10.15.A. - NexoBrid Codes - FY 2024																		
																		
Note:  The applicant provided the following codes and/or MS-DRGs that were used in performing a cost analysis for the Charges section of the new technology add-on payment application.																		
																		
Group 1 ICD-10-CM Codes:		Group 2 ICD-10-PCS Codes:		Group 3 ICD-10-PCS Codes:		Excluded ICD-10-PCS Codes:												
T2020XA		0HB0XZZ		0HR0X72		5A1522F												
T20211A		0HB1XZZ		0HR0X73		5A1522G												
T20212A		0HB2XZZ		0HR0X74		5A1522H												
T20219A		0HB3XZZ		0HR0XJ3		5A15A2F												
T2022XA		0HB4XZZ		0HR0XJ4		5A15A2G												
T2023XA		0HB5XZZ		0HR0XJZ		5A15A2H												
T2024XA		0HB6XZZ		0HR0XK3		5A1955Z												
T2025XA		0HB7XZZ		0HR0XK4		5A1935Z												
T2026XA		0HB8XZZ		0HR1X72		5A1945Z												
T2027XA		0HB9XZZ		0HR1X73		0B110F4												
T2029XA		0HBAXZZ		0HR1X74		0B110Z4												
T2030XA		0HBBXZZ		0HR1XJ3		0B114F4												
T20311A		0HBCXZZ		0HR1XJ4		0B114Z4												
T20312A		0HBDXZZ		0HR1XJZ		0B113F4												
T20319A		0HBEXZZ		0HR1XK3		0B113Z4												
T2032XA		0HBFXZZ		0HR1XK4		0B110D6												
T2033XA		0HBGXZZ		0HR2X72														
T2034XA		0HBHXZZ		0HR2X73														
T2035XA		0HBJXZZ		0HR2X74														
T2036XA		0HBKXZZ		0HR2XJ3														
T2037XA		0HBLXZZ		0HR2XJ4														
T2039XA		0HBMXZZ		0HR2XJZ														
T2120XA		0HBNXZZ		0HR2XK3														
T2121XA		0JB00ZZ		0HR2XK4														
T2122XA		0JB10ZZ		0HR3X72														
T2123XA		0JB40ZZ		0HR3X73														
T2124XA		0JB50ZZ		0HR3X74														
T2125XA		0JB60ZZ		0HR3XJ3														
T2126XA		0JB70ZZ		0HR3XJ4														
T2127XA		0JB80ZZ		0HR3XJZ														
T2129XA		0JB90ZZ		0HR3XK3														
T2130XA		0JBB0ZZ		0HR3XK4														
T2131XA		0JBC0ZZ		0HR4X72														
T2132XA		0JBD0ZZ		0HR4X73														
T2133XA		0JBF0ZZ		0HR4X74														
T2134XA		0JBG0ZZ		0HR4XJ3														
T2135XA		0JBH0ZZ		0HR4XJ4														
T2136XA		0JBJ0ZZ		0HR4XJZ														
T2137XA		0JBK0ZZ		0HR4XK3														
T2139XA		0JBL0ZZ		0HR4XK4														
T2220XA		0JBM0ZZ		0HR5X72														
T22211A		0JBN0ZZ		0HR5X73														
T22212A		0JBP0ZZ		0HR5X74														
T22219A		0JBQ0ZZ		0HR5XJ3														
T22221A		0JBR0ZZ		0HR5XJ4														
T22222A		0HD0XZZ		0HR5XJZ														
T22229A		0HD1XZZ		0HR5XK3														
T22231A		0HD2XZZ		0HR5XK4														
T22232A		0HD3XZZ		0HR6X72														
T22239A		0HD4XZZ		0HR6X73														
T22241A		0HD5XZZ		0HR6X74														
T22242A		0HD6XZZ		0HR6XJ3														
T22249A		0HD7XZZ		0HR6XJ4														
T22251A		0HD8XZZ		0HR6XJZ														
T22252A		0HD9XZZ		0HR6XK3														
T22259A		0HDAXZZ		0HR6XK4														
T22261A		0HDBXZZ		0HR7X72														
T22262A		0HDCXZZ		0HR7X73														
T22269A		0HDDXZZ		0HR7X74														
T22291A		0HDEXZZ		0HR7XJ3														
T22292A		0HDFXZZ		0HR7XJ4														
T22299A		0HDGXZZ		0HR7XJZ														
T2230XA		0HDHXZZ		0HR7XK3														
T22311A		0HDJXZZ		0HR7XK4														
T22312A		0HDKXZZ		0HR8X72														
T22319A		0HDLXZZ		0HR8X73														
T22321A		0HDMXZZ		0HR8X74														
T22322A		0HDNXZZ		0HR8XJ3														
T22329A				0HR8XJ4														
T22331A				0HR8XJZ														
T22332A				0HR8XK3														
T22339A				0HR8XK4														
T22341A				0HR9X72														
T22342A				0HR9X73														
T22349A				0HR9X74														
T22351A				0HR9XJ3														
T22352A				0HR9XJ4														
T22359A				0HR9XJZ														
T22361A				0HR9XK3														
T22362A				0HR9XK4														
T22369A				0HRAX72														
T22391A				0HRAX73														
T22392A				0HRAX74														
T22399A				0HRAXJ3														
T23201A				0HRAXJ4														
T23202A				0HRAXJZ														
T23209A				0HRAXK3														
T23211A				0HRAXK4														
T23212A				0HRBX72														
T23219A				0HRBX73														
T23221A				0HRBX74														
T23222A				0HRBXJ3														
T23229A				0HRBXJ4														
T23231A				0HRBXJZ														
T23232A				0HRBXK3														
T23239A				0HRBXK4														
T23241A				0HRCX72														
T23242A				0HRCX73														
T23249A				0HRCX74														
T23251A				0HRCXJ3														
T23252A				0HRCXJ4														
T23259A				0HRCXJZ														
T23261A				0HRCXK3														
T23262A				0HRCXK4														
T23269A				0HRDX72														
T23271A				0HRDX73														
T23272A				0HRDX74														
T23279A				0HRDXJ3														
T23291A				0HRDXJ4														
T23292A				0HRDXJZ														
T23299A				0HRDXK3														
T23301A				0HRDXK4														
T23302A				0HREX72														
T23309A				0HREX73														
T23311A				0HREX74														
T23312A				0HREXJ3														
T23319A				0HREXJ4														
T23321A				0HREXJZ														
T23322A				0HREXK3														
T23329A				0HREXK4														
T23331A				0HRFX72														
T23332A				0HRFX73														
T23339A				0HRFX74														
T23341A				0HRFXJ3														
T23342A				0HRFXJ4														
T23349A				0HRFXJZ														
T23351A				0HRFXK3														
T23352A				0HRFXK4														
T23359A				0HRGX72														
T23361A				0HRGX73														
T23362A				0HRGX74														
T23369A				0HRGXJ3														
T23371A				0HRGXJ4														
T23372A				0HRGXJZ														
T23379A				0HRGXK3														
T23391A				0HRGXK4														
T23392A				0HRHX72														
T23399A				0HRHX73														
T24201A				0HRHX74														
T24202A				0HRHXJ3														
T24209A				0HRHXJ4														
T24211A				0HRHXJZ														
T24212A				0HRHXK3														
T24219A				0HRHXK4														
T24221A				0HRJX72														
T24222A				0HRJX73														
T24229A				0HRJX74														
T24231A				0HRJXJ3														
T24232A				0HRJXJ4														
T24239A				0HRJXJZ														
T24291A				0HRJXK3														
T24292A				0HRJXK4														
T24299A				0HRKX72														
T24301A				0HRKX73														
T24302A				0HRKX74														
T24309A				0HRKXJ3														
T24311A				0HRKXJ4														
T24312A				0HRKXJZ														
T24319A				0HRKXK3														
T24321A				0HRKXK4														
T24322A				0HRLX72														
T24329A				0HRLX73														
T24331A				0HRLX74														
T24332A				0HRLXJ3														
T24339A				0HRLXJ4														
T24391A				0HRLXJZ														
T24392A				0HRLXK3														
T24399A				0HRLXK4														
T25211A				0HRMX72														
T25212A				0HRMX73														
T25219A				0HRMX74														
T25221A				0HRMXJ3														
T25222A				0HRMXJ4														
T25229A				0HRMXJZ														
T25231A				0HRMXK3														
T25232A				0HRMXK4														
T25239A				0HRNX72														
T25291A				0HRNX73														
T25292A				0HRNX74														
T25299A				0HRNXJ3														
T25311A				0HRNXJ4														
T25312A				0HRNXJZ														
T25319A				0HRNXK3														
T25321A				0HRNXK4														
T25322A																		
T25329A																		
T25331A																		
T25332A																		
T25339A																		
T25391A																		
T25392A																		
T25399A																		
