knowledge/icd_procedures.json

{
    "metadata": {
        "source": "ICD-10-PCS / NHA PMJAY / Indian hospital billing data",
        "description": "Common Indian hospital procedures with ICD codes, typical cost ranges by city tier, and insurance classification",
        "last_updated": "2025-09-01"
    },
    "procedures": [
        {
            "name": "Appendectomy (Laparoscopic)",
            "icd_code": "0DTJ4ZZ",
            "category": "general_surgery",
            "is_daycare": false,
            "typical_stay_days": [
                2,
                4
            ],
            "cost_range_tier1": [
                60000,
                180000
            ],
            "cost_range_tier2": [
                40000,
                120000
            ],
            "cost_range_tier3": [
                25000,
                80000
            ],
            "common_room_type": "semi_private",
            "waiting_period_applicable": false
        },
        {
            "name": "Appendectomy (Open)",
            "icd_code": "0DTJ0ZZ",
            "category": "general_surgery",
            "is_daycare": false,
            "typical_stay_days": [
                3,
                7
            ],
            "cost_range_tier1": [
                40000,
                120000
            ],
            "cost_range_tier2": [
                25000,
                80000
            ],
            "cost_range_tier3": [
                15000,
                50000
            ],
            "common_room_type": "general",
            "waiting_period_applicable": false
        },
        {
            "name": "Cholecystectomy (Laparoscopic)",
            "icd_code": "0FT44ZZ",
            "category": "general_surgery",
            "is_daycare": false,
            "typical_stay_days": [
                2,
                4
            ],
            "cost_range_tier1": [
                70000,
                200000
            ],
            "cost_range_tier2": [
                45000,
                140000
            ],
            "cost_range_tier3": [
                30000,
                90000
            ],
            "common_room_type": "semi_private",
            "waiting_period_applicable": false
        },
        {
            "name": "Total Knee Replacement (Unilateral)",
            "icd_code": "0SRD0JZ",
            "category": "orthopedic",
            "is_daycare": false,
            "typical_stay_days": [
                5,
                10
            ],
            "cost_range_tier1": [
                250000,
                500000
            ],
            "cost_range_tier2": [
                180000,
                350000
            ],
            "cost_range_tier3": [
                120000,
                250000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Total Knee Replacement (Bilateral)",
            "icd_code": "0SRD0JZ",
            "category": "orthopedic",
            "is_daycare": false,
            "typical_stay_days": [
                7,
                14
            ],
            "cost_range_tier1": [
                400000,
                900000
            ],
            "cost_range_tier2": [
                300000,
                650000
            ],
            "cost_range_tier3": [
                200000,
                450000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Coronary Artery Bypass Graft (CABG)",
            "icd_code": "0210093",
            "category": "cardiac",
            "is_daycare": false,
            "typical_stay_days": [
                7,
                14
            ],
            "cost_range_tier1": [
                300000,
                800000
            ],
            "cost_range_tier2": [
                200000,
                500000
            ],
            "cost_range_tier3": [
                150000,
                350000
            ],
            "common_room_type": "icu",
            "waiting_period_applicable": false,
            "notes": "Often emergency. Pre-existing heart disease may trigger PED waiting period."
        },
        {
            "name": "Angioplasty (PTCA) with Stent",
            "icd_code": "02703DZ",
            "category": "cardiac",
            "is_daycare": false,
            "typical_stay_days": [
                2,
                5
            ],
            "cost_range_tier1": [
                200000,
                600000
            ],
            "cost_range_tier2": [
                150000,
                400000
            ],
            "cost_range_tier3": [
                100000,
                300000
            ],
            "common_room_type": "icu",
            "waiting_period_applicable": false,
            "notes": "Drug-eluting stents are costlier. Some policies have stent sub-limits."
        },
        {
            "name": "Cataract Surgery (Phacoemulsification with IOL)",
            "icd_code": "08RJ3JZ",
            "category": "ophthalmology",
            "is_daycare": true,
            "typical_stay_days": [
                0,
                1
            ],
            "cost_range_tier1": [
                30000,
                80000
            ],
            "cost_range_tier2": [
                20000,
                60000
            ],
            "cost_range_tier3": [
                15000,
                40000
            ],
            "common_room_type": "daycare",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24,
            "notes": "Most policies have per-eye sub-limits (₹40K-₹80K per eye)"
        },
        {
            "name": "Caesarean Section (C-Section)",
            "icd_code": "10D00Z1",
            "category": "maternity",
            "is_daycare": false,
            "typical_stay_days": [
                4,
                7
            ],
            "cost_range_tier1": [
                80000,
                250000
            ],
            "cost_range_tier2": [
                50000,
                150000
            ],
            "cost_range_tier3": [
                30000,
                100000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24,
            "notes": "Maternity waiting period typically 24-36 months. Newborn coverage from day 1 in some policies."
        },
        {
            "name": "Normal Delivery",
            "icd_code": "10E0XZZ",
            "category": "maternity",
            "is_daycare": false,
            "typical_stay_days": [
                2,
                4
            ],
            "cost_range_tier1": [
                40000,
                120000
            ],
            "cost_range_tier2": [
                25000,
                80000
            ],
            "cost_range_tier3": [
                15000,
                50000
            ],
            "common_room_type": "semi_private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Hernia Repair (Laparoscopic)",
            "icd_code": "0YU60JZ",
            "category": "general_surgery",
            "is_daycare": false,
            "typical_stay_days": [
                1,
                3
            ],
            "cost_range_tier1": [
                50000,
                150000
            ],
            "cost_range_tier2": [
                35000,
                100000
            ],
            "cost_range_tier3": [
                20000,
                70000
            ],
            "common_room_type": "semi_private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Dialysis (Hemodialysis per session)",
            "icd_code": "5A1D70Z",
            "category": "nephrology",
            "is_daycare": true,
            "typical_stay_days": [
                0,
                0
            ],
            "cost_range_tier1": [
                2000,
                5000
            ],
            "cost_range_tier2": [
                1500,
                3500
            ],
            "cost_range_tier3": [
                1000,
                2500
            ],
            "common_room_type": "daycare",
            "waiting_period_applicable": false,
            "notes": "Pre-existing kidney disease may trigger PED waiting period."
        },
        {
            "name": "Chemotherapy (per cycle)",
            "icd_code": "3E04305",
            "category": "oncology",
            "is_daycare": true,
            "typical_stay_days": [
                0,
                2
            ],
            "cost_range_tier1": [
                20000,
                100000
            ],
            "cost_range_tier2": [
                15000,
                70000
            ],
            "cost_range_tier3": [
                10000,
                50000
            ],
            "common_room_type": "daycare",
            "waiting_period_applicable": false,
            "notes": "Immunotherapy can be significantly more expensive."
        },
        {
            "name": "Hip Replacement",
            "icd_code": "0SR9019",
            "category": "orthopedic",
            "is_daycare": false,
            "typical_stay_days": [
                5,
                10
            ],
            "cost_range_tier1": [
                250000,
                600000
            ],
            "cost_range_tier2": [
                180000,
                400000
            ],
            "cost_range_tier3": [
                120000,
                300000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Tonsillectomy",
            "icd_code": "0CTP0ZZ",
            "category": "ent",
            "is_daycare": true,
            "typical_stay_days": [
                0,
                2
            ],
            "cost_range_tier1": [
                25000,
                70000
            ],
            "cost_range_tier2": [
                15000,
                50000
            ],
            "cost_range_tier3": [
                10000,
                35000
            ],
            "common_room_type": "daycare",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Hysterectomy (Laparoscopic)",
            "icd_code": "0UT94ZZ",
            "category": "gynecology",
            "is_daycare": false,
            "typical_stay_days": [
                3,
                6
            ],
            "cost_range_tier1": [
                100000,
                300000
            ],
            "cost_range_tier2": [
                70000,
                200000
            ],
            "cost_range_tier3": [
                50000,
                150000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Kidney Stone Removal (PCNL/Lithotripsy)",
            "icd_code": "0TT60ZZ",
            "category": "urology",
            "is_daycare": false,
            "typical_stay_days": [
                2,
                5
            ],
            "cost_range_tier1": [
                60000,
                200000
            ],
            "cost_range_tier2": [
                40000,
                140000
            ],
            "cost_range_tier3": [
                25000,
                90000
            ],
            "common_room_type": "semi_private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Gallbladder Stone Removal",
            "icd_code": "0FT44ZZ",
            "category": "general_surgery",
            "is_daycare": false,
            "typical_stay_days": [
                2,
                4
            ],
            "cost_range_tier1": [
                60000,
                180000
            ],
            "cost_range_tier2": [
                40000,
                120000
            ],
            "cost_range_tier3": [
                25000,
                80000
            ],
            "common_room_type": "semi_private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24
        },
        {
            "name": "Spinal Fusion Surgery",
            "icd_code": "0SG10AJ",
            "category": "orthopedic",
            "is_daycare": false,
            "typical_stay_days": [
                5,
                10
            ],
            "cost_range_tier1": [
                300000,
                800000
            ],
            "cost_range_tier2": [
                200000,
                500000
            ],
            "cost_range_tier3": [
                150000,
                350000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": false
        },
        {
            "name": "Dengue/Malaria Treatment",
            "icd_code": "A90",
            "category": "infectious_disease",
            "is_daycare": false,
            "typical_stay_days": [
                3,
                7
            ],
            "cost_range_tier1": [
                30000,
                100000
            ],
            "cost_range_tier2": [
                20000,
                70000
            ],
            "cost_range_tier3": [
                10000,
                40000
            ],
            "common_room_type": "general",
            "waiting_period_applicable": false,
            "notes": "Covered after initial 30-day waiting period."
        },
        {
            "name": "Kidney Transplant (Recipient)",
            "icd_code": "0TY00Z0",
            "category": "nephrology",
            "is_daycare": false,
            "typical_stay_days": [
                10,
                21
            ],
            "cost_range_tier1": [
                600000,
                1500000
            ],
            "cost_range_tier2": [
                450000,
                1000000
            ],
            "cost_range_tier3": [
                300000,
                700000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 36,
            "notes": "Complex procedure. Donor expenses often covered up to specific sub-limits. Check immunosuppressant coverage."
        },
        {
            "name": "Robot-assisted Radical Prostatectomy",
            "icd_code": "0VT04ZZ",
            "category": "urology",
            "is_daycare": false,
            "typical_stay_days": [
                3,
                5
            ],
            "cost_range_tier1": [
                350000,
                700000
            ],
            "cost_range_tier2": [
                250000,
                500000
            ],
            "cost_range_tier3": [
                180000,
                350000
            ],
            "common_room_type": "private",
            "waiting_period_applicable": true,
            "typical_waiting_months": 24,
            "notes": "Modern robotic procedure. Many policies have sub-limits for robotic assistance (₹50K-₹1L)."
        }
    ]
}