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NEW YORK STATE MEDICAID PROGRAM

PHYSICIAN – PROCEDURE CODES

SECTION 5 - SURGERY

Physician – Procedure Codes, Section 5 - Surgery _____________________________________________________________________________

Table of Contents ANESTHESIA SECTION------------------------------------------------------------------------2 GENERAL INFORMATION AND RULES ------------------------------------------------2 CALCULATION OF TOTAL ANESTHESIA VALUES --------------------------------4 SURGERY SECTION ----------------------------------------------------------------------------5 GENERAL INFORMATION AND RULES ------------------------------------------------5 SURGERY SERVICES ------------------------------------------------------------------------ 11 GENERAL -------------------------------------------------------------------------------------- 11 INTERGUMENTARY SYSTEM ----------------------------------------------------------- 11 MUSCULOSKELETAL SYSTEM--------------------------------------------------------- 38 RESPIRATORY SYSTEM ---------------------------------------------------------------- 108 CARDIOVASCULAR SYSTEM --------------------------------------------------------- 122 HEMIC AND LYMPHATIC SYSTEMS ------------------------------------------------ 166 MEDIASTINUM AND DIAPHRAGM --------------------------------------------------- 169 DIGESTIVE SYSTEM---------------------------------------------------------------------- 170 URINARY SYSTEM ------------------------------------------------------------------------ 213 MALE GENITAL SYSTEM --------------------------------------------------------------- 230 REPRODUCTIVE SYSTEM PROCEDURES ---------------------------------------- 238 FEMALE GENITAL SYSTEM ----------------------------------------------------------- 238 MATERNITY CARE AND DELIVERY ------------------------------------------------- 250 ENDOCRINE SYSTEM-------------------------------------------------------------------- 254 NERVOUS SYSTEM----------------------------------------------------------------------- 256 EYE AND OCULAR ADNEXA ---------------------------------------------------------- 283 AUDITORY SYSTEM ---------------------------------------------------------------------- 299

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ANESTHESIA SECTION For moderate conscious sedation, see codes 99143 – 99150, in the Medicine section. This is the only specialty that will continue to be concerned with units for claim submission purposes. The maximum conversion factor is $10.00. Enter Total Anesthesia Value (total units) for each procedure in the units column of the MMIS Claim Form.

GENERAL INFORMATION AND RULES 1. The total values for anesthesia services include pre- and post-operative visits, the administration of the anesthetic and the administration of fluids and/or blood incident to the anesthesia or surgery. 2. Calculated values for anesthesia services are to be used only when the anesthesia is administered by a physician who remains in constant attendance during the procedure for the sole purpose of rendering such anesthesia service. When more than one anesthesiologist is billing due to attending in shifts only the first anesthesiologist is allowed to bill the Basic Value, all others should bill the anesthesia time only, do not add the Basic Value in addition to time when billing the second, third, shift etc. Anesthesiologists should bill on paper documenting their time in attendance. 3. When hypothermia and/or a pump oxygenator are employed in conjunction with an anesthetic, see procedure code(s) 99116, 99190, 99191, 99192. Do not report the Anesthesia Basic Value in addition to time when billing code(s) 99116, 99190, 99191, 99192 separately. To bill for the anesthesia time, report the appropriate surgery procedure code with modifier -AA. The total time billed should represent the anesthesia time only. Do not include the Anesthesia Basic Value in the calculation of the total anesthesia value. 4. If the general or regional anesthetic is administered by the attending surgeon, the fee will be fifty percent of the ordinarily calculated anesthesia value (see below). Such procedures shall be identified by adding the modifier -47 to the MMIS surgical procedure code. This does not apply to local anesthesia (see Rule #8). 5. In procedures where no value is listed, the basic portion of the calculated value will be the same as listed for comparable procedures. For claiming purposes, the closest comparable surgical procedure code will be used for such procedures. 6. Necessary drugs and materials provided by the anesthesiologist may be charged for separately. 7. Where unusual detention with the patient is essential for the safety and welfare of such patient, the necessary time will be valued on the same basis as indicated below for anesthesia time. 8. No fee will be allowed for local infiltration or digital block anesthesia administered by the operating surgeon.

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9. Anesthesia services not connected with surgery will be found in other sections of this fee schedule. 10. ALL anesthesia services must be identified by adding the modifier -23, -47, or -AA, to the same MMIS code number as the related surgical procedure. 11.

Anesthesia Report (or Operative Record) must document total time spent with the patient and include starting time, completion time and an explanation of any unusual occurrence which prolonged anesthesia time.

12. The following MMIS MODIFIERS are commonly used in anesthesia: -23

Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier -23 to the procedure code of the basic service. (Reimbursement will not exceed $30 plus time for the procedure.)

-47

Anesthesia By Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding the modifier -47 to the basic service. (This does not include local anesthesia.) (Reimbursement will not exceed 50% of the basic value plus time for the procedure.)

-AA

Anesthesia Services Preformed Personally By Anesthesiologist: All anesthesia services not reported with modifiers –23 or -47 will be identified by adding the modifier -AA to the procedure number of the surgical procedure. (Reimbursement will not exceed the basic value plus time for the procedure.)

For Anesthesia Complicated By Total Body Hypothermia and/or PUMP Oxygenator, see procedure code(s) 99116, 99190, 99191, 99192. Do not report these codes with an anesthesia modifier. See also Anesthesia Section, Rule #3.

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CALCULATION OF TOTAL ANESTHESIA VALUES Calculation of total anesthesia value is determined by adding the listed basic value and time units. To bill for the anesthesia time report the appropriate surgery procedure code with modifier –AA. When billing for anesthesia complicated by total body hypothermia and/or pump oxygenator, see procedure code(s) 99116, 99190, 99191, 99192. Do not report the anesthesia basic value in addition to time when billing code(s) 99116, 99190, 99191, 99192 separately. The total time billed on the service specific code should represent the anesthesia time only. A basic value is listed for most procedures. This includes the value of all anesthesia services except the value of the actual time spent administering the anesthesia or in unusual detention with the patient (see also Anesthesia Rule #7). The time units are computed by allowing one unit for each 15 minutes of anesthesia time. After the total anesthesia time is calculated, the resulting number of units should be rounded to the next whole number. Anesthesia time starts with the beginning of the administration of the anesthetic agents and ends when the anesthesiologist is no longer in personal attendance (when the patient may be safely placed under customary post-operative supervision). For example, in a procedure with a basic value of 5 units requiring two hours and forty-five minutes of an anesthesiologist's time, the time units total 11, and are added to the basic value of 5, producing a total anesthesia value of 16 units for this anesthesia service. Basic Value + Time Units = TOTAL ANESTHESIA VALUE CALCULATION OF ANESTHESIA VALUES FOR MULTIPLE/BILATERAL SURGICAL PROCEDURES When multiple or bilateral surgical procedures, which add time and complexity to patient care, are performed at the same operative session, the total anesthesia value should be calculated by taking 100% of the basic unit value assigned to the major surgical procedure plus the total time worked (1 hour 15 minutes, 2 hours 45 minutes, etc). The surgical procedure assigned the highest reimbursable fee may be considered the major procedure performed. Use the MMIS procedure code for the major procedure performed and the appropriate modifier (-23, -47, or -AA) when billing according to this instruction. (NOTE: Attach copy of Anesthesia Report to Operative Record which must verify total time spent with the patient.)

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SURGERY SECTION GENERAL INFORMATION AND RULES 1. FEES: Fees or values for office, home and hospital visits, consultations and other medical services are listed in the sections entitled MEDICINE. 2. FOLLOW-UP (F/U) DAYS: Listed dollar values for all surgical procedures include the surgery and the follow-up care for the period indicated in days in the column headed "F/U Days". Necessary follow-up care beyond this listed period is to be added on a fee-for-service basis. (See modifier -24) 3. BY REPORT: When the value of a procedure is indicated as "By Report" (BR), an Operative Report must be submitted with the MMIS claim form for a payment determination to be made. The Operative Report must include the following information: a. b. c. d. e. f.

Diagnosis (post-operative) Size, location and number of lesion(s) or procedure(s) where appropriate Major surgical procedure and supplementary procedure(s) Whenever possible, list the nearest similar procedure by number according to these studies Estimated follow-up period Operative time

Failure to submit an Operative Report when billing for a "By Report" procedure will cause your claim to be denied by MMIS. 4. ADDITIONAL SERVICES: Complications or other circumstances requiring additional and unusual services concurrent with the procedure(s) or during the listed period of normal follow-up care, may warrant additional charges on a fee-for-service basis. (See modifiers -24, -25, -79) 5. When an additional surgical procedure(s) is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue concurrently to their normal terminations. (See modifiers -78, -79) 6. SEPARATE PROCEDURE: Certain of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate charge. When such a procedure is carried out as a separate entity, not immediately related to other services, the indicated value for "Separate Procedure" is applicable.

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7. MULTIPLE SURGICAL PROCEDURES: a.

When multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed at the same operative session, the total dollar value shall be the value of the major procedure plus 50% of the value of the lesser procedure(s) unless otherwise specified. (For reporting bilateral surgical procedures, see modifier -50).

When an incidental procedure (eg, incidental appendectomy, lysis of adhesions, excision of previous scar, puncture of ovarian cyst) is performed through the same incision, the fee will be that of the major procedure only.

8. PROCEDURES NOT SPECIFICALLY LISTED: Will be given values comparable to those of the listed procedures of closest similarity. When no similar procedure can be identified, the MMIS procedure codes to be utilized may be found at the end of each section. 9. SUPPLEMENTAL SKILLS: When warranted by the necessity of supplemental skills, values for services rendered by two or more physicians will be allowed. 10. SKILLS OF TWO SURGEONS: a. When the skills of two surgeons are required in the management of a specific surgical procedure, by prior agreement, the total dollar value may be apportioned in relation to the responsibility and work done, provided the patient is made aware of the fee distribution according to medical ethics. The value may be increased by 25 percent under these circumstances. See MMIS modifier -62. b. PHYSICIAN ASSISTANT/NURSE PRACTITIONER SERVICES FOR ASSIST AT SURGERY: When a physician requests a nurse practitioner or a physician's assistant to participate in the management of a specific surgical procedure in lieu of another physician, by prior agreement, the total value may be apportioned in relation to the responsibility and work done, provided the patient is made aware of the fee distribution according to medical ethics. The value may be increased by 20 percent under these circumstances. The claim for these services will be submitted by the physician using the appropriate modifier.

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11. MATERIALS SUPPLIED BY A PHYSICIAN: Supplies and materials provided by the physician, eg, sterile trays/drugs, over and above those usually included with the office visit or other services rendered may be listed separately. List drugs, trays, supplies and materials provided. Identify as 99070. Reimbursement for drugs (including vaccines and immunglobulin) furnished by practitioners to their patients is based on the acquisition cost to the practitioner of the drug dose administered to the patient. For all drugs furnished in this fashion it is expected that the pracitioner will maintain auditable records of the actual itmeized invoice cost of the drug, including the numbers of doses of the drug represented on the invoice. New York State Medicaid does not intend to pay more than the acquisition cost of the drug dosage, as established by invoice, to the practitioner. Regardless of whether an invoice must be sumbitted to Medicaid for payment, the pracitioner is expected to limit his or her Medicaid claim amount to the actual invoice cost of the drug dosage administered. 12. PRIOR APPROVAL: Payment for those listed procedures where the MMIS code number is underlined is dependent upon obtaining the approval of the Department of Health prior to performance of the procedure. If such prior approval is not obtained, no reimbursement will be made. 13. INFORMED CONSENT FOR STERILIZATION: When procedures are performed for the primary purpose of rendering an individual incapable of reproducing, and in all cases when procedures identified by MMIS codes 55250, 55450, 58565, 58600, 58605, 58611, 58615, 58670 and 58671 are performed, the following rules will apply: a.

The patient must be 21 years of age or older at the time to consent to sterilization.

The patient must have been informed of the risks and benefits of sterilization and have signed the mandated consent form, (DSS-3134) not less than 30 days nor more than 180 days prior to the performance of the procedure. In cases of premature delivery and emergency abdominal surgery, consent must have been given at least 72 hours prior to sterilization.

No bill will be processed for payment without a properly completed consent form. (Refer to Billing Section for completion instructions).

NOTE: For procedures performed within the jurisdiction of NYC the guidelines established under NYC Local Law #37 of 1977 continue to be in force.

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14. RECEIPT OF HYSTERECTOMY INFORMATION: Hysterectomies must not be performed for the purpose of sterilization. When hysterectomy procedures are performed and in all cases when procedures identified by MMIS codes 51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, 59135, or 59525 are billed, a properly completed "Hysterectomy Receipt of Information Form" must be attached to the bill for payment. No bill will be processed without a properly completed "Hysterectomy Receipt of Information Form", (DSS-3113). 15. MMIS SURGERY MODIFIERS: -47

-50

Bilateral Procedure (Surgical): Unless otherwise identified in the listings, bilateral surgical procedures requiring a separate incision that are performed at the same operative session, should be identified by the appropriate five digit code describing the first procedure. To indicate a bilateral surgical procedure was done add modifier -50 to the procedure number. (Reimbursement will not exceed 150% of the maximum Fee Schedule amount. One claim line is to be billed representing the bilateral procedure. Amount billed should reflect total amount due.)

-54

Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management (or postoperative management is to be provided in an outpatient department when physician services are included in the rate), surgical services may be identified by adding the modifier -54 to the usual procedure number. (Reimbursement will not exceed 80% of the maximum Fee Schedule amount.)

-62

Two Surgeons: When two surgeons (usually of different skills) work together as primary surgeons performing distinct part(s) of a single reportable procedure, add the modifier –62 to the single definitive procedure code. [One surgeon should file one claim line representing the procedure performed by the two surgeons. Reimbursement will not exceed 125% of the maximum State Medical Fee Schedule amount.] If additional procedure(s) (including add-on procedure(s)) are performed during the same surgical session, separate code(s) may be reported without the modifier –62 added as appropriate. NOTE: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier –80 added, as appropriate.

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-63

Procedure Performed on Infants Less Than 4 kg: Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients. This circumstance may be reported by adding modifier –63 to the procedure number. Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20000-69999 code series. Modifier –63 should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections. (Reimbursement will not exceed 100% of the maximum Fee Schedule amount.)

-66

Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier -66 to the basic procedure number used for reporting services. (Reimbursement will not exceed 20% of the maximum Fee Schedule amount.)

-78

Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier -78 to the related procedure. (Reimbursement will not exceed 100% of the maximum Fee Schedule amount.)

-79

Unrelated Procedure or Service by the Same Practitioner During the Postoperative Period: The practitioner may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by adding the modifier -79. (Reimbursement will not exceed 100% of the maximum Fee Schedule amount.)

-80

Assistant Surgeon: Surgical assistant services may be identified by adding the modifier -80 to the usual procedure number(s). (Reimbursement will not exceed 20% of the maximum Fee Schedule amount.)

-82

Assistant Surgeon: (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier -82 appended to the usual procedure code number(s). (Reimbursement will not exceed 20% of the maximum Fee Schedule amount.)

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-AS

Physician Assistant or Nurse Practitioner Services for Assist at Surgery: When the physician requests that a Physician Assistant or Nurse Practitioner assist at surgery in lieu of another physician, Modifier -AS should be added to the appropriate code describing the procedure. One claim is to be filed. (Reimbursement will not exceed 120% of the maximum Fee Schedule amount).

-LT

Left Side (used to identify procedures performed on the left side of the body): Add modifier –LT to the usual procedure code number. (Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both sides done at same operative session.)

-RT

Right Side (used to identify procedures performed on the right side of the body): Add modifier –RT to the usual procedure code number. (Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both sides done at same operative session.)

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SURGERY SERVICES GENERAL 10021 10022

Fine needle aspiration; without imaging guidance with imaging guidance (For radiological supervision and interpretation, see 76942, 77002, 77012, 77021) (For percutaneous needle biopsy, other than fine needle aspiration, see 20206 for muscle, 32400 for pleura, 32405 for lung or mediastinum, 42400 for salivary gland, 47000, 47001 for liver, 48102 for pancreas, 49180 for abdominal or retroperitoneal mass, 60100 for thyroid, 62269 for spinal cord)

INTERGUMENTARY SYSTEM SKIN, SUBCUTANEOUS AND ACCESSORY STRUCTURES INCISION AND DRAINAGE (For excision, see 11400, et seq) 10040 10060 10061 10080 10081

Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single complicated or multiple Incision and drainage of pilonidal cyst; simple complicated (For excision of pilonidal cyst, see 11770-11772)

10120 10121

Incision and removal of foreign body, subcutaneous tissues; simple complicated (To report wound exploration due to penetrating trauma without laparotomy or thoracotomy, see 20100-20103, as appropriate) (To report debridement associated with open fracture(s) and/or dislocation(s), use 11010-11012, as appropriate)

10140

Incision and drainage of hematoma, seroma or fluid collection (If imaging guidance is performed, see 76942, 77012, 77021)

10160

Puncture aspiration of abscess, hematoma, bulla or cyst (If imaging guidance is performed, see 76942, 77012, 77021)

10180

Incision and drainage, complex, postoperative wound infection (For secondary closure of surgical wound, see 12020, 12021, 13160)

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EXCISION – DEBRIDEMENT (For dermabrasions, see 15780-15783) (For nail debridement, see 11720-11721) (For burn(s), see 16000-16035) 11000

Debridement of extensive eczematous or infected skin; up to 10% of body surface (For abdominal wall or genitalia debridement for necrotizing soft tissue infection, see 11004-11006)

11001

11004 11005 11006 11008

each additional 10% of the body surface (List separately in addition to primary procedure) (Use 11001 in conjunction with 11000) Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum abdominal wall, with or without fascial closure external genitalia, perineum and abdominal wall, with or without fascial closure Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to primary procedure) (Use 11008 in conjunction with 10180, 11004-11006) (Do not report 11008 in conjunction with 11000-11001, 11010-11044) (Report skin grafts or flaps separately when performed for closure at the same session as 11004-11008) (When insertion of mesh is used for closure, use 49568) (If orchiectomy is performed, use 54520) (If testicular transplantation is performed, use 54680)

11010 11011 11012 11040 11041 11042 11043 11044

Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues skin, subcutaneous tissue, muscle fascia, and muscle skin, subcutaneous tissue, muscle fascia, muscle, and bone Debridement; skin, partial thickness skin, full thickness skin, and subcutaneous tissue skin, subcutaneous tissue, and muscle skin, subcutaneous tissue, muscle, and bone

PARING OR CUTTING (To report destruction, see 17000-17004) 11055 11056 11057

Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion two to four lesions more than four lesions

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BIOPSY During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported. The use of a biopsy procedure code (eg, 11100, 11101) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other procedures/services provided at that time. Such biopsies are not considered components of other procedures when performed on different lesions or different sites on the same date, and are to be reported separately. (For biopsy of conjunctiva, use 68100; eyelid, use 67810) 11100 11101

Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion each separate/additional lesion (List separately in addition to primary procedure) (Use 11101 in conjunction with 11100)

REMOVAL OF SKIN TAGS Removal by scissoring, or any sharp method, ligature strangulation electrosurgical destruction or combination of treatment modalities including chemical or electrocauterization of wound, with or without local anesthesia. 11200 11201

Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions each additional ten lesions (List separately in addition to primary procedure) (Use 11201 in conjunction with 11200)

SHAVING OF EPIDERMAL OR DERMAL LESIONS Shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision. This includes local anesthesia, chemical or electrocauterization of the wound. The wound does not require suture closure. 11300 11301 11302 11303 11305 11306 11307 11308

Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm. or less lesion diameter 0.6 to 1.0 cm lesion diameter 1.1 to 2.0 cm lesion diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less lesion diameter 0.6 to 1.0 cm lesion diameter 1.1 to 2.0 cm lesion diameter over 2.0 cm

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11310 11311 11312 11313

Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less lesion diameter 0.6 to 1.0 cm lesion diameter 1.1 to 2.0 cm lesion diameter over 2.0 cm

EXCISION – BENIGN LESIONS Excision (including simple closure) of benign lesions of skin (eg, neoplasm, cicatricial, fibrous, inflammatory, congenital, cystic lesions), includes local anesthesia. See appropriate size and area below. For shave removal, see 11300 et seq., and for electrosurgical and other methods, see 17000 et seq. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Report separately each benign lesion excised. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgement. The measurement of lesion plus margin is made prior to excision. The excised diameter is the same whether the surgical defect is repaired in a linear fashion, or reconstructed (eg, with a skin graft). The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately. For excision of benign lesions requiring more than simple closure, ie, requiring intermediate or complex closure, report 11400-11466 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, see 11400-14300, 1500215261, 15570-15770. For definition of intermediate or complex closure, see Integumentary System, Repair (Closure). 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less excised diameter 0.6 to 1.0 cm excised diameter 1.1 to 2.0 cm excised diameter 2.1 to 3.0 cm excised diameter 3.1 to 4.0 cm excised diameter over 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less excised diameter 0.6 to 1.0 cm excised diameter 1.1 to 2.0 cm excised diameter 2.1 to 3.0 cm excised diameter 3.1 to 4.0 cm excised diameter over 4.0 cm

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11440 11441 11442 11443 11444 11446

Excision, other benign lesion including margins, (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less excised diameter 0.6 to 1.0 cm excised diameter 1.1 to 2.0 cm excised diameter 2.1 to 3.0 cm excised diameter 3.1 to 4.0 cm excised diameter over 4.0 cm (For eyelids involving more than skin, see also 67800 et seq)

11450 11451 11462 11463 11470 11471

Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair with complex repair Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair with complex repair Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal or umbilical; with simple or intermediate repair with complex repair (For bilateral procedure, add modifier 50) (When skin graft or flap is used for closure, use appropriate procedure code in addition)

EXCISION - MALIGNANT LESIONS Excision (including simple closure) of malignant lesions of skin (eg, basal cell carcinoma, squamous cell carcinoma, melanoma) includes local anesthesia. (See appropriate size and body area below). For destruction of malignant lesions of skin, see destruction codes 17260-17286. Excision is defined as full-thickness (through the dermis) removal of a lesion including margins, and includes simple (non-layered) closure when performed. Report separately each malignant lesion excised. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision. The excised diameter is the same whether the surgical defect is repaired in a linear fashion, or reconstructed (eg, with a skin graft). The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately. For excision of malignant lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11600-11646 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, see 14000-14300, 1500215261, 15570-15770. See definition of intermediate or complex closure. When frozen section pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision(s) based on the final widest excised diameter required for complete tumor removal at the same operative session.

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To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate. 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646

Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less excised diameter 0.6 to 1.0 cm excised diameter 1.1 to 2.0 cm excised diameter 2.1 to 3.0 cm excised diameter 3.1 to 4.0 cm excised diameter over 4.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less excised diameter 0.6 to 1.0 cm excised diameter 1.1 to 2.0 cm excised diameter 2.1 to 3.0 cm excised diameter 3.1 to 4.0 cm excised diameter over 4.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less excised diameter 0.6 to 1.0 cm excised diameter 1.1 to 2.0 cm excised diameter 2.1 to 3.0 cm excised diameter 3.1 to 4.0 cm excised diameter over 4.0 cm (For eyelids involving more than skin, see also 67800 et seq)

NAILS (For drainage of paronychia or onychia, see 10060, 10061) 11720 11721 11730 11732

Debridement of nail(s) by any method(s); one to five six or more Avulsion of nail plate, partial or complete, simple; single each additional nail plate (List separately in addition to primary procedure) (Use 11732 in conjunction with 11730)

11740 11750

Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal; with amputation of tuft of distal phalanx

11752

(For skin graft, if used, see 15050) 11755 11760 11762 11765

Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (seperate procedure) Repair of nail bed Reconstruction of nail bed with graft Wedge excision of skin of nail fold (eg, for ingrown toenail)

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PILONIDAL CYST 11770 11771 11772

Excision of pilonidal cyst or sinus; simple extensive complicated

INTRODUCTION 11900 11901

Injection, intralesional; up to and including seven lesions more than seven lesions (11900, 11901 are not to be used for preoperative local anesthetic injection) (For veins, see 36470, 36471) (For intralesional chemotherapy administration, see 96405, 96406)

11920 11921 11922

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less 6.1 to 20.0 sq cm each additional 20.0 sq cm (Report required) (List separately in addition to primary procedure) (Use 11922 in conjunction with 11921)

11950 11951 11952 11954 11960

Subcutaneous injection of filling material (eg, collagen); 1 cc or less (Report required) 1.1 to 5 cc (Report required) 5.1 to 10 cc (Report required) over 10 cc (Report required) Insertion of tissue expander(s) for other than breast, including subsequent expansion (For breast reconstruction with tissue expander(s), use 19357)

11970 11971 11975 11976 11977 11980 11981 11982 11983

Replacement of tissue expander with permanent prosthesis Removal of tissue expander(s) without insertion of prosthesis Insertion, implantable contraceptive capsules Removal, implantable contraceptive capsules Removal with reinsertion, implantable contraceptive capsules Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) Insertion, non-biodegradable drug delivery implant Removal, non-biodegradable drug delivery implant Removal with reinsertion, non-biodegradable drug delivery implant

REPAIR (CLOSURE) Use the codes in this section to designate wound closure utilizing sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code. DEFINITIONS:

The repair of wounds may be classified as Simple, Intermediate or Complex.

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SIMPLE REPAIR: is used when the wound is superficial; ie, involving primarily epidermis or

dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed. (For closure with adhesive strips, list appropriate Evaluation and Management service only). INTERMEDIATE REPAIR: includes the repair of wounds that, in addition to the above, require

layer closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair. COMPLEX REPAIR: includes the repairs of wounds requiring more than layered closure, viz, scar

revision, debridement, (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions. Instructions for listing services at time of wound repair: 1. The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular or stellate. 2. When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of imtermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (eg, face and extremities). Also, do not add together lengths of different classifications (eg, intermediate and complex repairs). 3. Decontamination and/or debridement: Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure. (For extensive debridement of soft tissue and/or bone, see 11040-11044) (For extensive debridement of soft tissue and/or bone, not associated with open fracture(s) and/or dislocation(s) resulting from penetrating and/or blunt trauma, see 11040-11044.) (For extensive debridement of subcutaneous tissue, muscle fascia, muscle, and/or bone associated with open fracture(s) and/or dislocation(s), see 11010-11012.) 4. Involvement of nerves, blood vessels and tendons: Report under appropriate system (Nervous, Cardiovascular, Musculoskeletal) for repair of these structures. The repair of these associated wounds is included in the primary procedure. Simple ligation of vessels in an open wound is considered as part of any wound closure.

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Simple exploration of nerves, blood vessels or tendons exposed in an open wound is also considered part of the essential treatment of the wound and is not a separate procedure unless appreciable dissection is required. If the wound requires enlargment, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle, fascia, and/or muscle, not requiring thoracotomy or laparotomy, use codes 20100-20103, as appropriate. REPAIR-SIMPLE (Sum of length of repairs for each group of anatomic sites) 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less 2.6 cm to 7.5 cm 7.6 cm to.12.5 cm 12.6 cm to 20.0 cm 20.1 cm to 30.0 cm over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 2.6 cm to 5.0 cm 5.1 cm to 7.5 cm 7.6 cm to 12.5 cm 12.6 cm to 20.0 cm 20.1 cm to 30.0 cm over 30.0 cm Treatment of superficial wound dehiscence; simple closure (For extensive or complicated secondary wound closure, see 13160)

REPAIR-INTERMEDIATE (Sum of length of repairs for each group of anatomic sites.) 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047

Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less 2.6 cm to 7.5 cm 7.6 cm to.12.5 cm 12.6 cm to 20.0 cm 20.1 cm to 30.0 cm over 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 2.6 cm to 7.5 cm 7.6 cm to.12.5 cm 12.6 cm to 20.0 cm 20.1 cm to 30.0 cm over 30.0 cm

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12051 12052 12053 12054 12055 12056 12057

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 2.6 cm to 5.0 cm 5.1 cm to 7.5 cm 7.6 cm to 12.5 cm 12.6 cm to 20.0 cm 20.1 cm to 30.0 cm over 30.0 cm

REPAIR-COMPLEX Reconstructive procedures, complicated wound closure. Sum of length of repairs for each group of anatomic sites. (For full thickness repair of lip or eyelid, see respective anatomical subsections.) 13100 13101 13102

Repair, complex, trunk; 1.1 cm to 2.5 cm 2.6 cm to 7.5 cm each additional 5 cm or less (List separately in addition to primary procedure) (Use 13102 in conjunction with 13101)

13120 13121 13122

Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm 2.6 cm to 7.5 cm each additional 5 cm or less (List separately in addition to primary procedure) (Use 13122 in conjunction with 13121)

13131

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm 2.6 cm to 7.5cm each additional 5 cm or less (List separately in addition to primary procedure) (Use 13133 in conjunction with 13132)

13132 13133

13150 13151 13152 13153

13160

Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less (See also 40650-40654, 67961-67975) 1.1 cm to 2.5 cm 2.6 cm to 7.5 cm each additional 5 cm or less (List separately in addition to primary procedure) (Use 13153 in conjunction with 13152) Secondary closure of surgical wound or dehiscence, extensive or complicated (For packing or simple secondary wound closure, see 12020)

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ADJACENT TISSUE TRANSFER OR REARRANGEMENT For full thickness repair of lip or eyelid, see respective anatomical subsections. Excision (including lesion) and/or repair by adjacent tissue transfer or rearrangement (eg, Z-plasty, W-plasty, V-Y plasty, rotation flap, advancement flap, double pedicle flap). When applied in repairing lacerations, the procedures listed must be developed by the surgeon to accomplish the repair. They do not apply when direct closure or rearrangement of traumatic wounds incidentally result in these configurations. Skin graft necessary to close secondary defect is considered an additional procedure. For purposes of code selection, the term “defect’’ includes the primary and secondary defects. The primary defect resulting from the excision and the secondary defect resulting from flap design to perform the reconstruction are measured together to determine the code. 14000 14001 14020 14021 14040 14041 14060 14061

Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm. or less defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less defect 10.1 sq cm to 30.0 sq cm (For eyelid, full thickness, see 67961 et seq)

14300 14350

Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area Filleted finger or toe flap, including preparation of recipient site

SKIN REPLACEMENT SURGERY AND SKIN SUBSTITUTES Identify by size and location of the defect (recipient area) and the type of graft or skin substitute; includes simple debridement of granulation tissue or recent avulsion. When a primary procedure such as orbitectomy, radical mastectomy or deep tumor removal requires skin graft for definitive closure, see appropriate anatomical subsection for primary procedure and this section for skin graft or skin substitute. Use 15002, 15005 for initial wound recipient site preparation. Use 15100-15261 for autogenous skin grafts. For autogenous tissue-cultured epidermal grafts, use 15150-15157. For harvesting of autologous keratinocytes and dermal tissue for tissuecultured skin grafts, use 15040. Procedures are coded by recipient site. Use 15170-15176 for acellular dermal replacement. Repair of donor site requiring skin graft or local flaps is to be added as an additional procedure.

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Codes 15002 and 15005 describe burn and wound preparation or incisional or excisional release of scar contracture resulting in an open wound requiring a skin graft. Codes 15100-15431 describe the application of skin replacements and skin substitutes. The following definition should be applied to those codes that reference “100 sq cm or one percent of body area of infants and children” when determining the involvement of body size: The measurement of 100 sq cm is applicable to adults and children age 10 and over, percentages of body surface area apply to infants and children under the age of 10. These codes are not intended to be reported for simple graft application alone or application stabilized with dressings (eg, simple gauze wrap) without surgical fixaton of the skin substitute/graft. The skin substitute/graft is anchored using the surgeon’s choice of fixation. When services are performed in the office, the supply of the skin substitute/graft should be reported separately. Routine dressing supplies are not reported separately. (For microvascular flaps, see 15756-15758) SURGICAL PREPARATION 15002

15003

15004

15005

Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to primary procedure) (Use 15003 in conjunction with 15002) Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to primary procedure) (Use 15005 in conjunction with 15004) (Report 15002-15005 in conjunction with code for appropriate skin grafts or replacements [15050-15261, 15330-15336]. List the graft or replacement separately by its procedure number when the graft, immediate or delayed, is applied) (For excision of benign lesions, see 11400-11471) (For excision of malignant lesions, see 11600-11646) (For excision to prepare or create recipient site with dressings or materials not listed in 15040-15431, use 15002-15005 only) (For excision with immediate allograft skin placement, use 15002-15005 in conjunction with 15300-15336 and 15360-15366) (For excision with immediate xenogeneic dermis placement, use 15002-15005 in conjunction with 15400-15421) (For excision with immediate skin grafting, use 15002-15005 in conjunction with 1505015261)

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GRAFTS AUTOGRAFT/TISSUE CULTURED AUTOGRAFT 15040 15050 15100 15101

15110 15111

15115

15116

15120

15121

Harvest of skin for tissue cultured skin autograft, 100 sq cm or less Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children (except 15050) each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15101 in conjunction with 15100) Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15111 in conjunction with 15110) Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15116 in conjunction with 15115) Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children (except 15050) each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15121 in conjunction with 15120) (For eyelids, see also 67961 et seq)

15130 15131

Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15131 in conjunction with 15130)

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15135

15136

15150 15151

15152

15155 15156

15157

Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15136 in conjunction with 15135) Tissue cultured epidermal autograft, trunk, arms, legs; first 25 sq cm or less additional 1 sq cm to 75 sq cm (List separately in addition to primary procedure) (Do not report 15151 more than once per session) (Use 15151 in conjunction with 15150) each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15152 in conjunction with 15151) Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less additional 1 sq cm to 75 sq cm (List separately in addition to primary procedure) (Do not report 15156 more than once per session) (Use 15156 in conjunction with 15155) each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15157 in conjunction with 15156)

ACELLULAR DERMAL REPLACEMENT 15170 15171

15175

15176

Acellular dermal replacement, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15171 in conjunction with 15170) Acellular dermal replacement, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15176 in conjunction with 15175)

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15200 15201

Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less each additional 20 sq cm (List separately in addition to primary procedure) (Use 15201 in conjunction with 15200)

15220

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less each additional 20 sq cm (List separately in addition to primary procedure) (Use 15221 in conjunction with 15220) Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less

15221

15240

(For finger tip graft, use 15050) (For repair of syndactyly, fingers, see 26560-26562) 15241

15260 15261

each additional 20 sq cm (List separately in addition to primary procedure) (Use 15241 in conjunction with 15240) Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less each additional 20 sq cm (List separately in addition to primary procedure) (Use 15261 in conjunction with 15260) (For eyelids, see also 67961 et seq) (Repair of donor site requiring skin graft or local flaps, to be added as additional separate procedure)

ALLOGRAFT/TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE Application of a non-autologous human skin graft (ie, homograft) from a donor to a part of the recipient’s body to resurface an area damaged by burns, traumatic injury, soft tissue infection and/or tissue necrosis or surgery. 15300 15301

15320

15321

Allograft skin for temporary wound closure, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15301 in conjunction with 15300) Allograft skin for temporary wound closure, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15321 in conjunction with 15320)

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15330 15331

15335

15336

Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15331 in conjunction with 15330) Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15336 in conjunction with 15335)

15340 15341

Tissue cultured allogeneic skin substitute; first 25 sq cm or less each additional 25 sq cm (Use 15341 in conjunction with 15340) (Do not report 15340, 15341 in conjunction with 11040-11042, 15002-15005)

15360

Tissue cultured allogeneic dermal substitute; trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15361 in conjunction with 15360)

15361

15365

15366

Tissue cultured allogeneic dermal substitute, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15366 in conjunction with 15365)

XENOGRAFT Application of a non-human skin graft or biologic wound dressing (eg, porcine tissue or pigskin) to a part of the recipient’s body following debridement of the burn wound or area of traumatic injury, soft tissue infection and/or tissue necrosis, or surgery. 15400 15401

Xenograft, skin (dermal), for temporary wound closure; trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15401 in conjunction with 15400)

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15420

15421

15430 15431

Xenograft skin (dermal), for temporary wound closure, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15421 in conjunction with 15420) Acellular xenograft implant; first 100 sq cm or less, or one percent of body area of infants and children each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to primary procedure) (Use 15431 in conjunction with 15430) (Do not report 15430, 15431 in conjunction with 11040-11042, 15002-15005)

FLAPS (SKIN AND/OR DEEP TISSUES) Regions listed refer to recipient area (not donor site) when flap is being attached in transfer or to final site. Regions listed refer to donor site when tube is formed for later transfer or when delay of flap is prior to transfer. Procedures 15570-15738 do not include extensive immobilization, (eg, large plaster casts and other immobilizing devices are considered additional separate procedures) Repair of donor site requiring skin graft or local flaps is considered an additional separate procedure. (For microvascular flaps, see 15756-15758) (For flaps without inclusion of a vascular pedicle, see 15570-15576) (For adjacent tissue transfer flaps, see 14000-14300) 15570 15572 15574 15576 15600 15610 15620 15630 15650

Formation of direct or tubed pedicle, with or without transfer; trunk scalp, arms, or legs forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet eyelids, nose, ears, lips, or intraoral Delay of flap or sectioning of flap (division and inset); at trunk at scalp, arms, or legs at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet at eyelids, nose, ears, or lips Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location (For eyelids, nose, ears or lips, see also specific anatomic section) (For revision, defatting or rearranging of transferred pedicle flap or skin graft, see 13100-14300)

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15731

Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap) (Procedures 15732-15738 are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap)

15732 15734 15736 15738

Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, massetermuscle, sternocleidomastoid, levator scapulae) trunk upper extremity lower extremity

OTHER FLAPS AND GRAFTS Repair of donor site requiring skin graft or local flaps should be reported as an additional procedure. 15740 15750 15756 15757 15758 15760 15770 15775 15776

Flap; island pedicle neurovascular pedicle Free muscle or myocutaneous flap with microvascular anastomosis Free skin flap with microvascular anastomosis Free fascial flap with microvascular anastomosis Graft; composite (full thickness of external ear or nasal ala), including primary closure, donor area derma-fat-fascia Punch graft for hair transplant; 1 to 15 punch grafts (Report required) more than 15 punch grafts (Report required) (For strip transplant, use 15220)

OTHER PROCEDURES 15780 15781 15782 15783 15786 15787

Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) segmental, face regional, other than face superficial, any site, (eg, tattoo removal) (Report required) Abrasion; single lesion (eg, keratosis, scar) each additional four lesions or less (List separately in addition to primary procedure) (Use 15787 in conjunction with 15786)

15788 15789 15792 15793 15819 15820 15821

Chemical peel, facial; epidermal dermal Chemical peel, nonfacial; epidermal dermal Cervicoplasty Blepharoplasty, lower eyelid; with extensive herniated fat pad

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15822 15823

Blepharoplasty, upper eyelid; with excessive skin weighting down lid (For bilateral blepharoplasty, add modifier 50)

15824

Rhytidectomy; forehead (For repair of brow ptosis, use 67900)

15825 15826 15828 15829

neck with platysmal tightening (platysmal flap, P-flap) glabellar frown lines cheek, chin, and neck superficial musculoaponeurotic system (SMAS) flap (Report required) (For bilateral rhytidectomy, add modifier 50)

15830

15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (Do not report 15830 in conjunction with 12031, 12032, 12034, 12035, 12036, 12037, 13100, 13101, 13102, 14000-14001, 14300) (To report abdominoplasty with panniculectomy, use 15830 in conjunction with 15847. to report other abdominoplasty, use 17999) thigh leg hip buttock arm forearm or hand submental fat pad other area (For bilateral procedure, add modifier 50) Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) (For bilateral procedure, add modifier 50) free muscle graft (including obtaining graft) free muscle flap by microsurgical technique regional muscle transfer (For intravenous fluorescein examination of blood flow in graft or flap, use 15860) (For nerve transfers, decompression, or repair, see 64831-64876, 64905, 64907, 69720, 69725, 69740, 69745, 69955)

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (Report required) (List separately in addition to primary procedure) (Use 15847 in conjunction with 15830) (For abdominal wall hernia repair, see 49491-49587) (To report other abdominoplasty, use 17999)

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15850 15851 15852 15860 15876 15877 15878 15879

Removal of sutures under anesthesia (other than local), same surgeon (See Rule 4) (Report required) Removal of sutures under anesthesia (other than local), other surgeon Dressing change (for other than burns) under anesthesia (other than local) (See Rule 4) Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft Suction assisted lipectomy; head and neck (Report required) trunk (Report required) upper extremity (Report required) lower extremity (Report required)

PRESSURE ULCERS (DECUBITIS ULCERS) 15920 15922 15931 15933 15934 15935 15936 15937

Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture with flap closure Excision, sacral pressure ulcer, with primary suture; with ostectomy Excision, sacral pressure ulcer, with skin flap closure with ostectomy Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy (For repair of defect using muscle or myocutaneous flap, use code(s) 15734 and/or 15738 in addition to 15936, 15937) (For repair of defect using split skin graft, use codes 15100 and/or 15101 in addition to 15936, 15937)

15940 15941 15944 15945 15946

Excision, ischial pressure ulcer, with primary suture; with ostectomy Excision, ischial pressure ulcer, with skin flap closure; with ostectomy Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure (For repair of defect using muscle or myocutaneous flap, use code(s) 15734 and/or 15738 in addition to 15946) (For repair of defect using split skin graft, use codes 15100 and/or 15101 in addition to 15946)

15950 15951 15952 15953

Excision, trochanteric pressure ulcer, with primary suture; with ostectomy Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy

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15956 15958

Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy (For repair of defect using muscle or myocutaneous flap, use code(s) 15734 and/or 15738 in addition to 15956, 15958) (For repair of defect using split skin graft, use codes 15100 and/or 15101 in addition to 15956, 15958)

15999

Unlisted procedure, excision pressure ulcer (For free skin graft to close ulcer or donor site, see 15002 et seq)

BURNS, LOCAL TREATMENT Procedures 16000-16036 refer to local treatment of burned surface only. Codes 16020-16030 include the application of materials (eg, dressings) not described in 15100-15431. List percentage of body surface involved and depth of burn. For necessary related medical services (eg, hospital visits, detention) in management of burned patients, see appropriate services in Evaluation and Management Services and Medicine Section. For the application of skin grafts or skin substitutes, see 15100-15650. 16000 16020 16025 16030 16035 16036

Initial treatment, first degree burn, when no more than local treatment is required Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) medium (eg, whole face or whole extremity or 5% to 10% total body surface area) large (eg, more than one extremity, or greater than 10% total body surface area) Escharotomy; initial incision each additional incision (List separately in addition to primary procedure) (Use 16036 in conjunction with code 16035) (For debridement, curettement of burn wound, see 16020-16030)

DESTRUCTION Destruction means the ablation of benign, pre-malignant or malignant tissues by any method, with or without curettement, including local anesthesia, and not usually requiring closure. Any method includes electrocautery, electrodesiccation, cryosurgery, laser and chemical treatment. Lesions include condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (ie, common, plantar, flat), milia, or other benign, pre-malignant (eg, actinic keratoses), or malignant lesions. (For destruction of lesion(s) in specific anatomic sites; see 40820, 46900-46917, 46924, 5405054057, 54065, 56501, 56515, 57061, 57065, 67850, 68135) (For paring or cutting of benign hyperkeratonic lesions (eg, corns or calluses), see 11055 – 11057)

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(For sharp removal or electrosurgical destruction of skin tags and fibrocutaneous tags, see 11200, 11201) (For cryotherapy of acne, use 17340) (For initiation or follow-up care of topical chemotherpay (eg, 5-FU or similar agents), see appropriate office visits) (For shaving of epidermal or dermal lesions, see 11300-11313) DESTRUCTION, BENIGN OR PREMALIGNANT LESIONS 17000 17003

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion (Report required) second through 14 lesions, each (List separately in addition to code for first lesion) (Use 17003 in conjunction with 17000) (For destruction of common or plantar warts, see 17110, 17111)

17004 17106 17107 17108 17110

17111 17250

15 or more lesions (Do not report 17004 in addition to 17000 – 17003) Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm 10.0 - 50.0 sq cm over 50.0 sq cm Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 15 or more lesions Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) (17250 is not to be used with excision/removal codes for the same lesions)

DESTRUCTION, MALIGNANT LESIONS, ANY METHOD 17260 17261 17262 17263 17264 17266 17270

17271 17272 17273 17274 17276

Destruction, malignant lesion, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less lesion diameter 0.6 to 1.0 cm lesion diameter 1.1 to 2.0 cm lesion diameter 2.1 to 3.0 cm lesion diameter 3.1 to 4.0 cm (Report required) lesion diameter over 4.0 cm (Report required) Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less lesion diameter 0.6 to 1.0 cm lesion diameter 1.1 to 2.0 cm lesion diameter 2.1 to 3.0 cm lesion diameter 3.1 to 4.0 cm lesion diameter over 4.0 cm

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17280

17281 17282 17283 17284 17286

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less lesion diameter 0.6 to 1.0 cm lesion diameter 1.1 to 2.0 cm lesion diameter 2.1 to 3.0 cm (Report required) lesion diameter 3.1 to 4.0 cm (Report required) lesion diameter over 4.0 cm (Report required)

MOHS’ MICROGRAPHIC SURGERY Mohs micrographic surgery is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It requires a single physician to act in two integrated but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports the services separately, these codes should not be reported. The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic examination. Thus a tissue block in Mohs surgery is defined as an individual tissue piece embedded in a mounting medium for sectioning. If repair is performed, use separate repair, flap, or graft codes. If a biopsy of a suspected skin cancer is performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report diagnostic skin biopsy (11100, 11101). 17311

17312

17313

17314

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to primary procedure) (Use 17312 in conjunction with 17311) Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to primary procedure) (Use 17314 in conjunction with 17313)

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17315

OTHER PROCEDURES 17340 17360 17380 17999

Cryotherapy (C02 slush, liquid N2) for acne Chemical exfoliation for acne (eg, acne paste, acid) Electrolusis epilation, each 30 minutes Unlisted procedure, skin, mucous membrane and subcutaneous tissue

BREAST INCISION 19000 19001

Puncture aspiration of cyst breast; each additional cyst (List separately in addition to primary procedure) (Use 19001 in conjunction with 19000) (If imaging guidance is performed, see 76942, 77021, 77031, 77032)

19020 19030

Mastotomy with exploration or drainage of abscess, deep Injection procedure only for mammary ductogram or galactogram (For radiological supervision and interpretation, see 77053, 77054)

EXCISION (To report bilateral procedures, use modifier -50) Excisional breast surgery includes certain biopsy procedures, the removal of cysts or other benign or malignant tumors or lesions, and the surgical treatment of breast and chest wall malignancies. Biopsy procedures may be percutaneous or open, and they involve the removal of differing amounts of tissue for diagnosis. Breast biopsies are reported using codes 19100-19103. The open excision of breast lesions (eg, lesions of the breast ducts, cysts, benign or malignant tumors), without specific attention to adequate surgical margins, with or without the preoperative placement of radiological markers, is reported using codes 19110-19126. Partial mastectomy procedures (eg, lumpectomy, tylectomy, quadrantectomy, or segmentectomy) describe open excisions of breast tissue with specific attention to adequate surgical margins. Partial mastectomy procedures are reported using codes 19301 or 19302 as appropriate. Documentation for partial mastectomy procedures includes attention to the removal of adequate surgical margins surrounding the breast mass or lesion.

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Total mastectomy procedures include simple mastectomy, complete mastectomy, subcutaneous mastectomy, modified radical mastectomy, radical mastectomy, and more extended procedures (eg, Urban type operation). Total mastectomy procedures are reported using codes 19303-19307 as appropriate. Excisions or resections of chest wall tumors including ribs, with or without reconstruction, with or without mediastinal lymphadenectomy, are reported using codes 19260, 19271, or 19272. Codes 19260-19272 are not restricted to breast tumors and are used to report resections of chest wall tumors originating from any chest wall component. (For excision of lung or pleura, see 32310 et seq.) 19100

Biopsy of breast; percutaneous, needle core, not using needle guidance (separate procedure) (For fine needle aspiration, use 10021) (For image guided breast biopsy, see 19102, 19103, 10022)

19101 19102

open, incisional percutaneous, needle code, using imaging guidance (For placement of percutaneous localization clip, use 19295)

19103

percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance (For imaging guidance performed in conjunction with 19102, 19103, see 76942, 77012, 77021, 77031, 77032) (For placement of percutaneous localization clip, use 19295)

19105

Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma (Do not report 19105 in conjunction with 76940, 76942) (For adjacent lesions treated with one cryoprobe insertion, report once)

19110 19112 19120

19125 19126

Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct Excision of lactiferous duct fistula Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions Excision of breast lesion identified by pre-operative placement of radiological marker, open; single lesion each additional lesion separately identified by a preoperative radiological maker (List separately in addition to primary procedure) (Use 19126 in conjunction with code 19125) (Do not report 19260, 19271, 19272 in conjunction with 32100, 32422, 32503, 32504, 32551 )

19260

Excision of chest wall tumor including ribs

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19271 19272

Excision of chest wall tumor involving ribs, with plastic reconstruction; without mediastinal lymphadenectomy with mediastinal lymphadenectomy

INTRODUCTION 19290 19291

Preoperative placement of needle localization wire, breast; each additional lesion (List separately in addition to primary procedure) (Use 19291 in conjunction with code 19290) (For radiological supervision and interpretation, see 76942, 77031, 77032)

19295

Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to primary procedure) (Use 19295 in conjunction with code 19102, 19103)

19296

Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy (Report required) concurrent with partial mastectomy (List separately in addition to primary procedure) (Use 19297 in conjunction with code 19301 or 19302)

19297

19298

Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance (Report required)

MASTECTOMY PROCEDURES (For immediate or delayed insertion of implant for codes 19303, 19304, 19305, 19306, 19307, see 19340, 19342) 19300 19301 19302

Mastectomy for gynecomastia Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy (For placement of radiotherapy afterloading balloon/brachytherapy catheters, see 19296-19298)

19303

Mastectomy, simple, complete (For gynecomastia, use 19300)

19304 19305 19306 19307

Mastectomy, subcutaneous Mastectomy, radical, including pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle

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REPAIR AND/OR RECONSTRUCTION (To report bilateral procedures, use modifier -50) 19316 19318 19324 19325

Mastopexy (unilateral) Reduction mammaplasty (unilateral) Mammaplasty, augmentation; without prosthetic implant with prosthetic implant (For flap or graft, use also appropriate number)

19328 19330 19340 19342

Removal of intact mammary implant Removal of implant material Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction (For physician supply of implant, use 99070) (For preparation of custom breast implant, use 19396)

19350 19355 19357 19361

Nipple/areola reconstruction Correction of inverted nipples Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast reconstruction with latissimus dorsi flap, without prosthetic implant (For insertion of prosthesis, use also 19340)

19364

Breast reconstruction with free flap (19364 includes harvesting of the flap, microvascular transfer, closure of the donor site, and inset shaping the flap into a breast)

19366

Breast reconstruction with other technique (For insertion of prosthesis, use also 19340 or 19342)

19367 19368 19369 19370 19371 19380 19396

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging) Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site Open periprosthetic capsulotomy, breast Periprosthetic capsulectomy, breast Revision of reconstructed breast Preparation of moulage for custom breast implant (Report required)

OTHER PROCEDURES 19499

Unlisted procedure, breast

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MUSCULOSKELETAL SYSTEM Casts and strapping procedures appear at the end of this section. The services listed below include the application and removal of the first cast or traction device only. Subsequent replacement of cast and/or traction device may require an additional listing. DEFINITIONS

The terms "closed treatment”, "open treatment" and "percutaneous skeletal fixation" have been carefully chosen to accurately reflect current orthopedic procedural treatments. CLOSED TREATMENT - specifically means that the fracture site is not surgically opened (exposed

to the external environment and directly visualized). This terminology is used to describe procedures that treat fractures by three methods: 1) without manipulation; 2) with manipulation; or 3) with or without traction. OPEN TREATMENT - is used when the fractured bone is either: 1) surgically opened (exposed to

the external environment) and the fracture (bone ends) visualized and internal fixation may be used; or 2) the fractured bone is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site (the fracture site is not opened and visualized). PERCUTANEOUS SKELETAL FIXATION - describes fracture treatment which is neither open nor

closed. In this procedure, the fracture fragments are not visualized, but fixation (eg, pins) is placed across the fracture site, usually under x-ray imaging. The type of fracture (eg, open, compound, closed) does not have any coding correlation with the type of treatment (eg, closed, open or percutaneous) provided. The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization). These codes can apply to either open (compound) or closed fractures or joint injuries. Skeletal traction is the application of a force (distracting or traction force) to a limb segment through a wire, pin, screw or clamp that is attached (eg, penetrates) to bone. Skin traction is the application of a force (longitudinal) to a limb using felt or strapping applied directly to skin only. External fixation is the usage of skeletal pins plus an attaching mechanism/device used for temporary or definitive treatment of acute or chronic bony deformity. Codes for obtaining autogenous bone grafts, cartilage, tendon fascia lata grafts or other tissues, through separate incisions are to be used only when the graft is not already listed as part of the basic procedure. Re-reduction of a fracture and/or dislocation performed by the primary physician may be identified by either the addition of the modifier -76 to the usual procedure number to indicate “Repeat Procedure by Same Physician.”

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Codes for external fixation are to be used only when external fixation is not already listed as part of the basic procedure. All codes for suction irrigation have been deleted. To report, list only the primary surgical procedure performed (eg, sequestrectomy, deep incision). MANIPULATION - is used throughout the musculoskeletal fracture and dislocation subsections to

specifically mean the attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the application of manually applied forces. GENERAL INCISION 20000 20005

Incision of soft tissue abscess (eg, secondary to osteomyelitis); superficial deep or complicated

WOUND EXPLORATION - TRAUMA (eg PENETRATING GUNSHOT, STAB WOUND) 20100-20103 relate to wound(s) resulting from penetrating trauma. These codes describe surgical exploration and enlargement of the wound, extension of dissection (to determine penetration), debridement, removal of foreign body(s) , ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle fascia, and/or muscle, not requiring thoracotomy or laparotomy. If a repair is done to major structure(s) or major blood vessel(s) requiring thoracotomy or laparotomy, then those specific code(s) would supersede the use of codes 20100-20103. To report Simple, Intermediate or Complex repair of wound(s) that do not require enlargement of the wound, extension of dissection, etc., as stated above, use specific Repair code(s) in the Integumentary System section. 20100 20101 20102 20103

Exploration of penetrating wound (separate procedure); neck chest abdomen/flank/back extremity

EXCISION 20150

Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision (For aspiration of bone marrow, use 38220)

20200 20205 20206

Biopsy, muscle; superficial deep Biopsy, muscle, percutaneous needle (If imaging guidance is performed, see 76942, 77012, 77021) (For fine needle aspiration, use 10021, 10022) (For excision of muscle tumor, deep, see specific anatomic section)

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20220 20225

Biopsy, bone, trocar or needle; superficial (eg, ilium, sternum, spinous process, ribs) deep (eg, vertebral body, femur) (For radiological supervision and interpretation, see 77002, 77012, 77021) (For bone marrow biopsy, use 38221)

20240 20245 20250 20251

Biopsy, bone, open; superficial (eg, ilium, sternum, spinous process, ribs, trochanter of femur) deep (eg, humerus, ischium, femur) Biopsy, vertebral body, open; thoracic lumbar or cervical (For sequestrectomy, osteomyelitis or drainage of bone abscess, see. specific anatomic section)

INTRODUCTION OR REMOVAL (For injection procedure for arthrography, see specific anatomic section) 20500 20501

Injection of sinus tract; therapeutic (separate procedure) diagnostic (sinogram) (For radiological supervision and interpretation, see 76080)

20520 20525 20526 20550 20551 20552 20553

Removal of foreign body in muscle, or tendon sheath, simple deep or complicated Injection, therapeutic (eg, local anesthetic; corticosteroid), carpal tunnel Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar ''fascia'') single tendon origin/insertion single or multiple trigger point(s), one or two muscle(s) single or multiple trigger point(s), three or more muscle(s) (If imaging guidance is performed, see 76942, 77002, 77021)

20555

Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) (For placement of devices into the breast for interstitial radioelement application, see 19296-19298) (For placement of needles, catheters, or devices into muscle or soft tissue of the head and neck, for interstitial radioelement application, use 41019) (For placement of needles or catheters for interstitial radioelement application into prostate, use 55875) (For placement of needles or catheters into the pelvic organs or genitalia [except prostate] for interstitial radioelement application, use 55920) (For imaging guidance, see 76942, 77002, 77012, 77021)

20600 20605

Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)

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20610

major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) (If imaging guidance is performed, see 76942, 77002, 77012, 77021)

20612 20615 20650 20660 20661 20662 20663 20664

20665 20670 20680 20690 20692 20693 20694

Aspiration and/or injection of ganglion cyst(s) any location Aspiration and injection for treatment of bone cyst Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure) Application of halo, including removal; cranial pelvic femoral Application of Halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta), requiring general anesthesia Removal of tongs or halo applied by another physician Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) deep, (eg, buried wire, pin, screw, metal band, nail, rod or plate) Application of a uniplane (pins or wires in one plane), unilateral, external fixation system Application of a multiplane (pins or wires in more than one plane),unilateral, external fixation system (eg, Ilizarov, Monticelli type) Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s), and/or new ring(s) or bar(s)) Removal, under anesthesia, of external fixation system

REPLANTATION 20802 20805 20808 20816 20822 20824 20827 20838

Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation Replantation, forearm, (includes radius and ulna to radial carpal joint), complete amputation Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation Replantation, thumb (includes distal tip to MP joint), complete amputation Replantation, foot, complete amputation

GRAFTS (OR IMPLANTS) Codes for obtaining autogenous bone, cartilage, tendon, fascia lata grafts, or other tissues through separate skin/fascial incisions should be reported separately unless the code descriptor references the harvesting of the graft or implant (eg, includes obtaining graft).

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Do not append modifier –62 to bone graft codes 20900-20938. (For spinal surgery bone graft(s) see codes 20930-20938) 20900 20902 20910 20912

Bone graft, any donor area; minor or small (eg, dowel or button) major or large Cartilage graft; costochondral nasal septum (For ear cartilage, use 21235)

20920 20922 20924 20926

Fascia lata graft; by stripper by incision and area exposure, complex or sheet Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) Tissue grafts, other (eg, paratenon, fat, dermis) (Codes 20930-20938 are reported in addition to codes for the definitive procedure(s). (Report only one bone graft code per operative session.)

20930

Allograft for spine surgery only; morselized (List separately in addition to primary procedure) (Use 20930 in conjunction with 22319, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22812)

20931

structural (List separately in addition to primary procedure) (Use 20931 in conjunction with 22319, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812)

20936

Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to primary procedure) (Use 20936 in conjunction with 22319, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22812)

20937

morselized (through separate skin or fascial incision) (List separately in addition to primary procedure) (Use 20937 in conjunction with 22319, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812)

20938

structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) (Use 20938 in conjunction with 22319, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812) (For needle aspiration of bone marrow for the purpose of bone grafting, use 38220)

OTHER PROCEDURES 20950

Monitoring of interstitial fluid pressure (includes insertion of device eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome

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20955 Bone graft with microvascular anastomosis; fibula 20956 iliac crest 20957 metatarsal 20962 other than fibula, iliac crest, or metatarsal 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe 20970 iliac crest (Report required) 20972 metatarsal (Report required) 20973 great toe with web space (Report required) (For great toe, wrap-around procedure, use 26551) 20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative) 20975 invasive (operative) 20979 Low intesity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) 20982 Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance (Report required) (Do not report 20982 in conjunction with 77013) 20999 Unlisted procedure, musculoskeletal system, general HEAD Skull, facial bones and temporomandibular joint INCISION (For drainage of superficial abscess and hematoma, see 20000) (For removal of embedded foreign body from dentoalveolar structure, see 41805, 41806) 21010 Arthrotomy, temporomandibular joint (To report bilateral procedures, use modifier -50) EXCISION 21015 Radical resection of tumor (eg, malignant neoplasm), soft tissue of face or scalp (To report excision of skull tumor for osteomyelitis, use 61501) 21025 21026 21029 21030 21031 21032 21034 21040

Excision of bone (eg, for osteomyelitis or bone abscess); mandible facial bone(s) Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage Excision of torus mandibularis Excision of maxillary torus palatinus Excision of malignant tumor of maxilla or zygoma Excision of benign tumor or cyst of mandible, by enucleation and/or curettage (For enucleation and/or curettage of benign cysts or tumors of mandible not requiring osteotomy, use 21040) (For excision of benign tumor or cyst of mandible requiring osteotomy, see 2104621047)

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21044 Excision of malignant tumor of mandible; 21045 radical resection (For bone graft, see 21215) 21046 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s)) 21047 requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion(s)) 21048 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s)) 21049 requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion(s)) 21050 Condylectomy, temporomandibular joint; (separate procedure) (For bilateral procedures use modifier -50) 21060 Meniscectomy, partial or complete, temporomandibular joint (separate procedure) (For bilateral procedures use modifier -50) 21070 Coronoidectomy (separate procedure) (For bilateral procedures use modifier -50) MANIPULATION 21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) (Report required) (For TMJ manipulation without an anesthesia service [ie, general or monitored anesthesia care], see 97140, 98925-98929, 98943) (For closed treatment of temporomandibular dislocation, see 21480, 21485) HEAD PROSTHESIS (For application or removal of caliper or tongs, see 20660,20665) Codes 21076-21089 describe professional services for the rehabilitation of patients with oral, facial or other anatomical deficiencies by means of prostheses such as an artificial eye, ear or nose or intraoral obturator to close a cleft. Codes 21076-21089 should only be used when the physician actually designs and prepares the prosthesis (ie, not prepared by an outside laboratory). 21076 Impression and custom preparation; surgical obturator prosthesis (Report required) 21077 orbital prosthesis (Report required) 21079 interim obturator prosthesis (Report required) 21080 definitive obturator prosthesis (Report required) 21081 mandibular resection prosthesis (Report required) 21082 palatal augmentation prosthesis (Report required) 21083 palatal lift prosthesis (Report required) 21084 speech aid prosthesis (Report required) 21085 oral surgical splint

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21086 auricular prosthesis (Report required) 21087 nasal prosthesis (Report required) 21088 facial prosthesis 21089 Unlisted maxillofacial prosthetic procedure INTRODUCTION OR REMOVAL 21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) (Report required) 21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal (For removal of interdental fixation by another physician, see 20670-20680) 21116 Injection procedure for temporomandibular joint arthrography (For radiological supervision and interpretation, use 70332. Do not report 77002 in conjunction with 70332) REPAIR, REVISION, AND/OR RECONSTRUCTION (For cranioplasty, see 21179, 21180 and 62116, 62120, 62140-62147) 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21121 sliding osteotomy, single piece 21122 sliding osteotomies, two or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) 21123 sliding, augmentation with interpositional bone grafts (includes obtaining autografts) (Report required) 21125 Augmentation, mandibular body or angle; prosthetic material 21127 with bone graft, onlay or interpositional (includes obtaining autograft) 21137 Reduction forehead; contouring only (Report required) 21138 contouring and application of prosthetic material or bone graft (includes obtaining autograft) 21139 contouring and setback of anterior frontal sinus wall (Report required) 21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft 21142 two pieces, segment movement in any direction, without bone graft 21143 three or more pieces, segment movement in any direction, without bone graft 21145 single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) 21146 two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) 21147 three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) 21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) (Report required) 21151 any direction, requiring bone grafts (includes obtaining autografts) (Report required) Version 2008 – 1 (5/15/2008)

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21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I 21155 with LeFort I 21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I (Report required) 21160 with LeFort I (Report required) 21172 Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) (For frontal or parietal craniotomy performed for craniosynostosis, use 61556) 21175 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) (For bifrontal craniotomy performed for craniosynostosis, use 61557) 21179 Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) (Report required) 21180 with autograft (includes obtaining grafts) (For extensive craniectomy for multiple suture craniosynostosis, use only 61558 or 61559) 21181 Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial 21182 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm (Report required) 21183 total area of bone grafting greater than 40 sq cm but less than 80 sq cm (Report required) 21184 total area of bone grafting greater than 80 sq cm (Report required) (For excision of benign tumor of cranial bones, see 61563, 61564) 21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) 21193 Reconstruction of mandibular rami, horizontal, vertical, "C", or "L" osteotomy; without bone graft 21194 with bone graft (includes obtaining graft) (Report required) 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation (Report required) 21196 with internal rigid fixation 21198 Osteotomy, mandible, segmental; 21199 with genioglossus advancement (To report total osteotomy of the maxilla, see 21141-21160) 21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)

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21208 Osteoplasty, facial bones; augmentation (autograft, allograft or prosthetic implant) 21209 reduction 21210 Graft, bone; nasal, maxillary and malar areas (includes obtaining graft) (For cleft palate repair, see 42200-42225) 21215 mandible (includes obtaining graft) 21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) 21235 ear cartilage, autograft, to nose or ear (includes obtaining graft) (To report graft augmentation of facial bones, use 21208) 21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) 21242 Arthroplasty, temporomandibular joint, with allograft 21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement (Report required) 21244 Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) 21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial 21246 complete 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial 21249 complete (Report required) (To report midface reconstruction, see 21141-21160) 21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) 21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) 21260 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach 21261 combined intra- and extracranial approach (Report required) 21263 with forehead advancement 21267 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach 21268 combined intra- and extracranial approach (Report required) 21270 Malar augmentation, prosthetic material (For malar augmentation with bone graft, see 21210) 21275 Secondary revision of orbitocraniofacial reconstruction 21280 Medial canthopexy (separate procedure) (For medial canthoplasty, use 67950) 21282 Lateral canthopexy 21295 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach (Report required) 21296 intraoral approach (Report required)

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OTHER PROCEDURES 21299 Unlisted craniofacial and maxillofacial procedure FRACTURE AND/OR DISLOCATION (For operative repair of skull fracture, see 62000-62010) (To report closed treatment of skull fracture, use the appropriate evaluation and management code) 21310 21315 21320 21325 21330 21335 21336 21337 21338 21339 21340 21343 21344 21345 21346 21347 21348 21355 21356 21360 21365

21366 21385 21386 21387 21390 21395

Closed treatment of nasal bone fracture without manipulation Closed treatment, nasal bone fracture; without stabilization with stabilization Open treatment of nasal fracture; uncomplicated complicated, with internal and/or external skeletal fixation with concomitant open treatment of fractured septum Open treatment of nasal septal fracture, with or without stabilization Closed treatment of nasal septal fracture, with or without stabilization Open treatment of nasoethmoid fracture; without external fixation with external fixation Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus Open treatment of depressed Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation requiring multiple open approaches with bone grafting (includes obtaining graft) Percutanous treatment of fracture of malar area, including zygomatic arch and malar tripod,with manipulation Open treatment of depressed zygomatic arch fracture (eg, Gilles approach) Open treatment of depressed malar fracture, including zygomatic arch and malar tripod Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s)of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches with bone grafting (includes obtaining graft) Open treatment of orbital floor blowout fracture; transantral approach(Caldwell-Luc type operations) periorbital approach combined approach periorbital approach, with alloplastic or other implant periorbital approach with bone graft (includes obtaining graft)

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21400 21401 21406 21407 21408 21421 21422 21423 21431 21432 21433 21435

Closed treatment of fracture of orbit, except blowout; without manipulation with manipulation Open treatment of fracture of orbit except blowout; without implant with implant with bone grafting (includes obtaining graft) Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation) (For removal of internal or external fixation device, use 20670)

21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470 21480 21485 21490

complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) (Report required) Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) Closed treatment of mandibular fracture; without manipulation with manipulation Percutaneous treatment of mandibular fracture, with external fixation Closed treatment of mandibular fracture with interdental fixation Open treatment of mandibular fracture with external fixation Open treatment of mandibular fracture; without interdental fixation with interdental fixation Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints Closed treatment of temporomandibular dislocation, initial or subsequent complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent (Report required) Open treatment of temporomandibular dislocation (For interdental wire fixation, use 21497)

21495 Open treatment of hyoid fracture (Report required) (For laryngoplasty with open reduction of fracture, use 31584) (To report treatment of closed fracture of larynx, use the applicable evaluation and management codes)

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OTHER PROCEDURES 21497 Interdental wiring, for condition other than fracture (Report required) 21499 Unlisted musculoskeletal procedure, head (For unlisted craniofacial or maxillofacial procedure, use 21299) NECK (SOFT TISSUES) AND THORAX (For cervical spine and back, see 21920 et seq) (For injection of fracture site or trigger point, see 20550) INCISION (For incision and drainage of abscess or hematoma, superficial, see 10060, 10140) 21501 Incision and drainage, deep abscess or hematoma, soft tissues of neck of thorax; (For posterior spine subfascial incision and drainage, see 22010-22015) 21502 with partial rib ostectomy 21510 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax EXCISION (For bone biopsy, see 20220-20251) 21550 Biopsy, soft tissue of neck or thorax (For needle biopsy of soft tissue, use 20206) 21555 Excision tumor, soft tissue of neck or thorax; subcutaneous 21556 deep, subfascial, intramuscular 21557 Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or thorax 21600 Excision of rib, partial (For radical resection of chest wall and rib cage for tumor, use 19260) (For radical debridement of chest wall and rib cage for injury, see 11040-11044) 21610 21615 21616 21620 21627

Costotransversectomy (separate procedure) Excision first and/or cervical rib; with sympathectomy Ostectomy of sternum, partial Sternal debridement (For debridement and closure, use 21750)

21630 Radical resection of sternum; 21632 with mediastinal lymphadenectomy REPAIR, REVISION AND/OR RECONSTRUCTION (For superficial wound, see Integumentary System section under REPAIR-SIMPLE)

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21685 Hyoid myotomy and suspension 21700 Division of scalenus anticus; without resection of cervical rib 21705 with resection of cervical rib 21720 Division of sternocleidomastoid for torticollis, open operation; without cast application (For transection of spinal accessory and cervical nerves, see 63191, 64722) 21725 with cast application 21740 Reconstructive repair of pectus excavatum or carinatum; open 21742 minimally invasive approach (Nuss procedure), without thoracoscopy (Report required) 21743 minimally invasive approach (Nuss procedure), with thorascopy (Report required) 21750 Closure of median sternotomy separation with or without debridement (separate procedure) FRACTURE AND/OR DISLOCATION 21800 21805 21810 21820 21825

Closed treatment of rib fracture, uncomplicated, each Open treatment of rib fracture without fixation, each (Report required) Treatment of rib fracture requiring external fixation (flail chest) (Report required) Closed treatment of sternum fracture Open treatment of sternum fracture with or without skeletal fixation (For sternoclavicular dislocation, see 23520-23532)

OTHER PROCEDURES 21899 Unlisted procedure, neck or thorax BACK AND FLANK EXCISION 21920 21925

Biopsy, soft tissue of back or flank; superficial deep (For needle biopsy of soft tissue, use 20206)

21930 21935

Excision, tumor, soft tissue of back or flank Radical resection of tumor (eg, malignant neoplasm), soft tissue of back or flank

SPINE (VERTEBRAL COLUMN) Cervical, thoracic, and lumbar spine. Within the SPINE section, bone grafting procedures are reported separately and in addition to arthrodesis. For bone grafts in other Musculoskeletal sections, see specific code(s) descriptor(s) and/or accompanying guidelines. To report bone grafts performed after arthrodesis, see codes 20930-20938. Do not append modifier –62 to bone graft codes 20900 – 20938. Example: Posterior arthrodesis of L5-S1 for degenerative disc disease utilizing morselized autogenous iliac bone graft harvested through a separate fascial incision. Report as 22612 and 20937.

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Within the SPINE section, instrumentation is reported separately and in addition to arthrodesis. To report instrumentation procedures performed with definitive vertebral procedure(s), see codes 22840-22855. Instrumentation procedure codes 22840-22848 and 22851 are reported in addition to the definitive procedure(s). The modifier –62 may not be appended to the definitive add-on spinal instrumentation procedure code(s) 22840 – 22848 and 22850-22852. Example: Posterior arthrodesis of L4-S1, utilizing morselized autogenous iliac bone graft harvested through separate fascial incision, and pedicle screw fixation. Report as 22612, 22614, 22842 and 20937. Vertebral procedures are sometimes followed by arthrodesis and in addition may include bone grafts and instrumentation. When arthrodesis is performed addition to another procedure, the arthrodesis should be reported in addition to the original procedure. Examples are after osteotomy, fracture care, vertebral corpectomy and laminectomy. Since bone grafts and instrumentation are never performed without arthrodesis, they are reported as add-on codes. Arthrodesis, however, may be performed in the absence of other procedures. Example: Treatment of a burst fracture of L2 by corpectomy followed by arthrodesis of Ll-L3, utilizing anterior instrumentation Ll-L3 and structural allograft. Report as 63090,22558-51, 22585, 22845 and 20931. (Do not append modifier 62 to bone graft code 20931) (For injection procedure for myelography, use 62284) (For injection procedure for discography, see 62290, 62291) (For injection procedure, chemonucleolysis, single or multiple levels, use 62292) (For injection procedure for facet joints, see 64470-64476, 64622-64627) (For needle or trocar biopsy, see 20220-20225) INCISION 22010 22015

Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic lumbar, sacral, or lumbosacral (Do not report 22015 in conjunction with 22010) (Do not report 22015 in conjunction with instrumentation removal, 10180, 22850, 22852) (For incision and drainage of abscess or hematoma, superficial, see 10060, 10140)

EXCISION For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of partial vertebral body excision, each surgeon should report his/her distinct operative work by appending the modifier –62 to the procedure code. In this situation, the modifier –62 may be appended to the procedure code(s) 22100-22102, 22110-22114 and, as appropriate, to the associated additional vertebral segment add-on code(s) 22103, 22116 as long as both surgeons continue to work together as primary surgeons. (For bone biopsy, see 20220-20251) (To report soft tissue biopsy of back or flank, see 21920-21925) (For needle biopsy of soft tissue, use 20206)

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(To report excision of soft tissue tumor of back or flank, use 21930) 22100 22101 22102 22103

22110 22112 22114 22116

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical thoracic lumbar each additional segment (List separately in addition to primary procedure) (Use 22103 in conjunction with codes 22100, 22101, 22102) Partial excision of vertebral body for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical thoracic lumbar each additional vertebral segment (List separately in addition to primary procedure) (Use 22116 only for codes 22110, 22112, 22114) (For complete or near complete resection of vertebral body, see vertebral corpectomy, 63081-63091) (For spinal reconstruction with bone graft (autograft, allograft) and/or methylmethacrylate of cervical vertebral body, use 63081 and 22554 and 20931 or 20938) (For spinal reconstruction with bone graft (autograft, allograft) and/or methylmethacrylate of thoracic vertebral body, use 63085 or 63087 and 22556 and 20931 or 20938) (For spinal reconstruction with bone graft (autograft, allograft) and/or methylmethacrylate of lumbar vertebral body, use 63087 or 63090 and 22558 and 20931 or 20938) (For spinal reconstruction following vertebral body resection, use 63082 or 63086 or 63088 or 63091, and 22585) (For harvest of bone autograft for vertebral reconstruction, see 20931 or 20938) (For cervical spinal reconstruction with prosthetic replacement of resected vertebral bodies, see codes 63081 and 22554 and 20931 or 20938 and 22851) (For thoracic spinal reconstruction with prosthetic replacement of resected vertebral bodies, see codes 63085 or 63087 and 22556 and 20931 or 20938 and 22851) (For lumbar spinal reconstruction with prosthetic replacement of resected vertebral bodies, see codes 63087 or 63090 and 22558, and 20931 or 20938 and 22851) (For osteotomy of spine, see 22210-22226)

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OSTEOTOMY To report arthrodesis, see codes 22590-22632. (Report in addition to code(s) for the definitive procedure) To report instrumentation procedures, see codes 22840-22855.(Report in addition to code(s) for the definitive procedure(s)). Do not append modifier –62 to spinal instrumentation codes 2284022848 and 22850-22852. To report bone graft procedures, see codes 20930-20938. (Report in addition to code(s) for the definitive procedure(s). Do not append modifier –62 to bone graft codes 20900-20938. For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of an anterior spine osteotomy, each surgeon should report his/her distinct operative work by appending the modifier –62 to the procedure code. In this situation, the modifier –62 may be appended to code(s) 22210-22214, 22220-22224 and, as appropriate, to associated additional segment add-on code(s) 22216, 22226 as long as both surgeons continue to work together as primary surgeons. 22206

Osteotomy of spine, posterior or posteriolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); thoracic (Do not report 22206 in conjunction with 22207)

22207

lumbar (Do not report 22207 in conjunction with 22206)

22208

each additional vertebral segment (List separately in addition to primary procedure) (Use 22208 in conjunction with 22206, 22207) (Do not report 22206, 22207, 22208 in conjunction with22210-22226, 22830, 6300163048, 63055-63066, 63075-63091, 63101-63103, when performed at the same level)

22210 22212 22214 22216

22220 22222 22224 22226

Osteotomy of spine, posterior or posteriolateral approach, one vertebral segment; cervical thoracic lumbar each additional segment (List separately in addition to primary procedure) (Use 22216 in conjunction with 22210, 22212, 22214) Osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; cervical thoracic lumbar each additional segment (List separately in addition to primary procedure) (Use 22226 only for codes 22220, 22222, 22224) (For vertebral corpectomy, see 63081-63091)

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FRACTURE AND/OR DISLOCATION To report arthrodesis, see codes 22590-22632. (Report in addition to code(s) for the definitive procedure) To report instrumentation procedures, see codes 22840-22855. (Report in addition to code(s) for the definitive procedure(s)). Do not append modifier –62 to spinal instrumentation codes 22840-22848 and 22850-22852. To report bone graft procedures, see codes 20930-20938. (Report in addition to code(s) for the definitive procedure(s)). Do not append modifier –62 to bone graft codes 20900-20938. For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of an open fracture and/or dislocation procedure(s), each surgeon should report his/her distinct operative work by appending the modifier –62 to the procedure code. In this situation, the modifier –62 may be appended to code(s) 22318-22327, and, as appropriate, to associated additional segment add-on code 22328 as long as both surgeons continue to work together as primary surgeons. 22305 22310 22315

22318

22319 22325 22326 22327 22328

Closed treatment of vertebral process fracture(s) Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing, with or without anesthesia, by manipulation or traction Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) including os odontoideum), anterior approach, including placement of internal fixation; without grafting with grafting (Report required) Open treatment and/or reduction of vertebral fracture (s) and/or dislocation(s); posterior approach, one fractured vertebrae or dislocated segment; lumbar cervical thoracic each additional fractured vertebrae or dislocated segment (List separately in addition to primary procedure) (Use 22328 in conjunction with codes 22325, 22326, 22327) (For treatment of vertebral fracture by the anterior approach, see corpectomy 6308163091, and appropriate arthrodesis, bone graft and instruments codes) (For decompression of spine following fracture, see 63001-63091) (For arthrodesis of spine following fracture, see 22548-22632)

MANIPULATION 22505

Manipulation of spine requiring anesthesia, any region

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VERTEBRAL BODY, EMBOLIZATION OR INJECTION 22520 22521 22522

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic lumbar each additional thoracic or lumbar vertebral body (List separately in addition to primary procedure) (Use 22522 in conjunction with codes 22520, 22521 as appropriate) (For radiological supervision and interpretation, see 72291, 72292)

22523

22524 22525

22526 22527

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic lumbar each additional thoracic or lumbar vertebral body (List separately in addition to primary procedure) (D not report 22525 in conjunction with 20225 when performed at the same level as 22523-22525) (Ue 22525 in conjunction with 22523, 22524) (For radiological supervision and interpretation, see 72291, 72292) Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level one or more additional levels (List separately in addition primary procedure) (Do not report codes 22526, 22527 in conjunction with 77002, 77003)

ARTHRODESIS To report instrumentation procedures, see 22840-22855. (Report in addition to code(s) for the definitive procedure(s)). Do not append modifier –62 to spinal instrumentation codes 22840-22848 and 22850-22852. To report exploration of fusion, use 22830. To report bone graft procedures, see codes 20930-20938. (Report in addition to code(s) for the definitive procedure(s)). Do not append modifier –62 to bone graft codes 20900-20938. LATERAL EXTRACAVITARY APPROACH TECHNIQUE 22532 22533 22534

Arthrodesis, lateral extracavitary technique, including minimal diskectomy to prepare interspace (other than for decompression); thoracic lumbar thoracic or lumbar, each additional vertebral segment (List separately in addition to primary procedure) (Use 22534 in conjunction with 22532 and 22533)

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ANTERIOR OR ANTEROLATERAL APPROACH TECHNIQUE Procedure codes 22554-22558 are for SINGLE interspace; for additional interspaces, use 22585. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies, which contains the intervertebral disk, and includes the nucleus pulposus, annulus fibrosus, and two cartilagenous endplates. For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of an anterior interbody arthrodesis, each surgeon should report his/her distinct operative work by appending the modifier –62 to the procedure code. In this situation, the modifier –62 may be appended to the procedure code(s) 22548-22558 and, as appropriate, to the associated additional interspace add-on code 22585 as long as both surgeons continue to work together as primary surgeons. 22548

Arthrodesis, anterior transoral or extraoral technique, clivus-Cl-C2 (atlas-axis), with or without excision of odontoid process (For intervertebral disk excision by laminotomy or laminectomy, see 63020-63042)

22554 22556 22558 22585

Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2 thoracic lumbar each additional interspace (List separately in addition to primary procedure) (Use 22585 in conjunction with 22554, 22556, 22558)

POSTERIOR, POSTEROLATERAL OR LATERAL TRANSVERSE PROCESS TECHNIQUE To report instrumentation procedures, see codes 22840-22855. (Report in addition to code(s) for the definitive procedure(s)). Do not append modifier –62 to spinal instrumentation codes 22840-22848 and 22850-22852. To report bone graft procedures, see codes 20930-20938. (Report in addition to code(s) for the definitive procedure(s)). Do not append modifier –62 to bone graft codes 20900-20938. A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies which contains the intervertebral disk, and includes the nucleus pulposus, annulus fibrosus, and two cartilagenous endplates. 22590 22595 22600 22610 22612 22614

Arthrodesis, posterior technique, craniocervical (occiput-C2) Arthrodesis, posterior technique, atlas-axis (Cl-C2) Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment thoracic (with or without lateral transverse technique) lumbar (with or without lateral transverse technique) each additional vertebral segment (List separately in addition to primary procedure) (Use 22614 in conjunction with 22600,22610,22612)

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22630

22632

Arthrodesis, posterior interbody technique, inlcuding laminectomy and/or diskectomy to prepare interspace (other than for decompression) single interspace; lumbar each additional interspace (List separately in addition to primary procedure) (Use 22632 in conjunction with 22630)

SPINE DEFORMITY (EG, SCOLIOSIS, KYPHOSIS) To report instrumentation procedures, see codes 22840-22855. (Report in addition to code(s) for the definitive procedure(s).) Do not append modifier –62 to spinal instrumentation codes 22840-22848 and 22850-22852. To report bone graft procedures, see codes 20930-20938. (Report in addition to code(s) for the definitive procedures(s).) Do not append modifier –62 to bone graft codes 20900-20938. A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single complete vertebral bone with its associated articular processes and laminae. For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of an arthrodesis for spinal deformity, each surgeon should report his/her distinct operative work by appending the modifier –62 to the procedure code. In this situation, the modifier –62 may be appended to the procedure code(s) 22800-22819 as long as both surgeons continue to work together as primary surgeons. 22800 22802 22804 22808 22810 22812 22818 22819

Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments 7 to 12 vertebral segments 13 or more vertebral segments Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments 4 to 7 vertebral segments 8 or more vertebral segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (inlcuding body and posterior elements); single or 2 segments 3 or more segments

EXPLORATION (To report bone graft procedures, see 20930-20938) 22830

Exploration of spinal fusion

SPINAL INSTRUMENTATION Segmental instrumentation is defined as fixation at each end of the construct and at least one additional interposed bony attachment. Non-segmental instrumentation is defined as fixation at each end of the construct and may span several vertebral segments without attachment to the intervening segments. Version 2008 – 1 (5/15/2008)

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Insertion of spinal instrumentation is reported separately and in addition to arthrodesis. Instrumentation procedure codes 22840-22848 and 22851 are reported in addition to the definitive procedure(s). Do not append modifier –62 to spinal instrumentation codes 22840-22848 and 22850-22852. To report bone graft procedures, see codes 20930-20938. (Report in addition to code(s) for definitive procedure(s).) Do not append modifier –62 to bone graft codes 2090020938. A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies, which contains the intervertebral disk, and includes the nucleus pulposus, annulus fibrosus, and two cartilagenous endplates. List 22840-22855 separately, in conjunction with code(s) for fracture, dislocation, arthrodesis or exploration of fusion of the spine 22325-22328, 22532-22534, 2254822812, and 22830. Codes 22840-22848, 22851 are reported in conjunction with code(s) for the definitive procedure(s). Code 22849 should not be reported with 22850, 22852, and 22855 at the same spinal levels. 22840

Posterior non-segmental instrumentation (eg, Harrington Rod Technique), pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation (List separately in addition to primary procedure) (Use 22840 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 6305063056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22841

Internal spinal fixation by wiring of spinous processes (List separately in addition to primary procedure) (Use 22841 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 6305063056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22842

Posterior segmental instrumentation (eg, pedical fixation, dual rods with multiple hooks and sublaminal wires); 3 to 6 vertebral segments (List separately in addition to primary procedure) (Use 22842 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 6305063056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

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22843

7 to 12 vertebral segments (List separately in addition to primary procedure) (Use 22843 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22812, 63001-63030, 63040-63042, 6304563047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22844

13 or more vertebral segments (Use 22844 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22812, 63001-63030, 63040-63042, 6304563047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22845

Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to primary procedure) (Use 22845 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 6305063056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22846

4 to 7 vertebral segments (Use 22846 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22812, 63001-63030, 63040-63042, 6304563047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22847

8 or more vertebral segments (Use 22847 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 22590-22612, 22630, 22800-22812, 63001-63030, 63040-63042, 6304563047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22848

Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to primary procedure) (Use 22848 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 6305063056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22849 22850

Reinsertion of spinal fixation device Removal of posterior nonsegmental instrumentation (eg, Harrington rod)

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22851

Application of intervertebral biomechanical device(s) (eg, synthetic cages, threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to primary procedure) (Use 22851 in conjunction with 22100-22102, 22110-22114, 22206-22208, 22210-22214, 22220-22224, 22305-22327, 22532-22533, 22548-22558, 2259022612, 22630, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 6305063056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170-63290, 63300-63307)

22852 22855

Removal of posterior segmental instrumentation Removal of anterior instrumentation (For spinal cord monitoring use 95925)

22857

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace (Do not report 22857 in conjunction with 22558, 22845, 22851, 49010 when performed at the same level)

22862

Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, lumbar, single interspace (Do not report 22862 in conjunction with 22558, 22845, 22851, 22865, 49010 when performed at the same level)

22865

Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace (Do not report 22865 in conjunction with 49010) (22857-22865 include fluoroscopy when performed) (For decompression, see 63001-63048)

OTHER PROCEDURES 22899

Unlisted procedure, spine

ABDOMEN EXCISION 22900

Excision, abdominal wall tumor, subfascial (eg, desmoid)

OTHER PROCEDURES 22999

Unlisted procedure, abdomen, musculoskeletal system

SHOULDER Clavicle, scapula, humerus head and neck, sternoclavicular joint, acromioclavicular joint and shoulder joint.

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INCISION 23000

Removal of subdeltoid calcareous deposits, open (For arthroscopic removal of bursal deposits, use 29999)

23020

Capsular contracture release (eg, Sever type procedure) (For incision and drainage procedures, superficial, see 10040-10160)

23030 23031 23035 23040 23044

Incision and drainage, shoulder area; deep abscess or hematoma infected bursa Incision, bone cortex (eg,for osteomyelitis or bone abscess), shoulder area Arthrotomy, glenohumeral joint, including exploration, drainage or removal of foreign body Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage or removal of foreign body

EXCISION 23065 23066

Biopsy, soft tissues; superficial deep (For needle biopsy of soft tissue, use 20206)

23075 23076 23077 23100 23101 23105 23106 23107 23120

Excision, soft tissue tumor, shoulder area; subcutaneous deep, subfascial or intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of shoulder area Arthrotomy, glenohumeral joint, including biopsy Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage Arthrotomy, glenohumeral joint with synovectomy, with or without biopsy sternoclavicular joint, with synovectomy, with or without biopsy Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body Claviculectomy; partial (For arthroscopic procedure, use 29824)

23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 23174

total Acromioplasty or acromionectomy, partial, with or without coracacromial ligament release Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft) with allograft Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft) with allograft Sequestrectomy (eg, for osteomyelitis or bone abscess); clavicle scapula humeral head to surgical neck

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23180 23182 23184 23190 23195

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); clavicle scapula proximal humerus Ostectomy of scapula, partial (eg, superior medial angle) Resection humeral head (For replacement with implant, use 23470)

23200 23210 23220 23221 23222

Radical resection of bone tumor; clavicle scapula Radical resection for tumor, proximal humerus; with autograft, (includes obtaining graft) with prosthetic replacement

INTRODUCTION OR REMOVAL (For arthrocentesis or needling of bursa, see 20610) (For K-wire or pin insertion or removal, see 20650, 20670, 20680) 23330 23331 23332 23350

Removal of foreign body, shoulder; subcutaneous deep (eg, Neer hemiarthroplasty removal) complicated (eg, total shoulder) (Report required) Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography (For radiographic arthrography, radiological supervision and interpretation, use 73040. Fluoroscopy (77002) is inclusive of radiographic arthrography) (When fluoroscopic guided injection is performed for enhanced CT arthrography, use 23350, 77002, and 73201 or 73202) (When fluoroscopic guided injection is performed for enhanced MR arthrography, use 23350, 77002, and 73222 or 73223) (For enhanced CT or enhanced MRI arthrography, use 77002 and either 73201, 73202, 73222 or 73223) (To report biopsy of the shoulder and joint, see 29805-29826)

REPAIR, REVISION AND/OR RECONSTRUCTION 23395 23397 23400 23405 23406 23410 23412

Muscle transfer, any type, shoulder or upper arm; single multiple Scapulopexy (eg, Sprengel's deformity or for paralysis) Tenotomy, shoulder area; single tendon multiple tendons through same incision Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute chronic (For arthroscopic procedure, use 29827)

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23415

Coracoacromial ligament release, with or without acromioplastym (For arthroscopic procedure, use 29826)

23420 23430 23440 23450

Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Tenodesis of long tendon of biceps Resection or transplantation of long tendon of biceps Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation (To report arthroscopic thermal capsulorrhaphy, use 29999)

23455

with labral repair (eg, Bankart procedure) (For arthroscopic procedure, use 29806)

23460 23462

Capsulorrhaphy, anterior, any type; with bone block with coracoid process transfer (To report open thermal capsulorrhaphy, use 23929)

23465

Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block (For sternoclavicular and acromioclavicular reconstruction, see 23530 and 23550)

23466 23470 23472

Capsulorrhaphy, glenohumeral joint, any type multi-directional instability Arthroplasty, glenohumeral joint; hemiarthoplasty total shoulder (glenoid and proximal humeral replacement (eg, total shoulder) (For removal of total shoulder implants, see 23331, 23332) (For osteotomy proximal humerus, use 24400)

23480 23485 23490 23491

Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate; clavicle proximal humerus

FRACTURE AND/OR DISLOCATION 23500 23505 23515 23520 23525 23530 23532 23540 23545

Closed treatment of clavicular fracture; without manipulation with manipulation Open treatment of clavicular fracture, includes internal fixation, when performed Closed treatment of sternoclavicular dislocation; without manipulation with manipulation Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) Closed treatment of acromioclavicular dislocation; without manipulation with manipulation

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23550 23552 23570 23575 23585 23600 23605 23615

23616 23620 23625 23630 23650 23655 23660

Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) Closed treatment of scapular fracture; without manipulation with manipulation, with or without skeletal traction (with or without shoulder joint involvement) Open treatment of scapular fracture (body, glenoid or acromion) with or without internal fixation Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation with manipulation, with or without skeletal traction Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement Closed treatment of greater humeral tuberosity fracture; without manipulation with manipulation Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performed Closed treatment of shoulder dislocation, with manipulation; without anesthesia requiring anesthesia Open treatment of acute shoulder dislocation (Repairs for recurrent dislocations, see 23450-23466)

23665 23670 23675 23680

Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed

MANIPULATION 23700

Manipulation under anesthesia, including application of fixation apparatus (dislocation excluded)

ARTHRODESIS 23800 23802

Arthrodesis, glenohumeral joint; (Report required) with autogenous graft (includes obtaining graft)

AMPUTATION 23900 23920 23921

Interthoracoscapular amputation (forequarter) Disarticulation of shoulder; secondary closure or scar revision

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OTHER PROCEDURES 23929

Unlisted procedure, shoulder

HUMERUS (UPPER ARM) AND ELBOW Elbow area includes head and neck of radius and olecranon process. INCISION (For incision/drainage procedures, superficial, see 10040 - 10160) 23930 23931 23935 24000 24006

Incision and drainage upper arm or elbow area; deep abscess or hematoma bursa Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow Arthrotomy, elbow, including exploration, drainage or removal of foreign body Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure)

EXCISION 24065 24066

Biopsy, soft tissue of upper arm or elbow area; superficial deep (sufascial or intramuscular) (For needle biopsy of soft tissue, use 20206)

24075 24076 24077 24100 24101 24102 24105 24110 24115 24116 24120 24125 24126 24130

Excision, tumor, soft tissue of upper arm or elbow area; subcutaneous deep, subfascial or intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of upper arm or elbow area Arthrotomy, elbow; with synovial biopsy only with joint exploration, with or without biopsy, with or without removal of loose or foreign body with synovectomy Excision, olecranon bursa Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) with allograft Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining graft) with allograft Excision, radial head (For replacement with implant, use 24366)

24134 24136 24138

Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus radial head or neck olecranon process

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24140 24145 24147 24149

Partial excision (craterization, saucerization or diaphysectomy) of bone (eg, for osteomyelitis); humerus radial head or neck olecranon process Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure) (For capsular and soft tissue release only, use 24006)

24150 24151 24152 24153 24155

Radical resection for tumor, shaft or distal humerus; with autograft (includes obtaining graft) Radical resection for tumor, radial head or neck; with autograft (includes obtaining graft) Resection of elbow joint (arthrectomy)

INTRODUCTION OR REMOVAL (For K-wire or pin insertion or removal, see 20650, 20670, 20680) (For arthrocentesis or needling of bursa or joint, use 20605) 24160 24164 24200 24201 24220

Implant removal; elbow joint radial head Removal of foreign body, upper arm or elbow area; subcutaneous deep (subfascial or intramuscular) Injection procedure for elbow arthrography (For radiological supervision and interpretation, use 73085. Do not report 77002 in conjunction with 73085) (For injection of tennis elbow, use 20550)

REPAIR, REVISION AND/OR RECONSTRUCTION 24300

Manipulation, elbow, under anesthesia (For application of external fixation, see 20690 or 20692)

24301 24305 24310 24320 24330 24331 24332 24340 24341 24342

Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) Tendon lengthening, upper arm or elbow, each tendon Tenotomy, open, elbow to shoulder, each tendon Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure) Flexor-plasty, elbow,(eg, Steindler type advancement); with extensor advancement Tenolysis, triceps Tenodesis of biceps tendon at elbow (separate procedure) Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cluff) Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft

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24343 24344 24345 24346 24357 24358 24359

24360 24361 24362 24363 24365 24366 24400 24410 24420 24430 24435

Repair lateral collateral ligament, elbow, with local tissue Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft) Repair medial collateral ligament, elbow, with local tissue Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft) Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneous Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment Arthroplasty, elbow; with membrane (eg, fascial) with distal humeral prosthetic replacement with implant and fascia lata ligament reconstruction with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) Arthroplasty, radial head; with implant Osteotomy, humerus, with or without internal fixation Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure) Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876) Repair of nonunion or malunion, humerus; without graft (eg, compression technique, etc) with iliac or other autograft (includes obtaining graft) (For proximal radius and/or ulna, see 25400-25420)

24470 24495 24498

Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus) Decompression fasciotomy, forearm, with brachial artery exploration Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, humeral shaft

FRACTURE AND/OR DISLOCATION 24500 24505 24515 24516 24530 24535

Closed treatment of humeral shaft fracture; without manipulation with manipulation, with or without skeletal traction Open treatment of humeral shaft fracture with plate/screws, with or without cerclage Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation with manipulation, with or without skin or skeletal traction

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24538 24545 24546 24560 24565 24566 24575 24576 24577 24579

Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension with intercondylar extension Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation with manipulation Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, when performed Closed treatment of humeral condylar fracture, medial or lateral; without manipulation with manipulation Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performed (To report closed treatment of fractures without manipulation, see 24530, 24560, 24576, 24650, 24670) (To report closed treatment of fractures with manipulation, see 24535, 24565, 24577, 24675)

24582 24586 24587 24600 24605 24615 24620 24635

24640 24650 24655 24665 24666

Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty (See also 24361) Treatment of closed elbow dislocation; without anesthesia requiring anesthesia Open treatment of acute or chronic elbow dislocation Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Closed treatment of radial head or neck fracture; without manipulation with manipulation Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head prosthetic replacement

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24670 24675 24685

Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process [es]); without manipulation with manipulation Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process [es] ), includes internal fixation, when performed

ARTHRODESIS 24800 24802

Arthrodesis, elbow joint; local with autogenous graft (includes obtaining graft)

AMPUTATION 24900 24920 24925 24930 24931 24935 24940

Amputation, arm through humerus; with primary closure open, circular (guillotine) secondary closure or scar revision reamputation with implant Stump elongation, upper extremity (Report required) Cineplasty, upper extremity, complete procedure

OTHER PROCEDURES 24999

Unlisted procedure, humerus or elbow

FOREARM AND WRIST Radius, ulna, carpal bones and joints. INCISION 25000

Incision, extensor tendon sheath, wrist (eg, deQuervains disease) (For decompression median nerve or for carpal tunnel syndrome, use 64721)

25001 25020 25023

Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis) Decompression fasciotomy, forearm and/or wrist, flexor or extensor compartment; without debridement of nonviable muscle and/or nerve with debridement of nonviable muscle and/or nerve (For decompression fasciotomy with brachial artery exploration, use 24495) (For incision and drainage procedures, superficial, see 10060-10160) (For debridement, see also 11000-11044)

25024 25025 25028 25031 25035

Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve with debridement of nonviable muscle and/or nerve Incision and drainage forearm and/or wrist; deep abscess or hematoma bursa Incision, deep, bone cortex, forearm and/or wrist (eg, for osteomyelitis or bone abscess)

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25040

Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body

EXCISION 25065 25066

Biopsy, soft tissue; superficial deep (subfascial or intramuscular) (For needle biopsy of soft tissue, use 20206)

25075 25076 25077 25085 25100 25101 25105 25107 25109 25110 25111 25112

Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous deep, subfascial or intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of forearm and/or wrist area Capsulotomy, wrist (eg, for contracture) Arthrotomy, wrist joint; with biopsy with joint exploration, with or without biopsy, with or without removal of loose or foreign body with synovectomy Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex Excision of tendon, forearm and/or wrist, flexor or extensor, each Excision, lesion of tendon sheath Excision of ganglion, wrist (dorsal or volar); primary recurrent (For hand or finger, use 26160)

25115 25116

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors extensors (with or without transposition of dorsal retinaculum) (For finger synovectomies, use 26145)

25118 25119 25120

Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); (For head or neck of radius or olecranon process, see 24120-24126)

25125 25126 25130 25135 25136 25145 25150 25151

with autograft (includes obtaining graft) with allograft Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft) with allograft Sequestrectomy (eg, for osteomyelitis or bone abscess) Partial excision (craterization, saucerization or diaphysectomy) of bone (eg, for osteomyelitis); ulna radius (For head or neck of radius or olecranon process, see 24145-24147)

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25170 25210

Radical resection for tumor, radius or ulna Carpectomy; one bone (For carpectomy with implant, see 25441-25445)

25215 25230 25240

all bones of proximal row Radial styloidectomy (separate procedure) Excision distal ulna partial or complete (eg, Darrach type or matched resection) (For implant replacement, distal ulna, see 25442) (For obtaining fascia for interposition, see 20920, 20922)

INTRODUCTION OR REMOVAL (For K-wire, pin, or rod insertion or removal, see 20650, 20670, 20680) 25246

Injection procedure for wrist arthrography (For radiological supervision and interpretation, use 73115. Do not report 77002 in conjunction with 73115) (For foreign body removal, superficial, use 20520)

25248 25250 25251 25259

Exploration with removal of deep foreign body, forearm or wrist Removal of wrist prosthesis; (separate procedure) (Report required) complicated, including total wrist (Report required) Manipulation, wrist, under anesthesia (For application of external fixation, see 20690 or 20692)

REPAIR, REVISION AND/OR RECONSTRUCTION 25260 25263 25265 25270 25272 25274 25275 25280 25290 25295 25300 25301

Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle secondary, single, each tendon or muscle secondary, with free graft (includes obtaining graft) each tendon or muscle Repair, tendon or muscle, extensor; forearm and/or wrist; primary, single, each tendon or muscle secondary, single, each tendon or muscle secondary, with free graft (includes obtaining graft), each tendon or muscle Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for exterior carpi ulnaris subluxation) Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist; single, each tendon Tenotomy, open, flexor or extensor tendon, forearm and/or wrist single, each tendon Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon Tenodesis at wrist; flexors of fingers extensors of fingers

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25310 25312 25315 25316 25320

25332

Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon with tendon graft(s) (includes obtaining graft), each tendon Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer Capsulorrhaphy or reconstruction, wrist, open, (eg, capsulodesis,ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability Arthroplasty, wrist, with or without interposition, with or without external or internal fixation (For obtaining fascia for interposition, see 20920-20922) (For prosthetic replacement arthroplasty, see 25441-25446)

25335 25337

Centralization of wrist on ulna (eg, radial club hand) Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint (For harvesting of fascia lata graft, see 20920, 20922)

25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25394 25400 25405 25415 25420 25425 25426 25430 25431 25440

Osteotomy, radius; distal third middle or proximal third Osteotomy; ulna radius AND ulna Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna radius AND ulna Osteoplasty, radius OR ulna; shortening lengthening with autograft Osteoplasty, radius AND ulna; shortening (excluding 64876) lengthening with autograft Osteoplasty, carpal bone, shortening Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique) with autograft (includes obtaining graft) Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) with autograft (includes obtaining graft) Repair of defect with autograft; radius OR ulna radius AND ulna Insertion of vascular pedicle into carpal bone (eg, Hori procedure) Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation)

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25441 25442 25443 25444 25445 25446 25447

Arthroplasty with prosthetic replacement; distal radius distal ulna scaphoid carpal (navicular) lunate trapezium distal radius and partial or entire carpus ("total wrist") Arthroplasty interposition, intercarpal or carpo-metacarpal joints (For wrist arthroplasty, see 25332)

25449 25450 25455 25490 25491 25492

Revision of arthroplasty, including removal of implant, wrist joint Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna distal radius AND ulna Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius ulna radius AND ulna

FRACTURE AND/OR DISLOCATION (For application of external fixation in addition to internal fixation, use 20690 and the appropriate internal fixation code) (Do not report 25600, 25605, 25606, 25607, 25608, 25609, in conjunction with 25650) 25500 25505 25515 25520 25525

25526

25530 25535 25545 25560 25565 25574 25575

Closed treatment of radial shaft fracture; without manipulation with manipulation Open treatment of radial shaft fracture, includes internal fixation, when performed Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radio-ulnar joint (Galeazzi fracture/dislocation) Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes percutaneous skeletal fixation, when performed Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex Closed treatment of ulnar shaft fracture; without manipulation with manipulation Open treatment of ulnar shaft fracture, includes internal fixation, when performed Closed treatment of radial and ulnar shaft fractures; without manipulation with manipulation Open treatment of radial and ulnar shaft fractures, with internal fixation, when performed; of radius or ulna of radius and ulna

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25600

25605 25606 25607 25608 25609

Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation with manipulation Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation with internal fixation of 2 fragments (Do not report 25608 in conjunction with 25609) Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments (For 25606, 25607, 25609 for percutaneous treatment of ulnar styloid fracture, use 25651) (For 25606, 25607, 25609 for open treatment of ulnar styloid fracture, use 25652)

25622 25624 25628 25630 25635 25645 25650 25651 25652 25660 25670 25671 25675 25676 25680 25685 25690 25695

Closed treatment of carpal scaphoid (navicular) fracture; without manipulation with manipulation Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each bone with manipulation, each bone Open treatment of carpal bone fracture (other than carpal scaphoid (navicular)), each bone Closed treatment of ulnar styloid fracture (Do not report 25650 in conjunction with 25600, 25605, 25607-25609) Percutaneous skeletal fixation of ulnar styloid fracture Open treatment of ulnar styloid fracture Closed treatment of radiocarpal or intercarpal dislocation, one or more bones, with manipulation Open treatment of radiocarpal or intercarpal dislocation, one or more bones Percutaneous skeletal fixation of distal radioulnar dislocation Closed treatment of distal radioulnar dislocation with manipulation Open treatment of distal radioulnar dislocation, acute or chronic Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Open treatment of trans-scaphoperilunar type of fracture dislocation Closed treatment of lunate dislocation, with manipulation Open treatment of lunate dislocation

ARTHRODESIS 25800

Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)

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25805 25810 25820 25825 25830

with sliding graft with iliac or other autograft (includes obtaining graft) Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) with autograft (includes obtaining graft) Arthrodesis with distal radioulnar joint and segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure)

AMPUTATION 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931

Amputation, forearm, through radius and ulna; open, circular (guillotine) secondary closure or scar revision re-amputation Krukenberg procedure Disarticulation through wrist; secondary closure or scar revision re-amputation Transmetacarpal amputation; secondary closure or scar revision re-amputation

OTHER PROCEDURES 25999

Unlisted procedure, forearm or wrist

HAND AND FINGERS INCISION 26010 26011 26020 26025 26030 26034 26035 26037

Drainage of finger abscess; simple complicated (eg, felon) Drainage of tendon sheath, one digit and/or palm, each Drainage of palmar bursa; single bursa multiple bursa Incision, bone cortex, hand or finger (eg,osteomyelitis or bone abscess) Decompression fingers and/or hand, injection injury (eg, grease gun) (Report required) Decompressive fasciotomy, hand (excludes 26035) (For injection injury, see 26035)

26040 26045

Fasciotomy, palmar, (eg, Dupuytren's contracture); percutaneous open, partial (For fasciectomy, see 26121-26125)

26055 26060 26070 26075 26080

Tendon sheath incision (eg, for trigger finger) Tenotomy, percutaneous, single, each digit Arthrotomy, with exploration, drainage, or removal of foreign body; carpometacarpal joint metacarpophalangeal joint, each interphalangeal joint, each

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EXCISION 26100 26105 26110 26115 26116 26117 26121 26123

26125

Arthrotomy with biopsy; carpometacarpal joint, each metacarpophalangeal joint, each interphalangeal joint, each Excision, tumor or vascular malformation, soft tissue of hand or finger; subcutaneous deep (subfascial or intramuscular) Radical resection of tumor (eg, malignant neoplasm), soft tissue of hand or finger Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) Fasciectomy, partial palmar with release,of single digit including promixal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to primary procedure) (Use 26125 in conjunction with code 26123) (For fasciotomy, see 26040, 26045)

26130 26135 26140 26145

Synovectomy, carpometacarpal joint Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendor, palm and/or finger, each tendon (For tendon sheath synovectomies at wrist, see 25115, 25116)

26160

Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger (For wrist ganglion, see 25111, 25112) (For trigger digit, see 26055)

26170

Excision of tendon, palm, flexor, or extensor, single, each tendon (Do not report 26170 in conjunction with 26390, 26415)

26180

Excision of tendon, finger, flexor or extensor, each tendon (Do not report 26180 in conjunction with 26390, 26415)

26185 26200 26205 26210

Sesamoidectomy, thumb or finger (separate procedure) Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal, middle or distal phalanx; with autograft (includes obtaining graft)

26215

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26230 26235 26236 26250 26255 26260 26261 26262

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, for osteomyelitis); metacarpal proximal or middle phalanx distal phalanx Radical resection metacarpal; (eg, tumor) with autograft (includes obtaining graft) Radical resection, proximal or middle phalanx of finger (eg, tumor); with autograft (includes obtaining graft) Radical resection, distal phalanx of finger (eg, tumor)

INTRODUCTION OR REMOVAL 26320

Removal of implant from finger or hand (For removal of foreign body in hand or finger, see 20520, 20525)

REPAIR, REVISION AND/OR RECONSTRUCTION 26340

Manipulation, finger joint, under anesthesia, each joint (For application of external fixation, see 20690 or 20692)

26350 26352 26356 26357 26358 26370 26372 26373 26390 26392 26410 26412 26415 26416 26418 26420

Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon secondary with free graft (includes obtaining graft), each tendon Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendon secondary, without free graft, each tendon secondary with free graft (includes obtaining graft), each tendon Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon secondary with free graft (includes obtaining graft), each tendon secondary without free graft, each tendon Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod Repair, extensor tendon, primary or secondary;without free graft, each tendon with free graft (includes obtaining graft), each tendon Excision of extensor tendon, implantation of synthetic rod for delayed tendon graft, hand or finger, each rod (Report required) Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod (Report required) Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon with free graft (includes obtaining each tendon graft)

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26426 26428 26432 26433 26434

Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger with free graft (includes obtaining graft), each finger Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) Repair extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger) with free graft (includes obtaining graft) (For tenovaginotomy for trigger finger, use 26055)

26437 26440 26442 26445 26449 26450 26455 26460 26471 26474 26476 26477 26478 26479 26480 26483 26485 26489 26490 26492 26494 26496

Realignment of extensor tendon, hand, each tendon Tenolysis, flexor tendon; palm OR finger, each tendon palm AND finger, each tendon Tenolysis, extensor tendon, hand or finger; each tendon Tenolysis, complex, extensor tendon, finger, including forearm, each tendon Tenotomy, flexor, palm, open, each tendon Tenotomy, flexor, finger, open, each tendon Tenotomy, extensor, hand or finger, open, each tendon Tenodesis; of proximal interphalangeal joint, each joint of distal joint, each joint Lengthening of tendon, extensor, hand or finger, each tendon Shortening of tendon, extensor, hand or finger, each tendon Lengthening of tendon, flexor, hand or finger, each tendon Shortening of tendon, flexor, hand or finger, each tendon Transfer or transplant of tendon, carpometacarpal area or dorsum of hand, without free graft, each tendon with free tendon graft (includes obtaining graft), each tendon Transfer or transplant of tendon, palmar; without free tendon graft, each tendon with free tendon graft (includes obtaining graft), each tendon Opponensplasty; superficialis tendon transfer type, each tendon tendon transfer with graft (includes obtaining graft), each tendon hypothenar muscle transfer other methods (For thumb fusion in opposition, use 26820)

26497 26498 26499 26500 26502 26508 26510

Transfer of tendon to restore intrinsic function; ring and small finger all four fingers Correction claw finger, other methods (Report required) Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) with tendon or fascial graft (includes obtaining graft) (separate procedure) Release of thenar muscle(s) (eg, thumb contracture) Cross intrinsic transfer, each tendon (Report required)

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26516 26517 26518 26520 26525

Capsulodesis, metacarpophalangeal joint; single digit two digits three or four digits Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint interphalangeal joint, each joint (To report carpometacarpal joint arthroplasty, use 25447)

26530 26531 26535 26536 26540 26541 26542 26545 26546 26548 26550 26551

Arthroplasty, metacarpophalangeal joint; each joint with prosthetic implant, each joint Arthroplasty interphalangeal joint; each joint with prosthetic implant, each joint Repair of collateral ligament, metacarpophalangeal or interphalangeal joint Reconstruction, collateral ligament, metacarpophalangeal joint, single, with tendon or fascial graft (includes obtaining graft) with local tissue (eg, adductor advancement) Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint Repair non-union, metacarpal or phalanx, (includes obtaining bone graft with or without external or internal fixation) Repair and reconstruction, finger, volar plate, interphalangeal joint Pollicization of a digit Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft (Report required) (For great toe with web space, use 20973)

26553 26554 26555 26556

other than great toe, single (Report required) other than great toe, double (Report required) Transfer, finger to another position without microvascular anastomosis (Report required) Transfer, free toe joint, with microvascular anastomosis (Report required) (To report great toe-to-hand transfer, use 20973)

26560 26561 26562 26565 26567 26568 26580 26587

Repair of syndactyly (web finger), each web space; with skin flaps with skin flaps and grafts complex (eg, involving bone, nails) Osteotomy; metacarpal, each phalanx of finger, each Osteoplasty, lengthening, metacarpal or phalanx (Report required) Repair cleft hand (Report required) Reconstruction of polydactylous digit, soft tissue and bone (For excision of polydactylous digit, soft tissue only, use 11200)

26590 26591 26593

Repair macrodactylia, each digit Repair, intrinsic muscles of hand, each muscle Release, intrinsic muscles of hand, each muscle

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26596

Excision of constricting ring of finger, with multiple Z-plasties (To report release of scar contracture or graft repairs see 11041-11042, 1404014041, or 15120, 15240)

FRACTURE AND/OR DISLOCATION 26600 26605 26607 26608 26615 26641 26645 26650 26665 26670 26675 26676 26685 26686 26700 26705 26706 26715 26720 26725 26727 26735 26740 26742

Closed treatment of metacarpal fracture, single; without manipulation, each bone with manipulation, each bone Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone Percutaneous skeletal fixation of metacarpal fracture, each bone Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone Closed treatment of carpometacarpal dislocation, thumb, with manipulation Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performed Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia requiring anesthesia Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each joint complex, multiple or delayed reduction Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia requiring anesthesia Percutaneous skeletal fixation of metacarpo-phalangeal dislocation, single, with manipulation Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when performed Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each with manipulation, with or without skin or skeletal traction, each Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each with manipulation, each

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26746 26750 26755 26756 26765 26770 26775 26776 26785

Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each with manipulation, each Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single

ARTHRODESIS 26820 26841 26842 26843 26844 26850 26852 26860 26861

Fusion in opposition, thumb, with autogenous graft (includes obtaining graft) Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft) Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft) Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to primary procedure) (Use 26861 in conjunction with 26860)

26862 26863

with autograft (includes obtaining graft) with autograft (includes obtaining graft), each additional joint (List separately in addition to primary procedure) (Use 26863 in conjunction with 26862)

AMPUTATION (For hand through metacarpal bones, use 25927) 26910

Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseus transfer (For repositioning, see 26550, 26555)

26951 26952

Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure with local advancement flap (V-Y, hood)

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(For repair of soft tissue defect requiring split or full thickness graft or other pedicle flaps, see 15050-15758) OTHER PROCEDURES 26989

Unlisted procedure, hands or fingers

PELVIS AND HIP JOINT Including head and neck of femur. INCISION (For incision and drainage procedures, superficial, see 10040-10160) 26990 26991 26992 27000 27001 27003 27005 27006 27025

Incision and drainage; pelvis or hip joint area; deep abscess or hematoma infected bursa Incision, bone cortex, pelvis and/or hip joint (eg, for osteomyelitis or bone abscess) Tenotomy, adductor of hip, percutaneous, (separate procedure) Tenotomy, adductor of hip, open Tenotomy, adductor, subcutaneous, open, with obturator neurectomy Tenotomy, hip flexor(s), open (separate procedure) Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) Fasciotomy, hip or thigh, any type (For 27001, 27003, 27025, to report bilateral procedures, use modifier -50)

27030 27033 27035

Arthrotomy, hip, with drainage (eg, infection) Arthrotomy, hip, including exploration or removal of loose or foreign body Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral or obturator nerves (Report required) (For obturator neurectomy, see 64763, 64766)

27036

Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas)

EXCISION 27040 27041

Biopsy, soft tissues of pelvis and hip area; superficial deep subfascial or intramuscular (For needle biopsy of soft tissue, use 20206)

27047 27048 27049 27050 27052 27054

Excision, tumor, pelvis and hip area; subcutaneous tissue deep, subfascial, intramuscular Radical resection of tumor, soft tissue of pelvis and hip area, (eg, malignant neoplasm) Arthrotomy, with biopsy; sacroiliac joint hip joint Arthrotomy with synovectomy, hip joint

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27060 27062

Excision; ischial bursa trochanteric bursa or calcification (For arthrocentesis or needling of bursa, see 20610)

27065

Excision of bone cyst or benign tumor; superficial (wing or ilium, symphysis pubis, or greater trochanter of femur) with or without autograft deep, with or without autograft with autograft requiring separate incision Partial excision (craterization, saucerization) (eg, osteotomyelitis or bone abscess); superficial (eg, wing of ilium, symphysis pubis or greater trochanter of femur) deep (subfascial or intramuscular) Radical resection of tumor or infection; wing of ilium, one pubic or ischial ramus or symphysis pubis ilium, including acetabulum, both pubic rami, or ischium and acetabulum innominate bone, total ischial tuberosity and greater trochanter of femur ischial tuberosity and greater trochanter of femur, with skin flaps Coccygectomy, primary

27066 27067 27070 27071 27075 27076 27077 27078 27079 27080

(For pressure (decubitus) ulcer, see 15920, 15922 and 15931-15958) INTRODUCTION OR REMOVAL 27086 27087 27090 27091 27093 27095

Removal of foreign body, pelvis or hip; subcutaneous tissue deep (subfacial or intramuscular) Removal of hip prosthesis; (separate procedure) complicated, including total hip prosthesis, methylmethacrylate, with or without insertion of spacer Injection procedure for hip arthrography; without anesthesia with anesthesia (For 27093, 27095 for radiological supervision and interpretation, use 73525. Do not report 77002 in conjunction with 73525)

27096

Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steriod (27096 is to be used only with imaging confirmation of intra-articular needle positioning) (27096 is a unilateral procedure. for bilateral procedure, use modifier -50) (For radiological supervision and interpretation, of sacroiliac joint arthrography use 73542) (For fluoroscopic guidance without formal arthrography, use 77003)

REPAIR, REVISION, AND/OR RECONSTRUCTION 27097 27098 27100

Release or recession, hamstring, proximal Transfer, adductor to ischium Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft)

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27105 27110 27111 27120 27122 27125

Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) (Report required) Transfer iliopsoas; to greater trochanter of femur to femoral neck Acetabuloplasty; (eg, Whitman, Colonna Haygroves, or cup type) resection, femoral head (Girdlestone procedure) Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) (For prosthetic replacement following fracture of hip, use 27236)

27130 27132 27134 27137 27138 27140 27146 27147 27151 27156 27158 27161 27165 27170 27175 27176 27177 27178 27179 27181 27185 27187

Arthroplasty, acetabular and proximal femoral prosthetic replacement, (total hip arthroplasty), with or without autograft or allograft Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft Revision of total hip arthroplasty; both components, with or without autograft or allograft acetabular component only, with or without autograft or allograft femoral component only, with or without allograft Osteotomy and transfer of greater trochanter of femur (separate procedure) Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip with femoral osteotomy with femoral osteotomy and with open reduction of hip Osteotomy, pelvis, bilateral (eg, congenital malformation) Osteotomy, femoral neck (separate procedure) Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft) Treatment of slipped femoral epiphysis; by traction, without reduction by single or multiple pinning, in situ Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) closed manipulation with single or multiple pinning osteoplasty of femoral neck (Heyman type procedure) osteotomy and internal fixation Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur

FRACTURE AND/OR DISLOCATION 27193 27194 27200 27202

Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation with manipulation, requiring more than local anesthesia Closed treatment of coccygeal fracture Open treatment of coccygeal fracture (Report required)

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27215 27216 27217 27218 27220 27222 27226 27227

27228

27230 27232 27235 27236 27238 27240 27244 27245 27246 27248 27250 27252 27253 27254

Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s) (eg, pelvic fracture(s) which do not disrupt the pelvic ring), with internal fixation Percutaneous skeletal fixation of posterior pelvic ring fracture and/or dislocation (includes ilium, sacroiliac joint and/or sacrum) Open treatment of anterior ring fracture and/or dislocation with internal fixation, (includes pubic symphysis and/or rami) Open treatment of posterior ring fracture and/or dislocation with internal fixation (includes ilium, sacroiliac joint and/or sacrum) Closed treatment of acetabulum (hip socket) fracture(s); without manipulation with manipulation, with or without skeletal traction Open treatment of posterior or anterior acetabular wall fracture, with internal fixation Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixation Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture; with internal fixation Closed treatment of femoral fracture, proximal end, neck; without manipulation with manipulation, with or without skeletal traction Percutaneous skeletal fixation of femoral fracture, proximal end, neck Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement Closed treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; without manipulation with manipulation, with or without skin or skeletal traction Treatment of intertrochanteric, pertrochanteric or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage with intramedullary implant, with or without interlocking screws and/or cerclage Closed treatment of greater trochanteric fracture, without manipulation Open treatment of greater trochanteric fracture, includes internal fixation, when performed Closed treatment of hip dislocation, traumatic; without anesthesia requiring anesthesia Open treatment of hip dislocation, traumatic, without internal fixation Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external fixation (For treatment of acetabular fracture with fixation, see 27226, 27227)

27256

27257

Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation with manipulation, requiring anesthesia

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27258

27259 27265 27266 27267 27268 27269

Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shortening Closed treatment of post hip arthroplasty dislocation; without anesthesia requiring regional or general anesthesia Closed treatment of femoral fracture, proximal end, head; without manipulation Closed treatment of femoral fracture, proximal end, head; with manipulation Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performed

MANIPULATION 27275

Manipulation, hip joint, requiring general anesthesia

ARTHRODESIS 27280

Arthrodesis, sacroiliac joint (including obtaining graft) (Report required) (To report bilateral procedures, use modifier -50)

27282 27284 27286

Arthrodesis, symphysis pubis (including obtaining graft) (Report required) Arthrodesis, hip joint (includes obtaining graft); with subtrochanteric osteotomy

AMPUTATION 27290 27295

Interpelviabdominal amputation (hind quarter amputation) (Report required) Disarticulation of hip

OTHER PROCEDURES 27299

Unlisted procedure, pelvis or hip joint

FEMUR (THIGH REGION) AND KNEE JOINT Including tibial plateaus. INCISION (For incision/drainage of abscess/hematoma, superficial, see 10040-10160) 27301 27303 27305

Incision and drainage of deep abscess, bursa, or hematoma, thigh or knee region Incision, deep with opening of bone cortex, femur or knee(eg, osteomyelitis or bone abscess) Fasciotomy, iliotibial (tenotomy), open (For combined Ober-Yount fasciotomy, see 27025)

27306 27307 27310

Tenotomy, percutaneous, adductor or hamstring, single tendon (separate procedure) multiple tendons Arthrotomy, knee, with exploration, drainage or removal of foreign body (eg, infection) Version 2008 – 1 (5/15/2008)

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EXCISION 27323 27324

Biopsy, soft tissue of thigh or knee area; superficial deep (subfacial or intramuscular) (For needle biopsy of soft tissue, use 20206)

27325 27326 27327 27328 27329 27330 27331 27332 27333 27334 27335 27340 27345 27347 27350 27355 27356 27357 27358

27360 27365

Neurectomy, hamstring muscle (Report required) Neurectomy, popliteal (gastrocnemius) Excision, tumor; thigh or knee area; subcutaneous deep, subfascial, or intramuscular Radical resection of tumor (eg, malignant neoplasm), soft tissue of thigh or knee area Arthrotomy, knee; with synovial biopsy only including joint exploration, biopsy, or removal of loose or foreign bodies Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral medial AND lateral Arthrotomy, with synovectomy; knee, anterior OR posterior anterior AND posterior including popliteal area Excision, prepatellar bursa Excision of synovial cyst of popliteal space (eg, Baker's cyst) Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee Patellectomy or hemipatellectomy Excision or curettage of bone cyst or benign tumor of femur; with allograft with autograft (includes obtaining graft) with internal fixation (List in addition to primary procedure) (Use 27358 in conjunction with 27355, 27356, or 27357) Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess) Radical resection of tumor, bone, femur or knee (For radical resection of tumor, soft tissue, use 27329)

INTRODUCTION OR REMOVAL 27370

Injection procedure for knee arthrography (For radiological supervision and interpretation, use 73580. Do not report 77002 in conjunction with 73580)

27372

Removal foreign body, deep, thigh region or knee area (For removal of knee prosthesis including "total knee", use 27488) (For surgical arthroscopic knee procedures, see 29870-29887)

REPAIR, REVISION, AND/OR RECONSTRUCTION 27380

Suture of infrapatellar tendon; primary Version 2008 – 1 (5/15/2008)

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27381 27385 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400 27403

secondary reconstruction, including fascial or tendon graft Suture of quadriceps or hamstring muscle rupture; primary secondary reconstruction, including fascial or tendon graft Tenotomy, open, hamstring, knee to hip; single tendon multiple tendons, one leg multiple tendons, bilateral Lengthening of hamstring tendon; single tendon multiple tendons, one leg multiple tendons, bilateral Transplant, hamstring tendon to patella; single tendon multiple tendons Transfer tendon or muscle, hamstrings to femur (eg, Eggers type procedure) Arthrotomy with open meniscus repair, knee (For arthroscopic repair, use 29882)

27405 27407

Repair, primary, torn ligament and/or capsule, knee; collateral cruciate (For cruciate ligament reconstruction, use 27427)

27409

collateral and cruciate ligaments (For ligament reconstruction, see 27427-27429)

27415

Osteochondral allograft, knee, open (For arthroscopic implant of osteochondral allograft, use 29867)

27416

Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) (Do not report 27416 in conjunction with 27415, 29870, 29871, 29875, 29884 when performed at the same session and/or 29874, 29877, 29879, 29885-29887 when performed in the same compartment) (For arthroscopic osteochondral autograft of knee, use 29866)

27418 27420 27422 27424 27425

Anterior tibial tubercleplasty (eg, Maquet type procedure) Reconstruction of dislocating patella; (eg, Hauser type procedure) with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) with patellectomy Lateral retinacular release open (For arthroscopic lateral release, use 29873)

27427 27428 27429

Ligamentous reconstruction (augmentation), knee; extra-articular intra-articular (open) intra-articular (open) and extra-articular (Report required) (For primary repair of ligament(s) performed in conjunction with reconstruction, report 27405, 27407 or 27409 in conjunction with 27427, 27428 or 27429)

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27430 27435 27437 27438 27440 27441 27442 27443 27445 27446 27447

Quadricepsplasty (eg, Bennett or Thompson type) Capsulotomy, posterior release, knee Arthroplasty, patella; without prosthesis (Report required) with prosthesis (Report required) Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy Arthroplasty, femoral condylesor tibial plateau(s), knee; with debridement and partial synovectomy Arthroplasty, knee, hinge prosthesis (eg, Walldius type) Arthroplasty, knee, condyle and plateau; medial OR lateral compartment medial AND lateral compartments with or without patella resurfacing (total knee replacement) (For revision of total knee arthroplasty, use 27487) (For removal of total knee prosthesis, use 27488) (To report 27448-27450, 27455-27457 as bilateral procedures, use modifier -50)

27448 27450 27454 27455

27457 27465 27466 27468 27470 27472 27475 27477 27479 27485 27486 27487 27488 27495 27496 27497

Osteotomy, femur, shaft or supracondylar; without fixation with fixation Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft, (eg, Sofield type procedure) Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)); before epiphyseal closure after epiphyseal closure Osteoplasty, femur; shortening (excluding 64876) lengthening combined, lengthening and shortening with femoral segment transfer Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique) with iliac or other autogenous bone graft (includes obtaining graft) Arrest, epiphyseal, any method (eg, epiphydiodesis); distal femur tibia and fibula, proximal combined distal femur, proximal tibia and fibula Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, for genu varus or valgus) Revision of total knee arthroplasty, with or without allograft; one component femoral and entire tibial component Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femur Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); with debridement of nonviable muscle and/or nerve

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27498 27499

Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable muscle and/or nerve

FRACTURE AND/OR DISLOCATION (For arthroscopic treatment of tibial fracture, see 29855, 29856) (For arthroscopic treatment of intercondylar spine(s) and tuberosity fracture(s) of the knee, see 29850, 29851) 27500 27501 27502 27503 27506 27507 27508 27509

27510 27511 27513 27514 27516 27517 27519 27520 27524 27530 27532

Closed treatment of femoral shaft fracture, without manipulation Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, without manipulation Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension; with manipulation, with or without skin or skeletal traction Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws Open treatment of femoral shaft fracture with plate/screws, with or without cerclage Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulation Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, includes internal fixation, when performed Open treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, includes internal fixation, when performed Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal fixation, when performed Closed treatment of distal femoral epiphyseal separation; without manipulation (Report required) with manipulation, with or without skin or skeletal traction (Report required) Open treatment of distal femoral epiphyseal separation, includes internal fixation, when performed Closed treatment of patellar fracture, without manipulation Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair Closed treatment of tibial fracture, proximal (plateau); without manipulation with or without manipulation, with skeletal traction (For arthroscopic treatment for 27532, 27536, see 29855, 29856)

27535 27536

Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed bicondylar, with or without internal fixation Version 2008 – 1 (5/15/2008)

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27538

Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation (For arthroscopic treatment, see 29850, 29851)

27540 27550 27552 27556 27557 27558 27560

Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed Closed treatment of knee dislocation; without anesthesia requiring anesthesia Open treatment of knee dislocation, includes internal fixation, when performed; without primary ligamentous repair or augmentation/reconstruction with primary ligamentous repair with primary ligamentous repair, with augmentation/reconstruction Closed treatment of patellar dislocation; without anesthesia (For recurrent dislocation, see 27420-27424)

27562 27566

requiring anesthesia Open treatment of patellar dislocation, with or without partial or total patellectomy

MANIPULATION 27570

Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

ARTHRODESIS 27580

Arthrodesis, knee, any technique

AMPUTATION 27590 27591 27592 27594 27596 27598

Amputation, thigh, through femur, any level; immediate fitting technique including first cast open, circular (guillotine) secondary closure or scar revision reamputation Disarticulation at knee

OTHER PROCEDURES 27599

Unlisted procedure, femur or knee

LEG (TIBIA AND FIBULA) AND ANKLE JOINT INCISION 27600 27601 27602

Decompression fasciotomy, leg; anterior and/or lateral compartments only posterior compartment(s) only anterior and/or lateral, and posterior compartment(s) (For incision/drainage procedures, superficial, see 10040-10160) (For decompression fasciotomy with debridement, see 27892-27894)

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27603 27604 27605 27606 27607 27610 27612

Incision and drainage; deep abscess or hematoma infected bursa Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia general anesthesia Incision, (eg, osteomyelitis or bone abscess) leg or ankle Arthrotomy, ankle, including exploration, drainage or removal of foreign body Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening (See also 27685)

EXCISION 27613 27614

Biopsy, soft tissues; superficial deep (subfacial or intramuscular) (For needle biopsy of soft tissue, use 20206)

27615 27618 27619 27620 27625 27626 27630 27635 27637 27638 27640 27641 27645 27646 27647

Radical resection of tumor (eg, malignant neoplasm), soft tissue of leg or ankle area Excision, tumor, leg or ankle area; subcutaneous tissue deep, (subfascial or intramuscular) Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body Arthrotomy, with synovectomy, ankle; including tenosynovectomy Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes obtaining graft) with allograft Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis or exostosis); tibia fibula Radical resection of tumor, bone; tibia fibula talus or calcaneus

INTRODUCTION OR REMOVAL 27648

Injection procedure for ankle arthrography (For radiological supervision and interpretation, use 73615. Do not report 77002 in conjunction with 73615) (For ankle arthroscopy, see 29894-29898)

REPAIR, REVISION, AND/OR RECONSTRUCTION 27650 27652 27654

Repair, primary, open or percutaneous ruptured Achilles tendon; with graft (includes obtaining graft) Repair, secondary, ruptured Achilles tendon, with or without graft

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27656 27658 27659 27664 27665 27675 27676 27680 27681 27685 27686 27687

Repair, fascial defect of leg Repair or suture of flexor tendon, leg; primary, without graft, each tendon secondary with or without graft, each tendon Repair, extensor tendon, leg; primary, without graft, each tendon secondary with or without graft, each tendon (Report required) Repair dislocating peroneal tendons; without fibular osteotomy with fibular osteotomy Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon multiple tendons (through same incision(s)) Lengthening or shortening of tendon; leg or ankle; single tendon (separate procedure) multiple tendons (through same incision), each Gastrocnemius recession (eg, Strayer procedure) (Toe extensors are considered as a group to be a single tendon when transplanted into midfoot)

27690 27691

27692

27695 27696 27698 27700 27702 27703 27704 27705 27707 27709 27712

Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot) deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallicus longus, or peroneal tendon to midfoot or hindfoot) each additional tendon (List separately in addition to primary procedure) (Use 27692 in conjunction with 27690, 27691) Repair, primary, disrupted ligment, ankle; collateral both collateral ligaments Repair, secondary disrupted ligament,ankle, collateral (eg, Watson-Jones procedure) Arthroplasty, ankle; with implant (total ankle) revision, total ankle (Report required) Removal of ankle implant Osteotomy; tibia fibula tibia and fibula multiple, with realignment on intramedullary rod (eg, Sofield type procedure) (For osteotomy to correct genu varus (bowleg) or genu valgus (knock-knee), see 27455-27457)

27715 27720 27722 27724 27725

Osteoplasty, tibia and fibula, lengthening or shortening Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) with sliding graft with iliac or other autograft (includes obtaining graft) by synostosis, with fibula, any method

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27726 27727 27730 27732 27734 27740 27742

repair of fibula nonunion and/or malunion with internal fixation (Do not report 27726 in conjunction with 27707) Repair of congenital pseudarthrosis, tibia (Report required) Arrest, epiphyseal (epiphysiodesis), open; distal tibia distal fibula distal tibia and fibula Arrest epiphyseal, (epiphysiodesis), any method; combined, proximal and distal tibia and fibula; and distal femur (For epiphyseal arrest of proximal tibia and fibula, use 27477)

27745

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia

FRACTURE AND/OR DISLOCATION 27750 27752 27756 27758 27759 27760 27762 27766 27767 27768 27769

Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation with manipulation, with or without skeletal traction Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws) Open treatment of tibial shaft fracture, (with or without fibular fracture) with plate/screws, with or without cerclage Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage Closed treatment of medial malleolus fracture; without manipulation with manipulation, with or without skin or skeletal traction Open treatment of medial malleolus fracture, includes internal fixation, when performed Closed treatment of posterior malleolus fracture; without manipulation with manipulation Open treatment of posterior malleolus fracture, includes internal fixation, when performed (Do not report 27767-27769 in conjunction with 27808-27823)

27780 27781 27784 27786 27788 27792

Closed treatment of proximal fibula or shaft fracture; without manipulation with manipulation Open treatment of proximal fibula or shaft fracture, includes internal fixation, when performed Closed treatment of distal fibular fracture (lateral malleolus); without manipulation with manipulation Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed (For treatment of tibia and fibula shaft fractures, see 27750-27759)

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27808 27810 27814

27816 27818 27822 27823 27824 27825 27826 27827 27828 27829 27830 27831 27832 27840 27842 27846 27848

Closed treatment of bimalleolar ankle fracture, (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation with manipulation Open treatment of bimalleolar ankle fracture, (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed Closed treatment of trimalleolar ankle fracture; without manipulation with manipulation Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip with fixation of posterior lip Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibal plafond), with or without anesthesia; without manipulation with skeletal traction and/or requiring manipulation Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation; when performed; of fibula only of tibia only of both tibia and fibula Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed Closed treatment of proximal tibiofibular joint dislocation; without anesthesia requiring anesthesia Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal fibula Closed treatment of ankle dislocation; without anesthesia requiring anesthesia, with or without percutaneous skeletal fixation Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixation with repair or internal or external fixation (For surgical or diagnostic arthroscopic procedures, see 29894-29898)

MANIPULATION 27860

Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus)

ARTHRODESIS 27870

Arthrodesis, ankle, open (For arthroscopic ankle arthrodesis, use 29899)

27871

Arthrodesis, tibiofibular joint, proximal or distal

AMPUTATION 27880 27881

Amputation leg, through tibia and fibula; with immediate fitting technique including application of first cast

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27882 27884 27886 27888 27889

open, circular (guillotine) secondary closure or scar revision reamputation Amputation, ankle, through malleoli of tibia and fibula (Syme, Pirogoff type procedures), with plastic closure and resection of nerves Ankle disarticulation

OTHER PROCEDURES 27892

Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve (For decompression fasciotomy of the leg without debridement, use 27600)

27893

posterior compartment(s) only, with debridement of nonviable muscle and/or nerve (For decompression fasciotomy of the leg without debridement, use 27601)

27894

anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle and/or nerve (For decompression fasciotomy of the leg without debridement, use 27602)

27899

Unlisted procedure, leg or ankle

FOOT AND TOES INCISION (For incision and drainage procedures, superficial, see 10040-10160) 28001 28002 28003 28005 28008 28010 28011

Incision and drainage bursa, foot Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space multiple areas Incision, bone cortex (eg, for osteomyelitis or bone abscess), foot Fasciotomy, foot and/or toe (See also 28060, 28062, 28250) Tenotomy, percutaneous, toe; single tendon multiple tendons (For open tenotomy, see 28230-28234)

28020 28022 28024 28035

Arthrotomy, with exploration, drainage or removal of loose or foreign body; intertarsal or tarsometatarsal joint metatarsophalangeal joint interphalangeal joint Release, tarsal tunnel (posterior tibial nerve decompression) (For other nerve entrapments, see 64704, 64722)

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EXCISION 28043 28045 28046 28050 28052 28054 28055 28060 28062

Excision, tumor, foot; subcutaneous tissue deep, subfascial, intramuscular Radical resection of tumor (malignant neoplasm), soft tissue of foot Arthrotomy with biopsy; intertarsal or tarsometatarsal joint metatarsophalangeal joint interphalangeal joint Neurectomy, intrinsic musculature of foot Fasciectomy, plantar fascia; partial (separate procedure) radical (separate procedure) (For plantar fasciotomy, see 28008, 28250)

28070 28072 28080 28086 28088 28090 28092 28100 28102 28103 28104 28106 28107 28108

Synovectomy; intertarsal or tarsometatarsal joint, each metatarsophalangeal joint, each Excision of interdigital (Morton) neuroma, single, each Synovectomy, tendon sheath, foot; flexor extensor Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (cyst or ganglion); foot toe(s), each Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes obtaining graft) with allograft Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with iliac or other autograft (includes obtaining graft) with allograft Excision or curettage of bone cyst or benign tumor, phalanges of foot (For ostectomy, partial (eg, hallux valgus, Silver type procedure), use 28290)

28110 28111 28112 28113 28114 28116 28118 28119 28120 28122

Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) Ostectomy, complete excision; first metatarsal head other metatarsal head (second, third or fourth) fifth metatarsal head all metatarsal heads, with partial proximal phyalangectomy, excluding first metatarsal (Clayton type procedure) Ostectomy, excision of tarsal coalition Ostectomy, calcaneus; for spur, with or without plantar fascial release Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus tarsal or metatarsal bone except talus or calcaneous (For partial excision of talus or calcaneus, use 28120) (For cheilectomy for hallux rigidus, use 28289)

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28124 28126 28130

phalanx of toe Resection, partial or complete, phalangeal base, each toe Talectomy (astragalectomy) (For calcanectomy, use 28118)

28140 28150 28153 28160 28171 28173 28175

Metatarsectomy Phalangectomy, toe, each toe Resection, condyle(s), distal end of phalanx, each toe Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each Radical resection of tumor, bone; tarsal (except talus or calcaneus) (Report required) metatarsal phalanx of toe (For talus or calcaneus, use 27647)

INTRODUCTION OR REMOVAL 28190 28192 28193

Remove foreign body, foot; subcutaneous deep complicated

REPAIR, REVISION, AND/OR RECONSTRUCTION 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234

Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon secondary with free graft, each tendon (includes obtaining graft) Repair, tendon, extensor, foot; primary or secondary, each tendon secondary with free graft, each tendon (includes obtaining graft) Tenolysis, flexor, foot; single tendon multiple tendons Tenolysis, extensor, foot; single tendon multiple tendons Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) toe, single tendon (separate procedure) Tenotomy, open, extensor, foot or toe, each tendon (For tendon transfer to midfoot or hindfoot, see 27690, 27691)

28238

Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (eg, Kidner type procedure) (For subcutaneous tenotomy, see 28010, 28011) (For transfer or transplant of tendon with muscle redirection or rerouting, see 27690-27692) (For extensor hallucis longus transfer with great toe IP fusion (Jones procedure), use 28760)

28240

Tenotomy lengthening, or release, abductor hallucis muscle

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28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322

Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure) Capsulotomy, midfoot; medial release only (separate procedure) with tendon lengthening extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity) Capsulotomy, midtarsal (eg, Heyman type procedure) Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) interphalangeal joint, each joint (separate procedure) Syndactylism, (eg, webbing or Kelikian type procedure) Correction, hammertoe;(eg, interphalangeal fusion, partial or total phalangectomy) Correcting cock-up fifth toe, with plastic skin closure (Ruiz-Mora type procedure) Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint Correction hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (Silver type procedure) Keller, McBride or Mayo type procedure resection of joint with implant with tendon transplants (Joplin type procedure) with metatarsal osteotomy (eg, Mitchell, Chevron, or concentric type procedures) Lapidus type procedure by phalanx osteotomy by double osteotomy Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation talus Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (eg, Fowler type) Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal first metatarsal with autograft (other than first toe) other than first metatarsal, each multiple, (eg, Swanson type cavus foot procedure) (Report required) Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) other phalanges, any toe Reconstruction, angular deformity of toe, soft tissue procedures only (overlapping second toe, fifth toe, curly toes) Sesamoidectomy, first toe (separate procedure) Repair of nonunion or malunion; tarsal bones metatarsal, with or without bone graft (includes obtaining graft)

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28340 28341 28344 28345 28360

Reconstruction, toe, macrodactyly; soft tissue resection requiring bone resection Reconstruction, toe(s); polydactyly syndactyly, with or without skin graft(s), each web Reconstruction, cleft foot

FRACTURE AND/OR DISLOCATION 28400 28405 28406 28415 28420 28430 28435 28436 28445 28446

Closed treatment of calcaneal fracture; without manipulation with manipulation Percutaneous skeletal fixation of calcaneal fracture, with manipulation Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft) Closed treatment of talus fracture; without manipulation with manipulation Percutaneous skeletal fixation of talus fracture, with manipulation Open treatment of talus fracture, includes internal fixation, when performed Open osteochondral autograft, talus (includes obtaining graft[s]) (Do not report 28446 in conjunction with 27705, 27707) (For arthroscopic osteochondral talus graft, use 29892) (For open osteochondral allograft or repairs with industrialgrafts, use 27599)

28450 28455 28456 28465 28470 28475 28476 28485 28490 28495 28496 28505 28510 28515 28525 28530

Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each with manipulation, each Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, each Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, each Closed treatment of metatarsal fracture; without manipulation, each with manipulation, each Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each Open treatment of metatarsal fracture, includes internal fixation, when performed, each Closed treatment of fracture great toe, phalanx or phalanges; without manipulation with manipulation Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation Open treatment of fracture, great toe, phalanx or phalanges, includes internal fixation, when performed Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each with manipulation, each Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal fixation, when performed, each Closed treatment of sesamoid fracture (Report required)

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28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675

Open treatment of sesamoid fracture, with or without internal fixation (Report required) Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia requiring anesthesia Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation Open treatment of tarsal bone dislocation, includes internal fixation, when performed Closed treatment of talotarsal joint dislocation; without anesthesia requiring anesthesia Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation Open treatment of talotarsal joint dislocation, includes internal fixation, when performed Closed treatment of tarsometatarsal joint dislocation; without anesthesia requiring anesthesia Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed Closed treatment of metatarsophalangeal joint dislocation; without anesthesia requiring anesthesia Percutaneous skeletal fixation of metatarso phalangeal joint dislocation, with manipulation Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performed Closed treatment of interphalangeal joint dislocation; without anesthesia requiring anesthesia Percutaneous skeletal fixation of interphalangeal joint dislocation, with manipulation Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed

ARTHRODESIS 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760

Arthrodesis, pantalar triple subtalar Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction) Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal, navicularcuneiform (eg, Miller type procedure) Arthrodesis, midtarsal or tarsometatarsal, single joint Arthrodesis, great toe; metatarsophalangeal joint interphalangeal joint Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint, (eg, Jones type procedure) (For hammertoe operation or interphalangeal fusion, use 28285)

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AMPUTATION 28800 28805 28810 28820 28825

Amputation, foot; midtarsal (eg, Chopart type procedure) transmetatarsal Amputation, metatarsal, with toe, single Amputation, toe; metatarsophalangeal joint interphalangeal joint

OTHER PROCEDURES 28899

Unlisted procedure, foot or toes

APPLICATION OF CASTS AND STRAPPING (Separate Procedure Only) The listed procedures apply to the application of a cast or strapping. Listed procedures include removal of cast or strapping. Use code 99070 for cost of materials. BODY AND UPPER EXTREMITY CASTS 29000

Application of halo type body cast (See 20661-20663 for insertion)

29010 29015 29020 29025 29035 29040 29044 29046 29049 29055 29058 29065 29075 29085 29086

Application of Risser jacket, localizer, body; only including head Application of turnbuckle jacket, body; only including head Application of body cast, shoulder to hips; including head, Minerva type including one thigh including both thighs Application, cast; figure-of-eight shoulder spica plaster Velpeau shoulder to hand (long arm) elbow to finger (short arm) hand and lower forearm (gauntlet) finger (eg, contracture)

SPLINTS 29105 29125 29126

Application of long arm splint (shoulder to hand) Application of short arm splint (forearm to hand); static dynamic

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LOWER EXTREMITY CASTS 29305 29325

Application of hip spica cast; one leg one and one-half spica or both legs (For hip spica (body) cast, including thighs only, use 29046)

29345 29355 29358 29365 29405 29425 29435 29440 29445 29450

Application of long leg cast (thigh to toes); walker or ambulatory type Application of long leg cast brace Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes); walking or ambulatory type Application of patellar tendon bearing (PTB) cast Adding walker to previously applied cast Application of rigid total contact leg cast Application of clubfoot cast with molding or manipulation, long or short leg

SPLINTS 29505 29515

Application of long leg splint (thigh to ankle or toes) Application of short leg splint (calf to foot)

STRAPPING-ANY AGE 29580 29590

Strapping; Unna boot Denis-Browne splint strapping

REMOVAL OR REPAIR Codes for cast removals should be employed only for casts applied by another physician. 29700 29705 29710 29715 29720 29730 29740 29750

Removal of bivalving; gauntlet, boot or body cast full arm or full leg cast shoulder or hip spica, Minerva, or Risser jacket, etc turnbuckle jacket Repair of spica, body cast or jacket Windowing of cast Wedging of cast (except clubfoot casts) Wedging of clubfoot cast (To report bilateral procedure, use modifier -50)

OTHER PROCEDURES 29799

Unlisted procedure, casting or strapping

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ENDOSCOPY/ARTHROSCOPY Surgical endoscopy/arthroscopy always includes a diagnostic endoscopy/arthroscopy. 29800 29804

Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, temporomandibular joint, surgical (For open procedure, use 21010)

29805

Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) (For open procedure, see 23065-23066, 23100-23101)

29806

Arthroscopy, shoulder, surgical; capsulorrhaphy (For open procedure, see 23450-23466) (To report thermal capsulorrhaphy, use 29999)

29807 29819 29820 29821

repair of slap lesion Arthroscopy, shoulder, surgical; with removal of loose body or foreign body (For open procedure, see 23040-23044, 23107) synovectomy, partial synovectomy, complete (For 29820 and 29821, for open procedure, see 23105)

29822 29823

debridement, limited debridement, extensive (For 29822 and 29823, for open procedures, see specific open shoulder procedure performed)

29824

Arthroscopy, distal claviculectomy including distal articular surface (Mumford procedure) (For open procedure, use 23120)

29825

with lysis and resection of adhesions with or without manipulation (For open procedures, see specific open shoulder procedure performed)

29826

decompression of subacromial space with partial acromioplasty with or without coracoacromial release (For open procedure, use 23130 or 23415)

29827

with rotator cuff (For open or mini-open rotator cuff repair, use 23412) (When arthroscopic subacromial decompression is performed at the same setting, use 29826) (When arthroscopic distal clavicle resection is performed at the same setting, use 29824)

29828

Arthroscopy, shoulder, surgical; biceps tenodesis (Do not report 29828 in conjunction with 29805, 29820, 29822) (For open biceps tenodesis, use 23430) Version 2008 – 1 (5/15/2008)

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29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29848

Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, elbow, surgical; with removal of loose body or foreign body synovectomy, partial synovectomy, complete debridement, limited debridement, extensive Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, wrist, surgical; for infection, lavage and drainage synovectomy, partial synovectomy, complete excision and/or repair of triangular fibrocartilage and/or joint debridement internal fixation for fracture or instability Endoscopy, wrist, surgical, with release of transverse carpal ligament (For open procedure, use 64721)

29850

Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy) with internal or external fixation (includes arthroscopy)

29851

(For bone graft, use 20900, 20902) 29855 29856

Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy) bicondylar, includes internal fixation, when performed (includes arthroscopy) (For bone graft, use 20900, 20902)

29860 29861 29862 29863 29866

Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) Arthroscopy, hip, surgical; with removal of loose body or foreign body with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum with synovectomy Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) (Do not report 29866 in conjunction with 29870, 29871, 29875, 29884 when performed at the same session and/or 29874, 29877, 29879, 29885-29887 when performed in the same compartment) (For open osteochondral autograft of knee, use 27416)

29867

osteochondral allograft (eg, mosaicplasty) (Do not report 29867 in conjunction with 27570, 29870, 29871, 29875, 29884 when performed at the same session and/or 29874, 29877, 29879, 29885-29887 when performed in the same compartment) (Do not report 29867 in conjunction with 27415)

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29868

29870 29871 29873

meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral (Do not report 29868 in conjunction with 29870, 29871, 29875, 29880, 29883, 29884 when performed at the same session or 29874, 29877, 29881, 29882 when performed in the same compartment) Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) Arthroscopy, knee, surgical; for infection, lavage and drainage with lateral release (For open lateral release, use 27425)

29874 29875 29876 29877 29879 29880 29881 29882 29883

for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) synovectomy, limited (eg, plica or shelf resection) (separate procedure) synovectomy, major, two or more compartments (eg, medial or lateral) debridement/shaving of articular cartilage (chondroplasty) abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture with meniscectomy (medial AND lateral, including any meniscal shaving) with meniscectomy (medial OR lateral, including any meniscal shaving) with meniscus repair (medial OR lateral) with meniscus repair (medial AND lateral) (For meniscal transplantation, medial or lateral, knee, use 29868)

29884 29885 29886 29887 29888 29889

with lysis of adhesions with or without manipulation (separate procedure) drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) drilling for intact osteochondritis dissecans lesion drilling for intact osteochondritis dissecans lesion with internal fixation Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction Arthroscopically aided posterior cruciate ligament repair/ augmentation or reconstruction (Procedures 29888 and 29889 should not be used with reconstruction procedures 27427-27429)

29891 29892

29893 29894 29895 29897

Arthroscopy, ankle, surgical; excision of osteochondral defect of talus and/or tibia, including drilling of the defect Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) Endoscopic plantar fasciotomy Arthroscopy ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body synovectomy, partial debridement, limited

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29898 29899

debridement, extensive with ankle arthrodesis (For open ankle arthrodesis, use 27870)

29900

Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy (Do not report 29900 with 29901, 29902)

29901 29902 29904 29905 29906 29907 29999

Arthroscopy, metacarpophalangeal joint, surgical; with debridement with reduction of displaced ulnar collateral ligament (eg, Stenar Lesion) Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body Arthroscopy, subtalar joint, surgical; with synovectomy Arthroscopy, subtalar joint, surgical; with debridement Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis Unlisted procedure, arthroscopy

RESPIRATORY SYSTEM NOSE INCISION 30000

Drainage abscess or hematoma, nasal, internal approach (For external approach, see 10060, 10140)

30020

Drainage abscess or hematoma, nasal septum (For lateral rhinotomy, see specific application, eg, 30118, 30320)

EXCISION 30100

Biopsy, intranasal (For biopsy skin of nose, see 11100, 11101)

30110

Excision, nasal polyp(s), simple (30110 would normally be completed in an office setting) (To report bilateral procedure, use modifier -50)

30115

Excision, nasal polyp(s), extensive (30115 would normally require the facilities available in a hospital setting.) (To report bilateral procedure, use modifier -50)

30117 30118 30120 30124 30125 30130

Excision or destruction, (eg, laser), intranasal lesion; internal approach external approach (lateral rhinotomy) Excision or surgical planing of skin of nose for rhinophyma Excision dermoid cyst, nose; simple, skin, subcutaneous complex, under bone or cartilage Excision inferior turbinate, partial or complete, any method (For excision of superior or middle turbinate, use 30999)

30140

Submucous resection inferior turbinate, partial or complete, any method (Do not report 30130 or 30140 in conjunction with 30801, 30802, 30930) Version 2008 – 1 (5/15/2008)

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(For submucous resection of superior or middle turbine,use 30999) (For endoscopic resection of concha bullosa of middle turbinate, use 31240) (For submucous resection of nasal septum, see 30520) 30150 30160

Rhinectomy; partial total (For closure and/or reconstruction, primary or delayed, see Integumentary System, 13150-13160, 14060-14300, 15120, 15121, 15260, 15261, 15760, 20900-20912)

INTRODUCTION 30200 30210 30220

Injection into turbinate(s), therapeutic Displacement therapy (Proetz type) Insertion, nasal septal prosthesis (button)

REMOVAL OF FOREIGN BODY 30300 30310 30320

Removal foreign body, intranasal; office type procedure requiring general anesthesia by lateral rhinotomy

REPAIR (For obtaining tissues for graft, see 20900-20926, 21210) 30400

Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip (For columellar reconstruction, see 13150 et seq)

30410 30420 30430 30435 30450 30460 30462 30465

30520

complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip including major septal repair Rhinoplasty, secondary; minor revision (small amount of nasal tip work) intermediate revision (bony work with osteotomies) major revision (nasal tip work and osteotomies) Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only tip, septum, osteotomies Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) (30465 excludes obtaining graft. For graft procedure, see 20900-20926, 21210) (30465 is used to report a bilateral procedure) Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft (For submucous resection of turbinates, use 30140)

30540 30545

Repair choanal atresia; intranasal transpalatine (Do not report modifier –63 in conjunction with 30540, 30545) Version 2008 – 1 (5/15/2008)

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30560 30580 30600 30620 30630

Lysis intranasal synechia Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) oronasal Septal or other intranasal dermatoplasty (does not include obtaining graft) Repair nasal septal perforations

DESTRUCTION 30801

Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method,(separate procedure); superficial (For cautery and ablation of superior or middle turbinates, use 30999)

30802

intramural (Do not report 30801, 30802, 30930 in conjunction with 30130 or 30140)

OTHER PROCEDURES 30901

Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method (To report bilateral procedure, use modifier -50)

30903

Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method (To report bilateral procedure, use modifier -50)

30905

Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial subsequent Ligation arteries; ethmoidal internal maxillary artery, transantral

30906 30915 30920

(For ligation external carotid artery, use 37600) 30930

Fracture nasal inferior turbinate(s), therapeutic (Do not report 30801, 30802, 30930 in conjunction with 30130 or 30140) (For fracture of superior or middle turbinate(s), use 30999)

30999

Unlisted procedure, nose

ACCESSORY SINUSES INCISION (For 31000, 31020, 31030, 31032, to report bilateral procedures, use modifier -50) 31000 31002 31020 31030 31032

Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) sphenoid sinus Sinusotomy, maxillary (antrotomy); intranasal radical (Caldwell-Luc) without removal of antrochoanal polyps radical (Caldwell-Luc) with removal antrochoanal polyps

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31040

Pterygomaxillary fossa surgery, any approach (Report required) (For transantral ligation of internal maxillary artery, use 30920)

31050 31051 31070

Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) Sinusotomy frontal; external, simple (trephine operation) (For frontal intranasal sinusotomy, use 31276)

31075 31080 31081 31084 31085 31086 31087 31090

transorbital, unilateral (for mucocele or osteoma, Lynch type) obliterative without osteoplastic flap, brow incision (includes ablation) obliterative, without osteoplastic flap, coronal incision (includes ablation) obliterative, with osteoplastic flap, brow incision obliterative, with osteoplastic flap, coronal incision nonobliterative, with osteoplastic flap, brow incision nonobliterative, witH osteoplastic flap, coronal incision Sinusotomy, unilateral, three or more paranasal sinuses, (frontal, maxillary, ethmoid, sphenoid)

EXCISION 31200 31201 31205 31225 31230

Ethmoidectomy; intranasal, anterior intranasal, total extranasal, total Maxillectomy; without orbital exenteration with orbital exenteration (en bloc) (For orbital exenteration only, see 65110 et seq) (For skin grafts, see 15120 et seq)

ENDOSCOPY A surgical sinus endoscopy always includes a sinusotomy (when appropriate) and diagnostic endoscopy. Codes 31231-31294 are used to report unilateral procedures unless otherwise specified. The codes 31231-31235 for diagnostic evaluation refer to employing a nasal/sinus endoscope to inspect the interior of the nasal cavity and the middle and superior meatus, the turbinates, and the spheno-ethmoid recess. Any time a diagnostic evaluation is performed all these areas would be inspected and a separate code is not reported for each area. 31231 31233 31235 31237 31238 31239 31240

Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) Nasal/sinus endoscopy, diagnostic; with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) with control of nasal hemorrhage with dacryocystorhinostomy with concha bullosa resection

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(For endoscopic osteomeatal complex (OMC) resection with antrostomy and/or anterior ethmoidectomy, with or without removal of polyp(s), use 31254 and 31256) (For endoscopic osteomeatal complex (OMC) resection with antrostomy, removal of antral mucosal disease, and/or anterior ethmoidectomy, with or without removal of polyp(s), use 31254 and 31267) (For endoscopic frontal sinus exploration, osteomeatal complex (OMC) resection and/or anterior ethmoidectomy, with or without removal of polyp(s), use 31254 and 31276) (For endoscopic frontal sinus exploration, osteomeatal complex (OMC) resection, antrostomy, and/or anterior ethmoidectomy, with or without removal of polyp(s), use 31254, 31256, and 31276) (For endoscopic nasal diagnostic endoscopy, see 31231-31235) (For endoscopic osteomeatal complex (OMC) resection, frontal sinus exploration, antrostomy, removal of antral mucosal disease, and/or anterior ethmoidectomy, with or without removal of polyp(s), use 31254, 31267, and 31276) 31254 31255 31256

Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) with ethmoidectomy, total (anterior and posterior) Nasal/sinus endoscopy, surgical, with maxillary antrostomy; (For endoscopic anterior and posterior ethmoidectomy (APE) and antrostomy, with or without removal of polyp(s), use 31255 and 31256) (For endoscopic anterior and posterior ethmoidectomy (APE), antrostomy and removal of antral mucosal disease, with or without removal of polyp(s), use 31255 and 31267) (For endoscopic anterior and posterior ethmoidectomy (APE), and frontal sinus exploration, with or without removal of polyp(s), use 31255 and 31276)

31267

with removal of tissue from maxillary sinus (For endoscopic anterior and posterior ethmoidectomy (APE), and frontal sinus exploration and antrostomy, with or without removal of polyp(s), use 31255, 31256, and 31276) (For endoscopic anterior and posterior ethmoidectomy (APE), frontal sinus exploration, antrostomy, and removal of antral mucosal disease, with or without removal of polyp(s), use 31255, 31267, and 31276)

31276

Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus (For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy (APS), with or without removal of polyp(s), use 31255, 31287 or 31288) (For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy (APS), and antrostomy, with or without removal of polyp(s), use 31255, 31256, and 31287 or 31288)

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(For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy (APS), antrostomy and removal of antral mucosal disease, with or without removal of polyp(s), use 31255, 31267, and 31287 or 31288) (For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy (APS), and frontal sinus exploration with or without removal of polyp(s), use 31255, 31287 or 31288, and 31276) (For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy (APS), with or without removal of polyp(s), with frontal sinus exploration and antrostomy, use 31255, 31256, 31287 or 31288, and 31276) (For unilateral endoscopy of two or more sinuses, see 31231-31235) (For endoscopic anterior and posterior ethmoidectomy and sphenoidotomy (APS), frontal sinus exploration, antrostomy and removal of antral mucosal disease, with or without removal of polyp(s), see 31255, 31267, 31287 or 31288 and 31276) 31287 31288 31290 31291 31292 31293 31294

Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from sphenoid sinus Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region sphenoid region Nasal/sinus endoscopy, surgical; with medial or inferior orbital wall decompression with medial orbital wall and inferior orbital wall decompression with optic nerve decompression (For hypophysectomy, transantral or transeptal approach, use 61548) (For transcranial hypophysectomy, use 61546)

OTHER PROCEDURES 31299

Unlisted procedure, accessory sinuses

LARYNX EXCISION 31300 31320 31360 31365 31367 31368 31370 31375 31380 31382 31390 31395

Laryngotomy (thyrotomy, laryngofissure); with removal of tumor or laryngocele, cordectomy diagnostic Laryngectomy; total, without radical neck dissection total, with radical neck dissection subtotal supraglottic, without radical neck dissection subtotal supraglottic, with radical neck dissection Partial laryngectomy (hemilaryngectomy); horizontal laterovertical anterovertical antero-latero-vertical Pharyngolaryngectomy, with radical neck dissection; without reconstruction with reconstruction

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31400

Arytenoidectomy or arytenoidopexy, external approach (For endoscopic arytenoidectomy, use 31560)

31420

Epiglottidectomy

INTRODUCTION 31500

Intubation, endotracheal, emergency procedure (For injection procedure for segmental bronchography, use 31656)

ENDOSCOPY For endoscopic procedures, code appropriate endoscopy of each anatomic site examined. If using operating microscope, telescope, or both, use the applicable code only once per operative session. 31505 31510 31511 31512 31513 31515 31520

Laryngoscopy, indirect; diagnostic (separate procedure) with biopsy with removal of foreign body with removal of lesion with vocal cord injection (Report required) Laryngoscopy, direct, with or without tracheoscopy; for aspiration diagnostic, newborn (Do not report 31520 with modifier –63)

31525 31526 31527 31528 31529 31530 31531 31535 31536 31540

diagnostic, except newborn diagnostic, with operating microscope or telescope with insertion of obturator (Report required) with dilation, initial with dilation, subsequent (Report required) Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or telescope Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s) reconstruction with graft(s) (includes obtaining autograft) (Do not report 31546 in addition to 20926 for graft harvest)

31541 31545

31546

(Do not report 31545 or 31546 in conjunction with 31540, 31541) (For reconstruction of vocal cord with allograft, use 31599) 31560 31561

Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope or telescope

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31570 31571 31575 31576 31577 31578

Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope Laryngoscopy, flexible fiberscopic; diagnostic with biopsy with removal of foreign body with removal of lesion (To report flexible fiberoptic endoscopic evaluation of swallowing, see 92612-92613) (To report flexible fiberoptic endoscopic evaluation with sensory testing, see 9261492615) (To report flexible fiberoptic endoscopic evaluation of swallowing with sensory testing, see 92616-92617) (For flexible fiberoptic laryngoscopy as part of flexible fiberoptic endoscopic evaluation of swallowing and/or laryngeal sensory testing by cine or video recording, see 92612-92617)

31579

Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy

REPAIR 31580 31582 31584 31587 31588 31590

Laryngoplasty; for laryngeal web, two stage, with keel insertion and removal for laryngeal stenosis, with graft or core mold, including tracheotomy with open reduction of fracture Laryngoplasty, cricoid split Laryngoplasty, not otherwise specified (eg, for burns, reconstruction after partial laryngectomy) Laryngeal reinnervation by neuromuscular pedicle

DESTRUCTION 31595

Section recurrent laryngeal nerve, therapeutic (separate procedure), unilateral (Report required)

OTHER PROCEDURES 31599

Unlisted procedure, larynx

TRACHEA AND BRONCHI INCISION 31600 31601 31603 31605 31610

Tracheostomy, planned (separate procedure); under two years Tracheostomy, emergency procedure; transtracheal cricothyroid membrane Tracheostomy, fenestration procedure with skin flaps (For endotracheal intubation, use 31500) (For tracheal aspiration under direct vision, use 31515)

31611

Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, voice button, Blom-Singer prosthesis)

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31612 31613 31614

Tracheal puncture, percutaneous with transtracheal aspiration and/or injection Tracheostoma revision; simple, without flap rotation complex, with flap rotation

ENDOSCOPY For endoscopy procedures, code appropriate endoscopy of each anatomic site examined. Surgical bronchoscopy always includes diagnostic bronchoscopy when performed by the same physician. Codes 31622-31646 include flouroscopic guidance, when performed. (For tracheoscopy, see laryngoscopy codes 31515-31578) 31615 31620

Tracheobronchoscopy through established tracheostomy incision Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to primary procedure(s)) (Use 31620 in conjunction with 31622-31646)

31622

Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure) with brushing or protected brushings with bronchial alveolar lavage with bronchial or endobronchial biopsy(s), single or multiple sites with transbronchial lung biopsy(s), single lobe (31628 should be reported only once regardless of how many transbronchial lung biopsies are performed in a lobe)

31623 31624 31625 31628

(To report transbronchial lung biopsies performed on additional lobe, use 31632) 31629

with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) (31629 should be reported only once for upper airway biopsies regardless of how many transbronchial needle aspiration biopsies are performed in the upper airway or in a lobe) (To report transbronchial needle aspiration biopsies performed on additional lobe(s), use 31633)

31630 31631

with tracheal/bronchial dilation or closed reduction of fracture with placement of tracheal stent(s) (includes tracheal/ bronchial dilation as required) (For placement of bronchial stent, see 31636, 31637) (For revision of tracheal/bronchial stent, use 31638)

31632

with transbronchial lung biopsy(s), each additional lobe (List separately in addition to primary procedure) (Use 31632 in conjunction with 31628) (31632 should be reported only once regardless of how many transbronchial lung biopsies are performed in a lobe)

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31633

with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to primary procedure) (Use 31633 in conjunction with 31629) (31633 should be reported only once regardless of how many transbronchial needle aspiration biopsies are performed in the trachea or the additional lobe)

31635 31636

with removal of foreign body with placement of bronchial stent(s) (includes tracheal/ bronchial dilation as required), initial bronchus each additional major bronchus stented (List separately in addition to primary procedure) (Use 31637 in conjunction with 31636)

31637

31638 31640 31641

31643

with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required) with excision of tumor Bronchoscopy, (rigid or flexible); with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) (For bronchoscopic photodynamic therapy, report 31641 in addition to 96570, 96571 as appropriate) with placement of catheter(s) for intracavitary radioelement application (For intracavitary radioelement application, see 77761-77763, 777781-77784)

31645 31646

with therapeutic aspiration of tracheobronchial tree, initial (eg, drainage of lung abscess) with therapeutic aspiration of tracheobronchial tree, subsequent (For catheter aspiration of tracheobronchial tree at bedside, use 31725)

31656

with injection of contrast material for segmental bronchography (fiberscope only) (For radiological supervision and interpretation, see 71040, 71060)

INTRODUCTION (For endotracheal intubation, see 31500) (For tracheal aspiration under direct vision, see 31515) 31715

Transtracheal injection for bronchography (For radiological supervision and interpretation, see 71040, 71060) (For prolonged services, see 99354-99357)

31717 31720 31725 31730

Catheterization with bronchial brush biopsy Catheter aspiration (separate procedure); nasotreacheal tracheobronchial with fiberscope, bedside Transtracheal (percutaneous) introduction of needle wire dilator/stent or indwelling tube for oxygen therapy

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EXCISION, REPAIR 31750 31755 31760 31766 31770 31775

Tracheoplasty; cervical tracheopharyngeal fistulization, each stage intrathoracic Carinal reconstruction (Report required) Bronchoplasty; graft repair excision stenosis and anastomosis (For lobectomy and bronchoplasty, use 32501)

31780 31781 31785 31786 31800 31805 31820 31825

Excision tracheal stenosis and anastomosis; cervical cervicothoracic Excision of tracheal tumor or carcinoma; cervical thoracic Suture of tracheal wound or injury; cervical intrathoracic Surgical closure tracheostomy or fistula; without plastic repair with plastic repair (For repair tracheoesophageal fistula, see 43305, 43312)

31830

Revision of tracheostomy scar

OTHER PROCEDURES 31899

Unlisted procedure, trachea, bronchi

LUNGS AND PLEURA INCISION 32035 32036 32095

Thoracostomy; with rib resection for empyema with open flap drainage for empyema Thoracotomy, limited, for biopsy of lung or pleura (To report wound exploration due to penetrating trauma without thoractomy, use 20102)

32100

Thoracotomy, major; with exploration and biopsy (Do not report 32100 in conjunction with 19260, 19271, 19272, 32503, 32504)

32110 32120 32124 32140 32141

with control of traumatic hemorrhage and/or repair of lung tear for postoperative complications with open intrapleural pneumonolysis with cyst(s) removal, with or without a pleural procedure with excision- plication of bullae, with or without any pleural procedure (For lung volume reduction, use 32491)

32150 32151

with removal of intrapleural foreign body or fibrin deposit with removal of intrapulmonary foreign body

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32160

with cardiac massage (For segmental or other resections of lung, see 32480-32504)

32200 32201

Pneumonostomy; with open drainage of abscess or cyst with percutaneous drainage of abcess or cyst (For radiological supervision and interpretation, use 75989)

32215 32220 32225

Pleural scarification for repeat pneumothorax Decortication, pulmonary (separate procedure); total partial

EXCISION 32310 32320 32400

Pleurectomy; parietal (separate procedure) Decortication and parietal pleurectomy Biopsy, pleura; percutaneous needle (If imaging guidance is performed, see 76942, 77002, 77012, 77021) (For fine needle aspiration, use 10021 or 10022)

32402 32405

open Biopsy, lung or mediastinum, percutaneous needle (For radiological supervision and interpretation see 76942, 77002, 77012, 77021) (For fine needle aspiration, use 10022)

REMOVAL 32420 32421

Pneumonocentesis, puncture of lung for aspiration Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent (If imaging guidance is performed, see 76942, 77002, 77012) (For total lung lavage, use 32997)

32422

Thoracentesis with insertion of tube, includes water seal (eg, for pneumothorax), when performed (separate procedure) (Do not report 32422 in conjunction with 19260, 19271, 19272, 32503, 32504) (if imaging guidance is performed, see 76942, 77002, 77012)

32440 32442 32445

Removal of lung, total pneumonectomy with resection of segment of trachea followed by bronco-tracheal anastomosis (sleeve pneumonectomy) (Report required) extrapleural (For extrapleural pneumonectomy, with empyemectomy, use 32445 and 32540) (If lung resection is performed with chest wall tumor resection, report the appropriate chest wall tumor resection code, 19260-19272, in addition to lung resection code 32440-32445)

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32480 32482 32484

Removal of lung, other than total pneumonectomy; single lobe (lobectomy) two lobes (bilobectomy) single segment (segmentectomy) (For removal of lung with bronchoplasty, use 32501)

32486 32488

with circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) all remaining lung following previous removal of a portion of lung (completion pneumonectomy) (For total or segmental lobectomy, with concomitant decortication, use 32320 and the appropriate removal of lung code)

32491

32500

excision-plication of emphysematous lung(s), (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, with or without any pleural procedure wedge resection, single or multiple (If lung resection is performed with chest wall tumor resection, report the appropriate chest wall tumor resection code, 19260-19272, in addition to lung resection code 32480-32500)

32501

Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately in addition to primary procedure) (Use 32501 in conjunction with codes 32480, 32482, 32484) (32501 is to be used when a portion of the bronchus to preserved lung is removed and requires plastic closure to preserve function of that preserved lung. It is not to be used for closure for the proximal end of a resected bronchus)

32503

Resection of apical lung tumor (eg, pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; without chest wall reconstruction(s) with chest wall reconstruction

32504

(Do not report 32503, 32504 in conjunction with 19260, 19271, 19272, 32100, 32422, 32551) (For performance of lung resection in conjunction with chest wall resection, see 19260, 19271, 19272 and 32480-32500, 32503, 32504) 32540

Extrapleural enucleation of empyema (empyemectomy); (For extrapleural enucleation of empyema (empyemectomy) with lobectomy, use 32540 and the appropriate removal of lung code)

INTRODUCTION 32550

Insertion of indwelling tunneled pleural catheter with cuff (Do not report 32550 in conjunction with 32421, 32422, 32551, 32560, 36000, 36410, 62318, 62319, 64450, 64470, 64475) (if imaging guidance is performed, use 75989)

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32551

Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure) (Do not report 32551 in conjunction with 19260, 19271, 19272, 32503, 32504) (If imaging guidance is performed, use 75989)

DESTRUCTION 32560

Chemical pleurodesis (eg, for recurrent or persistent pneumothorax)

ENDOSCOPY Surgical thoracoscopy always includes diagnostic thorascopy. For endoscopic procedures, code appropriate endoscopy of each anatomic site examined. 32601 32602 32603 32604 32605 32606 32650 32651 32652 32653 32654 32655 32656 32657 32658 32659 32660 32661 32662 32663 32664 32665

Thoracoscopy, diagnostic (separate procedure); lungs and pleural space, without biopsy lungs and pleural space, with biopsy pericardial sac, without biopsy pericardial sac, with biopsy mediastinal space, without biopsy mediastinal space, with biopsy Thoracoscopy, surgical; with pleurodesis, (eg, mechanical or chemical) with partial pulmonary decortication with total pulmonary decortication, including intrapleural pneumonolysis with removal of intrapleural foreign body or fibrin deposit with control of traumatic hemorrhage with excision-plication of bullae, including any pleural procedure with parietal pleurectomy with wedge resection of lung, single or multiple with removal of clot or foreign body from pericardial sac with creation of pericardial window or partial resection of pericardial sac for drainage with total pericardectomy with excision of pericardial cyst, tumor, or mass with excision of mediastinal cyst, tumor, or mass with lobectomy, total or segmental with thoracic sympathectomy with esophagomyotomy (Heller type) (For exploratory thoracoscopy, and exploratory thoracoscopy with biopsy, see 32601-32606)

REPAIR 32800 32810 32815 32820

Repair lung hernia through chest wall Closure of chest wall following open flap drainage for empyema (Clagett type procedure) Open closure of major bronchial fistula Major reconstruction, chest wall (post-traumatic) (Report required) Version 2008 – 1 (5/15/2008)

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LUNG TRANSPLANTATION 32851 32852 32853 32854

Lung transplant, single; without cardiopulmonary bypass with cardiopulmonary bypass Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass with cardiopulmonary bypass

SURGICAL COLLAPSE THERAPY; THORACOPLASTY (See also 32503, -32504) 32900 32905 32906

Resection of ribs, extrapleural, all stages Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula (For open closure of major bronchial fistula, use 32815) (For resection of first rib for thoracic outlet compression, see 21615, 21616)

32940 32960

Pneumonolysis, extraperiosteal, including filling or packing procedures Pneumothorax, therapeutic, intrapleural injection of air

OTHER PROCEDURES 32997

Total lung lavage (unilateral) (For bronchoscopic bronchial alveolar lavage, use 31624)

32998

Ablation therapy for reduction or eradication of one or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous,radiofrequency, unilateral (For imaging guidance and monitoring, see 76940, 77013, 77022)

32999

Unlisted procedure, lungs and pleura

CARDIOVASCULAR SYSTEM Selective vascular catheterizations should be coded to include introduction and all lesser order selective catheterizations used in the approach (eg, the description for a selective right middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries). Additional second and/or third order arterial catheterizations within the same family of arteries supplied by a single first order artery should be expressed by 36218 or 36248. Additional first order or higher catheterizations in vascular families supplied by a first order vessel different from a previously selected and coded family should be separately coded using the conventions described above. (For monitoring, operation of pump and other nonsurgical services, see 99190-99192, 99291, 99292, 99354-99357) (For radiological supervision and interpretation, see 75600-75978)

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HEART AND PERICARDIUM PERICARDIUM 33010 33011

Pericardiocentesis; initial subsequent (For 33010, 33011, for radiological supervision and interpretation, use 76930)

33015 33020 33025 33030 33031 33050

Tube pericardiostomy Pericardiotomy for removal of clot or foreign body (primary procedure) Creation of pericardial window or partial resection for drainage Pericardiectomy, subtotal or complete; without cardiopulmonary bypass with cardiopulmonary bypass Excision of pericardial cyst or tumor

CARDIAC TUMOR 33120 33130

Excision of intracardiac tumor, resection with cardiopulmonary bypass Resection of external cardiac tumor (Report required)

TRANSMYOCARDIAL REVASCULARIZATION 33140 33141

Transmyocardial laser revascularization, by thoracotomy (separate procedure) performed at the time of other open cardiac procedure(s) (List separately in addition to primary procedure) (Use 33141 in conjunction with codes 33400-33496, 33510-33536, 33542)

PACEMAKER OR PACING CARDIOVERTER-DEFIBRILLATOR A pacemaker system includes a pulse generator containing electronics and a battery, and one or more electrodes (leads). Pulse generators are placed in a subcutaneous "pocket" created in either a subclavicular or underneath the abdominal muscles just below the ribcage. Electrodes may be inserted through a vein (transvenous) or they may be placed on the surface of the heart (epicardial). The epicardial location of electrodes requires a thoracotomy for electrode insertion. A single chamber pacemaker system includes a pulse generator and one electrode inserted in either the atrium or ventricle. A dual chamber pacemaker system includes a pulse generator and one electrode inserted in the right atrium and one electrode inserted in the right ventricle. In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular pacing). In this event, transvenous (cardiac vein) placement of the electrode should be separately reported using code 33224 or 33225. Epicardial placement of the electrode should be separately reported using 33202-33203. Like a pacemaker system, a pacing cardioverter defibrillator system also includes a pulse generator and electrodes, although pacing cardioverter-defibrillators may require multiple leads, even when only a single chamber is being paced. A pacing cardioverter-defibrillator system may be inserted in a single chamber (pacing the ventricle) or in dual chambers (pacing the atrium and ventricle). These devices use a combination of antitachycardia pacing, low energy cardioversion or defibrillating shocks to treat ventricular tachycardia or ventricular fibrillation. Version 2008 – 1 (5/15/2008)

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Pacing cardioverter-defbrillator pulse generators may be implanted in a subcutaneous infraclavicular pocket or in an abdominal pocket. Removal of a pacing cardioverterdefibrillator pulse generator requires opening of the existing subcutaneous pocket and disconnection of the pulse generator from its electrode(s). A thoracotomy (or laparotomy in the case of abdominally placed pulse generators) is not required to remove the pulse generator. The electrodes (leads) of a pacing cardioverter-defibrillator system are positioned in the heart via the venous system (transvenously), in most circumstances. In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular pacing). In this event, transvenous (cardiac vein) placement of the electrode should be separately reported using code 33224 or 33225. Epicardial placement of the electrode should be separately reported using 33202-33203. Electrode positioning on the epicardial surface of the heart requires thoracotomy, or thoracosopic placement of the leads. Removal of electrode(s) may first be attempted by transvenous extraction (code 33244). However, if transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes (code 33243). Use codes 33212, 33213, 33240 as appropriate in addition to the thoracotomy or endoscopic epicardial lead placement codes to report the insertion of the generator if done by the same physician during the same session. When the "battery" of a pacemaker or pacing cardioverter-defibrillator is changed, it is actually the pulse generator that is changed. Replacement of a pulse generator should be reported with a code for removal of the pulse generator and another code for insertion of a pulse generator. Repositioning of a pacemaker electrode, pacing cardioverter-defibrillator electrode(s), or a left ventricular pacing electrode is reported using 33215 or 33226, as appropriate. Replacement of a pacemaker electrode, pacing cardioverter-defibrillator electrode(s), of a left ventricular pacing electrode is reported using 33206-33208, 33210-33213, or 33224, as appropriate. (For electronic, telephonic analysis of internal pacemaker system, see 93731-93736) (For radiological supervision and interpretation with insertion of pacemaker use 71090) 33202 33203

Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach) endoscopic approach (eg, thoracoscopy, pericardioscopy) (When epicardial lead placement is performed by the same physician at the same session as insertion of the generator, report 33202, 33203 in conjunction with 33212, 33213, as appropriate)

33206 33207 33208

Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial ventricular atrial and ventricular (Codes 33206-33208 include subcutaneous insertion of the pulse generator and transvenous placement of electrode(s))

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33210 33211 33212 33213

Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular dual chamber (Use 33212, 33213, as appropriate, in conjunction with the epicardial lead placement codes 33202, 33203 to report the insertion of the generator when done by the same physician during the same session)

33214

Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) (When epicardial electrode placement is performed, report 33214 in conjunction with 33202, 33203)

33215

Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode Insertion of transvenous electrode; single chamber (one electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator dual chamber (two electrodes) permanent pacemaker or dual chamber pacing cardioverter-defibrillator

33216 33217

(Do not report 33216-33217 in conjunction with code 33214) 33218

Repair of single transvenous electrode for a single chamber, permanent pacemaker or single chamber pacing cardioverter-defibrillator (For atrial or ventricular single chamber repair of pacemaker electrode(s) with replacement of pulse generator, see 33212 or 33213 and 33218 or 33220)

33220 33222 33223 33224

33225

Repair of two transvenous electrodes for a dual chamber permanent pacemaker or dual chamber pacing cardioverter-defibrillator Revision or relocation of skin pocket for pacemaker Revision of skin pocket for single of dual chamber pacing cardioverter defibrillator Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion and/or replacement of generator) (When epicardial electrode placement is performed, report 33224 in conjunction with 33202, 33203) Insertion of pacing electrode, cardiac venous system, for left ventrical pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) (List separately in addition to primary procedure) (Use 33225 in conjunction with 33206, 33207, 33208, 33212, 33213, 33214, 33216, 33217, 33222, 33233, 33234, 33235, 33240, 33249)

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33226 33233 33234 33235 33236 33237 33238 33240

33241

Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator) Removal of permanent pacemaker pulse generator Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular dual lead system Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular dual lead system Removal of permanent transvenous electrode(s) by thoracotomy Insertion single or dual chamber pacing of cardioverter-defibrillator pulse generator (Use 33240, as appropriate, in addition to the epicardial lead placement codes to report the insertion of the generator when done by the same physician during the same session) Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator (For removal of electrode(s) by thoracotomy, use 33243 in conjunction with 33241) (For removal of electrode(s) by transvenous extraction, use 33244 in conjunction with 33241) (For removal and reinsertion of a pacing cardioverter-defibrillator system (pulse generator and electrodes), report 33241 and 33243 or 33244 and 33249) (For repair of implantable cardioverter-defibrillator pulse generator and/or leads, see 33218, 33220)

33243 33244

Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by thoracotomy by transverse extraction (For subcutaneous removal of the pulse generator, use 33241 in conjunction with 33243 or 33244)

33249

Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator (For removal and reinsertion of a pacing cardioverter-defibrillator system (pulse generator and electrodes), report 33241 and 33243 or 33244 and 33249) (For insertion of implantable cardioverter-defibrillator lead(s), without thoracotomy, use 33216)

ELECTROPHYSIOLOGIC OPERATIVE PROCEDURES This family of codes describes the surgical treatment of supraventricular dysrhythmias. Tissue ablation, disruption and reconstruction can be accomplished by many methods including surgical incision or through the use of a variety of energy sources (eg, radiofrequency, cryotherapy, microwave, ultrasound, laser). If excision or solation of the left atrial appendage by any method, including stapling, oversewing, ligation, or plication, is performed in conjunction with any of the atrial tissue ablation and reconstruction (maze) procedures (33254-33256, 33265-33266), it is considered part of the procedure.

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Codes 33254-33256 are only to be reported when there is no concurrently performed procedure that requires median sternotomy or cardiopulmonary bypass. When 33254-33256 are performed with a concurrent procedure that requires a median sternotomy or cardiopulmonary bypass, report the operative (nonthoracoscopic) electrophysiologic procedure with unlisted procedure code 33999. DEFINITIONS Limited operative ablation and reconstruction includes: Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium. Extensive operative ablation and reconstruction includes: 1. The services included in ’’limited’’ 2. Additional ablation of atrial tissue to eliminate sustained supraventricular dysrhythmias. This must include operative ablation that involves either the right atrium, the atrial septum, or left atrium in continuity with the atrioventricular annulus. INCISION 33250

33251 33254 33255 33256

Operative ablation of supraventricular arrhythmogenic focus or pathway(eg, Wolff-Parkinson-White, atrioventricular node re-entry), tract(s) and/or focus (foci);without cardiopulmonary bypass with cardiopulmonary bypass Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass with cardiopulmonary bypass (Do not report 33254-33256 in conjunction with, 32100, 32551, 33120, 33130, 33210, 33211, 33400-33507, 33510-33523, 33533-33548, 33600-33853, 3386033863, 33910-33920)

33257

Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to primary procedure) (Use 33257 in conjunction with 33120-33130, 33250-33251, 33261, 33300-33335, 33400-33496, 33500-33507, 33510-33516, 33533-33548, 33600-33619, 3364133697, 33702-33732, 33735-33767, 33770-33814, 33840-33877, 33910-33922, 33925-33926, 33935, 33945, 33975-33980)

33258

Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to primary procedure) (Use 33258 in conjunction with 33130, 33250, 33300, 33310, 33320, 33321, 33330, 33332, 33401, 33414-33417, 33420, 33470-33472, 33501-33503, 33510-33516, 33533-33536, 33690, 33735, 33737, 33800-33813, 33840-33852, 33915, 33925 when the procedure is performed without cardiopulmonary bypass) Version 2008 – 1 (5/15/2008)

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33259

Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to primary procedure) (Use 33259 in conjunction with 33120, 33251, 33261, 33305, 33315, 33322, 33335, 33400, 33403-33413, 33422-33468, 33474-33478, 33496, 33500, 33504-33507, 33510-33516, 33533-33548, 33600-33688, 33692-33722, 33730, 33732, 33736, 33750-33767, 33770-33781, 33786-33788, 33814, 33853, 33860-33877, 33910, 33916-33922, 33926, 33935, 33945, 33975-33980 when the procedure is performed with cardiopulmonary bypass) (Do not report 33257, 33258 and 33259 in conjunction with 32551, 33210, 33211, 33254-33256, 33265, 33266)

33261

Operative ablation of ventricular arrhythmogenic focus with cardiopulmonary bypass

ENDOSCOPY 33265 33266

Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass extensive (eg, maze procedure), without cardiopulmonary bypass (Do not report 33265-33266 in conjunction with 32551, 33210, 33211)

PATIENT-ACTIVATED EVENT RECORDER 33282

Implantation of patient-activated cardiac event recorder (Initial implantation includes programming. For subsequent electronic analysis and/or reprogramming, use 93727)

33284

Removal of an implantable, patient-activated cardiac event recorder

WOUNDS OF THE HEART AND GREAT VESSELS 33300 33305 33310 33315

Repair of cardiac wound; without bypass with cardiopulmonary bypass Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); without bypass with cardiopulmonary bypass (Do not report removal of thrombus (33310-33315) in conjunction with other cardiac procedures unless a separate incision in the heart is required to remove the atrial or ventricular thrombus)

33320 33321 33322 33330 33332 33335

Suture repair of aorta or great vessels; without shunt or cardiopulmonary bypass with shunt bypass with cardiopulmonary bypass Insertion of graft, aorta or great vessels; without shunt, or cardiopulmonary bypass with shunt bypass (Report required) with cardiopulmonary bypass

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CARDIAC VALVES AORTIC VALVE 33400 33401 33403

Valvuloplasty, aortic valve; open, with cardiopulmonary bypass open, with inflow occlusion using transventricular dilation, with cardiopulmonary bypass (Report required) (Do not report modifier –63 in conjunction with 33401, 33403)

33404 33405 33406

Construction of apical-aortic conduit Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve with allograft valve (freehand) (For aortic valve valvotomy, (commissurotomy) with inflow occlusion, use 33401) (For aortic valve valvotomy, (commissurotomy) with cardiopulmonary bypass, use 33403)

33410 33411 33412 33413 33414 33415 33416 33417

with stentless tissue valve (Report required) Replacement, aortic valve; with aortic annulus enlargement, noncoronary cusp with transventricular aortic annulus enlargement (Konno procedure) by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract Resection or incision of subvalvular tissue for discrete subvalvular aortic stenosis Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (eg, asymmetric septal hyertrophy) Aortoplasty (gusset) for supravalvular stenosis

MITRAL VALVE 33420 33422 33425 33426 33427 33430

Valvotomy, mitral valve; closed heart open heart, with cardiopulmonary bypass Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring radical reconstruction, with or without ring Replacement, mitral valve, with cardiopulmonary bypass

TRICUSPID VALVE 33460 33463 33464 33465 33468

Valvectomy, tricuspid valve, with cardiopulmonary bypass; Valvuloplasty, tricuspid valve; without ring insertion with ring insertion Replacement, tricuspid valve, with cardiopulmonary bypass Tricuspid valve repositioning and plication for Ebstein anomaly

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PULMONARY VALVE (Do not report modifier –63 in conjunction with 33470, 33472) 33470 33471

Valvotomy, pulmonary valve, closed heart; transventricular via pulmonary artery (To report percutaneous valvuloplasty of pulmonary valve, use 92990)

33472 33474 33475 33476 33478

Valvotomy, pulmonary valve, open heart; with inflow occlusion with cardiopulmonary bypass Replacement, pulmonary valve Right ventricular resection for infundibular stenosis, with or without commissurotomy Outflow tract augmentation (gusset), with or without commissurotomy or infundibular resection (Use 33478 in conjunction with 33768 when a cavopulmonary anastomosis to a second superior vena cava is performed)

OTHER VALVULAR PROCEDURES 33496

Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate procedure) (For reoperation, use 33530 in addition to 33496)

CORONARY ARTERY ANOMALIES Basic procedures include endarterectomy or angioplasty. (Do not report modifier –63 in conjunction with 33502, 33503, 33505, 33506) 33500 33501 33502 33503 33504 33505 33506 33507

Repair of coronary arteriovenous or arteriocardiac chamber fistula; with cardio-pulmonary bypass without cardio-pulmonary bypass (Report required) Repair of anomalous coronary artery from pulmonary artery origin; by ligation (Report required) by graft, without cardiopulmonary bypass by graft, with cardiopulmonary bypass with construction of intrapulmonary artery tunnel (Takeuchi procedure) by translocation from pulmonary artery to aorta Repair of anomalous (eg, intramural) aortic origin of coronary artery by unroofing or translocation

ENDOSCOPY Surgical vascular endoscopy always inlcudes diagnostic endoscopy. 33508

Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List separately in addition to primary procedure) (Use 35508 in conjunction with code 33510-33523) (For open harvest of upper extremity vein procedure, use 35500)

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VENOUS GRAFTING ONLY FOR CORONARY ARTERY BYPASS The following codes are used to report coronary artery bypass procedures using venous grafts only. These codes should NOT be used to report the performance of coronary artery bypass procedures using arterial grafts and venous grafts during the same procedure. See 33517-33523 and 33533-33536 for reporting combined arterial-venous grafts. Procurement of the saphenous vein graft is included in the description of the work for 33510-33516 and should not be reported as a separate service or co-surgery. To report harvesting of an upper extremity vein, use 35500 in addition to the bypass procedure. To report harvesting of a femoropopliteal vein segment, report 35572 in addition to the bypass procedure. When surgical assistant performs graft procurement, add modifier –80 to 33510-33516. 33510 33511 33512 33513 33514 33516

Coronary artery bypass, vein only; single coronary venous graft two coronary venous grafts three coronary venous grafts four coronary venous grafts five coronary venous grafts six or more coronary venous grafts

COMBINED ARTERIAL-VENOUS GRAFTING FOR CORONARY BYPASS The following codes are used to report coronary artery bypass procedures using venous grafts and arterial grafts during the same procedure. These codes may NOT be used alone. To report combined arterial-venous grafts it is necessary to report two codes: 1) the appropriate combined arterial-venous graft code (33517-33523); and 2) the appropriate arterial graft code (33533-33536). Procurement of the saphenous vein graft is included in the description of the work for 33517-33523 and should not be reported as a separate service or co-surgery. Procurement of the artery for grafting is included in the description of the work for 3353333536 and should not be reported as a separate service or co-surgery, except when an upper extremity artery (eg, radial artery) is procured. To report harvesting of an upper extremity vein, use 35500 in addition to the bypass procedure. To report harvesting of an upper extremity artery, use 35600 in addition to the bypass procedure. To report harvesting of a femoropopliteal vein segment, report 35572 in addition to the bypass procedure. When surgical assistant performs arterial and/or venous graft procurement, add modifier -80 to 33517-33523, 33533-33536, as appropriate. 33517

Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to primary procedure) (Use 33517 in conjunction with 33533-33536)

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33518

two venous grafts (List separately in addition to primary procedure) (Use 33518 in conjunction with 33533-33536)

33519

three venous grafts (List separately in addition to primary procedure) (Use 33519 in conjunction with 33533-33536)

33521

four venous grafts (List separately in addition to primary procedure) (Use 33521 in conjunction with 33533-33536)

33522

five venous grafts (List separately in addition to primary procedure) (Use 33522 in conjunction with 33533-33536)

33523

six or more venous grafts (List separately in addition to primary procedure) (Use 33523 in conjunction with 33533-33536)

33530

Reoperation, coronary artery bypass procedure or valve procedure, more than one month after original operation (List separately in addition to primary procedure) (Use 33530 in conjunction with 33400-33496; 33510-33536, 33863)

ARTERIAL GRAFTING FOR CORONARY ARTERY BYPASS The following codes are used to report coronary artery bypass procedures using either arterial grafts only or a combination of arterial-venous grafts. The codes include the use of the internal mammary artery, gastroepiploic artery, epigastric artery, radial artery, and arterial conduits procured from other sites. To report combined arterial-venous grafts it is necessary to report two codes: 1) the appropriate arterial graft code (33533-33536); and 2) the appropriate combined arterial-venous graft code (33517-33523). Procurement of the artery for grafting is included in the description of the work for 3353333536 and should not be reported as a separate service or co-surgery, except when an upper extremity artery (eg, radial artery) is procured. To report harvesting of an upper extremity artery, use 35600 in addition to the bypass procedure. To report harvesting of an upper extremity vein, use 33500 in addition to the bypass procedure. To report harvesting of a femoropopliteal vein segment, report 33572 in addition to the bypass procedure. When surgical assistant performs arterial and/or venous graft procurement, add modifier -80 to 33517-33523, 33533-33536 as appropriate. 33533 33534 33535 33536 33542

Coronary artery bypass, using arterial graft(s); single arterial graft two coronary arterial grafts three coronary arterial grafts four or more coronary arterial grafts Myocardial resection (eg, ventricular aneurysmectomy)

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33545 33548

Repair of postinfarction ventricular septal defect, with or without myocardial resection Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, DOR procedures) (Do not report 33548 in conjunction with 32551, 33210, 33211, 33310, 33315) (For Batista procedure or pachopexy, use 33999)

CORONARY ENDARTERECTOMY 33572

Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List separately in addition to primary procedure) (Use 33572 in conjunction with 33510-33516, 33533-33536)

SINGLE VENTRICLE AND OTHER COMPLEX CARDIAC ANOMALIES (Do not report modifier –63 in conjunction with 33610, 33611 or 33619) 33600 33602 33606 33608

Closure of atrioventricular valve (mitral or tricuspid) by suture or patch Closure of semilunar valve (aortic or pulmonary) by suture or patch Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel procedure) Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacement of conduit from right or left ventricle to pulmonary artery (For repair of pulmonary artery arborization anomalies by unifocalization, see 33925-33926)

33610 33611 33612 33615

33617 33619

Repair of complex cardiac anomalies (eg, single ventricle with subaortic obstruction) by surgical enlargement of ventricular septal defect Repair of double outlet right ventricle with intraventricular tunnel repair; with repair of right ventricular outflow tract obstruction Repair of complex cardiac anomalies (eg, tricuspid atresia) by closure of atrial septal defect and anastomosis of atria or vena cava to pulmonary artery (simple Fontan procedure) Repair of complex cardiac anomalies (eg, single ventricle) by modified Fontan procedure Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (eg, Norwood procedure)

SEPTAL DEFECT (Do not report modifier -63 in conjunction with 33647, 33670, 33690 or 33694) 33641 33645

Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch Direct or patch closure, sinus venosus, with or without anomalous pulmonary venous drainage (Do not report 33645 in conjunction with 33724, 33726)

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33647

Repair of atrial septal defect and ventricular septal defect, with direct or patch closure (For repair of tricuspid atresia (eg, fontan, gago procedures), use 33615)

33660 33665 33670 33675 33676 33677

Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve repair Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair Repair of complete atrioventricular canal, with or without prosthetic valve Closure of multiple ventricular septal defects; with pulmonary valvotomy or infundibular resection (acyanotic) with removal of pulmonary artery band, with or without gusset (Do not report 33675-33677 in conjunction with 32100, 32422, 33210, 32551, 33681, 33684, 33688) (For percutaneous closure, use 93581)

33681 33684 33688

Closure of single ventricular septal defect, with or without patch; with pulmonary valvotomy or infundibular resection (acyanotic) with removal of pulmonary artery band, with or without gusset (For pulmonary vein repair requiring creation of atrial septal defect, use 33724)

33690 33692 33694

Banding of pulmonary artery Complete repair tetralogy of Fallot without pulmonary atresia; with transannular patch

33697

Complete repair tetralogy of Fallot with pulmonary atresia including construction of conduit from right ventricle to pulmonary artery and closure of ventricular septal defect (For ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure; see 33924)

SINUS OF VALSALVA 33702 33710 33720 33722

Repair sinus of Valsalva fistula, with cardiopulmonary bypass; with repair of ventricular septal defect Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass Closure of aortico-left ventricular tunnel (Report required)

VENOUS ANOMALIES (Do not report modifier –63 in conjunction with 33730, 33732) 33724 33726

Repair of isolated partial anomalous pulmonary venous return (eg, scimitar syndrome) Repair of pulmonary venous stenosis (Do not report 33724, 33726 in conjunction with 32551, 33210, 33211)

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33730

Complete repair of anomalous venous return (supracardiac, intracardiac, or infracardic types) (For partial anomalous pulmonary venous return, use 33724; for repair of pulmonary venous stenosis, use 33726)

33732

Repair of cor triatriatum or supravalvular mitral ring by resection of left atrial membrane

SHUNTING PROCEDURES (Do not report modifier –63 in conjunction with 33735, 33736, 33750, 33755, 33762) 33735 33736 33737

Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation) open heart with cardiopulmonary bypass open heart, with inflow occlusion (Report required) (For transvenous method cardiac catheterization balloon atrial septectomy or septostomy (rashkind type), use 92992) (For blade method cardiac catheterization atrial septectomy or septostomy (sang-park septostomy), use 92993)

33750 33755 33762 33764 33766 33767 33768

Shunt; subclavian to pulmonary artery (Blalock-Taussig type operation) ascending aorta to pulmonary artery (Waterston type operation) (Report required) descending aorta to pulmonary artery (Potts-Smith type operation) central, with prosthetic graft superior vena cava to pulmonary artery for flow to one lung (classical Glenn procedure) superior vena cava to pulmonary artery for flow to both lungs (bidrectional Glenn procedure) Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary procedure) (Use 33768 in conjunction with 33478, 33617, 33767) (Do not report 33768 in conjunction with 32551, 33210, 33211)

TRANSPOSITION OF THE GREAT VESSELS 33770 33771 33774 33775 33776 33777 33778

33779

Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; without surgical enlargement of ventricular septal defect with surgical enlargement of ventricular septal defect Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with removal of pulmonary band with closure of ventricular septal defect with repair of subpulmonic obstruction Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type) (Do not report modifier –63 in conjunction with 33778) with removal of pulmonary band

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33780 33781

with closure of ventricular septal defect with repair of subpulmonic obstruction

TRUNCUS ARTERIOSUS 33786

Total repair, truncus arteriosus (Rastelli type operation) (Do not report modifier –63 in conjunction with 33786)

33788

Reimplantation of an anomalous pulmonary artery (For pulmonary artery band, use 33690)

AORTIC ANOMALIES 33800 33802 33803 33813 33814 33820 33822 33824 33840 33845 33851 33852 33853

Aortic suspension (aortopexy) for tracheal decompression (eg, for tracheomalacia) (separate procedure) Division of aberrant vessel (vascular ring); with reanastomosis (Report required) Obliteration of aortopulmonary septal defect; without cardiopulmonary bypass with cardiopulmonary bypass Repair of patent ductus arteriosus; by ligation by division, under 18 years by division, 18 years and older Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with direct anastomosis with graft repair using either left subclavian artery or prosthetic material as gusset for enlargement Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; without cardiopulmonary bypass with cardiopulmonary bypass (For repair of hypoplastic left heart syndrome (eg, norwood type), via excision of coarctation of aorta, use 33619)

THORACIC AORTIC ANEURYSM 33860 33861 33863

Ascending aorta graft, with cardiopulmonary bypass, with or without valve suspension; with coronary reconstruction with aortic root replacement using composite prosthesis and coronary reconstruction (For graft of ascending aorta, with cardiopulmonary bypass and valve replacement, with or without coronary implant or valve suspension; use 33860 or 33861 and 33405 or 33406)

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33864

Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic annulus remodeling (eg, David procedure, Yacoub procedure) (Do not report 33864 in conjunction with 32551, 33210, 33211, 33400, 33860, 33863)

33870 33875 33877

Transverse arch graft, with cardiopulmonary bypass Descending thoracic aorta graft, with or without bypass Repair of thoracoabdominal aortic aneurysm with graft, with or without cardiopulmonary bypass

ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA Codes 33880-33891 represent a family of procedures to report placement of an endovascular graft for repair of the descending thoracic aorta. These codes include all device introduction, manipulation, positioning, and deployment. All balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, either before or after endograft deployment, are not separately reportable. Open arterial exposure and associated closure of the arteriotomy sites (eg, 34812, 34820, 34833, 34834), introduction of guidewires and catheters (eg, 36140, 36200-36218), and extensive repair or replacement of an artery (eg, 35226, 35286) should be additionally reported. Transposition of subclavian artery to carotid, and carotid-carotid bypass performed in conjunction with endovascular repair of the descending thoracic aorta (eg, 33889, 33891) should be separately reported. The primary codes, 33880 and 33881, include placement of all distal extensions, if required, in the distal thoracic aorta, while proximal extensions, if needed, are reported separately. For fluoroscopic guidance in conjunction with endovascular repair of the thoracic aorta, see codes 75956-75959 as appropriate. Codes 75956 and 75957 include all angiography of the thoracic aorta and its branches for diagnostic imaging prior to deployment of the primary endovascular devices (including all routine components of modular devices), fluoroscopic guidance in the delivery of the endovascular components, and intraprocedural arterial angiography (eg, confirm position, detect endoleak, evaluate runoff). Code 75958 includes the analogous services for placement of each proximal thoracic endovascular extension. Code 75959 includes the analogous services for placement of a distal thoracic endovascular extension(s) placed during a procedure after the primary repair. Other interventional procedures performed at the time of endovascular repair of the descending thoracic aorta should be additionally reported (eg, innominate, carotid, subclavian, visceral, or iliac artery transluminal angioplasty or stenting, arterial embolization, intravascular ultrasound) when performed before or after deployment of the aortic prostheses.

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33880

Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin (For radiological supervision and interpretation, use 75956 in conjunction with 33880)

33881

not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin (For radiological supervision and interpretation, use 75957 in conjunction with 33881)

33883

Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); initial extension (For radiological supervision and interpretation, use 75958 in conjunction with 33883) (Do not report 33881, 33883 when extension placement converts repair to cover left subclavian origin. use only 33880)

33884

each additional proximal extension (List separately in addition to primary procedure) (Use 33884 in conjunction with 33883) (For radiological supervision and interpretation, use 75958 in conjunction with 33884)

33886

Placement of distal extension prosthesis(s) delayed after endovascular repair of descending thoracic aorta (Do not report 33886 in conjunction with 33880, 33881) (Report 33886 once, regardless of number of modules deployed) (For radiological supervision and interpretation, use 75959 in conjunction with 33886)

33889

Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision, unilateral (Do not report 33889 in conjunction with 35694)

33891

Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision (Do not report 33891 in conjunction with 35509, 35601)

PULMONARY ARTERY 33910 33915

Pulmonary artery embolectomy; with cardiopulmonary bypass without cardiopulmonary bypass

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33916 33917 33920

Pulmonary endarterectomy with or without embolectomy, with cardiopulmonary bypass Repair of pulmonary artery stenosis by reconstruction with patch or graft Repair of pulmonary atresia with ventricular septal defect, by construction or replacement of conduit from right or left ventricle to pulmonary artery (For repair of other complex cardiac anomalies by construction or replacement of right or left ventricle to pulmonary artery conduit, use 33608)

33922

Transection of pulmonary artery with cardiopulmonary bypass (Do not report modifier –63 in conjunction with 33922)

33924

Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List separately in addition to primary procedure) (Use 33924 in conjunction with 33470-33475, 33600-33619, 33684-33688, 33692-33697, 33735-33767, 33770-33781, 33786, 33920-33922)

33925

Repair of pulmonary artery arborization anomalies by unifocalization; without cardiopulmonary bypass (Report required) with cardiopulmonary bypass

33926

(Do not report 33925, 33926 in conjunction with 33697) HEART/LUNG TRANSPLANTATION 33935 33945

Heart-lung transplant with recipient cardiectomy-pneumonectomy Heart transplant, with or without recipient cardiectomy

CARDIAC ASSIST 33960 33961

Prolonged extracorporeal circulation for cardiopulmonary insufficiency; initial 24 hours each additional 24 hours (List separately in addition to primary procedure) (Use 33961 in conjunction with 33960) (Do not report 33960, 33961 in conjunction with global neonatal and pediatric critical care codes 99293-99296) (Do not report modifier –63 in conjunction with 33960, 33961) (For insertion of cannula for prolonged extracorporeal circulation, use 36822)

33967 33968 33970 33971 33973

Insertion of intra-aortic balloon assist device, percutaneous Removal of intra-aortic balloon assist device, percutaneous Insertion of intra-aortic balloon assist device through the femoral artery, open approach Removal of intra-aortic ballon assist device including repair of femoral artery, with or without graft Insertion of intra-aortic balloon assist device through the ascending aorta

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33974 33975 33976 33977 33978 33979 33980

Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending aorta, with or without graft Insertion of ventricular assist device; extracorporeal, single ventricle extracorporeal, biventricular Removal of ventricular assist device; extracorporeal, single ventricle extracorporeal, biventricular Insertion of ventricular assist device, implantable intracorporeal, single ventricle Removal of ventricular assist device, implantable intracorporeal, single ventricle (Report required)

OTHER PROCEDURES 33999

Unlisted procedure, cardiac surgery

ARTERIES AND VEINS Primary vascular procedure listings include establishing both inflow and outflow by whatever procedures necessary. Also included is that portion of the operative arteriogram performed by the surgeon, as indicated. Sympathectomy, when done, is included in the listed aortic procedures. For unlisted vascular procedure, use 37799. EMBOLECTOMY/THROMBECTOMY ARTERIAL, WITH OR WITHOUT CATHETER 34001 34051 34101 34111 34151 34201 34203

Embolectomy or thrombectomy, with or without catheter; carotid, subclavian or innominate artery, by neck incision innominate, subclavian artery, by thoracic incision axillary, brachial, innominate, subclavian artery, by arm incision radial or u1nar artery, by arm incision renal, celiac, mesentery, aortoiliac artery, by abdominal incision femoropopliteal, aortoiliac artery, by leg incision popliteal-tibio-peroneal, by leg incision

VENOUS, DIRECT OR WITH CATHETER 34401 34421 34451 34471 34490

Thrombectomy, direct or with catheter; vena cava, iliac vein, by abdominal incision vena cava, iliac, femoropopliteal vein, by leg incision vena cava, iliac, femoropopliteal vein, by abdominal and leg incision subclavian vein, by neck incision axillary and subclavian vein, by arm incision

VENOUS RECONSTRUCTION 34501 34502 34510 34520 34530

Valvuloplasty, femoral vein Reconstruction of vena cava, any method Venous valve transposition, any vein donor Cross-over vein graft to venous system Saphenopopliteal vein anastomosis

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ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM Codes 34800-34826 represent a family of component procedures to report placement of an endovascular graft for abdominal aortic aneurysm repair. These codes describe open femoral or iliac artery exposure, device manipulation and deployment, and closure of the arteriotomy sites. Balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, either before or after endograft deployment, are not separately reportable. Introduction of guidewires and catheters should be reported separately (eg, 36200, 36245-36248, 36140). Extensive repair of an artery should be additionally reported (eg, 35226 or 35286). For fluoroscopic guidance in conjunction with endovascular aneurysm repair, see code 75952 or 75953, as appropriate. Code 75952 includes angiography of the aorta and its branches for diagnostic imaging prior to deployment of the endovascular device (including all routine components of modular devices), fluoroscopic guidance in the delivery of the endovascular components, and intraprocedural arterial angiography (eg, confirm position, detect endoleak, evaluate runoff). Code 75953 includes the analogous services for placement of additional extension prostheses (not for routine components of modular devices). Other interventional procedures performed at the time of endovascular abdominal aortic aneurysm repair should be additionally reported (eg, aortography before deployment of endoprosthesis, renal transluminal angioplasty, arterial embolization, intravascular ultrasound, balloon angioplasty or native artery(s) outside the endoprosthesis target zone when done before or after deployment of graft). 34800 34802 34803 34804 34805 34806

34808

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis using modular bifurcated prosthesis (one docking limb) using modular bifurcated prosthesis (two docking limbs) using unibody bifurcated prosthesis using aorto-uniiliac or aorto-unifemoral prosthesis Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and collection of pressure data (Do not report 34806 in conjunction with 93982) (Use 34806 in conjunction with 33880, 33881, 33886, 34800-34805, 34825, 34900) Endovascular placement of iliac artery occlusion device (List separately in addition to primary procedure) (Use 34808 in conjunction with codes 34800, 34805, 34813, 34825, 34826) (For radiological supervision and interpretation use 75952 in conjunction with 34800-34808) (For open arterial exposure, report 34812, 34820, 34833, 34834 as appropriate, in addition to 34800-34808)

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34812

Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (For bilateral procedure, use modifier -50)

34813

Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List separately in addition to primary procedure) (Use 34813 in conjunction with code 34812) (For femoral artery grafting, see 35521, 35533, 35539, 35540, 35551-35558, 35566, 35621, 35646, 35651-35661, 35666, 35700)

34820

Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (For bilateral procedure, use modifier -50)

34825

Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel each additional vessel (List separately in addition to primary procedure) (Use 34826 in conjunction with code 34825) (For radiological supervision and interpretation, use 75953)

34826

(Use 34825, 34826 in addition to 34800-34808, 34900 as appropriate) 34830 34831 34832 34833

34834

Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis aorto-bi-iliac prosthesis aorto-bifemoral prosthesis Open iliac artery exposure with creation of conduit for delivery of aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal incision, unilateral (Report required) (Do not report 34833 in addition to 34820) (For bilateral procedure, use modifier -50) Open brachial artery exposure to assist in the deployment of aortic or iliac endovascular prosthesis by arm incision, unilateral (Report required) (For bilateral procedure, use modifier -50)

ENDOVASCULAR RREPAIR OF ILIAC ANEURYSM Code 34900 represents a procedure to report introduction, positioning, and deployment of an endovascular graft for treatment of aneurysm, psuedoaneurysm, or arteriovenous malformation or trauma of the iliac artery (common, hypogastric, external). All balloon angioplasty and/or stent deployments within the target treatment zone for the endoprosthesis, either before or after endograft deployment, are included in the work of 34900 and are not separately reportable. Open femoral or iliac artery exposure (eg, 34812, 34820), introduction of guidewires and catheters (eg, 36200, 36215-36218), and extensive repair or replacement of an artery (eg, 35206-35286) should be also reported. Version 2008 – 1 (5/15/2008)

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For fluoroscopic guidance in conjunction with endovascular iliac aneurysm repair, see code 75954. Code 75954 includes angiography of the aorta and iliac arteries for diagnostic imaging prior to deployment of the endovascular device (including all routine components), fluoroscopic guidance in the delivery of the endovascular components, and intraprocedural arterial angiography to confirm appropriate position of the graft, detect endoleaks, and evaluate the status of the runoff vessels (eg, evaluation for dissection, stenosis, thrombosis, distal embolization, or iatrogenic injury). Other interventional procedures performed at the time of endovascular aortic aneurysm repair should be additionally reported (eg, transluminal angioplasty outside the aneurysm target zone, arterial embolization, intravascular ultrasound). 34900

Endovascular graft replacement for repair of iliac artery (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) (Report required) (For bilateral procedure, use modifier –50) (For radiological supervision and interpretation, use 75954) (For placement of extension prothesis during endovascular iliac artery repair, use 34825)

DIRECT REPAIR OF ANEURYSM OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION FOR ANEURSYM, PSEUDOANEURYSM, RUPTURED ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE Procedures 35001 - 35152 include preparation of artery for anastomosis including endarterectomy. (For direct repairs associated with occlusive disease only, see 35201-35286) (For intracranial aneurysm, see 61700 et seq) (For endovascular repair of abdominal aortic aneurysm, see 34800-34826) (For endovascular repair of iliac artery aneurysm, see 34900) (For thoracic aortic aneurysm, see 33860-33875) (For endovascular repair of descending thoracic aorta, involving coverage of left subclavian artery origin, use 33880) 35001

35002 35005 35011 35013 35021 35022 35045

Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, cartoid, subclavian artery, by neck incision for ruptured aneurysm, carotid, subclavian artery, by neck incision (Report required) for aneurysm, pseudoaneurysm, and associated occlusive disease, vertebral artery for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision for ruptured aneurysm, axillary- brachial artery, by arm incision for aneurysm, pseudoaneurysm, and associated occlusive disease, innominate, subclavian artery, by thoracic incision for ruptured aneurysm, innominate, subclavian artery, by thoracic incision for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery

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35081 35082 35091 35092 35102 35103 35111 35112 35121 35122 35131 35132 35141 35142 35151 35152

for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta for ruptured aneurysm, abdominal aorta for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) for ruptured aneurysm, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels (common, hypogastric, external) for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypogastric, external) for aneurysm, pseudoaneurysm, and associated occlusive disease, splenic artery for ruptured aneurysm, splenic artery for aneurysm, pseudoaneurysm, and associated occlusive disease, heptic,celiac, renal or mesenteric artery for ruptured aneurysm, hepatic, celiac, renal, or mesenteric artery for aneurysm, pseudoaneurysm, and associated occlusive disease, iliac artery (common, hypogastric, external) for ruptured aneurysm, iliac artery (common, hypogastric, external) for aneurysm, pseudoaneurysm, and associated occulsive disease, common femoral artery (profunda femoris, superficial femoral) for ruptured aneurysm, common femoral artery (profunda femoris,superficial femoral) for aneurysm, pseudoaneurysm, and associated occlusive disease, popliteal artery for ruptured aneurysm, popliteal artery

REPAIR ARTERIOVENOUS FISTULA 35180 35182 35184 35188 35189 35190

Repair, congenital arteriovenous fistula; head and neck thorax and abdomen (Report required) extremities (Report required) Repair, acquired or traumatic arteriovenous fistula; head and neck thorax and abdomen (Report required) extremities

REPAIR BLOOD VESSEL OTHER THAN FOR FISTULA, WITH OR WITHOUT PATCH ANGIOPLASTY (For AV fistula repair, see 35180-35190) 35201 35206 35207 35211 35216

Repair blood vessels, direct; neck upper extremity hand, finger intrathoracic, with bypass intrathoracic, without bypass

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35221 35226 35231 35236 35241 35246 35251 35256 35261 35266 35271 35276 35281 35286

intra-abdominal lower extremity Repair blood vessel with vein graft; neck upper extremity intrathoracic, with bypass intrathoracic, without bypass intra-abdominal lower extremity Repair blood vessel with graft other than vein; neck upper extremity intrathoracic, with bypass intrathoracic, without bypass intra-abdominal lower extremity

THROMBOENDARTERECTOMY (For coronary artery, see 33510-33536 and 33572) (35301-35372 include harvest of saphenous or upper extremity vein when performed) 35301 35302 35303

Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision superficial femoral artery popliteal artery (Do not report 35302, 35303 in conjunction with 35483, 35500)

35304 35305 35306

tibioperoneal trunk artery tibial or peroneal artery, initial vessel each additional tibial or peroneal artery (List separately in addition to primary procedure) (Use 35306 in conjunction with 35305) (Do not report 35304, 35305, 35306 in conjunction with 35485, 35500)

35311 35321 35331 35341 35351 35355 35361 35363 35371 35372

subclavian, innominate, by thoracic incision axillary-brachial abdominal aorta mesenteric, celiac, or renal iliac iliofemoral combined aortoiliac combined aortoiliofemoral common femoral deep (profunda) femoral (For thromboendarterectomy of the superficial femoral artery, use 35302; of the popliteal artery, use 35303; of the tibioperoneal trunk, use 35304; of the tibial or peroneal artery, see 35305, 35306)

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35390

Reoperation, carotid, thromboendarterectomy, more than one month after original operation (List separately in addition to primary procedure) (Use 35390 in conjunction with 35301)

ANGIOSCOPY 35400

Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (List separately in addition to primary procedure)

TRANSLUMINAL ANGIOPLASTY (For radiological supervision and interpretation, see 75962-75968 and 75978) OPEN 35450 35452 35454 35456 35458 35459 35460

Transluminal balloon angioplasty, open; renal or other visceral artery aortic iliac femoral-popliteal brachiocephalic trunk or branches, each vessel tibioperoneal trunk and branches venous

PERCUTANEOUS Codes for catheter placement and the radiologic supervision and interpretation should also be reported, in addition to the code(s) for the therapeutic aspect of the procedure. 35470 35471 35472 35473 35474 35475 35476

Transluminal balloon angioplasty, percutaneous; tibioperoneal trunk or branches, each vessel renal or visceral artery aortic iliac femoral-popliteal brachiocephalic trunk or branches, each vessel venous (For radiological supervision and interpretation, use 75978)

TRANSLUMINAL ATHERECTOMY (For radiological supervision and interpretation, see 75992-75996) OPEN 35480 35481 35482 35483 35484 35485

Transluminal peripheral atherectomy, open; renal or other visceral artery aortic iliac femoral-popliteal brachiocephalic trunk or branches, each vessel tibioperoneal trunk and branches

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Transluminal peripheral atherectomy, percutaneous; renal or other visceral artery aortic iliac femoral-popliteal brachiocephalic trunk or branches, each vessel tibioperoneal trunk and branches

BYPASS GRAFT VEIN Procurement of the saphenous vein graft is included in the description of the work for 35501-35587 and should not be reported as a separate service or co-surgery. To report harvesting of an upper extremity vein, use 35500 in addition to the bypass procedure. To report harvesting of a femoropopliteal vein segment, use 35572 in addition to the bypass procedure. To report harvesting and construction of an autogenous composite graft of two segments from two distant locations, report 35682 in addition to the bypass procedure, for autogenous composite of three or more segments from distant sites, report 35683. 35500

Harvest of upper extremity vein, one segment, for lower extremity or coronary artery bypass procedure (List separately in addition to primary procedure) (Use 35500 in conjunction with 33510-33536, 35556, 35566, 35571, 3558335587) (For harvest of more than one vein segment, see 35682, 35683) (For endoscopic procedure, use 33508)

35501 35506

Bypass graft, with vein; common carotid-ipsilateral internal carotid carotid-subclavian or subclavian-carotid (For subclavian-carotid bypass with vein, use 35506)

35508 35509 35510 35511 35512 35515 35516 35518 35521

carotid-vertebral carotid-contralateral carotid carotid-brachial subclavian-subclavian subclavian-brachial subclavian-vertebral subclavian-axillary axillary-axillary axillary-femoral (For bypass graft performed with synthetic graft, use 35621)

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35522 35523

axillary-brachial brachial-ulnar or -radial (Do not report 35523 in conjunction with 35206, 35500, 35525, 36838) (For bypass graft performed with synthetic conduit, use 37799)

35525 35526

brachial-brachial aortosubclavian or carotid (For bypass graft performed with synthetic graft, use 35626)

35531 35533

aortoceliac or aortomesenteric axillary-femoral-femoral (For bypass graft performed with synthetic graft, use 35654)

35536 35537

splenorenal aortoiliac (Do not report 35537 in conjunction with 35538) (For bypass graft performed with synthetic graft, use 35637)

35538

aortobi-iliac (Do not report 35538 in conjunction with 35537) (For bypass graft performed with synthetic graft, use 35638)

35539

aortofemoral (Do not report 35539 in conjunction with 35540) (For bypass graft performed with synthetic graft, use 35647)

35540

aortobifemoral (Do not report 35540 in conjunction with 35539) (For bypass graft performed with synthetic graft, use 35646) (For aortoiliac graft with vein, use 35537. For aortobi-iliac graft with vein, use 35538) (For aortofemoral graft with vein use 35539. For aortobifemoral graft with vein, use 35540)

35548

aortoiliofemoral, unilateral (For bypass graft performed with synthetic graft, use 37799)

35549

aortoiliofemoral, bilateral (For bypass graft performed with synthetic graft, use 37799)

35551 35556 35558 35560 35563

aortofemoral-popliteal femoral-popliteal femoral-femoral aortorenal ilioiliac

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35565 35566 35571 35572

iliofemoral femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels popliteal-tibial, -peroneal artery or other distal vessels Harvest of femoropopliteal vein, one segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to primary procedure) (Use 35572 in cojnuction with code 33510-33516, 33517-33523, 33523, 3353333536, 34502, 34520, 35001, 35002, 35011-35022, 35102, 35103, 3512135152, 35231-35256, 35501-35587, 35879-35907) (For bilateral procedure, use modifier -50)

IN-SITU VEIN (To report aortobifemoral bypass using synthetic conduit, and femoral-popliteal bypass with vein conduit in-situ, use 35646 and 35583. To report aorto(uni)femoral bypass with synthetic conduit, and femoral-popliteal bypass with vein conduit in-situ, use 35647 and 35583. To report aortofemoral bypass using vein conduit, and femoral-popliteal bypass with vein conduit in-situ, use 35539 and 35583) 35583 35585 35587

In-situ vein bypass; femoral-popliteal femoral-anterior tibial, posterior tibial, or peroneal artery popliteal-tibial, peroneal

OTHER THAN VEIN (For arterial transposition and/or reimplantation, see 35691-35695) 35600

Harvest of upper extremity artery, one segment, for coronary artery bypass procedure (List separately in addition to primary procedure) (Use 35600 in conjunction with 33533-33536)

35601 35606

Bypass graft, with other than vein; common carotid-ipsilateral internal carotid carotid-subclavian (For open transcervical common carotid-common carotid bypass performed in conjunction with endovascular repair of descending thoracic aorta, use 33891) (For open subclavian to carotid artery transposition performed in conjunction with endovascular thoracic aneurysm repair by neck incision, use 33889)

35612 35616 35621 35623 35626 35631 35636 35637

subclavian-subclavian subclavian-axillary axillary-femoral axillary-popliteal or -tibial aortosubclavian or carotid aortoceliac, aortomesenteric, aortorenal splenorenal (splenic to renal arterial anastomosis) aortoiliac (Do not report 35637 in conjunction with 35638, 35646)

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35638

aortobi-iliac (Do not report 35638 in conjunction with 35637, 35646) (For aortoiliac graft constructed with conduit other than vein, use 35637. For aortobiiliac graft with other than vein, use 35638) (For open placement of aortobi-iliac prosthesis following unsuccessful endovascular repair, use 34831)

35642 35645 35646

carotid-vertebral subclavian-vertebral aortobifemoral (For bypass graft performed with vein graft, use 35540) (For open placement of aortobifemoral prosthesis following unsuccessful endovascular repair, use 34832)

35647

aortofemoral (For bypass graft performed with vein graft, use 35539)

35650 35651 35654 35656 35661 35663 35665 35666 35671

axillary-axillary aortofemoral-popliteal axillary-femoral-femoral femoral-popliteal femoral-femoral ilioiliac iliofemoral femoral-anterior tibial, posterior tibial, or peroneal artery popliteal-tibial, or -peroneal artery

COMPOSITE GRAFTS Codes 35682-35683 are used to report harvest and anastomosis of multiple vein segments from distant sites for use as arterial bypass graft conduits. These codes are intended for use when the two or more vein segments are harvested from a limb other than that undergoing bypass. Add-on codes 35682 and 35683 are reported in addition to bypass graft codes 35556, 35566, 35571, 35583-35587, as appropriate. (Do not report 35681-35683 in addition to each other.) 35681

Bypass graft; composite, prosthetic and vein (List separately in addition to primary procedure)

35682

autogenous composite, two segments of veins from two locations (List separately in addition to primary procedure)

35683

autogenous composite, three or more segments of vein from two or more locations (List separately in addition to primary procedure)

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ADJUVANT TECHNIQUES Adjuvant (additional) technique(s) may be required at the time a bypass graft is created to improve patency of the lower extremity autogenous or synthetic bypass graft (eg, femoralpopliteal, femoral-tibial, or popliteal-tibial arteries). Code 35685 should be reported in addition to the primary synthetic bypass graft procedure, when an interposition of venous tissue (vein patch or cuff) is placed at the anastomosis between the synthetic bypass conduit and the involved artery (includes harvest). Code 35686 should be reported in addition to the primary bypass graft procedure, when autogenous vein is used to create a fistula between the tibial or peroneal artery and vein at or beyond the distal bypass anastomosis site of the involved artery. (For composite graft(s), see 35681-35683) 35685

Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (List separately in addition to primary procedure) (Use 35685 in conjunction with codes 35656, 35666, or 35671)

35686

Creation of distal arteriovenous fistula during lower extremity bypass surgery (nonhemodialysis) (List separately in addition to primary procedure) (Use 35686 in conjunction with codes 35556, 35566, 35571, 35583-35587, 35623, 35656, 35666, 35671)

ARTERIAL TRANSPOSITION 35691 35693 35694

Transposition and/or reimplantation; vertebral to carotid artery vertebral to subclavian artery subclavian to carotid artery (For open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, use 33889)

35695 35697

carotid to subclavian artery Reimplantation, visceral artery to infrarenal aortic prosthesis, each artery (List separately in addition to primary procedure) (Do not report 35697 in conjunction with 33877)

EXCISION, EXPLORATION, REPAIR, REVISION 35700

Reoperation, femoral-popliteal or femoral (popliteal) -anterior tibial, posterior tibial, peroneal artery or other distal vessels, more than one month after original operation (List separately in addition to primary procedure) (Use 35700 in conjunction with 35556, 35566, 35571, 35583, 35585, 35587, 35656, 35666, 35671)

35701

Exploration (not followed by surgical repair), with or without lysis of artery; carotid artery femoral artery

35721

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35741 35761 35800 35820 35840 35860 35870 35875 35876

popliteal artery other vessels Exploration for postoperative hemorrhage, thrombosis or infection; neck chest abdomen extremity Repair of graft-enteric fistula Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft (For thrombectomy of hemodialysis graft or fistula, see 36831, 36833) Codes 35879 and 35881 describe open revision of graft-threatening stenoses of lower extremity arterial bypass graft(s) (previously constructed with autogenous vein conduit) using vein patch angioplasty or segmental vein interposition techniques. For thrombectomy with revision of any non-coronary arterial or venous graft, including those of the lower extremity, (other than hemodialysis graft or fistula), use 35876. For direct repair (other than for fistula) of a lower extremity blood vessel (with or without patch angioplasty), use 35226. For repair (other than for fistula) of a lower extremity blood vessel using a vein graft, use 35256.

35879 35881

Revision, lower extremity arterial bypass, without thrombectomy, open; with vein patch angioplasty with segmental vein interposition (For revision of femoral anastomosis of synthetic arterial bypass graft, see 35883, 35884) (For excision of infected graft, see 35901-35907 and appropriate revascularization code)

35883

35884

35901 35903 35905 35907

Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (eg, dacron, eptfe, bovine pericardium) (For bilateral procedure, use modifier -50) (Do not report 35883 in conjunction with 35700, 35875, 35876, 35884) with autogenous vein patch graft (For bilateral procedure, use modifier -50) (Do not report 35884 in conjunction with 35700, 35875, 35876, 35883) Excision of infected graft; neck extremity thorax abdomen

VASCULAR INJECTION PROCEDURES Listed services for injection procedures include necessary local anesthesia introduction of needles or catheter, injection of contrast media with or without automatic power injection, and/or necessary pre- and postinjection care specifically related to the injection procedure.

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Catheters, drugs, and contrast media are not included in the listed service for the injection procedures. Selective vascular catheterization should be coded to include introduction all lesser order selective catheterization used in the approach (eg, the description for a selective right middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries). Additional second and/or third order arterial catheterization within the same family of arteries or veins supplied by a single first order vessel should be expressed by 36012, 36218 or 36248. Additional first order or higher catheterization in vascular families supplied by a first order vessel different from a previously selected and coded family should be separately coded using the conventions described above. (For injection procedures in conjunction with cardiac catheterization, see 93541-93545) (For chemotherapy of malignant disease, see 96401-96549) INTRAVENOUS An intracatheter is a sheathed combination of needle and short catheter. 36000

Introduction of needle or intracatheter, vein (For radiological vascular injection procedure not otherwise listed)

36002

Injection procedures (eg, thrombin) for percutaneous treatment of extremity pseudoaneurysm (Do not report 36002 for vascular sealant of an arteriotomy site) (For imaging guidance, see 76942, 77002, 77012, 77021) (For ultrasound guided compression repair of pseudoaneurysm, use 76936)

36005

Injection procedure for extremity venography (including introduction of needle or intracatheter) (For radiological supervision and interpretation, see 75820, 75822)

36010 36011

Introduction of catheter; superior or inferior vena cava Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) Introduction of catheter, right heart or main pulmonary artery Selective catheter placement, left or right pulmonary artery Selective catheter placement, segmental or subsegmental pulmonary artery

36012 36013 36014 36015

(For insertion of flow directed catheter (eg, Swan-Ganz), use 93503) (For venous catheterization for selective organ blood sampling, use 36500) INTRA-ARTERIAL - INTRA-AORTIC 36100

Introduction of needle or intracatheter, carotid or vertebral artery (For bilateral procedure, report 36100 with modifier -50)

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36120 36140 36145

Introduction of needle or intracatheter; retrograde brachial artery extremity artery arteriovenous shunt created for dialysis (cannula, fistula or graft) (For insertion of arteriovenous cannula, see 36810-36821)

36160 36200 36215

Introduction of needle or intracatheter, aortic, translumbar Introduction of catheter, aorta Selective catheter placement, arterial system; each first order thoracic or bracheocephalic branch, within a vascular family (For catheter placement for coronary angiography, use 93508)

36216 36217 36218

initial second order thoracic or bracheocephalic branch, within a vascular family initial third order or more selective thoracic or bracheocephalic branch, within a vascular family additional second order, third order and beyond, thoracic or bracheocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) (Use 36218 in conjunction with 36216, 36217) (For angiography, see 75600-75790) (For angioplasty, see 35470-35475) (For transcatheter therapies, see 37200-37208, 61624, 61626)

When coronary artery, arterial conduit (eg, internal mammary, inferior epigastric or free radial artery) or venous bypass graft angiography is performed in conjunction with cardiac catheterization, see the appropriate cardiac catheterization code(s) (93501-93556) in the Medicine section. When coronary artery, arterial coronary conduit or venous bypass graft angiography is performed without concomitant left heart cardiac catheterization, use 93508. When internal mammary artery angiography only is performed without a concomitant left heart cardiac catheterization, use 36216 or 36217 as appropriate. 36245 36246 36247 36248

36260 36261 36262 36299

Selective catheter placement, arterial system; each first order abdominal, pelvic or lower extremity artery branch, with a vascular family initial second order abdominal, pelvic or lower extremity artery branch, within a vascular family initial third order or more selective abdominal, pelvic or lower extremity artery branch, within a vascular family additional second order, third order and beyond, abdominal, pelvic or lower extremity artery branch, within a vascular family (Use 36248 in conjunction with 36246, 36247) Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) Revision of implanted intra-arterial infusion pump Removal of implanted intra-arterial infusion pump Unlisted procedure, vascular injection

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VENOUS Venipuncture, needle or catheter for diagnostic study or intravenous therapy, percutaneous. These codes are also used to report the therapy as specified. For collection of a specimen from a completely implantable venous access device, use 36591. (Do not report modifier –63 in conjunction with 36420, 36450, 36460, 36510) 36400 36405 36406 36420 36425 36430 36440 36450 36455 36460 36468 36469 36470 36471 36481 36500

Venipuncture, younger than age 3 years, necessitating physician's skill, not to be used for routine venipuncture; femoral or jugular vein (Report required) scalp vein (Report required) other vein (Report required) Venipuncture, cutdown; younger than age 1 year age 1 or over (Not to be used for routine venipuncture) (Report required) Transfusion, blood or blood components Push transfusion, blood, 2 years or younger Exchange transfusion, blood; newborn other than newborn Transfusion, intrauterine, fetal (For radiological supervision and interpretation, use 76941) Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk face Injection of sclerosing solution; single vein multiple veins, same leg Percutaneous portal vein catheterization by any method (For radiological supervision and interpretation, see 75885, 75887) Venous catheterization for selective organ blood sampling (For radiological supervision and interpretation, use 75893) (For catheterization in superior or inferior vena cava, use 36010)

36510 36511 36512 36513 36514 36515 36516 36522

Catheterization of umbilical vein for diagnosis or therapy, newborn Therapeutic apheresis; for white blood cells for red blood cells for platelets for plasma pheresis with extracorporeal immunoadsorption and plasma reinfusion with extracorporeal selective absorption or selective filtration and plasma reinfusion Photopheresis, extracorporeal

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CENTRAL VENOUS ACCESS PROCEDURES To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium. The venous access device may be either centrally inserted (jugular, subclavian, femoral vein or inferior vena cava catheter entry site) or peripherally inserted (eg, basilic or cephalic vein). The device may be accessed for use either via exposed catheter (external to the skin), via a subcutaneous port or via a subcutaneous pump. The procedures involving these types of devices fall into five categories: 1) Insertion (placement of catheter through a newly established venous access) 2) Repair (fixing device without replacement of either catheter or port/pump, other than pharmacologic or mechanical correction of intracatheter or pericatheter occlusion (see 36595 or 36596)) 3) Partial replacement of only the catheter component associated with a port/pump device, but not entire device 4) Complete replacement of entire device via same venous access site (complete exchange) 5) Removal of entire device. There is no coding distinction between venous access achieved percutaneously versus by cutdown or based on catheter size. For the repair, partial (catheter only) replacement, complete replacement, or removal of both catheters (placed from separate venous access sites) of a multi-catheter device, with or without subcutaneous ports/pumps, use the appropriate code describing the service with a frequency of two. If an existing central venous access device is removed and a new one placed via a separate venous access site, appropriate codes for both procedures (removal of old, if code exists, and insertion of new device) should be reported. When imaging is used for these procedures, either for gaining access to the venous entry site or for manipulating the catheter into final central position, use 76937, 77001. (For refilling and maintenance of an implantable pump or reservoir for intravenous or intraarterial drug delivery, use 96522) INSERTION OF CENTRAL VENOUS ACCESS DEVICE 36555

Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age (For peripherally inserted non-tunneled central venous catheter, younger than 5 years of age, use 36568)

36556

age 5 years or older (For peripherally inserted non-tunneled central venous catheter, age 5 years or older, use 36569)

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36557 36558

Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; under 5 years of age age 5 years or older (For peripherally inserted central venous catheter with port, 5 years or older, use 36571)

36560

Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; under 5 years of age (For peripherally inserted central venous access device with subcutaneous port, younger than 5 years of age, use 36570)

36561

age 5 years or older (For peripherally inserted central venous catheter with subcutaneous port, 5 years or older, use 36571)

36563 36565

36566 36568

Insertion of tunneled centrally inserted central venous access device with subcutaneous pump Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump (eg, tesio type catheter) with subcutaneous port(s) Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; under 5 years of age (For placement of centrally inserted non-tunneled central venous catheter, without subcutaneous port or pump, younger than 5 years of age, use 36555)

36569

age 5 years or older (For placement of centrally inserted non-tunneled central venous catheter, without subcutaneous port or pump, age 5 years or older, use 36556)

36570

Insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age (For insertion of tunneled centrally inserted central venous access device with subcutaneous port, younger than 5 years of age, use 36560)

36571

age 5 years or older (For insertion of tunneled centrally inserted central venous access device with subcutaneous port, age 5 years or older, use 36561)

REPAIR OF CENTRAL VENOUS ACCESS DEVICE (For mechanical removal of pericatheter obstructive material, use 36595) (For mechanical removal of intracatheter obstructive material, use 36596) 36575 36576

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PARTIAL REPLACEMENT OF CENTRAL VENOUS ACCESS DEVICE (CATHETER ONLY) 36578

Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site (For complete replacement of entire device through same venous access, use 36582 or 36583)

COMPLETE REPLACEMENT OF CENTRAL VENOUS ACCESS DEVICE THROUGH SAME VENOUS ACCESS SITE 36580 36581 36582 36583 36584 36585

Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access

REMOVAL OF CENTRAL VENOUS ACCESS DEVICE 36589 36590

Removal of tunneled central venous catheter, without subcutaneous port or pump Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion (Do not report 36589 or 36590 for removal of non-tunneled central venous catheters)

OTHER CENTRAL VENOUS ACCESS PROCEDURES 36591

Collection of blood specimen from a completely implantable venous access device (Do not report 36591 in conjunction with any other service)

36593 36595

Declotting by thrombolytic agent of implanted vascular access device or catheter Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access (Do not report 36595 in conjunction with 36593) (For radiological supervision and interpretation, use 75901) (For venous catheterization, see 36010-36012)

36596

Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen (Do not report 36596 in conjunction with 36593) (For radiological supervision and interpretation, use 75902) (For venous catheterization, see 36010-36012) Version 2008 – 1 (5/15/2008)

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36597

Repositioning of previously placed central venous catheter under fluoroscopic guidance (For fluoroscopic guidance, use 76000)

36598

Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report (Do not report 36598 in conjunction with 36595, 36596) (Do not report 36598 in conjunction with 76000) (For complete diagnostic studies, see 75820, 75825, 75827)

ARTERIAL 36600 36620 36625 36640

Arterial puncture, withdrawal of blood for diagnosis (Report required) Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous cutdown Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown (See also 96420-96425) (For arterial catheterization for occlusion therapy, see 75894)

36660

Catheterization, umbilical artery, newborn, for diagnosis or therapy (Do not report modifier 63 in conjunction with 36660)

INTRAOSSEOUS 36680

Placement of needle for intraosseous infusion

HEMODIALYSIS ACCESS, INTERVASCULAR CANNULIZATION FOR EXTRACORPOREAL CIRCULATION, OR SHUNT INSERTION 36800 36810 36815 36818

Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein arteriovenous, external (Scribner type) arteriovenous, external revision or closure Arteriovenous anastomosis, open; by upper arm cephalic vein transposition (Do not report 36818 in conjunction with 36819, 36820, 36821, 36830 during a unilateral upper extremity procedure. For bilateral upper extremity open arteriovenous anastomoses performed at the same operative session, use modifier -50)

36819

by upper arm basilic vein transposition (Do not report 36819 in conjunction with 36818, 36820, 36821, 36830 during a unilateral upper extremity procedure. For bilateral upper extremity open arteriovenous anastomoses performed at the same operative session, use modifier -50)

36820 36821

by forearm vein transposition direct, any site(eg. Cimino type) (separate procedure)

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36822

Insertion of cannula(s) for prolonged extracorporeal circulation for cardiopulmonary insufficiency (ECMO) (separate procedure) (For maintenance of prolonged extracorporal circulation, see 33960, 33961)

36823

Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) and repair of arteriotomy and venotomy sites (36823 includes chemotherapy perfusion supported by a membrane oxygenator/perfusion pump. Do not report 96409-96425 in conjunction with 36823)

36825

Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft nonautogenous graft (eg, biological collogen, thermoplastic graft)

36830

(For procedures 36825, 36830 for direct arteriovenous anastomosis, use 36821) 36831 36832 36833 36834 36835 36838

36860 36861

Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) Plastic repair of arteriovenous aneurysm (separate procedure) Insertion of Thomas shunt (separate procedure) Distal revascularization and interval ligation (dril), upper extremity hemodialysis access (steal syndrome) (Do not report 36838 in conjunction with 35512, 35522, 36832, 37607, 37618) External cannula declotting (separate procedure); without balloon catheter with balloon catheter (If imaging guidance is performed, use 76000)

36870

Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) (Do not report 36870 in conjunction with code 36593) (For radiological supervision and interpretation, use 75790) (For catheterization, use 36145)

PORTAL DECOMPRESSION PROCEDURES 37140

Venous anastomosis, open; portocaval (For peritoneal-venous shunt, use 49425)

37145 37160 37180

renoportal caval-mesenteric splenorenal, proximal

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37181

splenorenal, distal (selective decompression of esophagogastric varices, any technique) (For percutaneous procedure, use 37182)

37182

Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance and documentation (Do not report 75885 or 75887 in conjunction with 37182) (For open procedure, use 37140)

37183

Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilation, stent placement and all associated imaging guidance and documentation) (Do not report 75885 or 75887 in conjunction with code 37183) (For repair of arteriovenous aneurysm, use 36834)

TRANSCATHETER PROCEDURES Codes for catheter placement and the radiologic supervision and interpretation should also be reported, in addition to the code(s) for the therapeutic aspect of the procedure. Mechanical thrombectomy code(s) for catheter placement(s), diagnostic studies, and other percutaneous interventions (eg, transluminal balloon angioplasty, stent placement) provided are separately reportable. Codes 37184-37188 specifically include intraprocedural fluoroscopic radiological supervision and interpretation services for guidance of the procedure. Intraprocedural injection(s) of a thrombolytic agent is an included service and not separately reportable in conjunction with mechanical thrombectomy. However, subsequent or prior continuous infusion of a thrombolytic is not an included service and is separately reportable (see 37201, 75896, 75898). For coronary mechanical thrombectomy, use 92973. For mechanical thrombectomy for dialysis fistula, use 36870. Arterial mechanical thrombectomy may be performed as a ’’primary’’ transcatheter procedure with pretreatment planning, performance of the procedure, and postprocedure evaluation focused on providing this service. Typically, the diagnosis of thrombus has been made prior to the procedure, and a mechanical thrombectomy is planned preoperatively. Primary mechanical thrombectomy is reported per vascular family using 37184 for the initial vessel treated and 37185 for second or all subsequent vessel(s) within the same vascular family.

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Primary mechanical thrombectomy may precede or follow another percutaneous intervention. Most commonly primary mechanical thrombectomy will precede another percutaneous intervention with the decision regarding the need for other services not made until after mechanical thrombectomy has been performed. Occasionally, the performance of primary mechanical thrombectomy may follow another percutaneous intervention. Do NOT report 37184-37185 for mechanical thrombectomy performed for retrieval of short segments of thrombus or embolus evident during other percutaneous interventional procedures. See 37186 for these procedures. Arterial mechanical thrombectomy is considered a ’’secondary’’ transcatheter procedure for removal or retrieval of short segments of thrombus or embolus when performed either before or after another percutaneous intervention (eg, percutaneous transluminal balloon angioplasty, stent placement). Secondary mechanical thrombectomy is reported using 37186. Do NOT report 37186 in conjunction with 37184-37185. Venous mechanical thrombectomy use 37187 to report the initial application of venous mechanical thrombectomy. To report bilateral venous mechanical thrombectomy performed through a separate access site(s), use modifier -50 in conjunction with 37187. For repeat treatment on a subsequent day during a course of thrombolytic therapy, use 37188. ARTERIAL MECHANICAL THROMBECTOMY (Do not report 37184, 37185, 37816 in conjunction with 76000, 76001 37184

37185

37186

Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel (Do not report 37184 in conjunction with 99143-99150) second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure) Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to primary procedure)

VENOUS MECHANICAL THROMBECTOMY (Do not report 37187, 37188 in conjunction with 76000, 76001) 37187 37188

Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy

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OTHER PROCEDURES 37195 37200

Thrombolysis, cerebral, by intravenous infusion Transcatheter biopsy (For radiological supervision and interpretation, use 75970)

37201

Transcatheter therapy, infusion for thrombolysis other than coronary (For radiological supervision and interpretation, use 75896)

37202

Transcatheter therapy, infusion other than for thrombolysis, any type (eg, spasmolytic, vasoconstrictive) (For radiological supervision and interpretation, use 75896) (For thromolysis of coronary vessels, see 92975, 92977)

37203

Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter) (For radiological supervision and interpretation, use 75961)

37204

Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, non-central nervous system, non-head or neck (See also 61624, 61626) (For radiological supervision and interpretation, use 75894) (For uterine fibroid embolization [uterine artery embolization performed to treat uterine fibroids], use 37210) (For obstetrical and gynecologic embolization procedures other than uterine fibroid embolization [eg, embolization to treat obstetrical or postpartum hemorrhage], use 37204)

37205

Transcatheter placement of an intravascular stent(s), (except coronary, carotid, and vertebral vessel), percutaneous; initial vessel (For radiological supervision and interpretation, use 75960) (For coronary stent placement, see 92980, 92981; intracranial, use 61635)

37206

each additional vessel (List separately in addition to primary procedure) (Use 37206 in conjunction with 37205) (For radiological supervision and interpretation, use 75960) (For transcatheter placement of intravascular cervical carotid artery stent(s), see 37215, 37216)

37207 37208

Transcatheter placement of an intravascular stent(s), (non-coronary vessel), open; initial vessel each additional vessel (List separately in addition to primary procedure) (Use 37208 in conjunction with 37207) (For radiological supervision and interpretation, use 75960)

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(For catheterizations, see 36215-36248) (For transcatheter placement of intracoronary stent(s), see 92980, 92981) 37209

Exchange of a previously placed intravascular catheter during thrombolytic therapy (For radiological supervision and interpretation, use 75900)

37210

Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure (37210 includes all catheterizations and intraprocedural imaging required for a UFE procedure to confirm the presence of previously known fibroids and to roadmap vascular anatomy to enable appropriate therapy) (Do not report 37210 in conjunction with 36200, 36245-36248, 37204, 75894, 75898) (For all other non-central nervous system (CNS) embolization procedures, use 37204)

37215 37216

Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection without distal embolic protection (37215 and 37216 include all ipsilateral selective carotid catheterization, all diagnostic imaging for ipsilateral, cervical and cerebral carotid arteriography, and all related radiological supervision and interpretation. When ipsilateral carotid arteriogram (including imaging and selective catheterization) confirms the need for carotid stenting, 37215 and 37216 are inclusive of these services. If carotid stenting is not indicated, then the appropriate codes for carotid catheterization and imaging should be reported in lieu of 37215 and 37216) (Do not report 37215, 37216 in conjunction with 75671, 75680) (For percutaneous transcatheter placement of intravascular stents other than coronary, carotid, or vertebral, see 37205, 37206)

INTRAVASCULAR ULTRASOUND SERVICES Intravascular ultrasound services include all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention (eg, stent placement). Vascular access for intravascular ultrasound performed during a therapeutic intervention is not reported separately. 37250

Intrasvascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; initial vessel (List separately in addition to primary procedure)

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37251

each additional vessel (List separately in addition to primary procedure) (Use 37251 in conjunction with 37250) (For radiological supervision and interpretation see 75945, 75946) (For catheterizations, see 36215-36248) (For transcatheter therapies, see 37200-37208, 61624, 61626)

ENDOSCOPY Surgical vascular endoscopy always includes diagnostic endoscopy. 37500

Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) (For open procedure, use 37760)

37501

Unlisted vascular endoscopy procedure

LIGATION (For phleborraphy and arteriorraphy, see 35201-35286) (For bilateral procedures for 37650, 37700, 37718, 37722, 37735, 37780, 37785 use modifier -50) 37565 37600 37605 37606

Ligation, internal jugular vein Ligation; external carotid artery internal or common carotid artery internal or common carotid artery, with gradual occlusion, as with Selverstone or Crutchfield clamp (For transcatheter permanent arterial occlusion or embolization, see 61624 61626) (For endovascular temporary arterial balloon occlusion, use 61623) (For ligation treatment of intracranial aneurysm, use 61703)

37607 37609 37615 37616 37617 37618 37620

Ligation or banding of angioaccess arteriovenous fistula Ligation or biopsy, temporal artery Ligation, major artery (eg, post-traumatic, rupture); neck chest abdomen extremity Interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip, extravascular,intravascular (umbrella device) (For radiological supervision and interpretation, use 75940)

37650 37660 37700

Ligation of femoral vein Ligation of common iliac vein Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions (Do not report 37700 in conjunction with 37718, 37722)

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37718

Ligation, division and stripping, short saphenous vein (Do not report 37718 in conjunction with 37735, 37780)

37722

Ligation, division and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below (Do not report 37722 in conjunction with 37700, 37735) (For ligation, division, and stripping of the greater saphenous vein, use 37722) (For ligation, division, and stripping of the short saphenous vein, use 37718)

37735

Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia (Do not report 37735 in conjunction with 37700, 37718, 37722, 37780)

37760

Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open (For endoscopic procedure, use 37500)

37765

Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions (For less than 10 incisions, use 37799)

37766 37780 37785

more than 20 incisions Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) Ligation, division, and/or excision of recurrent or secondary varicose veins (clusters), one leg

OTHER PROCEDURES 37788 37790 37799

Penile revascularization, artery, with or without vein graft (Report required) Penile venous occlusive procedure Unlisted procedure, vascular surgery

HEMIC AND LYMPHATIC SYSTEMS SPLEEN EXCISION 38100 38101 38102

Splenectomy; total (separate procedure) partial total, en bloc for extensive disease, in conjunction with other procedure (List in addition to primary procedure)

REPAIR 38115

Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy

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LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 38120 38129

Laparoscopy, surgical, splenectomy Unlisted laparoscopy procedure, spleen

INTRODUCTION 38200

Injection procedure for splenoportography (For radiological supervision and interpretation, use 75810)

GENERAL BONE MARROW OR STEM CELL SERVICES/PROCEDURES 38220 38221 38230 38240 38241 38242

Bone marrow; aspiration only biopsy, needle or trocar (For bone marrow biopsy interpretation, use 88305) Bone marrow harvesting for transplantation Bone marrow or blood-derived peripheral stem cell transplantation; allogenic autologous allogeneic donor lymphocyte infusions

LYMPH NODES AND LYMPHATIC CHANNELS INCISION 38300 38305 38308 38380 38381 38382

Drainage of lymph node abscess or lymphadenitis; simple extensive Lymphangiotomy or other operations on lymphatic channels Suture and/or ligation of thoracic duct; cervical approach thoracic approach abdominal approach

EXCISION (For injection for sentinel node identification, use 38792) 38500 38505

Biopsy or excision of lymph node(s); open, superficial (Do not report 38500 with 38700-38780) by needle, superficial (eg, cervical, inguinal, axillary) (If imaging guidance is performed, see 76942, 77012, 77021) (For fine needle aspiration, use 10021, 10022)

38510 38520 38525

open, deep cervical node(s) open, deep cervical node(s) with excision scalene fat pad open, deep axillary node(s)

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38530

open, internal mammary node(s) (separate procedure) (Do not report 38530 with 38720-38746) (For percutaneous needle biopsy, retroperitoneal lymph node or mass, use 49180. For fine needle aspiration, use 10022)

38542

Dissection, deep jugular node(s) (For radical cervical neck dissection, use 38720)

38550 38555

Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection with deep neurovascular dissection

LIMITED LYMPHADENECTOMY FOR STAGING 38562

Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic (When combined with prostatectomy, use 55812 or 55842) (When combined with insertion of radioactive substance into prostate, use 55862)

38564

retroperitoneal (aortic and/or splenic)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 38570 38571 38572

Laparoscopy,surgical;with retroperitoneal lymph node sampling (biopsy), single or multiple with bilateral total pelvic Lymphadenectomy with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy) single or multiple (For drainage of lymphocele to peritoneal cavity, use 49323)

38589

Unlisted laparoscopy procedure, lymphatic system

RADICAL LYMPHADENECTOMY (RADICAL RESECTION OF LYMPH NODES) (For limited pelvic and retroperitoneal lymphadenectomies, see 38562, 38564) (For bilateral procedures for 38700, 38720, 38760, 38765, 38770, use modifier -50) 38700 38720 38724 38740 38745 38746

Suprahyoid lymphadenectomy Cervical lymphadenectomy (complete) Cervical lymphadenectomy (modified radical neck dissection) Axillary lymphadenectomy; superficial complete Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes (List separately in addition to primary procedure)

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See Also

#kinoshita hisashi | courtsidescenarios

38747

Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to primary procedure)

38760

Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure) Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure)

38765

38770 38780

(For excision and repair of lymphedematous skin and subcutaneous tissue, see 15004-15005, 15570-15650) INTRODUCTION 38790

Injection procedure; lymphangiography (For bilateral procedure, report 38790 with modifier 50) (For radiological supervision and interpretation, see 75801-75807)

38792

for identification of sentinel node (For excision of sentinel node, see 38500-38542) (For nuclear medicine lymphatics and lymph gland imaging, use 78195)

38794 38999

Cannulation, thoracic duct (Report required) Unlisted procedure, hemic or lymphatic system

MEDIASTINUM AND DIAPHRAGM MEDIASTINUM INCISION 39000 39010

Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach transthoracic approach, including either transthoracic or median sternotomy

EXCISION 39200 39220

Excision of mediastinal cyst Excision of mediastinal tumor (For substernal thyroidectomy, use 60270) (For thymectomy, use 60520)

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ENDOSCOPY 39400

Mediastinoscopy, with or without biopsy

OTHER PROCEDURES 39499

Unlisted procedure, mediastinum

DIAPHRAGM REPAIR (For transabdominal repair of diaphragmatic (esophageal hiatal) hernia, see 43324, 43325) 39501 39502 39503

39520 39530 39531 39540 39541 39545 39560 39561

Repair, laceration of diaphragm, any approach Repair, paraesophageal hiatus hernia, transabdominal, with or without fundoplasty, vagotomy, and/or pyloroplasty, except neonatal Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia (Do not report modifier 63 in conjunction with 39503) Repair, diaphragmatic hernia (esophageal hiatal); transthoracic combined, thoracoabdominal combined, thoracoabdominal, with dilation of stricture (with or without gastroplasty) Repair, diaphragmatic hernia (other than neonatal), traumatic; acute chronic Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic Resection, diaphragm, with simple repair (eg, primary suture) with complex repair (eg, prosthetic material, local muscle flap)

OTHER PROCEDURES 39599

Unlisted procedure, diaphragm

DIGESTIVE SYSTEM LIPS (For procedures on skin of lips, see 10060 et seq) EXCISION 40490 40500 40510 40520

Biopsy of lip Vermilionectomy (lip shave), with mucosal advancement Excision of lip; transverse wedge excision with primary closure V-excision with primary direct linear closure (For excision of mucous lesions, see 40810-40816)

40525 40527

full thickness, reconstruction with local flap (eg, Estlander or fan) full thickness, reconstruction with cross lip flap (Abbe-Estlander)

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40530

Resection lip, more than one-fourth, without reconstruction (For reconstruction, see 13131 et seq)

REPAIR (CHEILOPLASTY) 40650 40652 40654 40700 40701 40702 40720

Repair lip, full thickness; vermilion only up to half vertical height over one-half vertical height, or complex Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral primary bilateral, one stage procedure primary bilateral, one of two stages secondary, by recreation of defect and reclosure (For bilateral procedure, use modifier -50) (To report rhinoplasty only for nasal deformity secondary to congenital cleft lip, see 30460, 30462) (For repair of cleft lip, with cross lip pedicle flap (Abbe-Estlander type), use 40527)

40761

with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle (For repair cleft palate, see 42200 et seq) (For other reconstructive procedures, see 14060, 14061, 15120-15261, 15574, 15576, 15630)

OTHER PROCEDURES 40799

Unlisted procedure, lips

VESTIBULE OF MOUTH The vestibule is the part of the oral cavity outside the dentoalveolar structures, including the mucosal and submucosal tissue of lips and cheeks. INCISION 40800 40801 40804 40805 40806

Drainage of abscess, cyst, hematoma, vestibule of mouth; simple complicated Removal of embedded foreign body; vestibule of mouth; simple complicated (Report required) Incision of labial frenum (frenotomy)

EXCISION, DESTRUCTION 40808 40810 40812 40814 40816 40818

Biopsy, vestibule of mouth Excision of lesion of mucosa and submucosa vestibule of mouth; without repair with simple repair with complex repair complex with excision of underlying muscle Excision of mucosa of vestibule of mouth as donor graft (Report required)

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40819 40820

Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Destruction of lesion or scar by physical methods (eg, laser, thermal, cryo, chemical)

REPAIR 40830 40831 40840 40842 40843 40844 40845

Closure of laceration, vestibule of mouth; 2.5 cm or less over 2.5 cm or complex Vestibuloplasty; anterior posterior, unilateral (Report required) posterior, bilateral (Report required) entire arch (Report required) complex (including ridge extension, muscle repositioning) (For skin grafts, see 15002 et seq)

OTHER PROCEDURES 40899

Unlisted procedure, vestibule of mouth

TONGUE AND FLOOR OF MOUTH INCISION 41000 41005 41006 41007 41008 41009 41010 41015 41016 41017 41018

Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual sublingual, superficial sublingual, deep, supramylohyoid submental space submandibular space masticator space Incision of lingual frenum (frenotomy) Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual submental submandibular masticator space (For frenoplasty,use 41520)

41019

Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application (For imaging guidance, see 76942, 77002, 77012, 77021) (For stereotactic insertion of intracranial brachytherapy radiation sources, use 61770) (For interstitial radioelement application, see 77776-77784)

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EXCISION 41100 41105 41108 41110 41112 41113 41114

Biopsy of tongue; anterior two-thirds posterior one-third Biopsy of floor of mouth Excision of lesion of tongue without closure Excision of lesion of tongue with closure; anterior two-thirds posterior one-third with local tongue flap (Report required) (List 41114 in addition to code 41112 or 41113)

41115 41116 41120 41130 41135 41140

Excision of lingual frenum (frenectomy) Excision, lesion of floor of mouth Glossectomy; less than one-half tongue hemiglossectomy partial, with unilateral radical neck dissection complete or total, with or without tracheostomy, without radical neck dissection complete or total, with or without tracheostomy, with unilateral radical neck dissection composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection composite procedure with resection floor of mouth, with suprahyoid neck dissection composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type)

41145 41150 41153 41155 REPAIR 41250 41251 41252

Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue posterior one-third of tongue Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex

OTHER PROCEDURES 41500 41510 41520

Fixation of tongue, mechanical, other than suture (eg, K-wire) (Report required) Suture of tongue to lip for micrognathia (Douglas type procedure) Frenoplasty (surgical revision of frenum, eg, with Z-plasty) (For frenotomy, see 40806, 41010)

41599

Unlisted procedure, tongue, floor of mouth

DENTOALVEOLAR STRUCTURES INCISION 41800 41805 41806

Drainage of abscess, cyst, hematoma from dentoalveolar structures Removal of embedded foreign body from dentoalveolar structures; soft tissues bone

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EXCISION, DESTRUCTION 41820 41821 41822 41823 41825 41826 41827

Gingivectomy, excision gingiva, each quadrant (Report required) Operculectomy, excision pericoronal tissues (Report required) Excision of fibrous tuberosities, dentoalveolar structures (Report required) Excision of osseous tuberosities, dentoalveolar structures (Report required) Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair (Report required) with simple repair (Report required) with complex repair (For nonexcisional destruction, use 41850)

41828 41830 41850

Excision of hyperplastic alveolar mucosa, each quadrant (specify) (Report required) Alveolectomy, including curettage of osteitis or sequestrectomy Destruction of lesion (except excision), dentoalveolar structures (Report required)

OTHER PROCEDURES 41870 41872 41874

Periodontal mucosal grafting (Report required) Gingivoplasty, each quadrant (specify) (Report required) Alveoloplasty each quadrant (specify) (For closure of lacerations, see 40830, 40831) (For segmental osteotomy, use 21206) (For reduction of fractures, see 21421-21490)

41899

Unlisted procedure, dentoalveolar structures

PALATE AND UVULA INCISION 42000

Drainage of abscess of palate, uvula

EXCISION, DESTRUCTION 42100 42104 42106 42107

Biopsy of palate, uvula Excision, lesion of palate, uvula; without closure with simple primary closure with local flap closure (Report required) (For skin graft, see 14040-14300) (For mucosal graft, use 40818)

42120

Resection of palate or extensive resection of lesion (For reconstruction of palate with extraoral tissue, see 14040-14300,15050, 15120, 15240, 15576)

42140 42145

Uvulectomy, excision of uvula Palatopharyngoplasty eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

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(For removal of exostosis of the bony palate, see 21031, 21032) 42160

Destruction of lesion, palate or uvula (thermal, cryo or chemical)

REPAIR 42180 42182 42200 42205 42210 42215 42220 42225 42226 42227 42235

Repair, laceration of palate; up to 2 cm over 2 cm or complex Palatoplasty for cleft palate, soft and/or hard palate only Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only with bone graft to alveolar ridge (includes obtaining graft) Palatoplasty for cleft palate; major revision secondary lengthening procedure attachment pharyngeal flap Lengthening of palate, and pharyngeal flap Lengthening of palate, with island flap Repair of anterior palate, including vomer flap (For repair of oronasal fistula, use 30600)

42260

Repair of nasolabial fistula (For repair of cleft lip, see 40700 et seq)

OTHER PROCEDURES 42299

Unlisted procedure, palate, uvula

SALIVARY GLANDS AND DUCTS INCISION 42300 42305 42310 42320 42330 42335 42340

Drainage of abscess; parotid, simple parotid, complicated submaxillary or sublingual, intraoral submaxillary, external Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral submandibular (submaxillary), complicated, intraoral parotid, extraoral or complicated intraoral

EXCISION (If imaging guidance is performed for 42400, 42405, see 76942, 77002, 77012, 77021) 42400

Biopsy of salivary gland; needle (For fine needle aspiration, see 10021, 10022)

42405 42408

incisional Excision of sublingual salivary cyst (ranula)

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42409 42410 42415 42420 42425 42426

Marsupialization of sublingual salivary cyst (ranula) Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection lateral lobe, with dissection and preservation of facial nerve total, with dissection and preservation of facial nerve total, en bloc removal with sacrifice of facial nerve total, with unilateral radical neck dissection (For suture or grafting of facial nerve, see 64864, 64865, 69740, 69745)

42440 42450

Excision of submandibular (submaxillary) gland Excision of sublingual gland

REPAIR 42500 42505 42507 42508 42509 42510

Plastic repair of salivary duct, sialodochoplasty; primary or simple secondary or complicated Parotid duct diversion, bilateral (Wilke type procedure); (Report required) with excision of one submandibular gland (Report required) with excision of both submandibular glands (Report required) with ligation of both submandibular (Wharton's) ducts

OTHER PROCEDURES 42550

Injection procedure for sialography (For radiological supervision and interpretation, use 70390)

42600 42650 42660 42665 42699

Closure salivary fistula Dilation salivary duct Dilation and catheterization of salivary duct, with or without injection Ligation salivary duct, intraoral Unlisted procedure, salivary glands or ducts

PHARYNX, ADENOIDS, AND TONSILS INCISION 42700 42720 42725

Incision and drainage abscess; peritonsillar retropharyngeal or parapharyngeal, intraoral approach retropharyngeal or parapharyngeal, external approach

EXCISION, DESTRUCTION 42800 42802 42804 42806

Biopsy; oropharynx hypopharynx nasopharynx, visible lesion, simple nasopharynx, survey for unknown primary lesion (For laryngoscopic biopsy, see 31510, 31535, 31536)

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42808 42809 42810 42815 42820 42821 42825 42826 42830 42831 42835 42836 42842 42844 42845

Excision or destruction of lesion of pharynx, any method Removal of foreign body from pharynx Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx Tonsillectomy and adenoidectomy; under age 12 age 12 or over Tonsillectomy, primary or secondary; under age 12 age 12 or over Adenoidectomy, primary; under age 12 age 12 or over Adenoidectomy, secondary; under age 12 age 12 or over Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure closure with local flap (eg, tongue, buccal) closure with other flap (For closure with other flap(s), use appropriate number for flap(s)) (When combined with radical neck dissection, use also 38720).

42860 42870

Excision of tonsil tags Excision or destruction lingual tonsil, any method (separate procedure) (For resection of the nasopharynx (eg, juvenile angiofibroma) by bicoronal and/or transzygomatic approach, see 61586 and 61600)

42890 42892

Limited pharyngectomy Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls (When combined with radical neck dissection, use also 38720)

42894

Resection of pharyngeal wall requiring closure with myocutaneous flap (When combined with radical neck dissection, use also 38720) (For limited pharyngectomy with radical neck dissection, use 38720 with 42890)

REPAIR 42900 42950

Suture pharynx for wound or injury Pharyngoplasty (plastic or reconstructive operation on pharynx) (For pharyngeal flap, use 42225)

42953

Pharyngoesophageal repair (For closure with myocutaneous or other flap, use appropriate number in addition)

OTHER PROCEDURES 42955

Pharyngostomy (fistulization of pharynx, external for feeding)

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42960 42961 42962 42970

42971 42972 42999

Control oropharyngeal hemorrhage primary or secondary (eg, post-tonsillectomy); simple complicated, requiring hospitalization with secondary surgical intervention Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery complicated, requiring hospitalization with secondary surgical intervention Unlisted procedure, pharynx, adenoids, or tonsils

ESOPHAGUS INCISION (For esophageal intubation with laparotomy, use 43510) 43020 43030 43045

Esophagotomy, cervical approach, with removal of foreign body Cricopharyngeal myotomy Esophagotomy, thoracic approach, with removal of foreign body

EXCISION (For gastrointestinal reconstruction for previous esophagectomy, see 43360, 43361) 43100 43101

Excision of lesion, esophagus, with primary repair; cervical approach thoracic or abdominal approach (For wide excision of malignant lesion of cervical esophagus, with total laryngectomy without radical neck dissection, see 43107, 43116, 43124, and 31360) (For wide excision of malignant lesion of cervical esophagus, with total laryngectomy with radical neck dissection, see 43107, 43116, 43124, and 31365)

43107

43108 43112 43113 43116

Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal) with colon interposition or small intestine reconstruction, including intestine mobilization, preparation and anastomosis(es) Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction (For free jejunal graft with mircovascular anastomosis perfomed by another physician, use 43496)

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43117

43118

Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis) with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) (For total esophagectomy with gastropharyngostomy, see 43107, 43124) (For esophagogastrectomy (lower third) and vagotomy, use 43122)

43121

43122 43123 43124 43130 43135

Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy,with thoracic esophagogastrostomy, with or without pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, with or without pyloroplasty with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Total or partial esophagectomy, without reconstruction (any approach),with cervical esophagostomy Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach thoracic approach

ENDOSCOPY For endoscopic procedures, code appropriate endoscopy of each anatomic site examined. Surgical endoscopy always includes diagnostic endoscopy. (Do not report 43232, 43237, 43238, 43242 in conjunction with 76942, 76975) 43200 43201

Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with directed submucosal injection(s), any substance (For injection sclerosis of esophageal varcies, use 43204)

43202 43204 43205 43215

with biopsy, single or multiple with injection sclerosis of esophageal varices with band ligation of esophageal varcies with removal of foreign body (For radiological supervision and interpretation, use 74235)

43216

with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with insertion of plastic tube or stent with balloon dilation (less than 30 mm diameter)

43217 43219 43220

(If imaging guidance is performed, use 74360) (For endoscopic dilation with balloon 30 mm diameter or larger, use 43458) (For dilation without visualization, see 43450-43453)

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(For diagnostic fiberoptic esophagogastroscopy, use 43200, 43235) (For fiberoptic esophagogastroscopy with biopsy or collection of specimen, use 43200, 43202, 43235, 43239) (For fiberoptic esophagogastroscopy with removal of polyp(s), use 43217, 43251) (For fiberoptic esophagogastroscopy with removal of foreign body, use 43215, 43247) 43226

with insertion of guide wire followed by dilation over guide wire (For radiological supervision and interpretation, use 74360)

43227

43228

(For esophagoscopic photodynamic therapy, report 43228 in addition to 96570, 96571 as appropriate) 43231 43232 43234 43235

43236

with endoscopic ultrasound examination (Do not report 43231 in conjunction with 76975) with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) Upper gastrointestinal endoscopy, simple primary examination (eg, with small diameter flexible endoscope) (separate procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with directed submucosal injection(s), any substance (For injection sclerosis of esophageal and/or gastric varices, use 43243)

43237 43238

43239 43240 43241 43242

with endoscopic ultrasound examination limited to the esophagus with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) with biopsy, single or multiple with transmural drainage of pseudocyst with transendoscopic intraluminal tube or catheter placement with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) (For transendoscopic fine needle aspiration/biopsy limited to esophagus, use 43238)

43243 43244

with injection sclerosis of esophageal and/or gastric varices with band ligation of esophageal and/or gastric varices

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43245

with dilation of gastric outlet for obstruction (eg, balloon, guide wire, bougie) (Do not report 43245 in conjunction with 43256)

43246

with directed placement of percutaneous gastrostomy tube (For nonendoscopic percutaneous placement of gastrostomy tube, see 49440)

43247

with removal of foreign body (For radiological supervision and interpretation, use 74235)

43248

with insertion of guide wire followed by dilation of esophagus over guide wire with balloon dilation of esophagus (less than 30 mm diameter) with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with control of bleeding, any method with transendoscopic stent placement (includes predilation) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

43249 43250 43251 43255 43256 43258

(For injection sclerosis of esophageal varices, use 43204 or 43243) 43259

with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate (Do not report 43259 in conjunction with 76975) (For radiological supervision and interpretation for 43260, 43261, 43262, 43263, 43264, 43265, 43267, 43268, 43269, 43271, 43272 see 74328, 74329, 74330)

43260

43261 43262 43263

Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) (For radiological supervision and interpretation, see 74328, 74329, 74330) with biopsy, single or multiple with sphincterotomy/papillotomy with pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct) (For 43264, 43265, 43267, 43268, 43269, 43271, when done with sphincterotomy, also use 43262)

43264 43265 43267

with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method with endoscopic retrograde insertion of nasobiliary or nasopancreatic drainage tube

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43268 43269 43271 43272

with endoscopic retrogade insertion of tube or sent into bile or pancreatic duct with endoscopic retrograde removal of foreign body and/or change of tube or stent with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct(s) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 43280

Laparascopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) (For open approach, use 43324)

43289

Unlisted laparoscopy procedure, esophagus

REPAIR 43300 43305 43310 43312 43313

43314

Esophagoplasty, (plastic repair or reconstruction), cervical approach; without repair of tracheoesophageal fistula with repair of tracheoesophageal fistula Esophagoplasty, (plastic repair or reconstruction), thoracic approach; without repair of tracheoesophageal fistula with repair of tracheoesophageal fistula Esophagoplasty for congenital defect, (plastic repair or reconstruction), thoracic approach, without repair of congenital tracheoesophageal fistula (Report required) with repair of congenital tracheoesophageal fistula (Report required) (Do not report modifier –63 in conjunction with 43313, 43314)

43320 43324 43325

Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty, transabdominal or transthoracic approach Esophagogastric fundoplasty (eg, Nissen, Belsey IV, Hill procedures) (For laparoscopic procedure, use 43280) Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure) (For cricopharyngeal myotomy, see 43030)

43326 43330 43331

with gastroplasty (eg, Collis) Esophagomyotomy (Heller type); abdominal approach thoracic approach (For thoracoscopic esophagomyotomy, use 32665)

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43340 43341 43350 43351 43352 43360

43361 43400 43401 43405 43410 43415 43420 43425

Esophagojejunostomy (without total gastrectomy); abdominal approach thoracic approach Esophagostomy, fistulization of esophagus, external; abdominal approach thoracic approach cervical approach Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with stomach, with or without pyloroplasty with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Ligation, direct, esophageal varices Transection of esophagus with repair, for esophageal varices Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation Suture of esophageal wound or injury; cervical approach (Report required) transthoracic or transabdominal approach Closure of esophagostomy or fistula; cervical approach transthoracic or transabdominal approach (For repair of esophageal hiatal hernia, see 39520 et seq)

MANIPULATION (For associated esophagogram, use 74220) (For radiological supervision and interpretation for 43450, 43453, 43456, 43458 use 74360) 43450 43453

Dilation of esophagus; by unguided sound or bougie, single or multiple passes over guide wire (For dilation with direct visualization, use 43220) (For dilation of esophagus, by balloon or dilator, see 43220, 43458, and 74360)

43456 43458

by balloon or dilator, retrograde with balloon (30 mm diameter or larger) for achalasia (For dilation with balloon less than 30 mm diameter, see 43220)

43460

Esophagogastric tamponade, with balloon (Sengstaaken type) (For removal of esophageal foreign body by balloon catheter, see 43215, 43247, 74235)

OTHER PROCEDURES 43496 43499

Free jejunum transfer with microvascular anastomosis Unlisted procedure, esophagus

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STOMACH INCISION 43500 43501 43502 43510 43520

Gastrotomy; with exploration or foreign body removal with suture repair of bleeding ulcer with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss) with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin) Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation) (Do not report modifier 63 in conjunction with 43520)

EXCISION 43600 43605 43610 43611 43620 43621 43622 43631 43632 43633 43634 43635

Biopsy of stomach; by capsule, tube, peroral (one or more specimens) by laparotomy Excision, local; ulcer or benign tumor of stomach malignant tumor of stomach Gastrectomy, total; with esophagoenterostomy with Roux-en-Y reconstruction with formation of intestinal pouch, any type Gastrectomy, partial, distal; with gastroduodenostomy with gastrojejunostomy with Roux-en-Y reconstruction with formation of intestinal pouch (Report required) Vagotomy when performed with partial distal gastrectomy (List separately in addition to code(s) for primary procedure) (Use 43635 in conjunction with 43631, 43632, 43633, 43634)

43640

Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective (For pyloroplasty, use 43800) (For vagotomy, see 64752-64760)

43641

parietal cell (highly selective) (For upper gastrointestinal endoscopy, see 43234-43259)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. (For upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum, see 43235-43259) 43644

Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) (Do not report 43644 in conjunction with 43846, 49320) (For greater than 150 cm, use 43645) (For open procedure, use 43846)

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43645

with gastric bypass and small intestine reconstruction to limit absorption (Do not report 43645 in conjunction with 49320, 43847)

43651 43652 43653

Laparoscopy, surgical; transection of vagus nerves, truncal transection of vagus nerves, selective or highly selective gastrostomy, without construction of gastric tube (eg, Stamm procedure) (separate procedure) Unlisted laparoscopy procedure, stomach

43659

INTRODUCTION To report percutaneous gastrostomy tube insertion, use 43246) 43752

Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report) (Do not report 43752 in conjunction with critical care codes 99291-99292, neonatal critical care codes 99295-99296, pediatric critical care codes 9929399294 or low birth weight intensive care service codes 99298-99299) (For percutaneous placement of gastrostomy tube, use 49440) (For enteric tube placement, see 44500, 74340)

43760

Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance (To report fluoroscopically guided gastrostomy, use 49450) (For endoscopic placement of gastrostomy tube, see 43246)

43761

Repositioning of the gastric feeding tube, through the duodenum for enteric nutrition (Do not report 43761 in conjunction with 44500, 49446) (If imaging guidance is performed, use 76000) (For placement of a long gastrointestinal tube into the duodenum, use 44500) (For endoscopic conversion of a gastrostomy tube to jejunostomy tube, use 44373)

BARIATRIC SURGERY Bariatric surgical procedures may involve the stomach, duodenum, jejunum, and/or the ileum. LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (separate procedure), use 49320. Typical postoperative follow-up care after gastric restriction using the adjustable gastric band technique includes subsequent band adjustment(s) through the postoperative period for the typical patient. Band adjustment refers to changing the gastric band component diameter by injection or aspiration of fluid through the subcutaneous port component.

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43770

Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) (For individual component placement, report 43770 with modifier 52)

43771 43772 43773

revision of adjustable gastric restrictive device component only removal of adjustable gastric restrictive component only removal and replacement of adjustable gastric restrictive device component only (Do not report 43773 in conjunction with 43772)

43774

removal of adjustable gastric restrictive device and subcutaneous port components (For removal and replacement of both gastric band and subcutaneous port components, use 43659)

OTHER PROCEDURES 43800

Pyloroplasty (For pyloroplasty and vagotomy, use 43640)

43810 43820 43825 43830 43831

Gastroduodenostomy Gastrojejunostomy; without vagotomy with vagotomy, any type Gastrostomy, open; without construction of gastric tube (eg, Stamm procedure) (separate procedure) neonatal, for feeding (Do not report modifier –63 in conjunction with 43831) (For change of gastrostomy tube, use 43760)

43832

with construction of gastric tube (eg, Janeway procedure) (For percutaneous endoscopic gastrostomy, use 43246)

43840 43842 43843 43845

43846

Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty other than vertical-banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) (Report required) (Do not report 43845 in conjunction with 43633, 43847, 44130, 49000) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy (For laparoscopic procedure, use 43644) (For greater than 150 cm, use 43847)

43847

with small intestine reconstruction to limit absorption

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43848

Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) (For laparoscopic adjustable gastric restrictive procedures, see 43770-43774) (For gastric restrictive port procedures, see 43886-43888)

43850 43855 43860 43865 43870 43880 43886 43887 43888

Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy with vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy with vagotomy Closure of gastrostomy, surgical Closure of gastrocolic fistula Gastric restrictive procedure, open; revision of subcutaneous port component only removal of subcutaneous port component only removal and replacement of subcutaneous port component only (Do not report 43888 in conjunction with 43774, 43887) (For laparoscopic removal of both gastric band and subcutaneous port components, use 43774) (For removal and replacement of both gastric band and subcutaneous port components, use 43659)

43999

Unlisted procedure, stomach

INTESTINES (EXCEPT RECTUM) INCISION 44005

Enterolysis (freeing of intestinal adhesion) (separate procedure) (Do not report 44005 in addition to 45136) (For laparoscopic approach, use 44180)

44010 44015

Duodenotomy, for exploration, biopsy(s), or foreign body removal Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary procedure)

44020

Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s), or foreign body removal for decompression (eg, Baker tube) Colotomy, for exploration, biopsy(s), or foreign body removal

44021 44025

(For exteriorization of intestine (Mikulicz resection with crushing of spur), see 44602-44605) 44050 44055

Reduction of volvulus, intussusception, internal hernia, by laparotomy Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd procedure) (Do not report modifier 63 in conjunction with 44055)

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EXCISION 44100 44110 44111 44120 44121

44125 44126 44127 44128

Biopsy of intestine by capsule, tube, peroral (one or more specimens) Excision of one or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; single enterotomy multiple enterotomies Enterectomy, resection of small intestine; single resection and anastomosis (Do not report 44120 in addition to 45136) each additional resection and anastomosis (List separately in addition to primary procedure) (Use 44121 in conjunction with 44120) with enterostomy Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine, without tapering with tapering each additional resection and anastomosis (List separately in addition to primary procedure) (Use 44128 in conjunction with 44126, 44127) (Do not report modifier 63 in conjunction with 44126, 44127, 44128)

44130 44133 44135 44136 44137

Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separate procedure) Donor enterectomy, open, (with preparation and maintenance of allograft); partial, from living donor Intestinal allotransplantation; from cadavor donor from living donor Removal of transplanted intestinal allograft, complete (Report required) (For partial removal of transplant allograft, see 44120, 44121, 44140)

44139

Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure) (Use 44139 only for codes 44140-44147)

44140 44141

Colectomy, partial; with anastomosis with skin level cecostomy or colostomy (For laparoscopic procedure, use 44204)

44143

with end colostomy and closure of distal segment (Hartmann type procedure) (For laparoscopic procedure, use 44206)

44144 44145

with resection, with colostomy or ileostomy and creation of mucofistula with coloproctostomy (low pelvic anastomosis) (For laparoscopic procedure, use 44207)

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44146

with coloproctostomy (low pelvic anastomosis), with colostomy (For laparoscopic procedure, use 44208)

44147 44150

abdominal and transanal approach Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy (For laparoscopic procedure, use 44210)

44151 44155

with continent ileostomy Colectomy, total, abdominal, with proctectomy; with ileostomy (For laparoscopic procedure, use 44212)

44156 44157

with continent ileostomy with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed (For laparoscopic procedure, use 44211)

44158

44160

Colectomy, partial, with removal of terminal ileum with ileocolostomy

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. INCISION 44180

Laparoscopy, surgical; enterolysis (freeing of intestinal adhesion) (separate procedure) (For laparoscopy with salpingolysis, ovariolysis, use 58660)

ENTEROSTOMY-EXTERNAL FISTULIZATION OF INTESTINES 44186 44187

Laparoscopy, surgical; jejunostomy (eg, for decompression or feeding) ileostomy or jejunostomy, non-tube (For open procedure, use 44310)

44188

Laparoscopy, surgical, colostomy or skin level cecostomy (Do not report 44188 in conjunction with 44970) (For open procedure, use 44320)

EXCISION 44202 44203

Laparoscopy, surgical;enterectomy, resection of small intestine, single resection and anastomosis each additional small intestine resection and anastomosis (List separately in addition to primary procedure) (Use 44203 in conjunction with code 44202) (For open procedure, see 44120, 44121)

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44204

colectomy, partial, with anastomosis (For open procedure, use 44140)

44205

colectomy, partial, with removal of terminal ileum with ileocolostomy (For open procedure, use 44160)

44206

colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure) (For open procedure, use 44143)

44207

colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) (For open procedure, use 44145)

44208

colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy (For open procedure, use 44146)

44210

colectomy, total, abdominal, without protectomy, with ileostomy or ileoproctostomy (For open procedure, use 44150)

44211

colectomy, total, abdominal, with protectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when performed (For open procedure, see 44157, 44158)

44212

colectomy, total, abdominal, with proctectomy, with ileostomy (For open procedure, use 44155)

44213

Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure) (Use 44213 in conjunction with 44204-44208) (For open procedure, use 44139)

REPAIR 44227

Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection and anastomosis (For open procedure, see 44625, 44626)

OTHER PROCEDURES 44238

Unlisted laparoscopy procedure, intestine (except rectum)

ENTEROSTOMY - EXTERNAL FISTULIZATION OF INTESTINES 44300

Placement, enterostomy, or cecostomy, tube open (eg, for feeding or decompression) (separate procedure)

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(For percutaneous placement of duodenostomy, jejunostomy, gastro-jejunostomy or cecostomy [or other colonic] tube including fluoroscopic imaging guidance, see 49441-49442) 44310

Ileostomy or jejunostomy, non-tube (For laparoscopic procedure, use 44187) (Do not report 44310 in conjunction with 44144, 44150-44151, 44155, 44156, 45113, 45119, 45136)

44312 44314 44316

Revision of ileostomy; simple (release of superficial scar) (separate procedure) complicated (reconstruction in depth) (separate procedure) Continent ileostomy (Kock procedure) (separate procedure) (For fiberoptic evaluation, use 44385)

44320

Colostomy or skin level cecostomy; (For laparoscopic procedure, use 44188) (Do not report 44320 in conjunction with 44141, 44144, 44146, 44605, 45110, 45119, 45126, 45563, 45805, 45825, 50810, 51597, 57307, or 58240)

44322 44340 44345 44346

with multiple biopsies (eg, for congenital megacolon) (separate procedure) Revision of colostomy; simple (release of superficial scar) (separate procedure) complicated (reconstruction in depth) (separate procedure) with repair of paracolostomy hernia (separate procedure)

ENDOSCOPY, SMALL INTESTINE AND STOMAL Surgical endoscopy always includes diagnostic endoscopy. (For upper gastrointestinal endoscopy, see 43234-43258) 44360

44361 44363 44364 44365 44366 44369 44370 44372 44373

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with biopsy, single or multiple with removal of foreign body with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with control of bleeding, (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique with transendoscopic stent placement (includes predilation) with placement of percutaneous jejunostomy tube with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube (For fiberoptic jejunostomy through stoma, use 43235)

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44376

44377 44378 44379 44380 44382 44383 44385

44386 44388 44389 44390 44391 44392 44393 44394

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with biopsy, single or multiple with control of bleeding, (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with transendonscopic stent placement (includes predilation) Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with biopsy, single or multiple with transendoscopic stent placement (inlcudes predilation) Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with biopsy, single or multiple Colonscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with biopsy, single or multiple with removal of foreign body with control of bleeding,(eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) (Report required) with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique with removal of tumor(s), polyp(s), or other lesion(s) by snare techniques (For colonoscopy per rectum, see 45330-45385)

44397

with transendoscopic stent placement (includes predilation)

INTRODUCTION 44500

Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure) (For radiological supervision and interpretation, see 74340) (For naso- or oro-gastric tube placement, use 43752)

REPAIR 44602 44603 44604 44605 44615

Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury, or rupture; single perforation multiple perforations Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy with colostomy Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction

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44620 44625 44626

Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal with resection and colorecta anastomosis (eg, closure of Hartmann type procedure) (For laparoscopic procedure, use 44227)

44640 44650 44660 44661

Closure of intestinal cutaneous fistula Closure of enteroenteric or enterocolic fistula Closure of enterovesical fistula; without intestinal or bladder resection with intestine and/or bladder resection (For closure of renocolic fistula, see 50525, 50526) (For closure of gastrocolic fistula, use 43880) (For closure of rectovesical fistula, see 45800, 45805)

44680

Intestinal plication (separate procedure)

OTHER PROCEDURES 44700 44701

44799

Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum) Intraoperative colonic lavage (List separately in addition to primary procedure) (Use 44701 in conjunction with 44140, 44145, 44150, or 44604 as appropriate) (Do not report 44701 in conjunction with 44300, 44950-44960) Unlisted procedure, intestine (For unlisted laparoscopic procedure, intestine except rectum, use 44238)

MECKEL’S DIVERTICULUM AND THE MESENTERY EXCISION 44800 44820

Excision of Meckel's diverticulum (diverticulectomy) or omphalomesenteric duct Excision of lesion of mesentery (separate procedure) (With intestine resection, see 44120 or 44140 et seq)

SUTURE 44850

Suture of mesentery (separate procedure) (For reduction and repair of internal hernia, use 44050)

OTHER PROCEDURES 44899

Unlisted procedure, Meckel's diverticulum and the mesentery

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APPENDIX INCISION 44900 44901

Incision and drainage of appendiceal abscess; open percutaneous (For radiological supervision and interpretation, use 75989)

EXCISION 44950

Appendectomy; (Incidental appendectomy during intra-abdominal surgery does not warrant a separate identification)

44955

when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to primary procedure)

44960

for ruptured appendix with abscess or generalized peritonitis

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 44970 44979

Laparoscopy, surgical, appendectomy Unlisted laparoscopy procedure, appendix

RECTUM INCISION 45000 45005 45020

Transrectal drainage of pelvic abscess Incision and drainage of submucosal abscess, rectum Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess (See also 46050, 46060)

EXCISION 45100

Biopsy of anorectal wall, anal approach (eg, congenital megacolon) (For endoscopic biopsy, use 45305)

45108 45110

Anorectal myomectomy Proctectomy; complete, combined abdominoperineal, with colostomy (For laparoscopic procedure, use 45395)

45111 45112

partial resection of rectum, transabdominal approach Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) (For colo-anal anastomosis with colonic reservoir or pouch, use 45119)

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45113 45114 45116 45119

45120

45121 45123 45126

45130 45135 45136 45150 45160 45170

Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy Proctectomy, partial, with anastomosis; abdominal and transsacral approach transsacral approach only (Kraske type) Protectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservior (eg, J-pouch), with diverting enterostomy when performed (For laparoscopic procedure, use 45397) Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) with subtotal or total colectomy, with multiple biopsies Proctectomy, partial, without anastomosis, perineal approach Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), or any combination thereof Excision of rectal procidentia, with anastomosis; perineal approach abdominal and perineal approach Excision of ileoanal reservoir with Ileostomy (Do not report 45136 in addition to 44005, 44120, 44310) Division of stricture of rectum Excision of rectal tumor by proctotomy, transacral or transcoccygeal approach Excision of rectal tumor, transanal approach

DESTRUCTION 45190

Destruction of rectal tumor, (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach

ENDOSCOPY DEFINITIONS: PROCTOSIGMOIDOSCOPY- is the examination of the rectum and sigmoid colon. SIGMOIDOSCOPY- is the examination of the entire rectum, sigmoid colon and may include

examination of a portion of the descending colon. COLONOSCOPY- is the examination of the entire colon, from the rectum to the cecum, and

may include the examination of the terminal ileum. (Surgical endoscopy always includes diagnostic endoscopy) 45300 45303

Proctosigmoidoscopy, rigid; diagnostic,with or without collection of specimen(s) by brushing or washing (separate procedure) with dilation, (eg, balloon, guide wire, bougie) (For radiological supervision and interpretation, use 74360)

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45305 45307 45308 45309 45315 45317 45320

45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45339 45340 45341 45342

with biopsy, single or multiple with removal of foreign body with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery with removal of single tumor, polyp, or other lesion by snare technique with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique with control of bleeding, (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (eg, laser) with decompression of volvulus with transendoscopic stent placement (includes predilation) Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with biopsy, single or multiple with removal of foreign body with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with control of bleeding, (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with directed submucosal injection(s), any substance with decompression of volvulus, any method with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique with dilation by balloon, 1 or more strictures (Do not report 45340 in conjunction with 45345) with endoscopic ultrasound examination with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) (Do not report 45341, 45342 in conjunction with 76942,76975) (For transrectal ultrasound utilizing rigid probe device, use 76872)

45345 45355

with transendoscopic stent placement (includes predilation) Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple (For fiberoptic colonoscopy beyond 25cm to splenic flexure, see 45330-45345)

45378

45379 45380 45381

Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) with removal of foreign body with biopsy, single or multiple with directed submucosal injection(s), any substance

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45382

with control of bleeding, (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45383 45384 45385

(For small bowel and stomal endoscopy, see 44360-44393) 45386

with dilation by balloon, 1 or more strictures (Do not report 45386 in conjunction with 45387)

45387 45391 45392

with transendoscopic stent placement (includes predilation) with endoscopic ultrasound examination with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) (Do not report 45391, 45392 in conjunction with 45330, 45341, 45342, 45378, 76872)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. EXCISION 45395

45397

Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy (For open procedure, use 45110) proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when performed (For open procedure, use 45119)

REPAIR 45400 45402 45499

Laparoscopy, surgical; proctopexy (for prolapse) (For open procedure, use 45540, 45541) proctopexy (for prolapse), with sigmoid resection (For open procedure, use 45550) Unlisted laparoscopy procedure, rectum

REPAIR 45500 45505 45520

Proctoplasty; for stenosis for prolapse of mucous membrane Perirectal injection of sclerosing solution for prolapse

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45540

Proctopexy (eg, for prolapse); abdominal approach (For laparoscopic procedure, use 45400)

45541 45550

perineal approach with sigmoid resection, abdominal approach (For laparoscopic procedure, use 45402)

45560

Repair of rectocele (separate procedure) (For repair of rectocele with posterior colporrhapy, use 57250)

45562 45563 45800 45805 45820 45825

Exploration, repair, and presacral drainage for rectal injury; with colostomy Closure of rectovesical fistula; with colostomy Closure of rectourethral fistula; with colostomy (For rectovaginal fistula closure, see 57300-57308)

MANIPULATION 45900 45905 45910 45915

Reduction of procidentia (separate procedure) under anesthesia Dilation of anal sphincter (separate procedure) under anesthesia other than local Dilation of rectal stricture (separate procedure) under anesthesia other than local Removal of fecal impaction or foreign body (separate procedure) under anesthesia

OTHER PROCEDURES 45999

Unlisted procedure, rectum (For unlisted laparoscopic procedure, rectum, use 45499)

ANUS INCISION (For subcutaneous fistulotomy, use 46270) 46020

Placement of seton (Do not report 46020 in addition to 46060, 46280, 46600)

46030 46040

Removal of anal seton, other marker Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure) Incision and drainage of intramural, intramuscular or submucosal abscess, transanal, under anesthesia Incision and drainage, perianal abscess, superficial (See also 45020, 46060)

46045 46050

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46060

Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton (Do not report 46060 in addition to 46020) (See also 45020)

46070

Incision, anal septum (infant) (Do not report modifier –63 in conjunction with 46070) (For anoplasty, see 46700-46705)

46080 46083

Sphincterotomy, anal, division of sphincter (separate procedure) Incision of thrombosed hemorrhoid, external

EXCISION 46200 46210 46211 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262

Fissurectomy, with or without sphincterotomy Cryptectomy; single multiple (separate procedure) Papillectomy or excision of single tag, anus (separate procedure) Hemorrhoidectomy, by simple ligature (eg, rubber band) Excision of external hemorrhoid tags and/or multiple papillae Hemorrhoidectomy, external, complete Hemorrhoidectomy, internal and external, simple; with fissurectomy with fistulectomy, with or without fissurectomy Hemorrhoidectomy, internal and external, complex or extensive; with fissurectomy with fistulectomy, with or without fissurectomy (For injection of hemorrhoids, use 46500; for destruction, see 46934-46936; for ligation, see 46945, 46946; for hemorrhoidopexy, use 46947)

46270 46275 46280

Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous submuscular complex or multiple, with or without placement of seton (Do not report 46280 in addition to 46020)

46285 46288 46320

second stage Closure of anal fistula with rectal advancement flap Enucleation or excision of external thrombotic hemorrhoid

INTRODUCTION 46500

Injection of sclerosing solution, hemorrhoids (For excision of hemorrhoids, see 46250-46262; for destruction, see 4693446936; for ligation, see 46945, 46946; for hemorrhoidopexy, use 46947)

46505

Chemodenervation of internal anal sphincter (For chemodenervation of other muscles, see 64612-64614, 64640) (Report the specific service in conjunction with the specific substance(s) or drug(s) provided)

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ENDOSCOPY (Surgical endoscopy always includes diagnostic endoscopy) 46600

46604 46606 46608 46610 46611 46612 46614 46615

Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) (Do not report 46600 in addition to 46020) with dilation, (eg, balloon, guide wire, bougie) with biopsy, single or multiple with removal of foreign body with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery with removal of single tumor, polyp, or other lesion by snare technique with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique with control of bleeding, (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

REPAIR (Do not report modifier 63 in conjunction with 46705, 46715, 46716, 46730, 46735, 46740, 46742, 46744) 46700 46705

Anoplasty, plastic operation for stricture; adult infant (For simple incision of anal septum, see 46070)

46706 46710 46712 46715 46716 46730 46735 46740 46742 46744 46746 46748 46750 46751

Repair of anal fistula with fibrin glue Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; transperineal approach combined transperineal and transabdominal approach Repair of low imperforate anus; with an operineal fistula (cut-back procedure) with transposition of anoperineal or anovestibular fistula Repair of high imperforate anus without fistula; perineal or sacroperineal approach combined transabdominal and sacroperineal approaches Repair of high imperforate anus with rectourethral or rectovaginal fistula; perineal or sacroperineal approach combined transabdominal and sacroperineal approaches (Report required) Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty; sacroperineal approach Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach (Report required) with vaginal lengthening by intestinal graft and pedicle flaps Sphincteroplasty, anal, for incontinence or prolapse; adult child

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46753 46754 46760 46761 46762

Graft (Thiersch operation) for rectal incontinence and/or prolapse Removal of Thiersch wire or suture, anal canal (Report required) Sphincteroplasty, anal, for incontinence, adult; muscle transplant levator muscle imbrication(Park posterior anal repair) implantation artificial sphincter

DESTRUCTION 46900 46910 46916 46917 46922 46924

46934 46935 46936

Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical electrodesiccation cryosurgery laser surgery surgical excision Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Destruction of hemorrhoids, any method; internal external internal and external (For excision of hemorrhoids, see 46250-46262; for injection, use 46500; for ligation, see 46945, 46946; for hemorrhoidopexy, use 46947)

46937 46938 46940 46942

Cryosurgery of rectal tumor; benign malignant Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial subsequent

SUTURE 46945 46946 46947

Ligation of internal hemorrhoids; single procedure multiple procedures Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling (For excision of hemorrhoids, see 46250-46262; for injection, use 46500; for destruction, see 46934-46936)

OTHER PROCEDURES 46999

Unlisted procedure, anus

LIVER INCISION 47000

Biopsy of liver, needle; percutaneous (If imaging guidance is performed, see 76942, 77002, 77012, 77021)

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47001

when done for indicated purpose at time of other major procedure (List separately in addition to primary procedure) (If imaging guidance is performed, see 76942, 77002) (For fine needle aspiration in conjunction with 47000, 47001, see 10021, 10022)

47010 47011

Hepatotomy; for open drainage of abscess or cyst, one or two stages for percutaneous drainage of abscess or cyst, one or two stages (For radiological supervision and interpretation, use 75989)

47015

Laparotomy, with aspiration and/or injection of hepatic parasitic (eg, amoebic or echinococcal) cyst(s) or abscess(es)

EXCISION 47100 47120 47122 47125 47130

Biopsy of liver, wedge Hepatectomy, resection of liver; partial lobectomy trisegmentectomy total left lobectomy total right lobectomy

LIVER TRANSPLANTATION 47135

Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age

REPAIR 47300 47350 47360 47361 47362

Marsupialization of cyst or abscess of liver Management of liver hemorrhage; simple suture of liver wound or injury complex, suture of liver wound or injury, with or without hepatic artery ligation exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver re-exploration of hepatic wound for removal of packing

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 47370 47371 47379

Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency (For imaging guidance, use 76490) cryosurgical (For imaging guidance, use 76490) Unlisted laparoscopic procedure, liver

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OTHER PROCEDURES 47380

Ablation, open, of one or more liver tumor(s); radiofrequency (For imaging guidance, use 76490)

47381

cryosurgical (For imaging guidance, use 76490)

47382

Ablation, one or more liver tumor(s), percutaneous, radiofrequency (For imaging guidance and monitoring, see 76490, 77013, 77022)

47399

Unlisted procedure, liver

BILIARY TRACT INCISION 47400 47420

47425 47460 47480 47490

Hepaticotomy or hepaticostomy with exploration, drainage, or removal of calculus Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or sphincteroplasty with transduodenal sphincterotomy or sphincteroplasty Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction of calculus (separate procedure) Cholecystotomy or cholecystostomy with exploration, drainage, or removal of calculus (separate procedure) Percutaneous cholecystostomy (For radiological supervision and interpretation, use 75989)

INTRODUCTION 47500

Injection procedure for percutaneous transhepatic cholangiography (For radiological supervision and interpretation, use 74320)

47505

Injection procedure for cholangiography through an existing catheter (eg, percutaneous transhepatic or T-tube) (For radiological supervision and interpretation, use 74305)

47510

Introduction of percutaneous transhepatic catheter for biliary drainage (For radiological supervision and interpretation, use 75980)

47511

Introduction of percutaneous transhepatic stent for internal and external biliary drainage (For radiological supervision and interpretation, use 75982)

47525

Change of percutaneous biliary drainage catheter (For radiological supervision and interpretation, use 75984)

47530

Revision and/or reinsertion of transhepatic tube (For radiological supervision and interpretation, use 75984)

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ENDOSCOPY Surgical endoscopy always includes diagnostic endoscopy. 47550

Biliary endoscopy, intraoperative (choledochoscopy) (List separately in addition to primary procedure)

47552

Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, with or without collection of specimen(s) by brushing and/or washing (separate procedure) with biopsy, single or multiple ttt with removal of calculus/calculi with dilation of biliary duct stricture(s) without stent with dilation of biliary duct stricture(s) with stent

47553 47554 47555 47556

(For ERCP, see 43260-43272, 74363) (If imaging guidance is performed, see 74363, 75982) LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 47560 47561 47562 47563 47564 47570 47579

Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy with guided transhepatic cholangiography with biopsy cholecystectomy cholecystectomy with cholangiography cholecystectomy with exploration of common duct cholecystoenterostomy Unlisted laparoscopy procedure, biliary tract

EXCISION 47600 47605

Cholecystectomy; with cholangiography (For laparoscopic approach, see 47562-47564)

47610

Cholecystectomy with exploration of common duct; (For cholecystectomy with exploration of common duct with biliary endoscopy, use 47610 with 47550)

47612 47620 47630

47700

with choledochoenterostomy with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography Biliary duct stone extraction, percutaneous via T-tube tract, basket or snare (eg, Burhenne technique) (For radiological supervision and interpretation, use 74327) Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy, with or without cholangiography

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47701

Portoenterostomy (eg, Kasai procedure) (Do not report modifier 63 in conjunction with 47700, 47701)

47711 47712

Excision of bile duct tumor, with or without primary repair of bile duct; extrahepatic intraphepatic (For anastomosis, see 47760-47800)

47715

Excision of choledochal cyst

REPAIR 47720

Cholecystoenterostomy; direct (For laparoscopic approach, use 47570)

47721 47740 47741 47760 47765 47780 47785 47800 47801 47802 47900

with gastroenterostomy Roux-en-Y Roux-en-Y with gastroenterostomy Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract Anastomosis, of intrahepatic ducts and gastrointestinal tract Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end anastomosis Placement of choledochal stent U-tube hepaticoenterostomy Suture of extrahepatic biliary duct for pre-existing injury (separate procedure)

OTHER PROCEDURES 47999

Unlisted procedure, biliary tract

PANCREAS (For peroral pancreatic endoscopic procedures, see 43260-43272) INCISION 48000 48001 48020

Placement of drains, peripancreatic, for acute pancreatitis; with cholecystostomy, gastrostomy, and jejunostomy Removal of pancreatic calculus

EXCISION 48100 48102

Biopsy of pancreas, open, (eg, fine needle aspiration, needle core biopsy, wedge biopsy) Biopsy of pancreas, percutaneous needle (For radiological supervision and interpretation, see 76942, 77002, 77012, 77021) (For fine needle aspiration, use 10022)

48105

Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis

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48120 48140 48145 48146 48148 48150

48152 48153

48154 48155

Excision of lesion of pancreas (eg, cyst, adenoma) Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy with pancreaticojejunostomy Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure) Excision of ampulla of Vater Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, cholecystoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy without pancreatojejunostomy Pancreatectomy, proximal subtotal with near-total duodenectomy, cholecystoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy without pancreatojejunostomy (Report required) Pancreatectomy, total

INTRODUCTION 48400

Injection procedure for intraoperative pancreatography (List separately in addition to primary procedure) (For radiological supervision and interpretation, see 74300-74305)

REPAIR 48500 48510 48511

Marsupialization of pancreatic cyst External drainage, pseudocyst of pancreas; open percutaneous (For radiological supervision and interpretation, use 75989)

48520 48540 48545 48547 48548

Internal anastomosis of pancreatic cyst to gastrointestinal tract; direct Roux-en-Y Pancreatorrhaphy for injury Duodenal exclusion with gastrojejunostomy for pancreatic injury Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type operation)

PANCREAS TRANSPLANTATION 48554 48556

Transplantation of pancreatic allograft Removal of transplanted pancreatic allograft

OTHER PROCEDURES 48999

Unlisted procedure, pancreas

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ABDOMEN, PERITONEUM, AND OMENTUM INCISION (To report wound exploration due to penetrating trauma without laparotomy for 49000, 49010, use 20102) (For radiological supervision and interpretation for 49021, 49041, 49061, use 75989) 49000 49002

Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) Reopening of recent laparotomy (To report re-exploration of hepatic wound for removal of packing, use 47362)

49010 49020

Exploration, retroperitoneal area with or without biopsy(s) (separate procedure) Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open (For appendiceal abscess, use 44900)

49021 49040 49041 49060 49061

percutaneous Drainage of subdiaphragmatic or subphrenic abscess; open percutaneous Drainage of retroperitoneal abscess; open percutaneous (For laparoscopic drainage, use 49323)

49062 49080 49081

Drainage of extraperitoneal lymphocele to peritoneal cavity, open Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial subsequent (If imaging guidance is performed, see 76942, 77012)

EXCISION, DESTRUCTION (For lysis of intestinal adhesions, use 44005) 49180

Biopsy, abdominal or retroperitoneal mass, percutaneous needle (If imaging guidance is performed, see 76942, 77002, 77012, 77021) (For fine needle aspiration, use 10021 or 10022) (For resection of recurrent ovarian, tubal, primary peritoneal, or uterine malignancy, see 58957, 58958) (For open cryoablation of renal tumor, use 50250)

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49203

49204 49205

Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less largest tumor 5.1-10.0 cm diameter largest tumor greater than 10.0 cm diameter (Do not report 49203-49205 in conjunction with 38770, 38780, 49000, 49010, 49215, 50010, 50205, 50225, 50236, 50250, 50290, 58900-58960) (For colectomy, use 44140 in conjunction with 49203-49205) (For small bowel resection, use 44120 in conjunction with 49203-49205) (For vena caval resection with reconstruction, use 49203-49205 in conjunction with 37799) (For partial or total nephrectomy, use 50220 or 50240 inconjunction with 4920349205) (For resection of recurrent ovarian, tubal, primary peritoneal or uterine malignancy, see 58957, 58958) (For cryoablation of renal tumors, see 50250, 50593)

49215

Excision of presacral or sacrococcygeal tumor (Do not report modifier 63 in conjunction with 49215)

49220

Staging laparotomy for Hodgkin's disease or lymphoma (includes splenectomy, needle or open biopsies of both liver lobes, possibly also removal of abdominal nodes, abdominal node and/or bone marrow biopsies, ovarian repositioning) (Report required) Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) Omentectomy, epiploectomy, resection of omentum (separate procedure)

49250 49255

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy), (separate procedure), use 49320. For laparoscopic fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface use 58662. 49320 49321 49322 49323

Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Laparoscopy, surgical; with biopsy (single or multiple) with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) with drainage of lymphocele to peritoneal cavity (For percutaneous or open drainage, see 49060, 49061)

49324

with insertion of intraperitoneal cannula or catheter, permanent (For subcutaneous extension of intraperitoneal catheter with remote chest exit site, use 49435 in conjunction with 49324) (For open insertion of permanent intraperitoneal cannula or catheter, use 49421)

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49325 49326

49329

with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed with omentopexy (omental tacking procedure) (List separately in addition to primary procedure) (Use 49326 in conjunction with 49324, 49325) Unlisted laparoscopy procedure, abdomen, peritoneum and omentum

INTRODUCTION, REVISION AND/OR REMOVAL 49400

Injection of air or contrast into peritoneal cavity (separate procedure) (For radiological supervision and interpretation, use 74190)

49402

Removal of peritoneal foreign body from peritoneal cavity (For lysis of intestinal adhesions, use 44005)

49419

Insertion of intraperitoneal cannula or catheter, with subcutaneous reservoir, permanent (ie, totally implantable) (For removal, use 49422)

49420 49421

Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary permanent (For subcutaneous extension of intraperitoneal catheter with remote chest exit site, use 49435 in conjunction with 49421) (For laparoscopic insertion of permanent intraperitoneal cannula or catheter, use 49324)

49422

Removal of permanent intraperitoneal cannula or catheter (For removal of a temporary catheter/cannula, use appropriate E/M code)

49423

Exchange of previously placed abcess or cyst drainage catheter under radiological guidance (separate procedure) (For radiological supervision and interpretation, use 75984)

49424

Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure) (For radiological supervision and interpretation, use 76080)

49425 49426

Insertion of peritoneal-venous shunt Revision of peritoneal-venous shunt (For shunt patency test, use 78291)

49427

Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt (For radiological supervision and interpretation, see 75809, 78291)

49428 49429

Ligation of peritoneal-venous shunt Removal of peritoneal-venous shunt

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49435

Insertion of subcutaneous extension to intraperitoneal cannula or catheter with remote chest exit site (List separately in addition to primary procedure) (Use 49435 in conjunction with 49324, 49421)

49436

Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter

INITIAL PLACEMENT Do not additionally report 43752 for placement of a nasogastric(NG) or orogastric (OG) tube to insufflate the stomach prior to percutaneous gastrointestinal tube placement. NG or OG tube placement is considered part of the procedure in this family of codes. 49440

Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report (For conversion to a gastro-jejunostomy tube at the time of initial gastrostomy tube placement, use 49440 in conjunction with 49446)

49441

Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report (For conversion of gastrostomy tube to gastro-jejunostomy tube, use 49446)

49442

Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

CONVERSION 49446

Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report (For conversion to a gastro-jejunostomy tube at the time of initial gastrostomy tube placement, use 49446 in conjunction with 49440)

REPLACEMENT If an existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube is removed and a new tube is placed via a separate percutaneous access site, the placement of the new tube is not considered a replacement and would be reported using the appropriate initial placement codes 49440-49442. 49450

49451

49452

Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

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MECHANICAL REMOVAL OF OBSTRUCTIVE MATERIAL 49460

Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report (Do not report 49460 in conjunction with 49450-49452, 49465)

OTHER 49465

Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report (Do not report 49465 in conjunction with 49450-49460)

REPAIR HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY The hernia repair codes in this section are categorized primarily by the type of hernia (inguinal, femoral, incisional, etc.). Some types of hernias are further categorized as "initial" or "recurrent" based on whether or not the hernia has required previous repair(s). Additional variables accounted for by some of the codes include patient age and clinical presentation (reducible vs. incarcerated or strangulated). With the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prosthesis is not separately reported. The excision/repair of strangulated organs or structures such as testicle(s), intestine, ovaries are reported by using the appropriate code for the excision/repair (eg, 44120, 54520, and 58940) in addition to the appropriate code for the repair of the strangulated hernia. (For reduction and repair of intra-abdominal hernia, see 44050) (For debridement of abdominal wall, see 11042, 11043) (Codes 49491-49651 are unilateral procedures. To report bilateral procedures, report modifier 50 with the appropriate procedure code) (Do not report modifier 63 in conjunction with 49491, 49492, 49495, 49496, 49600, 49605, 49606, 49610, 49611) 49491

49492

Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks post-conception age, with or without hydrocelectomy; reducible incarcerated or strangulated (Postconception age equals gestational age at birth plus age of infant in weeks at the time of the hernia repair. Initial inguinal hernia repairs that are performed on preterm infants who are older than 50 weeks post-conception age and younger than 6 monthsof age at the time of surgery, should be reported using codes 49495, 49496)

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49495

49496

Repair initial inguinal hernia, full term infant younger than 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible incarcerated or strangulated (Postconceptual age equals gestational age at birth plus age in weeks at the time of the hernia repair. Initial inguinal hernia repairs that are performed on preterm infants who are younger than or up to 50 weeks postconceptual age but younger than 6 months of age since birth , should be reported using codes 49491, 49492. Inguinal hernia repairs on infants age 6 months to younger than 5 years should be reported using codes 49500-49501)

49500 49501 49505 49507

Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible incarcerated or strangulated Repair initial inguinal hernia, age 5 years or over; reducible incarcerated or strangulated (For inguinal hernia repair, with simple orchiectomy, see 49505 or 49507 and 54520) (For inguinal hernia repair, with excision of hydrocele or spermatocele, see 49505 or 49507 and 54840 or 55040)

49520 49521 49525

Repair recurrent inguinal hernia, any age; reducible incarcerated or strangulated Repair inguinal hernia, sliding, any age (For incarcerated or strangulated inguinal hernia repair, see 49496, 49501, 49507, 49521)

49540 49550 49553 49555 49557 49560 49561 49565 49566 49568

Repair lumbar hernia Repair initial femoral hernia, any age; reducible incarcerated or strangulated Repair recurrent femoral hernia; reducible incarcerated or strangulated Repair initial incisional or ventral hernia; reducible incarcerated or strangulated Repair recurrent incisional or ventral hernia; reducible incarcerated or strangulated Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) (Use 49568 in conjunction with 11004-11006, 49560-49566)

49570 49572 49580 49582

Repair epigastric hernia (eg. preperitoneal fat); reducible (separate procedure); incarcerated or strangulated Repair umbilical hernia, younger than age 5 years; reducible incarcerated or strangulated

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49585 49587 49590 49600 49605 49606 49610 49611

Repair umbilical hernia, age 5 years or over; reducible incarcerated or strangulated Repair spigelian hernia Repair of small omphalocele, with primary closure Repair of large omphalocele or gastroschisis; with or without prosthesis with removal of prosthesis, final reduction and closure, in operating room Repair of omphalocele (Gross type operation); first stage second stage (For diaphragmatic or hiatal hernia repair, see 39502-39541) (For surgical repair of omentum, use 49999)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy), (separate procedure), use 49320. 49650 49651 49659

Laparoscopy, surgical; repair initial inguinal hernia repair recurrent inguinal hernia Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy

SUTURE 49900

Suture, secondary, of abdominal wall for evisceration or dehiscence (For suture of ruptured diaphragm, see 39540, 39541) (For debridement of abdominal wall, see 11042, 11043)

OTHER PROCEDURES 49904

Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects) (Code 49904 includes harvest and transfer. If a second surgeon harvests the omental flap, then the two surgeons should code 49904 as co-surgeons, using modifier 62)

49905

Omental flap, intra-abdominal (List separately in addition to primary procedure) (Do not report 49905 in conjunction with 47700)

49906 49999

Free omental flap with microvascular anastomosis Unlisted procedure, abdomen, peritoneum and omentum

URINARY SYSTEM KIDNEY INCISION (For retroperitoneal exploration, abscess, tumor, or cyst, see 49010, 49060, 49203-49205) 50010

Renal exploration, not necessitating other specific procedures (For laparoscopic ablation of renal mass lesion(s), use 50542)

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50020 50021

Drainage of perirenal or renal abscess; open percutaneous (For radiological supervision and interpretation, use 75989)

50040 50045

Nephrostomy, nephrotomy with drainage Nephrotomy, with exploration (For renal endoscopy performed with nephrotomy, see 50570-50580)

50060 50065 50070 50075 50080 50081

Nephrolithotomy; removal of calculus secondary surgical operation for calculus complicated by congenital kidney abnormality removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy) Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting or basket extraction; up to 2 cm over 2 cm (For flourocopic guidance, see 76000-76001) (For establishment of nephrostomy without nephrostolithotomy, see 50040, 50395 or 52334)

50100 50120

Transection or repositioning of aberrant renal vessels (separate procedure) Pyelotomy; with exploration (For renal endoscopy performed in conjunction with this procedure, see 5057050580)

50125 50130

with drainage, pyelostomy with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy) complicated (eg, secondary operation, congenital kidney abnormality)

50135

(For supply of anticarcinogenic agents, use appropriate codes in addition to code for primary procedure) EXCISION (For excision of retroperitoneal tumor or cyst, see 49203-49205) (For laparoscopic ablation of renal mass lesion(s), use 50542) 50200

Renal biopsy; percutaneous, by trocar or needle (For radiological supervision and interpretation, see 76942, 77002, 77012, 77021) (For fine needle aspiration, use 10022)

50205 50220 50225 50230

by surgical exposure of kidney Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney radical, with regional lymphadenectomy and/or vena caval thrombectomy (When vena caval resection with reconstruction is necessary use 37799)

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50234 50236 50240

Nephrectomy with total ureterectomy and bladder cuff; through same incision through separate incision Nephrectomy, partial (For laparoscopic partial nephrectomy, use 50543)

50250

Ablation, open, one or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound, if performed (For laparoscopic ablation of renal mass lesions, use 50542) (For cryoablation of renal tumors, use 50593)

50280

Excision or unroofing of cyst(s)of kidney (For laparoscopic ablation of renal cysts, use 50541)

50290

Excision of perinephric cyst

RENAL TRANSPLANTATION (For dialysis, see 90935-90999) (For laparoscopy donor nephrectomy, use 50547) (For laparoscopic drainage of lymphocele to peritoneal cavity, use 49323) 50320 50340

Donor nephrectomy (including cold preservation); open, from living donor Recipient nephrectomy (separate procedure) (For bilateral procedure, report 50340 with modifier 50)

50360 50365 50370 50380

Renal allotransplantation, implantation of graft; without recipient nephrectomy with recipient nephrectomy Removal of transplanted renal allograft Renal autotransplantation, reimplantation of kidney

INTRODUCTION (For bilateral procedure for 50382, 50384, 50387, use modifier -50) RENAL PELVIS CATHETER PROCEDURES INTERNALLY DWELLING 50382 50384

Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation (Do not report 50382, 50384 in conjunction with 50395) (For removal of an internally dwelling ureteral stent via a transurethral approach, use 50386)

50385

Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation

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50386

Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation

EXTERNALLY ACCESSIBLE 50387

Removal and replacement of externally accessible transnephric ureteral stent (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation (For removal and replacement of externally accessible ureteral stent via ureterostomy or ilieal conduit, use 50688) (For removal without replacement of an externally accessible ureteral stent not requiring fluoroscopic guidance, see E/M services codes)

50389

Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) (Removal of nephrostomy tube not requiring fluoroscopic guidance is considered inherent to E/M services. Report the appropriate level of E/M service provided)

OTHER INTRODUCTION PROCEDURES 50390

Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous (For radiological supervision and interpretation, see 74425, 74470, 76942, 77002, 77012, 77021)

50391

Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube (eg, anticarcinogenic or antifungal agent) Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous (For radiological supervision and interpretation, see 74475, 76942, 77012)

50392

50393

Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous (For radiological supervision and interpretation, see 74480, 76942, 77002, 77012)

50394

Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter (For radiological supervision and interpretation, use 74425)

50395

Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous (For radiological supervision and interpretation, see 74475, 74480, 74485) (For nephrostolithotomy, see 50080, 50081) (For retrograde percutaneous nephrostomy, use 52334) (For endoscopic surgery, see 50551-50561)

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50396

Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter (For radiological supervision and interpretation, see 74425, 74475, 74480)

50398

Change of nephrostomy or pyelostomy tube (For radiological supervision and interpretation, use 75984)

REPAIR 50400

50405

Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; simple complicated (congenital kidney abnormality, secondary pyeloplasty, solitary kidney, calycoplasty) (For laparoscopic approach, use 50544)

50500 50520 50525 50526 50540

Nephrorrhaphy, suture of kidney wound or injury Closure of nephrocutaneous or pyelocutaneous fistula Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach thoracic approach Symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral (one operation)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy), (separate procedure), use 49320. 50541 50542

Laparoscopy, surgical; ablation of renal cysts ablation of renal mass lesion(s) (For open procedure, see 50220-50240) (For cryosurgical ablation, see 50250, 50593)

50543

partial nephrectomy (For open procedure, use 50240)

50544 50545

pyelopasty radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy) (For open procedure, use 50230)

50546 50547

nephrectomy, including partial ureterectomy donor nephrectomy (including cold preservation), from living donor (For open procedure, use 50320)

50548

nephrectomy with total ureterectomy (For open procedure, see 50234, 50236)

50549

Unlisted lapaoscopy procedure, renal (For laparoscopic drainage of lymphocele to peritoneal cavity, use 49323)

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ENDOSCOPY 50551 50553 50555 50557 50561 50562

Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter with biopsy with fulguration and/or incision, with or without biopsy with removal of foreign body or calculus with resection of tumor (When procedures 50570-50580 provide a significant identifiable service, they may be added to 50045 and 50120)

50570

Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; (For nephrotomy, use 50045) (For pyelotomy, use 50120)

50572 50574 50575

with ureteral catheterization, with or without dilation of ureter with biopsy with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent) with fulguration and/or incision, with or without biopsy with removal of foreign body or calculus

50576 50580

OTHER PROCEDURES (Codes 50592, 50593 are unilateral procedures, for bilateral procedures, report with modifier 50) 50590 50592

Lithotripsy, extracorporeal shock wave Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency (For imaging guidance and monitoring, see 76940, 77013, 77022)

50593

Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy (Report required) (For imaging guidance and monitoring, see codes 76940, 77013, 77022)

URETER INCISION 50600

Ureterotomy with exploration or drainage (separate procedure) (For ureteral endoscopy performed in conjunction with this procedure, see 50970-50980)

50605

Ureterotomy for insertion of indwelling stent, all types

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50610 50620 50630

Ureterolithotomy; upper one-third of ureter middle one-third of ureter lower one-third of ureter (For laparoscopic approach, use 50945) (For transvesical ureterolithotomy, use 51060) (For cystotomy with stone basket extraction of ureteral calculus, use 51065) (For endoscopic extraction or manipulation of ureteral calculus, see 50080, 50081, 50561, 50961, 50980, 52320-52330, 52352, 52353)

EXCISION (For ureterocele, see 51535, 52300) 50650 50660

Ureterectomy, with bladder cuff (separate procedure) Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach

INTRODUCTION (For procedures 50684, 50690, radiological supervision and interpretation, use 74425) 50684 50686 50688

Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter Manometric studies through ureterostomy or indwelling ureteral catheter Change of ureterostomy tube or externally accessible ureteral stend via ileal conduit (If imaging guidance is performed, use 75984)

50690

Injection procedure for visualization of ileal conduit and/or ureteropyelography, exclusive of radiologic service

REPAIR (For bilateral procedure, for 50715, 50780, 50785, 50800, 50815, 50820, 50840, 50860, use modifier -50) 50700 50715 50722 50725 50727 50728 50740 50750 50760 50770

Ureteroplasty, plastic operation on ureter (eg, stricture) Ureterolysis, with or without epositioning of ureter for retroperitoneal fibrosis Ureterolysis for ovarian vein syndrome Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava Revision of urinary-cutaneous anastomosis (any type urostomy); with repair of fascial defect and hernia Ureteropyelostomy, anastomosis of ureter and renal pelvis Ureterocalycostomy, anastomosis of ureter to renal calyx Ureteroureterostomy Transureteroureterostomy, anastomosis of ureter to contralateral ureter

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(Codes 50780-50785 include minor procedures to prevent vesicoureteral reflux) 50780

Ureteroneocystostomy; anastomosis of single ureter to bladder (When combined with cystourethroplasty or vesical neck revision, use 51820)

50782 50783 50785 50800 50810 50815 50820

anastomosis of duplicated ureter to bladder with extensive ureteral tailoring with vesico-psoas hitch or bladder flap Ureteroenterostomy, direct anastomosis of ureter to intestine Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including intestine anastomosis Ureterocolon conduit, including intestine anastomosis Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation) (For combination of 50800-50820 with cystectomy, see 51580-51595)

50825 50830

50840 50845 50860 50900 50920 50930 50940

Continent diversion, including intestine anastomosis using any segment of small and/or large bowel (Kock pouch or Camey enterocystoplasty) Urinary undiversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy with uretero-ureterostomy or ureteroneocystostomy) Replacement of all or part of ureter by intestine segment, including intestine anastomosis Cutaneous appendico-vesicostomy Ureterostomy, transplantation of ureter to skin Ureterorrhaphy, suture of ureter (separate procedure) Closure of ureterocutaneous fistula Closure of ureterovisceral fistula (including visceral repair) Delegation of ureter (For ureteroplasty, ureteroylysis, see 50700-50860)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy), (separate procedure), use 49320. 50945 50947 50948

Laparoscopy, surgical; ureterolithotomy ureteroneocystostomy with cystoscopy and ureteral stent placement ureteroneocystostomy without cystoscopy and ureteral stent placement (For open ureteroneocystostomy, see 50780-50785)

50949

Unlisted laparoscopic procedure, ureter

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ENDOSCOPY 50951 50953 50955 50957 50961

Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter with biopsy with fulguration and/or incision, with or without biopsy with removal of foreign body or calculus (When procedures 50970-50980 provide a significant identifiable service, they may be added to 50600)

50970

Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; (For ureterotomy, use 50600)

50972 50974 50976 50980

with ureteral catheterization, with or without dilation of ureter with biopsy with fulguration and/or incision, with or without biopsy with removal of foreign body or calculus

BLADDER INCISION 51020 51030 51040 51045 51050 51060 51065 51080

Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material with cryosurgical destruction of intravesical lesion Cystostomy, cystotomy with drainage Cystotomy, with insertion of ureteral catheter or stent (separate procedure) Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection Transvesical ureterolithotomy Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus Drainage of perivesical or prevesical space abscess

REMOVAL 51100 51101 51102

Aspiration of bladder; by needle by trocar or intracatheter with insertion of suprapubic catheter (For imaging guidance, see 76942, 77002, 77012)

EXCISION 51500 51520 51525 51530

Excision of urachal cyst or sinus, with or without umbilical hernia repair Cystotomy; for simple excision of vesical neck (separate procedure) for excision of bladder diverticulum, single or multiple (separate procedure) for excision of bladder tumor (For transurethral resection, see 52234-52240, 52305)

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51535

Cystotomy for excision, incision, or repair of ureterocele (For bilateral procedure, use modifier -50) (For transurethra excision, use 52300)

51550 51555 51565 51570 51575 51580 51585 51590 51595 51596 51597

Cystectomy, partial; simple complicated (eg, postradiation, previous surgery, difficult location) Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy) Cystectomy, complete; (separate procedure) with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Cystectomy, complete with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes Cystectomy, complete, with continent diversion, any technique, using any segment of small and/or large intestine to construct neobladder Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof (For pelvic exenteration for gynecologic malignancy, use 58240)

INTRODUCTION 51600

Injection procedure for cystography or voiding urethrocystography (For radiological supervision and interpretation, see 74430, 74455)

51605

Injection procedure and placement of chain for contrast and/or chain urethrocystography (For radiological supervision and interpretation, use 74430)

51610

Injection procedure for retrograde urethrocystography (For radiological supervision and interpretation, use 74450)

51700

Bladder irrigation, simple, lavage and/or instillation

51703

Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon) (Report required) (Code 51703 is reported only when performed independently. Do not report 51703 when catheter insertion is an inclusive component of another procedure)

51710

Change of cystostomy tube; complicated (Report required) (If imaging guidance is performed, use 75984)

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51715 51720

Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck Bladder instillation of anticarcinogenic agent (including retention time)

URODYNAMICS The following section (51725-51797) lists procedures that may be used separately or in many and varied combinations. All procedures in this section imply that these services are performed by, or are under the direct supervision of, a physician and that all instruments, equipment, fluids, gases, probes, catheters, technician's fees, medications, gloves, trays, tubing and other sterile supplies be provided by the physician. When the physician only interprets the results and/or operates the equipment, a professional component, modifier 26, should be used to identify physicians’ services. 51725 51726 51736 51741 51772 51784 51785 51792 51795 51797

51798

Simple cystometrogram (CMG) (eg, spinal manometer) Complex cystometrogram (eg, calibrated electronic equipment) Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter) Complex uroflowmetry (eg, calibrated electronic equipment) Urethral pressure profile studies (UPP) (urethral closure pressure profile), any technique Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique Needle electromyography studies (EMG) of anal or urethral sphincter, any technique Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time) Voiding pressure studies (VP); bladder voiding pressure, any technique intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal) (List separately in addition to primary procedure) (Use 51797 in conjuncton with 51795) Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging

REPAIR 51800

51820 51840 51841

Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck Cystourethroplasty with unilateral or bilateral ureteroneocystostomy Anterior vesicourethropexy, or urethropexy (Marshall-Marchetti-Krantz, Burch); simple complicated (eg, secondary repair) (For urethropexy (Pereyra type), use 57289)

51845

Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra)

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51860 51865 51880 51900

Cystorrhaphy, suture of bladder wound, injury or rupture; simple complicated Closure of cystostomy (separate procedure) Closure of vesicovaginal fistula, abdominal approach (For vaginal approach, see 57320-57330)

51920 51925

Closure of vesicouterine fistula; with hysterectomy (See Rule 14) (For closure of vesicoenteric fistula, see 44660, 44661) (For closure of rectovesical fistula, see 45800-45805)

51940

Closure, exstrophy of bladder (See also 54390)

51960 51980

Enterocystoplasty, including intestinal anastomosis Cutaneous vesicostomy

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 51990 51992

Laparoscopy, surgical; urethral suspension for stress incontinence sling operation for stress incontinence (eg, fascia or synthetic) (For open sling operation for stress incontinence, use 57288) (For reversal or removal of sling operation for stress incontinence, use 57287)

51999

Unlisted laparoscopy procedure, bladder

ENDOSCOPY - CYSTOSCOPY, URETHROSCOPY, CYSTOURETHROSCOPY Endoscopic descriptions are listed so that the main procedure can be identified without having to list all the minor related functions performed at the same time. For example: meatotomy, urethral calibration and/or dilation, urethroscopy, and cystoscopy prior to a transurethral resection of prostate; ureteral catheterization following extraction of ureteral calculus; internal urethrotomy and bladder neck fulguration when performing a cystourethroscopy for the female urethral syndrome. 52000 52001

Cystourethroscopy (separate procedure) Cystourethroscopy with irrigation and evacuation of multiple obstructing clots (Do not report 52001 in addition to 52000)

52005

Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service (For radiological supervision and interpretation, see 74440)

52007 52010

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TRANSURETHRAL SURGERY URETHRA AND BLADDER 52204 52214 52224 52234 52235 52240 52250 52260 52265 52270 52275 52276 52277 52281

52282 52283 52285

52290 52300 52301 52305 52310 52315 52317 52318

Cystourethroscopy, with biopsy(s) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s), with or without biopsy Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm) MEDIUM bladder tumor(s) (2.0 to 5.0 cm) LARGE bladder tumor(s) Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia local anesthesia Cystourethroscopy, with internal urethrotomy; female male Cystourethroscopy, with direct vision internal urethrotomy Cystourethroscopy, with resection of external sphincter (sphincterotomy) Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female Cystourethroscopy, with insertion of urethral stent Cystourethroscopy, with steroid injection into stricture Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral with incision or resection of orifice of bladder diverticulum, single or multiple Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple complicated Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm) complicated or large (over 2.5 cm)

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URETER AND PELVIS Therapeutic cystourethroscopy always includes diagnostic cystourethroscopy. To report a diagnostic cystourethroscopy, use 52000. Therapeutic cystourethroscopy with ureteroscopy and/or pyeloscopy always includes diagnostic cystourethroscopy with ureteroscopy and/or pyeloscopy. To report a diagnostic cystourethroscopy with ureteroscopy and/or pyeloscopy, use 52351. Do not report 52000 in conjunction with 52320-52343. Do not report 52351 in conjunction with 52344-52346, 52352-52355. The insertion and removal of a temporary ureteral catheter (52005) during diagnostic or therapeutic cystourethroscopic with ureteroscopy and/or pyeloscopy is included in 5232052355 and should not be reported separately. To report insertion of a self-retaining, indwelling stent performed during diagnostic or therapeutic cystourethroscopy with ureteroscopy and/or pyeloscopy report 52332, in addition to primary procedure(s) performed. 52332 is used to report a unilateral procedure unless otherwise specified. For bilateral insertion of self-retaining, indwelling ureteral stents, use code 52332, and modifier -50. To report cystourethroscopic removal of a self-retaining, indwelling ureteral stent, see 52310, 52315. 52320 52325 52327 52330 52332 52334

Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus with fragmentation of ureteral calculus (eg, ultrasonic or electro-hydraulic technique) with subureteric injection of implant material with manipulation, without removal of ureteral calculus Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double- J type) Cystourethroscopy, with insertion of ureteral guide wire through kidney to establish a percutaneous nephrostomy, retrograde (For cystourethroscopy, with ureteroscopy and/or pyeloscopy, see 52351-52355) (For cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves or obstructive hypertrophic mucosal folds, use 52400) (For percutaneous nephrostolithotomy, see 50080, 50081; for establishment of nephrostomy tract only, see 50395)

52341 52342 52343

Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision)

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52344 52345 52346

Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision) (For transurethral resection or incision of ejaculatory ducts, use 52402)

52351

52352 52353 52354 52355

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic (Do not report 52351 in conjunction with 52341-52346, 52352-52355) (For radiological supervision and interpretation, use 74485) with removal or manipulation of calculus (ureteral catheterization is included) with lithotripsy (ureteral catheterization is included) with biopsy and/or fulguration of ureteral or renal pelvic lesion with resection of ureteral or renal pelvic tumor

VESICAL NECK AND PROSTATE 52400 52402 52450 52500 52601

Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds Cystourethroscopy with transurethral resection or incision of ejaculatory ducts Transurethral incision of prostate Transurethral resection of bladder neck (separate procedure) Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) (For other approaches, see 55801-55845)

52606 52612 52614 52620 52630 52640 52647

52648

Transurethral fulguration for postoperative bleeding occurring after the usual follow-up time Transurethral resection of prostate; first stage of two-stage resection (partial resection) second stage of two-stage resection (resection completed) Transurethral resection; of residual obstructive tissue after 90 days postoperative of regrowth of obstructive tissue longer than one year postoperative of postoperative bladder neck contracture Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed) Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)

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52649

Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) (Do not report 52649 in conjunction with 52000, 52276, 52281, 52601, 52647, 52648, 53020, 55250)

52700

Transurethral drainage of prostatic abscess (For litholapaxy, use 52317, 52318)

URETHRA (For endoscopy, see cystoscopy, urethroscopy, cystourethroscopy, 52000-52700) (For injection procedure for urethrocystography, see 51600-51610) INCISION 53000 53010 53020 53025

Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra perineal urethra, external Meatotomy, cutting of meatus (separate procedure); except infant infant (Do not report modifier -63 in conjunction with 53025)

53040

Drainage of deep periurethral abscess (For subcutaneous abscess, see 10060, 10061)

53060 53080 53085

Drainage of Skene's gland abscess or cyst Drainage of perineal urinary extravasation; uncomplicated(separate procedure) complicated

EXCISION 53200 53210 53215 53220 53230 53235 53240 53250 53260

Biopsy of urethra Urethrectomy, total, including cystostomy; female male Excision or fulguration of carcinoma of urethra Excision of urethral diverticulum (separate procedure); female male Marsupialization of urethral diverticulum, male or female Excision of bulbourethral gland (Cowper's gland) Excision or fulguration; urethral polyp(s), distal urethra (For endoscopic approach, see 52214, 52224)

53265 53270 53275

urethral caruncle Skene's glands urethral prolapse

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REPAIR (For hypospadias, see 54300-54352) 53400 53405 53410 53415 53420 53425 53430 53431 53440 53442 53444 53445 53446 53447 53448

53449 53450

Urethroplasty; first stage, for fistula, diverticulum, or stricture, (eg, Johannsen type) second stage (formation of urethra), including urinary diversion Urethroplasty, one-stage reconstruction of male anterior urethra Urethroplasty, transpubic or perineal, one stage, for reconstruction or repair of prostatic or membranous urethra Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; first stage second stage Urethroplasty, reconstruction of female urethra Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence (eg, Tenago, Leadbetter procedure) Sling operation for correction of male urinary incontinence, (eg, fascia or synthetic) Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) (Report required) Insertion of tandem cuff (dual cuff) Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir and cuff at the same operative session Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue (Do not report 11040-11043 in addition to 53448) Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff (Report required) Urethromeatoplasty, with mucosal advancement (For meatotomy, see 53020-53025)

53460 53500

Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring) (Do not report 53500 in conjunction with 52000) (For urethrolysis by retropubic approach, use 53899)

53502 53505 53510 53515

Urethrorrhaphy, suture of urethral wound or injury; female (Report required) penile perineal prostatomembranous

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53520

Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure) (For closure of urethrovaginal fistula, use 57310) (For closure of urethrorectal fistula, see 45820, 45825)

MANIPULATION (For radiological supervision and interpretation, use 74485) 53600 53601 53605 53620 53621 53660 53661 53665

Dilation of urethral stricture by passage of sound or urethral dilator, male; initial subsequent Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia Dilation of urethral stricture by passage of filiform and follower, male; initial subsequent Dilation of female urethra including suppository and/or instillation; initial subsequent Dilation of female urethra, general or conduction (spinal) anesthesia

OTHER PROCEDURES 53850 53852 53853 53899

Transurethral destruction of prostate tissue; by microwave thermotherapy by radiofrequency thermotherapy by water-induced thermotherapy Unlisted procedure, urinary system

MALE GENITAL SYSTEM PENIS INCISION (For abdominal perineal gangrene debridement, see 11004-11006) 54000

Slitting of prepuce, dorsal or lateral (separate procedure); newborn (Do not report modifier –63 in conjunction with 54000)

54001 54015

except newborn Incision and drainage of penis, deep (For skin and subcutaneous abscess, see 10060-10160)

DESTRUCTION 54050 54055 54056 54057 54060

Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical electrodesiccation cryosurgery laser surgery surgical excision

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54065

Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive,(eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) (Report required) (For destruction or excision of other lesions, see Integumentary System)

EXCISION 54100 54105 54110 54111 54112 54115 54120 54125 54130 54135

Biopsy of penis; (separate procedure) deep structures Excision of penile plaque (Peyronie disease); with graft to 5 cm in length with graft greater than 5 cm in length Removal foreign body from deep penile tissue (eg, plastic implant) Amputation of penis; partial complete Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes (For lymphadenectomy (separate procedure), see 38760-38770)

54150

Circumcision, using clamp or other device with regional dorsal penile or ring block (Do not report modifier -63 in conjunction with 54150)

54160

Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) (Do not report modifier -63 in conjunction with 54160)

54161 54162 54163 54164

older than 28 days of age Lysis or excision of penile post-circumcision adhesions Repair incomplete circumcision Frenulotomy of penis (Do not report 54164 with circumcision codes 54150-54161, 54162, 54163)

INTRODUCTION 54200 54205 54220 54230

Injection procedure for Peyronie disease; with surgical exposure of plaque Irrigation of corpora cavernosa for priapism Injection procedure for corpora cavernosography (For radiological supervision and interpretation, use 74445)

54240 54250

Penile plethysmography Nocturnal penile tumescence and/or rigidity test

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REPAIR (For other urethroplasties, see 53400-53430) (For penile revascularization, see 37788) 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328

Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm greater than 3 cm Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, 3rd stage Cecil repair) One stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap) with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap) with urethroplasty by local skin flaps and mobilization of urethra with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap (For urethroplasty and straightening of chordee, use 54308)

54332

54336 54340 54344 54348 54352

54360 54380 54385 54390 54400 54401

One stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap One stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or excision, simple requiring mobilization of skin flaps and urethroplasty with flap or patch graft requiring extensive dissection and urethroplasty with flap, patch or tubed graft (includes urinary diversion) Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as flaps or grafts Plastic operation on penis to correct angulation Plastic operation on penis for epispadias distal to external sphincter; with incontinence (Report required) with exstrophy of bladder Insertion of penile prosthesis; non-inflatable (semi-rigid) inflatable (self contained) (For removal or replacement of penile prosthesis, see 54415, 54416)

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54405 54406 54408 54410 54411

54415 54416 54417

54420 54430 54435 54440

Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis Repair of component(s) of a multi-component, inflatable penile prosthesis Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue (Do not report 11040-11043 in addition to 54411) Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis Removal and replacement of non-inflatable (semi-rigid) or inflatable (selfcontained) penile prosthesis at the same operative session Removal and replacement of non-inflatable (semi-rigid) or inflatable (selfcontained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue (Do not report 11040-11043 in addition to 54417) Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for priapism Plastic operation of penis for injury

MANIPULATION 54450

Foreskin manipulation including lysis of preputial adhesions and stretching

TESTIS EXCISION (For abdominal perineal gangrene debridement, see 11004-11006) 54500

Biopsy of testis, needle (separate procedure) (For fine needle aspiration, see 10021, 10022)

54505

Biopsy of testis, incisional (separate procedure) (For bilateral procedure, use modifier -50)

54512 54520

Excision of extraparenchymal lesion of testis Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach (For bilateral procedure, use modifier -50)

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54522 54530 54535

Orchiectomy, partial Orchiectomy, radical, for tumor; inguinal approach with abdominal exploration (For orchiectomy with repair of hernia, see 49505 or 49507 and 54520) (For radical retroperitoneal lymphadenectomy, use 38780)

EXPLORATION (For 54550, 54560 for bilateral procedure, use modifier -50) 54550 54560

Exploration for undescended testis (inguinal or scrotal area) Exploration for undescended testis with abdominal exploration

REPAIR 54600 54620 54640

Reduction of torsion of testis, surgical, with or without fixation of contralateral testis Fixation of contralateral testis (separate procedure) Orchiopexy, inguinal approach, with or without hernia repair (For bilateral procedure, use modifier -50) (For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525)

54650

Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens) (For laparoscopic approach, use 54692)

54660

Insertion of testicular prosthesis (separate procedure) (For bilateral procedure, use modifier -50)

54670 54680

Suture or repair of testicular injury Transplantation of testis(es) to thigh (because of scrotal destruction)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 54690 54692 54699

Laparoscopy, surgical; orchiectomy orchiopexy for intra-abdominal testis Unlisted laparoscopy procedure, testis

EPIDIDYMIS INCISION 54700

Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) (For debridement of necrotizing soft tissue infection of external genitalia, see 11004-11006)

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EXCISION 54800

Biopsy of epididymis, needle (For fine needle aspiration, see 10021, 10022)

54830 54840 54860 54861

Excision of local lesion of epididymis Excision of spermatocele, with or without epididymectomy Epididymectomy; unilateral bilateral

EXPLORATION 54865

Exploration of epididymis, with or without biopsy

TUNICA VAGINALIS INCISION 55000

Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication

EXCISION 55040 55041

Excision of hydrocele; unilateral bilateral (With hernia repair, see 49495, 49501)

REPAIR 55060

Repair of tunica vaginalis hydrocele (Bottle type)

SCROTUM INCISION 55100

Drainage of scrotal wall abscess (See also 54700) (For debridement of necrotizing soft tissue infection of external genitalia, see 11004-11006)

55110 55120

Scrotal exploration Removal of foreign body in scrotum

EXCISION (For excision, local lesion of scrotum skin, see Integumentary System) 55150

Resection of scrotum

REPAIR 55175 55180

Scrotoplasty; simple complicated

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VAS DEFERENS INCISION 55200

Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)

EXCISION 55250

Vasectomy, unilateral or bilatera (separate procedure), including postoperative semen examination(s) (See Rule 13)

REPAIR 55400

Vasovasostomy, vasovasorrhaphy (For bilateral procedure, use modifier -50)

SUTURE 55450

Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) (See Rule 13)

SPERMATIC CORD EXCISION 55500 55520 55530 55535 55540

Excision of hydrocele of spermatic cord, unilateral (separate procedure) Excision of lesion of spermatic cord (separate procedure) Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) abdominal approach with hernia repair

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 55550 55559

Laparoscopy, surgical, with ligation of spermatic veins for vericocele Unlisted laparoscopy procedure, spermatic cord

SEMINAL VESICLES INCISION 55600 55605

Vesiculotomy; (For bilateral procedure, use modifier -50) complicated

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EXCISION 55650

Vesiculectomy, any approach (For bilateral procedure, use modifier -50)

55680

Excision of Mullerian duct cyst (For injection procedure, see 52010)

PROSTATE INCISION 55700

Biopsy, prostate; needle or punch, single or multiple, any approach (If imaging guidance is performed, use 76942) (For fine needle aspiration, see 10021, 10022)

55705 55720 55725

incisional, any approach Prostatotomy, external drainage of prostatic abscess, any approach; simple complicated (For transurethral drainage, use 52700)

EXCISION (For transurethral removal of prostate, see 52601-52640) (For transurethral desctruction of prostate, see 53850-53852) (For limited pelvic lymphadenectomy for staging (separate procedure), use 38562) (For independent node dissection, see 38770-38780) 55801

55810 55812 55815

55821

55831 55840 55842 55845

Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy) Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes (If 55815 is carried out on separate days, use 38770 and 55810) Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, one or two stages retropubic, subtotal Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes (If 55845 is carried out on separate days, use 38770 and 55840) (For laparoscopic retropubic radical prostatectomy, use 55866)

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55860

Exposure of prostate, any approach, for insertion of radioactive substance; (For application of interstitial radioelement, see 77776-77778)

55862 55865

with lymph node biopsy(s) (limited pelvic lymphadenectomy) with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoreoscopy) (separate procedure), use 49320 55866

Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing (For open procedure, use 55840)

OTHER PROCEDURES 55873 55875

Cryosurgical ablation of the prostate (includes ultrasounic guidance for intestinal cryosurgical probe placement) Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy (For placement of needles or catheters into pelvic organs and/or genitalia [except prostate] for interstitial radioelement application, use 55920) (For interstitial radioelement application, see 77776-77784) (For ultrasonic guidance for interstitial radioelement application, uee 76965)

55876

Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple (For imaging guidance, see 76942, 77002, 77012, 77021)

55899

Unlisted procedure, male genital system

REPRODUCTIVE SYSTEM PROCEDURES 55920

Placement of needles or catheters into pelvic organs and/ or genitalia (except prostate) for subsequent interstitial radioelement application (For placement of needles or catheters into prostate, use 55875) (For insertion of heyman capsules for clinical brachytherapy, use 58346) (For insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy, use 57155)

FEMALE GENITAL SYSTEM (For pelvic laparotomy, use 49000) (For paracentesis, see 49080, 49081) (For secondary closure of abdominal wall evisceration or disruption, use 49900) (For fulguration or excision of lesions, laparoscopic approach, use 58662) (For chemotherapy, see 96405-96549)

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(For excision or destruction of endometriomas, open method, see 49203-49205, 58957, 58958) VULVA, PERINEUM AND INTROITUS The following definitions apply to the vulvectomy codes (56620-56640): Simple: The removal of skin and superficial subcutaneous tissue. Radical: The removal of skin and deep subcutaneous tissue. Partial: Removal of less than 80% of the vulvar area. Complete: The removal of greater than 80% of the vulvar area. INCISION (For incision and drainage of sebaceous cyst, furuncle, or abscess, see 10040, 10060, 10061) 56405 56420

Incision and drainage of vulva or perineal abscess Incision and drainage of Bartholin's gland abscess (For incision and drainage of Skene's gland abscess or cyst, use 53060)

56440 56441 56442

Marsupialization of Bartholin's gland cyst Lysis of labial adhesions Hymenotomy, simple incision

DESTRUCTION 56501 56515

Destruction of lesion(s), vulva; simple, (laser surgery, electrosurgery, cryosurgery, chemosurgery) extensive, (laser surgery, electrosurgery, cryosurgery, chemosurgery) (For destruction of Skene's gland cyst or abscess, use 53270) (For cautery destruction of urethral caruncle, use 53265)

EXCISION 56605 56606

Biopsy of vulva or perineum. (separate procedure); one lesion each separate additional lesion (List separately in addition to primary procedure) (Use 56606 in conjunction with 56605) (For excision of local lesion, see 11420-11426, 11620-11626)

56620 56625

Vulvectomy simple; partial complete (For skin graft, see 15002 et seq)

56630

Vulvectomy, radical, partial; (For skin graft, if used, see 15004-15005, 15120, 15121, 15240, 15241)

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56631 56632 56633 56634 56637 56640

with unilateral inguinofemoral lymphadenectomy with bilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete; with unilateral inguinofemoral lymphadenectomy with bilateral inguinofemoral lymphadenectomy Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy (For bilateral procedure, use modifier -50) (For lymphadenectomy, see 38760-38780)

56700 56740

Partial hymenectomy or revision of hymenal ring Excision of Bartholin's gland or cyst (For excision of Skene's gland, use 53270) (For excision of urethral caruncle, use 53265) (For excision or fulguration of urethral carcinoma, use 53220) (For excision or marsupialization of urethral diverticulum, see 53230-53240)

REPAIR (For repair of urethra for mucosal prolapse, use 53275) 56800 56805 56810

Plastic repair of introitus Clitoroplasty for intersex state Perineoplasty, repair of perineum, non-obstetrical (separate procedure) (See also 56800) (For repair of wounds to genitalia, see 12001-12007, 12041-12047, 13131-13133) (For anal sphincteroplasty, see 46750, 46751) (For repair of recent injury of vagina and perineum, nonobstetrical, use 57210) (For episiorrhaphy, episioperineorrhaphy for recent injury of vulva and/or perineum, nonobstetrical, use 57210)

ENDOSCOPY 56820 56821

Colposcopy of the vulva; with biopsy(s) (For colposcopic examinations/procedures involving the vagina, see 57420, 57421; cervix, see 57452-57461)

VAGINA INCISION 57000 57010 57020 57022 57023

Colpotomy; with exploration with drainage of pelvic abscess Colpocentesis (separate procedure) Incision and drainage of vaginal hematoma; obstetrical/post-partum non-obstetrical (eg, post-trauma, spontaneous bleeding)

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DESTRUCTION 57061

Destruction of vaginal lesion(s); simple, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) extensive, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery)

57065

EXCISION 57100 57105 57106 57107 57109

Biopsy of vaginal mucosa; simple (separate procedure) extensive, requiring suture (including cysts) Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) Colpocleisis (Le Fort Type) Excision of vaginal septum Excision of vaginal cyst or tumor

57110 57111 57112 57120 57130 57135

INTRODUCTION 57150

Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease Insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy

57155

(For placement of needles or catheters into pelvic organs and/or genitalia [except prostate] for interstitial radioelement application, use 55920) (For insertion of radioelement sources or ribbons, see 77761-77763, 77781-77784) 57160 57180

Fitting and insertion of pessary or other intravaginal support device Introduction of any hemostatic agent or pack for spontaneous or traumatic non-obstetrical hemorrhage (separate procedure)

REPAIR (For urethral suspension, Marshall-Marchetti- Krantz type, abdominal approach, see 51840, 51841) (For laparoscopic suspension, use 51990) 57200 57210 57220 57230 57240 57250

Colporrhaphy, suture of injury of vagina (nonobstetrical) Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical) Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication) Plastic repair of urethrocele Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy (For repair of rectocele (separate procedure) without posterior colporrhapy, use 45560)

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57260 57265 57267

Combined anteroposterior colporrhaphy; with enterocele repair Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to primary procedure) (Use 57267 in addition to 45560, 57240-57265)

57268 57270 57280 57282 57283 57284

Repair of enterocele, vaginal approach (separate procedure) Repair of enterocele, abdominal approach (separate procedure) Colpopexy, abdominal approach Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) intra-peritoneal approach (uterosacral, levator myorrhaphy) Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach (Do not report 57284 in conjunction with 51840, 51841,51990, 57240, 57260, 57265, 58152, 58267)

57285

vaginal approach (Do not report 57285 in conjunction with 51990, 57240, 57260, 57265, 58267)

57287 57288

Removal or revision of sling for stress incontinence (eg, fascia or synthetic) Sling operation for stress incontinence (eg, fascia or synthetic) (For laparoscopic approach, use 51992)

57289 57291 57292 57295 57296 57300 57305 57307 57308

Pereyra procedure, including anterior colporrhaphy Construction of artificial vagina; without graft with graft Revision (including removal) of prosthetic vaginal graft, vaginal approach open abdominal approach Closure of rectovaginal fistula; vaginal or transanal approach abdominal approach abdominal approach, with concomitant colostomy transperineal approach, with perineal body reconstruction, with or without levator plication Closure of urethrovaginal fistula; with bulbocavernosus transplant (Report required) Closure of vesicovaginal fistula; vaginal approach

57310 57311 57320

(For concomitant cystostomy, see 51020-51040, 51101, 51102) 57330 57335

transvesical and vaginal approach (For abdominal approach, use 51900) Vaginoplasty for intersex state

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MANPULATION 57400 57410 57415

Dilation of vagina under anesthesia Pelvic examination under anesthesia (Report required) Removal of impacted vaginal foreign body (separate procedure) under anesthesia (For removal without anesthesia of an impacted vaginal foreign body, use the appropriate Evaluation and Management code)

ENDOSCOPY 57420 57421

Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix (For colposcopic visualization of cervix and adjacent upper vagina; use 57452) (For colposcopic examinations/procedures involving the vulva, see 56820, 56821; cervix, see 57452-57461) (For endometrial sampling (biopsy) performed in conjunction with colposcopy, use 58110)

57423

Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach (Do not report 57423 in conjunction with 49320, 51840, 51841, 51990, 57240, 57260, 58152, 58267)

57425

Laparoscopy, surgical, colpopexy (suspension of vaginal apex)

CERVIX UTERI ENDOSCOPY (For colposcopic examinations/procedures involving the vulva, see 56820, 56821, vagina, see 57420, 57421) 57452

Colposcopy of the cervix including upper/adjacent vagina; (Do not report 57452 in addition to 57454-57461)

57454 57455 57456 57460 57461

with biopsy(s) of the cervix and endocervical curettage with biopsy(s) of the cervix with endocervical curettage with loop electrode biopsy(s) of the cervix with loop electrode conization of the cervix (Do not report 57456 in addition to 57461) (For endometrial sampling (biopsy) performed in conjunction with colposcopy, use 58110)

EXCISION (For radical surgical procedures, see 58200-58240) 57500

Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)

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57505 57510 57511 57513 57520

Endocervical curettage (not done as part of a dilation and curettage) Cautery of cervix; electro or thermal cryocautery, initial or repeat laser ablation Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser (See also 58120)

57522 57530 57531

loop electrode excision Trachelectomy (cervicectomy), amputation of cervix (separate procedure) Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy, with or without removal of tube(s), with or without removal of ovary(s) (For radical abdominal hysterectomy, use 58210)

57540 57545 57550 57555 57556

Excision of cervical stump, abdominal approach; with pelvic floor repair Excision of cervical stump, vaginal approach; with anterior and/or posterior repair with repair of enterocele (For insertion of intrauterine device, use 58300) (For insertion of any hemostatic agent or pack for control of spontaneous nonobstetrical hemorrhage, see 57180)

57558

Dilation and curettage of cervical stump

REPAIR 57700 57720

Cerclage of uterine cervix, nonobstetrical Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach

MANIPULATION 57800

Dilation of cervical canal, instrumental (separate procedure)

CORPUS UTERI EXCISION 58100

Endometrial sampling (biopsy), with or without endocervical sampling(biopsy), without cervical dilation, any method (separate procedure) (For endocervical currettage only, use 57505) (For endometrial sampling (biopsy) performed in conjunction with colposcopy (57420, 57421, 57452-57461), use 58110)

58110

Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to primary procedure) (Use 58110 in conjunction with 57420, 57421, 57452-57461)

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58120

Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) (For postpartum hemorrhage, use 59160)

58140

58145 58146

Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach vaginal approach Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams, abdominal approach (Do not report 58146 in addition to 58140-58145, 58150-58240)

HYSTERECTOMY PROCEDURES (For codes 58150-58294, See Rule 14, Receipt of Hysterectomy Information) 58150 58152

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch) (For urethrocystopexy without hysterectomy, see 51840, 51841)

58180 58200

58210

Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) (For radical hysterectomy with ovarian transposition, use also 58825)

58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof (For pelvic ententeration for lower urinary tract or male genital malignancy, use 51597) 58260 58262 58263 58267 58270

Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s) with removal of tube(s), and/or ovary(s), with repair of enterocele (Do not report 58263 in addition to 57283) with colpo-urethrocystopexy (Marshall-Marchetti-Krantz Type, Pereyra type, with or without endoscopic control) with repair of enterocele (For repair of enterocele with removal of tubes and/or ovaries, use 58263)

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58275 58280 58285 58290 58291 58292 58293 58294

Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele Vaginal hysterectomy, radical (Schauta type operation) Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s) with removal of tube(s) and/or ovary(s), with repair of enterocele with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control with repair of enterocele

INTRODUCTION (For insertion, removal and supply of implantable contraceptive capsules, see 11975, 11976, 11977) 58300 58301 58340

Insertion of intrauterine device (IUD) Removal of intrauterine device (IUD) Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (sis) or hysterosalpingography (For radiological supervision and interpretation of saline infusion sonohysterography, use 76831) (For radiological supervision and interpretation of hysterosalpingography, use 74740)

58346

Insertion of Heyman capsules for clinical brachytherapy (For placement of needles or catheters into pelvic organs and/or genitalia [except prostate] for interstitial radioelement application, use 55920) (For insertion of radioelement sources or ribbons, see 77761-77763, 77781-77784)

58353

Endometrial ablation, thermal, without hysteroscopic guidance (For hysteroscopic procedure, use 58563)

REPAIR 58400 58410 58520 58540

Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate procedure) with presacral sympathectomy Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) Hysteroplasty, repair of uterine anomaly (Strassman type) (Report required) (For closure of vesicouterine fistula, use 51920)

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LAPAROSCOPY/HYSTEROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. To report a diagnostic hysteroscopy (separate procedure), use 58555. (For codes 58541-58544, 58548-58554, 58570-58573, See Rule 14, Receipt of Hysterectomy Information) (For code 58565, See Rule 13, Informed Consent for Sterilization) (Do not report 58541-58544, 58550-58552, 58553-58554, 58570-58575 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58150, 58545, 58546, 58561, 58661, 58670, 58671) 58541 58542 58543 58544 58545 58546 58548

58550 58552 58553 58554 58555 58558 58559 58560 58561 58562 58563 58565

58570 58571

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed (Do not report 58548 in conjunction with 38570-38572, 58210, 58285, 58550-58554) Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s) Hysteroscopy, diagnostic (separate procedure) Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C with lysis of intrauterine adhesions (any method) with division or resection of intrauterine septum (any method) with removal of leiomyomata with removal of impacted foreign body with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants (Do not report 58565 in conjunction with 58555 or 57800) Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

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58572 58573 58578 58579

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Unlisted laparoscopy procedure, uterus Unlisted hysteroscopy procedure, uterus

OVIDUCT/OVARY INCISION (For codes 58600-58615, See Rule 13, Informed Consent for Sterilization) 58600 58605

Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) (For laparoscopic procedures, use 58670, 58671)

58611

Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to primary procedure)

58615

Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach (For laparoscopic approach, use 58671) (For lysis of adnexal adhesions, use 58740)

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. (For codes 58670, 58671, See Rule 13, Informed Consent for Sterilization) 58660 58661 58662 58670 58671 58673

58679

Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method with fulguration of oviducts (with or without transection) with occlusion of oviducts by device (eg, band, clip, or Falope ring) with salpingostomy (salpingoneostomy) (Code 58673 is used to report unilateral procedures, for bilateral procedure, use modifier -50) Unlisted laparoscopy procedure, oviduct, ovary (For laparoscopic aspiration of ovarian cyst, use 49322) (For laparoscopic biopsy of the ovary or fallopian tube, use 49321)

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EXCISION 58700 58720

Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)

REPAIR 58740

Lysis of adhesions (salpingolysis, ovariolysis) (For laparascopic approach, use 58660) (For fulguration or excision of lesions, laparascopic approach, use 58662) (For excision/destruction of endometriomas, open method, see 49203-49205, 58957, 58958)

58770

Salpingostomy (salpingoneostomy) (For laparoscopic approach, use 58673)

OVARY INCISION 58800 58805 58820 58822 58823

Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); vaginal approach abdominal approach Drainage of ovarian abscess; vaginal approach, open abdominal approach Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous (eg, ovarian, pericolic) (For radiological supervision and interpretation, use 75989)

58825

Transposition, ovary(s)

EXCISION (For codes 58951, 58953, 58954, 58956, See Rule 14, Receipt of Hysterectomy Information) 58900

Biopsy of ovary, unilateral or bilateral (separate procedure) (For laparoscopic biopsy of the ovary or fallopian tube, use 49321)

58920 58925 58940

Wedge resection or bisection of ovary, unilateral or bilateral Ovarian cystectomy, unilateral or bilateral Oophorectomy, partial or total, unilateral or bilateral; (For oophorectomy with concomitant debulking for ovarian malignancy, use 58952)

58943

for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s) with or without omentectomy

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58950 58951 58952

Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy with radical dissection for debulking (ie, radical excision or destruction, intraabdominal or retroperitoneal tumors) (For resection of recurrent ovarian, tubal, primary peritoneal, or uterine malignancy, see 58957, 58958)

58953 58954 58956

58957

58958

Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy (Do not report 58956 in conjunction with 49255, 58150, 58180, 58262, 58263, 58550, 58661, 58700, 58720, 58900, 58925, 58940, 58957, 58958) Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy (Do not report 58957, 58958 in conjunction with 38770, 38780, 44005, 49000, 49203-49215, 49255, 58900-58960)

58960

Laparotomy, for staging or restaging of ovarian, tubal or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy (Do not report 58960 in conjunction with 58957, 58958)

58999

Unlisted procedure, female genital system, nonobstetrical

MATERNITY CARE AND DELIVERY The services normally provided in uncomplicated maternity cases include antepartum care, delivery, and postpartum care. Antepartum care includes the initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. Any other visits or services within this time period should be coded separately. Delivery services include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery. Medical problems complicating labor and delivery management may require additional resources and should be identified by utilizing the codes in the Medicine and E/M Services section in addition to codes for maternity care. Version 2008 – 1 (5/15/2008)

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Epidurals are to be billed using the delivery code with the -AA modifier. The number of units should indicate the actual face to face time spent with the patient. Postpartum care includes hospital and office visits following vaginal or cesarean section delivery. For medical complications of pregnancy (eg, cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, pre-term labor, premature rupture of membranes), see services in the Medicine and E/M Services section. For surgical complications of pregnancy (eg, appendectomy, hernia, ovarian cyst, bartholin cyst), see services in the Surgery section. If a physician provides all or part of the antepartum and/or postpartum patient care but does not perform delivery due to termination of pregnancy by abortion or referral to another physician for delivery, see the antepartum and postpartum care codes 59425-59426 and 59430. (For circumcision of newborn, see 54150, 54160) Reimbursement amounts for the Medicaid Obstetrical and Maternal Services Program (MOMS), are noted in the Surgery excel Fee Schedule. For information on the MOMS Program, see Policy Section. ANTEPARTUM SERVICES 59000

Amniocentesis; diagnostic (For radiological supervision and interpretation, use 76946)

59001 59012

therapeutic amniotic fluid reduction (includes ultrasound guidance) Cordocentesis (intrauterine), any method (For radiological supervision and interpretation, use 76941)

59015

Chorionic villus sampling, any method (For radiological supervision and interpretation, use 76945)

59020 59025 59030 59050

Fetal contraction stress test Fetal non-stress test Fetal scalp blood sampling Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; supervision and interpretation

EXCISION (For code 59135, See Rule 14, Receipt of Hysterectomy Information) 59100

Hysterotomy, abdominal (eg, for hydatidiform mole, abortion) (When tubal ligation is performed at the same time as hysterotomy, use 58611 in addition to 59100)

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59120 59121 59130 59135 59136 59140 59150 59151 59160

Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach tubal or ovarian, without salpingectomy and/or oophorectomy abdominal pregnancy interstitial, uterine pregnancy requiring total hysterectomy interstitial, uterine pregnancy with partial resection of uterus cervical, with evacuation (Report required) Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy with salpingectomy and/or oophorectomy Curettage, postpartum

INTRODUCTION (For intrauterine fetal transfusion, use 36460) (For introduction of hypertonic solution and/or prostaglandins to initiate labor, see 5985059857) 59200

Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure)

REPAIR (For tracheloplasty, use 57700) 59300 59320 59325 59350

Episiotomy or vaginal repair, by other than attending physician Cerclage of cervix, during pregnancy; vaginal abdominal Hysterorrhaphy of ruptured uterus

VAGINAL DELIVERY, ANTEPARTUM AND POSTPARTUM CARE 59400

59409

59410 59414

Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and (inpatient and outpatient) postpartum care (total, all-inclusive, "global" care) Vaginal delivery only (with or without episiotomy and/or forceps); (when only inpatient postpartum care is provided in addition to delivery, see appropriate HOSPITAL E/M code(s) for postpartum care visits) including (inpatient and outpatient) postpartum care Delivery of placenta (separate procedure) (For antepartum care only, see 59425, 59426 or appropriate E/M code(s)) (For 1-3 antepartum care visits, see appropriate E/M code(s))

59425

Antepartum care only; 4-6 visits Procedure code 59425 includes reimbursement for one initial antepartum encounter (54.00) and five subsequent encounters (31.00). If less than 6 antepartum encounters were provided, adjust the amount charged accordingly.

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59426

59430

7 or more visits Procedure code 59426 includes reimbursement for one initial antepartum encounter (54.00) and eight subsequent encounters (31.00). If less than 9 antepartum encounters were provided, adjust the amount charged accordingly. For 6 or less antepartum encounters, see code 59425. Postpartum care only (outpatient) (separate procedure)

CESAREAN DELIVERY (For low cervical or classical cesarean section, see 59510, 59515, 59525) 59510 59514

59515 59525

Routine obstetric care including antepartum care, cesarean delivery, and (inpatient and outpatient) postpartum care (total, all-inclusive, "global" care) Caesarean delivery only; (when only inpatient postpartum care is provided in addition to delivery, see appropriate HOSPITAL E/M code(s) for postpartum care visits) including (inpatient and outpatient) postpartum care Subtotal or total hysterectomy after cesarean delivery (See Rule 14) (List separately in addition to primary procedure) (Use 59525 in conjunction with 59510, 59514, 59515, or 59618, 59620, 59622) (For extraperitoneal cesarean section, or cesarean section with subtotal or total hysterectomy, see 59510, 59515, 59525)

DELIVERY AFTER PREVIOUS CESAREAN DELIVERY Patients who have had a previous cesarean delivery and now present with the expectation of a vaginal delivery are coded using codes 59610-59622. If the patient has a successful vaginal delivery after a previous cesarean delivery (VBAC), use codes 59610-59614. If the attempt is unsuccessful and another cesarean delivery is carried out, use codes 59618-59622. To report elective cesarean deliveries use code 59510, 59514 or 59515. 59610

59612

59614 59618

59620

59622

Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and (inpatient and outpatient) postpartum care, after previous cesarean delivery (total, all-inclusive, "global" care) Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); (when only inpatient postpartum care is provided in addition to delivery, see appropriate HOSPITAL E/M code(s) for postpartum care visits) including (inpatient and outpatient) postpartum care Routine obstetric care including antepartum care, cesarean delivery, and (inpatient and outpatient) postpartum care, following attempted vaginal delivery after previous cesarean delivery (total, all-inclusive, "global" care) Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; (when only inpatient postpartum care is provided in addition to delivery, see appropriate HOSPITAL E/Mcode(s) for postpartum care visits) including (inpatient and outpatient) postpartum care

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ABORTION (For surgical treatment of spontaneous abortion, use 59812) (For medical treatment of spontaneous complete abortion, any trimester, use E&M codes 99201-99233) (Ultrasound service(s) provided in conjunction with procedure codes 59812 through 59857 are reimbursable ONLY via echography code 76815. Procedure code 76815 should be billed regardless of the approach used to perform the ultrasound (eg, transvaginal)) 59812 59820 59821 59830 59840 59841 59850 59851 59852

Treatment of incomplete abortion, any trimester, completed surgically Treatment of missed abortion, completed surgically; first trimester second trimester Treatment of septic abortion, completed surgically Induced abortion, by dilation and curettage Induced abortion, by dilation and evacuation Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation with hysterotomy (failed intra-amniotic injection) (For insertion of cervical dilator, use 59200)

59855

59856 59857

Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation with hysterotomy (failed medical evaluation)

OTHER PROCEDURES 59870 59871 59898 59899

Uterine evacuation and curettage for hydatidiform mole Removal of cerclage suture under anesthesia (other than local) Unlisted laparoscopy procedure, maternity care and delivery Unlisted procedure, maternity care and delivery

ENDOCRINE SYSTEM (For pituitary and pineal surgery, see Nervous System) THYROID GLAND INCISION 60000

Incision and drainage of thyroglossal duct cyst, infected

EXCISION 60100

60200

Biopsy thyroid, percutaneous core needle (If image guidance is performed, see 76942, 77002, 77012, 77021) (For fine needle aspiration, use 10021, 10022) Excision of cyst or adenoma of thyroid, or transection of isthmus Version 2008 – 1 (5/15/2008)

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60210 60212 60220 60225 60240

Partial thyroid lobectomy, unilateral; with or without isthmusectomy with contralateral subtotal lobectomy, including isthmusectomy Total thyroid lobectomy, unilateral; with or without isthmusectomy with contralateral subtotal lobectomy, including isthmusectomy Thyroidectomy, total or complete (For thyroidectomy, subtotal or partial, use 60271)

60252 60254 60260

Thyroidectomy, total or subtotal for malignancy; with limited neck dissection with radical neck dissection Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid (For bilateral procedure, use modifier -50)

60270 60271 60280 60281

Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach cervical approach Excision of thyroglossal duct cyst or sinus; recurrent (For thyroid ultrasonography, see 76536)

REMOVAL 60300

Aspiration and/or injection, thyroid cyst (For fine needle aspiration, see 10021, 10022) (If imaging guidance is performed, see 76942, 77012)

PARATHYROID, THYMUS, ADRENAL GLANDS, PANCREAS, AND CARTOID BODY EXCISION 60500 60502 60505 60512

Parathyroidectomy or exploration of parathyroid(s); re-exploration with mediastinal exploration, sternal split or transthoracic approach Parathyroid autotransplantation (List separately in addition to primary procedure) (Use 60512 in conjunction with codes 60500, 60502, 60505, 60212, 60225, 60240, 60252, 60254, 60260, 60270, 60271)

60520 60521

Thymectomy, partial or total; transcervical approach (separate procedure) sternal split or transthoracic approach, without radical mediastinal dissection (separate procedure) sternal split or transthoracic approach, with radical mediastinal dissection (separate procedure)

60522

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60540 60545

Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor (For bilateral procedure, use modifier -50) (For laparoscopic approach, use 60650) (For excision of remote or disseminated pheochromocytoma, see 49203-49205)

60600 60605

Excision of carotid body tumor; without excision of carotid artery with excision of carotid artery

LAPAROSCOPY Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320. 60650 60659

Laparoscopy, surgical; with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal Unlisted laparoscopiy procedure, endocrine system

OTHER PROCEDURES 60699

Unlisted procedure, endocrine system

NERVOUS SYSTEM SKULL, MENINGES, AND BRAIN (For injection procedure for cerebral angiography, see 36100-36218) (For injection procedure for ventriculography, see 61026, 61120) (For injection procedure for pneumoencephalography, use 61055) INJECTION, DRAINAGE OR ASPIRATION 61000 61001 61020 61026 61050 61055 61070

Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial subsequent taps Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection with injection of medicament or other substance for diagnosis or treatment Cisternal or lateral cervical (Cl-C2) puncture; without injection (separate procedure) with injection of medicament or other substance for diagnosis or treatment (Cl-C2) Puncture of shunt tubing or reservoir for aspiration or injection procedure (For radiological supervision and interpretation, use 75809)

TWIST DRILL, BURR HOLE(S) OR TREPHINE (For codes 61107, 61210 for intracranial neuroendoscopic ventricular catheter placement, use 62160) 61105

Twist drill hole for subdural or ventricular puncture;

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61107

61108 61120 61140 61150 61151 61154 61156 61210 61215

Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device for evacuation and/or drainage of subdural hematoma Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye or radioactive material); Burr hole(s) or trephine; with biopsy of brain or intracranial lesion with drainage of brain abscess or cyst with subsequent tapping (aspiration) of intracranial abscess or cyst Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural (For bilateral procedure, use modifier -50) Burr hole(s); with aspiration of hematoma or cyst, intracerebral for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure) Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter (For refilling and maintenance of an implantable infusion pump for spinal or brain drug therapy, use 95990) (For chemotherapy, use 96450)

61250

Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery (For bilateral procedure, use modifier -50)

61253

Burr hole(s) or trephine, infratentorial, unilateral or bilateral (If burr hole(s) or trephine followed by craniotomy at same operative session use 61304-61321; do not use 61250 or 61253)

CRANIECTOMY OR CRANIOTOMY 61304 61305 61312 61313 61314 61315 61316

61320 61321

Craniectomy or craniotomy, exploratory; supratentorial infratentorial (posterior fossa) Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural intracerebral Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural intracerebellar Incision and subcutaneous placement of cranial bone graft (List separately in addition to primary procedure) (Use 61316 in conjunction with codes 61304, 61312, 61313, 61322, 61323, 61340, 61570, 61571, 61680-61705) Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial infratentorial

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61322

61323

Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy with lobectomy (Do not report 61313 in addition to 61322, 61323) (For subtemporal decompression, use 61340)

61330

Decompression of orbit only, transcranial approach (For bilateral procedure, use modifier -50)

61332 61333 61334 61340

Exploration of orbit (transcranial approach); with biopsy with removal of lesion with removal of foreign body Subtemporal cranial decompression (pseudotumor cerebri, slit ventrical syndrome) (For bilateral procedure, use modifier -50) (For decompressive craniotomy or craniectomy for intracranial hypertension, without hematoma evacuation, see 61322, 61323)

61343 61345

Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation) Other cranial decompression, posterior fossa (For orbital decompression by lateral wall approach, kroenlein type, use 67445)

61440 61450 61458 61460 61470 61480 61490 61500 61501 61510 61512 61514 61516

Craniotomy for section of tentorium cerebelli (separate procedure) Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion Craniectomy, suboccipital; for exploration or decompression of cranial nerves for section of one or more cranial nerves for medullary tractotomy for mesencephalic tractotomy or pedunculotomy Craniotomy for lobotomy, including cingulotomy (For bilateral procedure, use modifier -50) Craniectomy; with excision of tumor or other bone lesion of skull for osteomyelitis Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma for excision of meningioma, supratentorial for excision of brain abscess, supratentorial for excision or fenestration of cyst, supratentorial (For excision of pituitary tumor or craniopharyngioma, see 61545, 61546, 61548)

61517

Implantation of brain intracavitary chemotherapy agent (List separately in addition to primary procedure) (Use 61517 only in conjunction with codes 61510 or 61518) (Do not report 61517 for brachytherapy insertion. For intracavitary insertion of radioelement sources or ribons, see 77781-77784)

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61518 61519 61520 61521 61522 61524 61526 61530 61531

Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningloma, cerebellopontine angle tumor, or midline tumor at base of skull meningioma cerebellopontine angle tumor midline tumor at base of skull Craniectomy, infratentorial or posterior fossa; for excision of brain abscess for excision or fenestration of cyst Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy Subdural implantation of strip electrodes through one or more burr or trephine hole(s) for long term seizure monitoring (For stereotactic implantation of electrodes, see 61760) (For craniotomy for excision of intracranial arteriovenous malformation, see 6168061692)

61533

Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long term seizure monitoring (For continuous EEG monitoring, see 95950-95954)

61534 61535 61536 61537 61538 61539 61540 61541 61542 61543 61544 61545

for excision of epileptogenic focus without electrocorticography during surgery for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array) for lobectomy, temporal lobe, without electrocorticography during surgery for lobectomy, temporal lobe, with electrocorticography during surgery for lobectomy, other than temporal lobe, partial or total with electrocorticography during surgery for lobectomy, other than temporal lobe, partial or total, without electrocorticography during surgery for transection of corpus callosum for total hemispherectomy for partial or subtotal (functional) hemispherectomy for excision or coagulation of choroid plexus for excision of craniopharyngioma (For craniotomy for selective amygdalohippocampectomy, use 61566) (For craniotomy for multiple subpial transections during surgery, use 61567)

61546 61548 61550 61552

Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic Craniectomy for craniosynostosis;single cranial suture multiple cranial sutures

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(For cranial reconstruction for orbital hypertelorism, see 21260-21263) (For reconstruction, see 21172-21180) 61556 61557 61558 61559

Craniotomy for craniosynostosis; frontal or parietal bone flap bifrontal bone flap Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); not requiring bone grafts recontouring with multiple osteotomies and bone autografts (eg, barrel-stave procedure) (includes obtaining grafts) (For reconstruction, see 21172-21180)

61563 61564

Excision, intra- and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); without optic nerve decompression (Report required) with optic nerve decompression (For reconstruction, see 21181-21183)

61566 61567 61570 61571

Craniotomy with elevation of bone flap; for selective amygdalohippocampectomy for multiple subpial transections, with electrocorticography during surgery Craniectomy or craniotomy; with excision of foreign body from brain with treatment of penetrating wound of brain (For sequestrectomy for osteomyelitis, use 61501)

61575 61576

Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy) (For arthrodesis, use 22548)

SURGERY OF SKULL BASE The surgical management of lesions involving the skull base (base of anterior, middle and posterior cranial fossae) often requires the skills of several surgeons of different surgical specialties working together or in tandem during the operative session. These operations are usually not staged because of the need for definitive closure of dura, subcutaneous tissues and skin to avoid serious infections such as osteomyelitis and/or meningitis. The procedures are categorized according to 1) approach procedure necessary to obtain adequate exposure to the lesion (pathologic entity), 2) definitive procedure(s) necessary to biopsy, excise or otherwise treat the lesion, and 3) repair/reconstruction of the defect present following the definitive procedure(s). The approach procedure is described according to anatomical area involved, ie, anterior cranial fossa, middle cranial fossa, posterior cranial fossa and brain stem or upper spinal cord. The definitive procedure(s) describes the repair, biopsy, resection or excision of various lesions of the skull base and, when appropriate, primary closure of the dura, mucous membranes and skin.

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The repair/reconstruction procedure(s) is reported separately if extensive dural grafting, cranioplasty, local or regional myocutaneous pedicle flaps, or extensive skin grafts are required. For primary closure, see the appropriate codes, ie, 15732, 15756-15758. When one surgeon performs the approach procedure, another surgeon performs the definitive procedure, and another surgeon performs the repair/reconstruction procedure, each surgeon reports only the code for the specific procedure performed. APPROACH PROCEDURES 61580

61581 61582 61583 61584

61585 61586 61590

61591

61592

61595

61596

Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration extradural, including lateral rhinotomy, orbital exenteration, ethmoidectomy, sphenoidectomy and/or maxillectomy extradural, including unilateral or bifrontal craniotomy, elevation of frontal lobe(s), osteotomy of base of anterior cranial fossa intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); without orbital exenteration with orbital exenteration Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without internal fixation, without bone graft Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous carotid artery Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) including mastoidectomy, resection of sigmoid sinus, with or without decompression and/or mobilization of contents of auditory canal or petrous carotid artery Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, with or without mobilization Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including labyrinthectomy, decompression, with or without mobilization of facial nerve and/or petrous carotid artery

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61597

61598

Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull base including occipital condylectomy, mastoidectomy, resection of Cl-C3 vertebral body(s), decompression of vertebral artery, with or without mobilization Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus

DEFINITIVE PROCEDURES 61600 61601 61605 61606 61607 61608

Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural intradural, including dural repair, with or without graft Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; extradural intradural, including dural repair, with or without graft Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; extradural intradural, including dural repair, with or without graft (Codes 61609-61612 are reported in addition to code(s) for primary procedure(s) 61605-61608). Report only one transection or ligation of cartoid artery code per operative session)

61609 61610 61611 61612 61613 61615

61616

Transection or ligation, carotid artery in cavernous sinus; without repair (List separately in addition to primary procedure) with repair by anastomosis or graft (List separately in addition to primary procedure) Transection or ligation, carotid artery in petrous canal; without repair (List separately in addition to primary procedure) with repair by anastomosis or graft (List separately in addition to primary procedure) Obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by dissection within cavernous sinus Resection or excision of neoplastic vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or CI-C3 vertebral bodies; extradural intradural, including dural repair, with or without graft

REPAIR AND/OR RECONSTRUCTION OF SURGICAL DEFECTS OF SKULL BASE 61618

61619

Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts) by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occipitalis muscle)

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ENDOVASCULAR THERAPY 61623

Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion (If selective catheterization and angiography of arteries other than artery to be occluded is performed, use appropriate catheterization and radiologic supervision and interpretation codes) (If complete diagnostic angiography of the artery to be occluded is performed immediately prior to temporary occlusion, use appropriate radiologic supervision and interpretation codes only)

61624

61626

61630 61635

Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) (For radiological supervision and interpretation, use 75894) (See also 37204) non-central nervous system, head or neck (extracranial, brachiocephalic branch) (For radiological supervision and interpretation, use 75894) (See also 37204) Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous (Report required) Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if performed (Report required) (61630 and 61635 include all selective vascular catheterization of the target vascular family, all diagnostic imaging for arteriography of the target vascular family, and all related radiological supervision and interpretation. When diagnostic arteriogram (including imaging and selective catheterization) confirms the need for angioplasty or stent placement, 61630 and 61635 are inclusive of these services. If angioplasty or stenting are not indicated, then the appropriate codes for selective catheterization and imaging should be reported in lieu of 61630 and 61635)

61640 61641 61642

Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel (Report required) each additional vessel in same vascular family (Report required) (List separately in addition to primary procedure) each additional vessel in different vascular family (Report required) (List separately in addition to primary procedure) (Use 61641 and 61642 in conjunction with 61640) (61640, 61641, 61642 include all selective vascular catheterization of the target vessel, contrast injection(s), vessel measurement, roadmapping, postdilatation angiography, and fluoroscopic guidance for the balloon dilatation)

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SURGERY FOR ANEURYSM, ARTERIOVENOUS MALFORMATION OR VASCULAR DISEASE Includes craniotomy when appropriate for procedure. 61680 61682 61684 61686 61690 61692 61697 61698

Surgery of intracranial arteriovenous malformation; supratentorial, simple supratentorial, complex infratentorial, simple infratentorial, complex dural, simple dural, complex Surgery of complex intracranial aneurysm, intracranial approach; cartoid circulation veretrobasilar circulation (61697, 61698 involve aneurysms that are larger than 15 mm or with calcification of the aneurysm neck, or with incorporation of normal vessels into the aneurysm neck, or a procedure requiring temporary vessel occulsion, trapping or cardiopulmonary bypass to successfully treat the aneurysm)

61700 61702 61703

Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation vertebrobasilar circulation Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone-Crutchfield type) (For cervical approach for direct ligation of carotid artery, see 37600-37606)

61705 61708

Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery by intracranial electrothrombosis (For ligation or gradual occlusion of internal/common carotid artery, see 37605, 37606)

61710 61711

by intra-arterial embolization, injection procedure, or balloon catheter Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries (For carotid or vertebral thromboendarterectomy, use 35301)

STEREOTAXIS 61720 61735 61750 61751

Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus subcortical structure(s) other than globus pallidus or thalamus Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance (For radiological supervision and interpretation of computerized tomography, see 70450, 70460, or 70470 as appropriate) (For radiological supervision and interpretation of magnetic resonance imaging, see 70551, 70552, or 70553 as appropriate)

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61760 61770 61790 61791 61793

Stereotactic implantation of depth electrodes into the cerebrum for long term seizure monitoring Stereotactic localization, including burr hole(s); with insertion of catheter(s) or probe(s) for placement of radiation source Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion trigeminal medullary tract (Report required) Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator), one or more sessions

NEUROSTIMULATORS (INTRACRANIAL) Codes 61850-61888 apply to both simple and complex neurostimulators. For initial or subsequent electronic analysis and programming of neurostimulator pulse generators, see codes 95970-95975. Microelectrode recording, when performed by the operating surgeon in association with implantation of neurostimulator electrode arrays, is an inclusive service and should not be reported separately. If another physician participates in neurophysiological mapping during a deep brain stimulator implantation procedure, this service may be reported by the other physician with codes 95961-95962. 61850 61860 61863

61864

61867

61868

61870 61875 61880 61885 61886

Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral; cortical Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array each additional array (List separately in addition to primary procedure) (Use 61864 in conjunction with 61863) Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array each additional array (List separately in addition to primary procedure) (Use 61868 in conjunction with 61867) Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical subcortical Revision or removal of intracranial neurostimulator electrodes Incision or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array with connection to two or more electrode arrays

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(For open placement of cranial nerve (eg, vagal, trigeminal, neurostimulator electrode(s), use 64573) (For percutaneous placement of cranial nerve (eg, vagal, trigeminal) neurostimulator electrode(s), use 64553) (For revision or removal of cranial nerve (eg, vagal, trigeminal) neurostimulator electrode(s), use 64585) 61888

Revision or removal of cranial neurostimulator pulse generator or receiver (Do not report 61888 in conjunction with 61885 or 61886 for the same pulse generator)

REPAIR 62000 62005 62010 62100

Elevation of depressed skull fracture; simple, extradural compound or comminuted, extradural with repair of dura and/or debridement of brain Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea (For repair of spinal dural/CSF leak, see 63707 or 63709)

62115 62116 62117 62120 62121 62140 62141 62142 62143 62145 62146 62147 62148

Reduction of craniomegalic skull (eg, treated hydrocephalus); not requiring bone grafts or cranioplasty with simple cranioplasty requiring craniotomy and reconstruction with or without bone graft (includes obtaining grafts) Repair of encephalocele, skull vault, including cranioplasty Craniotomy for repair of encephalocele, skull base Cranioplasty for skull defect; up to 5 cm diameter larger than 5 cm diameter Removal of bone flap or prosthetic plate of skull Replacement of bone flap or prosthetic plate of skull Cranioplasty for skull defect with reparative brain surgery Cranioplasty with autograft (includes obtaining bone grafts); up to 5 cm diameter larger than 5 cm diameter Incision and retrieval of subcutaneous cranial bone graft for cranioplasty (List separately in addition to primary procedure) (Use 62148 in conjunction with codes 62140-62147)

NEUROENDOSCOPY Surgical endoscopy always includes diagnostic endoscopy. 62160

Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to primary procedure) (Use 62160 only in conjunction with codes 61107, 61210, 62220, 62223, 62225 or 62230)

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62161

62162 62163 62164 62165

Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter) with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage with retrieval of foreign body with excision of brain tumor, including placement of external ventricular catheter for drainage with excision of pituitary tumor, transnasal or transphenoidal approach

CEREBROSPINAL FLUID (CSF) SHUNT (For codes 62220, 62223, 62225, 62230, 62258, for intracranial neuroendoscopic ventricular catheter placement, use 62160) 62180 62190 62192 62194 62200 62201

Ventriculocisternostomy (Torkildsen type operation) Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular subarachnoid/subdural-peritoneal, -pleural, -other terminus Replacement or irrigation, subarachnoid/subdural catheter Ventriculocisternostomy, third ventricle stereotactic, neuroendoscopic method (For intracranial neuroendoscopic procedures, see 62161-62165)

62220 62223 62225 62230 62252 62256 62258

Creation of shunt; ventriculo-atrial, -jugular, -auricular ventriculo-peritoneal, -pleural, -other terminus Replacement or irrigation, ventricular catheter Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system Reprogramming of programmable cerebrospinal fluid shunt Removal of complete cerebrospinal fluid shunt system; without replacement with replacement by similar or other shunt at same operation (For percutaneous irrigation or aspiration of shunt reservoir, use 61070) (For reprogramming of programmable CSF shunt, use 62252)

SPINE AND SPINAL CORD (For application of caliper or tongs, use 20660) (For treatment of fracture or dislocation of spine, see 22305-22327) INJECTION, DRAINAGE OR ASPIRATION Injection of contrast during fluoroscopic guidance and localization is an inclusive component of codes 62263-62264, 62270-62273, 62280-62282, 62310-62319. Fluoroscopic guidance and localization is reported by code 77003, unless a formal contrast study (myelography, epidurography, or arthrography) is performed, in which case the use of fluoroscopy is included in the supervision and interpretation codes.

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For radiologic supervision and interpretation of epidurography, use 72275. Code 72275 is only to be used when a epidurogram is performed, images documented, and a formal radiologic report is issued. Code 62263 describes a catheter-based treatment involving targeted injection of various substances (eg, hypertonic saline, steroid, anesthetic) via an indwelling epidural catheter. Code 62263 includes percutaneous insertion and removal of an epidural catheter (remaining in place over a several-day period), for the administration of multiple injections of a neurolytic agent(s) performed during serial treatment sessions (ie, spanning two or more treatment days). If required, adhesions or scarring may also be lysed by mechanical means. Code 62263 is NOT reported for each adhesiolysis treatment, but should be reported ONCE to describe the entire series of injections/infusions spanning two or more treatment days. Code 62264 describes multiple adhesiolysis treatment sessions performed on the same day. Adhesions or scarring may be lysed by injections of neurolytic agent(s). If required, adhesions or scarring may also be lysed mechanically using a percutaneously-depolyed catheter. Codes 62263 and 62264 include the procedure of injections of contrast for epidurography (72275) and fluoroscopic guidance and localization (77003) during initial or subsequent sessions. (For daily hospital management of continuous epidural or subarachnoid drug administration performed in conjunction with codes 62318-62319, see E/M services.) 62263

62264

Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days 1 day (Do not report 62264 with 62263) (62263 and 62264 include codes 72275 and 77003)

62268

Percutaneous aspiration, spinal cord cyst or syrinx (For radiological supervision and interpretation, see 76942, 77002, 77012)

62269

Biopsy of spinal cord, percutaneous needle (For radiological supervision and interpretation, see 76942, 77002, 77012) (For fine needle aspiration, see 10021, 10022)

62270 62272 62273

Spinal puncture, lumbar, diagnostic Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) Injection, epidural, of blood or clot patch (For injection of diagnostic or therapeutic substance(s), see 62310, 62311, 62318, 62319)

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62280 62281 62282 62284

Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions)with or without other therapeutic substance; subarachnoid epidural, cervical or thoracic epidural, lumbar, sacral (caudal) Injection procedure for myelography and/or computed tomography, spinal (other than C1-C2 and posterior fossa) (For injection procedure at C1-C2, use 61055) (For radiological supervision and interpretation, see Radiology)

62287

Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk,any method, single or multiple levels,lumbar (eg, manual or automated percutaneous laser diskectomy) (For fluoroscopic guidance, use 77002) (For injection of non-neurolytic diagnostic or therapeutic substance(s), see 62310, 62311)

62290 62291

Injection procedure for diskography, each level; lumbar cervical or thoracic (For radiological supervision and interpretation, see 72285, 72295)

62292

Injection procedure for chemonucleolysis, including diskography, intervertebral disk, single or multiple levels, lumbar Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steriod, other solution), epidural or subarachnoid; cervical or thoracic lumbar, sacral (caudal) Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) including anesthetic, antispasmodic, opioid, steriod, other solution) epidural or subarachnoid; cervical or thoracic lumbar, sacral (caudal)

62294 62310

62311 62318

62319

(For transforaminal epidural injection, see 64479-64484) CATHETER IMPLANTATION (For percutaneous placement of intrathecal or epidural catheter, see codes 62270-62273, 62280-62284, 62310-62319) 62350

62351

Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir infusion pump; without laminectomy with laminectomy (For refiling and manitenance of an implantable reservoir or infusion pump, for spinal or brain drug therapy, use 95990, 95991)

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62355

Removal of previously implanted intrathecal or epidural catheter

RESEVOIR/PUMP IMPLANTATION 62360 62361 62362 62365 62367

62368

Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir non-programmable pump programmable pump, including preparation of pump, with or without programming Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming with reprogramming (For refilling and maintenance of an implantable infusion pump for spinal or brain drug therapy not involving reprogramming, use 95990, 95991)

POSTERIOR EXTRADURAL LAMINOTOMY OR LAMINECTOMY FOR EXPLORATION/ DECOMPRESSION OF NEURAL ELEMENTS OR EXCISION OF HERNIATED INTERVERTEBRAL DISKS (When 63001-63048 are followed by arthrodesis, see 22590-22614) 63001

63003 63005 63011 63012

63015

63016 63017

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy, (eg, spinal stenosis), one or two vertebral segments; cervical thoracic lumbar, except for spondylolisthesis sacral Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy, (eg. spinal stenosis), more than 2 vertebral segments; cervical thoracic lumbar (For codes 63020 – 63044, for bilateral procedures, use modifier -50)

63020

63030 63035

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical one interspace, lumbar (including open or endoscopically-assisted approach) each additional interspace, cervical or lumbar (List separately in addition to primary procedure) (Use 63035 in conjunction with 63020-63030)

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63040

63042 63043

63044

63045

63046 63047 63048

63050 63051

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration, single interspace; cervical lumbar each additional cervical interspace (List separately in addition to primary procedure) (Use 63043 in conjunction with 63040) each additional lumbar interspace (List separately in addition to primary procedure) (Use 63044 in conjunction with code 63042) Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; cervical thoracic lumbar each additional segment, cervical thoracic or lumbar (List separately in addition to primary procedure) (Use 63048 in conjunction with codes 63045-63047) Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices (eg, wire, suture, mini-plates), when performed) (Do not report 63050 or 63051 in conjunction with 22600, 22614, 22840-22842, 63001, 63015, 63045, 63048, 63295 for the same vertebral segment(s))

TRANSPEDICULAR OR COSTOVERTEBRAL APPROACH FOR POSTEROLATERAL EXTRADURAL EXPLORATION/DECOMPRESSION 63055 63056 63057

63064 63066

Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disk), single segment; thoracic lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disk) each additional segment, thoracic or lumbar (List separately in addition to primary procedure) (Use 63057 in conjunction with codes 63055, 63056) Costovertebral approach with decompression of spinal cord or nerve root(s), (eg, herniated intervertebral disk), thoracic; single segment each additional segment (List separately in addition to primary procedure) (Use 63066 in conjunction with code 63064) (For excision of thoracic intraspinal lesions by laminectomy, see 63266, 63271, 63276, 63281 and 63286)

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ANTERIOR OR ANTEROLATERAL APPROACH FOR EXTRADURAL EXPLORATION/DECOMPRESSION For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of spinal cord exploration/decompression operation, append modifier -62 to the procedure code (and any associated add-on codes for that procedure code as long as both surgeons continue to work together as primary surgeons). One surgeon should file one claim line representing the procedure performed by the two surgeons. In this situation, modifier -62 may be appended to the definitive procedure code(s) 63075, 63077, 63081, 63085, 63087, 63090 and, as appropriate, to associated additional interspace add-on code(s) 63076, 63078 or additional segment add-on code(s) 63082, 63086, 63088, 63091 as long as both surgeons continue to work together as primary surgeons. 63075 63076

63077 63078

63081

63082

Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace cervical, each additional interspace (List separately in addition to primary procedure) (Use 63076 in conjunction with 63075) thoracic, single interspace thoracic, each additional interspace (List separately in addition to primary procedure) (Use 63078 in conjunction with 63077) Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment cervical, each additional segment (List separately in addition to primary procedure) (Use 63082 in conjunction with 63081) (For transoral approach, see 61575-61576)

63085

63086

63087

63088

Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment thoracic, each additional segment (List separately in addition to primary procedure) (Use 63086 in conjunction with 63085) Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment each additional segment (List separately in addition to primary procedure) (Use 63088 in conjunction with 63087)

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63090

63091

Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment each additional segment (List separately in addition to primary procedure) (Use 63091 in conjunction with 63090) (Procedures 63081-63091 include diskectomy above and/or below vertebral segment) (If followed by arthrodesis, see 22548-22812) (For reconstruction of spine, use appropriate vertebral corpectomy codes 6308163091, bone graft codes 20930-20938, arthrodesis codes 22548-22812, and spinal instrumentation codes 22840-22855)

LATERAL EXTRACAVITARY APPROACH FOR EXTRADURAL EXPLORATION/DECOMPRESSION 63101

63102 63103

Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment lumbar, single segment thoracic or lumbar, each additional segment (List separately in addition to primary procedure) (Use 63103 in conjunction with 63101 and 63102)

INCISION 63170 63172 63173 63180 63182 63185 63190 63191

Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic or thoracolumbar Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space to peritoneal or plueral space Laminectomy and section of dentate ligaments, with or without dural graft, cervical; one or two segments more than two segments Laminectomy with rhizotomy; one or two segments more than two segments Laminectomy with section of spinal accessory nerve (For bilateral procedure, use modifier -50) (For resection of sternocleidomastoid muscle, use 21720)

63194 63195 63196 63197

Laminectomy with cordotomy, with section of one spinothalamic tract, one stage; cervical thoracic Laminectomy with cordotomy, with section of both spinothalamic tracts, one stage; cervical thoracic

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63198 63199 63200

Laminectomy with cordotomy, with section of both spinothalamic tracts, two stages within 14 days; cervical (Report required) thoracic (Report required) Laminectomy, with release of tethered spinal cord, lumbar

EXCISION BY LAMINECTONY OF LESION OTHER THAN HERNIATED DISK 63250 63251 63252 63265 63266 63267 63268 63270 63271 63272 63273 63275 63276 63277 63278 63280 63281 63282 63283 63285 63286 63287 63290

Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical thoracic thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical thoracic lumbar sacral Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical thoracic lumbar sacral Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical extradural, thoracic extradural, lumbar extradural, sacral intradural, extramedullary, cervical intradural, extramedullary, thoracic intradural, extramedullary, lumbar intradural, sacral intradural, intramedullary, cervical intradural, intramedullary, thoracic intradural, intramedullary, thoracolumbar combined extradural-intradural lesion, any level (For drainage of intramedullary cyst/syrinx, use 63172, 63173)

63295

Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to primary procedure) (Use 63295 in conjunction with 63172, 63173, 63185, 63190, 63200-63290) (Do not report 63295 in conjunction with 22590-22614, 22840-22844, 63050, 63051 for the same vertebral segment(s))

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EXCISION, ANTERIOR OR ANTEROLATERAL APPROACH, INTRASPINAL LESION For the following codes, when two surgeons work together as primary surgeons performing distinct part(s) of an anterior approach for an intraspinal excision, append modifier -62 to the single definitive procedure code. One surgeon should file one claim line representing the procedure performed by the two surgeons. In this situation, modifier 62 may be appended to the definitive procedure code(s) 63300-63307 and, as appropriate, to the associated additional segment add-on code 63308 as long as both surgeons continue to work together as primary surgeons. (For arthrodesis, see 22548-22632) (For reconstruction of spine, see 20930-20938) 63300 63301 63302 63303 63304 63305 63306 63307 63308

Vertebral corpectomy (vertebral body resection), partial or complete for excision of intraspinal lesion, single segment; extradural, cervical extradural, thoracic by transthoracic approach extradural, thoracic by thoracolumbar approach extradural, lumbar or sacral by transperitoneal or retroperitoneal approach intradural, cervical intradural, thoracic by transthoracic approach intradural, thoracic by thoracolumbar approach intradural, lumbar or sacral by transperitoneal or retroperitoneal approach each additional segment (List separately in addition to codes for single segment) (Use in conjunction with 63300-63307)

STEREOTAXIS 63600 63610 63615

Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/or recording) (Report required) Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery (Report required) Stereotactic biopsy, aspiration, or excision of lesion spinal cord (Report required)

NEUROSTIMULATORS (SPINAL) Codes 63650-63688 apply to both simple and complex neurostimulators. For initial or subsequent electronic analysis and programming of neurostimulator pulse generators, see codes 95970-95975. Codes 63650, 63655, and 63660 describe the operative placement, revision, or removal of the spinal neurostimulator system components to provide spinal electrical stimulation. A neurostimulator system includes an implanted neurostimulator, external controller, extension, and collection of contacts. Multiple contacts or electrodes (4 or more) provide the actual electrical stimulation in the epidural space. For percutaneously placed neurostimulator systems (63650, 63660), the contacts are on a catheter-like lead. An array defines the collection of contacts that are on one catheter.

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For systems placed via an open surgical exposure (63655, 63660), the contacts are on a plate or paddle-shaped surface. 63650 63655 63660 63685

63688

Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy for implantation of neuro-stimulator electrodes plate/paddle,epidural Revision or removal of spinal neurostimulator electrode percutaneous array(s) or plate/paddle(s) Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (Do not report 63685 in conjunction with 63688 for the same pulse generator or receiver) Revision or removal of implanted spinal neurostimulator pulse generator or receiver (For electronic analysis of implanted neurostimulator pulse generator system, see 95970-95975)

REPAIR (Do not use modifier –63 in conjunction with 63700-63706) 63700 63702 63704 63706 63707 63709 63710

Repair of meningocele; less than 5 cm diameter larger than 5 cm diameter Repair of myelomeningocele; less than 5 cm diameter larger than 5 cm diameter Repair of dural/cerebrospinal fluid leak, not requiring laminectomy Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy Dural graft, spinal (For laminectomy and section of dentate ligaments, with or without dural graft, cervical, see 63180-63182)

SHUNT, SPINAL CSF 63740 63741 63744 63746

Creation of shunt, lumbar, subarachnoid- peritoneal, -pleural, or other; including laminectomy percutaneous, not requiring laminectomy Replacement, irrigation or revision of lumbosubarachnoid shunt Removal of entire lumbosubarachnoid shunt system without replacement (For insertion of subarachnoid catheter with reservoir and/or pump for intermittent or continuous infusion of drug including laminectomy, see 62351 and 62360, 62361 or 62362) (For insertion or replacement of subarachnoid or epidural catheter, with reservoir and/or pump for drug infusion without laminectomy, see 62350 and 62360, 62361 or 62362)

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EXTRACRANIAL NERVES, PERIPHERAL NERVES, AND AUTONOMIC NERVOUS SYSTEM (For intracranial surgery on cranial nerves, see 61450, 61460, 61790) INTRODUCTION/INJECTION OF ANESTHETIC AGENT (NERVE BLOCK), DIAGNOSTIC 0R THERAPEUTIC: SOMATIC NERVES 64400 64402 64405 64408 64410 64412 64413 64415 64416 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447 64448 64449

64450

Injection, anesthetic agent; trigeminal nerve, any division or branch facial nerve greater occipital nerve vagus nerve phrenic nerve spinal accessory nerve cervical plexus brachial plexus, single brachial plexus,continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration axillary nerve suprascapular nerve intercostal nerve, single intercostal nerves, multiple, regional block ilioinguinal, iliohypogastric nerves pudendal nerve paracervical (uterine) nerve sciatic nerve, single sciatic nerve, continuous infusion by catheter, (including catheter placement) including daily management for anesthetic agent administration femoral nerve, single femoral nerve, continuous infusion by catheter, (including catheter placement) including daily management for anesthetic agent administration lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration other peripheral nerve or branch (For subarachnoid or subdural, injection, see 62280, 62310-62319) (For phenol destruction, see 64622-64627) (For epidural or caudal injection, see 62273, 62281-62282, 62310-62319) (Codes 64470-64484 are unilateral procedures, for bilateral procedures use modifier -50) (For fluoroscopic guidance and localization for needle placement and injection in conjunction with 64470-64484, use 77003)

64470

Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level

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64472

cervical or thoracic, each additional level (List separately in addition to primary procedure) (Use 64472 in conjunction with 64470)

64475 64476

lumbar or sacral, single level lumbar or sacral, each additional level (List separately in addition to primary procedure) (Use 64476 in conjunction with 64475)

64479 64480

64483 64484

Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level cervical or thoracic, each additional level (List separately in addition to primary procedure) (Use 64480 in conjunction with 64479) lumbar or sacral, single level lumbar or sacral, each additional level (List separately in addition to primary procedure) (Use 64484 in conjunction with 64483)

SYMPATHETIC NERVES 64505 64508 64510 64517 64520 64530

Injection, anesthetic agent; sphenopalatine ganglion carotid sinus (separate procedure) stellate ganglion (cervical sympathetic) superior hypogastric plexus lumbar or thoracic (paravertebral sympathetic) celiac plexus, with or without radiologic monitoring

NEUROSTIMULATORS (PERIPHERAL NERVE) Codes 64553-64595 apply to both simple and complex neurostimulators. For initial or subsequent electronic analysis and programming of neurostimulator pulse generators, see codes 95970-95975. (For codes 64553, 64573 for open placement of cranial nerve (eg, vagal, trigeminal) neurostimulator pulse generator or receiver, see 61885, 61886, as appropriate) 64553 64555 64560 64561 64565 64573

Percutaneous implantation of neurostimulator electrodes;cranial nerve peripheral nerve (excludes sacral nerve) autonomic nerve sacral nerve (transforaminal placement) neuromuscular (Report required) Incision for implantation of neurostimulator electrodes; cranial nerve (For revision or removal of cranial nerve (eg, vagal, trigeminal) neurostimulator pulse generator or receiver, use 61888)

64575 64577

peripheral nerve (excludes sacral nerve) autonomic nerve

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64580 64581 64585 64590

neuromuscular sacral nerve (transforaminal placement) (Report required) Revision or removal of peripheral neurostimulator electrodes Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling (Do not report 64590 in conjunction with 64595)

64595

Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver

DESTRUCTION BY NEUROLYTIC AGENT (EG, CHEMICAL, THERMAL, ELECTRICAL, RADIOFREOUENCY) Codes 64600-64681 include the injection of other therapeutic agents (eg, corticosteroids). SOMATIC NERVES 64600 64605 64610 64612 64613 64614

Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch second and third division branches at foramen ovale second and third division branches at foramen ovale under radiologic monitoring Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (eg, for blepharospasm, hemifacial spasm) neck muscle(s) (eg, for spasmodic torticollis, spasmotic dysphonia) extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis) (For chemodenervation of internal anal sphincter, use 46505) (For chemodenervation for strabismus involving the extraocular muscles, use 67345)

64620

Destruction by neurolytic agent; intercostal nerve (Codes 64622-64627 are unilateral procedures, for bilateral procedures use modifier -50) (For fluoroscopic guidance and localization for needle placement and neurolysis in conjunction with 64622-64627, use 77003)

64622 64623

64626 64627

Destruction by neurolytic agent, paravertebral facet joint nerve;lumbar or sacral, single level lumbar or sacral, each additional level (List separately in addition to primary procedure) (Use 64623 in conjunction with 64622) cervical or thoracic, single level cervical or thoracic, each additional level (List separately in addition to primary procedure) (Use 64627 in conjunction with 64626)

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64630 64640

Destruction by neurolytic agent; pudendal nerve other peripheral nerve or branch

SYMPATHETIC NERVES 64650 64653

Chemodenervation of eccrine glands; both axillae other area(s) (eg, scalp, face, neck), per day (Report the specific service in conjunction with code(s) for the specific substance(s) or drug(s) provided) (For chemodenervation of extremities (eg, hands or feet), use 64999)

64680 64681

Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus superior hypogastric plexus

NEUROPLASTY (EXPLORATION, NEUROLYSIS OR NERVE DECOMPRESSION) Neuroplasty is the decompression or freeing of intact nerve from scar tissue, including external neurolysis and/or transposition. (For facial nerve decompression, use 69720) (For neuroplasty with nerve wrapping, see 64702-64726, 64999) 64702 64704 64708 64712 64713 64714 64716 64718 64719 64721

Neuroplasty; digital, one or both, same digit nerve of hand or foot Neuroplasty, major peripheral nerve, arm or leg; other than specified sciatic nerve brachial plexus lumbar plexus Neuroplasty and/or transposition; cranial nerve (specify) ulnar nerve at elbow ulnar nerve at wrist median nerve at carpal tunnel (For arthroscopic procedure, use 29848)

64722 64726

Decompression; unspecified nerve(s) (specify) plantar digital nerve

TRANSECTION OR AVULSION (For stereotactic lesion of gasserian ganglion, use 61790) 64732 64734 64736 64738 64740 64742 64744 64746

Transection or avulsion of; supraorbital nerve infraorbital nerve mental nerve inferior alveolar nerve by osteotomy lingual nerve (Report required) facial nerve, differential or complete (Report required) greater occipital nerve phrenic nerve

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(For section of recurrent laryngeal nerve, use 31595) 64752 64755

vagus nerve (vagotomy), transthoracic vagus nerve limited to proximal stomach (selective proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy, supra- or highly selective vagotomy) (For laparoscopic approach, use 43652)

64760

vagus nerve (vagotomy), abdominal (Report required) (For laparoscopic approach, use 43651) (For procedures 64761, 64763, 64766, for bilateral procedure, use modifier -50)

64761 64763 64766 64771 64772

pudendal nerve (Report required) Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy Transection or avulsion of obturator nerve, intrapelvic, with or without adductor tenotomy Transection or avulsion of other cranial nerve, extradural Transection or avulsion of other spinal nerve, extradural (For excision of tender scar, skin and subcutaneous tissue, with or without tiny neuroma, see 11400-11446, 13100-13153)

EXCISION SOMATIC NERVES (For Morton neurectomy, use 28080) 64774 64776 64778

64782 64783

Excision of neuroma; cutaneous nerve, surgically identifiable digital nerve, one or both, same digit digital nerve, each additional digit (List separately in addition to primary procedure) (Use 64778 in conjunction with 64776) hand or foot, except digital nerve hand or foot, each additional nerve, except same digit (List separately in addition to primary procedure) (Use 64783 in conjunction with 64782)

64784 64786 64787

major peripheral nerve, except sciatic sciatic nerve Implantation of nerve end into bone or muscle (List separately in addition to neuroma excision) (Use 64787 in conjunction with 64774-64786)

64788 64790 64792 64795

Excision of neurofibroma or neurolemmoma; cutaneous nerve major peripheral nerve extensive (including malignant type) Biopsy of nerve

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SYMPATHETIC NERVES (For procedures 64802, 64804, 64809, 64818 for bilateral procedure, use modifier -50) 64802 64804 64809 64818 64820 64821 64822 64823

Sympathectomy, cervical cervicothoracic thoracolumbar lumbar digital arteries, each digit radial artery ulnar artery superficial palmar arch

NEURORRHAPHY 64831 64832

Suture of digital nerve, hand or foot; one nerve each additional digital nerve (List separately in addition to primary procedure) (Use 64832 in conjunction with 64831)

64834 64835 64836 64837

Suture of one nerve; hand or foot, common sensory nerve median motor thenar ulnar motor Suture of each additional nerve, hand or foot (List separately in addition to primary procedure) (Use 64837 in conjunction with 64834-64836)

64840 64856 64857 64858 64859

Suture of posterior tibial nerve Suture of major peripheral nerve, arm or leg, except sciatic; including transposition without transposition Suture of sciatic nerve Suture of each additional major peripheral nerve (List separately in addition to primary procedure) (Use 64859 in conjunction with 64856, 64857)

64861 64862 64864 64865 64866 64868 64870

Suture of; brachial plexus lumbar plexus Suture of facial nerve; extracranial infratemporal, with or without grafting Anastomosis; facial-spinal accessory facial-hypoglossal facial-phrenic (Use 64872, 64874, 64876 in conjunction with 64831-64865)

64872 64874

Suture of nerve; requiring secondary or delayed suture (List separately in addition to primary neurorrhaphy) requiring extensive mobilization, or transposition of nerve (List separately in addition to code for nerve suture)

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64876

requiring shortening of bone of extremity (Report required) (List separately in addition to code for nerve suture)

NEURORRHAPHY WITH NERVE GRAFT, VEIN GRAFT, OR CONDUIT 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901

Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length more than 4 cm in length Nerve graft (includes obtaining graft), single strand hand or foot; up to 4 cm length more than 4 cm length Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length more than 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length more than 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm. length more than 4 cm length Nerve graft, each additional nerve; single strand (List separately in addition to primary procedure) (Use 64901 in conjunction with 64885-64893)

64902

64905 64907 64910 64911

multiple strands (cable) (List separately in addition to primary procedure) (Use 64902 in conjunction with 64885, 64886, 64895-64898) Nerve pedicle transfer; first stage second stage Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve with autogenous vein graft (includes harvest of vein graft), each nerve

OTHER PROCEDURES 64999

Unlisted procedure, nervous system

EYE AND OCULAR ADNEXA (For diagnostic and treatment ophthalmological services, see MEDICINE, Ophthalmology, and 92002 et seq) EYEBALL REMOVAL OF EYE 65091 65093 65101 65103 65105

Evisceration of ocular contents; without implant with implant Enucleation of eye; without implant with implant, muscles not attached to implant with implant, muscles attached to implant (For conjunctivoplasty after enucleation, see 68320 et seq)

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65110 65112 65114

Exenteration of orbit (does not include skin graft), removal of orbital contents; only with therapeutic removal of bone with muscle or myocutaneous flap (For skin graft to orbit (split skin), see 15120, 15121; free, full thickness, see 15260, 15261) (For eyelid repair involving more than skin, see 67930 et seq)

SECONDARY IMPLANT(S) PROCEDURES An ocular implant is an implant inside muscular cone; an orbital implant is an implant outside muscular cone. 65125 65130 65135 65140 65150 65155 65175

Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle for prosthesis appendage) (separate procedure) (Report required) Insertion of ocular implant secondary; after evisceration, in scleral shell after enucleation, muscles not attached to implant after enucleation, muscles attached to implant Reinsertion of ocular implant; with or without conjunctival graft with use of foreign material for reinforcement and/or attachment of muscles to implant Removal of ocular implant (For orbital implant (implant outside muscle cone) insertion, use 67550; removal, use 67560)

REMOVAL OF FOREIGN BODY (For removal of implanted material: ocular implant, use 65175; anterior segment implant, use 65920; posterior segment implant, use 67120; orbital implant, use 67560) (For diagnostic X-ray for foreign body, use 70030) (For diagnostic echography for foreign body, use 76529) (For removal of foreign body from orbit: frontal approach, use 67413; lateral approach, use 67430; transcranial approach, use 61334) (For removal of foreign body from eyelid, embedded, use 67938) (For removal of foreign body from lacrimal system, use 68530) 65205 65210 65220 65222

Removal of foreign body, external eye; conjunctival superficial conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating corneal, without slit lamp corneal, with slit lamp (For repair of corneal laceration with foreign body, use 65275)

65235

Removal of foreign body, intraocular; from anterior chamber of eye or lens (For removal of implanted material from anterior segment, use 65920)

65260 65265

from posterior segment, magnetic extraction, anterior or posterior route from posterior segment, nonmagnetic extraction (For removal of implanted material from posterior segment, use 67120) Version 2008 – 1 (5/15/2008)

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REPAIR OF LACERATION (For fracture of orbit, see 21385 et seq) (For repair of wound of eyelid, skin, linear, simple, see 12011-12018; intermediate, layered closure, see 12051-12057; linear, complex, see 13150-13160; other, see 67930, 67935) (For repair of wound of lacrimal system, use 68700) (For repair of operative wound, use 66250) 65270 65272 65273 65275 65280 65285 65286

Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct closure conjunctiva, by mobilization and rearrangement, without hospitalization conjunctiva, by mobilization and rearrangement, with hospitalization cornea, nonperforating, with or without removal foreign body cornea and/or sclera, perforating, not involving uveal tissue cornea and/or sclera, perforating,with reposition or resection of uveal tissue application of tissue glue, wounds of cornea and/or sclera (Repair of laceration includes use of conjunctival flap and restoration of anterior chamber, by air or saline injection when indicated) (For repair of iris or ciliary body, use 66680)

65290

Repair of wound, extraocular muscle, tendon and/or Tenon's capsule

ANTERIOR SEGMENT CORNEA EXCISION 65400 65410 65420 65426

Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium Biopsy of cornea Excision or transposition of pterygium; without graft with graft

REMOVAL OR DESTRUCTION 65430 65435 65436 65450 65600

Scraping of cornea, diagnostic, for smear and/or culture Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) with application of chelating agent, eg, EDTA Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo)

KERATOPLASTY Corneal transplant includes use of fresh or preserved grafts, and preparation of donor material. (Keratoplasty excludes refractive keratoplasty procedures 65760, 65765 and 65767) 65710 65730 65750 65755

Keratoplasty (corneal transplant); lamellar penetrating (except in aphakia) penetrating (in aphakia) penetrating (in pseudophakia)

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OTHER PROCEDURES 65760 65765 65767 65770 65771 65772 65775

Keratomileusis Keratophakia Epikeratoplasty (Report required) Keratoprosthesis Radial keratotomy Corneal relaxing incision for correction of surgically induced astigmatism Corneal wedge resection for correction of surgically induced astigmatism (Report required) (For unlisted procedures on cornea, use 66999)

ANTERIOR CHAMBER INCISION 65800 65805 65810 65815

Paracentesis of anterior chamber of eye (separate procedure); with diagnostic aspiration of aqueous with therapeutic release of aqueous with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection with removal of blood, with or without irrigation and/or air injection (For injection, see 66020-66030) (For removal of blood clot, use 65930)

65820

Goniotomy (Do not report modifier -63 in conjunction with 65820) (For use of ophthalmic endoscope with 65820, use 66990)

65850 65855

Trabeculotomy ab externo Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) (For trabeculectomy, use 66170)

65860 65865

Severing adhesions of anterior segment, laser technique (separate procedure) Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae (For trabeculoplasty by laser surgery, use 65855)

65870 65875

anterior synechiae, except goniosynechiae posterior synechiae (For use of ophthalmic endoscope with 65875, use 66990)

65880

corneovitreal adhesions (For laser surgery, use 66821)

REMOVAL 65900 65920

Removal of epithelial downgrowth, anterior chamber of eye Removal of implanted material, anterior segment of eye (For use of ophthalmic endoscope with 65920, use 66990) Version 2008 – 1 (5/15/2008)

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65930

Removal of blood clot, anterior segment of eye

INTRODUCTION 66020 66030

Injection, anterior chamber of eye (separate procedure); air or liquid medication (For unlisted procedures on anterior segment, use 66999)

ANTERIOR SCLERA EXCISION (For removal of intraocular foreign body, use 65235) (For operations on posterior sclera, use 67250-67255) 66130 66150 66155 66160 66165 66170

Excision of lesion, sclera Fistulization of sclera for glaucoma; trephination with iridectomy thermocauterization with iridectomy sclerectomy with punch or scissors, with iridectomy iridencleisis or iridotasis trabeculectomy ab externo in absence of previous surgery (For trabeculotomy ab externo, use 65850) (For repair of operative wound, use 66250)

66172

trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents)

AQUEOUS SHUNT 66180 66185

Aqueous shunt to extraocular reservoir, (eg, Molteno, Schocket, Denver-Krupin) Revision of aqueous shunt to extraocular reservoir (For removal of implanted shunt, use 67120)

REPAIR OR REVISION (For scleral procedures in retinal surgery, see 67101 et seq) 66220 66225

Repair of scleral staphyloma; without graft (Report required) with graft (Report required) (For scleral reinforcement, see 67250, 67255)

66250

Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure (For unlisted procedure on anterior sclera, use 66999)

IRIS, CILIARY BODY INCISION 66500

Iridotomy by stab incision (separate procedure); except transfixion Version 2008 – 1 (5/15/2008)

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66505

with transfixion as for iris bombe (For iridotomy by photocoagulation, use 66761)

EXCISION 66600 66605 66625 66630 66635

Iridectomy, with corneoscleral or corneal section; for removal of lesion with cyclectomy peripheral for glaucoma (separate procedure) sector for glaucoma (separate procedure) optical (separate procedure) (For coreoplasty by photocoagulation, use 66762)

REPAIR 66680

Repair of iris, ciliary body (as for iridodialysis) (For reposition or resection or uveal tissue with perforating wound of cornea or sclera, use 65285)

66682

Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture)

DESTRUCTION 66700 66710 66711

Ciliary body destruction; diathermy, cyclophotocoagulation, transscleral cyclophotocoagulation, endoscopic (Do not report 66711 in conjunction with 66990)

66720 66740 66761 66762

cryotherapy cyclodialysis Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (one or more sessions) Iridoplasty by photocoagulation (one or more sessions) (eg, for improvement of vision for widening of anterior chamber angle) Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) (Report required)

66770

(For excision lesion iris, ciliary body, see 66600, 66605) (For removal epithelial downgrowth, use 65900) (For unlisted procedures on iris, ciliary body, use 66999) LENS INCISION 66820 66821 66825

Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) laser surgery (eg, YAG laser) (one or more stages) Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure)

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REMOVAL Lateral canthotomy, iridectomy, iridotomy, anterior capsulotomy, posterior capsulotomy, the use of viscoelastic agents, enzymatic zonulysis, use of other pharmacologic agents, and subconjunctival or sub-tenon injections are included as part of the code for the extraction of lens. 66830

66840 66850 66852 66920 66930 66940

Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy) Removal of lens material; aspiration technique, one or more stages phacofragmentation technique (mechanical or ultrasonic,) (eg, phacoemulsification), with aspiration pars plana approach, with or without vitrectomy intracapsular intracapsular, for dislocated lens extracapsular (other than 66840, 66850, 66852) (For removal of intralenticular foreign body without lens extraction, use 65235) (For repair of operative wound, use 66250)

INTRAOCULAR LENS PROCEDURES 66982

66983 66984

Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure) Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) (For complex extracapsular cataract removal, use 66982)

66985

Insertion of intraocular lens prosthesis (secondary implant)not associated with concurrent cataract removal (For use of ophthalmic endoscope with 66985, use 66990) (To code implant at time of concurrent cataract surgery, see 66982, 66983 or 66984) (For ultrasonic determination of intraocular lens power, use 76519) (For removal of implanted material from anterior segment, use 65920) (For secondary fixation (separate procedure) use 66682)

66986

Exchange of intraocular lens (For use of ophthalmic endoscope with 66986, use 66990)

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OTHER PROCEDURES 66990

Use of ophthalmic endoscope (List separately in addition to primary procedure) (66990 may be used only with codes 65820, 65875, 65920, 66985, 66986, 67036, 67039, 67040, 67041, 67042, 67043, 67112)

66999

Unlisted procedure, anterior segment, eye

POSTERIOR SEGMENT VITREOUS 67005 67010

Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal subtotal removal with mechanical vitrectomy (For removal of vitreous by paracentesis of anterior chamber, use 65810) (For removal of corneovitreal adhesions, see 65880)

67015 67025 67027

Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) Injection of vitreous substitute, pars plana or limbal approach, (fluid-gas exchange), with or without aspiration (separate procedure) Implantation of intravitreal drug delivery system (eg, Ganciclovir implant), includes concomitant removal of vitreous (For removal, use 67121)

67028 67030 67031 67036 67039 67040 67041 67042

67043

Intravitreal injection of a pharmacologic agent (separate procedure) Discission of vitreous strands (without removal), pars plana approach Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (one or more stages) Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation with endolaser panretinal photocoagulation with removal of preretinal cellular membrane (eg, macular pucker) with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation (For use of ophthalmic endoscope with 67036, 67039, 67040-67043, use 66990) (For associated lensectomy, use 66850) (For use of vitrectomy in retinal detachment surgery, see 67108, 67113) (For associated removal of foreign body, see 65260, 65265) (For unlisted procedures on vitreous, use 67299)

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RETINA OR CHOROID REPAIR (If diathermy, cryotherapy and/or photocoagulation are combined, report under principal modality used) 67101 67105 67107

67108

67110 67112

Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid photocoagulation with or without drainage of subretinal fluid Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), with or without implant, with or without cryotherapy, photo-coagulation and drainage of subretinal fluid with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique by injection of air or other gas (eg, pneumatic retinopexy) by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques (For use of ophthalmic endoscope with 67112, use 66990) (For aspiration or drainage of subretinal or subchoroidal fluid, use 67015)

67113

Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy ofprematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens (To report vitrectomy, pars plana approach, other than in retinal detachment surgery, see 67036-67043)

67115 67120 67121

Release of encircling material (posterior segment) Removal of implanted material, posterior segment; extraocular intraocular (For removal from anterior segment, use 65920) (For removal of foreign body, see 65260, 65265)

PROPHYLAXIS Codes 67141, 67145, 67208-67220, 67227, 67228, 67229 include treatment at one or more sessions that may occur at different encounters. These codes should be reported once during a defined treatment period. Repetitive services. The services listed below are often performed in multiple sessions or groups of sessions. The methods of reporting vary. The following descriptors are intended to include all sessions in a defined treatment period. 67141 67145

Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, one or more sessions; cryotherapy, diathermy photocoagulation (laser or xenon arc) Version 2008 – 1 (5/15/2008)

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DESTRUCTION 67208

Destruction of localized lesion of retina (eg, macular edema, tumors) one or more sessions; cryotherapy, diathermy photocoagulation radiation by implantation of source (includes removal of source) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), one or more sessions photodynamic therapy (includes intravenous infusion) photodynamic therapy, second eye, at single session (List separately in addition to primary eye treatment) (Use 67225 in conjunction with code 67221)

67210 67218 67220 67221 67225

67227

Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions; cryotherapy, diathermy Treatment of extensive or progressive retinopathy, one or more sessions; (eg, diabetic retinopathy),photocoagulation preterm infant (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathy of prematurity), photocoagulation or cryotherapy (For bilateral procedure, use modifier 50)

67228 67229

(For unlisted procedures on retina, use 67299) POSTERIOR SCLERAL REPAIR (For excision lesion sclera, use 66130) 67250 67255

Scleral reinforcement (separate procedure); without graft with graft (For repair scleral staphyloma, see 66220, 66225)

OTHER PROCEDURES 67299

Unlisted procedure, posterior segment

OCULAR ADNEXA EXTRAOCULAR MUSCLES 67311 67312 67314 67316

Strabismus surgery, recession or resection procedure; one horizontal muscle two horizontal muscles one vertical muscle (excluding superior oblique) two or more vertical muscles (excluding superior oblique) (For adjustable sutures, use 67335 in addition to codes 67311-67334 for primary procedure reflecting number of muscles operated on)

67318

Strabismus surgery, any procedure superior oblique muscle

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(Use 67320, 67331, 67332, 67334 in conjunction with 67311-67318) 67320

Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to primary procedure)

67331

Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in addition to primary procedure)

67332

Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List separately in addition to primary procedure)

67334

Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to primary procedure) (Use 67335, 67340, in conjunction with 67311-67334)

67335

Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery)

67340

Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to primary procedure)

67343

Release of extensive scar tissue without detaching extraocular muscle (separate procedure) (Use 67343 in conjunction with 67311-67340, when such procedures are performed other than on the affected muscle)

67345

Chemodenervation of extraocular muscle (For chemodenervation for blepharospasm and other neurological disorders, see 64612 and 64613)

67346

Biopsy of extraocular muscle (For repair of wound, extraocular muscle, tendon or Tenon's capsule, use 65290)

OTHER PROCEDURES 67399

Unlisted procedure, ocular muscle

ORBIT EXPLORATION, EXCISION, DECOMPRESSION 67400 67405

Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy with drainage only

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67412 67413 67414 67415

with removal of lesion with removal of foreign body with removal of bone for decompression Fine needle aspiration of orbital contents (For exenteration, enucleation, and repair, see 65101 et seq) (For optic nerve decompression use 67570)

67420 67430 67440 67445

Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion with removal of foreign body with drainage with removal of bone for decompression (For optic nerve sheath decompression, use 67570)

67450

for exploration, with or without biopsy (For orbitotomy, transcranial approach, see 61330-61334) (For orbital implant, see 67550, 67560) (For removal of eyeball or for repair after removal, see 65091-65175)

OTHER PROCEDURES 67500 67505 67515

Retrobulbar injection; medication (separate procedure, does not include supply of medication) alcohol Injection of medication or other substance into Tenon's capsule (For subconjunctival injection, use 68200)

67550 67560

Orbital implant (implant outside muscle cone); insertion removal or revision (For ocular implant (implant inside muscle cone), see 65093-65105, 65130-65175) (For treatment of fractures of malar area, orbit, see 21355 et seq)

67570 67599

Optic nerve decompression (eg, incision or fenestration of optic nerve sheath) Unlisted procedure, orbit

EYELIDS INCISION 67700 67710 67715

Blepharotomy, drainage of abscess, eyelid Severing of tarsorrhaphy Canthotomy (separate procedure) (For canthoplasty, use 67950) (For division of symblepharon, use 68340)

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EXCISION, DESTRUCTION Codes for removal of lesion include more than skin (i.e., involving lid margin, tarsus, and/or palpebral conjunctiva) (For removal of lesion, involving mainly skin of eyelid, see 11310-11313; 11440-11446; 11640-11646; 17000-17004) (For repair of wounds, blepharoplasty, grafts, reconstructive surgery, see 67930-67975) 67800 67801 67805 67808 67810 67820 67825 67830 67835 67840

Excision of chalazion; single multiple, same lid multiple, different lids under general anesthesia and/or requiring hospitalization, single or multiple Biopsy of eyelid Correction of trichiasis; epilation, by forceps only epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery) incision of lid margin incision of lid margin, with free mucous membrane graft Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure (For excision and repair of eyelid by reconstructive surgery, see 67961-67966)

67850

Destruction of lesion of lid margin (up to 1 cm) (Report required) (For Mohs’ micrographic surgery, see 17311-17315) (For initiation or follow-up care of topical chemotherapy, eg, 5-FU or similar agents, see appropriate office Evaluation and Management service)

TARSORRHAPHY 67875 67880 67882

Temporary closure of eyelids by suture (eg, Frost suture) Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate (For severing of tarsorrhaphy, Use 67710) (For canthoplasty, reconstruction canthus, Use 67950) (For canthotomy, Use 67715)

REPAIR (BROW PTOSIS, BLEPHAROPTOSIS, LID RETRACTION, ECTROPION, ENTROPION) 67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) (For forehead rhytidectomy, use 15824)

67901 67902

Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

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67903 67904 67906 67908 67909 67911

(tarso) levator resection or advancement, internal approach (tarso) levator resection or advancement, external approach superior rectus technique with fascial sling (includes obtaining fascia) conjunctivo-tarso-Muller’s muscle-levator resection (Fasanella Servat type) Reduction of overcorrection of ptosis Correction of lid retraction (For obtaining autogenous graft material, see 20920, 20922 or 20926) (For correction trichiasis by mucous membrane graft, use 67835)

67912 67914 67915 67916 67917

Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight) Repair of ectropion; suture thermocauterization excision tarsal wedge extensive (eg, tarsal strip operations) (For correction everted punctum, use 68705)

67921 67922 67923 67924

Repair of entropion; suture thermocauterization excision tarsal wedge extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) (For repair cicatricial ectropion or entropion requiring scar excision or skin graft, see also 67961 et seq)

RECONSTRUCTION Codes for blepharoplasty involve more than skin (ie, involving lid margin, tarsus, and/or palpebral conjunctiva) 67930 67935 67938

Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva, direct closure; partial thickness full thickness Removal of embedded foreign body, eyelid (For repair of skin of eyelid, see 12011-12018; 12051-12057; 13150-13153) (For tarsorrhaphy, canthorrhaphy, see 67880-67882) (For repair of blepharoptosis and lid retraction, see 67901-67911) (For blepharoplasty for entropion, ectropion, see 67916, 67917, 67923, 67924) (For correction of blepharochalsis (blepharorhytidectomy), see 15820-15823) (For repair of skin of eyelid, adjacent tissue transfer, see 14060, 14061; preparation for graft, use 15004; free graft, see 15120, 15121, 15260, 15261) (For excision of lesion of eyelid, use 67800 et seq) (For repair of lacrimal canaliculi, use 68700)

67950

Canthoplasty (reconstruction of canthus)

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67961

67966

Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin over one-fourth of lid margin (For canthoplasty, use 67950) (For free skin grafts, see 15120, 15121, 15260, 15261) (For tubed pedicle flap preparation, use 15576; for delay, use 15630; for attachment, use 15650)

67971 67973 67974 67975

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, one stage or first stage total eyelid, lower, one stage or first stage total eyelid, upper, one stage or first stage second stage

OTHER PROCEDURES 67999

Unlisted procedure, eyelids

CONJUNCTIVA (For removal of foreign body, see 65205 et seq) INCISION AND DRAINAGE 68020 68040

Incision of conjunctiva, drainage of cyst Expression of conjunctival follicles (eg, for trachoma)

EXCISION AND/OR DESTRUCTION 68100 68110 68115 68130 68135

Biopsy of conjunctiva Excision of lesion, conjunctiva; up to 1 cm over 1 cm with adjacent sclera (Report required) Destruction of lesion, conjunctiva

INJECTION (For injection into Tenon's capsule or retrobulbar injection, see 67500-67515) 68200

Subconjunctival injection

CONJUNCTIVOPLASTY (For wound repair, see 65270-65273) 68320 68325 68326 68328

Conjunctivoplasty; with conjunctival graft or extensive rearrangement with buccal mucous membrane graft (includes obtaining graft) Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement with buccal mucous membrane graft (includes obtaining graft)

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68330 68335

Repair of symblepharon; conjunctivoplasty, without graft with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) division of symblepharon with or without insertion of conformer or contact lens

68340

OTHER PROCEDURES 68360 68362

Conjunctival flap; bridge or partial (separate procedure) total (such as Gunderson thin flap or purse string flap) (For conjunctival flap for perforating injury, see 65280, 65285) (For repair of operative wound, use 66250) (For removal of conjunctival foreign body, see 65205, 65210)

68399

Unlisted procedure, conjunctiva

LACRIMAL SYSTEM INCISION 68400 68420 68440

Incision, drainage of lacrimal gland Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) Snip incision of lacrimal punctum

EXCISION 68500 68505 68510 68520 68525 68530 68540 68550

Excision of lacrimal gland (dacryoadenectomy), except for tumor; total partial Biopsy of lacrimal gland Excision of lacrimal sac (dacryocystectomy) Biopsy of lacrimal sac Removal of foreign body or dacryolith, lacrimal passages Excision of lacrimal gland tumor; frontal approach involving osteotomy

REPAIR 68700 68705 68720 68745 68750 68760 68761 68770

Plastic repair of canaliculi Correction of everted punctum, cautery Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube with insertion of tube or stent Closure of lacrimal punctum; by thermocauterization, ligation, or laser surgery by plug, each Closure of lacrimal fistula (separate procedure)

PROBING AND/OR RELATED PROCEDURES (For codes 68801 – 68816, for bilateral procedures, use modifier -50) 68801

Dilation of lacrimal punctum, with or without irrigation

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68810 68811 68815

Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia with insertion of tube or stent (See also 92018)

68816

Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation (Do not report 68816 in conjunction with 68810, 68811, 68815)

68840 68850

Probing of lacrimal canaliculi, with or without irrigation Injection of contrast medium for dacryocystography (For radiological supervision and interpretation, see 70170, 78660)

OTHER PROCEDURES 68899

Unlisted procedure, lacrimal system

AUDITORY SYSTEM (For diagnostic services, eg, audiometry, vestibular tests, see 92502 et seq) EXTERNAL EAR INCISION 69000 69005 69020

Drainage external ear, abscess or hematoma; simple complicated Drainage external auditory canal, abscess

EXCISION 69100 69105 69110 69120

Biopsy external ear Biopsy external auditory canal Excision external ear; partial, simple repair complete amputation (For reconstruction of ear, see 15120 et seq)

69140 69145 69150 69155

Excision exostosis(es), external auditory canal Excision soft tissue lesion, external auditory canal Radical excision external auditory canal lesion; without neck dissection with neck dissection (For resection of temporal bone, use 69535) (For skin grafting, see 15004-15261)

REMOVAL (For codes 69220, 69222, for bilateral procedures use modifier -50) 69200 69205 69220

Removal foreign body from external auditory canal; without general anesthesia (Report required) with general anesthesia Debridement, mastoidectomy cavity, simple (eg, routine cleaning)

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69222

Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning)

REPAIR (For suture of wound or injury of external ear, see 12011-14300) 69300

Otoplasty, protruding ear, with or without size reduction (For bilateral procedure, report 69300 with modifier 50)

69310

Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection), separate procedure Reconstruction of external auditory canal for congenital atresia, single stage

69320

(For combination with middle ear reconstruction, see 69631, 69641) (For other reconstructive procedures with grafts (eg, skin, cartilage, bone), see 1315015760, 21230-21235) OTHER PROCEDURES (For otoscopy under general anesthesia, see 92502) 69399

Unlisted procedure, external ear

MIDDLE EAR INTRODUCTION 69400 69401 69405

Eustachian tube inflation, transnasal; with catheterization without catheterization Eustachian tube catheterization, transtympanic

INCISION (For codes 69433, 69436, for bilateral procedures use modifier -50) 69420 69421 69433 69436 69440

Myringotomy including aspiration and/or eustachian tube inflation Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia Tympanostomy (requiring insertion of ventilating tube), general anesthesia Middle ear exploration through postauricular or ear canal incision (For atticotomy, see 69601 et seq)

69450

Tympanolysis, transcanal

EXCISION 69501 69502 69505 69511

Transmastoid antrotomy (simple mastoidectomy) Mastoidectomy; complete modified radical radical Version 2008 – 1 (5/15/2008)

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(For skin graft, see 15004 et seq) (For mastoidectomy cavity debridement, see 69220-69222) 69530 69535

Petrous apicectomy including radical mastoidectomy Resection temporal bone, external approach (Report required) (For middle fossa approach, see 69950-69970)

69540 69550 69552 69554

Excision aural polyp Excision aural glomus tumor; transcanal transmastoid extended (extratemporal)

REPAIR 69601 69602 69603 69604

Revision mastoidectomy; resulting in complete mastoidectomy resulting in modified radical mastoidectomy resulting in radical mastoidectomy resulting in tympanoplasty (For planned secondary tympanoplasty after mastoidectomy, see 69631, 69632)

69605

with apicectomy (For skin graft, see 15120, 15121, 15260, 15261)

69610 69620 69631 69632 69633

69635

69636 69637

69641 69642 69643 69644 69645 69646

Tympanic membrane repair, with or without site preparation or perforation for closure, with or without patch Myringoplasty (surgery confined to drumhead and donor area) Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction with ossicular chain reconstruction, (eg, postfenestration) with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis, (PORP), total ossicular replacement prosthesis, (TORP)) Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction with ossicular chain reconstruction with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis, (PORP), total ossicular replacement prosthesis, (TORP)) Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction with ossicular chain reconstruction with intact or reconstructed wall, without ossicular chain reconstruction with intact or reconstructed canal wall, with ossicular chain reconstruction radical or complete, without ossicular chain reconstruction radical or complete, with ossicular chain reconstruction

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69650 69660 69661 69662 69666 69667 69670 69676

Stapes mobilization Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out Revision of stapedectomy or stapedotomy Repair oval window fistula Repair round window fistula Mastoid obliteration (separate procedure) Tympanic neurectomy (For bilateral procedure, use modifier -50)

OTHER PROCEDURES 69700 69710

Closure postauricular fistula, mastoid (separate procedure) Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone (Replacement procedure includes removal of old device)

69711

Removal or repair of electromagnetic bone conduction hearing device in temporal bone (Report required) Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy with mastoidectomy Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy with mastoidectomy Decompression facial nerve, intratemporal; lateral to geniculate ganglion including medial to geniculate ganglion Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion including medial to geniculate ganglion

69714 69715 69717

69718 69720 69725 69740 69745

(For extracranial suture of facial nerve, use 64864) 69799

Unlisted procedure, middle ear

INNER EAR INCISION AND/OR DESTRUCTION 69801

69802

Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); transcanal (69801 includes all required infusions performed on initial and subsequent days of treatment) (69801 includes all required infusions performed on initial and subsequent days of treatment) with mastoidectomy

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69805 69806 69820 69840

Endolymphatic sac operation; without shunt with shunt Fenestration semicircular canal Revision fenestration operation

EXCISION 69905 69910 69915

Labyrinthectomy; transcanal with mastoidectomy Vestibular nerve section, translabyrinthine approach (Report required) (For transcranial approach, use 69950)

INTRODUCTION 69930

Cochlear device implantation, with or without mastoidectomy

OTHER PROCEDURES 69949

Unlisted procedure, inner ear

TEMPORAL BONE, MIDDLE FOSSA APPROACH (For external approach, use 69535) 69950 69955 69960 69970

Vestibular nerve section, transcranial approach (Report required) Total facial nerve decompression and/or repair (may include graft) Decompression internal auditory canal Removal of tumor, temporal bone

OTHER PROCEDURES 69979

Unlisted procedure, temporal bone, middle fossa approach

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