Government of Odisha

Health and Family Welfare Department

LetterNo: q 89 /H Dated
From
Shri Subhananda Mohapatra,OAS
Joint CEO (Admin),SHAS
To,
Chairman/ Managing Director/ Proprietor of
Empanelled Private Hospitals
Under Biju Swasthya Kalyan Yojana.
Sub: Implementationof Revised BSKY package and implant master 2022
Sir,
With reference to the subject cited above, I am directed to intimateyou that after
careful consideration of the proposals received from differentempanelled hospitals, private
hospital association and inputs of differentstake holders, the package and implant masters
have been revised with approval of Government. The total number of packages now stands
at 2056. In this connection a sensitizationmeetingwas held through virtual mode at 11.30
AM on 22.07.2022 to orient regarding revised package master.
Enclosures- 1. Revised Package Master
2. Revised Implantmaster

Yours faithfully

q 39 2..St Joint CEO ( SHAS

Memo No IH Dated

Copy submittedall Claim Panel Doctor/District Coordinator,SHAS / Kyros Soft Tech

Limited/All section and officers of SHAS for information.

Joint CEO (Aå)n), HAS

Memo No IH Dated
Copy submittedto the P.S to Principal Secretary, Departmentof Health and Family
Welfare for kind informationof Principal Secretary.

Joint CEO (A

Specialt
SL NO Specialty Sub-Specialty
y Code
1 Burns Management BM Burns Management
2 Burns Management BM Burns Management
3 Burns Management BM Burns Management
4 Burns Management BM Burns Management
5 Burns Management BM Burns Management
6 Burns Management BM Burns Management
7 Burns Management BM Burns Management
8 Burns Management BM Burns Management
9 Burns Management BM Burns Management
10 Burns Management BM Burns Management
11 Burns Management BM Burns Management
12 Burns Management BM Burns Management
MASTER PACKAGE BIJU SWASTHYA KALYAN YOJANA 072022
Outside State
Outside State NABH Entry Outside State
Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
Package Name Procedure Name Hospital with Level Package NABH Package
e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Post treatment clinical Reserved
b) MLC copy with number photograph
Criteria 1: % Total Body Surface Area Burns c) Clinical Photograph with b) Blood test (CBC, Sr.
(TBSA):less than 20% in adults and less than due consent of patient creatinine, Platelet etc.)
BM001 Thermal burns BM001A 7350 8085 8820 9555 10290 10657
10% in children younger than 12 years. d) Document showing % of c) X ray
Dressing without anesthesia burn through rule of 9 d) Discharge Summary
e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 2: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA): Upto 25%; Includes % TBSA skin c) Clinical Photograph with b) Blood test (CBC, Sr.
grafted, flap cover, follow-up dressings etc. as due consent of patient creatinine, Platelet etc.)
BM001 Thermal burns BM001B 52500 57750 63000 68250 73500 76125
deemed necessary; Surgical procedures are d) Document showing % of c) X ray
required for deep burns that are not amenable burn through rule of 9 d) Discharge Summary
to heal with dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 3: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA): 25-40 %; Includes % TBSA skin c) Clinical Photograph with b) Blood test (CBC, Sr.
grafted, flap cover, follow-up dressings etc. as due consent of patient creatinine, Platelet etc.)
BM001 Thermal burns BM001C 65625 72187 78750 85312 91875 95156
deemed necessary; Surgical procedures are d) Document showing % of c) X ray
required for deep burns that are not amenable burn through rule of 9 d) Discharge Summary
to heal with dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 4: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA):40- 60 %; Includes % TBSA skin c) Clinical Photograph with b) Blood test (CBC, Sr.
grafted, flap cover, follow-up dressings etc. as due consent of patient creatinine, Platelet etc.)
BM001 Thermal burns BM001D 105000 115500 126000 136500 147000 152250
deemed necessary; Surgical procedures are d) Document showing % of c) X ray
required for deep burns that are not amenable burn through rule of 9 d) Discharge Summary
to heal with dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 5: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA):60-80 %; Includes % TBSA skin grafted, c) Clinical Photograph with b) Blood test (CBC, Sr.
flap cover, follow-up dressings etc. as deemed due consent of patient creatinine, Platelet etc.)
BM001 Thermal burns BM001E 105000 115500 126000 136500 147000 152250
necessary; Surgical procedures are required for d) Document showing % of c) X ray
deep burns that are not amenable to heal with burn through rule of 9 d) Discharge Summary
dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical Reserved
b) MLC copy with number photograph
Criteria 1: % Total Body Surface Area Burns c) Clinical Photograph with b) Blood test (CBC, Sr.
(TBSA): less than 20% in adults and less than due consent of patient creatinine, Platelet etc.)
BM002 Scald burns BM002A 7350 8085 8820 9555 10290 10657
10% in children younger than 12 years. d) Document showing % of c) X ray
Dressing without anesthesia burn through rule of 9 d) Discharge Summary
e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 2: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA): Upto 25%; Includes % TBSA skin c) Clinical Photograph with b) Blood test (CBC, Sr.
grafted, flap cover, follow-up dressings etc. as due consent of patient creatinine, Platelet etc.)
BM002 Scald burns BM002B 52500 57750 63000 68250 73500 76125
deemed necessary; Surgical procedures are d) Document showing % of c) X ray
required for deep burns that are not amenable burn through rule of 9 d) Discharge Summary
to heal with dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 3: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA): 25-40 %; Includes % TBSA skin c) Clinical Photograph with b) Blood test (CBC, Sr.
grafted, flap cover, follow-up dressings etc. as due consent of patient creatinine, Platelet etc.)
BM002 Scald burns BM002C 65625 72187 78750 85312 91875 95156
deemed necessary; Surgical procedures are d) Document showing % of c) X ray
required for deep burns that are not amenable burn through rule of 9 d) Discharge Summary
to heal with dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 4: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA):40- 60 %; Includes % TBSA skin c) Clinical Photograph with b) Blood test (CBC, Sr.
grafted, flap cover, follow-up dressings etc. as due consent of patient creatinine, Platelet etc.)
BM002 Scald burns BM002D 105000 115500 126000 136500 147000 152250
deemed necessary; Surgical procedures are d) Document showing % of c) X ray
required for deep burns that are not amenable burn through rule of 9 d) Discharge Summary
to heal with dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
Criteria 5: % Total Body Surface Area Burns b) MLC copy with number photograph
(TBSA):60-80 %; Includes % TBSA skin grafted, c) Clinical Photograph with b) Blood test (CBC, Sr.
flap cover, follow-up dressings etc. as deemed due consent of patient creatinine, Platelet etc.)
BM002 Scald burns BM002E 105000 115500 126000 136500 147000 152250
necessary; Surgical procedures are required for d) Document showing % of c) X ray
deep burns that are not amenable to heal with burn through rule of 9 d) Discharge Summary
dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical Reserved
b) MLC copy with number photograph
% Total Body Surface Area Burns (TBSA) - any c) Clinical Photograph with b) Blood test (CBC, Sr.
% due consent of patient creatinine, Platelet etc.)
BM003 Flame burns BM003A 7350 8085 8820 9555 10290 10657
(not requiring admission). d) Document showing % of c) X ray
Needs at least 5-6 dressing burn through rule of 9 d) Discharge Summary
e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
% Total Body Surface Area Burns (TBSA): Upto b) MLC copy with number photograph
40 %; Includes % TBSA skin grafted, flap cover, c) Clinical Photograph with b) Blood test (CBC, Sr.
follow-up dressings etc. as deemed necessary; due consent of patient creatinine, Platelet etc.)
BM003 Flame burns BM003B 52500 57750 63000 68250 73500 76125
Surgical procedures are required for deep burns d) Document showing % of c) X ray
that are not amenable to heal with dressings burn through rule of 9 d) Discharge Summary
alone. e) Procedure/ operative
notes
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Post treatment clinical OPEN YES
% Total Body Surface Area Burns (TBSA): 40 % b) MLC copy with number photograph
- 60 %; Includes % TBSA skin grafted, flap c) Clinical Photograph with b) Blood test (CBC, Sr.
cover, follow-up dressings etc. as deemed due consent of patient creatinine, Platelet etc.)
13 Burns Management BM Burns Management BM003 Flame burns BM003C 65625 72187 78750 85312 91875 95156
necessary; Surgical procedures are required for d) Document showing % of c) X ray
deep burns that are not amenable to heal with burn through rule of 9 d) Discharge Summary
dressings alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN YES
% Total Body Surface Area Burns (TBSA): > 60 b) MLC copy with number photograph
%; Includes % TBSA skin grafted, flap cover, c) Clinical Photograph with b) Blood test (CBC, Sr.
follow-up dressings etc. as deemed necessary; due consent of patient creatinine, Platelet etc.)
14 Burns Management BM Burns Management BM003 Flame burns BM003D 105000 115500 126000 136500 147000 152250
Surgical procedures are required for deep burns d) Document showing % of c) X ray
that are not amenable to heal with dressings burn through rule of 9 d) Discharge Summary
alone. e) Procedure/ operative
notes
a) Clinical notes a) Post treatment clinical OPEN
mentioning the photograph
Electrical contact burns: Low voltage - without
circumstances that led to b) Blood test (CBC, Sr.
part of limb / limb loss; Includes % TBSA skin
low voltage electrical creatinine, Platelet etc.)
grafted, flap cover, follow-up dressings etc. as
15 Burns Management BM Burns Management BM004 Electrical contact burns BM004A 39375 43312 47250 51187 55125 57093 contact burns b) MLC copy c) X ray
deemed necessary; Surgical procedures are
with number c) d) Detailed Discharge
required for deep burns that are not amenable
Clinical Photograph Summary
to heal with dressings alone.
d) Document showing % of e) Detailed procedure /
burn through rule of 9 operative notes
a) Clinical notes a) Post treatment clinical OPEN YES
mentioning the photograph
Electrical contact burns: Low voltage - with part
circumstances that led to b) Blood test (CBC, Sr.
of limb / limb loss; Includes % TBSA skin
low voltage electrical creatinine, Platelet etc.)
grafted, flap cover, follow-up dressings
16 Burns Management BM Burns Management BM004 Electrical contact burns BM004B 52500 57750 63000 68250 73500 76125 contact burns b) MLC copy c) X ray
Amputation etc. as deemed necessary; Surgical
with number c) d) Detailed Discharge
procedures are required for deep burns that are
Clinical Photograph Summary
not amenable to heal with dressings alone.
d) Document showing % of e) Detailed procedure /
burn through rule of 9 operative notes
Electrical contact burns: High voltage - with part a) Clinical notes a) Post treatment clinical OPEN YES
of limb / limb loss; Includes % TBSA skin mentioning the photograph
grafted, flap cover,fasciotomy +/- circumstances that led to b) Blood test (CBC, Sr.
/amputation/Central IV Line/debridement/early low voltage electrical creatinine, Platelet etc.)
17 Burns Management BM Burns Management BM004 Electrical contact burns BM004C skin grafting pedicle or free flap coverage,follow- 78750 86625 94500 102375 110250 114187 contact burns b) MLC copy c) X ray
up dressings etc. as deemed necessary; with number c) d) Detailed Discharge
Surgical procedures are required for deep burns Clinical Photograph Summary
that are not amenable to heal with dressings d) Document showing % of e) Detailed procedure /
alone. burn through rule of 9 operative notes
a) Clinical notes a) Post treatment clinical OPEN YES
Electrical contact burns: High voltage - without
mentioning the photograph
part of limb / limb loss; Includes % TBSA skin
circumstances that led to b) Blood test (CBC, Sr.
grafted, flap cover, fasciotomy +/-
low voltage electrical creatinine, Platelet etc.)
/debridement/early skin grafting/flap cover:
18 Burns Management BM Burns Management BM004 Electrical contact burns BM004D 65625 72187 78750 85312 91875 95156 contact burns b) MLC copy c) X ray
pedicle or free flap coverage,follow-up dressings
with number c) d) Detailed Discharge
etc. as deemed necessary; Surgical procedures
Clinical Photograph Summary
are required for deep burns that are not
d) Document showing % of e) Detailed procedure /
amenable to heal with dressings alone.
burn through rule of 9 operative notes
Chemical burns: Without significant facial a) Clinical notes a) Post treatment clinical OPEN YES
scarring and/or loss of function; Includes % mentioning the photograph
TBSA skin grafted, flap cover, follow-up circumstances that led to b) Blood test (CBC, Sr.
dressings etc. as deemed necessary; Surgical Chemical Burn creatinine, Platelet etc.)
19 Burns Management BM Burns Management BM005 Chemical burns BM005A procedures are required for deep burns that are 52500 57750 63000 68250 73500 76125 b) MLC copy with number c) X ray
not amenable to heal with dressings c) Clinical Photograph d) Detailed Discharge
alone.(Similar to therma burns d) Document showing % of Summary
require more grafting, debridement,(skin burn through rule of 9 e) Detailed procedure /
grafing/canthopexy) operative notes
a) Clinical notes a) Post treatment clinical OPEN YES
Chemical burns: With significant facial scarring mentioning the photograph
and/or loss of function; Includes % TBSA skin circumstances that led to b) Blood test (CBC, Sr.
grafted, flap cover,debridement,skin Chemical Burn creatinine, Platelet etc.)
20 Burns Management BM Burns Management BM005 Chemical burns BM005B grafting,follow-up dressings etc. as deemed 78750 86625 94500 102375 110250 114187 b) MLC copy with number c) X ray
necessary; Surgical procedures are required for c) Clinical Photograph d) Detailed Discharge
deep burns that are not amenable to heal with d) Document showing % of Summary
dressings alone. burn through rule of 9 e) Detailed procedure /
operative notes
a) Clinical history detailing a) Detailed indoor case OPEN YES
Post Burn Contracture surgeries for Functional the burns - etiology, papers
Improvement (Package including splints, treatment given, and b) Detailed procedure/
pressure garments, silicone - gel sheet and resultant contractures left Operative notes
physiotherapy): Excluding Neck contracture; b) Functional disability to c) Post-operative clinical
Post Burn Contracture surgeries for
21 Burns Management BM Burns Management BM006 BM006A Contracture release with - Split thickness Skin 65625 72187 78750 85312 91875 95156 be detailed and expected photograph of the affected
Functional Improvement
Graft (STSG) / Full Thickness Skin Graft functional improvement to part
(FTSG) / Flap cover is done for each joint with be shared. d) Discharge summary
post - operative regular dressings for STSG / C) Pre-operative clinical
FTSG / Flap cover. photograph.

Post Burn Contracture surgeries for Functional a) Clinical history detailing a) Detailed indoor case OPEN YES
Improvement (Package including splints, the burns - etiology, papers
pressure garments,contracture release & split treatment given, and b) Detailed procedure/
skin graft with or without flap resultant contractures left Operative notes
reconstruction,silicone - gel sheet and b) Functional disability to c) Post-operative clinical
Post Burn Contracture surgeries for be detailed and expected photograph of the affected
22 Burns Management BM Burns Management BM006 BM006B physiotherapy): Neck contracture; Contracture 65625 72187 78750 85312 91875 95156
Functional Improvement functional improvement to part
release with - Split thickness Skin Graft (STSG)
/ be shared. d) Discharge summary
Full Thickness Skin Graft (FTSG) / Flap cover is C) Pre-operative clinical
done for each joint with post-operative regular photograph.
dressings for STSG / FTSG / Flap cover.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed clinical notes, OPEN Variable
evaluation findings, vitals and treatment given
planned line of treatment b) Detailed Procedure /
b) Pre-clinical photograph Operative Notes
Emergency Room Emergency Room
23 ER ER001 Laceration - Suturing / Dressing ER001A Laceration - Suturing / Dressing 2100 2310 2520 2730 2940 3045 c) Post procedure clinical
Packages Packages
photograph of the affected
part
d) Detailed Discharge
summary
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, Papers
indications for the b) Detailed Discharge
Emergency Room Emergency Room Emergency with stable
24 ER ER002 Cardiopulmonary emergency ER002A 2100 2310 2520 2730 2940 3045 procedure, and planned summary
Packages Packages cardiopulmonary status
line of treatment
b) Electrocardiogram
(ECG)report
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, Papers
Emergency with unstable cardiopulmonary indications for the b) Detailed Discharge
Emergency Room Emergency Room
25 ER ER002 Cardiopulmonary emergency ER002B status with 11550 12705 13860 15015 16170 16747 procedure, and planned summary
Packages Packages
resuccitation line of treatment
b) Electrocardiogram
(ECG)report
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
classification of bites, Papers
evaluation findings, b) Clinical Notes with
indications for the complete treatment details
procedure, and planned including no. of doses of
Emergency Room Emergency Room line of treatment vaccine with dates (as
26 ER ER003 Animal bites (Excluding Snake Bite) ER003A Animal bites (Excluding Snake Bite) 1785 1963 2142 2320 2499 2588
Packages Packages b) Pre-clinical photograph needed)
c) Invoice / bar code sticker
of the vaccine (If its
applicable)
d) Discharge summary and
follow-up advice
Infectious Diseases, Infectious Diseases, 0 0 OPEN Variable
27 ID ID005 Treatment of systemic fungal infections ID005A Treatment of systemic fungal infections 2250 2475 2700 2925 3150 3262
General Medicine General Medicine
Carotico-cavernous Fistula (CCF) embolization 0 0 OPEN YES
with coils.
Carotico-cavernous Fistula (CCF)
28 Interventional radiology IN Interventional radiology IN001 IN001A [includes 5 coils, guide catheter, micro-catheter, 196875 216562 236250 255937 275625 285468
embolization
micro-guidewire,
general items]
0 0 OPEN YES
Carotid-cavernous Fistula (CCF) embolization
Carotico-cavernous Fistula (CCF) with balloon (includes one balloon, guide
29 Interventional radiology IN Interventional radiology IN001 IN001B 98490 108339 118188 128037 137886 142810
embolization catheter, micro-catheter, micro-
guidewire, general items)
Intracranial balloon angioplasty with Intracranial balloon angioplasty with 0 0 OPEN YES
30 Interventional radiology IN Interventional radiology IN002 IN002A 210000 231000 252000 273000 294000 304500
stenting stenting
Intracranial thrombolysis / clot 0 0 OPEN YES
31 Interventional radiology IN Interventional radiology IN003 Intracranial thrombolysis / clot retrieval IN003A 210000 231000 252000 273000 294000 304500
retrieval
32 Interventional radiology IN Interventional radiology IN004 Balloon test occlusion IN004A Balloon test occlusion 91875 101062 110250 119437 128625 133218 0 0 OPEN YES
33 Interventional radiology IN Interventional radiology IN005 Parent vessel occlusion - Basic IN005A Parent vessel occlusion - Basic 39375 43312 47250 51187 55125 57093 0 0 OPEN
Primary percutaneous transhepatic biliary Primary percutaneous transhepatic biliary 0 0 OPEN YES
34 Interventional radiology IN Interventional radiology IN006 IN006A 53235 58558 63882 69205 74529 77190
stenting (SEMS) stenting (SEMS)
Percutaneous transhepatic biliary stenting Percutaneous transhepatic biliary stenting 0 0 OPEN
35 Interventional radiology IN Interventional radiology IN006 IN006B 37275 41002 44730 48457 52185 54048
(SEMS) after prior PTBD (SEMS) after prior PTBD
36 Interventional radiology IN Interventional radiology IN007 Percutaneous cholangioplasty IN007A Percutaneous cholangioplasty 15960 17556 19152 20748 22344 23142 0 0 OPEN
Hepatic venous wedge pressure Hepatic venous wedge pressure measurement 0 0 OPEN
37 Interventional radiology IN Interventional radiology IN008 IN008A 18270 20097 21924 23751 25578 26491
measurement (HVPG) (HVPG)
38 Interventional radiology IN Interventional radiology IN009 Tunnelled long-term venous catheter IN009A Tunnelled long-term venous catheter 15330 16863 18396 19929 21462 22228 0 0 OPEN
Tunelled longterm indwelling catheter for Tunelled longterm indwelling catheter for 0 0 OPEN
39 Interventional radiology IN Interventional radiology IN010 IN010A 17535 19288 21042 22795 24549 25425
refractory ascites/pleural effusion refractory ascites/pleural effusion
Peripherally inserted central catheter 0 0 OPEN
40 Interventional radiology IN Interventional radiology IN011 IN011A Peripherally inserted central catheter (PICC) 9345 10279 11214 12148 13083 13550
(PICC)
41 Interventional radiology IN Interventional radiology IN012 Chemoport/implantable lines IN012A Chemoport/implantable lines 15330 16863 18396 19929 21462 22228 0 0 OPEN
42 Interventional radiology IN Interventional radiology IN013 Percutaneous nephrostomy IN013A Percutaneous nephrostomy 23205 25525 27846 30166 32487 33647 0 0 OPEN
Primary percutaneous antegrade uretric 0 0 OPEN
43 Interventional radiology IN Interventional radiology IN014 IN014A Primary percutaneous antegrade uretric stenting 25410 27951 30492 33033 35574 36844
stenting
Percutaneous antegrade uretric stenting Percutaneous antegrade uretric stenting after 0 0 OPEN
44 Interventional radiology IN Interventional radiology IN015 IN015A 17430 19173 20916 22659 24402 25273
after prior PCN prior PCN
45 Interventional radiology IN Interventional radiology IN016 Lymphatic occlusion of chylous leak IN016A Lymphatic occlusion of chylous leak 22365 24601 26838 29074 31311 32429 0 0 OPEN
46 Interventional radiology IN Interventional radiology IN017 PVA embolization IN017A PVA embolization (without microcatheter) 16590 18249 19908 21567 23226 24055 0 0 OPEN
47 Interventional radiology IN Interventional radiology IN017 PVA embolization IN017B PVA embolization (with microcatheter) 39900 43890 47880 51870 55860 57855 0 0 OPEN
48 Interventional radiology IN Interventional radiology IN018 Glue embolization IN018A Glue embolization (without microcatheter) 26460 29106 31752 34398 37044 38367 0 0 OPEN
49 Interventional radiology IN Interventional radiology IN018 Glue embolization IN018B Glue embolization (with microcatheter) 42525 46777 51030 55282 59535 61661 0 0 OPEN YES
0 0 OPEN
50 Interventional radiology IN Interventional radiology IN019 Gelfoam embolization IN019A Gelfoam embolization (without microcatheter) 15330 16863 18396 19929 21462 22228
51 Interventional radiology IN Interventional radiology IN019 Gelfoam embolization IN019B Gelfoam embolization (with microcatheter) 30870 33957 37044 40131 43218 44761 0 0 OPEN
52 Interventional radiology IN Interventional radiology IN020 Coil embolization IN020A Coil embolization (without microcatheter) 21000 23100 25200 27300 29400 30450 0 0 OPEN
53 Interventional radiology IN Interventional radiology IN020 Coil embolization IN020B Coil embolization (with microcatheter) 39900 43890 47880 51870 55860 57855 0 0 OPEN
54 Interventional radiology IN Interventional radiology IN021 Alcohol embolisation IN021A Alcohol embolisation 30870 33957 37044 40131 43218 44761 0 0 OPEN
55 Interventional radiology IN Interventional radiology IN022 Vascular plug assisted embolization IN022A Vascular plug assisted embolization 51555 56710 61866 67021 72177 74754 0 0 OPEN YES
56 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023A Angioplasty (arterial) 37695 41464 45234 49003 52773 54657 0 0 OPEN
Angioplasty (arterial) using microguidewire and 0 0 OPEN YES
57 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023B 58485 64333 70182 76030 81879 84803
guiding catheter
58 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023C Angioplasty and bare metal stenting (arterial) 50610 55671 60732 65793 70854 73384 0 0 OPEN YES
Angioplasty and bare metal stenting (arterial) 0 0 OPEN YES
59 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023D 79905 87895 95886 103876 111867 115862
CTO lesion
Angioplasty and covered stent placement 0 0 OPEN YES
60 Interventional radiology IN Interventional radiology IN023 Angioplasty (arterial) IN023E 65835 72418 79002 85585 92169 95460
(arterial)
Catheter directed thrombolysis 0 0 OPEN YES
61 Interventional radiology IN Interventional radiology IN024 IN024A Catheter directed thrombolysis (arterial/venous) 46305 50935 55566 60196 64827 67142
(arterial/venous)
Thrombectomy followed by thrombolysis Thrombectomy followed by thrombolysis 0 0 OPEN YES
62 Interventional radiology IN Interventional radiology IN025 IN025A 57330 63063 68796 74529 80262 83128
(arterial/venous) (arterial/venous)
63 Interventional radiology IN Interventional radiology IN026 Angioplasty (venous) IN026A Angioplasty (venous) 26355 28990 31626 34261 36897 38214 0 0 OPEN
64 Interventional radiology IN Interventional radiology IN026 Angioplasty (venous) IN026B Angioplasty and stenting hepatic vein 65940 72534 79128 85722 92316 95613 0 0 OPEN YES
Angioplasty and bare metal stenting 0 0 OPEN YES
65 Interventional radiology IN Interventional radiology IN026 IN026C Angioplasty and bare metal stenting (venous) 46515 51166 55818 60469 65121 67446
(venous)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Angioplasty (IVC/central vein) with high 0 0 OPEN YES
66 Interventional radiology IN Interventional radiology IN026 Angioplasty (venous) IN026D 61215 67336 73458 79579 85701 88761
pressure balloon
Angioplasty and covered stent placement 0 0 OPEN YES
67 Interventional radiology IN Interventional radiology IN026 Angioplasty (venous) IN026E 59220 65142 71064 76986 82908 85869
(venous)
68 Interventional radiology IN Interventional radiology IN027 Angioplasty-Below knee angioplasty IN027A Angioplasty Below knee angioplasty 69930 76923 83916 90909 97902 101398 0 0 OPEN YES
Angioplasty (complex): cutting balloon/drug Angioplasty (complex): cutting balloon/drug 0 0 OPEN YES
69 Interventional radiology IN Interventional radiology IN028 IN028A 69825 76807 83790 90772 97755 101246
coated balloon coated balloon
Angioplasty with medicated SFA stent Angioplasty with medicated SFA stent 0 0 OPEN YES
70 Interventional radiology IN Interventional radiology IN029 IN029A 312480 343728 374976 406224 437472 453096
/Specialised stent (arterial) CTO lesion /Specialised stent (arterial) CTO lesion
Angioplasty (central vein/ CIV ) with high 0 0 OPEN YES
Angioplasty (central vein/ CIV ) with high
71 Interventional radiology IN Interventional radiology IN030 pressure balloon Aand specilaised venous IN030A 218190 240009 261828 283647 305466 316375
pressure balloon and specilaised venous stent
stent
72 Interventional radiology IN Interventional radiology IN031 Fenestration of dissecting aneurysm IN031A Fenestration of dissecting aneurysm 39165 43081 46998 50914 54831 56789 0 0 OPEN
73 Interventional radiology IN Interventional radiology IN032 TEVAR for aortic aneurysm/ dissection IN032A TEVAR for aortic aneurysm/ dissection 87990 96789 105588 114387 123186 127585 0 0 OPEN YES
74 Interventional radiology IN Interventional radiology IN033 Post EVAR endoleak management IN033A Post EVAR endoleak management 28665 31531 34398 37264 40131 41564 0 0 OPEN
75 Interventional radiology IN Interventional radiology IN034 IVC filter placement IN034A IVC filter placement 20370 22407 24444 26481 28518 29536 0 0 OPEN
IVC filter placement with Catheter directed IVC filter placement with Catheter directed 0 0 OPEN
76 Interventional radiology IN Interventional radiology IN034 IN034B 38010 41811 45612 49413 53214 55114
thrombolysis (arterial/venous) thrombolysis (arterial/venous)
77 Interventional radiology IN Interventional radiology IN034 IVC filter retrieval IN034C IVC filter retrieval 15120 16632 18144 19656 21168 21924 0 0 OPEN
78 Interventional radiology IN Interventional radiology IN035 Retrieval of intravascular foreign body IN035A Retrieval of intravascular foreign body 17745 19519 21294 23068 24843 25730 0 0 OPEN
79 Interventional radiology IN Interventional radiology IN036 Joint/bursa intervention IN036A Joint/bursa intervention 7245 7969 8694 9418 10143 10505 0 0 OPEN
80 Interventional radiology IN Interventional radiology IN037 Sacroiliac joint denervation IN037A Sacroiliac joint denervation 19845 21829 23814 25798 27783 28775 0 0 OPEN
Facet joint intra-articular intervention- Facet joint intra-articular intervention- 0 0 OPEN
81 Interventional radiology IN Interventional radiology IN038 IN038A 7245 7969 8694 9418 10143 10505
CS/Thoracic/LS CS/Thoracic/LS
0 0 OPEN
82 Interventional radiology IN Interventional radiology IN039 Median branch rhizotomy- CS/Thoracic/LS IN039A Median branch rhizotomy- CS/Thoracic/LS 19845 21829 23814 25798 27783 28775
0 0 OPEN
Radiofrequency ablation-Trigeminal Radiofrequency ablation-Trigeminal
83 Interventional radiology IN Interventional radiology IN040 nerve/genicular nerve /celiac plexus /stellate IN040A nerve/genicular nerve /celiac plexus /stellate 19845 21829 23814 25798 27783 28775
Ganglion/sympathetic nerve (any branch) Ganglion/sympathetic nerve (any branch)
PRP -suprascapular /tennis elbow/other 0 0 OPEN
84 Interventional radiology IN Interventional radiology IN041 IN041A PRP -suprascapular /tennis elbow/other tendon 7245 7969 8694 9418 10143 10505
tendon
Percutaneous Discotomy/nucleotomy using Percutaneous Discotomy/nucleotomy using 0 0 OPEN
85 Interventional radiology IN Interventional radiology IN042 IN042A 17745 19519 21294 23068 24843 25730
laser or nucleuotome laser or nucleuotome
86 Interventional radiology IN Interventional radiology IN043 Neural foraminal block IN043A Neural foraminal block 7245 7969 8694 9418 10143 10505 0 0 OPEN
Radiofrequency Ablation (RFA) of bone Radiofrequency Ablation (RFA) of bone tumor 0 0 OPEN
87 Interventional radiology IN Interventional radiology IN044 IN044A 33390 36729 40068 43407 46746 48415
tumor /metastases/osteoid osteoma /metastases/osteoid osteoma
Microwave ablation of bone tumor /osteoid Microwave ablation of bone tumor /osteoid 0 0 OPEN YES
88 Interventional radiology IN Interventional radiology IN045 IN045A 41790 45969 50148 54327 58506 60595
osteoma osteoma
89 Interventional radiology IN Interventional radiology IN046 Stroke-Stent Retreiver IN046A Stroke-Stent Retreiver 305550 336105 366660 397215 427770 443047 0 0 OPEN YES
90 Interventional radiology IN Interventional radiology IN046 Stroke-Aspiration Catheter IN046B Stroke-Aspiration Catheter 325815 358396 390978 423559 456141 472431 0 0 OPEN YES
Intervention for Acute stroke (Aspiration & Intervention for Acute stroke (Aspiration & stent 0 0 OPEN YES
91 Interventional radiology IN Interventional radiology IN047 IN047A 412860 454146 495432 536718 578004 598647
stent retrieval) retrieval)
Endovascular therapy for intracranial 0 0 OPEN YES
92 Interventional radiology IN Interventional radiology IN048 IN048A Aneurysm-3 Coil 144165 158581 172998 187414 201831 209039
aneurysm
Endovascular therapy for intracranial 0 0 OPEN YES
93 Interventional radiology IN Interventional radiology IN048 IN048B Aneurysm-5 Coil 283920 312312 340704 369096 397488 411684
aneurysm
Endovascular therapy for intracranial 0 0 OPEN YES
94 Interventional radiology IN Interventional radiology IN048 IN048C Aneurysm-7 Coil 337785 371563 405342 439120 472899 489788
aneurysm
Endovascular therapy for intracranial 0 0 OPEN YES
95 Interventional radiology IN Interventional radiology IN048 IN048D 3 Coil + Balloon 161070 177177 193284 209391 225498 233551
aneurysm
Endovascular therapy for intracranial 0 0 OPEN YES
96 Interventional radiology IN Interventional radiology IN048 IN048E 5 Coil + Balloon 362670 398937 435204 471471 507738 525871
aneurysm
Endovascular therapy for intracranial 0 0 OPEN YES
97 Interventional radiology IN Interventional radiology IN048 IN048F 3 Coil + Balloon+Stent 232470 255717 278964 302211 325458 337081
aneurysm
Endovascular therapy for intracranial 0 0 OPEN YES
98 Interventional radiology IN Interventional radiology IN048 IN048G 5 Coil + Balloon+Stent 453915 499306 544698 590089 635481 658176
aneurysm
Endovascular therapy for intracranial 0 0 OPEN YES
99 Interventional radiology IN Interventional radiology IN048 IN048H 7 Coil + Balloon+Stent 498015 547816 597618 647419 697221 722121
aneurysm
0 0 OPEN YES
Arteriovenous fistula (AVF)/Arteriovenous
100 Interventional radiology IN Interventional radiology IN049 IN049A Pial AVF (Single hole) 126420 139062 151704 164346 176988 183309
Malformation (AVM)
0 0 OPEN YES
Arteriovenous fistula (AVF)/Arteriovenous
101 Interventional radiology IN Interventional radiology IN049 IN049B AVF 136920 150612 164304 177996 191688 198534
Malformation (AVM)
0 0 OPEN YES
Arteriovenous fistula (AVF)/Arteriovenous
102 Interventional radiology IN Interventional radiology IN049 IN049C AVM (nidus upto 3 cm) 164535 180988 197442 213895 230349 238575
Malformation (AVM)
103 Interventional radiology IN Interventional radiology IN050 Carotid angioplasty & stenting IN050A Carotid stenting 131250 144375 157500 170625 183750 190312 0 0 OPEN YES
104 Interventional radiology IN Interventional radiology IN050 Carotid angioplasty & stenting IN050B Carotid stenting-membrane layered 185535 204088 222642 241195 259749 269025 0 0 OPEN YES
Intracranial stenting for Intracranial Intracranial stenting for Intracranial 0 0 OPEN YES
105 Interventional radiology IN Interventional radiology IN051 IN051A 382515 420766 459018 497269 535521 554646
atheroscelorosis disease (ICAD) atheroscelorosis disease (ICAD)
106 Interventional radiology IN Interventional radiology IN052 Dural sinus stenting IN052A Dural sinus stenting 139545 153499 167454 181408 195363 202340 0 0 OPEN YES
107 Interventional radiology IN Interventional radiology IN053 Carotid stenting with protection device IN053A Carotid stenting with protection device 218295 240124 261954 283783 305613 316527 0 0 OPEN YES
Vasospasm management-post Vasospasm management-post coiling/clipping 0 0 OPEN YES
108 Interventional radiology IN Interventional radiology IN054 IN054A 84945 93439 101934 110428 118923 123170
coiling/clipping (Cost per session) (Cost per session)
109 Interventional radiology IN Interventional radiology IN055 Retinoblastoma package IN055A Retinoblastoma under GA 94710 104181 113652 123123 132594 137329 0 0 OPEN YES
110 Interventional radiology IN Interventional radiology IN056 Percutaneous cholecystostomy IN056A Percutaneous cholecystostomy 23205 25525 27846 30166 32487 33647 0 0 OPEN
PAIR / percutaneous sclerotherapy for PAIR / percutaneous sclerotherapy for Hydatid 0 0 OPEN
111 Interventional radiology IN Interventional radiology IN057 IN057A 9660 10626 11592 12558 13524 14007
Hydatid cyst cyst
Oesophageal /gastric / duodenal / colonic Oesophageal /gastric / duodenal / colonic 0 0 OPEN
112 Interventional radiology IN Interventional radiology IN058 IN058A 25095 27604 30114 32623 35133 36387
stenting/balloon dilatation stenting/balloon dilatation
113 Interventional radiology IN Interventional radiology IN059 Transjugular Liver biopsy IN059A Transjugular Liver biopsy 18480 20328 22176 24024 25872 26796 0 0 OPEN
114 Interventional radiology IN Interventional radiology IN060 Percutaneous gastrostomy IN060A Percutaneous gastrostomy 8295 9124 9954 10783 11613 12027 0 0 OPEN
Transarterial chemoembolization - conventional 0 0 OPEN YES
115 Interventional radiology IN Interventional radiology IN061 Transarterial chemoembolization IN061A 63000 69300 75600 81900 88200 91350
(cTACE)
Transarterial chemoembolization - Drug eluting 0 0 OPEN YES
116 Interventional radiology IN Interventional radiology IN061 Transarterial chemoembolization IN061B 54075 59482 64890 70297 75705 78408
beads (DEB-TACE)
0 0 OPEN YES
Transjugular intrahepatic portosystemic Transjugular intrahepatic portosystemic shunt
117 Interventional radiology IN Interventional radiology IN062 shunt creation (TIPSS)/Direct transjugular IN062A creation (TIPSS)/Direct transjugular Intrahepatic 99435 109378 119322 129265 139209 144180
Intrahepatic Portosystemic shunt(DIPSS) Portosystemic shunt(DIPSS)
Balloon-occluded retrograde transvenous Balloon-occluded retrograde transvenous 0 0 OPEN YES
118 Interventional radiology IN Interventional radiology IN063 IN063A 53550 58905 64260 69615 74970 77647
obliteration (BRTO) obliteration (BRTO)
Plug-assisted retrograde transvenous Plug-assisted retrograde transvenous 0 0 OPEN YES
119 Interventional radiology IN Interventional radiology IN064 IN064A 60480 66528 72576 78624 84672 87696
obliteration (PARTO) obliteration (PARTO)
120 Interventional radiology IN Interventional radiology IN065 Pre-operative portal vein embolization IN065A Pre-operative portal vein embolization 35070 38577 42084 45591 49098 50851 0 0 OPEN
USG guided percutaneous ganglion/plexus USG guided percutaneous ganglion/plexus 0 0 OPEN
121 Interventional radiology IN Interventional radiology IN066 IN066A 11970 13167 14364 15561 16758 17356
block (Neuronolysis) block (Neuronolysis)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
CT guided percutaneous ganglion/plexus CT guided percutaneous ganglion/plexus block 0 0 OPEN
122 Interventional radiology IN Interventional radiology IN067 IN067A 15120 16632 18144 19656 21168 21924
block (Neuronolysis) (Neuronolysis)
123 Interventional radiology IN Interventional radiology IN068 Vertebroplasty/Cementoplasty IN068A Vertebroplasty/Cementoplasty 28980 31878 34776 37674 40572 42021 0 0 OPEN
124 Interventional radiology IN Interventional radiology IN069 Kyphoplasty IN069A Kyphoplasty 41685 45853 50022 54190 58359 60443 0 0 OPEN YES
125 Interventional radiology IN Interventional radiology IN070 Vaccum assisted breast biopsy IN070A Vaccum assisted breast biopsy 11235 12358 13482 14605 15729 16290 0 0 OPEN
USG guided percutaneous Microwave 0 0 OPEN
USG guided percutaneous Microwave Ablation
126 Interventional radiology IN Interventional radiology IN071 Ablation (MWA)- benign breast /thyroid IN071A 38640 42504 46368 50232 54096 56028
(MWA)- benign breast /thyroid tumor
tumor
127 Interventional radiology IN Interventional radiology IN072 Diagnostic angiography (DSA) IN072A Diagnostic angiography (DSA) 9135 10048 10962 11875 12789 13245 0 0 OPEN
Varicose vein: endovenous treatment (for Varicose vein: endovenous treatment (for one 0 0 OPEN
128 Interventional radiology IN Interventional radiology IN073 IN073A 16170 17787 19404 21021 22638 23446
one limb) limb)
Percutaneous Injection sclerotherapy for Percutaneous Injection sclerotherapy for low 0 0 OPEN
129 Interventional radiology IN Interventional radiology IN074 IN074A 11970 13167 14364 15561 16758 17356
low flow vascular malformation flow vascular malformation
130 Interventional radiology IN Interventional radiology IN075 Varicocele embolization IN075A Varicocele embolization 23835 26218 28602 30985 33369 34560 0 0 OPEN
Fistuloplasty / Thrombectomy of dialysis 0 0 OPEN YES Yes
131 Interventional radiology IN Interventional radiology IN076 IN076A Fistuloplasty / Thrombectomy of dialysis fistula 42630 46893 51156 55419 59682 61813
fistula
132 Interventional radiology IN Interventional radiology IN077 EVOH Package IN077A AVM (1 vial) 140910 155001 169092 183183 197274 204319 0 0 OPEN YES
133 Interventional radiology IN Interventional radiology IN077 EVOH Package IN077B AVM (3 vial) 140910 155001 169092 183183 197274 204319 0 0 OPEN YES
134 Interventional radiology IN Interventional radiology IN077 EVOH Package IN077C AVM (5 vial) 140910 155001 169092 183183 197274 204319 0 0 OPEN YES
135 Interventional radiology IN Interventional radiology IN078 Tumor Embolization IN078A Tumor Embolization 94605 104065 113526 122986 132447 137177 0 0 OPEN YES
a) Clinical Notes with a) Procedure/ Operation OPEN
planned line of treatment notes b)Detailed discharge
136 14437 15750 17062 18375 19031 and indication for summary c) Invoices of
Cardiology MC Cardiology MC001 Right / Left Heart Catheterization MC001A Right Heart Catheterization 13125
procedure catheter and other
b) ECG accessories used
c) Echo report with stills
a) Clinical Notes with a) Procedure/ Operation OPEN
planned line of treatment notes b)Detailed discharge
137 Cardiology MC Cardiology MC001 Right / Left Heart Catheterization MC001B Left Heart Catheterization 13125 14437 15750 17062 18375 19031 and indication for summary c) Invoices of
procedure catheter and other
b) ECG accessories used
a) Clinical Notes with a) Procedure/ Operation OPEN YES
planned line of treatment notes b) Post procedure
b) Colour Doppler/ CT Colour Doppler/ angio
angio Report report of affected limb
Cardiology, Interventional
138 Cardiology MC MC002 Catheter directed Thrombolysis MC002A For Deep vein thrombosis (DVT) 40425 44467 48510 52552 56595 58616 c) Detailed discharge
Radiology
summary d) Invoices of
catheter used e)
Invoice of thrombolytic drug
(tPA) used
a) Clinical Notes with a) Procedure/ Operation OPEN YES
planned line of treatment notes b) Post procedure
b) Doppler Report/CT colour doppler/ CT
angiogram report Angiogram of affected
Cardiology, Interventional vessel c)
139 Cardiology MC MC002 Catheter directed Thrombolysis MC002B For Mesenteric Thrombosis 40425 44467 48510 52552 56595 58616
Radiology Detailed discharge
summary d) Invoices of
catheter used e)
Invoice of thrombolytic drug
used
a) Clinical Notes with a) Procedure/ Operation OPEN YES
planned line of treatment notes b) Post procedure
b) Doppler Report/ colour doppler/Angio report
Angiogram report of affected limb
Cardiology, Interventional
140 Cardiology MC MC002 Catheter directed Thrombolysis MC002C For Peripheral vessels 40425 44467 48510 52552 56595 58616 c) Detailed discharge
Radiology
summary d) Invoices of
catheter used e) Invoice
of thrombolytic drug used

a) Clinical notes a) Procedure/ Operation OPEN YES

b) Echo/Doppler report and notes b) Post Procedure
Stills Echo/Angiogram with report
141 Cardiology MC Cardiology MC003 Balloon Dilatation MC003A Coarctation of Aorta 50715 55786 60858 65929 71001 73536 c) Detailed discharge
summary d) Barcode of the
balloon/implant, If used

a) Clinical notes a) Procedure/ Operation OPEN YES

b) Echo-Doppler report and notes b) Post Procedure
Stills c) Angiogram Report Echo/Angiogram with
142 Cardiology MC Cardiology MC003 Balloon Dilatation MC003B Pulmonary Artery Stenosis 50715 55786 60858 65929 71001 73536 and Stills reports and stills
c) Detailed discharge
summary d) Barcode of the
balloon, If used
a) Clinical notes with a) Procedure / Operative OPEN YES
planned line of treatment notes b) Post procedure
143 66000 72000 78000 84000 87000 b) Detailed Echo report stills of ECHO with report
Cardiology MC Cardiology MC004 Balloon Pulmonary / Aortic Valvotomy MC004A Balloon Pulmonary Valvotomy 60000
c) Detailed Discharge
Summary
d) Invoice of balloon used
a) Clinical notes with a) Procedure / Operative OPEN
planned line of treatment notes with indication of
b) Detailed Echo report procedure b) Post
144 33841 36918 39994 43071 44609 procedure stills of ECHO
Cardiology MC Cardiology MC004 Balloon Pulmonary / Aortic Valvotomy MC004B Balloon Aortic Valvotomy 30765
with report c)
Detailed Discharge
Summary
d) Invoice of balloon used
a) Clinical notes with a) Procedure / Operative OPEN YES
planned line of treatment notes
b) Detailed Echo /Doppler b) Post procedure stills of
145 66000 72000 78000 84000 87000 report ECHO with report
Cardiology MC Cardiology MC005 Balloon Mitral Valvotomy MC005A Balloon Mitral Valvotomy 60000
c) Detailed Discharge
Summary
d) Invoice/ barcode of
balloon used
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Procedure / Operative OPEN
planned line of treatment notes b) Post procedure
b) Echo report/ Doppler stills of ECHO with report
146 Cardiology MC Cardiology MC006 Balloon Atrial Septostomy MC006A Balloon Atrial Septostomy 32025 35227 38430 41632 44835 46436 report with stills c) Detailed Discharge
Summary
d) Invoice of blade/balloon
used
a)Clinical notes a)Procedure / Operative OPEN YES
b)Echo/Doppler report notes b) Post procedure
stills of ECHO with report
147 Cardiology MC Cardiology MC007 ASD Device Closure MC007A ASD Device Closure 75000 82500 90000 97500 105000 108750 c) Detailed Discharge
Summary
d) Invoice/ barcode of blade
/ device used
a) Clinical notes a) Procedure / Operative OPEN YES
b) Echo/Doppler report notes b) Post procedure
stills of ECHO with report
148 Cardiology MC Cardiology MC008 VSD Device Closure MC008A VSD Device Closure 75000 82500 90000 97500 105000 108750 c) Detailed Discharge
Summary
d) Invoice/ barcode of blade
/ device used
a) Clinical notes a) Procedure / Operative OPEN YES
b) Detailed Echo/ Doppler notes b) Post Procedure
report Echo/Doppler
149 Cardiology MC Cardiology MC009 PDA Device Closure MC009A PDA Device Closure 42840 47124 51408 55692 59976 62118 c) Detailed Discharge
Summary
d) Invoice/ barcode of blade
/ device used
a) Clinical notes a) Procedure / Operative OPEN YES
b) Echo report or notes
Angiography Report b) Per-procedure or Post
procedure stills of angio or
150 Cardiology MC Cardiology MC010 PDA stenting MC010A PDA stenting 52920 58212 63504 68796 74088 76734 ECHO showing stent in
place, with report
c) Detailed Discharge
Summary
d) Invoice of stent used
e) Barcode of stent used
a) Clinical notes a) Still image of the patient OPEN
b) Patient Photograph undergoing the procedure
c) Investigation reports with date & time
i. Electrocardiogram (ECG) b) Angiogram stills & report
ii. 2D ECHO showing stent & post stent
iii. Coronary Angiography flow c) Serial ECGs (Post
stills & reports (showing Procedure)
blockage) d) Cardiac enzymes
151 Cardiology MC Cardiology MC011 PTCA, inclusive of diagnostic angiogram MC011A PTCA, inclusive of diagnostic angiogram 92000 101200 110400 119600 128800 133400 iv. Cardiac enzymes (Troponins T/ I (if not
(Troponins T/ I (if not available then CPK-MB)
available then CPK-MB) e) Procedure/ Operation
v. Routine Biochemistry notes
(Haemogram, urea, f) Detailed discharge
creatinine, electrolytes, summary
sugar, fasting lipids, Liver g) Barcode of the stent(s)
function test, Urinalysis) used (Bare metal/ Drug
eluting stent)

a) Clinical notes a) Procedure / Operative OPEN

b) ECG with report of notes b) EP study report
cardiologist c) Detailed Discharge
152 Cardiology MC Cardiology MC012 Electrophysiological Study MC012A Electrophysiological Study 36435 40078 43722 47365 51009 52830 c) Echo/ colour doppler Summary
report with stills d) Invoice/ Bar code of
d) Indication for procedure catheters

a) Clinical notes a) Procedure / Operative OPEN

b) ECG with report of notes b) EP study report
cardiologist c) Detailed Discharge
Electrophysiological Study
153 Cardiology MC Cardiology MC012 Electrophysiological Study MC012B 36435 40078 43722 47365 51009 52830 c) Echo/ colour doppler Summary
with Radio Frequency Ablation
report with stills d) Invoice/ Bar code of
d) Indication for procedure catheters

a) Clinical notes a) Procedure / Operative OPEN YES

b) ECG with report of notes b) Post procedure
Percutaneous Transluminal Septal Percutaneous Transluminal Septal Myocardial cardiologist echo/colour Doppler report
154 Cardiology MC Cardiology MC013 MC013A 44625 49087 53550 58012 62475 64706
Myocardial Ablation Ablation c) Echo/ color Doppler and angio stills c) Detailed
report with stills Discharge Summary

a) Clinical notes a) Indoor case papers OPEN

b) ECG with report of b) Procedure / Operative
cardiologist notes with indication
c) ECG paced rhythm strip/
still frame of lead in situ
155 Cardiology MC Cardiology, CTVS MC014 Temporary Pacemaker implantation MC014A Temporary Pacemaker implantation 25200 27720 30240 32760 35280 36540 d) Detailed Discharge
Summary
e) Invoice & barcode of
designated pacemaker
pacing lead

a) Clinical notes with a) Procedure / Operative OPEN

indication for implantation notes b) X Ray showing
b) ECG with report of pacemaker in situ
Single Chamber Permanent Pacemaker Permanent Pacemaker Implantation -
156 Cardiology MC Cardiology, CTVS MC015 MC015A 32235 35458 38682 41905 45129 46740 cardiologist c) Detailed Discharge
Implantation Single Chamber
c) Angiogram report, if Summary
done d) Invoice/barcode of
designated pacemaker
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
A)Clinical notes. A)X Ray showing the OPEN YES
B) ECG. pacemaker in situ.
C) Report by cardiologist B) Invoice .
necessitating procedure. C) Barcode of designated
Double Chamber Permanent Pacemaker Permanent Pacemaker Implantation -
157 Cardiology MC Cardiology, CTVS MC016 MC016A 43365 47701 52038 56374 60711 62879 D) Angiogram if done pacemaker.
Implantation Double Chamber
D)Detailed Procedure .
E) Operative Notes.
F)detailed discharge
summary
a) Clinical notes a) Procedure / Operative OPEN YES
b) Doppler ultrasound/ notes b) Post procedure
Digital subtraction stills of Angio with report
angiography/ Computed c) Detailed Discharge
158 Cardiology MC Cardiology MC017 Peripheral Angioplasty MC017A Peripheral Angioplasty 45360 49896 54432 58968 63504 65772 tomography angiography/ Summary
magnetic resonance d) Invoice/ Barcode of stent
angiography report with used
stills
c) Angiogram Report with
stills
a) Clinical notes with a) Procedure / Operative OPEN YES
planned line of treatment notes b) Check
b) Chest X ray angiography of same
Bronchial artery Embolisation Bronchial artery Embolisation
159 Cardiology MC Cardiology MC018 MC018A 43050 47355 51660 55965 60270 62422 c) HRCT Chest/ CTPA bronchial artery after
(for Haemoptysis) (for Haemoptysis)
procedure
c) Detailed Discharge
Summary
a) Clinical notes a) Procedure / Operative OPEN
b) Echo/ color Doppler notes b) Post procedure
report with stills echo/colour Doppler report
Cardiology, c) Detailed Discharge
160 Cardiology MC MC019 Pericardiocentesis MC019A Pericardiocentesis 15960 17556 19152 20748 22344 23142
General Surgery Summary
d) Analysis of fluid removed

161 Cardiology MC Cardiology MC020 Systemic Thrombolysis (for MI) MC020A Systemic Thrombolysis (for MI) 23520 25872 28224 30576 32928 34104 0 0 OPEN
0 0 OPEN YES
162 Cardiology MC Cardiology MC021 Embolization MC021A Arteriovenous Malformation (AVM) in the Limbs 53340 58674 64008 69342 74676 77343
163 Cardiology MC Cardiology MC022 follow up -Cardiology MC022B Second Follow-up- After 3 months 4620 5082 5544 6006 6468 6699 0 0 OPEN
164 Cardiology MC Cardiology MC022 follow up -Cardiology MC022C Third Follow-up- After 3 months 2310 2541 2772 3003 3234 3349 0 0 OPEN
165 Cardiology MC Cardiology MC022 follow up -Cardiology MC022D fourth Follow-up- After 3 months 2310 2541 2772 3003 3234 3349 0 0 OPEN
166 Cardiology MC Cardiology MC022 follow up -Cardiology MC022E FifthFollow-up - After 3 months 2310 2541 2772 3003 3234 3349 0 0 OPEN
167 Cardiology MC Cardiology MC023 AICD implantation Single Chamber MC023A AICD implantation Single Chamber 25875 28462 31050 33637 36225 37518 0 0 OPEN
168 Cardiology MC Cardiology MC023 AICD implantation Dual Chamber MC023B AICD implantation Dual Chamber 36000 39600 43200 46800 50400 52200 0 0 OPEN
169 Cardiology MC Cardiology MC024 Combo device implantation MC024A Combo device implantation 40000 44000 48000 52000 56000 58000 0 0 OPEN
170 Cardiology MC Cardiology MC025 Coronary Angiography MC025A Coronary Angiography 8000 8800 9600 10400 11200 11600 0 0 OPEN
a) Clinical notes with a) Detailed Indoor case Reserved Variable
detailing history papers, Treatment details
General Medicine, b) CBC, ESR, Peripheral b) Post treatment CBC,
171 General Medicine MG Pediatric Medical MG001 Acute febrile illness MG001A Acute febrile illness 2250 2475 2700 2925 3150 3262 smear, LFT report ESR, Peripheral smear,
Management LFT reports
c) Detailed Discharge
Summary
a) Clinical notes a) Indoor case papers OPEN Variable
b) Complete Blood count b) Culture reports- Blood &
Urine Routine Urine
General Medicine,
172 2475 2700 2925 3150 3262 c) Planned line of c) Biochemistry- Renal
General Medicine MG Pediatric Medical MG002 Severe sepsis MG002A Severe sepsis 2250
management Function Test &
Management
Liver Function Test reports
d) Discharge summary

a) Clinical notes a) Indoor case papers OPEN Variable

b) Complete Blood count b) Culture reports- Blood &
Urine Routine Urine
General Medicine,
173 2475 2700 2925 3150 3262 c) Planned line of c) Biochemistry- Renal
General Medicine MG Pediatric Medical MG002 Severe sepsis MG002B Septic shock 2250
management Function Test &
Management
Liver Function Test reports
d) Discharge summary

a) Clinical Notes including a) Detailed Indoor case Reserved Variable

evaluation findings, paper
indications for the b) Post treatment Blood
General Medicine, procedure, and planned investigation report (CBC,
174 General Medicine MG Pediatric Medical MG003 Malaria MG003A Malaria 2250 2475 2700 2925 3150 3262 line of treatment MP, Platelet
Management b) Peripheral smear/RMT etc.)
test report c) Detailed discharge
c) Blood report (CBC, MP, summary
Platelet.)
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, paper
indications for the b) Post treatment Blood
General Medicine, procedure, and planned investigation report (CBC,
175 General Medicine MG Pediatric Medical MG003 Malaria MG003B Complicated malaria 2250 2475 2700 2925 3150 3262 line of treatment MP, Platelet
Management b) Peripheral smear/RMT etc.)
test report c) Detailed discharge
c) Blood report (CBC, MP, summary
Platelet.)
a) Clinical notes a) Indoor case papers Referral Variable
b)Complete Blood Count including monitoring of
(CBC) c) NS1 Antigen vitals b)
General Medicine,
176 2475 2700 2925 3150 3262 d)Peripheral blood film Complete Blood Count
General Medicine MG Pediatric Medical MG004 Dengue fever MG004A Dengue fever 2250
e) Planned line of (CBC)
Management
treatment c) All other investigation
reports
d) Discharge Summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Indoor case papers OPEN Variable
b)Complete Blood Count including monitoring of
(CBC) c) NS1 Antigen vitals b)
General Medicine,
177 2475 2700 2925 3150 3262 d)Peripheral blood film Complete Blood Count
General Medicine MG Pediatric Medical MG004 Dengue fever MG004B Dengue hemorrhagic fever 2250
e) Planned line of (CBC)
Management
treatment c) All other investigation
reports
d) Discharge Summary
a) Clinical notes a) Indoor case papers OPEN Variable
b)Complete Blood Count including monitoring of
(CBC) c) NS1 Antigen vitals b)
General Medicine,
178 2475 2700 2925 3150 3262 d)Peripheral blood film Complete Blood Count
General Medicine MG Pediatric Medical MG004 Dengue fever MG004C Dengue shock syndrome 2250
e) Planned line of (CBC)
Management
treatment c) All other investigation
reports
d) Discharge Summary
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers
indications for the b) Post procedure CBC
General Medicine,
179 2475 2700 2925 3150 3262 procedure, and planned report
General Medicine MG Pediatric Medical MG005 Chikungunya fever MG005A Chikungunya fever 2250
line of treatment c) Detailed Discharge
Management
b) CBC report Summary
c) IgM - ELISA test reports
for Chikungunya
a) Clinical notes with a) Detailed Indoor case Reserved Variable
detailing history papers, Treatment details
General Medicine, b) CBC, ESR, Peripheral b) Post treatment CBC,
180 General Medicine MG Pediatric Medical MG006 Enteric fever MG006A Enteric fever 2250 2475 2700 2925 3150 3262 smear, LFT report ESR, Peripheral smear,
Management LFT reports
c) Detailed Discharge
Summary
a) Clinical Notes including a) Detailed indoor case OPEN Variable
evaluation findings, papers and treatment given
indications for the b) Detailed Discharge
General Medicine,
181 2475 2700 2925 3150 3262 procedure, and planned Summary
General Medicine MG Pediatric Medical MG007 HIV with complications MG007A HIV with complications 2250
line of treatment
Management
b) CD4 cell count report
c) HIV-ELISA/HIV viral
load report
a) Clinical notes detailing a) Detailed Indoor case OPEN Variable
examination findings, papers and treatment
investigations, Planned line details
General Medicine,
182 2475 2700 2925 3150 3262 of treatment b) Detailed discharge
General Medicine MG Pediatric Medical MG008 Leptospirosis MG008A Leptospirosis 2250
b) MAT (Microscopic summary
Management
Agglutination Test), PCR or
IgM antibody test
c) LFT, KFT Reports
a) Clinical Notes including a) Detailed Indoor case Reserved Variable
evaluation findings, papers
General Medicine, indications for the b) Post treatment Stool
Pediatric Medical procedure, and planned culture report
183 General Medicine MG MG009 Acute gastroenteritis with dehydration MG009A Acute gastroenteritis with moderate dehydration 2250 2475 2700 2925 3150 3262
Management, line of treatment c) Post treatment Sr.
Gastroenterology b) CBC report Electrolyte report
c) Sr. Electrolyte report d) Detailed Discharge
Summary
a) Clinical Notes including a) Detailed Indoor case Reserved Variable
evaluation findings, papers
General Medicine, indications for the b) Post treatment Stool
Pediatric Medical procedure, and planned culture report
184 General Medicine MG MG009 Acute gastroenteritis with dehydration MG009B Acute gastroenteritis with severe dehydration 2250 2475 2700 2925 3150 3262
Management, line of treatment c) Post treatment Sr.
Gastroenterology b) CBC report Electrolyte report
c) Sr. Electrolyte report d) Detailed Discharge
Summary
0 0 OPEN Yes
General Medicine,
185 General Medicine MG MG010 Chronic PD catheter Insertion MG100A Chronic PD catheter Insertion 4305 4735 5166 5596 6027 6242
Nephrology- Interventional
General Medicine, 0 0 OPEN Variable
186 General Medicine MG MG0101 Acute severe ulcerative colitis MG101A Acute severe ulcerative colitis 2250 2475 2700 2925 3150 3262
Gastroenterology
General Medicine, 0 0 OPEN Variable
187 General Medicine MG MG0102 Mesenteric Ischemia MG102A Mesenteric Ischemia 2250 2475 2700 2925 3150 3262
Gastroenterology
General Medicine, 0 0 OPEN Variable
188 General Medicine MG MG0103 Intestinal obstruction MG103A Intestinal obstruction 2250 2475 2700 2925 3150 3262
Gastroenterology
General Medicine, 0 0 OPEN Variable
189 General Medicine MG MG0104 Acute necrotizing severe pancreatitis MG104A Acute necrotizing severe pancreatitis 2250 2475 2700 2925 3150 3262
Gastroenterology
General medicine /high end 0 0 OPEN
190 General Medicine MG MG0105 Pulmonary Thromboembolism MG105A Pulmonary Thromboembolism 26250 28875 31500 34125 36750 38062
drugs
General medicine /high end Diffuse alveolar Hemorrhage Associated Diffuse alveolar Hemorrhage Associated with 0 0 OPEN YES
191 General Medicine MG MG0106 MG106A 142800 157080 171360 185640 199920 207060
drugs with SLE/Vasculitis/GP Syndrome SLE/Vasculitis/GP Syndrome
General medicine /high end 0 0 OPEN YES
192 General Medicine MG MG0107 Severe/Refractory Vasculitis MG107A Severe/Refractory Vasculitis 78750 86625 94500 102375 110250 114187
drugs
0 0 OPEN YES
193 General Medicine MG General medicine MG0108 Acute liver failure/Fulminant Hepatitis MG108A Acute liver failure/Fulminant Hepatitis 52500 57750 63000 68250 73500 76125
0 0 OPEN Variable
194 General Medicine MG General medicine MG0109 Pulmonary thromboembolism MG109A Pulmonary thromboembolism 2250 2475 2700 2925 3150 3262
a) Clinical notes with a) Indoor case papers Reserved Variable
indications b) Planned line b) Stool report
General Medicine,
of management c) Chest X c) Discharge Summary
Pediatric Medical
195 General Medicine MG MG010 Diarrohea MG010A Chronic diarrohea 2250 2475 2700 2925 3150 3262 ray
Management,Gastroenterol
d) Stool pH
ogy
e) Stool Examination report

a) Clinical notes with a) Indoor case papers Reserved Variable

indications b) Planned line b) Stool report
General Medicine,
of management c) Chest X c) Discharge Summary
Pediatric Medical
196 General Medicine MG MG010 Diarrohea MG010B Persistent diarrohea 2250 2475 2700 2925 3150 3262 ray
Management,Gastroenterol
d) Stool pH
ogy
e) Stool Examination report
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
0 0 OPEN Variable
197 General Medicine MG General medicine MG0110 Acute liver failure MG110A Acute liver failure 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
198 General Medicine MG General medicine MG0111 Pleural Effusion MG111A Pleural Effusion 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
199 General Medicine MG General medicine MG0112 Hyberbilirubinemia MG112A Hyberbilirubinemia 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
200 General Medicine MG General medicine MG0113 Polytrauma MG113A Polytrauma 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
201 General Medicine MG General medicine MG0113 Trauma- FacioMaxillary MG113B Trauma- FacioMaxillary 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
202 General Medicine MG General medicine MG0113 Trauma Hand injury MG113C Trauma Hand injury 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
203 General Medicine MG General medicine MG0113 Trauma Rib fracture conservative MG113D Trauma Rib fracture conservative 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
204 General Medicine MG General medicine MG0113 Trauma Blunt injury conservative MG113E Trauma Blunt injury conservative 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
205 General Medicine MG General medicine MG0113 Trauma Contusion chest injury MG113F Trauma Contusion chest injury 2250 2475 2700 2925 3150 3262
0 0 OPEN Variable
206 General Medicine MG General medicine MG0114 Oesophageal Varices Banding MG114A Oesophageal Varices Banding 2250 2475 2700 2925 3150 3262
General Medicine, 0 0 OPEN 30
207 General Medicine MG neurology, pediatric MG0115 Inflammatory Myopathy/ Myaesthenic Crisis MG115A Inflammatory Myopathy/ Myaesthenic Crisis 2200 2420 2640 2860 3080 3190
medicine
General Medicine, 0 0 OPEN 30
208 General Medicine MG neurology, pediatric MG0116 Guillain Barre syndrome MG116A Guillain Barre syndrome (Plasmapheresis) 2200 2420 2640 2860 3080 3190
medicine
General Medicine, 0 0 OPEN 30
209 General Medicine MG neurology, pediatric MG0116 Myasthenic crisis (Plasmapheresis) MG116B Myasthenic crisis (Plasmapheresis) 2200 2420 2640 2860 3080 3190
medicine
General Medicine, 0 0 OPEN 30
210 General Medicine MG neurology, pediatric MG0117 Moyamoya revascularization MG117A Moyamoya revascularization 2200 2420 2640 2860 3080 3190
medicine
General Medicine, 0 0 OPEN 30
Evaluation of drug resistant epilepsy-Phase-
211 General Medicine MG neurology, pediatric MG0118 MG118A Evaluation of drug resistant epilepsy-Phase-1 2200 2420 2640 2860 3080 3190
1
medicine
General Medicine, 0 0 OPEN 30
212 General Medicine MG neurology, pediatric MG0119 Drug resistant epilepsy MG119A Drug resistant epilepsy 2200 2420 2640 2860 3080 3190
medicine
a) Clinical notes with a) Indoor case papers Reserved Variable
indications b) Planned line b) Stool report
General Medicine,
of management c) Chest X c) Discharge Summary
Pediatric Medical
213 General Medicine MG MG011 Dysentery MG011A Dysentery 2250 2475 2700 2925 3150 3262 ray
Management,Gastroenterol
d) Stool pH
ogy
e) Stool Examination report

General Medicine, Comprehensive medical rehabilitation for spinal 0 0 OPEN

214 General Medicine MG neurology, pediatric MG0120 Medical/ neuro rehablitation MG120A injury/ traumatic brain injury, CVA, Cerebral 26250 28875 31500 34125 36750 38062
medicine palsy with or without orthosis
Comprehensive medical rehabilitation for of 0 0 OPEN
General Medicine, complication secondary to specified
215 General Medicine MG neurology, pediatric MG0120 Medical/ neuro rehablitation MG120B disanility/multiple disability including 36750 40425 44100 47775 51450 53287
medicine procedures, chemodenevaration with or with
out orthosis
General Medicine, 0 0 OPEN
Single event multiple level surgery for spasticity
216 General Medicine MG neurology, pediatric MG0120 Medical/ neuro rehablitation MG120C 15750 17325 18900 20475 22050 22837
management in cerebral palsy
medicine
General Medicine, 0 0 OPEN
217 General Medicine MG neurology, pediatric MG0120 Medical/ neuro rehablitation MG120D Medical rehabilitation of muscular dystrophy 7350 8085 8820 9555 10290 10657
medicine
General Medicine, 0 0 OPEN
218 General Medicine MG neurology, pediatric MG0120 Medical/ neuro rehablitation MG120E Medical Rehabilitation intellectual dissability 7350 8085 8820 9555 10290 10657
medicine
General Medicine, 0 0 OPEN
Medical Rehabilitation special learning
219 General Medicine MG neurology, pediatric MG0120 Medical/ neuro rehablitation MG120F 7350 8085 8820 9555 10290 10657
disability
medicine
General Medicine, 0 0 OPEN
220 General Medicine MG neurology, pediatric MG0120 Medical/ neuro rehablitation MG120G Medical Rehabilitation multiple disability 7350 8085 8820 9555 10290 10657
medicine
a) Clinical notes detailing a) Detailed Indoor case OPEN Variable
examination findings, paper along with treatment
previous details
surgery/procedure, follow- b) Post treatment LFT
General Medicine, up visit details, (Liver function test), Serum
Pediatric Medical investigations, Planned line Bilirubin
221 General Medicine MG MG012 Acute viral hepatitis MG012A Acute viral hepatitis 2250 2475 2700 2925 3150 3262
Management,Gastroenterol of treatment c) Detailed discharge
ogy b) USG Whole Abdomen summary
c) LFT (Liver function test),
Serum Bilirubin
d) Serological test for
hepatitis
a) Clinical Notes including a) Detailed Indoor clinical OPEN Variable
evaluation findings, papers along with treatment
indications for the given details.
procedure, and planned B) Detailed Discharge
line of treatment Summary
General Medicine, b) Liver Function test,
Pediatric Medical Alpha fetoprotein, CBC,
222 General Medicine MG MG013 Chronic Hepatitis MG013A Chronic Hepatitis 2250 2475 2700 2925 3150 3262
Management,Gastroenterol Viral hepatitis
ogy markersreport
c) USG- Abdomen /Dual
phase CT Liver/ Upper GI
endoscopy/Fibro
scan for assessing hepatic
fibrosis
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, Papers with
General Medicine, indications for the treatment/aspiration
Pediatric Medical procedure, and planned details
223 General Medicine MG MG014 Liver abscess MG014A Liver abscess 2250 2475 2700 2925 3150 3262
Management,Gastroenterol line of treatment b) Post treatment USG
ogy b) Liver Function Test Abdomen report
c) Pretreatment USG c) Detailed discharge
Abdomen Summary
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, paper
indications for the b) Post treatment Blood
General Medicine,
procedure, and planned investigation report (CBC,
Pediatric Medical
224 General Medicine MG MG015 Visceral leishmaniasis MG015A Visceral leishmaniasis 2250 2475 2700 2925 3150 3262 line of treatment Platelet etc.)
Management,Gastroenterol
b) Rapid Dip Test (Rk-39) c) Detailed discharge
ogy
report summary
c) Blood report (CBC,
Platelet) reports
a)Clinical notes a)Indoor case papers OPEN Variable
B)X ray / CT chest b)Complete Blood Count
General Medicine, (CBC)
225 General Medicine MG Pediatric Medical MG016 Pneumonia MG016A Pneumonia 2250 2475 2700 2925 3150 3262 c)Liver Function Test (LFT)
Management,Pulmonology d)X Ray / CT Chest
d)COVID testing
e)Discharge Summary
a)Clinical notes a)Indoor case papers OPEN Variable
B)X ray / CT chest b)Complete Blood Count
(CBC)
General Medicine,
226 2475 2700 2925 3150 3262 c)Liver Function Test (LFT)
General Medicine MG Pediatric Medical MG017 Severe pneumonia MG017A Severe pneumonia 2250
d)X Ray / CT Chest
Management,Pulmonology
d)COVID testing
e)Discharge Summary
f)Pleural fluid culture
a ) Clinical Notes including a) Detailed Indoor clinical OPEN Variable
evaluation findings, papers with treatment
indications for the details
procedure, and planned b) Post treatment Chest X
General Medicine, line of treatment ray report/Drainage under
227 General Medicine MG Pediatric Medical MG018 Empyema MG018A Empyema 2250 2475 2700 2925 3150 3262 b) Hemogram report Ultrasound
Management,Pulmonology c) Chest X ray/Ultrasound guidance/Intercostal tube
chest/ CECT chest report drainage details (If
applicable)
c) Detailed Discharge
Summary
a) Clinical notes detailing a) Detailed Indoor case OPEN Variable
examination findings, papers
previous b) Post treatment Chest X
surgery/procedure, follow- ray
up visit details, c) Post treatment CBC,
investigations, advise for Blood Sugar (Fasting, PP
General Medicine, daycare procedure and Random) reports
228 General Medicine MG Pediatric Medical MG019 Lung abscess MG019A Lung abscess 2250 2475 2700 2925 3150 3262 b) Chest X Ray and CT d) Detailed discharge
Management,Pulmonology scan Chest (as applicable) summary
c) Sputum microscopy/
culture + sensitivity report
d) CBC, Blood Sugar
(Fasting, PP and Random)

a) Clinical Notes including a) Detailed Indoor case Reserved Variable

evaluation findings, papers with treatment
indications details
for the procedure, and b) Post treatment Chest x-
General Medicine, planned line of treatment ray
229 General Medicine MG Pediatric Medical MG020 Pericardial tuberculosis MG020A Pericardial tuberculosis 2250 2475 2700 2925 3150 3262 b) Erythrocyte c) Post treatment
Management,Pulmonology Sedimentation Rate (ESR) Electrocardiogram
report d) Detailed Discharge
c) X – Ray / MRI / CT scan Summary
(Chest) report
d) Electrocardiogram
(ECG) report
a) Clinical Notes including a) Detailed Indoor case Referral Variable
evaluation findings, papers with treatment
indications details
for the procedure, and b) Post treatment Chest x-
General Medicine, planned line of treatment ray
230 General Medicine MG Pediatric Medical MG020 Pleural tuberculosis MG020B Pleural tuberculosis 2250 2475 2700 2925 3150 3262 b) Erythrocyte c) Post treatment
Management,Pulmonology Sedimentation Rate (ESR) Electrocardiogram
report d) Detailed Discharge
c) X – Ray / MRI / CT scan Summary
(Chest) report
d) Electrocardiogram
(ECG) report
a)Clinical notes a) Indoor case papers Reserved Variable
b) On bed patient b )Prescribed medications
photograph. including culture sensitive
General Medicine, antibiotics c) Discharge
231 General Medicine MG Pediatric Medical MG021 Urinary Tract Infection MG021A Urinary Tract Infection 2250 2475 2700 2925 3150 3262 summary d) All
Management investigations reports
1. Urine culture/ sensitivity
2. Ultrasound KUB, if
indicated and available
 Outside State
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Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) Detailed discharge
showing vitals. summary.
General Medicine, c) Examination findings. d) All investigations reports.
232 General Medicine MG Pediatric Medical MG022 Viral Encephalitis MG022A Viral Encephalitis 2250 2475 2700 2925 3150 3262 d) Any investigations done.
Management e) Planned line of
management.

a) Clinical notes including a) Detailed indoor case Referral Variable

General Medicine, evaluation findings and papers with treatment
233 General Medicine MG Pediatric Medical MG023 Septic Arthritis MG023A Septic Arthritis 2250 2475 2700 2925 3150 3262 planned line of treatment details
Management b) CBC,X-ray report b) Detailed discharge
c) Synovial fluid analysis Summary
a) Clinical Notes including a) Detailed Indoor case Reserved Variable
evaluation findings, papers with treatment
indications for the details
General Medicine, procedure, and planned b) Post treatment CBC,
234 General Medicine MG Pediatric Medical MG024 Skin and soft tissue infections MG024A Skin and soft tissue infections 2250 2475 2700 2925 3150 3262 line of treatment ESR, LFT, Sr. Creatinine
Management b) CBC, ESR, LFT, Sr. reports
Creatine reports c) Detailed Discharge
c) C-reactive protein level Summary
report
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers
General Medicine, indications for the b) Post treatment Stool
Pediatric Medical procedure, and planned culture report
235 General Medicine MG MG025 Recurrent vomiting with dehydration MG025A Recurrent vomiting with dehydration 2250 2475 2700 2925 3150 3262
Management,Gastroenterol line of treatment c) Detailed Discharge
ogy b) CBC report Summary
c) Sr. Electrolyte report

a) Clinical notes with a) Detailed Indoor case OPEN Variable

detailing history papers, Treatment details
General Medicine, b) CBC, ESR, Peripheral b) Post treatment CBC,
236 General Medicine MG Pediatric Medical MG026 Pyrexia of unknown origin MG026A Pyrexia of unknown origin 2250 2475 2700 2925 3150 3262 smear, LFT report ESR, Peripheral smear,
Management LFT reports
c) Detailed Discharge
Summary
a) Clinical Notes including a) Indoor case papers OPEN Variable
evaluation findings, b) Post treatment Chest X
indications for the ray report
procedure, and planned c) Post treatment lung
General Medicine, line of treatment function test report
237 General Medicine MG Pediatric Medical MG027 Bronchiectasis MG027A Bronchiectasis 2250 2475 2700 2925 3150 3262 b) Chest X ray/CT report d) CBC, Blood Sugar
Management,Pulmonology Yes (Fasting, PP and Random)
c) CBC, Blood Sugar e) Detailed discharge
(Fasting, PP and Random) summary
reports
d) Lung function test report

a)Clinical notes with a)Clinical Notes Reserved Variable

General Medicine,
238 2475 2700 2925 3150 3262 indications and planned b)CBC
General Medicine MG Pediatric Medical MG028 Acute bronchitis MG028A Acute bronchitis 2250
line of management c) Chest X Ray
Management,Pulmonology
b) Chest X ray d)Discharge Summary
a)Clinical notes a)Detailed Indoor case OPEN Variable
b)Spirometry/ PFT reports, papers having treatment
if available, indicating and management including
airway obstruction SpO2 monitoring
General c) Chest X-ray b) detailed discharge
239 General Medicine MG MG029 Acute excaberation of COPD MG029A Acute excaberation of COPD 2250 2475 2700 2925 3150 3262 d) Planned line of summary c) all
Medicine,Pulmonology
management e)Photograph investigations reports
of the patient on bed including serial ABG if
(Routine ward/ HDU/ ICU). patient admitted in
ICU/HDU

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers
indications for the b) Post treatment Chest X
General Medicine, procedure, and planned ray / CT scan report
Acute excaberation of Interstitial Lung
240 General Medicine MG Pediatric Medical MG030 MG030A Acute excaberation of Interstitial Lung Disease 2250 2475 2700 2925 3150 3262 line of treatment c) Detailed discharge
Disease
Management,Pulmonology b) Chest X ray / CT scan summary
c) CBC, Blood Sugar
(Fasting, PP and Random)

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, paper
indications for the b) Post treatment Plain X
procedure, and planned ray erect
General Medicine, line of treatment Abdomen/USG/CT
241 General Medicine MG Pediatric Medical MG031 Endocarditis MG031A Bacterial Endocarditis 2250 2475 2700 2925 3150 3262 b) Serum Amylase, Lipase, abdomen
Management, Cardiology LFT, CBC reports c) Serum Amylase, Lipase,
c) USG Abdomen LFT, CBC
report/CT Abdomen d) Detailed discharge
(Contrast) summary

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, paper
indications for the b) Post treatment Plain X
procedure, and planned ray erect
General Medicine, line of treatment Abdomen/USG/CT
242 General Medicine MG Pediatric Medical MG031 Endocarditis MG031B Fungal Endocarditis 2250 2475 2700 2925 3150 3262 b) Serum Amylase, Lipase, abdomen
Management, Cardiology LFT, CBC reports c) Serum Amylase, Lipase,
c) USG Abdomen LFT, CBC
report/CT Abdomen d) Detailed discharge
(Contrast) summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical Notes including a) Detailed indoor case OPEN Variable
evaluation findings, papers along with
indications for the indications
procedure, and planned b) Biopsy report (if
General Medicine, line of treatment applicable)
243 General Medicine MG Pediatric Medical MG032 Vasculitis MG032A Vasculitis 2250 2475 2700 2925 3150 3262 b) C-reactive protein c) Antineutrophil
Management c) Urine Routine, ESR cytoplasmic antibodies
(ANCA) levels / The
antinuclear
antibody (ANA) test
d) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, paper
indications for the b) Post treatment Plain X
General Medicine, procedure, and planned ray erect
Pediatric Medical line of treatment Abdomen/USG/CT
244 General Medicine MG MG033 Pancreatitis MG033A Acute pancreatitis 2250 2475 2700 2925 3150 3262 b) Serum Amylase, Lipase, abdomen
Management,Gastroenterol
ogy LFT, CBC reports c) Serum Amylase, Lipase,
c) USG Abdomen LFT, CBC
report/CT Abdomen d) Detailed discharge
(Contrast) summary

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, paper
indications for the b) Post treatment Plain X
General Medicine, procedure, and planned ray erect
Pediatric Medical line of treatment Abdomen/USG/CT
245 General Medicine MG MG033 Pancreatitis MG033B Chronic pancreatitis 2250 2475 2700 2925 3150 3262 b) Serum Amylase, Lipase, abdomen
Management,Gastroenterol
ogy LFT, CBC reports c) Serum Amylase, Lipase,
c) USG Abdomen LFT, CBC
report/CT Abdomen d) Detailed discharge
(Contrast) summary

a) Clinical Notes including a) Detailed Indoor Case OPEN Variable

evaluation findings, Papers and Treatment
indications for the given
procedure, and planned b) Serum ascites albumin
General Medicine, line of treatment gradient (SAAG) report
Pediatric Medical b) Liver Function test c) Detailed Discharge
246 General Medicine MG MG034 Ascites MG034A Ascites 2250 2475 2700 2925 3150 3262 c) Ultrasound Summary
Management,Gastroenterol
ogy abdomen/Upper GI
endoscopy
d) Cancer markers CA-19-
9, CEA, CA-125 (females)
(as and when
applicable)
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment given
indications for the b) Detailed Discharge
General Medicine, procedure, and planned Summary
247 General Medicine MG Pediatric Medical MG035 Acute transverse myelitis MG035A Acute transverse myelitis 2250 2475 2700 2925 3150 3262 line of treatment
Management b) Relevant Investigations
a. Hemogram
b. Biochemistry
c) MRI/CT Spinal cord
a) Clinical notes a) Post treatment ECG OPEN Variable
b) Blood test b) Discharge Summary
i. Coagulation profile (PT, c) Detailed Indoor Case
General Medicine, INR) Papers (ICPs), Treatment
248 General Medicine MG Pediatric Medical MG036 Atrial Fibrillation MG036A Atrial Fibrillation 2250 2475 2700 2925 3150 3262 Yes details
Management, Cardiology ii. Sr. electrolytes d) All investigations reports
c) ECG it shows irregular
rhythm and abnormal heart
rate d) X- ray
Chest
a) Clinical Notes including a) Detailed indoor case OPEN Variable
evaluation findings, papers with treatment
indications for the details
procedure, and planned b) Post procedure
General Medicine,
249 General Medicine MG MG037 Cardiac Tamponade MG037A Cardiac Tamponade 2250 2475 2700 2925 3150 3262 line of treatment echo/color Doppler report
Cardiology
b) 12 lead ECG report c) Analysis of Fluid
c) Echo/ color Doppler Aspirated report
report with stills d) Detailed Discharge
Summary
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment
indications for the details
procedure, and planned b) Detailed procedure notes
line of treatment c) Detailed Discharge
b) ECG/ECHO with report Summary
General Medicine, c) Chest X-ray report
250 General Medicine MG Pediatric Medical MG038 Congestive heart failure MG038A Congestive heart failure 2250 2475 2700 2925 3150 3262 d) Blood investigations:
Management, Cardiology Biomarkers, Brain
natriuretic peptide (BNP),
N-terminal pro-brain
natriuretic peptide (NT-
proBNP), Creatine kinase
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) Detailed discharge
General Medicine, showing vitals. summary.
251 General Medicine MG Pediatric Medical MG039 Asthma MG039A Acute asthmatic attack 2250 2475 2700 2925 3150 3262 c) Examination findings. d) All investigations reports.
Management,Pulmonology d) Any investigations done.
e) Planned line of
management.

a) Clinical notes detailing a) Detailed ICPs. Referral Variable

history. b) Treatment details.
b) Admission notes c) Detailed discharge
General Medicine, showing vitals. summary.
252 General Medicine MG Pediatric Medical MG039 Asthma MG039B Status asthmaticus 2250 2475 2700 2925 3150 3262 c) Examination findings. d) All investigations reports.
Management,Pulmonology d) Any investigations done.
e) Planned line of
management.

a) Clinical notes detailing a) Detailed ICPs. OPEN Variable

history. b) Treatment details.
b) Admission notes c) Detailed discharge
General Medicine, showing vitals. summary.
253 General Medicine MG Pediatric Medical MG040 Respiratory failure MG040A Type 1 respiratory failure 2250 2475 2700 2925 3150 3262 c) Examination findings. d) All investigations reports.
Management,Pulmonology d) Any investigations done.
e) Planned line of
management.

a) Clinical notes detailing a) Detailed ICPs. OPEN Variable

history. b) Treatment details.
b) Admission notes c) Detailed discharge
General Medicine, showing vitals. summary.
254 General Medicine MG Pediatric Medical MG040 Respiratory failure MG040B Type 2 respiratory failure 2250 2475 2700 2925 3150 3262 c) Examination findings. d) All investigations reports.
Management,Pulmonology d) Any investigations done.
e) Planned line of
management.

a) Clinical notes with a)Still photograph of the OPEN Variable

APACHE patient undergoing the
score treatment (+/- ventilatory
b )Investigations support)
1. CBC b) Detailed Indoor case
2. Chest X-ray papers having treatment
3. ABG (if and management
General Medicine, available) c) Relevant investigations
Due to any cause (pneumonia, asthma, COPD, 4. ECG including serial ABGs (refer
255 General Medicine MG Pediatric Medical MG040 Respiratory failure MG040C 2250 2475 2700 2925 3150 3262
ARDS, foreign body, poisoning, head injury etc.) 5. NCCT Head para 1.5 i. b.) (ABG if
Management,Pulmonology
6. Fundus Available)
examination d) Detailed discharge
c )Clinical photograph of summary
the patient on
bed

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers with treatment given
indications for the details
General Medicine, procedure, and planned b) Detailed discharge
Pediatric Medical line of treatment summary
256 General Medicine MG MG041 Upper GI bleeding MG041A Upper GI bleeding (conservative) 2250 2475 2700 2925 3150 3262
Management,Gastroenterol b) Complete Blood count,
ogy platelets, Liver Function
Test, Hemoglobin
c) Upper endoscopy
report/CT
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment given
indications for the details
General Medicine, procedure, and planned b) Detailed discharge
Pediatric Medical line of treatment summary
257 General Medicine MG MG041 Upper GI bleeding MG041B Upper GI bleeding (endoscopic) 2250 2475 2700 2925 3150 3262
Management,Gastroenterol b) Complete Blood count,
ogy platelets, Liver Function
Test, Hemoglobin
c) Upper endoscopy
report/CT
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, Papers and Treatment
General Medicine, indications for the details
Pediatric Medical procedure, and planned b) Detailed Discharge
258 General Medicine MG MG042 Lower GI hemorrhage MG042A Lower GI hemorrhage 2250 2475 2700 2925 3150 3262
Management,Gastroenterol line of treatment Summary
ogy b) CBC, Platelets reports
c) Fecal tagging /
Colonoscopy reports
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers
indications for the b) ACTH stimulation test,
General Medicine, procedure, and planned Contrast-Enhanced CT
Pediatric Medical line of treatment Abdomen report
259 General Medicine MG MG043 Addison’s disease MG043A Addison’s disease 2250 2475 2700 2925 3150 3262 b) Sr. Electrolyte, Sr. c) Post treatment Blood
Management,Endocrinolog
y Cortisol Yes sugar test report
c) Blood Sugar test d) Post treatment Sr.
Cortisol level report
e) Detailed Discharge
Summary
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes detailing a) Detailed ICPs. Reserved Variable
history. b) Treatment details.
b) Admission notes c) Detailed discharge
showing vitals. summary.
General Medicine, General c) Examination findings. d) All investigations reports.
260 General Medicine MG MG044 Renal colic MG044A Renal colic 2250 2475 2700 2925 3150 3262
Surgery,Nephrology d) Any investigations done.
e) Planned line of
management

a)Clinical notes a)Clinical Notes / Indoor OPEN Variable

b) Pathological case papers
Examination (Complete b)Detail discharge
Blood count, Blood urea, Summary & dialysis chart
Serum Creatinine, GFR, (Only dialysis chart in
serum electrolytes). In chronic dialysis pts) c) All
chronic renal failure/ investigation reports
chronic dialysis patients
General Medicine, General investigations need to be
261 General Medicine MG MG045 AKI / Renal failure MG045A AKI / Renal failure 2250 2475 2700 2925 3150 3262 done and submitted only
Surgery,Nephrology
once. These investigations
to be repeated monthly.
Quarterly- Serum Iron,
ferritin, TIBC, TSAT,
SGOT, SGPT, viral
markers, calcium,
phosphate c)
Planned line of treatment
Pediatric Medical Pediatric Medical 0 0 OPEN Variable
262 MP MG047 Pediatric seizure disorders MG047A Status epilepticus 2250 2475 2700 2925 3150 3262
Management Management,Neurology
Pediatric Medical Pediatric Medical 0 0 OPEN Variable
263 MP MP017 Acute ischemic stroke MG049C Acute ischemic stroke 2250 2475 2700 2925 3150 3262
Management Management
a)Clinical notes with vitals a)Indoor case papers OPEN Variable
General
264 General Medicine MG MG049 Acute hemorrhagic stroke MG049D Acute hemorrhagic stroke 2250 2475 2700 2925 3150 3262 (Blood pressure, Pulse b)CT/MRI scan report
Medicine,Neurology
rate) c)Discharge Summary
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) Detailed discharge
General Medicine, showing vitals. summary.
265 General Medicine MG Pediatric Medical MG050 Immune mediated CNS disorders MG050A Immune mediated CNS disorders 2250 2475 2700 2925 3150 3262 c) Examination findings. d) All investigations reports.
Management d) Any investigations done.
e) Planned line of
management

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers with details of
General Medicine, indications for the treatment given
266 General Medicine MG Pediatric Medical MG051 Hydrocephalus MG051A Hydrocephalus 2250 2475 2700 2925 3150 3262 procedure, and planned b) Detailed procedure notes
Management line of treatment c) Detailed Discharge
b) Neuroimaging report Summary

a) Clinical Notes including a) Detailed Indoor Case OPEN Variable

evaluation findings, Papers with treatment given
indications for the details
procedure, and planned b) Post treatment FTSH,
General Medicine, line of treatment FT3 and FT4 level
Pediatric Medical b) Thyroid stimulating c) Detailed Discharge
267 General Medicine MG MG052 Myxedema coma MG052A Myxedema coma 2250 2475 2700 2925 3150 3262 hormone (TSH), Free Summary
Management,Endocrinolog
y Triiodothyronine (FT3) and
Free Thyroxine (FT4) level
reports
c) Sr. Electrolyte report
d) USG thyroid gland
report
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment
indications for the details
procedure, advise for b) Radionuclide Iodine
General Medicine, admission and planned line uptake study report
Pediatric Medical of treatment c) Post treatment Thyroid
268 General Medicine MG MG053 Thyrotoxic crisis MG053A Thyrotoxic crisis 2250 2475 2700 2925 3150 3262
Management,Endocrinolog b) Thyroid stimulating stimulating hormone, Free
y hormone, Free triiodothyonine
triiodothyonine (FT3), (FT3), Free Thyroxine (FT4)
Free Thyroxine (FT4) d) Detailed Discharge
c) Thyroid Ultrasound scan Summary

269 General Medicine MG General Medicine MG054 Gout MG054A Gout 2250 2475 2700 2925 3150 3262 0 0 Reserved Variable
a) Clinical notes detailing a) Detailed ICPs. Reserved Variable
history. b) Treatment details.
b) Admission notes c) Detailed discharge
General Medicine, showing vitals. summary.
270 General Medicine MG Pediatric Medical MG055 Pneumothorax MG055A Pneumothorax 2250 2475 2700 2925 3150 3262 c) Examination findings. d) All investigations reports.
Management,Pulmonology d) Any investigations done.
e) Planned line of
management
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment given
indications for the details.
procedure, and planned B) Detailed Discharge
General Medicine, line of treatment Summary
271 General Medicine MG Pediatric Medical MG056 Neuromuscular Disorders MG056A Neuromuscular Disorders 2250 2475 2700 2925 3150 3262 b) Creatine Phosphokinase
Management,Neurology (CPK), Electrolytes report
c) EMG studies, Nerve
conduction velocity
d) CT Angiography
studies/MRI/CT for spine

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

General Medicine, evaluation findings, papers with treatment
Pediatric Medical indications for the details b) Post
272 General Medicine MG MG057 Hypoglycemia MG057A Hypoglycemia 2250 2475 2700 2925 3150 3262
Management,Endocrinolog procedure, and planned treatment glucose level
y line of treatment c) Detailed Discharge
b) Blood glucose level Summary
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, papers along with treatment
indications for the details
procedure, and planned b) Post treatment glucose
General Medicine, General line of treatment level
273 General Medicine MG MG058 Diabetic Foot MG058A Diabetic Foot -- debridement 2250 2475 2700 2925 3150 3262
Surgery,Endocrinology b) Complete Blood count, c) Post treatment
Blood glucose level, photograph of affected foot
HbA1C Report d) Detailed Discharge
c) Photograph of affected Summary
foot
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers and treatment given
indications for the details
General Medicine, procedure, and planned b) Post procedure blood
Pediatric Medical line of treatment glucose (fasting and PP)
274 General Medicine MG MG059 Diabetic ketoacidosis MG059A Diabetic ketoacidosis 2250 2475 2700 2925 3150 3262
Management,Endocrinolog b) Blood glucose (RBS) c) Detailed Discharge
y c) Sr. Bicarbonate report summary
d) Arterial blood gas report
e) Urine Ketone report

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers with treatment
General Medicine, indications details
275 General Medicine MG Pediatric Medical MG060 Electrolyte Imbalance MG060A Hypercalcemia 2250 2475 2700 2925 3150 3262 for the procedure, and b) Post treatment serum
Management planned line of treatment calcium
b) Serum Calcium report d) Detailed Discharge
Summary
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment
General Medicine, indications details
276 General Medicine MG Pediatric Medical MG060 Electrolyte Imbalance MG060B Hypocalcemia 2250 2475 2700 2925 3150 3262 for the procedure, and b) Post treatment serum
Management planned line of treatment calcium
b) Serum Calcium report d) Detailed Discharge
Summary
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment
General Medicine, indications details b) Post treatment
277 General Medicine MG Pediatric Medical MG060 Electrolyte Imbalance MG060C Hyponatremia 2250 2475 2700 2925 3150 3262 for the procedure, and serum electrolytes
Management planned line of treatment c) Detailed Discharge
b) Other Serum Summary
Electrolytes
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment
General Medicine, indications details b) Post treatment
278 General Medicine MG Pediatric Medical MG060 Electrolyte Imbalance MG060D Hypernatremia 2250 2475 2700 2925 3150 3262 for the procedure, and serum electrolytes
Management planned line of treatment c) Detailed Discharge
b) Other Serum Summary
Electrolytes
279 General Medicine MG General Medicine MG060 Electrolyte Imbalance MG060E Hyperkalaemia 2250 2475 2700 2925 3150 3262 0 0 OPEN Variable
280 General Medicine MG General Medicine MG060 Electrolyte Imbalance MG060F Hypokalaemia 2250 2475 2700 2925 3150 3262 0 0 OPEN Variable
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, Papers with treatment given
indications for the details.
General Medicine, procedure, and planned B) Post treatment
281 General Medicine MG Pediatric Medical MG061 Hyperosmolar Non-Ketotic coma MG061A Hyperosmolar Non-Ketotic coma 2350 2585 2820 3055 3290 3407 line of treatment Investigations
Management b) Relevant Investigations 1. Blood glucose
1. Blood Glucose 2. Serum osmolarity
2. Serum osmolarity 3. HbA1C
3. urine ketones c) Detailed Discharge
4. hemogram Summary
a) Clinical Notes including a) Detailed Indoor case OPEN Variable
evaluation findings, papers with treatment given
General Medicine, indications for the b) Detailed procedure notes
282 General Medicine MG Pediatric Medical MG062 Accelerated hypertension MG062A Accelerated hypertension 2250 2475 2700 2925 3150 3262 procedure, and planned c) Detailed Discharge
Management line of treatment Summary
b) Fundoscopy report

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers with treatment given
General Medicine, indications for the b) Detailed procedure notes
283 General Medicine MG Pediatric Medical MG063 Hypertensive emergencies MG063A Hypertensive emergencies 2250 2475 2700 2925 3150 3262 procedure, and planned c) Detailed Discharge
Management line of treatment Summary
b) Fundoscopy report

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers and Treatment
General Medicine, indications for the details
284 General Medicine MG Pediatric Medical MG064 Severe anemia MG064A Severe anemia 2250 2475 2700 2925 3150 3262 procedure, and planned b) Post treatment CBC, Hb
Management line of treatment reports
b) CBC, Hb report c) Detailed Discharge
Summary
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical Notes including a) Detailed Indoor case Reserved Variable
evaluation findings, papers with treatment chart
indications for the b) High-performance liquid
General Medicine,
285 2475 2700 2925 3150 3262 procedure, and planned chromatography (HPLC)
General Medicine MG Pediatric Medical MG065 Sickle cell Anemia MG065A Sickle cell Anemia 2250
line of treatment c) Detailed Discharge
Management
b) Electrophoresis report Summary

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

history (Drug Hx, IV, Sub papers
cutaneous TM, Oral), b) Post treatment CBC
physical report
examination,evaluation c) Detailed Discharge
General Medicine, findings, indications for the Summary
286 General Medicine MG Pediatric Medical MG066 Anaphylaxis MG066A Anaphylaxis 2250 2475 2700 2925 3150 3262 procedure, and planned
Management line of treatment
b) Complete Blood Count
(CBC)/ allergen-specific
immunoglobulin E (IgE)
report

a) Clinical notes with a) Detailed Indoor Case Reserved Variable

detailing history and Papers (ICPs) with
Admission notes showing treatment details
vitals b) Post treatment WBC, Sr.
General Medicine, (Temperature, BP, Pulse) electrolytes
287 General Medicine MG Pediatric Medical MG067 Heat stroke MG067A Heat stroke 2250 2475 2700 2925 3150 3262 and planned line of c) Detailed Discharge
Management treatment Summary
b) White Blood Count, Sr.
electrolytes, Blood gas,
Creatine phosphokinase,
lactate dehydrogenase
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, Papers with treatment
indications for the details
procedure, advise for b) Detailed Discharge
admission and planned line Summary
General Medicine, of treatment
Systematic lupus erythematosus (SLE)/ Diffuse
288 General Medicine MG Pediatric Medical MG068 Systematic lupus erythematosus MG068A 2250 2475 2700 2925 3150 3262 b) Antinuclear antibody
alveolar hemmorhage associated with SLE
Management (ANA test)
c) Erythrocyte
sedimentation rate (ESR)
or C-reactive protein (CRP)
level
d) X ray report
General Medicine, 0 0 OPEN 30
289 General Medicine MG neurology, pediatric MG069 Guillain Barre syndrome MG069A Guillain Barre syndrome (IVIG) 2200 2420 2640 2860 3080 3190
medicine
a) Clinical Notes including a) Detailed Indoor Case OPEN Variable
evaluation findings, Papers with treatment
indications for the details
General Medicine,
290 2475 2700 2925 3150 3262 procedure, and planned b) Details of Anti-snake
General Medicine MG Pediatric Medical MG070 Snake bite MG070A Snake bite 2250
line of treatment venom used (If applicable)
Management
b) Urine examination for c) Detailed Discharge
albumin and blood report Summary

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers with treatment given
indications for the details
procedure, and planned b) Detailed discharge
General Medicine, line of treatment summary
291 General Medicine MG Pediatric Medical MG071 Poisoning MG071A Acute organophosphorus poisoning 2250 2475 2700 2925 3150 3262 b) Red cell cholinesterase
Management level, ECG, CBL, LFT, KFT
reports (as applicable)
c) Copy of Medico legal
certificate / FIR

a) Clinical Notes including a) Detailed Indoor case OPEN Variable

evaluation findings, papers with treatment given
indications for the details
procedure, and planned b) Detailed discharge
General Medicine, line of treatment summary
292 General Medicine MG Pediatric Medical MG071 Poisoning MG071B Other poisonings 2250 2475 2700 2925 3150 3262 b) Red cell cholinesterase
Management level, ECG, CBL, LFT, KFT
reports (as applicable)
c) Copy of Medico legal
certificate / FIR

a)Clinical notes a)Clinical Notes / Indoor OPEN Yes

b) Pathological case papers
Examination (Complete b)Detail discharge
Blood count, Blood urea, Summary & dialysis chart
Serum Creatinine, GFR, (Only dialysis chart in
serum electrolytes). In chronic dialysis pts) c) All
chronic renal failure/ investigation reports
chronic dialysis patients
General Medicine, As per Selected investigations need to be
293 General Medicine MG MG072 Haemodialysis / Peritoneal Dialysis MG072B Peritoneal Dialysis #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! done and submitted only
Nephrology Procedure
once. These investigations
to be repeated monthly.
Quarterly- Serum Iron,
ferritin, TIBC, TSAT,
SGOT, SGPT, viral
markers, calcium,
phosphate c)
Planned line of treatment
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
General Medicine, 0 0 OPEN Yes
294 General Medicine MG Nephrology, Organ MG072 Haemodialysis / Peritoneal Dialysis MG072C Haemodialysis (For Sero -ve patient) 1575 1732 1890 2047 2205 2283
transplantation
General Medicine, 0 0 OPEN Yes
295 General Medicine MG Nephrology, Organ MG072 Haemodialysis / Peritoneal Dialysis MG072D Haemodialysis (For Sero +ve patient) 2500 2750 3000 3250 3500 3625
transplantation
a) Clinical Notes including a) Detailed indoor case OPEN Yes
evaluation findings, papers along with
General Medicine, indications for the indications
296 General Medicine MG Pediatric Medical MG073 Plasmapheresis MG073A Plasmapheresis 2100 2310 2520 2730 2940 3045 procedure, and planned b) Detailed procedure notes
Management line of treatment c) Detailed discharge
summary

a) Clinical Notes including a) Detailed Indoor case OPEN Yes

evaluation findings, papers including treatment
indications for the details
procedure, and planned b) Post Transfusion
General Medicine, line of treatment hemogram
297 General Medicine MG Pediatric Medical MG074 Blood transfusion MG074A Whole Blood transfusion 2100 2310 2520 2730 2940 3045 b) Blood grouping (ABO c) Detailed Discharge
Management and Rh) Summary
c) Complete hemogram
d) Viral markers of the
donor e) Screening
for Malaria, Syphilis, HIV,
HBV, HCV, CMV
a) Clinical Notes including a) Detailed Indoor case OPEN Yes
evaluation findings, papers including treatment
indications for the details
procedure, and planned b) Post Transfusion
General Medicine, line of treatment hemogram
Blood component including platelet transfusion b) Blood grouping (ABO c) Detailed Discharge
298 General Medicine MG Pediatric Medical MG074 Blood transfusion MG074B 2100 2310 2520 2730 2940 3045
(RDP, PC, SDP) and Rh) Summary
Management
c) Complete hemogram
d) Viral markers of the
donor e) Screening
for Malaria, Syphilis, HIV,
HBV, HCV, CMV
Pediatric Medical Continuous renal replacement 0 0 OPEN 5
Continuous renal replacement therapy in AKI
299 General Medicine MG Management, General MG077 therapy/Continuous veno-venous MG077A 34650 38115 41580 45045 48510 50242
(initiation cost for disposable)
Medicine,Nephrology hemofiltration
0 0 OPEN Variable
General
300 General Medicine MG MG078 Alcoholic Liver Disease MG078A Alcoholic Liver Disease 2350 2585 2820 3055 3290 3407
Medicine,Gastroenterology
301 General Medicine MG General Medicine MG079 Peripheral Arterial Thrombosis MG079A Peripheral Arterial Thrombosis 2350 2585 2820 3055 3290 3407 0 0 OPEN Variable
302 General Medicine MG General Medicine MG081 IHD / CAD / Arrhythmia MG081A Arrhythmia 2350 2585 2820 3055 3290 3407 0 0 OPEN Variable
303 General Medicine MG General Medicine MG081 IHD / CAD / Arrhythmia MG081B CAD 2350 2585 2820 3055 3290 3407 0 0 OPEN Variable
Interventional General 0 0 OPEN Yes
304 General Medicine MG MG082 Bone marrow aspiration of biopsy MG082A Bone marrow aspiration of biopsy 1300 1430 1560 1690 1820 1885
Medicine
Interventional General 0 0 OPEN Yes
305 General Medicine MG MG083 Lumbar puncture MG083A Lumbar puncture 150 165 180 195 210 217
Medicine
Interventional General 0 0 OPEN Yes
306 General Medicine MG MG084 Joint Aspiration MG084A Joint Aspiration 250 275 300 325 350 362
Medicine
Interventional General DVT Pneumatic Compression Stockings DVT Pneumatic Compression Stockings (Add 0 0 OPEN Variable
307 General Medicine MG MG085 MG085A 1000 1100 1200 1300 1400 1450
Medicine (Add on package in ICU) on package in ICU)
General 0 0 OPEN Variable
308 General Medicine MG MG086 Acute Ischemic Stoke MG086A Acute Ischemic Stoke 2250 2475 2700 2925 3150 3262
Medicine,Neurology
Acute ischemic stroke- intravenous 0 0 OPEN Variable
General Acute ischemic stroke- intravenous
309 General Medicine MG MG086 MG086B thrombolysis -Recombinant tissue plasminogen 2250 2475 2700 2925 3150 3262
Medicine,Neurology thrombolysis
activator
General Acute ischemic stroke- Intravenous Acute ischemic stroke- Intravenous 0 0 OPEN Variable
310 General Medicine MG MG086 MG086C 2250 2475 2700 2925 3150 3262
Medicine,Neurology thrombolysis thrombolysis-Tenecteplase
General 0 0 OPEN Variable
311 General Medicine MG MG087 Venous sinus thrombosis MG087A Venous sinus thrombosis 2250 2475 2700 2925 3150 3262
Medicine,Neurology
General 0 0 OPEN Variable
312 General Medicine MG MG088 Pyogenic Meningitis MG088A Pyogenic Meningitis 2250 2475 2700 2925 3150 3262
Medicine,Neurology
General 0 0 OPEN Variable
313 General Medicine MG MG089 Fungal Meningitis MG089A Fungal Meningitis 2250 2475 2700 2925 3150 3262
Medicine,Neurology
General 0 0 OPEN Variable
314 General Medicine MG MG090 Autoimmune encephalitis MG090A Autoimmune encephalitis - Plasmapheresis 2250 2475 2700 2925 3150 3262
Medicine,Neurology
General Autoimmune encephalitis - Immunoglubulin 0 0 OPEN Variable
315 General Medicine MG MG090 Autoimmune encephalitis (IVIG) MG090B 2250 2475 2700 2925 3150 3262
Medicine,Neurology (IVIG)
General Acute transverse myelitis/ Acute Acute transverse myelitis/ Acute demyelinating 0 0 OPEN Variable
316 General Medicine MG MG090 MG090C 2250 2475 2700 2925 3150 3262
Medicine,Neurology demyelinating encephalitis encephalitis
General Acute hemorrhagic stroke- Hematoma Acute hemorrhagic stroke- Hematoma 0 0 OPEN Variable
317 General Medicine MG MG091 MG091A 2250 2475 2700 2925 3150 3262
Medicine,Neurology evacuation evacuation
General Acute hemorrhagic stroke- (Extra Acute hemorrhagic stroke- Extra ventricular 0 0 OPEN Variable
318 General Medicine MG MG091 MG091B 2250 2475 2700 2925 3150 3262
Medicine,Neurology ventricular drainage) drainage
General 0 0 OPEN Variable
319 General Medicine MG MG092 Myasthenic crisis (IVIG) MG092B Myasthenic crisis - Immunoglobulins (IVIG) 2250 2475 2700 2925 3150 3262
Medicine,Neurology
General 0 0 OPEN Variable
320 General Medicine MG MG093 Myasthenic crisis (Plasmapheresis) MG093A Myasthenic crisis - Plasmapheresis 2250 2475 2700 2925 3150 3262
Medicine,Neurology
General Tuberculous meningitis (Hydrocephalus – Tuberculous meningitis (Hydrocephalus – VP 0 0 OPEN Variable
321 General Medicine MG MG094 MG094A 2250 2475 2700 2925 3150 3262
Medicine,Neurology VP SHUNT/ EVD/Omaya) SHUNT/ EVD/Omaya)
0 0 OPEN Variable
General
322 General Medicine MG MG095 Cholangitis MG095A Cholangitis 2250 2475 2700 2925 3150 3262
medicine,Gastroenterology
General Medicine, 0 0 OPEN
323 General Medicine MG MG096 Fibreoptic bronchoscopy (FOB) MG096A Bronchoscopy 8925 9817 10710 11602 12495 12941
Pulmonology
General Medicine, 0 0 OPEN Variable
324 General Medicine MG Pulmonology, General MG096 Intercostal drainage MG096B Intercostal drainage 2250 2475 2700 2925 3150 3262
surgery
0 0 OPEN
General Medicine, Endobronchial Ultrasound guided fine needle
325 General Medicine MG MG097 Endobronchial Ultrasound (EBUS) MG097A 16500 18150 19800 21450 23100 23925
Pulmonology interventional biopsy
High end radiological diagnostic 0 0 OPEN
326 General Medicine MG General Medicine MG075 (CT, MRI, Imaging including nuclear MG075B FDG Whole body PET Scan 21554 23709 25864 28020 30175 31253
imaging)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
High end radiological diagnostic 0 0 OPEN
327 General Medicine MG General Medicine MG075 (CT, MRI, Imaging including nuclear MG075C Brain & Heart FDG PET Scan 15396 16935 18475 20014 21554 22324
imaging)
High end radiological diagnostic 0 0 OPEN
Gallium-68 Peptide PET imaging for
328 General Medicine MG General Medicine MG075 (CT, MRI, Imaging including nuclear MG075D 15750 17325 18900 20475 22050 22837
Neuroendocrine Tumor
imaging)
General Medicine, 0 0 OPEN
329 General Medicine MG Pediatric Medical MG099 Platelet pheresis MG099A Platelet pheresis 11550 12705 13860 15015 16170 16747
Management
a) Clinical notes with a) Detailed treatment notes OPEN
detailed history and b) Relevant investigations
Intellectual Disability (ID) chronicity 1. Neuroimaging
330 Mental Disorders MM Mental Disorders MM001 Mental Retardation (intellectual disability) MM001A 2250 2475 2700 2925 3150 3262 b) Admission document 2. Thyroid function Test
signed by empanelled c) Detailed Discharge
psychiatrist Summary

a) Clinical notes with a) Detailed treatment notes OPEN

detailed history and b) investigations require
chronicity b) 1. Complete hemogram
Admission document 2. Thyroid function test
signed by empanelled 3. Biochemistry
Mental disorders - Organic, including Mental disorders - Organic, including psychiatrist 4. liver function test
331 Mental Disorders MM Mental Disorders MM002 MM002A 2250 2475 2700 2925 3150 3262 5. VDRL
symptomatic symptomatic
6. Vit. D level
7. Vit. B12 level
8. Neuroimaging (CT/MRI)
c) Detailed Discharge
Summary

a) Clinical notes with a) Detailed treatment notes OPEN

detailed history and b) Detailed Discharge
Schizophrenia, schizotypal and delusional Schizophrenia, schizotypal and delusional chronicity Summary
332 Mental Disorders MM Mental Disorders MM003 MM003A 2250 2475 2700 2925 3150 3262
disorders disorders b) Admission document
signed by empanelled
psychiatrist
a) Clinical notes with a) Detailed treatment notes OPEN
detailed history and b) Detailed Discharge
Neurotic, stress-related and somatoform Neurotic, stress-related and somatoform chronicity b) Summary
333 Mental Disorders MM Mental Disorders MM004 MM004A 2250 2475 2700 2925 3150 3262
disorders disorders Admission document
signed by empanelled
psychiatrist
a) Clinical notes with a) Detailed treatment notes OPEN
detailed history and b) Investigations require
chronicity 1. Complete hemogram
b) Admission document 2. Thyroid function test
334 Mental Disorders MM Mental Disorders MM005 Mood (affective) disorders MM005A Mood (affective) disorders 2250 2475 2700 2925 3150 3262 signed by empaneled 3. Serum sodium
psychiatrist 4. Resting ECG
c) Detailed Discharge
Summary

a) Clinical notes with a) Detailed treatment notes OPEN

detailed history and b) Detailed Discharge
Behavioural syndromes associated with
Behavioural syndromes associated with chronicity b) Summary
335 Mental Disorders MM Mental Disorders MM006 physiological disturbances and physical MM006A 2250 2475 2700 2925 3150 3262
physiological disturbances and physical factors Admission document
factors
signed by empanelled
psychiatrist
a) Clinical notes with a) Detailed treatment notes OPEN
detailed history and b) Relevant investigations
chronicity 1. Complete hemogram
b) Admission document 2. Liver function test
Mental and Behavioural disorders due to Mental and Behavioural disorders due to
336 Mental Disorders MM Mental Disorders MM007 MM007A 2250 2475 2700 2925 3150 3262 signed by empanelled 3. Serum electrolytes
psychoactive substance use psychoactive substance use
psychiatrist 4. Random blood glucose
c) Detailed Discharge
Summary

A)Detailed history with A)Detailed treatment notes. OPEN

Package (Cognitive Tests, Complete Package (Cognitive Tests, Complete
chronicity. B) all investigations done.
Haemogram, Liver Function Test, Renal Haemogram, Liver Function Test, Renal
B) need for specific C)detailed discharge
Function Test, Serum Electrolytes, Electro Function Test, Serum Electrolytes, Electro
treatment. summary.
Cardiogram (ECG), CT / MRI Brain, Cardiogram (ECG), CT / MRI Brain,
337 Mental Disorders MM Mental Disorders MM008 MM008A 10000 11000 12000 13000 14000 14500 C)expected results.
Electroencephalogram, Thyroid Function Electroencephalogram, Thyroid Function Test,
D) Admission under
Test, VDRL, HIV Test, Vitamin B12 levels, VDRL, HIV Test, Vitamin B12 levels, Folate
empanneled Psychiatrist is
Folate levels, Lipid Profile, Homocysteine levels, Lipid Profile, Homocysteine levels),
a must
levels), serum Lithium level serum Lithium level
A)Detailed history with A)Detailed treatment notes. OPEN
chronicity. B) all investigations done.
B) need for specific C)detailed discharge
Electro Convulsive Therapy (ECT) - per treatment. summary.
338 Mental Disorders MM Mental Disorders MM009 MM009A Electro Convulsive Therapy (ECT) - per session 3465 3811 4158 4504 4851 5024
session C)expected results.
D) Admission under
empanneled Psychiatrist is
a must
NeuroDevelopmental Disorders (NDD) 0 0 OPEN
339 Mental Disorders MM Mental Disorders MM010 MM010A Autism Spectrum Disorder 2250 2475 2700 2925 3150 3262
Other than Intellectual Disability
NeuroDevelopmental Disorders (NDD) 0 0 OPEN
340 Mental Disorders MM Mental Disorders MM010 MM010B Mixed Developmental Disorder 2250 2475 2700 2925 3150 3262
Other than Intellectual Disability
NeuroDevelopmental Disorders (NDD) 0 0 OPEN
341 Mental Disorders MM Mental Disorders MM010 MM010C Tourette Syndrome / Chronic Tic Disorder 2250 2475 2700 2925 3150 3262
Other than Intellectual Disability
NeuroDevelopmental Disorders (NDD) 0 0 OPEN
342 Mental Disorders MM Mental Disorders MM010 MM010D Attention Deficit Hyperactivity Disorder (ADHD) 2250 2475 2700 2925 3150 3262
Other than Intellectual Disability
NeuroDevelopmental Disorders (NDD) 0 0 OPEN
343 Mental Disorders MM Mental Disorders MM010 MM010E Specific Developmental Disorders 2250 2475 2700 2925 3150 3262
Other than Intellectual Disability
Behavioral and motional Disorders of 0 0 OPEN
344 Mental Disorders MM Mental Disorders MM011 MM011A Oppositional Defiant Disorder 2250 2475 2700 2925 3150 3262
Childhood and Adolescence
Behavioral and motional Disorders of 0 0 OPEN
345 Mental Disorders MM Mental Disorders MM011 MM011B Conduct Disorder 2250 2475 2700 2925 3150 3262
Childhood and Adolescence
Behavioral and motional Disorders of 0 0 OPEN
346 Mental Disorders MM Mental Disorders MM011 MM011C Mixed Disorder of Conduct and Emotions 2250 2475 2700 2925 3150 3262
Childhood and Adolescence
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Behavioral and motional Disorders of 0 0 OPEN
347 Mental Disorders MM Mental Disorders MM011 MM011D Anxiety and Depressive Disorders 2250 2475 2700 2925 3150 3262
Childhood and Adolescence
Behavioral and motional Disorders of Other Internalizing and Externalizing Disorders 0 0 OPEN
348 Mental Disorders MM Mental Disorders MM011 MM011E 2250 2475 2700 2925 3150 3262
Childhood and Adolescence of Childhood and Adolescence
Psychological, Behavioural and Developmental 0 0 OPEN
and Educational Interventions (Typically
Includes Child Counselling / Psychotherapy,
Family Counselling / Psychotherapy / Training
Such As Parent Management Training,
Behavioral / Cognitive-Behavioral Interventions,
349 Mental Disorders MM Mental Disorders MM012 Non-Pharmacological Interventions MM012A 3465 3811 4158 4504 4851 5024
Developmental Interventions Such As Early
Intervention, Speech / Language Therapy,
Occupational Therapy, Physiotherapy,
Remediation For Specific Learning Disability
and Other Rehabilitative / Psychosocial
Interventions)
Common Medications Used in Management of 0 0 OPEN
350 Mental Disorders MM Mental Disorders MM013 Pharmacological Interventions MM013A Child & Adult Psycholoigical DisordersiIncluding 2310 2541 2772 3003 3234 3349
Anti-ADHD Medication
0 0 OPEN
Psychological Assessments (Includes IQ
Testing, Specific Learning Disability
Psychological / Psychosocial Assessment Assessments, Assessments For Autism
351 Mental Disorders MM Mental Disorders MM014 Package for All Child And Adolescent MM014A Spectrum Disorder, Developmental 3000 3300 3600 3900 4200 4350
Psychiatric Disorders Assessments, Projective Tests and Other Tests
Of Psychopathology), Other Psychosocial
Assessments (Family, Schooling)
a) Clinical notes including a) Indoor case papers / OPEN 30
evaluation findings and clinical notes
planned line of b) Investigations reports (if
management done)
b) Documentation of c) Detailed Procedure notes
feeding difficulties and indication (if any)
Neonates 1800-2500g OR Neonates of any c) Clinical photograph (in
Basic neonatal care package: Babies that weight requiring closer monitoring or short-term case orofacial deformities)
can be managed by side of mother in care on mother's bedside for conditions like, but d) Birth asphyxia
postnatal ward without requiring admission not limited to: * Neonate resuscitation
in SNCU/NICU: o Birth asphyxia (need for positive pressure notes
• Any newborn needing feeding support ventilation at birth; no HIE) *Indication for monitoring
• Babies requiring closer monitoring or short- o Moderate jaundice requiring phototherapy in postnatal ward
352 Neo - natal Care MN Neo - natal Care MN001 term care for conditions like: MN001A o Large for dates (>97 percentile) or Small for 1050 1155 1260 1365 1470 1522 *Neonate vital monitoring
o Birth asphyxia (need for positive pressure gestational age (less than 3rd centile) e) Moderate jaundice
ventilation; no HIE) o Rule-out sepsis . requiring phototherapy
o Moderate jaundice requiring phototherapy o Investigations warranted because of antenatal *Total serum bilirubin
o Large for dates (>97 percentile) Babies scan findings. *Blood group: Mother and
o Small for gestational age (less than 3rd Includes activities listed under Basic Neonatal baby f) Large for dates
centile) care package and Kangaroo Mother Care (>97 percentile) Babies
support *Blood glucose
*Serum calcium
*Complete blood count
*Feeding monitoring
*Vitals monitoring
g) Small for gestation age
(<3 percentile) Babies
a) Clinical notes including a) Detailed Indoor case OPEN 30
evaluation findings and papers
planned line of b) Investigations reports (if
management done)
Neonates between 1500-1799g OR Neonates b) Mild Respiratory c) Detailed Procedure notes
of any weight with mild illness like, but not Distress/tachypnea and indication (if any)
Special Neonatal Care Package: Babies
limited to: *Chest X-ray d) Detailed discharge
that required admission to SNCU or NICU:
• Mild Respiratory Distress/tachypnea *Hemoglobin summary
Babies admitted for short term care for
• Mild encephalopathy *Blood sugar
conditions like:
• Severe jaundice requiring intensive *Sepsis screen
• Mild Respiratory Distress/tachypnea
phototherapy *Blood culture
• Mild encephalopathy
• Unwell baby requiring monitoring c) Mild encephalopathy
• Severe jaundice requiring intensive
• Some dehydration *Arterial Blood Gas
phototherapy
353 Neo - natal Care MN Neo - natal Care MN002 MN002A • Hypoglycaemia 4200 4620 5040 5460 5880 6090 (ABG)/Cord blood analysis
• Haemorrhagic disease of newborn
The above list is illustrative but not limited to *Blood sugar
• Unwell baby requiring monitoring
these conditions. *Serum Electrolytes
• Some dehydration
The required procedures may include radiant *Serum Creatinine
• Hypoglycaemia
warmer care, gavage feeding, oxygen therapy, d)Severe jaundice requiring
Mother's stay and food in the hospital for
IV fluid administration, blood transfusion. intensive phototherapy
breastfeeding, family centred care and
The package includes food and stay for the *Liver function test
(Kangaroo Mother Care) KMC is mandatory
mother in the hospital for breastfeeding, *Coomb`s test (Direct)
and included in the package rate
Kangaroo Mother Care (KMC) and Family *Hemoglobin, reticulocyte
centered care. count, peripheral smear for
evidence of hemolysis
*Blood grouping (mother
and newborn)
e) Haemorrhagic disease
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN 30
evaluation findings and papers
Intensive Neonatal Care Package planned line of b) Investigations reports (if
Babies with birthweight 1500-1799 g Neonates of any birthweight with moderate management done)
or illness like b) Babies with birthweight c) Detailed Procedure notes
Babies of any birthweight and at least one • Need for mechanical ventilation for less than 1500-1799 g Birth weight and indication (if any)
of the following conditions: 24 hours or non-invasive respiratory support *Gestation age d) Detailed discharge
• Need for mechanical ventilation for less (CPAP, HFFNC) *Ballard scoring for summary
than 24 hours or non-invasive respiratory • Sepsis / pneumonia without complications determining maturity
support (CPAP, HFFNC) • Hyperbilirubinemia requiring exchange *Respiratory support -
• Sepsis / pneumonia without complications transfusion Silverman score need for
• Hyperbilirubinemia requiring exchange • Seizures requring anti-convulsants Surfactant/Chest X-
transfusion • Major congenital malformations (pre-surgical ray/CPAP/MV
354 Neo - natal Care MN Neo - natal Care MN003 MN003A 6300 6930 7560 8190 8820 9135 *Retinopathy of
• Seizures stabilization)
• Major congenital malformations (pre- • Cholestasis requiring investigations and in- Prematurity (ROP)
surgical stabilization, not requiring hospital management screening (can be
ventilation) • Congestive heart failure or shock discharged – First ROP
• Cholestasis significant enough requiring The above list is illustrative but not limited to screening venue/date
work up and in-hospital management these conditions. should be documented on
• Congestive heart failure or shock The package includes mandatory stay and food the discharge summary to
Mother's stay and food in the hospital for of the mother in the hospital for breastfeeding, be done before 30 days of
breastfeeding, family centred care and Kangaroo Mother Care (KMC) and Family age and <2kg weight)
(Kangaroo Mother Care) KMC is mandatory centered care c) Need for mechanical
and included in the package rate ventilation for less than 24
hours or non-invasive
respiratory support Pulse
oximetry
a) Clinical notes including a) Detailed Indoor case OPEN 30
evaluation findings and papers
Advanced Neonatal Care Package: planned line of b) Investigations reports (if
Babies with birthweight of 1200-1499 g Neonates between 1200-1499 g OR management done)
or Neonates of any weight with at least one of the b) Babies with birthweight c) Detailed Procedure notes
Babies of any birthweight with at least one following conditions: of 1200-1499 g and indication (if any)
of the following conditions: • Any condition requiring invasive ventilation *Ballard scoring d) Detailed discharge
• Any condition requiring invasive longer than 24 hours *Birth weight summary
ventilation longer than 24 hours • Moderate to Severe Hypoxic Ischemic *Gestation age
• Hypoxic Ischemic encephalopathy encephalopathy *Respiratory support -
requiring Therapeutic Hypothermia • Cardiac rhythm disorders needing intervention Silverman score need for
• Cardiac rhythm disorders needing (the cost of cardiac surgery or implant will be Surfactant/Chest X-
intervention (the cost of cardiac surgery or covered under cardiac surgery packages) ray/CPAP/MV
355 Neo - natal Care MN Neo - natal Care MN004 MN004A 8150 8965 9780 10595 11410 11817 *Retinopathy of
implant will be covered under cardiac • Sepsis with complications such as meningitis
surgery packages) or bone and joint infection, DIC or shock Prematurity (ROP)
• Sepsis with complications such as • Renal failure requiring dialysis screening (can be
meningitis or bone and joint infection, DIC • Inborn errors of metabolism discharged – First ROP
or shock The above list is illustrative but not limited to screening venue/date
• Renal failure requiring dialysis these conditions. should be documented on
• Inborn errors of metabolism The package includes mandatory stay and food the discharge summary to
Mother's stay and food in the hospital for of the mother in the hospital for breastfeeding, be done before 30 days of
breastfeeding, family centred care and Kangaroo Mother Care (KMC) and Family age and <2kg weight)
(Kangaroo Mother Care) KMC is mandatory centered care *Neurosonogram
and included in the package rate c) Investigation
*Chest X-ray
*Arterial Blood Gas
analysis
a) Clinical notes including a) Detailed Indoor case OPEN 30
evaluation findings and papers b) Birth weight
planned line of documentation c) Chest X-
management ray/ABG d) Documentation
Neonates <1200 g OR b) Babies with birthweight of Indication for
Critical Care Neonatal Package: Neonates of any weight with at least one of the of <1200 g requirement mechanical
Babies with birthweight of <1200 g following conditions: *Ballard scoring to ventilation and multiple
or • Severe Respiratory Failure requiring High determine maturity inotropes e) 2D ECHO
Babies of any birthweight with at least one Frequency Ventilation or inhaled Nitric Oxide *Birth weight report
of the following conditions: (iNO) *Gestation age f) Detailed Procedure notes
• Severe Respiratory Failure requiring High • Multisystem failure requiring multiple organ *Respiratory support - and indication (if any)
Frequency Ventilation or inhaled Nitric support including mechanical ventilation and Silverman score need for g) Detailed discharge
Oxide (iNO) multiple inotropes Surfactant/Chest X- summary
356 Neo - natal Care MN Neo - natal Care MN005 MN005A 10400 11440 12480 13520 14560 15080 ray/CPAP/MV
• Multisystem failure requiring multiple • Reuiring parenteral nutrition
organ support including mechanical Critical congenital heart disease (excluding *Retinopathy of
ventilation and multiple inotropes surgical costs) Prematurity (ROP)
• Critical congenital heart disease The above list is illustrative but not limited to screening
Mother's stay and food in the hospital for these conditions. *Neurosonogram
breastfeeding, family centred care and The package includes mandatory stay and food *Caffeine administration
(Kangaroo Mother Care) KMC is mandatory of the mother in the hospital for breastfeeding, documentation
and included in the package rate Kangaroo Mother Care (KMC) and Family c) Severe Respiratory
centered care Failure requiring High
Frequency Ventilation or
inhaled Nitric Oxide (iNO)
*Chest X-ray while on
conventional ventilator
*Arterial Base Gas (ABG)
a) Clinical notes including a) Detailed Indoor case OPEN 30
evaluation findings and papers
planned line of b) Investigations reports (if
management done)
b) Necrotizing Enterocolitis c) Detailed Procedure notes
Neonates in Special Neonatal Care, Special *Complete blood count and indication (if any)
Chronic Care Package: If the baby requires
Neonatal Care-Plus, Intensive Neonatal Care or *Arterial Blood Gas (ABG) d) Detailed discharge
stay beyond the upper limit of usual stay in
Critical Neonatal Care packages Analysis summary
Package no MN004A or MN005A for
357 Neo - natal Care MN Neo - natal Care MN006 MN006A (MN002,MN003,MN004, MN005) who have not 4200 4620 5040 5460 5880 6090 *Serum Electrolytes
conditions like severe BPD requiring
fully recovered and continue to require *Occult stool test
respiratory support, severe NEC requiring
NICU/SNCU care, e.g. for respiratory support, *Abdominal X-ray(AP &
prolonged TPN support
gavage feeding, thermal support, etc., lateral decubitus)
*USG Abdomen
c) Bronchopulmonary
dysplasia
Chest X-ray
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Discharge summary of a) Progress notes at the OPEN Variable
Includes but not limited to minimum six follow-
the last admission time of visit
up visits at 40 weeks PMA, and corrected ages
High Risk Newborn Post Discharge Care b) Clinical examination of
358 Neo - natal Care MN Neo - natal Care MN007 MN007A of 3,6,9, 12 and 18 months for Assessment 1050 1155 1260 1365 1470 1522
Package (Protocol Driven) the current visit
and Management of growth and development.
Neurosonogram at 40 weeks PMA if indicated.
a) Clinical notes a) Indoor case papers OPEN
b) Indirect ophthalmoscopy (ICPs)
examination b) Intra-procedure
Laser Therapy for Retinopathy of Laser Therapy for Retinopathy of Prematurity
Neo - natal c) Planned line of photograph(optional)
359 Neo - natal Care MN MN008 Prematurity (Irrespective of no. of eyes MN008A (Irrespective of no. of eyes affected) 2000 2200 2400 2600 2800 2900
Care/opthalmology treatment c) Detailed Procedure /
affected) - per session per session
operative notes
d) Detailed discharge
summary
a) Clinical notes a) Indoor case papers OPEN
b) Indirect ophthalmoscopy (ICPs)
examination b) Intra-procedure
Advanced Surgery for Retinopathy of Advanced Surgery for Retinopathy c) Planned line of photograph(optional)
360 Neo - natal Care MN Neo - natal Care MN009 MN009A 19750 21725 23700 25675 27650 28637
Prematurity of Prematurity treatment c) Detailed Procedure /
operative notes
d) Detailed discharge
summary
a) Clinical notes a) Indoor case papers OPEN
b) Clinical picture (ICPs)
c) Neurosonogram/CT b) Post-procedure
Ventriculoperitoneal Shunt Surgery (VP) or Ventriculoperitoneal Shunt Surgery (VP) or
361 22000 24000 26000 28000 29000 Brain/MRI Brain photograph (Optional)
Neo - natal Care MN Neo - natal Care MN010 Omaya Reservoir or External Drainage for MN010A Omaya Reservoir or External Drainage for 20000
d) Planned line of c) Detailed Procedure /
Hydrocephalus Hydrocephalus
treatment operative notes
d) Detailed discharge
summary
Neonates > 2.5 kg nursed with mother : 0 0 OPEN 30
Includes clinical monitoring, breastfeeding
362 Neo - natal Care MN Neo - natal Care MN011 Basic neonatal care (Level IA) MN011A support, birth vaccination, thyroid screening, 820 902 984 1066 1148 1189
universal hearing screening and pre-discharge
counselling
363 Neo - natal Care MN Neo - natal Care MN012 ROP screening MN012A ROP screening 580 638 696 754 812 841 0 0 OPEN
BERAn (Brainstem Evoked Response 0 0 OPEN
364 Neo - natal Care MN Neo - natal Care MN013 MN013A BERA 1740 1914 2088 2262 2436 2523
Audiometry)
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
Cyclophosphamide + Epirubcin e) ECG. c) DISCHARGE SUMMARY
365 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001A Cyclophosphamide - 600 mg /m2 D1 8500 9350 10200 11050 11900 12325 f) 2D-ECHO. OF INPATIENT
Epirubicin -90mg/m2 D1 every 21 days g) USG abdomen DEPARTMENT.
h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT.
j) abdomen e) CHARTS OF
k) pelvis in case of CHEMOTHERAPY
metastatic disease REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
e) ECG. c) DISCHARGE SUMMARY
Weekly Paclitaxel for Adjuvant Therapy f) 2D-ECHO. OF INPATIENT
366 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001B 6950 7645 8340 9035 9730 10077
Paclitaxel 80mg/m2 every week g) USG abdomen DEPARTMENT.
h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT.
j) abdomen e) CHARTS OF
k) pelvis in case of CHEMOTHERAPY
metastatic disease REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
e) ECG. c) DISCHARGE SUMMARY
Weekly Paclitaxel in metastatic setting f) 2D-ECHO. OF INPATIENT
367 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001C 6950 7645 8340 9035 9730 10077
Paclitaxel 80mg/m2 every week g) USG abdomen DEPARTMENT.
h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT.
j) abdomen e) CHARTS OF
k) pelvis in case of CHEMOTHERAPY
metastatic disease REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
Cyclophosphamide + Methotrexate + 5 - FU e) ECG. c) DISCHARGE SUMMARY
Cyclophosphamide - 100mg/m2 orally D1-D14 f) 2D-ECHO. OF INPATIENT
368 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001D 4100 4510 4920 5330 5740 5945
Methotrexate 40mg/m2 IV D1 g) USG abdomen DEPARTMENT.
D8 5FU 600 mg/m2 D1, D8 every 28 days h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT.
j) abdomen e) CHARTS OF
k) pelvis in case of CHEMOTHERAPY
metastatic disease REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
Docetaxel + Cyclophosphamide e) ECG. c) DISCHARGE SUMMARY
Docetaxel 75mg/m2 D1 f) 2D-ECHO. OF INPATIENT
369 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001E 10710 11781 12852 13923 14994 15529
Cyclophosphamide 600 mg/m2 D1 every 21 g) USG abdomen DEPARTMENT.
days h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT.
j) abdomen e) CHARTS OF
k) pelvis in case of CHEMOTHERAPY
metastatic disease REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. BAR CODE OF THE OPEN

b) LFT. DRUGS, REPORTS OF
c) RFT. THE TESTS
d) Biopsy report or surgical (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
Trastuzumab conservation surgery. BIOCHEMISTRY,ETC.)
Trastuzumab 8 mg/Kg in Cycle 1 D1 e) ECG. DISCHARGE SUMMARY
370 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001F 24570 27027 29484 31941 34398 35626
Trastuzumab 6 mg/kg D1 from C2 every 21 f) 2D-ECHO. OF INPATIENT
days g) USG abdomen DEPARTMENT,
h) pelvis. DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT, CHARTS
j) abdomen OF CHEMOTHERAPY
k) pelvis in case of REGIMEN, TRANFUSION
metastatic disease SLIPS

a) BAR CODE OF THE OPEN

DRUGS.
a) CBC. b) REPORTS OF THE
b) LFT. TESTS (PATHOLOGY,
c) RFT. RADIOLOGY,
d) Biopsy report or surgical MICROBIOLOGY,
pathology report of HEMATOLOGY,
Modified radical BIOCHEMISTRY,ETC.)
mastectomy or breast c) DISCHARGE SUMMARY
Tamoxifen conservation surgery. OF INPATIENT
371 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001G 1365 1501 1638 1774 1911 1979 e) ECG. DEPARTMENT.
Tamoxifem 20 mg orally daily
f) 2D-ECHO. d) DISCHARGE SUMMARY
g) USG abdomen OF DAY CARE
h) pelvis. DEPARTMENT.
i) CXR PA view or CECT e) CHARTS OF
chest CHEMOTHERAPY
j) abdomen REGIMEN.
k) pelvis in case of f) TRANFUSION SLIPS.
metastatic disease
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) BAR CODE OF THE OPEN
DRUGS.
a) CBC. b) REPORTS OF THE
b) LFT. TESTS (PATHOLOGY,
c) RFT. RADIOLOGY,
d) Biopsy report or surgical MICROBIOLOGY,
pathology report of HEMATOLOGY,
Modified radical BIOCHEMISTRY,ETC.)
mastectomy or breast c) DISCHARGE SUMMARY
Letrozole conservation surgery. OF INPATIENT
372 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001H 4515 4966 5418 5869 6321 6546 e) ECG. DEPARTMENT.
Letrozole 2.5 mg orally daily
f) 2D-ECHO. d) DISCHARGE SUMMARY
g) USG abdomen OF DAY CARE
h) pelvis. DEPARTMENT.
i) CXR PA view or CECT e) CHARTS OF
chest CHEMOTHERAPY
j) abdomen REGIMEN.
k) pelvis in case of f) TRANFUSION SLIPS.
metastatic disease

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
Carboplatin + Paclitaxel e) ECG. c) DISCHARGE SUMMARY
373 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001I Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 f) 2D-ECHO. OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days g) USG abdomen DEPARTMENT.
h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT.
j) abdomen e) CHARTS OF
k) pelvis in case of CHEMOTHERAPY
metastatic disease REGIMEN.
f) TRANFUSION SLIPS.

a) BAR CODE OF THE OPEN

DRUGS.
a) CBC. b) REPORTS OF THE
b) LFT. TESTS (PATHOLOGY,
c) RFT. RADIOLOGY,
d) Biopsy report or surgical MICROBIOLOGY,
pathology report of HEMATOLOGY,
Modified radical BIOCHEMISTRY,ETC.)
Capecitabine mastectomy or breast c) DISCHARGE SUMMARY
374 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001J Capecitabine - 1000mg/m2 orally twice daily D1- 8610 9471 10332 11193 12054 12484 conservation surgery. OF INPATIENT
D14 every 21 days e) ECG. DEPARTMENT.
f) 2D-ECHO. d) DISCHARGE SUMMARY
g) USG abdomen OF DAY CARE
h) pelvis. DEPARTMENT.
i) CXR PA view or CECT e) CHARTS OF
chest CHEMOTHERAPY
j) abdomen REGIMEN.
k) pelvis in case of f) TRANFUSION SLIPS.
metastatic disease
a) BAR CODE OF THE OPEN
DRUGS.
a) CBC. b) REPORTS OF THE
b) LFT. TESTS (PATHOLOGY,
c) RFT. RADIOLOGY,
d) Biopsy report or surgical MICROBIOLOGY,
pathology report of HEMATOLOGY,
Carboplatin + Gemcitabine Modified radical BIOCHEMISTRY,ETC.)
Gemcitabine - 1000mg/m2 D1 D8 mastectomy or breast c) DISCHARGE SUMMARY
375 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001K Carboplatin AUC 2 D1 D8 16065 17671 19278 20884 22491 23294 conservation surgery. OF INPATIENT
Gemcitabine - 1000mg/m2 D1 D8 e) ECG. DEPARTMENT.
Carboplatin AUC 5-6 D1 only f) 2D-ECHO. d) DISCHARGE SUMMARY
g) USG abdomen OF DAY CARE
h) pelvis. DEPARTMENT.
i) CXR PA view or CECT e) CHARTS OF
chest CHEMOTHERAPY
j) abdomen REGIMEN.
k) pelvis in case of f) TRANFUSION SLIPS.
metastatic disease
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
Cyclophosphamide + Adriamycin e) ECG. c) DISCHARGE SUMMARY
376 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001L Cyclophosphamide - 600 mg /m2 D1 5250 5775 6300 6825 7350 7612 f) 2D-ECHO. OF INPATIENT
Adriamycin - 60mg/m2 D1 every 21 days g) USG abdomen DEPARTMENT.
h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest DEPARTMENT.
j) abdomen e) CHARTS OF
k) pelvis in case of CHEMOTHERAPY
metastatic disease REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN YES

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
Fulvestrant e) ER or PR positive . c) DISCHARGE SUMMARY
377 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001M Fulvestrant 500 mg D1 D15 D28 then every 28 41580 45738 49896 54054 58212 60291 f) mammography. OF INPATIENT
days g) USG abdomen DEPARTMENT.
h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest abdomen and pelvis DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report or surgical TESTS (PATHOLOGY,
pathology report of RADIOLOGY,
Modified radical MICROBIOLOGY,
mastectomy or breast HEMATOLOGY,
conservation surgery. BIOCHEMISTRY,ETC.)
e) ER or PR positive . c) DISCHARGE SUMMARY
Paclitaxel f) mammography. OF INPATIENT
378 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001N 13650 15015 16380 17745 19110 19792
Paclitaxel 175 mg/m2 D1 every 21 days g) USG abdomen DEPARTMENT.
h) pelvis. d) DISCHARGE SUMMARY
i) CXR PA view or CECT OF DAY CARE
chest abdomen and pelvis DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) Biopsy report TESTS (PATHOLOGY,
e) surgical pathology report RADIOLOGY,
of Modified radical MICROBIOLOGY,
mastectomy HEMATOLOGY,
f) breast conservation BIOCHEMISTRY,ETC.)
surgery. c) DISCHARGE SUMMARY
Exemestane g) ER OF INPATIENT
379 Medical Oncology MO Medical Oncology MO001 CT for CA Breast MO001O 4515 4966 5418 5869 6321 6546
Exemestane 25 mg orally daily (q 3 monthsly) h) PR positive . DEPARTMENT.
i) mammography. d) DISCHARGE SUMMARY
j) USG abdomen OF DAY CARE
k) pelvis. DEPARTMENT.
l) CXR PA view e) CHARTS OF
m) CECT chest abdomen CHEMOTHERAPY
and pelvis REGIMEN.
f) TRANFUSION SLIPS.

Lapatinib 0 0 OPEN
380 Medical Oncology Mo Medical Oncology MO001 CT for CA Breast MO001P 17430 19173 20916 22659 24402 25273
Lapatinib 500 mg BD orally , daily
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) RFT. a) BAR CODE OF THE OPEN
b) skeletal survey DRUGS.
c) bone scan b) REPORTS OF THE
d) PET-CT showing bone TESTS (PATHOLOGY,
metastasis histopathology RADIOLOGY,
showing myeloma. MICROBIOLOGY,
e) lung cancer. HEMATOLOGY,
f) Breast cancer. BIOCHEMISTRY,ETC.)
g) renal cancer or other c) DISCHARGE SUMMARY
CT for Metastatic bone malignancy and Zoledronic Acid cancer OF INPATIENT
381 Medical Oncology MO Medical Oncology MO002 MO002A 4100 4510 4920 5330 5740 5945
multiple myeloma Zoledronic acid 4 mg IV Monthly DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBc. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CA-125. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
Cisplatin + Irinotecan i) HPR or cytology c) DISCHARGE SUMMARY
382 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003A Cisplatin 60mg/m2 D1 15120 16632 18144 19656 21168 21924 suggestive of ovarian OF INPATIENT
Irinotecan 60 mg/m2 D1 D8 D15 every 28 days adenocarcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBc. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CA-125. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
Lipodox + Carboplatin i) HPR or cytology c) DISCHARGE SUMMARY
383 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003B Lipopdox 30 mg/m2 D1 19950 21945 23940 25935 27930 28927 suggestive of ovarian OF INPATIENT
Carboplatin AUC 5-6 D1 every 28 days adenocarcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBc. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CA-125. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
i) HPR or cytology c) DISCHARGE SUMMARY
384 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003C 3990 4389 4788 5187 5586 5785 suggestive of ovarian OF INPATIENT
Etoposide 50 mg/m2 OD D1-D21 every 28 days adenocarcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBc. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CA-125. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
i) HPR or cytology c) DISCHARGE SUMMARY
Irinotecan suggestive of ovarian OF INPATIENT
385 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003D 12705 13975 15246 16516 17787 18422
Irinotecan 60 -90 mg/m2 D1 D8 every 21 days adenocarcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBc. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CA-125. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
i) HPR or cytology c) DISCHARGE SUMMARY
Lipodox suggestive of ovarian OF INPATIENT
386 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003E 20790 22869 24948 27027 29106 30145
Lipodox 40 mg/m2 IV every 28 days adenocarcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBc. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CA-125. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
Carboplatin + Gemcitabine h) Pelvis. BIOCHEMISTRY,ETC.)
Gemcitabine - 1000mg/m2 D1 D8 i) HPR or cytology c) DISCHARGE SUMMARY
387 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003F Carboplatin AUC 2 D1 D8 16065 17671 19278 20884 22491 23294 suggestive of ovarian OF INPATIENT
Gemcitabine - 1000mg/m2 D1 D8 adenocarcinoma DEPARTMENT.
Carboplatin AUC 5-6 D1 only d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBc. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CA-125. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
Carboplatin + Paclitaxel i) HPR or cytology c) DISCHARGE SUMMARY
388 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003G Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 suggestive of ovarian OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days adenocarcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

0 0 OPEN
389 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003H Cyclophosphamide 50 mg/m2 OD D1-D21 3255 3580 3906 4231 4557 4719
every 28 days
Tamoxifen 0 0 OPEN
390 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003I 1470 1617 1764 1911 2058 2131
Tamoxifem 20 mg orally daily (3 months)
Letrozole 0 0 OPEN
391 Medical Oncology MO Medical Oncology MO003 CT for CA Ovary MO003J 4515 4966 5418 5869 6321 6546
Letrozole 2.5 mg orally daily (3 months)
Single agent Carboplatin 0 0 OPEN
392 Medical Oncology Mo Medical Oncology MO003 CT for CA Ovary MO003K Carboplatin AUC 5-6 D1 every 21 days ( 8085 8893 9702 10510 11319 11723
maximum -6 cycle)
Cisplatin 0 0 OPEN
393 Medical Oncology Mo Medical Oncology MO003 CT for CA Ovary MO003L Cisplatin 40 mg/m2 every week (maximum- 6 4830 5313 5796 6279 6762 7003
cycles)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) BAR CODE OF THE OPEN
DRUGS.
a) CBC. b) REPORTS OF THE
b) LFT. TESTS (PATHOLOGY,
c) RFT. RADIOLOGY,
d) RBS. MICROBIOLOGY,
e) Beta- HCG. HEMATOLOGY,
f) AFP. BIOCHEMISTRY,ETC.)
g) LDH. c) DISCHARGE SUMMARY
Carboplatin (AUC 7) h) CECT Thorax. OF INPATIENT
394 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004A 8500 9350 10200 11050 11900 12325
Carboplatin AUC 7 every 21 days i) Abdomen DEPARTMENT.
j) Pelvis. d) DISCHARGE SUMMARY
k) ECG. OF DAY CARE
l) Histopathology -testicular DEPARTMENT.
seminoma e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta-HCG. RADIOLOGY,
f) AFP. MICROBIOLOGY,
g) LDH. HEMATOLOGY,
h) CECT Thorax. BIOCHEMISTRY,ETC.)
Bleomycin + Etoposide + Cisplatin i) Abdomen c) DISCHARGE SUMMARY
Bleomycin 30 units D1 D8 D15 j) Pelvis. OF INPATIENT
395 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004B 14280 15708 17136 18564 19992 20706
Cisplatin 20 mg/m2 IV D1-D5 k) ECG. DEPARTMENT.
Etoposide 100mg/m2 D1-D5 every 21 days l) PFT DLCo. d) DISCHARGE SUMMARY
m) Histopathology - OF DAY CARE
Ovarian. DEPARTMENT.
n) testicular. e) CHARTS OF
o) mediastinal CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) AFP. MICROBIOLOGY,
g) LDH. HEMATOLOGY,
h) CECT Thorax. BIOCHEMISTRY,ETC.)
Etoposide + Cisplatin i) abdomen c) DISCHARGE SUMMARY
396 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004C Cisplatin 20 mg/m2 IV D1-D5 12600 13860 15120 16380 17640 18270 j) Pelvis. OF INPATIENT
Etoposide 100mg/m2 D1-D5 every 21 days k) ECG. DEPARTMENT.
l) Histopathology - d) DISCHARGE SUMMARY
Ovarian. OF DAY CARE
m) testicular. DEPARTMENT.
n) mediastinal e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) AFP. MICROBIOLOGY,
g) LDH. HEMATOLOGY,
h) CECT Thorax. BIOCHEMISTRY,ETC.)
Gemcitabine + Oxaliplatin i) abdomen c) DISCHARGE SUMMARY
397 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004D Gemcitabine 1000mg/m2 D1 D8 20265 22291 24318 26344 28371 29384 j) Pelvis. OF INPATIENT
Oxaiplatin 130mg/m2 D1 every 21 days k) ECG. DEPARTMENT.
l) Histopathology - d) DISCHARGE SUMMARY
Ovarian. OF DAY CARE
m) testicular. DEPARTMENT.
n) mediastinal e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) AFP. MICROBIOLOGY,
g) LDH. HEMATOLOGY,
h) CECT Thorax. BIOCHEMISTRY,ETC.)
Gemcitabine + Paclitaxel i) abdomen c) DISCHARGE SUMMARY
398 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004E Gemcitabine 1000mg/m2 D1 D8 D15 20265 22291 24318 26344 28371 29384 j) Pelvis. OF INPATIENT
Paclitaxel 100 mg/m2 D1 D8 D15 every 28 days k) ECG. DEPARTMENT.
l) Histopathology - d) DISCHARGE SUMMARY
Ovarian. OF DAY CARE
m) testicular. DEPARTMENT.
n) mediastinal e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) AFP. MICROBIOLOGY,
g) LDH. HEMATOLOGY,
Paclitaxel + Ifosfamide + Cisplatin h) CECT Thorax. BIOCHEMISTRY,ETC.)
Paclitaxel 240 mg/m2 D1 i) abdomen c) DISCHARGE SUMMARY
399 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004F Ifosfamide 1500mg/m2 D2-D5 28245 31069 33894 36718 39543 40955 j) Pelvis. OF INPATIENT
Mesna 300 mg/m2 0h 4h 8h D2-D5 k) ECG. DEPARTMENT.
Cisplatin 25mg/m2 D2-D5 every 21 days l) Histopathology - d) DISCHARGE SUMMARY
Ovarian. OF DAY CARE
m) testicular. DEPARTMENT.
n) mediastinal e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) AFP. MICROBIOLOGY,
g) LDH. HEMATOLOGY,
Vinblastin + Ifosfamide + Cisplatin h) CECT Thorax. BIOCHEMISTRY,ETC.)
Vinblastine 0.11 mg/kg IV D1-D2 i) abdomen c) DISCHARGE SUMMARY
400 Medical Oncology MO Medical Oncology MO004 CT for Germ Cell Tumor MO004G Mesna 240mg/m2 0h 4h 8h D1-D5 15750 17325 18900 20475 22050 22837 j) Pelvis. OF INPATIENT
Ifosfamide 1200mg/m2 D1-D5 k) ECG. DEPARTMENT.
Cisplatin 20 mg/m2 D1-D5 every 21 days l) Histopathology - d) DISCHARGE SUMMARY
Ovarian. OF DAY CARE
m) testicular. DEPARTMENT.
n) mediastinal e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
Etoposide + Methotrexate + Dactinomycin- g) Abdomen HEMATOLOGY,
Cyclophosphamide + Vincristine h) Pelvis BIOCHEMISTRY,ETC.)
Etoposide 100mg/m2 IV D1 D2 c) DISCHARGE SUMMARY
Dactinomycin 0.5 mg IV push D1 D2 OF INPATIENT
401 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005A 13965 15361 16758 18154 19551 20249
Methotrexate 300 mg /m2 D1 DEPARTMENT.
Leucovorin 15 mg PO every 12 hrs for 4 doses d) DISCHARGE SUMMARY
Cyclophosphamide 600mg/m2 D8 OF DAY CARE
Vincrstine 1 mg/m2 D8 every 2 weeks DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
Etoposide + Methotrexate + Dactinomycin + g) Abdomen HEMATOLOGY,
Cisplatin h) Pelvis BIOCHEMISTRY,ETC.)
Etoposide 100mg/m2 IV D1 D2 D8 c) DISCHARGE SUMMARY
402 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005B Dactinomycin 0.5 mg IV push D1 D2 14805 16285 17766 19246 20727 21467 OF INPATIENT
Methotrexate 300 mg /m2 D1 DEPARTMENT.
Leucovorin 15 mg PO every 12 hrs for 4 doses d) DISCHARGE SUMMARY
Cisplatin 75mg/m2 D8 every 2 weeks OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Beta- HCG. RADIOLOGY,
f) CECT Thorax. MICROBIOLOGY,
g) Abdomen HEMATOLOGY,
Methotrexate h) Pelvis BIOCHEMISTRY,ETC.)
Methotrexate 1/mg/kg IM every other day x 4 c) DISCHARGE SUMMARY
403 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005C days D1 3 D5 D7 1470 1617 1764 1911 2058 2131 OF INPATIENT
Alternating every other day with DEPARTMENT.
Leucovorin 15 mg PO repeat every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

0 0 OPEN
Dactinomycin
404 Medical Oncology MO Medical Oncology MO005 CT for Gestational Trophoblastic Neoplasia MO005D 8085 8893 9702 10510 11319 11723
Inj Dactinomycin 0.5 mg D1- D5 every 14 days
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
Carboplatin + Paclitaxel c) DISCHARGE SUMMARY
405 Medical Oncology MO Medical Oncology MO006 CT for Cervical Cancer MO006A Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Cisplatin OF INPATIENT
406 Medical Oncology MO Medical Oncology MO006 CT for Cervical Cancer MO006B 2730 3003 3276 3549 3822 3958
Cisplatin 40 mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
Carboplatin + Paclitaxel c) DISCHARGE SUMMARY
407 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007A Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 OF INPATIENT
Carboplatin AUC 5 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis.histopathology . HEMATOLOGY,
h) ECG. BIOCHEMISTRY,ETC.)
Cisplatin + Doxorubicin i) 2D ECHO c) DISCHARGE SUMMARY
408 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007B Doxorubicin 60 mg/m2 D1 5145 5659 6174 6688 7203 7460 OF INPATIENT
Cisplatin 50mg/m2 every 3 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

Lipodox + Carboplatin 0 0 OPEN

409 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007C Lipopdox 30 mg/m2 D1 19950 21945 23940 25935 27930 28927
Carboplatin AUC 5 D1 every 28 days
Carboplatin + Gemcitabine 0 0 OPEN
Gemcitabine - 1000mg/m2 D1 D8
410 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007D Carboplatin AUC 2 D1 D8 16065 17671 19278 20884 22491 23294
Gemcitabine - 1000mg/m2 D1 D8
Carboplatin AUC 5-6 D1 only every 3 weeks
Anastrozole 0 0 OPEN
411 Medical Oncology MO Medical Oncology MO007 CT for Endometrial Cancer MO007E 4515 4966 5418 5869 6321 6546
1 mg orally daily (for 3 months)
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) MRI pelvis. RADIOLOGY,
f) histopathology MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Cisplatin + 5 FU c) DISCHARGE SUMMARY
412 Medical Oncology MO Medical Oncology MO008 CT for Vulvar Cancer MO008A 5 FU 1000mg/m2 D1-D4 9555 10510 11466 12421 13377 13854 OF INPATIENT
Cisplatin 75mg/m2 D1 every 3 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) MRI pelvis. RADIOLOGY,
f) histopathology MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Cisplatin OF INPATIENT
413 Medical Oncology MO Medical Oncology MO008 CT for Vulvar Cancer MO008B 2730 3003 3276 3549 3822 3958
Cisplatin 40 mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

Carboplatin + Paclitaxel 0 0 OPEN

414 Medical Oncology MO Medical Oncology MO008 CT for Vulvar Cancer MO008C Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360
Carboplatin AUC 5 D1 every 21 days
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) PET CT b) REPORTS OF THE
d) CT CHEST TESTS (PATHOLOGY,
e) BONE SCAN. RADIOLOGY,
Vincristine + Topotecan + Cyclophosphamide + f) Bone marrow studies. MICROBIOLOGY,
Irinotecan + Temozolamide g) Biopsy. HEMATOLOGY,
Vincristine 1.5mg/m2( day 1) h) ECG. BIOCHEMISTRY,ETC.)
Topotecan 1.5mg/m2 (day 1-5) i) 2D-ECHO c) DISCHARGE SUMMARY
415 Medical Oncology MO Medical Oncology MO009 CT for Ewing Sarcoma MO009A Cyclophosphamide 250mg/m2 (days 1-5) 26775 29452 32130 34807 37485 38823 OF INPATIENT
Given every 3 weeks DEPARTMENT.
Irinotecan 10-50 mg/sqM days 1-5 and days 8- d) DISCHARGE SUMMARY
12 Temozolamide 100mg/m2 days 1-5 of each OF DAY CARE
cycle every 3 weeks DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

Vincristine + Ifosfamide + Etoposide b) Biochemistry. DRUGS.
Vincristine + Doxorubicin + Cyclophosphamide c) PET CT b) REPORTS OF THE
Vincristine + Cyclophosphamide + d) CT CHEST TESTS (PATHOLOGY,
Dactinomycin. e) BONE SCAN. RADIOLOGY,
4 cycles VIE, 6 cycles VAC, 4 cycles VCD f) Bone marrow studies. MICROBIOLOGY,
Vincristine 1.5mg/m2 (day 1, 8 and 15) g) Biopsy. HEMATOLOGY,
Ifosfamide: 1800mg/m2 (days1-5) h) ECG. BIOCHEMISTRY,ETC.)
Etposide: 100mg/sq.m (days 1-5) i) 2D-ECHO c) DISCHARGE SUMMARY
416 Medical Oncology MO Medical Oncology MO009 CT for Ewing Sarcoma MO009B Given every 3 weeks 11445 12589 13734 14878 16023 16595 OF INPATIENT
Vincristine 1.5mg/m2 (day 1 and 8) DEPARTMENT.
Adriamyicn: 60mg/m2 (day 1) d) DISCHARGE SUMMARY
Cyclophosphamide 600mg/m2 (day 1) OF DAY CARE
Given 2-3 weekly DEPARTMENT.
Vincristine 1.5mg/m2 (day 1 and 8) e) CHARTS OF
Cyclophosphamide 600mg/m2 (day 1) CHEMOTHERAPY
Dactinomycin1mg/m2 (day1) REGIMEN.
Given 3 weekly f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT b) REPORTS OF THE
d) CT CHEST TESTS (PATHOLOGY,
e) BONE SCAN. RADIOLOGY,
Vincristine + Adriamycin + Cyclophosphamide f) Bone marrow studies. MICROBIOLOGY,
Ifosfamide + Etoposide g) Biopsy. HEMATOLOGY,
Ifosfamide: 1800mg/m2 (days1-5) h) ECG. BIOCHEMISTRY,ETC.)
Etposide: 100mg/sq.m (days 1-5) i) 2D-ECHO c) DISCHARGE SUMMARY
417 Medical Oncology MO Medical Oncology MO009 CT for Ewing Sarcoma MO009C Given every 2-3 weekly 14700 16170 17640 19110 20580 21315 OF INPATIENT
Vincristine 1.5mg/m2 (day 1 and 8) DEPARTMENT.
Adriamyicn: 75mg/m2 (day 1) d) DISCHARGE SUMMARY
Cyclophosphamide 1200mg/m2 (day 1) OF DAY CARE
Given 2-3 weekly DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) DTPA GFR. RADIOLOGY,
f) NCCT chest. MICROBIOLOGY,
g) MRI of the involved site. HEMATOLOGY,
h) 2D ECHO. BIOCHEMISTRY,ETC.)
Doxorubicin + Cisplatin i) Pure tone c) DISCHARGE SUMMARY
418 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010A Cisplatin 100mg/m2 21800 23980 26160 28340 30520 31610 audiometry.histopathology OF INPATIENT
Doxorubicin 75mg/m2 given every 3 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) BAR CODE OF THE OPEN
DRUGS.
b) REPORTS OF THE
a) CBC. TESTS (PATHOLOGY,
b) Biochemistry. RADIOLOGY,
c) CT CHEST. MICROBIOLOGY,
d) BONE SCAN. HEMATOLOGY,
Methotrexate + Doxorubicin + Cisplatin for e) Biopsy. BIOCHEMISTRY,ETC.)
Relapsed Osteogenic Sarcoma f) ECG. c) DISCHARGE SUMMARY
Cisplatin 120mg/sq.m g) 2D-ECHO. OF INPATIENT
419 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010B 31185 34303 37422 40540 43659 45218
Doxorubicin 75mg/m2 h) AUDIOMETRY. DEPARTMENT.
Methotrexate 8-12 gram/m2 i) GFR d) DISCHARGE SUMMARY
Each cycle for 5 weeks OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) DTPA GFR. RADIOLOGY,
f) NCCT chest. MICROBIOLOGY,
g) MRI of the involved site. HEMATOLOGY,
OGS - 12 h) 2D ECHO. BIOCHEMISTRY,ETC.)
Ifosfamide 1800 mg/m2 D1-D5 i) Pure tone c) DISCHARGE SUMMARY
420 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010C Mesna 600mg/m2 0h 3h 6h 9h D1-D5 34230 37653 41076 44499 47922 49633 audiometry.histopathology OF INPATIENT
Adriamycin 25mg/m2 D1- D3 DEPARTMENT.
Cisplatin 33 mg/m2 D1-D3 every 21 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) DTPA GFR. RADIOLOGY,
f) 2D ECHO. MICROBIOLOGY,
g) Pure tone. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
OGS - 12 c) DISCHARGE SUMMARY
Ifosfamide 1800 mg/m2 D1-D5 OF INPATIENT
421 Medical Oncology MO Medical Oncology MO010 CT for Osteogenic Sarcoma MO010D 36200 39820 43440 47060 50680 52490
Mesna 600mg/m2 0h 3h 6h 9h D1-D5 DEPARTMENT.
Cisplatin 33 mg/m2 D1-D3 every 21 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) ECHO. b) REPORTS OF THE
d) MRI of the involved TESTS (PATHOLOGY,
part. RADIOLOGY,
e) CECT Thorax. MICROBIOLOGY,
f) abdomen HEMATOLOGY,
g) Pelvis. BIOCHEMISTRY,ETC.)
Gemcitabine + Docetaxel h) histopathology c) DISCHARGE SUMMARY
422 Medical Oncology MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011A Gemcitabine 900 mg/m2 D1 D8 30900 33990 37080 40170 43260 44805 OF INPATIENT
Docetaxel 100 mg/m2 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) ECHO. b) REPORTS OF THE
d) MRI of the involved TESTS (PATHOLOGY,
part. RADIOLOGY,
e) CECT Thorax. MICROBIOLOGY,
f) abdomen HEMATOLOGY,
Ifosfamide + Adriamycin g) Pelvis. BIOCHEMISTRY,ETC.)
Doxorubicin 30mg/m2 D1 D2 h) histopathology c) DISCHARGE SUMMARY
423 Medical Oncology MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011B Ifosfamide 2000 to 3000mg/m2 15855 17440 19026 20611 22197 22989 OF INPATIENT
Mesna 400 to 600 mg/m2 0h 4h 8h D1 - D3 DEPARTMENT.
Every 21 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

424 Medical Oncology MO Medical Oncology MO011 CT for Soft Tissue Sarcoma MO011C Doxorubicin 60-75/m2, every 21 days 4620 5082 5544 6006 6468 6699 0 0 OPEN
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
Dacarbazine + Cisplatin c) DISCHARGE SUMMARY
425 Medical Oncology MO Medical Oncology MO012 CT for Metastatic Melanoma MO012A Dacarbazine 250mg/m2 D1-D5 8295 9124 9954 10783 11613 12027 OF INPATIENT
Cisplatin 75 mg/m2 Every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Temozolamide OF INPATIENT
426 Medical Oncology MO Medical Oncology MO012 CT for Metastatic Melanoma MO012B 5775 6352 6930 7507 8085 8373
Temozolamide 200mg/m2 D1-D5 every 28 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

Imatinib 0 0 OPEN
427 Medical Oncology MO Medical Oncology MO012 CT for Metastatic Melanoma MO012C Tab Imatinib 400/800 mg daily 5775 6352 6930 7507 8085 8373

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) MRI Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
5 FU + Mitomycin C i) Histopathology c) DISCHARGE SUMMARY
428 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013A 5 FU 1000mg/m2 D1-D4 D29-D32 12705 13975 15246 16516 17787 18422 OF INPATIENT
Mitomycin 10mg/m2 D1 DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) MRI Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
Capecitabine + Mitomycin C i) Histopathology c) DISCHARGE SUMMARY
Capecitabine 825mg/m2 PO twice daily till OF INPATIENT
429 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013B 19530 21483 23436 25389 27342 28318
completion of RT DEPARTMENT.
Mitomycin 10mg/2 D1 d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
Cisplatin + 5 FU i) Histopathology c) DISCHARGE SUMMARY
430 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013C 5 FU 1000mg/m2 D1-D4 9450 10395 11340 12285 13230 13702 OF INPATIENT
Cisplatin 75mg/m2 D1 every 4 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
Carboplatin + Paclitaxel i) Histopathology c) DISCHARGE SUMMARY
431 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013D Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
Cisplatin + Paclitaxel i) Histopathology c) DISCHARGE SUMMARY
432 Medical Oncology MO Medical Oncology MO013 CT for Anal Cancer MO013E Paclitaxel 175 mg/m2 D1 15435 16978 18522 20065 21609 22380 OF INPATIENT
Cisplatin 75mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
5 FU + Leucovorin i) Histopathology . c) DISCHARGE SUMMARY
433 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014A 5 FU 1200mg/m2 D1 D2 6400 7040 7680 8320 8960 9280 j) Colonoscopy OF INPATIENT
Leucovorin 400mg/m2 D1 every 14 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
Capecitabine + Irinotecan i) Histopathology c) DISCHARGE SUMMARY
434 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014B Capecitabine 1000mg/m2 D1-D14 14490 15939 17388 18837 20286 21010 OF INPATIENT
Irinotecan 200 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
5 FU + Leucovorin + Oxaliplatin i) Histopathology . c) DISCHARGE SUMMARY
5 FU 1200mg/m2 D1 D2 j) Colonoscopy OF INPATIENT
435 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014C 15855 17440 19026 20611 22197 22989
Leucovorin 400mg/m2 D1 DEPARTMENT.
Oxaliplatin 85 mg/m2 D1 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
5FU + Leucovorin + Irinotecan h) CEA. BIOCHEMISTRY,ETC.)
5 FU 1200mg/m2 D1 D2 i) Histopathology c) DISCHARGE SUMMARY
436 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014D Leucovorin 400mg/m2 D1 11130 12243 13356 14469 15582 16138 OF INPATIENT
Irinotecan 180mg/m2 85 mg/m2 D1 every 14 DEPARTMENT.
days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
Capecitabine + Oxaliplatin i) Histopathology . c) DISCHARGE SUMMARY
437 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014E Capecitabine 1000mg/m2 D1-D14 16500 18150 19800 21450 23100 23925 j) Colonoscopy OF INPATIENT
Oxaliplatin 130 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
i) Histopathology . c) DISCHARGE SUMMARY
Capecitabine along with RT j) Colonoscopy OF INPATIENT
438 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014F 8400 9240 10080 10920 11760 12180
Capecitabine 825 mg/m2 twice daily DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) CEA. BIOCHEMISTRY,ETC.)
Capecitabine i) Histopathology . c) DISCHARGE SUMMARY
439 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014G Capecitabine 1000mg/m2 D1-D14 every 21 8500 9350 10200 11050 11900 12325 j) Colonoscopy OF INPATIENT
days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
5FU + Leucovorin + Oxaliplatin + Irinotecan h) CEA. BIOCHEMISTRY,ETC.)
5 FU 1200mg/m2 D1 D2 i) Histopathology . c) DISCHARGE SUMMARY
440 Medical Oncology MO Medical Oncology MO014 CT for Colorectal Cancer MO014H Leucovorin 400mg/m2 D1 21735 23908 26082 28255 30429 31515 j) Colonoscopy OF INPATIENT
Oxaliplatin 85 mg/m2 D1 DEPARTMENT.
Irinotecan 180mg/m2 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
Carboplatin + Paclitaxel i) UGI endoscospy c) DISCHARGE SUMMARY
441 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015A Paclitaxel 175mg/m2 D1 17220 18942 20664 22386 24108 24969 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
Cisplatin + 5 FU i) UGI endoscospy c) DISCHARGE SUMMARY
442 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015B 5 FU 1000mg/m2 D1-D4 11235 12358 13482 14605 15729 16290 OF INPATIENT
Cisplatin 75mg/m2 D1 every 4 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
Cisplatin + 5 FU i) UGI endoscospy c) DISCHARGE SUMMARY
443 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015C Cisplatin 75mg/m2 D1 D29 16380 18018 19656 21294 22932 23751 OF INPATIENT
5FU 1000mg/m2 D1-D4 D29 D32 every 35 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin i) UGI endoscospy c) DISCHARGE SUMMARY
444 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015D Paclitaxel 50mg/m2 D1 31395 34534 37674 40813 43953 45522 OF INPATIENT
Carboplatin AUC 2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin i) UGI endoscospy c) DISCHARGE SUMMARY
445 Medical Oncology MO Medical Oncology MO015 CT for Esophageal Cancer MO015E Paclitaxel 50mg/m2 D1 31395 34534 37674 40813 43953 45522 OF INPATIENT
Carboplatin AUC 2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
Cisplatin + Docetaxel h) Histopathology . BIOCHEMISTRY,ETC.)
Docetaxel 40mg/m2 D1 i) UGI endoscospy c) DISCHARGE SUMMARY
446 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016A Cisplatin 40 mg/m2 D1 16065 17671 19278 20884 22491 23294 OF INPATIENT
Leucovorin 400mg/m2 D1 DEPARTMENT.
5FU 1000mg/m2 D1 D2 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
i) UGI endoscospy c) DISCHARGE SUMMARY
Irinotecan OF INPATIENT
447 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016B 12700 13970 15240 16510 17780 18415
Irinotecan 60- 90 mg/m2 D1 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
i) UGI endoscospy c) DISCHARGE SUMMARY
5 FU OF INPATIENT
448 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016C 10920 12012 13104 14196 15288 15834
5 FU 250 mg/m2 D1-D5 over 24 hrs every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
i) UGI endoscospy c) DISCHARGE SUMMARY
Capecitabine OF INPATIENT
449 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016D 8400 9240 10080 10920 11760 12180
Capecitabine 825 mg/m2 twice daily DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
Capecitabine + Oxaliplatin i) UGI endoscospy c) DISCHARGE SUMMARY
450 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016E Capecitabine 1000mg/m2 D1-D14 16500 18150 19800 21450 23100 23925 OF INPATIENT
Oxaliplatin 130 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
Docetaxel + Cisplatin + 5 FU h) Histopathology . BIOCHEMISTRY,ETC.)
Docetaxel 40mg/m2 D1 i) UGI endoscospy c) DISCHARGE SUMMARY
451 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016F Cisplatin 40 mg/m2 D1 16800 18480 20160 21840 23520 24360 OF INPATIENT
Leucovorin 400mg/m2 D1 DEPARTMENT.
5FU 1000mg/m2 D1 D2 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
Docetaxel + Cisplatin + Capecitabine h) Histopathology . BIOCHEMISTRY,ETC.)
Docetaxel 40mg/m2 D1 i) UGI endoscospy c) DISCHARGE SUMMARY
452 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016G Cisplatin 40 mg/m2 D1 19700 21670 23640 25610 27580 28565 OF INPATIENT
Capecitabine 825mg/m2 twice daily every 14 DEPARTMENT.
days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
Docetaxel + Oxaliplatin + 5 FU h) Histopathology . BIOCHEMISTRY,ETC.)
Docetaxel 50mg/m2 D1 i) UGI endoscospy c) DISCHARGE SUMMARY
453 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016H Oxaliplatin 85 mg/m2 D1 21420 23562 25704 27846 29988 31059 OF INPATIENT
Leucovorin 400mg/m2 D1 DEPARTMENT.
5FU 1200mg/m2 D1 D2 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
Docetaxel + Oxaliplatin + Capecitabine h) Histopathology . BIOCHEMISTRY,ETC.)
Docetaxel 50mg/m2 D1 i) UGI endoscospy c) DISCHARGE SUMMARY
454 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016I Oxaliplatin 85 mg/m2 D1 24900 27390 29880 32370 34860 36105 OF INPATIENT
Capecitabine 825 mg/m2 Twice daily every 14 DEPARTMENT.
days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
5FU + Leucovorin + Irinotecan h) Histopathology . BIOCHEMISTRY,ETC.)
5 FU 1200mg/m2 D1 D2 i) UGI endoscospy c) DISCHARGE SUMMARY
455 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016J Leucovorin 400mg/m2 D1 11130 12243 13356 14469 15582 16138 OF INPATIENT
Irinotecan 180mg/m2 85 mg/m2 D1 every 14 DEPARTMENT.
days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
5FU + Leucovorin + Oxaliplatin i) UGI endoscospy c) DISCHARGE SUMMARY
5 FU 1200mg/m2 D1 D2 OF INPATIENT
456 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016K 15855 17440 19026 20611 22197 22989
Leucovorin 400mg/m2 D1 DEPARTMENT.
Oxaliplatin 85 mg/m2 D1 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
i) UGI endoscospy c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
457 Medical Oncology MO Medical Oncology MO016 CT for Esophageal / Stomach Cancer MO016L 6930 7623 8316 9009 9702 10048
Paclitaxel 80mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Triphasic CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
i) AFP. c) DISCHARGE SUMMARY
Doxorubicin (TACE) j) MRI OF INPATIENT
458 Medical Oncology MO Medical Oncology MO017 CT for Hepatocellular Carcinoma MO017A 26040 28644 31248 33852 36456 37758
Doxorubicin 30-75 mg/m2 one course DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Triphasic CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology . BIOCHEMISTRY,ETC.)
i) AFP. c) DISCHARGE SUMMARY
Sorafenib j) Lipid Profile. OF INPATIENT
459 Medical Oncology MO Medical Oncology MO017 CT for Hepatocellular Carcinoma MO017B 10395 11434 12474 13513 14553 15072
Sorafenib 400mg PO twice daily k) Urine R/M. DEPARTMENT.
l) 2D ECHO d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

460 Medical Oncology MO Medical Oncology MO017 CT for Hepatocellular Carcinoma MO017C Lenvatinib 12 mg daily 19635 21598 23562 25525 27489 28470 0 0 OPEN
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
Gemcitabine + Nanopaclitaxel i) FNAC. c) DISCHARGE SUMMARY
Gemcitabine 1000mg/m2 D1 D8 D16 j) CA19.9. OF INPATIENT
461 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018A 32865 36151 39438 42724 46011 47654
Albumin bound Paclitaxel 125mg/m2 D1 D8 DEPARTMENT.
D15 every 28 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
i) FNAC. c) DISCHARGE SUMMARY
Gemcitabine j) CA19.9. OF INPATIENT
462 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018B 10395 11434 12474 13513 14553 15072
Gemcitabine 1000mg /m2 D1 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
i) FNAC. c) DISCHARGE SUMMARY
Gemcitabine j) CA19.9. OF INPATIENT
463 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018C 4620 5082 5544 6006 6468 6699
Gemcitabine 300mg/m2 weekly DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
5FU + Leucovorin + Oxaliplatin + Irinotecan h) Histopathology BIOCHEMISTRY,ETC.)
5 FU 1200mg/m2 D1 D2 i) FNAC. c) DISCHARGE SUMMARY
464 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018D Leucovorin 400mg/m2 D1 21840 24024 26208 28392 30576 31668 j) CA19.9. OF INPATIENT
Oxaliplatin 85 mg/m2 D1 DEPARTMENT.
Irinotecan 180mg/m2 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
i) FNAC. c) DISCHARGE SUMMARY
Capecitabine j) CA19.9. OF INPATIENT
465 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018E 8400 9240 10080 10920 11760 12180
Capecitabine 825 mg/m2 twice daily DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
Capecitabine + Gemcitabine i) FNAC. c) DISCHARGE SUMMARY
Gemcitabine 1000mg/m2 D1 D8 D15 j) CA19.9. OF INPATIENT
466 Medical Oncology MO Medical Oncology MO018 CT for Panceratic Cancer MO018F 39480 43428 47376 51324 55272 57246
Capecitabine 830mg/m2 twice daily D1-D21 DEPARTMENT.
every 28 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
Capecitabine i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / j) CA19.9. OF INPATIENT
467 Medical Oncology MO Medical Oncology MO019 MO019A Capecitabine 1000 - 1250 mg/m2 twice daily D1 8500 9350 10200 11050 11900 12325
Cholangiocarcinoma DEPARTMENT.
-D14 every 21 days
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
Cisplatin + Gemcitabine i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / j) CA19.9. OF INPATIENT
468 Medical Oncology MO Medical Oncology MO019 MO019B Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401
Cholangiocarcinoma DEPARTMENT.
Cisplatin 25 mg/m2 D1 D8 every 21 days
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
5FU + Leucovorin + Irinotecan h) Histopathology BIOCHEMISTRY,ETC.)
5 FU 1200mg/m2 D1 D2 i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / j) CA19.9. OF INPATIENT
469 Medical Oncology MO Medical Oncology MO019 MO019C Leucovorin 400mg/m2 D1 11130 12243 13356 14469 15582 16138
Cholangiocarcinoma DEPARTMENT.
Irinotecan 180mg/m2 85 mg/m2 D1 every 14
days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN 30
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
Gemcitabine i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / j) CA19.9. OF INPATIENT
470 Medical Oncology MO Medical Oncology MO019 MO019D Gemcitabine 300 mg/m2 D 1every week (till RT 4620 5082 5544 6006 6468 6699
Cholangiocarcinoma DEPARTMENT.
ends)
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / Gemcitabine j) CA19.9. OF INPATIENT
471 Medical Oncology MO Medical Oncology MO019 MO019E 10395 11434 12474 13513 14553 15072
Cholangiocarcinoma Gemcitabine 1000mg /m2 D1 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
Oxaliplatin + Gemcitabine i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / j) CA19.9. OF INPATIENT
472 Medical Oncology MO Medical Oncology MO019 MO019F Gemcitabine 1000 mg/m2 D1 20160 22176 24192 26208 28224 29232
Cholangiocarcinoma DEPARTMENT.
Oxaliplatin 100 mg/m2 D1 every 14 days
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
Capecitabine + Irinotecan i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / j) CA19.9. OF INPATIENT
473 Medical Oncology MO Medical Oncology MO019 MO019G Capecitabine 1000mg/m2 D1-D14 14490 15939 17388 18837 20286 21010
Cholangiocarcinoma DEPARTMENT.
Irinotecan 200 mg/m2 D1 every 21 days
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
5FU + Leucovorin + Oxaliplatin i) FNAC. c) DISCHARGE SUMMARY
CT for Gall Bladder Cancer / 5 FU 1200mg/m2 D1 D2 j) CA19.9. OF INPATIENT
474 Medical Oncology MO Medical Oncology MO019 MO019H 15855 17440 19026 20611 22197 22989
Cholangiocarcinoma Leucovorin 400mg/m2 D1 DEPARTMENT.
Oxaliplatin 85 mg/m2 D1 every 14 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
i) FNAC. c) DISCHARGE SUMMARY
Imatinib j) Ckit-mutation (not OF INPATIENT
475 Medical Oncology MO Medical Oncology MO020 CT for Gastointestinal stromal tumor MO020A 19400 21340 23280 25220 27160 28130
Imatinib 400 mg once daily mandatory) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax . RADIOLOGY,
f) abdomen . MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) Histopathology BIOCHEMISTRY,ETC.)
i) FNAC. c) DISCHARGE SUMMARY
Sunitinib j) Ckit-mutation (not OF INPATIENT
476 Medical Oncology MO Medical Oncology MO020 CT for Gastointestinal stromal tumor MO020B 24400 26840 29280 31720 34160 35380
Sunitinb 37.5 mg once daily mandatory) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) MRI brain. RADIOLOGY,
f) Histopathology MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Temozolamide c) DISCHARGE SUMMARY
477 Medical Oncology MO Medical Oncology MO021 CT for CA Brain MO021A Temozolomide 150 - 200 mg/m2 D1-D5 every 5775 6352 6930 7507 8085 8373 OF INPATIENT
28 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) MRI brain. RADIOLOGY,
f) Histopathology MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Temozolamide OF INPATIENT
478 Medical Oncology MO Medical Oncology MO021 CT for CA Brain MO021B 34650 38115 41580 45045 48510 50242
Temozolomide 75mg/m2 once daily DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
Gemcitabine + Cisplatin c) DISCHARGE SUMMARY
479 Medical Oncology MO Medical Oncology MO022 CT for Mesothelioma MO022A Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 OF INPATIENT
Cisplatin 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
Pemetrexed + Cisplatin c) DISCHARGE SUMMARY
480 Medical Oncology MO Medical Oncology MO022 CT for Mesothelioma MO022B Pemetrexed 500mg/m2 D1 10920 12012 13104 14196 15288 15834 OF INPATIENT
Cisplatin 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
Pemetrexed + Carboplatin c) DISCHARGE SUMMARY
481 Medical Oncology MO Medical Oncology MO022 CT for Mesothelioma MO022C Pemetrexed 500mg/m2 D1 11760 12936 14112 15288 16464 17052 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology . BIOCHEMISTRY,ETC.)
Cisplatin + Etoposide i) ECHO c) DISCHARGE SUMMARY
482 Medical Oncology MO Medical Oncology MO023 CT for Thymic Carcinoma MO023A Etoposide 100mg/m2 D1 - D3 8190 9009 9828 10647 11466 11875 OF INPATIENT
Cisplatin 75-100 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
Cisplatin + Adriamycin + Cyclophosphamide h) histopathology . BIOCHEMISTRY,ETC.)
Cisplatin 50 mg/m2 D1 i) ECHO c) DISCHARGE SUMMARY
483 Medical Oncology MO Medical Oncology MO023 CT for Thymic Carcinoma MO023B Doxorubicin 50 mg/m2 D1 6825 7507 8190 8872 9555 9896 OF INPATIENT
Cyclophosphamide 500 mg/m2 D1 every 21 DEPARTMENT.
days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT RADIOLOGY,
f) MR Face MICROBIOLOGY,
g) neck. HEMATOLOGY,
h) histopathology - BIOCHEMISTRY,ETC.)
Cisplatin + Docetaxel squamous carcinoma. c) DISCHARGE SUMMARY
484 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024A Docetaxel 75 mg/m2 D1 14385 15823 17262 18700 20139 20858 i) Nasopharyngeal OF INPATIENT
Cisplatin 75 mg/m2 D1 every 21 days carcinoma Pure tone DEPARTMENT.
audiometry d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT RADIOLOGY,
f) MR Face MICROBIOLOGY,
g) neck. HEMATOLOGY,
h) histopathology - BIOCHEMISTRY,ETC.)
squamous carcinoma. c) DISCHARGE SUMMARY
Cisplatin i) nasopharyngeal OF INPATIENT
485 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024B 11340 12474 13608 14742 15876 16443
Cisplatin 100mg/m2 every 21 days carcinoma. DEPARTMENT.
j) Pure tone audiometry d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
Carboplatin + Gemcitabine g) salivary gland c) DISCHARGE SUMMARY
486 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024C Gemcitabine 1000 mg/m2 D1 D8 16065 17671 19278 20884 22491 23294 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
Docetaxel + Cisplatin + 5 FU g) salivary gland c) DISCHARGE SUMMARY
Docetaxel 75 mg/m2 D1 OF INPATIENT
487 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024D 16800 18480 20160 21840 23520 24360
Cisplatin 75 mg/m2 D1 DEPARTMENT.
5 FU 750 mg/m2 D1- D5 every 21 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
g) salivary gland c) DISCHARGE SUMMARY
Docetaxel OF INPATIENT
488 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024E 3780 4158 4536 4914 5292 5481
Docetaxel 20mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT RADIOLOGY,
f) MR Face MICROBIOLOGY,
g) neck. HEMATOLOGY,
h) histopathology - BIOCHEMISTRY,ETC.)
squamous carcinoma c) DISCHARGE SUMMARY
Docetaxel OF INPATIENT
489 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024F 14400 15840 17280 18720 20160 20880
Docetaxel 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology - RADIOLOGY,
esthesioneuroblastoma. MICROBIOLOGY,
f) Neuroendocrine. HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Etoposide + Carboplatin c) DISCHARGE SUMMARY
490 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024G Etoposide 100mg/m2 D1 - D3 8925 9817 10710 11602 12495 12941 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology - RADIOLOGY,
esthesioneuroblastoma. MICROBIOLOGY,
f) Neuroendocrine. HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Etoposide + Cisplatin c) DISCHARGE SUMMARY
491 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024H Etoposide 100mg/m2 D1 - D3 10710 11781 12852 13923 14994 15529 OF INPATIENT
Cisplatin 75-100 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
g) salivary gland c) DISCHARGE SUMMARY
Gemcitabine OF INPATIENT
492 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024I 10395 11434 12474 13513 14553 15072
Gemcitabine 1000 mg/m2 D1 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
Gemcitabine + Cisplatin g) salivary gland c) DISCHARGE SUMMARY
493 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024J Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 OF INPATIENT
Cisplatin 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin g) salivary gland c) DISCHARGE SUMMARY
494 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024K Paclitaxel 80mg/m2 D1 8925 9817 10710 11602 12495 12941 OF INPATIENT
Carboplatin AUC 2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
g) salivary gland c) DISCHARGE SUMMARY
Paclitaxel + Carboplatin OF INPATIENT
495 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024L 16800 18480 20160 21840 23520 24360
Paclitaxel 175mg/m2 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) salivary gland HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
496 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024M 6930 7623 8316 9009 9702 10048
Paclitaxel 80mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) histopathology- RADIOLOGY,
squamous carcinoma. MICROBIOLOGY,
f) nasopharyngeal HEMATOLOGY,
carcinoma. BIOCHEMISTRY,ETC.)
g) salivary gland c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
497 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024N 13650 15015 16380 17745 19110 19792
Paclitaxel 175mg/m2 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT RADIOLOGY,
f) MR Face MICROBIOLOGY,
g) neck. HEMATOLOGY,
h) histopathology - BIOCHEMISTRY,ETC.)
squamous carcinoma. c) DISCHARGE SUMMARY
Carboplatin i) nasopharyngeal OF INPATIENT
498 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024O 3150 3465 3780 4095 4410 4567
Carboplatin AUC 2 every week carcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT RADIOLOGY,
f) MR Face MICROBIOLOGY,
g) neck. HEMATOLOGY,
h) histopathology - BIOCHEMISTRY,ETC.)
squamous carcinoma. c) DISCHARGE SUMMARY
Cisplatin OF INPATIENT
499 Medical Oncology MO Medical Oncology MO024 CT for CA Head & Neck MO024P 2730 3003 3276 3549 3822 3958
Cisplatin 40mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) RBS. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) lipid profile. HEMATOLOGY,
h) 2 D ECHO. BIOCHEMISTRY,ETC.)
i) TFT. c) DISCHARGE SUMMARY
Sunitinib j) 24 hour urine protein OF INPATIENT
500 Medical Oncology MO Medical Oncology MO025 CT for Renal Cell Cancer MO025A 11550 12705 13860 15015 16170 16747
50 mg once daily 4 weeks on 2 weeks off DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

Cabozantinib 60 mg od x 1 month 0 0 OPEN

501 Medical Oncology MO Medical Oncology MO025 CT for Renal Cell Cancer MO025B every 4 weeks 15015 16516 18018 19519 21021 21771

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
Cisplatin + Methotrexate + Vinblastin BIOCHEMISTRY,ETC.)
Methotrexate 30mg/m2 D1 D8 c) DISCHARGE SUMMARY
Vinblastine 4 mg/m2 D1 D8 OF INPATIENT
502 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026A 7875 8662 9450 10237 11025 11418
Doxorubicin 30 mg/m2 D2 DEPARTMENT.
Cisplatin 100 mg/m2 D2 d) DISCHARGE SUMMARY
Leucovorin 15 mg PO D2 D9 every 21 days OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) MRI. HEMATOLOGY,
h) histopathology BIOCHEMISTRY,ETC.)
Carboplatin + Gemcitabine c) DISCHARGE SUMMARY
503 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026B Gemcitabine 1000 mg/m2 D1 D8 16065 17671 19278 20884 22491 23294 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) MRI. HEMATOLOGY,
h) ECG. BIOCHEMISTRY,ETC.)
Cisplatin + Gemcitabine i) 2D-ECHO c) DISCHARGE SUMMARY
504 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026C Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 j) .Histopathology OF INPATIENT
Cisplatin 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Cisplatin + 5 FU c) DISCHARGE SUMMARY
505 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026D 5 FU 1000mg/m2 D1-D4 9450 10395 11340 12285 13230 13702 OF INPATIENT
Cisplatin 75mg/m2 D1 every 4 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Cisplatin + Paclitaxel c) DISCHARGE SUMMARY
506 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026E Paclitaxel 175 mg /m2 D1 15435 16978 18522 20065 21609 22380 OF INPATIENT
Cisplatin 75 mg /m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Docetaxel OF INPATIENT
507 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026F 14400 15840 17280 18720 20160 20880
Docetaxel 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Gemcitabine + Paclitaxel c) DISCHARGE SUMMARY
508 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026G Gemcitabine 2500 mg/m2 D1 17955 19750 21546 23341 25137 26034 OF INPATIENT
Paclitaxel 150 mg/m2 D1 every 14 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Gemcitabine OF INPATIENT
509 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026H 10395 11434 12474 13513 14553 15072
Gemcitabine 1000mg /m2 D1 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) MRI. HEMATOLOGY,
Methotrexate + Vinblastin + Doxorubicin + h) histopathology. BIOCHEMISTRY,ETC.)
Cisplatin i) ECG. c) DISCHARGE SUMMARY
Methotrexate 30mg/m2 D1 j) ECHO OF INPATIENT
510 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026I 8715 9586 10458 11329 12201 12636
Vinblastine 3 mg/m2 D2 DEPARTMENT.
Doxorubicin 30 mg/m2 D2 d) DISCHARGE SUMMARY
Cuisplatin 70 mg/m2 D2 every 14 days OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin c) DISCHARGE SUMMARY
511 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026J Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
512 Medical Oncology MO Medical Oncology MO026 CT for Ureter / Bladder / Urethra MO026K 7455 8200 8946 9691 10437 10809
Paclitaxel 80 mg/m2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Cisplatin + Paclitaxel c) DISCHARGE SUMMARY
513 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027A Paclitaxel 175 mg/m2 D1 15435 16978 18522 20065 21609 22380 OF INPATIENT
Cisplatin 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
5 FU + Cisplatin c) DISCHARGE SUMMARY
514 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027B 5 FU 1000mg/m2 D1-D4 9450 10395 11340 12285 13230 13702 OF INPATIENT
Cisplatin 75mg/m2 D1 every 4 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Capecitabine c) DISCHARGE SUMMARY
515 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027C Capecitabine 1000-1250 mg/m2 PO twice daily 8500 9350 10200 11050 11900 12325 OF INPATIENT
D1 -D14 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin c) DISCHARGE SUMMARY
516 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027D Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
517 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027E 6930 7623 8316 9009 9702 10048
Paclitaxel 80 mg/m2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
518 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027F 13650 15015 16380 17745 19110 19792
Paclitaxel 175 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) CECT Thorax. TESTS (PATHOLOGY,
e) abdomen RADIOLOGY,
f) Pelvis. MICROBIOLOGY,
g) histopathology HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin c) DISCHARGE SUMMARY
519 Medical Oncology MO Medical Oncology MO027 CT for CA Penis MO027G Paclitaxel 80 mg/m2 D1 8925 9817 10710 11602 12495 12941 OF INPATIENT
Carboplatin AUC 2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
i) bone scan. c) DISCHARGE SUMMARY
Docetaxel j) histopathology OF INPATIENT
520 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028A 11700 12870 14040 15210 16380 16965
Docetaxel 60 mg/m2 D1 every 14 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
i) bone scan. c) DISCHARGE SUMMARY
Docetaxel j) histopathology OF INPATIENT
521 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028B 14100 15510 16920 18330 19740 20445
Docetaxel 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
Etoposide + Carboplatin i) bone scan. c) DISCHARGE SUMMARY
522 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028C Etoposide 100mg/m2 D1 - D3 8925 9817 10710 11602 12495 12941 j) histopathology OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
i) bone scan. c) DISCHARGE SUMMARY
LHRH Agonist j) histopathology OF INPATIENT
523 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028D 17745 19519 21294 23068 24843 25730
Leuprolide 22.5 ug every 3 months DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
Mitoxantrone + Prednisolone i) bone scan. c) DISCHARGE SUMMARY
524 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028E Mitoxantrone 12mg/m2 every 3 weeks 4935 5428 5922 6415 6909 7155 j) histopathology OF INPATIENT
Prednsiolone 10 mg daily y DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin i) bone scan. c) DISCHARGE SUMMARY
525 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028F Paclitaxel 80mg/m2 D1 8925 9817 10710 11602 12495 12941 j) histopathology OF INPATIENT
Carboplatin AUC 2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin i) bone scan. c) DISCHARGE SUMMARY
526 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028G Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 j) histopathology OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) PSA. TESTS (PATHOLOGY,
e) ECG. RADIOLOGY,
f) CECTThorax. MICROBIOLOGY,
g) abdomen HEMATOLOGY,
h) Pelvis. BIOCHEMISTRY,ETC.)
i) bone scan. c) DISCHARGE SUMMARY
Docetaxel j) histopathology OF INPATIENT
527 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028H 3780 4158 4536 4914 5292 5481
Docetaxel 20mg/m2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

Abiraterone 1000 mg + Prednisolone 10mg 0 0 OPEN

528 Medical Oncology MO Medical Oncology MO028 CT for CA Prostate MO028I daily 15015 16516 18018 19519 21021 21771
Once every month
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen . TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
Rituximab + Cyclophosphamide + Etoposide + f) Biopsy or fluid flow. HEMATOLOGY,
Prednsiolone g) PB cytometry. BIOCHEMISTRY,ETC.)
Rituximab 375mg/m2 h) ECG. c) DISCHARGE SUMMARY
CT for B - Cell NHL - High Grade Cyclophosphamide 750 mg/m2 i) 2D-ECHO OF INPATIENT
529 Medical Oncology MO Medical Oncology MO029 MO029A 30345 33379 36414 39448 42483 44000
(Except Burkitt's & PCNSL) Vincristine 1.4 mg/m2, on Day1 DEPARTMENT.
Etoposide 65mg/m2 Day 1 to 3 d) DISCHARGE SUMMARY
Prednisolone 100 mg Day 1-5 OF DAY CARE
Total 6 cycles, repeat 21 days DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen . TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
Rituximab + Cyclophosphamide + Doxorubicin + f) Biopsy or fluid flow. HEMATOLOGY,
Prednsiolone g) PB cytometry. BIOCHEMISTRY,ETC.)
Rituximab 375mg/m2 h) ECG. c) DISCHARGE SUMMARY
CT for B - Cell NHL - High Grade Cyclophosphamide 750 mg/m2 i) 2D-ECHO OF INPATIENT
530 Medical Oncology MO Medical Oncology MO029 MO029B 31185 34303 37422 40540 43659 45218
(Except Burkitt's & PCNSL) Doxorubicin 50mg/m2 DEPARTMENT.
Vincristine 1.4 mg/m2 on Day1 d) DISCHARGE SUMMARY
Prednisolone 100 mg Day 1-5 OF DAY CARE
Total 6 cycles, repeat 21 days DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN YES

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
Rituxmab + Dexamethasone + High Dose f) Biopsy or fluid flow HEMATOLOGY,
Cytarabine + Cisplatin cytometry. BIOCHEMISTRY,ETC.)
Rituximab 375mg/m2 Day 1 c) DISCHARGE SUMMARY
Cytarabine 2g/m2 BD on day 2 OF INPATIENT
531 Medical Oncology MO Medical Oncology MO030 CT for High - Grade NHL - B Cell MO030A 40320 44352 48384 52416 56448 58464
Dexamethasone 40 mg Day 1 - 4 DEPARTMENT.
Cisplatin 75mg/m2 or d) DISCHARGE SUMMARY
Carboplatin AUC-5 on day 1 OF DAY CARE
Cycle to be repeated every 21days DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN YES
b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
GDP - R f) Biopsy or fluid flow HEMATOLOGY,
Rituximab 375mg/m2 Day 1 cytometry. BIOCHEMISTRY,ETC.)
Gemcitabine 1000mg/m2 on day 1 and 8 c) DISCHARGE SUMMARY
CT for Relapsed B - Cell NHL - High Grade OF INPATIENT
532 Medical Oncology MO Medical Oncology MO031 MO031A Dexamethasone 40 mg Day 1 - 4 40845 44929 49014 53098 57183 59225
(Except Burkitt's & PCNSL) DEPARTMENT.
Cisplatin 75mg/m2 on day 1
Cycle to be repeated every 21days d) DISCHARGE SUMMARY
Total- 6 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) BAR CODE OF THE OPEN

DRUGS.
a) CBC. b) REPORTS OF THE
b) Biochemistry. TESTS (PATHOLOGY,
c) PET CT or CECT Chest RADIOLOGY,
abdomen MICROBIOLOGY,
ICE - R d) pelvis. HEMATOLOGY,
Rituximab 375mg/m2 e) Bone marrow studies. BIOCHEMISTRY,ETC.)
Ifosfamide 1.66g/m2 on day 1 - 3 f) Biopsy or fluid flow c) DISCHARGE SUMMARY
CT for Relapsed B - Cell NHL - High Grade cytometry. OF INPATIENT
533 Medical Oncology MO Medical Oncology MO031 MO031B Mesna 1.66g/m2 day 1 - 3 36855 40540 44226 47911 51597 53439
(Except Burkitt's & PCNSL) DEPARTMENT.
Carboplatin AUC 5 on day 1
Etoposide 100mg/m2 on day 1 - 3 d) DISCHARGE SUMMARY
Cycle every 21days for 6 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
Etoposide + Prednsiolone + Vincristine + d) pelvis. RADIOLOGY,
Cyclophosphamide + Doxorubicin e) Bone marrow studies. MICROBIOLOGY,
Rituximab 375mg/m2 Day 1 f) Biopsy or fluid flow HEMATOLOGY,
Etoposide 50mg/m2 cytometry. BIOCHEMISTRY,ETC.)
VCR 0.4mg/m2 g) ECG. c) DISCHARGE SUMMARY
CT for PMBCL / Burkitt's Lymphoma /
Doxorubicin 10mg/m2 Day1 - 4 h) 2D-ECHO OF INPATIENT
534 Medical Oncology MO Medical Oncology MO032 Seropositive MO032A 36645 40309 43974 47638 51303 53135
Cyclophosphamide 750mg/m2 on day 5 DEPARTMENT.
B - Cell NHLR
Prednisolone 100 mg day 1-5 d) DISCHARGE SUMMARY
Every 21 days OF DAY CARE
Dose adjustment each cycle depending on nadir DEPARTMENT.
counts e) CHARTS OF
Total- 6 cycles CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) ECG. c) DISCHARGE SUMMARY
Codox - M - IVAC / GMALL / BFM / Hyper h) 2D-ECHO OF INPATIENT
535 Medical Oncology MO Medical Oncology MO033 CT for Burkitt's NHL MO033A 39900 43890 47880 51870 55860 57855
CVAD DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
Bendamustine + Rituximab c) DISCHARGE SUMMARY
Bendamustine 90mg/m2 on day 1, 2 OF INPATIENT
536 Medical Oncology MO Medical Oncology MO034 CT for Low Grade B - Cell NHL MO034A 30700 33770 36840 39910 42980 44515
Rituximab 375mg/m2 on day 1 DEPARTMENT.
Repeat every 28 days, Total 6 cycles d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
Lenalidomide + Rituximab c) DISCHARGE SUMMARY
537 Medical Oncology MO Medical Oncology MO034 CT for Low Grade B - Cell NHL MO034B Rituximab 375mg/m2 Day 1 27500 30250 33000 35750 38500 39875 OF INPATIENT
Lenlidomide 25 mg D1-28, for 8 cycles DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Rituximab OF INPATIENT
538 Medical Oncology MO Medical Oncology MO035 CT for Low Grade NHL MO035A 24800 27280 29760 32240 34720 35960
Rituximab 375mg/m2 per week for 6 weeks DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC, a) BAR CODE OF THE OPEN

b) Biochemistry, DRUGS.
c) USG abdmen b) REPORTS OF THE
d) Pelvis CECT Chest TESTS (PATHOLOGY,
abdomen RADIOLOGY,
e) pelvis, MICROBIOLOGY,
Rituximab + Cyclophosphamide + Vincristine + f) Bone marrow studies, HEMATOLOGY,
Prednisolone g) Biopsy or fluid flow BIOCHEMISTRY,ETC.)
Rituximab 375 mg/m2 cytometry. c) DISCHARGE SUMMARY
539 Medical Oncology MO Medical Oncology MO035 CT for Low Grade NHL MO035B Cyclophosphamide 750mg/m2 25800 28380 30960 33540 36120 37410 OF INPATIENT
Vincristine 1.4mg/m2 Day 1 DEPARTMENT.
Prednisolone 100 mg Day 1 - 5 d) DISCHARGE SUMMARY
Repeat every 21days. Total 6 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) Chest X ay b) REPORTS OF THE
d) USG abdomen TESTS (PATHOLOGY,
e) pelvis or CECT Chest RADIOLOGY,
abdomen MICROBIOLOGY,
f) pelvis. HEMATOLOGY,
g) Bone marrow studies. BIOCHEMISTRY,ETC.)
Fludarabine + Cyclophosphamide h) Biopsy or fluid flow c) DISCHARGE SUMMARY
Fludarabine 25mg/m2 D1-3 cytometry OF INPATIENT
540 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036A 21000 23100 25200 27300 29400 30450
Cyclophosphamide 250 mg/m2 D1-3 every 28 DEPARTMENT.
days for 6 cycles d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Chest X ay b) REPORTS OF THE
d) USG abdomen TESTS (PATHOLOGY,
e) pelvis or CECT Chest RADIOLOGY,
abdomen MICROBIOLOGY,
f) pelvis. HEMATOLOGY,
g) Bone marrow studies. BIOCHEMISTRY,ETC.)
Rituxmab + Chlorambucil h) Biopsy or fluid flow c) DISCHARGE SUMMARY
Rituximab 375mg/m2 Day 1 cytometry OF INPATIENT
541 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036B 24900 27390 29880 32370 34860 36105
Chlorambucil 10 mg/m2 D1-7 DEPARTMENT.
Repeat every 28 days for 12 cycles d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN YES

b) Biochemistry. DRUGS.
c) Chest X ay b) REPORTS OF THE
d) USG abdomen TESTS (PATHOLOGY,
e) pelvis or CECT Chest RADIOLOGY,
abdomen MICROBIOLOGY,
f) pelvis. HEMATOLOGY,
Rituximab + Fludarabine + Cyclophosphamide g) Bone marrow studies. BIOCHEMISTRY,ETC.)
Rituximab 375mg/m2 on day 1 h) Biopsy or fluid flow c) DISCHARGE SUMMARY
542 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036C Fludarabine 25mg/m2 D1 - 3 47040 51744 56448 61152 65856 68208 cytometry OF INPATIENT
Cyclophosphamide 250 mg/m2 D1 - 3 DEPARTMENT.
Every 28 days for 6 cycles . d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Chest X ay b) REPORTS OF THE
d) USG abdomen TESTS (PATHOLOGY,
e) pelvis or CECT Chest RADIOLOGY,
abdomen MICROBIOLOGY,
f) pelvis. HEMATOLOGY,
g) Bone marrow studies. BIOCHEMISTRY,ETC.)
Lenalidomide h) Biopsy or fluid flow c) DISCHARGE SUMMARY
543 Medical Oncology MO Medical Oncology MO036 CT for Chronic Lymphocytic Leukemia MO036D lenalidomide-10-25 mg/day day 1 to 21 every 28 5565 6121 6678 7234 7791 8069 cytometry OF INPATIENT
days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) LDH. b) REPORTS OF THE
d) PET CECT or CECT TESTS (PATHOLOGY,
chest abdomen RADIOLOGY,
e) pelvis. MICROBIOLOGY,
CHOEP f) Bone marrow studies. HEMATOLOGY,
Cyclophosphamide 750mg/m2 D1 g) Biopsy BIOCHEMISTRY,ETC.)
Vincristine 1.4mg/m2 D1 c) DISCHARGE SUMMARY
544 Medical Oncology MO Medical Oncology MO037 CT for Peripheral T - Cell Lymphoma MO037A Adriamycin 50 mg/m2 D1 6090 6699 7308 7917 8526 8830 OF INPATIENT
Etoposide 100mg/m2 D1-3 DEPARTMENT.
Prednisolone 100 mg D1-5 d) DISCHARGE SUMMARY
Every 21days. Total 6 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) LDH. b) REPORTS OF THE
d) PET CECT or CECT TESTS (PATHOLOGY,
chest abdomen RADIOLOGY,
e) pelvis. MICROBIOLOGY,
f) Bone marrow studies. HEMATOLOGY,
CHOP g) Biopsy BIOCHEMISTRY,ETC.)
Cyclophosphamide 750mg/m2 D1 c) DISCHARGE SUMMARY
Vincristine 1.4mg/m2 D1 OF INPATIENT
545 Medical Oncology MO Medical Oncology MO037 CT for Peripheral T - Cell Lymphoma MO037B 5985 6583 7182 7780 8379 8678
Adriamycin 50 mg/m2 D1 DEPARTMENT.
Prednisolone 100 mg D1-5 d) DISCHARGE SUMMARY
Every 21days. Total 6 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) LDH. b) REPORTS OF THE
d) PET CECT TESTS (PATHOLOGY,
e) CECT chest abdomen RADIOLOGY,
f) pelvis. MICROBIOLOGY,
g) Bone marrow studies. HEMATOLOGY,
SMILE h) Biopsy BIOCHEMISTRY,ETC.)
Methotrexate 2gm/m2 D1 c) DISCHARGE SUMMARY
Ifosfamide 1500mg/m2 D2-4 OF INPATIENT
546 Medical Oncology MO Medical Oncology MO037 CT for Peripheral T - Cell Lymphoma MO037C 22785 25063 27342 29620 31899 33038
Etoposide 100mg/m2 D2-4 DEPARTMENT.
L-asparginase 6000U/m2 D8,10,12,14,16,18,20 d) DISCHARGE SUMMARY
Dexamethasone 40mg D1-4 every 28 days OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) LDH. b) REPORTS OF THE
d) PET CECT TESTS (PATHOLOGY,
e) CECT chest abdomen RADIOLOGY,
f) pelvis. MICROBIOLOGY,
g) Bone marrow studies. HEMATOLOGY,
GELOX h) Biopsy BIOCHEMISTRY,ETC.)
Gemcitabine 1000mg/m2 D1 and D8 c) DISCHARGE SUMMARY
547 Medical Oncology MO Medical Oncology MO038 CT for NK - T Cell Lymphoma MO038A Oxaliplatin 130mg/m2 D1 22365 24601 26838 29074 31311 32429 OF INPATIENT
L- asparginase 6000 U/m2 D1-7 DEPARTMENT.
Repeat every 21 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) LDH. b) REPORTS OF THE
d) PET CECT TESTS (PATHOLOGY,
e) CECT chest abdomen RADIOLOGY,
f) pelvis. MICROBIOLOGY,
g) Bone marrow studies. HEMATOLOGY,
LVP h) Biopsy BIOCHEMISTRY,ETC.)
L-asparginase 6000U/m2 D1-5 c) DISCHARGE SUMMARY
548 Medical Oncology MO Medical Oncology MO038 CT for NK - T Cell Lymphoma MO038B Vincristine 1.4mg/m2 D1 9240 10164 11088 12012 12936 13398 OF INPATIENT
Prednisolone 100mg D1-5 DEPARTMENT.
Repeat every 21 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
COPP BIOCHEMISTRY,ETC.)
Cyclophosphamide 650mg/m2 D1, 8 c) DISCHARGE SUMMARY
Vincristine 1.4mg/m2 D1, 8 OF INPATIENT
549 Medical Oncology MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039A 4515 4966 5418 5869 6321 6546
Procarbazine 100 mg/m2 D1-14 DEPARTMENT.
Prednisolone 40mg/m2 D1-14 d) DISCHARGE SUMMARY
Every 28days. Total 6 - 8 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
ABVD BIOCHEMISTRY,ETC.)
Adriamycin 25mg/m2 c) DISCHARGE SUMMARY
Bleomycin 10unit/m2 OF INPATIENT
550 Medical Oncology MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039B 11865 13051 14238 15424 16611 17204
Vinblastine 6mg/m2 DEPARTMENT.
Dacarbazine 375 mg/m2 Day 1,15 d) DISCHARGE SUMMARY
Every 28 days for 6 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
AEVD BIOCHEMISTRY,ETC.)
Adriamycin 25mg/m2 c) DISCHARGE SUMMARY
Vinblastine 6mg/m2 OF INPATIENT
551 Medical Oncology MO Medical Oncology MO039 CT for Hodgkin's Lymphoma MO039C 11865 13051 14238 15424 16611 17204
Dacarbazine 375 mg/m2 Day 1,15 DEPARTMENT.
Etoposide 65mg/m2 Day 1-3, 15-17 d) DISCHARGE SUMMARY
Every 28 days for 6 cycles OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) LDH. b) REPORTS OF THE
d) PET CECT or CECT TESTS (PATHOLOGY,
chest abdomen RADIOLOGY,
e) pelvis. MICROBIOLOGY,
f) Bone marrow studies. HEMATOLOGY,
ICE g) Biopsy BIOCHEMISTRY,ETC.)
Ifosfamide 1.5 mg/m2 D1-3 c) DISCHARGE SUMMARY
552 Medical Oncology MO Medical Oncology MO040 CT for Relapsed Hodgkin Lymphoma MO040A Carboplatin AUC5 D2 12180 13398 14616 15834 17052 17661 OF INPATIENT
Etoposide 100mg/m2 D1-3 DEPARTMENT.
Every 3 weeks d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) LDH. b) REPORTS OF THE
d) PET CECT or CECT TESTS (PATHOLOGY,
chest abdomen RADIOLOGY,
e) pelvis. MICROBIOLOGY,
f) Bone marrow studies. HEMATOLOGY,
MINE g) Biopsy BIOCHEMISTRY,ETC.)
Ifosfamide 4 gm/m2 over 3days (D1-3) c) DISCHARGE SUMMARY
553 Medical Oncology MO Medical Oncology MO040 CT for Relapsed Hodgkin Lymphoma MO040B Mitoxantrone 8mg/m2 12180 13398 14616 15834 17052 17661 OF INPATIENT
Etoposide 65mg/m2 D1-3 DEPARTMENT.
Every 3 weeks d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
PTCL - GDP BIOCHEMISTRY,ETC.)
Gemcitabine 1000mg/m2 D1 and D8 c) DISCHARGE SUMMARY
Dexamethasone 40mg D1-4 OF INPATIENT
554 Medical Oncology MO Medical Oncology MO040 CT for Relapsed Hodgkin Lymphoma MO040C 17115 18826 20538 22249 23961 24816
Cisplatin 75mg/m2 D1 or DEPARTMENT.
Cacrboplatin AUC-5 d) DISCHARGE SUMMARY
Every 3 weeks OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
DHAP BIOCHEMISTRY,ETC.)
Dexamethasone 40mg D1-4 c) DISCHARGE SUMMARY
Cisplatin 100mg/m2 or OF INPATIENT
555 Medical Oncology MO Medical Oncology MO041 CT for Relapsed NHL & HL MO041A 14490 15939 17388 18837 20286 21010
Carboplatin AUC-5D1 DEPARTMENT.
Cytarabine 2 gm/m2 BD D2 d) DISCHARGE SUMMARY
Repeat every 21 days OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Lenalidomide + Dexamethasone g) Skeletal survey. c) DISCHARGE SUMMARY
Lenalidomide 25 mg daily Day1-21 h) Urine BJP OF INPATIENT
556 Medical Oncology MO Medical Oncology MO042 CT for MM / Amyloidosis / POEMS MO042A 6090 6699 7308 7917 8526 8830
Dexamethasone 40mg Day 1, 8, 15, 22 DEPARTMENT.
Every 28days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Pomalidomide + Dexamethasone g) Skeletal survey. c) DISCHARGE SUMMARY
Pomalidomide 4 mg daily Day 1-21 h) Urine BJP OF INPATIENT
557 Medical Oncology MO Medical Oncology MO042 CT for MM / Amyloidosis / POEMS MO042B 8295 9124 9954 10783 11613 12027
Dexamethasone 40mg Day 1, 8, 15, 22 DEPARTMENT.
Every 28 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
Cyclophosphamide + Thalidomide + f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Dexamethasone g) Skeletal survey. c) DISCHARGE SUMMARY
Cyclophosphamide 100mg D1-D14 h) Urine BJP OF INPATIENT
558 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043A 4725 5197 5670 6142 6615 6851
Thalidomide 100-200 mg daily Day 1-28 DEPARTMENT.
Dexamethasone 40mg Day 1, 8, 15, 22 d) DISCHARGE SUMMARY
Every 28 days OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
Melphalan + Thalidomide + Prednisolone f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Melphalan 9mg/m2 D1-D4 g) Skeletal survey. c) DISCHARGE SUMMARY
559 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043B Thalidomide 100mg D1-28 4830 5313 5796 6279 6762 7003 h) Urine BJP OF INPATIENT
Prednisolone 100mg Day1-4 DEPARTMENT.
Every 28days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) BAR CODE OF THE OPEN
a) CBC. DRUGS.
b) Biochemistry. b) REPORTS OF THE
c) Serum protein TESTS (PATHOLOGY,
electrophoresis. RADIOLOGY,
d) Bone marrow studies. MICROBIOLOGY,
Bortezomib + Cyclophosphamide + e) skeletal survey. HEMATOLOGY,
Dexamethasone f) Urine BJP. BIOCHEMISTRY,ETC.)
Cyclophosphamide - 300 mg/m2 day 1, 8, 15, c) DISCHARGE SUMMARY
560 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043C 22 16905 18595 20286 21976 23667 24512 OF INPATIENT
Dexamethasone 40mg Day 1, 8, 15, 22 DEPARTMENT.
Bortezomib 1.3 mg/m2 Day1, 8, 15, 22 d) DISCHARGE SUMMARY
Every 28 days OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Bortezomib + Dexamethasone g) Skeletal survey. c) DISCHARGE SUMMARY
Bortezomib 1.3 mg/m2 Day1, 8, 15, 22 h) Urine BJP OF INPATIENT
561 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043D 15435 16978 18522 20065 21609 22380
Dexamethasone 40mg Day1, 8, 15, 22 DEPARTMENT.
Every 28 day d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
Bortezomib + Melphalan + Prednsiolone f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Melphalan 9mg/m2 D1-D4 g) Skeletal survey. c) DISCHARGE SUMMARY
562 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043E Prednisolone 100mg Day 1-4 14595 16054 17514 18973 20433 21162 h) Urine BJP OF INPATIENT
Bortezomib 1.3 mg/m2 Day 1, 8, 15, 22 DEPARTMENT.
Every 28 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
Bortezomib + Lenalidomide + Dexamethasone f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Lenalidomide 25 mg daily Day 1 - 21 g) Skeletal survey. c) DISCHARGE SUMMARY
563 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043F Dexamethasone 40mg Day 1, 8, 15, 22 20580 22638 24696 26754 28812 29841 h) Urine BJP OF INPATIENT
Bortezomib 1.3 mg/m2 Day 1, 8, 15, 22 DEPARTMENT.
Every 28 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) Serum protein b) REPORTS OF THE
electrophoresis. TESTS (PATHOLOGY,
d) Immunofixation. RADIOLOGY,
e) Serum free light chain MICROBIOLOGY,
assay. HEMATOLOGY,
Bortezomib + Thalidomide + Dexamethasone f) Bone marrow studies. BIOCHEMISTRY,ETC.)
Thalidomide 100 mg daily Day 1 - 28 g) Skeletal survey. c) DISCHARGE SUMMARY
564 Medical Oncology MO Medical Oncology MO043 CT for MM / Amyloidosis MO043G Dexamethasone 40 mg Day 1, 8, 15, 22 17325 19057 20790 22522 24255 25121 h) Urine BJP OF INPATIENT
Bortezomib 1.3 mg/m2 Day 1, 8, 15, 22 DEPARTMENT.
Every 28 days d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) MDC. TESTS (PATHOLOGY,
e) BONE MARROW. RADIOLOGY,
f) BIOPSY. MICROBIOLOGY,
g) CYTOGENETICS. HEMATOLOGY,
h) RQ PCR BCR ABL BIOCHEMISTRY,ETC.)
Imatinib c) DISCHARGE SUMMARY
565 Medical Oncology MO Medical Oncology MO044 CT for Chronic Myeloid Leukemia MO044A Imatinib 400 mg, 600 mg, 800 mg 19400 21340 23280 25220 27160 28130 OF INPATIENT
(per month X 5 years) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

566 Medical Oncology MO Medical Oncology MO044 CT for Chronic Myeloid Leukemia MO044B Dasatinib 100 mg once a day 5775 6352 6930 7507 8085 8373 0 0 OPEN
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) MDC. TESTS (PATHOLOGY,
e) BONE MARROW . RADIOLOGY,
f) CYTOGENETICS MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Hydroxurea c) DISCHARGE SUMMARY
567 Medical Oncology MO Medical Oncology MO045 CT for Myeloproliferative Neoplasm MO045A Hydroxurea daily 2625 2887 3150 3412 3675 3806 OF INPATIENT
(Dose will be based on blood counts) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN YES

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Bone marrow aspiration. RADIOLOGY,
f) flow cytometry or MICROBIOLOGY,
Peripheral blood flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) cytogenetics. c) DISCHARGE SUMMARY
Cytarabine 2 gm / M2 BD for 3 days h) Molecular OF INPATIENT
568 Medical Oncology MO Medical Oncology MO046 CT for Acute Myeloid Leukemia MO046A 82320 90552 98784 107016 115248 119364
Every 21 days for 3 cycles DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN YES
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Bone marrow aspiration. RADIOLOGY,
f) flow cytometry or MICROBIOLOGY,
Peripheral blood flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
Cytarabine 100 mg / M2 7 days g) cytogenetics. c) DISCHARGE SUMMARY
Daunomycin 60 mg / M2 3 days ( this does not h) Molecular OF INPATIENT
569 Medical Oncology MO Medical Oncology MO046 CT for Acute Myeloid Leukemia MO046B 122010 134211 146412 158613 170814 176914
include antibiotics, antifungals, blood and DEPARTMENT.
platelets transfusion) d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC BIOCHEM. a) BAR CODE OF THE OPEN YES

DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
BFM-90 HEMATOLOGY,
BFM-95 BIOCHEMISTRY,ETC.)
BFM-2000 c) DISCHARGE SUMMARY
570 Medical Oncology MO Medical Oncology MO047 CT for Acute Lymphoblastic Leukemia MO047A HyperCVAD 184800 203280 221760 240240 258720 267960 OF INPATIENT
UKALL DEPARTMENT.
GMALL ( this does not include antibiotics, d) DISCHARGE SUMMARY
antifungals, blood and platelets transfusion) OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN YES

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) 2D ECHO. MICROBIOLOGY,
g) NCCT CHEST. HEMATOLOGY,
BFM-90 h) BONE MARROW or BIOCHEMISTRY,ETC.)
BFM-95 Peripheral bloodFLOW c) DISCHARGE SUMMARY
BFM-2000 CYTOMETRY. OF INPATIENT
571 Medical Oncology MO Medical Oncology MO047 CT for Acute Lymphoblastic Leukemia MO047B 143010 157311 171612 185913 200214 207364
HyperCVAD i) CYTOGENETICS. DEPARTMENT.
UKALL j) Molecular. d) DISCHARGE SUMMARY
GMALL k) BIOPSY. OF DAY CARE
l) PET-CT or CECT chest DEPARTMENT.
abdomen e) CHARTS OF
m) Pelvis(if LBL) CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) BIOCHEM. MICROBIOLOGY,
g) CSF HEMATOLOGY,
CYTOMORPHOLOGY. BIOCHEMISTRY,ETC.)
h) FLOW CYTOMETRY. c) DISCHARGE SUMMARY
6 Mercaptopurine 50 mg / M2 daily i) BONE MARROW FLOW OF INPATIENT
572 Medical Oncology MO Medical Oncology MO047 CT for Acute Lymphoblastic Leukemia MO047C 4620 5082 5544 6006 6468 6699
Methotrexate 25 mg / M2 Weekly for 2 years CYTOMETRY. DEPARTMENT.
j) CYTOGENETICS. d) DISCHARGE SUMMARY
k) NGS. OF DAY CARE
l) BIOPSY DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC BIOCHEM. a) BAR CODE OF THE OPEN YES
DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BFM-90 BIOCHEMISTRY,ETC.)
BFM-95 c) DISCHARGE SUMMARY
BFM-2000 OF INPATIENT
573 Medical Oncology MO Medical Oncology MO048 CT for Lymphoblastic Lymphoma MO048A 184800 203280 221760 240240 258720 267960
HyperCVAD DEPARTMENT.
UKALL d) DISCHARGE SUMMARY
GMALL OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN YES

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) 2D ECHO. MICROBIOLOGY,
g) NCCT CHEST. HEMATOLOGY,
BFM-90 h) BONE MARROW or BIOCHEMISTRY,ETC.)
BFM-95 Peripheral bloodFLOW c) DISCHARGE SUMMARY
BFM-2000 CYTOMETRY. OF INPATIENT
574 Medical Oncology MO Medical Oncology MO048 CT for Lymphoblastic Lymphoma MO048B 143010 157311 171612 185913 200214 207364
HyperCVAD i) CYTOGENETICS. DEPARTMENT.
UKALL j) Molecular. d) DISCHARGE SUMMARY
GMALL k) BIOPSY. OF DAY CARE
l) PET-CT or CECT chest DEPARTMENT.
abdomen e) CHARTS OF
m) Pelvis(if LBL) CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) BIOCHEM. MICROBIOLOGY,
g) CSF HEMATOLOGY,
CYTOMORPHOLOGY. BIOCHEMISTRY,ETC.)
h) FLOW CYTOMETRY. c) DISCHARGE SUMMARY
6 Mercaptopurine 50 mg/M2 daily and i) BONE MARROW FLOW OF INPATIENT
575 Medical Oncology MO Medical Oncology MO048 CT for Lymphoblastic Lymphoma MO048C 4620 5082 5544 6006 6468 6699
Methotrexate 25 mg/M2 Weekly for 2 Years CYTOMETRY. DEPARTMENT.
j) CYTOGENETICS. d) DISCHARGE SUMMARY
k) NGS. OF DAY CARE
l) BIOPSY DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC BIOCHEM a) BAR CODE OF THE OPEN YES

b) ECG BONEMARROW DRUGS.
c) RQPCR PML RARA b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Arsenic trioxide c) DISCHARGE SUMMARY
CT for Acute Promyelocytic Leukemia ATRA OF INPATIENT
576 Medical Oncology MO Medical Oncology MO049 MO049A 83160 91476 99792 108108 116424 120582
(High Risk) Daunomycin or Idarubcin DEPARTMENT.
Cytarabine - multiagent - vary in each protocol d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN YES
b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) BIOCHEM. MICROBIOLOGY,
g) PT. HEMATOLOGY,
h) APTT. BIOCHEMISTRY,ETC.)
Arsenic trioxide i) FIBRINOGEN. c) DISCHARGE SUMMARY
CT for Acute Promyelocytic Leukemia ATRA j) 2D ECHO. OF INPATIENT
577 Medical Oncology MO Medical Oncology MO049 MO049B 111825 123007 134190 145372 156555 162146
(High Risk) Daunomycin or Idarubcin k) NCCT CHEST. DEPARTMENT.
Cytarabine - multiagent - vary on protocol l) BONE MARROW FLOW d) DISCHARGE SUMMARY
CYTOMETRY. OF DAY CARE
m) CYTOGENETICS. DEPARTMENT.
n) RQPCR PML RARA. e) CHARTS OF
o) BIOPSY CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) BIOCHEM. MICROBIOLOGY,
g) PT. HEMATOLOGY,
h) APTT. BIOCHEMISTRY,ETC.)
6 MP 50 mg / day daily i) FIBRINOGEN. c) DISCHARGE SUMMARY
CT for Acute Promyelocytic Leukemia Methotrexate 15 mg Weekly j) 2D ECHO. OF INPATIENT
578 Medical Oncology MO Medical Oncology MO049 MO049C 9240 10164 11088 12012 12936 13398
(High Risk) ATRA 45 mg / M2 for 14 days k) NCCT CHEST. DEPARTMENT.
Every three months for 18 Months l) BONE MARROW FLOW d) DISCHARGE SUMMARY
CYTOMETRY. OF DAY CARE
m) CYTOGENETICS. DEPARTMENT.
n) RQPCR PML RARA. e) CHARTS OF
o) BIOPSY CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a)CBC LFT a) BAR CODE OF THE OPEN YES

DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
ATO 0.15 mg / kg day 1-Day 5, day 8-12, day c) DISCHARGE SUMMARY
CT for Acute Promyelocytic Leukemia 15-19, day 22-26 every 56 days for 4 cycles OF INPATIENT
579 Medical Oncology MO Medical Oncology MO050 MO050A 63525 69877 76230 82582 88935 92111
(Low Risk) ATRA 45 mg / M2 day 1-Day 14 and Day 29-43 DEPARTMENT.
every 56 days for 4 cycles d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC BIOCHEM. a) BAR CODE OF THE OPEN YES

DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
CT for Acute Promyelocytic Leukemia ATO 0.15 mg / kg day 1-45 or 60 OF INPATIENT
580 Medical Oncology MO Medical Oncology MO050 MO050B 93555 102910 112266 121621 130977 135654
(Low Risk) ATRA 45 mg / M2 - day 1-45 or 60 DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) BIOCHEM. DRUGS.
c) ECG. b) REPORTS OF THE
d) BONE MARROW. TESTS (PATHOLOGY,
Cefoperazone + Sulbactum e) RQ PCR. RADIOLOGY,
Piperalicillin + Tazobactum f) PML RARA MICROBIOLOGY,
Cefoperazone HEMATOLOGY,
Piperacillin BIOCHEMISTRY,ETC.)
Amikacin c) DISCHARGE SUMMARY
581 Medical Oncology MO Medical Oncology MO051 Febrile Neutopenia MO051A Gentamicin 38430 42273 46116 49959 53802 55723 OF INPATIENT
Cefipime DEPARTMENT.
Levofloxacin d) DISCHARGE SUMMARY
Amoxycillin and clavulanate OF DAY CARE
Teicoplanin DEPARTMENT.
Vancomycin e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN YES

b) LFT. DRUGS.
c) RQ b) REPORTS OF THE
d) PCR. TESTS (PATHOLOGY,
e) PML RARA RADIOLOGY,
MICROBIOLOGY,
Meropenem HEMATOLOGY,
Imipenem BIOCHEMISTRY,ETC.)
Colistin c) DISCHARGE SUMMARY
Tigecyclin OF INPATIENT
582 Medical Oncology MO Medical Oncology MO051 Febrile Neutopenia MO051B 91035 100138 109242 118345 127449 132000
Linezolid DEPARTMENT.
Voriconazole d) DISCHARGE SUMMARY
Caspfungin OF DAY CARE
Amphotericin - B DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) Serum Electrolytes b) REPORTS OF THE
d) Blood Phosphate levels. TESTS (PATHOLOGY,
e) Uric Acid. RADIOLOGY,
f) BUN MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
Rasburicase c) DISCHARGE SUMMARY
Chemotherapy Complications - Tumor Febuxostat OF INPATIENT
583 Medical Oncology MO Medical Oncology MO052 MO052A 27720 30492 33264 36036 38808 40194
Lysis Syndrome Allopurinol DEPARTMENT.
Sevelamer d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Bone marrow. DRUGS.
c) RFT. b) REPORTS OF THE
d) LFT TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
5 microgram / kg / day c) DISCHARGE SUMMARY
(max 300 microgram per day) for 7 days or OF INPATIENT
584 Medical Oncology MO Medical Oncology MO053 Granulocyte Colony Stimulating Factor Use MO053A 5250 5775 6300 6825 7350 7612
PEG - GCSF 6mg one single dose per DEPARTMENT.
chemotherapy cycle d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) MDC. TESTS (PATHOLOGY,
e) BONE MARROW. RADIOLOGY,
f) BIOPSY. MICROBIOLOGY,
g) SKELETAL SURVEY HEMATOLOGY,
h) PET CECT BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Langerhans Cell Histiocytosis OF INPATIENT
585 Medical Oncology MO Medical Oncology MO054 CT for Langerhans Cell Histiocytosis MO054A 29295 32224 35154 38083 41013 42477
(Histiocytosis Protocol - Induction) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) RFT. DRUGS.
c) LFT. b) REPORTS OF THE
d) MDC. TESTS (PATHOLOGY,
e) BONE MARROW. RADIOLOGY,
f) SKELETAL SURVEY MICROBIOLOGY,
g) PET CECT HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Langerhans Cell Histiocytosis OF INPATIENT
586 Medical Oncology MO Medical Oncology MO054 CT for Langerhans Cell Histiocytosis MO054B 33390 36729 40068 43407 46746 48415
(Histiocytosis Protocol - Maintenance) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) MRI. b) REPORTS OF THE
d) Biopsy TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
Vincristine + Carboplatin BIOCHEMISTRY,ETC.)
Vincristine 1.5mg/m2 (day 1, 8 and 15 for first 4 c) DISCHARGE SUMMARY
587 Medical Oncology MO Medical Oncology MO055 CT for Low Grade Glioma MO055A cycles and then only day 1 from cycle 5 to 17) 6825 7507 8190 8872 9555 9896 OF INPATIENT
Carboplatin 550mg/m2 every 3 weeks (all DEPARTMENT.
cycles) d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) MRI. b) REPORTS OF THE
d) Biopsy TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Vinblastin OF INPATIENT
588 Medical Oncology MO Medical Oncology MO055 CT for Low Grade Glioma MO055B 3885 4273 4662 5050 5439 5633
Vinblastine 6 mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) MRI (BRAIN AND b) REPORTS OF THE
SPINE). TESTS (PATHOLOGY,
d) Biopsy. RADIOLOGY,
e) CSF CYTOLOGY. MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
589 Medical Oncology MO Medical Oncology MO056 CT for Medulloblastoma / Brain PNET MO056A PACKER 7350 8085 8820 9555 10290 10657 OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) MRI (BRAIN AND b) REPORTS OF THE
SPINE). TESTS (PATHOLOGY,
d) Biopsy. RADIOLOGY,
e) CSF CYTOLOGY. MICROBIOLOGY,
HEMATOLOGY,
Cisplatin + Cyclophosphamide + Vincristine BIOCHEMISTRY,ETC.)
Cyclophosphamide 1000mg/m2 (2 days every c) DISCHARGE SUMMARY
cycles) OF INPATIENT
590 Medical Oncology MO Medical Oncology MO056 CT for Medulloblastoma / CNS PNET MO056B 9660 10626 11592 12558 13524 14007
Vincristine 1.5mg/m2 (days 1 and 8) DEPARTMENT.
Cisplatin 100mg/m2 (1 day per cycle) d) DISCHARGE SUMMARY
Cycles given every 3 weekly OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) CECT b) REPORTS OF THE
d) MRI. TESTS (PATHOLOGY,
e) BONE MARROW RADIOLOGY,
STUDIES. MICROBIOLOGY,
f) MIBG OR BONE OR HEMATOLOGY,
Cabroplatin + Etoposide + Cyclophosphamide + PET CT SCAN. BIOCHEMISTRY,ETC.)
Doxorubicin g) BIOPSY. c) DISCHARGE SUMMARY
Carboplatin 600mg/m2 h) FISH OF INPATIENT
591 Medical Oncology MO Medical Oncology MO057 CT for Neuroblastoma MO057A 9975 10972 11970 12967 13965 14463
Etoposide 100mg/m2 (days 1-5) DEPARTMENT.
Cyclophosphamide d) DISCHARGE SUMMARY
Doxorubicin OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) CECT b) REPORTS OF THE
d) MRI. TESTS (PATHOLOGY,
e) BONE MARROW RADIOLOGY,
STUDIES. MICROBIOLOGY,
f) MIBG OR BONE OR HEMATOLOGY,
PET CT SCAN. BIOCHEMISTRY,ETC.)
g) BIOPSY. c) DISCHARGE SUMMARY
Carboplatin + Cisplatin + Cyclophosphamide + h) FISH OF INPATIENT
592 Medical Oncology MO Medical Oncology MO057 CT for Neuroblastoma MO057B 8820 9702 10584 11466 12348 12789
Vincristine + Etoposide DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
13-cis retinoic acid 160mg/m2 per day for 2 c) DISCHARGE SUMMARY
593 Medical Oncology MO Medical Oncology MO057 CT for Neuroblastoma MO057C weeks 2415 2656 2898 3139 3381 3501 OF INPATIENT
Each cycle given 4 weekly DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) MRI (BRAIN AND b) REPORTS OF THE
ORBITS). TESTS (PATHOLOGY,
d) CT (BRAIN AND RADIOLOGY,
ORBITS). MICROBIOLOGY,
e) ULTRASONOGRAPHY. HEMATOLOGY,
f) BONE MARROW BIOCHEMISTRY,ETC.)
Vincristine + Carboplatin + Etoposide g) CSF STUDIES c) DISCHARGE SUMMARY
Carboplatin 600mg/m2 day 1 OF INPATIENT
594 Medical Oncology MO Medical Oncology MO058 CT for Retinoblastoma MO058A 8610 9471 10332 11193 12054 12484
Etoposide 150mg/m2 days 1-3 DEPARTMENT.
Vincristine1.5mg/m2 day 1 d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) MRI OR CECT. b) REPORTS OF THE
d) BONE MARROW TESTS (PATHOLOGY,
STUDIES. RADIOLOGY,
e) BONE SCAN OR PET MICROBIOLOGY,
CT. HEMATOLOGY,
Vincristine + Cyclophosphamide + f) Biopsy BIOCHEMISTRY,ETC.)
Dactinomycin c) DISCHARGE SUMMARY
Vincristine 1.5mg/m2 (day 1, 8 and 15) OF INPATIENT
595 Medical Oncology MO Medical Oncology MO059 CT for Rhabdomyosarcoma MO059A 6615 7276 7938 8599 9261 9591
Cyclophosphamie 1200 - 2200 mg/m2 (day 1) DEPARTMENT.
Dactinomycin 1.5mg / m2 (day 1) d) DISCHARGE SUMMARY
3 weekly cycle OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) MRI OR CECT. b) REPORTS OF THE
d) BONE MARROW TESTS (PATHOLOGY,
STUDIES. RADIOLOGY,
e) BONE SCAN OR PET MICROBIOLOGY,
CT. HEMATOLOGY,
Vincristine + Ifosfamide + Etoposide f) Biopsy BIOCHEMISTRY,ETC.)
Vincristine 1.5mg/m2 (days 1, 8 and 15) c) DISCHARGE SUMMARY
596 Medical Oncology MO Medical Oncology MO059 CT for Rhabdomyosarcoma MO059B Ifosfamide 1.8gm/m2 (days 1-5) 18795 20674 22554 24433 26313 27252 OF INPATIENT
Etoposide 100mg/m2 (days 1-5) DEPARTMENT.
Each cycle every 3 weeks d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) MRI OR CECT. b) REPORTS OF THE
d) BONE MARROW TESTS (PATHOLOGY,
Vincristine + Topotecan + Cyclophosphamide STUDIES. RADIOLOGY,
and e) BONE SCAN OR PET MICROBIOLOGY,
Vincristine + Adriamycin + Cyclophosphamide CT. HEMATOLOGY,
Vincristine 1.5mg/m2 (day 1) f) Biopsy. BIOCHEMISTRY,ETC.)
Topotecan 1.5mg/m2 (day 1-5) g) 2D ECHO c) DISCHARGE SUMMARY
597 Medical Oncology MO Medical Oncology MO060 CT for Relapse Rhabdomyosarcoma MO060A Cyclophosphamide 250mg/m2 (days 1-5) 14385 15823 17262 18700 20139 20858 OF INPATIENT
3 - weekly DEPARTMENT.
Vincristine 1.5mg/m2 d) DISCHARGE SUMMARY
Adriamyicn 60mg/m2 OF DAY CARE
Cyclophosphamide 600mg/m2 (all Day 1) DEPARTMENT.
Every 3 weeks. Cycles given in couplets e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) CT CHEST ABDOMEN. b) REPORTS OF THE
d) ULTRASONOGRAPHY. TESTS (PATHOLOGY,
e) BIOPSY RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
Vincristine + Actinomycin D BIOCHEMISTRY,ETC.)
Vincristine 1.5 mg/m2 weekly for 12 weeks and c) DISCHARGE SUMMARY
598 Medical Oncology MO Medical Oncology MO061 CT for Wilms Tumor MO061A then 3 weekly 4410 4851 5292 5733 6174 6394 OF INPATIENT
Actinomycin D 45 microgram / kg 3 weekly for DEPARTMENT.
24 weeks d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) CT CHEST ABDOMEN. b) REPORTS OF THE
d) ULTRASONOGRAPHY. TESTS (PATHOLOGY,
e) BIOPSY. RADIOLOGY,
f) 2D ECHO MICROBIOLOGY,
HEMATOLOGY,
Vincristine + Actinomycin D + Doxorubicin BIOCHEMISTRY,ETC.)
Vincristine 1.5 mg/m2 weekly for 12 weeks and c) DISCHARGE SUMMARY
599 Medical Oncology MO Medical Oncology MO061 CT for Wilms Tumor MO061B then 3 weekly 5775 6352 6930 7507 8085 8373 OF INPATIENT
Actinomycin D 45 microgram/kg 3 weekly DEPARTMENT.
Doxorubicin 60mg/m2 for 24 weeks d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) CT CHEST ABDOMEN. b) REPORTS OF THE
d) ULTRASONOGRAPHY. TESTS (PATHOLOGY,
e) BIOPSY. RADIOLOGY,
f) 2D ECHO MICROBIOLOGY,
Cyclophosphamide + Doxorubicin + Etoposide + HEMATOLOGY,
Vincristine + Dactinomycin BIOCHEMISTRY,ETC.)
Vincristine 1.5 mg/m2 c) DISCHARGE SUMMARY
Dactinomycin 45 microgram/kg OF INPATIENT
600 Medical Oncology MO Medical Oncology MO061 CT for Wilms Tumor MO061C 17640 19404 21168 22932 24696 25578
Adriamyicn 60mg/m2 DEPARTMENT.
Cyclophosphamide d) DISCHARGE SUMMARY
Etoposide OF DAY CARE
Weekly chemotherapy - varying hybrid regimen DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC BIOCHEM. a) BAR CODE OF THE OPEN YES
DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
CT for Pediatric Acute Lymphoblastic Consolidation OF INPATIENT
601 Medical Oncology MO Medical Oncology MO062 MO062A 276885 304573 332262 359950 387639 401483
Leukemia (Phase II, CNS Therapy Reinduction) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN YES

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) 2D ECHO. MICROBIOLOGY,
g) NCCT CHEST. HEMATOLOGY,
h) BONE MARROW or BIOCHEMISTRY,ETC.)
ICICLE Peripheral bloodFLOW c) DISCHARGE SUMMARY
CT for Pediatric Acute Lymphoblastic BFM CYTOMETRY. OF INPATIENT
602 Medical Oncology MO Medical Oncology MO062 MO062B 100485 110533 120582 130630 140679 145703
Leukemia KLALL i) CYTOGENETICS. DEPARTMENT.
MCP:841 j) Molecular. d) DISCHARGE SUMMARY
k) BIOPSY. OF DAY CARE
l) PET-CT or CECT chest DEPARTMENT.
abdomen e) CHARTS OF
m) Pelvis(if LBL) CHEMOTHERAPY
REGIMEN.

a) CBC. BAR CODE OF THE OPEN

b) MDC. DRUGS, REPORTS OF
c) HIV. THE TESTS
d) HBSAG. (PATHOLOGY,
e) HCV. RADIOLOGY,
f) BIOCHEM. MICROBIOLOGY,
6 - Mercaptopurine 75mg/m2 daily g) CSF HEMATOLOGY,
CT for Pediatric Acute Lymphoblastic Methotrexate 20mg/m2 weekly CYTOMORPHOLOGY. BIOCHEMISTRY,ETC.)
603 Medical Oncology MO Medical Oncology MO062 MO062C 3150 3465 3780 4095 4410 4567 h) FLOW CYTOMETRY. DISCHARGE SUMMARY
Leukemia Vincristine 1.5mg/m2 monthly
Intrathecal methotrexate 12 mg 3 monthly i) BONE MARROW FLOW OF INPATIENT
CYTOMETRY. DEPARTMENT,
j) CYTOGENETICS. DISCHARGE SUMMARY
k) NGS. OF DAY CARE
l) BIOPSY DEPARTMENT, CHARTS
OF CHEMOTHERAPY
REGIMEN

CT for Ph+ve Pediatric Acute 0 0 OPEN

Dasatinib + chemo (to be used only with ALL
604 Medical Oncology MO Medical Oncology MO062 Lymphoblastic Leukemia for adult and MO062D 5775 6352 6930 7507 8085 8373
therapy)
paediatric
CT for Ph+ve Pediatric Acute 0 0 OPEN
Imatinib + chemo ((to be used only with ALL
605 Medical Oncology MO Medical Oncology MO062 Lymphoblastic Leukemia for adult and MO062E 5775 6352 6930 7507 8085 8373
therapy)
paediatric
a) CBC BIOCHEM. a) BAR CODE OF THE OPEN YES
DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Consolidation OF INPATIENT
606 Medical Oncology MO Medical Oncology MO063 CT for Pediatric Lymphoblastic Lymphoma MO063A 276885 304573 332262 359950 387639 401483
(Phase II, CNS Therapy Reinduction) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) BAR CODE OF THE OPEN YES
a) CBC. DRUGS.
b) MDC. b) REPORTS OF THE
c) HIV. TESTS (PATHOLOGY,
d) HBSAG RADIOLOGY,
e) HCV. MICROBIOLOGY,
f) 2D ECHO. HEMATOLOGY,
g) NCCT CHEST. BIOCHEMISTRY,ETC.)
ICICLE h) BONE MARROW or c) DISCHARGE SUMMARY
BFM Peripheral bloodFLOW OF INPATIENT
607 Medical Oncology MO Medical Oncology MO063 CT for Pediatric Lymphoblastic Lymphoma MO063B 100485 110533 120582 130630 140679 145703
KLALL CYTOMETRY. DEPARTMENT.
MCP:841 i) CYTOGENETICS. d) DISCHARGE SUMMARY
j) Molecular. OF DAY CARE
k) BIOPSY. DEPARTMENT.
l) PET-CT or CECT chest e) CHARTS OF
abdomen CHEMOTHERAPY
m) Pelvis(if LBL) REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) BIOCHEM. MICROBIOLOGY,
g) CSF HEMATOLOGY,
CYTOMORPHOLOGY. BIOCHEMISTRY,ETC.)
6 - Mercaptopurine 75mg/m2 daily h) FLOW CYTOMETRY. c) DISCHARGE SUMMARY
Methotrexate 20mg/m2 weekly i) BONE MARROW FLOW OF INPATIENT
608 Medical Oncology MO Medical Oncology MO063 CT for Pediatric Lymphoblastic Lymphoma MO063C 3150 3465 3780 4095 4410 4567
Vincristine 1.5mg/m2 monthly CYTOMETRY. DEPARTMENT.
Intrathecal methotrexate 12 mg 3 monthly j) CYTOGENETICS. d) DISCHARGE SUMMARY
k) NGS. OF DAY CARE
l) BIOPSY DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN YES

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Bone marrow aspiration. RADIOLOGY,
f) flow cytometry or MICROBIOLOGY,
Peripheral blood flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) cytogenetics. c) DISCHARGE SUMMARY
Cytrabine 3 gram/m2 twice a day h) Molecular OF INPATIENT
609 Medical Oncology MO Medical Oncology MO064 CT for Pediatric Acute Myeloid Leukemia MO064A 66570 73227 79884 86541 93198 96526
Days 1, 3 and 5 DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN YES

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Bone marrow aspiration. RADIOLOGY,
f) flow cytometry or MICROBIOLOGY,
Peripheral blood flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
Cytrabine 200mg/m2/day days 1-10 and g) cytogenetics. c) DISCHARGE SUMMARY
610 Medical Oncology MO Medical Oncology MO064 CT for Pediatric Acute Myeloid Leukemia MO064B Daunorubicin 50mg/m2 days 1, 3 and 5 121590 133749 145908 158067 170226 176305 h) Molecular OF INPATIENT
Etposide 100mg/m2 days 1-5 DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN YES
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) Bone marrow aspiration. RADIOLOGY,
f) flow cytometry or MICROBIOLOGY,
Peripheral blood flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) cytogenetics. c) DISCHARGE SUMMARY
Cytrabine 100-200mg/m2/day days 1-7 and h) Molecular OF INPATIENT
611 Medical Oncology MO Medical Oncology MO064 CT for Pediatric Acute Myeloid Leukemia MO064C 121170 133287 145404 157521 169638 175696
Daunorubicin 50mg/m2 days 1, 3 and 5 DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC BIOCHEM a) BAR CODE OF THE OPEN YES

b) ECG BONEMARROW DRUGS.
c) RQPCR PML RARA b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
CT for Pediatric Acute Promyelocytic OF INPATIENT
612 Medical Oncology MO Medical Oncology MO065 MO065A Consolidation 67935 74728 81522 88315 95109 98505
Leukemia DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC BIOCHEM. a) BAR CODE OF THE OPEN YES

DRUGS.
b) REPORTS OF THE
TESTS (PATHOLOGY,
RADIOLOGY,
MICROBIOLOGY,
HEMATOLOGY,
BIOCHEMISTRY,ETC.)
CT for Pediatric Acute Promyelocytic c) DISCHARGE SUMMARY
613 Medical Oncology MO Medical Oncology MO065 MO065B Induction 149520 164472 179424 194376 209328 216804 OF INPATIENT
Leukemia
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN YES

b) MDC. DRUGS.
c) HIV. b) REPORTS OF THE
d) HBSAG. TESTS (PATHOLOGY,
e) HCV. RADIOLOGY,
f) BIOCHEM. MICROBIOLOGY,
g) PT. HEMATOLOGY,
h) APTT. BIOCHEMISTRY,ETC.)
i) FIBRINOGEN. c) DISCHARGE SUMMARY
CT for Pediatric Acute Promyelocytic j) 2D ECHO. OF INPATIENT
614 Medical Oncology MO Medical Oncology MO065 MO065C Maintenance (18 months total cost) 45465 50011 54558 59104 63651 65924
Leukemia k) NCCT CHEST. DEPARTMENT.
l) BONE MARROW FLOW d) DISCHARGE SUMMARY
CYTOMETRY. OF DAY CARE
m) CYTOGENETICS. DEPARTMENT.
n) RQPCR PML RARA. e) CHARTS OF
o) BIOPSY CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
615 Medical Oncology MO Medical Oncology MO066 CT for Pediatric Hodgkins Lymphoma MO066A COPDAC 10920 12012 13104 14196 15288 15834 OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
616 Medical Oncology MO Medical Oncology MO066 CT for Pediatric Hodgkins Lymphoma MO066B OPEA 15015 16516 18018 19519 21021 21771 OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
BIOCHEMISTRY,ETC.)
CT for Pediatric Hodgkins Lymphoma c) DISCHARGE SUMMARY
617 Medical Oncology MO Medical Oncology MO067 MO067A ICE 21500 23650 25800 27950 30100 31175 OF INPATIENT
Relapse
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
CT for Pediatric Hodgkins Lymphoma OF INPATIENT
618 Medical Oncology MO Medical Oncology MO067 MO067B DECA 17800 19580 21360 23140 24920 25810
Relapse DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) node Biopsy. HEMATOLOGY,
BIOCHEMISTRY,ETC.)
CT for Pediatric Hodgkins Lymphoma c) DISCHARGE SUMMARY
619 Medical Oncology MO Medical Oncology MO067 MO067C IGVD 39270 43197 47124 51051 54978 56941 OF INPATIENT
Relapse
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN YES

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) ECG. c) DISCHARGE SUMMARY
620 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068A LMB 89 - 96 - Consolidation (second month) 49245 54169 59094 64018 68943 71405 h) 2D-ECHO OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN YES
b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) ECG. c) DISCHARGE SUMMARY
LMB 89 - 96 - Induction - COPADAM ( first h) 2D-ECHO OF INPATIENT
621 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068B 49035 53938 58842 63745 68649 71100
month) DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN YES

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) ECG. c) DISCHARGE SUMMARY
622 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068C LMB 89 - 96 - Maintenance 76020 83622 91224 98826 106428 110229 h) 2D-ECHO OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN YES

b) Biochemistry. DRUGS.
c) PET CT or CECT Chest b) REPORTS OF THE
abdomen TESTS (PATHOLOGY,
d) pelvis. RADIOLOGY,
e) Bone marrow studies. MICROBIOLOGY,
f) Biopsy or fluid flow HEMATOLOGY,
cytometry. BIOCHEMISTRY,ETC.)
g) ECG. c) DISCHARGE SUMMARY
623 Medical Oncology MO Medical Oncology MO068 CT for Pediatric Non Hodgkins Lymphoma MO068D MCP - 842 114030 125433 136836 148239 159642 165343 h) 2D-ECHO OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) TUMOR MARKERS. b) REPORTS OF THE
d) CECT CHEST TESTS (PATHOLOGY,
e) ABDOMEN. RADIOLOGY,
f) Biopsy. MICROBIOLOGY,
g) AUDIOMETRY. HEMATOLOGY,
h) GFR BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
624 Medical Oncology MO Medical Oncology MO069 PEDIATRIC-GCT/JEB MO069A Pediatric - Germ Cell Tumor / JEB 12390 13629 14868 16107 17346 17965 OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) Biochemistry. DRUGS.
c) CECT CHEST b) REPORTS OF THE
d) ABDOMEN. TESTS (PATHOLOGY,
e) Biopsy. RADIOLOGY,
f) ECG. MICROBIOLOGY,
g) 2D-ECHO. HEMATOLOGY,
h) AUDIOMETRY. BIOCHEMISTRY,ETC.)
i) GFR c) DISCHARGE SUMMARY
625 Medical Oncology MO Medical Oncology MO070 CT for Pediatric Hepatoblastoma MO070A Carboplatin + Cisplatin + Doxorubicin 6510 7161 7812 8463 9114 9439 OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) Biochemistry. DRUGS.
c) S.AFP. b) REPORTS OF THE
d) CECT CHEST TESTS (PATHOLOGY,
e) ABDOMEN. RADIOLOGY,
f) Biopsy. MICROBIOLOGY,
g) AUDIOMETRY. HEMATOLOGY,
h) GFR BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
626 Medical Oncology MO Medical Oncology MO070 CT for Pediatric Hepatoblastoma MO070B Cisplatin 6510 7161 7812 8463 9114 9439 OF INPATIENT
DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis HEMATOLOGY,
BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Docetaxel OF INPATIENT
627 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071A 9870 10857 11844 12831 13818 14311
Docetaxel 75 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) EGFR mutation positive BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Erlotinib OF INPATIENT
628 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071B 5250 5775 6300 6825 7350 7612
Erlotinib 150 mg once daily DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) Abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) EGFR mutation positive BIOCHEMISTRY,ETC.)
c) DISCHARGE SUMMARY
Gefitnib OF INPATIENT
629 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071C 2940 3234 3528 3822 4116 4263
Gefitinib 250 mg once daily DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology (non BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin small cell carcinoma) c) DISCHARGE SUMMARY
630 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071D Paclitaxel 175mg/m2 D1 16800 18480 20160 21840 23520 24360 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) BAR CODE OF THE OPEN

DRUGS.
a) CBC. b) REPORTS OF THE
b) LFT. TESTS (PATHOLOGY,
c) RFT. RADIOLOGY,
d) RBS. MICROBIOLOGY,
e) CECT Thorax. HEMATOLOGY,
f) abdomen BIOCHEMISTRY,ETC.)
Pemetrexed + Carboplatin g) Pelvis. c) DISCHARGE SUMMARY
631 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071E Pemetrexed 500mg/m2 D1 11760 12936 14112 15288 16464 17052 h) histopathology (non OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days small cell – DEPARTMENT.
adenocarcinoma or d) DISCHARGE SUMMARY
adenosquamous OF DAY CARE
carcinoma DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology - Small BIOCHEMISTRY,ETC.)
Cell Lung Carcinoma c) DISCHARGE SUMMARY
Topotecan OF INPATIENT
632 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071F 28455 31300 34146 36991 39837 41259
Topotecan 1.5 mg/m2 D1-D5 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Small cell Lung cancer c) DISCHARGE SUMMARY
Docetaxel OF INPATIENT
633 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071G 3675 4042 4410 4777 5145 5328
Docetaxel 20 mg/m2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology - Small BIOCHEMISTRY,ETC.)
Etoposide + Carboplatin Cell Lung Carcinoma c) DISCHARGE SUMMARY
634 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071H Etoposide 100mg/m2 D1 - D3 8925 9817 10710 11602 12495 12941 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology - Small BIOCHEMISTRY,ETC.)
Etoposide + Cisplatin Cell Lung Carcinoma c) DISCHARGE SUMMARY
635 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071I Etoposide 100mg/m2 D1 - D3 7875 8662 9450 10237 11025 11418 OF INPATIENT
Cisplatin 75-100 mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology (non BIOCHEMISTRY,ETC.)
small cell carcinoma) c) DISCHARGE SUMMARY
Gemcitabine OF INPATIENT
636 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071J 10395 11434 12474 13513 14553 15072
Gemcitabine 1000mg /m2 D1 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Gemcitabine + Carboplatin Small cell Lung cancer c) DISCHARGE SUMMARY
637 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071K Gemcitabine 1000 mg/m2 D1 D8 16065 17671 19278 20884 22491 23294 OF INPATIENT
Carboplatin AUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Gemcitabine + Cisplatin Small cell Lung cancer c) DISCHARGE SUMMARY
638 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071L Gemcitabine 1000 mg/m2 D1 D8 14070 15477 16884 18291 19698 20401 OF INPATIENT
Cisplatin 75 mg/m2 D1 D8 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Small cell Lung cancer c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
639 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071M 6930 7623 8316 9009 9702 10048
Paclitaxel 80mg/m2 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Small cell Lung cancer c) DISCHARGE SUMMARY
Paclitaxel OF INPATIENT
640 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071N 13650 15015 16380 17745 19110 19792
Paclitaxel 175mg/m2 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology (non BIOCHEMISTRY,ETC.)
Paclitaxel + Carboplatin small cell carcinoma) c) DISCHARGE SUMMARY
641 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071O Paclitaxel 50mg/m2 D1 8925 9817 10710 11602 12495 12941 OF INPATIENT
Carboplatin AUC 2 D1 every week DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Paclitaxel + Cisplatin Small cell Lung cancer c) DISCHARGE SUMMARY
642 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071P Paclitaxel 175 mg/m2 D1 15435 16978 18522 20065 21609 22380 OF INPATIENT
Cisplatin 75mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology – BIOCHEMISTRY,ETC.)
Pemetrexed + Cisplatin adenocarcinoma c) DISCHARGE SUMMARY
643 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071Q Pemetrexed 500mg/m2 D1 10920 12012 13104 14196 15288 15834 i) adenosquamous OF INPATIENT
Cisplatin 75 mg/m2 D1 every 21 days carcinoma DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) BAR CODE OF THE OPEN

DRUGS.
a) CBC. b) REPORTS OF THE
b) LFT. TESTS (PATHOLOGY,
c) RFT. RADIOLOGY,
d) RBS. MICROBIOLOGY,
e) CECT Thorax. HEMATOLOGY,
f) abdomen BIOCHEMISTRY,ETC.)
g) Pelvis. c) DISCHARGE SUMMARY
Pemetrexed h) histopathology (non OF INPATIENT
644 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071R 8820 9702 10584 11466 12348 12789
Pemetrexed 500mg/m2 D1 every 21 days small cell - DEPARTMENT.
adenocarcinoma or d) DISCHARGE SUMMARY
adenosquamous OF DAY CARE
carcinoma) DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CBC. a) BAR CODE OF THE OPEN
b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Vinorelbine + Carboplatin Small cell Lung cancer c) DISCHARGE SUMMARY
645 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071S Vinorelbine 25mg/m2 D1 D8 22800 25080 27360 29640 31920 33060 OF INPATIENT
CarboplatinAUC 5-6 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

a) CBC. a) BAR CODE OF THE OPEN

b) LFT. DRUGS.
c) RFT. b) REPORTS OF THE
d) RBS. TESTS (PATHOLOGY,
e) CECT Thorax. RADIOLOGY,
f) abdomen MICROBIOLOGY,
g) Pelvis. HEMATOLOGY,
h) histopathology- Non BIOCHEMISTRY,ETC.)
Vinorelbine + Cisplatin Small cell Lung cancer c) DISCHARGE SUMMARY
646 Medical Oncology MO Medical Oncology MO071 CT for CA Lung MO071T Vinorelbine 25mg/m2 D1 D8 20600 22660 24720 26780 28840 29870 OF INPATIENT
Cisplatin 75mg/m2 D1 every 21 days DEPARTMENT.
d) DISCHARGE SUMMARY
OF DAY CARE
DEPARTMENT.
e) CHARTS OF
CHEMOTHERAPY
REGIMEN.
f) TRANFUSION SLIPS.

647 Medical Oncology MO Medical Oncology MO072 CT for CA Cervix MO072A Carboplatin Carboplatin AUC 2 every week 3150 3465 3780 4095 4410 4567 0 0 OPEN
De-Angelis/MTR (methotrexate, 0 0 OPEN YES
648 Medical Oncology MO Medical Oncology MO073 CT for primary CNS lymphoma MO073A dexamethasone, procarbazine, vincristine, 41580 45738 49896 54054 58212 60291
intrathecal MTX, CYTARABINE)
6930 per cycle. Max 4 6930 per cycle. Max 4 OPEN
649 7623 8316 9009 9702 10048 cycles once every 3 week cycles once every 3 week
Medical Oncology MO Medical Oncology M0074 GCT Testis MO074A SA Carboplatin AUC 7 once every 3 weeks 6930
Hospital Undertaking for Hospital Undertaking for
user of Per Cycle user of Per Cycle
Denosumab 0 0 OPEN
Denosumab 120 mg s/c D1, 8, 15 then every 28
650 Medical Oncology MO Medical Oncology MO075 CT for GCT of bone MO075A 20790 22869 24948 27027 29106 30145
days

Temozolamide 150mg/m2 D9-14 + 0 0 OPEN

651 Medical Oncology MO Medical Oncology MO076 GEP NET Neuroendocrine carcinoma MO076A 9240 10164 11088 12012 12936 13398
Capecitabine 1gm/me D1-14 every 28 days
GEP NET high grade Neuroendocrine Carboplatin AUC 5 + Etoposide 100mg/m2 D1- 0 0 OPEN
652 Medical Oncology MO Medical Oncology MO076 MO076B 15540 17094 18648 20202 21756 22533
carcinoma D3 every 21 days
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical c) planned line d) All investigations reports.
653 MP MP001 Pediatric seizure disorders MP001A Febrile seizures 2250 2475 2700 2925 3150 3262
Management Management management.
d) 1st seizure or past
history.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical
654 MP Management, General MP001 Pediatric seizure disorders MP001D Acute non-febrile seizures 2250 2475 2700 2925 3150 3262
Management
Medicine
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical c) planned line d) All investigations reports.
655 MP MP002 Epileptic encephalopathy MP002A Epileptic encephalopathy 2250 2475 2700 2925 3150 3262
Management Management management.
d) past h.
e) epilepsy.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical
656 MP Management, General MP003 ACUTE ENCEPHALOPATHY MP003A Acute Febrile encephalopathy 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
657 MP Management, General MP003 ACUTE ENCEPHALOPATHY MP003B Acute Disseminated Encephalomyelitis 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical hypertensive/metabolic/febrile/hepatic
658 MP Management, General MP004 ACUTE ENCEPHALOPATHY MP004A 2350 2585 2820 3055 3290 3407
Management encephalopathy
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND
659 MP Management, General MP005 MP005A Acute meningo encephalitis pyogenic 2350 2585 2820 3055 3290 3407
Management MENINGOENCEPHALITIS.
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND
660 MP Management, General MP005 MP005B Aseptic meningitis tubercular, 2250 2475 2700 2925 3150 3262
Management MENINGOENCEPHALITIS.
Medicine
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN Variable
history, evaluation findings, papers
vital monitoring,and (including any cross-
planned specialty
Pediatric Medical Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND line of management referral that has been done)
661 MP MP005 MP005C Febrile encephalopathy fungal 2250 2475 2700 2925 3150 3262 b) Lumbar Puncture b) Investigation reports (if
Management Management MENINGOENCEPHALITIS.
c) Complete blood count required)
d) CT/MRI scan c) Detailed Discharge
e) Blood culture Summary

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND
662 MP Management, General MP005 MP005D Hypertensive encehalopathy viral, 2250 2475 2700 2925 3150 3262
Management MENINGOENCEPHALITIS.
Medicine
a) Clinical notes including a) Detailed Indoor case OPEN Variable
history, evaluation findings, papers
vital monitoring,and (including any cross-
planned specialty
Pediatric Medical Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND line of management referral that has been done)
663 MP MP005 MP005E Metabolic encephalopathy parasitic, 2250 2475 2700 2925 3150 3262 b) Lumbar Puncture b) Investigation reports (if
Management Management MENINGOENCEPHALITIS.
c) Complete blood count required)
d) CT/MRI scan c) Detailed Discharge
e) Blood culture Summary

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical ACUTE INFECTIOUS MENINGITIS AND Brain abscess/Intracranial abscess/ Aseptic
664 MP Management, General MP005 MP005G 2250 2475 2700 2925 3150 3262
Management MENINGOENCEPHALITIS. meningitis
Medicine
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
c) examination findings d) All investigations reports.
Pediatric Medical Pediatric Medical (incl neurological
665 MP MP006 Meningitis MP006A Chronic meningitis 2350 2585 2820 3055 3290 3407 examination).
Management Management
d) any investigations done.
e) planned line of
management.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical
666 MP Management, General MP006 Meningitis MP006B Partially treated pyogenic meningitis 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
667 MP Management, General MP006 Meningitis MP006C Neuro tuberculosis 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
668 MP Management, General MP006 Meningitis MP006D Complicated bacterial meningitis 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
669 MP Management, General MP006 Meningitis MP006E Acute meningitis 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical Raised ICP due to neuro surgical 0 0 OPEN Variable
Pediatric Medical Medical Management for Raised
670 MP Management, General MP008 MP008A procedures/due to trauma/malignancies/ 2250 2475 2700 2925 3150 3262
Management intracranial pressure
Medicine meningo-encephalitis
a) Clinical notes showing a) Detailed Indoor case OPEN Variable
vitals, examination papers (ICPs) with
findings, planned line of treatment details
treatment & advice for b) Improved Glasgow coma
admission scale score
b) Glasgow coma scale c) Cranial ultrasonography
Pediatric Medical Pediatric Medical INTRACRANIAL SPACE OCCUPYING findings and examination /CT/MRI Brain
671 MP MP009 MP009A Intracranial hemorrhage 2250 2475 2700 2925 3150 3262
Management Management LESIONS findings d) Detailed Operative
c) Cranial /Procedures notes
ultrasonography/CT/MRI (optional) e) Detailed
Brain discharge summary
d) Electroencephalography
(optional)

a) Clinical notes detailing a) Detailed ICPs. OPEN Variable

history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical INTRACRANIAL SPACE OCCUPYING Intracranial space occupying lesion c) examination findings. d) All investigations reports.
672 MP MP010 MP010A 2350 2585 2820 3055 3290 3407 d) any investigations done.
Management Management LESIONS tuberculoma,
e) planned line of
management.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical INTRACRANIAL SPACE OCCUPYING
673 MP Management, General MP011 MP011A neurocysticercosis, brain tumours 2350 2585 2820 3055 3290 3407
Management LESIONS
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical Juvenile myasthenia- requiring admission for
674 MP Management, General MP015 Juvenile myasthenia MP015A 2350 2585 2820 3055 3290 3407
Management work-up or in-patient care
Medicine
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes showing a) Detailed Indoor case OPEN Variable
vitals, examination papers (ICPs) with
findings, planned line of treatment details
treatment and advice for b) Nerve conduction test
admission (ENMG)/MRI/CT/Viral
b) Nerve conduction test serology (Optional)
(ENMG)/MRI/CT c) Detailed discharge
c) Viral serology summary
d) Optional based on
Pediatric Medical Pediatric Medical etiology and availability
675 MP MP016 Acute ataxia MP016A Acute ataxia 2250 2475 2700 2925 3150 3262
Management Management Toxicological testing, blood
glucose, metabolic
evaluation, Cerebrospinal
fluid examination, Viral
serology, Urinalysis,
Serum Electrolytes,
Vitamins, Complete blood
count, liver function test

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical
676 MP Management, General MP018 Acute childhood asthma MP018A Acute asthma/Status asthmaticus 2250 2475 2700 2925 3150 3262
Management
Medicine
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical
677 MP MP020 Acute urticaria / Anaphylaxis MP020A Acute urticaria/anaphylaxis 2250 2475 2700 2925 3150 3262 c) planned line d) All investigations reports.
Management Management
management.
d) specify the trigger.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical
678 MP Management, General MP020 Acute urticaria / Anaphylaxis MP020B Steven Johnson syndrome 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
679 MP Management, General MP021 Acute abdomen MP021A Acute abdomen pain 2250 2475 2700 2925 3150 3262
Management
Medicine
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical Celiac disease-requiring admission for Work c) examination findings. d) All investigations reports.
680 MP MP022 Celiac disease MP022A 2250 2475 2700 2925 3150 3262 d) any investigations done.
Management Management Up and/or in-patient management
e) planned line of
management.

Pediatric Medical Unexplained hepatosplenomegaly-requiring 0 0 OPEN Variable

Pediatric Medical
681 MP Management, General MP023 Unexplained hepatosplenomegaly MP023A admission for Work Up and/or in-patient 2250 2475 2700 2925 3150 3262
Management
Medicine management
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical Neonatal/infantile cholestasis / Choledochal
682 MP Management, General MP024 Neonatal/ Infantile cholestasis MP024A 2250 2475 2700 2925 3150 3262
Management cysts
Medicine
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical
683 MP MP025 Acute glomerulonephritis MP025A Acute glomerulonephritis 2250 2475 2700 2925 3150 3262 c) planned line d) All investigations reports.
Management Management
management.
d) investigations done.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical
684 MP Management, General MP026 NEPHROTIC SYNDROME MP026A Nephrotic syndrome with peritonitis 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
685 MP Management, General MP026 NEPHROTIC SYNDROME MP026B Steroid dependent or resistent 2350 2585 2820 3055 3290 3407
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
686 MP Management, General MP027 Haemolytic uremic syndrome MP027A Haemolytic uremic syndrome 2250 2475 2700 2925 3150 3262
Management
Medicine
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN Variable
history, symptoms, signs, papers (ICPs) with
vitals, examination treatment details
findings, planned line of b) All investigation done
treatment and advice for c) Detailed discharge
admission 1. Intellectual summary
Disorders (ID)
i. Intelligence Quotient (IQ)
test
ii. Social maturity
assessment (Vineland
Social Maturity Scale -
Global developmental delay/Intellectual VSMS)
Pediatric Medical Pediatric Medical Global developmental delay / Intellectual
687 MP MP029 MP029A disability-requiring admission for Work Up 2250 2475 2700 2925 3150 3262 iii. Developmental
Management Management disability of unknown etiology
and/or in-patient management screening test (DST)
iv. CT/MRI Brain (Optional)
2. Global developmental
delay (GDD)
i. Imaging: EEG, CT, MRI,
MRS (as per the patient
condition)
ii. IQ test (>5 years)
iii. Social maturity
assessment (VSMS)
iv. Developmental
screening test (DST)
v. CT/MRI Brain (Optional)
a) Clinical notes showing a) Detailed Indoor case OPEN Variable
vitals, examination papers (ICPs) with
findings, planned line of treatment details
treatment and advice for b) Detailed discharge
admission summary
b) Investigations
1. X-ray
PA wrist/radius/ulna or
Pediatric Medical Pediatric Medical Rickets - requiring admission for Work Up Knee/tibia/fibula
688 MP MP030 Rickets - requiring admission for Work Up MP030A 2250 2475 2700 2925 3150 3262 2. Serum Calcium
Management Management and/or in-patient management
3. Serum Phosphorus
4. Alkaline phosphatase
c) Based on clinical
condition and availability
Desirable:
25-OH-Vitamin D,
Complete blood count,
Serum electrolytes, Renal
function tests
a) Still image of the child at a) Still image of the child at OPEN Variable
the time of admission with the time of discharge with
patient ID and date patient ID and date
b) Clinical notes with b) Detailed indoor case
indications such as: papers with treatment
i. Faulty feeding habits details indicating
(Not exclusively Breast fed i. Monitoring of vitals with
for 6 months/ bottle Input-output charting as
feeding/ delayed or well as urine frequency,
inadequate complementary stool/ vomitus volumes
feeding) ii. Intake: IV fluids (IVF)
ii. Poor appetite (DNS) 4ml/ Kg/hr for 2-3
Pediatric Medical Pediatric Medical iii. Lethargy/ Irritability days with early/
689 MP MP031 Acute severe malnutrition MP031A Acute severe malnutrition 2250 2475 2700 2925 3150 3262 iv. Any delayed concomitant initiation of
Management Management
developmental milestones oral feeds (130 ml/kg/day)
including Weight iii. Condition/ complication
v. Vitals- Pulse rate (PR), specific treatment such as
respiratory rate (RR), Antibiotics for Infection,
Capillary refill time (CRT) Dextrose for Hypoglycemia/
vi. Loss of Subcutaneous severe dehydration,
fat, muscle wasting, pallor, Potassium/ Magnesium for
mid-upper arm electrolyte imbalance,
circumference (MUAC) less Whole blood/ PRBC
than normal transfusion for Anemia.
vii. Signs of Vitamin B, K c) Detailed essential
and A deficiencies (if any investigation reports
of these symptoms are i. Haemogram
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN Variable
history, symptoms, signs, papers (ICPs) with
vitals, examination treatment details
findings, planned line of b) All investigation done
treatment and advice for c) Detailed discharge
admission 1. Intellectual summary
Disorders (ID)
i. Intelligence Quotient (IQ)
test
ii. Social maturity
assessment (Vineland
Social Maturity Scale -
Pediatric Medical Pediatric Medical Developmental and behavioral disorders for VSMS)
690 MP MP032 Developmental and behavioral disorders MP032A 2250 2475 2700 2925 3150 3262 iii. Developmental
Management Management Work Up and/or in-patient management
screening test (DST)
iv. CT/MRI Brain (Optional)
2. Global developmental
delay (GDD)
i. Imaging: EEG, CT, MRI,
MRS (as per the patient
condition)
ii. IQ test (>5 years)
iii. Social maturity
assessment (VSMS)
iv. Developmental
screening test (DST)
v. CT/MRI Brain (Optional)
a) Clinical notes showing a) Detailed Indoor case OPEN Variable
vitals, examination papers (ICPs) with
findings, planned line of treatment details including
treatment and advice for Establishing
admission diagnosis/clinical
b) Investigations: improvement b) Detailed
Complete blood count, discharge summary
Erythrocyte sedimentation
rate, Serum electrolytes,
Liver function test, Kidney
function test, Urine
analysis, Stool analysis, X-
Pediatric Medical Pediatric Medical ray of left hand and wrist/X-
691 MP MP033 Short stature MP033A Short stature- requiring admission for Work Up 2250 2475 2700 2925 3150 3262 ray elbow AP
Management Management
c) Optional based on
Etiology and availability
Tuberculin test and chest X-
ray, thyroid hormones (T4
and TSH), blood gas
analysis, tests for celiac
disease (anti-endomysial
and transglutaminase
antibodies), Serum IGF-1,
Chromosome analysis and
karyotype, growth hormone
provocation test, MRI brain

a) Clinical notes including a) Detailed Indoor Case OPEN Variable

history, evaluation findings, Papers
and b) Investigation reports (if
planned line of required)
management b) Based on c) Detailed Discharge
Etiology Summary
*Whole body scanning
Pediatric Medical Pediatric Medical Children with dysmorphic features- requiring * DNA/chromosomal
692 MP MP034 Children with dysmorphic features MP034A 2250 2475 2700 2925 3150 3262 /biochemical assay
Management Management admission for work-up
*Skeletal Survey
*USG
*Electrocardiogram (ECG)
*2D ECHO
*Thyroid profile
*Viral Serology markers

a) Clinical notes including a) Detailed Indoor Case OPEN Variable

history, evaluation findings, Papers mentioning the
and treatment details b)
planned line of Investigation reports (if
management required)
b) Based on Etiology c) Detailed Discharge
*CT or MRI Summary
*Neurosonogram
*Muscle and nerve biopsy
Pediatric Medical Pediatric Medical Floppy infant syndrome requiring admission for *Electromyography (EMG)
693 MP MP035 Floppy infant syndrome MP035A 2250 2475 2700 2925 3150 3262 *Electroencephalogram
Management Management work-up
(EEG)
*X-Ray (chest or limb etc.)
*Spinal tap
*Blood culture
*Genetic testing
*Metabolic profile
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed ICPs OPEN Variable
history, evaluation findings, mentioning the treatment
and details
planned line of b) Detailed Discharge
management b)Based on Summary
Etiology
*Cerebrospinal fluid (CSF)
examination
*Liver Function Test
*Kidney Function Test
*Arterial blood gas
Pediatric Medical Pediatric Medical Inborn errors of metabolism-requiring admission *Ammonia
694 MP MP036 Inborn errors of metabolism MP036A 2250 2475 2700 2925 3150 3262
Management Management for work-up and/or inpatient care *Urine for ketones and
reducing substance
*USG
*CT/MRI
*X Ray
*Tandem Mass
Spectrometer (TMS)
*Gas chromatography-
mass spectrometry
(GCMS)
*Gene testing
*Exome sequencing
a) Clinical notes a) Detailed Indoor case OPEN Variable
b) Serum ceruloplasmin papers (ICPs)
c) 24-hour urine copper b) Detailed Discharge
Pediatric Medical Pediatric Medical Wilson’s disease-requiring admission for work- d) Slit lamp examination Summary
695 MP MP037 Wilson’s disease MP037A 2250 2475 2700 2925 3150 3262
Management Management up and/or inpatient care (Kayser-Fleischer ring)(If c) Serum ceruloplasmin
available) d) 24-hour urine copper
e) Planned line of
treatment
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical c) examination findings. d) All investigations reports.
696 MP MP038 Juvenile Arthritis MP038A Juvenile Arthritis 2250 2475 2700 2925 3150 3262 d) any investigations done.
Management Management
e) planned line of
management.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical Acute rheumatic fever
697 MP Management, General MP039 Rheumatic fever MP039A 2250 2475 2700 2925 3150 3262
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
698 MP Management, General MP039 Rheumatic fever MP039B Rheumatic valvular heart disease 2350 2585 2820 3055 3290 3407
Management
Medicine
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
699 MP Management, General MP040 Cyanotic spells MP040A Cyanotic spells without CHD 2250 2475 2700 2925 3150 3262
Management
Medicine
a) Clinical notes a) Detailed Indoor case OPEN Variable
b) Investigations papers (ICPs) with
1. Chest X-ray treatment details
2. Blood gas analysis b) Investigations/Imaging
3. Echocardiography reports
4. Complete blood count, c) Detailed Discharge
serum ferritin, blood summary with follow-up
Pediatric Medical Pediatric Medical glucose advise at the time of
700 MP MP040 Cyanotic spells MP040B Cyanotic spells with CHD 2250 2475 2700 2925 3150 3262
Management Management 5. Serum Calcium discharge
6. Hyperoxia test
7. ECG/ECHO
8. Measurement of oxygen
saturation / co-oximetry
c) Planned line of
treatment

a) Clinical notes showing a) Detailed Indoor case OPEN Variable

vitals, examination papers (ICPs) with
findings, planned line of treatment details
treatment & advice for b) DCT, CBC, peripheral
admission smear
b) Direct Coomb`s test c) Detailed discharge
(DCT) summary
c) Complete blood count
(CBC), peripheral smear,
Pediatric Medical Pediatric Medical urinalysis, reticulocyte,
701 MP MP041 SEVERE ANEMIA IN CHILDREN MP041A Iron deficiency anemia 2250 2475 2700 2925 3150 3262 haptoglobin, total serum
Management Management
bilirubin
d) Optional (based on
clinical condition and
availability)
Indirect Coomb`s test
(ICT), Kidney function
tests, Bone marrow
aspiration, Chest X-ray,
lactate dehydrogenase
(LDH), viral serology
Pediatric Medical Pediatric Medical 0 0 OPEN Variable
702 MP MP041 SEVERE ANEMIA IN CHILDREN MP041B Thalessmia 2350 2585 2820 3055 3290 3407
Management Management
Pediatric Medical Pediatric Medical 0 0 OPEN Variable
703 MP MP041 SEVERE ANEMIA IN CHILDREN MP041D Other anemias 2350 2585 2820 3055 3290 3407
Management Management
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
Pediatric Medical Pediatric Medical c) examination findings. d) All investigations reports.
704 MP MP042 Idiopathic Thrombocytopenic Purpura MP042A Idiopathic Thrombocytopenic Purpura 2250 2475 2700 2925 3150 3262 d) any investigations done.
Management Management
e) planned line of
management.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical
705 MP Management, General MP043 Kawasaki Disease MP043A Kawasaki Disease 2250 2475 2700 2925 3150 3262
Management
Medicine
a) Clinical notes detailing a) Detailed ICPs. OPEN Variable
history (incl drug intake b) Treatment details.
history). c) detailed discharge
b) Admission notes summary.
showing vitals. d) All investigations reports.
Pediatric Medical Pediatric Medical c) examination findings.
706 MP MP044 Steve Johnson syndrome MP044A Steve Johnson syndrome 2250 2475 2700 2925 3150 3262
Management Management d) any investigations done.
e) planned line of
management.

a) Clinical notes detailing a) Detailed ICPs. OPEN Variable

history. b) Treatment details.
b) Admission notes c) detailed discharge
showing vitals. summary.
c) examination findings d) All investigations reports.
Pediatric Medical Pediatric Medical Ketogenic diet initiation in refractory (incl neurological
707 MP MP046 MP046A Ketogenic diet initiation in refractory epilepsy 2250 2475 2700 2925 3150 3262 examination).
Management Management epilepsy
d) any investigations done.
e) planned line of
management.

Pediatric Medical 0 0 OPEN Variable

Pediatric Medical Acute laryngotracheobronchitis/Acute
708 MP Management, General MP047 Croup syndrome MP047A 2250 2475 2700 2925 3150 3262
Management epiglottitis
Medicine
Pediatric Medical Pediatric Medical 0 0 OPEN Variable
709 MP MP048 Hemostatic Disorders MP048A Hemophilia 2250 2475 2700 2925 3150 3262
Management Management
Pediatric Medical Pediatric Medical 0 0 OPEN Variable
710 MP MP048 Hemostatic Disorders MP048B Platelet disorders 2350 2585 2820 3055 3290 3407
Management Management
Pediatric Medical 0 0 OPEN Variable
Pediatric Medical
711 MP Management, General MP050 NEPHROTIC SYNDROME MP050A Uncomplicated steroid sensitive 2350 2585 2820 3055 3290 3407
Management
Medicine
Pediatric Medical Pediatric Medical 0 0 OPEN Variable
712 MP MP051 Staphylococcal scalded skin syndrome MP051A Staphylococcal scalded skin syndrome 2350 2585 2820 3055 3290 3407
Management Management
a) HPE report. Detailed Discahrge OPEN
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Linear Accelerator, External Beam (documents confirming the
713 Radiation Oncology MR Radiation Oncology MR004 Radiotherapy 3D CRT (6 Fractions) MR001A Radical 24255 26680 29106 31531 33957 35169 Procedure indicated and
(Inclusive of Simulation & Planning Cost) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
2D External Beam Radiotherapy (Telecobalt
(documents confirming the
/ Strock LA)
714 Radiation Oncology MR Radiation Oncology MR001 MR001B Adjuvant 12705 13975 15246 16516 17787 18422 Procedure indicated and
(6 Fractions)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
2D External Beam Radiotherapy (Telecobalt
(documents confirming the
/ Strock LA)
715 Radiation Oncology MR Radiation Oncology MR001 MR001C Neoadjuvant 12705 13975 15246 16516 17787 18422 Procedure indicated and
(6 Fractions)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).

2D External Beam Radiotherapy (Telecobalt 2D External Beam Radiotherapy (Telecobalt / 0 0 OPEN

/ Strock LA) Strock LA)
716 Radiation Oncology MR Radiation Oncology MR001 MR001D 10440 11484 12528 13572 14616 15138
(6 Fractions) (6 Fractions)
(Inclusive of Simulation & Planning Cost) (Inclusive of Simulation & Planning Cost)
a) HPE report. Detailed Discahrge OPEN
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
2D External Beam Radiotherapy - Palliative
(documents confirming the
(Telecobalt / Strock LA)
717 Radiation Oncology MR Radiation Oncology MR002 MR002A Palliative 15000 16500 18000 19500 21000 21750 Procedure indicated and
(Upto 10 Fractions)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) HPE report. Detailed Discahrge OPEN
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
2D External Beam Radiotherapy (Telecobalt
(documents confirming the
/ Strock LA)
718 Radiation Oncology MR Radiation Oncology MR003 MR003A Radical 23100 25410 27720 30030 32340 33495 Procedure indicated and
(25 Fractions)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
2D External Beam Radiotherapy (Telecobalt
(documents confirming the
/ Strock LA)
719 Radiation Oncology MR Radiation Oncology MR003 MR003B Adjuvant 23100 25410 27720 30030 32340 33495 Procedure indicated and
(25 Fractions)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
2D External Beam Radiotherapy (Telecobalt
(documents confirming the
/ Strock LA)
720 Radiation Oncology MR Radiation Oncology MR003 MR003C Neoadjuvant 23100 25410 27720 30030 32340 33495 Procedure indicated and
(25 Fractions)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).

2D External Beam Radiotherapy (Telecobalt 2D External Beam Radiotherapy (Telecobalt / 0 0 OPEN

/ Strock LA) Strock LA)
721 Radiation Oncology MR Radiation Oncology MR003 MR003D 5800 6380 6960 7540 8120 8410
(25 Fractions) (25 Fractions)
(Inclusive of Simulation & Planning Cost) (Inclusive of Simulation & Planning Cost)
a) HPE report. Detailed Discahrge OPEN
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
2D External Beam Radiotherapy (Telecobalt
(documents confirming the
/ Strock LA)
722 Radiation Oncology MR Radiation Oncology MR004 MR004A Radical 21000 23100 25200 27300 29400 30450 Procedure indicated and
(6 Fractions)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Linear Accelerator, External Beam (documents confirming the
723 Radiation Oncology MR Radiation Oncology MR004 Radiotherapy 3D CRT (6 Fractions) MR004B Adjuvant 24255 26680 29106 31531 33957 35169 Procedure indicated and
(Inclusive of Simulation & Planning Cost) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Linear Accelerator, External Beam (documents confirming the
724 Radiation Oncology MR Radiation Oncology MR004 Radiotherapy 3D CRT (6 Fractions) MR004C Neoadjuvant 24255 26680 29106 31531 33957 35169 Procedure indicated and
(Inclusive of Simulation & Planning Cost) details of RT treatment
plan).

Linear Accelerator, External Beam 0 0 OPEN

Linear Accelerator, External Beam Radiotherapy
725 Radiation Oncology MR Radiation Oncology MR004 Radiotherapy 3D CRT (6 Fractions) MR004D 20700 22770 24840 26910 28980 30015
3D CRT (6 Fractions)
(Inclusive of Simulation & Planning Cost)
a) HPE report. Detailed Discahrge OPEN YES
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Linear Accelerator, External Beam (documents confirming the
726 Radiation Oncology MR Radiation Oncology MR005 Radiotherapy 3D CRT (25 Fractions) MR005A Radical 46200 50820 55440 60060 64680 66990 Procedure indicated and
(Inclusive of Simulation & Planning Cost) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Linear Accelerator, External Beam (documents confirming the
727 Radiation Oncology MR Radiation Oncology MR005 Radiotherapy 3D CRT (25 Fractions) MR005B Adjuvant 46200 50820 55440 60060 64680 66990 Procedure indicated and
(Inclusive of Simulation & Planning Cost) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Linear Accelerator, External Beam (documents confirming the
728 Radiation Oncology MR Radiation Oncology MR005 Radiotherapy 3D CRT (25 Fractions) MR005C Neoadjuvant 46200 50820 55440 60060 64680 66990 Procedure indicated and
(Inclusive of Simulation & Planning Cost) details of RT treatment
plan).

Linear Accelerator, External Beam 0 0 OPEN

Linear Accelerator, External Beam Radiotherapy
729 Radiation Oncology MR Radiation Oncology MR005 Radiotherapy 3D CRT (25 Fractions) MR005D 11500 12650 13800 14950 16100 16675
3D CRT (25 Fractions)
(Inclusive of Simulation & Planning Cost)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) HPE report. Detailed Discahrge OPEN YES
b) Clinical notes with Summary (with RT
Linear Accelerator, External Beam planned line of treatment treatment and doses given).
Radiotherapy IMRT (Intensity Modulated (documents confirming the
730 Radiation Oncology MR Radiation Oncology MR006 Radiotherapy) MR006A Radical 80850 88935 97020 105105 113190 117232 Procedure indicated and
(20 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator, External Beam planned line of treatment treatment and doses given).
Radiotherapy IMRT (Intensity Modulated (documents confirming the
731 Radiation Oncology MR Radiation Oncology MR006 Radiotherapy) MR006B Adjuvant 80850 88935 97020 105105 113190 117232 Procedure indicated and
(20 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator, External Beam planned line of treatment treatment and doses given).
Radiotherapy IMRT (Intensity Modulated (documents confirming the
732 Radiation Oncology MR Radiation Oncology MR006 Radiotherapy) MR006C Neoadjuvant 80850 88935 97020 105105 113190 117232 Procedure indicated and
(20 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

Linear Accelerator, External Beam 0 0 OPEN

Linear Accelerator, External Beam Radiotherapy
Radiotherapy IMRT (Intensity Modulated
IMRT (Intensity Modulated Radiotherapy)
733 Radiation Oncology MR Radiation Oncology MR006 Radiotherapy) MR006D 34500 37950 41400 44850 48300 50025
(20 Fractions)
(20 Fractions)
(Inclusive of Simulation & Planning Cost)
(Inclusive of Simulation & Planning Cost)
a) HPE report. Detailed Discahrge OPEN YES
b) Clinical notes with Summary (with RT
Linear Accelerator, External Beam planned line of treatment treatment and doses given).
Radiotherapy IMRT (Intensity Modulated (documents confirming the
734 Radiation Oncology MR Radiation Oncology MR007 Radiotherapy) MR007A Radical 48510 53361 58212 63063 67914 70339 Procedure indicated and
(6 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator, External Beam planned line of treatment treatment and doses given).
Radiotherapy IMRT (Intensity Modulated (documents confirming the
735 Radiation Oncology MR Radiation Oncology MR007 Radiotherapy) MR007B Adjuvant 48510 53361 58212 63063 67914 70339 Procedure indicated and
(6 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator, External Beam planned line of treatment treatment and doses given).
Radiotherapy IMRT (Intensity Modulated (documents confirming the
736 Radiation Oncology MR Radiation Oncology MR007 Radiotherapy) MR007C Neoadjuvant 48510 53361 58212 63063 67914 70339 Procedure indicated and
(6 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

Linear Accelerator, External Beam 0 0 OPEN YES

Linear Accelerator, External Beam Radiotherapy
Radiotherapy IMRT (Intensity Modulated
IMRT (Intensity Modulated Radiotherapy)
737 Radiation Oncology MR Radiation Oncology MR007 Radiotherapy) MR007D 41400 45540 49680 53820 57960 60030
(6 Fractions)
(6 Fractions)
(Inclusive of Simulation & Planning Cost)
(Inclusive of Simulation & Planning Cost)
a) HPE report. Detailed Discahrge OPEN YES
b) Clinical notes with Summary (with RT
Linear Accelerator External Beam planned line of treatment treatment and doses given).
Radiotherapy IGRT (Image Guided (documents confirming the
738 Radiation Oncology MR Radiation Oncology MR008 radiotherapy) with 3D CRT or IMRT MR008A Radical 103950 114345 124740 135135 145530 150727 Procedure indicated and
(20 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator External Beam planned line of treatment treatment and doses given).
Radiotherapy IGRT (Image Guided (documents confirming the
739 Radiation Oncology MR Radiation Oncology MR008 radiotherapy) with 3D CRT or IMRT MR008B Adjuvant 103950 114345 124740 135135 145530 150727 Procedure indicated and
(20 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator External Beam planned line of treatment treatment and doses given).
Radiotherapy IGRT (Image Guided (documents confirming the
740 Radiation Oncology MR Radiation Oncology MR008 radiotherapy) with 3D CRT or IMRT MR008C Neoadjuvant 103950 114345 124740 135135 145530 150727 Procedure indicated and
(20 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

Linear Accelerator External Beam Linear Accelerator External Beam Radiotherapy 0 0 OPEN YES
Radiotherapy IGRT (Image Guided IGRT (Image Guided radiotherapy) with 3D CRT
741 Radiation Oncology MR Radiation Oncology MR008 radiotherapy) with 3D CRT or IMRT MR008D or IMRT 43500 47850 52200 56550 60900 63075
(20 Fractions) (20 Fractions)
(Inclusive of Simulation & Planning Cost) (Inclusive of Simulation & Planning Cost)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) HPE report. Detailed Discahrge OPEN YES
b) Clinical notes with Summary (with RT
Linear Accelerator External Beam planned line of treatment treatment and doses given).
Radiotherapy IGRT (Image Guided (documents confirming the
742 Radiation Oncology MR Radiation Oncology MR009 radiotherapy) with 3D CRT or IMRT MR009A Radical 63525 69877 76230 82582 88935 92111 Procedure indicated and
(6 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator External Beam planned line of treatment treatment and doses given).
Radiotherapy IGRT (Image Guided (documents confirming the
743 Radiation Oncology MR Radiation Oncology MR009 radiotherapy) with 3D CRT or IMRT MR009B Adjuvant 63525 69877 76230 82582 88935 92111 Procedure indicated and
(6 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
Linear Accelerator External Beam planned line of treatment treatment and doses given).
Radiotherapy IGRT (Image Guided (documents confirming the
744 Radiation Oncology MR Radiation Oncology MR009 radiotherapy) with 3D CRT or IMRT MR009C Neoadjuvant 63525 69877 76230 82582 88935 92111 Procedure indicated and
(6 Fractions) details of RT treatment
(Inclusive of Simulation & Planning Cost) plan).

Linear Accelerator External Beam Linear Accelerator External Beam Radiotherapy 0 0 OPEN YES
Radiotherapy IGRT (Image Guided IGRT (Image Guided radiotherapy) with 3D CRT
745 Radiation Oncology MR Radiation Oncology MR009 radiotherapy) with 3D CRT or IMRT MR009D or IMRT 52200 57420 62640 67860 73080 75690
(6 Fractions) (6 Fractions)
(Inclusive of Simulation & Planning Cost) (Inclusive of Simulation & Planning Cost)
a) HPE report. Detailed Discahrge OPEN YES
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
SRT / SBRT with IGRT
(documents confirming the
(Stereotacatic radiotherapy) SRT / SBRT with IGRT
746 Radiation Oncology MR Radiation Oncology MR010 MR010A 100000 110000 120000 130000 140000 145000 Procedure indicated and
(4 Fractions) (Stereotacatic radiotherapy)
details of RT treatment
(Inclusive of Simulation & Planning Cost)
plan).

SRT / SBRT with IGRT SRT / SBRT with IGRT 0 0 OPEN YES
(Stereotacatic radiotherapy) (Stereotacatic radiotherapy)
747 Radiation Oncology MR Radiation Oncology MR010 MR010B 50800 55880 60960 66040 71120 73660
(4 Fractions) (4 Fractions)
(Inclusive of Simulation & Planning Cost) (Inclusive of Simulation & Planning Cost)
a) Biopsy. Detailed Discahrge OPEN YES
SRS with IGRT (Stereotacatic radiotherapy) b) HPE report of Summary (with RT
748 Radiation Oncology MR Radiation Oncology MR011 MR011A SRS with IGRT (Stereotacatic radiotherapy) 80850 88935 97020 105105 113190 117232 malignancy. treatment and doses given).
(Inclusive of Simulation & Planning Cost)
c) Justification of SRS.

a) Clinical notes. Detailed Discahrge OPEN YES

b) Documentary evidence Summary (with RT
confirming the need of treatment and doses given).
Respiratory Gating along with Linear Respiratory-gated
Respiratory Gating along with Linear radiotherapy (tumours that
749 Radiation Oncology MR Radiation Oncology MR012 Accelerator planning (5 Fractions) MR012A 80000 88000 96000 104000 112000 116000
Accelerator planning move with respiration
(Inclusive of Simulation & Planning Cost)
during radiotherapy (lung,
breast and upper
abdominal tumpurs).
Respiratory Gating along with Linear Respiratory Gating along with Linear 0 0 OPEN YES
750 Radiation Oncology MR Radiation Oncology MR012 Accelerator planning (5 Fractions) MR012B Accelerator planning (5 Fractions) 40425 44467 48510 52552 56595 58616
(Inclusive of Simulation & Planning Cost) (Inclusive of Simulation & Planning Cost)
a) HPE report. Detailed Discahrge OPEN
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Brachytherapy High Dose Radiation (2D/X- (documents confirming the
751 Radiation Oncology MR Radiation Oncology MR013 ray) MR013A Intracavitory 4095 4504 4914 5323 5733 5937 Procedure indicated and
(Maximum of 4 session) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Brachytherapy High Dose Radiation (2D/X- (documents confirming the
752 Radiation Oncology MR Radiation Oncology MR013 ray) MR013B Intraluminal 4095 4504 4914 5323 5733 5937 Procedure indicated and
(Maximum of 4 session) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Brachytherapy High Dose Radiation (2D/X- (documents confirming the
753 Radiation Oncology MR Radiation Oncology MR013 ray) MR013C Endobiliary 4095 4504 4914 5323 5733 5937 Procedure indicated and
(Maximum of 4 session) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given)
Brachytherapy High Dose Radiation (2D/X- (documents confirming the
754 Radiation Oncology MR Radiation Oncology MR013 ray) MR013D Endobronchial 4095 4504 4914 5323 5733 5937 Procedure indicated and
(Maximum of 4 session) details of RT treatment
plan).
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) HPE report. Detailed Discahrge OPEN
b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Brachytherapy High Dose Radiation (2D/X- (documents confirming the
755 Radiation Oncology MR Radiation Oncology MR013 ray) MR013E CVS 4095 4504 4914 5323 5733 5937 Procedure indicated and
(Maximum of 4 session) details of RT treatment
plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Brachytherapy High Dose Radiation (5
(documents confirming the
doses) Interstitial / Intracavitary complex planning like
756 Radiation Oncology MR Radiation Oncology MR014 MR014A 50000 55000 60000 65000 70000 72500 Procedure indicated and
(Inclusive of Simulation, Planning Cost, OT CT or MR
details of RT treatment
& other charges )
plan).

a) HPE report. Detailed Discahrge OPEN YES

b) Clinical notes with Summary (with RT
planned line of treatment treatment and doses given).
Brachytherapy High Dose Radiation (5
(documents confirming the
doses) Surface Mould / Intracavitary complex planning
757 Radiation Oncology MR Radiation Oncology MR014 MR014B 48510 53361 58212 63063 67914 70339 Procedure indicated and
(Inclusive of Simulation, Planning Cost, OT like CT or MR
details of RT treatment
& other charges )
plan).

Brachytherapy High Dose Radiation (5 0 0 OPEN

Brachytherapy High Dose Radiation (5 doses)
doses)
758 Radiation Oncology MR Radiation Oncology MR014 MR014C (Inclusive of Simulation, Planning Cost, OT & 21735 23908 26082 28255 30429 31515
(Inclusive of Simulation, Planning Cost, OT
other charges )
& other charges )
large Dose scan/ Pre Ablation - calculation of 0 0 OPEN
759 Radiation Oncology MR Radiation Oncology MR015 iodine treatment 3 mCi MR015A 11970 13167 14364 15561 16758 17356
treatment
760 Radiation Oncology MR Radiation Oncology MR015 iodine treatment 30 mCi MR015B Ablation residual disease any risk 17745 19519 21294 23068 24843 25730 0 0 OPEN
Ablation of residual neck disease 0 0 OPEN
761 Radiation Oncology MR Radiation Oncology MR016 Iodine treatment 50 mCi MR016A 18900 20790 22680 24570 26460 27405
low/intermediate
762 Radiation Oncology MR Radiation Oncology MR017 Iodine treatment 100 mCi MR017A Ablation for metastatic disease, High risk 23520 25872 28224 30576 32928 34104 0 0 OPEN
763 Radiation Oncology MR Radiation Oncology MR018 Iodine treatment 150 mCi MR018A Ablation for metastatic disease, High risk 31600 34760 37920 41080 44240 45820 0 0 OPEN
764 Radiation Oncology MR Radiation Oncology MR019 Iodine treatment 200 mCi MR019A Ablation for metastatic disease, High risk 36225 39847 43470 47092 50715 52526 0 0 OPEN
765 Radiation Oncology MR Radiation Oncology MR020 Iodine treatment 250 mCi MR020A Ablation for metastatic disease, High risk 42000 46200 50400 54600 58800 60900 0 0 OPEN YES
0 0 OPEN YES
Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs
1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male
members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5
Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for
Female member Female member Female member Female member Female member Female member
766 Organ & Tissue Transplant OT Organ & Tissue Transplant OT001 Bone Marrow Transplantation OT001A Bone Marrow Transplantation
Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be
utilized) with utilized) with utilized) with utilized) with utilized) with utilized) with
validation of validation of validation of validation of validation of validation of
balance available balance available balance available balance available balance available balance available
in the card in the card in the card in the card in the card in the card
0 0 OPEN YES
Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs Maximum Rs
1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male 1000000 (Male
members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5 members Rs 5
Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for Lakh and for
Female member Female member Female member Female member Female member Female member
767 Organ & Tissue Transplant OT Organ & Tissue Transplant OT002 Liver Transplantation OT002A Liver Transplantation
Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be Rs 10 lakh can be
utilized) with utilized) with utilized) with utilized) with utilized) with utilized) with
validation of validation of validation of validation of validation of validation of
balance available balance available balance available balance available balance available balance available
in the card in the card in the card in the card in the card in the card
Palliative Care Approach to managing 0 0 OPEN YES
Urology/Medical/Surigal Haematuria in advanced cancer patients-
768 Palliative Medicine PM PM001 PM001A Hematuria Palliative Interventions 46200 50820 55440 60060 64680 66990
Oncology/Radiotherapy Endoscopic/Surgical/Radiological,
Radiotherpay interventions
0 0 OPEN YES
Surgical
Management of bleeding malignant head Haemostatic Surgery in advance cancer
769 Palliative Medicine PM Oncology/Radiation PM002 PM002A 46200 50820 55440 60060 64680 66990
and neck / inguinal lesions patient/Haemostatic Radiotherapy
Oncology / Genral Surgery
Surgical 0 0 OPEN YES
Management of bleeding in malignant head
770 Palliative Medicine PM Oncology/Radiation PM003 PM003A Trans arterial Embolization 69300 76230 83160 90090 97020 100485
and neck / inguinal malignancies
Oncology
Surgical Oncology/ Oro- 0 0 OPEN YES
Palliative Care Management of
771 Palliative Medicine PM facio-maxillary surgeons / PM004 PM004A Osteoradionecrosis -Surgical intervention 46200 50820 55440 60060 64680 66990
Osteoradionecrosis -Surgical intervention
Radiation Oncology
Palliative Care approach to managing 0 0 OPEN YES
Surgical Oncology / PMR /
772 Palliative Medicine PM PM005 Pressure sore in advanced chronic diseases PM005A Pressure sore-Interventions 46200 50820 55440 60060 64680 66990
General Surgery
who are bed ridden-Surgical
Palliative surgical interventions like- 0 0 OPEN YES
Colostomy, Tracheostomy, Feeding
Surgical / Medical /
773 Palliative Medicine PM PM006 Jejunostomy/Gastrostomy, Bowel bypas, PM006A Palliative surgical interventions 46200 50820 55440 60060 64680 66990
Radiation Oncology
Fistulas, Urinary diversions etc.in advanced
cancer patients
Malignant Spinal Cord compression with 0 0 OPEN
Radiation
774 Palliative Medicine PM PM007 Diagnostics, palliative radiotherapy, Brace PM007A Malignant Spinal cord compression 17325 19057 20790 22522 24255 25121
Oncology/Neurosurgery
in advanced cancer patients
0 0 OPEN YES
Radiation Palliative nerurosurgical interventions for
775 Palliative Medicine PM PM008 PM008A Palliative neurological interventions 69300 76230 83160 90090 97020 100485
Oncology/Neurosurgery secondary vertebral and brain metastasis
Palliative Care Management of 0 0 OPEN variable
palliativemedicine /
776 Palliative Medicine PM PM009 Osteoradionecrosis -Conservative PM009A Osteoradionecrosis -Conservative 2350 2585 2820 3055 3290 3407
orthopedics
management
Communications in Adavnced chronic 0 0 OPEN variable
diseases/ terminal stage of illness, for
Palliativemedcine /general Communications terminal stage/ end of life care
777 Palliative Medicine PM PM010 patient and family members with PM010A 2350 2585 2820 3055 3290 3407
medicine Conservative
discussions on Goals of care and facilitated
shared decision making
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Palliative care management of 0 0 OPEN variable
Palliativemedcine /general Breathlessness in advanced cancers and
778 Palliative Medicine PM PM011 PM011A Palliative Management of Breathlessnes 2350 2585 2820 3055 3290 3407
medicine chronic respiratory diseases -Conservative
management
Palliativemedcine /general Palliative Care Management of Pain for 0 0 OPEN variable
779 Palliative Medicine PM PM012 PM012A Cancer Pain Management 2350 2585 2820 3055 3290 3407
medicine treating Pain crisis, analgesic titration
0 0 OPEN variable
Palliativemedcine /general Palliative Care approach to managing
780 Palliative Medicine PM PM013 PM013A Pressure sore-in palliative care 2350 2585 2820 3055 3290 3407
medicine Pressure sore -Conservative management
Palliativemedcine /general 0 0 OPEN variable
781 Palliative Medicine PM PM014 Palliative Care Package for Hiccups PM014A Hiccups in Palliative care 2350 2585 2820 3055 3290 3407
medicine
Conservative management of post 0 0 OPEN variable
procedural or teratment related
Palliativemedcine /general
782 Palliative Medicine PM PM015 complications in palliative medicine PM015A Complications in palliative care patients 2350 2585 2820 3055 3290 3407
medicine
including electrolyte disorders (including
hypercalcemia and ketoacidosis).
Malignant Ascites drainage with long term 0 0 OPEN YES
Pallative medicine/medical Ascitis tapping with long term indwelling
783 Palliative Medicine PM PM016 catheter insertion in advanced cancer PM016A 46200 50820 55440 60060 64680 66990
oncology catheter
patients
Palliative Care Approach to managing 0 0 OPEN variable
Pallative medicine/medical
784 Palliative Medicine PM PM017 Haematuria in advanced cancer patients - PM017A Hematuria in advance cancer patient 2350 2585 2820 3055 3290 3407
oncology
Conservative management
Central lines in cancer patients for drug 0 0 OPEN
Pallative medicine/medical
785 Palliative Medicine PM PM018 therapy -Silicon catheters in advanced PM018A Long term indwelling venous catheter 11550 12705 13860 15015 16170 16747
oncology
cancer patients- Long term central lines
Symptom Management of Cough in 0 0 OPEN variable
Pallative medicine/medical Intractable Cough in cancer patients -
786 Palliative Medicine PM PM019 advanced cancer patients -Conservative PM019A 2350 2585 2820 3055 3290 3407
oncology Conservative management
management
0 0 OPEN variable
Pallative medicine/medical Palliative Care Management of Trismus,
787 Palliative Medicine PM PM020 PM020A Palliative care in Trismus mucositis 2350 2585 2820 3055 3290 3407
oncology mucositis in advanced cancer patient
0 0 OPEN variable
Pallative medicine/medical Management of terminal /fatal bleeding Conservative management of fatal bleeding in
788 Palliative Medicine PM PM021 PM021A 2350 2585 2820 3055 3290 3407
oncology malignant head and neck / inguinal lesions cancer patients
Palliative Care Management of Symptom 0 0 OPEN variable
Pallative medicine/medical
789 Palliative Medicine PM PM022 Cluster – Fatigue in advanced cancer PM022A Fatigue in Palliative care 2350 2585 2820 3055 3290 3407
oncology
patients
Malignant Pleural Effusion for Pleural tap 0 0 OPEN
Medical/Surigal/Radiation
with Pig tail catheter/chest tube insertion
790 Palliative Medicine PM Oncology and Pulmonary PM023 PM023A Pleural effusion & Pleurodesis 8715 9586 10458 11329 12201 12636
with Pleurodesis in advanced cancer
Medicine
patients
Medical/Surigal/Radiation Malignant Ascites drainage with catheter Management of malignant Ascitis,Tapping & 0 0 OPEN variable
791 Palliative Medicine PM PM024 PM024A 2350 2585 2820 3055 3290 3407
Oncology & Radiology insertion in advanced cancer patients conservative management
Symptom Management of Cough in 0 0 OPEN YES
Medical/Surigal/ Radiation
advanced cancer patients-
792 Palliative Medicine PM Oncology and Pulmonary PM025 PM025A Malignant Cough- Invasive intervantions 46200 50820 55440 60060 64680 66990
endoscopic/Surgical/Radiological/Radiother
Medicine
pay interventions
Palliative care management of 0 0 OPEN YES
Medical/Surigal/ Radiation Breathlessness in advanced cancers and
793 Palliative Medicine PM Oncology and Pulmonary PM026 chronic respiraroty diseases- PM026A Palliative Breathlessness Intervntions 46200 50820 55440 60060 64680 66990
Medicine endoscopic/Surgical/Radiological,
Radiotherpay interventions
Symptom Management of Delirium in 0 0 OPEN variable
Medical/Surigal/ Radiation
794 Palliative Medicine PM PM027 advanced chronic diseases -Conservative PM027A Palliative Delirium in advance chronic disease 2350 2585 2820 3055 3290 3407
Oncology
management
Palliative Care approach for malignant 0 0 OPEN variable
Medical/Surigal wound -Conservative management using
795 Palliative Medicine PM PM028 PM028A Palliative Wound Conservative management 2350 2585 2820 3055 3290 3407
Oncology/Radiotherapy drugs and dressings including special
dressings.
0 0 OPEN
Palliative Care Management of Constipation
Medical/Surigal / Radiation in advanced cancer patients -
796 Palliative Medicine PM PM029 PM029A Constipation - Palliative Invasive interventions 34650 38115 41580 45045 48510 50242
oncology & Radiology endoscopic/Surgical/Radiological
interventions
Palliative care management of Nausea 0 0 OPEN
Medical/Surigal / Radiation &Vomiting in advanced cancer patients-
797 Palliative Medicine PM PM030 PM030A Pallitive Nausea and vomiting interventions 34650 38115 41580 45045 48510 50242
Oncology & Radiology Endoscopic/Surgical/Radiological,
Radiotherapy interventions.
0 0 OPEN variable
Palliative Care Management of
Medical/Surigal / Radiation Lymphadema in cancer patients including
798 Palliative Medicine PM PM031 PM031A Conservative management of Lymphedema 2350 2585 2820 3055 3290 3407
oncology (Information, Education, Communication
(IEC), and pneumatic compression therapy
Palliative Radiological Interventions. Like- 0 0 OPEN
Medical/Surigal & Palliative Radiological and endoscopical
799 Palliative Medicine PM PM032 PM032A PTBD/ERCP/PCN//Pericardiostomy, DJ 23100 25410 27720 30030 32340 33495
Radiation Oncology Interventions
Stenting, etc
0 0 OPEN YES
Medical, Surgical Radiation
800 Palliative Medicine PM PM033 Vertebroplasty/Kyphoplasty PM033A Vertebroplasty/Kyphoplasty 46200 50820 55440 60060 64680 66990
Oncology / Orthopaedics
Palliative Care Management of Constipation 0 0 OPEN variable
801 Palliative Medicine PM Medical Oncology PM034 in advanced cancer patients - Conservative PM034A Palliative care in Constipation 2350 2585 2820 3055 3290 3407
menagament
Palliative Care management of Malignant 0 0 OPEN variable
Palliative care in Bowel Obstruction
802 Palliative Medicine PM Medical Oncology PM035 bowel obstruction -Conservative PM035A 2350 2585 2820 3055 3290 3407
Conservative management
management
0 0 OPEN YES
Medical / Surgical Palliative Care management of Malignant
oncology/ gastroenterology bowel obstruction-
803 Palliative Medicine PM PM036 PM036A Palliative Bowel Obstruction interventions 46200 50820 55440 60060 64680 66990
/ / Radiation Oncology & endoscopic/Surgical/Radiological
Radiology interventions
0 0 OPEN variable
Palliative management of thrombosis and
Medical / Radiation
804 Palliative Medicine PM PM036 embolism like DVT, Pulmonary embolism in PM036B Thrombosis and Embolism in chronic disease 2350 2585 2820 3055 3290 3407
Oncology
advanced chronic diseases, TED stockings
Palliative care management of Nausea & 0 0 OPEN variable
Medical & Radiation
805 Palliative Medicine PM PM037 Vomiting in cancer patients-Conservative PM037A Pallitive care in Nausea and vomiting. 2350 2585 2820 3055 3290 3407
Oncology
management
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical Notes including a) Detailed Indoor case OPEN variable
evaluation findings, papers with treatment
indications for the details
procedure, and planned b) Detailed procedure notes
line of treatment c) Detailed Discharge
b) ECG/ECHO with report Summary
c) Chest X-ray report
General medicine/Medical Management of Diarrhea in cancer patients - d) Blood investigations:
806 Palliative Medicine PM PM038 PM038A Palliative care in Diarrhoea 2350 2585 2820 3055 3290 3407
& Radiation Oncology Conservative management Biomarkers, Brain
natriuretic peptide (BNP),
N-terminal pro-brain
natriuretic peptide (NT-
proBNP), Creatine kinase

Cardiac, Neuro, Palliative and supportive care for non- 0 0 OPEN variable
807 Palliative Medicine PM Pulmonary, Nephrology & PM039 malignant disease at advanced or end PM039C Palliative care end stage disease 2350 2585 2820 3055 3290 3407
Geriatric Medicine stage
Cardiac, Neuro, Palliative and supportive care for non- 0 0 OPEN variable
808 Palliative Medicine PM Pulmonary, Nephrology & PM039 malignant disease at advanced or end PM039D Palliative care end stage disease 2350 2585 2820 3055 3290 3407
Geriatric Medicine stage
Spinal/Epidural/Regional Nerve block, 0 0 OPEN
Anaesthesiology/Pain
809 Palliative Medicine PM PM040 Radiofrequency ablation (RFA) for PM040A Cancer pain interventions 8715 9586 10458 11329 12201 12636
specialists/Radiology
analgesia
Celiac Plexus Block/Hypogastric plexus 0 0 OPEN
Anaesthesiology/Pain
810 Palliative Medicine PM PM041 block/ganglion impar block and Neurolysis PM041A Cancer pain plexus interventions 11550 12705 13860 15015 16170 16747
specialists/Radiology
in advanced cancer patients
a) Clinical notes with a) Detailed Indoor Case OPEN
history, signs, symptoms, Papers
evaluation findings, b) Post procedure X-ray
indication for procedure, labelled with patient ID,
Orthopedics, Emergency Fracture - Conservative Management - Fracture - Conservative Management - planned line of date and side (Left/ Right)
811 Orthopedics SB SB001 SB001A 2415 2656 2898 3139 3381 3501 management and advice of affected part
Room Packages Without plaster Without plaster
for admission c) Detailed Procedure /
b) X-ray of affected part Operative Notes
labelled with patient ID, d) Detailed Discharge
date and side (Left/ Right) summary

a) Clinical notes with a) Detailed Indoor case OPEN

indication for surgery papers
b) Clinical photograph of b) Post Procedure clinical
812 4042 4410 4777 5145 5328 affected part photograph with pins.
Orthopedics SB Orthopedics SB002 Application of Traction SB002A Skeletal Tractions with pin 3675
c) X-ray labelled with c) Detailed Procedure /
patient ID, date and side Operative Notes.
(Left/ Right) of affected d) Discharge Summary
limb.
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers (ICPs)
b) Clinical photograph of b) Detailed Procedure /
813 1039 1134 1228 1323 1370 affected part Operative Notes.
Orthopedics SB Orthopedics SB002 Application of Traction SB002B Skin Traction 945
c) X-ray labelled with c) Discharge Summary
patient ID, date and side
(Left/ Right) of affected
limb.
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers (ICPs)
b) Clinical photograph of b) Detailed Procedure /
814 3465 3780 4095 4410 4567 affected part Operative Notes.
Orthopedics SB Orthopedics SB003 Application of P.O.P. casts SB003A Upper Limbs 3150
c) X-ray labelled with c) Post Procedure clinical
patient ID, date and side photograph with POP cast
(Left/ Right) of affected d) Discharge Summary
limb.
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers (ICPs)
b) Clinical photograph of b) Detailed Procedure /
815 3465 3780 4095 4410 4567 affected part Operative Notes.
Orthopedics SB Orthopedics SB003 Application of P.O.P. casts SB003B Lower Limbs 3150
c) X-ray labelled with c) Post Procedure clinical
patient ID, date and side photograph with POP cast
(Left/ Right) of affected d) Discharge Summary
limb.
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers (ICPs)
b) Clinical photograph of b) Post Procedure clinical
816 4042 4410 4777 5145 5328 affected part photograph with POP Spika
Orthopedics SB Orthopedics SB004 Application of P.O.P. Spikas & Jackets SB004A Spikas 3675
c) X-ray labelled with c) Detailed Procedure /
patient ID, date and side Operative Notes.
(Left/ Right) of affected d) Discharge Summary
limb.
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers (ICPs)
b) Clinical photograph of b) Post Procedure clinical
817 4042 4410 4777 5145 5328 affected part photograph with POP
Orthopedics SB Orthopedics SB004 Application of P.O.P. Spikas & Jackets SB004B Jackets 3675
c) X-ray labelled with Jacket c) Detailed
patient ID, date and side Procedure / Operative
(Left/ Right) of affected Notes d)
limb. Discharge Summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) Clinical photograph of b) Post Procedure clinical
affected part photograph
818 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005A Long bone 14700 16170 17640 19110 20580 21315 c) X-ray labelled with c) Detailed Procedure /
patient ID, date and side Operative Notes
(Left/ Right) of affected d) Invoice and barcode of
part implant
e) Detailed discharge
Summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) Clinical photograph of b) Post Procedure clinical
affected part photograph
819 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005B Small bone 9975 10972 11970 12967 13965 14463 c) X-ray labelled with c) Detailed Procedure /
patient ID, date and side Operative Notes
(Left/ Right) of affected d) Invoice and barcode of
part implant
e) Detailed discharge
Summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) Clinical photograph of b) Post Procedure clinical
affected part photograph
820 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005C Pelvis 20160 22176 24192 26208 28224 29232 c) X-ray labelled with c) Detailed Procedure /
patient ID, date and side Operative Notes
(Left/ Right) of affected d) Invoice and barcode of
part implant
e) Detailed discharge
Summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) Clinical photograph of b) Post Procedure clinical
affected part photograph
821 Orthopedics SB Orthopedics SB005 External fixation of Fracture SB005D Both bones - forearms + JESS Ligamentotaxis 15000 16500 18000 19500 21000 21750 c) X-ray labelled with c) Detailed Procedure /
patient ID, date and side Operative Notes
(Left/ Right) of affected d) Invoice and barcode of
part implant
e) Detailed discharge
Summary
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed procedure /
and planned line of operation notes
management, advise for c) Post procedure X-ray
822 Orthopedics SB Orthopedics SB006 Percutaneous - Fixation of Fracture SB006A Percutaneous - Fixation of Fracture 3150 3465 3780 4095 4410 4567 the procedure. labelled with patient ID,
b) Clinical photograph of date and side (Left/ Right) -
affected part affected part
c) X-ray labelled with d) Discharge Summary
patient ID, date and side
(Left/ Right) of affected
part
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed procedure /
and planned line of operation notes
management, advise for c) Post procedure X-ray
823 Orthopedics SB Orthopedics SB007 Elastic nailing for fracture fixation SB007A Femur + shaft tibia 11550 12705 13860 15015 16170 16747 the procedure. labelled with patient ID,
b) Clinical photograph of date and side (Left/ Right) -
affected part affected part
c) X-ray labelled with d) Discharge Summary
patient ID, date and side
(Left/ Right) of affected
part
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed procedure /
and planned line of operation notes
management, advise for c) Post procedure X-ray
824 Orthopedics SB Orthopedics SB007 Elastic nailing for fracture fixation SB007B Humerus 20055 22060 24066 26071 28077 29079 the procedure. labelled with patient ID,
b) Clinical photograph of date and side (Left/ Right) -
affected part affected part
c) X-ray labelled with d) Discharge Summary
patient ID, date and side
(Left/ Right) of affected
part
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed procedure /
and planned line of operation notes
management, advise for c) Post procedure X-ray
825 Orthopedics SB Orthopedics SB007 Elastic nailing for fracture fixation SB007C Forearm 18165 19981 21798 23614 25431 26339 the procedure. labelled with patient ID,
b) Clinical photograph of date and side (Left/ Right) -
affected part affected part
c) X-ray labelled with d) Discharge Summary
patient ID, date and side
(Left/ Right) of affected
part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-procedure X-ray
indication for procedure, labelled with patient ID,
planned line of date and side (Left/ Right)
management and advice showing implant
826 Orthopedics SB Orthopedics SB008 Internal Fixation of Small Bones SB008A ORIF Small Bones 11865 13051 14238 15424 16611 17204 for admission c) Post-operative
b) X-ray labelled with photographs
patient ID, date and side d)Detailed procedure /
(Left/ Right) Operative Notes
c) Clinical photograph of e) Invoice of Implant
affected part f) Discharge summary with
follow-up advise.
Fracture - Long Bones - Metaphyseal - 0 0 OPEN
827 Orthopedics SB Orthopedics SB009 SB009A Fracture - Long Bones - Metaphyseal - ORIF 17220 18942 20664 22386 24108 24969
ORIF
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor Case OPEN
history, signs, symptoms, Papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Intra operative still image
management and advice with patient name
for admission d) Post procedure X-ray
Fixation of Diaphyseal Fracture - Long b) X-ray labelled with showing implant labelled
828 Orthopedics SB Orthopedics SB010 SB010A ORIF Long Bones 21840 24024 26208 28392 30576 31668
Bone patient ID, date and side with patient ID, date and
(Left/ Right) - affected part side (Left/ Right) - affected
c) Clinical Photograph of part
affected part e) Invoice and bar code of
implant
f) Post Procedure clinical
photograph
g) Discharge Summary
a) Clinical notes with a) Detailed Indoor Case OPEN
history, signs, symptoms, Papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Intra operative still image
management and advice with patient name
for admission d) Post procedure X-ray
Fixation of Diaphyseal Fracture - Long Closed Reduction & Internal Fixation of long b) X-ray labelled with showing implant labelled
829 Orthopedics SB Orthopedics SB010 SB010B 21840 24024 26208 28392 30576 31668
Bone bones Fixation patient ID, date and side with patient ID, date and
(Left/ Right) - affected part side (Left/ Right) - affected
c) Clinical Photograph of part
affected part e) Invoice and bar code of
implant
f) Post Procedure clinical
photograph
g) Discharge Summary
a) Clinical notes detailing a) Indoor case papers OPEN
indication b) Procedure / operation
b) Clinical photograph of notes
affected part c) Post procedure X-ray
c) X-ray labelled with labelled with patient ID,
Surgery for Comminuted Fracture - patient ID, date and side date and side (Left/ Right) -
830 Orthopedics SB Orthopedics SB011 SB011A Plating olecrenon fracture, ulna 12390 13629 14868 16107 17346 17965
Olecranon of Ulna (Left/ Right) - affected part affected part
d) Invoice and barcode of
implant
e) Post Procedure clinical
photograph
f) Discharge Summary
a) Clinical notes detailing a) Indoor case papers OPEN
indication b) Procedure / operation
b) Clinical photograph of notes
affected part c) Post procedure X-ray
c) X-ray labelled with labelled with patient ID,
831 Orthopedics SB Orthopedics SB012 Fracture Head radius SB012A Fixation 10500 11550 12600 13650 14700 15225 patient ID, date and side date and side (Left/ Right) -
(Left/ Right) - affected part affected part
d) Invoice and barcode of
implant
e) Post Procedure clinical
photograph
f) Discharge Summary
a) Clinical notes detailing a) Indoor case papers OPEN
indication b) Procedure / operation
b) Clinical photograph of notes
affected part c) Post procedure X-ray
832 Orthopedics SB Orthopedics SB012 Fracture Head radius SB012B Excision 9660 10626 11592 12558 13524 14007 c) X-ray labelled with labelled with patient ID,
patient ID, date and side date and side (Left/ Right) -
(Left/ Right) - affected part affected part
d) Post Procedure clinical
photograph
e) Discharge Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-procedure X-ray
indication for procedure, labelled with patient ID,
planned line of date and side (Left/ Right)
management and advice –Showing implant
Fracture - Single Bone - Forearm - ORIF - Fracture - Single Bone - Forearm - ORIF - for admission c) Post procedure clinical
833 Orthopedics SB Orthopedics SB013 SB013A 9345 10279 11214 12148 13083 13550
Plating / Nailing Plating / Nailing/DCP/LCP b) X-ray labelled with photograph
patient ID, date and side d) Detailed Procedure /
(Left/ Right) – confirming Operative Notes
the diagnosis e) Invoice/barcode of
c) Clinical photograph of Implant used
affected part f) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-procedure X-ray
indication for procedure, labelled with patient ID,
planned line of date and side (Left/ Right)
management and advice –Showing implant
Fracture - Both Bones - Forearm - ORIF - Fracture - Both Bones - Forearm - ORIF - for admission c) Post procedure clinical
834 Orthopedics SB Orthopedics SB014 SB014A 16900 18590 20280 21970 23660 24505
Plating / Nailing Plating / Nailing /DCP/LCP b) X-ray labelled with photograph
patient ID, date and side d) Detailed Procedure /
(Left/ Right) – confirming Operative Notes
the diagnosis e) Invoice/barcode of
c) Clinical photograph of Implant used
affected part f) Detailed Discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
A)Clinical notes. A)Post Procedure clinical OPEN
B)X-ray confirming the photgraph.
diagnosis. B)Post procedure X-
C)Clinical photograph of rayshowing implant.
835 Orthopedics SB Orthopedics SB015 Fracture Condyle - Humerus - ORIF SB015A Lateral Condyle 8925 9817 10710 11602 12495 12941 affected part. C)Detailed Procedure.
D)Operative Notes .
E)Detailed discharge
summary. E)Invoice.
F)Barcode of implant.
A)Clinical notes. A)Clinical notes. OPEN
B)X-ray confirming the B)X-ray confirming the
836 Orthopedics SB Orthopedics SB015 Fracture Condyle - Humerus - ORIF SB015B ORIF with screw/wire of Medial Condyle 8925 9817 10710 11602 12495 12941 diagnosis. diagnosis.
C)Clinical photograph of C)Clinical photograph of
affected part. affected part.
a) Clinical notes detailing a) Indoor case papers OPEN
indication b) Procedure / operation
b) Clinical photograph of notes
affected part c) Post procedure X-ray
c) X-ray labelled with labelled with patient ID,
Fracture intercondylar Humerus + ORIF Fracture intercondylar Humerus + patient ID, date and side date and side (Left/ Right) -
837 Orthopedics SB Orthopedics SB016 SB016A 15855 17440 19026 20611 22197 22989
olecranon osteotomy olecranon osteotomy + TBW (Left/ Right) - affected part affected part
d) Invoice and barcode of
implant
e) Post Procedure clinical
photograph
f) Discharge Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Did the Post-procedure X-
indication for procedure, ray labelled with patient ID,
planned line of date and side (Left/ Right)
management and advice showing implant?
for admission c) Post-procedure clinical
838 Orthopedics SB Orthopedics SB017 Displaced Clavicle Fracture SB017A Open Reduction Internal Fixation 20000 22000 24000 26000 28000 29000 b) X-ray labelled with photographs
patient ID, date and side d) Detailed procedure /
(Left/ Right) confirming the Operative Notes
diagnosis e) Invoice/barcode of
Implant used.
f) Discharge summary with
follow-up advise at the time
of discharge.

a) Clinical notes with a) Detailed Indoor Case OPEN

history, signs, symptoms, Papers (ICPs)
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Invoice and bar code of
839 Orthopedics SB Orthopedics SB018 Fracture - Acetabulum SB018A ORIF THROUGH Single Approach PLATING 29400 32340 35280 38220 41160 42630 management and advice implant
for admission d) Post procedure X-ray
b) X-ray labelled with labelled with patient ID,
patient ID, date and side date and side (Left/ Right) -
(Left/ Right) - affected limb affected limb
e) Discharge Summary
a) Clinical notes with a) Detailed Indoor Case OPEN
history, signs, symptoms, Papers (ICPs)
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Invoice and bar code of
840 Orthopedics SB Orthopedics SB018 Fracture - Acetabulum SB018B ORIF THROUGH combined Approach PLATING 35175 38692 42210 45727 49245 51003 management and advice implant
for admission d) Post procedure X-ray
b) X-ray labelled with labelled with patient ID,
patient ID, date and side date and side (Left/ Right) -
(Left/ Right) - affected limb affected limb
e) Discharge Summary
A)Clinical notes. A)Post procedure imaging OPEN
B)X-ray confirming the study (X Ray).
diagnosis. B)Post Procedure clinical
Closed Reduction and Percutaneous Screw C)Clinical photograph of photgraph.
841 Orthopedics SB Orthopedics SB019 Fracture - Neck Femur SB019A 16275 17902 19530 21157 22785 23598
Fixation affected part. C)Detailed Procedure.
D)Operative Notes.
E)Invoice.
F)Barcode of implant.
A)Clinical notes. A)Post procedure imaging OPEN
B)X-ray confirming the study (X Ray).
diagnosis. B)Post Procedure clinical
ORIF Intertrochanteric Fracture with Dynamic C)Clinical photograph of photgraph.
842 Orthopedics SB Orthopedics SB019 Fracture - Neck Femur SB019B 19320 21252 23184 25116 27048 28014
Hip Screw affected part. C)Detailed Procedure.
D)Operative Notes.
E)Invoice.
F)Barcode of implant.
A)Clinical notes. A)Post procedure imaging OPEN
B)X-ray confirming the study (X Ray).
diagnosis. B)Post Procedure clinical
ORIF Intertrochanteric Fracture with Proximal C)Clinical photograph of photgraph.
843 Orthopedics SB Orthopedics SB019 Fracture - Neck Femur SB019C 16900 18590 20280 21970 23660 24505
Femoral Nail affected part. C)Detailed Procedure.
D)Operative Notes.
E)Invoice.
F)Barcode of implant.
a) Clinical notes with a) Post Procedure clinical OPEN
indication for surgery photograph
b) X-ray labelled with b) Post op X-ray is labelled
patient ID, date and side with patient ID, date and
ORIF of medial malleolus or bimalleolar fracture
844 Orthopedics SB Orthopedics SB020 Ankle Fractures SB020A 16380 18018 19656 21294 22932 23751 (Left/ Right) -affected limb. side (Left/ Right) showing
or Trimalleolar fracture
C) Clinical photograph of affected part.
affected part c) Detailed operative note
d) Discharge Summary
including follow up advice
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor Case OPEN
planned line of treatment Papers (ICPs)
b) X-ray labelled with b) Post-procedure X-ray
patient ID, date and side labelled with patient ID,
(Left/ Right) - affected part date and side (Left/ Right) -
845 Orthopedics SB Orthopedics SB021 Cervical spine fixation including odontoid SB021A Cervical spine fixation including odontoid 28035 30838 33642 36445 39249 40650 affected part
c) Detailed Procedure /
Operative Notes
d) Detailed Discharge
summary
e) Invoice and barcode of
implant
a) Clinical notes with a) Detailed Indoor case OPEN YES
history, signs, symptoms, papers
evaluation findings, b) Post-procedure X-ray
indication for procedure, films labelled with patient
planned line of ID, date and side (Left/
Dorsal and lumber spine fixation THROUGH management and advice Right) -affected part
846 Orthopedics SB Orthopedics SB022 Dorsal and lumber spine fixation SB022A 52500 57750 63000 68250 73500 76125
Anterior approach for admission c) Detailed Procedure /
b) X-ray films labelled with Operative Notes
patient ID, date and side d) Detailed Discharge
(Left/ Right) -affected part summary
e) Invoice and barcode of
implant
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-procedure X-ray
indication for procedure, films labelled with patient
planned line of ID, date and side (Left/
Dorsal and lumber spine fixation THROUGH management and advice Right) -affected part
847 Orthopedics SB Orthopedics SB022 Dorsal and lumber spine fixation SB022B 39375 43312 47250 51187 55125 57093
Posterior approach for admission c) Detailed Procedure /
b) X-ray films labelled with Operative Notes
patient ID, date and side d) Detailed Discharge
(Left/ Right) -affected part summary
e) Invoice and barcode of
implant
a) Clinical notes detailing a) Post Procedure clinical OPEN
earlier surgery that resulted photograph of donor and
in non-union recipient sites
b) Clinical photograph of b) Post procedure imaging
affected part study (X-ray labelled with
848 Orthopedics SB Orthopedics SB023 Bone grafting for Non union SB023A Bone grafting for Fracture Non union 19530 21483 23436 25389 27342 28318 c) Radiological patient ID, date and side
investigations confirming (Left/ Right) showing
the diagnosis (X-ray affected part)
labelled with patient ID, c) Detailed procedure/
date and side (Left/ Right) operative notes
showing affected part.) d) Discharge Summary

a) Clinical notes confirming a) Detailed Indoor case OPEN

the diagnosis papers
b) X-ray labelled with b) Post-procedure X-ray
patient ID, date and side labelled with patient ID,
(Left/ Right) of affected date and side (Left/ Right)
849 Orthopedics SB Orthopedics SB024 Arthorotomy of any joint SB024A Arthorotomy of any joint 14700 16170 17640 19110 20580 21315 part of affected part
c) Clinical photograph of c) Detailed Procedure /
affected part Operative Notes
d) Post procedure clinical
photograph
e) Detailed Discharge
summary
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray labelled with b) Post-procedure X-ray
patient ID, date and side labelled with patient ID,
(Left/ Right) of affected date and side (Left/ Right)
850 Orthopedics SB Orthopedics SB025 Arthrolysis of joint SB025A Elbow 15750 17325 18900 20475 22050 22837 part of affected part
c) Clinical photograph of c) Detailed Procedure /
affected part Operative Notes
d) Post procedure clinical
photograph
e) Detailed Discharge
summary
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray labelled with b) Post-procedure X-ray
patient ID, date and side labelled with patient ID,
(Left/ Right) of affected date and side (Left/ Right)
851 Orthopedics SB Orthopedics SB025 Arthrolysis of joint SB025B Knee 15750 17325 18900 20475 22050 22837 part of affected part
c) Clinical photograph of c) Detailed Procedure /
affected part Operative Notes
d) Post procedure clinical
photograph
e) Detailed Discharge
summary
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray labelled with b) Post-procedure X-ray
patient ID, date and side labelled with patient ID,
(Left/ Right) of affected date and side (Left/ Right)
852 Orthopedics SB Orthopedics SB025 Arthrolysis of joint SB025C Ankle 15750 17325 18900 20475 22050 22837 part of affected part
c) Clinical photograph of c) Detailed Procedure /
affected part Operative Notes
d) Post procedure clinical
photograph
e) Detailed Discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes detailing a) Detailed Indoor case OPEN
indication papers
b) Clinical photograph of b) Detailed Procedure /
affected part Operative Notes
c) X-ray labelled with c) Post procedure X-ray
patient ID, date and side labelled with patient ID,
853 Orthopedics SB Orthopedics SB026 Arthrodesis SB026A Ankle / Triple with implant 17955 19750 21546 23341 25137 26034 (Left/ Right) of affected date and side (Left/ Right)
part of affected part
d) Invoice and bar code of
implant
e) Post Procedure clinical
photograph
f) Detailed discharge
summary
a) Clinical notes detailing a) Detailed Indoor case OPEN
indication papers
b) Clinical photograph of b) Detailed Procedure /
affected part Operative Notes
c) X-ray labelled with c) Post procedure X-ray
patient ID, date and side labelled with patient ID,
854 Orthopedics SB Orthopedics SB026 Arthrodesis SB026B Shoulder 17955 19750 21546 23341 25137 26034 (Left/ Right) of affected date and side (Left/ Right)
part of affected part
d) Invoice and bar code of
implant
e) Post Procedure clinical
photograph
f) Detailed discharge
summary
a) Clinical notes detailing a) Detailed Indoor case OPEN
indication papers
b) Clinical photograph of b) Detailed Procedure /
affected part Operative Notes
c) X-ray labelled with c) Post procedure X-ray
patient ID, date and side labelled with patient ID,
855 Orthopedics SB Orthopedics SB026 Arthrodesis SB026C Wrist, Wrist with plating 17955 19750 21546 23341 25137 26034 (Left/ Right) of affected date and side (Left/ Right)
part of affected part
d) Invoice and bar code of
implant
e) Post Procedure clinical
photograph
f) Detailed discharge
summary
a) Clinical notes detailing a) Detailed Indoor case OPEN
indication papers
b) Clinical photograph of b) Detailed Procedure /
affected part Operative Notes
c) X-ray labelled with c) Post procedure X-ray
patient ID, date and side labelled with patient ID,
856 Orthopedics SB Orthopedics SB026 Arthrodesis SB026D Knee, Knee with plating/Nailing 17955 19750 21546 23341 25137 26034 (Left/ Right) of affected date and side (Left/ Right)
part of affected part
d) Invoice and bar code of
implant
e) Post Procedure clinical
photograph
f) Detailed discharge
summary
a) Clinical notes detailing a) Detailed Indoor case OPEN
indication papers
b) Clinical photograph of b) Detailed Procedure /
affected part Operative Notes
c) X-ray labelled with c) Post procedure X-ray
Orthopedics, Surgical patient ID, date and side labelled with patient ID,
857 Orthopedics SB SB026 Arthrodesis SB026E Hand 28350 31185 34020 36855 39690 41107
Oncology (Left/ Right) of affected date and side (Left/ Right)
part of affected part
d) Post Procedure clinical
photograph
e) Detailed discharge
summary
a) Clinical notes detailing a) Detailed Indoor case OPEN
indication papers
b) Clinical photograph of b) Detailed Procedure /
affected part Operative Notes
c) X-ray labelled with c) Post procedure X-ray
Orthopedics, Surgical patient ID, date and side labelled with patient ID,
858 Orthopedics SB SB026 Arthrodesis SB026F Foot 28350 31185 34020 36855 39690 41107
Oncology (Left/ Right) of affected date and side (Left/ Right)
part of affected part
d) Post Procedure clinical
photograph
e) Detailed discharge
summary
a) Clinical notes detailing a) Detailed Indoor case OPEN
indication papers
b) Clinical photograph of b) Detailed Procedure /
affected part Operative Notes
c) X-ray labelled with c) Post procedure X-ray
859 Orthopedics SB Orthopedics SB026 Arthrodesis SB026G Ankle / Triple without implant 18270 20097 21924 23751 25578 26491 patient ID, date and side labelled with patient ID,
(Left/ Right) of affected date and side (Left/ Right)
part of affected part
d) Post Procedure clinical
photograph
e) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes justifying a) Detailed Indoor case OPEN
the diagnosis and Papers (ICPs)
indication for proceeding b) Post-procedure clinical
with surgery along with photograph
planned line of treatment c) Detailed Procedure /
b) X-ray/MRI/PET labelled Operative Notes
860 Orthopedics SB Orthopedics SB027 Disarticulation SB027A Hind quarter 32865 36151 39438 42724 46011 47654 with patient ID, date and d) Detailed Discharge
side (Left/ Right) -affected summary
limb
c) Clinical photograph of
the affected part showing
the gangrene/injury/severe
anatomical deformity

a) Clinical notes justifying a) Detailed Indoor case OPEN

the diagnosis and Papers (ICPs)
indication for proceeding b) Post-procedure clinical
with surgery along with photograph
planned line of treatment c) Detailed Procedure /
b) X-ray/MRI/PET labelled Operative Notes
861 Orthopedics SB Orthopedics SB027 Disarticulation SB027B Fore quarter 26250 28875 31500 34125 36750 38062 with patient ID, date and d) Detailed Discharge
side (Left/ Right) -affected summary
limb
c) Clinical photograph of
the affected part showing
the gangrene/injury/severe
anatomical deformity

a) Clinical notes with a) Detailed Indoor case OPEN

history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post procedure X-ray
management and advice labelled with patient ID,
862 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028A Hip 11970 13167 14364 15561 16758 17356 for admission date and side (Left/ Right)
b) Clinical photograph of of affected part
affected part d) Post Procedure clinical
c) X-ray labelled with photograph
patient ID, date and side e) Discharge Summary
(Left/ Right) of affected
part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post procedure X-ray
management and advice labelled with patient ID,
863 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028B Shoulder 5775 6352 6930 7507 8085 8373 for admission date and side (Left/ Right)
b) Clinical photograph of of affected part
affected part d) Post Procedure clinical
c) X-ray labelled with photograph
patient ID, date and side e) Discharge Summary
(Left/ Right) of affected
part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post procedure X-ray
management and advice labelled with patient ID,
864 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028C Elbow 13860 15246 16632 18018 19404 20097 for admission date and side (Left/ Right)
b) Clinical photograph of of affected part
affected part d) Post Procedure clinical
c) X-ray labelled with photograph
patient ID, date and side e) Discharge Summary
(Left/ Right) of affected
part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post procedure X-ray
management and advice labelled with patient ID,
865 Orthopedics SB Orthopedics SB028 Closed reduction of joint dislocation SB028D Knee 11970 13167 14364 15561 16758 17356 for admission date and side (Left/ Right)
b) Clinical photograph of of affected part
affected part d) Post Procedure clinical
c) X-ray labelled with photograph
patient ID, date and side e) Discharge Summary
(Left/ Right) of affected
part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-op X-ray -ray
indication for procedure, labelled with patient ID,
planned line of date and side (Left/ Right) -
Open Reduction of Small Joint without management and advice affected limb
866 Orthopedics SB Orthopedics SB029 Open Reduction of Small Joint SB029A fixation/Open Reduction of Small Joint with 8925 9817 10710 11602 12495 12941 for admission c) Post procedure clinical
fixation b) X-ray labelled with photograph
patient ID, date and side d) Invoice and barcode of
(Left/ Right) - affected limb implant
c) Clinical photograph of e) Detailed Procedure /
child/Patient Operative Notes
f) Detailed Discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers (ICPs)
evaluation findings, b) Post-op X-ray labelled
indication for procedure, with patient ID, date and
planned line of side (Left/ Right) - affected
867 Orthopedics SB Orthopedics SB030 Tension Band Wiring SB030A Tension Band Wiring 13650 15015 16380 17745 19110 19792 management and advice limb
for admission c) Invoice and barcode of
b) X-ray labelled with implant
patient ID, date and side d) Detailed Procedure /
(Left/ Right) - affected limb Operative Notes
e) Detailed Discharge
summary
A)Clinical notes. A)Post Procedure clinical OPEN
B)X-ray. photgraph.
C)CT justifying the surgery. B)Detailed discharge
summary. C)Detailed
868 Orthopedics SB Orthopedics SB031 Hemiarthroplasty SB031A Unipolar 18270 20097 21924 23751 25578 26491 Procedure. D)Operative
Notes.
E)Post op X-ray showing
the implant.
F)Invoice.
G)Bar code of implant.
A)Clinical notes. A)Post Procedure clinical OPEN
B)X-ray. photgraph.
C)CT justifying the surgery. B)Detailed discharge
summary. C)Detailed
Bipolar (Non - Modular) cemented /non Procedure. D)Operative
869 Orthopedics SB Orthopedics SB031 Hemiarthroplasty SB031B 18270 20097 21924 23751 25578 26491
cemented Notes.
E)Post op X-ray showing
the implant.
F)Invoice.
G)Bar code of implant.
A)Clinical notes. A)Post Procedure clinical OPEN
B)X-ray. photgraph.
C)CT justifying the surgery. B)Detailed discharge
summary. C)Detailed
870 Orthopedics SB Orthopedics SB031 Hemiarthroplasty SB031C Bipolar (Modular) cemented/non cemented 18270 20097 21924 23751 25578 26491 Procedure. D)Operative
Notes.
E)Post op X-ray showing
the implant.
F)Invoice.
G)Bar code of implant.
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray/ MRI labelled with b) Post-op X-ray labelled
patient ID, date and side with patient ID, date and
(Left/ Right) of affected side (Left/ Right) of
871 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032A Rockwood Type - I 21525 23677 25830 27982 30135 31211 limb operated limb
c) Detailed Procedure /
Operative Notes
d) Invoice and barcode of
implant
e) Detailed Discharge
summary
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray/ MRI labelled with b) Post-op X-ray labelled
patient ID, date and side with patient ID, date and
(Left/ Right) of affected side (Left/ Right) of
872 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032B Rockwood Type - II 21525 23677 25830 27982 30135 31211 limb operated limb
c) Detailed Procedure /
Operative Notes
d) Invoice and barcode of
implant
e) Detailed Discharge
summary
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray/ MRI labelled with b) Post-op X-ray labelled
patient ID, date and side with patient ID, date and
(Left/ Right) of affected side (Left/ Right) of
873 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032C Rockwood Type - III 21525 23677 25830 27982 30135 31211 limb operated limb
c) Detailed Procedure /
Operative Notes
d) Invoice and barcode of
implant
e) Detailed Discharge
summary
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray/ MRI labelled with b) Post-op X-ray labelled
patient ID, date and side with patient ID, date and
(Left/ Right) of affected side (Left/ Right) of
874 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032D Rockwood Type - IV 21525 23677 25830 27982 30135 31211 limb operated limb
c) Detailed Procedure /
Operative Notes
d) Invoice and barcode of
implant
e) Detailed Discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray/ MRI labelled with b) Post-op X-ray labelled
patient ID, date and side with patient ID, date and
(Left/ Right) of affected side (Left/ Right) of
875 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032E Rockwood Type - V 21525 23677 25830 27982 30135 31211 limb operated limb
c) Detailed Procedure /
Operative Notes
d) Invoice and barcode of
implant
e) Detailed Discharge
summary
a) Clinical notes confirming a) Detailed Indoor case OPEN
the diagnosis papers
b) X-ray/ MRI labelled with b) Post-op X-ray labelled
patient ID, date and side with patient ID, date and
(Left/ Right) of affected side (Left/ Right) of
876 Orthopedics SB Orthopedics SB032 AC Joint reconstruction / Stabilization SB032F Rockwood Type - VI 21525 23677 25830 27982 30135 31211 limb operated limb
c) Detailed Procedure /
Operative Notes
d) Invoice and barcode of
implant
e) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor Case OPEN
history, signs, symptoms, Papers
evaluation findings, b) Post-operative clinical
indication for procedure, photograph
planned line of c) Detailed Procedure /
management and advice Operative Notes
877 Orthopedics SB Orthopedics SB033 Excision Arthoplasty of Femur head SB033A Excision Arthoplasty of Femur head 18375 20212 22050 23887 25725 26643 for admission d) Detailed Discharge
b) Clinical photograph of summary
affected part
c) X-ray/MRI labelled with
patient ID, date and side
(Left/ Right) - affected limb

a) Clinical notes confirming a) Post-op X-ray labelled OPEN

CDH with patient ID, date and
b) X-ray/Ultrasonography side (Left/ Right)
–both Hips confirming CDH b) Post Procedure clinical
878 Orthopedics SB Orthopedics SB034 Open Reduction of CDH SB034A Open Reduction of CDH 21000 23100 25200 27300 29400 30450 labelled with patient ID, photograph
date. c) detailed Procedure /
c) Clinical photograph Operative Notes
d) Detailed Discharge
summary
a) Clinical notes a) Post Procedure clinical OPEN
b) X-ray of the patella photograph
justifying the procedure b) Post procedure imaging
879 12705 13860 15015 16170 16747 with patient ID, date and study (X Ray)
Orthopedics SB Orthopedics SB035 Patellectomy SB035A Patellectomy 11550
side (Left/ Right) c) Detailed Procedure /
c) Clinical photograph of Operative Notes.
affected part d) Detailed discharge
summary.
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers (ICPs)
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Intra operative still image
Arthroscopic Meniscus Repair / management and advice with patient name
880 Orthopedics SB Orthopedics SB036 SB036A Arthroscopic Meniscus Repair / Meniscectomy 12600 13860 15120 16380 17640 18270 for admission d) Post Procedure clinical
Meniscectomy
b) MRI scan of affected photograph
part labelled with patient e) Discharge Summary
ID, date and side (Left/
Right)
c) Clinical Photograph of
affected part
a) Clinical notes a) Post Procedure clinical OPEN
b) X-ray/ CT labelled with photograph
patient ID, date and side b) Detailed discharge
(Left/ Right)-affected limb summary.
justifying the surgery c) Detailed Procedure /
881 Orthopedics SB Orthopedics SB037 Elbow replacement SB037A Elbow replacement 35000 38500 42000 45500 49000 50750 Operative Notes.
d) Post op X-ray labelled
with patient ID, date and
side (Left/ Right)-affected
limb, showing the implant
e) Invoice / bar code of
implant
a )Clinical notes with a) Indoor case papers OPEN YES
indication for surgery b) Post op clinical
b) X-ray / CT of Hip photograph c) Post op X-
labelled with patient ID, ray showing the implant.
882 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038A Cemented 64680 71148 77616 84084 90552 93786 date and side (Left/ Right) The X-ray is labelled with
patient ID, date and side
(Left/ Right)
d ) Invoice / bar code of
implant
e) Detailed OT note
a )Clinical notes with a) Indoor case papers OPEN YES
indication for surgery b) Post op clinical
b) X-ray / CT of Hip photograph c) Post op X-
labelled with patient ID, ray showing the implant.
883 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038B Cementless 48615 53476 58338 63199 68061 70491 date and side (Left/ Right) The X-ray is labelled with
patient ID, date and side
(Left/ Right)
d ) Invoice / bar code of
implant
e) Detailed OT note
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a )Clinical notes with a) Indoor case papers OPEN YES
indication for surgery b) Post op clinical
b) X-ray / CT of Hip photograph c) Post op X-
labelled with patient ID, ray showing the implant.
884 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038C Hybrid 66885 73573 80262 86950 93639 96983 date and side (Left/ Right) The X-ray is labelled with
patient ID, date and side
(Left/ Right)
d ) Invoice / bar code of
implant
e) Detailed OT note
a )Clinical notes with a) Indoor case papers OPEN YES
indication for surgery b) Post op clinical
b) X-ray / CT of Hip photograph c) Post op X-
labelled with patient ID, ray showing the implant.
885 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB038D Revision - Total Hip Replacement 140000 154000 168000 182000 196000 203000 date and side (Left/ Right) The X-ray is labelled with
c) Pre-op X – ray of the patient ID, date and side
affected hip shows implant (Left/ Right)
d ) Invoice / bar code of
implant
e) Detailed OT note
a) Clinical notes with a) Indoor case papers OPEN YES
indication for surgery b) Post op clinical
b) X-ray / CT of Knee photograph c) Post op X-
labelled with patient ID, ray of the operated knee
date and side (Left/ Right) showing the implant. The X-
ray is labelled with patient
886 Orthopedics SB Orthopedics SB039 Total Knee Replacement SB039A Primary - Total Knee Replacement 100000 110000 120000 130000 140000 145000 ID, date and side (Left/
Right) d)
Invoice / bar code of
implant e) Detailed
operative / procedure note
f) Discharge Summary

a) Clinical notes with a) Indoor case papers OPEN YES

indication for surgery b) Post op clinical
b) X-ray / CT of Knee photograph c) Post op X-
labelled with patient ID, ray of the operated knee
date and side (Left/ Right) showing the implant. The X-
c) Pre-op X – ray of the ray is labelled with patient
887 Orthopedics SB Orthopedics SB039 Total Knee Replacement SB039B Revision - Total Knee Replacement 130000 143000 156000 169000 182000 188500 affected knee shows ID, date and side (Left/
implant Right) d)
Invoice / bar code of
implant e) Detailed
operative / procedure note
f) Discharge Summary

a) Clinical notes with a) Detailed Indoor case OPEN YES

planned line of Treatment papers
b) X-ray/MRI labelled with b) Procedure / operation
patient ID, date and side notes
(Left/ Right) of affected c) Histopathology of
part excised tissue
Bone Tumour Excision (malignant) Bone Tumour Excision (malignant) including c) Biopsy report d) Invoice and bar code of
888 Orthopedics SB Orthopedics SB040 including GCT + Joint replacement SB040A GCT + Joint replacement 85365 93901 102438 110974 119511 123779 d) Clinical photograph of implant
(depending upon type of joint and implant) (depending upon type of joint and implant) affected part e) Post procedure X-ray
labelled with patient ID,
date and side (Left/ Right)
of affected part
f) Post Procedure clinical
photograph
g) Detailed Discharge
Summary
A)Clinical notes justifying a) Post procedure imaging OPEN
need of this surgery. study (X Ray).
B)X-ray. b) Post procedure clinical
C)MRI of affected part. photgraph.
D)Biopsy. c) Detailed Procedure.
Orthopedics, Surgical E)Clinical photograph of d) Operative Note.
889 Orthopedics SB SB041 Bone Tumour Excision + reconstruction SB041A Bone Tumour Excision + reconstruction 39375 43312 47250 51187 55125 57093
Oncology affected part. e) Detailed discharge
summary.
f) Invoice and barcode of
implant.

a) Clinical notes justifying a) Post procedure imaging OPEN

need of this surgery. study (X Ray).
b) X-ray. b) Post Procedure clinical
c) MRI of affected part. photgraph of both donor.
d) Biopsy. c)Recipient sites.
Bone Tumour (benign) curettage / Excision Bone Tumour (benign) curettage / Excision and e) Clinical photograph of d) Detailed Procedure.
890 Orthopedics SB Orthopedics SB042 SB042A 29085 31993 34902 37810 40719 42173 affected part. e) Operative Notes.
and bone grafting bone grafting
f) Histopathology of
curreted tissue.
g) Detailed Discharge
summary.

a) Clinical notes with a) Detailed Indoor case OPEN

indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
891 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043A Above Elbow 16334 17967 19600 21234 22867 23684 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
892 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043B Below Elbow 17010 18711 20412 22113 23814 24664 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
893 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043C Above Knee 19000 20900 22800 24700 26600 27550 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
894 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043D Below Knee 19530 21483 23436 25389 27342 28318 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
895 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043E Foot 19530 21483 23436 25389 27342 28318 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
896 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043F Hand 19530 21483 23436 25389 27342 28318 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
897 Orthopedics SB Orthopedics SB043 Single Stage Amputation SB043G Wrist 19530 21483 23436 25389 27342 28318 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
898 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044A Above Elbow 24360 26796 29232 31668 34104 35322 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
899 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044B Below Elbow 24360 26796 29232 31668 34104 35322 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
900 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044C Above Knee 24360 26796 29232 31668 34104 35322 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
901 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044D Below Knee 24360 26796 29232 31668 34104 35322 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
902 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044E Foot 24360 26796 29232 31668 34104 35322 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
903 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044F Hand 24360 26796 29232 31668 34104 35322 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
904 Orthopedics SB Orthopedics SB044 Two Stage Amputation SB044G Wrist 24360 26796 29232 31668 34104 35322 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
905 Orthopedics SB Orthopedics SB045 Amputation - Fingers / Toes SB045A Finger(s) 14175 15592 17010 18427 19845 20553 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) X-ray labelled with b) Post-operative X-ray
patient ID, date and side labelled with patient ID,
906 Orthopedics SB Orthopedics SB045 Amputation - Fingers / Toes SB045B Toe(s) 14175 15592 17010 18427 19845 20553 (Left/ Right) of affected date and side (Left/ Right)
limb/part showing affected part
c) MLC/ FIR (if traumatic c) Detailed Procedure /
patient) Operative Notes
d) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post Procedure clinical
management and advice photograph of affected part
907 Orthopedics SB Orthopedics SB046 Tendon Grafting / Repair SB046A Tendon Grafting 16380 18018 19656 21294 22932 23751 for admission (of donor and recipient sites-
b) Clinical photograph of for tendon graft) (Only for
affected part Tendon grafting)
d) Post Procedure clinical
photograph of affected part
e) Discharge Summary

a) Clinical notes with a) Detailed Indoor case OPEN

history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post Procedure clinical
management and advice photograph of affected part
908 Orthopedics SB Orthopedics SB046 Tendon Grafting / Repair SB046B Tendon Repair 16380 18018 19656 21294 22932 23751 for admission (of donor and recipient sites-
b) Clinical photograph of for tendon graft) (Only for
affected part Tendon grafting)
d) Post Procedure clinical
photograph of affected part
e) Discharge Summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post Procedure clinical
management and advice photograph of affected part
909 Orthopedics SB Orthopedics SB047 Tendon Release / Tenotomy SB047A Tendon Release / Tenotomy 5250 5775 6300 6825 7350 7612 for admission (of donor and recipient sites-
b) Clinical photograph of for tendon graft) (Only for
affected part Tendon grafting)
d) Post Procedure clinical
photograph of affected part
e) Discharge Summary

a) Clinical notes with a) Detailed Indoor case OPEN

history, signs, symptoms, papers
evaluation findings, b) Post Procedure clinical
indication for procedure, photograph
910 Orthopedics SB Orthopedics SB048 Tenolysis SB048A Tenolysis 5250 5775 6300 6825 7350 7612 planned line of c) Detailed
management and advice procedure/operative notes
for admission including agent used for
b) Clinical photograph of lysis of tendon
affected part d) Detailed Discharge
Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers (ICPs)
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Intra operative still image
management and advice with patient name
for admission (In case of Arthroscopic
b) MRI scan of affected surgery)
Reconstruction of Cruciate Ligament with part labelled with patient d) Post procedure X-ray
911 Orthopedics SB Orthopedics SB049 SB049A Anterior 33810 37191 40572 43953 47334 49024 ID, date and side (Left/ showing implant labelled
implant and brace
Right) with patient ID, date and
c) Clinical Photograph of side (Left/ Right) - affected
affected part part
e) Invoice and bar code of
implant ensure brace is
provided in package cost.
f) Post Procedure clinical
photograph
g) Discharge Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers (ICPs)
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Intra operative still image
management and advice with patient name
for admission (In case of Arthroscopic
b) MRI scan of affected surgery)
Reconstruction of Cruciate Ligament with part labelled with patient d) Post procedure X-ray
912 Orthopedics SB Orthopedics SB049 SB049B Posterior 33810 37191 40572 43953 47334 49024 ID, date and side (Left/ showing implant labelled
implant and brace
Right) with patient ID, date and
c) Clinical Photograph of side (Left/ Right) - affected
affected part part
e) Invoice and bar code of
implant ensure brace is
provided in package cost.
f) Post Procedure clinical
photograph
g) Discharge Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-Procedure clinical
indication for procedure, photograph
planned line of c) Detailed Procedure /
management and advice Operative Notes
913 Orthopedics SB Orthopedics SB050 Fasciotomy SB050A Fasciotomy 11025 12127 13230 14332 15435 15986 for admission d) Detailed Discharge
b) USG report labelled with summary
patient ID, date and side
(Left/ Right) of Affected
part c)
Clinical photograph of
affected part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-Procedure clinical
indication for procedure, photograph
planned line of c) Detailed Procedure /
Duputryen’s Contracture release + management and advice Operative Notes
914 Orthopedics SB Orthopedics SB051 SB051A Duputryen’s Contracture release + rehabilitation 14490 15939 17388 18837 20286 21010 for admission d) Detailed Discharge
rehabilitation
b) USG report labelled with summary
patient ID, date and side
(Left/ Right) of Affected
part c)
Clinical photograph of
affected part
a) Clinical notes with a) Detailed Indoor Case OPEN
planned line of treatment Papers (ICPs)
b) X-ray labelled with b) Post-procedure clinical
patient ID, date and side photograph
Debridement & Closure of injuries - (Left/ Right) - affected part c) Evidence of dressing
915 Orthopedics SB Orthopedics SB052 SB052A Anti-biotic + dressing - minimum of 5 sessions 15750 17325 18900 20475 22050 22837
contused lacerated wounds and confirming the sessions
diagnosis d) Detailed Procedure /
c) Clinical photograph of Operative Notes
affected part e) Detailed Discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor Case OPEN
planned line of treatment Papers (ICPs)
b) X-ray labelled with b) Post-procedure clinical
patient ID, date and side photograph
Debridement & Closure of injuries - (Left/ Right) - affected part c) Evidence of dressing
916 Orthopedics SB Orthopedics SB052 SB052B Anti-biotic + dressing - minimum of 2 sessions 5145 5659 6174 6688 7203 7460
contused lacerated wounds and confirming the sessions
diagnosis d) Detailed Procedure /
c) Clinical photograph of Operative Notes
affected part e) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post-op X-ray labelled
indication for procedure, with patient ID, date and
planned line of side (Left/ Right) - affected
917 Orthopedics SB Orthopedics SB053 Sequestectomy / Curettage SB053A Sequestectomy / Curettage 10500 11550 12600 13650 14700 15225 management and advice part
for admission c) Detailed Procedure /
b) X-ray/CT labelled with Operative Notes
patient ID, date and side d) Detailed Discharge
(Left/ Right) - affected part summary

a) Clinical notes confirming a) Detailed Indoor case OPEN

the diagnosis papers
b) X-ray with film with b) Detailed Procedure /
patient ID, date and side operation notes
(Left/ Right) of affected c) Post-operative X-ray with
As per Number of part film showing implant
918 Orthopedics SB Orthopedics SB054 Spine deformity correction SB054A Spine deformity correction #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! labelled with patient ID,
Screw
date and side (Left/ Right)
of affected part
d) Invoice and barcode of
implant
e) Detailed discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes c) Post procedure X-
planned line of ray with patient ID, date
management and advice and side (Left/ Right)
919 Orthopedics SB Orthopedics SB055 Osteotomy SB055A Long Bone 20000 22000 24000 26000 28000 29000 for admission d) Invoice and barcode of
b) X-ray with patient ID, implant
date and side (Left/ Right) - e) Post procedure clinical
affected part justifying the photograph
procedure f) Discharge Summary
c) Clinical photograph of
affected part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes c) Post procedure X-
planned line of ray with patient ID, date
management and advice and side (Left/ Right)
920 Orthopedics SB Orthopedics SB055 Osteotomy SB055B Small Bone 10500 11550 12600 13650 14700 15225 for admission d) Post procedure clinical
b) X-ray with patient ID, photograph
date and side (Left/ Right) - e) Discharge Summary
affected part justifying the
procedure
c) Clinical photograph of
affected part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers (ICPs)
evaluation findings, b) Post-procedure clinical
indication for procedure, photograph
planned line of c) Post procedure imaging
management and advice study (X Ray) pelvis
921 Orthopedics SB Orthopedics SB056 Pelvic Osteotomy and fixation SB056A Pelvic Osteotomy and fixation 21000 23100 25200 27300 29400 30450 for admission labelled with patient ID,
b) Clinical photograph of date and side (Left/ Right)
affected part d) Detailed Procedure /
c) X-ray of pelvis labelled Operative Notes
with patient ID, date and e) Detailed Discharge
side (Left/ Right) summary

a) Clinical notes with a) Post operation clinical OPEN

indication for surgery photograph
b) Weightbearing (FLWB)/ b) Post op X-ray is labelled
922 18480 20160 21840 23520 24360 Standing X-ray labelled with patient ID, date and
Orthopedics SB Orthopedics SB057 High Tibial Osteotomy SB057A High Tibial Osteotomy 16800
with patient ID, date and side (Left/ Right) showing
side (Left/ Right)-affected affected part.
limb justifying the c) Detailed operative note
indication; d) Discharge Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post procedure clinical
management and advice photograph
for admission d) Post procedure X-ray
923 Orthopedics SB Orthopedics SB058 Ilizarov Fixation SB058A Ilizarov Fixation 15750 17325 18900 20475 22050 22837 b) Radiological showing implant labelled
investigations confirming with patient ID, date and
the diagnosis side (Left/ Right) - affected
c) Clinical photograph of part
affected part e) Intra procedure still
pictures
f) Invoice/barcode of
implant
g) Discharge Summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post procedure clinical
management and advice photograph
for admission d) Post procedure X-ray
Limb Lengthening / Bone Transport by b) Radiological showing implant labelled
924 Orthopedics SB Orthopedics SB059 SB059A Limb Lengthening / Bone Transport by Ilizarov 24885 27373 29862 32350 34839 36083
Ilizarov investigations confirming with patient ID, date and
the diagnosis side (Left/ Right) - affected
c) Clinical photograph of part
affected part e) Intra procedure still
pictures
f) Invoice/barcode of
implant
g) Discharge Summary
a) Clinical notes with a) Detailed Indoor Case OPEN
history, signs, symptoms, Papers
evaluation findings, b) Post-procedure X-ray
indication for procedure, labelled with patient ID,
planned line of date and side (Left/ Right) -
925 Orthopedics SB Orthopedics SB060 Growth Modulation and fixation SB060A Growth Modulation and fixation 5985 6583 7182 7780 8379 8678 management and advice affected limb
for admission c) Detailed Procedure /
b) X-ray labelled with Operative Notes
patient ID, date and side d) Invoice and bar code of
(Left/ Right) - affected limb implant
e) Detailed Discharge
summary
a) Clinical notes with a) Detailed indoor case OPEN
planned line of papers
Surgery/Treatment b) Procedure / operation
b) X-ray/MRI labelled with notes c) Post procedure X-
926 Orthopedics SB Orthopedics SB061 Corrective Surgery for foot deformities SB061A Vertical Talus 15750 17325 18900 20475 22050 22837 patient ID, date and side ray labelled with patient ID,
(Left/ Right) of affected date and side (Left/ Right)
part of affected part
c) Clinical photograph of d) Post Procedure clinical
affected part photograph
e) Discharge Summary
a) Clinical notes with a) Detailed indoor case OPEN
planned line of papers
Surgery/Treatment b) Procedure / operation
b) X-ray/MRI labelled with notes c) Post procedure X-
927 Orthopedics SB Orthopedics SB061 Corrective Surgery for foot deformities SB061B Other foot deformities 15750 17325 18900 20475 22050 22837 patient ID, date and side ray labelled with patient ID,
(Left/ Right) of affected date and side (Left/ Right)
part of affected part
c) Clinical photograph of d) Post Procedure clinical
affected part photograph
e) Discharge Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post procedure clinical
indication for procedure, photograph with cast
planned line of c)Detailed Procedure /
management and advice Operative Notes
928 Orthopedics SB Orthopedics SB062 Correction of club foot per cast SB062A Correction of club foot per cast 5985 6583 7182 7780 8379 8678 for admission d) Post procedure X-ray
b) X-ray/MRI labelled with labelled with patient ID,
patient ID, date and side date and side (Left/ Right) -
(Left/ Right) of affected affected part
part e) Detailed Discharge
c) Clinical photograph of summary
affected part
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post procedure clinical
indication for procedure, photograph with cast
planned line of c) Invoice/bar code of
management and advice implant
Corrective Surgery in Club Foot / JESS for admission d) Detailed Procedure /
929 Orthopedics SB Orthopedics SB063 SB063A Corrective Surgery in Club Foot / JESS Fixator 20000 22000 24000 26000 28000 29000
Fixator b) X-ray/MRI labelled with Operative Notes
patient ID, date and side e) Post procedure X-ray
(Left/ Right) of affected labelled with patient ID,
part date and side (Left/ Right) -
c) Clinical photograph of affected part
affected part f) Detailed Discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
planned line of Treatment papers
b) X-ray/MRI labelled with b) Procedure / operation
930 11550 12600 13650 14700 15225 patient ID, date and side notes
Orthopedics SB Orthopedics SB064 Excision of Osteochondroma / Exostosis SB064A Osteochondroma 10500
(Left/ Right) of affected c) Histopathology of
part excised tissue
c) Clinical photograph of d) Detailed Discharge
affected part Summary
a) Clinical notes with a) Detailed Indoor case OPEN
planned line of Treatment papers
b) X-ray/MRI labelled with b) Procedure / operation
931 11550 12600 13650 14700 15225 patient ID, date and side notes
Orthopedics SB Orthopedics SB064 Excision of Osteochondroma / Exostosis SB064B Exostosis 10500
(Left/ Right) of affected c) Histopathology of
part excised tissue
c) Clinical photograph of d) Detailed Discharge
affected part Summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes detailing a) Post-procedure clinical OPEN
findings confirming the photograph
diagnosis b) Detailed Procedure /
b) Clinical photograph of Operative Notes
Orthopedics,
932 Orthopedics SB SB065 Excision of Bursa SB065A Excision of Bursa 3150 3465 3780 4095 4410 4567 the affected part c) Detailed Discharge
General Surgery
c) X-ray labelled with summary
patient ID, date and side
(Left/ Right) -affected part
justifying the indication.
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) EMG/NCV/MRI labelled b) Detailed Procedure /
933 15015 16380 17745 19110 19792 with patient ID, date and operation notes
Orthopedics SB Orthopedics SB066 Nerve Transposition / Release / Neurolysis SB066A Nerve Transposition 13650
side (Left/ Right) of c) Post procedure clinical
affected part photograph
d) Detailed Discharge
Summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) EMG/NCV/MRI labelled b) Detailed Procedure /
934 15015 16380 17745 19110 19792 with patient ID, date and operation notes
Orthopedics SB Orthopedics SB066 Nerve Transposition / Release / Neurolysis SB066B Nerve Release 13650
side (Left/ Right) of c) Post procedure clinical
affected part photograph
d) Detailed Discharge
Summary
a) Clinical notes with a) Detailed Indoor case OPEN
indication for surgery papers
b) EMG/NCV/MRI labelled b) Detailed Procedure /
935 15015 16380 17745 19110 19792 with patient ID, date and operation notes
Orthopedics SB Orthopedics SB066 Nerve Transposition / Release / Neurolysis SB066C Nerve Neurolysis 13650
side (Left/ Right) of c) Post procedure clinical
affected part photograph
d) Detailed Discharge
Summary
a) Clinical notes with a) Detailed Indoor case OPEN
history, signs, symptoms, papers
evaluation findings, b) Post Procedure clinical
indication for procedure, photograph
936 Orthopedics SB Orthopedics SB067 Nerve Repair Surgery SB067A Nerve Repair Surgery 14490 15939 17388 18837 20286 21010 planned line of c) Detailed procedure /
management and advice Operative Notes
for admission d) Discharge summary with
b) MRI / EMG/ NCV report follow-up advise at the time
to confirm the diagnosis of discharge

a) Clinical notes with a) Detailed Indoor case OPEN

history, signs, symptoms, papers
evaluation findings, b) Post Procedure clinical
indication for procedure, photograph
planned line of c) Detailed procedure /
937 Orthopedics SB Orthopedics, Neurosurgery SB068 Nerve root block SB068A Nerve root block 3150 3465 3780 4095 4410 4567 management and advice Operative Notes
for admission d) Discharge summary with
b) X-ray of affected part follow-up advise at the time
labelled with patient ID, of discharge
date and side (Left/ Right)

a) Clinical notes with a) Detailed Indoor case OPEN

history, signs, symptoms, papers
evaluation findings, b) Post Procedure clinical
indication for procedure, photograph
planned line of c) Detailed procedure /
938 Orthopedics SB Orthopedics SB069 Exploration and Ulnar nerve Repair SB069A Exploration and Ulnar nerve Repair 10290 11319 12348 13377 14406 14920 management and advice Operative Notes
for admission d) Discharge summary with
b) Radiological follow-up advise at the time
investigations confirming of discharge
the need of surgery; +/-
NCV report
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Post-op X-ray labelled
and planned line of with patient ID, date and
939 Orthopedics SB Orthopedics SB070 Implant Removal under LA SB070A K - Wire 5250 5775 6300 6825 7350 7612 management, advise for side (Left/ Right) - confirm
the procedure. the removal of Implant
b) X-ray labelled with c) Detailed procedure /
patient ID, date and side operative notes
(Left/ Right) - affected part d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Post-op X-ray labelled
and planned line of with patient ID, date and
940 Orthopedics SB Orthopedics SB070 Implant Removal under LA SB070B Screw 5250 5775 6300 6825 7350 7612 management, advise for side (Left/ Right) - confirm
the procedure. the removal of Implant
b) X-ray labelled with c) Detailed procedure /
patient ID, date and side operative notes
(Left/ Right) - affected part d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Post-op X-ray labelled
and planned line of with patient ID, date and
941 Orthopedics SB Orthopedics SB071 Implant Removal under RA / GA SB071A Nail 15750 17325 18900 20475 22050 22837 management, advise for side (Left/ Right) - confirm
the procedure. the removal of Implant
b) X-ray labelled with c) Detailed procedure /
patient ID, date and side operative notes
(Left/ Right) - affected part d) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Post-op X-ray labelled
and planned line of with patient ID, date and
942 Orthopedics SB Orthopedics SB071 Implant Removal under RA / GA SB071B Plate 15750 17325 18900 20475 22050 22837 management, advise for side (Left/ Right) - confirm
the procedure. the removal of Implant
b) X-ray labelled with c) Detailed procedure /
patient ID, date and side operative notes
(Left/ Right) - affected part d) Detailed discharge
summary
943 Orthopedics SB Orthopedics SB072 Core Decompression SB072A Core Decompression 14800 16280 17760 19240 20720 21460 0 0 OPEN
944 Orthopedics SB Orthopedics SB074 Arthroscopy / open - synovectomy SB074A Arthroscopy / open - synovectomy 10500 11550 12600 13650 14700 15225 0 0 OPEN
945 Orthopedics SB Orthopedics SB002 Application of Traction SB075A crutchfiled tong cervical spine traction 5250 5775 6300 6825 7350 7612 0 0 OPEN
946 Orthopedics SB Orthopedics SB002 Application of Traction SB076A POP slab 2100 2310 2520 2730 2940 3045 0 0 OPEN
947 Orthopedics SB Orthopedics SB003 Application of P.O.P. casts SB076B POP slab 2310 2541 2772 3003 3234 3349 0 0 OPEN
948 Orthopedics SB Orthopedics SB012 Fracture Head radius SB077A Replacement with Head Radius Prosthesis 10500 11550 12600 13650 14700 15225 0 0 OPEN
949 Orthopedics SB Orthopedics SB015 Fracture Condyle - Humerus - ORIF SB078A ORIF with screw of proximal humerus 8925 9817 10710 11602 12495 12941 0 0 OPEN
0 0 OPEN YES
950 Orthopedics SB Orthopedics SB038 Total Hip Replacement SB079A Revision of failed hemi Arthroplasty in to THR 55125 60637 66150 71662 77175 79931
Combined spinal segment - front and back 0 0 OPEN
As per Number of
951 Orthopedics SB Orthopedics SB054 Spine deformity correction SB080A (anterior/posterior/ combined anterior and #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!
Screw
posterior)
a) Clinical notes with a) Procedure. OPEN YES
planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
952 Surgical Oncology SC Surgical Oncology SC001 Glossectomy SC001A Hemiglossectomy 92715 101986 111258 120529 129801 134436 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
953 Surgical Oncology SC Surgical Oncology SC001 Glossectomy SC001B Total Glossectomy 108780 119658 130536 141414 152292 157731 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) Biopsy. b) Operative Notes.
c) Clinical photograph. c) Clinical photgraph
d) CT showing scar.
954 Surgical Oncology SC Surgical Oncology, ENT SC002 Palatectomy SC002A Soft palate 59220 65142 71064 76986 82908 85869 e) MRI d) Detailed discharge
summary.
e) HPE.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) Biopsy. b) Operative Notes.
c) Clinical photograph. c) Clinical photgraph
d) CT showing scar.
955 Surgical Oncology SC Surgical Oncology, ENT SC002 Palatectomy SC002B Hard palate 67620 74382 81144 87906 94668 98049 e) MRI d) Detailed discharge
summary.
e) HPE.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) Biopsy. b) Operative Notes.
c) CECT. c) Clinical Photograph
showing scar.
956 Surgical Oncology SC Surgical Oncology SC003 Maxillectomy SC003A Partial 79800 87780 95760 103740 111720 115710 d) HPE report.
e) Detailed discharge
summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) Biopsy. b) Operative Notes.
c) CECT. c) Clinical Photograph
showing scar.
957 Surgical Oncology SC Surgical Oncology SC003 Maxillectomy SC003B Radical 70560 77616 84672 91728 98784 102312 d) HPE report.
e) Detailed discharge
summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) Biopsy. b) Operative Notes.
c) CECT. c) Clinical Photograph
showing scar.
958 Surgical Oncology SC Surgical Oncology SC003 Maxillectomy SC003C Total 88095 96904 105714 114523 123333 127737 d) HPE report.
e) Detailed discharge
summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) Biopsy. b) Operative Notes.
c) CT reports. c) Clinical Photograph
d) Clinical photograph. showing scar.
959 Surgical Oncology SC Surgical Oncology SC004 Composite resection (Oral Cavity) SC004A Composite resection (Oral Cavity) 57330 63063 68796 74529 80262 83128 d) HPE report.
e) Detailed discharge
summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes. a) Barcode of Stent. OPEN YES
b) CECT. b) Detailed Procedure.
c) OGD Scopy. c) Operative Notes.
960 Surgical Oncology SC Surgical Oncology SC005 Oesophageal / Tracheal stenting SC005A Oesophageal stenting 86835 95518 104202 112885 121569 125910 d) Detailed Discharge
summary.

a) Clinical notes. a) Barcode of Stent. OPEN YES

b) CECT. b) Detailed Procedure.
c) OGD Scopy. c) Operative Notes.
961 Surgical Oncology SC Surgical Oncology SC005 Oesophageal / Tracheal stenting SC005B Tracheal stenting 86835 95518 104202 112885 121569 125910 d) Detailed Discharge
summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
962 Surgical Oncology SC Surgical Oncology SC006 Transthoracic esophagectomy: 2F / 3F SC006A Open 135345 148879 162414 175948 189483 196250 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
963 Surgical Oncology SC Surgical Oncology SC006 Transthoracic esophagectomy: 2F / 3F SC006B MIS 135345 148879 162414 175948 189483 196250 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
964 Surgical Oncology SC Surgical Oncology SC007 Gastric pull-up / Jejunal Graft SC007A Gastric pull-up / Jejunal Graft 107100 117810 128520 139230 149940 155295 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
965 Surgical Oncology SC Surgical Oncology SC008 Radical Small Bowel Resection SC008A Open 101955 112150 122346 132541 142737 147834 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
966 Surgical Oncology SC Surgical Oncology SC008 Radical Small Bowel Resection SC008B Lap. 135975 149572 163170 176767 190365 197163 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
967 Surgical Oncology SC Surgical Oncology SC009 Intersphincteric resection SC009A Open 92190 101409 110628 119847 129066 133675 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) FNAC c) Post Procedure
c) BIOPSY Photographs of surgical
968 Surgical Oncology SC Surgical Oncology SC009 Intersphincteric resection SC009B Lap. 92190 101409 110628 119847 129066 133675 d) CECT site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) CT abdomen reports. b) Operative Notes.
c) Biopsy. c) Clinical Photograph
showing scar.
969 Surgical Oncology SC Surgical Oncology SC010 Surgery for Abdominal wall tumour SC010A Abdominal wall tumour resection 60585 66643 72702 78760 84819 87848 d) HPE report.
e) Detailed discharge
summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes. a) Detailed Procedure. OPEN YES
b) CT abdomen reports. b) Operative Notes.
c) Biopsy. c) Clinical Photograph
showing scar.
Abdominal wall tumour resection with
970 Surgical Oncology SC Surgical Oncology SC010 Surgery for Abdominal wall tumour SC010B 89250 98175 107100 116025 124950 129412 d) HPE report.
reconstruction
e) Detailed discharge
summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) CECT. c) Post Procedure
Photographs of surgical
Exploratory laparotomy f / b diversion site.
971 Surgical Oncology SC Surgical Oncology SC011 SC011A Exploratory laparotomy f / b diversion stoma 79905 87895 95886 103876 111867 115862
stoma / bypass d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) CECT. c) Post Procedure
Photographs of surgical
Exploratory laparotomy f / b diversion site.
972 Surgical Oncology SC Surgical Oncology SC011 SC011B Exploratory laparotomy f / b diversion bypass 79905 87895 95886 103876 111867 115862
stoma / bypass d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE b) HPE report.
973 Surgical Oncology SC Surgical Oncology SC012 Abdominoperineal resection SC012A Open 91245 100369 109494 118618 127743 132305 c) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE b) HPE report.
974 Surgical Oncology SC Surgical Oncology SC012 Abdominoperineal resection SC012B Lap. 91245 100369 109494 118618 127743 132305 c) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN

planned line of treatment. b) Operative Notes.
b) HPE c) Post Procedure
Photographs of surgical
975 Surgical Oncology SC Surgical Oncology SC013 Omentectomy SC013A Omentectomy 37380 41118 44856 48594 52332 54201 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE c) Post Procedure
Photographs of surgical
976 Surgical Oncology SC Surgical Oncology SC014 Procedures Requiring Bypass Techniques SC014A Procedures Requiring Bypass Techniques 64470 70917 77364 83811 90258 93481 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) Biopsy. b) Operative Notes.
c) CECT c) Clinical Photograph
d) MRI showing scar.
977 Surgical Oncology SC Surgical Oncology SC015 Segmentectomy - hepatobiliary system SC015A Segmentectomy - hepatobiliary system 72765 80041 87318 94594 101871 105509 d) HPE report.
e) Detailed discharge
summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) CECT b) Operative Notes.
c) MRI reports. c) Clinical Photograph
d) Biopsy. showing scar.
978 Surgical Oncology SC Surgical Oncology SC016 Radical / Revision Cholecystectomy SC016A Radical 91245 100369 109494 118618 127743 132305 d) HPE report.
e) Detailed discharge
summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) CECT b) Operative Notes.
c) MRI reports. c) Clinical Photograph
d) Biopsy. showing scar.
979 Surgical Oncology SC Surgical Oncology SC016 Radical / Revision Cholecystectomy SC016B Revision 91245 100369 109494 118618 127743 132305 d) HPE report.
e) Detailed discharge
summary.

a) Clinical notes. a) Detailed Procedure. OPEN YES

b) CECT b) Operative Notes.
c) MRI c) Clinical Photograph
d) Biopsy. showing scar.
980 Surgical Oncology SC Surgical Oncology SC017 Enucleation of pancreatic neoplasm SC017A Enucleation of pancreatic neoplasm 62790 69069 75348 81627 87906 91045 e) IHC report. d) HPE report.
e) Detailed discharge
summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Procedure. OPEN YES
planned line of treatment. b) Operative Notes.
b) HPE c) Post Procedure
c) CT Photographs of surgical
Surgical Oncology, site.
981 Surgical Oncology SC SC018 Hepatoblastoma Excision SC018A Hepatoblastoma Excision 89565 98521 107478 116434 125391 129869
Pediatric Surgery d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE c) Post Procedure
c) CT Photographs of surgical
982 Surgical Oncology SC Surgical Oncology SC019 Hemipelvectomy - Internal SC019A Hemipelvectomy - Internal 97230 106953 116676 126399 136122 140983 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE c) HPE report.
983 Surgical Oncology SC Surgical Oncology SC020 Pelvic Exenteration SC020A Anterior - Open 136080 149688 163296 176904 190512 197316 c) CT d) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE c) HPE report.
984 Surgical Oncology SC Surgical Oncology SC020 Pelvic Exenteration SC020B Anterior - Lap. 136080 149688 163296 176904 190512 197316 c) CT d) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE c) HPE report.
985 Surgical Oncology SC Surgical Oncology SC020 Pelvic Exenteration SC020C Total - Open 136080 149688 163296 176904 190512 197316 c) CT d) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE c) HPE report.
986 Surgical Oncology SC Surgical Oncology SC020 Pelvic Exenteration SC020D Total - Lap. 136080 149688 163296 176904 190512 197316 c) CT d) Detailed Discharge
Summary.

Clinical notes with planned a) Procedure. OPEN YES

line of treatment, b) Operative Notes.
Biopsy/HPE, CT abdomen c) Post Procedure
Photographs of surgical
Surgical Oncology, site.
987 Surgical Oncology SC SC021 Wilms tumors: surgery SC021A Wilms tumors: surgery 59850 65835 71820 77805 83790 86782
Pediatric Surgery d) HPE report.
e) Detailed Discharge
Summary.

a) CT KUB a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
988 Surgical Oncology SC Surgical Oncology SC022 Ureteric end to end anastomosis SC022A Ureteric end to end anastomosis 46200 50820 55440 60060 64680 66990 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) CT KUB a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
989 Surgical Oncology SC Surgical Oncology, Urology SC023 Distal ureterectomy with reimplantation SC023A Distal ureterectomy with reimplantation 46725 51397 56070 60742 65415 67751 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
990 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024A With continent diversion - Open 131355 144490 157626 170761 183897 190464 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
991 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024B With Ileal Conduit - Open 170310 187341 204372 221403 238434 246949 site.
d) HPE report.
e) Detailed Discharge
Summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) HPE a) Procedure. OPEN YES
b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
992 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024C With Ileal Conduit - Lap. 170310 187341 204372 221403 238434 246949 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
993 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024D With neobladder - Open 194985 214483 233982 253480 272979 282728 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
994 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024E With neobladder - Lap 194985 214483 233982 253480 272979 282728 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
995 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024F With ureterosigmoidostomy - Open 151935 167128 182322 197515 212709 220305 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
996 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024G With ureterosigmoidostomy - Lap 101955 112150 122346 132541 142737 147834 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
997 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024H With ureterostomy -Open 101640 111804 121968 132132 142296 147378 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
c) CT Photographs of surgical
998 Surgical Oncology SC Surgical Oncology, Urology SC024 Radical cystectomy SC024I With ureterostomy -Lap. 101640 111804 121968 132132 142296 147378 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) PSA c) HPE report.
999 Surgical Oncology SC Surgical Oncology SC025 Channel TURP SC025A Channel TURP 40215 44236 48258 52279 56301 58311 c) USG- prostate. d) Detailed Discharge
Summary.

a) CT KUB. a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
1000 Surgical Oncology SC Surgical Oncology, Urology SC026 Radical Urethrectomy SC026A Radical Urethrectomy 51030 56133 61236 66339 71442 73993 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE. a) Procedure. OPEN

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) HPE report.
Penile preserving surgery Penile preserving surgery
1001 Surgical Oncology SC Surgical Oncology, Urology SC027 SC027A 37900 41690 45480 49270 53060 54955 d) Detailed Discharge
(WLE, Glansectomy, Laser) (WLE, Glansectomy, Laser)
Summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CT a) Procedure. OPEN
b) Clinical notes with b) Operative Notes.
planned line of treatment. c) HPE report.
1002 Surgical Oncology SC Surgical Oncology SC028 Excision of undescended testicular mass SC028A Excision of undescended testicular mass 37485 41233 44982 48730 52479 54353 d) Detailed Discharge
Summary

a) Beta HCG. a) Procedure. OPEN YES

b) AFP. b) Operative Notes.
c) USG. c) HPE report.
1003 51397 56070 60742 65415 67751 d) CT. d) Detailed Discharge
Surgical Oncology SC Surgical Oncology SC029 Germ Cell Tumour Excision SC029A Germ Cell Tumour Excision 46725
e) Clinical notes with Summary
planned line of treatment.

1004 Obstetrics & Gynecology SO OBG & Gynec SC030 Salpingoophorectomy SC030A Open 26250 28875 31500 34125 36750 38062 0 0 OPEN
1005 Obstetrics & Gynecology SO OBG & Gynec SC030 Salpingoophorectomy SC030B Lap. 26250 28875 31500 34125 36750 38062 0 0 OPEN
a) Clinical notes with a) Procedure. OPEN YES
planned line of treatment. b) Operative Notes.
b) USG. c) Post Procedure
Photographs of surgical
1006 Surgical Oncology SC Surgical Oncology SC031 Leiomyoma excision SC031A Open 103215 113536 123858 134179 144501 149661 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) USG. c) Post Procedure
Photographs of surgical
1007 Surgical Oncology SC Surgical Oncology SC031 Leiomyoma excision SC031B MIS 103215 113536 123858 134179 144501 149661 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
c) CECT Photographs of surgical
Surgical Oncology, Class I radical hysterectomy + bilateral d) MRI site.
1008 Surgical Oncology SC SC032 Radical Hysterectomy SC032A 56280 61908 67536 73164 78792 81606
Obstetrics & Gynecology salpingoophorectomy + BPLND - Lap. d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
c) CECT Photographs of surgical
Surgical Oncology, Class I radical hysterectomy + bilateral d) MRI site.
1009 Surgical Oncology SC SC032 Radical Hysterectomy SC032B 56280 61908 67536 73164 78792 81606
Obstetrics & Gynecology salpingoophorectomy + BPLND - Open d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
c) CECT Photographs of surgical
Surgical Oncology, Class I radical Hysterectomy +/- bilateral d) MRI site.
1010 Surgical Oncology SC SC032 Radical Hysterectomy SC032C 40425 44467 48510 52552 56595 58616
Obstetrics & Gynecology salpingoophorectomy - Lap. d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
c) CECT Photographs of surgical
Surgical Oncology, Class I radical Hysterectomy +/- bilateral d) MRI site.
1011 Surgical Oncology SC SC032 Radical Hysterectomy SC032D 40425 44467 48510 52552 56595 58616
Obstetrics & Gynecology salpingoophorectomy - Open d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
c) CECT Photographs of surgical
Surgical Oncology, d) MRI site.
1012 Surgical Oncology SC SC032 Radical Hysterectomy SC032E Class II radical hysterctomy + BPLND 56280 61908 67536 73164 78792 81606
Obstetrics & Gynecology d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
c) CECT Photographs of surgical
Surgical Oncology, d) MRI site.
1013 Surgical Oncology SC SC032 Radical Hysterectomy SC032F Class III radical hysterctomy + BPLND 56280 61908 67536 73164 78792 81606
Obstetrics & Gynecology d) HPE report.
e) Detailed Discharge
Summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Procedure. OPEN YES
planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
Hysterectomy + bilateral salpingoophorectomy + c) CECT Photographs of surgical
Surgical Oncology, d) MRI site.
1014 Surgical Oncology SC SC032 Radical Hysterectomy SC032G omentectomy + peritonectomy and organ 92500 101750 111000 120250 129500 134125
Obstetrics & Gynecology d) HPE report.
resections
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) CECT. b) Operative Notes.
c) Biopsy. c) Post Procedure
Photographs of surgical
1015 Surgical Oncology SC Surgical Oncology SC033 Radical vaginectomy SC033A Radical vaginectomy 50500 55550 60600 65650 70700 73225 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Biopsy. c) Post Procedure
c) HPE. Photographs of surgical
Surgical Oncology, site.
1016 Surgical Oncology SC SC034 Vulvectomy + reconstruction procedures SC034A Vulvectomy + reconstruction procedures 76125 83737 91350 98962 106575 110381
Obstetrics & Gynecology d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) CECT. b) Operative Notes.
c) Biopsy. c) Post Procedure
Photographs of surgical
1017 Surgical Oncology SC Surgical Oncology SC035 Radical Trachelectomy SC035A Radical Trachelectomy 62685 68953 75222 81490 87759 90893 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
Photographs of surgical
1018 Surgical Oncology SC Surgical Oncology SC036 Sacral Tumour Excision SC036A Anterior + Posterior approach 150150 165165 180180 195195 210210 217717 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
Photographs of surgical
1019 Surgical Oncology SC Surgical Oncology SC036 Sacral Tumour Excision SC036B Posterior approach 128520 141372 154224 167076 179928 186354 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) Biopsy of primary. b) Operative Notes.
c) CECT. c) Post Procedure
d) MRI. Photographs of surgical
1020 Surgical Oncology SC Surgical Oncology SC037 Resection of nasopharyngeal tumour SC037A Resection of nasopharyngeal tumour 73600 80960 88320 95680 103040 106720 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
1021 Surgical Oncology SC Surgical Oncology SC038 Total Pharyngectomy SC038A Total Pharyngectomy 70770 77847 84924 92001 99078 102616 d) MRI. site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
1022 Surgical Oncology SC Surgical Oncology SC039 Parapharyngeal Tumour Excision SC039A Parapharyngeal Tumour Excision 50190 55209 60228 65247 70266 72775 d) MRI. site.
d) HPE report.
e) Detailed Discharge
Summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes and a) Procedure. OPEN YES
Biopsy. b) Operative Notes.
b) CECT film. c) Post Procedure
c) Report. Photographs of surgical
1023 Surgical Oncology SC Surgical Oncology SC040 Laryngectomy SC040A Partial laryngectomy (voice preserving) 99225 109147 119070 128992 138915 143876 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes and a) Procedure. OPEN YES

Biopsy. b) Operative Notes.
b) CECT film. c) Post Procedure
c) Report. Photographs of surgical
1024 Surgical Oncology SC Surgical Oncology SC040 Laryngectomy SC040B Total Laryngectomy 98800 108680 118560 128440 138320 143260 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) CECT. b) Operative Notes.
c) Biopsy confirming c) Post Procedure
diagnosis. Photographs of surgical
1025 Surgical Oncology SC Surgical Oncology SC041 Tracheal resection SC041A Tracheal resection 69195 76114 83034 89953 96873 100332 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
1026 Surgical Oncology SC Surgical Oncology SC042 Tracheal / Carinal resection SC042A Tracheal / Carinal resection 101640 111804 121968 132132 142296 147378 d) MRI. site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
Tracheal Stenosis (End to end Tracheal Stenosis (End to end Anastamosis) d) MRI. site.
1027 Surgical Oncology SC Surgical Oncology SC043 SC043A 52500 57750 63000 68250 73500 76125
Anastamosis) (Throat) (Throat) d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
1028 Surgical Oncology SC Surgical Oncology SC044 Central airway tumour debulking SC044A Central airway tumour debulking 36855 40540 44226 47911 51597 53439 d) MRI. site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Cinical notes. a) Procedure. OPEN

b) Radiological evidence b) Operative Notes.
for indication. c) Post Procedure
Photographs of surgical
1029 Surgical Oncology SC Surgical Oncology SC045 Diagnostic thoracoscopy SC045A Diagnostic thoracoscopy 27195 29914 32634 35353 38073 39432 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) FNAC. b) Operative Notes.
c) BIOPSY. c) Post Procedure
d) CECT. Photographs of surgical
1030 Surgical Oncology SC Surgical Oncology SC046 Sleeve resection of lung cancer SC046A Sleeve resection of lung cancer 120540 132594 144648 156702 168756 174783 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Cinical notes. a) Procedure. OPEN YES

b) Radiological evidence b) Operative Notes.
for indication. c) Post Procedure
Photographs of surgical
1031 Surgical Oncology SC Surgical Oncology SC047 Mediastinoscopy SC047A Diagnostic 56700 62370 68040 73710 79380 82215 site.
d) HPE report.
e) Detailed Discharge
Summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Cinical notes. a) Procedure. OPEN YES
b) Radiological evidence b) Operative Notes.
for indication. c) Post Procedure
Photographs of surgical
1032 Surgical Oncology SC Surgical Oncology SC047 Mediastinoscopy SC047B Staging 56700 62370 68040 73710 79380 82215 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
1033 Surgical Oncology SC Surgical Oncology SC048 Removal of Chest Wall Tumour SC048A Chest Wall Tumour Excision 115290 126819 138348 149877 161406 167170 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
Removal of chest wall tumour with site.
1034 Surgical Oncology SC Surgical Oncology SC048 Removal of Chest Wall Tumour SC048B 130410 143451 156492 169533 182574 189094
reconstruction d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
1035 Surgical Oncology SC Surgical Oncology SC049 Pleurectomy Decortication SC049A Pleurectomy Decortication 67410 74151 80892 87633 94374 97744 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN

planned line of treatment. b) Operative Notes.
b) CT Thorax. c) Post Procedure
Photographs of surgical
1036 Surgical Oncology SC Surgical Oncology SC050 Chamberlain procedure SC050A Chamberlain procedure 32235 35458 38682 41905 45129 46740 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) HPE. c) Post Procedure
c) CT. Photographs of surgical
1037 Surgical Oncology SC Surgical Oncology SC051 Extrapleural pneumonectomy SC051A Extrapleural pneumonectomy 113610 124971 136332 147693 159054 164734 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) CT Thorax. c) Post Procedure
c) Biopsy. Photographs of surgical
1038 Surgical Oncology SC Surgical Oncology SC052 Pneumonectomy SC052A Pneumonectomy 99855 109840 119826 129811 139797 144789 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) FNAC. b) Operative Notes.
c) BIOPSY. c) Post Procedure
d) CECT. Photographs of surgical
1039 Surgical Oncology SC Surgical Oncology SC053 Lung metastectomy SC053A Open 77595 85354 93114 100873 108633 112512 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) FNAC. b) Operative Notes.
c) BIOPSY. c) Post Procedure
d) CECT. Photographs of surgical
1040 Surgical Oncology SC Surgical Oncology SC053 Lung metastectomy SC053B VATS 77595 85354 93114 100873 108633 112512 site.
d) HPE report.
e) Detailed Discharge
Summary.
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Procedure. OPEN
planned line of treatment. b) Operative Notes.
b) Clinical photograph. c) Post Procedure
Photographs of surgical
1041 Surgical Oncology SC Surgical Oncology SC054 Thoracostomy SC054A Thoracostomy 31080 34188 37296 40404 43512 45066 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) CT. c) Post Procedure
Photographs of surgical
1042 Surgical Oncology SC Surgical Oncology SC055 Mediastinal lymphadenectomy SC055A Open 103320 113652 123984 134316 144648 149814 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) CT. c) Post Procedure
Photographs of surgical
1043 Surgical Oncology SC Surgical Oncology SC055 Mediastinal lymphadenectomy SC055B Video - assisted 103320 113652 123984 134316 144648 149814 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment b) Operative Notes.
and CT Thorax. c) Post Procedure
b) Biopsy. Photographs of surgical
Mediastinal mass excision with lung site.
1044 Surgical Oncology SC Surgical Oncology SC056 SC056A Mediastinal mass excision with lung resection 106785 117463 128142 138820 149499 154838
resection d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment b) Operative Notes.
and CT Thorax. c) Post Procedure
b) Biopsy. Photographs of surgical
1045 Surgical Oncology SC Surgical Oncology SC057 Segmental resection of lung SC057A Open 91350 100485 109620 118755 127890 132457 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment b) Operative Notes.
and CT Thorax. c) Post Procedure
b) Biopsy. Photographs of surgical
1046 Surgical Oncology SC Surgical Oncology SC057 Segmental resection of lung SC057B Thoracoscopic 91350 100485 109620 118755 127890 132457 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment b) Operative Notes.
and CT Thorax. c) Post Procedure
b) Biopsy. Photographs of surgical
1047 Surgical Oncology SC Surgical Oncology SC058 Wedge resection lung SC058A Open 105000 115500 126000 136500 147000 152250 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment b) Operative Notes.
and CT Thorax. c) Post Procedure
b) Biopsy. Photographs of surgical
1048 Surgical Oncology SC Surgical Oncology SC058 Wedge resection lung SC058B Thoracoscopic 105000 115500 126000 136500 147000 152250 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN YES

b) Mammography. b) Operative Notes.
c) FNAC. c) Post Procedure
d) BIOPSY. Photographs of surgical
Breast conserving surgery e) CT. site.
1049 Surgical Oncology SC Surgical Oncology SC059 Breast conserving surgery SC059A 64575 71032 77490 83947 90405 93633
(lumpectomy + axillary surgery) f) MRI. d) HPE report.
e) Detailed Discharge
Summary.
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes. a) Procedure. OPEN YES
b) Mammography. b) Operative Notes.
c) FNAC. c) Post Procedure
d) BIOPSY. Photographs of surgical
1050 Surgical Oncology SC Surgical Oncology SC059 Breast conserving surgery SC059B Breast conserving surgery with Oncoplasty 59430 65373 71316 77259 83202 86173 e) CT. site.
f) MRI. d) HPE report.
e) Detailed Discharge
Summary.

a) FNAC. a) Procedure. OPEN

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
1051 Surgical Oncology SC Surgical Oncology SC060 Axillary Sampling / Sentinel Node Biopsy SC060A Axillary Sampling / Sentinel Node Biopsy 27195 29914 32634 35353 38073 39432 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN

b) FNAC. b) Operative Notes.
c) BIOPSY. c) Post Procedure
d) CECT. Photographs of surgical
1052 Surgical Oncology SC Surgical Oncology SC061 Axillary dissection SC061A Axillary dissection 33810 37191 40572 43953 47334 49024 e) Chest X-ray. site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE. a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
Scalp tumour excision with skull bone site.
1053 Surgical Oncology SC Surgical Oncology SC062 SC062A Scalp tumour excision with skull bone excision 46725 51397 56070 60742 65415 67751
excision d) HPE report.
e) Detailed Discharge
Summary.

a) HPE. a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
1054 Surgical Oncology SC Surgical Oncology SC063 Neuroblastoma Excision SC063A Neuroblastoma Excision 110985 122083 133182 144280 155379 160928 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE. a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Excision of Pinna for Growths / Injuries - Photographs of surgical
1055 Surgical Oncology SC Surgical Oncology, ENT SC064 Total Amputation & Excision of External SC064A Growth - Squamous 59115 65026 70938 76849 82761 85716 site.
Auditory Meatus d) HPE report.
e) Detailed Discharge
Summary.

a) HPE. a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Excision of Pinna for Growths / Injuries - Photographs of surgical
1056 Surgical Oncology SC Surgical Oncology, ENT SC064 Total Amputation & Excision of External SC064B Growth - Basal 59115 65026 70938 76849 82761 85716 site.
Auditory Meatus d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Clinical photograph. c) Post Procedure
Excision of Pinna for Growths / Injuries - Photographs of surgical
1057 Surgical Oncology SC Surgical Oncology, ENT SC064 Total Amputation & Excision of External SC064C Injury 59115 65026 70938 76849 82761 85716 site.
Auditory Meatus d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes. a) Procedure. OPEN

b) USG. b) Operative Notes.
c) CT neck. c) Post Procedure
d) Biopsy. Photographs of surgical
1058 Surgical Oncology SC Surgical Oncology SC065 Neck dissection - comprehensive SC065A Neck dissection - comprehensive 34965 38461 41958 45454 48951 50699 e) FNAC. site.
d) HPE report.
e) Detailed Discharge
Summary.
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) HPE. a) Procedure. OPEN
b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
1059 Surgical Oncology SC Surgical Oncology SC066 Benign Soft Tissue Tumour - Excision SC066A Benign Soft Tissue Tumour - Excision (Small) 20265 22291 24318 26344 28371 29384 site.
d) HPE report.
e) Detailed Discharge
Summary.

a) HPE. a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
Malignant Soft Tissue Tumour (Small)- Excision site.
1060 Surgical Oncology SC Surgical Oncology SC067 Malignant Soft Tissue Tumour -Excision SC067A 53550 58905 64260 69615 74970 77647
(New procedure) d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes a) Detailed Procedure. OPEN YES

b) Biopsy of primary b) Operative Notes.
c) Clinical photgraph
Surgical Oncology, Plastic showing scar.
1061 Surgical Oncology SC SC068 Regional flap SC068A Myocutaneous flap 68565 75421 82278 89134 95991 99419
& Reconstructive Surgery d) Detailed discharge
summary.

a) Clinical notes a) Detailed Procedure. OPEN YES

b) Biopsy of primary b) Operative Notes.
c) Clinical photgraph
Surgical Oncology, Plastic showing scar.
1062 Surgical Oncology SC SC068 Regional flap SC068B Fasciocutaneous flap 68565 75421 82278 89134 95991 99419
& Reconstructive Surgery d) Detailed discharge
summary.

Clinical notes with planned a) Procedure. OPEN YES

line of treatment. b) Operative Notes.
c) Post Procedure
Photographs of surgical
1063 Surgical Oncology SC Surgical Oncology SC069 Rotationplasty SC069A Rotationplasty 84100 92510 100920 109330 117740 121945 site.
d) Detailed Discharge
Summary.

a) HPE. a) Procedure. OPEN YES

b) Clinical notes with b) Operative Notes.
planned line of treatment. c) Post Procedure
Photographs of surgical
Surgical Oncology, Bone tumors / soft tissue sarcomas: site.
1064 Surgical Oncology SC SC070 SC070A Bone tumors / soft tissue sarcomas: surgery 55440 60984 66528 72072 77616 80388
Orthopedics surgery d) HPE report.
e) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Radiological evidence c) Post Procedure
for indication. Photographs of surgical
1065 Surgical Oncology SC Surgical Oncology SC071 Endoprosthesis Revision SC071A Complete 101955 112150 122346 132541 142737 147834 site.
d) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Radiological evidence c) Post Procedure
for indication. Photographs of surgical
1066 Surgical Oncology SC Surgical Oncology SC071 Endoprosthesis Revision SC071B Partial 70980 78078 85176 92274 99372 102921 site.
d) Detailed Discharge
Summary.

a) Clinical notes with a) Procedure. OPEN YES

planned line of treatment. b) Operative Notes.
b) Radiological evidence c) Post Procedure
for indication. Photographs of surgical
Vertebral Tumour Excision and
1067 Surgical Oncology SC Surgical Oncology SC072 SC072A Vertebral Tumour Excision and Reconstruction 105000 115500 126000 136500 147000 152250 site.
Reconstruction
d) Detailed Discharge
Summary.

a) Clinical notes. a) Detailed discharge OPEN YES

b) Biopsy of primary with summary.
details of earlier surgery b) Detailed Procedure.
done. c) Operative Notes.
Surgical Oncology, Plastic
1068 Surgical Oncology SC SC073 Microvascular reconstruction (free flaps) SC073A Microvascular reconstruction (free flaps) 76230 83853 91476 99099 106722 110533 c) Establishing need of d) Clinical Photograph
& Reconstructive Surgery
microvascular showing scar.
reconstruction.

Surgical Oncology, CTVS, Clincal notes. Detailed Discharge OPEN YES

1069 Surgical Oncology SC Plastic & Reconstructive SC074 Vascular reconstruction SC074A Vascular reconstruction 100065 110071 120078 130084 140091 145094 Summary.
Surgery
Clincal notes. Detailed Discharge OPEN
1070 Surgical Oncology SC Surgical Oncology SC075 Curopsy / Sclerotherapy SC075A Curopsy / Sclerotherapy 29295 32224 35154 38083 41013 42477
Summary.
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Clinical notes with planned a) Procedure. OPEN
line of treatment. b) Operative Notes.
c) Discharge summary.
1071 Surgical Oncology SC Surgical Oncology SC076 Chemo Port Insertion SC076A Chemo Port Insertion 25200 27720 30240 32760 35280 36540 d) Invoice of Chemo port
used.

1072 Surgical Oncology SC Surgical Oncology SC077 Posterior Exenteration (Gynaec) SC077A Posterior Exenteration (Gynaec) 106155 116770 127386 138001 148617 153924 0 0 OPEN YES
Bilateral pelvic lymph Node Dissection 0 0 OPEN YES
1073 Surgical Oncology SC Surgical Oncology SC078 SC078A Bilateral pelvic lymph Node Dissection (BPLND) 58900 64790 70680 76570 82460 85405
(BPLND)18
1074 Surgical Oncology SC Surgical Oncology SC079 Plastic surgery flap division SC079A Head & Neck Flap Cutting any type 25200 27720 30240 32760 35280 36540 0 0 OPEN
1075 Surgical Oncology SC Surgical Oncology SC081 Cytoreductive surgery for ovarian cancer SC081A Cytoreductive surgery for ovarian cancer 95340 104874 114408 123942 133476 138243 0 0 OPEN YES
1076 Surgical Oncology SC Surgical Oncology SC082 Wide Excision- Oral Cavity Malignancy SC082A Wide Excision- Oral Cavity Malignancy 51450 56595 61740 66885 72030 74602 0 0 OPEN YES
a) Clinical notes a) Detailed Discharge Referral
b) Admission Notes summary
1077 9240 10080 10920 11760 12180 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE001 Ptosis Surgery SE001A Ptosis Surgery 8400
the affected eye notes
(Photograph in primary
position & lateral gazes)
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
1078 7623 8316 9009 9702 10048 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE002 Entropion correction SE002A Entropion correction 6930
the affected eye notes
(Photograph in primary
position & lateral gazes)
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
1079 7507 8190 8872 9555 9896 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE003 Ectropion correction SE003A Ectropion correction 6825
the affected eye notes
(Photograph in primary
position & lateral gazes)
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
1080 8893 9702 10510 11319 11723 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE004 Lid Tear Repair SE004A Lid Tear Repair 8085
the affected eye notes
(Photograph in primary
position & lateral gazes)
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
1081 6583 7182 7780 8379 8678 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE005 Lid Abscess Drainage SE005A Lid Abscess Drainage 5985
the affected eye notes c) Histopathology/
(Photograph in primary microbiology report of host
position & lateral gazes) tissue
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
1082 16170 17640 19110 20580 21315 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE006 Lid Tumor excision + Lid Reconstruction SE006A Lid Tumor excision + Lid Reconstruction 14700
the affected eye notes c) Histopathology/
(Photograph in primary microbiology report of host
position & lateral gazes) tissue
a) Clinical notes a) Operative/ procedure OPEN
b) Admission Notes notes b) Detailed Discharge
c) Clinical Photograph summary
1083 Ophthalmology SE Ophthalmology SE007 Chalazion Removal SE007A Chalazion Removal 2100 2310 2520 2730 2940 3045 c) Histopathology report
d) Intraoperative
photograph with time and
date stamp
a) Clinical notes detailing a) Detailed Discharge Referral
which muscle is affected summary
b) Admission Notes b) Procedure notes/
1084 4730 5160 5590 6020 6235 c) Clinical Photograph operative notes
Ophthalmology SE Ophthalmology SE008 Squint correction SE008A Minor - upto 2 muscles 4300
d) Indication for GA, if c) Intraoperative
required photograph with patient ID,
date and time (optional)

a) Clinical notes detailing a) Detailed Discharge Referral

which muscle is affected summary
b) Admission Notes b) Procedure notes/
Major - 3 or more muscles (complex surgery c) Clinical Photograph operative notes
1085 Ophthalmology SE Ophthalmology SE008 Squint correction SE008B 14000 15400 16800 18200 19600 20300
involving four muscles or oblique muscles) d) Indication for GA, if c) Intraoperative
required photograph with patient ID,
date and time (optional)

a) Clinical notes a) Detailed Discharge OPEN

b) Admission Notes summary
c) Clinical Photograph of b) Operative/ procedure
the affected eye notes c) Histopathology
Conjunctival tumour excision including Conjunctival tumour excision including Amniotic report d)
1086 Ophthalmology SE Ophthalmology SE009 SE009A 7350 8085 8820 9555 10290 10657
Amniotic Membrane Graft Membrane Graft Intraoperative photograph
with Patient ID, time and
date stamp (optional)
e) Postoperative
photograph after excision
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
c) Clinical Photograph b) Operative/ Procedure
Canaliculo Dacryocystorhinostomy with Silicon d) Dye disappearance test notes c) Intraoperative
1087 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010A 13125 14437 15750 17062 18375 19031
Tube / Stent e) Tear meniscus height photograph with time and
measurement date (Optional) d) Invoice/
f) Probing & irrigation barcode/ sticker of implant

a) Clinical notes a) Detailed Discharge OPEN

b) Admission Notes summary
c) Clinical Photograph b) Operative/ Procedure
Canaliculo Dacryocystorhinostomy without d) Dye disappearance test notes c) Intraoperative
1088 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010B 10500 11550 12600 13650 14700 15225
Silicon Tube / Stent e) Tear meniscus height photograph with time and
measurement date (Optional)
f) Probing & irrigation
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
c) Clinical Photograph b) Operative/ Procedure
d) Dye disappearance test notes c) Intraoperative
Dacryocystorhinostomy with Silicon Tube /
1089 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010C 13125 14437 15750 17062 18375 19031 e) Probing & irrigation photograph with time and
Stent
date (Optional) d)
Histopathology report
e) Invoice/ barcode/ sticker
of implant
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
c) Clinical Photograph b) Operative/ Procedure
Dacryocystorhinostomy without Silicon Tube /
1090 Ophthalmology SE Ophthalmology SE010 Dacryocystorhinostomy SE010D 10500 11550 12600 13650 14700 15225 d) Dye disappearance test notes c) Intraoperative
Stent
e) Probing & irrigation photograph with time and
date (Optional) d)
Histopathology report
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
1091 5775 6300 6825 7350 7612 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE011 Corneal Ulcer Management SE011A Corneal Ulcer Management 5250
the affected eye notes c) Histopathology/
d) Ultrasound B-scan Microbiology report of the
e) Slit lamp examination host tissue/sample
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
c) Clinical Photograph of b) Operative/ procedure
1092 15823 17262 18700 20139 20858 the affected eye notes c) Histopathology/
Ophthalmology SE Ophthalmology SE012 Corneal Grafting SE012A Corneal Grafting 14385
d) Ultrasound B-scan Microbiology report of the
e) Slit lamp examination host tissue/sample
f) History of corneal d) Details of donor cornea
grafting in the same eye
1093 Ophthalmology SE Ophthalmology SE012 Corneal Grafting SE012B Corneal Graft - Follow Up 2000 2200 2400 2600 2800 2900 0 0 OPEN
1094 Ophthalmology SE Ophthalmology SE012 Corneal Grafting SE012C Lamellar Keratoplasty 18060 19866 21672 23478 25284 26187 0 0 OPEN
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
c) Clinical Photograph of b) Operative/ procedure
1095 Ophthalmology SE Ophthalmology SE013 Corneal Collagen Crosslinking SE013A Corneal Collagen Crosslinking 18375 20212 22050 23887 25725 26643 the affected eye notes
d) Pentacam progression
maps 3 to 6 months apart
e) Slit lamp examination
a) Clinical notes a) Still image of the patient Reserved
b) Keratometry undergoing the procedure
c) Retinoscopy or with patient ID and date
Autorefraction (AR) b) Other essential
d) Clinical photograph of investigations- Blood
1096 Ophthalmology SE Ophthalmology SE014 Pterygium + Conjunctival Autograft SE014A Pterygium + Conjunctival Autograft 12285 13513 14742 15970 17199 17813 the affected part with full Pressure & Blood Sugar
face picture of the patient (Fasting, PP and Random)
c) Operative notes
d) Detailed discharge
summary

a) Clinical notes a) Detailed Discharge OPEN

b) Admission Notes summary
1097 12650 13800 14950 16100 16675 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE015 Corneo / Scleral / Corneo scleral tear repair SE015A Corneo / Scleral / Corneo scleral tear repair 11500
the affected eye notes
d) Ultrasound B-scan
e) Slit lamp examination
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
1098 8431 9198 9964 10731 11114 c) Clinical Photograph of b) Operative/ procedure
Ophthalmology SE Ophthalmology SE016 Corneal / Scleral Patch Graft SE016A Corneal / Scleral Patch Graft 7665
the affected eye notes c) Details of donor
d) Ultrasound B-scan cornea
e) Slit lamp examination
a) Clinical notes with a) Detailed Discharge Referral
indication for surgery summary
b) Admission Notes b) Operative/ procedure
c) Clinical Photograph of notes
the affected eye c) Investigation reports-
1099 Ophthalmology SE Ophthalmology SE017 Scleral buckling surgery SE017A Scleral buckling surgery 25935 28528 31122 33715 36309 37605 Fundus examination/ B-
scan
e) Intraoperative
photograph with Patient ID,
time and date(optional)

a) Clinical notes with a) Detailed Discharge OPEN

indication for surgery summary
b) Admission Notes b) Operative/ procedure
c) Clinical Photograph of notes
the affected eye c) Microbiology report of
the host tissue
1100 Ophthalmology SE Ophthalmology SE018 Scleral Buckle Removal SE018A Scleral Buckle Removal 7245 7969 8694 9418 10143 10505 d) Investigation reports-
Fundus examination/ B-
scan
e) Intraoperative
photograph with Patient ID,
time and date(optional)

a) Clinical notes with a) Detailed Discharge OPEN

indication b) Admission summary
Notes b) Procedure/ operative
c) Clinical Photograph of notes
the affected eye c) Intraoperative
1101 Ophthalmology SE Ophthalmology SE019 Limbal Dermoid Removal SE019A Limbal Dermoid Removal 2625 2887 3150 3412 3675 3806 photograph with Patient ID,
time and date (optional)
d) Evidence of submission
of removed tissue for
histopathology examination
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Still image of the patient OPEN
b) Occular Biometry undergoing the procedure
c) Slit lamp Examination with patient ID and date
d)Clinical photograph of b.)Operative notes
Phaco emulsification with foldable hydrophobic the affected part with full c )Detailed discharge
1102 Ophthalmology SE Ophthalmology SE020 Cataract surgery SE020A 4725 5197 5670 6142 6615 6851 face picture of the patient summary d )Barcode of IOL
acrylic IOL
e) Other essential
investigations- Blood
Pressure & Blood Sugar
(Fasting, PP and Random)

a) Clinical notes a) Still image of the patient Referral

b) Occular Biometry undergoing the procedure
c) Slit lamp Examination with patient ID and date
d)Clinical photograph of b.)Operative notes
the affected part with full c )Detailed discharge
1103 Ophthalmology SE Ophthalmology SE020 Cataract surgery SE020B SICS with non-foldable IOL 4200 4620 5040 5460 5880 6090 face picture of the patient summary d )Barcode of IOL
e) Other essential
investigations- Blood
Pressure & Blood Sugar
(Fasting, PP and Random)

a) Clinical notes (detailing a) Detailed Discharge OPEN

Indication for Lensectomy summary with visual
/pediatric lens aspiration/ outcomes
membranectomy and b) Procedure/ Operative
1104 Ophthalmology SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021A Paediatric lensectomy 12075 13282 14490 15697 16905 17508 supporting investigation) notes
b) Admission Notes c) Intraoperative
c) Clinical Photograph photograph with time and
date (optional)
d) Barcode of IOL used
a) Clinical notes (detailing a) Detailed Discharge Referral
Indication for Lensectomy summary with visual
/pediatric lens aspiration/ outcomes
membranectomy and b) Procedure/ Operative
Pediatric lens aspiration with posterior
1105 Ophthalmology SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021B 12075 13282 14490 15697 16905 17508 supporting investigation) notes
capsulotomy & anterior vitrectomy
b) Admission Notes c) Intraoperative
c) Clinical Photograph photograph with time and
date (optional)
d) Barcode of IOL used
a) Clinical notes (detailing a) Detailed Discharge OPEN
Indication for Lensectomy summary with visual
/pediatric lens aspiration/ outcomes
membranectomy and b) Procedure/ Operative
Paediatric Membranectomy & anterior
1106 Ophthalmology SE Ophthalmology SE021 Surgery for Pediatric Cataract SE021C 10500 11550 12600 13650 14700 15225 supporting investigation) notes
vitrectomy
b) Admission Notes c) Intraoperative
c) Clinical Photograph photograph with time and
date (optional)
d) Barcode of IOL used
a) Clinical notes (detailing a) Detailed Discharge OPEN
when was cataract surgery summary
done & indications for b) Procedure note/
doing the procedure with operative note
1107 Ophthalmology SE Ophthalmology SE022 Capsulotomy (YAG) SE022A Capsulotomy (YAG) 1995 2194 2394 2593 2793 2892 details of vision and fundus c) Intraoperative
examination) photograph with time and
b) Admission Notes date (Optional)
c) Clinical Photograph of
the affected eye

a) Clinical notes with a) Still image of the patient Referral

indications and planned undergoing the procedure
line of management with patient ID, date & time
1108 21714 23688 25662 27636 28623 b) Clinical photograph of b) Operative/ Procedure
Ophthalmology SE Ophthalmology SE023 SFIOL (inclusive of Vitrectomy) SE023A SFIOL (inclusive of Vitrectomy) 19740
the affected part with full notes c) Detailed discharge
face picture of the patient summary d) Barcode of IOL

a) Clinical notes with a) Still image of the patient OPEN

indications and planned undergoing the procedure
line of management with patient ID, date & time
1109 Ophthalmology SE Ophthalmology SE024 Secondary IOL / IOL Exchange / Explant SE024A Secondary IOL / IOL Exchange / Explant 6510 7161 7812 8463 9114 9439 b) Clinical photograph of b) Operative/ Procedure
the affected part with full notes c) Detailed discharge
face picture of the patient summary

a) Clinical notes with a) Still image of the patient OPEN

indications and planned undergoing the procedure
line of management with patient ID, date & time
1110 Ophthalmology SE Ophthalmology SE025 IRIS Prolapse – Repair SE025A IRIS Prolapse – Repair 4725 5197 5670 6142 6615 6851 b) Clinical photograph of b) Operative/ Procedure
the affected part with full notes c) Detailed discharge
face picture of the patient summary

a) Clinical notes a) Detailed Discharge OPEN

b) Admission Notes summary
c) Clinical Photograph of b) Procedure/ operative
the affected eye note
d) Tonometry report c) Histopathology report
1111 Ophthalmology SE Ophthalmology SE026 Iridectomy SE026A Iridectomy 2100 2310 2520 2730 2940 3045 e) Gonioscopy report (incase of Melanoma of iris)
d) Intraoperative
photograph with patient ID,
time and date (Optional)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Detailed Discharge OPEN
b) Indication (Open angle summary with Intraocular
Glaucoma: Moderate/ pressure, Fundus and
advanced Glaucoma/ end corneal diameter
stage refractory Glaucoma) b) Procedure/ operative
1112 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027A Cyclocryotherapy / Cyclophotocoagulation 4935 5428 5922 6415 6909 7155 c) Documentation of recent notes c) Intraoperative
field of vision (Perimetry photograph with patient ID,
examination) time and date (optional)
d) Admission Notes e)
Clinical Photograph

a) Clinical notes a) Detailed Discharge Referral

b) Indication(Open angle summary with Intraocular
Glaucoma: Moderate/ pressure, Fundus and
Advanced Glaucoma; corneal diameter
Glaucoma Surgery (Trabeculectomy only) with Closed angle Glaucoma) b) Procedure/ operative
or without Mitomycin C, including postoperative c) Documentation of recent notes c) Intraoperative
medications for 12 weeks field of vision (Perimetry photograph with patient ID,
1113 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027B 14910 16401 17892 19383 20874 21619
(and wherever surgical or laser procedures examination) time and date (optional)
required for bleb augmentation and anterior d) Intra-ocular pressure
chamber maintenance) measurement
d) Evidence of failed
Trabeculectomy
e) Admission Notes
f) Clinical Photograph
a) Clinical notes a) Detailed Discharge Referral
b) Indication(Open angle summary with Intraocular
Glaucoma: Moderate/ pressure, Fundus and
Advanced Glaucoma) corneal diameter
c) Documentation of recent b) Procedure/ operative
field of vision (Perimetry notes c) Intraoperative
1114 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027C Glaucoma Shunt Surgery 17115 18826 20538 22249 23961 24816 examination) photograph with patient ID,
d) Intra-ocular pressure time and date (optional)
measurement
e) Evidence of failed
Trabeculectomy
f) Admission Notes
g) Clinical Photograp
a) Clinical notes a) Detailed Discharge Referral
b) Pediatric Glaucoma summary with Intraocular
c) Documentation of recent pressure, Fundus and
field of vision (Perimetry corneal diameter
examination) b) Procedure/ operative
d) Intra-ocular pressure notes c) Pre-anesthesia
1115 Ophthalmology SE Ophthalmology SE027 Glaucoma Surgery SE027D Pediatric Glaucoma Surgery 19740 21714 23688 25662 27636 28623 measurement check-up d)
e) Admission Notes Documentation of
f) Clinical Photograph Examination
Under Anesthesia (EUA)
e) Intraoperative
photograph with patient ID,
time and date (optional)

a) Clinical notes a) Detailed Discharge OPEN

b) Indication(Pediatric summary with Intraocular
Glaucoma) pressure, Fundus and
c) Admission Notes corneal diameter
d) Clinical Photograph b) Procedure/ operative
notes c) Pre-anesthesia
EUA for Confirmation of Pediatric check-up d)
1116 Ophthalmology SE Ophthalmology SE028 SE028A EUA for Confirmation of Pediatric Glaucoma 3150 3465 3780 4095 4410 4567
Glaucoma Documentation of
Examination
Under Anesthesia (EUA)
e) Intraoperative
photograph with patient ID,
time and date (optional)

a) Clinical notes a) Detailed Discharge OPEN

b) Admission Notes summary
b) Procedure notes/
1117 Ophthalmology SE Ophthalmology SE029 Retinal Laser Photocoagulation SE029A For retinal tear repair Per Eye Per Sitting 1575 1732 1890 2047 2205 2283 Operative notes
c) Intra-Procedure
photograph with time and
date (optional)
a) Clinical notes a) Detailed Discharge OPEN
summary
Pan Retinal Photocoagulation (PRP) - Retinal
b) Procedure notes/
Laser including 3 sittings / package of retino
1118 Ophthalmology SE Ophthalmology SE029 Retinal Laser Photocoagulation SE029B 8925 9817 10710 11602 12495 12941 Operative notes
laser photocoagulation
c) Intra-Procedure
(3 sittings per eye for both eyes)
photograph with time and
date (optional)
a) Clinical notes a) Indoor case papers OPEN
b) Indirect ophthalmoscopy (ICPs)
examination b) Intra-procedure
1119 5775 6300 6825 7350 7612 c) Planned line of photograph(optional)
Ophthalmology SE Ophthalmology SE030 ROP Laser - Per Eye SE030A ROP Laser - Per Eye 5250
treatment c) Detailed Procedure /
operative notes
d) Detailed discharge
summary
a) Clinical notes with a) Detailed Discharge OPEN
indication for procedure summary
b) Admission Notes b) Operative/ procedure
1120 4389 4788 5187 5586 5785 notes
Ophthalmology SE Ophthalmology SE031 Retinal Cryopexy SE031A Retinal Cryopexy 3990
c) Intraoperative
photograph with Patient ID,
time and date (optional)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
c) Fundus examination b) Procedure/ operative
d) B-Scan(optional) notes
Vitreoretinal Surgery (with Silicon Oil c) Sticker/ Barcode of the
1121 Ophthalmology SE Ophthalmology SE032 SE032A Vitreoretinal Surgery (with Silicon Oil Insertion) 26565 29221 31878 34534 37191 38519 Intraocular lens (IOL) (If
Insertion)
IOL Used)
d) Intraoperative
photograph with patient ID,
time and date stamp
(optional)
a) Clinical notes a) Detailed Discharge OPEN
b) Admission Notes summary
c) Fundus examination b) Procedure/ operative
d) B-Scan(optional) notes
c) Sticker/ Barcode of the
1122 Ophthalmology SE Ophthalmology SE033 SOR (Silicon Oil Removal) SE033A SOR (Silicon Oil Removal) 9765 10741 11718 12694 13671 14159 Intraocular lens (IOL) (If
IOL Used)
d) Intraoperative
photograph with patient ID,
time and date stamp
(optional)
a) Clinical notes with a) Still image of the patient OPEN
indications and planned undergoing the procedure
line of management with patient ID, date & time
1123 8800 9600 10400 11200 11600 b) Clinical photograph of b) Operative/ Procedure
Ophthalmology SE Ophthalmology SE034 Endophthalmitis (excluding Vitrectomy) SE034A Endophthalmitis (excluding Vitrectomy) 8000
the affected part with full notes c) Detailed discharge
face picture of the patient summary d) Barcode of IOL

a) Clinical notes with a) Detailed Discharge OPEN

indication b) summary
Recommendation/ opinion b) Procedure/ operative
of 2 ophthalmologists for notes c) Histopathology
the procedure report/ filled specimen form
1124 Ophthalmology SE Ophthalmology SE035 Enucleation SE035A Without implant 12495 13744 14994 16243 17493 18117 c) Admission Notes sent for histopathology
d) Clinical Photograph of
the affected eye
e) CT-scan/ MRI of Head
(including affected eye)

a) Clinical notes with a) Detailed Discharge OPEN

indication b) summary
Recommendation/ opinion b) Procedure/ operative
of 2 ophthalmologists for notes c) Histopathology
the procedure report/ filled specimen form
1125 Ophthalmology SE Ophthalmology SE035 Enucleation SE035B With implant 13965 15361 16758 18154 19551 20249 c) Admission Notes sent for histopathology
d) Clinical Photograph of d) Barcode/ sticker of the
the affected eye implant used
e) CT-scan/ MRI of Head
(including affected eye)

a) Clinical notes with a) Detailed Discharge OPEN

indication b) summary
Recommendation/ opinion b) Procedure/ operative
of 2 ophthalmologists for notes c) Histopathology
the procedure report/ filled specimen form
1126 Ophthalmology SE Ophthalmology SE036 Evisceration SE036A Evisceration 13965 15361 16758 18154 19551 20249 c) Admission Notes sent for histopathology
d) Clinical Photograph of
the affected eye
e) CT-scan/ MRI of Head
(including affected eye)

a) Clinical notes with a) Detailed Discharge OPEN

indication b) summary
Recommendation/ opinion b) Procedure/ operative
of 2 ophthalmologists for notes c) Histopathology
Ophthalmology, Surgical the procedure report/ filled specimen form
1127 Ophthalmology SE SE037 Exenteration SE037A Exenteration 24885 27373 29862 32350 34839 36083 c) Admission Notes sent for histopathology
Oncology
d) Clinical Photograph of
the affected eye
e) CT-scan/ MRI of Head
(including affected eye)

a) Clinical notes with a) Detailed Discharge OPEN

indication b) summary
Recommendation/ opinion b) Procedure/ operative
of 2 ophthalmologists for notes
Socket Reconstruction including Amniotic Socket Reconstruction including Amniotic the procedure
1128 Ophthalmology SE Ophthalmology SE038 SE038A 14700 16170 17640 19110 20580 21315 c) Admission Notes
Membrane Graft Membrane Graft
d) Clinical Photograph of
the affected eye
e) CT-scan/ MRI of Head
(including affected eye)

a) Clinical notes with a) Detailed Discharge OPEN

indication summary
b) Admission Notes b) Procedure/ operative
c) CT scan of Head notes
(including affected eye) c) Histopathology report
1129 Ophthalmology SE Ophthalmology SE039 Orbitotomy SE039A Orbitotomy 18375 20212 22050 23887 25725 26643 d) Clinical Photograph of d) Intraoperative
the affected eye photograph with patient ID,
time and date (optional)
e) Still image of the gross
specimen removed
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Clinical Notes justifying the a) Clinical Notes for the OPEN
need for GA in the associated surgery.
associated surgery b) disease along with Pre
Ophthalmology, ENT, OP.
1130 Ophthalmology SE General Surgery, Radiation SE040 GA / EUA separate add on package SE040A GA / EUA separate add on package 3150 3465 3780 4095 4410 4567 c) Operative and
Oncology Anesthesia.
d) Post OP notes.

1131 Ophthalmology SE Ophthalmology SE041 Orbital fracture repair SE041A Orbital fracture repair under GA 11025 12127 13230 14332 15435 15986 0 0 OPEN
Ophthalmology,Pediatric 0 0 OPEN
1132 Ophthalmology SE Medical Management, MP007 Optic neuritis SE042A Optic neuritis 2200 2420 2640 2860 3080 3190
General Medicine
Ophthalmology/ General 0 0 OPEN
1133 Ophthalmology SE SE043 Glaucoma Screening SE043A Vision Refraction-IOP & Fundus 840 924 1008 1092 1176 1218
Medicine
Ophthalmology/ General Vision Refraction-IOP & Fundus OCT & Visual 0 0 OPEN
1134 Ophthalmology SE SE043 Glaucoma Screening SE043B 1575 1732 1890 2047 2205 2283
Medicine Fields
Ophthalmology/ General 0 0 OPEN
1135 Ophthalmology SE SE044 Diabetic Retinopathy Screening SE044A Vision refraction,fundus photo and OCT 1050 1155 1260 1365 1470 1522
Medicine
Clinical notes and a) Histopath OPEN YES
a) USG b) Intra procedure clinical
b) CT photograph
c) MRI c) detailed discharge
General Surgery, Surgical
1136 General Surgery SG SG001 Oesophagectomy SG001A Oesophagectomy 131250 144375 157500 170625 183750 190312 d) Biopsy summary
Oncology
report confirming the d) Detailed Operative notes
diagnosis for which the
surgery is done.

a) Clinical notes a) Detailed Indoor case OPEN YES

b) Barium contrast swallow papers (ICPs)
/ Upper Gastrointestinal b) Detailed
Endoscopy procedure/operative notes
General Surgery, Pediatric Operations for Replacement of Operations for Replacement of Oesophagus by
1137 General Surgery SG SG002 SG002A 64260 70686 77112 83538 89964 93177 c) Planned line of c) Detailed discharge
Surgery Oesophagus by Colon Colon
treatment summary
e) Barium contrast swallow

a) Clinical notes explaining a) Detailed Indoor case OPEN YES

endoscopy has failed, or papers (ICPs)
other indication for b) Detailed Procedure /
proceeding with surgery operative notes
Bleeding Ulcer - Partial Gastrectomy without b) Upper GI Endoscopy c) Intra-operative
1138 General Surgery SG General Surgery SG003 Gastrectomy SG003A 65625 72187 78750 85312 91875 95156
Vagotomy with photographs photographs
c) Planned line of d) Histopathological
treatment examination
e) Detailed discharge
summary
a) Clinical notes explaining a) Detailed Indoor case OPEN YES
endoscopy has failed, or papers (ICPs)
other indication for b) Detailed Procedure /
proceeding with surgery operative notes
Bleeding Ulcer - Partial Gastrectomy with b) Upper GI Endoscopy c) Intra-operative
1139 General Surgery SG General Surgery SG003 Gastrectomy SG003B 65625 72187 78750 85312 91875 95156
Vagotomy with photographs photographs
c) Planned line of d) Histopathological
treatment examination
e) Detailed discharge
summary
a) Clinical notes and a) Intra procedure clinical OPEN YES
b) mandatory Biopsy photograph
c) Endoscopy b) Histopathology report
d) CT Scan confirming the c) post procedure clinical
General Surgery, Surgical diagnosis photograph
1140 General Surgery SG SG003 Gastrectomy SG003C Partial Gastrectomy for Carcinoma 45675 50242 54810 59377 63945 66228
Oncology e) Clinical photograph d) Detailed Operative notes
e) Detailed discharge
summary

a) Clinical notes and a) Intra procedure clinical OPEN YES

b) mandatory Biopsy photograph
Endoscopy b) Histopathology report
c) CT Scan confirming the c) post procedure clinical
General Surgery, Surgical diagnosis photograph
1141 General Surgery SG SG003 Gastrectomy SG003D Subtotal Gastrectomy for Carcinoma 45675 50242 54810 59377 63945 66228
Oncology d) Clinical photograph d) Detailed Operative notes
e) Detailed discharge
summary

a) Clinical notes a) Intra procedure clinical OPEN

b) Endoscopy report Video photograph
c) Biopsy b) Histopathology report
d) CT Scan c) post procedure clinical
General Surgery, Surgical confirming the diagnosis photograph
1142 General Surgery SG SG003 Gastrectomy SG003E Total Gastrectomy - Lap. 85365 93901 102438 110974 119511 123779 for which this surgery is d) Detailed Operative notes
Oncology
done. e) Detailed discharge
summary

a) Clinical notes a) Intra procedure clinical OPEN

b) Endoscopy report Video photograph
c) Biopsy b) Histopathology report
d) CT Scan c) post procedure clinical
General Surgery, Surgical confirming the diagnosis photograph
1143 General Surgery SG SG003 Gastrectomy SG003F Total Gastrectomy - Open 85365 93901 102438 110974 119511 123779
Oncology for which this surgery is d) Detailed Operative notes
done. e) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes, specifying a) Detailed Indoor case OPEN
need for gastrostomy papers (ICPs)
(indication) b) Detailed Procedure /
General Surgery, Pediatric b) Clinical Evaluation operative notes
1144 General Surgery SG SG004 Operative Gastrostomy SG004A Operative Gastrostomy 26250 28875 31500 34125 36750 38062
Surgery c) Planned line of c) Intra-operative
treatment photographs (optional)
d) Detailed discharge
summary
a) Clinical notes a) Indoor case papers OPEN
b) X ray / CT Scan (ICPs) b) Treatment detail
1145 37191 40572 43953 47334 49024 c) Intra operative
General Surgery SG General Surgery SG005 Vagotomy SG005A G J Vagotomy 33810
photograph d) Discharge
summary e)
Histopathological report
a) Clinical notes a) Indoor case papers OPEN
b) X ray / CT Scan (ICPs) b) Treatment detail
1146 37191 40572 43953 47334 49024 c) Intra operative
General Surgery SG General Surgery SG005 Vagotomy SG005B Vagotomy + Pyloroplasty 33810
photograph d) Discharge
summary e)
Histopathological report
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication of procedure, treatment details
1147 31416 34272 37128 39984 41412 and planned line of b) Detailed Procedure /
General Surgery SG General Surgery SG006 Operation for Bleeding Peptic Ulcer SG006A Operation for Bleeding Peptic Ulcer 28560
management operative notes
b) Confirmed case of c) Detailed discharge
peptic ulcer disease summary
c) Upper endoscopy
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication of procedure and treatment details b)
Operation for Gastric / Duodenal
1148 General Surgery SG General Surgery SG007 SG007A Gastric Perforation 23730 26103 28476 30849 33222 34408 planned line of Detailed Procedure /
Perforation
management operative notes
b) X-ray Chest/Abdomen / c) Detailed discharge
USG/CT Abdomen summary
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication of procedure and treatment details b)
Operation for Gastric / Duodenal
1149 General Surgery SG General Surgery SG007 SG007B Duodenal Perforation 23730 26103 28476 30849 33222 34408 planned line of Detailed Procedure /
Perforation
management operative notes
b) X-ray Chest/Abdomen / c) Detailed discharge
USG/CT Abdomen summary
a) Clinical notes including a) Detailed Indoor case Referral
evaluation findings, papers (ICPs) with
indication for procedure, treatment
and planned line of details
General Surgery, Pediatric
1150 General Surgery SG SG008 Pyloroplasty SG008A Pyloroplasty 21735 23908 26082 28255 30429 31515 management b) Detailed Procedure /
Surgery
b) USG Abdomen/ Upper operative notes
Gastrointestinal c) Detailed discharge
Endoscopy/ summary
Barium meal series
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication for procedure, treatment
and planned line of details
General Surgery, Pediatric
1151 General Surgery SG SG009 Pyloromyotomy SG009A Pyloromyotomy 39375 43312 47250 51187 55125 57093 management b) Detailed Procedure /
Surgery
b) USG Abdomen/ Upper operative notes
Gastrointestinal c) Detailed discharge
Endoscopy/ summary
Barium meal series
General Surgery, Surgical Open 0 0 OPEN
1152 General Surgery SG SG0106 Subtotal Colectomy SG106A 36645 40309 43974 47638 51303 53135
Oncology
General Surgery, Surgical Lap 0 0 OPEN
1153 General Surgery SG SG0106 Subtotal Colectomy SG106B 36645 40309 43974 47638 51303 53135
Oncology
a) Clinical notes and a) Histopath Reserved
b) Scrotal USG b) Intra procedure clinical
confirming the diagnosis. photograph
General Surgery, Pediatric c) Detailed Operative notes
1154 General Surgery SG SG056 Operation for Hydrocele (U/L) SG056A Operation for Hydrocele (U/L) 10500 11550 12600 13650 14700 15225
Surgery d) Detailed discharge
summary

General Surgery, Pediatric 0 0 OPEN

1155 General Surgery SG SG056 Operation for Hydrocele (B/L) SG056B Operation for Hydrocele (B/L) 15750 17325 18900 20475 22050 22837
Surgery
General Surgery, Pediatric 0 0 OPEN
1156 General Surgery SG SG073 Sympathectomy SG108A Sympathectomy-Bilateral (B/L) 36750 40425 44100 47775 51450 53287
Surgery
0 0 OPEN
1157 General Surgery SG General Surgery SG0109 ERCP SG109A ERCP 15750 17325 18900 20475 22050 22837
a) Clinical notes and a) Intra operative OPEN
Endoscopy report OR photograph
b) Biopsy OR b) Detailed Operative notes
c) CT Scan c) detailed discharge
General Surgery, Surgical
1158 General Surgery SG SG010 Gastrojejunostomy SG010A Gastrojejunostomy 31500 34650 37800 40950 44100 45675 confirming the diagnosis summary
Oncology
for which this surgery is
done.

0 0 OPEN
1159 General Surgery SG General Surgery SG0110 Brachial sinus excision SG110A Brachial sinus excision 21000 23100 25200 27300 29400 30450
0 0 OPEN
1160 General Surgery SG General Surgery SG0111 Epididymal Excision under GA SG111A Epididymal Excision under GA 2100 2310 2520 2730 2940 3045
0 0 OPEN
1161 General Surgery SG General Surgery SG0112 Mesentric cyst excision SG112A Mesentric cyst excision 21000 23100 25200 27300 29400 30450
0 0 OPEN
1162 General Surgery SG General Surgery SG0113 Mole Excision SG113A Mole Excision 2100 2310 2520 2730 2940 3045
0 0 OPEN
1163 General Surgery SG General Surgery SG0114 Neurofibroma Excision under LA SG114A Neurofibroma Excision under LA 2100 2310 2520 2730 2940 3045
0 0 OPEN
1164 General Surgery SG General Surgery SG0115 Ingrowing Toe Nail SG115A Ingrowing Toe Nail 2100 2310 2520 2730 2940 3045
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
0 0 OPEN YES
1165 General Surgery SG General Surgery SG0116 Splenorenal Anastomosis SG116A Splenorenal Anastomosis 73500 80850 88200 95550 102900 106575
Replacement Surgery For Corrosive Injury Replacement Surgery For Corrosive Injury 0 0 OPEN YES
1166 General Surgery SG General Surgery SG0117 SG117A 52500 57750 63000 68250 73500 76125
Stomach Stomach
Choledochoduodenostomy Or Choledocho Choledochoduodenostomy Or Choledocho 0 0 OPEN
1167 General Surgery SG General Surgery SG0118 SG118A 36750 40425 44100 47775 51450 53287
Jejunostomy Jejunostomy
0 0 OPEN YES
1168 General Surgery SG General Surgery SG0119 Hepatico Jejunostomy for biliary stricture SG119A Hepatico Jejunostomy for biliary stricture 47250 51975 56700 61425 66150 68512
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1169 General Surgery SG SG011 Surgical Management of PseudoCyst SG011A CystoJejunostomy - Open 23625 25987 28350 30712 33075 34256 management operative notes
Surgery
b) White blood cell count, c) Detailed discharge
serum amylase reports summary
c) USG/CECT/MRI
Abdomen
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1170 General Surgery SG SG011 Surgical Management of PseudoCyst SG011B CystoJejunostomy - Lap 23625 25987 28350 30712 33075 34256 management operative notes
Surgery
b) White blood cell count, c) Detailed discharge
serum amylase reports summary
c) USG/CECT/MRI
Abdomen
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1171 General Surgery SG SG011 Surgical Management of PseudoCyst SG011C Cystogastrostomy - Open 27615 30376 33138 35899 38661 40041 management operative notes
Surgery
b) White blood cell count, c) Detailed discharge
serum amylase reports summary
c) USG/CECT/MRI
Abdomen
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1172 General Surgery SG SG011 Surgical Management of PseudoCyst SG011D Cystogastrostomy - Lap 27615 30376 33138 35899 38661 40041 management operative notes
Surgery
b) White blood cell count, c) Detailed discharge
serum amylase reports summary
c) USG/CECT/MRI
Abdomen
I Stage- Sub Total Colectomy + Ileostomy + I Stage- Sub Total Colectomy + Ileostomy + J - 0 0 OPEN YES
1173 General Surgery SG General Surgery SG0120 SG120A 84000 92400 100800 109200 117600 121800
J - Pouch Pouch
0 0 OPEN YES
1174 General Surgery SG General Surgery SG0121 Pancreatic Necrosectomy SG121A Pancreatic Necrosectomy 63000 69300 75600 81900 88200 91350
0 0 OPEN YES
1175 General Surgery SG General Surgery SG0122 Distal Pancreatectomy + Splenectomy SG122A Distal Pancreatectomy + Splenectomy 63000 69300 75600 81900 88200 91350
0 0 OPEN
1176 General Surgery SG General Surgery SG0123 Heller Myotomy (Lap./Open) SG123A Heller Myotomy (Lap./Open) 31500 34650 37800 40950 44100 45675
0 0 OPEN YES
1177 General Surgery SG General Surgery SG0124 I Stage-Sub Total Colectomy + Ileostomy SG124A I Stage-Sub Total Colectomy + Ileostomy 42000 46200 50400 54600 58800 60900
a) Clinical notes and a) Intra procedure clinical OPEN
b) Endoscopy report +/- photograph
Video b) detailed discharge
General Surgery, Surgical c) Biopsy summary
1178 General Surgery SG Oncology, Pediatric SG012 Feeding Jejunostomy SG012A Feeding Jejunostomy 15750 17325 18900 20475 22050 22837 d) CT Scan c) Detailed Operative notes
Surgery confirming the diagnosis
for which this surgery is
done.

a) Clinical notes a) Indoor case papers OPEN

b) X ray abdomen (erect (ICPs) b) Detailed operative
posture) notes c) Intra-
General Surgery, Pediatric
1179 General Surgery SG SG013 Ileostomy SG013A Ileostomy 17325 19057 20790 22522 24255 25121 operative clinical
Surgery
photograph/ stills
d) Detailed Discharge
summary
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical Evaluation papers (ICPs)
Upper / lower b) Detailed Procedure /
gastrointestinal series operative notes
General Surgery, Pediatric Congenital Atresia & Stenosis of Small contrast study c) Intraoperative photos
1180 General Surgery SG SG014 SG014A Congenital Atresia & Stenosis of Small Intestine 39375 43312 47250 51187 55125 57093
Surgery Intestine c) Optional (optional)
d) X-ray erect/CT/MRI d) Detailed discharge
Abdomen summary
e) Planned line of
treatment
a) Clinical notes a) Detailed Indoor case Referral
b) CT/MRI papers (ICPs)
c) Endoscopic ultrasound ± b) Detailed operative/
General Surgery, Pediatric fine needle aspiration procedure notes
1181 General Surgery SG SG015 Operation for Duplication of Intestine SG015A Operation for Duplication of Intestine 26670 29337 32004 34671 37338 38671
Surgery d) Planned line of c) Detailed discharge
treatment summary
d) Histopathological
examination
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication of procedure and b) Detailed Procedure /
planned line of operative notes
management c) Histopathological
b) Barium X-ray / Upper GI examination report
Endoscopy /
1182 General Surgery SG General Surgery SG016 Diverticulectomy SG016A Excision Duodenal Diverticulum 26250 28875 31500 34125 36750 38062 USG/CECT/MRI Abdomen
/ Meckel
scan (99mTcpertechnetate
Scintigraphy –
gastrointestinal bleeding) /
Double
balloon Enteroscopy

a) Clinical notes including a) Detailed Indoor case Referral

evaluation findings, papers
indication of procedure and b) Detailed Procedure /
planned line of operative notes
management c) Histopathological
b) Barium X-ray / Upper GI examination report
Endoscopy /
General Surgery, Pediatric USG/CECT/MRI Abdomen
1183 General Surgery SG SG016 Diverticulectomy SG016B Excision Meckel's Diverticulum 17745 19519 21294 23068 24843 25730
Surgery / Meckel
scan (99mTcpertechnetate
Scintigraphy –
gastrointestinal bleeding) /
Double
balloon Enteroscopy

a) Clinical notes a) Histopathology report OPEN

b) USG b) Intra procedure clinical
confirming the diagnosis. photograph of removed
appendix
General Surgery, Pediatric c) post procedure clinical
1184 General Surgery SG SG017 Appendicectomy SG017A Open 21000 23100 25200 27300 29400 30450 photograph
Surgery
d) Detailed Operative notes
e) Detailed discharge
summary

a) Clinical notes a) Histopathology report OPEN

b) USG b) Intra procedure clinical
confirming the diagnosis. photograph of removed
appendix
General Surgery, Pediatric c) post procedure clinical
1185 General Surgery SG SG017 Appendicectomy SG017B Lap 21000 23100 25200 27300 29400 30450 photograph
Surgery
d) Detailed Operative notes
e) Detailed discharge
summary

a) Clinical notes a) Histopath OPEN

b) X Ray Abdomen Erect b) Intra procedure clinical
c) USG photograph
General Surgery, Pediatric confirming the diagnosis. c) detailed discharge
1186 General Surgery SG SG018 Appendicular Perforation SG018A Appendicular Perforation 21000 23100 25200 27300 29400 30450
Surgery summary
d) Detailed Operative notes

a) Clinical notes a) Intra Operative clinical OPEN

b) USG photograph
General Surgery, Pediatric Operative drainage of Appendicular b) Detailed Operative notes
1187 General Surgery SG SG019 SG019A Operative drainage of Appendicular Abscess 15750 17325 18900 20475 22050 22837
Surgery Abscess c) discharge summary.

a) Clinical notes and a) Histopathology OPEN YES

b) CT Scan b) Intra procedure clinical
c) Colonoscopy confirming photograph
General Surgery, Surgical Open the diagnosis and need of c) detailed discharge
1188 General Surgery SG SG020 Total Colectomy SG020A 50715 55786 60858 65929 71001 73536
Oncology surgery summary
d) Biopsy of the lsoion d) Detailed Operative notes

a) Clinical notes and a) Histopathology OPEN YES

b) CT Scan b) Intra procedure clinical
c) Colonoscopy confirming photograph
General Surgery, Surgical Lap the diagnosis and need of c) detailed discharge
1189 General Surgery SG SG020 Total Colectomy SG020B 50715 55786 60858 65929 71001 73536
Oncology surgery summary
d) Biopsy of the lsoion d) Detailed Operative notes

a) Clinical notes and a) Histopathology report OPEN

b) CT Scan and
c) Colonoscopy confirming b) Intra procedure Clinical
the diagnosis and need of photograph of removed
General Surgery, Surgical
1190 General Surgery SG SG021 Hemi colectomy SG021A Right-Open 36960 40656 44352 48048 51744 53592 surgery colon
Oncology
d) Biopsy of the lsoion c) Detailed discharge
summary
d) Detailed Operative notes
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes and a) Histopathology report OPEN
b) CT Scan and
c) Colonoscopy confirming b) Intra procedure Clinical
the diagnosis and need of photograph of removed
General Surgery, Surgical
1191 General Surgery SG SG021 Hemi colectomy SG021B Right- Lap 36960 40656 44352 48048 51744 53592 surgery colon
Oncology
d) Biopsy of the lsoion c) Detailed discharge
summary
d) Detailed Operative notes

a) Clinical notes and a) Histopathology report OPEN

b) CT Scan and
c) Colonoscopy confirming b) Intra procedure Clinical
the diagnosis and need of photograph of removed
General Surgery, Surgical
1192 General Surgery SG SG021 Hemi colectomy SG021C Left-Open 36960 40656 44352 48048 51744 53592 surgery colon
Oncology
d) Biopsy of the lsoion c) Detailed discharge
summary
d) Detailed Operative notes

a) Clinical notes and a) Histopathology report OPEN

b) CT Scan and
c) Colonoscopy confirming b) Intra procedure Clinical
the diagnosis and need of photograph of removed
General Surgery, Surgical
1193 General Surgery SG SG021 Hemi colectomy SG021D Left- Lap 36960 40656 44352 48048 51744 53592 surgery colon
Oncology
d) Biopsy of the lsoion c) Detailed discharge
summary
d) Detailed Operative notes

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings and papers (ICPs) with
planned line of treatment details
management b) Detailed Procedure /
General Surgery, Pediatric Operative Management of Volvulus of Operative Management of Volvulus of Large
1194 General Surgery SG SG022 SG022A 34545 37999 41454 44908 48363 50090 b) X-ray erect Abdomen or operative notes
Surgery Large Bowel Bowel
Barium Enema or CT c) Post-operative X-ray
abdomen Abdomen
d) Detailed discharge
summary
a) Clinical notes a) Post procedure clinical OPEN
b) CT photograph
c) MRI b) Detailed Operative notes
General Surgery, Surgical
1195 23100 25200 27300 29400 30450 d) Colonoscopy c) detailed surgery notes.
General Surgery SG Oncology, Pediatric SG023 Colostomy SG023A Colostomy 21000
evidence of need of
Surgery
surgery.

Clinical notes detailing why a) Post procedure clinical OPEN

colostomy was done? photograph
General Surgery, Surgical Clinical photograph b) Detailed Operative notes
1196 General Surgery SG Oncology, Pediatric SG024 Closure of stoma SG024A Closure of stoma 17535 19288 21042 22795 24549 25425 c) Detailed discharge
Surgery summary

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings and papers (ICPs) with
planned line of treatment details
management b) Detailed Procedure /
1197 General Surgery SG General Surgery SG025 Sigmoid Resection SG025A Sigmoid Resection 24255 26680 29106 31531 33957 35169 b) X-ray erect Abdomen or operative notes
Barium Enema or CT c) Post-operative X-ray
abdomen Abdomen
d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings papers (ICPs) with
especially per rectal treatment details
1198 General Surgery SG General Surgery SG026 Perineal Procedure for Rectal Prolapse SG026A Perineal Procedure for Rectal Prolapse 19740 21714 23688 25662 27636 28623 examination, indication for b) Detailed Procedure /
procedure, and planned operative notes
line of management c) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Referral
evaluation findings papers (ICPs) with
especially per rectal treatment details
Open
1199 General Surgery SG General Surgery SG027 Abdominal Procedure for Rectal Prolapse SG027A 21315 23446 25578 27709 29841 30906 examination, indication for b) Detailed Procedure /
procedure, and planned operative notes
line of management c) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Referral
evaluation findings papers (ICPs) with
especially per rectal treatment details
Lap
1200 General Surgery SG General Surgery SG027 Abdominal Procedure for Rectal Prolapse SG027B 21315 23446 25578 27709 29841 30906 examination, indication for b) Detailed Procedure /
procedure, and planned operative notes
line of management c) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Referral
evaluation findings papers (ICPs) with
especially per rectal treatment details
General Surgery, Surgical
1201 General Surgery SG SG028 Rectal Polyp Excision SG028A Rectal Polyp Excision 10500 11550 12600 13650 14700 15225 examination, indication for b) Detailed Procedure /
Oncology
procedure, and planned operative notes
line of management c) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings papers (ICPs) with
especially per rectal treatment details
General Surgery, Surgical
1202 General Surgery SG SG029 Anterior Resection of rectum SG029A Open 52500 57750 63000 68250 73500 76125 examination, indication for b) Detailed Procedure /
Oncology
procedure, and planned operative notes
line of management c) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Histopathology report OPEN YES
b) Biopsy b) post procedure clinical
c) Colonoscopy photograph
General Surgery, Surgical Lap c) Detailed Operative notes
1203 General Surgery SG SG029 Anterior Resection of rectum SG029B 52500 57750 63000 68250 73500 76125
Oncology d) detailed discharge
summary

a) Clinical notes a) Indoor case papers OPEN

b) X ray abdomen (erect (ICPs) b) Detailed operative
posture) notes c) Intra-operative
clinical photograph/ stills
General Surgery, Pediatric
1204 General Surgery SG SG030 Resection Anastomosis SG030A Open 28035 30838 33642 36445 39249 40650 d) Detailed Discharge
Surgery
summary
e) Histopathological report

a) Clinical notes a) Indoor case papers OPEN

b) X ray abdomen (erect (ICPs) b) Detailed operative
posture) notes c) Intra-operative
clinical photograph/ stills
General Surgery, Pediatric Lap
1205 General Surgery SG SG030 Resection Anastomosis SG030B 28035 30838 33642 36445 39249 40650 d) Detailed Discharge
Surgery
summary
e) Histopathological report

a) Clinical notes a) Indoor case papers Referral

b) Anal examination (ICPs)
1206 11550 12600 13650 14700 15225 findings b) Detailed Procedure /
General Surgery SG General Surgery SG031 Procedure for Fissure in Ano SG031A Procedure for Fissure in Ano 10500
operative notes
c) Detailed discharge
summary
a) Clinical notes a) Indoor case papers Referral
b) Clinical Examination (ICPs)
c) Proctoscopy b) Detailed Procedure /
1207 16500 18000 19500 21000 21750 operative notes
General Surgery SG General Surgery SG032 Haemorroidectomy SG032A without Stapler 15000
c) Intra-op clinical
photographs
d) Detailed discharge
summary
a) Clinical notes a) Indoor case papers Referral
b) Clinical Examination (ICPs)
c) Proctoscopy b) Detailed Procedure /
1208 35200 38400 41600 44800 46400 operative notes
General Surgery SG General Surgery SG032 Haemorroidectomy SG032B with Stapler 32000
c) Intra-op clinical
photographs
d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Reserved
evaluation findings, papers (ICPs) with
indication for procedure treatment details
and planned line of b) Detailed Procedure /
1209 General Surgery SG General Surgery SG033 Management of Pilonidal Sinus SG033A Management of Pilonidal Sinus 5985 6583 7182 7780 8379 8678 management operative notes
c) Histopathological
examination report for
chronic cases
d) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case Reserved
b) Clinical picture (private papers (ICPs)
parts may be covered) b) Detailed Procedure /
c) Planned line of operative notes
1210 General Surgery SG General Surgery SG034 Exicision of Sinus and Curettage SG034A Exicision of Sinus and Curettage 5250 5775 6300 6825 7350 7612 treatment c) Post-operative clinical
photograph (optional)
d) Histopathological
examination
e) Detailed discharge
summary
a) Clinical notes a) Indoor case papers OPEN
b) X ray abdomen (erect (ICPs) b) Detailed operative
posture) notes c) Intra-operative
clinical photograph/ stills
General Surgery, Pediatric
1211 General Surgery SG SG035 Exploratory Laparotomy SG035A Exploratory Laparotomy 13000 14300 15600 16900 18200 18850 d) Detailed Discharge
Surgery
summary
e) Histopathological report

a) Clinical notes a) Detailed Indoor case OPEN

b) Clinical Photograph papers
c) Planned line of b) Procedure operative
General Surgery, Pediatric
1212 17325 18900 20475 22050 22837 treatment notes
General Surgery SG Surgery, Obstetrics & SG036 Closure of Burst Abdomen SG036A Closure of Burst Abdomen 15750
c) Post operative
Gynecology
photographs
d) Detailed discharge
summary
a) Clinical notes and a) Histopath OPEN
b) USG b) Intra procedure clinical
c) CT photograph
General Surgery, Surgical d) MRI c) detailed discharge
1213 General Surgery SG Oncology, Pediatric SG037 Hepatic Resection SG037A Open 39375 43312 47250 51187 55125 57093 e) Biopsy summary
Surgery report confirming the d) Detailed Operative notes
justification of surgery.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes and a) Histopath OPEN
b) USG b) Intra procedure clinical
c) CT photograph
General Surgery, Surgical d) MRI c) detailed discharge
1214 General Surgery SG Oncology, Pediatric SG037 Hepatic Resection SG037B Lap 39375 43312 47250 51187 55125 57093 e) Biopsy summary
Surgery report confirming the d) Detailed Operative notes
justification of surgery.

a) Clinical notes a) Indoor case papers Referral

b) USG/CT/MRI Abdomen (ICPs)
b) Detailed Procedure /
General Surgery, Pediatric Operation forAbdominal Hydatid Cyst Operation forAbdominal Hydatid Cyst (Single operative notes
1215 General Surgery SG SG038 SG038A 22050 24255 26460 28665 30870 31972
Surgery (Single Organ) - Change in Name Organ) - Change in Name c) Detailed discharge
summary
d) Intra-operative
Photographs (optional)
a)Clinical notes a) Operative notes Referral
b) USG upper abdomen b)Pre-anesthesia check-up
c)LFT (Liver function test) report
c)Detailed Discharge
General Surgery, Pediatric Summary d)Intraoperative
1216 General Surgery SG SG039 Cholecystectomy SG039A Without Exploration of CBD - Open 32655 35920 39186 42451 45717 47349 photograph and
Surgery
Pictures of gross specimen
removed
e)Histopathology report
(can be submitted within 7
days of discharge)
a)Clinical notes a) Operative notes Referral
b) USG upper abdomen b)Pre-anesthesia check-up
c)LFT (Liver function test) report
c)Detailed Discharge
General Surgery, Pediatric Summary d)Intraoperative
1217 General Surgery SG SG039 Cholecystectomy SG039B With Exploration of CBD - Open 32655 35920 39186 42451 45717 47349 photograph and
Surgery
Pictures of gross specimen
removed
e)Histopathology report
(can be submitted within 7
days of discharge)
a)Clinical notes a) Operative notes OPEN
b) USG upper abdomen b)Pre-anesthesia check-up
c)LFT (Liver function test) report
c)Detailed Discharge
General Surgery, Pediatric Summary d)Intraoperative
1218 General Surgery SG SG039 Cholecystectomy SG039C Without Exploration of CBD - Lap 32655 35920 39186 42451 45717 47349 photograph and
Surgery
Pictures of gross specimen
removed
e)Histopathology report
(can be submitted within 7
days of discharge)
a)Clinical notes a) Operative notes Referral
b) USG upper abdomen b)Pre-anesthesia check-up
c)LFT (Liver function test) report
c)Detailed Discharge
General Surgery, Pediatric Summary d)Intraoperative
1219 General Surgery SG SG039 Cholecystectomy SG039D With Exploration of CBD - Lap 32655 35920 39186 42451 45717 47349 photograph and
Surgery
Pictures of gross specimen
removed
e)Histopathology report
(can be submitted within 7
days of discharge)
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical evaluation papers (ICPs)
c) USG/CT Abdomen / b) Detailed Procedure /
General Surgery, Pediatric Liver function test / White operative notes
1220 General Surgery SG SG040 Operative Cholecystostomy SG040A Open 11865 13051 14238 15424 16611 17204
Surgery blood count / c) Operative photographs
Hepatobiliaryiminodiacetic d) Detailed discharge
acid scan (HIDA scan- summary
optional)
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical evaluation papers (ICPs)
c) USG/CT Abdomen / b) Detailed Procedure /
General Surgery, Pediatric Liver function test / White operative notes
1221 General Surgery SG SG040 Operative Cholecystostomy SG040B Lap 11865 13051 14238 15424 16611 17204
Surgery blood count / c) Operative photographs
Hepatobiliaryiminodiacetic d) Detailed discharge
acid scan (HIDA scan- summary
optional)
a) Clinical notes including a) Detailed Indoor case Referral
evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1222 General Surgery SG SG041 Operation of Choledochal Cyst SG041A Operation of Choledochal Cyst 33285 36613 39942 43270 46599 48263 management operative notes
Surgery
b) Ultrasound Abdomen c) Detailed discharge
c) Magnetic Resonance summary
Cholangiopancreatography
(MRCP)
a) Clinical notes a) Detailed Indoor case Referral
b) Clinical Evaluation papers (ICPs)
c) USG/CECT Abdomen b) Detailed Procedure /
d) Planned line of operative notes
General Surgery, Pediatric treatment c) Intra-operative
1223 General Surgery SG SG042 Splenectomy SG042A Open 36960 40656 44352 48048 51744 53592
Surgery photographs (optional)
d) Histopathological
examination
e) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Detailed Operative notes OPEN
b) USG b) Histopath
c) CT Scan c) Detailed discharge
General Surgery, Pediatric d) Lab investigations summary
1224 General Surgery SG SG042 Splenectomy SG042B Lap 36960 40656 44352 48048 51744 53592
Surgery confirming the diagnosis
and justifying the surgery.

Clinical and radiological a) Histopathology report OPEN YES

evidence of inoperability. b) Intra operative clinical
( photograph
a) Biopsy c) Detailed Operative notes
General Surgery, Surgical
1225 General Surgery SG SG043 Bypass - Inoperable Pancreas SG043A Bypass - Inoperable Pancreas 65625 72187 78750 85312 91875 95156 b) ERCP. and
Oncology
c) MRCP d) Discharge summary.
)

a) Clinical notes and a) Histopath OPEN YES

b) Sr Amylase b) Intra procedure clinical
c) CT photograph
General Surgery, Surgical
Distal Pancreatectomy with Distal Pancreatectomy/Pancreatico d) USG c) Detailed discharge
1226 General Surgery SG Oncology, Pediatric SG044 SG044A 46830 51513 56196 60879 65562 67903
Pancreatico Jejunostomy Jejunostomy with/without spleenlectomy e) ERCP summary
Surgery
justifying the surgery. d) Detailed Operative notes

a) Clinical notes and a) Histopath OPEN YES

b) Sr Amylase b) Intra procedure clinical
c) CT photograph
General Surgery, Surgical d) USG c) Detailed discharge
1227 General Surgery SG SG045 PancreaticoDuodenectomy (Whipple's) SG045A PancreaticoDuodenectomy (Whipple's) 131250 144375 157500 170625 183750 190312
Oncology e) ERCP summary
justifying the surgery. d) Detailed Operative notes

a) Clinical notes including a) Detailed Indoor case OPEN YES

evaluation findings, papers (ICPs) with
indication of procedure and treatment details
planned line of b) Detailed Procedure /
1228 General Surgery SG General Surgery SG046 Porto Caval Anastomosis SG046A Porto Caval Anastomosis 52500 57750 63000 68250 73500 76125 management operative notes
b) Complete blood count c) Detailed discharge
c) Liver function tests summary
d)Oesophagogastroduoden
oscopy
e) USG/CT Abdomen
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers (ICPs) with
indication of procedure and treatment details
planned line of b) Detailed Procedure /
1229 General Surgery SG General Surgery SG047 Mesenteric Caval Anastomosis SG047A Mesenteric Caval Anastomosis 51030 56133 61236 66339 71442 73993 management operative notes
b) Complete blood count c) Detailed discharge
c) Liver function tests summary
d)Oesophagogastroduoden
oscopy
e) USG/CT Abdomen
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1230 General Surgery SG SG048 Mesenteric Cyst – Excision SG048A Mesenteric Cyst – Excision 21735 23908 26082 28255 30429 31515 management operative notes
Surgery
b) USG/CT/MRI Abdomen c) Histopathology
examination
d) Detailed discharge
summary
a) Clinical notes and a) Histopath Referral YES
b) X- Ray b) Intra procedure clinical
c) USG photograph
General Surgery, Surgical
1231 45276 49392 53508 57624 59682 d) CT Abdomen c) Detailed discharge
General Surgery SG Oncology, Pediatric SG049 Retroperitoneal Tumor – Excision SG049A Retroperitoneal Tumor – Excision 41160
confirming the diagnosis. summary and
Surgery
d) Detailed Operative notes

a)Clinical notes a)Post op clinical Referral

b) Photograph showing photograph b)Operative
hernia / bulge notes c)Invoice of
1232 23100 25200 27300 29400 30450 the Mesh / tacker used
General Surgery SG General Surgery SG050 Groin Hernia Repair SG050A Inguinal - Open 21000
d)Detailed Discharge
Summary e)Pre-anesthesia
check-up report

a)Clinical notes a)Post op clinical Referral

b) Photograph showing photograph b)Operative
hernia / bulge notes c)Invoice of
1233 23100 25200 27300 29400 30450 the Mesh / tacker used
General Surgery SG General Surgery SG050 Groin Hernia Repair SG050B Inguinal - Lap. 21000
d)Detailed Discharge
Summary e)Pre-anesthesia
check-up report

a) Clinical notes including a) Detailed Indoor case Referral

evaluation findings, papers (ICPs) with
indication for implant as treatment details
applicable, and planned b) Detailed Procedure /
line of management operative notes
1234 General Surgery SG General Surgery SG050 Groin Hernia Repair SG050C Femoral - Open 21000 23100 25200 27300 29400 30450 b) Ultrasound/CT/MRI of c) Implant details –
the groin (for obturator barcode/invoice (if
hernia applicable)
diagnosed preoperatively) d) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case Referral
evaluation findings, papers (ICPs) with
indication for implant as treatment details
applicable, and planned b) Detailed Procedure /
line of management operative notes
1235 General Surgery SG General Surgery SG050 Groin Hernia Repair SG050D Femoral - Lap 21315 23446 25578 27709 29841 30906 b) Ultrasound/CT/MRI of c) Implant details –
the groin (for obturator barcode/invoice (if
hernia applicable)
diagnosed preoperatively) d) Detailed discharge
summary

a) Clinical notes including a) Detailed Indoor case Referral

evaluation findings, papers (ICPs) with
indication for implant as treatment details
applicable, and planned b) Detailed Procedure /
General Surgery, Pediatric line of management operative notes
1236 General Surgery SG SG050 Groin Hernia Repair SG050E Obturator - Lap. 24045 26449 28854 31258 33663 34865 b) Ultrasound/CT/MRI of c) Implant details –
Surgery
the groin (for obturator barcode/invoice (if
hernia applicable)
diagnosed preoperatively) d) Detailed discharge
summary

a) Clinical notes and a) Post procedure clinical Referral

b) USG (specifying size of photograph
defect) b) Detailed discharge
General Surgery, Pediatric c) Clinical photograph summary
1237 General Surgery SG SG051 Hernia - Ventral SG051A Epigastric 21000 23100 25200 27300 29400 30450
Surgery c) Detailed Operative notes
d) Invoice of Mesh used

a) Clinical notes and a) Post procedure clinical Referral

b) USG (specifying size of photograph
defect) b) Detailed discharge
General Surgery, Pediatric c) Clinical photograph summary
1238 General Surgery SG SG051 Hernia - Ventral SG051B Umbilical 26250 28875 31500 34125 36750 38062
Surgery c) Detailed Operative notes
d) Invoice of Mesh used

a) Clinical notes and a) Post procedure clinical OPEN

b) USG (specifying size of photograph
defect) b) Detailed discharge
General Surgery, Pediatric c) Clinical photograph summary
1239 General Surgery SG SG051 Hernia - Ventral SG051C Paraumbilical 26250 28875 31500 34125 36750 38062
Surgery c) Detailed Operative notes
d) Invoice of Mesh used

a) Clinical notes and a) Post procedure clinical OPEN

b) USG (specifying size of photograph
defect) b) Detailed discharge
General Surgery, Pediatric c) Clinical photograph summary
1240 General Surgery SG SG051 Hernia - Ventral SG051D Spigelian 26250 28875 31500 34125 36750 38062
Surgery c) Detailed Operative notes
d) Invoice of Mesh used

a) Clinical notes including a) Post procedure clinical Referral

info about previous surgery photograph
in whose incision this b) Detailed discharge
hernia has occurred summary
General Surgery, Pediatric
1241 General Surgery SG SG052 Repair of Incisional Hernia SG052A Repair of Incisional Hernia Lap/Open 21315 23446 25578 27709 29841 30906 b) USG (specifying size of c) Detailed Operative notes
Surgery
defect) d) Invoice of Mesh used
c) Clinical photograph

a) Clinical notes a) Detailed Indoor case Referral

b) Clinical Evaluation papers (ICPs)
c) Upper gastrointestinal b) Detailed Procedure /
series/barium swallow operative notes
General Surgery, Pediatric d) Upper endoscopy c) Detailed discharge
1242 General Surgery SG SG053 Hiatus Hernia Repair / Fundoplication SG053A Hiatus Hernia Repair - Open 27615 30376 33138 35899 38661 40041
Surgery e) 24-hr pH-monitoring summary
f) Oesophageal manometry
g) Planned line of
treatment

a) Clinical notes a) Detailed Indoor case Referral

b) Clinical Evaluation papers (ICPs)
c) Upper gastrointestinal b) Detailed Procedure /
series/barium swallow operative notes
General Surgery, Pediatric d) Upper endoscopy c) Detailed discharge
1243 General Surgery SG SG053 Hiatus Hernia Repair / Fundoplication SG053B Hiatus Hernia Repair - Lap 27615 30376 33138 35899 38661 40041
Surgery e) 24-hr pH-monitoring summary
f) Oesophageal manometry
g) Planned line of
treatment

a) Clinical notes a) Detailed Indoor case Referral

b) Clinical Evaluation papers (ICPs)
c) Upper gastrointestinal b) Detailed Procedure /
series/barium swallow operative notes
General Surgery, Pediatric d) Upper endoscopy c) Detailed discharge
1244 General Surgery SG SG053 Hiatus Hernia Repair / Fundoplication SG053C Fundoplication - Open(+/- Hiatus Hernia repair) 27615 30376 33138 35899 38661 40041
Surgery e) 24-hr pH-monitoring summary
f) Oesophageal manometry
g) Planned line of
treatment
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case Reserved
evaluation findings, papers (ICPs) with
indication for procedure treatment details
and planned line of b) Detailed Procedure /
Excision of cyst / Sebaceous Cysts over
1245 General Surgery SG General Surgery SG054 SG054A Single Cyst 2835 3118 3402 3685 3969 4110 management operative notes Yes
scrotum
b) Scrotal ultrasound (not c) Histopathological
required for sebaceous examination
cysts) d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Reserved
evaluation findings, papers (ICPs) with
indication for procedure treatment details
and planned line of b) Detailed Procedure /
Excision of cyst / Sebaceous Cysts over
1246 General Surgery SG General Surgery SG054 SG054B Multiple Cysts 7000 7700 8400 9100 9800 10150 management operative notes Yes
scrotum
b) Scrotal ultrasound (not c) Histopathological
required for sebaceous examination
cysts) d) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case Reserved
b) Clinical photographs papers
c) Peripheral blood b) Detailed Procedure /
1247 9240 10080 10920 11760 12180 examination operative notes
General Surgery SG General Surgery SG055 Excision Filarial Scrotum SG055A Excision Filarial Scrotum 8400
d) USG Abdomen and c) Post-operative
scrotum Photographs
d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Reserved
evaluation findings, papers (ICPs) with
indication for procedure treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1248 General Surgery SG SG057 Epididymal Cyst / Nodule Excision SG057A Epididymal Cyst excision 5565 6121 6678 7234 7791 8069 management operative notes Yes
Surgery
b) Scrotal ultrasound (not c) Histopathological
required for sebaceous examination
cysts) d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Reserved
evaluation findings, papers (ICPs) with
indication for procedure treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1249 General Surgery SG SG057 Epididymal Cyst / Nodule Excision SG057B Epididymal Nodule excision 5565 6121 6678 7234 7791 8069 management operative notes Yes
Surgery
b) Scrotal ultrasound (not c) Histopathological
required for sebaceous examination
cysts) d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Referral
evaluation findings, papers (ICPs) with
indication for procedure, treatment details
1250 General Surgery SG General Surgery, Urology SG058 Vasovasostomy SG058A Vasovasostomy 12600 13860 15120 16380 17640 18270 and planned line of b) Detailed Procedure /
management operative notes
b) Pre-operative scrotal c) Detailed discharge
examination summary
a) Clinical notes and a) Histopath OPEN
b) Describing Swelling in b) Intra operative clinical
scrotum photograph
General Surgery, Surgical c) USG of scrotum c) Detailed Operative notes
1251 General Surgery SG Oncology, Pediatric SG059 Orchidectomy SG059A Orchidectomy 12600 13860 15120 16380 17640 18270 d) FNAC d) Detailed discharge
Surgery e) Tumour markers (if summary
cancer of prostate/testis
etc. is the indication)
justification of orchidectmy.

a) Clinical notes a) Histopath OPEN

b) USG b) Intra procedure clinical
c) Biopsy photograph
General Surgery, Pediatric report confirming the c) Detailed discharge
1252 General Surgery SG SG060 Inguinal Node (dissection) - U/L SG060A Inguinal Node (dissection) - U/L 20790 22869 24948 27027 29106 30145
Surgery diagnosis for which the summary
surgery is done. d) Detailed Operative notes

a) Clinical notes detailing a) Post procedure clinical OPEN

the original pathology thet photograph
has led to this surgery with b) Detailed Operative notes
suporting investigation c) Detailed discharge
General Surgery, Surgical
1253 General Surgery SG SG061 Estlander Operation (lip) SG061A Estlander Operation (lip) 19425 21367 23310 25252 27195 28166 reports. summary
Oncology
b) FIR/MLC in case of
traumatic aetiology
c) Clinical Photograph
Photograph
a) Clinical notes a) Histopath OPEN
b) Biopsy report b) Post procedure clinical
c) Clinical Photograph photograph
General Surgery, Surgical c) Detailed Operative notes
1254 General Surgery SG SG062 Operation for Carcinoma Lip SG062A Wedge Excision 26355 28990 31626 34261 36897 38214
Oncology d) Detailed discharge
summary

a) Clinical notes a) Histopath OPEN

b) Biopsy report b) Post procedure clinical
c) Clinical Photograph photograph
General Surgery, Surgical c) Detailed Operative notes
1255 General Surgery SG SG062 Operation for Carcinoma Lip SG062B Wedge Excision and Vermilionectomy 39375 43312 47250 51187 55125 57093
Oncology d) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Histopath OPEN
b) Biopsy report b) Post procedure clinical
c) Clinical Photograph photograph
General Surgery, Surgical c) Detailed Operative notes
1256 General Surgery SG SG062 Operation for Carcinoma Lip SG062C Cheek advancement 39375 43312 47250 51187 55125 57093
Oncology d) Detailed discharge
summary

a) Clinical notes confirming a) Histopath OPEN

the diagnosis b) Post procedure clinical
b) Clinical Photograph photograph
General Surgery, Surgical
Complete Excision of Growth from Tongue Complete Excision of Growth from Tongue only c) FNAC if done c) Detailed Operative notes
1257 General Surgery SG Oncology, Pediatric SG063 SG063A 21945 24139 26334 28528 30723 31820
only (inclusive of Histopathology) (inclusive of Histopathology) d) Detailed discharge
Surgery
summary

a) Clinical notes a) Histopath OPEN YES

b) USG b) Post procedure clinical
c) CT photograph
d) MRI c) Detailed Operative notes
General Surgery, Surgical Excision of Growth from Tongue with neck Excision of Growth from Tongue with neck node e) Clinical Photograph d) Detailed discharge
1258 General Surgery SG SG064 SG064A 41160 45276 49392 53508 57624 59682
Oncology node dissection dissection report confirming the summary
diagnosis

a) Clinical notes a) Post procedure Nasal OPEN

b) Nasal Endoscopy Endoscopy
confirming the diagnosis b) Post procedure clinical
for which this surgery is photograph
done. c) Intra procedure clinical
1259 General Surgery SG General Surgery SG065 Microlaryngoscopic Surgery SG065A Microlaryngoscopic Surgery 19425 21367 23310 25252 27195 28166 photograph
d) Detailed discharge
summary
e) Detailed Operative notes

a) Clinical notes a) Histopath OPEN

b) USG b) Post procedure clinical
c) CT Scan confirming the photograph
diagnosis for which the c) Detailed Operative notes
General Surgery, Surgical
1260 General Surgery SG SG066 Submandibular Mass Excision SG066A Submandibular Mass Excision 26250 28875 31500 34125 36750 38062 surgery is done d) Detailed discharge
Oncology
d) Biopsy summary
e) FNAC
f) Clinical Photograph

a) Clinical notes a) Histopath OPEN

b) CT Scan b) Intra procedure clinical
c) MRI Neck confirming the photograph
diagnosis c) Post procedure clinical
General Surgery, Surgical d) Biopsy photograph
1261 General Surgery SG SG067 Radical Neck Dissection SG067A Radical Neck Dissection 35385 38923 42462 46000 49539 51308
Oncology, ENT e) Clinical Photograph d) Detailed discharge
summary
e) Detailed Operative notes

a) Clinical notes with signs, a) Indoor case papers OPEN

symptoms, indications, (ICPs) b) Detailed
planned line of Procedure / operative notes
management and advise c) Intra-operative
1262 General Surgery SG General Surgery, ENT SG068 Surgical removal of Branchial Cyst/Sinus SG068A Surgical removal of Branchial Cyst/Sinus 21000 23100 25200 27300 29400 30450 for admission photographs (optional)
b) Clinical Photograph d) Detailed discharge
c) USG Neck/ Fine needle summary e)
aspiration cytology (FNAC) Histopathological
d) Optional CT/MRI examination

a) Clinical notes a) Intra procedure clinical Referral

b) USG Neck photograph
c) Colour Doppler b) Detailed Operative notes
General Surgery, Surgical confirming the diagnosis. c) Histopathology
1263 General Surgery SG SG069 Carotid Body tumour - Excision SG069A Carotid Body tumour - Excision 39375 43312 47250 51187 55125 57093
Oncology, CTVS d) Detailed discharge
summary

a) Clinical notes a) Histopath report Referral

b) Thyroid Function Test b) Post procedure clinical
c) FNAC photograph
General Surgery, Surgical
1264 30376 33138 35899 38661 40041 d) USG c) Detailed Operative notes
General Surgery SG Oncology, Pediatric SG070 Thyroidectomy SG070A Hemi thyroidectomy 27615
confirming the diagnosis d) Detailed discharge
Surgery, ENT
and justifying the surgery. summary

a) Clinical notes a) Histopath report Referral

b) Thyroid Function Test b) Post procedure clinical
c) FNAC photograph
General Surgery, Surgical
1265 30376 33138 35899 38661 40041 d) USG c) Detailed Operative notes
General Surgery SG Oncology, Pediatric SG070 Thyroidectomy SG070B Total thyroidectomy 27615
confirming the diagnosis d) Detailed discharge
Surgery, ENT
and justifying the surgery. summary

a) Clinical notes a) Histopath report Referral YES

b) FNAC b) Post procedure clinical
c) Biopsy photograph
General Surgery, Surgical d) Thyroid Function Test c) Scar Photo
1266 General Surgery SG Oncology, Pediatric SG070 Thyroidectomy SG070C Total Thyroidectomy with Block Dissection 45780 50358 54936 59514 64092 66381 e) USG d) Detailed discharge
Surgery, ENT confirming the diagnosis summary
and need for surgery e) Detailed Operative notes
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Histopathology Referral
b) USG b) Intra procedure clinical
c) CT Scan photograph
General Surgery, Surgical
Excision of Parathyroid Adenoma / d) Nuclear Imaging c) Detailed discharge
1267 General Surgery SG Oncology, Pediatric SG071 SG071A Excision of Parathyroid Adenoma/Carcinoma 26250 28875 31500 34125 36750 38062
Carcinoma confirming the diagnosis. summary
Surgery
d) Detailed Operative notes

a) Clinical notes a) Detailed Indoor case Referral YES

b) Clinical Evaluation papers (ICPs)
c) Investigations (Optional b) Detailed Procedure /
– Based on Etiology) operative notes
1. CT/MRI/PET c) Histopathological
2. Thoracoscopy examination
3. Biopsy d) Detailed discharge
4. Pulmonary function test summary
General Surgery, Pediatric 5. Thyroid profile
1268 General Surgery SG SG072 Thymectomy SG072A Thymectomy 63000 69300 75600 81900 88200 91350
Surgery 6. Nerve conduction
studies
(EMG/ENMG)/Prostigmine/
Tensilon test/
7. Ach receptor antibody
testing
d) Planned line of
treatment

a) Clinical notes a) Detailed Indoor case Referral

b) Clinical photographs papers (ICPs)
c) Investigations b) Detailed Procedure /
General Surgery, Pediatric
1269 General Surgery SG SG073 Sympathectomy SG073A Sympathectomy-Unilateral (U/L) 21735 23908 26082 28255 30429 31515 1. Doppler ultrasound operative notes
Surgery
blood flow c) Detailed discharge
d) Planned line of summary
treatment
a) Clinical notes a) Histopathology report OPEN
b) Sono mammogram b) Intra operative clinical
c) Mamography showing photograph
General Surgery, Surgical breast lump c) Detailed Operative notes
1270 General Surgery SG SG074 Breast Lump Excision (Benign) SG074A Breast Lump Excision (Benign) 10500 11550 12600 13650 14700 15225
Oncology d) FNAC report d) Detailed discharge
summary.

a) Clinical notes a) Histopath Referral

b) Mammography b) Post procedure clinical
c) Biopsy confirming the photograph
General Surgery, Surgical diagnosis c) Detailed Operative notes
1271 General Surgery SG SG075 Mastectomy SG075A Simple Mastectomy 26250 28875 31500 34125 36750 38062
Oncology d) Clinical Photograph d) Detailed discharge
summary

a) Clinical notes a) Histopath OPEN

b) Mammography b) Detailed discharge
General Surgery, Surgical c) Biopsy summary
1272 General Surgery SG SG075 Mastectomy SG075B Radical / Modified Radical Mastectomy 34545 37999 41454 44908 48363 50090
Oncology justifying surgery. c) Detailed Operative notes

a) Clinical notes including a) Detailed Indoor case Reserved

evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
1273 General Surgery SG General Surgery SG076 Excision Mammary Fistula SG076A Excision Mammary Fistula 14500 15950 17400 18850 20300 21025 management operative notes
b) Ultrasound of the c) Histopathological
affected site examination
d) Detailed discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN
evaluation findings, papers
indication of procedure and b) Detailed Procedure /
General Surgery, Pediatric planned line of Operative notes
1274 General Surgery SG SG077 Intercostal drainage Only SG077A Intercostal drainage Only 5880 6468 7056 7644 8232 8526
Surgery, CTVS management c) Post procedure Chest X-
b) Chest X-Ray PA ray with reports
d) Detailed Discharge
Summary
a) Clinical notes with a) Detailed Indoor case OPEN
evaluation findings, papers (ICPs) with
indication of procedure, treatment
and planned line of details
General Surgery, Pediatric management b) Detailed Procedure /
1275 General Surgery SG SG078 Rib Resection & Drainage SG078A Rib Resection & Drainage 21000 23100 25200 27300 29400 30450 b) X-ray/CT/MRI Chest operative notes
Surgery
report c) Pus culture report
d) Postoperative Chest X-
ray
e) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case Referral
b) Clinical Evaluation papers (ICPs)
c) Chest X-ray/CT/MRI b) Detailed Procedure /
General Surgery, Pediatric d) Planned line of operative notes
1276 General Surgery SG SG079 Thoracoplasty SG079A Thoracoplasty 30000 33000 36000 39000 42000 43500
Surgery treatment c) X-ray Chest prior to
discharge
d) Detailed discharge
summary
a) Clinical notes a) Histopathology OPEN
b) USG b) Detailed discharge
c) CT Scan confirming the summary
General Surgery, Pediatric
1277 General Surgery SG SG080 Decortication (Pleurectomy) SG080A Decortication (Pleurectomy) 34650 38115 41580 45045 48510 50242 diagnosis for which the c) Detailed Operative notes
Surgery
surgery is done
d) Biopsy
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Intra procedure clinical OPEN
b) CT Thorax confirming photograph
the diagnosis b) Detailed Operative notes,
c) Biopsy c) Histopath
General Surgery, Pediatric
1278 General Surgery SG SG081 Lobectomy SG081A Thoracoscopic 34545 37999 41454 44908 48363 50090 d) Cytology d) Detailed discharge
Surgery, Surgical Oncology
summary
e) Scar Photo

a) Clinical notes a) Intra procedure clinical OPEN

b) CT Thorax confirming photograph
the diagnosis b) Detailed Operative notes,
c) Biopsy c) Histopath
General Surgery, Pediatric
1279 General Surgery SG SG081 Lobectomy SG081B Open 34545 37999 41454 44908 48363 50090 d) Cytology d) Detailed discharge
Surgery, Surgical Oncology
summary
e) Scar Photo

a) Clinical notes a) Intra procedure clinical OPEN YES

b) CT Thorax confirming photograph
the diagnosis b) Detailed Operative notes,
c) Biopsy c) Histopath
General Surgery, Pediatric
1280 General Surgery SG SG082 Thoracoscopic Segmental Resection SG082A Thoracoscopic Segmental Resection 41895 46084 50274 54463 58653 60747 d) Cytology d) Detailed discharge
Surgery
summary
e) Scar Photo

a) Clinical notes including a) Detailed Indoor case Referral

evaluation findings, papers (ICPs) with
indication for procedure, treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric management operative notes
1281 General Surgery SG SG083 Lung Hydatid Cyst removal SG083A Lung Hydatid Cyst removal 27615 30376 33138 35899 38661 40041 b) CT/MRI Chest c) Histopathological
Surgery
examination report
d) Postoperative Chest X-
ray or CT
e) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case Reserved
evaluation findings, papers (ICPs) with
indication for procedure treatment details
and planned line of b) Detailed Procedure /
General Surgery, Pediatric
1282 General Surgery SG SG084 Incision & Drainage of Abscess SG084A Incision & Drainage of Abscess 5250 5775 6300 6825 7350 7612 management operative notes
Surgery
b) Clinical Photograph c) Culture report of wound
c) Sepsis screen/blood or pus
culture d) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case Reserved
b) Clinical photographs papers (ICPs)
c) Planned line of b) Detailed Procedure /
treatment operative notes
Lipoma / Cyst / other cutaneous swellings c) Post-operative
1283 General Surgery SG General Surgery SG085 SG085A Lipoma Excision 5250 5775 6300 6825 7350 7612
Excision photographs
d) Histopathological
examination
e) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical photographs papers (ICPs)
c) Planned line of b) Detailed Procedure /
treatment operative notes
Lipoma / Cyst / other cutaneous swellings c) Post-operative
1284 General Surgery SG General Surgery SG085 SG085B Cyst Excision 5250 5775 6300 6825 7350 7612
Excision photographs
d) Histopathological
examination
e) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical photographs papers (ICPs)
c) Planned line of b) Detailed Procedure /
treatment operative notes
Lipoma / Cyst / other cutaneous swellings c) Post-operative
1285 General Surgery SG General Surgery SG085 SG085C Other cutaneous swellings Excision 5250 5775 6300 6825 7350 7612
Excision photographs
d) Histopathological
examination
e) Detailed discharge
summary
a) Clinical notes including a) Detailed Reserved
evaluation findings, Indoor case papers ( with
indication of procedure and treatment details
planned line of b) Detailed Procedure
1286 General Surgery SG General Surgery SG086 Debridement of Ulcer SG086A Debridement of Ulcer 5250 5775 6300 6825 7350 7612 management operative notes
b) Clinical Photographs of c) Post procedure
the affected part photographs
d) Detailed discharge
summary
a) Clinical notes detailing a) Post procedure clinical OPEN
the original pathology that photograph
has led to this surgery with b) Detailed Operative notes
General Surgery, Surgical
1287 General Surgery SG SG087 Flap Reconstructive Surgery SG087A Flap Reconstructive Surgery 37900 41690 45480 49270 53060 54955 supporting investigation c) Detailed discharge
Oncology
reports. summary
b) Clinical Photograph
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes detailing a) Detailed Indoor Case OPEN
original pathology (In case Papers
of Split thickness b) Detailed
skin graft time of burn) procedure/Operative notes
General Surgery, Plastic &
1288 General Surgery SG SG088 Free Grafts - Wolfe Grafts SG088A Free Grafts - Wolfe Grafts 32865 36151 39438 42724 46011 47654 b) Supporting reports and c) Post procedure clinical
Reconstructive Surgery
clinical photograph. photograph of the affected
part
d) Discharge summary

a) Clinical notes detailing a) Clinical notes detailing OPEN

original pathology original pathology
1289 40656 44352 48048 51744 53592 b) Evidence of confirmed b) Previous surgery report
General Surgery SG General Surgery SG089 Tissue Reconstruction Flap SG089A Tissue Reconstruction Flap 36960
diagnosis of Leprosy (If and indication of current
applicable) procedure
c) Clinical photograph. c) Clinical photograph.
a) Clinical notes detailing a) Detailed Indoor Case OPEN
original pathology (In case Papers
of Split thickness b) Detailed
General Surgery, Plastic & skin graft time of burn) procedure/Operative notes
1290 General Surgery SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090A Small (< 4% TBSA) 19740 21714 23688 25662 27636 28623 b) Supporting reports and c) Post procedure clinical
Pediatric Surgery clinical photograph. photograph of the affected
part
d) Discharge summary

a) Clinical notes detailing a) Detailed Indoor Case OPEN

original pathology (In case Papers
of Split thickness b) Detailed
General Surgery, Plastic & skin graft time of burn) procedure/Operative notes
1291 General Surgery SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090B Medium (4 - 8% TBSA) 19000 20900 22800 24700 26600 27550 b) Supporting reports and c) Post procedure clinical
Pediatric Surgery clinical photograph. photograph of the affected
part
d) Discharge summary

a) Clinical notes detailing a) Detailed Indoor Case OPEN

original pathology (In case Papers
of Split thickness b) Detailed
General Surgery, Plastic & skin graft time of burn) procedure/Operative notes
1292 General Surgery SG Reconstructive Surgery, SG090 Split thickness skin grafts SG090C Large (> 8% TBSA) 21420 23562 25704 27846 29988 31059 b) Supporting reports and c) Post procedure clinical
Pediatric Surgery clinical photograph. photograph of the affected
part
d) Discharge summary

a) Clinical notes detailing a) Detailed Indoor case OPEN

original pathology papers
b) Previous surgery report b) Detailed procedure/
General Surgery, Surgical
1293 33264 36288 39312 42336 43848 and indication of current Operative notes
General Surgery SG Oncology, Plastic & SG091 Skin Flaps - Rotation Flaps SG091A Skin Flaps - Rotation Flaps 30240
procedure c) Post procedure clinical
Reconstructive Surgery
c) Clinical photograph. photograph of the
affected part
d) Discharge summary
a) Clinical notes with a) Detailed Indoor Case Referral
history, signs, symptoms, Papers
evaluation findings, b) Post op clinical
indication for procedure, photograph
planned line of c) Detailed operative note
General Surgery, management and advice d) Detailed Discharge
1294 General Surgery SG SG092 Tendon Transfer SG092A Tendon Transfer 26250 28875 31500 34125 36750 38062
Orthopedics for admission Summary
b) Clinical photograph of
affected part
c) Evidence of confirmed
diagnosis of Leprosy (If
applicable)
a) Clinical notes a) Detailed Indoor case Referral
b) Clinical picture papers (ICPs)
c) Planned line of b) Detailed Procedure /
treatment operative notes
Lymphatics Excision of Subcutaneous Lymphatics Excision of Subcutaneous Tissues c) Post-operative clinical
1295 General Surgery SG General Surgery SG093 SG093A 15750 17325 18900 20475 22050 22837
Tissues In Lymphoedema In Lymphoedema photograph
d) Histopathological
examination
e) Detailed discharge
summary
a)Clinical notes a)Clinical Notes / Indoor OPEN
b) Pathological case papers
Examination (Complete b)Detail discharge
Blood count, Blood urea, Summary c) All
Serum Creatinine, GFR, investigation reports
serum electrolytes). In
chronic renal failure/
chronic dialysis patients
investigations need to be
1296 General Surgery SG General Surgery SG094 AV Fistula without prosthesis SG094A AV Fistula without prosthesis 19320 21252 23184 25116 27048 28014 done and submitted only
once. These investigations
to be repeated monthly.
Quarterly- Serum Iron,
ferritin, TIBC, TSAT,
SGOT, SGPT, viral
markers, calcium,
phosphate c)
Planned line of treatment
a) Clinical notes with a) Indoor case papers Referral
details of clinical (ICPs)
examination and planned b) Detailed Procedure /
Management of Varicose Veins-Operative line of treatment operative notes
1297 General Surgery SG General Surgery SG095 Management of Varicose Veins SG095A 17325 19057 20790 22522 24255 25121
management b) Clinical photographs c) Post-op clinical
c) Duplex scan photographs
d) Detailed discharge
summary
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Detailed discharge Referral
b) Duplex ultrasonography summary
c) Colour Doppler b) Post procedure clinical
1298 SG095B Laser ablation of varicose veins 18975 20700 22425 24150 25012 confirming the diagnosis photograph
General Surgery SG General Surgery SG095 Management of Varicose Veins 17250
d) pre-op clinical c) Detailed Operative notes
photograph

1299 General Surgery SG General Surgery SG095 Management of Varicose Veins SG095C Minor sclerotherapy 5250 5775 6300 6825 7350 7612 0 0 OPEN
a) Clinical notes with a) Detailed indoor case OPEN
supporting investigations papers
b) Clinical photograph b) Other Investigation
General Surgery, Pediatric reports if done
1300 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096A Lymph Node 5250 5775 6300 6825 7350 7612 c) Detailed procedure notes
Gynecology d) Histopathological
Examination
e) Detailed Discharge
Summary

a) Clinical notes with OPEN

supporting investigations a) Other Investigation
b) Indication for procedure reports if done
General Surgery, Pediatric b) Detailed procedure notes
1301 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096B Endometrial Aspiration 2835 3118 3402 3685 3969 4110 c) Histopathological
Gynecology Examination
d) Detailed Discharge
Summary

a) Clinical notes with OPEN

supporting investigations a) Other Investigation
b) Indication for procedure reports if done
General Surgery, Pediatric b) Detailed procedure notes
1302 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096C Cervix Cancer screening (PAP + Colposcopy) 2625 2887 3150 3412 3675 3806 c) Histopathological
Gynecology Examination
d) Detailed Discharge
Summary

a) Clinical notes with OPEN

supporting investigations a) Other Investigation
b) Indication for procedure reports if done
General Surgery, Pediatric b) Detailed procedure notes
1303 General Surgery SG Surgery, Obstetrics & SG096 Biopsy SG096E Vulval 2625 2887 3150 3412 3675 3806 c) Histopathological
Gynecology Examination
d) Detailed Discharge
Summary

a) Discharge summary of a) Photographic evidence of OPEN

the last admission stoma complication, if any
b) Clinical notes including b) Invoice/receipt of
examination findings of the consumables (optional) if
current visit colostomy bag changed
1304 General Surgery SG General Surgery SG097 Stoma Management SG097A Stoma Management follow up of Ileostomy 5775 6352 6930 7507 8085 8373 c) Signed statement from
pt. that s/he has received
the consumables:
Ileostomy / Colostomy -
bags, adhesive, clips etc.
for 2 months

a) Discharge summary of a) Photographic evidence of OPEN

the last admission stoma complication, if any
b) Clinical notes including b) Invoice/receipt of
examination findings of the consumables (optional) if
current visit colostomy bag changed
1305 General Surgery SG General Surgery SG097 Stoma Management SG097B Stoma Management follow up of Colostomy 5775 6352 6930 7507 8085 8373 c) Signed statement from
pt. that s/he has received
the consumables:
Ileostomy / Colostomy -
bags, adhesive, clips etc.
for 2 months

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings, papers
indication for procedure, b) Procedure note/
and planned line of operative note
General Surgery, Pediatric management, advise for c) Post procedure clinical
1306 General Surgery SG SG098 Foreign Body Removal SG098A Foreign Body Removal 7350 8085 8820 9555 10290 10657 the day care procedure. photograph/ relevant
Surgery, ENT
b) X-ray report/ clinical imaging study for pre and
picture of the affected part post procedure comparison
confirming the diagnosis d) Detailed Discharge
and justify the procedure. summary

A) Clinical notes A) Post procedure clinical OPEN

B) X-ray photograph
C) USG report of the B) Detailed Operative notes
1307 SG099A Fistulectomy 13200 14400 15600 16800 17400 affected part confirming the C) detailed discharge
General Surgery SG General Surgery SG099 Fistulectomy 12000
diagnosis summary
D) Still Photograph of the D) relevant imaging study
imaging for comparison

1308 General Surgery SG General Surgery SG099 Necrotising fasciitis / Fournier Gangrene SG099B Necrotising fasciitis 14800 16280 17760 19240 20720 21460 0 0 OPEN
1309 General Surgery SG General Surgery SG099 Necrotising fasciitis / Fournier Gangrene SG099C Fournier Gangrene 14800 16280 17760 19240 20720 21460 0 0 OPEN
0 0 OPEN
Surgical management of Lower GI bleed Surgical management of Lower GI bleed
(inclusive of sigmoidoscopy / colonoscopy) - (inclusive of sigmoidoscopy / colonoscopy) -
1310 General Surgery SG General Surgery SG100 SG100A 26250 28875 31500 34125 36750 38062
Colonoscopic management only excluding Colonoscopic management only excluding local
local perineal conditions perineal conditions
1311 General Surgery SG General Surgery SG101 Caecopexy SG101A Caecopexy 26250 28875 31500 34125 36750 38062 0 0 OPEN
1312 General Surgery SG General Surgery SG102 Repair of Renal Artery Stenosis SG102A Repair of Renal Artery Stenosis 79800 87780 95760 103740 111720 115710 0 0 OPEN YES
1313 General Surgery SG General Surgery SG103 ERCP SG103A ERCP + Stenting/Stone removal 26250 28875 31500 34125 36750 38062 0 0 OPEN
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Circumcision - Phimosis / Paraphimosis or any 0 0 OPEN
1314 General Surgery SG General Surgery SG104 Circumcision SG104A 10500 11550 12600 13650 14700 15225
other clinical condition
0 0 OPEN
Interventional Percutaneous transhepatic external biliary Percutaneous transhepatic external biliary
1315 General Surgery SG SG105 SG105A 26460 29106 31752 34398 37044 38367
Radiology/General surgery drainage (PTBD) drainage (PTBD)
a) Clinical notes a) Intra procedure clinical Referral
b) X-ray photograph
1316 SG053D Fundoplication - Lap. 23500 25850 28200 30550 32900 34075 c) USG b) Detailed Operative notes
General Surgery SG General Surgery SG053 Hiatus Hernia Repair / Fundoplication
d) UGI Endoscopy &
c) Discharge summary

a) History a) Histopath report Referral

b) Pre-op Clinical b) Post procedure clinical
photograph photograph of affected part
c) Biopsy c) Detailed Procedure
1317 ENT SL ENT SL001 Pinna surgery for tumour / trauma SL001A Pinna surgery for tumor 10500 11550 12600 13650 14700 15225 d) Operative Notes
e) Detailed discharge
summary

a) History a) Post procedure clinical OPEN

b) Pre-op Clinical photograph of affected part
photograph b) Detailed Procedure
1318 11550 12600 13650 14700 15225 c) Operative Notes
ENT SL ENT SL001 Pinna surgery for tumour / trauma SL001B Pinna surgery for trauma 10500
d) Detailed discharge
summary

a) Clinical notes (detailing a) Detailed Discharge Referral

signs, symptoms, ear summary
examination findings, b) Indoor case papers
indications for doing the c) Procedure note/
Tympanoplasty (can be stratified (GA/LA) and procedure & advice for operative note
1319 ENT SL ENT SL002 Tympanoplasty SL002A 16170 17787 19404 21021 22638 23446
price adjusted accordingly ) admission) d) Intra-operative
b) Audiogram report photograph with time and
date (optional) e)
Invoice of the ossicular
prosthesis used, if any
a) Clinical notes (detailing a) Indoor case papers OPEN
signs, symptoms, ear b) Procedure note/
examination findings, operative note
indications for doing the c) Detailed Discharge
procedure& advise for summary
1320 ENT SL ENT SL003 Stapedectomy / tympanotomy SL003A Stapedectomy 18165 19981 21798 23614 25431 26339 admission) d) Intra-operative
b) Audiometry report photograph with time and
confirming conductive date (optional) e) Invoice
deafness and of the ossicular prosthesis/
Tympanometry piston used, if any

a) Clinical notes (detailing a) Indoor case papers OPEN

signs, symptoms, ear b) Procedure note/
examination findings, operative note
indications for doing the c) Detailed Discharge
procedure& advise for summary
1321 ENT SL ENT SL003 Stapedectomy / tympanotomy SL003B Tympanotomy 15750 17325 18900 20475 22050 22837 admission) d) Intra-operative
b) Audiometry report photograph with time and
confirming conductive date (optional) e) Invoice
deafness and of the ossicular prosthesis/
Tympanometry piston used, if any

a) Clinical notes confirming a) Scar photo Referral

the indication for the b) Post procedure clinical
procedure with imaging (X- photograph
ray/ CT) Evidence c) Detailed Procedure
1322 ENT SL ENT, Surgical Oncology SL004 Mastoidectomy SL004A Simple 29400 32340 35280 38220 41160 42630 b) Audiometry d) Operative Notes
e) Detailed discharge
summary
f) Histopath

a) Clinical notes confirming a) Scar photo Referral

the indication for the b) Post procedure clinical
procedure with imaging (X- photograph
ray/ CT) Evidence c) Detailed Procedure
1323 ENT SL ENT, Surgical Oncology SL004 Mastoidectomy SL004B Radical 29400 32340 35280 38220 41160 42630 b) Audiometry d) Operative Notes
e) Detailed discharge
summary
f) Histopath

a) Clinical notes a) Photograph of patient OPEN

b) Audiogram while undergoing the
justifying surgery. procedure
1324 8778 9576 10374 11172 11571 b) Detailed Procedure
ENT SL ENT, Surgical Oncology SL005 Myringotomy with or without Grommet SL005A Unilateral 7980
c) Operative Notes
d) Detailed discharge
summary

a) Clinical notes a) Photograph of patient OPEN

b) Audiogram while undergoing the
justifying surgery. procedure
1325 8778 9576 10374 11172 11571 b) Detailed Procedure
ENT SL ENT, Surgical Oncology SL005 Myringotomy with or without Grommet SL005B Bilateral 7980
c) Operative Notes
d) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes (detailing a) Detailed Discharge OPEN
signs, symptoms, summary
indications for doing the b) Indoor case papers
procedure& advise for c) Procedure note/
1326 ENT SL ENT SL006 Endoscopic DCR SL006A Endoscopic DCR 21000 23100 25200 27300 29400 30450 admission) operative note
b) Examination/ d) Intraoperative
investigation findings- Dye photograph with time and
disappearance test/ date (Optional)
Probing & irrigation
a) Clinical notes clearly a) Indoor case papers OPEN 30
indicating symptoms and available indicating
signs b) Lab investigations i. Signs & symptoms
(Complete Blood count, ii. Physical & local
Haemoglobin, Coagulation examination
profile) c) iii. Investigations performed
Report of local examination iv. Screening for
by anterior rhinoscopy/ coagulation disorders/
endoscopy identifying the anticoagulation
source of bleeding medications/ hematological
1327 ENT SL ENT SL007 Epistaxis treatment - packing SL007A Epistaxis treatment - packing 2625 2887 3150 3412 3675 3806 available malignancies
v. Appropriate treatment
given based on the cause
of bleeding b) Clinical
photograph of patient and
the affected part c)
Discharge Summary with
appropriate discharge
advise

a) Clinical notes (detailing a) Indoor case papers b) OPEN

signs, symptoms, Operative/ procedure notes
examination findings, c) Detailed Discharge
indications for doing the summary
procedure, circumstances
of the incident which led to
disfigurement and advise
1328 ENT SL ENT SL008 Functional septo rhinoplasty SL008A Functional septo rhinoplasty 23835 26218 28602 30985 33369 34560 for admission)
b) Clinical picture of the
affected part along with full
face of the patient and
anterior rhinoscopy/
endoscopic picture
showing deviated septum

a) Clinical notes : a) Clinical notes OPEN

(detailing signs, symptoms, b) Procedure note/
examination findings, operative note
indications for doing the c) Detailed Discharge
procedure, circumstances summary
of the incident which led to
1329 ENT SL ENT SL009 Septoplasty SL009A Septoplasty 14595 16054 17514 18973 20433 21162 Deviated Nasal Septum&
advise for admission)
b) Anterior rhinoscopy/
endoscopic picture
showing deviated nasal
septum

a) Clinical notes (detailing a) Detailed Indoor Case OPEN

signs, symptoms, Papers
examination findings, b) Detailed Procedure /
planned line of treatment & Operative Notes
advise for admission) c) Post procedure X-ray
b) X-ray/CT report of the d) Post procedure clinical
affected part photograph of the affected
1330 ENT SL ENT SL010 Fracture - setting nasal bone SL010A Fracture - setting nasal bone 9135 10048 10962 11875 12789 13245 c) Medico-legal case (MLC) part
/ First information report e) Detailed discharge
(FIR) for traumatic injuries summary
and circumstances of the
incident which led to
fracture (In applicable
cases)

a) Clinical notes (detailing a) Indoor case papers OPEN

signs, symptoms, b) Procedure note/
examination findings, operative note
indications for doing the c) Detailed Discharge
1331 ENT SL ENT SL011 Inferior turbinate reduction under GA SL011A Inferior turbinate reduction under GA 6300 6930 7560 8190 8820 9135 procedure& advise for summary
admission) d) Intra-operative stills of
b) Nasal Endoscopic the affected part with time
picture of the affected part, and date (optional)
if available
a) Clinical notes (detailing a) Detailed Discharge OPEN
signs, symptoms, summary
chronicity of sinusitis, b) Indoor case papers
Open sinus surgery(Open Sinus Surgery examination findings, c) Procedure note/
1332 ENT SL ENT SL012 Open sinus surgery SL012A 17010 18711 20412 22113 23814 24664
(Single/Multiple Sinuses) indications for doing the operative note
procedure& advise for d) Histopathology report
admission)
b) CT (PNS) report
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes (detailing a) Detailed Discharge OPEN
signs, symptoms, summary
chronicity of sinusitis, b) Indoor case papers
examination findings, c) Procedure note/
Functional Endoscopic Sinus (FESS)stratified
1333 ENT SL ENT SL013 Functional Endoscopic Sinus (FESS) SL013A 15435 16978 18522 20065 21609 22380 indications for doing the operative note
as U/L or B/L and cost adjusted
procedure& advise for d) Intra procedure Still
admission) images of the affected part
b) CT (PNS) report with time and date
e) Histopathology report
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed
and planned line of procedure/Operative notes
Ant. Ethmoidal / sphenopalatine artery management, advise for c) Detailed discharge
1334 ENT SL ENT SL014 SL014A Ant. Ethmoidal artery ligation - Open 17010 18711 20412 22113 23814 24664 the procedure. summary
ligation
b) Contrast Enhanced
Computerized Tomography
(CECT) Scan of nose and
paranasal sinuses

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings, papers
indication for procedure, b) Detailed
and planned line of procedure/Operative notes
Ant. Ethmoidal / sphenopalatine artery management, advise for c) Detailed discharge
1335 ENT SL ENT SL014 SL014B Ant. Ethmoidal artery ligation - Endoscopic 17010 18711 20412 22113 23814 24664 the procedure. summary
ligation
b) Contrast Enhanced
Computerized Tomography
(CECT) Scan of nose and
paranasal sinuses

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings, papers
indication for procedure, b) Detailed
and planned line of procedure/Operative notes
Ant. Ethmoidal / sphenopalatine artery management, advise for c) Detailed discharge
1336 ENT SL ENT SL014 SL014C Sphenopalatine artery ligation - Open 17010 18711 20412 22113 23814 24664 the procedure. summary
ligation
b) Contrast Enhanced
Computerized Tomography
(CECT) Scan of nose and
paranasal sinuses

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings, papers
indication for procedure, b) Detailed
and planned line of procedure/Operative notes
Ant. Ethmoidal / sphenopalatine artery management, advise for c) Detailed discharge
1337 ENT SL ENT SL014 SL014D Sphenopalatine artery ligation - Endoscopic 17010 18711 20412 22113 23814 24664 the procedure. summary
ligation
b) Contrast Enhanced
Computerized Tomography
(CECT) Scan of nose and
paranasal sinuses

a) Clinical notes (detailing a) Indoor case papers OPEN

signs, symptoms, b) Procedure note/
examination findings, operative note
1338 10857 11844 12831 13818 14311 indications for doing the c) Detailed Discharge
ENT SL ENT SL015 Adenoidectomy SL015A Adenoidectomy 9870
procedure & advise for summary
admission)
b) X-ray of Nasopharynx
(lateral view)
a) Clinical notes (detailing a) Indoor case papers Referral
signs, symptoms, b) Procedure note/
examination findings, operative note
indications for doing the c) Detailed Discharge
Tonsillectomy - U/L tonsillectomy
1339 ENT SL ENT SL016 Tonsillectomy SL016A 12810 14091 15372 16653 17934 18574 procedure & advise for summary
(unilateral/bilateral)
admission) d) Histopathology report
b) Throat culture report e) Post procedure clinical
photograph of the affected
part
a) Clinical notes (detailing a) Indoor case papers Referral
signs, symptoms, b) Procedure note/
examination findings, operative note
indications for doing the c) Detailed Discharge
1340 ENT SL ENT SL016 Tonsillectomy SL016B Tonsillectomy - B/L adenotonsillectomy 12810 14091 15372 16653 17934 18574 procedure & advise for summary
admission) d) Histopathology report
b) Throat culture report e) Post procedure clinical
photograph of the affected
part
a) Clinical notes (detailing a) Indoor case papers OPEN
signs, symptoms, b) Procedure note/
examination findings, operative note
Peritonsillar abscess drainage / intraoral indications for doing the c) Detailed Discharge
1341 ENT SL ENT,Pediatric Surgery SL017 calculus SL017A Peritonsillar abscess drainage 6090 6699 7308 7917 8526 8830 procedure & advise for summary
removal admission) d) Culture/ Sensitivity report
b) Throat culture report of pus
e) Post procedure clinical
photograph of the affected
part
a) Doctor's notes with a) C/S of pus Reserved
presenting complaints b) Post procedure clinical
b) Duration and physical photograph of affected part
Peritonsillar abscess drainage / intraoral examination findings of c) Detailed Procedure
1342 ENT SL ENT,Pediatric Surgery SL017 calculus SL017B Intraoral calculus removal 6090 6699 7308 7917 8526 8830 oral cavity and tonsils d) Operative Notes
removal c) Clinical photograph if e) Detailed discharge
possible summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes (detailing a) Detailed Indoor case Referral
signs, symptoms, papers
examination b) Procedure note/
findings, indications for operative note
doing the procedure & c) Histopathology
advise for examination report
Thyroglossal / Branchial cyst / sinus / admission) d) Photograph of the Gross
1343 ENT SL ENT SL018 SL018A Thyroglossal cyst excision 17850 19635 21420 23205 24990 25882
fistula excision b) Pre-operative clinical specimen of the tissue
photograph of the affected removed
part e) Post procedure clinical
photograph of the affected
part
f) Detailed Discharge
summary
a) Clinical notes (detailing a) Detailed Indoor case Referral
signs, symptoms, papers
examination b) Procedure note/
findings, indications for operative note
doing the procedure & c) Histopathology
advise for examination report
Thyroglossal / Branchial cyst / sinus / admission) d) Photograph of the Gross
1344 ENT SL ENT SL018 SL018B Thyroglossal sinus excision 17850 19635 21420 23205 24990 25882
fistula excision b) Pre-operative clinical specimen of the tissue
photograph of the affected removed
part e) Post procedure clinical
photograph of the affected
part
f) Detailed Discharge
summary
a) Clinical notes (detailing a) Detailed Indoor case Referral
signs, symptoms, papers
examination b) Procedure note/
findings, indications for operative note
doing the procedure & c) Histopathology
advise for examination report
Thyroglossal / Branchial cyst / sinus / admission) d) Photograph of the Gross
1345 ENT SL ENT SL018 SL018C Thyroglossal fistula excision 17850 19635 21420 23205 24990 25882
fistula excision b) Pre-operative clinical specimen of the tissue
photograph of the affected removed
part e) Post procedure clinical
photograph of the affected
part
f) Detailed Discharge
summary
a) Clinical notes with signs, a) Indoor case papers Referral
symptoms, indications, (ICPs) b) Detailed
planned line of Procedure / operative notes
management and advise c) Intra-operative
Thyroglossal / Branchial cyst / sinus / for admission photographs (optional)
1346 ENT SL ENT SL018 SL018D Branchial sinus excision 17850 19635 21420 23205 24990 25882
fistula excision b) Clinical Photograph d) Detailed discharge
c) USG Neck/ Fine needle summary e)
aspiration cytology (FNAC) Histopathological
d) Optional CT/MRI examination

a) Clinical notes with signs, a) Indoor case papers Referral

symptoms, indications, (ICPs) b) Detailed
planned line of Procedure / operative notes
management and advise c) Intra-operative
Thyroglossal / Branchial cyst / sinus / for admission photographs (optional)
1347 ENT SL ENT SL018 SL018E Branchial fistula excision 17850 19635 21420 23205 24990 25882
fistula excision b) Clinical Photograph d) Detailed discharge
c) USG Neck/ Fine needle summary e)
aspiration cytology (FNAC) Histopathological
d) Optional CT/MRI examination

a) Clinical notes (detailing a) Indoor case papers OPEN

signs, symptoms, b) Procedure note/
examination findings, operative note
1348 23100 25200 27300 29400 30450 indications for doing the c) Detailed Discharge
ENT SL ENT SL019 Uvulopalatopharyngoplasty (UPPP) SL019A Uvulopalatopharyngoplasty (UPPP) 21000
procedure & advise for summary
admission) d) Post procedure clinical
b) Polysomnography (sleep photograph of the affected
study) part
a) CT Scan a) Procedure OPEN
b) Biopsy b) Operative Notes
c) Clinical notes with c) Post Procedure
Excision of tumour of oral cavity / paranasal Excision of tumour of oral cavity / paranasal
1349 14437 15750 17062 18375 19031 planned line of treatment Photograph of affected part
ENT SL ENT,Surgical Oncology SL020 sinus / laryngopharynx with or without SL020A sinus / laryngopharynx 13125
d) Pre operative Clinical d) Histopathology report
reconstruction without reconstruction
Photograph of affected
part.

a) CT Scan a) Procedure OPEN YES

b) Biopsy b) Operative Notes
Excision of tumour of oral cavity / paranasal Excision of tumour of oral cavity / paranasal c) Clinical Photograph of c) Post Procedure
1350 ENT SL ENT,Surgical Oncology SL020 sinus / laryngopharynx with or without SL020B sinus / laryngopharynx 47985 52783 57582 62380 67179 69578 affected part Photograph of affected part
reconstruction with pedicled flap reconstruction d) Histopathology report

a) CT Scan a) Procedure OPEN

b) Biopsy b) Operative Notes
Excision of tumour of oral cavity / paranasal Excision of tumour of oral cavity / c) Clinical Photograph of c) Post Procedure
1351 ENT SL ENT,Surgical Oncology SL020 sinus / laryngopharynx with or without SL020C paranasal sinus / laryngopharynx with free flap 35050 38555 42060 45565 49070 50822 affected part Photograph of affected part
reconstruction reconstruction d) Histopathology report
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) CT Scan a) Histopathology report OPEN
b) FNAC b) Post procedure clinical
c) Clinical Photograph of photograph of affected part
ENT, Surgical Oncology, affected part c) Detailed Procedure
1352 ENT SL General SL021 Parotidectomy SL021A Total Parotidectomy 30708 33778 36849 39920 42991 44526 d) Operative Notes
Surgery e) Detailed discharge
summary.

a) CT Scan a) Histopathology report OPEN

b) FNAC b) Post procedure clinical
c) Clinical Photograph of photograph of affected part
ENT, Surgical Oncology, affected part c) Detailed Procedure
1353 ENT SL General SL021 Parotidectomy SL021B Superficial Parotidectomy 25916 28507 31099 33690 36282 37578 d) Operative Notes
Surgery e) Detailed discharge
summary.

a) Clinical notes to a) Histopathology report OPEN

establish indication; Biopsy b) Post procedure clinical
if tumour photograph of affected part
b) Clinical Photograph of c) Detailed Procedure
1354 ENT SL ENT SL022 Removal of Submandibular Salivary gland SL022A Removal of Submandibular Salivary gland 30450 33495 36540 39585 42630 44152 affected part d) Operative Notes
e) Detailed discharge
summary.

a) Clinical notes a) Histopathology report OPEN

b) Clinical photograph b) Post procedure clinical
c) MLC/FIR for traumatic photograph of affected part
injuries and circumstances c) Detailed Procedure
1355 ENT SL ENT SL022 Removal of Submandibular Salivary gland SL022B Removal of Ranula 30450 33495 36540 39585 42630 44152 of the incident which led to d) Operative Notes
rupture of salivary duct. e) Detailed discharge
summary.

Clinical notes with planned a) Procedure Notes OPEN

line of treatment b) Operative Notes
c) Post Procedure
Rigid laryngoscopy / bronchoscopy / Rigid laryngoscopy - Diagnostic + / -
1356 ENT SL ENT,Pediatric Surgery SL023 SL023A 7350 8085 8820 9555 10290 10657 Photograph of affected part
oesophagoscopy - Diagnostic + / - biopsy biopsy
d) Histopathology report

Clinical notes with planned a) Procedure Notes OPEN

line of treatment b) Operative Notes
c) Post Procedure
Rigid laryngoscopy / bronchoscopy / Rigid bronchoscopy - Diagnostic + /
1357 ENT SL ENT,Pediatric Surgery SL023 SL023B 7350 8085 8820 9555 10290 10657 Photograph of affected part
oesophagoscopy - Diagnostic + / - biopsy - biopsy
d) Histopathology report

Clinical notes with planned a) Procedure Notes OPEN

line of treatment b) Operative Notes
c) Post Procedure
Rigid laryngoscopy / bronchoscopy / Rigid oesophagoscopy - Diagnostic
1358 ENT SL ENT,Pediatric Surgery SL023 SL023C 7350 8085 8820 9555 10290 10657 Photograph of affected part
oesophagoscopy - Diagnostic + / - biopsy + / - biopsy
d) Histopathology report

a) Clinical notes (detailing a) Detailed Indoor case OPEN

signs, symptoms, papers
examination findings, b) Detailed Procedure/
planned line of treatment & Operative notes
advise for admission) c) Histopathology report (In
1359 ENT SL ENT SL024 Microlaryngeal surgery with or without laser SL024A Microlaryngeal surgery with or without laser 17850 19635 21420 23205 24990 25882 b) laryngoscopy all applicable cases)
findings/Laryngeal d) Post procedure
electromyography clinical/Intraprocedural
confirming the diagnosis photograph of the affected
and indication for surgery part
e) Detailed Discharge
summary
Clinical notes to establish a) Histopathology report in OPEN
indication and justification case of tumours
of surgery b) Post procedure clinical
Evidence through photograph of affected part
Open laryngeal framework surgery / a) CT c) Detailed Procedure
1360 ENT SL ENT,Surgical Oncology SL025 SL025A Open laryngeal framework surgery / Thyroplasty 5250 5775 6300 6825 7350 7612
Thyroplasty b) MRI d) Operative Notes
c) Biopsy e) Detailed discharge
d) Clinical Photograph summary

a) Detailed Clinical notes a) Detailed indoor case OPEN

with history, symptoms, papers
signs and indication for b) Detailed Procedure /
procedure Operative note
ENT,General c) Post procedure clinical
1361 ENT SL SL026 Tracheostomy / Tracheotomy SL026A Tracheostomy 29400 32340 35280 38220 41160 42630 photograph of the affected
Surgery,Peadiatric Surgery
part
d) Histopathology report (In
applicable cases)
e) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed Clinical notes a) Detailed indoor case OPEN
with history, symptoms, papers
signs and indication for b) Detailed Procedure /
procedure Operative note
ENT,General c) Post procedure clinical
1362 ENT SL SL026 Tracheostomy / Tracheotomy SL026B Tracheotomy 29400 32340 35280 38220 41160 42630 photograph of the affected
Surgery,Peadiatric Surgery
part
d) Histopathology report (In
applicable cases)
e) Detailed discharge
summary
Indication for surgery with a) Histopathology report OPEN
supporting investigation b) Post procedure Imaging
reports c) Post procedure clinical
a) X-ray photograph of affected part
b) CT d) Detailed Procedure
ENT,General Surgery, Selective Benign neck tumour c) MRI e) Operative Notes
1363 ENT SL SL027 Neck dissection SL027A 24675 27142 29610 32077 34545 35778
Surgical Oncology excision f) Detailed discharge
A. FNAC/ Biospy in case of summary
tumours
B. Clinical Photograph

Indication for surgery witha) Histopathology report OPEN

supporting investigation b) Post procedure Imaging
reports c) Post procedure clinical
a) X-ray photograph of affected part
b) CT d) Detailed Procedure
ENT,General Surgery, Comprehensive Benign neck tumour c) MRI e) Operative Notes
1364 ENT SL SL027 Neck dissection SL027B 24675 27142 29610 32077 34545 35778
Surgical Oncology excision f) Detailed discharge
A. FNAC/ Biospy in case of summary
tumours
B. Clinical Photograph

Indication for surgery witha) Histopathology report OPEN

supporting investigation b) Post procedure Imaging
reports c) Post procedure clinical
a) X-ray photograph of affected part
b) CT d) Detailed Procedure
ENT,General Surgery, Selective Pharyngeal diverticulum c) MRI e) Operative Notes
1365 ENT SL SL027 Neck dissection SL027C 24675 27142 29610 32077 34545 35778
Surgical Oncology excision f) Detailed discharge
A. FNAC/ Biospy in case of summary
tumours
B. Clinical Photograph

Indication for surgery witha) Histopathology report OPEN

supporting investigation b) Post procedure Imaging
reports c) Post procedure clinical
a) X-ray photograph of affected part
b) CT d) Detailed Procedure
ENT,General Surgery, Comprehensive Pharyngeal c) MRI e) Operative Notes
1366 ENT SL SL027 Neck dissection SL027D 24675 27142 29610 32077 34545 35778
Surgical Oncology diverticulum excision f) Detailed discharge
A. FNAC/ Biospy in case of summary
tumours
B. Clinical Photograph

a) Clinical notes (detailing a) Detailed Indoor case OPEN

signs, symptoms, papers
examination findings, b) Detailed Procedure note/
indications for doing the operative note
Deep neck abscess drainage/ Post trauma procedure & advice for c) Post procedure clinical
ENT,General admission) photograph of the affected
1367 ENT SL SL028 neck SL028A Deep neck abscess drainage 17640 19404 21168 22932 24696 25578
Surgery,Peadiatric Surgery b) Clinical photograph of part
exploration
the affected part d) Culture/ sensitivity report
c) Contrast enhanced CT/ of the pus removed
lateral soft tissue neck X- e) Detailed Discharge
ray supporting the summary
diagnosis/ USG of neck
a) Clinical notes (detailing a) Detailed Indoor case OPEN
signs, symptoms, papers
examination findings, b) Detailed Procedure note/
indications for doing the operative note
Deep neck abscess drainage/ Post trauma procedure & advice for c) Post procedure clinical
ENT,General admission) photograph of the affected
1368 ENT SL SL028 neck SL028B Post trauma neck exploration 22050 24255 26460 28665 30870 31972
Surgery,Peadiatric Surgery b) Clinical photograph of part
exploration
the affected part d) Culture/ sensitivity report
c) Contrast enhanced CT/ of the pus removed
lateral soft tissue neck X- e) Detailed Discharge
ray supporting the summary
diagnosis/ USG of neck
a) Clinical notes with a) Procedure Notes OPEN
planned line of treatment b) Operative Notes
detailing aetiology c) Post Procedure
ENT,Surgical
1369 ENT SL SL029 Anterior skull base surgery SL029A Endoscopic CSF Rhinorrhea Repair 34125 37537 40950 44362 47775 49481 b) MLC/ FIR if traumatic Photograph of affected part.
Oncology,Neurosurgery
c) CT to confirm need of
surgery

a) Clinical notes with a) Procedure Notes OPEN

planned line of treatment b) Operative Notes
detailing aetiology c) Post Procedure
ENT,Surgical
1370 ENT SL SL029 Anterior skull base surgery SL029B Optic nerve decompression 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic Photograph of affected part.
Oncology,Neurosurgery
c) CT to confirm need of
surgery
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with a) Procedure Notes OPEN
planned line of treatment b) Operative Notes
detailing aetiology c) Post Procedure
ENT,Surgical
1371 ENT SL SL029 Anterior skull base surgery SL029C Orbital decompression 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic Photograph of affected part.
Oncology,Neurosurgery
c) CT to confirm need of
surgery

a) Clinical notes with a) Procedure Notes OPEN

planned line of treatment b) Operative Notes
detailing aetiology c) Post Procedure
ENT,Surgical
1372 ENT SL SL029 Anterior skull base surgery SL029D Craniofacial resection 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic Photograph of affected part.
Oncology,Neurosurgery
c) CT to confirm need of
surgery

a) Clinical notes with a) Procedure Notes OPEN

planned line of treatment b) Operative Notes
detailing aetiology c) Post Procedure
ENT,Surgical
1373 ENT SL SL029 Anterior skull base surgery SL029E Maxillary swing 33495 36844 40194 43543 46893 48567 b) MLC/ FIR if traumatic Photograph of affected part.
Oncology,Neurosurgery
c) CT to confirm need of
surgery

Clinical notes with planned a) Procedure Notes OPEN YES

line of treatment and b) Operative Notes
Coronal c) Post Procedure
a) CT Photograph of affected part.
1374 ENT SL ENT,Surgical Oncology SL030 Advanced anterior skull base surgery SL030A Endoscopic Hypophysectomy 52290 57519 62748 67977 73206 75820 b)MRI d) Histopathology report
establishing diagnosis
and establishing need of
surgery.

Clinical notes with planned a) Procedure Notes OPEN YES

line of treatment and b) Operative Notes
Coronal c) Post Procedure
a) CT Photograph of affected part.
1375 ENT SL ENT,Surgical Oncology SL030 Advanced anterior skull base surgery SL030B Clival tumour excision 52290 57519 62748 67977 73206 75820 b)MRI d) Histopathology report
establishing diagnosis
and establishing need of
surgery.

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings, papers with daily vitals and
indication for procedure, line of treatment
and planned line of b) Detailed Procedure /
management, advise for operative note
1376 ENT SL ENT,Surgical Oncology SL031 Lateral skull base procedures SL031A Subtotal petrosectomy 32445 35689 38934 42178 45423 47045 the procedure c) Histopathology report
b) CT/MRI/ biopsy to d) Post procedure clinical
establish the indication and photograph of the affected
justify the surgery part
c) Audiogram report e) Detailed Discharge
justifying surgery (if summary
applicable)
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers with daily vitals and
indication for procedure, line of treatment
and planned line of b) Detailed Procedure /
management, advise for operative note
Post-traumatic facial nerve the procedure c) Histopathology report
1377 ENT SL ENT,Surgical Oncology SL031 Lateral skull base procedures SL031B 32445 35689 38934 42178 45423 47045
decompression b) CT/MRI/ biopsy to d) Post procedure clinical
establish the indication and photograph of the affected
justify the surgery part
c) Audiogram report e) Detailed Discharge
justifying surgery (if summary
applicable)
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers with daily vitals and
indication for procedure, line of treatment
and planned line of b) Detailed Procedure /
management, advise for operative note
1378 ENT SL ENT,Surgical Oncology SL031 Lateral skull base procedures SL031C CSF Otorrhoea repair 32445 35689 38934 42178 45423 47045 the procedure c) Histopathology report
b) CT/MRI/ biopsy to d) Post procedure clinical
establish the indication and photograph of the affected
justify the surgery part
c) Audiogram report e) Detailed Discharge
justifying surgery (if summary
applicable)
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers with daily vitals and
indication for procedure, line of treatment
and planned line of b) Detailed Procedure /
management, advise for operative note
1379 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032A Fisch approach 52395 57634 62874 68113 73353 75972 the procedure c) Histopathology report
b) CT/MRI/ biopsy to d) Post procedure clinical
establish the indication and photograph of the affected
justify the surgery part
c) Audiogram report e) Detailed Discharge
justifying surgery (if summary
applicable)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers with daily vitals and
indication for procedure, line of treatment
and planned line of b) Detailed Procedure /
management, advise for operative note
1380 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032B Translabyrinthine approach 52395 57634 62874 68113 73353 75972 the procedure c) Histopathology report
b) CT/MRI/ biopsy to d) Post procedure clinical
establish the indication and photograph of the affected
justify the surgery part
c) Audiogram report e) Detailed Discharge
justifying surgery (if summary
applicable)
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers with daily vitals and
indication for procedure, line of treatment
and planned line of b) Detailed Procedure /
management, advise for operative note
1381 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032C Transcochlear approach 52395 57634 62874 68113 73353 75972 the procedure c) Histopathology report
b) CT/MRI/ biopsy to d) Post procedure clinical
establish the indication and photograph of the affected
justify the surgery part
c) Audiogram report e) Detailed Discharge
justifying surgery (if summary
applicable)
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers with daily vitals and
indication for procedure, line of treatment
and planned line of b) Detailed Procedure /
management, advise for operative note
1382 ENT SL ENT,Surgical Oncology SL032 Advanced lateral skull base surgery SL032D Temporal Bone resection 52395 57634 62874 68113 73353 75972 the procedure c) Histopathology report
b) CT/MRI/ biopsy to d) Post procedure clinical
establish the indication and photograph of the affected
justify the surgery part
c) Audiogram report e) Detailed Discharge
justifying surgery (if summary
applicable)
a) Clinical notes (detailing a) Indoor case papers & OPEN
signs, symptoms, Consent (informed written)
examination findings, b) Procedure note/
clinical photographs operative note & Anesthesia
(intraoral & extraoral), Notes, (where applicable)
indications for doing c) Barcode of Implants
the procedure & advise for used
admission) d) Post-Operative X-ray of
b) Document required for the affected part
Investigation of fracture: e) Detailed Discharge
• X-ray Nasal bone Lateral summary
view (Right/Left) for nasal
Closed reduction / intermaxillary fixation for As per Selected bone
1383 ENT SL ENT SL033 SL033A Closed reduction for fracture of maxilla #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! fracture or
fracture of maxilla / mandible / zygoma Procedure
• X-Ray mandible latera
Oblique, PA view for
Mandible
Fracture or Submento
vertex, CBCT/ CT/ OPG.
•
OPG(Orthopantomogram)
for mandible fracture or
• X-ray Lateral oblique view
(Right/Left) for mandible or
• X-ray cranial PA
view(skull) or
c) Clinical photograph of
a) Clinical notes (detailing a) Indoor case papers & OPEN
signs, symptoms, Consent (informed written)
examination findings, b) Procedure note/
clinical photographs operative note & Anesthesia
(intraoral & extraoral), Notes, (where applicable)
indications for doing c) Barcode of Implants
the procedure & advise for used
admission) d) Post-Operative X-ray of
b) Document required for the affected part
Investigation of fracture: e) Detailed Discharge
• X-ray Nasal bone Lateral summary
view (Right/Left) for nasal
Closed reduction / intermaxillary fixation for As per Selected bone
1384 ENT SL ENT SL033 SL033B Closed reduction for fracture of mandible #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! fracture or
fracture of maxilla / mandible / zygoma Procedure
• X-Ray mandible latera
Oblique, PA view for
Mandible
Fracture or Submento
vertex, CBCT/ CT/ OPG.
•
OPG(Orthopantomogram)
for mandible fracture or
• X-ray Lateral oblique view
(Right/Left) for mandible or
• X-ray cranial PA
view(skull) or
c) Clinical photograph of
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes (detailing a) Indoor case papers & OPEN
signs, symptoms, Consent (informed written)
examination findings, b) Procedure note/
clinical photographs operative note & Anesthesia
(intraoral & extraoral), Notes, (where applicable)
indications for doing c) Barcode of Implants
the procedure & advise for used
admission) d) Post-Operative X-ray of
b) Document required for the affected part
Investigation of fracture: e) Detailed Discharge
• X-ray Nasal bone Lateral summary
view (Right/Left) for nasal
Closed reduction / intermaxillary fixation for As per Selected bone
1385 ENT SL ENT SL033 SL033C Closed reduction for fracture of zygoma #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! fracture or
fracture of maxilla / mandible / zygoma Procedure
• X-Ray mandible latera
Oblique, PA view for
Mandible
Fracture or Submento
vertex, CBCT/ CT/ OPG.
•
OPG(Orthopantomogram)
for mandible fracture or
• X-ray Lateral oblique view
(Right/Left) for mandible or
• X-ray cranial PA
view(skull) or
c) Clinical photograph of
a) Clinical notes (detailing a) Indoor case papers & OPEN
signs, symptoms, Consent (informed written)
examination findings, b) Procedure note/
clinical photographs operative note & Anesthesia
(intraoral & extraoral), Notes, (where applicable)
indications for doing c) Barcode of Implants
the procedure & advise for used
admission) d) Post-Operative X-ray of
b) Document required for the affected part
Investigation of fracture: e) Detailed Discharge
• X-ray Nasal bone Lateral summary
view (Right/Left) for nasal
Closed reduction / intermaxillary fixation for Closed reduction and Intermaxillary fixation for As per Selected bone
1386 ENT SL ENT SL033 SL033D #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! fracture or
fracture of maxilla / mandible / zygoma fracture of mandible Procedure
• X-Ray mandible latera
Oblique, PA view for
Mandible
Fracture or Submento
vertex, CBCT/ CT/ OPG.
•
OPG(Orthopantomogram)
for mandible fracture or
• X-ray Lateral oblique view
(Right/Left) for mandible or
• X-ray cranial PA
view(skull) or
c) Clinical photograph of
a) Clinical notes (detailing a) Indoor case papers OPEN
signs, symptoms, (including Informed written
examination findings, consent)
clinical b) Procedure note/
photographs(intraoral operative note & Anesthesia
& extraoral) indications for Notes
doing the procedure & c) Barcode of Implants
advise for admission) used
Procedure / Operative d) Post-operative X-Ray
Notes, Post Procedure e) Detailed Discharge
ENT,Oral & Maxillofacial Photograph of affected summary
Open reduction and internal fixation of
1387 ENT SL Surgery,Plastic & SL034 SL034A Open reduction and internal fixation of maxilla 18000 19800 21600 23400 25200 26100 part.
maxilla / mandible / zygoma
Reconstructive Surgery b) X-ray of Paranasal sinus
(PNS) with Water’s view/
mandible latera Oblique,
antero- posterior for
Mandible Fracture/
mandible lateral oblique,
Submento vertex or
CBCT/CT/OPG. (Xray in 2
planes).
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes (detailing a) Indoor case papers OPEN
signs, symptoms, (including Informed written
examination findings, consent)
clinical b) Procedure note/
photographs(intraoral operative note & Anesthesia
& extraoral) indications for Notes
doing the procedure & c) Barcode of Implants
advise for admission) used
Procedure / Operative d) Post-operative X-Ray
Notes, Post Procedure e) Detailed Discharge
ENT,Oral & Maxillofacial Photograph of affected summary
Open reduction and internal fixation of
1388 ENT SL Surgery,Plastic & SL034 SL034B Open reduction and internal fixation of mandible 18000 19800 21600 23400 25200 26100 part.
maxilla / mandible / zygoma
Reconstructive Surgery b) X-ray of Paranasal sinus
(PNS) with Water’s view/
mandible latera Oblique,
antero- posterior for
Mandible Fracture/
mandible lateral oblique,
Submento vertex or
CBCT/CT/OPG. (Xray in 2
planes).

a) Clinical notes (detailing a) Indoor case papers OPEN

signs, symptoms, (including Informed written
examination findings, consent)
clinical b) Procedure note/
photographs(intraoral operative note & Anesthesia
& extraoral) indications for Notes
doing the procedure & c) Barcode of Implants
advise for admission) used
Procedure / Operative d) Post-operative X-Ray
Notes, Post Procedure e) Detailed Discharge
ENT,Oral & Maxillofacial Photograph of affected summary
Open reduction and internal fixation of
1389 ENT SL Surgery,Plastic & SL034 SL034C Open reduction and internal fixation of zygoma 18000 19800 21600 23400 25200 26100 part.
maxilla / mandible / zygoma
Reconstructive Surgery b) X-ray of Paranasal sinus
(PNS) with Water’s view/
mandible latera Oblique,
antero- posterior for
Mandible Fracture/
mandible lateral oblique,
Submento vertex or
CBCT/CT/OPG. (Xray in 2
planes).

a) Clinical notes including a) Clinical notes detailing OPEN

evaluation findings, signs and symptoms,
indication for procedure, treatment given
and planned line of b) Procedure note/
management, advise for operative note
the day care procedure. c) Post procedure clinical
b) Nasoendoscopy/ picture (biopsy, wide bore
Clinic based therapeutic interventions of radiology/ audiometry aspiration), endoscopy
1390 ENT SL ENT SL035 SL035A Turbinate reduction 1260 1386 1512 1638 1764 1827
ENT findings to justify the need picture (IT reduction),
for Procedure. radiology (optional, wide
bore needle aspiration),
audiology and radiology (IT
injections)
d) Discharge summary
report

a) Clinical notes including a) Clinical notes detailing OPEN

evaluation findings, signs and symptoms,
indication for procedure, treatment given
and planned line of b) Procedure note/
management, advise for operative note
the day care procedure. c) Post procedure clinical
b) Nasoendoscopy/ picture (biopsy, wide bore
Clinic based therapeutic interventions of radiology/ audiometry aspiration), endoscopy
1391 ENT SL ENT SL035 SL035B Biopsy 1260 1386 1512 1638 1764 1827
ENT findings to justify the need picture (IT reduction),
for Procedure. radiology (optional, wide
bore needle aspiration),
audiology and radiology (IT
injections)
d) Discharge summary
report

a) Clinical notes including a) Clinical notes detailing OPEN

evaluation findings, signs and symptoms,
indication for procedure, treatment given
and planned line of b) Procedure note/
management, advise for operative note
the day care procedure. c) Post procedure clinical
b) Nasoendoscopy/ picture (biopsy, wide bore
Clinic based therapeutic interventions of radiology/ audiometry aspiration), endoscopy
1392 ENT SL ENT SL035 SL035C Intratympanic injections 1260 1386 1512 1638 1764 1827
ENT findings to justify the need picture (IT reduction),
for Procedure. radiology (optional, wide
bore needle aspiration),
audiology and radiology (IT
injections)
d) Discharge summary
report
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Clinical notes detailing OPEN
evaluation findings, signs and symptoms,
indication for procedure, treatment given
and planned line of b) Procedure note/
management, advise for operative note
the day care procedure. c) Post procedure clinical
b) Nasoendoscopy/ picture (biopsy, wide bore
Clinic based therapeutic interventions of radiology/ audiometry aspiration), endoscopy
1393 ENT SL ENT SL035 SL035D Wide bore aspiration 1260 1386 1512 1638 1764 1827
ENT findings to justify the need picture (IT reduction),
for Procedure. radiology (optional, wide
bore needle aspiration),
audiology and radiology (IT
injections)
d) Discharge summary
report

0 0 OPEN YES
Cochlear Implant Surgery* Surgery(53000)
Cochlear Implant Surgery* Surgery(53000) *pre -
*pre -op evaluation(including vaccine for
op evaluation(including vaccine for meningitis)-
meningitis)- 10000/- *Initial mapping and
10000/- *Initial mapping and swithch on - 5000/-
1394 ENT SL ENT SL036 swithch on - 5000/-Rehabilitation Therapy SL036A 170625 187687 204750 221812 238875 247406
Rehabilitation Therapy (part- 1 for first 6
(part- 1 for first 6 months) -21700
months) -21700 Rehabilitation Therapy (part- 2
Rehabilitation Therapy (part- 2 for second 6
for second 6 months)-40300
months)-40300
a) Clinical notes (detailing a) Indoor case papers & Reserved
signs, symptoms, Consent (informed written)
examination findings, b) Procedure note/
indications for doing the operative note & Anesthesia
procedure) notes
Oral & Maxillofacial Oral & Maxillofacial b) Document required for (where applicable)
1395 SM SM001 Extraction of impacted tooth under LA SM001A Extraction of impacted tooth under LA 840 924 1008 1092 1176 1218
Surgery Surgery Investigation: c) Barcode of Implants
• Pre-op photo (extraoral d) Investigation reports
and intraoral) (post procedure)
c) Radiological imaging of • Photograph of affected
Impacted tooth part/Treated part.

Oral & Maxillofacial Oral & Maxillofacial Osteomyelitis -Acute 0 0 OPEN

1396 SM SM002 Sequestrectomy Debridement SM002A 2100 2310 2520 2730 2940 3045
Surgery Surgery
Oral & Maxillofacial Oral & Maxillofacial 0 0 OPEN
1397 SM SM002 Sequestrectomy Debridement SM002B Osteomyelitis-Chronic 3990 4389 4788 5187 5586 5785
Surgery Surgery
a) Clinical Photograph. a) Post procedure clinical OPEN
b) X-Ray of affected area. photograph with mouth
c) CT. open.
1.TM joint ankylosis of both jaws - under GA b) X Ray.
Oral & Maxillofacial Oral & Maxillofacial (Unilateral) c) Detailed discharge
1398 SM SM003 TM joint ankylosis of both jaws - under GA SM003A 15750 17325 18900 20475 22050 22837
Surgery Surgery summary.
d) Detailed Procedure.
e) Operative Notes.

2.TM joint ankylosis of both jaws - under GA 0 0 OPEN

Oral & Maxillofacial Oral & Maxillofacial
1399 SM SM003 TM joint ankylosis of both jaws - under GA SM003B (Bilateral)- 32865 36151 39438 42724 46011 47654
Surgery Surgery
(Covering Reconstruction)
a) Circumstances that led a) Detailed Discharge OPEN
to fracture. Summary.
b) MLC copy with number. b) Detailed Procedure.
Oral & Maxillofacial Oral & Maxillofacial Closed reduction (1 jaw) using wires - under c) Clinical Photograph. c) Operative Notes.
1400 SM SM004 Fixation of fracture of jaw SM004A 5250 5775 6300 6825 7350 7612
Surgery Surgery LA/GA d) X Ray Mandible. d) Post procedure X ray
mandible showing wires
used.

a) Circumstances that led a) Detailed Discharge OPEN

to fracture. Summary.
b) MLC copy with number. b) Detailed Procedure.
Open reduction (1 jaw) and fixing of plates / wire
Oral & Maxillofacial Oral & Maxillofacial c) Clinical Photograph. c) Operative Notes.
1401 SM SM004 Fixation of fracture of jaw SM004B – under LA/GA 12600 13860 15120 16380 17640 18270
Surgery Surgery d) X Ray Mandible. d) Post procedure X ray
Cost of implant Titanium:- TBF at pre-auth
mandible showing wires
used.

a) Are the Clinical notes a) Indoor case papers & OPEN

(detailing signs, symptoms, Consent (informed written)
examination findings, b) Are the Procedure note/
clinical photographs operative note & Anesthesia
(intraoral and extraoral), notes (where
indications applicable) submitted?
for doing the procedure & c) Are the barcode of
advise for admission Implants used submitted?
submitted? d) Are the Investigation
Oral & Maxillofacial Oral & Maxillofacial Surgery for Cyst & tumour of Maxilla / Enucleation / excision of cyst / tumour of jaws b) Are the Investigation report of Cyst/Tumour such
1402 SM SM005 SM005A 2835 3118 3402 3685 3969 4110 reports of Cyst/Tumour as:
Surgery Surgery Mandible under LA +cost of implant
such as: X-ray for Odontogenic cyst
X-ray for Odontogenic cyst Or Intraoral Radiograph &/
CBCT or CT of Jaws or or
Intraoral Radiograph and/ OPG Orthopantomograph
OPG Orthopantomograph y to confirm the existence &
y to confirm the existence Histopathology report,
submitted? Biopsy or FNAC
Submitted?
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Are the Clinical notes a) Indoor case papers & OPEN
(detailing signs, symptoms, Consent (informed written)
examination findings, b) Are the Procedure note/
clinical photographs operative note & Anesthesia
(intraoral and extraoral), notes (where
indications applicable) submitted?
for doing the procedure & c) Are the barcode of
advise for admission Implants used submitted?
submitted? d) Are the Investigation
Oral & Maxillofacial Oral & Maxillofacial Surgery for Cyst & tumour of Maxilla / b) Are the Investigation report of Cyst/Tumour such
1403 SM SM005 SM005B 5775 6352 6930 7507 8085 8373 reports of Cyst/Tumour as:
Surgery Surgery Mandible Enucleation / excision of cyst / tumour of jaws
under GA such as: X-ray for Odontogenic cyst
X-ray for Odontogenic cyst Or Intraoral Radiograph &/
CBCT or CT of Jaws or or
Intraoral Radiograph and/ OPG Orthopantomograph
OPG Orthopantomograph y to confirm the existence &
y to confirm the existence Histopathology report,
submitted? Biopsy or FNAC
Submitted?

a) Are the Clinical notes a) Indoor case papers & OPEN

(detailing signs, symptoms, Consent (informed written)
examination findings, b) Are the Procedure note/
clinical photographs operative note & Anesthesia
(intraoral and extraoral), notes (where
indications applicable) submitted?
for doing the procedure & c) Are the barcode of
advise for admission Implants used submitted?
submitted? d) Are the Investigation
Oral & Maxillofacial Oral & Maxillofacial Mandible Tumour Resection and Maxilla / Mandible neoplastic Tumour Resection b) Are the Investigation report of Cyst/Tumour such
1404 SM SM006 SM006A 14175 15592 17010 18427 19845 20553 reports of Cyst/Tumour as:
Surgery Surgery reconstruction / Cancer surgery and reconstruction (Cancer surgery)
such as: X-ray for Odontogenic cyst
X-ray for Odontogenic cyst Or Intraoral Radiograph &/
CBCT or CT of Jaws or or
Intraoral Radiograph and/ OPG Orthopantomograph
OPG Orthopantomograph y to confirm the existence &
y to confirm the existence Histopathology report,
submitted? Biopsy or FNAC
Submitted?

a) Clinical notes (detailing a) Indoor case papers & OPEN

signs, symptoms, Consent (informed written)
examination findings, b) Procedure note/
clinical photographs operative note & Anesthesia
1.Release of fibrous bands & grafting - in (intraoral & extraoral) notes
Oral & Maxillofacial Oral & Maxillofacial Release of fibrous bands & grafting - in indications for doing the c) Investigation reports
1405 SM SM007 SM007A (OSMF) treatment under LA: 5000 3465 3811 4158 4504 4851 5024
Surgery Surgery (OSMF) treatment under GA procedure & advise for (post procedure):
admission). Histopathology report
B) X-ray: OPG/ CBCT/CT/ showing OSMF to confirm
Lateral Oblique and PA the existence
mandible

0 0 OPEN
Oral & Maxillofacial Oral & Maxillofacial Release of fibrous bands & grafting - in 2. Release of fibrous release bands &
1406 SM SM007 SM007B 19740 21714 23688 25662 27636 28623
Surgery Surgery (OSMF) treatment under GA coronoidectomy with grafting - in (OSMF)
treatment under GA
Apicoectomy (A) 0 0 OPEN
Oral & Maxillofacial Oral & Maxillofacial
1407 SM SM008 Apicoectomy (A) Tooth SM008A (1-3 teeth) LA/GA 1575 1732 1890 2047 2205 2283
Surgery Surgery
3-6:4000
Oral & Maxillofacial Oral & Maxillofacial 0 0 OPEN
1408 SM SM009 Correction of oro-antral communication SM009A Correction of oro-antral Fistula 7350 8085 8820 9555 10290 10657
Surgery Surgery
Oral & Maxillofacial Oral & Maxillofacial 0 0 OPEN
1409 SM SM010 Submandibular sialolithotomy SM010A Intraoral submandibular sialolithotomy LA/ GA 7350 8085 8820 9555 10290 10657
Surgery Surgery
Oral & Maxillofacial Oral & Maxillofacial 0 0 OPEN
1410 SM SM010 Submandibular sialolithotomy SM010C Submandibular sialolithotomy 9450 10395 11340 12285 13230 13702
Surgery Surgery
Oral & Maxillofacial Oral & Maxillofacial Dentoalveolar trauma - wiring (dental /trauma 0 0 OPEN
1411 SM SM011 Dentoalveolar trauma - wiring SM011A 3150 3465 3780 4095 4410 4567
Surgery Surgery wiring- one jaw)
Oral & Maxillofacial Oral & Maxillofacial 0 0 OPEN
1412 SM SM012 Parotid sialolithotomy SM012A Extraoral parotid sialolithotomy under GA 12600 13860 15120 16380 17640 18270
Surgery Surgery
Oral & Maxillofacial Oral & Maxillofacial 0 0 OPEN
1413 SM SM012 Parotid sialolithotomy SM012B Intraoral parotid sialolithotomy 7350 8085 8820 9555 10290 10657
Surgery Surgery
Re-implantation of Avulsed tooth with wiring (1- 0 0 OPEN
Oral & Maxillofacial Oral & Maxillofacial
1414 SM SM013 Re-implantation of Avulsed tooth with wiring SM013A 3 teeth) 1785 1963 2142 2320 2499 2588
Surgery Surgery
3-6 :6000
Osteoradionecrosis of jaws management by 0 0 OPEN
Oral & Maxillofacial Oral & Maxillofacial Osteoradionecrosis management by
1415 SM SM014 SM014A excision under LA 5250 5775 6300 6825 7350 7612
Surgery Surgery excision
2.Osteoradionecrosis of Jaws management by 0 0 OPEN
Oral & Maxillofacial Oral & Maxillofacial Osteoradionecrosis management by
1416 SM SM014 SM014B excision and / or reconstruction under GA + 15750 17325 18900 20475 22050 22837
Surgery Surgery excision
Implant : 12000 +Implant
a) Clinical notes. a) Post procedure Imaging OPEN YES
b) CT confirming with film (CT).
diagnosis. b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge
1417 Neurosurgery SN Neurosurgery SN001 Depressed Skull Fracture SN001A Surgery for Depressed Skull fracture 52500 57750 63000 68250 73500 76125 summary.
d) Detailed Procedure.
e) Operative Notes.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical Notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication of procedure, b) Post Procedure X-ray
1418 39732 43344 46956 50568 52374 and planned line of with report of skull
Neurosurgery SN Neurosurgery SN002 CranioPlasty SN002A Cranioplasty with autologus bone graft 36120
treatment c) Detailed Procedure/
b. CT/ MRI report of skull Operative notes
d) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication of procedure, b) Post Procedure X-ray
and planned line of with report of skull
1419 Neurosurgery SN Neurosurgery SN002 CranioPlasty SN002B Cranioplasty with exogenous Graft 36120 39732 43344 46956 50568 52374 treatment c) Detailed Procedure/
b) CT/ MRI report of skull Operative notes
c) Indication of implant d) Invoice/Barcode details
requirement of implant
e) Detailed discharge
summary
a) Clinical notes with signs, a) Detailed Indoor case OPEN
symptoms, indications, papers (ICPs)
planned line of b) CT Brain
1420 Neurosurgery SN Neurosurgery SN003 Twist Drill Craniostomy SN003A Twist Drill Craniostomy 19740 21714 23688 25662 27636 28623 management and advice c) Detailed Procedure /
for admission operative notes
b) Clinical Evaluation e) Detailed discharge
c) CT/MRI Brain summary
a) Clinical Notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers
indication of procedure and b) Post Procedure X-ray
Cranial vault remodeling/ surgery for planned line of with report of skull
1421 Neurosurgery SN Neurosurgery SN004 Craniostenosis SN004A 49560 54516 59472 64428 69384 71862
"Craniosynostosis" management c) Detailed Procedure/
b) CT/ MRI report of skull Operation notes
establishing need for d) Detailed discharge
surgery summary
a) Clinical notes with signs, a) Detailed Indoor case Referral YES
symptoms, indications, papers (ICPs)
planned line of b) Detailed Procedure /
Anterior cranial fossa management and advice operative notes
1422 Neurosurgery SN Neurosurgery SN005 Meningocele SN005A 65520 72072 78624 85176 91728 95004
encephalocele/meningocele repair for admission c) Detailed discharge
b) Clinical picture summary
c) Plain X-ray skull
CT/MRI Brain/Spine
a) Clinical notes with signs, a) Detailed Indoor case Referral YES
symptoms, indications, papers (ICPs)
planned line of b) Detailed Procedure /
1423 54169 59094 64018 68943 71405 management and advice operative notes
Neurosurgery SN Neurosurgery SN005 Meningocele SN005B Surgery for spina bifida cystica/occulta 49245
for admission c) Detailed discharge
b) Clinical picture summary
c) Plain X-ray skull
CT/MRI Brain/Spine
a) Clinical notes with signs, a) Detailed Indoor case Referral
symptoms, indications, papers (ICPs)
planned line of b) Detailed Procedure /
Posterior cranial fossa management and advice operative notes
1424 Neurosurgery SN Neurosurgery SN005 Meningocele SN005C 67725 74497 81270 88042 94815 98201
encephalocele/meningocele repair for admission c) Detailed discharge
b) Clinical picture summary
c) Plain X-ray skull
CT/MRI Brain/Spine
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings papers
b) CT/ MRI Brain b) Detailed Procedure /
c) Planned line of operative notes
Surgery for supratentorial Extra-axial Tumours treatment c) Post-op CT Brain
1425 Neurosurgery SN Neurosurgery SN006 Surgery for tumour meninges SN006A 67725 74497 81270 88042 94815 98201
(Meningioma etc) Yes
d) Histopathological
Examination report
e) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings papers
b) CT/ MRI Brain b) Detailed Procedure /
c) Planned line of operative notes
Surgery for infratentorial treatment c) Post-op CT Brain
1426 Neurosurgery SN Neurosurgery SN006 Surgery for tumour meninges SN006B 67725 74497 81270 88042 94815 98201
ExtraaxialTumour(meningioma etc) Yes
d) Histopathological
Examination report
e) Detailed discharge
summary
a) Clinical notes with signs, a) Detailed Indoor case OPEN
symptoms, indications, papers
planned line of b) Post-op CT CVJ
management and advice (craniovertebral junction)
Duroplasty with Endogenous graft- (May be for admission c) Implant details if
1427 Neurosurgery SN Neurosurgery SN007 Duroplasty SN007A 16485 18133 19782 21430 23079 23903 b) Clinical photograph applicable
perfomed as a add-on procedure)
(optional) for associated (barcode/invoice)
conditions d) Detailed Procedure /
c) MRI Brain and Spine operative notes
d) Indication of implant e) Detailed discharge
requirement if applicable summary
a) Clinical notes with signs, a) Detailed Indoor case OPEN
symptoms, indications, papers
planned line of b) Post-op CT CVJ
management and advice (craniovertebral junction)
Duroplasty with Exogenous graft- (May be for admission c) Implant details if
1428 Neurosurgery SN Neurosurgery SN007 Duroplasty SN007B perfomed as an add-on procedure) Cost of graft 16485 18133 19782 21430 23079 23903 b) Clinical photograph applicable
will be extra (optional) for associated (barcode/invoice)
conditions d) Detailed Procedure /
c) MRI Brain and Spine operative notes
d) Indication of implant e) Detailed discharge
requirement if applicable summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical Evaluation papers
c) CT Scan/MRI brain b) CT Brain
Burr hole surgery for evacuation of hematoma/ d) Optional c) Detailed Procedure /
1429 Neurosurgery SN Neurosurgery SN008 Burr hole surgery SN008A biopsy/ pus drainage/Placement of ICP 14490 15939 17388 18837 20286 21010 Complete Blood Count operative notes
monitoring device C-reactive protein d) Detailed discharge
X ray - skull summary
e) Planned line of
treatment
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical Evaluation papers
c) CT Scan/MRI brain b) CT Brain
d) Optional c) Detailed Procedure /
Burr hole surgery with chronic Sub Dural
1430 Neurosurgery SN Neurosurgery SN008 Burr hole surgery SN008B 32865 36151 39438 42724 46011 47654 Complete Blood Count operative notes
Haematoma
C-reactive protein d) Detailed discharge
X ray - skull summary
e) Planned line of
treatment
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, and papers
planned line of b) Detailed Procedure /
management operative notes
Evacuation of Post-trauamtic Intraparenchymal b) Glasgow coma score c) Glasgow coma score
1431 Neurosurgery SN Neurosurgery SN009 Surgery for Haematoma - Intracranial SN009A 73920 81312 88704 96096 103488 107184 (GCS) (GCS)/ Pediatric GCS
Hematoma
c) Blood pressure documentation
monitoring d) Detailed discharge
d) Fundus examination summary
e) Coagulation profile
f) CT/MRI Brain
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, and papers
planned line of b) Detailed Procedure /
management operative notes
Spontaneous Intraparenchymal hematoma b) Glasgow coma score c) Glasgow coma score
1432 Neurosurgery SN Neurosurgery SN009 Surgery for Haematoma - Intracranial SN009B 67725 74497 81270 88042 94815 98201 (GCS) (GCS)/ Pediatric GCS
evacuation
c) Blood pressure documentation
monitoring d) Detailed discharge
d) Fundus examination summary
e) Coagulation profile
f) CT/MRI Brain
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, and papers
planned line of b) Detailed Procedure /
management operative notes
Evacuation of Post-trauamtic Intraparenchymal b) Pediatric GCS (<2 c) Glasgow coma score
1433 Neurosurgery SN Neurosurgery SN009 Surgery for Haematoma - Intracranial SN009C 67725 74497 81270 88042 94815 98201 years/>2 years) (GCS)/ Pediatric GCS
Hematoma in Pediatric Age group
c) Blood pressure documentation
monitoring d) Detailed discharge
d) Fundus examination summary
e) Coagulation profile
f) CT/MRI Brain
a) Clinical notes with signs, a) Detailed Indoor case OPEN YES
symptoms, indications, papers (ICPs)
planned line of b) Detailed Procedure /
management and advice operative notes
1434 Neurosurgery SN Neurosurgery SN010 Excision of Brain Abscess SN010A Excision of Brain abscess 65520 72072 78624 85176 91728 95004 for admission c) CT brain (Preop & Post
b) Clinical Evaluation op)
c) CECT/MRI brain d) Histopathology
examination
e) Detailed discharge
summary
a) Clinical notes with signs, a) Detailed Indoor case OPEN
symptoms, indications, papers (ICPs)
planned line of b) Detailed Procedure /
management and advice operative notes
Craniotomy/Burr hole and Tapping of Brain for admission c) CT brain (Preop & Post
1435 Neurosurgery SN Neurosurgery SN011 Abscess Tapping SN011A 32865 36151 39438 42724 46011 47654
Abscess b) Clinical Evaluation op)
c) CECT/MRI brain d) Histopathology
examination
e) Detailed discharge
summary
a) Clinical notes with signs, a) Detailed Indoor case OPEN YES
symptoms, indications, papers (ICPs)
planned line of b) Detailed Procedure /
management and advice operative notes
1436 Neurosurgery SN Neurosurgery SN012 Epilepsy Surgery SN012A Epilepsy Surgery 90300 99330 108360 117390 126420 130935 for admission c) Preop MRI & Postop
b) Clinical Evaluation MRI/CT
c) Electroencephalogram d) Post op EEG
(EEG) e) Detailed discharge
d) Video EEG summary
e) CT/MRI brain
a) Clinical notes. a) Histopathology. OPEN
b) CT. b) Post procedure Clinical
c) MRI. photgraph showing scar.
d) Suspected differential c) Detailed discharge
1437 Neurosurgery SN Neurosurgery SN013 Brain Biopsy SN013A Brain Biopsy- Open/Stereotactic guided 22155 24370 26586 28801 31017 32124 diagnosis. summary.
d) Detailed Procedure.
e) Operative Notes.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes. a) Post procedure Imaging OPEN YES
b) CT. with film (CT).
c) MRI report. b) Post procedure Clinical
photgraph showing scar.
c) Detailed discharge
1438 Neurosurgery SN Neurosurgery SN014 Excision of Orbital Tumour SN014A Excision of Orbital Tumour 65625 72187 78750 85312 91875 95156 summary.
d) Detailed Procedure.
e) Operative Notes.
f) HPE report.

a) Clinical notes. a) Histopathology. OPEN YES

b) CT. b) Post procedure Imaging
c) MRI. with film (CT).
c) Post procedure Clinical
photgraph showing scar.
1439 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015A Parasagital Tumours 67725 74497 81270 88042 94815 98201 d) Detailed discharge
summary. e)Detailed
Procedure.
f) Operative Notes.

a) Clinical notes. a) Histopathology. OPEN YES

b) CT. b) Post procedure Imaging
c) MRI. with film (CT).
c) Post procedure Clinical
photgraph showing scar.
1440 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015B Skull Base Tumours 67725 74497 81270 88042 94815 98201 d) Detailed discharge
summary. e)Detailed
Procedure.
f) Operative Notes.

a) Clinical notes. a) Histopathology. OPEN YES

b) CT. b) Post procedure Imaging
c) MRI. with film (CT).
c) Post procedure Clinical
photgraph showing scar.
1441 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015C Surgerey for infratentorial intra-axial tumours 67725 74497 81270 88042 94815 98201 d) Detailed discharge
summary. e)Detailed
Procedure.
f) Operative Notes.

a) Clinical notes. a) Histopathology. OPEN YES

b) CT. b) Post procedure Imaging
c) MRI. with film (CT).
c) Post procedure Clinical
photgraph showing scar.
1442 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015D C P Angle 67725 74497 81270 88042 94815 98201 d) Detailed discharge
summary. e)Detailed
Procedure.
f) Operative Notes.

a) Clinical notes. a) Histopathology. OPEN YES

b) CT. b) Post procedure Imaging
c) MRI. with film (CT).
c) Post procedure Clinical
photgraph showing scar.
1443 Neurosurgery SN Neurosurgery SN015 Excision of Brain Tumor Supratentorial SN015E Supratentorial & other Tumours 73920 81312 88704 96096 103488 107184 d) Detailed discharge
summary. e)Detailed
Procedure.
f) Operative Notes.

a) Clinical notes including a) Detailed Indoor case OPEN YES

clinical evaluation, papers
indication of procedure, b) Detailed Procedure /
1444 Neurosurgery SN Neurosurgery SN016 Stereotactic Lesioning SN016A Stereotactic Lesioning for movement disoders 98490 108339 118188 128037 137886 142810 and planned line of operative notes
management c) Detailed discharge
b) MRI Brain / MRI summary
Angiography
a) Clinical notes. a) Histopathology. OPEN
b) MRI supporting surgery. b) Post procedure Imaging
with film (MRI).
c) Detailed Procedure.
Endoscpic/Microscopic Trans Sphenoidal
1445 Neurosurgery SN Neurosurgery SN017 Trans Sphenoidal Surgery SN017A 67725 74497 81270 88042 94815 98201 d) Operative Notes.
Surgery
e) Detailed discharge
summary.

a) Clinical notes with signs, a) Detailed Indoor case OPEN YES

symptoms, indications, papers (ICPs)
planned line of b) Preop and post op CT-
management and advice CVJ
1446 Neurosurgery SN Neurosurgery SN018 Trans oral Surgery SN018A Trans oral Surgery 71400 78540 85680 92820 99960 103530 for admission c) Detailed Procedure /
b) Clinical Evaluation operative notes
c) CT/ MRI CVJ/ cervical d) Detailed discharge
spine - X ray summary
d) Planned line of
treatment
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN YES
indication of implant papers
requirement, evaluation b) Post op CT-CVJ
findings confirming the (Craniovertebral junction)
Transoral surgery (Anterior) and CV Trans oral anterior decompression and diagnosis report
1447 Neurosurgery SN Neurosurgery SN019 SN019A 97650 107415 117180 126945 136710 141592 b) CT + MRI CVJ c) Detailed Procedure /
Junction (Posterior Sterilisation) Posterior stabilisation ov C V junction
(Craniovertebral junction) + operative notes
cervical spine - X ray d) Implant details
c) Planned line of (barcode/invoice)
treatment e) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case OPEN YES
b) Clinical Evaluation papers (ICPs)
c) CT/MRI brain b) Detailed Procedure /
d) Cerebrospinal Fluid operative notes
External Ventricular Drainage (EVD) (CSF) Analysis c) CT brain (Preop & Post
1448 Neurosurgery SN Neurosurgery SN020 SN020A External Ventricular Drainage (EVD) 44310 48741 53172 57603 62034 64249
including antibiotics e) Coagulation Profile op)
f) Planned line of treatment d) Histopathology
examination
e) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical Evaluation papers (ICPs)
c) CT/MRI brain b) Detailed Procedure /
d) Cerebrospinal Fluid operative notes
1449 Neurosurgery SN Neurosurgery SN021 Ventricular Puncture SN021A Ventricular Tap 19740 21714 23688 25662 27636 28623 (CSF) Analysis c) CT brain (Preop & Post
e) Coagulation Profile op)
f) Planned line of treatment d) Histopathology
examination
e) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor Case OPEN YES
evaluation findings and Papers
Ventriculo-Peritoneal Shunt (Low/Medium/High planned line of treatment b) Detailed Procedure/
1450 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022A 44310 48741 53172 57603 62034 64249
Pressure or Flow regulated valve) b) CT/ MRI report of brain Operative notes
c) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor Case OPEN YES
evaluation findings and Papers
Ventriculo - pleural Shunt (Low/Medium/High planned line of treatment b) Detailed Procedure/
1451 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022B 44310 48741 53172 57603 62034 64249
Pressure or Flow regulated valve) b) CT/ MRI report of brain Operative notes
c) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor Case OPEN YES
evaluation findings and Papers
Ventriculo - atrial Shunt (Low/Medium/High planned line of treatment b) Detailed Procedure/
1452 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022C 44310 48741 53172 57603 62034 64249
Pressure or Flow regulated valve) b) CT/ MRI report of brain Operative notes
c) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor Case OPEN YES
evaluation findings and Papers
Theco - peritoneal Shunt (Low/Medium/High planned line of treatment b) Detailed Procedure/
1453 Neurosurgery SN Neurosurgery SN022 Shunt Surgery SN022D 44310 48741 53172 57603 62034 64249
Pressure or Flow regulated valve) b) CT/ MRI report of brain Operative notes
c) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers
indication of implant, and b) Detailed Procedure/
planned line of Operation notes
1454 Neurosurgery SN Neurosurgery SN023 Aneurysm Clipping including angiogram SN023A Aneurysm Clipping including DSA or CTA 90300 99330 108360 117390 126420 130935 management c) Invoice/barcode of clips
b) CTA/ MRA/ DSA (Digital used
Subtraction Angiography) d) Detailed discharge
report of brain establishing summary
need for surgery

a) Clinical Notes including a) Detailed Indoor case OPEN YES

evaluation findings, papers
indication of procedure and b) Detailed Procedure/
Superficial Temporal Artery (STA): middle Superficial Temporal Artery (STA): middle planned line of Operation notes
1455 Neurosurgery SN Neurosurgery SN024 cerebral artery (MCA) or (other EC - IC) SN024A cerebral artery (MCA) or (other EC - IC) Bypass 88620 97482 106344 115206 124068 128499 management c) Detailed discharge
Bypass procedure procedure b) MRA/Digital Subtraction summary
Angiography (DSA) report
of brain establishing need
for surgery

a) Clinical notes including a) Detailed Indoor case OPEN YES

evaluation findings, papers
indication for procedure, b) Detailed Procedure /
Arterio venous malformation (AVM) Craniotmy and excision of arteriovenous
1456 Neurosurgery SN Neurosurgery SN025 SN025A 90300 99330 108360 117390 126420 130935 and planned line of operative notes
excision malformation
management c) Detailed discharge
b) CT/MRI Brain/Spine summary
c) Angiography
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers
indication for procedure, b) Detailed Procedure /
Arterio venous malformation (AVM) Laminectomy/Laminotomy and excision of
1457 Neurosurgery SN Neurosurgery SN025 SN025B 90300 99330 108360 117390 126420 130935 and planned line of operative notes
excision Intraspinal arteriovenous malformation
management c) Detailed discharge
b) CT/MRI Brain/Spine summary
c) Angiography
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers
indication for procedure, b) Detailed Procedure /
Arterio venous malformation (AVM)
1458 Neurosurgery SN Neurosurgery SN025 SN025C Excision of scalp arteriovenous malformation 45150 49665 54180 58695 63210 65467 and planned line of operative notes
excision
management c) Detailed discharge
b) CT/MRI Brain/Spine summary
c) Angiography
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes with signs, a) Detailed Indoor case OPEN
symptoms, indications, papers (ICPs)
planned line of b) Post-operative
Foramen magnum decompression for Chiari management and advice photographs (optional)
1459 Neurosurgery SN Neurosurgery SN026 Foramen Magnum Decompression SN026A malormation with or without duraplasty or 98490 108339 118188 128037 137886 142810 for admission c) Post-op CT CVJ
tonsillar resection. b) Clinical picture (craniovertebral junction)
(optional) for associated d) Detailed Procedure /
conditions operative notes
c) MRI Brain and Spine e) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical evaluation papers (ICPs)
c) Cervical X-ray/CT/MRI b) Post-procedure
d) Planned line of photograph (optional)
treatment c) Lateral C-spine X-rays
within 6 hours after
1460 Neurosurgery SN Neurosurgery SN027 Skull Traction SN027A Skull Traction 13125 14437 15750 17062 18375 19031 application of traction
d) In case of accident was
FIR done (optional)
e) Detailed Procedure /
operative notes
f) Detailed discharge
summary
a) Clinical notes with a)Detailed Indoor case OPEN YES
evaluation findings, papers
indication of procedure, b) Detailed Procedure /
Posterior Cervical Discetomy without Posterior cervical laminoforaminotomy and and planned line of operative notes
1461 Neurosurgery SN Neurosurgery SN028 SN028A 44310 48741 53172 57603 62034 64249
implant discectomy treatment c) Detailed discharge
b) Clinical photograph summary
c) X-ray / MRI Cervical
spine
a) Clinical notes with a)Detailed Indoor case OPEN YES
evaluation findings, papers
indication of procedure, b) Detailed Procedure /
and planned line of operative notes
Posterior Cervical Fusion with implant Posterior cervical fusion using lateral mass or
1462 Neurosurgery SN Neurosurgery SN029 SN029A 68985 75883 82782 89680 96579 100028 treatment c) Detailed discharge
(Lateral mass fixation) pedicle screws and rods
b) Clinical photograph summary d) Implant details
c) X-ray / MRI Cervical (invoice/barcode)
spine d) Indication
of implant requirement
a) Clinical notes with a)Detailed Indoor case OPEN YES
evaluation findings, papers
indication of procedure, b) Detailed Procedure /
1463 72187 78750 85312 91875 95156 and planned line of operative notes
Neurosurgery SN Neurosurgery SN030 Cervical Disc Multiple level without Fusion SN030A Anterior cervical discectomy without fusion 65625
treatment c) Detailed discharge
b) Clinical photograph summary
c) X-ray / MRI Cervical
spine
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical photograph papers
c) Cervical X-ray b) Detailed Procedure /
1464 Neurosurgery SN Neurosurgery SN031 Excision of Cervical Ribs SN031A Excision of Cervical Ribs 37800 41580 45360 49140 52920 54810 CT/MRI Chest and Cervical operative notes
Spine d) Planned line of c) Cervical/Chest X-ray
treatment d) Detailed discharge
summary
a) Clinical notes with a) Detailed Indoor case OPEN YES
history, signs, symptoms, papers
evaluation findings, b) Procedure / operation
indication for procedure, notes
planned line of c) Post procedure Imaging
Cervical/Thoracic/ Lumbar corpectomy with management and advice with film (X ray) showing
1465 Neurosurgery SN Neurosurgery, Orthopedics SN032 Thoracic / Lumbar Corpectomy with fusion SN032A 98490 108339 118188 128037 137886 142810 for admission the implants
fusion for Tumor/Infection/Trauma
b) MRI labelled with patient d) Post procedure Clinical
ID, date and side (Left/ photograph showing scar
Right) - affected part e) Invoice/barcode of
implant
f) Discharge Summary

a) Clinical notes a) Detailed Indoor case OPEN YES

b) Clinical Evaluation papers
Microscopic/Endoscopic Lumbar Discectomy c) MRI Lumbar spine b) Detailed Procedure /
1466 Neurosurgery SN Neurosurgery SN033 Lumbar Discectomy SN033A 44310 48741 53172 57603 62034 64249.5
(One level) d) Planned line of operative notes
treatment c) Detailed discharge
summary
a) Clinical notes. a) Post procedure X-ray OPEN YES
b) MRI establishing need of showing fixation & fusion.
surgery. b) Post procedure Clinical
photgraph showing scar.
Laminectomy without fusion for lumbar or c) Detailed discharge
1467 Neurosurgery SN Neurosurgery, Orthopedics SN034 Laminectomy SN034A 65625 72187 78750 85312 91875 95156 summary Detailed
cervical canal stenosis
Procedure.
d) Operative Notes.

a) Clinical notes. a) Post procedure X-ray OPEN YES

b) MRI establishing need of showing fixation & fusion.
surgery. b) Post procedure Clinical
Laminectomy with fusion and fixation for photgraph showing scar.
lumbar/cervical/thoracic canal stenosis or for c) Detailed discharge
1468 Neurosurgery SN Neurosurgery, Orthopedics SN034 Laminectomy SN034B 71400 78540 85680 92820 99960 103530 summary Detailed
tumor / trauma/Bleed(Cost of implants to be
extra) Procedure.
d) Operative Notes.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN
clinical evaluation, papers
indication of procedure, b) Detailed Procedure /
1469 Neurosurgery SN Neurosurgery SN035 Neurectomy SN035A Peripheral Neurectomy 26250 28875 31500 34125 36750 38062 and planned line of operative notes
management c) Detailed discharge
b) MRI Brain / MRI summary
Angiography
a) Clinical notes including a) Detailed Indoor case OPEN
clinical evaluation, papers
indication of procedure, b) Detailed Procedure /
Neurosurgery, ENT, Oral &
1470 Neurosurgery SN SN035 Neurectomy SN035B Trigeminal Nerve Neurectomy 32655 35920 39186 42451 45717 47349 and planned line of operative notes
Maxillofacial Surgery
management c) Detailed discharge
b) MRI Brain / MRI summary
Angiography
a) Clinical notes with a)Detailed Indoor case OPEN YES
evaluation findings, papers
indication of procedure, b) Detailed Procedure /
Anterior Cervical Discectomy with fusion (Cost and planned line of operative notes
1471 Neurosurgery SN Neurosurgery SN036 Micro discectomy SN036A 65625 72187 78750 85312 91875 95156
of implants to be extra) treatment c) Detailed discharge
b) Clinical photograph summary
c) X-ray / MRI Cervical
spine
a) Clinical notes with a) Detailed Indoor case OPEN YES
evaluation findings, papers
indication of procedure, b) Detailed Procedure /
1472 Neurosurgery SN Neurosurgery SN039 Spine - Extradural Haematoma SN039A Intraspinal Extradural hematoma evacuation 44310 48741 53172 57603 62034 64249 and planned line of operative notes
management c) Post-op X-ray Spine
b) CT/MRI Spine d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN YES
evaluation findings papers
b) Based on Etiology b) Detailed Procedure /
*CT/ MRI Brain/Spine operative notes
*Positron emission c) Post-op CT Spine
tomography (PET) scan d) Histopathological/Biopsy
*Chest X-ray report
1473 Neurosurgery SN Neurosurgery SN041 Spine - Extradural Tumour SN041A Excision of extradural spinal tumor 56700 62370 68040 73710 79380 82215 * Mammography
* Ultrasound of abdomen
*Bone scan
*CT/MRI of other regions if
symptomatic
c) Planned line of
treatment

a) Clinical notes including a) Detailed Indoor case OPEN YES

evaluation findings papers
b) Based on Etiology b) Detailed Procedure /
*CT/ MRI Brain/Spine operative notes
*Positron emission c) Post-op CT Spine
tomography (PET) scan d) Implant details
*Chest X-ray (barcode/invoice)
Excision of extradural spinal tumor with fusion * Mammography e) Histopathological/Biopsy
1474 Neurosurgery SN Neurosurgery SN041 Spine - Extradural Tumour SN041B 56700 62370 68040 73710 79380 82215 * Ultrasound of abdomen report
and fixation (Cost of implants to be extra)
*Bone scan
*CT/MRI of other regions if
symptomatic
c) Planned line of
treatment d)
Indication of implant
requirement

a) Clinical notes including a) Detailed Indoor case OPEN YES

evaluation findings papers
b) CT/ MRI Spine b) Detailed Procedure /
c) Planned line of operative notes
1475 Neurosurgery SN Neurosurgery SN042 Spine - Intradural Tumour SN042A Excision of Intradural extramedullary tumor 65625 72187 78750 85312 91875 95156 treatment c) Post-op CT Spine
d) Histopathological/Biopsy
report
e) Detailed discharge
summary

a) Clinical notes including a) Detailed Indoor case OPEN YES

evaluation findings papers
b) CT/ MRI Spine b) Detailed Procedure /
c) Indication of implant operative notes
Excision of Intradural extramedullary tumor with requirement c) Post-op CT Spine
1476 Neurosurgery SN Neurosurgery SN042 Spine - Intradural Tumour SN042B fusion and ficxation (Cost of implants to be 71400 78540 85680 92820 99960 103530 d) Planned line of d) Implant details
extra) treatment (barcode/invoice)
e) Histopathological/Biopsy
report
f) Detailed discharge
summary

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings papers
b) CT/ MRI Spine b) Detailed Procedure /
c) Planned line of operative notes
treatment Optional c) Post-op CT Spine
*PET scan d) Histopathological/Biopsy
1477 Neurosurgery SN Neurosurgery SN043 Spine - Intramedullar Tumour SN043A Excision of Intramedullary tumor of spine 67725 74497 81270 88042 94815 98201 *Chest X-ray report
*Bone scan e) Detailed discharge
*Mammography summary
*Ultrasound of abdomen
*CT/MRI of other regions if
symptomatic
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings papers
b) CT/ MRI Spine b) Detailed Procedure /
c) Indication of implant operative notes
requirement c) Post-op CT Spine
Excision of Intramedullary tumor with fusion and d) Planned line of d) Implant details
1478 Neurosurgery SN Neurosurgery SN043 Spine - Intramedullar Tumour SN043B 67725 74497 81270 88042 94815 98201
ficxation (Cost of implants to be extra) treatment (barcode/invoice)
e) Histopathological/Biopsy
report
f) Detailed discharge
summary

a) Clinical notes including a) Detailed Indoor case OPEN

clinical evaluation, papers
indication of procedure, b) Detailed Procedure /
1479 Neurosurgery SN Neurosurgery SN044 R. F. Lesioning for Trigeminal Neuralgia SN044A R. F. Lesioning for Trigeminal Neuralgia 26250 28875 31500 34125 36750 38062 and planned line of operative notes
management c) Detailed discharge
b) MRI Brain / MRI summary
Angiography
a) Clinical notes a) Detailed Indoor case OPEN YES
b) Clinical Evaluation papers
c) Electromyography b) Detailed Procedure /
1480 52899 57708 62517 67326 69730 (EMG) operative notes
Neurosurgery SN Neurosurgery SN045 Brachial Plexus – Repair SN045A Brachial Plexus repair 48090
d) Nerve conduction c) In case of accidents –
studies e) FIR (optional)
Planned line of treatment d) Detailed discharge
summary
a) Clinical notes confirming a) Detailed Indoor Case OPEN
the diagnosis Papers
b) Ultrasound imaging b) Detailed Procedure /
(USG) labelled with patient Operative Notes
1481 Neurosurgery SN Neurosurgery, Orthopedics SN046 Carpal Tunnel Release SN046A Carpal tunnel release 19740 21714 23688 25662 27636 28623 ID, date and side (Left/ c) Detailed discharge
Right) of affected limb summary
c) Nerve Conduction
Velocity (NCV)

a) Clinical notes confirming a) Detailed Indoor Case OPEN

the diagnosis Papers
b) Ultrasound imaging b) Detailed Procedure /
(USG) labelled with patient Operative Notes
1482 Neurosurgery SN Neurosurgery SN047 Nerve Decompression SN047A Peripheral nerve repair/Neurolysis 22470 24717 26964 29211 31458 32581 ID, date and side (Left/ c) Detailed discharge
Right) of affected limb summary
c) Nerve Conduction
Velocity (NCV)

a) Clinical notes a) Detailed Indoor case OPEN

b) Clinical evaluation papers (ICPs)
c) EMG b)Detailed Procedure /
1483 36151 39438 42724 46011 47654 (Electromyography) operative notes
Neurosurgery SN Neurosurgery SN048 Cranial Nerve Anastomosis SN048A Cranial nerve re-anastomosis/Repair (Facial/) 32865
d) Nerve conduction study c) Detailed discharge
e) Planned line of summary
treatment

a) Clinical notes confirming a) Detailed Indoor Case OPEN YES

the diagnosis Papers
b) Ultrasound imaging b) Detailed Procedure /
(USG) labelled with patient Operative Notes
1484 Neurosurgery SN Neurosurgery SN049 Peripheral Nerve Surgery SN049B Peripheral nerve tumor excision and repair 44310 48741 53172 57603 62034 64249 ID, date and side (Left/ c) Detailed discharge
Right) of affected limb summary
c) Nerve Conduction
Velocity (NCV)

a) Clinical notes a) Detailed Indoor case OPEN

b) Clinical Evaluation papers
c) Electromyography b) Detailed Procedure /
1485 10857 11844 12831 13818 14311 (EMG) operative notes
Neurosurgery SN Neurosurgery SN050 Nerve Biopsy excluding Hensens SN050A Nerve Biopsy excluding Hansen's 9870
d) Nerve conduction c) In case of accidents –
studies e) FIR (optional)
Planned line of treatment d) Detailed discharge
summary
a) Clinical notes a) Detailed Indoor case OPEN
b) Clinical Evaluation papers (ICPs)
c) Planned line of b) Histopathological
1486 10857 11844 12831 13818 14311 treatment examination
Neurosurgery SN Neurosurgery SN051 Muscle Biopsy with report SN051A Muscle Biopsy 9870
c) Detailed Procedure /
operative notes
d) Detailed discharge
summary
a) Clinical Notes including a) Detailed Indoor case OPEN YES
evaluation findings, papers
indication b) Histopathological report
Gamma Knife radiosurgery (GKRS) / SRS
Gamma Knife Radiosurgery for tumors/AVMs/ of procedure and planned of muscle biopsy
1487 Neurosurgery SN Neurosurgery SN054 for tumours / Arteriovenous malformation SN054A 98490 108339 118188 128037 137886 142810
Trigeminal Neuralgia line of management c) Detailed Procedure/
(AVM)
b) Electromyography Operative notes
(EMG) report d) Detailed discharge
summary
1488 Neurosurgery SN Neurosurgery SN057 Endoscopic Third Ventriculostomy SN057A Endoscopic Third ventriculostomy 48090 52899 57708 62517 67326 69730 0 0 OPEN YES
1489 Neurosurgery SN Neurosurgery SN059 R. F. Lesioning SN059A Radiofrequency lesioning for sacroilitis 10710 11781 12852 13923 14994 15529 0 0 OPEN
0 0 OPEN
1490 Neurosurgery SN Neurosurgery SN059 R. F. Lesioning SN059B Radiofrequency lesioning for chronic back pain 10710 11781 12852 13923 14994 15529
1491 Neurosurgery SN Neurosurgery SN060 Discectomy - Dorsal SN060A Discectomy - Dorsal 44310 48741 53172 57603 62034 64249 0 0 OPEN YES
0 0 OPEN
Diagnostic Cerebral / Spinal Angiography Diagnostic Cerebral / Spinal Angiography (DSA -
1492 Neurosurgery SN Neurosurgery SN061 SN061A 21840 24024 26208 28392 30576 31668
(DSA - Digital Substraction Angiography) Digital Substraction Angiography)
0 0 OPEN
1493 Neurosurgery SN Neurosurgery SN062 Reexploration for Cranial / Spinal surgeries SN062A Reexploration for Cranial / Spinal surgeries 32865 36151 39438 42724 46011 47654
Conservative management of high cervical Conservatively managed spinal injury with 0 0 OPEN
1494 Neurosurgery SN Neurosurgery SN063 SN063A 2350 2585 2820 3055 3290 3407
injury ventilator
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Conservative management of high cervical 0 0 OPEN variable
1495 Polytrauma ST Polytrauma SN063 SN063B Moderate head injury 2350 2585 2820 3055 3290 3407
injury
Conservative management of high cervical 0 0 OPEN
1496 Neurosurgery SN Neurosurgery SN063 SN063C Conservatively managed Severe Head injury 2350 2585 2820 3055 3290 3407
injury
Conservative management of high cervical 0 0 OPEN variable
1497 Polytrauma ST Polytrauma SN063 SN063D Simple head injury 2350 2585 2820 3055 3290 3407
injury
1498 Neurosurgery SN Neurosurgery SN064 AVM EMBOLISATION SN064A AVM EMBOLISATION/THROMBECTOMY 229740 252714 275688 298662 321636 333123 0 0 OPEN YES
Ventricular tapping with Omayya 0 0 OPEN
1499 Neurosurgery SN Neurosurgery SN065 Ventricular tap SN065A 26250 28875 31500 34125 36750 38062
reservoir/external ventricular drain
Craniectomy/ DECRA for head injury/acute 0 0 OPEN YES
1500 Neurosurgery SN Neurosurgery SN066 Decompressive Caniectomy SN066A 98490 108339 118188 128037 137886 142810
stroke/cerebral venous thrombosis
a)Clinical notes and USG a)Histopathology. Referral
Abdomen . b) Detailed Operative notes.
b) Pelvis. c)per op pic of specimen
Obstetrics & Gynecology, Laparotomy and proceed for Ovarian Laparotomy and proceed for Ovarian Cancers.
1501 43890 47880 51870 55860 57855 c) CT abdomen. removed.
Surgical Oncology sc Surgical Oncology, SO002 Cancers. Omentomy with Bilateral Salpingo- SO002A Omentomy with Bilateral 39900
d)Pelvis establishing d)Detailed Discharge
Pediatric Surgery oophorectomy Salpingo-oophorectomy
indication. Summary.

a) Detailed Clinical notes a) Detailed Indoor Case OPEN

with history, symptoms, Papers
signs, examination b) Detailed Procedure /
findings, indication for operative notes
procedure, planned line of c) Serum Beta hCG level
Laparoscopic tubal surgeries treatment, and advice for (in case of ectopic
Obstetrics & Gynecology, Laparoscopic tubal surgeries admission pregnancy)
1502 Surgical Oncology sc SO003 (for any indication including ectopic SO003A 14595 16054 17514 18973 20433 21162
Surgical Oncology (for any indication including ectopic pregnancy) b) Serum Beta human d) Histopathological
pregnancy)
chorionic gonadotropin Examination
(hCG) titers c) e) Blood transfusion notes
USG abdomen/pelvis (if blood transfusion was
given)
f) Detailed Discharge
Summary
a) Detailed Clinical notes a) Detailed indoor case OPEN
with history, indications, papers
symptoms, signs, b) Detailed
Procedure on Fallopian Tube for examination findings and procedure/operative notes
Obstetrics & Gynecology, Procedure on Fallopian Tube for advice for admission c) Detailed Discharge
1503 Surgical Oncology sc SO004 establishing Tubal SO004A 12180 13398 14616 15834 17052 17661
Surgical Oncology establishing Tubal Patency b) HSG Summary
Patency
(hysterosalpingogram) / d) HSG
Sonosalpingography (hysterosalpingogram) –
c) Planned line of post operative
treatment
a)Clinical notes a)Detailed Operative notes. Referral
establishing indication. b)HPE.
b)USG Abdomen Pelvis. c) Pic of specimen removed-
c) MRI abdomen. Pap Gross and Histopathology.
1504 Obstetrics & Gynecology SO OBG & Gynec SO006 Abdominal Myomectomy SO006A Abdominal Myomectomy 26250 28875 31500 34125 36750 38062 smear. d)Detailed discharge
summary

a)physical examination a)Detailed Operative notes. Referral

findings with indications for b) HPE.
the procedure. USG pelvis c) Intraop stills with date &
1505 13860 15120 16380 17640 18270 b) MRI Pelvis patient ID.
Obstetrics & Gynecology SO OBG & Gynec SO007 Hysteroscopic Myomectomy SO007A Hysteroscopic Myomectomy 12600
d) Detailed discharge
summary

a)Admission Notes a)Detailed Procedure. OPEN

comprising of history. b)Operative Notes together
b) Examination with with indication of surgery.
indications for the c)Intraop. stills with date &
procedure. patient ID.
1506 Obstetrics & Gynecology SO OBG & Gynec SO009 Hysteroscopic polypectomy SO009A Hysteroscopic polypectomy 11025 12127 13230 14332 15435 15986 c) Relavant Investigations d)Pic off
(establishing diagnosis). specimenremoved.HPE.
d)USG showing polyp. e)Progress notes.
f)detailed discharge
summary.

a) Clinical notes clearly a. Indoor case papers Referral

indicating reason(s) for b. Detailed Operative notes
hysterectomy including c. Discharge summary with
medical management tried follow up advise
for at least 4-6 months, of d. Picture(s) of specimen
which at least 2-3 months removed (Gross)
(i.e. 2-3 cycles) should be e. Histopathology report of
of hormone therapy and it the specimen removed
failed, or it was not
indicated, with reason
thereof b)
Lab investigations
(Complete Blood count,
1507 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010A Abdominal Hysterectomy 21000 23100 25200 27300 29400 30450 Blood sugar- fasting and
post prandial, Renal
function test, liver function
test, Urine- routine and
microscopy)
c)Electrocardiogram
d) X-ray chest
e)Ultrasonography (USG)
Abdomen + Pelvis
f )Pap smear & Cervical
biopsy (Both these
investigations are essential
only in those hysterectomy
cases which are getting
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes clearly a. Indoor case papers Referral
indicating reason(s) for b. Detailed Operative notes
hysterectomy including c. Discharge summary with
medical management tried follow up advise
for at least 4-6 months, of d. Picture(s) of specimen
which at least 2-3 months removed (Gross)
(i.e. 2-3 cycles) should be e. Histopathology report of
of hormone therapy and it the specimen removed
failed, or it was not f)Intra-operative stills (in
indicated, with reason cases of laparoscopy)
thereof b)
Lab investigations
Abdominal Hysterectomy + Salpingo- (Complete Blood count,
1508 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010B 21000 23100 25200 27300 29400 30450 Blood sugar- fasting and
oophorectomy
post prandial, Renal
function test, liver function
test, Urine- routine and
microscopy)
c)Electrocardiogram
d) X-ray chest
e)Ultrasonography (USG)
Abdomen + Pelvis
f )Pap smear & Cervical
biopsy (Both these
investigations are essential
only in those hysterectomy
cases which are getting
a) Clinical notes clearly a. Indoor case papers Referral
indicating reason(s) for b. Detailed Operative notes
hysterectomy including c. Discharge summary with
medical management tried follow up advise
for at least 4-6 months, of d. Picture(s) of specimen
which at least 2-3 months removed (Gross)
(i.e. 2-3 cycles) should be e. Histopathology report of
of hormone therapy and it the specimen removed
failed, or it was not
indicated, with reason
thereof b)
Lab investigations
(Complete Blood count,
1509 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010C Non descent vaginal hysterectomy 21000 23100 25200 27300 29400 30450 Blood sugar- fasting and
post prandial, Renal
function test, liver function
test, Urine- routine and
microscopy)
c)Electrocardiogram
d) X-ray chest
e)Ultrasonography (USG)
Abdomen + Pelvis
f )Pap smear & Cervical
biopsy (Both these
investigations are essential
only in those hysterectomy
cases which are getting
a) Clinical notes clearly a. Indoor case papers Referral
indicating reason(s) for b. Detailed Operative notes
hysterectomy including c. Discharge summary with
medical management tried follow up advise
for at least 4-6 months, of d. Picture(s) of specimen
which at least 2-3 months removed (Gross)
(i.e. 2-3 cycles) should be e. Histopathology report of
of hormone therapy and it the specimen removed
failed, or it was not
indicated, with reason
thereof b)
Lab investigations
Vaginal hysterectomy with anterior and posterior (Complete Blood count,
1510 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010D 21000 23100 25200 27300 29400 30450 Blood sugar- fasting and
colpoperineorrhaphy
post prandial, Renal
function test, liver function
test, Urine- routine and
microscopy)
c)Electrocardiogram
d) X-ray chest
e)Ultrasonography (USG)
Abdomen + Pelvis
f )Pap smear & Cervical
biopsy (Both these
investigations are essential
only in those hysterectomy
cases which are getting
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes clearly a. Indoor case papers Referral
indicating reason(s) for b. Detailed Operative notes
hysterectomy including c. Discharge summary with
medical management tried follow up advise
for at least 4-6 months, of d. Picture(s) of specimen
which at least 2-3 months removed (Gross)
(i.e. 2-3 cycles) should be e. Histopathology report of
of hormone therapy and it the specimen removed
failed, or it was not
indicated, with reason
thereof b)
Lab investigations
(Complete Blood count,
1511 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010E Laparoscopic hysterectomy (TLH) 21000 23100 25200 27300 29400 30450 Blood sugar- fasting and
post prandial, Renal
function test, liver function
test, Urine- routine and
microscopy)
c)Electrocardiogram
d) X-ray chest
e)Ultrasonography (USG)
Abdomen + Pelvis
f )Pap smear & Cervical
biopsy (Both these
investigations are essential
only in those hysterectomy
cases which are getting
a) Clinical notes clearly a. Indoor case papers Referral
indicating reason(s) for b. Detailed Operative notes
hysterectomy including c. Discharge summary with
medical management tried follow up advise
for at least 4-6 months, of d. Picture(s) of specimen
which at least 2-3 months removed (Gross)
(i.e. 2-3 cycles) should be e. Histopathology report of
of hormone therapy and it the specimen removed
failed, or it was not
indicated, with reason
thereof b)
Lab investigations
Laparoscopically assisted vaginal hysterectomy (Complete Blood count,
1512 Obstetrics & Gynecology SO OBG & Gynec SO010 Hysterectomy SO010F 21000 23100 25200 27300 29400 30450 Blood sugar- fasting and
(LAVH)
post prandial, Renal
function test, liver function
test, Urine- routine and
microscopy)
c)Electrocardiogram
d) X-ray chest
e)Ultrasonography (USG)
Abdomen + Pelvis
f )Pap smear & Cervical
biopsy (Both these
investigations are essential
only in those hysterectomy
cases which are getting
a. Clinical notes clearly a. Detailed Operative notes OPEN
indicating reason(s) for b. Discharge summary with
being a life-saving follow up advise
procedure and performing c. Delivery note (including
caesarean hysterectomy birth outcomes)
b. Lab investigations d. Pictures of specimen
(Complete Blood count, removed (Gross)
Blood sugar- fasting and e. Histopathology report of
1513 Obstetrics & Gynecology SO OBG & Gynec SO011 Caesarean hysterectomy SO011A Caesarean hysterectomy 21000 23100 25200 27300 29400 30450 post prandial, Renal the specimen removed
function test, liver function
test, Urine- routine and
microscopy)
c. Ultrasonography (USG)
Abdomen (Pregnancy USG
report / scan)

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Investigation reports (If
examination findings required)
confirming diagnosis and c) Detailed
1514 Obstetrics & Gynecology SO OBG & Gynec SO012 Manchester Repair SO012A Manchester Repair 21000 23100 25200 27300 29400 30450 advice for admission procedure/operative notes
b) Planned line of d) Detailed Discharge
treatment Summary
e) Blood transfusion notes
(if blood transfusion was
given)

a) Detailed Clinical notes a) Detailed Indoor Case Referral

with history, indications, Papers
symptoms, signs, b) Investigation reports (if
1515 Obstetrics & Gynecology SO OBG & Gynec SO013 Sling Surgeries for Prolapse SO013A Surgeries for Prolapse - Sling Surgeries 32865 36151 39438 42724 46011 47654 examination findings and done)
advice for admission c) Detailed
b) USG Abdomen/pelvis procedure/operative notes
 Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed Clinical notes a) Detailed indoor case OPEN
with history, symptoms, papers
signs, examination findings b) Documentation of
and advice for admission indication of surgery
b) History and clinical c) Detailed
presentation confirming the operative/procedure notes
1516 Obstetrics & Gynecology SO OBG & Gynec SO014 Hysterotomy SO014A Hysterotomy 6720 7392 8064 8736 9408 9744 diagnosis d) Histopathological
c) Planned line of Examination
treatment e) Blood transfusion notes
(if blood transfusion was
given)
f) Detailed Discharge
Summary

a) Detailed clinical notes a) Detailed Indoor Case Referral

with history, symptoms, Papers
signs, examination b) Investigation reports (if
findings, indication for required)
Lap. Surgery for Endometriosis Lap. Surgery for Endometriosis procedure, planned line of c) Detailed Procedure /
1517 Obstetrics & Gynecology SO OBG & Gynec SO015 SO015A 18270 20097 21924 23751 25578 26491
(Other than Hysterectomy) (Other than Hysterectomy) treatment, advice for operative notes
admission d) Histopathology
b) USG Abdomen/pelvis examination report
e) Detailed discharge
summary
a) Detailed clinical notes a) Detailed Indoor Case OPEN
with history, symptoms, Papers
signs, examination b) Diagnostic hysteroscopy
findings, indications, and c) Histopathology report
advice for admission d) Photograph of removed
1518 Obstetrics & Gynecology SO OBG & Gynec SO016 Diagnostic hysteroscopy SO016A With biopsy 8400 9240 10080 10920 11760 12180 b) Hemoglobin, Complete IUCD
blood count e) Detailed operative/
c) Urine complete procedure notes
examination (CUE) f) Detailed Discharge
d) USG abdomen/pelvis Summary

a) Detailed clinical notes a) Detailed Indoor Case OPEN

with history, symptoms, Papers
signs, examination b) Diagnostic hysteroscopy
findings, indications, and c) Detailed operative/
1519 Obstetrics & Gynecology SO OBG & Gynec SO016 Diagnostic hysteroscopy SO016B Without biopsy 8400 9240 10080 10920 11760 12180 advice for admission procedure notes
b) Hemoglobin, Complete d) Detailed Discharge
blood count Summary
c) Urine complete
examination (CUE)
d) USG abdomen/pelvis
a) Detailed clinical notes a) Detailed Indoor Case OPEN
with history, symptoms, Papers
signs, examination b) Photograph of removed
findings, indications, and IUCD
1520 Obstetrics & Gynecology SO OBG & Gynec SO017 Hysteroscopic IUCD removal SO017A Hysteroscopic IUCD removal 5250 5775 6300 6825 7350 7612 advice for admission c) Detailed operative/
b) Hemoglobin, Complete procedure notes
blood count d) Detailed Discharge
c) Urine complete Summary
examination (CUE)
d) USG abdomen/pelvis
a) Admission Notes a) Detailed Procedure. Reserved
comprising of history. b) Operative Notes.
b) examination with c) Intraop. Stills.
indications for the d) Histopathology of
procedure,Relavant curetted material.
1521 Obstetrics & Gynecology SO OBG & Gynec SO018 D&C (Dilatation&curretage) SO018A D&C (Dilatation&curretage) 5250 5775 6300 6825 7350 7612 Investigations (establishing e) Progress notes.
diagnosis). f) Detailed discharge
c) (USG Abdomen + summary.
Pelvis)- optional.

a) Detailed clinical notes a) Detailed Indoor Case Reserved

with history, symptoms, Papers
signs, examination b) Detailed operative/
findings, indications, and procedure notes
advice for admission c) Investigation reports (if
b) Ultrasound report for required)
1522 Obstetrics & Gynecology SO OBG & Gynec SO019 Dilation and Evacuation (D&E) SO019A Dilation and Evacuation (D&E) 5250 5775 6300 6825 7350 7612 establishing the diagnosis d) however in certain
c) Rh ABO blood grouping conditions such as molar
d) Complete blood count pregnancy or any other
e) Serum HCG levels (for suspected pathology it
hydatidiform mole) should be available
e) Detailed Discharge
Summary
a) Detailed clinical notes a) Detailed indoor case OPEN
with history, symptoms, papers
signs, examination b) Detailed operative/
findings, indication for procedure notes
procedure, planned line of c) Culture & sensitivity
treatment, and advice for report of the drained pus/
1523 Obstetrics & Gynecology SO OBG & Gynec SO020 Pyometra drainage SO020A Pyometra drainage 5250 5775 6300 6825 7350 7612 admission fluid
b) Ultrasound d) Histopathological
Abdomen/pelvis examination
c) Urine routine, e) Detailed discharge
microscopic examination summary
d) Complete Blood Count
 Outside State
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y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed clinical notes a) Detailed Indoor Case OPEN
with history, symptoms, Papers
signs, examination b) Detailed Procedure /
findings, indication for operative notes
procedure, planned line for c) Fetal blood
treatment and advice for sampling/cordocentesis
admission d) Blood transfusion notes
b) Ultrasound report for (if required)
1524 Obstetrics & Gynecology SO OBG & Gynec SO021 Intrauterine transfusions SO021A Intrauterine transfusions 10500 11550 12600 13650 14700 15225 foetal signs of haemolytic e) Detailed Discharge
disease & gestation age Summary
c) Complete blood count
(CBC)
d) ABO Rh of both partners
e) Indirect Coomb`s test
and titre
f) Color Doppler study of
MCA-PSV

a) Detailed Clinical notes a) Detailed indoor case OPEN

with history, indications, papers
symptoms, signs, b) Investigation reports (If
examination findings and done)
1525 Obstetrics & Gynecology SO OBG & Gynec SO022 Hysteroscopic adhesiolysis SO022A Hysteroscopic adhesiolysis 8400 9240 10080 10920 11760 12180 advice for admission c) Detailed
b) USG Pelvis/Abdomen operative/procedure notes
c) Planned line of d) Detailed Discharge
treatment Summary

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Investigation reports (if
examination findings and done)
advice for admission c) Detailed operative notes
1526 Obstetrics & Gynecology SO OBG & Gynec SO023 Laparoscopic adhesiolysis SO023A Laparoscopic adhesiolysis 10290 11319 12348 13377 14406 14920 b) USG Pelvis d) Detailed Discharge
Summary
e) Blood transfusion notes
(if blood transfusion was
given)

a) Detailed Clinical notes a) Detailed Indoor Case Referral

with history, indications, Papers
symptoms, signs, b) Investigation reports (if
evaluation findings, required)
1527 Obstetrics & Gynecology SO OBG & Gynec SO024 Trans - vaginal tape / Trans-obturator tape SO024A Trans-vaginal tape 8400 9240 10080 10920 11760 12180 planned line of c) Detailed
management, and advice procedure/operative notes
for admission d) Detailed Discharge
b) Clinical diagnosis Summary

a) Detailed Clinical notes a) Detailed Indoor Case Referral

with history, indications, Papers
symptoms, signs, b) Investigation reports (if
evaluation findings, required)
1528 Obstetrics & Gynecology SO OBG & Gynec SO024 Trans - vaginal tape / Trans-obturator tape SO024B Trans-obturator tape 8400 9240 10080 10920 11760 12180 planned line of c) Detailed
management, and advice procedure/operative notes
for admission d) Detailed Discharge
b) Clinical diagnosis Summary

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Investigation reports (if
examination findings and required)
1529 Obstetrics & Gynecology SO OBG & Gynec SO025 Sacrocolpopexy (Abdominal) SO025A Open 23900 26290 28680 31070 33460 34655 advice for admission c) Detailed
b) Pelvic/Abdominal USG procedure/operative notes
c) Planned line of d) Detailed Discharge
treatment Summary

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Investigation reports (if
examination findings and required)
1530 Obstetrics & Gynecology SO OBG & Gynec SO025 Sacrocolpopexy (Abdominal) SO025B Lap. 23900 26290 28680 31070 33460 34655 advice for admission c) Detailed
b) Pelvic/Abdominal USG procedure/operative notes
c) Planned line of d) Detailed Discharge
treatment Summary

a) Admission Notes a) Detailed Procedure. OPEN

comprising of history. b) Operative Notes.
b) examination with c) Intraop. stills with date &
indications for the patient ID.
procedure. d) HPE of specimen.
c) Relavant Investigations e) Progress notes.
LLETZ (including PAP smear and (establishing diagnosis). f) Detailed discharge
1531 Obstetrics & Gynecology SO OBG & Gynec SO026 SO026A LLETZ (including PAP smear and colposcopy) 9900 10890 11880 12870 13860 14355 d) Evidence of cervical pre- summary.
colposcopy)
cancer (PAP smear)
Colposcopiy.
e) Cervical Biopsy is
optional.

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Investigation reports (if
examination findings and required)
1532 Obstetrics & Gynecology SO OBG & Gynec SO027 Vaginal Sacrospinus fixation with repair SO027A Vaginal Sacrospinus fixation with repair 17745 19519 21294 23068 24843 25730 advice for admission c) Detailed
b) Pelvic/Abdominal USG procedure/operative notes
c) Planned line of d) Detailed Discharge
treatment Summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed Clinical notes a) Detailed indoor case Referral
with history, indications, papers
symptoms, signs, b) Investigation reports (if
examination findings and done)
1533 Obstetrics & Gynecology SO OBG & Gynec SO028 Excision of Vaginal Septum (vaginal route) SO028A Excision of Vaginal Septum (vaginal route) 25935 28528 31122 33715 36309 37605 advice for admission c) Detailed
b) Clinical Examination procedure/operative notes
c) Pelvic/Abdominal USG / d) Detailed Discharge
MRI Summary
d) Planned line of
treatment
a) Detailed Clinical notes a) Detailed indoor case Reserved
with history, indications, papers
symptoms, signs, b) Investigation reports
1534 3927 4284 4641 4998 5176 examination findings and c) Detailed
Obstetrics & Gynecology SO OBG & Gynec SO029 Hymenectomy for imperforate hymen SO029A Hymenectomy for imperforate hymen 3570
advice for admission procedure/operative notes
b) USG pelvis d) Detailed Discharge
Summary

a) Detailed Clinical notes a) Detailed indoor case OPEN

with history, indications, papers
symptoms, signs, b) Detailed
examination findings and operative/procedure notes
1535 Obstetrics & Gynecology SO OBG & Gynec SO030 Anterior & Posterior Colpoperineorrhapy SO030A Anterior & Posterior Colpoperineorrhapy 11865 13051 14238 15424 16611 17204 advice for admission c) Detailed Discharge
b) USG abdomen/pelvis Summary
c) Pap smear d) Blood transfusion notes
d) Planned line of (if blood transfusion was
treatment given)

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Investigation reports (if
examination findings and done)
1536 Obstetrics & Gynecology SO OBG & Gynec SO031 Vaginoplasty (McIndoe procedure) SO031A Vaginoplasty (McIndoe procedure) 21000 23100 25200 27300 29400 30450 advice for admission c) Detailed
b) Pelvic/Abdominal USG procedure/operative notes
d) Detailed Discharge
Summary

a) Detailed Clinical notes a) Detailed indoor case Referral YES

with history, indications, papers
symptoms, signs, b) Investigation reports (If
examination findings and required)
Vaginal repair for vesico-vaginal fistula advice for admission c) Detailed
1537 Obstetrics & Gynecology SO OBG & Gynec SO032 SO032A Vaginal repair for vesico-vaginal fistula (Open) 42000 46200 50400 54600 58800 60900 b)Cystoscopy/Cystourethro procedure/operative notes
(Repair for VVF)
scopy d) Detailed Discharge
c) Complete Urine Summary
Examination (CUE)
d) Planned line of
treatment
a) Admission Notes a) Detailed Procedure. Referral
comprising of history. b) Operative Notes.
b) examination with c) Intraop. stills with date &
indications for the patient ID.
1538 Obstetrics & Gynecology SO OBG & Gynec SO033 Rectovaginal fistula repair SO033A Rectovaginal fistula repair 26250 28875 31500 34125 36750 38062 procedure. d) Progress notes.
c) Relavant Investigations e) detailed discharge
(establishing diagnosis) . summary.

a) Detailed Clinical notes a) Detailed indoor case OPEN

with history, indications, papers
symptoms, signs, b) Investigation reports
examination findings and c) Detailed operative notes
1539 Obstetrics & Gynecology SO OBG & Gynec SO034 Vulval Hematoma drainage SO034A Vulval Hematoma drainage 3570 3927 4284 4641 4998 5176 advice for admission d) Detailed Discharge
b) Delivery notes (whether Summary
haematoma is formed after e) Blood transfusion notes
delivery), if available/ (if blood transfusion was
reason for non-availability given)

a) Admission Notes a) Detailed Procedure. Referral

comprising of history. b) Operative Notes.
b) examination with c) Intra procedure clinical
indications for the photograph.
procedure. d) Stills.
c) Relavant Investigations e) Histopathology.
1540 Obstetrics & Gynecology SO OBG & Gynec SO035 Vulvectomy simple SO035A Vulvectomy simple 21000 23100 25200 27300 29400 30450 (establishing diagnosis) f) progress notes.
with Evidence (biopsy). g) Detailed discharge
Clinical pic if patient summary.
permits

a) Admission Notes a) Detailed Procedure. OPEN YES

comprising of history. b) Operative Notes together
b) examination with with indication of surgery.
indications for the c) Intraop. stills with date &
procedure. patient ID.
c) Relavant Investigations d) pic off gross specimen
Radical Vulvectomy with Inguinal and Radical Vulvectomy with Inguinal and Pelvic (establishing diagnosis). removed.
1541 Obstetrics & Gynecology SO OBG & Gynec SO036 SO036A 52500 57750 63000 68250 73500 76125
Pelvic lymph node disection lymph node disection d) vulval biopsy. e) HPE.
e) CT/MRI for staging. f) Progress notes.
g) detailed discharge
summary.
 Outside State
Outside State NABH Entry Outside State
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SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed Clinical notes a) Detailed indoor case OPEN
with history, indications, papers
symptoms, signs, b) Investigation reports (If
examination findings and done)
Abdomino Perineal repair for Mullerian advice for admission c) Detailed
1542 Obstetrics & Gynecology SO OBG & Gynec SO037 SO037A Abdomino Perineal repair for Mullerian Anomaly 36435 40078 43722 47365 51009 52830
Anomaly b) USG Transvaginal/Trans procedure/operative notes
abdominal (TVS/TAS) d) Detailed Discharge
c) Planned line of Summary
treatment

a) Detailed clinical notes a) Detailed Indoor Case OPEN

including history Papers
symptoms, signs, b) Investigation reports (If
examination findings, required)
1543 Obstetrics & Gynecology SO OBG & Gynec SO038 Colpotomy SO038A Colpotomy 5145 5659 6174 6688 7203 7460 planned line of treatment, c) Detailed operative/
and admission advice procedure notes
b) Complete blood count d) Detailed Discharge
(CBC) Summary
c) USG abdomen/pelvis
a) Admission Notes a) Detailed Procedure. OPEN
comprising of history. b) Operative Notes together
b) Examination. with indication of surgery.
c) Relavant Investigations c) Intraop. stills with date &
(establishing diagnosis). patient ID.
d) pic off gross specimen
1544 Obstetrics & Gynecology SO OBG & Gynec SO039 Diagnostic laparoscopy SO039A Diagnostic laparoscopy 12600 13860 15120 16380 17640 18270 removed .
e) HPE.
f) Progress notes.
g) detailed discharge
summary.

a) Detailed Clinical notes a) Detailed indoor case OPEN

with history, symptoms, papers
signs, examination b) Serum Beta Hcg level
findings, planned line of follow-up for medical
1545 Obstetrics & Gynecology SO OBG & Gynec SO040 Laparotomy for ectopic/ benign disorders SO040A Open 21000 23100 25200 27300 29400 30450 treatment, and advice for management
admission c) Blood transfusion notes
b) Serum Beta human (if blood transfusion was
chorionic gonadotropin given)
(hCG) titers d) Detailed Discharge
c) USG abdomen/pelvis Summary
a) Detailed Clinical notes a) Detailed indoor case Referral
with history, indications, papers
symptoms, signs, b) Investigation reports (if
examination findings and done)
advice for admission c) Detailed
b) Hemogram with procedure/operative notes
Erythrocyte sedimentation d) Detailed Discharge
1546 Obstetrics & Gynecology SO OBG & Gynec SO040 Laparotomy for ectopic/ benign disorders SO040B PID 21000 23100 25200 27300 29400 30450 rate, liver function test, Summary
renal function test, serum e) Blood transfusion notes
electrolytes, blood culture (if blood transfusion was
c) USG abdomen and given)
pelvis (if adnexal mass)
d) Planned line of
treatment

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Investigation reports if
examination findings and done
advice for admission c) Detailed
1547 Obstetrics & Gynecology SO OBG & Gynec SO041 Cystectomy SO041A Lap 21000 23100 25200 27300 29400 30450 b) USG Abdomen/pelvis procedure/operative notes
c) CA 125 Tumor marker d) Histopathological
d) Planned line of Examination
treatment e) Detailed Discharge
Summary

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, b) Detailed
examination findings and operative/procedure notes
1548 Obstetrics & Gynecology SO OBG & Gynec SO042 Cystocele - Anterior repair SO042A Cystocele - Anterior repair 8400 9240 10080 10920 11760 12180 advice for admission c) Detailed Discharge
b) USG abdomen/pelvis Summary
c) Pap smear d) Blood transfusion notes
d) Planned line of (if blood transfusion was
treatment given)

a) Detailed Clinical notes a) Detailed Indoor Case OPEN

with history, indications, Papers
symptoms, signs, b) Investigation reports (if
evaluation findings, required)
1549 Obstetrics & Gynecology SO OBG & Gynec SO043 Burch SO043A Abdominal 30000 33000 36000 39000 42000 43500 planned line of c) Detailed
management, and advice procedure/operative notes
for admission d) Detailed Discharge
b) Clinical diagnosis Summary

a) Detailed Clinical notes a) Detailed Indoor Case OPEN

with history, indications, Papers
symptoms, signs, b) Investigation reports (if
evaluation findings, required)
1550 Obstetrics & Gynecology SO OBG & Gynec SO043 Burch SO043B Laparoscopic 30000 33000 36000 39000 42000 43500 planned line of c) Detailed
management, and advice procedure/operative notes
for admission d) Detailed Discharge
b) Clinical diagnosis Summary
 Outside State
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Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed clinical notes a) Detailed clinical notes OPEN
with history, symptoms, b) Investigation reports
signs, examination c) Detailed operative/
findings, indications, and procedure notes
advice for admission d) Post procedure
1551 Obstetrics & Gynecology SO OBG & Gynec SO044 Electro Cauterisation / Cryo Surgery SO044A Electro Cauterisation / Cryo Surgery 5985 6583 7182 7780 8379 8678 b) Patient is in post- instructions
menstrual phase
c) Pap smear – mandatory
or Colposcopy (optional)
findings, if available

a) Detailed Clinical notes a) Detailed indoor case Referral

with history, indications, papers
symptoms, signs, Yes
examination findings and b) Detailed
advice for admission procedure/operative notes
EUA for (minor girls / unmarried sexually EUA for (minor girls / unmarried sexually b) Vaginal examination c) Medicolegal case
1552 Obstetrics & Gynecology SO OBG & Gynec SO045 SO045A 2835 3118 3402 3685 3969 4110
inactive / victims of sexual abuse) inactive / victims of sexual abuse) c) Vaginal swab (in cases documentation (in cases of
of sexual assault) sexual assault)
d) Informed consent from d) Detailed Discharge
parents/adult patient Summary
e) Planned line of
treatment
a) Detailed clinical notes a) Detailed Indoor Case OPEN
with history, symptoms, Papers
signs, examination b) Investigation reports (if
findings, planned line for done)
management, and advice c) Detailed
for admission operative/procedure notes,
b) Blood pressure (if applicable)
1553 Obstetrics & Gynecology SO OBG & Gynec SO046 Hospitalisation for Antenatal Complications SO046A Hospitalisation for Antenatal Complications 2200 2420 2640 2860 3080 3190 documentation d) Blood transfusion notes,
c) Complete Blood Count if given
d) Urine routine and e) Detailed Discharge
microscopic examination Summary
e) Blood glucose
f) USG Abdomen/pelvis
g) Oral Glucose Tolerance
Test (OGTT)

a) Detailed clinical notes a) Detailed Indoor Case OPEN

with history, indications, Papers (ICPs) with details
symptoms, signs, of indication
examination findings and b) Detailed procedure notes
advice for admission c) Claim processing
b) Report of biochemical submission with amniotic
1554 Obstetrics & Gynecology SO OBG & Gynec SO047 Amniocentesis SO047A Amniocentesis 14500 15950 17400 18850 20300 21025 tests fluid report (usually within 2
c) Nuchal translucency weeks)
(NT) and/or Early TIFFA d) Detailed Discharge
(Targeted imaging for fetal Summary
anomalies) scan reports
d) Planned line of
treatment

a) Detailed Clinical notes a) Detailed indoor case OPEN

with history, indications, papers
symptoms, signs, b) Detailed
examination findings and procedure/operative notes
advice for admission c) Nuchal translucency (NT)
1555 Obstetrics & Gynecology SO OBG & Gynec SO048 Chorionic villus sampling SO048A Chorionic villus sampling 14500 15950 17400 18850 20300 21025 b) Planned line of and Early TIFFA (Targeted
treatment imaging for fetal anomalies)
scan reports
d) Detailed Discharge
Summary

a) Detailed Clinical notes a) Detailed indoor case OPEN

with history, indications, papers
symptoms, signs, b) Detailed
examination findings and procedure/operative notes
advice for admission c) Nuchal translucency (NT)
1556 Obstetrics & Gynecology SO OBG & Gynec SO049 Cordocentesis SO049A Cordocentesis 14500 15950 17400 18850 20300 21025 b) Planned line of and Early TIFFA (Targeted
treatment imaging for fetal anomalies)
scan reports
d) Detailed Discharge
Summary

a) Detailed clinical notes a) Indoor case papers OPEN

with history, symptoms, b) Investigation reports
signs, indications & including detailed USG
examination findings scan c) Detailed
b) Investigations such as procedural / operative notes
1557 Obstetrics & Gynecology SO OBG & Gynec SO050 McDonald's stitch SO050A McDonald's stitch 8400 9240 10080 10920 11760 12180 USG report (if available) d) Detailed discharge
c) Antenatal record of summary, including advice
current pregnancy, if on getting the cerclage
available removal at 37th week

a) Detailed clinical notes a) Indoor case papers OPEN

with history, symptoms, b) Investigation reports
signs, indications & including detailed USG
examination findings scan c) Detailed
b) Investigations such as procedural / operative notes
1558 Obstetrics & Gynecology SO OBG & Gynec SO051 Shirodkar's stitch SO051A Shirodkar's stitch 4725 5197 5670 6142 6615 6851 USG report (if available) d) Detailed discharge
c) Antenatal record of summary, including advice
current pregnancy, if on getting the cerclage
available removal at 37th week
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed Clinical notes a) Detailed indoor case Reserved
with history, symptoms, papers
signs, examination b) Detailed
findings, planned line of operative/procedure notes
treatment, and advice for c) Histopathological
admission Examination
1559 Obstetrics & Gynecology SO OBG & Gynec SO052 Medical management of ectopic pregnancy SO052A Medical management of ectopic pregnancy 2200 2420 2640 2860 3080 3190 b) Indication of procedure d) Blood transfusion notes
documentation (if blood transfusion was
c) Serum Beta human given)
chorionic gonadotropin e) Detailed Discharge
(hCG) titers Summary
d) USG abdomen/pelvis

a) Detailed Admission a) Detailed Operative notes: Reserved

notes with History & • Method used for
indication termination
b) Findings of clinical • Medications/anaesthesia
examination used
c) How was pregnancy • Outcomes of the
confirmed? UPT/ Clinical procedure
examination/ USG b) Detailed Discharge
d) Reports of mandatory Summary:
investigations: • Prescription of drugs
o Hemoglobin, Packed cell • Warning signs and
volume (PCV) symptoms
o Urine routine • Contraceptive use
1560 Obstetrics & Gynecology SO OBG & Gynec SO053 Medical Termination of Pregnancy SO053A MTP upto 8 weeks 5250 5775 6300 6825 7350 7612 examination • Follow up visit date
o ABO Rh (MTP >8 weeks) c) Completed entry in
o USG (if available), MTP/Admission Register
mandatory for pregnancy
>8 weeks-12 weeks & >12
weeks to 20 weeks e) MTP
form
f) Detailed operative note
g) Age proof
h) Completed Consent
form
i) Completed RMP Opinion
Form

a) Detailed Admission a) Detailed Operative notes: Reserved

notes with History & • Method used for
indication termination
b) Findings of clinical • Medications/anaesthesia
examination used
c) How was pregnancy • Outcomes of the
confirmed? UPT/ Clinical procedure
examination/ USG b) Detailed Discharge
d) Reports of mandatory Summary:
investigations: • Prescription of drugs
o Hemoglobin, Packed cell • Warning signs and
volume (PCV) symptoms
o Urine routine • Contraceptive use
1561 Obstetrics & Gynecology SO OBG & Gynec SO053 Medical Termination of Pregnancy SO053B MTP 8 to 12 weeks 7350 8085 8820 9555 10290 10657 examination • Follow up visit date
o ABO Rh (MTP >8 weeks) c) Completed entry in
o USG (if available), MTP/Admission Register
mandatory for pregnancy
>8 weeks-12 weeks & >12
weeks to 20 weeks e) MTP
form
f) Detailed operative note
g) Age proof
h) Completed Consent
form
i) Completed RMP Opinion
Form

a) Detailed Admission a) Detailed Operative notes: Reserved

notes with History & • Method used for
indication termination
b) Findings of clinical • Medications/anaesthesia
examination used
c) How was pregnancy • Outcomes of the
confirmed? UPT/ Clinical procedure
examination/ USG b) Detailed Discharge
d) Reports of mandatory Summary:
investigations: • Prescription of drugs
o Hemoglobin, Packed cell • Warning signs and
volume (PCV) symptoms
o Urine routine • Contraceptive use
1562 Obstetrics & Gynecology SO OBG & Gynec SO053 Medical Termination of Pregnancy SO053C MTP > 12 weeks 7350 8085 8820 9555 10290 10657 examination • Follow up visit date
o ABO Rh (MTP >8 weeks) c) Completed entry in
o USG (if available), MTP/Admission Register
mandatory for pregnancy
>8 weeks-12 weeks & >12
weeks to 20 weeks e) MTP
form
f) Detailed operative note
g) Age proof
h) Completed Consent
form
i) Completed RMP Opinion
Form
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Admission Notes a) Detailed delivery notes. OPEN
comprising of history. b) PNC notes along with
b) detailed Ante natal care relevant investigation
records. details.
c) reasons for non- c) status of the child at the
Mothers with eclampsia / imminent eclampsia / availability of ANC records. time of delivery and at the
1563 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054B 15750 17325 18900 20475 22050 22837 Obstetric USG. All high time of discharge.
severe pre-eclampsia
risk deliveries are to be d) progress notes.
clubbed & case specific e) Detailed discharge
documents required. summary.

a) Admission Notes a) Detailed delivery notes. OPEN

comprising of history. b) PNC notes along with
b) detailed Ante natal care relevant investigation
records. details.
c) reasons for non- c) status of the child at the
Major Fetal malformation requiring intervention availability of ANC records. time of delivery and at the
1564 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054C 15750 17325 18900 20475 22050 22837 Obstetric USG. All high time of discharge.
immediately after birth
risk deliveries are to be d) progress notes.
clubbed & case specific e) Detailed discharge
documents required. summary.

a) Admission Notes a) Detailed delivery notes. OPEN

comprising of history. b) PNC notes along with
b) detailed Ante natal care relevant investigation
records. details.
c) reasons for non- c) status of the child at the
availability of ANC records. time of delivery and at the
1565 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054D Mothers with severe anaemia (<7 g/dL) 11500 12650 13800 14950 16100 16675 Obstetric USG. All high time of discharge.
risk deliveries are to be d) progress notes.
clubbed & case specific e) Detailed discharge
documents required. summary.

a) Admission Notes a) Detailed delivery notes. OPEN

comprising of history. b) PNC notes along with
b) detailed Ante natal care relevant investigation
records with special details.
reference to investigations c) status of the child at the
supporting the diagnosis. time of delivery and at the
Other maternal and fetal conditions as per c) reasons for non- time of discharge.
guidelines-eg previous caesarean section, availability of ANC records. d) progress notes.
1566 Obstetrics & Gynecology SO OBG & Gynec SO054 High risk delivery SO054E 11500 12650 13800 14950 16100 16675
diabetes, severe growth retardation, etc that Obstetric USG. All high e) Detailed discharge
qualify for high risk delivery. risk deliveries are to be summary.
clubbed & case specific
documents required.

a) Detailed clinical notes Detailed indoor case papers OPEN

including Delivery notes (if Yes
available) with history, a) Investigation reports (last
symptoms, signs, Pre-delivery reports incl.
examination findings, Haemoglobin, Urine
indications and advice for albumin, sugar, ABO-Rh &
admission post-delivery:
Haemoglobin)
b) Detailed operative /
procedure notes
1567 Obstetrics & Gynecology SO OBG & Gynec SO055 Manual removal of placenta SO055A Manual removal of placenta 8925 9817 10710 11602 12495 12941 c) Documentation of
General anaesthesia
(preferable) or Intravenous
sedation
d) Detailed discharge
summary including follow
up advice
e) Blood transfusion notes
(if blood transfusion was
given)
a) Detailed clinical notes a) Detailed Indoor Case OPEN
with history, symptoms, Papers
signs, examination b) Local swab for culture &
findings, indications, sensitivity Report
planned line of treatment c) Detailed
1568 Obstetrics & Gynecology SO OBG & Gynec SO056 Secondary suturing of episiotomy SO056A Secondary suturing of episiotomy 3150 3465 3780 4095 4410 4567 and advice for admission operative/procedure notes
b) Delivery notes, if d) Detailed Discharge
available Summary including care of
c) Complete blood count the episiotomy site
(CBC); Urine albumin,
sugar, microscopic
examination
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Admission Notes a) Detailed Procedure. OPEN
comprising of history. b) Operative Notes.
b) examination with c) status of the child at the
detailed Ante natal care time of delivery and at the
records. time of discharge.
c) reasons for non- d) progress notes.
availability of ANC records. e) Detailed discharge
1569 Obstetrics & Gynecology SO OBG & Gynec SO057 Caesarean Delivery SO057A Caesarean Delivery 15000 16500 18000 19500 21000 21750 Indications for the summary.
procedure. USG Obstetrics
with Doppler is case
specific & optional. Labor
charting, CTG if available.

a) Detailed clinical notes a) Detailed Indoor Case OPEN

with history, symptoms, Papers
signs, examination b) Detailed operative/
findings, indication for procedure notes
procedure and advice for c) Investigation report (if
admission required)
b) Complete blood count d) Histopathological
(CBC), Complete urine examination report
examination (CUE) e) Detailed Discharge
c) Planned line of Summary
Vulvo vaginal / bartholin cyst/ abscess Vulvo vaginal/ bartholin cyst/ abscess treatment d)Optional
1570 Obstetrics & Gynecology SO OBG & Gynec SO059 SO059A 7350 8085 8820 9555 10290 10657
enucleation / drainage enucleation • If cyst was aspirated
earlier, fluid for:
➢ culture & sensitivity,
➢ Gram staining
• MRI (in case of huge cyst
to assess the extent)
• Blood glucose
• USG of the affected part
• C-reactive protein (CRP)

a) Detailed clinical notes a) Detailed Indoor Case OPEN

with history, symptoms, Papers
signs, examination b) Detailed operative/
findings, indication for procedure notes
procedure and advice for c) Investigation report (if
admission required)
b) Complete blood count d) Culture & sensitivity
(CBC), Complete urine report of aspirated fluid
examination (CUE) e) Detailed Discharge
c) Planned line of Summary
Vulvo vaginal / bartholin cyst/ abscess treatment d)Optional
1571 Obstetrics & Gynecology SO OBG & Gynec SO059 SO059B Vulvo vaginal/ bartholin cyst/ abscess drainage 7350 8085 8820 9555 10290 10657
enucleation / drainage • If cyst was aspirated
earlier, fluid for:
➢ culture & sensitivity,
➢ Gram staining
• MRI (in case of huge cyst
to assess the extent)
• Blood glucose
• USG of the affected part
• C-reactive protein (CRP)

Staging laparotomy for ovarian cancer Hysterrectomy + salpingo opherectomy + 0 0 OPEN YES
1572 Obstetrics & Gynecology SO OBG & Gynec SO060 SO060A 52500 57750 63000 68250 73500 76125
(simple) omentectomy + BPLND- Open
1573 Obstetrics & Gynecology SO OBG & Gynec SO061 Vaginal Myomectomy SO061A Vaginal Myomectomy 15750 17325 18900 20475 22050 22837 0 0 OPEN
1574 Obstetrics & Gynecology SO OBG & Gynec SO062 Cystectomy SO062A Open 21000 23100 25200 27300 29400 30450 0 0 OPEN
Laparoscopy for Ectopic/ other benign 0 0 OPEN
1575 Obstetrics & Gynecology SO OBG & Gynec SO063 SO063A lap 21000 23100 25200 27300 29400 30450
disorders
1576 Obstetrics & Gynecology SO OBG & Gynec SO064 Sterilisation SO064A Sterilisation- Open 7350 8085 8820 9555 10290 10657 0 0 OPEN
1577 Obstetrics & Gynecology SO OBG & Gynec SO064 Sterilisation SO064B Sterilisation- Lap 10500 11550 12600 13650 14700 15225 0 0 OPEN
Reversal of Sterilisation/ Tuboplasty (lap/ 0 0 OPEN
1578 Obstetrics & Gynecology SO OBG & Gynec SO065 SO065A Reversal of Sterilisation/ Tuboplasty (lap/ open) 26250 28875 31500 34125 36750 38062
open)
Diagnostic Hystero - Laparoscopy with/ Diagnostic Hystero - Laparoscopy with/ without 0 0 OPEN
1579 Obstetrics & Gynecology SO OBG & Gynec SO066 SO066A 15750 17325 18900 20475 22050 22837
without Chromopertubation Chromopertubation
Laparotomy for Broad Ligament Hematoma 0 0 OPEN
1580 Obstetrics & Gynecology SO OBG & Gynec SO067 Laparotomy for Broad Ligament Hematoma SO067A 36750 40425 44100 47775 51450 53287
(with internal iliac ligation)
1581 Obstetrics & Gynecology SO OBG & Gynec SO068 Complete Perineal Tear SO068A Complete Perineal Tear 26250 28875 31500 34125 36750 38062 0 0 OPEN
1582 Obstetrics & Gynecology SO OBG & Gynec SO069 Molar follow up for chemotherapy SO069A Molar follow up for chemotherapy 6300 6930 7560 8190 8820 9135 0 0 OPEN
1583 Obstetrics & Gynecology SO OBG & Gynec SO070 Resuturing of wounds SO070A Resuturing of wounds 5250 5775 6300 6825 7350 7612 0 0 OPEN
1584 Obstetrics & Gynecology SO OBG & Gynec SO071 Post coital / Injury Repair SO071A Post coital / Injury Repair 7350 8085 8820 9555 10290 10657 0 0 OPEN
0 0 OPEN

1585 Obstetrics & Gynecology SO OBG & Gynec SO072 Cone biopsy SO072A Cone biopsy 7350 8085 8820 9555 10290 10657

Biopsy- Cervical, Endometrial EA/ ECC; Biopsy- Cervical, Endometrial EA/ ECC; Vulvar; 0 0 OPEN
1586 Obstetrics & Gynecology SO OBG & Gynec SO073 SO073A 5250 5775 6300 6825 7350 7612
Vulvar; Polypectomy Polypectomy
Operative vaginal delivery (Vacuum/ 0 0 OPEN
1587 Obstetrics & Gynecology SO OBG & Gynec SO075 SO075A Operative vaginal delivery (Vacuum/ forceps) 10500 11550 12600 13650 14700 15225
forceps)
Surgical management of PPH after vaginal Surgical management of PPH after vaginal 0 0 OPEN
1588 Obstetrics & Gynecology SO OBG & Gynec SO076 SO076A 15750 17325 18900 20475 22050 22837
delivery delivery
a)Clinical notes a)Detailed Operative Referral
establishing indication. notes,HPE Pic of specimen.
b)USG Abdomen Pelvis/ Intraop stills with date &
1589 Obstetrics & Gynecology SO Obstetrics & Gynecology SO001 Lap. Salpingo-oophrectomy SO001A Lap. Salpingo-oophrectomy 14000 15400 16800 18200 19600 20300 CT/ MRI abdomen Pelvis. patient ID.
b) Detailed discharge
summary.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a)Clinical notes with a)Detailed discharge Referral
physical examination summary.
1590 SO005A Laparotomy for broad ligament haematoma 16000 17600 19200 20800 22400 23200 findings supported by b) Detailed Operative notes.
Obstetrics & Gynecology SO Obstetrics & Gynecology SO005 Laparotomy for broad ligament haematoma
evidence of hematoma Intra procedure clinical
(USG). photograph.

a) Clinical notes detailing a) Detailed indoor case OPEN YES

events that led to pressure papers and treatment given
sores b) Detailed
b) Supporting reports and procedure/Operative notes
Plastic & Reconstructive Plastic & Reconstructive Clinical photograph c) Post procedure clinical
1591 SP SP001 Pressure Sore – Surgery SP001A Pressure Sore – Surgery 44310 48741 53172 57603 62034 64249 photograph of the affected
Surgery Surgery
part
d) Discharge summary and
follow up details

a) Clinical notes with a) Detailed indoor case OPEN

planned line of treatment papers and treatment given
detailing diabetic foot b) Detailed
extent of damage procedure/Operative notes
b) Supporting reports and c) Post procedure clinical
Plastic & Reconstructive Plastic & Reconstructive Clinical photograph. photograph of the affected
1592 SP SP002 Diabetic Foot – Surgery SP002A Diabetic Foot – Conservative management 30000 33000 36000 39000 42000 43500
Surgery Surgery part
d) Detailed Discharge
summary and follow-up
details

a) Detailed Clinical notes a) Detailed indoor case OPEN YES

with planned line of papers with treatment
treatment and advice for information b)
admission. Detailed procedure/
Plastic & Reconstructive Plastic & Reconstructive
1593 SP SP003 Revascularization of limb / digit SP003A Revascularization of limb / digit (single didgit) 41895 46084 50274 54463 58653 60747 B) Doppler report Operative notes
Surgery Surgery
c) Clinical photograph of c) Detailed discharge
the affected part summary
d) MLC/FIR report (If
traumatic)
Plastic & Reconstructive Plastic & Reconstructive Revascularization of limb / digit(morethan one 0 0 OPEN YES
1594 SP SP003 Revascularization of limb / digit SP003B 118125 129937 141750 153562 165375 171281
Surgery Surgery digit)
a) Clinical notes with a) Detailed indoor case OPEN YES
planned line of treatment, papers and treatment
supporting information
documents if indication is b) Detailed
non traumatic. procedure/operative notes
Ear Pinna Reconstruction with costal Ear Pinna Reconstruction with costal cartilage / B) In case of injury then c) Clinical photograph of
Plastic & Reconstructive Plastic & Reconstructive
1595 SP SP004 cartilage / Prosthesis SP004A Prosthesis 51765 56941 62118 67294 72471 75059 MLC/FIR report the affected ear
Surgery Surgery
(including the cost of prosthesis / implants) (including the cost of prosthesis / implants) c) Supporting reports and d) Invoice/Barcode of
Clinical photograph. Prosthesis/ Implant used (if
applicable)
e) Detailed Discharge
summary

0 0 OPEN YES
Ear Pinna Reconstruction with costal Ear Pinna Reconstruction with costal cartilage /
Plastic & Reconstructive Plastic & Reconstructive
1596 SP SP004 cartilage / Prosthesis SP004B Prosthesis 105000 115500 126000 136500 147000 152250
Surgery Surgery
(including the cost of prosthesis / implants) (including the cost of prosthesis / implants)
a) Clinical notes including a) Detailed Indoor Case OPEN YES
evaluation findings, papers with treatment given
indications for the b) Post procedure clinical
procedure, and planned photograph of the affected
Plastic & Reconstructive Plastic & Reconstructive line of treatment and part
1597 SP SP005 Scalp avulsion reconstruction SP005A Scalp avulsion reconstruction 78750 86625 94500 102375 110250 114187
Surgery Surgery advice for admission c) Detailed procedure/
b) Supporting reports and Operative notes
Clinical photograph d) Detailed discharge
c) MLC/FIR report (If summary
traumatic)
a) Detailed clinical notes of a) Detailed indoor case OPEN YES
original clinical event papers
having led to disfigurement b) Invoice/barcode of the
or confirming details/ expander used
Tissue Expander for disfigurement following Investigations of congenital c) Post procedure clinical
Plastic & Reconstructive Plastic & Reconstructive Tissue Expander for disfigurement following event photograph of the affected
1598 SP SP006 burns / trauma / congenital deformity SP006A 65625 72187 78750 85312 91875 95156
Surgery Surgery burns b) Clinical Photograph of part
(including cost of expander / implant)
the affected part d) Detailed procedure/
Operative notes
e) Detailed discharge
summary

a) Detailed clinical notes of a) Detailed indoor case OPEN YES

original clinical event papers
having led to disfigurement b) Invoice/barcode of the
or confirming details/ expander used
Tissue Expander for disfigurement following Investigations of congenital c) Post procedure clinical
Plastic & Reconstructive Plastic & Reconstructive Tissue Expander for disfigurement following event photograph of the affected
1599 SP SP006 burns / trauma / congenital deformity SP006B 65625 72187 78750 85312 91875 95156
Surgery Surgery trauma b) Clinical Photograph of part
(including cost of expander / implant)
the affected part d) Detailed procedure/
Operative notes
e) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed clinical notes of a) Detailed indoor case OPEN YES
original clinical event papers
having led to disfigurement b) Invoice/barcode of the
or confirming details/ expander used
Tissue Expander for disfigurement following Investigations of congenital c) Post procedure clinical
Plastic & Reconstructive Plastic & Reconstructive Tissue Expander for disfigurement following event photograph of the affected
1600 SP SP006 burns / trauma / congenital deformity SP006C 65625 72187 78750 85312 91875 95156
Surgery Surgery congenital deformity b) Clinical Photograph of part
(including cost of expander / implant)
the affected part d) Detailed procedure/
Operative notes
e) Detailed discharge
summary

a) Clinical notes with a) Detailed Indoor case OPEN

history, indications, papers
symptoms, signs, b) Detailed Procedure /
examination findings and operative notes
advice for admission c) Sclerosing agent details
Plastic & Reconstructive Plastic & Reconstructive b) Clinical photograph (if applicable) Yes
1601 SP SP007 Hemangioma SP007A Sclerotherapy under GA 35000 38500 42000 45500 49000 50750
Surgery Surgery c) Complete blood count d) Detailed discharge
d) Coagulation profile summary
e) USG affected part
f) Doppler study
g) Planned line of
treatment
a) Clinical notes with a) Detailed Indoor case OPEN YES
history, indications, papers
symptoms, signs, b) Detailed Procedure /
examination findings and operative notes
advice for admission c) Sclerosing agent details
Plastic & Reconstructive Plastic & Reconstructive b) Clinical photograph (if applicable) Yes
1602 SP SP007 Hemangioma SP007B Debulking 52500 57750 63000 68250 73500 76125
Surgery Surgery c) Complete blood count d) Detailed discharge
d) Coagulation profile summary
e) USG affected part
f) Doppler study
g) Planned line of
treatment
a) Clinical notes with a) Detailed Indoor case OPEN YES
history, indications, papers
symptoms, signs, b) Detailed Procedure /
examination findings and operative notes
advice for admission c) Sclerosing agent details
Plastic & Reconstructive Plastic & Reconstructive b) Clinical photograph (if applicable) Yes
1603 SP SP007 Hemangioma SP007C Excision 52920 58212 63504 68796 74088 76734
Surgery Surgery c) Complete blood count d) Detailed discharge
d) Coagulation profile summary
e) USG affected part
f) Doppler study
g) Planned line of
treatment
a) Clinical notes with a) Detailed Indoor case OPEN
history, symptoms, signs, papers
examination b) Detailed Procedure /
findings, and advice for operative notes
Plastic & Reconstructive Plastic & Reconstructive admission c) Post-operative
1604 SP SP008 NPWT SP008A NPWT 4935 5428 5922 6415 6909 7155
Surgery Surgery b) Clinical photograph photographs
c) Indication of procedure d) Detailed discharge
d) Planned line of summary
treatment

Orthopaedics,Oral and 0 0 OPEN

Maxillofacial
Surgery,Otorhinolaryngolo
gy,Paediatric
Resuturing of Any Wound gap
1605 Surgical Oncology SC surgery,Plastic & SP009 Resuturing of Any Wound gap Surgeries SP009A 3990 4389 4788 5187 5586 5785
Surgeries
reconstructive
Surgery,Surgical
Oncology,Urology,Polytrau
ma
Plastic & Reconstructive Plastic & Reconstructive 0 0 OPEN YES
1606 SP SP009 Diabetic Foot – Surgery SP009B Diabetic Foot – Surgery 59115 65026 70938 76849 82761 85716
Surgery Surgery
a) Clinical notes a) Indoor case papers Referral
b) Clinical Photography b) Detailed operative notes
Pediatric Surgery, Oral & c) Post procedure clinical
Maxillofacial Surgery, photograph
1607 Pediatric Surgery SS SS001 Cleft Lip and Palate Surgery (per stage) SS001A Cleft Lip and Palate Surgery (per stage) 22365 24601 26838 29074 31311 32429
Plastic & Reconstructive d) Pre-anesthesia check-up
Surgery report
e) Discharge summary

a)Clinical notes with a) Indoor case papers OPEN

indications b)Grading of b) Detailed Procedure /
ankyloglossia operative notes
c) Detailed discharge
summary d) Pre & Post-
1608 Pediatric Surgery SS Pediatric Surgery SS002 Ankyloglossia SS002A Ankyloglossia Minor 9450 10395 11340 12285 13230 13702 operative photograph
e) Documentary evidence
of failed/ non-indicated
conservative management
of ankyloglossia in patient
aged >/= 2 years
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a)Clinical notes with a) Indoor case papers OPEN
indications b)Grading of b) Detailed Procedure /
ankyloglossia operative notes
c) Detailed discharge
summary d) Pre & Post-
1609 Pediatric Surgery SS Pediatric Surgery SS002 Ankyloglossia SS002B Ankyloglossia Major 19740 21714 23688 25662 27636 28623 operative photograph
e) Documentary evidence
of failed/ non-indicated
conservative management
of ankyloglossia in patient
aged >/= 2 years

a) Clinical notes a) Indoor case papers OPEN

b) Upper GI Endoscopy (ICPs) b) Detailed
Procedure / operative notes
c) Intra-operative
1610 Pediatric Surgery SS Pediatric Surgery SS003 Anti GERD Surgery SS003A Anti GERD Surgery 28140 30954 33768 36582 39396 40803 photograph d) Pre-
anesthesia check-up report
e) Detailed discharge
summary

a) Clinical notes a) Detailed Indoor case OPEN

b) Barium contrast swallow papers (ICPs)
/ Upper Gastrointestinal b) Detailed
Endoscopy procedure/operative notes
Gastrostomy + Esophagoscopy +
1611 Pediatric Surgery SS Pediatric Surgery SS004 SS004A Gastrostomy + Esophagoscopy + Threading 29085 31993 34902 37810 40719 42173 c) Planned line of c) Detailed discharge
Threading
treatment summary
e) Barium contrast swallow

a) Clinical notes a) Indoor case papers OPEN YES

b) Investigations: Plain X- (ICPs) b) Detailed
ray erect abdomen/Upper Procedure / operative notes
GI contrast series/USG c) Intra-operative
abdomen/CECT photograph d)
Investigations:
1612 Pediatric Surgery SS Pediatric Surgery SS005 Ladds Procedure SS005A Ladds Procedure 51240 56364 61488 66612 71736 74298 Plain X ray erect abdomen/
Upper GI contrast follow
through/ USG Abdomen
e) Histopathology report
f) Detailed discharge
summary

a) Clinical notes a) Detailed Indoor case OPEN

b) CT/MRI papers (ICPs)
c) Endoscopic ultrasound ± b) Detailed operative/
1613 35574 38808 42042 45276 46893 fine needle aspiration procedure notes
Pediatric Surgery SS Pediatric Surgery SS006 Duplication Cyst Excision SS006A Duplication Cyst Excision 32340
d) Planned line of c) Detailed discharge
treatment summary
d) Histopathological
examination
a) Clinical notes a) Indoor case papers OPEN
b) USG abdomen (ICPs) b) Detailed
Procedure / operative notes
c) Detailed discharge
summary d) USG Abdomen
e) Documentary evidence
1614 Pediatric Surgery SS Pediatric Surgery SS007 Intussusception SS007A Non – Operative Reduction in infants 30240 33264 36288 39312 42336 43848 that conservative
management has been tried
but failed/ conservative
management is not
indicated, with reason(s)

a) Clinical notes a) Indoor case papers OPEN

b) USG abdomen (ICPs) b) Detailed
Procedure / operative notes
c) Detailed discharge
summary d) USG Abdomen
e) Documentary evidence
1615 Pediatric Surgery SS Pediatric Surgery SS007 Intussusception SS007B Operative in infants 35490 39039 42588 46137 49686 51460 that conservative
management has been tried
but failed/ conservative
management is not
indicated, with reason(s)

a) Clinical notes a) Indoor case papers OPEN

b) X Ray abdomen / USG (ICPs) b) Detailed
Abdomen / Dye test / Procedure / operative notes
sigmoidoscopy / c) Pre-anesthesia check-up
colonoscopy report
1616 Pediatric Surgery SS Pediatric Surgery SS008 Surgery for Hirschsprung’s Disease SS008A Myectomy 33600 36960 40320 43680 47040 48720 d) Detailed discharge
summary e) Histopathology
examination report (within 7
days of discharge)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Indoor case papers OPEN
b) X Ray abdomen / USG (ICPs) b) Detailed
Abdomen / Dye test / Procedure / operative notes
sigmoidoscopy / c) Pre-anesthesia check-up
colonoscopy report
1617 Pediatric Surgery SS Pediatric Surgery SS008 Surgery for Hirschsprung’s Disease SS008B Pull Through 32550 35805 39060 42315 45570 47197 d) Detailed discharge
summary e) Histopathology
examination report (within 7
days of discharge)

a) Clinical notes a) Indoor case papers OPEN

b) X Ray abdomen / USG (ICPs) b) Detailed
Abdomen / Dye test / Procedure / operative notes
sigmoidoscopy / c) Pre-anesthesia check-up
colonoscopy report
1618 Pediatric Surgery SS Pediatric Surgery SS008 Surgery for Hirschsprung’s Disease SS008C Rectal Biopsy - Punch 16800 18480 20160 21840 23520 24360 d) Detailed discharge
summary e) Histopathology
examination report (within 7
days of discharge)

a) Clinical notes a) Indoor case papers OPEN

b) X Ray abdomen / USG (ICPs) b) Detailed
Abdomen / Dye test / Procedure / operative notes
sigmoidoscopy / c) Pre-anesthesia check-up
colonoscopy report
1619 Pediatric Surgery SS Pediatric Surgery SS008 Surgery for Hirschsprung’s Disease SS008D Rectal Biopsy – Open 17325 19057 20790 22522 24255 25121 d) Detailed discharge
summary e) Histopathology
examination report (within 7
days of discharge)

a) Clinical notes a) Indoor case papers OPEN

b) X Ray abdomen / USG (ICPs) b) Detailed
Abdomen / Dye test / Procedure / operative notes
sigmoidoscopy / c) Pre-anesthesia check-up
colonoscopy report
1620 Pediatric Surgery SS Pediatric Surgery SS008 Surgery for Hirschsprung’s Disease SS008E Sphinecterotomy 21735 23908 26082 28255 30429 31515 d) Detailed discharge
summary e) Histopathology
examination report (within 7
days of discharge)

a) Clinical notes a) Indoor case papers OPEN

b) Digital rectal (ICPs)
examination c) b) Detailed operative notes
Sigmoidoscopy/Colonosco c) Detailed discharge
py d) Optional based on summary
Rectal Polypectomy - Sigmoiescopic Under clinical condition and d) Histopathological
1621 Pediatric Surgery SS Pediatric Surgery SS009 SS009A Rectal Polypectomy - Sigmoiescopic Under GA 15330 16863 18396 19929 21462 22228
GA availability examination
Fecal occult blood testing
Barium enema
CECT abdomen
CT colonography

a) Clinical notes indicating a)Indoor case papers OPEN

whether other associated b)Detailed Procedure /
congenital disorders like operative notes
those of spine, anus, heart, c) Detailed discharge
trachea, esophagus, summary d) Post procedure
kidneys, or limbs, etc. clinical photograph
1622 Pediatric Surgery SS Pediatric Surgery SS010 Ano Rectal Malformation SS010A Abd - Perineal PSARP 33495 36844 40194 43543 46893 48567 b) Clinical Photograph e) Pre-anesthesia check-up
c) Distal Cologram/ Barium report
enema (if available)
d) USG Abdomen
e) Xray Lumbosacral spine
(inverted position)

a) Clinical notes indicating a)Indoor case papers OPEN

whether other associated b)Detailed Procedure /
congenital disorders like operative notes
those of spine, anus, heart, c) Detailed discharge
trachea, esophagus, summary d) Post procedure
kidneys, or limbs, etc. clinical photograph
1623 Pediatric Surgery SS Pediatric Surgery SS010 Ano Rectal Malformation SS010B Anoplasty 30030 33033 36036 39039 42042 43543 b) Clinical Photograph e) Pre-anesthesia check-up
c) Distal Cologram/ Barium report
enema (if available)
d) USG Abdomen
e) Xray Lumbosacral spine
(inverted position)

a) Clinical notes indicating a)Indoor case papers OPEN

whether other associated b)Detailed Procedure /
congenital disorders like operative notes
those of spine, anus, heart, c) Detailed discharge
trachea, esophagus, summary d) Post procedure
kidneys, or limbs, etc. clinical photograph
1624 Pediatric Surgery SS Pediatric Surgery SS010 Ano Rectal Malformation SS010C Cutback 26250 28875 31500 34125 36750 38062 b) Clinical Photograph e) Pre-anesthesia check-up
c) Distal Cologram/ Barium report
enema (if available)
d) USG Abdomen
e) Xray Lumbosacral spine
(inverted position)
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes indicating a)Indoor case papers OPEN
whether other associated b)Detailed Procedure /
congenital disorders like operative notes
those of spine, anus, heart, c) Detailed discharge
trachea, esophagus, summary d) Post procedure
kidneys, or limbs, etc. clinical photograph
1625 Pediatric Surgery SS Pediatric Surgery SS010 Ano Rectal Malformation SS010D PSARP 33075 36382 39690 42997 46305 47958 b) Clinical Photograph e) Pre-anesthesia check-up
c) Distal Cologram/ Barium report
enema (if available)
d) USG Abdomen
e) Xray Lumbosacral spine
(inverted position)

a) Clinical notes indicating a)Indoor case papers OPEN

whether other associated b)Detailed Procedure /
congenital disorders like operative notes
those of spine, anus, heart, c) Detailed discharge
trachea, esophagus, summary d) Post procedure
kidneys, or limbs, etc. clinical photograph
1626 Pediatric Surgery SS Pediatric Surgery SS010 Ano Rectal Malformation SS010E Redo - Pullthrough 31500 34650 37800 40950 44100 45675 b) Clinical Photograph e) Pre-anesthesia check-up
c) Distal Cologram/ Barium report
enema (if available)
d) USG Abdomen
e) Xray Lumbosacral spine
(inverted position)

a) Clinical notes indicating a)Indoor case papers OPEN

whether other associated b)Detailed Procedure /
congenital disorders like operative notes
those of spine, anus, heart, c) Detailed discharge
trachea, esophagus, summary d) Post procedure
kidneys, or limbs, etc. clinical photograph
1627 Pediatric Surgery SS Pediatric Surgery SS010 Ano Rectal Malformation SS010F Transposition 28140 30954 33768 36582 39396 40803 b) Clinical Photograph e) Pre-anesthesia check-up
c) Distal Cologram/ Barium report
enema (if available)
d) USG Abdomen
e) Xray Lumbosacral spine
(inverted position)

a) Clinical notes a) Indoor case papers OPEN

b) (ICPs)
1628 40887 44604 48321 52038 53896 CT/Fistulography/Barium b) Detailed Procedure /
Pediatric Surgery SS Pediatric Surgery SS011 Fecal Fistula Closure SS011A Fecal Fistula Closure 37170
study operative notes
c) Detailed discharge
summary
a) Clinical notes. a) HPR. OPEN YES
b) USG. b) Detailed Procedure.
c) CT. c) Operative Notes.
d) Biopsy. d) Intra procedure clinical
photograph.
1629 Pediatric Surgery SS Pediatric Surgery SS012 GI Tumor Excision SS012A GI Tumor Excision 43785 48163 52542 56920 61299 63488 e) Detailed Procedure.
f) Operative Notes.
g) Detailed discharge
summary.

a) Clinical notes a) Indoor case papers OPEN YES

b) Chest X ray AP/ Lateral b) Detailed operative notes
c) USG/ CT scan stills/ c) Detailed discharge
report summary d) Fetal
1630 Pediatric Surgery SS Pediatric Surgery SS013 Congenital Diaphragmatic Hernia SS013A Congenital Diaphragmatic Hernia 52920 58212 63504 68796 74088 76734 Cardiogram e)
Xray Chest AP/Lat stills/
report
f) Pre-anesthesia check-up
report
a) Clinical notes a) Indoor case papers OPEN YES
b) Clinical photographs (ICPs)
b) Detailed operative notes
1631 44467 48510 52552 56595 58616 c) Detailed discharge
Pediatric Surgery SS Pediatric Surgery SS014 Exomphalos / Gastroschisis SS014A Exomphalos 40425
summary
d) Post-operative
photographs

a) Clinical notes a) Indoor case papers OPEN YES

b) Clinical photographs (ICPs)
b) Detailed operative notes
1632 44467 48510 52552 56595 58616 c) Detailed discharge
Pediatric Surgery SS Pediatric Surgery SS014 Exomphalos / Gastroschisis SS014B Gastroschisis 40425
summary
d) Post-operative
photographs

a) Clinical notes. a) Detailed Procedure. OPEN

b) USG. b) Operative Notes.
c) Clinical Photograph. c) Post procedure clinical
photograph showing scar.
1633 Pediatric Surgery SS Pediatric Surgery SS015 Hernia & Hydrocele SS015A Hernia & Hydrocele 26250 28875 31500 34125 36750 38062 d) Detailed Procedure.
e) Operative Notes.
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes a) Indoor case papers OPEN
b) Clinical Photograph (ICPs) b) Detailed
c) USG/CT/MRI Abdomen Procedure / operative notes
1634 37999 41454 44908 48363 50090 c) Detailed discharge
Pediatric Surgery SS Pediatric Surgery SS016 Retro - Peritoneal Lymphangioma Excision SS016A Retro - Peritoneal Lymphangioma Excision 34545
summary d)
Histopathological
examination report

a) Clinical notes a) Indoor case papers OPEN

b) CT/MRI of the primary (ICPs) b) Detailed operative
site c) Serum levels of notes c) Detailed
alpha-fetoprotein (AFP) discharge summary d) MRI
1635 Pediatric Surgery SS Pediatric Surgery SS017 Surgery for Sacrococcygeal Teratoma SS017A Surgery for Sacrococcygeal Teratoma 32025 35227 38430 41632 44835 46436 and beta human chorionic of the primary site e)
gonadotropin (beta-hCG) Post procedure clinical
d) Clinical photograph photograph
f) Histopathology
examination report

a) Clinical notes a) Indoor case papers OPEN YES

b) Posteroanterior chest X- b) Detailed Procedure /
ray c) CT Chest operative notes
1636 Pediatric Surgery SS Pediatric Surgery SS018 Surgery for Congenital Lobar Emphysema SS018A Surgery for Congenital Lobar Emphysema 42525 46777 51030 55282 59535 61661 c) Posteroanterior chest X-
ray/ CT chest
d) Detailed discharge
summary
a) Clinical notes a) Indoor case papers OPEN
b) USG abdomen and (ICPs) b) Detailed
1637 22753 24822 26890 28959 29993 pelvis Procedure / operative notes
Pediatric Surgery SS Pediatric Surgery SS019 Undescended Testis SS019A Bilateral - Palpable + Nonpalpable 20685
c) Detailed discharge
summary

a) Clinical notes a) Indoor case papers OPEN

b) USG abdomen and (ICPs) b) Detailed
1638 22753 24822 26890 28959 29993 pelvis Procedure / operative notes
Pediatric Surgery SS Pediatric Surgery SS019 Undescended Testis SS019B Bilateral Palpable 20685
c) Detailed discharge
summary

a) Clinical notes a) Indoor case papers OPEN

b) USG abdomen and (ICPs) b) Detailed
1639 27489 29988 32487 34986 36235 pelvis Procedure / operative notes
Pediatric Surgery SS Pediatric Surgery SS019 Undescended Testis SS019C Bilateral Non - Palpable 24990
c) Detailed discharge
summary

a) Clinical notes a) Indoor case papers OPEN

b) USG abdomen and (ICPs) b) Detailed
1640 22753 24822 26890 28959 29993 pelvis Procedure / operative notes
Pediatric Surgery SS Pediatric Surgery SS019 Undescended Testis SS019D Unilateral - Palpable 20685
c) Detailed discharge
summary

a) Clinical notes a) Indoor case papers OPEN

b) USG abdomen and (ICPs) b) Detailed
1641 25987 28350 30712 33075 34256 pelvis Procedure / operative notes
Pediatric Surgery SS Pediatric Surgery SS019 Undescended Testis SS019E Reexploration / Second Stage 23625
c) Detailed discharge
summary

1642 Pediatric Surgery SS Pediatric Surgery SS020 Excision of accessory auricle SS020A Excision of accessory auricle 24990 27489 29988 32487 34986 36235 0 0 OPEN
1643 Pediatric Surgery SS Pediatric Surgery SS021 MACROSTOMIA REPAIR SS021A Repair of macrostomia 51240 56364 61488 66612 71736 74298 0 0 OPEN YES
1644 Pediatric Surgery SS Pediatric Surgery SS022 PARATHYROIDECTOMY SS022A Parathyroidectomy 51240 56364 61488 66612 71736 74298 0 0 OPEN YES
1645 Pediatric Surgery SS Pediatric Surgery SS023 STENSON'S DUCT DILATATION SS023A Dilatation of Stenson's duct 14490 15939 17388 18837 20286 21010 0 0 OPEN
1646 Pediatric Surgery SS Pediatric Surgery SS024 SUPERNUMMERY DIGIT EXISION SS024A Excision of supernumerary digit 18375 20212 22050 23887 25725 26643 0 0 OPEN
1647 Pediatric Surgery SS Pediatric Surgery SS025 SYNDACTYLY SS025A Syndactyly repair 45990 50589 55188 59787 64386 66685 0 0 OPEN YES
1648 Pediatric Surgery SS Pediatric Surgery SS026 TONGUE LACERATION SS026A Repair of tongue laceration 18375 20212 22050 23887 25725 26643 0 0 OPEN
1649 Pediatric Surgery SS Pediatric Surgery SS027 TORTICOLLIS SS027A Sternomastoid division 19740 21714 23688 25662 27636 28623 0 0 OPEN
1650 Pediatric Surgery SS Pediatric Surgery SS028 LIVER TRAUMA NON-OP SS028A Non-operative management of liver trauma 52500 57750 63000 68250 73500 76125 0 0 OPEN YES
1651 Pediatric Surgery SS Pediatric Surgery SS029 PORTAL HYPERTENSION SS029A NON-SHUNTS 59115 65026 70938 76849 82761 85716 0 0 OPEN YES
1652 Pediatric Surgery SS Pediatric Surgery SS030 CONJOINED TWINS SS030A Separation of twins 124740 137214 149688 162162 174636 180873 0 0 OPEN YES
1653 Pediatric Surgery SS Pediatric Surgery SS031 ESOPHAGEAL ATRESIA/TEF SS031A PRIMARY REPAIR 85365 93901 102438 110974 119511 123779 0 0 OPEN YES
1654 Pediatric Surgery SS Pediatric Surgery SS032 MALROTATION SS032A Ladd's procedure 51240 56364 61488 66612 71736 74298 0 0 OPEN YES
1655 Pediatric Surgery SS Pediatric Surgery SS033 POSTERIOR URETHERAL VALVES SS033A VESICOSTOMY 53865 59251 64638 70024 75411 78104 0 0 OPEN YES
1656 Pediatric Surgery SS Pediatric Surgery SS034 SPLENORRHAPHY SS034A Splenorapphy 40740 44814 48888 52962 57036 59073 0 0 OPEN YES
1657 Pediatric Surgery SS Pediatric Surgery SS035 ESOPHAGEAL DILATATION SS035A Esophageal dilatation 39375 43312 47250 51187 55125 57093 0 0 OPEN
1658 Pediatric Surgery SS Pediatric Surgery SS036 OPEN KIDNEY BIOPSY SS036A Kiidney biopsy 43365 47701 52038 56374 60711 62879 0 0 OPEN YES
0 0 OPEN YES
1659 Pediatric Surgery SS Pediatric Surgery SS037 APPENDICO-VESICOSTOMY/Mitraffanof SS037A Appendicovesicostomy or Monti procedure 56490 62139 67788 73437 79086 81910
1660 Pediatric Surgery SS Pediatric Surgery SS038 VESICOSTOMY SS038A Vesicostomy 36750 40425 44100 47775 51450 53287 0 0 OPEN
1661 Pediatric Surgery SS Pediatric Surgery SS039 SUPRAGLOTTOPLASTY SS039A Supra-glotoplasty 35490 39039 42588 46137 49686 51460 0 0 OPEN
SINGLE STAGE AIRWAY 0 0 OPEN YES
1662 Pediatric Surgery SS Pediatric Surgery SS040 SS040A Airway reconstruction 72240 79464 86688 93912 101136 104748
RECONSTRUCTION
0 0 OPEN YES
1663 Pediatric Surgery SS Pediatric Surgery SS041 STAGED AIRWAY RECONSTRUCTION SS041A Staged airway reconstruction 65625 72187 78750 85312 91875 95156
1664 Pediatric Surgery SS Pediatric Surgery SS042 SLIDE TRACHEOPLASTY SS042A Slide tracheoplasty 78750 86625 94500 102375 110250 114187 0 0 OPEN YES
a) Clinical Notes detailing a) Detailed Indoor case OPEN variable
the injury with admission papers
Polytrauma, Orthopedics, Glasgow coma scale score b) Detailed Procedure/
1665 Polytrauma ST Neurosurgery, General ST001 Conservative Management of Head Injury ST001A Severe 1050 1155 1260 1365 1470 1522 b) CT head Operative notes
Surgery c) Post-op CT head
d) Detailed discharge
summary
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the injury with admission papers
Polytrauma, Orthopedics, Glasgow coma scale score b) Detailed Procedure/
1666 Polytrauma ST Neurosurgery, General ST001 Conservative Management of Head Injury ST001B Depressed Fracture 5250 5775 6300 6825 7350 7612 b) CT head Operative notes
Surgery c) Post-op CT head
d) Detailed discharge
summary
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes (detailing a) Indoor case papers OPEN YES
signs, symptoms, (including Informed written
examination findings, consent)
clinical b) Procedure note/
photographs(intraoral operative note & Anesthesia
& extraoral) indications for Notes
doing the procedure & c) Barcode of Implants
advise for admission) used
Procedure / Operative d) Post-operative X-Ray
Polytrauma, Orthopedics, Notes, Post Procedure e) Detailed Discharge
Neurosurgery, General Head injury with repair of Facio-Maxillary Head injury with repair of Facio-Maxillary Injury Photograph of affected summary
1667 Polytrauma ST ST002 ST002A 40740 44814 48888 52962 57036 59073 part.
Surgery, Oral & Injury & fixations (including implants) & fixations (including implants)
Maxillofacial Surgery b) X-ray of Paranasal sinus
(PNS) with Water’s view/
mandible latera Oblique,
antero- posterior for
Mandible Fracture/
mandible lateral oblique,
Submento vertex or
CBCT/CT/OPG. (Xray in 2
planes).

a) Clinical Notes detailing a) Detailed Indoor case OPEN

the injury and need for papers b) Detailed
surgery Procedure/ Operative notes
Polytrauma, Orthopedics, b) Medico legal case c) Post op X-ray film and
Craniotomy and evacuation of Haematoma Subdural hematoma along with fixation of report/ FIR copy of report of skull
1668 Polytrauma ST Neurosurgery, General ST003 ST003A 78750 86625 94500 102375 110250 114187
with fixation of fracture of long bone fracture of single long bone accident d) Detailed discharge
Surgery
c) X-ray/ CT report of summary
fractured limb
d) CT/ MRI Brain film and
report
a) Clinical notes detailing a) Detailed Indoor case OPEN
the injury and need for papers
surgery b) Detailed Procedure/
Polytrauma, Orthopedics, b) Medico legal case Operative notes
Craniotomy and evacuation of Haematoma Extradural hematoma along with fixation of report/ FIR copy of c) Post op X-ray film and
1669 Polytrauma ST Neurosurgery, General ST003 ST003B 78750 86625 94500 102375 110250 114187
with fixation of fracture of long bone fracture of single long bone accident report of skull
Surgery
c) X-ray/ CT report of d) Detailed discharge
fractured limb summary
d) CT/ MRI Brain film and
report
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the injury and need for papers b) Detailed
surgery Procedure/ Operative notes
Polytrauma, Orthopedics, b) Medico legal case c) Post op X-ray film and
Craniotomy and evacuation of Haematoma Subdural hematoma along with fixation of report/ FIR copy of report of skull
1670 Polytrauma ST Neurosurgery, General ST003 ST003C 98490 108339 118188 128037 137886 142810
with fixation of fracture of long bone fracture of 2 or more long bone. accident d) Detailed discharge
Surgery
c) X-ray/ CT report of summary
fractured limb
d) CT/ MRI Brain film and
report
a) Clinical notes detailing a) Detailed Indoor case OPEN
the injury and need for papers
surgery b) Detailed Procedure/
Polytrauma, Orthopedics, b) Medico legal case Operative notes
Craniotomy and evacuation of Haematoma Extradural hematoma along with fixation of report/ FIR copy of c) Post op X-ray film and
1671 Polytrauma ST Neurosurgery, General ST003 ST003D 98490 108339 118188 128037 137886 142810
with fixation of fracture of long bone fracture of 2 or more long bone. accident report of skull
Surgery
c) X-ray/ CT report of d) Detailed discharge
fractured limb summary
d) CT/ MRI Brain film and
report
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the injury and need for papers
surgery b) Detailed Procedure/
Polytrauma, Orthopedics, b) Medico legal case Operative notes
Management of Chest injury with fracture of Management of Chest injury with fixation of report/ FIR copy of c) Post op X-ray film and
1672 Polytrauma ST Neurosurgery, General ST004 ST004A 35000 38500 42000 45500 49000 50750
Long bone Single Long bone accident report of chest
Surgery
c) X-ray/ CT report of d) Invoice/Barcode of
fractured limb implant, if used
d) CT chest film and report e) Detailed discharge
summary
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the injury and need for papers
surgery b) Detailed Procedure/
Polytrauma, Orthopedics, b) Medico legal case Operative notes
Management of Chest injury with fracture of Management of Chest injury with fixation of 2 or report/ FIR copy of c) Post op X-ray film and
1673 Polytrauma ST Neurosurgery, General ST004 ST004B 47250 51975 56700 61425 66150 68512
Long bone more Long bones accident report of chest
Surgery
c) X-ray/ CT report of d) Invoice/Barcode of
fractured limb implant, if used
d) CT chest film and report e) Detailed discharge
summary
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the injury and need for papers
surgery b) Detailed Procedure/
Polytrauma, Orthopedics, b) Medico legal case Operative notes
Management of Visceral injury and fracture Surgical intervention for Visceral injury and report/ FIR copy of c) Detailed discharge
1674 Polytrauma ST Neurosurgery, General ST005 ST005A 39375 43312 47250 51187 55125 57093
long bone fixation of fracture of single long bone accident summary
Surgery
c) X-ray/ CT report of
fractured limb
d. CT abdomen film and
report
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the injury and need for papers
surgery b) Detailed Procedure/
Polytrauma, Orthopedics, b) Medico legal case Operative notes
Management of Visceral injury and fracture Surgical intervention for Visceral injury and report/ FIR copy of c) Detailed discharge
1675 Polytrauma ST Neurosurgery, General ST005 ST005B 59115 65026 70938 76849 82761 85716
long bone fixation of fracture of 2 or more long bones accident summary
Surgery
c) X-ray/ CT report of
fractured limb
d. CT abdomen film and
report
a) Clinical Notes detailing a) Indoor case papers OPEN YES
the injury and need for b) Procedure/ Operation
surgery b) Medico notes c) Detailed discharge
Polytrauma, Orthopedics, legal case report/ FIR copy summary d) Post-op
1676 Polytrauma ST Neurosurgery, General ST006 Internal fixation of Pelviacetabular fracture ST006A Internal fixation of Pelviacetabular fracture 42000 46200 50400 54600 58800 60900 of accident if due to road clinical photograph of
Surgery traffic accidents (optional) patient(Optional)
c) X-ray/ CT report of
pelvis

a) Clinical Notes detailing a) Indoor case papers OPEN YES

the injury and need for b) Procedure/ Operation
surgery b) X- notes c) Detailed discharge
Polytrauma, Orthopedics,
Internal fixation with Flap cover Surgery for Internal fixation with Flap cover Surgery for ray/ CT report of fractured summary d) Post op clinical
1677 Polytrauma ST Neurosurgery, General ST007 ST007A 42000 46200 50400 54600 58800 60900
wound in compound fracture wound in compound fracture limb photograph showing
Surgery
c) Pre op clinical implant for fixation and flap
photograph of cover (Optional)
injury(Optional)
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the injury and need for papers
Polytrauma, Orthopedics, surgery b) Detailed Procedure/
Emergency tendons repair ± Peripheral Emergency tendons repair ± Peripheral Nerve
1678 Polytrauma ST Neurosurgery, General ST008 ST008A 39375 43312 47250 51187 55125 57093 b) Medico legal case Operative notes
Nerve repair/ reconstructive surgery repair
Surgery report/FIR copy of c) Detailed discharge
accident, if due to accident summary

a. Clinical Notes detailing a) Indoor case papers OPEN

the injury and need for b) Procedure/ Operation
Polytrauma, Orthopedics, Nerve and/or tendon injury. A. Wound surgery notes
Management of Nerve Plexus / Tendon As per Selected
1679 Polytrauma ST Neurosurgery, General ST009 ST009A exploration and closure. B. Nerve repair. C. #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! b. Medico legal case c) Detailed discharge
injuries Procedure
Surgery Tendon repair report/ FIR copy of summary
accident, if the injury was
due to accident
a. Clinical Notes detailing a) Indoor case papers OPEN
the injury and need for b) Procedure/ Operation
Polytrauma, Orthopedics, Nerve and/or tendon injury. A. Wound surgery notes
Management of Nerve Plexus / Tendon As per Selected
1680 Polytrauma ST Neurosurgery, General ST009 ST009B exploration and closure. B. Nerve graft. C. #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! b. Medico legal case c) Detailed discharge
injuries Procedure
Surgery Tendon graft/transfer report/ FIR copy of summary
accident, if the injury was
due to accident
a) Clinical Notes detailing a) Indoor case papers OPEN
the injury and need for c) Procedure/ Operation
Polytrauma, Orthopedics,
Management of Nerve Plexus / Tendon surgery b) notes
1681 Polytrauma ST Neurosurgery, General ST009 ST009C Tendon injury repair 52500 57750 63000 68250 73500 76125
injuries Medico legal case report/ d) Detailed discharge
Surgery
FIR copy if due to accident summary

a) Clinical Notes detailing a) Indoor case papers OPEN

the injury and need for c) Procedure/ Operation
Polytrauma, Orthopedics,
Management of Nerve Plexus / Tendon surgery b) notes
1682 Polytrauma ST Neurosurgery, General ST009 ST009D Tendon graft repair 52500 57750 63000 68250 73500 76125
injuries Medico legal case report/ d) Detailed discharge
Surgery
FIR copy if due to accident summary

a) Clinical Notes detailing a) Indoor case papers OPEN

the injury and need for c) Procedure/ Operation
Polytrauma, Orthopedics,
Management of Nerve Plexus / Tendon surgery b) notes
1683 Polytrauma ST Neurosurgery, General ST009 ST009E Tendon Transfer 50000 55000 60000 65000 70000 72500
injuries Medico legal case report/ d) Detailed discharge
Surgery
FIR copy if due to accident summary

a) Clinical Notes detailing a) Indoor case papers OPEN

the injury and need for b) Intra operative
Polytrauma, Orthopedics, Nerve and/or tendon injury. A. Wound surgery photograph
Plexus injury along with Vascular injury As per Selected
1684 Polytrauma ST Neurosurgery, General ST010 ST010A exploration and closure. B. Nerve repair. C. #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! b) Medico legal case c) Procedure/ Operation
repair / graft Procedure
Surgery Tendon repair D. Vascular repair/graft report/ FIR copy of notes
accident, if the injury was d) Detailed discharge
due to accident summary
a) Clinical Notes detailing a) Indoor case papers OPEN
the injury and need for b) Intra operative
Polytrauma, Orthopedics, surgery photograph
Plexus injury along with Vascular injury
1685 Polytrauma ST Neurosurgery, General ST010 ST010B Plexus injury along with Vascular injury graft 78750 86625 94500 102375 110250 114187 b) Medico legal case c) Procedure/ Operation
repair / graft
Surgery report/ FIR copy of notes
accident, if the injury was d) Detailed discharge
due to accident summary
a) Detailed Clinical notes a) Detailed indoor case OPEN
with history, indications, papers
symptoms, signs, b) Detailed Procedure /
examination findings and operation notes
advice for admission c) Post Procedure clinical
b) CT/MRI/FNAC/Biopsy/ photograph
Urology & Pediatric MIBG (iodine meta- d) Detailed discharge
1686 Urology SU SU001 Adrenalectomy SU001A Open 31395 34534 37674 40813 43953 45522 iodobenzylguanidine) scan/ summary
Surgery
DOTONOC report
c) Sr. Cortisol, Sr.
electrolytes, 24 Hr. Urinary
catecholamine level/Sr.
Urinary metanephrine
normetanephrine
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed Clinical notes a) Detailed indoor case OPEN
with history, indications, papers
symptoms, signs, b) Detailed Procedure /
examination findings and operation notes
advice for admission c) Post Procedure clinical
b) CT/MRI/FNAC/Biopsy/ photograph
Urology & Pediatric MIBG (iodine meta- d) Detailed discharge
1687 Urology SU SU001 Adrenalectomy SU001B Lap. 30555 33610 36666 39721 42777 44304 iodobenzylguanidine) scan/ summary
Surgery
DOTONOC report
c) Sr. Cortisol, Sr.
electrolytes, 24 Hr. Urinary
catecholamine level/Sr.
Urinary metanephrine
normetanephrine

a) Clinical notes including a) Detailed indoor case OPEN YES

evaluation findings and papers
planned line of treatment b) Intra operative
b) USG/CT scan, +/- Photograph
Urology, Pediatric Surgery, FNAC/Biopsy /IVP for c) Post procedure X ray
1688 Urology SU SU003 Nephrectomy SU003A For Benign pathology - Open 43155 47470 51786 56101 60417 62574 confirming the need for report
Surgical Oncology
surgery reports d) Histopathology report
e) Detailed Procedure /
Operative Notes
f) Detailed discharge
summary
a) Clinical notes including a) Detailed indoor case OPEN YES
evaluation findings and papers
planned line of treatment b) Intra operative
b) USG/CT scan, +/- Photograph
Urology, Pediatric Surgery, FNAC/Biopsy /IVP for c) Post procedure X ray
1689 Urology SU SU003 Nephrectomy SU003B For Benign pathology - Lap. 48090 52899 57708 62517 67326 69730 confirming the need for report
Surgical Oncology
surgery reports d) Histopathology report
e) Detailed Procedure /
Operative Notes
f) Detailed discharge
summary
a) Clinical notes. a) Histopathology. OPEN YES
b) CT. b) Intra operative
c) MRI confirming the need photograph.
for surgery . c) Post procedure X-ray.
Urology, Pediatric Surgery, d) FNAC. Detailed discharge
1690 Urology SU SU003 Nephrectomy SU003C Radical (Renal tumor) - Open 43155 47470 51786 56101 60417 62574
Surgical Oncology e) Biopsy. summary.
d) detailed Procedure.
e) Operative Notes.

a) Clinical notes. a) Histopathology. OPEN YES

b) CT. b) Intra operative
c) MRI confirming the need photograph.
for surgery . c) Post procedure X-ray.
Urology, Pediatric Surgery, d) FNAC. Detailed discharge
1691 Urology SU SU003 Nephrectomy SU003D Radical (Renal tumor) - Lap. 48090 52899 57708 62517 67326 69730
Surgical Oncology e) Biopsy. summary.
d) detailed Procedure.
e) Operative Notes.

a) Clinical notes including a) Detailed indoor case OPEN

evaluation findings and papers
planned line of treatment b) Intra operative
b) CT/MRI scan, IVP (for Photograph
Urology, Pediatric Surgery,
1692 Urology SU SU004 Nephrectomy - Partial or Hemi SU004A Open 57225 62947 68670 74392 80115 82976 Open.) report c) Histopathology report
Surgical Oncology
d) Detailed Procedure /
Operative Notes
e) Detailed discharge
summary
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings and papers
planned line of treatment b) Intra operative
b) CT/MRI scan, IVP (for Photograph
Urology, Pediatric Surgery,
1693 Urology SU SU004 Nephrectomy - Partial or Hemi SU004B Lap. 60690 66759 72828 78897 84966 88000 Open.) report c) Histopathology report
Surgical Oncology
d) Detailed Procedure /
Operative Notes
e) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed Procedure /
and planned line of operation notes
management, advise for c) Post procedure X Ray /
1694 Urology SU Urology SU005 Nephrolithotomy SU005A Open 39900 43890 47880 51870 55860 57855 the procedure. USG KUB showing the
b) Intravenous pyelogram stone removed
(IVP) / Non-contrast e) Detailed discharge
computed tomography summary
(NCCT)/CT-IVP reports

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings, papers
indication for procedure, b) Detailed Procedure /
and planned line of operation notes
management, advise for c) Post procedure X Ray /
1695 Urology SU Urology SU005 Nephrolithotomy SU005B Anatrophic 39900 43890 47880 51870 55860 57855 the procedure. USG KUB showing the
b) Intravenous pyelogram stone removed
(IVP) / Non-contrast e) Detailed discharge
computed tomography summary
(NCCT)/CT-IVP reports
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a)Clinical notes a)Operative notes OPEN YES
b)Intravenous Pyelogram b)Detailed Discharge
1696 Urology SU Urology SU007 PCNL (Percutaneous Nephrolithotomy) SU007A PCNL (Percutaneous Nephrolithotomy) 47250 51975 56700 61425 66150 68512 (IVP) / NCCT/ CT-IVP Summary
c) X-ray / USG post
procedure
Urology, Pediatric Surgery, 0 0 OPEN
Nephrostomy - Percutaneous ultrasound
1697 Urology SU Interventional SU008 SU008A Nephrostomy - Percutaneous ultrasound guided 19740 21714 23688 25662 27636 28623
guided
Neuroradiology
0 0 OPEN
1698 Urology SU Urology SU0100 Torsion of testis SU100A Torsion of testis 19740 21714 23688 25662 27636 28623
0 0 OPEN yes
1699 Urology SU Urology SU0101 Follow up for urological procedures SU101A Follow up for urological procedures 1995 2194 2394 2593 2793 2892
a) Clinical notes including a) Detailed indoor case OPEN YES
evaluation findings and papers
planned line of treatment b) Intra operative
b) CT/ CT-IVP/MRI/MR Photograph
Urology, Pediatric Surgery,
1700 Urology SU SU010 Nephro ureterectomy (Benign) SU010A Open 43155 47470 51786 56101 60417 62574 Urogram report confirming c) Histopathology report
Surgical Oncology
the need for surgery d) Detailed Procedure /
Operative Notes
e) Detailed discharge
summary
a) Clinical notes including a) Detailed indoor case OPEN YES
evaluation findings and papers
planned line of treatment b) Intra operative
b) CT/ CT-IVP/MRI/MR Photograph
Urology, Pediatric Surgery,
1701 Urology SU SU010 Nephro ureterectomy (Benign) SU010B Lap. 48090 52899 57708 62517 67326 69730 Urogram report confirming c) Histopathology report
Surgical Oncology
the need for surgery d) Detailed Procedure /
Operative Notes
e) Detailed discharge
summary
a) Clinical notes including a) Detailed indoor case OPEN YES
evaluation findings and papers
planned line of treatment b) Intra operative
b) CT/ CT-IVP/MRI/MR Photograph
Urology, Pediatric Surgery,
1702 Urology SU SU011 Nephro ureterectomy with cuff of bladder SU011A Open 43155 47470 51786 56101 60417 62574 Urogram report confirming c) Histopathology report
Surgical Oncology
the need for surgery d) Detailed Procedure /
Operative Notes
e) Detailed discharge
summary
a) Clinical notes including a) Detailed indoor case OPEN YES
evaluation findings and papers
planned line of treatment b) Intra operative
b) CT/ CT-IVP/MRI/MR Photograph
Urology, Pediatric Surgery,
1703 Urology SU SU011 Nephro ureterectomy with cuff of bladder SU011B Lap. 48090 52899 57708 62517 67326 69730 Urogram report confirming c) Histopathology report
Surgical Oncology
the need for surgery d) Detailed Procedure /
Operative Notes
e) Detailed discharge
summary
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings and papers
planned line of treatment b) Detailed Procedure /
1704 28875 31500 34125 36750 38062 b) USG/CT report Operative Notes
Urology SU Urology SU013 Perinephric Abscess drainage SU013A Open 26250
confirming the diagnosis of c) Intra procedure still
perinephric abscess. photograph
d) Detailed Discharge
Summary
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings and papers
planned line of treatment b) Detailed Procedure /
1705 21714 23688 25662 27636 28623 b) USG/CT report Operative Notes
Urology SU Urology SU013 Perinephric Abscess drainage SU013B Percutaneous 19740
confirming the diagnosis of c) Intra procedure still
perinephric abscess. photograph
d) Detailed Discharge
Summary
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings and papers
planned line of treatment b) Post procedure Imaging
b) IVP / NCCT+ CT-IVP X Ray/USG showing stone
Ureteroscopy + Stone removal with confirming the indication is removed.
1706 Urology SU Urology SU014 SU014A Lower Ureter 39375 43312 47250 51187 55125 57093
lithotripsy for the procedure C) Detailed Procedure /
Operative Notes
d) Detailed discharge
summary

a) Clinical notes including a) Detailed indoor case OPEN

evaluation findings and papers
planned line of treatment b) Post procedure Imaging
b) IVP / NCCT+ CT-IVP X Ray/USG showing stone
Ureteroscopy + Stone removal with confirming the indication is removed.
1707 Urology SU Urology SU014 SU014B Upper Ureter 39375 43312 47250 51187 55125 57093
lithotripsy for the procedure C) Detailed Procedure /
Operative Notes
d) Detailed discharge
summary

a) Clinical notes. a) Intra operative OPEN

b) IVP. photograph. Detailed
c) NCCT. discharge summary.
d) CT-IVP confirming the b) detailed Procedure .
Extracoporeal shock - wave Lithotripsy Extracoporeal shock - wave Lithotripsy (ESWL) indication. c) Operative Notes.
1708 Urology SU Urology SU016 SU016A 25000 27500 30000 32500 35000 36250
(ESWL) stone, with or without stent (one side) e) need for ESWL.
f) Is EHCP registered for
ESWL?

0 0 OPEN
1709 Urology SU Urology, Pediatric Surgery SU018 Ureterolithotomy SU018A Open 30030 33033 36036 39039 42042 43543
0 0 OPEN
1710 Urology SU Urology, Pediatric Surgery SU018 Ureterolithotomy SU018B Lap. 29610 32571 35532 38493 41454 42934
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
Pyeloplasty / Pyeloureterostomy / 0 0 OPEN YES
1711 Urology SU Urology, Pediatric Surgery SU021 SU021A Pyeloplasty - Open 40635 44698 48762 52825 56889 58920
Pyelopyelostomy
Pyeloplasty / Pyeloureterostomy / 0 0 OPEN YES
1712 Urology SU Urology, Pediatric Surgery SU021 SU021B Pyeloplasty - Laparoscopic 45570 50127 54684 59241 63798 66076
Pyelopyelostomy
Pyeloplasty / Pyeloureterostomy / 0 0 OPEN YES
1713 Urology SU Urology, Pediatric Surgery SU021 SU021C Pyeloureterostomy - Open 40635 44698 48762 52825 56889 58920
Pyelopyelostomy
Pyeloplasty / Pyeloureterostomy / 0 0 OPEN YES
1714 Urology SU Urology, Pediatric Surgery SU021 SU021D Pyeloureterostomy - Laparoscopic 45570 50127 54684 59241 63798 66076
Pyelopyelostomy
Pyeloplasty / Pyeloureterostomy / 0 0 OPEN YES
1715 Urology SU Urology, Pediatric Surgery SU021 SU021E Pyelopyelostomy - Open 40635 44698 48762 52825 56889 58920
Pyelopyelostomy
Pyeloplasty / Pyeloureterostomy / 0 0 OPEN YES
1716 Urology SU Urology, Pediatric Surgery SU021 SU021F Pyelopyelostomy - Laparoscopic 45570 50127 54684 59241 63798 66076
Pyelopyelostomy
0 0 OPEN YES
1717 Urology SU Urology, Pediatric Surgery SU023 Ureterocalycostomy SU023A Ureterocalycostomy - Open 41895 46084 50274 54463 58653 60747
0 0 OPEN YES
1718 Urology SU Urology, Pediatric Surgery SU023 Ureterocalycostomy SU023B Ureterocalycostomy - Laparoscopic 46830 51513 56196 60879 65562 67903
0 0 OPEN
1719 Urology SU Urology, Pediatric Surgery SU024 Pyelolithotomy SU024A Open 39375 43312 47250 51187 55125 57093
0 0 OPEN
1720 Urology SU Urology, Pediatric Surgery SU024 Pyelolithotomy SU024B Lap. 39375 43312 47250 51187 55125 57093
a) Clinical Notes detailing a) Detailed Indoor case OPEN
the signs and symptoms papers
and need for surgery b) Detailed Procedure /
b) Retrograde operation notes
Internal Urethrotomy including cystoscopy Internal Urethrotomy including cystoscopy as an
1721 Urology SU Urology SU025 SU025A 13335 14668 16002 17335 18669 19335 Urethrogram/ Micturating c) Endoscopic Intra
as an independent procedure independent procedure
Cystourethrography reports procedure still photograph
confirming the diagnosis d) Detailed discharge
summary

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings and papers
planned line of treatment b) Intra procedure still
b) CT-IVP/ MRI Urogram photograph
Ureterolysis for retroperitoneal fibrosis report confirming the c) Detailed Procedure /
1722 Urology SU Urology SU026 SU026A Open 39375 43312 47250 51187 55125 57093
(with or without omental wrapping) diagnosis Operative Notes including
details of omental wrapping
if done
d) Detailed discharge
summary
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings and papers
planned line of treatment b) Intra procedure still
b) CT-IVP/ MRI Urogram photograph
Ureterolysis for retroperitoneal fibrosis report confirming the c) Detailed Procedure /
1723 Urology SU Urology SU026 SU026B Lap. 38430 42273 46116 49959 53802 55723
(with or without omental wrapping) diagnosis Operative Notes including
details of omental wrapping
if done
d) Detailed discharge
summary
0 0 OPEN
1724 Urology SU Urology, Pediatric Surgery SU027 Ureterostomy SU027A Ureterostomy (Cutaneous) 26670 29337 32004 34671 37338 38671
0 0 OPEN
1725 Urology SU Urology, Pediatric Surgery SU028 Uretero-ureterostomy SU028A Open 39375 43312 47250 51187 55125 57093
0 0 OPEN YES
1726 Urology SU Urology, Pediatric Surgery SU028 Uretero-ureterostomy SU028B Lap. 44310 48741 53172 57603 62034 64249
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed Operative notes
and planned line of / Procedure notes
Urology , Obstetrics & management c) Intra procedure still
1727 Urology SU SU029 Uretero-vaginal / Uterine fistula repair SU029A Uretero - vaginal fistula repair - Open 34545 37999 41454 44908 48363 50090
Gynecology b) Intravenous pyelogram photograph
(IVP)/ CT-IVP/CT-urogram d) Detailed Discharge
report + Summary
cystoscopy and
vaginoscopy report
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed Operative notes
and planned line of / Procedure notes
Urology , Obstetrics & management c) Intra procedure still
1728 Urology SU SU029 Uretero-vaginal / Uterine fistula repair SU029B Uretero - Uterine fistula repair - Open 34545 37999 41454 44908 48363 50090
Gynecology b) Intravenous pyelogram photograph
(IVP)/ CT-IVP/CT-urogram d) Detailed Discharge
report + Summary
cystoscopy and
vaginoscopy report
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed Operative notes
and planned line of / Procedure notes
Urology , Obstetrics & management c) Intra procedure still
1729 Urology SU SU029 Uretero-vaginal / Uterine fistula repair SU029C Uretero - vaginal fistula repair - Laparoscopic 34545 37999 41454 44908 48363 50090
Gynecology b) Intravenous pyelogram photograph
(IVP)/ CT-IVP/CT-urogram d) Detailed Discharge
report + Summary
cystoscopy and
vaginoscopy report
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed Operative notes
and planned line of / Procedure notes
Urology , Obstetrics & management c) Intra procedure still
1730 Urology SU SU029 Uretero-vaginal / Uterine fistula repair SU029D Uretero - Uterine fistula repair - Laparoscopic 34545 37999 41454 44908 48363 50090
Gynecology b) Intravenous pyelogram photograph
(IVP)/ CT-IVP/CT-urogram d) Detailed Discharge
report + Summary
cystoscopy and
vaginoscopy report
0 0 OPEN
1731 Urology SU Urology, Pediatric Surgery SU030 Ureteric reimplantation SU030A Open 33495 36844 40194 43543 46893 48567
0 0 OPEN
1732 Urology SU Urology, Pediatric Surgery SU030 Ureteric reimplantation SU030B Lap. 33495 36844 40194 43543 46893 48567
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed indoor case OPEN YES
evaluation findings and papers
planned line of treatment b) Detailed Procedure /
b) Intravenous pyelogram Operative Notes
1733 Urology SU Urology SU031 Boari flap for ureteric stricture SU031A Open 41895 46084 50274 54463 58653 60747 /CT- Intravenous c) Detailed Discharge
pyelogram +/- Micturating Summary
Cysto-Urethrogram

a) Clinical notes including a) Detailed indoor case OPEN YES

evaluation findings and papers
planned line of treatment b) Detailed Procedure /
b) Intravenous pyelogram Operative Notes
1734 Urology SU Urology SU031 Boari flap for ureteric stricture SU031B Lap. 44310 48741 53172 57603 62034 64249 /CT- Intravenous c) Detailed Discharge
pyelogram +/- Micturating Summary
Cysto-Urethrogram

a) Clinical notes a) Indoor case papers OPEN YES

b) Antegrade and b) Detailed procedure /
Retrograde Pyelography operative notes
1735 93901 102438 110974 119511 123779 c) Computed Tomography c) Detailed discharge
Urology SU Urology SU032 Ileal replacement for ureteric stricture SU032A Ileal replacement for ureteric stricture 85365
KUB/ Urography summary
d) Diuretic renography/
creatinine clearance

0 0 OPEN
DJ stenting including cystoscopy, ureteric DJ stenting including cystoscopy, ureteric
1736 Urology SU Urology, Pediatric Surgery SU033 SU033A 13230 14553 15876 17199 18522 19183
catheterization, retrograde pyelogram catheterization, retrograde pyelogram
a) Clinical notes with a) Detailed Indoor Case OPEN
planned line of treatment Papers
b) Discharge Summary of b) Detailed Procedure /
1737 7623 8316 9009 9702 10048 previous of DJ Stent operation notes
Urology SU Urology SU034 DJ Stent Removal SU034A DJ Stent Removal 6930
insertion c) Detailed Discharge
c) Pre procedure imaging Summary
showing DJ stent (X-
ray/USG KUB)
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings and papers
planned line of treatment b) Evidence of cystoscopy,
Ureterocele incision including cystoscopy, b) USG/IVP/CT-IVP ureteric catheterization,
Ureterocele incision including cystoscopy, confirming the diagnosis retrograde pyelogram
1738 Urology SU Urology SU035 ureteric catheterization, retrograde SU035A 26250 28875 31500 34125 36750 38062
ureteric catheterization, retrograde pyelogram c) Detailed Procedure /
pyelogram
Operative Notes
d) Detailed discharge
summary

a) Clinical notes including a) Detailed indoor case OPEN

evaluation findings and papers
Ureteric sampling including cystoscopy, planned line of treatment b) Histopathology report
Ureteric sampling including cystoscopy, ureteric
1739 Urology SU Urology SU036 ureteric catheterization, retrograde SU036A 19740 21714 23688 25662 27636 28623 b) X-ray/USG/CT Scan c) Detailed Procedure /
catheterization, retrograde pyelogram
pyelogram report Operative
d) Detailed discharge
summary
Acute management of upper urinary tract 0 0 OPEN 5
Acute management of upper urinary tract
1740 Urology SU Urology, Pediatric Surgery SU037 SU037A trauma – 11550 12705 13860 15015 16170 16747
trauma – conservative
conservative
a) Clinical notes a) Detailed Indoor case OPEN
b) Intravenous pyelogram papers
/CT- Intravenous b) Detailed procedure /
1741 43312 47250 51187 55125 57093 pyelogram +/- Micturating operative notes
Urology SU Urology SU038 Endopyelotomy SU038A Retrograde with laser / bugbee 39375
Cysto-Urethrogram c) Bugbee electrode
c) Diuretic renogram (barcode)
d) Detailed Discharge
Summary
a) Clinical notes a) Detailed Indoor case OPEN
b) Intravenous pyelogram papers
/CT- Intravenous b) Detailed procedure /
1742 43312 47250 51187 55125 57093 pyelogram +/- Micturating operative notes
Urology SU Urology SU038 Endopyelotomy SU038B Antegrade with laser / bugbee 39375
Cysto-Urethrogram c) Bugbee electrode
c) Diuretic renogram (barcode)
d) Detailed Discharge
Summary
Cystolithotomy - Open, including 0 0 OPEN
1743 Urology SU Urology, Pediatric Surgery SU040 SU040A Open - including cystoscopy 26145 28759 31374 33988 36603 37910
cystoscopy
Cystolithotripsy / Urethral Stone Cystolithotripsy endoscopic, including 0 0 OPEN
1744 Urology SU Urology, Pediatric Surgery SU041 SU041A 26145 28759 31374 33988 36603 37910
endoscopic, including cystoscopy cystoscopy
Cystolithotripsy / Urethral Stone Urethral Stone removal endoscopic, including 0 0 OPEN
1745 Urology SU Urology, Pediatric Surgery SU041 SU041B 26145 28759 31374 33988 36603 37910
endoscopic, including cystoscopy cystoscopy
1746 Urology SU Urology SU042 Diagnostic Cystoscopy SU042A Diagnostic Cystoscopy 6500 7150 7800 8450 9100 9425 0 0 OPEN
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings and papers
Urology, Surgical planned line of treatment b) Histopathology report
1747 Urology SU Oncology, Pediatric SU043 Partial Cystectomy SU043A Open 34440 37884 41328 44772 48216 49938 b) CT/ MRI report c) Detailed procedure /
Surgery c) FNAC / Biopsy report operative Notes
d) Detailed discharge
summary
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings and papers
Urology, Surgical planned line of treatment b) Histopathology report
1748 Urology SU Oncology, Pediatric SU043 Partial Cystectomy SU043B Lap. 33495 36844 40194 43543 46893 48567 b) CT/ MRI report c) Detailed procedure /
Surgery c) FNAC / Biopsy report operative Notes
d) Detailed discharge
summary
1749 Urology SU Urology SU044 Partial Cystectomy - Follow Up SU044A Partial Cystectomy - Follow Up 1000 1100 1200 1300 1400 1450 0 0 OPEN yes
0 0 OPEN YES
1750 Urology SU Urology, Pediatric Surgery SU045 Augmentation cystoplasty SU045A Open 41895 46084 50274 54463 58653 60747
0 0 OPEN YES
1751 Urology SU Urology, Pediatric Surgery SU045 Augmentation cystoplasty SU045B Lap. 46830 51513 56196 60879 65562 67903
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Detailed Clinical notes a) Detailed clinical papers OPEN
with history, indications, along with the treatment
symptoms, signs, given
1752 6121 6678 7234 7791 8069 examination findings and b) Detailed procedure notes
Urology SU Urology SU046 Deflux for VUR SU046A Deflux for VUR(only procedure charge) 5565
advice for admission c) Intravenous urography
b) Discharge summary of d) Detailed Discharge
last admission for Deflux Summary
for VUR
Open bladder diverticulectomy with / Open bladder diverticulectomy with / without 0 0 OPEN
1753 Urology SU Urology, Pediatric Surgery SU048 SU048A 34545 37999 41454 44908 48363 50090
without ureteric re-implantation ureteric re-implantation
Bladder injury repair Bladder injury repair 0 0 OPEN
1754 Urology SU Urology, Pediatric Surgery SU049 SU049A 33495 36844 40194 43543 46893 48567
(with or without urethral injury) (with or without urethral injury)
Bladder injury repair with colostomy Bladder injury repair with colostomy 0 0 OPEN
1755 Urology SU Urology, Pediatric Surgery SU050 SU050A 38220 42042 45864 49686 53508 55419
(with or without urethral injury) (with or without urethral injury)
Extrophy Bladder repair including 0 0 OPEN YES
Extrophy Bladder repair including osteotomy if
1756 Urology SU Urology, Pediatric Surgery SU051 osteotomy if needed + epispadias repair + SU051A 118125 129937 141750 153562 165375 171281
needed + epispadias repair + ureteric reimplant
ureteric reimplant
Neurogenic bladder - Package for Neurogenic bladder - Package for evaluation / 0 0 OPEN
evaluation / investigation (catheter + investigation (catheter + ultrasound + culture +
1757 Urology SU Urology, Pediatric Surgery SU052 SU052A 21525 23677 25830 27982 30135 31211
ultrasound + culture + RGU/ MCU) for 1 RGU/ MCU) for 1 month (medicines -
month (medicines - antibiotics) antibiotics)
a) Detailed Clinical notes a) Detailed indoor case OPEN
with history, indication for papers
procedure/surgery, b) Detailed Procedure /
1758 23908 26082 28255 30429 31515 symptoms, signs, operation notes
Urology SU Urology SU054 Bladder Neck incision - Endoscopic SU054A Bladder Neck incision - Endoscopic 21735
examination findings and c) Post Procedure
advice for admission endoscopic photograph
b) Uroflowmetry/ USG- d) Detailed discharge
KUB/PVR tests summary
a) Clinical notes. a) Histopathology. OPEN
b) USG. b) Detailed discharge
c) CT. summary.
TURBT
TURBT d) MRI confirming the c) detailed Procedure.
1759 Urology SU Urology, Surgical Oncology SU055 (Transurethral Resection of the Bladder SU055A 38220 42042 45864 49686 53508 55419
(Transurethral Resection of the Bladder Tumor) diagnosis bladder tumour. d) Operative Notes.
Tumor)

a) Clinical notes. a) Intra procedure still OPEN

b) USG. photograph Histopathology.
c) CT. b) Detailed discharge
d) MRI confirming the summary.
1760 Urology SU Urology, Surgical Oncology SU056 TURBT - Restage SU056A TURBT - Restage 26040 28644 31248 33852 36456 37758 diagnosis bladder tumour. c) detailed Procedure.
d) Operative Notes.

a) Detailed Clinical notes a) Detailed clinical notes OPEN

with history, indications, and treatment given
symptoms, signs, b) Histopathology/ biopsy
examination findings and report confirming the
Post TURBT - Check Cystoscopy (Per Post TURBT - Check Cystoscopy (Per sitting) advice for admission diagnosis of bladder cancer
1761 Urology SU Urology SU057 SU057A 13125 14437 15750 17062 18375 19031 b) CT Scan recommending submitted? (If applicable)
sitting) with cold-cup biopsy with cold-cup biopsy
the Biopsy procedure to c) Detailed Procedure /
rule out bladder cancer (If Operative Notes
applicable) d) Detailed discharge
summary

a) Clinical notes including a) Detailed indoor case OPEN

evaluation findings, papers
indication for procedure, b) Operative Notes /
1762 Urology SU Urology SU058 Urachal Cyst excision SU058A Urachal Cyst excision - Open 28875 31762 34650 37537 40425 41868 and planned line of Procedure Notes
management c) Histopathology report
b) USG abdomen/ CT/MRI d) Detailed Discharge
report Summary
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Operative Notes /
1763 Urology SU Urology SU058 Urachal Cyst excision SU058B Urachal Cyst excision - Laparoscopic 31290 34419 37548 40677 43806 45370 and planned line of Procedure Notes
management c) Histopathology report
b) USG abdomen/ CT/MRI d) Detailed Discharge
report Summary
a) Clinical notes. a) Detailed discharge OPEN
b) Histopathology. summary.
c) biopsy confirming the b) Detailed Procedure.
Induction cycles (PC)
1764 16500 18000 19500 21000 21750 diagnosis of bladder c) Operative Notes.
Urology SU Urology, Medical Oncology SU060 Intravesical BCG / Mitomycin SU060A Rate per dose -Rs 5000 max no- 06 (including 15000
cancer. d) original bills of medicines
drug)
administered.

0 0 OPEN
1765 Urology SU Urology, Pediatric Surgery SU061 Suprapubic Drainage - Closed / Trocar SU061A Suprapubic Drainage - Closed / Trocar 6720 7392 8064 8736 9408 9744
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed Procedure /
1766 34072 37170 40267 43365 44913 and planned line of operative notes
Urology SU Urology, Surgical Oncology SU062 Stress incontinence surgery SU062A Stress incontinence surgery - Open 30975
management c) Barcode/invoice for
b) Cystoscopy/ USG Implant used
/Urodynamic study to d) Detailed discharge
confirm the diagnosis summary
Emergency management of Acute retention Emergency management of Acute retention of 0 0 OPEN 30 yes
1767 Urology SU Urology, Pediatric Surgery SU064 SU064A 2415 2656 2898 3139 3381 3501
of Urine Urine
0 0 OPEN
1768 Urology SU Urology, Pediatric Surgery SU065 Meatotomy / Meatoplasty SU065A Meatotomy 5460 6006 6552 7098 7644 7917
0 0 OPEN
1769 Urology SU Urology, Pediatric Surgery SU065 Meatotomy / Meatoplasty SU065B Meatoplasty 6195 6814 7434 8053 8673 8982
0 0 OPEN
1770 Urology SU Urology, Pediatric Surgery SU066 Urethroplasty SU066A Urethroplasty - End to end 39375 43312 47250 51187 55125 57093
0 0 OPEN
1771 Urology SU Urology, Pediatric Surgery SU066 Urethroplasty SU066B Urethroplasty - Substitution - single stage 39375 43312 47250 51187 55125 57093
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
0 0 OPEN YES
1772 Urology SU Urology, Pediatric Surgery SU066 Urethroplasty SU066C Urethroplasty - Substitution - two stage 78750 86625 94500 102375 110250 114187
0 0 OPEN YES
1773 Urology SU Urology, Pediatric Surgery SU066 Urethroplasty SU066D Urethroplasty - Transpubic 45360 49896 54432 58968 63504 65772
0 0 OPEN
1774 Urology SU Urology, Pediatric Surgery SU068 Urethral Dilatation SU068A Non endoscopic as an independent procedure 3360 3696 4032 4368 4704 4872
0 0 OPEN
1775 Urology SU Urology, Pediatric Surgery SU068 Urethral Dilatation SU068B Endoscopic as an independent procedure 7455 8200 8946 9691 10437 10809
0 0 OPEN
1776 Urology SU Urology, Pediatric Surgery SU069 Perineal Urethrostomy without closure SU069A Perineal Urethrostomy without closure 26670 29337 32004 34671 37338 38671
Post. Urethral Valve fulguration(to be checked 0 0 OPEN
1777 Urology SU Urology, Pediatric Surgery SU070 Post. Urethral Valve fulguration SU070A 26250 28875 31500 34125 36750 38062
from pead surgery)
Urology, Pediatric Surgery, 0 0 OPEN YES
1778 Urology SU Plastic & Reconstructive SU071 Hypospadias repair SU071A Single stage 52500 57750 63000 68250 73500 76125
Surgery
Urology, Pediatric Surgery, 0 0 OPEN
1779 Urology SU Plastic & Reconstructive SU071 Hypospadias repair SU071B Two or more stage (First Stage) 21420 23562 25704 27846 29988 31059
Surgery
Urology, Pediatric Surgery, 0 0 OPEN
1780 Urology SU Plastic & Reconstructive SU071 Hypospadias repair SU071D Two or more stage (Final Stage)/Fistula repair 30000 33000 36000 39000 42000 43500
Surgery
Urology, Pediatric Surgery, Emergency management of Hematuria(per 0 0 OPEN
1781 Urology SU SU073 Emergency management of Hematuria SU073A 2835 3118 3402 3685 3969 4110
Emergency day) LOS-1-5 days
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Detailed Operative/
1782 8200 8946 9691 10437 10809 and planned line of procedure notes
Urology SU Urology SU074 Excision of Urethral Caruncle SU074A Excision of Urethral Caruncle 7455
management c) Histopathology
b) Cystourethroscopy examination report
report (if applicable) d) Detailed Discharge
Summary
a) Detailed Clinical notes a) Detailed indoor case OPEN YES
with history, indications, papers
symptoms, signs, b) Investigation reports (If
Urology, Obstetrics & examination findings and required)
1783 Urology SU Gynecology, Pediatric SU075 Urethrovaginal fistula repair SU075A Urethrovaginal fistula repair 52500 57750 63000 68250 73500 76125 advice for admission c) Detailed
Surgery b) USG pelvis/abdomen procedure/operative notes
c) Three swab test d) Detailed Discharge
d) Planned line of Summary
treatment
0 0 OPEN YES
1784 Urology SU Urology, Pediatric Surgery SU076 Urethrorectal fistula repair SU076A Urethrorectal fistula repair 65625 72187 78750 85312 91875 95156
a) Clinical notes including a) Detailed Indoor case OPEN
evaluation findings and papers
planned line of treatment b) Histopathology report
b) USG with prostate size c) Detailed Procedure /
1785 Urology SU Urology SU077 Open simple prostatetctomy for BPH SU077A Open simple prostatetctomy for BPH 39165 43081 46998 50914 54831 56789 and Post Void Volume +/- Operative Notes
PSA, +/- uroflowmetry d) Detailed discharge
report confirming the summary
diagnosis

a) Clinical notes. a) Histopathology of OPEN YES

b) MRI. prostate.
c) CT prostrate. b) Detailed discharge
d) PSA. summary.
1786 Urology SU Urology SU078 Radical prostatectomy SU078A Open (to be checked with surg onco) 71400 78540 85680 92820 99960 103530 e) Biopsy. c) detailed Procedure.
d) Operative Notes with
details of nodes removed.

a) Clinical notes. a) Histopathology of OPEN YES

b) MRI. prostate.
c) CT prostrate. b) Detailed discharge
d) PSA. summary.
1787 Urology SU Urology SU078 Radical prostatectomy SU078B Lap.(to be checked with surg. Onco) 73920 81312 88704 96096 103488 107184 e) Biopsy. c) detailed Procedure.
d) Operative Notes with
details of nodes removed.

a) Clinical notes including a) Detailed Indoor case OPEN YES

evaluation findings and papers
planned line of treatment b) Histopathology report
b) USG with prostate size c) Detailed Procedure /
TURP-Transurethral Resection of the
1788 Urology SU Urology SU080 SU080A Monopolar 40635 44698 48762 52825 56889 58920 and Post Void Volume +/- Operative Notes
Prostate, BPH
PSA, +/- uroflowmetry d) Detailed discharge
report confirming the summary
diagnosis

a) Clinical notes including a) Detailed Indoor case OPEN YES

evaluation findings and papers
planned line of treatment b) Histopathology report
b) USG with prostate size c) Detailed Procedure /
TURP-Transurethral Resection of the
1789 Urology SU Urology SU080 SU080B Bipolar 40635 44698 48762 52825 56889 58920 and Post Void Volume +/- Operative Notes
Prostate, BPH
PSA, +/- uroflowmetry d) Detailed discharge
report confirming the summary
diagnosis
 Outside State
Outside State NABH Entry Outside State
Specialt Packag Procedur Non-NABH NABH Package NABH Entry Mandatory Documents - Mandatory Documents - Package Maximum Multiple Mendatory Fixed/ Veriable Day Care
SL NO Specialty Sub-Specialty Package Name Procedure Name Hospital with Level Package NABH Package
y Code e Code e Code Package Cost Cost Level Package Pre Authorization Claim Processing Category Type Day Procedures Pre-auth length of stay Procedure
>100 Bed Cost Cost
Cost
a) Clinical notes including a) Detailed indoor case OPEN
evaluation findings, papers
indication for procedure, b) Histopathology showing
and planned line of reporting of minimum 12
Transrectal Ultrasound guided prostate Transrectal Ultrasound guided prostate biopsy management, advise for core samples of prostate.
1790 Urology SU Urology SU081 SU081A 13335 14668 16002 17335 18669 19335 the procedure (As applicable)
biopsy (minimum 12 core) (minimum 12 core)
b) USG with prostate size c) Detailed Procedure /
and Post Void Volume Operative Notes
establishing suspicion of d) Detailed discharge
malignancy summary

a) Clinical notes including a) Detailed Indoor case OPEN

evaluation findings, papers
indication for procedure, b) Detailed Procedure /
1791 28875 31500 34125 36750 38062 and planned line of operative notes
Urology SU Urology, Surgical Onc