Package definitions

Sl.No Package Benefits of the Package

1 Non Surgical (Medical) These package rates will include bed charges (General ward), Nursing and
treatment in General boarding charges, Surgeons, Anaesthetists, Medical Practitioner, Consultants
Ward-Adult /Paediatrics fees, Anaesthesia, Blood, Oxygen, O.T. Charges, Medicines and Drugs, X-Ray
and Diagnostic Tests including CT and MRI scans. Expenses incurred for
diagnostic test and medicines upto 3 days before the admission of the patient
and cost of diagnostic test and medicine upto 5 days of the discharge from the
hospital for the same ailment / surgery be the part of package. The package
should cover the entire cost of treatment of the patient from date of reporting (3
days Pre hospitalisation) to his discharge from hospital and 5 days after
discharge and any complication while in hospital, making the transaction truly
cashless to the patient.

2 If admitted in This includes bed charges (HDU/SNCU), Nursing and boarding charges,
HDU/SNCU Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia,
Blood, Oxygen, O.T. Charges, Medicines and Drugs, X-Ray and Diagnostic
Tests etc. during stay in HDU/SNCU

3 If admitted in This includes bed charges ICU/NICU), Nursing and boarding charges,
ICU/NICU(without Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia,
Ventilation) Blood, Oxygen, O.T. Charges, Medicines and Drugs, X-Ray and Diagnostic
Tests etc. during stay in ICU/NICU
4 If admitted in This includes bed charges (ICU/NICU with ventilator), Nursing and boarding
ICU/NICU(withVentilati charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees,
on) Anesthesia, Blood, Oxygen, O.T. Charges, Medicines and Drugs, X-Ray and
Diagnostic Tests etc. during stay in ICU/NICU with ventilation

5 Surgical Procedures in This includesbed charges (General ward), Nursing and boarding charges,
General Ward ( not Surgeons, Anaesthetists, Medical Practitioner, Consultants fees, Anaesthesia,
specified in packages) Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and
Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests etc.
Expenses incurred for diagnostic test and medicines upto 3 days before the
admission of the patient and cost of diagnostic test and medicine upto 5 days of
the discharge from the hospital for the same ailment / surgery will also be the
part of package. The package should cover the entire cost of treatment of the
patient from date of reporting (3 day Pre hospitalisation) to his discharge from
hospital and 5 days after discharge and any complication while in hospital,
making the transaction truly cashless to the patient.
Recommended Rate
Rs 750/per day

Rs 1250/per day

Rs 1500/per day
Rs 2000/per day

Package Cost
 INDEX
Sl.No Speciality Code System
S1 GENERAL SURGERY
S2 ENT
S OPTHALMOLOGY
S4 GYNAECOLOGY
S5 ORTHOPAEDICS
S6 POLY TRAUMA
S7 UROLOGY
S8 NEURO SURGERY
S9 INTERVENTIONAL RADIOLOGY
S10 PLASTIC & RECONSTRUCTIVE SURGERY
S11 BURNS
S12 CARDIOLOGY
S13 CV &CT
S14 PAEDIATRICS SURGERY
S15 SURGICAL ONCOLOGY
S16 ORAL &MAXILLOFACIAL SURGERY
M1 GENERAL MEDICINE
M2 PAEDIATRICS MEDICINE
M3 NEONATOLOGY
M4 PAEDIATRICS ONCOLOGY
M5 MEDICAL ONCOLOGY
M6 RADIATION ONCOLOGY
M7 EMERGENCY ROOM MANAGEMENT
M8 MENTAL DISORDER
M9 UNSPECIFIED PROCEDURE

Surgical Gastro Enterology is included in General Surgery.Medical Neurology and

Nephrology are included in General Medicine.
Except Cardiology and Cardio Vascular & Cardio Thoracic Surgery ,all other speciality
and super speciality procedures are overlapping.Hence all those claims performed by
any specialist has to be honoured.
 Surgical Gastro Enterology is included in General Surgery.Medical Neurology and
Nephrology are included in General Medicine.
Except Cardiology and Cardio Vascular & Cardio Thoracic Surgery ,all other speciality
and super speciality procedures are overlapping.Hence all those claims performed by
any specialist has to be honoured.
 General Surgery

Package
Amount Preaut Average Govt
h length of Reser
Require Stay ved
Speci Packa d or (Includin Proce
alty ge Not Mandatory investigations for pre- Post-Op investigations for g Days in dure
code Code Package Name (Y/N) auth claims submission ICU) (Y/N)

15875 Procedure Note with

S1 00001 Adventious Burse – Excision N Discharge Summary 3 N

Admission note with relevant

20,000 investigation result report Procedure Note with
S1 00002 Anterior Resection for CA Y including Biopsy Discharge Summary 4 N

11000 Procedure Note with

S1 00003 Appendicectomy N Discharge Summary 2 N

12,000 Procedure Note with

S1 00004 Appendicular Abscess – Drainage N Discharge Summary 2 N

Arteriovenous (AV) Malformation of Soft 15,875 Procedure Note with

S1 00005 Tissue Tumour - Excision N Discharge Summary 3 N

6,000 Procedure Note with

S1 00006 Bakers Cyst – Excision N Discharge Summary 3 N

20,000 Procedure Note with

S1 00007 Bilateral Inguinal block dissection N Discharge Summary 3 N
 25,000 Procedure Note with
S1 00008 Bleeding Ulcer - Gastrectomy & vagotomy N Discharge Summary 5 N

25,000 Procedure Note with

S1 00009 Bleeding Ulcer - Partial Gastrectomy N Discharge Summary 5 N

14,725 Procedure Note with

S1 00010 Block dissection Cervical Nodes N Discharge Summary 3 N

14,725 Procedure Note with

S1 00011 Branchial Fistula N Discharge Summary 2 N

7,000 Procedure Note with

S1 00012 Breast Lump - UL – Excision N Discharge Summary 1 N

7,000 Procedure Note with

S1 00014 Branchial Cyst N Discharge Summary 2 N

4,525 Procedure Note with

S1 00015 Bursa – Excision N Discharge Summary 2 N

20,000 Procedure Note with

S1 00016 Bypass - Inoperable Pancreas N Discharge Summary 4 N

5000 Procedure Note with

S1 00017 Cervial Lymphnodes – Excision N Discharge Summary 1 N

14,000 Procedure Note with

S1 00018 Colostomy N Discharge Summary 4 N
 2,000 Procedure Note with
S1 00019 Cyst over Scrotum – Excision N Discharge Summary 1 N

2,000 Procedure Note with

S1 00020 Cystic Mass – Excision N Discharge Summary 1 N

4,000 Procedure Note with

S1 00021 Dermoid Cyst - Large – Excision N Discharge Summary D N

2,000 Procedure Note with

S1 00022 Dermoid Cyst - Small – Excision N Discharge Summary D N

5000 Procedure Note with

S1 00023 Drainage of Ischio Rectal Abscess N Discharge Summary 1 N

4,000 Procedure Note with

S1 00024 Incision and Drainage of large Abscess N Discharge Summary D N

7,500 Procedure Note with

S1 00025 Drainage of Psoas Abscess N Discharge Summary 2 N

12,000 Procedure Note with

S1 00026 Drainage of Subdiaphramatic Abscess N Discharge Summary 3 N

13,750 Procedure Note with

S1 00027 Drainage Pericardial Effusion N Discharge Summary 5 N

20,000 Procedure Note with

S1 00028 Duodenal Diverticulum N Discharge Summary 5 N
 20,000 Procedure Note with
S1 00029 Duodenal Jejunostomy N Discharge Summary 5 N

18,000 Procedure Note with

S1 00030 Duplication of Intestine N Discharge Summary 5 N

8,000 Procedure Note with

S1 00031 Hydrocele + Orchidectomy N Discharge Summary 2 N

8,975 Procedure Note with

S1 00032 Epididymectomy N Discharge Summary 3 N

6,175 Procedure Note with

S1 00033 Epididymal Swelling –Excision N Discharge Summary 2 N

4,000 Procedure Note with

S1 00034 Epididymal Cyst N Discharge Summary D N

5,600 Procedure Note with

S1 00035 Evacuation of Scrotal Hematoma N Discharge Summary 2 N

16,875 Procedure Note with

S1 00036 Excision Benign Tumor -Small intestine N Discharge Summary 5 N

9,200 Procedure Note with

S1 00037 Excision Bronchial Sinus N Discharge Summary 2 N

14,725 Procedure Note with

S1 00038 Drainage of liver Abscess N Discharge Summary 3 N
 11,500 Procedure Note with
S1 00039 Excision Filarial Scrotum N Discharge Summary 3 N

6,175 Procedure Note with

S1 00040 Excision Mammary Fistula N Discharge Summary 2 N

17,025 Procedure Note with

S1 00041 Excision Meckel's Diverticulum N Discharge Summary 3 N

10,000 Procedure Note with

S1 00042 Excision Pilonidal Sinus N Discharge Summary 2 N

17,000 Procedure Note with

S1 00043 Excision Small Intestinal Fistula N Discharge Summary 5 N

6,000 Procedure Note with

S1 00044 Excision of Growth from Tongue only N Discharge Summary 1 N

Excision of Growth from Tongue with neck 15,000 Procedure Note with
S1 00045 node dissection N Discharge Summary 4 N

5,000 Procedure Note with

S1 00046 Excision of Swelling in Right Cervical Region N Discharge Summary D N

3,000 Procedure Note with

S1 00047 Excision of Large Swelling in Hand N Discharge Summary D N

1725 Procedure Note with

S1 00048 Excision of Small Swelling in Hand N Discharge Summary D N
 3,000 Procedure Note with
S1 00049 Excision of Neurofibroma N Discharge Summary 2 N

7,900 Procedure Note with

S1 00050 Exicision of Sinus and Curettage N Discharge Summary 2 N

9,000 Procedure Note with

S1 00051 Fibroadenoma – Bilateral N Discharge Summary 2 N

7,000 Procedure Note with

S1 00052 Fibrodenoma – Unilateral N Discharge Summary 2 N

8,000 Procedure Note with

S1 00053 Fissurectomy N Discharge Summary 2 N

12,750 Procedure Note with

S1 00054 Fissurectomy and Haemorrhoidectomy N Discharge Summary 2 N

10,000 Procedure Note with

S1 00055 Eversion of Hydrocele Sac – Bilateral N Discharge Summary 2 N

7,000 Procedure Note with

S1 00056 Eversion of Hydrocele Sac – Unilateral N Discharge Summary 2 N

12,750 Procedure Note with

S1 00057 Fissurectomy with Sphincterotomy N Discharge Summary 2 N

Foreign Body Removal in Deep Region 5600 Procedure Note with

S1 00058 requiring GA N Discharge Summary 2 N
 20,000 Procedure Note with
S1 00059 Fundoplication N Discharge Summary 3 N

19,000 Procedure Note with

S1 00060 G J Vagotomy/ Vagotomy + Pyloroplasty N Discharge Summary 5 N

4,525 Procedure Note with

S1 00061 Ganglion - large – Excision N Discharge Summary 1 N

3,250 Procedure Note with

S1 00062 Ganglion - Small – Excision N Discharge Summary D N

18,000 Procedure Note with

S1 00063 Gastrojejunostomy N Discharge Summary 4 N

16,725 Procedure Note with

S1 00064 Gastrostomy N Discharge Summary 4 N

18,000 Procedure Note with

S1 00065 Graham's Operation for duodenal perforation N Discharge Summary 5 N

4,525 Procedure Note with

S1 00066 Granuloma – Excision N Discharge Summary 1 N

10,000 Procedure Note with

S1 00067 Haemangioma – Excision (large) N Discharge Summary 3 N

5,000 Procedure Note with

S1 00068 Haemangioma – Excision (small) N Discharge Summary 2 N
 17,025 Procedure Note with
S1 00069 Haemorrhage of Small Intestine N Discharge Summary 3 N

20,000 Admission note with relevant

investigation result Procedure Note with
S1 00070 Hepatic Resection (lobectomy) Y reportincluding USG/CT Abdomen Discharge Summary 7 N

12,000 Procedure Note with

S1 00071 Hernia – Epigastric N Discharge Summary 2 N

15,000 Procedure Note with

S1 00072 Hernia – Incisional N Discharge Summary 3 N

15,000 Procedure Note with

S1 00073 Hernia - Repair & release of obstruction N Discharge Summary 3 N

12,000 Procedure Note with

S1 00074 Hernia – Umbilical N Discharge Summary 3 N

12,000 Procedure Note with

S1 00075 Hernia – Femoral N Discharge Summary 2 N

10,000 Procedure Note with

S1 00076 Hernioplasty – Inguinal N Discharge Summary 2 N

10,000 Procedure Note with

S1 00077 Herniorraphy=inguinal N Discharge Summary 2 N

15,000 Procedure Note with

S1 00078 Hiatus Hernia – Trans abdominal N Discharge Summary 5 N
 15,000 Procedure Note with
S1 00079 Hydatid Cyst of Liver N Discharge Summary 3 N

5,000 Procedure Note with

S1 00080 Hydrocele - Excision – Unilateral N Discharge Summary 2 N

10,000 Procedure Note with

S1 00081 Hydrocele - Excision – Bilateral N Discharge Summary 2 N

17,000 Procedure Note with

S1 00082 IlieoSigmoidostomy N Discharge Summary 5 N

4,525 Procedure Note with

S1 00083 Infected Bunion Foot – Excision N Discharge Summary 1 N

7,000 Procedure Note with

S1 00084 Inguinal Node (dissection) - Unilateral N Discharge Summary 2 N

17,000 Procedure Note with

S1 00085 Intestinal Obstruction N Discharge Summary 5 N

17,000 Procedure Note with

S1 00086 Intestinal perforation N Discharge Summary 5 N

17,000 Procedure Note with

S1 00087 Intussusception N Discharge Summary 6 N

20,000 Procedure Note with

S1 00088 Jejunostomy N Discharge Summary 5 N
 16,000 Procedure Note with
S1 00089 Gastric Perforation N Discharge Summary 5 N

Intestinal Perforation (Resection 20,000 Procedure Note with

S1 00090 Anastomosis) N Discharge Summary 5 N

15,000 Procedure Note with

S1 00091 Appendicular Perforation N Discharge Summary 5 N

15,000 Procedure Note with

S1 00092 Burst Abdomen Obstruction N Discharge Summary 6 N

15,150 Procedure Note with

S1 00093 Closure of Hollow Viscus Perforation N Discharge Summary 5 N

Laryngectomy & Pharyngeal Diverticulum 16,000 Procedure Note with

S1 00094 (Throat) N Discharge Summary 3 N

19,600 Procedure Note with

S1 00095 Ileostomy N Discharge Summary 4 N

2,875 Procedure Note with

S1 00096 Lipoma excision N Discharge Summary D N

19,750 Procedure Note with

S1 00097 Loop Colostomy Sigmoid N Discharge Summary 4 N

14,000 Procedure Note with

S1 00098 Mastectomy N Discharge Summary 2 N
 17,000 Procedure Note with
S1 00099 Mesenteric Cyst – Excision N Discharge Summary 3 N

18,000 Procedure Note with

S1 00100 Mesenteric Caval Anastomosis N Discharge Summary 5 N

15,000 Procedure Note with

S1 00101 Microlaryngoscopic Surgery N Discharge Summary 3 N

7,500 Procedure Note with

S1 00102 Oeshophagoscopy for foreign body removal N Discharge Summary D N

17,500 Procedure Note with

S1 00103 Oesophagectomy N Discharge Summary 5 N

50,000 Admission note with relevant

investigation result Procedure Note with
S1 00104 Portal Hypertension shunt surgery Y reportincluding USG/CT Abdomen Discharge Summary 5 Y

10,000 Procedure Note with

S1 00105 Pelvic Abscess - Open Drainage N Discharge Summary 4 N

25,000 Admission note with relevant

investigation result Procedure Note with
S1 00106 PancreaticoDuodenectomy Y reportincluding USG/CT Abdomen Discharge Summary 6 N

50,000 Admission note with relevant

Distal Pancreatectomy with investigation result Procedure Note with
S1 00107 PancreaticoJejunostomy Y reportincluding USG/CT Abdomen Discharge Summary 7 Y

4,000 Procedure Note with

S1 00108 Papilloma /Polyp Rectum – Excision N Discharge Summary 2 N
 15,000 Procedure Note with
S1 00109 Haemorroidectomy+ Fistulectomy N Discharge Summary 2 N

4,000 Procedure Note with

S1 00110 Growth in the Scalp – Excision N Discharge Summary 1 N

Admission note with relevant

30,000 investigation result Procedure Note with
S1 00111 Porto Caval Anastomosis Y reportincluding USG/CT Discharge Summary 5 N

14,000 Procedure Note with

S1 00112 Pyeloroplasty N Discharge Summary 4 N

Admission note with relevant

20,000 investigation result report Procedure Note with
S1 00113 Radical Mastectomy Y including Biopsy Discharge Summary 2 N

21,200 Admission note with relevant

investigation result report Procedure Note with
S1 00114 Radical Neck Dissection – Excision Y including Biopsy Discharge Summary 6 N

12,000 Procedure Note with

S1 00115 Hernia – Spigelian N Discharge Summary 3 N

5,100 Procedure Note with

S1 00116 Rectal Dilation N Discharge Summary 1 N

12,000 Procedure Note with

S1 00117 Prolapse of Rectal Mass – Excision N Discharge Summary 2 N

15,000 Procedure Note with

S1 00118 Rectopexy N Discharge Summary 3 N
 17,000 Procedure Note with
S1 00119 Repair of Common Bile Duct N Discharge Summary 3 N

17,000 Procedure Note with

S1 00120 Resection Anastomosis (Large Intestine) N Discharge Summary 7 N

18,000 Procedure Note with

S1 00121 Resection Anastomosis (Small Intestine) N Discharge Summary 7 N

Admission note with relevant

20,000 investigation result Procedure Note with
S1 00122 Retroperitoneal Tumor – Excision Y reportincluding USG/CT/Biopsy Discharge Summary 5 N

10,200 Procedure Note with

S1 00123 Haemorroidectomy N Discharge Summary 2 N

12,000 Procedure Note with

S1 00125 Segmental Resection of Breast N Discharge Summary 3 N

6,175 Procedure Note with

S1 00126 Scrotal Swelling (Multiple) – Excision N Discharge Summary 2 N

18,000 Procedure Note with

S1 00127 Sigmoid Diverticulum N Discharge Summary 6 N

15,000 Procedure Note with

S1 00128 Simple closure - Peptic perforation N Discharge Summary 5 N

5,600 Procedure Note with

S1 00129 Sinus – Excision N Discharge Summary 2 N
 5,000 Procedure Note with
S1 00130 Soft Tissue Tumor (small) – Excision N Discharge Summary 2 N

10,000 Procedure Note with

S1 00131 Soft Tissue Tumor (large) – Excision N Discharge Summary 3 N

30,000 Admission note with relevant

investigation result Procedure Note with
S1 00132 Splenectomy Y reportincluding USG/CT Abdomen Discharge Summary 6 N

5,000 Procedure Note with

S1 00133 Submandibular Lymph node – Excision N Discharge Summary 2 N

Admission note with relevant

Submandibular Mass Excision + 20,000 investigation result report Procedure Note with
S1 00134 Reconstruction Y including Biopsy Discharge Summary 5 N

1,500 Procedure Note with

S1 00135 Swelling in foot (small) – Excision N Discharge Summary D N

3,500 Procedure Note with

S1 00136 Swelling in foot (large) – Excision N Discharge Summary D N

30,000 Admission note with relevant

investigation result report Procedure Note with
S1 00137 Colectomy – Total Y including Colonoscopy/CT Discharge Summary 6 N

Tracheal Stenosis (End to end Anastamosis) 17,000 Procedure Note with

S1 00139 (Throat) N Discharge Summary 6 N

17,000 Procedure Note with

S1 00140 Tracheoplasty (Throat) N Discharge Summary 6 N
 5,600 Procedure Note with
S1 00141 Umbilical Sinus – Excision N Discharge Summary 2 N

10,000 Procedure Note with

S1 00142 Varicose Veins - Excision and Ligation N Discharge Summary 3 N

12,425 Procedure Note with

S1 00143 Vasovasostomy N Discharge Summary 3 N

26,000 Procedure Note with

S1 00144 Volvlous of Large Bowel N Discharge Summary 4 N

12,000 Procedure Note with

S1 00145 Cleft lip operation N Discharge Summary 2 N

14,000 Procedure Note with

S1 00146 Cleft palate repair (for each stage) N Discharge Summary 2 N

15,000 Procedure Note with

S1 00147 Cleft lip & palate operation (for each stage) N Discharge Summary 2 N
Admission note with
relevant investigation
36,000
result report including Procedure Note with
S1 00148 Aneurysm not Requiring Bypass Techniques Y CT/Angiogram report Discharge Summary 5 N
Admission note with
36,000 relevant investigation
Procedure Note with
S1 00149 Aneurysm Resection & Grafting Y result report including Discharge Summary 5 N
CT/Angiogram report
Admission note with relevant
23,000 investigation result
reportincluding USG/CT Procedure Note with
S1 00150 Arterial Embolectomy Y angiogram Discharge Summary 5 N
 Admission note with relevant
20,000 investigation result
reportincluding USG/CT Procedure Note with
S1 00151 Carotid artery aneurysm repair Y angiogram Discharge Summary 5 N
Admission note with relevant
20,000 investigation result
reportincluding USG/CT Procedure Note with
S1 00152 Carotid Body tumour - Excision Y angiogram Discharge Summary 5 N

22,000 Admission note with relevant

investigation result report Procedure Note with
S1 00153 Cholecystectomy & Exploration of CBD Y including USG/CT abdomen Discharge Summary 6 N

16000 Admission note with relevant

investigation result Procedure Note with
S1 00154 Cholecystostomy Y reportincluding USG/CT abdomen Discharge Summary 5 N

Admission note with relevant

24,150 investigation result Procedure Note with
S1 00155 Congential Arteriovenus Fistula (large) Y reportincluding USG/CT/X-ray Discharge Summary 5 N

10,000 Procedure Note with

S1 00156 Congential Arteriovenus Fistula (small) N Discharge Summary 3 N
Admission note with relevant
20,000 investigation result report
including Radiological Procedure Note with
S1 00157 Decortication (Pleurectomy) Y investigations Discharge Summary 5 N
Admission note with
36,000 relevant investigation
Procedure Note with
S1 00158 Dissecting Aneurysms Y result report including Discharge Summary 6 N
CT/Angiogram report
Admission note with
36,000 relevant investigation
Procedure Note with
S1 00159 Distal Abdominal Aorta repair Y result report including Discharge Summary 5 N
CT/Angiogram report
 7,250 Procedure Note with
S1 00160 Estlander Operation (lip) N Discharge Summary 1 N

15,000 Procedure Note with

S1 00161 Excision and Skin Graft of Venous Ulcer N Discharge Summary 3 N

Admission note with relevant

22,000 investigation result report Procedure Note with
S1 00162 Excision of Parathyroid Adenoma/Carcinoma Y including Biopsy Discharge Summary 5 N

25,875 Admission note with relevant Procedure Note with

S1 00163 Flap Reconstructive Surgery Y investigation result report Discharge Summary 5 N

5,000 Procedure Note with

S1 00164 Split thickness skin grafts – Small (< 4% TBSA) N Discharge Summary D N

Split thickness skin grafts – Medium (4 - 8% 10,000 Procedure Note with

S1 00165 TBSA) N Discharge Summary D N

15,000 Procedure Note with

S1 00166 Split thickness skin grafts – Large (> 8% TBSA) N Discharge Summary D N

10,000 Procedure Note with

S1 00167 Free Grafts - Wolfe Grafts N Discharge Summary 2 N

11,000 Procedure Note with

S1 00168 Hemi thyroidectomy N Discharge Summary 3 N

20,000 Admission note with relevant

investigation result Procedure Note with
S1 00169 Total thyroidectomy Y reportincluding USG/FNAC Discharge Summary 5 N
 20,000 Admission note with relevant
investigation result Procedure Note with
S1 00173 Lap. Assisted small bowel resection Y reportincluding USG/CT abdomen Discharge Summary 3 N

35,000 Admission note with relevant

investigation result Procedure Note with
S1 00174 Lap. Assisted Total Colectomy Y reportincluding USG/CT abdomen Discharge Summary 3 N

25,000 Admission note with relevant

investigation result Procedure Note with
S1 00175 Lap. Cholecystectomy & CBD exploration Y reportincluding USG/CT abdomen Discharge Summary 3 N

19,000 Admission note with relevant

investigation result Procedure Note with
S1 00176 Lap. For intestinal obstruction Y reportincluding USG/CT abdomen Discharge Summary 3 N

Admission note with relevant

25,000 investigation result Procedure Note with
S1 00177 Lap. Hepatic resection Y reportincluding USG/CT abdomen Discharge Summary 3 N

20,000 Admission note with relevant

investigation result Procedure Note with
S1 00178 Lap. Hydatid of liver surgery Y reportincluding USG/CT abdomen Discharge Summary 3 N

19,550 Admission note with relevant Procedure Note with

S1 00179 Laparoscopic Adhesinolysis Y investigation result report Discharge Summary 3 N

18,000 Admission note with relevant Procedure Note with

S1 00180 Laparoscopic Appendicectomy Y investigation result report Discharge Summary 3 N

20,000 Admission note with relevant

investigation result Procedure Note with
S1 00181 Laparoscopic Cholecystectomy Y reportincluding USG/CT abdomen Discharge Summary 3 N
 20,000 Admission note with relevant
investigation result Procedure Note with
S1 00182 Laparoscopic cystogastrostomy Y reportincluding USG/CT abdomen Discharge Summary 3 N

19,000 Admission note with relevant

investigation result Procedure Note with
S1 00183 Laparoscopic Gastrostomy Y reportincluding USG/CT abdomen Discharge Summary 3 N

22,000 Admission note with relevant Procedure Note with

S1 00184 Laparoscopic Hiatus Hernia Repair Y investigation result report Discharge Summary 3 N

20,000 Admission note with relevant

investigation result Procedure Note with
S1 00185 Laparoscopic Pyloromyotomy Y reportincluding USG/CT abdomen Discharge Summary 3 N

20,000 Admission note with relevant

investigation result Procedure Note with
S1 00186 Laparoscopic Rectopexy Y reportincluding USG/CT abdomen Discharge Summary 3 N

22,000 Admission note with relevant

investigation result Procedure Note with
S1 00187 Laparoscopic Spleenectomy Y reportincluding USG/CT abdomen Discharge Summary 3 N

18,000 Admission note with relevant Procedure Note with

S1 00188 Laparoscopic umbilical hernia repair Y investigation result report Discharge Summary 3 N

20,000 Admission note with relevant Procedure Note with

S1 00189 Laparoscopic ventral hernia repair Y investigation result report Discharge Summary 3 N

13,000 Procedure Note with

S1 00190 Laparotomy-peritonitis lavage and drainage N Discharge Summary 3 N
 11,850 Procedure Note with
S1 00191 Ligation of Ankle Perforators N Discharge Summary 3 N

Lymphatics Excision of Subcutaneous Tissues 10,000 Procedure Note with

S1 00192 In Lymphoedema N Discharge Summary 3 N

Admission note with relevant

30,000 investigation result report Procedure Note with
S1 00193 Repair of Main Arteries of the Limbs Y including Doppler study Discharge Summary 5 N

Admission note with relevant

26,450 investigation result Procedure Note with
S1 00194 Mediastinal Tumour Y reportincluding USG/CT/Biopsy Discharge Summary 5 N

Admission note with relevant

25,000 investigation result Procedure Note with
S1 00195 Oesophagectomy for Carcinoma Oesophagus Y reportincluding USG/CT/Biopsy Discharge Summary 7 N

20,000 Procedure Note with

S1 00196 Operation for Bleeding Peptic Ulcer N Discharge Summary 5 N

Operation for Carcinoma Lip – 10,000 Procedure Note with

S1 00197 Vermilionectomy N Discharge Summary 6 N

Operation for Carcinoma Lip - Wedge Excision 12,000 Procedure Note with
S1 00198 and Vermilionectomy N Discharge Summary 6 N

10,000 Procedure Note with

S1 00199 Operation for Carcinoma Lip - Wedge-Excision N Discharge Summary 6 N

Appendicectomy - Appendicular Abscess – 12,000 Procedure Note with

S1 00200 Drainage N Discharge Summary 5 N
 11,000 Procedure Note with
S1 00201 Caecostomy N Discharge Summary 3 N

5,000 Procedure Note with

S1 00202 Closure of Colostomy N Discharge Summary 2 N

Admission note with relevant

16,000 investigation result report Procedure Note with
S1 00203 Coccygeal Teratoma Excision Y including Biopsy Discharge Summary 3 N

Congenital Atresia & Stenosis of Small 20,000 Admission note with relevant Procedure Note with
S1 00204 Intestine Y investigation result report Discharge Summary 5 N

10,000 Procedure Note with

S1 00206 Drainage of perivertebral abscess N Discharge Summary 3 N

Admission note with relevant

25,000 investigation result report Procedure Note with
S1 00207 Hernia -hiatus-Transthoracic Y including X-Ray chest Discharge Summary 5 N

3,000 Procedure Note with

S1 00208 Intercostal drainage N Discharge Summary D N

Admission note with relevant

Operation for carcinoma lip- cheek 12,000 investigation result report Procedure Note with
S1 00209 advancement Y including Biopsy Discharge Summary 5 N

Admission note with relevant

20,000 investigation result Procedure Note with
S1 00210 Thymectomy Y reportincluding USG/CT Discharge Summary 5 N

17,000 Admission note with relevant

investigation result Procedure Note with
S1 00211 Operation of Choledochal Cyst Y reportincluding USG/CT abdomen Discharge Summary 5 N
 21,900 Admission note with relevant
investigation result report Procedure Note with
S1 00212 Operations for Acquired Arteriovenous Fistula Y including local Angiogram Discharge Summary 5 N

Admission note with relevant

25,000 investigation result report
Operations for Replacement of Oesophagus including Radiological Procedure Note with
S1 00213 by Colon Y nvestigations/UGI Discharge Summary 7 N

Admission note with relevant

20,000 investigation result report Procedure Note with
S1 00215 Parapharyngeal Tumour Excision Y including Biopsy Discharge Summary 5 N

Admission note with relevant

22,000 investigation result Procedure Note with
S1 00216 Partial/Subtotal Gastrectomy for Carcinoma Y reportincluding USG/CT abdomen Discharge Summary 5 N

Admission note with relevant

20,000 investigation result Procedure Note with
S1 00217 Patch Graft Angioplasty Y reportincluding USG/CT Discharge Summary 5 N

Admission note with relevant

30,000 investigation result Procedure Note with
S1 00218 Pericardiostomy Y reportincluding USG/CT Discharge Summary 6 N

Admission note with relevant

25,000 investigation result Procedure Note with
S1 00219 Pneumonectomy Y reportincluding USG/CT Chest Discharge Summary 6 N

Removal of Foreign Body from Trachea or 5,000 Procedure Note with

S1 00220 Oesophagus N Discharge Summary D N

Admission note with relevant

20,000 investigation result report Procedure Note with
S1 00221 Removal Tumours of Chest Wall Y including Biopsy Discharge Summary 5 N

35,000 Admission note with relevant Procedure Note with

S1 00222 Procedures Requiring Bypass Techniques Y investigation result report Discharge Summary 7 N
 12,000 Admission note with relevant Procedure Note with
S1 00223 Resection Enucleation of Adenoma (lung) Y investigation result report Discharge Summary 5 N

10,000 Procedure Note with

S1 00224 Rib Resection & Drainage N Discharge Summary 3 N

8,970 Procedure Note with

S1 00225 Skin Flaps - Rotation Flaps N Discharge Summary 2 N

20,000 Admission note with relevant

investigation result report Procedure Note with
S1 00226 Splenectomy - For Trauma Y including CT/Angio report Discharge Summary 5 N

20,000 Admission note with relevant

investigation result report Procedure Note with
S1 00227 Surgery for Arterial Aneurism Spleen Artery Y including CT/Angio report Discharge Summary 5 N

25,000 Admission note with relevant

investigation result report Procedure Note with
S1 00228 Surgery for Arterial Aneurism –Vertebral Y including CT/Angio report Discharge Summary 5 N

Admission note with relevant

22000 investigation result report Procedure Note with
S1 00229 Sympathetectomy – Cervical Y including radiological investigation Discharge Summary 5 N

Admission note with relevant

15000 investigation result report Procedure Note with
S1 00230 Temporal Bone resection Y including Biopsy Discharge Summary 3 N

12,000 Admission note with relevant Procedure Note with

S1 00231 Thorachostomy Y investigation result report Discharge Summary 3 N
 14,000 Admission note with relevant Procedure Note with
S1 00232 Thoracocentesis Y investigation result report Discharge Summary 3 N

Admission note with relevant

25,000 investigation result report Procedure Note with
S1 00233 Thoracoplasty Y including USG/CT Chest Discharge Summary 5 N

Admission note with relevant

25,000 investigation result report Procedure Note with
S1 00234 Thoracoscopic Decortication Y including USG/CT Chest Discharge Summary 5 N

Admission note with relevant

20,000 investigation result report Procedure Note with
S1 00235 Thoracoscopic Hydatid Cyst excision Y including radiological Discharge Summary 3 N

Admission note with relevant

25,000 investigation result report Procedure Note with
S1 00236 Thoracoscopic Lobectomy Y including radiological Discharge Summary 3 N

Admission note with relevant

30,000 investigation result report Procedure Note with
S1 00237 Thoracoscopic Pneumonectomy Y including radiological Discharge Summary 3 N

25,000 Admission note with relevant

investigation result report Procedure Note with
S1 00238 Thoracoscopic Segmental Resection Y including radiological Discharge Summary 3 N

15,000 Admission note with relevant

investigation result report Procedure Note with
S1 00239 Thoracoscopic Sympathectomy Y including radiological Discharge Summary 3 N

15,000 Admission note with relevant

investigation result report Procedure Note with
S1 00240 Thrombendarterectomy Y including radiological Discharge Summary 3 N
 15,000 Procedure Note with
S1 00241 Thorax (penetrating wounds) N Discharge Summary 5 N

Admission note with relevant

25,000 investigation result report Procedure Note with
S1 00242 Total Thyroidectomy and Block Dissection Y including Biopsy Discharge Summary 5 N

10,000 Procedure Note with

S1 00243 Trendelenburg Operation N Discharge Summary 2 N

5,000 Procedure Note with

S1 00244 Debridement of Ulcer-Leprosy N Discharge Summary 2 N

25,000 Procedure Note with

S1 00245 Tissue Reconstruction Flap Leprosy N Discharge Summary 5 N

25,000 Procedure Note with

S1 00246 Tendon Transfer-Leprosy N Discharge Summary 5 N

23,000 Procedure Note with

S1 00247 Adhenolysis + Appendicectomy N Discharge Summary 5 N

Hernia - Repair & release of obstruction+ 20,000 Procedure Note with

S1 00248 Hernioplasty N Discharge Summary 5 N

3,000 Procedure Note with

S1 00249 Aspiration of cold Abscess of Lymphnode N Discharge Summary D N

2,500 Procedure Note with

S1 00250 Aspiration of Empyema N Discharge Summary D N
 2,500 Procedure Note with
S1 00253 Vasectomy N Discharge Summary D N

Abbe Operation 8400 Procedure Note with

S1 N Discharge Summary 3 N

Admission note with relevant

Abdomino Perineal Resection 28000 investigation result report Procedure Note with
S1 Y including Biopsy Discharge Summary 5 N

Admission note with relevant

Anorectoplasty 15950 investigation result report Procedure Note with
S1 Y including Biopsy Discharge Summary 3 N
Anterior Exenteration
Admission note with relevant
50000 investigation result report Procedure Note with
S1 Y including Biopsy Discharge Summary 5 Y
Anterior Resection + TME (Stapled
Anastomosis) 60000 Admission note with relevant
investigation result report Procedure Note with
S1 Y including Biopsy Discharge Summary 5 Y

Axillary Lymph node - Excision 5,000 Procedure Note with

S1 N Discharge Summary 1 N

Benign Tumour Excisions 4000 Procedure Note with

S1 N Discharge Summary 1 N
Biliary Enteric and Duodenal Bypass
Admission note with relevant
20000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N

Caecopexy 16000 Procedure Note with

S1 N Discharge Summary 3 N
 Carbuncle excision 4000 Procedure Note with
S1 N Discharge Summary D N

CAVERNOSTOMY 15000 Procedure Note with

S1 N Discharge Summary 5 N

Admission note with relevant

Cholecysto jejunostomy 18000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N
Cholecystectomy
Admission note with relevant
16,000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N

Corn - Excision 575 Procedure Note with

S1 N Discharge Summary D N

Cyto Reductive Surgery 10,000 Procedure Note with

S1 N Discharge Summary 3 N
Diagnostic Laparoscopy
8000 Procedure Note with
S1 N Discharge Summary D N
Distal Pancreatectomy
Admission note with relevant
40000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 7 Y

Dorsal Slit and Reduction of Paraphimosis 2000 Procedure Note with

S1 N Discharge Summary D N

Dressing under GA 1000 Procedure Note with

S1 N Discharge Summary D N
 Admission note with relevant
Duodenectomy 22475 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N

Examination under Anesthesia 1650 Procedure Note with

S1 N Discharge Summary D N

Excision of Lingual Thyroid 14000 Procedure Note with

S1 N Discharge Summary 3 N

Excision of Moles 350 Procedure Note with

S1 N Discharge Summary D N

Excision of Molluscum contagiosum 400 Procedure Note with

S1 N Discharge Summary D N
Excision of Swelling in Neck
5,000 Procedure Note with
S1 N Discharge Summary D N
Excision, klatskins tumour
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT/MRI Discharge Summary 7 Y
Exploratory Laparotomy
10000 Procedure Note with
S1 N Discharge Summary 5 N

Exploratory Thoracotomy 17,300 Procedure Note with

S1 N Discharge Summary 5 N
Extended cholecystectomy
Admission note with relevant
40000 investigation result report Procedure Note with
S1 Y including USG/CT/MRI Discharge Summary 7 Y
 Facial Decompression 16,875 Procedure Note with
S1 N Discharge Summary 3 N

Femoropopliteal by pass procedure Admission note with relevant

26,500 investigation result report Procedure Note with
S1 Y including angiogram report Discharge Summary 5 N

Fibro Lipoma of Spermatic with Lord Excision 7,000 Procedure Note with
S1 N Discharge Summary 3 N

Fibroma – Excision 7000 Procedure Note with

S1 N Discharge Summary D N

Fistulectomy 10200 Procedure Note with

S1 N Discharge Summary 2 N
Foreign Body Removal in Suprficial
region without GA 2,000 Procedure Note with
S1 N Discharge Summary D N
Freys procedure
Admission note with relevant
50000 investigation result report Procedure Note with
S1 Y including USG/CT/MRI Discharge Summary 7 Y

Fulguration 3500 Procedure Note with

S1 N Discharge Summary 2 N

Gastro jejuno Colic Fistula 17000 Procedure Note with

S1 N Discharge Summary 5 N

Haemorrhoid – injection 750 Procedure Note with

S1 N Discharge Summary D N
 Admission note with relevant
Hemicolectomy 20,000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N

Hemithyroplasty 14000 Procedure Note with

S1 N Discharge Summary 3 N
Hernia - Ventral 14000 Procedure Note with
S1 N Discharge Summary 3 N
Hernia-inguinal and Hydrocele -unilateral. 13000 Procedure Note with
S1 N Discharge Summary 3 N
Herniorrhaphy/hernioplasty-Inguinal- Procedure Note with
13000
S1 bilateral N Discharge Summary 3 N
Ileotransverse/colocolic Anastomosis 12000 Procedure Note with
S1 N Discharge Summary 3 N

Isthmusectomy 9000 Procedure Note with

S1 N Discharge Summary 2 N
Ivor lewis procedure
Admission note with relevant
40000 investigation result report Procedure Note with
S1 Y including USG/CT/Biopsy Discharge Summary 5 Y
Lap. Assisted Hemi colectomy
Right/Left Admission note with relevant
25,000 investigation result report Procedure Note with
S1 Y including USG/CT/Biopsy Discharge Summary 2 N

Admission note with relevant

Lap/Enodscopic Intestinal resection 19,000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 2 N

Admission note with relevant

LAPARAOSCOPIC HELLERS’S PROCEDURE 60000 investigation result report Procedure Note with
S1 Y including USG/CT/UGI Discharge Summary 3 Y

Laparoscopic Inguinal Hernia - Bilateral 18,000 Admission note with relevant Procedure Note with
S1 Y investigation result report Discharge Summary 2 N
 Laparoscopic Inguinal hernia - Unilateral 14,000 Admission note with relevant Procedure Note with
S1 Y investigation result report Discharge Summary 2 N
Laparoscopic Anterior resection
Admission note with relevant
80000 investigation result report Procedure Note with
S1 Y including USG/CT/Biopsy Discharge Summary 3 Y
Laparoscopic APR
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT/Biopsy Discharge Summary 3 Y
Laparoscopic Cardiomyotomy
Admission note with relevant
50000 investigation result report Procedure Note with
S1 Y including USG/CT/UGI Discharge Summary 3 Y
Laparoscopic deroofing cyst
Admission note with relevant
20000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 2 N
Laparoscopic fundoplication
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT/UGI Discharge Summary 3 Y
Laparoscopic Hernia Repair-other
than ventral,inguinal &hiatus 18,000 Admission note with relevant Procedure Note with
S1 Y investigation result report Discharge Summary 2 N

Admission note with relevant

LAPAROSCOPIC MILES PROCEDURE 60000 investigation result report Procedure Note with
S1 Y including USG/CT/Biopsy Discharge Summary 3 Y

Admission note with relevant

LAPAROSCOPIC PROCTECTOMY 70000 investigation result report Procedure Note with
S1 Y including USG/CT/Biopsy Discharge Summary 3 Y

LAPROSCOPIC NISSEN’S PROCEDURE 50000 Admission note with relevant

investigation result report Procedure Note with
S1 Y including USG/CT-abdomen/UGI Discharge Summary 3 Y
 Laser Ablation Varicose Vein 18000 Procedure Note with
S1 N Discharge Summary 1 N
Left Hepatectomy
60000 Admission note with relevant
investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
Left Lateral sectionectomy
50000 Admission note with relevant
investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
Left Trisectionectomy
Admission note with relevant
85000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y

Lord's Procedure (haemorrhoids) 5600 Procedure Note with

S1 N Discharge Summary 1 N
Median pancreatectomy
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y

Microdochectomy 5000 Procedure Note with

S1 N Discharge Summary 2 N
Pancreatic Necrosectomy
Admission note with relevant
100000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 7 Y

Nodular Cyst –Excision 3450 Procedure Note with

S1 N Discharge Summary 1 N

Oesophageal Varices Banding 6000 Procedure Note with

S1 N Discharge Summary D N
 Oesophagus Portal Hypertension 22000 Procedure Note with
S1 N Discharge Summary 5 N

Orchidectomy + Herniorraphy 14000 Procedure Note with

S1 N Discharge Summary 3 N
Palliative Gastro Jejunostomy
2500 Procedure Note with
S1 N Discharge Summary D N

Partial Thyroidectomy 12000 Procedure Note with

S1 N Discharge Summary 3 N

Admission note with relevant

Partial Pericardectomy 20000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N

Phimosis Under LA 2000 Procedure Note with

S1 N Discharge Summary D N
Posterior Exentration
Admission note with relevant
60000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
R Lateral sectionectomy
Admission note with relevant
50000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
R Trisectionectomy
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
Radical Cholecystectomy
Admission note with relevant
60000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
 Radio Ablation Varicose vein 1250 Procedure Note with
S1 N Discharge Summary D N

Admission note with relevant

Repair Stenosis of Renal Artery 30000 investigation result report Procedure Note with
S1 Y including USG/CT/Angiogram Discharge Summary 5 N

Resection Enucleation of Adenoma Thyroid 12000 Procedure Note with

S1 N Discharge Summary 3 N
Restorative Proctocolectomy
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT/colonoscopy Discharge Summary 5 Y
Resuturing of Burst Abdomen
15000 Procedure Note with
S1 N Discharge Summary 3 N
Right Hepatectomy
Admission note with relevant
50000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
Sigmoid Colectomy
Admission note with relevant
25000 investigation result report Procedure Note with
S1 Y including USG/CT/colonoscopy Discharge Summary 5 N
Sleeve resection, stomach
Admission note with relevant
20000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N

Soft Tissue Sarcoma 14000 Procedure Note with

S1 N Discharge Summary 3 N

Subtotal Thyroidectomy 13000 Procedure Note with

S1 N Discharge Summary 3 N
 Superficial Varicosity 2650 Procedure Note with
S1 N Discharge Summary 2 N

Swelling Over Scapular Region 4525 Procedure Note with

S1 N Discharge Summary D N

Sympathetectomy - Lumbar 15000 Procedure Note with

S1 N Discharge Summary 5 N

Terminal Colostomy 14000 Procedure Note with

S1 N Discharge Summary 3 N

Admission note with relevant

Thyroidectomy-Endoscopic 22,000 investigation result Procedure Note with
S1 Y reportincluding USG/FNAC Discharge Summary 2 N
Total Colectomy
Admission note with relevant
30000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N
Total Gastrectomy
Admission note with relevant
35000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N
Total Gastrectomy + D2 Dissection
Admission note with relevant
50000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 7 Y
Total Pelvic Exenteration
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 7 Y
Trans abdominal esophago gastrectomy
Admission note with relevant
50000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 Y
 Trans Hiatal Oesophagectomy
Admission note with relevant
40000 investigation result report Procedure Note with
S1 Y including USG/CT/UGI Discharge Summary 5 Y

Tranverse Colostomy 14,000 Procedure Note with

S1 N Discharge Summary 3 N

Upper GI endoscopy 1,100 Procedure Note with

S1 N Discharge Summary D N

Upper GI endoscopy with biopsy 1,500 Procedure Note with

S1 N Discharge Summary D N

Vagotomy 16,000 Procedure Note with

S1 N Discharge Summary 5 N

Vagotomy & Drainage 18,000 Procedure Note with

S1 N Discharge Summary 5 N

Varicose veins – injection 1,500 Procedure Note with

S1 N Discharge Summary D N
Video Assisted Thoracoscopic
Admission note with relevant
Surgery/Thoracolaparoscopic 80000 investigation result report Procedure Note with
S1 oesophagectomy Y including USG/CT/UGI Discharge Summary 5 Y

Admission note with relevant

Warren Shunt 17,000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 5 N
Whipple’s (Any Type)
Admission note with relevant
70000 investigation result report Procedure Note with
S1 Y including USG/CT Discharge Summary 7 Y
 Capped
amount
(pacakge
cannot be
used more Reserve
Medica than the d for
l (M) or mentioned Trust
Surgical monetary Paymen
(S) limit) t (Y/N)

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
 ENT

Preau Average Govt

th length of Reserv
Requi Stay ed Medical
Speci red or Mandatory (Including Proced (M) or
alty Packag Package Not investigations for pre- Post-Op investigations for Days in ure Surgical
code e Code Package name Amount (Y/N) auth claims submission ICU) (Y/N) (S)
Procedure Note with
S2 00001 Aural polypectomy 8550 N Discharge Summary 1N S
Procedure Note with
S2 00002 Labyrinthectomy 20000 N Discharge Summary 2N S
Procedure Note with
S2 00003 Mastoidectomy 12500 N Discharge Summary 2N S
Procedure Note with
S2 00004 Mastoidectomy corticol modified/ radical 18500 N Discharge Summary 2N S
Procedure Note with
S2 00005 Mastoidectomy with tympanoplasty 16000 N Discharge Summary 2N S
Procedure Note with
S2 00006 Myringoplasty 9050 N Discharge Summary 1N S
Procedure Note with
S2 00007 Myringoplasty with Ossiculoplasty 14225 N Discharge Summary 2N S
Procedure Note with
S2 00008 Myringotomy – Bilateral 7325 N Discharge Summary 1N S
Procedure Note with
S2 00009 Myringotomy – Unilateral 4450 N Discharge Summary 1N S
Procedure Note with
S2 00010 Myringotomy with Grommet - One ear 6500 N Discharge Summary 1N S
 Procedure Note with
S2 00011 Myrinogotomy with Grommet - Both ear 10200 N Discharge Summary 1N S
Procedure Note with
S2 00012 Ossiculoplasty 9500 N Discharge Summary 1N S
Procedure Note with
S2 00013 Partial amputation – Pinna 4000 N Discharge Summary 1N S

Excision of Pinna for Growths

(Squamous/Basal) Injuries - Total
Amputation & Excision of External Auditory Procedure Note with
S2 00014 Meatus 8000 N Discharge Summary 2N S

Excision of Pinna for Growths Procedure Note with

S2 00015 (Squamous/Basal) Injuries Total Amputation 6500 N Discharge Summary 1N S
Procedure Note with
S2 00016 Stapedectomy 11350 N Discharge Summary 1N S
Procedure Note with
S2 00017 Tympanoplasty 12000 N Discharge Summary 1N S
Procedure Note with
S2 00018 Vidian neurectomy – Micro 9000 N Discharge Summary 1N S
Procedure Note with
S2 00019 Ear lobe repair - single (daycare) 1500 N Discharge Summary D N S

Excision of Pinna for Growth

(Squamous/Basal/ Injuries) Skin and Procedure Note with
S2 00020 Cartilage 4,000 N Discharge Summary 1N S
Excision of Pinna for Growth Procedure Note with
S2 00021 (Squamous/Basal/ Injuries) Skin Only 2,500 N Discharge Summary D N S
Procedure Note with
S2 00022 Pharyngectomy and reconstruction 25000 N Discharge Summary 3N S
Procedure Note with
S2 00023 Skull base surgery 37000 N Discharge Summary 5N S
Total Amputation & Excision of External Procedure Note with
S2 00024 Auditory Meatus 9050 N Discharge Summary 2N S
 Procedure Note with
S2 00025 Tympanotomy 4000 N Discharge Summary 1N S
Procedure Note with
S2 00026 Removal of foreign body from ear 3000 N Discharge Summary D N S
Procedure Note with
S2 00027 Aural polypectomy +Tympanoplasty 14000 N Discharge Summary 2N S
Ant. Ethmoidal artery ligation - open/ Procedure Note with
S2 00028 endoscopic 13575 N Discharge Summary 2N S
Procedure Note with
S2 00029 Antrostomy – Bilateral 8500 N Discharge Summary 1N S
Procedure Note with
S2 00030 Antrostomy – Unilateral 6000 N Discharge Summary 1N S
Procedure Note with
S2 00031 Cryosurgery 7900 N Discharge Summary 1N S
Procedure Note with
S2 00032 CSF Rhinorrhoea – Repair 14000 N Discharge Summary 3N S
Procedure Note with
S2 00033 Septoplasty + FESS 11500 N Discharge Summary 1N S
Procedure Note with
S2 00034 Ethmoidectomy – External 11500 N Discharge Summary 1N S
Fracture reduction nose with septal Procedure Note with
S2 00035 correction 9125 N Discharge Summary 1N S
Procedure Note with
S2 00036 Fracture - setting maxilla 9625 N Discharge Summary 1N S
Procedure Note with
S2 00037 Fracture - setting nasal bone 5000 N Discharge Summary 1N S
Procedure Note with
S2 00038 Functional Endoscopic Sinus (FESS) 11000 N Discharge Summary 1N S
Procedure Note with
S2 00039 Intra Nasal Ethmoidectomy 7900 N Discharge Summary 1N S
Procedure Note with
S2 00040 Rhinotomy – Lateral 12069 N Discharge Summary 1N S
 Procedure Note with
S2 00041 Nasal polypectomy – Bilateral 9000 N Discharge Summary 1N S
Procedure Note with
S2 00042 Nasal polypectomy – Unilateral 6000 N Discharge Summary 1N S
Procedure Note with
S2 00043 Turbinectomy Partial – Bilateral 7825 N Discharge Summary 1N S
Procedure Note with
S2 00044 Turbinectomy Partial – Unilateral 4950 N Discharge Summary 1N S
Procedure Note with
S2 00045 Radical fronto ethmo sphenodectomy 18000 N Discharge Summary 3N S
Procedure Note with
S2 00046 Rhinoplasty 15000 N Discharge Summary 2N S
Procedure Note with
S2 00047 Septoplasty 7325 N Discharge Summary 1N S
Procedure Note with
S2 00048 Youngs operation 6175 N Discharge Summary 1N S
Procedure Note with
S2 00049 Angiofibrom Excision 18000 N Discharge Summary 3N S
Procedure Note with
S2 00050 Cranio-facial resection 22500 N Discharge Summary 5N S
Procedure Note with
S2 00051 Endoscopic DCR 7000 N Discharge Summary 1N S
Procedure Note with
S2 00052 Endoscopic Hypophysectomy 21000 N Discharge Summary 2N S
Procedure Note with
S2 00053 Intranasal Diathermy 3000 N Discharge Summary 1N S
Procedure Note with
S2 00054 Rhinosporidiosis 14000 N Discharge Summary 2N S
Procedure Note with
S2 00055 Septo-rhinoplasty 12500 N Discharge Summary 1N S
Procedure Note with
S2 00056 Adeno Tonsillectomy 12500 N Discharge Summary 1N S
 Procedure Note with
S2 00057 Adenoidectomy 5675 N Discharge Summary 1N S
Procedure Note with
S2 00058 Arytenoidectomy 17100 N Discharge Summary 2N S
Procedure Note with
S2 00059 Choanal atresia 12500 N Discharge Summary 2N S
Procedure Note with
S2 00060 Tonsillectomy + Myrinogotomy 11275 N Discharge Summary 1N S
Procedure Note with
S2 00061 Pharyngeal diverticulum's – Excision 13650 N Discharge Summary 2N S
Procedure Note with
S2 00062 Laryngectomy with block dissection 25000 N Discharge Summary 3N S
Procedure Note with
S2 00063 Laryngofissure 5000 N Discharge Summary 1N S
Procedure Note with
S2 00064 Laryngophayryngectomy 20000 N Discharge Summary 3N S
Procedure Note with
S2 00065 Maxilla – Excision 12500 N Discharge Summary 2N S
Procedure Note with
S2 00066 Oro Antral fistula 11350 N Discharge Summary 1N S
Procedure Note with
S2 00067 Parapharyngeal – Exploration 12500 N Discharge Summary 1N S
Procedure Note with
S2 00068 Parapharyngeal Abscess – Drainage 12500 N Discharge Summary 1N S
Procedure Note with
S2 00069 Peritonsillor abscess under LA 2500 N Discharge Summary D N S
Procedure Note with
S2 00070 Pharyngoplasty 13650 N Discharge Summary 2N S
Procedure Note with
S2 00071 Retro pharyngeal abscess – Drainage 5750 N Discharge Summary 1N S
Procedure Note with
S2 00072 Tonsillectomy + Styloidectomy 14225 N Discharge Summary 2N S
 Procedure Note with
S2 00073 Thyroglossal Fistula/ cyst – Excision 11350 N Discharge Summary 2N S
Procedure Note with
S2 00074 Tonsillectomy – (Uni/ Bilateral) 9125 N Discharge Summary 1N S
Procedure Note with
S2 00075 Total Parotidectomy 18000 N Discharge Summary 3N S
Procedure Note with
S2 00076 Superficial Parotidectomy 12000 N Discharge Summary 2N S
Procedure Note with
S2 00077 Uvulophanyngo Plasty 14000 N Discharge Summary 2N S
Procedure Note with
S2 00078 Commondo Operation (glossectomy) 20000 N Discharge Summary 3N S
Procedure Note with
S2 00079 Excision of Branchial Cyst 7000 N Discharge Summary 1N S
Procedure Note with
S2 00080 Excision of Branchial Sinus 9200 N Discharge Summary 2N S
Procedure Note with
S2 00081 Excision of Cystic Hygroma Major/ Extensive 10000 N Discharge Summary 2N S
Procedure Note with
S2 00082 Excision of Cystic Hygroma Minor 5000 N Discharge Summary 1N S
Procedure Note with
S2 00083 Excision of the Mandible Segmental 9000 N Discharge Summary 1N S
Procedure Note with
S2 00084 Hemi-mandibulectomy with graft 17025 N Discharge Summary 2N S
Procedure Note with
S2 00085 Hemiglossectomy 12000 N Discharge Summary 2N S
Procedure Note with
S2 00086 Palatopharyngoplasty 15950 N Discharge Summary 2N S
Procedure Note with
S2 00087 Partial Glossectomy 8000 N Discharge Summary 2N S
Procedure Note with
S2 00088 Ranula excision 5000 N Discharge Summary 1N S
 Procedure Note with
S2 00089 Removal of Submandibular Salivary gland 12000 N Discharge Summary 2N S
Procedure Note with
S2 00090 Total Glossectomy 18000 N Discharge Summary 3N S

Admission note with

relevant investigation
result report including Procedure Note with
S2 00091 Total Laryngectomy + Neck dissection 25000 Y Biopsy Discharge Summary 5N S

Admission note with

relevant investigation
Laryngopharyngectomy with Gastric pull-up/ result report including Procedure Note with
S2 00092 jejunal graft 30000 Y Biopsy Discharge Summary 5N S

Admission note with

relevant investigation
Excision of CA cheek/ oral cavity + radial result report including Procedure Note with
S2 00093 forearm flap 30000 Y Biopsy Discharge Summary 5N S
Excision of growth Jaw + free fibular flap Procedure Note with
S2 00094 reconstruction 30000 Y Discharge Summary 5N S
Caldwell - luc- Unilateral Procedure Note with
S2 5025 N Discharge Summary 1N S
Decompression sac Procedure Note with
S2 11350 N Discharge Summary 2N S
Excision of Cystic Hygroma Extensive Procedure Note with
S2 8250 N Discharge Summary 1N S
Facial nerve decompression Procedure Note with
S2 9050 N Discharge Summary 1N S
Fenestration Procedure Note with
S2 7900 N Discharge Summary 1N S
 Glomus Tympanicum Excision Procedure Note with
S2 10000 N Discharge Summary 2N S
Mastoid Abscess Drainage Procedure Note with
S2 5000 N Discharge Summary 1N S
Mastoidectomy With Myringoplasty Procedure Note with
S2 15000 N Discharge Summary 2N S
Maxillectomy Procedure Note with
S2 11125 N Discharge Summary 2N S
Otoendoscopy Procedure Note with
S2 1500 N Discharge Summary D N S

Parotidectomy - Conservative Admission note with

relevant investigation
result report including Procedure Note with
S2 14000 Y Biopsy Discharge Summary 3N S

Parotidectomy - Radical Total Admission note with

relevant investigation
result report including Procedure Note with
S2 18000 Y Biopsy Discharge Summary 5N S
Perichondritis Pinna Debridement Procedure Note with
S2 5000 N Discharge Summary 1N S
Preauricular sinus Procedure Note with
S2 5600 N Discharge Summary 1N S
Release of Tongue Tie Procedure Note with
S2 3375 N Discharge Summary D N S
Repair of Parotid Duct Procedure Note with
S2 8250 N Discharge Summary 1N S
Sinus Antroscopy Procedure Note with
S2 5100 N Discharge Summary 1N S
Styloidectomy - One side Procedure Note with
S2 8975 N Discharge Summary 1N S
 Styloidectomy - Both side Procedure Note with
S2 11275 N Discharge Summary 1N S
Submucos resection Procedure Note with
S2 6500 N Discharge Summary 1N S
Thyroglossal Fistula - Excision Procedure Note with
S2 11275 N Discharge Summary 2N S
Tracheostomy Procedure Note with
S2 5000 N Discharge Summary 1N S
Trans Antral Ethmoidectomy Procedure Note with
S2 6750 N Discharge Summary 1N S
Capped amount
(pacakge cannot
be used more Reserved
than the for Trust
mentioned Payment
monetary limit) (Y/N)

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
 Opthalmology
Package name

Average
length
Preauth of Stay Govt Medical
Specia Require Post-Op (Includin Reserved (M) or
lty Package Package d or Not Mandatory investigations investigations for g Days in Procedur Surgical
code Code Amount (Y/N) for pre-auth claims submission ICU) e (Y/N) (S)
Buckle Removal
Procedure Note with
S3 00001 7,500 N Discharge Summary D N S
Canaliculo Dacryocysto Rhinostomy
Procedure Note with
S3 00002 10,000 N Discharge Summary 1 N S
Capsulotomy (YAG)
Procedure Note with
S3 00003 2,225 N Discharge Summary D N S
Corneal Grafting
Procedure Note with
S3 00004 6,000 N Discharge Summary D N S
Prophylactic Cryoretinopexy- Closed
Procedure Note with
S3 00005 5,675 N Discharge Summary 1 N S
Cyclocryotherapy/Cyclophotocoagulatio
n
Procedure Note with
S3 00006 4,025 N Discharge Summary D N S
Pterygium + ConjunctivalAutograft
Procedure Note with
S3 00007 7,500 N Discharge Summary D N S
 Dacryocystectomy with implants
Procedure Note with
S3 00008 11,000 N Discharge Summary D N S
Enucleation
Procedure Note with
SS 00009 5,000 N Discharge Summary 1 N S
Enucleation with Implant
Procedure Note with
S3 00010 7,500 N Discharge Summary 1 N S
Exenteration
Procedure Note with
S3 00011 7,500 N Discharge Summary D N S
Glaucoma Surgery (Trabeculectomy
only) with or without Mitomycin C,
including postoperative medications for
12 weeks (and wherever surgical or laser
procedures required for bleb
augmentation and anterior chamber
maintenance)
Procedure Note with
S3 00012 10,000 N Discharge Summary 1 N S
Intraocular Foreign Body Removal from
Anterior Segment
Procedure Note with
S3 00013 4,000 N Discharge Summary D N S
Intraocular Foreign Body Removal from
Posterior Segment
Procedure Note with
S3 00014 20,000 N Discharge Summary 1 N S
Lensectomy /pediatric lens aspiration
Procedure Note with
S3 00015 9,000 N Discharge Summary D N S
Limbal Dermoid Removal
Procedure Note with
S3 00016 4,000 N Discharge Summary D N S
 Surgical Membranectomy
Procedure Note with
S3 00017 8,000 N Discharge Summary D N S
Perforating Corneo - Scleral Injury
Procedure Note with
S3 00018 10,000 N Discharge Summary 2 N S
Ptosis Surgery
Procedure Note with
S3 00019 10,000 N Discharge Summary D N S
IRIS Prolapse – Repair
Procedure Note with
S3 00020 5,600 N Discharge Summary D N S
Retinal Detachment Surgery
Procedure Note with
S3 00021 15,000 N Discharge Summary 2 N S
Small Tumour of Lid – Excision + Lid
Reconstruction
Procedure Note with
S3 00022 5,000 N Discharge Summary D N S
Socket Reconstruction with amniotic
membrane
Procedure Note with
S3 00023 8,000 N Discharge Summary 1 N S
Iridectomy – Laser
Procedure Note with
S3 00024 2,000 N Discharge Summary D N S
Iridectomy – Surgical
Procedure Note with
S3 00025 3,000 N Discharge Summary D N S
Iris cyst removal
2300 Procedure Note with
S3 00026 N Discharge Summary D N S
 Vitrectomy
Procedure Note with
SS 00027 7,500 N Discharge Summary 1 N S
Vitrectomy + Retinal Detachment
surgery (pre-auth required)
Procedure Note with
S3 00028 17,500 N Discharge Summary 1 N S
Cataract with foldable hydrophobic
acrylic IOL by Phaco emulsification tech
Procedure Note with
S3 00029 7,500 N Discharge Summary D N S
Cataract with non-foldable IOL using
SICS technique
Procedure Note with
S3 00030 5,750 N Discharge Summary D N S
Cataract with foldable hydrophobic
acrylic IOL by Phaco emulsification tech
+ Glaucoma Procedure Note with
S3 00031 15,000 N Discharge Summary D N S
Cataract with non-foldable IOL using
SICS technique + Glaucoma
Procedure Note with
S3 00032 12,500 N Discharge Summary D N S
Conjunctival tumour excision + AMG
Procedure Note with
S3 00033 5,000 N Discharge Summary D N S
Entropion correction
Procedure Note with
S3 00034 4,000 N Discharge Summary D N S
Ectropion correction
Procedure Note with
S3 00035 5,000 N Discharge Summary D N S
Evisceration
Procedure Note with
SS 00036 3,500 N Discharge Summary D N S
 Laser for retinopathy (per sitting)
Procedure Note with
S3 00037 1,500 N Discharge Summary D N S
Lid tear
Procedure Note with
S3 00038 3,500 N Discharge Summary D N S
Orbitotomy
Procedure Note with
SS 00039 10,000 N Discharge Summary 1 N S
Squint correction (per muscle)
Procedure Note with
S3 00040 4,000 N Discharge Summary D N S
Anterior Chamber Reconstruction
+Perforating corneo - Scleral Injury + IOL
Procedure Note with
S3 00041 11,500 N Discharge Summary 2N S
PRP - Retinal Laser including 3 sittings
Procedure Note with
S3 00042 5,000 N Discharge Summary D N S
Abscess Drainage of Lid
575 Procedure Note with
S3 N Discharge Summary D N S
Acid and alkali burns
Procedure Note with
S3 1,300 N Discharge Summary D N S
ALT-Argon laser trabeculoplasty
Procedure Note with
S3 1,725 N Discharge Summary D N S
Amniotic Membrane grafting
Procedure Note with
S3 2725 N Discharge Summary D N S
 Argon/diode laser for Retinal
Detachment
Procedure Note with
S3 1,300 N Discharge Summary D N S
Bandage Contact Lenses for Corneal
perforation
Procedure Note with
S3 575 N Discharge Summary D N S
Canaliculoplasty
Procedure Note with
S3 2500 N Discharge Summary D N S
Cataract – Unilateral-ECCE.
4250 Procedure Note with
S3 N Discharge Summary D N S
Cauterisation of ulcer/subconjuctival
injection - both eye 250 Procedure Note with
S3 N Discharge Summary D N S
Cauterisation of ulcer/subconjuctival
injection - One eye 125 Procedure Note with
S3 N Discharge Summary D N S
Chalazion - both eye
750 Procedure Note with
S3 N Discharge Summary D N S
Chalazion - one eye
600 Procedure Note with
S3 N Discharge Summary D N S
Collagen crosslinking (UV radiation Kerat
Procedure Note with
S3 2500 N Discharge Summary D N S
Corneal Foreign Body Removal
Procedure Note with
S3 500 N Discharge Summary D N S
 Dacryocystorhinostomy(DCR)-plain
3300 Procedure Note with
S3 N Discharge Summary D N S
DALK-Deep AnteriorLamellar
Keratoplasty 19000 Procedure Note with
S3 N Discharge Summary 2N S
DSAEK Descement's stripping automated
endothelial keratoplasty 18000 Procedure Note with
S3 N Discharge Summary 2N S
Ectropion Correction -one lid
2500 Procedure Note with
S3 N Discharge Summary D N S
Entropion correction -one lid
2000 Procedure Note with
S3 N Discharge Summary D N S
Epicantuhus correction
2500 Procedure Note with
S3 N Discharge Summary D N S
Epiliation
300 Procedure Note with
S3 N Discharge Summary D N S
ERG/EOG/VEP
1500 Procedure Note with
S3 N Discharge Summary D N S
Fracture Orbital repair
10500 Procedure Note with
S3 N Discharge Summary 2N S
Glaucoma Surgery with valve
Procedure Note with
S3 10,000 N Discharge Summary 1N S
 Injection Botulinum for
Blepharospasm,Squint,etc 3000 Procedure Note with
S3 N Discharge Summary D N S
Intravitreal Injection of Antibiotics
3500 Procedure Note with
S3 N Discharge Summary D N S
Iris cyst removal
Procedure Note with
S3 2,500 N Discharge Summary D N S
Keratoplasty
9125 Procedure Note with
S3 N Discharge Summary 1N S
Keratoprosthesis Stage 1&2
15000 Procedure Note with
S3 N Discharge Summary 2N S
Optic Nerve Decompression
10000 Procedure Note with
S3 N Discharge Summary 1N S
Orbital Decompression
10000 Procedure Note with
S3 N Discharge Summary 1N S
Orbital Abscess I&D
4000 Procedure Note with
S3 N Discharge Summary D N S
Probing and syringing of Lacrimal sac
Unilateral/bilateralunder GA 2000 Procedure Note with
S3 N Discharge Summary D N S
Pterygium (Day care)
1500 Procedure Note with
S3 N Discharge Summary D N S
 Ptosis Surgery -fasanella servat
procedure-one lid 3000 Procedure Note with
S3 N Discharge Summary D N S
Ptosis Surgery -LPS resection -one lid
7000 Procedure Note with
S3 N Discharge Summary 1N S
Silicon Oil removal Surgery
Procedure Note with
S3 3000 N Discharge Summary D N S
Telecanthus correction
5800 Procedure Note with
S3 N Discharge Summary 1N S
Tumours of IRIS
4450 Procedure Note with
S3 N Discharge Summary 1N S
UV radiation for cross linkig for
Keratoconus 2250 Procedure Note with
S3 N Discharge Summary D N S
YAG Laser capsulotomy
Procedure Note with
S3 1,500 N Discharge Summary D N S
 Gynecology
Package name Average
length
of Stay
(Includi
ng Days
Preaut in ICU) Govt
h Reserv
Requir ed
Speci ed or Proced
alty Package Package Not Post-Op investigations ure
code Code Amount (Y/N) Mandatory investigations for pre-auth for claims submission (Y/N)
Hysterectomy -abdominal/vaginal± Salpingo- 5
oophorectomy
Admission note with relevant Procedure Note with
S4 00001 20000 Y investigation result report including USG Discharge Summary N
Abdominal Myomectomy 5
Procedure Note with
S4 00002 16000 N Discharge Summary N
Surgeries for Prolapse - Sling Surgeries 5
Procedure Note with
S4 00003 16000 N Discharge Summary N
Surgeries for Stress Incontinence 'Burch' 5
Admission note with relevant Procedure Note with
S4 00004 35000 Y investigation result report Discharge Summary N
Hysterotomes - 2nd Trimester abortions D
Procedure Note with
S4 00005 5000 N Discharge Summary N
Incisional Hernia Repair 3
Procedure Note with
00006 15,000 N Discharge Summary
Radical Hysterectomy (Wertheims) 5
Admission note with relevant
investigation result report including USG Procedure Note with
S4 00007 25000 Y and Biopsy Discharge Summary N
Laparotomy and proceed for Ovarian 5
Cancers. Omentomy with Bilateral Salpingo- Admission note with relevant
oophorectomy investigation result report including USG Procedure Note with
S4 00008 20,000 Y and Biopsy Discharge Summary N
Non descent vaginal hysterectomy 4
Procedure Note with
S4 00009 14000 N Discharge Summary N
 Vaginal hysterectomy with anterior and 5
posterior colpoperineorrhaphy
Admission note with relevant Procedure Note with
S4 00010 22000 Y investigation result report including USG Discharge Summary N
Sacrocolpopexy 3
Procedure Note with
S4 00012 16000 N Discharge Summary N
Repair for rectovaginal fitulas 3
Procedure Note with
S4 00013 16000 N Discharge Summary N
Vaginoplasty 3
Procedure Note with
S4 00014 10000 N Discharge Summary N
LLETZ 3
Procedure Note with
S4 00015 15000 N Discharge Summary N
Colpotomy D
Procedure Note with
S4 00016 1500 N Discharge Summary N
Dilation and Evacuation (D&E) D
Procedure Note with
S4 00017 5100 N Discharge Summary N
Cervical biopsy and Polypectomy D
Procedure Note with
S4 00018 4500 N Discharge Summary N
Bartholins Cyst Enucleation/ Incision D
drainage Procedure Note with
S4 00019 3000 N Discharge Summary N
Vulvectomy simple 3
Procedure Note with
S4 00020 15000 N Discharge Summary N
Radical Vulvectomy 3
Admission note with relevant
investigation result report including Procedure Note with
S4 00021 17000 Y Biopsy Discharge Summary N
Diagnostic laparoscopy 1
Procedure Note with
S4 00022 11000 N Discharge Summary N
Laparoscopic hysterectomy (TLH) 2
Admission note with relevant Procedure Note with
S4 00023 25000 Y investigation result report including USG Discharge Summary N
Laparoscopic myomectomy 2
Admission note with relevant Procedure Note with
S4 00024 17000 Y investigation result report including USG Discharge Summary N
 Laparoscopic cystectomy 2
Admission note with relevant Procedure Note with
S4 00025 15000 Y investigation result report including USG Discharge Summary N
Laparoscopic ovarotomy 2
Admission note with relevant Procedure Note with
S4 00026 12000 Y investigation result report including USG Discharge Summary N
Laparoscopic adhesiolysis 1
Procedure Note with
S4 00027 6000 N Discharge Summary N
Laparoscopic tubal surgeries - salpingectomy, 2
salpingotomy Procedure Note with
S4 00028 12500 N Discharge Summary N
Drag hysteroscopy 1
Procedure Note with
S4 00029 6000 N Discharge Summary N
Hysteroscopic myomectomies 1
Procedure Note with
S4 00030 6000 N Discharge Summary N
Hysteroscopic adhesiolysis 1
Procedure Note with
S4 00031 6000 N Discharge Summary N
Hysteroscopic polypectomy 1
Procedure Note with
S4 00032 8050 N Discharge Summary N
Hysteroscopic IUCD removal 1
Procedure Note with
S4 00033 3000 N Discharge Summary N
Caesarian Delivery 5
Procedure Note with
S4 00034 12000 N Discharge Summary N
Caesarian hysterectomy 5
Procedure Note with
S4 00035 22000 N Discharge Summary N
High risk delivery: Pre-mature delivery Procedure Note with
3
S4 00036 9000 N Discharge Summary N
High risk delivery: Expected Gestation at 3
delivery less than 35 weeks Procedure Note with
S4 00037 9000 N Discharge Summary N
High risk delivery: Mothers with 3
eclampsia or imminent eclampsia Procedure Note with
S4 00038 10000 N Discharge Summary N
High risk delivery: Obstructed labour- 3
forceps/vacuum delivery Procedure Note with
S4 00039 10000 N Discharge Summary N
 High risk delivery: Major Fetal 3
malformation requiring intervention
immediately after birth Procedure Note with
S4 00040 10000 N Discharge Summary N
High risk delivery: Mothers with severe 3
anaemia (<7 g/dL) Procedure Note with
S4 00041 9,000 N Discharge Summary N
High risk delivery: Other maternal and 3
fetal conditions as per guidelines-Such as
Rh haemolytic disease, uncontrolled
diabetes, severe growth retardation etc Procedure Note with
S4 00042 that qualify for high risk delivery etc. 10000 N Discharge Summary N
Manual removal of placenta 1
Procedure Note with
S4 00043 5000 N Discharge Summary N
Laparotomy for ruptured ectopic 3
Procedure Note with
S4 00044 14000 N Discharge Summary N
MTP > 12 weeks 1
Procedure Note with
S4 00045 6500 N Discharge Summary N
MTP upto 12 weeks 1
Procedure Note with
S4 00046 5000 N Discharge Summary N
MTP upto 8 weeks 1
Procedure Note with
S4 00047 3500 N Discharge Summary N
McDonald's stitch D
Procedure Note with
S4 00048 5000 N Discharge Summary N
Shirodkar's stitch D
Procedure Note with
S4 00049 4000 N Discharge Summary N
Tuboplasty 2
Procedure Note with
S4 00050 10000 N Discharge Summary N
Laparotomy for broad ligament haematoma 3
Admission note with relevant Procedure Note with
S4 00051 16000 Y investigation result report including USG Discharge Summary N
Trans-vaginal tape/ Trans-obturator tape D
Procedure Note with
S4 00052 5000 N Discharge Summary N
 Abdominal Perineal neo construction Cx + 5
Uteria + Vagina Admission note with relevant
investigation result report including USG Procedure Note with
S4 00053 20000 Y and Biopsy Discharge Summary N
Ablation of Endometriotic Spot + 2
Adhenolysis Procedure Note with
S4 00054 10000 N Discharge Summary N
Ablation of Endometriotic Spot 2
+Salpingostomy Procedure Note with
S4 00055 10000 N Discharge Summary N
Adhenolysis + Hernia - Ventral - 2
Lipectomy/Incision Procedure Note with
S4 00056 16000 N Discharge Summary N
Adhenolysis+ Ovarian Cystectomy 2
Procedure Note with
S4 00057 10000 N Discharge Summary N
Adhenolysis+ Salpingostomy 2
Procedure Note with
S4 00058 10000 N Discharge Summary N
Broad Ligment Haemotoma drainage 2
Procedure Note with
S4 00059 10000 N Discharge Summary N
Brust abdomen repair 3
Procedure Note with
00060 15000 N Discharge Summary
Cone Biopsy Cervix 1
Procedure Note with
S4 00061 1500 N Discharge Summary N
Conventional Tubectomy 1
Procedure Note with
S4 00062 4000 N Discharge Summary N
Cyst -Vaginal Enucleation D
Procedure Note with
S4 00063 3000 N Discharge Summary N
Cyst-Labial D
Procedure Note with
S4 00064 3000 N Discharge Summary N
Cystocele - Anterior repair 3
Procedure Note with
S4 00065 12000 N Discharge Summary N
Cystocele - Anterior Repair + Perineal Tear 3
Repair Procedure Note with
S4 00066 14000 N Discharge Summary N
D&C (Dilatation &curretage) + Electro D
Cauterisation Cryo Surgery Procedure Note with
S4 00067 4000 N Discharge Summary N
 D&C (Dilatation&curretage) D
Procedure Note with
S5 00068 3000 N Discharge Summary N
Electro Cauterisation Cryo Surgery D
Procedure Note with
S4 00070 4000 N Discharge Summary N
Exploration of abdominal haematoma (after 3
laparotomy + LSCS) Admission note with relevant Procedure Note with
S4 00071 14000 Y investigation result report Discharge Summary N
Fractional Curretage D
Procedure Note with
S4 00072 4000 N Discharge Summary N
Gaping Perineal wound secondary suturing/ 1
episiotomy Procedure Note with
S4 00073 2500 N Discharge Summary N
HaematoColpo/Excision - Vaginal Septum 1
Procedure Note with
S4 00074 5000 N Discharge Summary N
Hymenectomy& Repair of Hymen 1
Procedure Note with
S4 00075 7000 N Discharge Summary N
Amniocentesis D
Procedure Note with
S4 00076 5000 N Discharge Summary N
Chorionic villus sampling D
Procedure Note with
S4 00077 5000 N Discharge Summary N
Cordocentesis D
Procedure Note with
S4 00078 5000 N Discharge Summary N
Intrauterine transfusions D
Procedure Note with
S4 00079 10000 N Discharge Summary N
1
Ablation of Endometrium Procedure Note with
S4 5750 N Discharge Summary N
1
Cervical Tear Procedure Note with
S4 5000 N Discharge Summary N
1
Destructive operation Procedure Note with
S4 6000 N Discharge Summary N
D
Procedure Note with
S4 Foreign Body retrieval from vagina 3000 N Discharge Summary N
3
Fothergill's operation Admission note with relevant Procedure Note with
S4 17000 Y investigation result report Discharge Summary N
 D
Fractional Curretage Procedure Note with
S4 4000 N Discharge Summary N
2
Hysteroscopic Tubal Cannulation Procedure Note with
S4 15000 N Discharge Summary N
3
Admission note with relevant
Hysterotomy -Tumors removal investigation result report including Procedure Note with
S4 17000 Y Biopsy Discharge Summary N
3
Laparotomy -failed laproscopy to explore Admission note with relevant Procedure Note with
S4 14000 Y investigation result report Discharge Summary N
3
Laparotomy for ectopic pregnancy Procedure Note with
S4 12000 N Discharge Summary N
3
Laparotomy to explore for IUCD perforation Procedure Note with
S4 14000 N Discharge Summary N
2
Normal Vaginal delivery Procedure Note with
S4 7000 N Discharge Summary N
Normal Vaginal delivery with 3rd /4th 3
Procedure Note with
S4 degree Perineal Tear Repair 8000 N Discharge Summary N
3
Ovarian Cystectomy Procedure Note with
S4 17000 N Discharge Summary N
3
Admission note with relevant Procedure Note with
S4 Ovarian Cystectomy in Pregnancy 18000 Y investigation result report including USG Discharge Summary N
2
Ovariectomy/Oophorectomy Procedure Note with
S4 11520 N Discharge Summary N
Perforation of Uterus after D&C-laparotomy 3
Procedure Note with
S4 and closure 15725 N Discharge Summary N
D
Perineal Tear Repair Procedure Note with
S4 2200 N Discharge Summary N
3
Prolapse Uterus - Manchester Admission note with relevant Procedure Note with
S4 15000 Y investigation result report Discharge Summary N
3
Prolapse Uterus -L forts Admission note with relevant Procedure Note with
S4 15000 Y investigation result report Discharge Summary N
 1
Pyometra Dilation Procedure Note with
S4 5000 N Discharge Summary N
D
Repair of post coital tear, perineal injury Procedure Note with
S4 3500 N Discharge Summary N
3
Rupture Uterus and repair with tubal ligation Procedure Note with
S4 20000 N Discharge Summary N
1
Uterine Synechia - Cutting Procedure Note with
S4 8625 N Discharge Summary N
D
Vaginal Tear -Repair Procedure Note with
S4 3600 N Discharge Summary N
2
Vulval Tumors - Removal Procedure Note with
S4 6000 N Discharge Summary N
3
Salpingo-Oophorectomy Procedure Note with
S4 11500 N Discharge Summary N
 Capped amount
(pacakge cannot
Medical be used more Reserved
(M) or than the for Trust
Surgical mentioned Payment
(S) monetary limit) (Y/N)

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N
 Orthopaedics
Preaut
h
Requir Average
ed or length of Govt
Not Stay Reserve
Speci (Y/N) (Including d
alty Package Package Mandatory investigations Post-Op investigations for Days in Procedu
code Code Package name Amount for pre-auth claims submission ICU) re (Y/N)
25,000

AC joint reconstruction/ Stabilization/

Acromionplasty (Nonoperative management is
recommended for Rockwood type I and II injuries,
whereas surgical reconstruction is recommended Admission note with
for type IV and VI separations. The management relevant investigation result
for type III and V injuries is more controversial and report including Procedure Note with
S5 00001 is determined on a case-by-case basis) Y Radiological report Discharge Summary 4 N

Accessory bone – Excision (limbs) – congenital, Procedure Note with

S5 00002 Accessory digits sometime can be removed 13575 N Discharge Summary 3 N
16875 Procedure Note with
S5 00003 Amputation - Below Elbow N Discharge Summary 3 N
15,000 Procedure Note with
S5 00004 Amputation - Above Elbow N Discharge Summary 3 N
6000 Procedure Note with
00005 Amputation – one or more fingers N Discharge Summary 1 N
15,000 Procedure Note with
S5 00006 Amputation – Wrist N Discharge Summary 3 N
Procedure Note with
00007 Amputation - one or more toes/ digits 6,000 N Discharge Summary 1 N
Procedure Note with
S5 00008 Amputation – Below Knee 15,000 N Discharge Summary 3 N
 18,000 Procedure Note with
S5 00009 Amputation – Above Knee N Discharge Summary 3 N
Procedure Note with
S5 00010 Foot & Hand Amputation (whole/ partial) 15,000 N Discharge Summary 3 N
25,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00011 Disarticulation (hind & for quarter) Y Radiological report Discharge Summary 7 N
35,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00012 Anterior Spine Fixation Y Radiological report Discharge Summary 5 N

Admission note with

22550 relevant investigation result
report including Procedure Note with
S5 00013 Posterior Spine Fixation Y Radiological report Discharge Summary 5 N
15,000 Procedure Note with
S5 00015 Excision Arthoplasty N Discharge Summary 3 N
16725 Procedure Note with
S5 00016 Arthorotomy of any joint N Discharge Summary 7 N

Admission note with

20000 relevant investigation result
report including Procedure Note with
S5 00017 Arthrodesis Ankle Triple Y Radiological report Discharge Summary 6 N

Admission note with

relevant investigation result
report including Procedure Note with
S5 00018 Excision Arthoplasty of Femur head 22,500 Y Radiological report Discharge Summary 6 N
15,000 Procedure Note with
S5 00019 Bimalleolar Fracture Fixation N Discharge Summary 5 N
 Admission note with
relevant investigation result
Bone Tumour Excision + reconstruction using report including Procedure Note with
S5 00020 implant (malignant/ benign) 50,000 Y Radiological report Discharge Summary 4 N
20,000
Admission note with
relevant investigation result
Bone Tumour (malignant/ benign) curettage and report including Procedure Note with
S5 00021 bone grafting Y Radiological report Discharge Summary 7 N
###
Admission note with
Bone Tumour Excision (malignant/ benign) + Joint relevant investigation result
replacement (depending upon type of joint and report including Procedure Note with
S5 00022 implant) Y Radiological report Discharge Summary 7 N
Clavicle fracture management - conservative 3,000 Procedure Note with
S5 00023 (daycare) N Discharge Summary D N
7825 Procedure Note with
S5 00024 Close Fixation - Hand Bones N Discharge Summary 2 N
7325 Procedure Note with
S5 00025 Close Fixation - Foot Bones N Discharge Summary 2 N
4,000 Procedure Note with
S5 00026 Close Reduction - Small Joints N Discharge Summary 1 N
Closed Interlock Nailing + Bone Grafting – Procedure Note with
S5 00027 femur/tibia/humerous/radius / ulna 19,000 N Discharge Summary 5 N
Closed Interlocking Intramedullary 17,500 Procedure Note with
S5 00028 -femur/tibia/humerous/radius / ulna N Discharge Summary 5 N
Closed Interlocking Tibia + Orif of Fracture Procedure Note with
S5 00029 Fixation 17000 N Discharge Summary 5 N
6750 Procedure Note with
S5 00030 Closed Reduction and Internal Fixation with K wire N Discharge Summary D N
Closed Reduction and Percutaneous Screw 15,000 Procedure Note with
S5 00031 Fixation (neck femur) N Discharge Summary 3 N
15,000 Procedure Note with
S5 00032 Closed Reduction and Percutaneous Pinning N Discharge Summary 2 N
 Procedure Note with
S5 00033 Closed Reduction and Percutaneous Nailing 20,000 N Discharge Summary 3 N
Closed Reduction of the Hip D/L (including hip Procedure Note with
S5 00034 Spika) 9000 N Discharge Summary D N
7,000
Debridement & Closure of Major injuries -
contused lacerated wounds (anti-biotic + Procedure Note with
S5 00035 dressing) - minimum of 3 sessions N Discharge Summary D N
3375 Procedure Note with
S5 00036 Debridement & Closure of Minor injuries N Discharge Summary D N
6,000 Procedure Note with
S5 00037 Closed reduction of dislocation (Knee/ Hip) N Discharge Summary D N
5,000 Procedure Note with
S5 00038 Closed reduction of dislocation (Shoulder/ Elbow) N Discharge Summary D N
13500 Procedure Note with
S5 00039 Duputryen’s Contracture release + rehabilitation N Discharge Summary 3 N
15,000 Procedure Note with
S5 00041 External fixation - Long bone N Discharge Summary 3 N
13075 Procedure Note with
S5 00042 External fixation - Small bone N Discharge Summary 2 N
17500 Procedure Note with
S5 00043 External fixation - Pelvis N Discharge Summary 5 N
8000 Procedure Note with
S5 00044 Fasciotomy N Discharge Summary 2 N

Admission note with

21000 relevant investigation result
report including Procedure Note with
S5 00045 Fixator with Joint Arthrolysis Y Radiological report Discharge Summary 5 N

Admission note with

relevant investigation result
report including Procedure Note with
S5 00046 Fracture - Acetabulum 30,000 Y Radiological report Discharge Summary 5 N
 12000 Procedure Note with
S5 00047 Fracture - Fibula Internal Fixation N Discharge Summary 3 N

Admission note with

relevant investigation result
Fracture - Hip Internal Fixation (Intertrochanteric report including Procedure Note with
S5 00048 Fracture with implant) + rehabilitation 20,000 Y Radiological report Discharge Summary 5 N
17,000 Procedure Note with
S5 00049 Fracture - Humerus Internal Fixation N Discharge Summary 5 N
13425 Procedure Note with
S5 00050 Fracture - Olecranon of Ulna N Discharge Summary 2 N
12000 Procedure Note with
S5 00051 Fracture - Radius Internal Fixation N Discharge Summary 2 N
17,000 Procedure Note with
S5 00052 Fracture - TIBIA Internal Fixation plating N Discharge Summary 3 N
11000 Procedure Note with
S5 00053 Fracture - Ulna Internal Fixation N Discharge Summary 3 N
17025 Procedure Note with
S5 00054 Head Radius – Excision N Discharge Summary 3 N
17,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00055 High Tibial Osteotomy Y Radiological report Discharge Summary 5 N
11200 Procedure Note with
S5 00057 Internal Fixation Lateral Epicondyle N Discharge Summary 4 N
Internal Fixation of other Small Bones 10,000 Procedure Note with
S5 00058 (metatarsals/metacarpals) N Discharge Summary 3 N
25,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00059 Limb Lengthening Y Radiological report Discharge Summary 5 N
Procedure Note with
S5 00061 Multiple Tendon Repair 20,000 N Discharge Summary 5 N
 15,000 Procedure Note with
S5 00062 Nerve Repair Surgery N Discharge Summary 5 N
17000 Procedure Note with
S5 00063 Nerve Transposition/Release/ Neurolysis N Discharge Summary 5 N
13425 Procedure Note with
S5 00064 Open Reduction Internal Fixation (2 Small Bones) N Discharge Summary 3 N
20,000 Procedure Note with
S5 00065 Open Reduction Internal Fixation (Large Bone) N Discharge Summary 5 N
30,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00066 Open Reduction of CDH Y Radiological report Discharge Summary 5 N
15,000 Procedure Note with
S5 00067 Open Reduction of Small Joint N Discharge Summary 1 N
Procedure Note with
S5 00068 Open Reduction with bone grafting of nonunion 20,000 N Discharge Summary 3 N

Admission note with

20250 relevant investigation result
report including Procedure Note with
S5 00069 Osteotomy -Small Bone Y Radiological report Discharge Summary 5 N
30,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00070 Osteotomy -Long Bone Y Radiological report Discharge Summary 7 N
16725 Procedure Note with
S5 00071 Patellectomy N Discharge Summary 5 N

Admission note with

relevant investigation result
report including Procedure Note with
S5 00072 Pelvic Osteotomy with fixation with plaster 30,000 Y Radiological report Discharge Summary 5 N
7,000 Procedure Note with
S5 00073 Percutaneous - Fixation of Fracture N Discharge Summary 5 N
 Procedure Note with
00074 Excision of Bursa 4,525 N Discharge Summary 2 N

Admission note with

relevant investigation result
Reconstruction of ACL/PCL with implant and report including Procedure Note with
S5 00075 brace 30,000 Y Radiological report Discharge Summary 3 N
Sequestrectomy of Long Bones + anti-biotics + 25,000 Procedure Note with
S5 00076 dressing N Discharge Summary 5 N
5675 Procedure Note with
S5 00077 Tendo Achilles Tenotomy N Discharge Summary 2 N
20475 Procedure Note with
S5 00078 Tendon Grafting N Discharge Summary 2 N
Procedure Note with
S5 00079 Tendon Release/ Tenotomy 5,000 N Discharge Summary 2 N
9050 Procedure Note with
S5 00080 Tenolysis N Discharge Summary 2 N
15,000 Procedure Note with
S5 00081 Tension Band Wiring Patella N Discharge Summary 3 N
Application of P.O.P. casts for Upper & Lower 3,000 Procedure Note with
S5 00082 Limbs N Discharge Summary D N
3,500 Procedure Note with
S5 00083 Application of P.O.P. Spikas& Jackets N Discharge Summary D N
3,000 Procedure Note with
S5 00084 Application of Skeletal Tractions with pin N Discharge Summary D N
1,000 Procedure Note with
S5 00085 Application of Skin Traction N Discharge Summary D N
Head radius - Excision + Fracture - Ulna Internal 20,000 Procedure Note with
S5 00086 Fixation N Discharge Summary 3 N
25,000 Procedure Note with
S5 00087 External fixation - both bones of forearms N Discharge Summary 3 N
Fracture intercondylarHumerus + olecranon 20,000 Procedure Note with
S5 00088 osteotomy N Discharge Summary 3 N
 20,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00090 Arthroscopic Meniscus Repair/ Meniscectomy Y Radiological report Discharge Summary 3 N
75,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00091 Total Hip Replacement (cemented) Y Radiological report Discharge Summary 7 N
90,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00092 Total Hip Replacement (cementless) Y Radiological report Discharge Summary 7 N

Admission note with

relevant investigation result
report including Procedure Note with
S5 00093 Total Hip Replacement (hybrid) 75,000 Y Radiological report Discharge Summary 7 N
35,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00094 Bipolar Hemiarthroplasty (hip & shoulder) Y Radiological report Discharge Summary 7 N
27,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00095 Unipolar Hemiarthroplasty Y Radiological report Discharge Summary 7 N
80,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00096 Total Knee Replacement Y Radiological report Discharge Summary 7 N
40,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00097 Elbow replacement Y Radiological report Discharge Summary 7 N
 40,000
Admission note with
relevant investigation result
report including Procedure Note with
S5 00098 Arthrodesis of shoulder Y Radiological report Discharge Summary 7 N

Admission note with

relevant investigation result
report including Procedure Note with
S5 00099 Arthrodesis of Knee (with implant) 40,000 Y Radiological report Discharge Summary 7 N

Admission note with

relevant investigation result
report including Procedure Note with
S5 00100 Arthrodesis of Wrist (with implant) 30,000 Y Radiological report Discharge Summary 7 N

Admission note with

relevant investigation result
report including Procedure Note with
S5 00101 Arthrodesis of Ankle (with implant) 30,000 Y Radiological report Discharge Summary 7 N
AMPUTATION - PART OF TOE &FIXATION OF K Procedure Note with
5375
S5 WIRE N Discharge Summary D N
AMPUTATION ANKLE 13425 Procedure Note with
S5 N Discharge Summary 3N
15,000 Procedure Note with
AMPUTATION FORE FOOT/hand(whole/Partial)
S5 N Discharge Summary 3N
APPLICATION OF FUNCTIONAL CAST BRACE Procedure Note with
S5 3500 N Discharge Summary D N

Admission note with

relevant investigation result
report including Procedure Note with
S5 Arthrodesis Subtalar joint 15000 Y Radiological report Discharge Summary 3N

Admission note with

ARTHROSCOPIC SYNOVIAL BIOPSY 17100 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N
 Admission note with
ARTHROSCOPIC ACL/PCL AVULSION FIXATION relevant investigation result
report including Procedure Note with
S5 20000 Y Radiological report Discharge Summary 2N

Admission note with

ARTHROSCOPIC JOINT DEBRIDEMENT 20550 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N
ARTHROSCOPIC LATERAL RELEASE PATELLAR Procedure Note with
5375
S5 DISLOCATION N Discharge Summary 2N

Admission note with

ARTHROSCOPIC OCD FIXATION 22850 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

Admission note with

ARTHROTOMY & SYNEVECTOMY 17025 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N
S5 ASPIRATION& INTRA ARTICULAR INJECTIONS 900 N D N
BANDAGE&STAPPING FOR FRACTURES 500 Procedure Note with
S5 N Discharge Summary D N
BONE BIOPSY 5675 Procedure Note with
S5 N Discharge Summary 1N
BONE GRAFTING 11275 Procedure Note with
S5 N Discharge Summary 3N

BONE TUMOUR & RECONSTRUCTION - MAJOR Admission note with

16000 relevant investigation result
EXCISION
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N
 BONE TUMOUR & RECONSTRUCTION - MINOR Admission note with
12000 relevant investigation result
EXCISION
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

Admission note with

BOTH BONE FOREARM FRACTURE 17000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

CALCANEAL FRACTURE ORIF (Plate ) 16000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N
CALCANEAL SPUR - EXICISION U/L 6675 Procedure Note with
S5 N Discharge Summary 2N
CALCANEAL SPUR - EXICISION OF BOTH 10125 Procedure Note with
S5 N Discharge Summary 2N
CDH CLOSED REDUCTION & HIP SPICA 17100 Procedure Note with
S5 N Discharge Summary 2N

Admission note with

CERVICAL DISCECTOMY & FUSION 22625 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
CHRONIC OSTEO MYELITIS & CEMENT BEADS 16950 Procedure Note with
S5 N Discharge Summary 3N
CLAVICLE SURGERY 16875 Procedure Note with
S5 N Discharge Summary 3N
CLOSED REDUCTION INTERNAL FIXATION OF Procedure Note with
13575
S5 RADIUS N Discharge Summary 3N
CLOSED REDUCTION OF FRCATURES OF LIMB Procedure Note with
S5 &P.O.P 4000 N Discharge Summary D N
Clubfoot Phase 3 Bracing Visit 1200 Procedure Note with
S5 N Discharge Summary D N
 CRUSH INJURY SINGLE FINGER TIP 2500 Procedure Note with
S5 N Discharge Summary D N
CTEV JESS 21000 Procedure Note with
S5 N Discharge Summary 3N
CTEV POP CAST B/L 1500 Procedure Note with
S5 N Discharge Summary D N
CTEV POP CAST U/L 1000 Procedure Note with
S5 N Discharge Summary D N
CTEV TENOTOMY B/L 7000 Procedure Note with
S5 N Discharge Summary 3N
CTEV TENOTOMY U/L 5000 Procedure Note with
S5 N Discharge Summary 3N
Procedure Note with
S5 Debridement and VAC 5000 N Discharge Summary 3N

DECOMPRESSION AND FUSION OF CERVICAL/ Admission note with

28300 relevant investigation result
THORACIC/LUMBAR VERTEBRA
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

DECOMPRESSION & STABILISATION WITH Admission note with

22550 relevant investigation result
MOSSMIAMI
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
DECOMPRESSION OF CARPAL TUNNEL SYNDROME 6000 Procedure Note with
S5 N Discharge Summary 1N
DQTS 4600 Procedure Note with
S5 N Discharge Summary 1N
DRAINAGE OF ABSCESS COLD 2300 Procedure Note with
S5 N Discharge Summary D N
ELBOW ARTHROSCOPY-ADHESIOLYSIS 16950 Procedure Note with
S5 N Discharge Summary 2N
 Admission note with
ELBOW ARTHROSCOPY-CAPITELLUM FIXATION 22700 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

Admission note with

ELBOW ARTHROSCOPY-TENNIS ELBOW RELEASE 18100 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N
EPIDURAL STEROID INJECTION 2875 Procedure Note with
S5 N Discharge Summary D N
EPIPHYSEAL STIMULATION 11275 Procedure Note with
S5 N Discharge Summary 2N
EXPLORATION & NERVE REPAIR 11200 Procedure Note with
S5 N Discharge Summary 2N

FRACTURE- FEMORAL NECK OPEN REDUCTION Admission note with

18000 relevant investigation result
&PINNING
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

FRACTURE FIXATION MIPPO 28375 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
FRACTURED FRAGMENT EXCISION 8475 Procedure Note with
S5 N Discharge Summary 2N

FRACTURE-FEMORAL NECK-MUA &INTERNAL Admission note with

28225 relevant investigation result
FIXATION
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

Admission note with

GCT CURRETAGE& CEMENT 22700 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
 Admission note with
GCT CURRETAGE&BG 20400 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

Admission note with

GIRDLE STONE ARTHROPLASTY 17000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

HIP ARTHROSCOPY LABRAL FIXATION 30000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

Admission note with

HIP REGION SURGERY 20175 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
Hip Spica 4600 Procedure Note with
S5 N Discharge Summary D N

Admission note with

ILIZAROV FIXATION - Deformity CORRECTION 28375 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

Admission note with

ILIZAROV FIXATION FOR NONUNION LONGBONES 28375 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
IMPLANT REMOVAL-any type of implants 6750 Procedure Note with
S5 N Discharge Summary 1N
INTERNAL FIXATION RADIAL EPICONDYLE 11200 Procedure Note with
S5 N Discharge Summary 3N
 Admission note with
INTERTROCHANTERIC FRACTURE FIXATION 22700 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
900 Procedure Note with
S5 INTRA articular STEROID INJECTION N Discharge Summary D N
INTRA LESIONAL STEROID INJECTION 800 Procedure Note with
S5 N Discharge Summary D N
JOINT RECONSTRUCTION 27000 Procedure Note with
S5 N Discharge Summary 5N
K-Wire Removal Procedure Note with
2000
S5 N Discharge Summary D N

Admission note with

LAMINECTOMY 21000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
LISFRANK FRACTURE SURGERY 8400 Procedure Note with
S5 N Discharge Summary 3N
LOOSE BODY ARTHROSCOPIC SURGERY 11425 Procedure Note with
S5 N Discharge Summary 1N
LOOSE BODY EXCISION/REMOVAL-OPEN 8550 Procedure Note with
S5 N Discharge Summary 2N
LOWER END RADIUS FRACTURE-ORIF 15725 Procedure Note with
S5 N Discharge Summary 3N

Admission note with

LRS (LIMB RECONSTRUCTION SURGERY) 28375 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

Admission note with

LUMBAR DISCECTOMY&FUSION 24000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
 MONOMALLEOLAR FRACTURE FIXATION 8475 Procedure Note with
S5 N Discharge Summary 2N
NAIL BED AVULSION 5000 Procedure Note with
S5 N Discharge Summary 1N
OLECRANON RECONSTRUCTION/FIXATION 13425 Procedure Note with
S5 N Discharge Summary 3N
OPEN MENISECTOMY 13650 Procedure Note with
S5 N Discharge Summary 3N
20,000
Admission note with
OPEN REDUCTION WITH PHEMISTER GRAFTING relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N
OSTEOCHONDROMA - FIBULA EXICISION 13350 Procedure Note with
S5 N Discharge Summary 2N
OSTEOCHONDROMA FEMUR - EXCISION 16725 Procedure Note with
S5 N Discharge Summary 2N
OSTEOCHONDROMA - HUMERUS EXCISION 16725 Procedure Note with
S5 N Discharge Summary 2N
OSTEOCHONDROMA - PATELLA – EXCISION 13350 Procedure Note with
S5 N Discharge Summary 2N
OSTEOCHONDROMA - RADIUS EXCISION 13350 Procedure Note with
S5 N Discharge Summary 2N
OSTEOCHONDROMA - TIBIA EXICISION 13350 Procedure Note with
S5 N Discharge Summary 2N
OSTEOCHONDROMA - ULNA EXCISION 13350 Procedure Note with
S5 N Discharge Summary 2N
10,000 Procedure Note with
OSTEOCHONDROMA SMALL BONES – EXCISION
S5 N Discharge Summary 2N

Admission note with

PELVIC Acetabular FRACTURE-FIXATION 30000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
 30,000
Admission note with
PELVIC OSTEOTOMY relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
PHALANX FRACTURE-Fixation 4225 Procedure Note with
S5 N Discharge Summary D N
1,000 Procedure Note with
S5 POP Cast wedging (Day care) N Discharge Summary D N
PREPATTELLAR BURSA AND REPAIR OF MCL OF Procedure Note with
17300
S5 KNEE N Discharge Summary 3N
PROXIMAL HUMERAL FRACTURE 16875 Procedure Note with
S5 N Discharge Summary 3N
RADIAL HEAD RECONSTRUCTION 17000 Procedure Note with
S5 N Discharge Summary 3N

Admission note with

RADIAL HEAD REPLACEMENT 30000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

RDP( Recurrent Dislocation Patella) OPEN Admission note with

17025 relevant investigation result
SURGERY
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

RECONSTRUCTION PLC 16875 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

RECONSTRUCTION MCL 16875 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N
 Admission note with
RECONSTRUCTION MPFL 20325 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

relevant investigation result
report including Procedure Note with
S5 RECONSTRUCTION OF ACL/ PCL with meniscal repai32,000 Y Radiological report Discharge Summary 5N
REDUCTION OF FACIAL FRACTURES OF MAXILLA 9700 Procedure Note with
S5 N Discharge Summary 2N
REDUCTION OF COMPOUND FRACTURES and Procedure Note with
20000
S5 External Fixature N Discharge Summary 3N
REDUCTION OF FRACTURES OF MANDIBLE &
MAXILLA- EYE LEFT SPLINTING 13000 Procedure Note with
S5 N Discharge Summary 3N
REDUCTION OF FRACTURES OF MANDIBLE &
MAXILLA- GUMMING SPLINTS 13000 Procedure Note with
S5 N Discharge Summary 3N
REDUCTION OF FRACTURES OF MANDIBLE &
MAXILLA-CAST NETAL SPLINTS 13000 Procedure Note with
S5 N Discharge Summary 3N
RETROCALCANEAL BURSA- EXCISION 11200 Procedure Note with
S5 N Discharge Summary 3N
SCAPHOID FRACTURE-Internal fixation 13425 Procedure Note with
S5 N Discharge Summary 2N
SCAPULA FRACTURE-FIXATION 11125 Procedure Note with
S5 N Discharge Summary 2N

Admission note with

relevant investigation result
report including Procedure Note with
S5 Scoliosis Correction Surgery 160000 Y Radiological report Discharge Summary 7Y

Admission note with

SHOULDER ARTHROSCOPY - BANKARTS REPAIR 28450 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N
 Admission note with
relevant investigation result
report including Procedure Note with
S5 SHOULDER ARTHROSCOPY - BANKARTS REPAIR with38200 Y Radiological report Discharge Summary 5N

Admission note with

SHOULDER ARTHROSCOPY-ACJ RECONSTRUCTION 27300 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 5N

Admission note with

SHOULDER ARTHROSCOPY-ADHESIOLYSIS PAS 11200 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

Admission note with

SHOULDER ARTHROSCOPY-BICEPS TENODESIS 13500 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

SHOULDER ARTHROSCOPY-CALCIFIC TENDINITIS Admission note with

16950 relevant investigation result
DECOMPRESSION
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

SHOULDER ARTHROSCOPY-CAPSULAR SHIFT 20400 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

SHOULDER ARTHROSCOPY-LATERAL END Admission note with

13500 relevant investigation result
CLAVICLE EXCISION
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

SHOULDER ARTHROSCOPY-LATERJET PROCEDURE 30000 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N
 SHOULDER ARTHROSCOPY-LOOSE BODY Admission note with
13500 relevant investigation result
REMOVAL
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

Admission note with

SHOULDER ARTHROSCOPY-REMPLISSAGE 13500 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

SHOULDER ARTHROSCOPY-ROTATOR CUFF SSP ISP 28450 Admission note with

REPAIR relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

SHOULDER ARTHROSCOPY-ROTATOR CUFF Admission note with

22700 relevant investigation result
SUPRASPINATUS REPAIR
report including Procedure Note with
S5 Y Radiological report Discharge Summary 3N

Admission note with

SHOULDER ARTHROSCOPY-SLAP REPAIR 16950 relevant investigation result
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

SHOULDER ARTHROSCOPY-SUBACROMIAL Admission note with

11200 relevant investigation result
DECOMPRESSION
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N

SHOULDER ARTHROSCOPY-SUPRASCAPULAR Admission note with

15800 relevant investigation result
NERVE DECOMPRESSION
report including Procedure Note with
S5 Y Radiological report Discharge Summary 2N
SHOULDER JACKET 5750 Procedure Note with
S5 N Discharge Summary D N
SINUS OVER SACRUM EXCISION 8475 Procedure Note with
S5 N Discharge Summary 1N
 SKIN GRAFTING 8475 Procedure Note with
S5 N Discharge Summary 1N
SUPRACONDYLAR FRACTURE PAEDIATRIC-Internal 12000 Procedure Note with
S5 fixation N Discharge Summary 2N
SUPRACONDYLARINTERCONDYLAR FRACTURE- Procedure Note with
17000
S5 ADULT-Internal Fixation N Discharge Summary 2N
SYNOVECTOMY 20175 Procedure Note with
S5 N Discharge Summary 3N
SYNOVIAL CYST- EXCISION 8550 Procedure Note with
S5 N Discharge Summary 2N
TENDO ACHILLES REPAIR 11350 Procedure Note with
S5 N Discharge Summary 2N
5,000 Procedure Note with
TENDON RELEASE
S5 N Discharge Summary D N
TENDON REPAIR MULTIPLE- single tendon with Procedure Note with
9050
S5 multiple muscle involvement N Discharge Summary 1N
TENDON REPAIR SINGLE -single tendon with Procedure Note with
6825
S5 single muscle involvement N Discharge Summary 1N
TENDON SURGERY OF FOOT 2225 Procedure Note with
S5 N Discharge Summary 1N
TENOLYSIS 9050 Procedure Note with
S5 N Discharge Summary 2N
TENOTOMY 9050 Procedure Note with
S5 N Discharge Summary 2N
TENSION BAND WIRING OLECRANON 14150 Procedure Note with
S5 N Discharge Summary 2N
TRIGGER THUMB& TRIGGER FINGER 2875 Procedure Note with
S5 N Discharge Summary D N
TRU CUT BIOPSY BONE TUMOR 5000 Procedure Note with
S5 N Discharge Summary 1N
TUBEROSITY AVULSION HUMEROUS 11125 Procedure Note with
S5 N Discharge Summary 1N
 Procedure Note with
S5 Tumour of bone - Prophylactic fixation 15000 N Discharge Summary 3N
WOUND DEBRIDIMENT 1150 Procedure Note with
S5 N Discharge Summary D N
 Capped amount
(pacakge cannot
Medical be used more Reserved
(M) or than the for Trust
Surgical mentioned Payment
(S) monetary limit) (Y/N)

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
 N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N
s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N

s N
s N

s N
 Poly Trauma

Preaut Average Govt

Spe h length of Reser
cial Requir Stay ved
ty ed or (Includin Proce
cod Packag Package Not Mandatory investigations for pre- Post-Op investigations for claims g Days in dure
e e Code Package name Amount (Y/N) auth submission ICU (Y/N)

Admission note with relevant

investigation result report
Nerve Plexus injuries, Tendon injury including Nerve conduction Procedure Note with Discharge
S6 00001 repair/reconstruction/ Transfer 50,000 Y velocity (NCV) study Summary 5-10 days N

Admission note with relevant

investigation result report
Plexus injury along with Vascular injury including Nerve conduction Procedure Note with Discharge
S6 00002 repair/ graft 60,000 Y velocity (NCV) and doppler study Summary,Post-op. Doppler study 5-10 days N

Admission note with relevant Procedure Note with Discharge

Internal fixation with Flap cover Surgery for investigation result report Summary including Post operative
S6 00003 wound in compound fracture 40,000 Y including radiological report radiological report 5-10 days N

Admission note with relevant Procedure Note with Discharge

Head injury requiring Facio-Maxillary Injury investigation result report Summary including Post operative
S6 00004 repairs & fixations (including implants) 35,000 Y including radiological report radiological report 5-10 days N

Admission note with relevant Procedure Note with Discharge

investigation result report Summary including Post operative
S6 00005 Internal fixation of Pelviacetabular fracture 40,000 Y including radiological report radiological report 5-10 days N

Craniotomy and evacuation of Haematoma Admission note with relevant Procedure Note with Discharge
– subdural/Extra dural along with fixation of investigation result report Summary including Post operative
S6 00006 fracture of single long bone 60,000 Y including radiological report radiological report 5-10 days N
 Craniotomy and evacuation of Haematoma Admission note with relevant Procedure Note with Discharge
– subdural/Extra dural along with fixation of investigation result report Summary including Post operative
S6 00007 fracture of 2 or more long bone. 75,000 Y including radiological report radiological report 5-10 days N

Admission note with relevant

Visceral injury requiring surgical investigation result report Procedure Note with Discharge
intervention along with fixation of fracture including radiological report and Summary including Post operative
S6 00008 of single long bone. 30,000 Y USG radiological report 5-10 days N

Admission note with relevant

Visceral injury requiring surgical investigation result report Procedure Note with Discharge
intervention along with fixation of fracture including radiological report and Summary including Post operative
S6 00009 of 2 or more long bones. 45,000 Y USG radiological report 5-10 days N

Admission note with relevant Procedure Note with Discharge

Chest injury with one fracture of long bone investigation result report Summary including Post operative
S6 00010 (with implants) 35,000 Y including radiological report radiological report 5-10 days N

Admission note with relevant Procedure Note with Discharge

Chest injury with fracture of 2 or more long investigation result report Summary including Post operative
S6 00011 bones 45,000 Y including radiological report radiological report 5-10 days N

Admission note with relevant

Emergency tendons repair ± Peripheral investigation result report/ Nerve Procedure Note with Discharge
S6 00012 Nerve repair/ reconstructive surgery 30,000 Y conduction velocity (NCV) study Summary 5-10 days N
 Capped amount
(pacakge cannot
Medica be used more Reserved
l (M) or than the for Trust
Surgical mentioned Payment
(S) monetary limit) (Y/N)

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N
 Urology
Post-Op
investigations for
claims submission

Packag
e Code
Preaut Average Govt
h length of Reser
Requir Stay ved
Spec ed or (Includin Proce
ialty Package Not g Days in dure
code Package name Amount (Y/N) Mandatory investigations for pre-auth ICU) (Y/N)
Procedure Note
Admission note with relevant with Discharge
00001 investigation result report including Summary
S7 Adrenalectomy-unilateral, open 25000 Y CT/MRI/USG 5 N
Procedure Note
Admission note with relevant with Discharge
00002 investigation result report including Summary
S7 Adrenalectomy-unilateral, Laparoscopic 30000 Y CT/MRI/USG 2 N
Procedure Note
Admission note with relevant with Discharge
00003 investigation result report including Summary
S7 Adrenalectomy-bilateral, open 32000 Y CT/MRI/USG 5 N
Procedure Note
Admission note with relevant with Discharge
00004 investigation result report including Summary
S7 Adrenalectomy-biilateral, Laparoscopic 40000 Y CT/MRI/USG 2 N
Procedure Note
Admission note with relevant with Discharge
00005 investigation result report including Summary
S7 Paraganglioma excision with liver mobilization 50000 Y CT/MRI/USG 5 N
Procedure Note
Admission note with relevant with Discharge
00006 investigation result report including Summary
S7 Nephrectomy (Benign) Open 30000 Y CT/MRI/ USG/KUB/Urography 5 N
 Procedure Note
Admission note with relevant with Discharge
00007 investigation result report including Summary
S7 Nephrectomy (Benign) Laparoscopic 35000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00008 investigation result report including Summary
S7 Nephrectomy-Radical (Renal tumor) Open 35000 Y CT/MRI/ USG/KUB/Urography/HP 5 N
Procedure Note
Admission note with relevant with Discharge
00009 investigation result report including Summary
S7 Nephrectomy-Radical (Renal tumor) Laparoscopic 40000 Y CT/MRI/ USG/KUB/Urography/HP 2 N
Procedure Note
Admission note with relevant with Discharge
00010 investigation result report including Summary
S7 Nephrectomy-Partial or Hemi, Open 25000 Y CT/MRI/ USG/KUB/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00011 investigation result report including Summary
S7 Nephrectomy-Partial or Hemi, Laparoscopic 30000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00012 investigation result report including Summary
S7 Nephro ureterectomy (Benign) Open 31000 Y CT/MRI/ USG/KUB/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00013 investigation result report including Summary
S7 Nephro ureterectomy (Benign) Laparoscopic 36000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00014 investigation result report including Summary
S7 Nephro ureterectomy with cuff of bladder Open 35000 Y CT/MRI/ USG/KUB/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00015 Nephro ureterectomy with cuff of bladder investigation result report including Summary
S7 Laparoscopic 40000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00016 Pyeloplasty/pyeloureterostomy/pyelopyelostomy investigation result report including Summary
S7 Open 25000 Y CT/MRI/ USG/KUB/Urography 3 N
 Procedure Note
Admission note with relevant with Discharge
00017 Pyeloplasty/pyeloureterostomy/pyelopyelostomy investigation result report including Summary
S7 Laparoscopic 30000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00018 investigation result report including Summary
S7 Endopyelotomy (retrograde with laser/bugbee) 25000 Y CT/MRI/ USG/KUB/Urography 1 N
Procedure Note
Admission note with relevant with Discharge
00019 investigation result report including Summary
S7 Endopyelotomy (antegrade with laser/bugbee) 28000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00020 investigation result report including Summary
S7 Ureterocalycostomy Open 25000 Y CT/MRI/ USG/KUB/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00021 investigation result report including Summary
S7 Ureterocalycostomy Laparoscopic 30000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00022 investigation result report including Summary
S7 Uretero-ureterostomy Open 25000 Y CT/MRI/ USG/KUB/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
00023 investigation result report including Summary
S7 Uretero-ureterostomy Laparoscopic 35000 Y CT/MRI/ USG/KUB/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00024 investigation result report including Summary
S7 PCNL (Percutaneous Nephrolithotomy) - Bilateral 40000 Y CT/MRI/ USG/KUB/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
00025 investigation result report including Summary
S7 PCNL (Percutaneous Nephrolithotomy) - Unilateral 25000 Y CT/MRI/ USG/KUB/Urography 3 N
Procedure Note
with Discharge D (up to
00026 Extracoporeal shock-wave Lithotripsy (ESWL) 3
Summary
S7 stone, with or without stent (one side) 13000 N sittings) N
 Procedure Note
with Discharge D (up to
00027 Extracoporeal shock-wave Lithotripsy (ESWL) 3
Summary
S7 stone, with or without stent (both sides) 22750 N sittings) N
Procedure Note
Admission note with relevant with Discharge
00028 investigation result report including CT/ Summary
S7 Pyelolithotomy-Open 20000 Y USG/KUB/IVP 3 N
Procedure Note
Admission note with relevant with Discharge
00029 investigation result report including CT/ Summary
S7 Pyelolithotomy-Laparoscopic 30000 Y USG/KUB/IVP 2 N
Procedure Note
Admission note with relevant with Discharge
00030 investigation result report including CT/ Summary
S7 Nephrolithotomy-Open 20000 Y USG/KUB/IVP 3 N
Procedure Note
Admission note with relevant with Discharge
00031 investigation result report including CT/ Summary
S7 Anatrophic nephrolithotomy 30000 Y USG/KUB/IVP 5 N
Procedure Note
00032 with Discharge
Summary
S7 Perinephric Abscess drainage (percutaneous) 10000 N 2 N
Procedure Note
00033 with Discharge
Summary
S7 Perinephric Abscess drainage (Open) 20000 N 3 N
Procedure Note
Admission note with relevant with Discharge
00034 investigation result report including Summary
S7 Renal Cyst deroofing or marsupialization-Open 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00035 Renal Cyst deroofing or marsupialization- investigation result report including Summary
S7 Laparoscopic 30000 Y radiological/USG report 3 N
Procedure Note
00036 with Discharge
Summary
S7 Nephrostomy-percutaneous ultrasound guided 11925 N D N
 Procedure Note
Admission note with relevant with Discharge
00037 investigation result report including Summary
S7 Ureterolithotomy-Open 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00038 investigation result report including Summary
S7 Ureterolithotomy-Laparoscopic 30000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00039 Ureteroscopy+stone removal with lithotripsy, investigation result report including Summary
S7 lower ureter, unilateral 20000 Y radiological/USG report 1 N
Procedure Note
Admission note with relevant with Discharge
00040 Ureteroscopy+stone removal with lithotripsy, investigation result report including Summary
S7 upper ureter, unilateral 25000 Y radiological/USG report 1 N
Procedure Note
Admission note with relevant with Discharge
00041 Ureteroscopy+stone removal with lithotripsy, investigation result report including Summary
S7 bilateral 30000 Y radiological/USG report 1 N
Procedure Note
Admission note with relevant with Discharge
00042 investigation result report including Summary
S7 Ureterotomy (Cutaneous) 20000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00043 investigation result report including Summary
S7 Endoureterotomy (laser/bugbee) 20000 Y radiological/USG report 1 N
Procedure Note
Admission note with relevant with Discharge
00044 investigation result report including Summary
S7 Ureteric reimplantation-unilateral-open 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00045 investigation result report including Summary
S7 Ureteric reimplantation-bilateral-open 25000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00046 investigation result report including Summary
S7 Ureteric reimplantation-unilateral-Laparoscopic 30000 Y radiological/USG report 2 N
 Procedure Note
Admission note with relevant with Discharge
00047 investigation result report including Summary
S7 Ureteric reimplantation-bilateral-Laparoscopic 35000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00048 investigation result report including Summary
S7 Uretero-vaginal/uterine fistula repair open 27000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00049 investigation result report including Summary
S7 Uretero-vaginal/uterine fistula repair Laparoscopic 37000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00050 Ureterolysis-open, for retroperitoneal fibrosis investigation result report including Summary
S7 (with or without omental wrapping) 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00051 Ureterolysis-Laparoscopic, for retroperitoneal investigation result report including Summary
S7 fibrosis (with or without omental wrapping) 30000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00052 investigation result report including Summary
S7 Boari flap for ureteric stricture, open 30000 Y radiological/USG report/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
00053 investigation result report including Summary
S7 Boari flap for ureteric stricture, Laparoscopic 40000 Y radiological/USG report/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00054 investigation result report including Summary
S7 Ileal replacement for ureteric stricture 40000 Y radiological/USG report/Urography 5 N
Procedure Note
00055 DJ stent unilateral including cystoscopy, ureteric with Discharge
Summary
S7 catheterization, retrograde pyelogram 10000 N D N
Procedure Note
00056 DJ stent bilateral including cystoscopy, ureteric with Discharge
Summary
S7 catheterization, retrograde pyelogram 12000 N D N
 Procedure Note
00057 Ureteric sampling including cystoscopy, ureteric with Discharge
Summary
S7 catheterization, retrograde pyelogram 10,000 N D N
Procedure Note
00058 Ureterocele incision including cystoscopy, ureteric with Discharge
Summary
S7 catheterization, retrograde pyelogram 15000 N 1 N
Procedure Note
00059 with Discharge
Summary
S7 Urachal Cyst excision -open 15000 N 2 N
Procedure Note
00060 with Discharge
Summary
S7 Cystolithotomy-open, including cystoscopy 15000 N 2 N
Procedure Note
00061 Cystolithotripsy/Urethral Stone endoscopic, with Discharge
Summary
S7 including cystoscopy 15000 N 1 N
Procedure Note
Admission note with relevant with Discharge
00062 TURBT (Transurethral Resection of the Bladder investigation result report including Summary
S7 Tumor) 25000 Y radiological/USG report/HP 2 N
Procedure Note
Admission note with relevant with Discharge
00063 TUR-fulgration (Transurethral fulgration of the investigation result report including Summary
S7 Bladder Tumor) 18000 Y radiological/USG report/HP 2 N
Procedure Note
00064 Intravesical BCG/Mitomycin 6 induction cycles with Discharge
Summary
S7 (weekly for 6 weeks-total cost of 6 cycles) 12000 N D N
Procedure Note
Admission note with relevant with Discharge
00065 Intravesical BCG/Mitomycin maintenance for 12 investigation result report including Summary
S7 doses (total cost of 12 doses) 24000 Y radiological/USG report D N
Procedure Note
00066 Post TURBT - Check Cystoscopy (Per sitting) with with Discharge
Summary
S7 or without cold-cup biopsy 10000 N D N
 Procedure Note
00067 with Discharge
Summary
S7 Diagnostic Cystoscopy 5000 N D N
Procedure Note
00068 with Discharge
Summary
S7 Bladder Neck incision-endoscopic 15000 N 1 N
Procedure Note
Admission note with relevant with Discharge
00069 Extrophy Bladder repair including osteotomy if investigation result report including Summary
S7 needed + epispadias repair + ureteric reimplant 50000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00070 Bladder injury repair (as an independent investigation result report including Summary
S7 procedure with or without urethral injury) 20000 Y radiological/USG report/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
00071 Bladder injury repair (only to be used if done as a investigation result report including Summary
S7 part of ongoing laparotomy/other surgery) 10000 Y radiological/USG report/Urography 2 N
Procedure Note
Bladder injury repair with colostomy (as an Admission note with relevant with Discharge
00072 independent procedure with or without urethral investigation result report including Summary
S7 injury) 25000 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00073 investigation result report including Summary
S7 Partial Cystectomy-open 20000 Y radiological/USG report/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
00074 investigation result report including Summary
S7 Partial Cystectomy-Laparoscopic 30000 Y radiological/USG report/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
00075 investigation result report including Summary
S7 Radical cystectomy with neobladder-open 50000 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00076 investigation result report including Summary
S7 Radical cystectomy with continent diversion-open 50000 Y radiological/USG report/Urography 5 N
 Procedure Note
Admission note with relevant with Discharge
00077 investigation result report including Summary
S7 Radical Cystectomy with Ileal Conduit-open 50000 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00078 investigation result report including Summary
S7 Radical Cystectomy with ureterostomy-open 35000 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00079 Radical Cystectomy with ureterosigmoidostomy- investigation result report including Summary
S7 open 35000 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00080 investigation result report including Summary
S7 Other Cystectomies 30000 Y radiological/USG report/Urography 2 N
Procedure Note
00081 Suprapubic Cystostomy - Open, as an independent with Discharge
Summary
S7 procedure 10000 N D N
Procedure Note
00082 with Discharge
Summary
S7 Suprapubic Drainage - Closed/Trocar 5000 N D N
Procedure Note
Admission note with relevant with Discharge
00083 investigation result report including Summary
S7 VVF/Uterovaginal Repair - Transvaginal approach 25000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00084 investigation result report including Summary
S7 VVF/Uterovaginal Repair - Abdominal,Open 25000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00085 VVF/Uterovaginal Repair - Abdominal, investigation result report including Summary
S7 Laparoscopic 30000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00087 investigation result report including Summary
S7 Urethrovaginal fistula repair 30000 Y radiological/USG report/IVP 3 N
 Procedure Note
Admission note with relevant with Discharge
00088 Y V Plasty of Bladder Neck/Bladder Neck investigation result report including Summary
S7 Reconstruction 20000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00089 investigation result report including Summary
S7 Augmentation cystoplasty-open 30000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00090 investigation result report including Summary
S7 Augmentation cystoplasty-Laparoscopic 40000 Y radiological/USG report/Urography 2 N
Procedure Note
Admission note with relevant with Discharge
00091 Open bladder diverticulectomy with/without investigation result report including Summary
S7 ureteric re-implantation 25000 Y radiological/USG report/IVP 3 N
Procedure Note
Admission note with relevant with Discharge
00092 investigation result report including Summary
S7 Open simple prostatetctomy for BPH 25000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00093 TURP-Transurethral Resection of the Prostate, investigation result report including Summary
S7 BPH, Monopolar/Bipolar/Laser 25000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00094 investigation result report including Summary
S7 Holmium Laser Prostatectomy 40000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00095 investigation result report including Summary
S7 TURP/Laser + Circumcision 26000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00096 investigation result report including Summary
S7 TURP/Laser + Cystolithotripsy 35000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00097 investigation result report including Summary
S7 TURP/Laser + Cystolithotomy-open 32000 Y radiological/USG report 2 N
 Procedure Note
Admission note with relevant with Discharge
00098 investigation result report including Summary
S7 TURP/Laser + Orchidectomy 28000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00099 investigation result report including Summary
S7 TURP/Laser + TURBT 30000 Y radiological/USG report/HP 2 N
Procedure Note
Admission note with relevant with Discharge
00100 investigation result report including Summary
S7 TURP/Laser + URS with stone removal 31000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00101 investigation result report including Summary
S7 TURP/Laser + VIU (visual internal Ureterotomy) 30000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00102 investigation result report including Summary
S7 TURP/Laser + Hydrocele surgery 28000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00103 investigation result report including Summary
S7 TURP/Laser + Hernioplasty 30000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00104 investigation result report including Summary
S7 TURP/Laser + Urethral dilatation-non endoscopic 26000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00105 investigation result report including Summary
S7 TURP/Laser + Urethral dilatation-endoscopic 27500 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00106 investigation result report including Summary
S7 Radical prostatectomy - open 50000 Y radiological/USG report/HP 5 N
Procedure Note
Admission note with relevant with Discharge
00107 investigation result report including Summary
S7 Radical prostatectomy - laparoscopic 70000 Y radiological/USG report/HP 2 N
 Procedure Note
00108 Transrectal Ultrasound guided prostate biopsy with Discharge
Summary
S7 (minimum 12 core) 10000 N 1 N
Procedure Note
00109 with Discharge
Summary
S7 Reduction of Paraphimosis 2000 N D N
Procedure Note
00110 with Discharge
Summary
S7 Excision of Urethral Caruncle 6000 N 1 N
Procedure Note
00111 with Discharge
Summary
S7 Meatoplasty 3500 N 1 N
Procedure Note
00112 with Discharge
Summary
S7 Meatotomy 3500 N 1 N
Procedure Note
00113 with Discharge
Summary
S7 Post Urethral Valve fulguration 10275 N 1 N
Procedure Note
Admission note with relevant with Discharge
00114 investigation result report including Summary
S7 Urethroplasty-End to end 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
00115 investigation result report including Summary
S7 Urethroplasty-Substitution-single stage 30000 Y radiological/USG report/RGU 3 N
Procedure Note
Admission note with relevant with Discharge
00116 investigation result report including Summary
S7 Urethroplasty-Substitution-two stage 35000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00117 investigation result report including Summary
S7 Urethroplasty-Transpubic 30000 Y radiological/USG report/RGU 5 N
 Procedure Note
Admission note with relevant with Discharge
00118 investigation result report including Summary
S7 Urethroplasty-two stage without substitution 30000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
00119 investigation result report including Summary
S7 Perineal Urethrostomy without closure 20000 Y radiological/USG report 2 N
Procedure Note
Admission note with relevant with Discharge
00120 investigation result report including Summary
S7 Urethrorectal fistula repair 40000 Y radiological/USG report 5 N
Procedure Note
00121 Urethral Dilatation-non endocopic as an with Discharge
Summary
S7 independent procedure 2000 N D N
Procedure Note
00122 Urethral Dilatation-endocopic as an independent with Discharge
Summary
S7 procedure 5000 N D N
Procedure Note
00123 Internal Ureterotomy including cystoscopy as an with Discharge
Summary
S7 independent procedure 10000 N 1 N
Procedure Note
Admission note with relevant with Discharge
00124 investigation result report including Summary
S7 Hypospadias repair-single stage 20000 Y radiological/USG report/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
00125 investigation result report including Summary
S7 Hypospadias repair-two or more stage 30000 Y radiological/USG report/Urography 3 N
Procedure Note
00126 with Discharge
Summary
S7 Orchiopexy-without laparoscopy, unilateral 10000 N 2 N
Procedure Note
00127 with Discharge
Summary
S7 Orchiopexy-without laparoscopy, bilateral 15000 N 2 N
 Procedure Note
00128 with Discharge
Admission note with relevant Summary
S7 Orchiopexy-with laparoscopy, unilateral 20000 Y investigation result report 2 N
Procedure Note
00129 with Discharge
Admission note with relevant Summary
S7 Orchiopexy-with laparoscopy, bilateral 25000 Y investigation result report 2 N
Procedure Note
Admission note with relevant with Discharge
00130 investigation result report including Summary
S7 Stress incontinence surgery, open 20000 Y radiological/USG report/Urography 4 N
Procedure Note
Admission note with relevant with Discharge
00131 investigation result report including Summary
S7 Stress incontinence surgery, laparoscopic 30000 Y radiological/USG report/Urography 4 N
Procedure Note
Admission note with relevant with Discharge
00132 investigation result report including Summary
S7 Stress incontinence surgery with slings 35000 Y radiological/USG report/Urography 3 N
Procedure Note
00133 with Discharge
Admission note with relevant Summary
S7 Partial Penectomy 15000 Y investigation result report 2 N
Procedure Note
00134 with Discharge
Admission note with relevant Summary
S7 Total Penectomy + Perineal Urethrostomy 20000 Y investigation result report 2 N
Procedure Note
00135 with Discharge
Admission note with relevant Summary
S7 Ilio-Inguinal lymphadenectomy-unilateral 15000 Y investigation result report 3 N
Procedure Note
00136 with Discharge
Admission note with relevant Summary
S7 Ilio-Inguinal lymphadenectomy-bilateral 25000 Y investigation result report 3 N
Procedure Note
Admission note with relevant with Discharge
00137 Pelvic lymphadenectomy open, after prior cancer investigation result report including Summary
S7 surgery 25000 Y radiological/USG report 3 N
 Procedure Note
Admission note with relevant with Discharge
00138 Pelvic lymphadenectomy laparoscopic, after prior investigation result report including Summary
S7 cancer surgery 30000 Y radiological/USG report 3 N
Procedure Note
00139 with Discharge
Summary
S7 Orchiectomy-High inguinal 12000 N 2 N
Procedure Note
00140 with Discharge
Summary
Orchiectomy-simple 10,000 N 2 N
Procedure Note
00142 with Discharge
Admission note with relevant Summary
S7 Retroperitoneal lymph node dissection-open 25000 Y investigation result report 3 N
Procedure Note
00143 Retroperitoneal lymph node dissection- with Discharge
Admission note with relevant Summary
S7 Laparoscopic 35000 Y investigation result report 2 N
Procedure Note
00148 with Discharge
Summary
S7 Varicocele-unilateral-non microsurgical 10000 N 1 N
Procedure Note
00149 with Discharge
Admission note with relevant Summary
S7 Varicocele-unilateral-microsurgical 12000 Y investigation result report 1 N
Procedure Note
00150 with Discharge
Summary
S7 Varicocele-bilateral-non microsurgical 15000 N 1 N
Procedure Note
00151 with Discharge
Admission note with relevant Summary
S7 Varicocele-bilateral-microsurgical 20000 Y investigation result report 1 N
Procedure Note
00152 Penile prosthesis insertion, Malleable (Indian with Discharge
Admission note with relevant Summary
S7 implant) 30000 Y investigation result report 3 N
 Procedure Note
00153 with Discharge
Summary
S7 Priapism-aspiration/shunt 15000 N 2 N
Procedure Note
with Discharge
Summary
00154 Neurogenic bladder-Package for
evaluation/investigation (catheter + ultrasound +
culture + RGU/ MCU) for 1 month (medicines -
S7 antibiotics). Follow up visit once in 3 months 7500 N D N
Procedure Note
with Discharge
Summary
00155 Chronic prostatitis-Package for
evaluation/investigation (ultrasound + culture +
prostate massage) for 1 month (medicines). Follow
S7 up visit once in 3 months 2500 N D N
Procedure Note
with Discharge
00156 Emergency management of Ureteric stone - Summary
Package for evaluation/investigation (ultrasound +
S7 culture) for 3 weeks (medicines). 3500 N D N
Procedure Note
00157 with Discharge
Summary
S7 Emergency management of Hematuria 750 N D N
Procedure Note
00158 Emergency management of Acute retention of with Discharge
Summary
S7 Urine 750 N D N
Procedure Note
00159 Acute management of upper urinary tract trauma with Discharge
Summary
S7 – conservative 750 N D N
Procedure Note
Admission note with relevant with Discharge
00160 investigation result report including Summary
S7 Urinary tract trauma – open surgery (exploratory) 20000 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
00161 investigation result report including Summary
S7 Urinary tract trauma – Laparoscopy surgery 30000 Y radiological/USG report/Urography 5 N
 Procedure Note
Admission note with relevant with Discharge
ANDERSON HYNES PYELOPLASTY 15000 investigation result report including Summary
S7 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
BILATERAL NEPHROURETECTOMY (NATIVE) 20000 investigation result report including Summary
S7 Y radiological/USG report 3 N
Procedure Note
BIOPSY OF BLADDER (CYSTOSCOPIC) 6000 with Discharge
Summary
S7 N 1 N
Procedure Note
Bladder Tumour (Fulguration) with Discharge
Summary
S7 5000 N 1 N
Procedure Note
CAECO CYSTOPLASTY 12000 with Discharge
Summary
S7 N 3 N
Procedure Note
CIRCUMCISION -medically indicated 2950 with Discharge
Summary
S7 N D N
Procedure Note
CLOSURE OF URETHRAL FISTULA 10000 with Discharge
Summary
S7 N 2 N
Procedure Note
Correction of Exstrophy of Bladder with Discharge
Admission note with relevant Summary
S7 20000 Y investigation result report 3 N
Procedure Note
Admission note with relevant with Discharge
Cysto Gastrostomy investigation result report including Summary
S7 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
Cysto Jejunostomy investigation result report including Summary
S7 20000 Y radiological/USG report 3 N
 Procedure Note
Cystolitholapaxy with Discharge
Summary
S7 10000 N 3 N
Procedure Note
Admission note with relevant with Discharge
CYSTOPLASTY 20000 investigation result report including Summary
S7 Y radiological/USG report 3 N
Procedure Note
DILATATION OF STRICTURE URETHRA UNDER G.A. 3000 with Discharge
Summary
S7 N D N
Procedure Note
DIVERTICULECTOMY 18000 with Discharge
Summary
S7 N 3 N
Procedure Note
Dormia Extraction of Calculus with Discharge
Summary
S7 7000 N 1 N
S7 Drainage of Perinepheric Abscess 10000 N N
Procedure Note
ENDOSCOPIC TEFLON INJECT 4000 with Discharge
Summary
S7 N D N
Procedure Note
EPIDIDYMECTOMY 8500 with Discharge
Summary
S7 N 2 N
Procedure Note
Exploration of Epididymis (Unsuccesful Vaso with Discharge
vasostomy) Summary
S7 8475 N 2 N
Procedure Note
EXPLORATORY SCROTOTOMY 6200 with Discharge
Summary
S7 N 2 N
Procedure Note
Hypospadias Repair and Orchiopexy with Discharge
Summary
S7 18300 N N
 Procedure Note
Admission note with relevant with Discharge
Internal Urethrotomy investigation result report including Summary
S7 10000 radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
LAPROSCOPIC OPERATION FOR VARICOCELE 14500 investigation result report including Summary
S7 radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
Lithotripsy investigation result report including Summary
S7 12500 radiological/USG report 2 N
Nephropexy Procedure Note
Admission note with relevant with Discharge
investigation result report including Summary
S7 15000 radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
Open Resection of Bladder Neck investigation result report including Summary
S7 12000 radiological/USG report/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
Operation for Cyst of Kidney investigation result report including Summary
S7 15000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
Operation for Double Ureter investigation result report including Summary
S7 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
Operation for ectopic ureter investigation result report including Summary
S7 20000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
OPERATIONS FOR HYDRONEPHROSIS 16000 investigation result report including Summary
S7 Y radiological/USG report 3 N
Procedure Note
PALOMO’S BILATERAL 10000 with Discharge
Admission note with relevant Summary
S7 investigation result report 3 N
 Procedure Note
PALOMO’S UNILATERAL 6000 with Discharge
Admission note with relevant Summary
S7 investigation result report 3 N
Procedure Note
Admission note with relevant with Discharge
Retroperitoneal Fibrosis investigation result report including Summary
S7 29800 Y radiological/USG report 5 N
Procedure Note
RETROPERITONEOSCOPIC OPERATION FOR Admission note with relevant with Discharge
25000 investigation result report including
HYDERONEPHROSIS Summary
S7 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
RETROPERITONEOSCOPIC PYELOLITHOTOMY 25200 investigation result report including Summary
S7 Y radiological/USG report/Urography 5 N
Procedure Note
RETROPERITONEOSCOPIC SURGERY FOR RENAL Admission note with relevant with Discharge
19700 investigation result report including
CYST Summary
S7 Y radiological/USG report/Urography 3 N
Procedure Note
Admission note with relevant with Discharge
RETROPERITONEOSCOPIC URETEROLITHOTOMY 25000 investigation result report including Summary
S7 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
RETROPERITONEOSCOPY NEPHRECTOMY 35000 investigation result report including Summary
S7 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
RETROPERITONEOSCOPY PARTIAL NEPHRECTOMY 30000 investigation result report including Summary
S7 Y radiological/USG report/Urography 5 N
Procedure Note
Admission note with relevant with Discharge
Retropubic Prostatectomy investigation result report including Summary
S7 16950 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
Stricture Urethra investigation result report including Summary
S7 9000 radiological/Urography 1 N
 Procedure Note
TESTICULAR BIOPSY 4000 with Discharge
Admission note with relevant Summary
S7 investigation result report D N
Procedure Note
Admission note with relevant with Discharge
Trans Vesical Prostatectomy investigation result report including Summary
S7 18000 radiological/USG report 3 N
Procedure Note
Transurethral Fulguration with Discharge
Admission note with relevant Summary
S7 5000 investigation result report 1 N
Procedure Note
Admission note with relevant with Discharge
TURP + Fissurectomy investigation result report including Summary
S7 28000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
TURP + Fistulectomy investigation result report including Summary
S7 28000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
TURP + Haemorrhoidectomy investigation result report including Summary
S7 30000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
TURP + Herniorraphy investigation result report including Summary
S7 30000 Y radiological/USG report N
Procedure Note
Admission note with relevant with Discharge
TURP + Nephrectomy investigation result report including Summary
S7 35000 Y radiological/USG report 5 N
Procedure Note
Admission note with relevant with Discharge
TURP + Urethrolithotomy investigation result report including Summary
S7 30000 Y radiological/USG report 3 N
Procedure Note
Admission note with relevant with Discharge
TURP + URS investigation result report including Summary
S7 27000 Y radiological/USG report N
 TURP/Laser + Orchidectomy Procedure Note
Admission note with relevant with Discharge
investigation result report including Summary
S7 27500 Y radiological/USG report N
Procedure Note
URETERIC CATHETERISATION 1700 with Discharge
Summary
S7 N D N
Procedure Note
Admission note with relevant with Discharge
URETERO-COLIC ANASTOMOSIS 20000 investigation result report including Summary
S7 Y radiological/USG report 3 N
Procedure Note
URS Extraction of Stone - Bilateral with Discharge
Summary
S7 17025 N 2 N
Procedure Note
URS Extraction of Stone - Unilateral with Discharge
Summary
S7 11850 N 2 N
Procedure Note
URS extraction with DJ stenting-Bilateral with Discharge
Summary
S7 18500 N 2 N
Procedure Note
URS extraction with DJ stenting-Unilateral with Discharge
Summary
S7 13000 N 2 N
Procedure Note
URS extraction with ESWL-Bilateral with Discharge
Summary
S7 20000 N 2 N
Procedure Note
URS extraction with ESWL-Unilateral with Discharge
Summary
S7 15000 N 2 N
Procedure Note
URS with DJ Stenting With ESWL-Unilateral with Discharge
Summary
S7 17025 N 2 N
 Procedure Note
VASOVASOSTOMY 11700 with Discharge
Summary
S7 N 2 N
Procedure Note
Vesico Ureteric Reflux - Unilateral with Discharge
Summary
S7 15000 N 3 N
Procedure Note
Vesico ureteric Reflux - Bilateral with Discharge
Summary
S7 20000 N 3 N
Procedure Note
VIU (Visual Internal Urethrotomy ) with Discharge
Summary
S7 8400 N 2 N
Procedure Note
VIU + Cystolithopexy with Discharge
Summary
S7 15000 N 3 N
Procedure Note
VIU + Hydrocelectomy with Discharge
Summary
S7 17100 N 3 N
Procedure Note
VIU and Meatoplasty with Discharge
Summary
S7 10200 N 3 N
 Capped
amount
(pacakge
Medi cannot be
cal used more
(M) than the
or mentione Reserved
Surgi d for Trust
cal monetary Payment
(S) limit) (Y/N)

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

M N

M N

M N

M N

M N

M N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N
 Neuro Surgery

Average Govt
length of Reserv
Spec Preauth Stay ed Medical
ialty Packa Require (Including Proced (M) or
cod ge Package d or Not Mandatory investigations for Post-Op investigations Days in ure Surgical
e Code Package name Amount (Y/N) pre-auth for claims submission ICU) (Y/N) (S)

Admission note with relevant

investigation result report Procedure Note with
S8 00001 Anterior Encephalocele 50000 Y including CT/MRI Report of Brain Discharge Summary 7 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00002 Burr hole 15000 N including CT/MRI Report of Brain Discharge Summary 2 N S
20,000

Burr hole with chronic Sub Dural Admission note with relevant
Haematoma (including pre and post Op. investigation result report Procedure Note with
S8 00003 CT) Y including CT/MRI Report of Brain Discharge Summary 3 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00005 Cervical Ribs – Bilateral 35000 Y including Radiological report Discharge Summary 3 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00006 Cervical Ribs – Unilateral 20000 Y including Radiological report Discharge Summary 3 N S
20,000

Admission note with relevant

investigation result report Procedure Note with
S8 00007 CranioPlasty - Endogenous graft Y including CT/MRI Report of Brain Discharge Summary 3 N S
 20,000

Admission note with relevant

CranioPlasty - Exogenous graft(+cost of investigation result report Procedure Note with
S8 00008 implant) Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00009 Craniostenosis 28000 Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00010 Duroplasty - Endogenous 12500 Y including CT/MRI Report of Brain Discharge Summary 3 N S
12500
+cost
of Admission note with relevant
implan investigation result report Procedure Note with
S8 00011 Duroplasty - Exogenous(+cost of implant) Y including CT/MRI Report of Brain Discharge Summary 5 N S
t

Admission note with relevant

Haematoma - Brain (head injuries) investigation result report Procedure Note with
S8 00012 (including pre and post Op. CT) 55000 Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00013 Haematoma - Brain (hypertensive) 50000 Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

Haematoma (Child subdural) inclusive of investigation result report Procedure Note with
S8 00014 General anaesthesia, pre and post Op. CT 50000 Y including CT/MRI Report of Brain Discharge Summary 5 N S
50,000

Admission note with relevant

investigation result report Procedure Note with
S8 00015 Laminectomy with Fusion and fixation Y including CT/MRI Report of Spine Discharge Summary 5 N S
 Admission note with relevant
investigation result report Procedure Note with
S8 00016 Laminectomy with Fusion 40000 Y including CT/MRI Report of Spine Discharge Summary 5 N S
16,000 Admission note with relevant Procedure Note with
S8 00017 Local Neurectomy Y investigation result report Discharge Summary 2 N S
30,000

Admission note with relevant Procedure Note with

Lumbar Disc Surgery including pre and post investigation result report Discharge Summary
S8 00018 Op. MRI Y including CT/MRI Report of Spine and post operative MRI 5 N S

Admission note with relevant

investigation result report
including CT/MRI Report of Brain Procedure Note with
S8 00019 Meningocele – Anterior 36000 Y and Spinal cord Discharge Summary 5 N S

Admission note with relevant

investigation result report
including CT/MRI Report of Brain Procedure Note with
S8 00020 Meningocele – Lumbar 36000 Y and spinal cord Discharge Summary 5 N S

Admission note with relevant

investigation result report
including CT/MRI Report of Brain Procedure Note with
S8 00021 Meningococcal – Occipital 50000 Y and spinal cord Discharge Summary 5 N S

Admission note with relevant

investigation result report
including CT/MRI Report of Brain Procedure Note with
S8 00022 Micro discectomy – Cervical 40000 Y and spinal cord Discharge Summary 3 N S

Admission note with relevant

investigation result report
including CT/MRI Report of Brain Procedure Note with
S8 00023 Micro discectomy – Lumbar 40000 Y and spinal cord Discharge Summary 3 N S
 Admission note with relevant
investigation result report Procedure Note with
S8 00024 Brachial Plexus – Repair 27000 Y including CT/MRI Report Discharge Summary 5 N S

Admission note with relevant

Shunt (peritoneal, ventriculo-atrial/ investigation result report Procedure Note with
S8 00025 peritoneal, theco peritoneal) 30000 Y including CT/MRI Report of Brain Discharge Summary 3 N S
Admission note with relevant Procedure Note with
S8 00026 Skull Traction 8825 N investigation result report Discharge Summary 3 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00027 Spine - Canal Stenosis 40000 Y including CT/MRI Report of Spine Discharge Summary 4 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00028 Spine - Decompression & Fusion 40000 Y including CT/MRI Report of Spine Discharge Summary 4 N S
50,000

Admission note with relevant

Spine - Decompression & Fusion with investigation result report Procedure Note with
S8 00029 fixation Y including CT/MRI Report of Spine Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00030 Spine - Extradural Tumour 30000 Y including CT/MRI Report of Spine Discharge Summary 5 N S
40,000

Admission note with relevant

investigation result report Procedure Note with
S8 00031 Spine - Extradural Tumour with fixation Y including CT/MRI Report of Spine Discharge Summary 5 N S
 30,000

Admission note with relevant

investigation result report Procedure Note with
S8 00032 Spine - Extradural Haematoma Y including CT/MRI Report of Spine Discharge Summary 5 N S
40,000

Admission note with relevant

Spine - Extradural Haematoma with investigation result report Procedure Note with
S8 00033 fixation Y including CT/MRI Report of Spine Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00034 Spine - Intradural Tumour 40000 Y including CT/MRI Report of Spine Discharge Summary 5 N S
50,000

Admission note with relevant

investigation result report Procedure Note with
S8 00035 Spine - Intradural Tumour with fixation Y including CT/MRI Report of Spine Discharge Summary 5 N S
40,000

Admission note with relevant

investigation result report Procedure Note with
S8 00036 Spine - Intradural Haematoma Y including CT/MRI Report of Spine Discharge Summary 5 N S
50,000

Admission note with relevant

Spine - Intradural Haematoma with investigation result report Procedure Note with
S8 00037 fixation Y including CT/MRI Report of Spine Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00038 Spine - Intramedullar Tumour 50000 Y including CT/MRI Report of Spine Discharge Summary 5 N S
60,000

Admission note with relevant

investigation result report Procedure Note with
S8 00039 Spine - Intramedullar Tumour - fixation Y including CT/MRI Report of Spine Discharge Summary 5 N S
 50,000

Admission note with relevant

Trans Sphenoidal surgeries including pre investigation result report Procedure Note with
S8 00040 and post Op. MRI Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00041 Tumours – Supratentorial 50000 Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00042 Tumours Meninges – Gocussa 50000 Y including CT/MRI Report of Brain Discharge Summary 5 N S
50,000

Admission note with relevant

investigation result report Procedure Note with
S8 00043 Tumours Meninges – Posterior Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00044 Ventricular Puncture 15000 Y including CT/MRI Report of Brain Discharge Summary 2 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00045 Brain Biopsy 15000 Y including CT/MRI Report of Brain Discharge Summary 2 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00046 Cranial Nerve Anastomosis 32000 Y including CT/MRI Report Discharge Summary 3 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00047 Depressed Fracture 40000 Y including CT/MRI Report of Brain Discharge Summary 5 N S
 Admission note with relevant Procedure Note with
S8 00048 Nerve Biopsy excluding Hensens 7000 N investigationresult report. Discharge Summary 1 N S
16,500 Admission note with relevant Procedure Note with
S8 00049 Peripheral Neurectomy (Trigeminal) Y investigationresult report. Discharge Summary 2 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00050 R.F. Lesion for Trigeminal Neuralgia 16500 Y including CT/MRI Report of Brain Discharge Summary 3 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00051 Twist Drill Craniostomy 15000 Y including CT/MRI Report of Brain Discharge Summary 3 N S
50,000

Admission note with relevant

Excision of Brain TumorSupratentorial- investigation result report Procedure Note with
S8 00052 Parasagital Y including CT/MRI Report of Brain Discharge Summary 5 N S
50,000

Admission note with relevant

Excision of Brain TumorSupratentorial- investigation result report Procedure Note with
S8 00053 Basal Y including CT/MRI Report of Brain Discharge Summary 5 N S
50,000

Admission note with relevant

Excision of Brain TumorSupratentorial- investigation result report Procedure Note with
S8 00054 Brainstem Y including CT/MRI Report of Brain Discharge Summary 5 N S
50,000

Admission note with relevant

Excision of Brain TumorSupratentorial-C P investigation result report Procedure Note with
S8 00055 Angle Y including CT/MRI Report of Brain Discharge Summary 5 N S
55,000

Admission note with relevant

Excision of Brain TumorSupratentorial& investigation result report Procedure Note with
S8 00056 others Y including CT/MRI Report of Brain Discharge Summary 5 N S
 20,000

Admission note with relevant

investigation result report Procedure Note with
S8 00057 Abscess Tapping single Y including CT/MRI Report of Brain Discharge Summary 5 N S
30,000

Admission note with relevant

investigation result report Procedure Note with
S8 00058 Abscess Tapping multiple Y including CT/MRI Report of Brain Discharge Summary 5 N S
36,000

Admission note with relevant

investigation result report Procedure Note with
S8 00059 Excision of Brain Abscess Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00060 Aneurysm Clipping including angiogram 65000 Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

Additonal clip for Aneurysm Clipping investigation result report Procedure Note with
S9 00061 15,000 Y including CT/MRI Report of Brain Discharge Summary 3 N S
30,000

Admission note with relevant

External Ventricular Drainage (EVD) investigation result report Procedure Note with
S8 00062 including antibiotics Y including CT/MRI Report of Brain Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00063 Spinal Fusion Procedure with implant 40,000 Y including CT/MRI Report of Spine Discharge Summary 5 N S

Admission note with relevant

investigation result report Procedure Note with
S8 00064 Spina Bifida Surgery 36000 Y including CT/MRI Report of Spine Discharge Summary 5 N S
 60,000
Procedure Note with
Admission note with relevant Discharge Summary
investigation result report and post operative
S8 00065 Stereotactic Lesioning Y including CT/MRI Report of Brain MRI/CT 5 N S
30,000

Admission note with relevant

Posterior Cervical Discetomy without investigation result report Procedure Note with
S8 00066 implant Y including CT/MRI Report of Spine Discharge Summary 5 N S
50,000
Procedure Note with
Admission note with relevant Discharge Summary
Posterior Cervical Fusion with implant investigation result report and post operative X-
S8 00067 (Lateral mass fixation) Y including CT/MRI Report of Spine ray 5 N S
40,000
Procedure Note with
Admission note with relevant Discharge Summary
investigation result report and post operative X-
S8 00068 Cervical Disc Multiple level without Fusion Y including CT/MRI Report of Spine ray 5 N S
60,000
Procedure Note with
Admission note with relevant Discharge Summary
Thoracic/Lumbar Corpectomy with fusion investigation result report and post operative X-
S8 00069 inclusive of implant Y including CT/MRI Report of Spine ray 5 N S
S8 00070 Transoral surgery (Anterior) and CV 55000
Junction (Posterior Sterlization) +cost Admission note with relevant Procedure Note with
of investigation result report Discharge Summary
implan including X-ray/CT/MRI Report of and post operative X-
Y Brain / Spinal cord ray 5 N S
t
40,000
Admission note with relevant Procedure Note with
investigation result report Discharge Summary
including X-ray/CT/MRI Report of and post operative X-
S8 00071 Trans oral Surgery Y Brain / Spinal cord ray 5 N S
45,000
Admission note with relevant Procedure Note with
investigation result report Discharge Summary
including X-ray/CT/MRI Report of and post operative X-
S8 00072 Foramen Magnum Decompression Y Brain / Spinal cord ray 5 N S
 35000
+cost
of glue Admission note with relevant
investigation result report Procedure Note with
S8 00073 Endoscopic CSF Rhinorrhea Repair Y including CT/MRI Report of Brain Discharge Summary 3 N S
7,000 Procedure Note with
S8 00074 Muscle Biopsy N Discharge Summary 1 N S
16,000 Admission note with relevant Procedure Note with
S8 00075 Nerve Decompression Y investigationresult report. Discharge Summary 3 N S
30,000 Admission note with relevant Procedure Note with
S8 00076 Peripheral Nerve Surgery Major Y investigationresult report. Discharge Summary 3 N S
Admission note with relevant Procedure Note with
S8 00077 Peripheral Nerve Surgery Minor 15000 Y investigationresult report. Discharge Summary 3 N S
50,000

Admission note with relevant

investigation result report Procedure Note with
S8 00078 Epilepsy Surgery Y including CT/MRI Report of Brain Discharge Summary 5 N S
50,000

Admission note with relevant

Arterio venous malformation (AVM) investigation result report Procedure Note with
S8 00079 excision (whatever size and location) Y including CT/MRI Report of Brain Discharge Summary 5 N S
25,000

Admission note with relevant

investigation result report Procedure Note with
S8 00080 Scalp Arterio venous malformation (AVM) Y including CT/MRI Report of Brain Discharge Summary 3 N S
60,000

Superficial Temporal Artery (STA): middle Admission note with relevant

cerebral artery (MCA) or (other EC - IC) investigation result report Procedure Note with
S8 00081 Bypass procedure Y including CT/MRI Report of Brain Discharge Summary 5 N S
40,000

Admission note with relevant

investigation result report Procedure Note with
S8 00082 Excision of Orbital Tumour Y including CT/MRI Report of Brain Discharge Summary 5 N S
 75,000

Gamma Knife radiosurgery (GKRS)/ SRS for Admission note with relevant
tumours/ Arteriovenous malformation investigation result report Procedure Note with
S8 00083 (AVM) Y including CT/MRI Report of Brain Discharge Summary 5 N S
5000 Procedure Note with
S8 Brain mapping N Discharge Summary 1 N S

Carotid Endarterectomy Admission note with relevant

investigation result report Procedure Note with
S8 40000 Y including CT/MRI Report of Brain Discharge Summary 5 N S

Corpectomy for Spinal Fixation with Procedure Note with

implant Admission note with relevant Discharge Summary
investigation result report and post operative X-
S8 55000 Y including CT/MRI Report of Spine ray 5 N S

Corpectomy for Spinal Fixation (without Procedure Note with

implant) Admission note with relevant Discharge Summary
investigation result report and post operative X-
S8 45000 Y including CT/MRI Report of Spine ray 5 N S
Lumbar pressure monitoring 5390
Procedure Note with
S8 N Discharge Summary 1 N S
3000 Procedure Note with
S8 Placement of icp monitor - N Discharge Summary 1 N S

22000 Admission note with relevant

investigation result report Procedure Note with
S8 R.F. lesion for trigeminal neuralgia - Y including CT/MRI Report of Brain Discharge Summary 3 N S
34320 Admission note with relevant Procedure Note with
S8 Spasticity surgery - Y investigationresult report. Discharge Summary 5 N S
1958 Procedure Note with
S8 Subdural tapping N Discharge Summary 1 N S
 18,000
Temporal Rhizotomy Admission note with relevant
investigation result report Procedure Note with
S8 Y including CT/MRI Report of Brain Discharge Summary 3 N S
3000 Procedure Note with
S8 Trans cranial doppler N Discharge Summary D N S

16000 Admission note with relevant

investigation result report Procedure Note with
S8 Trigeminal rhizotomy Y including CT/MRI Report of Brain Discharge Summary 3 N S
Capped amount
(pacakge cannot be Reserved
used more than the for Trust
mentioned Payment
monetary limit) (Y/N)

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
 Interventional Radiology
Package name

Preaut Average Govt

Spe h length of Reserv
cialt Requir Stay ed
y Packa ed or (Including Proced
cod ge Package Not Mandatory investigations for Post-Op investigations for Days in ure
e Code Amount (Y/N) pre-auth claims submission ICU) (Y/N)
Coil embolization for aneurysms (includes cost of first
3 coils + balloon and/ or stent if used) 1 to 20 coils Admission note with relevant
may be required as per need. investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00001 1,00,000 Y Brain post operative CT/MRI 3Y
Additional coil for coil embolization for aneurysms
Admission note with relevant
investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00002 24000 Y Brain post operative CT/MRI 3Y
Dural AVMs/AVFs (per sitting) with glue
Admission note with relevant
investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00003 70,000 Y Brain post operative CT/MRI 3Y
Dural AVMs/AVFs (per sitting) with onyx
Admission note with relevant
investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00004 1,50,000 Y Brain post operative CT/MRI 3Y
Carotico-cavernous Fistula (CCF) embolization with
coils. [includes 5 coils, guide catheter, micro-catheter, Admission note with relevant
micro-guidewire, general items] investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00005 1,50,000 Y Brain post operative CT/MRI 3Y
 Carotid-cavernous Fistula (CCF) embolization with
balloon (includes one balloon, guide catheter, micro- Admission note with relevant
catheter, micro-guidewire, general items) investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00006 75,000 Y Brain post operative CT/MRI 3Y
Cerebral & Spinal AVM embolization (per sitting).
Using Histoacryl
Admission note with relevant
investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00007 1,00,000 Y Brain/spine post operative CT/MRI 3Y
Parent vessel occlusion - Basic

Admission note with relevant

investigationresult report Procedure Note with
S9 00008 30,000 Y including angiogram Discharge Summary 3Y
Additonal coil for Parent Vessel Occlusion

Admission note with relevant

investigationresult report Procedure Note with
S9 00009 24,000 Y including angiogram Discharge Summary 3Y
Additonal balloon for Parent Vessel Occlusion

Admission note with relevant

investigationresult report Procedure Note with
S9 00010 11,000 Y including angiogram Discharge Summary 3Y
Balloon test occlusion

Admission note with relevant

investigationresult report
including X-ray with Procedure Note with
S9 00011 70,000 Y contrast/ angiogram Discharge Summary 3Y
Intracranial balloon angioplasty with stenting
Admission note with relevant
investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00012 1,60,000 Y Brain post operative CT/MRI 3Y
 Intracranial thrombolysis / clot retrieval
Admission note with relevant
investigation result report Procedure Note with
including CT/MRI Report of Discharge Summary and
S9 00013 1,60,000 Y Brain post operative CT/MRI 3Y
Pre-operative tumour embolization (per session)

Admission note with relevant

investigation result report
including CT/MRI Report of Procedure Note with
S9 00014 40,000 Y Brain and HPE Discharge Summary 3Y
Vertebroplasty

Admission note with relevant

investigation result report
including CT/MRI Report of Procedure Note with
S9 00015 40,000 Y Spine/angiogram Discharge Summary 3Y
Radio Frequency Ablation of tumors under CT,USG
and/or DSA guidance
Admission note with relevant
investigation result report Procedure Note with
S9 50,000 Y including HPE Discharge Summary 3Y
TACE (Trans Arterial Chemo -Embolisation )

Admission note with relevant

investigation result report Procedure Note with
S9 100,000 Y including HPE Discharge Summary 3Y
PTA (Percutaneus Trans arterial Angioplasty)

Admission note with relevant

investigation result report Procedure Note with
S9 60,000 Y including angiogram/ECG Discharge Summary 3Y
PTA and Stenting-1 STENT

Admission note with relevant

investigation result report Procedure Note with
S9 90,000 Y including angiogram/ECG Discharge Summary 3Y
 PTA and Stenting-2 STENTS

Admission note with relevant

investigation result report Procedure Note with
S9 1,20,000 Y including angiogram/ECG Discharge Summary 3Y
PTBD (percutanoeus trans hepatic biliary drainage)

Admission note with relevant

investigation result report Procedure Note with
S9 25,000 Y including CT/MRI abdomen Discharge Summary 3Y
PTBD and Stenting

Admission note with relevant

investigation result report Procedure Note with
S9 80,000 Y including CT/MRI abdomen Discharge Summary 3Y
TIPS( Trans jugular Porto-systemic shunting) treatment
of Portal hypertension
Admission note with relevant
investigation result report Procedure Note with
S9 1,80,000 Y including CT/MRI abdomen Discharge Summary 5Y
Direct Puncture Procedures
Admission note with relevant Procedure Note with
S9 5,000 Y investigation result report Discharge Summary 1Y
Pain procedures -direct
Admission note with relevant Procedure Note with
S9 5,000 Y investigation result report Discharge Summary 1Y
Pain Procedures with catheter
Admission note with relevant Procedure Note with
S9 20,000 Y investigation result report Discharge Summary 1Y
SEMS( Self Expandable Metallic Stent deployment in
oesophagus for treating cancer)
Admission note with relevant
investigation result report Procedure Note with
S9 35,000 Y including HPE Discharge Summary 3Y
 Capped amount
(pacakge cannot
Medical be used more Reserved
(M) or than the for Trust
Surgical mentioned Payment
(S) monetary limit) (Y/N)

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N
S N

S N

S N

S N

S N

S N

S N

S N
 Plastic & Reconstructive Surgery

Preaut Average Govt

h length of Reserv
Requir Stay ed
Spec Packa ed or (Including Proced
ialty ge Package Not Mandatory investigations Post-Op investigations for Days in ure
code Code Package name Amount (Y/N) for pre-auth claims submission ICU) (Y/N)

Ear Pinna Reconstruction with costal cartilage/ Prosthesis

(including the cost of prosthesis/implants). *If requiring Admission note with Procedure Note with
multiple stages, each stage will cost Rs. 30,000 provided the relevant investigation result Discharge Summaryand/or
operating surgeon demonstrates the photographic results report and/or relevant relevant imaging
S10 00001 of previous stages. 30,000 Y imaging photograph photograph 5 N

Admission note with

relevant investigation result
report including vascularity Procedure Note with
S10 00002 Revascularization of limb/digit 25,000 Y study Discharge Summary 5 N

Admission note with Procedure Note with

relevant investigation result Discharge Summaryand/or
report and/or relevant relevant imaging
S10 00003 Hemangioma – Sclerotherapy (under GA) 35,000 Y imaging photograph photograph 3 N

Admission note with Procedure Note with

relevant investigation result Discharge Summaryand/or
report and/or relevant relevant imaging
S10 00004 Hemangioma – Debulking/ Excision 35,000 Y imaging photograph photograph 4 N
 Admission note with Procedure Note with
relevant investigation result Discharge Summaryand/or
Tissue Expander for disfigurement following burns/ trauma/ report and/or relevant relevant imaging
S10 00005 congenital deformity (including cost of expander / implant) 50,000 Y imaging photograph photograph 5 N

Admission note with Procedure Note with

relevant investigation result Discharge Summaryand/or
report and/or relevant relevant imaging
S10 00006 Scalp avulsion reconstruction 50,000 Y imaging photograph photograph 5 N
2,000/d Procedure Note with
S10 00007 NPWT (Inpatient only) ay N Discharge Summary 3 N

Admission note with

relevant investigation result Procedure Note with
S10 00008 Pressure Sore – Surgery 30,000 Y report Discharge Summary 3 N

Admission note with

relevant investigation result Procedure Note with
S10 00009 Diabetic Foot – Surgery 30,000 Y report Discharge Summary 3 N
 Capped
amount
(pacakge
Medica cannot be used Reserved
l (M) or more than the for Trust
Surgica mentioned Payment
l (S) monetary limit) (Y/N)

S N

S N

S N

S N
S N

S N

S N

S N

S N
 Burns

Preaut
h
Spec Packa Package Requir Mandatory investigations Post-Op investigations
ialty ge Package name Amount ed or for pre-auth for claims submission
code Code Not
(Y/N)

% Total Body Surface Area Burns (TBSA) (thermal/ scald/

flame burns) - any % (not requiring admission). Needs at
least 5-6 dressing Procedure Note with
S11 00001 7,000 N Discharge Summary
% Total Body Surface Area Burns (TBSA) (thermal/ scald/ Admission note with
flame burns): Upto 40 %; Includes % TBSA skin grafted, relevant investigation result
flap cover, follow-up dressings etc. as deemed necessary; report/Clinical photograph
Surgical procedures are required for deep burns that are and diagram with Rule of 9/
not amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00002 40,000 Y clinical phptograph
% Total Body Surface Area Burns (TBSA) (thermal/ scald/ Admission note with
flame burns): 40 % - 60 %; Includes % TBSA skin grafted, relevant investigation result
flap cover, follow-up dressings etc. as deemed necessary; report/Clinical photograph
Surgical procedures are required for deep burns that are and diagram with Rule of 9/
not amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00003 50,000 Y clinical phptograph
% Total Body Surface Area Burns (TBSA) (thermal/ scald/ Admission note with
flame burns): > 60 %; Includes % TBSA skin grafted, flap relevant investigation result
cover, follow-up dressings etc. as deemed necessary; report/Clinical photograph
Surgical procedures are required for deep burns that are and diagram with Rule of 9/
not amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00004 80,000 Y clinical phptograph
 Electrical contact burns: Low voltage- without part of Admission note with
limb/limb loss; Includes % TBSA skin grafted, flap cover, relevant investigation result
follow-up dressings etc. as deemed necessary; Surgical report/Clinical photograph
procedures are required for deep burns that are not and diagram with Rule of 9/
amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00005 30,000 Y clinical phptograph
Electrical contact burns: Low voltage- with part of Admission note with
limb/limb loss; Includes % TBSA skin grafted, flap cover, relevant investigation result
follow-up dressings etc. as deemed necessary; Surgical report/Clinical photograph
procedures are required for deep burns that are not and diagram with Rule of 9/
amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00006 40,000 Y clinical phptograph
Electrical contact burns: High voltage- without part of Admission note with
limb/limb loss; Includes % TBSA skin grafted, flap cover, relevant investigation result
follow-up dressings etc. as deemed necessary; Surgical report/Clinical photograph
procedures are required for deep burns that are not and diagram with Rule of 9/
amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00007 50,000 Y clinical phptograph
Electrical contact burns: High voltage- with part of Admission note with
limb/limb loss; Includes % TBSA skin grafted, flap cover, relevant investigation result
follow-up dressings etc. as deemed necessary; Surgical report/Clinical photograph
procedures are required for deep burns that are not and diagram with Rule of 9/
amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00008 60,000 Y clinical phptograph
Chemical burns: Without significant facial scarring Admission note with
and/or loss of function; Includes % TBSA skin grafted, relevant investigation result
flap cover, follow-up dressings etc. as deemed necessary; report/Clinical photograph
Surgical procedures are required for deep burns that are and diagram with Rule of 9/
not amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00009 40,000 Y clinical phptograph
 Chemical burns: With significant facial scarring and/or Admission note with
loss of function; Includes % TBSA skin grafted, flap cover, relevant investigation result
follow-up dressings etc. as deemed necessary; Surgical report/Clinical photograph
procedures are required for deep burns that are not and diagram with Rule of 9/
amenable to heal with dressings alone. L & B Chart for extent of
burns Procedure Note with
Discharge Summary and
S11 00010 60,000 Y clinical phptograph
Post Burn Contracture surgeries for Functional Admission note with
Improvement (Package including splints, pressure relevant investigation result
garments, silicone-gel sheet and physiotherapy): report/Clinical photograph
Excluding Neck contracture; Contracture release with - and diagram with Rule of 9/
Split thickness Skin Graft (STSG) / Full Thickness Skin L & B Chart for extent of
Graft (FTSG)/ Flap cover is done for each joint with post- burns
operative regular dressings for STSG / FTSG / Flap cover.
Procedure Note with
Discharge Summary and
S11 00011 50,000 Y clinical phptograph
Post Burn Contracture surgeries for Functional Admission note with
Improvement (Package including splints, pressure relevant investigation result
garments, silicone-gel sheet and physiotherapy): Neck report/Clinical photograph
contracture; Contracture release with - Split thickness and diagram with Rule of 9/
Skin Graft (STSG) / L & B Chart for extent of
Full Thickness Skin Graft (FTSG)/ Flap cover is done for burns
each joint with post-operative regular dressings for
STSG / FTSG / Flap cover.
Procedure Note with
Discharge Summary and
S11 00012 50,000 Y clinical phptograph
 Govt
Reserv Medica
Average length of Stay ed l (M) or Capped amount
(Including Days in intensive Proced Surgical (pacakge cannot be Reserved
care units) ure (S) used more than for Trust
(Y/N) the mentioned Payment
monetary limit) (Y/N)

D N S N

Moderate to severe burns

need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N

Moderate to severe burns

need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N

Moderate to severe burns

need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N
Moderate to severe burns
need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N

Moderate to severe burns

need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N

Moderate to severe burns

need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N

Moderate to severe burns

need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N

Moderate to severe burns

need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N
Moderate to severe burns
need initial ICU stay ranging
from 2 – 5 days and then 10
- 14 days of ward stay with
alternate day dressings N S N

10-14 days N S N

10-14 days N S N
 Cardiology

Average
length of
Preauth Stay
Spec Packa Required (Includin
ialty ge Package or Not Mandatory investigations for Post-Op investigations for g Days in
code Code Package name Amount (Y/N) pre-auth claims submission ICU)
25,000 Y
Admission note with relevant
investigation result report
including ColourDoppler ECHO Procedure Note with Discharge
S12 00001 Balloon Atrial Septostomy report Summary with procedure report 2
35000 Y
Admission note with relevant
investigation result report
including ColourDoppler ECHO Procedure Note with Discharge
S12 00002 Balloon Aortic Valvotomy report Summary with procedure report 2
40000 Y
Admission note with relevant
investigation result report
including ColourDoppler ECHO Procedure Note with Discharge
S12 00003 Balloon Mitral Valvotomy report Summary with procedure report 2
35000 Y
Admission note with relevant
investigation result report
including ColourDoppler ECHO Procedure Note with Discharge
S12 00004 Balloon Pulmonary Valvotomy report Summary with procedure report 2
60000 Y
Procedure Note with Discharge
Admission note with relevant Summary with procedure report
Vertebral Angioplasty with single stent investigation result report and bar code sticker of the
S12 00005 (medicated) including angiogram Stent. 2
 90000 Y
Admission note with relevant
Vertebral Angioplasty with double investigation result report
S12 00006 stent(medicated) including angiogram
130000 Y
Admission note with relevant
investigation result report
S12 00007 Carotid angioplasty with stent (medicated) including angiogram
60000 Y
Admission note with relevant
Renal Angioplasty with single stent investigation result report
S12 00008 (medicated) including angiogram
90000 Y
Admission note with relevant
Renal Angioplasty with double stent investigation result report
S12 00009 (medicated) including angiogram
25000 Y
Admission note with relevant
investigation result report
S12 00010 Peripheral Angioplasty with balloon including peripheral angiogram Summarywith procedure report 2
60000 Y
Admission note with relevant
investigation result report
S12 00011 Peripheral Angioplasty with stent (medicated) including peripheral angiogram Stent.
30000 Y
Admission note with relevant
investigation result report
including ColourDoppler ECHO
S12 00012 Coarctation dilatation report /CT angiography
Procedure Note with Discharge
Summary with procedure report
and bar code sticker of the
Stent. 2
Procedure Note with Discharge
Summary with procedure report
and bar code sticker of the
Stent. 3
Procedure Note with Discharge
Summarywith procedure note
and bar code sticker of the
Stent. 2
Procedure Note with Discharge
Summarywith procedure report
and bar code sticker of the
Stent. 2
Procedure Note with Discharge
Procedure Note with Discharge
Summary with procedure report
and bar code sticker of the
2
Procedure Note with Discharge
Summary with procedure report 2
 15000

Admission note with relevant Procedure Note with Discharge

Medical treatment of Acute MI with investigation result report Summary including ECG /ECHO
S12 00013 Thrombolysis /Stuck Valve Thrombolysis including ECG/ECHO report report 3
85000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
including 2D ECHO and bar code sticker of the
S12 00014 ASD Device Closure /Tranoesophagal ECHO report consumable. 2
90000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summarywith procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00015 VSD Device Closure report consumable. 2
40000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summarywith procedure note
including ColourDoppler ECHO and bar code sticker of the
S12 00016 PDA Device Closure report consumable. 2
20000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summarywith procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00017 PDA multiple Coil insertion report consumable. 2
15000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summarywith procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00018 PDA Coil (one) insertion report consumable. 2
 40000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summarywith procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00019 PDA stenting report consumable. 2
2500
Admission note with relevant Procedure Note with Discharge
S12 00020 Pericardiocentesis investigation result report Summary 2
3500

Admission note with relevant Procedure Note with Discharge

investigation result report Summary including procedure
S12 00021 Temporary Pacemaker implantation including ECG report and ECG report 1
140000 Y

Procedure Note with Discharge

Permanent pacemaker implantation including Admission note with relevant Summary with procedure
Pacemaker value/pulse generator replacement investigation result report report,ECG report and bar code
S12 00022 (DOUBLE CHAMBER) including ECG/Holter report sticker of the consumable. 5
70000 Y

Procedure Note with Discharge

Permanent pacemaker implantation (only VVI) Admission note with relevant Summary with procedure
including Pacemaker value/pulse generator investigation result report report,ECG report and bar code
S12 00023 replacement (SINGLE CHAMBER) including ECG/Holter report sticker of the consumable. 5
65,000 Y

Procedure Note with Discharge

Summary with procedure
Admission note with relevant report,post operative ECG/CAG
PTCA - single stent (medicated, inclusive of investigation result report report and bar code sticker of
S12 00024 diagnostic angiogram) including ECG/CAG /ECHO report the consumable. 2
 96750 Y

Procedure Note with Discharge

Summary with procedure
Admission note with relevant report,post operative ECG/CAG
PTCA - double stent (medicated, inclusive of investigation result report report and bar code sticker of
S12 00025 diagnostic angiogram) including ECG/CAG /ECHO report the consumable. 2
31750 Y

Procedure Note with Discharge

Summary with procedure
Admission note with relevant report,post operative ECG/CAG
PTCA - additonal stent (linked to package investigation result report report and bar code sticker of
S12 00026 no:0025) including ECG/CAG /ECHO report the consumable.
30000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00027 PTSMA report consumable. 2
45000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00028 Pulmonary artery stenting report consumable. 2
70000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00029 Pulmonary artery stenting (double) report consumable. 2
45000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
including ColourDoppler ECHO and bar code sticker of the
S12 00030 Right ventricular outflow tract (RVOT) stenting report consumable. 2
 70000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
including coronary angiogram and bar code sticker of the
S12 00031 Rotablation+ Balloon Angioplasty report consumables. 2
110000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
Rotablation+ Balloon Angioplasty + 1 stent including coronary angiogram and bar code sticker of the
S12 00032 (medicated) report consumables. 3
135000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary with procedure report
Rotablation+ Balloon Angioplasty + 2 stent including coronary angiogram and bar code sticker of the
S12 00033 (medicated) report consumables. 3
10000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary including procedure
including Peripheral note and post lysis
S12 00034 Thrombolysis for peripheral ischemia angiogram /doppler study report angiogram/doppler study report 2
30000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary including procedure
Bronchial artery Embolisation (for including CT angiogram/direct note and bar code sticker of
S12 00035 Haemoptysis) catheter angiogram report consumables 2
25000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary including procedure
Percutaneous Transluminal Tricuspid including ColourDoppler ECHO note and bar code sticker of
S12 00036 Commissurotormy (PTTC) report consumables 2
 55000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary including procedure
including CT angiogaram/ direct note and bar code sticker of
S12 00037 Coiling - Pseudoaneurysms of Abdomen angiogram report consumables 2
40000 Y

Admission note with relevant Procedure Note with Discharge

investigation result report Summary including procedure
Embolization - Arteriovenous Malformation including CT angiogaram/ direct note and post procedure
S12 00038 (AVM) in the Limbs angiogram report angiogram 2
30000 Y

Admission note with relevant Procedure Note with Discharge

Catheter directed Thrombolysis for: Deep vein investigation result report Summary including procedure
thrombosis (DVT), Mesenteric Thrombosis & including doppler study /CT report and post lysis doppler
S12 00039 Peripheral vessels angiogram report study /angiogram report 2
310000 Y

CARDIAC RESYNCHRONISATION THERAPY Admission note with relevant Procedure Note with Discharge
[CRT] investigation result Summary including procedure
reportincluding ECHO and ECG note and bar code of
S12 report consumables. 5
Coarctoplasty with stenting 45000 Y

Procedure Note with Discharge

Admission note with relevant Summary including procedure
investigation result report note and bar code of the
S12 including ECHO/CT report consumables 2
S12 CORONARY ANGIOGRAM 5000 N CAG report D
20000 Y

ELECTROPHYSIOLOGICAL STUDY Admission note with relevant Procedure Note with Discharge
investigation result report Summary including procedure
S12 including ECG/Holter report report 1
 15000 N

FAILED PTCA Admission note with relevant

investigation result report Procedure Note with Discharge
S12 inclding ECG/CAG report including procedure report 1
350000 Y

IMPLANTABLE CARDIAC DEFIBRILLATOR [ICD] Admission note with relevant Procedure Note with Discharge
investigation result report including procedure report and
S12 including ECHO and ECG report bar code of consumables 5
PERIPHERAL ANGIOGRAM INCLUDING 6000 D
S12 CAROTID, FOUR VESSEL ANGIOGRAM Clinical note /ECG Procedure report D
60000 Y

IVC FILTER Procedure Note with Discharge

Admission note with relevant Summary including procedure
investigation result report note and bar code of
S12 including Venous doppler consumables.
100000 Y

PERCUTANEOUS SEPTAL MYOCARDIAL Admission note with relevant
ABLATION REQUIRING PPI investigation result report
including colour doppler
S12 ECHO/ECG report
35000 Y
Procedure Note with Discharge
Summary including procedure
note and bar code of
consumables. 3

Plain Old Balloon Angioplasty-POBA Procedure Note with Discharge

Admission note with relevant Summary including procedure
investigation result report note and bar code of
S12 including CAG/ECG report consumables. 2
500 N
TEST OF PACEMAKER
S12 pacemaker intorrogation report D
 Capped amount
(pacakge cannot
Govt Medical be used more Reserved
Reserved (M) or than the for Trust
Procedur Surgical mentioned Payment
e (Y/N) (S) monetary limit) (Y/N)

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N
N M N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

Y S N

N S N
N S N

N S N
N S N

Y S N

N S N

N S N

N S N

N S N

N S N
 Cardio Vascular & Cardio Thoracic Surgery

Preaut
h
Requir
Spec ed or
ialty Packag Package Not Mandatory investigations for pre-
code e Code Package name Amount (Y/N) auth

Admission note with relevant

investigation result report
S13 00001 Coronary artery bypass grafting (CABG) 90000 Y including CAG/ECHO report

Admission note with relevant

Coronary artery bypass grafting (CABG) with Intra- investigation result report
S13 00002 aortic balloon pump (IABP) 125000 Y including CAG/ECHO report

Coronary artery bypass grafting (CABG) + one Admission note with relevant
mechanical Valve Replacement + Intra-aortic balloon investigation result report
S13 00003 pump (IABP) 175000 Y including CAG/ECHO report

Admission note with relevant

Coronary artery bypass grafting (CABG) with LV investigation result report
S13 00004 Aneurysmal repair 100000 Y including CAG/ECHO report

Admission note with relevant

Coronary artery bypass grafting (CABG) with Mitral investigation result report
S13 00005 Valve repair without ring 100000 Y including CAG/ECHO report

Admission note with relevant

Coronary artery bypass grafting (CABG) with Mitral investigation result report
S13 00006 Valve repair with ring 125000 Y including CAG/ECHO report

Coronary artery bypass grafting (CABG) with post MI Admission note with relevant
Ventricular Septal Defect (Ventricular Septal Defect) investigation result report
S13 00007 repair 125000 Y including CAG/ECHO report
 Admission note with relevant
investigation result including
ECHO report /CAG report if >40
S13 00008 Open Mitral Valvotomy 75000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00009 Closed Mitral Valvotomy 30000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00010 Open Pulmonary Valvotomy 75000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00011 Mitral Valve Repair 120000 Y years

Admission note with relevant

investigation result report
S13 00012 Tricuspid Valve Repair 100000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00013 Aortic Valve Repair 80000 Y including ECHO report

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00014 Ring for any Valve Repair 30000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00015 Mitral Valve Replacement (mechanical valve) 120000 Y years
 Admission note with relevant
investigation result including
ECHO report /CAG report if >40
S13 00016 Mitral Valve Replacement (biological valve) 150000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00017 Aortic Valve Replacement (mechanical valve) 120000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00018 Aortic Valve Replacement (biological valve) 150000 Y years

Admission note with relevant

investigation result report
S13 00019 Tricuspid Valve Replacement (mechanical valve) 120000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00020 Tricuspid Valve Replacement (biological valve) 125000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00021 Double Valve Replacement (mechanical valve) 150000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00022 Double Valve Replacement (biological valve) 175000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00023 Ross Procedure 105000 Y including ECHO report/CT chest

Admission note with relevant

investigation result report
S13 00024 Atrial Septal Defect (ASD) 90000 Y including ECHO report
 Admission note with relevant
investigation result report
S13 00025 Ventricular Septal Defect (VSD) 75000 Y including ECHO report

Admission note with relevant

Atrioventricular septal defect/ Atrioventricular (AV) investigation result report
S13 00026 Canal Defect 100000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00027 Intracardiac repair (ICR) for Tetralogy of Fallot (TOF) 100000 Y including ECHO report

Admission note with relevant

investigation result including
Pulmonary Valvotomy + Right Ventricular Outflow ECHO report /CAG report if >40
S13 00028 Tract (RVOT) Resection 90000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00029 Aortopulmonary Window (AP Window) 90000 Y years

Admission note with relevant

investigation result including
Surgery for Hypertrophic Obstructive Cardiomyopathy ECHO report /CAG report if >40
S13 00030 (HOCM) 120000 Y years

Admission note with relevant

investigation result report
S13 00031 Ebsteins 90000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00032 Fontan 90000 Y including ECHO report

Admission note with relevant

Total Anomalous Pulmonary Venous Connection investigation result report
S13 00033 (TAPVC) 105000 Y including ECHO report
 Admission note with relevant
investigation result report
S13 00034 Any RV to PA conduit (Valved) 115000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00035 Arterial Switch Operation 120000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00036 Double Switch Operation 120000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00037 Sennings 105000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00038 Mustards 105000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00039 Truncus Arteriosus Surgery 115000 Y including ECHO report

Admission note with relevant

investigation result including
Root Replacement (Aortic Aneurysm/ Aortic ECHO report /CAG report if >40
S13 00040 Dissection) / Bental Procedure 175000 Y years/CT chest report

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
years/CT chest contrast and
S13 00041 Aortic Arch Replacement 160000 Y abdomen report

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
Aortic Aneurysm Repair using Cardiopulmonary years/CT chest contrast and
S13 00042 bypass (CPB) 150000 Y abdomen report
 Admission note with relevant
investigation result including
ECHO report /CAG report if >40
Aortic Aneurysm Repair without using years/CT chest contrast and
S13 00043 Cardiopulmonary bypass (CPB) 75000 Y abdomen report

Admission note with relevant

investigation result report
including ECHO report/CT-
S13 00044 Pulmonary Embolectomy 125000 Y Pulmonary angiogram

Admission note with relevant

investigation result including
Surgery for Cardiac Tumour/ Left Atrial (LA) Myxoma/ ECHO report /CAG report if >40
S13 00045 Right Atrial (RA) Myxoma 95000 Y years

Admission note with relevant

investigation result report
S13 00046 Patent Ductus Arteriosus (PDA) Closure 30000 Y including ECHO report

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00047 Coarctation Repair 30000 Y years

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00048 Coarctation Repair with interpostion graft 38000 Y years

Admission note with relevant

Blalock–Thomas–Taussig (BT) Shunt (inclusives of investigation result report
S13 00049 grafts) 100000 Y including ECHO report

Admission note with relevant

investigation result report
S13 00050 Glenn Shunt (without cardiopulmonary bypass) 35000 Y including ECHO report
 Admission note with relevant
investigation result report
S13 00051 Central Shunt 50000 Y including ECHO report

Admission note with relevant

investigation result report
including ECHO report/CT Chest
S13 00052 Pericardiectomy 45000 Y report

Admission note with relevant

investigation result report
including ECHO report/CT
S13 00053 Pulmonary AV Fistula surgery 45000 Y Pulmonary angiogram

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00054 Lung Cyst 50000 Y report

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00055 Space-Occupying Lesion (SOL) mediastinum 50000 Y /bronchoscopy report

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00056 Surgical Correction of Bronchopleural Fistula 50000 Y report

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00057 Diaphragmatic Eventeration 40000 Y report

Admission note with relevant

investigation result report
including Chest X-ray/CT
S13 00058 Oesophageal Diverticula /Achalasia Cardia 40000 Y chest/OGD report
 Admission note with relevant
investigation result report
including Chest X-ray/CT chest
S13 00059 Diaphragmatic Injuries/Repair 40000 Y report(P&C)

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00060 Thoracotomy, Thoraco Abdominal Approach 30,000 Y report(P&C)

Admission note with relevant

investigation result report
S13 00061 Foreign Body Removal with scope 20000 Y including Chest X-ray report

Admission note with relevant

investigation result report
including Chest X-ray
S13 00062 Bronchial Repair Surgery for Injuries due to FB 40000 Y /Bronchoscopy report

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00063 Lung Injury repair 35000 Y report(P&C)

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00064 Thyomectomy 35000 Y report(P&C)

Admission note with relevant

investigation result including
ECHO report /CAG report if >40
S13 00065 Pulmonary Valve Replacement 120000 Y years

Admission note with relevant

investigation result report
Intercostal Drainage and Management of ICD, including Chest X-ray/CT chest
S13 00066 Intercostal Block, Antibiotics & Physiotherapy 10000 N report(P&C)
 Admission note with relevant
investigation result report
including Chest X-ray/CT chest
S13 00067 Encysted Empyema/Pleural Effusion - Tubercular 10000 N report(C)

Admission note with relevant

First rib Excision by transaxillary approach, Excision of investigation result report
cervical rib / fibrous band / muscle by cervical including Chest X-ray/CT chest
S13 00068 approach 30000 Y report(C)

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00069 Congenital Cystic Lesions 30000 Y report(C)

Admission note with relevant

investigation result report
including Chest X-ray/CT chest
S13 00070 Pulmonary Sequestration Resection 40000 Y report(P&C)

Admission note with relevant

investigation result report
including ECHO report/CT
S13 00071 Pulmonary artero venous malformation 40000 Y Pulmonary angiogram

Admission note with relevant

investigation result including
Thromboembolectomy (pre-auth not required, Doppler/Peripheral Angiogram
S13 00072 usually done as emergency) 20000 Y report

Admission note with relevant

investigation result report
Surgery for Arterial Aneursysm -Upper/Distal including CT abdomen and Chest
S13 00073 Abdominal Aorta 90000 Y (P&C)/ECHO report

Admission note with relevant

investigation result report
Intrathoracic Aneurysm-Aneurysm not Requiring including Chest CT(P&C)/ECHO
S13 00074 Bypass Techniques 90000 Y /CAG report
 Admission note with relevant
investigation result report
including Chest CT(P&C)/ECHO
S13 00075 Intrathoracic Aneurysm-Requiring Bypass Techniques 125000 Y report

Admission note with relevant

investigation result report
including Abdomen CT/Renal
S13 00076 Surgery for Arterial Aneurysm Renal Artery 40000 Y artery Doppler report

Admission note with relevant

investigation result report
including regional Angiogram
S13 00077 Operations for Congenital Arteriovenous Fistula 15000 Y report/CT contrast

Admission note with relevant

investigation result report
including Abdomen CT/Renal
S13 00078 Operations for Stenosis of Renal Arteries 40000 Y artery Doppler report

Admission note with relevant

investigation result report
Aorto Bi-lliac / Bi femoral /Axillo bi femoral bypass including CT Angiogram/ Doppler
S13 00079 with Synthetic Graft(double) 100000 Y report

Admission note with relevant

investigation result report
Femoro Distal / Femoral - Femoral / Femoral infra including Doppler/Peripheral
S13 00080 popliteal Bypass with Vein Graft 70000 Y angiogram report

Admission note with relevant

investigation result report
Femoro Distal / Femoral - Femoral / Femoral infra including Doppler/Peripheral
S13 00081 popliteal Bypass with Synthetic Graft 70000 Y angiogram report

Admission note with relevant

investigation result report
including Doppler/Peripheral
S13 00082 Axillo Brachial Bypass using with Synthetic Graft 65000 Y angiogram report
 Admission note with relevant
investigation result report
including Doppler/Peripheral
S13 00083 Brachio - Radial Bypass with Synthetic Graft 45000 Y angiogram report

Admission note with relevant

investigation result report
including Doppler/CT angiogram
S13 00084 Excision of body Tumor with vascular repair 45000 Y report

Admission note with relevant

investigation result report
including Doppler/CT angiogram
S13 00085 Carotid artery bypass with Synthetic Graft 60000 Y report

Admission note with relevant

investigation result report
including CT angiogram/MRA
S13 00086 Excision of Arterio Venous malformation - Large 50000 Y report

Admission note with relevant

investigation result report
including CT angiogram/MRA
S13 00087 Excision of Arterio Venous malformation - Small 30000 Y report

Admission note with relevant

investigation result report
Deep Vein Thrombosis (DVT) - Inferior Vena Cava including Doppler/CT angiogram
S13 00088 (IVC) filter 80000 Y report

Admission note with relevant

investigation result report
including Doppler/CT angiogram
S13 00089 Carotid endarterectomy 40000 Y report

Admission note with relevant

Aortic Angioplasty with two stents / Iliac angioplasty investigation result report
S13 00090 with stent Bilateral 90000 Y including ECG/ECHO/CAG report
 Admission note with relevant
investigation result report
including Doppler
study/Peripheral angiogram
S13 00091 Bilateral thrombo embolectomy 30000 Y report

Admission note with relevant

investigation result report
Aorto-uni-iliac/uni-femoral bypass with synthetic including CT Angiogram/ Doppler
S13 00092 graft 70000 Y report

Admission note with relevant

AORTIC DISSECTION TYPE A 200000 investigation result report
including ECHO/CT contrast Chest
S13 Y and Abdomen report

Admission note with relevant

Aortaplasty with stent (Aorta Repair) for Coarctation investigation result report
S13 45000 Y including ECHO/CAG report

Aorto Bi lliac / Bi femoral /Axillo bi femoral bypass Admission note with relevant
with (single) Synthetic Graft investigation result report
including CT Angiogram/ Doppler
S13 50000 Y report

Admission note with relevant

ASCENDING AORTIC ANEURSYM 150000 investigation result report
including ECHO/CT contrast
S13 Y Chest /CAG report

Admission note with relevant

AV REPAIR+MV REPAIR 200000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

AVReplacement+MV REPAIR 200000 investigation result including
ECHO report /CAG report if >40
S13 Y years
 Admission note with relevant
AVReplacement+MV REPAIR+TV REPAIR 220000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

AVReplacement+OMV 200000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

AVR+VSD 200000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

CABG+ANUERYSM 200000 investigation result including
ECHO report /CAG /CT contrast
S13 Y Chest and Abdomen report

Admission note with relevant

CABG+AORTO CAROTID BYPASS 200000 investigation result including
ECHO report /CAG /CT contrast
Chest and Neck /CT aortogram
S13 Y report

Admission note with relevant

CABG+ASD 100000 investigation result including
S13 Y ECHO report /CAG report

CABG+AVReplacement+MVReplacement/Repair 225000 Admission note with relevant

investigation result including
S13 Y ECHO report /CAG report

Admission note with relevant

CABG+CAROTID ENDARTERECTOMY 150000 investigation result including
ECHO report /CAG/Carotid
Doppler study/CT aortogram
S13 Y report
 Admission note with relevant
CABG+DVReplacement 225000 investigation result including
S13 Y ECHO report /CAG report

Admission note with relevant

CABG+DVReplacement+TVReplacement 275000 investigation result including
S13 Y ECHO report /CAG report

Admission note with relevant

CABG+LA MYXOMA 150000 investigation result including
S13 Y ECHO report /CAG report

Admission note with relevant

CABG+MVReplacement+TVReplacement 200000 investigation result including
S13 Y ECHO report /CAG report

CABG+POVD 160000 Admission note with relevant

investigation result including
ECHO report /CAG /Peripheral
S13 Y Angiogram/ Doppler study report

Admission note with relevant

CABG+TVReplacement 150000 investigation result including
S13 Y ECHO report /CAG report

Admission note with relevant

CABG+VSR WITH IABP SUPPORT 150000 investigation result including
S13 Y ECHO report /CAG report

Admission note with relevant

COR TRIATRIATUM 120000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

DAVID PROCEDURE 225000 investigation result including
ECHO report /CAG report if >40
years/CT Chest (contrast)/CT
S13 Y Aortogram
 Admission note with relevant
DVReplacement+TVReplacement 225000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

LVOT EXCISION 150000 investigation result including
S13 Y ECHO report /CAG report

Admission note with relevant

MV REPAIR+TVReplacement 125000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

MVReplacement+TVReplacement 150000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Oesophageal tumour excision and follow up care Admission note with relevant
(open preferred) investigation result including
ECHO report /CAG report if >40
S13 60000 Y years

Admission note with relevant

OMV+TVReplacement 150000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

Pulmonary Valve Replacement+TVReplacement 120000 investigation result including
ECHO report /CAG report if >40
S13 Y years

Admission note with relevant

RSOV 100000 investigation result including
ECHO report /CAG report if >40
S13 Y years
 Dissecting Aneurysms with Cardiopulmonary bypass Admission note with relevant
(CPB) (inclu. Graft) investigation result report
including ECHO/CT contrast Chest
S13 125000 Y and Abdomen report

Dissecting Aneurysms without Cardiopulmonary Admission note with relevant

bypass (CPB) (incl. graft) investigation result report
including ECHO/CT contrast Chest
S13 60000 Y and Abdomen report
Surgery

Capped
amount
(pacakge
Average Govt cannot be
length Reser used more
of Stay ved Medica than the
(Includi Proce l (M) or mentioned Reserved for
ng Days dure Surgica monetary Trust Payment
Post-Op investigations for claims submission in ICU) (Y/N) l (S) limit) (Y/N)

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report/Chest x-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N
Procedure Note with Discharge Summary
including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 2 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 3 N S N
Procedure Note with Discharge Summary
including procedure report and post operative
X-ray report 3 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
bronchoscopy report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Chest X-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report/Chest x-ray report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
doppler/Peripheral angiogram report 3 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Chest X-ray 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
ECHO report 5 to 7 N S N
Procedure Note with Discharge Summary
including procedure report and post operative
ECHO report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report 5 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N
Procedure Note with Discharge Summary
including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
ECHO /CAG report 5 to 7 N S N
Procedure Note with Discharge Summary
including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 7 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
Doppler study report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 Y S N
Procedure Note with Discharge Summary
including procedure report and post
operative ECHO report 5 to 10 Y S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post
operative ECHO report 5 to 10 N S N
Procedure Note with Discharge Summary
including procedure report and post operative
ECHO report 5 to 10 N S N

Procedure Note with Discharge Summary

including procedure report and post operative
ECHO report 5 to 10 N S N
 Paediatrics Surgery

Average
length of
Stay
Preauth (Including
Required Mandatory Days in
Specialt Package Package or Not investigations for Post-Op investigations for intensive
y code Code Package name Amount (Y/N) pre-auth claims submission care units)
Procedure Note with
S14 00001 Ankyloglossia Major 15000 N Discharge Summary 3
Procedure Note with
S14 00002 Ankyloglossia Minor 5000 N Discharge Summary 2
Procedure Note with
S14 00003 Hernia & Hydrocele B/L 15000 N Discharge Summary 3
Procedure Note with
S14 00004 Sacrococcygeal Teratoma 20000 N Discharge Summary 5
Procedure Note with
S14 00005 Undescended Testis - Bilateral-Palp /Nonpalp 20,000 N Discharge Summary 5
Procedure Note with
S14 00008 Undescended Testis - Reexploration/ Second Stage 20,000 N Discharge Summary 5
Undescended Testis - Unilateral-Palpable/non Procedure Note with
S14 00009 palpable 15,000 N Discharge Summary 5
Procedure Note with
S14 00010 Ano Rectal Malformation - Abd-Perineal PSARP 20000 N Discharge Summary 5
Procedure Note with
S14 00011 Ano Rectal Malformation – Anoplasty 20000 N Discharge Summary 5
Procedure Note with
S14 00012 Ano Rectal Malformation – Cutback 7500 N Discharge Summary 3
 Procedure Note with
S14 00013 Ano Rectal Malformation - PSARP 22000 N Discharge Summary 5
Procedure Note with
S14 00014 Ano Rectal Malformation - Redo Pullthrough 15000 N Discharge Summary 3

Procedure Note with

S14 00015 Ano Rectal Malformation - Transposition 16500 N Discharge Summary 5
Procedure Note with
S14 00016 Anti GERD Surgery 11000 N Discharge Summary 3
Procedure Note with
S14 00017 Duplication Cyst Excision 20000 N Discharge Summary 5
Procedure Note with
S14 00018 Fecal Fistula Closure 25000 N Discharge Summary 5
Procedure Note with
S14 00019 Gastrostomy + Esophagoscopy+ Threading 20000 N Discharge Summary 5

Admission note with

relevant investigation
result report Procedure Note with
S14 00020 GI Tumor Excision 30000 Y including Biopsy Discharge Summary 5
Procedure Note with
S14 00021 Hirschsprung’s Disease - Myectomy 25000 N Discharge Summary 5
Procedure Note with
S14 00022 Hirschsprung’s Disease - Pull Through 25000 N Discharge Summary 5
Procedure Note with
S14 00023 Hirschsprung’s Disease - Retal Biopsy-Punch 7000 N Discharge Summary 3
Procedure Note with
S14 00024 Hirschsprung’s Disease - Retal Biopsy –Open 10000 N Discharge Summary 3
Procedure Note with
S14 00025 Hirschsprung’s Disease - Sphinecterotomy 10000 N Discharge Summary 3
Procedure Note with
S14 00026 Intussusception - Non –Operative Reduction in infants 10000 N Discharge Summary 3
 Procedure Note with
S14 00027 Intussusception – Operative in infants 25000 N Discharge Summary 5
Procedure Note with
S14 00028 Ladds Procedure 20000 N Discharge Summary 5
Procedure Note with
S14 00029 Rectal Polypectomy - Sigmoiescopic (Ga) 8000 N Discharge Summary 3
Procedure Note with
S14 00030 Retro-Peritoneal Lymphangioma Excision 25000 N Discharge Summary 5
Procedure Note with
S14 00031 Congenital Diaphragmatic Hernia 25000 N Discharge Summary 5
Procedure Note with
S14 00032 Congenital Lobar Emphysema 25000 N Discharge Summary 5
Procedure Note with
S14 00033 Exomphalos/gastroschisis 25000 N Discharge Summary 5
Procedure Note with
00034 Cleft Lip and Palate Surgery (per stage) 15,000 N Discharge Summary 2
Hernia & Hydrocele UL Procedure Note with
S14 10000 N Discharge Summary 3
Anal Dilatation Procedure Note with
S14 5000 N Discharge Summary 1
Anal Transposition for Ectopic Anus Procedure Note with
S14 19025 N Discharge Summary 5
Chordee Correction Procedure Note with
S14 11125 N Discharge Summary 3
Closure Colostomy Procedure Note with
S14 5000 N Discharge Summary 2
Colectomy Procedure Note with
S14 20000 N Discharge Summary 5
Colostomy Procedure Note with
S14 12000 N Discharge Summary 3
Colon Transplant Procedure Note with
S14 25000 N Discharge Summary 5
 Cystolithotomy Procedure Note with
S14 10000 N Discharge Summary 3
Esophageal Atresia (Fistula) Procedure Note with
S14 20475 N Discharge Summary 5
Gastrostomy Procedure Note with
S14 15000 N Discharge Summary 3
Hernia - Diaphragmatic Procedure Note with
S14 12000 N Discharge Summary 5
Hernia - Epigastric Procedure Note with
S14 8450 N Discharge Summary 3
Hernia-Inguinal – Unilateral Procedure Note with
S14 9000 N Discharge Summary 3
Hernia-Inguinal – Bilateral Procedure Note with
S14 12000 N Discharge Summary 3
Meckel's Diverticulectomy Procedure Note with
S14 13870 N Discharge Summary 5
Meniscectomy Procedure Note with
S14 6675 N Discharge Summary 3
Nephrolithotomy Procedure Note with
S14 15000 N Discharge Summary 5
Orchidopexy - Bilateral Procedure Note with
S14 11000 N Discharge Summary 3
Orchidopexy - Unilateral) Procedure Note with
S14 7000 N Discharge Summary 3
Pyelolithotomy Procedure Note with
S14 15000 N Discharge Summary 5
Pyeloplasty Procedure Note with
S14 17500 N Discharge Summary 5
Pyloric Stenosis (Ramsted OP) Procedure Note with
S14 12500 N Discharge Summary 5
Rectal Polyp Procedure Note with
S14 4000 N Discharge Summary 2
 Resection & Anastamosis of Intestine Procedure Note with
S14 16000 N Discharge Summary 5
Undescended Testis - Bilateral Non- Procedure Note with
S14 Palpable (laparoscopic) 25000 N Discharge Summary 5
Procedure Note with
S14 Bronchoscopy Diagnostic (GA) 5000 N Discharge Summary D
Procedure Note with
S14 Bronchoscopy for foreign body 12000 N Discharge Summary 2
Procedure Note with
S14 Cystoscopy - Diagnostic 4000 N Discharge Summary D
Procedure Note with
S14 Cystoscopy - Valve ablation 15000 N Discharge Summary 2
Procedure Note with
S14 Cystoscopy- Stent Removal & RGP 10000 N Discharge Summary 2
Procedure Note with
S14 Cystoscopy - Injection Deflux 15000 N Discharge Summary 1
Procedure Note with
S14 Proctoscopy 1500 N Discharge Summary D
Procedure Note with
S14 Sigmaidoscopy 5000 N Discharge Summary D
Procedure Note with
S14 Oesophagoscopy & dilation 8000 N Discharge Summary D
Procedure Note with
S14 Oesophagoscopy - Foresign Body removal 8000 N Discharge Summary 1
Procedure Note with
S14 Thoracoscopy - Diagnostic 10000 N Discharge Summary 1
Procedure Note with
S14 Throracoscopy - Theraputic for Empyema 20000 N Discharge Summary 3
Procedure Note with
S14 Thorocostomy 10000 N Discharge Summary 5
 Admission note with
relevant investigation Procedure Note with
S14 Ectopiavesica Primary Repair 30000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Bladder augmentation 30000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Ureteric Reimplantation - unilateral 20000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Ureteric Reimplantation -Bilateral 25000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Nephrectomy - Unilateral 30000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Choleclochal cyst Excision 20000 Y result report Discharge Summary 5
Procedure Note with
S14 Cholecystectomy - open 15000 N Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Cholecystectomy - Laparoscopic 25000 Y result report Discharge Summary 3
 Admission note with
relevant investigation Procedure Note with
S14 Hepatic Lobectomy - Cancer 25000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 KASAI- Operation -Biliaryatresia 30000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Splenectomy (Open) 25000 Y result report Discharge Summary 5

Admission note with

relevant investigation Procedure Note with
S14 Splenectomy (Laparoscopic) 30000 Y result report Discharge Summary 3
Procedure Note with
S14 Appendicectomy (Open) 11000 N Discharge Summary 5
Procedure Note with
S14 Appendicectomy (Laparocscopic) 18000 N Discharge Summary 2
Procedure Note with
S14 Thyroglossal Cyst Exersion 12000 N Discharge Summary 5
Procedure Note with
S14 Thyroidectomy (Hemi) 12000 N Discharge Summary 5
Procedure Note with
S14 Thyroidectomy -Total 20000 N Discharge Summary 5
Procedure Note with
S14 Lymphnode Biopsy neck/axilla,inguinal (one side) 7000 N Discharge Summary 2
Procedure Note with
S14 Lymphnode Biopsy (both side) 10000 N Discharge Summary 2
Procedure Note with
S14 Ranula Excision 5000 N Discharge Summary 2
 Procedure Note with
S14 Excision small swellings 1500 N Discharge Summary D
Supra Pubic Drainage - Open Procedure Note with
S14 4895 N Discharge Summary 1
Torsion Testis Procedure Note with
S14 12250 N Discharge Summary 3
Tracheo Esophageal Fistula Procedure Note with
S14 23320 N Discharge Summary 5
Ureterotomy Procedure Note with
S14 11125 N Discharge Summary 3
Urethroplasty Procedure Note with
S14 16875 N Discharge Summary 3
Vesicostomy Procedure Note with
S14 13425 N Discharge Summary 5
 Capped amount
(pacakge cannot
Govt Medical be used more Reserved
Reserved (M) or than the for Trust
Procedure Surgical mentioned Payment
(Y/N) (S) monetary limit) (Y/N)

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N

N S N
N S N

N S N

N S N

N S N

N S N

N S N

N S N
 Surgical Oncology

Average
length of
Stay
(Includin
Preauth g Days in
Spec Required intensive
ialty Packag Package or Not Mandatory investigations for Post-Op investigations for care
code e Code Package name Amount (Y/N) pre-auth claims submission units)

Admission note with relevant

investigation result report Procedure Note with
S15 00001 Tracheal resection 25,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00002 Sternotomy with superior mediastinal dissection 40,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00003 Substernal bypass 30,000 Y including Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report
including CECT/Biopsy/MRI Procedure Note with
S15 00004 Resection of nasopharyngeal tumour 40,000 Y report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00005 Myocutaneous flap 20,000 Y including Biopsy report Discharge Summary 5 to 7
 Admission note with relevant
investigation result report Procedure Note with
S15 00006 Fasciocutaneous flap 15,000 Y including Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report
including CECT/Biopsy/MRI Procedure Note with
S15 00007 Palatectomy- Soft palate 20,000 Y report Discharge Summary 5 to 7

Admission note with relevant

investigation result report
including CECT/Biopsy/MRI Procedure Note with
S15 00008 Palatectomy- Hard palate 20,000 Y report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00009 Microvascular reconstruction 45,000 Y including Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report
including CECT/Biopsy/MRI Procedure Note with
S15 00010 Composite resection 40,000 Y report Discharge Summary 5 to 7

Admission note with relevant

investigation result report
Composite resection with reconstruction(excluding including CECT/Biopsy/MRI Procedure Note with
S15 00011 microvascular) 60,000 Y report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00012 Neck dissection-selective 12,000 Y including Biopsy/FNAC report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00013 Neck dissection-comprehensive 16,000 Y including Biopsy report Discharge Summary 5 to 7
 Admission note with relevant
investigation result report
including CECT/Biopsy/MRI Procedure Note with
S15 00014 Total Maxillectomy 18,000 Y report Discharge Summary 5 to 7

Admission note with relevant

investigation result report
including CECT/Biopsy/MRI Procedure Note with
S15 00015 Radical Maxillectomy 25,000 Y report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00016 Radical parotidectomy 25,000 Y including CECT/FNAC/MRI report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00017 Partial laryngectomy ( voice preserving) 20,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00018 Voice prosthesis 30,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

Total Thyroidectomy with central compartment LN investigation result report Procedure Note with
S15 00019 dissection 20,000 Y including CECT/FNACreport Discharge Summary 5 to 7

Admission note with relevant

Total Thyroidectomy with central compartment LN investigation result report Procedure Note with
S15 00020 dissection with Lateral LN dissection 25,000 Y including CECT/FNAC report Discharge Summary 5 to 7

Admission note with relevant Procedure Note with

S15 00021 Tracheostomy 5,000 Y investigation result report Discharge Summary 1
 Admission note with relevant
investigation result report Procedure Note with
S15 00022 Axillary dissection 15,000 Y including Biopsy/FNAC report Discharge Summary 3

Admission note with relevant

Breast conserving surgery (lumpectomy + axillary investigation result report Procedure Note with
S15 00023 surgery) 12,000 Y including Biopsy/FNAC report Discharge Summary 3

Admission note with relevant Procedure Note with

investigation result report Discharge Summary
including CECT/FNAC/Biopsy including post operative
S15 00024 Lung metastectomy- solitary 30,000 Y report Chest X-ray 5 to 7

Admission note with relevant Procedure Note with

investigation result report Discharge Summary
including CECT/FNAC/Biopsy including post operative
S15 00025 Lung metastectomy- multiple (< four) 50,000 Y report Chest X-ray 5 to 7

Admission note with relevant Procedure Note with

investigation result report Discharge Summary
including CECT/FNAC/Biopsy including post operative
S15 00026 Lung metastectomy- multiple (> four) 60,000 Y report Chest X-ray 5 to 7

Admission note with relevant Procedure Note with

investigation result report Discharge Summary
including CECT/FNAC/Biopsy including post operative
S15 00027 Sleeve resection of lung cancer 70,000 Y report Chest X-ray 5 to 7

Admission note with relevant Procedure Note with

investigation result report Discharge Summary
including CECT/UGI including post operative
S15 00028 Oesophagectomy with two field lymphadenectomy 60,000 Y Endoscopy/Biopsy report Chest X-ray 5 to 7

Admission note with relevant Procedure Note with

investigation result report Discharge Summary
including CECT/UGI including post operative
S15 00029 Oesophagectomy with three field lymphadenectomy 60,000 Y Endoscopy/Biopsy report Chest X-ray 5 to 7
 Admission note with relevant
investigation result report Procedure Note with
S15 00030 Enucleation of pancreatic neoplasm 25,000 Y including CECT report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00031 Radical Cholecystectomy 25,000 Y including CECT/MRI report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00032 Abdominal wall tumour resection 25,000 Y including CECT report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00033 Abdominal wall tumour resection with reconstruction 35,000 Y including CECT report Discharge Summary 5 to 7

Procedure Note with

Admission note with relevant Discharge Summary
investigation result report including bar code of the
S15 00034 Oesophageal stenting including stent cost 40,000 Y including CECT report Stent 5 to 7

Admission note with relevant

investigation result report
including CECT/ Biopsy/ Procedure Note with
S15 00035 Triple bypass GI tract 30,000 Y Endoscopy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00036 Segmentectomy- hepatobiliary system 50,000 Y including CECT/MRI report Discharge Summary 5 to 7

Radical Hysterectomy + Bilateral pelvic lymph node Admission note with relevant
dissection + bilateral salpingo ophorectomy (BSO)/ investigation result report Procedure Note with
S15 00037 ovarian transposition 50,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant Procedure Note with

S15 00038 Skin Tumours Wide Excision + Reconstruction 25,000 Y investigation result report Discharge Summary 5 to 7
 Admission note with relevant Procedure Note with
S15 00039 Skin Tumours Amputation 8,000 Y investigation result report Discharge Summary 3

Admission note with relevant

investigation result report Procedure Note with
S15 00040 Radical Vaginectomy 30,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00041 Radical Vaginectomy + Reconstruction 35,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00042 Bilateral Pelvic Lymph Node Dissection (BPLND) 20,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00043 Radical Trachelectomy 40,000 Y including CECT/Biopsy report Discharge Summary 5 to 7

Admission note with relevant

investigation result report Procedure Note with
S15 00044 Vulvectomy with bilateral groin dissection 45,000 Y including Biopsy report Discharge Summary 5 to 7

Admission note with relevant Procedure Note with

investigation result report Discharge Summary
including CECT/Biopsy/ including X-ray showing
S15 00045 Limb salvage surgery for bone tumor with prosthesis 70,000 Y MRI/Bone scan report prosthesis 5 to 10

Admission note with relevant

investigation result report
including CECT/Biopsy/MRI Procedure Note with
S15 00046 Hemipelvectomy 45,000 Y report Discharge Summary 5 to 10
 Admission note with relevant
investigation result report
including CECT/Biopsy/MRI-Pelvis Procedure Note with
S15 00047 Sacral resection 40,000 Y report Discharge Summary 5 to 10

Admission note with relevant

investigation result report Procedure Note with
Chest wall resection with reconstruction for soft tissue including CT/Biopsy/ Chest x-ray Discharge Summary
S15 00048 / bone tumors 40,000 Y report including Chest x-ray 5 to 10
 Capped amount
(pacakge cannot
Govt Medical be used more Reserved
Reserved (M) or than the for Trust
Procedure Surgical mentioned Payment
(Y/N) (S) monetary limit) (Y/N)

Y S N

Y S N

Y S N

Y S N

Y S N
Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N
Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N
Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N
Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N
Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N

Y S N
Y S N

Y S N
 Oral & Maxillofacial Surgery
Special Packag Preauth Mandatory Post-Op investigations for claims Average Govt
ty code e Code Required investigations submission length of Reserved
or Not for pre-auth Stay Procedure
(Y/N) (Including (Y/N)
Days in
intensive
care units)

Package
Package name Amount

Procedure Note with Discharge

Fixation of fracture of jaw with closed reduction (1 Summary including Post operative
S16 00001 jaw) using wires - under LA 5,000 N X-ray D N

Procedure Note with Discharge

Fixation of fracture of jaw with open reduction (1 Summary including Post operative
S16 00002 jaw) and fixing of plates/ wire – under GA 22,000 N X-ray 2 N
Procedure Note with Discharge
S16 00003 Sequestrectomy 11,000 N Summary D N
Procedure Note with Discharge
S16 00004 TM joint ankylosis of both jaws - under GA 15,000 N Summary 2 N
Release of fibrous bands & grafting -in (OSMF) Procedure Note with Discharge
S16 00005 treatment under GA 3,000 N Summary 1 N
Procedure Note with Discharge
S16 00006 Extraction of impacted tooth under LA 500 N Summary D N

Cyst & tumour of Maxilla/mandible by Procedure Note with Discharge

S16 00007 enucleation/excision/marsupialization under LA 3,500 N Summary D N
Mandible Tumour Resection and Procedure Note with Discharge
S16 00008 reconstruction/Cancer surgery 9,000 N Summary including X-ray 2 N
2000 Procedure Note with Discharge
S16 Alveoloplasty- LA N Summary D N
 1000 Procedure Note with Discharge
S16 Apicoectomy N Summary D N
500 Procedure Note with Discharge
S16 Complicated Ext. per Tooth under LA N Summary D N
7000 Procedure Note with Discharge
S16 Correction of oro-antral communication- GA N Summary 2 N
5000 Procedure Note with Discharge
S16 Correction of sialocoele under GA N Summary 2 N
2000 Procedure Note with Discharge
S16 Correction of sialocoele under LA N Summary D N
I & D Dentoalveolar infection without extension to 1000 Procedure Note with Discharge
S16 fascial spaces N Summary D N
Dentoalveolar infection with extension to fascial 5000 Procedure Note with Discharge
S16 spaces N Summary 2 N
3000 Procedure Note with Discharge
S16 Dentoalveolar trauma - wiring N Summary D N
En bloc resection for benign aggressive tumors 14000 Procedure Note with Discharge
S16 under GA N Summary 3 N
7000 Procedure Note with Discharge
S16 Enucleation of odontogenic Cyst under GA N Summary 2 N
3000 Procedure Note with Discharge
S16 Enucleation of odontogenic Cyst under LA N Summary D N
Excision biopsy of precancerous/ suspicious hard 1000 Procedure Note with Discharge
S16 tissue lesions N Summary D N
1000 Procedure Note with Discharge
S16 Excision of mucocoele of U/L lip under LA N Summary D N
150 Procedure Note with Discharge
S16 Extraction of tooth including LA N Summary D N
11000 Procedure Note with Discharge
S16 Extraoral parotid sialolithotomy under GA N Summary 3 N
350 Procedure Note with Discharge
S16 Flap operation per Tooth N Summary D N
 Procedure Note with Discharge
Fracture mandible- open reduction and internal 9000 Summary including Post operative
S16 fixation under LA N X-ray 2 N

Procedure Note with Discharge

29000 Summary including Post operative
S16 Fracture mandible- management of complications N X-ray 3 N

Procedure Note with Discharge

5000 Summary including Post operative
S16 Fracture middle third of face- Closed reduction- LA N X-ray D N

Procedure Note with Discharge

Fracture middle third of face -Conservative 5000 Summary including Post operative
S16 management N X-ray D N

Procedure Note with Discharge

24000 Summary including Post operative
S16 Fracture middle third of face- Open reduction- GA N X-ray 3 N

Procedure Note with Discharge

6900 Summary including Post operative
S16 Fracture wiring under LA N X-ray D N

Procedure Note with Discharge

Fracture Zygoma open reduction and internal 25000 Summary including Post operative
S16 fixation- GA N X-ray 3 N
500 Procedure Note with Discharge
S16 Gingivectomy per Tooth N Summary D N
1000 Procedure Note with Discharge
S16 Impacted Molar including LA N Summary D N
9000 Procedure Note with Discharge
S16 Intraoral parotid sialolithotomy under GA N Summary 1 N
2000 Procedure Note with Discharge
S16 Intraoral parotid sialolithotomy under LA N Summary D N
2000 Procedure Note with Discharge
S16 Intraoral submandibular sialolithotomy under LA N Summary D N
 Intraoral/ Extra oral submandibular sialolithotomy 9000 Procedure Note with Discharge
S16 under GA N Summary 1 N
2000 Procedure Note with Discharge
S16 Labial frenum excision-LA N Summary D N
2000 Procedure Note with Discharge
S16 Lingual frenum excision- LA N Summary D N
2000 Procedure Note with Discharge
S16 Marsupialization of cysts under LA N Summary D N

Procedure Note with Discharge

24000 Summary including Post operative
S16 Naso- orbital fractures- management under GA N X-ray 3 N

Procedure Note with Discharge

Orbital blow out fractures correction with 24000 Summary including Post operative
S16 homogenous grafts, alloplastic grafts N X-ray 3 N
5000 Procedure Note with Discharge
S16 Osteoradionecrosis management by sequestrectomy N Summary 2 N
9000 Procedure Note with Discharge
S16 Osteoradionecrosis management by excision N Summary 2 N
Osteoradionecrosis management by excision and 29000 Procedure Note with Discharge
S16 vascularized grafts N Summary 3 N
2000 Procedure Note with Discharge
S16 Pyogenic granuloma excision N Summary D N

Segmental resection for benign aggressive tumors

with reconstruction plate and nonvascularized 14500 Procedure Note with Discharge
S16 homografts under GA N Summary 2 N

Segmental Resection for benign aggressive tumors

with reconstruction plate and vascularized 29000 Procedure Note with Discharge
S16 homografts under GA N Summary 3 N
Segmental resection for benign aggressive tumors 14000 Procedure Note with Discharge
S16 with reconstruction plate under GA N Summary 2 N
1000 Procedure Note with Discharge
S16 Stripping of precancerous lesions with local closure N Summary D N
 10000 Procedure Note with Discharge
S16 Stripping of precancerous lesions with grafting N Summary 2 N
2000 Procedure Note with Discharge
S16 Sulcus extension procedures- LA N Summary D N
Trigeminal neuralgia management by absolute 1000 Procedure Note with Discharge
S16 alcohol injection N Summary D N
Trigeminal neuralgia management by peripheral 2000 Procedure Note with Discharge
S16 neurectomy N Summary D N
Medical
(M) or
Surgical
(S)

S
S

S
S

S
S

S
S

S
Capped amount
(pacakge cannot
be used more Reserved
than the for Trust
mentioned Payment
monetary limit) (Y/N)

N
N

N
N

N
N

N
N

N
 General Medicine
Specia Package Package name Package Amount per day (drop down) for Preauth Mandatory
lty Code admission type: Routine General ward (Rs Require investigations for pre-
code 750/ HDU (Rs 1250)/ ICU (without ventilator) d or Not auth
(Rs 1500)/ ICU (with ventilator)(Rs 2000) (Y/N)

The minimum number of days needed has to N Admission note with

be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00001 Acute gastroenteritis with moderate dehydration
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00002 Recurrent vomiting with dehydration
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00003 Dysentery
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00004 Renal colic
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00005 Acute bronchitis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00006 Pneumothroax
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00007 Accelerated hypertension
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00008 Congestive heart failure
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00009 Severe anemia
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00010 Diabetic ketoacidosis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00011 Acute febrile illness
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00012 Acutre excaberation of COPD
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00013 UTI
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00014 Malaria
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00015 Dengue fever
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00016 Chikungunya fever
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00017 Leptospirosis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00018 Enteric fever
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00019 Pneumonia
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00020 Acute excaberation of ILD
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00021 Liver abscess
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00022 Acute viral hepatitis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00023 Snake bite
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00024 Acute organophosphorus poisoning
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00025 Other poisoning
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00026 Pyrexia of unknown origin
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00027 Pericardial/ Pleural tuberculosis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00028 Systematic lupus erythematosus
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00029 Vasculitis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00030 Seizures
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00031 Bacterial/ fungal endocarditis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00033 Lung abscess/ Empyema
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00036 Persistent/ Chronic diarrohea
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00037 Acute and chronic pancreatitis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00038 Visceral leishmaniasis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00039 HIV with complications
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00041 Metabolic encephalopathy
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00042 Sickle cell Anemia
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00043 Poisonings with unstable vitals
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00044 Type 1/2 respiratory failure
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00045 Acute asthmatic attack
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00046 Acutre excaberation of COPD
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00047 Severe pneumonia
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00048 Acute gastroenteritis with severe dehydration
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00049 Hypertensive emergencies
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00050 Dengue hemorrhagic fever/Dengue shock syndrome
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00051 Complicated malaria
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00052 Heat stroke
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00053 Hyperosmolar Non-Ketotic coma
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00054 Cerebrovascular accident
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00055 Severe sepsis/Septic shock
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00056 Upper GI bleeding (conservative)
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00057 Upper GI bleeding (endoscopic)
 The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00058 Lower GI hemorrhage
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00062 Hydrocephalus
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00063 Cerebral sino-venous thrombosis
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
AKI/ renal failure(dialysis payable separately as an add
M1 00064 on package for )
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00065 Status epilepticus
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
documents
M1 00066 Status asthmaticus
The minimum number of days needed has to N Admission note with
be blocked first,depending on the needs it can relevant investigation
be enhanced by providing the supportive result report
Respiratory failure due to any cause (pneumonia, documents
asthma, COPD, ARDS, foreign body, poisoning, head
M1 00067 injury etc.)
M1 00068 Blood and blood component transfusion (admission 1000/day N
for a diagnostic procedure leading to treatment
requiring admission, e.g. bone marrow and bone
biopsy, endoscopy, liver biopsy, bronchoscopy, CT/MRI
under GA, broncho-alveolar lavage, lumbar puncture,
muscle biopsy, pleural aspiration, ascitic tapping etc.)

M1 00069 PLASMAPHERESIS(PLASMA FILTER)+DOUBLE LUMEN 25000 Y Admission note with

HEMODIALYSIS CATHETER with albumin replacement. relevant investigation
result report

M1 00071 High end radiological diagnostic (CT& MRI) - can only capped @ Rs 5000 per annum for a family Y Admission note with
be clubbed with medical package. Rs 5000 per annum relevant investigation
limit to a family result report

M1 00072 High end histopathology (Biopsies) and advanced capped @ Rs 5000 per annum for a family Y Admission note with
serology investigations - can only be clubbed with relevant investigation
medical package. Rs 5000 per annum limit to a family result report

M1 GENERAL MEDICINE-Any ailments can be admitted in the The minimum number of days needed has to Admission note with
respective ward as per the decision of the treating be blocked first,depending on the needs it can relevant investigation
Doctor,but has to be supported with substantiative be enhanced by providing the supportive result report
documents. documents

M1 Acute disseminated Encephalomyelities ,Multiple In addition cost of the drug-IV Methyl Y Admission note with
Sclerosis,Auto immune encephalities,longitudinally Prednisolone/Immunoglobulin if needed can relevant investigation
extensive myelities ,Acute Transverse Myelitis,Guillian be claimed using the template attached, along result report and the
Barre Syndrome with utilise Plasmapheresis package ,if template for additional
needed. request
M1 GENERAL MEDICINE-Acute Stroke In addition if Chemical Thrombolectomy is Y Admission note with
indicated cost of the drug can be claimed relevant investigation
using the template result report and the
template for additional
request

M1 GENERAL MEDICINE-Neuro muscular weakness due to In addition IV Immunoglobulin if needed can Y Admission note with
immune based diseases like AIDP,Myasthenia and be claimed using the template attached, along relevant investigation
CIDP with/without haemodynamic compromise with utilise Plasmapheresis package ,if result report and the
autonomic disturbance needed. template for additional
request

M1 GENERAL MEDICINE-Meningitis/Encephalitis- In addition the drugs needed exclusively for Y Admission note with
Bacterial/Fungal/Viral the care of the infection if needed can be relevant investigation
claimed using the template attached result report and the
template for additional
request

M1 GENERAL MEDICINE-Neck In addition the cost of Inj Botulinum toxin if Y Admission note with
dystonia/Blepharospasm/Hemifacial spasam /Writers needed can be claimed using the template relevant investigation
crampwhich needs treatment with Inj Botulinum toxin attached result report and the
template for additional
request

M1 APD with Cycler initiation and continuous dialysis for 5 days 15000 Y Admission note with
relevant investigation
result report

M1 CAPD initiation with fluid 17500 Y Admission note with

relevant investigation
result report
M1 CHARCOAL HEMOPERFUSION FOR POISONING 12500 Y Admission note with
(CATRIDGE+HEMODIALYSIS CATHETER ) relevant investigation
result report

M1 CONTINUOUS ARTERIO VENUS DIALYSIS (CAVD) 15000 Y Admission note with

relevant investigation
result report

M1 CRRT continuation one day additional 25000 Y Admission note with

relevant investigation
result report

M1 CRRT/CVVHDF initiation + cost for disposable 35000 Y Admission note with

relevant investigation
result report

M1 DIALYSIS FEMORAL CATHETERISATION BILATERAL 1500 N

M1 DONOR NEPHRECTOMY 45000 Y Admission note with

relevant investigation
result report

M1 DOUBLE LUMEN SUB CLAVIAN CATHETER 1500 N

M1 EMERGENCY DIALYSIS FEMORAL PUNCTURE 1000 N

M1 EMERGENCY DIALYSIS SUBCLAVIAN PUNCTURE 1250 N

M1 HAEMO DIALYSIS 900 N

M1 INTERMITANT PERITONEAL DIALYSIS 3000 N

M1 KIDNEY BIOPSY (NEEDLE AND LIGHT MICROSCOPY) 4000 Y Admission note with
relevant investigation
result report

M1 KIDNEY BIOPSY (NEEDLE+IMMUNOFLUORESCENCE AND 6000 Y Admission note with

LIGHT MICROSCOPY ) relevant investigation
result report

M1 KIDNEY BIOPSY (NEEDLE+IMMUNOFLUORESCENCE+LIGHT 13000 Y Admission note with

MICROSCOPY +Electron Microscopy) relevant investigation
result report

M1 Permanent Catheter ( double cuffed permeath )insertion 12500 Y Admission note with
alone relevant investigation
result report
M1 RENAL TRANSPLANTATION with conventional 150000 Y Admission note with
immunosupressant relevant investigation
result including
Biopsy/CT abdomen
report

M1 RENAL TRANSPLANTATION with induction 200000 Y Admission note with

immunosupressant relevant investigation
result including
Biopsy/CT abdomen
report

M1 Temporary Dialysis Catheter insertion 2500 N

M1 AV Shunt for dialysis 6,000 N

Post-Op Average Govt Medica
investigations for length of Reserve l (M) or
claims submission Stay d Surgical
(Including Proced (S)
Days in ure Capped
intensive (Y/N) amount
care units) (pacakge
cannot be
used more
than the Reserved
mentioned for Trust
monetary Payment
limit) (Y/N)
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Clinical Note with N M N
Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary
Procedure Note with N M N
Discharge Summary

Procedure Note with N S N

Discharge Summary

Procedure Note with N M N

Discharge Summary

Procedure Note with N M N

Discharge Summary

Clinical Note with N M N

Discharge Summary

Clinical Note with Y M N

Discharge Summary
Clinical Note with Y M N
Discharge Summary

Clinical Note with Y M N

Discharge Summary

Clinical Note with Y M N

Discharge Summary

Clinical Note with Y M N

Discharge Summary

Procedure Note with Y S N

Discharge Summary

Procedure Note with Y S N

Discharge Summary
Procedure Note with Y S N
Discharge Summary

Procedure Note with Y S N

Discharge Summary

Procedure Note with Y S N

Discharge Summary

Procedure Note with Y S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary

Procedure Note with N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary
Maintain a register in D N S N
the hospital to
document the dialysis
performed

Maintain a register in Domiciliary/D Y S N

the hospital to
document the patient
details and the copy
of bill for the solution,
to be retained
verification.

Procedure Note with D N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary
Procedure Note with 7 N S N
Discharge Summary

Procedure Note with 7 N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary

Procedure Note with D N S N

Discharge Summary
 Paediatrics Medicine
Package Amount per day (drop down)
for admission type: Routine General
ward (Rs 750)/ HDU /SNCU(Rs 1250)/
ICU/NICU (without ventilator) (Rs
1500)NICU/ ICU (with ventilator)(Rs
2000)

Preauth
Required Mandatory
Specialty Package or Not investigations for pre-
code Code Package name (Y/N) auth
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00001 Diarrhoea N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00002 Acute dysentery N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00003 Pneumonia N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00004 Urinary tract infection N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00005 Acute Exacerbation of asthma N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00006 Acute glomerulonephritis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00007 Acute urticaria/ Anaphylaxis acute asthma N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00008 Poisonings with normal vital signs N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00009 Febrile seizures/other seizures N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00010 Epileptic encephalopathy N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00011 Optic neuritis N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00012 Aseptic meningitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00013 Trauma N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00014 Pyrexia of unexplained origin N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00015 Chronic cough N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00016 Wheezing N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00017 Unexplained seizures N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
Global developmental delay/ Intellectual disability of relevant investigation
M2 00018 unknown etiology N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00019 Dysmorphic children N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00020 Rickets N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00021 Unexplained severe anemia N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00022 Short stature N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00023 Musculoskeletal problems N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00024 Developmental and behavioral disorders N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00025 Diabetic ketoacidosis N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00026 Nephrotic syndrome with peritonitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00027 Pyogenic meningitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00028 Persistent/ Chronic diarrhea N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00029 Acute severe malnutrition N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00030 Dengue N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00031 Enteric fever N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00032 Chikungunya N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00033 Acute hepatitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00034 Kala azar N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00035 Tuberculosis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00036 HIV with complications N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00037 Infantile cholestasis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00038 Haemolytic uremic syndrome N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00039 ITP N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00040 Juvenile myasthenia N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00041 Kawasaki Disease N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00042 Persistent pneumonia N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00043 Empyema N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00044 Immune haemolytic anemia N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00045 Cyanotic spells N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00046 Rheumatic fever N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00047 Rheumatoid arthritis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00048 Encephalitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00049 Chronic meningitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
Intracranial ring enhancing lesion with complication relevant investigation
M2 00050 (neurocysticercosis, tuberculoma) N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00051 Refractory seizures N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00052 Floppy infant N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00053 Acute neuroregression N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00054 Neuromuscular disorders N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00055 Opsoclonus myoclonus syndrome N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00056 Acute ataxia N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00057 Steven Johnson syndrome N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00058 Metabolic encephalopathy N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00059 Ketogenic diet initiation in refractory epilepsy N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00060 Inborn errors of metabolism N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00061 Wilson’s disease N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00062 Celiac disease N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00063 Unexplained jaundice N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00064 Unexplained hepatosplenomegaly N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00065 Severe pneumonia N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00066 Severe exacerbation of asthma N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00067 Acute kidney injury N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00068 Poisonings N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00069 Serious trauma with unstable vitals N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00070 Upper GI hemorrhage N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00071 Lower GI hemorrhage N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00072 Acute abdomen N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00073 Liver abscess N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00074 Complicated malaria N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00075 Severe dengue with shock N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00076 Congestive cardiac failure N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00077 Brain abscess N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00078 Acute encephalitic syndrome N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00079 Acute demyelinating myelopathy, N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
Immune mediated CNS disorders such as autoimmune relevant investigation
M2 00080 encephalitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00081 Acute transverse myelitis N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00082 Guillain Barre Syndrome N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00083 Hydrocephalus N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00084 Intracranial space occupying lesion N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00085 Cerebral malaria N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00086 Acute ischemic stroke N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00087 Cerebral sino-venous thrombosis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
Respiratory failure due to any causes (pneumonia, relevant investigation
M2 00088 asthma, foreign body, poisoning, head injury etc.) N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00089 Acute transverse myelitis N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00090 Acute encephalitis –infectious/immune-mediated N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00091 Convulsive & non convulsive status epilepticus N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00092 Cerebral herniation N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00093 Intracranial hemorrhage N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00094 Hepatic encephalopathy N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00095 Complicated bacterial meningitis N result report
 The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00096 Raised intracranial pressure N result report
The minimum number of days has to be
blocked first,depending on the needs it
can be enhanced providing the
supportive documents Admission note with
relevant investigation
M2 00097 Hypertensive encephalopathy N result report

Admission note with

relevant investigation
M2 00098 CRRT (per session) 20,000 Y result report

Blood and blood component transfusion up to a limit of

2 days(admission for a diagnostic procedure leading to
treatment requiring admission, e.g. bone marrow and
bone biopsy, endoscopy, liver biopsy, bronchoscopy,
CT/MRI under GA, broncho-alveolar lavage, lumbar
puncture, muscle biopsy, FNAC, pleural aspiration,
M2 00099 ascitic tapping, neostigmine challenge test etc.) 1000/ day N

Blood and blood component transfusion for indications

like Thalassemia/Hemoglobinopathies - upto a limit of 2
M2 00100 days 1000/ day N

High end radiological diagnostic (CT, MRI, Imaging Admission note with
including nuclear imaging) - can only be clubbed capped @ Rs 5000 per annum for a relevant investigation
M2 00101 with medical package. family Y result report

High end histopathology (Biopsies) and advanced Admission note with

serology investigations - can only be clubbed with capped @ Rs 5000 per annum for a relevant investigation
M2 00102 medical package. family Y result report
 PAEDIATRICS MEDICINE-Any ailments can be admitted The minimum number of days has to be
in the respective ward as per the decision of the treating blocked first,depending on the needs it
Doctor,but has to be supported with substantiative can be enhanced providing the
documents. supportive documents
Admission note with
relevant investigation
M2 N result report
 Average
length of
Stay
(Including
Days in Govt Medical
intensive Reserved (M) or
Post-Op investigations care Procedur Surgical
for claims submission units) e (Y/N) (S)

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M
clinical Note with
Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M
clinical Note with
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clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M
clinical Note with
Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M
clinical Note with
Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M
clinical Note with
Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

Discharge Summary N M

clinical Note with

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clinical Note with

Discharge Summary N M
clinical Note with
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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

Discharge Summary N M
clinical Note with
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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with

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clinical Note with
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clinical Note with

Discharge Summary N M

Procedure Note with

Discharge Summary N M

Procedure Note with

Discharge Summary N M

Procedure Note with

Discharge Summary N M

Procedure Note with

Discharge Summary N M

Procedure Note with

Discharge Summary N M
clinical Note with
Discharge Summary N M
Capped
amount
(pacakge
cannot
be used
more
than the
mentione Reserved
d for Trust
monetary Payment
limit) (Y/N)

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N

N
N
 Neonatology

Preauth
Required
Package or Not
Package name Amount (Y/N)
M3 00001
Basic neonatal care package (Rs. 500 per day, maximum 1500): Babies that can be
managed by side of mother in postnatal ward without requiring admission in
SNCU/NICU:
• Any newborn needing feeding support
• Babies requiring closer monitoring or short-term care for conditions like: 500/ day
o Birth asphyxia (need for positive pressure ventilation; no HIE)
o Moderate jaundice requiring phototherapy
o Large for dates (>97 percentile) Babies
o Small for gestational age (less than 3rd centile)
N
M3 00002 Special Neonatal Care Package (Rs. 2500 per day, maximum of 15000 - pre-auth after 4
days): Babies that required admission to SNCU or NICU
Babies admitted for short term care for conditions like:
• Mild Respiratory Distress/tachypnea
• Mild encephalopathy
• Severe jaundice requiring intensive phototherapy
• Haemorrhagic disease of newborn
• Unwell baby requiring monitoring
• Some dehydration
• Hypoglycaemia
Mother's stay in the hospital for breastfeeding, family centred care and (Kangaroo
Mother Care) KMC is mandatory and included in the package rate

2500/day Y
M3 00003 Intensive Neonatal Care Package (Rs. 4000 per day, maximum of Rs. 40,000 – pre-auth is
needed after 5 days)
Babies with birthweight 1500-1799 g

or
Babies of any birthweight and at least one of the following conditions:

• Need for mechanical ventilation for less than 24 hours or non-invasive respiratory
support (CPAP, HFFNC)

• Sepsis / pneumonia without complications

• Hyperbilirubinemia requiring exchange transfusion

• Seizures
• Major congenital malformations (pre-surgical stabilization, not requiring ventilation)

• Cholestasis significant enough requiring work up and in-hospital management

• Congestive heart failure or shock
Mother's stay and food in the hospital for breastfeeding, family centred care and
(Kangaroo Mother Care) KMC is mandatory and included in the package rate

4000/day Y
 is needed after 7 days):
M3 00004 Babies with birthweight of 1200-1499 g

or
Babies of any birthweight with at least one of the following conditions:
• Any condition requiring invasive ventilation longer than 24 hours

• Hypoxic Ischemic encephalopathy requiring Therapeutic Hypothermia

• Cardiac rhythm disorders needing intervention (the cost of cardiac surgery or implant
will be covered under cardiac surgery packages)

• Sepsis with complications such as meningitis or bone and joint infection, DIC or shock
• Renal failure requiring dialysis

• Inborn errors of metabolism

Mother's stay in the hospital for breastfeeding, family centred care and (Kangaroo
Mother Care) KMC is mandatory and included in the package rate
5000/day Y
M3 00005 Critical Care Neonatal Package (Rs. 6000 per day, maximum of Rs. 90,000 – pre-auth
after 10 days):
Babies with birthweight of <1200 g

or
Babies of any birthweight with at least one of the following conditions:

• Severe Respiratory Failure requiring High Frequency Ventilation or inhaled Nitric Oxide
(iNO)
• Multisystem failure requiring multiple organ support including mechanical ventilation
and multiple inotropes
• Critical congenital heart disease
Mother's stay in the hospital for breastfeeding, family centred care and (Kangaroo
Mother Care) KMC is mandatory and included in the package rate

6000/day Y
M3 00006 Chronic Care Package (Rs. 2500 per day, maximum of Rs. 25,000): If the baby requires
stay beyond the upper limit of usual stay in Package no 0004 or 0005 for conditions like
severe BPD requiring respiratory support, severe NEC requiring prolonged TPN support

2500/day Y
M3 00008
Laser Therapy for Retinopathy of Prematurity (Irrespective of no. of eyes affected) 1,500 Y
M3 00009
Advanced Surgery for Retinopathy of Prematurity 15,000 Y
M3 00010
Ventriculoperitoneal Shunt Surgery (VP) or Omaya Reservoir or External Drainage 5,000 Y
onatology

Medical
Average length of Stay (M) or
Mandatory investigations for pre- Post-Op investigations (Including Days in Govt Reserved Surgical
auth for claims submission intensive care units) Procedure (Y/N) (S)
<5 Days N

Clinical Note with

Discharge Summary M
Admission note on diagnosis and <7 Days N
supported by investigations Blood
sugar, Complete blood picture,
Bilirubin, Coombs test, blood
group

Clinical Note with

Discharge Summary M
Admission note on diagnosis and 7 to 14 days N
supported by investigations Blood
sugar, Complete blood picture,
Bilirubin, Coombs test, blood
group, Serum Calcium and Serum
magnesium. Imaging methods
and other documentation as
required.

Clinical Note with

Discharge Summary M
Admission note on diagnosis and 7 to 14 days N
supported by investigations
Blood sugar, Complete blood
picture, Bilirubin, Coombs test,
blood group, Serum Calcium and
Serum magnesium, x-ray chest.
High end imaging methods and
other documentation as required.

Clinical Note with

Discharge Summary M
Admissionl note on diagnosis and 14 to 21 days N
supported by investigations
Blood sugar, Complete blood
picture, Bilirubin, Coombs test,
blood group, Serum Calcium and
Serum magnesium, x-ray chest.
High end imaging methods and
other documentation as required.

Clinical Note with

Discharge Summary M
Clinical notes supporting the 21 to 42 dys N
request

Clinical Note with

Discharge Summary M
Clinical notes supporting the N
request Clinical Note with
Discharge Summary S
N
Admission note with relevant Procedure Note with
investigation result report Discharge Summary S
N
Admission note with relevant Procedure Note with
investigation result report Discharge Summary S
Capped
amount
(pacakge
cannot
be used
more
than the
mentione Reserved
d for Trust
monetary Payment
limit) (Y/N)

N
N
N

N
N

N
cccccccccccccc
cccccccccccccccccccccccccc

Specialt Packag
y code e Code Package name
Acute lymphoblastic leukemia
(chemotherapy including
M3 00001 diagnostics): induction
Acute lymphoblastic leukemia
(chemotherapy including
M3 00002 diagnostics): consolidation 35,000
Acute lymphoblastic leukemia
(chemotherapy including
M3 00003 diagnostics): maintainence
Paediatrics Oncology
Average
Preauth length of Stay
Require (Including Govt
d or Days in Reserved
Package Not Mandatory investigations Post-Op investigations for intensive care Procedure
Amount (Y/N) for pre-auth claims submission units) (Y/N)
Clinical note including
result of relevant
investigations like Clinical note with Physical
Haematology Bone examination, Blood
marrow examination, FISH investigations, Bone marrow
55,000 Y study, CSF cytology examination result Y
Clinical note including
result of relevant
investigations like Clinical note with Physical
Haematology Bone examination, Blood
marrow examination, FISH investigations, Bone marrow
Y study, CSF cytology examination result Y
Clinical note including
result of relevant
investigations like Clinical note with Physical
Haematology Bone examination, Blood
marrow examination, FISH investigations, Bone marrow
15,000 Y study, CSF cytology examination result Y

Acute lymphoblastic leukemia:
M3 00004 radiation 5,000
Acute lymphoblastic leukemia:
M3 00005 Supportive care/ rehabilitation 20,000
Acute myeloid leukemia
(chemotherapy including
M3 00006 diagnostics): induction 55,000
Acute myeloid leukemia
(chemotherapy including
M3 00007 diagnostics): consolidation 35,000
Acute myeloid leukemia:
M3 00008 Supportive care/ rehabilitation 30,000
Hodgkin Lymphoma (Favorable
group) (chemotherapy
including diagnostics):
M3 00009 induction 45,000
Clinical note including
result of relevant
investigations like Clinical note with Physical
Haematology Bone examination, Blood
marrow examination, FISH investigations, Bone marrow
Y study, CSF cytology examination result Y
Clinical note including
result of relevant
investigations like Clinical note with Physical
Haematology Bone examination, Blood
marrow examination, FISH investigations, Bone marrow
Y study, CSF cytology examination result Y
Clinical note including
Clinical assessment and
result of relevant Chemotherapy drug batch
Haematology number with bar code and the
Y investigations bill of the medicines Y
Clinical note including
Clinical assessment and
result of relevant Chemotherapy drug batch
Haematology number with bar code and the
Y investigations bill of the medicines Y
Clinical note including
Clinical assessment and
result of relevant Clinical assesssment and Bill of
Y investigations the medicines Y
Clinical note including Chemotherapy drug batch
Clinical assessment and number with bar code and the
Y result of Biopsy/CT bill of the medicines Y
 Clinical note including
Clinical assessment and
Hodgkin Lymphoma (Favorable result of relevant Data of Radiation treatment
M3 00010 group): radiation 10,000 Y investigations plan & dose Y

Clinical note including

Hodgkin Lymphoma (Favorable Clinical assessment and
group): Supportive care/ result of relevant Clinical assesssment and Bill of
M3 00011 rehabilitation 15,000 Y investigations the medicines Y

Hodgkin Lymphoma
(unfavorable group): Clinical note including Chemotherapy drug batch
chemotherapy including Clinical assessment and number with bar code and the
M3 00012 diagnostics 70,000 Y result of Biopsy/CT bill of the medicines Y

Clinical note including

Clinical assessment and
Hodgkin Lymphoma result of relevant Data of Radiation treatment
M3 00013 (unfavorable group): radiation 15,000 Y investigations plan & dose Y

Clinical note including

Hodgkin Lymphoma Clinical assessment and
(unfavorable group): result of relevant Clinical assesssment and Bill of
M3 00014 Supportive care/ rehabilitation 25,000 Y investigations the medicines Y

Non-Hodgkin Lymphoma: Clinical note including Chemotherapy drug batch

chemotherapy including Clinical assessment and number with bar code and the
M3 00015 diagnostics 100,000 Y result of Biopsy/CT bill of the medicines Y

Clinical note including

Clinical assessment and
Non-Hodgkin Lymphoma: result of relevant Clinical assesssment and Bill of
M3 00016 Supportive care/ rehabilitation 50,000 Y investigations the medicines Y

Clinical note including

Retinoblastoma (Intraocular): Clinical assessment and Chemotherapy drug batch
chemotherapy including result of relevant number with bar code and the
M3 00017 diagnostics 45,000 Y investigations bill of the medicines Y
 Clinical note including
Clinical assessment and
Retinoblastoma (Intraocular): result of relevant Data of Radiation treatment
M3 00018 radiation 10,000 Y investigations plan & dose Y

Clinical note including

Clinical assessment and Procedure note with Clinical
Retinoblastoma (Intraocular): result of relevant assessment and discharge
M3 00019 surgery 10,000 Y investigations summary Y

Clinical note including

Clinical assessment and
Retinoblastoma (Intraocular): result of relevant Clinical assesssment and Bill of
M3 00020 supportive care/ rehabilitation 20,000 Y investigations the medicines Y

Clinical note including

Retinoblastoma (extraocular): Clinical assessment and Chemotherapy drug batch
chemotherapy including result of relevant number with bar code and the
M3 00021 diagnostics 65,000 Y investigations bill of the medicines Y

Clinical note including

Clinical assessment and
Retinoblastoma (extraocular): result of relevant Data of Radiation treatment
M3 00022 radiation 10,000 Y investigations plan & dose Y

Clinical note including

Clinical assessment and
Retinoblastoma (extraocular): result of relevant Clinical assesssment and Bill of
M3 00023 supportive care/ rehabilitation 35,000 Y investigations the medicines Y

Clinical note including

Clinical assessment and Chemotherapy drug batch
Brain tumors: chemotherapy result of relevant number with bar code and the
M3 00024 including diagnostics 40,000 Y investigations bill of the medicines Y

Clinical note including

Clinical assessment and
result of relevant Data of Radiation treatment
M3 00025 Brain tumors: radiation 30,000 Y investigations plan & dose Y
 Clinical note including Procedure note with Clinical
Clinical assessment and assessment and discharge
result of relevant summary including post
M3 00026 Brain tumors: surgery 40,000 Y investigations including CT operative CT Y

Clinical note including

Clinical assessment and
Brain tumors: supportive care/ result of relevant Clinical assesssment and Bill of
M3 00027 rehabilitation 25,000 Y investigations the medicines Y

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Wilms tumors: chemotherapy investigations including number with bar code and the
M3 00028 including diagnostics 20,000 Y CT/Biopsy bill of the medicines Y

Clinical note including

Clinical assessment and
result of relevant Data of Radiation treatment
M3 00029 Wilms tumors: radiation 5,000 Y investigations plan & dose Y

Clinical note including

Clinical assessment and Procedure note with Clinical
result of relevant assessment and discharge
M3 00030 Wilms tumors: surgery 20,000 Y investigations summary Y

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Histiocytosis: chemotherapy investigations including number with bar code and the
M3 00031 including diagnostics 45,000 Y CT/Biopsy bill of the medicines Y

Clinical note including

Clinical assessment and
Histiocytosis: supportive care/ result of relevant Clinical assesssment and Bill of
M3 00032 rehabilitation 5,000 Y investigations the medicines Y

Bone tumors/soft tissue
sarcomas : chemotherapy
M3 00033 including diagnostics
Bone tumors/soft tissue
M3 00034 sarcomas : radiation
Bone tumors/soft tissue
sarcomas : surgery (inlcuding
M3 00035 prosthesis)
Bone tumors/soft tissue
sarcomas : supportive care/
M3 00036 rehabilitation
Chronic Myeloid Leukemia :
chemotherapy including
M3 00037 diagnostics
Clinical note including
Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
investigations including number with bar code and the
80,000 Y CT/X-ray/CT scan/Biopsy bill of the medicines Y
Clinical note including
Clinical assessment and
result of relevant
investigations including Data of RT treatment plan &
25,000 Y CT/X-ray/CT scan/Biopsy dose Y
Clinical note including
Clinical assessment and
result of relevant Procedure note with Clinical
investigations including assessment and discharge
80,000 Y CT/X-ray/CT scan/Biopsy summary Y
Clinical note including
Clinical assessment and
result of relevant
investigations including Clinical assesssment and Bill of
50,000 Y CT/X-ray/CT scan/Biopsy the medicines Y
Clinical note including
Clinical assessment and Clinical assesssment,relevant
result of relevant investigation results like CBC
investigations including with periphersl smear/bone
Bone marrow aspiration marrow cytologyand Bill of the
80,000 Y cytology medicines Y
 Clinical note including
Clinical assessment and Clinical assesssment,relevant
result of relevant investigation results like CBC
investigations including with periphersl smear/bone
Chronic Myeloid Leukemia : Bone marrow aspiration marrow cytologyand Bill of the
M3 00038 supportive care/ rehabilitation 20,000 Y cytology medicines Y

If the treating Doctor suggest a chemotherapy for a

PAEDIATRICS ONCOLOGY- malignancy condition not enlisted here,the cost of that
Request for Chemotherapy drug as per KMSCL rate has to be reimbursed based on the
-based on a template Y request submitted in the Template Y

If the treating Doctor suggest a radiation treatment for a

PAEDIATRICS ONCOLOGY- malignancy condition not enlisted here,the cost of that
Request for Radiation-based radiation therapy has to be reimbursed based on the
on a template Y request submitted in the Template Y
 Capped
amount
(pacakge
Medical cannot be used Reserved
(M) or more than the for Trust
Surgical mentioned Payment
(S) monetary limit) (Y/N)

M N

M N

M N
M N

M N

M N

M N

M N

M N
M N

M N

M N

M N

M N

M N

M N

M N
M N

M N

M N

M N

M N

M N

M N

M N
M N

M N

M N

M N

M N

M N

M N
M N

M N

M N

M N

M N
M N

M N

M N
 Preauth
Speci Required
alty Package Package or Not Mandatory investigations Post-Op investigations for claims
code Code Site Package name Amount (Y/N) for pre-auth submission

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Lymphoma, Non- investigations including number with bar code and the
M5 00001 Hodgkin’s R-CHOP Regimen (per cycle) x 6 25,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Chemotherapy drug batch
Multiple Bortezomib+ lenalidomide+ result of relevant number with bar code and the
M5 00002 Myeloma dexamethasone, per cycle x6 20,000 Y investigations bill of the medicines

Clinical note including

Clinical assessment and Chemotherapy drug batch
Multiple Bortezomib+ cyclophosphamide+ result of relevant number with bar code and the
M5 00003 Myeloma dexamethasone, per cycle x 6 10,000 Y investigations bill of the medicines

Clinical note including

Clinical assessment and Chemotherapy drug batch
Multiple MPT - melphalan, thalidomide and result of relevant number with bar code and the
M5 00004 Myeloma prednisolone, per cycle x 9 6,000 Y investigations bill of the medicines

Clinical note including

Clinical assessment and Chemotherapy drug batch
Multiple Bortezomib + dexamethasone, per result of relevant number with bar code and the
M5 00005 Myeloma cycle x 9 6,000 Y investigations bill of the medicines

Clinical note including

Clinical assessment and Chemotherapy drug batch
Multiple Thalidomide+Dexamethasone(Oral)/ result of relevant number with bar code and the
M5 00006 Myeloma month - max 12 months 3,000 Y investigations bill of the medicines
 Clinical note including
Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
5-Fluorouracil-Oxaliplatin - Leucovorin investigations including number with bar code and the
M5 00007 Colon Rectum (FOLFOX) - Max. 6 cycles (Per cycle) 10,000 Y CT/Biopsy bill of the medicines

Bone Clinical note including

Tumors/Osteosar Clinical assessment and Clinical assessment,
coma/ result of relevant Chemotherapy drug batch
Hepatoblastoma Cisplatin/carboplatin - Adriamycin- investigations including number with bar code and the
M5 00008 -Operable max 6 cycles (Per cycle) 3,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
Adriamycin Bleomycin result of relevant Chemotherapy drug batch
Lymphoma, VinblastinDacarbazine (ABVD) - max 8 investigations including number with bar code and the
M5 00009 Hodgkin'S cycles (Per cycle) (Day 1 & Day 15) 10,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Cisplatin/Carboplatin (AUC2) along investigations including number with bar code and the
M5 00010 Cervix with RT- max 6 cycles (Per cycle) 5,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Neuroblastoma Variable Regimen – Neuroblastoma - investigations including number with bar code and the
M5 00011 Stage I –III max 1 year (Per cycle) 9,000 Y CT/Biopsy bill of the medicines

Clinical note including

SIOP/National Wilms Tumour Study Clinical assessment and Clinical assessment,
Group (NWTS) regimen(Stages I - V)- result of relevant Chemotherapy drug batch
max 6 months (Per month) - Wilm's investigations including number with bar code and the
M5 00012 Wilm'sTumor tumour 7,000 Y CT/Biopsy bill of the medicines
 Clinical note including
Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
investigations including number with bar code and the
M5 00013 Colon - rectum Monthly 5-FU 4,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
investigations including number with bar code and the
M5 00014 Breast Paclitaxel weekly x 12 weeks 4,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Cyclophosphamide/Methotrexate/5Fl investigations including number with bar code and the
M5 00015 Breast uorouracil (CMF) (Per cycle) 1,500 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Tamoxifen tabs - maximum 12 cycles investigations including number with bar code and the
M5 00016 Breast (Per month) 100 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Adriamycin/Cyclophosphamide (AC) – investigations including number with bar code and the
M5 00017 Breast per cycle (Maximum 4 cycles) 3,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
5- Fluorouracil A-C (FAC) – per cycle investigations including number with bar code and the
M5 00018 Breast (Maximum 6 cycles) 3,100 Y CT/Biopsy bill of the medicines
 Clinical note including
Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
investigations including number with bar code and the
M5 00019 Breast AC (AC Then Taxol) 3,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Small Cell Lung Cisplastin/Etoposide (IIIB) – per cycle investigations including number with bar code and the
M5 00020 Cancer (Max. 6 cycles only) 4,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
Cisplatin + 5 FU(Neoadjuvant result of relevant Chemotherapy drug batch
Oncology Chemotherapy)/Adjuvant (ADJ)- per investigations including number with bar code and the
M5 00021 oesophagus cycle (Max. of 6 cycles only) 3,000 Y CT/Biopsy bill of the medicines

Clinical note including

Docetaxel +Oxaliplatin+5FU Clinical assessment and Clinical assessment,
20,000 per cycle for 4 cycles result of relevant Chemotherapy drug batch
CapOX- 10,000 per cycle for 8 cycles investigations including number with bar code and the
M5 00022 Stomach 4,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
Aromatase Inhibitors result of relevant Chemotherapy drug batch
(Anastazole/Letrozole/Exemestane) - investigations including number with bar code and the
M5 00023 Breast maximum 12 cycles (Per month) 900 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Weekly Cisplatin/Carboplatin- max 6 investigations including number with bar code and the
M5 00024 Urinary Bladder cycles with RT (Per week) 2,000 Y CT/Biopsy bill of the medicines
 Clinical note including
Clinical assessment and
result of relevant
MethotraxateVinblastin Adriamycin investigations including
M5 00025 Urinary Bladder Cyclophosphamide (MVAC) 5,000 Y CT/Biopsy
Clinical assessment,
Chemotherapy drug batch
number with bar code and the
bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Carbo/Etoposide/Vincristine-max 6 investigations including number with bar code and the
M5 00026 Retinoblastoma cycles (Per cycle) 4,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Febrile IV antibiotics and other supportive investigations including number with bar code and the
M5 00027 Neutropenia therapy (Per episode) 30,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Vaginal/ Vulval investigations including number with bar code and the
M5 00028 Cancer Cisplastin/5-FU 3,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Taxol + Carboplatin-max 6 cycles (Per investigations including number with bar code and the
M5 00029 Ovary cycle) 15,000 Y CT/Biopsy bill of the medicines

Clinical note including

Melphalan -Prednisone (oral) – per Clinical assessment and Chemotherapy drug batch
Multiple month (max 12 months) - Ovarian CA, result of relevant number with bar code and the
M5 00030 Myeloma Bone CA 1,500 Y investigations bill of the medicines
 Clinical note including
Clinical assessment and
result of relevant Chemotherapy drug batch
Rectal Cancer Gemcitabine +capecitabine-15,000 investigations including number with bar code and the
M5 00031 Stage 2 And 3 per cycle for 6 cycles 4,000 Y Beta - HCG report,CT bill of the medicines

Clinical note including

Clinical assessment and
result of relevant Chemotherapy drug batch
Multiple Zoledronic acid - Max 12 cycles (Per investigations including number with bar code and the
M5 00032 Myeloma month) 2,000 Y Beta - HCG report,CT bill of the medicines

Clinical note including

Etoposide-Methotrexate- Clinical assessment and
Gestational Actinomycin / Cyclophosphamide result of relevant Chemotherapy drug batch
Trophoblast Ds. -Vincristine (EMA-CO)-max 6 cycles investigations including number with bar code and the
M5 00033 High Risk (Per cycle) 10,000 Y Beta - HCG report,CT bill of the medicines

Clinical note including

Clinical assessment and
Gestational result of relevant Chemotherapy drug batch
Trophoblast Ds. investigations including number with bar code and the
M5 00034 Low Risk Actinomycin- max 10 cycles (Per cycle) 1,000 Y Beta - HCG report,CT bill of the medicines

Clinical note including

Clinical assessment and
Gestational result of relevant Chemotherapy drug batch
Trophoblast Ds. Weekly Methotrexate (Per week) max. investigations including number with bar code and the
M5 00035 Low Risk 10 cycles 1,000 Y Beta - HCG report,CT bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Ovary Germ Cell Bleomycin-Etoposide-Cisplatin (BEP) - investigations including number with bar code and the
M5 00036 Tumour max cycles 4 (Per cycle) 6,000 Y CT/Biopsy bill of the medicines
 Clinical note including
Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
investigations including number with bar code and the
M5 00037 Prostate Hormonal Therapy - Per month 3,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
Bleomycin-Etoposide-Cisplatin (BEP) result of relevant Chemotherapy drug batch
regimen for germ cell tumour - max investigations including number with bar code and the
M5 00038 Testis cycles 4 (Per cycle) 10,000 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
Induction Phase, up to (Daunomycin result of relevant Chemotherapy drug batch
Acute Myeloid and cytosine arabinoside (3:7)) investigations including number with bar code and the
M5 00039 Leukemia 100,000 Y Hematology bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
Consolidation Phase, up to (High dose result of relevant Chemotherapy drug batch
Acute Myeloid cytosine arabinoside – per cycle, max. investigations including number with bar code and the
M5 00040 Leukemia of 3 to 4 cycles) 75,000 Y Hematology bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Variable Regimen-Histocyosis-max 1 investigations including number with bar code and the
M5 00041 Histocytosis year (Per month) 8,000 Y CT/Biopsy bill of the medicines

Clinical note including

Vincristine-Actinomycin- Clinical assessment and Clinical assessment,
Cyclophosphamide (VACTC) based result of relevant Chemotherapy drug batch
Rhabdomyosarco chemo - max 1 year (Per month) - investigations including number with bar code and the
M5 00042 ma Rhabdomyosarcoma 6,000 Y CT/Biopsy bill of the medicines
 Clinical note including
Clinical assessment and
result of relevant
Variable Regimen Inv - Hematology, investigations including
M5 00043 Ewing’s Sarcoma Biopsy – Payable 6,000 Y CT/Biopsy
Clinical assessment,
Chemotherapy drug batch
number with bar code and the
bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Unlisted investigations including number with bar code and the
M5 00044 Regimen Palliative CT- Max 6 cycles (Per cycle) 5,000 Y CT/Biopsy bill of the medicines
Palliative And Supportive Therapy -
M5 00045 Terminally Ill Per month 3,000 Y

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Acute Lymphatic investigations including number with bar code and the
M5 00046 Leukemia Maintenance Phase - Per month (x 24) 5,000 Y Hematology bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Acute Lymphatic investigations including number with bar code and the
M5 00047 Leukemia Induction 50,000 Y Hematology bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Acute Lymphatic investigations including number with bar code and the
M5 00048 Leukemia Consolidation Phase 50,000 Y Hematology bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Tab Geftinib/Erlotinib-Max 1 Year (Per investigations including number with bar code and the
M5 00049 Head and Neck month) 3,000 Y CT/Biopsy bill of the medicines
 Clinical note including
Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Renal cell investigations including number with bar code and the
M5 00050 carcinoma Sunitinib/ Pazopanib (per day) 2,500 Y CT/Biopsy bill of the medicines

Clinical note including

Clinical assessment and
result of relevant Clinical assessment,
investigations including Chemotherapy drug batch
Chronic myeloid Bone Marrow Aspiration number with bar code and the
M5 00051 leukemia Imatinib (per month) x 5 years 6,000 Y Report bill of the medicines

Clinical note including

Clinical assessment and Clinical assessment,
result of relevant Chemotherapy drug batch
Gall Bladder Gemcitabine + cisplatin (per cycle) – investigations including number with bar code and the
M5 00052 Cancer for 6 cycles 10,000 Y CT/Biopsy bill of the medicines

If the treating Doctor suggest a chemotherapy for a

malignancy condition not enlisted here,the cost of that drug
MEDICAL ONCOLOGY-Chemotherapy as per KMSCL rate has to be reimbursed based on the
M5 based on a request in Template Y request submitted in the Template
Average
length of
Stay Govt
(Including Reserve Medical
Days in d (M) or
intensive Procedur Surgical
care units) e (Y/N) (S)

Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M

Y M

Y M

Y M
Y M

Y M

Y M

Y M
 Radiation Oncology

Preauth
Special Required
ty Package Package or Not Mandatory investigations for pre- Post-Op investigations for
code Code Package name Amount (Y/N) auth claims submission

Clinical note including Clinical

Cobalt 60 External Beam Radiotherapy assessment and result of relevant
M6 00001 (Radical/Adjuvant / Neoadjuvant) 20,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

assessment and result of relevant
M6 00002 Cobalt 60 External Beam Radiotherapy (Palliative) 10,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

Linear Accelerator External Beam Radiotherapy assessment and result of relevant
M6 00003 (Palliative) 20,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

Linear Accelerator, External Beam Radiotherapy 3D assessment and result of relevant
M6 00004 CRT/2D Planning (Radical/Adjuvant/ Neoadjuvant) 50,000 Y investigations including CT/Biopsy Clinical assessment
 Linear Accelerator, External Beam Radiotherapy Clinical note including Clinical
IMRT (Intensity Modulated Radiotherapy) assessment and result of relevant
M6 00005 (Radical/Adjuvant/Neoadjuvant) 75,000 Y investigations including CT/Biopsy Clinical assessment

Linear Accelerator External Beam Radiotherapy IGRT Clinical note including Clinical
(Image Guided radiotherapy) assessment and result of relevant
M6 00006 (Radical/Adjuvant/Neoadjuvent) 120,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

assessment and result of relevant
M6 00007 SRT(Stereota1036ic radiotherapy) 70,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

assessment and result of relevant
M6 00008 SRS (Streotactic radiosurgery) 70,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

Respiratory Gating along with Linear Accelerator assessment and result of relevant
M6 00009 planning 70,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

assessment and result of relevant
M6 00010 Electron beam with Linear accelerator (Radical) 50,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

assessment and result of relevant
M6 00011 Tomotherapy(Radical/Adjuvant/Neoadjuvant) 75,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

Brachytherapy High Dose Radiation (Intracavitory) - assessment and result of relevant
M6 00012 per fraction, maximum of 4 sessions 4,500 Y investigations including CT/Biopsy Clinical assessment
 Clinical note including Clinical
Brachytherapy High Dose Radiation (Interstitial) - for assessment and result of relevant
M6 00013 one application, multiple dose 30,000 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

Brachytherapy High Dose Radiation (Intraluminal) - assessment and result of relevant
M6 00014 per fraction, maximum 4 sessions 4,500 Y investigations including CT/Biopsy Clinical assessment

Clinical note including Clinical

RADIATION ONCOLOGY-Request for radiation in assessment and result of relevant
M6 Template Y investigations including CT/Biopsy Clinical assessment
 Capped
amount
(pacakge
cannot
be used
more
Average length than the
of Stay Govt Medical mentione Reserved
(Including Days Reserved (M) or d for Trust
in intensive care Procedure Surgical monetary Payment
units) (Y/N) (S) limit) (Y/N)

Y M N

Y M N

Y M N

Y M N
Y M N

Y M N

Y M N

Y M N

Y M N

Y M N

Y M N

Y M N
Y M N

Y M N

Y M N
 Emergency Room Management

Average length
Preauth of Stay
Speci Required Mandatory Post-Op (Including Days
alty Package Package or Not investigations for investigations for in intensive care
code Code Package name Amount (Y/N) pre-auth claims submission units)

Emergency with stable cardiopulmonary status 1000

M7 00001 N Clinical note D

Emergency consultation: acute colic, high fever,

1000
cut, stitches, soft tissue injury, FB removal
M7 00002 N Clinical note D
Single bone fracture plaster, nebulization for
asthmatic attack, moderate dehydration, 1000
hypoglycaemia in a diabetic, Dengue without
complication, Syncope, Food poisoning etc
M7 00003 N Clinical note D
Animal bites (Payment after completion of 5th 1700
dose)
M7 00004 N Clinical note D
 Capped
amount
(pacakge
cannot
be used
more
than the
Medical mentione Reserved
Govt Reserved (M) or d for Trust
Procedure Surgical monetary Payment
(Y/N) (S) limit) (Y/N)

N M N

N M/S N

N M/S N

N M/S N
 Mental Disorder

Package Amount per

day (drop down) for Preauth
Special admission type: Require Mandatory
ty Package Routine ward (Rs 750)/ d or Not investigations Post-Op investigations for claims
code Code Package name HDU (Rs (Rs 1250) (Y/N) for pre-auth submission
Organic, including symptomatic, mental disorders Clinical assessment& Report/ Mental
M8 00001 (routine ward) N Status Examination
Mental and Behavioural disorders due to psychoactive Clinical assessment& Report/ Mental
M8 00002 substance use (routine ward) N Status Examination
Schizophrenia, schizotypal and delusional disorders Clinical assessment& Report/ Mental
M8 00003 (routine ward) N Status Examination
Clinical assessment& Report/ Mental
M8 00004 Mood (affective) disorders (routine ward) N Status Examination
Neurotic, stress-related and somatoform disorders Clinical assessment& Report/ Mental
M8 00005 (routine ward) N Status Examination

Behavioural syndromes associated with physiological Clinical assessment& Report/ Mental

M8 00006 disturbances and physical factors (routine ward) N Status Examination
Clinical assessment& Report/ Mental
M8 00007 Mental retardation (routine ward) N Status Examination
Organic, including symptomatic, mental disorders Clinical assessment& Report/ Mental
M8 00008 (HDU) N Status Examination
Mental and Behavioural disorders due to psychoactive Clinical assessment& Report/ Mental
M8 00009 substance use (HDU) N Status Examination
 Schizophrenia, schizotypal and delusional disorders Clinical assessment& Report/ Mental
M8 00010 (HDU) N Status Examination
Clinical assessment& Report/ Mental
M8 00011 Mood (affective) disorders (HDU) N Status Examination
Neurotic, stress-related and somatoform disorders Clinical assessment& Report/ Mental
M8 00012 (HDU) N Status Examination

Behavioural syndromes associated with physiological Clinical assessment& Report/ Mental

M8 00013 disturbances and physical factors (HDU) N Status Examination
Clinical assessment& Report/ Mental
M8 00014 Mental Retardation (HDU) N Status Examination

Pre- Electro Convulsive Therapy (ECT) and Pre-

Transcranial Magnetic Stimulation (TMS) Package
(Cognitive Tests, Complete Haemogram, Liver Function
Test, Renal Function Test, Serum Electrolytes, Electro
Cardiogram (ECG), CT/MRI Brain,
Electroencephalogram, Thyroid Function Test, VDRL,
HIV Test, Vitamin B12 levels, Folate levels, Lipid Profile, Clinical assessment& Report/ Mental
M8 00015 Homocysteine levels) 10,000 N Status Examination
Clinical assessment& Report/ Mental
M8 00016 Electro Convulsive Therapy (ECT) - per session 3,000 N Status Examination
Clinical assessment& Report/ Mental
M8 00017 Transcranial Magnetic Stimulation (TMS) - per session 1,000 N Status Examination
 Capped
amount
(pacakge
Average length of Medical cannot be used Reserved
Stay (Including Govt Reserved (M) or more than the for Trust
Days in intensive Procedure Surgical mentioned Payment
care units) (Y/N) (S) monetary limit) (Y/N)

7 to 21 days N M N

7 to 21 days N M N

7 to 21 days N M N

7 to 21 days N M N

7 to 21 days N M N

7 to 21 days N M N

7 to 21 days N M N

5 to 10 days N M N

5 to 10 days N M N
5 to 10 days N M N

5 to 10 days N M N

5 to 10 days N M N

5 to 10 days N M N

5 to 10 days N M N

N M N

N M N

N M N
 Unspecified Procedures

Preauth Required or Not Average length of Govt

Special (Y/N): only for extensions Mandatory Stay (Including Reserved
ty Packag Package Package as mentioned in the investigations for pre- Post-Op investigations Days in intensive Procedure Medical (M) or
code e Code name Amount package details auth for claims submission care units) (Y/N) Surgical (S)

Unspecifi Price Admission note Clinical note along

ed approva including the with procedure report
Surgical l with respective and the respective
U1 00001 Package IC/Trust Y investigation result investigation result N S/M
Capped amount
(pacakge cannot Reserved
be used more than for Trust
the mentioned Payment
monetary limit) (Y/N)

Decided by SHA N