CLASSIFICATION OF PROCEDURES

Reference: CDC website

0. PROCEDURES AND INTERVENTIONS , NOT ELSEWHERE CLASSIFIED (00)
1. OPERATIONS ON THE NERVOUS SYSTEM (01-05)
2. OPERATIONS ON THE ENDOCRINE SYSTEM (06-07)
3. OPERATIONS ON THE EYE (08-16)
4. OPERATIONS ON THE EAR (18-20)
5. OPERATIONS ON THE NOSE, MOUTH, AND PHARYNX (21-29)
6. OPERATIONS ON THE RESPIRATORY SYSTEM (30-34)
7. OPERATIONS ON THE CARDIOVASCULAR SYSTEM (35-39)
8. OPERATIONS ON THE HEMIC AND LYMPHATIC SYSTEM (40-41)
9. OPERATIONS ON THE DIGESTIVE SYSTEM (42-54)
10. OPERATIONS ON THE URINARY SYSTEM (55-59)
11. OPERATIONS ON THE MALE GENITAL ORGANS (60-64)
12. OPERATIONS ON THE FEMALE GENITAL ORGANS (65-71)
13. OBSTETRICAL PROCEDURES (72-75)
14. OPERATIONS ON THE MUSCULOSKELETAL SYSTEM (76-84)
15. OPERATIONS ON THE INTEGUMENTARY SYSTEM (85-86)
16. MISCELLANEOUS DIAGNOSTIC AND THERAPEUTIC PROCEDURES (87-99)

0. PROCEDURES AND INTERVENTIONS , NOT ELSEWHERE CLASSIFIED (00) back to top

00            Procedures and interventions, Not Elsewhere Classified

00.0            Therapeutic ultrasound

Excludes: diagnostic ultrasound (non-invasive) (88.71-88.79)

intracardiac echocardiography [ICE] (heart chamber(s)) (37.28)

intravascular imaging (adjunctive) (00.21-00.29)

00.01            Therapeutic ultrasound of vessels of head and neck

Anti-restenotic ultrasound

Intravascular non-ablative ultrasound

Excludes: diagnostic ultrasound of:

eye (95.13)

head and neck (88.71)

that of inner ear (20.79)

ultrasonic:

angioplasty of non-coronary vessel (39.50)

embolectomy (38.01, 38.02)

endarterectomy (38.11, 38.12)

thrombectomy (38.01, 38.02)

00.02            Therapeutic ultrasound of heart

Anti-restenotic ultrasound

Intravascular non-ablative ultrasound

Excludes:diagnostic ultrasound of heart (88.72)

ultrasonic ablation of heart lesion (37.34)

ultrasonic angioplasty of coronary vessels (00.66, 36.09)

00.03            Therapeutic ultrasound of peripheral vascular vessels

Anti-restenotic ultrasound

Intravascular non-ablative ultrasound

Excludes:diagnostic ultrasound of peripheral vascular system (88.77)

ultrasonic angioplasty of:

non-coronary vessel (39.50)

00.09            Other therapeutic ultrasound

Excludes:ultrasonic:

fragmentation of urinary stones (59.95)

percutaneous nephrostomy with fragmentation (55.04)

physical therapy (93.35)

transurethral guided laser induced prostatectomy (TULIP) (60.21)

00.1            Pharamaceuticals

00.10            Implantation of chemotherapeutic agent

Brain wafer chemotherapy

Interstitial/ intracavitary

Excludes:injection or infusion of cancer chemotherapeutic substance (99.25)

00.11            Infusion of drotrecogin alfa (activated)

Infusion of recombinant protein

00.12            Administration of inhaled nitric oxide

Nitric oxide therapy

00.13            Injection or infusion of nesiritide

Human B-type natriuretic peptide (hBNP)

00.14            Injection or infusion of oxazolidinone class of antibiotics

Linezolid injection

00.15            High-dose infusion interleukin-2 [IL-2]

Infusion (IV bolus, CIV) interleukin

Injection of aldesleukin

Excludes: low-dose infusion interleukin-2 (99.28)

00.16            Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance

Ex-vivo treatment of vessel

Hyperbaric pressurized graft [conduit]

00.17            Infusion of vasopressor agent

00.18            Infusion of immunosuppressive antibody therapy during induction phase of solid organ transplantation

monoclonal antibody therapy

polyclonal antibody therapy

00.2            Intravascular imaging of blood vessels

Endovascular ultrasonography

Intravascular ultrasound (IVUS)

Intravascular [ultrasound] imaging of blood vessels

Note: real-time imaging of lumen of blood vessel(s) using sound waves

Code also any synchronous diagnostic or therapeutic procedures

Excludes: adjunct vascular system procedures, number of vessels treated (00.40-00.43)

diagnostic procedures on blood vessels (38.21-38.29)

diagnostic ultrasound of peripheral vascular system (88.77)

magnetic resonance imaging (MRI) (88.91-88.97)

therapeutic ultrasound (00.01-00.09)

00.21            Intravascular imaging of extracranial cerebral vessels

Common carotid vessels and branches

Intravascular ultrasound (IVUS), extracranial cerebral vessels

Excludes: diagnostic ultrasound (non-invasive) of head and neck (88.71)

00.22            Intravascular imaging of intrathoracic vessels

Aorta and aortic arch

Intravascular ultrasound (IVUS), intrathoracic vessels

Vena cava (superior) (inferior)

Excludes: diagnostic ultrasound (non-invasive) of other sites of thorax (88.73)

00.23            Intravascular imaging of peripheral vessels

Imaging of:

  vessels of arm(s)

  vessels of leg(s)

Intravascular ultrasound (IVUS), peripheral vessels

Excludes: diagnostic ultrasound (non-invasive) of peripheral vascular system (88.77)

00.24            Intravascular imaging of coronary vessels

Intravascular ultrasound (IVUS), coronary vessels

Excludes: diagnostic ultrasound (non-invasive) of heart (88.72)

intracardiac echocardiography [ICE] (ultrasound of heart chamber(s)) (37.28)

00.25            Intravascular imaging of renal vessels

Intravascular ultrasound (IVUS), renal vessels

Renal artery

Excludes: diagnostic ultrasound (non-invasive) of urinary system (88.75)

00.28            Intravascular imaging, other specified vessel(s)

00.29            Intravascular imaging, unspecified vessel(s)

00.3            Computer assisted surgery [CAS]

CT-free navigation

Image guided navigation (IGN)

Image guided surgery (IGS)

Imageless navigation

Code also diagnostic or therapeutic procedure

Excludes: stereotactic frame application only (93.59)

00.31            Computer assisted surgery with CT/CTA

00.32            Computer assisted surgery with MR/MRA

00.33            Computer assisted surgery with fluoroscopy

00.34            Imageless computer assisted surgery

00.35            Computer assisted surgery with multiple datasets

00.39            Other computer assisted surgery

Computer assisted surgery NOS

00.4      Adjunct Vascular System Procedures

Note: These codes can apply to both coronary and peripheral vessels. These codes are to be used in conjunction with other

therapeutic procedure codes to provide additional information on the number of vessels upon which a procedure

was performed and/or the number of stents inserted. As appropriate, code both the number of vessels operated

on (00.40-00.43), and the number of stents inserted (00.45-00.48).

Code also any:

  angioplasty or atherectomy (00.61-00.62, 00.66, 39.50)

  endarterectomy (38.10-38.18)

  insertion of vascular stent(s) (00.55, 00.63-00.65, 36.06-36.07, 39.90)

  other removal of coronary artery obstruction (36.09)

00.40            Procedure on single vessel

Number of vessels, unspecified

Excludes: (aorto)coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

00.41            Procedure on two vessels

Excludes: (aorto) coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

00.42            Procedure on three vessels

Excludes: (aorto) coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

00.43            Procedure on four or more vessels

Excludes: (aorto) coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

00.45            Insertion of one vascular stent

Number of stents, unspecified

00.46            Insertion of two vascular stents

00.47            Insertion of three vascular stents

00.48            Insertion of four or more vascular stents

00.5      Other cardiovascular procedures

00.50    Implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system [CRT-P]

Biventricular pacing without internal cardiac defibrillator

Implantation of cardiac resynchronization (biventricular) pulse generator pacing device, formation of

pocket, transvenous leads including placement of lead into left ventricular coronary venous system, and

intraoperative procedures for evaluation of lead signals.

That with CRT-P generator and one or more leads

Excludes: implantation of cardiac resynchronization defibrillator, total system [CRT-D] (00.51)

insertion or replacement of any type pacemaker device (37.80-37.87)

replacement of cardiac resynchronization defibrillator pulse generator only [CRT-D](00.54)

replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P](00.53)

00.51            Implantation of cardiac resynchronization defibrillator, total system [CRT-D]

Biventricular pacing with internal cardiac defibrillator

Implantation of a cardiac resynchronization (biventricular) pulse generator with defibrillator [AICD], formation

of pocket, transvenous leads, including placement of lead into left ventricular coronary venous system,

intraoperative procedures for evaluation of lead signals, and obtaining defibrillator threshold measurements.

That with CRT-D generator and one or more leads

Excludes: implantation of cardiac resynchronization pacemaker, total system [CRT-P](00.50)

implantation or replacement of automatic cardioverter/defibrillator, total system [AICD] (37.94)

replacement of cardiac resynchronization defibrillator pulse generator, only [CRT-D](00.54)

00.52            Implantation or replacement of transvenous lead [electrode] into left ventricular coronary venous system

Excludes: implantation of cardiac resynchronization defibrillator, total system [CRT-D](00.51)

implantation of cardiac resynchronization pacemaker, total system [CRT-P](00.50)

initial insertion of transvenous lead [electrode] (37.70-37.72)

replacement of transvenous atrial and/or ventricular lead(s) [electrodes] (37.76)

00.53            Implantation or replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P]

Implantation of CRT-P device with removal of any existing CRT-P or other pacemaker device

Excludes: implantation of cardiac resynchronization pacemaker, total system [CRT-P] (00.50)

implantation or replacement of cardiac resynchronization defibrillator pulse generator only [CRT-D](00.54)

insertion or replacement of any type pacemaker device (37.80-37.87)

00.54            Implantation or replacement of cardiac resynchronization defibrillator pulse generator device only [CRT-D]

Implantation of CRT-D device with removal of any existing CRT-D, CRT-P, pacemaker, or defibrillator

  device

Excludes: implantation of automatic cardioverter/defibrillator pulse generator only (37.96)

implantation of cardiac resynchronization defibrillator, total system [CRT-D] (00.51)

implantation or replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P] (00.53)

00.55            Insertion of drug-eluting peripheral vessel stent(s)

Endograft(s)

Endovascular graft(s)

Stent grafts

Code also any:

angioplasty or atherectomy of other non-coronary vessel(s) (39.50)

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

Excludes: drug-coated peripheral stents, e.g., heparin coated (39.90)

insertion of cerebrovascular stent(s) (00.63-00.65)

insertion of drug-eluting coronary artery stent (36.07)

insertion of non-drug-eluting stent(s):

coronary artery (36.06)

peripheral vessel (39.90)

that for aneurysm repair (39.71 - 39.79)

00.6            Procedures on blood vessels

00.61            Percutaneous angioplasty or atherectomy of precerebral (extracranial) vessel(s)

Basilar

Carotid

Vertebral

Code also any:

injection or infusion of thrombolytic agent (99.10)

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

percutaneous insertion of carotid artery stent(s) (00.63)

percutaneous insertion of other precerebral artery stent(s) (00.64)

Excludes: angioplasty or atherectomy of other non-coronary vessel(s) (39.50)

removal of cerebrovascular obstruction of vessel(s) by open approach (38.01-38.02, 38.11-38.12, 38.31-38.32, 38.41-38.42)

00.62            Percutaneous angioplasty or atherectomy of intracranial vessel(s)

Code also any:

injection or infusion of thrombolytic agent (99.10)

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

percutaneous insertion of intracranial stent(s) (00.65)

Excludes: angioplasty or atherectomy of other non-coronary vessel(s) (39.50)

removal of cerebrovascular obstruction of vessel(s) by open approach (38.01-38.02, 38.11-38.12, 38.31-38.32, 38.41-38.42)

00.63            Percutaneous insertion of carotid artery stent(s)

Includes the use of any embolic protection device, distal protection device, filter device, or stent delivery system

Non-drug-eluting stent

Code also any:

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

percutaneous angioplasty or atherectomy of precerebral vessel(s) (00.61)

Excludes: angioplasty or atherectomy of other non-coronary vessel(s)(39.50)

insertion of drug-eluting peripheral vessel stent(s) (00.55)

00.64            Percutaneous insertion of other precerebral (extracranial) artery stent(s)

Includes the use of any embolic protection device, distal protection device, filter device, or stent delivery

system

Basilar stent

Vertebral stent

Code also any:

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

percutaneous angioplasty or atherectomy of precerebral vessel(s) (00.61)

Excludes: angioplasty or atherectomy of other non-coronary vessel(s)(39.50)

insertion of drug-eluting peripheral vessel stent(s) (00.55)

00.65            Percutaneous insertion of intracranial vascular stent(s)

Includes the use of any embolic protection device, distal protection device, filter device, or stent delivery

system

Code also any:

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

percutaneous angioplasty or atherectomy of intracranial vessel(s) (00.62)

Excludes: angioplasty or atherectomy of other non-coronary vessel(s)(39.50)

insertion of drug-eluting peripheral vessel stent(s) (00.55)

00.66            Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy

Balloon angioplasty of coronary artery

Coronary atherectomy

Percutaneous coronary angioplasty NOS

PTCA NOS

Code also any:

injection or infusion of thrombolytic agent (99.10)

insertion of coronary artery stent(s) (36.06-36.07)

intracoronary artery thrombolytic infusion (36.04)

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

00.7      Other hip procedures

00.70            Revision of hip replacement, both acetabular and femoral components

Total hip revision

Code also any:

removal of (cement) (joint) spacer (84.57)

type of bearing surface, if known (00.74-00.76)

Excludes:

revision of hip replacement, acetabular component only (00.71)

revision of hip replacement, femoral component only (00.72)

revision of hip replacement, Not Otherwise Specified (81.53)

revision with replacement of acetabular liner and/or femoral head only (00.73)

00.71            Revision of hip replacement, acetabular component

Partial, acetabular component only

That with:

exchange of acetabular cup and liner

exchange of femoral head

Code also any type of bearing surface, if known (00.74-00.76)

Excludes:

revision of hip replacement, both acetabular and femoral components (00.70)

revision of hip replacement, femoral component (00.72)

revision of hip replacement, Not Otherwise Specified (81.53)

revision with replacement of acetabular liner and/or femoral head only (00.73)

00.72            Revision of hip replacement, femoral component

Partial, femoral component only

That with:

exchange of acetabular liner

exchange of femoral stem and head

Code also any type of bearing surface, if known (00.74-00.76)

Excludes:

revision of hip replacement, acetabular component (00.71)

revision of hip replacement, both acetabular and femoral components (00.70)

revision of hip replacement, not otherwise specified (81.53)

revision with replacement of acetabular liner and/or femoral head only (00.73)

00.73            Revision of hip replacement, acetabular liner and/or femoral head only

Code also any type of bearing surface, if known (00.74-00.76)

00.74            Hip replacement bearing surface, metal on polyethylene

00.75            Hip replacement bearing surface, metal-on-metal

00.76            Hip replacement bearing surface, ceramic-on-ceramic

00.8      Other knee procedures

Note: Report up to two components using 00.81 - 00.83 to describe revision of knee replacements. If all three components are revised, report 00.80.

00.80            Revision of knee replacement, total (all components)

Replacement of femoral, tibial, and patellar components (all components)

Code also any removal of (cement) (joint) spacer (84.57)

Excludes:

revision of only one or two components (tibial, femoral or patellar component) (00.81-00.84)

00.81            Revision of knee replacement, tibial component

Replacement of tibial baseplate and tibial insert (liner)

Excludes:

revision of knee replacement, total (all components) (00.80)

00.82            Revision of knee replacement, femoral component

That with replacement of tibial insert (liner)

Excludes:

revision of knee replacement, total (all components) (00.80)

00.83            Revision of knee replacement, patellar component

Excludes:

revision of knee replacement, total (all components) (00.80)

00.84            Revision of total knee replacement, tibial insert (liner)

Replacement of tibial insert (liner)

Excludes:

that with replacement of tibial component (tibial baseplate and liner) (00.81)

00.9      Other procedures and interventions

00.91            Transplant from live related donor

Code also organ transplant procedure

00.92            Transplant from live non-related donor

Code also organ transplant procedure

00.93            Transplant from cadaver

Code also organ transplant procedure

1. OPERATIONS ON THE NERVOUS SYSTEM (01-05) back to top

01         Incision and excision of skull, brain, and cerebral meninges

01.0      Cranial puncture

01.01            Cisternal puncture

Cisternal tap

Excludes:            pneumocisternogram (87.02)

01.02            Ventriculopuncture through previously implanted catheter

Puncture of ventricular shunt tubing

01.09            Other cranial puncture

Aspiration of:

subarachnoid space

subdural space

Cranial aspiration NOS

Puncture of anterior fontanel

Subdural tap (through fontanel)

01.1            Diagnostic procedures on skull, brain, and cerebral meninges

01.11            Closed [percutaneous] [needle] biopsy of cerebral meninges

Burr hole approach

01.12            Open biopsy of cerebral meninges

01.13            Closed [percutaneous] [needle] biopsy of brain

Burr hole approach

Stereotactic method

01.14            Open biopsy of brain

01.15            Biopsy of skull

01.18            Other diagnostic procedures on brain and cerebral meninges

Excludes:            cerebral:

arteriography (88.41)

thermography (88.81)

contrast radiogram of brain (87.01-87.02)

echoencephalogram (88.71)

electroencephalogram (89.14)

microscopic examination of specimen from nervous system and of spinal fluid (90.01-90.09)

neurologic examination (89.13)

phlebography of head and neck (88.61)

pneumoencephalogram (87.01)

radioisotope scan:

cerebral (92.11)

head NEC (92.12)

tomography of head:

C.A.T. scan (87.03)

other (87.04)

01.19            Other diagnostic procedures on skull

Excludes:            transillumination of skull (89.16)

x-ray of skull (87.17)

01.2            Craniotomy and craniectomy

Excludes:            decompression of skull fracture (02.02)

exploration of orbit (16.01-16.09)

that as operative approach -- omit code

01.21            Incision and drainage of cranial sinus

01.22            Removal of intracranial neurostimulator lead(s)

Code also any removal of neurostimulator pulse generator (86.05)

Excludes:            removal with synchronous replacement (02.93)

01.23            Reopening of craniotomy site

01.24            Other craniotomy

Cranial:

decompression

exploration

trephination

Craniotomy NOS

Craniotomy with removal of:

epidural abscess

extradural hematoma

foreign body of skull

Excludes:            removal of foreign body with incision into brain (01.39)

01.25            Other craniectomy

Debridement of skull NOS

Sequestrectomy of skull

Excludes:            debridement of compound fracture of skull (02.02)

strip craniectomy (02.01)

01.26            Insertion of catheter into cranial cavity

Code also any concomitant procedure (e.g. resection (01.59))

01.27            Removal of catheter from cranial cavity

01.3      Incision of brain and cerebral meninges

01.31            Incision of cerebral meninges

Drainage of:

intracranial hygroma

subarachnoid abscess (cerebral)

subdural empyema

01.32            Lobotomy and tractotomy

Division of:

brain tissue

cerebral tracts

Percutaneous (radiofrequency) cingulotomy

01.39            Other incision of brain

Amygdalohippocampotomy

Drainage of intracerebral hematoma

Incision of brain NOS

Excludes:            division of cortical adhesions (02.91)

01.4            Operations on thalamus and globus pallidus

01.41            Operations on thalamus

Chemothalamectomy

  Thalamotomy

Excludes: that by stereotactic radiosurgery (92.30 - 92.39)

01.42            Operations on globus pallidus

Pallidoansectomy

Pallidotomy

Excludes: that by stereotactic radiosurgery (92.30 - 92.39)

01.5      Other excision or destruction of brain and meninges

01.51            Excision of lesion or tissue of cerebral meninges

Decortication of (cerebral) meninges

Resection of (cerebral) meninges

Stripping of subdural membrane of (cerebral) meninges

Excludes:            biopsy of cerebral meninges (01.11-01.12)

01.52            Hemispherectomy

01.53            Lobectomy of brain

01.59            Other excision or destruction of lesion or tissue of brain

Curettage of brain

Debridement of brain

Marsupialization of brain cyst

Transtemporal (mastoid) excision of brain tumor

Excludes:            biopsy of brain (01.13-01.14)

that by stereotactic radiosurgery (92.30 - 92.39)

01.6            Excision of lesion of skull

Removal of granulation tissue of cranium

Excludes:            biopsy of skull (01.15)

sequestrectomy (01.25)

02         Other operations on skull, brain, and cerebral meninges

02.0            Cranioplasty

Excludes:    that with synchronous repair of encephalocele (02.12)

02.01            Opening of cranial suture

Linear craniectomy

Strip craniectomy

02.02            Elevation of skull fracture fragments

Debridement of compound fracture of skull

Decompression of skull fracture

Reduction of skull fracture

Code also any synchronous debridement of brain (01.59)

Excludes:            debridement of skull NOS (01.25)

removal of granulation tissue of cranium (01.6)

02.03            Formation of cranial bone flap

Repair of skull with flap

02.04            Bone graft to skull

Pericranial graft (autogenous) (heterogenous)

02.05            Insertion of skull plate

Replacement of skull plate

02.06            Other cranial osteoplasty

Repair of skull NOS

Revision of bone flap of skull

02.07            Removal of skull plate

Excludes:            removal with synchronous replacement (02.05)

02.1      Repair of cerebral meninges

Excludes:            marsupialization of cerebral lesion (01.59)

02.11            Simple suture of dura mater of brain

02.12            Other repair of cerebral meninges

Closure of fistula of cerebrospinal fluid

Dural graft

Repair of encephalocele including synchronous cranioplasty

Repair of meninges NOS

Subdural patch

02.13            Ligation of meningeal vessel

Ligation of:

longitudinal sinus

middle meningeal artery

02.14            Choroid plexectomy

Cauterization of choroid plexus

02.2            Ventriculostomy

Anastomosis of ventricle to:

cervical subarachnoid space

cisterna magna

Insertion of Holter valve

Ventriculocisternal intubation

02.3            Extracranial ventricular shunt

Includes:            that with insertion of valve

02.31            Ventricular shunt to structure in head and neck

Ventricle to nasopharynx shunt

Ventriculomastoid anastomosis

02.32            Ventricular shunt to circulatory system

Ventriculoatrial anastomosis

Ventriculocaval shunt

02.33            Ventricular shunt to thoracic cavity

Ventriculopleural anastomosis

02.34            Ventricular shunt to abdominal cavity and organs

Ventriculocholecystostomy

Ventriculoperitoneostomy

02.35            Ventricular shunt to urinary system

Ventricle to ureter shunt

02.39            Other operations to establish drainage of ventricle

Ventricle to bone marrow shunt

Ventricular shunt to extracranial site NEC

02.4            Revision, removal, and irrigation of ventricular shunt

Excludes:            revision of distal catheter of ventricular shunt (54.95)

02.41            Irrigation and exploration of ventricular shunt

Exploration of ventriculoperitoneal shunt at ventricular site

Re-programming of ventriculoperitoneal shunt

02.42            Replacement of ventricular shunt

Reinsertion of Holter valve

Replacement of ventricular catheter

Revision of ventriculoperitoneal shunt at ventricular site

02.43            Removal of ventricular shunt

02.9      Other operations on skull, brain, and cerebral meninges

Excludes:            operations on:

pineal gland (07.17, 07.51-07.59)

pituitary gland [hypophysis] (07.13-07.15, 07.61-07.79)

02.91            Lysis of cortical adhesions

02.92            Repair of brain

02.93            Implantation or replacement of intracranial neurostimulator lead(s)

Implantation, insertion, placement, or replacement of intracranial:

brain pacemaker [neuropacemaker]

depth electrodes

epidural pegs

electroencephalographic receiver

foramen ovale electrodes

intracranial electrostimulator

subdural grids

subdural strips

Code also any insertion of neurostimulator pulse generator (86.94-86.96)

02.94            Insertion or replacement of skull tongs or halo traction device

02.95            Removal of skull tongs or halo traction device

02.96            Insertion of sphenoidal electrodes

02.99            Other

Excludes:            chemical shock therapy (94.24)

electroshock therapy:

subconvulsive (94.26)

other (94.27)

03            Operations on spinal cord and spinal canal structures

Code also any application or administration of an adhesion barrier substance (99.77)

03.0            Exploration and decompression of spinal canal structures

03.01            Removal of foreign body from spinal canal

03.02            Reopening of laminectomy site

03.09            Other exploration and decompression of spinal canal

Decompression:

laminectomy

laminotomy

Expansile laminoplasty

Exploration of spinal nerve root

Foraminotomy

Excludes:            drainage of spinal fluid by anastomosis (03.71-03.79)

laminectomy with excision of intervertebral disc (80.51)

spinal tap (03.31)

that as operative approach -- omit code

03.1      Division of intraspinal nerve root

Rhizotomy

03.2            Chordotomy

03.21            Percutaneous chordotomy

Stereotactic chordotomy

03.29            Other chordotomy

Chordotomy NOS

Tractotomy (one-stage) (two-stage) of spinal cord

Transection of spinal cord tracts

03.3            Diagnostic procedures on spinal cord and spinal canal structures

03.31            Spinal tap

Lumbar puncture for removal of dye

Excludes:            lumbar puncture for injection of dye [myelogram] (87.21)

03.32            Biopsy of spinal cord or spinal meninges

03.39            Other diagnostic procedures on spinal cord and spinal canal structures

Excludes:            microscopic examination of specimen from nervous system or of spinal fluid (90.01-90.09)

x-ray of spine (87.21-87.29)

03.4            Excision or destruction of lesion of spinal cord or spinal meninges

Curettage of spinal cord or spinal meninges

Debridement of spinal cord or spinal meninges

Marsupialization of cyst of spinal cord or spinal meninges

Resection of spinal cord or spinal meninges

Excludes:            biopsy of spinal cord or meninges (03.32)

03.5      Plastic operations on spinal cord structures

03.51            Repair of spinal meningocele

Repair of meningocele NOS

03.52            Repair of spinal myelomeningocele

03.53            Repair of vertebral fracture

Elevation of spinal bone fragments

Reduction of fracture of vertebrae

Removal of bony spicules from spinal canal

Excludes:                        kyphoplasty (81.66)

vertebroplasty (81.65)

03.59            Other repair and plastic operations on spinal cord structures

Repair of:

diastematomyelia

spina bifida NOS

spinal cord NOS

spinal meninges NOS

vertebral arch defect

03.6      Lysis of adhesions of spinal cord and nerve roots

03.7      Shunt of spinal theca

Includes:            that with valve

03.71            Spinal subarachnoid-peritoneal shunt

03.72            Spinal subarachnoid-ureteral shunt

03.79            Other shunt of spinal theca

Lumbar-subarachnoid shunt NOS

Pleurothecal anastomosis

Salpingothecal anastomosis

03.8      Injection of destructive agent into spinal canal

03.9      Other operations on spinal cord and spinal canal structures

03.90            Insertion of catheter into spinal canal for infusion of therapeutic or palliative substances

Insertion of catheter into epidural, subarachnoid, or subdural space of spine with intermittent or continuous infusion of drug (with creation of any reservoir)

Code also any implantation of infusion pump (86.06)

03.91            Injection of anesthetic into spinal canal for analgesia

Excludes:            that for operative anesthesia -- omit code

03.92            Injection of other agent into spinal canal

Intrathecal injection of steroid

Subarachnoid perfusion of refrigerated saline

Excludes:            injection of:

contrast material for myelogram (87.21)

destructive agent into spinal canal (03.8)

03.93            Implantation or replacement of spinal neurostimulator lead(s)

Code also any insertion of neurostimulator pulse generator (86.94-86.96)

03.94            Removal of spinal neurostimulator lead(s)

Code also any removal of neurostimulator pulse generator (86.05)

03.95            Spinal blood patch

03.96            Percutaneous denervation of facet

03.97            Revision of spinal thecal shunt

03.98            Removal of spinal thecal shunt

03.99            Other

04            Operations on cranial and peripheral nerves

04.0      Incision, division, and excision of cranial and peripheral nerves

Excludes:            opticociliary neurectomy (12.79)

sympathetic ganglionectomy (05.21-05.29)

04.01            Excision of acoustic neuroma

That by craniotomy

Excludes:            that by stereotactic radiosurgery (92.30 - 92.39)

04.02            Division of trigeminal nerve

Retrogasserian neurotomy

04.03            Division or crushing of other cranial and peripheral nerves

Excludes:            that of:

glossopharyngeal nerve (29.92)

laryngeal nerve (31.91)

nerves to adrenal glands (07.42)

phrenic nerve for collapse of lung (33.31)

vagus nerve (44.00-44.03)

04.04            Other incision of cranial and peripheral nerves

04.05            Gasserian ganglionectomy

04.06            Other cranial or peripheral ganglionectomy

Excludes:            sympathetic ganglionectomy (05.21-05.29)

04.07            Other excision or avulsion of cranial and peripheral nerves

Curettage of peripheral nerve

Debridement of peripheral nerve

Resection of peripheral nerve

Excision of peripheral neuroma [Morton's]

Excludes:            biopsy of cranial or peripheral nerve (04.11-04.12)

04.1            Diagnostic procedures on peripheral nervous system

04.11            Closed [percutaneous] [needle] biopsy of cranial or peripheral nerve or ganglion

04.12            Open biopsy of cranial or peripheral nerve or ganglion

04.19            Other diagnostic procedures on cranial and peripheral nerves and ganglia

Excludes:            microscopic examination of specimen from nervous system (90.01-90.09)

neurologic examination (89.13)

04.2            Destruction of cranial and peripheral nerves

Destruction of cranial or peripheral nerves by:

cryoanalgesia

injection of neurolytic agent

radiofrequency

Radiofrequency ablation

04.3      Suture of cranial and peripheral nerves

04.4      Lysis of adhesions and decompression of cranial and peripheral nerves

04.41            Decompression of trigeminal nerve root

04.42            Other cranial nerve decompression

04.43            Release of carpal tunnel

04.44            Release of tarsal tunnel

04.49            Other peripheral nerve or ganglion decompression or lysis of adhesions

Peripheral nerve neurolysis NOS

04.5      Cranial or peripheral nerve graft

04.6            Transposition of cranial and peripheral nerves

Nerve transplantation

04.7      Other cranial or peripheral neuroplasty

04.71            Hypoglossal-facial anastomosis

04.72            Accessory-facial anastomosis

04.73            Accessory-hypoglossal anastomosis

04.74            Other anastomosis of cranial or peripheral nerve

04.75            Revision of previous repair of cranial and peripheral nerves

04.76            Repair of old traumatic injury of cranial and peripheral nerves

04.79            Other neuroplasty

04.8      Injection into peripheral nerve

Excludes:            destruction of nerve (by injection of neurolytic agent) (04.2)

04.80            Peripheral nerve injection, not otherwise specified

04.81            Injection of anesthetic into peripheral nerve for analgesia

Excludes:            that for operative anesthesia -- omit code

04.89            Injection of other agent, except neurolytic

Excludes:            injection of neurolytic agent (04.2)

04.9      Other operations on cranial and peripheral nerves

04.91            Neurectasis

04.92            Implantation or replacement of peripheral neurostimulator lead(s)

Code also any insertion of neurostimulator pulse generator (86.94-86.96)

04.93            Removal of peripheral neurostimulator lead(s)

Code also any removal of neurostimulator pulse generator (86.05)

04.99            Other

05            Operations on sympathetic nerves or ganglia

Excludes:            paracervical uterine denervation (69.3)

05.0      Division of sympathetic nerve or ganglion

Excludes:    that of nerves to adrenal glands (07.42)

05.1            Diagnostic procedures on sympathetic nerves or ganglia

05.11            Biopsy of sympathetic nerve or ganglion

05.19            Other diagnostic procedures on sympathetic nerves or ganglia

05.2            Sympathectomy

05.21            Sphenopalatine ganglionectomy

05.22            Cervical sympathectomy

05.23            Lumbar sympathectomy

05.24            Presacral sympathectomy

05.25            Periarterial sympathectomy

05.29            Other sympathectomy and ganglionectomy

Excision or avulsion of sympathetic nerve NOS

Sympathetic ganglionectomy NOS

Excludes:            biopsy of sympathetic nerve or ganglion (05.11)

opticociliary neurectomy (12.79)

periarterial sympathectomy (05.25)

tympanosympathectomy (20.91)

05.3      Injection into sympathetic nerve or ganglion

Excludes:            injection of ciliary sympathetic ganglion (12.79)

05.31            Injection of anesthetic into sympathetic nerve for analgesia

05.32            Injection of neurolytic agent into sympathetic nerve

05.39            Other injection into sympathetic nerve or ganglion

05.8      Other operations on sympathetic nerves or ganglia

05.81            Repair of sympathetic nerve or ganglion

05.89            Other

05.9      Other operations on nervous system

2. OPERATIONS ON THE ENDOCRINE SYSTEM (06-07) back to top

06            Operations on thyroid and parathyroid glands

Includes:            incidental resection of hyoid bone

06.0      Incision of thyroid field

Excludes:            division of isthmus (06.91)

06.01            Aspiration of thyroid field

Percutaneous or needle drainage of thyroid field

Excludes:            aspiration biopsy of thyroid (06.11)

drainage by incision (06.09)

postoperative aspiration of field (06.02)

06.02            Reopening of wound of thyroid field

Reopening of wound of thyroid field for:

control of (postoperative) hemorrhage

examination

exploration

removal of hematoma

06.09            Other incision of thyroid field

Drainage of hematoma by incision

Drainage of thyroglossal tract by incision

Exploration:

neck by incision

thyroid (field) by incision

Removal of foreign body by incision

Thyroidotomy NOS by incision

Excludes:            postoperative exploration (06.02)

removal of hematoma by aspiration (06.01)

06.1            Diagnostic procedures on thyroid and parathyroid glands

06.11            Closed [percutaneous] [needle] biopsy of thyroid gland

Aspiration biopsy of thyroid

06.12            Open biopsy of thyroid gland

06.13            Biopsy of parathyroid gland

06.19            Other diagnostic procedures on thyroid and parathyroid glands

Excludes:            radioisotope scan of:

parathyroid (92.13)

thyroid (92.01)

soft tissue x-ray of thyroid field (87.09)

06.2            Unilateral thyroid lobectomy

Complete removal of one lobe of thyroid (with removal of isthmus or portion of other lobe)

Hemithyroidectomy

Excludes:            partial substernal thyroidectomy (06.51)

06.3      Other partial thyroidectomy

06.31            Excision of lesion of thyroid

Excludes:            biopsy of thyroid (06.11-06.12)

06.39            Other

Isthmectomy

Partial thyroidectomy NOS

Excludes:            partial substernal thyroidectomy (06.51)

06.4            Complete thyroidectomy

Excludes:            complete substernal thyroidectomy (06.52)

that with laryngectomy (30.3-30.4)

06.5            Substernal thyroidectomy

06.50            Substernal thyroidectomy, not otherwise specified

06.51            Partial substernal thyroidectomy

06.52            Complete substernal thyroidectomy

06.6            Excision of lingual thyroid

Excision of thyroid by:

submental route

transoral route

06.7            Excision of thyroglossal duct or tract

06.8            Parathyroidectomy

06.81            Complete parathyroidectomy

06.89            Other parathyroidectomy

Parathyroidectomy NOS

Partial parathyroidectomy

Excludes:            biopsy of parathyroid (06.13)

06.9      Other operations on thyroid (region) and parathyroid

06.91            Division of thyroid isthmus

Transection of thyroid isthmus

06.92            Ligation of thyroid vessels

06.93            Suture of thyroid gland

06.94            Thyroid tissue reimplantation

Autotransplantation of thyroid tissue

06.95            Parathyroid tissue reimplantation

Autotransplantation of parathyroid tissue

06.98            Other operations on thyroid glands

06.99            Other operations on parathyroid glands

07            Operations on other endocrine glands

Includes:            operations on:

adrenal glands

pineal gland

pituitary gland

thymus

Excludes:            operations on:

aortic and carotid bodies (39.8)

ovaries (65.0-65.99)

pancreas (52.01-52.99)

testes (62.0-62.99)

07.0            Exploration of adrenal field

Excludes:            incision of adrenal (gland) (07.41)

07.00            Exploration of adrenal field, not otherwise specified

07.01            Unilateral exploration of adrenal field

07.02            Bilateral exploration of adrenal field

07.1            Diagnostic procedures on adrenal glands, pituitary gland, pineal gland, and thymus

07.11            Closed [percutaneous] [needle] biopsy of adrenal gland

07.12            Open biopsy of adrenal gland

07.13            Biopsy of pituitary gland, transfrontal approach

07.14            Biopsy of pituitary gland, transsphenoidal approach

07.15            Biopsy of pituitary gland, unspecified approach

07.16            Biopsy of thymus

07.17            Biopsy of pineal gland

07.19            Other diagnostic procedures on adrenal glands, pituitary gland, pineal gland, and thymus

Excludes:            microscopic examination of specimen from endocrine gland (90.11-90.19)

radioisotope scan of pituitary gland (92.11)

07.2      Partial adrenalectomy

07.21            Excision of lesion of adrenal gland

Excludes:            biopsy of adrenal gland (07.11-07.12)

07.22            Unilateral adrenalectomy

Adrenalectomy NOS

Excludes:            excision of remaining adrenal gland (07.3)

07.29            Other partial adrenalectomy

Partial adrenalectomy NOS

07.3      Bilateral adrenalectomy

Excision of remaining adrenal gland

Excludes:            bilateral partial adrenalectomy (07.29)

07.4      Other operations on adrenal glands, nerves, and vessels

07.41            Incision of adrenal gland

Adrenalotomy (with drainage)

07.42            Division of nerves to adrenal glands

07.43            Ligation of adrenal vessels

07.44            Repair of adrenal gland

07.45            Reimplantation of adrenal tissue

Autotransplantation of adrenal tissue

07.49            Other

07.5            Operations on pineal gland

07.51            Exploration of pineal field

Excludes:            that with incision of pineal gland (07.52)

07.52            Incision of pineal gland

07.53            Partial excision of pineal gland

Excludes:            biopsy of pineal gland (07.17)

07.54            Total excision of pineal gland

Pinealectomy (complete) (total)

07.59            Other operations on pineal gland

07.6            Hypophysectomy

07.61            Partial excision of pituitary gland, transfrontal approach

Cryohypophysectomy, partial transfrontal approach

Division of hypophyseal stalk transfrontal approach

Excision of lesion of pituitary [hypophysis] transfrontal approach

Hypophysectomy, subtotal transfrontal approach

Infundibulectomy, hypophyseal transfrontal approach

Excludes:            biopsy of pituitary gland, transfrontal approach (07.13)

07.62            Partial excision of pituitary gland, transsphenoidal approach

Excludes:            biopsy of pituitary gland, transsphenoidal approach (07.14)

07.63            Partial excision of pituitary gland, unspecified approach

Excludes:            biopsy of pituitary gland NOS (07.15)

07.64            Total excision of pituitary gland, transfrontal approach

Ablation of pituitary by implantation (strontium-yttrium) (Y) transfrontal approach

Cryohypophysectomy, complete transfrontal approach

07.65            Total excision of pituitary gland, transsphenoidal approach

07.68            Total excision of pituitary gland, other specified approach

07.69            Total excision of pituitary gland, unspecified approach

Hypophysectomy NOS

Pituitectomy NOS

07.7      Other operations on hypophysis

07.71            Exploration of pituitary fossa

Excludes:            exploration with incision of pituitary gland (07.72)

07.72            Incision of pituitary gland

Aspiration of:

craniobuccal pouch

craniopharyngioma

hypophysis

pituitary gland

Rathke's pouch

07.79            Other

Insertion of pack into sella turcica

07.8            Thymectomy

07.80            Thymectomy, not otherwise specified

07.81            Partial excision of thymus

Excludes:            biopsy of thymus (07.16)

07.82            Total excision of thymus

07.9      Other operations on thymus

07.91            Exploration of thymus field

Excludes:            exploration with incision of thymus (07.92)

07.92            Incision of thymus

07.93            Repair of thymus

07.94            Transplantation of thymus

07.99            Other

Thymopexy

3. OPERATIONS ON THE EYE (08-16) back to top

08            Operations on eyelids

Includes:            operations on the eyebrow

08.0      Incision of eyelid

08.01            Incision of lid margin

08.02            Severing of blepharorrhaphy

08.09            Other incision of eyelid

08.1            Diagnostic procedures on eyelid

08.11            Biopsy of eyelid

08.19            Other diagnostic procedures on eyelid

08.2            Excision or destruction of lesion or tissue of eyelid

Code also any synchronous reconstruction (08.61-08.74)

Excludes:            biopsy of eyelid (08.11)

08.20            Removal of lesion of eyelid, not otherwise specified

Removal of meibomian gland NOS

08.21            Excision of chalazion

08.22            Excision of other minor lesion of eyelid

Excision of:

verucca

wart

08.23            Excision of major lesion of eyelid, partial-thickness

Excision involving one-fourth or more of lid margin, partial-thickness

08.24            Excision of major lesion of eyelid, full-thickness

Excision involving one-fourth or more of lid margin, full-thickness

Wedge resection of eyelid

08.25            Destruction of lesion of eyelid

08.3      Repair of blepharoptosis and lid retraction

08.31            Repair of blepharoptosis by frontalis muscle technique with suture

08.32            Repair of blepharoptosis by frontalis muscle technique with fascial sling

08.33            Repair of blepharoptosis by resection or advancement of levator muscle or aponeurosis

08.34            Repair of blepharoptosis by other levator muscle techniques

08.35            Repair of blepharoptosis by tarsal technique

08.36            Repair of blepharoptosis by other techniques

Correction of eyelid ptosis NOS

Orbicularis oculi muscle sling for correction of blepharoptosis

08.37            Reduction of overcorrection of ptosis

08.38            Correction of lid retraction

08.4      Repair of entropion or ectropion

08.41            Repair of entropion or ectropion by thermocauterization

08.42            Repair of entropion or ectropion by suture technique

08.43            Repair of entropion or ectropion with wedge resection

08.44            Repair of entropion or ectropion with lid reconstruction

08.49            Other repair of entropion or ectropion

08.5      Other adjustment of lid position

08.51            Canthotomy

Enlargement of palpebral fissure

08.52            Blepharorrhaphy

Canthorrhaphy

Tarsorrhaphy

08.59            Other

Canthoplasty NOS

Repair of epicanthal fold

08.6            Reconstruction of eyelid with flaps or grafts

Excludes:    that associated with repair of entropion and ectropion (08.44)

08.61            Reconstruction of eyelid with skin flap or graft

08.62            Reconstruction of eyelid with mucous membrane flap or graft

08.63            Reconstruction of eyelid with hair follicle graft

08.64            Reconstruction of eyelid with tarsoconjunctival flap

Transfer of tarsoconjunctival flap from opposing lid

08.69            Other reconstruction of eyelid with flaps or grafts

08.7      Other reconstruction of eyelid

Excludes:    that associated with repair of entropion and ectropion (08.44)

08.70            Reconstruction of eyelid, not otherwise specified

08.71            Reconstruction of eyelid involving lid margin, partial-thickness

08.72            Other reconstruction of eyelid, partial-thickness

08.73            Reconstruction of eyelid involving lid margin, full-thickness

08.74            Other reconstruction of eyelid, full-thickness

08.8      Other repair of eyelid

08.81            Linear repair of laceration of eyelid or eyebrow

08.82            Repair of laceration involving lid margin, partial-thickness

08.83            Other repair of laceration of eyelid, partial-thickness

08.84            Repair of laceration involving lid margin, full-thickness

08.85            Other repair of laceration of eyelid, full-thickness

08.86            Lower eyelid rhytidectomy

08.87            Upper eyelid rhytidectomy

08.89            Other eyelid repair

08.9      Other operations on eyelids

08.91            Electrosurgical epilation of eyelid

08.92            Cryosurgical epilation of eyelid

08.93            Other epilation of eyelid

08.99            Other

09            Operations on lacrimal system

09.0      Incision of lacrimal gland

Incision of lacrimal cyst (with drainage)

09.1            Diagnostic procedures on lacrimal system

09.11            Biopsy of lacrimal gland

09.12            Biopsy of lacrimal sac

09.19            Other diagnostic procedures on lacrimal system

Excludes:            contrast dacryocystogram (87.05)

soft tissue x-ray of nasolacrimal duct (87.09)

09.2            Excision of lesion or tissue of lacrimal gland

09.20            Excision of lacrimal gland, not otherwise specified

09.21            Excision of lesion of lacrimal gland

Excludes:            biopsy of lacrimal gland (09.11)

09.22            Other partial dacryoadenectomy

Excludes:            biopsy of lacrimal gland (09.11)

09.23            Total dacryoadenectomy

09.3      Other operations on lacrimal gland

09.4            Manipulation of lacrimal passage

Includes:            removal of calculus

that with dilation

Excludes:            contrast dacryocystogram (87.05)

09.41            Probing of lacrimal punctum

09.42            Probing of lacrimal canaliculi

09.43            Probing of nasolacrimal duct

Excludes:            that with insertion of tube or stent (09.44)

09.44            Intubation of nasolacrimal duct

Insertion of stent into nasolacrimal duct

09.49            Other manipulation of lacrimal passage

09.5      Incision of lacrimal sac and passages

09.51            Incision of lacrimal punctum

09.52            Incision of lacrimal canaliculi

09.53            Incision of lacrimal sac

09.59            Other incision of lacrimal passages

Incision (and drainage) of nasolacrimal duct NOS

09.6            Excision of lacrimal sac and passage

Excludes:            biopsy of lacrimal sac (09.12)

09.7      Repair of canaliculus and punctum

Excludes:            repair of eyelid (08.81-08.89)

09.71            Correction of everted punctum

09.72            Other repair of punctum

09.73            Repair of canaliculus

09.8            Fistulization of lacrimal tract to nasal cavity

09.81            Dacryocystorhinostomy [DCR]

09.82            Conjunctivocystorhinostomy

Conjunctivodacryocystorhinostomy [CDCR]

Excludes:            that with insertion of tube or stent (09.83)

09.83            Conjunctivorhinostomy with insertion of tube or stent

09.9      Other operations on lacrimal system

09.91            Obliteration of lacrimal punctum

09.99            Other

10            Operations on conjunctiva

10.0            Removal of embedded foreign body from conjunctiva by incision

Excludes:            removal of:

embedded foreign body without incision (98.22)

superficial foreign body (98.21)

10.1      Other incision of conjunctiva

10.2            Diagnostic procedures on conjunctiva

10.21            Biopsy of conjunctiva

10.29            Other diagnostic procedures on conjunctiva

10.3            Excision or destruction of lesion or tissue of conjunctiva

10.31            Excision of lesion or tissue of conjunctiva

Excision of ring of conjunctiva around cornea

Excludes:            biopsy of conjunctiva (10.21)

10.32            Destruction of lesion of conjunctiva

Excludes:            excision of lesion (10.31)

thermocauterization for entropion (08.41)

10.33            Other destructive procedures on conjunctiva

Removal of trachoma follicles

10.4            Conjunctivoplasty

10.41            Repair of symblepharon with free graft

10.42            Reconstruction of conjunctival cul-de-sac with free graft

Excludes:            revision of enucleation socket with graft (16.63)

10.43            Other reconstruction of conjunctival cul-de-sac

Excludes:            revision of enucleation socket (16.64)

10.44            Other free graft to conjunctiva

10.49            Other conjunctivoplasty

Excludes:            repair of cornea with conjunctival flap (11.53)

10.5      Lysis of adhesions of conjunctiva and eyelid

Division of symblepharon (with insertion of conformer)

10.6      Repair of laceration of conjunctiva

Excludes:    that with repair of sclera (12.81)

10.9      Other operations on conjunctiva

10.91            Subconjunctival injection

10.99            Other

11            Operations on cornea

11.0            Magnetic removal of embedded foreign body from cornea

Excludes:    that with incision (11.1)

11.1      Incision of cornea

Incision of cornea for removal of foreign body

11.2            Diagnostic procedures on cornea

11.21            Scraping of cornea for smear or culture

11.22            Biopsy of cornea

11.29            Other diagnostic procedures on cornea

11.3            Excision of pterygium

11.31            Transposition of pterygium

11.32            Excision of pterygium with corneal graft

11.39            Other excision of pterygium

11.4            Excision or destruction of tissue or other lesion of cornea

11.41            Mechanical removal of corneal epithelium

That by chemocauterization

Excludes:            that for smear or culture (11.21)

11.42            Thermocauterization of corneal lesion

11.43            Cryotherapy of corneal lesion

11.49            Other removal or destruction of corneal lesion

Excision of cornea NOS

Excludes:            biopsy of cornea (11.22)

11.5      Repair of cornea

11.51            Suture of corneal laceration

11.52            Repair of postoperative wound dehiscence of cornea

11.53            Repair of corneal laceration or wound with conjunctival flap

11.59            Other repair of cornea

11.6      Corneal transplant

Excludes:            excision of pterygium with corneal graft (11.32)

11.60            Corneal transplant, not otherwise specified

Keratoplasty NOS

Note: To report donor source - see codes 00.91-00.93

11.61            Lamellar keratoplasty with autograft

11.62            Other lamellar keratoplasty

11.63            Penetrating keratoplasty with autograft

Perforating keratoplasty with autograft

11.64            Other penetrating keratoplasty

Perforating keratoplasty (with homograft)

11.69            Other corneal transplant

11.7      Other reconstructive and refractive surgery on cornea

11.71            Keratomileusis

11.72            Keratophakia

11.73            Keratoprosthesis

11.74            Thermokeratoplasty

11.75            Radial keratotomy

11.76            Epikeratophakia

11.79            Other

11.9      Other operations on cornea

11.91            Tattooing of cornea

11.92            Removal of artificial implant from cornea

11.99            Other

12            Operations on iris, ciliary body, sclera, and anterior chamber

Excludes:            operations on cornea (11.0-11.99)

12.0            Removal of intraocular foreign body from anterior segment of eye

12.00            Removal of intraocular foreign body from anterior segment of eye, not otherwise specified

12.01            Removal of intraocular foreign body from anterior segment of eye with use of magnet

12.02            Removal of intraocular foreign body from anterior segment of eye without use of magnet

12.1            Iridotomy and simple iridectomy

Excludes:            iridectomy associated with:

cataract extraction (13.11-13.69)

removal of lesion (12.41-12.42)

scleral fistulization (12.61-12.69)

12.11            Iridotomy with transfixion

12.12            Other iridotomy

Corectomy

Discission of iris

Iridotomy NOS

12.13            Excision of prolapsed iris

12.14            Other iridectomy

Iridectomy (basal) (peripheral) (total)

12.2            Diagnostic procedures on iris, ciliary body, sclera, and anterior chamber

12.21            Diagnostic aspiration of anterior chamber of eye

12.22            Biopsy of iris

12.29            Other diagnostic procedures on iris, ciliary body, sclera, and anterior chamber

12.3            Iridoplasty and coreoplasty

12.31            Lysis of goniosynechiae

Lysis of goniosynechiae by injection of air or liquid

12.32            Lysis of other anterior synechiae

Lysis of anterior synechiae:

NOS

by injection of air or liquid

12.33            Lysis of posterior synechiae

Lysis of iris adhesions NOS

12.34            Lysis of corneovitreal adhesions

12.35            Coreoplasty

Needling of pupillary membrane

12.39            Other iridoplasty

12.4            Excision or destruction of lesion of iris and ciliary body

12.40            Removal of lesion of anterior segment of eye, not otherwise specified

12.41            Destruction of lesion of iris, nonexcisional

Destruction of lesion of iris by:

cauterization

cryotherapy

photocoagulation

12.42            Excision of lesion of iris

Excludes:            biopsy of iris (12.22)

12.43            Destruction of lesion of ciliary body, nonexcisional

12.44            Excision of lesion of ciliary body

12.5            Facilitation of intraocular circulation

12.51            Goniopuncture without goniotomy

12.52            Goniotomy without goniopuncture

12.53            Goniotomy with goniopuncture

12.54            Trabeculotomy ab externo

12.55            Cyclodialysis

12.59            Other facilitation of intraocular circulation

12.6      Scleral fistulization

Excludes:            exploratory sclerotomy (12.89)

12.61            Trephination of sclera with iridectomy

12.62            Thermocauterization of sclera with iridectomy

12.63            Iridencleisis and iridotasis

12.64            Trabeculectomy ab externo

12.65            Other scleral fistulization with iridectomy

12.66            Postoperative revision of scleral fistulization procedure

Revision of filtering bleb

Excludes:            repair of fistula (12.82)

12.69            Other fistulizing procedure

12.7      Other procedures for relief of elevated intraocular pressure

12.71            Cyclodiathermy

12.72            Cyclocryotherapy

12.73            Cyclophotocoagulation

12.74            Diminution of ciliary body, not otherwise specified

12.79            Other glaucoma procedures

12.8            Operations on sclera

Excludes:            those associated with:

retinal reattachment (14.41-14.59)

scleral fistulization (12.61-12.69)

12.81            Suture of laceration of sclera

Suture of sclera with synchronous repair of conjunctiva

12.82            Repair of scleral fistula

Excludes:            postoperative revision of scleral fistulization procedure (12.66)

12.83            Revision of operative wound of anterior segment, not elsewhere classified

Excludes:            postoperative revision of scleral fistulization procedure (12.66)

12.84            Excision or destruction of lesion of sclera

12.85            Repair of scleral staphyloma with graft

12.86            Other repair of scleral staphyloma

12.87            Scleral reinforcement with graft

12.88            Other scleral reinforcement

12.89            Other operations on sclera

Exploratory sclerotomy

12.9      Other operations on iris, ciliary body, and anterior chamber

12.91            Therapeutic evacuation of anterior chamber

Paracentesis of anterior chamber

Excludes:            diagnostic aspiration (12.21)

12.92            Injection into anterior chamber

Injection of:

air into anterior chamber

liquid into anterior chamber

medication into anterior chamber

12.93            Removal or destruction of epithelial downgrowth from anterior chamber

Excludes:            that with iridectomy (12.41-12.42)

12.97            Other operations on iris

12.98            Other operations on ciliary body

12.99            Other operations on anterior chamber

13            Operations on lens

13.0            Removal of foreign body from lens

Excludes:            removal of pseudophakos (13.8)

13.00            Removal of foreign body from lens, not otherwise specified

13.01            Removal of foreign body from lens with use of magnet

13.02            Removal of foreign body from lens without use of magnet

13.1            Intracapsular extraction of lens

Code also any synchronous insertion of pseudophakos (13.71)

13.11            Intracapsular extraction of lens by temporal inferior route

13.19            Other intracapsular extraction of lens

Cataract extraction NOS

Cryoextraction of lens

Erysiphake extraction of cataract

Extraction of lens NOS

13.2            Extracapsular extraction of lens by linear extraction technique

13.3            Extracapsular extraction of lens by simple aspiration (and irrigation) technique

Irrigation of traumatic cataract

13.4            Extracapsular extraction of lens by fragmentation and aspiration technique

13.41            Phacoemulsification and aspiration of cataract

13.42            Mechanical phacofragmentation and aspiration of cataract by posterior route

Code also any synchronous vitrectomy (14.74)

13.43            Mechanical phacofragmentation and other aspiration of cataract

13.5      Other extracapsular extraction of lens

Code also any synchronous insertion of pseudophakos (13.71)

13.51            Extracapsular extraction of lens by temporal inferior route

13.59            Other extracapsular extraction of lens

13.6      Other cataract extraction

Code also any synchronous insertion of pseudophakos (13.71)

13.64            Discission of secondary membrane [after cataract]

13.65            Excision of secondary membrane [after cataract] Capsulectomy

13.66            Mechanical fragmentation of secondary membrane [after cataract]

13.69            Other cataract extraction

13.7            Insertion of prosthetic lens [pseudophakos]

13.70            Insertion of pseudophakos, not otherwise specified

13.71            Insertion of intraocular lens prosthesis at time of cataract extraction, one-stage

Code also synchronous extraction of cataract (13.11-13.69)

13.72            Secondary insertion of intraocular lens prosthesis

13.8            Removal of implanted lens

Removal of pseudophakos

13.9      Other operations on lens

14            Operations on retina, choroid, vitreous, and posterior chamber

14.0            Removal of foreign body from posterior segment of eye

Excludes:            removal of surgically implanted material (14.6)

14.00            Removal of foreign body from posterior segment of eye, not otherwise specified

14.01            Removal of foreign body from posterior segment of eye with use of magnet

14.02            Removal of foreign body from posterior segment of eye without use of magnet

14.1            Diagnostic procedures on retina, choroid, vitreous, and posterior chamber

14.11            Diagnostic aspiration of vitreous

14.19            Other diagnostic procedures on retina, choroid, vitreous, and posterior chamber

14.2            Destruction of lesion of retina and choroid

Includes:            destruction of chorioretinopathy or isolated chorioretinal lesion

Excludes:    that for repair of retina (14.31-14.59)

14.21            Destruction of chorioretinal lesion by diathermy

14.22            Destruction of chorioretinal lesion by cryotherapy

14.23            Destruction of chorioretinal lesion by xenon arc photocoagulation

14.24            Destruction of chorioretinal lesion by laser photocoagulation

14.25            Destruction of chorioretinal lesion by photocoagulation of unspecified type

14.26            Destruction of chorioretinal lesion by radiation therapy

14.27            Destruction of chorioretinal lesion by implantation of radiation source

14.29            Other destruction of chorioretinal lesion

Destruction of lesion of retina and choroid NOS

14.3      Repair of retinal tear

Includes:            repair of retinal defect

Excludes:            repair of retinal detachment (14.41-14.59)

14.31            Repair of retinal tear by diathermy

14.32            Repair of retinal tear by cryotherapy

14.33            Repair of retinal tear by xenon arc photocoagulation

14.34            Repair of retinal tear by laser photocoagulation

14.35            Repair of retinal tear by photocoagulation of unspecified type

14.39            Other repair of retinal tear

14.4      Repair of retinal detachment with scleral buckling and implant

14.41            Scleral buckling with implant

14.49            Other scleral buckling

Scleral buckling with:

air tamponade

resection of sclera

vitrectomy

14.5      Other repair of retinal detachment

Includes:            that with drainage

14.51            Repair of retinal detachment with diathermy

14.52            Repair of retinal detachment with cryotherapy

14.53            Repair of retinal detachment with xenon arc photocoagulation

14.54            Repair of retinal detachment with laser photocoagulation

14.55            Repair of retinal detachment with photocoagulation of unspecified type

14.59            Other

14.6            Removal of surgically implanted material from posterior segment of eye

14.7            Operations on vitreous

14.71            Removal of vitreous, anterior approach

Open sky technique

Removal of vitreous, anterior approach (with replacement)

14.72            Other removal of vitreous

Aspiration of vitreous by posterior sclerotomy

14.73            Mechanical vitrectomy by anterior approach

14.74            Other mechanical vitrectomy

14.75            Injection of vitreous substitute

Excludes:            that associated with removal (14.71-14.72)

14.79            Other operations on vitreous

14.9      Other operations on retina, choroid, and posterior chamber

15            Operations on extraocular muscles

15.0            Diagnostic procedures on extraocular muscles or tendons

15.01            Biopsy of extraocular muscle or tendon

15.09            Other diagnostic procedures on extraocular muscles and tendons

15.1            Operations on one extraocular muscle involving temporary detachment from globe

15.11            Recession of one extraocular muscle

15.12            Advancement of one extraocular muscle

15.13            Resection of one extraocular muscle

15.19            Other operations on one extraocular muscle involving temporary detachment from globe

Excludes:            transposition of muscle (15.5)

15.2      Other operations on one extraocular muscle

15.21            Lengthening procedure on one extraocular muscle

15.22            Shortening procedure on one extraocular muscle

15.29            Other

15.3            Operations on two or more extraocular muscles involving temporary detachment from globe, one or both eyes

15.4      Other operations on two or more extraocular muscles, one or both eyes

15.5            Transposition of extraocular muscles

Excludes:    that for correction of ptosis (08.31-08.36)

15.6      Revision of extraocular muscle surgery

15.7      Repair of injury of extraocular muscle

Freeing of entrapped extraocular muscle

Lysis of adhesions of extraocular muscle

Repair of laceration of extraocular muscle, tendon, or Tenon's capsule

15.9      Other operations on extraocular muscles and tendons

16            Operations on orbit and eyeball

Excludes:            reduction of fracture of orbit (76.78-76.79)

16.0            Orbitotomy

16.01            Orbitotomy with bone flap

Orbitotomy with lateral approach

16.02            Orbitotomy with insertion of orbital implant

Excludes:            that with bone flap (16.01)

16.09            Other orbitotomy

16.1            Removal of penetrating foreign body from eye, not otherwise specified

Excludes:            removal of nonpenetrating foreign body (98.21)

16.2            Diagnostic procedures on orbit and eyeball

16.21            Ophthalmoscopy

16.22            Diagnostic aspiration of orbit

16.23            Biopsy of eyeball and orbit

16.29            Other diagnostic procedures on orbit and eyeball

Excludes:            examination of form and structure of eye (95.11-95.16)

general and subjective eye examination (95.01-95.09)

microscopic examination of specimen from eye (90.21-90.29)

objective functional tests of eye (95.21-95.26)

ocular thermography (88.82)

tonometry (89.11)

x-ray of orbit (87.14, 87.16)

16.3            Evisceration of eyeball

16.31            Removal of ocular contents with synchronous implant into scleral shell

16.39            Other evisceration of eyeball

16.4            Enucleation of eyeball

16.41            Enucleation of eyeball with synchronous implant into Tenon's capsule with attachment of muscles

Integrated implant of eyeball

16.42            Enucleation of eyeball with other synchronous implant

16.49            Other enucleation of eyeball

Removal of eyeball NOS

16.5            Exenteration of orbital contents

16.51            Exenteration of orbit with removal of adjacent structures

Radical orbitomaxillectomy

16.52            Exenteration of orbit with therapeutic removal of orbital bone

16.59            Other exenteration of orbit

Evisceration of orbit NOS

Exenteration of orbit with temporalis muscle transplant

16.6            Secondary procedures after removal of eyeball

Excludes:    that with synchronous:

enucleation of eyeball (16.41-16.42)

evisceration of eyeball (16.31)

16.61            Secondary insertion of ocular implant

16.62            Revision and reinsertion of ocular implant

16.63            Revision of enucleation socket with graft

16.64            Other revision of enucleation socket

16.65            Secondary graft to exenteration cavity

16.66            Other revision of exenteration cavity

16.69            Other secondary procedures after removal of eyeball

16.7            Removal of ocular or orbital implant

16.71            Removal of ocular implant

16.72            Removal of orbital implant

16.8      Repair of injury of eyeball and orbit

16.81            Repair of wound of orbit

Excludes:            reduction of orbital fracture (76.78-76.79)

repair of extraocular muscles (15.7)

16.82            Repair of rupture of eyeball

Repair of multiple structures of eye

Excludes:            repair of laceration of:

cornea (11.51-11.59)

sclera (12.81)

16.89            Other repair of injury of eyeball or orbit

16.9      Other operations on orbit and eyeball

Excludes:            irrigation of eye (96.51)

prescription and fitting of low vision aids (95.31-95.33)

removal of:

eye prosthesis NEC (97.31)

nonpenetrating foreign body from eye without incision (98.21)

16.91            Retrobulbar injection of therapeutic agent

Excludes:            injection of radiographic contrast material (87.14)

opticociliary injection (12.79)

16.92            Excision of lesion of orbit

Excludes:            biopsy of orbit (16.23)

16.93            Excision of lesion of eye, unspecified structure

Excludes:            biopsy of eye NOS (16.23)

16.98            Other operations on orbit

16.99            Other operations on eyeball

4. OPERATIONS ON THE EAR (18-20) back to top

18            Operations on external ear

Includes:            operations on:

external auditory canal

skin and cartilage of:

auricle

meatus

18.0      Incision of external ear

Excludes:            removal of intraluminal foreign body (98.11)

18.01            Piercing of ear lobe

Piercing of pinna

18.02            Incision of external auditory canal

18.09            Other incision of external ear

18.1            Diagnostic procedures on external ear

18.11            Otoscopy

18.12            Biopsy of external ear

18.19            Other diagnostic procedures on external ear

Excludes:            microscopic examination of specimen from ear (90.31-90.39)

18.2            Excision or destruction of lesion of external ear

18.21            Excision of preauricular sinus

Radical excision of preauricular sinus or cyst

Excludes:            excision of preauricular remnant [appendage] (18.29)

18.29            Excision or destruction of other lesion of external ear

Cauterization of external ear

Coagulation of external ear

Cryosurgery of external ear

Curettage of external ear

Electrocoagulation of external ear

Enucleation of external ear

Excision of:

exostosis of external auditory canal

preauricular remnant [appendage]

Partial excision of ear

Excludes:            biopsy of external ear (18.12)

radical excision of lesion (18.31)

removal of cerumen (96.52)

18.3      Other excision of external ear

Excludes:            biopsy of external ear (18.12)

18.31            Radical excision of lesion of external ear

Excludes:            radical excision of preauricular sinus (18.21)

18.39            Other

Amputation of external ear

Excludes:            excision of lesion (18.21-18.29, 18.31)

18.4      Suture of laceration of external ear

18.5      Surgical correction of prominent ear

Ear:

pinning

setback

18.6            Reconstruction of external auditory canal

Canaloplasty of external auditory meatus

Construction [reconstruction] of external meatus of ear:

osseous portion

skin-lined portion (with skin graft)

18.7      Other plastic repair of external ear

18.71            Construction of auricle of ear

Prosthetic appliance for absent ear

Reconstruction:

auricle

ear

18.72            Reattachment of amputated ear

18.79            Other plastic repair of external ear

Otoplasty NOS

Postauricular skin graft

Repair of lop ear

18.9      Other operations on external ear

Excludes:            irrigation of ear (96.52)

packing of external auditory canal (96.11)

removal of:

cerumen (96.52)

foreign body (without incision) (98.11)

19            Reconstructive operations on middle ear

19.0      Stapes mobilization

Division, otosclerotic:

material

process

Remobilization of stapes

Stapediolysis

Transcrural stapes mobilization

Excludes:    that with synchronous stapedectomy (19.11-19.19)

19.1            Stapedectomy

Excludes:            revision of previous stapedectomy (19.21-19.29)

stapes mobilization only (19.0)

19.11            Stapedectomy with incus replacement

Stapedectomy with incus:

homograft

prosthesis

19.19            Other stapedectomy

19.2      Revision of stapedectomy

19.21            Revision of stapedectomy with incus replacement

19.29            Other revision of stapedectomy

19.3      Other operations on ossicular chain

Incudectomy NOS

Ossiculectomy NOS

Reconstruction of ossicles, second stage

19.4            Myringoplasty

Epitympanic, type I

Myringoplasty by:

cauterization

graft

Tympanoplasty (type I)

19.5      Other tympanoplasty

19.52            Type II tympanoplasty

Closure of perforation with graft against incus or malleus

19.53            Type III tympanoplasty

Graft placed in contact with mobile and intact stapes

19.54            Type IV tympanoplasty

Mobile footplate left exposed with air pocket between round window and graft

19.55            Type V tympanoplasty

Fenestra in horizontal semicircular canal covered by graft

19.6      Revision of tympanoplasty

19.9      Other repair of middle ear

Closure of mastoid fistula

Mastoid myoplasty

Obliteration of tympanomastoid cavity

20         Other operations on middle and inner ear

20.0            Myringotomy

20.01            Myringotomy with insertion of tube

Myringostomy

20.09            Other myringotomy

Aspiration of middle ear NOS

20.1            Removal of tympanostomy tube

20.2      Incision of mastoid and middle ear

20.21            Incision of mastoid

20.22            Incision of petrous pyramid air cells

20.23            Incision of middle ear

Atticotomy

Division of tympanum

Lysis of adhesions of middle ear

Excludes:            division of otosclerotic process (19.0)

stapediolysis (19.0)

that with stapedectomy (19.11-19.19)

20.3            Diagnostic procedures on middle and inner ear

20.31            Electrocochleography

20.32            Biopsy of middle and inner ear

20.39            Other diagnostic procedures on middle and inner ear

Excludes:            auditory and vestibular function tests (89.13, 95.41-95.49)

microscopic examination of specimen from ear (90.31-90.39)

20.4            Mastoidectomy

Code also any:

skin graft (18.79)

tympanoplasty (19.4-19.55)

Excludes:    that with implantation of cochlear prosthetic device (20.96-20.98)

20.41            Simple mastoidectomy

20.42            Radical mastoidectomy

20.49            Other mastoidectomy

Atticoantrostomy

Mastoidectomy:

NOS

modified radical

20.5      Other excision of middle ear

Excludes:    that with synchronous mastoidectomy (20.41-20.49)

20.51            Excision of lesion of middle ear

Excludes:            biopsy of middle ear (20.32)

20.59            Other

Apicectomy of petrous pyramid

Tympanectomy

20.6            Fenestration of inner ear

20.61            Fenestration of inner ear (initial)

Fenestration of:

labyrinth with graft (skin) (vein)

semicircular canals with graft (skin) (vein)

vestibule with graft (skin) (vein)

Excludes:            that with tympanoplasty, type V (19.55)

20.62            Revision of fenestration of inner ear

20.7      Incision, excision, and destruction of inner ear

20.71            Endolymphatic shunt

20.72            Injection into inner ear

Destruction by injection (alcohol):

inner ear

semicircular canals

vestibule

20.79            Other incision, excision, and destruction of inner ear

Decompression of labyrinth

Drainage of inner ear

Fistulization:

endolymphatic sac

labyrinth

Incision of endolymphatic sac

Labyrinthectomy (transtympanic)

Opening of bony labyrinth

Perilymphatic tap

Excludes:            biopsy of inner ear (20.32)

20.8            Operations on Eustachian tube

Catheterization of Eustachian tube

Inflation of Eustachian tube

Injection (Teflon paste) of Eustachian tube

Insufflation (boric acid-salicylic acid) Intubation of Eustachian tube

Politzerization of Eustachian tube

20.9      Other operations on inner and middle ear

20.91            Tympanosympathectomy

20.92            Revision of mastoidectomy

20.93            Repair of oval and round windows

Closure of fistula:

oval window

perilymph

round window

20.94            Injection of tympanum

20.95            Implantation of electromagnetic hearing device

Bone conduction hearing device

Excludes:            cochlear prosthetic device (20.96-20.98)

20.96            Implantation or replacement of cochlear prosthetic device, not otherwise specified

Implantation of receiver (within skull) and insertion of electrode(s) in the cochlea

Includes:            mastoidectomy

Excludes:            electromagnetic hearing device (20.95)

20.97            Implantation or replacement of cochlear prosthetic device, single channel

Implantation of receiver (within skull) and insertion of electrode in the cochlea

Includes:            mastoidectomy

Excludes:            electromagnetic hearing device (20.95)

20.98            Implantation or replacement of cochlear prosthetic device, multiple channel

Implantation of receiver (within skull) and insertion of electrodes in the cochlea

Includes:            mastoidectomy

Excludes:            electromagnetic hearing device (20.95)

20.99            Other operations on middle and inner ear

Repair or removal of cochlear prosthetic device (receiver) (electrode)

Excludes:            adjustment (external components) of cochlear prosthetic device (95.49)

fitting of hearing aid (95.48)

5. OPERATIONS ON THE NOSE, MOUTH, AND PHARYNX (21-29) back to top

21            Operations on nose

Includes:            operations on:

bone of nose

skin of nose

21.0      Control of epistaxis

21.00            Control of epistaxis, not otherwise specified

21.01            Control of epistaxis by anterior nasal packing

21.02            Control of epistaxis by posterior (and anterior) packing

21.03            Control of epistaxis by cauterization (and packing)

21.04            Control of epistaxis by ligation of ethmoidal arteries

21.05            Control of epistaxis by (transantral) ligation of the maxillary artery

21.06            Control of epistaxis by ligation of the external carotid artery

21.07            Control of epistaxis by excision of nasal mucosa and skin grafting of septum and lateral nasal wall

21.09            Control of epistaxis by other means

21.1      Incision of nose

Chondrotomy

Incision of skin of nose

Nasal septotomy

21.2            Diagnostic procedures on nose

21.21            Rhinoscopy

21.22            Biopsy of nose

21.29            Other diagnostic procedures on nose

Excludes:            microscopic examination of specimen from nose (90.31-90.39)

nasal:

function study (89.12)

x-ray (87.16)

rhinomanometry (89.12)

21.3      Local excision or destruction of lesion of nose

Excludes:            biopsy of nose (21.22)

nasal fistulectomy (21.82)

21.30            Excision or destruction of lesion of nose, not otherwise specified

21.31            Local excision or destruction of intranasal lesion

Nasal polypectomy

21.32            Local excision or destruction of other lesion of nose

21.4            Resection of nose

Amputation of nose

21.5            Submucous resection of nasal septum

21.6            Turbinectomy

21.61            Turbinectomy by diathermy or cryosurgery

21.62            Fracture of the turbinates

21.69            Other turbinectomy

Excludes:            turbinectomy associated with sinusectomy (22.31-22.39, 22.42, 22.60-22.64)

21.7            Reduction of nasal fracture

21.71            Closed reduction of nasal fracture

21.72            Open reduction of nasal fracture

21.8      Repair and plastic operations on the nose

21.81            Suture of laceration of nose

21.82            Closure of nasal fistula

Nasolabial fistulectomy

Nasopharyngeal fistulectomy

Oronasal fistulectomy

21.83            Total nasal reconstruction

Reconstruction of nose with:

arm flap

forehead flap

21.84            Revision rhinoplasty

Rhinoseptoplasty

Twisted nose rhinoplasty

21.85            Augmentation rhinoplasty

Augmentation rhinoplasty with:

graft

synthetic implant

21.86            Limited rhinoplasty

Plastic repair of nasolabial flaps

Tip rhinoplasty

21.87            Other rhinoplasty

Rhinoplasty NOS

21.88            Other septoplasty

Crushing of nasal septum

Repair of septal perforation

Excludes:            septoplasty associated with submucous resection of septum (21.5)

21.89            Other repair and plastic operations on nose

Reattachment of amputated nose

21.9      Other operations on nose

21.91            Lysis of adhesions of nose

Posterior nasal scrub

21.99            Other

Excludes:            dilation of frontonasal duct (96.21)

irrigation of nasal passages (96.53)

removal of:

intraluminal foreign body without incision (98.12)

nasal packing (97.32)

replacement of nasal packing (97.21)

22            Operations on nasal sinuses

22.0            Aspiration and lavage of nasal sinus

22.00            Aspiration and lavage of nasal sinus, not otherwise specified

22.01            Puncture of nasal sinus for aspiration or lavage

22.02            Aspiration or lavage of nasal sinus through natural ostium

22.1            Diagnostic procedures on nasal sinus

22.11            Closed [endoscopic] [needle] biopsy of nasal sinus

22.12            Open biopsy of nasal sinus

22.19            Other diagnostic procedures on nasal sinuses

Endoscopy without biopsy

Excludes:            transillumination of sinus (89.35)

x-ray of sinus (87.15-87.16)

22.2            Intranasal antrotomy

Excludes:            antrotomy with external approach (22.31-22.39)

22.3      External maxillary antrotomy

22.31            Radical maxillary antrotomy

Removal of lining membrane of maxillary sinus using Caldwell-Luc approach

22.39            Other external maxillary antrotomy

Exploration of maxillary antrum with Caldwell-Luc approach

22.4      Frontal sinusotomy and sinusectomy

22.41            Frontal sinusotomy

22.42            Frontal sinusectomy

Excision of lesion of frontal sinus

Obliteration of frontal sinus (with fat)

Excludes:            biopsy of nasal sinus (22.11-22.12)

22.5      Other nasal sinusotomy

22.50            Sinusotomy, not otherwise specified

22.51            Ethmoidotomy

22.52            Sphenoidotomy

22.53            Incision of multiple nasal sinuses

22.6      Other nasal sinusectomy

Includes:            that with incidental turbinectomy

Excludes:            biopsy of nasal sinus (22.11-22.12)

22.60            Sinusectomy, not otherwise specified

22.61            Excision of lesion of maxillary sinus with Caldwell-Luc approach

22.62            Excision of lesion of maxillary sinus with other approach

22.63            Ethmoidectomy

22.64            Sphenoidectomy

22.7      Repair of nasal sinus

22.71            Closure of nasal sinus fistula

Repair of oro-antral fistula

22.79            Other repair of nasal sinus

Reconstruction of frontonasal duct

Repair of bone of accessory sinus

22.9      Other operations on nasal sinuses

Exteriorization of maxillary sinus

Fistulization of sinus

Excludes:            dilation of frontonasal duct (96.21)

23            Removal and restoration of teeth

23.0      Forceps extraction of tooth

23.01            Extraction of deciduous tooth

23.09            Extraction of other tooth

Extraction of tooth NOS

23.1      Surgical removal of tooth

23.11            Removal of residual root

23.19            Other surgical extraction of tooth

Odontectomy NOS

Removal of impacted tooth

Tooth extraction with elevation of mucoperiosteal flap

23.2            Restoration of tooth by filling

23.3            Restoration of tooth by inlay

23.4      Other dental restoration

23.41            Application of crown

23.42            Insertion of fixed bridge

23.43            Insertion of removable bridge

23.49            Other

23.5            Implantation of tooth

23.6            Prosthetic dental implant

Endosseous dental implant

23.7            Apicoectomy and root canal therapy

23.70            Root canal, not otherwise specified

23.71            Root canal therapy with irrigation

23.72            Root canal therapy with apicoectomy

23.73            Apicoectomy

24         Other operations on teeth, gums, and alveoli

24.0      Incision of gum or alveolar bone

Apical alveolotomy

24.1            Diagnostic procedures on teeth, gums, and alveoli

24.11            Biopsy of gum

24.12            Biopsy of alveolus

24.19            Other diagnostic procedures on teeth, gums, and alveoli

Excludes:            dental:

examination (89.31)

x-ray:

full-mouth (87.11)

other (87.12)

microscopic examination of dental specimen (90.81-90.89)

24.2            Gingivoplasty

Gingivoplasty with bone or soft tissue graft

24.3      Other operations on gum

24.31            Excision of lesion or tissue of gum

Excludes:            biopsy of gum (24.11)

excision of odontogenic lesion (24.4)

24.32            Suture of laceration of gum

24.39            Other

24.4            Excision of dental lesion of jaw

Excision of odontogenic lesion

24.5            Alveoloplasty

Alveolectomy (interradicular) (intraseptal) (radical) (simple) (with graft or implant)

Excludes:            biopsy of alveolus (24.12)

en bloc resection of alveolar process and palate (27.32)

24.6            Exposure of tooth

24.7            Application of orthodontic appliance

Application, insertion, or fitting of:

arch bars

orthodontic obturator

orthodontic wiring

periodontal splint

Excludes:            nonorthodontic dental wiring (93.55)

24.8      Other orthodontic operation

Closure of diastema (alveolar) (dental)

Occlusal adjustment

Removal of arch bars

Repair of dental arch

Excludes:            removal of nonorthodontic wiring (97.33)

24.9      Other dental operations

24.91            Extension or deepening of buccolabial or lingual sulcus

24.99            Other

Excludes:            dental:

debridement (96.54)

examination (89.31)

prophylaxis (96.54)

scaling and polishing (96.54)

wiring (93.55)

fitting of dental appliance [denture] (99.97)

microscopic examination of dental specimen (90.81-90.89)

removal of dental:

packing (97.34)

prosthesis (97.35)

wiring (97.33)

replacement of dental packing (97.22)

25            Operations on tongue

25.0            Diagnostic procedures on tongue

25.01            Closed [needle] biopsy of tongue

25.02            Open biopsy of tongue

Wedge biopsy

25.09            Other diagnostic procedures on tongue

25.1            Excision or destruction of lesion or tissue of tongue

Excludes:            biopsy of tongue (25.01-25.02)

frenumectomy:

labial (27.41)

lingual (25.92)

25.2      Partial glossectomy

25.3            Complete glossectomy

Glossectomy NOS

Code also any neck dissection (40.40-40.42)

25.4      Radical glossectomy

Code also any:

neck dissection (40.40-40.42)

tracheostomy (31.1-31.29)

25.5      Repair of tongue and glossoplasty

25.51            Suture of laceration of tongue

25.59            Other repair and plastic operations on tongue

Fascial sling of tongue

Fusion of tongue (to lip)

Graft of mucosa or skin to tongue

Excludes:            lysis of adhesions of tongue (25.93)

25.9      Other operations on tongue

25.91            Lingual frenotomy

Excludes:            labial frenotomy (27.91)

25.92            Lingual frenectomy

Excludes:            labial frenectomy (27.41)

25.93            Lysis of adhesions of tongue

25.94            Other glossotomy

25.99            Other

26            Operations on salivary glands and ducts

Includes:            operations on:

lesser salivary gland and duct

parotid gland and duct

sublingual gland and duct

submaxillary gland and duct

Code also any neck dissection (40.40-40.42)

26.0      Incision of salivary gland or duct

26.1            Diagnostic procedures on salivary glands and ducts

26.11            Closed [needle] biopsy of salivary gland or duct

26.12            Open biopsy of salivary gland or duct

26.19            Other diagnostic procedures on salivary glands and ducts

Excludes:            x-ray of salivary gland (87.09)

26.2            Excision of lesion of salivary gland

26.21            Marsupialization of salivary gland cyst

26.29            Other excision of salivary gland lesion

Excludes:            biopsy of salivary gland (26.11-26.12)

salivary fistulectomy (26.42)

26.3            Sialoadenectomy

26.30            Sialoadenectomy, not otherwise specified

26.31            Partial sialoadenectomy

26.32            Complete sialoadenectomy

En bloc excision of salivary gland lesion

Radical sialoadenectomy

26.4      Repair of salivary gland or duct

26.41            Suture of laceration of salivary gland

26.42            Closure of salivary fistula

26.49            Other repair and plastic operations on salivary gland or duct

Fistulization of salivary gland

Plastic repair of salivary gland or duct NOS

Transplantation of salivary duct opening

26.9      Other operations on salivary gland or duct

26.91            Probing of salivary duct

26.99            Other

27         Other operations on mouth and face

Includes:            operations on:

lips

palate

soft tissue of face and mouth, except tongue and gingiva

Excludes:            operations on:

gingiva (24.0-24.99)

tongue (25.01-25.99)

27.0            Drainage of face and floor of mouth

Drainage of:

facial region (abscess)

fascial compartment of face

Ludwig's angina

Excludes:            drainage of thyroglossal tract (06.09)

27.1      Incision of palate

27.2            Diagnostic procedures on oral cavity

27.21            Biopsy of bony palate

27.22            Biopsy of uvula and soft palate

27.23            Biopsy of lip

27.24            Biopsy of mouth, unspecified structure

27.29            Other diagnostic procedures on oral cavity

Excludes:            soft tissue x-ray (87.09)

27.3            Excision of lesion or tissue of bony palate

27.31            Local excision or destruction of lesion or tissue of bony palate

Local excision or destruction of palate by:

cautery

chemotherapy

cryotherapy

Excludes:            biopsy of bony palate (27.21)

27.32            Wide excision or destruction of lesion or tissue of bony palate

En bloc resection of alveolar process and palate

27.4            Excision of other parts of mouth

27.41            Labial frenectomy

Excludes:            division of labial frenum (27.91)

27.42            Wide excision of lesion of lip

27.43            Other excision of lesion or tissue of lip

27.49            Other excision of mouth

Excludes:            biopsy of mouth NOS (27.24)

excision of lesion of:

palate (27.31-27.32)

tongue (25.1)

uvula (27.72)

fistulectomy of mouth (27.53)

frenectomy of:

lip (27.41)

tongue (25.92)

27.5      Plastic repair of mouth

Excludes:            palatoplasty (27.61-27.69)

27.51            Suture of laceration of lip

27.52            Suture of laceration of other part of mouth

27.53            Closure of fistula of mouth

Excludes:            fistulectomy:

nasolabial (21.82)

oro-antral (22.71)

oronasal (21.82)

27.54            Repair of cleft lip

27.55            Full-thickness skin graft to lip and mouth

27.56            Other skin graft to lip and mouth

27.57            Attachment of pedicle or flap graft to lip and mouth

27.59            Other plastic repair of mouth

27.6            Palatoplasty

27.61            Suture of laceration of palate

27.62            Correction of cleft palate

Correction of cleft palate by push-back operation

Excludes:            revision of cleft palate repair (27.63)

27.63            Revision of cleft palate repair

Secondary:

attachment of pharyngeal flap

lengthening of palate

27.64            Insertion of palatal implant

27.69            Other plastic repair of palate

Code also any insertion of palatal implant (27.64)

Excludes:            fistulectomy of mouth (27.53)

27.7            Operations on uvula

27.71            Incision of uvula

27.72            Excision of uvula

Excludes:            biopsy of uvula (27.22)

27.73            Repair of uvula

Excludes:            that with synchronous cleft palate repair (27.62)

uranostaphylorrhaphy (27.62)

27.79            Other operations on uvula

27.9      Other operations on mouth and face

27.91            Labial frenotomy

Division of labial frenum

Excludes:            lingual frenotomy (25.91)

27.92            Incision of mouth, unspecified structure

Excludes:            incision of:

gum (24.0)

palate (27.1)

salivary gland or duct (26.0)

tongue (25.94)

uvula (27.71)

27.99            Other operations on oral cavity

Graft of buccal sulcus

Excludes:            removal of:

intraluminal foreign body (98.01)

penetrating foreign body from mouth without incision (98.22)

28            Operations on tonsils and adenoids

28.0      Incision and drainage of tonsil and peritonsillar structures

Drainage (oral) (transcervical) of:

parapharyngeal abscess

peritonsillar abscess

retropharyngeal abscess

tonsillar abscess

28.1            Diagnostic procedures on tonsils and adenoids

28.11            Biopsy of tonsils and adenoids

28.19            Other diagnostic procedures on tonsils and adenoids

Excludes:            soft tissue x-ray (87.09)

28.2            Tonsillectomy without adenoidectomy

28.3            Tonsillectomy with adenoidectomy

28.4            Excision of tonsil tag

28.5            Excision of lingual tonsil

28.6            Adenoidectomy without tonsillectomy

Excision of adenoid tag

28.7      Control of hemorrhage after tonsillectomy and adenoidectomy

28.9      Other operations on tonsils and adenoids

28.91            Removal of foreign body from tonsil and adenoid by incision

Excludes:            that without incision (98.13)

28.92            Excision of lesion of tonsil and adenoid

Excludes:            biopsy of tonsil and adenoid (28.11)

28.99            Other

29            Operations on pharynx

Includes:            operations on:

hypopharynx

nasopharynx

oropharynx

pharyngeal pouch

pyriform sinus

29.0            Pharyngotomy

Drainage of pharyngeal bursa

Excludes:            incision and drainage of retropharyngeal abscess (28.0)

removal of foreign body (without incision) (98.13)

29.1            Diagnostic procedures on pharynx

29.11            Pharyngoscopy

29.12            Pharyngeal biopsy

Biopsy of supraglottic mass

29.19            Other diagnostic procedures on pharynx

Excludes:            x-ray of nasopharynx:

contrast (87.06)

other (87.09)

29.2            Excision of branchial cleft cyst or vestige

Excludes:            branchial cleft fistulectomy (29.52)

29.3            Excision or destruction of lesion or tissue of pharynx

29.31            Cricopharyngeal myotomy

Excludes:            that with pharyngeal diverticulectomy (29.32)

29.32            Pharyngeal diverticulectomy

29.33            Pharyngectomy (partial)

Excludes:            laryngopharyngectomy (30.3)

29.39            Other excision or destruction of lesion or tissue of pharynx

29.4      Plastic operation on pharynx

Correction of nasopharyngeal atresia

Excludes:            pharyngoplasty associated with cleft palate repair (27.62-27.63)

29.5      Other repair of pharynx

29.51            Suture of laceration of pharynx

29.52            Closure of branchial cleft fistula

29.53            Closure of other fistula of pharynx

Pharyngoesophageal fistulectomy

29.54            Lysis of pharyngeal adhesions

29.59            Other

29.9      Other operations on pharynx

29.91            Dilation of pharynx

Dilation of nasopharynx

29.92            Division of glossopharyngeal nerve

29.99            Other

Excludes:            insertion of radium into pharynx and nasopharynx (92.27)

removal of intraluminal foreign body (98.13)

6. OPERATIONS ON THE RESPIRATORY SYSTEM (30-34) back to top

30            Excision of larynx

30.0            Excision or destruction of lesion or tissue of larynx

30.01            Marsupialization of laryngeal cyst

30.09            Other excision or destruction of lesion or tissue of larynx

Stripping of vocal cords

Excludes:            biopsy of larynx (31.43)

laryngeal fistulectomy (31.62)

laryngotracheal fistulectomy (31.62)

30.1            Hemilaryngectomy

30.2      Other partial laryngectomy

30.21            Epiglottidectomy

30.22            Vocal cordectomy

Excision of vocal cords

30.29            Other partial laryngectomy

Excision of laryngeal cartilage

30.3            Complete laryngectomy

Block dissection of larynx (with thyroidectomy) (with synchronous tracheostomy)

Laryngopharyngectomy

Excludes:    that with radical neck dissection (30.4)

30.4      Radical laryngectomy

Complete [total] laryngectomy with radical neck dissection (with thyroidectomy) (with synchronous tracheostomy)

31         Other operations on larynx and trachea

31.0      Injection of larynx

Injection of inert material into larynx or vocal cords

31.1            Temporary tracheostomy

Tracheotomy for assistance in breathing

31.2            Permanent tracheostomy

31.21            Mediastinal tracheostomy

31.29            Other permanent tracheostomy

Excludes:            that with laryngectomy (30.3-30.4)

31.3      Other incision of larynx or trachea

Excludes:    that for assistance in breathing (31.1-31.29)

31.4            Diagnostic procedures on larynx and trachea

31.41            Tracheoscopy through artificial stoma

Excludes:            that with biopsy (31.43-31.44)

31.42            Laryngoscopy and other tracheoscopy

Excludes:            that with biopsy (31.43-31.44)

31.43            Closed [endoscopic] biopsy of larynx

31.44            Closed [endoscopic] biopsy of trachea

31.45            Open biopsy of larynx or trachea

31.48            Other diagnostic procedures on larynx

Excludes:            contrast laryngogram (87.07)

microscopic examination of specimen from larynx (90.31-90.39)

soft tissue x-ray of larynx NEC (87.09)

31.49            Other diagnostic procedures on trachea

Excludes:            microscopic examination of specimen from trachea (90.41-90.49)

x-ray of trachea (87.49)

31.5      Local excision or destruction of lesion or tissue of trachea

Excludes:            biopsy of trachea (31.44-31.45)

laryngotracheal fistulectomy (31.62)

tracheoesophageal fistulectomy (31.73)

31.6      Repair of larynx

31.61            Suture of laceration of larynx

31.62            Closure of fistula of larynx

Laryngotracheal fistulectomy

Take-down of laryngostomy

31.63            Revision of laryngostomy

31.64            Repair of laryngeal fracture

31.69            Other repair of larynx

Arytenoidopexy

Graft of larynx

Transposition of vocal cords

Excludes:            construction of artificial larynx (31.75)

31.7      Repair and plastic operations on trachea

31.71            Suture of laceration of trachea

31.72            Closure of external fistula of trachea

Closure of tracheotomy

31.73            Closure of other fistula of trachea

Tracheoesophageal fistulectomy

Excludes:            laryngotracheal fistulectomy (31.62)

31.74            Revision of tracheostomy

31.75            Reconstruction of trachea and construction of artificial larynx

Tracheoplasty with artificial larynx

31.79            Other repair and plastic operations on trachea

31.9      Other operations on larynx and trachea

31.91            Division of laryngeal nerve

31.92            Lysis of adhesions of trachea or larynx

31.93            Replacement of laryngeal or tracheal stent

31.94            Injection of locally-acting therapeutic substance into trachea

31.95            Tracheoesophageal fistulization

31.98            Other operations on larynx

Dilation of larynx

Division of congenital web of larynx

Removal of keel or stent of larynx

Excludes:            removal of intraluminal foreign body from larynx without incision (98.14)

31.99            Other operations on trachea

Excludes:            removal of:

intraluminal foreign body from trachea without incision (98.15)

tracheostomy tube (97.37)

replacement of tracheostomy tube (97.23)

tracheostomy toilette (96.55)

32            Excision of lung and bronchus

Includes:            rib resection as operative approach

sternotomy as operative approach

sternum-splitting incision as operative approach

thoracotomy as operative approach

Code also any synchronous bronchoplasty (33.48)

32.0      Local excision or destruction of lesion or tissue of bronchus

Excludes:            biopsy of bronchus (33.24-33.25)

bronchial fistulectomy (33.42)

32.01            Endoscopic excision or destruction of lesion or tissue of bronchus

32.09            Other local excision or destruction of lesion or tissue of bronchus

Excludes:            that by endoscopic approach (32.01)

32.1      Other excision of bronchus

Resection (wide sleeve) of bronchus

Excludes:            radical dissection [excision] of bronchus (32.6)

32.2      Local excision or destruction of lesion or tissue of lung

32.21            Plication of emphysematous bleb

32.22            Lung volume reduction surgery

32.28            Endoscopic excision or destruction of lesion or tissue of lung

Excludes:            biopsy of lung (33.26-33.27)

32.29            Other local excision or destruction of lesion or tissue of lung

Resection of lung:

NOS

wedge

Excludes:            biopsy of lung (33.26-33.27)

that by endoscopic approach (32.28)

wide excision of lesion of lung (32.3)

32.3            Segmental resection of lung

Partial lobectomy

32.4            Lobectomy of lung

Lobectomy with segmental resection of adjacent lobes of lung

Excludes:    that with radical dissection [excision] of thoracic structures (32.6)

32.5            Complete pneumonectomy

Excision of lung NOS

Pneumonectomy (with mediastinal dissection)

32.6      Radical dissection of thoracic structures

Block [en bloc] dissection of bronchus, lobe of lung, brachial plexus, intercostal structure, ribs (transverse process), and sympathetic nerves

32.9      Other excision of lung

Excludes:            biopsy of lung and bronchus (33.24-33.27)

pulmonary decortication (34.51)

33         Other operations on lung and bronchus

Includes:            rib resection as operative approach

sternotomy as operative approach

sternum-splitting incision as operative approach

thoracotomy as operative approach

33.0      Incision of bronchus

33.1      Incision of lung

Excludes:            puncture of lung (33.93)

33.2            Diagnostic procedures on lung and bronchus

33.21            Bronchoscopy through artificial stoma

Excludes:            that with biopsy (33.24,33.27)

33.22            Fiber-optic bronchoscopy

Excludes:            that with biopsy (33.24,33.27)

33.23            Other bronchoscopy

Excludes:            that for:

aspiration (96.05)

biopsy (33.24,33.27)

33.24            Closed [endoscopic] biopsy of bronchus

Bronchoscopy (fiberoptic) (rigid) with:

brush biopsy of "lung"

brushing or washing for specimen collection

excision (bite) biopsy

Diagnostic bronchoalveolar lavage (BAL)

Excludes:            closed biopsy of lung, other than brush biopsy of "lung" (33.26,33.27)

whole lung lavage (33.99)

33.25            Open biopsy of bronchus

Excludes:            open biopsy of lung (33.28)

33.26            Closed [percutaneous] [needle] biopsy of lung

Excludes:            endoscopic biopsy of lung (33.27)

33.27            Closed endoscopic biopsy of lung

Fiber-optic (flexible) bronchoscopy with fluoroscopic guidance with biopsy

Transbronchial lung biopsy

Excludes:            brush biopsy of "lung" (33.24)

percutaneous biopsy of lung (33.26)

33.28            Open biopsy of lung

33.29            Other diagnostic procedures on lung and bronchus

Excludes:            contrast bronchogram:

endotracheal (87.31)

other (87.32)

lung scan (92.15)

magnetic resonance imaging (88.92)

microscopic examination of specimen from bronchus or lung (90.41-90.49)

routine chest x-ray (87.44)

ultrasonography of lung (88.73)

vital capacity determination (89.37)

x-ray of bronchus or lung NOS (87.49)

33.3      Surgical collapse of lung

33.31            Destruction of phrenic nerve for collapse of lung

33.32            Artificial pneumothorax for collapse of lung

Thoracotomy for collapse of lung

33.33            Pneumoperitoneum for collapse of lung

33.34            Thoracoplasty

33.39            Other surgical collapse of lung

Collapse of lung NOS

33.4      Repair and plastic operation on lung and bronchus

33.41            Suture of laceration of bronchus

33.42            Closure of bronchial fistula

Closure of bronchostomy

Fistulectomy:

bronchocutaneous

bronchoesophageal

bronchovisceral

Excludes:            closure of fistula:

bronchomediastinal (34.73)

bronchopleural (34.73)

bronchopleuromediastinal (34.73)

33.43            Closure of laceration of lung

33.48            Other repair and plastic operations on bronchus

33.49            Other repair and plastic operations on lung

Excludes:            closure of pleural fistula (34.73)

33.5      Lung transplant

Note: To report donor source - see codes 00.91-00.93

Excludes:            combined heart-lung transplantation (33.6)

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

33.50            Lung transplantation, not otherwise specified

33.51            Unilateral lung transplantation

33.52            Bilateral lung transplantation

Double-lung transplantation

En bloc transplantation

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

33.6            Combined heart-lung transplantation

Note: To report donor source - see codes 00.91-00.93

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

33.9      Other operations on lung and bronchus

33.91            Bronchial dilation

33.92            Ligation of bronchus

33.93            Puncture of lung

Excludes:            needle biopsy (33.26)

33.98            Other operations on bronchus

Excludes:            bronchial lavage (96.56)

removal of intraluminal foreign body from bronchus without incision (98.15)

33.99            Other operations on lung

Whole lung lavage

Excludes:            other continuous mechanical ventilation (96.70-96.72)

respiratory therapy (93.90-93.99)

34            Operations on chest wall, pleura, mediastinum, and diaphragm

Excludes:            operations on breast (85.0-85.99)

34.0      Incision of chest wall and pleura

Excludes:    that as operative approach -- omit code

34.01            Incision of chest wall

Extrapleural drainage

Excludes:            incision of pleura (34.09)

34.02            Exploratory thoracotomy

34.03            Reopening of recent thoracotomy site

34.04            Insertion of intercostal catheter for drainage

Chest tube

Closed chest drainage

Revision of intercostal catheter (chest tube) (with lysis of adhesions)

34.05            Creation of pleuroperitoneal shunt

34.09            Other incision of pleura

Creation of pleural window for drainage

Intercostal stab

Open chest drainage

Excludes:            thoracoscopy (34.21)

thoracotomy for collapse of lung (33.32)

34.1      Incision of mediastinum

Excludes:            mediastinoscopy (34.22)

mediastinotomy associated with pneumonectomy (32.5)

34.2            Diagnostic procedures on chest wall, pleura, mediastinum, and diaphragm

34.21            Transpleural thoracoscopy

34.22            Mediastinoscopy

Code also any lymph node biopsy (40.11)

34.23            Biopsy of chest wall

34.24            Pleural biopsy

34.25            Closed [percutaneous] [needle] biopsy of mediastinum

34.26            Open mediastinal biopsy

34.27            Biopsy of diaphragm

34.28            Other diagnostic procedures on chest wall, pleura, and diaphragm

Excludes:            angiocardiography (88.50-88.58)

aortography (88.42)

arteriography of:

intrathoracic vessels NEC (88.44)

pulmonary arteries (88.43)

microscopic examination of specimen from chest wall, pleura, and diaphragm (90.41-90.49)

phlebography of:

intrathoracic vessels NEC (88.63)

pulmonary veins (88.62)

radiological examinations of thorax:

C.A.T. scan (87.41)

diaphragmatic x-ray (87.49)

intrathoracic lymphangiogram (87.34)

routine chest x-ray (87.44)

sinogram of chest wall (87.38)

soft tissue x-ray of chest wall NEC (87.39)

tomogram of thorax NEC (87.42)

ultrasonography of thorax 88.73)

34.29            Other diagnostic procedures on mediastinum

Excludes:            mediastinal:

pneumogram (87.33)

x-ray NEC (87.49)

34.3            Excision or destruction of lesion or tissue of mediastinum

Excludes:            biopsy of mediastinum (34.25-34.26)

mediastinal fistulectomy (34.73)

34.4            Excision or destruction of lesion of chest wall

Excision of lesion of chest wall NOS (with excision of ribs)

Excludes:            biopsy of chest wall (34.23)

costectomy not incidental to thoracic procedure (77.91)

excision of lesion of:

breast (85.20-85.25)

cartilage (80.89)

skin (86.2-86.3)

fistulectomy (34.73)

34.5            Pleurectomy

34.51            Decortication of lung

34.59            Other excision of pleura

Excision of pleural lesion

Excludes:            biopsy of pleura (34.24)

pleural fistulectomy (34.73)

34.6            Scarification of pleura

Pleurosclerosis

Excludes:            injection of sclerosing agent (34.92)

34.7      Repair of chest wall

34.71            Suture of laceration of chest wall

Excludes:            suture of skin and subcutaneous tissue alone (86.59)

34.72            Closure of thoracostomy

34.73            Closure of other fistula of thorax

Closure of:

bronchopleural fistula

bronchopleurocutaneous fistula

bronchopleuromediastinal fistula

34.74            Repair of pectus deformity

Repair of:

pectus carinatum (with implant)

pectus excavatum (with implant)

34.79            Other repair of chest wall

Repair of chest wall NOS

34.8            Operations on diaphragm

34.81            Excision of lesion or tissue of diaphragm

Excludes:            biopsy of diaphragm (34.27)

34.82            Suture of laceration of diaphragm

34.83            Closure of fistula of diaphragm

Thoracicoabdominal fistulectomy

Thoracicogastric fistulectomy

Thoracicointestinal fistulectomy

34.84            Other repair of diaphragm

Excludes:            repair of diaphragmatic hernia (53.7-53.82)

34.85            Implantation of diaphragmatic pacemaker

34.89            Other operations on diaphragm

34.9      Other operations on thorax

34.91            Thoracentesis

34.92            Injection into thoracic cavity

Chemical pleurodesis

Injection of cytotoxic agent or tetracycline

Requires additional code for any cancer chemotherapeutic substance (99.25)

Excludes:            that for collapse of lung (33.32)

34.93            Repair of pleura

34.99            Other

Excludes:            removal of:

mediastinal drain (97.42)

sutures (97.43)

thoracotomy tube (97.41)

7. OPERATIONS ON THE CARDIOVASCULAR SYSTEM (35-39) back to top

35            Operations on valves and septa of heart

Includes:            sternotomy (median) (transverse) as operative approach

thoracotomy as operative approach

Code also cardiopulmonary bypass [extracorporeal

circulation] [heart-lung machine] (39.61)

35.0      Closed heart valvotomy

Excludes:            percutaneous (balloon) valvuloplasty (35.96)

35.00            Closed heart valvotomy, unspecified valve

35.01            Closed heart valvotomy, aortic valve

35.02            Closed heart valvotomy, mitral valve

35.03            Closed heart valvotomy, pulmonary valve

35.04            Closed heart valvotomy, tricuspid valve

35.1      Open heart valvuloplasty without replacement

Includes:            open heart valvotomy

Excludes:    that associated with repair of:

endocardial cushion defect (35.54, 35.63, 35.73)

valvular defect associated with atrial and ventricular septal defects (35.54, 35.63, 35.73)

percutaneous (balloon) valvuloplasty (35.96)

Code also cardiopulmonary bypass if performed [extracorporeal circulation] [heart-lung machine] (39.61)

35.10            Open heart valvuloplasty without replacement, unspecified valve

35.11            Open heart valvuloplasty of aortic valve without replacement

35.12            Open heart valvuloplasty of mitral valve without replacement

35.13            Open heart valvuloplasty of pulmonary valve without replacement

35.14            Open heart valvuloplasty of tricuspid valve without replacement

35.2            Replacement of heart valve

Includes:            excision of heart valve with replacement

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

Excludes:    that associated with repair of:

endocardial cushion defect (35.54, 35.63, 35.73)

valvular defect associated with atrial and ventricular septal defects (35.54, 35.63, 35.73)

35.20            Replacement of unspecified heart valve

Repair of unspecified heart valve with tissue graft or prosthetic implant

35.21            Replacement of aortic valve with tissue graft

Repair of aortic valve with tissue graft (autograft) (heterograft) (homograft)

35.22            Other replacement of aortic valve

Repair of aortic valve with replacement:

NOS

prosthetic (partial) (synthetic) (total)

35.23            Replacement of mitral valve with tissue graft

Repair of mitral valve with tissue graft (autograft) (heterograft) (homograft)

35.24            Other replacement of mitral valve

Repair of mitral valve with replacement:

NOS

prosthetic (partial) (synthetic) (total)

35.25            Replacement of pulmonary valve with tissue graft

Repair of pulmonary valve with tissue graft (autograft) (heterograft) (homograft)

35.26            Other replacement of pulmonary valve

Repair of pulmonary valve with replacement:

NOS

prosthetic (partial) (synthetic) (total)

35.27            Replacement of tricuspid valve with tissue graft

Repair of tricuspid valve with tissue graft (autograft) (heterograft) (homograft)

35.28            Other replacement of tricuspid valve

Repair of tricuspid valve with replacement:

NOS

prosthetic (partial) (synthetic) (total)

35.3            Operations on structures adjacent to heart valves

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

35.31            Operations on papillary muscle

Division of papillary muscle

Reattachment of papillary muscle

Repair of papillary muscle

35.32            Operations on chordae tendineae

Division of chordae tendineae

Repair of chordae tendineae

35.33            Annuloplasty

Plication of annulus

35.34            Infundibulectomy

Right ventricular infundibulectomy

35.35            Operations on trabeculae carneae cordis

Division of trabeculae carneae cordis

Excision of trabeculae carneae cordis

Excision of aortic subvalvular ring

35.39            Operations on other structures adjacent to valves of heart

Repair of sinus of Valsalva (aneurysm)

35.4            Production of septal defect in heart

35.41            Enlargement of existing atrial septal defect

Rashkind procedure

Septostomy (atrial) (balloon)

35.42            Creation of septal defect in heart

Blalock-Hanlon operation

35.5      Repair of atrial and ventricular septa with prosthesis

Includes:            repair of septa with synthetic implant or patch

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

35.50            Repair of unspecified septal defect of heart with prosthesis

Excludes:            that associated with repair of:

endocardial cushion defect (35.54)

septal defect associated with valvular defect (35.54)

35.51            Repair of atrial septal defect with prosthesis, open technique

Atrioseptoplasty with prosthesis

Correction of atrial septal defect with prosthesis

Repair:

foramen ovale (patent)

with prosthesis ostium secundum defect with prosthesis

Excludes:            that associated with repair of:

atrial septal defect associated with valvular and ventricular septal defects (35.54)

endocardial cushion defect (35.54)

35.52            Repair of atrial septal defect with prosthesis, closed technique

Insertion of atrial septal umbrella [King-Mills]

35.53            Repair of ventricular septal defect with prosthesis

Correction of ventricular septal defect with prosthesis

Repair of supracristal defect with prosthesis

Excludes:            that associated with repair of:

endocardial cushion defect (35.54)

ventricular defect associated with valvular and atrial septal defects (35.54)

35.54            Repair of endocardial cushion defect with prosthesis

Repair:

atrioventricular canal with prosthesis (grafted to septa)

ostium primum defect with prosthesis (grafted to septa)

valvular defect associated with atrial and ventricular septal defects with prosthesis (grafted to septa)

Excludes:            repair of isolated:

atrial septal defect (35.51-35.52)

valvular defect (35.20, 35.22, 35.24, 35.26, 35.28)

ventricular septal defect (35.53)

35.6      Repair of atrial and ventricular septa with tissue graft

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

35.60            Repair of unspecified septal defect of heart with tissue graft

Excludes:            that associated with repair of:

endocardial cushion defect (35.63)

septal defect associated withvalvular defect (35.63)

35.61            Repair of atrial septal defect with tissue graft

Atrioseptoplasty with tissue graft

Correction of atrial septal defect with tissue graft

Repair:

foramen ovale (patent) with tissue graft

ostium secundum defect with tissue graft

Excludes:            that associated with repair of:

atrial septal defect associated with valvular and ventricular septal defects (35.63)

endocardial cushion defect (35.63)

35.62            Repair of ventricular septal defect with tissue graft

Correction of ventricular septal defect with tissue graft

Repair of supracristal defect with tissue graft

Excludes:            that associated with repair of:

endocardial cushion defect(35.63)

ventricular defect associate with valvular and atrial septal defects (35.63)

35.63            Repair of endocardial cushion defect with tissue graft

Repair of:

atrioventricular canal with tissue graft

ostium primum defect with tissue graft

valvular defect associated with atrial and ventricular septal defects with tissue graft

Excludes:            repair of isolated:

atrial septal defect (35.61)

valvular defect (35.20-35.21, 35.23, 35.25, 35.27)

ventricular septal defect (35.62)

35.7      Other and unspecified repair of atrial and ventricular septa

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

35.70            Other and unspecified repair of unspecified septal defect of heart

Repair of septal defect NOS

Excludes:            that associated with repair of:

endocardial cushion defect (35.73)

septal defect associated wit valvular defect (35.73)

35.71            Other and unspecified repair of atrial septal defect

Repair NOS:

atrial septum

foramen ovale (patent)

ostium secundum defect

Excludes:            that associated with repair of:

atrial septal defect associated with valvular ventricular septal defects (35.73)

endocardial cushion defect (35.73)

35.72            Other and unspecified repair of ventricular septal defect

Repair NOS:

supracristal defect

ventricular septum

Excludes:            that associated with repair of:

endocardial cushion defect (35.73)

ventricular septal defect associated with valvular and atrial septal defects (35.73)

35.73            Other and unspecified repair of endocardial cushion defect

Repair NOS:

atrioventricular canal

ostium primum defect

valvular defect associated with atrial and ventricular septal defects

Excludes:            repair of isolated:

atrial septal defect (35.71)

valvular defect (35.20, 35.22, 35.24, 35.26, 35.28)

ventricular septal defect (35.72)

35.8      Total repair of certain congenital cardiac anomalies

Note:    For partial repair of defect [e.g. repair of atrial septal defect in tetralogy of Fallot] -- code to specific procedure

35.81            Total repair of tetralogy of Fallot

One-stage total correction of tetralogy of Fallot with or without:

commissurotomy of pulmonary valve

infundibulectomy

outflow tract prosthesis

patch graft of outflow tract

prosthetic tube for pulmonary artery

repair of ventricular septal defect (with prosthesis)

take-down of previous systemic-pulmonary artery anastomosis

35.82            Total repair of total anomalous pulmonary venous connection

One-stage total correction of total anomalous pulmonary venous connection with or without:

anastomosis between (horizontal) common pulmonary trunk and posterior wall of left atrium (side-to-side)

enlargement of foramen ovale

incision [excision] of common wall between posterior left atrium and coronary sinus and roofing of resultant defect with patch graft (synthetic)

ligation of venous connection (descending anomalous vein) (to left innominate vein) (to superior vena cava)

repair of atrial septal defect (with prosthesis)

35.83            Total repair of truncus arteriosus

One-stage total correction of truncus arteriosus with or without:

construction (with aortic homograft) (with prosthesis) of a pulmonary artery placed from right ventricle to arteries supplying the lung

ligation of connections between aorta and pulmonary artery

repair of ventricular septal defect (with prosthesis)

35.84            Total correction of transposition of great vessels, not elsewhere classified

Arterial switch operation [Jatene]

Total correction of transposition of great arteries at the arterial level by switching the great arteries, including the left or both coronary arteries, implanted in the wall of the pulmonary artery

Excludes:            baffle operation [Mustard] [Senning] (35.91)

creation of shunt between right ventricle and pulmonary artery [Rastelli] (35.92)

35.9      Other operations on valves and septa of heart

Code also cardiopulmonary bypass, if performed [extracorporeal circulation] [heart-lung machine] (39.61)

35.91            Interatrial transposition of venous return

Baffle:

atrial

interatrial

Mustard's operation

Resection of atrial septum and insertion of patch to direct systemic venous return to tricuspid valve and pulmonary venousreturn to mitral valve

35.92            Creation of conduit between right ventricle and pulmonary artery

Creation of shunt between right ventricle and (distal) pulmonary artery

Excludes:            that associated with total repair of truncus arteriosus (35.83)

35.93            Creation of conduit between left ventricle and aorta

Creation of apicoaortic shunt

Shunt between apex of left ventricle and aorta

35.94            Creation of conduit between atrium and pulmonary artery

Fontan procedure

35.95            Revision of corrective procedure on heart

Replacement of prosthetic heart valve poppet

Resuture of prosthesis of:

septum

valve

Excludes:            complete revision -- code to specific procedure

replacement of prosthesis or graft of:

septum (35.50-35.63)

valve (35.20-35.28)

35.96            Percutaneous valvuloplasty

Percutaneous balloon valvuloplasty

35.98            Other operations on septa of heart

35.99            Other operations on valves of heart

36            Operations on vessels of heart

Includes:            sternotomy (median) (transverse) as operative approach

thoracotomy as operative approach

Code also any:

cardiopulmonary bypass, if performed [extracorporeal circulation] [heart-lung machine] (39.61)

injection or infusion of platelet inhibitor (99.20)

injection or infusion of thrombolytic agent (99.10)

36.0            Removal of coronary artery obstruction and insertion of stent(s)

36.03            Open chest coronary artery angioplasty

Coronary (artery):

endarterectomy (with patch graft)

thromboendarterectomy (with patch graft)

Open surgery for direct relief of coronary artery obstruction

Excludes:            that with coronary artery bypass graft (36.10-36.19)

Code also any:

insertion of drug-eluting coronary stent(s) (36.07)

insertion of non-drug-eluting coronary stent(s) (36.06)

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

36.04            Intracoronary artery thrombolytic infusion

That by direct coronary artery injection, infusion, or catheterization

enzyme infusion

Platelet inhibitor

Excludes:            infusion of platelet inhibitor (99.20)

infusion of thrombolytic agent (99.10)

that associated with any procedure in 00.66, 36.03

36.06            Insertion of non-drug-eluting coronary artery stent(s)

Bare stent(s)

Bonded stent(s)

Drug-coated stent(s), i.e. heparin coated

Endograft(s)

Endovascular graft(s)

Stent grafts

Code also any:

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

open chest coronary artery angioplasty (36.03)

percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy (00.66)

Excludes: insertion of drug-eluting coronary artery stent(s) (36.07)

36.07            Insertion of drug-eluting coronary artery stent(s)

Endograft(s)

Endovascular graft(s)

Stent graft(s)

Code also any:

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

open chest coronary artery angioplasty (36.03)

percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy (00.66)

Excludes: drug-coated stents, e.g., heparin coated (36.06)

insertion of non-drug-eluting coronary artery stent(s) (36.06)

36.09            Other removal of coronary artery obstruction

Coronary angioplasty NOS

Code also any:

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

Excludes:            that by open angioplasty (36.03)

that by percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy (00.66)

36.1      Bypass anastomosis for heart revascularization

Note: Do not assign codes from series 00.40-00.43 with codes from series 36.10-36.19

Code also : cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance, if performed (00.16)

36.10            Aortocoronary bypass for heart revascularization, not otherwise specified

Direct revascularization:

cardiac with catheter stent, prosthesis, or vein graft

coronary with catheter stent, prosthesis, or vein graft

heart muscle with catheter stent, prosthesis, or vein graft

myocardial with catheter stent, prosthesis, or vein graft

Heart revascularization NOS

36.11            (Aorto)coronary bypass of one coronary artery

36.12            (Aorto)coronary bypass of two coronary arteries

36.13            (Aorto)coronary bypass of three coronary arteries

36.14            (Aorto)coronary bypass of four or more coronary arteries

36.15            Single internal mammary-coronary artery bypass

Anastomosis (single):

mammary artery to coronary artery

thoracic artery to coronary artery

36.16            Double internal mammary-coronary artery bypass

Anastomosis, double:

mammary artery to coronary artery

thoracic artery to coronary artery

36.17            Abdominal - coronary artery bypass

Anastomosis:

Gastroepiploic - coronary artery

36.19            Other bypass anastomosis for heart revascularization

36.2      Heart revascularization by arterial implant

Implantation of:

aortic branches [ascending aortic branches] into heart muscle

blood vessels into myocardium

internal mammary artery [internal thoracic artery] into:

heart muscle

myocardium

ventricle

ventricular wall

Indirect heart revascularization NOS

36.3      Other heart revascularization

36.31            Open chest transmyocardial revascularization

36.32            Other transmyocardial revascularization

Percutaneous transmyocardial revascularization

Thoracoscopic transmyocardial revascularization

36.39            Other heart revascularization

Abrasion of epicardium

Cardio-omentopexy

Intrapericardial poudrage

Myocardial graft:

mediastinal fat

omentum

pectoral muscles

36.9      Other operations on vessels of heart

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

36.91            Repair of aneurysm of coronary vessel

36.99            Other operations on vessels of heart

Exploration of coronary artery

Incision of coronary artery

Ligation of coronary artery

Repair of arteriovenous fistula

37         Other operations on heart and pericardium

Code also any injection or infusion of platelet inhibitor (99.20)

37.0            Pericardiocentesis

37.1            Cardiotomy and pericardiotomy

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

37.10            Incision of heart, not otherwise specified

Cardiolysis NOS

37.11            Cardiotomy

Incision of:

atrium

endocardium

myocardium

ventricle

37.12            Pericardiotomy

Pericardial window operation

Pericardiolysis

Pericardiotomy

37.2            Diagnostic procedures on heart and pericardium

37.21            Right heart cardiac catheterization

Cardiac catheterization NOS

Excludes:            that with catheterization of left heart (37.23)

37.22            Left heart cardiac catheterization

Excludes:            that with catheterization of right heart (37.23)

37.23            Combined right and left heart cardiac catheterization

37.24            Biopsy of pericardium

37.25            Biopsy of heart

37.26            Cardiac electrophysiologic stimulation and recording studies

Electrophysiologic studies [EPS]

Non-invasive programmed electrical stimulation (NIPS)

Programmed electrical stimulation

Code also any concomitant procedure

Excludes:            device interrogation only without arrhythmia induction (bedside check) (89.45-89.49)

His bundle recording (37.29)

37.27            Cardiac mapping

Code also any concomitant procedure

Excludes:            electrocardiogram (89.52)

His bundle recording (37.29)

37.28            Intracardiac echocardiography

Echocardiography of heart chambers

ICE

Code also any synchronous Doppler flow mapping (88.72)

Excludes: intravascular imaging of coronary vessels (intravascular ultrasound)(IVUS) (00.24)

37.29            Other diagnostic procedures on heart and pericardium

Excludes:            angiocardiography (88.50-88.58)

cardiac function tests (89.41-89.69)

cardiovascular radioisotopic scan and function study (92.05)

coronary arteriography (88.55-88.57)

diagnostic pericardiocentesis (37.0)

diagnostic ultrasound of heart (88.72)

x-ray of heart (87.49)

37.3            Pericardiectomy and excision of lesion of heart

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

37.31            Pericardiectomy

Excision of:

adhesions of pericardium constricting scar of:

epicardium

pericardium

37.32            Excision of aneurysm of heart

Repair of aneurysm of heart

37.33            Excision or destruction of other lesion or tissue of heart,open approach

Ablation of heart tissue (cryoablation) (electrocurrent) (laser) (microwave) (radiofrequency) (resection), open chest approach

Cox-maze procedure

Maze procedure

Modified maze procedure, trans-thoracic approach

Excludes:            ablation,excision or destruction of lesion or tissue of heart, endovascular approach (37.34)

37.34    Excision or destruction of other lesion or tissue of heart,other approach

Ablation of heart tissue (cryoablation) (electrocurrent)(laser) (microwave) (radiofrequency) (resection), via peripherally inserted catheter

Modified maze procedure, endovascular approach

37.35            Partial ventriculectomy

Ventricular reduction surgery

Ventricular remodeling

Code also any synchronous:mitral valve repair (35.02, 35.12)

                mitral valve replacement (35.23 - 35.24)

37.4      Repair of heart and pericardium

37.41            Implantation of prosthetic cardiac support device around the heart

Cardiac support device (CSD)

Epicardial support device

Fabric (textile) (mesh) device

Ventricular support device on surface of heart

Code also any:

cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] if performed (39.61)

mitral valve repair (35.02, 35.12)

mitral valve replacement (35.23 - 35.24)

transesophageal echocardiography (88.72)

Excludes:

circulatory assist systems (37.61 - 37.68)

37.49            Other repair of heart and pericardium

37.5      Heart replacement procedures

37.51            Heart transplantation

Excludes:            combined heart-lung transplantation (33.6)

37.52            Implantation of total replacement heart system

Artificial heart

Implantation of fully implantable total replacement heart system, including ventriculectomy

Excludes: implantation of heart assist system [VAD] (37.62, 37.65, 37.66)

37.53            Replacement or repair of thoracic unit of total replacement heart system

Excludes: replacement and repair of heart assist system [VAD](37.63)

37.54            Replacement or repair of other implantable component of total replacement heart system

Implantable battery

Implantable controller

Transcutaneous energy transfer [TET] device

Excludes: replacement and repair of heart assist system [VAD] (37.63)

replacement or repair of thoracic unit of total replacement heart system (37.53)

37.6            Implantation of heart and circulatory assist system

Excludes: implantation of prosthetic cardiac support system (37.41)

37.61            Implant of pulsation balloon

37.62            Insertion of non-implantable heart assist system

Insertion of heart assist system, NOS

Insertion of heart pump

Excludes: implantation of total replacement heart system (37.52)

insertion of percutaneous external heart assist device (37.68)

37.63            Repair of heart assist system

Replacement of parts of an existing ventricular assist device (VAD)

Excludes: replacement or repair of other implantable component of total replacement heart system [artificial heart]

(37.54)

replacement or repair of thoracic unit of total replacement heart system [artificial heart] (37.53)

37.64            Removal of heart assist system

Excludes:            that with replacement of implant (37.63)

explantation [removal] of percutaneous external heart assist device (97.44)

nonoperative removal of heart assist system (97.44)

37.65            Implant of external heart assist system

Note:            Device (outside the body but connected to heart) with external circulation and pump.

Includes open chest (sternotomy) procedure for cannulae attachments

Excludes:            implant of pulsation balloon (37.61)

implantation of total replacement heart system (37.52)

insertion of percutaneous external heart assist device (37.68)

37.66            Insertion of implantable heart assist system

Axial flow heart assist system

Diagonal pump heart assist system

Left ventricular assist device (LVAD)

Pulsatile heart assist system

Right ventricular assist device (RVAD)

Rotary pump heart assist system

Ventricular assist device (VAD) not otherwise specified

Note:            Device directly connected to the heart and implanted in the upper left quadrant of peritoneal cavity.

Transportable, implantable heart assist system.

Excludes: implant of pulsation balloon (37.61)

implantation of total replacement heart system [artificial heart] (37.52)

insertion of percutaneous external heart assist device (37.68)

37.67            Implantation of cardiomyostimulation system

Note:            Two-step open procedure consisting of transfer of one end of the latissimus dorsi muscle; wrapping it around the heart; rib resection; implantation of epicardial cardiac pacing leads into the right ventricle; tunneling and pocket creation for the cardiomyostimulator.

37.68            Insertion of percutaneous external heart assist device

Includes percutaneous [femoral] insertion of cannulae attachments

Circulatory assist device

Extrinsic heart assist device

pVAD

Percutaneous heart assist device

37.7            Insertion, revision, replacement, and removal of pacemaker leads; insertion of temporary pacemaker system; or revision of cardiac device pocket

Code also any insertion and replacement of pacemaker device (37.80-37.87)

Excludes: implantation or replacement of transvenous lead [electrode] into left ventricular cardiac venous system (00.52)

37.70            Initial insertion of lead [electrode], not otherwise specified

Excludes:            insertion of temporary transvenous pacemaker system (37.78)

replacement of atrial and/or ventricular lead(s) (37.76)

37.71            Initial insertion of transvenous lead [electrode] into ventricle

Excludes:            insertion of temporary transvenous pacemaker system (37.78)

replacement of atrial and/or ventricular lead(s) (37.76)

37.72            Initial insertion of transvenous leads [electrodes] into atrium and ventricle

Excludes:            insertion of temporary transvenous pacemaker system (37.78)

replacement of atrial and/or ventricular lead(s) (37.76)

37.73            Initial insertion of transvenous lead [electrode] into atrium

Excludes:            insertion of temporary transvenous pacemaker system (37.78)

replacement of atrial and/or ventricular lead(s) (37.76)

37.74            Insertion or replacement of epicardial lead [electrode] into epicardium

Insertion or replacement of epicardial by:

sternotomy

thoracotomy

Excludes:            replacement of atrial and/or ventricular lead(s) (37.76)

37.75            Revision of lead [electrode]

Repair of electrode [removal with re-insertion]

Repositioning of lead [electrode]

Revision of lead NOS

Excludes:            repositioning of temporary transvenous pacemaker system -- omit code

37.76            Replacement of transvenous atrial and/or ventricular lead(s) [electrode]

Removal or abandonment of existing transvenous or epicardial lead(s) with transvenous lead(s) replacement

Excludes:            replacement of epicardial lead [electrode] (37.74)

37.77            Removal of lead(s) [electrode] without replacement

Removal:

epicardial lead (transthoracic approach)

transvenous lead(s)

Excludes:            removal of temporary transvenous pacemaker system -- omit code

that with replacement of:

atrial and/or ventricular lead(s) [electrode] (37.76)

epicardial lead [electrode] (37.74)

37.78            Insertion of temporary transvenous pacemaker system

Excludes:            intraoperative cardiac pacemaker (39.64)

37.79            Revision or relocation of cardiac device pocket

Debridement and reforming pocket (skin and subcutaneous tissue)

Relocation of pocket [creation of new pocket] pacemaker or CRT-P

Revision or relocation of pacemaker, defibrillator, or other implanted cardiac device pocket

37.8            Insertion, replacement, removal, and revision of pacemaker device

Code also any lead insertion, lead replacement, lead removal and/or lead revision (37.70-37.77)

Excludes: implantation of cardiac resynchronization pacemaker [CRT-P] (00.50)

implantation or replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P] (00.53)

37.80            Insertion of permanent pacemaker, initial or replacement, type of device not specified

37.81            Initial insertion of single-chamber device, not specified as rate responsive

Excludes:            replacement of existing pacemaker device (37.85- 37.87)

37.82            Initial insertion of single-chamber device, rate responsive

Rate responsive to physiologic stimuli other than atrial rate

Excludes:            replacement of existing pacemaker device (37.85- 37.87)

37.83            Initial insertion of dual-chamber device

Atrial ventricular sequential device

Excludes:            replacement of existing pacemaker device (37.85- 37.87)

37.85            Replacement of any type pacemaker device with single-chamber device, not specified as rate responsive

37.86            Replacement of any type of pacemaker device with single-chamber device, rate responsive

Rate responsive to physiologic stimuli other than atrial rate

37.87            Replacement of any type pacemaker device with dual-chamber device

Atrial ventricular sequential device

37.89            Revision or removal of pacemaker device

Removal without replacement of cardiac resynchronization pacemaker device [CRT-P]

Repair of pacemaker device

Excludes:            removal of temporary transvenous pacemaker system -- omit code

replacement of existing pacemaker device (37.85-37.87)

replacement of existing pacemaker device with CRT-P pacemaker device (00.53)

37.9      Other operations on heart and pericardium

37.90            Insertion of left atrial appendage device

Left atrial filter

Left atrial occluder

Transseptal catheter technique

37.91            Open chest cardiac massage

Excludes:            closed chest cardiac massage (99.63)

37.92            Injection of therapeutic substance into heart

37.93            Injection of therapeutic substance into pericardium

37.94            Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD]

Implantation of defibrillator with leads (epicardial patches), formation of pocket (abdominal fascia) (subcutaneous), any transvenous leads, intraoperative procedures for evaluation of lead signals, and obtaining defibrillator threshold measurements (electrophysiologic studies [EPS])

Techniques:

lateral thoracotomy

medial sternotomy

subxiphoid procedure

Code also extracorporeal circulation, if performed (39.61)

Code also any concomitant procedure [e.g., coronary bypass] (36.00-36.19)

Excludes:implantation of cardiac resynchronization defibrillator, total system [CRT-D] (00.51)

37.95            Implantation of automatic cardioverter/defibrillator lead(s) only

37.96            Implantation of automatic cardioverter/defibrillator pulse generator only

Excludes: implantation or replacement of cardiac resynchronization defibrillator, pulse generator

device only [CRT-D] (00.54)

37.97            Replacement of automatic cardioverter/defibrillator lead(s) only

37.98            Replacement of automatic cardioverter/defibrillator pulse generator only

Excludes:replacement of cardiac resynchronization defibrillator, pulse generator device only [CRT-D] (00.54)

37.99            Other

Removal of cardioverter/defibrillator pulse generator only without replacement

Removal without replacement of cardiac resynchronization defibrillator device [CRT-D]

Repositioning of lead(s) (sensing) (pacing) [electrode]

Repositioning of pulse generator

Revision of cardioverter/defibrillator (automatic) pocket

Revision or relocation of CRT-D pocket

Excludes:            cardiac retraining (93.36)

conversion of cardiac rhythm (99.60-99.69)

implantation of prosthetic cardiac support device (37.41)

insertion of left atrial appendage device (37.90)

maze procedure (Cox-maze), open (37.33)

maze procedure, endovascular approach (37.34)

38         Incision, excision, and occlusion of vessels

Code also

any application or administration of an adhesion barrier substance (99.77)

cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

Excludes:    that of coronary vessels (36.01-36.99)

The following fourth-digit subclassification is for use with appropriate categories in section 38.0, 38.1, 38.3, 38.5, 38.6, 38.8, and 38.9 according to site. Valid fourth-digits are in [brackets] at the end of each code/description.

0   unspecified site

1   intracranial vessels

Cerebral (anterior) (middle)

Circle of Willis

Posterior communicating artery

2   other vessels of head and neck

Carotid artery (common) (external) (internal)

Jugular vein (external) (internal)

3   upper limb vessels

Axillary

Brachial

Radial

Ulnar

4   aorta

5   other thoracic vessels

Innominate

Pulmonary (artery) (vein)

Subclavian

Vena cava, superior

6   abdominal arteries

Celiac

Gastric

Hepatic

Iliac

Mesenteric

Renal

Splenic

Umbilical

Excludes:   abdominal aorta (4)

7   abdominal veins

Iliac

Portal

Renal

Splenic

Vena cava (inferior)

8   lower limb arteries

Femoral (common) (superficial)

Popliteal

Tibial

9   lower limb veins

Femoral

Popliteal

Saphenous

Tibial

38.0      Incision of vessel

[0-9]

Embolectomy

Thrombectomy

Excludes:            puncture or catheterization of any:

artery (38.91, 38.98)

vein (38.92-38.95, 38.99)

38.1            Endarterectomy

[0-6,8]

Endarterectomy with:

embolectomy

patch graft

temporary bypass during procedure

thrombectomy

Code also any:

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

38.2            Diagnostic procedures on blood vessels

Excludes: adjunct vascular system procedures (00.40-00.43)

38.21            Biopsy of blood vessel

38.22            Percutaneous angioscopy

Excludes:            angioscopy of eye (95.12)

38.29            Other diagnostic procedures on blood vessels

Excludes:            blood vessel thermography (88.86)

circulatory monitoring (89.61-89.69)

contrast:

angiocardiography (88.50-88.58)

arteriography (88.40-88.49)

phlebography (88.60-88.67)

impedance phlebography (88.68)

peripheral vascular ultrasonography (88.77)

plethysmogram (89.58)

38.3            Resection of vessel with anastomosis

[0-9]

Angiectomy

Excision of:

aneurysm (arteriovenous) with anastomosis

blood vessel (lesion) with anastomosis

38.4            Resection of vessel with replacement

[0-9]

Angiectomy

Excision of:

aneurysm (arteriovenous) or blood vessel (lesion) with replacement

Excludes: endovascular repair of aneurysm (39.71 - 39.79)

Requires the use of one of the following fourth-digit subclassifications to identify site:

0   unspecified site

1   intracranial vessels

Cerebral (anterior) (middle)

Circle of Willis

Posterior communicating artery

2   other vessels of head and neck

Carotid artery (common) (external) (internal)

Jugular vein (external) (internal)

3   upper limb vessels

Axillary

Brachial

Radial

Ulnar

4   aorta, abdominal

Code also any thoracic vessel involvement thoracoabdominal procedure) (38.45)

5   thoracic vessels

Aorta (thoracic)

Innominate

Pulmonary (artery) (vein)

Subclavian

Vena cava, superior

Code also any abdominal aorta involvement (thoracoabdominal procedure) (38.44)

6   abdominal arteries

Celiac

Gastric

Hepatic

Iliac

Mesenteric

Renal

Splenic

Umbilical

Excludes:   abdominal aorta (4)

7   abdominal veins

Iliac

Portal

Renal

Splenic

Vena cava (inferior)

8   lower limb arteries

Femoral (common) (superficial)

Popliteal

Tibial

9   lower limb veins

Femoral

Popliteal

Saphenous

Tibial

38.5      Ligation and stripping of varicose veins

[0-3,5,7,9]

Excludes:            ligation of varices:

esophageal (42.91)

gastric (44.91)

38.6      Other excision of vessel

[0-9]

Excision of blood vessel (lesion) NOS

Excludes:            excision of vessel for aortocoronary bypass (36.10-36.14)

excision with:

anastomosis (38.30-38.39)

graft replacement (38.40-38.49)

implant (38.40-38.49)

38.7            Interruption of the vena cava

Insertion of implant or sieve in vena cava

Ligation of vena cava (inferior) (superior)

Plication of vena cava

38.8      Other surgical occlusion of vessels

[0-9]

Clamping of blood vessel

Division of blood vessel

Ligation of blood vessel

Occlusion of blood vessel

Excludes:            adrenal vessels (07.43)

esophageal varices (42.91)

gastric or duodenal vessel for ulcer (44.40-44.49)

gastric varices (44.91)

meningeal vessel (02.13)

percutaneous transcatheter infusion embolization (99.29)

spermatic vein for varicocele (63.1)

surgical occlusion of vena cava (38.7)

that for chemoembolization (99.25)

that for control of (postoperative) hemorrhage:

anus (49.95)

bladder (57.93)

following vascular procedure (39.41)

nose (21.00-21.09)

prostate (60.94)

tonsil (28.7)

thyroid vessel (06.92)

transcatheter (infusion) 99.29

38.9            Puncture of vessel

Excludes:    that for circulatory monitoring (89.60-89.69)

38.91            Arterial catheterization

38.92            Umbilical vein catheterization

38.93            Venous catheterization, not elsewhere classified

Excludes:            that for cardiac catheterization (37.21-37.23)

that for renal dialysis (38.95)

38.94            Venous cutdown

38.95            Venous catheterization for renal dialysis

Excludes:            insertion of totally implantable vascular access device [VAD] (86.07)

38.98            Other puncture of artery

Excludes:            that for:

arteriography (88.40-88.49)

coronary arteriography (88.55-88.57)

38.99            Other puncture of vein

Phlebotomy

Excludes:            that for:

angiography (88.60-88.69)

extracorporeal circulation (39.61, 50.92)

injection or infusion of:

sclerosing solution (39.92)

therapeutic or prophylactic substance (99.11-99.29)

perfusion (39.96-39.97)

phlebography (88.60-88.69)

transfusion (99.01-99.09)

39         Other operations on vessels

Excludes:            those on coronary vessels (36.00-36.99)

39.0            Systemic to pulmonary artery shunt

Descending aorta-pulmonary artery anastomosis (graft)

Left to right anastomosis (graft)

Subclavian-pulmonary anastomosis (graft)

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

39.1      Intra-abdominal venous shunt

Anastomosis:

mesocaval

portacaval

portal vein to inferior vena cava

splenic and renal veins

transjugular intrahepatic portosystemic shunt (TIPS)

Excludes:            peritoneovenous shunt (54.94)

39.2      Other shunt or vascular bypass

Code also pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance, if performed (00.16)

39.21            Caval-pulmonary artery anastomosis

Code also cardiopulmonary bypass (39.61)

39.22            Aorta-subclavian-carotid bypass

Bypass (arterial):

aorta to carotid and brachial

aorta to subclavian and carotid

carotid to subclavian

39.23            Other intrathoracic vascular shunt or bypass

Intrathoracic (arterial) bypass graft NOS

Excludes:            coronary artery bypass (36.10-36.19)

39.24            Aorta-renal bypass

39.25            Aorta-iliac-femoral bypass

Bypass:

aortofemoral

aortoiliac

aortoiliac to popliteal

aortopopliteal

iliofemoral [iliac-femoral]

39.26            Other intra-abdominal vascular shunt or bypass

Bypass:

aortoceliac

aortic-superior mesenteric

common hepatic-common iliac-renal

Intra-abdominal arterial bypass graft NOS

Excludes:            peritoneovenous shunt (54.94)

39.27            Arteriovenostomy for renal dialysis

Anastomosis for renal dialysis

Formation of (peripheral) arteriovenous

fistula for renal [kidney] dialysis

Code also any renal dialysis (39.95)

39.28            Extracranial-intracranial (EC-IC) vascular bypass

39.29            Other (peripheral) vascular shunt or bypass

Bypass (graft):

axillary-brachial

axillary-femoral [axillofemoral] (superficial)

brachial

femoral-femoral

femoroperoneal

femoropopliteal (arteries)

femorotibial (anterior) (posterior)

popliteal

vascular NOS

Excludes:            peritoneovenous shunt (54.94)

39.3      Suture of vessel

Repair of laceration of blood vessel

Excludes:    any other vascular puncture closure device - omit code

suture of aneurysm (39.52)

that for control of hemorrhage (postoperative):

anus (49.95)

bladder (57.93)

following vascular procedure (39.41)

nose (21.00-21.09)

prostate (60.94)

tonsil (28.7)

39.30            Suture of unspecified blood vessel

39.31            Suture of artery

39.32            Suture of vein

39.4      Revision of vascular procedure

39.41            Control of hemorrhage following vascular surgery

Excludes:            that for control of hemorrhage (post operative):

anus (49.95)

bladder (57.93)

nose (21.00-21.09)

prostate (60.94)

tonsil (28.7)

39.42            Revision of arteriovenous shunt for renal dialysis

Conversion of renal dialysis:

end-to-end anastomosis to end-to-side

end-to-side anastomosis to end-to-end

vessel-to-vessel cannula to arteriovenous shunt

Removal of old arteriovenous shunt and creation of new shunt

Excludes:            replacement of vessel-to-vessel cannula (39.94)

39.43            Removal of arteriovenous shunt for renal dialysis

Excludes:            that with replacement [revision] of shunt (39.42)

39.49            Other revision of vascular procedure

Declotting (graft)

Revision of:

anastomosis of blood vessel

vascular procedure (previous)

39.5      Other repair of vessels

39.50            Angioplasty or atherectomy of other non-coronary vessel(s)

Percutaneous transluminal angioplasty (PTA) of non-coronary vessels:

Lower extremity vessels

Mesenteric artery

Renal artery

Upper extremity vessels

Code also any:

injection or infusion of thrombolytic agent (99.10)

Insertion of non-coronary stent(s) or stent grafts(s) (39.90)

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

Excludes: percutaneous angioplasty or atherectomy of precerebral or cerebral vessel(s) (00.61 -00.62)

39.51            Clipping of aneurysm

Excludes:            clipping of arteriovenous fistula (39.53)

39.52            Other repair of aneurysm

Repair of aneurysm by:

coagulation

electrocoagulation

filipuncture

methyl methacrylate

suture

wiring

wrapping

Excludes:            endovascular repair of aneurysm (39.71 - 39.79)

re-entry operation (aorta) (39.54)

that with:

graft replacement (38.40-38.49)

resection (38.30-38.49, 38.60-38.69)

39.53            Repair of arteriovenous fistula

Embolization of carotid cavernous fistula

Repair of arteriovenous fistula by:

clipping

coagulation

ligation and division

Excludes:            repair of :

arteriovenous shunt for renal dialysis (39.42)

head and neck vessels, endovascular approach (39.72)

that with:

graft replacement (38.40-38.49)

resection (38.30-38.49, 38.60-38.69)

39.54            Re-entry operation (aorta)

Fenestration of dissecting aneurysm of thoracic aorta

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

39.55            Reimplantation of aberrant renal vessel

39.56            Repair of blood vessel with tissue patch graft

Excludes:            that with resection (38.40-38.49)

39.57            Repair of blood vessel with synthetic patch graft

Excludes:            that with resection (38.40-38.49)

39.58            Repair of blood vessel with unspecified type of patch graft

Excludes:            that with resection (38.40-38.49)

39.59            Other repair of vessel

Aorticopulmonary window operation

Arterioplasty NOS

Construction of venous valves (peripheral)

Plication of vein (peripheral)

Reimplantation of artery

Code also cardiopulmonary bypass [extracorporeal circulation] [heart-lung machine] (39.61)

Excludes:            interruption of the vena cava (38.7)

reimplantation of renal artery (39.55)

that with:

graft (39.56-39.58)

resection (38.30-38.49, 38.60-38.69)

39.6            Extracorporeal circulation and procedures auxiliary to heart surgery

39.61            Extracorporeal circulation auxiliary to open heart surgery

Artificial heart and lung

Cardiopulmonary bypass

Pump oxygenator

Excludes:            extracorporeal hepatic assistance (50.92)

extracorporeal membrane oxygenation [ECMO] (39.65)

hemodialysis (39.95)

percutaneous cardiopulmonary bypass (39.66)

39.62            Hypothermia (systemic) incidental to open heart surgery

39.63            Cardioplegia

Arrest:

anoxic

circulatory

39.64            Intraoperative cardiac pacemaker

Temporary pacemaker used during and immediately following cardiac surgery

39.65            Extracorporeal membrane oxygenation [ECMO]

Excludes:            extracorporeal circulation auxiliary to open heart surgery (39.61)

percutaneous cardiopulmonary bypass (39.66)

39.66            Percutaneous cardiopulmonary bypass

Closed chest

Excludes:            extracorporeal circulation auxiliary to open heart surgery (39.61)

extracorporeal hepatic assistance (50.92)

extracorporeal membrane oxygenation [ECMO] (39.65)

hemodialysis (39.95)

39.7            Endovascular repair of vessel

Endoluminal repair

Excludes:            angioplasty or atherectomy of other non-coronary vessel(s) (39.50)

insertion of non-drug-eluting peripheral vessel stent(s) (39.90)

other repair of aneurysm (39.52)

percutaneous insertion of carotid artery stent(s) (00.63)

percutaneous insertion of intracranial stent(s) (00.65)

percutaneous insertion of other precerebral artery stent(s) (00.64)

resection of abdominal aorta with replacement (38.44)

resection of lower limb arteries with replacement (38.48)

resection of thoracic aorta with replacement (38.45)

resection of upper limb vessels with replacement (38.43)

39.71            Endovascular implantation of graft in abdominal aorta

Endovascular repair of abdominal aortic aneurysm with graft

Stent graft(s)

39.72            Endovascular repair or occlusion of head and neck vessels

   Coil embolization or occlusion

   Endograft(s)

   Endovascular graft(s)

   Liquid tissue adhesive (glue) embolization or occlusion

   Other implant or substance for repair, embolization or occlusion

   That for repair of aneurysm, arteriovenous malformation[AVM] or fistula

39.73            Endovascular implantation of graft in thoracic aorta

Endograft(s)

Endovascular graft(s)

Endovascular repair of defect of thoracic aorta with graft(s) or device(s)

Stent graft(s) or device(s)

That for repair of aneurysm, dissection, or injury

Excludes: fenestration of dissecting aneurysm of thoracic aorta (39.54)

39.79            Other endovascular repair (of aneurysm) of other vessels

Coil embolization or occlusion

Endograft(s)

Endovascular graft(s)

Liquid tissue adhesive (glue) embolization or occlusion

Other implant or substance for repair, embolization or occlusion

Excludes: endovascular implantation of graft in thoracic aorta (39.73)

endovascular repair or occlusion of head and neck vessels (39.72)

insertion of drug-eluting peripheral vessel stent(s) (00.55)

insertion of non-drug-eluting peripheral vessel (s) (for other than aneurysm repair) (39.90)

non-endovascular repair of arteriovenous fistula (39.53)

other surgical occlusion of vessels -see category 38.8

percutaneous transcatheter infusion (99.29)

transcatheter embolization for gastric or duodenal bleeding (44.44)

39.8            Operations on carotid body and other vascular bodies

Chemodectomy

Denervation of:

aortic body

carotid body

Glomectomy, carotid

Implantation into carotid body:

electronic stimulator

pacemaker

Excludes:            excision of glomus jugulare (20.51)

39.9      Other operations on vessels

39.90            Insertion of non-drug-eluting peripheral vessel stent(s)

Bare stent(s)

Bonded stent(s)

Drug-coated stent(s), i.e., heparin coated

Endograft(s)

Endovascular graft(s)

Endovascular recanalization techniques

Stent graft(s)

Code also any:

non-coronary angioplasty or atherectomy (39.50)

number of vascular stents inserted (00.45-00.48)

number of vessels treated (00.40-00.43)

Excludes:                        insertion of drug-eluting peripheral vessel stent(s) (00.55)

percutaneous insertion of carotid artery stent(s) (00.63)

percutaneous insertion of intracranial stent(s) (00.65)

percutaneous insertion of other precerebral artery stent(s) (00.64)

that for aneurysm repair (39.71 - 39.79)

39.91            Freeing of vessel

Dissection and freeing of adherent tissue:

artery-vein-nerve bundle

vascular bundle

39.92            Injection of sclerosing agent into vein

Excludes:                        injection:

esophageal varices (42.33)

hemorrhoids (49.42)

39.93            Insertion of vessel-to-vessel cannula

Formation of:

arteriovenous:

fistula by external cannula

shunt by external cannula

Code also any renal dialysis (39.95)

39.94            Replacement of vessel-to-vessel cannula

Revision of vessel-to-vessel cannula

39.95            Hemodialysis

Artificial kidney

Hemodiafiltration

Hemofiltration

Renal dialysis

Excludes:            peritoneal dialysis (54.98)

39.96            Total body perfusion

Code also substance perfused (99.21-99.29)

39.97            Other perfusion

Perfusion NOS

Perfusion, local [regional] of:

carotid artery

coronary artery

head

lower limb

neck

upper limb

Code also substance perfused (99.21-99.29)

Excludes:            perfusion of:

kidney (55.95)

large intestine (46.96)

liver (50.93)

small intestine (46.95)

39.98            Control of hemorrhage, not otherwise specified

Angiotripsy

Control of postoperative hemorrhage NOS

Venotripsy

Excludes:            control of hemorrhage postoperative):

anus (49.95)

bladder (57.93)

following vascular procedure (39.41)

nose (21.00-21.09)

prostate (60.94)

tonsil (28.7)

that by:

ligation (38.80-38.89)

suture (39.30-39.32)

39.99            Other operations on vessels

Excludes:            injection or infusion of therapeutic or prophylactic substance (99.11-99.29)

transfusion of blood and blood components (99.01-99.09)

8. OPERATIONS ON THE HEMIC AND LYMPHATIC SYSTEM (40-41) back to top

40            Operations on lymphatic system

40.0      Incision of lymphatic structures

40.1            Diagnostic procedures on lymphatic structures

40.11            Biopsy of lymphatic structure

40.19            Other diagnostic procedures on lymphatic structures

Excludes:            lymphangiogram:

abdominal (88.04)

cervical (87.08)

intrathoracic (87.34)

lower limb (88.36)

upper limb (88.34)

microscopic examination of specimen (90.71-90.79)

radioisotope scan (92.16)

thermography (88.89)

40.2      Simple excision of lymphatic structure

Excludes:            biopsy of lymphatic structure (40.11)

40.21            Excision of deep cervical lymph node

40.22            Excision of internal mammary lymph node

40.23            Excision of axillary lymph node

40.24            Excision of inguinal lymph node

40.29            Simple excision of other lymphatic structure

Excision of:

cystic hygroma

lymphangioma

Simple lymphadenectomy

40.3            Regional lymph node excision

Extended regional lymph node excision

Regional lymph node excision with excision of lymphatic drainage area including skin, subcutaneous tissue, and fat

40.4      Radical excision of cervical lymph nodes

Resection of cervical lymph nodes down to muscle and deep fascia

Excludes:    that associated with radical laryngectomy (30.4)

40.40            Radical neck dissection, not otherwise specified

40.41            Radical neck dissection, unilateral

40.42            Radical neck dissection, bilateral

40.5      Radical excision of other lymph nodes

Excludes:    that associated with radical mastectomy (85.45-85.48)

40.50            Radical excision of lymph nodes, not otherwise specified

Radical (lymph) node dissection NOS

40.51            Radical excision of axillary lymph nodes

40.52            Radical excision of periaortic lymph nodes

40.53            Radical excision of iliac lymph nodes

40.54            Radical groin dissection

40.59            Radical excision of other lymph nodes

Excludes:            radical neck dissection (40.40-40.42)

40.6            Operations on thoracic duct

40.61            Cannulation of thoracic duct

40.62            Fistulization of thoracic duct

40.63            Closure of fistula of thoracic duct

40.64            Ligation of thoracic duct

40.69            Other operations on thoracic duct

40.9      Other operations on lymphatic structures

Anastomosis of peripheral lymphatics

Dilation of peripheral lymphatics

Ligation of peripheral lymphatics

Obliteration of peripheral lymphatics

Reconstruction of peripheral lymphatics

Repair of peripheral lymphatics

Transplantation of peripheral lymphatics

Correction of lymphedema of limb, NOS

Excludes:            reduction of elephantiasis of scrotum (61.3)

41            Operations on bone marrow and spleen

41.0      Bone marrow or hematopoietic stem cell transplant

Note: To report donor source - see codes 00.91-00.93

Excludes:            aspiration of bone marrow from donor (41.91)

41.00            Bone marrow transplant, not otherwise specified

41.01            Autologous bone marrow transplant without purging

Excludes:            that with purging (41.09)

41.02            Allogeneic bone marrow transplant with purging

Allograft of bone marrow with in vitro removal (purging) of T-cells

41.03            Allogeneic bone marrow transplant without purging

Allograft of bone marrow NOS

41.04            Autologous hematopoietic stem cell transplant without purging

Excludes:            that with purging (41.07)

41.05             Allogeneic hematopoietic stem cell transplant without purging

Excludes:            that with purging (41.08)

41.06            Cord blood stem cell transplant

41.07            Autologous hematopoietic stem cell transplant with purging

Cell depletion

41.08            Allogeneic hematopoietic stem cell transplant

Cell depletion

41.09            Autologous bone marrow transplant with purging

With extracorporeal purging of malignant cells from marrow

Cell depletion

41.1            Puncture of spleen

Excludes:            aspiration biopsy of spleen (41.32)

41.2            Splenotomy

41.3            Diagnostic procedures on bone marrow and spleen

41.31            Biopsy of bone marrow

41.32            Closed [aspiration] [percutaneous] biopsy of spleen

41.33            Open biopsy of spleen

41.38            Other diagnostic procedures on bone marrow

Excludes:            microscopic examination of specimen from bone marrow (90.61-90.69)

radioisotope scan (92.05)

41.39            Other diagnostic procedures on spleen

Excludes:            microscopic examination of specimen from spleen (90.61-90.69)

radioisotope scan (92.05)

41.4            Excision or destruction of lesion or tissue of spleen

Code also any application or administration of an adhesion barrier substance (99.77)

Excludes:            excision of accessory spleen (41.93)

41.41            Marsupialization of splenic cyst

41.42            Excision of lesion or tissue of spleen

Excludes:            biopsy of spleen (41.32-41.33)

41.43            Partial splenectomy

41.5      Total splenectomy

Splenectomy NOS

Code also any application or administration of an adhesion barrier substance (99.77)

41.9      Other operations on spleen and bone marrow

Code also any application or administration of an adhesion barrier substance (99.77)

41.91            Aspiration of bone marrow from donor for transplant

Excludes:            biopsy of bone marrow (41.31)

41.92            Injection into bone marrow

Excludes:            bone marrow transplant (41.00-41.03)

41.93            Excision of accessory spleen

41.94            Transplantation of spleen

41.95            Repair and plastic operations on spleen

41.98            Other operations on bone marrow

41.99            Other operations on spleen

9. OPERATIONS ON THE DIGESTIVE SYSTEM (42-54) back to top

42            Operations on esophagus

42.0            Esophagotomy

42.01            Incision of esophageal web

42.09            Other incision of esophagus

Esophagotomy NOS

Excludes:            esophagomyotomy (42.7)

esophagostomy (42.10-42.19)

42.1            Esophagostomy

42.10            Esophagostomy, not otherwise specified

42.11            Cervical esophagostomy

42.12            Exteriorization of esophageal pouch

42.19            Other external fistulization of esophagus

Thoracic esophagostomy

Code also any resection (42.40-42.42)

42.2            Diagnostic procedures on esophagus

42.21            Operative esophagoscopy by incision

42.22            Esophagoscopy through artificial stoma

Excludes:            that with biopsy (42.24)

42.23            Other esophagoscopy

Excludes:            that with biopsy (42.24)

42.24            Closed [endoscopic] biopsy of esophagus

Brushing or washing for specimen collection

Esophagoscopy with biopsy

Suction biopsy of the esophagus

Excludes:            esophagogastroduodenoscopy [EGD] with closed biopsy (45.16)

42.25            Open biopsy of esophagus

42.29            Other diagnostic procedures on esophagus

Excludes:            barium swallow (87.61)

esophageal manometry (89.32)

microscopic examination of specimen from esophagus (90.81-90.89)

42.3      Local excision or destruction of lesion or tissue of esophagus

42.31            Local excision of esophageal diverticulum

42.32            Local excision of other lesion or tissue of esophagus

Excludes:            biopsy of esophagus (42.24-42.25)

esophageal fistulectomy (42.84)

42.33            Endoscopic excision or destruction of lesion or tissue of esophagus

Ablation of esophageal neoplasm by endoscopic approach

Control of esophageal bleeding by endoscopic approach

Esophageal polypectomy by endoscopic approach

Esophageal varices by endoscopic approach

Injection of esophageal varices by endoscopic approach

Excludes:            biopsy of esophagus (42.24-42.25)

fistulectomy (42.84)

open ligation of esophageal varices (42.91)

42.39            Other destruction of lesion or tissue of esophagus

Excludes:            that by endoscopic approach (42.33)

42.4            Excision of esophagus

Excludes:            esophagogastrectomy NOS (43.99)

42.40            Esophagectomy, not otherwise specified

42.41            Partial esophagectomy

Code also any synchronous:

anastomosis other than end-to-end (42.51-42.69)

esophagostomy (42.10-42.19)

gastrostomy (43.11-43.19)

42.42            Total esophagectomy

Code also any synchronous:

gastrostomy (43.11-43.19)

interposition or anastomosis other than end-to-end (42.51-42.69)

Excludes:            esophagogastrectomy (43.99)

42.5            Intrathoracic anastomosis of esophagus

Code also any synchronous:

esophagectomy (42.40-42.42)

gastrostomy (43.1)

42.51            Intrathoracic esophagoesophagostomy

42.52            Intrathoracic esophagogastrostomy

42.53            Intrathoracic esophageal anastomosis with interposition of small bowel

42.54            Other intrathoracic esophagoenterostomy

Anastomosis of esophagus to intestinal segment NOS

42.55            Intrathoracic esophageal anastomosis with interposition of colon

42.56            Other intrathoracic esophagocolostomy

Esophagocolostomy NOS

42.58            Intrathoracic esophageal anastomosis with other interposition

Construction of artificial esophagus

Retrosternal formation of reversed gastric tube

42.59            Other intrathoracic anastomosis of esophagus

42.6            Antesternal anastomosis of esophagus

Code also any synchronous:

esophagectomy (42.40-42.42)

gastrostomy (43.1)

42.61            Antesternal esophagoesophagostomy

42.62            Antesternal esophagogastrostomy

42.63            Antesternal esophageal anastomosis with interposition of small bowel

42.64            Other antesternal esophagoenterostomy

Antethoracic:

esophagoenterostomy

esophagoileostomy

esophagojejunostomy

42.65            Antesternal esophageal anastomosis with interposition of colon

42.66            Other antesternal esophagocolostomy

Antethoracic esophagocolostomy

42.68            Other antesternal esophageal anastomosis with interposition

42.69            Other antesternal anastomosis of esophagus

42.7            Esophagomyotomy

42.8      Other repair of esophagus

42.81            Insertion of permanent tube into esophagus

42.82            Suture of laceration of esophagus

42.83            Closure of esophagostomy

42.84            Repair of esophageal fistula, not elsewhere classified

Excludes:            repair of fistula:

bronchoesophageal (33.42)

esophagopleurocutaneous (34.73)

pharyngoesophageal (29.53)

tracheoesophageal (31.73)

42.85            Repair of esophageal stricture

42.86            Production of subcutaneous tunnel without esophageal anastomosis

42.87            Other graft of esophagus

Excludes:            antesternal esophageal anastomosis with interposition of:

colon (42.65)

small bowel (42.63)

antesternal esophageal anastomosis with other interposition (42.68)

intrathoracic esophageal anastomosis with interposition of:

colon (42.55)

small bowel (42.53)

intrathoracic esophageal anastomosis with other interposition (42.58)

42.89            Other repair of esophagus

42.9      Other operations on esophagus

42.91            Ligation of esophageal varices

Excludes:            that by endoscopic approach (42.33)

42.92            Dilation of esophagus

Dilation of cardiac sphincter

Excludes:            intubation of esophagus (96.03, 96.06-96.08)

42.99            Other

Excludes:            insertion of Sengstaken tube (96.06)

intubation of esophagus (96.03, 96.06-96.08)

removal of intraluminal foreign body from esophagus without incision (98.02)

tamponade of esophagus (96.06)

43         Incision and excision of stomach

Code also any application or administration of an adhesion barrier substance (99.77)

43.0            Gastrotomy

Excludes:            gastrostomy (43.11-43.19)

that for control of hemorrhage (44.49)

43.1            Gastrostomy

43.11            Percutaneous [endoscopic] gastrostomy [PEG]

Percutaneous transabdominal gastrostomy

43.19            Other gastrostomy

Excludes:            percutaneous [endoscopic] gastrostomy [PEG] (43.11)

43.3            Pyloromyotomy

43.4      Local excision or destruction of lesion or tissue of stomach

43.41            Endoscopic excision or destruction of lesion or tissue of stomach

Gastric polypectomy by endoscopic approach

Gastric varices by endoscopic approach

Excludes:            biopsy of stomach (44.14-44.15)

control of hemorrhage (44.43)

open ligation of gastric varices (44.91)

43.42            Local excision of other lesion or tissue of stomach

Excludes:            biopsy of stomach (44.14-44.15)

gastric fistulectomy (44.62-44.63)

partial gastrectomy (43.5-43.89)

43.49            Other destruction of lesion or tissue of stomach

Excludes:            that by endoscopic approach(43.41)

43.5      Partial gastrectomy with anastomosis to esophagus

Proximal gastrectomy

43.6      Partial gastrectomy with anastomosis to duodenum

Billroth I operation

Distal gastrectomy

Gastropylorectomy

43.7      Partial gastrectomy with anastomosis to jejunum

Billroth II operation

43.8      Other partial gastrectomy

43.81            Partial gastrectomy with jejunal transposition

Henley jejunal transposition operation

Code also any synchronous intestinal resection (45.51)

43.89            Other

Partial gastrectomy with bypass gastrogastrostomy

Sleeve resection of stomach

43.9      Total gastrectomy

43.91            Total gastrectomy with intestinal interposition

43.99            Other total gastrectomy

Complete gastroduodenectomy

Esophagoduodenostomy with complete gastrectomy

Esophagogastrectomy NOS

Esophagojejunostomy with complete gastrectomy

Radical gastrectomy

44         Other operations on stomach

Code also any application or administration of an adhesion barrier substance (99.77)

44.0            Vagotomy

44.00            Vagotomy, not otherwise specified

Division of vagus nerve NOS

44.01            Truncal vagotomy

44.02            Highly selective vagotomy

Parietal cell vagotomy

Selective proximal vagotomy

44.03            Other selective vagotomy

44.1            Diagnostic procedures on stomach

44.11            Transabdominal gastroscopy

Intraoperative gastroscopy

Excludes:            that with biopsy (44.14)

44.12            Gastroscopy through artificial stoma

Excludes:            that with biopsy (44.14)

44.13            Other gastroscopy

Excludes:            that with biopsy (44.14)

44.14            Closed [endoscopic] biopsy of stomach

Brushing or washing for specimen collection

Excludes:            esophagogastroduodenoscopy [EGD] with closed biopsy (45.16)

44.15            Open biopsy of stomach

44.19            Other diagnostic procedures on stomach

Excludes:            gastric lavage (96.33)

microscopic examination of specimen from stomach (90.81-90.89)

upper GI series (87.62)

44.2            Pyloroplasty

44.21            Dilation of pylorus by incision

44.22            Endoscopic dilation of pylorus

Dilation with balloon endoscope

Endoscopic dilation of gastrojejunostomy site

44.29            Other pyloroplasty

Pyloroplasty NOS

Revision of pylorus

44.3            Gastroenterostomy without gastrectomy

44.31            High gastric bypass

Printen and Mason gastric bypass

44.32            Percutaneous [endoscopic] gastrojejunostomy

Endoscopic conversion of gastrostomy to jejunostomy

PEG

44.38            Laparoscopic gastroenterostomy

Bypass: gastroduodenostomy

              gastroenterostomy

              gastrogastrostomy

Laparoscopic gastrojejunostomy without gastrectomy NEC

Excludes: gastroenterostomy, open approach (44.39)

44.39            Other gastroenterostomy

Bypass:

gastroduodenostomy

gastroenterostomy

gastrogastrostomy

Gastrojejunostomy without gastrectomy NOS

44.4      Control of hemorrhage and suture of ulcer of stomach or duodenum

44.40            Suture of peptic ulcer, not otherwise specified

44.41            Suture of gastric ulcer site

Excludes:            ligation of gastric varices (44.91)

44.42            Suture of duodenal ulcer site

44.43            Endoscopic control of gastric or duodenal bleeding

44.44            Transcatheter embolization for gastric or duodenal bleeding

Excludes:            surgical occlusion of abdominal vessels (38.86-38.87)

44.49            Other control of hemorrhage of stomach or duodenum

That with gastrotomy

44.5      Revision of gastric anastomosis

Closure of:

gastric anastomosis

gastroduodenostomy

gastrojejunostomy

Pantaloon operation

44.6      Other repair of stomach

44.61            Suture of laceration of stomach

Excludes:            that of ulcer site (44.41)

44.62            Closure of gastrostomy

44.63            Closure of other gastric fistula

Closure of:

gastrocolic fistula

gastrojejunocolic fistula

44.64            Gastropexy

44.65            Esophagogastroplasty

Belsey operation

Esophagus and stomach cardioplasty

44.66            Other procedures for creation of esophagogastric sphincteric competence

Fundoplication

Gastric cardioplasty

Nissen's fundoplication

Restoration of cardio-esophageal angle

Excludes: that by laparoscopy (44.67)

44.67            Laparoscopic procedures for creation of esophagogastric sphincteric competence

Fundoplication

Gastric cardioplasty

Nissen's fundoplication

Restoration of cardio-esophageal angle

44.68            Laparoscopic gastroplasty

Banding

Silastic vertical banding

Vertical banded gastroplasty (VBG)

Code also any synchronous laparoscopic gastroenterostomy (44.38)

Excludes:                        insertion, laparoscopic adjustable gastric band (restrictive procedure) (44.95)

other repair of stomach, open approach (44.61-44.65, 44.69)

44.69            Other

Inversion of gastric diverticulum

Repair of stomach NOS

44.9      Other operations on stomach

44.91            Ligation of gastric varices

Excludes:            that by endoscopic approach (43.41)

44.92            Intraoperative manipulation of stomach

Reduction of gastric volvulus

44.93            Insertion of gastric bubble (balloon)

44.94            Removal of gastric bubble (balloon)

44.95            Laparoscopic gastric restrictive procedure

Adjustable gastric band and port insertion

Excludes: laparoscopic gastroplasty (44.68)

other repair of stomach (44.69)

44.96            Laparoscopic revision of gastric restrictive procedure

Revision or replacement of:

adjustable gastric band

subcutaneous gastric port device

44.97            Laparoscopic removal of gastric restrictive device(s)

Removal of either or both:

adjustable gastric band

subcutaneous port device

Excludes: nonoperative removal of gastric restrictive device(s) (97.86)

open removal of gastric restrictive device(s) (44.99)

44.98            (Laparoscopic) adjustment of size of adjustable gastric restrictive device

Infusion of saline for device tightening

Withdrawal of saline for device loosening

Code also any:

abdominal ultrasound (88.76)

abdominal wall fluoroscopy (88.09)

barium swallow (87.61)

44.99            Other

Excludes:            change of gastrostomy tube (97.02)

dilation of cardiac sphincter (42.92)

gastric:

cooling (96.31)

freezing (96.32)

gavage (96.35)

hypothermia (96.31)

lavage (96.33)

insertion of nasogastric tube (96.07)

irrigation of gastrostomy (96.36)

irrigation of nasogastric tube (96.34)

removal of:

gastrostomy tube (97.51)

intraluminal foreign body from stomach without incision (98.03)

replacement of:

gastrostomy tube (97.02)

(naso-)gastric tube (97.01)

45         Incision, excision, and anastomosis of intestine

Code also any application or administration of an adhesion barrier substance (99.77)

45.0            Enterotomy

Excludes:            duodenocholedochotomy (51.41-51.42, 51.51)

that for destruction of lesion (45.30-45.34)

that of exteriorized intestine (46.14, 46.24, 46.31)

45.00            Incision of intestine, not otherwise specified

45.01            Incision of duodenum

45.02            Other incision of small intestine

45.03            Incision of large intestine

Excludes:            proctotomy (48.0)

45.1            Diagnostic procedures on small intestine

Code also any laparotomy (54.11-54.19)

45.11            Transabdominal endoscopy of small intestine

Intraoperative endoscopy of small intestine

Excludes:            that with biopsy (45.14)

45.12            Endoscopy of small intestine through artificial stoma

Excludes:            that with biopsy (45.14)

45.13            Other endoscopy of small intestine

Esophagogastroduodenoscopy [EGD]

Excludes:            that with biopsy (45.14, 45.16)

45.14            Closed [endoscopic] biopsy of small intestine

Brushing or washing for specimen collection

Excludes:            esophagogastroduodenoscopy [EGD] with closed biopsy (45.16)

45.15            Open biopsy of small intestine

45.16            Esophagogastroduodenoscopy [EGD] with closed biopsy

Biopsy of one or more sites involving esophagus, stomach, and/or duodenum

45.19            Other diagnostic procedures on small intestine

Excludes:            microscopic examination of specimen from small intestine (90.91-90.99)

radioisotope scan (92.04)

ultrasonography (88.74)

x-ray (87.61-87.69)

45.2            Diagnostic procedures on large intestine

Code also any laparotomy (54.11-54.19)

45.21            Transabdominal endoscopy of large intestine

Intraoperative endoscopy of large intestine

Excludes:            that with biopsy (45.25)

45.22            Endoscopy of large intestine through artificial stoma

Excludes:            that with biopsy (45.25)

45.23            Colonoscopy

Flexible fiberoptic colonoscopy

Excludes:            endoscopy of large intestine through artificial stoma (45.22)

flexible sigmoidoscopy (45.24)

rigid proctosigmoidoscopy (48.23)

transabdominal endoscopy of large intestine (45.21)

45.24            Flexible sigmoidoscopy

Endoscopy of descending colon

Excludes:            rigid proctosigmoidoscopy (48.23)

45.25            Closed [endoscopic] biopsy of large intestine

Biopsy, closed, of unspecified intestinal site

Brushing or washing for specimen collection

Colonoscopy with biopsy

Excludes:            proctosigmoidoscopy with biopsy (48.24)

45.26            Open biopsy of large intestine

45.27            Intestinal biopsy, site unspecified

45.28            Other diagnostic procedures on large intestine

45.29            Other diagnostic procedures on intestine, site unspecified

Excludes:            microscopic examination of specimen (90.91-90.99)

scan and radioisotope function study (92.04)

ultrasonography (88.74)

x-ray (87.61-87.69)

45.3      Local excision or destruction of lesion or tissue of small intestine

45.30            Endoscopic excision or destruction of lesion of duodenum

Excludes:            biopsy of duodenum (45.14-45.15)

control of hemorrhage (44.43)

fistulectomy (46.72)

45.31            Other local excision of lesion of duodenum

Excludes:            biopsy of duodenum (45.14-45.15)

fistulectomy (46.72)

multiple segmental resection (45.61)

that by endoscopic approach (45.30)

45.32            Other destruction of lesion of duodenum

Excludes:            that by endoscopic approach (45.30)

45.33            Local excision of lesion or tissue of small intestine, except duodenum

Excision of redundant mucosa of ileostomy

Excludes:            biopsy of small intestine (45.14-45.15)

fistulectomy (46.74)

multiple segmental resection (45.61)

45.34            Other destruction of lesion of small intestine, except duodenum

45.4      Local excision or destruction of lesion or tissue of large intestine

45.41            Excision of lesion or tissue of large intestine

Excision of redundant mucosa of colostomy

Excludes:            biopsy of large intestine (45.25-45.27)

endoscopic polypectomy of large intestine (45.42)

fistulectomy (46.76)

multiple segmental resection (45.71)

that by endoscopic approach (45.42-45.43)

45.42            Endoscopic polypectomy of large intestine

Excludes:            that by open approach (45.41)

45.43            Endoscopic destruction of other lesion or tissue of large intestine

Endoscopic ablation of tumor of large intestine

Endoscopic control of colonic bleeding

Excludes:            endoscopic polypectomy of large intestine (45.42)

45.49            Other destruction of lesion of large intestine

Excludes:            that by endoscopic approach (45.43)

45.5      Isolation of intestinal segment

Code also any synchronous:

anastomosis other than end-to-end (45.90-45.94)

enterostomy (46.10-46.39)

45.50            Isolation of intestinal segment, not otherwise specified

Isolation of intestinal pedicle flap

Reversal of intestinal segment

45.51            Isolation of segment of small intestine

Isolation of ileal loop

Resection of small intestine for interposition

45.52            Isolation of segment of large intestine

Resection of colon for interposition

45.6      Other excision of small intestine

Code also any synchronous:

anastomosis other than end-to-end (45.90-45.93, 45.95)

colostomy (46.10-46.13)

enterostomy (46.10-46.39)

Excludes:            cecectomy (45.72)

enterocolectomy (45.79)

gastroduodenectomy (43.6-43.99)

ileocolectomy (45.73)

pancreatoduodenectomy (52.51-52.7)

45.61            Multiple segmental resection of small intestine

Segmental resection for multiple traumatic lesions of small intestine

45.62            Other partial resection of small intestine

Duodenectomy

Ileectomy

Jejunectomy

Excludes:            duodenectomy with synchronous pancreatectomy (52.51-52.7)

resection of cecum and terminal ileum (45.72)

45.63            Total removal of small intestine

45.7      Partial excision of large intestine

Code also any synchronous:

anastomosis other than end-to-end (45.92-45.94)

enterostomy (46.10-46.39)

45.71            Multiple segmental resection of large intestine

Segmental resection for multiple traumatic lesions of large intestine

45.72            Cecectomy

Resection of cecum and terminal ileum

45.73            Right hemicolectomy

Ileocolectomy

Right radical colectomy

45.74            Resection of transverse colon

45.75            Left hemicolectomy

Excludes:            proctosigmoidectomy (48.41-48.69)

second stage Mikulicz operation (46.04)

45.76            Sigmoidectomy

45.79            Other partial excision of large intestine

Enterocolectomy NEC

45.8      Total intra-abdominal colectomy

Excision of cecum, colon, and sigmoid

Excludes:            coloproctectomy (48.41-48.69)

45.9            Intestinal anastomosis

Code also any synchronous resection (45.31-45.8, 48.41-48.69)

Excludes:            end-to-end anastomosis -- omit code

45.90            Intestinal anastomosis, not otherwise specified

45.91            Small-to-small intestinal anastomosis

45.92            Anastomosis of small intestine to rectal stump

Hampton procedure

45.93            Other small-to-large intestinal anastomosis

45.94            Large-to-large intestinal anastomosis

Excludes:            rectorectostomy (48.74)

45.95            Anastomosis to anus

Formation of endorectal ileal pouch (H- pouch) (J-pouch) (S-pouch) with anastomosis of small intestine to anus

46         Other operations on intestine

Code also any application or administration of an adhesion barrier substance (99.77)

46.0            Exteriorization of intestine

Includes:            loop enterostomy

multiple stage resection of intestine

46.01            Exteriorization of small intestine

Loop ileostomy

46.02            Resection of exteriorized segment of small intestine

46.03            Exteriorization of large intestine

Exteriorization of intestine NOS

First stage Mikulicz exteriorization of intestine

Loop colostomy

46.04            Resection of exteriorized segment of large intestine

Resection of exteriorized segment of intestine NOS

Second stage Mikulicz operation

46.1            Colostomy

Code also any synchronous resection (45.49, 45.71-45.79, 45.8)

Excludes:    loop colostomy (46.03)

that with abdominoperineal resection of rectum (48.5)

that with synchronous anterior rectal resection (48.62)

46.10            Colostomy, not otherwise specified

46.11            Temporary colostomy

46.13            Permanent colostomy

46.14            Delayed opening of colostomy

46.2            Ileostomy

Code also any synchronous resection (45.34, 45.61-45.63)

Excludes:    loop ileostomy (46.01)

46.20            Ileostomy, not otherwise specified

46.21            Temporary ileostomy

46.22            Continent ileostomy

46.23            Other permanent ileostomy

46.24            Delayed opening of ileostomy

46.3      Other enterostomy

Code also any synchronous resection (45.61-45.8)

46.31            Delayed opening of other enterostomy

46.32            Percutaneous (endoscopic) jejunostomy [PEJ]

46.39            Other

Duodenostomy

Feeding enterostomy

46.4      Revision of intestinal stoma

46.40            Revision of intestinal stoma, not otherwise specified

Plastic enlargement of intestinal stoma

Reconstruction of stoma of intestine

Release of scar tissue of intestinal stoma

Excludes:            excision of redundant mucosa (45.41)

46.41            Revision of stoma of small intestine

Excludes:            excision of redundant mucosa (45.33)

46.42            Repair of pericolostomy hernia

46.43            Other revision of stoma of large intestine

Excludes:            excision of redundant mucosa (45.41)

46.5      Closure of intestinal stoma

Code also any synchronous resection (45.34, 45.49, 45.61-45.8)

46.50            Closure of intestinal stoma, not otherwise specified

46.51            Closure of stoma of small intestine

46.52            Closure of stoma of large intestine

Closure or take-down of:

cecostomy

colostomy

sigmoidostomy

46.6      Fixation of intestine

46.60            Fixation of intestine, not otherwise specified

Fixation of intestine to abdominal wall

46.61            Fixation of small intestine to abdominal wall

Ileopexy

46.62            Other fixation of small intestine

Noble plication of small intestine

Plication of jejunum

46.63            Fixation of large intestine to abdominal wall

Cecocoloplicopexy

Sigmoidopexy (Moschowitz)

46.64            Other fixation of large intestine

Cecofixation

Colofixation

46.7      Other repair of intestine

Excludes:            closure of:

ulcer of duodenum (44.42)

vesicoenteric fistula (57.83)

46.71            Suture of laceration of duodenum

46.72            Closure of fistula of duodenum

46.73            Suture of laceration of small intestine, except duodenum

46.74            Closure of fistula of small intestine, except duodenum

Excludes:            closure of:

artificial stoma (46.51)

vaginal fistula (70.74)

repair of gastrojejunocolic fistula (44.63)

46.75            Suture of laceration of large intestine

46.76            Closure of fistula of large intestine

Excludes:            closure of:

gastrocolic fistula (44.63)

rectal fistula (48.73)

sigmoidovesical fistula (57.83)

stoma (46.52)

vaginal fistula (70.72-70.73)

vesicocolic fistula (57.83)

vesicosigmoidovaginal fistula (57.83)

46.79            Other repair of intestine

Duodenoplasty

46.8      Dilation and manipulation of intestine

46.80            Intra-abdominal manipulation of intestine, not otherwise specified

Correction of intestinal malrotation

Reduction of:

intestinal torsion

intestinal volvulus

intussusception

Excludes: reduction of intussusception with:

fluoroscopy (96.29)

ionizing radiation enema (96.29)

ultrasonography guidance (96.29)

46.81            Intra-abdominal manipulation of small intestine

46.82            Intra-abdominal manipulation of large intestine

46.85            Dilation of intestine

Dilation (balloon) of duodenum

Dilation (balloon) of jejunum

Endoscopic dilation (balloon) of large intestine

That through rectum or colostomy

46.9      Other operations on intestines

46.91            Myotomy of sigmoid colon

46.92            Myotomy of other parts of colon

46.93            Revision of anastomosis of small intestine

46.94            Revision of anastomosis of large intestine

46.95            Local perfusion of small intestine

Code also substance perfused (99.21-99.29)

46.96            Local perfusion of large intestine

Code also substance perfused (99.21-99.29)

46.97            Transplant of intestine

Note: To report donor source - see codes 00.91-00.93

46.99            Other

Ileoentectropy

Excludes:            diagnostic procedures on intestine (45.11-45.29)

dilation of enterostomy stoma (96.24)

intestinal intubation (96.08)

removal of:

intraluminal foreign body from large intestine without incision (98.04)

intraluminal foreign body from small intestine without incision (98.03)

tube from large intestine (97.53)

tube from small intestine (97.52)

replacement of:

large intestine tube or enterostomy device (97.04)

small intestine tube or enterostomy device (97.03)

47            Operations on appendix

Includes:            appendiceal stump

Code also any application or administration of an adhesion barrier substance (99.77)

47.0            Appendectomy

Excludes:            incidental appendectomy, so described

laparoscopic (47.11)

other (47.19)

47.01            Laparoscopic appendectomy

47.09            Other appendectomy

47.1            Incidental appendectomy

47.11            Laparoscopic incidental appendectomy

47.19            Other incidental appendectomy

47.2            Drainage of appendiceal abscess

Excludes:    that with appendectomy (47.0)

47.9      Other operations on appendix

47.91            Appendicostomy

47.92            Closure of appendiceal fistula

47.99            Other

Anastomosis of appendix

Excludes:            diagnostic procedures on appendix (45.21-45.29)

48            Operations on rectum, rectosigmoid and perirectal tissue

Code also any application or administration of an adhesion barrier substance (99.77)

48.0            Proctotomy

Decompression of imperforate anus

Panas' operation [linear proctotomy]

Excludes:            incision of perirectal tissue (48.81)

48.1            Proctostomy

48.2            Diagnostic procedures on rectum, rectosigmoid and perirectal tissue

48.21            Transabdominal proctosigmoidoscopy

Intraoperative proctosigmoidoscopy

Excludes:            that with biopsy (48.24)

48.22            Proctosigmoidoscopy through artificial stoma

Excludes:            that with biopsy (48.24)

48.23            Rigid proctosigmoidoscopy

Excludes:            flexible sigmoidoscopy (45.24)

48.24            Closed [endoscopic] biopsy of rectum

Brushing or washing for specimen collection

Proctosigmoidoscopy with biopsy

48.25            Open biopsy of rectum

48.26            Biopsy of perirectal tissue

48.29            Other diagnostic procedures on rectum, rectosigmoid and perirectal tissue

Excludes:            digital examination of rectum (89.34)

lower GI series (87.64)

microscopic examination of specimen from rectum (90.91-90.99)

48.3      Local excision or destruction of lesion or tissue of rectum

48.31            Radical electrocoagulation of rectal lesion or tissue

48.32            Other electrocoagulation of rectal lesion or tissue

48.33            Destruction of rectal lesion or tissue by laser

48.34            Destruction of rectal lesion or tissue by cryosurgery

48.35            Local excision of rectal lesion or tissue

Excludes:            biopsy of rectum (48.24-48.25)

excision of perirectal tissue (48.82)

hemorrhoidectomy (49.46)

[endoscopic] polypectomy of rectum (48.36)

rectal fistulectomy (48.73)

48.36            [Endoscopic] polypectomy of rectum

48.4      Pull-through resection of rectum

Code also any synchronous anastomosis other than end-to-end (45.90, 45.92-45.95)

48.41            Soave submucosal resection of rectum

Endorectal pull-through operation

48.49            Other pull-through resection of rectum

Abdominoperineal pull-through

Altemeier operation

Swenson proctectomy

Excludes:            Duhamel abdominoperineal pull through (48.65)

48.5            Abdominoperineal resection of rectum

Includes: with synchronous colostomy

Combined abdominoendorectal resection

Complete proctectomy

Code also any synchronous anastomosis other than end-to-end (45.90, 45.92-45.95)

Excludes:            Duhamel abdominoperineal pull-through (48.65)

that as part of pelvic exenteration (68.8)

48.6      Other resection of rectum

Code also any synchronous anastomosis other than end-to-end (45.90, 45.92-45.95)

48.61            Transsacral rectosigmoidectomy

48.62            Anterior resection of rectum with synchronous colostomy

48.63            Other anterior resection of rectum

Excludes:            that with synchronous colostomy (48.62)

48.64            Posterior resection of rectum

48.65            Duhamel resection of rectum

Duhamel abdominoperineal pull-through

48.69            Other

Partial proctectomy

Rectal resection NOS

48.7      Repair of rectum

Excludes:            repair of:

current obstetric laceration (75.62)

vaginal rectocele (70.50, 70.52)

48.71            Suture of laceration of rectum

48.72            Closure of proctostomy

48.73            Closure of other rectal fistula

Excludes:            fistulectomy:

perirectal (48.93)

rectourethral (58.43)

rectovaginal (70.73)

rectovesical (57.83)

rectovesicovaginal (57.83)

48.74            Rectorectostomy

Rectal anastomosis NOS

48.75            Abdominal proctopexy

Frickman procedure

Ripstein repair of rectal prolapse

48.76            Other proctopexy

Delorme repair of prolapsed rectum

Proctosigmoidopexy

Puborectalis sling operation

Excludes:            manual reduction of rectal prolapse (96.26)

48.79            Other repair of rectum

Repair of old obstetric laceration of rectum

Excludes:            anastomosis to:

large intestine (45.94)

small intestine (45.92-45.93)

repair of:

current obstetrica laceration (75.62)

vaginal rectocele (70.50, 70.52)

48.8      Incision or excision of perirectal tissue or lesion

Includes:            pelvirectal tissue

rectovaginal septum

48.81            Incision of perirectal tissue

Incision of rectovaginal septum

48.82            Excision of perirectal tissue

Excludes:            perirectal biopsy (48.26)

perirectofistulectomy (48.93)

rectal fistulectomy (48.73)

48.9      Other operations on rectum and perirectal tissue

48.91            Incision of rectal stricture

48.92            Anorectal myectomy

48.93            Repair of perirectal fistula

Excludes:            that opening into rectum (48.73)

48.99            Other

Excludes:            digital examination of rectum (89.34)

dilation of rectum (96.22)

insertion of rectal tube (96.09)

irrigation of rectum (96.38-96.39)

manual reduction of rectal prolapse (96.26)

proctoclysis (96.37)

rectal massage (99.93)

rectal packing (96.19)

removal of:

impacted feces (96.38)

intraluminal foreign body from rectum without incision (98.05)

rectal packing (97.59)

transanal enema (96.39)

49            Operations on anus

Code also any application or administration of an adhesion barrier substance (99.77)

49.0      Incision or excision of perianal tissue

49.01            Incision of perianal abscess

49.02            Other incision of perianal tissue

Undercutting of perianal tissue

Excludes:            anal fistulotomy (49.11)

49.03            Excision of perianal skin tags

49.04            Other excision of perianal tissue

Excludes:            anal fistulectomy (49.12)

biopsy of perianal tissu (49.22)

49.1      Incision or excision of anal fistula

Excludes:            closure of anal fistula (49.73)

49.11            Anal fistulotomy

49.12            Anal fistulectomy

49.2            Diagnostic procedures on anus and perianal tissue

49.21            Anoscopy

49.22            Biopsy of perianal tissue

49.23            Biopsy of anus

49.29            Other diagnostic procedures on anus and perianal tissue

Excludes:            microscopic examination of specimen from anus (90.91-90.99)

49.3      Local excision or destruction of other lesion or tissue of anus

Anal cryptotomy

Cauterization of lesion of anus

Excludes:            biopsy of anus (49.23)

control of (postoperative) hemorrhage of anus (49.95)

hemorrhoidectomy (49.46)

49.31            Endoscopic excision or destruction of lesion or tissue of anus

49.39            Other local excision or destruction of lesion or tissue of anus

Excludes:            that by endoscopic approach (49.31)

49.4            Procedures on hemorrhoids

49.41            Reduction of hemorrhoids

49.42            Injection of hemorrhoids

49.43            Cauterization of hemorrhoids

Clamp and cautery of hemorrhoids

49.44            Destruction of hemorrhoids by cryotherapy

49.45            Ligation of hemorrhoids

49.46            Excision of hemorrhoids

Hemorrhoidectomy NOS

49.47            Evacuation of thrombosed hemorrhoids

49.49            Other procedures on hemorrhoids

Lord procedure

49.5      Division of anal sphincter

49.51            Left lateral anal sphincterotomy

49.52            Posterior anal sphincterotomy

49.59            Other anal sphincterotomy

Division of sphincter NOS

49.6            Excision of anus

49.7      Repair of anus

Excludes:            repair of current obstetric laceration (75.62)

49.71            Suture of laceration of anus

49.72            Anal cerclage

49.73            Closure of anal fistula

Excludes:            excision of anal fistula (49.12)

49.74            Gracilis muscle transplant for anal incontinence

49.75            Implantation or revision of artificial anal sphincter

Removal with subsequent replacement

Replacement during same or subsequent operative episode

49.76            Removal of artificial anal sphincter

Explantation or removal without replacement

Excludes: revision with implantation during same operative episode (49.75)

49.79            Other repair of anal sphincter

Repair of old obstetric laceration of anus

Excludes:            anoplasty with synchronous hemorrhoidectomy (49.46)

repair of current obstetric laceration (75.62)

49.9      Other operations on anus

Excludes:            dilation of anus (sphincter) (96.23)

49.91            Incision of anal septum

49.92            Insertion of subcutaneous electrical anal stimulator

49.93            Other incision of anus

Removal of:

foreign body from anus with incision

seton from anus

Excludes:            anal fistulotomy (49.11)

removal of intraluminal foreign body without incision (98.05)

49.94            Reduction of anal prolapse

Excludes:            manual reduction of rectal prolapse (96.26)

49.95            Control of (postoperative) hemorrhage of anus

49.99            Other

50            Operations on liver

Code also any application or administration of an adhesion barrier substance (99.77)

50.0            Hepatotomy

Incision of abscess of liver

Removal of gallstones from liver

Stromeyer-Little operation

50.1            Diagnostic procedures on liver

50.11            Closed (percutaneous) [needle] biopsy of liver

Diagnostic aspiration of liver

50.12            Open biopsy of liver

Wedge biopsy

50.19            Other diagnostic procedures on liver

Laparoscopic liver biopsy

Excludes:            liver scan and radioisotope function study (92.02)

microscopic examination of specimen from liver (91.01-91.09)

50.2      Local excision or destruction of liver tissue or lesion

50.21            Marsupialization of lesion of liver

50.22            Partial hepatectomy

Wedge resection of liver

Excludes:            biopsy of liver (50.11-50.12)

hepatic lobectomy (50.3)

50.29            Other destruction of lesion of liver

Cauterization of hepatic lesion

Enucleation of hepatic lesion

Evacuation of hepatic lesion

Excludes:            percutaneous aspiration of lesion (50.91)

50.3            Lobectomy of liver

Total hepatic lobectomy with partial excision of other lobe

50.4      Total hepatectomy

50.5      Liver transplant

Note: To report donor source - see codes 00.91-00.93

50.51            Auxiliary liver transplant

Auxiliary hepatic transplantation leaving patient's own liver in situ

50.59            Other transplant of liver

50.6      Repair of liver

50.61            Closure of laceration of liver

50.69            Other repair of liver

Hepatopexy

50.9      Other operations on liver

Excludes:            lysis of adhesions (54.5)

50.91            Percutaneous aspiration of liver

Excludes:            percutaneous biopsy (50.11)

50.92            Extracorporeal hepatic assistance

Liver dialysis

50.93            Localized perfusion of liver

50.94            Other injection of therapeutic substance into liver

50.99            Other

51            Operations on gallbladder and biliary tract

Includes:            operations on:

ampulla of Vater

common bile duct

cystic duct

hepatic duct

intrahepatic bile duct

sphincter of Oddi

Code also any application or administration of an adhesion barrier substance (99.77)

51.0            Cholecystotomy and cholecystostomy

51.01            Percutaneous aspiration of gallbladder

Percutaneous cholecystotomy for drainage

That by: needle or catheter

Excludes:            needle biopsy (51.12)

51.02            Trocar cholecystostomy

51.03            Other cholecystostomy

51.04            Other cholecystotomy

Cholelithotomy NOS

51.1            Diagnostic procedures on biliary tract

Excludes:    that for endoscopic procedures classifiable to 51.64, 51.84-51.88, 52.14, 52.21, 52.93-52.94, 52.97-52.98

51.10            Endoscopic retrograde cholangiopancreatography [ERCP]

Excludes:            endoscopic retrograde:

cholangiography [ERC] (51.11)

pancreatography [ERP] (52.13)

51.11            Endoscopic retrograde cholangiography [ERC]

Laparoscopic exploration of common bile duct

Excludes:            endoscopic retrograde:

cholangiopancreatography [ERCP] (51.10)

pancreatography [ERP] (52.13)

51.12            Percutaneous biopsy of gallbladder or bile ducts

Needle biopsy of gallbladder

51.13            Open biopsy of gallbladder or bile ducts

51.14            Other closed [endoscopic] biopsy of biliary duct or sphincter of Oddi

Brushing or washing for specimen collection

Closed biopsy of biliary duct or sphincter of Oddi by procedures classifiable to 51.10-51.11, 52.13

51.15            Pressure measurement of sphincter of Oddi

Pressure measurement of sphincter by procedures classifiable to 51.10-51.11, 52.13

51.19            Other diagnostic procedures on biliary tract

Excludes:            biliary tract x-ray (87.51-87.59)

microscopic examination of specimen from biliary tract (91.01-91.09)

51.2            Cholecystectomy

51.21            Other partial cholecystectomy

Revision of prior cholecystectomy

Excludes:            that by laparoscope (51.24)

51.22            Cholecystectomy

Excludes:            laparoscopic cholecystectomy (51.23)

51.23            Laparoscopic cholecystectomy

That by laser

51.24            Laparoscopic partial cholecystectomy

51.3            Anastomosis of gallbladder or bile duct

Excludes:            resection with end-to-end anastomosis (51.61-51.69)

51.31            Anastomosis of gallbladder to hepatic ducts

51.32            Anastomosis of gallbladder to intestine

51.33            Anastomosis of gallbladder to pancreas

51.34            Anastomosis of gallbladder to stomach

51.35            Other gallbladder anastomosis

Gallbladder anastomosis NOS

51.36            Choledochoenterostomy

51.37            Anastomosis of hepatic duct to gastrointestinal tract

Kasai portoenterostomy

51.39            Other bile duct anastomosis

Anastomosis of bile duct NOS

Anastomosis of unspecified bile duct to:

intestine

liver

pancreas

stomach

51.4      Incision of bile duct for relief of obstruction

51.41            Common duct exploration for removal of calculus

Excludes:            percutaneous extraction (51.96)

51.42            Common duct exploration for relief of other obstruction

51.43            Insertion of choledochohepatic tube for decompression

Hepatocholedochostomy

51.49            Incision of other bile ducts for relief of obstruction

51.5      Other incision of bile duct

Excludes:that for relief of obstruction (51.41-51.49)

51.51            Exploration of common duct

Incision of common bile duct

51.59            Incision of other bile duct

51.6      Local excision or destruction of lesion or tissue of biliary ducts and sphincter of Oddi

Code also anastomosis other than end-to-end (51.31,51.36-51.39)

Excludes:biopsy of bile duct (51.12-51.13)

51.61            Excision of cystic duct remnant

51.62            Excision of ampulla of Vater (with reimplantation of common duct)

51.63            Other excision of common duct

Choledochectomy

Excludes:            fistulectomy (51.72)

51.64            Endoscopic excision or destruction of lesion of biliary ducts or sphincter of Oddi

Excision or destruction of lesion of biliary duct by procedures classifiable to 51.10-51.11, 52.13

51.69            Excision of other bile duct

Excision of lesion of bile duct NOS

Excludes:            fistulectomy (51.79)

51.7      Repair of bile ducts

51.71            Simple suture of common bile duct

51.72            Choledochoplasty

Repair of fistula of common bile duct

51.79            Repair of other bile ducts

Closure of artificial opening of bile duct

NOS

Suture of bile duct NOS

Excludes:            operative removal of prosthetic device (51.95)

51.8      Other operations on biliary ducts and sphincter of Oddi

51.81            Dilation of sphincter of Oddi

Dilation of ampulla of Vater

Excludes:            that by endoscopic approach (51.84)

51.82            Pancreatic sphincterotomy

Incision of pancreatic sphincter

Transduodenal ampullary sphincterotomy

Excludes:            that by endoscopic approach (51.85)

51.83            Pancreatic sphincteroplasty

51.84            Endoscopic dilation of ampulla and biliary duct

Dilation of ampulla and biliary duct by procedures classifiable to 51.10-51.11, 52.13

51.85            Endoscopic sphincterotomy and papillotomy

Sphincterotomy and papillotomy by procedures classifiable to 51.10-51.11, 52.13

51.86            Endoscopic insertion of nasobiliary drainage tube

Insertion of nasobiliary tube by procedures classifiable to 51.10-51.11, 52.13

51.87            Endoscopic insertion of stent (tube) into bile duct

Endoprosthesis of bile duct

Insertion of stent into bile duct by procedures classifiable to 51.10-51.11, 52.13

Excludes:            nasobiliary drainage tub (51.86)

replacement of stent (tube) (97.05)

51.88            Endoscopic removal of stone(s) from biliary tract

Laparoscopic removal of stone(s) from biliary tract

Removal of biliary tract stone(s) by procedures classifiable to 51.10-51.11, 52.13

Excludes:            percutaneous extraction of common duct stones (51.96)

51.89            Other operations on sphincter of Oddi

51.9      Other operations on biliary tract

51.91            Repair of laceration of gallbladder

51.92            Closure of cholecystostomy

51.93            Closure of other biliary fistula

Cholecystogastroenteric fistulectomy

51.94            Revision of anastomosis of biliary tract

51.95            Removal of prosthetic device from bile duct

Excludes:            nonoperative removal (97.55)

51.96            Percutaneous extraction of common duct stones

51.98            Other percutaneous procedures on biliary tract

Percutaneous biliary endoscopy via existing T-tube or other tract for:

dilation of biliary duct stricture

removal of stone(s) except common duct stone

exploration (postoperative)

Percutaneous transhepatic biliary drainage

Excludes:            percutaneous aspiration of gallbladder (51.01)

percutaneous biopsy and/or collection of specimen by brushing or washing (51.12)

percutaneous removal of common duct stone(s) (51.96)

51.99            Other

Insertion or replacement of biliary tract prosthesis

Excludes:            biopsy of gallbladder (51.12-51.13)

irrigation of cholecystostomy and other biliary tube (96.41)

lysis of peritoneal adhesions (54.5)

nonoperative removal of:

cholecystostomy tube (97.54)

tube from biliary tract or liver (97.55)

52            Operations on pancreas

Includes:            operations on pancreatic duct

Code also any application or administration of an adhesion barrier substance (99.77)

52.0            Pancreatotomy

52.01            Drainage of pancreatic cyst by catheter

52.09            Other pancreatotomy

Pancreatolithotomy

Excludes:            drainage by anastomosis (52.4, 52.96)

incision of pancreatic sphincte (51.82)

marsupialization of cyst (52.3)

52.1            Diagnostic procedures on pancreas

52.11            Closed [aspiration] [needle] [percutaneous] biopsy of pancreas

52.12            Open biopsy of pancreas

52.13            Endoscopic retrograde pancreatography [ERP]

Excludes:            endoscopic retrograde:

cholangiography [ERC] (51.11)

cholangiopancreatography [ERCP] (51.10)

that for procedures classifiabl to 51.14-51.15, 51.64, 51.84-51.88, 52.14, 52.21, 52.92-52.94, 52.97-52.98

52.14            Closed [endoscopic] biopsy of pancreatic duct

Closed biopsy of pancreatic duct by procedures classifiable to 51.10-51.11, 52.13

52.19            Other diagnostic procedures on pancreas

Excludes:            contrast pancreatogram (87.66)

endoscopic retrograde pancreatography [ERP] (52.13)

microscopic examination of specimen from pancreas (91.01-91.09)

52.2      Local excision or destruction of pancreas and pancreatic duct

Excludes:            biopsy of pancreas (52.11-52.12, 52.14)

pancreatic fistulectomy (52.95)

52.21            Endoscopic excision or destruction of lesion or tissue of pancreatic duct

Excision or destruction of lesion or tissue of pancreatic duct by procedures classifiable to 51.10-51.11, 52.13

52.22            Other excision or destruction of lesion or tissue of pancreas or pancreatic duct

52.3            Marsupialization of pancreatic cyst

Excludes:            drainage of cyst by catheter (52.01)

52.4      Internal drainage of pancreatic cyst

Pancreaticocystoduodenostomy

Pancreaticocystogastrostomy

Pancreaticocystojejunostomy

52.5      Partial pancreatectomy

Excludes:            pancreatic fistulectomy (52.95)

52.51            Proximal pancreatectomy

Excision of head of pancreas (with part of body)

Proximal pancreatectomy with synchronous duodenectomy

52.52            Distal pancreatectomy

Excision of tail of pancreas (with part of body)

52.53            Radical subtotal pancreatectomy

52.59            Other partial pancreatectomy

52.6      Total pancreatectomy

Pancreatectomy with synchronous duodenectomy

52.7      Radical pancreaticoduodenectomy

One-stage pancreaticoduodenal resection with choledochojejunal anastomosis, pancreaticojejunal anastomosis, and gastrojejunostomy

Two-stage pancreaticoduodenal resection (first stage) (second stage)

Radical resection of the pancreas

Whipple procedure

Excludes:            radical subtotal pancreatectomy (52.53)

52.8            Transplant of pancreas

Note: To report donor source - see codes 00.91-00.93

52.80            Pancreatic transplant, not otherwise specified

52.81            Reimplantation of pancreatic tissue

52.82            Homotransplant of pancreas

52.83            Heterotransplant of pancreas

52.84            Autotransplantation of cells of Islets of Langerhans

Homotransplantation of islet cells of pancreas

52.85            Allotransplantation of cells of Islets of Langerhans

Heterotransplantation of islet cells of pancreas

52.86            Transplantation of cells of Islets of Langerhans, not otherwise specified

52.9      Other operations on pancreas

52.92            Cannulation of pancreatic duct

Excludes:            that by endoscopic approach (52.93)

52.93            Endoscopic insertion of stent (tube) into pancreatic duct

Insertion of cannula or stent into pancreatic duct by procedures classifiable to 51.10-51.11, 52.13

Excludes:            endoscopic insertion of nasopancreatic drainage tube (52.97)

replacement of stent (tube) (97.05)

52.94            Endoscopic removal of stone(s) from pancreatic duct

Removal of stone(s) from pancreatic duct by procedures classifiable to 51.10-51.11, 52.13

52.95            Other repair of pancreas

Fistulectomy of pancreas

Simple suture of pancreas

52.96            Anastomosis of pancreas

Anastomosis of pancreas (duct) to:

intestine

jejunum

stomach

Excludes:            anastomosis to:

bile duct (51.39)

gallbladder (51.33)

52.97            Endoscopic insertion of nasopancreatic drainage tube

Insertion of nasopancreatic drainage tube by procedures classifiable to 51.10-51.11, 52.13

Excludes:            drainage of pancreatic cyst by catheter (52.01)

replacement of stent (tube) (97.05)

52.98            Endoscopic dilation of pancreatic duct

Dilation of Wirsung's duct by procedures classifiable to 51.10-51.11, 52.13

52.99            Other

Dilation of pancreatic [Wirsung's] duct by open approach

Repair of pancreatic [Wirsung's] duct by open approach

Excludes:            irrigation of pancreatic tube (96.42)

removal of pancreatic tub (97.56)

53         Repair of hernia

Includes:            hernioplasty

herniorrhaphy

Code also any application or administration of an adhesion barrier substance (99.77)

Excludes:            manual reduction of hernia (96.27)

53.0            Unilateral repair of inguinal hernia

53.00            Unilateral repair of inguinal hernia, not otherwise specified

Inguinal herniorrhaphy NOS

53.01            Repair of direct inguinal hernia

53.02            Repair of indirect inguinal hernia

53.03            Repair of direct inguinal hernia with graft or prosthesis

53.04            Repair of indirect inguinal hernia with graft or prosthesis

53.05            Repair of inguinal hernia with graft or prosthesis, not otherwise specified

53.1      Bilateral repair of inguinal hernia

53.10            Bilateral repair of inguinal hernia, not otherwise specified

53.11            Bilateral repair of direct inguinal hernia

53.12            Bilateral repair of indirect inguinal hernia

53.13            Bilateral repair of inguinal hernia, one direct and one indirect

53.14            Bilateral repair of direct inguinal hernia with graft or prosthesis

53.15            Bilateral repair of indirect inguinal hernia with graft or prosthesis

53.16            Bilateral repair of inguinal hernia, one direct and one indirect, with graft or prosthesis

53.17            Bilateral inguinal hernia repair with graft or prosthesis, not otherwise specified

53.2            Unilateral repair of femoral hernia

53.21            Unilateral repair of femoral hernia with graft or prosthesis

53.29            Other unilateral femoral herniorrhaphy

53.3      Bilateral repair of femoral hernia

53.31            Bilateral repair of femoral hernia with graft or prosthesis

53.39            Other bilateral femoral herniorrhaphy

53.4      Repair of umbilical hernia

Excludes:            repair of gastroschisis (54.71)

53.41            Repair of umbilical hernia with prosthesis

53.49            Other umbilical herniorrhaphy

53.5      Repair of other hernia of anterior abdominal wall (without graft or prosthesis)

53.51            Incisional hernia repair

53.59            Repair of other hernia of anterior abdominal wall

Repair of hernia:

epigastric

hypogastric

spigelian

ventral

53.6      Repair of other hernia of anterior abdominal wall with graft or prosthesis

53.61            Incisional hernia repair with prosthesis

53.69            Repair of other hernia of anterior abdominal wall with prosthesis

53.7      Repair of diaphragmatic hernia, abdominal approach

53.8      Repair of diaphragmatic hernia, thoracic approach

53.80            Repair of diaphragmatic hernia with thoracic approach, not otherwise specified

Thoracoabdominal repair of diaphragmatic hernia

53.81            Plication of the diaphragm

53.82            Repair of parasternal hernia

53.9      Other hernia repair

Repair of hernia:

ischiatic

ischiorectal

lumbar

obturator

omental

retroperitoneal

sciatic

Excludes:            relief of strangulated hernia with exteriorization of intestine (46.01, 46.03)

repair of pericolostomy hernia (46.42)

repair of vaginal enterocele (70.92)

54         Other operations on abdominal region

Includes:            operations on:

epigastric region

flank

groin region

hypochondrium

inguinal region

loin region

male pelvic cavity

mesentery

omentum

peritoneum

retroperitoneal tissue space

Code also any application or administration of an adhesion barrier substance (99.77)

Excludes:            female pelvic cavity (69.01-70.92)

hernia repair (53.00-53.9)

obliteration of cul-de-sac (70.92)

retroperitoneal tissue dissection (59.00-59.09)

skin and subcutaneous tissue of abdominal

wall (86.01-86.99)

54.0      Incision of abdominal wall

Drainage of:

abdominal wall

extraperitoneal abscess

retroperitoneal abscess

Excludes:            incision of peritoneum (54.95)

laparotomy (54.11-54.19)

54.1            Laparotomy

54.11            Exploratory laparotomy

Excludes:            exploration incidental to intra abdominal surgery -- omit code

54.12            Reopening of recent laparotomy site

Reopening of recent laparotomy site for:

control of hemorrhage

exploration

incision of hematoma

54.19            Other laparotomy

Drainage of intraperitoneal abscess or hematoma

Excludes:            culdocentesis (70.0)

drainage of appendiceal abscess (47.2)

exploration incidental to intra abdominal surgery -- omit code

Ladd operation (54.95)

percutaneous drainage of abdomen (54.91)

removal of foreign body (54.92)

54.2            Diagnostic procedures of abdominal region

54.21            Laparoscopy

Peritoneoscopy

Excludes:            laparoscopic cholecystectomy (51.23)

that incidental to destruction of fallopian tubes (66.21-66.29)

54.22            Biopsy of abdominal wall or umbilicus

54.23    Biopsy of peritoneum

Biopsy of:

mesentery

omentum

peritoneal implant

Excludes:closed biopsy of:

omentum (54.24)

peritoneum (54.24)

54.24            Closed [percutaneous] [needle] biopsy of intra-abdominal mass

Closed biopsy of:

omentum

peritoneal implant

peritoneum

Excludes:            that of:

fallopian tube (66.11)

ovary (65.11)

uterine ligaments (68.15)

uterus (68.16)

54.25            Peritoneal lavage

Diagnostic peritoneal lavage

Excludes:            peritoneal dialysis (54.98)

54.29            Other diagnostic procedures on abdominal region

Excludes:            abdominal lymphangiogram (88.04)

abdominal x-ray NEC (88.19)

angiocardiography of venae cava (88.51)

C.A.T. scan of abdomen (88.01)

contrast x-ray of abdominal cavity (88.11-88.15)

intra-abdominal arteriography NEC (88.47)

microscopic examination of peritoneal and retroperitoneal specimen (91.11-91.19)

phlebography of:

intra-abdominal vessels NEC (88.65)

portal venous system (88.64)

sinogram of abdominal wall (88.03)

soft tissue x-ray of abdominal wall NEC (88.09)

tomography of abdomen NE (88.02)

ultrasonography of abdomen and retroperitoneum (88.76)

54.3            Excision or destruction of lesion or tissue of abdominal wall or umbilicus

Debridement of abdominal wall

Omphalectomy

Excludes:            biopsy of abdominal wall or umbilicus (54.22)

size reduction operation (86.83)

that of skin of abdominal wall (86.22, 86.26, 86.3)

54.4            Excision or destruction of peritoneal tissue

Excision of:

appendices epiploicae

falciform ligament

gastrocolic ligament

lesion of:

mesentery

omentum

peritoneum

presacral lesion NOS

retroperitoneal lesion NOS

Excludes:            biopsy of peritoneum (54.23)

endometrectomy of cul-de-sac (70.32)

54.5      Lysis of peritoneal adhesions

Freeing of adhesions of:

biliary tract

intestines

liver

pelvic peritoneum

peritoneum

spleen

uterus

Excludes:            lysis of adhesions of:

bladder (59.11)

fallopian tube and ovary

laparoscopic (65.81)

other (65.89)

kidney (59.02)

ureter (59.02)

54.51            Laparoscopic lysis of peritoneal adhesions

54.59            Other lysis of peritoneal adhesions

54.6      Suture of abdominal wall and peritoneum

54.61            Reclosure of postoperative disruption of abdominal wall

54.62            Delayed closure of granulating abdominal wound

Tertiary subcutaneous wound closure

54.63            Other suture of abdominal wall

Suture of laceration of abdominal wall

Excludes:            closure of operative wound -- omit code

54.64            Suture of peritoneum

Secondary suture of peritoneum

Excludes:            closure of operative wound -- omit code

54.7      Other repair of abdominal wall and peritoneum

54.71            Repair of gastroschisis

54.72            Other repair of abdominal wall

54.73            Other repair of peritoneum

Suture of gastrocolic ligament

54.74            Other repair of omentum

Epiplorrhaphy

Graft of omentum

Omentopexy

Reduction of torsion of omentum

Excludes:            cardio-omentopexy (36.39)

54.75            Other repair of mesentery

Mesenteric plication

Mesenteropexy

54.9      Other operations of abdominal region

Excludes:            removal of ectopic pregnancy (74.3)

54.91            Percutaneous abdominal drainage

Paracentesis

Excludes:            creation of cutaneoperitoneal fistula (54.93)

54.92            Removal of foreign body from peritoneal cavity

54.93            Creation of cutaneoperitoneal fistula

54.94            Creation of peritoneovascular shunt

Peritoneovenous shunt

54.95            Incision of peritoneum

Exploration of ventriculoperitoneal shunt at peritoneal site

Ladd operation

Revision of distal catheter of ventricular shunt

Revision of ventriculoperitoneal shunt at peritoneal site

Excludes:            that incidental to laparotomy (54.11-54.19)

54.96            Injection of air into peritoneal cavity

Pneumoperitoneum

Excludes:            that for:

collapse of lung (33.33)

radiography (88.12-88.13, 88.15)

54.97            Injection of locally-acting therapeutic substance into peritoneal cavity

Excludes:            peritoneal dialysis (54.98)

54.98            Peritoneal dialysis

Excludes:            peritoneal lavage (diagnostic) (54.25)

54.99            Other

Excludes:            removal of:

abdominal wall suture (97.83)

peritoneal drainage device (97.82)

retroperitoneal drainage device (97.81)

10. OPERATIONS ON THE URINARY SYSTEM (55-59) back to top

55            Operations on kidney

Includes:            operations on renal pelvis

Code also any application or administration of an adhesion barrier substance (99.77)

Excludes:            perirenal tissue (59.00-59.09, 59.21-59.29,59.91-59.92)

55.0            Nephrotomy and nephrostomy

Excludes:            drainage by:

anastomosis (55.86)

aspiration (55.92)

incision of kidney pelvis (55.11-55.12)

55.01            Nephrotomy

Evacuation of renal cyst

Exploration of kidney

Nephrolithotomy

55.02            Nephrostomy

55.03            Percutaneous nephrostomy without fragmentation

Nephrostolithotomy, percutaneous (nephroscopic)

Percutaneous removal of kidney stone(s) by:

basket extraction

forceps extraction (nephroscopic)

Pyelostolithotomy, percutaneous (nephroscopic)

With placement of catheter down ureter

Excludes:            percutaneous removal by fragmentation (55.04)

repeat nephroscopic removal during current episode (55.92)

55.04            Percutaneous nephrostomy with fragmentation

Percutaneous nephrostomy with disruption of kidney stone by ultrasonic energy and extraction (suction) through endoscope

With placement of catheter down ureter

With fluoroscopic guidance

Excludes:            repeat fragmentation during current episode (59.95)

55.1            Pyelotomy and pyelostomy

Excludes:            drainage by anastomosis (55.86)

percutaneous pyelostolithotomy (55.03)

removal of calculus without incision (56.0)

55.11            Pyelotomy

Exploration of renal pelvis

Pyelolithotomy

55.12            Pyelostomy

Insertion of drainage tube into renal pelvis

55.2            Diagnostic procedures on kidney

55.21            Nephroscopy

55.22            Pyeloscopy

55.23            Closed [percutaneous] [needle] biopsy of kidney

Endoscopic biopsy via existing nephrostomy, nephrotomy, pyelostomy, or pyelotomy

55.24            Open biopsy of kidney

55.29            Other diagnostic procedures on kidney

Excludes:            microscopic examination of specimen from kidney (91.21-91.29)

pyelogram:

intravenous (87.73)

percutaneous (87.75)

retrograde (87.74)

radioisotope scan (92.03)

renal arteriography (88.45)

tomography:

C.A.T. scan (87.71)

other (87.72)

55.3      Local excision or destruction of lesion or tissue of kidney

55.31            Marsupialization of kidney lesion

55.39            Other local destruction or excision of renal lesion or tissue

Obliteration of calyceal diverticulum

Excludes:            biopsy of kidney (55.23-55.24)

partial nephrectomy (55.4)

percutaneous aspiration of kidney (55.92)

wedge resection of kidney (55.4)

55.4      Partial nephrectomy

Calycectomy

Wedge resection of kidney

Code also any synchronous resection of ureter (56.40-56.42)

55.5            Complete nephrectomy

Code also any synchronous excision of:

adrenal gland (07.21-07.3)

bladder segment (57.6)

lymph nodes (40.3, 40.52-40.59)

55.51            Nephroureterectomy

Nephroureterectomy with bladder cuff

Total nephrectomy (unilateral)

Excludes:            removal of transplanted kidney (55.53)

55.52            Nephrectomy of remaining kidney

Removal of solitary kidney

Excludes:            removal of transplanted kidney (55.53)

55.53            Removal of transplanted or rejected kidney

55.54            Bilateral nephrectomy

Excludes:            complete nephrectomy NOS (55.51)

55.6            Transplant of kidney

Note: To report donor source - see codes 00.91-00.93

55.61            Renal autotransplantation

55.69            Other kidney transplantation

55.7            Nephropexy

Fixation or suspension of movable [floating] kidney

55.8      Other repair of kidney

55.81            Suture of laceration of kidney

55.82            Closure of nephrostomy and pyelostomy

55.83            Closure of other fistula of kidney

55.84            Reduction of torsion of renal pedicle

55.85            Symphysiotomy for horseshoe kidney

55.86            Anastomosis of kidney

Nephropyeloureterostomy

Pyeloureterovesical anastomosis

Ureterocalyceal anastomosis

Excludes:            nephrocystanastomosis NO (56.73)

55.87            Correction of ureteropelvic junction

55.89            Other

55.9      Other operations on kidney

Excludes:            lysis of perirenal adhesions (59.02)

55.91            Decapsulation of kidney

Capsulectomy of kidney

Decortication of kidney

55.92            Percutaneous aspiration of kidney (pelvis)

Aspiration of renal cyst

Renipuncture

Excludes:            percutaneous biopsy of kidney (55.23)

55.93            Replacement of nephrostomy tube

55.94            Replacement of pyelostomy tube

55.95            Local perfusion of kidney

55.96            Other injection of therapeutic substance into kidney

Injection into renal cyst

55.97            Implantation or replacement of mechanical kidney

55.98            Removal of mechanical kidney

55.99            Other

Excludes:            removal of pyelostomy or nephrostomy tube (97.61)

56            Operations on ureter

Code also any application or administration of an adhesion barrier substance (99.77)

56.0            Transurethral removal of obstruction from ureter and renal pelvis

Removal of:

blood clot from ureter or renal pelvis without incision

calculus from ureter or renal pelvis without incision

foreign body from ureter or renal pelvis without incision

Excludes:manipulation without removal of obstruction (59.8)

that by incision (55.11, 56.2)

transurethral insertion of ureteral stent for passage of calculus (59.8)

56.1      Ureteral meatotomy

56.2            Ureterotomy

Incision of ureter for:

drainage

exploration

removal of calculus

Excludes:cutting of ureterovesical orifice (56.1)

removal of calculus without incision (56.0)

transurethral insertion of ureteral stent for passage of calculus (59.8)

urinary diversion (56.51-56.79)

56.3            Diagnostic procedures on ureter

56.31            Ureteroscopy

56.32            Closed percutaneous biopsy of ureter

Excludes:            endoscopic biopsy of ureter (56.33)

56.33            Closed endoscopic biopsy of ureter

Cystourethroscopy with ureteral biopsy

Transurethral biopsy of ureter

Ureteral endoscopy with biopsy through ureterotomy

Ureteroscopy with biopsy

Excludes:            percutaneous biopsy of ureter (56.32)

56.34            Open biopsy of ureter

56.35            Endoscopy (cystoscopy) (looposcopy)of ileal conduit

56.39            Other diagnostic procedures on ureter

Excludes:            microscopic examination of specimen from ureter (91.21-91.29)

56.4            Ureterectomy

Code also anastomosis other than end-to-end (56.51-56.79)

Excludes:            fistulectomy (56.84)

nephroureterectomy (55.51-55.54)

56.40            Ureterectomy, not otherwise specified

56.41            Partial ureterectomy

Excision of lesion of ureter

Shortening of ureter with reimplantation

Excludes:            biopsy of ureter (56.32-56.34)

56.42            Total ureterectomy

56.5            Cutaneous uretero-ileostomy

56.51            Formation of cutaneous uretero-ileostomy

Construction of ileal conduit

External ureteral ileostomy

Formation of open ileal bladder

Ileal loop operation

Ileoureterostomy (Bricker's) (ileal bladder)

Transplantation of ureter into ileum with external diversion

Excludes:            closed ileal bladder (57.87)

replacement of ureteral defect by ileal segment (56.89)

56.52            Revision of cutaneous uretero-ileostomy

56.6      Other external urinary diversion

56.61            Formation of other cutaneous ureterostomy

Anastomosis of ureter to skin

Ureterostomy NOS

56.62            Revision of other cutaneous ureterostomy

Revision of ureterostomy stoma

Excludes:            nonoperative removal of ureterostomy tube (97.62)

56.7      Other anastomosis or bypass of ureter

Excludes:            ureteropyelostomy (55.86)

56.71            Urinary diversion to intestine

Anastomosis of ureter to intestine

Internal urinary diversion NOS

Code also any synchronous colostomy (46.10-46.13)

Excludes:            external ureteral ileostomy (56.51)

56.72            Revision of ureterointestinal anastomosis

Excludes:            revision of external ureteral ileostomy (56.52)

56.73            Nephrocystanastomosis, not otherwise specified

56.74            Ureteroneocystostomy

Replacement of ureter with bladder flap

Ureterovesical anastomosis

56.75            Transureteroureterostomy

Excludes:            ureteroureterostomy associated with partial resection (56.41)

56.79            Other

56.8      Repair of ureter

56.81            Lysis of intraluminal adhesions of ureter

Excludes:            lysis of periureteral adhesions (59.01-59.02)

ureterolysis (59.01-59.02)

56.82            Suture of laceration of ureter

56.83            Closure of ureterostomy

56.84            Closure of other fistula of ureter

56.85            Ureteropexy

56.86            Removal of ligature from ureter

56.89            Other repair of ureter

Graft of ureter

Replacement of ureter with ileal segment implanted into bladder

Ureteroplication

56.9      Other operations on ureter

56.91            Dilation of ureteral meatus

56.92            Implantation of electronic ureteral stimulator

56.93            Replacement of electronic ureteral stimulator

56.94            Removal of electronic ureteral stimulator

Excludes:            that with synchronou replacement (56.93)

56.95            Ligation of ureter

56.99            Other

Excludes:            removal of ureterostomy tube an ureteral catheter (97.62)

ureteral catheterization (59.8)

57            Operations on urinary bladder

Code also any application or administration of an adhesion barrier substance (99.77)

Excludes:perivesical tissue (59.11-59.29, 59.91-59.92)

ureterovesical orifice (56.0-56.99)

57.0            Transurethral clearance of bladder

Drainage of bladder without incision

Removal of:

blood clots from bladder without incision

calculus from bladder without incision

foreign body from bladder without incision

Excludes:    that by incision (57.19)

57.1            Cystotomy and cystostomy

Excludes:            cystotomy and cystostomy as operative approach -- omit code

57.11            Percutaneous aspiration of bladder

57.12            Lysis of intraluminal adhesions with incision into bladder

Excludes:            transurethral lysis of intraluminal adhesions (57.41)

57.17            Percutaneous cystostomy

Closed cystostomy

Percutaneous suprapubic cystostomy

Excludes:            removal of cystostomy tub (97.63)

replacement of cystostomy tube (59.94)

57.18            Other suprapubic cystostomy

Excludes:            percutaneous cystostomy (57.17)

removal of cystostomy tub (97.63)

replacement of cystostomy tube (59.94)

57.19            Other cystotomy

Cystolithotomy

Excludes:            percutaneous cystostomy (57.17)

suprapubic cystostomy (57.18)

57.2            Vesicostomy

Excludes:            percutaneous cystostomy (57.17)

suprapubic cystostomy (57.18)

57.21            Vesicostomy

Creation of permanent opening from bladder to skin using a bladder flap

57.22            Revision or closure of vesicostomy

Excludes:            closure of cystostomy (57.82)

57.3            Diagnostic procedures on bladder

57.31            Cystoscopy through artificial stoma

57.32            Other cystoscopy

Transurethral cystoscopy

Excludes:            cystourethroscopy with ureteral biopsy (56.33)

retrograde pyelogram (87.74)

that for control of hemorrhage (postoperative):

bladder (57.93)

prostate (60.94)

57.33            Closed [transurethral] biopsy of bladder

57.34            Open biopsy of bladder

57.39            Other diagnostic procedures on bladder

Excludes:            cystogram NEC (87.77)

microscopic examination of specimen from bladder (91.31-91.39)

retrograde cystourethrogram (87.76)

therapeutic distention of bladder (96.25)

57.4            Transurethral excision or destruction of bladder tissue

57.41            Transurethral lysis of intraluminal adhesions

57.49            Other transurethral excision or destruction of lesion or tissue of bladder

Endoscopic resection of bladder lesion

Excludes:            transurethral biopsy of bladder (57.33)

transurethral fistulectomy (57.83-57.84)

57.5      Other excision or destruction of bladder tissue

Excludes:    that with transurethral approach (57.41-57.49)

57.51            Excision of urachus

Excision of urachal sinus of bladder

Excludes:            excision of urachal cyst of abdominal wall (54.3)

57.59            Open excision or destruction of other lesion or tissue of bladder

Endometrectomy of bladder

Suprapubic excision of bladder lesion

Excludes:            biopsy of bladder (57.33-57.34)

fistulectomy of bladder (57.83-57.84)

57.6      Partial cystectomy

Excision of bladder dome

Trigonectomy

Wedge resection of bladder

57.7      Total cystectomy

Includes: total cystectomy with urethrectomy

57.71            Radical cystectomy

Pelvic exenteration in male

Removal of bladder, prostate, seminal vesicles, and fat

Removal of bladder, urethra, and fat in a female

Code also any:

lymph node dissection (40.3, 40.5)

urinary diversion (56.51-56.79)

Excludes:            that as part of pelvic exenteration in female (68.8)

57.79            Other total cystectomy

57.8      Other repair of urinary bladder

Excludes:            repair of:

current obstetric laceration (75.61)

cystocele (70.50-70.51)

that for stress incontinence (59.3-59.79)

57.81            Suture of laceration of bladder

57.82            Closure of cystostomy

57.83            Repair of fistula involving bladder and intestine

Rectovesicovaginal fistulectomy

Vesicosigmoidovaginal fistulectomy

57.84            Repair of other fistula of bladder

Cervicovesical fistulectomy

Urethroperineovesical fistulectomy

Uterovesical fistulectomy

Vaginovesical fistulectomy

Excludes:            vesicoureterovagina fistulectomy (56.84)

57.85            Cystourethroplasty and plastic repair of bladder neck

Plication of sphincter of urinary bladder

V-Y plasty of bladder neck

57.86            Repair of bladder exstrophy

57.87            Reconstruction of urinary bladder

Anastomosis of bladder with isolated segment of ileum

Augmentation of bladder

Replacement of bladder with ileum or sigmoid [closed ileal bladder]

Code also resection of intestine (45.50-45.52)

57.88            Other anastomosis of bladder

Anastomosis of bladder to intestine NOS

Cystocolic anastomosis

Excludes:            formation of closed ilea bladder (57.87)

57.89            Other repair of bladder

Bladder suspension, not elsewhere classified

Cystopexy NOS

Repair of old obstetric laceration of bladder

Excludes:            repair of current obstetric laceration (75.61)

57.9      Other operations on bladder

57.91            Sphincterotomy of bladder

Division of bladder neck

57.92            Dilation of bladder neck

57.93            Control of (postoperative) hemorrhage of bladder

57.94            Insertion of indwelling urinary catheter

57.95            Replacement of indwelling urinary catheter

57.96            Implantation of electronic bladder stimulator

57.97            Replacement of electronic bladder stimulator

57.98            Removal of electronic bladder stimulator

Excludes:            that with synchronou replacement (57.97)

57.99            Other

Excludes:            irrigation of:

cystostomy (96.47)

other indwelling urinary catheter (96.48)

lysis of external adhesions (59.11)

removal of:

cystostomy tube (97.63)

other urinary drainage devic (97.64)

therapeutic distention o bladder (96.25)

58            Operations on urethra

Includes:            operations on:

bulbourethral gland [Cowper's gland]

periurethral tissue

Code also any application or administration of an adhesion barrier substance (99.77)

58.0            Urethrotomy

Excision of urethral septum

Formation of urethrovaginal fistula

Perineal urethrostomy

Removal of calculus from urethra by incision

Excludes:            drainage of bulbourethral gland or periurethral tissue (58.91)

internal urethral meatotomy (58.5)

removal of urethral calculus without incision (58.6)

58.1      Urethral meatotomy

Excludes:            internal urethral meatotomy (58.5)

58.2            Diagnostic procedures on urethra

58.21            Perineal urethroscopy

58.22            Other urethroscopy

58.23            Biopsy of urethra

58.24            Biopsy of periurethral tissue

58.29            Other diagnostic procedures on urethra and periurethral tissue

Excludes:            microscopic examination of specimen from urethra (91.31-91.39)

retrograde cystourethrogram (87.76)

urethral pressure profil (89.25)

urethral sphincter electromyogram (89.23)

58.3            Excision or destruction of lesion or tissue of urethra

Excludes:            biopsy of urethra (58.23)

excision of bulbourethral gland (58.92)

fistulectomy (58.43)

urethrectomy as part of:

complete cystectomy (57.79)

pelvic evisceration (68.8)

radical cystectomy (57.71)

58.31            Endoscopic excision or destruction of lesion or tissue of urethra

Fulguration of urethral lesion

58.39            Other local excision or destruction of lesion or tissue of urethra

Excision of:

congenital valve of urethra

lesion of urethra

stricture of urethra

Urethrectomy

Excludes:            that by endoscopic approach (58.31)

58.4      Repair of urethra

Excludes:            repair of current obstetric laceration (75.61)

58.41            Suture of laceration of urethra

58.42            Closure of urethrostomy

58.43            Closure of other fistula of urethra

Excludes:            repair of urethroperineovesical fistula (57.84)

58.44            Reanastomosis of urethra

Anastomosis of urethra

58.45            Repair of hypospadias or epispadias

58.46            Other reconstruction of urethra

Urethral construction

58.47            Urethral meatoplasty

58.49            Other repair of urethra

Benenenti rotation of bulbous urethra

Repair of old obstetric laceration of urethra

Urethral plication

Excludes:            repair of:

current obstetric laceration (75.61)

urethrocele (70.50-70.51)

58.5      Release of urethral stricture

Cutting of urethral sphincter

Internal urethral meatotomy

Urethrolysis

58.6      Dilation of urethra

Dilation of urethrovesical junction

Passage of sounds through urethra

Removal of calculus from urethra without incision

Excludes:            urethral calibration (89.29)

58.9      Other operations on urethra and periurethral tissue

58.91            Incision of periurethral tissue

Drainage of bulbourethral gland

58.92            Excision of periurethral tissue

Excludes:            biopsy of periurethral tissue (58.24)

lysis of periurethral adhesions

laparoscopic (59.12)

other (59.11)

58.93            Implantation of artificial urinary sphincter [AUS]

Placement of inflatable:

bladder sphincter

urethral sphincter

Removal with replacement of sphincter device [AUS]

With pump and/or reservoir

58.99            Other

Removal of inflatable urinary sphincter without replacement

Repair of inflatable sphincter pump and/or reservoir

Surgical correction of hydraulic pressure of inflatable sphincter device

Excludes:            removal of:

intraluminal foreign bod from urethra without incision (98.19)

urethral stent (97.65)

59         Other operations on urinary tract

Code also any application or administration of an adhesion barrier substance (99.77)

59.0            Dissection of retroperitoneal tissue

59.00            Retroperitoneal dissection, not otherwise specified

59.02            Other lysis of perirenal or periureteral adhesions

Excludes: that by laparoscope (59.03)

59.03            Laparoscopic lysis of perirenal or periureteral adhesions

59.09            Other incision of perirenal or periureteral tissue

Exploration of perinephric area

Incision of perirenal abscess

59.1      Incision of perivesical tissue

59.11            Other lysis of perivesical adhesions

59.12            Laparoscopic lysis of perivesical adhesions

59.19            Other incision of perivesical tissue

Exploration of perivesical tissue

Incision of hematoma of space of Retzius

Retropubic exploration

59.2            Diagnostic procedures on perirenal and perivesical tissue

59.21            Biopsy of perirenal or perivesical tissue

59.29            Other diagnostic procedures on perirenal tissue, perivesical tissue, and retroperitoneum

Excludes:            microscopic examination of specimen from:

perirenal tissue (91.21-91.29)

perivesical tissue (91.31-91.39)

retroperitoneum NEC (91.11-91.19)

retroperitoneal x-ray (88.14-88.16)

59.3            Plication of urethrovesical junction

Kelly-Kennedy operation on urethra

Kelly-Stoeckel urethral plication

59.4            Suprapubic sling operation

Goebel-Frangenheim-Stoeckel urethrovesical suspension

Millin-Read urethrovesical suspension

Oxford operation for urinary incontinence

Urethrocystopexy by suprapubic suspension

59.5            Retropubic urethral suspension

Burch procedure

Marshall-Marchetti-Krantz operation

Suture of periurethral tissue to symphysis pubis

Urethral suspension NOS

59.6            Paraurethral suspension

Pereyra paraurethral suspension

Periurethral suspension

59.7      Other repair of urinary stress incontinence

59.71            Levator muscle operation for urethrovesical suspension

Cystourethropexy with levator muscle sling

Gracilis muscle transplant for urethrovesical suspension

Pubococcygeal sling

59.72            Injection of implant into urethra and/or bladder neck

Collagen implant

Endoscopic injection of implant

Fat implant

Polytef implant

59.79            Other

Anterior urethropexy

Repair of stress incontinence NOS

Tudor "rabbit ear" urethropexy

59.8      Ureteral catheterization

Drainage of kidney by catheter

Insertion of ureteral stent

Ureterovesical orifice dilation

Code also any ureterotomy (56.2)

Excludes:    that for:

retrograde pyelogram (87.74)

transurethral removal of calculus or clot from ureter and renal pelvis (56.0)

59.9      Other operations on urinary system

Excludes:            nonoperative removal of therapeutic device (97.61-97.69)

59.91            Excision of perirenal or perivesical tissue

Excludes:            biopsy of perirenal or perivesical tissue (59.21)

59.92            Other operations on perirenal or perivesical tissue

59.93            Replacement of ureterostomy tube

Change of ureterostomy tube

Reinsertion of ureterostomy tube

Excludes:            nonoperative removal of ureterostomy tube (97.62)

59.94            Replacement of cystostomy tube

Excludes:            nonoperative removal of cystostomy tube (97.63)

59.95            Ultrasonic fragmentation of urinary stones

Shattered urinary stones

Excludes:            percutaneous nephrostomy with fragmentation (55.04)

shock-wave disintegratio (98.51)

59.99            Other

Excludes:            instillation of medication into urinary tract (96.49)

irrigation of urinary tract (96.45-96.48)

11. OPERATIONS ON THE MALE GENITAL ORGANS (60-64) back to top

60            Operations on prostate and seminal vesicles

Includes:            operations on periprostatic tissue

Code also any application or administration of an adhesion barrier substance (99.77)

Excludes:    that associated with radical cystectomy (57.71)

60.0      Incision of prostate

Drainage of prostatic abscess

Prostatolithotomy

Excludes:            drainage of periprostatic tissue only (60.81)

60.1            Diagnostic procedures on prostate and seminal vesicles

60.11            Closed [percutaneous] [needle] biopsy of prostate

Approach:

transrectal

transurethral

Punch biopsy

60.12            Open biopsy of prostate

60.13            Closed [percutaneous] biopsy of seminal vesicles

Needle biopsy of seminal vesicles

60.14            Open biopsy of seminal vesicles

60.15            Biopsy of periprostatic tissue

60.18            Other diagnostic procedures on prostate and periprostatic tissue

Excludes:            microscopic examination of specimen from prostate (91.31-91.39)

x-ray of prostate (87.92)

60.19            Other diagnostic procedures on seminal vesicles

Excludes:            microscopic examination of specimen from seminal vesicles (91.31-91.39)

x-ray:

contrast seminal vesiculogra (87.91)

other (87.92)

60.2            Transurethral prostatectomy

Excludes:            local excision of lesion of prostate (60.61)

60.21            Transurethral (ultrasound) guided laser induced prostatectomy (TULIP)

Ablation (contact) (noncontact) by laser

60.29            Other transurethral prostatectomy

Excision of median bar by transurethral approach

Transurethral electrovaporization of prostrate (TEVAP)

Transurethral enucleative procedure

Transurethral prostatectomy NOS

Transurethral resection of prostate (TURP)

60.3            Suprapubic prostatectomy

Transvesical prostatectomy

Excludes:            local excision of lesion of prostate (60.61)

radical prostatectomy (60.5)

60.4            Retropubic prostatectomy

Excludes:            local excision of lesion of prostate (60.61)

radical prostatectomy (60.5)

60.5      Radical prostatectomy

Prostatovesiculectomy

Radical prostatectomy by any approach

Excludes:            cystoprostatectomy (57.71)

60.6      Other prostatectomy

60.61            Local excision of lesion of prostate

Excision of prostatic lesion by any approach

Excludes:            biopsy of prostate (60.11-60.12)

60.62            Perineal prostatectomy

Cryoablation of prostate

Cryoprostatectomy

Cryosurgery of prostate

Radical cryosurgical ablation of prostate (RCSA)

Excludes:            local excision of lesion of prostate (60.61)

60.69            Other

60.7            Operations on seminal vesicles

60.71            Percutaneous aspiration of seminal vesicle

Excludes:            needle biopsy of seminal vesicl (60.13)

60.72            Incision of seminal vesicle

60.73            Excision of seminal vesicle

Excision of Müllerian duct cyst

Spermatocystectomy

Excludes:            biopsy of seminal vesicle (60.13-60.14)

prostatovesiculectomy (60.5)

60.79            Other operations on seminal vesicles

60.8      Incision or excision of periprostatic tissue

60.81            Incision of periprostatic tissue

Drainage of periprostatic abscess

60.82            Excision of periprostatic tissue

Excision of lesion of periprostatic tissue

Excludes:            biopsy of periprostatic tissue (60.15)

60.9      Other operations on prostate

60.91            Percutaneous aspiration of prostate

Excludes:            needle biopsy of prostat (60.11)

60.92            Injection into prostate test link

60.93            Repair of prostate

60.94            Control of (postoperative) hemorrhage of prostate

Coagulation of prostatic bed

Cystoscopy for control of prostatic hemorrhage

60.95            Transurethral balloon dilation of the prostatic urethra

60.96            Transurethral destruction of prostate tissue by microwave thermotherapy

Transurethral microwave thermotherapy (TUMT) of prostate

Excludes:                        Prostatectomy:

      other (60.61 - 60.69)

      radical (60.5)

      retropubic (60.4)

      suprapubic (60.3)

      transurethral (60.21 - 60.29)

60.97            Other transurethral destruction of prostate tissue by other thermotherapy

Radiofrequency thermotherapy

Transurethral needle ablation (TUNA) of prostate

Excludes:                        Prostatectomy:

      other (60.61 - 60.69)

      radical (60.5)

      retropubic (60.4)

      suprapubic (60.3)

      transurethral (60.21 - 60.29)

60.99            Other

Excludes:            prostatic massage (99.94)

61            Operations on scrotum and tunica vaginalis

61.0      Incision and drainage of scrotum and tunica vaginalis

Excludes:            percutaneous aspiration of hydrocele (61.91)

61.1            Diagnostic procedures on scrotum and tunica vaginalis

61.11            Biopsy of scrotum or tunica vaginalis

61.19            Other diagnostic procedures on scrotum and tunica vaginalis

61.2            Excision of hydrocele (of tunica vaginalis)

Bottle repair of hydrocele of tunica vaginalis

Excludes:            percutaneous aspiration of hydrocele (61.91)

61.3            Excision or destruction of lesion or tissue of scrotum

Fulguration of lesion of scrotum

Reduction of elephantiasis of scrotum

Partial scrotectomy of scrotum

Excludes:            biopsy of scrotum (61.11)

scrotal fistulectomy (61.42)

61.4      Repair of scrotum and tunica vaginalis

61.41            Suture of laceration of scrotum and tunica vaginalis

61.42            Repair of scrotal fistula

61.49            Other repair of scrotum and tunica vaginalis

Reconstruction with rotational or pedicle flaps

61.9      Other operations on scrotum and tunica vaginalis

61.91            Percutaneous aspiration of tunica vaginalis

Aspiration of hydrocele of tunica vaginalis

61.92            Excision of lesion of tunica vaginalis other than hydrocele

Excision of hematocele of tunica vaginalis

61.99            Other

Excludes:            removal of foreign body from scrotum without incision (98.24)

62            Operations on testes

62.0      Incision of testis

62.1            Diagnostic procedures on testes

62.11            Closed [percutaneous] [needle] biopsy of testis

62.12            Open biopsy of testis

62.19            Other diagnostic procedures on testes

62.2            Excision or destruction of testicular lesion

Excision of appendix testis

Excision of cyst of Morgagni in the male

Excludes:            biopsy of testis (62.11-62.12)

62.3            Unilateral orchiectomy

Orchidectomy (with epididymectomy) NOS

62.4      Bilateral orchiectomy

Male castration

Radical bilateral orchiectomy (with epididymectomy)

Code also any synchronous lymph node dissection (40.3, 40.5)

62.41            Removal of both testes at same operative episode

Bilateral orchidectomy NOS

62.42            Removal of remaining testis

Removal of solitary testis

62.5            Orchiopexy

Mobilization and replacement of testis in scrotum

Orchiopexy with detorsion of testis

Torek (-Bevan) operation (orchidopexy) (first stage) (second stage)

Transplantation to and fixation of testis in scrotum

62.6      Repair of testes

Excludes:            reduction of torsion (63.52)

62.61            Suture of laceration of testis

62.69            Other repair of testis

Testicular graft

62.7            Insertion of testicular prosthesis

62.9      Other operations on testes

62.91            Aspiration of testis

Excludes:            percutaneous biopsy of testis (62.11)

62.92            Injection of therapeutic substance into testis

62.99            Other

63            Operations on spermatic cord, epididymis, and vas deferens

63.0            Diagnostic procedures on spermatic cord, epididymis, and vas deferens

63.01            Biopsy of spermatic cord, epididymis, or vas deferens

63.09            Other diagnostic procedures on spermatic cord, epididymis, and vas deferens

Excludes:            contrast epididymogram (87.93)

contrast vasogram (87.94)

other x-ray of epididymis and vas deferens (87.95)

63.1            Excision of varicocele and hydrocele of spermatic cord

High ligation of spermatic vein

Hydrocelectomy of canal of Nuck

63.2            Excision of cyst of epididymis

Spermatocelectomy

63.3            Excision of other lesion or tissue of spermatic cord and epididymis

Excision of appendix epididymis

Excludes:            biopsy of spermatic cord or epididymis (63.01)

63.4            Epididymectomy

Excludes:    that synchronous with orchiectomy (62.3-62.42)

63.5      Repair of spermatic cord and epididymis

63.51            Suture of laceration of spermatic cord and epididymis

63.52            Reduction of torsion of testis or spermatic cord

Excludes:            that associated with orchiopexy (62.5)

63.53            Transplantation of spermatic cord

63.59            Other repair of spermatic cord and epididymis

63.6            Vasotomy

Vasostomy

63.7            Vasectomy and ligation of vas deferens

63.70            Male sterilization procedure, not otherwise specified

63.71            Ligation of vas deferens

Crushing of vas deferens

Division of vas deferens

63.72            Ligation of spermatic cord

63.73            Vasectomy

63.8      Repair of vas deferens and epididymis

63.81            Suture of laceration of vas deferens and epididymis

63.82            Reconstruction of surgically divided vas deferens

63.83            Epididymovasostomy

63.84            Removal of ligature from vas deferens

63.85            Removal of valve from vas deferens

63.89            Other repair of vas deferens and epididymis

63.9      Other operations on spermatic cord, epididymis, and vas deferens

63.91            Aspiration of spermatocele

63.92            Epididymotomy

63.93            Incision of spermatic cord

63.94            Lysis of adhesions of spermatic cord

63.95            Insertion of valve in vas deferens

63.99            Other

64            Operations on penis

Includes:            operations on:

corpora cavernosa

glans penis

prepuce

64.0            Circumcision

64.1            Diagnostic procedures on the penis

64.11            Biopsy of penis

64.19            Other diagnostic procedures on penis

64.2      Local excision or destruction of lesion of penis

Excludes:            biopsy of penis (64.11)

64.3            Amputation of penis

64.4      Repair and plastic operation on penis

64.41            Suture of laceration of penis

64.42            Release of chordee

64.43            Construction of penis

64.44            Reconstruction of penis

64.45            Replantation of penis

Reattachment of amputated penis

64.49            Other repair of penis

Excludes:            repair of epispadias and hypospadias (58.45)

64.5            Operations for sex transformation, not elsewhere classified

64.9      Other operations on male genital organs

64.91            Dorsal or lateral slit of prepuce

64.92            Incision of penis

64.93            Division of penile adhesions

64.94            Fitting of external prosthesis of penis

Penile prosthesis NOS

64.95            Insertion or replacement of non-inflatable penile prosthesis

Insertion of semi-rigid rod prosthesis into shaft of penis

Excludes:            external penile prosthesi (64.94)

inflatable penile prosthesis (64.97)

plastic repair, penis (64.43-64.49)

that associated with:

construction (64.43)

reconstruction (64.44)

64.96            Removal of internal prosthesis of penis

Removal without replacement of non- inflatable or inflatable penile prosthesis

64.97            Insertion or replacement of inflatable penile prosthesis

Insertion of cylinders into shaft of penis and placement of pump and reservoir

Excludes:            external penile prosthesi (64.94)

non-inflatable penile prosthesi (64.95)

plastic repair, penis (64.43-64.49)

64.98            Other operations on penis

Corpora cavernosa-corpus spongiosum shunt

Corpora-saphenous shunt

Irrigation of corpus cavernosum

Excludes:            removal of foreign body:

intraluminal (98.19)

without incision (98.24)

stretching of foreskin (99.95)

64.99            Other

Excludes:            collection of sperm fo artificial insemination (99.96)

12. OPERATIONS ON THE FEMALE GENITAL ORGANS (65-71) back to top

65            Operations on ovary

Code also any application or administration of an adhesion barrier substance (99.77)

65.0            Oophorotomy

Salpingo-oophorotomy

65.01            Laparoscopic oophorotomy

65.09            Other oophorotomy

65.1            Diagnostic procedures on ovaries

65.11            Aspiration biopsy of ovary

65.12            Other biopsy of ovary

65.13            Laparoscopic biopsy of ovary

65.14            Other laparoscopic diagnostic procedures on ovaries

65.19            Other diagnostic procedures on ovaries

Excludes:            microscopic examination of specimen from ovary (91.41-91.49)

65.2      Local excision or destruction of ovarian lesion or tissue

65.21            Marsupialization of ovarian cyst

Excludes:            that by laparoscope (65.23)

65.22            Wedge resection of ovary

Excludes:            that by laparoscope (65.24)

65.23            Laparoscopic marsupialization of ovarian cyst

65.24            Laparoscopic wedge resection of ovary

65.25            Other laparoscopic local excision or destruction of ovary

65.29            Other local excision or destruction of ovary

Bisection of ovary

Cauterization of ovary

Partial excision of ovary

Excludes:            biopsy of ovary (65.11-65.13)

that by laparoscope (65.25)

65.3            Unilateral oophorectomy

65.31            Laparoscopic unilateral oophorectomy

65.39            Other unilateral oophorectomy

Excludes:            that by laparoscope (65.31)

65.4            Unilateral salpingo-oophorectomy

65.41            Laparoscopic unilateral salpingo-oophorectomy

65.49            Other unilateral salpingo-oophorectomy

65.5      Bilateral oophorectomy

65.51            Other removal of both ovaries at same operative episode

Female castration

Excludes:            that by laparoscope (65.53)

65.52            Other removal of remaining ovary

Removal of solitary ovary

Excludes:            that by laparoscope (65.54)

65.53            Laparoscopic removal of both ovaries at same operative episode

65.54            Laparoscopic removal of remaining ovary

65.6      Bilateral salpingo-oophorectomy

65.61            Other removal of both ovaries and tubes at same operative episode

Excludes:            that by laparoscope (65.63)

65.62            Other removal of remaining ovary and tube

Removal of solitary ovary and tube

Excludes:            that by laparoscope (65.64)

65.63            Laparoscopic removal of both ovaries and tubes at same operative episode

65.64            Laparoscopic removal of remaining ovary and tube

65.7      Repair of ovary

Excludes:            salpingo-oophorostomy (66.72)

65.71            Other simple suture of ovary

Excludes:            that by laparoscope (65.74)

65.72            Other reimplantation of ovary

Excludes:            that by laparoscope (65.75)

65.73            Other salpingo-oophoroplasty

Excludes:            that by laparoscope (65.76)

65.74            Laparoscopic simple suture of ovary

65.75            Laparoscopic reimplantation of ovary

65.76            Laparoscopic salpingo-oophoroplasty

65.79            Other repair of ovary

Oophoropexy

65.8      Lysis of adhesions of ovary and fallopian tube

65.81            Laparoscopic lysis of adhesions of ovary and fallopian tube

65.89            Other lysis of adhesions of ovary and fallopian tube

Excludes:            that by laparoscope (65.81)

65.9      Other operations on ovary

65.91            Aspiration of ovary

Excludes:            aspiration biopsy of ovary (65.11)

65.92            Transplantation of ovary

Excludes:            reimplantation of ovary

laparoscopic (65.75))

other (65.72)

65.93            Manual rupture of ovarian cyst

65.94            Ovarian denervation

65.95            Release of torsion of ovary

65.99            Other

Ovarian drilling

66            Operations on fallopian tubes

Code also any application or administration of an adhesion barrier substance (99.77)

66.0            Salpingotomy and salpingostomy

66.01            Salpingotomy

66.02            Salpingostomy

66.1            Diagnostic procedures on fallopian tubes

66.11            Biopsy of fallopian tube

66.19            Other diagnostic procedures on fallopian tubes

Excludes:            microscopic examination of specimen from fallopian tubes (91.41-91.49)

radiography of fallopian tubes (87.82-87.83, 87.85)

Rubin's test (66.8)

66.2      Bilateral endoscopic destruction or occlusion of fallopian tubes

Includes:            bilateral endoscopic destruction or occlusion of fallopian tubes by:

culdoscopy

endoscopy

hysteroscopy

laparoscopy

peritoneoscopy

endoscopic destruction of solitary fallopian tube

66.21            Bilateral endoscopic ligation and crushing of fallopian tubes

66.22            Bilateral endoscopic ligation and division of fallopian tubes

66.29            Other bilateral endoscopic destruction or occlusion of fallopian tubes

66.3      Other bilateral destruction or occlusion of fallopian tubes

Includes:            destruction of solitary fallopian tube

Excludes:            endoscopic destruction or occlusion of fallopian tubes (66.21-66.29)

66.31            Other bilateral ligation and crushing of fallopian tubes

66.32            Other bilateral ligation and division of fallopian tubes

Pomeroy operation

66.39            Other bilateral destruction or occlusion of fallopian tubes

Female sterilization operation NOS

66.4      Total unilateral salpingectomy

66.5      Total bilateral salpingectomy

Excludes:            bilateral partial salpingectomy for sterilization (66.39)

that with oophorectomy (65.61-65.64)

66.51            Removal of both fallopian tubes at same operative episode

66.52            Removal of remaining fallopian tube

Removal of solitary fallopian tube

66.6      Other salpingectomy

Includes:            salpingectomy by:

cauterization

coagulation

electrocoagulation

excision

Excludes:            fistulectomy (66.73)

66.61            Excision or destruction of lesion of fallopian tube

Excludes:            biopsy of fallopian tube (66.11)

66.62            Salpingectomy with removal of tubal pregnancy

Code also any synchronous oophorectomy (65.31, 65.39)

66.63            Bilateral partial salpingectomy, not otherwise specified

66.69            Other partial salpingectomy

66.7      Repair of fallopian tube

66.71            Simple suture of fallopian tube

66.72            Salpingo-oophorostomy

66.73            Salpingo-salpingostomy

66.74            Salpingo-uterostomy

66.79            Other repair of fallopian tube

Graft of fallopian tube

Reopening of divided fallopian tube

Salpingoplasty

66.8            Insufflation of fallopian tube

Insufflation of fallopian tube with:

air

dye

gas

saline

Rubin's test

Excludes:            insufflation of therapeutic agent (66.95)

that for hysterosalpingography (87.82-87.83)

66.9      Other operations on fallopian tubes

66.91            Aspiration of fallopian tube

66.92            Unilateral destruction or occlusion of fallopian tube

Excludes:            that of solitary tube (66.21-66.39)

66.93            Implantation or replacement of prosthesis of fallopian tube

66.94            Removal of prosthesis of fallopian tube

66.95            Insufflation of therapeutic agent into fallopian tubes

66.96            Dilation of fallopian tube

66.97            Burying of fimbriae in uterine wall

66.99            Other

Excludes:            lysis of adhesions of ovary and tube

laparoscopic (65.81)

other (65.89)

67            Operations on cervix

Code also any application or administration of an adhesion barrier substance (99.77)

67.0      Dilation of cervical canal

Excludes:            dilation and curettage (69.01-69.09)

that for induction of labor (73.1)

67.1            Diagnostic procedures on cervix

67.11            Endocervical biopsy

Excludes:            conization of cervix (67.2)

67.12            Other cervical biopsy

Punch biopsy of cervix NOS

Excludes:            conization of cervix (67.2)

67.19            Other diagnostic procedures on cervix

Excludes:            microscopic examination of specimen from cervix (91.41-91.49)

67.2            Conization of cervix

Excludes:    that by:

cryosurgery (67.33)

electrosurgery (67.32)

67.3      Other excision or destruction of lesion or tissue of cervix

67.31            Marsupialization of cervical cyst

67.32            Destruction of lesion of cervix by cauterization

Electroconization of cervix

LEEP (loop electrosurgical excision procedure)

LLETZ (large loop excision of the transformation zone)

67.33            Destruction of lesion of cervix by cryosurgery

Cryoconization of cervix

67.39            Other excision or destruction of lesion or tissue of cervix

Excludes:            biopsy of cervix (67.11-67.12)

cervical fistulectomy (67.62)

conization of cervix (67.2)

67.4            Amputation of cervix

Cervicectomy with synchronous colporrhaphy

67.5      Repair of internal cervical os

67.51            Transabdominal cerclage of cervix

67.59            Other repair of internal cervical os

Cerclage of isthmus uteri

McDonald operation

Shirodkar operation

Transvaginal cerclage

Excludes:laparoscopically assisted supracervical hysterectomy [LASH] (68.31)

transabdominal cerclage of cervix (67.51)

67.6      Other repair of cervix

Excludes:            repair of current obstetric laceration (75.51)

67.61            Suture of laceration of cervix

67.62            Repair of fistula of cervix

Cervicosigmoidal fistulectomy

Excludes:            fistulectomy:

cervicovesical (57.84)

ureterocervical (56.84)

vesicocervicovaginal (57.84)

67.69            Other repair of cervix

Repair of old obstetric laceration of cervix

68         Other incision and excision of uterus

Code also any application or administration of an adhesion barrier substance (99.77)

68.0            Hysterotomy

Hysterotomy with removal of hydatidiform mole

Excludes:            hysterotomy for termination of pregnancy (74.91)

68.1            Diagnostic procedures on uterus and supporting structures

68.11            Digital examination of uterus

Excludes:            pelvic examination, so describe (89.26)

postpartal manual exploration o uterine cavity (75.7)

68.12            Hysteroscopy

Excludes:            that with biopsy (68.16)

68.13            Open biopsy of uterus

Excludes:            closed biopsy of uterus(68.16)

68.14            Open biopsy of uterine ligaments

Excludes:            closed biopsy of uterin ligaments (68.15)

68.15            Closed biopsy of uterine ligaments

Endoscopic (laparoscopy) biopsy of uterine adnexa, except ovary and fallopian tube

68.16            Closed biopsy of uterus

Endoscopic (laparoscopy) hysteroscopy) biopsy of uterus

Excludes:            open biopsy of uterus (68.13)

68.19            Other diagnostic procedures on uterus and supporting structures

Excludes:            diagnostic:

aspiration curettage (69.59)

dilation and curettage (69.09)

microscopic examination of specimen from uterus (91.41-91.49)

pelvic examination (89.26)

radioisotope scan of:

placenta (92.17)

uterus (92.19)

ultrasonography of uterus (88.78-88.79)

x-ray of uterus (87.81-87.89)

68.2            Excision or destruction of lesion or tissue of uterus

68.21            Division of endometrial synechiae

Lysis of intraluminal uterine adhesions

68.22            Incision or excision of congenital septum of uterus

68.23            Endometrial ablation

Dilation and curettage

Hysteroscopic endometrial ablation

68.29            Other excision or destruction of lesion of uterus

Uterine myomectomy

Excludes:            biopsy of uterus (68.13, 68.16)

uterine fistulectomy (69.42)

68.3      Subtotal abdominal hysterectomy

68.31            Laparoscopic supracervical hysterectomy [LSH]

Classic infrafascial SEMM hysterectomy [CISH]

Laparoscopically assisted supracervical hysterectomy [LASH]

68.39            Other subtotal abdominal hysterectomy, NOS

Supracervical hysterectomy

Excludes:classic infrafascial SEMM hysterectomy [CISH] (68.31)

laparoscopic supracervical hysterectomy [LSH] (68.31)

68.4      Total abdominal hysterectomy

Hysterectomy:

extended

Code also any synchronous removal of tubes and ovaries (65.3-65.6)

68.5      Vaginal hysterectomy

Code also any synchronous:

removal of tubes and ovaries (65.31-65.64)

repair of cystocele or rectocele (70.50-70.52)

repair of pelvic floor (70.79)

68.51            Laparoscopically assisted vaginal hysterectomy (LAVH)

68.59            Other vaginal hysterectomy

Excludes:            laparoscopically assisted vaginal hysterectomy (LAVH) (68.51)

radical vaginal hysterectomy (68.7)

68.6      Radical abdominal hysterectomy

Modified radical hysterectomy

Wertheim's operation

Code also any synchronous:

lymph gland dissection (40.3, 40.5)

removal of tubes and ovaries (65.61-65.64)

Excludes:            pelvic evisceration (68.8)

68.7      Radical vaginal hysterectomy

Schauta operation

Code also any synchronous:

lymph gland dissection (40.3, 40.5)

removal of tubes and ovaries (65.61-65.64)

68.8      Pelvic evisceration

Removal of ovaries, tubes, uterus, vagina, bladder, and urethra (with removal of sigmoid colon and rectum)

Code also any synchronous:

colostomy (46.12-46.13)

lymph gland dissection (40.3, 40.5)

urinary diversion (56.51-56.79)

68.9      Other and unspecified hysterectomy

Hysterectomy NOS

Excludes:            abdominal hysterectomy, any approach (68.31-68.39, 68.4, 68.6)

vaginal hysterectomy, any approach (68.51, 68.59, 68.7)

69         Other operations on uterus and supporting structures

Code also any application or administration of an adhesion barrier substance (99.77)

69.0      Dilation and curettage of uterus

Excludes:            aspiration curettage of uterus (69.51-69.59)

69.01            Dilation and curettage for termination of pregnancy

69.02            Dilation and curettage following delivery or abortion

69.09            Other dilation and curettage

Diagnostic D and C

69.1            Excision or destruction of lesion or tissue of uterus and supporting structures

69.19            Other excision or destruction of uterus and supporting structures

Excludes:            biopsy of uterine ligamen (68.14)

69.2      Repair of uterine supporting structures

69.21            Interposition operation

Watkins procedure

69.22            Other uterine suspension

Hysteropexy

Manchester operation

Plication of uterine ligament

69.23            Vaginal repair of chronic inversion of uterus

69.29            Other repair of uterus and supporting structures

69.3            Paracervical uterine denervation

69.4      Uterine repair

Excludes:            repair of current obstetric laceration (75.50-75.52)

69.41            Suture of laceration of uterus

69.42            Closure of fistula of uterus

Excludes:            uterovesical fistulectom (57.84)

69.49            Other repair of uterus

Repair of old obstetric laceration of uterus

69.5            Aspiration curettage of uterus

Excludes:            menstrual extraction (69.6)

69.51            Aspiration curettage of uterus for termination of pregnancy

Therapeutic abortion NOS

69.52            Aspiration curettage following delivery or abortion

69.59            Other aspiration curettage of uterus

69.6            Menstrual extraction or regulation

69.7            Insertion of intrauterine contraceptive device

69.9      Other operations on uterus, cervix, and supporting structures

Excludes:            obstetric dilation or incision of cervix (73.1, 73.93)

69.91            Insertion of therapeutic device into uterus

Excludes:            insertion of:

intrauterine contraceptive device (69.7)

laminaria (69.93)

obstetric insertion of bag, bougie, or pack (73.1)

69.92            Artificial insemination

69.93            Insertion of laminaria

69.94            Manual replacement of inverted uterus

Excludes:            that in immediate postpartal period (75.94)

69.95            Incision of cervix

Excludes:            that to assist delivery (73.93)

69.96            Removal of cerclage material from cervix

69.97            Removal of other penetrating foreign body from cervix

Excludes:            removal of intraluminal foreign body from cervix (98.16)

69.98            Other operations on supporting structures of uterus

Excludes:            biopsy of uterine ligamen (68.14)

69.99            Other operations on cervix and uterus

Excludes:            removal of:

foreign body (98.16)

intrauterine contraceptive device (97.71)

obstetric bag, bougie, or pack (97.72)

packing (97.72)

70            Operations on vagina and cul-de-sac

Code also any application or administration of an adhesion barrier substance (99.77)

70.0            Culdocentesis

70.1      Incision of vagina and cul-de-sac

70.11            Hymenotomy

70.12            Culdotomy

70.13            Lysis of intraluminal adhesions of vagina

70.14            Other vaginotomy

Division of vaginal septum

Drainage of hematoma of vaginal cuff

70.2            Diagnostic procedures on vagina and cul-de-sac

70.21            Vaginoscopy

70.22            Culdoscopy

70.23            Biopsy of cul-de-sac

70.24            Vaginal biopsy

70.29            Other diagnostic procedures on vagina and cul- de-sac

70.3      Local excision or destruction of vagina and cul-de-sac

70.31            Hymenectomy

70.32            Excision or destruction of lesion of cul-de- sac

Endometrectomy of cul-de-sac

Excludes:            biopsy of cul-de-sac (70.23)

70.33            Excision or destruction of lesion of vagina

Excludes:            biopsy of vagina (70.24)

vaginal fistulectomy (70.72-70.75)

70.4            Obliteration and total excision of vagina

Vaginectomy

Excludes:            obliteration of vaginal vault (70.8)

70.5      Repair of cystocele and rectocele

70.50            Repair of cystocele and rectocele

70.51            Repair of cystocele

Anterior colporrhaphy (with urethrocele repair)

70.52            Repair of rectocele

Posterior colporrhaphy

70.6      Vaginal construction and reconstruction

70.61            Vaginal construction

70.62            Vaginal reconstruction

70.7      Other repair of vagina

Excludes:            lysis of intraluminal adhesions (70.13)

repair of current obstetric laceration (75.69)

that associated with cervical amputation (67.4)

70.71            Suture of laceration of vagina

70.72            Repair of colovaginal fistula

70.73            Repair of rectovaginal fistula

70.74            Repair of other vaginoenteric fistula

70.75            Repair of other fistula of vagina

Excludes:            repair of fistula:

rectovesicovaginal (57.83)

ureterovaginal (56.84)

urethrovaginal (58.43)

uterovaginal (69.42)

vesicocervicovaginal (57.84)

vesicosigmoidovaginal (57.83)

vesicoureterovaginal (56.84)

vesicovaginal (57.84)

70.76            Hymenorrhaphy

70.77            Vaginal suspension and fixation

70.79            Other repair of vagina

Colpoperineoplasty

Repair of old obstetric laceration of vagina

70.8            Obliteration of vaginal vault

LeFort operation

70.9      Other operations on vagina and cul-de-sac

70.91            Other operations on vagina

Excludes:            insertion of:

diaphragm (96.17)

mold (96.15)

pack (96.14)

pessary (96.18)

suppository (96.49)

removal of:

diaphragm (97.73)

foreign body (98.17)

pack (97.75)

pessary (97.74)

replacement of:

diaphragm (97.24)

pack (97.26)

pessary (97.25)

vaginal dilation (96.16)

vaginal douche (96.44)

70.92            Other operations on cul-de-sac

Obliteration of cul-de-sac

Repair of vaginal enterocele

71            Operations on vulva and perineum

Code also any application or administration of an adhesion barrier substance (99.77)

71.0      Incision of vulva and perineum

71.01            Lysis of vulvar adhesions

71.09            Other incision of vulva and perineum

Enlargement of introitus NOS

Excludes:            removal of foreign body without incision (98.23)

71.1            Diagnostic procedures on vulva

71.11            Biopsy of vulva

71.19            Other diagnostic procedures on vulva

71.2            Operations on Bartholin's gland

71.21            Percutaneous aspiration of Bartholin's gland (cyst)

71.22            Incision of Bartholin's gland (cyst)

71.23            Marsupialization of Bartholin's gland (cyst)

71.24            Excision or other destruction of Bartholin's gland (cyst)

71.29            Other operations on Bartholin's gland

71.3      Other local excision or destruction of vulva and perineum

Division of Skene's gland

Excludes:            biopsy of vulva (71.11)

vulvar fistulectomy (71.72)

71.4            Operations on clitoris

Amputation of clitoris

Clitoridotomy

Female circumcision

71.5      Radical vulvectomy

Code also any synchronous lymph gland dissection (40.3, 40.5)

71.6      Other vulvectomy

71.61            Unilateral vulvectomy

71.62            Bilateral vulvectomy

Vulvectomy NOS

71.7      Repair of vulva and perineum

Excludes:            repair of current obstetric laceration (75.69)

71.71            Suture of laceration of vulva or perineum

71.72            Repair of fistula of vulva or perineum

Excludes:            repair of fistula:

urethroperineal (58.43)

urethroperineovesical (57.84)

vaginoperineal (70.75)

71.79            Other repair of vulva and perineum

Repair of old obstetric laceration of vulva or perineum

71.8      Other operations on vulva

Excludes:            removal of:

foreign body without incision (98.23)

packing (97.75)

replacement of packing (97.26)

71.9      Other operations on female genital organs

13. OBSTETRICAL PROCEDURES (72-75) back to top

72            Forceps, vacuum, and breech delivery

72.0      Low forceps operation

Outlet forceps operation

72.1      Low forceps operation with episiotomy

Outlet forceps operation with episiotomy

72.2      Mid forceps operation

72.21            Mid forceps operation with episiotomy

72.29            Other mid forceps operation

72.3      High forceps operation

72.31            High forceps operation with episiotomy

72.39            Other high forceps operation

72.4      Forceps rotation of fetal head

DeLee maneuver

Key-in-lock rotation

Kielland rotation

Scanzoni's maneuver

Code also any associated forceps extraction (72.0-72.39)

72.5      Breech extraction

72.51            Partial breech extraction with forceps to aftercoming head

72.52            Other partial breech extraction

72.53            Total breech extraction with forceps to aftercoming head

72.54            Other total breech extraction

72.6      Forceps application to aftercoming head

Piper forceps operation

Excludes:            partial breech extraction with forceps to aftercoming head (72.51)

total breech extraction with forceps to aftercoming head (72.53)

72.7      Vacuum extraction

Includes:            Malström's extraction

72.71            Vacuum extraction with episiotomy

72.79            Other vacuum extraction

72.8      Other specified instrumental delivery

72.9            Unspecified instrumental delivery

73         Other procedures inducing or assisting delivery

73.0      Artificial rupture of membranes

73.01            Induction of labor by artificial rupture of membranes

Surgical induction NOS

Excludes:            artificial rupture of membranes after onset of labor (73.09)

73.09            Other artificial rupture of membranes

Artificial rupture of membranes at time of delivery

73.1      Other surgical induction of labor

Induction by cervical dilation

Excludes:            injection for abortion (75.0)

insertion of suppository for abortion (96.49)

73.2      Internal and combined version and extraction

73.21            Internal and combined version without extraction

Version NOS

73.22            Internal and combined version with extraction

73.3      Failed forceps

Application of forceps without delivery

Trial forceps

73.4      Medical induction of labor

Excludes:            medication to augment active labor -- omit code

73.5            Manually assisted delivery

73.51            Manual rotation of fetal head

73.59            Other manually assisted delivery

Assisted spontaneous delivery

Crede maneuver

73.6            Episiotomy

Episioproctotomy

Episiotomy with subsequent episiorrhaphy

Excludes:    that with:

high forceps (72.31)

low forceps (72.1)

mid forceps (72.21)

outlet forceps (72.1)

vacuum extraction (72.71)

73.8            Operations on fetus to facilitate delivery

Clavicotomy on fetus

Destruction of fetus

Needling of hydrocephalic head

73.9      Other operations assisting delivery

73.91            External version

73.92            Replacement of prolapsed umbilical cord

73.93            Incision of cervix to assist delivery

Dührssen's incisions

73.94            Pubiotomy to assist delivery

Obstetrical symphysiotomy

73.99            Other

Excludes:            dilation of cervix, obstetrical to induce labor (73.1)

insertion of bag or bougie to induce labor (73.1)

removal of cerclage material (69.96)

74            Cesarean section and removal of fetus

Code also any synchronous:

hysterectomy (68.3-68.4, 68.6, 68.8)

myomectomy (68.29)

sterilization (66.31-66.39, 66.63)

74.0            Classical cesarean section

Transperitoneal classical cesarean section

74.1      Low cervical cesarean section

Lower uterine segment cesarean section

74.2            Extraperitoneal cesarean section

Supravesical cesarean section

74.3            Removal of extratubal ectopic pregnancy

Removal of:

ectopic abdominal pregnancy

fetus from peritoneal or extraperitoneal cavity following uterine or tubal rupture

Excludes:    that by salpingostomy (66.02)

that by salpingotomy (66.01)

that with synchronous salpingectomy (66.62)

74.4            Cesarean section of other specified type

Peritoneal exclusion cesarean section

Transperitoneal cesarean section NOS

Vaginal cesarean section

74.9            Cesarean section of unspecified type

74.91            Hysterotomy to terminate pregnancy

Therapeutic abortion by hysterotomy

74.99            Other cesarean section of unspecified type

Cesarean section NOS

Obstetrical abdominouterotomy

Obstetrical hysterotomy

75         Other obstetric operations

75.0      Intra-amniotic injection for abortion

Injection of:

prostaglandin for induction of abortion

saline for induction of abortion

Termination of pregnancy by intrauterine injection

Excludes:            insertion of prostaglandin suppository for abortion (96.49)

75.1            Diagnostic amniocentesis

75.2            Intrauterine transfusion

Exchange transfusion in utero

Insertion of catheter into abdomen of fetus for transfusion

Code also any hysterotomy approach (68.0)

75.3      Other intrauterine operations on fetus and amnion

Code also any hysterotomy approach (68.0)

75.31            Amnioscopy

Fetoscopy

Laparoamnioscopy

75.32            Fetal EKG (scalp)

75.33            Fetal blood sampling and biopsy

75.34            Other fetal monitoring

Antepartum fetal nonstress test

Fetal monitoring, not otherwise specified

Excludes: fetal pulse oximetry (75.38)

75.35            Other diagnostic procedures on fetus and amnion

Intrauterine pressure determination

Excludes:            amniocentesis (75.1)

diagnostic procedures on gravid uterus and placenta (87.81, 88.46, 88.78, 92.17)

75.36            Correction of fetal defect

75.37            Amnioinfusion

Code also injection of antibiotic (99.21)

75.38            Fetal pulse oximetry

Transcervical fetal oxygen saturation monitoring

Transcervical fetal SpO2 monitoring

75.4      Manual removal of retained placenta

Excludes:            aspiration curettage (69.52)

dilation and curettage (69.02)

75.5      Repair of current obstetric laceration of uterus

75.50            Repair of current obstetric laceration of uterus, not otherwise specified

75.51            Repair of current obstetric laceration of cervix

75.52            Repair of current obstetric laceration of corpus uteri

75.6      Repair of other current obstetric laceration

75.61            Repair of current obstetric laceration of bladder and urethra

75.62            Repair of current obstetric laceration of rectum and sphincter ani

75.69            Repair of other current obstetric laceration

Episioperineorrhaphy

Repair of:

pelvic floor

perineum

vagina

vulva

Secondary repair of episiotomy

Excludes:            repair of routine episiotomy (73.6)

75.7      Manual exploration of uterine cavity, postpartum

75.8            Obstetric tamponade of uterus or vagina

Excludes:            antepartum tamponade (73.1)

75.9      Other obstetric operations

75.91            Evacuation of obstetrical incisional hematoma of perineum

Evacuation of hematoma of:

episiotomy perineorrhaphy

75.92            Evacuation of other hematoma of vulva or vagina

75.93            Surgical correction of inverted uterus

Spintelli operation

Excludes:            vaginal repair of chronic inversion of uterus (69.23)

75.94            Manual replacement of inverted uterus

75.99            Other

14. OPERATIONS ON THE MUSCULOSKELETAL SYSTEM (76-84) back to top

76            Operations on facial bones and joints

Excludes:            accessory sinuses (22.00-22.9)

nasal bones (21.00-21.99)

skull (01.01-02.99)

76.0      Incision of facial bone without division

76.01            Sequestrectomy of facial bone

Removal of necrotic bone chip from facial bone

76.09            Other incision of facial bone

Reopening of osteotomy site of facial bone

Excludes:            osteotomy associated with orthognathic surgery (76.61-76.69)

removal of internal fixation device (76.97)

76.1            Diagnostic procedures on facial bones and joints

76.11            Biopsy of facial bone

76.19            Other diagnostic procedures on facial bones and joints

Excludes:            contrast arthrogram of temporomandibular joint (87.13)

other x-ray (87.11-87.12, 87.14-87.16)

76.2      Local excision or destruction of lesion of facial bone

Excludes:            biopsy of facial bone (76.11)

excision of odontogenic lesion (24.4)

76.3      Partial ostectomy of facial bone

76.31            Partial mandibulectomy

Hemimandibulectomy

Excludes:            that associated with temporomandibular arthroplasty (76.5)

76.39            Partial ostectomy of other facial bone

Hemimaxillectomy (with bone graft or prosthesis)

76.4            Excision and reconstruction of facial bones

76.41            Total mandibulectomy with synchronous reconstruction

76.42            Other total mandibulectomy

76.43            Other reconstruction of mandible

Excludes:            genioplasty (76.67-76.68)

that with synchronous total mandibulectomy (76.41)

76.44            Total ostectomy of other facial bone with synchronous reconstruction

76.45            Other total ostectomy of other facial bone

76.46            Other reconstruction of other facial bone

Excludes:            that with synchronous total ostectomy (76.44)

76.5            Temporomandibular arthroplasty

76.6      Other facial bone repair and orthognathic surgery

Code also any synchronous:

bone graft (76.91)

synthetic implant (76.92)

Excludes:            reconstruction of facial bones (76.41-76.46)

76.61            Closed osteoplasty [osteotomy] of mandibular ramus

Gigli saw osteotomy

76.62            Open osteoplasty [osteotomy] of mandibular ramus

76.63            Osteoplasty [osteotomy] of body of mandible

76.64            Other orthognathic surgery on mandible

Mandibular osteoplasty NOS

Segmental or subapical osteotomy

76.65            Segmental osteoplasty [osteotomy] of maxilla

Maxillary osteoplasty NOS

76.66            Total osteoplasty [osteotomy] of maxilla

76.67            Reduction genioplasty

Reduction mentoplasty

76.68            Augmentation genioplasty

Mentoplasty:

NOS

with graft or implant

76.69            Other facial bone repair

Osteoplasty of facial bone NOS

76.7            Reduction of facial fracture

Includes:            internal fixation

Code also any synchronous:

bone graft (76.91)

synthetic implant (76.92)

Excludes:    that of nasal bones (21.71-21.72)

76.70            Reduction of facial fracture, not otherwise specified

76.71            Closed reduction of malar and zygomatic fracture

76.72            Open reduction of malar and zygomatic fracture

76.73            Closed reduction of maxillary fracture

76.74            Open reduction of maxillary fracture

76.75            Closed reduction of mandibular fracture

76.76            Open reduction of mandibular fracture

76.77            Open reduction of alveolar fracture

Reduction of alveolar fracture with stabilization of teeth

76.78            Other closed reduction of facial fracture

Closed reduction of orbital fracture

Excludes:            nasal bone (21.71)

76.79            Other open reduction of facial fracture

Open reduction of orbit rim or wall

Excludes:            nasal bone (21.72)

76.9      Other operations on facial bones and joints

76.91            Bone graft to facial bone

Autogenous graft to facial bone

Bone bank graft to facial bone

Heterogenous graft to facial bone

76.92            Insertion of synthetic implant in facial bone

Alloplastic implant to facial bone

76.93            Closed reduction of temporomandibular dislocation

76.94            Open reduction of temporomandibular dislocation

76.95            Other manipulation of temporomandibular joint

76.96            Injection of therapeutic substance into temporomandibular joint

76.97            Removal of internal fixation device from facial bone

Excludes:            removal of:

dental wiring (97.33)

external mandibular fixation device NEC (97.36)

76.99            Other

77         Incision, excision, and division of other bones

Excludes:            laminectomy for decompression (03.09)

operations on:

accessory sinuses (22.00-22.9)

ear ossicles (19.0-19.55)

facial bones (76.01-76.99)

joint structures (80.00-81.99)

mastoid (19.9-20.99)

nasal bones (21.00-21.99)

skull (01.01-02.99)

The following fourth-digit subclassification is for use with appropriate categories in section 77 to identify the site. Valid fourth-digit categories are in brackets under each code.

0   unspecified site

1   scapula, clavicle, and thorax [ribs and sternum]

2   humerus

3   radius and ulna

4   carpals and metacarpals

5   femur

6   patella

7    tibia and fibula

8   tarsals and metatarsals

9   other

Pelvic bones

Phalanges (of foot) (of hand)

Vertebrae

77.0            Sequestrectomy

[0-9]

77.1      Other incision of bone without division

[0-9]

Reopening of osteotomy site

Excludes:            aspiration of bone marrow (41.31, 41.91)

removal of internal fixation device (78.60-78.69)

77.2      Wedge osteotomy

[0-9]

Excludes:    that for hallux valgus (77.51)

77.3      Other division of bone

[0-9]

Osteoarthrotomy

Excludes:            clavicotomy of fetus (73.8)

laminotomy or incision of vertebra (03.01-03.09)

pubiotomy to assist delivery (73.94)

sternotomy incidental to thoracic operation -- omit code

77.4      Biopsy of bone

[0-9]

77.5            Excision and repair of bunion and other toe deformities

77.51            Bunionectomy with soft tissue correction and osteotomy of the first metatarsal

77.52            Bunionectomy with soft tissue correction and arthrodesis

77.53            Other bunionectomy with soft tissue correction

77.54            Excision or correction of bunionette

That with osteotomy

77.56            Repair of hammer toe

Fusion of hammer toe

Phalangectomy (partial) of hammer toe

Filleting of hammer toe

77.57            Repair of claw toe

Fusion of claw toe

Phalangectomy (partial) of claw toe

Capsulotomy of claw toe

Tendon lengthening of claw toe

77.58            Other excision, fusion and repair of toes

Cockup toe repair

Overlapping toe repair

That with use of prosthetic materials

77.59            Other bunionectomy

Resection of hallux valgus joint with insertion of prosthesis

77.6      Local excision of lesion or tissue of bone

[0-9]

Excludes:            biopsy of bone (77.40-77.49)

debridement of compound fracture (79.60-79.69)

77.7            Excision of bone for graft

[0-9]

77.8      Other partial ostectomy

[0-9]

Condylectomy

Excludes:            amputation (84.00-84.19, 84.91)

arthrectomy (80.90-80.99)

excision of bone ends associated with:

arthrodesis (81.00-81.29)

arthroplasty (81.31-81.87)

excision of cartilage (80.5-80.6, 80.80-80.99)

excision of head of femur with synchronous replacement (00.70-00.73, 81.51-81.53)

hemilaminectomy (03.01-03.09)

laminectomy (03.01-03.09)

ostectomy for hallux valgus (77.51-77.59)

partial amputation:

finger (84.01)

thumb (84.02)

toe (84.11)

resection of ribs incidental to thoracic operation -- omit code

that incidental to other operation -- omit code

77.9      Total ostectomy

[0-9]

Excludes:            amputation of limb (84.00-84.19, 84.91)

that incidental to other operation -- omit code

78         Other operations on bones, except facial bones

Excludes:            operations on:

accessory sinuses (22.00-22.9)

facial bones (76.01-76.99)

joint structures (80.00-81.99)

nasal bones (21.00-21.99)

skull (01.01-02.99)

The following fourth-digit subclassification is for use with categories in section 78 to identify the site. Valid fourth- digit categories are in [brackets] under each code.

0   unspecified site

1   scapula, clavicle, and thorax [ribs and sternum]

2   humerus

3   radius and ulna

4   carpals and metacarpals

5   femur

6   patella

7    tibia and fibula

8   tarsals and metatarsals

9   other

Pelvic bones

Phalanges (of foot) (of hand)

Vertebrae

78.0      Bone graft

[0-9]

Bone:

bank graft

graft (autogenous) (heterogenous)

That with debridement of bone graft site (removal of sclerosed, fibrous or necrotic bone or tissue)

Transplantation of bone

Code also any excision of bone for graft (77.70-77.79)

Excludes:    that for bone lengthening (78.30-78.39)

78.1            Application of external fixator device

[0-9]

Fixator with insertion of pins/wires/screws into bone

Code also any type of fixator device, if known (84.71-84.73)

Excludes:            other immobilization, pressure, and attention to wound (93.51-93.59)

78.2      Limb shortening procedures

[0,2-5,7-9]

Epiphyseal stapling

Open epiphysiodesis

Percutaneous epiphysiodesis

Resection/osteotomy

78.3      Limb lengthening procedures

[0,2-5,7-9]

Bone graft with or without internal fixation devices or osteotomy

Distraction technique with or without corticotomy/osteotomy

Code also any application of an external fixation device (78.10-78.19)

78.4      Other repair or plastic operations on bone

[0-9]

Other operation on bone NEC

Repair of malunion or nonunion fracture NEC

Excludes:            application of external fixation device (78.10-78.19)

limb lengthening procedures (78.30-78.39)

limb shortening procedures (78.20-78.29)

osteotomy (77.3)

reconstruction of thumb (82.61-82.69)

repair of pectus deformity (34.74)

repair with bone graft (78.00-78.09)

78.5      Internal fixation of bone without fracture reduction

[0-9]

Internal fixation of bone (prophylactic)

Reinsertion of internal fixation device

Revision of displaced or broken fixation device

Excludes:            arthroplasty and arthrodesis (81.00-81.85)

bone graft (78.00-78.09)

limb shortening procedures (78.20-78.29)

that for fracture reduction (79.10-79.19,79.30-79.59)

78.6            Removal of implanted devices from bone

[0-9]

External fixator device (invasive)

Internal fixation device

Removal of bone growth stimulator (invasive)

Removal of internal limb lengthening device

Excludes:            removal of cast, splint, and traction device (Kirschner wire) (Steinmann pin) (97.88)

removal of skull tongs or halo traction device (02.95)

78.7            Osteoclasis

[0-9]

78.8            Diagnostic procedures on bone, not elsewhere classified

[0-9]

 

Excludes:            biopsy of bone (77.40-77.49)

magnetic resonance imaging (88.94)

microscopic examination of specimen from bone (91.51-91.59)

radioisotope scan (92.14)

skeletal x-ray (87.21-87.29, 87.43, 88.21-88.33)

thermography (88.83)

78.9            Insertion of bone growth stimulator

[0-9]

Insertion of:

bone stimulator (electrical) to aid bone healing

osteogenic electrodes for bone growth stimulation

totally implanted device (invasive)

Excludes:            non-invasive (transcutaneous) (surface) stimulator (99.86)

79            Reduction of fracture and dislocation

Includes:            application of cast or splint reduction with insertion of traction device (Kirschner wire) (Steinmann pin)

Code also any:

application of external fixator device (78.10-78.19)

type of fixator device, if known (84.71-84.73)

Excludes:            external fixation alone for immobilization of fracture (93.51-93.56, 93.59)

internal fixation without reduction of fracture (78.50-78.59)

operations on:

facial bones (76.70-76.79)

nasal bones (21.71-21.72)

orbit (76.78-76.79)

skull (02.02)

vertebrae (03.53)

removal of cast or splint (97.88)

replacement of cast or splint (97.11-97.14)

traction alone for reduction of fracture (93.41-93.46)

The following fourth-digit subclassification is for use with appropriate categories in section 79 to identify the site. Valid fourth-digit categories are in [brackets] under each code.

0   unspecified site

1   humerus

2   radius and ulna

Arm NOS

3   carpals and metacarpals

Hand NOS

4   phalanges of hand

5   femur

6    tibia and fibula

Leg NOS

7   tarsals and metatarsals

Foot NOS

8   phalanges of foot

9   other specified bone

79.0      Closed reduction of fracture without internal fixation

[0-9]

Excludes:    that for separation of epiphysis (79.40-79.49)

79.1      Closed reduction of fracture with internal fixation

[0-9]

Excludes:    that for separation of epiphysis (79.40-79.49)

79.2      Open reduction of fracture without internal fixation

[0-9]

Excludes:    that for separation of epiphysis (79.50-79.59)

79.3      Open reduction of fracture with internal fixation

[0-9]

Excludes:    that for separation of epiphysis (79.50-79.59)

79.4      Closed reduction of separated epiphysis

[0-2,5,6,9]

Reduction with or without internal fixation

79.5      Open reduction of separated epiphysis

[0-2,5,6,9]

Reduction with or without internal fixation

79.6            Debridement of open fracture site

[0-9]

Debridement of compound fracture

79.7      Closed reduction of dislocation

Includes:            closed reduction (with external traction device)

Excludes:            closed reduction of dislocation of temporomandibular joint (76.93)

79.70            Closed reduction of dislocation of unspecified site

79.71            Closed reduction of dislocation of shoulder

79.72            Closed reduction of dislocation of elbow

79.73            Closed reduction of dislocation of wrist

79.74            Closed reduction of dislocation of hand and finger

79.75            Closed reduction of dislocation of hip

79.76            Closed reduction of dislocation of knee

79.77            Closed reduction of dislocation of ankle

79.78            Closed reduction of dislocation of foot and toe

79.79            Closed reduction of dislocation of other specified sites

79.8      Open reduction of dislocation

Includes:            open reduction (with internal and external fixation devices)

Excludes:            open reduction of dislocation of temporomandibular joint (76.94)

79.80            Open reduction of dislocation of unspecified site

79.81            Open reduction of dislocation of shoulder

79.82            Open reduction of dislocation of elbow

79.83            Open reduction of dislocation of wrist

79.84            Open reduction of dislocation of hand and finger

79.85            Open reduction of dislocation of hip

79.86            Open reduction of dislocation of knee

79.87            Open reduction of dislocation of ankle

79.88            Open reduction of dislocation of foot and toe

79.89            Open reduction of dislocation of other specified sites

79.9            Unspecified operation on bone injury

[0-9]

80         Incision and excision of joint structures

Includes:            operations on:

capsule of joint

cartilage

condyle

ligament

meniscus

synovial membrane

Excludes:            cartilage of:

ear (18.01-18.9)

nose (21.00-21.99)

temporomandibular joint (76.01-76.99)

The following fourth-digit subclassification is for use with appropriate categories in section 80 to identify the site:

0   unspecified site

1   shoulder

2   elbow

3   wrist

4   hand and finger

5    hip

6   knee

7   ankle

8    foot and toe

9   other specified sites

Spine

80.0            Arthrotomy for removal of prosthesis

[0-9]

Code also any:

insertion of (cement)(joint) spacer (84.56)

removal of (cement)(joint) spacer (84.57)

80.1      Other arthrotomy

[0-9]

Arthrostomy

Excludes:    that for:

arthrography (88.32)

arthroscopy (80.20-80.29)

injection of drug (81.92)

operative approach -- omit code

80.2            Arthroscopy

[0-9]

80.3      Biopsy of joint structure

[0-9]

Aspiration biopsy

80.4      Division of joint capsule, ligament, or cartilage

[0-9]

Goldner clubfoot release

Heyman-Herndon(-Strong) correction of metatarsus varus

Release of:

adherent or constrictive joint capsule

joint

ligament

Excludes:            symphysiotomy to assist delivery (73.94)

that for:

carpal tunnel syndrome (04.43)

tarsal tunnel syndrome (04.44)

80.5            Excision or destruction of intervertebral disc

80.50            Excision or destruction of intervertebral disc, unspecified

Unspecified as to excision or destruction

80.51            Excision of intervertebral disc

Diskectomy

Removal of herniated nucleus pulposus

Level:

cervical

thoracic

lumbar (lumbosacral)

That by laminotomy or hemilaminectomy

That with decompression of spinal nerve root at same level

Requires additional code for any concomitant decompression of spinal nerve root at different level from excision site

Code also any concurrent spinal fusion (81.00 - 81.09)

Excludes:            that for insertion of (non-fusion) spinal disc replacement device (84.60 - 84.69)

  intervertebral chemonucleolysis (80.52)

laminectomy for exploration of intraspinal canal (03.09)

laminotomy for decompression of spinal nerve root only (03.09)

80.52            Intervertebral chemonucleolysis

With aspiration of disc fragments

With diskography

Injection of proteolytic enzyme into intervertebral space (chymopapain)

Excludes:            injection of anestheti substance (03.91)

injection of other substances (03.92)

80.59            Other destruction of intervertebral disc

Destruction NEC

That by laser

80.6            Excision of semilunar cartilage of knee

Excision of meniscus of knee

80.7            Synovectomy

[0-9]

Complete or partial resection of synovial membrane

Excludes:            excision of Baker's cyst (83.39)

80.8      Other local excision or destruction of lesion of joint

[0-9]

80.9      Other excision of joint

[0-9]

Excludes:            cheilectomy of joint (77.80-77.89)

excision of bone ends (77.80-77.89)

81         Repair and plastic operations on joint structures

81.0      Spinal fusion

Includes:            arthrodesis of spine with:

bone graft

internal fixation

Code also any insertion of interbody spinal fusion device (84.51)

any insertion of recombinant bone morphogenetic protein (84.52)

the total number of vertebrae fused (81.62-81.64)

Excludes:correction of pseudarthrosis of spine (81.30- 81.39)

refusion of spine (81.30 - 81.39)

81.00            Spinal fusion, not otherwise specified

81.01            Atlas-axis spinal fusion

Craniocervical fusion by anterior, transoral, or posterior technique

C1-C2 fusion by anterior, transoral, or posterior technique

Occiput C2 fusion by anterior, transoral, or posterior technique

81.02            Other cervical fusion, anterior technique

Arthrodesis of C2 level or below:

anterior (interbody) technique

anterolateral technique

81.03            Other cervical fusion, posterior technique

Arthrodesis of C2 level or below:

posterior (interbody) technique

posterolateral technique

81.04            Dorsal and dorsolumbar fusion, anterior technique

Arthrodesis of thoracic or thoracolumbar region:

anterior (interbody) technique

anterolateral technique

81.05            Dorsal and dorsolumbar fusion, posterior technique

Arthrodesis of thoracic or thoracolumbar region:

posterior (interbody) technique

posterolateral technique

81.06            Lumbar and lumbosacral fusion, anterior technique

Anterior lumbar interbody fusion (ALIF)

Arthrodesis of lumbar or lumbosacral region:

anterior (interbody) technique

anterolateral technique

81.07            Lumbar and lumbosacral fusion, lateral transverse process technique

81.08            Lumbar and lumbosacral fusion, posterior technique

Arthrodesis of lumbar or lumbosacral region:

posterior (interbody) technique

posterolateral technique

Posterior lumbar interbody fusion (PLIF)

Transforaminal lumbar interbody fusion (TLIF)

81.1            Arthrodesis and arthroereisis of foot and ankle

Includes:            arthrodesis of foot and ankle with:

bone graft

external fixation device

81.11            Ankle fusion

Tibiotalar fusion

81.12            Triple arthrodesis

Talus to calcaneus and calcaneus to cuboid and navicular

81.13            Subtalar fusion

Excludes: arthroereisis (81.18)

81.14            Midtarsal fusion

81.15            Tarsometatarsal fusion

81.16            Metatarsophalangeal fusion

81.17            Other fusion of foot

81.18            Subtalar joint arthroereisis

81.2            Arthrodesis of other joint

Includes:            arthrodesis with:

bone graft

external fixation device

excision of bone ends and compression

81.20            Arthrodesis of unspecified joint

81.21            Arthrodesis of hip

81.22            Arthrodesis of knee

81.23            Arthrodesis of shoulder

81.24            Arthrodesis of elbow

81.25            Carporadial fusion

81.26            Metacarpocarpal fusion

81.27            Metacarpophalangeal fusion

81.28            Interphalangeal fusion

81.29            Arthrodesis of other specified joints

81.3            Refusion of spine

Includes:            arthrodesis of spine with:

bone graft

internal fixation

correction of pseudarthrosis of spine

Code also any insertion of interbody spinal fusion device (84.51)

any insertion of recombinant bone morphogenetic protein (84.52)

the total number of vertebrae fused (81.62-81.64)

81.30            Refusion of spine, not otherwise specified

81.31            Refusion of atlas-axis spine

Craniocervical fusion by anterior, transoral, or posterior technique

C1-C2 fusion by anterior, transoral, or posterior technique

Occiput C2 fusion by anterior, transoral, or posterior technique

81.32            Refusion of other cervical spine, anterior technique

Arthrodesis of C2 level or below:

anterior (interbody) technique

anterolateral technique

81.33            Refusion of other cervical spine, posterior technique

Arthrodesis of C2 level or below:

posterior (interbody) technique

posterolateral technique

81.34            Refusion of dorsal and dorsolumbar spine, anterior technique

Arthrodesis of thoracic or thoracolumbar region:

anterior (interbody) technique

anterolateral technique

81.35            Refusion of dorsal and dorsolumbar spine, posterior technique

Arthrodesis of thoracic or thoracolumbar region:

posterior (interbody) technique

posterolateral technique

81.36            Refusion of lumbar and lumbosacral spine, anterior technique

Anterior lumbar interbody fusion (ALIF)

Arthrodesis of lumbar or lumbosacral region:

anterior (interbody) technique

anterolateral technique

81.37            Refusion of lumbar and lumbosacral spine, lateral transverse process technique

81.38            Refusion of lumbar and lumbosacral spine, posterior technique

Arthrodesis of lumbar or lumbosacral region:

posterior (interbody) technique

posterolateral technique

Posterior lumbar interbody fusion (PLIF)

Transforaminal lumbar interbody fusion (TLIF)

81.39            Refusion of spine, not elsewhere classified

81.4      Other repair of joint of lower extremity

Includes:            arthroplasty of lower extremity with:

external traction or fixation

graft of bone (chips) or cartilage

internal fixation device

81.40            Repair of hip, not elsewhere classified

81.42            Five-in-one repair of knee

Medial meniscectomy, medial collateral ligament repair, vastus medialis advancement, semitendinosus advancement, and pes anserinus transfer

81.43            Triad knee repair

Medial meniscectomy with repair of the anterior cruciate ligament and the medial collateral ligament

O'Donoghue procedure

81.44            Patellar stabilization

Roux-Goldthwait operation for recurrent dislocation of patella

81.45            Other repair of the cruciate ligaments

81.46            Other repair of the collateral ligaments

81.47            Other repair of knee

81.49            Other repair of ankle

81.5      Joint replacement of lower extremity

Includes:            arthroplasty of lower extremity with:

external traction or fixation

graft of bone (chips) or cartilage

internal fixation device or prosthesis

removal of cement spacer

81.51            Total hip replacement

Replacement of both femoral head and acetabulum by prosthesis

Total reconstruction of hip

Code also any type of bearing surface, if known (00.74-00.76)

81.52            Partial hip replacement

Bipolar endoprosthesis

Code also any type of bearing surface, if known (00.74 - 00.76)

81.53            Revision of hip replacement, not otherwise specified

Revision of hip replacement, not specified as to components(s) replaced, (acetabular, femoral or both)

Code also any:

removal of (cement)(joint) spacer (84.57)

type of bearing surface, if known (00.74-00.76)

Excludes: revision of hip replacement, components specified (00.70-00.73)

81.54            Total knee replacement

Bicompartmental

Tricompartmental

Unicompartmental (hemijoint)

81.55            Revision of knee replacement,not otherwise specified

Code also any removal of (cement) spacer (84.57)

Excludes:            arthrodesis of knee (81.22)

revision of knee replacement, components specified (00.80-00.84)

81.56            Total ankle replacement

81.57            Replacement of joint of foot and toe

81.59            Revision of joint replacement of lower extremity, not elsewhere classified

81.6      Other procedures on spine

Note:    Number of vertebrae

          The vertebral spine consists of 25 vertebrae in the following order and number:

Cervical: C1 (atlas), C2 (axis), C3, C4, C5, C6, C7

Thoracic or Dorsal: T1, T2, T3, T4, T5, T6, T7, T8, T9, T10, T11, T12

Lumbar and Sacral: L1, L2, L3, L4, L5, S1

 

Coders should report only one code from the series 81.62 or 81.63 or 81.64 to show the total number of vertebrae fused on the patient.

Code also the level and approach of the fusion or refusion (81.00-81.08, 81.30-81.39)

81.62            Fusion or refusion of 2-3 vertebrae

81.63            Fusion or refusion of 4- 8 vertebrae

81.64            Fusion or refusion of 9 or more vertebrae

81.65            Vertebroplasty

Injection of bone void filler (cement) (polymethylmethacrylate) (PMMA) into the diseased or fractured

vertebral body

Excludes: kyphoplasty (81.66)

81.66            Kyphoplasty

Insertion of inflatable balloon, bone tamp, or other device to create a cavity for partial restoration of height of

diseased or fractured vertebral body prior to injection of bone void filler (cement)(polymethylmethacrylate)

PMMA)

Excludes: vertebroplasty (81.65)

81.7            Arthroplasty and repair of hand, fingers and wrist

Includes:            arthroplasty of hand and finger with:

external traction or fixation

graft of bone (chips) or cartilage

internal fixation device or prosthesis

Excludes:            operations on muscle, tendon and fascia of hand (82.01-82.99)

81.71            Arthroplasty of metacarpophalangeal and interphalangeal joint with implant

81.72            Arthroplasty of metacarpophalangeal and interphalangeal joint without implant

81.73            Total wrist replacement

81.74            Arthroplasty of carpocarpal or carpometacarpal joint with implant

81.75            Arthroplasty of carpocarpal or carpometacarpal joint without implant

81.79            Other repair of hand, fingers and wrist

81.8            Arthroplasty and repair of shoulder and elbow

Includes:            arthroplasty of upper limb NEC with:

external traction or fixation

graft of bone (chips) or cartilage

internal fixation device or prosthesis

81.80            Total shoulder replacement

81.81            Partial shoulder replacement

81.82            Repair of recurrent dislocation of shoulder

81.83            Other repair of shoulder

Revision of arthroplasty of shoulder

81.84            Total elbow replacement

81.85            Other repair of elbow

81.9      Other operations on joint structures

81.91            Arthrocentesis

Joint aspiration

Excludes:            that for:

arthrography (88.32)

biopsy of joint structure 80.30-80.39)

injection of drug (81.92)

81.92            Injection of therapeutic substance into joint or ligament

81.93            Suture of capsule or ligament of upper extremity

Excludes:            that associated wit arthroplasty (81.71-81.75, 81.80-81.81, 81.84)

81.94            Suture of capsule or ligament of ankle and foot

Excludes:            that associated wit arthroplasty (81.56-81.59)

81.95            Suture of capsule or ligament of other lower extremity

Excludes:            that associated wit arthroplasty (81.51-81.55, 81.59)

81.96            Other repair of joint

81.97            Revision of joint replacement of upper extremity

Partial

Removal of cement spacer

Total

81.98            Other diagnostic procedures on joint structures

Excludes:            arthroscopy (80.20-80.29)

biopsy of joint structure (80.30-80.39)

microscopic examination of specimen from joint (91.51-91.59)

thermography (88.83)

x-ray (87.21-87.29, 88.21-88.33)

81.99            Other

82            Operations on muscle, tendon, and fascia of hand

Includes:            operations on:

aponeurosis

synovial membrane (tendon sheath)

tendon sheath

82.0      Incision of muscle, tendon, fascia, and bursa of hand

82.01            Exploration of tendon sheath of hand

Incision of tendon sheath of hand

Removal of rice bodies in tendon sheath of hand

Excludes:            division of tendon (82.11)

82.02            Myotomy of hand

Excludes:            myotomy for division (82.19)

82.03            Bursotomy of hand

82.04            Incision and drainage of palmar or thenar space

82.09            Other incision of soft tissue of hand

Excludes:            incision of skin an subcutaneous tissue alone (86.01-86.09)

82.1      Division of muscle, tendon, and fascia of hand

82.11            Tenotomy of hand

Division of tendon of hand

82.12            Fasciotomy of hand

Division of fascia of hand

82.19            Other division of soft tissue of hand

Division of muscle of hand

82.2            Excision of lesion of muscle, tendon, and fascia of hand

82.21            Excision of lesion of tendon sheath of hand

Ganglionectomy of tendon sheath (wrist)

82.22            Excision of lesion of muscle of hand

82.29            Excision of other lesion of soft tissue of hand

Excludes:            excision of lesion of skin and subcutaneous tissue (86.21-86.3)

82.3      Other excision of soft tissue of hand

Code also any skin graft (86.61-86.62, 86.73)

Excludes:            excision of skin and subcutaneous tissue (86.21-86.3)

82.31            Bursectomy of hand

82.32            Excision of tendon of hand for graft

82.33            Other tenonectomy of hand

Tenosynovectomy of hand

Excludes:            excision of lesion of:

tendon (82.29)

sheath (82.21)

82.34            Excision of muscle or fascia of hand for graft

82.35            Other fasciectomy of hand

Release of Dupuytren's contracture

Excludes:            excision of lesion of fascia (82.29)

82.36            Other myectomy of hand

Excludes:            excision of lesion of muscle (82.22)

82.39            Other excision of soft tissue of hand

Excludes:            excision of skin (86.21-86.3)

excision of soft tissue lesion (82.29)

82.4      Suture of muscle, tendon, and fascia of hand

82.41            Suture of tendon sheath of hand

82.42            Delayed suture of flexor tendon of hand

82.43            Delayed suture of other tendon of hand

82.44            Other suture of flexor tendon of hand

Excludes:            delayed suture of flexor tendon of hand (82.42)

82.45            Other suture of other tendon of hand

Excludes:            delayed suture of other tendon of hand (82.43)

82.46            Suture of muscle or fascia of hand

82.5            Transplantation of muscle and tendon of hand

82.51            Advancement of tendon of hand

82.52            Recession of tendon of hand

82.53            Reattachment of tendon of hand

82.54            Reattachment of muscle of hand

82.55            Other change in hand muscle or tendon length

82.56            Other hand tendon transfer or transplantation

Excludes:            pollicization of thumb (82.61)

transfer of finger, except thum (82.81)

82.57            Other hand tendon transposition

82.58            Other hand muscle transfer or transplantation

82.59            Other hand muscle transposition

82.6            Reconstruction of thumb

Includes:            digital transfer to act as thumb

Code also any amputation for digital transfer (84.01, 84.11)

82.61            Pollicization operation carrying over nerves and blood supply

82.69            Other reconstruction of thumb

"Cocked-hat" procedure [skin flap and bone]

Grafts:

bone to thumb skin (pedicle) to thumb

82.7      Plastic operation on hand with graft or implant

82.71            Tendon pulley reconstruction

Reconstruction for opponensplasty

82.72            Plastic operation on hand with graft of muscle or fascia

82.79            Plastic operation on hand with other graft or implant

Tendon graft to hand

82.8      Other plastic operations on hand

82.81            Transfer of finger, except thumb

Excludes:            pollicization of thumb (82.61)

82.82            Repair of cleft hand

82.83            Repair of macrodactyly

82.84            Repair of mallet finger

82.85            Other tenodesis of hand

Tendon fixation of hand NOS

82.86            Other tenoplasty of hand

Myotenoplasty of hand

82.89            Other plastic operations on hand

Plication of fascia

Repair of fascial hernia

Excludes:            that with graft or implant (82.71-82.79)

82.9      Other operations on muscle, tendon, and fascia of hand

Excludes:            diagnostic procedures on soft tissue of hand (83.21-83.29)

82.91            Lysis of adhesions of hand

Freeing of adhesions of fascia, muscle, and tendon of hand

Excludes:            decompression of carpal tunnel (04.43)

that by stretching o manipulation only (93.26)

82.92            Aspiration of bursa of hand

82.93            Aspiration of other soft tissue of hand

Excludes:            skin and subcutaneous tissue (86.01)

82.94            Injection of therapeutic substance into bursa of hand

82.95            Injection of therapeutic substance into tendon of hand

82.96            Other injection of locally-acting therapeutic substance into soft tissue of hand

Excludes:            subcutaneous or intramuscular injection (99.11-99.29)

82.99            Other operations on muscle, tendon, and fascia of hand

83            Operations on muscle, tendon, fascia, and bursa, except hand

Includes:            operations on:

aponeurosis

synovial membrane of bursa and tendon sheaths

tendon sheaths

Excludes:            diaphragm (34.81-34.89)

hand (82.01-82.99)

muscles of eye (15.01-15.9)

83.0      Incision of muscle, tendon, fascia, and bursa

83.01            Exploration of tendon sheath

Incision of tendon sheath

Removal of rice bodies from tendon sheath

83.02            Myotomy

Excludes:            cricopharyngeal myotomy (29.31)

83.03            Bursotomy

Removal of calcareous deposit of bursa

Excludes:            aspiration of burs (percutaneous) (83.94)

83.09            Other incision of soft tissue

Incision of fascia

Excludes:            incision of skin an subcutaneous tissue alone (86.01-86.09)

83.1      Division of muscle, tendon, and fascia

83.11            Achillotenotomy

83.12            Adductor tenotomy of hip

83.13            Other tenotomy

Aponeurotomy

Division of tendon

Tendon release

Tendon transection

Tenotomy for thoracic outlet decompression

83.14            Fasciotomy

Division of fascia

Division of iliotibial band

Fascia stripping

Release of Volkmann's contracture by fasciotomy

83.19            Other division of soft tissue

Division of muscle

Muscle release

Myotomy for thoracic outlet decompression

Myotomy with division

Scalenotomy

Transection of muscle

83.2            Diagnostic procedures on muscle, tendon, fascia, and bursa, including that of hand

83.21            Biopsy of soft tissue

Excludes:            biopsy of chest wall (34.23)

biopsy of skin and subcutaneous tissue (86.11)

83.29            Other diagnostic procedures on muscle, tendon, fascia, and bursa, including that of hand

Excludes:            microscopic examination of specimen (91.51-91.59)

soft tissue x-ray (87.09, 87.38-87.39, 88.09, 88.35, 88.37)

thermography of muscle (88.84)

83.3            Excision of lesion of muscle, tendon, fascia, and bursa

Excludes:            biopsy of soft tissue (83.21)

83.31            Excision of lesion of tendon sheath

Excision of ganglion of tendon sheath, except of hand

83.32            Excision of lesion of muscle

Excision of:

heterotopic bone

muscle scar for release of Volkmann's contracture

myositis ossificans

83.39            Excision of lesion of other soft tissue

Excision of Baker's cyst

Excludes:            bursectomy (83.5)

excision of lesion of skin and subcutaneous tissue (86.3)

synovectomy (80.70-80.79)

83.4      Other excision of muscle, tendon, and fascia

83.41            Excision of tendon for graft

83.42            Other tenonectomy

Excision of:

aponeurosis

tendon sheath

Tenosynovectomy

83.43            Excision of muscle or fascia for graft

83.44            Other fasciectomy

83.45            Other myectomy

Debridement of muscle NOS

Scalenectomy

83.49            Other excision of soft tissue

83.5            Bursectomy

83.6      Suture of muscle, tendon, and fascia

83.61            Suture of tendon sheath

83.62            Delayed suture of tendon

83.63            Rotator cuff repair

83.64            Other suture of tendon

Achillorrhaphy

Aponeurorrhaphy

Excludes:            delayed suture of tendon (83.62)

83.65            Other suture of muscle or fascia

Repair of diastasis recti

83.7            Reconstruction of muscle and tendon

Excludes:            reconstruction of muscle and tendon associated with arthroplasty

83.71            Advancement of tendon

83.72            Recession of tendon

83.73            Reattachment of tendon

83.74            Reattachment of muscle

83.75            Tendon transfer or transplantation

83.76            Other tendon transposition

83.77            Muscle transfer or transplantation

Release of Volkmann's contracture by muscle transplantation

83.79            Other muscle transposition

83.8      Other plastic operations on muscle, tendon, and fascia

Excludes:            plastic operations on muscle, tendon, and fascia associated with arthroplasty

83.81            Tendon graft

83.82            Graft of muscle or fascia

83.83            Tendon pulley reconstruction

83.84            Release of clubfoot, not elsewhere classified

Evans operation on clubfoot

83.85            Other change in muscle or tendon length

Hamstring lengthening

Heel cord shortening

Plastic achillotenotomy

Tendon plication

83.86            Quadricepsplasty

83.87            Other plastic operations on muscle

Musculoplasty

Myoplasty

83.88            Other plastic operations on tendon

Myotenoplasty

Tendon fixation

Tenodesis

Tenoplasty

83.89            Other plastic operations on fascia

Fascia lengthening

Fascioplasty

Plication of fascia

83.9      Other operations on muscle, tendon, fascia, and bursa

Excludes:            nonoperative:

manipulation (93.25-93.29)

stretching (93.27-93.29)

83.91            Lysis of adhesions of muscle, tendon, fascia, and bursa

Excludes:            that for tarsal tunnel syndrome (04.44)

83.92            Insertion or replacement of skeletal muscle stimulator

Implantation, insertion, placement, or replacement of skeletal muscle:

electrodes

stimulator

83.93            Removal of skeletal muscle stimulator

83.94            Aspiration of bursa

83.95            Aspiration of other soft tissue

Excludes:            that of skin and subcutaneous tissue (86.01)

83.96            Injection of therapeutic substance into bursa

83.97            Injection of therapeutic substance into tendon

83.98            Injection of locally-acting therapeutic substance into other soft tissue

Excludes:            subcutaneous or intramuscular injection (99.11-99.29)

83.99            Other operations on muscle, tendon, fascia, and bursa

Suture of bursa

84         Other procedures on musculoskeletal system

84.0            Amputation of upper limb

Excludes:            revision of amputation stump (84.3)

84.00            Upper limb amputation, not otherwise specified

Closed flap amputation of upper limb NOS

Kineplastic amputation of upper limb NOS

Open or guillotine amputation of upper limb NOS

Revision of current traumatic amputation of upper limb NOS

84.01            Amputation and disarticulation of finger

Excludes:            ligation of supernumerary finge (86.26)

84.02            Amputation and disarticulation of thumb

84.03            Amputation through hand

Amputation through carpals

84.04            Disarticulation of wrist

84.05            Amputation through forearm

Forearm amputation

84.06            Disarticulation of elbow

84.07            Amputation through humerus

Upper arm amputation

84.08            Disarticulation of shoulder

84.09            Interthoracoscapular amputation

Forequarter amputation

84.1            Amputation of lower limb

Excludes:            revision of amputation stump (84.3)

84.10            Lower limb amputation, not otherwise specified

Closed flap amputation of lower limb NOS

Kineplastic amputation of lower limb NOS

Open or guillotine amputation of lower limb NOS

Revision of current traumatic amputation of lower limb NOS

84.11            Amputation of toe

Amputation through metatarsophalangeal joint

Disarticulation of toe

Metatarsal head amputation

Ray amputation of foot (disarticulation of the metatarsal head of the toe extending across the forefoot just proximal to the metatarsophalangeal crease)

Excludes:            ligation of supernumerary toe (86.26)

84.12            Amputation through foot

Amputation of forefoot

Amputation through middle of foot

Chopart's amputation

Midtarsal amputation

Transmetatarsal amputation (amputation of the forefoot, including all the toes)

Excludes:            Ray amputation of foot (84.11)

84.13            Disarticulation of ankle

84.14            Amputation of ankle through malleoli of tibia and fibula

84.15            Other amputation below knee

Amputation of leg through tibia and fibula NOS

84.16            Disarticulation of knee

Batch, Spitler, and McFaddin amputation

Mazet amputation

S.P. Roger's amputation

84.17            Amputation above knee

Amputation of leg through femur

Amputation of thigh

Conversion of below-knee amputation into above-knee amputation

Supracondylar above-knee amputation

84.18            Disarticulation of hip

84.19            Abdominopelvic amputation

Hemipelvectomy

Hindquarter amputation

84.2            Reattachment of extremity

84.21            Thumb reattachment

84.22            Finger reattachment

84.23            Forearm, wrist, or hand reattachment

84.24            Upper arm reattachment

Reattachment of arm NOS

84.25            Toe reattachment

84.26            Foot reattachment

84.27            Lower leg or ankle reattachment

Reattachment of leg NOS

84.28            Thigh reattachment

84.29            Other reattachment

84.3      Revision of amputation stump

Reamputation of stump

Secondary closure of stump

Trimming of stump

Excludes:            revision of current traumatic amputation [revision by further amputation of current injury] (84.00-84.19, 84.91)

84.4            Implantation or fitting of prosthetic limb device

84.40            Implantation or fitting of prosthetic limb device, not otherwise specified

84.41            Fitting of prosthesis of upper arm and shoulder

84.42            Fitting of prosthesis of lower arm and hand

84.43            Fitting of prosthesis of arm, not otherwise specified

84.44            Implantation of prosthetic device of arm

84.45            Fitting of prosthesis above knee

84.46            Fitting of prosthesis below knee

84.47            Fitting of prosthesis of leg, not otherwise specified

84.48            Implantation of prosthetic device of leg

84.5            Implantation of other musculoskeletal devices and substances

Excludes: insertion of (non-fusion) spinal disc replacement device (84.60 - 84.69)

84.51            Insertion of interbody spinal fusion device

Insertion of:cages (carbon, ceramic, metal, plastic or titanium)

           interbody fusion cage

           synthetic cages or spacers

           threaded bone dowels

Code also refusion of spine (81.30 - 81.39)

Code also spinal fusion (81.00 - 81.08)

84.52            Insertion of recombinant bone morphogenetic protein

rhBMP

That via collagen sponge, coral, ceramic and other carriers

Code also primary procedure performed:

           fracture repair (79.00-79.99)

           spinal fusion (81.00 - 81.08)

           spinal refusion (81.30 - 81.39)

84.53            Implantation of internal limb lengthening device with kinetic distraction

Code also limb lengthening procedure (78.30 - 78.39)

84.54            Implantation of other internal limb lengthening device

Implantation of internal limb lengthening device, Not Otherwise Specified (NOS)

Code also limb lengthening procedure (78.30 - 78.39)

84.55            Insertion of bone void filler

Insertion of:

acrylic cement (PMMA)

bone void cement

calcium based bone void filler

polymethylmethacrylate (PMMA)

Excludes:             that with kyphoplasty (81.66)

   that with vertebroplasty (81.65)

84.56            Insertion of (cement) spacer

Insertion of joint spacer

84.57            Removal of (cement) spacer

Removal of joint spacer

84.58            Implantation of interspinous process decompression device

Excludes: fusion of spine (81.00-81.08, 81.30-81.39)

84.59            Insertion of other spinal devices

84.6            Replacement of spinal disc

Includes: non-fusion arthroplasty of the spine with insertion of artificial disc prosthesis

84.60            Insertion of spinal disc prosthesis, not otherwise specified

Replacement of spinal disc, NOS

Includes: diskectomy (discectomy)

84.61            Insertion of partial spinal disc prosthesis, cervical

Nuclear replacement device, cervical

Partial artificial disc prosthesis (flexible), cervical

Replacement of nuclear disc (nucleus pulposus), cervical

Includes: diskectomy (discectomy)

84.62            Insertion of total spinal disc prosthesis, cervical

Replacement of cervical spinal disc, NOS

Replacement of total spinal disc, cervical

Total artificial disc prosthesis (flexible), cervical

Includes: diskectomy (discectomy)

84.63            Insertion of spinal disc prosthesis, thoracic

Artificial disc prosthesis (flexible), thoracic

Replacement of thoracic spinal disc, partial or total

Includes: diskectomy (discectomy)

84.64            Insertion of partial spinal disc prosthesis, lumbosacral

Nuclear replacement device, lumbar

Partial artificial disc prosthesis (flexible), lumbar

Replacement of nuclear disc (nucleus pulposus), lumbar

Includes: diskectomy (discectomy)

84.65            Insertion of total spinal disc prosthesis, lumbosacral

Replacement of lumbar spinal disc, NOS

Replacement of total spinal disc, lumbar

Total artificial disc prosthesis (flexible), lumbar

Includes: diskectomy (discectomy)

84.66            Revision or replacement of artificial spinal disc prosthesis, cervical

Removal of (partial) (total) spinal disc prosthesis with synchronous insertion of new (partial) (total) spinal

disc prosthesis, cervical

Repair of previously inserted spinal disc prosthesis, cervical

84.67            Revision or replacement of artificial spinal disc prosthesis, thoracic

Removal of (partial) (total) spinal disc prosthesis with synchronous insertion of new (partial) (total) spinal

disc prosthesis, thoracic

Repair of previously inserted spinal disc prosthesis, thoracic

84.68            Revision or replacement of artificial spinal disc prosthesis, lumbosacral

Removal of (partial) (total) spinal disc prosthesis with synchronous insertion of new (partial)(total) spinal

disc prosthesis, lumbosacral

Repair of previously inserted spinal disc prosthesis, lumbosacral

84.69            Revision or replacement of artificial spinal disc prosthesis, not otherwise specified

Removal of (partial) (total) spinal disc prosthesis with synchronous insertion of new (partial)(total) spinal

disc prosthesis

Repair of previously inserted spinal disc prosthesis

84.7      Adjunct codes for external fixator devices

Code also any primary procedure performed:

application of external fixator device (78.10, 78.12-78.13, 78.15, 78.17- 78.19)

reduction of fracture and dislocation (79.00-79.89)

84.71            Application of external fixator device, monoplanar system

Excludes: other hybrid device or system (84.73)

ring device or system (84.72)

84.72            Application of external fixator device, ring system

Ilizarov type

Sheffield type

Excludes:            monoplanar device or system (84.71)

other hybrid device or system (84.73)

84.73            Application of hybrid external fixator device

Hybrid system using both ring and monoplanar devices

Excludes: monoplanar device or system, when used alone (84.71)

ring device or system, when used alone (84.72)

84.9      Other operations on musculoskeletal system

Excludes:            nonoperative manipulation (93.25-93.29)

84.91            Amputation, not otherwise specified

84.92            Separation of equal conjoined twins

84.93            Separation of unequal conjoined twins

Separation of conjoined twins NOS

84.99            Other

15. OPERATIONS ON THE INTEGUMENTARY SYSTEM (85-86) back to top

85            Operations on the breast

Includes:            operations on the skin and subcutaneous tissue of:

breast female or male

previous mastectomy site female or male

revision of previous mastectomy site

85.0            Mastotomy

Incision of breast (skin)

Mammotomy

Excludes:            aspiration of breast (85.91)

removal of implant (85.94)

85.1            Diagnostic procedures on breast

85.11            Closed [percutaneous] [needle] biopsy of breast

85.12            Open biopsy of breast

85.19            Other diagnostic procedures on breast

Excludes:            mammary ductogram (87.35)

mammography NEC (87.37)

manual examination (89.36)

microscopic examination of specimen (91.61-91.69)

thermography (88.85)

ultrasonography (88.73)

xerography (87.36)

85.2            Excision or destruction of breast tissue

Excludes:            mastectomy (85.41-85.48)

reduction mammoplasty (85.31-85.32)

85.20            Excision or destruction of breast tissue, not otherwise specified

85.21            Local excision of lesion of breast

Lumpectomy

Removal of area of fibrosis from breast

Excludes:            biopsy of breast (85.11-85.12)

85.22            Resection of quadrant of breast

85.23            Subtotal mastectomy

Excludes:            quadrant resection (85.22)

85.24            Excision of ectopic breast tissue

Excision of accessory nipple

85.25            Excision of nipple

Excludes:            excision of accessory nipple (85.24)

85.3            Reduction mammoplasty and subcutaneous mammectomy

85.31            Unilateral reduction mammoplasty

Unilateral:

amputative mammoplasty

size reduction mammoplasty

85.32            Bilateral reduction mammoplasty

Amputative mammoplasty

Reduction mammoplasty (for gynecomastia)

85.33            Unilateral subcutaneous mammectomy with synchronous implant

Excludes:            that without synchronous implan (85.34)

85.34            Other unilateral subcutaneous mammectomy

Removal of breast tissue with preservation of skin and nipple

Subcutaneous mammectomy NOS

85.35            Bilateral subcutaneous mammectomy with synchronous implant

Excludes:            that without synchronous implan (85.36)

85.36            Other bilateral subcutaneous mammectomy

85.4            Mastectomy

85.41            Unilateral simple mastectomy

Mastectomy:

NOS

complete

85.42            Bilateral simple mastectomy

Bilateral complete mastectomy

85.43            Unilateral extended simple mastectomy

Extended simple mastectomy NOS

Modified radical mastectomy

Simple mastectomy with excision of regional lymph nodes

85.44            Bilateral extended simple mastectomy

85.45            Unilateral radical mastectomy

Excision of breast, pectoral muscles, and regional lymph nodes [axillary, clavicular, supraclavicular]

Radical mastectomy NOS

85.46            Bilateral radical mastectomy

85.47            Unilateral extended radical mastectomy

Excision of breast, muscles, and lymph nodes [axillary, clavicular, supraclavicular, internal mammary, and mediastinal]

Extended radical mastectomy NOS

85.48            Bilateral extended radical mastectomy

85.5            Augmentation mammoplasty

Excludes:    that associated with subcutaneous mammectomy (85.33, 85.35)

85.50            Augmentation mammoplasty, not otherwise specified

85.51            Unilateral injection into breast for augmentation

85.52            Bilateral injection into breast for augmentation

Injection into breast for augmentation NOS

85.53            Unilateral breast implant

85.54            Bilateral breast implant

Breast implant NOS

85.6            Mastopexy

85.7      Total reconstruction of breast

85.8      Other repair and plastic operations on breast

Excludes:    that for:

augmentation (85.50-85.54)

reconstruction (85.7)

reduction (85.31-85.32)

85.81            Suture of laceration of breast

85.82            Split-thickness graft to breast

85.83            Full-thickness graft to breast

85.84            Pedicle graft to breast

85.85            Muscle flap graft to breast

85.86            Transposition of nipple

85.87            Other repair or reconstruction of nipple

85.89            Other mammoplasty

85.9      Other operations on the breast

85.91            Aspiration of breast

Excludes:            percutaneous biopsy of breast (85.11)

85.92            Injection of therapeutic agent into breast

Excludes:            that for augmentation of breast (85.51-85.52)

85.93            Revision of implant of breast

85.94            Removal of implant of breast

85.95            Insertion of breast tissue expander

Insertion (soft tissue) of tissue expander (one or more) under muscle or platysma to develop skin flaps for donor use

85.96            Removal of breast tissue expander

85.99            Other

86            Operations on skin and subcutaneous tissue

Includes:            operations on:

hair follicles

male perineum

nails

sebaceous glands

subcutaneous fat pads

sudoriferous glands

superficial fossae

Excludes:            those on skin of:

anus (49.01-49.99)

breast (mastectomy site) (85.0-85.99)

ear (18.01-18.9)

eyebrow (08.01-08.99)

eyelid (08.01-08.99)

female perineum (71.01-71.9)

lips (27.0-27.99)

nose (21.00-21.99)

penis (64.0-64.99)

scrotum (61.0-61.99)

vulva (71.01-71.9)

86.0      Incision of skin and subcutaneous tissue

86.01            Aspiration of skin and subcutaneous tissue

Aspiration of:

abscess of nail, skin, or subcutaneous tissue

hematoma of nail, skin, or subcutaneous tissue

seroma of nail, skin, or subcutaneous tissue

86.02            Injection or tattooing of skin lesion or defect

Injection of filling material

Insertion of filling material

Pigmenting of skin of filling material

86.03            Incision of pilonidal sinus or cyst

Excludes:            marsupialization (86.21)

86.04            Other incision with drainage of skin and subcutaneous tissue

Excludes:            drainage of:

fascial compartments of face and mouth (27.0)

palmar or thenar spac 82.04)

pilonidal sinus or cys 86.03)

86.05            Incision with removal of foreign body or device from skin and subcutaneous tissue

Removal of loop recorder

Removal of neurostimulator pulse generator (single array, dual array)

Removal of tissue expander(s) from skin or soft tissue other than breast tissue

Excludes:            removal of foreign body without incision (98.20-98.29)

86.06            Insertion of totally implantable infusion pump

Code also any associated catheterization

Excludes:            insertion of totally implantable vascular access device (86.07)

86.07            Insertion of totally implantable vascular access device [VAD]

Totally implanted port

Excludes:            insertion of totally implantable infusion pump (86.06)

86.09            Other incision of skin and subcutaneous tissue

Creation of thalamic stimulator pulse generator pocket, new site

Escharotomy

Exploration:

sinus tract, skin

superficial fossa

Relocation of subcutaneous device pocket NEC

Reopening subcutaneous pocket for device revision without replacement

Undercutting of hair follicle

Excludes:            creation of loop recorder pocket, new site and insertion/relocation of device (37.79)

creation of pocket for implantable, patient-activated cardiac event recorder and insertion/relocation of device (37.79)

removal of catheter from cranial cavity (01.27)

that of:

cardiac pacemaker pocket, new site (37.79)

fascial compartments of face and mouth (27.0)

86.1            Diagnostic procedures on skin and subcutaneous tissue

86.11            Biopsy of skin and subcutaneous tissue

86.19            Other diagnostic procedures on skin and subcutaneous tissue

Excludes:            microscopic examination of specimen from skin and subcutaneous tissue (91.61-91.79)

86.2            Excision or destruction of lesion or tissue of skin and subcutaneous tissue

86.21            Excision of pilonidal cyst or sinus

Marsupialization of cyst

Excludes:            incision of pilonidal cyst or sinus (86.03)

86.22            Excisional debridement of wound, infection, or burn

Removal by excision of:

devitalized tissue

necrosis

slough

Excludes:            debridement of:

abdominal wall (wound) (54.3)

bone (77.60-77.69)

muscle (83.45)

of hand (82.36)

nail (bed) (fold) (86.27)

nonexcisional debridement of wound, infection, or burn (86.28)

open fracture site (79.60-79.69)

pedicle or flap graft (86.75)

86.23            Removal of nail, nail bed, or nail fold

86.24            Chemosurgery of skin

Chemical peel of skin

86.25            Dermabrasion

That with laser

Excludes:            dermabrasion of wound to remove embedded debris (86.28)

86.26            Ligation of dermal appendage

Excludes:            excision of preauricula appendage (18.29)

86.27            Debridement of nail, nail bed, or nail fold

Removal of:

necrosis

slough

Excludes:            removal of nail, nail bed, or nail fold (86.23)

86.28            Nonexcisional debridement of wound, infection or burn

Debridement NOS

Maggot therapy

Removal of devitalized tissue, necrosis and slough by such methods as:

brushing

irrigation (under pressure)

scrubbing

washing

86.3      Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue

Destruction of skin by:

cauterization cryosurgery

fulguration

laser beam

That with Z-plasty

Excludes:            adipectomy (86.83)

biopsy of skin (86.11)

wide or radical excision of skin (86.4)

Z-plasty without excision (86.84)

86.4      Radical excision of skin lesion

Wide excision of skin lesion involving underlying or adjacent structure

Code also any lymph node dissection (40.3-40.5)

86.5      Suture or other closure of skin and subcutaneous tissue

86.51            Replantation of scalp

86.59            Closure of skin and subcutaneous tissue of other sites

Adhesives (surgical) (tissue)

Staples

Sutures

Excludes:                        application of adhesive strips (butterfly) - omit code

86.6      Free skin graft

Includes:            excision of skin for autogenous graft

Excludes:            construction or reconstruction of:

penis (64.43-64.44)

trachea (31.75)

vagina (70.61-70.62)

86.60            Free skin graft, not otherwise specified

86.61            Full-thickness skin graft to hand

Excludes:            heterograft (86.65)

homograft (86.66)

86.62            Other skin graft to hand

Excludes:            heterograft (86.65)

homograft (86.66)

86.63            Full-thickness skin graft to other sites

Excludes:            heterograft (86.65)

homograft (86.66)

86.64            Hair transplant

Excludes:            hair follicle transplant to eyebrow or eyelash (08.63)

86.65            Heterograft to skin

Pigskin graft

Porcine graft

Excludes: application of dressing only (93.57)

86.66            Homograft to skin

Graft to skin of:

amnionic membrane from donor skin from donor

86.67    Dermal regenerative graft

Artificial skin, NOS

Creation of "neodermis"

Decellularized allodermis

Integumentary matrix implants

Prosthetic implant of dermal layer of skin

Regenerate dermal layer of skin

Excludes:            heterograft to skin (86.65)

homograft to skin (86.66)

86.69    Other skin graft to other sites

Excludes:            heterograft (86.65)

homograft (86.66)

86.7      Pedicle grafts or flaps

Excludes:            construction or reconstruction of:

penis (64.43-64.44)

trachea (31.75)

vagina (70.61-70.62)

86.70            Pedicle or flap graft, not otherwise specified

86.71            Cutting and preparation of pedicle grafts or flaps

Elevation of pedicle from its bed

Flap design and raising

Partial cutting of pedicle or tube

Pedicle delay

Excludes:            pollicization or digita transfer (82.61, 82.81)

revision of pedicle (86.75)

86.72            Advancement of pedicle graft

86.73            Attachment of pedicle or flap graft to hand

Excludes:            pollicization or digita transfer (82.61, 82.81)

86.74            Attachment of pedicle or flap graft to other sites

Attachment by:

advanced flap

double pedicled flap

pedicle graft

rotating flap

sliding flap

tube graft

86.75            Revision of pedicle or flap graft

Debridement of pedicle or flap graft

Defatting of pedicle or flap graft

86.8      Other repair and reconstruction of skin and subcutaneous tissue

86.81            Repair for facial weakness

86.82            Facial rhytidectomy

Face lift

Excludes:            rhytidectomy of eyelid (08.86-08.87)

86.83            Size reduction plastic operation

Liposuction

Reduction of adipose tissue of:

abdominal wall (pendulous)

arms (batwing)

buttock

thighs (trochanteric lipomatosis)

Excludes:            breast (85.31-85.32)

86.84            Relaxation of scar or web contracture of skin

Z-plasty of skin

Excludes:            Z-plasty with excision of lesio (86.3)

86.85            Correction of syndactyly

86.86            Onychoplasty

86.89            Other repair and reconstruction of skin and subcutaneous tissue

Excludes:            mentoplasty (76.67-76.68)

86.9      Other operations on skin and subcutaneous tissue

86.91            Excision of skin for graft

Excision of skin with closure of donor site

Excludes:            that with graft at sam operative episode (86.60- 86.69)

86.92            Electrolysis and other epilation of skin

Excludes:            epilation of eyelid (08.91-08.93)

86.93            Insertion of tissue expander

Insertion (subcutaneous) (soft tissue) of expander(one or more) in scalp (subgaleal space), face, neck, trunk except breast, and upper and lower extremities for development of skin flaps for donor use

Excludes:            flap graft preparation (86.71)

tissue expander, breast (85.95)

86.94            Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable

Pulse generator (single array, single channel) for intracranial, spinal, and peripheral neurostimulator

Code also any associated lead implantation (02.93,03.93,04.92)

Excludes: insertion or replacement of single array rechargeable neurostimulator pulse generator (86.97)

86.95            Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable

Pulse generator (dual array, dual channel) for intracranial, spinal, and peripheral neurostimulator

Code also any associated lead implantation (02.93,03.93,04.92)

Excludes: insertion or replacement of dual array rechargeable neurostimulator pulse generator (86.98)

86.96            Insertion or replacement of other neurostimulator pulse generator

Code also any associated lead implantation (02.93,03.93,04.92)

Excludes: insertion of dual array neurostimulator pulse generator (86.95, 86.98)

insertion of single array neurostimulator pulse generator (86.94, 86.97)

86.97            Insertion or replacement of single array rechargeable neurostimulator pulse generator

Rechargeable pulse generator (single array, single channel) for intracranial, spinal, and peripheral neurostimulator

Code also any associated lead implantation (02.93,03.93,04.92)

86.98            Insertion or replacement of dual array rechargeable neurostimulator pulse generator

Rechargeable pulse generator (dual array, dual channel) for intracranial, spinal, and peripheral neurostimulator

Code also any associated lead implantation (02.93,03.93,04.92)

86.99            Other

Excludes:            removal of sutures from:

abdomen (97.83)

head and neck (97.38)

thorax (97.43)

trunk NEC (97.84)

wound catheter:

irrigation (96.58)

replacement (97.15)

16. MISCELLANEOUS DIAGNOSTIC AND THERAPEUTIC PROCEDURES (87-99) back to top

87            Diagnostic Radiology

87.0      Soft tissue x-ray of face, head, and neck

Excludes:            angiography (88.40-88.68)

87.01            Pneumoencephalogram

87.02            Other contrast radiogram of brain and skull

Pneumocisternogram

Pneumoventriculogram

Posterior fossa myelogram

87.03            Computerized axial tomography of head

C.A.T. scan of head

87.04            Other tomography of head

87.05            Contrast dacryocystogram

87.06            Contrast radiogram of nasopharynx

87.07            Contrast laryngogram

87.08            Cervical lymphangiogram

87.09            Other soft tissue x-ray of face, head, and neck

Noncontrast x-ray of:

adenoid

larynx

nasolacrimal duct

nasopharynx

salivary gland

thyroid region

uvula

Excludes:            x-ray study of eye (95.14)

87.1      Other x-ray of face, head, and neck

Excludes:            angiography (88.40-88.68)

87.11            Full-mouth x-ray of teeth

87.12            Other dental x-ray

Orthodontic cephalogram or cephalometrics

Panorex examination of mandible

Root canal x-ray

87.13            Temporomandibular contrast arthrogram

87.14            Contrast radiogram of orbit

87.15            Contrast radiogram of sinus

87.16            Other x-ray of facial bones

X-ray of:

frontal area

mandible

maxilla

nasal sinuses

nose

orbit

supraorbital area

symphysis menti

zygomaticomaxillary complex

87.17            Other x-ray of skull

Lateral projection of skull

Sagittal projection

Tangential projection

87.2      X-ray of spine

87.21            Contrast myelogram

87.22            Other x-ray of cervical spine

87.23            Other x-ray of thoracic spine

87.24            Other x-ray of lumbosacral spine

Sacrococcygeal x-ray

87.29            Other x-ray of spine

Spinal x-ray NOS

87.3      Soft tissue x-ray of thorax

Excludes:            angiocardiography (88.50-88.58)

angiography (88.40-88.68)

87.31            Endotracheal bronchogram

87.32            Other contrast bronchogram

Transcricoid bronchogram

87.33            Mediastinal pneumogram

87.34            Intrathoracic lymphangiogram

87.35            Contrast radiogram of mammary ducts

87.36            Xerography of breast

87.37            Other mammography

87.38            Sinogram of chest wall

Fistulogram of chest wall

87.39            Other soft tissue x-ray of chest wall

87.4      Other x-ray of thorax

Excludes:            angiocardiography (88.50-88.58)

angiography (88.40-88.68)

87.41            Computerized axial tomography of thorax

C.A.T. scan of thorax

Crystal linea scan of x-ray beam of thorax

Electronic substraction of thorax

Photoelectric response of thorax

Tomography with use of computer, x-rays, and camera of thorax

87.42            Other tomography of thorax

Cardiac tomogram

87.43            X-ray of ribs, sternum, and clavicle

Examination for:

cervical rib

fracture

87.44            Routine chest x-ray, so described

X-ray of chest NOS

87.49            Other chest x-ray

X-ray of:

bronchus NOS

diaphragm NOS

heart NOS

lung NOS

mediastinum NOS

trachea NOS

87.5      Biliary tract x-ray

87.51            Percutaneous hepatic cholangiogram

87.52            Intravenous cholangiogram

87.53            Intraoperative cholangiogram

87.54            Other cholangiogram

87.59            Other biliary tract x-ray

Cholecystogram

87.6      Other x-ray of digestive system

87.61            Barium swallow

87.62            Upper GI series

87.63            Small bowel series

87.64            Lower GI series

87.65            Other x-ray of intestine

87.66            Contrast pancreatogram

87.69            Other digestive tract x-ray

87.7      X-ray of urinary system

Excludes:            angiography of renal vessels (88.45, 88.65)

87.71            Computerized axial tomography of kidney

C.A.T. scan of kidney

87.72            Other nephrotomogram

87.73            Intravenous pyelogram

Diuretic infusion pyelogram

87.74            Retrograde pyelogram

87.75            Percutaneous pyelogram

87.76            Retrograde cystourethrogram

87.77            Other cystogram

87.78            Ileal conduitogram

87.79            Other x-ray of the urinary system

KUB x-ray

87.8      X-ray of female genital organs

87.81            X-ray of gravid uterus

Intrauterine cephalometry by x-ray

87.82            Gas contrast hysterosalpingogram

87.83            Opaque dye contrast hysterosalpingogram

87.84            Percutaneous hysterogram

87.85            Other x-ray of fallopian tubes and uterus

87.89            Other x-ray of female genital organs

87.9      X-ray of male genital organs

87.91            Contrast seminal vesiculogram

87.92            Other x-ray of prostate and seminal vesicles

87.93            Contrast epididymogram

87.94            Contrast vasogram

87.95            Other x-ray of epididymis and vas deferens

87.99            Other x-ray of male genital organs

88         Other diagnostic radiology and related techniques

88.0      Soft tissue x-ray of abdomen

Excludes:            angiography (88.40-88.68)

88.01            Computerized axial tomography of abdomen

C.A.T. scan of abdomen

Excludes:            C.A.T. scan of kidney (87.71)

88.02            Other abdomen tomography

Excludes:            nephrotomogram (87.72)

88.03            Sinogram of abdominal wall

Fistulogram of abdominal wall

88.04            Abdominal lymphangiogram

88.09            Other soft tissue x-ray of abdominal wall

88.1      Other x-ray of abdomen

88.11            Pelvic opaque dye contrast radiography

88.12            Pelvic gas contrast radiography

Pelvic pneumoperitoneum

88.13            Other peritoneal pneumogram

88.14            Retroperitoneal fistulogram

88.15            Retroperitoneal pneumogram

88.16            Other retroperitoneal x-ray

88.19            Other x-ray of abdomen

Flat plate of abdomen

88.2      Skeletal x-ray of extremities and pelvis

Excludes:            contrast radiogram of joint (88.32)

88.21            Skeletal x-ray of shoulder and upper arm

88.22            Skeletal x-ray of elbow and forearm

88.23            Skeletal x-ray of wrist and hand

88.24            Skeletal x-ray of upper limb, not otherwise specified

88.25            Pelvimetry

88.26            Other skeletal x-ray of pelvis and hip

88.27            Skeletal x-ray of thigh, knee, and lower leg

88.28            Skeletal x-ray of ankle and foot

88.29            Skeletal x-ray of lower limb, not otherwise specified

88.3      Other x-ray

88.31            Skeletal series

X-ray of whole skeleton

88.32            Contrast arthrogram

Excludes:            that of temporomandibular joint (87.13)

88.33            Other skeletal x-ray

Excludes:            skeletal x-ray of:

extremities and pelvi 88.21-88.29)

face, head, and neck (87.11-87.17)

spine (87.21-87.29)

thorax (87.43)

88.34            Lymphangiogram of upper limb

88.35            Other soft tissue x-ray of upper limb

88.36            Lymphangiogram of lower limb

88.37            Other soft tissue x-ray of lower limb

Excludes:            femoral angiography (88.48,88.66)

88.38            Other computerized axial tomography

C.A.T. scan NOS

Excludes:            C.A.T. scan of:

abdomen (88.01)

head (87.03)

kidney (87.71)

thorax (87.41)

88.39            X-ray, other and unspecified

88.4            Arteriography using contrast material

Includes:            angiography of arteries

arterial puncture for injection of contrast material

radiography of arteries (by fluoroscopy)

retrograde arteriography

The fourth-digit subclassification identifies the site to be viewed, not the site of injection.

Excludes:            arteriography using:

radioisotopes or radionuclides (92.01-92.19)

ultrasound (88.71-88.79)

fluorescein angiography of eye (95.12)

88.40            Arteriography using contrast material, unspecified site

88.41            Arteriography of cerebral arteries

Angiography of:

basilar artery

carotid (internal)

posterior cerebral circulation

vertebral artery

88.42            Aortography

Arteriography of aorta and aortic arch

88.43            Arteriography of pulmonary arteries

88.44            Arteriography of other intrathoracic vessels

Excludes:            angiocardiography (88.50-88.58)

arteriography of coronary arteries (88.55-88.57)

88.45            Arteriography of renal arteries

88.46            Arteriography of placenta

Placentogram using contrast material

88.47            Arteriography of other intra-abdominal arteries

88.48            Arteriography of femoral and other lower extremity arteries

88.49            Arteriography of other specified sites

88.5            Angiocardiography using contrast material

Includes:            arterial puncture and insertion of arterial catheter for injection of contrast material

cineangiocardiography

selective angiocardiography

Code also synchronous cardiac catheterization (37.21-37.23)

Excludes:            angiography of pulmonary vessels (88.43, 88.62)

88.50            Angiocardiography, not otherwise specified

88.51            Angiocardiography of venae cavae

Inferior vena cavography

Phlebography of vena cava (inferior) (superior)

88.52            Angiocardiography of right heart structures

Angiocardiography of:

pulmonary valve

right atrium

right ventricle (outflow tract)

Excludes:            that combined with left heart angiocardiography (88.54)

88.53            Angiocardiography of left heart structures

Angiocardiography of:

aortic valve

left atrium

left ventricle (outflow tract)

Excludes:            that combined with right heart angiocardiography (88.54)

88.54            Combined right and left heart angiocardiography

88.55            Coronary arteriography using a single catheter

Coronary arteriography by Sones technique

Direct selective coronary arteriography

using a single catheter

88.56            Coronary arteriography using two catheters

Coronary arteriography by:

Judkins technique

Ricketts and Abrams technique

Direct selective coronary arteriography using two catheters

88.57            Other and unspecified coronary arteriography

Coronary arteriography NOS

88.58            Negative-contrast cardiac roentgenography

Cardiac roentgenography with injection of carbon dioxide

88.6            Phlebography

Includes:            angiography of veins

radiography of veins (by fluoroscopy)

retrograde phlebography

venipuncture for injection of contrast material

venography using contrast material

Note:    The fourth-digit subclassification (88.60-88.67) identifies the site to be viewed, not the site of injection.

Excludes:            angiography using:

radioisotopes or radionuclides (92.01-92.19)

ultrasound (88.71-88.79)

fluorescein angiography of eye (95.12)

88.60            Phlebography using contrast material, unspecified site

88.61            Phlebography of veins of head and neck using contrast material

88.62            Phlebography of pulmonary veins using contrast material

88.63            Phlebography of other intrathoracic veins using contrast material

88.64            Phlebography of the portal venous system using contrast material

Splenoportogram (by splenic arteriography)

88.65            Phlebography of other intra-abdominal veins using contrast material

88.66            Phlebography of femoral and other lower extremity veins using contrast material

88.67            Phlebography of other specified sites using contrast material

88.68            Impedance phlebography

88.7            Diagnostic ultrasound

Includes:            Echography

Non-invasive ultrasound

Ultrasonic angiography

Ultrasonography

Excludes: intravascular imaging (adjunctive) (IVUS) (00.21-00.29)

therapeutic ultrasound (00.01 -00.09)

88.71            Diagnostic ultrasound of head and neck

Determination of midline shift of brain

Echoencephalography

Excludes:            eye (95.13)

88.72            Diagnostic ultrasound of heart

Echocardiography

Transesophageal echocardiography

Excludes: echocardiography of heart chambers (37.28)

intracardiac echocardiography (ICE) (37.28)

intravascular (IVUS) imaging of coronary vessels (00.24)

88.73            Diagnostic ultrasound of other sites of thorax

Aortic arch ultrasonography

Breast ultrasonography

Lung ultrasonography

88.74            Diagnostic ultrasound of digestive system

88.75            Diagnostic ultrasound of urinary system

88.76            Diagnostic ultrasound of abdomen and retroperitoneum

88.77            Diagnostic ultrasound of peripheral vascular system

Deep vein thrombosis ultrasonic scanning

Excludes:adjunct vascular system procedures (00.40-00.43)

88.78            Diagnostic ultrasound of gravid uterus

Intrauterine cephalometry:

echo

ultrasonic

Placental localization by ultrasound

88.79            Other diagnostic ultrasound

Ultrasonography of:

multiple sites

nongravid uterus

total body

88.8            Thermography

88.81            Cerebral thermography

88.82            Ocular thermography

88.83            Bone thermography

Osteoarticular thermography

88.84            Muscle thermography

88.85            Breast thermography

88.86            Blood vessel thermography

Deep vein thermography

88.89            Thermography of other sites

Lymph gland thermography

Thermography NOS

88.9      Other diagnostic imaging

88.90            Diagnostic imaging, not elsewhere classified

88.91            Magnetic resonance imaging of brain and brain stem

Excludes: intraoperative magnetic resonance imaging (88.96)

real-time magnetic resonance imaging (88.96)

88.92            Magnetic resonance imaging of chest and myocardium

For evaluation of hilar and mediastinal lymphadenopathy

88.93            Magnetic resonance imaging of spinal canal

Spinal cord levels:

cervical

thoracic

lumbar (lumbosacral)

Spinal cord

Spine

88.94            Magnetic resonance imaging of musculoskeletal

Bone marrow blood supply

Extremities (upper) (lower)

88.95            Magnetic resonance imaging of pelvis, prostate, and bladder

88.96            Other intraoperative magnetic resonance imaging

iMRI

Real-time magnetic resonance imaging

88.97            Magnetic resonance imaging of other and unspecified sites

Abdomen

Eye orbit

Face

Neck

88.98            Bone mineral density studies

Dual photon absorptiometry

Quantitative computed tomography (CT)

studies

Radiographic densitometry

Single photon absorptiometry

89            Interview, evaluation, consultation, and examination

89.0            Diagnostic interview, consultation, and evaluation

Excludes:            psychiatric diagnostic interview (94.11-94.19)

89.01            Interview and evaluation, described as brief

Abbreviated history and evaluation

89.02            Interview and evaluation, described as limited

Interval history and evaluation

89.03            Interview and evaluation, described as comprehensive

History and evaluation of new problem

89.04            Other interview and evaluation

89.05            Diagnostic interview and evaluation, not otherwise specified

89.06            Consultation, described as limited

Consultation on a single organ system

89.07            Consultation, described as comprehensive

89.08            Other consultation

89.09            Consultation, not otherwise specified

89.1            Anatomic and physiologic measurements and manual examinations -- nervous system and sense organs

Excludes:    ear examination (95.41-95.49)

eye examination (95.01-95.26)

the listed procedures when done as part of a general physical examination (89.7)

89.10            Intracarotid amobarbital test

Wada test

89.11            Tonometry

89.12            Nasal function study

Rhinomanometry

89.13            Neurologic examination

89.14            Electroencephalogram

Excludes:            that with polysomnogram (89.17)

89.15            Other nonoperative neurologic function tests

89.16            Transillumination of newborn skull

89.17            Polysomnogram

Sleep recording

89.18            Other sleep disorder function tests

Multiple sleep latency test [MSLT]

89.19            Video and radio-telemetered electroencephalographic monitoring

Radiographic EEG monitoring

Video EEG monitoring

89.2            Anatomic and physiologic measurements and manual examinations -- genitourinary system

Excludes:    the listed procedures when done as part of a general physical examination (89.7)

89.21            Urinary manometry

Manometry through:

indwelling ureteral catheter

nephrostomy

pyelostomy

ureterostomy

89.22            Cystometrogram

89.23            Urethral sphincter electromyogram

89.24            Uroflowmetry [UFR]

89.25            Urethral pressure profile [UPP]

89.26            Gynecological examination

Pelvic examination

89.29            Other nonoperative genitourinary system measurements

Bioassay of urine

Renal clearance

Urine chemistry

89.3      Other anatomic and physiologic measurements and manual examinations

Excludes:    the listed procedures when done as part of a general physical examination (89.7)

89.31            Dental examination

Oral mucosal survey

Periodontal survey

89.32            Esophageal manometry

89.33            Digital examination of enterostomy stoma

Digital examination of colostomy stoma

89.34            Digital examination of rectum

89.35            Transillumination of nasal sinuses

89.36            Manual examination of breast

89.37            Vital capacity determination

89.38            Other nonoperative respiratory measurements

Plethysmography for measurement of respiratory function

Thoracic impedance plethysmography

89.39            Other nonoperative measurements and examinations

14 C-Urea breath test

Basal metabolic rate [BMR]

Gastric:

analysis

function NEC

Excludes:            body measurement (93.07)

cardiac tests (89.41-89.69)

fundus photography (95.11)

limb length measurement (93.06)

89.4      Cardiac stress tests, pacemaker and defibrillator checks

89.41            Cardiovascular stress test using treadmill

89.42            Masters' two-step stress test

89.43            Cardiovascular stress test using bicycle ergometer

89.44            Other cardiovascular stress test

Thallium stress test with or without transesophageal pacing

89.45            Artificial pacemaker rate check

Artificial pacemaker function check NOS

Bedside device check of pacemaker or cardiac resynchronization pacemaker [CRT-P]

Interrogation only without arrhythmia induction

Excludes: electrophysiologic studies [EPS] (37.26)

non-invasive programmed electrical stimulation [NIPS] (arrhythmia induction) (37.26)

89.46            Artificial pacemaker artifact wave form check

89.47            Artificial pacemaker electrode impedance check

89.48            Artificial pacemaker voltage or amperage threshold check

89.49            Automatic implantable cardioverter/defibrillator (AICD) check

     Bedside check of an AICD or cardiac resynchronization defibrillator [CRT-D]

     Checking pacing thresholds of device

     Interrogation only without arrhythmia induction

Excludes: electrophysiologic studies [EPS] (37.26)

non-invasive programmed electrical stimulation [NIPS] (arrhythmia induction) (37.26)

89.5      Other nonoperative cardiac and vascular diagnostic procedures

Excludes:    fetal EKG (75.32)

89.50            Ambulatory cardiac monitoring

Analog devices [Holter-type]

89.51            Rhythm electrocardiogram

Rhythm EKG (with one to three leads)

89.52            Electrocardiogram

ECG NOS

EKG (with 12 or more leads)

89.53            Vectorcardiogram (with ECG)

89.54            Electrographic monitoring

Telemetry

Excludes:            ambulatory cardiac monitoring (89.50)

electrographic monitoring durin surgery -- omit code

89.55            Phonocardiogram with ECG lead

89.56            Carotid pulse tracing with ECG lead

Excludes:            oculoplethysmography (89.58)

89.57            Apexcardiogram (with ECG lead)

89.58            Plethysmogram

Penile plethysmography with nerve stimulation

Excludes:            plethysmography (for):

measurement of respiratory function (89.38)

thoracic impedance (89.38)

89.59            Other nonoperative cardiac and vascular measurements

89.6            Circulatory monitoring

Excludes:            electrocardiographic monitoring during surgery -- omit code

89.60            Continuous intra-arterial blood gas monitoring

Insertion of blood gas monitoring system and continuous monitoring of blood gases through an intra-arterial sensor

89.61            Systemic arterial pressure monitoring

89.62            Central venous pressure monitoring

89.63            Pulmonary artery pressure monitoring

Excludes:            pulmonary artery wedge monitoring (89.64)

89.64            Pulmonary artery wedge monitoring

Pulmonary capillary wedge [PCW] monitoring

Swan-Ganz catheterization

89.65            Measurement of systemic arterial blood gases

Excludes: continuous intra-arterial blood gas monitoring (89.60)

89.66            Measurement of mixed venous blood gases

89.67            Monitoring of cardiac output by oxygen consumption technique

Fick method

89.68            Monitoring of cardiac output by other technique

Cardiac output monitor by thermodilution indicator

89.69            Monitoring of coronary blood flow

Coronary blood flow monitoring by coincidence counting technique

89.7      General physical examination

89.8      Autopsy

90            Microscopic examination-I

The following fourth-digit subclassification is for use with categories in section 90 to identify type of examination:

1   bacterial smear

2   culture

3   culture and sensitivity

4   parasitology

5   toxicology

6    cell block and Papanicolaou smear

9   other microscopic examination

90.0            Microscopic examination of specimen from nervous system and of spinal fluid

90.1            Microscopic examination of specimen from endocrine gland, not elsewhere classified

90.2            Microscopic examination of specimen from eye

90.3            Microscopic examination of specimen from ear, nose, throat, and larynx

90.4            Microscopic examination of specimen from trachea, bronchus, pleura, lung, and other thoracic specimen, and of sputum

90.5            Microscopic examination of blood

90.6            Microscopic examination of specimen from spleen and of bone marrow

90.7            Microscopic examination of specimen from lymph node and of lymph

90.8            Microscopic examination of specimen from upper gastrointestinal tract and of vomitus

90.9            Microscopic examination of specimen from lower gastrointestinal tract and of stool

91            Microscopic examination-II

The following fourth-digit subclassification is for use with categories in section 91 to identify type of examination

1   bacterial smear

2   culture

3   culture and sensitivity

4   parasitology

5   toxicology

6    cell block and Papanicolaou smear

9   other microscopic examination

91.0            Microscopic examination of specimen from liver, biliary tract, and pancreas

91.1            Microscopic examination of peritoneal and retroperitoneal specimen

91.2            Microscopic examination of specimen from kidney, ureter, perirenal and periureteral tissue

91.3            Microscopic examination of specimen from bladder, urethra, prostate, seminal vesicle, perivesical tissue, and of urine and semen

91.4            Microscopic examination of specimen from female genital tract

Amnionic sac

Fetus

91.5            Microscopic examination of specimen from musculoskeletal system and of joint fluid

Microscopic examination of:

bone

bursa

cartilage

fascia

ligament

muscle

synovial membrane

tendon

91.6            Microscopic examination of specimen from skin and other integument

Microscopic examination of:

hair

nails

skin

Excludes:            mucous membrane -- code to organ site that of operative wound (91.70-91.79)

91.7            Microscopic examination of specimen from operative wound

91.8            Microscopic examination of specimen from other site

91.9            Microscopic examination of specimen from unspecified site

92         Nuclear medicine

92.0            Radioisotope scan and function study

92.01            Thyroid scan and radioisotope function studies

Iodine-131 uptake

Protein-bound iodine

Radio-iodine uptake

92.02            Liver scan and radioisotope function study

92.03            Renal scan and radioisotope function study

Renal clearance study

92.04            Gastrointestinal scan and radioisotope function study

Radio-cobalt B12 Schilling test

Radio-iodinated triolein study

92.05            Cardiovascular and hematopoietic scan and radioisotope function study

Bone marrow scan or function study

Cardiac output scan or function study

Circulation time scan or function study

Radionuclide cardiac ventriculogram scan or function study

Spleen scan or function study

92.09            Other radioisotope function studies

92.1      Other radioisotope scan

92.11            Cerebral scan

Pituitary

92.12            Scan of other sites of head

Excludes:            eye (95.16)

92.13            Parathyroid scan

92.14            Bone scan

92.15            Pulmonary scan

92.16            Scan of lymphatic system

92.17            Placental scan

92.18            Total body scan

92.19            Scan of other sites

92.2            Therapeutic radiology and nuclear medicine

Excludes:    that for:

ablation of pituitary gland (07.64-07.69)

destruction of chorioretinal lesion (14.26-14.27)

92.20            Infusion of liquid brachytherapy radioisotope

I-125 radioisotope

Intracavitary brachytherapy

Includes: removal of radioisotope

92.21            Superficial radiation

Contact radiation [up to 150 KVP]

92.22            Orthovoltage radiation

Deep radiation [200-300 KVP]

92.23            Radioisotopic teleradiotherapy

Teleradiotherapy using:

cobalt-60

iodine-125

radioactive cesium

92.24            Teleradiotherapy using photons

Megavoltage NOS

Supervoltage NOS

Use of:

Betatron

linear accelerator

92.25            Teleradiotherapy using electrons

Beta particles

92.26            Teleradiotherapy of other particulate radiation

Neutrons

Protons NOS

92.27            Implantation or insertion of radioactive elements

Intravascular brachytherapy

Code also incision of site

Excludes: infusion of liquid brachytherapy radioisotope (92.20)

92.28            Injection or instillation of radioisotopes

Injection or infusion of radioimmunoconjugate

Intracavitary injection or instillation

Intravenous injection or instillation

Iodine-131 [I-131] tositumomab

Radioimmunotherapy

Ytrium-90 [Y-90] ibritumomab tiuxetan

Excludes: infusion of liquid brachytherapy radioisotope (92.20)

92.29            Other radiotherapeutic procedure

92.3            Stereotactic radiosurgery

Code also stereotactic head frame application (93.59)

Excludes:   stereotactic biopsy

92.30            Stereotactic radiosurgery, not otherwise specified

92.31            Single source photon radiosurgery

High energy x-rays

Linear accelerator (LINAC)

92.32            Multi-source photon radiosurgery

Cobalt 60 radiation

Gamma irradiation

92.33            Particulate radiosurgery

Particle beam radiation (cyclotron)

Proton accerlerator

92.39            Stereotactic radiosurgery, not elsewhere classified

93            Physical therapy, respiratory therapy, rehabilitation, and related procedures

93.0            Diagnostic physical therapy

93.01            Functional evaluation

93.02            Orthotic evaluation

93.03            Prosthetic evaluation

93.04            Manual testing of muscle function

93.05            Range of motion testing

93.06            Measurement of limb length

93.07            Body measurement

Girth measurement

Measurement of skull circumference

93.08            Electromyography

Excludes:            eye EMG (95.25)

that with polysomnogram (89.17)

urethral sphincter EMG (89.23)

93.09            Other diagnostic physical therapy procedure

93.1            Physical therapy exercises

93.11            Assisting exercise

Excludes:            assisted exercise in poo (93.31)

93.12            Other active musculoskeletal exercise

93.13            Resistive exercise

93.14            Training in joint movements

93.15            Mobilization of spine

93.16            Mobilization of other joints

Excludes:            manipulation o temporomandibular joint (76.95)

93.17            Other passive musculoskeletal exercise

93.18            Breathing exercise

93.19            Exercise, not elsewhere classified

93.2      Other physical therapy musculoskeletal manipulation

93.21            Manual and mechanical traction

Excludes:            skeletal traction (93.43-93.44)

skin traction (93.45-93.46)

spinal traction (93.41-93.42)

93.22            Ambulation and gait training

93.23            Fitting of orthotic device

93.24            Training in use of prosthetic or orthotic device

Training in crutch walking

93.25            Forced extension of limb

93.26            Manual rupture of joint adhesions

93.27            Stretching of muscle or tendon

93.28            Stretching of fascia

93.29            Other forcible correction of deformity

93.3      Other physical therapy therapeutic procedures

93.31            Assisted exercise in pool

93.32            Whirlpool treatment

93.33            Other hydrotherapy

93.34            Diathermy

93.35            Other heat therapy

Acupuncture with smouldering moxa

Hot packs

Hyperthermia NEC

Infrared irradiation

Moxibustion

Paraffin bath

Excludes:            hyperthermia for treatment of cancer (99.85)

93.36            Cardiac retraining

93.37            Prenatal training

Training for natural childbirth

93.38            Combined physical therapy without mention of the components

93.39            Other physical therapy

93.4      Skeletal traction and other traction

93.41            Spinal traction using skull device

Traction using:

caliper tongs

Crutchfield tongs

halo device

Vinke tongs

Excludes:            insertion of tongs or halo traction device (02.94)

93.42            Other spinal traction

Cotrel's traction

Excludes:            cervical collar (93.52)

93.43            Intermittent skeletal traction

93.44            Other skeletal traction

Bryant's traction

Dunlop's traction

Lyman Smith traction

Russell's traction

93.45            Thomas' splint traction

93.46            Other skin traction of limbs

Adhesive tape traction

Boot traction

Buck's traction

Gallows traction

93.5      Other immobilization, pressure, and attention to wound

Excludes:            external fixator device (84.71-84.73)

wound cleansing (96.58-96.59)

93.51            Application of plaster jacket

Excludes:            Minerva jacket (93.52)

93.52            Application of neck support

Application of:

cervical collar

Minerva jacket

molded neck support

93.53            Application of other cast

93.54            Application of splint

Plaster splint

Tray splint

Excludes:            periodontal splint (24.7)

93.55            Dental wiring

Excludes:            that for orthodontia (24.7)

93.56            Application of pressure dressing

Application of:

Gibney bandage

Robert Jones' bandage

Shanz dressing

93.57            Application of other wound dressing

Porcine wound dressing

93.58            Application of pressure trousers

Application of:

anti-shock trousers

MAST trousers

vasopneumatic device

93.59            Other immobilization, pressure, and attention to wound

Elastic stockings

Electronic gaiter

Intermittent pressure device

Oxygenation of wound (hyperbaric)

Stereotactic head frame application

Velpeau dressing

93.6            Osteopathic manipulative treatment

93.61            Osteopathic manipulative treatment for general mobilization

General articulatory treatment

93.62            Osteopathic manipulative treatment using high- velocity, low-amplitude forces

Thrusting forces

93.63            Osteopathic manipulative treatment using low- velocity, high-amplitude forces

Springing forces

93.64            Osteopathic manipulative treatment using isotonic, isometric forces

93.65            Osteopathic manipulative treatment using indirect forces

93.66            Osteopathic manipulative treatment to move tissue fluids

Lymphatic pump

93.67            Other specified osteopathic manipulative treatment

93.7      Speech and reading rehabilitation and rehabilitation of the blind

93.71            Dyslexia training

93.72            Dysphasia training

93.73            Esophageal speech training

93.74            Speech defect training

93.75            Other speech training and therapy

93.76            Training in use of lead dog for the blind

93.77            Training in braille or Moon

93.78            Other rehabilitation for the blind

93.8      Other rehabilitation therapy

93.81            Recreation therapy

Diversional therapy

Play therapy

Excludes:            play psychotherapy (94.36)

93.82            Educational therapy

Education of bed-bound children

Special schooling for the handicapped

93.83            Occupational therapy

Daily living activities therapy

Excludes:            training in activities of daily living for the blind (93.78)

93.84            Music therapy

93.85            Vocational rehabilitation

Sheltered employment

Vocational:

assessment

retraining

training

93.89            Rehabilitation, not elsewhere classified

93.9            Respiratory therapy

Excludes:            insertion of airway (96.01-96.05)

other continuous mechanical ventilation (96.70-96.72)

93.90            Continuous positive airway pressure [CPAP]

Bi-level airway pressure

Non-invasive positive pressure (NIPPV)

93.91            Intermittent positive pressure breathing [IPPB]

93.93            Nonmechanical methods of resuscitation

Artificial respiration

Manual resuscitation

Mouth-to-mouth resuscitation

93.94            Respiratory medication administered by nebulizer

Mist therapy

93.95            Hyperbaric oxygenation

Excludes:            oxygenation of wound (93.59)

93.96            Other oxygen enrichment

Catalytic oxygen therapy

Cytoreductive effect

Oxygenators

Oxygen therapy

Excludes:            oxygenation of wound (93.59)

93.97            Decompression chamber

93.98            Other control of atmospheric pressure and composition

Antigen-free air conditioning

Helium therapy

Excludes: inhaled nitric oxide therapy (INO) (00.12)

93.99            Other respiratory procedures

Continuous negative pressure ventilation [CNP]

Postural drainage

94            Procedures related to the psyche

94.0            Psychologic evaluation and testing

94.01            Administration of intelligence test

Administration of:

Stanford-Binet

Wechsler Adult Intelligence Scale

Wechsler Intelligence Scale for Children

94.02            Administration of psychologic test

Administration of:

Bender Visual-Motor Gestalt Test

Benton Visual Retention Test

Minnesota Multiphasic Personality Inventory

Wechsler Memory Scale

94.03            Character analysis

94.08            Other psychologic evaluation and testing

94.09            Psychologic mental status determination, not otherwise specified

94.1            Psychiatric interviews, consultations, and evaluations

94.11            Psychiatric mental status determination

Clinical psychiatric mental status determination

Evaluation for criminal responsibility

Evaluation for testimentary capacity

Medicolegal mental status determination

Mental status determination NOS

94.12            Routine psychiatric visit, not otherwise specified

94.13            Psychiatric commitment evaluation

Pre-commitment interview

94.19            Other psychiatric interview and evaluation

Follow-up psychiatric interview NOS

94.2            Psychiatric somatotherapy

94.21            Narcoanalysis

Narcosynthesis

94.22            Lithium therapy

94.23            Neuroleptic therapy

94.24            Chemical shock therapy

94.25            Other psychiatric drug therapy

94.26            Subconvulsive electroshock therapy

94.27            Other electroshock therapy

Electroconvulsive therapy (ECT)

EST

94.29            Other psychiatric somatotherapy

94.3            Individual psychotherapy

94.31            Psychoanalysis

94.32            Hypnotherapy

Hypnodrome

Hypnosis

94.33            Behavior therapy

Aversion therapy

Behavior modification

Desensitization therapy

Extinction therapy

Relaxation training

Token economy

94.34            Individual therapy for psychosexual dysfunction

Excludes:            that performed in group setting (94.41)

94.35            Crisis intervention

94.36            Play psychotherapy

94.37            Exploratory verbal psychotherapy

94.38            Supportive verbal psychotherapy

94.39            Other individual psychotherapy

Biofeedback

94.4      Other psychotherapy and counselling

94.41            Group therapy for psychosexual dysfunction

94.42            Family therapy

94.43            Psychodrama

94.44            Other group therapy

94.45            Drug addiction counselling

94.46            Alcoholism counselling

94.49            Other counselling

94.5      Referral for psychologic rehabilitation

94.51            Referral for psychotherapy

94.52            Referral for psychiatric aftercare:

That in:

halfway house

outpatient (clinic) facility

94.53            Referral for alcoholism rehabilitation

94.54            Referral for drug addiction rehabilitation

94.55            Referral for vocational rehabilitation

94.59            Referral for other psychologic rehabilitation

94.6      Alcohol and drug rehabilitation and detoxification

94.61            Alcohol rehabilitation

94.62            Alcohol detoxification

94.63            Alcohol rehabilitation and detoxification

94.64            Drug rehabilitation

94.65            Drug detoxification

94.66            Drug rehabilitation and detoxification

94.67            Combined alcohol and drug rehabilitation

94.68            Combined alcohol and drug detoxification

94.69            Combined alcohol and drug rehabilitation and detoxification

95            Ophthalmologic and otologic diagnosis and treatment

95.0      General and subjective eye examination

95.01            Limited eye examination

Eye examination with prescription of spectacles

95.02            Comprehensive eye examination

Eye examination covering all aspects of the visual system

95.03            Extended ophthalmologic work-up

Examination (for):

glaucoma

neuro-ophthalmology

retinal disease

95.04            Eye examination under anesthesia

Code also type of examination

95.05            Visual field study

95.06            Color vision study

95.07            Dark adaptation study

95.09            Eye examination, not otherwise specified

Vision check NOS

95.1            Examinations of form and structure of eye

95.11            Fundus photography

95.12            Fluorescein angiography or angioscopy of eye

95.13            Ultrasound study of eye

95.14            X-ray study of eye

95.15            Ocular motility study

95.16            P32 and other tracer studies of eye

95.2            Objective functional tests of eye

Excludes:    that with polysomnogram (89.17)

95.21            Electroretinogram [ERG]

95.22            Electro-oculogram [EOG]

95.23            Visual evoked potential [VEP]

95.24            Electronystagmogram [ENG]

95.25            Electromyogram of eye [EMG]

95.26            Tonography, provocative tests, and other glaucoma testing

95.3      Special vision services

95.31            Fitting and dispensing of spectacles

95.32            Prescription, fitting, and dispensing of contact lens

95.33            Dispensing of other low vision aids

95.34            Ocular prosthetics

95.35            Orthoptic training

95.36            Ophthalmologic counselling and instruction

Counselling in:

adaptation to visual loss

use of low vision aids

95.4            Nonoperative procedures related to hearing

95.41            Audiometry

Békésy 5-tone audiometry

Impedance audiometry

Stapedial reflex response

Subjective audiometry

Tympanogram

95.42            Clinical test of hearing

Tuning fork test

Whispered speech test

95.43            Audiological evaluation

Audiological evaluation by:

Bárány noise machine

blindfold test

delayed feedback

masking

Weber lateralization

95.44            Clinical vestibular function tests

Thermal test of vestibular function

95.45            Rotation tests

Bárány chair

95.46            Other auditory and vestibular function tests

95.47            Hearing examination, not otherwise specified

95.48            Fitting of hearing aid

Excludes:            implantation of electromagnetic hearing device (20.95)

95.49            Other nonoperative procedures related to hearing

Adjustment (external components) of cochlear prosthetic device

96            Nonoperative intubation and irrigation

96.0            Nonoperative intubation of gastrointestinal and respiratory tracts

96.01            Insertion of nasopharyngeal airway

96.02            Insertion of oropharyngeal airway

96.03            Insertion of esophageal obturator airway

96.04            Insertion of endotracheal tube

96.05            Other intubation of respiratory tract

96.06            Insertion of Sengstaken tube

Esophageal tamponade

96.07            Insertion of other (naso-)gastric tube

Intubation for decompression

Excludes:            that for enteral infusion of nutritional substance (96.6)

96.08            Insertion of (naso-)intestinal tube

Miller-Abbott tube (for decompression)

96.09            Insertion of rectal tube

Replacement of rectal tube

96.1      Other nonoperative insertion

Excludes:            nasolacrimal intubation (09.44)

96.11            Packing of external auditory canal

96.14            Vaginal packing

96.15            Insertion of vaginal mold

96.16            Other vaginal dilation

96.17            Insertion of vaginal diaphragm

96.18            Insertion of other vaginal pessary

96.19            Rectal packing

96.2            Nonoperative dilation and manipulation

96.21            Dilation of frontonasal duct

96.22            Dilation of rectum

96.23            Dilation of anal sphincter

96.24            Dilation and manipulation of enterostomy stoma

96.25            Therapeutic distention of bladder

Intermittent distention of bladder

96.26            Manual reduction of rectal prolapse

96.27            Manual reduction of hernia

96.28            Manual reduction of enterostomy prolapse

96.29            Reduction of intussusception of alimentary tract

With:

fluoroscopy

ionizing radiation enema

ultrasonography guidance

Hydrostatic reduction

Pneumatic reduction

Excludes:            intra-abdominal manipulation of intestine, not otherwise specified (46.80)

96.3            Nonoperative alimentary tract irrigation, cleaning, and local instillation

96.31            Gastric cooling

Gastric hypothermia

96.32            Gastric freezing

96.33            Gastric lavage

96.34            Other irrigation of (naso-)gastric tube

96.35            Gastric gavage

96.36            Irrigation of gastrostomy or enterostomy

96.37            Proctoclysis

96.38            Removal of impacted feces

Removal of impaction:

by flushing manually

96.39    Other transanal enema

Rectal irrigation

Excludes:            reduction of intussusception of alimentary tract by ionizing radiation enema (96.29)

96.4            Nonoperative irrigation, cleaning, and local instillation of other digestive and genitourinary organs

96.41            Irrigation of cholecystostomy and other biliary tube

96.42            Irrigation of pancreatic tube

96.43            Digestive tract instillation, except gastric gavage

96.44            Vaginal douche

96.45            Irrigation of nephrostomy and pyelostomy

96.46            Irrigation of ureterostomy and ureteral catheter

96.47            Irrigation of cystostomy

96.48            Irrigation of other indwelling urinary catheter

96.49            Other genitourinary instillation

Insertion of prostaglandin suppository

96.5      Other nonoperative irrigation and cleaning

96.51            Irrigation of eye

Irrigation of cornea

Excludes:            irrigation with removal of foreign body (98.21)

96.52            Irrigation of ear

Irrigation with removal of cerumen

96.53            Irrigation of nasal passages

96.54            Dental scaling, polishing, and debridement

Dental prophylaxis

Plaque removal

96.55            Tracheostomy toilette

96.56            Other lavage of bronchus and trachea

Excludes: diagnostic bronchoalveolar lavage (BAL)(33.24)

whole lung lavage (33.99)

96.57            Irrigation of vascular catheter

96.58            Irrigation of wound catheter

96.59            Other irrigation of wound

Wound cleaning NOS

Excludes:            debridement (86.22, 86.27-86.28)

96.6      Enteral infusion of concentrated nutritional substances

96.7      Other continuous mechanical ventilation

Includes:            Endotracheal respiratory assistance

Intermittent mandatory ventilation [IMV]

Positive end expiratory pressure [PEEP]

Pressure support ventilation [PSV]

That by tracheostomy

Weaning of an intubated (endotracheal tube) patient

Excludes:    bi-level airway pressure (93.90)

continuous negative pressure ventilation [CNP] (iron lung) (cuirass) (93.99)

continuous positive airway pressure [CPAP] (93.90)

intermittent positive pressure breathing [IPPB] (93.91)

non-invasive positive pressure (NIPPV) (93.90)

that by face mask (93.90-93.99)

that by nasal cannula (93.90-93.99)

that by nasal catheter (93.90-93.99)

Code also any associated:

endotracheal tube insertion (96.04)

tracheostomy (31.1-31.29)

Note:   Endotracheal Intubation

To calculate the number of hours (duration) of continuous mechanical ventilation during a hospitalization, begin the count from the start of the (endotracheal) intubation. The duration ends with (endotracheal) extubation.

If a patient is intubated prior to admission, begin counting the duration from the time of the admission. If a patient is transferred (discharged) while intubated, the duration would end at the time of transfer (discharge).

For patients who begin on (endotracheal) intubation and subsequently have a tracheostomy performed for mechanical ventilation, the duration begins with the (endotracheal) intubation and ends when the mechanical ventilation is turned off (after the weaning period).

Tracheostomy

To calculate the number of hours of continuous mechanical ventilation during a hospitalization, begin counting the duration when mechanical ventilation is started. The duration ends when the mechanical ventilator is turned off (after the weaning period).

If a patient has received a tracheostomy prior to admission and is on mechanical ventilation at the time of admission, begin counting the duration from the time of admission. If a patient is transferred (discharged) while still on mechanical ventilation via tracheostomy, the duration would end at the time of the transfer (discharge).

96.70            Continuous mechanical ventilation of unspecified duration

Mechanical ventilation NOS

96.71            Continuous mechanical ventilation for less than 96 consecutive hours

96.72            Continuous mechanical ventilation for 96 consecutive hours or more

97            Replacement and removal of therapeutic appliances

97.0            Nonoperative replacement of gastrointestinal appliance

97.01            Replacement of (naso-)gastric or esophagostomy tube

97.02            Replacement of gastrostomy tube

97.03            Replacement of tube or enterostomy device of small intestine

97.04            Replacement of tube or enterostomy device of large intestine

97.05            Replacement of stent (tube) in biliary or pancreatic duct

97.1            Nonoperative replacement of musculoskeletal and integumentary system appliance

97.11            Replacement of cast on upper limb

97.12            Replacement of cast on lower limb

97.13            Replacement of other cast

97.14            Replacement of other device for musculoskeletal immobilization

97.15            Replacement of wound catheter

97.16            Replacement of wound packing or drain

Excludes:            repacking of:

dental wound (97.22)

vulvar wound (97.26)

97.2      Other nonoperative replacement

97.21            Replacement of nasal packing

97.22            Replacement of dental packing

97.23            Replacement of tracheostomy tube

97.24            Replacement and refitting of vaginal diaphragm

97.25            Replacement of other vaginal pessary

97.26            Replacement of vaginal or vulvar packing or drain

97.29            Other nonoperative replacements

97.3            Nonoperative removal of therapeutic device from head and neck

97.31            Removal of eye prosthesis

Excludes:            removal of ocular implan (16.71)

removal of orbital implan (16.72)

97.32            Removal of nasal packing

97.33            Removal of dental wiring

97.34            Removal of dental packing

97.35            Removal of dental prosthesis

97.36            Removal of other external mandibular fixation device

97.37            Removal of tracheostomy tube

97.38            Removal of sutures from head and neck

97.39            Removal of other therapeutic device from head and neck

Excludes:            removal of skull tongs (02.94)

97.4            Nonoperative removal of therapeutic device from thorax

97.41            Removal of thoracotomy tube or pleural cavity drain

97.42            Removal of mediastinal drain

97.43            Removal of sutures from thorax

97.44            Nonoperative removal of heart assist system

Explantation [removal] of circulatory assist device

Explantation [removal] of percutaneous external heart assist device

Intra-aortic balloon pump [IABP]

Removal of extrinsic heart assist device

Removal of pVAD

Removal of percutaneous heart assist device

97.49            Removal of other device from thorax

97.5            Nonoperative removal of therapeutic device from digestive system

97.51            Removal of gastrostomy tube

97.52            Removal of tube from small intestine

97.53            Removal of tube from large intestine or appendix

97.54            Removal of cholecystostomy tube

97.55            Removal of T-tube, other bile duct tube, or liver tube

Removal of bile duct stent

97.56            Removal of pancreatic tube or drain

97.59            Removal of other device from digestive system

Removal of rectal packing

97.6            Nonoperative removal of therapeutic device from urinary system

97.61            Removal of pyelostomy and nephrostomy tube

97.62            Removal of ureterostomy tube and ureteral catheter

97.63            Removal of cystostomy tube

97.64            Removal of other urinary drainage device

Removal of indwelling urinary catheter

97.65            Removal of urethral stent

97.69            Removal of other device from urinary system

97.7            Nonoperative removal of therapeutic device from genital system

97.71            Removal of intrauterine contraceptive device

97.72            Removal of intrauterine pack

97.73            Removal of vaginal diaphragm

97.74            Removal of other vaginal pessary

97.75            Removal of vaginal or vulvar packing

97.79            Removal of other device from genital tract

Removal of sutures

97.8      Other nonoperative removal of therapeutic device

97.81            Removal of retroperitoneal drainage device

97.82            Removal of peritoneal drainage device

97.83            Removal of abdominal wall sutures

97.84            Removal of sutures from trunk, not elsewhere classified

97.85            Removal of packing from trunk, not elsewhere classified

97.86            Removal of other device from abdomen

97.87            Removal of other device from trunk

97.88            Removal of external immobilization device

Removal of:

brace

cast

splint

97.89            Removal of other therapeutic device

98            Nonoperative removal of foreign body or calculus

98.0            Removal of intraluminal foreign body from digestive system without incision

Excludes:            removal of therapeutic device (97.51-97.59)

98.01            Removal of intraluminal foreign body from mouth without incision

98.02            Removal of intraluminal foreign body from esophagus without incision

98.03            Removal of intraluminal foreign body from stomach and small intestine without incision

98.04            Removal of intraluminal foreign body from large intestine without incision

98.05            Removal of intraluminal foreign body from rectum and anus without incision

98.1            Removal of intraluminal foreign body from other sites without incision

Excludes:            removal of therapeutic device (97.31-97.49, 97.61-97.89)

98.11            Removal of intraluminal foreign body from ear without incision

98.12            Removal of intraluminal foreign body from nose without incision

98.13            Removal of intraluminal foreign body from pharynx without incision

98.14            Removal of intraluminal foreign body from larynx without incision

98.15            Removal of intraluminal foreign body from trachea and bronchus without incision

98.16            Removal of intraluminal foreign body from uterus without incision

Excludes:            removal of intrauterine contraceptive device (97.71)

98.17            Removal of intraluminal foreign body from vagina without incision

98.18            Removal of intraluminal foreign body from artificial stoma without incision

98.19            Removal of intraluminal foreign body from urethra without incision

98.2            Removal of other foreign body without incision

Excludes:            removal of intraluminal foreign body (98.01-98.19)

98.20            Removal of foreign body, not otherwise specified

98.21            Removal of superficial foreign body from eye without incision

98.22            Removal of other foreign body without incision from head and neck

Removal of embedded foreign body from eyelid or conjunctiva without incision

98.23            Removal of foreign body from vulva without incision

98.24            Removal of foreign body from scrotum or penis without incision

98.25            Removal of other foreign body without incision from trunk except scrotum, penis, or vulva

98.26            Removal of foreign body from hand without incision

98.27            Removal of foreign body without incision from upper limb, except hand

98.28            Removal of foreign body from foot without incision

98.29            Removal of foreign body without incision from lower limb, except foot

98.5            Extracorporeal shockwave lithotripsy [ESWL]

Lithotriptor tank procedure

Disintegration of stones by extracorporeal induced shockwaves

That with insertion of stent

98.51            Extracorporeal shockwave lithotripsy [ESWL] of the kidney, ureter and/or bladder

98.52            Extracorporeal shockwave lithotripsy [ESWL] of the gallbladder and/or bile duct

98.59            Extracorporeal shockwave lithotripsy of other sites

99         Other nonoperative procedures

99.0            Transfusion of blood and blood components

Use additional code for that done via catheter or cutdown (38.92-38.94)

99.00            Perioperative autologous transfusion of whole blood or blood components

Intraoperative blood collection

Postoperative blood collection

Salvage

99.01            Exchange transfusion

Transfusion:

exsanguination

replacement

99.02            Transfusion of previously collected autologous blood

Blood component

99.03            Other transfusion of whole blood

Transfusion:

blood NOS

hemodilution

NOS

99.04            Transfusion of packed cells

99.05            Transfusion of platelets

Transfusion of thrombocytes

99.06            Transfusion of coagulation factors

Transfusion of antihemophilic factor

99.07            Transfusion of other serum

Transfusion of plasma

Excludes:            injection [transfusion] of:

antivenin (99.16)

gamma globulin (99.14)

99.08            Transfusion of blood expander

Transfusion of Dextran

99.09            Transfusion of other substance

Transfusion of:

blood surrogate

granulocytes

Excludes:            transplantation [transfusion] of bone marrow (41.0)

99.1      Injection or infusion of therapeutic or prophylactic substance

Includes:            injection or infusion given:

hypodermically acting locally or systemically intramuscularly acting locally or systemically

intravenously acting locally or systemically

99.10            Injection or infusion of thrombolytic agent

Streptokinase

Tissue plasminogen activator (TPA)

Urokinase

Excludes:                        aspirin - omit code

GP IIB/IIIa plalet inhibitor (99.20)

heparin (99.19)

warfarin - omit code

99.11            Injection of Rh immune globulin

Injection of:

Anti-D (Rhesus) globulin

RhoGAM

99.12            Immunization for allergy

Desensitization

99.13            Immunization for autoimmune disease

99.14            Injection of gamma globulin

Injection of immune sera

99.15            Parenteral infusion of concentrated nutritional substances

Hyperalimentation

Total parenteral nutrition [TPN]

Peripheral parenteral nutrition [PPN]

99.16            Injection of antidote

Injection of:

antivenin

heavy metal antagonist

99.17            Injection of insulin

99.18            Injection or infusion of electrolytes

99.19            Injection of anticoagulant

Excludes: infusion of drotrecogin alfa (activated)(00.11)

99.2      Injection or infusion of other therapeutic or prophylactic substance

Includes:            injection or infusion given:

hypodermically acting locally or systemically

intramuscularly acting locally or systemically

intravenously acting locally or systemically

Use additional code for:

injection (into):

breast (85.92)

bursa (82.94, 83.96)

intraperitoneal (cavity) (54.97)

intrathecal (03.92)

joint (76.96, 81.92)

kidney (55.96)

liver (50.94)

orbit (16.91)

other sites -- see Alphabetic Index

perfusion:

NOS (39.97)

intestine (46.95, 46.96)

kidney (55.95)

liver (50.93)

total body (39.96)

99.20            Injection or infusion of platelet inhibitor

Glycoprotein IIB/IIIa inhibitor

GP IIB/IIIa inhibitor

GP IIB-IIIa inhibitor

Excludes:infusion of heparin (99.19)

injection or infusion of thrombolytic agent (99.10)

99.21            Injection of antibiotic

Excludes: injection or infusion of oxazolidinone class of antibiotics (00.14)

99.22            Injection of other anti-infective

Excludes: injection or infusion of oxazolidinone class of antibiotics (00.14)

99.23            Injection of steroid

Injection of cortisone

Subdermal implantation of progesterone

99.24            Injection of other hormone

99.25            Injection or infusion of cancer chemotherapeutic substance

Chemoembolization

Injection or infusion of antineoplastic agent

Excludes:immunotherapy, antineoplastic (00.15, 99.28)

implantation of chemotherapeutic agent (00.10)

injection of radioisotope (92.28)

injection or infusion of biological response modifier [BRM] as an antineoplastic agent (99.28)

99.26            Injection of tranquilizer

99.27            Iontophoresis

99.28            Injection or infusion of biological response modifier [BRM] as an antineoplastic agent

Low-dose interleukin-2 (IL-2) therapy

Immunotherapy, antineoplastic

Interleukin therapy

Tumor vaccine

Excludes:high-dose infusion interleukin-2 [IL-2] (00.15)

99.29            Injection or infusion of other therapeutic or prophylactic substance

Excludes:            administration of neuroprotective agent (99.75)

immunization (99.31-99.59)

injection of sclerosing agent into:

esophageal varices (42.33)

hemorrhoids (49.42)

veins (39.92)

injection or infusion of human B-type natriuretic peptide (hBNP)(00.13)

injection or infusion of nesiritide (00.13)

injection or infusion of platelet inhibitor (99.20)

injection or infusion of thrombolytic agent (99.10)

99.3            Prophylactic vaccination and inoculation against certain bacterial diseases

99.31            Vaccination against cholera

99.32            Vaccination against typhoid and paratyphoid fever

Administration of TAB vaccine

99.33            Vaccination against tuberculosis

Administration of BCG vaccine

99.34            Vaccination against plague

99.35            Vaccination against tularemia

99.36            Administration of diphtheria toxoid

Excludes:            administration of:

diphtheria antitoxin (99.58)

diphtheria-tetanus-pertussis, combined (99.39)

99.37            Vaccination against pertussis

Excludes:            administration of diphtheria tetanus-pertussis, combined (99.39)

99.38            Administration of tetanus toxoid

Excludes:            administration of:

diphtheria-tetanus-pertussis, combined (99.39)

tetanus antitoxin (99.56)

99.39            Administration of diphtheria-tetanus- pertussis, combined

99.4            Prophylactic vaccination and inoculation against certain viral diseases

99.41            Administration of poliomyelitis vaccine

99.42            Vaccination against smallpox

99.43            Vaccination against yellow fever

99.44            Vaccination against rabies

99.45            Vaccination against measles

Excludes:            administration of measles-mumps rubella vaccine (99.48)

99.46            Vaccination against mumps

Excludes:            administration of measles-mumps rubella vaccine (99.48)

99.47            Vaccination against rubella

Excludes:            administration of measles-mumps rubella vaccine (99.48)

99.48            Administration of measles-mumps-rubella vaccine

99.5      Other vaccination and inoculation

99.51            Prophylactic vaccination against the common cold

99.52            Prophylactic vaccination against influenza

99.53            Prophylactic vaccination against arthropod- borne viral encephalitis

99.54            Prophylactic vaccination against other arthropod-borne viral diseases

99.55            Prophylactic administration of vaccine against other diseases

Vaccination against:

anthrax

brucellosis

Rocky Mountain spotted fever

Staphylococcus

Streptococcus

typhus

99.56            Administration of tetanus antitoxin

99.57            Administration of botulism antitoxin

99.58            Administration of other antitoxins

Administration of:

diphtheria antitoxin

gas gangrene antitoxin

scarlet fever antitoxin

99.59            Other vaccination and inoculation

Vaccination NOS

Excludes:            injection of:

gamma globulin (99.14)

Rh immune globulin (99.11)

immunization for:

allergy (99.12)

autoimmune disease (99.13)

99.6            Conversion of cardiac rhythm

Excludes:            open chest cardiac:

electric stimulation (37.91)

massage (37.91)

99.60            Cardiopulmonary resuscitation, not otherwise specified

99.61            Atrial cardioversion

99.62            Other electric countershock of heart

Cardioversion:

NOS

external

Conversion to sinus rhythm

Defibrillation

External electrode stimulation

99.63            Closed chest cardiac massage

Cardiac massage NOS

Manual external cardiac massage

99.64            Carotid sinus stimulation

99.69            Other conversion of cardiac rhythm

99.7            Therapeutic apheresis or other injection, administration, or infusion of other therapeutic or prophylactic substance

99.71            Therapeutic plasmapheresis

Excludes: extracorporeal immunoadsorption [ECI] 99.76

99.72            Therapeutic leukopheresis

Therapeutic leukocytapheresis

99.73            Therapeutic erythrocytapheresis

Therapeutic erythropheresis

99.74            Therapeutic plateletpheresis

99.75            Administration of neuroprotective agent

99.76            Extracorporeal immunoadsorption

Removal of antibodies from plasma with protein A columns

99.77            Application or administration of adhesion barrier substance