathological Examination
Sheet with operation Notes
Routine Histopathological Examination, CT
Chemotherapy for low risk Gestationallocal area without contrast, USG local area,
1261 99.25.67 S12 B Hcg Levels, Case Sheet with operation Notes 5290 5590 6613 6988
trophoblast DS with Actinomycin Beta HCG(Human Chorionic Gonadotropin)
Levels, Chest X-Ray PA View(1 Film)
LFT(liver function tests), USG local area, Chest
Chemotherapy for Chronic lymphoid
1262 99.25.68 S12 X-Ray PA View(1 Film), Chest X-Ray Lateral Clinical Photograph 14990 14990 18738 18738
leukemia with Sunitinib
View(1 Film)
Routine Histopathological Examination, CT
Chemotherapy With Temozolamide(brain Clinical Photograph, Case Sheet with operation
1263 99.25.69 S12 Brain Plain and Contrast /MRI Brain with 10000 10000 12500 12500
tumours) Notes
contrast
LFT(liver function tests), Routine
Histopathological Examination, Chest X-Ray
PA View(1 Film), USG local area, Bone
Chemotherapy With Benadamustin - Marrow Profile, CT Brain Plain and Contrast , Clinical Photograph, Case Sheet with operation
1264 99.25.70 S12 59990 59990 74988 74988
RITUXIMAB CT Scan Chest With Contrast/CT Scan Notes
neck(thyroid, para thyroid, soft tissues) with
contrast/CT Scan with Abdomen with contrast,
Renal Profile, Complete Blood Picture [CBP]

Beta HCG(Human Chorionic Gonadotropin)


Levels, Alpha Feto Protiens Levels, Lactate Clinical Photograph, Case Sheet with operation
1265 99.25.71 S12 Chemotherapy With TIP(GCT 2nd line) 20000 20000 25000 25000
Dehydrogenase (LDH), CT Scan Chest With Notes
Contrast, CT Scan with Abdomen with contrast
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination,
Prostate-Specific Antigen (PSA), Estrogen
Chemotherapy for Breast Cancer with
1266 99.25.72 S12 Receptor/Progesterone Receptor, Chest X-Ray Clinical Photograph 10290 10590 12863 13238
Docetaxel
PA View(1 Film), Chest X-Ray Lateral View(1
Film), USG local area, Bone Scan
Routine Histopathological Examination, USG
local area, CT local area without
Chemotherapy for Cervical Cancer with Clinical Photograph, Case Sheet with operation
1267 99.25.73 S12 contrast/Dynamic MRI/Functional MRIRenal 1990 1990 2488 2488
Weekly Cisplatin Notes
Profile, Complete Blood Picture [CBP],Chest X-
Ray PA View(1 Film), Clinical Photograph
Routine Histopathological Examination, CT
local area without contrast,MRI Brain without
Chemotherapy for high risk Gestational
contrast,USG local area, Beta HCG(Human
trophoblast DS with Etoposide- Beta HCG(Human Chorionic Gonadotropin)
1268 99.25.78 S12 Chorionic Gonadotropin) Levels, Chest X-Ray 7590 8190 9488 10238
Methotrexate -Actinomycin / Levels, Case Sheet with operation Notes
PA View(1 Film), USG Abdomen, Beta
Cyclophosphamide Vincristine (Ema-Co)
HCG(Human Chorionic Gonadotropin) Levels,
Clinical Photograph
Routine Histopathological Examination, CT
Scan Chest without Contrast,/CT Scan
Chemotherapy for Testicular Cancer with Abdomen Without Contrast,USG local area,
1269 99.25.83 S12 Bleomycin with Etoposide-Cisplatin Beta HCG(Human Chorionic Gonadotropin) Case Sheet with operation Notes 8590 9190 10738 11488
(Bep) Levels, Chest X-Ray PA View(1 Film), Alpha
Feto Protiens Levels, Lactate Dehydrogenase
(LDH), Clinical Photograph
Alpha Feto Protiens Levels, Routine
Chemotherapy Chemotherapy for
1270 99.25.84 S12 Histopathological Examination, LFT(liver Case Sheet with operation Notes 9990 9990 12488 12488
Hepatoblastoma operable with Sorafenib
function tests), USG local area
CT Scan Abdomen Without Contrast,Routine
1271 99.25.85 S12 Chemotherapy with Capeiri(metastatic) Case Sheet with operation Notes 8310 8910 10388 11138
Histopathological Examination
Chemotherapy with Capeox(adjuvant) and CT Scan Abdomen Without Contrast,Routine
1272 99.25.86 S12 Case Sheet with operation Notes 7790 8390 9738 10488
metastatic Histopathological Examination
S13 RADIATION ONCOLOGY
Routine Histopathological Examination/
Brachytherapy Intracavitary I. Ldr Per Contrast Enhanced USG, Chest X-Ray PA
1273 92.20.1 S13 Biometric chart, RT treatment with dose, time 6750 7650 8438 9563
Application View(1 Film), RT treatment with dose, time,
Case sheet with clinical History
Price for Semi Price for Price for Semi Price for
Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Routine Histopathological Examination/
Brachytherapy Intracavitary II. Hdr Per Contrast Enhanced USG, Chest X-Ray PA
1274 92.20.2 S13 RT treatment with dose, time 3550 3850 4438 4813
Application View(1 Film), RT treatment with dose, time,
Case sheet with clinical History
CT local Area/Routine Histopathological
Radical Treatment with Cobalt 60 Examination/ Contrast Enhanced USG, Chest X-
1275 92.23.1 S13 RT treatment with dose, time 26000 26000 32500 32500
External Beam Radiotherapy Ray PA View(1 Film), Case Sheet with Clinical
History
CT local Area/Routine Histopathological
Palliative Treatment with Cobalt 60 Examination/ Contrast Enhanced USG, Chest X-
1276 92.23.2 S13 RT treatment with dose, time 13300 13600 16625 17000
External Beam Radiotherapy Ray PA View(1 Film), Case sheet with clinical
History
CT local Area/Routine Histopathological
Adjuvant Treatment with Cobalt 60 Examination/ Contrast Enhanced USG, Chest X-
1277 92.23.3 S13 RT treatment with dose, time 15000 15000 18750 18750
External Beam Radiotherapy Ray PA View(1 Film), Case sheet with clinical
History
CT local Area/Routine Histopathological
Radical Treatment With Photons External
Examination/ Contrast Enhanced USG, Chest X-
1278 92.24.1 S13 Beam Radiotherapy (on Linear Case Sheet with treatment details 65000 65000 81250 81250
Ray PA View(1 Film), Complete staging report,
Accelerator)
Case sheet with clinical History
CT local Area or Routine Histopathological
Palliative Treatment With Photons
Examination/ Contrast Enhanced USG, Chest X-
1279 92.24.2 S13 External Beam Radiotherapy (on Linear Case Sheet with treatment details 30500 35000 38125 43750
Ray PA View(1 Film), Case sheet with clinical
Accelerator)
History
CT local Area or Routine Histopathological
Adjuvant Treatment With
Examination/ Contrast Enhanced USG, Chest X-
1280 92.24.3 S13 Photons/Electrons / (92.25)External Beam Case Sheet with treatment details 45000 45000 56250 56250
Ray PA View(1 Film), Case sheet with clinical
Radiotherapy (on Linear Accelerator)
History
CT local Area/ Routine Histopathological
Brachytherapy Interstitial I. Ldr Per Examination/ Contrast Enhanced USG, Chest X-
1281 92.27.1 S13 Case Sheet with treatment details 17530 18730 21913 23413
Application Ray PA View(1 Film), RT treatment with dose,
time, Case sheet with clinical History
CT local Area/ Routine Histopathological
Brachytherapy Interstitial II. Hdr One Examination/ Contrast Enhanced USG, Chest X-
1282 92.27.2 S13 Case Sheet with treatment details 25900 26800 32375 33500
Application And Multiple Dose Fractions Ray PA View(1 Film), RT treatment with dose,
time, Case sheet with clinical History
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Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Specialized Radiation therapy- IMRT
CT local Area/MRI Local Area, Biopsy, Case BEAMLET information, RT treatment with dose,
1283 92.29.1 S13 (Intensity modulated radiotherapy) Upto 115700 115700 144625 144625
sheet with clinical History time
40 Fractions IMRT In 8 Weeks
Specialized Radiation therapy - 3DCRT(3- CT local Area/ MRI Local Area, Routine
1284 92.29.2 S13 D conformational radiotherapy)Upto 30 Histopathological Examination, Case sheet with Case Sheet with treatment details 95000 95000 118750 118750
Fractions 3DCRT In 6 Weeks clinical History
CT local Area/ MRI Local Area, Routine
Specialized Radiation therapy - SRS/SRT
1285 92.29.3 S13 Histopathological Examination, Case sheet with Case Sheet with treatment details 95000 95000 118750 118750
Upto 30 Fractions In SRS/SRT 6 Weeks
clinical History
S14 PLASTIC SURGERY
CT Scan Head Without Contrast ,CT Angio Of CT Scan Head Without Contrast ,CT Angio Of
1286 01.24.3 S14 Skull base surgery 102400 104800 128000 131000
Brain(Head) /MRI Brain Without Contrast Brain(Head) /MRI Brain Without Contrast
CT-Scan Brain Plain And Contrast, CT Angio
1287 02.01 S14 Surgical correction for Craniosynostosis X-Ray Skull 92070 96270 115088 120338
Of Brain(Head) /MRI Brain Without Contrast
Surgical Correction of Nerve and Tendon Nerve conduction study, Clinical Photograph,
1288 04.3.2 S14 Nerve conduction study, Clinical Photograph 49780 52780 62225 65975
Repair + Vascular Repair (82.4+39.3) Case Sheet with operation Notes
1289 04.76.2 S14 Sequalae of brachial plexus injuries Nerve conduction study, Clinical Photograph Clinical Photograph 42680 44780 53350 55975
Conservative treatment for brachial MRI Local Area,Nerve conduction study,
1290 04.76.3 S14 Clinical Photograph 10900 11800 13625 14750
plexus injuries Clinical Photograph
Corrective surgery for Hyperchalonism
1291 08.23 S14 CT Orbits With Contrast, Clinical Photograph X-Ray Orbit,Clinical Photograph 55440 58140 69300 72675
elecanthes
Tarsorrhaphy surgery to prevent exposure
Clinical Photograph, Case Sheet with operation
1292 08.52 S14 keratitis to prevent loss or impairment of Clinical Photograph 10900 11800 13625 14750
Notes
vision especially in facial burns
Clinical Photograph, Case Sheet with operation
1293 18.6 S14 Ear reconstruction Clinical Photograph 44880 47880 56100 59850
Notes
Reconstruction or prosthetic appliance for Clinical Photograph, Case Sheet with operation
1294 18.71.1 S14 Clinical Photograph 32990 35990 41238 44988
absent ear Notes
Surgical Correction of anamolies of Ear Clinical Photograph, Case Sheet with operation
1295 18.79 S14 Clinical Photograph 28600 32200 35750 40250
(cup & bat ears) Notes
1296 21.7.1 S14 Nose fractures with implants CT of Nose \ Nasopharynx, X-Ray Facial Bones X-Ray Facial Bones 47400 49800 59250 62250
Nose deformities with functional CT of Nose \ Nasopharynx, CT PNS Without
1297 21.8 S14 X-Ray Facial Bones 61800 63600 77250 79500
disturbances Contrast
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Applicable
Procedure private ward - Private ward - private ward - Private ward -
S No Speciality Procedure Name Preauth Evidence Claim Evidence
ICD Code Non NABH Non NABH NABH NABH
Code
Hospitals Hospitals Hospitals Hospitals
Clinical Photograph, Case Sheet with operation
1298 25.2.3 S14 Macroglossia Correction Clinical Photograph 47400 49800 59250 62250
Notes
Orthopantomography (OPG), Clinical
1299 25.59 S14 Micrognathia - pierre robbinsequalae Orthopantomography (OPG), 68310 71610 85388 89513
Photograph
Clinical Photograph, Case Sheet with operation
1300 27.5 S14 Tessier¿s cleft Clinical Photograph 54800 58100 68500 72625
Notes
Clinical Photograph, Case Sheet with operation
1301 27.53 S14 Palatal fistula Repair Clinical Photograph 43090 46390 53863 57988
Notes
Clinical Photograph, Case Sheet with operation
1302 27.54.1 S14 Surgical Management Of Cleft Lip Clinical Photograph 27400 29800 34250 37250
Notes
Clinical Photograph, Case Sheet with operation
1303 27.54.4 S14 Cleft lip nasal deformity correction Clinical Photograph 76800 78600 96000 98250
Notes
Clinical Photograph, Case Sheet with operation
1304 27.63 S14 Secondary correction of cleft lip/palate Clinical Photograph 61800 63600 77250 79500
Notes
Dynamic MRI/Functional MRI/Digital Dynamic MRI/Functional MRI/CT Local Area,
Surgical correction for Vascular
1305 39.7 S14 Subtraction Angiogram/CT Local Area,USG Routine Histopathological Examination, USG 35940 38940 44925 48675
malformations
local area local area
Clinical Photograph, Case Sheet with operation
1306 58.45.6 S14 Hypospadias cripples Clinical Photograph 42680 45680 53350 57100
Notes
Clinical Photograph, Case Sheet with operation
1307 58.45.7 S14 Epispadias / exstrophy Clinical Photograph 21990 22890 27488 28613
Notes
Clinical Photograph, Case Sheet with operation
1308 63.8 S14 Vasovasalanastamosis Semen Analysis 63000 66000 78750 82500