(AMA) CPT 2021 Professional Edition

Symbols
▲ Revised code
● New code
▶◀ New or revised text
➲ Reference to CPT Assistant, Clinical Examples in Radiology, and CPT Changes
✚ Add-on code
⃠ Exemptions to modifier 51
⚡ Product pending FDA approval
# Out-of-numerical sequence code
★ Telemedicine
Duplicate PLA test
⇅ Category I PLA
Modifiers (See Appendix A for definitions)

22 Increased Procedural Services
23 Unusual Anesthesia
24 Unrelated Evaluation and Management Service by the Same Physician or Other
Qualified Health Care Professional During a Postoperative Period
25 Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician or Other Qualified Health Care Professional on the Same Day of the
Procedure or Other Service
26 Professional Component
32 Mandated Services
33 Preventive Services
47 Anesthesia by Surgeon
50 Bilateral Procedure
51 Multiple Procedures
52 Reduced Services
53 Discontinued Procedure
54 Surgical Care Only
55 Postoperative Management Only
56 Preoperative Management Only
57 Decision for Surgery
58 Staged or Related Procedure or Service by the Same Physician or Other Qualified
Health Care Professional During the Postoperative Period
59 Distinct Procedural Service
62 Two Surgeons
63 Procedure Performed on Infants less than 4 kg
66 Surgical Team
76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care
Professional
77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional
78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other
Qualified Health Care Professional Following Initial Procedure for a Related
Procedure During the Postoperative Period
79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health
Care Professional During the Postoperative Period
80 Assistant Surgeon
81 Minimum Assistant Surgeon
82 Assistant Surgeon (when qualified resident surgeon not available)
90 Reference (Outside) Laboratory
91 Repeat Clinical Diagnostic Laboratory Test
92 Alternative Laboratory Platform Testing
95 Synchronous Telemedicine Service Rendered via a Real-Time Interactive Audio and
Video Telecommunications System
96 Habilitative Services
97 Rehabilitative Services
99 Multiple Modifiers
Category II Modifiers
1P Performance Measure Exclusion Modifier due to Medical Reasons
2P Performance Measure Exclusion Modifier due to Patient Reasons
3P Performance Measure Exclusion Modifier due to System Reasons
8P Performance measure reporting modifier–action not performed, reason not otherwise
specified
Anesthesia Physical Status Modifiers

P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes
Modifiers Approved for Hospital Outpatient

Use
Level I (CPT)
25 Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician or Other Qualified Health Care Professional on the Same Day of the
Procedure or Other Service
27 Multiple Outpatient Hospital E/M Encounters on the Same Date
33 Preventive Services
50 Bilateral Procedure
52 Reduced Services
58 Staged or Related Procedure or Service by the Same Physician or Other Qualified
Health Care Professional During the Postoperative Period
59 Distinct Procedural Service
73 Discontinued Outpatient Procedure Prior to Anesthesia Administration
74 Discontinued Outpatient Procedure After Anesthesia Administration
76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care
Professional
77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional
78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other
Qualified Health Care Professional Following Initial Procedure for a Related
Procedure During the Postoperative Period
79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health
Care Professional During the Postoperative Period
91 Repeat Clinical Diagnostic Laboratory Test
Level II (HCPCS/National)
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
GG Performance and payment of a screening mammogram and diagnostic mammogram
on the same patient, same day
GH Diagnostic mammogram converted from screening mammogram on same day
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LM Left main coronary artery
QM Ambulance service provided under arrangement by a provider of services
QN Ambulance service furnished directly by a provider of services
RC Right coronary artery
RI Ramus intermedius coronary artery
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
Place-of-Service Codes for
Professional Claims
Listed below are place-of-service codes and descriptions. These
codes should be used on professional claims to specify the entity
where service(s) were rendered. Check with individual payers
(eg, Medicare, Medicaid, other private insurance) for
reimbursement policies regarding these codes. If you would like
to comment on a code(s) or description(s), please send your
request to [email protected].
Place
of
Service Place of Service
Code(s) Name Place of Service Description
A facility or location where drugs and
other medically related items and
01 Pharmacy services are sold, dispensed, or
otherwise provided directly to
patients. (Effective 10/1/03)
The location where health services
and health related services are
02 Telehealth provided or received, through a
telecommunication system. (Effective
1/1/17)
A facility whose primary purpose is
03 School
education.
04 Homeless Shelter A facility or location whose primary
purpose is to provide temporary
housing to homeless individuals (eg,
emergency shelters, individual or
family shelters).
A facility or location, owned and
operated by the Indian Health Service,
Indian Health which provides diagnostic, therapeutic
05 Service Free- (surgical and non-surgical), and
Standing Facility rehabilitation services to American
Indians and Alaska Natives who do
not require hospitalization.
A facility or location, owned and
operated by the Indian Health Service,
which provides diagnostic, therapeutic
Indian Health
(surgical and non-surgical), and
06 Service Provider-
rehabilitation services rendered by, or
Based Facility
under the supervision of, physicians to
American Indians and Alaska Natives
admitted as inpatients or outpatients.
A facility or location owned and
operated by a federally recognized
American Indian or Alaska Native
tribe or tribal organization under a 638
Tribal 638 Free-
07 agreement, which provides diagnostic,
Standing Facility
therapeutic (surgical and non-
surgical), and rehabilitation services
to tribal members who do not require
hospitalization.
08 Tribal 638 A facility or location owned and
Provider-Based operated by a federally recognized
Facility American Indian or Alaska Native
tribe or tribal organization under a 638
agreement, which provides diagnostic,
therapeutic (surgical and non-
surgical), and rehabilitation services
to tribal members admitted as
inpatients or outpatients.
A prison, jail, reformatory, work farm,
detention center, or any other similar
facility maintained by either Federal,
Prison/Correctional
09 State, or local authorities for the
Facility
purpose of confinement or
rehabilitation of adult or juvenile
criminal offenders. (Effective 7/1/06)
10 Unassigned N/A
Location, other than a hospital, skilled
nursing facility (SNF), military
treatment facility, community health
center, State or local public health
clinic, or intermediate care facility
11 Office
(ICF), where the health professional
routinely provides health
examinations, diagnosis, and treatment
of illness or injury on an ambulatory
basis.
Location, other than a hospital or other
12 Home facility, where the patient receives
care in a private residence.
Congregate residential facility with
self-contained living units providing
assessment of each resident’s needs
Assisted Living and on-site support 24 hours a day, 7
13
Facility days a week, with the capacity to
deliver or arrange for services
including some health care and other
services. (Effective 10/1/03)
14 Group Home A residence, with shared living areas,
where clients receive supervision and
other services such as social and/or
behavioral services, custodial service,
and minimal services (eg, medication
administration). (Effective 10/1/03)
A facility/unit that moves from place-
to-place equipped to provide
15 Mobile Unit
preventive, screening, diagnostic,
and/or treatment services.
A short term accommodation such as a
hotel, camp ground, hostel, cruise ship
or resort where the patient receives
16 Temporary Lodging
care, and which is not identified by
any other POS code. (Effective
1/1/08)
A walk-in health clinic, other than an
office, urgent care facility, pharmacy,
or independent clinic, and not
described by any other Place of
Walk-in Retail
17 Service code, that is located within a
Health Clinic
retail operation and provides, on an
ambulatory basis, preventive and
primary care services. (Effective
5/1/10)
A location, not described by any other
POS code, owned or operated by a
public or private entity where the
patient is employed, and where a
Place of
health professional provides on-going
18 Employment—
or episodic occupational medical,
Worksite
therapeutic or rehabilitative services
to the individual. (This code is
available for use effective January 1,
2013 but no later than May 1, 2013.)
19 Off Campus— A portion of an off-campus hospital
Outpatient Hospital provider based department which
provides diagnostic, therapeutic (both
surgical and nonsurgical), and
rehabilitation services to sick or
injured persons who do not require
hospitalization or institutionalization.
(Effective January 1, 2016)
Location, distinct from a hospital
emergency room, an office, or a clinic,
Urgent Care whose purpose is to diagnose and treat
20
Facility illness or injury for unscheduled,
ambulatory patients seeking immediate
medical attention. (Effective 1/1/03)
A facility, other than psychiatric,
which primarily provides diagnostic,
therapeutic (both surgical and non-
21 Inpatient Hospital surgical), and rehabilitation services
by, or under, the supervision of
physicians to patients admitted for a
variety of medical conditions.
A portion of a hospital’s main campus
which provides diagnostic, therapeutic
(both surgical and non-surgical), and
On Campus— rehabilitation services to sick or
22
Outpatient Hospital injured persons who do not require
hospitalization or institutionalization.
(Description change effective January
1, 2016)
A portion of a hospital where
Emergency Room
23 emergency diagnosis and treatment of
—Hospital
illness or injury is provided.
24 Ambulatory A free-standing facility, other than a
Surgical Center physician’s office, where surgical and
diagnostic services are provided on an
ambulatory basis.
A facility, other than a hospital’s
maternity facilities or a physician’s
office, which provides a setting for
25 Birthing Center
labor, delivery, and immediate
postpartum care as well as immediate
care of newborn infants.
A medical facility operated by one or
more of the Uniformed Services.
Military Treatment Facility (MTF)
Military Treatment also refers to certain former U.S.
26
Facility Public Health Service (USPHS)
facilities now designated as
Uniformed Service Treatment
Facilities (USTF).
27-30 Unassigned N/A
A facility which primarily provides
inpatient skilled nursing care and
related services to patients who
Skilled Nursing
31 require medical, nursing, or
Facility
rehabilitative services but does not
provide the level of care or treatment
available in a hospital.
A facility which primarily provides to
residents skilled nursing care and
related services for the rehabilitation
of injured, disabled, or sick persons,
32 Nursing Facility
or, on a regular basis, health-related
care services above the level of
custodial care to other than individuals
with intellectual disabilities.
33 Custodial Care A facility that provides room, board,
Facility and other personal assistance services,
generally on a long-term basis, and
which does not include a medical
component.
A facility, other than a patient’s home,
in which palliative and supportive
34 Hospice
care for terminally ill patients and
their families are provided.
A land vehicle specifically designed,
41 Ambulance—Land equipped and staffed for lifesaving and
transporting the sick or injured.
An air or water vehicle specifically
Ambulance—Air designed, equipped, and staffed for
42
or Water lifesaving and transporting the sick or
injured.
A location, not part of a hospital and
not described by any other Place of
Service code, that is organized and
49 Independent Clinic operated to provide preventive,
diagnostic, therapeutic, rehabilitative,
or palliative services to outpatients
only. (Effective 10/1/03)
A facility located in a medically
underserved area that provides
Federally Qualified
50 Medicare beneficiaries preventive
Health Center
primary medical care under the
general direction of a physician.
A facility that provides inpatient
psychiatric services for the diagnosis
Inpatient
51 and treatment of mental illness on a
Psychiatric Facility
24-hour basis, by or under the
supervision of a physician.
52 Psychiatric Facility A facility for the diagnosis and
—Partial treatment of mental illness that
Hospitalization provides a planned therapeutic
program for patients who do not
require full time hospitalization, but
who need broader programs than are
possible from outpatient visits to a
hospital-based or hospital-affiliated
facility.
A facility that provides the following
services: outpatient services, including
specialized outpatient services for
children, the elderly, individuals who
are chronically ill, and residents of the
CMHC’s mental health services area
who have been discharged from
inpatient treatment at a mental health
Community Mental facility; 24 hour a day emergency care
53
Health Center services; day treatment, other partial
hospitalization services, or
psychosocial rehabilitation services;
screening for patients being
considered for admission to State
mental health facilities to determine
the appropriateness of such admission;
and consultation and education
services.
A facility which primarily provides
health-related care and services above
Intermediate Care
the level of custodial care to
Facility/Individuals
54 individuals with intellectual
with Intellectual
disabilities but does not provide the
Disabilities
level of care or treatment available in
a hospital or SNF.
55 Residential A facility which provides treatment for
Substance Abuse substance (alcohol and drug) abuse to
Treatment Facility live-in residents who do not require
acute medical care. Services include
individual and group therapy and
counseling, family counseling,
laboratory tests, drugs and supplies,
psychological testing, and room and
board.
A facility or distinct part of a facility
Psychiatric for psychiatric care which provides a
56 Residential total 24-hour therapeutically planned
Treatment Center and professionally staffed group living
and learning environment.
A location which provides treatment
for substance (alcohol and drug) abuse
on an ambulatory basis. Services
Non-residential
include individual and group therapy
57 Substance Abuse
and counseling, family counseling,
Treatment Facility
laboratory tests, drugs and supplies,
and psychological testing. (Effective
10/1/03)
A location that provides treatment for
opioid use disorder on an ambulatory
Non-residential
basis. Services include methadone and
58 Opioid Treatment
other forms of Medication Assisted
Facility
Treatment (MAT). (Effective January
1, 2020)
59 Unassigned N/A
60 Mass Immunization A location where providers administer
Center pneumococcal pneumonia and
influenza virus vaccinations and
submit these services as electronic
media claims, paper claims, or using
the roster billing method. This
generally takes place in a mass
immunization setting, such as, a public
health center, pharmacy, or mall but
may include a physician office setting.
A facility that provides comprehensive
rehabilitation services under the
Comprehensive supervision of a physician to inpatients
Inpatient with physical disabilities. Services
61
Rehabilitation include physical therapy, occupational
Facility therapy, speech pathology, social or
psychological services, and orthotics
and prosthetics services.
A facility that provides comprehensive
rehabilitation services under the
Comprehensive
supervision of a physician to
Outpatient
62 outpatients with physical disabilities.
Rehabilitation
Services include physical therapy,
Facility
occupational therapy, and speech
pathology services.
A facility other than a hospital, which
End-Stage Renal provides dialysis treatment,
65 Disease Treatment maintenance, and/or training to
Facility patients or caregivers on an
ambulatory or home-care basis.
A facility maintained by either State or
local health departments that provides
Public Health
71 ambulatory primary medical care
Clinic
under the general direction of a
physician.
72 Rural Health Clinic A certified facility which is located in
a rural medically underserved area
that provides ambulatory primary
medical care under the general
direction of a physician.
A laboratory certified to perform
Independent diagnostic and/or clinical tests
81
Laboratory independent of an institution or a
physician’s office.
Other Place of Other place of service not identified
99
Service above.
Executive Vice President, Chief Executive Officer: James L. Madara,
MD
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1
Professional ISBN: 978-1-64016-049-1

ISSN: 0276-8283
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1977, 1981, 1983-2020 by the American Medical Association. All rights
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2nd Edition printed 1970
3rd Edition printed 1973
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About CPT
Current Procedural Terminology (CPT®), Fourth Edition, is a listing of
descriptive terms and identifying codes for reporting medical services and
procedures performed by physicians and other qualified health care
professionals. The purpose of the terminology is to provide a uniform
language that will accurately describe medical, surgical, and diagnostic
services, and will thereby provide an effective means for reliable
nationwide communication among physicians and other qualified health care
professionals, patients, and third parties. CPT 2021 is the most recent
revision of a work that first appeared in 1966.
CPT descriptive terms and identifying codes currently serve a wide variety
of important functions in the field of medical nomenclature. The CPT code
set is useful for administrative management purposes such as claims
processing and for the development of guidelines for medical care review.
The uniform language is also applicable to medical education and outcomes,
health services, and quality research by providing a useful basis for local,
regional, and national utilization comparisons. The CPT code set is the most
widely accepted nomenclature for the reporting of physician and other
qualified health care professional procedures and services under government
and private health insurance programs. In 2000, the CPT code set was
designated by the Department of Health and Human Services as the national
coding standard for physician and other health care professional services and
procedures under the Health Insurance Portability and Accountability Act
(HIPAA). This means that for all financial and administrative health care
transactions sent electronically, the CPT code set will need to be used.
The changes that appear in this revision have been prepared by the CPT
Editorial Panel with the assistance of physicians and representatives of other
health care professions representing all specialties of medicine, and with
important contributions from many third-party payers and governmental
agencies.
The American Medical Association trusts that this revision will continue the
usefulness of its predecessors in identifying, describing, and coding medical,
surgical, and diagnostic services.
Maintenance and Authorship of the
CPT Code Set
The CPT Editorial Panel (Panel) is tasked with ensuring that CPT codes
remain up to date and reflect the latest medical care provided to patients. In
order to do this, the Panel maintains an open process and convenes meetings
at a minimum three times per year.
The Panel wishes to sincerely thank the many national medical specialty
societies, health insurance organizations and agencies, and individual
physicians and other health professionals who have made contributions. In
particular, the Panel acknowledges the efforts of the following Panel
Organizational and Coding Liaison Participants:
Sue Bowman, RHIA, American Health Information Management
Association
Raemarie Jiminez, CPC, American Academy of Professional Coders
Nelly Leon-Chisen, American Hospital Association
Mary E. Little, RN, CPC, Blue Cross and Blue Shield Association
Karen Nakano, MD, MS, Centers for Medicare & Medicaid Services
Also key to authorship of the code set and resulting CPT Professional
Edition codebook is AMA CPT staff. This experienced team prepares
agenda materials for each panel meeting, facilitates the application process,
compiles and reviews advisor comments, reconciles differences in opinions,
and ultimately compiles all resulting information into a codebook filled with
informative guidelines, practical tips, and procedural illustrations.
AMA CPT Staff
Shawn Agyeman
Jay T. Ahlman
Thilani Attale, MS
Jennifer Bell, BS, RHIT, CPC, CPMA, CPC-I, CEMC, CPEDC
Barbara Benstead
Andrei Besleaga, BS, RHIT
Judy Connelly
Kyle Dahl
Caitlin Dale
Martha Espronceda
Desiree D. Evans, BS
DeHandro Hayden, BS
Zach Hochstetler, MPP, MBA, CPC
Janette Meggs, RHIA
Karen E. O’Hara, BS, CCS-P
Michael Pellegrino
Leslie W. Prellwitz, MBA, CCS, CCS-P
Desiree Rozell, MPA
Nancy Spector, BSN, MSC
Lianne Stancik, BA, RHIT
Keisha A. Sutton-Asaya, MHA, CPC
Donna Tyler, BS, CPC, COBGC
Okwara Uzoh
Ada Walker, CCA
Arletrice Watkins, MHA, RHIA
Rejina L. Young
AMA CPT Advisory Committee
American Academy of Child & Adolescent Psychiatry
Benjamin N. Shain, MD, PhD
Jason V. Chang, MD
American Academy of Dermatology
Alexander Miller, MD
Ann F. Haas, MD
American Academy of Family Physicians
Bradley P. Fox, MD, FAAFP
Samuel L. Church, MD, MPH, CPC, CRC, FAAFP
American Academy of Neurology
Bruce H. Cohen, MD, FAAN
Neil A. Busis, MD
American Academy of Ophthalmology
Michael X. Repka, MD, MBA
John M. Haley, MD
American Academy of Orthopaedic Surgeons
Frank R. Voss, MD
Julie Bishop, MD
American Academy of Otolaryngic Allergy
Paul T. Fass, MD, FACS
American Academy of Otolaryngology Head and Neck Surgery
James Lin, MD, FACS
Jay Shah, MD
American Academy of Pain Medicine
Eduardo M. Fraifeld, MD
Gregory R. Polston, MD
American Academy of Pediatrics
Joel F. Bradley, Jr, MD, FAAP
Renee Slade, MD, FAAP
American Academy of Physical Medicine and Rehabilitation
Annie D. Purcell, DO
Scott I. Horn, DO
American Association for Thoracic Surgery
Richard K. Freeman, II, MD
Kristine Guleserian, MD
American Association of Clinical Endocrinologists
William C. Biggs, MD, FACE, ECNU
Pavan Chava, DO, FACE
American Association of Clinical Urologists
Jeffery Glaser, MD, FACS
American Association of Neurological Surgeons
Joseph S. Cheng, MD, MS, FACS, FAANS
American Association of Neuromuscular and Electrodiagnostic Medicine
John C. Kincaid, MD
Earl J. Craig, MD
American Clinical Neurophysiology Society
Marc R. Nuwer, MD, PhD, FAAN, FACP
American College of Allergy, Asthma and Immunology
James L. Sublett, MD‡
Gary N. Gross, MD
American College of Cardiology
Randall C. Thompson, MD
Dmitriy Feldman, MD
American College of Chest Physicians
Steve G. Peters, MD
Michael E. Nelson, MD, FCCP
American College of Emergency Physicians
Jacob Mark J. Meredith, III, MD, MMM, FACEP
Michael J. Lemanski, MD, FACEP, FAAFP
American College of Gastroenterology
Christopher Y. Kim, MD, MBA, FACG, FASGE, AGAF, FACP
American College of Medical Genetics and Genomics
David B. Flannery, MD
American College of Mohs Surgery
David B. Pharis, MD, PC
Kishwer S. Nehal, MD
American College of Nuclear Medicine
Gary L. Dillehay, MD, FACNP, FACR
Alan K. Klitzke, MD, FACNM
American College of Obstetricians and Gynecologists
Judith Volkar, MD, MBA
Kathy Y. Jones, MD
American College of Physicians
Jeannine Z. Engel, MD, FACP
American College of Preventive Medicine
Andrew Karasick, MD‡
American College of Radiation Oncology
Sheila Rege, MD, FACRO
Andy W. Su, MD
American College of Radiology
Mark D. Alson, MD, FACR, RCC‡
Timothy A. Crummy, MD, RCC
American College of Rheumatology
Joseph E. Huffstutter, MD
American College of Surgeons
Samuel D. Smith, MD
Megan E. McNally, MD, FACS
American Dental Association
Joshua E. Everts, DDS, MD
Adam S. Pitts, DDS, MD
American Gastroenterological Association
Braden Kuo, MD
Joseph Losurdo, MD‡
American Geriatrics Society
Robert A. Zorowitz, MD, MBA, FACP, AGSF, CMD
American Institute of Ultrasound in Medicine
James M. Shwayder, MD, JD
American Orthopaedic Association
Blair C. Filler, MD
M. Bradford Henley, MD
American Orthopaedic Foot and Ankle Society
John A. DiPreta, MD
Scott Shawen, MD
American Osteopathic Association
James M. Bailey, DO, PhD
Boyd Buser, DO, FACOFP
American Psychiatric Association
Jeremy S. Musher, MD, DFAPA
Sarah Parsons, DO
American Rhinologic Society
Bradford Woodworth, MD
Stacey Gray, MD
American Roentgen Ray Society
Eric M. Rubin, MD
Dana H. Smetherman, MD, MPH, FACR
American Society for Aesthetic Plastic Surgery, Inc.
Paul R. Weiss, MD
American Society for Clinical Pathology
Lee H. Hilborne, MD, MPH, FASCP
American Society for Dermatologic Surgery
Murad Alam, MD, MBA
American Society for Gastrointestinal Endoscopy
Glenn D. Littenberg, MD, MACP
Daniel C. DeMarco, MD, FACP‡
American Society for Metabolic and Bariatric Surgery
Matthew L. Brengman, MD
American Society for Radiation Oncology
Corbin R. Johnson, MD
Catheryn Yashar, MD
American Society for Surgery of the Hand
Steven H. Goldberg, MD, FAAOS‡
American Society of Addiction Medicine
Joel V. Brill, MD, FACP, AGAF
Shawn Ryan, MD‡
American Society of Anesthesiologists
Peter A. Goldzweig, DO
Padma Gulur, MD
American Society of Breast Surgeons
Richard E. Fine, MD, FACS
American Society of Clinical Oncology
Christian A. Thomas, MD
Joseph J. Merchant, MD‡
American Society of Colon and Rectal Surgeons
William J. Harb, MD, FACS
Sonia Ramamoorthy, MD, FACS
American Society of Dermatopathology
Jonathan S. Ralston, MD
Aleodor A. Andea, MD, MBA
American Society of Echocardiography
Michael L. Main, MD
Susan A. Mayer, MD
American Society of General Surgeons
George K. Gillian, MD, FACS
Christopher C. Smith, MD
American Society of Hematology
Samuel M. Silver, MD, PhD, MACP, FAHA, FASCO‡
Chancellor E. Donald, MD
American Society of Interventional Pain Physicians
Sachin Jha, MD, MS
American Society of Neuroimaging
Ryan Hakimi, DO, MS
American Society of Neuroradiology
Raymond K. Tu, MD, FACR
Colin Segovis, MD
American Society of Ophthalmic Plastic and Reconstructive Surgery
L. Neal Freeman, MD, MBA, CCS-P, FACS
American Society of Plastic Surgeons
Daniel T. Ness, MD
Jeffrey H. Kozlow, MD, MS
American Society of Retina Specialists
Gayatri S. Reilly, MD
Christopher R. Henry, MD
American Thoracic Society
Stephen P. Hoffmann, MD
Michael E. Nelson, MD, FCCP
American Urological Association
Ronald P. Kaufman, Jr, MD, FACS
Jonathan R. Rubenstein, MD‡
American Vein & Lymphatic Society
Satish Vayuvegula, MD, MS
Michael S. Graves, MD
Association of University Radiologists
Andrew Degnan, MD
Richard Duszak, Jr, MD, FACR
College of American Pathologists
Jerry Hussong, MD, DDS, MS, MBA
Ronald W. McLawhon, MD, PhD
Congress of Neurological Surgeons
Henry H. Woo, MD, FACS, FAANS
Cheerag Upadhyaya, MD, MS, FACS
Heart Rhythm Society
JoEllyn C. Moore, MD, FACC
Steven C. Hao, MD, FACC, FHRS‡
Infectious Disease Society of America
Steven K. Schmitt, MD
Ronald E. Devine, MD
International Society for the Advancement of Spine Surgery
James J. Yue, MD
National Association of Medical Examiners
Allecia M. Wilson, MD
North American Neuromodulation Society
Corey W. Hunter, MD
North American Spine Society
William Mitchell, MD
David R. O’Brien, Jr, MD
Radiological Society of North America
Timothy A. Crummy, MD
Andrew Degnan, MD
Renal Physicians Association
Chester A. Amedia, Jr, MD, FACP
Timothy A. Pflederer, MD
Society for Cardiovascular Angiography and Interventions
Arthur C. Lee, MD, FSCAI
Sergio Bartakian, MD, FSCAI
Society for Investigative Dermatology
Stephen P. Stone, MD
Society for Vascular Surgery
Sean P. Roddy, MD, FACS
Sunita Srivastava, MD‡
Society of American Gastrointestinal Endoscopic Surgeons
John S. Roth, MD, FACS
Kevin E. Wasco, MD, FACS
Society of Critical Care Medicine
Piyush Mathur, MD
Society of Interventional Radiology
Timothy L. Swan, MD
Clifford M. Hawkins, MD
Society of Nuclear Medicine and Molecular Imaging
Scott C. Bartley, MD
Gary L. Dillehay, MD, FACNP, FACR
Society of Thoracic Surgeons
Francis C. Nichols, III, MD
Jeffrey P. Jacobs, MD, FACS, FACC, FCCP
The Endocrine Society
Ilona Lorincz, MD
The Spinal Intervention Society
Scott I. Horn, DO
The Triological Society
Richard W. Waguespack, MD, FACS
Brian J. McKinnon, MD, MBA
United States and Canadian Academy of Pathology
Michael O. Idowu, MD, MPH
‡New Advisors
AMA Health Care Professionals
Advisory Committee (HCPAC)
Mark S. Synovec, MD*, Co-Chair
AMA CPT Editorial Panel
Douglas C. Morrow, OD, Co-Chair
AMA CPT Editorial Panel
Academy of Nutrition and Dietetics
Keith-Thomas Ayoob, EdD, RN, FADA, CSP
Jessie M. Pavlianc, MS, RD, CSR, LD
American Academy of Audiology
Brad A. Stach, PhD
Annette A. Burton, AuD
American Academy of Physician Assistants
Patrick J. Cafferty, MPAS, PA-C
American Association of Naturopathic Physicians
Eva Miller, ND
Amy E. Hobson, ND
American Association for Respiratory Care
Susan Rinaldo-Gallo, MEd, RRT, FAARC, CTTS
American Chiropractic Association
Leo Bronston, DC, MAppSc
Kris Anderson, DC, MS‡
American Massage Therapy Association
Nancy M. Porambo, BA, MS, LMT, NCTMB
Angela Barker, DCTMB, LMT
American Nurses Association
Jamesetta A. Newland, PhD, RN, FNP-BC, FAANP, DPNAP
Jill Olmstead, MSN, NP-C, ANP-BC, FAANP
American Occupational Therapy Association
Leslie F. Davidson, PhD, OTR/L‡
Tippi Geron, MS, OTR/L, FAOTA
American Optometric Association
Rebecca H. Wartman, OD
Harvey B. Richman, OD, FAAO
American Physical Therapy Association
Kathleen M. Picard, PT
Angela Brooks, PT
American Podiatric Medical Association
Ira H. Kraus, DPM
Phillip E. Ward, DPM
American Psychological Association
Neil H. Pliskin, PhD, ABPP-CN
American Speech-Language-Hearing Association
Stuart G. Trembath, MA, CCC-A
National Athletic Trainers’ Association
Karen D. Fennell, MS, ATC
Joseph J. Greene, MS, ATC‡
National Association of Social Workers
Mirean F. Coleman, LICSW
Doris F. Tomer, LCSW, BCD
National Society of Genetic Counselors
Karen E. Lewis, MS, MM, CGC
Pharmacy Health Information Technology Collaborative
Brian J. Isetts, PhD, BCPS, FAPhA
*Member of the CPT Executive Committee

‡New Advisors
Contents
About CPT
Maintenance and Authorship of the CPT Code Set
AMA CPT Staff
Introduction
▶ Release of CPT Codes◀
Section Numbers and Their Sequences
Instructions for Use of the CPT Codebook
Format of the Terminology
Requests to Update the CPT Nomenclature
Application Submission Requirements
General Criteria for Category I, II, and III Codes
Category-Specific Requirements
Guidelines
Add-on Codes
Modifiers
Place of Service and Facility Reporting
Unlisted Procedure or Service
Results, Testing, Interpretation, and Report
Special Report
Time
Code Symbols
Alphabetical Reference Index
Use of Anti-Piracy Technology in CPT Professional 2021
Codebook
CPT 2021 in Electronic Formats
References to AMA Resources
Illustrated Anatomical and Procedural Review

Prefixes, Suffixes, and Roots
Numbers
Surgical Procedures
Conditions
Directions and Positions
Additional References
Medical Dictionaries
Anatomy References
Lists of Illustrations
Anatomical Illustrations
Procedural Illustrations
Evaluation and Management Tables
Evaluation and Management (E/M) Services Guidelines

▶ E/M Guidelines Overview◀
Classification of Evaluation and Management (E/M) Services
Definitions of Commonly Used Terms
▶ Guidelines Common to All E/M Services◀
▶ Guidelines for Hospital Observation, Hospital Inpatient,
Consultations, Emergency Department, Nursing Facility, Domiciliary,
Rest Home, or Custodial Care, and Home E/M Services◀
▶ Instructions
for Selecting a Level of E/M Service for Hospital
Observation, Hospital Inpatient, Consultations, Emergency Department,
Nursing Facility, Domiciliary, Rest Home, or Custodial Care, and Home
E/M Services◀
▶ Guidelines for Office or Other Outpatient E/M Services◀
▶ Instructions for Selecting a Level of Office or Other Outpatient E/M
Services◀
Unlisted Service
Special Report
Clinical Examples
Evaluation and Management

Office or Other Outpatient Services
Hospital Observation Services
Hospital Inpatient Services
Consultations
Emergency Department Services
Critical Care Services
Nursing Facility Services
Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care
Services
Domiciliary, Rest Home (eg, Assisted Living Facility), or Home Care
Plan Oversight Services
Home Services
Prolonged Services
Case Management Services
Care Plan Oversight Services
Preventive Medicine Services
Non-Face-to-Face Services
Special Evaluation and Management Services
Newborn Care Services
Delivery/Birthing Room Attendance and Resuscitation Services
Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal
Cognitive Assessment and Care Plan Services
Care Management Services
Psychiatric Collaborative Care Management Services
Transitional Care Management Services
Advance Care Planning
General Behavioral Health Integration Care Management
Other Evaluation and Management Services
Anesthesia Guidelines
Time Reporting
Anesthesia Services
Supplied Materials
Separate or Multiple Procedures
Unlisted Service or Procedure
Special Report
Anesthesia Modifiers
Qualifying Circumstances
Anesthesia
Head
Neck
Thorax (Chest Wall and Shoulder Girdle)
Intrathoracic
Spine and Spinal Cord
Upper Abdomen
Lower Abdomen
Perineum
Pelvis (Except Hip)
Upper Leg (Except Knee)
Knee and Popliteal Area
Lower Leg (Below Knee, Includes Ankle and Foot)
Shoulder and Axilla
Upper Arm and Elbow
Forearm, Wrist, and Hand
Radiological Procedures
Burn Excisions or Debridement
Obstetric
Other Procedures
Surgery Guidelines
Services
CPT Surgical Package Definition
Follow-Up Care for Diagnostic Procedures
Follow-Up Care for Therapeutic Surgical Procedures
Supplied Materials
Reporting More Than One Procedure/Service
Separate Procedure
Special Report
Imaging Guidance
Surgical Destruction
Surgery
General
Integumentary System
Musculoskeletal System
Respiratory System
Cardiovascular System
Hemic and Lymphatic Systems
Mediastinum and Diaphragm
Digestive System
Urinary System
Male Genital System
Reproductive System Procedures
Intersex Surgery
Female Genital System
Maternity Care and Delivery
Endocrine System
Nervous System
Eye and Ocular Adnexa
Auditory System
Operating Microscope
Radiology Guidelines (Including Nuclear Medicine and Diagnostic

Ultrasound)
Subject Listings
Separate Procedures
Special Report
Supervision and Interpretation, Imaging Guidance
Administration of Contrast Material(s)
Written Report(s)
Radiology
Diagnostic Radiology (Diagnostic Imaging)
Diagnostic Ultrasound
Radiologic Guidance
Breast, Mammography
Bone/Joint Studies
Radiation Oncology
Nuclear Medicine
Pathology and Laboratory Guidelines

Services in Pathology and Laboratory
Special Report
Pathology and Laboratory

Organ or Disease-Oriented Panels
Drug Assay
Therapeutic Drug Assays
Evocative/Suppression Testing
Consultations (Clinical Pathology)
Urinalysis
Molecular Pathology
Genomic Sequencing Procedures and Other Molecular Multianalyte
Assays
Multianalyte Assays with Algorithmic Analyses
Chemistry
Hematology and Coagulation
Immunology
Transfusion Medicine
Microbiology
Anatomic Pathology
Cytopathology
Cytogenetic Studies
Surgical Pathology
In Vivo (eg, Transcutaneous) Laboratory Procedures
Other Procedures
Reproductive Medicine Procedures
Proprietary Laboratory Analyses
Medicine Guidelines
Add-on Codes
Separate Procedures
Special Report
Imaging Guidance
Supplied Materials
Medicine
Immune Globulins, Serum or Recombinant Products
Immunization Administration for Vaccines/Toxoids
Vaccines, Toxoids
Psychiatry
Biofeedback
Dialysis
Gastroenterology
Ophthalmology
Special Otorhinolaryngologic Services
Cardiovascular
Noninvasive Vascular Diagnostic Studies
Pulmonary
Allergy and Clinical Immunology
Endocrinology
Neurology and Neuromuscular Procedures
Medical Genetics and Genetic Counseling Services
Adaptive Behavior Services
Central Nervous System Assessments/Tests (eg, Neuro-Cognitive,
Mental Status, Speech Testing)
Health Behavior Assessment and Intervention
Hydration, Therapeutic, Prophylactic, Diagnostic Injections and
Infusions, and Chemotherapy and Other Highly Complex Drug or Highly
Complex Biologic Agent Administration
Photodynamic Therapy
Special Dermatological Procedures
Physical Medicine and Rehabilitation
Medical Nutrition Therapy
Acupuncture
Osteopathic Manipulative Treatment
Chiropractic Manipulative Treatment
Education and Training for Patient Self-Management
Non-Face-to-Face Nonphysician Services
Special Services, Procedures and Reports
Qualifying Circumstances for Anesthesia
Moderate (Conscious) Sedation
Other Services and Procedures
Home Health Procedures/Services
Medication Therapy Management Services
Category II Codes
Modifiers
Composite Codes
Patient Management
Patient History
Physical Examination
Diagnostic/Screening Processes or Results
Therapeutic, Preventive, or Other Interventions
Follow-up or Other Outcomes
Patient Safety
Structural Measures
Nonmeasure Code Listing
Category III Codes
Appendix A—Modifiers
Appendix B—Summary of Additions, Deletions, and Revisions
Appendix C—Clinical Examples

Subsequent Hospital Care
Consultations
Prolonged Services
Prolonged Clinical Staff Services with Physician or Other Qualified
Health Care Professional Supervision
Inpatient Neonatal Intensive Care Service and Pediatric and Neonatal
Appendix D—Summary of CPT Add-on Codes
Appendix E—Summary of CPT Codes Exempt from Modifier 51
Appendix F—Summary of CPT Codes Exempt from Modifier 63
Appendix G—Summary of CPT Codes That Include Moderate

(Conscious) Sedation
Appendix H—Alphabetical Clinical Topics Listing (AKA – Alphabetical

Listing)
Appendix I—Genetic Testing Code Modifiers
Appendix J—Electrodiagnostic Medicine Listing of Sensory, Motor, and

Mixed Nerves
Appendix K—Product Pending FDA Approval
Appendix L—Vascular Families
Appendix M—Renumbered CPT Codes–Citations Crosswalk
Appendix N—Summary of Resequenced CPT Codes
Appendix O—Multianalyte Assays with Algorithmic Analyses and

Appendix P—CPT Codes That May Be Used For Synchronous

Telemedicine Services
Index
Introduction
Current Procedural Terminology (CPT®), Fourth Edition, is a set of codes,

descriptions, and guidelines intended to describe procedures and services
performed by physicians and other health care professionals, or entities.
Each procedure or service is identified with a five-digit code. The use of
CPT codes simplifies the reporting of procedures and services. In the CPT
code set, the term “procedure” is used to describe services, including
diagnostic tests.
Inclusion of a descriptor and its associated five-digit code number in the
CPT Category I code set is based on whether the procedure or service is
consistent with contemporary medical practice and is performed by many
practitioners in clinical practice in multiple locations. Inclusion in the CPT
code set of a procedure or service, or proprietary name, does not represent
endorsement by the American Medical Association (AMA) of any particular
diagnostic or therapeutic procedure or service or proprietary test or
manufacturer. Inclusion or exclusion of a procedure or service, or
proprietary name, does not imply any health insurance coverage or
reimbursement policy.
▶The main body of the Category I section is listed in six sections. Each
section is divided into subsections with anatomic, procedural, condition, or
descriptor subheadings. The procedures and services with their identifying
codes are presented in numeric order with one exception—the entire
Evaluation and Management section (99202-99499) appears at the
beginning of the listed procedures. These items are used by most physicians
in reporting a significant portion of their services.◀
▶ Release of CPT Codes◀

▶The CPT code set is published annually in late summer or early fall as
both electronic data files and books. The release of CPT data files occurs
annually on or around August 31. The release of the CPT Professional
publication comes several weeks later. However, to meet the needs of a
rapidly changing health care environment, the CPT code set is periodically
updated throughout the year on a set schedule. Each update has both a release
date and an effective date. The interval between the release of the update and
the effective date is considered an implementation period and is intended to
allow physicians and other providers, payers, and vendors to incorporate
CPT changes into their systems. Changes to the CPT code set are meant to be
applied prospectively from the effective date. The following table outlines
the complete CPT code set update calendar.
New CPT codes have been created to streamline services related to the
novel coronavirus. It is imperative to check the AMA CPT public website at
https://www.ama-assn.org/practice-management/cpt/covid-19-coding-and-
guidance throughout the year to obtain the necessary frequent updates to the
CPT code set.◀
▶ CPT Code Set Update Calendar◀

Release Effective
▶ CPT Category/Section Timeline Timeline
Category I
August 31 January 1
Category II
Category III January 1 July 1
Immune Globulins, Serum, or Recombinant
Products July 1 January 1
Vaccines, Toxoids
Molecular Pathology Tier 2 April 1 July 1
Administrative MAAA July 1 October 1
October 1* January 1
PLA January 1 April 1
April 1 July 1
July 1 October 1
October 1 January 1
* Note that the release date may be delayed by several days due to the timing of the CPT Panel fall
meeting.◀
▶It is imperative to check the AMA CPT public website throughout the year
to obtain the necessary updates to the CPT code set. The following are
several links on the AMA CPT website where these updates can be found:
• Category III codes: ama-assn.org/cpt-cat-iii-codes
• Immune globulins, serum, or recombinant products and vaccines, toxoids:
ama-assn.org/cpt-cat-i-vaccine-codes
• Proprietrary Laboratory Analyses (PLA) codes: ama-assn.org/cpt-pla-
codes
• Administrative MAAA codes: ama-assn.org/maaa-code
• Molecular pathology tier 2 codes: ama-assn.org/mo-path-tier-2-codes
• General errata and technical correction updates: ama-assn.org/practice-
management/cpt/errata-technical-corrections◀
Section Numbers and Their Sequences

Evaluation and Management 99202-99499
Anesthesiology 00100-01999, 99100-
99140
Surgery 10004-69990
Radiology (Including Nuclear Medicine and
Diagnostic Ultrasound) 70010-79999
Pathology and Laboratory 80047-89398,
0001U-0222U
Medicine (except Anesthesiology) 90281-99199, 99500-
99607
The first and last code numbers and the subsection name of the items appear
at the top margin of most pages (eg, “10140-11006 Surgery/Integumentary
System”). The continuous pagination of the CPT codebook is found on the
lower margin of each page along with explanation of any code symbols that
are found on that page.
Instructions for Use of the CPT

Codebook
Select the name of the procedure or service that accurately identifies the
service performed. Do not select a CPT code that merely approximates the
service provided. If no such specific code exists, then report the service
using the appropriate unlisted procedure or service code. In surgery, it may
be an operation; in medicine, a diagnostic or therapeutic procedure; in
radiology, a radiograph. Other additional procedures performed or pertinent
special services are also listed. When necessary, any modifying or
extenuating circumstances are added. Any service or procedure should be
adequately documented in the medical record.
It is equally important to recognize that as techniques in medicine and surgery
have evolved, new types of services, including minimally invasive surgery,
as well as endovascular, percutaneous, and endoscopic interventions have
challenged the traditional distinction of Surgery vs Medicine. Thus, the
listing of a service or procedure in a specific section of this book should not
be interpreted as strictly classifying the service or procedure as “surgery” or
“not surgery” for insurance or other purposes. The placement of a given
service in a specific section of the book may reflect historical or other
considerations (eg, placement of the percutaneous peripheral vascular
endovascular interventions in the Surgery/Cardiovascular System section,
while the percutaneous coronary interventions appear in the
Medicine/Cardiovascular section).
When advanced practice nurses and physician assistants are working with
physicians, they are considered as working in the exact same specialty and
exact same subspecialties as the physician. A “physician or other qualified
health care professional” is an individual who is qualified by education,
training, licensure/regulation (when applicable), and facility privileging
(when applicable) who performs a professional service within his/her scope
of practice and independently reports that professional service. These
professionals are distinct from “clinical staff.” A clinical staff member is a
person who works under the supervision of a physician or other qualified
health care professional and who is allowed by law, regulation, and facility
policy to perform or assist in the performance of a specified professional
service, but who does not individually report that professional service. Other
policies may also affect who may report specific services.
Throughout the CPT code set the use of terms such as “physician,” “qualified
health care professional,” or “individual” is not intended to indicate that
other entities may not report the service. In selected instances, specific
instructions may define a service as limited to professionals or limited to
other entities (eg, hospital or home health agency).
Instructions, typically included as parenthetical notes with selected codes,
indicate that a code should not be reported with another code or codes.
These instructions are intended to prevent errors of significant probability
and are not all inclusive. For example, the code with such instructions may
be a component of another code and therefore it would be incorrect to report
both codes even when the component service is performed. These
instructions are not intended as a listing of all possible code combinations
that should not be reported, nor do they indicate all possible code
combinations that are appropriately reported. When reporting codes for
services provided, it is important to assure the accuracy and quality of
coding through verification of the intent of the code by use of the related
guidelines, parenthetical instructions, and coding resources, including CPT
Assistant and other publications resulting from collaborative efforts of the
American Medical Association with the medical specialty societies (ie,
Clinical Examples in Radiology).
Format of the Terminology

The CPT code set has been developed as stand-alone descriptions of
medical procedures. However, some of the procedures in the CPT codebook
are not printed in their entirety but refer back to a common portion of the
procedure listed in a preceding entry. This is evident when an entry is
followed by one or more indentations. This is done in an effort to conserve
space.
Example
25100 Arthrotomy, wrist joint; with biopsy
25105 with synovectomy
Note that the common part of code 25100 (the part before the semicolon)
should also be considered part of code 25105. Therefore, the full procedure
represented by code 25105 should read:
25105 Arthrotomy, wrist joint; with synovectomy
Requests to Update the CPT Nomenclature

The effectiveness of the CPT nomenclature depends on constant updating to
reflect changes in medical practice. This can only be accomplished through
the interest and timely suggestions of practicing physicians and other
qualified health care professionals, specialty/professional societies, state
medical associations, organizations, agencies, individual users of the CPT
code set, and other stakeholders. Accordingly, the AMA welcomes
correspondence, inquiries, and suggestions concerning CPT coding and
nomenclature for old and new procedures and services, as well as any
matters relating to the CPT code set.
For information on submission of an application to add, delete, or revise
codes contained in the CPT code set, please see www.ama-assn.org/go/cpt-
processfaq or contact:
CPT Editorial Research & Development
American Medical Association
330 North Wabash Avenue
Suite 39300
Chicago IL 60611-5885
Code change applications are available at the AMA’s CPT website at
https://www.ama-assn.org/practice-management/cpt/cpt-code-change-
applications.
All proposed changes to the CPT code set will be considered by the CPT
Editorial Panel, in consultation with medical specialty societies as
represented by the CPT Advisory Committee, other health care professional
societies as represented by the Health Care Professionals Advisory
Committee (HCPAC), and other interested parties.
Application Submission Requirements

All complete CPT code change applications are reviewed and evaluated by
the CPT staff, the CPT/HCPAC Advisory Committee, and the CPT Editorial
Panel. Strict conformance with the following is required for review of a
code change application:
• Submission of a complete application, including all necessary supporting
documents;
• Adherence to all posted deadlines;
• Cooperation with requests from the CPT staff and/or Editorial Panel
members for clarification and information; and
• Compliance with CPT Lobbying Policy.
General Criteria for Category I, II, and III

Codes
All Category I, II, and III code change applications must satisfy each of the
following criteria:
• The proposed descriptor is unique, well-defined, and describes a
procedure or service that is clearly identified and distinguished from
existing procedures and services already in the CPT code set;
• The descriptor structure, guidelines, and instructions are consistent with
the current CPT Editorial Panel standards for maintenance of the code set;
• The proposed descriptor for the procedure or service is neither a
fragmentation of an existing procedure or service nor currently reportable
as a complete service by one or more existing codes (with the exclusion of
unlisted codes). However, procedures and services frequently performed
together may require new or revised codes;
• The structure and content of the proposed code descriptor accurately
reflects the procedure or service as typically performed. If always or
frequently performed with one or more other procedures or services, the
descriptor structure and content will reflect the typical combination or
complete procedure or service;
• The descriptor for the procedure or service is not proposed as a means to
report extraordinary circumstances related to the performance of a
procedure or service already described in the CPT code set; and
• The procedure or service satisfies the category-specific criteria set forth
below.
Category-Specific Requirements
Category I Criteria
A proposal for a new or revised Category I code must satisfy all of the
following criteria:
• All devices and drugs necessary for performance of the procedure or
service have received FDA clearance or approval when such is required
for performance of the procedure or service;
• The procedure or service is performed by many physicians or other
qualified health care professionals across the United States;
• The procedure or service is performed with frequency consistent with the
intended clinical use (ie, a service for a common condition should have
high volume, whereas a service commonly performed for a rare condition
may have low volume);
• The procedure or service is consistent with current medical practice; and
• The clinical efficacy of the procedure or service is documented in
literature that meets the requirements set forth in the CPT code change
application.
Category II Criteria
The following criteria are used by the CPT/HCPAC and the CPT Editorial
Panel for evaluating Category II code applications:
• Measurements that were developed and tested by a national organization;
• Evidence-based measurements with established ties to health outcomes;
• Measurements that address clinical conditions of high prevalence, high
risk, or high cost; and
• Well-established measurements that are currently being used by large
segments of the health care industry across the country.
In addition, all of the following are required:
• Definition or purpose of the measure is consistent with its intended use
(quality improvement and accountability, or solely quality improvement)
• Aspect of care measured is substantially influenced by the physician (or
other qualified health care professional or entity for which the code may
be relevant)
• Reduces data collection burden on physicians (or other qualified health
care professionals or entities)
• Significant
○ Affects a large segment of health care community
○ Tied to health outcomes
○ Addresses clinical conditions of high prevalence, high costs, high risks
• Evidence-based
○ Agreed upon
○ Definable
○ Measurable
• Risk-adjustment specifications and instructions for all outcome measures
submitted or compelling evidence as to why risk adjustment is not relevant
• Sufficiently detailed to make it useful for multiple purposes
• Facilitates reporting of performance measure(s)
• Inclusion of select patient history, testing (eg, glycohemoglobin), other
process measures, cognitive or procedure services within CPT, or
physiologic measures (eg, blood pressure) to support performance
measurements
• Performance measure–development process that includes
○ Nationally recognized expert panel
○ Multidisciplinary
○ Vetting process
Category III Criteria
The following criteria are used by the CPT/HCPAC Advisory Committee
and the CPT Editorial Panel for evaluating Category III code applications:
• The procedure or service is currently or recently performed in humans;
and
At least one of the following additional criteria has been met:
• The application is supported by at least one CPT or HCPAC advisor
representing practitioners who would use this procedure or service; or
• The actual or potential clinical efficacy of the specific procedure or
service is supported by peer reviewed literature, which is available in
English for examination by the CPT Editorial Panel; or
• There is (a) at least one Institutional Review Board–approved protocol of
a study of the procedure or service being performed; (b) a description of a
current and ongoing United States trial outlining the efficacy of the
procedure or service; or (c) other evidence of evolving clinical utilization.
Guidelines
Specific guidelines are presented at the beginning of each of the sections.
These guidelines define items that are necessary to appropriately interpret
and report the procedures and services contained in that section. For
example, in the Medicine section, specific instructions are provided for
handling unlisted services or procedures, special reports, and supplies and
materials provided. Guidelines also provide explanations regarding terms
that apply only to a particular section. For instance, Radiology Guidelines
provide a definition of the unique term, “radiological supervision and
interpretation.” While in Anesthesia, a discussion of reporting time is
included.
A written report (eg, handwritten or electronic) signed by the interpreting
individual should be considered an integral part of a radiologic procedure or
interpretation. Please see the guidelines regarding Imaging Guidance in each
individual section.
Add-on Codes
Some of the listed procedures are commonly carried out in addition to the
primary procedure performed. These additional or supplemental procedures
are designated as add-on codes with the ✚ symbol and they are listed in
Appendix D of the CPT codebook. Add-on codes in CPT 2021 can be
readily identified by specific descriptor nomenclature that includes phrases
such as “each additional” or “(List separately in addition to primary
procedure).”
The add-on code concept in CPT 2021 applies only to add-on procedures or
services performed by the same physician. Add-on codes describe additional
intra-service work associated with the primary procedure, eg, additional
digit(s), lesion(s), neurorrhaphy(s), vertebral segment(s), tendon(s), joint(s).
Add-on codes are always performed in addition to the primary service or
procedure and must never be reported as a stand-alone code. When the add-
on procedure can be reported bilaterally and is performed bilaterally, the
appropriate add-on code is reported twice, unless the code descriptor,
guidelines, or parenthetical instructions for that particular add-on code
instructs otherwise. Do not report modifier 50, Bilateral procedures, in
conjunction with add-on codes. All add-on codes in the CPT code set are
exempt from the multiple procedure concept. See the definitions of modifier
50 and 51 in Appendix A.
Modifiers
A modifier provides the means to report or indicate that a service or
procedure that has been performed has been altered by some specific
circumstance but not changed in its definition or code. Modifiers also enable
health care professionals to effectively respond to payment policy
requirements established by other entities. The judicious application of
modifiers obviates the necessity for separate procedure listings that may
describe the modifying circumstance. Modifiers may be used to indicate to
the recipient of a report that:
• A service or procedure had both a professional and technical component.
• A service or procedure was performed by more than one physician or
other health care professional and/or in more than one location.
• A service or procedure was increased or reduced.
• Only part of a service was performed.
• An adjunctive service was performed.
• A bilateral procedure was performed.
• A service or procedure was provided more than once.
• Unusual events occurred.
Example
A physician providing diagnostic or therapeutic radiology services,
ultrasound, or nuclear medicine services in a hospital would add modifier 26
to report the professional component.
73090 with modifier 26 = Professional component only for an X ray of the
forearm
Example
Two surgeons may be required to manage a specific surgical problem. When
two surgeons work together as primary surgeons performing distinct part(s)
of a procedure, each surgeon should report his/her distinct operative work by
adding modifier 62 to the procedure code and any associated code(s) for that
procedure as long as both surgeons continue to work together as primary
surgeons. Each surgeon should report the co-surgery once using the same
procedure code. Modifier 62 would be applicable. For instance, a
neurological surgeon and an otolaryngologist are working as co-surgeons in
performing transphenoidal excision of a pituitary neoplasm.
The first surgeon would report:
61548 62 = Hypophysectomy or excision of pituitary tumor, transnasal or
transseptal approach, nonstereotactic + two surgeons modifier
and the second surgeon would report:
61548 62 = Hypophysectomy or excision of pituitary tumor, transnasal or
transseptal approach, nonstereotactic + two surgeons modifier
If additional procedure(s) (including add-on procedure[s]) are performed
during the same surgical session, separate code(s) may also be reported with
modifier 62 added. It should be noted that if a co-surgeon acts as an assistant
in the performance of additional procedure(s) during the same surgical
session, those services may be reported using separate procedure code(s)
with modifier 80 or modifier 82 added, as appropriate. A complete listing of
modifiers is found in Appendix A.
Place of Service and Facility Reporting

Some codes have specified places of service (eg, evaluation and
management codes are specific to a setting). Other services and procedures
may have instructions specific to the place of service (eg, therapeutic,
prophylactic, and diagnostic injections and infusions). The CPT code set is
designated for reporting physician and other qualified health care
professional services. It is also the designated code set for reporting services
provided by organizations or facilities (eg, hospitals) in specific
circumstances. Throughout the CPT code set, the use of terms such as
“physician,” “qualified health care professional,” or “individual” is not
intended to indicate that other entities may not report the service. In selected
instances, specific instructions may define a service as limited to
professionals or limited to other entities (eg, hospital or home health
agency). The CPT code set uses the term “facility” to describe such
providers and the term “nonfacility” to describe services settings or
circumstances in which no facility reporting may occur. Services provided in
the home by an agency are facility services. Services provided in the home
by a physician or other qualified health care professional who is not a
representative of the agency are nonfacility services.
Unlisted Procedure or Service
It is recognized that there may be services or procedures performed by
physicians or other qualified health care professionals that are not found in
the CPT code set. Therefore, a number of specific code numbers have been
designated for reporting unlisted procedures. When an unlisted procedure
number is used, the service or procedure should be described (see specific
section guidelines). Each of these unlisted procedural code numbers (with
the appropriate accompanying topical entry) relates to a specific section of
the book and is presented in the guidelines of that section.
In some cases, alternative coding and procedural nomenclature as contained
in other code sets may allow appropriate reporting of a more specific code.
CPT references to use an unlisted procedure code do not preclude the
reporting of an appropriate code that may be found in other code sets.
Results, Testing, Interpretation, and

Report
Results are the technical component of a service. Testing leads to results;
results lead to interpretation. Reports are the work product of the
interpretation of test results. Certain procedures or services described in
CPT involve a technical component (eg, tests), which produces “results” (eg,
data, images, slides). For clinical use, some of these results require
interpretation. Some CPT descriptors specifically require interpretation and
reporting in order to report that code.
Special Report
A service that is rarely provided, unusual, variable, or new may require a
special report. Pertinent information should include an adequate definition or
description of the nature, extent, and need for the procedure and the time,
effort, and equipment necessary to provide the service.
Time
The CPT code set contains many codes with a time basis for code selection.
The following standards shall apply to time measurement, unless there are
code or code-range–specific instructions in guidelines, parenthetical
instructions, or code descriptors to the contrary. Time is the face-to-face time
with the patient. Phrases such as “interpretation and report” in the code
descriptor are not intended to indicate in all cases that report writing is part
of the reported time. A unit of time is attained when the mid-point is passed.
For example, an hour is attained when 31 minutes have elapsed (more than
midway between zero and sixty minutes). A second hour is attained when a
total of 91 minutes has elapsed. When codes are ranked in sequential typical
times and the actual time is between two typical times, the code with the
typical time closest to the actual time is used. See also the Evaluation and
Management (E/M) Services Guidelines. When another service is
performed concurrently with a time-based service, the time associated with
the concurrent service should not be included in the time used for reporting
the time-based service. Some services measured in units other than days
extend across calendar dates. When this occurs a continuous service does not
reset and create a first hour. However, any disruption in the service does
create a new initial service. For example, if intravenous hydration (96360,
96361) is given from 11 PM to 2 AM, 96360 would be reported once and
96361 twice. For facility reporting on a single date of service or for
continuous services that last beyond midnight (ie, over a range of dates),
report the total units of time provided continuously.
Code Symbols
A summary listing of additions, deletions, and revisions applicable to the
CPT codebook is found in Appendix B. New procedure numbers added to
the CPT codebook are identified throughout the text with the ● symbol
placed before the code number. In instances where a code revision has
resulted in a substantially altered procedure descriptor, the ▲ symbol is
placed before the code number. The ▶ ◀ symbols are used to indicate new
and revised text other than the procedure descriptors. These symbols indicate
CPT Editorial Panel actions. The AMA reserves the right to correct
typographical errors and make stylistic improvements.
CPT add-on codes are annotated by the ✚ symbol and are listed in Appendix
D. The symbol ⃠ is used to identify codes that are exempt from the use of
modifier 51 but have not been designated as CPT add-on procedures or
services. A list of codes exempt from modifier 51 usage is included in
Appendix E. The ⚡ symbol is used to identify codes for vaccines that are
pending FDA approval (see Appendix K). The # symbol is used to identify
codes that are listed out of numerical sequence (see Appendix N). The ★
symbol is used to identify codes that may be used to report tele medicine
services when appended by modifier 95 (see Appendix P).
Resequenced codes that are not placed numerically are identified with the #
symbol, and a reference placed numerically (ie, Code is out of numerical
sequence. See…) as a navigational alert to direct the user to the location of
the out-of-sequence code (see Appendix N). Resequencing is utilized to
allow placement of related concepts in appropriate locations within the
families of codes regardless of the availability of numbers for sequential
numerical placement.
Duplicate proprietary laboratory analyses (PLA) tests are annotated by the
symbol. PLA codes describe proprietary clinical laboratory analyses and can
be either provided by a single (“sole-source”) laboratory or licensed or
marketed to multiple providing laboratories (eg, cleared or approved by the
Food and Drug Administration [FDA]). All codes that are included in the
PLA section are also included in Appendix O, with the procedure’s
proprietary name. In some instances, the descriptor language of PLA codes
may be identical and the code may only be differentiated by the listed
proprietary name in Appendix O. When more than one PLA test has an
identical descriptor, the codes will be denoted by the symbol .
Unless specifically noted, even though the Proprietary Laboratory Analyses
section of the code set is located at the end of the Pathology and Laboratory
section of the code set, a PLA code does not fulfill Category I code criteria.
A PLA code(s) that has Category I status is annotated by the ⇅ symbol.
Alphabetical Reference Index

This codebook features an expanded alphabetical index that includes listings
by procedure and anatomic site. Procedures and services commonly known
by their eponyms or other designations are also included.
Use of Anti-Piracy Technology in CPT

Professional 2021 Codebook
The AMA takes the act of and/or the prospect of piracy of its books and
copyrighted content very seriously, and is committed to providing the most
effective anti-piracy service to its authors and readers. To help combat print
piracy and protect our intellectual properties and customers’ right to AMA-
certified content, the AMA has adopted anti-piracy technology in the CPT
Professional 2021 codebook.
To protect the copyrighted content and prevent counterfeiting of the CPT
Professional 2021 codebook using color copiers, this book is protected and
equipped with state-of-the-art anti-piracy technology within its pages.
Therefore, you will notice light-yellow dots at the bottom of most pages in
this book. As a result of the implementation of this anti-piracy technology,
you will notice the pages in this codebook cannot be reproduced by
photocopy or scan in accordance with current copyright rules and laws.
In addition to the anti-piracy technology used in the pages of this book, there
is an authentic-QR code on the front cover of this book. We require you to
scan the QR code with your phone to ensure your copy of the book is an
authentic, AMA-certified product. By scanning and registering your authentic
copy with the AMA, you will receive access to valuable CPT® resources,
and have an opportunity to receive important CPT® updates and news in the
future via e-mail from the AMA.
In addition to stopping counterfeit book production and protecting the
copyrighted content of this manual, the use of anti-piracy technology is
designed specifically to protect you, the end-user, by ensuring that you are
using an accurate, high-quality, and authentic AMA-certified version of the
reference manual. We appreciate your efforts and cooperation in reducing
content piracy and improving copyright protections.
CPT 2021 in Electronic Formats
CPT 2021 procedure codes and descriptions are available as downloadable
data files. The CPT data files are available in ASCII and EBCDIC formats
and provide a convenient way to import the 2021 CPT codes and
descriptions into existing documentation or into any billing and claims
reporting software that accepts a text (.TXT) file format. The data files
contain the complete official AMA CPT guidelines, descriptor package, and
new descriptors for consumers and clinicians.
The CPT Professional codebook is also available as an e-book. For more
information about CPT electronic formats, call 800 621-8335 or visit
amastore.com.
References to AMA Resources

The symbols ➲ ➲ and ➲ appear after many codes throughout this
codebook, which indicate that the AMA has published reference material
regarding that particular code.
The symbol ➲ refers to the CPT Changes: An Insider’s View, an annual
book with all of the coding changes for the current year, the ➲ refers to the
CPT Assistant monthly newsletter. The symbol ➲ refers to the quarterly
newsletter Clinical Examples in Radiology.
Example
36598 Contrast injection(s) for radiologic evaluation of existing
central venous access device, including fluoroscopy,
image documentation and report
➲ CPT Changes: An Insider’s View 2006
➲ Clinical Examples in Radiology Winter 2006:15
In this example, the blue reference symbol indicates that in the 2006 edition
of CPT Changes: An Insider’s View information is available that may assist
in understanding the application of the code. The red reference symbol
indicates that the 2006 Winter issue of Clinical Examples in Radiology
(page 15) should be consulted.
CPT Assistant and Clinical Examples in Radiology are available online.
Benefits exclusive to the online versions include:
• Monthly (CPT Assistant) and quarterly (Clinical Examples in Radiology)
updates! The home screen notifies you when a new issue is available, and
you can review the latest issue in its entirety.
• Unlimited access to every archived issue and article dating back to when
the newsletters first published.
• A historical CPT code list that references when a code was added,
deleted, and/or revised since 1990.
• Simple search capabilities, including intuitive menus and a cumulative
index of article titles.
• Anatomical illustrations, charts, and graphs for quick reference.
• A full archive of CPT Assistant articles (1990-2019) is also available in
the CPT Professional Print and Digital app bundle (see the following
information about the CPT QuickRef app).
The CPT QuickRef app is available for iOS (Apple) and Android devices
(smart phones and tablets). The QuickRef app contains important coding and
billing tools, including:
• The entire CPT 2021 code set (full codes, descriptions, icons,
illustrations, and parenthetical notes), plus the entire 2020 code set to
facilitate the year-end code set transition.
• Facility and non-facility RVUs and Global Days.
• Medicare Physician Fee Schedule calculator that can be set to a specific
geographic region (GPCI)
• E/M Code Selection Wizard with the option to apply CPT, CMS ‘95, or
CMS ‘97 guidelines.
• CPT Assistant Archive: all content and every issue of CPT Assistant from
1990 through 2018, linked to the pertinent CPT codes and available for
browsing.
• Official AMA CPT coding guidelines linked to each CPT code.
• Up to 4,200 clinical examples/vignettes.
• More than 200 AMA-created colorized procedural and anatomical
illustrations
• Modifiers
• Keyword and code number search
• Favorites capability, to store most-frequently used codes or modifiers for
easy access.
For more information, call 800 621-8335.
▶◀ = Contains new or revised text

Illustrated Anatomical and
Procedural Review
It is essential that coders have a thorough understanding of medical
terminology and anatomy to code accurately. The following section
reviewing the basics of vocabulary and anatomy can be used as a quick
reference to help you with your coding. It is not intended as a replacement for
up-to-date medical dictionaries and anatomy texts, which are essential tools
for accurate coding.
Prefixes, Suffixes, and Roots

Although medical terminology may seem complex, many medical terms can
be broken into component parts, which makes them easier to understand.
Many of these terms are derived from Latin or Greek words, but some
include the names of physicians.
Prefixes are word parts that appear at the beginning of a word and modify its
meaning; suffixes are found at the end of words. By learning what various
prefixes and suffixes mean, it is possible to decipher the meaning of a word
quickly. The following lists are a quick reference for some common prefixes
and suffixes.
Numbers
Prefix Meaning Example
mono-, uni- one monocyte, unilateral
bi- two bilateral
tri- three triad
quadr- four quadriplegia
hex-, sex- six hexose
diplo- double diplopia
Surgical Procedures
Suffix Meaning Example
-centesis puncture a cavity to amniocentesis
remove fluid
-ectomy surgical removal appendectomy
(excision)
-ostomy a new permanent colostomy
opening
-otomy cutting into (incision) tracheotomy
-orrhaphy surgical repair/suture herniorrhaphy
-opexy surgical fixation nephropexy
-oplasty surgical repair rhinoplasty
-otripsy crushing, destroying lithotripsy
Conditions
ambi- both ambidextrous
aniso- unequal anisocoria
dys- bad, painful, difficult dysphoria
eu- good, normal euthanasia
hetero- different heterogeneous
homo- same homogeneous
hyper- excessive, above hypergastric
hypo- deficient, below hypogastric
iso- equal, same isotonic
mal- bad, poor malaise
megalo- large megalocardia
Suffix Meaning Example

-algia pain neuralgia
-asthenia weakness myasthenia
-emia blood anemia
-iasis condition of amebiasis
-itis inflammation appendicitis
-lysis destruction, break down hemolysis
-lytic destroy, break down hemolytic
-oid like lipoid
-oma tumor carcinoma
-opathy disease of arthropathy
-orrhagia hemorrhage menorrhagia
-orrhea flow or discharge amenorrhea
-osis abnormal condition of tuberculosis
-paresis weakness hemiparesis
-plasia growth hyperplasia
-plegia paralysis paraplegia
-pnea breathing apnea
Directions and Positions

ab- away from abduction
ad- toward adduction
ecto, exo- outside ectopic, exocrine
endo- within endoscope
epi- upon epigastric
infra- below, under infrastructure
ipsi- same ipsilateral
meso- middle mesopexy
meta- after, beyond, metastasis
transformation
peri- surrounding pericardium
retro- behind, back retroversion
trans- across, through transvaginal
Word Meaning
anterior or ventral at or near the front surface of the
body
posterior or dorsal at or near the back surface of the
body
superior above
inferior below
lateral side
distal farthest from center
proximal nearest to center
medial middle
supine face up or palm up
prone face down or palm down
sagittal vertical body plane, divides the
body into equal right and left sides
transverse horizontal body plane, divides the
body into top and bottom sections
coronal vertical body plane, divides the
body into front and back sections
Additional References
For best coding results, you will need to use other reference materials in
addition to your CPT® coding books. These references include medical
dictionaries and anatomy books.
Medical Dictionaries
Dorland’s Illustrated Medical Dictionary, 32nd ed.
Philadelphia, PA: Elsevier; 2011.
Stedman’s CPT® Dictionary, 2nd ed.
Chicago, IL: American Medical Association; 2009.
OP:300609
Stedman’s Medical Dictionary. 28th ed.
Philadelphia, PA: Lippencott; 2005.
Anatomy References
Bernard, SP. Netter’s Atlas of Human Anatomy for CPT® Surgery.
OP495015
Kirschner, CG. Netter’s Atlas of Human Anatomy for CPT® Coding, 3rd ed.
OP490619
Netter, FH. Atlas of Human Anatomy, 6th ed.
Philadelphia, PA; Elsevier; 2014.
OP936714
Lists of Illustrations
To further aid coders in properly assigning CPT codes, the codebook
contains a number of anatomical and procedural illustrations.
Anatomical Illustrations
Thirty-two anatomical illustrations are located on the following
pages:
Page Illustration Title
xxiv Body Planes—3/4 View
xxiv Body Aspects—Side View
xxiv Body Planes—Front View
87 Structure of Skin
127 Skeletal System
128 Skull—Front and Lateral Views
128 Thoracic Vertebra—Superior View
128 Lumbar Vertebra—Superior View
128 Lumbar Vertebrae—Lateral View
130 Bones, Muscles, and Tendons of Hand
131 Bones and Muscles of Foot
133 Muscular System—Front
134 Muscular System—Back
211 Paranasal Sinuses
212 Respiratory System
233 Aortic Anatomy
234 Cardiac Anatomy, Heart Blood Flow
236 Circulatory System, Arteries
237 Circulatory System, Veins
238 Brachial Artery
239 Lymphatic System
332 Digestive System
394 Urinary System
418 Male Genital System
427 Female Genital System
448 Nervous System
449 Brain Anatomy
449 Sagittal Section of Brain and Brain Stem
486 Eye Anatomy
503 Ear Anatomy
511 Endocrine System
780 Cranial Nerves
Procedural Illustrations
Procedural illustrations are placed throughout the codebook and
are associated with the following specific CPT codes.
CPT Code(s) Illustration Title
11005 Debridement of Abdominal Wall
11102, 11103 Tangential Biopsy of Skin
11104, 11105 Punch Biopsy of Skin
11106, 11107 Incisional Biopsy of Skin
11200, 11201 Removal of Skin Tags
11300-11313 Shaving of Epidermal and Dermal Lesion
11400, 11600 Excision of Lesion
11423, 11600, 11606, 11642 Measuring and Coding the Removal of a
Lesion
11719-11765 Lateral Nail View
11719-11765 Dorsal Nail View
14000-14061 Adjacent Tissue Repairs
15730 Midface Flap Surgery
15731 Axial Pattern Forehead Flap
16000-16030 Lund-Browder Diagram and Classification
Method Table for Burn Estimations
17004 Destruction, Benign or Premalignant
Lesions
20552, 20553 Trigger Point Injection
20610 Arthrocentesis, Aspiration, or Injection of
Major Joint or Bursa
20664 Halo Application for Thin Skull Osteology
20690 Uniplane External Fixation System
20692 Multiplane External Fixation System
20932 Postoperative Osteoarticular Allograft
Left Humerus Fixed with Plates
20933 Parosteal Osteosarcoma Replaced with
Hemicortical Intercalary Allograft
20934 Osteosarcoma Femur with Complete
Intercalary Allograft with Plate Fixation
21196 Reconstruction of Mandibular Rami
22510 Percutaneous Vertebroplasty
22548 Arthrodesis (Anterior Transoral
Technique)
22554 Anterior Approach for Cervical Fusion
22558 Anterior Approach for Lumbar Fusion
(Anterior Retroperitoneal Exposure)
22840 Non-Segmental Spinal Instrumentation
22842-22844 Segmental Spinal Instrumentation
22853, 22854, 22859 Spinal Prosthetic Devices
27125 Partial Hip Replacement With or Without
Bipolar Prosthesis
27130 Total Hip Replacement
27235 Percutaneous Treatment of Femoral
Fracture
27236 Open Treatment of Femoral Fracture
27405, 27427 Posterolateral Corner of the Knee
28289 Hallux Rigidus Correction
28291 Hallux Rigidus Correction with Implant
28292 Hallux Valgus Correction
28292 Hallux Valgus Correction with Proximal
Phalanx Base Resection
First Metatarsal Osteotomy
28296 Hallux Valgus Correction with Distal First
Metatarsal Osteotomy
28297 Hallux Valgus Correction with Metatarsal-
Medial Cuneiform Joint Arthrodesis
Phalanx Osteotomy
28299 Hallux Valgus Correction with Double
Osteotomy
29824 Arthroscopy, Shoulder, Distal
Claviculectomy (Mumford Procedure)
29866-29887 Arthroscopy of the Knee
29894-29899 Arthroscopy of the Ankle
30465 Surgical Repair of Vestibular Stenosis
31070 Sinusotomy, Frontal
31231-31294 Sinus Endoscopy
31622-31661 Bronchoscopy
32554, 32555 Thoracentesis
32601-32665 Thoracoscopy
32674 Mediastinal Lymph Nodes: Station
Number and Descriptions
32994 Cryoablation Therapy of Pulmonary
Tumors
33210 Temporary Pacemaker
33212, 33214 A. Implanted Pacemaker—Single
Chamber
33212, 33214 B. Implanted Pacemaker—Two Chambers
33224-33226 Biventricular Pacing
33510-33516 A. Coronary Artery Bypass—Venous
Grafting Only—Single Graft
33510-33516 B. Coronary Artery Bypass—Venous
Grafting Only—Three Coronary Grafts
33517-33530 Coronary Artery Bypass—Combined
Arterial-Venous Grafting
33517-33530 Coronary Artery Bypass—Sequential
Combined Arterial-Venous Grafting
33621 Initial Hybrid Palliation
33622 Hybrid Reconstruction
33820 Patent Ductus Arteriosus
33864 Aortic Root Remodeling: Coronary
Arteries Reimplanted
33927-33929 Total Heart Implantation Device
33979 Insertion of Implantable Single Ventricle
Assist Device
34705, 34706, 34709, 34710, Endovascular Repair
34711
34717, 34718 Endovascular Repair
35371-35372 Thromboendarterectomy
35571 Bypass Graft, Vein
35600 Harvest of Upper Extremity Artery
36002 Injection Procedure (eg, Thrombin) for
Percutaneous Treatment of Extremity
Pseudoaneurysm
36222-36228 Angiography, Carotid Artery
36555-36556 Insertion of Non-Tunneled Centrally
Inserted Central Venous Catheter
36557-36558 Insertion of Tunneled Central Venous
Catheter
36570, 36571, 36576, 36578 Implantable Venous Access Port
36572 Peripherally Inserted Central Catheter
36821 Arteriovenous Anastomosis, Direct
36825-36830 Arteriovenous Fistula
37191 Vena Cava Filter
37220, 37222 Transluminal Ballon Angioplasty
37220-37235 Iliac and Lower Extremity Arterial
Anatomy Territory
37246 Transluminal Balloon Angioplasty
37700 Ligation and Division of Long Saphenous
Vein
38230 Bone Marrow Harvesting for
Transplantation
38746 Mediastinal Lymph Nodes: Station
Number and Descriptions
43235 Esophagogastroduodenoscopy
43260 Endoscopic Retrograde
Cholangiopancreatography (ERCP)
43280 Laparoscopic Fundoplasty
43284 Laparoscopic Esophageal Sphincter
Augmentation
43287 Ivor Lewis Esophagectomy
43327, 43328 Nissen Fundoplasty
43753 Gastric Intubation
43846 Gastric Bypass for Morbid Obesity
44127 Enterectomy, Resection for Congenital
Atresia
44140 Colectomy, Partial
44160 Colectomy With Removal of Terminal
Ileum and Ileocolostomy
45171-45172 Rectal Tumor Excision
45378 Colonoscopy
45385, 45388 Colonoscopy With Lesion Ablation or
Removal
46020 Placement of Seton
46250-46262 Hemorrhoidectomy of Internal Prolapsed
Hemorrhoid Columns
47533, 47534, 47538, 47539, Percutaneous Biliary Stent(s) and Drain
47540 Placement
47562 Laparoscopic Cholecystectomy
49320 Laparoscopy
50020 Drainage of Renal Abscess
50060-50075 Nephrolithotomy With Calculus Removal
50432 Introduction of Catheter Into Renal Pelvis
50545 Laparoscopic Radical Nephrectomy
50546 Laparoscopic Nephrectomy
50590 Lithotripsy
50605 Indwelling Ureteral Stent
50820 Ureteroileal Conduit
50947 Laparoscopic Ureteroneocystostomy
51798 Measurement of Postvoiding
51990 Laparoscopic Sling Suspension Urinary
Incontinence
52005 Cystourethroscopy With Ureteral
Catheterization
52601 Transurethral Resection of Prostate,
Complete
52648 Contact Laser Vaporization of Prostate
53855 Temporary Prostatic Urethral Stent
Insertion
54692 Laparoscopic Orchiopexy
57106 Vaginectomy, Partial Removal of Vaginal
Wall
57111 Vaginectomy, Complete Removal of
Vaginal Wall (Radical Vaginectomy)
57426 Laparoscopic Revision of Prosthetic
Vaginal Graft
58563 Hysteroscopy
59001 Amniocentesis, Therapeutic Amniotic
Fluid Reduction
59150 Laparoscopic Treatment of Ectopic
Pregnancy
59400-59410 Vaginal Delivery
59510-59515 Cesarean Delivery
60220 Thyroid Lobectomy
60512 Posterior View of the Pharynx
60650 Laparoscopic Adrenalectomy
61700 Intracranial Aneurysm, Intracranial
Approach
61867-61868, 61885 Placement of Cranial Neurostimulator
62223 Cerebrospinal Fluid (CSF) Shunt
(Ventricular Peritoneal)
62362 Intrathecal or Epidural Drug Infusion
Pump Implantation
63005 Lumbar Laminectomy
63650 Percutaneous Implantation of
Neurostimulator Electrodes
63655 Placement of Neurostimulator Electrodes
Through Laminectomy
64568-64570 Implantation Neurostimulator Electrodes,
Cranial Nerve (Vagus Nerve Stimulation)
64581 Incisional Implantation of Sacral Nerve
Neurostimulator
64642 Chemodenervation of Extremity
65450 Cryotherapy of Lesion on Cornea
65820 Goniotomy
66150-66172, 66183 Minimally Invasive Glaucoma Surgery
(External Approach)
67027 Intravitreal Drug Delivery System
67107 Repair of Retinal Detachment
67311-67346 Extraocular Muscles of Right Eye
67311-67312 Strabismus Surgery—Horizontal Muscles
67314-67316 Strabismus Surgery—Vertical Muscles
67320 Transposition Procedure
67335 Strabismus Surgery—Adjustable Sutures
67820-67825 Trichiasis
68761 Closure of Lacrimal Punctum by Plug
68816 Probing of Nasolacrimal Duct
69433-69436 Tympanostomy
69635-69646 Tympanoplasty
69930 Cochlear Device Implantation
69990 Operating Microscope
72275 Epidurography
75600-75630 Aortography
75820-75822 Venography
77067 Screening Mammography
91034 Esophageal Acid Reflux Test
92201, 92202 Extended Ophthalmoscopy
92235 Fluorescein Angiography
92601-92604 A View of the Outer Cochlear Implant
92978 Intravascular Ultrasound (Coronary Vessel
or Graft)
93312-93318 Transesophageal Echocardiography (TEE)
93451 Right Heart Catheterization
93452 Left Heart Catherization
93454 Coronary Angiography Without
Concomitant Left Heart Catheterization
93571 Intravascular Distal Blood Flow Velocity
95829 Intraoperative Electrocorticography
(ECoG)
95836 Extraoperative ECoG
97810-97811 Acupuncture, Needle
0191T, 0253T, 0376T, 0449T, Minimally Invasive Glaucoma Surgery
0450T, 0474T (Internal Approach)
Figure 1A
Body Planes — 3/4 View
Figure 1B
Body Aspects — Side View
Figure 1C
Body Planes — Front View
Evaluation and Management Tables
Notes
Evaluation and Management (E/M)
Services Guidelines
The following is a listing of headings and subheadings that
appear within the Evaluation and Management section of the CPT
codebook. The subheadings or subsections denoted with
asterisks (*) below have special instructions unique to that
subsection. Where these are indicated, special notes or guidelines
will be presented preceding those procedural terminology
listings, referring to that subsection specifically.
▶E/M Guidelines Overview* ◀
Classification of Evaluation and Management (E/M)
Services*
Definitions of Commonly Used Terms*
▶Guidelines Common to All E/M Services◀
▶Levels of E/M Services* ◀
New and Established Patient*
Time*
Concurrent Care and Transfer of Care*
Counseling*
▶Services Reported Separately* ◀
▶Guidelines for Hospital Observation, Hospital Inpatient,
Consultations, Emergency Department, Nursing Facility,
Domiciliary, Rest Home, or Custodial Care, and Home E/M
Services◀
Levels of E/M Services*
Chief Complaint*
History of Present Illness*
Nature of Presenting Problem*
Past History*
Family History*
Social History*
System Review (Review of Systems)*
▶Instructions for Selecting a Level of E/M Service for
Hospital Observation, Hospital Inpatient, Consultations,
Emergency Department, Nursing Facility, Domiciliary, Rest
Home, or Custodial Care, and Home E/M Services◀
Review the Level of E/M Service Descriptors and Examples
in the Selected Category or Subcategory*
Determine the Extent of History Obtained*
Determine the Extent of Examination Performed*
Determine the Complexity of Medical Decision Making*
Select the Appropriate Level of E/M Services Based on the
Following*
▶Guidelines for Office or Other Outpatient E/M Services◀
▶History and/or Examination* ◀
▶Number and Complexity of Problems Addressed at the
Encounter* ◀
▶Instructions for Selecting a Level of Office or Other
Outpatient E/M Services* ◀
▶Medical Decision Making* ◀
▶Time* ◀
Unlisted Service*
Special Report*
Clinical Examples*

Office or Other Outpatient Services* (99202-99215)
New Patient (99202-99205)
Established Patient (99211-99215)
Hospital Observation Services* (92217-99220, 99224-99226)
Observation Care Discharge Services* (99217)
Initial Observation Care (99218-99220)
New or Established Patient* (99218-99220)
Subsequent Observation Care* (99224-99226)
Hospital Inpatient Services* (99221-99223, 99231-99239)
Initial Hospital Care (99221-99223)
Subsequent Hospital Care* (99231-99233)
Observation or Inpatient Care Services (Including Admission
and Discharge Services)* (99234-99236)
Hospital Discharge Services* (99238-99239)
Consultations* (99241-99255)
Office or Other Outpatient Consultations (99241-99245)
Inpatient Consultations (99251-99255)
Emergency Department Services (99281-99288)
Other Emergency Services* (99288)
Critical Care Services* (99291-99292)
Nursing Facility Services* (99304-99318)
Initial Nursing Facility Care (99304-99306)
Subsequent Nursing Facility Care* (99307-99310)
Nursing Facility Discharge Services* (99315-99316)
Other Nursing Facility Services (99318)
Domiciliary, Rest Home (eg, Boarding Home), or Custodial
Care Services* (99324-99337)
Domiciliary, Rest Home (eg, Assisted Living Facility), or
Home Care Plan Oversight Services (99339-99340)
Home Services* (99341-99350)
Prolonged Services (99354-99360, 99415-99417)
▶Prolonged Service With Direct Patient Contact (Except
with Office or Other Outpatient Services)* ◀ (99354-99357)
Prolonged Service Without Direct Patient Contact* (99358-
99359)
Prolonged Clinical Staff Services With Physician or Other
Qualified Health Care Professional Supervision* (99415-
99416)
▶Prolonged Service With or Without Direct Patient Contact
on the Date of an Office or Other Outpatient Service* ◀
(99417)
Standby Services* (99360)
Case Management Services* (99366-99368)
Anticoagulant Management
Medical Team Conferences* (99366-99368)
Medical Team Conference, Direct (Face-to-Face) Contact With
Patient and/or Family (99366)
Medical Team Conference, Without Direct (Face-to-Face) Contact
With Patient and/or Family (99367-99368)
Care Plan Oversight Services* (99374-99380)
Preventive Medicine Services* (99381-99429)
Counseling Risk Factor Reduction and Behavior Change
Intervention (99401-99429)
Preventive Medicine, Individual Counseling (99401-99404)
Behavior Change Interventions, Individual (99406-99409)
Preventive Medicine, Group Counseling (99411-99412)
Other Preventive Medicine Services (99429)
Non-Face-to-Face Services (99441-99458)
Telephone Services* (99441-99443)
Online Digital Evaluation and Management Services*
(99421-99423)
Interprofessional Telephone/Internet/Electronic Health
Record Consultations* (99446-99449, 99451-99452)
Digitally Stored Data Services/Remote Physiologic
Monitoring* (99453-99454, 99091, 99473-99474)
Remote Physiologic Monitoring Treatment Management
Services* (99457-99458)
Special Evaluation and Management Services* (99450-
99456)
Basic Life and/or Disability Evaluation Services (99450)
Work Related or Medical Disability Evaluation Services
(99455-99456)
Newborn Care Services* (99460-99463)
Delivery/Birthing Room Attendance and Resuscitation
Services (99464-99465)
Inpatient Neonatal Intensive Care Services and Pediatric
and Neonatal Critical Care Services (99466-99486)
Pediatric Critical Care Patient Transport* (99466-99467,
99485-99486)
Inpatient Neonatal and Pediatric Critical Care* (99468-
99476)
Initial and Continuing Intensive Care Services* (99477-
99480)
Cognitive Assessment and Care Plan Services* (99483)
Care Management Services* (99439, 99487, 99489, 99490-
99491)
Chronic Care Management Services* (99439, 99490-99491)
Complex Chronic Care Management Services* (99487,
99489)
Psychiatric Collaborative Care Management Services*
(99492-99494)
Transitional Care Management Services* (99495-99496)
Advance Care Planning* (99497-99498)
General Behavioral Health Integration Care Management*
(99484)
Other Evaluation and Management Services (99499)
Evaluation and Management (E/M)
Services Guidelines
In addition to the information presented in the Introduction, several other
items unique to this section are defined or identified here.
▶ E/M Guidelines Overview◀

▶The E/M guidelines have sections that are common to all E/M categories
and sections that are category specific. Most of the categories and many of
the subcategories of service have special guidelines or instructions unique to
that category or subcategory. Where these are indicated, eg, “Inpatient
Hospital Care,” special instructions are presented before the listing of the
specific E/M services codes. It is important to review the instructions for
each category or subcategory. These guidelines are to be used by the
reporting physician or other qualified health care professional to select the
appropriate level of service. These guidelines do not establish documentation
requirements or standards of care. The main purpose of documentation is to
support care of the patient by current and future health care team(s).
There are two sets of guidelines: one for office or other outpatient services
and another for the remaining E/M services. There are sections that are
common to both (ie, Guidelines in Common). These guidelines are presented
as Guidelines Common to all E/M Services, Guidelines for E/M Services
(Hospital Observation, Hospital Inpatient, Consultations, Emergency
Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care,
Home) and Guidelines for Office or Other Outpatient Services.
The main differences between the two sets of guidelines is that the office or
other outpatient services use medical decision making (MDM) or time as the
basis for selecting a code level, whereas the other E/M codes use history,
examination, and MDM and only use time when counseling and/or
coordination of care dominates the service. The definitions of time are
different for different categories of services.◀
▶Summary of Guideline Differences◀
▶ Component(s) Office or Other Other E/M Services (Hospital Observation,

for Code Outpatient Hospital Inpatient, Consultations, Emergency
Selection Services Department, Nursing Facility, Domiciliary, Rest
Home, or Custodial Care, Home)
History and • As medically • Use key components (history, examination,
Examination appropriate. Not MDM)
used in code
selection
Medical • May use MDM or • Use key components (history, examination,
Decision total time on the MDM)
Making date of the
(MDM) encounter
Time • May use MDM or • May use face-to-face time or time at the bedside
total time on the and on the patient’s floor or unit when
date of the counseling and/or coordination of care
encounter dominates the service.
Time is not a descriptive component for the
emergency department levels of E/M services.
MDM • Number and • Number of diagnoses or management options
Elements complexity of • Amount and/or complexity of data to be
problems reviewed
addressed at the • Risk of complications and/or morbidity or
encounter mortality◀
• Amount and/or
complexity of data
to be reviewed
and analyzed
• Risk of
complications
and/or morbidity
or mortality of
patient
management
Classification of Evaluation and
Management (E/M) Services
▶The E/M section is divided into broad categories such as office visits,
hospital visits, and consultations. Most of the categories are further divided
into two or more subcategories of E/M services. For example, there are two
subcategories of office visits (new patient and established patient) and there
are two subcategories of hospital visits (initial and subsequent). The
subcategories of E/M services are further classified into levels of E/M
services that are identified by specific codes.
The basic format of the levels of E/M services is the same for most
categories. First, a unique code number is listed. Second, the place and/or
type of service is specified, eg, office consultation. Third, the content of the
service is defined. Fourth, time is specified. (A detailed discussion of time is
provided following the Decision Tree for New vs Established Patients.)◀
Definitions of Commonly Used Terms

▶Certain key words and phrases are used throughout the E/M section. The
following definitions are intended to reduce the potential for differing
interpretations and to increase the consistency of reporting by physicians and
other qualified health care professionals. The definitions in the E/M section
are provided solely for the basis of code selection.
Some definitions are common to all categories of services and others are
specific to one or more categories only.◀
▶ Guidelines Common to All E/M Services◀

▶ Levels of E/M Services◀
Within each category or subcategory of E/M service, there are three to five
levels of E/M services available for reporting purposes. Levels of E/M
services are not interchangeable among the different categories or
subcategories of service. For example, the first level of E/M services in the
subcategory of office visit, new patient, does not have the same definition as
the first level of E/M services in the subcategory of office visit, established
patient. Each level of E/M services may be used by all physicians or other
qualified health care professionals.
New and Established Patient

Solely for the purposes of distinguishing between new and established
patients, professional services are those face-to-face services rendered by
physicians and other qualified health care professionals who may report
evaluation and management services reported by a specific CPT code(s). A
new patient is one who has not received any professional services from the
physician/qualified health care professional or another physician/qualified
health care professional of the exact same specialty and subspecialty who
belongs to the same group practice, within the past three years.
An established patient is one who has received professional services from
the physician/qualified health care professional or another
physician/qualified health care professional of the exact same specialty and
subspecialty who belongs to the same group practice, within the past three
years. See Decision Tree for New vs Established Patients.
In the instance where a physician/qualified health care professional is on call
for or covering for another physician/qualified health care professional, the
patient’s encounter will be classified as it would have been by the
physician/qualified health care professional who is not available. When
advanced practice nurses and physician assistants are working with
physicians, they are considered as working in the exact same specialty and
exact same subspecialties as the physician.
No distinction is made between new and established patients in the
emergency department. E/M services in the emergency department category
may be reported for any new or established patient who presents for
treatment in the emergency department.
The Decision Tree for New vs Established Patients is provided to aid in
determining whether to report the E/M service provided as a new or an
established patient encounter.
Coding Tip
Coding Tip
When advanced practice nurses and physician assistants are working with physicians, they
are considered as working in the exact same specialty and exact same subspecialties as the
physician. A “physician or other qualified health care professional” is an individual who
is qualified by education, training, licensure/regulation (when applicable), and facility
privileging (when applicable) who performs a professional service within his or her scope
of practice and independently reports that professional services. These professionals are
distinct from “clinical staff.” A clinical staff member is a person who works under the
supervision of a physician or other qualified health care professional, and who is allowed
by law, regulation and facility policy to perform or assist in the performance of a specific
professional service, but does not individually report that professional service. Other
CPT Coding Guidelines, Introduction, Instructions for Use of the CPT Codebook
Decision Tree for New vs Established Patients

Time
▶The inclusion of time in the definitions of levels of E/M services has been
implicit in prior editions of the CPT codebook. The inclusion of time as an
explicit factor beginning in CPT 1992 was done to assist in selecting the most
appropriate level of E/M services. Beginning with CPT 2021, except for
99211, time alone may be used to select the appropriate code level for the
office or other outpatient E/M services codes (99202, 99203, 99204, 99205,
99212, 99213, 99214, 99215). Different categories of services use time
differently. It is important to review the instructions for each category.◀
Time is not a descriptive component for the emergency department levels of
E/M services because emergency department services are typically provided
on a variable intensity basis, often involving multiple encounters with several
patients over an extended period of time. Therefore, it is often difficult to
provide accurate estimates of the time spent face-to-face with the patient.
▶Time may be used to select a code level in office or other outpatient
services whether or not counseling and/or coordination of care dominates the
service. Time may only be used for selecting the level of the other E/M
services when counseling and/or coordination of care dominates the service.
When time is used for reporting E/M services codes, the time defined in the
service descriptors is used for selecting the appropriate level of services. The
E/M services for which these guidelines apply require a face-to-face
encounter with the physician or other qualified health care professional. For
office or other outpatient services, if the physician’s or other qualified health
care professional’s time is spent in the supervision of clinical staff who
perform the face-to-face services of the encounter, use 99211.
A shared or split visit is defined as a visit in which a physician and other
qualified health care professional(s) jointly provide the face-to-face and non-
face-to-face work related to the visit. When time is being used to select the
appropriate level of services for which time-based reporting of shared or
split visits is allowed, the time personally spent by the physician and other
qualified health care professional(s) assessing and managing the patient on
the date of the encounter is summed to define total time. Only distinct time
should be summed for shared or split visits (ie, when two or more
individuals jointly meet with or discuss the patient, only the time of one
individual should be counted).
When prolonged time occurs, the appropriate prolonged services code may
be reported. The appropriate time should be documented in the medical
record when it is used as the basis for code selection.
Face-to-face time (outpatient consultations [99241, 99242, 99243, 99244,
99245], domiciliary, rest home, or custodial services [99324, 99325, 99326,
99327, 99328, 99334, 99335, 99336, 99337], home services [99341,
99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350], cognitive
assessment and care plan services [99483]): For coding purposes, face-to-
face time for these services is defined as only that time spent face-to-face
with the patient and/or family. This includes the time spent performing such
tasks as obtaining a history, examination, and counseling the patient.
Unit/floor time (hospital observation services [99218, 99219, 99220,
99224, 99225, 99226, 99234, 99235, 99236], hospital inpatient services
[99221, 99222, 99223, 99231, 99232, 99233], inpatient consultations
[99251, 99252, 99253, 99254, 99255], nursing facility services [99304,
99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318]): For
coding purposes, time for these services is defined as unit/floor time, which
includes the time present on the patient’s hospital unit and at the bedside
rendering services for that patient. This includes the time to establish and/or
review the patient’s chart, examine the patient, write notes, and communicate
with other professionals and the patient’s family.
Total time on the date of the encounter (office or other outpatient services
[99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]): For coding
purposes, time for these services is the total time on the date of the
encounter. It includes both the face-to-face and non-face-to-face time
personally spent by the physician and/or other qualified health care
professional(s) on the day of the encounter (includes time in activities that
require the physician or other qualified health care professional and does not
include time in activities normally performed by clinical staff).
Physician/other qualified health care professional time includes the following
activities, when performed:
■ preparing to see the patient (eg, review of tests)
■ obtaining and/or reviewing separately obtained history
■ performing a medically appropriate examination and/or evaluation
■ counseling and educating the patient/family/caregiver
■ ordering medications, tests, or procedures
■ referring and communicating with other health care professionals (when
not separately reported)
■ documenting clinical information in the electronic or other health record
■ independently interpreting results (not separately reported) and
communicating results to the patient/family/caregiver
■ care coordination (not separately reported)◀
Concurrent Care and Transfer of Care

Concurrent care is the provision of similar services (eg, hospital visits) to the
same patient by more than one physician or other qualified health care
professional on the same day. When concurrent care is provided, no special
reporting is required. Transfer of care is the process whereby a physician or
other qualified health care professional who is providing management for
some or all of a patient’s problems relinquishes this responsibility to another
physician or other qualified health care professional who explicitly agrees to
accept this responsibility and who, from the initial encounter, is not
providing consultative services. The physician or other qualified health care
professional transferring care is then no longer providing care for these
problems though he or she may continue providing care for other conditions
when appropriate. Consultation codes should not be reported by the
physician or other qualified health care professional who has agreed to
accept transfer of care before an initial evaluation but are appropriate to
report if the decision to accept transfer of care cannot be made until after the
initial consultation evaluation, regardless of site of service.
Counseling
Counseling is a discussion with a patient and/or family concerning one or
more of the following areas:
■ Diagnostic results, impressions, and/or recommended diagnostic studies
■ Prognosis
■ Risks and benefits of management (treatment) options
■ Instructions for management (treatment) and/or follow-up
■ Importance of compliance with chosen management (treatment) options
■ Risk factor reduction
■ Patient and family education
(For psychotherapy, see 90832-90834, 90836-90840)
▶ Services Reported Separately◀

▶Any specifically identifiable procedure or service (ie, identified with a
specific CPT code) performed on the date of E/M services may be reported
separately.
The actual performance and/or interpretation of diagnostic tests/studies
during a patient encounter are not included in determining the levels of E/M
services when reported separately. Physician performance of diagnostic
tests/studies for which specific CPT codes are available may be reported
separately, in addition to the appropriate E/M code. The physician’s
interpretation of the results of diagnostic tests/studies (ie, professional
component) with preparation of a separate distinctly identifiable signed
written report may also be reported separately, using the appropriate CPT
code and, if required, with modifier 26 appended. If a test/study is
independently interpreted in order to manage the patient as part of the E/M
service, but is not separately reported, it is part of MDM.
The physician or other qualified health care professional may need to
indicate that on the day a procedure or service identified by a CPT code was
performed, the patient’s condition required a significant separately
identifiable E/M service. The E/M service may be caused or prompted by the
symptoms or condition for which the procedure and/or service was
provided. This circumstance may be reported by adding modifier 25 to the
appropriate level of E/M service. As such, different diagnoses are not
required for reporting of the procedure and the E/M services on the same
date.◀
▶Guidelines for Hospital Observation,
Hospital Inpatient, Consultations, Emergency
Department, Nursing Facility, Domiciliary,
Rest Home, or Custodial Care, and Home
E/M Services◀
Levels of E/M Services
The descriptors for the levels of E/M services recognize seven components,
six of which are used in defining the levels of E/M services. These
components are:
■ History
■ Examination
■ Medical decision making
■ Counseling
■ Coordination of care
■ Nature of presenting problem
■ Time
The first three of these components (history, examination, and medical
decision making) are considered the key components in selecting a level of
E/M services. (See “Determine the Extent of History Obtained.”)
The next three components (counseling, coordination of care, and the nature
of the presenting problem) are considered contributory factors in the
majority of encounters. Although the first two of these contributory factors
are important E/M services, it is not required that these services be provided
at every patient encounter.
Coordination of care with other physicians, other health care professionals,
or agencies without a patient encounter on that day is reported using the case
management codes.
▶The final component, time, is discussed in detail following the Decision
Tree for New vs Established Patients.◀
Chief Complaint
A chief complaint is a concise statement describing the symptom, problem,
condition, diagnosis, or other factor that is the reason for the encounter,
usually stated in the patient’s words.
History of Present Illness

A chronological description of the development of the patient’s present
illness from the first sign and/or symptom to the present. This includes a
description of location, quality, severity, timing, context, modifying factors,
and associated signs and symptoms significantly related to the presenting
problem(s).
Nature of Presenting Problem

A presenting problem is a disease, condition, illness, injury, symptom, sign,
finding, complaint, or other reason for encounter, with or without a
diagnosis being established at the time of the encounter. The E/M codes
recognize five types of presenting problems that are defined as follows:
Minimal: A problem that may not require the presence of the physician or
other qualified health care professional, but service is provided under the
physician’s or other qualified health care professional’s supervision.
▶Self-limited or minor: A problem that runs a definite and prescribed
course, is transient in nature, and is not likely to permanently alter health
status.◀
Low severity: A problem where the risk of morbidity without treatment is
low; there is little to no risk of mortality without treatment; full recovery
without functional impairment is expected.
Moderate severity: A problem where the risk of morbidity without treatment
is moderate; there is moderate risk of mortality without treatment; uncertain
prognosis OR increased probability of prolonged functional impairment.
High severity: A problem where the risk of morbidity without treatment is
high to extreme; there is a moderate to high risk of mortality without
treatment OR high probability of severe, prolonged functional impairment.
Past History
A review of the patient’s past experiences with illnesses, injuries, and
treatments that includes significant information about:
■ Prior major illnesses and injuries
■ Prior operations
■ Prior hospitalizations
■ Current medications
■ Allergies (eg, drug, food)
■ Age appropriate immunization status
■ Age appropriate feeding/dietary status
Family History
A review of medical events in the patient’s family that includes significant
information about:
■ The health status or cause of death of parents, siblings, and children
■ Specific diseases related to problems identified in the Chief Complaint or
History of the Present Illness, and/or System Review
■ Diseases of family members that may be hereditary or place the patient at
risk
Social History
An age appropriate review of past and current activities that includes
significant information about:
■ Marital status and/or living arrangements
■ Current employment
■ Occupational history
■ Military history
■ Use of drugs, alcohol, and tobacco
■ Level of education
■ Sexual history
■ Other relevant social factors
System Review (Review of Systems)

An inventory of body systems obtained through a series of questions seeking
to identify signs and/or symptoms that the patient may be experiencing or has
experienced. For the purposes of the CPT codebook the following elements
of a system review have been identified:
■ Constitutional symptoms (fever, weight loss, etc)
■ Eyes
■ Ears, nose, mouth, throat
■ Cardiovascular
■ Respiratory
■ Gastrointestinal
■ Genitourinary
■ Musculoskeletal
■ Integumentary (skin and/or breast)
■ Neurological
■ Psychiatric
■ Endocrine
■ Hematologic/lymphatic
■ Allergic/immunologic
The review of systems helps define the problem, clarify the differential
diagnosis, identify needed testing, or serves as baseline data on other systems
that might be affected by any possible management options.
▶Instructions for Selecting a Level of E/M
Service for Hospital Observation, Hospital
Inpatient, Consultations, Emergency
Department, Nursing Facility, Domiciliary,
Rest Home, or Custodial Care, and Home
E/M Services◀
Review the Level of E/M Service Descriptors and
Examples in the Selected Category or Subcategory
The descriptors for the levels of E/M services recognize seven components,
six of which are used in defining the levels of E/M services. These
components are:
■ History
■ Examination
■ Medical decision making
■ Counseling
■ Coordination of care
■ Nature of presenting problem
■ Time
▶The first three of these components (ie, history, examination, and medical
decision making) should be considered the key components in selecting the
level of E/M services. An exception to this rule is in the case of visits that
consist predominantly of counseling or coordination of care.◀
The nature of the presenting problem and time are provided in some levels to
assist the physician in determining the appropriate level of E/M service.
Determine the Extent of History Obtained

The extent of the history is dependent upon clinical judgment and on the
nature of the presenting problem(s). The levels of E/M services recognize
four types of history that are defined as follows:
Problem focused: Chief complaint; brief history of present illness or
problem.
Expanded problem focused: Chief complaint; brief history of present illness;
problem pertinent system review.
Detailed: Chief complaint; extended history of present illness; problem
pertinent system review extended to include a review of a limited number of
additional systems; pertinent past, family, and/or social history directly
related to the patient’s problems.
Comprehensive: Chief complaint; extended history of present illness; review
of systems that is directly related to the problem(s) identified in the history of
the present illness plus a review of all additional body systems; complete
past, family, and social history.
The comprehensive history obtained as part of the preventive medicine E/M
service is not problem-oriented and does not involve a chief complaint or
present illness. It does, however, include a comprehensive system review
and comprehensive or interval past, family, and social history as well as a
comprehensive assessment/history of pertinent risk factors.
Determine the Extent of Examination Performed

The extent of the examination performed is dependent on clinical judgment
and on the nature of the presenting problem(s). The levels of E/M services
recognize four types of examination that are defined as follows:
Problem focused: A limited examination of the affected body area or organ
system.
Expanded problem focused: A limited examination of the affected body area
or organ system and other symptomatic or related organ system(s).
Detailed: An extended examination of the affected body area(s) and other
symptomatic or related organ system(s).
Comprehensive: A general multisystem examination or a complete
examination of a single organ system. Note: The comprehensive
examination performed as part of the preventive medicine E/M service is
multisystem, but its extent is based on age and risk factors identified.
For the purposes of these CPT definitions, the following body areas are
recognized:
■ Head, including the face
■ Neck
■ Chest, including breasts and axilla
■ Abdomen
■ Genitalia, groin, buttocks
■ Back
■ Each extremity
For the purposes of these CPT definitions, the following organ systems are
recognized:
■ Eyes
■ Ears, nose, mouth, and throat
■ Cardiovascular
■ Respiratory
■ Gastrointestinal
■ Genitourinary
■ Musculoskeletal
■ Skin
■ Neurologic
■ Psychiatric
■ Hematologic/lymphatic/immunologic
Determine the Complexity of Medical Decision
Making
Medical decision making refers to the complexity of establishing a diagnosis
and/or selecting a management option as measured by:
■ The number of possible diagnoses and/or the number of management
options that must be considered
■ The amount and/or complexity of medical records, diagnostic tests, and/or
other information that must be obtained, reviewed, and analyzed
■ The risk of significant complications, morbidity, and/or mortality, as well
as comorbidities, associated with the patient’s presenting problem(s), the
diagnostic procedure(s), and/or the possible management options
Four types of medical decision making are recognized: straightforward, low
complexity, moderate complexity, and high complexity. To qualify for a
given type of decision making, two of the three elements in Table 1 must be
met or exceeded.
Comorbidities/underlying diseases, in and of themselves, are not considered
in selecting a level of E/M services unless their presence significantly
increases the complexity of the medical decision making.
Select the Appropriate Level of E/M Services

Based on the Following
▶1. For the following categories/subcategories, all of the key components,
ie, history, examination, and medical decision making, must meet or
exceed the stated requirements to qualify for a particular level of E/M
service: initial observation care; initial hospital care; observation or
inpatient hospital care (including admission and discharge services);
office or other outpatient consultations; inpatient consultations;
emergency department services; initial nursing facility care; other nursing
facility services; domiciliary care, new patient; and home services, new
patient.
2. For the following categories/subcategories, two of the three key
components (ie, history, examination, and medical decision making)
must meet or exceed the stated requirements to qualify for a particular
level of E/M services: subsequent observation care; subsequent hospital
care; subsequent nursing facility care; domiciliary care, established
patient; and home services, established patient.◀
3. When counseling and/or coordination of care dominates (more than
50%) the encounter with the patient and/or family (face-to-face time in
the office or other outpatient setting or floor/unit time in the hospital or
nursing facility), then time shall be considered the key or controlling
factor to qualify for a particular level of E/M services. This includes time
spent with parties who have assumed responsibility for the care of the
patient or decision making whether or not they are family members (eg,
foster parents, person acting in loco parentis, legal guardian). The extent
of counseling and/or coordination of care must be documented in the
medical record.
Table 1
Complexity of Medical Decision Making
Number of
Diagnoses or Amount and/or Risk of Complications Type of
Management Complexity of Data to and/or Morbidity or Decision
Options be Reviewed Mortality Making
minimal minimal or none minimal straightforward
limited limited low low complexity
multiple moderate moderate moderate
complexity
extensive extensive high high complexity
▶Guidelines for Office or Other Outpatient

E/M Services◀
▶ History and/or Examination◀
▶Office or other outpatient services include a medically appropriate history
and/or physical examination, when performed. The nature and extent of the
history and/or physical examination are determined by the treating physician
or other qualified health care professional reporting the service. The care
team may collect information and the patient or caregiver may supply
information directly (eg, by electronic health record [EHR] portal or
questionnaire) that is reviewed by the reporting physician or other qualified
health care professional. The extent of history and physical examination is
not an element in selection of the level of office or other outpatient codes.◀
▶Number and Complexity of Problems Addressed

at the Encounter◀
▶One element used in selecting the level of office or other outpatient
services is the number and complexity of the problems that are addressed at
an encounter. Multiple new or established conditions may be addressed at the
same time and may affect MDM. Symptoms may cluster around a specific
diagnosis and each symptom is not necessarily a unique condition.
Comorbidities/underlying diseases, in and of themselves, are not considered
in selecting a level of E/M services unless they are addressed, and their
presence increases the amount and/or complexity of data to be reviewed and
analyzed or the risk of complications and/or morbidity or mortality of patient
management. The final diagnosis for a condition does not, in and of itself,
determine the complexity or risk, as extensive evaluation may be required to
reach the conclusion that the signs or symptoms do not represent a highly
morbid condition. Multiple problems of a lower severity may, in the
aggregate, create higher risk due to interaction.
Definitions for the elements of MDM (see Table 2, Levels of Medical
Decision Making) for other office or other outpatient services are:
Problem: A problem is a disease, condition, illness, injury, symptom, sign,
finding, complaint, or other matter addressed at the encounter, with or
without a diagnosis being established at the time of the encounter.
Problem addressed: A problem is addressed or managed when it is
evaluated or treated at the encounter by the physician or other qualified
health care professional reporting the service. This includes consideration of
further testing or treatment that may not be elected by virtue of risk/benefit
analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s
medical record that another professional is managing the problem without
additional assessment or care coordination documented does not qualify as
being addressed or managed by the physician or other qualified health care
professional reporting the service. Referral without evaluation (by history,
examination, or diagnostic study[ies]) or consideration of treatment does not
qualify as being addressed or managed by the physician or other qualified
health care professional reporting the service.
Minimal problem: A problem that may not require the presence of the
physician or other qualified health care professional, but the service is
provided under the physician’s or other qualified health care professional’s
supervision (see 99211).
Self-limited or minor problem: A problem that runs a definite and
prescribed course, is transient in nature, and is not likely to permanently alter
health status.
Stable, chronic illness: A problem with an expected duration of at least one
year or until the death of the patient. For the purpose of defining chronicity,
conditions are treated as chronic whether or not stage or severity changes
(eg, uncontrolled diabetes and controlled diabetes are a single chronic
condition). “Stable” for the purposes of categorizing MDM is defined by the
specific treatment goals for an individual patient. A patient who is not at his
or her treatment goal is not stable, even if the condition has not changed and
there is no short-term threat to life or function. For example, in a patient with
persistently poorly controlled blood pressure for whom better control is a
goal is not stable, even if the pressures are not changing and the patient is
asymptomatic, the risk of morbidity without treatment is significant.
Examples may include well-controlled hypertension, non-insulin-dependent
diabetes, cataract, or benign prostatic hyperplasia.
Acute, uncomplicated illness or injury: A recent or new short-term problem
with low risk of morbidity for which treatment is considered. There is little
to no risk of mortality with treatment, and full recovery without functional
impairment is expected. A problem that is normally self-limited or minor but
is not resolving consistent with a definite and prescribed course is an acute,
uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a
simple sprain.
Chronic illness with exacerbation, progression, or side effects of treatment:
A chronic illness that is acutely worsening, poorly controlled, or progressing
with an intent to control progression and requiring additional supportive care
or requiring attention to treatment for side effects but that does not require
consideration of hospital level of care.
Undiagnosed new problem with uncertain prognosis: A problem in the
differential diagnosis that represents a condition likely to result in a high risk
of morbidity without treatment. An example may be a lump in the breast.
Acute illness with systemic symptoms: An illness that causes systemic
symptoms and has a high risk of morbidity without treatment. For systemic
general symptoms, such as fever, body aches, or fatigue in a minor illness
that may be treated to alleviate symptoms, shorten the course of illness, or to
prevent complications, see the definitions for self-limited or minor problem
or acute, uncomplicated illness or injury. Systemic symptoms may not be
general but may be single system. Examples may include pyelonephritis,
pneumonitis, or colitis.
Acute, complicated injury: An injury which requires treatment that includes
evaluation of body systems that are not directly part of the injured organ, the
injury is extensive, or the treatment options are multiple and/or associated
with risk of morbidity. An example may be a head injury with brief loss of
consciousness.
Chronic illness with severe exacerbation, progression, or side effects of
treatment: The severe exacerbation or progression of a chronic illness or
severe side effects of treatment that have significant risk of morbidity and
may require hospital level of care.
Acute or chronic illness or injury that poses a threat to life or bodily
function: An acute illness with systemic symptoms, an acute complicated
injury, or a chronic illness or injury with exacerbation and/or progression or
side effects of treatment, that poses a threat to life or bodily function in the
near term without treatment. Examples may include acute myocardial
infarction, pulmonary embolus, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential threat to self or
others, peritonitis, acute renal failure, or an abrupt change in neurologic
status.
Test: Tests are imaging, laboratory, psychometric, or physiologic data. A
clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test.
The differentiation between single or multiple unique tests is defined in
accordance with the CPT code set.
External: External records, communications and/or test results are from an
external physician, other qualified health care professional, facility, or health
care organization.
External physician or other qualified health care professional: An external
physician or other qualified health care professional who is not in the same
group practice or is of a different specialty or subspecialty. This includes
licensed professionals who are practicing independently. The individual may
also be a facility or organizational provider such as from a hospital, nursing
facility, or home health care agency.
Independent historian(s): An individual (eg, parent, guardian, surrogate,
spouse, witness) who provides a history in addition to a history provided by
the patient who is unable to provide a complete or reliable history (eg, due to
developmental stage, dementia, or psychosis) or because a confirmatory
history is judged to be necessary. In the case where there may be conflict or
poor communication between multiple historians and more than one
historian is needed, the independent historian requirement is met.
Independent interpretation: The interpretation of a test for which there is a
CPT code and an interpretation or report is customary. This does not apply
when the physician or other qualified health care professional is reporting
the service or has previously reported the service for the patient. A form of
interpretation should be documented but need not conform to the usual
standards of a complete report for the test.
Appropriate source: For the purpose of the discussion of management data
element (see Table 2, Levels of Medical Decision Making), an appropriate
source includes professionals who are not health care professionals but may
be involved in the management of the patient (eg, lawyer, parole officer, case
manager, teacher). It does not include discussion with family or informal
caregivers.
Risk: The probability and/or consequences of an event. The assessment of
the level of risk is affected by the nature of the event under consideration.
For example, a low probability of death may be high risk, whereas a high
chance of a minor, self-limited adverse effect of treatment may be low risk.
Definitions of risk are based upon the usual behavior and thought processes
of a physician or other qualified health care professional in the same
specialty. Trained clinicians apply common language usage meanings to
terms such as high, medium, low, or minimal risk and do not require
quantification for these definitions (though quantification may be provided
when evidence-based medicine has established probabilities). For the
purposes of MDM, level of risk is based upon consequences of the
problem(s) addressed at the encounter when appropriately treated. Risk also
includes MDM related to the need to initiate or forego further testing,
treatment, and/or hospitalization.
Morbidity: A state of illness or functional impairment that is expected to be
of substantial duration during which function is limited, quality of life is
impaired, or there is organ damage that may not be transient despite
treatment.
Social determinants of health: Economic and social conditions that influence
the health of people and communities. Examples may include food or
housing insecurity.
Drug therapy requiring intensive monitoring for toxicity: A drug that
requires intensive monitoring is a therapeutic agent that has the potential to
cause serious morbidity or death. The monitoring is performed for
assessment of these adverse effects and not primarily for assessment of
therapeutic efficacy. The monitoring should be that which is generally
accepted practice for the agent but may be patient-specific in some cases.
Intensive monitoring may be long-term or short-term. Long-term intensive
monitoring is not performed less than quarterly. The monitoring may be
performed with a laboratory test, a physiologic test, or imaging. Monitoring
by history or examination does not qualify. The monitoring affects the level
of MDM in an encounter in which it is considered in the management of the
patient. Examples may include monitoring for cytopenia in the use of an
antineoplastic agent between dose cycles or the short-term intensive
monitoring of electrolytes and renal function in a patient who is undergoing
diuresis. Examples of monitoring that do not qualify include monitoring
glucose levels during insulin therapy, as the primary reason is the therapeutic
effect (even if hypoglycemia is a concern); or annual electrolytes and renal
function for a patient on a diuretic, as the frequency does not meet the
threshold.◀
▶Instructions for Selecting a Level of Office

or Other Outpatient E/M Services◀
▶Select the appropriate level of E/M services based on the following:
1. The level of the MDM as defined for each service, or
2. The total time for E/M services performed on the date of the encounter.◀
▶ Medical Decision Making◀

▶MDM includes establishing diagnoses, assessing the status of a condition,
and/or selecting a management option. MDM in the office or other outpatient
services codes is defined by three elements:
■ The number and complexity of problem(s) that are addressed during the
encounter.
■ The amount and/or complexity of data to be reviewed and analyzed. These
data include medical records, tests, and/or other information that must be
obtained, ordered, reviewed, and analyzed for the encounter. This includes
information obtained from multiple sources or interprofessional
communications that are not reported separately and interpretation of tests
that are not reported separately. Ordering a test is included in the category
of test result(s) and the review of the test result is part of the encounter
and not a subsequent encounter. Data are divided into three categories:
• Tests, documents, orders, or independent historian(s). (Each unique test, order, or
document is counted to meet a threshold number.)
• Independent interpretation of tests.
• Discussion of management or test interpretation with external physician or other
qualified health care professional or appropriate source.
■ The risk of complications and/or morbidity or mortality of patient
management decisions made at the visit, associated with the patient’s
problem(s), the diagnostic procedure(s), treatment(s). This includes the
possible management options selected and those considered but not
selected, after shared MDM with the patient and/or family. For example, a
decision about hospitalization includes consideration of alternative levels
of care. Examples may include a psychiatric patient with a sufficient
degree of support in the outpatient setting or the decision to not hospitalize
a patient with advanced dementia with an acute condition that would
generally warrant inpatient care, but for whom the goal is palliative
treatment.
Four types of MDM are recognized: straightforward, low, moderate, and
high. The concept of the level of MDM does not apply to 99211.
Shared MDM involves eliciting patient and/or family preferences, patient
and/or family education, and explaining risks and benefits of management
options.
MDM may be impacted by role and management responsibility.
When the physician or other qualified health care professional is reporting a
separate CPT code that includes interpretation and/or report, the
interpretation and/or report should not count toward the MDM when
selecting a level of office or other outpatient services. When the physician or
other qualified health care professional is reporting a separate service for
discussion of management with a physician or another qualified health care
professional, the discussion is not counted toward the MDM when selecting a
level of office or other outpatient services.
The Levels of Medical Decision Making (MDM) table (Table 2) is a guide to
assist in selecting the level of MDM for reporting an office or other
outpatient E/M services code. The table includes the four levels of MDM (ie,
straightforward, low, moderate, high) and the three elements of MDM (ie,
number and complexity of problems addressed at the encounter, amount
and/or complexity of data reviewed and analyzed, and risk of complications
and/or morbidity or mortality of patient management). To qualify for a
particular level of MDM, two of the three elements for that level of MDM
must be met or exceeded. See Table 2: Levels of Medical Decision Making
(MDM) on the following page. ◀
▶Table 2: Levels of Medical Decision Making (MDM)◀
▶ Code Level of MDM Elements of Medical Decision Making

(Based on 2 out Amount and/or
of 3 Elements of Complexity of Data to
MDM) be Reviewed and
Analyzed Risk of
*Each unique test, Complications
Number and order, or document and/or
Complexity of contributes to the Morbidity or
Problems combination of 2 or Mortality of
Addressed at combination of 3 in Patient
the Encounter Category 1 below. Management
99211 N/A N/A N/A N/A
99202 Straightforward Minimal Minimal or none Minimal risk of
99212 • 1 self-limited morbidity from
or minor additional
problem diagnostic
testing or
treatment
99203 Low Low Limited Low risk of
99213 • 2 or more (Must meet the morbidity from
self-limited or requirements of at least 1 additional
minor of the 2 categories) diagnostic
problems; Category 1: Tests and testing or
or documents treatment
• 1 stable, • Any combination of 2
chronic from the following:
illness; ■ Review of prior
or external note(s) from
• 1 acute, each unique source*;
uncomplicated ■ Review of the
illness or result(s) of each
injury unique test*;
■ Ordering of each
unique test*
or
Category 2: Assessment
requiring an independent
historian(s)
(For the categories of
independent
interpretation of tests and
discussion of
management or test
interpretation, see
moderate or high)
99204 Moderate Moderate Moderate Moderate risk
99214 • 1 or more (Must meet the of morbidity
chronic requirements of at least 1 from additional
illnesses with out of 3 categories) diagnostic
exacerbation, Category 1: Tests, testing or
progression, documents, or treatment
or side effects independent historian(s) Examples only:
of treatment; • Any combination of 3 • Prescription
or from the following: drug
• 2 or more ■ Review of prior management
stable, external note(s) from • Decision
chronic each unique source*; regarding
illnesses; ■ Review of the minor surgery
or result(s) of each with identified
• 1 undiagnosed unique test*; patient or
new problem ■ Ordering of each procedure risk
with uncertain unique test*; factors
prognosis; ■ Assessment requiring • Decision
or an independent regarding
• 1 acute illness historian(s) elective major
with systemic or surgery
symptoms; Category 2: Independent without
or interpretation of tests identified
• 1 acute, • Independent patient or
complicated interpretation of a test procedure risk
injury performed by another factors
physician/other • Diagnosis or
qualified health care treatment
professional (not significantly
separately reported); limited by
or social
Category 3: Discussion determinants
of management or test of health
interpretation
• Discussion of
management or test
interpretation with
external physician/other
qualified health care
professional/appropriate
source (not separately
reported)
99205 High High Extensive High risk of
99215 • 1 or more (Must meet the morbidity from
chronic requirements of at least 2 additional
illnesses with out of 3 categories) diagnostic
severe testing or
Category 1: Tests,
exacerbation, treatment
documents, or
progression, Examples only:
independent historian(s)
or side effects • Drug therapy
of treatment; Any combination of 3 requiring
•
or from the following: intensive
• 1 acute or ■ Review of prior monitoring for
chronic external note(s) from toxicity
illness or each unique source*; • Decision
injury that ■ Review of the regarding
poses a threat result(s) of each elective major
to life or unique test*; surgery with
bodily ■ Ordering of each identified
function unique test*; patient or
■ Assessment requiring procedure risk
an independent factors
historian(s) • Decision
or regarding
Category 2: Independent emergency
interpretation of tests major surgery
• Independent • Decision
interpretation of a test regarding
performed by another hospitalization
physician/other • Decision not
qualified health care to resuscitate
professional (not or to de-
separately reported); escalate care
or because of
Category 3: Discussion poor
of management or test prognosis◀
interpretation
• Discussion of
management or test
interpretation with
external physician/other
qualified health care
professional/appropriate
source (not separately
reported)
▶ Time◀
▶For instructions on using time to select the level of office or other
outpatient E/M services code, see the Time subsection in the Guidelines
Common to All E/M Services.◀
Unlisted Service
An E/M service may be provided that is not listed in this section of the CPT
codebook. When reporting such a service, the appropriate unlisted code may
be used to indicate the service, identifying it by “Special Report,” as
discussed in the following paragraph. The “Unlisted Services” and
accompanying codes for the E/M section are as follows:
99429 Unlisted preventive medicine service
99499 Unlisted evaluation and management service
Special Report
An unlisted service or one that is unusual, variable, or new may require a
special report demonstrating the medical appropriateness of the service.
Pertinent information should include an adequate definition or description of
the nature, extent, and need for the procedure and the time, effort, and
equipment necessary to provide the service. Additional items that may be
included are complexity of symptoms, final diagnosis, pertinent physical
findings, diagnostic and therapeutic procedures, concurrent problems, and
follow-up care.
Clinical Examples
Clinical examples of the codes for E/M services are provided to assist in
understanding the meaning of the descriptors and selecting the correct code.
The clinical examples are listed in Appendix C. Each example was developed
by the specialties shown.
The same problem, when seen by different specialties, may involve different
amounts of work. Therefore, the appropriate level of encounter should be
reported using the descriptors rather than the examples.
★ = Telemedicine ✚ = Add-on code ⚡ = FDA approval pending #=

Resequenced code ⃠ = Modifier 51 exempt ➲➲➲ = See p xviii for
details ▲ = Revised code ● = New code ▶◀ = Contains new or
revised text = Duplicate PLA test ⇅ = Category I PLA
Office or Other Outpatient Services

The following codes are used to report evaluation and
management services provided in the office or in an outpatient or
other ambulatory facility. A patient is considered an outpatient
until inpatient admission to a health care facility occurs.
To report services provided to a patient who is admitted to a
hospital or nursing facility in the course of an encounter in the
office or other ambulatory facility, see the notes for initial
hospital inpatient care (page 23) or initial nursing facility care
(page 33).
For services provided in the emergency department, see 99281-
99285.
For observation care, see 99217-99226.
For observation or inpatient care services (including admission
and discharge services), see 99234-99236.
Coding Tip
Determination of Patient Status as New or Established Patient
Solely for the purposes of distinguishing between new and established

patients, professional services are those face-to-face services rendered by
physicians and other qualified health care professionals who may report
evaluation and management services reported by a specific CPT code(s). A
new patient is one who has not received any professional services from the
physician/qualified health care professional or another physician/qualified
health care professional of the exact same specialty and subspecialty who
belongs to the same group practice, within the past three years.
An established patient is one who has received professional services from

the physician/qualified health care professional or another
physician/qualified health care professional of the exact same specialty and
subspecialty who belongs to the same group practice, within the past three
years.
In the instance where a physician/qualified health care professional is on call

for or covering for another physician/qualified health care professional, the
patient’s encounter will be classified as it would have been by the
physician/qualified health care professional who is not available. When
advanced practice nurses and physician assistants are working with
physicians they are considered as working in the exact same specialty and
exact same subspecialties as the physician.
CPT Coding Guidelines, Evaluation and Management, Guidelines

Common to All E/M Services, New and Established Patient
New Patient
▶ (99201 has been deleted. To report, use 99202)◀
★▲ 99202 Office or other outpatient visit for the evaluation and
management of a new patient, which requires a medically
appropriate history and/or examination and straightforward
medical decision making.
When using time for code selection, 15-29 minutes of total
time is spent on the date of the encounter.
➲ CPT Changes: An Insider’s View 2013, 2017, 2021
➲ CPT Assistant Winter 91:11, Spring 92:13, 24, Summer
92:1, 24, Spring 93:34, Summer 93:2, Fall 93:9, Spring
95:1, Summer 95:4, Fall 95:9, Jul 98:9, Sep 98:5, Feb
00:11, Aug 01:2, Apr 02:14, Oct 04:10, Apr 05:1, 3, Jun
05:11, Dec 05:10, May 06:1, Jun 06:1, Oct 06:15, Apr
07:11, Sep 07:1, Mar 09:3, Aug 09:5, Dec 09:9, Jan
11:3, Mar 12:4, 8, Jan 13:9, Jun 13:3, Aug 13:13, 14, Jan
15:12, Mar 16:11, Sep 16:6, Apr 18:10, Sep 18:14, Jan
19:3, Jan 20:3, Feb 20:3, Mar 20:3
appropriate history and/or examination and low level of
00:11, Aug 01:2, Apr 02:14, Oct 04:10, Feb 05:9, Apr
05:1, 3, Jun 05:11, Dec 05:10, May 06:1, Jun 06:1, Oct
06:15, Apr 07:11, Sep 07:1, Mar 09:3, Aug 09:5, Dec
09:9, Jan 11:3, Mar 12:4, 8, Jan 13:9, Jun 13:3, Aug
13:13, 14, Jan 15:12, Mar 16:11, Sep 16:6, Apr 18:10,
Sep 18:14, Jan 19:3, Jan 20:3, Feb 20:3, Mar 20:3

appropriate history and/or examination and moderate level
of medical decision making.
00:11, Aug 01:2, Apr 02:14, May 02:1, Oct 04:10, Apr
09:9, Jan 11:3, Mar 12:4, 8, Jan 13:9, Jun 13:3, Aug
13:13, 14, Jan 15:12, Mar 16:11, Sep 16:6, Apr 18:10,
Sep 18:14, Jan 19:3, Jan 20:3, Feb 20:3, Mar 20:3
appropriate history and/or examination and high level of
00:11, Aug 01:2, Apr 02:2, May 02:1, Oct 04:10, Apr
09:9, Jul 10:4, Jan 11:3, Jan 12:3, Mar 12:4, 8, Jan 13:9,
Jun 13:3, Aug 13:13, 14, Jan 15:12, Mar 16:11, Sep
16:6, Apr 18:10, Sep 18:14, Jan 19:3, Jan 20:3, Feb
20:3, Mar 20:3
▶ (Forservices 75 minutes or longer, use prolonged services

code 99417)◀
Established Patient
▲ 99211 Office or other outpatient visit for the evaluation and
management of an established patient, that may not require
the presence of a physician or other qualified health care
professional. Usually, the presenting problem(s) are
minimal.
➲ CPT Changes: An Insider’s View 2013, 2021
95:1, Summer 95:4, Fall 95:9, Oct 96:10, Feb 97:9, May
97:4, Jul 98:9, Sep 98:5, Oct 99:9, Feb 00:11, Aug 01:2,
Jan 02:2, Oct 04:10, Feb 05:15, Mar 05:11, Apr 05:1, 3,
May 05:1, Jun 05:11, Nov 05:1, Dec 05:10, Feb 06:14,
May 06:1, Jun 06:1, Jul 06:19, Oct 06:15, Nov 06:21,
Apr 07:11, Jul 07:1, Sep 07:1, Dec 07:9, Mar 08:3, Aug
08:13, Mar 09:3, Aug 09:5, Apr 10:10, Jan 11:3, Jan
12:3, Mar 12:4, 8, Apr 12:10, Jan 13:9, Mar 13:13, Jun
13:3, Aug 13:13, 14, Nov 13:3, Mar 14:14, Jan 15:12,
Mar 16:11, Sep 16:6, Mar 17:10, Apr 18:10, Sep 18:14,
Jan 19:3, Jan 20:3, Feb 20:3, Mar 20:3
management of an established patient, which requires a
medically appropriate history and/or examination and
straightforward medical decision making.
00:11, Jun 00:11, Aug 01:2, Jan 02:2, May 02:3, Apr
04:14, Oct 04:10, Apr 05:1, 3, Jun 05:11, Dec 05:10,
May 06:1, Jun 06:1, 11, Sep 06:8, Oct 06:15, Apr 07:11,
Jul 07:1, Sep 07:1, Mar 08:3, Mar 09:3, Aug 09:5, Feb
10:13, Jul 10:4, Sep 10:4, Jan 11:3, Jun 11:3, Mar 12:4,
8, Apr 12:17, Jan 13:9, Mar 13:13, Jun 13:3, Aug 13:13,
14, Feb 14:11, Jan 15:12, Mar 16:11, Sep 16:6, Dec
16:12, Oct 17:6, Apr 18:10, Sep 18:14, Jan 19:3, Jan
20:3, Feb 20:3, Mar 20:3
medically appropriate history and/or examination and low
level of medical decision making.
95:1, Summer 95:4, Fall 95:9, Jan 97:10, Jul 98:9, Sep
98:5, Aug 01:2, May 02:3, Oct 03:5, Apr 04:14, Oct
04:10, Mar 05:11, Apr 05:1, 3, Jun 05:11, Dec 05:10,
Jul 07:1, Sep 07:1, Mar 08:3, Mar 09:3, Aug 09:5, Sep
10:4, Jan 11:3, Jun 11:3, Mar 12:4, 8, Jan 13:9, Mar
13:13, Jun 13:3, Aug 13:13, 14, Jan 15:12, Mar 16:11,
Sep 16:6, Apr 18:10, Sep 18:14, Jan 19:3, Jan 20:3, Feb
20:3, Mar 20:3
medically appropriate history and/or examination and
moderate level of medical decision making.
95:1, Summer 95:4, Fall 95:9, May 97:4, Jul 98:9, Sep
98:5, Aug 01:2, Jan 02:2, May 02:1-2, Oct 03:5, Apr
04:14, Oct 04:10, Apr 05:1, 3, Jun 05:11, Dec 05:10,
Jul 07:1, Sep 07:1, Mar 08:3, Mar 09:3, Aug 09:5, Sep
10:4, Jan 11:3, Jun 11:3, Mar 12:4, 8, Jan 13:9, Mar
13:13, Jun 13:3, Aug 13:13, 14, Jan 15:12, Oct 15:3,
Mar 16:11, Sep 16:6, Apr 18:10, Sep 18:14, Jan 19:3,
Jan 20:3, Feb 20:3, Mar 20:3
medically appropriate history and/or examination and high
level of medical decision making.
95:1, Summer 95:4, Fall 95:9, Jan 97:10, Jul 98:9, Sep
98:5, Aug 01:2, Jan 02:2, May 02:1, 3, Apr 04:14, Oct
04:10, Mar 05:11, Apr 05:1, 3, Jun 05:11, Dec 05:10,
Jul 07:1, Sep 07:1, Mar 08:3, Mar 09:3, Aug 09:5, Jul
10:4, Sep 10:4, Jan 11:3, Jun 11:3, Jan 12:3, Mar 12:4,
8, Apr 12:10, Jan 13:9, Mar 13:13, Jun 13:3, Aug 13:13,
14, Nov 13:3, Aug 14:3, Oct 14:3, Nov 14:14, Jan
15:12, Mar 16:11, Sep 16:6, Apr 18:10, Sep 18:14, Jan
19:3, Oct 19:10, Jan 20:3, Feb 20:3, Mar 20:3
▶ (Forservices 55 minutes or longer, use prolonged services
code 99417)◀
Hospital Observation Services

management services provided to patients designated/admitted as
“observation status” in a hospital. It is not necessary that the
patient be located in an observation area designated by the
hospital.
If such an area does exist in a hospital (as a separate unit in the
hospital, in the emergency department, etc.), these codes are to be
utilized if the patient is placed in such an area.
For definitions of key components and commonly used terms,
please see Evaluation and Management Services Guidelines.
Coding Tip
The Significance of Time as a Factor in Selection of an Evaluation and
Management Code from This Section
The inclusion of time as an explicit factor beginning in CPT 1992 was done
to assist in selecting the most appropriate level of E/M services included in
codes in this section. Beginning with CPT 2021, except for 99211, time alone
may be used to select the appropriate code level for the office or other
outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213,
99214, 99215). Different categories of services use time differently. It is
important to review the instructions for each category.

99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318]):
For coding purposes, time for these services is defined as unit/floor time,
which includes the time present on the patient’s hospital unit and at the
bedside rendering services for that patient. This includes the time to establish
and/or review the patient’s chart, examine the patient, write notes, and
communicate with other professionals and the patient’s family.
Common to All E/M Services, Time
Observation Care Discharge Services

Observation care discharge of a patient from “observation status”
includes final examination of the patient, discussion of the
hospital stay, instructions for continuing care, and preparation of
discharge records. For observation or inpatient hospital care
including the admission and discharge of the patient on the same
date, see codes 99234-99236 as appropriate.
99217 Observation care discharge day management (This code is
to be utilized to report all services provided to a patient on
discharge from outpatient hospital “observation status” if the
discharge is on other than the initial date of “observation
status.” To report services to a patient designated as
“observation status” or “inpatient status” and discharged on
the same date, use the codes for Observation or Inpatient
Care Services [including Admission and Discharge
Services, 99234-99236 as appropriate.])
➲ CPT Assistant Nov 97:2, Mar 98:1, May 98:3, Sep 98:5,
Sep 00:3, May 05:1, Nov 05:10, Sep 06:8, Dec 06:14,
Sep 10:4, Jun 11:3, Jul 12:10, 11, 14, Jan 13:9, Jun 13:3,
Nov 14:14, Jul 19:10
Initial Observation Care

New or Established Patient
The following codes are used to report the encounter(s) by the
supervising physician or other qualified health care professional
with the patient when designated as outpatient hospital
“observation status.” This refers to the initiation of observation
status, supervision of the care plan for observation and
performance of periodic reassessments. For observation
encounters by other physicians, see office or other outpatient
consultation codes (99241-99245) or subsequent observation care
codes (99224-99226) as appropriate.
To report services provided to a patient who is admitted to the
hospital after receiving hospital observation care services on the
same date, see the notes for initial hospital inpatient care (page
23). For observation care services on other than the initial or
discharge date, see subsequent observation services codes
(99224-99226). For a patient admitted to the hospital on a date
subsequent to the date of observation status, the hospital
admission would be reported with the appropriate initial hospital
care code (99221-99223). For a patient admitted and discharged
from observation or inpatient status on the same date, the
services should be reported with codes 99234-99236 as
appropriate. Do not report observation discharge (99217) in
conjunction with a hospital admission (99221-99223).
When “observation status” is initiated in the course of an
encounter in another site of service (eg, hospital emergency
department, office, nursing facility) all evaluation and
management services provided by the supervising physician or
other qualified health care professional in conjunction with
initiating “observation status” are considered part of the initial
observation care when performed on the same date. The
observation care level of service reported by the supervising
physician or other qualified health care professional should
include the services related to initiating “observation status”
provided in the other sites of service as well as in the observation
setting.
▶Evaluation and management services including new or
established patient office or other outpatient services (99202-
99215), emergency department services (99281-99285), nursing
facility services (99304-99318), domiciliary, rest home, or
custodial care services (99324-99337), home services (99341-
99350), and preventive medicine services (99381-99429) on the
same date related to the admission to “observation status” should
not be reported separately.◀
These codes may not be utilized for post-operative recovery if the
procedure is considered part of the surgical “package.” These
codes apply to all evaluation and management services that are
provided on the same date of initiating “observation status.”
99218 Initial observation care, per day, for the evaluation and
management of a patient which requires these 3 key
components:
■ A detailed or comprehensive history;
■ A detailed or comprehensive examination; and
■ Medical decision making that is straightforward or of
low complexity.
Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs.
Usually, the problem(s) requiring admission to outpatient
hospital “observation status” are of low severity. Typically,
30 minutes are spent at the bedside and on the patient’s
hospital floor or unit.
➲ CPT Assistant Spring 93:34, Fall 95:9, Nov 97:2, Mar
98:1, Sep 98:5, Sep 00:3, Jan 03:10, Aug 04:11, May
05:1, Nov 05:10, Sep 06:8, Dec 06:14, Sep 10:4, Oct
10:6, Jun 11:3, Jul 12:11, 14, Jan 13:9, Jun 13:3, Aug
13:13, Mar 15:3, Jul 15:3, Dec 18:8, Jul 19:10
management of a patient, which requires these 3 key
components:
■ A comprehensive history;
■ A comprehensive examination; and
■ Medical decision making of moderate complexity.
hospital “observation status” are of moderate severity.
Typically, 50 minutes are spent at the bedside and on the
patient’s hospital floor or unit.
98:1, Sep 98:5, Sep 00:3, Jan 03:10, Aug 04:11, Nov
05:10, Sep 06:8, Dec 06:14, Sep 10:4, Oct 10:6, Jun
11:3, Jul 12:11, 14, Jan 13:9, Jun 13:3, Aug 13:13, Dec
18:8, Jul 19:10
components:
■ Medical decision making of high complexity.
hospital “observation status” are of high severity. Typically,
70 minutes are spent at the bedside and on the patient’s
hospital floor or unit.
98:1, Sep 98:5, Sep 00:3, Jan 03:10, Aug 04:11, Nov
05:10, Sep 06:8, Dec 06:14, Sep 10:4, Oct 10:6, Jun
11:3, Jul 12:11, Jan 13:9, Jun 13:3, Aug 13:13, Nov
14:14, Dec 18:8, Jul 19:10
Subsequent Observation Care

All levels of subsequent observation care include reviewing the
medical record and reviewing the results of diagnostic studies
and changes in the patient’s status (ie, changes in history, physical
condition, and response to management) since the last
assessment.
# 99224 Subsequent observation care, per day, for the evaluation
and management of a patient, which requires at least 2 of
these 3 key components:
■ Problem focused interval history;
■ Problem focused examination;
low complexity.
Usually, the patient is stable, recovering, or improving.
➲ CPT Assistant Jun 11:3, Aug 11:11, Jul 12:10, 11, Jun
13:3, Aug 13:13, Nov 14:14, Jul 19:10
■ An expanded problem focused interval history;
■ An expanded problem focused examination;
Usually, the patient is responding inadequately to therapy or
has developed a minor complication. Typically, 25 minutes
are spent at the bedside and on the patient’s hospital floor or
unit.
➲ CPT Assistant Jun 11:3, Aug 11:11, Jul 12:10, 11, Jan
13:9, Jun 13:3, Aug 13:13, Jul 19:10
■ A detailed interval history;
■ A detailed examination;
Usually, the patient is unstable or has developed a
significant complication or a significant new problem.
➲ CPT Assistant Jun 11:3, Aug 11:11, Jul 12:10, 11, Jan
13:9, Jun 13:3, Aug 13:13, Nov 14:14, Jul 19:10

management services provided to hospital inpatients. Hospital
inpatient services include those services provided to patients in a
“partial hospital” setting. These codes are to be used to report
these partial hospitalization services. See also psychiatry notes in
the full text of the CPT code set.
see Evaluation and Management Services Guidelines. For
Hospital Observation Services, see 99218-99220, 99224-99226.
For a patient admitted and discharged from observation or
inpatient status on the same date, the services should be reported
with codes 99234-99236 as appropriate.
Coding Tip

99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318]):

Initial Hospital Care

The following codes are used to report the first hospital inpatient
encounter with the patient by the admitting physician.
For initial inpatient encounters by physicians other than the
admitting physician, see initial inpatient consultation codes
(99251-99255) or subsequent hospital care codes (99231-99233)
as appropriate.
For admission services for the neonate (28 days of age or
younger) requiring intensive observation, frequent interventions,
and other intensive care services, see 99477.
When the patient is admitted to the hospital as an inpatient in the
course of an encounter in another site of service (eg, hospital
emergency department, observation status in a hospital, office,
nursing facility) all evaluation and management services provided
by that physician in conjunction with that admission are
considered part of the initial hospital care when performed on the
same date as the admission. The inpatient care level of service
reported by the admitting physician should include the services
related to the admission he/she provided in the other sites of
service as well as in the inpatient setting.
▶Evaluation and management services including new or
99215), emergency department services (99281-99285), nursing
custodial care services (99324-99337), home services (99341-
99350), and preventive medicine services (99381-99397) on the
same date related to the admission to “observation status” should
not be reported separately. For a patient admitted and discharged
from observation or inpatient status on the same date, the
services should be reported with codes 99234-99236 as
appropriate.◀
99221 Initial hospital care, per day, for the evaluation and
components:
low complexity.
Usually, the problem(s) requiring admission are of low
severity. Typically, 30 minutes are spent at the bedside and
on the patient’s hospital floor or unit.
92:10, 24, Fall 92:1, Spring 93:34, Spring 95:1, Fall
95:9, Jul 96:11, Sep 96:10, Nov 97:2, Mar 98:1, Sep
98:5, Jan 02:2-3, Apr 03:26, Apr 04:14, Aug 04:11, May
05:1, Sep 06:8, Jul 07:12, Jul 12:12, Jan 13:9, Jun 13:3,
Aug 13:13, Feb 14:11, May 14:4, Nov 14:14, Dec 15:16,
Mar 16:11, Dec 18:8
components:
Usually, the problem(s) requiring admission are of moderate
98:5, Jan 02:2-3, Apr 03:26, Apr 04:14, Aug 04:11, Sep
06:8, Jul 07:12, Jul 12:12, Jan 13:9, Jun 13:3, Aug
13:13, Mar 15:3, Dec 15:16, Mar 16:11, Dec 18:8
components:
Usually, the problem(s) requiring admission are of high
98:5, Jan 02:2-3, Apr 03:26, Apr 04:14, Aug 04:11, Sep
06:8, Jul 07:12, Jul 12:12, Jan 13:9, Jun 13:3, Aug
13:13, May 14:4, Nov 14:14, Dec 15:16, Mar 16:11,
Dec 18:8
99224 Code is out of numerical sequence. See 99219-99222

All levels of subsequent hospital care include reviewing the
medical record and reviewing the results of diagnostic studies
condition and response to management) since the last assessment.
★ 99231 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
key components:
■ A problem focused interval history;
■ A problem focused examination;
low complexity.
Usually, the patient is stable, recovering or improving.
95:16, Nov 97:2, Sep 98:5, Jan 99:10, Nov 99:5, Aug
01:2, Jan 02:2-3, Apr 04:14, Aug 04:11, Mar 05:11, May
05:1, May 06:1, 16, Jul 06:4, Mar 07:9, Jul 07:1, Mar
09:3, Dec 09:9, Jun 11:3, Jul 12:12, Jan 13:9, Jun 13:3,
Aug 13:14, Sep 13:18, May 14:4, Nov 14:14, Dec 18:8
key components:
are spent at the bedside and on the patient’s hospital floor or
unit.
95:16, Nov 97:2, Sep 98:5, Jan 99:10, Nov 99:5, Jan
00:11, Aug 01:2, Apr 04:14, Aug 04:11, May 06:1, 16,
Jul 06:4, Mar 07:9, Jul 07:1, Mar 09:3, Dec 09:9, Jun
11:3, Jul 12:12, Jan 13:9, Jun 13:3, Aug 13:14, Oct 16:8,
Dec 18:8
key components:
significant complication or a significant new problem.
95:16, Nov 97:2, Sep 98:5, Jan 99:10, Nov 99:5, Aug
01:2, Apr 04:14, Aug 04:11, May 06:1, 16, Jul 06:4, Mar
07:9, Jul 07:1, Mar 09:3, Dec 09:9, Jun 11:3, Jul 12:12,
Jan 13:9, Jun 13:3, Aug 13:13, 14, May 14:4, Nov 14:14,
Oct 16:8, Dec 18:8
Observation or Inpatient Care Services

(Including Admission and Discharge
Services)
The following codes are used to report observation or inpatient
hospital care services provided to patients admitted and
discharged on the same date of service. When a patient is
admitted to the hospital from observation status on the same date,
only the initial hospital care code should be reported. The initial
hospital care code reported by the admitting physician or other
qualified health care professional should include the services
related to the observation status services he/she provided on the
same date of inpatient admission.
When “observation status” is initiated in the course of an
encounter in another site of service (eg, hospital emergency
department, office, nursing facility) all evaluation and
management services provided by the supervising physician or
other qualified health care professional in conjunction with
initiating “observation status” are considered part of the initial
observation care when performed on the same date. The
observation care level of service should include the services
related to initiating “observation status” provided in the other
sites of service as well as in the observation setting when
provided by the same individual.
For patients admitted to observation or inpatient care and
discharged on a different date, see codes 99217, 99218-99220,
99224-99226, or 99221-99223, 99238 and 99239.
99234 Observation or inpatient hospital care, for the evaluation
and management of a patient including admission and
discharge on the same date, which requires these 3 key
components:
low complexity.
Usually the presenting problem(s) requiring admission are
of low severity. Typically, 40 minutes are spent at the
bedside and on the patient’s hospital floor or unit.
Jan 00:11, Sep 00:3, Jan 02:2, Jun 02:10, Jan 03:10, May
05:1, Nov 05:10, Sep 06:8, Dec 06:14, Sep 10:4, Jun
11:3, Jul 12:14, Jun 13:3, Apr 18:10, Dec 18:8
components:
of moderate severity. Typically, 50 minutes are spent at the
Jan 00:11, Sep 00:3, Jan 02:2, Jun 02:10, Jan 03:10, Nov
05:10, Sep 06:8, Dec 06:14, Sep 10:4, Jun 11:3, Jul
12:14, Jun 13:3, Apr 18:10, Dec 18:8
components:
of high severity. Typically, 55 minutes are spent at the
Jan 00:11, Sep 00:3, Jan 02:2, Jun 02:10, Jan 03:10, Nov
05:10, Sep 06:8, Dec 06:14, Sep 10:4, Jun 11:3, Jul
12:14, Jun 13:3, Apr 18:10, Dec 18:8
Hospital Discharge Services

The hospital discharge day management codes are to be used to
report the total duration of time spent by a physician for final
hospital discharge of a patient. The codes include, as appropriate,
final examination of the patient, discussion of the hospital stay,
even if the time spent by the physician on that date is not
continuous, instructions for continuing care to all relevant
caregivers, and preparation of discharge records, prescriptions
and referral forms. For a patient admitted and discharged from
observation or inpatient status on the same date, the services
should be reported with codes 99234-99236 as appropriate.
99238 Hospital discharge day management; 30 minutes or less
➲ CPT Assistant Fall 92:1, Spring 93:4, Nov 97:4, Mar
98:3, 11, May 98:2, Jan 99:10, Jan 02:2, Aug 04:11, May
05:1, Sep 06:8, Nov 09:10, Dec 09:9, Jul 11:16, Jul
12:10, 12, Jun 13:3, Aug 13:13, Dec 18:8
99239 more than 30 minutes
➲ CPT Assistant Nov 97:4, Mar 98:3, 11, May 98:2,
Jan 99:10, Jan 02:2, Aug 04:11, Sep 06:8, Nov
09:10, Dec 09:9, Jul 11:16, Jul 12:12, Jun 13:3, Aug
13:13, Dec 18:8
(These codes are to be utilized to report all services
provided to a patient on the date of discharge, if other than
the initial date of inpatient status. To report services to a
patient who is admitted as an inpatient and discharged on the
same date, see codes 99234-99236 for observation or
inpatient hospital care including the admission and
discharge of the patient on the same date. To report
concurrent care services provided by an individual other
than the physician or qualified health care professional
performing the discharge day management service, use
subsequent hospital care codes [99231-99233] on the day of
discharge.)
(For Observation Care Discharge, use 99217)
(For observation or inpatient hospital care including the
admission and discharge of the patient on the same date, see
99234-99236)
(For Nursing Facility Care Discharge, see 99315, 99316)
(For discharge services provided to newborns admitted and
discharged on the same date, use 99463)
Consultations
A consultation is a type of evaluation and management service
provided at the request of another physician or appropriate
source to either recommend care for a specific condition or
problem or to determine whether to accept responsibility for
ongoing management of the patient’s entire care or for the care of
a specific condition or problem.
A physician consultant may initiate diagnostic and/or therapeutic
services at the same or subsequent visit.
A “consultation” initiated by a patient and/or family, and not
requested by a physician or other appropriate source (eg,
physician assistant, nurse practitioner, doctor of chiropractic,
physical therapist, occupational therapist, speech-language
pathologist, psychologist, social worker, lawyer, or insurance
company), is not reported using the consultation codes but may
be reported using the office visit, home service, or
domiciliary/rest home care codes as appropriate.
The written or verbal request for consult may be made by a
physician or other appropriate source and documented in the
patient’s medical record by either the consulting or requesting
physician or appropriate source. The consultant’s opinion and
any services that were ordered or performed must also be
documented in the patient’s medical record and communicated by
written report to the requesting physician or other appropriate
source.
If a consultation is mandated (eg, by a third-party payer) modifier
32 should also be reported.
Any specifically identifiable procedure (ie, identified with a
specific CPT code) performed on or subsequent to the date of the
initial consultation should be reported separately.
If subsequent to the completion of a consultation the consultant
assumes responsibility for management of a portion or all of the
patient’s condition(s), the appropriate Evaluation and
Management services code for the site of service should be
reported. In the hospital or nursing facility setting, the consultant
should use the appropriate inpatient consultation code for the
initial encounter and then subsequent hospital or nursing facility
care codes. In the office setting, the consultant should use the
appropriate office or other outpatient consultation codes and then
the established patient office or other outpatient services codes.
To report services provided to a patient who is admitted to a
hospital or nursing facility in the course of an encounter in the
office or other ambulatory facility, see the notes for Initial
Hospital Inpatient Care (page 23) or Initial Nursing Facility Care
(page 33).
Office or Other Outpatient Consultations

The following codes are used to report consultations provided in
the office or in an outpatient or other ambulatory facility,
including hospital observation services, home services,
domiciliary, rest home, or emergency department (see the
preceding consultation definition above). Follow-up visits in the
consultant’s office or other outpatient facility that are initiated by
the consultant or patient are reported using the appropriate codes
for established patients, office visits (99211-99215), domiciliary,
rest home (99334-99337), or home (99347-99350). If an
additional request for an opinion or advice regarding the same or
a new problem is received from another physician or other
appropriate source and documented in the medical record, the
office consultation codes may be used again. Services that
constitute transfer of care (ie, are provided for the management
of the patient’s entire care or for the care of a specific condition
or problem) are reported with the appropriate new or established
patient codes for office or other outpatient visits, domiciliary, rest
home services, or home services.
Coding Tip
Definition of Transfer of Care
Transfer of care is the process whereby a physician or other qualified health

care professional who is providing management for some or all of a patient’s
problems relinquishes this responsibility to another physician or other
qualified health care professional who explicitly agrees to accept this
responsibility and who, from the initial encounter, is not providing
consultative services. The physician or other qualified health care
professional transferring care is then no longer providing care for these
problems though he or she may continue providing care for other conditions
when appropriate. Consultation codes should not be reported by the
physician or other qualified health care professional who has agreed to
accept transfer of care before an initial evaluation but are appropriate to
report if the decision to accept transfer of care cannot be made until after the
initial consultation evaluation, regardless of site of service.

Common to All E/M Services, Concurrent Care and Transfer of Care
★ 99241 Office consultation for a new or established patient, which

requires these 3 key components:
■ A problem focused history;
■ A problem focused examination; and
■ Straightforward medical decision making.
Usually, the presenting problem(s) are self limited or minor.
Typically, 15 minutes are spent face-to-face with the patient
and/or family.
➲ CPT Assistant Winter 91:11, Spring 92:4, 23-24,
Summer 92:12, Spring 93:4, Spring 95:1, Oct 97:1, Sep
98:5, Jun 99:10, Apr 00:10, Aug 01:3, Jan 02:2, Jul
02:2, Sep 02:11, May 05:1, Dec 05:10, Jan 06:46, May
06:1, 16, Jun 06:1, Sep 06:8, Jan 07:28, Apr 07:11, Jul
07:1, May 08:13, Nov 08:10, Aug 09:9, Jan 10:3, Jul
10:4, Jun 11:3, Apr 12:10, Jan 13:9, Jun 13:3, Aug 14:3,
Sep 14:13, Nov 14:14, Jan 15:12, Dec 15:18, Sep 16:6,
Apr 18:10
➲ Clinical Examples in Radiology Summer 09:3

■ An expanded problem focused history;
■ An expanded problem focused examination; and
Usually, the presenting problem(s) are of low severity.
and/or family.
Summer 92:12, Spring 93:2, 34, Spring 95:1, Oct 97:1,
Sep 98:5, Aug 01:3, Jan 02:2, Jul 02:2, Sep 02:11, Dec
05:10, May 06:1, 16, Jun 06:1, Sep 06:8, Apr 07:11, Jul
07:1, Jan 10:3, Jun 11:3, Jan 13:9, Jun 13:3, Sep 14:13,
Jan 15:12, Sep 16:6, Apr 18:10

■ A detailed history;
■ A detailed examination; and
■ Medical decision making of low complexity.
Usually, the presenting problem(s) are of moderate severity.
and/or family.
Sep 98:5, Aug 01:3, Jan 02:2, Jul 02:2, Sep 02:11, Oct
03:5, Dec 05:10, May 06:1, 16, Jun 06:1, Sep 06:8, Apr
07:11, Jul 07:1, Jan 10:3, Jun 11:3, Jan 13:9, Jun 13:3,
Sep 14:13, Jan 15:12, Sep 16:6, Apr 18:10
Usually, the presenting problem(s) are of moderate to high
severity. Typically, 60 minutes are spent face-to-face with
the patient and/or family.
Sep 98:5, Aug 01:3, Jan 02:2, Jul 02:2, Sep 02:11, Oct
03:5, Dec 05:10, May 06:1, 16, Jun 06:1, Sep 06:8, Apr
07:11, Jul 07:1, Jan 10:3, Jun 11:3, Jan 13:9, Jun 13:3,
Aug 13:12, Sep 14:13, Jan 15:12, Sep 16:6, Apr 18:10
➲ Clinical Examples in Radiology Summer 09:2, 3

Sep 98:5, Aug 01:2, Jan 02:2, Jul 02:2, Sep 02:11, Dec
05:10, May 06:1, 16, Jun 06:1, Sep 06:8, Apr 07:11, Jul
07:1, Jan 10:3, Jul 10:4, Jun 11:3, Apr 12:10, Jan 13:9,
Jun 13:3, Aug 14:3, Sep 14:13, Jan 15:12, Sep 16:6, Apr
18:10
Inpatient Consultations
The following codes are used to report physician or other
qualified health care professional consultations provided to
hospital inpatients, residents of nursing facilities, or patients in a
partial hospital setting. Only one consultation should be reported
by a consultant per admission. Subsequent services during the
same admission are reported using subsequent hospital care
codes (99231-99233) or subsequent nursing facility care codes
(99307-99310), including services to complete the initial
consultation, monitor progress, revise recommendations, or
address a new problem. Use subsequent hospital care codes
(99231-99233) or subsequent nursing facility care codes (99307-
99310) to report transfer of care services (see page 8, Concurrent
Care and Transfer of Care definitions).
When an inpatient consultation is performed on a date that a
patient is admitted to a hospital or nursing facility, all evaluation
and management services provided by the consultant related to
the admission are reported with the inpatient consultation service
code (99251-99255). If a patient is admitted after an outpatient
consultation (office, emergency department, etc), and the patient
is not seen on the unit on the date of admission, only report the
outpatient consultation code (99241-99245). If the patient is seen
by the consultant on the unit on the date of admission, report all
evaluation and management services provided by the consultant
related to the admission with either the inpatient consultation
code (99251-99255) or with the initial inpatient admission service
code (99221-99223). Do not report both an outpatient
consultation (99241-99245) and inpatient consultation (99251-
99255) for services related to the same inpatient stay. When
transfer of care services are provided on a date subsequent to the
outpatient consultation, use the subsequent hospital care codes
(99231-99233) or subsequent nursing facility care codes (99307-
99310).
★ 99251 Inpatient consultation for a new or established patient,
which requires these 3 key components:
Summer 92:12, Spring 93:34, Spring 95:1, Oct 97:1, Sep
98:5, Aug 01:3, Sep 02:11, May 05:1, May 06:1, 16, Jun
06:1, Jul 06:19, Jul 07:1, Jan 10:3, Jan 13:9, Jun 13:3
Summer 92:12, Summer 93:34, Spring 95:1, Oct 97:1,
Sep 98:5, Aug 01:4, Sep 02:11, May 06:1, 16, Jun 06:1,
Jul 06:19, Jul 07:1, Jan 10:3, Jan 13:9, Jun 13:3



Jul 06:19, Jul 07:1, Jan 10:3, Jan 13:9, Jun 13:3, Nov
14:14

management services provided in the emergency department. No
distinction is made between new and established patients in the
emergency department.
An emergency department is defined as an organized hospital-
based facility for the provision of unscheduled episodic services
to patients who present for immediate medical attention. The
facility must be available 24 hours a day.
For critical care services provided in the emergency department,
see Critical Care notes and 99291, 99292.
For evaluation and management services provided to a patient in
an observation area of a hospital, see 99217-99220.
For observation or inpatient care services (including admission
and discharge services), see 99234-99236.
Coding Tip
Time as a Factor in the Emergency Department Setting
Time is not a descriptive component for the emergency department levels of

E/M services because emergency department services are typically provided
on a variable intensity basis, often involving multiple encounters with
several patients over an extended period of time. Therefore, it is often
difficult for physicians to provide accurate estimates of the time spent face-
to-face with the patient.

99281 Emergency department visit for the evaluation and

components:
➲ CPT Assistant Winter 91:11, Spring 92:24, Summer
92:18, Spring 93:34, Spring 95:1, Feb 96:3, Sep 98:5,
Jan 00:11, Feb 00:11, Sep 00:3, Apr 02:14, Jul 02:2,
Nov 05:10, Feb 06:14, Dec 06:14, Dec 07:13, Jan 13:9,
Jun 13:3, Nov 14:14, Jan 15:12, Jul 19:10
components:
Usually, the presenting problem(s) are of low to moderate
severity.
92:18, Spring 93:34, Spring 95:1, Summer 95:1, Feb
96:3, Sep 98:5, Jan 00:11, Feb 00:11, Sep 00:3, Apr
02:14, Jul 02:2, Nov 05:10, Feb 06:14, Dec 06:14, Dec
07:13, Jan 13:9, Jun 13:3, Jan 15:12, Jul 19:10
components:
07:13, Jan 13:9, Jun 13:3, Jan 15:12, Jul 19:10
components:
Usually, the presenting problem(s) are of high severity, and
require urgent evaluation by the physician, or other qualified
health care professionals but do not pose an immediate
significant threat to life or physiologic function.
07:13, Jan 13:9, Jun 13:3, Jan 15:12, Jul 19:10
components within the constraints imposed by the urgency of
the patient’s clinical condition and/or mental status:
Usually, the presenting problem(s) are of high severity and
pose an immediate significant threat to life or physiologic
function.
96:3, Aug 98:8, Sep 98:5, Nov 99:23, Jan 00:11, Feb
00:11, Sep 00:3, Apr 02:14, Jul 02:2, Sep 02:11, Mar
05:11, Nov 05:10, Feb 06:14, Dec 06:14, Dec 07:13, Jan
13:9, Jun 13:3, Nov 14:14, Jan 15:12, Jul 19:10, Jan
20:12
Coding Tip
Emergency Department Classification of New vs Established Patient
No distinction is made between new and established patients in the

emergency department. E/M services in the emergency department category
may be reported for any new or established patient who presents for
treatment in the emergency department.

Common to All E/M Services, New and Established Patient
Other Emergency Services
In directed emergency care, advanced life support, the physician
or other qualified health care professional is located in a hospital
emergency or critical care department, and is in two-way voice
communication with ambulance or rescue personnel outside the
hospital. Direction of the performance of necessary medical
procedures includes but is not limited to: telemetry of cardiac
rhythm; cardiac and/or pulmonary resuscitation; endotracheal or
esophageal obturator airway intubation; administration of
intravenous fluids and/or administration of intramuscular,
intratracheal or subcutaneous drugs; and/or electrical conversion
of arrhythmia.
99288 Physician or other qualified health care professional
direction of emergency medical systems (EMS) emergency
care, advanced life support
➲ CPT Assistant Summer 92:18, May 05:1, Nov 07:5, May
13:6

Critical care is the direct delivery by a physician(s) or other
qualified health care professional of medical care for a critically
ill or critically injured patient. A critical illness or injury acutely
impairs one or more vital organ systems such that there is a high
probability of imminent or life threatening deterioration in the
patient’s condition. Critical care involves high complexity
decision making to assess, manipulate, and support vital system
function(s) to treat single or multiple vital organ system failure
and/or to prevent further life threatening deterioration of the
patient’s condition. Examples of vital organ system failure
include, but are not limited to: central nervous system failure,
circulatory failure, shock, renal, hepatic, metabolic, and/or
respiratory failure. Although critical care typically requires
interpretation of multiple physiologic parameters and/or
application of advanced technology(s), critical care may be
provided in life threatening situations when these elements are
not present. Critical care may be provided on multiple days, even
if no changes are made in the treatment rendered to the patient,
provided that the patient’s condition continues to require the level
of attention described above.
Providing medical care to a critically ill, injured, or post-
operative patient qualifies as a critical care service only if both
the illness or injury and the treatment being provided meet the
above requirements. Critical care is usually, but not always, given
in a critical care area, such as the coronary care unit, intensive
care unit, pediatric intensive care unit, respiratory care unit, or
the emergency care facility.
Inpatient critical care services provided to infants 29 days
through 71 months of age are reported with pediatric critical care
codes 99471-99476. The pediatric critical care codes are reported
as long as the infant/young child qualifies for critical care
services during the hospital stay through 71 months of age.
Inpatient critical care services provided to neonates (28 days of
age or younger) are reported with the neonatal critical care codes
99468 and 99469. The neonatal critical care codes are reported as
long as the neonate qualifies for critical care services during the
hospital stay through the 28th postnatal day. The reporting of the
pediatric and neonatal critical care services is not based on time
or the type of unit (eg, pediatric or neonatal critical care unit) and
it is not dependent upon the type of physician or other qualified
health care professional delivering the care. To report critical care
services provided in the outpatient setting (eg, emergency
department or office), for neonates and pediatric patients up
through 71 months of age, see the critical care codes 99291,
99292. If the same individual provides critical care services for a
neonatal or pediatric patient in both the outpatient and inpatient
settings on the same day, report only the appropriate neonatal or
pediatric critical care code 99468-99472 for all critical care
services provided on that day. Also report 99291-99292 for
neonatal or pediatric critical care services provided by the
individual providing critical care at one facility but transferring
the patient to another facility. Critical care services provided by a
second individual of a different specialty not reporting a per day
neonatal or pediatric critical care code can be reported with codes
99291, 99292. For additional instructions on reporting these
services, see the Neonatal and Pediatric Critical Care section and
codes 99468-99476.
Services for a patient who is not critically ill but happens to be in
a critical care unit are reported using other appropriate E/M
codes.
Critical care and other E/M services may be provided to the same
patient on the same date by the same individual.
For reporting by professionals, the following services are
included in critical care when performed during the critical
period by the physician(s) providing critical care: the
interpretation of cardiac output measurements (93561, 93562),
chest X rays (71045, 71046), pulse oximetry (94760, 94761,
94762), blood gases, and collection and interpretation of
physiologic data (eg, ECGs, blood pressures, hematologic data);
gastric intubation (43752, 43753); temporary transcutaneous
pacing (92953); ventilatory management (94002-94004, 94660,
94662); and vascular access procedures (36000, 36410, 36415,
36591, 36600). Any services performed that are not included in
this listing should be reported separately. Facilities may report the
above services separately.
Codes 99291, 99292 should be reported for the attendance during
the transport of critically ill or critically injured patients older
than 24 months of age to or from a facility or hospital. For
transport services of critically ill or critically injured pediatric
patients 24 months of age or younger, see 99466, 99467.
Codes 99291, 99292 are used to report the total duration of time
spent in provision of critical care services to a critically ill or
critically injured patient, even if the time spent providing care on
that date is not continuous. For any given period of time spent
providing critical care services, the individual must devote his or
her full attention to the patient and, therefore, cannot provide
services to any other patient during the same period of time.
Time spent with the individual patient should be recorded in the
patient’s record. The time that can be reported as critical care is
the time spent engaged in work directly related to the individual
patient’s care whether that time was spent at the immediate
bedside or elsewhere on the floor or unit. For example, time
spent on the unit or at the nursing station on the floor reviewing
test results or imaging studies, discussing the critically ill patient’s
care with other medical staff or documenting critical care services
in the medical record would be reported as critical care, even
though it does not occur at the bedside. Also, when the patient is
unable or lacks capacity to participate in discussions, time spent
on the floor or unit with family members or surrogate decision
makers obtaining a medical history, reviewing the patient’s
condition or prognosis, or discussing treatment or limitation(s) of
treatment may be reported as critical care, provided that the
conversation bears directly on the management of the patient.
Time spent in activities that occur outside of the unit or off the
floor (eg, telephone calls whether taken at home, in the office, or
elsewhere in the hospital) may not be reported as critical care
since the individual is not immediately available to the patient.
Time spent in activities that do not directly contribute to the
treatment of the patient may not be reported as critical care, even
if they are performed in the critical care unit (eg, participation in
administrative meetings or telephone calls to discuss other
patients). Time spent performing separately reportable
procedures or services should not be included in the time
reported as critical care time.
Code 99291 is used to report the first 30-74 minutes of critical
care on a given date. It should be used only once per date even if
the time spent by the individual is not continuous on that date.
Critical care of less than 30 minutes total duration on a given date
should be reported with the appropriate E/M code.
Code 99292 is used to report additional block(s) of time, of up to
30 minutes each beyond the first 74 minutes. (See the following
table.)
The following examples illustrate the correct reporting of critical
care services:
Total Duration of
Critical Care Codes
less than 30 minutes appropriate E/M codes
30-74 minutes 99291 X 1
(30 minutes - 1 hr. 14
min.)
75-104 minutes 99291 X 1 AND 99292 X 1
(1 hr. 15 min. - 1 hr.
44 min.)
105-134 minutes 99291 X 1 AND 99292 X 2
(1 hr. 45 min. - 2 hr.
14 min.)
135-164 minutes 99291 X 1 AND 99292 X 3
(2 hr. 15 min. - 2 hr.
44 min.)
165-194 minutes 99291 X 1 AND 99292 X 4
(2 hr. 45 min. - 3 hr.
14 min.)
195 minutes or longer 99291 and 99292 as appropriate (see illustrated
(3 hr. 15 min. - etc.) reporting examples above)
99291 Critical care, evaluation and management of the critically

ill or critically injured patient; first 30-74 minutes
➲ CPT Assistant Summer 92:18, Summer 93:1, Summer
95:1, Jan 96:7, Apr 97:3, Dec 98:6, Nov 99:3, Apr 00:6,
Sep 00:1, Dec 00:15, Jul 02:2, Feb 03:15, Oct 03:2, Aug
04:7, 10, Oct 04:14, May 05:1, Jul 05:15, Nov 05:10, Jul
06:4, Dec 06:13, Nov 07:5, Jan 09:5, Mar 09:3, Jul
09:10, Aug 11:10, Sep 11:3, Jul 12:13, Feb 13:17, May
13:6, May 14:4, Aug 14:5, Oct 14:14, Feb 15:10, May
16:3, Aug 16:9, Oct 16:8, Jun 18:9, Dec 18:8, Jul 19:10,
Aug 19:8, Dec 19:14, Jan 20:12, Feb 20:7
✚ 99292 each additional 30 minutes (List separately in addition to
code for primary service)
➲ CPT Assistant Summer 92:18, Summer 93:1, Summer
95:1, Jan 96:7, Apr 97:3, Dec 98:6, Nov 99:3, Apr
00:6, Sep 00:1, Dec 00:15, Feb 03:15, Oct 03:2, Aug
04:10, Oct 04:14, Jul 05:15, Nov 05:10, Jul 06:4,
Dec 06:13, Nov 07:5, Jan 09:5, Mar 09:3, Aug 11:10,
Sep 11:3, Feb 13:17, May 13:6, May 14:4, Aug 14:5,
Oct 14:14, Feb 15:10, May 16:3, Aug 16:9, Jun 18:9,
Dec 18:8, Jul 19:10, Aug 19:8, Dec 19:14, Feb 20:7
(Use 99292 in conjunction with 99291)
Coding Tip
Services Included in Critical Care Services
For reporting by professionals, the following services are included in

critical care when performed during the critical period by the physician(s)
providing critical care: the interpretation of cardiac output measurements
(93561, 93562), chest X rays (71045, 71046), pulse oximetry (94760,
94761, 94762), blood gases, and collection and interpretation of physiologic
data (eg, ECGs, blood pressures, hematologic data); gastric intubation
(43752, 43753); temporary transcutaneous pacing (92953); ventilatory
management (94002-94004, 94660, 94662); and vascular access procedures
(36000, 36410, 36415, 36591, 36600). Any services performed that are not
listed above should be reported separately. Facilities may report the above
services separately
CPT Coding Guideline, Critical Care

management services to patients in nursing facilities (formerly
called skilled nursing facilities [SNFs], intermediate care facilities
[ICFs], or long-term care facilities [LTCFs]).
These codes should also be used to report evaluation and
management services provided to a patient in a psychiatric
residential treatment center (a facility or a distinct part of a facility
for psychiatric care, which provides a 24-hour therapeutically
planned and professionally staffed group living and learning
environment). If procedures such as medical psychotherapy are
provided in addition to evaluation and management services,
these should be reported in addition to the evaluation and
management services provided.
Nursing facilities that provide convalescent, rehabilitative, or
long term care are required to conduct comprehensive, accurate,
standardized, and reproducible assessments of each resident’s
functional capacity using a Resident Assessment Instrument
(RAI). All RAIs include the Minimum Data Set (MDS), Resident
Assessment Protocols (RAPs), and utilization guidelines. The
MDS is the primary screening and assessment tool; the RAPs
trigger the identification of potential problems and provide
guidelines for follow-up assessments.
Physicians have a central role in assuring that all residents receive
thorough assessments and that medical plans of care are instituted
or revised to enhance or maintain the residents’ physical and
psychosocial functioning. This role includes providing input in
the development of the MDS and a multi-disciplinary plan of
care, as required by regulations pertaining to the care of nursing
facility residents.
Two major subcategories of nursing facility services are
recognized: Initial Nursing Facility Care and Subsequent Nursing
Facility Care. Both subcategories apply to new or established
patients.
(For care plan oversight services provided to nursing
facility residents, see 99379-99380)
Initial Nursing Facility Care

When the patient is admitted to the nursing facility in the course
of an encounter in another site of service (eg, hospital emergency
department, office), all evaluation and management services
provided by that physician in conjunction with that admission are
considered part of the initial nursing facility care when
performed on the same date as the admission or readmission. The
nursing facility care level of service reported by the admitting
physician should include the services related to the admission
he/she provided in the other sites of service as well as in the
nursing facility setting.
Hospital discharge or observation discharge services performed
on the same date of nursing facility admission or readmission
may be reported separately. For a patient discharged from
inpatient status on the same date of nursing facility admission or
readmission, the hospital discharge services should be reported
with codes 99238, 99239 as appropriate. For a patient discharged
from observation status on the same date of nursing facility
admission or readmission, the observation care discharge
services should be reported with code 99217. For a patient
admitted and discharged from observation or inpatient status on
the same date, see codes 99234-99236.
(For nursing facility care discharge, see 99315, 99316)
Coding Tip
Coding Tip

99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318]):

99304 Initial nursing facility care, per day, for the evaluation and
components:
low complexity.
Usually, the problem(s) requiring admission are of low
on the patient’s facility floor or unit.
➲ CPT Changes: An Insider’s View 2006, 2008, 2010,
2013
➲ CPT Assistant Jul 10:4, Jan 11:3, Jun 11:3, Jan 12:3, Jul
12:12, Jan 13:9, Jun 13:3, Nov 14:14
components:
Usually, the problem(s) requiring admission are of moderate
2013
➲ CPT Assistant Jan 11:3, Jun 11:3, Jul 12:12, Jan 13:9,
Jun 13:3
components:
Usually, the problem(s) requiring admission are of high
2013
➲ CPT Assistant Jan 11:3, Jun 11:3, Jan 12:3, Jul 12:12,
Jan 13:9, Jun 13:3
Subsequent Nursing Facility Care

All levels of subsequent nursing facility care include reviewing
the medical record and reviewing the results of diagnostic studies
condition, and response to management) since the last assessment
by the physician or other qualified health are professional.
★ 99307 Subsequent nursing facility care, per day, for the evaluation
patient’s facility floor or unit.
2013, 2017
➲ CPT Assistant May 06:1, 16, Jun 06:1, 19, Mar 07:9, Jul
07:1, Jul 09:3, 8, Jan 11:3, Jan 12:3, Jul 12:12, Jan 13:9,
Jun 13:3
are spent at the bedside and on the patient’s facility floor or
unit.
2013, 2017
07:1, Jul 09:3, 8, Jan 11:3, Jul 12:12, Jan 13:9, Jun 13:3
Usually, the patient has developed a significant complication
or a significant new problem. Typically, 25 minutes are
spent at the bedside and on the patient’s facility floor or unit.
2013, 2017
07:1, Jul 09:3, 8, Jan 11:3, Jul 12:12, Jan 13:9, Jun 13:3
■ A comprehensive interval history;
■ A comprehensive examination;
The patient may be unstable or may have developed a
significant new problem requiring immediate physician
attention. Typically, 35 minutes are spent at the bedside and
2013, 2017
07:1, Jul 09:3, 8, Jul 10:4, Jan 11:3, Jan 12:3, Jul 12:12,
Jan 13:9, Jun 13:3
Nursing Facility Discharge Services

The nursing facility discharge day management codes are to be
used to report the total duration of time spent by a physician or
other qualified health care professional for the final nursing
facility discharge of a patient. The codes include, as appropriate,
final examination of the patient, discussion of the nursing facility
stay, even if the time spent on that date is not continuous.
Instructions are given for continuing care to all relevant
caregivers, and preparation of discharge records, prescriptions
and referral forms.
99315 Nursing facility discharge day management; 30 minutes or
less
➲ CPT Assistant Nov 97:5-6, Sep 98:5, May 02:19, Nov
02:11, May 05:1, Jul 09:3, Jan 11:3, Jan 12:3, Jul 12:12,
Jan 13:9, Jun 13:3
99316 more than 30 minutes
➲ CPT Assistant Nov 97:5-6, Sep 98:5, May 02:19,
Nov 02:11, Jul 09:3, Jan 11:3, Jul 12:12, Jan 13:9,
Jun 13:3
Other Nursing Facility Services

99318 Evaluation and management of a patient involving an annual
nursing facility assessment, which requires these 3 key
components:
■ Medical decision making that is of low to moderate
complexity.
patient’s facility floor or unit.
2013
➲ CPT Assistant Jan 11:3, Jan 12:3, Jan 13:9, Jun 13:3,
Nov 14:14
(Do not report 99318 on the same date of service as nursing
facility services codes 99304-99316)
Domiciliary, Rest Home (eg, Boarding

Home), or Custodial Care Services
management services in a facility which provides room, board
and other personal assistance services, generally on a long-term
basis. These codes include evaluation and management services
provided in an assisted living facility, group home, custodial care,
and intermediate care facilities.
The facility’s services do not include a medical component.
(For care plan oversight services provided to a patient in a
domiciliary facility under the care of a home health agency,
see 99374, 99375, and for hospice agency, see 99377,
99378. For care plan oversight provided to a patient under
hospice or home health agency care, see 99339, 99340)
New Patient
99324 Domiciliary or rest home visit for the evaluation and
management of a new patient, which requires these 3 key
components:
Typically, 20 minutes are spent with the patient and/or
family or caregiver.
➲ CPT Assistant Jan 06:1, Jun 06:1, Jul 09:8, Aug 09:5,
Jan 11:3, Jan 12:3, Apr 12:10, Jan 13:9, Jun 13:3, Oct
14:3, Nov 14:14
components:
Jan 11:3, Jan 13:9, Jun 13:3
components:
severity. Typically, 45 minutes are spent with the patient
and/or family or caregiver.
Jan 11:3, Jan 13:9, Jun 13:3
components:
Usually, the presenting problem(s) are of high severity.
Jan 11:3, Jan 13:9, Jun 13:3
components:
attention. Typically, 75 minutes are spent with the patient
Jan 11:3, Jan 12:3, Jan 13:9, Jun 13:3
Established Patient
management of an established patient, which requires at
least 2 of these 3 key components:
Usually, the presenting problem(s) are self-limited or minor.
➲ CPT Assistant Jan 06:1, Jun 06:1, Jul 07:1, Jul 09:8, Aug
09:5, Jan 11:3, Jan 12:3, Jan 13:9, Jun 13:3, Nov 13:3
09:5, Jan 11:3, Jan 13:9, Jun 13:3
09:5, Jan 11:3, Jan 13:9, Jun 13:3
■ Medical decision making of moderate to high
complexity.
severity. The patient may be unstable or may have
developed a significant new problem requiring immediate
physician attention. Typically, 60 minutes are spent with the
patient and/or family or caregiver.
09:5, Jan 11:3, Jan 12:3, Apr 12:10, Jan 13:9, Jun 13:3,
Nov 13:3, Oct 14:3, Nov 14:14
Domiciliary, Rest Home (eg, Assisted
Living Facility), or Home Care Plan
Oversight Services
(For instructions on the use of 99339, 99340, see
introductory notes for 99374-99380)
(For care plan oversight services for patients under the care
of a home health agency, hospice, or nursing facility, see
99374-99380)
(Do not report 99339, 99340 for time reported with 98966,
98967, 98968, 99421, 99422, 99423, 99441, 99442, 99443)
99339 Individual physician supervision of a patient (patient not
present) in home, domiciliary or rest home (eg, assisted
living facility) requiring complex and multidisciplinary care
modalities involving regular physician development and/or
revision of care plans, review of subsequent reports of
patient status, review of related laboratory and other
studies, communication (including telephone calls) for
purposes of assessment or care decisions with health care
professional(s), family member(s), surrogate decision
maker(s) (eg, legal guardian) and/or key caregiver(s)
involved in patient’s care, integration of new information
into the medical treatment plan and/or adjustment of medical
therapy, within a calendar month; 15-29 minutes
➲ CPT Assistant Jan 06:1, Dec 06:4, Mar 07:11, Sep 08:3,
Jul 09:5, 10, Jan 12:3, Apr 13:3, Jun 13:3, Sep 13:15,
Nov 13:3, Oct 14:3
99340 30 minutes or more
➲ CPT Assistant Jan 06:1, Dec 06:4, Mar 07:11, Sep
08:3, Jul 09:5, 10, Jan 12:3, Apr 13:3, Jun 13:3, Sep
13:15, Nov 13:3, Oct 14:3
(Do not report 99339, 99340 for patients under the care of a
home health agency, enrolled in a hospice program, or for
nursing facility residents)
(Do not report 99339, 99340 during the same month with
99487-99489)
Home Services
management services provided in a home. Home may be defined
as a private residence, temporary lodging, or short term
accommodation (eg, hotel, campground, hostel, or cruise ship).
(For care plan oversight services provided to a patient in
the home under the care of a home health agency, see 99374,
99375, and for hospice agency, see 99377, 99378. For care
plan oversight provided to a patient under hospice or home
health agency care, see 99339, 99340)
New Patient
99341 Home visit for the evaluation and management of a new
patient, which requires these 3 key components:
and/or family.
92:12, Spring 93:34, Spring 95:1, Jun 97:6, Nov 97:6-8,
Oct 98:6, Oct 03:7, May 05:1, Jan 06:1, Jul 09:8, Aug
09:5, Jan 11:3, Jan 12:3, Apr 12:10, Jan 13:9, Jun 13:3,
Oct 14:3, Nov 14:14
and/or family.
Oct 98:6, Jan 06:1, Jul 09:8, Aug 09:5, Jan 11:3, Jan
13:9, Jun 13:3
Oct 98:6, Jan 06:1, Jul 09:8, Aug 09:5, Jan 11:3, Jan
13:9, Jun 13:3
Usually, the presenting problem(s) are of high severity.
and/or family.
➲ CPT Assistant Nov 97:6-8, Oct 98:6, Jan 06:1, Jul 09:8,
Aug 09:5, Jan 11:3, Jan 13:9, Jun 13:3
attention. Typically, 75 minutes are spent face-to-face with
Aug 09:5, Jan 11:3, Jan 12:3, Jan 13:9, Jun 13:3
Established Patient
99347 Home visit for the evaluation and management of an
established patient, which requires at least 2 of these 3 key
components:
and/or family.
➲ CPT Assistant Nov 97:6-8, Oct 98:6, May 05:1, Jan
06:1, Jul 07:1, Jul 09:8, Aug 09:5, Jan 11:3, Jan 12:3,
Jan 13:9, Jun 13:3, Nov 13:3
components:
Jul 09:8, Aug 09:5, Jan 11:3, Jan 13:9, Jun 13:3
components:
Usually, the presenting problem(s) are moderate to high
Jul 09:8, Aug 09:5, Jan 13:9, Jun 13:3
components:
■ Medical decision making of moderate to high
complexity.
severity. The patient may be unstable or may have
developed a significant new problem requiring immediate
physician attention. Typically, 60 minutes are spent face-to-
face with the patient and/or family.
➲ CPT Assistant Nov 97:6-8, Oct 98:6, Oct 03:7, Jan 06:1,
Jul 07:1, Jul 09:8, Aug 09:5, Jan 12:3, Apr 12:10, Jan
13:9, Jun 13:3, Nov 13:3, Oct 14:3, Nov 14:14
Prolonged Services
▶Prolonged Service With Direct Patient
Contact (Except with Office or Other
Outpatient Services)◀
▶Codes 99354-99357 are used when a physician or other
qualified health care professional provides prolonged service(s)
involving direct patient contact that is provided beyond the usual
service in either the inpatient, observation or outpatient setting,
except with office or other outpatient services (99202, 99203,
99204, 99205, 99212, 99213, 99214, 99215). Direct patient contact
is face-to-face and includes additional non-face-to-face services
on the patient’s floor or unit in the hospital or nursing facility
during the same session. This service is reported in addition to
the primary procedure. Appropriate codes should be selected for
supplies provided or other procedures performed in the care of
the patient during this period.
Codes 99354-99355 are used to report the total duration of face-
to-face time spent by a physician or other qualified health care
professional on a given date providing prolonged service in the
outpatient setting, even if the time spent by the physician or other
qualified health care professional on that date is not continuous.
Codes 99356-99357 are used to report the total duration of time
spent by a physician or other qualified health care professional at
the bedside and on the patient’s floor or unit in the hospital or
nursing facility on a given date providing prolonged service to a
patient, even if the time spent by the physician or other qualified
health care professional on that date is not continuous.◀
Time spent performing separately reported services other than the
E/M or psychotherapy service is not counted toward the
prolonged services time.
Code 99354 or 99356 is used to report the first hour of prolonged
service on a given date, depending on the place of service.
▶Either code should be used only once per date, even if the time
spent by the physician or other qualified health care professional
is not continuous on that date. Prolonged service of less than 30
minutes total duration on a given date is not separately
reported.◀
Code 99355 or 99357 is used to report each additional 30 minutes
beyond the first hour, depending on the place of service. Either
code may also be used to report the final 15-30 minutes of
prolonged service on a given date. Prolonged service of less than
15 minutes beyond the first hour or less than 15 minutes beyond
the final 30 minutes is not reported separately.
The use of the time based add-on codes requires that the primary
evaluation and management service have a typical or specified
time published in the CPT codebook.
▶For E/M services that require prolonged clinical staff time and
may include face-to-face services by the physician or other
qualified health care professional, use 99415, 99416. Do not
report 99354, 99355 with 99415, 99416, 99417.
For prolonged total time in addition to office or other outpatient
services (ie, 99205, 99215), use 99417.
The following table illustrates the correct reporting of prolonged
physician or other qualified health care professional service with
direct patient contact in the inpatient or observation setting
beyond the usual service time.◀
▶ Total Duration of
Prolonged Services Code(s)
less than 30 minutes Not reported separately
30-74 minutes 99356 X 1
(30 minutes - 1 hr. 14 min.)
75-104 minutes 99356 X 1 AND 99357 X 1
(1 hr. 15 min. - 1 hr. 44
min.)
105 minutes or more 99356 X 1 AND 99357 X 2 or more for each
(1 hr. 45 min. or more) additional 30 minutes.◀
★✚▲ 99354 Prolonged service(s) in the outpatient setting requiring

direct patient contact beyond the time of the usual service;
first hour (List separately in addition to code for outpatient
Evaluation and Management or psychotherapy service,
except with office or other outpatient services [99202,
99203, 99204, 99205, 99212, 99213, 99214, 99215])
2017, 2021
➲ CPT Assistant Spring 94:30, 32, May 97:3, Sep 98:5,
Sep 00:2, Jul 01:2, May 05:1, Nov 05:10, Jun 08:12, Sep
08:3, Jul 09:8, Apr 12:10, Aug 12:3, 4, 5, May 13:12,
Jun 13:3, Oct 13:11, Apr 14:6, Jun 14:14, Oct 15:3, 9,
Jun 19:7, Oct 19:10
▶ (Use99354 in conjunction with 90837, 90847, 99241-
99245, 99324-99337, 99341-99350, 99483)◀
▶ (Donot report 99354 in conjunction with 99202, 99203,
99204, 99205, 99212, 99213, 99214, 99215, 99415, 99416,
99417)◀
★✚▲ 99355 each additional 30 minutes (List separately in addition to
code for prolonged service)
2017, 2021
➲ CPT Assistant Spring 94:30, 32, May 97:3, Sep 98:5,
Sep 00:2, Jul 01:2, Nov 05:10, Jun 08:12, Sep 08:3,
Jul 09:8, Apr 12:10, Aug 12:3, 4, 5, May 13:12, Jun
13:3, Oct 13:11, Apr 14:6, Jun 14:14, Oct 15:3, 9,
Jun 19:7, Oct 19:10
99204, 99205, 99212, 99213, 99214, 99215, 99415, 99416,
99417)◀
✚▲ 99356 Prolonged service in the inpatient or observation setting,
requiring unit/floor time beyond the usual service; first hour
(List separately in addition to code for inpatient or
observation Evaluation and Management service)
➲ CPT Assistant Spring 94:30, 32, Apr 97:3, May 97:3,
Sep 98:5, Sep 00:2, Jul 01:2, Nov 05:10, Jun 08:12, Sep
08:3, Jul 09:8, Jun 11:3, Aug 11:11, Jul 12:11, Aug 12:3,
4, 5, May 13:12, Jun 13:3, Oct 13:11, Apr 14:6, Jun
14:14, Oct 15:3, 9, Jun 19:7
(Use 99356 in conjunction with 90837, 90847, 99218-
99220, 99221-99223, 99224-99226, 99231-99233, 99234-
99236, 99251-99255, 99304-99310)
➲ CPT Assistant Spring 94:34, Apr 97:3, May 97:3,
Sep 98:5, Sep 00:2, Jul 01:2, Nov 05:10, Jun 08:12,
Sep 08:3, Jul 09:8, Jun 11:3, Aug 11:11, Jul 12:11,
Aug 12:3, 4, 5, May 13:12, Jun 13:3, Oct 13:11, Apr
14:6, Jun 14:14, Oct 15:3, 9, Jun 19:7
Prolonged Service Without Direct Patient

Contact
▶Codes 99358 and 99359 are used when a prolonged service is
provided that is neither face-to-face time in the outpatient,
inpatient, or observation setting, nor additional unit/floor time in
the hospital or nursing facility setting. Codes 99358, 99359 may
be used during the same session of an evaluation and
management service, except office or other outpatient services
(99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). For
prolonged total time in addition to office or other outpatient
services (ie, 99205, 99215) on the same date of service without
direct patient contact, use 99417. Codes 99358, 99359 may also be
used for prolonged services on a date other than the date of a
face-to face encounter.
This service is to be reported in relation to other physician or
other qualified health care professional services, including
evaluation and management services at any level. This prolonged
service may be reported on a different date than the primary
service to which it is related. For example, extensive record
review may relate to a previous evaluation and management
service performed at an earlier date. However, it must relate to a
service or patient where (face-to-face) patient care has occurred
or will occur and relate to ongoing patient management.◀
Codes 99358 and 99359 are used to report the total duration of
non-face-to-face time spent by a physician or other qualified
health care professional on a given date providing prolonged
service, even if the time spent by the physician or other qualified
health care professional on that date is not continuous. Code
99358 is used to report the first hour of prolonged service on a
given date regardless of the place of service. It should be used
only once per date.
▶Prolonged service of less than 30 minutes total duration on a
given date is not separately reported.
Code 99359 is used to report each additional 30 minutes beyond
the first hour. It may also be used to report the final 15 to 30
minutes of prolonged service on a given date.◀
Prolonged service of less than 15 minutes beyond the first hour
or less than 15 minutes beyond the final 30 minutes is not
reported separately.
▶Do not report 99358, 99359 for time without direct patient
contact reported in other services such as care plan oversight
services (99339, 99340, 99374-99380), chronic care management
by a physician or other qualified health care professional (99491),
home and outpatient INR monitoring (93792, 93793), medical
team conferences (99366-99368), interprofessional
telephone/Internet/electronic health record consultations (99446,
99447, 99448, 99449, 99451, 99452), or online digital evaluation
and management services (99421, 99422, 99423).◀
99358 Prolonged evaluation and management service before
and/or after direct patient care; first hour
➲ CPT Assistant Spring 94:34, Nov 98:3, Sep 00:3, Nov
05:10, Jun 08:12, Sep 08:3, Aug 12:3, 4, 5, Apr 13:3,
Oct 13:11, Nov 13:3, Oct 14:3, Oct 18:9, Jan 19:13, Jun
19:7
➲ CPT Assistant Spring 94:34, Sep 00:3, Nov 05:10,
Jun 08:12, Sep 08:3, Aug 12:3, 4, 5, Apr 13:3, Oct
13:11, Nov 13:3, Oct 14:3, Oct 18:9, Jan 19:13, Jun
19:7
▶ (Do not report 99358, 99359 on the same date of service
as 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99417)◀
Total Duration of Prolonged Services

Without Direct Face-to-Face Contact Code(s)
30-74 minutes 99358 X 1
75-104 minutes 99358 X 1 AND 99359 X 1
(1 hr. 15 min. - 1 hr. 44 min.)
105 minutes or more 99358 X 1 AND 99359 X 2 or
(1 hr. 45 min. or more) more for each additional 30
minutes.
Prolonged Clinical Staff Services With
Physician or Other Qualified Health Care
Professional Supervision
▶Codes 99415, 99416 are used when a prolonged evaluation and
management (E/M) service is provided in the office or outpatient
setting that involves prolonged clinical staff face-to-face time
beyond the highest total time of the E/M service, as stated in the
ranges of time in the code descriptions. The physician or
qualified health care professional is present to provide direct
supervision of the clinical staff. This service is reported in
addition to the designated E/M services and any other services
provided at the same session as E/M services.◀
Codes 99415, 99416 are used to report the total duration of face-
to-face time spent by clinical staff on a given date providing
prolonged service in the office or other outpatient setting, even if
the time spent by the clinical staff on that date is not continuous.
E/M service is not counted toward the prolonged services time.
▶Code 99415 is used to report the first hour of prolonged clinical
staff service on a given date. Code 99415 should be used only
once per date, even if the time spent by the clinical staff is not
continuous on that date. Prolonged service of less than 30
minutes total duration on a given date is not separately reported
because the clinical staff time involved is included in the E/M
codes. The highest total time in the time ranges of the code
descriptions is used in defining when prolonged services time
begins. For example, prolonged clinical staff services for 99214
begin after 39 minutes, and 99415 is not reported until at least 69
minutes total face-to-face clinical staff time has been performed.
When face-to-face time is noncontiguous, use only the face-to-
face time provided to the patient by the clinical staff.◀
Code 99416 is used to report each additional 30 minutes of
prolonged clinical staff service beyond the first hour. Code 99416
may also be used to report the final 15-30 minutes of prolonged
service on a given date. Prolonged service of less than 15 minutes
beyond the first hour or less than 15 minutes beyond the final 30
minutes is not reported separately.
▶Codes 99415, 99416 may be reported for no more than two
simultaneous patients. The use of the time-based add-on codes
requires that the primary E/M service has a time published in the
CPT code set.
For prolonged services by the physician or other qualified health
care professional, see 99354, 99355, 99417. Do not report 99415,
99416 with 99354, 99355, 99417.◀
Facilities may not report 99415, 99416.
#✚▲ 99415 Prolonged clinical staff service (the service beyond the
highest time in the range of total time of the service) during
an evaluation and management service in the office or
outpatient setting, direct patient contact with physician
supervision; first hour (List separately in addition to code
for outpatient Evaluation and Management service)
➲ CPT Assistant Oct 15:3, Feb 16:13, Oct 19:10
▶ (Use99415 in conjunction with 99202, 99203, 99204,

99205, 99212, 99213, 99214, 99215)◀
99417)◀
#✚▲ 99416 each additional 30 minutes (List separately in addition to
➲ CPT Assistant Oct 15:3, Feb 16:13, Oct 19:10
99417)◀
▶The Total Duration of Prolonged Services Table illustrates the
correct reporting of prolonged services provided by clinical staff
with physician supervision in the office setting beyond the initial
30 minutes of clinical staff time:
Total Duration of
Prolonged Services Code(s)
30-74 minutes 99415 X 1
75-104 minutes 99415 X 1 AND 99416 X 1
(1 hr. 15 min. - 1 hr. 44
min.)
105 minutes or more 99415 X 1 AND 99416 X 2 or more for each
(1 hr. 45 min. or more) additional 30 minutes.◀
▶Prolonged Service With or Without

Direct Patient Contact on the Date of an
Office or Other Outpatient Service◀
▶Code 99417 is used to report prolonged total time (ie,
combined time with and without direct patient contact) provided
by the physician or other qualified health care professional on the
date of office or other outpatient services (ie, 99205, 99215).
Code 99417 is only used when the office or other outpatient
service has been selected using time alone as the basis and only
after the minimum time required to report the highest-level
service (ie, 99205 or 99215) has been exceeded by 15 minutes.
To report a unit of 99417, 15 minutes of additional time must
have been attained. Do not report 99417 for any additional time
increment of less than 15 minutes. The listed time ranges for
99205 (ie, 60-74 minutes) and 99215 (ie, 40-54 minutes) represent
the complete range of time for which each code may be reported.
Therefore, when reporting 99417, the initial time unit of 15
minutes should be added once the minimum time in the primary
E/M code has been surpassed by 15 minutes. For example, to
report the initial unit of 99417 for a new patient encounter
(99205), do not report 99417 until at least 15 minutes of time has
been accumulated beyond 60 minutes (ie, 75 minutes) on the date
of the encounter. For an established patient encounter (99215),
do not report 99417 until at least 15 minutes of time has been
accumulated beyond 40 minutes (ie, 55 minutes) on the date of
the encounter.
E/M service is not counted toward the time to report 99205,
99215 and prolonged services time.
For prolonged services on a date other than the date of a face-to-
face encounter, including office or other outpatient services
(99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215), see
99358, 99359. For E/M services that require prolonged clinical
staff time and may include face-to-face services by the physician
or other QHP, see 99415, 99416. Do not report 99417 in
conjunction with 99354, 99355, 99358, 99359, 99415, 99416.
Prolonged services of less than 15 minutes total time is not
reported on the date of office or other outpatient service when
the highest level is reached (ie, 99205, 99215).◀
#★✚● 99417 Prolonged office or other outpatient evaluation and
management service(s) beyond the minimum required time
of the primary procedure which has been selected using total
time, requiring total time with or without direct patient
contact beyond the usual service, on the date of the primary
service, each 15 minutes of total time (List separately in
addition to codes 99205, 99215 for office or other
outpatient Evaluation and Management services)
▶ (Use 99417 in conjunction with 99205, 99215)◀

▶ (Donot report 99417 on the same date of service as
99354, 99355, 99358, 99359, 99415, 99416)◀
▶ (Do not report 99417 for any time unit less than 15
minutes)◀
New Patient Office or
Other Outpatient Services (use with
99205) Code(s)
75-89 minutes 99205 X 1 and 99417 X 1
90-104 minutes 99205 X 1 and 99417 X 2
105 minutes or more 99205 X 1 and 99417 X 3 or
more for each additional 15
minutes
Total Duration of Established Patient Code(s)

Office or Other Outpatient Services (use
with 99215)
55-69 minutes 99215 X 1 and 99417 X 1
70-84 minutes 99215 X 1 and 99417 X 2
85 minutes or more 99215 X 1 and 99417 X 3 or
more for each additional 15
minutes◀
Standby Services
Code 99360 is used to report physician or other qualified health
care professional standby services that are requested by another
individual and that involve prolonged attendance without direct
(face-to-face) patient contact. Care or services may not be
provided to other patients during this period. This code is not
used to report time spent proctoring another individual. It is also
not used if the period of standby ends with the performance of a
procedure, subject to a surgical package by the individual who
was on standby.
Code 99360 is used to report the total duration of time spent on a
given date on standby. Standby service of less than 30 minutes
total duration on a given date is not reported separately.
Second and subsequent periods of standby beyond the first 30
minutes may be reported only if a full 30 minutes of standby was
provided for each unit of service reported.
99360 Standby service, requiring prolonged attendance, each 30
minutes (eg, operative standby, standby for frozen section,
for cesarean/high risk delivery, for monitoring EEG)
➲ CPT Assistant Spring 94:32, Apr 97:10, Aug 97:18, Nov
97:8, Nov 99:5-6, Aug 00:3, Sep 00:3, May 05:1, Nov
05:10, Nov 06:23, Mar 08:14, Feb 11:3, May 13:8, Apr
14:5, 11
(For hospital mandated on call services, see 99026, 99027)
(99360 may be reported in addition to 99460, 99465 as
appropriate)
(Do not report 99360 in conjunction with 99464)

Case management is a process in which a physician or another
qualified health care professional is responsible for direct care of
a patient and, additionally, for coordinating, managing access to,
initiating, and/or supervising other health care services needed by
the patient.
(99363, 99364 have been deleted. To report, see 93792,
93793)
Medical Team Conferences

Medical team conferences include face-to-face participation by a
minimum of three qualified health care professionals from
different specialties or disciplines (each of whom provide direct
care to the patient), with or without the presence of the patient,
family member(s), community agencies, surrogate decision
maker(s) (eg, legal guardian), and/or caregiver(s). The
participants are actively involved in the development, revision,
coordination, and implementation of health care services needed
by the patient. Reporting participants shall have performed face-
to-face evaluations or treatments of the patient, independent of
any team conference, within the previous 60 days.
Physicians or other qualified health care professionals who may
report evaluation and management services should report their
time spent in a team conference with the patient and/or family
present using evaluation and management (E/M) codes (and time
as the key controlling factor for code selection when counseling
and/or coordination of care dominates the service). These
introductory guidelines do not apply to services reported using
E/M codes (see E/M services guidelines). However, the individual
must be directly involved with the patient, providing face-to-face
services outside of the conference visit with other physicians, and
qualified health care professionals, or agencies.
Reporting participants shall document their participation in the
team conference as well as their contributed information and
subsequent treatment recommendations.
No more than one individual from the same specialty may report
99366-99368 at the same encounter.
Individuals should not report 99366-99368 when their
participation in the medical team conference is part of a facility or
organizational service contractually provided by the organization
or facility.
The team conference starts at the beginning of the review of an
individual patient and ends at the conclusion of the review. Time
related to record keeping and report generation is not reported.
The reporting participant shall be present for all time reported.
The time reported is not limited to the time that the participant is
communicating to the other team members or patient and/or
family. Time reported for medical team conferences may not be
used in the determination of time for other services such as care
plan oversight (99374-99380), home, domiciliary, or rest home
care plan oversight (99339-99340), prolonged services (99354-
99359), psychotherapy, or any E/M service. For team conferences
where the patient is present for any part of the duration of the
conference, nonphysician qualified health care professionals (eg,
speech-language pathologists, physical therapists, occupational
therapists, social workers, dietitians) report the team conference
face-to-face code 99366.
▶Comparison of Prolonged Services Codes (99354, 99355,

99356, 99357, 99358, 99359, 99417) Table ◀
▶ Code Patient Minimum Use In *Do Other

Contact Reportable Conjunction With Not Prolonged
Prolonged Report Service(s)
Services With Reportable
Time On Same
(Single Date Of
Date of Service
Service)
✚99354 Face-to- 30 minutes 90837, 90847, 99202- 99358,
Face Only (Beyond 99241-99245, 99205, 99359
listed 99324-99337, 99212-
typical 99341-99350, 99215,
time) 99483 99415,
99416,
99417
✚99355 Face-to- Each 99354 99202- 99358,
Face Only additional 99205, 99359
15 minutes 99212-
99215,
(Beyond 99415,
99354) 99416,
99417
✚99356 Face-to- 30 minutes 90837, 90847, 99358,
Face and (Beyond 99218-99220, 99359
Unit/Floor listed 99221-99223,
Time typical 99224-99226,
time) 99231-99233,
99234-99236,
99251-99255,
99304-99310
✚99357 Face-to- Each 99356 99358,
Face and additional 99359
Unit/Floor 15 minutes
Time (Beyond
99356)
99358 Non- 30 minutes Must relate to a 99202- 99354,
Face-to- service where face- 99205, 99356
Face Only to-face care has or 99212-
will occur. This is 99215,
not an add-on code 99417
and is not used in On
conjunction with a same
base code. date of
service
✚99359 Non- Each 99358 99202- 99354,
Face-to- additional 99205, 99356
Face Only 15 minutes 99212-
(Beyond 99215,
99358) 99417
On
same
date of
service
✚99417 Face-to- Reported 99205, 99215 99354, N/A
Face with 99355,
and/or 99205: 99358,
Non- 75 minutes 99359,
Face-to- or more 99415,
Face Reported 99416
with
99215: 55
minutes or
more
(Total time
on the date
of
encounter)
*Do not count the time of any separately reported service as prolonged
services time
99355 is for prolonged services time beyond 99354 and may be reported in
multiple units
multiple units
multiple units
99417 is for prolonged services time beyond 99205 or 99215 and may be
reported in multiple units of at least 15 minutes◀
Medical Team Conference, Direct (Face-to-Face)

Contact With Patient and/or Family
99366 Medical team conference with interdisciplinary team of
health care professionals, face-to-face with patient and/or
family, 30 minutes or more, participation by nonphysician
qualified health care professional
➲ CPT Assistant Apr 13:3, Jun 14:3, Oct 14:3
(Team conference services of less than 30 minutes duration

are not reported separately)
(For team conference services by a physician with patient
and/or family present, see Evaluation and Management
services)
▶ (Donot report 99366 during the same month with 99439,
99487, 99489, 99490, 99491)◀
Medical Team Conference, Without Direct (Face-

to-Face) Contact With Patient and/or Family
99367 Medical team conference with interdisciplinary team of
health care professionals, patient and/or family not present,
30 minutes or more; participation by physician
➲ CPT Assistant Apr 13:3, Jun 14:3, Dec 19:14
99368 participation by nonphysician qualified health care

professional
➲ CPT Assistant Apr 13:3, Jun 14:3, Oct 14:3
(Team conference services of less than 30 minutes duration

are not reported separately)
▶ (Donot report 99367, 99368 during the same month with
99439, 99487, 99489, 99490, 99491)◀

Care plan oversight services are reported separately from codes
for office/outpatient, hospital, home, nursing facility or
domiciliary, or non-face-to-face services. The complexity and
approximate time of the care plan oversight services provided
within a 30-day period determine code selection. Only one
individual may report services for a given period of time, to
reflect the sole or predominant supervisory role with a particular
patient. These codes should not be reported for supervision of
patients in nursing facilities or under the care of home health
agencies unless they require recurrent supervision of therapy.
The work involved in providing very low intensity or infrequent
supervision services is included in the pre- and post-encounter
work for home, office/outpatient and nursing facility or
domiciliary visit codes.
(For care plan oversight services of patients in the home,
domiciliary, or rest home [eg, assisted living facility], see
99339, 99340, and for hospice agency, see 99377, 99378)
(Do not report 99374-99380 for time reported with 98966,
98967, 98968, 99421, 99422, 99423, 99441, 99442, 99443)
(Do not report 99374-99378 during the same month with
99487-99489)
99374 Supervision of a patient under care of home health agency
(patient not present) in home, domiciliary or equivalent
environment (eg, Alzheimer’s facility) requiring complex
and multidisciplinary care modalities involving regular
development and/or revision of care plans by that
individual, review of subsequent reports of patient status,
review of related laboratory and other studies,
communication (including telephone calls) for purposes of
assessment or care decisions with health care
➲ CPT Assistant Summer 94:9, Nov 97:8-9, May 05:1,
Dec 06:4, Mar 07:11, Mar 08:6, Sep 08:3, Jul 09:5, 10,
Apr 13:3, Jul 13:11, Sep 13:15, Nov 13:3, Feb 14:11,
Oct 14:3
➲ CPT Assistant Summer 94:9, Nov 97:8-9, Dec 06:4,
Mar 07:11, Mar 08:6, Sep 08:3, Jul 09:5, 10, Apr
13:3, Jul 13:11, Sep 13:15
99377 Supervision of a hospice patient (patient not present)
requiring complex and multidisciplinary care modalities
involving regular development and/or revision of care plans
by that individual, review of subsequent reports of patient
status, review of related laboratory and other studies,
➲ CPT Assistant Nov 97:8-9, Dec 06:4, Mar 07:11, Sep
08:3, Jul 09:5, 10, Apr 13:3, Jul 13:11, Sep 13:15
➲ CPT Assistant Nov 97:8-9, Dec 06:4, Mar 07:11,
Mar 08:6, Sep 08:3, Jul 09:5, 10, Apr 13:3, Jul
13:11, Sep 13:15
99379 Supervision of a nursing facility patient (patient not present)
requiring complex and multidisciplinary care modalities
involving regular development and/or revision of care plans
by that individual, review of subsequent reports of patient
status, review of related laboratory and other studies,
➲ CPT Assistant Dec 06:4, Mar 08:6, Sep 08:3, Jul 09:5,
Apr 13:3, Jul 13:11, Sep 13:15
➲ CPT Assistant Nov 97:8-9, Dec 06:4, Mar 08:6, Sep
08:3, Jul 09:5, Apr 13:3, Jul 13:11, Sep 13:15, Nov
13:3, Oct 14:3
Preventive Medicine Services

The following codes are used to report the preventive medicine
evaluation and management of infants, children, adolescents, and
adults.
The extent and focus of the services will largely depend on the
age of the patient.
▶If an abnormality is encountered or a preexisting problem is
addressed in the process of performing this preventive medicine
evaluation and management service, and if the problem or
abnormality is significant enough to require additional work to
perform the key components of a problem-oriented evaluation
and management service, then the appropriate office/outpatient
code 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214,
99215 should also be reported. Modifier 25 should be added to
the office/outpatient code to indicate that a significant, separately
identifiable evaluation and management service was provided on
the same day as the preventive medicine service. The appropriate
preventive medicine service is additionally reported.◀
An insignificant or trivial problem/abnormality that is
encountered in the process of performing the preventive
medicine evaluation and management service and which does not
require additional work and the performance of the key
components of a problem-oriented E/M service should not be
reported.
▶The “comprehensive” nature of the preventive medicine
services codes 99381-99397 reflects an age- and gender-
appropriate history/exam and is not synonymous with the
“comprehensive” examination required in evaluation and
management codes 99202-99350.◀
Codes 99381-99397 include counseling/anticipatory guidance/risk
factor reduction interventions which are provided at the time of
the initial or periodic comprehensive preventive medicine
examination. (Refer to 99401, 99402, 99403, 99404, 99411, and
99412 for reporting those counseling/anticipatory guidance/risk
factor reduction interventions that are provided at an encounter
separate from the preventive medicine examination.)
(For behavior change intervention, see 99406, 99407, 99408,
99409)
Vaccine/toxoid products, immunization administrations, ancillary
studies involving laboratory, radiology, other procedures, or
screening tests (eg, vision, hearing, developmental) identified
with a specific CPT code are reported separately. For
immunization administration and vaccine risk/benefit counseling,
see 90460, 90461, 90471-90474. For vaccine/toxoid products, see
90476-90749.
New Patient
99381 Initial comprehensive preventive medicine evaluation and
management of an individual including an age and gender
appropriate history, examination, counseling/anticipatory
guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient;
infant (age younger than 1 year)
➲ CPT Assistant Winter 91:11, Spring 93:14, 34, Spring
95:1, Aug 97:1, Jul 98:9, Sep 98:5, Nov 98:3-4, May
02:1, May 05:1, Aug 05:15, Oct 06:15, Mar 09:3, Jul
09:7, Aug 09:5, Jan 13:9, Dec 14:18, Mar 16:7
99382 early childhood (age 1 through 4 years)
➲ CPT Assistant Winter 91:11, Spring 93:14, 34,
Spring 95:1, Aug 97:1, Jul 98:9, Sep 98:5, Nov 98:3-
4, May 02:1, Aug 05:15, Oct 06:15, Jul 09:5, Aug
09:5, Jan 13:9, Dec 14:18, Mar 16:7
99383 late childhood (age 5 through 11 years)
09:5, Jan 13:9, Dec 14:18, Mar 16:7
99384 adolescent (age 12 through 17 years)
09:5, Jan 13:9, Dec 14:18, Jan 15:12, Mar 16:7
99385 18-39 years
09:5, Jan 13:9, Dec 14:18, Jan 15:12, Mar 16:7
99386 40-64 years
09:5, Jan 13:9, Dec 14:18, Jan 15:12, Mar 16:7
99387 65 years and older
09:5, Jan 13:9, Dec 14:18, Mar 16:7
Established Patient
99391 Periodic comprehensive preventive medicine reevaluation
and management of an individual including an age and
gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic
procedures, established patient; infant (age younger than 1
year)
➲ CPT Assistant Winter 91:11, Spring 93:14, 34, Spring
95:1, Aug 97:1, Jul 98:9, Sep 98:5, Nov 98:3-4, May
02:1, May 05:1, Aug 05:15, Oct 06:15, Mar 09:3, Jul
09:7, Aug 09:5, Jan 13:9, Dec 14:18, Mar 16:7
99392 early childhood (age 1 through 4 years)
4, May 02:1, Aug 05:15, Oct 06:15, Jul 09:7, Jan
13:9, Dec 14:18, Mar 16:7
99393 late childhood (age 5 through 11 years)
13:9, Dec 14:18, Mar 16:7
99394 adolescent (age 12 through 17 years)
13:9, Dec 14:18, Jan 15:12, Mar 16:7
99395 18-39 years
4, May 02:1, Aug 05:15, Oct 06:15, Mar 08:3, Jul
09:7, Jan 13:9, Dec 14:18, Jan 15:12, Mar 16:7
99396 40-64 years
4, May 02:1, Aug 05:15, Oct 06:15, Jul 09:7, Mar
12:4, Jan 13:9, Dec 14:18, Jan 15:12, Mar 16:7, Sep
17:11
99397 65 years and older
13:9, Dec 14:18, Mar 16:7
Counseling Risk Factor Reduction and

Behavior Change Intervention
These codes are used to report services provided face-to-face by
a physician or other qualified health care professional for the
purpose of promoting health and preventing illness or injury.
They are distinct from evaluation and management (E/M)
services that may be reported separately with modifier 25 when
performed. Risk factor reduction services are used for persons
without a specific illness for which the counseling might
otherwise be used as part of treatment.
Preventive medicine counseling and risk factor reduction
interventions will vary with age and should address such issues
as family problems, diet and exercise, substance use, sexual
practices, injury prevention, dental health, and diagnostic and
laboratory test results available at the time of the encounter.
Behavior change interventions are for persons who have a
behavior that is often considered an illness itself, such as tobacco
use and addiction, substance abuse/misuse, or obesity. Behavior
change services may be reported when performed as part of the
treatment of condition(s) related to or potentially exacerbated by
the behavior or when performed to change the harmful behavior
that has not yet resulted in illness. Any E/M services reported on
the same day must be distinct and reported with modifier 25, and
time spent providing these services may not be used as a basis for
the E/M code selection. Behavior change services involve specific
validated interventions of assessing readiness for change and
barriers to change, advising a change in behavior, assisting by
providing specific suggested actions and motivational counseling,
and arranging for services and follow-up.
For counseling groups of patients with symptoms or established
illness, use 99078.
Health behavior assessment and intervention services (96156,
96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171) should
not be reported on the same day as codes 99401-99412.
Preventive Medicine, Individual Counseling

99401 Preventive medicine counseling and/or risk factor
reduction intervention(s) provided to an individual
(separate procedure); approximately 15 minutes
➲ CPT Assistant Aug 97:1, Jan 98:12, May 05:1, Aug 07:9,
Oct 10:3, Dec 10:3, Jan 13:9, Aug 14:5, Mar 16:7
99402 approximately 30 minutes
➲ CPT Assistant Aug 97:1, Jan 98:12, May 05:1, Oct
10:3, Dec 10:3, Jan 13:9, Mar 16:7
➲
CPT Assistant Aug 97:1, Jan 98:12, May 05:1, Oct
10:3, Dec 10:3, Jan 13:9, Mar 16:7
➲ CPT Assistant Aug 97:1, Jan 98:12, May 05:1, Oct
10:3, Dec 10:3, Jan 13:9, Aug 14:5, Mar 16:7
Behavior Change Interventions, Individual

★ 99406 Smoking and tobacco use cessation counseling visit;
intermediate, greater than 3 minutes up to 10 minutes
➲ CPT Assistant Jan 08:1, Sep 09:11, Oct 10:3, Dec 10:3,
Jan 13:9, Mar 16:7
★ 99407 intensive, greater than 10 minutes
➲ CPT Assistant Jan 08:1, Sep 09:11, Oct 10:3, Dec
10:3, Jan 13:9, Mar 16:7
★ 99408 Alcohol and/or substance (other than tobacco) abuse
structured screening (eg, AUDIT, DAST), and brief
intervention (SBI) services; 15 to 30 minutes
➲ CPT Assistant Oct 10:3, Dec 10:3, Jan 13:9, Mar 16:7,
Nov 16:5
(Do not report services of less than 15 minutes with 99408)
★ 99409 greater than 30 minutes
➲ CPT Assistant Oct 10:3, Dec 10:3, Jan 13:9, Mar
16:7, Nov 16:5
(Do not report 99408, 99409 in conjunction with 96160,
96161)
(Use 99408, 99409 only for initial screening and brief
intervention)
Preventive Medicine, Group Counseling

99411 Preventive medicine counseling and/or risk factor
reduction intervention(s) provided to individuals in a group
setting (separate procedure); approximately 30 minutes
➲ CPT Assistant Aug 97:1, Jan 98:12, Sep 98:5, May 05:1,
Oct 10:3, Dec 10:3, Jan 13:9, Mar 16:7
➲ CPT Assistant Aug 97:1, Jan 98:12, Sep 98:5, May
05:1, Aug 07:9, Oct 10:3, Dec 10:3, Jan 13:9, Mar
16:7
Other Preventive Medicine Services

99429 Unlisted preventive medicine service
➲ CPT Assistant Sep 98:5, May 05:1, Oct 10:3, Dec 10:3,
Jan 13:9, Mar 16:7
Non-Face-to-Face Services
Telephone Services
Telephone services are non-face-to-face evaluation and
management (E/M) services provided to a patient using the
telephone by a physician or other qualified health care
professional, who may report evaluation and management
services. These codes are used to report episodes of patient care
initiated by an established patient or guardian of an established
patient. If the telephone service ends with a decision to see the
patient within 24 hours or next available urgent visit
appointment, the code is not reported; rather the encounter is
considered part of the preservice work of the subsequent E/M
service, procedure, and visit. Likewise, if the telephone call refers
to an E/M service performed and reported by that individual
within the previous seven days (either requested or unsolicited
patient follow-up) or within the postoperative period of the
previously completed procedure, then the service(s) is considered
part of that previous E/M service or procedure. (Do not report
99441-99443, if 99421, 99422, 99423 have been reported by the
same provider in the previous seven days for the same problem.)
(For telephone services provided by a qualified
nonphysician who may not report evaluation and
management services [eg, speech-language pathologists,
physical therapists, occupational therapists, social workers,
dietitians), see 98966-98968)
99441 Telephone evaluation and management service by a
physician or other qualified health care professional who
may report evaluation and management services provided to
an established patient, parent, or guardian not originating
from a related E/M service provided within the previous 7
days nor leading to an E/M service or procedure within the
next 24 hours or soonest available appointment; 5-10
minutes of medical discussion
➲ CPT Assistant Mar 08:6, Apr 13:3, Oct 13:11, Nov 13:3,
Oct 14:3, Mar 18:7, Jan 19:13, Mar 19:8
99442 11-20 minutes of medical discussion
➲ CPT Assistant Mar 08:6, Apr 13:3, Oct 13:11, Mar
18:7, Jan 19:13, Mar 19:8
➲ CPT Assistant Mar 08:6, Apr 13:3, Oct 13:11, Nov
13:3, Oct 14:3, Mar 18:7, Jan 19:13, Mar 19:8
(Do not report 99441-99443 when using 99339-99340,
99374-99380 for the same call[s])
(Do not report 99441-99443 for home and outpatient INR
monitoring when reporting 93792, 93793)
(Do not report 99441-99443 during the same month with
99487-99489)
(Do not report 99441-99443 when performed during the
service time of codes 99495 or 99496)
Online Digital Evaluation and

Management Services
Online digital evaluation and management (E/M) services (99421,
99422, 99423) are patient-initiated services with physicians or
other qualified health care professionals (QHPs). Online digital
E/M services require physician or other QHP’s evaluation,
assessment, and management of the patient. These services are
not for the nonevaluative electronic communication of test
results, scheduling of appointments, or other communication that
does not include E/M. While the patient’s problem may be new to
the physician or other QHP, the patient is an established patient.
Patients initiate these services through Health Insurance
Portability and Accountability Act (HIPAA)-compliant secure
platforms, such as electronic health record (EHR) portals, secure
email, or other digital applications, which allow digital
communication with the physician or other QHP.
Online digital E/M services are reported once for the physician’s
or other QHP’s cumulative time devoted to the service during a
seven-day period. The seven-day period begins with the
physician’s or other QHP’s initial, personal review of the patient-
generated inquiry. Physician’s or other QHP’s cumulative service
time includes review of the initial inquiry, review of patient
records or data pertinent to assessment of the patient’s problem,
personal physician or other QHP interaction with clinical staff
focused on the patient’s problem, development of management
plans, including physician- or other QHP generation of
prescriptions or ordering of tests, and subsequent communication
with the patient through online, telephone, email, or other
digitally supported communication, which does not otherwise
represent a separately reported E/M service. All professional
decision making, assessment, and subsequent management by
physicians or other QHPs in the same group practice contribute
to the cumulative service time of the patient’s online digital E/M
service. Online digital E/M services require permanent
documentation storage (electronic or hard copy) of the encounter.
If within seven days of the initiation of an online digital E/M
service, a separately reported E/M visit occurs, then the physician
or other QHP work devoted to the online digital E/M service is
incorporated into the separately reported E/M visit (eg, additive
of visit time for a time-based E/M visit or additive of decision-
making complexity for a key component-based E/M visit). This
includes E/M visits and procedures that are provided through
synchronous telemedicine visits using interactive audio and video
telecommunication equipment, which are reported with modifier
95 appended to the E/M service code. If the patient initiates an
online digital inquiry for the same or a related problem within
seven days of a previous E/M service, then the online digital visit
is not reported. If the online digital inquiry is related to a surgical
procedure and occurs during the postoperative period of a
previously completed procedure, then the online digital E/M
service is not reported separately. If the patient generates the
initial online digital inquiry for a new problem within seven days
of a previous E/M visit that addressed a different problem, then
the online digital E/M service may be reported separately. If the
patient presents a new, unrelated problem during the seven-day
period of an online digital E/M service, then the physician’s or
other QHP’s time spent on evaluation, assessment, and
management of the additional problem is added to the cumulative
service time of the online digital E/M service for that seven-day
period.
(For online digital E/M services provided by a qualified
nonphysician health care professional who may not report
the physician or other qualified health care professional
E/M services [eg, speech-language pathologists, physical
therapists, occupational therapists, social workers,
dietitians], see 98970, 98971, 98972)
# 99421 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during
the 7 days; 5-10 minutes
➲ CPT Assistant Jan 20:3, Mar 20:6
# 99422 11-20 minutes
# 99423 21 or more minutes

(Report 99421, 99422, 99423 once per 7-day period)

(Clinical staff time is not calculated as part of cumulative
time for 99421, 99422, 99423)
(Do not report online digital E/M services for cumulative
service time less than 5 minutes)
(Do not count 99421, 99422, 99423 time otherwise reported
with other services)
▶ (Do not report 99421, 99422, 99423 on a day when the
physician or other qualified health care professional reports
E/M services [99202, 99203, 99204, 99205, 99212, 99213,
99214, 99215, 99241, 99242, 99243, 99244, 99245])◀
▶ (Donot report 99421, 99422, 99423 when using 99091,
99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380,
99487, 99489 for the same communication[s])◀
(Do not report 99421, 99422, 99423 for home and outpatient
INR monitoring when reporting 93792, 93793)
(99444 has been deleted. To report, see 99421, 99422,
99423)
Interprofessional
Telephone/Internet/Electronic Health
Record Consultations
The consultant should use codes 99446, 99447, 99448, 99449,
99451 to report interprofessional telephone/Internet/electronic
health record consultations. An interprofessional
telephone/Internet/electronic health record consultation is an
assessment and management service in which a patient’s treating
(eg, attending or primary) physician or other qualified health care
professional requests the opinion and/or treatment advice of a
physician with specific specialty expertise (the consultant) to
assist the treating physician or other qualified health care
professional in the diagnosis and/or management of the patient’s
problem without patient face-to-face contact with the consultant.
The patient for whom the interprofessional
telephone/Internet/electronic health record consultation is
requested may be either a new patient to the consultant or an
established patient with a new problem or an exacerbation of an
existing problem. However, the consultant should not have seen
the patient in a face-to-face encounter within the last 14 days.
When the telephone/Internet/electronic health record consultation
leads to a transfer of care or other face-to-face service (eg, a
surgery, a hospital visit, or a scheduled office evaluation of the
patient) within the next 14 days or next available appointment
date of the consultant, these codes are not reported.
Review of pertinent medical records, laboratory studies, imaging
studies, medication profile, pathology specimens, etc is included
in the telephone/Internet/electronic health record consultation
service and should not be reported separately when reporting
99446, 99447, 99448, 99449, 99451. The majority of the service
time reported (greater than 50%) must be devoted to the medical
consultative verbal or Internet discussion. If greater than 50% of
the time for the service is devoted to data review and/or analysis,
99446, 99447, 99448, 99449 should not be reported. However, the
service time for 99451 is based on total review and
interprofessional-communication time.
If more than one telephone/Internet/electronic health record
contact(s) is required to complete the consultation request (eg,
discussion of test results), the entirety of the service and the
cumulative discussion and information review time should be
reported with a single code. Codes 99446, 99447, 99448, 99449,
99451 should not be reported more than once within a seven-day
interval.
The written or verbal request for telephone/Internet/electronic
health record advice by the treating/requesting physician or other
qualified health care professional should be documented in the
patient’s medical record, including the reason for the request.
Codes 99446, 99447, 99448, 99449 conclude with a verbal
opinion report and written report from the consultant to the
treating/requesting physician or other qualified health care
professional. Code 99451 concludes with only a written report.
Telephone/Internet/electronic health record consultations of less
than five minutes should not be reported. Consultant
communications with the patient and/or family may be reported
using 98966, 98967, 98968, 99421, 99422, 99423, 99441, 99442,
99443, and the time related to these services is not used in
reporting 99446, 99447, 99448, 99449. Do not report 99358,
99359 for any time within the service period, if reporting 99446,
99447, 99448, 99449, 99451.
When the sole purpose of the telephone/Internet/electronic health
record communication is to arrange a transfer of care or other
face-to-face service, these codes are not reported.
The treating/requesting physician or other qualified health care
professional may report 99452 if spending 16-30 minutes in a
service day preparing for the referral and/or communicating with
the consultant. Do not report 99452 more than once in a 14-day
period. The treating/requesting physician or other qualified health
care professional may report the prolonged service codes 99354,
99355, 99356, 99357 for the time spent on the interprofessional
telephone/Internet/electronic health record discussion with the
consultant (eg, specialist) if the time exceeds 30 minutes beyond
the typical time of the appropriate E/M service performed and the
patient is present (on-site) and accessible to the
treating/requesting physician or other qualified health care
professional. If the interprofessional telephone/Internet/electronic
health record assessment and management service occurs when
the patient is not present and the time spent in a day exceeds 30
minutes, then the non-face-to-face prolonged service codes
99358, 99359 may be reported by the treating/requesting
physician or other qualified health care professional.
(For telephone services provided by a physician to a
patient, see 99441, 99442, 99443)
(For telephone services provided by a qualified health care
professional to a patient, see 98966, 98967, 98968)
(For online digital E/M services provided by a physician or
other qualified health care professional to a patient, see
99421, 99422, 99423)
99446 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a
consultative physician, including a verbal and written report
to the patient’s treating/requesting physician or other
qualified health care professional; 5-10 minutes of medical
consultative discussion and review
➲ CPT Assistant Jun 14:14, Jan 19:3, Jun 19:7
99447 11-20 minutes of medical consultative discussion and
review
99448 21-30 minutes of medical consultative discussion and

review
99449 31 minutes or more of medical consultative discussion

and review
# 99451 Interprofessional telephone/Internet/electronic health record

assessment and management service provided by a
consultative physician, including a written report to the
patient’s treating/requesting physician or other qualified
health care professional, 5 minutes or more of medical
consultative time
➲ CPT Assistant Jan 19:3, Jun 19:7
# 99452 Interprofessional telephone/Internet/electronic health record

referral service(s) provided by a treating/requesting
physician or other qualified health care professional, 30
minutes
Digitally Stored Data Services/Remote

Physiologic Monitoring
Codes 99453 and 99454 are used to report remote physiologic
monitoring services (eg, weight, blood pressure, pulse oximetry)
during a 30-day period. To report 99453, 99454, the device used
must be a medical device as defined by the FDA, and the service
must be ordered by a physician or other qualified health care
professional. Code 99453 may be used to report the set-up and
patient education on use of the device(s). Code 99454 may be
used to report supply of the device for daily recording or
programmed alert transmissions. Codes 99453, 99454 are not
reported if monitoring is less than 16 days. Do not report 99453,
99454 when these services are included in other codes for the
duration of time of the physiologic monitoring service (eg, 95250
for continuous glucose monitoring requires a minimum of 72
hours of monitoring).
Code 99091 should be reported no more than once in a 30-day
period to include the physician or other qualified health care
professional time involved with data accession, review and
interpretation, modification of care plan as necessary (including
communication to patient and/or caregiver), and associated
documentation.
If the services described by 99091 or 99474 are provided on the
same day the patient presents for an evaluation and management
(E/M) service to the same provider, these services should be
considered part of the E/M service and not reported separately.
▶Do not report 99091 for time in the same calendar month when
used to meet the criteria for care plan oversight services (99374,
99375, 99377, 99378, 99379, 99380), home, domiciliary, or rest
home care plan oversight services (99339, 99340), remote
physiologic monitoring services (99457), or personally
performed chronic care management (99491). Do not report
99091 if other more specific codes exist (eg, 93227, 93272 for
cardiographic services; 95250 for continuous glucose
monitoring). Do not report 99091 for transfer and interpretation
of data from hospital or clinical laboratory computers.◀
Code 99453 is reported for each episode of care. For coding
remote monitoring of physiologic parameters, an episode of care
is defined as beginning when the remote monitoring physiologic
service is initiated, and ends with attainment of targeted treatment
goals.
# 99453 Remote monitoring of physiologic parameter(s) (eg, weight,
blood pressure, pulse oximetry, respiratory flow rate),
initial; set-up and patient education on use of equipment
(Do not report 99453 more than once per episode of care)
(Do not report 99453 for monitoring of less than 16 days)
# 99454 device(s) supply with daily recording(s) or programmed
alert(s) transmission, each 30 days
(For physiologic monitoring treatment management services,

use 99457)
(Do not report 99454 for monitoring of less than 16 days)
(Do not report 99453, 99454 in conjunction with codes for
more specific physiologic parameters [eg, 93296, 94760])
(For self-measured blood pressure monitoring, see 99473,
99474)
# 99091 Collection and interpretation of physiologic data (eg, ECG,
blood pressure, glucose monitoring) digitally stored and/or
transmitted by the patient and/or caregiver to the physician
or other qualified health care professional, qualified by
education, training, licensure/regulation (when applicable)
requiring a minimum of 30 minutes of time, each 30 days
➲ CPT Assistant May 02:19, Jun 03:10, Aug 06:6, Sep
06:15, Jan 07:30, Apr 09:7, Dec 09:6, Apr 13:3, Nov
13:3, Oct 14:3, Feb 18:7, Mar 18:5, Dec 18:11, Feb
20:7, Apr 20:5
▶ (Do not report 99091 for time in a calendar month when
used to meet the criteria for 99339, 99340, 99374, 99375,
99377, 99378, 99379, 99380, 99457, 99491)◀
# 99473 Self-measured blood pressure using a device validated for
clinical accuracy; patient education/training and device
calibration
➲ CPT Assistant Jan 20:3, Feb 20:7, Apr 20:5
(Do not report 99473 more than once per device)

(For ambulatory blood pressure monitoring, see 93784,
93786, 93788, 93790)
# 99474 separate self-measurements of two readings one minute
apart, twice daily over a 30-day period (minimum of 12
readings), collection of data reported by the patient
and/or caregiver to the physician or other qualified
health care professional, with report of average systolic
and diastolic pressures and subsequent communication of
a treatment plan to the patient
➲ CPT Assistant Jan 20:3, Feb 20:7, Apr 20:5
▶ (Do not report 99473, 99474 in the same calendar month

as 93784, 93786, 93788, 93790, 99091, 99439, 99453,
99454, 99457, 99487, 99489, 99490, 99491)◀
(Do not report 99474 more than once per calendar month)
Remote Physiologic Monitoring Treatment

Management Services
▶Remote physiologic monitoring treatment management services
are provided when clinical staff/physician/other qualified health
care professional use the results of remote physiological
monitoring to manage a patient under a specific treatment plan.
To report remote physiological monitoring, the device used must
be a medical device as defined by the FDA, and the service must
be ordered by a physician or other qualified health care
professional. Do not use 99457, 99458 for time that can be
reported using more specific monitoring services (eg, for the
patient that requires reevaluation of medication regimen and/or
changes in treatment). Codes 99457, 99458 may be reported
during the same service period as chronic care management
services (99439, 99487, 99489, 99490, 99491), transitional care
management services (99495, 99496), and behavioral health
integration services (99484, 99492, 99493, 99494); however, time
spent performing these services should remain separate and no
time should be counted toward the required time for both
services in a single month. Codes 99457, 99458 require a live,
interactive communication with the patient/caregiver. For the first
completed 20 minutes of clinical staff/physician/other qualified
health care professional time in a calendar month report 99457,
and report 99458 for each additional completed 20 minutes. Do
not report 99457, 99458 for services of less than 20 minutes.
Report 99457 one time regardless of the number of physiologic
monitoring modalities performed in a given calendar month.
Do not count any time on a day when the physician or other
qualified health care professional reports an E/M service (office
or other outpatient services 99202, 99203, 99204, 99205, 99211,
99212, 99213, 99214, 99215, domiciliary, rest home services
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337,
home services 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350, inpatient services 99221, 99222, 99223, 99231,
99232, 99233, 99251, 99252, 99253, 99254, 99255). Do not count
any time related to other reported services (eg, 93290, 93793,
99291, 99292).◀
# 99457 Remote physiologic monitoring treatment management
services, clinical staff/physician/other qualified health care
professional time in a calendar month requiring interactive
communication with the patient/caregiver during the month;
first 20 minutes
➲ CPT Assistant Jan 19:3, Jun 19:3, Feb 20:7, Apr 20:5
(Report 99457 once each 30 days, regardless of the number

of parameters monitored)
(Do not report 99457 for services of less than 20 minutes)
(Do not report 99457 in conjunction with 93264, 99091)
(Do not report 99457 in the same month as 99473, 99474)
#✚ 99458 each additional 20 minutes (List separately in addition to
code for primary procedure)
➲ CPT Assistant Feb 20:7

(Do not report 99458 for services of less than an additional
increment of 20 minutes)
Special Evaluation and Management
Services
The following codes are used to report evaluations performed to
establish baseline information prior to life or disability insurance
certificates being issued. This service is performed in the office
or other setting, and applies to both new and established patients.
When using these codes, no active management of the
problem(s) is undertaken during the encounter.
If other evaluation and management services and/or procedures
are performed on the same date, the appropriate E/M or
procedure code(s) should be reported in addition to these codes.
Basic Life and/or Disability Evaluation

Services
99450 Basic life and/or disability examination that includes:
■ Measurement of height, weight, and blood pressure;
■ Completion of a medical history following a life
insurance pro forma;
■ Collection of blood sample and/or urinalysis complying
with “chain of custody” protocols; and
■ Completion of necessary documentation/certificates.
➲ CPT Assistant Summer 95:14, Sep 98:5, May 05:1, Jun
19:7
Work Related or Medical Disability
Evaluation Services
99455 Work related or medical disability examination by the
treating physician that includes:
■ Completion of a medical history commensurate with
the patient’s condition;
■ Performance of an examination commensurate with
■ Formulation of a diagnosis, assessment of capabilities
and stability, and calculation of impairment;
■ Development of future medical treatment plan; and
■ Completion of necessary documentation/certificates
and report.
➲ CPT Assistant Summer 95:14, Sep 98:5, May 05:1, Aug
13:13
99456 Work related or medical disability examination by other
than the treating physician that includes:
■ Completion of a medical history commensurate with
■ Performance of an examination commensurate with
■ Formulation of a diagnosis, assessment of capabilities
and stability, and calculation of impairment;
■ Development of future medical treatment plan; and
■ Completion of necessary documentation/certificates
and report.
➲ CPT Assistant Summer 95:14, Sep 98:5, Aug 13:13
(Do not report 99455, 99456 in conjunction with 99080 for

the completion of Workman’s Compensation forms)
Newborn Care Services

The following codes are used to report the services provided to
newborns (birth through the first 28 days) in several different
settings. Use of the normal newborn codes is limited to the initial
care of the newborn in the first days after birth prior to home
discharge.
Evaluation and Management (E/M) services for the newborn
include maternal and/or fetal and newborn history, newborn
physical examination(s), ordering of diagnostic tests and
treatments, meetings with the family, and documentation in the
medical record.
When delivery room attendance services (99464) or delivery
room resuscitation services (99465) are required, report these in
addition to normal newborn services Evaluation and Management
codes.
For E/M services provided to newborns who are other than
normal, see codes for hospital inpatient services (99221-99233)
and neonatal intensive and critical care services (99466-99469,
99477-99480). When normal newborn services are provided by
the same individual on the same date that the newborn later
becomes ill and receives additional intensive or critical care
services, report the appropriate E/M code with modifier 25 for
these services in addition to the normal newborn code.
Procedures (eg, 54150, newborn circumcision) are not included
with the normal newborn codes, and when performed, should be
reported in addition to the newborn services.
▶When newborns are seen in follow-up after the date of
discharge in the office or outpatient setting, see 99202-99215,
99381, 99391 as appropriate.◀
99460 Initial hospital or birthing center care, per day, for
evaluation and management of normal newborn infant
99461 Initial care, per day, for evaluation and management of

normal newborn infant seen in other than hospital or birthing
center
99462 Subsequent hospital care, per day, for evaluation and

management of normal newborn
99463 Initial hospital or birthing center care, per day, for

evaluation and management of normal newborn infant
admitted and discharged on the same date
(For newborn hospital discharge services provided on a

date subsequent to the admission date, see 99238, 99239)
Delivery/Birthing Room Attendance

and Resuscitation Services
99464 Attendance at delivery (when requested by the delivering
physician or other qualified health care professional) and
initial stabilization of newborn
(99464 may be reported in conjunction with 99460, 99468,

99477)
99465 Delivery/birthing room resuscitation, provision of positive
pressure ventilation and/or chest compressions in the
presence of acute inadequate ventilation and/or cardiac
output
(99465 may be reported in conjunction with 99460, 99468,

99477)
(Procedures that are performed as a necessary part of the
resuscitation [eg, intubation, vascular lines] are reported
separately in addition to 99465. In order to report these
procedures, they must be performed as a necessary
component of the resuscitation and not as a convenience
before admission to the neonatal intensive care unit)
Inpatient Neonatal Intensive Care

Services and Pediatric and Neonatal
Pediatric Critical Care Patient Transport
Codes 99466, 99467 are used to report the physical attendance
and direct face-to-face care by a physician during the interfacility
transport of a critically ill or critically injured pediatric patient 24
months of age or younger. Codes 99485, 99486 are used to report
the control physician’s non-face-to-face supervision of
interfacility transport of a critically ill or critically injured
pediatric patient 24 months of age or younger. These codes are
not reported together for the same patient by the same physician.
For the purpose of reporting 99466 and 99467, face-to-face care
begins when the physician assumes primary responsibility of the
pediatric patient at the referring facility, and ends when the
receiving facility accepts responsibility for the pediatric patient’s
care. Only the time the physician spends in direct face-to-face
contact with the patient during the transport should be reported.
Pediatric patient transport services involving less than 30 minutes
of face-to-face physician care should not be reported using
99466, 99467. Procedure(s) or service(s) performed by other
members of the transporting team may not be reported by the
supervising physician.
Codes 99485, 99486 may be used to report control physician’s
non-face-to-face supervision of interfacility pediatric critical care
transport, which includes all two-way communication between
the control physician and the specialized transport team prior to
transport, at the referring facility and during transport of the
patient back to the receiving facility. The “control” physician is
the physician directing transport services. These codes do not
include pretransport communication between the control
physician and the referring facility before or following patient
transport. These codes may only be reported for patients 24
months of age or younger who are critically ill or critically
injured. The control physician provides treatment advice to a
specialized transport team who are present and delivering the
hands-on patient care. The control physician does not report any
services provided by the specialized transport team. The control
physician’s non-face-to-face time begins with the first contact by
the control physician with the specialized transport team and ends
when the patient’s care is handed over to the receiving facility
team. Refer to 99466 and 99467 for face-to-face transport care of
the critically ill/injured patient. Time spent with the individual
patient’s transport team and reviewing data submissions should
be recorded. Code 99485 is used to report the first 16-45 minutes
of direction on a given date and should only be used once even if
time spent by the physician is discontinuous. Do not report
services of 15 minutes or less or any time when another
physician is reporting 99466, 99467. Do not report 99485 or
99486 in conjunction with 99466, 99467 when performed by the
same physician.
For the definition of the critically injured pediatric patient, see the
Neonatal and Pediatric Critical Care Services section.
The non-face-to-face direction of emergency care to a patient’s
transporting staff by a physician located in a hospital or other
facility by two-way communication is not considered direct face-
to-face care and should not be reported with 99466, 99467.
Physician-directed non-face-to-face emergency care through
outside voice communication to transporting staff personnel is
reported with 99288 or 99485, 99486 based upon the age and
clinical condition of the patient.
Emergency department services (99281-99285), initial hospital
care (99221-99223), critical care (99291, 99292), initial date
neonatal intensive (99477) or critical care (99468) may only be
reported after the patient has been admitted to the emergency
department, the inpatient floor, or the critical care unit of the
receiving facility. If inpatient critical care services are reported in
the referring facility prior to transfer to the receiving hospital, use
the critical care codes (99291, 99292).
The following services are included when performed during the
pediatric patient transport by the physician providing critical care
and may not be reported separately: routine monitoring
evaluations (eg, heart rate, respiratory rate, blood pressure, and
pulse oximetry), the interpretation of cardiac output
measurements (93562), chest X rays (71045, 71046), pulse
oximetry (94760, 94761, 94762), blood gases and information
data stored in computers (eg, ECGs, blood pressures,
hematologic data), gastric intubation (43752, 43753), temporary
transcutaneous pacing (92953), ventilatory management (94002,
94003, 94660, 94662), and vascular access procedures (36000,
36400, 36405, 36406, 36415, 36591, 36600). Any services
performed which are not listed above should be reported
separately.
Services provided by the specialized transport team during non-
face-to-face transport supervision are not reported by the control
physician.
Code 99466 is used to report the first 30 to 74 minutes of direct
face-to-face time with the transport pediatric patient and should
be reported only once on a given date. Code 99467 is used to
report each additional 30 minutes provided on a given date. Face-
to-face services of less than 30 minutes should not be reported
with these codes.
Code 99485 is used to report the first 30 minutes of non-face-to-
face supervision of an interfacility transport of a critically ill or
critically injured pediatric patient and should be reported only
once per date of service. Only the communication time spent by
the supervising physician with the specialty transport team
members during an interfacility transport should be reported.
Code 99486 is used to report each additional 30 minutes beyond
the initial 30 minutes. Non-face-to-face interfacility transport of
15 minutes or less is not reported.
(For total body and selective head cooling of neonates, use
99184)
99466 Critical care face-to-face services, during an interfacility
transport of critically ill or critically injured pediatric
patient, 24 months of age or younger; first 30-74 minutes of
hands-on care during transport
➲ CPT Assistant Sep 11:3, May 13:6, May 14:4, Jun 18:9

➲ CPT Assistant Sep 11:3, May 13:6, May 14:4, Jun
18:9
(Critical care of less than 30 minutes total duration should
be reported with the appropriate E/M code)
# 99485 Supervision by a control physician of interfacility transport
care of the critically ill or critically injured pediatric
patient, 24 months of age or younger, includes two-way
communication with transport team before transport, at the
referring facility and during the transport, including data
interpretation and report; first 30 minutes
➲ CPT Assistant May 13:6, May 14:4, Jun 18:9


(For physician direction of emergency medical systems
supervision for a pediatric patient older than 24 months of
age, or at any age if not critically ill or injured, use 99288)
(Do not report 99485, 99486 with any other services
reported by the control physician for the same period)
99467 when performed by the same physician)
Inpatient Neonatal and Pediatric Critical

Care
The same definitions for critical care services apply for the adult,
child, and neonate.
Codes 99468, 99469 may be used to report the services of
directing the inpatient care of a critically ill neonate or infant 28
days of age or younger. They represent care starting with the date
of admission (99468) for critical care services and all subsequent
day(s) (99469) that the neonate remains in critical care. These
codes may be reported only by a single individual and only once
per calendar day, per patient. Initial inpatient neonatal critical care
(99468) may only be reported once per hospital admission. If
readmitted for neonatal critical care services during the same
hospital stay, then report the subsequent inpatient neonatal critical
care code (99469) for the first day of readmission to critical care,
and 99469 for each day of critical care following readmission.
The initial inpatient neonatal critical care code (99468) can be
used in addition to 99464 or 99465 as appropriate, when the
physician or other qualified health care professional is present for
the delivery (99464) or resuscitation (99465) is required. Other
procedures performed as a necessary part of the resuscitation (eg,
endotracheal intubation [31500]) may also be reported separately,
when performed as part of the pre-admission delivery room care.
In order to report these procedures separately, they must be
performed as a necessary component of the resuscitation and not
simply as a convenience before admission to the neonatal
intensive care unit.
Codes 99471-99476 may be used to report the services of
directing the inpatient care of a critically ill infant or young child
from 29 days of postnatal age through 5 years of age. They
represent care starting with the date of admission (99471, 99475)
for pediatric critical care services and all subsequent day(s)
(99472, 99476) that the infant or child remains in critical
condition. These codes may only be reported by a single
individual and only once per calendar day, per patient. Services
for the critically ill or critically injured child 6 years of age or
older would be reported with the time-based critical care codes
(99291, 99292). Initial inpatient critical care (99471, 99475) may
only be reported once per hospital admission. If readmitted to the
pediatric critical care unit during the same hospital stay, then
report the subsequent inpatient pediatric critical care code 99472
or 99476 for the first day of readmission to critical care and
99472 or 99476 for each day of critical care following
readmission.
The pediatric and neonatal critical care codes include those
procedures listed for the critical care codes (99291, 99292). In
addition, the following procedures are also included (and are not
separately reported by professionals, but may be reported by
facilities) in the pediatric and neonatal critical care service codes
(99468-99472, 99475, 99476) and the intensive care services
codes (99477-99480).
Any services performed that are not included in these listings
may be reported separately. For initiation of selective head or
total body hypothermia in the critically ill neonate, report 99184.
Facilities may report the included services separately.
Invasive or non-invasive electronic monitoring of vital signs
Vascular access procedures
Peripheral vessel catheterization (36000)
Other arterial catheters (36140, 36620)
Umbilical venous catheters (36510)
Central vessel catheterization (36555)
Vascular access procedures (36400, 36405, 36406)
Vascular punctures (36420, 36600)
Umbilical arterial catheters (36660)
Airway and ventilation management
Endotracheal intubation (31500)
Ventilatory management (94002-94004)
Bedside pulmonary function testing (94375)
Surfactant administration (94610)
Continuous positive airway pressure (CPAP) (94660)
Monitoring or interpretation of blood gases or oxygen saturation
(94760-94762)
Car Seat Evaluation (94780-94781)
Transfusion of blood components (36430, 36440)
Oral or nasogastric tube placement (43752)
Suprapubic bladder aspiration (51100)
Bladder catheterization (51701, 51702)
Lumbar puncture (62270)
Any services performed which are not listed above may be
When a neonate or infant is not critically ill but requires intensive
observation, frequent interventions, and other intensive care
services, the Continuing Intensive Care Services codes (99477-
99480) should be used to report these services.
To report critical care services provided in the outpatient setting
(eg, emergency department or office) for neonates and pediatric
patients of any age, see the Critical Care codes 99291, 99292. If
the same individual provides critical care services for a neonatal
or pediatric patient less than 6 years of age in both the outpatient
and inpatient settings on the same day, report only the
appropriate Neonatal or Pediatric Critical Care codes 99468-
99476 for all critical care services provided on that day. Critical
care services provided by a second individual of a different
specialty not reporting a per-day neonatal or pediatric critical care
code can be reported with 99291, 99292.
When critical care services are provided to neonates or pediatric
patients less than 6 years of age at two separate institutions by an
individual from a different group on the same date of service, the
individual from the referring institution should report their
critical care services with the time-based critical care codes
(99291, 99292) and the receiving institution should report the
appropriate initial day of care code 99468, 99471, 99475 for the
same date of service.
Critical care services to a pediatric patient 6 years of age or older
are reported with the time based critical care codes 99291, 99292.
When the critically ill neonate or pediatric patient improves and is
transferred to a lower level of care to another individual in
another group within the same facility, the transferring individual
does not report a per day critical care service. Subsequent
hospital care (99231-99233) or time-based critical care services
(99291-99292) is reported, as appropriate based upon the
condition of the neonate or child. The receiving individual
reports subsequent intensive care (99478-99480) or subsequent
hospital care (99231-99233) services, as appropriate based upon
the condition of the neonate or child.
When the neonate or infant becomes critically ill on a day when
initial or subsequent intensive care services (99477-99480),
hospital services (99221-99233), or normal newborn services
(99460, 99461, 99462) have been performed by one individual
and is transferred to a critical care level of care provided by a
different individual in a different group, the transferring
individual reports either the time-based critical care services
performed (99291, 99292) for the time spent providing critical
care to the patient, the intensive care service (99477-99480),
hospital care services (99221-99233), or normal newborn service
(99460, 99461, 99462) performed, but only one service. The
receiving individual reports initial or subsequent inpatient
neonatal or pediatric critical care (99468-99476), as appropriate
based upon the patient’s age and whether this is the first or
subsequent admission to the critical care unit for the hospital stay.
When a newborn becomes critically ill on the same day they have
already received normal newborn care (99460, 99461, 99462),
and the same individual or group assumes critical care, report
initial critical care service (99468) with modifier 25 in addition to
the normal newborn code.
When a neonate, infant, or child requires initial critical care
services on the same day the patient already has received hospital
care or intensive care services by the same individual or group,
only the initial critical care service code (99468, 99471, 99475) is
reported.
Time-based critical care services (99291, 99292) are not
reportable by the same individual or different individual of the
same specialty and same group, when neonatal or pediatric
critical care services (99468-99476) may be reported for the same
patient on the same day. Time-based critical care services (99291,
99292) may be reported by an individual of a different specialty
from either the same or different group on the same day that
neonatal or pediatric critical care services are reported. Critical
care interfacility transport face-to-face (99466, 99467) or
supervisory (99485, 99486) services may be reported by the same
or different individual of the same specialty and same group,
when neonatal or pediatric critical care services (99468-99476)
are reported for the same patient on the same day.
99468 Initial inpatient neonatal critical care, per day, for the
evaluation and management of a critically ill neonate, 28
days of age or younger
➲ CPT Assistant Nov 11:5, May 14:4, Feb 15:10, Oct
15:8, May 16:3, Jun 18:9, Dec 18:8
99469 Subsequent inpatient neonatal critical care, per day, for
the evaluation and management of a critically ill neonate, 28
days of age or younger
➲ CPT Assistant Nov 11:5, May 14:4, Feb 15:10, Oct
15:8, May 16:4, Jun 18:9, Dec 18:8
99471 Initial inpatient pediatric critical care, per day, for the
evaluation and management of a critically ill infant or young
child, 29 days through 24 months of age
➲ CPT Assistant Nov 11:5, Feb 15:10, May 16:3, Jun 18:9,
Dec 18:8
99472 Subsequent inpatient pediatric critical care, per day, for
the evaluation and management of a critically ill infant or
young child, 29 days through 24 months of age
➲ CPT Assistant Nov 11:5, Feb 15:10, May 16:4, Jun 18:9,
Dec 18:8
99475 Initial inpatient pediatric critical care, per day, for the
evaluation and management of a critically ill infant or young
child, 2 through 5 years of age
➲ CPT Assistant Feb 15:10, May 16:3, Jun 18:9, Dec 18:8
99476 Subsequent inpatient pediatric critical care, per day, for

the evaluation and management of a critically ill infant or
young child, 2 through 5 years of age
➲ CPT Assistant Feb 15:10, May 16:4, Jun 18:9, Dec 18:8
Initial and Continuing Intensive Care

Services
Code 99477 represents the initial day of inpatient care for the
child who is not critically ill but requires intensive observation,
frequent interventions, and other intensive care services. Codes
99478-99480 are used to report the subsequent day services of
directing the continuing intensive care of the low birth weight
(LBW 1500-2500 grams) present body weight infant, very low
birth weight (VLBW less than 1500 grams) present body weight
infant, or normal (2501-5000 grams) present body weight
newborn who does not meet the definition of critically ill but
continues to require intensive observation, frequent
interventions, and other intensive care services. These services
are for infants and neonates who are not critically ill but continue
to require intensive cardiac and respiratory monitoring,
continuous and/or frequent vital sign monitoring, heat
maintenance, enteral and/or parenteral nutritional adjustments,
laboratory and oxygen monitoring, and constant observation by
the health care team under direct supervision of the physician or
other qualified health care professional. Codes 99477-99480 may
be reported by a single individual and only once per day, per
patient in a given facility. If readmitted to the intensive care unit
during the same hospital stay, report 99478-99480 for the first day
of intensive care and for each successive day that the child
requires intensive care services.
These codes include the same procedures that are outlined in the
Neonatal and Pediatric Critical Care Services section and
these services should not be separately reported.
The initial day neonatal intensive care code (99477) can be used
in addition to 99464 or 99465 as appropriate, when the physician
or other qualified health care professional is present for the
delivery (99464) or resuscitation (99465) is required. In this
situation, report 99477 with modifier 25. Other procedures
performed as a necessary part of the resuscitation (eg,
endotracheal intubation [31500]) are also reported separately
when performed as part of the pre-admission delivery room care.
In order to report these procedures separately, they must be
performed as a necessary component of the resuscitation and not
simply as a convenience before admission to the neonatal
intensive care unit.
The same procedures are included as bundled services with the
neonatal intensive care codes as those listed for the neonatal
(99468, 99469) and pediatric (99471-99476) critical care codes.
When the neonate or infant improves after the initial day and no
longer requires intensive care services and is transferred to a
lower level of care, the transferring individual does not report a
per day intensive care service. Subsequent hospital care (99231-
99233) or subsequent normal newborn care (99460, 99462) is
reported as appropriate based upon the condition of the neonate
or infant. If the transfer to a lower level of care occurs on the
same day as initial intensive care services were provided by the
transferring individual, 99477 may be reported.
When the neonate or infant is transferred after the initial day
within the same facility to the care of another individual in a
different group, both individuals report subsequent hospital care
(99231-99233) services. The receiving individual reports
subsequent hospital care (99231-99233) or subsequent normal
newborn care (99462).
initial or subsequent intensive care services (99477-99480) have
been reported by one individual and is transferred to a critical
care level of care provided by a different individual from a
different group, the transferring individual reports either the
time-based critical care services performed (99291, 99292) for the
time spent providing critical care to the patient or the initial or
subsequent intensive care (99477-99480) service, but not both.
The receiving individual reports initial or subsequent inpatient
neonatal or pediatric critical care (99468-99476) based upon the
patient’s age and whether this is the first or subsequent admission
to critical care for the same hospital stay.
initial or subsequent intensive care services (99477-99480) have
been performed by the same individual or group, report only
initial or subsequent inpatient neonatal or pediatric critical care
(99468-99476) based upon the patient’s age and whether this is
the first or subsequent admission to critical care for the same
hospital stay.
For the subsequent care of the sick neonate younger than 28 days
of age but more than 5000 grams who does not require intensive
or critical care services, use codes 99231-99233.
management of the neonate, 28 days of age or younger, who
requires intensive observation, frequent interventions, and
other intensive care services
➲ CPT Assistant Jan 08:8, Jul 08:10, Mar 09:3, Nov 11:5,
May 14:4, Dec 18:8
(For the initiation of inpatient care of the normal newborn,
use 99460)
(For the initiation of care of the critically ill neonate, use
99468)
(For initiation of inpatient hospital care of the ill neonate not
requiring intensive observation, frequent interventions, and
other intensive care services, see 99221-99223)
99478 Subsequent intensive care, per day, for the evaluation and
management of the recovering very low birth weight infant
(present body weight less than 1500 grams)
➲ CPT Assistant Jun 18:11, Dec 18:8
management of the recovering low birth weight infant
(present body weight of 1500-2500 grams)
management of the recovering infant (present body weight of
2501-5000 grams)
➲ CPT Assistant May 14:4, Jul 15:3, Jun 18:11, Dec 18:8
Cognitive Assessment and Care Plan

Services
Cognitive assessment and care plan services are provided when a
comprehensive evaluation of a new or existing patient, who
exhibits signs and/or symptoms of cognitive impairment, is
required to establish or confirm a diagnosis, etiology and severity
for the condition. This service includes a thorough evaluation of
medical and psychosocial factors, potentially contributing to
increased morbidity. Do not report cognitive assessment and care
plan services if any of the required elements are not performed or
are deemed unnecessary for the patient’s condition. For these
services, see the appropriate evaluation and management code. A
single physician or other qualified health care professional
should not report 99483 more than once every 180 days.
Services for cognitive assessment and care plan include a
cognition-relevant history, as well as an assessment of factors that
could be contributing to cognitive impairment, including, but not
limited to, psychoactive medication, chronic pain syndromes,
infection, depression and other brain disease (eg, tumor, stroke,
normal pressure hydrocephalus). Medical decision making
includes current and likely progression of the disease, assessing
the need for referral for rehabilitative, social, legal, financial, or
community-based services, meal, transportation, and other
personal assistance services.
99483 Assessment of and care planning for a patient with cognitive
impairment, requiring an independent historian, in the office
or other outpatient, home or domiciliary or rest home, with
all of the following required elements:
■ Cognition-focused evaluation including a pertinent history
and examination;
■ Medical decision making of moderate or high complexity;
■ Functional assessment (eg, basic and instrumental
activities of daily living), including decision-making
capacity;
■ Use of standardized instruments for staging of dementia
(eg, functional assessment staging test [FAST], clinical
dementia rating [CDR]);
■ Medication reconciliation and review for high-risk
medications;
■ Evaluation for neuropsychiatric and behavioral
symptoms, including depression, including use of
standardized screening instrument(s);
■ Evaluation of safety (eg, home), including motor vehicle
operation;
■ Identification of caregiver(s), caregiver knowledge,
caregiver needs, social supports, and the willingness of
caregiver to take on caregiving tasks;
■ Development, updating or revision, or review of an
Advance Care Plan;
■ Creation of a written care plan, including initial plans to
address any neuropsychiatric symptoms, neuro-cognitive
symptoms, functional limitations, and referral to
community resources as needed (eg, rehabilitation
services, adult day programs, support groups) shared with
the patient and/or caregiver with initial education and
support.
➲ CPT Assistant Apr 18:9, Jul 18:12
▶ (Do not report 99483 in conjunction with E/M services

[99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99241, 99242, 99243, 99244, 99245, 99324,
99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337,
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349,
99350, 99366, 99367, 99368, 99497, 99498]; psychiatric
diagnostic procedures [90785, 90791, 90792]; brief
emotional/behavioral assessment [96127]; psychological or
neuropsychological test administration [96146]; health risk
assessment administration [96160, 96161]; medication
therapy management services [99605, 99606, 99607])◀
Care Management Services

Care management services are management and support services
provided by clinical staff, under the direction of a physician or
other qualified health care professional, or may be provided
personally by a physician or other qualified health care
professional to a patient residing at home or in a domiciliary, rest
home, or assisted living facility. Services include establishing,
implementing, revising, or monitoring the care plan, coordinating
the care of other professionals and agencies, and educating the
patient or caregiver about the patient’s condition, care plan, and
prognosis. The physician or other qualified health care
professional provides or oversees the management and/or
coordination of services, as needed, for all medical conditions,
psychosocial needs, and activities of daily living.
▶A comprehensive plan of care for health problems is based on
a physical, mental, cognitive, social, functional, and
environmental evaluation. It is intended to provide a simple and
concise overview of the patient, and be a useful resource for
patients, caregivers, health care professionals, and others, as
necessary.
A typical plan of care is not limited to, but may include:
■ Problem list
■ Expected outcome and prognosis
■ Measurable treatment goals
■ Cognitive assessment
■ Functional assessment
■ Symptom management
■ Planned interventions
■ Medical management
■ Environmental evaluation
■ Caregiver assessment
■ Interaction and coordination with outside resources and other
health care professionals and others, as necessary
■ Summary of advance directives
The above elements are intended to be a guide for creating a
meaningful plan of care rather than a strict set of requirements,
so should be addressed only as appropriate for the individual.
The plan of care should include specific and achievable goals for
each condition and be relevant to the patient’s well-being and
lifestyle. When possible, the treatment goals should also be
measurable and time bound. The plan should be updated
periodically based on status or goal changes. The entire care plan
should be reviewed at least annually.
An electronic and/or printed plan of care must be documented
and shared with the patient and/or caregiver.
Codes 99487, 99489, 99490, 99491 are reported only once per
calendar month and 99439 is reported no more than twice per
calendar month. Codes 99439, 99487, 99489, 99490, 99491 may
only be reported by the single physician or other qualified health
care professional who assumes the care management role with a
particular patient for the calendar month.
For 99439, 99487, 99489, 99490 the face-to-face and non-face-to-
face time spent by the clinical staff in communicating with the
patient and/or family, caregivers, other professionals, and
agencies; creating, revising, documenting, and implementing the
care plan; or teaching self-management is used in determining the
care management clinical staff time for the month. Only the time
of the clinical staff of the reporting professional is counted. Only
count the time of one clinical staff member when two or more
clinical staff members are meeting about the patient. For 99491,
only count the time personally spent by the physician or other
qualified health care professional. Do not count any of the
clinical staff time spent on the day of an initiating visit (the
creation of the care plan, initial explanation to the patient and/or
caregiver, and obtaining consent).◀
Care management activities performed by clinical staff, or
personally by the physician or other qualified health care
professional, typically include:
■ communication and engagement with patient, family members,
guardian or caretaker, surrogate decision makers, and/or other
professionals regarding aspects of care;
■ communication with home health agencies and other
community services utilized by the patient;
■ collection of health outcomes data and registry documentation;
■ patient and/or family/caregiver education to support self-
management, independent living, and activities of daily living;
■ assessment and support for treatment regimen adherence and
medication management;
■ identification of available community and health resources;
■ facilitating access to care and services needed by the patient
and/or family;
■ management of care transitions not reported as part of
transitional care management (99495, 99496);
■ ongoing review of patient status, including review of
laboratory and other studies not reported as part of an E/M
service, noted above;
■ development, communication, and maintenance of a
comprehensive care plan.
▶The care management office/practice must have the following
capabilities:
■ provide 24/7 access to physicians or other qualified health care
professionals or clinical staff including providing
patients/caregivers with a means to make contact with health
care professionals in the practice to address urgent needs
regardless of the time of day or day of week;
■ provide continuity of care with a designated member of the
care team with whom the patient is able to schedule successive
routine appointments;
■ provide timely access and management for follow-up after an
emergency department visit or facility discharge;
■ utilize an electronic health record system so that care providers
have timely access to clinical information;
■ use a standardized methodology to identify patients who
require care management services;
■ have an internal care management process/function whereby a
patient identified as meeting the requirements for these services
starts receiving them in a timely manner;
■ use a form and format in the medical record that is
standardized within the practice;
■ be able to engage and educate patients and caregivers as well as
coordinate care among all service professionals, as appropriate
for each patient;
■ reporting physician or other qualified health care professional
oversees activities of the care team;
■ all care team members providing services are clinically
integrated.
Each minute of service time is counted toward only one service.
Do not count any time and activities used to meet criteria for
another reported service. However, time of clinical staff and time
of a physician or other qualified health care professional are
distinct when each provides a distinct, separately reportable
service to the same patient during the same period of time (eg,
calendar month). A list of services not reported in the same
calendar month as 99439, 99487, 99489, 99490 is provided in the
parenthetical instructions following 99439, 99489. See the
parenthetical instruction below 99491 for a list of services not
separately reported in the same calendar month that 99491 is
reported. Do not report 99439, 99487, 99489, 99490 when
reporting 99491 for the same calendar month. If the care
management services are performed within the postoperative
period of a reported surgery, the same individual may not report
99439, 99487, 99489, 99490, 99491. For service time used for
reporting 99439, 99487, 99489, 99490, 99491, do not also include
service time used to report 99421, 99422, 99423.
Care management may be reported in any calendar month during
which the clinical staff time or physician or other qualified health
care professional personal time requirements are met. ◀
When behavioral or psychiatric collaborative care management
services are also provided, 99484, 99492, 99493, 99494 may be
reported in addition.
Chronic Care Management Services

▶Chronic care management services are provided when medical
and/or psychosocial needs of the patient require establishing,
implementing, revising, or monitoring the care plan. Patients who
receive chronic care management services have two or more
chronic continuous or episodic health conditions that are
expected to last at least 12 months, or until the death of the
patient, and that place the patient at significant risk of death,
acute exacerbation/decompensation, or functional decline. Code
99490 is reported when, during the calendar month, at least 20
minutes of clinical staff time is spent in care management
activities. Code 99439 is reported in conjunction with 99490 for
each additional 20 minutes of clinical staff time spent in care
management activities during the calendar month up to a
maximum of 60 minutes total time (ie, 99439 may only be
reported twice per calendar month). Code 99491 is reported
when 30 minutes of physician or other qualified health care
professional personal time is spent in care management activities.
Do not report 99439, 99490 in the same calendar month as 99491.
If reporting 99491, do not count any physician or other qualified
health care professional time on the date of a face-to-face E/M
encounter towards the time used in reporting 99491.◀
#▲ 99490 Chronic care management services with the following
required elements:
■ multiple (two or more) chronic conditions expected to
last at least 12 months, or until the death of the patient,
■ chronic conditions place the patient at significant risk of
death, acute exacerbation/decompensation, or functional
decline,
■ comprehensive care plan established, implemented,
revised, or monitored; first 20 minutes of clinical staff
time directed by a physician or other qualified health care
professional, per calendar month.
➲ CPT Assistant Oct 14:3, Feb 15:3, Feb 18:7, Mar 18:5,
Oct 18:9, Feb 20:7
#✚● 99439 each additional 20 minutes of clinical staff time directed
by a physician or other qualified health care
professional, per calendar month (List separately in
addition to code for primary procedure)
▶ (Use 99439 in conjunction with 99490)◀
(Chronic care management services of less than 20 minutes
duration, in a calendar month, are not reported separately)
▶ (Chronic care management services of 60 minutes or more
and requiring moderate or high complexity medical decision
making may be reported using 99487, 99489)◀
▶ (Donot report 99439 more than twice per calendar
month)◀
▶ (Do not report 99439, 99490 in the same calendar month
with 90951-90970, 99339, 99340, 99374, 99375, 99377,
99378, 99379, 99380, 99487, 99489, 99491, 99605, 99606,
99607)◀
▶ (Do not report 99439, 99490 for service time reported
with 93792, 93793, 98960, 98961, 98962, 98966, 98967,
98968, 98970, 98971, 98972, 99071, 99078, 99080, 99091,
99358, 99359, 99366, 99367, 99368, 99421, 99422, 99423,
99441, 99442, 99443, 99605, 99606, 99607)◀
Staff Care
Management Services Chronic Care Management
20 to 39 minutes 99490 X 1
40-59 minutes 99490 X 1 and 99439 X 1
60 minutes or more 99490 X 1 and 99439 X 2 (see
(1 hour or more) also 99487)◀
# 99491 Chronic care management services, provided personally by

a physician or other qualified health care professional, at
least 30 minutes of physician or other qualified health care
professional time, per calendar month, with the following
required elements:
last at least 12 months, or until the death of the patient;
decline;
revised, or monitored.
➲ CPT Assistant Oct 18:9
▶ (Donot report 99491 in the same calendar month with

90951-90970, 99339, 99340, 99374, 99375, 99377, 99378,
99379, 99380, 99439, 99487, 99489, 99490, 99605, 99606,
99607)◀
▶ (Donot report 99491 for service time reported with
93792, 93793, 98960, 98961, 98962, 98966, 98967, 98968,
99071, 99078, 99080, 99091, 99358, 99359, 99366, 99367,
99368, 99421, 99422, 99423, 99441, 99442, 99443)◀
▶ (Do not report 99491 when performed during the service
time of 99495, 99496, if reporting 99495, 99496)◀
Complex Chronic Care Management

Services
▶Complex chronic care management services are provided
during a calendar month that includes criteria for chronic care
management services including establishing, revising,
implementing, or monitoring the care plan; medical, functional,
and/or psychosocial problems requiring medical decision making
of moderate or high complexity; and clinical staff care
management services for at least 60 minutes, under the direction
of a physician or other qualified health care professional. Medical
decision making as defined in the Evaluation and Management
(E/M) guidelines is determined by the problems addressed by the
reporting individual during the month.◀
Patients who require complex chronic care management services
may be identified by practice-specific or other published
algorithms that recognize multiple illnesses, multiple medication
use, inability to perform activities of daily living, requirement for
a caregiver, and/or repeat admissions or emergency department
visits. Typical adult patients who receive complex chronic care
management services are treated with three or more prescription
medications and may be receiving other types of therapeutic
interventions (eg, physical therapy, occupational therapy). Typical
pediatric patients receive three or more therapeutic interventions
(eg, medications, nutritional support, respiratory therapy). All
patients have two or more chronic continuous or episodic health
conditions that are expected to last at least 12 months, or until the
death of the patient, and that place the patient at significant risk
of death, acute exacerbation/decompensation, or functional
decline. Typical patients have complex diseases and morbidities
and, as a result, demonstrate one or more of the following:
■ need for the coordination of a number of specialties and
services;
■ inability to perform activities of daily living and/or cognitive
impairment resulting in poor adherence to the treatment plan
without substantial assistance from a caregiver;
■ psychiatric and other medical comorbidities (eg, dementia and
chronic obstructive pulmonary disease or substance abuse and
diabetes) that complicate their care; and/or
■ social support requirements or difficulty with access to care.
Total Duration of Staff Care

Management Services Complex Chronic Care Management
60 to 89 minutes 99487 X 1
(1 hour - 1 hr. 29 min.)
90 - 119 minutes 99487 X 1 and 99489 X 1
(1 hr. 30 min. - 1 hr. 59 min.)
120 minutes or more 99487 X 1 and 99489 X 2 and 99489 for
(2 hours or more) each additional 30 minutes
▲ 99487 Complex chronic care management services with the

following required elements:
decline,
revised, or monitored,
■ moderate or high complexity medical decision making;
first 60 minutes of clinical staff time directed by a physician
or other qualified health care professional, per calendar
month.
➲ CPT Assistant Apr 13:3, Sep 13:15, Nov 13:3, Feb 14:3,
Jun 14:3, 5, Oct 14:3, Apr 17:9, Feb 18:7, Mar 18:5, Oct
18:9, Feb 20:7
(Complex chronic care management services of less than 60
minutes duration, in a calendar month, are not reported
separately)
✚▲ 99489 each additional 30 minutes of clinical staff time directed
by a physician or other qualified health care
professional, per calendar month (List separately in
➲ CPT Assistant Apr 13:3, Sep 13:15, Nov 13:3, Jun
14:5, Oct 14:3, Apr 17:9, Feb 18:7, Mar 18:5, Oct
18:9, Feb 20:7
(Report 99489 in conjunction with 99487)
(Do not report 99489 for care management services of less
than 30 minutes additional to the first 60 minutes of complex
chronic care management services during a calendar month)
▶ (Do not report 99487, 99489 during the same calendar
month with 90951-90970, 99339, 99340, 99374, 99375,
99377, 99378, 99379, 99380, 99439, 99490, 99491, 99605,
99606, 99607)◀
▶ (Do not report 99487, 99489 for service time reported
with 93792, 93793, 98960, 98961, 98962, 98966, 98967,
98968, 98969, 98970, 98971, 98972, 99071, 99078, 99080,
99091, 99358, 99359, 99366, 99367, 99368, 99421, 99422,
99423, 99441, 99442, 99443, 99605, 99606, 99607)◀
Coding Tip
If the physician personally performs the clinical staff activities, his or her
time may be counted toward the required clinical staff time to meet the
elements of the code.

Psychiatric Collaborative Care
Management Services
Psychiatric collaborative care services are provided under the
direction of a treating physician or other qualified health care
professional (see definitions below) during a calendar month.
These services are reported by the treating physician or other
qualified health care professional and include the services of the
treating physician or other qualified health care professional, the
behavioral health care manager (see definition below), and the
psychiatric consultant (see definition below), who has contracted
directly with the treating physician or other qualified health care
professional, to provide consultation. Patients directed to the
behavioral health care manager typically have behavioral health
signs and/or symptoms or a newly diagnosed behavioral health
condition, may need help in engaging in treatment, have not
responded to standard care delivered in a nonpsychiatric setting,
or require further assessment and engagement, prior to
consideration of referral to a psychiatric care setting.
These services are provided when a patient requires a behavioral
health care assessment; establishing, implementing, revising, or
monitoring a care plan; and provision of brief interventions.
The following definitions apply to this section:
Definitions
Episode of care patients are treated for an episode of care, which
is defined as beginning when the patient is directed by the
treating physician or other qualified health care professional to
the behavioral health care manager and ending with:
■ the attainment of targeted treatment goals, which typically
results in the discontinuation of care management services and
continuation of usual follow-up with the treating physician or
other qualified health care professional; or
■ failure to attain targeted treatment goals culminating in referral
to a psychiatric care provider for ongoing treatment of the
behavioral health condition; or
■ lack of continued engagement with no psychiatric collaborative
care management services provided over a consecutive six
month calendar period (break in episode).
A new episode of care starts after a break in episode of six
calendar months or more.
Health care professionals refers to the treating physician or other
qualified health care professional who directs the behavioral
health care manager and continues to oversee the patient’s care,
including prescribing medications, providing treatments for
medical conditions, and making referrals to specialty care when
needed. Evaluation and management (E/M) and other services
may be reported separately by the same physician or other
qualified health care professional during the same calendar
month.
Behavioral health care manager refers to clinical staff with a
masters-/doctoral-level education or specialized training in
behavioral health who provides care management services as
well as an assessment of needs, including the administration of
validated rating scales, the development of a care plan, provision
of brief interventions, ongoing collaboration with the treating
physician or other qualified health care professional, maintenance
of a registry, all in consultation with a psychiatric consultant.
Services are provided both face-to-face and non-face-to-face and
psychiatric consultation is provided minimally on a weekly basis,
typically non-face-to-face.
The behavioral health care manager providing other services in
the same calendar month, such as psychiatric evaluation (90791,
90792), psychotherapy (90832, 90833, 90834, 90836, 90837,
90838), psychotherapy for crisis (90839, 90840), family
psychotherapy (90846, 90847), multiple family group
psychotherapy (90849), group psychotherapy (90853), smoking
and tobacco use cessation counseling (99406, 99407), and alcohol
and/or substance abuse structured screening and brief
intervention services (99408, 99409), may report these services
separately. Activities for services reported separately are not
included in the time applied to 99492, 99493, 99494.
Psychiatric consultant refers to a medical professional, who is
trained in psychiatry or behavioral health, and qualified to
prescribe the full range of medications. The psychiatric
consultant advises and makes recommendations, as needed, for
psychiatric and other medical care, including psychiatric and
other medical differential diagnosis, treatment strategies regarding
appropriate therapies, medication management, medical
management of complications associated with treatment of
psychiatric disorders, and referral for specialty services, which
are typically communicated to the treating physician or other
qualified health care professional through the behavioral health
care manager. The psychiatric consultant typically does not see
the patient or prescribe medications, except in rare circumstances.
The psychiatric consultant may provide services in the calendar
month described by other codes, such as evaluation and
management (E/M) services and psychiatric evaluation (90791,
90792). These services may be reported separately by the
psychiatric consultant. Activities for services reported separately
are not included in the services reported using 99492, 99493,
99494.
Type of Service Total Duration of Collaborative Code(s)

Care Management Over
Calendar Month
Initial - 70 minutes Less than 36 minutes Not
reported
separately
36-85 minutes 99492 X 1
(36 minutes - 1 hr. 25 minutes)
Initial plus each additional 86-115 minutes 99492 X 1
increment up to 30 minutes (1 hr. 26 minutes - 1 hr. 55 AND 99494
minutes) X1
Subsequent - 60 minutes Less than 31 minutes Not
reported
separately
31-75 minutes 99493 X 1
(31 minutes - 1 hr. 15 minutes)
Subsequent plus each 76-105 minutes 99493 X 1
additional increment up to (1 hr. 16 minutes - 1 hr. 45 AND 99494
30 minutes minutes) X1
Do not report 99492 and 99493 in the same calendar month.

99492 Initial psychiatric collaborative care management, first
70 minutes in the first calendar month of behavioral health
care manager activities, in consultation with a psychiatric
consultant, and directed by the treating physician or other
qualified health care professional, with the following
required elements:
■ outreach to and engagement in treatment of a patient
directed by the treating physician or other qualified health
care professional;
■ initial assessment of the patient, including administration
of validated rating scales, with the development of an
individualized treatment plan;
■ review by the psychiatric consultant with modifications of
the plan if recommended;
■ entering patient in a registry and tracking patient follow-
up and progress using the registry, with appropriate
documentation, and participation in weekly caseload
consultation with the psychiatric consultant; and
■ provision of brief interventions using evidence-based
techniques such as behavioral activation, motivational
interviewing, and other focused treatment strategies.
➲ CPT Assistant Nov 17:3, Feb 18:7, Mar 18:5, Jul 18:12,
Feb 20:7
99493 Subsequent psychiatric collaborative care management,
first 60 minutes in a subsequent month of behavioral health
care manager activities, in consultation with a psychiatric
consultant, and directed by the treating physician or other
qualified health care professional, with the following
required elements:
■ tracking patient follow-up and progress using the registry,
with appropriate documentation;
■ participation in weekly caseload consultation with the
psychiatric consultant;
■ ongoing collaboration with and coordination of the
patient’s mental health care with the treating physician or
other qualified health care professional and any other
treating mental health providers;
■ additional review of progress and recommendations for
changes in treatment, as indicated, including medications,
based on recommendations provided by the psychiatric
consultant;
■ provision of brief interventions using evidence-based
techniques such as behavioral activation, motivational
interviewing, and other focused treatment strategies;
■ monitoring of patient outcomes using validated rating
scales; and
■ relapse prevention planning with patients as they achieve
remission of symptoms and/or other treatment goals and
are prepared for discharge from active treatment.
Feb 20:7
✚ 99494 Initial or subsequent psychiatric collaborative care
management, each additional 30 minutes in a calendar
month of behavioral health care manager activities, in
consultation with a psychiatric consultant, and directed by
the treating physician or other qualified health care
professional (List separately in addition to code for primary
procedure)
Feb 20:7
(Use 99494 in conjunction with 99492, 99493)
Coding Tip
If the treating physician or other qualified health care professional personally
performs behavioral health care manager activities and those activities are
not used to meet criteria for a separately reported code, his or her time may
be counted toward the required behavioral health care manager time to meet
the elements of 99492, 99493, 99494.
Transitional Care Management

Services
Codes 99495 and 99496 are used to report transitional care
management services (TCM). These services are for a new or
established patient whose medical and/or psychosocial problems
require moderate or high complexity medical decision making
during transitions in care from an inpatient hospital setting
(including acute hospital, rehabilitation hospital, long-term acute
care hospital), partial hospital, observation status in a hospital, or
skilled nursing facility/nursing facility to the patient’s community
setting (home, domiciliary, rest home, or assisted living). TCM
commences upon the date of discharge and continues for the next
29 days.
TCM is comprised of one face-to-face visit within the specified
timeframes, in combination with non-face-to-face services that
may be performed by the physician or other qualified health care
professional and/or licensed clinical staff under his/her direction.
Non-face-to-face services provided by clinical staff, under the
direction of the physician or other qualified health care
professional, may include:
■ communication (with patient, family members, guardian or
caretaker, surrogate decision makers, and/or other
professionals) regarding aspects of care,
communication with home health agencies and other
■ community services utilized by the patient,
■ patient and/or family/caretaker education to support self-
management, independent living, and activities of daily living,
■ assessment and support for treatment regimen adherence and
medication management,
■ identification of available community and health resources,
■ facilitating access to care and services needed by the patient
and/or family
Non-face-to-face services provided by the physician or other
qualified health care provider may include:
■ obtaining and reviewing the discharge information (eg,
discharge summary, as available, or continuity of care
documents);
■ reviewing need for or follow-up on pending diagnostic tests
and treatments;
■ interaction with other qualified health care professionals who
will assume or reassume care of the patient’s system-specific
problems;
■ education of patient, family, guardian, and/or caregiver;
■ establishment or reestablishment of referrals and arranging for
needed community resources;
■ assistance in scheduling any required follow-up with
community providers and services.
TCM requires a face-to-face visit, initial patient contact, and
medication reconciliation within specified time frames. The first
face-to-face visit is part of the TCM service and not reported
separately. Additional E/M services provided on subsequent dates
after the first face-to-face visit may be reported separately. TCM
requires an interactive contact with the patient or caregiver, as
appropriate, within two business days of discharge. The contact
may be direct (face-to-face), telephonic, or by electronic means.
Medication reconciliation and management must occur no later
than the date of the face-to-face visit.
These services address any needed coordination of care
performed by multiple disciplines and community service
agencies. The reporting individual provides or oversees the
management and/or coordination of services, as needed, for all
medical conditions, psychosocial needs and activity of daily
living support by providing first contact and continuous access.
Medical decision making and the date of the first face-to-face
visit are used to select and report the appropriate TCM code. For
99496, the face-to-face visit must occur within 7 calendar days of
the date discharge and medical decision making must be of high
complexity. For 99495, the face-to-face visit must occur within 14
calendar days of the date of discharge and medical decision
making must be of at least moderate complexity.
Type of Medical Face-to-Face Visit Face-to-Face Visit Within

Decision Making Within 7 Days 8 to 14 Days
Moderate Complexity 99495 99495
High Complexity 99496 99495
Medical decision making is defined by the E/M Services

Guidelines. The medical decision making over the service period
reported is used to define the medical decision making of TCM.
Documentation includes the timing of the initial post discharge
communication with the patient or caregivers, date of the face-to-
face visit, and the complexity of medical decision making.
Only one individual may report these services and only once per
patient within 30 days of discharge. Another TCM may not be
reported by the same individual or group for any subsequent
discharge(s) within the 30 days. The same individual may report
hospital or observation discharge services and TCM. However,
the discharge service may not constitute the required face-to-face
visit. The same individual should not report TCM services
provided in the postoperative period of a service that the
individual reported.
★ 99495 Transitional Care Management Services with the
■ Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days
of discharge
■ Medical decision making of at least moderate complexity
during the service period
■ Face-to-face visit, within 14 calendar days of discharge
➲ CPT Assistant Apr 13:3, Jul 13:11, Aug 13:13, Sep
13:15, Nov 13:3, Dec 13:11, Mar 14:13, Oct 14:3, Feb
18:7, Mar 18:5, Jan 20:3, Feb 20:7
★ 99496 Transitional Care Management Services with the
■ Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days
of discharge
■ Medical decision making of high complexity during the
service period
■ Face-to-face visit, within 7 calendar days of discharge
➲ CPT Assistant Apr 13:3, Jul 13:11, Aug 13:13, Sep
13:15, Nov 13:3, Mar 14:13, Oct 14:3, Feb 18:7, Mar
18:5, Jan 20:3, Feb 20:7
Coding Tip
If another individual provides TCM services within the postoperative
period of a surgical package, modifier 54 is not required.
The required contact with the patient or caregiver, as appropriate, may be by

the physician or qualified health care professional or clinical staff. Within
two business days of discharge is Monday through Friday except holidays
without respect to normal practice hours or date of notification of discharge.
The contact must include capacity for prompt interactive communication
addressing patient status and needs beyond scheduling follow-up care. If two
or more separate attempts are made in a timely manner, but are unsuccessful
and other transitional care management criteria are met, the service may be
reported.
Advance Care Planning

Codes 99497, 99498 are used to report the face-to-face service
between a physician or other qualified health care professional
and a patient, family member, or surrogate in counseling and
discussing advance directives, with or without completing
relevant legal forms. An advance directive is a document
appointing an agent and/or recording the wishes of a patient
pertaining to his/her medical treatment at a future time should
he/she lack decisional capacity at that time. Examples of written
advance directives include, but are not limited to, Health Care
Proxy, Durable Power of Attorney for Health Care, Living Will,
and Medical Orders for Life-Sustaining Treatment (MOLST).
When using codes 99497, 99498, no active management of the
problem(s) is undertaken during the time period reported.
▶Codes 99497, 99498 may be reported separately if these
services are performed on the same day as another Evaluation
and Management service (99202-99215, 99217, 99218, 99219,
99220, 99221, 99222, 99223, 99224, 99225, 99226, 99231, 99232,
99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243,
99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282,
99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309,
99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328,
99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345,
99347, 99348, 99349, 99350, 99381-99397, 99495, 99496).◀
99497 Advance care planning including the explanation and
discussion of advance directives such as standard forms
(with completion of such forms, when performed), by the
physician or other qualified health care professional; first
30 minutes, face-to-face with the patient, family member(s),
and/or surrogate
➲ CPT Assistant Dec 14:11, Feb 16:7


(Do not report 99497 and 99498 on the same date of service
as 99291, 99292, 99468, 99469, 99471, 99472, 99475,
99476, 99477, 99478, 99479, 99480, 99483)
General Behavioral Health Integration
Care Management
▶General behavioral health integration care management services
(99484) are reported by the supervising physician or other
qualified health care professional. The services are performed by
clinical staff for a patient with a behavioral health (including
substance use) condition that requires care management services
(face-to-face or non-face-to-face) of 20 or more minutes in a
calendar month. A treatment plan as well as the specified
elements of the service description is required. The assessment
and treatment plan is not required to be comprehensive and the
office/practice is not required to have all the functions of chronic
care management (99439, 99487, 99489, 99490). Code 99484 may
be used in any outpatient setting, as long as the reporting
professional has an ongoing relationship with the patient and
clinical staff and as long as the clinical staff is available for face-
to-face services with the patient.◀
The reporting professional must be able to perform the
evaluation and management (E/M) services of an initiating visit.
General behavioral integration care management (99484) and
chronic care management services may be reported by the same
professional in the same month, as long as distinct care
management services are performed. Behavioral health
integration care management (99484) and psychiatric
collaborative care management (99492, 99493, 99494) may not be
reported by the same professional in the same month. Behavioral
health care integration clinical staff are not required to have
qualifications that would permit them to separately report
services (eg, psychotherapy), but, if qualified and they perform
such services, they may report such services separately, as long as
the time of the service is not used in reporting 99484.
# 99484 Care management services for behavioral health conditions,
at least 20 minutes of clinical staff time, directed by a
physician or other qualified health care professional, per
calendar month, with the following required elements:
■ initial assessment or follow-up monitoring, including the
use of applicable validated rating scales;
■ behavioral health care planning in relation to
behavioral/psychiatric health problems, including
revision for patients who are not progressing or whose
status changes;
■ facilitating and coordinating treatment such as
psychotherapy, pharmacotherapy, counseling and/or
psychiatric consultation; and
■ continuity of care with a designated member of the care
team.
➲ CPT Assistant Feb 18:7, Mar 18:5, Jul 18:12, Feb 20:7
(Do not report 99484 in conjunction with 99492, 99493,

99494 in the same calendar month)
▶(E/M services, including care management services [99439,
99487, 99489, 99490, 99495, 99496], and psychiatric services
[90785-90899] may be reported separately by the same physician
or other qualified health care professional on the same day or
during the same calendar month, but time and activities used to
meet criteria for another reported service do not count toward
meeting criteria for 99484)◀
Coding Tip
If the treating physician or other qualified health care professional personally
performs behavioral health care manager activities and those activities are
not used to meet the criteria for a separately reported code, his or her time
may be counted toward the required behavioral health care manager time to
meet the elements of 99484, 99492, 99493, 99494.
Clinical staff time spent coordinating care with the emergency department
may be reported using 99484, but time spent while the patient is inpatient or
admitted to observation status may not be reported using 99484.
Other Evaluation and Management

Services
99499 Unlisted evaluation and management service
➲ CPT Assistant Apr 96:11, Mar 05:11, May 05:1, Jan
06:46, Sep 06:8, Jan 07:30, May 11:7, Apr 12:10, Jul
12:10, 11, Nov 12:13, Oct 14:9, Aug 19:8
Notes
★ = Telemedicine ✚ = Add-on code ⚡ = FDA approval

pending # = Resequenced code ⃠ = Modifier 51
exempt ➲➲➲ = See p xviii for details ▲ = Revised
code ● = New code ▶◀ = Contains new or revised text
= Duplicate PLA test ⇅ = Category I PLA
appear within the Anesthesia section of the CPT codebook. The
subheadings or subsections denoted with asterisks (*) below
have special instructions unique to that subsection. Where these
are indicated, special notes or guidelines will be presented
preceding those procedural terminology listings, referring to that
subsection specifically.
Time Reporting
Anesthesia Services
Supplied Materials
Special Report
Physical Status Modifiers
Anesthesia
Head (00100-00222)
Neck (00300-00352)
Thorax (Chest Wall and Shoulder Girdle) (00400-00474)
Intrathoracic (00500-00580)
Spine and Spinal Cord (00600-00670)
Upper Abdomen (00700-00797)
Lower Abdomen (00800-00882)
Perineum (00902-00952)
Pelvis (Except Hip) (01112-01173)
Upper Leg (Except Knee) (01200-01274)
Knee and Popliteal Area (01320-01444)
Lower Leg (Below Knee, Includes Ankle and Foot) (01462-
01522)
Shoulder and Axilla* (01610-01680)
Upper Arm and Elbow (01710-01782)
Forearm, Wrist, and Hand (01810-01860)
Radiological Procedures (01916-01936)
Burn Excisions or Debridement (01951-01953)
Obstetric (01958-01969)
Other Procedures (01990-01999)
Services involving administration of anesthesia are reported by
the use of the anesthesia five-digit procedure code (00100-01999)
plus modifier codes (defined under “Anesthesia Modifiers” later
in these Guidelines).
The reporting of anesthesia services is appropriate by or under
the responsible supervision of a physician. These services may
include but are not limited to general, regional, supplementation
of local anesthesia, or other supportive services in order to afford
the patient the anesthesia care deemed optimal by the
anesthesiologist during any procedure. These services include the
usual preoperative and postoperative visits, the anesthesia care
during the procedure, the administration of fluids and/or blood
and the usual monitoring services (eg, ECG, temperature, blood
pressure, oximetry, capnography, and mass spectrometry).
Unusual forms of monitoring (eg, intra-arterial, central venous,
and Swan-Ganz) are not included.
Items used by all physicians in reporting their services are
presented in the Introduction. Some of the commonalities are
repeated in this section for the convenience of those physicians
referring to this section on Anesthesia. Other definitions and
items unique to anesthesia are also listed.
To report moderate (conscious) sedation provided by a physician
also performing the service for which conscious sedation is being
provided, see codes 99151, 99152, 99153.
When a second physician other than the health care professional
performing the diagnostic or therapeutic services provides
moderate (conscious) sedation in the facility setting (eg, hospital,
outpatient hospital/ambulatory surgery center, skilled nursing
facility), the second physician reports the associated moderate
sedation procedure/service 99155, 99156, 99157; when these
services are performed by the second physician in the nonfacility
setting (eg, physician office, freestanding imaging center), codes
99155, 99156, 99157 would not be reported. Moderate sedation
does not include minimal sedation (anxiolysis), deep sedation, or
monitored anesthesia care (00100-01999).
To report regional or general anesthesia provided by a physician
also performing the services for which the anesthesia is being
provided, see modifier 47 in Appendix A.
Time Reporting
Time for anesthesia procedures may be reported as is customary
in the local area. Anesthesia time begins when the
anesthesiologist begins to prepare the patient for the induction of
anesthesia in the operating room (or in an equivalent area) and
ends when the anesthesiologist is no longer in personal
attendance, that is, when the patient may be safely placed under
postoperative supervision.
Anesthesia Services
▶Services rendered in the office, home, or hospital; consultation;
and other medical services are listed in the Evaluation and
Management Services section (99202-99499 series) on page 18.
“Special Services, Procedures, and Reports” (99000-99082 series)
are listed in the Medicine section.◀
Supplied Materials
Supplies and materials provided (eg, sterile trays, drugs) over
and above those usually included with the office visit or other
services rendered may be listed separately. Drugs, tray supplies,
and materials provided should be listed and identified with 99070
or the appropriate supply code.

When multiple surgical procedures are performed during a single
anesthetic administration, the anesthesia code representing the
most complex procedure is reported. The time reported is the
combined total for all procedures.

A service or procedure may be provided that is not listed in this
edition of the CPT codebook. When reporting such a service, the
appropriate “Unlisted Procedure” code may be used to indicate
the service, identifying it by “Special Report” as discussed in the
section below. The “Unlisted Procedures” and accompanying
code for Anesthesia is as follows:
01999 Unlisted anesthesia procedure(s)
Special Report
A service that is rarely provided, unusual, variable, or new may
require a special report. Pertinent information should include an
adequate definition or description of the nature, extent, and need
for the procedure and the time, effort, and equipment necessary
to provide the service.
All anesthesia services are reported by use of the anesthesia five-
digit procedure code (00100-01999) plus the addition of a
physical status modifier. The use of other optional modifiers may
be appropriate.
Physical Status Modifiers

Physical Status modifiers are represented by the initial letter ‘P’
followed by a single digit from 1 to 6 as defined in the following
list:
P1: A normal healthy patient
P2: A patient with mild systemic disease
P3: A patient with severe systemic disease
P4: A patient with severe systemic disease that is a constant
threat to life
P5: A moribund patient who is not expected to survive without
the operation
P6: A declared brain-dead patient whose organs are being
removed for donor purposes
These six levels are consistent with the American Society of
Anesthesiologists (ASA) ranking of patient physical status.
Physical status is included in the CPT codebook to distinguish
among various levels of complexity of the anesthesia service
provided.
Example: 00100-P1
More than one qualifying circumstance may be selected.
Many anesthesia services are provided under particularly difficult
circumstances, depending on factors such as extraordinary
condition of patient, notable operative conditions, and/or unusual
risk factors. This section includes a list of important qualifying
circumstances that significantly affect the character of the
anesthesia service provided. These procedures would not be
reported alone but would be reported as additional procedure
numbers qualifying an anesthesia procedure or service.
✚ 99100 Anesthesia for patient of extreme age, younger than 1 year
and older than 70 (List separately in addition to code for
primary anesthesia procedure)
(For procedure performed on infants younger than 1 year of
age at time of surgery, see 00326, 00561, 00834, 00836)
✚ 99116 Anesthesia complicated by utilization of total body
hypothermia (List separately in addition to code for primary
anesthesia procedure)
✚ 99135 Anesthesia complicated by utilization of controlled
hypotension (List separately in addition to code for primary
✚ 99140 Anesthesia complicated by emergency conditions (specify)
(List separately in addition to code for primary anesthesia
procedure)
(An emergency is defined as existing when delay in
treatment of the patient would lead to a significant increase
in the threat to life or body part)

Anesthesia
Head
00100 Anesthesia for procedures on salivary glands, including
biopsy
➲ CPT Assistant Feb 97:4, Nov 99:6, Feb 06:9, Mar
06:15, Nov 07:8, Oct 11:3, Jul 12:13, Aug 14:6, Dec
17:8, Oct 19:10
➲ Clinical Examples in Radiology Summer 11:2, Spring
13:5, Summer 13:5, Winter 13:5, Spring 14:7, Winter
16:4
00102 Anesthesia for procedures involving plastic repair of cleft
lip
➲ CPT Assistant Nov 99:6
00103 Anesthesia for reconstructive procedures of eyelid (eg,

blepharoplasty, ptosis surgery)
00104 Anesthesia for electroconvulsive therapy

00120 Anesthesia for procedures on external, middle, and inner ear
including biopsy; not otherwise specified
00124 otoscopy
00126 tympanotomy
00140 Anesthesia for procedures on eye; not otherwise specified
00142 lens surgery
00144 corneal transplant
00145 vitreoretinal surgery
00147 iridectomy
00148 ophthalmoscopy
00160 Anesthesia for procedures on nose and accessory sinuses;
not otherwise specified
00162 radical surgery
00164 biopsy, soft tissue
00170 Anesthesia for intraoral procedures, including biopsy; not
otherwise specified
00172 repair of cleft palate
00174 excision of retropharyngeal tumor
00176 radical surgery
00190 Anesthesia for procedures on facial bones or skull; not
otherwise specified
00192 radical surgery (including prognathism)

00210 Anesthesia for intracranial procedures; not otherwise
specified
00211 craniotomy or craniectomy for evacuation of hematoma
00212 subdural taps

00214 burr holes, including ventriculography
00215 cranioplasty or elevation of depressed skull fracture,
extradural (simple or compound)
00216 vascular procedures

00218 procedures in sitting position
00220 cerebrospinal fluid shunting procedures
00222 electrocoagulation of intracranial nerve
➲ CPT Assistant Jul 12:13
Neck
00300 Anesthesia for all procedures on the integumentary system,
muscles and nerves of head, neck, and posterior trunk, not
otherwise specified
➲ CPT Assistant Nov 99:7, Mar 06:15, Oct 11:3, Jul 12:13
00320 Anesthesia for all procedures on esophagus, thyroid, larynx,

trachea and lymphatic system of neck; not otherwise
specified, age 1 year or older
00322 needle biopsy of thyroid

(For procedures on cervical spine and cord, see 00600,
00604, 00670)
00326 Anesthesia for all procedures on the larynx and trachea in
children younger than 1 year of age
➲ CPT Assistant Dec 17:8

00350 Anesthesia for procedures on major vessels of neck; not
otherwise specified
00352 simple ligation
➲ CPT Assistant Nov 07:8, Jul 12:13
(For arteriography, use 01916)
Thorax (Chest Wall and Shoulder

Girdle)
00400 Anesthesia for procedures on the integumentary system on
the extremities, anterior trunk and perineum; not otherwise
specified
➲ CPT Assistant Mar 06:15, Nov 07:8, Oct 11:3, Jul 12:13
00402 reconstructive procedures on breast (eg, reduction or

augmentation mammoplasty, muscle flaps)
00404 radical or modified radical procedures on breast
00406 radical or modified radical procedures on breast with
internal mammary node dissection
00410 electrical conversion of arrhythmias
00450 Anesthesia for procedures on clavicle and scapula; not
otherwise specified
00454 biopsy of clavicle
00470 Anesthesia for partial rib resection; not otherwise specified
00472 thoracoplasty (any type)
00474 radical procedures (eg, pectus excavatum)
Intrathoracic
00500 Anesthesia for all procedures on esophagus
00520 Anesthesia for closed chest procedures; (including
bronchoscopy) not otherwise specified
00522 needle biopsy of pleura

00524 pneumocentesis
00528 mediastinoscopy and diagnostic thoracoscopy not
utilizing 1 lung ventilation
(For tracheobronchial reconstruction, use 00539)

00529 mediastinoscopy and diagnostic thoracoscopy utilizing 1
lung ventilation
➲ CPT Assistant Jun 04:3
00530 Anesthesia for permanent transvenous pacemaker insertion

00532 Anesthesia for access to central venous circulation

00534 Anesthesia for transvenous insertion or replacement of
pacing cardioverter-defibrillator
(For transthoracic approach, use 00560)

00537 Anesthesia for cardiac electrophysiologic procedures
including radiofrequency ablation
00539 Anesthesia for tracheobronchial reconstruction

00540 Anesthesia for thoracotomy procedures involving lungs,

pleura, diaphragm, and mediastinum (including surgical
thoracoscopy); not otherwise specified
00541 utilizing 1 lung ventilation
(For thoracic spine and cord anesthesia procedures via an

anterior transthoracic approach, see 00625-00626)
00542 decortication
00546 pulmonary resection with thoracoplasty
00548 intrathoracic procedures on the trachea and bronchi
00550 Anesthesia for sternal debridement

00560 Anesthesia for procedures on heart, pericardial sac, and

great vessels of chest; without pump oxygenator
00561 with pump oxygenator, younger than 1 year of age

(Do not report 00561 in conjunction with 99100, 99116, and

99135)
00562 with pump oxygenator, age 1 year or older, for all
noncoronary bypass procedures (eg, valve procedures)
or for re-operation for coronary bypass more than 1
month after original operation
00563 with pump oxygenator with hypothermic circulatory

arrest
00566 Anesthesia for direct coronary artery bypass grafting;

without pump oxygenator
00567 with pump oxygenator

00580 Anesthesia for heart transplant or heart/lung transplant


00600 Anesthesia for procedures on cervical spine and cord; not
otherwise specified
➲ CPT Assistant Mar 06:15, May 07:9, Nov 07:8, Oct
11:3, Jul 12:13
(For percutaneous image-guided spine and spinal cord
anesthesia procedures, see 01935, 01936)
00604 procedures with patient in the sitting position
00620 Anesthesia for procedures on thoracic spine and cord, not

otherwise specified
➲ CPT Assistant Mar 07:9
00625 Anesthesia for procedures on the thoracic spine and cord,

via an anterior transthoracic approach; not utilizing 1 lung
ventilation
00626 utilizing 1 lung ventilation

(For anesthesia for thoracotomy procedures other than

spinal, see 00540-00541)
00630 Anesthesia for procedures in lumbar region; not otherwise
specified
00632 lumbar sympathectomy
00635 diagnostic or therapeutic lumbar puncture
00640 Anesthesia for manipulation of the spine or for closed

procedures on the cervical, thoracic or lumbar spine
00670 Anesthesia for extensive spine and spinal cord procedures

(eg, spinal instrumentation or vascular procedures)
Upper Abdomen
00700 Anesthesia for procedures on upper anterior abdominal
wall; not otherwise specified
00702 percutaneous liver biopsy

00730 Anesthesia for procedures on upper posterior abdominal
wall
00731 Anesthesia for upper gastrointestinal endoscopic
procedures, endoscope introduced proximal to duodenum;
00732 endoscopic retrograde cholangiopancreatography

(ERCP)
(For combined upper and lower gastrointestinal endoscopic
procedures, use 00813)
(00740 has been deleted. To report, see 00731, 00732)
00750 Anesthesia for hernia repairs in upper abdomen; not
otherwise specified
00752 lumbar and ventral (incisional) hernias and/or wound
dehiscence
00754 omphalocele
00756 transabdominal repair of diaphragmatic hernia
00770 Anesthesia for all procedures on major abdominal blood
vessels
00790 Anesthesia for intraperitoneal procedures in upper abdomen
including laparoscopy; not otherwise specified
00792 partial hepatectomy or management of liver hemorrhage
(excluding liver biopsy)
00794 pancreatectomy, partial or total (eg, Whipple procedure)

00796 liver transplant (recipient)
(For harvesting of liver, use 01990)
00797 gastric restrictive procedure for morbid obesity
Lower Abdomen
00800 Anesthesia for procedures on lower anterior abdominal
wall; not otherwise specified
00802 panniculectomy
00813)
00811 Anesthesia for lower intestinal endoscopic procedures,
endoscope introduced distal to duodenum; not otherwise
specified
00812 screening colonoscopy

(Report 00812 to describe anesthesia for any screening

colonoscopy regardless of ultimate findings)
00813 Anesthesia for combined upper and lower gastrointestinal
endoscopic procedures, endoscope introduced both
proximal to and distal to the duodenum
00820 Anesthesia for procedures on lower posterior abdominal

wall
00830 Anesthesia for hernia repairs in lower abdomen; not
otherwise specified
00832 ventral and incisional hernias
(For hernia repairs in the infant 1 year of age or younger, see
00834, 00836)
00834 Anesthesia for hernia repairs in the lower abdomen not
otherwise specified, younger than 1 year of age

00836 Anesthesia for hernia repairs in the lower abdomen not
otherwise specified, infants younger than 37 weeks
gestational age at birth and younger than 50 weeks
gestational age at time of surgery

00840 Anesthesia for intraperitoneal procedures in lower abdomen
including laparoscopy; not otherwise specified
00842 amniocentesis
00844 abdominoperineal resection
00846 radical hysterectomy
00848 pelvic exenteration
00851 tubal ligation/transection
00860 Anesthesia for extraperitoneal procedures in lower

abdomen, including urinary tract; not otherwise specified
00862 renal procedures, including upper one-third of ureter, or
donor nephrectomy
00864 total cystectomy
00865 radical prostatectomy (suprapubic, retropubic)
00866 adrenalectomy
00868 renal transplant (recipient)
(For donor nephrectomy, use 00862)
(For harvesting kidney from brain-dead patient, use 01990)
00870 cystolithotomy
00872 Anesthesia for lithotripsy, extracorporeal shock wave; with
water bath
00873 without water bath
00880 Anesthesia for procedures on major lower abdominal
vessels; not otherwise specified
00882 inferior vena cava ligation
Perineum
(For perineal procedures on integumentary system, muscles
and nerves, see 00300, 00400)
00902 Anesthesia for; anorectal procedure
➲ CPT Assistant Mar 06:15, Oct 11:3, Jul 12:13
00904 radical perineal procedure

00906 vulvectomy
00908 perineal prostatectomy
00910 Anesthesia for transurethral procedures (including
urethrocystoscopy); not otherwise specified
00912 transurethral resection of bladder tumor(s)
00914 transurethral resection of prostate
00916 post-transurethral resection bleeding
00918 with fragmentation, manipulation and/or removal of
ureteral calculus
➲ CPT Assistant Nov 99:8, Apr 09:8
00920 Anesthesia for procedures on male genitalia (including open

urethral procedures); not otherwise specified
➲ CPT Assistant Sep 12:16
00921 vasectomy, unilateral or bilateral

00922 seminal vesicles
00924 undescended testis, unilateral or bilateral
00926 radical orchiectomy, inguinal
00928 radical orchiectomy, abdominal
00930 orchiopexy, unilateral or bilateral
00932 complete amputation of penis
00934 radical amputation of penis with bilateral inguinal
lymphadenectomy
00936 radical amputation of penis with bilateral inguinal and
iliac lymphadenectomy
00938 insertion of penile prosthesis (perineal approach)
00940 Anesthesia for vaginal procedures (including biopsy of
labia, vagina, cervix or endometrium); not otherwise
specified
00942 colpotomy, vaginectomy, colporrhaphy, and open urethral
procedures
00944 vaginal hysterectomy

00948 cervical cerclage
00950 culdoscopy
00952 hysteroscopy and/or hysterosalpingography
Pelvis (Except Hip)

01112 Anesthesia for bone marrow aspiration and/or biopsy,
anterior or posterior iliac crest
01120 Anesthesia for procedures on bony pelvis

01130 Anesthesia for body cast application or revision
01140 Anesthesia for interpelviabdominal (hindquarter)
amputation
01150 Anesthesia for radical procedures for tumor of pelvis,
except hindquarter amputation
01160 Anesthesia for closed procedures involving symphysis pubis
or sacroiliac joint
01170 Anesthesia for open procedures involving symphysis pubis
or sacroiliac joint
01173 Anesthesia for open repair of fracture disruption of pelvis
or column fracture involving acetabulum
➲ CPT Assistant Jun 04:3-4
(01180, 01190 have been deleted)
Upper Leg (Except Knee)

01200 Anesthesia for all closed procedures involving hip joint
➲ CPT Assistant Mar 06:15, Nov 07:8, Jul 12:13
01202 Anesthesia for arthroscopic procedures of hip joint

01210 Anesthesia for open procedures involving hip joint; not
otherwise specified
01212 hip disarticulation
01214 total hip arthroplasty
01215 revision of total hip arthroplasty
01220 Anesthesia for all closed procedures involving upper two-

thirds of femur
01230 Anesthesia for open procedures involving upper two-thirds
of femur; not otherwise specified
01232 amputation
01234 radical resection
01250 Anesthesia for all procedures on nerves, muscles, tendons,
fascia, and bursae of upper leg
01260 Anesthesia for all procedures involving veins of upper leg,
including exploration
01270 Anesthesia for procedures involving arteries of upper leg,
including bypass graft; not otherwise specified
01272 femoral artery ligation
01274 femoral artery embolectomy
Knee and Popliteal Area

fascia, and bursae of knee and/or popliteal area
01340 Anesthesia for all closed procedures on lower one-third of

femur
01360 Anesthesia for all open procedures on lower one-third of
femur
01380 Anesthesia for all closed procedures on knee joint
01382 Anesthesia for diagnostic arthroscopic procedures of knee
joint
01390 Anesthesia for all closed procedures on upper ends of tibia,

fibula, and/or patella
01392 Anesthesia for all open procedures on upper ends of tibia,
fibula, and/or patella
01400 Anesthesia for open or surgical arthroscopic procedures on
knee joint; not otherwise specified
01402 total knee arthroplasty

01404 disarticulation at knee

01420 Anesthesia for all cast applications, removal, or repair
involving knee joint
01430 Anesthesia for procedures on veins of knee and popliteal
area; not otherwise specified
01432 arteriovenous fistula
01440 Anesthesia for procedures on arteries of knee and popliteal
area; not otherwise specified
01442 popliteal thromboendarterectomy, with or without patch
graft
01444 popliteal excision and graft or repair for occlusion or
aneurysm
Lower Leg (Below Knee, Includes

Ankle and Foot)
01462 Anesthesia for all closed procedures on lower leg, ankle,
and foot
01464 Anesthesia for arthroscopic procedures of ankle and/or foot

01470 Anesthesia for procedures on nerves, muscles, tendons, and

fascia of lower leg, ankle, and foot; not otherwise specified
01472 repair of ruptured Achilles tendon, with or without graft
01474 gastrocnemius recession (eg, Strayer procedure)
01480 Anesthesia for open procedures on bones of lower leg,
ankle, and foot; not otherwise specified
01482 radical resection (including below knee amputation)
01484 osteotomy or osteoplasty of tibia and/or fibula

01486 total ankle replacement
01490 Anesthesia for lower leg cast application, removal, or
repair
01500 Anesthesia for procedures on arteries of lower leg,
including bypass graft; not otherwise specified
01502 embolectomy, direct or with catheter
01520 Anesthesia for procedures on veins of lower leg; not
otherwise specified
01522 venous thrombectomy, direct or with catheter
Shoulder and Axilla

Includes humeral head and neck, sternoclavicular joint,
acromioclavicular joint, and shoulder joint.
fascia, and bursae of shoulder and axilla
01620 Anesthesia for all closed procedures on humeral head and

neck, sternoclavicular joint, acromioclavicular joint, and
shoulder joint
01622 Anesthesia for diagnostic arthroscopic procedures of
shoulder joint
01630 Anesthesia for open or surgical arthroscopic procedures on

humeral head and neck, sternoclavicular joint,
acromioclavicular joint, and shoulder joint; not otherwise
specified
01634 shoulder disarticulation

01636 interthoracoscapular (forequarter) amputation
01638 total shoulder replacement
01650 Anesthesia for procedures on arteries of shoulder and axilla;
01652 axillary-brachial aneurysm
01654 bypass graft
01656 axillary-femoral bypass graft
01670 Anesthesia for all procedures on veins of shoulder and
axilla
01680 Anesthesia for shoulder cast application, removal or repair,
(01682 has been deleted)
Upper Arm and Elbow
01710 Anesthesia for procedures on nerves, muscles, tendons,
fascia, and bursae of upper arm and elbow; not otherwise
specified
01712 tenotomy, elbow to shoulder, open

01714 tenoplasty, elbow to shoulder
01716 tenodesis, rupture of long tendon of biceps
01730 Anesthesia for all closed procedures on humerus and elbow
01732 Anesthesia for diagnostic arthroscopic procedures of elbow
joint
01740 Anesthesia for open or surgical arthroscopic procedures of

the elbow; not otherwise specified
01742 osteotomy of humerus

01744 repair of nonunion or malunion of humerus
01756 radical procedures
01758 excision of cyst or tumor of humerus
01760 total elbow replacement
01770 Anesthesia for procedures on arteries of upper arm and
elbow; not otherwise specified
01772 embolectomy
01780 Anesthesia for procedures on veins of upper arm and elbow;
01782 phleborrhaphy
Forearm, Wrist, and Hand
fascia, and bursae of forearm, wrist, and hand
01820 Anesthesia for all closed procedures on radius, ulna, wrist,

or hand bones
01829 Anesthesia for diagnostic arthroscopic procedures on the
wrist
01830 Anesthesia for open or surgical arthroscopic/endoscopic

procedures on distal radius, distal ulna, wrist, or hand
joints; not otherwise specified
01832 total wrist replacement

01840 Anesthesia for procedures on arteries of forearm, wrist, and
hand; not otherwise specified
01842 embolectomy
01844 Anesthesia for vascular shunt, or shunt revision, any type
(eg, dialysis)
01850 Anesthesia for procedures on veins of forearm, wrist, and
hand; not otherwise specified
01852 phleborrhaphy
01860 Anesthesia for forearm, wrist, or hand cast application,
removal, or repair
Radiological Procedures
01916 Anesthesia for diagnostic arteriography/venography
➲ CPT Assistant Nov 07:8, Oct 11:3, Jul 12:13
(Do not report 01916 in conjunction with therapeutic codes
01924-01926, 01930-01933)
01920 Anesthesia for cardiac catheterization including coronary
angiography and ventriculography (not to include Swan-
Ganz catheter)
01922 Anesthesia for non-invasive imaging or radiation therapy
01924 Anesthesia for therapeutic interventional radiological
procedures involving the arterial system; not otherwise
specified
01925 carotid or coronary

01926 intracranial, intracardiac, or aortic

01930 Anesthesia for therapeutic interventional radiological

procedures involving the venous/lymphatic system (not to
include access to the central circulation); not otherwise
specified
01931 intrahepatic or portal circulation (eg, transvenous

intrahepatic portosystemic shunt[s] [TIPS])
➲ CPT Assistant Apr 08:3
01932 intrathoracic or jugular

01933 intracranial
01935 Anesthesia for percutaneous image guided procedures on the

spine and spinal cord; diagnostic
01936 therapeutic
Burn Excisions or Debridement

01951 Anesthesia for second- and third-degree burn excision or
debridement with or without skin grafting, any site, for total
body surface area (TBSA) treated during anesthesia and
surgery; less than 4% total body surface area
01952 between 4% and 9% of total body surface area

✚ 01953 each additional 9% total body surface area or part

thereof (List separately in addition to code for primary
procedure)
➲ CPT Assistant Jun 11:13, Jul 12:13
Obstetric
01958 Anesthesia for external cephalic version procedure
➲ CPT Assistant Jun 04:5-6, Oct 11:3, Jul 12:13
01960 Anesthesia for vaginal delivery only

01961 Anesthesia for cesarean delivery only
01962 Anesthesia for urgent hysterectomy following delivery

01963 Anesthesia for cesarean hysterectomy without any labor

analgesia/anesthesia care
01965 Anesthesia for incomplete or missed abortion procedures

01966 Anesthesia for induced abortion procedures

01967 Neuraxial labor analgesia/anesthesia for planned vaginal

delivery (this includes any repeat subarachnoid needle
placement and drug injection and/or any necessary
replacement of an epidural catheter during labor)
➲ CPT Assistant Dec 01:3, Oct 14:14
✚ 01968 Anesthesia for cesarean delivery following neuraxial labor

analgesia/anesthesia (List separately in addition to code for
primary procedure performed)
➲ CPT Assistant Dec 01:3, Jun 11:13, Oct 14:14

✚ 01969 Anesthesia for cesarean hysterectomy following neuraxial
labor analgesia/anesthesia (List separately in addition to
code for primary procedure performed)
➲ CPT Assistant Dec 01:3, Jun 11:13, Jul 12:13
Other Procedures
01990 Physiological support for harvesting of organ(s) from brain-
dead patient
01991 Anesthesia for diagnostic or therapeutic nerve blocks and

injections (when block or injection is performed by a
different physician or other qualified health care
professional); other than the prone position
01992 prone position

(Do not report 01991 or 01992 in conjunction with 99151,

99152, 99153, 99155, 99156, 99157)
(When regional intravenous administration of local
anesthetic agent or other medication in the upper or lower
extremity is used as the anesthetic for a surgical procedure,
report the appropriate anesthesia code. To report a Bier
block for pain management, use 64999)
(For intra-arterial or intravenous therapy for pain
management, see 96373, 96374)
01996 Daily hospital management of epidural or subarachnoid
continuous drug administration
➲ CPT Assistant Feb 97:5, Nov 97:10, May 99:6, Jul 12:5,
Oct 12:14, May 15:10
(Report code 01996 for daily hospital management of
continuous epidural or subarachnoid drug administration
performed after insertion of an epidural or subarachnoid
catheter)
01999 Unlisted anesthesia procedure(s)
➲ CPT Assistant Feb 97:4, Feb 06:9, Mar 06:15, Jan
07:30, Nov 07:8, Oct 11:3, Jul 12:13, Aug 14:6, 14, May
15:10, Dec 17:8, Oct 19:10
13:5, Summer 13:5, Winter 13:5, Spring 14:7, Winter
16:4
Notes

Surgery Guidelines
Services
Follow-Up Care for Diagnostic Procedures
Follow-Up Care for Therapeutic Surgical Procedures
Supplied Materials
Reporting More Than One Procedure/Service
Separate Procedure
Special Report
Imaging Guidance
Surgery Guidelines
Guidelines to direct general reporting of services are presented in
the Introduction. Some of the commonalities are repeated here
for the convenience of those referring to this section on Surgery.
Other definitions and items unique to Surgery are also listed.
Services
▶Services rendered in the office, home, or hospital,
consultations, and other medical services are listed in the
Evaluation and Management Services section (99202-99499)
beginning on page 18. “Special Services, Procedures, and
Reports” (99000-99082) are listed in the Medicine section.◀

By their very nature, the services to any patient are variable. The
CPT codes that represent a readily identifiable surgical procedure
thereby include, on a procedure-by-procedure basis, a variety of
services. In defining the specific services “included” in a given
CPT surgical code, the following services related to the surgery
when furnished by the physician or other qualified health care
professional who performs the surgery are included in addition
to the operation per se:
■ Evaluation and Management (E/M) service(s) subsequent to the
decision for surgery on the day before and/or day of surgery
(including history and physical)
■ Local infiltration, metacarpal/metatarsal/digital block or topical
anesthesia
■ Immediate postoperative care, including dictating operative
notes, talking with the family and other physicians or other
qualified health care professionals
■ Writing orders
■ Evaluating the patient in the postanesthesia recovery area
■ Typical postoperative follow-up care
Follow-Up Care for Diagnostic

Procedures
Follow-up care for diagnostic procedures (eg, endoscopy,
arthroscopy, injection procedures for radiography) includes only
that care related to recovery from the diagnostic procedure itself.
Care of the condition for which the diagnostic procedure was
performed or of other concomitant conditions is not included and
may be listed separately.
Follow-Up Care for Therapeutic

Surgical Procedures
Follow-up care for therapeutic surgical procedures includes only
that care which is usually a part of the surgical service.
Complications, exacerbations, recurrence, or the presence of
other diseases or injuries requiring additional services should be
separately reported.
Supplied Materials
Supplies and materials (eg, sterile trays/drugs), over and above
those usually included with the procedure(s) rendered are
reported separately. List drugs, trays, supplies, and materials
provided. Identify as 99070 or specific supply code.
Reporting More Than One

Procedure/Service
When more than one procedure/service is performed on the same
date, same session or during a post-operative period (subject to
the “surgical package” concept), several CPT modifiers may
apply (see Appendix A for definition).
Separate Procedure
Some of the procedures or services listed in the CPT codebook
that are commonly carried out as an integral component of a total
service or procedure have been identified by the inclusion of the
term “separate procedure.” The codes designated as “separate
procedure” should not be reported in addition to the code for the
total procedure or service of which it is considered an integral
component.
However, when a procedure or service that is designated as a
“separate procedure” is carried out independently or considered
to be unrelated or distinct from other procedures/services
provided at that time, it may be reported by itself, or in addition
to other procedures/services by appending modifier 59 to the
specific “separate procedure” code to indicate that the procedure
is not considered to be a component of another procedure, but is
a distinct, independent procedure. This may represent a different
session, different procedure or surgery, different site or organ
system, separate incision/excision, separate lesion, or separate
injury (or area of injury in extensive injuries).

the service, identifying it by “Special Report” as discussed in the
section below. The “Unlisted Procedures” and accompanying
codes for Surgery are as follows:
15999 Unlisted procedure, excision pressure ulcer
17999 Unlisted procedure, skin, mucous membrane and
subcutaneous tissue
19499 Unlisted procedure, breast
20999 Unlisted procedure, musculoskeletal system, general
21089 Unlisted maxillofacial prosthetic procedure
21299 Unlisted craniofacial and maxillofacial procedure
21499 Unlisted musculoskeletal procedure, head
21899 Unlisted procedure, neck or thorax
22899 Unlisted procedure, spine
22999 Unlisted procedure, abdomen, musculoskeletal system
23929 Unlisted procedure, shoulder
24999 Unlisted procedure, humerus or elbow
25999 Unlisted procedure, forearm or wrist
26989 Unlisted procedure, hands or fingers
27299 Unlisted procedure, pelvis or hip joint
27599 Unlisted procedure, femur or knee
27899 Unlisted procedure, leg or ankle
28899 Unlisted procedure, foot or toes
29799 Unlisted procedure, casting or strapping
29999 Unlisted procedure, arthroscopy
30999 Unlisted procedure, nose
31299 Unlisted procedure, accessory sinuses
31599 Unlisted procedure, larynx
31899 Unlisted procedure, trachea, bronchi
32999 Unlisted procedure, lungs and pleura
33999 Unlisted procedure, cardiac surgery
36299 Unlisted procedure, vascular injection
37501 Unlisted vascular endoscopy procedure
37799 Unlisted procedure, vascular surgery
38129 Unlisted laparoscopy procedure, spleen
38589 Unlisted laparoscopy procedure, lymphatic system
38999 Unlisted procedure, hemic or lymphatic system
39499 Unlisted procedure, mediastinum
39599 Unlisted procedure, diaphragm
40799 Unlisted procedure, lips
40899 Unlisted procedure, vestibule of mouth
41599 Unlisted procedure, tongue, floor of mouth
41899 Unlisted procedure, dentoalveolar structures
42299 Unlisted procedure, palate, uvula
42699 Unlisted procedure, salivary glands or ducts
42999 Unlisted procedure, pharynx, adenoids, or tonsils
43289 Unlisted laparoscopy procedure, esophagus
43499 Unlisted procedure, esophagus
43659 Unlisted laparoscopy procedure, stomach
43999 Unlisted procedure, stomach
44238 Unlisted laparoscopy procedure, intestine (except rectum)
44799 Unlisted procedure, small intestine
44899 Unlisted procedure, Meckel’s diverticulum and the
mesentery
44979 Unlisted laparoscopy procedure, appendix
45399 Unlisted procedure, colon
45499 Unlisted laparoscopy procedure, rectum
45999 Unlisted procedure, rectum
46999 Unlisted procedure, anus
47379 Unlisted laparoscopic procedure, liver
47399 Unlisted procedure, liver
47579 Unlisted laparoscopy procedure, biliary tract
47999 Unlisted procedure, biliary tract
48999 Unlisted procedure, pancreas
49329 Unlisted laparoscopy procedure, abdomen, peritoneum and
omentum
49659 Unlisted laparoscopy procedure, hernioplasty,
herniorrhaphy, herniotomy
49999 Unlisted procedure, abdomen, peritoneum and omentum
50549 Unlisted laparoscopy procedure, renal
50949 Unlisted laparoscopy procedure, ureter
51999 Unlisted laparoscopy procedure, bladder
53899 Unlisted procedure, urinary system
54699 Unlisted laparoscopy procedure, testis
55559 Unlisted laparoscopy procedure, spermatic cord
55899 Unlisted procedure, male genital system
58578 Unlisted laparoscopy procedure, uterus
58579 Unlisted hysteroscopy procedure, uterus
58679 Unlisted laparoscopy procedure, oviduct, ovary
58999 Unlisted procedure, female genital system (nonobstetrical)
59897 Unlisted fetal invasive procedure, including ultrasound
guidance, when performed
59898 Unlisted laparoscopy procedure, maternity care and
delivery
59899 Unlisted procedure, maternity care and delivery
60659 Unlisted laparoscopy procedure, endocrine system
60699 Unlisted procedure, endocrine system
64999 Unlisted procedure, nervous system
66999 Unlisted procedure, anterior segment of eye
67299 Unlisted procedure, posterior segment
67399 Unlisted procedure, extraocular muscle
67599 Unlisted procedure, orbit
67999 Unlisted procedure, eyelids
68399 Unlisted procedure, conjunctiva
68899 Unlisted procedure, lacrimal system
69399 Unlisted procedure, external ear
69799 Unlisted procedure, middle ear
69949 Unlisted procedure, inner ear
69979 Unlisted procedure, temporal bone, middle fossa approach
Special Report
for the procedure, and the time, effort, and equipment necessary
Imaging Guidance
When imaging guidance or imaging supervision and
interpretation is included in a surgical procedure, guidelines for
image documentation and report, included in the guidelines for
Radiology (Including Nuclear Medicine and Diagnostic
Ultrasound), will apply. Imaging guidance should not be reported
for use of a nonimaging-guided tracking or localizing system (eg,
radar signals, electromagnetic signals). Imaging guidance should
only be reported when an imaging modality (eg, radiography,
fluoroscopy, ultrasonography, magnetic resonance imaging,
computed tomography, or nuclear medicine) is used and is
appropriately documented.
Surgical destruction is a part of a surgical procedure and different
methods of destruction are not ordinarily listed separately unless
the technique substantially alters the standard management of a
problem or condition. Exceptions under special circumstances are
provided for by separate code numbers.

Surgery
The following is a listing of headings and subheadings that appear within the
Integumentary System section of the CPT codebook. The subheadings or
subsections denoted with asterisks (*) below have special instructions
unique to that subsection. Where these are indicated, special notes or
guidelines will be presented preceding those procedural terminology listings,
referring to that subsection specifically.
General (10004-10021)
Fine Needle Aspiration (FNA) Biopsy* (10004-10021)
Integumentary System (10030-19499)
Skin, Subcutaneous, and Accessory Structures (10030-
11646)
Introduction and Removal (10030-10036)
Incision and Drainage (10040-10180)
Debridement* (11000-11047)
Paring or Cutting (11055-11057)
Biopsy* (11102-11107)
Removal of Skin Tags* (11200-11201)
Shaving of Epidermal or Dermal Lesions* (11300-11313)
Excision—Benign Lesions* (11400-11471)
Excision—Malignant Lesions* (11600-11646)
Nails (11719-11765)
Pilonidal Cyst (11770-11772)
Introduction (11900-11983)
Structure of Skin
Repair (Closure)* (12001-16036)
Repair—Simple* (12001-12021)
Repair—Intermediate* (12031-12057)
Repair—Complex* (13100-13160)
Adjacent Tissue Transfer or Rearrangement* (14000-14350)
Skin Replacement Surgery* (15002-15278)
Definitions*
Surgical Preparation (15002-15278)
Autografts/Tissue Cultured Autograft (15040-15261)
Skin Substitute Grafts* (15271-15278)
Flaps (Skin and/or Deep Tissues)* (15570-15738)
Other Flaps and Grafts* (15740-15777)
Pressure Ulcers (Decubitus Ulcers) (15920-15999)
Burns, Local Treatment* (16000-16036)
Destruction* (17000-17999)
Destruction, Benign or Premalignant Lesions (17000-17250)
Destruction, Malignant Lesions, Any Method (17260-17286)
Mohs Micrographic Surgery* (17311-17315)
Breast (19000-19499)
Introduction* (19281-19298)
Mastectomy Procedures* (19300-19307)
Repair and/or Reconstruction* (19316-19396)
Other Procedures (19499)
Surgery
General
Fine Needle Aspiration (FNA) Biopsy
A fine needle aspiration (FNA) biopsy is performed when
material is aspirated with a fine needle and the cells are examined
cytologically. A core needle biopsy is typically performed with a
larger bore needle to obtain a core sample of tissue for
histopathologic evaluation. FNA biopsy procedures are
performed with or without imaging guidance. Imaging guidance
codes (eg, 76942, 77002, 77012, 77021) may not be reported
separately with 10004, 10005, 10006, 10007, 10008, 10009, 10010,
10011, 10012, 10021. Codes 10004, 10005, 10006, 10007, 10008,
10009, 10010, 10011, 10012, 10021 are reported once per lesion
sampled in a single session. When more than one FNA biopsy is
performed on separate lesions at the same session, same day,
same imaging modality, use the appropriate imaging modality
add-on code for the second and subsequent lesion(s). When
more than one FNA biopsy is performed on separate lesions,
same session, same day, using different imaging modalities,
report the corresponding primary code with modifier 59 for each
additional imaging modality and corresponding add-on codes for
subsequent lesions sampled. This instruction applies regardless
of whether the lesions are ipsilateral or contralateral to each
other, and/or whether they are in the same or different
organs/structures. When FNA biopsy and core needle biopsy
both are performed on the same lesion, same session, same day
using the same type of imaging guidance, do not separately report
the imaging guidance for the core needle biopsy. When FNA
biopsy is performed on one lesion and core needle biopsy is
performed on a separate lesion, same session, same day using the
same type of imaging guidance, both the core needle biopsy and
the imaging guidance for the core needle biopsy may be reported
separately with modifier 59. When FNA biopsy is performed on
one lesion and core needle biopsy is performed on a separate
lesion, same session, same day using different types of imaging
guidance, both the core needle biopsy and the imaging guidance
for the core needle biopsy may be reported with modifier 59.
10021 Fine needle aspiration biopsy, without imaging guidance;
first lesion
➲ CPT Assistant Aug 02:10, Mar 05:11, Apr 19:4, May
19:10
➲ Clinical Examples in Radiology Fall 08:4, Fall 10:3, 8,
Spring 14:3, Winter 17:4
10007, 10008, 10009, 10010, 10011, 10012)
#✚ 10004 each additional lesion (List separately in addition to
➲ CPT Assistant Feb 19:8, Apr 19:4

10006, 10007, 10008, 10009, 10010, 10011, 10012 for the
same lesion)
(For evaluation of fine needle aspirate, see 88172, 88173,
88177)
# 10005 Fine needle aspiration biopsy, including ultrasound
guidance; first lesion
➲ CPT Assistant Feb 19:8, Apr 19:4, May 19:10
➲ Clinical Examples in Radiology Winter 19:2, Summer
19:10

(Do not report 10005, 10006 in conjunction with 76942)
88177)
# 10007 Fine needle aspiration biopsy, including fluoroscopic
guidance; first lesion

88177)
# 10009 Fine needle aspiration biopsy, including CT guidance; first
lesion


88177)
# 10011 Fine needle aspiration biopsy, including MR guidance; first
lesion


88177)
▶ (For percutaneous needle biopsy other than fine needle
aspiration, see 19081-19086 for breast, 20206 for muscle,
32400 for pleura, 32408 for lung or mediastinum, 42400 for
salivary gland, 47000 for liver, 48102 for pancreas, 49180
for abdominal or retroperitoneal mass, 50200 for kidney,
54500 for testis, 54800 for epididymis, 60100 for thyroid,
62267 for nucleus pulposus, intervertebral disc, or
paravertebral tissue, 62269 for spinal cord)◀
(For percutaneous image-guided fluid collection drainage by
catheter of soft tissue [eg, extremity, abdominal wall, neck],
use 10030)
Skin, Subcutaneous, and Accessory
Structures
Introduction and Removal
10030 Image-guided fluid collection drainage by catheter (eg,
abscess, hematoma, seroma, lymphocele, cyst), soft tissue
(eg, extremity, abdominal wall, neck), percutaneous
➲ CPT Assistant Fall 13:6, May 14:3, 9, Aug 17:9
15:8, Winter 16:10, Fall 18:15
(Report 10030 for each individual collection drained with a
separate catheter)
77002, 77003, 77012, 77021)
(For image-guided fluid collection drainage, percutaneous
or transvaginal/transrectal of visceral, peritoneal, or
retroperitoneal collections, see 49405-49407)
Soft tissue-marker placement with imaging guidance is reported
with 10035 and 10036. If a more specific site descriptor than soft
tissue is applicable (eg, breast), use the site-specific codes for
marker placement at that site. Report 10035 and 10036 only once
per target, regardless of how many markers (eg, clips, wires,
pellets, radioactive seeds) are used to mark that target.
10035 Placement of soft tissue localization device(s) (eg, clip,
metallic pellet, wire/needle, radioactive seeds),
percutaneous, including imaging guidance; first lesion
19:10
✚ 10036 each additional lesion (List separately in addition to
➲ Clinical Examples in Radiology Winter 16:5,
Summer 19:10
77002, 77012, 77021)
(To report a second procedure on the same side or
contralateral side, use 10036)
Incision and Drainage

(For excision, see 11400, et seq)
10040 Acne surgery (eg, marsupialization, opening or removal of
multiple milia, comedones, cysts, pustules)
➲ CPT Assistant Fall 92:10, Feb 08:8
10060 Incision and drainage of abscess (eg, carbuncle, suppurative

hidradenitis, cutaneous or subcutaneous abscess, cyst,
furuncle, or paronychia); simple or single
10061 complicated or multiple

10080 Incision and drainage of pilonidal cyst; simple

➲ CPT Assistant Fall 92:13, Dec 06:15, May 07:5
10081 complicated
➲ CPT Assistant Fall 92:13, Dec 06:15, May 07:5
(For excision of pilonidal cyst, see 11770-11772)

10120 Incision and removal of foreign body, subcutaneous tissues;
simple
➲ CPT Assistant Sep 12:10, Apr 13:10, Dec 13:16
10121 complicated
➲ CPT Assistant Spring 91:7, Dec 06:15, Sep 12:10,
Dec 13:16
(To report wound exploration due to penetrating trauma
without laparotomy or thoracotomy, see 20100-20103, as
appropriate)
(To report debridement associated with open fracture(s)
and/or dislocation(s), use 11010-11012, as appropriate)
10140 Incision and drainage of hematoma, seroma or fluid
collection
10160 Puncture aspiration of abscess, hematoma, bulla, or cyst

➲ CPT Assistant Aug 17:9
➲ Clinical Examples in Radiology Fall 09:8, Summer
14:9, Spring 15:8, Winter 16:10
(If imaging guidance is performed, see 76942, 77002,
77012, 77021)
10180 Incision and drainage, complex, postoperative wound
infection
(For secondary closure of surgical wound, see 12020,

12021, 13160)
Debridement
Wound debridements (11042-11047) are reported by depth of
tissue that is removed and by surface area of the wound. These
services may be reported for injuries, infections, wounds and
chronic ulcers. When performing debridement of a single wound,
report depth using the deepest level of tissue removed. In
multiple wounds, sum the surface area of those wounds that are
at the same depth, but do not combine sums from different
depths. For example: When bone is debrided from a 4 sq cm heel
ulcer and from a 10 sq cm ischial ulcer, report the work with a
single code, 11044. When subcutaneous tissue is debrided from a
16 sq cm dehisced abdominal wound and a 10 sq cm thigh
wound, report the work with 11042 for the first 20 sq cm and
11045 for the second 6 sq cm. If all four wounds were debrided
on the same day, use modifier 59 with either 11042, or 11044 as
appropriate.
(For dermabrasions, see 15780-15783)
(For nail debridement, see 11720-11721)
(For burn(s), see 16000-16035)
(For pressure ulcers, see 15920-15999)
Coding Tip
Use of Depth and Surface Area For Reporting Debridement of Wounds
When performing debridement of a single wound, report depth using the

deepest level of tissue removed. In multiple wounds, sum the surface area of
those wounds that are at the same depth, but do not combine sums from
different depths.
CPT Coding Guidelines, Debridement
11000 Debridement of extensive eczematous or infected skin; up to

10% of body surface
➲ CPT Assistant May 99:10, Oct 12:3, Feb 18:10
(For abdominal wall or genitalia debridement for

necrotizing soft tissue infection, see 11004-11006)
✚ 11001 each additional 10% of the body surface, or part thereof
(List separately in addition to code for primary
procedure)
➲ CPT Assistant May 99:10, Oct 12:3, Feb 18:10
11004 Debridement of skin, subcutaneous tissue, muscle and fascia
for necrotizing soft tissue infection; external genitalia and
perineum
➲ CPT Assistant Jan 12:6, Oct 12:3, Oct 13:15, Feb 18:10,
Nov 19:14
11005 abdominal wall, with or without fascial closure
➲ CPT Assistant Jan 12:6, Oct 12:3, Oct 13:15, Feb
18:10, Nov 19:14
Debridement of Abdominal Wall

11005
11006 external genitalia, perineum and abdominal wall, with or
without fascial closure
➲ CPT Assistant Jan 12:6, Oct 12:3, Oct 13:15, Nov
19:14
(If orchiectomy is performed, use 54520)
(If testicular transplantation is performed, use 54680)
✚ 11008 Removal of prosthetic material or mesh, abdominal wall for
infection (eg, for chronic or recurrent mesh infection or
necrotizing soft tissue infection) (List separately in addition
to code for primary procedure)
➲ CPT Assistant Jan 12:6, Oct 12:3
(Use 11008 in conjunction with 10180, 11004-11006)

(Report skin grafts or flaps separately when performed for
closure at the same session as 11004-11008)
(When insertion of mesh is used for closure, use 49568)
11010 Debridement including removal of foreign material at the
site of an open fracture and/or an open dislocation (eg,
excisional debridement); skin and subcutaneous tissues
➲ CPT Assistant Mar 97:2, Apr 97:10, Aug 97:6, Oct
03:10, May 11:3, Oct 12:13
11011 skin, subcutaneous tissue, muscle fascia, and muscle
➲ CPT Assistant Mar 97:2, Apr 97:10, Aug 97:6, May
11:3, Oct 12:13
11012 skin, subcutaneous tissue, muscle fascia, muscle, and
bone
➲ CPT Assistant Mar 97:2, Apr 97:10, Aug 97:6, Oct
03:10, May 11:3, Oct 12:13
(For debridement of skin [ie, epidermis and/or dermis only],
see 97597, 97598)
(For active wound care management, see 97597, 97598)
(For debridement of burn wounds, see 16020-16030)
11042 Debridement, subcutaneous tissue (includes epidermis and
dermis, if performed); first 20 sq cm or less
CPT Assistant Winter 92:10, May 96:6, Feb 97:7, Aug
➲
97:6, Jun 05:1, 10, Oct 07:15, Nov 10:9, May 11:3, Sep
11:11, Jan 12:6, Mar 12:3, Oct 12:13, Feb 13:16, Sep
13:17, Oct 13:15, Nov 14:5, Feb 16:14, Aug 16:9, Oct
16:3
(For debridement of skin [ie, epidermis and/or dermis only],
see 97597, 97598)
#✚ 11045 each additional 20 sq cm, or part thereof (List separately
in addition to code for primary procedure)
➲ CPT Assistant May 11:3, Sep 11:11, Jan 12:6, Mar
12:3, Oct 12:13, Nov 14:5, Aug 16:9, Oct 16:3
11043 Debridement, muscle and/or fascia (includes epidermis,
dermis, and subcutaneous tissue, if performed); first 20 sq
cm or less
➲ CPT Assistant May 96:6, Feb 97:7, Apr 97:11, Aug
97:6, Dec 99:10, Jun 05:1, 10, Oct 07:15, Nov 10:9,
May 11:3, Sep 11:11, Jan 12:6, Mar 12:3, Oct 12:13,
Feb 13:16, Nov 14:5, Aug 16:9, Oct 16:3, Mar 20:14
#✚ 11046 each additional 20 sq cm, or part thereof (List separately
12:3, Oct 12:13, Feb 13:16, Nov 14:5, Aug 16:9, Oct
16:3
11044 Debridement, bone (includes epidermis, dermis,
subcutaneous tissue, muscle and/or fascia, if performed);
first 20 sq cm or less
➲ CPT Assistant Fall 93:21, Mar 96:10, May 96:6, Feb
97:7, Apr 97:11, Aug 97:6, Jun 05:1, 10, Oct 07:15, Nov
10:9, May 11:3, Sep 11:11, Jan 12:6, Mar 12:3, Oct
12:13, Feb 13:16, Nov 14:5, Aug 16:9, Oct 16:3
✚ 11047 each additional 20 sq cm, or part thereof (List separately
12:3, Oct 12:13, Nov 14:5, Aug 16:9, Oct 16:3
(Do not report 11042-11047 in conjunction with 97597-
97602 for the same wound)
Paring or Cutting
(To report destruction of benign lesions other than skin tags
or cutaneous vascular proliferative lesions, see 17110,
17111)
11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or
callus); single lesion
➲ CPT Assistant Nov 97:11, Jan 99:11
11056 2 to 4 lesions
➲ CPT Assistant Nov 97:11, Jan 99:11, Sep 10:9
11057 more than 4 lesions

➲ CPT Assistant Nov 97:11, Jan 99:11, May 99:10
Biopsy
The use of a biopsy procedure code (eg, 11102, 11103, 11104,
11105, 11106, 11107) indicates that the procedure to obtain tissue
solely for diagnostic histopathologic examination was performed
independently, or was unrelated or distinct from other
procedures/services provided at that time. Biopsies performed on
different lesions or different sites on the same date of service
may be reported separately, as they are not considered
components of other procedures.
During certain surgical procedures in the integumentary system,
such as excision, destruction, or shave removals, the removed
tissue is often submitted for pathologic examination. The
obtaining of tissue for pathology during the course of these
procedures is a routine component of such procedures. This
obtaining of tissue is not considered a separate biopsy procedure
and is not separately reported.
Partial-thickness biopsies are those that sample a portion of the
thickness of skin or mucous membrane and do not penetrate
below the dermis or lamina propria. Full-thickness biopsies
penetrate into tissue deep to the dermis or lamina propria, into
the subcutaneous or submucosal space.
Sampling of stratum corneum only, by any modality (eg, skin
scraping, tape stripping) does not constitute a skin biopsy
procedure and is not separately reportable.
An appropriate biopsy technique is selected based on optimal
tissue-sampling considerations for the type of neoplastic,
inflammatory, or other lesion requiring a tissue diagnosis. Biopsy
of the skin is reported under three distinct techniques:
Tangential biopsy (eg, shave, scoop, saucerize, curette) is
performed with a sharp blade, such as a flexible biopsy blade,
obliquely oriented scalpel or curette to remove a sample of
epidermal tissue with or without portions of underlying dermis.
The intent of a tangential biopsy (11102, 11103) is to obtain a
tissue sample from a lesion for the purpose of diagnostic
pathologic examination. Biopsy of lesions by tangential technique
(11102, 11103) is not considered an excision. Tangential biopsy
technique may be represented by a superficial sample and does
not involve the full thickness of the dermis, which could result in
portions of the lesion remaining in the deeper layers of the
dermis.
For therapeutic removal of epidermal or dermal lesion(s) using
shave technique, see 11300-11313.
An indication for a shave removal (11300-11313) procedure may
include a symptomatic lesion that rubs on waistband or bra, or
any other reason why an elevated lesion is being completely
removed with the shave technique, suggesting a therapeutic
intent. It is the responsibility of the physician or qualified health
care professional performing the procedure to clearly indicate the
purpose of the procedure.
Punch biopsy requires a punch tool to remove a full-thickness
cylindrical sample of skin. The intent of a punch biopsy (11104,
11105) is to obtain a cylindrical tissue sample of a cutaneous
lesion for the purpose of diagnostic pathologic examination.
Simple closure of the defect is included in the service.
Manipulation of the biopsy defect to improve wound
approximation is included in simple closure.
Incisional biopsy requires the use of a sharp blade (not a punch
tool) to remove a full-thickness sample of tissue via a vertical
incision or wedge, penetrating deep to the dermis, into the
subcutaneous space. The intent of an incisional biopsy (11106,
11107) is to obtain a full-thickness tissue sample of a skin lesion
for the purpose of diagnostic pathologic examination. This type
of biopsy may sample subcutaneous fat, such as those performed
for the evaluation of panniculitis. Although closure is usually
performed on incisional biopsies, simple closure is not separately
reported.
(For complete lesion excision with margins, see 11400-11646)
When multiple biopsy techniques are performed during the same
encounter, only one primary lesion biopsy code (11102, 11104,
11106) is reported. Additional biopsy codes should be selected
based on the following convention:
If multiple biopsies of the same type are performed, the primary
code for that biopsy should be used along with the corresponding
add-on code(s).
If an incisional biopsy is performed, report 11106 in combination
with a tangential (11103), punch (11105), or incisional biopsy
(11107) for the additional biopsy procedures.
If a punch biopsy is performed, report 11104 in combination with
a tangential (11103), or punch (11105), for the additional biopsy
procedures.
If multiple tangential biopsies are performed, report tangential
biopsy (11102) in combination with 11103 for the additional
tangential biopsy procedures.
When two or more biopsies of the same technique (ie, tangential,
punch, or incisional) are performed on separate/additional
lesions, use the appropriate add-on code (11103, 11105, 11107) to
specify each additional biopsy. When two or three different
biopsy techniques (ie, tangential, punch, or incisional) are
performed to sample separate/additional lesions, select the
appropriate biopsy code (11102, 11104, 11106) plus an additional
add-on code (11103, 11105, 11107) for each additional biopsy
performed.
The following table provides an illustration of the appropriate
use of these codes for multiple biopsies:
Procedures Performed CPT Code(s) Reported

2 tangential biopsies 11102 X 1, 11103 X 1
3 punch biopsies 11104 X 1, 11105 X 2
2 incisional biopsies 11106 X 1, 11107 X 1
1 incisional biopsy, 1 tangential biopsy and 1 11106 X 1, 11103 X 1,
punch biopsy 11105 X 1
1 punch biopsy and 2 tangential biopsies 11104 X 1, 11103 X 2
(For biopsy of nail unit, use 11755)

(For biopsy, intranasal, use 30100)
(For biopsy of lip, use 40490)
(For biopsy of vestibule of mouth, use 40808)
(For biopsy of tongue, anterior two-thirds, use 41100)
(For biopsy of floor of mouth, use 41108)
(For biopsy of penis, use 54100)
(For biopsy of vulva or perineum, see 56605, 56606)
(For biopsy of eyelid skin including lid margin, use 67810)
(For biopsy of conjunctiva, use 68100)
(For biopsy of ear, use 69100)
11106)
11107)
11102 Tangential biopsy of skin (eg, shave, scoop, saucerize,
curette); single lesion
➲ CPT Assistant Jan 19:9, Dec 19:9
✚ 11103 each separate/additional lesion (List separately in

(Report 11103 in conjunction with 11102, 11104, 11106,

when different biopsy techniques are performed to sample
separate/additional lesions for each type of biopsy
technique used)
11104 Punch biopsy of skin (including simple closure, when
performed); single lesion

(Report 11105 in conjunction with 11104, 11106, when

different biopsy techniques are performed to sample
separate/additional lesions for each type of biopsy
technique used)
Tangential Biopsy of Skin

11102, 11103
Tangential biopsy of skin shown with scalpel blade.
Punch Biopsy of Skin

11104, 11105
Punch biopsy of skin shown with punch device.
11106 Incisional biopsy of skin (eg, wedge) (including simple
closure, when performed); single lesion

Incisional Biopsy of Skin

11106, 11107
Incisional biopsy of skin shown with scalpel.
Removal of Skin Tags
Removal by scissoring or any sharp method, ligature
strangulation, electrosurgical destruction or combination of
treatment modalities, including chemical destruction or
electrocauterization of wound, with or without local anesthesia.
11200 Removal of skin tags, multiple fibrocutaneous tags, any area;
up to and including 15 lesions
➲ CPT Assistant Winter 90:3, Nov 97:11-12, Nov 02:11,
Aug 09:7, Jun 11:13
✚ 11201 each additional 10 lesions, or part thereof (List
separately in addition to code for primary procedure)
➲ CPT Assistant Winter 90:3, Nov 97:11-12, Nov
02:11, Jun 11:13
Removal of Skin Tags

11200,11201
Shaving of Epidermal or Dermal Lesions
Shaving is the sharp removal by transverse incision or horizontal
slicing to remove epidermal and dermal lesions without a full-
thickness dermal excision. This includes local anesthesia,
chemical or electrocauterization of the wound. The wound does
not require suture closure.
11300 Shaving of epidermal or dermal lesion, single lesion, trunk,
arms or legs; lesion diameter 0.5 cm or less
➲ CPT Assistant Feb 00:11, Nov 02:11, Feb 08:1, Dec
17:14, Feb 18:10, Jan 19:9
11301 lesion diameter 0.6 to 1.0 cm
➲ CPT Assistant Feb 00:11, Feb 08:1, Dec 17:14, Feb
18:10, Jan 19:9
18:10, Jan 19:9
11303 lesion diameter over 2.0 cm
18:10, Jan 19:9
11305 Shaving of epidermal or dermal lesion, single lesion, scalp,
neck, hands, feet, genitalia; lesion diameter 0.5 cm or less
18:10, Jan 19:9
18:10, Jan 19:9
Shaving of Epidermal and Dermal Lesion

11300-11313
Shaving of epidermal and dermal lesion with flexible blade and entire lesion removed.
18:10, Jan 19:9
18:10, Jan 19:9
11310 Shaving of epidermal or dermal lesion, single lesion, face,
ears, eyelids, nose, lips, mucous membrane; lesion diameter
0.5 cm or less
➲ CPT Assistant Feb 00:11, Feb 08:1, Feb 13:16, Mar
13:6, Dec 17:14, Feb 18:10, Jan 19:9
➲
CPT Assistant Feb 00:11, Feb 08:1, Feb 13:16, Mar
13:6, Feb 18:10, Jan 19:9
13:6, Feb 18:10, Jan 19:9
13:6, Feb 18:10, Jan 19:9
Measuring and Coding the Removal of a Lesion

Measuring lesion removal.
A. Example: Excision, malignant lesion of the back, 1.0 cm. Code 11606.
B. Example: Excision of benign lesion of the neck, 1.0 cm by 2.0 cm. Code 11423.
C. Example: Excision, malignant lesion of the nose, 0.9 cm. Code 11642.
Excision—Benign Lesions
Excision (including simple closure) of benign lesions of skin (eg,
neoplasm, cicatricial, fibrous, inflammatory, congenital, cystic
lesions), includes local anesthesia. See appropriate size and area
below. For shave removal, see 11300 et seq, and for
electrosurgical and other methods see 17000 et seq.
Excision is defined as full-thickness (through the dermis)
removal of a lesion, including margins, and includes simple
(non-layered) closure when performed. Report separately each
benign lesion excised. Code selection is determined by measuring
the greatest clinical diameter of the apparent lesion plus that
margin required for complete excision (lesion diameter plus the
most narrow margins required equals the excised diameter). The
margins refer to the most narrow margin required to adequately
excise the lesion, based on individual judgment. The
measurement of lesion plus margin is made prior to excision. The
excised diameter is the same whether the surgical defect is
repaired in a linear fashion, or reconstructed (eg, with a skin
graft).
The closure of defects created by incision, excision, or trauma
may require intermediate or complex closure. Repair by
intermediate or complex closure should be reported separately.
For excision of benign lesions requiring more than simple
closure, ie, requiring intermediate or complex closure, report
11400-11446 in addition to appropriate intermediate (12031-
12057) or complex closure (13100-13153) codes. For
reconstructive closure, see 15002-15261, 15570-15770. For
excision performed in conjunction with adjacent tissue transfer,
report only the adjacent tissue transfer code (14000-14302).
Excision of lesion (11400-11446) is not separately reportable with
adjacent tissue transfer. See page 102 for the definition of
intermediate or complex closure.
(For destruction [eg, laser surgery, electrosurgery,
cryosurgery, chemosurgery, surgical curette] of benign
lesions other than skin tags or cutaneous vascular
proliferative lesions, see 17110, 17111; premalignant
lesions, see 17000, 17003, 17004; cutaneous vascular
proliferative lesions, see 17106, 17107, 17108; malignant
lesions, see 17260-17286)
(For excision of cicatricial lesion[s] [eg, full thickness
excision, through the dermis], see 11400-11446)
(For incisional removal of burn scar, see 16035, 16036)
(For fractional ablative laser fenestration for functional
improvement of traumatic or burn scars, see 0479T, 0480T)
11400 Excision, benign lesion including margins, except skin tag
(unless listed elsewhere), trunk, arms or legs; excised
diameter 0.5 cm or less
➲ CPT Assistant Summer 92:22, Fall 93:7, Fall 95:3, May
96:11, Aug 00:5, Nov 02:5, 7, Aug 06:10, Jul 08:5, Apr
10:3, Jul 10:10, Jan 11:9, May 12:13, Mar 14:4, 12, Apr
14:10, Apr 16:3, Feb 18:10, Sep 18:7, Nov 19:3
Excision of Lesion
11400 and 11600 series
11401 excised diameter 0.6 to 1.0 cm
➲ CPT Assistant Summer 92:22, Fall 93:7, Fall 95:3,
May 96:11, Nov 02:5, 7, Jul 10:10, Jan 11:9, May
12:13, Mar 14:4, 12, Apr 16:3, Feb 18:10, Sep 18:7,
Nov 19:3
12:13, Mar 14:4, 12, Apr 16:3, Feb 18:10, Sep 18:7,
Nov 19:3
12:13, Mar 14:4, 12, Apr 16:3, Feb 18:10, Sep 18:7,
Nov 19:3
12:13, Mar 14:4, 12, Apr 16:3, Feb 18:10, Sep 18:7,
Nov 19:3
11406 excised diameter over 4.0 cm
12:13, Mar 14:4, 12, Apr 14:10, Apr 16:3, Feb
18:10, Sep 18:7, Nov 19:3
(For unusual or complicated excision, add modifier 22)
11420 Excision, benign lesion including margins, except skin tag
(unless listed elsewhere), scalp, neck, hands, feet, genitalia;
excised diameter 0.5 cm or less
➲ CPT Assistant Summer 92:22, Fall 95:3, Jul 08:5, Jul
10:10, May 12:13, Jan 13:15, Mar 14:4, 12, Apr 16:3,
Feb 18:10, Sep 18:7, Nov 19:3
➲ CPT Assistant Summer 92:22, Fall 95:3, May 96:11,
Jul 10:10, May 12:13, Jan 13:15, Mar 14:4, 12, Apr
16:3, Feb 18:10, Sep 18:7, Nov 19:3
Aug 00:5, Jul 10:10, Mar 12:4, May 12:13, Jan
13:15, Mar 14:4, 12, Apr 16:3, Feb 18:10, Sep 18:7,
Nov 19:3
16:3, Feb 18:10, Sep 18:7, Nov 19:3
16:3, Feb 18:10, Sep 18:7, Nov 19:3
16:3, Feb 18:10, Sep 18:7, Nov 19:3
11440 Excision, other benign lesion including margins, except skin
tag (unless listed elsewhere), face, ears, eyelids, nose, lips,
mucous membrane; excised diameter 0.5 cm or less
➲ CPT Assistant Summer 92:22, Fall 95:3, May 96:11, Jul
08:5, Jul 10:10, May 12:13, Mar 14:4, 12, Apr 16:3, Feb
18:10, Sep 18:7, Nov 19:3
CPT Assistant Summer 92:22, Fall 95:3, May 96:11,
➲
Jul 10:10, May 12:13, Mar 14:4, 12, Apr 16:3, Feb
18:10, Sep 18:7, Nov 19:3
Aug 00:5, Jun 08:14, Jul 10:10, May 12:13, Mar
14:4, 12, Apr 16:3, Feb 18:10, Sep 18:7, Nov 19:3
18:10, Sep 18:7, Nov 19:3
18:10, Sep 18:7, Nov 19:3
Aug 06:10, Jul 08:5, Apr 10:3, Jul 10:10, May 12:13,
Mar 14:4, 12, Apr 16:3, Feb 18:10, Sep 18:7, Nov
19:3
(For eyelids involving more than skin, see also 67800 et
seq)
11450 Excision of skin and subcutaneous tissue for hidradenitis,
axillary; with simple or intermediate repair
➲ CPT Assistant May 12:13, Aug 16:9, Feb 18:10, Sep
18:7
11451 with complex repair
18:7
inguinal; with simple or intermediate repair
18:7
18:7
perianal, perineal, or umbilical; with simple or intermediate
repair
➲ CPT Assistant May 12:13, Aug 16:9, Feb 18:10

18:7
(When skin graft or flap is used for closure, use appropriate
procedure code in addition)
(For bilateral procedure, add modifier 50)
Excision—Malignant Lesions
Excision (including simple closure) of malignant lesions of skin
(eg, basal cell carcinoma, squamous cell carcinoma, melanoma)
includes local anesthesia. (See appropriate size and body area
below.) For destruction of malignant lesions of skin, see
destruction codes 17260-17286.
Excision is defined as full-thickness (through the dermis)
removal of a lesion including margins, and includes simple (non-
layered) closure when performed. Report separately each
malignant lesion excised. Code selection is determined by
measuring the greatest clinical diameter of the apparent lesion
plus that margin required for complete excision (lesion diameter
plus the most narrow margins required equals the excised
diameter). The margins refer to the most narrow margin required
to adequately excise the lesion, based on the physician’s
judgment. The measurement of lesion plus margin is made prior
to excision. The excised diameter is the same whether the surgical
defect is repaired in a linear fashion, or reconstructed (eg, with a
skin graft).
The closure of defects created by incision, excision, or trauma
may require intermediate or complex closure. Repair by
intermediate or complex closure should be reported separately.
For excision of malignant lesions requiring more than simple
closure, ie, requiring intermediate or complex closure, report
11600-11646 in addition to appropriate intermediate (12031-
12057) or complex closure (13100-13153) codes. For
reconstructive closure, see 15002-15261, 15570-15770. For
excision performed in conjunction with adjacent tissue transfer,
report only the adjacent tissue transfer code (14000-14302).
Excision of lesion (11600-11646) is not separately reportable with
adjacent tissue transfer. See page 102 for the definition of
intermediate or complex closure.
When frozen section pathology shows the margins of excision
were not adequate, an additional excision may be necessary for
complete tumor removal. Use only one code to report the
additional excision and re-excision(s) based on the final widest
excised diameter required for complete tumor removal at the
same operative session. To report a re-excision procedure
performed to widen margins at a subsequent operative session,
see codes 11600-11646, as appropriate. Append modifier 58 if the
re-excision procedure is performed during the postoperative
period of the primary excision procedure.
11600 Excision, malignant lesion including margins, trunk, arms, or
legs; excised diameter 0.5 cm or less
➲ CPT Assistant Fall 95:3, May 96:11, Nov 02:5, Oct
04:4, Feb 08:8, Feb 10:3, Apr 10:3, May 12:13, Jul
12:12, Mar 14:4, 12, Sep 18:7, Nov 19:3
Measuring and Coding the Removal of a Lesion

11600
Example: Excision, malignant lesion, 0.4 cm. Code 11600.

➲ CPT Assistant Fall 95:3, May 96:11, Nov 02:5, Feb
10:3, Mar 12:7, May 12:13, Jul 12:12, Mar 14:4, 12,
Sep 18:7, Nov 19:3
08:8, Feb 10:3, Apr 10:3, Mar 12:4, May 12:13, Jul
12:12, Mar 14:4, 12, Sep 18:7, Nov 19:3
08:8, Feb 10:3, May 12:13, Jul 12:12, Mar 14:4, 12,
Sep 18:7, Nov 19:3
08:8, Feb 10:3, May 12:13, Jul 12:12, Mar 14:4, 12,
Sep 18:7, Nov 19:3
➲ CPT Assistant Fall 91:6, Fall 95:3, May 96:11, Nov
02:5, Feb 08:8, Feb 10:3, May 12:13, Jul 12:12, Mar
14:4, 12, Sep 18:7, Nov 19:3
11620 Excision, malignant lesion including margins, scalp, neck,
hands, feet, genitalia; excised diameter 0.5 cm or less
➲ CPT Assistant Fall 95:3, Nov 02:5, Oct 04:4, Feb 08:8,
Feb 10:3, May 12:13, Jul 12:12, Mar 14:4, 12, Sep 18:7,
Nov 19:3
CPT Assistant Fall 95:3, May 96:11, Nov 02:5, Feb
➲
08:8, Feb 10:3, May 12:13, Mar 14:4, 12, Sep 18:7,
Nov 19:3
08:8, Feb 10:3, May 12:13, Mar 14:4, 12, Sep 18:7,
Nov 19:3
08:8, Feb 10:3, May 12:13, Mar 14:4, 12, Sep 18:7,
Nov 19:3
08:8, Feb 10:3, May 12:13, Mar 14:4, 12, Sep 18:7,
Nov 19:3
08:8, Feb 10:3, May 12:13, Mar 14:4, 12, Sep 18:7,
Nov 19:3
11640 Excision, malignant lesion including margins, face, ears,
eyelids, nose, lips; excised diameter 0.5 cm or less
➲ CPT Assistant Fall 95:3, May 96:11, Nov 02:5, Oct
04:4, Feb 08:8, Feb 10:3, May 12:13, Mar 14:4, 12, Sep
18:7, Nov 19:3
CPT Assistant Fall 95:3, May 96:11, Feb 08:8, Feb
➲
10:3, May 12:13, Mar 14:4, 12, Sep 18:7, Nov 19:3
➲ CPT Assistant Fall 95:3, May 96:11, Feb 08:8, Feb
10:3, May 12:13, Mar 14:4, 12, Sep 18:7, Nov 19:3
10:3, May 12:13, Mar 14:4, 12, Sep 18:7, Nov 19:3
10:3, May 12:13, Mar 14:4, 12, Sep 18:7, Nov 19:3
10:3, Apr 10:3, May 12:13, Mar 14:4, 12, Sep 18:7,
Nov 19:3
(For eyelids involving more than skin, see also 67800 et
seq)
Nails
(For drainage of paronychia or onychia, see 10060, 10061)
11719 Trimming of nondystrophic nails, any number
➲ CPT Assistant Nov 97:12, Dec 02:4
Lateral Nail View

11719-11765
11720 Debridement of nail(s) by any method(s); 1 to 5
11721 6 or more
11730 Avulsion of nail plate, partial or complete, simple; single

➲ CPT Assistant Mar 96:10, Dec 02:4, Dec 03:11
✚ 11732 each additional nail plate (List separately in addition to


11740 Evacuation of subungual hematoma
11750 Excision of nail and nail matrix, partial or complete (eg,

ingrown or deformed nail), for permanent removal
(For pinch graft, use 15050)

11755 Biopsy of nail unit (eg, plate, bed, matrix, hyponychium,
proximal and lateral nail folds) (separate procedure)
➲ CPT Assistant Mar 96:11, Dec 02:4, Oct 04:14
11760 Repair of nail bed
11762 Reconstruction of nail bed with graft

11765 Wedge excision of skin of nail fold (eg, for ingrown toenail)
Dorsal Nail View

11719-11765
Pilonidal Cyst
11770 Excision of pilonidal cyst or sinus; simple
11771 extensive
11772 complicated
(For incision of pilonidal cyst, see 10080, 10081)
Introduction
11900 Injection, intralesional; up to and including 7 lesions
➲ CPT Assistant Sep 96:5, May 98:10, Nov 99:8, Feb
00:11, Sep 04:12, Nov 13:14
11901 more than 7 lesions
➲ CPT Assistant Sep 96:5, May 98:10, Nov 99:8, Feb
00:11, Sep 04:12
(11900, 11901 are not to be used for preoperative local
anesthetic injection)
(For veins, see 36470, 36471)
(For intralesional chemotherapy administration, see 96405,
96406)
11920 Tattooing, intradermal introduction of insoluble opaque
pigments to correct color defects of skin, including
micropigmentation; 6.0 sq cm or less
11921 6.1 to 20.0 sq cm

✚ 11922 each additional 20.0 sq cm, or part thereof (List


11950 Subcutaneous injection of filling material (eg, collagen); 1
cc or less
➲ CPT Assistant Jun 12:15, Aug 19:10
11951 1.1 to 5.0 cc

11952 5.1 to 10.0 cc

11954 over 10.0 cc

11960 Insertion of tissue expander(s) for other than breast,
including subsequent expansion
➲ CPT Assistant Winter 91:2

29848, 64702-64726)◀
▶ (Forinsertion of tissue expander in breast reconstruction,
use 19357)◀
▲ 11970 Replacement of tissue expander with permanent implant
➲ CPT Assistant Aug 05:1, Jan 13:15
▲ 11971 Removal of tissue expander without insertion of implant

▶ (Do not report 11971 in conjunction with 11960, 11970)◀

▶ (For removal of breast-tissue expander and replacement
with breast implant, use 11970)◀
11976 Removal, implantable contraceptive capsules
11980 Subcutaneous hormone pellet implantation (implantation of
estradiol and/or testosterone pellets beneath the skin)
11981 Insertion, non-biodegradable drug delivery implant

➲ CPT Assistant Apr 11:12, Mar 20:14
(For manual preparation and insertion of deep [eg, sub-

fascial], intramedullary, or intra-articular drug-delivery
device, see 20700, 20702, 20704)
20704)
11982 Removal, non-biodegradable drug delivery implant
(For removal of deep [eg, subfascial], intramedullary, or

intra-articular drug-delivery device, see 20701, 20703,
20705)
20705)
11983 Removal with reinsertion, non-biodegradable drug delivery
implant
Repair (Closure)
Use the codes in this section to designate wound closure utilizing
sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either
singly or in combination with each other, or in combination with
adhesive strips. Wound closure utilizing adhesive strips as the
sole repair material should be coded using the appropriate E/M
code.
Definitions
The repair of wounds may be classified as Simple, Intermediate,
or Complex.
Simple repair is used when the wound is superficial; eg,
involving primarily epidermis or dermis, or subcutaneous tissues
without significant involvement of deeper structures, and
requires simple one layer closure. This includes local anesthesia
and chemical or electrocauterization of wounds not closed.
Intermediate repair includes the repair of wounds that, in
addition to the above, require layered closure of one or more of
the deeper layers of subcutaneous tissue and superficial (non-
muscle) fascia, in addition to the skin (epidermal and dermal)
closure. It includes limited undermining (defined as a distance
less than the maximum width of the defect, measured
perpendicular to the closure line, along at least one entire edge of
the defect). Single-layer closure of heavily contaminated wounds
that have required extensive cleaning or removal of particulate
matter also constitutes intermediate repair.
Complex repair includes the repair of wounds that, in addition to
the requirements for intermediate repair, require at least one of
the following: exposure of bone, cartilage, tendon, or named
neurovascular structure; debridement of wound edges (eg,
traumatic lacerations or avulsions); extensive undermining
(defined as a distance greater than or equal to the maximum
width of the defect, measured perpendicular to the closure line
along at least one entire edge of the defect); involvement of free
margins of helical rim, vermilion border, or nostril rim;
placement of retention sutures. Necessary preparation includes
creation of a limited defect for repairs or the debridement of
complicated lacerations or avulsions. Complex repair does not
include excision of benign (11400-11446) or malignant (11600-
11646) lesions, excisional preparation of a wound bed (15002-
15005) or debridement of an open fracture or open dislocation.
Extensive Undermining
Instructions for listing services at time of wound repair:
1. The repaired wound(s) should be measured and recorded in
centimeters, whether curved, angular, or stellate.
2. When multiple wounds are repaired, add together the lengths
of those in the same classification (see above) and from all
anatomic sites that are grouped together into the same code
descriptor. For example, add together the lengths of
intermediate repairs to the trunk and extremities. Do not add
lengths of repairs from different groupings of anatomic sites
(eg, face and extremities). Also, do not add together lengths of
different classifications (eg, intermediate and complex repairs).
When more than one classification of wounds is repaired, list the
more complicated as the primary procedure and the less
complicated as the secondary procedure, using modifier 59.
3. Decontamination and/or debridement: Debridement is
considered a separate procedure only when gross
contamination requires prolonged cleansing, when appreciable
amounts of devitalized or contaminated tissue are removed, or
when debridement is carried out separately without immediate
primary closure.
(For extensive debridement of soft tissue and/or bone, not
associated with open fracture(s) and/or dislocation(s)
resulting from penetrating and/or blunt trauma, see 11042-
11047.)
(For extensive debridement of subcutaneous tissue, muscle
fascia, muscle, and/or bone associated with open fracture(s)
and/or dislocation(s), see 11010-11012.)
4. Involvement of nerves, blood vessels and tendons: Report
under appropriate system (Nervous, Cardiovascular,
Musculoskeletal) for repair of these structures. The repair of
these associated wounds is included in the primary procedure
unless it qualifies as a complex repair, in which case modifier
59 applies.
Simple ligation of vessels in an open wound is considered as part
of any wound closure.
Simple “exploration” of nerves, blood vessels or tendons
exposed in an open wound is also considered part of the essential
treatment of the wound and is not a separate procedure unless
appreciable dissection is required. If the wound requires
enlargement, extension of dissection (to determine penetration),
debridement, removal of foreign body(s), ligation or coagulation
of minor subcutaneous and/or muscular blood vessel(s) of the
subcutaneous tissue, muscle fascia, and/or muscle, not requiring
thoracotomy or laparotomy, use codes 20100-20103, as
appropriate.
Repair—Simple
Sum of lengths of repairs for each group of anatomic sites.
12001 Simple repair of superficial wounds of scalp, neck, axillae,
external genitalia, trunk and/or extremities (including hands
and feet); 2.5 cm or less
➲ CPT Assistant Jun 96:7, Feb 98:11, Jan 00:11, Feb
00:10, Apr 00:8, Jul 00:10, Jan 02:10, Feb 07:10, Feb
08:8, Mar 12:5, Dec 17:15, Sep 18:7
12002 2.6 cm to 7.5 cm
➲ CPT Assistant Feb 00:10, Jan 02:10, Feb 08:8, Oct
14:14, Sep 18:7
12004 7.6 cm to 12.5 cm
➲ CPT Assistant Feb 00:10, Jan 02:10, Feb 08:8, Sep
18:7
12005 12.6 cm to 20.0 cm
18:7
12006 20.1 cm to 30.0 cm
➲ CPT Assistant Feb 98:11, Feb 00:10, Jan 02:10, Feb
08:8, Sep 18:7
12007 over 30.0 cm
18:7
12011 Simple repair of superficial wounds of face, ears, eyelids,
nose, lips and/or mucous membranes; 2.5 cm or less
➲ CPT Assistant Feb 00:10, May 00:8, Jan 02:10, Feb
08:8, May 14:5, Sep 18:7
12013 2.6 cm to 5.0 cm
18:7
12014 5.1 cm to 7.5 cm
CPT Assistant Feb 00:10, Jan 02:10, Feb 08:8, Sep
➲
18:7
12015 7.6 cm to 12.5 cm
18:7
12016 12.6 cm to 20.0 cm
18:7
12017 20.1 cm to 30.0 cm
18:7
12018 over 30.0 cm
➲ CPT Assistant Feb 00:10, Jan 02:10, Feb 07:10, Feb
08:8, May 14:5, Sep 18:7
12020 Treatment of superficial wound dehiscence; simple closure
➲ CPT Assistant Feb 00:10, Jan 02:10, Feb 08:8
12021 with packing

➲ CPT Assistant Feb 00:10, Jan 02:10, Feb 08:8
(For extensive or complicated secondary wound closure,

use 13160)
Repair—Intermediate
12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or
extremities (excluding hands and feet); 2.5 cm or less
➲ CPT Assistant Sep 97:11, Feb 00:10, Apr 00:8, Jan
02:10, Aug 06:1, Feb 07:10, Apr 10:3, Sep 18:7
12032 2.6 cm to 7.5 cm
➲ CPT Assistant May 96:6, Jun 96:8, Feb 00:10, Jan
02:10, Feb 07:10, Sep 18:7
12034 7.6 cm to 12.5 cm
➲ CPT Assistant Fall 91:6, Feb 00:10, Jan 02:10, Feb
07:10, Sep 18:7
12035 12.6 cm to 20.0 cm
18:7
12036 20.1 cm to 30.0 cm
18:7
12037 over 30.0 cm
18:7
12041 Repair, intermediate, wounds of neck, hands, feet and/or
external genitalia; 2.5 cm or less
02:10, Feb 07:10, Jan 13:15, Sep 18:7
12042 2.6 cm to 7.5 cm
➲ CPT Assistant Feb 00:10, Apr 00:9, Jan 02:10, Feb
07:10, Jan 13:15, Sep 18:7
12044 7.6 cm to 12.5 cm
CPT Assistant Feb 00:10, Jan 02:10, Feb 07:10, Jan
➲ 13:15, Sep 18:7
12045 12.6 cm to 20.0 cm
➲ CPT Assistant Feb 00:10, Jan 02:10, Feb 07:10, Jan
13:15, Sep 18:7
12046 20.1 cm to 30.0 cm
13:15, Sep 18:7
12047 over 30.0 cm
13:15, Sep 18:7
12051 Repair, intermediate, wounds of face, ears, eyelids, nose,
lips and/or mucous membranes; 2.5 cm or less
02:10, Feb 07:10, May 14:5, Sep 18:7
12052 2.6 cm to 5.0 cm
➲ CPT Assistant Feb 00:10, Aug 00:9, Jan 02:10, Feb
07:10, Jul 08:5, Sep 18:7
12053 5.1 cm to 7.5 cm
18:7
12054 7.6 cm to 12.5 cm
18:7
12055 12.6 cm to 20.0 cm
18:7
12056 20.1 cm to 30.0 cm
18:7
12057 over 30.0 cm
➲ CPT Assistant Feb 00:10, Jan 02:10, Feb 07:10, Apr
10:3, May 14:5, Sep 18:7
Repair—Complex
Reconstructive procedures, complicated wound closure.
(For full thickness repair of lip or eyelid, see respective
anatomical subsections)
13100 Repair, complex, trunk; 1.1 cm to 2.5 cm
➲ CPT Assistant Sep 97:11, Dec 98:5, Nov 99:9-10, Feb
00:10, Apr 00:8, Feb 10:3, Apr 10:3, May 11:4, Jan
12:8, Dec 12:6, Apr 17:9, Sep 18:7, Nov 19:14
(For 1.0 cm or less, see simple or intermediate repairs)
13101 2.6 cm to 7.5 cm
➲ CPT Assistant Dec 98:5, Nov 99:9-10, Feb 00:10,
Apr 00:9, Feb 10:3, May 11:4, Jan 12:8, Dec 12:6,
Apr 17:9, Sep 18:7, Dec 19:14
✚ 13102 each additional 5 cm or less (List separately in addition
➲ CPT Assistant Nov 99:9-10, Feb 00:10, Apr 00:9,
Feb 10:3, May 11:4, Jan 12:8, Dec 12:6, Apr 17:9,
Sep 18:7, Nov 19:14
13120 Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm
➲ CPT Assistant Sep 97:11, Apr 99:11, Nov 99:9-10, Feb
00:10, Apr 00:8, Feb 10:3, May 11:4, Jan 12:8, Dec
12:6, Sep 18:7
13121 2.6 cm to 7.5 cm
➲ CPT Assistant Dec 98:5, Nov 99:9-10, Feb 00:10,
Feb 10:3, Apr 10:3, May 11:4, Jan 12:8, Dec 12:6,
Sep 18:7
➲ CPT Assistant Nov 99:10, Feb 10:3, May 11:4, Jan
12:8, Dec 12:6, Sep 18:7
13131 Repair, complex, forehead, cheeks, chin, mouth, neck,
axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm
➲ CPT Assistant Fall 93:7, Sep 97:11, Dec 98:5, Nov
99:10, Feb 00:10, Apr 00:8, Feb 10:3, May 11:4, Jan
12:8, Dec 12:6, Jan 13:15, Apr 17:9, Sep 18:7
13132 2.6 cm to 7.5 cm
➲ CPT Assistant Fall 93:7, Dec 98:5, Nov 99:10, Dec
99:10, Feb 00:10, Apr 00:9, Aug 00:9, Feb 10:3,
May 11:4, Jan 12:8, Dec 12:6, Jan 13:15, Oct 14:14,
Apr 17:9, Sep 18:7
➲ CPT Assistant Fall 93:7, Feb 00:10, Apr 00:9, Feb
10:3, May 11:4, Jan 12:8, Dec 12:6, Jan 13:15, Apr
17:9, Sep 18:7
13151 Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to
2.5 cm
➲ CPT Assistant Dec 98:5, Nov 99:10, Feb 00:10, Feb
10:3, May 11:4, Jan 12:8, Dec 12:6, Mar 14:12, May
14:3, 5, Sep 18:7
13152 2.6 cm to 7.5 cm
➲ CPT Assistant Dec 98:5, Nov 99:10, Feb 00:10, Feb
10:3, May 11:4, Jan 12:8, Dec 12:6, May 14:3, Oct
14:14, Sep 18:7
➲ CPT Assistant Nov 99:10, Feb 00:10, Feb 10:3, Apr
10:3, May 11:4, Jan 12:8, Dec 12:6, May 14:3, 5,
Sep 18:7
13160 Secondary closure of surgical wound or dehiscence,
extensive or complicated
➲ CPT Assistant Sep 97:11, Dec 98:5, Apr 00:8, May
11:4, Dec 12:6
▶ (Do not report 13160 in conjunction with 11960)◀
(For packing or simple secondary wound closure, see
12020, 12021)
Adjacent Tissue Transfer or Rearrangement

For full thickness repair of lip or eyelid, see respective
anatomical subsections.
Codes 14000-14302 are used for excision (including lesion)
and/or repair by adjacent tissue transfer or rearrangement (eg, Z-
plasty, W-plasty, V-Y plasty, rotation flap, random island flap,
advancement flap). When applied in repairing lacerations, the
procedures listed must be performed by the surgeon to
accomplish the repair. They do not apply to direct closure or
rearrangement of traumatic wounds incidentally resulting in these
configurations. Undermining alone of adjacent tissues to achieve
closure, without additional incisions, does not constitute adjacent
tissue transfer, see complex repair codes 13100-13160. The
excision of a benign lesion (11400-11446) or a malignant lesion
(11600-11646) is not separately reportable with codes 14000-
14302.
Skin graft necessary to close secondary defect is considered an
additional procedure. For purposes of code selection, the term
“defect” includes the primary and secondary defects. The primary
defect resulting from the excision and the secondary defect
resulting from flap design to perform the reconstruction are
measured together to determine the code.
14000 Adjacent tissue transfer or rearrangement, trunk; defect 10
sq cm or less
➲ CPT Assistant Sep 96:11, Jul 99:3, Jul 00:10, Jan 06:47,
Dec 06:15, Jul 08:5, Mar 10:4, Apr 10:3, Jan 12:8, May
12:13, Nov 12:13, Dec 12:6, Apr 14:10, Feb 15:10, Sep
15:12, Oct 17:9
14001 defect 10.1 sq cm to 30.0 sq cm
➲ CPT Assistant Aug 96:8, Jul 99:3, Jan 06:47, Dec
06:15, Jul 08:5, Mar 10:4, Jan 12:8, May 12:13, Nov
12:13, Dec 12:6, Apr 14:10, Feb 15:10, Oct 17:9
14020 Adjacent tissue transfer or rearrangement, scalp, arms
and/or legs; defect 10 sq cm or less
➲ CPT Assistant Jul 99:3, Jan 06:47, Dec 06:15, Jul 08:5,
Mar 10:4, Jan 12:8, May 12:13, Nov 12:13, Dec 12:6
➲ CPT Assistant Jul 99:3, Jan 06:47, Dec 06:15, Jul
08:5, Mar 10:4, Jan 12:8, May 12:13, Nov 12:13,
Dec 12:6
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks,
chin, mouth, neck, axillae, genitalia, hands and/or feet;
defect 10 sq cm or less
➲ CPT Assistant Jul 99:3, Jul 00:10, Jan 06:47, Dec 06:15,
Jul 08:5, Mar 10:4, Jan 12:8, May 12:13, Nov 12:13,
Dec 12:6
08:5, Mar 10:4, Jan 12:8, May 12:13, Nov 12:13,
Dec 12:6
14060 Adjacent tissue transfer or rearrangement, eyelids, nose,
ears and/or lips; defect 10 sq cm or less
➲ CPT Assistant Fall 93:7, Jul 99:3, Jan 06:47, Dec 06:15,
Jul 08:5, Mar 10:4, Jan 12:8, May 12:13, Aug 12:13,
Nov 12:13, Dec 12:6, Mar 20:14
08:5, Mar 10:4, Jan 12:8, May 12:13, Nov 12:13,
Dec 12:6
(For eyelid, full thickness, see 67961 et seq)
14301 Adjacent tissue transfer or rearrangement, any area; defect
30.1 sq cm to 60.0 sq cm
➲ CPT Assistant May 12:13, Nov 12:13, Dec 12:6, Apr
17:9
✚ 14302 each additional 30.0 sq cm, or part thereof (List
➲ CPT Assistant May 12:13, Nov 12:13, Dec 12:6

14350 Filleted finger or toe flap, including preparation of recipient
site
➲ CPT Assistant Jan 06:47, Jul 08:5, Mar 10:4, May
12:13, Dec 12:6
Skin Replacement Surgery

Skin replacement surgery consists of surgical preparation and
topical placement of an autograft (including tissue cultured
autograft) or skin substitute graft (ie, homograft, allograft,
xenograft). The graft is anchored using the individual’s choice of
fixation. When services are performed in the office, routine
dressing supplies are not reported separately.
The following definition should be applied to those codes that
reference “100 sq cm or 1% of body area of infants and children”
when determining the involvement of body size: The
measurement of 100 sq cm is applicable to adults and children 10
years of age and older; and percentages of body surface area
apply to infants and children younger than 10 years of age. The
measurements apply to the size of the recipient area.
Procedures involving wrist and/or ankle are reported with codes
that include arm or leg in the descriptor.
When a primary procedure requires a skin substitute or skin
autograft for definitive skin closure (eg, orbitectomy, radical
mastectomy, deep tumor removal), use 15100-15278 in
conjunction with primary procedure.
For biological implant for soft tissue reinforcement, use 15777 in
conjunction with primary procedure.
The supply of skin substitute graft(s) should be reported
separately in conjunction with 15271-15278.
Definitions
Surgical preparation codes 15002-15005 for skin replacement

surgery describe the initial services related to preparing a clean
and viable wound surface for placement of an autograft, flap,
skin substitute graft or for negative pressure wound therapy. In
some cases, closure may be possible using adjacent tissue transfer
(14000-14061) or complex repair (13100-13153). In all cases,
appreciable nonviable tissue is removed to treat a burn, traumatic
wound or a necrotizing infection. The clean wound bed may also
be created by incisional release of a scar contracture resulting in a
surface defect from separation of tissues. The intent is to heal the
wound by primary intention, or by the use of negative pressure
wound therapy. Patient conditions may require the closure or
application of graft, flap, or skin substitute to be delayed, but in
all cases the intent is to include these treatments or negative
pressure wound therapy to heal the wound. Do not report 15002-
15005 for removal of nonviable tissue/debris in a chronic wound
(eg, venous or diabetic) when the wound is left to heal by
secondary intention. See active wound management codes
(97597, 97598) and debridement codes (11042-11047) for this
service. For necrotizing soft tissue infections in specific anatomic
locations, see 11004-11008.
Adjacent Tissue Repairs

14000-14061
Repair of primary and secondary defects requires assignment of a code based upon the location and the
approximate description (as demonstrated below) of the area required.
A. Advancement Flap
B. Rotation Flap
Select the appropriate code from 15002-15005 based upon
location and size of the resultant defect. For multiple wounds,
sum the surface area of all wounds from all anatomic sites that
are grouped together into the same code descriptor. For example,
sum the surface area of all wounds on the trunk and arms. Do
not sum wounds from different groupings of anatomic sites (eg,
face and arms). Use 15002 or 15004, as appropriate, for excisions
and incisional releases resulting in wounds up to and including
100 sq cm of surface area. Use 15003 or 15005 for each
additional 100 sq cm or part thereof. For example: Surgical
preparation of a 20 sq cm wound on the right hand and a 15 sq
cm wound on the left hand would be reported with a single code,
15004. Surgical preparation of a 75 sq cm wound on the right
thigh and a 75 sq cm wound on the left thigh would be reported
with 15002 for the first 100 sq cm and 15003 for the second 50 sq
cm. If all four wounds required surgical preparation on the same
day, use modifier 59 with 15002, and 15004.
Autografts/tissue cultured autografts include the harvest and/or
application of an autologous skin graft. Repair of donor site
requiring skin graft or local flaps is reported separately. Removal
of current graft and/or simple cleansing of the wound is included,
when performed. Do not report 97602. Debridement is
considered a separate procedure only when gross contamination
requires prolonged cleansing, when appreciable amounts of
devitalized or contaminated tissue are removed, or when
debridement is carried out separately without immediate primary
closure.
Select the appropriate code from 15040-15261 based upon type
of autograft and location and size of the defect. The
measurements apply to the size of the recipient area. For multiple
wounds, sum the surface area of all wounds from all anatomic
sites that are grouped together into the same code descriptor. For
example, sum the surface area of all wounds on the trunk and
arms. Do not sum wounds from different groupings of anatomic
sites (eg, face and arms).
Skin substitute grafts include non-autologous human skin
(dermal or epidermal, cellular and acellular) grafts (eg,
homograft, allograft), non-human skin substitute grafts (ie,
xenograft), and biological products that form a sheet scaffolding
for skin growth. These codes are not to be reported for
application of non-graft wound dressings (eg, gel, powder,
ointment, foam, liquid) or injected skin substitutes. Application
of non-graft wound dressings is not separately reportable.
Removal of current graft and/or simple cleansing of the wound is
included, when performed. Do not report 97602. Debridement is
considered a separate procedure only when gross contamination
requires prolonged cleansing, when appreciable amounts of
devitalized or contaminated tissue are removed, or when
debridement is carried out separately without immediate primary
closure.
Select the appropriate code from 15271-15278 based upon
location and size of the defect. For multiple wounds, sum the
surface area of all wounds from all anatomic sites that are
grouped together into the same code descriptor. For example,
sum the surface area of all wounds on the trunk and arms. Do
not sum wounds from different groupings of anatomic sites (eg,
face and arms). The supply of skin substitute graft(s) should be
reported separately in conjunction with 15271, 15272, 15273,
15274, 15275, 15276, 15277, 15278. For biologic implant for soft
tissue reinforcement, use 15777 in conjunction with code for
primary procedure.
Surgical Preparation
15002 Surgical preparation or creation of recipient site by excision
of open wounds, burn eschar, or scar (including
subcutaneous tissues), or incisional release of scar
contracture, trunk, arms, legs; first 100 sq cm or 1% of body
area of infants and children
➲ CPT Assistant Jan 12:6, Oct 12:13, Dec 12:6, Feb
13:16, Mar 14:12, Oct 16:3, Nov 19:3
(For linear scar revision, see 13100-13153)
✚ 15003 each additional 100 sq cm, or part thereof, or each
additional 1% of body area of infants and children (List
➲ CPT Assistant Jan 12:6, Oct 12:13, Feb 13:16, Mar
14:12, Oct 16:3, Nov 19:3
15004 Surgical preparation or creation of recipient site by excision
of open wounds, burn eschar, or scar (including
subcutaneous tissues), or incisional release of scar
contracture, face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet and/or multiple digits; first 100 sq cm
or 1% of body area of infants and children
14:12, Oct 16:3, Nov 19:3
✚ 15005 each additional 100 sq cm, or part thereof, or each
additional 1% of body area of infants and children (List
14:12, Oct 16:3, Nov 19:3
Autografts/Tissue Cultured Autograft
15040 Harvest of skin for tissue cultured skin autograft, 100 sq cm or less
➲ CPT Assistant Aug 06:10, Oct 06:1, Feb 08:3, Apr 10:3, Jan 12:6
15050 Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area
(except on face), up to defect size 2 cm diameter
➲ CPT Assistant Apr 97:4, Sep 97:2, Nov 98:6, Jan 12:6, Jun 16:8
15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of
infants and children (except 15050)
➲ CPT Assistant Fall 93:7, Apr 97:4, Aug 97:6, Sep 97:3, Nov 98:6, Sep 02:3, Oct 06:1,
Feb 08:3, Mar 11:9, Jan 12:6, Oct 12:3, Jun 16:8
✚ 15101 each additional 100 sq cm, or each additional 1% of body area of infants and children,
or part thereof (List separately in addition to code for primary procedure)
➲ CPT Assistant Apr 97:4, Nov 98:6, Sep 02:3, Feb 08:3, Mar 11:9, Jan 12:6, Oct
12:3, Jun 16:8
15110 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of
infants and children
➲ CPT Assistant Feb 08:3, Mar 11:9, Jan 12:6, Oct 12:3

15115 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet,
and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands,
feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and
children (except 15050)
➲ CPT Assistant Apr 97:4, Aug 97:6, Sep 97:3, Nov 98:6, Jan 99:4, Sep 02:3, Feb 08:3,
Jul 08:5, Mar 11:9, Jan 12:6, Oct 12:3, Jun 16:8
➲ CPT Assistant Apr 97:4, Aug 97:6, Sep 97:3, Nov 98:6, Jan 99:4, Sep 02:3, Feb
08:3, Mar 11:9, Jan 12:6, Oct 12:3, Jun 16:8
(For eyelids, see also 67961-67975)
15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants
and children

15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet,
and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children
➲ CPT Assistant Mar 11:9, Jan 12:6, Oct 12:3

15150 Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less
➲ CPT Assistant Oct 06:1, Feb 08:3, Mar 11:9, Jan 12:6, Oct 12:3
✚ 15151 additional 1 sq cm to 75 sq cm (List separately in addition to code for primary

procedure)
(Do not report 15151 more than once per session)


15155 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia,
hands, feet, and/or multiple digits; first 25 sq cm or less
✚ 15156 additional 1 sq cm to 75 sq cm (List separately in addition to code for primary

procedure)

➲ CPT Assistant Oct 06:1, Feb 08:3, Apr 10:3, Mar 11:9, Jan 12:6, Oct 12:3

15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less
➲ CPT Assistant Aug 96:11, Aug 97:6, Sep 97:3, Feb 08:3, Mar 08:14, Jan 12:6, Oct
12:3, Jun 16:8
✚ 15201 each additional 20 sq cm, or part thereof (List separately in addition to code for
primary procedure)
➲ CPT Assistant Apr 97:4, Aug 97:6, Sep 97:3, Feb 08:3, Mar 08:14, Jan 12:6, Oct
12:3, Jun 16:8
15220 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs;
20 sq cm or less
➲ CPT Assistant Apr 97:4, Aug 97:6, Sep 97:3, Aug 98:9, Feb 08:3, Mar 08:14, Jan
12:6, Oct 12:3, Jun 16:8
primary procedure)
➲ CPT Assistant Apr 97:4, Aug 97:6, Sep 97:3, Aug 98:9, Feb 08:3, Mar 08:14, Jan
12:6, Oct 12:3, Jun 16:8
15240 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin,
mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less
➲ CPT Assistant Apr 97:4, Aug 97:6, Sep 97:3, Nov 00:10, Feb 08:3, Mar 08:14, Jan
12:6, Oct 12:3, Jun 16:8
(For fingertip graft, use 15050)
(For repair of syndactyly, fingers, see 26560-26562)
primary procedure)
➲ CPT Assistant Apr 97:4, Aug 97:6, Sep 97:3, Feb 08:3, Mar 08:14, Jan 12:6, Oct
12:3, Jun 16:8
15260 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or
lips; 20 sq cm or less
➲ CPT Assistant Fall 91:7, Fall 93:7, Apr 97:4, Aug 97:6, Sep 97:3, Jul 99:3, Feb 08:3,
Mar 08:14, Jan 12:6, Oct 12:3, Jun 16:8
primary procedure)
➲ CPT Assistant Fall 91:7, Apr 97:4, Aug 97:6, Sep 97:3, Feb 08:3, Mar 08:14, Apr
10:3, Jan 12:6, Oct 12:3, Jun 16:8
(For eyelids, see also 67961-67975)
(Repair of donor site requiring skin graft or local flaps is considered a separate
procedure)
Skin Substitute Grafts
The supply of skin substitute graft(s) should be reported separately in conjunction with
15271-15278. For biologic implant for soft tissue reinforcement, use 15777 in conjunction
with code for primary procedure.
15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100
sq cm; first 25 sq cm or less wound surface area
➲ CPT Assistant Jan 12:6, Oct 12:3, Jun 14:14, Oct 17:9
✚ 15272 each additional 25 sq cm wound surface area, or part thereof (List separately in
➲ CPT Assistant Jan 12:6, Oct 12:3, Oct 13:15, Jun 14:14

(For total wound surface area greater than or equal to 100 sq cm, see 15273, 15274)
(Do not report 15271, 15272 in conjunction with 15273, 15274)
15273 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater
than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of
infants and children
➲ CPT Assistant Jan 12:6, Oct 12:3, Oct 13:15, Nov 13:14, Jun 14:14
✚ 15274 each additional 100 sq cm wound surface area, or part thereof, or each additional 1%
of body area of infants and children, or part thereof (List separately in addition to code
for primary procedure)

(For total wound surface area up to 100 sq cm, see 15271, 15272)
15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first
25 sq cm or less wound surface area
✚ 15276 each additional 25 sq cm wound surface area, or part thereof (List separately in

(For total wound surface area greater than or equal to 100 sq cm, see 15277, 15278)
15277 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal
to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and
children
✚ 15278 each additional 100 sq cm wound surface area, or part thereof, or each additional 1%
of body area of infants and children, or part thereof (List separately in addition to code

(For total wound surface area up to 100 sq cm, see 15275, 15276)
(Do not report 15271-15278 in conjunction with 97602)
Flaps (Skin and/or Deep Tissues)

The regions listed refer to the recipient area (not the donor site) when a flap is being
attached in a transfer or to a final site.
The regions listed refer to a donor site when a tube is formed for later transfer or when a
“delay” of flap occurs prior to the transfer. Codes 15733-15738 are described by donor site
of the muscle, myocutaneous, or fasciocutaneous flap.
Codes 15570-15738 do not include extensive immobilization (eg, large plaster casts and
other immobilizing devices are considered additional separate procedures).
A repair of a donor site requiring a skin graft or local flaps is considered an additional
separate procedure.
(For microvascular flaps, see 15756-15758)
(For flaps without inclusion of a vascular pedicle, see 15570-15576)
(For adjacent tissue transfer flaps, see 14000-14302)
15570 Formation of direct or tubed pedicle, with or without transfer; trunk
➲ CPT Assistant Nov 02:7, Mar 10:4, Apr 10:3, Dec 12:6
15572 scalp, arms, or legs

➲ CPT Assistant Mar 10:4, Dec 12:6
15574 forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet
15576 eyelids, nose, ears, lips, or intraoral

15600 Delay of flap or sectioning of flap (division and inset); at trunk

➲ CPT Assistant Nov 99:10, Mar 10:4, Dec 12:6, Jun 19:14
15610 at scalp, arms, or legs

15620 at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet

15630 at eyelids, nose, ears, or lips

15650 Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any
location
(For eyelids, nose, ears, or lips, see also anatomical area)

(For revision, defatting or rearranging of transferred pedicle flap or skin graft, see 13100-
14302)
15730 Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)
Midface Flap Surgery

15730
Midface muscles surrounding eye [skin and muscle flap procedures]
15731 Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian
forehead flap)
➲ CPT Assistant Dec 12:6, Nov 17:6
(For muscle, myocutaneous, or fasciocutaneous flap of the head or neck, use 15733)
(15732 has been deleted. To report myocutaneous or fasciocutaneous flap, use 15733)
Axial Pattern Forehead Flap

15731
Reconstruction of a nasal defect with a forehead flap based on the left supratrochlear vessels
15733 Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular
pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator
scapulae)
(For forehead flap with preservation of vascular pedicle, use 15731)

(For anterior pericranial flap on named vascular pedicle, for repair of extracranial defect,
use 15731)
(For repair of head and neck defects using non-axial pattern advancement flaps [including
lesion] and/or repair by adjacent tissue transfer or rearrangement [eg, Z-plasty, W-plasty,
V-Y plasty, rotation flap, random island flap, advancement flap], see 14040, 14041,
14060, 14061, 14301, 14302)
15734 trunk
➲ CPT Assistant Dec 12:6, Oct 13:15, Apr 14:10, Nov 17:6, Aug 18:10
15736 upper extremity

➲ CPT Assistant Dec 12:6, Mar 13:13, Nov 17:6
15738 lower extremity

➲ CPT Assistant Sep 03:15, Apr 10:3, Dec 12:6, Nov 17:6
Other Flaps and Grafts

Code 15740 describes a cutaneous flap, transposed into a nearby but not immediately
adjacent defect, with a pedicle that incorporates an anatomically named axial vessel into its
design. The flap is typically transferred through a tunnel underneath the skin and sutured
into its new position. The donor site is closed directly.
Neurovascular pedicle procedures are reported with 15750. This code includes not only
skin but also a functional motor or sensory nerve(s). The flap serves to reinnervate a
damaged portion of the body dependent on touch or movement (eg, thumb).
Repair of donor site requiring skin graft or local flaps should be reported as an additional
procedure.
For random island flaps, V-Y subcutaneous flaps, advancement flaps, and other flaps from
adjacent areas without clearly defined anatomically named axial vessels, see 14000-14302.
Code 15769 may be used to report autologous soft tissue grafts, such as fat, dermis, fascia,
or other soft tissues, which are harvested from the patient using an excisional technique.
The autologous soft tissue grafts are then placed into a defect during the same operation.
Autologous grafts that are already defined in the CPT code set, including skin, bone, nerve,
tendon, fascia lata or vessels, should be reported with the specific codes for each tissue
type. For harvesting, preparation or injection(s) of platelet-rich plasma, use 0232T.
Codes 15771, 15772, 15773, 15774 may be used to report autologous fat grafting when the
adipose cells are harvested via a liposuction technique, prepared with minimal
manipulation, and then injected via cannula in multiple small aliquots to the defect. The
regions listed refer to the recipient area (not the donor site). Volumes are based on total
injectate. For multiple sites of injection, sum the total volume of injectate to anatomic sites
that are grouped together into the same code descriptor. Do not report 11950, 11951, 11952,
11954 in conjunction with 15771, 15772, 15773, 15774, for the same anatomic site.
15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial
vessel
➲ CPT Assistant Mar 04:11, Sep 04:12, Oct 04:15, Apr 10:3, Dec 12:6, Dec 17:14
15750 neurovascular pedicle

15756 Free muscle or myocutaneous flap with microvascular anastomosis

➲ CPT Assistant Apr 97:5, Nov 97:12, Nov 98:6
(Do not report code 69990 in addition to code 15756)

15757 Free skin flap with microvascular anastomosis
➲ CPT Assistant Apr 97:5, Nov 98:6, Apr 16:8

15758 Free fascial flap with microvascular anastomosis
➲ CPT Assistant Apr 97:5, Nov 98:6

15760 Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure,
donor area

15770 derma-fat-fascia
➲ CPT Assistant Sep 97:3, Apr 10:3, Oct 19:5
# 15769 Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis,
fascia)
(For injection[s] of platelet-rich plasma, use 0232T)

15771 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms,
and/or legs; 50 cc or less injectate
➲ CPT Assistant Oct 19:5, Apr 20:10
(Report 15771 only once per session)

✚ 15772 each additional 50 cc injectate, or part thereof (List separately in addition to code for
primary procedure)

15773 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck,
ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate

✚ 15774 each additional 25 cc injectate, or part thereof (List separately in addition to code for
primary procedure)

(Do not report 15769, 15771, 15772, 15773, 15774 in conjunction with 15876, 15877,
15878, 15879, 0232T, 0481T, 0489T, 0490T)
(For injection[s], autologous white blood cell concentrate [autologous protein solution],
any site, including image guidance, harvesting and preparation, when performed, use
0481T)
15775 Punch graft for hair transplant; 1 to 15 punch grafts
15776 more than 15 punch grafts

(For strip transplant, use 15220)
✚ 15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement
(ie, breast, trunk) (List separately in addition to code for primary procedure)
➲ CPT Assistant Jan 12:10, Oct 13:15, Nov 19:14
(For implantation of biologic implants for soft tissue reinforcement in tissues other than
breast and trunk, use 17999)
(For bilateral breast procedure, report 15777 twice. Do not report modifier 50 in
conjunction with 15777)
(For implantation of mesh or other prosthesis for open incisional or ventral hernia repair,
use 49568 in conjunction with 49560-49566)
(For insertion of mesh or other prosthesis for closure of a necrotizing soft tissue infection
wound, use 49568 in conjunction with 11004-11006)
(For topical application of skin substitute graft to a wound surface, see 15271-15278)
(For repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS]),
use 46707)
(For insertion of mesh or other prosthesis for repair of pelvic floor defect, use 57267)
(For implantation of non-biologic or synthetic implant for fascial reinforcement of the
abdominal wall, use 0437T)
(The supply of biologic implant should be reported separately in conjunction with 15777)
Other Procedures
15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
15781 segmental, face

15782 regional, other than face
15783 superficial, any site (eg, tattoo removal)
15786 Abrasion; single lesion (eg, keratosis, scar)

✚ 15787 each additional 4 lesions or less (List separately in addition to code for primary
procedure)
15788 Chemical peel, facial; epidermal
15789 dermal
15792 Chemical peel, nonfacial; epidermal
15793 dermal
15819 Cervicoplasty
15820 Blepharoplasty, lower eyelid;
➲ CPT Assistant Feb 04:11, May 04:12, Feb 05:16
15821 with extensive herniated fat pad
15822 Blepharoplasty, upper eyelid;

15823 with excessive skin weighting down lid

➲ CPT Assistant Sep 00:7, Feb 04:11, May 04:12, Feb 05:16, Aug 11:8
(For bilateral blepharoplasty, add modifier 50)

15824 Rhytidectomy; forehead
(For repair of brow ptosis, use 67900)

15825 neck with platysmal tightening (platysmal flap, P-flap)
15826 glabellar frown lines

15828 cheek, chin, and neck
15829 superficial musculoaponeurotic system (SMAS) flap
(For bilateral rhytidectomy, add modifier 50)
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen,
infraumbilical panniculectomy
(Do not report 15830 in conjunction with 12031-12037, 13100-13102, 14000, 14001,
15832 thigh
15833 leg
15834 hip
15835 buttock
15836 arm
15837 forearm or hand
15838 submental fat pad
15839 other area
15840 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)
15841 free muscle graft (including obtaining graft)
15842 free muscle flap by microsurgical technique

15845 regional muscle transfer
(For intravenous fluorescein examination of blood flow in graft or flap, use 15860)
(For nerve transfers, decompression, or repair, see 64831-64876, 64905, 64907, 69720,
69725, 69740, 69745, 69955)
✚ 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg,
abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in

(For abdominal wall hernia repair, see 49491-49587)
(To report other abdominoplasty, use 17999)
15850 Removal of sutures under anesthesia (other than local), same surgeon
➲ CPT Assistant Spring 93:34, Nov 97:22
15851 Removal of sutures under anesthesia (other than local), other surgeon
➲ CPT Assistant Spring 93:34, Nov 97:22
15852 Dressing change (for other than burns) under anesthesia (other than local)
15860 Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft
15876 Suction assisted lipectomy; head and neck

15877 trunk
➲ CPT Assistant Oct 99:10, Feb 05:14, Aug 19:10


(Do not report 15876, 15877, 15878, 15879 in conjunction with 15771, 15772, 15773,
15774, 0489T, 0490T)
(For harvesting of adipose tissue for autologous adipose-derived regenerative cell therapy,
use 0489T)
(For autologous fat grafting harvested by liposuction technique, see 15771, 15772, 15773,
15774)
Pressure Ulcers (Decubitus Ulcers)

15920 Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture
15922 with flap closure
15931 Excision, sacral pressure ulcer, with primary suture;
15933 with ostectomy
15934 Excision, sacral pressure ulcer, with skin flap closure;
15936 Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin
graft closure;
➲ CPT Assistant Nov 98:6-7

(For repair of defect using muscle or myocutaneous flap, use code(s) 15734 and/or 15738
in addition to 15936, 15937. For repair of defect using split skin graft, use codes 15100
and/or 15101 in addition to 15936, 15937)
15940 Excision, ischial pressure ulcer, with primary suture;
15941 with ostectomy (ischiectomy)
15944 Excision, ischial pressure ulcer, with skin flap closure;
15946 Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or
myocutaneous flap or skin graft closure
➲ CPT Assistant Nov 98:6-7, Jun 02:10, Jan 03:23
in addition to 15946. For repair of defect using split skin graft, use codes 15100 and/or
15101 in addition to 15946)
15950 Excision, trochanteric pressure ulcer, with primary suture;
15952 Excision, trochanteric pressure ulcer, with skin flap closure;
15956 Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or
skin graft closure;

in addition to 15956, 15958. For repair of defect using split skin graft, use codes 15100
and/or 15101 in addition to 15956, 15958)
15999 Unlisted procedure, excision pressure ulcer
(For free skin graft to close ulcer or donor site, see 15002 et seq)
Burns, Local Treatment

Procedures 16000-16036 refer to local treatment of burned surface only. Codes 16020-
16030 include the application of materials (eg, dressings) not described in codes 15100-
15278.
List percentage of body surface involved and depth of burn.
For necessary related medical services (eg, hospital visits, detention) in management of
burned patients, see appropriate services in Evaluation and Management and Medicine
sections.
For the application of skin grafts or skin substitutes, see codes 15100-15777.
(For fractional ablative laser fenestration for functional improvement of traumatic or burn
scars, see 0479T, 0480T)
16000 Initial treatment, first degree burn, when no more than local treatment is required
➲ CPT Assistant Aug 97:6, Oct 12:3
16020 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less
than 5% total body surface area)
16025 medium (eg, whole face or whole extremity, or 5% to 10% total body surface area)
➲ CPT Assistant Aug 97:6, Jun 08:14, Oct 12:3
Lund-Browder Diagram and Classification Method Table for Burn Estimations

The Lund-Browder Classification Method is used for estimating the extent, depth, and percentage of burns, allowing for the varying proportion of
body surface in persons of different ages.
Birth 10-
1 1-4 5-9 14 15 2 3 Donor
Area year years years years years Adult degrees degrees Total areas
Head 19 17 13 11 9 7
Neck 2 2 2 2 2 2
Ant. 13 13 13 13 13 13
trunk
Post. 13 13 13 13 13 13
trunk
R. 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2
buttock
L. 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2
buttock
Genitalia 1 1 1 1 1 1
R. U. 4 4 4 4 4 4
arm
L. U. 4 4 4 4 4 4
arm
R. L. 3 3 3 3 3 3
arm
L. L. 3 3 3 3 3 3
arm
R. hand 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2
L. hand 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2 2 1/2
R. thigh 5 1/2 6 1/2 8 8 1/2 9 9 1/2
L. thigh 5 1/2 6 1/2 8 8 1/2 9 9 1/2
R. leg 5 5 5 1/2 6 6 1/2 7
L. leg 5 5 5 1/2 6 6 1/2 7
R. foot 3 1/2 3 1/2 3 1/2 3 1/2 3 1/2 3 1/2
L. foot 3 1/2 3 1/2 3 1/2 3 1/2 3 1/2 3 1/2
Total
16030 large (eg, more than 1 extremity, or greater than 10% total body surface area)
16035 Escharotomy; initial incision

✚ 16036 each additional incision (List separately in addition to code for primary procedure)
(For debridement, curettement of burn wound, see 16020-16030)
Destruction
Destruction means the ablation of benign, premalignant or malignant tissues by any
method, with or without curettement, including local anesthesia, and not usually requiring
closure.
Any method includes electrosurgery, cryosurgery, laser and chemical treatment. Lesions
include condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (ie,
common, plantar, flat), milia, or other benign, premalignant (eg, actinic keratoses), or
malignant lesions.
(For destruction of lesion(s) in specific anatomic sites, see 40820, 46900-46917, 46924,
54050-54057, 54065, 56501, 56515, 57061, 57065, 67850, 68135)
(For laser treatment for inflammatory skin disease, see 96920-96922)
(For paring or cutting of benign hyperkeratotic lesions (eg, corns or calluses), see 11055-
11057)
(For sharp removal or electrosurgical destruction of skin tags and fibrocutaneous tags, see
11200, 11201)
(For cryotherapy of acne, use 17340)
(For initiation or follow-up care of topical chemotherapy (eg, 5-FU or similar agents), see
appropriate office visits)
(For shaving of epidermal or dermal lesions, see 11300-11313)
(For excision of cicatricial lesion[s] [eg, full thickness excision, through the dermis], see
11400-11446)
(For incisional removal of burn scar, see 16035, 16036)
(For fractional ablative laser fenestration for functional improvement of traumatic or burn
scars, see 0479T, 0480T)
Destruction, Benign or Premalignant Lesions

17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical
curettement), premalignant lesions (eg, actinic keratoses); first lesion
➲ CPT Assistant Winter 90:3, Nov 97:12, Jun 99:10, May 06:19, Feb 07:10, Aug 09:7,
Mar 10:10, Mar 12:7, May 12:13, Dec 17:14
✚ 17003 second through 14 lesions, each (List separately in addition to code for first lesion)
➲ CPT Assistant Nov 97:12, Jun 99:10, May 06:19, Feb 07:10, Aug 09:7, Mar 10:10,
Dec 17:14
(For destruction of common or plantar warts, see 17110, 17111)
curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions
➲ CPT Assistant Nov 97:12, Nov 98:7, Jun 99:10, Mar 03:21, Feb 07:10, Aug 09:7, Mar
10:10, Dec 17:14
(Do not report 17004 in conjunction with 17000-17003)
17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10
sq cm
➲ CPT Assistant Winter 90:3, Apr 07:11, Jun 08:14, Aug 09:7, Dec 17:14, Sep 19:10
17107 10.0 to 50.0 sq cm

➲ CPT Assistant Winter 90:3, Apr 07:11, Jun 08:14, Aug 09:7, Dec 17:14
17108 over 50.0 sq cm

➲ CPT Assistant Winter 90:3, Apr 07:11, Jun 08:14, Aug 09:7, Dec 17:14

curettement), of benign lesions other than skin tags or cutaneous vascular proliferative
lesions; up to 14 lesions
➲ CPT Assistant Nov 97:13, Feb 07:10, Apr 07:11, Nov 08:10, Aug 09:7, Apr 16:3, Dec
17:14, Apr 20:10
17111 15 or more lesions
➲ CPT Assistant Nov 97:13, Feb 07:10, Apr 07:11, Nov 08:10, Aug 09:7, Apr 16:3,
Dec 17:14
(For destruction of extensive cutaneous neurofibroma over 50-100 lesions, see 0419T,
0420T)
Destruction, Benign or Premalignant Lesions

17004
17250 Chemical cauterization of granulation tissue (ie, proud flesh)
➲ CPT Assistant May 12:13, Dec 12:15, Dec 17:14
(Do not report 17250 with removal or excision codes for the same lesion)
(Do not report 17250 when chemical cauterization is used to achieve wound hemostasis)
(Do not report 17250 in conjunction with 97597, 97598, 97602 for the same lesion)
Destruction, Malignant Lesions, Any Method

17260 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery,
surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less
➲ CPT Assistant May 12:13, Dec 17:14




surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less





surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter
0.5 cm or less





Mohs Micrographic Surgery

Mohs micrographic surgery is a technique for the removal of complex or ill-defined skin
cancer with histologic examination of 100% of the surgical margins. It requires the
integration of an individual functioning in two separate and distinct capacities: surgeon and
pathologist. If either of these responsibilities is delegated to another physician or other
qualified health care professional who reports the services separately, these codes should
not be reported. The Mohs surgeon removes the tumor tissue and maps and divides the
tumor specimen into pieces, and each piece is embedded into an individual tissue block for
histopathologic examination. Thus a tissue block in Mohs surgery is defined as an
individual tissue piece embedded in a mounting medium for sectioning.
If repair is performed, use separate repair, flap, or graft codes. If a biopsy of a suspected
skin cancer is performed on the same day as Mohs surgery because there was no prior
pathology confirmation of a diagnosis, then report a diagnostic skin biopsy (11102, 11104,
11106) and frozen section pathology (88331) with modifier 59 to distinguish from the
subsequent definitive surgical procedure of Mohs surgery.
(If additional special pathology procedures, stains or immunostains are required, see
88311-88314, 88342)
(Do not report 88314 in conjunction with 17311-17315 for routine frozen section stain (eg,
hematoxylin and eosin, toluidine blue) performed during Mohs surgery. When a nonroutine
histochemical stain on frozen tissue is utilized, report 88314 with modifier 59)
(Do not report 88302-88309 on the same specimen as part of the Mohs surgery)
17311 Mohs micrographic technique, including removal of all gross tumor, surgical excision of
tissue specimens, mapping, color coding of specimens, microscopic examination of
specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg,
hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location
with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels;
first stage, up to 5 tissue blocks
➲ CPT Assistant Feb 14:10, Oct 14:14
✚ 17312 each additional stage after the first stage, up to 5 tissue blocks (List separately in

17313 Mohs micrographic technique, including removal of all gross tumor, surgical excision of
hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue
blocks
✚ 17314 each additional stage after the first stage, up to 5 tissue blocks (List separately in

✚ 17315 Mohs micrographic technique, including removal of all gross tumor, surgical excision of
hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks,
any stage (List separately in addition to code for primary procedure)
➲ CPT Assistant May 12:13, Feb 14:10, Oct 14:14
(Use 17315 in conjunction with 17311-17314)
Other Procedures
17340 Cryotherapy (CO2 slush, liquid N2) for acne
➲ CPT Assistant May 12:13
17360 Chemical exfoliation for acne (eg, acne paste, acid)
17380 Electrolysis epilation, each 30 minutes
(For actinotherapy, use 96900)
17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue
➲ CPT Assistant Dec 98:9, May 99:11, Jun 05:11, Nov 08:10, Mar 11:9, May 12:13, Oct
13:15, May 16:13, Dec 17:13, Mar 19:10, Sep 19:10
Breast
19000 Puncture aspiration of cyst of breast;
➲ CPT Assistant Fall 94:18, Apr 05:6, Nov 08:10, Dec 13:17
✚ 19001 each additional cyst (List separately in addition to code for primary procedure)
➲ CPT Assistant Fall 94:18, Apr 05:6, Dec 13:17

(If imaging guidance is performed, see 76942, 77021)
19020 Mastotomy with exploration or drainage of abscess, deep
➲ CPT Assistant Apr 05:6, Dec 14:16
19030 Injection procedure only for mammary ductogram or galactogram

➲ CPT Assistant Jul 04:8, Apr 05:6
(For radiological supervision and interpretation, see 77053, 77054)

Breast biopsy procedures may be performed via a percutaneous or open approach and with
or without imaging guidance.
Percutaneous image-guided breast biopsies, including the placement of breast localization
device(s), when performed, are reported with 19081, 19082, 19083, 19084, 19085, 19086.
Imaging codes 76098, 76942, 77002, 77021 may not be separately reported for the same
lesion. When more than one percutaneous breast biopsy with or without localization device
placement is performed using the same imaging modality, use an add-on code whether the
additional service(s) is on the same or contralateral breast. If additional percutaneous
biopsies with or without localization device placements are performed using different
imaging modalities, report another primary code for each additional biopsy with or without
localization device placement performed using a different image guidance modality.
To report bilateral image-guided breast biopsies, report 19081, 19083, 19085 for the initial
biopsy. The contralateral and each additional breast image-guided biopsy are then reported
with 19082, 19084, 19086.
Percutaneous breast biopsies without imaging guidance are reported with 19100.
Open incisional breast biopsy (19101) does not include imaging guidance. However, if an
open incisional biopsy is performed after image-guided placement of a localization device,
the appropriate image-guided localization device placement code (19281, 19282, 19283,
19284, 19285, 19286, 19287, 19288) may also be reported.
Percutaneous cryosurgical ablation of a fibroadenoma (19105) includes ultrasound
guidance and, therefore, 76940, 76942 may not be separately reported. Code 19105 may
only be reported once per cryoprobe insertion site, even if several adjacent lesions are
ablated.
Open excision of a breast lesion (eg, lesions of breast duct[s], cyst[s], benign or malignant
tumor[s]), without specific attention to adequate surgical margins, with or without the
preoperative placement of radiological markers are reported with 19110, 19112, 19120,
19125, 19126. If an open excision of a breast lesion is performed after image-guided
placement of a localization device, the appropriate image-guided localization device
placement code (19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288) may also be
reported.
To report bilateral procedures for 19100, 19101, 19105, 19110, 19112, 19120, report
modifier 50 with the procedure code.
19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet),
when performed, and imaging of the biopsy specimen, when performed, percutaneous; first
lesion, including stereotactic guidance
➲ CPT Assistant May 14:3, Jun 14:14, Mar 15:5, May 15:8, Jun 16:3
➲ Clinical Examples in Radiology Spring 14:4, 10, Winter 17:5
✚ 19082 each additional lesion, including stereotactic guidance (List separately in addition to

lesion, including ultrasound guidance
➲ Clinical Examples in Radiology Spring 14:2, 3, Winter 17:5, Spring 18:13
✚ 19084 each additional lesion, including ultrasound guidance (List separately in addition to
➲ Clinical Examples in Radiology Spring 14:10, Winter 17:5

lesion, including magnetic resonance guidance
✚ 19086 each additional lesion, including magnetic resonance guidance (List separately in
➲ Clinical Examples in Radiology Spring 14:4, Winter 17:5

(Do not report 19081-19086 in conjunction with 19281-19288, 76098, 76942, 77002,
77021 for same lesion)
19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate
procedure)
➲ CPT Assistant Spring 93:35, Fall 94:18, Apr 96:8, Mar 97:4, Nov 97:24, Nov 98:7,
Jan 01:10, May 02:18, Apr 05:6, Dec 06:10, Nov 08:10, May 14:3
➲ Clinical Examples in Radiology Fall 10:3, Spring 14:10, Winter 17:5
(For fine needle aspiration biopsy, see 10004, 10005, 10006, 10007, 10008, 10009,
10010, 10011, 10012, 10021)
19101 open, incisional
➲ CPT Assistant Spring 93:35, Fall 94:19, Nov 97:24, Jan 01:8, May 02:18, Apr
05:6, May 14:3
➲ Clinical Examples in Radiology Spring 14:10
(For placement of percutaneous localization clip with imaging guidance, see 19281-
19288)
19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each
fibroadenoma
(For cryoablation of malignant breast tumor[s], use 0581T)
(For adjacent lesions treated with 1 cryoprobe insertion, report once)
19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma
lactiferous duct
19112 Excision of lactiferous duct fistula

19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue,
duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more
lesions
➲ CPT Assistant Feb 96:9, Nov 97:14, Jan 01:8, May 01:10, Apr 05:6, 13, Mar 14:13,
Mar 15:5
19125 Excision of breast lesion identified by preoperative placement of radiological marker,
open; single lesion
➲ CPT Assistant Fall 94:18, Mar 98:10, Jan 01:8, Apr 05:6, Mar 09:10, Mar 15:5
✚ 19126 each additional lesion separately identified by a preoperative radiological marker (List
➲ CPT Assistant Fall 94:18, Mar 98:10, Jan 01:8, Apr 05:6

(Intraoperative placement of clip[s] is not separately reported)
(19260 has been deleted. To report, use 21601)
Introduction
Percutaneous image-guided placement of breast localization device(s) without image-
guided breast biopsy(ies) is reported with 19281, 19282, 19283, 19284, 19285, 19286,
19287, 19288. When more than one localization device placement without image-guided
biopsy is performed using the same imaging modality, report an add-on code whether the
additional service(s) is on the same or contralateral breast. If additional localization device
placements without image-guided biopsy(ies) are performed using different imaging
modalities, report another primary code for each additional localization device placement
without image-guided biopsy performed using a different image guidance modality.
To report bilateral image-guided placement of localization devices report 19281, 19283,
19285, or 19287 for the initial lesion localized. The contra-lateral and each additional breast
image-guided localization device placement is reported with code 19282, 19284, 19286 or
19288.
When an open breast biopsy or open excision of a breast lesion is performed after image-
guided percutaneous placement of a localization device, the appropriate image-guided
localization device placement code (19281, 19282, 19283, 19284, 19285, 19286, 19287,
19288) may also be reported.
Code 19294 is used to report the preparation of the tumor cavity with placement of an
intraoperative radiation therapy applicator concurrent with partial mastectomy (19301,
19302).
Codes 19296, 19297, 19298 describe placement of radiotherapy catheters (afterloading
expandable or afterloading brachytherapy) into the breast for interstitial radioelement
application either concurrent or on a separate date from a partial mastectomy procedure.
Imaging guidance is included and may not be separately reported.
19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle,
radioactive seeds), percutaneous; first lesion, including mammographic guidance
➲ CPT Assistant May 14:3, Jun 14:14, May 15:8, Jun 16:3
➲ Clinical Examples in Radiology Spring 14:8, Spring 18:3
✚ 19282 each additional lesion, including mammographic guidance (List separately in addition
➲ CPT Assistant May 14:3, Jun 14:14, May 15:8, Jun 16:3

radioactive seeds), percutaneous; first lesion, including stereotactic guidance
➲ CPT Assistant May 14:3, May 15:8, May 16:13, Jun 16:3
✚ 19284 each additional lesion, including stereotactic guidance (List separately in addition to

radioactive seeds), percutaneous; first lesion, including ultrasound guidance
✚ 19286 each additional lesion, including ultrasound guidance (List separately in addition to

19287 Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle,
radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance
✚ 19288 each additional lesion, including magnetic resonance guidance (List separately in
➲ Clinical Examples in Radiology Spring 14:8, Spring 18:3

(Do not report 19281-19288 in conjunction with 19081-19086, 76942, 77002, 77021 for
same lesion)
(For surgical specimen radiography, use 76098)
(To report image-guided placement of breast localization devices during image-guided
biopsy, see 19081-19086. To report image-guided placement of breast localization
devices without image-guided biopsy, see 19281-19288)
✚ 19294 Preparation of tumor cavity, with placement of a radiation therapy applicator for
intraoperative radiation therapy (IORT) concurrent with partial mastectomy (List

19296 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into
the breast for interstitial radioelement application following partial mastectomy, includes
imaging guidance; on date separate from partial mastectomy
➲ CPT Assistant Apr 05:6-8, Nov 05:15, Apr 09:3, Dec 09:9, Mar 10:10
✚ 19297 concurrent with partial mastectomy (List separately in addition to code for primary
procedure)
➲ CPT Assistant Apr 05:6-8, Nov 05:15, Apr 09:3, Mar 10:10, Apr 19:10
(Use 19297 in conjunction with 19301 or 19302)

19298 Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button
type) into the breast for interstitial radioelement application following (at the time of or
subsequent to) partial mastectomy, includes imaging guidance
➲ CPT Assistant Apr 05:6-7, 9, 16, Nov 05:15, Apr 09:3, Mar 10:10
Mastectomy Procedures
Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either
for treatment or prevention of breast cancer.
Code 19301 describes a partial mastectomy where only a portion of the ipsilateral breast
tissue is removed (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy). When a
complete axillary lymphadenectomy is performed in addition to a partial mastectomy,
report 19302. When breast tissue is removed for breast-size reduction and not for treatment
or prevention of breast cancer, report 19318 (reduction mammaplasty).
Code 19303 describes total removal of ipsilateral breast tissue with or without removal of
skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer. Code
19303 does not include excision of pectoral muscle(s) and/or axillary and internal
mammary lymph nodes. When a total mastectomy is performed for gynecomastia, report
19300.
Codes 19305, 19306, 19307 describe radical procedures that include total removal of the
ipsilateral breast tissue, including the nipple for treatment of breast cancer and excision of
pectoral muscle(s) and/or axillary lymph nodes and/or internal mammary lymph nodes.
To report bilateral procedures for 19300, 19301, 19302, 19303, 19305, 19306, 19307, report
modifier 50 with the procedure code.
19300 Mastectomy for gynecomastia
➲ CPT Assistant Feb 07:4, Mar 14:13
(For breast tissue removed for breast-size reduction for other than gynecomastia, use
19318)
19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);
➲ CPT Assistant Feb 07:4, Dec 07:8, Sep 08:5, Mar 10:10, Nov 13:14, Mar 15:5, Oct
17:9
19302 with axillary lymphadenectomy
➲ CPT Assistant Feb 07:4, Dec 07:8, Sep 08:5, Mar 10:10, Mar 15:5
(For placement of radiotherapy afterloading balloon/brachytherapy catheters, see 19296-

19298)
(For the preparation of tumor cavity with placement of an intraoperative radiation therapy
applicator concurrent with partial mastectomy, use 19294)
(For radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time
of partial mastectomy, with report, use 0546T)
19303 Mastectomy, simple, complete
➲ CPT Assistant Feb 07:4, Mar 15:5, Dec 19:4
(For immediate or delayed insertion of implant, see 19340, 19342)
(For gynecomastia, use 19300)
(For breast tissue removed for breast-size reduction for gynecomastia, use 19300)
(For breast tissue removed for breast-size reduction for other than gynecomastia, use
19318)
19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes
➲ CPT Assistant Feb 07:4, Sep 08:5

19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph
nodes (Urban type operation)

19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis
minor muscle, but excluding pectoralis major muscle
➲ CPT Assistant Feb 07:4, Sep 08:5, Mar 15:5

Repair and/or Reconstruction

▶Breast reconstruction is performed to repair defects due to congenital anomaly or loss of
breast tissue after a surgical excision. The goal of breast reconstruction is to correct the
anatomic defect and to restore form and breast symmetry. A breast can be reconstructed
using a single technique or a combination of techniques, and each technique can stand
alone. In addition, both breasts may be reconstructed at the same time, but may use
different techniques or a combination of techniques. In many instances breast
reconstruction requires more than one planned procedure or may require revisions.
The native breast may be altered using different techniques. The breast and breast mound
can be lifted with a mastopexy (19316), reduced in volume with a breast reduction (19318),
or augmented with a breast implant (19325).
Post-mastectomy breast reconstruction may be performed using a variety of techniques. An
implant-based reconstruction involves placement of a device filled with fluid (eg, saline,
silicone gel) to provide volume to the breast. In immediate reconstruction, an implant is
primarily placed at the time of a mastectomy (19340). In delayed reconstruction, an implant
is placed at any date separate from the mastectomy (19342). This includes placement of any
new implant or replacement of an existing implant within the mastectomy defect or
reconstructed breast. The removal of an intact breast implant for replacement is included in
19342.
A breast implant cannot always be placed due to the lack of an adequate skin envelope.
Code 19357 describes insertion of a tissue expander, which is a device that is surgically
implanted to create an adequately sized pocket for subsequent insertion of a permanent
implant. A tissue expander is an inflatable device placed beneath the skin and chest muscle,
into which saline is injected over a period of weeks in the office to create the implant
pocket. The tissue expander is eventually removed and may be replaced with a permanent
breast implant (11970). Placement of either a breast implant (19340, 19342) or tissue
expander (19357) may be reported separately when performed with flap reconstruction
(19361, 19364, 19367, 19368, 19369).
Code 11970 describes the removal of a tissue expander with concurrent insertion of a
permanent breast implant. Code 11970 includes removal of the expander, minor revisions
to the breast capsule and placement of the new breast implant. Code 19370 may be reported
in addition to 11970 if more extensive capsular revision is performed. Code 11971
describes the removal of a tissue expander without the replacement of an expander or
implant.
Autologous breast reconstruction involves harvesting a flap of skin, subcutaneous fat
and/or muscle from one area of the body and relocating the tissue to the anterior chest to
create a new breast mound. Flap reconstruction may be performed at the time of
mastectomy or in a delayed fashion depending on patient preference and other oncologic
treatments.
Code 19361 describes breast reconstruction with a flap composed of the latissimus dorsi
muscle including some of the overlying skin and subcutaneous fat to reconstruct the breast
mound. This flap is left on its vascular pedicle and tunneled beneath the armpit skin to the
anterior chest to rebuild the breast. The blood supply to the flap is left attached to its origin
in the axilla. To give the breast mound additional volume, a tissue expander or permanent
breast implant may be placed beneath the latissimus flap. Placement of either a breast
implant (19340, 19342) or tissue expander (19357) may be reported separately.
Code 19364 describes a microsurgical free tissue transfer of skin and subcutaneous fat
and/or muscle for breast reconstruction. This code includes the flap harvest, microsurgical
anastomosis of one artery and two veins with use of an operating microscope, flap inset as
a breast mound, and donor-site closure. Typical free flaps include free transverse rectus
abdominis myocutaneous (f TRAM), deep inferior epigastric perforator (DIEP), superficial
inferior epigastric artery (SIEA), or gluteal artery perforator (GAP) flaps.
Code 19367 describes a single-pedicled transverse rectus abdominis myocutaneous
(TRAM) flap, in which skin, subcutaneous fat, and a large portion of the rectus abdominis
muscle from the lower abdomen is moved beneath the upper abdominal wall skin up to the
chest to rebuild the breast. The blood supply to the flap is left attached to its origin in the
abdomen.
Code 19368 describes “supercharging” of a single-pedicled TRAM flap. This is typically
performed to increase blood flow in TRAM flaps with marginal circulation to ensure flap
survival. In addition to the standard unipedicle TRAM procedure, the inferior epigastric
artery and/or veins are also anastomosed to recipient vessels in the chest using
microsurgical techniques.
Code 19369 describes a bipedicled TRAM flap in which skin, subcutaneous fat, and both
rectus muscles are harvested for the reconstruction of a single breast. The dual-blood
supply to the flap is left attached to its origins in the abdomen.
Secondary and ancillary breast-reconstruction procedures include nipple reconstruction
(19350), implant adjustments through revisions to the breast capsule (19370), or removal of
the entire breast capsule via a complete capsulectomy (19371) to achieve correct breast
tissue positioning. In addition, procedures may be performed on the contralateral breast to
create symmetry (19316, 19318, 19325). Removal of an intact breast implant without
replacement is reported with 19328. Removal of a ruptured breast implant, including the
implant contents, is reported with 19330. A complete capsulectomy (19371) includes
removal of the breast implant and all intracapsular contents.
Code 19380 describes a revision of a reconstructed breast, including significant excision of
tissue re-advancement or re-inset of flaps. For autologous reconstruction, 19380 includes
revisions of the flap position on the chest wall, removal of portions of the flap (via direct
excision or liposuction), re-shaping of the flap, or scar revisions. However, if a limited
procedure is performed with a defined code (eg, scar revision) then the more specific code
should be used. The placement of a new implant (19342) or autologous fat grafting for
increased volume (15771, 15772) may be separately reportable. For implant-based
reconstruction, 19380 includes revisions to the skin and capsule when performed together.
The exchange for a new or different size/shape/type of implant (19342) or autologous fat
grafting for increased volume/contour irregularities (15771, 15772) may be reported
separately. Nipple reconstruction is reported with 19350 and includes local flaps (14000,
14001), areolar skin grafting (15100, 15200, 15201), and subsequent tattooing (11920,
11921, 11922).
Code 19396 describes the formation of a moulage cast of a patient’s chest defect. The mold
is used to fabricate a specific, custom-made implant that fits the patient’s defect.◀
(To report bilateral procedure, report modifier 50 with the procedure code)
(For biologic implant for soft tissue reinforcement, use 15777 in conjunction with primary
procedure)
19316 Mastopexy
➲ CPT Assistant Jan 03:7, Apr 05:6, Feb 12:11
▲ 19318 Breast reduction

➲ CPT Assistant Jan 03:7, Apr 05:6, Apr 14:10
▶ (19324 has been deleted. To report breast augmentation with fat grafting, see 15771,
15772)◀
▲ 19325 Breast augmentation with implant
▶ (For fat grafting performed in conjunction with 19325, see 15771, 15772)◀
▲ 19328 Removal of intact breast implant
▶ (Do not report 19328 for removal of tissue expander)◀

▶ (For removal of tissue expander with placement of breast implant, use 11970)◀
▶ (For removal of tissue expander without replacement, use 11971)◀
▲ 19330 Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)
▶ (Do not report 19330 for removal of ruptured tissue expander)◀

▶ (For removal of ruptured tissue expander with placement of breast implant, use 11970)◀
▶ (For removal of ruptured tissue expander without replacement, use 11971)◀
▶ (For placement of new breast implant during same operative session, use 19342)◀
▲ 19340 Insertion of breast implant on same day of mastectomy (ie, immediate)
➲ CPT Assistant Aug 96:8, Apr 05:6, Aug 05:1, Mar 10:9, Dec 15:18
▲ 19342 Insertion or replacement of breast implant on separate day from mastectomy

➲ CPT Assistant Aug 96:8, Apr 05:6, Aug 05:1, Jan 13:15, Nov 15:10
▶ (Do not report 19342 in conjunction with 19328 for removal of implant in same breast)◀
▶ (For removal of tissue expander and replacement with breast implant, use 11970)◀
(For supply of implant, use 99070)
19350 Nipple/areola reconstruction
➲ CPT Assistant Aug 96:11, Apr 05:6, Jan 13:15, Aug 16:9
▶ (Donot report 19350 in conjunction with 11920, 11921, 11922, 14000, 14001, 15100,
15200, 15201)◀
19355 Correction of inverted nipples
▲ 19357 Tissue expander placement in breast reconstruction, including subsequent expansion(s)

➲ CPT Assistant Winter 91:2, Apr 05:6, Aug 05:1, Mar 10:9, Oct 13:15, Feb 15:10
▲ 19361 Breast reconstruction; with latissimus dorsi flap

➲ CPT Assistant Apr 05:6, Aug 05:1, Mar 10:9, Feb 15:10, Nov 19:14
▶ (Forinsertion of breast implant with latissimus dorsi flap on same day of mastectomy,
use 19340)◀
▶ (Forinsertion of breast implant with latissimus dorsi flap on day separate from
mastectomy, use 19342)◀
▶ (For insertion of tissue expander with latissimus dorsi flap, use 19357)◀
▲ 19364 with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)
➲ CPT Assistant Aug 96:8, Nov 98:7, Apr 05:6, Aug 05:1, Jun 10:8, Dec 11:14, Jul
12:12, Mar 13:13, Apr 14:10, Feb 15:10, Nov 19:14
▶ (19366 has been deleted)◀
▲ 19367 with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap
➲ CPT Assistant Nov 98:7, Apr 05:6, Aug 05:1, Feb 15:10, Nov 19:14
▲ 19368 with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap,

requiring separate microvascular anastomosis (supercharging)
➲ CPT Assistant Nov 98:7, Apr 05:6, Aug 05:1, Feb 15:10, Nov 19:14

▲ 19369 with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap
➲ CPT Assistant Oct 00:3, Apr 05:6, Aug 05:1, Feb 15:10, Nov 19:14
▶ (19361, 19364, 19367, 19368, 19369 include harvesting of the flap, closure of the donor
site, insetting and shaping the flap)◀
▲ 19370 Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or
partial capsulectomy
➲ CPT Assistant Aug 96:8, Apr 05:6, Dec 15:18
▶ (Do not report 19370 in conjunction with 19328 for removal and replacement of same
implant to access capsule)◀
▶ (For removal and replacement with new implant, use 19342)◀
▲ 19371 Peri-implant capsulectomy, breast, complete, including removal of all intracapsular
contents
➲ CPT Assistant Aug 96:8, Nov 01:11, Apr 05:6, Jan 13:15

▶ (Do not report 19371 in conjunction with 19370 in same breast)◀
▶ (For removal and replacement with new implant, use 19342)◀
▲ 19380 Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or
re-inset of flaps in autologous reconstruction or significant capsular revision combined
with soft tissue excision in implant-based reconstruction)
➲ CPT Assistant Apr 05:6, Dec 15:18, Dec 17:13, Nov 19:14
▶ (Donot report 19380 in conjunction with 12031, 12032, 12034, 12035, 12036, 12037,
13100, 13101, 13102, 15877, 19316, 19318, 19370, for the same breast)◀
19396 Preparation of moulage for custom breast implant
➲ CPT Assistant Jan 03:7, Apr 05:6
Other Procedures
19499 Unlisted procedure, breast
➲ CPT Assistant Apr 05:6, Dec 09:9, Nov 13:14, Dec 14:16, Dec 16:16, Apr 19:10, Aug
19:10
➲ Clinical Examples in Radiology Fall 08:4, Summer 09:15
★ = Telemedicine ✚ = Add-on code ⚡ = FDA approval pending # = Resequenced

code ⃠ = Modifier 51 exempt ➲➲➲ = See p xviii for details ▲ = Revised
code ● = New code ▶◀ = Contains new or revised text = Duplicate PLA
test ⇅ = Category I PLA
Surgery
Musculoskeletal System* (20100-29999)
Musculoskeletal System section of the CPT codebook. The subheadings or
General (20100-20999)
Incision
Wound Exploration—Trauma (eg, Penetrating Gunshot, Stab
Wound)* (20100-20103)
Excision (20150-20251)
Introduction or Removal (20500-20705)
Replantation (20802-20838)
Skeletal System
Skull, Frontal View
Skull, Lateral View
Thoracic Vertebra—Superior View

Lumbar Vertebra—Superior View
Lumbar Vertebrae—Lateral View

Grafts (or Implants)* (20900-20939)
Head* (21010-21499)
Incision (21010)
Excision (21011-21070)
Manipulation (21073)
Head Prosthesis* (21076-21089)
Repair, Revision, and/or Reconstruction (21120-21296)
Fracture and/or Dislocation (21310-21497)
Neck (Soft Tissues) and Thorax (21501-21899)
Incision (21501-21510)
Excision (21550-21632)
Back and Flank (21920-21936)
Excision (21920-21936)
Spine (Vertebral Column)* (22010-22899)
Incision (22010-22015)
Excision* (22100-22116)
Osteotomy* (22206-22226)
Fracture and/or Dislocation* (22310-22328)
Percutaneous Vertebroplasty and Vertebral Augmentation* (22510-
22515)
Percutaneous Augmentation and Annuloplasty (22526-22527)
Arthrodesis* (22532-22819)
Lateral Extracavitary Approach Technique (22532-22534)
Anterior or Anterolateral Approach Technique* (22548-22586)
Posterior, Posterolateral or Lateral Transverse Process
Technique* (22590-22634)
Spine Deformity (eg, Scoliosis, Kyphosis)* (22800-22819)
Exploration* (22830)
Spinal Instrumentation* (22840-22870)
Abdomen (22900-22999)
Excision (22900-22905)
Shoulder* (23000-23929)
Incision (23000-23044)
Excision (23065-23220)
Arthrodesis (23800-23802)
Amputation (23900-23921)
Humerus (Upper Arm) and Elbow* (23930-24999)
Incision (23930-24006)
Excision (24065-24155)
Forearm and Wrist* (25000-25999)
Incision (25000-25040)
Excision (25065-25240)
Bones, Muscles, and Tendons of Hand

Hand and Fingers (26010-26989)
Incision (26010-26080)
Excision (26100-26262)
Introduction or Removal (26320)
Pelvis and Hip Joint* (26990-27299)
Incision (26990-27036)
Excision (27040-27080)
Femur (Thigh Region) and Knee Joint* (27301-27599)
Incision (27301-27310)
Excision (27323-27365)
Arthrodesis (27580)
Leg (Tibia and Fibula) and Ankle Joint (27600-27899)
Incision (27600-27612)
Excision (27613-27647)
Introduction or Removal (27648)
Bones and Muscles of Foot
Foot and Toes (28001-28899)

Incision (28001-28035)
Excision (28039-28175)
Application of Casts and Strapping* (29000-29799)
Body and Upper Extremity (29000-29280)
Casts (29000-29086)
Splints (29105-29131)
Strapping—Any Age (29200-29280)
Lower Extremity (29305-29584)
Casts (29305-29450)
Splints (29505-29515)
Strapping—Any Age (29520-29584)
Removal or Repair* (29700-29750)
Endoscopy/Arthroscopy* (29800-29999)
Muscular System, Front
Muscular System, Back
Cast and strapping procedures appear at the end of this section.
The services listed below include the application and removal of
the first cast or traction device only. Subsequent replacement of
cast and/or traction device may require an additional listing.
Definitions
The terms “closed treatment,” “open treatment,” and
“percutaneous skeletal fixation” have been carefully chosen to
accurately reflect current orthopaedic procedural treatments.
Closed treatment specifically means that the fracture site is not
surgically opened (exposed to the external environment and
directly visualized). This terminology is used to describe
procedures that treat fractures by three methods: (1) without
manipulation; (2) with manipulation; or (3) with or without
traction.
Open treatment is used when the fractured bone is either: (1)
surgically opened (exposed to the external environment) and the
fracture (bone ends) visualized and internal fixation may be used;
or (2) the fractured bone is opened remote from the fracture site
in order to insert an intramedullary nail across the fracture site
(the fracture site is not opened and visualized).
Percutaneous skeletal fixation describes fracture treatment
which is neither open nor closed. In this procedure, the fracture
fragments are not visualized, but fixation (eg, pins) is placed
across the fracture site, usually under X-ray imaging.
The type of fracture (eg, open, compound, closed) does not have
any coding correlation with the type of treatment (eg, closed,
open, or percutaneous) provided.
The codes for treatment of fractures and joint injuries
(dislocations) are categorized by the type of manipulation
(reduction) and stabilization (fixation or immobilization). These
codes can apply to either open (compound) or closed fractures or
joint injuries.
Skeletal traction is the application of a force (distracting or
traction force) to a limb segment through a wire, pin, screw, or
clamp that is attached (eg, penetrates) to bone.
Skin traction is the application of a force (longitudinal) to a limb
using felt or strapping applied directly to skin only.
External fixation is the usage of skeletal pins plus an attaching
mechanism/device used for temporary or definitive treatment of
acute or chronic bony deformity.
Codes for obtaining autogenous bone grafts, cartilage, tendon,
fascia lata grafts or other tissues through separate incisions are to
be used only when the graft is not already listed as part of the
basic procedure.
Re-reduction of a fracture and/or dislocation performed by the
primary physician or other qualified health care professional may
be identified by the addition of modifier 76 to the usual
procedure number to indicate “Repeat Procedure or Service by
Same Physician or Other Qualified Health Care Professional.”
(See Appendix A guidelines.)
Codes for external fixation are to be used only when external
fixation is not already listed as part of the basic procedure.
All codes for suction irrigation have been deleted. To report, list
only the primary surgical procedure performed (eg,
sequestrectomy, deep incision).
Manipulation is used throughout the musculoskeletal fracture
and dislocation subsections to specifically mean the attempted
reduction or restoration of a fracture or joint dislocation to its
normal anatomic alignment by the application of manually
applied forces.
Excision of subcutaneous soft connective tissue tumors
(including simple or intermediate repair) involves the simple or
marginal resection of tumors confined to subcutaneous tissue
below the skin but above the deep fascia. These tumors are
usually benign and are resected without removing a significant
amount of surrounding normal tissue. Code selection is based on
the location and size of the tumor. Code selection is determined
by measuring the greatest diameter of the tumor plus that margin
required for complete excision of the tumor. The margins refer to
the most narrow margin required to adequately excise the tumor,
based on the physician’s judgment. The measurement of the
tumor plus margin is made at the time of the excision.
Appreciable vessel exploration and/or neuroplasty should be
reported separately. Extensive undermining or other techniques to
close a defect created by skin excision may require a complex
repair which should be reported separately. Dissection or
elevation of tissue planes to permit resection of the tumor is
included in the excision. For excision of benign lesions of
cutaneous origin (eg, sebaceous cyst), see 11400-11446.
Excision of fascial or subfascial soft tissue tumors (including
simple or intermediate repair) involves the resection of tumors
confined to the tissue within or below the deep fascia, but not
involving the bone. These tumors are usually benign, are often
intramuscular, and are resected without removing a significant
amount of surrounding normal tissue. Code selection is based on
size and location of the tumor. Code selection is determined by
measuring the greatest diameter of the tumor plus that margin
required for complete excision of the tumor. The margins refer to
the most narrow margin required to adequately excise the tumor,
based on individual judgment. The measurement of the tumor
plus margin is made at the time of the excision. Appreciable
vessel exploration and/or neuroplasty should be reported
separately. Extensive undermining or other techniques to close a
defect created by skin excision may require a complex repair
which should be reported separately. Dissection or elevation of
tissue planes to permit resection of the tumor is included in the
excision.
Digital (ie, fingers and toes) subfascial tumors are defined as
those tumors involving the tendons, tendon sheaths, or joints of
the digit. Tumors which simply abut but do not breach the
tendon, tendon sheath, or joint capsule are considered
subcutaneous soft tissue tumors.
Radical resection of soft connective tissue tumors (including
simple or intermediate repair) involves the resection of the tumor
with wide margins of normal tissue. Appreciable vessel
exploration and/or neuroplasty repair or reconstruction (eg,
adjacent tissue transfer[s], flap[s]) should be reported separately.
Extensive undermining or other techniques to close a defect
created by skin excision may require a complex repair which
should be reported separately. Dissection or elevation of tissue
planes to permit resection of the tumor is included in the
excision. Although these tumors may be confined to a specific
layer (eg, subcutaneous, subfascial), radical resection may
involve removal of tissue from one or more layers. Radical
resection of soft tissue tumors is most commonly used for
malignant connective tissue tumors or very aggressive benign
connective tissue tumors. Code selection is based on size and
location of the tumor. Code selection is determined by measuring
the greatest diameter of the tumor plus that margin required for
complete excision of the tumor. The margins refer to the most
narrow margin required to adequately excise the tumor, based on
individual judgment. The measurement of the tumor plus margin
is made at the time of the excision. For radical resection of
tumor(s) of cutaneous origin (eg, melanoma), see 11600-11646.
Radical resection of bone tumors (including simple or
intermediate repair) involves the resection of the tumor with wide
margins of normal tissue. Appreciable vessel exploration and/or
neuroplasty and complex bone repair or reconstruction (eg,
adjacent tissue transfer[s], flap[s]) should be reported separately.
Extensive undermining or other techniques to close a defect
created by skin excision may require a complex repair which
should be reported separately. Dissection or elevation of tissue
planes to permit resection of the tumor is included in the
excision. It may require removal of the entire bone if tumor
growth is extensive (eg, clavicle). Radical resection of bone
tumors is usually performed for malignant tumors or very
aggressive benign tumors. If surrounding soft tissue is removed
during these procedures, the radical resection of soft tissue tumor
codes should not be reported separately. Code selection is based
solely on the location of the tumor, not on the size of the tumor
or whether the tumor is benign or malignant, primary or
metastatic.
General
Incision
(For incision and drainage of subfascial soft tissue abscess,
see appropriate incision and drainage for specific anatomic
sites)
Wound Exploration—Trauma (eg, Penetrating

Gunshot, Stab Wound)
20100-20103 relate to wound(s) resulting from penetrating
trauma. These codes describe surgical exploration and
enlargement of the wound, extension of dissection (to determine
penetration), debridement, removal of foreign body(s), ligation
or coagulation of minor subcutaneous and/or muscular blood
vessel(s), of the subcutaneous tissue, muscle fascia, and/or
muscle, not requiring thoracotomy or laparotomy. If a repair is
done to major structure(s) or major blood vessel(s) requiring
thoracotomy or laparotomy, then those specific code(s) would
supersede the use of codes 20100-20103. To report simple,
intermediate, or complex repair of wound(s) that do not require
enlargement of the wound, extension of dissection, etc, as stated
above, use specific Repair code(s) in the Integumentary System
section.
20100 Exploration of penetrating wound (separate procedure);
neck
➲ CPT Assistant Jun 96:7, Aug 96:10, Sep 06:13
20101 chest
➲ CPT Assistant Jun 96:7, Sep 06:13
20102 abdomen/flank/back
20103 extremity
➲ CPT Assistant Jun 96:7, Aug 96:10, Sep 06:13
Excision
20150 Excision of epiphyseal bar, with or without autogenous soft
tissue graft obtained through same fascial incision
20200 Biopsy, muscle; superficial
20205 deep
20206 Biopsy, muscle, percutaneous needle
➲ Clinical Examples in Radiology Summer 08:5, Fall
10:7, Winter 17:5
77012, 77021)
(For fine needle aspiration biopsy, see 10004, 10005,
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
(For evaluation of fine needle aspirate, see 88172-88173)
(For excision of muscle tumor, deep, see specific anatomic
section)
20220 Biopsy, bone, trocar, or needle; superficial (eg, ilium,
sternum, spinous process, ribs)
➲ CPT Assistant Winter 92:17, Jul 98:4
10:7, Winter 17:5
20225 deep (eg, vertebral body, femur)
➲ CPT Assistant Winter 92:17, Jul 98:4, Jun 12:10, Jan
15:8
➲ Clinical Examples in Radiology Fall 10:8, Winter
17:5
22512, 22513, 22514, 22515, 0200T, 0201T, when
performed at the same level)
(For bone marrow biopsy[ies] and/or aspiration[s], see
38220, 38221, 38222)
(For radiologic supervision and interpretation, see 77002,
77012, 77021)
20240 Biopsy, bone, open; superficial (eg, sternum, spinous
process, rib, patella, olecranon process, calcaneus, tarsal,
metatarsal, carpal, metacarpal, phalanx)
➲ CPT Assistant Winter 92:17, Jul 98:4, Aug 04:11, Aug
05:13
20245 deep (eg, humeral shaft, ischium, femoral shaft)
20250 Biopsy, vertebral body, open; thoracic

20251 lumbar or cervical

(For sequestrectomy, osteomyelitis or drainage of bone

abscess, see anatomical area)
Introduction or Removal
(For injection procedure for arthrography, see anatomical
area)
(For injection of autologous adipose-derived regenerative
cells, use 0490T)
20500 Injection of sinus tract; therapeutic (separate procedure)
20501 diagnostic (sinogram)

(For radiological supervision and interpretation, use 76080)
(For contrast injection[s] and radiological assessment of
gastrostomy, duodenostomy, jejunostomy, gastrojejunostomy,
or cecostomy [or other colonic] tube including fluoroscopic
imaging guidance, use 49465)
20520 Removal of foreign body in muscle or tendon sheath; simple
20525 deep or complicated
20526 Injection, therapeutic (eg, local anesthetic, corticosteroid),
carpal tunnel
20527 Injection, enzyme (eg, collagenase), palmar fascial cord (ie,

Dupuytren’s contracture)
➲ CPT Assistant Jul 12:8, 14
(For manipulation of palmar fascial cord (ie, Dupuytren’s

cord) post enzyme injection (eg, collagenase), use 26341)
20550 Injection(s); single tendon sheath, or ligament, aponeurosis
(eg, plantar “fascia”)
➲ CPT Assistant Jan 96:7, Jun 98:10, Mar 02:7, Aug
03:14, Sep 03:13, Dec 03:11, Jan 09:6, Jul 12:14, Oct
14:9
(For injection of Morton’s neuroma, see 64455, 64632)

20551 single tendon origin/insertion
➲ CPT Assistant Mar 02:7, Sep 03:13, Oct 14:9, Dec
17:16
10:14
(Do not report 20550, 20551 in conjunction with 0232T,
0481T)
(For harvesting, preparation, and injection[s] of platelet-
rich plasma, use 0232T)
20552 Injection(s); single or multiple trigger point(s), 1 or 2
muscle(s)
➲ CPT Assistant Mar 02:7, May 03:19, Sep 03:11, Feb
10:9, Feb 11:5, Jul 11:16, Apr 12:19, Oct 14:9, Jun
17:10, Dec 17:16, Feb 20:9
➲ Clinical Examples in Radiology Winter 10:14, Fall
11:10
20553 single or multiple trigger point(s), 3 or more muscles
➲ CPT Assistant Mar 02:7, May 03:19, Sep 03:11, Jun
08:8, Feb 10:9, Feb 11:5, Jul 11:16, Oct 14:9, Jun
17:10, Dec 18:8, Feb 20:9

20561 for the same muscle[s])
77021)
Trigger Point Injection

20552, 20553
Insertion of needle into muscle trigger point for injection of therapeutic agent
# 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s)

# 20561 3 or more muscles

20555 Placement of needles or catheters into muscle and/or soft
tissue for subsequent interstitial radioelement application (at
the time of or subsequent to the procedure)
(For placement of devices into the breast for interstitial

radioelement application, see 19296-19298)
(For placement of needles, catheters, or devices into muscle
or soft tissue of the head and neck, for interstitial
radioelement application, use 41019)
(For placement of needles or catheters for interstitial
radioelement application into prostate, use 55875)
(For placement of needles or catheters into the pelvic organs
or genitalia [except prostate] for interstitial radioelement
application, use 55920)
(For interstitial radioelement application, see 77770,
77771, 77772, 77778)
(For imaging guidance, see 76942, 77002, 77012, 77021)
20600 Arthrocentesis, aspiration and/or injection, small joint or
bursa (eg, fingers, toes); without ultrasound guidance
➲ CPT Assistant Dec 07:10, Feb 15:6, Nov 15:10, Aug
17:9
20604 with ultrasound guidance, with permanent recording and

reporting
➲ CPT Assistant Feb 15:6, Jul 15:10
0489T, 0490T)
(If fluoroscopic, CT, or MRI guidance is performed, see
77002, 77012, 77021)
20605 Arthrocentesis, aspiration and/or injection, intermediate
joint or bursa (eg, temporomandibular, acromioclavicular,
wrist, elbow or ankle, olecranon bursa); without ultrasound
guidance
➲ CPT Assistant Dec 07:10, Feb 15:6, Nov 15:10, Aug
17:9

reporting

77002, 77012, 77021)
20610 Arthrocentesis, aspiration and/or injection, major joint or
bursa (eg, shoulder, hip, knee, subacromial bursa); without
ultrasound guidance
➲ CPT Assistant Spring 92:8, Mar 01:10, Apr 04:15, Jul
06:1, Dec 07:10, Jul 08:9, Mar 12:6, Jun 12:14, Dec
14:18, Feb 15:6, Aug 15:6, Nov 15:10, Apr 17:10, Aug
19:7
➲ Clinical Examples in Radiology Spring 13:11, Spring
15:7, Summer 18:15, Winter 19:14
Arthrocentesis, Aspiration, or Injection of Major Joint or
Bursa
20610
Insertion of needle into major joint or bursa for injection of therapeutic or diagnostic agent, aspiration, or
arthrocentesis

reporting
➲ CPT Assistant Feb 15:6, Jul 15:10, Aug 15:6, Nov
15:10, Aug 19:7
➲ Clinical Examples in Radiology Spring 15:7, Winter
19:14
76942)
77002, 77012, 77021)
20612 Aspiration and/or injection of ganglion cyst(s) any location
(To report multiple ganglion cyst aspirations/injections, use

20612 and append modifier 59)
20615 Aspiration and injection for treatment of bone cyst
20650 Insertion of wire or pin with application of skeletal traction,
including removal (separate procedure)
20660 Application of cranial tongs, caliper, or stereotactic frame,
including removal (separate procedure)
➲ CPT Assistant Jun 96:10, Nov 97:14, Jan 06:46, Dec
06:10, Feb 08:8, Jul 08:10, Nov 09:6, Apr 12:11, Aug
12:14
20661 Application of halo, including removal; cranial
➲ CPT Assistant Nov 97:14, Aug 12:14
20662 pelvic
20663 femoral
20664 Application of halo, including removal, cranial, 6 or more
pins placed, for thin skull osteology (eg, pediatric patients,
hydrocephalus, osteogenesis imperfecta)
➲ CPT Assistant Nov 97:14, Aug 12:5, Aug 13:12
20665 Removal of tongs or halo applied by another individual

20670 Removal of implant; superficial (eg, buried wire, pin or

rod) (separate procedure)
➲ CPT Assistant Dec 07:7, 8, Jun 09:7, Apr 12:17
Halo Application for Thin Skull Osteology

20664
A cranial halo is placed on the head of a child whose skull is unusually thin due to congenital or
developmental problems.
20680 deep (eg, buried wire, pin, screw, metal band, nail, rod
or plate)
➲ CPT Assistant Spring 92:11, Jun 09:7, Sep 12:16,
Mar 14:4, Nov 15:10, Nov 16:9, Jan 18:3
(For removal of sinus tarsi implant, use 0510T)
(For removal and reinsertion of sinus tarsi implant, use
0511T)
20690 Application of a uniplane (pins or wires in 1 plane),
unilateral, external fixation system
➲ CPT Assistant Winter 90:4, Winter 92:11, Fall 93:21,
Oct 99:5, Jan 04:27, Jun 05:12, Oct 07:7, Jan 08:4, Feb
08:9, Jun 09:7, Jan 18:3
Uniplane External Fixation System

20690
The following figures are examples of types of stabilization devices. Codes 20690 and 20692 describe
the placement of types of external fixation devices. The method of stabilization depends upon fracture
grade (degree of soft tissue injury/skin integrity disruption), type (eg, comminuted, spiral, impacted), and
location (eg, extremity, pelvis).
20692 Application of a multiplane (pins or wires in more than 1
plane), unilateral, external fixation system (eg, Ilizarov,
Monticelli type)
➲ CPT Assistant Winter 90:4, Fall 93:21, Oct 99:5, Jul
00:11, Feb 08:9, Jun 09:7, Jan 18:3, May 19:10
Multiplane External Fixation System
20692
The following figure is an example of a type of multiplane stabilization device. Codes 20690 and 20692
describe the placement of types of external fixation devices. The method of stabilization depends upon
fracture grade (degree of soft tissue injury/skin integrity disruption), type (eg, comminuted, spiral,
impacted), and location (eg, extremity, pelvis).
20693 Adjustment or revision of external fixation system requiring

anesthesia (eg, new pin[s] or wire[s] and/or new ring[s] or
bar[s])
➲ CPT Assistant Fall 93:21, Oct 99:5, Jul 00:11, Jun 09:7,
Jan 18:3
20694 Removal, under anesthesia, of external fixation system
➲ CPT Assistant Winter 92:10, Fall 93:21, Oct 99:5, Jul
00:11, Jan 18:3
20696 Application of multiplane (pins or wires in more than 1
plane), unilateral, external fixation with stereotactic
computer-assisted adjustment (eg, spatial frame), including
imaging; initial and subsequent alignment(s), assessment(s),
and computation(s) of adjustment schedule(s)
➲ CPT Assistant Jan 18:3

⃠ 20697 exchange (ie, removal and replacement) of strut, each

Manual preparation involves the mixing and preparation of
antibiotics or other therapeutic agent(s) with a carrier substance
by the physician or other qualified health care professional
during the surgical procedure and then shaping the mixture into a
drug-delivery device(s) (eg, beads, nails, spacers) for placement
in the deep (eg, subfascial) intramedullary or intra-articular
space(s). Codes 20700, 20702, 20704 are add-on codes for the
manual preparation and insertion of the drug-delivery device
during the associated primary surgical procedure listed with each
add-on code. Codes 20701, 20703, 20705 are add-on codes for
the removal of drug-delivery device(s) during the associated
primary surgical procedures listed in the parenthetical codes
associated with each add-on code. Insertion of a prefabricated
drug device(s) may not be reported with 20700, 20702, 20704.
Report 20680, if removal of drug-delivery device(s) is performed
alone. Report 20700, 20701, 20702, 20703, 20704, 20705 once per
anatomic location.
✚ 20700 Manual preparation and insertion of drug-delivery
device(s), deep (eg, subfascial) (List separately in addition
(Use 20700 in conjunction with 11010, 11011, 11012,

11043, 11044, 11046, 11047, 20240, 20245, 20250, 20251,
21010, 21025, 21026, 21501, 21502, 21510, 21627, 21630,
22010, 22015, 23030, 23031, 23035, 23040, 23044, 23170,
23172, 23174, 23180, 23182, 23184, 23334, 23335, 23930,
23931, 23935, 24000, 24134, 24136, 24138, 24140, 24147,
24160, 25031, 25035, 25040, 25145, 25150, 25151, 26070,
26230, 26235, 26236, 26990, 26991, 26992, 27030, 27070,
27071, 27090, 27301, 27303, 27310, 27360, 27603, 27604,
27610, 27640, 27641, 28001, 28002, 28003, 28020, 28120,
28122)
✚ 20701 Removal of drug-delivery device(s), deep (eg, subfascial)
(List separately in addition to code for primary procedure)

11043, 11044, 11046, 11047, 20240, 20245, 20250, 20251,
21010, 21025, 21026, 21501, 21502, 21510, 21627, 21630,
22010, 22015, 23030, 23031, 23035, 23040, 23044, 23170,
23172, 23174, 23180, 23182, 23184, 23334, 23335, 23930,
23931, 23935, 24000, 24134, 24136, 24138, 24140, 24147,
24160, 25031, 25035, 25040, 25145, 25150, 25151, 26070,
26230, 26235, 26236, 26990, 26991, 26992, 27030, 27070,
27071, 27090, 27301, 27303, 27310, 27360, 27603, 27604,
27610, 27640, 27641, 28001, 28002, 28003, 28020, 28120,
28122)
device(s), intramedullary (List separately in addition to

20694, 20802, 20805, 20838, 21510, 23035, 23170, 23180,
23184, 23515, 23615, 23935, 24134, 24138, 24140, 24147,
24430, 24516, 25035, 25145, 25150, 25151, 25400, 25515,
25525, 25526, 25545, 25574, 25575, 27245, 27259, 27360,
27470, 27506, 27640, 27720)
✚ 20703 Removal of drug-delivery device(s), intramedullary (List

20802, 20805, 20838, 21510, 23035, 23170, 23180, 23184,
23515, 23615, 23935, 24134, 24138, 24140, 24147, 24430,
24516, 25035, 25145, 25150, 25151, 25400, 25515, 25525,
25526, 25545, 25574, 25575, 27245, 27259, 27360, 27470,
27506, 27640, 27720)
device(s), intra-articular (List separately in addition to code

23044, 23334, 24000, 24160, 25040, 25250, 25251, 26070,
26075, 26080, 26990, 27030, 27090, 27301, 27310, 27603,
27610, 28020)
27488)
✚ 20705 Removal of drug-delivery device(s), intra-articular (List

23044, 23334, 24000, 24160, 25040, 25250, 25251, 26070,
26075, 26080, 26990, 27030, 27090, 27301, 27310, 27603,
27610, 28020)
27091, 27125, 27130, 27134, 27137, 27138, 27236, 27438,
27446, 27486, 27487, 27488)
Replantation
20802 Replantation, arm (includes surgical neck of humerus
through elbow joint), complete amputation
(To report replantation of incomplete arm amputation, see
specific code[s] for repair of bone[s], ligament[s],
tendon[s], nerve[s], or blood vessel[s] with modifier 52)
20805 Replantation, forearm (includes radius and ulna to radial
carpal joint), complete amputation
(To report replantation of incomplete forearm amputation,
see specific code[s] for repair of bone[s], ligament[s],
20808 Replantation, hand (includes hand through
metacarpophalangeal joints), complete amputation
(To report replantation of incomplete hand amputation, see
20816 Replantation, digit, excluding thumb (includes
metacarpophalangeal joint to insertion of flexor sublimis
tendon), complete amputation
(To report replantation of incomplete digit amputation,
excluding thumb, see specific code[s] for repair of bone[s],
ligament[s], tendon[s], nerve[s], or blood vessel[s] with
modifier 52)
20822 Replantation, digit, excluding thumb (includes distal tip to
sublimis tendon insertion), complete amputation
(To report replantation of incomplete digit amputation,
excluding thumb, see specific code[s] for repair of bone[s],
ligament[s], tendon[s], nerve[s], or blood vessel[s] with
modifier 52)
20824 Replantation, thumb (includes carpometacarpal joint to MP
joint), complete amputation
(To report replantation of incomplete thumb amputation, see
20827 Replantation, thumb (includes distal tip to MP joint),
complete amputation
(To report replantation of incomplete thumb amputation, see
(To report replantation of complete leg amputation, see
(To report replantation of incomplete leg amputation, see
20838 Replantation, foot, complete amputation
(To report replantation of incomplete foot amputation, see
Grafts (or Implants)
Codes for obtaining autogenous bone, cartilage, tendon, fascia
lata grafts, bone marrow, or other tissues through separate
skin/fascial incisions should be reported separately, unless the
code descriptor references the harvesting of the graft or implant
(eg, includes obtaining graft). Autologous grafts that are already
defined in the CPT code set, including skin, bone, nerve, tendon,
fascia lata, or vessels, should be reported with the more specific
codes for each tissue type. Code 15769 may be used for other
autologous soft tissue grafts harvested by direct excision. See
15771, 15772, 15773, 15774 for autologous fat grafting harvested
by liposuction technique.
Do not append modifier 62 to bone graft codes 20900-20938.
(For spinal surgery bone graft[s] see codes 20930-20938)
20900 Bone graft, any donor area; minor or small (eg, dowel or
button)
➲ CPT Assistant Dec 00:15, Jul 11:18, Jul 18:14
20902 major or large

➲ CPT Assistant Dec 00:15, Jul 11:18, Jul 18:14
20910 Cartilage graft; costochondral

➲ CPT Assistant Jan 13:15, Jul 18:14
20912 nasal septum

(For ear cartilage, use 21235)

20920 Fascia lata graft; by stripper
➲ CPT Assistant Aug 99:5, Jan 05:8, Jul 18:14
20922 by incision and area exposure, complex or sheet
20924 Tendon graft, from a distance (eg, palmaris, toe extensor,

plantaris)

(To report autologous soft tissue grafts harvested by direct
excision, use 15769)
(To report autologous fat grafting harvested by liposuction
technique, see 15771, 15772, 15773, 15774)
✚ 20930 Allograft, morselized, or placement of osteopromotive
material, for spine surgery only (List separately in addition
➲ CPT Assistant Feb 96:6, Mar 96:4, Sep 97:8, Nov
99:10, Feb 02:6, Jan 04:27, Dec 07:1, Feb 08:8, Nov
10:8, Jul 11:18, Dec 11:15, Apr 12:14, Jun 12:11, Jul
13:3, Jul 18:14, May 19:7
22548-22558, 22590-22612, 22630, 22633, 22634, 22800-
22812)
✚ 20931 Allograft, structural, for spine surgery only (List separately
➲ CPT Assistant Feb 96:6, Feb 02:6, Feb 05:15, Feb 08:8,
Nov 10:8, Jul 11:18, Sep 11:12, Dec 11:15, Apr 12:14,
Jun 12:11, Jul 13:3, Jul 18:14, May 19:7
(Use 20931 in conjunction with 22319, 22532-22533,
22548-22558, 22590-22612, 22630, 22633, 22634, 22800-
22812)
✚ 20932 Allograft, includes templating, cutting, placement and
internal fixation, when performed; osteoarticular, including
articular surface and contiguous bone (List separately in

23200, 24152, 27078, 27090, 27091, 27448, 27646, 27647,
27648)
Postoperative Osteoarticular Allograft Left Humerus Fixed

with Plates
20932
✚ 20933 hemicortical intercalary, partial (ie, hemicylindrical)

procedure)

20955, 20956, 20957, 20962, 23146, 23156, 23200, 24116,
24126, 24152, 25126, 25136, 27078, 27090, 27091, 27130,
27132, 27134, 27138, 27236, 27244, 27356, 27448, 27638,
27646, 27647, 27648, 28103, 28107)
Parosteal Osteosarcoma Replaced with Hemicortical

Intercalary Allograft
20933
✚ 20934 intercalary, complete (ie, cylindrical) (List separately in

23200, 24152, 27078, 27090, 27091, 27448, 27646, 27647,
27648)
(Insertion of joint prosthesis may be separately reported)
(Use 20932, 20933, 20934 in conjunction with 23210,
23220, 24150, 25170, 27075, 27076, 27077, 27365, 27645,
27704)
Osteosarcoma Femur with Complete Intercalary Allograft

with Plate Fixation
20934
✚ 20936 Autograft for spine surgery only (includes harvesting the

graft); local (eg, ribs, spinous process, or laminar
fragments) obtained from same incision (List separately in
➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, Feb 08:8,
Dec 11:15, Apr 12:14, Jun 12:11, Jul 13:3, Jul 18:14
22548-22558, 22590-22612, 22630, 22633, 22634, 22800-
22812)
✚ 20937 morselized (through separate skin or fascial incision)
procedure)
➲ CPT Assistant Feb 96:6, Sep 97:8, Dec 99:2, Feb
02:6, Feb 08:8, Dec 11:15, Apr 12:11, Jun 12:11, Jul
13:3, Jul 18:14
22548-22558, 22590-22612, 22630, 22633, 22634, 22800-
22812)
✚ 20938 structural, bicortical or tricortical (through separate skin
or fascial incision) (List separately in addition to code
➲ CPT Assistant Feb 96:6, Mar 96:5, Sep 97:8, Feb
02:6, Feb 08:8, Jul 11:18, Dec 11:15, Apr 12:12,
May 12:11, Jun 12:11, Jul 13:3
22548-22558, 22590-22612, 22630, 22633, 22634, 22800-
22812)
(For aspiration of bone marrow for bone grafting, spine
surgery only, use 20939)
✚ 20939 Bone marrow aspiration for bone grafting, spine surgery
only, through separate skin or fascial incision (List
22534, 22548, 22551, 22552, 22554, 22556, 22558, 22590,
22595, 22600, 22610, 22612, 22630, 22633, 22634, 22800,
22802, 22804, 22808, 22810, 22812)
(For bilateral procedure, report 20939 twice. Do not report
modifier 50 in conjunction with 20939)
(For aspiration of bone marrow for the purpose of bone
grafting, other than spine surgery and other therapeutic
musculoskeletal applications, use 20999)
(For bone marrow aspiration[s] for platelet-rich stem cell
injection, use 0232T)
(For diagnostic bone marrow aspiration[s], see 38220,
38222)
Other Procedures
20950 Monitoring of interstitial fluid pressure (includes insertion
of device, eg, wick catheter technique, needle manometer
technique) in detection of muscle compartment syndrome
20955 Bone graft with microvascular anastomosis; fibula

20956 iliac crest

20957 metatarsal
20962 other than fibula, iliac crest, or metatarsal

(Do not report code 69990 in addition to codes 20955-

20962)
20969 Free osteocutaneous flap with microvascular anastomosis;
other than iliac crest, metatarsal, or great toe
➲ CPT Assistant Apr 97:4, Oct 19:10
20970 iliac crest

20972 metatarsal
20973 great toe with web space


20973)
(For great toe, wrap-around procedure, use 26551)
⃠ 20974 Electrical stimulation to aid bone healing; noninvasive
(nonoperative)
➲ CPT Assistant Sep 96:11, Nov 00:8
⃠ 20975 invasive (operative)

20979 Low intensity ultrasound stimulation to aid bone healing,

noninvasive (nonoperative)
➲ CPT Assistant Nov 99:10, Nov 00:8
20982 Ablation therapy for reduction or eradication of 1 or more

bone tumors (eg, metastasis) including adjacent soft tissue
when involved by tumor extension, percutaneous, including
imaging guidance when performed; radiofrequency
➲ CPT Assistant Jul 15:8, Sep 15:12
20983 cryoablation
77002, 77013, 77022)
✚ 20985 Computer-assisted surgical navigational procedure for
musculoskeletal procedures, image-less (List separately in

(For computer-assisted navigational procedures with image
guidance based on pre-operative and intraoperatively
obtained images, see 0054T, 0055T)
20999 Unlisted procedure, musculoskeletal system, general
➲ CPT Assistant Sep 03:13, Jul 15:8, May 18:3
Head
Skull, facial bones, and temporomandibular joint.
Incision
(For incision and drainage procedures,
cutaneous/subcutaneous, see 10060, 10061)
(For removal of embedded foreign body from dentoalveolar
structure, see 41805, 41806)
21010 Arthrotomy, temporomandibular joint
(To report bilateral procedure, report 21010 with modifier
50)
Excision
21011 Excision, tumor, soft tissue of face or scalp, subcutaneous;
less than 2 cm
➲ CPT Assistant Feb 10:3, Apr 10:3, Sep 18:7
21012 2 cm or greater
(For excision of benign lesions of cutaneous origin [eg,

sebaceous cyst], see 11420-11426)
21013 Excision, tumor, soft tissue of face and scalp, subfascial (eg,
subgaleal, intramuscular); less than 2 cm
21015 Radical resection of tumor (eg, sarcoma), soft tissue of face

or scalp; less than 2 cm
(To report excision of skull tumor for osteomyelitis, use

61501)
(For radical resection of tumor[s] of cutaneous origin [eg,

melanoma], see 11620-11646)
21025 Excision of bone (eg, for osteomyelitis or bone abscess);
mandible
21026 facial bone(s)

21029 Removal by contouring of benign tumor of facial bone (eg,
fibrous dysplasia)
21030 Excision of benign tumor or cyst of maxilla or zygoma by
enucleation and curettage
21031 Excision of torus mandibularis

21032 Excision of maxillary torus palatinus
21034 Excision of malignant tumor of maxilla or zygoma
21040 Excision of benign tumor or cyst of mandible, by enucleation

and/or curettage
(For enucleation and/or curettage of benign cysts or tumors

of mandible not requiring osteotomy, use 21040)
(For excision of benign tumor or cyst of mandible requiring
osteotomy, see 21046-21047)
21044 Excision of malignant tumor of mandible;
21045 radical resection
(For bone graft, use 21215)
21046 Excision of benign tumor or cyst of mandible; requiring
intra-oral osteotomy (eg, locally aggressive or destructive
lesion[s])
21047 requiring extra-oral osteotomy and partial
mandibulectomy (eg, locally aggressive or destructive
lesion[s])
21048 Excision of benign tumor or cyst of maxilla; requiring intra-

oral osteotomy (eg, locally aggressive or destructive
lesion[s])
21049 requiring extra-oral osteotomy and partial maxillectomy

(eg, locally aggressive or destructive lesion[s])
21050 Condylectomy, temporomandibular joint (separate

procedure)
(For bilateral procedures, report 21050 with modifier 50)
21060 Meniscectomy, partial or complete, temporomandibular
joint (separate procedure)
21070 Coronoidectomy (separate procedure)
Manipulation
21073 Manipulation of temporomandibular joint(s) (TMJ),
therapeutic, requiring an anesthesia service (ie, general or
monitored anesthesia care)
➲ CPT Assistant Feb 08:9, Jan 18:3
(For TMJ manipulation without an anesthesia service [ie,
general or monitored anesthesia care], see 97140, 98925-
98929, 98943)
(For closed treatment of temporomandibular dislocation, see
21480, 21485)
Head Prosthesis
Codes 21076-21089 describe professional services for the
rehabilitation of patients with oral, facial, or other anatomical
deficiencies by means of prostheses such as an artificial eye, ear,
or nose or intraoral obturator to close a cleft. Codes 21076-21089
should only be used when the physician or other qualified health
care professional actually designs and prepares the prosthesis (ie,
not prepared by an outside laboratory).
(For application or removal of caliper or tongs, see 20660,
20665)
21076 Impression and custom preparation; surgical obturator
prosthesis
21077 orbital prosthesis
21079 interim obturator prosthesis
➲ CPT Assistant Winter 90:5, Sep 06:13, Dec 06:10
21080 definitive obturator prosthesis

21081 mandibular resection prosthesis

21082 palatal augmentation prosthesis

21083 palatal lift prosthesis

21084 speech aid prosthesis
21085 oral surgical splint

➲ CPT Assistant Winter 90:5, Sep 06:13, Dec 06:10,
Sep 17:14
21086 auricular prosthesis
21087 nasal prosthesis

21088 facial prosthesis

Other Procedures
21089 Unlisted maxillofacial prosthetic procedure

21100 Application of halo type appliance for maxillofacial
fixation, includes removal (separate procedure)
21110 Application of interdental fixation device for conditions
other than fracture or dislocation, includes removal
(For removal of interdental fixation by another individual,

see 20670-20680)
21116 Injection procedure for temporomandibular joint
arthrography
➲ CPT Assistant Aug 15:6, May 16:13
(For radiological supervision and interpretation, use 70332.
Do not report 77002 in conjunction with 70332)
Repair, Revision, and/or Reconstruction

(For cranioplasty, see 21179, 21180 and 62120, 62140-
62147)
21120 Genioplasty; augmentation (autograft, allograft, prosthetic
material)
21121 sliding osteotomy, single piece
21122 sliding osteotomies, 2 or more osteotomies (eg, wedge
excision or bone wedge reversal for asymmetrical chin)
21123 sliding, augmentation with interpositional bone grafts
(includes obtaining autografts)
21125 Augmentation, mandibular body or angle; prosthetic material
21127 with bone graft, onlay or interpositional (includes
obtaining autograft)
21137 Reduction forehead; contouring only
21138 contouring and application of prosthetic material or bone
graft (includes obtaining autograft)
21139 contouring and setback of anterior frontal sinus wall
21141 Reconstruction midface, LeFort I; single piece, segment
movement in any direction (eg, for Long Face Syndrome),
without bone graft
21142 2 pieces, segment movement in any direction, without
bone graft
21143 3 or more pieces, segment movement in any direction,
without bone graft
21145 single piece, segment movement in any direction,
requiring bone grafts (includes obtaining autografts)
21146 2 pieces, segment movement in any direction, requiring
bone grafts (includes obtaining autografts) (eg, ungrafted
unilateral alveolar cleft)
21147 3 or more pieces, segment movement in any direction,
requiring bone grafts (includes obtaining autografts) (eg,
ungrafted bilateral alveolar cleft or multiple
osteotomies)
21150 Reconstruction midface, LeFort II; anterior intrusion (eg,
Treacher-Collins Syndrome)
21151 any direction, requiring bone grafts (includes obtaining
autografts)
21154 Reconstruction midface, LeFort III (extracranial), any type,
requiring bone grafts (includes obtaining autografts); without
LeFort I
21155 with LeFort I
21159 Reconstruction midface, LeFort III (extra and intracranial)
with forehead advancement (eg, mono bloc), requiring bone
grafts (includes obtaining autografts); without LeFort I
21160 with LeFort I
21172 Reconstruction superior-lateral orbital rim and lower
forehead, advancement or alteration, with or without grafts
(includes obtaining autografts)
(For frontal or parietal craniotomy performed for
craniosynostosis, use 61556)
21175 Reconstruction, bifrontal, superior-lateral orbital rims and
lower forehead, advancement or alteration (eg,
plagiocephaly, trigonocephaly, brachycephaly), with or
without grafts (includes obtaining autografts)
(For bifrontal craniotomy performed for craniosynostosis,
use 61557)
21179 Reconstruction, entire or majority of forehead and/or
supraorbital rims; with grafts (allograft or prosthetic
material)
21180 with autograft (includes obtaining grafts)
(For extensive craniectomy for multiple suture
craniosynostosis, use only 61558 or 61559)
21181 Reconstruction by contouring of benign tumor of cranial
bones (eg, fibrous dysplasia), extracranial
21182 Reconstruction of orbital walls, rims, forehead,
nasoethmoid complex following intra- and extracranial
excision of benign tumor of cranial bone (eg, fibrous
dysplasia), with multiple autografts (includes obtaining
grafts); total area of bone grafting less than 40 sq cm
21183 total area of bone grafting greater than 40 sq cm but less
than 80 sq cm
21184 total area of bone grafting greater than 80 sq cm

(For excision of benign tumor of cranial bones, see 61563,

61564)
21188 Reconstruction midface, osteotomies (other than LeFort
type) and bone grafts (includes obtaining autografts)
21193 Reconstruction of mandibular rami, horizontal, vertical, C,
or L osteotomy; without bone graft
21194 with bone graft (includes obtaining graft)

21195 Reconstruction of mandibular rami and/or body, sagittal

split; without internal rigid fixation
21196 with internal rigid fixation
Reconstruction of Mandibular Rami

21196
The mandibular ramus is reconstructed to lengthen, set back, or rotate the mandible.
21198 Osteotomy, mandible, segmental;

21199 with genioglossus advancement

(To report total osteotomy of the maxilla, see 21141-21160)

21206 Osteotomy, maxilla, segmental (eg, Wassmund or
Schuchard)
21208 Osteoplasty, facial bones; augmentation (autograft, allograft,
or prosthetic implant)
21209 reduction
21210 Graft, bone; nasal, maxillary or malar areas (includes
obtaining graft)
(For cleft palate repair, see 42200-42225)
21215 mandible (includes obtaining graft)
21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear
(includes obtaining graft)
21235 ear cartilage, autogenous, to nose or ear (includes
obtaining graft)
(To report graft augmentation of facial bones, use 21208)
21240 Arthroplasty, temporomandibular joint, with or without
autograft (includes obtaining graft)
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with prosthetic joint
replacement
21244 Reconstruction of mandible, extraoral, with transosteal bone
plate (eg, mandibular staple bone plate)
21245 Reconstruction of mandible or maxilla, subperiosteal
implant; partial
21246 complete
21247 Reconstruction of mandibular condyle with bone and
cartilage autografts (includes obtaining grafts) (eg, for
hemifacial microsomia)
21248 Reconstruction of mandible or maxilla, endosteal implant
(eg, blade, cylinder); partial
21249 complete
(To report midface reconstruction, see 21141-21160)
21255 Reconstruction of zygomatic arch and glenoid fossa with
bone and cartilage (includes obtaining autografts)
21256 Reconstruction of orbit with osteotomies (extracranial) and
with bone grafts (includes obtaining autografts) (eg, micro-
ophthalmia)
21260 Periorbital osteotomies for orbital hypertelorism, with bone
grafts; extracranial approach
21261 combined intra- and extracranial approach
21263 with forehead advancement
21267 Orbital repositioning, periorbital osteotomies, unilateral,
with bone grafts; extracranial approach
21268 combined intra- and extracranial approach
21270 Malar augmentation, prosthetic material
(For malar augmentation with bone graft, use 21210)
21275 Secondary revision of orbitocraniofacial reconstruction
21280 Medial canthopexy (separate procedure)
(For medial canthoplasty, use 67950)
21282 Lateral canthopexy
21295 Reduction of masseter muscle and bone (eg, for treatment of
benign masseteric hypertrophy); extraoral approach
21296 intraoral approach
Other Procedures
21299 Unlisted craniofacial and maxillofacial procedure
Fracture and/or Dislocation

(For operative repair of skull fracture, see 62000-62010)
(To report closed treatment of skull fracture, use the
appropriate Evaluation and Management code)
21310 Closed treatment of nasal bone fracture without
manipulation
➲ CPT Assistant Jan 18:3, Sep 19:3, Nov 19:12
21315 Closed treatment of nasal bone fracture; without

stabilization
➲ CPT Assistant Jan 18:3, Sep 19:3
21320 with stabilization

21325 Open treatment of nasal fracture; uncomplicated

21330 complicated, with internal and/or external skeletal
fixation
21335 with concomitant open treatment of fractured septum
21336 Open treatment of nasal septal fracture, with or without
stabilization
21337 Closed treatment of nasal septal fracture, with or without
stabilization
21338 Open treatment of nasoethmoid fracture; without external

fixation
21339 with external fixation
21340 Percutaneous treatment of nasoethmoid complex fracture,
with splint, wire or headcap fixation, including repair of
canthal ligaments and/or the nasolacrimal apparatus
21343 Open treatment of depressed frontal sinus fracture
21344 Open treatment of complicated (eg, comminuted or
involving posterior wall) frontal sinus fracture, via coronal
or multiple approaches
21345 Closed treatment of nasomaxillary complex fracture (LeFort
II type), with interdental wire fixation or fixation of denture
or splint
21346 Open treatment of nasomaxillary complex fracture (LeFort II
type); with wiring and/or local fixation
21347 requiring multiple open approaches
21348 with bone grafting (includes obtaining graft)
21355 Percutaneous treatment of fracture of malar area, including
zygomatic arch and malar tripod, with manipulation
21356 Open treatment of depressed zygomatic arch fracture (eg,
Gillies approach)
21360 Open treatment of depressed malar fracture, including
zygomatic arch and malar tripod
21365 Open treatment of complicated (eg, comminuted or
involving cranial nerve foramina) fracture(s) of malar area,
including zygomatic arch and malar tripod; with internal
fixation and multiple surgical approaches
21385 Open treatment of orbital floor blowout fracture; transantral
approach (Caldwell-Luc type operation)
21386 periorbital approach
21387 combined approach
21390 periorbital approach, with alloplastic or other implant
21395 periorbital approach with bone graft (includes obtaining
graft)
21400 Closed treatment of fracture of orbit, except blowout;
without manipulation
21401 with manipulation
21406 Open treatment of fracture of orbit, except blowout; without
implant
21407 with implant
21421 Closed treatment of palatal or maxillary fracture (LeFort I
type), with interdental wire fixation or fixation of denture or
splint
21422 Open treatment of palatal or maxillary fracture (LeFort I
type);
21423 complicated (comminuted or involving cranial nerve
foramina), multiple approaches
21431 Closed treatment of craniofacial separation (LeFort III type)
using interdental wire fixation of denture or splint
21432 Open treatment of craniofacial separation (LeFort III type);
with wiring and/or internal fixation
21433 complicated (eg, comminuted or involving cranial nerve
foramina), multiple surgical approaches
21435 complicated, utilizing internal and/or external fixation
techniques (eg, head cap, halo device, and/or
intermaxillary fixation)
(For removal of internal or external fixation device, use
20670)
21436 complicated, multiple surgical approaches, internal
fixation, with bone grafting (includes obtaining graft)
21440 Closed treatment of mandibular or maxillary alveolar ridge
fracture (separate procedure)
21445 Open treatment of mandibular or maxillary alveolar ridge
fracture (separate procedure)
21450 Closed treatment of mandibular fracture; without
manipulation
21452 Percutaneous treatment of mandibular fracture, with external
fixation
21453 Closed treatment of mandibular fracture with interdental
fixation
➲ CPT Assistant Dec 07:7, 8
21454 Open treatment of mandibular fracture with external fixation

21461 Open treatment of mandibular fracture; without interdental
fixation
21462 with interdental fixation
21465 Open treatment of mandibular condylar fracture
21470 Open treatment of complicated mandibular fracture by
multiple surgical approaches including internal fixation,
interdental fixation, and/or wiring of dentures or splints
21480 Closed treatment of temporomandibular dislocation; initial

or subsequent
21485 complicated (eg, recurrent requiring intermaxillary
fixation or splinting), initial or subsequent
21490 Open treatment of temporomandibular dislocation
(For interdental wire fixation, use 21497)
(To report treatment of closed fracture of larynx, use the
applicable Evaluation and Management codes)
21497 Interdental wiring, for condition other than fracture
Other Procedures
21499 Unlisted musculoskeletal procedure, head
(For unlisted craniofacial or maxillofacial procedure, use
21299)
Neck (Soft Tissues) and Thorax
(For cervical spine and back, see 21920 et seq)
(For injection of fracture site or trigger point, use 20550)
Incision
(For incision and drainage of abscess or hematoma,
superficial, see 10060, 10140)
21501 Incision and drainage, deep abscess or hematoma, soft
tissues of neck or thorax;
(For posterior spine subfascial incision and drainage, see

22010-22015)
21502 with partial rib ostectomy
21510 Incision, deep, with opening of bone cortex (eg, for
osteomyelitis or bone abscess), thorax
Excision
(For bone biopsy, see 20220-20251)
21550 Biopsy, soft tissue of neck or thorax
(For needle biopsy of soft tissue, use 20206)
21555 Excision, tumor, soft tissue of neck or anterior thorax,
subcutaneous; less than 3 cm
# 21552 3 cm or greater
21556 Excision, tumor, soft tissue of neck or anterior thorax,
subfascial (eg, intramuscular); less than 5 cm
21557 Radical resection of tumor (eg, sarcoma), soft tissue of neck

or anterior thorax; less than 5 cm
➲ CPT Assistant Apr 10:11, Apr 20:10

21600 Excision of rib, partial
➲ CPT Assistant Jul 12:12, Mar 13:13
(For radical resection of chest wall and rib cage for tumor,
use 21601)
(For radical debridement of chest wall and rib cage for
injury, see 11044, 11047)
21601 Excision of chest wall tumor including rib(s)
21602 Excision of chest wall tumor involving rib(s), with plastic

reconstruction; without mediastinal lymphadenectomy
21603 with mediastinal lymphadenectomy
(Do not report 21601, 21602, 21603 in conjunction with

32100, 32503, 32504, 32551, 32554, 32555)
21610 Costotransversectomy (separate procedure)
21615 Excision first and/or cervical rib;
21616 with sympathectomy

21620 Ostectomy of sternum, partial
21627 Sternal debridement
(For debridement and closure, use 21750)

21630 Radical resection of sternum;
21632 with mediastinal lymphadenectomy

(For superficial wound, see Integumentary System section
under Repair—Simple)
21685 Hyoid myotomy and suspension
21700 Division of scalenus anticus; without resection of cervical

rib
21705 with resection of cervical rib
21720 Division of sternocleidomastoid for torticollis, open

operation; without cast application
(For transection of spinal accessory and cervical nerves,
see 63191, 64722)
21725 with cast application
21740 Reconstructive repair of pectus excavatum or carinatum;
open
21742 minimally invasive approach (Nuss procedure), without

thoracoscopy
21743 minimally invasive approach (Nuss procedure), with

thoracoscopy
21750 Closure of median sternotomy separation with or without

debridement (separate procedure)

(To report closed treatment of an uncomplicated rib fracture,
use the Evaluation and Management codes)
21811 Open treatment of rib fracture(s) with internal fixation,
includes thoracoscopic visualization when performed,
unilateral; 1-3 ribs
(For bilateral procedure, report 21811 with modifier 50)

21812 4-6 ribs
21813 7 or more ribs

21820 Closed treatment of sternum fracture
21825 Open treatment of sternum fracture with or without skeletal
fixation
(For sternoclavicular dislocation, see 23520-23532)
Other Procedures
21899 Unlisted procedure, neck or thorax
Back and Flank

Excision
21920 Biopsy, soft tissue of back or flank; superficial
21925 deep
21930 Excision, tumor, soft tissue of back or flank, subcutaneous;
less than 3 cm

21932 Excision, tumor, soft tissue of back or flank, subfascial (eg,
intramuscular); less than 5 cm
21935 Radical resection of tumor (eg, sarcoma), soft tissue of back

or flank; less than 5 cm

Spine (Vertebral Column)

Cervical, thoracic, and lumbar spine.
Within the spine section, bone grafting procedures are reported
separately and in addition to arthrodesis. For bone grafts in other
Musculoskeletal sections, see specific code(s) descriptor(s)
and/or accompanying guidelines.
To report bone grafts performed after arthrodesis, see 20930-
20938. Do not append modifier 62 to bone graft codes 20900-
20938.
Example:
Posterior arthrodesis of L5-S1 for degenerative disc disease
utilizing morselized autogenous iliac bone graft harvested
through a separate fascial incision.
Report as 22612 and 20937.
Within the spine section, instrumentation is reported separately
and in addition to arthrodesis. To report instrumentation
procedures performed with definitive vertebral procedure(s), see
22840-22855, 22859. Instrumentation procedure codes 22840-
22848, 22853, 22854, 22859 are reported in addition to the
definitive procedure(s). Modifier 62 may not be appended to the
definitive or add-on spinal instrumentation procedure code(s)
22840-22848, 22850, 22852, 22853, 22854, 22859.
Example:
Posterior arthrodesis of L4-S1, utilizing morselized autogenous
iliac bone graft harvested through separate fascial incision, and
pedicle screw fixation.
Report as 22612, 22614, 22842, and 20937.
Vertebral procedures are sometimes followed by arthrodesis and
in addition may include bone grafts and instrumentation.
When arthrodesis is performed in addition to another procedure,
the arthrodesis should be reported in addition to the original
procedure with modifier 51 (multiple procedures). Examples are
after osteotomy, fracture care, vertebral corpectomy, and
laminectomy. Bone grafts and instrumentation are never
performed without arthrodesis.
Example:
Treatment of a burst fracture of L2 by corpectomy followed by
arthrodesis of L1-L3, utilizing anterior instrumentation L1-L3 and
structural allograft.
Report as 63090, 22558-51, 22585, 22845, and 20931.
When two surgeons work together as primary surgeons
performing distinct part(s) of a single reportable procedure, each
surgeon should report his/her distinct operative work by
appending modifier 62 to the single definitive procedure code. If
additional procedure(s) (including add-on procedure[s]) are
performed during the same surgical session, separate code(s) may
be reported by each co-surgeon, with modifier 62 appended (see
Appendix A).
Example:
A 42-year-old male with a history of posttraumatic degenerative
disc disease at L3-4 and L4-5 (internal disc disruption) underwent
surgical repair. Surgeon A performed an anterior exposure of the
spine with mobilization of the great vessels. Surgeon B
performed anterior (minimal) discectomy and fusion at L3-4 and
L4-5 using anterior interbody technique.
Report surgeon A: 22558 append modifier 62, 22585 append
modifier 62
Report surgeon B: 22558 append modifier 62, 22585 append
modifier 62, 20931
(Do not append modifier 62 to bone graft code 20931)
(For injection procedure for myelography, use 62284)
(For injection procedure for discography, see 62290,
62291)
(For injection procedure, chemonucleolysis, single or
multiple levels, use 62292)
(For injection procedure for facet joints, see 64490-64495,
64633-64636)
(For needle or trocar biopsy, see 20220-20225)
Incision
22010 Incision and drainage, open, of deep abscess (subfascial),
posterior spine; cervical, thoracic, or cervicothoracic
22015 lumbar, sacral, or lumbosacral

(Do not report 22015 in conjunction with instrumentation
removal, 10180, 22850, 22852)
superficial, see 10060, 10140)
Excision
For the following codes, when two surgeons work together as
primary surgeons performing distinct part(s) of partial vertebral
body excision, each surgeon should report his/her distinct
operative work by appending modifier 62 to the procedure code.
In this situation, modifier 62 may be appended to the procedure
code(s) 22100-22102, 22110-22114 and, as appropriate, to the
associated additional vertebral segment add-on code(s) 22103,
22116 as long as both surgeons continue to work together as
primary surgeons.
(For bone biopsy, see 20220-20251)
(To report soft tissue biopsy of back or flank, see 21920-
21925)
(To report excision of soft tissue tumor of back or flank, use
21930)
22100 Partial excision of posterior vertebral component (eg,
spinous process, lamina or facet) for intrinsic bony lesion,
single vertebral segment; cervical
22101 thoracic
22102 lumbar
(For insertion of posterior spinous process distraction

devices, see 22867, 22868, 22869, 22870)
✚ 22103 each additional segment (List separately in addition to
(Use 22103 in conjunction with 22100, 22101, 22102)

22110 Partial excision of vertebral body, for intrinsic bony lesion,
without decompression of spinal cord or nerve root(s),
22112 thoracic
22114 lumbar
✚ 22116 each additional vertebral segment (List separately in


(For complete or near complete resection of vertebral body,
see vertebral corpectomy, 63081-63091)
(For spinal reconstruction with bone graft [autograft,
allograft] and/or methylmethacrylate of cervical vertebral
body, use 63081 and 22554 and 20931 or 20938)
allograft] and/or methylmethacrylate of thoracic vertebral
body, use 63085 or 63087 and 22556 and 20931 or 20938)
allograft] and/or methylmethacrylate of lumbar vertebral
body, use 63087 or 63090 and 22558 and 20931 or 20938)
(For spinal reconstruction following vertebral body
resection, use 63082 or 63086 or 63088 or 63091, and
22585)
(For harvest of bone autograft for vertebral reconstruction,
see 20931 or 20938)
(For cervical spinal reconstruction with prosthetic
replacement of resected vertebral bodies, see codes 63081
and 22554 and 20931 or 20938 and 22853, 22854, 22859)
(For thoracic spinal reconstruction with prosthetic
or 63087 and 22556 and 20931 or 20938 and 22853, 22854,
22859)
(For lumbar spinal reconstruction with prosthetic
or 63090 and 22558 and 20931 or 20938 and 22853, 22854,
22859)
(For osteotomy of spine, see 22210-22226)
Osteotomy
To report arthrodesis, see codes 22590-22632. (Report in addition
to code[s] for the definitive procedure with modifier 51.)
To report instrumentation procedures, see 22840-22855, 22859.
(Report in addition to code[s] for the definitive procedure[s].)
Do not append modifier 62 to spinal instrumentation codes
22840-22848, 22850, 22852, 22853, 22854, 22859.
To report bone graft procedures, see 20930-20938. (Report in
addition to code[s] for the definitive procedure[s].) Do not
append modifier 62 to bone graft codes 20900-20938.
primary surgeons performing distinct part(s) of an anterior spine
osteotomy, each surgeon should report his/her distinct operative
work by appending modifier 62 to the procedure code. In this
situation, modifier 62 may be appended to the procedure code(s)
22210-22214, 22220-22224 and, as appropriate, to associated
additional segment add-on code(s) 22216, 22226 as long as both
surgeons continue to work together as primary surgeons.
Spinal osteotomy procedures are reported when a portion(s) of
the vertebral segment(s) is cut and removed in preparation for re-
aligning the spine as part of a spinal deformity correction. For
excision of an intrinsic lesion of the vertebra without deformity
correction, see 22100-22116. For decompression of the spinal
cord and/or nerve roots, see 63001-63308.
The three columns are defined as anterior (anterior two-thirds of
the vertebral body), middle (posterior third of the vertebral body
and the pedicle), and posterior (articular facets, lamina, and
spinous process).
22206 Osteotomy of spine, posterior or posterolateral approach, 3
columns, 1 vertebral segment (eg, pedicle/vertebral body
subtraction); thoracic

22207 lumbar

22210-22226, 22830, 63001-63048, 63055-63066, 63075-
63091, 63101-63103, when performed at the same level)
22210 Osteotomy of spine, posterior or posterolateral approach, 1
vertebral segment; cervical
22212 thoracic
➲ CPT Assistant Dec 07:1, Jul 13:3
22214 lumbar
➲ CPT Assistant Dec 07:1, Jul 13:3, Dec 14:16

addition to primary procedure)

22220 Osteotomy of spine, including discectomy, anterior
approach, single vertebral segment; cervical
22222 thoracic
22224 lumbar

➲ CPT Assistant Feb 96:6, Feb 02:4
(For vertebral corpectomy, see 63081-63091)

To report arthrodesis, see codes 22590-22632. (Report in addition
to code[s] for the definitive procedure with modifier 51.)
22840-22848, 22850, 22852, 22853, 22854, 22859.
primary surgeons performing distinct part(s) of open fracture
and/or dislocation procedure(s), each surgeon should report
his/her distinct operative work by appending modifier 62 to the
procedure code. In this situation, modifier 62 may be appended
to the procedure code(s) 22318-22327 and, as appropriate, the
associated additional fracture vertebrae or dislocated segment
add-on code 22328 as long as both surgeons continue to work
together as primary surgeons.
(22305 has been deleted. To report, see the appropriate
evaluation and management codes)
22310 Closed treatment of vertebral body fracture(s), without
manipulation, requiring and including casting or bracing
➲ CPT Assistant Jun 12:10, Jul 13:3, Jul 14:8
22512, 22513, 22514, 22515, when performed at the same
level)
22315 Closed treatment of vertebral fracture(s) and/or
dislocation(s) requiring casting or bracing, with and
including casting and/or bracing by manipulation or traction
➲ CPT Assistant Apr 12:11, Jun 12:10, Jul 13:3

level)
(For spinal subluxation, use 97140)
22318 Open treatment and/or reduction of odontoid fracture(s) and
or dislocation(s) (including os odontoideum), anterior
approach, including placement of internal fixation; without
grafting
➲ CPT Assistant Nov 99:11, Apr 12:13, Jul 13:3
22319 with grafting

22325 Open treatment and/or reduction of vertebral fracture(s)

and/or dislocation(s), posterior approach, 1 fractured
vertebra or dislocated segment; lumbar
➲ CPT Assistant Sep 97:8, Jun 12:10, Jul 13:3, Aug 17:9

22514, 22515 when performed at the same level)
22326 cervical
➲ CPT Assistant Sep 97:8, Jul 13:3

when performed at the same level)
22327 thoracic
➲ CPT Assistant Sep 97:8, Jun 12:10, Jul 13:3

22513, 22515 when performed at the same level)
✚ 22328 each additional fractured vertebra or dislocated segment
procedure)

(For treatment of vertebral fracture by the anterior approach,
see corpectomy 63081-63091, and appropriate arthrodesis,
bone graft and instrument codes)
(For decompression of spine following fracture, see 63001-
63091; for arthrodesis of spine following fracture, see
22548-22632)
Manipulation
(For spinal manipulation without anesthesia, use 97140)
22505 Manipulation of spine requiring anesthesia, any region
➲ CPT Assistant Mar 97:11, Jan 99:11
Percutaneous Vertebroplasty and Vertebral

Augmentation
Codes 22510, 22511, 22512, 22513, 22514, 22515 describe
procedures for percutaneous vertebral augmentation that include
vertebroplasty of the cervical, thoracic, lumbar, and sacral spine
and vertebral augmentation of the thoracic and lumbar spine.
For the purposes of reporting 22510, 22511, 22512, 22513, 22514,
22515, “vertebroplasty” is the process of injecting a material
(cement) into the vertebral body to reinforce the structure of the
body using image guidance. “Vertebral augmentation” is the
process of cavity creation followed by the injection of the
material (cement) under image guidance. For 0200T and 0201T,
“sacral augmentation (sacroplasty)” refers to the creation of a
cavity within a sacral vertebral body followed by injection of a
material to fill that cavity.
The procedure codes are inclusive of bone biopsy, when
performed, and imaging guidance necessary to perform the
procedure. Use one primary procedure code and an add-on code
for additional levels. When treating the sacrum, sacral procedures
are reported only once per encounter.
22510 Percutaneous vertebroplasty (bone biopsy included when
performed), 1 vertebral body, unilateral or bilateral
injection, inclusive of all imaging guidance; cervicothoracic
15:14
Percutaneous Vertebroplasty
22510
Augmentation of a vertebral fracture is achieved by percutaneous injections of polymethylmethacrylate
under fluoroscopic guidance.
22511 lumbosacral
➲ Clinical Examples in Radiology Fall 14:3, 4
✚ 22512 each additional cervicothoracic or lumbosacral vertebral

body (List separately in addition to code for primary
procedure)
➲ Clinical Examples in Radiology Fall 14:3, 4,
Summer 15:14
20225, 22310, 22315, 22325, 22327, when performed at the
same level as 22510, 22511, 22512)
22513 Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy included when
performed) using mechanical device (eg, kyphoplasty), 1
vertebral body, unilateral or bilateral cannulation, inclusive
of all imaging guidance; thoracic
➲ Clinical Examples in Radiology Fall 14:3
22514 lumbar
✚ 22515 each additional thoracic or lumbar vertebral body (List


20225, 22310, 22315, 22325, 22327, when performed at the
same level as 22513, 22514, 22515)
Percutaneous Augmentation and Annuloplasty

22526 Percutaneous intradiscal electrothermal annuloplasty,
unilateral or bilateral including fluoroscopic guidance;
single level
➲ CPT Assistant Sep 07:10, Nov 10:3, Jan 11:8, Jan 15:8
✚ 22527 1 or more additional levels (List separately in addition

➲ CPT Assistant Sep 07:10, Nov 10:3, Jan 11:8, Jan
15:8
(Do not report codes 22526, 22527 in conjunction with
77002, 77003)
(For percutaneous intradiscal annuloplasty using method
other than electrothermal, use 22899)
Arthrodesis
Arthrodesis may be performed in the absence of other
procedures and therefore when it is combined with another
definitive procedure (eg, osteotomy, fracture care, vertebral
corpectomy or laminectomy), modifier 51 is appropriate.
However, arthrodesis codes 22585, 22614, and 22632 are
considered add-on procedure codes and should not be used with
modifier 51.
(Codes 22840-22848, 22853, 22854, 22859 are reported in
conjunction with code[s] for the definitive procedure[s]. When
instrumentation reinsertion or removal is reported in conjunction
with other definitive procedures, including arthrodesis,
decompression, and exploration of fusion, append modifier 51 to
22849, 22850, 22852, and 22855.) To report exploration of fusion,
use 22830. (When exploration is reported in conjunction with
other definitive procedures, including arthrodesis and
decompression, append modifier 51 to 22830.) Do not append
modifier 62 to spinal instrumentation codes 22840-22848, 22850,
22852, 22853, 22854, 22859.
Lateral Extracavitary Approach Technique

22532 Arthrodesis, lateral extracavitary technique, including
minimal discectomy to prepare interspace (other than for
decompression); thoracic
22533 lumbar
✚ 22534 thoracic or lumbar, each additional vertebral segment

procedure)
(Use 22534 in conjunction with 22532 and 22533)
Anterior or Anterolateral Approach Technique
Procedure codes 22554-22558 are for SINGLE interspace; for

additional interspaces, use 22585. A vertebral interspace is the
non-bony compartment between two adjacent vertebral bodies,
which contains the intervertebral disc, and includes the nucleus
pulposus, annulus fibrosus, and two cartilaginous endplates.
primary surgeons performing distinct part(s) of an anterior
interbody arthrodesis, each surgeon should report his/her distinct
In this situation, modifier 62 may be appended to the procedure
code(s) 22548-22558 and, as appropriate, to the associated
additional interspace add-on code 22585 as long as both surgeons
continue to work together as primary surgeons.
22548 Arthrodesis, anterior transoral or extraoral technique,
clivus-C1-C2 (atlas-axis), with or without excision of
odontoid process
➲ CPT Assistant Spring 93:36, Feb 96:7, Sep 97:8, Sep
00:10, Feb 02:4, Apr 12:16, Jul 13:3
(For intervertebral disc excision by laminotomy or
laminectomy, see 63020-63042)
Arthrodesis (Anterior Transoral Technique)

22548
22551 Arthrodesis, anterior interbody, including disc space

preparation, discectomy, osteophytectomy and
decompression of spinal cord and/or nerve roots; cervical
below C2
➲ CPT Assistant Apr 12:16, Jul 13:3, Jan 15:13, May
16:13, Aug 18:10
✚ 22552 cervical below C2, each additional interspace (List
➲ CPT Assistant Apr 12:16, Jul 13:3, Aug 18:10

22554 Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for
decompression); cervical below C2
➲ CPT Assistant Spring 93:36, Sep 97:8, Sep 00:10, Jan
01:12, Feb 02:4, Apr 12:16, Jul 13:3, Apr 15:7
(Do not report 22554 in conjunction with 63075, even if
performed by a separate individual. To report anterior
cervical discectomy and interbody fusion at the same level
during the same session, use 22551)
Anterior Approach for Cervical Fusion

22554
An example of an exposure technique used to reach anterior cervical vertebrae for spinal procedures
(eg, discectomy, arthrodesis, spinal instrumentation)
22556 thoracic
➲ CPT Assistant Spring 93:36, Jul 96:7, Sep 97:8, Sep
00:10, Feb 02:4, Apr 12:16, Jul 13:3
22558 lumbar
➲ CPT Assistant Spring 93:36, Mar 96:6, Jul 96:7, Sep
97:8, Sep 00:10, Feb 02:4, Oct 09:9, Apr 12:16, Jul
13:3, Mar 15:9
(For arthrodesis using pre-sacral interbody technique, use
22586)
Anterior Approach for Lumbar Fusion (Anterior

Retroperitoneal Exposure)
22558
An example of an exposure technique used to reach anterior lumbar vertebrae for spinal procedures
(eg, discectomy, arthrodesis, spinal instrumentation)
✚ 22585 each additional interspace (List separately in addition to
➲ CPT Assistant Spring 93:36, Feb 96:6, Mar 96:6,
Sep 97:8, Sep 00:10, Feb 02:4, Apr 08:11
performed by a separate individual. To report anterior
22586 Arthrodesis, pre-sacral interbody technique, including disc
space preparation, discectomy, with posterior
instrumentation, with image guidance, includes bone graft
when performed, L5-S1 interspace
(Do not report 22586 in conjunction with 20930-20938,
22840, 22848, 72275, 77002, 77003, 77011, 77012)
Posterior, Posterolateral or Lateral Transverse

Process Technique

22840-22848, 22850, 22852, 22853, 22854, 22859.
A vertebral segment describes the basic constituent part into
which the spine may be divided. It represents a single complete
vertebral bone with its associated articular processes and laminae.
A vertebral interspace is the non-bony compartment between two
adjacent vertebral bodies which contains the intervertebral disc,
and includes the nucleus pulposus, annulus fibrosus, and two
cartilaginous endplates.
22590 Arthrodesis, posterior technique, craniocervical (occiput-
C2)
➲ CPT Assistant Spring 93:36, Sep 97:8, Apr 12:16, Jul
13:3
22595 Arthrodesis, posterior technique, atlas-axis (C1-C2)
➲ CPT Assistant Spring 93:36, Sep 97:8, Apr 12:12, Jul
13:3
22600 Arthrodesis, posterior or posterolateral technique, single
level; cervical below C2 segment
➲ CPT Assistant Spring 93:36, Sep 97:8, Nov 10:8, Apr
12:16, Jun 12:11, Jul 13:3
22610 thoracic (with lateral transverse technique, when
performed)
➲ CPT Assistant Spring 93:36, Sep 97:8, Nov 10:8,
Apr 12:16, Jun 12:10, Jul 13:3
22612 lumbar (with lateral transverse technique, when
performed)
➲ CPT Assistant Spring 93:36, Mar 96:7, Sep 97:8, 11,
Apr 08:11, Jul 08:7, Oct 09:9, Nov 10:8, Dec 11:14,
Jan 12:3, Apr 12:16, Jun 12:10, Jul 13:3, Dec 13:14
(Do not report 22612 in conjunction with 22630 for the
same interspace and segment, use 22633)
➲ CPT Assistant Feb 96:6, Mar 96:7, Nov 10:8, Jun
12:11, Jul 13:3
22630 or 22633 when performed at a different level. When
performing a posterior or posterolateral technique for
fusion/arthrodesis at an additional level, use 22614. When
performing a posterior interbody fusion arthrodesis at an
additional level, use 22632. When performing a combined
posterior or posterolateral technique with posterior
interbody arthrodesis at an additional level, use 22634)
(For facet joint fusion, see 0219T-0222T)
(For placement of a posterior intrafacet implant, see 0219T-
0222T)
22630 Arthrodesis, posterior interbody technique, including
laminectomy and/or discectomy to prepare interspace (other
than for decompression), single interspace; lumbar
➲ CPT Assistant Spring 93:36, Sep 97:8, Nov 99:11, Dec
99:2, Jan 01:12, Oct 09:9, Nov 11:10, Dec 11:14, Jan
12:3, Apr 12:16, Jun 12:11, Jul 13:3
same interspace and segment, use 22633)
✚ 22632 each additional interspace (List separately in addition to
➲ CPT Assistant Feb 96:6, Sep 97:8, Dec 99:2, Jun
12:11, Jul 13:3
(Use 22632 in conjunction with 22612, 22630, or 22633
when performed at a different level. When performing a
posterior interbody fusion arthrodesis at an additional level,
use 22632. When performing a posterior or posterolateral
technique for fusion/arthrodesis at an additional level, use
22614. When performing a combined posterior or
posterolateral technique with posterior interbody
arthrodesis at an additional level, use 22634)
22633 Arthrodesis, combined posterior or posterolateral technique
with posterior interbody technique including laminectomy
and/or discectomy sufficient to prepare interspace (other
than for decompression), single interspace and segment;
lumbar
➲ CPT Assistant Dec 11:14, Jan 12:3, Jun 12:10, Jul 13:3,
Oct 16:11, May 18:9, Jul 18:14
(Do not report with 22612 or 22630 at the same level)
✚ 22634 each additional interspace and segment (List separately
CPT Assistant Dec 11:14, Jan 12:3, Jun 12:10, Jul
➲
13:3, Jul 18:14
Spine Deformity (eg, Scoliosis, Kyphosis)

22840-22848, 22850, 22852, 22853, 22854, 22859.
primary surgeons performing distinct part(s) of an arthrodesis for
spinal deformity, each surgeon should report his/her distinct
In this situation, modifier 62 may be appended to procedure
code(s) 22800-22819 as long as both surgeons continue to work
22800 Arthrodesis, posterior, for spinal deformity, with or without
cast; up to 6 vertebral segments
➲ CPT Assistant Apr 12:16, Jul 13:3, Sep 17:14
22802 7 to 12 vertebral segments

➲ CPT Assistant Mar 96:10, Apr 12:16, Jul 13:3, Sep
17:14, Jul 18:14
22804 13 or more vertebral segments
➲ CPT Assistant Apr 12:16, Jul 13:3, Sep 17:14
22808 Arthrodesis, anterior, for spinal deformity, with or without
cast; 2 to 3 vertebral segments
➲ CPT Assistant Feb 02:4, Apr 12:16, Jul 13:3, Sep 17:14
22810 4 to 7 vertebral segments

➲ CPT Assistant Mar 96:10, Sep 97:8, Feb 02:4, Apr
12:16, Jul 13:3, Sep 17:14
22812 8 or more vertebral segments
➲ CPT Assistant Feb 02:4, Apr 12:16, Jul 13:3, Sep
17:14
22818 Kyphectomy, circumferential exposure of spine and
resection of vertebral segment(s) (including body and
posterior elements); single or 2 segments
➲ CPT Assistant Nov 97:14, Sep 17:14
22819 3 or more segments

(To report arthrodesis, see 22800-22804 and add modifier

51)
Exploration
(Codes 22840-22848, 22853, 22854, 22859 are reported in
conjunction with code[s] for the definitive procedure[s]. When
instrumentation reinsertion or removal is reported in conjunction
with other definitive procedures, including arthrodesis,
decompression, and exploration of fusion, append modifier 51 to
22849, 22850, 22852, and 22855.) Code 22849 should not be
reported with 22850, 22852, and 22855 at the same spinal levels.
To report exploration of fusion, see 22830. (When exploration is
reported in conjunction with other definitive procedures,
including arthrodesis and decompression, append modifier 51 to
22830.)
(To report bone graft procedures, see 20930-20938)
22830 Exploration of spinal fusion
➲ CPT Assistant Sep 97:11, Mar 10:9, Mar 20:14
Spinal Instrumentation
Segmental instrumentation is defined as fixation at each end of
the construct and at least one additional interposed bony
attachment.
Non-segmental instrumentation is defined as fixation at each end
of the construct and may span several vertebral segments without
attachment to the intervening segments.
Insertion of spinal instrumentation is reported separately and in
addition to arthrodesis. Instrumentation procedure codes 22840-
22848, 22853, 22854, 22859 are reported in addition to the
definitive procedure(s). Do not append modifier 62 to spinal
instrumentation codes 22840-22848, 22850, 22852, 22853, 22854,
22859.
addition to code[s] for definitive procedure[s].) Do not append
modifier 62 to bone graft codes 20900-20938.
A vertebral interspace is the non-bony compartment between two
adjacent vertebral bodies, which contains the intervertebral disc,
and includes the nucleus pulposus, annulus fibrosus, and two
cartilaginous endplates.
Codes 22849, 22850, 22852, and 22855 are subject to modifier 51
if reported with other definitive procedure(s), including
arthrodesis, decompression, and exploration of fusion. Code
22849 should not be reported in conjunction with 22850, 22852,
and 22855 at the same spinal levels. Only the appropriate
insertion code (22840-22848) should be reported when
previously placed spinal instrumentation is being removed or
revised during the same session where new instrumentation is
inserted at levels including all or part of the previously
instrumented segments. Do not report the reinsertion (22849) or
removal (22850, 22852, 22855) procedures in addition to the
insertion of the new instrumentation (22840-22848).
✚ 22840 Posterior non-segmental instrumentation (eg, Harrington rod
technique, pedicle fixation across 1 interspace, atlantoaxial
transarticular screw fixation, sublaminar wiring at C1, facet
screw fixation) (List separately in addition to code for
primary procedure)
➲ CPT Assistant Feb 96:6, Jul 96:10, Sep 97:8, Nov
99:12, Feb 02:6, Nov 10:8, Jan 11:9, Dec 11:15, Apr
12:12, Jun 12:11, Jul 13:3, Dec 13:17, Oct 14:15, Jun
17:10
(Use 22840 in conjunction with 22100-22102, 22110-
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
Non-Segmental Spinal Instrumentation

22840
Fixation at each end of the construct
✚ 22841 Internal spinal fixation by wiring of spinous processes (List

➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, Jun 12:11,
Jul 13:3
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
✚ 22842 Posterior segmental instrumentation (eg, pedicle fixation,
dual rods with multiple hooks and sublaminar wires); 3 to 6
vertebral segments (List separately in addition to code for
primary procedure)
➲ CPT Assistant Feb 96:6, Mar 96:7, Sep 97:8, Feb 02:6,
Dec 11:15, Jun 12:11, Jul 13:3
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
✚ 22843 7 to 12 vertebral segments (List separately in addition to
➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, Dec
11:15, Jun 12:11, Jul 13:3, Jul 18:14
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
✚ 22844 13 or more vertebral segments (List separately in
➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, Dec
11:15, Jun 12:11, Jul 13:3
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
Segmental Spinal Instrumentation

22842-22844
Fixation at each end of the construct and at least one additional interposed bony attachment
✚ 22845 Anterior instrumentation; 2 to 3 vertebral segments (List

➲ CPT Assistant Feb 96:6, Mar 96:10, Jul 96:7, 10, Sep
97:8, Feb 02:6, Jun 12:11, Jul 13:3, Nov 14:14, Jan
15:13, Mar 15:9, Apr 15:7, May 16:13, Mar 17:7
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
✚ 22846 4 to 7 vertebral segments (List separately in addition to
➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, Jun
12:11, Jul 13:3, May 16:13
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
✚ 22847 8 or more vertebral segments (List separately in addition
12:11, Jul 13:3, May 16:13
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
✚ 22848 Pelvic fixation (attachment of caudal end of instrumentation
to pelvic bony structures) other than sacrum (List separately
Jul 13:3
22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
22849 Reinsertion of spinal fixation device
➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, Nov 02:3,
Oct 11:10, Jun 12:11, Jul 13:3, May 16:13, Jun 17:10
22850 Removal of posterior nonsegmental instrumentation (eg,
Harrington rod)
Jul 13:3, May 16:13, Jun 17:10
22852 Removal of posterior segmental instrumentation
➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, May 06:16,
Jun 12:11, Jun 17:10
✚ 22853 Insertion of interbody biomechanical device(s) (eg,
synthetic cage, mesh) with integral anterior instrumentation
for device anchoring (eg, screws, flanges), when performed,
to intervertebral disc space in conjunction with interbody
arthrodesis, each interspace (List separately in addition to
➲ CPT Assistant Mar 17:7, Aug 17:9, Jul 18:14

22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
(Report 22853 for each treated intervertebral disc space)
✚ 22854 Insertion of intervertebral biomechanical device(s) (eg,
synthetic cage, mesh) with integral anterior instrumentation
for device anchoring (eg, screws, flanges), when performed,
to vertebral corpectomy(ies) (vertebral body resection,
partial or complete) defect, in conjunction with interbody
arthrodesis, each contiguous defect (List separately in

22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
#✚ 22859 Insertion of intervertebral biomechanical device(s) (eg,
synthetic cage, mesh, methylmethacrylate) to intervertebral
disc space or vertebral body defect without interbody
arthrodesis, each contiguous defect (List separately in

22114, 22206, 22207, 22210-22214, 22220-22224, 22310-
22327, 22532, 22533, 22548-22558, 22590-22612, 22630,
22633, 22634, 22800-22812, 63001-63030, 63040-63042,
63045-63047, 63050-63056, 63064, 63075, 63077, 63081,
63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-
63307)
(22853, 22854, 22859 may be reported more than once for
noncontiguous defects)
(For application of an intervertebral bone device/graft, see
20930, 20931, 20936, 20937, 20938)
Spinal Prosthetic Devices

22853, 22854, 22859
Application of prosthetic device
22855 Removal of anterior instrumentation
➲ CPT Assistant Feb 96:6, Sep 97:8, Feb 02:6, Nov 02:2,
Jun 12:11, Jun 17:10
22856 Total disc arthroplasty (artificial disc), anterior approach,
including discectomy with end plate preparation (includes
osteophytectomy for nerve root or spinal cord
decompression and microdissection); single interspace,
cervical

level)
(For additional interspace cervical total disc arthroplasty,
use 22858)
#✚ 22858 second level, cervical (List separately in addition to

22857 Total disc arthroplasty (artificial disc), anterior approach,
including discectomy to prepare interspace (other than for
decompression), single interspace, lumbar

22853, 22854, 22859, 49010 when performed at the same
level)
(For additional interspace, use Category III code 0163T)
22861 Revision including replacement of total disc arthroplasty
(artificial disc), anterior approach, single interspace;
cervical

level)
(For additional interspace revision of cervical total disc
arthroplasty, use 0098T)
22862 lumbar

22853, 22854, 22859, 22865, 49010 when performed at the
same level)
(For additional interspace, use Category III code 0165T)
22864 Removal of total disc arthroplasty (artificial disc), anterior
approach, single interspace; cervical

(For additional interspace removal of cervical total disc
arthroplasty, use 0095T)
22865 lumbar
➲ CPT Assistant Jun 07:1, Mar 20:14

(For additional interspace, see Category III code 0164T)
(22856-22865 include fluoroscopy when performed)
(For decompression, see 63001-63048)
22867 Insertion of interlaminar/interspinous process
stabilization/distraction device, without fusion, including
image guidance when performed, with open decompression,
lumbar; single level
✚ 22868 second level (List separately in addition to code for

primary procedure)

22533, 22534, 22558, 22612, 22614, 22630, 22632, 22633,
22634, 22800, 22802, 22804, 22840, 22841, 22842, 22869,
22870, 63005, 63012, 63017, 63030, 63035, 63042, 63044,
63047, 63048, 77003 for the same level)
(For insertion of interlaminar/interspinous process
stabilization/distraction device, without open
decompression or fusion, see 22869, 22870)
22869 Insertion of interlaminar/interspinous process
stabilization/distraction device, without open
decompression or fusion, including image guidance when
performed, lumbar; single level

primary procedure)
22533, 22534, 22558, 22612, 22614, 22630, 22632, 22633,
22634, 22800, 22802, 22804, 22840, 22841, 22842, 63005,
63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048,
77003)
Other Procedures
22899 Unlisted procedure, spine
➲ CPT Assistant May 00:11, Sep 00:10, Jul 06:19, Feb
10:13, Nov 10:4, Jan 12:14, Sep 12:16, Dec 12:13, Dec
13:14, 17, Oct 14:15, Jan 15:8, Feb 17:9, May 18:10
Abdomen
Excision
22900 Excision, tumor, soft tissue of abdominal wall, subfascial
(eg, intramuscular); less than 5 cm
22902 Excision, tumor, soft tissue of abdominal wall,


22904 Radical resection of tumor (eg, sarcoma), soft tissue of
abdominal wall; less than 5 cm

Other Procedures
22999 Unlisted procedure, abdomen, musculoskeletal system
Shoulder
The area known as the shoulder is made up of the clavicle,
scapula, humerus head and neck, sternoclavicular joint,
acromioclavicular joint, and shoulder joint.
Incision
23000 Removal of subdeltoid calcareous deposits, open
(For arthroscopic removal of bursal deposits, use 29999)

23020 Capsular contracture release (eg, Sever type procedure)
(For incision and drainage procedures, superficial, see
10040-10160)
23030 Incision and drainage, shoulder area; deep abscess or
hematoma
23031 infected bursa
23035 Incision, bone cortex (eg, osteomyelitis or bone abscess),
shoulder area
23040 Arthrotomy, glenohumeral joint, including exploration,
drainage, or removal of foreign body
➲ CPT Assistant Nov 98:8, Mar 20:14
23044 Arthrotomy, acromioclavicular, sternoclavicular joint,

including exploration, drainage, or removal of foreign body
Excision
23065 Biopsy, soft tissue of shoulder area; superficial
23066 deep
23075 Excision, tumor, soft tissue of shoulder area, subcutaneous;
less than 3 cm
➲ CPT Assistant Summer 92:22, Nov 98:8, Sep 18:7

23076 Excision, tumor, soft tissue of shoulder area, subfascial (eg,
intramuscular); less than 5 cm
➲ CPT Assistant Summer 92:22, Oct 09:7, Sep 18:7
shoulder area; less than 5 cm

23100 Arthrotomy, glenohumeral joint, including biopsy
23101 Arthrotomy, acromioclavicular joint or sternoclavicular

joint, including biopsy and/or excision of torn cartilage
23105 Arthrotomy; glenohumeral joint, with synovectomy, with or

without biopsy
23106 sternoclavicular joint, with synovectomy, with or without

biopsy
23107 Arthrotomy, glenohumeral joint, with joint exploration, with
or without removal of loose or foreign body
23120 Claviculectomy; partial
(For arthroscopic procedure, use 29824)

23125 total
23130 Acromioplasty or acromionectomy, partial, with or without
coracoacromial ligament release
➲ CPT Assistant Aug 01:11, Feb 15:10, Mar 15:7
23140 Excision or curettage of bone cyst or benign tumor of

clavicle or scapula;
23145 with autograft (includes obtaining graft)
23146 with allograft
proximal humerus;
23170 Sequestrectomy (eg, for osteomyelitis or bone abscess),
clavicle
scapula
humeral head to surgical neck
23180 Partial excision (craterization, saucerization, or
diaphysectomy) bone (eg, osteomyelitis), clavicle

diaphysectomy) bone (eg, osteomyelitis), scapula

diaphysectomy) bone (eg, osteomyelitis), proximal humerus
23190 Ostectomy of scapula, partial (eg, superior medial angle)

23195 Resection, humeral head
(For replacement with implant, use 23470)
23200 Radical resection of tumor; clavicle
23210 scapula
23220 Radical resection of tumor, proximal humerus
(For arthrocentesis or needling of bursa, use 20610)
(For K-wire or pin insertion or removal, see 20650, 20670,
20680)
23330 Removal of foreign body, shoulder; subcutaneous
➲ CPT Assistant Aug 99:3, Mar 14:4
(To report removal of foreign body, see 23330, 23333)

23333 deep (subfascial or intramuscular)
23334 Removal of prosthesis, includes debridement and

synovectomy when performed; humeral or glenoid
component
➲ CPT Assistant Mar 14:4, Mar 20:14
23335 humeral and glenoid components (eg, total shoulder)


23474 if a prosthesis [ie, humeral and/or glenoid
component(s)] is being removed and replaced in the same
shoulder during the same surgical session)
(To report removal of hardware, other than humeral and/or
glenoid prosthesis, use 20680)
23350 Injection procedure for shoulder arthrography or enhanced
CT/MRI shoulder arthrography
➲ CPT Assistant Jul 01:3, Aug 15:6, May 16:13
09:6, 7, Summer 18:14
(For radiographic arthrography, radiological supervision
and interpretation, use 73040. Fluoroscopy [77002] is
inclusive of radiographic arthrography)
(When fluoroscopic guided injection is performed for
enhanced CT arthrography, use 23350, 77002, and 73201 or
73202)
enhanced MR arthrography, use 23350, 77002, and 73222 or
73223)
(For enhanced CT or enhanced MRI arthrography, use
77002 and either 73201, 73202, 73222, or 73223)
(To report biopsy of the shoulder and joint, see 29805-
29826)

23395 Muscle transfer, any type, shoulder or upper arm; single
23397 multiple
23400 Scapulopexy (eg, Sprengels deformity or for paralysis)
23405 Tenotomy, shoulder area; single tendon
23406 multiple tendons through same incision

23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff)

open; acute
➲ CPT Assistant Aug 01:11, Feb 02:11
23412 chronic
15:10
23415 Coracoacromial ligament release, with or without
acromioplasty

23420 Reconstruction of complete shoulder (rotator) cuff avulsion,
chronic (includes acromioplasty)
23430 Tenodesis of long tendon of biceps

(For arthroscopic biceps tenodesis, use 29828)
23440 Resection or transplantation of long tendon of biceps
23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson
type operation
(To report arthroscopic thermal capsulorrhaphy, use 29999)
23455 with labral repair (eg, Bankart procedure)

23460 Capsulorrhaphy, anterior, any type; with bone block
23462 with coracoid process transfer
(To report open thermal capsulorrhaphy, use 23929)
23465 Capsulorrhaphy, glenohumeral joint, posterior, with or
without bone block
(For sternoclavicular and acromioclavicular reconstruction,
see 23530, 23550)
23466 Capsulorrhaphy, glenohumeral joint, any type
multidirectional instability
23470 Arthroplasty, glenohumeral joint; hemiarthroplasty

23472 total shoulder (glenoid and proximal humeral

replacement (eg, total shoulder))
➲ CPT Assistant Jun 96:10, Nov 98:8, Mar 13:12, Mar
14:4
(For removal of total shoulder implants, see 23334, 23335)
(For osteotomy, proximal humerus, use 24400)
23473 Revision of total shoulder arthroplasty, including allograft
when performed; humeral or glenoid component
➲ CPT Assistant Feb 13:11, Mar 13:12, Mar 14:4
23474 humeral and glenoid component


23335 if a prosthesis [ie, humeral and/or glenoid
component(s)] is being removed and replaced in the same
shoulder during the same surgical session)
23480 Osteotomy, clavicle, with or without internal fixation;
23485 with bone graft for nonunion or malunion (includes
obtaining graft and/or necessary fixation)
23490 Prophylactic treatment (nailing, pinning, plating or wiring)
with or without methylmethacrylate; clavicle
23491 proximal humerus
Coding Tip
Reporting for Categories of Manipulation and/or Fracture
The codes for treatment of fractures and joint injuries (dislocations) are
categorized by the type of manipulation (reduction) and stabilization (fixation
or immobilization). These codes can apply to either open (compound) or
closed fractures or joint injuries.
CPT Coding Guidelines, Musculoskeletal System
23500 Closed treatment of clavicular fracture; without

manipulation
23515 Open treatment of clavicular fracture, includes internal
fixation, when performed
23520 Closed treatment of sternoclavicular dislocation; without

manipulation
23530 Open treatment of sternoclavicular dislocation, acute or
chronic;
23532 with fascial graft (includes obtaining graft)
23540 Closed treatment of acromioclavicular dislocation; without
manipulation
23550 Open treatment of acromioclavicular dislocation, acute or
chronic;
23552 with fascial graft (includes obtaining graft)
23570 Closed treatment of scapular fracture; without manipulation

23575 with manipulation, with or without skeletal traction (with
or without shoulder joint involvement)
23585 Open treatment of scapular fracture (body, glenoid or
acromion) includes internal fixation, when performed
23600 Closed treatment of proximal humeral (surgical or

anatomical neck) fracture; without manipulation
23605 with manipulation, with or without skeletal traction
23615 Open treatment of proximal humeral (surgical or anatomical
neck) fracture, includes internal fixation, when performed,
includes repair of tuberosity(s), when performed;
23616 with proximal humeral prosthetic replacement

23620 Closed treatment of greater humeral tuberosity fracture;


23630 Open treatment of greater humeral tuberosity fracture,
includes internal fixation, when performed
23650 Closed treatment of shoulder dislocation, with manipulation;

without anesthesia
23655 requiring anesthesia
23660 Open treatment of acute shoulder dislocation
(Repairs for recurrent dislocations, see 23450-23466)

23665 Closed treatment of shoulder dislocation, with fracture of
greater humeral tuberosity, with manipulation
23670 Open treatment of shoulder dislocation, with fracture of

greater humeral tuberosity, includes internal fixation, when
performed
23675 Closed treatment of shoulder dislocation, with surgical or

anatomical neck fracture, with manipulation
23680 Open treatment of shoulder dislocation, with surgical or
anatomical neck fracture, includes internal fixation, when
performed
Manipulation
23700 Manipulation under anesthesia, shoulder joint, including
application of fixation apparatus (dislocation excluded)
➲ CPT Assistant Jan 99:10, Apr 05:14, May 09:8, Jun
15:10
Arthrodesis
23800 Arthrodesis, glenohumeral joint;
23802 with autogenous graft (includes obtaining graft)
Amputation
23900 Interthoracoscapular amputation (forequarter)
23920 Disarticulation of shoulder;
23921 secondary closure or scar revision
Other Procedures
23929 Unlisted procedure, shoulder
Humerus (Upper Arm) and Elbow

The elbow area includes the head and neck of the radius and
olecranon process.
Incision
10040-10160)
23930 Incision and drainage, upper arm or elbow area; deep
abscess or hematoma
23931 bursa
23935 Incision, deep, with opening of bone cortex (eg, for

osteomyelitis or bone abscess), humerus or elbow
24000 Arthrotomy, elbow, including exploration, drainage, or
removal of foreign body
➲ CPT Assistant Nov 98:8-9, Mar 20:14
24006 Arthrotomy of the elbow, with capsular excision for

capsular release (separate procedure)
Excision
24065 Biopsy, soft tissue of upper arm or elbow area; superficial
24075 Excision, tumor, soft tissue of upper arm or elbow area,

24076 Excision, tumor, soft tissue of upper arm or elbow area,

upper arm or elbow area; less than 5 cm

24100 Arthrotomy, elbow; with synovial biopsy only
24101 with joint exploration, with or without biopsy, with or
without removal of loose or foreign body
24105 Excision, olecranon bursa
24110 Excision or curettage of bone cyst or benign tumor, humerus;
24120 Excision or curettage of bone cyst or benign tumor of head
or neck of radius or olecranon process;
24130 Excision, radial head
(For replacement with implant, use 24366)
shaft or distal humerus
radial head or neck
olecranon process
diaphysectomy) bone (eg, osteomyelitis), humerus

diaphysectomy) bone (eg, osteomyelitis), radial head or
neck

diaphysectomy) bone (eg, osteomyelitis), olecranon process
24149 Radical resection of capsule, soft tissue, and heterotopic

bone, elbow, with contracture release (separate procedure)
(For capsular and soft tissue release only, use 24006)

24150 Radical resection of tumor, shaft or distal humerus
24152 Radical resection of tumor, radial head or neck

24155 Resection of elbow joint (arthrectomy)
(For K-wire or pin insertion or removal, see 20650, 20670,
20680)
(For arthrocentesis or needling of bursa or joint, use 20605)
24160 Removal of prosthesis, includes debridement and
synovectomy when performed; humeral and ulnar
components
(To report removal of foreign body, elbow, see 24200,

24201)
(To report removal of hardware from the distal humerus or
proximal ulna, other than humeral and ulnar prosthesis, use
20680)
(Do not report 24160 in conjunction with 24370 or 24371 if
a prosthesis [ie, humeral and/or ulnar component(s)] is
being removed and replaced in the same elbow during the
same surgical session)
24164 radial head
(To report removal of foreign body, elbow, see 24200,
24201)
(To report removal of hardware from proximal radius, other
than radial head prosthesis, use 20680)
24200 Removal of foreign body, upper arm or elbow area;
subcutaneous

24220 Injection procedure for elbow arthrography


(For injection for tennis elbow, use 20550)

24300 Manipulation, elbow, under anesthesia
(For application of external fixation, see 20690 or 20692)

24301 Muscle or tendon transfer, any type, upper arm or elbow,
single (excluding 24320-24331)
24305 Tendon lengthening, upper arm or elbow, each tendon
24310 Tenotomy, open, elbow to shoulder, each tendon

24320 Tenoplasty, with muscle transfer, with or without free graft,

elbow to shoulder, single (Seddon-Brookes type procedure)
24330 Flexor-plasty, elbow (eg, Steindler type advancement);
24331 with extensor advancement
24332 Tenolysis, triceps
24340 Tenodesis of biceps tendon at elbow (separate procedure)

24341 Repair, tendon or muscle, upper arm or elbow, each tendon
or muscle, primary or secondary (excludes rotator cuff)
24342 Reinsertion of ruptured biceps or triceps tendon, distal, with

or without tendon graft
24343 Repair lateral collateral ligament, elbow, with local tissue

24344 Reconstruction lateral collateral ligament, elbow, with

tendon graft (includes harvesting of graft)
24345 Repair medial collateral ligament, elbow, with local tissue

24346 Reconstruction medial collateral ligament, elbow, with

tendon graft (includes harvesting of graft)
24357 Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis

elbow, golfer’s elbow); percutaneous
24358 debridement, soft tissue and/or bone, open

24359 debridement, soft tissue and/or bone, open with tendon
repair or reattachment
(Do not report 24357-24359 in conjunction with 29837,

29838)
24360 Arthroplasty, elbow; with membrane (eg, fascial)
24361 with distal humeral prosthetic replacement

24362 with implant and fascia lata ligament reconstruction
24363 with distal humerus and proximal ulnar prosthetic
replacement (eg, total elbow)
(For revision of total elbow implant, see 24370, 24371)

24365 Arthroplasty, radial head;
24366 with implant
24370 Revision of total elbow arthroplasty, including allograft
when performed; humeral or ulnar component
24371 humeral and ulnar component

(Do not report 24370, 24371 in conjunction with 24160 if a

prosthesis [ie, humeral and/or ulnar component(s)] is being
removed and replaced in the same elbow)
24400 Osteotomy, humerus, with or without internal fixation
24410 Multiple osteotomies with realignment on intramedullary

rod, humeral shaft (Sofield type procedure)
24420 Osteoplasty, humerus (eg, shortening or lengthening)
(excluding 64876)
24430 Repair of nonunion or malunion, humerus; without graft (eg,
compression technique)
24435 with iliac or other autograft (includes obtaining graft)
(For proximal radius and/or ulna, see 25400-25420)
24470 Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal
humerus)
24495 Decompression fasciotomy, forearm, with brachial artery
exploration
24498 Prophylactic treatment (nailing, pinning, plating or wiring),
with or without methylmethacrylate, humeral shaft
Coding Tip
24500 Closed treatment of humeral shaft fracture; without

manipulation
24515 Open treatment of humeral shaft fracture with plate/screws,
with or without cerclage
24516 Treatment of humeral shaft fracture, with insertion of
intramedullary implant, with or without cerclage and/or
locking screws
➲ CPT Assistant Feb 96:4, Jun 09:7, Jan 18:3
24530 Closed treatment of supracondylar or transcondylar humeral

fracture, with or without intercondylar extension; without
manipulation
24535 with manipulation, with or without skin or skeletal
traction
24538 Percutaneous skeletal fixation of supracondylar or
transcondylar humeral fracture, with or without
intercondylar extension
24545 Open treatment of humeral supracondylar or transcondylar

fracture, includes internal fixation, when performed; without
intercondylar extension
24546 with intercondylar extension

24560 Closed treatment of humeral epicondylar fracture, medial or

lateral; without manipulation
24566 Percutaneous skeletal fixation of humeral epicondylar
fracture, medial or lateral, with manipulation
24575 Open treatment of humeral epicondylar fracture, medial or
lateral, includes internal fixation, when performed
24576 Closed treatment of humeral condylar fracture, medial or
lateral; without manipulation
24579 Open treatment of humeral condylar fracture, medial or
lateral, includes internal fixation, when performed
(To report closed treatment of fractures without

manipulation, see 24530, 24560, 24576, 24650, 24670)
(To report closed treatment of fractures with manipulation,
see 24535, 24565, 24577, 24675)
24582 Percutaneous skeletal fixation of humeral condylar fracture,
medial or lateral, with manipulation
24586 Open treatment of periarticular fracture and/or dislocation
of the elbow (fracture distal humerus and proximal ulna
and/or proximal radius);
24587 with implant arthroplasty
(See also 24361)
24600 Treatment of closed elbow dislocation; without anesthesia
24615 Open treatment of acute or chronic elbow dislocation
24620 Closed treatment of Monteggia type of fracture dislocation
at elbow (fracture proximal end of ulna with dislocation of
radial head), with manipulation
24635 Open treatment of Monteggia type of fracture dislocation at
elbow (fracture proximal end of ulna with dislocation of
radial head), includes internal fixation, when performed
24640 Closed treatment of radial head subluxation in child,

nursemaid elbow, with manipulation
24650 Closed treatment of radial head or neck fracture; without
manipulation
24665 Open treatment of radial head or neck fracture, includes
internal fixation or radial head excision, when performed;
24666 with radial head prosthetic replacement

24670 Closed treatment of ulnar fracture, proximal end (eg,

olecranon or coronoid process[es]); without manipulation

24685 Open treatment of ulnar fracture, proximal end (eg,

olecranon or coronoid process[es]), includes internal
Arthrodesis
24800 Arthrodesis, elbow joint; local
24802 with autogenous graft (includes obtaining graft)
Amputation
24900 Amputation, arm through humerus; with primary closure
24920 open, circular (guillotine)
24930 re-amputation
24931 with implant
24935 Stump elongation, upper extremity
24940 Cineplasty, upper extremity, complete procedure
Other Procedures
24999 Unlisted procedure, humerus or elbow
Forearm and Wrist

Radius, ulna, carpal bones, and joints.
Incision
25000 Incision, extensor tendon sheath, wrist (eg, de Quervains
disease)
(For decompression median nerve or for carpal tunnel

syndrome, use 64721)
25001 Incision, flexor tendon sheath, wrist (eg, flexor carpi
radialis)
25020 Decompression fasciotomy, forearm and/or wrist, flexor OR

extensor compartment; without debridement of nonviable
muscle and/or nerve
25023 with debridement of nonviable muscle and/or nerve

(For decompression fasciotomy with brachial artery
exploration, use 24495)
10060-10160)
(For debridement, see also 11000-11044)
25024 Decompression fasciotomy, forearm and/or wrist, flexor
AND extensor compartment; without debridement of
nonviable muscle and/or nerve

25028 Incision and drainage, forearm and/or wrist; deep abscess

or hematoma
25031 bursa
25035 Incision, deep, bone cortex, forearm and/or wrist (eg,

osteomyelitis or bone abscess)
25040 Arthrotomy, radiocarpal or midcarpal joint, with
exploration, drainage, or removal of foreign body
Excision
25065 Biopsy, soft tissue of forearm and/or wrist; superficial

25075 Excision, tumor, soft tissue of forearm and/or wrist area,

25076 Excision, tumor, soft tissue of forearm and/or wrist area,

forearm and/or wrist area; less than 3 cm

25085 Capsulotomy, wrist (eg, contracture)
25100 Arthrotomy, wrist joint; with biopsy
25101 with joint exploration, with or without biopsy, with or
without removal of loose or foreign body
25107 Arthrotomy, distal radioulnar joint including repair of
triangular cartilage, complex
25109 Excision of tendon, forearm and/or wrist, flexor or extensor,
each
25110 Excision, lesion of tendon sheath, forearm and/or wrist

25111 Excision of ganglion, wrist (dorsal or volar); primary
25112 recurrent
(For hand or finger, use 26160)
25115 Radical excision of bursa, synovia of wrist, or forearm
tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other
granulomas, rheumatoid arthritis); flexors
25116 extensors, with or without transposition of dorsal

retinaculum
(For finger synovectomies, use 26145)
25118 Synovectomy, extensor tendon sheath, wrist, single
compartment;
➲ CPT Assistant Apr 12:17, Jun 15:10
25119 with resection of distal ulna

25120 Excision or curettage of bone cyst or benign tumor of radius
or ulna (excluding head or neck of radius and olecranon
process);
(For head or neck of radius or olecranon process, see
24120-24126)
25130 Excision or curettage of bone cyst or benign tumor of carpal
bones;
forearm and/or wrist
diaphysectomy) of bone (eg, for osteomyelitis); ulna
25151 radius
(For head or neck of radius or olecranon process, see
24145, 24147)
25170 Radical resection of tumor, radius or ulna
25210 Carpectomy; 1 bone

(For carpectomy with implant, see 25441-25445)
25215 all bones of proximal row
25230 Radial styloidectomy (separate procedure)

25240 Excision distal ulna partial or complete (eg, Darrach type or
matched resection)
(For implant replacement, distal ulna, use 25442)
(For obtaining fascia for interposition, see 20920, 20922)
(For K-wire, pin or rod insertion or removal, see 20650,
20670, 20680)
25246 Injection procedure for wrist arthrography

(For foreign body removal, superficial use 20520)
25248 Exploration with removal of deep foreign body, forearm or
wrist
25250 Removal of wrist prosthesis; (separate procedure)
25251 complicated, including total wrist
25259 Manipulation, wrist, under anesthesia


25260 Repair, tendon or muscle, flexor, forearm and/or wrist;
primary, single, each tendon or muscle
25263 secondary, single, each tendon or muscle
25265 secondary, with free graft (includes obtaining graft), each
tendon or muscle
25270 Repair, tendon or muscle, extensor, forearm and/or wrist;
primary, single, each tendon or muscle
25272 secondary, single, each tendon or muscle
tendon or muscle
25275 Repair, tendon sheath, extensor, forearm and/or wrist, with

free graft (includes obtaining graft) (eg, for extensor carpi
ulnaris subluxation)
25280 Lengthening or shortening of flexor or extensor tendon,

forearm and/or wrist, single, each tendon
25290 Tenotomy, open, flexor or extensor tendon, forearm and/or
wrist, single, each tendon
25295 Tenolysis, flexor or extensor tendon, forearm and/or wrist,
single, each tendon
➲ CPT Assistant Apr 97:11, Aug 98:10
25300 Tenodesis at wrist; flexors of fingers

25301 extensors of fingers
25310 Tendon transplantation or transfer, flexor or extensor,
forearm and/or wrist, single; each tendon
25312 with tendon graft(s) (includes obtaining graft), each

tendon
25315 Flexor origin slide (eg, for cerebral palsy, Volkmann
contracture), forearm and/or wrist;
25316 with tendon(s) transfer
25320 Capsulorrhaphy or reconstruction, wrist, open (eg,
capsulodesis, ligament repair, tendon transfer or graft)
(includes synovectomy, capsulotomy and open reduction) for
carpal instability
25332 Arthroplasty, wrist, with or without interposition, with or

without external or internal fixation
(For obtaining fascia for interposition, see 20920, 20922)

(For prosthetic replacement arthroplasty, see 25441-25446)
25335 Centralization of wrist on ulna (eg, radial club hand)
25337 Reconstruction for stabilization of unstable distal ulna or

distal radioulnar joint, secondary by soft tissue stabilization
(eg, tendon transfer, tendon graft or weave, or tenodesis)
with or without open reduction of distal radioulnar joint
(For harvesting of fascia lata graft, see 20920, 20922)
25350 Osteotomy, radius; distal third
25355 middle or proximal third
25360 Osteotomy; ulna
25365 radius AND ulna
25370 Multiple osteotomies, with realignment on intramedullary
rod (Sofield type procedure); radius OR ulna
25390 Osteoplasty, radius OR ulna; shortening
25391 lengthening with autograft
25392 Osteoplasty, radius AND ulna; shortening (excluding 64876)
25393 lengthening with autograft
25394 Osteoplasty, carpal bone, shortening
25400 Repair of nonunion or malunion, radius OR ulna; without

graft (eg, compression technique)
25415 Repair of nonunion or malunion, radius AND ulna; without

graft (eg, compression technique)
25425 Repair of defect with autograft; radius OR ulna

25430 Insertion of vascular pedicle into carpal bone (eg, Hori
procedure)
25431 Repair of nonunion of carpal bone (excluding carpal

scaphoid (navicular)) (includes obtaining graft and
necessary fixation), each bone
25440 Repair of nonunion, scaphoid carpal (navicular) bone, with

or without radial styloidectomy (includes obtaining graft and
necessary fixation)
25441 Arthroplasty with prosthetic replacement; distal radius

➲ CPT Assistant Jan 05:8-9, Aug 17:9
25442 distal ulna

➲ CPT Assistant Jan 05:8-9, Aug 17:9
25443 scaphoid carpal (navicular)

➲ CPT Assistant Jan 05:8-9
25444 lunate
➲ CPT Assistant Jan 05:8, 10
25445 trapezium
25446 distal radius and partial or entire carpus (total wrist)

25447 Arthroplasty, interposition, intercarpal or carpometacarpal

joints
➲ CPT Assistant Nov 98:8, Jan 05:8, 11-12
(For wrist arthroplasty, use 25332)

25449 Revision of arthroplasty, including removal of implant,
wrist joint
25450 Epiphyseal arrest by epiphysiodesis or stapling; distal
radius OR ulna
25455 distal radius AND ulna
with or without methylmethacrylate; radius
25491 ulna

(For application of external fixation in addition to internal
fixation, use 20690 and the appropriate internal fixation
code)
25500 Closed treatment of radial shaft fracture; without
manipulation
25515 Open treatment of radial shaft fracture, includes internal
25520 Closed treatment of radial shaft fracture and closed

treatment of dislocation of distal radioulnar joint (Galeazzi
fracture/dislocation)

fixation, when performed, and closed treatment of distal
radioulnar joint dislocation (Galeazzi fracture/dislocation),
includes percutaneous skeletal fixation, when performed

fixation, when performed, and open treatment of distal
radioulnar joint dislocation (Galeazzi fracture/dislocation),
includes internal fixation, when performed, includes repair
of triangular fibrocartilage complex
25530 Closed treatment of ulnar shaft fracture; without
manipulation

25545 Open treatment of ulnar shaft fracture, includes internal

➲ CPT Assistant Fall 93:23, Oct 99:5
25560 Closed treatment of radial and ulnar shaft fractures; without

manipulation
25574 Open treatment of radial AND ulnar shaft fractures, with
internal fixation, when performed; of radius OR ulna
25575 of radius AND ulna

25600 Closed treatment of distal radial fracture (eg, Colles or

Smith type) or epiphyseal separation, includes closed
treatment of fracture of ulnar styloid, when performed;


25606 Percutaneous skeletal fixation of distal radial fracture or
epiphyseal separation
(For percutaneous treatment of ulnar styloid fracture, use
25651)
(For open treatment of ulnar styloid fracture, use 25652)
25607 Open treatment of distal radial extra-articular fracture or
epiphyseal separation, with internal fixation
➲ CPT Assistant Oct 07:7, Nov 12:13

25651)
25608 Open treatment of distal radial intra-articular fracture or
epiphyseal separation; with internal fixation of 2 fragments

25609 with internal fixation of 3 or more fragments
➲ CPT Assistant Oct 07:7, Mar 13:13, Dec 13:14

25651)
25622 Closed treatment of carpal scaphoid (navicular) fracture;
25628 Open treatment of carpal scaphoid (navicular) fracture,
25630 Closed treatment of carpal bone fracture (excluding carpal
scaphoid [navicular]); without manipulation, each bone
25635 with manipulation, each bone
25645 Open treatment of carpal bone fracture (other than carpal
scaphoid [navicular]), each bone
25650 Closed treatment of ulnar styloid fracture


25607-25609)
25651 Percutaneous skeletal fixation of ulnar styloid fracture
25652 Open treatment of ulnar styloid fracture

25660 Closed treatment of radiocarpal or intercarpal dislocation, 1

or more bones, with manipulation
25670 Open treatment of radiocarpal or intercarpal dislocation, 1
or more bones
25671 Percutaneous skeletal fixation of distal radioulnar
dislocation
25675 Closed treatment of distal radioulnar dislocation with

manipulation
25676 Open treatment of distal radioulnar dislocation, acute or
chronic
25680 Closed treatment of trans-scaphoperilunar type of fracture
dislocation, with manipulation
25685 Open treatment of trans-scaphoperilunar type of fracture
dislocation
25690 Closed treatment of lunate dislocation, with manipulation
25695 Open treatment of lunate dislocation
Arthrodesis
25800 Arthrodesis, wrist; complete, without bone graft (includes
radiocarpal and/or intercarpal and/or carpometacarpal
joints)
25805 with sliding graft

25820 Arthrodesis, wrist; limited, without bone graft (eg,
intercarpal or radiocarpal)

25830 Arthrodesis, distal radioulnar joint with segmental resection

of ulna, with or without bone graft (eg, Sauve-Kapandji
procedure)
Amputation
25900 Amputation, forearm, through radius and ulna;
25909 re-amputation
25915 Krukenberg procedure
25920 Disarticulation through wrist;
25924 re-amputation
25927 Transmetacarpal amputation;
25931 re-amputation
Other Procedures
25999 Unlisted procedure, forearm or wrist
Hand and Fingers

Incision
26010 Drainage of finger abscess; simple
26011 complicated (eg, felon)
26020 Drainage of tendon sheath, digit and/or palm, each
26025 Drainage of palmar bursa; single, bursa
26030 multiple bursa

26034 Incision, bone cortex, hand or finger (eg, osteomyelitis or

bone abscess)
26035 Decompression fingers and/or hand, injection injury (eg,

grease gun)
26037 Decompressive fasciotomy, hand (excludes 26035)
(For injection injury, use 26035)
26040 Fasciotomy, palmar (eg, Dupuytren’s contracture);
percutaneous
➲ CPT Assistant Nov 98:8, Apr 10:10, Oct 10:10
26045 open, partial

(For palmar fasciotomy by enzyme injection (eg,
collagenase), see 20527, 26341)
(For fasciectomy, see 26121-26125)
26055 Tendon sheath incision (eg, for trigger finger)
26060 Tenotomy, percutaneous, single, each digit
26070 Arthrotomy, with exploration, drainage, or removal of loose
or foreign body; carpometacarpal joint
26075 metacarpophalangeal joint, each

➲ CPT Assistant Sep 12:10, Mar 20:14
26080 interphalangeal joint, each

Excision
26100 Arthrotomy with biopsy; carpometacarpal joint, each
26105 metacarpophalangeal joint, each
26110 interphalangeal joint, each
26115 Excision, tumor or vascular malformation, soft tissue of
hand or finger, subcutaneous; less than 1.5 cm
# 26111 1.5 cm or greater

26116 Excision, tumor, soft tissue, or vascular malformation, of
hand or finger, subfascial (eg, intramuscular); less than 1.5
cm

26117 Radical resection of tumor (eg, sarcoma), soft tissue of hand

or finger; less than 3 cm

26121 Fasciectomy, palm only, with or without Z-plasty, other
local tissue rearrangement, or skin grafting (includes
obtaining graft)
➲ CPT Assistant Oct 10:10, Jun 11:13
26123 Fasciectomy, partial palmar with release of single digit

including proximal interphalangeal joint, with or without Z-
plasty, other local tissue rearrangement, or skin grafting
(includes obtaining graft);
➲ CPT Assistant Jan 05:8, Oct 10:10, Jun 11:13
✚ 26125 each additional digit (List separately in addition to code

➲ CPT Assistant Jan 05:8, Oct 10:10, Jun 11:13
(For palmar fasciotomy by enzyme injection (eg,
collagenase), see 20527, 26341)
(For fasciotomy, see 26040, 26045)
26130 Synovectomy, carpometacarpal joint
26135 Synovectomy, metacarpophalangeal joint including intrinsic
release and extensor hood reconstruction, each digit
26140 Synovectomy, proximal interphalangeal joint, including
extensor reconstruction, each interphalangeal joint
26145 Synovectomy, tendon sheath, radical (tenosynovectomy),
flexor tendon, palm and/or finger, each tendon
(For tendon sheath synovectomies at wrist, see 25115,

25116)
26160 Excision of lesion of tendon sheath or joint capsule (eg,
cyst, mucous cyst, or ganglion), hand or finger
(For wrist ganglion, see 25111, 25112)

(For trigger digit, use 26055)
26170 Excision of tendon, palm, flexor or extensor, single, each
tendon

26180 Excision of tendon, finger, flexor or extensor, each tendon
26185 Sesamoidectomy, thumb or finger (separate procedure)
metacarpal;
proximal, middle, or distal phalanx of finger;
diaphysectomy) bone (eg, osteomyelitis); metacarpal
26235 proximal or middle phalanx of finger
26236 distal phalanx of finger

26250 Radical resection of tumor, metacarpal

26260 Radical resection of tumor, proximal or middle phalanx of

finger
26262 Radical resection of tumor, distal phalanx of finger

26320 Removal of implant from finger or hand
(For removal of foreign body in hand or finger, see 20520,
20525)
26340 Manipulation, finger joint, under anesthesia, each joint

26341 Manipulation, palmar fascial cord (ie, Dupuytren’s cord),
post enzyme injection (eg, collagenase), single cord
➲ CPT Assistant Jul 12:8, 14
(For enzyme injection (eg, collagenase), palmar fascial cord

(eg, Dupuytren’s contracture), use 20527)
(Report custom orthotic fabrication/application separately)
26350 Repair or advancement, flexor tendon, not in zone 2 digital
flexor tendon sheath (eg, no man’s land); primary or
secondary without free graft, each tendon
26352 secondary with free graft (includes obtaining graft), each

tendon
26356 Repair or advancement, flexor tendon, in zone 2 digital
flexor tendon sheath (eg, no man’s land); primary, without
free graft, each tendon
➲ CPT Assistant Nov 98:8, Dec 98:9, Dec 08:6, Sep
14:13, Dec 17:15
26357 secondary, without free graft, each tendon

tendon
26370 Repair or advancement of profundus tendon, with intact
superficialis tendon; primary, each tendon
26372 secondary with free graft (includes obtaining graft), each

tendon
26373 secondary without free graft, each tendon

26390 Excision flexor tendon, with implantation of synthetic rod

for delayed tendon graft, hand or finger, each rod
26392 Removal of synthetic rod and insertion of flexor tendon

graft, hand or finger (includes obtaining graft), each rod
26410 Repair, extensor tendon, hand, primary or secondary;

without free graft, each tendon
26412 with free graft (includes obtaining graft), each tendon

26415 Excision of extensor tendon, with implantation of synthetic

rod for delayed tendon graft, hand or finger, each rod
26416 Removal of synthetic rod and insertion of extensor tendon

graft (includes obtaining graft), hand or finger, each rod
26418 Repair, extensor tendon, finger, primary or secondary;

without free graft, each tendon
➲ CPT Assistant Nov 98:8, Dec 99:10, Dec 00:14
26420 with free graft (includes obtaining graft) each tendon
26426 Repair of extensor tendon, central slip, secondary (eg,
boutonniere deformity); using local tissue(s), including
lateral band(s), each finger
26428 with free graft (includes obtaining graft), each finger

26432 Closed treatment of distal extensor tendon insertion, with or

without percutaneous pinning (eg, mallet finger)
26433 Repair of extensor tendon, distal insertion, primary or

secondary; without graft (eg, mallet finger)
26434 with free graft (includes obtaining graft)

(For tenovaginotomy for trigger finger, use 26055)
26437 Realignment of extensor tendon, hand, each tendon
26440 Tenolysis, flexor tendon; palm OR finger, each tendon

26442 palm AND finger, each tendon

26445 Tenolysis, extensor tendon, hand OR finger, each tendon
➲ CPT Assistant Nov 98:8, Dec 02:11, Mar 03:20
26449 Tenolysis, complex, extensor tendon, finger, including

forearm, each tendon
26450 Tenotomy, flexor, palm, open, each tendon
26455 Tenotomy, flexor, finger, open, each tendon

26460 Tenotomy, extensor, hand or finger, open, each tendon

26471 Tenodesis; of proximal interphalangeal joint, each joint

26474 of distal joint, each joint

26476 Lengthening of tendon, extensor, hand or finger, each tendon

26477 Shortening of tendon, extensor, hand or finger, each tendon

26478 Lengthening of tendon, flexor, hand or finger, each tendon

26479 Shortening of tendon, flexor, hand or finger, each tendon

26480 Transfer or transplant of tendon, carpometacarpal area or

dorsum of hand; without free graft, each tendon
26483 with free tendon graft (includes obtaining graft), each

tendon
26485 Transfer or transplant of tendon, palmar; without free tendon
graft, each tendon
26489 with free tendon graft (includes obtaining graft), each

tendon
26490 Opponensplasty; superficialis tendon transfer type, each
tendon
26492 tendon transfer with graft (includes obtaining graft), each
tendon
26494 hypothenar muscle transfer
26496 other methods
(For thumb fusion in opposition, use 26820)
26497 Transfer of tendon to restore intrinsic function; ring and
small finger
26498 all 4 fingers

26499 Correction claw finger, other methods
26500 Reconstruction of tendon pulley, each tendon; with local
tissues (separate procedure)
26502 with tendon or fascial graft (includes obtaining graft)

(separate procedure)
26508 Release of thenar muscle(s) (eg, thumb contracture)
26510 Cross intrinsic transfer, each tendon

26516 Capsulodesis, metacarpophalangeal joint; single digit

26517 2 digits
26518 3 or 4 digits
26520 Capsulectomy or capsulotomy; metacarpophalangeal joint,
each joint
26525 interphalangeal joint, each joint
➲ CPT Assistant Nov 98:8, Apr 02:18, Mar 03:20, Jun
15:10
26530 Arthroplasty, metacarpophalangeal joint; each joint
(To report carpometacarpal joint arthroplasty, use 25447)

26531 with prosthetic implant, each joint
26535 Arthroplasty, interphalangeal joint; each joint

26536 with prosthetic implant, each joint

26540 Repair of collateral ligament, metacarpophalangeal or

interphalangeal joint
26541 Reconstruction, collateral ligament, metacarpophalangeal

joint, single; with tendon or fascial graft (includes obtaining
graft)
26542 with local tissue (eg, adductor advancement)

26545 Reconstruction, collateral ligament, interphalangeal joint,

single, including graft, each joint
26546 Repair non-union, metacarpal or phalanx (includes obtaining
bone graft with or without external or internal fixation)
26548 Repair and reconstruction, finger, volar plate,

interphalangeal joint
26550 Pollicization of a digit
26551 Transfer, toe-to-hand with microvascular anastomosis; great
toe wrap-around with bone graft
➲ CPT Assistant Nov 96:6, Apr 97:7, Jun 97:9, Nov 98:8,
10-11
(For great toe with web space, use 20973)
26553 other than great toe, single
➲ CPT Assistant Nov 96:6, Apr 97:7, Jun 97:9, Nov
98:8, 10-11
26554 other than great toe, double
98:8, 10-11
26554)
26555 Transfer, finger to another position without microvascular
anastomosis
➲ CPT Assistant Nov 98:8, 10-11
26556 Transfer, free toe joint, with microvascular anastomosis

➲ CPT Assistant Nov 96:6, Apr 97:7, Jun 97:9, Nov 98:8

(To report great toe-to-hand transfer, use 20973)
26560 Repair of syndactyly (web finger) each web space; with
skin flaps
26561 with skin flaps and grafts
26562 complex (eg, involving bone, nails)
26565 Osteotomy; metacarpal, each
26567 phalanx of finger, each

26568 Osteoplasty, lengthening, metacarpal or phalanx

26580 Repair cleft hand
26587 Reconstruction of polydactylous digit, soft tissue and bone
➲ CPT Assistant Oct 01:10, Aug 03:14, May 04:16
(For excision of polydactylous digit, soft tissue only, use

11200)
26590 Repair macrodactylia, each digit
➲ CPT Assistant Oct 01:10, Aug 03:14, May 04:16
26591 Repair, intrinsic muscles of hand, each muscle

➲ CPT Assistant May 98:11, Jul 98:11, Nov 98:8, 11
26593 Release, intrinsic muscles of hand, each muscle

➲ CPT Assistant Nov 98:8, 11
26596 Excision of constricting ring of finger, with multiple Z-

plasties
(To report release of scar contracture or graft repairs see
11042, 14040-14041, or 15120, 15240)
Coding Tip

26600 Closed treatment of metacarpal fracture, single; without
manipulation, each bone
26605 with manipulation, each bone
26607 Closed treatment of metacarpal fracture, with manipulation,
with external fixation, each bone
26608 Percutaneous skeletal fixation of metacarpal fracture, each

bone
26615 Open treatment of metacarpal fracture, single, includes
internal fixation, when performed, each bone
26641 Closed treatment of carpometacarpal dislocation, thumb,

with manipulation
26645 Closed treatment of carpometacarpal fracture dislocation,
thumb (Bennett fracture), with manipulation
26650 Percutaneous skeletal fixation of carpometacarpal fracture
dislocation, thumb (Bennett fracture), with manipulation
26665 Open treatment of carpometacarpal fracture dislocation,

thumb (Bennett fracture), includes internal fixation, when
performed
26670 Closed treatment of carpometacarpal dislocation, other than

thumb, with manipulation, each joint; without anesthesia

26676 Percutaneous skeletal fixation of carpometacarpal
dislocation, other than thumb, with manipulation, each joint
26685 Open treatment of carpometacarpal dislocation, other than

thumb; includes internal fixation, when performed, each
joint
26686 complex, multiple, or delayed reduction

26700 Closed treatment of metacarpophalangeal dislocation,
single, with manipulation; without anesthesia

26706 Percutaneous skeletal fixation of metacarpophalangeal
dislocation, single, with manipulation
26715 Open treatment of metacarpophalangeal dislocation, single,
26720 Closed treatment of phalangeal shaft fracture, proximal or

middle phalanx, finger or thumb; without manipulation, each
traction, each
26727 Percutaneous skeletal fixation of unstable phalangeal shaft
fracture, proximal or middle phalanx, finger or thumb, with
manipulation, each
26735 Open treatment of phalangeal shaft fracture, proximal or
middle phalanx, finger or thumb, includes internal fixation,
when performed, each
26740 Closed treatment of articular fracture, involving

metacarpophalangeal or interphalangeal joint; without
manipulation, each
26742 with manipulation, each
26746 Open treatment of articular fracture, involving
metacarpophalangeal or interphalangeal joint, includes
internal fixation, when performed, each
26750 Closed treatment of distal phalangeal fracture, finger or

thumb; without manipulation, each
26756 Percutaneous skeletal fixation of distal phalangeal fracture,
finger or thumb, each
26765 Open treatment of distal phalangeal fracture, finger or
thumb, includes internal fixation, when performed, each
26770 Closed treatment of interphalangeal joint dislocation, single,

with manipulation; without anesthesia
26776 Percutaneous skeletal fixation of interphalangeal joint
dislocation, single, with manipulation
26785 Open treatment of interphalangeal joint dislocation, includes
internal fixation, when performed, single
Arthrodesis
26820 Fusion in opposition, thumb, with autogenous graft (includes
obtaining graft)
26841 Arthrodesis, carpometacarpal joint, thumb, with or without
internal fixation;
26843 Arthrodesis, carpometacarpal joint, digit, other than thumb,
each;

26850 Arthrodesis, metacarpophalangeal joint, with or without
internal fixation;
26860 Arthrodesis, interphalangeal joint, with or without internal
fixation;
✚ 26861 each additional interphalangeal joint (List separately in
✚ 26863 with autograft (includes obtaining graft), each additional
joint (List separately in addition to code for primary
procedure)
Amputation
(For hand through metacarpal bones, use 25927)
26910 Amputation, metacarpal, with finger or thumb (ray
amputation), single, with or without interosseous transfer
(For repositioning, see 26550, 26555)
26951 Amputation, finger or thumb, primary or secondary, any joint
or phalanx, single, including neurectomies; with direct
closure
26952 with local advancement flaps (V-Y, hood)
(For repair of soft tissue defect requiring split or full
thickness graft or other pedicle flaps, see 15050-15758)
Other Procedures
26989 Unlisted procedure, hands or fingers
Pelvis and Hip Joint
Including head and neck of femur.
Incision
10040-10160)
26990 Incision and drainage, pelvis or hip joint area; deep abscess
or hematoma

26992 Incision, bone cortex, pelvis and/or hip joint (eg,
osteomyelitis or bone abscess)
27000 Tenotomy, adductor of hip, percutaneous (separate

procedure)
27001 Tenotomy, adductor of hip, open
50)
27003 Tenotomy, adductor, subcutaneous, open, with obturator
neurectomy
50)
27005 Tenotomy, hip flexor(s), open (separate procedure)
27006 Tenotomy, abductors and/or extensor(s) of hip, open
27025 Fasciotomy, hip or thigh, any type
50)
27027 Decompression fasciotomy(ies), pelvic (buttock)
compartment(s) (eg, gluteus medius-minimus, gluteus
maximus, iliopsoas, and/or tensor fascia lata muscle),
unilateral

50)
27030 Arthrotomy, hip, with drainage (eg, infection)
27033 Arthrotomy, hip, including exploration or removal of loose

or foreign body
➲ CPT Assistant Spring 92:11
27035 Denervation, hip joint, intrapelvic or extrapelvic intra-

articular branches of sciatic, femoral, or obturator nerves
(For obturator neurectomy, see 64763, 64766)

27036 Capsulectomy or capsulotomy, hip, with or without excision
of heterotopic bone, with release of hip flexor muscles (ie,
gluteus medius, gluteus minimus, tensor fascia latae, rectus
femoris, sartorius, iliopsoas)
Excision
27040 Biopsy, soft tissue of pelvis and hip area; superficial
27041 deep, subfascial or intramuscular

27047 Excision, tumor, soft tissue of pelvis and hip area,

27048 Excision, tumor, soft tissue of pelvis and hip area,

pelvis and hip area; less than 5 cm

27050 Arthrotomy, with biopsy; sacroiliac joint
27052 hip joint
27054 Arthrotomy with synovectomy, hip joint
27057 Decompression fasciotomy(ies), pelvic (buttock)
compartment(s) (eg, gluteus medius-minimus, gluteus
maximus, iliopsoas, and/or tensor fascia lata muscle) with
debridement of nonviable muscle, unilateral
50)
27060 Excision; ischial bursa
27062 trochanteric bursa or calcification
(For arthrocentesis or needling of bursa, use 20610)
27065 Excision of bone cyst or benign tumor, wing of ilium,
symphysis pubis, or greater trochanter of femur; superficial,
includes autograft, when performed
27066 deep (subfascial), includes autograft, when performed

27067 with autograft requiring separate incision

27070 Partial excision, wing of ilium, symphysis pubis, or greater

trochanter of femur, (craterization, saucerization) (eg,
osteomyelitis or bone abscess); superficial

27075 Radical resection of tumor; wing of ilium, 1 pubic or ischial

ramus or symphysis pubis
27076 ilium, including acetabulum, both pubic rami, or ischium

and acetabulum
27077 innominate bone, total

27078 ischial tuberosity and greater trochanter of femur

27080 Coccygectomy, primary
(For pressure (decubitus) ulcer, see 15920, 15922 and
15931-15958)
27086 Removal of foreign body, pelvis or hip; subcutaneous tissue

27090 Removal of hip prosthesis; (separate procedure)

27091 complicated, including total hip prosthesis,

methylmethacrylate with or without insertion of spacer
27093 Injection procedure for hip arthrography; without anesthesia

➲ Clinical Examples in Radiology Fall 07:7, Spring 13:11,
Summer 18:15
27095 with anesthesia
➲ CPT Assistant Jun 12:14, Aug 15:6, Jan 16:11
18:15
27096 Injection procedure for sacroiliac joint, anesthetic/steroid,
with image guidance (fluoroscopy or CT) including
arthrography when performed
➲ CPT Assistant Nov 99:12, Apr 03:8, Apr 04:15, Jul
08:9, Jan 12:3, Aug 15:6
18:15
(27096 is to be used only with CT or fluoroscopic imaging
confirmation of intra-articular needle positioning)
(If CT or fluoroscopy imaging is not performed, use 20552)
(Code 27096 is a unilateral procedure. For bilateral
procedure, use modifier 50)

27097 Release or recession, hamstring, proximal
27098 Transfer, adductor to ischium

27100 Transfer external oblique muscle to greater trochanter

including fascial or tendon extension (graft)
27105 Transfer paraspinal muscle to hip (includes fascial or
tendon extension graft)
27110 Transfer iliopsoas; to greater trochanter of femur
27111 to femoral neck

27120 Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup
type)
27122 resection, femoral head (eg, Girdlestone procedure)
27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis,
bipolar arthroplasty)
➲ CPT Assistant Spring 92:8, Feb 98:11, Nov 98:8
(For prosthetic replacement following fracture of the hip,
use 27236)
27130 Arthroplasty, acetabular and proximal femoral prosthetic
replacement (total hip arthroplasty), with or without
autograft or allograft
➲ CPT Assistant Spring 92:8, Jan 07:1, Dec 11:14
27132 Conversion of previous hip surgery to total hip arthroplasty,

with or without autograft or allograft
➲ CPT Assistant Spring 92:11, Dec 08:3, May 17:10, Sep
17:14
27134 Revision of total hip arthroplasty; both components, with or
without autograft or allograft
➲ CPT Assistant Spring 92:7, Dec 08:3
27137 acetabular component only, with or without autograft or

allograft
27138 femoral component only, with or without allograft

27140 Osteotomy and transfer of greater trochanter of femur

27146 Osteotomy, iliac, acetabular or innominate bone;

27147 with open reduction of hip

27151 with femoral osteotomy
27156 with femoral osteotomy and with open reduction of hip
27158 Osteotomy, pelvis, bilateral (eg, congenital malformation)
27161 Osteotomy, femoral neck (separate procedure)
27165 Osteotomy, intertrochanteric or subtrochanteric including
internal or external fixation and/or cast
27170 Bone graft, femoral head, neck, intertrochanteric or

subtrochanteric area (includes obtaining bone graft)
27175 Treatment of slipped femoral epiphysis; by traction, without

reduction
Partial Hip Replacement With or Without Bipolar Prosthesis

27125
The femoral neck is excised so the physician can measure and then replace the femoral stem.
Total Hip Replacement

27130
The femoral head is excised, osteophytes are removed, and acetabulum is reamed out before
replacement is inserted in the femoral shaft.
27176 by single or multiple pinning, in situ
27177 Open treatment of slipped femoral epiphysis; single or
multiple pinning or bone graft (includes obtaining graft)
27178 closed manipulation with single or multiple pinning
27179 osteoplasty of femoral neck (Heyman type procedure)
27181 osteotomy and internal fixation
27185 Epiphyseal arrest by epiphysiodesis or stapling, greater
trochanter of femur

with or without methylmethacrylate, femoral neck and
proximal femur
Coding Tip
27197 Closed treatment of posterior pelvic ring fracture(s),

dislocation(s), diastasis or subluxation of the ilium,
sacroiliac joint, and/or sacrum, with or without anterior
pelvic ring fracture(s) and/or dislocation(s) of the pubic
symphysis and/or superior/inferior rami, unilateral or
bilateral; without manipulation
27198 with manipulation, requiring more than local anesthesia

(ie, general anesthesia, moderate sedation,
spinal/epidural)
➲ CPT Assistant Jun 17:9, Jan 18:3
(To report closed treatment of only anterior pelvic ring

fracture(s) and/or dislocation(s) of the pubic symphysis
and/or superior/inferior rami, unilateral or bilateral, use the
appropriate evaluation and management services codes)
27200 Closed treatment of coccygeal fracture
27202 Open treatment of coccygeal fracture
27215 Open treatment of iliac spine(s), tuberosity avulsion, or iliac
wing fracture(s), unilateral, for pelvic bone fracture patterns
that do not disrupt the pelvic ring, includes internal fixation,
when performed

50)
27216 Percutaneous skeletal fixation of posterior pelvic bone
fracture and/or dislocation, for fracture patterns that disrupt
the pelvic ring, unilateral (includes ipsilateral ilium,
sacroiliac joint and/or sacrum)

50)
(For percutaneous/minimally invasive arthrodesis of the
sacroiliac joint without fracture and/or dislocation, use
27279)
27217 Open treatment of anterior pelvic bone fracture and/or
dislocation for fracture patterns that disrupt the pelvic ring,
unilateral, includes internal fixation, when performed
(includes pubic symphysis and/or ipsilateral
superior/inferior rami)

50)
27218 Open treatment of posterior pelvic bone fracture and/or
dislocation, for fracture patterns that disrupt the pelvic ring,
unilateral, includes internal fixation, when performed
(includes ipsilateral ilium, sacroiliac joint and/or sacrum)
50)
27279)
27220 Closed treatment of acetabulum (hip socket) fracture(s);
27226 Open treatment of posterior or anterior acetabular wall
fracture, with internal fixation
27227 Open treatment of acetabular fracture(s) involving anterior
or posterior (one) column, or a fracture running transversely
across the acetabulum, with internal fixation
27228 Open treatment of acetabular fracture(s) involving anterior
and posterior (two) columns, includes T-fracture and both
column fracture with complete articular detachment, or
single column or transverse fracture with associated
acetabular wall fracture, with internal fixation
27230 Closed treatment of femoral fracture, proximal end, neck;
27235 Percutaneous skeletal fixation of femoral fracture, proximal
end, neck
Percutaneous Treatment of Femoral Fracture

27235
Femoral fracture treatment without fracture exposure
27236 Open treatment of femoral fracture, proximal end, neck,
internal fixation or prosthetic replacement
➲ CPT Assistant Spring 92:10, Feb 98:11, Jan 07:1, Nov
16:9
27238 Closed treatment of intertrochanteric, peritrochanteric, or
subtrochanteric femoral fracture; without manipulation
➲ CPT Assistant Summer 93:12

traction
27244 Treatment of intertrochanteric, peritrochanteric, or

subtrochanteric femoral fracture; with plate/screw type
implant, with or without cerclage
27245 with intramedullary implant, with or without interlocking

screws and/or cerclage
➲ CPT Assistant Summer 93:12, Sep 13:17
27246 Closed treatment of greater trochanteric fracture, without
manipulation
27248 Open treatment of greater trochanteric fracture, includes
internal fixation, when performed
27250 Closed treatment of hip dislocation, traumatic; without

anesthesia
27253 Open treatment of hip dislocation, traumatic, without
internal fixation
Open Treatment of Femoral Fracture

27236
A. Femoral fracture treatment by internal fixation device (with fracture exposure)
B. Femoral fracture treatment by prosthetic replacement
27254 Open treatment of hip dislocation, traumatic, with acetabular
wall and femoral head fracture, with or without internal or
external fixation
(For treatment of acetabular fracture with fixation, see
27226, 27227)
27256 Treatment of spontaneous hip dislocation (developmental,
including congenital or pathological), by abduction, splint or
traction; without anesthesia, without manipulation
27257 with manipulation, requiring anesthesia
27258 Open treatment of spontaneous hip dislocation
(developmental, including congenital or pathological),
replacement of femoral head in acetabulum (including
tenotomy, etc);
27259 with femoral shaft shortening
27265 Closed treatment of post hip arthroplasty dislocation;
without anesthesia
27266 requiring regional or general anesthesia
27267 Closed treatment of femoral fracture, proximal end, head;

27269 Open treatment of femoral fracture, proximal end, head,


Manipulation
27275 Manipulation, hip joint, requiring general anesthesia
➲ CPT Assistant Jan 16:11, May 16:13
Arthrodesis
27279 Arthrodesis, sacroiliac joint, percutaneous or minimally
invasive (indirect visualization), with image guidance,
includes obtaining bone graft when performed, and
placement of transfixing device

27280 Arthrodesis, open, sacroiliac joint, including obtaining bone
graft, including instrumentation, when performed

50)
27279)
27282 Arthrodesis, symphysis pubis (including obtaining graft)
27284 Arthrodesis, hip joint (including obtaining graft);
27286 with subtrochanteric osteotomy
Amputation
27290 Interpelviabdominal amputation (hindquarter amputation)
27295 Disarticulation of hip
Other Procedures
27299 Unlisted procedure, pelvis or hip joint
➲ CPT Assistant Jan 02:10, Dec 05:9, Dec 08:3, Oct
12:14, Nov 12:13, Mar 14:13, Jun 16:8
Femur (Thigh Region) and Knee Joint

Including tibial plateaus.
Incision
superficial, see 10040-10160)
27301 Incision and drainage, deep abscess, bursa, or hematoma,
thigh or knee region
27303 Incision, deep, with opening of bone cortex, femur or knee

(eg, osteomyelitis or bone abscess)
27305 Fasciotomy, iliotibial (tenotomy), open

(For combined Ober-Yount fasciotomy, use 27025)
27306 Tenotomy, percutaneous, adductor or hamstring; single
tendon (separate procedure)
27307 multiple tendons

27310 Arthrotomy, knee, with exploration, drainage, or removal of

foreign body (eg, infection)
Excision
27323 Biopsy, soft tissue of thigh or knee area; superficial

➲ CPT Assistant Mar 97:4, Nov 98:8

27325 Neurectomy, hamstring muscle
27326 Neurectomy, popliteal (gastrocnemius)

27327 Excision, tumor, soft tissue of thigh or knee area,


27328 Excision, tumor, soft tissue of thigh or knee area, subfascial

27330 Arthrotomy, knee; with synovial biopsy only

27331 including joint exploration, biopsy, or removal of loose

or foreign bodies
➲ CPT Assistant May 96:6, Nov 98:8, Nov 12:13
27332 Arthrotomy, with excision of semilunar cartilage
(meniscectomy) knee; medial OR lateral
27333 medial AND lateral

27334 Arthrotomy, with synovectomy, knee; anterior OR posterior

27335 anterior AND posterior including popliteal area

27340 Excision, prepatellar bursa
27345 Excision of synovial cyst of popliteal space (eg, Baker’s
cyst)
27347 Excision of lesion of meniscus or capsule (eg, cyst,
ganglion), knee
27350 Patellectomy or hemipatellectomy

27355 Excision or curettage of bone cyst or benign tumor of femur;
✚ 27358 with internal fixation (List in addition to code for

primary procedure)
(Use 27358 in conjunction with 27355, 27356, or 27357)
diaphysectomy) bone, femur, proximal tibia and/or fibula
(eg, osteomyelitis or bone abscess)
# 27329 Radical resection of tumor (eg, sarcoma), soft tissue of thigh
or knee area; less than 5 cm

27365 Radical resection of tumor, femur or knee
(For radical resection of tumor, soft tissue of thigh or knee

area, see 27329, 27364)
27369 Injection procedure for contrast knee arthrography or
contrast enhanced CT/MRI knee arthrography

73722, 73723)
29871)
(For arthrocentesis of the knee or injection of any material
other than contrast for subsequent arthrography, see 20610,
20611)
enhanced CT arthrography, use 27369, 77002, and 73701 or
73702)
enhanced MR arthrography, use 27369, 77002, and 73722 or
73723)
(For arthroscopic lavage and drainage of the knee, use
29871)
(For radiographic arthrography, radiological supervision
and interpretation, use 73580)
(For arthrocentesis of the knee or injection of any material
other than contrast for subsequent arthrography, see 20610,
20611)
(For injection procedure for contrast knee arthrography or
contrast enhanced CT/MRI knee arthrography, use 27369)
27372 Removal of foreign body, deep, thigh region or knee area
(For removal of knee prosthesis including “total knee,” use
27488)
(For surgical arthroscopic knee procedures, see 29870-
29887)

27380 Suture of infrapatellar tendon; primary
27381 secondary reconstruction, including fascial or tendon
graft
27385 Suture of quadriceps or hamstring muscle rupture; primary
27386 secondary reconstruction, including fascial or tendon

graft
27390 Tenotomy, open, hamstring, knee to hip; single tendon

27391 multiple tendons, 1 leg
27392 multiple tendons, bilateral

27393 Lengthening of hamstring tendon; single tendon

27394 multiple tendons, 1 leg

27395 multiple tendons, bilateral

27396 Transplant or transfer (with muscle redirection or

rerouting), thigh (eg, extensor to flexor); single tendon

27400 Transfer, tendon or muscle, hamstrings to femur (eg, Egger’s

type procedure)
27403 Arthrotomy with meniscus repair, knee

➲ CPT Assistant Nov 98:8, May 19:10
(For arthroscopic repair, use 29882)

27405 Repair, primary, torn ligament and/or capsule, knee;
collateral
27407 cruciate
(For cruciate ligament reconstruction, use 27427)
27409 collateral and cruciate ligaments
(For ligament reconstruction, see 27427-27429)
27412 Autologous chondrocyte implantation, knee

15772, 15773, 15774, 27331, 27570)
(For harvesting of chondrocytes, use 29870)
27415 Osteochondral allograft, knee, open
(For arthroscopic implant of osteochondral allograft, use

29867)
27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty)
(includes harvesting of autograft[s])

29871, 29875, 29884 when performed at the same session
and/or 29874, 29877, 29879, 29885-29887 when performed
in the same compartment)
(For arthroscopic osteochondral autograft of knee, use
29866)
27418 Anterior tibial tubercleplasty (eg, Maquet type procedure)
27420 Reconstruction of dislocating patella; (eg, Hauser type

procedure)
27422 with extensor realignment and/or muscle advancement or
release (eg, Campbell, Goldwaite type procedure)
27424 with patellectomy

27425 Lateral retinacular release, open
➲ CPT Assistant Nov 00:11, Mar 11:9, Nov 15:7
(For arthroscopic lateral release, use 29873)

27427 Ligamentous reconstruction (augmentation), knee; extra-
articular
➲ CPT Assistant Nov 99:13, Dec 12:12, May 17:10
27428 intra-articular (open)

27429 intra-articular (open) and extra-articular

Posterolateral Corner of the Knee

27405, 27427
(For primary repair of ligament(s) performed in conjunction
with reconstruction, report 27405, 27407 or 27409 in
conjunction with 27427, 27428 or 27429)
27430 Quadricepsplasty (eg, Bennett or Thompson type)
27435 Capsulotomy, posterior capsular release, knee
27437 Arthroplasty, patella; without prosthesis

27438 with prosthesis
27440 Arthroplasty, knee, tibial plateau;
27441 with debridement and partial synovectomy
27442 Arthroplasty, femoral condyles or tibial plateau(s), knee;
➲ CPT Assistant Nov 99:13, Jun 16:8
27443 with debridement and partial synovectomy

27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type)
27446 Arthroplasty, knee, condyle and plateau; medial OR lateral

compartment
27447 medial AND lateral compartments with or without

patella resurfacing (total knee arthroplasty)
(For revision of total knee arthroplasty, use 27487)

(For removal of total knee prosthesis, use 27488)
27448 Osteotomy, femur, shaft or supracondylar; without fixation
50)
27450 with fixation
50)
27454 Osteotomy, multiple, with realignment on intramedullary
rod, femoral shaft (eg, Sofield type procedure)
27455 Osteotomy, proximal tibia, including fibular excision or
osteotomy (includes correction of genu varus [bowleg] or
genu valgus [knock-knee]); before epiphyseal closure
50)
27457 after epiphyseal closure
50)
27465 Osteoplasty, femur; shortening (excluding 64876)
27466 lengthening
27468 combined, lengthening and shortening with femoral
segment transfer
27470 Repair, nonunion or malunion, femur, distal to head and
neck; without graft (eg, compression technique)
27472 with iliac or other autogenous bone graft (includes
obtaining graft)
27475 Arrest, epiphyseal, any method (eg, epiphysiodesis); distal
femur
27477 tibia and fibula, proximal

27479 combined distal femur, proximal tibia and fibula
27485 Arrest, hemiepiphyseal, distal femur or proximal tibia or
fibula (eg, genu varus or valgus)
27486 Revision of total knee arthroplasty, with or without

allograft; 1 component
➲ CPT Assistant Dec 13:16, Jul 15:10, Apr 18:10
27487 femoral and entire tibial component

27488 Removal of prosthesis, including total knee prosthesis,
methylmethacrylate with or without insertion of spacer, knee
➲ CPT Assistant Nov 98:8, Jul 13:6, Mar 20:14
27495 Prophylactic treatment (nailing, pinning, plating, or wiring)

with or without methylmethacrylate, femur
27496 Decompression fasciotomy, thigh and/or knee, 1
compartment (flexor or extensor or adductor);
27498 Decompression fasciotomy, thigh and/or knee, multiple
compartments;
Coding Tip
(For arthroscopic treatment of intercondylar spine[s] and

tuberosity fracture[s] of the knee, see 29850, 29851)
(For arthroscopic treatment of tibial fracture, see 29855,
29856)
27500 Closed treatment of femoral shaft fracture, without
manipulation
27501 Closed treatment of supracondylar or transcondylar femoral
fracture with or without intercondylar extension, without
manipulation
27502 Closed treatment of femoral shaft fracture, with
manipulation, with or without skin or skeletal traction
27503 Closed treatment of supracondylar or transcondylar femoral

fracture with or without intercondylar extension, with
manipulation, with or without skin or skeletal traction
27506 Open treatment of femoral shaft fracture, with or without
external fixation, with insertion of intramedullary implant,
with or without cerclage and/or locking screws
➲ CPT Assistant Winter 92:10, Jun 09:7
27507 Open treatment of femoral shaft fracture with plate/screws,

with or without cerclage
27508 Closed treatment of femoral fracture, distal end, medial or
lateral condyle, without manipulation
27509 Percutaneous skeletal fixation of femoral fracture, distal
end, medial or lateral condyle, or supracondylar or
transcondylar, with or without intercondylar extension, or
distal femoral epiphyseal separation
27510 Closed treatment of femoral fracture, distal end, medial or

lateral condyle, with manipulation
27511 Open treatment of femoral supracondylar or transcondylar
fracture without intercondylar extension, includes internal
27513 Open treatment of femoral supracondylar or transcondylar

fracture with intercondylar extension, includes internal
27514 Open treatment of femoral fracture, distal end, medial or

lateral condyle, includes internal fixation, when performed
27516 Closed treatment of distal femoral epiphyseal separation;

traction
27519 Open treatment of distal femoral epiphyseal separation,
27520 Closed treatment of patellar fracture, without manipulation

27524 Open treatment of patellar fracture, with internal fixation
and/or partial or complete patellectomy and soft tissue
repair
27530 Closed treatment of tibial fracture, proximal (plateau);
27532 with or without manipulation, with skeletal traction
(For arthroscopic treatment, see 29855, 29856)
27535 Open treatment of tibial fracture, proximal (plateau);
unicondylar, includes internal fixation, when performed
27536 bicondylar, with or without internal fixation

27538 Closed treatment of intercondylar spine(s) and/or tuberosity
fracture(s) of knee, with or without manipulation
27540 Open treatment of intercondylar spine(s) and/or tuberosity
fracture(s) of the knee, includes internal fixation, when
performed
27550 Closed treatment of knee dislocation; without anesthesia

27556 Open treatment of knee dislocation, includes internal
fixation, when performed; without primary ligamentous
repair or augmentation/reconstruction
27557 with primary ligamentous repair

27558 with primary ligamentous repair, with

augmentation/reconstruction
27560 Closed treatment of patellar dislocation; without anesthesia

(For recurrent dislocation, see 27420-27424)

27566 Open treatment of patellar dislocation, with or without
partial or total patellectomy
Manipulation
27570 Manipulation of knee joint under general anesthesia
(includes application of traction or other fixation devices)
Arthrodesis
27580 Arthrodesis, knee, any technique
Amputation
27590 Amputation, thigh, through femur, any level;
27591 immediate fitting technique including first cast

27596 re-amputation
27598 Disarticulation at knee
Other Procedures
27599 Unlisted procedure, femur or knee
➲ CPT Assistant Mar 08:14, Dec 12:13, Jan 14:9, Jan
15:13, Jun 16:8, Nov 16:9, Mar 17:10, Aug 17:9, Apr
18:10, Dec 18:10, Apr 19:10
Leg (Tibia and Fibula) and Ankle Joint

Incision
27600 Decompression fasciotomy, leg; anterior and/or lateral
compartments only
27601 posterior compartment(s) only
27602 anterior and/or lateral, and posterior compartment(s)
10040-10160)
(For decompression fasciotomy with debridement, see
27892-27894)
27603 Incision and drainage, leg or ankle; deep abscess or
hematoma
27605 Tenotomy, percutaneous, Achilles tendon (separate
procedure); local anesthesia
27606 general anesthesia

27607 Incision (eg, osteomyelitis or bone abscess), leg or ankle

27610 Arthrotomy, ankle, including exploration, drainage, or
removal of foreign body
27612 Arthrotomy, posterior capsular release, ankle, with or

without Achilles tendon lengthening
(See also 27685)
Excision
27613 Biopsy, soft tissue of leg or ankle area; superficial

27615 Radical resection of tumor (eg, sarcoma), soft tissue of leg
or ankle area; less than 5 cm

27618 Excision, tumor, soft tissue of leg or ankle area,

27619 Excision, tumor, soft tissue of leg or ankle area, subfascial
27620 Arthrotomy, ankle, with joint exploration, with or without

biopsy, with or without removal of loose or foreign body
27625 Arthrotomy, with synovectomy, ankle;
27626 including tenosynovectomy

27630 Excision of lesion of tendon sheath or capsule (eg, cyst or
ganglion), leg and/or ankle
27635 Excision or curettage of bone cyst or benign tumor, tibia or
fibula;

diaphysectomy), bone (eg, osteomyelitis); tibia
(For exostosis excision, use 27635)

27641 fibula
(For exostosis excision, use 27635)

27645 Radical resection of tumor; tibia
27646 fibula
27647 talus or calcaneus

27648 Injection procedure for ankle arthrography

(For ankle arthroscopy, see 29894-29898)

27650 Repair, primary, open or percutaneous, ruptured Achilles
tendon;
27652 with graft (includes obtaining graft)

27654 Repair, secondary, Achilles tendon, with or without graft
➲ CPT Assistant Jul 14:5, Dec 16:16, Mar 20:14
27656 Repair, fascial defect of leg

27658 Repair, flexor tendon, leg; primary, without graft, each
tendon
27659 secondary, with or without graft, each tendon

27664 Repair, extensor tendon, leg; primary, without graft, each

tendon
27665 secondary, with or without graft, each tendon

27675 Repair, dislocating peroneal tendons; without fibular

osteotomy
27676 with fibular osteotomy
27680 Tenolysis, flexor or extensor tendon, leg and/or ankle;
single, each tendon
27681 multiple tendons (through separate incision[s])

27685 Lengthening or shortening of tendon, leg or ankle; single

tendon (separate procedure)
➲ CPT Assistant Nov 98:8, Sep 09:11, Sep 18:14
27686 multiple tendons (through same incision), each

27687 Gastrocnemius recession (eg, Strayer procedure)

(Toe extensors are considered as a group to be a single
tendon when transplanted into midfoot)
27690 Transfer or transplant of single tendon (with muscle
redirection or rerouting); superficial (eg, anterior tibial
extensors into midfoot)
27691 deep (eg, anterior tibial or posterior tibial through
interosseous space, flexor digitorum longus, flexor
hallucis longus, or peroneal tendon to midfoot or
hindfoot)
✚ 27692 each additional tendon (List separately in addition to
27695 Repair, primary, disrupted ligament, ankle; collateral
27696 both collateral ligaments

27698 Repair, secondary, disrupted ligament, ankle, collateral (eg,

Watson-Jones procedure)
27700 Arthroplasty, ankle;

27702 with implant (total ankle)
27703 revision, total ankle
27704 Removal of ankle implant
27705 Osteotomy; tibia
27707 fibula
27709 tibia and fibula
27712 multiple, with realignment on intramedullary rod (eg,
Sofield type procedure)
(For osteotomy to correct genu varus [bowleg] or genu
valgus [knock-knee], see 27455-27457)
27715 Osteoplasty, tibia and fibula, lengthening or shortening
27720 Repair of nonunion or malunion, tibia; without graft, (eg,
compression technique)
27722 with sliding graft
27725 by synostosis, with fibula, any method

27726 Repair of fibula nonunion and/or malunion with internal
fixation

27727 Repair of congenital pseudarthrosis, tibia
27730 Arrest, epiphyseal (epiphysiodesis), open; distal tibia
27732 distal fibula

27734 distal tibia and fibula
27740 Arrest, epiphyseal (epiphysiodesis), any method, combined,
proximal and distal tibia and fibula;
27742 and distal femur

(For epiphyseal arrest of proximal tibia and fibula, use
27477)
with or without methylmethacrylate, tibia

Coding Tip
Coding Tip
27750 Closed treatment of tibial shaft fracture (with or without

fibular fracture); without manipulation
➲ CPT Assistant Winter 92:10, Fall 93:21, Mar 96:10

➲ CPT Assistant Winter 92:10, Fall 93:21, Feb 96:3,
Mar 96:10, Jan 18:3
27756 Percutaneous skeletal fixation of tibial shaft fracture (with
or without fibular fracture) (eg, pins or screws)
27758 Open treatment of tibial shaft fracture (with or without

fibular fracture), with plate/screws, with or without
cerclage
➲ CPT Assistant Winter 92:10, Mar 00:11
27759 Treatment of tibial shaft fracture (with or without fibular

fracture) by intramedullary implant, with or without
interlocking screws and/or cerclage
27760 Closed treatment of medial malleolus fracture; without

manipulation
traction
27766 Open treatment of medial malleolus fracture, includes
27767 Closed treatment of posterior malleolus fracture; without

manipulation

27769 Open treatment of posterior malleolus fracture, includes


27823)
27780 Closed treatment of proximal fibula or shaft fracture;

27784 Open treatment of proximal fibula or shaft fracture, includes
27786 Closed treatment of distal fibular fracture (lateral

malleolus); without manipulation
27792 Open treatment of distal fibular fracture (lateral malleolus),
(For treatment of tibia and fibula shaft fractures, see 27750-

27759)
27808 Closed treatment of bimalleolar ankle fracture (eg, lateral
and medial malleoli, or lateral and posterior malleoli or
medial and posterior malleoli); without manipulation

27814 Open treatment of bimalleolar ankle fracture (eg, lateral and

medial malleoli, or lateral and posterior malleoli, or medial
and posterior malleoli), includes internal fixation, when
performed
27816 Closed treatment of trimalleolar ankle fracture; without

manipulation
27822 Open treatment of trimalleolar ankle fracture, includes
internal fixation, when performed, medial and/or lateral
malleolus; without fixation of posterior lip
27823 with fixation of posterior lip

27824 Closed treatment of fracture of weight bearing articular

portion of distal tibia (eg, pilon or tibial plafond), with or
without anesthesia; without manipulation
27825 with skeletal traction and/or requiring manipulation
27826 Open treatment of fracture of weight bearing articular
surface/portion of distal tibia (eg, pilon or tibial plafond),
with internal fixation, when performed; of fibula only
27827 of tibia only

27828 of both tibia and fibula
27829 Open treatment of distal tibiofibular joint (syndesmosis)

disruption, includes internal fixation, when performed
➲ CPT Assistant Winter 92:11, Mar 09:10, Feb 16:13
27830 Closed treatment of proximal tibiofibular joint dislocation;

without anesthesia
27832 Open treatment of proximal tibiofibular joint dislocation,
includes internal fixation, when performed, or with excision
of proximal fibula
27840 Closed treatment of ankle dislocation; without anesthesia

27842 requiring anesthesia, with or without percutaneous
skeletal fixation
27846 Open treatment of ankle dislocation, with or without
percutaneous skeletal fixation; without repair or internal
fixation
27848 with repair or internal or external fixation
(For surgical or diagnostic arthroscopic procedures, see
29894-29898)
Manipulation
27860 Manipulation of ankle under general anesthesia (includes
application of traction or other fixation apparatus)
Arthrodesis
27870 Arthrodesis, ankle, open
(For arthroscopic ankle arthrodesis, use 29899)

27871 Arthrodesis, tibiofibular joint, proximal or distal
Amputation
27880 Amputation, leg, through tibia and fibula;
27881 with immediate fitting technique including application of
first cast
27886 re-amputation
27888 Amputation, ankle, through malleoli of tibia and fibula (eg,
Syme, Pirogoff type procedures), with plastic closure and
resection of nerves
27889 Ankle disarticulation
Other Procedures
27892 Decompression fasciotomy, leg; anterior and/or lateral
compartments only, with debridement of nonviable muscle
and/or nerve
(For decompression fasciotomy of the leg without
debridement, use 27600)
27893 posterior compartment(s) only, with debridement of
nonviable muscle and/or nerve
27894 anterior and/or lateral, and posterior compartment(s),
with debridement of nonviable muscle and/or nerve
27899 Unlisted procedure, leg or ankle
➲ CPT Assistant Aug 00:11, Dec 16:16, Mar 20:14
Foot and Toes

Incision
10040-10160)
28001 Incision and drainage, bursa, foot
28002 Incision and drainage below fascia, with or without tendon

sheath involvement, foot; single bursal space
28003 multiple areas

28005 Incision, bone cortex (eg, osteomyelitis or bone abscess),

foot
28008 Fasciotomy, foot and/or toe

(See also 28060, 28062, 28250)
28010 Tenotomy, percutaneous, toe; single tendon

(For open tenotomy, see 28230-28234)
28020 Arthrotomy, including exploration, drainage, or removal of
loose or foreign body; intertarsal or tarsometatarsal joint
28022 metatarsophalangeal joint

28024 interphalangeal joint
28035 Release, tarsal tunnel (posterior tibial nerve
decompression)
(For other nerve entrapments, see 64704, 64722)
Excision
28043 Excision, tumor, soft tissue of foot or toe, subcutaneous; less
than 1.5 cm


28045 Excision, tumor, soft tissue of foot or toe, subfascial (eg,
intramuscular); less than 1.5 cm

28046 Radical resection of tumor (eg, sarcoma), soft tissue of foot

or toe; less than 3 cm

28050 Arthrotomy with biopsy; intertarsal or tarsometatarsal joint
28052 metatarsophalangeal joint
28055 Neurectomy, intrinsic musculature of foot
28060 Fasciectomy, plantar fascia; partial (separate procedure)

28062 radical (separate procedure)

(For plantar fasciotomy, see 28008, 28250)
28070 Synovectomy; intertarsal or tarsometatarsal joint, each
28072 metatarsophalangeal joint, each
28080 Excision, interdigital (Morton) neuroma, single, each
28086 Synovectomy, tendon sheath, foot; flexor
28088 extensor
28090 Excision of lesion, tendon, tendon sheath, or capsule
(including synovectomy) (eg, cyst or ganglion); foot
28092 toe(s), each

28100 Excision or curettage of bone cyst or benign tumor, talus or
calcaneus;
28104 Excision or curettage of bone cyst or benign tumor, tarsal or
metatarsal, except talus or calcaneus;

28108 Excision or curettage of bone cyst or benign tumor,
phalanges of foot
(For partial excision of bossing or exostosis for phalanx in
the foot, use 28124)
28110 Ostectomy, partial excision, fifth metatarsal head
(bunionette) (separate procedure)
➲ CPT Assistant Oct 98:10, Sep 00:9, Dec 10:17
28111 Ostectomy, complete excision; first metatarsal head

28112 other metatarsal head (second, third or fourth)
28113 fifth metatarsal head
28114 all metatarsal heads, with partial proximal
phalangectomy, excluding first metatarsal (eg, Clayton
type procedure)
28116 Ostectomy, excision of tarsal coalition
28118 Ostectomy, calcaneus;
➲ CPT Assistant May 11:9, Jan 15:13
28119 for spur, with or without plantar fascial release

28120 Partial excision (craterization, saucerization,

sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis
or bossing); talus or calcaneus
28122 tarsal or metatarsal bone, except talus or calcaneus
(For partial excision of talus or calcaneus, use 28120)

(For cheilectomy for hallux rigidus, use 28289)
28124 phalanx of toe
28126 Resection, partial or complete, phalangeal base, each toe
28130 Talectomy (astragalectomy)

(For calcanectomy, use 28118)
28140 Metatarsectomy
28150 Phalangectomy, toe, each toe
28153 Resection, condyle(s), distal end of phalanx, each toe

28160 Hemiphalangectomy or interphalangeal joint excision, toe,

proximal end of phalanx, each
28171 Radical resection of tumor; tarsal (except talus or

calcaneus)
28173 metatarsal
28175 phalanx of toe

(For talus or calcaneus, use 27647)
28190 Removal of foreign body, foot; subcutaneous
28192 deep
28193 complicated

28200 Repair, tendon, flexor, foot; primary or secondary, without
free graft, each tendon
➲ CPT Assistant Nov 98:8, Jul 14:5, Feb 16:15
28202 secondary with free graft, each tendon (includes

obtaining graft)
28208 Repair, tendon, extensor, foot; primary or secondary, each
tendon
28210 secondary with free graft, each tendon (includes

obtaining graft)
28220 Tenolysis, flexor, foot; single tendon

28225 Tenolysis, extensor, foot; single tendon


28230 Tenotomy, open, tendon flexor; foot, single or multiple

tendon(s) (separate procedure)
28232 toe, single tendon (separate procedure)
➲ CPT Assistant Nov 98:8, Mar 15:9, Apr 20:10
28234 Tenotomy, open, extensor, foot or toe, each tendon

(For tendon transfer to midfoot or hindfoot, see 27690,

27691)
28238 Reconstruction (advancement), posterior tibial tendon with
excision of accessory tarsal navicular bone (eg, Kidner type
procedure)
(For subcutaneous tenotomy, see 28010, 28011)

(For transfer or transplant of tendon with muscle redirection
or rerouting, see 27690-27692)
(For extensor hallucis longus transfer with great toe IP
fusion (Jones procedure), use 28760)
28240 Tenotomy, lengthening, or release, abductor hallucis muscle
28250 Division of plantar fascia and muscle (eg, Steindler
stripping) (separate procedure)
28260 Capsulotomy, midfoot; medial release only (separate
procedure)
28261 with tendon lengthening
28262 extensive, including posterior talotibial capsulotomy and
tendon(s) lengthening (eg, resistant clubfoot deformity)
28264 Capsulotomy, midtarsal (eg, Heyman type procedure)
28270 Capsulotomy; metatarsophalangeal joint, with or without
tenorrhaphy, each joint (separate procedure)
➲ CPT Assistant Sep 10:9, Sep 11:11, Sep 14:13
28272 interphalangeal joint, each joint (separate procedure)

28280 Syndactylization, toes (eg, webbing or Kelikian type
procedure)
28285 Correction, hammertoe (eg, interphalangeal fusion, partial

or total phalangectomy)
➲ CPT Assistant Nov 98:8, May 06:18, Sep 10:9, Sep
11:11, Mar 15:9, Jun 16:8
28286 Correction, cock-up fifth toe, with plastic skin closure (eg,
Ruiz-Mora type procedure)
28288 Ostectomy, partial, exostectomy or condylectomy, metatarsal

head, each metatarsal head
28289 Hallux rigidus correction with cheilectomy, debridement
and capsular release of the first metatarsophalangeal joint;
without implant
➲ CPT Assistant Nov 98:11, May 11:3, Sep 15:12, Dec
16:7
Hallux Rigidus Correction

28289
28291 with implant
28292 Correction, hallux valgus (bunionectomy), with

sesamoidectomy, when performed; with resection of
proximal phalanx base, when performed, any method
➲ CPT Assistant Dec 96:5, Sep 00:9, Jan 07:31, May 10:9,
Dec 10:12, Dec 16:3
Hallux Rigidus Correction with Implant

28291
A single- or double-stem implant may be used
Hallux Valgus Correction
28292
Hallux Valgus Correction with Proximal Phalanx Base
Resection
28292
28296 with distal metatarsal osteotomy, any method
➲ CPT Assistant Dec 96:6, Jan 97:10, Jan 07:31, May
10:9, Sep 13:17, Dec 16:4, Sep 18:14
# 28295 with proximal metatarsal osteotomy, any method
Hallux Valgus Correction with Proximal First Metatarsal

Osteotomy
28295
Hallux Valgus Correction with Distal First Metatarsal
Osteotomy
28296
A single or multiple plane osteotomy originating through the distal aspect of the first metatarsal
Hallux Valgus Correction with Metatarsal-Medial Cuneiform
Joint Arthrodesis
28297
28297 with first metatarsal and medial cuneiform joint
arthrodesis, any method
➲ CPT Assistant Dec 96:6, Jan 07:31, May 10:9, Dec
16:5
28298 with proximal phalanx osteotomy, any method
➲ CPT Assistant Dec 96:7, Jan 07:31, May 10:9, Oct
13:18, Dec 16:6
28299 with double osteotomy, any method
➲ CPT Assistant Dec 96:7, Jan 07:31, May 10:9, Sep
13:17, Oct 13:18, Apr 16:8, Dec 16:6
28300 Osteotomy; calcaneus (eg, Dwyer or Chambers type
procedure), with or without internal fixation
28302 talus
28304 Osteotomy, tarsal bones, other than calcaneus or talus;
28305 with autograft (includes obtaining graft) (eg, Fowler

type)
Hallux Valgus Correction with Proximal Phalanx Osteotomy

28298
28306 Osteotomy, with or without lengthening, shortening or

angular correction, metatarsal; first metatarsal
➲ CPT Assistant Nov 98:8, Dec 99:7, Dec 10:12
28307 first metatarsal with autograft (other than first toe)
28308 other than first metatarsal, each

28309 multiple (eg, Swanson type cavus foot procedure)
28310 Osteotomy, shortening, angular or rotational correction;

proximal phalanx, first toe (separate procedure)
28312 other phalanges, any toe

28313 Reconstruction, angular deformity of toe, soft tissue
procedures only (eg, overlapping second toe, fifth toe, curly
toes)
28315Sesamoidectomy, first toe (separate procedure)

28320 Repair, nonunion or malunion; tarsal bones
28322 metatarsal, with or without bone graft (includes obtaining

graft)
Hallux Valgus Correction with Double Osteotomy

28299
These illustrations depict medial resection of the first metatarsal along with several first ray double
osteotomy options for hallux valgus and metatarsus primus adductus (high intermetatarsal angle)
correction.
28340 Reconstruction, toe, macrodactyly; soft tissue resection
28341 requiring bone resection
28344 Reconstruction, toe(s); polydactyly
28345 syndactyly, with or without skin graft(s), each web
28360 Reconstruction, cleft foot
Coding Tip
28400 Closed treatment of calcaneal fracture; without manipulation

28406 Percutaneous skeletal fixation of calcaneal fracture, with
manipulation
28415 Open treatment of calcaneal fracture, includes internal
fixation, when performed;
28420 with primary iliac or other autogenous bone graft

28430 Closed treatment of talus fracture; without manipulation

28436 Percutaneous skeletal fixation of talus fracture, with
manipulation
28445 Open treatment of talus fracture, includes internal fixation,
when performed
28446 Open osteochondral autograft, talus (includes obtaining

graft[s])

(For arthroscopic osteochondral talus graft, use 29892)
(For open osteochondral allograft or repairs with industrial
grafts, use 28899)
28450 Treatment of tarsal bone fracture (except talus and
calcaneus); without manipulation, each

28456 Percutaneous skeletal fixation of tarsal bone fracture (except
talus and calcaneus), with manipulation, each
28465 Open treatment of tarsal bone fracture (except talus and
calcaneus), includes internal fixation, when performed, each
28470 Closed treatment of metatarsal fracture; without

manipulation, each
28476 Percutaneous skeletal fixation of metatarsal fracture, with
manipulation, each
28485 Open treatment of metatarsal fracture, includes internal
fixation, when performed, each
28490 Closed treatment of fracture great toe, phalanx or phalanges;

28496 Percutaneous skeletal fixation of fracture great toe, phalanx
or phalanges, with manipulation
28505 Open treatment of fracture, great toe, phalanx or phalanges,
28510 Closed treatment of fracture, phalanx or phalanges, other

than great toe; without manipulation, each
28525 Open treatment of fracture, phalanx or phalanges, other than
great toe, includes internal fixation, when performed, each
28530 Closed treatment of sesamoid fracture

28531 Open treatment of sesamoid fracture, with or without
internal fixation
28540 Closed treatment of tarsal bone dislocation, other than
talotarsal; without anesthesia
28546 Percutaneous skeletal fixation of tarsal bone dislocation,
other than talotarsal, with manipulation
28555 Open treatment of tarsal bone dislocation, includes internal
28570 Closed treatment of talotarsal joint dislocation; without

anesthesia
28576 Percutaneous skeletal fixation of talotarsal joint dislocation,
with manipulation
28585 Open treatment of talotarsal joint dislocation, includes
28600 Closed treatment of tarsometatarsal joint dislocation;

without anesthesia
28606 Percutaneous skeletal fixation of tarsometatarsal joint
28615 Open treatment of tarsometatarsal joint dislocation, includes
28630 Closed treatment of metatarsophalangeal joint dislocation;

without anesthesia
28636 Percutaneous skeletal fixation of metatarsophalangeal joint
28645 Open treatment of metatarsophalangeal joint dislocation,
28660 Closed treatment of interphalangeal joint dislocation;

without anesthesia
28666 Percutaneous skeletal fixation of interphalangeal joint
28675 Open treatment of interphalangeal joint dislocation, includes
Arthrodesis
28705 Arthrodesis; pantalar
28715 triple
28725 subtalar
28730 Arthrodesis, midtarsal or tarsometatarsal, multiple or

transverse;
28735 with osteotomy (eg, flatfoot correction)
28737 Arthrodesis, with tendon lengthening and advancement,

midtarsal, tarsal navicular-cuneiform (eg, Miller type
procedure)
28740 Arthrodesis, midtarsal or tarsometatarsal, single joint

28750 Arthrodesis, great toe; metatarsophalangeal joint
➲ CPT Assistant Dec 96:7, Dec 16:8

28760 Arthrodesis, with extensor hallucis longus transfer to first
metatarsal neck, great toe, interphalangeal joint (eg, Jones
type procedure)
(For hammertoe operation or interphalangeal fusion, use

28285)
Amputation
28800 Amputation, foot; midtarsal (eg, Chopart type procedure)
28805 transmetatarsal
28810 Amputation, metatarsal, with toe, single

28820 Amputation, toe; metatarsophalangeal joint
Other Procedures
28890 Extracorporeal shock wave, high energy, performed by a
physician or other qualified health care professional,
requiring anesthesia other than local, including ultrasound
guidance, involving the plantar fascia
➲ CPT Assistant Dec 05:10, Mar 06:1, Dec 18:5
(For extracorporeal shock wave therapy involving

musculoskeletal system not otherwise specified, see 0101T,
0102T)
integumentary system not otherwise specified, see 0512T,
0513T)
(Do not report 28890 in conjunction with 0512T, 0513T,
when treating the same area)
28899 Unlisted procedure, foot or toes
➲ CPT Assistant Sep 11:12, Nov 15:10, Jun 16:8, Sep
17:14, Nov 17:10, Oct 18:11
Application of Casts and Strapping

The listed procedures apply when the cast application or
strapping is a replacement procedure used during or after the
period of follow-up care, or when the cast application or
strapping is an initial service performed without a restorative
treatment or procedure(s) to stabilize or protect a fracture, injury,
or dislocation and/or to afford comfort to a patient. Restorative
treatment or procedure(s) rendered by another individual
following the application of the initial cast/splint/strap may be
reported with a treatment of fracture and/or dislocation code.
An individual who applies the initial cast, strap, or splint and also
assumes all of the subsequent fracture, dislocation, or injury care
cannot use the application of casts and strapping codes as an
initial service, since the first cast/splint or strap application is
included in the treatment of fracture and/or dislocation codes.
(See notes under Musculoskeletal System, page 135.) A
temporary cast/splint/strap is not considered to be part of the
preoperative care, and the use of the modifier 56 is not
applicable. Additional evaluation and management services are
reportable only if significant identifiable further services are
provided at the time of the cast application or strapping.
If cast application or strapping is provided as an initial service
(eg, casting of a sprained ankle or knee) in which no other
procedure or treatment (eg, surgical repair, reduction of a
fracture, or joint dislocation) is performed or is expected to be
performed by an individual rendering the initial care only, use the
casting, strapping, and/or supply code (99070) in addition to an
evaluation and management code as appropriate.
Listed procedures include removal of cast or strapping.
(For orthotics management and training, see 97760, 97761,
97763)
Body and Upper Extremity
Casts
29000 Application of halo type body cast (see 20661-20663 for
insertion)
➲ CPT Assistant Feb 96:3, 5, Apr 02:13, Jan 18:3
29010 Application of Risser jacket, localizer, body; only

29015 including head

29035 Application of body cast, shoulder to hips;

29040 including head, Minerva type

29044 including 1 thigh

29046 including both thighs

29049 Application, cast; figure-of-eight

29055 shoulder spica

29058 plaster Velpeau

29065 shoulder to hand (long arm)

29075 elbow to finger (short arm)

➲ CPT Assistant Feb 96:3-4, Apr 02:13
29085 hand and lower forearm (gauntlet)
➲ CPT Assistant Feb 96:3, Apr 02:13, Dec 02:11
29086 finger (eg, contracture)

Splints
29105 Application of long arm splint (shoulder to hand)

➲ CPT Assistant Feb 96:3, Apr 02:13, May 09:8, Jan 18:3
29125 Application of short arm splint (forearm to hand); static

➲ CPT Assistant Feb 96:3-4, Apr 02:13, Jan 18:3
29126 dynamic
29130 Application of finger splint; static

29131 dynamic
Strapping—Any Age
29200 Strapping; thorax
(To report low back strapping, use 29799)

29240 shoulder (eg, Velpeau)
➲ CPT Assistant Feb 96:3, Apr 02:13, Jun 10:8
29260 elbow or wrist

29280 hand or finger

Lower Extremity
Casts
29305 Application of hip spica cast; 1 leg
29325 1 and one-half spica or both legs

(For hip spica (body) cast, including thighs only, use 29046)
29345 Application of long leg cast (thigh to toes);
29355 walker or ambulatory type

➲ CPT Assistant Feb 96:3, Apr 02:13, Sep 11:11, Jan
18:3
29358 Application of long leg cast brace
29365 Application of cylinder cast (thigh to ankle)

29405 Application of short leg cast (below knee to toes);

➲ CPT Assistant Feb 96:3, Apr 02:13, Mar 03:17, Sep
11:11, Jan 18:3
29425 walking or ambulatory type
29435 Application of patellar tendon bearing (PTB) cast

29440 Adding walker to previously applied cast

29445 Application of rigid total contact leg cast
29450 Application of clubfoot cast with molding or manipulation,

long or short leg
(To report bilateral procedure, use 29450 with modifier 50)
Splints
29505 Application of long leg splint (thigh to ankle or toes)
➲ CPT Assistant Feb 96:3, Apr 02:13, May 09:8
29515 Application of short leg splint (calf to foot)

➲ CPT Assistant Feb 96:3, Apr 02:13, Mar 03:18, Jan
18:3, Oct 19:10
Strapping—Any Age
29520 Strapping; hip
29530 knee
➲ CPT Assistant Feb 96:3, Apr 02:13, Jun 10:8, Aug
10:15
29540 ankle and/or foot
➲ CPT Assistant Feb 96:3, Apr 02:13, Mar 03:17, Jun
10:8, Aug 10:15, Mar 14:4
(Do not report 29540 in conjunction with 29580, 29581, for
the same extremity)
29550 toes
29580 Unna boot

➲ CPT Assistant Feb 96:3, Jul 99:10, Apr 02:13, Mar
14:4
the same extremity)
29581 Application of multi-layer compression system; leg (below
knee), including ankle and foot
➲ CPT Assistant May 11:11, Sep 12:16, Sep 13:17, Mar
14:4, Oct 14:6, Mar 15:10, Aug 16:3
the same extremity)
(Do not report 29520, 29530, 29540, 29550, 29580, 29581
in conjunction with 36465, 36466, 36468, 36470, 36471,
36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483,
for the same extremity)
29584 upper arm, forearm, hand, and fingers
➲ CPT Assistant Mar 15:10, Aug 16:3

36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478,
36479, 36482, 36483, for the same extremity)
Removal or Repair
Codes for cast removals should be employed only for casts
applied by another individual.
29700 Removal or bivalving; gauntlet, boot or body cast
29705 full arm or full leg cast

29710 shoulder or hip spica, Minerva, or Risser jacket, etc.
29720 Repair of spica, body cast or jacket

29730 Windowing of cast

29740 Wedging of cast (except clubfoot casts)

29750 Wedging of clubfoot cast

➲ CPT Assistant Apr 02:13, Jan 18:3
Other Procedures
29799 Unlisted procedure, casting or strapping
➲ CPT Assistant Sep 12:16, Aug 16:11, Jan 18:3
Endoscopy/Arthroscopy
Surgical endoscopy/arthroscopy always includes a diagnostic
endoscopy/arthroscopy.
When arthroscopy is performed in conjunction with arthrotomy,
add modifier 51.
▶Arthroscopic removal of loose body(ies) or foreign body(ies)
(ie, 29819, 29834, 29861, 29874, 29894, 29904) may be reported
only when the loose body(ies) or foreign body(ies) is equal to or
larger than the diameter of the arthroscopic cannula(s) used for
the specific procedure, and can only be removed through a
cannula larger than that used for the specific procedure or
through a separate incision or through a portal that has been
enlarged to allow removal of the loose or foreign body(ies).◀
29800 Arthroscopy, temporomandibular joint, diagnostic, with or
without synovial biopsy (separate procedure)
29804 Arthroscopy, temporomandibular joint, surgical

(For open procedure, use 21010)

29805 Arthroscopy, shoulder, diagnostic, with or without synovial
biopsy (separate procedure)
➲ CPT Assistant May 13:12, Jun 15:10
(For open procedure, see 23065-23066, 23100-23101)

29806 Arthroscopy, shoulder, surgical; capsulorrhaphy
➲ CPT Assistant May 13:12, Mar 15:7, Jul 15:10, Jun
18:11
(For open procedure, see 23450-23466)
(To report thermal capsulorrhaphy, use 29999)
29807 repair of SLAP lesion
➲ CPT Assistant May 13:12, Mar 15:7
29819 with removal of loose body or foreign body

➲ CPT Assistant May 13:12, Mar 15:7, Jun 18:11
(For open procedure, see 23040-23044, 23107)

29820 synovectomy, partial
➲ CPT Assistant May 13:12, Jun 13:13, Mar 15:7
(For open procedure, see 23105)
29821 synovectomy, complete
➲ CPT Assistant May 13:12, Jun 13:13, Mar 15:7
(For open procedure, see 23105)

▲ 29822 debridement, limited, 1 or 2 discrete structures (eg,
humeral bone, humeral articular cartilage, glenoid bone,
glenoid articular cartilage, biceps tendon, biceps anchor
complex, labrum, articular capsule, articular side of the
rotator cuff, bursal side of the rotator cuff, subacromial
bursa, foreign body[ies])
➲ CPT Assistant May 01:9, Apr 12:17, Sep 12:16, May
13:12, Mar 15:7, Jan 18:7
(For open procedure, see specific open shoulder procedure
performed)
▲ 29823 debridement, extensive, 3 or more discrete structures
(eg, humeral bone, humeral articular cartilage, glenoid
bone, glenoid articular cartilage, biceps tendon, biceps
anchor complex, labrum, articular capsule, articular side
of the rotator cuff, bursal side of the rotator cuff,
subacromial bursa, foreign body[ies])
➲ CPT Assistant Apr 12:17, Sep 12:16, May 13:12,
Mar 15:7, Dec 16:16, Jan 18:7
performed)
29824 distal claviculectomy including distal articular surface
(Mumford procedure)

29825 with lysis and resection of adhesions, with or without
manipulation

performed)
✚ 29826 decompression of subacromial space with partial
acromioplasty, with coracoacromial ligament (ie, arch)
release, when performed (List separately in addition to
➲ CPT Assistant May 01:9, Aug 02:10, May 13:12,
Mar 15:7
(For open procedure, use 23130 or 23415)
(Use 29826 in conjunction with 29806-29825, 29827,
29828)
29827 with rotator cuff repair
➲ CPT Assistant Mar 08:14, May 13:12, Mar 15:7, Jul
16:8
(For open or mini-open rotator cuff repair, use 23412)
(When arthroscopic distal clavicle resection is performed at
the same setting, use 29824 and append modifier 51)
Arthroscopy, Shoulder, Distal Claviculectomy (Mumford

Procedure)
29824
29828 biceps tenodesis
➲ CPT Assistant Feb 08:9, May 13:12, Mar 15:7, Jul
16:8
29822)
(For open biceps tenodesis, use 23430)
29830 Arthroscopy, elbow, diagnostic, with or without synovial
29834 Arthroscopy, elbow, surgical; with removal of loose body
or foreign body


29837 debridement, limited

29838 debridement, extensive

29840 Arthroscopy, wrist, diagnostic, with or without synovial

29843 Arthroscopy, wrist, surgical; for infection, lavage and

drainage


➲ CPT Assistant Dec 03:11, May 13:12
29846 excision and/or repair of triangular fibrocartilage and/or

joint debridement
29847 internal fixation for fracture or instability

29848 Endoscopy, wrist, surgical, with release of transverse

carpal ligament
➲ CPT Assistant Dec 99:7, May 13:12, Jul 15:10, Jan
17:6, Apr 18:10
29850 Arthroscopically aided treatment of intercondylar spine(s)
and/or tuberosity fracture(s) of the knee, with or without
manipulation; without internal or external fixation (includes
arthroscopy)
29851 with internal or external fixation (includes arthroscopy)

(For bone graft, use 20900, 20902)

29855 Arthroscopically aided treatment of tibial fracture, proximal
(plateau); unicondylar, includes internal fixation, when
performed (includes arthroscopy)
➲ CPT Assistant May 13:12, Sep 18:14, Nov 19:13
29856 bicondylar, includes internal fixation, when performed

(includes arthroscopy)
(For bone graft, use 20900, 20902)

29860 Arthroscopy, hip, diagnostic with or without synovial
➲ CPT Assistant Nov 97:15, Jul 98:8, Sep 11:6, May
13:12
29861 Arthroscopy, hip, surgical; with removal of loose body or
foreign body
13:12
29862 with debridement/shaving of articular cartilage
(chondroplasty), abrasion arthroplasty, and/or resection
of labrum
13:12
13:12
# 29914 with femoroplasty (ie, treatment of cam lesion)
# 29915 with acetabuloplasty (ie, treatment of pincer lesion)


29863)
# 29916 with labral repair

29863)
29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg,
mosaicplasty) (includes harvesting of the autograft[s])

29875, 29884 when performed at the same session and/or
29874, 29877, 29879, 29885-29887 when performed in the
same compartment)
(For open osteochondral autograft of knee, use 27416)
29867 osteochondral allograft (eg, mosaicplasty)

29871, 29875, 29884 when performed at the same session
and/or 29874, 29877, 29879, 29885-29887 when performed
in the same compartment)
29868 meniscal transplantation (includes arthrotomy for
meniscal insertion), medial or lateral

session or 29874, 29877, 29881, 29882 when performed in
the same compartment)
29870 Arthroscopy, knee, diagnostic, with or without synovial
➲ CPT Assistant Dec 07:10, Mar 11:9, May 13:12, Nov
19:14
(For open autologous chondrocyte implantation of the knee,
use 27412)
Arthroscopy of the Knee

29866-29887
Portal incisions are made on either side of the patellar tendon and compartments of the knee are
examined using the arthroscope and a probe. Additional treatment is performed as needed.
29871 Arthroscopy, knee, surgical; for infection, lavage and
drainage
➲ CPT Assistant Aug 01:6, May 13:12, Aug 19:7

(For implantation of osteochondral graft for treatment of
articular surface defect, see 27412, 27415, 29866, 29867)
29873 with lateral release
➲ CPT Assistant Dec 07:10, Aug 09:11, May 13:12,
Nov 15:7
(For open lateral release, use 27425)
29874 for removal of loose body or foreign body (eg,
osteochondritis dissecans fragmentation, chondral
fragmentation)
➲ CPT Assistant Aug 01:6, Apr 03:12, May 13:12
29875 synovectomy, limited (eg, plica or shelf resection)

➲ CPT Assistant Aug 01:6, May 13:12, May 14:10, Jan
16:11
29876 synovectomy, major, 2 or more compartments (eg, medial
or lateral)
29877 debridement/shaving of articular cartilage

(chondroplasty)
➲ CPT Assistant Feb 96:9, Jun 99:11, Aug 01:7, Apr
03:7, Apr 05:14, Dec 07:10, May 13:12
(When performed with arthroscopic meniscectomy, see
29880 or 29881)
29879 abrasion arthroplasty (includes chondroplasty where
necessary) or multiple drilling or microfracture
➲ CPT Assistant Nov 99:13, Aug 01:7, May 13:12
29880 with meniscectomy (medial AND lateral, including any

meniscal shaving) including debridement/shaving of
articular cartilage (chondroplasty), same or separate
compartment(s), when performed
➲ CPT Assistant Jun 99:11, Aug 01:7, Jan 12:3, May
13:12
29881 with meniscectomy (medial OR lateral, including any
meniscal shaving) including debridement/shaving of
articular cartilage (chondroplasty), same or separate
compartment(s), when performed
➲ CPT Assistant Feb 96:9, Jun 99:11, Aug 01:7, Oct
03:11, Apr 05:14, Dec 07:10, Jan 12:3, May 13:12,
May 14:10, Jan 16:11, Nov 19:14
29882 with meniscus repair (medial OR lateral)
CPT Assistant Aug 01:7, Sep 04:12, Dec 07:10, Dec
➲
11:15, May 13:12, May 19:10
29883 with meniscus repair (medial AND lateral)
➲ CPT Assistant Aug 01:7, Sep 04:12, Dec 07:10, Dec
11:15, May 13:12
(For meniscal transplantation, medial or lateral, knee, use
29868)
29884 with lysis of adhesions, with or without manipulation
➲ CPT Assistant Aug 01:7, Mar 11:9, May 13:12
29885 drilling for osteochondritis dissecans with bone grafting,

with or without internal fixation (including debridement
of base of lesion)
29886 drilling for intact osteochondritis dissecans lesion

29887 drilling for intact osteochondritis dissecans lesion with

internal fixation
29888 Arthroscopically aided anterior cruciate ligament

repair/augmentation or reconstruction
➲ CPT Assistant Oct 03:11, Dec 07:10, May 13:12, Nov
16:9, May 17:10
29889 Arthroscopically aided posterior cruciate ligament
repair/augmentation or reconstruction
➲ CPT Assistant Sep 96:9, Oct 98:11, Aug 01:8, Dec
07:10, May 13:12
29891 Arthroscopy, ankle, surgical, excision of osteochondral
defect of talus and/or tibia, including drilling of the defect
29892 Arthroscopically aided repair of large osteochondritis
dissecans lesion, talar dome fracture, or tibial plafond
fracture, with or without internal fixation (includes
arthroscopy)
➲ CPT Assistant Nov 97:15, Dec 08:6, May 13:12
29893 Endoscopic plantar fasciotomy

29894 Arthroscopy, ankle (tibiotalar and fibulotalar joints),

surgical; with removal of loose body or foreign body

29897 debridement, limited

29898 debridement, extensive

29899 with ankle arthrodesis

(For open ankle arthrodesis, use 27870)
Arthroscopy of the Ankle

29894-29899
Incisions are made allowing the ankle to be examined using the arthroscope and a probe. Additional
treatment is performed as needed.
29900 Arthroscopy, metacarpophalangeal joint, diagnostic,
includes synovial biopsy
(Do not report 29900 with 29901, 29902)

29901 Arthroscopy, metacarpophalangeal joint, surgical; with
debridement
29902 with reduction of displaced ulnar collateral ligament (eg,

Stener lesion)
29904 Arthroscopy, subtalar joint, surgical; with removal of loose

body or foreign body

29906 with debridement
29907 with subtalar arthrodesis


29999 Unlisted procedure, arthroscopy
➲ CPT Assistant Aug 02:10, Sep 04:12, Nov 08:10, Mar
09:10, Dec 11:15, Apr 12:17, May 13:12, Dec 15:18,
Dec 16:16, Apr 17:9, Nov 19:13, Dec 19:12
Notes

Surgery
Respiratory System (30000-32999)
appear within the Respiratory System section of the CPT
codebook. The subheadings or subsections denoted with
asterisks (*) below have special instructions unique to that
subsection. Where these are indicated, special notes or guidelines
will be presented preceding those procedural terminology
listings, referring to that subsection specifically.
Nose (30000-30999)
Incision (30000-30020)
Excision (30100-30160)
Removal of Foreign Body (30300-30320)
Repair (30400-30630)
Destruction (30801-30802)
Accessory Sinuses (31000-31299)
Incision (31000-31090)
Excision (31200-31230)
Endoscopy* (31231-31298)
Paranasal Sinuses
Larynx (31300-31599)
Excision (31300-31420)
Endoscopy* (31505-31579)
Repair (31580-31592)
Destruction
Trachea and Bronchi (31600-31899)
Incision (31600-31614)
Endoscopy* (31615-31654)
Bronchial Thermoplasty (31660-31661)
Excision, Repair (31750-31830)
Lungs and Pleura* (32035-32999)
Incision (32035-32225)
Excision/Resection (32310-32408)
Removal (32440-32540)
Introduction and Removal (32550-32557)
Thoracoscopy (Video-assisted thoracic surgery [VATS])* (32601-
32674)
Stereotactic Radiation Therapy* (32701)
Repair (32800-32820)
Lung Transplantation* (32850-32856)
Surgical Collapse Therapy; Thoracoplasty (32900-32960)
Respiratory System
Respiratory System
Nose
Incision
30000 Drainage abscess or hematoma, nasal, internal approach
(For external approach, see 10060, 10140)
30020 Drainage abscess or hematoma, nasal septum
(For lateral rhinotomy, see specific application [eg, 30118,
30320])
Excision
30100 Biopsy, intranasal
(For biopsy skin of nose, see 11102, 11103, 11104, 11105,
11106, 11107)
30110 Excision, nasal polyp(s), simple
(30110 would normally be completed in an office setting)
30115 Excision, nasal polyp(s), extensive
(30115 would normally require the facilities available in a
hospital setting)
30117 Excision or destruction (eg, laser), intranasal lesion;
internal approach
➲ CPT Assistant Jul 19:10, Nov 19:14
30118 external approach (lateral rhinotomy)

30120 Excision or surgical planing of skin of nose for rhinophyma

30124 Excision dermoid cyst, nose; simple, skin, subcutaneous

30125 complex, under bone or cartilage
30130 Excision inferior turbinate, partial or complete, any method
➲ CPT Assistant Feb 98:11, Nov 98:11, Sep 01:10, May
03:5
(For excision of superior or middle turbinate, use 30999)
30140 Submucous resection inferior turbinate, partial or complete,
any method
➲ CPT Assistant Nov 98:11, Dec 02:10, Apr 03:26, May
03:5, Dec 04:18, Mar 08:14, Jan 20:12
30802, 30930)
(For submucous resection of superior or middle turbinate,
use 30999)
(For endoscopic resection of concha bullosa of middle
turbinate, use 31240)
(For submucous resection of nasal septum, use 30520)
30150 Rhinectomy; partial
30160 total
(For closure and/or reconstruction, primary or delayed, see
Integumentary System,13151-13160, 14060-14302,
15120, 15121, 15260, 15261, 15760, 20900-20912)
Introduction
30200 Injection into turbinate(s), therapeutic
30210 Displacement therapy (Proetz type)

30220 Insertion, nasal septal prosthesis (button)
Removal of Foreign Body

30300 Removal foreign body, intranasal; office type procedure
30310 requiring general anesthesia

30320 by lateral rhinotomy
Repair
(For obtaining tissues for graft, see 15769, 20900, 20902,
20910, 20912, 20920, 20922, 20924, 21210)
(For correction of nasal defects using fat harvested via
liposuction technique, see 15773, 15774)
30400 Rhinoplasty, primary; lateral and alar cartilages and/or
elevation of nasal tip
(For columellar reconstruction, see 13151 et seq)
30410 complete, external parts including bony pyramid, lateral
and alar cartilages, and/or elevation of nasal tip
30420 including major septal repair
30430 Rhinoplasty, secondary; minor revision (small amount of
nasal tip work)
30435 intermediate revision (bony work with osteotomies)
30450 major revision (nasal tip work and osteotomies)
30460 Rhinoplasty for nasal deformity secondary to congenital
cleft lip and/or palate, including columellar lengthening; tip
only
30462 tip, septum, osteotomies

30465 Repair of nasal vestibular stenosis (eg, spreader grafting,

lateral nasal wall reconstruction)
▶ (30465 excludes obtaining graft. For graft procedure, see

15769, 20900, 20902, 20910, 20912, 20920, 20922, 20924,
21210, 21235)◀
(30465 is used to report a bilateral procedure. For
unilateral procedure, use modifier 52)
▶ (Do not report 30465 in conjunction with 30468, when
performed on the ipsilateral side)◀
▶ (Forrepair of nasal vestibular lateral wall collapse with
subcutaneous/submucosal lateral wall implant[s], use
30468)◀
● 30468 Repair of nasal valve collapse with
subcutaneous/submucosal lateral wall implant(s)
▶ (30468 is used to report a bilateral procedure. For

unilateral procedure, use modifier 52)◀
▶ (Do not report 30468 in conjunction with 30465, when
performed on the ipsilateral side)◀
▶ (For repair of nasal vestibular stenosis [eg, spreader
grafting, lateral nasal wall reconstruction], use 30465)◀
▶ (For repair of nasal vestibular stenosis or collapse
without cartilage graft, lateral wall reconstruction, or
subcutaneous/submucosal implant [eg, radiofrequency
remodeling, lateral wall suspension, or stenting without
graft or subcutaneous/submucosal implant], use 30999)◀
30520 Septoplasty or submucous resection, with or without
cartilage scoring, contouring or replacement with graft
➲ CPT Assistant Oct 97:11, Dec 02:10, Mar 12:9, Jul
15:10, Jul 19:10
(For submucous resection of turbinates, use 30140)
30540 Repair choanal atresia; intranasal
30545 transpalatine
(Do not report modifier 63 in conjunction with 30540,
30545)
30560 Lysis intranasal synechia
30580 Repair fistula; oromaxillary (combine with 31030 if
antrotomy is included)
30600 oronasal
30620 Septal or other intranasal dermatoplasty (does not include
obtaining graft)
Surgical Repair of Vestibular Stenosis

30465
An incision is made in the upper lateral cartilage and continued as an osteotomy of the medial aspect of
the nasal bones. The spreader graft is placed to widen the nasal vestibule.
30630 Repair nasal septal perforations
Destruction
30801 Ablation, soft tissue of inferior turbinates, unilateral or
bilateral, any method (eg, electrocautery, radiofrequency
ablation, or tissue volume reduction); superficial
(For ablation of superior or middle turbinates, use 30999)

30802 intramural (ie, submucosal)
➲ CPT Assistant Mar 08:14, Sep 10:10, Jul 19:10

30130 or 30140)
(For cautery performed for control of nasal hemorrhage, see
30901-30906)
Other Procedures
30901 Control nasal hemorrhage, anterior, simple (limited cautery
and/or packing) any method
30903 Control nasal hemorrhage, anterior, complex (extensive
cautery and/or packing) any method
30905 Control nasal hemorrhage, posterior, with posterior nasal
packs and/or cautery, any method; initial
30906 subsequent
30915 Ligation arteries; ethmoidal
30920 internal maxillary artery, transantral
(For ligation external carotid artery, use 37600)
30930 Fracture nasal inferior turbinate(s), therapeutic
➲ CPT Assistant Jul 01:11, Dec 02:10, Jul 03:15, Aug
03:14, Dec 04:18, Sep 10:10, Jul 16:8
30130 or 30140)
(For fracture of superior or middle turbinate[s], use 30999)
30999 Unlisted procedure, nose
➲ CPT Assistant Feb 13:13, Nov 19:14
Accessory Sinuses
Incision
31000 Lavage by cannulation; maxillary sinus (antrum puncture or
natural ostium)

31002 sphenoid sinus
31020 Sinusotomy, maxillary (antrotomy); intranasal
31030 radical (Caldwell-Luc) without removal of antrochoanal
polyps
31032 radical (Caldwell-Luc) with removal of antrochoanal
polyps
31040 Pterygomaxillary fossa surgery, any approach
(For transantral ligation of internal maxillary artery, use
30920)
31050 Sinusotomy, sphenoid, with or without biopsy;
31051 with mucosal stripping or removal of polyp(s)
31070 Sinusotomy frontal; external, simple (trephine operation)
(For frontal intranasal sinusotomy, use 31276)
Sinusotomy, Frontal
31070
A trephine is used to access the frontal sinus.
31075 transorbital, unilateral (for mucocele or osteoma, Lynch
type)
31080 obliterative without osteoplastic flap, brow incision
(includes ablation)
31081 obliterative, without osteoplastic flap, coronal incision
(includes ablation)
31084 obliterative, with osteoplastic flap, brow incision
31085 obliterative, with osteoplastic flap, coronal incision
31086 nonobliterative, with osteoplastic flap, brow incision
31087 nonobliterative, with osteoplastic flap, coronal incision
31090 Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal,
maxillary, ethmoid, sphenoid)
Excision
31200 Ethmoidectomy; intranasal, anterior
31201 intranasal, total
31205 extranasal, total

31225 Maxillectomy; without orbital exenteration

31230 with orbital exenteration (en bloc)
(For orbital exenteration only, see 65110 et seq)
(For skin grafts, see 15120 et seq)
Endoscopy
A surgical sinus endoscopy includes a sinusotomy (when
appropriate) and diagnostic endoscopy.
Codes 31295-31298 describe dilation of sinus ostia by
displacement of tissue, any method, and include fluoroscopy if
performed.
Stereotactic computer-assisted navigation may be used to
facilitate the performance of endoscopic sinus surgery, and may
be reported with 61782.
Codes 31233-31298 are used to report unilateral procedures
unless otherwise specified.
Codes 31231-31235 for diagnostic evaluation refer to employing
a nasal/sinus endoscope to inspect the interior of the nasal cavity
and the middle and superior meatus, the turbinates, and the
spheno-ethmoid recess. Any time a diagnostic evaluation is
performed all these areas would be inspected and a separate code
is not reported for each area. To report these services when all of
the elements are not fully examined (eg, judged not clinically
pertinent), or because the clinical situation precludes such exam
(eg, technically unable, altered anatomy), append modifier 52 if
repeat examination is not planned, or modifier 53 if repeat
examination is planned.
31231 Nasal endoscopy, diagnostic, unilateral or bilateral
➲ CPT Assistant Winter 93:22, Jan 97:4, Feb 16:10, Jan
17:6, Apr 18:3
31233 Nasal/sinus endoscopy, diagnostic; with maxillary
sinusoscopy (via inferior meatus or canine fossa puncture)
➲ CPT Assistant Winter 93:22, Jan 97:4, Jun 11:11, Apr
18:3
31295, when performed on the ipsilateral side)
31235 with sphenoid sinusoscopy (via puncture of sphenoidal
face or cannulation of ostium)
➲ CPT Assistant Winter 93:22, Jan 97:4, Apr 18:3

31287, 31288, 31297, 31298, when performed on the
ipsilateral side)
(To report endoscopic placement of a drug-eluting implant
in the ethmoid sinus without any other nasal/sinus
endoscopic surgical service, use 31299. To report
endoscopic placement of a drug-eluting implant in the
ethmoid sinus in conjunction with biopsy, polypectomy, or
31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy
or debridement (separate procedure)
➲ CPT Assistant Winter 93:23, Jan 97:4, Dec 01:6, May
03:5, Dec 11:13, Jan 15:13, Feb 16:10, Apr 18:3, Apr
19:10, Jul 19:7, Jan 20:12
31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287,
31288, 31290, 31291, 31292, 31293, 31294, when
performed on the ipsilateral side)
Sinus Endoscopy
31231-31294
The physician uses an endoscope for visualizing and magnifying the internal structure of the sinuses.
31238 with control of nasal hemorrhage

when performed on the ipsilateral side)
31239 with dacryocystorhinostomy
31240 with concha bullosa resection

➲ CPT Assistant Winter 93:23, Jan 97:4, May 03:5, Feb
16:10, Apr 18:3
31241 with ligation of sphenopalatine artery
(Do not report 31241 in conjunction with 31238, when

31254 Nasal/sinus endoscopy, surgical with ethmoidectomy;
partial (anterior)
➲ CPT Assistant Winter 93:23, Jan 97:4, Sep 97:10, Oct
97:5, Dec 01:6, May 03:5, Jul 11:13, Feb 16:10, Apr
18:3
31255, 31257, 31259, 31290, 31291, 31292, 31293, 31294,
31255 total (anterior and posterior)
➲ CPT Assistant Winter 93:23, Jan 97:4, Dec 02:10,
May 03:5, Jul 11:13, Feb 16:10, Apr 18:4
31254, 31257, 31259, 31276, 31287, 31288, 31290, 31291,
31292, 31293, 31294, when performed on the ipsilateral
side)
# 31253 total (anterior and posterior), including frontal sinus
exploration, with removal of tissue from frontal sinus,
when performed

31255, 31276, 31290, 31291, 31292, 31293, 31294, 31296,
# 31257 total (anterior and posterior), including sphenoidotomy

31254, 31255, 31259, 31287, 31288, 31290, 31291, 31292,
ipsilateral side)
# 31259 total (anterior and posterior), including sphenoidotomy,
with removal of tissue from the sphenoid sinus

31254, 31255, 31257, 31287, 31288, 31290, 31291, 31292,
ipsilateral side)
31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy;
➲ CPT Assistant Winter 93:23, Jan 97:4, Jun 11:11, Jul
11:13, Jun 13:13, Apr 18:11, Apr 19:10
31267, 31295, when performed on the ipsilateral side)
31267 with removal of tissue from maxillary sinus
➲ CPT Assistant Jan 97:4, Dec 01:6, Jun 11:11, Jul
11:13, Apr 18:3, Apr 19:10
31276 Nasal/sinus endoscopy, surgical, with frontal sinus
exploration, including removal of tissue from frontal sinus,
when performed
➲ CPT Assistant Winter 93:24, Jan 97:4, Jan 10:11, Jun
11:13, Apr 18:4, Apr 19:10
31255, 31296, 31298, when performed on the ipsilateral
side)
31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy;
➲ CPT Assistant Winter 93:24, Jan 97:4, Jun 11:11, Apr
18:3, Apr 19:10
31255, 31257, 31259, 31288, 31291, 31294, 31297, 31298,
31288 with removal of tissue from the sphenoid sinus
➲ CPT Assistant Winter 93:24, Jan 97:4, Jun 11:11, Feb
16:10, Apr 18:3, Apr 19:10
31255, 31257, 31259, 31287, 31291, 31294, 31297, 31298,
31290 Nasal/sinus endoscopy, surgical, with repair of
cerebrospinal fluid leak; ethmoid region
➲ CPT Assistant Winter 93:24, Jan 97:4, Jul 11:13, Feb
16:10, Apr 18:3
ipsilateral side)
31291 sphenoid region
➲ CPT Assistant Winter 93:24, Jan 97:4, Jul 11:13, Apr
18:3
31254, 31255, 31257, 31259, 31287, 31288, when
31292 Nasal/sinus endoscopy, surgical, with orbital
decompression; medial or inferior wall
18:3
31254, 31255, 31257, 31259, 31293, 31296, when
31293 medial and inferior wall
18:3
31254, 31255, 31257, 31259, 31292, when performed on
the ipsilateral side)
31294 Nasal/sinus endoscopy, surgical, with optic nerve
decompression
CPT Assistant Winter 93:24, Jan 97:4, Jul 11:13, Apr
➲
18:3
31254, 31255, 31257, 31259, 31287, 31288, when
31295 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon
dilation); maxillary sinus ostium, transnasal or via canine
fossa
➲ CPT Assistant Jun 11:11, Apr 18:3

31296 frontal sinus ostium

31297 sphenoid sinus ostium

31259, 31287, 31288, 31296, 31298, when performed on
the ipsilateral side)
31298 frontal and sphenoid sinus ostia

31257, 31259, 31276, 31287, 31288, 31296, 31297, when
Other Procedures
(For hypophysectomy, transantral or transeptal approach,
use 61548)
(For transcranial hypophysectomy, use 61546)
31299 Unlisted procedure, accessory sinuses
➲ CPT Assistant Jan 10:11, Jun 11:11, Jun 13:13, Jul
15:10, Feb 16:10, Apr 19:10, Jul 19:7
Larynx
Excision
31300 Laryngotomy (thyrotomy, laryngofissure), with removal of
tumor or laryngocele, cordectomy
31360 Laryngectomy; total, without radical neck dissection
31365 total, with radical neck dissection

➲ CPT Assistant Oct 01:10, Aug 10:4
31367 subtotal supraglottic, without radical neck dissection

31368 subtotal supraglottic, with radical neck dissection

31370 Partial laryngectomy (hemilaryngectomy); horizontal
31375 laterovertical
31380 anterovertical
31382 antero-latero-vertical
31390 Pharyngolaryngectomy, with radical neck dissection; without
reconstruction
31395 with reconstruction
31400 Arytenoidectomy or arytenoidopexy, external approach
(For endoscopic arytenoidectomy, use 31560)
31420 Epiglottidectomy
Introduction
31500 Intubation, endotracheal, emergency procedure
➲ CPT Assistant Nov 99:32-33, Oct 03:2, Aug 04:8, Jul
06:4, Jul 07:1, Dec 09:10, May 16:3, Oct 16:8
31502 Tracheotomy tube change prior to establishment of fistula
tract
Endoscopy
For endoscopic procedures, report appropriate endoscopy of
each anatomic site examined. Laryngoscopy includes examination
of the tongue base, larynx, and hypopharynx. The anatomic
structures examined with this procedure include both midline
(single anatomic sites) and paired structures. Midline, single
anatomic sites include tongue base, vallecula, epiglottis,
subglottis, and posterior pharyngeal wall. Paired structures
include true vocal cords, arytenoids, false vocal cords, ventricles,
pyriform sinuses, and aryepiglottic folds. For the purposes of
reporting therapeutic interventions, all paired structures contained
within one side of the larynx/pharynx are considered unilateral. If
using operating microscope, telescope, or both, use the applicable
code only once per operative session.
31505 Laryngoscopy, indirect; diagnostic (separate procedure)
31510 with biopsy
31511 with removal of foreign body

31512 with removal of lesion

31513 with vocal cord injection

31515 Laryngoscopy direct, with or without tracheoscopy; for

aspiration
31520 diagnostic, newborn
(Do not report modifier 63 in conjunction with 31520)
31525 diagnostic, except newborn
31526 diagnostic, with operating microscope or telescope

➲ CPT Assistant Nov 98:11-12, Jun 17:10

31527 with insertion of obturator
31528 with dilation, initial
31529 with dilation, subsequent

31530 Laryngoscopy, direct, operative, with foreign body removal;

31531 with operating microscope or telescope
31535 Laryngoscopy, direct, operative, with biopsy;

31540 Laryngoscopy, direct, operative, with excision of tumor
and/or stripping of vocal cords or epiglottis;
➲ CPT Assistant Nov 98:11-12, Jun 17:10, Jul 19:10,
Sep 19:10
31545 Laryngoscopy, direct, operative, with operating microscope
or telescope, with submucosal removal of non-neoplastic
lesion(s) of vocal cord; reconstruction with local tissue
flap(s)
31546 reconstruction with graft(s) (includes obtaining autograft)


15772, 15773, 15774 for graft harvest)
(For reconstruction of vocal cord with allograft, use 31599)
31541, 69990)
31560 Laryngoscopy, direct, operative, with arytenoidectomy;

31570 Laryngoscopy, direct, with injection into vocal cord(s),
therapeutic;
➲ CPT Assistant Jan 14:6, Jan 17:6

➲ CPT Assistant Nov 98:11-12, Nov 12:14, Jan 14:6,
Jan 17:6, Jun 17:10
31575 Laryngoscopy, flexible; diagnostic
➲ CPT Assistant Dec 16:13, Apr 17:8, Jul 17:7
(Do not report 31575 in conjunction with 31231, unless

performed for a separate condition using a separate
endoscope)
31574, 31576, 31577, 31578, 43197, 43198, 92511, 92612,
92614, 92616)
31576 with biopsy(ies)
31577 with removal of foreign body(s)
31578 with removal of lesion(s), non-laser

# 31572 with ablation or destruction of lesion(s) with laser,

unilateral
➲ CPT Assistant Dec 16:13, Apr 17:8, Jul 17:7, Sep
19:10
(To report flexible endoscopic evaluation of swallowing,
see 92612-92613)
(To report flexible endoscopic evaluation with sensory
testing, see 92614-92615)
(To report flexible endoscopic evaluation of swallowing
with sensory testing, see 92616-92617)
(For flexible laryngoscopy as part of flexible endoscopic
evaluation of swallowing and/or laryngeal sensory testing
by cine or video recording, see 92612-92617)
# 31573 with therapeutic injection(s) (eg, chemodenervation
agent or corticosteroid, injected percutaneous, transoral,
or via endoscope channel), unilateral
➲ CPT Assistant Dec 16:13, Apr 17:8, Jul 17:7, May
18:7
# 31574 with injection(s) for augmentation (eg, percutaneous,
transoral), unilateral
➲ CPT Assistant Dec 16:13, Apr 17:8, Jul 17:7, May
18:7
31579 Laryngoscopy, flexible or rigid telescopic, with stroboscopy
Repair
31580 Laryngoplasty; for laryngeal web, with indwelling keel or
stent insertion
➲ CPT Assistant Mar 17:10, Apr 17:5

31553, 31554)
(To report tracheostomy, see 31600, 31601, 31603, 31605,
31610)
(To report removal of the keel or stent, use 31599)
# 31551 for laryngeal stenosis, with graft, without indwelling
stent placement, younger than 12 years of age
➲ CPT Assistant Mar 17:10, Apr 17:5, Jul 17:7
(Do not report graft separately if harvested through the

laryngoplasty incision [eg, thyroid cartilage graft])
31554, 31580)
31610)
# 31552 for laryngeal stenosis, with graft, without indwelling
stent placement, age 12 years or older
31554, 31580)
31610)
# 31553 for laryngeal stenosis, with graft, with indwelling stent
placement, younger than 12 years of age

31554, 31580)
31610)
(To report removal of the stent, use 31599)
# 31554 for laryngeal stenosis, with graft, with indwelling stent
placement, age 12 years or older

31553, 31580)
31610)
(To report removal of the stent, use 31599)
31584 with open reduction and fixation of (eg, plating) fracture,
includes tracheostomy, if performed

31587 Laryngoplasty, cricoid split, without graft placement

31610)
31590 Laryngeal reinnervation by neuromuscular pedicle
31591 Laryngoplasty, medialization, unilateral

31592 Cricotracheal resection

➲ CPT Assistant Feb 17:14, Mar 17:10, Apr 17:5, Jul 17:7
(Do not report graft separately if harvested through

cricotracheal resection incision [eg, trachealis muscle])
(Do not report local advancement and rotational flaps
separately if performed through the same incision)
31610)
(To report excision of tracheal stenosis and anastomosis,
see 31780, 31781)
Destruction
Other Procedures
31599 Unlisted procedure, larynx
Trachea and Bronchi

Incision
31600 Tracheostomy, planned (separate procedure);
➲ CPT Assistant Aug 10:5, Sep 19:10
31601 younger than 2 years

31603 Tracheostomy, emergency procedure; transtracheal
31605 cricothyroid membrane
31610 Tracheostomy, fenestration procedure with skin flaps
(For endotracheal intubation, use 31500)
(For tracheal aspiration under direct vision, use 31515)
31611 Construction of tracheoesophageal fistula and subsequent
insertion of an alaryngeal speech prosthesis (eg, voice
button, Blom-Singer prosthesis)
31612 Tracheal puncture, percutaneous with transtracheal
aspiration and/or injection
31613 Tracheostoma revision; simple, without flap rotation
31614 complex, with flap rotation
Endoscopy
For endoscopy procedures, code appropriate endoscopy of each
anatomic site examined. Surgical bronchoscopy always includes
diagnostic bronchoscopy when performed by the same physician.
Codes 31622-31651, 31660, 31661 include fluoroscopic guidance,
when performed.
Codes 31652 and 31653 are complete services used for sampling
(eg, aspiration/biopsy) lymph node(s) or adjacent structure(s)
utilizing endobronchial ultrasound (EBUS) and are reported
separately. Code 31654 is an add-on code and should be reported
for identifying one or more peripheral lesion(s) with
transendoscopic ultrasound.
31615 Tracheobronchoscopy through established tracheostomy
incision
(For tracheoscopy, see laryngoscopy codes 31515-31574)

(For bronchoscopy with endobronchial ultrasound [EBUS]
guided transtracheal/transbronchial sampling of mediastinal
and/or hilar lymph node stations or structures, see 31652,
31653. For transendoscopic ultrasound during
bronchoscopic diagnostic or therapeutic intervention[s] for
peripheral lesion[s], use 31654)
31622 Bronchoscopy, rigid or flexible, including fluoroscopic
guidance, when performed; diagnostic, with cell washing,
when performed (separate procedure)
➲ CPT Assistant Jul 96:11, Nov 98:12, Dec 98:8, Mar
99:3, Apr 00:10, Jun 01:10, Jan 02:10, Sep 04:8, 12,
Aug 05:4, Dec 09:10, Feb 10:6, Apr 10:5, Feb 11:8
31623 with brushing or protected brushings
➲
CPT Assistant Nov 98:12, Mar 99:3, Nov 99:13, Jan
02:10, Sep 04:8, Aug 05:4, May 08:15, Apr 10:5,
Mar 13:8
31624 with bronchial alveolar lavage
➲ CPT Assistant Nov 98:12, Feb 99:9, Mar 99:3, 11,
Jan 02:10, Sep 04:8, Aug 05:4, May 08:15, Feb 10:6,
Apr 10:5, Mar 13:8, Jun 17:10
31625 with bronchial or endobronchial biopsy(s), single or
multiple sites
➲ CPT Assistant Spring 91:2, Jan 02:10, Jun 02:10, Sep
03:15, Sep 04:9, Aug 05:4, Feb 10:6, Apr 10:5, Mar
13:8
Bronchoscopy
31622-31661
A rigid or flexible bronchoscope is inserted through the oropharynx and vocal cords and beyond the
trachea into the right or left bronchi.
31626 with placement of fiducial markers, single or multiple
➲ CPT Assistant Feb 10:6, Apr 10:5, Jan 11:6, Mar
13:8, Jun 15:6, Jun 17:10
(Report supply of device separately)
✚ 31627 with computer-assisted, image-guided navigation (List
separately in addition to code for primary procedure[s])
➲ CPT Assistant Feb 10:6, Apr 10:5, Jan 11:6, Mar
13:8
(31627 includes 3D reconstruction. Do not report 31627 in
conjunction with 76376, 76377)
31628-31631, 31635, 31636, 31638-31643)
31628 with transbronchial lung biopsy(s), single lobe
➲ CPT Assistant Jun 01:10, Jan 02:10, Sep 04:9, Aug
05:4, May 08:15, Feb 10:6, Apr 10:5, Mar 13:8, Jun
17:10
(31628 should be reported only once regardless of how
many transbronchial lung biopsies are performed in a lobe)
(To report transbronchial lung biopsies performed on
additional lobe, use 31632)
31629 with transbronchial needle aspiration biopsy(s), trachea,
main stem and/or lobar bronchus(i)
➲ CPT Assistant Apr 00:10, Jan 02:10, Sep 03:15, May
04:15, Jul 04:13, Aug 05:4, Nov 09:8, Feb 10:6, Apr
10:5, Apr 11:12, Mar 13:8
(31629 should be reported only once for upper airway
biopsies regardless of how many transbronchial needle
aspiration biopsies are performed in the upper airway or in
a lobe)
(To report transbronchial needle aspiration biopsies
performed on additional lobe[s], use 31633)
31630 with tracheal/bronchial dilation or closed reduction of
fracture
➲ CPT Assistant Jan 02:10, Aug 05:4, Feb 10:6, Apr
10:5, Mar 13:8
31631 with placement of tracheal stent(s) (includes
tracheal/bronchial dilation as required)
➲
CPT Assistant Jan 02:10, Aug 05:4, Feb 10:6, Apr
10:5, Mar 13:8
(For placement of bronchial stent, see 31636, 31637)
(For revision of tracheal/bronchial stent, use 31638)
✚ 31632 with transbronchial lung biopsy(s), each additional lobe
procedure)
➲ CPT Assistant Jan 02:10, Sep 04:9, Aug 05:4, Mar
13:8
many transbronchial lung biopsies are performed in a lobe)
✚ 31633 with transbronchial needle aspiration biopsy(s), each
additional lobe (List separately in addition to code for
primary procedure)
➲ CPT Assistant Jan 02:10, May 04:15, Jul 04:13, Sep
04:10, Aug 05:4, Nov 09:8, Apr 11:12, Mar 13:8
many transbronchial needle aspiration biopsies are
performed in the trachea or the additional lobe)
31634 with balloon occlusion, with assessment of air leak, with
administration of occlusive substance (eg, fibrin glue), if
performed
(Do not report 31634 in conjunction with 31647, 31651 at

the same session)
➲ CPT Assistant Jan 02:10, Jun 02:10, Feb 10:6, Apr
10:5, Jan 11:6, Mar 13:8
(For removal of implanted bronchial valves, see 31648-
31649)
31636 with placement of bronchial stent(s) (includes
tracheal/bronchial dilation as required), initial bronchus
➲ CPT Assistant Aug 05:4, Apr 10:5, Mar 13:8
✚ 31637 each additional major bronchus stented (List separately


31638 with revision of tracheal or bronchial stent inserted at
previous session (includes tracheal/bronchial dilation as
required)
➲ CPT Assistant Aug 05:4, Apr 10:5, Mar 13:8
31640 with excision of tumor

➲ CPT Assistant Jan 02:10, Aug 05:4, Apr 10:5, Mar
13:8
31641 with destruction of tumor or relief of stenosis by any
method other than excision (eg, laser therapy,
cryotherapy)
➲ CPT Assistant Nov 99:13, Sep 00:5, Jan 02:10, Aug
05:4, Apr 10:5, Oct 11:11, Mar 13:8, Apr 13:8
(For bronchoscopic photodynamic therapy, report 31641 in
addition to 96570, 96571 as appropriate)
31643 with placement of catheter(s) for intracavitary
radioelement application
➲ CPT Assistant Nov 98:12, Mar 99:3, Jan 02:10, Aug
05:4, Apr 09:3, Mar 13:8
(For intracavitary radioelement application, see 77761-
77763, 77770, 77771, 77772)
31645 with therapeutic aspiration of tracheobronchial tree,
initial
➲ CPT Assistant Jan 02:10, Aug 05:4, Mar 13:8
31646 with therapeutic aspiration of tracheobronchial tree,

subsequent, same hospital stay
➲ CPT Assistant Jan 02:10, Aug 05:4, Mar 13:8
(For catheter aspiration of tracheobronchial tree with

fiberscope at bedside, use 31725)
31647 with balloon occlusion, when performed, assessment of
air leak, airway sizing, and insertion of bronchial
valve(s), initial lobe
#✚ 31651 with balloon occlusion, when performed, assessment of

air leak, airway sizing, and insertion of bronchial
valve(s), each additional lobe (List separately in
addition to code for primary procedure[s])
➲ CPT Assistant Mar 13:8, Sep 18:3
31648 with removal of bronchial valve(s), initial lobe
(For removal and insertion of a bronchial valve at the same

session, see 31647, 31648, and 31651)
✚ 31649 with removal of bronchial valve(s), each additional lobe
procedure)

31652 with endobronchial ultrasound (EBUS) guided
transtracheal and/or transbronchial sampling (eg,
aspiration[s]/biopsy[ies]), one or two mediastinal and/or
hilar lymph node stations or structures
31653 with endobronchial ultrasound (EBUS) guided

transtracheal and/or transbronchial sampling (eg,
aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or
hilar lymph node stations or structures
✚ 31654 with transendoscopic endobronchial ultrasound (EBUS)

during bronchoscopic diagnostic or therapeutic
intervention(s) for peripheral lesion(s) (List separately
in addition to code for primary procedure[s])
31625, 31626, 31628, 31629, 31640, 31643, 31645, 31646)
(For EBUS to access mediastinal or hilar lymph node
station[s] or adjacent structure[s], see 31652, 31653)
(Report 31652, 31653, 31654 only once per session)
Bronchial Thermoplasty
31660 Bronchoscopy, rigid or flexible, including fluoroscopic
guidance, when performed; with bronchial thermoplasty, 1
lobe
31661 with bronchial thermoplasty, 2 or more lobes

Introduction
(For tracheal aspiration under direct vision, see 31515)
31717 Catheterization with bronchial brush biopsy
31720 Catheter aspiration (separate procedure); nasotracheal

31725 tracheobronchial with fiberscope, bedside
31730 Transtracheal (percutaneous) introduction of needle wire

dilator/stent or indwelling tube for oxygen therapy
Excision, Repair
31750 Tracheoplasty; cervical
31755 tracheopharyngeal fistulization, each stage

31760 intrathoracic
31766 Carinal reconstruction
31770 Bronchoplasty; graft repair
31775 excision stenosis and anastomosis
(For lobectomy and bronchoplasty, use 32501)
31780 Excision tracheal stenosis and anastomosis; cervical
31781 cervicothoracic
31785 Excision of tracheal tumor or carcinoma; cervical

31786 thoracic
31800 Suture of tracheal wound or injury; cervical
31805 intrathoracic
31820 Surgical closure tracheostomy or fistula; without plastic
repair
31825 with plastic repair
(For repair tracheoesophageal fistula, see 43305, 43312)
31830 Revision of tracheostomy scar
Other Procedures
31899 Unlisted procedure, trachea, bronchi
Lungs and Pleura
Pleural cavity or lung biopsy procedures may be accomplished
using a percutaneous, thoracoscopic (Video-Assisted
Thoracoscopic Surgery [VATS]), or thoracotomy approach. They
involve the removal of differing amounts of tissue for diagnosis.
A biopsy may be performed using different techniques such as
incision or wedge. Lung resection procedures include diagnostic
and therapeutic procedures, including the removal of blebs,
bullae, cysts, and benign or malignant tumors or lesions. These
procedures may involve the removal of small portions of the
lung or even an entire lung. Additionally, lung resection
procedures may require the removal of adjacent structures. Both
diagnostic lung biopsies and therapeutic lung resections can be
performed utilizing a wedge technique. However, a diagnostic
biopsy of a lung nodule using a wedge technique requires only
that a tissue sample be obtained without particular attention to
resection margins. A therapeutic wedge resection requires
attention to margins and complete resection even when the wedge
resection is ultimately followed by a more extensive resection. In
the case of a wedge resection in which intraoperative pathology
consultation determines that a more extensive resection is
required in the same anatomic location, it becomes classified as a
diagnostic wedge resection (32507, 32668). When no more
extensive resection is required, the same procedure is a
therapeutic wedge resection (32505, 32666).
▶Pleural or lung biopsies or diagnostic wedge resections should
be reported using codes 32096, 32097, 32098, 32400, 32408,
32507, 32607, 32608, 32609, or 32668. The open or thoracoscopic
(VATS) therapeutic resection of lung mass or nodules via a
wedge resection is reported using codes 32505, 32506, 32666, and
32667. More extensive anatomic lung resection procedures,
which can be performed with either thoracotomy or
thoracoscopic (VATS) approaches, include: segmentectomy,
lobectomy, bilobectomy, and pneumonectomy.◀
When diagnostic biopsy(ies) of the lung are performed,
regardless of the approach (ie, open or thoracoscopic [VATS]) or
technique (eg, incisional resection, cautery resection, or stapled
wedge), and the specimen is sent for intraoperative pathology
consultation, and during that same operative session the surgeon
uses these results to determine the extent of the necessary surgical
resection that includes the anatomical location biopsied, only the
most extensive procedure performed (eg, segmentectomy,
lobectomy, thoracoscopic [VATS] lobectomy) should be
reported.
The therapeutic wedge resection codes (32505, 32506, 32666, or
32667) should not be reported in addition to the more extensive
lung procedure (eg, lobectomy) unless the therapeutic wedge
resection was performed on a different lobe or on the
contralateral lung, whether or not an intraoperative pathology
consultation is used to determine the extent of lung resection.
When a diagnostic wedge resection is followed by a more
extensive procedure in the same anatomical location, report add-
on codes 32507 or 32668 with the more extensive procedure(s).
When a therapeutic wedge resection (32505, 32506, 32666, or
32667) is performed in a different lobe than the more extensive
lung resection (eg, lobectomy), report the therapeutic wedge
resection with modifier 59.
Incision
32035 Thoracostomy; with rib resection for empyema
32036 with open flap drainage for empyema
without thoractomy, use 20101)
32096 Thoracotomy, with diagnostic biopsy(ies) of lung
infiltrate(s) (eg, wedge, incisional), unilateral
(Do not report 32096 more than once per lung)

32445, 32488)
32097 Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s)
or mass(es) (eg, wedge, incisional), unilateral

32445, 32488)
32098 Thoracotomy, with biopsy(ies) of pleura
32100 Thoracotomy; with exploration

➲ CPT Assistant Mar 07:1, Sep 12:3, Jan 13:6

21603, 32503, 32504, 33955, 33956, 33957, 33963, 33964)
32110 with control of traumatic hemorrhage and/or repair of
lung tear
32120 for postoperative complications

32124 with open intrapleural pneumonolysis
32140 with cyst(s) removal, includes pleural procedure when

performed
32141 with resection-plication of bullae, includes any pleural

procedure when performed
(For lung volume reduction, use 32491)

32150 with removal of intrapleural foreign body or fibrin
deposit
32151 with removal of intrapulmonary foreign body

32160 with cardiac massage

(For segmental or other resections of lung, see 32480-

32504)
32200 Pneumonostomy, with open drainage of abscess or cyst
(For percutaneous image-guided drainage of abscess or cyst

of lungs or mediastinum by catheter placement, use 49405)
32215 Pleural scarification for repeat pneumothorax
32220 Decortication, pulmonary (separate procedure); total
32225 partial
Excision/Resection
32310 Pleurectomy, parietal (separate procedure)
32320 Decortication and parietal pleurectomy
32400 Biopsy, pleura, percutaneous needle
➲ CPT Assistant Fall 94:1-2
➲ Clinical Examples in Radiology Summer 08:5, 6, Winter
17:5
77012, 77021)
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
▶A core needle biopsy is typically performed with a needle that
is designed to obtain a core sample of tissue for histopathologic
evaluation. A fine needle aspiration (FNA) biopsy is performed
when material is aspirated with a fine needle and the cells are
examined cytologically.
A core needle biopsy of the lung or mediastinum is most
commonly performed with imaging guidance (ie, ultrasound,
fluoroscopy, CT, MRI). Imaging guidance codes (ie, 76942,
77002, 77012, 77021) may not be reported separately with 32408.
Code 32408 is reported once per lesion sampled in a single
session.
Code 32408 includes all imaging guidance regardless of the
number of imaging modalities used on the same lesion during the
same session.
When more than one core needle biopsy of the lung or
mediastinum with imaging guidance is performed on separate
lesions at the same session on the same day, use 32408 once for
each lesion with modifier 59 for the second and each additional
core needle lung or mediastinal biopsy.
When a core needle biopsy of the lung or mediastinum with
imaging guidance is performed at the same session as a core
biopsy of a site other than the lung or mediastinum (eg, liver),
both the core needle biopsy for the other site (eg, 47000) and the
imaging guidance for that additional core needle biopsy may be
reported separately with modifier 59.
When FNA biopsy and core needle biopsy of the lung or
mediastinum are performed on the same lesion at the same
session on the same day using the same type of imaging
guidance, modifier 52 should be used with either the FNA biopsy
code or the core lung or mediastinal biopsy code.
When FNA biopsy and core needle biopsy of the lung or
mediastinum are performed on the same lesion at the same
session on the same day using different types of imaging
guidance, both image-guided biopsy codes may be reported
separately and one of them should be appended with modifier 59.
When FNA biopsy is performed on one lesion and core needle
biopsy of the lung or mediastinum is performed on a separate
lesion at the same session on the same day using the same type of
imaging guidance, both the modality-specific image-guided FNA
biopsy code and 32408 may be reported separately and one of the
codes should be appended with modifier 59.
When FNA biopsy is performed on one lesion and core needle
biopsy of the lung or mediastinum is performed on a separate
lesion at the same session on the same day using different types
of imaging guidance, both the modality-specific image-guided
FNA biopsy code and 32408 may be reported separately and one
of the codes should be appended with modifier 59.◀
▶ (32405 has been deleted. To report percutaneous core
needle biopsy of lung or mediastinum, use 32408)◀
● 32408 Core needle biopsy, lung or mediastinum, percutaneous,
including imaging guidance, when performed

77012, 77021)◀
(For open biopsy of lung, see 32096, 32097. For open
biopsy of mediastinum, see 39000 or 39010. For
thoracoscopic [VATS] biopsy of lung, pleura, pericardium,
or mediastinal space structure, see 32604, 32606, 32607,
32608, 32609)
▶ (Forfine needle aspiration biopsy, see 10004, 10005,
10006, 10007, 10008, 10009, 10010, 10011, 10012,
10021)◀
Removal
32440 Removal of lung, pneumonectomy;
➲ CPT Assistant Fall 94:1, Sep 12:3
32442 with resection of segment of trachea followed by

broncho-tracheal anastomosis (sleeve pneumonectomy)
➲ CPT Assistant Fall 94:1, 3, Jun 17:10
32445 extrapleural
➲ CPT Assistant Fall 94:1, 3, Sep 12:3
(For extrapleural pneumonectomy, with empyemectomy, use
32445 and 32540)
(If lung resection is performed with chest wall tumor
resection, report the appropriate chest wall tumor resection
code [21601, 21602, 21603], in addition to lung resection
code [32440-32445])
32480 Removal of lung, other than pneumonectomy; single lobe
(lobectomy)
➲ CPT Assistant Spring 91:5, Fall 94:1, 4, Sep 12:3
32482 2 lobes (bilobectomy)

➲ CPT Assistant Fall 94:1, 4, Jan 07:31, Sep 12:3
32484 single segment (segmentectomy)

(For removal of lung with bronchoplasty, use 32501)

32486 with circumferential resection of segment of bronchus
followed by broncho-bronchial anastomosis (sleeve
lobectomy)
➲ CPT Assistant Fall 94:1, 4, Jun 17:10
32488 with all remaining lung following previous removal of a

portion of lung (completion pneumonectomy)
(For lobectomy or segmentectomy, with concomitant

decortication, use 32320 and the appropriate removal of
lung code)
32491 with resection-plication of emphysematous lung(s)
(bullous or non-bullous) for lung volume reduction,
sternal split or transthoracic approach, includes any
pleural procedure, when performed

code [21601, 21602, 21603] in addition to lung resection
code [32480, 32482, 32484, 32486, 32488, 32505, 32506,
32507])
✚ 32501 Resection and repair of portion of bronchus (bronchoplasty)
when performed at time of lobectomy or segmentectomy
(32501 is to be used when a portion of the bronchus to
preserved lung is removed and requires plastic closure to
preserve function of that preserved lung. It is not to be used
for closure for the proximal end of a resected bronchus)
32503 Resection of apical lung tumor (eg, Pancoast tumor),
including chest wall resection, rib(s) resection(s),
neurovascular dissection, when performed; without chest
wall reconstruction(s)
32504 with chest wall reconstruction


21602, 21603, 32100, 32551, 32554, 32555)
32505 Thoracotomy; with therapeutic wedge resection (eg, mass,
nodule), initial
32445, 32488)
✚ 32506 with therapeutic wedge resection (eg, mass or nodule),
each additional resection, ipsilateral (List separately in
(Report 32506 only in conjunction with 32505)

code [21601, 21602, 21603], in addition to lung resection
code [32480, 32482, 32484, 32486, 32488, 32505, 32506,
32507])
✚ 32507 with diagnostic wedge resection followed by anatomic
lung resection (List separately in addition to code for
primary procedure)

32480, 32482, 32484, 32486, 32488, 32503, 32504)
32540 Extrapleural enucleation of empyema (empyemectomy)
(For extrapleural enucleation of empyema [empyemectomy]
with lobectomy, use 32540 and the appropriate removal of
lung code)
Introduction and Removal

32550 Insertion of indwelling tunneled pleural catheter with cuff
➲ CPT Assistant Jul 10:10, Mar 14:14, May 14:3
32556, 32557 when performed on the same side of the
chest)
(If imaging guidance is performed, use 75989)
32551 Tube thoracostomy, includes connection to drainage system
(eg, water seal), when performed, open (separate
procedure)
➲ CPT Assistant Feb 09:7, Sep 10:6, Aug 11:4, Nov 12:3,
May 14:3, Jun 17:10, Jul 18:7
➲ Clinical Examples in Radiology Fall 10:10, Winter 13:5
(Do not report 32551 in conjunction with 33020, 33025, if

pleural drain/chest tube is placed on the ipsilateral side)
32552 Removal of indwelling tunneled pleural catheter with cuff
32553 Placement of interstitial device(s) for radiation therapy

guidance (eg, fiducial markers, dosimeter), percutaneous,
intra-thoracic, single or multiple
➲ CPT Assistant Feb 10:6, 7, Jun 15:6, Jun 16:3

(For percutaneous placement of interstitial device[s] for
intra-abdominal, intrapelvic, and/or retroperitoneal
radiation therapy guidance, use 49411)
32554 Thoracentesis, needle or catheter, aspiration of the pleural
space; without imaging guidance
➲ Clinical Examples in Radiology Summer 13:6, Winter
13:5, 6
32555 with imaging guidance
➲ Clinical Examples in Radiology Summer 13:6,
Winter 13:6
32556 Pleural drainage, percutaneous, with insertion of indwelling
catheter; without imaging guidance
13:6
Thoracentesis
32554, 32555
Accumulated fluid or air is removed from the pleural space by puncturing space between the ribs. In
32555, a tube is inserted and a syringe attached to the catheter for the removal of fluid and/or air.

➲ Clinical Examples in Radiology Summer 13:5, 6,
Winter 13:5, 6
(For insertion of indwelling tunneled pleural catheter with
cuff, use 32550)
32551 when performed on the same side of the chest)
76942, 77002, 77012, 77021)
Destruction
The instillation of a fibrinolytic agent may be performed multiple
times per day over the course of several days. Code 32561 should
be reported only once on the initial day treatment. Code 32562
should be reported only once on each subsequent day of
treatment.
32560 Instillation, via chest tube/catheter, agent for pleurodesis
(eg, talc for recurrent or persistent pneumothorax)
(For chest tube insertion, use 32551)

32561 Instillation(s), via chest tube/catheter, agent for fibrinolysis
(eg, fibrinolytic agent for break up of multiloculated
effusion); initial day

32562 subsequent day

Thoracoscopy (Video-assisted thoracic surgery
[VATS])
Surgical thoracoscopy (video-assisted thoracic surgery [VATS])
always includes diagnostic thoracoscopy.
32601 Thoracoscopy, diagnostic (separate procedure); lungs,
pericardial sac, mediastinal or pleural space, without
biopsy
➲ CPT Assistant Fall 94:1, 4, Sep 12:3, Aug 13:14
32604 pericardial sac, with biopsy

➲ CPT Assistant Fall 94:1, 4, Aug 13:14
(For open pericardial biopsy, use 39010)

32606 mediastinal space, with biopsy
32607 Thoracoscopy; with diagnostic biopsy(ies) of lung

infiltrate(s) (eg, wedge, incisional), unilateral
➲ CPT Assistant Sep 12:3, Aug 13:14
Thoracoscopy
32601-32665
The inside of the chest cavity is examined through a fiberoptic endoscope.
32445, 32488, 32671)
32608 with diagnostic biopsy(ies) of lung nodule(s) or mass(es)
(eg, wedge, incisional), unilateral

32445, 32488, 32671)
32609 with biopsy(ies) of pleura
32650 Thoracoscopy, surgical; with pleurodesis (eg, mechanical or
chemical)
32651 with partial pulmonary decortication

32652 with total pulmonary decortication, including intrapleural

pneumonolysis
32653 with removal of intrapleural foreign body or fibrin

deposit
32654 with control of traumatic hemorrhage

32655 with resection-plication of bullae, includes any pleural

procedure when performed
➲ CPT Assistant Fall 94:1, 6, Aug 05:15, Aug 13:14
(For thoracoscopic [VATS] lung volume reduction surgery,

use 32672)
32656 with parietal pleurectomy
32658 with removal of clot or foreign body from pericardial

sac
32659 with creation of pericardial window or partial resection

of pericardial sac for drainage
32661 with excision of pericardial cyst, tumor, or mass

32662 with excision of mediastinal cyst, tumor, or mass
32663 with lobectomy (single lobe)

➲ CPT Assistant Fall 94:1, 6, Sep 12:3, Aug 13:14
(For thoracoscopic [VATS] segmentectomy, use 32669)

32664 with thoracic sympathectomy
➲ CPT Assistant Fall 94:1, Oct 99:10, Aug 13:14, Dec
15:16
32665 with esophagomyotomy (Heller type)
(For exploratory thoracoscopy, and exploratory

thoracoscopy with biopsy, see 32601-32609)
32666 with therapeutic wedge resection (eg, mass, nodule),
initial unilateral

50)
32445, 32488, 32671)
✚ 32667 with therapeutic wedge resection (eg, mass or nodule),
each additional resection, ipsilateral (List separately in
(Report 32667 only in conjunction with 32666)

32445, 32488, 32671)
✚ 32668 with diagnostic wedge resection followed by anatomic
lung resection (List separately in addition to code for
primary procedure)

32480, 32482, 32484, 32486, 32488, 32503, 32504, 32663,
32669, 32670, 32671)
32669 with removal of a single lung segment (segmentectomy)
32670 with removal of two lobes (bilobectomy)

32671 with removal of lung (pneumonectomy)

32672 with resection-plication for emphysematous lung

(bullous or non-bullous) for lung volume reduction
(LVRS), unilateral includes any pleural procedure, when
performed
32673 with resection of thymus, unilateral or bilateral

(For open thymectomy see 60520, 60521, 60522)

(For open excision mediastinal cyst, see 39200; for open
excision mediastinal tumor, use 39220)
(For exploratory thoracoscopy, and exploratory
thoracoscopy with biopsy, see 32601-32609)
✚ 32674 with mediastinal and regional lymphadenectomy (List
➲ CPT Assistant Sep 12:3, Aug 13:14, May 14:3
(On the right, mediastinal lymph nodes include the

paratracheal, subcarinal, paraesophageal, and inferior
pulmonary ligament)
(On the left, mediastinal lymph nodes include the
aortopulmonary window, subcarinal, paraesophageal, and
inferior pulmonary ligament)
31786, 32096-32200, 32220-32320, 32440-32491, 32503-
32505, 32601-32663, 32666, 32669-32673, 32815, 33025,
33030, 33050-33130, 39200-39220, 39560, 39561, 43101,
43112, 43117, 43118, 43122, 43123, 43287, 43288, 43351,
60270, 60505)
(To report mediastinal and regional lymphadenectomy via
thoracotomy, use 38746)
Mediastinal Lymph Nodes: Station Number and Descriptions

32674
Relevant mediastinal lymph nodes typically removed with procedures described by code 38746, and
sampled removal described with code 39402.
Station # Lymph Node Descriptions
1 Low cervical, supraclavicular, and sternal notch
2 Upper paratracheal (R & L)
4 Lower paratracheal (R & L)
5 Subaortic or aortopulmonary window
6 Para-aortic
7 Subcarinal
8 Paraesophageal (below the carina)
9 Inferior pulmonary ligament
*Station #3 is not depicted as it is not applicable to the use of codes 32674, 38746, or 39402.
Stereotactic Radiation Therapy

Thoracic stereotactic body radiation therapy (SRS/SBRT) is a
distinct procedure which may involve collaboration between a
surgeon and radiation oncologist. The surgeon identifies and
delineates the target for therapy. The radiation oncologist reports
the appropriate code(s) for clinical treatment planning, physics
and dosimetry, treatment delivery and management from the
Radiation Oncology section (see 77295, 77331, 77370, 77373,
77435). The same physician should not report target delineation
services with radiation treatment management codes (77427-
77499).
Target delineation involves specific determination of tumor
borders to identify tumor volume and relationship with adjacent
structures (eg, chest wall, intraparenchymal vasculature and
atelectatic lung) and previously placed fiducial markers, when
present. Target delineation also includes availability to identify
and validate the thoracic target prior to treatment delivery when a
fiducial-less tracking system is utilized.
Do not report target delineation more than once per entire course
of treatment when the treatment requires greater than one session.
32701 Thoracic target(s) delineation for stereotactic body
radiation therapy (SRS/SBRT), (photon or particle beam),
entire course of treatment
(For placement of fiducial markers, see 31626, 32553)
Repair
32800 Repair lung hernia through chest wall
32810 Closure of chest wall following open flap drainage for
empyema (Clagett type procedure)
32815 Open closure of major bronchial fistula
32820 Major reconstruction, chest wall (posttraumatic)
Lung Transplantation
Lung allotransplantation involves three distinct components of
physician work:
1. Cadaver donor pneumonectomy(s), which include(s)
harvesting the allograft and cold preservation of the allograft
(perfusing with cold preservation solution and cold
maintenance) (use 32850).
2. Backbench work:
Preparation of a cadaver donor single lung allograft prior to
transplantation, including dissection of the allograft from
surrounding soft tissues to prepare the pulmonary venous/atrial
cuff, pulmonary artery, and bronchus unilaterally (use 32855).
Preparation of a cadaver donor double lung allograft prior to
surrounding soft tissues to prepare the pulmonary venous/atrial
cuff, pulmonary artery, and bronchus bilaterally (use 32856).
3. Recipient lung allotransplantation, which includes
transplantation of a single or double lung allograft and care of
the recipient (see 32851-32854).
(For ex-vivo assessment of marginal donor lung transplant,
see 0494T, 0495T, 0496T)
32850 Donor pneumonectomy(s) (including cold preservation),
from cadaver donor
32851 Lung transplant, single; without cardiopulmonary bypass

32852 with cardiopulmonary bypass
32853 Lung transplant, double (bilateral sequential or en bloc);
without cardiopulmonary bypass
32855 Backbench standard preparation of cadaver donor lung
allograft prior to transplantation, including dissection of
allograft from surrounding soft tissues to prepare pulmonary
venous/atrial cuff, pulmonary artery, and bronchus;
unilateral
32856 bilateral
(For repair or resection procedures on the donor lung, see

32491, 32505, 32506, 32507, 35216, 35276)
Surgical Collapse Therapy; Thoracoplasty

(See also 32503, 32504)
32900 Resection of ribs, extrapleural, all stages
32905 Thoracoplasty, Schede type or extrapleural (all stages);
32906 with closure of bronchopleural fistula
(For open closure of major bronchial fistula, use 32815)
(For resection of first rib for thoracic outlet compression,
see 21615, 21616)
32940 Pneumonolysis, extraperiosteal, including filling or packing
procedures
32960 Pneumothorax, therapeutic, intrapleural injection of air
Other Procedures
32997 Total lung lavage (unilateral)
(For bronchoscopic bronchial alveolar lavage, use 31624)

32998 Ablation therapy for reduction or eradication of 1 or more
pulmonary tumor(s) including pleura or chest wall when
involved by tumor extension, percutaneous, including
imaging guidance when performed, unilateral;
radiofrequency
# 32994 cryoablation
(For bilateral procedure, report 32994, 32998 with modifier

50)
32999 Unlisted procedure, lungs and pleura
➲ CPT Assistant Jan 02:11, Feb 02:11, Jul 08:10, Apr
10:10, Aug 11:9, Jun 15:6, Dec 15:16
➲ Clinical Examples in Radiology Spring 06:8-9
Cryoablation Therapy of Pulmonary Tumors

32994
Surgery
Cardiovascular System* (33016-37799)
Cardiovascular System section of the CPT codebook. The subheadings or
Heart and Pericardium (33016-33999)
Pericardium* (33016-33050)
Cardiac Tumor (33120-33130)
Transmyocardial Revascularization (33140-33141)
Pacemaker or Implantable Defibrillator* (33202-33275)
Electrophysiologic Operative Procedures* (33250-33266)
Incision (33250-33261)
Endoscopy (33265-33266)
Aortic Anatomy
Subcutaneous Cardiac Rhythm Monitor* (33285-33286)
Implantable Hemodynamic Monitors* (33289)
Heart (Including Valves) and Great Vessels* (33300-33340)
Cardiac Valves (33361-33478)
Aortic Valve* (33361-33417, 33440)
Mitral Valve* (33418-33430)
Tricuspid Valve (33460-33468)
Pulmonary Valve* (33470-33478)
Other Valvular Procedures (33496)
Coronary Artery Anomalies* (33500-33507)
Endoscopy* (33508)
Venous Grafting Only for Coronary Artery Bypass* (33510-33516)
Combined Arterial-Venous Grafting for Coronary Bypass* (33517-
33530)
Arterial Grafting for Coronary Artery Bypass* (33533-33548)
Cardiac Anatomy, Heart Blood Flow
Coronary Endarterectomy (33572)

Single Ventricle and Other Complex Cardiac Anomalies (33600-
33622)
Septal Defect (33641-33697)
Sinus of Valsalva (33702-33722)
Venous Anomalies (33724-33732)
Shunting Procedures* (33735-33768)
Transposition of the Great Vessels (33770-33783)
Truncus Arteriosus (33786-33788)
Aortic Anomalies (33800-33853)
Thoracic Aortic Aneurysm* (33858-33877)
Endovascular Repair of Descending Thoracic Aorta* (33880-33891)
Pulmonary Artery (33910-33926)
Heart/Lung Transplantation* (33927-33945)
Extracorporeal Membrane Oxygenation or Extracorporeal Life
Support Services* (33946-33989)
Cardiac Assist* (33967-33997)
Arteries and Veins* (34001-37799)
Embolectomy/Thrombectomy (34001-34490)
Arterial, With or Without Catheter (34001-34203)
Venous, Direct or With Catheter (34401-34490)
Venous Reconstruction (34501-34530)
Endovascular Repair of Abdominal Aorta and/or Iliac Arteries*
(34701-34834)
Fenestrated Endovascular Repair of the Visceral and Infrarenal
Aorta* (34839-34848)
Endovascular Repair of Iliac Aneurysm
Direct Repair of Aneurysm or Excision (Partial or Total) and Graft
Insertion for Aneurysm, Pseudoaneurysm, Ruptured Aneurysm,
and Associated Occlusive Disease* (35001-35152)
Repair Arteriovenous Fistula (35180-35190)
Repair Blood Vessel Other Than for Fistula, With or Without Patch
Angioplasty (35201-35286)
Thromboendarterectomy (35301-35390)
Angioscopy (35400)
Bypass Graft (35500-35671)
Vein* (35500-35572)
In-Situ Vein (35583-35587)
Other Than Vein (35600-35671)
Composite Grafts* (35681-35683)
Adjuvant Techniques* (35685-35686)
Arterial Transposition (35691-35697)
Excision, Exploration, Repair, Revision (35700-35907)
Vascular Injection Procedures* (36000-36598)
Intravenous* (36000-36015)
Intra-Arterial—Intra-Aortic* (36100-36299)
Venous* (36400-36522)
Central Venous Access Procedures* (36555-36598)
Insertion of Central Venous Access Device (36555-
36573)
Repair of Central Venous Access Device (36575-36576)
Partial Replacement of Central Venous Access Device
(Catheter Only) (36578)
Complete Replacement of Central Venous Access
Device Through Same Venous Access Site (36580-
36585)
Removal of Central Venous Access Device (36589-
36590)
Other Central Venous Access Procedures (36591-
36598)
Arterial (36600-36660)
Intraosseous (36680)
Hemodialysis Access, Intervascular Cannulation for Extracorporeal
Circulation, or Shunt Insertion (36800-36861)
Dialysis Circuit* (36901-36909)
Portal Decompression Procedures (37140-37183)
Transcatheter Procedures* (37184-37218)
Arterial Mechanical Thrombectomy (37184-37186)
Venous Mechanical Thrombectomy (37187-37188)
Circulatory System, Arteries
Circulatory System, Veins

Endovascular Revascularization (Open or Percutaneous,
Transcatheter)* (37220-37239, 37246-37249)
Vascular Embolization and Occlusion* (37241-37244)
Intravascular Ultrasound Services* (37252-37253)
Endoscopy* (37500-37501)
Ligation (37565-37785)
Hemic and Lymphatic Systems (38100-38999)
Spleen (38100-38200)
Excision (38100-38102)
Repair (38115)
Laparoscopy* (38120-38129)
Introduction (38200)
General (38204-38232)
Bone Marrow or Stem Cell Services/Procedures* (38204-38232)
Transplantation and Post-Transplantation Cellular
Infusions* (38240-38243)
Lymph Nodes and Lymphatic Channels (38300-38999)
Incision (38300-38382)
Excision (38500-38555)
Limited Lymphadenectomy for Staging (38562-38564)
Brachial Artery
Radical Lymphadenectomy (Radical Resection of Lymph Nodes)
(38700-38780)
Lymphatic System
Mediastinum and Diaphragm (39000-39599)

Mediastinum (39000-39499)
Incision (39000-39010)
Excision/Resection (39200-39220)
Endoscopy (39401-39402)
Diaphragm (39501-39599)
Repair (39501-39561)
Selective vascular catheterizations should be coded to include
introduction and all lesser order selective catheterizations used in
the approach (eg, the description for a selective right middle
cerebral artery catheterization includes the introduction and
placement catheterization of the right common and internal
carotid arteries).
Additional second and/or third order arterial catheterizations
within the same family of arteries supplied by a single first order
artery should be expressed by 36218 or 36248. Additional first
order or higher catheterizations in vascular families supplied by a
first order vessel different from a previously selected and coded
family should be separately coded using the conventions
described above.
(For monitoring, operation of pump and other nonsurgical
services, see 99190-99192, 99291, 99292, 99354-99360)
(For other medical or laboratory related services, see
appropriate section)
(For radiological supervision and interpretation, see 75600-
75970)
(For anatomic guidance of arterial and venous anatomy, see
Appendix L)
Heart and Pericardium

Pericardium
In order to report pericardial drainage with insertion of
indwelling catheter (33017, 33018, 33019), the catheter needs to
remain in place when the procedure is completed. Codes 33017,
33018, 33019 should not be reported when a catheter is placed to
aspirate fluid and then removed at the conclusion of the
procedure.
Congenital cardiac anomaly for reporting percutaneous
pericardial drainage with insertion of indwelling catheter is
defined as abnormal situs (heterotaxy, dextrocardia, mesocardia),
single ventricle anomaly/physiology, or any patient in the first 90-
day postoperative period after repair of a congenital cardiac
anomaly.
(For thoracoscopic (VATS) pericardial procedures, see
32601, 32604, 32658, 32659, 32661)
33017, 33018, 33019)
33019)
33016 Pericardiocentesis, including imaging guidance, when
performed

77012, 77021)
33017 Pericardial drainage with insertion of indwelling catheter,
percutaneous, including fluoroscopy and/or ultrasound
guidance, when performed; 6 years and older without
congenital cardiac anomaly
33018 birth through 5 years of age or any age with congenital
cardiac anomaly

76942, 77002, 77012, 77021)
93303-93325 when echocardiography is performed solely
for the purpose of pericardiocentesis guidance)
(For CT-guided pericardial drainage, use 33019)
33019 Pericardial drainage with insertion of indwelling catheter,
percutaneous, including CT guidance

77002, 77012, 77021)
33020 Pericardiotomy for removal of clot or foreign body (primary
procedure)
33025 Creation of pericardial window or partial resection for
drainage
(Do not report 33020, 33025 in conjunction with 32551, if
pleural drain/chest tube is placed on the ipsilateral side)
(For thoracoscopic (VATS) pericardial window, use 32659)
33030 Pericardiectomy, subtotal or complete; without
cardiopulmonary bypass
33050 Resection of pericardial cyst or tumor
(For open pericardial biopsy, use 39010)
(For thoracoscopic (VATS) resection of pericardial cyst,
tumor or mass, use 32661)
Cardiac Tumor
33120 Excision of intracardiac tumor, resection with
33130 Resection of external cardiac tumor

Transmyocardial Revascularization
33140 Transmyocardial laser revascularization, by thoracotomy;
➲ CPT Assistant Nov 99:14, Nov 00:5, Apr 01:7
✚ 33141 performed at the time of other open cardiac procedure(s)

procedure)

33496, 33510-33536, 33542)
Pacemaker or Implantable Defibrillator

A pacemaker system with lead(s) includes a pulse generator
containing electronics, a battery, and one or more leads. A lead
consists of one or more electrodes, as well as conductor wires,
insulation, and a fixation mechanism. Pulse generators are placed
in a subcutaneous “pocket” created in either a subclavicular site
or just above the abdominal muscles just below the ribcage.
Leads may be inserted through a vein (transvenous) or they may
be placed on the surface of the heart (epicardial). The epicardial
location of leads requires a thoracotomy for insertion.
A single chamber pacemaker system with lead includes a pulse
generator and one electrode inserted in either the atrium or
ventricle. A dual chamber pacemaker system with two leads
includes a pulse generator and one lead inserted in the right
atrium and one lead inserted in the right ventricle. In certain
circumstances, an additional lead may be required to achieve
pacing of the left ventricle (bi-ventricular pacing). In this event,
transvenous (cardiac vein) placement of the lead should be
separately reported using code 33224 or 33225. Epicardial
placement of the lead should be separately reported using 33202,
33203.
A leadless cardiac pacemaker system includes a pulse generator
with built-in battery and electrode for implantation in a cardiac
chamber via a transcatheter approach. For implantation of a
leadless pacemaker system, use 33274. Insertion, replacement, or
removal of a leadless pacemaker system includes insertion of a
catheter into the right ventricle.
Right heart catheterization (93451, 93453, 93456, 93457, 93460,
93461, 93530, 93531, 93532, 93533) may not be reported in
conjunction with leadless pacemaker insertion and removal codes
33274, 33275 unless complete right heart catheterization is
performed for an indication distinct from the leadless pacemaker
procedure.
Like a pacemaker system, an implantable defibrillator system
includes a pulse generator and electrodes. Three general
categories of implantable defibrillators exist: transvenous
implantable pacing cardioverter-defibrillator (ICD), subcutaneous
implantable defibrillator (S-ICD), and substernal implantable
cardioverter-defibrillator. Implantable pacing cardioverter-
defibrillator devices use a combination of antitachycardia pacing,
low-energy cardioversion or defibrillating shocks to treat
ventricular tachycardia or ventricular fibrillation. The
subcutaneous implantable defibrillator uses a single subcutaneous
electrode to treat ventricular tachyarrhythmias. The substernal
implantable cardioverter-defibrillator uses at least one substernal
electrode to perform defibrillation, cardioversion, and
antitachycardia pacing. Subcutaneous implantable defibrillators
differ from transvenous implantable pacing cardioverter-
defibrillators in that subcutaneous defibrillators do not provide
antitachycardia pacing or chronic pacing. Substernal implantable
defibrillators differ from both subcutaneous and transvenous
implantable pacing cardioverter-defibrillators in that they provide
antitachycardia pacing, but not chronic pacing.
Implantable defibrillator pulse generators may be implanted in a
subcutaneous infraclavicular, axillary, or abdominal pocket.
Removal of an implantable defibrillator pulse generator requires
opening of the existing subcutaneous pocket and disconnection
of the pulse generator from its electrode(s). A thoracotomy (or
laparotomy in the case of abdominally placed pulse generators) is
not required to remove the pulse generator.
The electrodes (leads) of an implantable defibrillator system may
be positioned within the atrial and/or ventricular chambers of the
heart via the venous system (transvenously), or placed on the
surface of the heart (epicardial), or positioned under the skin
overlying the heart (subcutaneous). Electrode positioning on the
epicardial surface of the heart requires a thoracotomy or
thoracoscopic placement of the leads. Epicardial placement of
electrode(s) may be separately reported using 33202, 33203. The
electrode (lead) of a subcutaneous implantable defibrillator
system is tunneled under the skin to the left parasternal margin.
Subcutaneous placement of electrode may be reported using
33270 or 33271. The electrode (lead) of a substernal implantable
defibrillator system is tunneled subcutaneously and placed into
the substernal anterior mediastinum without entering the
pericardial cavity and may be reported using 0571T, 0572T. In
certain circumstances, an additional electrode may be required to
achieve pacing of the left ventricle (bi-ventricular pacing). In this
event, transvenous (cardiac vein) placement of the electrode may
be separately reported using 33224 or 33225.
Removal of a transvenous electrode(s) may first be attempted by
transvenous extraction (33234, 33235, or 33244). However, if
transvenous extraction is unsuccessful, a thoracotomy may be
required to remove the electrodes (33238 or 33243). Use 33212,
33213, 33221, 33230, 33231, 33240 as appropriate, in addition to
the thoracotomy or endoscopic epicardial lead placement codes
(33202 or 33203) to report the insertion of the generator if done
by the same physician during the same session. Removal of a
subcutaneous implantable defibrillator electrode may be
separately reported using 33272. For removal of a leadless
pacemaker system without replacement, use 33275. For removal
and replacement of a leadless pacemaker system during the same
session, use 33274.
When the “battery” of a pacemaker system with lead(s) or
implantable defibrillator is changed, it is actually the pulse
generator that is changed. Removal of only the pacemaker or
implantable defibrillator pulse generator is reported with 33233
or 33241. If only a pulse generator is inserted or replaced without
any right atrial and/or right ventricular lead(s) inserted or
replaced, report the appropriate code for only pulse generator
insertion or replacement based on the number of final existing
lead(s) (33227, 33228, 33229 and 33262, 33263, 33264). Do not
report removal of a pulse generator (33233 or 33241) separately
for this service. Insertion of a new pulse generator, when existing
lead(s) are already in place and when no prior pulse generator is
removed, is reported with 33212, 33213, 33221, 33230, 33231,
33240. When a pulse generator insertion involves the insertion or
replacement of one or more right atrial and/or right ventricular
lead(s) or subcutaneous lead(s), use system codes 33206, 33207,
33208 for pacemaker, 33249 for implantable pacing cardioverter-
defibrillator, or 33270 for subcutaneous implantable defibrillator.
When reporting the system insertion or replacement codes,
removal of a pulse generator (33233 or 33241) may be reported
separately, when performed. In addition, extraction of leads
33234, 33235 or 33244 for transvenous or 33272 for
subcutaneous may be reported separately, when performed. An
exception involves a pacemaker upgrade from single to dual
system that includes removal of pulse generator, replacement of
new pulse generator, and insertion of new lead, reported with
33214.
Revision of a skin pocket is included in 33206-33249, 33262,
33263, 33264, 33270, 33271, 33272, 33273. When revision of a
skin pocket involves incision and drainage of a hematoma or
complex wound infection, see 10140, 10180, 11042, 11043,
11044, 11045, 11046, 11047, as appropriate.
Relocation of a skin pocket for a pacemaker (33222) or
implantable defibrillator (33223) is necessary for various clinical
situations such as infection or erosion. Relocation of an existing
pulse generator may be performed as a stand-alone procedure or
at the time of a pulse generator or electrode insertion,
replacement, or repositioning. When skin pocket relocation is
performed as part of an explant of an existing generator followed
by replacement with a new generator, the pocket relocation is
reported separately. Skin pocket relocation includes all work
associated with the initial pocket (eg, opening the pocket, incision
and drainage of hematoma or abscess if performed, and any
closure performed), in addition to the creation of a new pocket
for the new generator to be placed.
Repositioning of a pacemaker electrode, implantable defibrillator
electrode(s), or a left ventricular pacing electrode is reported
using 33215, 33226, or 33273, as appropriate.
Device evaluation codes 93260, 93261, 93279-93298 for
pacemaker system with lead(s) may not be reported in
conjunction with pulse generator and lead insertion or revision
codes 33206-33249, 33262, 33263, 33264, 33270, 33271, 33272,
33273. For leadless pacemaker systems, device evaluation codes
93279, 93286, 93288, 93294, 93296 may not be reported in
conjunction with leadless pacemaker insertion and removal codes
33274, 33275. Defibrillator threshold testing (DFT) during
transvenous implantable defibrillator insertion or replacement
may be separately reported using 93640, 93641. DFT testing
during subcutaneous implantable defibrillator system insertion is
not separately reportable. DFT testing for transvenous or
subcutaneous implantable defibrillator in follow-up or at the time
of replacement may be separately reported using 93642 or 93644.
Radiological supervision and interpretation related to the
pacemaker or implantable defibrillator procedure is included in
33206-33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273,
33274, 33275. Fluoroscopy (76000, 77002), ultrasound guidance
for vascular access (76937), right ventriculography (93566), and
femoral venography (75820) are included in 33274, 33275, when
performed). To report fluoroscopic guidance for diagnostic lead
evaluation without lead insertion, replacement, or revision
procedures, use 76000.
The following definitions apply to 33206-33249, 33262, 33263,
33264, 33270, 33271, 33272, 33273.
Single lead: a pacemaker or implantable defibrillator with pacing
and sensing function in only one chamber of the heart or a
subcutaneous electrode.
Dual lead: a pacemaker or implantable defibrillator with pacing
and sensing function in only two chambers of the heart.
Multiple lead: a pacemaker or implantable defibrillator with
pacing and sensing function in three or more chambers of the
heart.
▶ Procedure System
Pacemaker Implantable
Defibrillator
Insert transvenous single lead only without 33216 33216
pulse generator
Insert transvenous dual leads without pulse 33217 33217
generator
Insert transvenous multiple leads without 33217 + 33224 33217 +
pulse generator 33224
Insert subcutaneous defibrillator electrode N/A 33271
only without pulse generator
Initial pulse generator insertion only with 33212 33240
existing single lead, includes transvenous
or subcutaneous defibrillator lead
existing dual leads
existing multiple leads
Initial pulse generator insertion or 33206 (atrial) or 33249
replacement plus insertion of transvenous 33207
single lead (ventricular)
Initial pulse generator insertion or 33208 33249
replacement plus insertion of transvenous
dual leads
Initial pulse generator insertion or 33208 + 33225 33249 +
replacement plus insertion of transvenous 33225
multiple leads
Initial pulse generator insertion or N/A 33270
replacement plus insertion of subcutaneous
defibrillator electrode
Insertion, replacement, or removal and 33274 N/A
replacement of permanent leadless
pacemaker
Upgrade single chamber system to dual 33214 (includes 33241 +
chamber system removal of 33249
existing pulse
generator)
Removal pulse generator only (without 33233 33241
replacement)
Removal pulse generator with replacement 33227 33262
pulse generator only single lead system
(applies to transvenous or subcutaneous
defibrillator lead systems)
pulse generator only dual lead system
(transvenous)
pulse generator only multiple lead system
(transvenous)
Removal transvenous electrode only single 33234 33244
lead system
Removal transvenous electrode only dual 33235 33244
lead system
Removal subcutaneous defibrillator lead N/A 33272
only
Removal and replacement of pulse 33233 + (33234 33241 +
generator and transvenous electrodes or 33235) + 33244 +
(33206, 33207 or 33249 and
33208) and 33225, when
33225, when appropriate
appropriate
Removal and replacement of implantable N/A 33272 +
defibrillator pulse generator and 33241 +
subcutaneous electrode 33270
Removal of permanent leadless pacemaker 33275 N/A
Conversion of existing system to bi- 33225 + 33228 or 33225 +
ventricular system (addition of LV lead 33229 33263 or
and removal of current pulse generator 33264◀
with insertion of new pulse generator with
bi-ventricular pacing capabilities)
33202 Insertion of epicardial electrode(s); open incision (eg,
thoracotomy, median sternotomy, subxiphoid approach)
➲ CPT Assistant Jun 12:5, Nov 14:5, May 15:3, Aug 16:5,
Mar 19:6
33203 endoscopic approach (eg, thoracoscopy,
pericardioscopy)
➲ CPT Assistant Jun 12:4, Nov 14:5, May 15:3, Aug
16:5
(When epicardial lead placement is performed with
insertion of the generator, report 33202, 33203 in
conjunction with 33212, 33213, 33221, 33230, 33231,
33240)
33206 Insertion of new or replacement of permanent pacemaker
with transvenous electrode(s); atrial
➲ CPT Assistant Summer 94:10, 17, Oct 96:9, Nov 99:15,
Jun 08:14, Jun 12:3, Apr 13:10, Nov 14:5, May 15:3,
Aug 16:5
33207 ventricular
➲ CPT Assistant Summer 94:10, 17, Oct 96:9, Nov
99:15, Jun 08:14, Jun 12:3, Apr 13:10, May 15:3,
Aug 16:5
33208 atrial and ventricular
➲ CPT Assistant Summer 94:10, 17, Jul 96:10, Nov
99:15, Jun 08:14, Jun 12:3, Apr 13:10, Nov 14:5,
May 15:3, Aug 16:5
33229)
33216, 33217)
(Codes 33206-33208 include subcutaneous insertion of the
pulse generator and transvenous placement of electrode[s])
(For removal and replacement of pacemaker pulse generator
and transvenous electrode(s), use 33233 in conjunction with
either 33234 or 33235 and 33206-33208)
33210 Insertion or replacement of temporary transvenous single
chamber cardiac electrode or pacemaker catheter (separate
procedure)
➲ CPT Assistant Summer 94:10, 17, Mar 07:1, Aug 11:4,
Jun 12:3, Jan 13:6, May 15:3, Aug 16:5
33211 Insertion or replacement of temporary transvenous dual
chamber pacing electrodes (separate procedure)
➲ CPT Assistant Summer 94:10, 17, Mar 07:1, Aug 11:4,
Jun 12:3, May 15:3, Aug 16:5
33212 Insertion of pacemaker pulse generator only; with existing
single lead
➲ CPT Assistant Summer 94:10, 18, Fall 94:24, May
04:15, Jun 08:14, Jun 12:3, Nov 14:5, May 15:3, Aug
16:5
Temporary Pacemaker
33210
The pacemaker pulse generator with the electrodes transvenously placed
33213 with existing dual leads
➲ CPT Assistant Summer 94:10, 18, Oct 96:10, Feb
98:11, Jun 12:3, Nov 14:5, May 15:3, Aug 16:5
# 33221 with existing multiple leads
➲ CPT Assistant Jun 12:3, Nov 14:5, May 15:3, Aug
16:5
33216, 33217)
33233 for removal and replacement of the pacemaker pulse
generator. Use 33227-33229, as appropriate, when pulse
generator replacement is indicated)
insertion of generator, report 33202, 33203 in conjunction
with 33212, 33213, 33221)
33214 Upgrade of implanted pacemaker system, conversion of
single chamber system to dual chamber system (includes
removal of previously placed pulse generator, testing of
existing lead, insertion of new lead, insertion of new pulse
generator)
➲ CPT Assistant Summer 94:10, 18, Fall 94:24, Jun 08:14,
Jun 12:3, Nov 14:5, Aug 16:5
33227, 33228, 33229)
Implanted Pacemaker
33212-33214
A. In 33212, a pacemaker pulse generator is inserted with an existing single lead.
B. In 33213, a pacemaker pulse generator is inserted or replaced in two chambers. In 33214, an

upgrade to an existing pacemaker system is done.
33215 Repositioning of previously implanted transvenous
pacemaker or implantable defibrillator (right atrial or right
ventricular) electrode
➲ CPT Assistant Jun 12:3, Nov 14:5, Aug 16:5
33216 Insertion of a single transvenous electrode, permanent

pacemaker or implantable defibrillator
2015, 2017
➲ CPT Assistant Summer 94:10, 18, Jul 96:10, Nov 99:15-
16, Aug 16:5
33208, 33212, 33213, 33214, 33221, 33227, 33228, 33229,
33230, 33231, 33240, 33249, 33262, 33263, 33264)
33217 Insertion of 2 transvenous electrodes, permanent pacemaker
or implantable defibrillator
2017
➲ CPT Assistant Summer 94:10, 18, Jul 96:10, Nov 99:15-
16, Jul 00:5, Apr 09:8, Jun 12:3, Aug 16:5
33208, 33212, 33213, 33214, 33221, 33227, 33228, 33229,
33230, 33231, 33240, 33249, 33262, 33263, 33264)
(For insertion or replacement of a cardiac venous system
lead, see 33224, 33225)
33218 Repair of single transvenous electrode, permanent
2017
➲ CPT Assistant Summer 94:10, 19, Oct 96:9, Nov 99:15-
16, Jun 12:3, Aug 16:5
(For repair of single permanent pacemaker or implantable
defibrillator electrode with replacement of pulse generator,
see 33227, 33228, 33229 or 33262, 33263, 33264 and
33218)
33220 Repair of 2 transvenous electrodes for permanent
2017
➲ CPT Assistant Summer 94:10, 19, Oct 96:9, Nov 99:15-
16, Jun 08:14, Jun 12:3, Aug 16:5
(For repair of 2 transvenous electrodes for permanent
pacemaker or implantable defibrillator with replacement of
pulse generator, use 33220 in conjunction with 33228,
33229, 33263, 33264)
33222 Relocation of skin pocket for pacemaker
➲ CPT Assistant Spring 94:30, Summer 94:10, Nov 99:15-
16, Jun 08:14, Jun 12:3, Nov 14:5, May 15:3, Aug 16:5
11042, 11043, 11044, 11045, 11046, 11047, 13100, 13101,
13102)
33223 Relocation of skin pocket for implantable defibrillator
2015, 2017
➲ CPT Assistant Summer 94:10, 19, Nov 99:15-16, Jun
08:14, Jun 12:3, Nov 14:5, Aug 16:5
11042, 11043, 11044, 11045, 11046, 11047, 13100, 13101,
13102)
33224 Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, with attachment to previously placed
pacemaker or implantable defibrillator pulse generator
(including revision of pocket, removal, insertion, and/or
replacement of existing generator)
➲ CPT Assistant Dec 07:16, Jun 12:3, Nov 14:5, May
15:3, Aug 16:5
(When epicardial electrode placement is performed, report
33224 in conjunction with 33202, 33203)
Biventricular Pacing
33224-33226
Insertion or repositioning of venous pacing electrode
✚ 33225 Insertion of pacing electrode, cardiac venous system, for left
ventricular pacing, at time of insertion of implantable
defibrillator or pacemaker pulse generator (eg, for upgrade
to dual chamber system) (List separately in addition to code
2015
➲ CPT Assistant Dec 07:16, Jun 12:3, Nov 14:5, May
15:3, Aug 16:5
33212, 33213, 33214, 33216, 33217, 33221, 33223, 33228,
33229, 33230, 33231, 33233, 33234, 33235, 33240, 33249,
33263, 33264)
(Use 33225 in conjunction with 33222 only with pacemaker
pulse generator pocket relocation and with 33223 only with
implantable defibrillator [ICD] pocket relocation)
33226 Repositioning of previously implanted cardiac venous
system (left ventricular) electrode (including removal,
insertion and/or replacement of existing generator)
➲ CPT Assistant Jun 12:3, Nov 14:5, May 15:3, Aug 16:5

33233 Removal of permanent pacemaker pulse generator only
➲ CPT Assistant Summer 94:10, 19, Fall 94:24, Oct 96:10,
Jun 12:3, Nov 14:5, Aug 16:5
# 33227 Removal of permanent pacemaker pulse generator with
replacement of pacemaker pulse generator; single lead
system
➲ CPT Assistant Jun 12:3, Apr 13:10, Nov 14:5, Aug 16:5
# 33228 dual lead system

➲ CPT Assistant Jun 12:3, Apr 13:10, Aug 16:5
# 33229 multiple lead system

➲ CPT Assistant Jun 12:3, Apr 13:10, Nov 14:5, Aug
16:5
33214, 33216, 33217, 33233)
(For removal and replacement of pacemaker pulse generator
and transvenous electrode[s], use 33233 in conjunction with
either 33234 or 33235 and 33206-33208)
33234 Removal of transvenous pacemaker electrode(s); single lead
system, atrial or ventricular
➲ CPT Assistant Summer 94:10, 19, Nov 99:16, Jun 12:3,
Oct 12:15, Nov 14:5, Aug 16:5
33235 dual lead system
➲ CPT Assistant Summer 94:10, 19, Nov 99:16, Jun
12:3, Oct 12:15, Dec 13:14, Nov 14:5, Aug 16:5
33236 Removal of permanent epicardial pacemaker and electrodes
by thoracotomy; single lead system, atrial or ventricular
Aug 16:5
33237 dual lead system
➲ CPT Assistant Summer 94:10, 19, Nov 99:16, Jun
12:3, Aug 16:5, Mar 19:6
33238 Removal of permanent transvenous electrode(s) by
thoracotomy
Nov 14:5, Aug 16:5
33240 Insertion of implantable defibrillator pulse generator only;
with existing single lead
2017
➲ CPT Assistant Summer 94:40, Jun 96:10, Nov 99:16-17,
Jul 00:5, Apr 04:6, Jun 08:14, Jun 12:3, Nov 14:5, Aug
16:5
93261)
(Use 33240, as appropriate, in addition to the epicardial
lead placement codes to report the insertion of the generator
when done by the same physician during the same session)
# 33230 with existing dual leads
# 33231 with existing multiple leads


33216, 33217)
33241 for removal and replacement of the implantable
defibrillator pulse generator. Use 33262, 33263, 33264, as
appropriate, when pulse generator replacement is indicated)
insertion of generator, report 33202, 33203 in conjunction
with 33230, 33231, 33240)
33241 Removal of implantable defibrillator pulse generator only
2017
➲ CPT Assistant Summer 94:40, Nov 99:16-17, Jun 12:3,
Nov 14:5, Aug 16:5
33240 for removal and replacement of the implantable
defibrillator pulse generator. Use 33262, 33263, 33264, as
appropriate, when pulse generator replacement is indicated)
(For removal and replacement of an implantable
defibrillator pulse generator and electrode[s], use 33241 in
conjunction with either 33243 or 33244 and 33249 for
transvenous electrode[s] or 33270 and 33272 for
subcutaneous electrode)
(For removal of implantable defibrillator with substernal
lead, generator only, use 0580T)
# 33262 Removal of implantable defibrillator pulse generator with
replacement of implantable defibrillator pulse generator;
single lead system

93261, 0614T)◀
▶ (For removal and replacement of substernal implantable
pulse generator, use 0614T)◀
# 33263 dual lead system
➲ CPT Assistant Jun 12:3, Dec 13:17, Nov 14:5, Aug
16:5
# 33264 multiple lead system
➲ CPT Assistant Jun 12:3, Dec 13:17, Nov 14:5, Aug
16:5
33216, 33217, 33241)
(For removal of electrode[s] by thoracotomy in conjunction
with pulse generator removal or replacement, use 33243 in
conjunction with 33241 or 33262, 33263, 33264)
(For removal of electrode[s] by transvenous extraction in
conjunction with pulse generator removal or replacement,
use 33244 in conjunction with 33241 or 33262, 33263,
33264)
(For repair of implantable defibrillator pulse generator
and/or leads, see 33218, 33220)
(For removal of subcutaneous electrode in conjunction with
implantable defibrillator pulse generator removal or
replacement, use 33272 in conjunction with 33241 or
33262)
Coding Tip
Reporting for Electrode Removal and Lead Placement
Removal of electrode(s) may first be attempted by transvenous extraction

(code 33244). However, if transvenous extraction is unsuccessful, a
thoracotomy may be required to remove the electrodes (code 33243). Use
codes 33212, 33213, 33240 as appropriate in addition to the thoracotomy or
endoscopic epicardial lead placement codes to report the insertion of the
generator if done by the same physician during the same session.
CPT Coding Guidelines, Pacemaker or Pacing Cardioverter-Defibrillator
33243 Removal of single or dual chamber implantable defibrillator

electrode(s); by thoracotomy
➲ CPT Assistant Summer 94:40, Nov 99:16-17, Jun 12:3,
Nov 14:5, Aug 16:5
33244 by transvenous extraction
2017
➲ CPT Assistant Summer 94:40, Nov 99:16-17, Jul
00:5, Jun 12:3, Nov 14:5, Aug 16:5
33249 Insertion or replacement of permanent implantable
defibrillator system, with transvenous lead(s), single or dual
chamber
2017
➲ CPT Assistant Summer 94:21, Nov 99:16-17, Apr 04:6,
May 08:14, Jun 08:14, Jun 12:3, Nov 14:5, Aug 16:5
defibrillator pulse generator and transvenous electrode[s],
use 33241 in conjunction with either 33243 or 33244 and
33249)
(For insertion of transvenous implantable defibrillator
lead(s), without thoracotomy, use 33216 or 33217)
# 33270 Insertion or replacement of permanent subcutaneous
implantable defibrillator system, with subcutaneous
electrode, including defibrillation threshold evaluation,
induction of arrhythmia, evaluation of sensing for arrhythmia
termination, and programming or reprogramming of sensing
or therapeutic parameters, when performed

93261, 93644)
defibrillator pulse generator and subcutaneous electrode,
use 33241 in conjunction with 33270 and 33272)
(For insertion of subcutaneous implantable defibrillator
lead[s], use 33271)
(For insertion or replacement of permanent implantable
defibrillator system with substernal electrode, use 0571T)
# 33271 Insertion of subcutaneous implantable defibrillator electrode
33270, 93260, 93261)
(For insertion or replacement of a cardiac venous system
lead, see 33224, 33225)
(For insertion of substernal defibrillator electrode, use
0572T)
# 33272 Removal of subcutaneous implantable defibrillator
electrode
(For removal of substernal defibrillator electrode, use

0573T)
# 33273 Repositioning of previously implanted subcutaneous
implantable defibrillator electrode

93261)
(For repositioning of substernal defibrillator electrode, use
0574T)
# 33274 Transcatheter insertion or replacement of permanent
leadless pacemaker, right ventricular, including imaging
guidance (eg, fluoroscopy, venous ultrasound,
ventriculography, femoral venography) and device
evaluation (eg, interrogation or programming), when
performed
# 33275 Transcatheter removal of permanent leadless pacemaker,

right ventricular, including imaging guidance (eg,
fluoroscopy, venous ultrasound, ventriculography, femoral
venography), when performed

(Do not report 33274, 33275 in conjunction with femoral
venography [75820], fluoroscopy [76000, 77002],
ultrasound guidance for vascular access [76937], right
ventriculography [93566])
93453, 93456, 93457, 93460, 93461, 93530, 93531, 93532,
93533, unless complete right heart catheterization is
performed for indications distinct from the leadless
pacemaker procedure)
(For subsequent leadless pacemaker device evaluation, see
93279, 93286, 93288, 93294, 93296)
(For insertion, replacement, repositioning, and removal of
pacemaker systems with leads, see 33202, 33203, 33206,
33207, 33208, 33212, 33213, 33214, 33215, 33216, 33217,
33218, 33220, 33221, 33227, 33228, 33229, 33233, 33234,
33235, 33236, 33237)
Electrophysiologic Operative Procedures

This family of codes describes the surgical treatment of
supraventricular dysrhythmias. Tissue ablation, disruption, and
reconstruction can be accomplished by many methods including
surgical incision or through the use of a variety of energy sources
(eg, radiofrequency, cryotherapy, microwave, ultrasound, laser).
If excision or isolation of the left atrial appendage by any
method, including stapling, oversewing, ligation, or plication, is
performed in conjunction with any of the atrial tissue ablation
and reconstruction (maze) procedures (33254-33259, 33265-
33266), it is considered part of the procedure. Codes 33254-
33256 are only to be reported when there is no concurrently
performed procedure that requires median sternotomy or
cardiopulmonary bypass. The appropriate atrial tissue ablation
add-on code, 33257, 33258, 33259 should be reported in addition
to an open cardiac procedure requiring sternotomy or
cardiopulmonary bypass if performed concurrently.
Definitions
Limited operative ablation and reconstruction includes:
Surgical isolation of triggers of supraventricular dysrhythmias by
operative ablation that isolates the pulmonary veins or other
anatomically defined triggers in the left or right atrium.
Extensive operative ablation and reconstruction includes:
1. The services included in “limited”
2. Additional ablation of atrial tissue to eliminate sustained
supraventricular dysrhythmias. This must include operative
ablation that involves either the right atrium, the atrial septum,
or left atrium in continuity with the atrioventricular annulus.
Incision
33250 Operative ablation of supraventricular arrhythmogenic focus
or pathway (eg, Wolff-Parkinson-White, atrioventricular
node re-entry), tract(s) and/or focus (foci); without
➲ CPT Assistant Summer 94:16, Nov 99:17-18
(For intraoperative pacing and mapping by a separate
provider, use 93631)
➲ CPT Assistant Summer 94:16, Nov 99:17-18
Coding Tip
Reporting Restriction for Operative Tissue Ablation
Codes 33254-33256 are only to be reported when there is no concurrently

performed procedure that requires median sternotomy or cardiopulmonary
bypass.
CPT Coding Guidelines, Electrophysiologic Operative Procedures
33254 Operative tissue ablation and reconstruction of atria, limited

(eg, modified maze procedure)
33255 Operative tissue ablation and reconstruction of atria,

extensive (eg, maze procedure); without cardiopulmonary
bypass


32551, 33120, 33130, 33210, 33211, 33390, 33391, 33404-
33507, 33510-33523, 33533-33548, 33600-33853, 33858,
33859, 33863, 33864, 33910-33920)
✚ 33257 Operative tissue ablation and reconstruction of atria,
performed at the time of other cardiac procedure(s), limited
(eg, modified maze procedure) (List separately in addition

33251, 33261, 33300-33335, 33365, 33390, 33391, 33404-
33417, 33420-33476, 33478, 33496, 33500-33507, 33510-
33516, 33533-33548, 33600-33619, 33641-33697, 33702-
33732, 33735-33767, 33770-33877, 33910-33922, 33925,
33926, 33975, 33976, 33977, 33978, 33979, 33980, 33981,
33982, 33983)
performed at the time of other cardiac procedure(s),
extensive (eg, maze procedure), without cardiopulmonary
bypass (List separately in addition to code for primary
procedure)

33310, 33320, 33321, 33330, 33365, 33420, 33470, 33471,
33501-33503, 33510-33516, 33533-33536, 33690, 33735,
33737, 33750, 33755, 33762, 33764, 33766, 33800-33813,
33820, 33822, 33824, 33840, 33845, 33851, 33852, 33875,
33877, 33915, 33925, 33981, 33982, when the procedure is
performed without cardiopulmonary bypass)
performed at the time of other cardiac procedure(s),
extensive (eg, maze procedure), with cardiopulmonary
bypass (List separately in addition to code for primary
procedure)

33305, 33315, 33322, 33335, 33390, 33391, 33404, 33405,
33406, 33410, 33411, 33412, 33413, 33414, 33415, 33416,
33417, 33422-33468, 33474, 33475, 33476, 33478, 33496,
33500, 33504-33507, 33510-33516, 33533-33548, 33600-
33688, 33692-33726, 33730, 33732, 33736, 33767, 33770,
33783, 33786-33788, 33814, 33853, 33858-33877, 33910,
33916-33922, 33926, 33975-33980, 33983, when the
procedure is performed with cardiopulmonary bypass)
(Do not report 33257, 33258 and 33259 in conjunction with
32551, 33210, 33211, 33254-33256, 33265, 33266)
33261 Operative ablation of ventricular arrhythmogenic focus with

Endoscopy
33265 Endoscopy, surgical; operative tissue ablation and

reconstruction of atria, limited (eg, modified maze
procedure), without cardiopulmonary bypass
33266 operative tissue ablation and reconstruction of atria,

extensive (eg, maze procedure), without

33210, 33211)
Subcutaneous Cardiac Rhythm Monitor

A subcutaneous cardiac rhythm monitor, also known as a cardiac
event recorder or implantable/insertable loop recorder (ILR), is a
subcutaneously placed device that continuously records the
electrocardiographic rhythm, triggered automatically by rapid,
irregular and/or slow heart rates or by the patient during a
symptomatic episode. A subcutaneous cardiac rhythm monitor is
placed using a small parasternal incision followed by insertion of
the monitor into a small subcutaneous pre-pectoral pocket,
followed by closure of the incision.
33286)
33285 Insertion, subcutaneous cardiac rhythm monitor, including
programming
33286 Removal, subcutaneous cardiac rhythm monitor

(Initial insertion includes programming. For subsequent

electronic analysis and/or reprogramming, see 93285,
93291, 93298)
Implantable Hemodynamic Monitors
Transcatheter implantation of a wireless pulmonary artery
pressure sensor (33289) establishes an intravascular device used
for long-term remote monitoring of pulmonary artery pressures
(93264). The hemodynamic data derived from this device is used
to guide management of patients with heart failure. Code 33289
includes deployment and calibration of the sensor, right heart
catheterization, selective pulmonary artery catheterization,
radiological supervision and interpretation, and pulmonary artery
angiography, when performed.
33289 Transcatheter implantation of wireless pulmonary artery
pressure sensor for long-term hemodynamic monitoring,
including deployment and calibration of the sensor, right
heart catheterization, selective pulmonary catheterization,
radiological supervision and interpretation, and pulmonary
artery angiography, when performed
(For remote monitoring of an implantable wireless

pulmonary artery pressure sensor, use 93264)
36015, 75741, 75743, 75746, 76000, 93451, 93453, 93456,
93457, 93460, 93461, 93530, 93531, 93532, 93533, 93568)
Heart (Including Valves) and Great Vessels

▶Patients receiving major cardiac procedures may require
simultaneous cardiopulmonary bypass insertion of cannulae into
the venous and arterial vasculatures with support of circulation
and oxygenation by a heart-lung machine. Most services are
described by codes in dyad arrangements to allow distinct
reporting of procedures with or without cardiopulmonary bypass.
Cardiopulmonary bypass is distinct from support of cardiac
output using devices (eg, ventricular assist or intra-aortic
balloon). For cardiac assist services, see 33946, 33947, 33948,
33949, 33967-33983, 33990, 33991, 33992, 33993, 33995,
33997.◀
33300 Repair of cardiac wound; without bypass
33310 Cardiotomy, exploratory (includes removal of foreign body,
atrial or ventricular thrombus); without bypass

➲ CPT Assistant Oct 10:12, Dec 10:12
(Do not report removal of thrombus [33310-33315] in

conjunction with other cardiac procedures unless a separate
incision in the heart is required to remove the atrial or
ventricular thrombus)
(If removal of thrombus with cardiopulmonary bypass
[33315] is reported in conjunction with 33120, 33130,
33420-33430, 33460-33468, 33496, 33542, 33545, 33641-
33647, 33670, 33681, 33975-33980 which requires a
separate heart incision, report 33315 with modifier 59)
33320 Suture repair of aorta or great vessels; without shunt or
➲ CPT Assistant Fall 91:7, Jun 18:11
33321 with shunt bypass


33330 Insertion of graft, aorta or great vessels; without shunt, or


33340 Percutaneous transcatheter closure of the left atrial

appendage with endocardial implant, including fluoroscopy,
transseptal puncture, catheter placement(s), left atrial
angiography, left atrial appendage angiography, when
performed, and radiological supervision and interpretation

93458, 93459, 93460, 93461, 93531, 93532, 93533, unless
catheterization of the left ventricle is performed by a non-
transseptal approach for indications distinct from the left
atrial appendage closure procedure)
93456, 93460, 93461, 93530, 93531, 93532, 93533, unless
complete right heart catheterization is performed for
indications distinct from the left atrial appendage closure
procedure)
Cardiac Valves
(For multiple valve procedures, see 33390, 33391, 33404-
33478 and add modifier 51 to the secondary valve
procedure code)
Aortic Valve
Codes 33361, 33362, 33363, 33364, 33365, 33366 are used to

report transcatheter aortic valve replacement
(TAVR)/transcatheter aortic valve implantation (TAVI).
TAVR/TAVI requires two physician operators and all components
of the procedure are reported using modifier 62.
Codes 33361, 33362, 33363, 33364, 33365, 33366 include the
work, when performed, of percutaneous access, placing the
access sheath, balloon aortic valvuloplasty, advancing the valve
delivery system into position, repositioning the valve as needed,
deploying the valve, temporary pacemaker insertion for rapid
pacing (33210), and closure of the arteriotomy when performed.
Codes 33361, 33362, 33363, 33364, 33365, 33366 include open
arterial or cardiac approach.
Angiography, radiological supervision, and interpretation
performed to guide TAVR/TAVI (eg, guiding valve placement,
documenting completion of the intervention, assessing the
vascular access site for closure) are included in these codes.
Diagnostic left heart catheterization codes (93452, 93453, 93458-
93461) and the supravalvular aortography code (93567) should
not be used with TAVR/TAVI services (33361, 33362, 33363,
33364, 33365, 33366) to report:
1. Contrast injections, angiography, roadmapping, and/or
fluoroscopic guidance for the TAVR/TAVI,
2. Aorta/left ventricular outflow tract measurement for the
TAVR/TAVI, or
3. Post-TAVR/TAVI aortic or left ventricular angiography, as this
work is captured in the TAVR/TAVI services codes (33361,
33362, 33363, 33364, 33365, 33366).
Diagnostic coronary angiography performed at the time of
TAVR/TAVI may be separately reportable if:
No prior catheter-based coronary angiography study is
1. available and a full diagnostic study is performed, or
2. A prior study is available, but as documented in the medical

record:
a. The patient’s condition with respect to the clinical indication
has changed since the prior study, or
b. There is inadequate visualization of the anatomy and/or
pathology, or
c. There is a clinical change during the procedure that requires
new evaluation.
d. For same session/same day diagnostic coronary angiography
services, report the appropriate diagnostic cardiac
catheterization code(s) appended with modifier 59 indicating
separate and distinct procedural service from TAVR/TAVI.
Diagnostic coronary angiography performed at a separate session
from an interventional procedure may be separately reportable.
Other cardiac catheterization services may be reported separately
when performed for diagnostic purposes not intrinsic to
TAVR/TAVI.
Percutaneous coronary interventional procedures are reported
separately, when performed.
▶When transcatheter ventricular support is required in
conjunction with TAVR/TAVI, the appropriate code may be
reported with the appropriate ventricular assist device (VAD)
procedure code (33975, 33976, 33990, 33991, 33992, 33993,
33995, 33997) or balloon pump insertion code (33967, 33970,
33973).◀
The TAVR/TAVI cardiovascular access and delivery procedures
are reported with 33361, 33362, 33363, 33364, 33365, 33366.
When cardiopulmonary bypass is performed in conjunction with
TAVR/TAVI, codes 33361, 33362, 33363, 33364, 33365, 33366
should be reported with the appropriate add-on code for
percutaneous peripheral bypass (33367), open peripheral bypass
(33368), or central bypass (33369).
33361 Transcatheter aortic valve replacement (TAVR/TAVI) with
prosthetic valve; percutaneous femoral artery approach
➲ CPT Assistant Jan 13:6, Jan 14:5, Jul 14:8, Mar 15:9
33362 open femoral artery approach

➲ CPT Assistant Jan 13:6, Jan 14:5, Mar 15:9
33363 open axillary artery approach

33364 open iliac artery approach

33365 transaortic approach (eg, median sternotomy,

mediastinotomy)
33366 transapical exposure (eg, left thoracotomy)

➲ CPT Assistant Jan 14:5, Jul 14:8, Mar 15:9
✚ 33367 cardiopulmonary bypass support with percutaneous

peripheral arterial and venous cannulation (eg, femoral
vessels) (List separately in addition to code for primary
procedure)
➲ CPT Assistant Jan 13:6, Sep 15:3, Mar 16:5

33364, 33365, 33366, 33418, 33477, 0483T, 0484T, 0544T,
0545T, 0569T, 0570T)
✚ 33368 cardiopulmonary bypass support with open peripheral
arterial and venous cannulation (eg, femoral, iliac,
axillary vessels) (List separately in addition to code for
primary procedure)

33364, 33365, 33366, 33418, 33477, 0483T, 0484T, 0544T,
0545T, 0569T, 0570T)
✚ 33369 cardiopulmonary bypass support with central arterial and
venous cannulation (eg, aorta, right atrium, pulmonary
artery) (List separately in addition to code for primary
procedure)

33364, 33365, 33366, 33418, 33477, 0483T, 0484T, 0544T,
0545T, 0569T, 0570T)
33390 Valvuloplasty, aortic valve, open, with cardiopulmonary
bypass; simple (ie, valvotomy, debridement, debulking,
and/or simple commissural resuspension)
33391 complex (eg, leaflet extension, leaflet resection, leaflet
reconstruction, or annuloplasty)

33404 Construction of apical-aortic conduit
➲ CPT Assistant Jan 04:28, Feb 05:14
33405 Replacement, aortic valve, open, with cardiopulmonary

bypass; with prosthetic valve other than homograft or
stentless valve
➲ CPT Assistant Nov 99:18, Feb 05:14, Aug 11:3, Jan
13:6, May 17:9, Apr 19:6
33406 with allograft valve (freehand)
➲ CPT Assistant Nov 99:18, Feb 05:14, Aug 11:3, May
17:9, Apr 19:6
33410 with stentless tissue valve
➲ CPT Assistant Nov 99:18, Feb 05:14, Aug 11:3, May
17:9, Apr 19:6
# 33440 Replacement, aortic valve; by translocation of autologous
pulmonary valve and transventricular aortic annulus
enlargement of the left ventricular outflow tract with valved
conduit replacement of pulmonary valve (Ross-Konno
procedure)
33410, 33411, 33412, 33413, 33414, 33416, 33417, 33475,
33608, 33920)
33411 with aortic annulus enlargement, noncoronary sinus
➲ CPT Assistant Feb 05:14, Aug 11:3, Apr 19:6
33412 with transventricular aortic annulus enlargement (Konno

procedure)

(For replacement of aortic valve with transventricular aortic
annulus enlargement [Konno procedure] in conjunction with
translocation of autologous pulmonary valve with allograft
replacement of pulmonary valve [Ross procedure], use
33440)
33413 by translocation of autologous pulmonary valve with
allograft replacement of pulmonary valve (Ross
procedure)

(For replacement of aortic valve with transventricular aortic
annulus enlargement [Konno procedure] in conjunction with
translocation of autologous pulmonary valve with allograft
replacement of pulmonary valve [Ross procedure], use
33440)
33414 Repair of left ventricular outflow tract obstruction by patch
enlargement of the outflow tract
33415 Resection or incision of subvalvular tissue for discrete

subvalvular aortic stenosis
33416 Ventriculomyotomy (-myectomy) for idiopathic hypertrophic
subaortic stenosis (eg, asymmetric septal hypertrophy)
(For percutaneous transcatheter septal reduction therapy, use

93583)
33417 Aortoplasty (gusset) for supravalvular stenosis
Mitral Valve
Codes 33418 and 33419 are used to report transcatheter mitral

valve repair (TMVR). Code 33419 should only be reported once
per session.
Codes 33418 and 33419 include the work, when performed, of
percutaneous access, placing the access sheath, transseptal
puncture, advancing the repair device delivery system into
position, repositioning the device as needed, and deploying the
device(s).
Angiography, radiological supervision, and interpretation
performed to guide TMVR (eg, guiding device placement and
documenting completion of the intervention) are included in
these codes.
Diagnostic right and left heart catheterization codes (93451,
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530,
93531, 93532, 93533) should not be used with 33418, 33419 to
report:
1. Contrast injections, angiography, road-mapping, and/or
fluoroscopic guidance for the transcatheter mitral valve repair
(TMVR),
2. Left ventricular angiography to assess mitral regurgitation for
guidance of TMVR, or
3. Right and left heart catheterization for hemodynamic
measurements before, during, and after TMVR for guidance of
TMVR.
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530,
93531, 93532, 93533) and diagnostic coronary angiography codes
(93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93563,
93564) may be reported with 33418, 33419, representing separate
and distinct services from TMVR, if:
1. No prior study is available and a full diagnostic study is
performed, or
record:
a. There is inadequate visualization of the anatomy and/or
pathology, or
b. The patient’s condition with respect to the clinical indication
new evaluation.
when performed for diagnostic purposes not intrinsic to TMVR.
For same session/same day diagnostic cardiac catheterization
services, report the appropriate diagnostic cardiac catheterization
code(s) appended with modifier 59 indicating separate and
distinct procedural service from TMVR.
Percutaneous coronary interventional procedures may be
reported separately, when performed.
conjunction with TMVR, the appropriate code may be reported
with the appropriate ventricular assist device (VAD) procedure
code (33990, 33991, 33992, 33993, 33995, 33997) or balloon
pump insertion code (33967, 33970, 33973).◀
TMVR, 33418, 33419 may be reported with the appropriate add-
on code for percutaneous peripheral bypass (33367), open
peripheral bypass (33368), or central bypass (33369).
33418 Transcatheter mitral valve repair, percutaneous approach,
including transseptal puncture when performed; initial
prosthesis
(Do not report 33418 in conjunction with 93462 unless

transapical puncture is performed)
✚ 33419 additional prosthesis(es) during same session (List

(For transcatheter mitral valve repair, percutaneous
approach via the coronary sinus, use 0345T)
(For transcatheter mitral valve implantation/replacement
[TMVI], see 0483T, 0484T)
(For transcatheter mitral valve annulus reconstruction, use
0544T)
33420 Valvotomy, mitral valve; closed heart
33422 open heart, with cardiopulmonary bypass

33425 Valvuloplasty, mitral valve, with cardiopulmonary bypass;

➲ CPT Assistant May 03:19, Feb 05:14
33426 with prosthetic ring

33427 radical reconstruction, with or without ring

33430 Replacement, mitral valve, with cardiopulmonary bypass

Tricuspid Valve
(For transcatheter tricuspid valve repair [TTVr], see 0569T,

0570T)
33460 Valvectomy, tricuspid valve, with cardiopulmonary bypass
33463 Valvuloplasty, tricuspid valve; without ring insertion

33464 with ring insertion

33465 Replacement, tricuspid valve, with cardiopulmonary bypass

33468 Tricuspid valve repositioning and plication for Ebstein

anomaly
(For transcatheter tricuspid valve annulus reconstruction,

use 0545T)
Pulmonary Valve
Code 33477 is used to report transcatheter pulmonary valve

implantation (TPVI). Code 33477 should only be reported once
per session.
Code 33477 includes the work, when performed, of percutaneous
access, placing the access sheath, advancing the repair device
delivery system into position, repositioning the device as needed,
and deploying the device(s). Angiography, radiological
supervision, and interpretation performed to guide TPVI (eg,
guiding device placement and documenting completion of the
intervention) are included in the code.
Code 33477 includes all cardiac catheterization(s),
intraprocedural contrast injection(s), fluoroscopic radiological
supervision and interpretation, and imaging guidance performed
to complete the pulmonary valve procedure. Do not report 33477
in conjunction with 76000, 93451, 93453, 93454, 93455, 93456,
93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533,
93563, 93566, 93567, 93568 for angiography intrinsic to the
procedure.
Code 33477 includes percutaneous balloon angioplasty of the
conduit/treatment zone, valvuloplasty of the pulmonary valve
conduit, and stent deployment within the pulmonary conduit or
an existing bioprosthetic pulmonary valve, when performed. Do
not report 33477 in conjunction with 37236, 37237, 92997, 92998
for pulmonary artery angioplasty/valvuloplasty or stenting within
the prosthetic valve delivery site.
Codes 92997, 92998 may be reported separately when pulmonary
artery angioplasty is performed at a site separate from the
prosthetic valve delivery site. Codes 37236, 37237 may be
reported separately when pulmonary artery stenting is performed
at a site separate from the prosthetic valve delivery site.
Diagnostic right heart catheterization and diagnostic coronary
angiography codes (93451, 93453, 93454, 93455, 93456, 93457,
93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533, 93563,
93566, 93567, 93568) should not be used with 33477 to report:
fluoroscopic guidance for the TPVI,
2. Pulmonary conduit angiography for guidance of TPVI, or
3. Right heart catheterization for hemodynamic measurements
before, during, and after TPVI for guidance of TPVI.
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530,
93531, 93532, 93533), diagnostic coronary angiography codes
(93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93563,
93564), and diagnostic pulmonary angiography code (93568) may
be reported with 33477, representing separate and distinct
services from TPVI, if:
performed, or
record:
pathology, or
new evaluation.
when performed for diagnostic purposes not intrinsic to TPVI.
code(s) appended with modifier 59 to indicate separate and
distinct procedural services from TPVI.
from an interventional procedure may be separately reportable,
when performed.
Percutaneous pulmonary artery branch interventions may be
conjunction with TPVI, the appropriate code may be reported
with the appropriate percutaneous ventricular assist device (VAD)
procedure codes (33990, 33991, 33992, 33993, 33995, 33997),
extracorporeal membrane oxygenation (ECMO) or extracorporeal
life support services (ECLS) procedure codes (33946-33989), or
balloon pump insertion codes (33967, 33970, 33973).◀
TPVI, code 33477 may be reported with the appropriate add-on
code for percutaneous peripheral bypass (33367), open
33470 Valvotomy, pulmonary valve, closed heart; transventricular

33471 via pulmonary artery
(To report percutaneous valvuloplasty of pulmonary valve,

use 92990)
33474 Valvotomy, pulmonary valve, open heart, with
33475 Replacement, pulmonary valve

33476 Right ventricular resection for infundibular stenosis, with or

without commissurotomy
33477 Transcatheter pulmonary valve implantation, percutaneous

approach, including pre-stenting of the valve delivery site,
when performed
33478 Outflow tract augmentation (gusset), with or without

commissurotomy or infundibular resection
(Use 33478 in conjunction with 33768 when a

cavopulmonary anastomosis to a second superior vena cava
is performed)
Other Valvular Procedures
33496 Repair of non-structural prosthetic valve dysfunction with
cardiopulmonary bypass (separate procedure)
➲ CPT Assistant Nov 97:16, Feb 05:14
(For reoperation, use 33530 in addition to 33496)
Coronary Artery Anomalies

Basic procedures include endarterectomy or angioplasty.
33500 Repair of coronary arteriovenous or arteriocardiac chamber
fistula; with cardiopulmonary bypass
33501 without cardiopulmonary bypass
33502 Repair of anomalous coronary artery from pulmonary artery
origin; by ligation
33503 by graft, without cardiopulmonary bypass

33503)
33504 by graft, with cardiopulmonary bypass
33505 with construction of intrapulmonary artery tunnel
(Takeuchi procedure)
33506 by translocation from pulmonary artery to aorta
33506)
33507 Repair of anomalous (eg, intramural) aortic origin of
coronary artery by unroofing or translocation
Endoscopy
Surgical vascular endoscopy always includes diagnostic
endoscopy.
✚ 33508 Endoscopy, surgical, including video-assisted harvest of
vein(s) for coronary artery bypass procedure (List

(For open harvest of upper extremity vein procedure, use
35500)
Venous Grafting Only for Coronary Artery Bypass

The following codes are used to report coronary artery bypass
procedures using venous grafts only. These codes should NOT
be used to report the performance of coronary artery bypass
procedures using arterial grafts and venous grafts during the
same procedure. See 33517-33523 and 33533-33536 for reporting
combined arterial-venous grafts.
▶Procurement of the saphenous vein graft is included in the
description of the work for 33510-33516 and should not be
reported as a separate service or co-surgery. To report harvesting
of an upper extremity vein, use 35500 in addition to the bypass
procedure. To report harvesting of a femoropopliteal vein
segment, report 35572 in addition to the bypass procedure. When
surgical assistant performs graft procurement, add modifier 80 to
33510-33516. For percutaneous ventricular assist device
insertion, removal, repositioning, see 33990, 33991, 33992,
33993, 33995, 33997.◀
33510 Coronary artery bypass, vein only; single coronary venous
graft
➲ CPT Assistant Fall 91:5, Winter 92:12, Jul 99:11, Apr
01:7, Feb 05:14, Jan 07:7, Mar 07:1, Aug 14:14
33511 2 coronary venous grafts
➲ CPT Assistant Fall 91:5, Winter 92:12, Jul 99:11,
Apr 01:7, Feb 05:14, Jan 07:7, Mar 07:1
➲ CPT Assistant Fall 91:5, Winter 92:12, Apr 01:7,
Feb 05:14, Jan 07:7, Mar 07:1
Feb 05:14, Jan 07:7, Mar 07:1
Feb 05:14, Jan 07:7, Mar 07:1
33516 6 or more coronary venous grafts
➲ CPT Assistant Fall 91:5, Winter 92:12, Jul 99:11,
Apr 01:7, Feb 05:14, Jan 07:7, Mar 07:1, Aug 14:14
Coronary Artery Bypass-Venous Grafting Only

33510-33516
A. Use 33510 to report a single coronary venous graft.
B. Report 33512 when 3 coronary venous grafts are performed.
Combined Arterial-Venous Grafting for Coronary

Bypass
procedures using venous grafts and arterial grafts during the
same procedure. These codes may NOT be used alone.
To report combined arterial-venous grafts it is necessary to report
two codes: (1) the appropriate combined arterial-venous graft
code (33517-33523); and (2) the appropriate arterial graft code
(33533-33536).
▶Procurement of the saphenous vein graft is included in the
reported as a separate service or co-surgery. Procurement of the
artery for grafting is included in the description of the work for
33533-33536 and should not be reported as a separate service or
co-surgery, except when an upper extremity artery (eg, radial
artery) is procured. To report harvesting of an upper extremity
artery, use 35600 in addition to the bypass procedure. To report
harvesting of an upper extremity vein, use 35500 in addition to
the bypass procedure. To report harvesting of a femoropopliteal
vein segment, report 35572 in addition to the bypass procedure.
When surgical assistant performs arterial and/or venous graft
procurement, add modifier 80 to 33517-33523, 33533-33536, as
appropriate. For percutaneous ventricular assist device insertion,
removal, repositioning, see 33990, 33991, 33992, 33993, 33995,
33997.◀
✚ 33517 Coronary artery bypass, using venous graft(s) and arterial
graft(s); single vein graft (List separately in addition to code
➲ CPT Assistant Fall 91:5, Winter 92:13, Nov 99:18, Apr
01:7, Feb 05:14
✚ 33518 2 venous grafts (List separately in addition to code for
primary procedure)
Feb 05:14, Jan 07:7, Mar 07:1
primary procedure)
Feb 05:14, Jan 07:7, Mar 07:1
primary procedure)
Feb 05:14, Jan 07:7, Mar 07:1
primary procedure)
Feb 05:14, Jan 07:7, Mar 07:1
Coronary Artery Bypass Combined Arterial-Venous Grafting

33517-33530
Both venous and arterial grafts are used in these bypass procedures. The appropriate arterial graft
codes (33533-33536) must also be reported in conjunction with codes 33517-33530.
Coronary Artery Bypass-Sequential Combined Arterial-
Venous Grafting
33517-33530
Note: To determine the number of bypass grafts in a coronary artery bypass (CABG), count the number
of distal anastomoses (contact point[s]) where the bypass graft artery or vein is sutured to the diseased
coronary artery(s).
✚ 33523 6 or more venous grafts (List separately in addition to

Feb 05:14, Jan 07:7, Mar 07:1
✚ 33530 Reoperation, coronary artery bypass procedure or valve
procedure, more than 1 month after original operation (List
➲ CPT Assistant Winter 90:6, Fall 91:5, Winter 92:13, Apr
01:7, Jul 01:11, Feb 05:13-14, Jan 07:7, Feb 11:8
33496, 33510-33523, 33533, 33534, 33535, 33536, 33863)
Arterial Grafting for Coronary Artery Bypass

procedures using either arterial grafts only or a combination of
arterial-venous grafts. The codes include the use of the internal
mammary artery, gastroepiploic artery, epigastric artery, radial
artery, and arterial conduits procured from other sites.
To report combined arterial-venous grafts it is necessary to report
two codes: (1) the appropriate arterial graft code (33533-33536);
and (2) the appropriate combined arterial-venous graft code
(33517-33523).
▶Procurement of the artery for grafting is included in the
reported as a separate service or co-surgery, except when an
upper extremity artery (eg, radial artery) is procured. To report
harvesting of an upper extremity artery, use 35600 in addition to
the bypass procedure. To report harvesting of an upper extremity
vein, use 35500 in addition to the bypass procedure. To report
harvesting of a femoropopliteal vein segment, report 35572 in
addition to the bypass procedure. When surgical assistant
performs arterial and/or venous graft procurement, add modifier
80 to 33517-33523, 33533-33536, as appropriate. For
percutaneous ventricular assist device insertion, removal,
repositioning, see 33990, 33991, 33992, 33993, 33995, 33997.◀
33533 Coronary artery bypass, using arterial graft(s); single
arterial graft
➲ CPT Assistant Winter 92:12, Nov 99:18, Apr 01:7, Feb
05:14, Jan 07:7, Mar 07:1, Nov 14:14
33534 2 coronary arterial grafts
➲ CPT Assistant Winter 92:12, Apr 01:7, Feb 05:14,
Jan 07:7, Mar 07:1
33535 3 coronary arterial grafts
Jan 07:7, Mar 07:1
33536 4 or more coronary arterial grafts
Jan 07:7, Mar 07:1, Nov 14:14
33542 Myocardial resection (eg, ventricular aneurysmectomy)
33545 Repair of postinfarction ventricular septal defect, with or

without myocardial resection
33548 Surgical ventricular restoration procedure, includes

prosthetic patch, when performed (eg, ventricular
remodeling, SVR, SAVER, Dor procedures)

33211, 33310, 33315)
(For Batista procedure or pachopexy, use 33999)
Coronary Endarterectomy
✚ 33572 Coronary endarterectomy, open, any method, of left anterior
descending, circumflex, or right coronary artery performed
in conjunction with coronary artery bypass graft procedure,
each vessel (List separately in addition to primary
procedure)
33536)
Single Ventricle and Other Complex Cardiac

Anomalies
33600 Closure of atrioventricular valve (mitral or tricuspid) by
suture or patch
33602 Closure of semilunar valve (aortic or pulmonary) by suture

or patch
33606 Anastomosis of pulmonary artery to aorta (Damus-Kaye-
Stansel procedure)
33608 Repair of complex cardiac anomaly other than pulmonary
atresia with ventricular septal defect by construction or
replacement of conduit from right or left ventricle to
pulmonary artery
(For repair of pulmonary artery arborization anomalies by

unifocalization, see 33925-33926)
33610 Repair of complex cardiac anomalies (eg, single ventricle
with subaortic obstruction) by surgical enlargement of
ventricular septal defect

33611 Repair of double outlet right ventricle with intraventricular
tunnel repair;
33612 with repair of right ventricular outflow tract obstruction
33615 Repair of complex cardiac anomalies (eg, tricuspid atresia)
by closure of atrial septal defect and anastomosis of atria or
vena cava to pulmonary artery (simple Fontan procedure)
33617 Repair of complex cardiac anomalies (eg, single ventricle)
by modified Fontan procedure
(Use 33617 in conjunction with 33768 when a
cavopulmonary anastomosis to a second superior vena cava
is performed)
33619 Repair of single ventricle with aortic outflow obstruction
and aortic arch hypoplasia (hypoplastic left heart syndrome)
(eg, Norwood procedure)
➲ CPT Assistant Mar 07:1, Apr 11:6, May 12:14, Jul 16:3

33620 Application of right and left pulmonary artery bands (eg,
hybrid approach stage 1)
➲ CPT Assistant Apr 11:3, May 12:14, Jul 16:3
(For banding of the main pulmonary artery related to septal

defect, use 33690)
33621 Transthoracic insertion of catheter for stent placement with
catheter removal and closure (eg, hybrid approach stage 1)
(For placement of stent, use 37236)

(Report both 33620, 33621 if performed in same session)
Initial Hybrid Palliation

33621
33622 Reconstruction of complex cardiac anomaly (eg, single
ventricle or hypoplastic left heart) with palliation of single
ventricle with aortic outflow obstruction and aortic arch
hypoplasia, creation of cavopulmonary anastomosis, and
removal of right and left pulmonary bands (eg, hybrid
approach stage 2, Norwood, bidirectional Glenn, pulmonary
artery debanding)
➲ CPT Assistant Apr 11:3, May 12:14, Jul 16:3

33822, 33840, 33845, 33851, 33853, 33917)
(For bilateral, bidirectional Glenn procedure, use 33622 in
Hybrid Reconstruction
33622
Septal Defect
33641 Repair atrial septal defect, secundum, with cardiopulmonary
bypass, with or without patch
33645 Direct or patch closure, sinus venosus, with or without

anomalous pulmonary venous drainage
33647 Repair of atrial septal defect and ventricular septal defect,
with direct or patch closure
(For repair of tricuspid atresia (eg, Fontan, Gago
procedures), use 33615)
33660 Repair of incomplete or partial atrioventricular canal
(ostium primum atrial septal defect), with or without
atrioventricular valve repair
33665 Repair of intermediate or transitional atrioventricular canal,
with or without atrioventricular valve repair
33670 Repair of complete atrioventricular canal, with or without
prosthetic valve
33675 Closure of multiple ventricular septal defects;
33676 with pulmonary valvotomy or infundibular resection

(acyanotic)
33677 with removal of pulmonary artery band, with or without

gusset

32551, 32554, 32555, 33210, 33681, 33684, 33688)
(For percutaneous closure, use 93581)
33681 Closure of single ventricular septal defect, with or without
patch;
33684 with pulmonary valvotomy or infundibular resection

(acyanotic)
33688 with removal of pulmonary artery band, with or without
gusset
(For pulmonary vein repair requiring creation of atrial
septal defect, use 33724)
33690 Banding of pulmonary artery
➲ CPT Assistant Apr 11:4, May 12:14
(For right and left pulmonary artery banding in a single
ventricle [eg, hybrid approach stage 1], use 33620)
33692 Complete repair tetralogy of Fallot without pulmonary
atresia;
33694 with transannular patch
(For ligation and takedown of a systemic-to-pulmonary
artery shunt, performed in conjunction with a congenital
heart procedure; see 33924)
33697 Complete repair tetralogy of Fallot with pulmonary atresia
including construction of conduit from right ventricle to
pulmonary artery and closure of ventricular septal defect
(For ligation and takedown of a systemic-to-pulmonary

artery shunt, performed in conjunction with a congenital
heart procedure; see 33924)
Sinus of Valsalva
33702 Repair sinus of Valsalva fistula, with cardiopulmonary
bypass;
33710 with repair of ventricular septal defect

33720 Repair sinus of Valsalva aneurysm, with cardiopulmonary
bypass
33722 Closure of aortico-left ventricular tunnel
Venous Anomalies
33724 Repair of isolated partial anomalous pulmonary venous
return (eg, Scimitar Syndrome)

33211)
33726 Repair of pulmonary venous stenosis

33211)
33730 Complete repair of anomalous pulmonary venous return
(supracardiac, intracardiac, or infracardiac types)

(For partial anomalous pulmonary venous return, use 33724;
for repair of pulmonary venous stenosis, use 33726)
33732 Repair of cor triatriatum or supravalvular mitral ring by
resection of left atrial membrane
Shunting Procedures
▶Codes 33741, 33745 are used to report creation of effective
intracardiac blood flow in the setting of congenital heart defects.
Code 33741 (transcatheter atrial septostomy) involves the
percutaneous creation of improved atrial blood flow (eg,
balloon/blade method), typically in infants ≤4 kg with congenital
heart disease. Code 33745 is typically used for intracardiac shunt
creation by stent placement to establish improved intracardiac
blood flow (eg, atrial septum, Fontan fenestration, right
ventricular outflow tract, Mustard/Senning/Warden baffles). Code
33746 is used to describe each additional intracardiac shunt
creation by stent placement at a separate location during the same
session as the primary intervention (33745).
Code 33741 includes percutaneous access, placing the access
sheath(s), advancement of the transcatheter delivery system, and
creation of effective intracardiac atrial blood flow. Codes 33741,
33745 include, when performed, ultrasound guidance for
vascular access and fluoroscopic guidance for the intervention.
Code 33745 additionally includes intracardiac stent placement,
target zone angioplasty preceding or after stent implantation, and
complete diagnostic right and left heart catheterization, when
performed.
Diagnostic cardiac catheterization is not typically performed at the
same session as transcatheter atrial septostomy (33741) and,
when performed, may be separately reported. Diagnostic cardiac
catheterization is typically performed at the same session with
33745 and the code descriptor includes this work, when
performed.
Cardiovascular injection procedures for diagnostic angiography
reported using 93563, 93565, 93566, 93567, 93568 are not
typically performed at the same session as 33741. Although
diagnostic angiography is typically performed during 33745,
target vessels and chambers are highly variable and, when
performed, for an evaluation separate and distinct from the shunt
creation may be reported separately.
Codes 33745, 33746 are used to describe intracardiac stent
placement. Multiple stents placed in a single location may only be
reported with a single code. When additional, different
intracardiac locations are treated in the same session, 33746 may
be reported. Codes 33745, 33746 include any and all balloon
angioplasty(ies) performed in the target lesion, including any pre-
dilation (whether performed as a primary or secondary dilation),
post-dilation following stent placement, or use of larger/smaller
balloon to achieve therapeutic result. Angioplasty in a separate
and distinct intracardiac lesion may be reported separately. Use
33746 in conjunction with 33745.
93452, 93453, 93456, 93458, 93460, 93530, 93531, 93532, 93533)
should not be used in conjunction with 33741, 33745 to report:
1. Fluoroscopic guidance for the intervention, or
2. Limited hemodynamic and angiographic data used solely for
purposes of accomplishing the intervention (eg, measurement
of atrial pressures before and after septostomy, atrial injections
to determine appropriate catheter position)
Diagnostic congenital right and left heart catheterization codes
(93530, 93531, 93532, 93533) performed at the same session as
33741, may be separately reported, if:
1. No prior study is available, and a full diagnostic study is
performed, or
record:
pathology, or
The patient’s condition with respect to the clinical indication
b. has changed since the prior study, or

a more thorough evaluation.
For same-session diagnostic congenital catheterization services,
the appropriate diagnostic cardiac catheterization code(s) for
congenital anomalies (93530, 93531, 93532, 93533) may be
reported by appending modifier 59, indicating separate and
distinct procedural service(s) from 33741. For same-session
diagnostic cardiac angiography for an evaluation separate and
distinct from the shunt creation, the appropriate contrast
injection(s) performed (93563, 93565, 93566, 93567, 93568) may
be reported by appending modifier 59, indicating separate and
distinct procedural service(s) from 33741, 33745.◀
33735 Atrial septectomy or septostomy; closed heart (Blalock-
Hanlon type operation)
33736 open heart with cardiopulmonary bypass

33736)
33737 open heart, with inflow occlusion
● 33741 Transcatheter atrial septostomy (TAS) for congenital cardiac
anomalies to create effective atrial flow, including all
imaging guidance by the proceduralist, when performed, any
method (eg, Rashkind, Sang-Park, balloon, cutting balloon,
blade)
▶ (Do not report modifier 63 in conjunction with 33741)◀

▶ (For transseptal puncture, use 93462)◀
● 33745 Transcatheter intracardiac shunt (TIS) creation by stent
placement for congenital cardiac anomalies to establish
effective intracardiac flow, including all imaging guidance
by the proceduralist, when performed, left and right heart
diagnostic cardiac catherization for congenital cardiac
anomalies, and target zone angioplasty, when performed (eg,
atrial septum, Fontan fenestration, right ventricular outflow
tract, Mustard/Senning/Warden baffles); initial intracardiac
shunt
✚● 33746 each additional intracardiac shunt location (List

▶ (Use 33746 in conjunction with 33745)◀

▶ (Donot report 33745, 33746 in conjunction with 93530,
93531, 93532, 93533)◀
33750 Shunt; subclavian to pulmonary artery (Blalock-Taussig type
operation)
33755 ascending aorta to pulmonary artery (Waterston type
operation)
33762 descending aorta to pulmonary artery (Potts-Smith type
operation)
33755, 33762)
33764 central, with prosthetic graft
33766 superior vena cava to pulmonary artery for flow to 1 lung
(classical Glenn procedure)
33767 superior vena cava to pulmonary artery for flow to both
lungs (bidirectional Glenn procedure)
✚ 33768 Anastomosis, cavopulmonary, second superior vena cava
(List separately in addition to primary procedure)

33767)
33211)
Transposition of the Great Vessels

33770 Repair of transposition of the great arteries with ventricular
septal defect and subpulmonary stenosis; without surgical
enlargement of ventricular septal defect
33771 with surgical enlargement of ventricular septal defect

33774 Repair of transposition of the great arteries, atrial baffle
procedure (eg, Mustard or Senning type) with
cardiopulmonary bypass;
33775 with removal of pulmonary band
33776 with closure of ventricular septal defect
33777 with repair of subpulmonic obstruction
33778 Repair of transposition of the great arteries, aortic
pulmonary artery reconstruction (eg, Jatene type);
33779 with removal of pulmonary band
33780 with closure of ventricular septal defect
33781 with repair of subpulmonic obstruction
33782 Aortic root translocation with ventricular septal defect and

pulmonary stenosis repair (ie, Nikaidoh procedure); without
coronary ostium reimplantation

33608, 33681, 33770, 33771, 33778, 33780, 33920)
33783 with reimplantation of 1 or both coronary ostia
Truncus Arteriosus
33786 Total repair, truncus arteriosus (Rastelli type operation)

33788 Reimplantation of an anomalous pulmonary artery
(For pulmonary artery band, use 33690)
Aortic Anomalies
33800 Aortic suspension (aortopexy) for tracheal decompression
(eg, for tracheomalacia) (separate procedure)
33802 Division of aberrant vessel (vascular ring);

33803 with reanastomosis
33813 Obliteration of aortopulmonary septal defect; without
33820 Repair of patent ductus arteriosus; by ligation
Patent Ductus Arteriosus
33820
The tissues surrounding the ductus are dissected away and then several heavy ligatures are passed
around the ductus and tied off on both ends.
33822 by division, younger than 18 years

33824 by division, 18 years and older

(For percutaneous transcatheter closure of patent ductus
arteriosus, use 93582)
33840 Excision of coarctation of aorta, with or without associated
patent ductus arteriosus; with direct anastomosis
33845 with graft

33851 repair using either left subclavian artery or prosthetic

material as gusset for enlargement
33852 Repair of hypoplastic or interrupted aortic arch using

autogenous or prosthetic material; without cardiopulmonary
bypass
(For repair of hypoplastic left heart syndrome (eg, Norwood

type), via excision of coarctation of aorta, use 33619)
Thoracic Aortic Aneurysm

When ascending aortic disease involves the aortic arch, an aortic
hemiarch graft may be necessary in conjunction with the
ascending aortic graft and may be reported with add-on code
33866 in conjunction with the appropriate ascending aortic graft
code (33858, 33859, 33863, 33864). Aortic hemiarch graft
requires all of the following components:
1. Either total circulatory arrest or isolated cerebral perfusion
(retrograde or antegrade);
2. Incision into the transverse arch extending under one or more
of the arch vessels (eg, innominate, left common carotid, or
left subclavian arteries); and
3. Extension of the ascending aortic graft under the aortic arch by
construction of a beveled anastomosis to the distal ascending
aorta and aortic arch without a cross-clamp (an open
anastomosis).
An ascending aortic repair with a beveled anastomosis into the
arch with a cross-clamp cannot be reported separately as a
hemiarch graft using 33866. Use 33866 for aortic hemiarch graft
when performed in conjunction with the ascending aortic graft
codes 33858, 33859, 33863, 33864. Code 33871 describes a
complete transverse arch graft placement, and is not used to
report an aortic hemiarch graft procedure.
33858 Ascending aorta graft, with cardiopulmonary bypass,
includes valve suspension, when performed; for aortic
dissection
33859 for aortic disease other than dissection (eg, aneurysm)


33863 Ascending aorta graft, with cardiopulmonary bypass, with
aortic root replacement using valved conduit and coronary
reconstruction (eg, Bentall)
➲ CPT Assistant Feb 05:14, Mar 07:1, Aug 11:3, Nov 19:9

33410, 33411, 33412, 33413, 33858, 33859)
33864 Ascending aorta graft, with cardiopulmonary bypass with
valve suspension, with coronary reconstruction and valve-
sparing aortic root remodeling (eg, David Procedure,
Yacoub Procedure)
➲ CPT Assistant Aug 11:3, Nov 19:9

33863)
✚ 33866 Aortic hemiarch graft including isolation and control of the
arch vessels, beveled open distal aortic anastomosis
extending under one or more of the arch vessels, and total
circulatory arrest or isolated cerebral perfusion (List
(Use 33866 for aortic hemiarch graft performed in
conjunction with ascending aortic graft [33858, 33859,
33863, 33864])
Aortic Root Remodeling: Coronary Arteries Reimplanted

33864
Valve-sparing aortic root replacement (code 33864)
33871 Transverse aortic arch graft, with cardiopulmonary bypass,
with profound hypothermia, total circulatory arrest and
isolated cerebral perfusion with reimplantation of arch
vessel(s) (eg, island pedicle or individual arch vessel
reimplantation)
(Do not report 33871 for aortic hemiarch graft)

(For aortic hemiarch graft performed in conjunction with
ascending aortic graft [33858, 33859, 33863, 33864], use
33866)
33875 Descending thoracic aorta graft, with or without bypass
33877 Repair of thoracoabdominal aortic aneurysm with graft, with
or without cardiopulmonary bypass
Endovascular Repair of Descending Thoracic

Aorta
Codes 33880-33891 represent a family of procedures to report
placement of an endovascular graft for repair of the descending
thoracic aorta. These codes include all device introduction,
manipulation, positioning, and deployment. All balloon
angioplasty and/or stent deployment within the target treatment
zone for the endoprosthesis, either before or after endograft
deployment, are not separately reportable.
Open arterial exposure and associated closure of the arteriotomy
sites (eg, 34714, 34715, 34716, 34812, 34820, 34833, 34834),
introduction of guidewires and catheters (eg, 36140, 36200-
36218), and extensive repair or replacement of an artery (eg,
35226, 35286) may be additionally reported. Transposition of
subclavian artery to carotid, and carotid-carotid bypass
performed in conjunction with endovascular repair of the
descending thoracic aorta (eg, 33889, 33891) may be separately
reported. The primary codes, 33880 and 33881, include
placement of all distal extensions, if required, in the distal
thoracic aorta, while proximal extensions, if needed, may be
For fluoroscopic guidance in conjunction with endovascular
repair of the thoracic aorta, see codes 75956-75959 as
appropriate. Codes 75956 and 75957 include all angiography of
the thoracic aorta and its branches for diagnostic imaging prior to
deployment of the primary endovascular devices (including all
routine components of modular devices), fluoroscopic guidance
in the delivery of the endovascular components, and
intraprocedural arterial angiography (eg, confirm position, detect
endoleak, evaluate runoff). Code 75958 includes the analogous
services for placement of each proximal thoracic endovascular
extension. Code 75959 includes the analogous services for
placement of a distal thoracic endovascular extension(s) placed
during a procedure after the primary repair.
Other interventional procedures performed at the time of
endovascular repair of the descending thoracic aorta should be
additionally reported (eg, innominate, carotid, subclavian,
visceral, or iliac artery transluminal angioplasty or stenting,
arterial embolization, intravascular ultrasound) when performed
before or after deployment of the aortic prostheses.
33880 Endovascular repair of descending thoracic aorta (eg,
aneurysm, pseudoaneurysm, dissection, penetrating ulcer,
intramural hematoma, or traumatic disruption); involving
coverage of left subclavian artery origin, initial
endoprosthesis plus descending thoracic aortic extension(s),
if required, to level of celiac artery origin
(For radiological supervision and interpretation, use 75956

in conjunction with 33880)
33881 not involving coverage of left subclavian artery origin,
initial endoprosthesis plus descending thoracic aortic
extension(s), if required, to level of celiac artery origin

33883 Placement of proximal extension prosthesis for
endovascular repair of descending thoracic aorta (eg,
intramural hematoma, or traumatic disruption); initial
extension

(Do not report 33881, 33883 when extension placement
converts repair to cover left subclavian origin. Use only
33880)
✚ 33884 each additional proximal extension (List separately in

33886 Placement of distal extension prosthesis(s) delayed after
endovascular repair of descending thoracic aorta
(Report 33886 once, regardless of number of modules
deployed)
33889 Open subclavian to carotid artery transposition performed in
conjunction with endovascular repair of descending thoracic
aorta, by neck incision, unilateral

33891 Bypass graft, with other than vein, transcervical
retropharyngeal carotid-carotid, performed in conjunction
with endovascular repair of descending thoracic aorta, by
neck incision
Pulmonary Artery
33910 Pulmonary artery embolectomy; with cardiopulmonary
bypass
33915 without cardiopulmonary bypass

33916 Pulmonary endarterectomy, with or without embolectomy,

with cardiopulmonary bypass
33917 Repair of pulmonary artery stenosis by reconstruction with
patch or graft
33920 Repair of pulmonary atresia with ventricular septal defect,

by construction or replacement of conduit from right or left
ventricle to pulmonary artery
(For repair of other complex cardiac anomalies by

construction or replacement of right or left ventricle to
pulmonary artery conduit, use 33608)
33922 Transection of pulmonary artery with cardiopulmonary
bypass
✚ 33924 Ligation and takedown of a systemic-to-pulmonary artery
shunt, performed in conjunction with a congenital heart
procedure (List separately in addition to code for primary
procedure)
33617, 33622, 33684-33688, 33692-33697, 33735-33767,
33770-33783, 33786, 33917, 33920, 33922, 33925, 33926,
33935, 33945)
33925 Repair of pulmonary artery arborization anomalies by
unifocalization; without cardiopulmonary bypass

Heart/Lung Transplantation
Heart with or without lung allotransplantation involves three
distinct components of physician work:
1. Cadaver donor cardiectomy with or without pneumonectomy,
which includes harvesting the allograft and cold preservation
of the allograft (perfusing with cold preservation solution and
cold maintenance) (see 33930, 33940).
2. Backbench work:
Preparation of a cadaver donor heart and lung allograft prior to
surrounding soft tissues to prepare the aorta, superior vena
cava, inferior vena cava, and trachea for implantation (use
33933).
Preparation of a cadaver donor heart allograft prior to
surrounding soft tissues to prepare aorta, superior vena cava,
inferior vena cava, pulmonary artery, and left atrium for
implantation (use 33944).
3. Recipient heart with or without lung allotransplantation,
which includes transplantation of allograft and care of the
recipient (see 33935, 33945).
(For implantation of a total replacement heart system
[artificial heart] with recipient cardiectomy, use 33927)
33927 Implantation of a total replacement heart system (artificial
heart) with recipient cardiectomy
▶ (Forimplantation of ventricular assist device, see 33975,

33976, 33979, 33990, 33991, 33995)◀
33928 Removal and replacement of total replacement heart system
(artificial heart)
(For revision or replacement of components only of a
replacement heart system [artificial heart], use 33999)
✚ 33929 Removal of a total replacement heart system (artificial
heart) for heart transplantation (List separately in addition to
Total Heart Implantation Device

33927, 33928, 33929
Total heart implantation device in place after cardiectomy
33930 Donor cardiectomy-pneumonectomy (including cold

preservation)
33933 Backbench standard preparation of cadaver donor heart/lung
allograft from surrounding soft tissues to prepare aorta,
superior vena cava, inferior vena cava, and trachea for
implantation
33935 Heart-lung transplant with recipient cardiectomy-

pneumonectomy
33940 Donor cardiectomy (including cold preservation)
➲ CPT Assistant Apr 05:10-11
33944 Backbench standard preparation of cadaver donor heart

allograft from surrounding soft tissues to prepare aorta,
superior vena cava, inferior vena cava, pulmonary artery,
and left atrium for implantation
(For repair or resection procedures on the donor heart, see

33300, 33310, 33320, 33390, 33463, 33464, 33510, 33641,
35216, 35276, 35685)
33945 Heart transplant, with or without recipient cardiectomy
Extracorporeal Membrane Oxygenation or

Extracorporeal Life Support Services
Prolonged extracorporeal membrane oxygenation (ECMO) or
extracorporeal life support (ECLS) is a procedure that provides
cardiac and/or respiratory support to the heart and/or lungs,
which allows them to rest and recover when sick or injured.
ECMO/ECLS supports the function of the heart and/or lungs by
continuously pumping some of the patient’s blood out of the
body to an oxygenator (membrane lung) where oxygen is added
to the blood, carbon dioxide (CO 2)is removed, and the blood is
warmed before it is returned to the patient. There are two
methods that can be used to accomplish ECMO/ECLS. One
method is veno-arterial extracorporeal life support, which will
support both the heart and lungs. Veno-arterial ECMO/ECLS
requires that two cannula(e) are placed—one in a large vein and
one in a large artery. The other method is veno-venous
extracorporeal life support. Veno-venous ECMO/ECLS is used
for lung support only and requires one or two cannula(e), which
are placed in a vein.
Services directly related to the cannulation, initiation,
management, and discontinuation of the ECMO/ECLS circuit and
parameters (33946, 33947, 33948, 33949) are distinct from the
daily overall management of the patient. The daily overall
management of the patient is a factor that will vary greatly
depending on the patient’s age, disease process, and condition.
Daily overall management of the patient may be separately
reported using the relevant hospital observation services, hospital
inpatient services, or critical care evaluation and management
codes (99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232,
99233, 99234, 99235, 99236, 99291, 99292, 99468, 99469, 99471,
99472, 99475, 99476, 99477, 99478, 99479, 99480).
Services directly related to the ECMO/ECLS involve the initial
cannulation and repositioning, removing, or adding cannula(e)
while the patient is being supported by the ECMO/ECLS.
Initiation of the ECMO/ECLS circuit and setting parameters
(33946, 33947) is performed by the physician and involves
determining the necessary ECMO/ECLS device components,
blood flow, gas exchange, and other necessary parameters to
manage the circuit. The daily management of the ECMO/ECLS
circuit and monitoring parameters (33948, 33949) requires
physician oversight to ensure that specific features of the
interaction of the circuit with the patient are met. Daily
management of the circuit and parameters includes management
of blood flow, oxygenation, CO 2 clearance by the membrane
lung, systemic response, anticoagulation and treatment of
bleeding, and cannula(e) positioning, alarms and safety. Once the
patient’s heart and/or lung function has sufficiently recovered,
the physician will wean the patient from the ECMO/ECLS circuit
and finally decannulate the patient. The basic management of the
ECMO/ECLS circuit and parameters are similar, regardless of the
patient’s condition.
ECMO/ECLS commonly involves multiple physicians and
supporting nonphysician personnel to manage each patient.
Different physicians may insert the cannula(e) and initiate
ECMO/ECLS, manage the ECMO/ECLS circuit, and decannulate
the patient. In addition, it would be common for one physician to
manage the ECMO/ECLS circuit and patient-related issues (eg,
anticoagulation, complications related to the ECMO/ECLS
devices), while another physician manages the overall patient
medical condition and underlying disorders, all on a daily basis.
The physicians involved in the patient’s care are commonly of
different specialties, and significant physician team interaction
may be required. Depending on the type of circuit and the
patient’s condition, there is substantial nonphysician work by
ECMO/ECLS specialists, cardiac perfusionists, respiratory
therapists, and specially trained nurses who provide long periods
of constant attention.
If the same physician provides any or all of the services for
placing a patient on an ECMO/ECLS circuit, they may report the
appropriate codes for the services they performed, which may
include codes for the cannula(e) insertion (33951, 33952, 33953,
33954, 33955, 33956), ECMO/ECLS initiation (33946 or 33947),
and overall patient management (99218, 99219, 99220, 99221,
99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291,
99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478,
99479, 99480).
ECMO/ECLS daily management (33948, 33949) and repositioning
services (33957, 33958, 33959, 33962, 33963, 33964) may not be
reported on the same day as initiation services (33946, 33947) by
the same or different individuals.
If different physicians provide parts of the service, each
physician may report the correct code(s) for the service(s) they
provided, except as noted.
Repositioning of the ECMO/ECLS cannula(e) (33957, 33958,
33959, 33962, 33963, 33964) at the same session as insertion
(33951, 33952, 33953, 33954, 33955, 33956) is not separately
reportable. Replacement of ECMO/ECLS cannula(e) in the same
vessel should only be reported using the insertion code (33951,
33952, 33953, 33954, 33955, 33956). If cannula(e) are removed
from one vessel and new cannula(e) are placed in a different
vessel, report the appropriate cannula(e) removal (33965, 33966,
33969, 33984, 33985, 33986) and insertion (33951, 33952, 33953,
33954, 33955, 33956) codes. Extensive repair or replacement of
an artery may be additionally reported (eg, 35266, 35286, 35371,
and 35665). Fluoroscopic guidance used for cannula(e)
repositioning (33957, 33958, 33959, 33962, 33963, 33964) is
included in the procedure when performed and should not be
Daily management codes (33948 and 33949) should not be
reported on the same day as initiation of ECMO (33946 or
33947).
Initiation codes (33946 or 33947) should not be reported on the
same day as repositioning codes (33957, 33958, 33959, 33962,
33963, 33964). See the CPT codes for ECMO/ECLS Procedure
Chart.
33946 Extracorporeal membrane oxygenation
(ECMO)/extracorporeal life support (ECLS) provided by
physician; initiation, veno-venous

33947, 33948, 33949)
(For insertion of cannula[e] for extracorporeal circulation,
see 33951, 33952, 33953, 33954, 33955, 33956)
33947 initiation, veno-arterial

33947, 33948, 33949)
33949, 33957, 33958, 33959, 33962, 33963, 33964)
33948 daily management, each day, veno-venous
33947, 33948, 33949)
33949 daily management, each day, veno-arterial

33947, 33948, 33949)
33947)
33951 insertion of peripheral (arterial and/or venous)
cannula(e), percutaneous, birth through 5 years of age
(includes fluoroscopic guidance, when performed)
(For initiation and daily management of extracorporeal

circulation, see 33946, 33947, 33948, 33949)
cannula(e), percutaneous, 6 years and older (includes
fluoroscopic guidance, when performed)
(For maintenance of extracorporeal circulation, see 33946,

33947, 33948, 33949)
cannula(e), open, birth through 5 years of age

33947, 33948, 33949)
cannula(e), open, 6 years and older

34715, 34716, 34812, 34820, 34833, 34834)
33947, 33948, 33949)
33955 insertion of central cannula(e) by sternotomy or
thoracotomy, birth through 5 years of age

33947, 33948, 33949)
33956 insertion of central cannula(e) by sternotomy or
thoracotomy, 6 years and older

39010)
33947, 33948, 33949)
33957 reposition peripheral (arterial and/or venous)
(includes fluoroscopic guidance, when performed)

cannula(e), percutaneous, 6 years and older (includes
cannula(e), open, birth through 5 years of age (includes
# 33962 reposition peripheral (arterial and/or venous)
cannula(e), open, 6 years and older (includes

34715, 34716, 34812, 34820, 34834)
# 33963 reposition of central cannula(e) by sternotomy or
thoracotomy, birth through 5 years of age (includes
# 33964 reposition central cannula(e) by sternotomy or

thoracotomy, 6 years and older (includes fluoroscopic
guidance, when performed)

39010)
(Do not report 33957, 33958, 33959, 33962, 33963, 33964
in conjunction with 33946, 33947)
# 33965 removal of peripheral (arterial and/or venous)

cannula(e), percutaneous, 6 years and older

cannula(e), open, birth through 5 years of age

34716, 34812, 34820, 34834, 35201, 35206, 35211, 35226)
CPT Codes For ECMO/ECLS Procedures
Abbreviations: Yrs indicates years; and ≥ indicates greater or equal to.

cannula(e), open, 6 years and older
34716, 34812, 34820, 34834, 35201, 35206, 35211, 35226)
# 33985 removal of central cannula(e) by sternotomy or
thoracotomy, birth through 5 years of age

# 33986 removal of central cannula(e) by sternotomy or
thoracotomy, 6 years and older

#✚ 33987 Arterial exposure with creation of graft conduit (eg, chimney
graft) to facilitate arterial perfusion for ECMO/ECLS (List

33956)
34833)
# 33988 Insertion of left heart vent by thoracic incision (eg,
sternotomy, thoracotomy) for ECMO/ECLS
# 33989 Removal of left heart vent by thoracic incision (eg,

sternotomy, thoracotomy) for ECMO/ECLS
Cardiac Assist
▶A ventricular assist device is placed to provide hemodynamic
support to the right heart, left heart, or both. The insertion of a
ventricular assist device (VAD) can be performed via
percutaneous (33990, 33991, 33995) or transthoracic (33975,
33976, 33979) approach. The location of the ventricular assist
device may be intracorporeal or extracorporeal.
Removal of a transthoracic ventricular assist device (33977,
33978, 33980) or percutaneous ventricular assist device (33992,
33997) includes removal of the entire device, including the
cannulas. Removal of a percutaneous ventricular assist device at
the same session as insertion is not separately reportable. For
removal of a percutaneous ventricular assist device at a separate
and distinct session, but on the same day as insertion, report
33992, 33997 appended with modifier 59 indicating a distinct
procedural service.◀
Repositioning of a percutaneous ventricular assist device at the
same session as insertion is not separately reportable.
Repositioning of percutaneous ventricular assist device not
necessitating imaging guidance is not a reportable service. For
repositioning of a percutaneous ventricular assist device
necessitating imaging guidance at a separate and distinct session,
but on the same day as insertion, report 33993 with modifier 59
indicating a distinct procedural service.
Replacement of a ventricular assist device pump (ie, 33981-
33983) includes the removal of the pump and insertion of a new
pump, connection, de-airing, and initiation of the new pump.
▶Replacement of the entire implantable ventricular assist device
system, ie, pump(s) and cannulas, is reported using the insertion
codes (ie, 33975, 33976, 33979). Removal (ie, 33977, 33978,
33980) of the ventricular assist device system being replaced is
not separately reported. Replacement of a percutaneous
ventricular assist device is reported using implantation codes (ie,
33990, 33991, 33995). Removal (ie, 33992, 33997) is not reported
separately when a device is replaced.◀
33967 Insertion of intra-aortic balloon assist device, percutaneous
➲ CPT Assistant Feb 02:2, Nov 11:8, Mar 13:10, Sep
15:3, Mar 16:5
33968 Removal of intra-aortic balloon assist device, percutaneous
➲ CPT Assistant Nov 99:19, Jan 00:10, Nov 11:8
(For removal of implantable aortic counterpulsation

ventricular assist system, see 0455T, 0456T, 0457T, 0458T)
33970 Insertion of intra-aortic balloon assist device through the
femoral artery, open approach
➲ CPT Assistant Nov 99:19, Nov 11:8, Mar 13:10, Sep
15:3, Mar 16:5
(For insertion or replacement of implantable aortic
counterpulsation ventricular assist system, see 0451T,
0452T, 0453T, 0454T)
33971 Removal of intra-aortic balloon assist device including
repair of femoral artery, with or without graft

33973 Insertion of intra-aortic balloon assist device through the
ascending aorta
➲ CPT Assistant Nov 11:8, Mar 13:10, Sep 15:3, Mar 16:5

0452T, 0453T, 0454T)
33974 Removal of intra-aortic balloon assist device from the
ascending aorta, including repair of the ascending aorta,
with or without graft

33975 Insertion of ventricular assist device; extracorporeal, single
ventricle
➲ CPT Assistant Feb 92:2, Jan 04:28, Nov 09:10, Jan
10:11, Apr 10:6, Mar 13:10
33976 extracorporeal, biventricular
➲ CPT Assistant Feb 02:2, Nov 09:10, Jan 10:11, Apr
10:6, Mar 13:10
33977 Removal of ventricular assist device; extracorporeal, single
ventricle
10:6, Mar 13:10
33978 extracorporeal, biventricular
10:6, Mar 13:10
33979 Insertion of ventricular assist device, implantable
intracorporeal, single ventricle
➲ CPT Assistant Feb 02:3, Jan 04:28, Nov 09:10, Jan
10:11, Apr 10:6, Mar 13:10
0452T, 0453T, 0454T)
33980 Removal of ventricular assist device, implantable
intracorporeal, single ventricle
➲ CPT Assistant Feb 02:3, Nov 09:10, Apr 10:6, Mar
13:10
33981 Replacement of extracorporeal ventricular assist device,
single or biventricular, pump(s), single or each pump
33982 Replacement of ventricular assist device pump(s);

implantable intracorporeal, single ventricle, without
33983 implantable intracorporeal, single ventricle, with

0452T, 0453T, 0454T)
#● 33995 Insertion of ventricular assist device, percutaneous,
including radiological supervision and interpretation; right
heart, venous access only
▲ 33990 left heart, arterial access only

➲ CPT Assistant Mar 13:10, Oct 14:15, Sep 15:3, Mar
16:5
Insertion of Implantable Single Ventricle Assist Device

33979
▲ 33991 left heart, both arterial and venous access, with
transseptal puncture
➲ CPT Assistant Mar 13:10, Sep 15:3, Mar 16:5

0452T, 0453T, 0454T)
▲ 33992 Removal of percutaneous left heart ventricular assist device,
arterial or arterial and venous cannula(s), at separate and
distinct session from insertion

#● 33997 Removal of percutaneous right heart ventricular assist
device, venous cannula, at separate and distinct session
from insertion
▶ (Forremoval of left or right heart ventricular assist device

via open approach, see appropriate vessel repair code [eg,
35206, 35226, 35286, 35371])◀
▲ 33993 Repositioning of percutaneous right or left heart ventricular
assist device with imaging guidance at separate and distinct
session from insertion
(For relocating and repositioning of implantable aortic

0460T, 0461T)
Other Procedures
33999 Unlisted procedure, cardiac surgery
➲ CPT Assistant Oct 99:11, Jan 04:7, Mar 07:1, Nov
09:10, Jan 10:11, Apr 10:6, Feb 13:13, Mar 13:10, Dec
13:14, Dec 14:17, Apr 19:10
Arteries and Veins

Primary vascular procedure listings include establishing both
inflow and outflow by whatever procedures necessary. Also
included is that portion of the operative arteriogram performed
by the surgeon, as indicated. Sympathectomy, when done, is
included in the listed aortic procedures. For unlisted vascular
procedure, use 37799.
Embolectomy/Thrombectomy
Arterial, With or Without Catheter
34001 Embolectomy or thrombectomy, with or without catheter;
carotid, subclavian or innominate artery, by neck incision
34051 innominate, subclavian artery, by thoracic incision
34101 axillary, brachial, innominate, subclavian artery, by arm
incision
34111 radial or ulnar artery, by arm incision
34151 renal, celiac, mesentery, aortoiliac artery, by abdominal
incision
34201 femoropopliteal, aortoiliac artery, by leg incision
34203 popliteal-tibio-peroneal artery, by leg incision
Venous, Direct or With Catheter

34401 Thrombectomy, direct or with catheter; vena cava, iliac
vein, by abdominal incision
34421 vena cava, iliac, femoropopliteal vein, by leg incision
34451 vena cava, iliac, femoropopliteal vein, by abdominal and

leg incision
34471 subclavian vein, by neck incision
34490 axillary and subclavian vein, by arm incision
Venous Reconstruction
34501 Valvuloplasty, femoral vein
34502 Reconstruction of vena cava, any method
34510 Venous valve transposition, any vein donor
34520 Cross-over vein graft to venous system
34530 Saphenopopliteal vein anastomosis
Endovascular Repair of Abdominal Aorta and/or

Iliac Arteries
Codes 34701, 34702, 34703, 34704, 34705, 34706 describe
introduction, positioning, and deployment of an endograft for
treatment of abdominal aortic pathology (with or without
rupture), such as aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, or traumatic disruption in the infrarenal
abdominal aorta with or without extension into the iliac
artery(ies). The terms, endovascular graft, endoprosthesis,
endograft, and stentgraft, refer to a covered stent. The infrarenal
aortic endograft may be an aortic tube device, a bifurcated
unibody device, a modular bifurcated docking system with
docking limb(s), or an aorto-uni-iliac device. Codes 34707 and
34708 describe introduction, positioning, and deployment of an
ilio-iliac endograft for treatment of isolated arterial pathology
(with or without rupture), such as aneurysm, pseudoaneurysm,
arteriovenous malformation, or trauma involving the iliac artery.
For treatment of atherosclerotic occlusive disease in the iliac
artery(ies) with a covered stent(s), see 37221, 37223. For covered
stent placement for atherosclerotic occlusive disease in the aorta,
see 37236, 37237.
Add-on code 34717 is reported at the time of aorto-iliac artery
endograft placement (34703, 34704, 34705, 34706) for
deployment of a bifurcated endograft in the common iliac artery
with extension(s) into both the internal iliac and external iliac
arteries, when performed, to maintain perfusion in both vessels
for treatment of iliac artery pathology (with or without rupture),
such as aneurysm, pseudoaneurysm, dissection, penetrating ulcer,
arteriovenous malformation, or traumatic disruption. The iliac
branched endograft is a multi-piece system consisting of a
bifurcated device that is placed in the common iliac artery and
then additional extension(s) are placed into both the internal iliac
artery and external iliac/common femoral arteries as needed, as
well as a proximal extension that overlaps with an aorto-iliac
endograft, when performed. All additional extensions proximally
into the common iliac artery or distally into the external iliac
and/or common femoral arteries are inherent to these codes.
Report 34705 or 34706 for simultaneous bilateral iliac artery
aneurysm repairs with aorto-bi-iliac endograft. For isolated
bilateral iliac artery repair using iliac artery tube endografts,
report 34707 or 34708 with modifier 50 appended.
Decompressive laparotomy for abdominal compartment
syndrome after ruptured abdominal aortic and/or iliac artery
aneurysm repair may be separately reported with 49000 in
addition to 34702, 34704, 34706, or 34708.
The treatment zone for endograft procedures is defined by those
vessels that contain an endograft(s) (main body, docking limb[s],
and/or extension[s]) deployed during that operative session.
Adjunctive procedures outside the treatment zone may be
separately reported (eg, angioplasty, endovascular stent
placement, embolization). For example, when an endograft
terminates in the common iliac artery, any additional treatment
performed in the external and/or internal iliac artery may be
separately reportable. Placement of a docking limb is inherent to
a modular endograft(s), and, therefore, 34709 may not be
reported separately if the docking limb extends into the external
iliac artery. In addition, any interventions (eg, angioplasty,
stenting, additional stent graft extension[s]) in the external iliac
artery where the docking limb terminates may not be reported
separately. Any catheterization or treatment of the internal iliac
artery, such as embolization, may be separately reported. For
34701 and 34702, the abdominal aortic treatment zone is defined
as the infrarenal aorta. For 34703 and 34704, the abdominal aortic
treatment zone is typically defined as the infrarenal aorta and
ipsilateral common iliac artery. For 34705 and 34706, the
abdominal aortic treatment zone is typically defined as the
infrarenal aorta and both common iliac arteries. For 34707,
34708, 34717, 34718, the treatment zone is defined as the portion
of the iliac artery(ies) (eg, common, internal, external iliac
arteries) that contains the endograft.
Codes 34702, 34704, 34706, 34708 are reported when
endovascular repair is performed on ruptured aneurysm in the
aorta or iliac artery(ies). Rupture is defined as clinical and/or
radiographic evidence of acute hemorrhage for purposes of
reporting these codes. A chronic, contained rupture is considered
a pseudoaneurysm, and endovascular treatment of a chronic,
contained rupture is reported with 34701, 34703, 34705, or 34707.
Code 34709 is reported for placement of extension prosthesis(es)
that terminate(s) either in the internal iliac, external iliac, or
common femoral artery(ies) or in the abdominal aorta proximal
to the renal artery(ies) in conjunction with 34701, 34702, 34703,
34704, 34705, 34706, 34707, 34708. Code 34709 may only be
reported once per vessel treated (ie, multiple endograft extensions
placed in a single vessel may only be reported once). Endograft
extension(s) that terminate(s) in the common iliac arteries are
included in 34703, 34704, 34705, 34706, 34707, 34708 and are not
separately reported. Treatment zone angioplasty/stenting, when
performed, is included in 34709. In addition, proximal infrarenal
abdominal aortic extension prosthesis(es) that terminate(s) in the
aorta below the renal artery(ies) are also included in 34701,
34702, 34703, 34704, 34705, 34706 and are not separately
reportable.
Codes 34710, 34711 are reported for delayed placement of distal
or proximal extension prosthesis(es) for endovascular repair of
infrarenal abdominal aortic or iliac aneurysm, false aneurysm,
dissection, endoleak, or endograft migration. Pre-procedure
sizing and device selection, all nonselective catheterization(s), all
associated radiological supervision and interpretation, and
treatment zone angioplasty/stenting, when performed, are
included in 34710 and 34711. Codes 34710 and 34711 may only
be reported once per vessel treated (ie, multiple endograft
extensions placed in a single vessel may only be reported once).
If an aorto-iliac artery endograft (34703, 34704, 34705, 34706) is
not being placed during the same operative session, 34718 may
be reported for placement of a bifurcated endograft in the
common iliac artery with extension(s) into both the internal iliac
and external iliac arteries, to maintain perfusion in both vessels
for treatment of iliac artery pathology (without rupture), such as
aneurysm, pseudoaneurysm, dissection, arteriovenous
malformation. The iliac branched endograft is a multi-piece
system consisting of a bifurcated device that is placed in the
common iliac artery and then additional extension(s) are placed
into both the internal iliac artery and external iliac/common
femoral arteries as needed as well as a proximal extension that
overlaps with an aorto-iliac endograft, when performed. All
additional extensions placed proximally into the common iliac
artery or distally into the external iliac and/or common femoral
arteries are inherent to these codes. For isolated bilateral iliac
artery repair using iliac artery branched endografts, use 34718
with modifier 50 appended.
Codes 34709, 34710, 34711 may not be separately reported with
34717, 34718 for ipsilateral extension prosthesis(es). However,
34709, 34710, 34711 may be reported separately for extension
prosthesis(es) in the iliac/femoral arteries contralateral to the iliac
branched endograft.
Nonselective catheterization is included in 34701, 34702, 34703,
34704, 34705, 34706, 34707, 34708 and is not separately reported.
However, selective catheterization of the hypogastric artery(ies),
renal artery(ies), and/or arterial families outside the treatment
zone of the endograft may be separately reported. Intravascular
ultrasound (37252, 37253) performed during endovascular
aneurysm repair may be separately reported. Balloon angioplasty
and/or stenting within the treatment zone of the endograft, either
before or after endograft deployment, is not separately reported.
Fluoroscopic guidance and radiological supervision and
interpretation in conjunction with endograft repair is not
separately reported, and includes all intraprocedural imaging (eg,
angiography, rotational CT) of the aorta and its branches prior to
deployment of the endovascular device, fluoroscopic guidance
and roadmapping used in the delivery of the endovascular
components, and intraprocedural and completion angiography
(eg, confirm position, detect endoleak, evaluate runoff)
performed at the time of the endovascular infrarenal aorta and/or
iliac repair.
Selective arterial catheterization of the internal and external iliac
arteries (eg, 36245, 36246, 36247, 36248) ipsilateral to an iliac
branched endograft is included in 34717, 34718 and not
separately reported. However, selective catheterization of the
renal artery(ies), the contralateral hypogastric artery, and/or
arterial families outside the treatment zone of the graft may be
separately reported. Intravascular ultrasound (37252, 37253)
performed during endovascular aneurysm repair may be
separately reported. Balloon angioplasty within the target
treatment zone of the endograft, either before or after endograft
deployment, is not separately reported. Fluoroscopic guidance
and radiological supervision and interpretation performed in
conjunction with endovascular iliac branched repair is not
separately reported. Endovascular iliac branched repair includes
all intraprocedural imaging (eg, angiography, rotational CT) of
the aorta and its branches prior to deployment of the
endovascular device, fluoroscopic guidance in the delivery of the
endovascular components, and intraprocedural arterial
angiography (eg, confirm position, detect endoleak, evaluate
runoff) performed at the time of the endovascular aorto-iliac
repair).
Codes 34709, 34710, 34711 include nonselective introduction of
guidewires and catheters into the treatment zone from peripheral
artery access(es). However, selective catheterization of the
hypogastric artery(ies), renal artery(ies), and/or arterial families
outside the treatment zone may be separately reported. Codes
34709, 34710, 34711 also include balloon angioplasty and/or
stenting within the treatment zone of the endograft extension,
either before or after deployment of the endograft, fluoroscopic
guidance, and all associated radiological supervision and
interpretation performed in conjunction with endovascular
endograft extension (eg, angiographic diagnostic imaging of the
aorta and its branches prior to deployment of the endovascular
device, fluoroscopic guidance in the delivery of the endovascular
components, and intraprocedural and completion angiography to
confirm endograft position, detect endoleak, and evaluate
runoff).
Code 34712 describes transcatheter delivery of accessory-
enhanced fixation devices to the endograft (eg, anchor, screw,
tack), including all associated radiological supervision and
interpretation. Code 34712 may only be reported once per
operative session.
Vascular access requiring use of closure devices for large sheaths
(ie, 12 French or larger) or access requiring open surgical arterial
exposure may be separately reported (eg, 34713, 34714, 34715,
34716, 34812, 34820, 34833, 34834). Code 34713 describes
percutaneous access and closure of a femoral arteriotomy for
delivery of endovascular prosthesis through a large arterial sheath
(ie, 12 French or larger). Ultrasound guidance (ie, 76937), when
performed, is included in 34713. (Percutaneous access using a
sheath smaller than 12 French is included in 34701-34712 and is
not separately reported.)
Code 34812 describes open repair and closure of the femoral
artery. Extensive repair of an artery (eg, 35226, 35286, 35371)
may also be reported separately. Iliac exposure for device
delivery through a retroperitoneal incision, open brachial
exposure, or axillary or subclavian exposure through an
infraclavicular, or supraclavicular or sternotomy incision during
endovascular aneurysm repair may be separately reported (eg,
34715, 34812, 34820, 34834). Endovascular device delivery or
establishment of cardiopulmonary bypass that requires creation
of a prosthetic conduit utilizing a femoral artery, iliac artery with
a retroperitoneal incision, or axillary or subclavian artery
exposure through an infraclavicular, supraclavicular, or
sternotomy incision (34714, 34716, 34833) and oversewing of the
conduit at the time of procedure completion may be separately
reported during endovascular aneurysm repair or cardiac
procedures requiring cardiopulmonary bypass. If a conduit is
converted to a bypass, report the bypass (eg, 35665) and not the
arterial exposure with conduit (34714, 34716, 34833). Arterial
embolization(s) of renal, lumbar, inferior mesenteric, hypogastric
or external iliac arteries to facilitate complete endovascular
aneurysm exclusion may be separately reported (eg, 37242).
Balloon angioplasty and/or stenting at the sealing zone(s) of an
endograft is an integral part of the procedure and is not separately
reported. However, balloon angioplasty and/or stent deployment
in vessels that do not contain endograft (outside the treatment
zone for the endograft), either before or after endograft
deployment, may be separately reported (eg, 37220, 37221,
37222, 37223).
endovascular abdominal aortic aneurysm repair may be
additionally reported (eg, renal transluminal angioplasty, arterial
embolization, intravascular ultrasound, balloon angioplasty or
stenting of native artery[s] outside the endograft treatment zone,
when done before or after deployment of endograft).
(For fenestrated endovascular repair of the visceral aorta,
see 34841-34844. For fenestrated endovascular repair of
the visceral aorta and concomitant infrarenal abdominal
aorta, see 34845-34848)
34701 Endovascular repair of infrarenal aorta by deployment of an
aorto-aortic tube endograft including pre-procedure sizing
and device selection, all nonselective catheterization(s), all
associated radiological supervision and interpretation, all
endograft extension(s) placed in the aorta from the level of
the renal arteries to the aortic bifurcation, and all
angioplasty/stenting performed from the level of the renal
arteries to the aortic bifurcation; for other than rupture (eg,
for aneurysm, pseudoaneurysm, dissection, penetrating
ulcer)
(For covered stent placement[s] for atherosclerotic

occlusive disease isolated to the aorta, see 37236, 37237)
34702 for rupture including temporary aortic and/or iliac
balloon occlusion, when performed (eg, for aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, traumatic
disruption)
34703 Endovascular repair of infrarenal aorta and/or iliac

artery(ies) by deployment of an aorto-uni-iliac endograft
including pre-procedure sizing and device selection, all
nonselective catheterization(s), all associated radiological
supervision and interpretation, all endograft extension(s)
placed in the aorta from the level of the renal arteries to the
iliac bifurcation, and all angioplasty/stenting performed
from the level of the renal arteries to the iliac bifurcation;
for other than rupture (eg, for aneurysm, pseudoaneurysm,
dissection, penetrating ulcer)

disruption)
34705 Endovascular repair of infrarenal aorta and/or iliac

artery(ies) by deployment of an aorto-bi-iliac endograft
supervision and interpretation, all endograft extension(s)
placed in the aorta from the level of the renal arteries to the
iliac bifurcation, and all angioplasty/stenting performed
from the level of the renal arteries to the iliac bifurcation;
for other than rupture (eg, for aneurysm, pseudoaneurysm,
dissection, penetrating ulcer)

disruption)
34707 Endovascular repair of iliac artery by deployment of an ilio-

iliac tube endograft including pre-procedure sizing and
device selection, all nonselective catheterization(s), all
all endograft extension(s) proximally to the aortic
bifurcation and distally to the iliac bifurcation, and treatment
zone angioplasty/stenting, when performed, unilateral; for
other than rupture (eg, for aneurysm, pseudoaneurysm,
dissection, arteriovenous malformation)
occlusive disease of the abdominal aorta, see 37236,
37237)
occlusive disease of the iliac artery, see 37221, 37223)
pseudoaneurysm, dissection, arteriovenous
malformation, traumatic disruption)
(For endovascular repair of iliac artery by deployment of an

iliac branched endograft, see 34717, 34718)
#✚ 34717 Endovascular repair of iliac artery at the time of aortoiliac
artery endograft placement by deployment of an iliac
branched endograft including pre-procedure sizing and
device selection, all ipsilateral selective iliac artery
catheterization(s), all associated radiological supervision
and interpretation, and all endograft extension(s) proximally
to the aortic bifurcation and distally in the internal iliac,
external iliac, and common femoral artery(ies), and
treatment zone angioplasty/stenting, when performed, for
rupture or other than rupture (eg, for aneurysm,
pseudoaneurysm, dissection, arteriovenous malformation,
penetrating ulcer, traumatic disruption), unilateral (List

34706)
(34717 may only be reported once per side. For bilateral
procedure, report 34717 twice. Do not report modifier 50 in
(Do not report 34717 in conjunction with 34709 on the same
side)
(For placement of an iliac branched endograft at a separate
setting than aorto-iliac endograft placement, use 34718)
✚ 34709 Placement of extension prosthesis(es) distal to the common
iliac artery(ies) or proximal to the renal artery(ies) for
endovascular repair of infrarenal abdominal aortic or iliac
aneurysm, false aneurysm, dissection, penetrating ulcer,
supervision and interpretation, and treatment zone
angioplasty/stenting, when performed, per vessel treated

34704, 34705, 34706, 34707, 34708, 34845, 34846, 34847,
34848)
(34709 may only be reported once per vessel treated [ie,
multiple endograft extensions placed in a single vessel may
only be reported once])
(Do not report 34709 for placement of a docking limb that
extends into the external iliac artery)
(For placement of an iliac branched endograft, see 34717,
34718)
(For endograft placement into a renal artery that is being
covered by a proximal extension, see 37236, 37237)
Endovascular Repair
34705, 34706, 34709, 34710, 34711
Endovascular repair of abdominal aorta and/or iliac arteries
# 34718 Endovascular repair of iliac artery, not associated with

placement of an aorto-iliac artery endograft at the same
session, by deployment of an iliac branched endograft,
ipsilateral selective iliac artery catheterization(s), all
all endograft extension(s) proximally to the aortic
bifurcation and distally in the internal iliac, external iliac,
and common femoral artery(ies), and treatment zone
angioplasty/stenting, when performed, for other than rupture
(eg, for aneurysm, pseudoaneurysm, dissection,
arteriovenous malformation, penetrating ulcer), unilateral
(For bilateral placement of an iliac branched endograft,

report modifier 50)
Endovascular Repair
34717, 34718
A. Placement of iliac branch endoprosthesis (IBE) associated with placement of aorto-bi-iliac artery
endoprosthesis (same session)
B. Placement of IBE, not associated with placement of aorto-bi-iliac endoprosthesis (different session)
34703, 34704, 34705, 34706, 34707, 34708, 34709, 34717)
(Do not report 34718 in conjunction with 34710, 34711 on
the same side)
(For placement of an iliac branched endograft in the same
setting as aorto-iliac endograft placement, use 34717)
(For placement of an isolated iliac branched endograft for
rupture, use 37799)
34710 Delayed placement of distal or proximal extension
prosthesis for endovascular repair of infrarenal abdominal
aortic or iliac aneurysm, false aneurysm, dissection,
endoleak, or endograft migration, including pre-procedure
sizing and device selection, all nonselective
catheterization(s), all associated radiological supervision
and interpretation, and treatment zone angioplasty/stenting,
when performed; initial vessel treated
✚ 34711 each additional vessel treated (List separately in


(34710, 34711 may each be reported only once per
operative session [ie, multiple endograft extensions placed
in a single vessel may only be reported with a single code])
(For decompressive laparotomy, use 49000 in conjunction
with 34702, 34704, 34706, 34708, 34710)
(If the delayed revision is a transcatheter enhanced fixation
device [eg, anchors, screws], report 34712)
34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709)
(Do not report 34710, 34711 in conjunction with 34718 on
the same side)
34842, 34843, 34844, 34845, 34846, 34847, 34848)
(For endovascular repair of iliac artery bifurcation [eg,
aneurysm, pseudoaneurysm, arteriovenous malformation,
trauma] using bifurcated endograft, see 34717, 34718)
(Report 37252, 37253 for intravascular ultrasound when
performed during endovascular aneurysm repair)
(For isolated bilateral iliac artery repair using iliac artery
tube endografts, report 34707 or 34708 with modifier 50)
(For open arterial exposure, report 34714, 34715, 34716,
34812, 34820, 34833, 34834 as appropriate, in conjunction
with 34701, 34702, 34703, 34704, 34705, 34706, 34707,
34708, 34710, 34712, 34718)
(For percutaneous arterial closure, report 34713 as
appropriate, in conjunction with 34701, 34702, 34703,
34704, 34705, 34706, 34707, 34708, 34710, 34712, 34718)
(For simultaneous bilateral iliac artery aneurysm repairs
with aorto-biiliac endograft, see 34705, 34706, as
appropriate)
34712 Transcatheter delivery of enhanced fixation device(s) to the
endograft (eg, anchor, screw, tack) and all associated
radiological supervision and interpretation
(Report 34712 only once per operative session)

✚ 34713 Percutaneous access and closure of femoral artery for
delivery of endograft through a large sheath (12 French or
larger), including ultrasound guidance, when performed,
unilateral (List separately in addition to code for primary
procedure)

33884, 33886, 34701, 34702, 34703, 34704, 34705, 34706,
34707, 34708, 34710, 34712, 34718, 34841, 34842, 34843,
34844, 34845, 34846, 34847, 34848, as appropriate. Do not
report 34713 in conjunction with 33880, 33881, 33883,
33884, 33886, 34701, 34702, 34703, 34704, 34705, 34706,
34707, 34708, 34710, 34712, 34718, 34841, 34842, 34843,
34844, 34845, 34846, 34847, 34848, for percutaneous
closure of femoral artery after delivery of endovascular
prosthesis if a sheath smaller than 12 French was used)
(Do not report ultrasound guidance [ie, 76937] for
percutaneous vascular access in conjunction with 34713 for
the same access)
(Do not report 34713 for percutaneous access and closure of
the femoral artery in conjunction with 37221, 37223, 37236,
37237)
(Do not report 34713 in conjunction with 37221, 37223 for
covered stent placement[s] for atherosclerotic occlusive
disease of the iliac artery[ies])
#✚ 34812 Open femoral artery exposure for delivery of endovascular
prosthesis, by groin incision, unilateral (List separately in
➲ CPT Assistant Dec 00:6, Sep 02:3, Feb 03:2, Mar 04:10,
Jul 06:7, Mar 13:10, Dec 13:8, Dec 17:3

33884, 33886, 33990, 33991, 34701, 34702, 34703, 34704,
34705, 34706, 34707, 34708, 34710, 34712, 34718, 34841,
34842, 34843, 34844, 34845, 34846, 34847, 34848)
33959, 33962, 33969, 33984, 33987)
✚ 34714 Open femoral artery exposure with creation of conduit for
delivery of endovascular prosthesis or for establishment of
cardiopulmonary bypass, by groin incision, unilateral (List
33120, 33251, 33256, 33259, 33261, 33305, 33315, 33322,
33335, 33390, 33391, 33404, 33405, 33406, 33410, 33411,
33412, 33413, 33414, 33415, 33416, 33417, 33422, 33425,
33426, 33427, 33430, 33440, 33460, 33463, 33464, 33465,
33468, 33474, 33475, 33476, 33478, 33496, 33500, 33502,
33504, 33505, 33506, 33507, 33510, 33511, 33512, 33513,
33514, 33516, 33533, 33534, 33535, 33536, 33542, 33545,
33548, 33600-33688, 33692, 33694, 33697, 33702, 33710,
33720, 33722, 33724, 33726, 33730, 33732, 33736, 33750,
33755, 33762, 33764, 33766, 33767, 33770-33783, 33786,
33788, 33802, 33803, 33814, 33820, 33822, 33824, 33840,
33845, 33851, 33853, 33858, 33859, 33863, 33864, 33871,
33875, 33877, 33880, 33881, 33883, 33884, 33886, 33910,
33916, 33917, 33920, 33922, 33926, 33935, 33945, 33975,
33976, 33977, 33978, 33979, 33980, 33983, 33990, 33991,
34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708,
34710, 34712, 34718, 34841, 34842, 34843, 34844, 34845,
34846, 34847, 34848)
33954, 33959, 33962, 33969, 33984, 34812 when
performed on the same side)
#✚ 34820 Open iliac artery exposure for delivery of endovascular
prosthesis or iliac occlusion during endovascular therapy,
by abdominal or retroperitoneal incision, unilateral (List
➲ CPT Assistant Dec 00:7-8, Sep 02:3, Feb 03:4, Aug
04:10, Jul 06:7, Dec 17:3
33884, 33886, 33990, 33991, 34701, 34702, 34703, 34704,
34705, 34706, 34707, 34708, 34710, 34712, 34718, 34841,
34842, 34843, 34844, 34845, 34846, 34847, 34848)
33959, 33962, 33969, 33984)
#✚ 34833 Open iliac artery exposure with creation of conduit for
delivery of endovascular prosthesis or for establishment of
cardiopulmonary bypass, by abdominal or retroperitoneal
incision, unilateral (List separately in addition to code for
primary procedure)
➲ CPT Assistant Feb 03:4, Aug 04:10, Jul 06:7, Dec 17:3

33120, 33251, 33256, 33259, 33261, 33305, 33315, 33322,
33335, 33390, 33391, 33404, 33405, 33406, 33410, 33411,
33412, 33413, 33414, 33415, 33416, 33417, 33422, 33425,
33426, 33427, 33430, 33440, 33460, 33463, 33464, 33465,
33468, 33474, 33475, 33476, 33478, 33496, 33500, 33502,
33504, 33505, 33506, 33507, 33510, 33511, 33512, 33513,
33514, 33516, 33533, 33534, 33535, 33536, 33542, 33545,
33548, 33600-33688, 33692, 33694, 33697, 33702, 33710,
33720, 33722, 33724, 33726, 33730, 33732, 33736, 33750,
33755, 33762, 33764, 33766, 33767, 33770-33783, 33786,
33788, 33802, 33803, 33814, 33820, 33822, 33824, 33840,
33845, 33851, 33853, 33858, 33859, 33863, 33864, 33871,
33875, 33877, 33880, 33881, 33883, 33884, 33886, 33910,
33916, 33917, 33920, 33922, 33926, 33935, 33945, 33975,
33976, 33977, 33978, 33979, 33980, 33983, 33990, 33991,
34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708,
34710, 34712, 34718, 34841, 34842, 34843, 34844, 34845,
34846, 34847, 34848)
33954, 33959, 33962, 33969, 33984, 34820 when
performed on the same side)
#✚ 34834 Open brachial artery exposure for delivery of endovascular
prosthesis, unilateral (List separately in addition to code for
primary procedure)
➲ CPT Assistant Feb 03:4, Jul 06:7, Dec 17:3

33884, 33886, 33990, 33991, 34701, 34702, 34703, 34704,
34705, 34706, 34707, 34708, 34710, 34712, 34718, 34841,
34842, 34843, 34844, 34845, 34846, 34847, 34848)
33959, 33962, 33969, 33984)
✚ 34715 Open axillary/subclavian artery exposure for delivery of
endovascular prosthesis by infraclavicular or
supraclavicular incision, unilateral (List separately in

33884, 33886, 33990, 33991, 34701, 34702, 34703, 34704,
34705, 34706, 34707, 34708, 34710, 34712, 34718, 34841,
34842, 34843, 34844, 34845, 34846, 34847, 34848)
33954, 33959, 33962, 33969, 33984, 0451T, 0452T, 0455T,
0456T)
✚ 34716 Open axillary/subclavian artery exposure with creation of
conduit for delivery of endovascular prosthesis or for
establishment of cardiopulmonary bypass, by infraclavicular
or supraclavicular incision, unilateral (List separately in

33120, 33251, 33256, 33259-33261, 33305, 33315, 33322,
33335, 33390, 33391, 33404, 33405, 33406, 33410, 33411,
33412, 33413, 33414, 33415, 33416, 33417, 33422, 33425,
33426, 33427, 33430, 33440, 33460, 33463, 33464, 33465,
33468, 33474, 33475, 33476, 33478, 33496, 33500, 33502,
33504, 33505, 33506, 33507, 33510, 33511, 33512, 33513,
33514, 33516, 33533, 33534, 33535, 33536, 33542, 33545,
33548, 33600-33688, 33692, 33694, 33697, 33702-33722,
33724, 33726, 33730, 33732, 33736, 33750, 33755, 33762,
33764, 33766, 33767, 33770-33783, 33786, 33788, 33802,
33803, 33814, 33820, 33822, 33824, 33840, 33845, 33851,
33853, 33858, 33859, 33863, 33864, 33871, 33875, 33877,
33880, 33881, 33883, 33884, 33886, 33910, 33916, 33917,
33920, 33922, 33926, 33935, 33945, 33975, 33976, 33977,
33978, 33979, 33980, 33983, 33990, 33991, 34701, 34702,
34703, 34704, 34705, 34706, 34707, 34708, 34710, 34712,
34718, 34841, 34842, 34843, 34844, 34845, 34846, 34847,
34848)
33959, 33962, 33969, 33984, 0451T, 0452T, 0455T,
0456T)
✚ 34808 Endovascular placement of iliac artery occlusion device
➲ CPT Assistant Dec 00:6, Sep 02:3, Apr 12:3

34704, 34707, 34708, 34709, 34710, 34813, 34841, 34842,
34843, 34844)
✚ 34813 Placement of femoral-femoral prosthetic graft during
endovascular aortic aneurysm repair (List separately in
➲ CPT Assistant Dec 00:6, Sep 02:3, Apr 12:3

(For femoral artery grafting, see 35521, 35533, 35539,
35540, 35556, 35558, 35566, 35621, 35646, 35654-35661,
35666, 35700)
34830 Open repair of infrarenal aortic aneurysm or dissection, plus
repair of associated arterial trauma, following unsuccessful
endovascular repair; tube prosthesis
➲ CPT Assistant Dec 00:6, Sep 02:3, Oct 08:10
34831 aorto-bi-iliac prosthesis
34832 aorto-bifemoral prosthesis


Fenestrated Endovascular Repair of the Visceral

and Infrarenal Aorta
The upper abdominal aorta that contains the celiac, superior
mesenteric, and renal arteries is termed the visceral aorta. For
reporting purposes, the thoracic aorta extends from the aortic
valve to the aortic segment just proximal to the celiac artery.
Code 34839 is used to report the physician planning and sizing
for a patient-specific fenestrated visceral aortic endograft. The
planning includes review of high-resolution cross-sectional
images (eg, CT, CTA, MRI) and utilization of 3D software for
iterative modeling of the aorta and device in multiplanar views
and center line of flow analysis. Code 34839 may only be
reported when the physician spends a minimum of 90 total
minutes performing patient-specific fenestrated endograft
planning. Physician planning time does not need to be
continuous and should be clearly documented in the patient
record. Code 34839 is reported on the date that planning work is
complete and may not include time spent on the day before or the
day of the fenestrated endovascular repair procedure (34841,
34842, 34843, 34844, 34845, 34846, 34847, 34848) nor be
reported on the day before or the day of the fenestrated
endovascular repair procedure.
Codes 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848
are used to report placement of a fenestrated endovascular graft
in the visceral aorta, either alone or in combination with the
infrarenal aorta for aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic disruption.
The fenestrated main body endoprosthesis is deployed within the
visceral aorta. Fenestrations within the fabric allow for selective
catheterization of the visceral and/or renal arteries and
subsequent placement of an endoprosthesis (ie, bare metal or
covered stent) to maintain flow to the visceral artery. Patient
variation in the location and relative orientation of the renal and
visceral artery origins requires use of a patient-specific
fenestrated endograft for endovascular repair that preserves flow
to essential visceral arteries and allows proximal seal and fixation
to be achieved above the renal level as well as in the distal aorta
or iliac vessel(s).
Fenestrated aortic repair is reported based on the extent of aorta
treated. Codes 34841, 34842, 34843, 34844 describe repair using
proximal endoprostheses that span from the visceral aortic
component to one, two, three, or four visceral artery origins and
distal extent limited to the infrarenal aorta. These devices do not
extend into the common iliac arteries. Codes 34845, 34846,
34847, 34848 are used to report deployment of a fenestrated
endograft that spans from the visceral aorta (including one, two,
three, or four visceral artery origins) through the infrarenal aorta
into the common iliac arteries. The infrarenal component may be
a bifurcated unibody device, a modular bifurcated docking
system with docking limb(s), or an aorto-uniiliac device. Codes
34845, 34846, 34847, 34848 include placement of unilateral or
bilateral docking limbs (depending on the device). Any additional
endograft extensions that terminate in the common iliac arteries
are included in 34845, 34846, 34847, 34848. Codes 34709, 34710,
34711 may not be separately reported for proximal abdominal
aortic extension prosthesis(es) or for distal extension
prosthesis(es) that terminate(s) in the aorta or the common iliac
arteries. However, 34709, 34710, 34711 may be reported for distal
extension prosthesis(es) that terminate(s) in the internal iliac,
external iliac, or common femoral artery(ies).
Codes 34841-34844 and 34845-34848 define the total number of
visceral and/or renal arteries (ie, celiac, superior mesenteric,
and/or unilateral or bilateral renal artery[s]) requiring placement
of an endoprosthesis (ie, bare metal or covered stent) through an
aortic endograft fenestration.
Introduction of guide wires and catheters in the aorta and visceral
and/or renal arteries is included in the work of 34841-34848 and
is not separately reportable. However, catheterization of the
hypogastric artery(s) and/or arterial families outside the treatment
zone of the graft may be separately reported. Balloon angioplasty
within the target treatment zone of the endograft, either before or
after endograft deployment, is not separately reportable.
Fluoroscopic guidance and radiological supervision and
interpretation in conjunction with fenestrated endovascular aortic
repair is not separately reportable and includes angiographic
diagnostic imaging of the aorta and its branches prior to
deployment of the fenestrated endovascular device, fluoroscopic
guidance in the delivery of the fenestrated endovascular
components, and intraprocedural arterial angiography (eg,
confirm position, detect endoleak, evaluate runoff) done at the
time of the endovascular aortic repair.
Exposure of the access vessels (eg, 34713, 34714, 34715, 34716,
34812, 34820, 34833, 34834) may be reported separately.
Extensive repair of an artery (eg, 35226, 35286) may be reported
separately. For concomitant endovascular treatment of the
descending thoracic aorta, 33880-33886 and 75956-75959 may be
reported with 34841, 34842, 34843, 34844, 34845, 34846, 34847,
34848. For isolated endovascular infrarenal abdominal aortic
aneurysm repair that does not require placement of a fenestrated
graft to preserve flow to the visceral branch(es), see 34701,
34702, 34703, 34704, 34705, 34706.
fenestrated endovascular abdominal aortic aneurysm repair may
be reported separately (eg, arterial embolization, intravascular
ultrasound, balloon angioplasty or stenting of native artery[s]
outside the endoprosthesis target zone, when done before or after
deployment of endoprosthesis).
34839 Physician planning of a patient-specific fenestrated visceral
aortic endograft requiring a minimum of 90 minutes of
physician time

34843, 34844, 34845, 34846, 34847, 34848, when
performed on the day before or the day of the fenestrated
endovascular repair procedure)
34841 Endovascular repair of visceral aorta (eg, aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural
hematoma, or traumatic disruption) by deployment of a
fenestrated visceral aortic endograft and all associated
radiological supervision and interpretation, including target
zone angioplasty, when performed; including one visceral
artery endoprosthesis (superior mesenteric, celiac or renal
artery)
34842 including two visceral artery endoprostheses (superior

mesenteric, celiac and/or renal artery[s])
34843 including three visceral artery endoprostheses (superior

34844 including four or more visceral artery endoprostheses

(superior mesenteric, celiac and/or renal artery[s])
(Do not report 34841, 34842, 34843, 34844 in conjunction

with 34701, 34702, 34703, 34704, 34705, 34706, 34845,
34846, 34847, 34848)
with 34839, when planning services are performed on the
day before or the day of the fenestrated endovascular repair
procedure)
34845 Endovascular repair of visceral aorta and infrarenal
abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection,
penetrating ulcer, intramural hematoma, or traumatic
disruption) with a fenestrated visceral aortic endograft and
concomitant unibody or modular infrarenal aortic endograft
and all associated radiological supervision and
interpretation, including target zone angioplasty, when
performed; including one visceral artery endoprosthesis
(superior mesenteric, celiac or renal artery)
34846 including two visceral artery endoprostheses (superior
34847 including three visceral artery endoprostheses (superior

34848 including four or more visceral artery endoprostheses

(superior mesenteric, celiac and/or renal artery[s])
➲ CPT Assistant Dec 13:8, Jul 16:6, Aug 17:10, Dec
17:3
with 34701, 34702, 34703, 34704, 34705, 34706, 34841,
34842, 34843, 34844, 35081, 35102)
with 34839, when planning services are performed on the
day before or the day of the fenestrated endovascular repair
procedure)
37237 for bare metal or covered stents placed into the
visceral branches within the endoprosthesis target zone)
(For placement of distal extension prosthesis[es] terminating
in the internal iliac, external iliac, or common femoral
artery[ies], see 34709, 34710, 34711, 34718)
(Use 34845, 34846, 34847, 34848 in conjunction with
37220, 37221, 37222, 37223, only when 37220, 37221,
37222, 37223 are performed outside the target treatment
zone of the endoprosthesis)
Endovascular Repair of Iliac Aneurysm

Direct Repair of Aneurysm or Excision (Partial or

Total) and Graft Insertion for Aneurysm,
Pseudoaneurysm, Ruptured Aneurysm, and
Associated Occlusive Disease
Procedures 35001-35152 include preparation of artery for
anastomosis including endarterectomy.
(For direct repairs associated with occlusive disease only,
see 35201-35286)
(For intracranial aneurysm, see 61700 et seq)
(For endovascular repair of abdominal aortic and/or iliac
artery aneurysm, see 34701-34716)
(For thoracic aortic aneurysm, see 33858-33875)
(For endovascular repair of descending thoracic aorta,
involving coverage of left subclavian artery origin, use
33880)
35001 Direct repair of aneurysm, pseudoaneurysm, or excision
(partial or total) and graft insertion, with or without patch
graft; for aneurysm and associated occlusive disease,
carotid, subclavian artery, by neck incision
35002 for ruptured aneurysm, carotid, subclavian artery, by

neck incision
35005 for aneurysm, pseudoaneurysm, and associated occlusive
disease, vertebral artery
35011 for aneurysm and associated occlusive disease, axillary-

brachial artery, by arm incision
35013 for ruptured aneurysm, axillary-brachial artery, by arm
incision
disease, innominate, subclavian artery, by thoracic
incision
35022 for ruptured aneurysm, innominate, subclavian artery, by

thoracic incision
disease, radial or ulnar artery

disease, abdominal aorta
➲ CPT Assistant Dec 00:2, Dec 01:7, Dec 13:8
35082 for ruptured aneurysm, abdominal aorta

disease, abdominal aorta involving visceral vessels
(mesenteric, celiac, renal)
35092 for ruptured aneurysm, abdominal aorta involving

visceral vessels (mesenteric, celiac, renal)
disease, abdominal aorta involving iliac vessels
(common, hypogastric, external)
35103 for ruptured aneurysm, abdominal aorta involving iliac
vessels (common, hypogastric, external)
disease, splenic artery
35112 for ruptured aneurysm, splenic artery

disease, hepatic, celiac, renal, or mesenteric artery
35122 for ruptured aneurysm, hepatic, celiac, renal, or

mesenteric artery
disease, iliac artery (common, hypogastric, external)
35132 for ruptured aneurysm, iliac artery (common,

hypogastric, external)
disease, common femoral artery (profunda femoris,
superficial femoral)
35142 for ruptured aneurysm, common femoral artery (profunda

femoris, superficial femoral)
disease, popliteal artery
35152 for ruptured aneurysm, popliteal artery

Repair Arteriovenous Fistula
35180 Repair, congenital arteriovenous fistula; head and neck
35182 thorax and abdomen

35184 extremities
35188 Repair, acquired or traumatic arteriovenous fistula; head

and neck
35189 thorax and abdomen

35190 extremities
Repair Blood Vessel Other Than for Fistula, With

or Without Patch Angioplasty
(For AV fistula repair, see 35180-35190)
35201 Repair blood vessel, direct; neck

33985, 33986)
➲ CPT Assistant Oct 00:3, Nov 03:5, Apr 12:4, Apr
14:10
33985, 33986)
35207 hand, finger
35211 intrathoracic, with bypass
33985, 33986)
35216 intrathoracic, without bypass

33985, 33986)
35221 intra-abdominal
➲ CPT Assistant Apr 12:8, 9, Mar 13:10, Dec 13:8, Jul
17:5, Jul 19:11
33985, 33986)
35231 Repair blood vessel with vein graft; neck

35261 Repair blood vessel with graft other than vein; neck
➲ CPT Assistant Apr 12:8, 9, Mar 13:10, Dec 13:8,
Apr 14:10, Jul 17:5, Jul 19:11
Thromboendarterectomy
(For coronary artery, see 33510-33536 and 33572)
(35301-35372 include harvest of saphenous or upper
extremity vein when performed)
35301 Thromboendarterectomy, including patch graft, if performed;
carotid, vertebral, subclavian, by neck incision
35302 superficial femoral artery

35303 popliteal artery


37227 when performed in the same vessel)
35304 tibioperoneal trunk artery
35305 tibial or peroneal artery, initial vessel

✚ 35306 each additional tibial or peroneal artery (List separately

37229, 37231, 37233, 37235 when performed in the same
vessel)
35311 subclavian, innominate, by thoracic incision
35321 axillary-brachial
35331 abdominal aorta
35341 mesenteric, celiac, or renal
35351 iliac
35355 iliofemoral
35361 combined aortoiliac
35363 combined aortoiliofemoral
35371 common femoral
35372 deep (profunda) femoral

35371-35372
The common femoral artery (35371) or the deep (profunda) femoral artery (35372) is incised and the
plaque and lining are removed, enlarging the diameter of the artery.
✚ 35390 Reoperation, carotid, thromboendarterectomy, more than 1
month after original operation (List separately in addition to
Angioscopy
✚ 35400 Angioscopy (noncoronary vessels or grafts) during
therapeutic intervention (List separately in addition to code
Bypass Graft
Vein
Procurement of the saphenous vein graft is included in the

reported as a separate service or co-surgery. To report harvesting
of an upper extremity vein, use 35500 in addition to the bypass
procedure. To report harvesting of a femoropopliteal vein
segment, use 35572 in addition to the bypass procedure. To
report harvesting and construction of an autogenous composite
graft of two segments from two distant locations, report 35682 in
addition to the bypass procedure, for autogenous composite of
three or more segments from distant sites, report 35683.
✚ 35500 Harvest of upper extremity vein, 1 segment, for lower
extremity or coronary artery bypass procedure (List
➲ CPT Assistant Nov 98:13, Mar 99:6, Nov 99:19, Jan
07:7, Apr 12:4
35566, 35570, 35571, 35583-35587)
(For harvest of more than one vein segment, see 35682,
35683)
(For endoscopic procedure, use 33508)
35501 Bypass graft, with vein; common carotid-ipsilateral internal
carotid
35506 carotid-subclavian or subclavian-carotid

➲ CPT Assistant Oct 04:6, Jan 07:7
35508 carotid-vertebral
35509 carotid-contralateral carotid
35510 carotid-brachial
35511 subclavian-subclavian
35512 subclavian-brachial
35515 subclavian-vertebral
35516 subclavian-axillary
35518 axillary-axillary
35521 axillary-femoral
(For bypass graft performed with synthetic graft, use 35621)
35522 axillary-brachial
35523 brachial-ulnar or -radial


35525, 36838)
(For bypass graft performed with synthetic conduit, use
37799)
35525 brachial-brachial
35526 aortosubclavian, aortoinnominate, or aortocarotid

35531 aortoceliac or aortomesenteric
35533 axillary-femoral-femoral
35535 hepatorenal

35281, 35500, 35536, 35560, 35631, 35636)
35536 splenorenal
35537 aortoiliac

35538 aortobi-iliac

35539 aortofemoral

35540 aortobifemoral

35556 femoral-popliteal
➲ CPT Assistant Fall 92:20, May 97:10, Jan 07:7, Nov
07:8
35558 femoral-femoral
35560 aortorenal
35563 ilioiliac
35565 iliofemoral
35566 femoral-anterior tibial, posterior tibial, peroneal artery

or other distal vessels
➲ CPT Assistant Jan 07:7, Nov 07:8
35570 tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-

tibial

35571 popliteal-tibial, -peroneal artery or other distal vessels
Bypass Graft, Vein

35571
The physician creates a bypass around the popliteal artery, using a harvested vein that is sutured to the
tibial artery.
✚ 35572 Harvest of femoropopliteal vein, 1 segment, for vascular
reconstruction procedure (eg, aortic, vena caval, coronary,
peripheral artery) (List separately in addition to code for
primary procedure)

33523, 33533-33536, 34502, 34520, 35001, 35002, 35011-
35022, 35102, 35103, 35121-35152, 35231-35256, 35501-
35571, 35583, 35585, 35587, 35879-35907)
In-Situ Vein
(To report aortobifemoral bypass using synthetic conduit,
and femoral-popliteal bypass with vein conduit in-situ, use
35646 and 35583. To report aorto[uni]femoral bypass with
synthetic conduit, and femoral-popliteal bypass with vein
conduit in-situ, use 35647 and 35583. To report
aortofemoral bypass using vein conduit, and femoral-
popliteal bypass with vein conduit in-situ, use 35539 and
35583)
35583 In-situ vein bypass; femoral-popliteal
35585 femoral-anterior tibial, posterior tibial, or peroneal

artery
35587 popliteal-tibial, peroneal

➲ CPT Assistant Apr 99:11, Jan 07:7, Nov 07:8
Other Than Vein

(For arterial transposition and/or reimplantation, see 35691-
35695)
✚ 35600 Harvest of upper extremity artery, 1 segment, for coronary
artery bypass procedure (List separately in addition to code
(Use 35600 in conjunction with 33533–33536)
Harvest of Upper Extremity Artery

35600
Open procurement of a radial artery to secure conduit for construction of a coronary artery bypass graft
35601 Bypass graft, with other than vein; common carotid-
ipsilateral internal carotid
➲ CPT Assistant Jul 06:7, Jan 07:7
35606 carotid-subclavian
(For open transcervical common carotid-common carotid
bypass performed in conjunction with endovascular repair
of descending thoracic aorta, use 33891)
(For open subclavian to carotid artery transposition
performed in conjunction with endovascular thoracic
aneurysm repair by neck incision, use 33889)
35612 subclavian-subclavian
35616 subclavian-axillary
35621 axillary-femoral
35623 axillary-popliteal or -tibial
35626 aortosubclavian, aortoinnominate, or aortocarotid
35631 aortoceliac, aortomesenteric, aortorenal

35632 ilio-celiac

35281, 35531, 35631)
35633 ilio-mesenteric

35281, 35531, 35631)
35634 iliorenal

35281, 35560, 35536, 35631)
35636 splenorenal (splenic to renal arterial anastomosis)
35637 aortoiliac

35638 aortobi-iliac

(For open placement of aortobi-iliac prosthesis following
unsuccessful endovascular repair, use 34831)
35642 carotid-vertebral
35645 subclavian-vertebral
35646 aortobifemoral
(For bypass graft performed with vein graft, use 35540)

(For open placement of aortobifemoral prosthesis following
unsuccessful endovascular repair, use 34832)
35647 aortofemoral
(For bypass graft performed with vein graft, use 35539)

35650 axillary-axillary
35654 axillary-femoral-femoral
35656 femoral-popliteal
35661 femoral-femoral
➲ CPT Assistant Dec 04:6, Jan 07:7
35663 ilioiliac
35665 iliofemoral
35666 femoral-anterior tibial, posterior tibial, or peroneal

artery
35671 popliteal-tibial or -peroneal artery
Composite Grafts
Codes 35682-35683 are used to report harvest and anastomosis of
multiple vein segments from distant sites for use as arterial
bypass graft conduits. These codes are intended for use when the
two or more vein segments are harvested from a limb other than
that undergoing bypass.
✚ 35681 Bypass graft; composite, prosthetic and vein (List separately
➲ CPT Assistant Nov 98:13-14, Mar 99:6, Apr 99:11
(Do not report 35681 in addition to 35682, 35683)

✚ 35682 autogenous composite, 2 segments of veins from 2
locations (List separately in addition to code for primary
procedure)
➲ CPT Assistant Nov 98:13-14, Mar 99:6, Apr 99:11,
Sep 02:4
35571, 35583-35587)
✚ 35683 autogenous composite, 3 or more segments of vein from
2 or more locations (List separately in addition to code
➲ CPT Assistant Nov 98:13-14, Mar 99:6, Apr 99:11,
Sep 02:4
35571, 35583-35587)
Adjuvant Techniques
Adjuvant (additional) technique(s) may be required at the time a
bypass graft is created to improve patency of the lower extremity
autogenous or synthetic bypass graft (eg, femoral-popliteal,
femoral-tibial, or popliteal-tibial arteries). Code 35685 should be
reported in addition to the primary synthetic bypass graft
procedure, when an interposition of venous tissue (vein patch or
cuff) is placed at the anastomosis between the synthetic bypass
conduit and the involved artery (includes harvest).
Code 35686 should be reported in addition to the primary bypass
graft procedure, when autogenous vein is used to create a fistula
between the tibial or peroneal artery and vein at or beyond the
distal bypass anastomosis site of the involved artery.
(For composite graft(s), see 35681-35683)
✚ 35685 Placement of vein patch or cuff at distal anastomosis of
bypass graft, synthetic conduit (List separately in addition to

✚ 35686 Creation of distal arteriovenous fistula during lower
extremity bypass surgery (non-hemodialysis) (List
➲ CPT Assistant Sep 02:3, Apr 12:4

35571, 35583-35587, 35623, 35656, 35666, 35671)
Arterial Transposition
35691 Transposition and/or reimplantation; vertebral to carotid
artery
35693 vertebral to subclavian artery
35694 subclavian to carotid artery
(For open subclavian to carotid artery transposition
performed in conjunction with endovascular repair of
descending thoracic aorta, use 33889)
35695 carotid to subclavian artery
✚ 35697 Reimplantation, visceral artery to infrarenal aortic
prosthesis, each artery (List separately in addition to code
Excision, Exploration, Repair, Revision

✚ 35700 Reoperation, femoral-popliteal or femoral (popliteal)-
anterior tibial, posterior tibial, peroneal artery, or other
distal vessels, more than 1 month after original operation

35571, 35583, 35585, 35587, 35656, 35666, 35671)
35701 Exploration not followed by surgical repair, artery; neck
(eg, carotid, subclavian)

35261, 35800, when performed on the same side of the
neck)
35702 upper extremity (eg, axillary, brachial, radial, ulnar)
35703 lower extremity (eg, common femoral, deep femoral,

superficial femoral, popliteal, tibial, peroneal)
(When additional surgical procedures are performed at the
same setting by the same surgeon, 35701, 35702, 35703 may
only be reported when a nonvascular surgical procedure is
performed and only when the artery exploration is
performed through a separate incision)
35207, 35236, 35256, 35266, 35286, 35860 in the same
extremity)
(Do not report 35701, 35702, 35703 to explore and identify
a recipient artery [eg, external carotid artery] when
performed in conjunction with 15756, 15757, 15758, 20955,
20956, 20957, 20962, 20969, 20970, 20972, 20973, 43496,
49906)
(To report exploration of lower extremity artery, use 35703)
(To report vascular exploration not followed by surgical
repair, other than neck artery, upper extremity artery, lower
extremity artery, chest, abdomen, or retroperitoneal area,
use 37799)
(For vascular exploration of the chest not followed by
surgical repair, use 32100)
(For vascular exploration of the abdomen not followed by
surgical repair, use 49000)
(For vascular exploration of the retroperitoneal area not
followed by surgical repair, use 49010)
35800 Exploration for postoperative hemorrhage, thrombosis or
infection; neck
35820 chest
35840 abdomen
35860 extremity
➲ CPT Assistant Fall 92:21, Apr 14:10
35870 Repair of graft-enteric fistula

35875 Thrombectomy of arterial or venous graft (other than
hemodialysis graft or fistula);
➲ CPT Assistant Nov 98:14, Feb 99:6, Mar 99:6, Apr
00:10
35876 with revision of arterial or venous graft
(For thrombectomy of hemodialysis graft or fistula, see

36831, 36833)
Codes 35879 and 35881 describe open revision of graft-
threatening stenoses of lower extremity arterial bypass graft(s)
(previously constructed with autogenous vein conduit) using vein
patch angioplasty or segmental vein interposition techniques. For
thrombectomy with revision of any noncoronary arterial or
venous graft, including those of the lower extremity, (other than
hemodialysis graft or fistula), use 35876. For direct repair (other
than for fistula) of a lower extremity blood vessel (with or
without patch angioplasty), use 35226. For repair (other than for
fistula) of a lower extremity blood vessel using a vein graft, use
35256.
35879 Revision, lower extremity arterial bypass, without
thrombectomy, open; with vein patch angioplasty
35881 with segmental vein interposition
(For revision of femoral anastomosis of synthetic arterial

bypass graft, see 35883, 35884)
(For excision of infected graft, see 35901-35907 and
appropriate revascularization code)
35883 Revision, femoral anastomosis of synthetic arterial bypass
graft in groin, open; with nonautogenous patch graft (eg,
Dacron, ePTFE, bovine pericardium)
(For bilateral procedure, use modifier 50)

35876, 35884)
35884 with autogenous vein patch graft

35876, 35883)
35901 Excision of infected graft; neck
35903 extremity
35905 thorax
35907 abdomen
Vascular Injection Procedures

Listed services for injection procedures include necessary local
anesthesia, introduction of needles or catheter, injection of
contrast media with or without automatic power injection, and/or
necessary pre- and postinjection care specifically related to the
injection procedure.
Selective vascular catheterization should be coded to include
introduction and all lesser order selective catheterization used in
carotid arteries).
Additional second and/or third order arterial catheterization
within the same family of arteries or veins supplied by a single
first order vessel should be expressed by 36012, 36218, or 36248.
Additional first order or higher catheterization in vascular
families supplied by a first order vessel different from a
previously selected and coded family should be separately coded
using the conventions described above.
(For radiological supervision and interpretation, see
Radiology)
(For injection procedures in conjunction with cardiac
catheterization, see 93452-93461, 93563-93568)
(For chemotherapy of malignant disease, see 96401-96549)
Intravenous
An intracatheter is a sheathed combination of needle and short

catheter.
36000 Introduction of needle or intracatheter, vein
➲ CPT Assistant Summer 95:2, Apr 98:1, 3, 7, Jul 98:1,
Apr 03:26, Oct 03:2, Jul 06:4, Feb 07:10, Jul 07:1, Dec
08:7, May 14:4, Sep 14:13, Oct 14:6, Aug 19:8
36002 Injection procedures (eg, thrombin) for percutaneous
treatment of extremity pseudoaneurysm
➲ CPT Assistant Nov 13:6, Oct 14:6

(For ultrasound guided compression repair of
pseudoaneurysms, use 76936)
(Do not report 36002 for vascular sealant of an arteriotomy
site)
Injection Procedure (eg, Thrombin) for Percutaneous

Treatment of Extremity Pseudoaneurysm
36002
36005 Injection procedure for extremity venography (including
introduction of needle or intracatheter)
(For radiological supervision and interpretation, see 75820,
75822)
36010 Introduction of catheter, superior or inferior vena cava
➲ CPT Assistant Aug 96:2, Apr 98:7, Sep 00:11, May
01:10, Jul 03:12, Oct 08:11, Jan 09:7, Apr 12:4, Feb
17:14
➲ Clinical Examples in Radiology Winter 05:5-6, Spring
08:7-8, Winter 12:3, Spring 13:3, Winter 16:2
36011 Selective catheter placement, venous system; first order
branch (eg, renal vein, jugular vein)
➲ CPT Assistant Aug 96:11, Apr 98:7, Jul 03:12, Dec
03:2, Apr 12:5
16:3
36012 second order, or more selective, branch (eg, left adrenal
vein, petrosal sinus)
➲ CPT Assistant Aug 96:11, Sep 98:7, Jul 03:12, Apr
12:5, Oct 18:3
36013 Introduction of catheter, right heart or main pulmonary artery

➲ CPT Assistant Aug 96:11, Oct 08:11, Jan 09:7, Jun 19:3
36014 Selective catheter placement, left or right pulmonary artery

➲ CPT Assistant Aug 96:11, Apr 98:7, Jun 19:3
36015 Selective catheter placement, segmental or subsegmental

pulmonary artery
➲ CPT Assistant Aug 96:11, Sep 00:11, Mar 12:10, Jun
19:3
➲ Clinical Examples in Radiology Summer 12:1, 2, Spring
13:1, 2
(For insertion of flow directed catheter (eg, Swan-Ganz),
use 93503)
(For venous catheterization for selective organ blood
sampling, use 36500)
Intra-Arterial—Intra-Aortic
Radiology)
36100 Introduction of needle or intracatheter, carotid or vertebral
artery

36140 Introduction of needle or intracatheter, upper or lower
extremity artery
➲ CPT Assistant Fall 93:16, Aug 96:3, Nov 99:32-33, Oct
03:2, Jul 06:4, 7, Jul 07:1, Dec 07:10, 11, Jun 09:10, Jul
11:5
(For insertion of arteriovenous cannula, see 36810-36821)
36160 Introduction of needle or intracatheter, aortic, translumbar
Diagnostic Studies of Cervicocerebral Arteries: Codes 36221-

36228 describe non-selective and selective arterial catheter
placement and diagnostic imaging of the aortic arch, carotid, and
vertebral arteries. Codes 36221-36226 include the work of
accessing the vessel, placement of catheter(s), contrast
injection(s), fluoroscopy, radiological supervision and
interpretation, and closure of the arteriotomy by pressure, or
application of an arterial closure device. Codes 36221-36228
describe arterial contrast injections with arterial, capillary, and
venous phase imaging, when performed.
Code 36227 is an add-on code to report unilateral selective
arterial catheter placement and diagnostic imaging of the
ipsilateral external carotid circulation and includes all the work of
accessing the additional vessel, placement of catheter(s), contrast
injection(s), fluoroscopy, radiological supervision and
interpretation. Code 36227 is reported in conjunction with 36222,
36223, or 36224.
Code 36228 is an add-on code to report unilateral selective
arterial catheter placement and diagnostic imaging of the initial
and each additional intracranial branch of the internal carotid or
vertebral arteries. Code 36228 is reported in conjunction with
36223, 36224, 36225 or 36226. This includes any additional
second or third order catheter selective placement in the same
primary branch of the internal carotid, vertebral, or basilar artery
and includes all the work of accessing the additional vessel,
placement of catheter(s), contrast injection(s), fluoroscopy,
radiological supervision and interpretation. It is not reported
more than twice per side, regardless of the number of additional
branches selectively catheterized.
Codes 36221-36226 are built on progressive hierarchies with
more intensive services inclusive of less intensive services. The
code inclusive of all of the services provided for that vessel
should be reported (ie, use the code inclusive of the most
intensive services provided). Only one code in the range 36222-
36224 may be reported for each ipsilateral carotid territory. Only
one code in the range 36225-36226 may be reported for each
ipsilateral vertebral territory.
Code 36221 is reported for non-selective arterial catheter
placement in the thoracic aorta and diagnostic imaging of the
aortic arch and great vessel origins. Codes 36222-36228 are
reported for unilateral artery catheterization. Do not report 36221
in conjunction with 36222-36226 as these selective codes include
the work of 36221 when performed.
Do not report 36222, 36223, or 36224 together for ipsilateral
angiography. Instead, select the code that represents the most
comprehensive service using the following hierarchy of
complexity (listed in descending order of complexity):
36224>36223>36222.
Do not report 36225 and 36226 together for ipsilateral
angiography. Select the code that represents the more
comprehensive service using the following hierarchy of
complexity (listed in descending order of complexity):
36226>36225.
When bilateral carotid and/or vertebral arterial catheterization and
imaging is performed, report 36222, 36223, 36224, 36225, 36226
with modifier 50, and report add-on codes 36227, 36228 twice
(do not report modifier 50 in conjunction with 36227, 36228) if
the same procedure is performed on both sides. For example,
iblateral extracranial carotid angiography with selective
catheterization of each common carotid artery would be reported
with 36222 and modifier 50. However, when different
territory(ies) is studied in the same session on both sides of the
body, modifiers may be required to report the imaging
performed. Use modifier 59 to denote that different carotid
and/or vertebral arteries are being studied. For example, when
selective right internal carotid artery catheterization accompanied
by right extracranial and intracranial carotid angiography is
followed by selective left common carotid artery catheterization
with left extracranial carotid angiography, use 36224 to report the
right side and 36222-59 to report the left side.
Diagnostic angiography of the cervicocerebral vessels may be
followed by an interventional procedure at the same session.
Interventional procedures may be separately reportable using
standard coding conventions.
Do not report 36218 or 75774 as part of diagnostic angiography
of the extracranial and intracranial cervicocerebral vessels. It may
be appropriate to report 36218 and 75774 for diagnostic
angiography of upper extremities and other vascular beds of the
neck and/or shoulder girdle performed in the same session as
vertebral angiography (eg, workup of a neck tumor that requires
catheterization and angiography of the vertebral artery as well as
other brachiocephalic arteries).
Report 76376 or 76377 for 3D rendering when performed in
conjunction with 36221-36228.
Report 76937 for ultrasound guidance for vascular access, when
performed in conjunction with 36221-36228.
36200 Introduction of catheter, aorta
➲ CPT Assistant Fall 93:16, Aug 96:3, Jul 06:7, Dec
07:10, 14, Apr 08:11, Dec 09:13, Jul 11:5, Oct 11:9, Apr
12:4, Feb 13:16, Mar 17:4
14:5-6, Summer 14:2, 3
(For non-selective angiography of the extracranial carotid
and/or cerebral vessels and cervicocerebral arch, when
performed, use 36221)
36215 Selective catheter placement, arterial system; each first
order thoracic or brachiocephalic branch, within a vascular
family
➲ CPT Assistant Fall 93:15, Aug 96:3, Nov 97:16, Apr
98:9, Sep 00:11, Oct 00:4, Feb 03:3, Apr 12:4, Mar
17:4, May 17:8
13:4, 5, 6, Winter 18:2
(For catheter placement for coronary angiography, see
93454-93461)
36216 initial second order thoracic or brachiocephalic branch,
within a vascular family
➲ CPT Assistant Fall 93:15, Aug 96:3, Oct 00:4, Dec
07:10, Dec 11:12, Apr 12:4, Nov 13:14
➲ Clinical Examples in Radiology Spring 13:4, 5, 6,
Winter 18:2
36217 initial third order or more selective thoracic or
brachiocephalic branch, within a vascular family
➲ CPT Assistant Fall 93:15, Aug 96:3, Oct 00:4, Dec
07:10, Dec 11:12, Apr 12:5
✚ 36218 additional second order, third order, and beyond,

thoracic or brachiocephalic branch, within a vascular
family (List in addition to code for initial second or third
order vessel as appropriate)
➲ CPT Assistant Fall 93:15, Aug 96:3, Oct 00:4, Jul
06:7, Dec 07:10, Apr 12:5, May 13:3, Oct 18:3
➲ Clinical Examples in Radiology Winter 15:4, 5, 6,
Winter 18:2
36226)
(For angiography, see 36222-36228, 75600-75774)
(For transluminal balloon angioplasty [except lower
extremity artery[ies] for occlusive disease, intracranial,
coronary, pulmonary, or dialysis circuit], see 37246, 37247)
(For transcatheter therapies, see 37200, 37211, 37213,
37214, 37236, 37237, 37238, 37239, 37241, 37242, 37243,
37244, 61624, 61626)
(When coronary artery, arterial conduit [eg, internal
mammary, inferior epigastric or free radical artery] or
venous bypass graft angiography is performed in conjunction
with cardiac catheterization, see the appropriate cardiac
catheterization, injection procedure, and imaging
supervision code[s] [93455, 93457, 93459, 93461, 93530-
93533, 93564] in the Medicine section. When internal
mammary artery angiography only is performed without a
concomitant cardiac catheterization, use 36216 or 36217 as
appropriate)
36221 Non-selective catheter placement, thoracic aorta, with
angiography of the extracranial carotid, vertebral, and/or
intracranial vessels, unilateral or bilateral, and all
associated radiological supervision and interpretation,
includes angiography of the cervicocerebral arch, when
performed
➲ CPT Assistant Feb 13:16, May 13:3, Jun 13:12, Oct
13:18, Mar 14:8, May 15:7
(Do not report 36221 with 36222-36226)

36222 Selective catheter placement, common carotid or innominate
artery, unilateral, any approach, with angiography of the
ipsilateral extracranial carotid circulation and all associated
radiological supervision and interpretation, includes
angiography of the cervicocerebral arch, when performed
CPT Assistant Feb 13:17, May 13:3, Jun 13:12, Oct
➲
13:18, Nov 13:14, Mar 14:8, May 15:7, Nov 15:10
➲ Clinical Examples in Radiology Winter 15:6, Spring
16:6
37218 for the treated carotid artery)
36223 Selective catheter placement, common carotid or innominate
artery, unilateral, any approach, with angiography of the
ipsilateral intracranial carotid circulation and all associated
radiological supervision and interpretation, includes
angiography of the extracranial carotid and cervicocerebral
arch, when performed
13:18, Mar 14:8
16:6
36224 Selective catheter placement, internal carotid artery,
unilateral, with angiography of the ipsilateral intracranial
carotid circulation and all associated radiological
supervision and interpretation, includes angiography of the
extracranial carotid and cervicocerebral arch, when
performed
13:18, Mar 14:8
➲ Clinical Examples in Radiology Winter 15:5, 6, Spring
16:5
36225 Selective catheter placement, subclavian or innominate
artery, unilateral, with angiography of the ipsilateral
vertebral circulation and all associated radiological
supervision and interpretation, includes angiography of the
cervicocerebral arch, when performed
➲ CPT Assistant May 13:3, Jun 13:12, Oct 13:18, Nov
13:14, Mar 14:8
15:6
Angiography, Carotid Artery

36222-36228
A radiologic contrast study is performed on the carotid artery vascular family.
36226 Selective catheter placement, vertebral artery, unilateral,

with angiography of the ipsilateral vertebral circulation and
all associated radiological supervision and interpretation,
includes angiography of the cervicocerebral arch, when
performed
➲ CPT Assistant May 13:3, Jun 13:12, Oct 13:18, Mar
14:8
➲ Clinical Examples in Radiology Winter 15:4, 5, 6,
Winter 18:2
✚ 36227 Selective catheter placement, external carotid artery,
unilateral, with angiography of the ipsilateral external
carotid circulation and all associated radiological
supervision and interpretation (List separately in addition to
13:18, Mar 14:8, Nov 15:10
16:5
(Do not report 36221-36227 in conjunction with 37217 for
ipsilateral services)
✚ 36228 Selective catheter placement, each intracranial branch of the
internal carotid or vertebral arteries, unilateral, with
angiography of the selected vessel circulation and all
associated radiological supervision and interpretation (eg,
middle cerebral artery, posterior inferior cerebellar artery)
13:18
(Use 36228 in conjunction with 36223, 36224, 36225 or
36226)
(Do not report 36228 more than twice per side)
36245 Selective catheter placement, arterial system; each first
order abdominal, pelvic, or lower extremity artery branch,
within a vascular family
➲ CPT Assistant Fall 93:15, Aug 96:3, Jan 01:14, Jan
07:7, Dec 07:10, Jul 11:5, Oct 11:9, Apr 12:4, Nov
13:14
➲ Clinical Examples in Radiology Summer 08:1-3, Fall
11:3, Winter 14:2-3, Winter 18:2, Spring 19:2
36246 initial second order abdominal, pelvic, or lower
extremity artery branch, within a vascular family
07:7, Dec 07:10, 11, Jul 11:5, Oct 11:9, Apr 12:4,
Nov 13:14
➲ Clinical Examples in Radiology Winter 13:2, 3,
Winter 14:1-3, Winter 18:11, Spring 19:3
36247 initial third order or more selective abdominal, pelvic,
or lower extremity artery branch, within a vascular
family
07:7, Dec 07:10, Jul 11:5, Apr 12:4, Fall 13:2, 3, 4,
Nov 13:14
Summer 08:1-3, Winter 13:1, 3, Summer 15:2, Winter
18:11, Summer 18:2, Summer 19:4
✚ 36248 additional second order, third order, and beyond,
abdominal, pelvic, or lower extremity artery branch,
within a vascular family (List in addition to code for
initial second or third order vessel as appropriate)
➲ CPT Assistant Fall 93:15, Aug 96:3, Apr 98:1, 7, Oct
00:4, Jan 01:14, Jan 07:7, Jul 11:5, Apr 12:4, Oct
18:3
36251 Selective catheter placement (first-order), main renal artery
and any accessory renal artery(s) for renal angiography,
including arterial puncture and catheter placement(s),
fluoroscopy, contrast injection(s), image postprocessing,
permanent recording of images, and radiological
supervision and interpretation, including pressure gradient
measurements when performed, and flush aortogram when
performed; unilateral
➲ CPT Assistant Apr 12:6, Aug 12:13, Nov 13:14
➲ Clinical Examples in Radiology Fall 11:2, Spring 19:2
36252 bilateral
36253 Superselective catheter placement (one or more second

order or higher renal artery branches) renal artery and any
accessory renal artery(s) for renal angiography, including
arterial puncture, catheterization, fluoroscopy, contrast
injection(s), image postprocessing, permanent recording of
images, and radiological supervision and interpretation,
including pressure gradient measurements when performed,
and flush aortogram when performed; unilateral
➲ CPT Assistant Apr 12:6, Aug 12:13, Nov 13:14
(Do not report 36253 in conjunction with 36251 when

performed for the same kidney)
36254 bilateral
(Placement of closure device at the vascular access site is
not separately reported with 36251-36254)
with 0338T, 0339T)
36260 Insertion of implantable intra-arterial infusion pump (eg, for
chemotherapy of liver)
➲ CPT Assistant Fall 95:5
36261 Revision of implanted intra-arterial infusion pump

36262 Removal of implanted intra-arterial infusion pump
36299 Unlisted procedure, vascular injection
Venous
Venipuncture, needle or catheter for diagnostic study or

intravenous therapy, percutaneous. These codes are also used to
report the therapy as specified. For collection of a specimen from
an established catheter, use 36592. For collection of a specimen
from a completely implantable venous access device, use 36591.
36400 Venipuncture, younger than age 3 years, necessitating the
skill of a physician or other qualified health care
professional, not to be used for routine venipuncture;
femoral or jugular vein
➲ CPT Assistant Jul 06:4, Jul 07:1, Dec 08:7, May 14:4
36405 scalp vein

➲ CPT Assistant Jul 06:4, Jul 07:1, Dec 08:7, May 14:4
19:12
36406 other vein
➲ CPT Assistant Jul 06:4, Jul 07:1, May 14:4
19:12
36410 Venipuncture, age 3 years or older, necessitating the skill of
a physician or other qualified health care professional
(separate procedure), for diagnostic or therapeutic purposes
(not to be used for routine venipuncture)
➲ CPT Assistant Jun 96:10, May 01:11, Aug 02:2, Oct
03:10, Feb 07:10, Jul 07:1, Dec 08:7, Sep 13:18, Oct
14:6, Aug 19:8
➲ Clinical Examples in Radiology Spring 09:8, Fall 18:9,
Winter 19:12
Coding Tip
(when applicable) who performs a professional service within his or her
scope of practice and independently reports that professional service. These
health care professional, and who is allowed by law, regulation, and facility
policy to perform or assist in the performance of a specific professional
service, but does not individually report that professional service. Other
CPT Coding Guidelines, Introduction, Instructions for Use of the CPT

Codebook
36415 Collection of venous blood by venipuncture

➲ CPT Assistant Jun 96:10, Mar 98:10, Oct 99:11, Aug
00:2, Feb 07:10, Jul 07:1, Dec 08:7, May 14:4, Aug 19:8
36416 Collection of capillary blood specimen (eg, finger, heel, ear
stick)
36420 Venipuncture, cutdown; younger than age 1 year

➲ CPT Assistant Nov 99:32-33, Aug 00:2, Oct 03:2, Jul
06:4
36425 age 1 or over

36478)
36430 Transfusion, blood or blood components
➲ CPT Assistant Aug 97:18, Nov 99:32-33, Aug 00:2, Mar
01:10, Oct 03:2, Jul 06:4, Jul 07:1, Jul 17:4
(When a partial exchange transfusion is performed in a
newborn, use 36456)
36440 Push transfusion, blood, 2 years or younger
➲ CPT Assistant Aug 00:2, Oct 03:2, Jul 06:4, Jul 07:1, Jul
17:4
newborn, use 36456)
36450 Exchange transfusion, blood; newborn

newborn, use 36456)
▶ (Formanual red cell exchange, see 36450, 36455,
36456)◀
▶ (For automated red cell exchange, use 36512)◀
36455 other than newborn
36456 Partial exchange transfusion, blood, plasma or crystalloid
necessitating the skill of a physician or other qualified
health care professional, newborn

36450)
36460 Transfusion, intrauterine, fetal
Codes 36468, 36470, 36471 describe injection(s) of a sclerosant
for sclerotherapy of telangiectasia and/or incompetent vein(s).
Code 36468 may only be reported once per extremity per session,
regardless of the number of needle injections performed. Codes
36466, 36471 may only be reported once per extremity, regardless
of the number of veins treated. Ultrasound guidance (76942),
when performed, is not included in 36468, 36470, 36471 and may
be reported separately.
Codes 36465, 36466 describe injection(s) of a non-compounded
foam sclerosant into an extremity truncal vein (eg, great
saphenous vein, accessory saphenous vein) using ultrasound-
guided compression of the junction of the central vein
(saphenofemoral junction or saphenopopliteal junction) to limit
the dispersion of injectate. Do not report 36465, 36466 for
injection of compounded foam sclerosant(s).
Compounding is a practice in which a qualified health care
professional (eg, pharmacist, physician) combines, mixes, or
alters ingredients of a drug to create a medication tailored to the
needs of an individual patient.
When performed in the office setting, all required supplies and
equipment are included in 36465, 36466, 36468, 36470, 36471
and may not be separately reported. In addition, application of
compression dressing(s) (eg, compression bandages/stockings) is
included in 36465, 36466, 36468, 36470, 36471, when performed,
and may not be reported separately.
36468 Injection(s) of sclerosant for spider veins (telangiectasia),
limb or trunk
➲ CPT Assistant Aug 14:14, Oct 14:6, Apr 15:10, Nov
16:3, Mar 18:3
17:3
(For ultrasound imaging guidance performed in conjunction
with 36468, use 76942)
29540, 29550, 29580, 29581, 29584, for the same
extremity)
(Do not report 36468 more than once per extremity)
(Do not report 36468 in conjunction with 37241 in the same
surgical field)
36470 Injection of sclerosant; single incompetent vein (other than
telangiectasia)
➲ CPT Assistant Oct 14:6, Apr 15:10, Nov 15:10, Nov
16:3, Mar 18:3, Dec 18:10
17:3
36471 multiple incompetent veins (other than telangiectasia),
same leg
➲ CPT Assistant Oct 14:6, Apr 15:10, Aug 15:8, Nov
15:10, Nov 16:3, Mar 18:3, Dec 18:10
Spring 17:3
(For ultrasound imaging guidance performed in conjunction
with 36470, 36471, use 76942)
29530, 29540, 29550, 29580, 29581, 29584, for the same
extremity)
(If the targeted vein is an extremity truncal vein and
injection of non-compounded foam sclerosant with
ultrasound guided compression maneuvers to guide
dispersion of the injectate is performed, see 36465, 36466)
(Do not report 36470, 36471 in conjunction with 37241 in
the same surgical field)
# 36465 Injection of non-compounded foam sclerosant with
ultrasound compression maneuvers to guide dispersion of
the injectate, inclusive of all imaging guidance and
monitoring; single incompetent extremity truncal vein (eg,
great saphenous vein, accessory saphenous vein)
➲ CPT Assistant Mar 18:3, Dec 18:10, Feb 19:9
# 36466 multiple incompetent truncal veins (eg, great saphenous

vein, accessory saphenous vein), same leg

29530, 29540, 29550, 29580, 29581, 29584, for the same
extremity)
(Do not report 36465, 36466 in conjunction with 37241 in
the same surgical field)
(For extremity truncal vein injection of compounded foam
sclerosant[s], see 36470, 36471)
(For injection of a sclerosant into an incompetent vein
without compression maneuvers to guide dispersion of the
injectate, see 36470, 36471)
(For endovenous ablation therapy of incompetent vein[s] by
transcatheter delivery of a chemical adhesive, see 36482,
36483)
(For vascular embolization and occlusion procedures, see
37241, 37242, 37243, 37244)
Codes 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483
describe endovascular ablation therapy of incompetent extremity
vein(s), including all necessary imaging guidance and
monitoring. Sclerosant injection(s) of vein(s) by needle or mini-
catheter (36468, 36470, 36471) followed by a compression
technique is not endovascular ablation therapy. Codes 36473,
36474, 36482, 36483 can be performed under local anesthesia
without the need for tumescent (peri-saphenous) anesthesia.
Codes 36475, 36476, 36478, 36479 are performed using
adjunctive tumescent anesthesia.
Codes 36473, 36474 involve concomitant use of an intraluminal
device that mechanically disrupts/abrades the venous intima and
infusion of a physician-specified medication in the target vein(s).
Codes 36482, 36483 involve positioning an intravenous catheter
the length of an incompetent vein, remote from the percutaneous
access site, with subsequent delivery of a chemical adhesive to
ablate the incompetent vein. This often includes ultrasound
compression of the outflow vein to limit the dispersion of the
injected solution.
Codes 36475, 36476 involve advancing a radiofrequency device
the length of an incompetent vein, with subsequent delivery of
radiofrequency energy to ablate the incompetent vein.
Codes 36478, 36479 involve advancing a laser device the length
of an incompetent vein, with subsequent delivery of thermal
energy to ablate the incompetent vein.
Codes 36474, 36476, 36479, 36483 for subsequent vein(s) treated
in the same extremity may only be reported once per extremity,
regardless of the number of additional vein(s) treated.
When performed in the office setting, all required supplies and
equipment are included in 36473, 36474, 36475, 36476, 36478,
36479, 36482, 36483 and may not be separately reported. In
addition, application of compression dressing(s) (eg,
compression bandages/stockings) is included in 36473, 36474,
36475, 36476, 36478, 36479, 36482, 36483, when performed, and
may not be reported separately.
36473 Endovenous ablation therapy of incompetent vein, extremity,
inclusive of all imaging guidance and monitoring,
percutaneous, mechanochemical; first vein treated
➲ CPT Assistant Nov 16:3, May 17:3, Mar 18:3, Feb 19:9
✚ 36474 subsequent vein(s) treated in a single extremity, each

through separate access sites (List separately in addition
➲ CPT Assistant Nov 16:3, May 17:3, Mar 18:3, Feb
19:9

29530, 29540, 29550, 29580, 29581, 29584, for the same
extremity)
36002, 36005, 36410, 36425, 36475, 36476, 36478, 36479,
37241, 75894, 76000, 76937, 76942, 76998, 77022, 93970,
93971, in the same surgical field)
percutaneous, radiofrequency; first vein treated
➲ CPT Assistant Jul 10:11, Mar 14:4, Oct 14:6, Apr 15:10,
Nov 16:3, Mar 18:3

➲ CPT Assistant Jul 10:11, Mar 14:4, Oct 14:6, Apr
15:10, Nov 16:3, Mar 18:3

29530, 29540, 29550, 29580, 29581, 29584, for the same
extremity)
36002, 36005, 36410, 36425, 36478, 36479, 36482, 36483,
37241-37244, 75894, 76000, 76937, 76942, 76998, 77022,
93970, 93971, in the same surgical field)
percutaneous, laser; first vein treated
➲ CPT Assistant Jul 12:12, Mar 14:4, Oct 14:6, Apr 15:10,
Nov 16:3, Mar 18:3

➲ CPT Assistant Jul 10:11, Jul 12:12, Mar 14:4, Aug
14:14, Oct 14:6, Apr 15:10, Nov 16:3, Mar 18:3
29530, 29540, 29550, 29580, 29581, 29584, for the same
extremity)
36002, 36005, 36410, 36425, 36475, 36476, 36482, 36483,
37241, 75894, 76000, 76937, 76942, 76998, 77022, 93970,
# 36482 Endovenous ablation therapy of incompetent vein, extremity,
by transcatheter delivery of a chemical adhesive (eg,
cyanoacrylate) remote from the access site, inclusive of all
imaging guidance and monitoring, percutaneous; first vein
treated
➲ CPT Assistant Mar 18:3, Feb 19:9
#✚ 36483 subsequent vein(s) treated in a single extremity, each


29530, 29540, 29550, 29580, 29581, 29584, for the same
extremity)
36002, 36005, 36410, 36425, 36475, 36476, 36478, 36479,
37241, 75894, 76000, 76937, 76942, 76998, 77022, 93970,
36481 Percutaneous portal vein catheterization by any method
➲ CPT Assistant Oct 96:1, Mar 02:10, Dec 03:2

75887)
36500 Venous catheterization for selective organ blood sampling
(For catheterization in superior or inferior vena cava, use

36010)
36510 Catheterization of umbilical vein for diagnosis or therapy,
newborn
➲ CPT Assistant Nov 99:5-6, Aug 00:2, Oct 03:2, Jul 06:4,
Jul 07:1, May 16:3
36511 Therapeutic apheresis; for white blood cells
36512 for red blood cells

▶ (Formanual red cell exchange, see 36450, 36455,

36456)◀
▶ (For automated red cell exchange, use 36512)◀
36513 for platelets
(Report 36513 only when platelets are removed by

apheresis for treatment of the patient. Do not report 36513
for donor platelet collections)
36514 for plasma pheresis
➲ CPT Assistant Oct 13:3, May 18:10
(36515 has been deleted. For therapeutic apheresis with

extracorporeal immunoadsorption and plasma reinfusion,
use 36516)
36516 with extracorporeal immunoadsorption, selective
adsorption or selective filtration and plasma reinfusion
(For professional evaluation, use modifier 26)

36522 Photopheresis, extracorporeal
➲ CPT Assistant Fall 93:25, Jun 09:3, Sep 09:3, Aug
10:12, Oct 13:3, May 18:10
(For dialysis services, see 90935-90999)
(For ultrafiltration, use 90999)
(For therapeutic apheresis for white blood cells, red blood
cells, platelets and plasma pheresis, see 36511, 36512,
36513, 36514)
(For therapeutic apheresis extracorporeal adsorption
Central Venous Access Procedures

To qualify as a central venous access catheter or device, the tip of
the catheter/device must terminate in the subclavian,
brachiocephalic (innominate) or iliac veins, the superior or
inferior vena cava, or the right atrium. The venous access device
may be either centrally inserted (jugular, subclavian, femoral vein
or inferior vena cava catheter entry site) or peripherally inserted
(eg, basilic, cephalic, or saphenous vein entry site). The device
may be accessed for use either via exposed catheter (external to
the skin), via a subcutaneous port or via a subcutaneous pump.
The procedures involving these types of devices fall into five
categories:
1. Insertion (placement of catheter through a newly established
venous access)
2. Repair (fixing device without replacement of either catheter or
port/pump, other than pharmacologic or mechanical correction
of intracatheter or pericatheter occlusion [see 36595 or 36596])
3. Partial replacement of only the catheter component associated
with a port/pump device, but not entire device
4. Complete replacement of entire device via same venous access
site (complete exchange)
5. Removal of entire device.
There is no coding distinction between venous access achieved
percutaneously versus by cutdown or based on catheter size.
For the repair, partial (catheter only) replacement, complete
replacement, or removal of both catheters (placed from separate
venous access sites) of a multi-catheter device, with or without
subcutaneous ports/pumps, use the appropriate code describing
the service with a frequency of two.
If an existing central venous access device is removed and a new
one placed via a separate venous access site, appropriate codes
for both procedures (removal of old, if code exists, and insertion
of new device) should be reported.
When imaging guidance is used for centrally inserted central
venous catheters, for gaining access to the venous entry site
and/or for manipulating the catheter into final central position,
imaging guidance codes (eg, 76937, 77001) may be reported
separately. Do not use 76937, 77001 in conjunction with 36568,
36569, 36572, 36573, 36584.
(For refilling and maintenance of an implantable pump or
reservoir for intravenous or intra-arterial drug delivery, use
96522)
Insertion of Central Venous Access Device
36555 Insertion of non-tunneled centrally inserted central venous

catheter; younger than 5 years of age
➲ CPT Assistant Dec 04:7, Jul 06:4, Jul 07:1, Jun 08:8
➲ Clinical Examples in Radiology Summer 06:8-9, Winter
09:9, Spring 09:10, Winter 17:8
(For peripherally inserted non-tunneled central venous
catheter, younger than 5 years of age, use 36568)
36556 age 5 years or older
➲ CPT Assistant Dec 04:7, Jun 08:8, Nov 18:11
➲ Clinical Examples in Radiology Summer 06:8-9,
Spring 08:7, 8, Winter 09:8, 9, Spring 09:10, Winter
17:8
(For peripherally inserted non-tunneled central venous
catheter, age 5 years or older, use 36569)
36557 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port
or pump; younger than 5 years of age
➲ CPT Assistant Dec 04:7, Jun 08:8
➲ Clinical Examples in Radiology Winter 09:9, Spring 09:10, Winter 17:10

➲ CPT Assistant Dec 04:7, Jun 08:8, Jan 15:13
(For peripherally inserted central venous catheter with port, 5 years or older, use 36571)
Insertion of Non-Tunneled Centrally Inserted Central Venous Catheter

36555
During placement of a central venous catheter, a short tract is developed as the catheter is advanced from the skin entry site to the point of
venous cannulation. The catheter tip must reside in the subclavian, innominate or iliac veins, the inferior or superior vena cava, or right atrium to
be considered a “central venous” catheter.
36560 Insertion of tunneled centrally inserted central venous access device, with subcutaneous
port; younger than 5 years of age
➲ CPT Assistant Dec 04:7, Jun 08:8, Dec 09:11
(For peripherally inserted central venous access device with subcutaneous port, younger
than 5 years of age, use 36570)
(For peripherally inserted central venous catheter with subcutaneous port, 5 years or older,
use 36571)
36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous
pump
Insertion of Non-Tunneled Centrally Inserted Central Venous Catheter

36556
During placement of a central venous catheter, a short tract is developed as the catheter is advanced from the skin entry site to the point of
venous cannulation. The catheter tip must reside in the subclavian, innominate or iliac veins, the inferior or superior vena cava, or right atrium, to
be considered a “central venous” catheter.
Insertion of Tunneled Central Venous Catheter

36557-36558
36565 Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters
via 2 separate venous access sites; without subcutaneous port or pump (eg, Tesio type
catheter)
36566 with subcutaneous port(s)

Peripherally inserted central venous catheters (PICCs) may be placed or replaced with or
without imaging guidance. When performed without imaging guidance, report using 36568
or 36569. When imaging guidance (eg, ultrasound, fluoroscopy) is used for PICC
placement or complete replacement, bundled service codes 36572, 36573, 36584 include all
imaging necessary to complete the procedure, image documentation (representative images
from all modalities used are stored to patient’s permanent record), associated radiological
supervision and interpretation, venography performed through the same venous puncture,
and documentation of final central position of the catheter with imaging. Ultrasound
guidance for PICC placement should include documentation of evaluation of the potential
puncture sites, patency of the entry vein, and real-time ultrasound visualization of needle
entry into the vein.
Codes 71045, 71046, 71047, 71048 should not be reported for the purpose of documenting
the final catheter position on the same day of service as 36572, 36573, 36584. Codes 36572,
36573, 36584 include confirmation of catheter tip location. The physician or other qualified
health care professional reporting image-guided PICC insertion cannot report confirmation
of catheter tip location separately (eg, via X ray, ultrasound). Report 36572, 36573, 36584
with modifier 52 when performed without confirmation of catheter tip location.
“Midline” catheters by definition terminate in the peripheral venous system. They are not
central venous access devices and may not be reported as a PICC service. Midline catheter
placement may be reported with 36400, 36406, or 36410. PICCs placed using magnetic
guidance or any other guidance modality that does not include imaging or image
documentation are reported with 36568, 36569.
36568 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous
port or pump, without imaging guidance; younger than 5 years of age
➲ CPT Assistant Oct 04:14, Dec 04:8, May 05:13, Jun 08:8, Nov 12:14, May 19:3
➲ Clinical Examples in Radiology Winter 09:9, Spring 09:10, Winter 17:10, Fall 18:7,
Winter 19:12
(For placement of centrally inserted non-tunneled central venous catheter, without
subcutaneous port or pump, younger than 5 years of age, use 36555)
(For placement of peripherally inserted non-tunneled central venous catheter, without
subcutaneous port or pump, with imaging guidance, younger than 5 years of age, use
36572)
➲ CPT Assistant Oct 04:14, Dec 04:8, May 05:13, Jun 08:8, Nov 12:14, Sep 13:18,
Sep 14:13, May 19:3
➲ Clinical Examples in Radiology 2004_Inaugural 04:1-2, Spring 08:7, Fall 08:5, 6,
Winter 09:9, Spring 09:10, Winter 17:10, Fall 18:7, Winter 19:12
subcutaneous port or pump, age 5 years or older, use 36556)
subcutaneous port or pump, with imaging guidance, age 5 years or older, use 36573)
# 36572 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous
port or pump, including all imaging guidance, image documentation, and all associated
radiological supervision and interpretation required to perform the insertion; younger than
5 years of age
➲ CPT Assistant Mar 19:10, May 19:3

subcutaneous port or pump, younger than 5 years of age, use 36555)
subcutaneous port or pump, without imaging guidance, younger than 5 years of age, use
36568)
# 36573 age 5 years or older

subcutaneous port or pump, age 5 years or older, use 36556)
subcutaneous port or pump, without imaging guidance, age 5 years or older, use 36569)
Peripherally Inserted Central Catheter

36572
A peripherally inserted central catheter, which is non-tunneled and without a subcutaneous port/pump, is placed in a child younger than 5 years of
age.
36570 Insertion of peripherally inserted central venous access device, with subcutaneous port;
younger than 5 years of age
(For insertion of tunneled centrally inserted central venous access device with
subcutaneous port, younger than 5 years of age, use 36560)
Implantable Venous Access Port

36570, 36571, 36576, 36578

(For insertion of tunneled centrally inserted central venous access device with
subcutaneous port, age 5 years or older, use 36561)
Repair of Central Venous Access Device
(For mechanical removal of pericatheter obstructive material, use 36595)

(For mechanical removal of intracatheter obstructive material, use 36596)
36575 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous
port or pump, central or peripheral insertion site
➲ Clinical Examples in Radiology Spring 09:10, Summer 10:11
The Central Venous Access Procedures Table

Non- Tunneled Central Tunneled Tunneled Peripheral <5 ≥5 Any Age
tunneled Without Tunneled With Port With years years
Port or (w/port)
Pump Pump
(w/out (w/pump)
port or
pump)
Insertion
Catheter 36555 36555
(without 36556 36556
imaging
guidance) 36557 36557 36557
36558 36558 36558
36568 (w/o 36568 (w/o 36568
port or pump) port or pump) (w/o
port or
pump)
36569 (w/o 36569 (w/o 36569
port or pump) port or pump) (w/o
port or
pump)
Catheter 36572 (w/o 36572
(with port or pump) (w/o
bundled port or
imaging pump)
guidance) 36573 (w/o 36573
port or pump) (w/o
port or
pump)
Device 36560 36560 36560
36561 36561 36561
36563 36563 36563
36565 36565 36565
36566 36566
36570 36570 36570 (w/port) 36570
(w/port) (w/port) (w/port)
36571 36571 36571 (w/port) 36571
(w/port) (w/port) (w/port)
Repair
Catheter 36575 (w/o 36575 (w/o 36575 (w/o 36575 (w/o 36575
port or pump) port or pump) port or pump) port or pump)
Device 36576 36576 (w/port 36576
(w/port or or pump)
pump)
Partial Replacement - Central Venous Access Device (Catheter only)
36578 36578 36578 36578 36578
Complete Replacement - Central Venous Access Device (Through Same Venous Access Site)
Catheter 36580 (w/o 36580
(without port or pump)
imaging
guidance) 36581 36581 36581
Catheter 36584 (w/o 36584 (w/o 36584 (w/o

(with port or pump) port or pump) port or pump)
bundled
imaging
guidance)
Device 36582 36582 36582
36583 36583 36583
36585 36585 (w/port) 36585
(w/port)
Removal
Catheter 36589 36589
Device 36590 36590 36590 36590 36590
Removal of Obstructive Material from Device
36595 36595 36595 36595 36595 36595 36595
(pericatheter) (pericatheter) (pericatheter) (pericatheter) (pericatheter) (pericatheter) (pericatheter)
36596 36596 36596 36596 36596 36596 36596
(intraluminal) (intraluminal) (intraluminal) (intraluminal) (intraluminal) (intraluminal) (intraluminal)
Repositioning of Catheter
36597 36597 36597 36597 36597 36597 36597 36597 36597
36576 Repair of central venous access device, with subcutaneous port or pump, central or
peripheral insertion site
Partial Replacement of Central Venous Access Device (Catheter Only)
36578 Replacement, catheter only, of central venous access device, with subcutaneous port or
pump, central or peripheral insertion site
(For complete replacement of entire device through same venous access, use 36582 or
36583)
Complete Replacement of Central Venous Access Device Through Same Venous

Access Site
36580 Replacement, complete, of a non-tunneled centrally inserted central venous catheter,

without subcutaneous port or pump, through same venous access
36581 Replacement, complete, of a tunneled centrally inserted central venous catheter, without
subcutaneous port or pump, through same venous access
36582 Replacement, complete, of a tunneled centrally inserted central venous access device, with
subcutaneous port, through same venous access
36583 Replacement, complete, of a tunneled centrally inserted central venous access device, with
subcutaneous pump, through same venous access
➲ CPT Assistant Dec 04:10-11, Jun 08:8
36584 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without
subcutaneous port or pump, through same venous access, including all imaging guidance,
image documentation, and all associated radiological supervision and interpretation
required to perform the replacement
➲ CPT Assistant Dec 04:11, Jun 08:8, Mar 19:10, May 19:3
➲ Clinical Examples in Radiology Winter 09:9, Spring 09:10, Winter 17:10, Fall 18:8
(For replacement of a peripherally inserted central venous catheter [PICC] without

subcutaneous port or pump, through same venous access, without imaging guidance, use
37799)
36585 Replacement, complete, of a peripherally inserted central venous access device, with
subcutaneous port, through same venous access
Removal of Central Venous Access Device
36589 Removal of tunneled central venous catheter, without subcutaneous port or pump
➲ CPT Assistant Dec 04:11, Jun 08:8, Nov 15:10
36590 Removal of tunneled central venous access device, with subcutaneous port or pump,
central or peripheral insertion
➲ CPT Assistant Dec 04:11, Jun 08:8, Jul 10:10
(Do not report 36589 or 36590 for removal of non-tunneled central venous catheters)
Other Central Venous Access Procedures
36591 Collection of blood specimen from a completely implantable venous access device
➲ CPT Assistant Apr 08:9, Jul 11:16, May 14:4, Aug 19:8
(Do not report 36591 in conjunction with other services except a laboratory service)
(For collection of venous blood specimen by venipuncture, use 36415)
(For collection of capillary blood specimen, use 36416)
36592 Collection of blood specimen using established central or peripheral catheter, venous, not
otherwise specified
(For blood collection from an established arterial catheter, use 37799)

(Do not report 36592 in conjunction with other services except a laboratory service)
36593 Declotting by thrombolytic agent of implanted vascular access device or catheter
➲ CPT Assistant Apr 08:9, Dec 09:11, Aug 11:9, Feb 13:3
36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central
venous device via separate venous access

(For venous catheterization, see 36010-36012)
36596 Mechanical removal of intraluminal (intracatheter) obstructive material from central
venous device through device lumen

36597 Repositioning of previously placed central venous catheter under fluoroscopic guidance
➲ CPT Assistant Dec 04:12, Sep 14:5
(For fluoroscopic guidance, use 76000)

36598 Contrast injection(s) for radiologic evaluation of existing central venous access device,
including fluoroscopy, image documentation and report
➲ Clinical Examples in Radiology Winter 06:15, Spring 08:7, Summer 12:4

(For complete diagnostic studies, see 75820, 75825, 75827)
Arterial
36600 Arterial puncture, withdrawal of blood for diagnosis
➲ CPT Assistant Fall 95:7, Aug 00:2, Oct 03:2, Jul 05:11, Jul 06:4, Feb 07:10, Jul 07:1,
May 14:4, Aug 19:8
36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate
procedure); percutaneous
➲ CPT Assistant Fall 95:7, Apr 98:3, Nov 99:32-33, Aug 00:2, Oct 03:2, Jul 06:4, Jul
07:1
36625 cutdown
36640 Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown

(See also 96420-96425)

(For arterial catheterization for occlusion therapy, see 75894)
36660 Catheterization, umbilical artery, newborn, for diagnosis or therapy
➲ CPT Assistant Fall 95:8, Oct 03:2, Jul 06:4, Jul 07:1
Intraosseous
36680 Placement of needle for intraosseous infusion
Hemodialysis Access, Intervascular Cannulation for Extracorporeal

Circulation, or Shunt Insertion
36800 Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein
36810 arteriovenous, external (Scribner type)

➲ CPT Assistant Fall 93:3, May 97:10
36815 arteriovenous, external revision, or closure

36818 Arteriovenous anastomosis, open; by upper arm cephalic vein transposition

➲ CPT Assistant Jul 05:9, Mar 16:10, Mar 17:5
(Do not report 36818 in conjunction with 36819, 36820, 36821, 36830 during a unilateral
upper extremity procedure. For bilateral upper extremity open arteriovenous anastomoses
performed at the same operative session, use modifier 50 or 59 as appropriate)
36819 by upper arm basilic vein transposition
(Do not report 36819 in conjunction with 36818, 36820, 36821, 36830 during a unilateral
upper extremity procedure. For bilateral upper extremity open arteriovenous anastomoses
performed at the same operative session, use modifier 50 or 59 as appropriate)
36820 by forearm vein transposition
➲ CPT Assistant Fall 93:4, Jul 05:9, Mar 17:5
36821 direct, any site (eg, Cimino type) (separate procedure)
➲ CPT Assistant Fall 93:3, Feb 97:2, Nov 99:20, Jul 05:9, Aug 15:8, Mar 17:5
Arteriovenous Anastomosis, Direct

36821
A section of artery and a neighboring vein are joined, allowing blood to flow down the artery and into the vein for the purpose of increasing blood
flow, usually in hemodialysis.
36823 Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including
regional chemotherapy perfusion to an extremity, with or without hyperthermia, with
removal of cannula(s) and repair of arteriotomy and venotomy sites
(36823 includes chemotherapy perfusion supported by a membrane oxygenator/perfusion

pump. Do not report 96409-96425 in conjunction with 36823)
36825 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate
procedure); autogenous graft
➲ CPT Assistant Fall 93:3, Feb 97:2, Jul 05:9, Mar 17:5
(For direct arteriovenous anastomosis, use 36821)

36830 nonautogenous graft (eg, biological collagen, thermoplastic graft)
➲ CPT Assistant Fall 93:3, Feb 97:2, Jul 05:9, Jan 15:13, Mar 17:5
(For direct arteriovenous anastomosis, use 36821)
Arteriovenous Fistula
36825-36830
A donor’s vein (36825) or a synthetic vein (36830) is used to connect an artery and vein.
36831 Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous
dialysis graft (separate procedure)
➲ CPT Assistant Nov 98:14-15, Feb 99:6, Mar 99:6, Apr 99:11, Mar 17:5
36832 Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous

dialysis graft (separate procedure)
➲ CPT Assistant Fall 93:3, Feb 97:2, Nov 98:15, Feb 99:6, Mar 99:6, Apr 99:11, Nov
99:20-21, Mar 17:5
36833 with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)
➲ CPT Assistant Nov 98:15, Feb 99:6, Apr 99:11, Mar 17:5
(For percutaneous thrombectomy within the dialysis circuit, see 36904, 36905, 36906)
(For central dialysis segment angioplasty in conjunction with 36818-36833, use 36907)
(For central dialysis segment stent placement in conjunction with 36818-36833, use
36908)
(Do not report 36832, 36833 in conjunction with 36901, 36902, 36903, 36904, 36905,
36906 for revision of the dialysis circuit)
36835 Insertion of Thomas shunt (separate procedure)
36838 Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access
(steal syndrome)
(Do not report 36838 in conjunction with 35512, 35522, 35523, 36832, 37607, 37618)
36860 External cannula declotting (separate procedure); without balloon catheter
➲ CPT Assistant Fall 93:3, Feb 97:2, Nov 98:15, Feb 99:6, May 01:3
36861 with balloon catheter

➲ CPT Assistant Fall 93:3, Feb 97:2, May 01:3

Dialysis Circuit
Definitions
Dialysis circuit: The arteriovenous (AV) dialysis circuit is designed for easy and repetitive
access to perform hemodialysis. It begins at the arterial anastomosis and extends to the right
atrium. The circuit may be created using either an arterial-venous anastomosis, known as
an arteriovenous fistula (AVF), or a prosthetic graft placed between an artery and vein,
known as an arteriovenous graft (AVG). The dialysis circuit is comprised of two segments,
termed the (1) peripheral dialysis segment and (2) central dialysis segment. Both are
defined as follows.
Peripheral dialysis segment: The peripheral dialysis segment is the portion of the dialysis
circuit that begins at the arterial anastomosis and extends to the central dialysis segment. In
the upper extremity, the peripheral dialysis segment extends through the axillary vein (or
entire cephalic vein in the case of cephalic venous outflow). In the lower extremity, the
peripheral dialysis segment extends through the common femoral vein. The peripheral
dialysis segment includes the historic “peri-anastomotic region” (defined below).
Central dialysis segment: The central dialysis segment includes all draining veins central to
the peripheral dialysis segment. In the upper extremity, the central dialysis segment includes
the veins central to the axillary and cephalic veins, including the subclavian and innominate
veins through the superior vena cava. In the lower extremity, the central dialysis segment
includes the veins central to the common femoral vein, including the external iliac and
common iliac veins through the inferior vena cava.
Peri-anastomotic region: A historic term referring to the region of a dialysis circuit near
the arterial anastomosis encompassing a short segment of the parent artery, the
anastomosis, and a short segment of the dialysis circuit immediately adjacent to the
anastomosis. The peri-anastomotic region is included within the peripheral segment of the
dialysis circuit.
Performed through dialysis circuit: Any diagnostic study or therapeutic intervention within
the dialysis circuit that is performed through a direct percutaneous access to the dialysis
circuit.
Code 36901 includes direct access and imaging of the entire dialysis circuit. Antegrade
and/or retrograde punctures of the dialysis circuit are typically used for imaging, and
contrast may be injected directly through a needle or through a catheter placed into the
dialysis circuit. All dialysis circuit punctures required to perform the procedure are
included in 36901. Occasionally, the catheter needs to be advanced further into the circuit
to adequately visualize the arterial anastomosis or the central veins, or selective
catheterization of a venous branch may be required. All manipulation(s) of the catheter for
diagnostic imaging of the dialysis circuit is included in 36901. Advancement of the catheter
to the vena cava to adequately image that segment of the dialysis circuit is included in
36901 and is not separately reported. Code 36901 also includes catheterization of additional
venous side branches communicating with the dialysis circuit, known as accessory veins.
Advancement of the catheter tip through the arterial anastomosis to adequately visualize the
anastomosis is also included in the service described by 36901 and is not separately
reported. Evaluation of the peri-anastomotic portion of the inflow is an integral part of the
dialysis circuit angiogram and is included in 36901.
For the purposes of reporting dialysis access maintenance services, the arterial inflow to the
dialysis circuit is considered a separate vessel. If a more proximal arterial inflow problem
separate from the peripheral dialysis segment is suspected, additional catheter placement
and imaging required for adequate evaluation of the artery may be separately reported. If a
catheter is selectively advanced from the dialysis circuit puncture beyond the peri-
anastomotic segment into the inflow artery, an additional catheterization code may be
reported. For example, 36215 may be used to report image-guided retrograde catheter
placement into the inflow artery and into the aorta, if necessary (36200 is not reported in
addition to 36215 in this example). Note that 75710 may also be reported if contrast
injection for diagnostic arteriography is performed through this catheter and radiological
supervision and interpretation and imaging documentation is performed.
Ultrasound guidance for puncture of the dialysis circuit access is not typically performed
and is not included in 36901, 36902, 36903, 36904, 36905, 36906. However, in the case of a
new (immature) or failing AVF, ultrasound may be necessary to safely and effectively
puncture the dialysis circuit for evaluation, and this may be reported separately with 76937,
if all the appropriate elements for reporting 76937 are performed and documented.
For radiological supervision and interpretation of dialysis circuit angiography performed
through existing access(es) or catheter-based arterial access, report 36901 with modifier 52.
Dialysis Circuit Interventions (AV Grafts and AV Fistulae): For the purposes of coding
interventional procedures in the dialysis circuit (both AVF and AVG), the dialysis circuit is
artificially divided into two distinct segments: peripheral dialysis segment and central
dialysis segment (see definitions).
Codes 36901, 36902, 36903 and 36904, 36905, 36906 are built on progressive hierarchies
that have more intensive services, which include less intensive services. Report only one
code (36901, 36902, 36903, 36904, 36905, 36906) for services provided in a dialysis circuit.
Code 36901 describes the diagnostic evaluation of the dialysis circuit, and this service is
included in the services described by 36901, 36902, 36903, 36904, 36905, 36906. All
catheterizations required to perform diagnostic fistulography are included in 36901. All
catheterizations required to perform additional interventional services are included in codes
36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909 and not separately reported. All
angiography, fluoroscopic image guidance, roadmapping, and radiological supervision and
interpretation required to perform each service are included in each code. Closure of the
puncture(s) by any method is included in the service of each individual code.
Code 36902 includes the services in 36901 plus transluminal balloon angioplasty in the
peripheral segment of the dialysis circuit. Code 36902 would be reported only once per
session to describe all angioplasty services performed in the peripheral segment of the
dialysis circuit, regardless of the number of distinct lesions treated within that segment, the
number of times the balloon is inflated, or the number of balloon catheters or sizes
required to open all lesions, and includes angioplasty of the peri-anastomotic segment
when performed. Code 36903 includes the services in 36902 plus transcatheter stent
placement in the peripheral segment of the dialysis circuit. Code 36903 is reported only
once per session to describe placing stent(s) within the peripheral segment, regardless of
the number of stent(s) placed or the number of discrete lesion(s) treated within the
peripheral segment. If both angioplasty and stenting are performed in the peripheral
segment, including treatment of separate lesions, report 36903 only once.
Code 36904 describes percutaneous transluminal mechanical thrombectomy and/or
infusion for thrombolysis in the dialysis circuit (all thrombus treated in both the peripheral
and central dialysis circuit segments) and includes diagnostic angiography (36901),
fluoroscopic image guidance, catheter placement(s), and all maneuvers required to remove
thrombus from the peripheral and/or central segments, including all intraprocedural
pharmacological thrombolytic injection(s)/infusion(s). It is never appropriate to report
removal of the arterial plug during a declot/thrombectomy procedure as an angioplasty
(36905). Removal of the arterial plug is included in a fistula thrombectomy, even if a
balloon catheter is used to mechanically dislodge the resistant thrombus. Codes 36905
(angioplasty) and 36906 (stent) describe services in the peripheral circuit when performed
in conjunction with thrombolysis/thrombectomy. Code 36905 includes the services in
36904 plus transluminal balloon angioplasty in the peripheral segment of the dialysis
circuit. Code 36905 may be reported only once per session to describe all angioplasty
performed in the peripheral segment of the dialysis circuit, regardless of the number of
distinct lesions treated within that segment, the number of times the balloon is inflated, or
the number of balloon catheters required to open all lesions. Code 36906 includes the
services in 36905 plus transcatheter stent placement in the peripheral segment of the dialysis
circuit. Code 36906 is reported only once per session to describe placing stent(s) within the
peripheral segment, regardless of the number of stent(s) placed or the number of discrete
lesion(s) treated within the peripheral segment.
Codes 36907 and 36908 describe procedures performed through puncture(s) in the dialysis
circuit. Similar procedures performed from a different access (eg, common femoral vein)
may be reported using 37248, 37249 or 37238, 37239. Code 36907 is an add-on code used
in conjunction with 36901, 36902, 36903, 36904, 36905, 36906 to report angioplasty within
the central dialysis segment when performed through puncture of the dialysis circuit, and is
reported once per session independent of the number of discrete lesions treated, the
number of balloon inflations, and number of balloon catheters or sizes required. These
additional services should be clearly documented in the patient record, including the
recorded images. Code 36907 may be reported only once per session with 36901, 36902,
36903, 36904, 36905, 36906, as appropriate. Report 36907 once for all angioplasty
performed within the central dialysis segment.
Code 36908 is an add-on code used in conjunction with 36901, 36902, 36903, 36904,
36905, 36906 to report stenting lesion(s) in the central dialysis segment when performed
through puncture of the dialysis circuit. It is reported once, regardless of the number of
discrete lesions treated or the number of stents placed. Code 36908 includes the services in
36907; therefore, 36908 may not be reported with 36907 in the same session. Code 36908
may be reported only once per session with 36901, 36902, 36903, 36904, 36905, 36906, as
appropriate.
Code 36909 is an add-on code used to report endovascular embolization or occlusion of the
main vessel or side branches arising from (emptying into) the dialysis circuit. Code 36909
may only be reported once per therapeutic session, irrespective of the number of branches
embolized or occluded. Embolization or occlusion of the main vessel or these side branches
may not be reported with 37241.
If open dialysis circuit creation, revision, and/or thrombectomy (36818-36833) are
performed, completion angiography is bundled, as is peripheral segment angioplasty and/or
stent placement (36901, 36902, 36903) and, therefore, not separately reported. However,
dialysis circuit central segment angioplasty and/or stent placement may be separately
reported (36907, 36908).
36901 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography
of the dialysis circuit, including all direct puncture(s) and catheter placement(s),
injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent
artery through entire venous outflow including the inferior or superior vena cava,
fluoroscopic guidance, radiological supervision and interpretation and image
documentation and report;
(Do not report 36901 in conjunction with 36833, 36902, 36903, 36904, 36905, 36906)
36902 with transluminal balloon angioplasty, peripheral dialysis segment, including all
imaging and radiological supervision and interpretation necessary to perform the
angioplasty

36903 with transcatheter placement of intravascular stent(s), peripheral dialysis segment,
including all imaging and radiological supervision and interpretation necessary to
perform the stenting, and all angioplasty within the peripheral dialysis segment
(Do not report 36902, 36903 in conjunction with 36833, 36904, 36905, 36906)
(Do not report 36901, 36902, 36903 more than once per operative session)
(For transluminal balloon angioplasty within central vein(s) when performed through
dialysis circuit, use 36907)
(For transcatheter placement of intravascular stent(s) within central vein(s) when
performed through dialysis circuit, use 36908)
36904 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis,
dialysis circuit, any method, including all imaging and radiological supervision and
interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and
intraprocedural pharmacological thrombolytic injection(s);
(For open thrombectomy within the dialysis circuit, see 36831, 36833)
36905 with transluminal balloon angioplasty, peripheral dialysis segment, including all
imaging and radiological supervision and interpretation necessary to perform the
angioplasty

36906 with transcatheter placement of intravascular stent(s), peripheral dialysis segment,
including all imaging and radiological supervision and interpretation necessary to
perform the stenting, and all angioplasty within the peripheral dialysis circuit
(Do not report 36906 in conjunction with 36901, 36902, 36903, 36904, 36905)
(Do not report 36904, 36905, 36906 more than once per operative session)
(For transluminal balloon angioplasty within central vein(s) when performed through
dialysis circuit, use 36907)
(For transcatheter placement of intravascular stent(s) within central vein(s) when
performed through dialysis circuit, use 36908)
✚ 36907 Transluminal balloon angioplasty, central dialysis segment, performed through dialysis
circuit, including all imaging and radiological supervision and interpretation required to
perform the angioplasty (List separately in addition to code for primary procedure)
(Use 36907 in conjunction with 36818-36833, 36901, 36902, 36903, 36904, 36905,
36906)
(Report 36907 once for all angioplasty performed within the central dialysis segment)
✚ 36908 Transcatheter placement of intravascular stent(s), central dialysis segment, performed
through dialysis circuit, including all imaging and radiological supervision and
interpretation required to perform the stenting, and all angioplasty in the central dialysis
segment (List separately in addition to code for primary procedure)
(Use 36908 in conjunction with 36818-36833, 36901, 36902, 36903, 36904, 36905,
36906)
(Report 36908 once for all stenting performed within the central dialysis segment)
✚ 36909 Dialysis circuit permanent vascular embolization or occlusion (including main circuit or
any accessory veins), endovascular, including all imaging and radiological supervision and
interpretation necessary to complete the intervention (List separately in addition to code
(36909 includes all permanent vascular occlusions within the dialysis circuit and may only
be reported once per encounter per day)
(Report 36909 in conjunction with 36901, 36902, 36903, 36904, 36905, 36906)
(For open ligation/occlusion in dialysis access, use 37607)
Portal Decompression Procedures

37140 Venous anastomosis, open; portocaval
(For peritoneal-venous shunt, use 49425)

37145 renoportal
37160 caval-mesenteric
37180 splenorenal, proximal
37181 splenorenal, distal (selective decompression of esophagogastric varices, any technique)
(For percutaneous procedure, use 37182)
37182 Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous
access, hepatic and portal vein catheterization, portography with hemodynamic evaluation,
intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance
and documentation)
(Do not report 75885 or 75887 in conjunction with 37182)

37183 Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous
access, hepatic and portal vein catheterization, portography with hemodynamic evaluation,
intrahepatic tract recannulization/dilatation, stent placement and all associated imaging
guidance and documentation)
(Do not report 75885 or 75887 in conjunction with 37183)
(For repair of arteriovenous aneurysm, use 36832)
Transcatheter Procedures
Codes for catheter placement and the radiologic supervision and interpretation should also
be reported, in addition to the code(s) for the therapeutic aspect of the procedure.
Mechanical Thrombectomy
Code(s) for catheter placement(s), diagnostic studies, and other percutaneous interventions
(eg, transluminal balloon angioplasty, stent placement) provided are separately reportable.
Codes 37184-37188 specifically include intraprocedural fluoroscopic radiological
supervision and interpretation services for guidance of the procedure.
Intraprocedural injection(s) of a thrombolytic agent is an included service and not
separately reportable in conjunction with mechanical thrombectomy. However, subsequent
or prior continuous infusion of a thrombolytic is not an included service and is separately
reportable (see 37211-37214).
For coronary mechanical thrombectomy, use 92973.
For intracranial arterial mechanical thrombectomy, use 61645.
Transcatheter Thrombolytic Infusion
Codes 37211 or 37212 are used to report the initial day of transcatheter thrombolytic
infusion(s) including follow-up arteriography/venography, and catheter position change or
exchange, when performed. To report bilateral thrombolytic infusion through a separate
access site(s), use modifier 50 in conjunction with 37211, 37212. Code 37213 is used to
report continued transcatheter thrombolytic infusion(s) on subsequent day(s), other than
initial day and final day of treatment. Code 37214 is used to report final day of transcatheter
thrombolytic infusion(s). When initiation and completion of thrombolysis occur on the
same day, report only 37211 or 37212.
Code(s) for catheter placement(s), diagnostic studies, and other percutaneous interventions
(eg, transluminal balloon angioplasty, stent placement) provided may be separately
reportable.
Codes 37211-37214 include fluoroscopic guidance and associated radiological supervision
and interpretation.
Ongoing evaluation and management services on the day of the procedure related to
thrombolysis are included in 37211-37214. If a significant, separately identifiable E/M
service is performed by the same physician on the same day of the procedure, report the
appropriate level of E/M service and append modifier 25.
Ultrasound guidance for vascular access is not included in 37211-37214. Code 76937 may
be reported separately when performed if all the required elements are performed.
For intracranial arterial mechanical thrombectomy and/or infusion for thrombolysis, use
61645.
Arterial Mechanical Thrombectomy
Arterial mechanical thrombectomy may be performed as a “primary” transcatheter
procedure with pretreatment planning, performance of the procedure, and postprocedure
evaluation focused on providing this service. Typically, the diagnosis of thrombus has been
made prior to the procedure, and a mechanical thrombectomy is planned preoperatively.
Primary mechanical thrombectomy is reported per vascular family using 37184 for the
initial vessel treated and 37185 for second or all subsequent vessel(s) within the same
vascular family. To report mechanical thrombectomy of an additional vascular family
treated through a separate access site, use modifier 59 in conjunction with the primary
service code (37184) for the mechanical transluminal thrombectomy.
Primary mechanical thrombectomy may precede or follow another percutaneous
intervention. Most commonly primary mechanical thrombectomy will precede another
percutaneous intervention with the decision regarding the need for other services not made
until after mechanical thrombectomy has been performed. Occasionally, the performance
of primary mechanical thrombectomy may follow another percutaneous intervention.
Do NOT report 37184-37185 for mechanical thrombectomy performed for the retrieval of
short segments of thrombus or embolus evident during other percutaneous interventional
procedures. See 37186 for these procedures.
Arterial mechanical thrombectomy is considered a “secondary” transcatheter procedure for
removal or retrieval of short segments of thrombus or embolus when performed either
before or after another percutaneous intervention (eg, percutaneous transluminal balloon
angioplasty, stent placement). Secondary mechanical thrombectomy is reported using
37186. Do NOT report 37186 in conjunction with 37184-37185.
Venous Mechanical Thrombectomy
Use 37187 to report the initial application of venous mechanical thrombectomy. To report
bilateral venous mechanical thrombectomy performed through a separate access site(s), use
modifier 50 in conjunction with 37187. For repeat treatment on a subsequent day during a
course of thrombolytic therapy, use 37188.
Arterial Mechanical Thrombectomy
37184 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-

intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and
intraprocedural pharmacological thrombolytic injection(s); initial vessel
➲ CPT Assistant Nov 11:11, Feb 13:3, Apr 15:10, Nov 15:3, Sep 19:5
➲ Clinical Examples in Radiology Winter 06:15, Summer 10:4, Winter 13:2-4, Spring
16:3
(Do not report 37184 in conjunction with 61645, 76000, 96374)
✚ 37185 second and all subsequent vessel(s) within the same vascular family (List separately in
addition to code for primary mechanical thrombectomy procedure)
➲ CPT Assistant Nov 11:11, Feb 13:3, Apr 15:10, Nov 15:3, Sep 19:5
➲ Clinical Examples in Radiology Winter 06:15, Winter 13:2, 3, Spring 16:3

(Do not report 37185 in conjunction with 61645 for treatment of the same vascular
territory. See Nervous System Endovascular Therapy)
✚ 37186 Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare
basket, suction technique), noncoronary, non-intracranial, arterial or arterial bypass graft,
including fluoroscopic guidance and intraprocedural pharmacological thrombolytic
injections, provided in conjunction with another percutaneous intervention other than
primary mechanical thrombectomy (List separately in addition to code for primary
procedure)
➲ CPT Assistant Jul 11:11, Nov 11:9, Feb 13:3, Nov 15:3, Sep 19:5
➲ Clinical Examples in Radiology Winter 06:15, Winter 13:4, Spring 16:3

(Do not report 37186 in conjunction with 61645 for treatment of the same vascular
territory. See Nervous System Endovascular Therapy)
Venous Mechanical Thrombectomy
37187 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural

pharmacological thrombolytic injections and fluoroscopic guidance
➲ Clinical Examples in Radiology Winter 06:15, Winter 12:3, Winter 13:4, Summer
13:1-4
37188 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural
pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on
subsequent day during course of thrombolytic therapy
➲ Clinical Examples in Radiology Winter 06:15, Winter 12:3, Winter 13:4, Summer 13:4
Other Procedures
37191 Insertion of intravascular vena cava filter, endovascular approach including vascular
access, vessel selection, and radiological supervision and interpretation, intraprocedural
roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
➲ CPT Assistant Apr 12:8, Feb 13:3, May 16:11, Feb 17:14
➲ Clinical Examples in Radiology Winter 12:1, Winter 16:4
(For open surgical interruption of the inferior vena cava through a laparotomy or
retroperitoneal exposure, use 37619)
37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular
access, vessel selection, and radiological supervision and interpretation, intraprocedural
roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
➲ CPT Assistant Apr 12:8, Feb 13:3, May 16:11
➲ Clinical Examples in Radiology Winter 12:2, Winter 16:4
Vena Cava Filter

37191
37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including
vascular access, vessel selection, and radiological supervision and interpretation,
intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when
performed
➲ CPT Assistant Apr 12:8, Feb 13:3, May 16:11
➲ Clinical Examples in Radiology Winter 12:2, Winter 16:4, Summer 16:12, Summer
18:13
37195 Thrombolysis, cerebral, by intravenous infusion
37197 Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous
or arterial catheter), includes radiological supervision and interpretation, and imaging
guidance (ultrasound or fluoroscopy), when performed
(For percutaneous retrieval of a vena cava filter, use 37193)

(For transcatheter removal of permanent leadless pacemaker, use 33275)
37200 Transcatheter biopsy
37211 Transcatheter therapy, arterial infusion for thrombolysis other than coronary or intracranial,
any method, including radiological supervision and interpretation, initial treatment day
➲ CPT Assistant Feb 13:3, Nov 15:3, Mar 16:3, Sep 19:6
➲ Clinical Examples in Radiology Winter 13:2-4, Spring 13:11, Summer 13:3, 4, Spring
16:3
(For intracranial arterial mechanical thrombectomy and/or infusion for thrombolysis, use
61645)
37212 Transcatheter therapy, venous infusion for thrombolysis, any method, including
radiological supervision and interpretation, initial treatment day
➲ Clinical Examples in Radiology Winter 13:4, Spring 13:11, Summer 13:4, Spring 16:4
37213 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any
method, including radiological supervision and interpretation, continued treatment on
subsequent day during course of thrombolytic therapy, including follow-up catheter
contrast injection, position change, or exchange, when performed;
➲ Clinical Examples in Radiology Winter 13:4, Spring 13:11, Summer 13:1-4, Spring
16:4
37214 cessation of thrombolysis including removal of catheter and vessel closure by any
method
➲ Clinical Examples in Radiology Winter 13:4, Spring 13:11, Summer 13:2-4, Spring
16:4
(Report 37211-37214 once per date of treatment)
(For declotting by thrombolytic agent of implanted vascular access device or catheter, use
36593)
37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, open or
percutaneous, including angioplasty, when performed, and radiological supervision and
interpretation; with distal embolic protection
➲ CPT Assistant May 05:7, Feb 13:3, Mar 14:8
➲ Clinical Examples in Radiology Winter 15:2, 3
37216 without distal embolic protection

➲ CPT Assistant May 05:7, Feb 13:3, Mar 14:8
(37215 and 37216 include all ipsilateral selective carotid catheterization, all diagnostic
imaging for ipsilateral, cervical and cerebral carotid arteriography, and all related
radiological supervision and interpretation. When ipsilateral carotid arteriogram
(including imaging and selective catheterization) confirms the need for carotid stenting,
37215 and 37216 are inclusive of these services. If carotid stenting is not indicated, then
the appropriate codes for carotid catheterization and imaging should be reported in lieu of
37215 and 37216)
(Do not report 37215, 37216 in conjunction with 36222-36224 for the treated carotid
artery)
(For open or percutaneous transcatheter placement of extracranial vertebral artery stent[s],
see Category III codes 0075T, 0076T)
37217 Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or
innominate artery by retrograde treatment, open ipsilateral cervical carotid artery
exposure, including angioplasty, when performed, and radiological supervision and
interpretation
(37217 includes open vessel exposure and vascular access closure, all access and
selective catheterization of the vessel, traversing the lesion, and any radiological
supervision and interpretation directly related to the intervention when performed,
standard closure of arteriotomy by suture, and imaging performed to document completion
of the intervention in addition to the intervention[s] performed. Carotid artery
revascularization services [eg, 33891, 35301, 35509, 35510, 35601, 35606] performed
during the same session may be reported separately, when performed)
(Do not report 37217 in conjunction with 35201, 36221-36227, 37246, 37247 for
ipsilateral services)
(For open or percutaneous transcatheter placement of intravascular cervical carotid artery
stent[s], see 37215, 37216)
(For open or percutaneous antegrade transcatheter placement of innominate and/or
intrathoracic carotid artery stent[s], use 37218)
see 0075T, 0076T)
(For transcatheter placement of intracranial stent[s], use 61635)
37218 Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or
innominate artery, open or percutaneous antegrade approach, including angioplasty, when
performed, and radiological supervision and interpretation
(37218 includes all ipsilateral extracranial intrathoracic selective innominate and carotid
catheterization, all diagnostic imaging for ipsilateral extracranial intrathoracic innominate
and/or carotid artery stenting, and all related radiologic supervision and interpretation.
Report 37218 when the ipsilateral extracranial intrathoracic carotid arteriogram (including
imaging and selective catheterization) confirms the need for stenting. If stenting is not
indicated, report the appropriate codes for selective catheterization and imaging)
(Do not report 37218 in conjunction with 36222, 36223, 36224 for the treated carotid
artery)
(For open or percutaneous transcatheter placement of intravascular cervical carotid artery
stent[s], see 37215, 37216)
see 0075T, 0076T)
(For transcatheter placement of intracranial stent[s], use 61635)
Endovascular Revascularization (Open or Percutaneous,

Transcatheter)
Codes 37220-37235 are to be used to describe lower extremity endovascular
revascularization services performed for occlusive disease. These lower extremity codes are
built on progressive hierarchies with more intensive services inclusive of lesser intensive
services. The code inclusive of all of the services provided for that vessel should be
reported (ie, use the code inclusive of the most intensive services provided). Only one code
from this family (37220-37235) should be reported for each lower extremity vessel treated.
These lower extremity endovascular revascularization codes all include the work of
accessing and selectively catheterizing the vessel, traversing the lesion, radiological
supervision and interpretation directly related to the intervention(s) performed, embolic
protection if used, closure of the arteriotomy by pressure and application of an arterial
closure device or standard closure of the puncture by suture, and imaging performed to
document completion of the intervention in addition to the intervention(s) performed.
Extensive repair or replacement of an artery may be additionally reported (eg, 35226 or
35286). These codes describe endovascular procedures performed percutaneously and/or
through an open surgical exposure. These codes include balloon angioplasty (eg, low-
profile, cutting balloon, cryoplasty), atherectomy (eg, directional, rotational, laser), and
stenting (eg, balloon-expandable, self-expanding, bare metal, covered, drug-eluting). Each
code in this family (37220-37235) includes balloon angioplasty, when performed.
These codes describe revascularization therapies (ie, transluminal angioplasty, atherectomy,
and stent placement) provided in three arterial vascular territories: iliac, femoral/popliteal,
and tibial/peroneal.
When treating multiple vessels within a territory, report each additional vessel using an
add-on code, as applicable. Select the base code that represents the most complex service
using the following hierarchy of complexity (in descending order of complexity):
atherectomy and stent>atherectomy>stent>angioplasty. When treating multiple lesions
within the same vessel, report one service that reflects the combined procedures, whether
done on one lesion or different lesions, using the same hierarchy.
1. Iliac Vascular Territory—The iliac territory is divided into 3 vessels: common iliac,
internal iliac, and external iliac.
2. Femoral/Popliteal Vascular Territory—The entire femoral/popliteal territory in 1 lower
extremity is considered a single vessel for CPT reporting specifically for the
endovascular lower extremity revascularization codes 37224-37227.
3. Tibial/Peroneal Territory—The tibial/peroneal territory is divided into 3 vessels: anterior
tibial, posterior tibial, and peroneal arteries.
There are specific coding guidelines for each of the 3 vascular territories.
1. Iliac Vascular Territory—A single primary code is used for the initial iliac artery treated
in each leg (37220 or 37221). If other iliac vessels are also treated in that leg, these
interventions are reported with the appropriate add-on code(s) (37222, 37223). Up to 2
add-on codes can be used in a unilateral iliac vascular territory since there are 3 vessels
which could be treated. Add-on codes are used for different vessels, not distinct lesions
within the same vessel.
2. Femoral/Popliteal Territory—A single interventional code is used no matter what
combination of angioplasty/stent/atherectomy is applied to all segments, including the
common, deep and superficial femoral arteries as well as the popliteal artery (37224,
37225, 37226, or 37227). There are no add-on codes for additional vessels treated within
the femoral/popliteal territory. Because only 1 service is reported when 2 lesions are
treated in this territory, report the most complex service (eg, use 37227 if a stent is placed
for 1 lesion and an atherectomy is performed on a second lesion).
3. Tibial/Peroneal Territory—A single primary code is used for the initial tibial/peroneal
artery treated in each leg (37228, 37229, 37230, or 37231). If other tibial/peroneal vessels
are also treated in the same leg, these interventions are reported with the appropriate add-
on code(s) (37232-37235). Up to 2 add-on codes could be used to describe services
provided in a single leg since there are 3 tibial/peroneal vessels which could be treated.
Add-on codes are used for different vessels, not distinct lesions within the same vessel.
The common tibio-peroneal trunk is considered part of the tibial/peroneal territory, but is
not considered a separate, fourth segment of vessel in the tibio-peroneal family for CPT
reporting of endovascular lower extremity interventions. For instance, if lesions in the
common tibio-peroneal trunk are treated in conjunction with lesions in the posterior
tibial artery, a single code would be reported for treatment of this segment.
When treating multiple territories in the same leg, one primary lower extremity
revascularization code is used for each territory treated. When second or third vessel(s) are
treated in the iliac and/or tibial/peroneal territories, add-on code(s) are used to report the
additional service(s). When more than one stent is placed in the same vessel, the code
should be reported only once.
When multiple vessels in multiple territories in a single leg are treated at the same setting,
the primary code for the treatment in the initial vessel in each vascular territory is reported.
Add-on code(s) are reported when second and third iliac or tibial/peroneal arteries are
treated in addition to the initial vessel in that vascular territory.
If a lesion extends across the margins of one vessel vascular territory into another, but can
be opened with a single therapy, this intervention should be reported with a single code
despite treating more than one vessel and/or vascular territory. For instance, if a stenosis
extends from the common iliac artery into the proximal external iliac artery, and a single
stent is placed to open the entire lesion, this therapy should be coded as a single stent
placement in the iliac artery (37221). In this example, a code for an additional vessel
treatment would not be used (do not report both 37221 and 37223).
For bifurcation lesions distal to the common iliac origins which require therapy of 2
distinct branches of the iliac or tibial/peroneal vascular territories, a primary code and an
add-on code would be used to describe the intervention. In the femoral/popliteal territory,
all branches are included in the primary code, so treatment of a bifurcation lesion would be
reported as a single code.
When the same territory(ies) of both legs are treated in the same session, modifiers may be
required to describe the interventions. Use modifier 59 to denote that different legs are
being treated, even if the mode of therapy is different.
Mechanical thrombectomy and/or thrombolysis in the lower extremity vessels are
sometimes necessary to aid in restoring flow to areas of occlusive disease, and are reported
separately.
37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial
vessel; with transluminal angioplasty
➲ CPT Assistant Jul 11:3, Oct 11:9, Dec 13:8, Jul 16:8, Jun 19:14
➲ Clinical Examples in Radiology Winter 11:3, Spring 14:9
37221 with transluminal stent placement(s), includes angioplasty within the same vessel, when
performed
➲ CPT Assistant Jul 11:3, Oct 11:9, Jan 15:13, Jul 16:8, Jun 19:14
(Use 37220, 37221 in conjunction with 34701-34711, 34718, 34845, 34846, 34847,
34848, only when 37220 or 37221 is performed outside the treatment zone of the
endograft)
Transluminal Balloon Angioplasty

37220 and 37222
A balloon catheter is passed into the iliac artery and inflated to stretch the blood vessel to a larger diameter.
✚ 37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional

ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code
➲ CPT Assistant Jul 11:3, Oct 11:9, Jul 16:8, Jun 19:14

✚ 37223 with transluminal stent placement(s), includes angioplasty within the same vessel, when
performed (List separately in addition to code for primary procedure)
➲ CPT Assistant Jul 11:3, Oct 11:9, Apr 12:8, Dec 13:8, Jul 16:8, Jun 19:14

(Use 37222, 37223 in conjunction with 34701-34711, 34718, 34845, 34846, 34847, 34848
only when 37222 or 37223 are performed outside the treatment zone of the endograft)
37224 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s),
unilateral; with transluminal angioplasty
➲ Clinical Examples in Radiology Winter 11:3, Summer 11:10, Spring 16:13
37225 with atherectomy, includes angioplasty within the same vessel, when performed
➲ CPT Assistant Jul 11:3, Oct 11:9, Nov 11:9, Jul 16:8, Jun 19:14
➲ Clinical Examples in Radiology Winter 11:3, Spring 11:3, Spring 16:13
performed
37227 with transluminal stent placement(s) and atherectomy, includes angioplasty within the
same vessel, when performed
(Do not report 37224, 37225, 37226, 37227 in conjunction with 0505T, within the
femoral-popliteal segment)
37228 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral,
initial vessel; with transluminal angioplasty
37229 with atherectomy, includes angioplasty within the same vessel, when performed
performed
37231 with transluminal stent placement(s) and atherectomy, includes angioplasty within the
same vessel, when performed
✚ 37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral,

each additional vessel; with transluminal angioplasty (List separately in addition to code
➲ CPT Assistant Jul 11:3, Oct 11:9, Apr 12:8, Jul 16:8, Jun 19:14
✚ 37233 with atherectomy, includes angioplasty within the same vessel, when performed (List
➲ CPT Assistant Jul 11:3, Oct 11:9, Nov 11:9, Apr 12:8, Jul 16:8, Jun 19:14
Iliac and Lower Extremity Arterial Anatomy Territory

37220-37235
✚ 37234 with transluminal stent placement(s), includes angioplasty within the same vessel, when
performed (List separately in addition to code for primary procedure)
➲ CPT Assistant Jul 11:3, Oct 11:9, Apr 12:9, Jul 16:8, Jun 19:14

✚ 37235 with transluminal stent placement(s) and atherectomy, includes angioplasty within the
same vessel, when performed (List separately in addition to code for primary
procedure)
➲ Clinical Examples in Radiology Winter 11:3, Spring 11:3, Spring 14:9, Spring
16:13
Codes 37246, 37247, 37248, 37249 describe open or percutaneous transluminal balloon
angioplasty (eg, conventional, low profile, cutting, drug-coated balloon). Codes 37246,
37247 describe transluminal balloon angioplasty in an artery excluding the central nervous
system (61630, 61635), coronary (92920-92944), pulmonary (92997, 92998), and lower
extremities for occlusive disease (37220-37235). Codes 37248 and 37249 describe
transluminal balloon angioplasty in a vein excluding the dialysis circuit (36902, 36905,
36907) when approached through the ipsilateral dialysis access. Transluminal balloon
angioplasty is inherent to stenting in the extracranial carotid and innominate arteries (37215,
37216, 37217, 37218), peripheral arteries (37220-37237), and in peripheral veins (37238,
37239) and, therefore, is not separately reportable. Multiple angioplasties performed in a
single vessel, including treatment of separate and distinct lesions within a single vessel, are
reported with a single code. If a lesion extends across the margins of one vessel into
another, but can be treated with a single therapy, the intervention should be reported only
once. When additional, separate and distinct ipsilateral or contralateral vessels are treated in
the same session, 37247 and/or 37249 may be reported as appropriate.
Non-selective and/or selective catheterization (eg, 36005, 36010, 36011, 36012, 36200,
36215, 36216, 36217, 36218, 36245, 36246, 36247, 36248) is reported separately. Codes
37246, 37247, 37248, 37249 include radiological supervision and interpretation directly
related to the intervention performed and imaging performed to document completion of
the intervention. Extensive repair or replacement of an artery may be reported separately
(eg, 35226, 35286). Intravascular ultrasound may be reported separately (ie, 37252, 37253).
Mechanical thrombectomy and/or thrombolytic therapy, when performed, may be reported
separately (eg, 37184, 37185, 37186, 37187, 37188, 37211, 37212, 37213, 37214).
# 37246 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive
disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous,
including all imaging and radiological supervision and interpretation necessary to perform
the angioplasty within the same artery; initial artery
➲ CPT Assistant May 17:3, Jul 17:3
#✚ 37247 each additional artery (List separately in addition to code for primary procedure)

(Do not report 37246, 37247 in conjunction with 37215, 37216, 37217, 37218, 37220-
37237 when performed in the same artery during the same operative session)
(Do not report 37246, 37247 in conjunction with 34841, 34842, 34843, 34844, 34845,
34846, 34847, 34848 for angioplasty[ies] performed, when placing bare metal or covered
stents into the visceral branches within the endoprosthesis target zone)
# 37248 Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including
all imaging and radiological supervision and interpretation necessary to perform the
angioplasty within the same vein; initial vein
➲ CPT Assistant Mar 17:4, May 17:3, Jul 17:3
#✚ 37249 each additional vein (List separately in addition to code for primary procedure)
➲ CPT Assistant Mar 17:4, May 17:3, Jul 17:3

(Do not report 37248, 37249 in conjunction with 37238, 37239 when performed in the
same vein during the same operative session)
(Do not report 37248, 37249 in conjunction with 0505T, within the femoral-popliteal
segment)
▶ (Donot report 37248, 37249 in conjunction with 0620T within the tibial-peroneal
segment)◀
(For transluminal balloon angioplasty in aorta/visceral artery[ies] in conjunction with
fenestrated endovascular repair, see 34841, 34842, 34843, 34844, 34845, 34846, 34847,
34848)
(For transluminal balloon angioplasty in iliac, femoral, popliteal, or tibial/peroneal
artery[ies] for occlusive disease, see 37220-37235)
(For transluminal balloon angioplasty in a dialysis circuit performed through the circuit,
see 36902, 36903, 36904, 36905, 36906, 36907, 36908)
(For transluminal balloon angioplasty in an intracranial artery, see 61630, 61635)
(For transluminal balloon angioplasty in a coronary artery, see 92920-92944)
Transluminal Balloon Angioplasty

37246
A balloon catheter is inserted and advanced across the lesion into the narrowed portion of the vessel. The balloon is inflated to enlarge the
diameter and restore normal blood flow.
(For transluminal balloon angioplasty in a pulmonary artery, see 92997, 92998)
Codes 37236-37239 are used to report endovascular revascularization for vessels other than
lower extremity artery(ies) for occlusive disease (ie, 37221, 37223, 37226, 37227, 37230,
37231, 37234, 37235), cervical carotid (ie, 37215, 37216), intracranial (ie, 61635),
intracoronary (ie, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944),
innominate and/or intrathoracic carotid artery through an antegrade approach (37218),
extracranial vertebral (ie, 0075T, 0076T) performed percutaneously and/or through an open
surgical exposure, open retrograde intrathoracic common carotid or innominate (37217), or
dialysis circuit when performed through the dialysis circuit (36903, 36905, 36908).
Codes 37236, 37237 describe transluminal intravascular stent insertion in an artery while
37238, 37239 describe transluminal intravascular stent insertion in a vein. Multiple stents
placed in a single vessel may only be reported with a single code. If a lesion extends across
the margins of one vessel into another, but can be treated with a single therapy, the
intervention should be reported only once. When additional, different vessels are treated in
the same session, report 37237 and/or 37239 as appropriate. Each code in this family
(37236-37239) includes any and all balloon angioplasty(s) performed in the treated vessel,
including any pre-dilation (whether performed as a primary or secondary angioplasty),
post-dilation following stent placement, treatment of a lesion outside the stented segment
but in the same vessel, or use of larger/smaller balloon to achieve therapeutic result.
Angioplasty in a separate and distinct vessel may be reported separately. Non-selective
and/or selective catheterization(s) (eg, 36005, 36010-36015, 36200, 36215-36218, 36245-
36248) is reported separately.
Codes 37236-37239 include radiological supervision and interpretation directly related to
the intervention(s) performed, closure of the arteriotomy by pressure, application of an
arterial closure device or standard closure of the puncture by suture, and imaging
performed to document completion of the intervention in addition to the intervention(s)
performed. Extensive repair or replacement of an artery may be reported separately (eg,
35226 or 35286). Report 76937 for ultrasound guidance for vascular access, when
performed in conjunction with 37236-37239. Intravascular ultrasound may be reported
separately (ie, 37252, 37253). For mechanical thrombectomy and/or thrombolytic therapy,
when performed, see 37184-37188, 37211-37214.
Intravascular stents, both covered and uncovered, are a class of devices that may be used as
part of an embolization procedure. As such, there is the potential for overlap among codes
used for placement of vascular stents and those used for embolization. When a stent is
placed for the purpose of providing a latticework for deployment of embolization coils,
such as for embolization of an aneurysm, the embolization code is reported and not the
stent code. If a covered stent is deployed as the sole management of an aneurysm,
pseudoaneurysm, or vascular extravasation, then the stent deployment code should be
reported and not the embolization code.
37236 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for
occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid,
intracranial, or coronary), open or percutaneous, including radiological supervision and
interpretation and including all angioplasty within the same vessel, when performed; initial
artery
➲ CPT Assistant Dec 13:8, May 15:7, Mar 16:5, Jul 16:3
➲ Clinical Examples in Radiology Winter 14:5-6, Spring 14:9, Spring 16:13
✚ 37237 each additional artery (List separately in addition to code for primary procedure)
➲ CPT Assistant Dec 13:8, Mar 16:5, Jul 16:6

(Do not report 37236, 37237 in conjunction with 34841-34848 for bare metal or covered
stents placed into the visceral branches within the endoprosthesis target zone)
(For stent placement(s) in iliac, femoral, popliteal, or tibial/peroneal artery(s) for
occlusive disease, see 37221, 37223, 37226, 37227, 37230, 37231, 37234, 37235)
(For transcatheter placement of intravascular cervical carotid artery stent(s), see 37215,
37216)
(For transcatheter placement of intracranial stent(s), use 61635)
(For transcatheter placement of intracoronary stent(s), see 92928, 92929, 92933, 92934,
92937, 92938, 92941, 92943, 92944)
(For stenting of visceral arteries in conjunction with fenestrated endovascular repair, see
34841-34848)
(For open or percutaneous antegrade transcatheter placement of intrathoracic
carotid/innominate artery stent(s), use 37218)
(For open or percutaneous transcatheter placement of extracranial vertebral artery stent(s),
see Category III codes 0075T, 0076T)
(For open retrograde transcatheter placement of intrathoracic common carotid/innominate
artery stent(s), use 37217)
(For placement of a stent at the arterial anastomosis of a dialysis circuit with or without
transluminal mechanical thrombectomy and/or infusion for thrombolysis, see 36903,
36906)
37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including
radiological supervision and interpretation and including angioplasty within the same
vessel, when performed; initial vein
➲ CPT Assistant Jun 16:8, Jul 16:6, Mar 17:4
✚ 37239 each additional vein (List separately in addition to code for primary procedure)

(Do not report 37238, 37239 in conjunction with 0505T, within the femoral-popliteal
segment)
▶ (Donot report 37238, 37239 in conjunction with 0620T within the tibial-peroneal
segment)◀
(For placement of a stent[s] within the peripheral segment of the dialysis circuit, see
36903, 36906)
(For transcatheter placement of an intravascular stent[s] within central dialysis segment
when performed through the dialysis circuit, use 36908)
Vascular Embolization and Occlusion

Codes 37241-37244 are used to describe vascular embolization and occlusion procedures,
excluding the central nervous system and the head and neck, which are reported using
61624, 61626, 61710, and 75894, and excluding the ablation/sclerotherapy procedures for
venous insufficiency/telangiectasia of the extremities/skin, which are reported using 36468,
36470, and 36471. Embolization and occlusion procedures are performed for a wide variety
of clinical indications and in a range of vascular territories. Arteries, veins, and lymphatics
may all be the target of embolization.
The embolization codes include all associated radiological supervision and interpretation,
intra-procedural guidance and road-mapping, and imaging necessary to document
completion of the procedure. They do not include diagnostic angiography and all necessary
catheter placement(s). Code(s) for catheter placement(s) may be separately reported using
selective catheter placement code(s), if used consistent with guidelines. Code(s) for
diagnostic angiography may also be separately reported, when performed according to
guidelines for diagnostic angiography during endovascular procedures, using the
appropriate diagnostic angiography codes. Report these services with an appropriate
modifier (eg, modifier 59). Please see the guidelines on the reporting of diagnostic
angiography preceding 75600 in the Vascular Procedures, Aorta and Arteries section.
Code 37241 is used to report endovascular embolization or occlusion procedures
performed for venous conditions other than hemorrhage or hemodialysis access. Examples
include embolization of venous malformations, capillary hemangiomas, varicoceles, and
visceral varices. (For endovascular embolization or occlusion of side branch[es] of an
outflow vein[s] from a hemodialysis access, use 36909.)
Code 37242 is used to report vascular embolization or occlusion performed for arterial
conditions other than hemorrhage or tumor such as arteriovenous malformations and
arteriovenous fistulas whether congenital or acquired. Embolizations of aneurysms and
pseudoaneurysms are also reported with 37242. Tumor embolization is reported with
37243. Note that injection to treat an extremity pseudoaneurysm is correctly reported with
36002. Sometimes, embolization and occlusion of an artery are performed prior to another
planned interventional procedure; an example is embolization of the left gastric artery prior
to planned implantation of a hepatic artery chemotherapy port. The artery embolization is
reported with 37242.
Code 37243 is used to report embolization for the purpose of tissue ablation and organ
infarction or ischemia. This can be performed in many clinical circumstances, including
embolization of benign or malignant tumors of the liver, kidney, uterus, or other organs.
When chemotherapy is given as part of an embolization procedure, additional codes (eg,
96420) may be separately reported. When a radioisotope (eg, Yttrium-90) is injected as part
of an embolization, then additional codes (eg, 79445) may be separately reported. Uterine
fibroid embolization is reported with 37243.
Code 37244 is used to report embolization for treatment of hemorrhage or vascular or
lymphatic extravasation. Examples include embolization for management of gastrointestinal
bleed, trauma-induced hemorrhage of the viscera or pelvis, embolization of the thoracic
duct for chylous effusion and bronchial artery embolization for hemoptysis. Embolization
of the uterine arteries for management of hemorrhage (eg, postpartum hemorrhage) is also
reported with 37244.
Intravascular stents, both covered and uncovered, are a class of devices that may be used as
part of an embolization procedure. As such, there is the potential for overlap among codes
used for placement of vascular stents and those used for embolization. When a stent is
placed for the purpose of providing a latticework for deployment of embolization coils,
such as for embolization of an aneurysm, the embolization code is reported and not the
stent code. If a stent is deployed as the sole management of an aneurysm, pseudoaneurysm,
or vascular extravasation, then the stent deployment code should be reported and not the
embolization code.
Only one embolization code should be reported for each surgical field (ie, the area
immediately surrounding and directly involved in a treatment/procedure). Embolization
procedures performed at a single setting and including multiple surgical fields (eg, a patient
with multiple trauma and bleeding from the pelvis and the spleen) may be reported with
multiple embolization codes with the appropriate modifier (eg, modifier 59).
There may be overlapping indications for an embolization procedure. The code for the
immediate indication for the embolization should be used. For instance, if the immediate
cause for embolization is bleeding in a patient with an aneurysm, report 37244.
37241 Vascular embolization or occlusion, inclusive of all radiological supervision and
interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete
the intervention; venous, other than hemorrhage (eg, congenital or acquired venous
malformations, venous and capillary hemangiomas, varices, varicoceles)
➲ CPT Assistant Nov 13:6, Aug 14:14, Oct 14:6, Apr 15:10, Aug 15:8, Nov 15:3, Mar
18:3, Sep 19:6
➲ Clinical Examples in Radiology Spring 14:7, Spring 16:4, Winter 18:10, Summer 18:4,
Spring 19:4, Summer 19:6
(Do not report 37241 in conjunction with 36468, 36470, 36471, 36473, 36474, 36475-
36479, 75894, 75898 in the same surgical field)
(For sclerosis of veins or endovenous ablation of incompetent extremity veins, see 36468-
36479)
(For dialysis circuit permanent endovascular embolization or occlusion, use 36909)
37242 arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial
malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms,
pseudoaneurysms)
➲ CPT Assistant Nov 13:6, Oct 14:6, Nov 15:3, Jul 18:14, Sep 19:6
➲ Clinical Examples in Radiology Spring 14:8, Summer 15:8, Spring 16:4, Winter
18:10, Summer 18:2, Spring 19:4, Summer 19:6
(For percutaneous treatment of extremity pseudoaneurysm, use 36002)
37243 for tumors, organ ischemia, or infarction
➲ CPT Assistant Nov 13:7, Oct 14:6, Nov 15:3, Sep 19:6
➲ Clinical Examples in Radiology Winter 14:4, Summer 15:2, Spring 16:4, Winter
18:10, Summer 18:4, Spring 19:4, Summer 19:4
37244 for arterial or venous hemorrhage or lymphatic extravasation
➲ CPT Assistant Nov 13:7, Aug 14:14, Oct 14:6, Nov 15:3, Oct 17:9, Jul 18:14, Sep
19:6
➲ Clinical Examples in Radiology Winter 14:2-4, Spring 14:7, Summer 15:8, Spring
16:4, Winter 18:11, Summer 18:4, Spring 19:2, Summer 19:6
(Do not report 37242-37244 in conjunction with 75894, 75898 in the same surgical field)
(For embolization procedures of the central nervous system or head and neck, see 61624,
61626, 61710)
Intravascular Ultrasound Services

Intravascular ultrasound (IVUS) services include all transducer manipulations and
repositioning within the specific vessel being examined during a diagnostic procedure or
before, during, and/or after therapeutic intervention (eg, stent or stent graft placement,
angioplasty, atherectomy, embolization, thrombolysis, transcatheter biopsy).
IVUS is included in the work described by codes 37191, 37192, 37193, 37197 (intravascular
vena cava [IVC] filter placement, repositioning and removal, and intravascular foreign
body retrieval) and should not be separately reported with those procedures. If a lesion
extends across the margins of one vessel into another, this should be reported with a single
code despite imaging more than one vessel.
Non-selective and/or selective vascular catheterization may be separately reportable (eg,
36005-36248).
✚ 37252 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or
therapeutic intervention, including radiological supervision and interpretation; initial
noncoronary vessel (List separately in addition to code for primary procedure)
➲ CPT Assistant May 16:11, Mar 17:4, Nov 19:6
✚ 37253 each additional noncoronary vessel (List separately in addition to code for primary
procedure)
➲ CPT Assistant May 16:11, Mar 17:4, Nov 19:6

(Report 37252, 37253 in conjunction with 33361, 33362, 33363, 33364, 33365, 33366,
33367, 33368, 33369, 33477, 33880, 33881, 33883, 33884, 33886, 34701, 34702, 34703,
34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712, 34718, 34841, 34842,
34843, 34844, 34845, 34846, 34847, 34848, 36010, 36011, 36012, 36013, 36014, 36015,
36100, 36140, 36160, 36200, 36215, 36216, 36217, 36218, 36221, 36222, 36223, 36224,
36225, 36226, 36227, 36228, 36245, 36246, 36247, 36248, 36251, 36252, 36253, 36254,
36481, 36555-36571, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 36595, 36901,
36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909, 37184, 37185, 37186, 37187,
37188, 37200, 37211, 37212, 37213, 37214, 37215, 37216, 37218, 37220, 37221, 37222,
37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234,
37235, 37236, 37237, 37238, 37239, 37241, 37242, 37243, 37244, 37246, 37247, 37248,
37249, 61623, 75600, 75605, 75625, 75630, 75635, 75705, 75710, 75716, 75726, 75731,
75733, 75736, 75741, 75743, 75746, 75756, 75774, 75805, 75807, 75810, 75820, 75822,
75825, 75827, 75831, 75833, 75860, 75870, 75872, 75885, 75887, 75889, 75891, 75893,
75894, 75898, 75901, 75902, 75956, 75957, 75958, 75959, 75970, 76000, 77001, 0075T,
0076T, 0234T, 0235T, 0236T, 0237T, 0238T, 0338T)
Endoscopy
Surgical vascular endoscopy always includes diagnostic endoscopy.
37500 Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)

37501 Unlisted vascular endoscopy procedure
Ligation
(For phleborrhaphy and arteriorrhaphy, see 35201-35286)
37565 Ligation, internal jugular vein
37600 Ligation; external carotid artery
37605 internal or common carotid artery
37606 internal or common carotid artery, with gradual occlusion, as with Selverstone or
Crutchfield clamp
(For transcatheter permanent arterial occlusion or embolization, see 61624-61626)
(For endovascular temporary arterial balloon occlusion, use 61623)
(For ligation treatment of intracranial aneurysm, use 61703)
37607 Ligation or banding of angioaccess arteriovenous fistula
37609 Ligation or biopsy, temporal artery
37615 Ligation, major artery (eg, post-traumatic, rupture); neck
37616 chest
37617 abdomen
37618 extremity
37619 Ligation of inferior vena cava
(For endovascular delivery of an inferior vena cava filter, use 37191)

37650 Ligation of femoral vein
37660 Ligation of common iliac vein
37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal
interruptions
➲ CPT Assistant Aug 96:10, Nov 16:3, Mar 18:3

37718 Ligation, division, and stripping, short saphenous vein

37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral
junction to knee or below
(For ligation and stripping of the short saphenous vein, use 37718)
(For ligation, division, and stripping of the greater saphenous vein, use 37722. For
ligation, division, and stripping of the short saphenous vein, use 37718)
Ligation and Division of Long Saphenous Vein

37700
The physician ligates sections of the saphenous vein along the leg.
37735 Ligation and division and complete stripping of long or short saphenous veins with radical
excision of ulcer and skin graft and/or interruption of communicating veins of lower leg,
with excision of deep fascia
(Do not report 37735 in conjunction with 37700, 37718, 37722, 37780)
37760 Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when
performed, open, 1 leg
➲ CPT Assistant Jul 10:6, Nov 16:3, Mar 18:3
(For endoscopic procedure, use 37500)

37761 Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when
performed, 1 leg

(For endoscopic ligation of subfascial perforator veins, use 37500)
37765 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions
➲ CPT Assistant Aug 04:6, Nov 10:9, Oct 14:6, Nov 16:3, Mar 18:3
(For less than 10 incisions, use 37799)

(For more than 20 incisions, use 37766)
37766 more than 20 incisions
➲ CPT Assistant Aug 04:6, Sep 13:17, Oct 14:6, Nov 16:3, Mar 18:3
37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate
procedure)

37785 Ligation, division, and/or excision of varicose vein cluster(s), 1 leg
➲ CPT Assistant Aug 04:5, Nov 10:9, Nov 16:3
Other Procedures
37788 Penile revascularization, artery, with or without vein graft
37790 Penile venous occlusive procedure
37799 Unlisted procedure, vascular surgery
➲ CPT Assistant Spring 93:12, Fall 93:3, Feb 97:10, Sep 97:10, May 01:11, Oct 04:16,
Nov 10:9, Aug 11:9, Nov 13:14, Mar 14:8, Aug 14:14, Oct 14:6, Apr 15:10, Nov 16:3,
Nov 18:11
➲ Clinical Examples in Radiology Summer 15:7, Spring 17:3, Fall 18:8
Hemic and Lymphatic Systems

Spleen
Excision
38100 Splenectomy; total (separate procedure)
➲ CPT Assistant Summer 93:10, July 93:9, Sep 12:11
38101 partial (separate procedure)

✚ 38102 total, en bloc for extensive disease, in conjunction with other procedure (List in
Repair
38115 Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy
Laparoscopy
Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic
laparoscopy (peritoneoscopy) (separate procedure), use 49320.
38120 Laparoscopy, surgical, splenectomy
➲ CPT Assistant Nov 99:20-21, Mar 00:8, Sep 12:11
38129 Unlisted laparoscopy procedure, spleen

➲ CPT Assistant Nov 99:20-21, Mar 00:8, Sep 12:11
Introduction
38200 Injection procedure for splenoportography
General
Bone Marrow or Stem Cell Services/Procedures
Codes 38207-38215 describe various steps used to preserve, prepare and purify bone
marrow/stem cells prior to transplantation or reinfusion. Each code may be reported only
once per day regardless of the quantity of bone marrow/stem cells manipulated.
38204 Management of recipient hematopoietic progenitor cell donor search and cell acquisition
38205 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection;
allogeneic
38206 autologous
38207 Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage

➲ CPT Assistant Jul 03:9, Jun 09:3, Oct 13:3
(For diagnostic cryopreservation and storage, use 88240)

38208 thawing of previously frozen harvest, without washing, per donor
➲ CPT Assistant Jul 03:9, Jun 09:3, Oct 13:3
(For diagnostic thawing and expansion of frozen cells, use 88241)
38209 thawing of previously frozen harvest, with washing, per donor
38210 specific cell depletion within harvest, T-cell depletion

38211 tumor cell depletion

38212 red blood cell removal

38213 platelet depletion

38214 plasma (volume) depletion

38215 cell concentration in plasma, mononuclear, or buffy coat layer

(Do not report 38207-38215 in conjunction with 88182, 88184-88189)

38220 Diagnostic bone marrow; aspiration(s)
➲ CPT Assistant Jan 04:26, Jun 07:10, Apr 12:15, May 12:11, Oct 13:3, Mar 15:9, May
18:3

(For diagnostic bone marrow biopsy[ies] and aspiration[s] performed at the same session,
use 38222)
(For aspiration of bone marrow for bone graft, spine surgery only, use 20939)
(For bone marrow aspiration[s] for platelet-rich stem cell injection, use 0232T)
38221 biopsy(ies)

(For diagnostic bone marrow biopsy[ies] and aspiration[s] performed at the same session,
use 38222)
38222 biopsy(ies) and aspiration(s)
➲ Clinical Examples in Radiology Spring 18:4, Fall 18:12
(Do not report 38222 in conjunction with 38220 and 38221)

(For bilateral procedure, report 38220, 38221, 38222 with modifier 50)
(For bone marrow biopsy interpretation, use 88305)
38230 Bone marrow harvesting for transplantation; allogeneic
➲ CPT Assistant Apr 96:1, Jun 09:3, May 12:11, Oct 13:3
Bone Marrow Harvesting for Transplantation

38230
A biopsy needle is inserted into the marrow cavity of the iliac crest and bone marrow is removed from the donor.
38232 autologous
(For autologous and allogeneic blood-derived peripheral stem cell harvesting for
transplantation, see 38205, 38206)
(For diagnostic bone marrow aspiration[s], see 38220, 38222)
Transplantation and Post-Transplantation Cellular Infusions

Hematopoietic cell transplantation (HCT) refers to the infusion of hematopoietic progenitor
cells (HPC) obtained from bone marrow, peripheral blood apheresis, and/or umbilical cord
blood. These procedure codes (38240-38243) include physician monitoring of multiple
physiologic parameters, physician verification of cell processing, evaluation of the patient
during as well as immediately before and after the HPC/lymphocyte infusion, physician
presence during the HPC/lymphocyte infusion with associated direct physician supervision
of clinical staff, and management of uncomplicated adverse events (eg, nausea, urticaria)
during the infusion, which is not separately reportable.
HCT may be autologous (when the HPC donor and recipient are the same person) or
allogeneic (when the HPC donor and recipient are not the same person). Code 38241 is
used to report any autologous transplant while 38240 is used to report an allogeneic
transplant. In some cases allogeneic transplants involve more than one donor and cells
from each donor are infused sequentially whereby one unit of 38240 is reported for each
donor infused. Code 38242 is used to report a donor lymphocyte infusion. Code 38243 is
used to report a HPC boost from the original allogeneic HPC donor. A lymphocyte infusion
or HPC boost can occur days, months or even years after the initial hematopoietic cell
transplant. HPC boost represents an infusion of hematopoietic progenitor cells from the
original donor that is being used to treat post-transplant cytopenia(s). Codes 38240, 38242,
and 38243 should not be reported together on the same date of service.
If a separately identifiable evaluation and management service is performed on the same
date of service, the appropriate E/M service code, including office or other outpatient
services, established (99211-99215), hospital observation services (99217-99220, 99224-
99226), hospital inpatient services (99221-99223, 99231-99239), and inpatient neonatal and
pediatric critical care (99471, 99472, 99475, 99476) may be reported, using modifier 25, in
addition to 38240, 38242 or 38243. Post-transplant infusion management of adverse
reactions is reported separately using the appropriate E/M, prolonged service or critical care
code(s). In accordance with place of service and facility reporting guidelines, the fluid used
to administer the cells and other infusions for incidental hydration (eg, 96360, 96361) are
not separately reportable. Similarly, infusion(s) of any medication(s) concurrently with the
transplant infusion are not separately reportable. However, hydration or administration of
medications (eg, antibiotics, narcotics) unrelated to the transplant are separately reportable
using modifier 59.
38240 Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor
➲ CPT Assistant Apr 96:2, Nov 98:15, Nov 99:21, Jun 09:3, Oct 13:3
38241 autologous transplantation

➲ CPT Assistant Apr 96:2, Nov 98:15, Nov 99:21, Jun 09:3, Oct 13:3, Feb 15:10
# 38243 HPC boost
➲ CPT Assistant Jun 13:13, Oct 13:3, Feb 15:10
38242 Allogeneic lymphocyte infusions

➲ CPT Assistant Jun 13:13, Oct 13:3
(For diagnostic bone marrow aspiration[s], see 38220, 38222)

(For modification, treatment, and processing of hematopoietic progenitor cell specimens
for transplantation, see 38210-38215)
(For cryopreservation, freezing, and storage of hematopoietic progenitor cells for
transplantation, use 38207)
(For thawing and expansion of hematopoietic progenitor cells for transplantation, see
38208, 38209)
(For compatibility studies, see 81379-81383, 86812, 86813, 86816, 86817, 86821)
Lymph Nodes and Lymphatic Channels

Incision
38300 Drainage of lymph node abscess or lymphadenitis; simple
38305 extensive
38308 Lymphangiotomy or other operations on lymphatic channels
38380 Suture and/or ligation of thoracic duct; cervical approach
38381 thoracic approach
38382 abdominal approach
Excision
(For injection for sentinel node identification, use 38792)
38500 Biopsy or excision of lymph node(s); open, superficial
➲ CPT Assistant Jun 97:5, Jul 99:7, Oct 05:23, Dec 07:8, Sep 08:5, Jan 09:7, Jun 12:15

38505 by needle, superficial (eg, cervical, inguinal, axillary)
➲ CPT Assistant Jul 99:6, Jan 09:7, Feb 19:8
(If imaging guidance is performed, see 76942, 77002, 77012, 77021)
(For fine needle aspiration biopsy, see 10004, 10005, 10006, 10007, 10008, 10009,
10010, 10011, 10012, 10021)
(For evaluation of fine needle aspirate, see 88172, 88173)
38510 open, deep cervical node(s)
➲ CPT Assistant May 98:10, Jul 99:6, Jun 12:15
38520 open, deep cervical node(s) with excision scalene fat pad
38525 open, deep axillary node(s)

➲ CPT Assistant May 98:10, Jul 99:7, Oct 05:23, Dec 07:8, Sep 08:5, Apr 14:11, Mar
15:5
38530 open, internal mammary node(s)
➲ CPT Assistant May 98:10, Jul 99:6, Aug 10:6, Apr 14:11, Feb 19:8

(For percutaneous needle biopsy, retroperitoneal lymph node or mass, use 49180)
(For fine needle aspiration biopsy, retroperitoneal lymph node or mass, see 10005, 10006,
10007, 10008, 10009, 10010, 10011, 10012)
38531 open, inguinofemoral node(s)

38542 Dissection, deep jugular node(s)
➲ CPT Assistant Jul 99:7, Aug 10:6
(For radical cervical neck dissection, use 38720)

38550 Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection
38555 with deep neurovascular dissection
Limited Lymphadenectomy for Staging

38562 Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic
(When combined with prostatectomy, use 55812 or 55842)

(When combined with insertion of radioactive substance into prostate, use 55862)
38564 retroperitoneal (aortic and/or splenic)
Laparoscopy
Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic
laparoscopy (peritoneoscopy) (separate procedure), use 49320.
38570 Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or
multiple
38571 with bilateral total pelvic lymphadenectomy

38572 with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling
(biopsy), single or multiple
(For drainage of lymphocele to peritoneal cavity, use 49323)

38573 with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling,
peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings,
including diaphragmatic and other serosal biopsy(ies), when performed
(Do not report 38573 in conjunction with 38562, 38564, 38570, 38571, 38572, 38589,
38770, 38780, 49255, 49320, 49326, 58541, 58542, 58543, 58544, 58548, 58550, 58552,
58553, 58554)
38589 Unlisted laparoscopy procedure, lymphatic system
Radical Lymphadenectomy (Radical Resection of Lymph Nodes)

(For limited pelvic and retroperitoneal lymphadenectomies, see 38562, 38564)
38700 Suprahyoid lymphadenectomy
➲ CPT Assistant Aug 02:8, Aug 10:3

38720 Cervical lymphadenectomy (complete)
➲ CPT Assistant Oct 01:10, Aug 02:8, Aug 10:4, Apr 20:10

38724 Cervical lymphadenectomy (modified radical neck dissection)
➲ CPT Assistant Jan 01:13, Aug 02:8, Aug 10:4, Dec 12:3, Mar 19:11
38740 Axillary lymphadenectomy; superficial

38745 complete
✚ 38746 Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy
➲ CPT Assistant Sep 12:3, May 14:3
(On the right, mediastinal lymph nodes include the paratracheal, subcarinal,
paraesophageal, and inferior pulmonary ligament)
(On the left, mediastinal lymph nodes include the aortopulmonary window, subcarinal,
paraesophageal, and inferior pulmonary ligament)
Mediastinal Lymph Nodes: Station Number and Descriptions

38746
Relevant mediastinal lymph nodes typically removed with procedures described by code 38746, and sampled removal described with code 39402.
Station # Lymph Node Descriptions

1 Low cervical, supraclavicular, and sternal notch
2 Upper paratracheal (R & L)
4 Lower paratracheal (R & L)
5 Subaortic or aortopulmonary window
6 Para-aortic
7 Subcarinal
8 Paraesophageal (below the carina)
9 Inferior pulmonary ligament
*Station #3 is not depicted as it is not applicable to the use of codes 32674, 38746, or 39402.
(Report 38746 in conjunction with 21601, 31760, 31766, 31786, 32096-32200, 32220-
32320, 32440-32491, 32503-32505, 33025, 33030, 33050-33130, 39200-39220, 39560,
39561, 43101, 43112, 43117, 43118, 43122, 43123, 43351, 60270, 60505)
(To report mediastinal and regional lymphadenectomy via thoracoscopy [VATS], see
32674)
✚ 38747 Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic,
with or without para-aortic and vena caval nodes (List separately in addition to code for
primary procedure)
38760 Inguinofemoral lymphadenectomy, superficial, including Cloquet’s node (separate

procedure)
38765 Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy,
including external iliac, hypogastric, and obturator nodes (separate procedure)
38770 Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes
38780 Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and
renal nodes (separate procedure)
(For excision and repair of lymphedematous skin and subcutaneous tissue, see 15004-
15005, 15570-15650)
Introduction
38790 Injection procedure; lymphangiography

(For radiological supervision and interpretation, see 75801-75807)
38792 radioactive tracer for identification of sentinel node
➲ CPT Assistant Nov 98:15, Jul 99:6, Dec 99:8, Sep 08:5, Mar 15:5
(For excision of sentinel node, see 38500-38542)

(For nuclear medicine lymphatics and lymph gland imaging, use 78195)
(For intraoperative identification (eg, mapping) of sentinel lymph node(s) including
injection of non-radioactive dye, see 38900)
38794 Cannulation, thoracic duct
Other Procedures
✚ 38900 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of
non-radioactive dye, when performed (List separately in addition to code for primary
procedure)
(Use 38900 in conjunction with 19302, 19307, 38500, 38510, 38520, 38525, 38530,
38531, 38542, 38562, 38564, 38570, 38571, 38572, 38740, 38745, 38760, 38765, 38770,
38780, 56630, 56631, 56632, 56633, 56634, 56637, 56640)
(For injection of radioactive tracer for identification of sentinel node, use 38792)
38999 Unlisted procedure, hemic or lymphatic system
Mediastinum and Diaphragm

Mediastinum
Incision
39000 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical
approach
39010 transthoracic approach, including either transthoracic or median sternotomy
➲ CPT Assistant Jan 13:6, Jan 14:5
(For VATS pericardial biopsy, use 32604)
Excision/Resection
39200 Resection of mediastinal cyst
39220 Resection of mediastinal tumor

(For substernal thyroidectomy, use 60270)

(For thymectomy, use 60520)
(For thoracoscopic [VATS] resection of mediastinal cyst, tumor, or mass, use 32662)
Endoscopy
39401 Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when
performed
39402 with lymph node biopsy(ies) (eg, lung cancer staging)

Other Procedures
39499 Unlisted procedure, mediastinum
Diaphragm
Repair
(For transabdominal repair of diaphragmatic [esophageal hiatal] hernia, use 43325)
(For laparoscopic repair of diaphragmatic [esophageal hiatal] hernias and fundoplication,
see 43280, 43281, 43282)
39501 Repair, laceration of diaphragm, any approach
(For laparoscopic paraesophageal hernia repair, see 43281, 43282)

39503 Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or
without creation of ventral hernia

(For laparoscopic paraesophageal hernia repair, see 43281, 43282)
39540 Repair, diaphragmatic hernia (other than neonatal), traumatic; acute
39541 chronic
39545 Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or
nonparalytic
39560 Resection, diaphragm; with simple repair (eg, primary suture)

39561 with complex repair (eg, prosthetic material, local muscle flap)
Other Procedures
39599 Unlisted procedure, diaphragm
★ = Telemedicine ✚ = Add-on code ⚡ = FDA approval pending # = Resequenced

code ⃠ = Modifier 51 exempt ➲➲➲ = See p xviii for details ▲ = Revised
code ● = New code ▶◀ = Contains new or revised text = Duplicate PLA
test ⇅ = Category I PLA
Surgery
Digestive System (40490-49999)
Digestive System section of the CPT codebook. The subheadings or
Lips (40490-40799)
Excision (40490-40530)
Repair (Cheiloplasty) (40650-40761)
Vestibule of Mouth* (40800-40899)
Incision (40800-40806)
Excision, Destruction (40808-40820)
Repair (40830-40845)
Tongue and Floor of Mouth (41000-41599)
Incision (41000-41019)
Excision (41100-41155)
Repair (41250-41252)
Dentoalveolar Structures (41800-41899)
Incision (41800-41806)
Palate and Uvula (42000-42299)
Incision (42000)
Repair (42180-42281)
Salivary Gland and Ducts (42300-42699)
Incision (42300-42340)
Excision (42400-42450)
Repair (42500-42510)
Pharynx, Adenoids, and Tonsils (42700-42999)
Incision (42700-42725)
Repair (42900-42953)
Esophagus (43020-43499)
Incision (43020-43045)
Excision (43100-43135)
Endoscopy* (43180-43278)
Esophagoscopy (43180-43232)
Esophagogastroduodenoscopy* (43210, 43233, 43235-43259,
43266, 43270)
Endoscopic Retrograde Cholangiopancreatography (ERCP)*
(43260-43265, 43273-43278)
Repair (43300-43425)
Manipulation (43450-43460)
Digestive System
Stomach (43500-43999)
Incision (43500-43520)
Excision (43605-43641)
Bariatric Surgery* (43770-43775)
Intestines (Except Rectum) (44005-44799)
Incision (44005-44055)
Excision* (44100-44160)
Incision (44180)
Enterostomy—External Fistulization of Intestines (44186-44188)
Excision (44202-44213)
Repair (44227)
Enterostomy—External Fistulization of Intestines (44300-44346)
Endoscopy, Small Intestine* (44360-44379)
Endoscopy, Stomal* (44380-44408)
Repair (44602-44680)
Meckel’s Diverticulum and the Mesentery (44800-44899)
Excision (44800-44820)
Suture (44850)
Appendix (44900-44979)
Incision (44900)
Excision (44950-44960)
Colon and Rectum (45000-45999)
Incision (45000-45020)
Excision (45100-45172)
Destruction (45190)
Endoscopy* (45300-45393, 45398)
Excision (45395-45397)
Repair (45400-45499)
Repair (45500-45825)
Other Procedures* (45399, 45990, 45999)
Anus* (46020-46999)
Incision (46020-46083)
Excision (46200, 46220-46221, 46230, 46250-46288, 46320, 46945-
46946, 46948)
Endoscopy* (46600-46615)
Repair (46700-46761, 46947)
Liver (47000-47399)
Incision (47000-47015)
Excision (47100-47130)
Liver Transplantation* (47133-47147)
Repair (47300-47362)
Biliary Tract (47400-47999)
Incision (47400-47480)
Introduction* (47490-47544)
Endoscopy* (47550-47556)
Excision (47600-47715)
Repair (47720-47900)
Pancreas (48000-48999)
Incision (48000-48020)
Excision (48100-48160)
Repair (48500-48548)
Pancreas Transplantation* (48550-48556)
Abdomen, Peritoneum, and Omentum (49000-49999)
Incision (49000-49084)
Excision, Destruction* (49180-49255)
Introduction, Revision, Removal (49400-49465)
Initial Placement* (49440-49442)
Conversion (49446)
Replacement* (49450-49452)
Mechanical Removal of Obstructive Material (49460)
Other (49465)
Repair (49491-49659)
Hernioplasty, Herniorrhaphy, Herniotomy* (49491-49659)
Suture (49900)
Digestive System
Lips
(For procedures on skin of lips, see 10040 et seq)
Excision
40490 Biopsy of lip
40500 Vermilionectomy (lip shave), with mucosal advancement
40510 Excision of lip; transverse wedge excision with primary
closure
40520 V-excision with primary direct linear closure
(For excision of mucous lesions, see 40810-40816)
40525 full thickness, reconstruction with local flap (eg,
Estlander or fan)
40527 full thickness, reconstruction with cross lip flap (Abbe-
Estlander)
40530 Resection of lip, more than one-fourth, without
reconstruction
(For reconstruction, see 13131 et seq)
Repair (Cheiloplasty)
40650 Repair lip, full thickness; vermilion only
40652 up to half vertical height
40654 over one-half vertical height, or complex

40700 Plastic repair of cleft lip/nasal deformity; primary, partial or

complete, unilateral
40701 primary bilateral, 1-stage procedure

40702 primary bilateral, 1 of 2 stages
40720 secondary, by recreation of defect and reclosure

(To report rhinoplasty only for nasal deformity secondary to
congenital cleft lip, see 30460, 30462)
(For repair of cleft lip, with cross lip pedicle flap (Abbe-
Estlander type), use 40527)
40761 with cross lip pedicle flap (Abbe-Estlander type),
including sectioning and inserting of pedicle
(For repair cleft palate, see 42200 et seq)
(For other reconstructive procedures, see 14060, 14061,
15120-15261, 15574, 15576, 15630)
Other Procedures
40799 Unlisted procedure, lips
Vestibule of Mouth
The vestibule is the part of the oral cavity outside the
dentoalveolar structures; it includes the mucosal and submucosal
tissue of lips and cheeks.
Incision
40800 Drainage of abscess, cyst, hematoma, vestibule of mouth;
simple
40801 complicated
40804 Removal of embedded foreign body, vestibule of mouth;
simple
40805 complicated
40806 Incision of labial frenum (frenotomy)
Excision, Destruction
40808 Biopsy, vestibule of mouth
40810 Excision of lesion of mucosa and submucosa, vestibule of
mouth; without repair
40812 with simple repair
40816 complex, with excision of underlying muscle
40818 Excision of mucosa of vestibule of mouth as donor graft
40819 Excision of frenum, labial or buccal (frenumectomy,
frenulectomy, frenectomy)
40820 Destruction of lesion or scar of vestibule of mouth by
physical methods (eg, laser, thermal, cryo, chemical)
Repair
40830 Closure of laceration, vestibule of mouth; 2.5 cm or less
40831 over 2.5 cm or complex
40840 Vestibuloplasty; anterior
40842 posterior, unilateral
40843 posterior, bilateral
40844 entire arch
40845 complex (including ridge extension, muscle
repositioning)
(For skin grafts, see 15002 et seq)
Other Procedures
40899 Unlisted procedure, vestibule of mouth
Tongue and Floor of Mouth

Incision
41000 Intraoral incision and drainage of abscess, cyst, or
hematoma of tongue or floor of mouth; lingual
41005 sublingual, superficial
41006 sublingual, deep, supramylohyoid
41007 submental space
41008 submandibular space
41009 masticator space
41010 Incision of lingual frenum (frenotomy)
41015 Extraoral incision and drainage of abscess, cyst, or

hematoma of floor of mouth; sublingual
41016 submental
41017 submandibular
41018 masticator space
(For frenoplasty, use 41520)
41019 Placement of needles, catheters, or other device(s) into the
head and/or neck region (percutaneous, transoral, or
transnasal) for subsequent interstitial radioelement
application

(For stereotactic insertion of intracranial brachytherapy
radiation sources, use 61770)
77771, 77772, 77778)
Excision
41100 Biopsy of tongue; anterior two-thirds
41105 posterior one-third
41108 Biopsy of floor of mouth
41110 Excision of lesion of tongue without closure
41112 Excision of lesion of tongue with closure; anterior two-
thirds
41113 posterior one-third
41114 with local tongue flap
(Do not report 41114 in conjunction with 41112 or 41113)
41115 Excision of lingual frenum (frenectomy)
41116 Excision, lesion of floor of mouth

41120 Glossectomy; less than one-half tongue
41130 hemiglossectomy
41135 partial, with unilateral radical neck dissection

41140 complete or total, with or without tracheostomy, without

radical neck dissection
41145 complete or total, with or without tracheostomy, with

unilateral radical neck dissection
41150 composite procedure with resection floor of mouth and

mandibular resection, without radical neck dissection
41153 composite procedure with resection floor of mouth, with

suprahyoid neck dissection
41155 composite procedure with resection floor of mouth,

mandibular resection, and radical neck dissection
(Commando type)
➲ CPT Assistant Jan 01:13, Aug 10:3
Repair
41250 Repair of laceration 2.5 cm or less; floor of mouth and/or
anterior two-thirds of tongue
41251 posterior one-third of tongue
41252 Repair of laceration of tongue, floor of mouth, over 2.6 cm
or complex
Other Procedures
41510 Suture of tongue to lip for micrognathia (Douglas type
procedure)
41512 Tongue base suspension, permanent suture technique

➲ CPT Assistant Aug 10:11, Aug 12:13
(For suture of tongue to lip for micrognathia, use 41510)

41520 Frenoplasty (surgical revision of frenum, eg, with Z-plasty)
(For frenotomy, see 40806, 41010)

41530 Submucosal ablation of the tongue base, radiofrequency, 1
or more sites, per session
41599 Unlisted procedure, tongue, floor of mouth

Dentoalveolar Structures
Incision
41800 Drainage of abscess, cyst, hematoma from dentoalveolar
structures
41805 Removal of embedded foreign body from dentoalveolar
structures; soft tissues
41806 bone
41820 Gingivectomy, excision gingiva, each quadrant
41821 Operculectomy, excision pericoronal tissues
41822 Excision of fibrous tuberosities, dentoalveolar structures
41823 Excision of osseous tuberosities, dentoalveolar structures
41825 Excision of lesion or tumor (except listed above),
dentoalveolar structures; without repair
41826 with simple repair
(For nonexcisional destruction, use 41850)
41828 Excision of hyperplastic alveolar mucosa, each quadrant
(specify)
41830 Alveolectomy, including curettage of osteitis or
sequestrectomy
41850 Destruction of lesion (except excision), dentoalveolar
structures
Other Procedures
41870 Periodontal mucosal grafting
41872 Gingivoplasty, each quadrant (specify)
41874 Alveoloplasty, each quadrant (specify)
(For closure of lacerations, see 40830, 40831)
(For segmental osteotomy, use 21206)
(For reduction of fractures, see 21421-21490)
41899 Unlisted procedure, dentoalveolar structures
Palate and Uvula

Incision
42000 Drainage of abscess of palate, uvula
42100 Biopsy of palate, uvula
42104 Excision, lesion of palate, uvula; without closure
42106 with simple primary closure
42107 with local flap closure
(For skin graft, see 14040-14302)
(For mucosal graft, use 40818)
42120 Resection of palate or extensive resection of lesion
(For reconstruction of palate with extraoral tissue, see
14040-14302, 15050, 15120, 15240, 15576)
42140 Uvulectomy, excision of uvula
42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty,
uvulopharyngoplasty)
(For removal of exostosis of the bony palate, see 21031,

21032)
42160 Destruction of lesion, palate or uvula (thermal, cryo or
chemical)
Repair
42180 Repair, laceration of palate; up to 2 cm
42182 over 2 cm or complex
42200 Palatoplasty for cleft palate, soft and/or hard palate only
42205 Palatoplasty for cleft palate, with closure of alveolar ridge;
soft tissue only
42210 with bone graft to alveolar ridge (includes obtaining
graft)
42215 Palatoplasty for cleft palate; major revision
42220 secondary lengthening procedure
42225 attachment pharyngeal flap
42226 Lengthening of palate, and pharyngeal flap
42227 Lengthening of palate, with island flap
42235 Repair of anterior palate, including vomer flap
(For repair of oronasal fistula, use 30600)

42260 Repair of nasolabial fistula
(For repair of cleft lip, see 40700 et seq)
42280 Maxillary impression for palatal prosthesis
42281 Insertion of pin-retained palatal prosthesis
Other Procedures
42299 Unlisted procedure, palate, uvula
➲ CPT Assistant Dec 04:19, Apr 10:10, Nov 10:9, Jul 14:8
Salivary Gland and Ducts

Incision
42300 Drainage of abscess; parotid, simple
42305 parotid, complicated
42310 Drainage of abscess; submaxillary or sublingual, intraoral
42320 submaxillary, external

42330 Sialolithotomy; submandibular (submaxillary), sublingual or
parotid, uncomplicated, intraoral
42335 submandibular (submaxillary), complicated, intraoral
42340 parotid, extraoral or complicated intraoral
Excision
42400 Biopsy of salivary gland; needle

10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
77012, 77021)
42405 incisional
77012, 77021)
42408 Excision of sublingual salivary cyst (ranula)
42409 Marsupialization of sublingual salivary cyst (ranula)
42410 Excision of parotid tumor or parotid gland; lateral lobe,
without nerve dissection
42415 lateral lobe, with dissection and preservation of facial
nerve
42420 total, with dissection and preservation of facial nerve
42425 total, en bloc removal with sacrifice of facial nerve

42426 total, with unilateral radical neck dissection
(For suture or grafting of facial nerve, see 64864, 64865,
69740, 69745)
42440 Excision of submandibular (submaxillary) gland
42450 Excision of sublingual gland
Repair
42500 Plastic repair of salivary duct, sialodochoplasty; primary or
simple
42505 secondary or complicated
42507 Parotid duct diversion, bilateral (Wilke type procedure);
42509 with excision of both submandibular glands
42510 with ligation of both submandibular (Wharton’s) ducts
Other Procedures
42550 Injection procedure for sialography

42600 Closure salivary fistula
42650 Dilation salivary duct
42660 Dilation and catheterization of salivary duct, with or without
injection
42665 Ligation salivary duct, intraoral
42699 Unlisted procedure, salivary glands or ducts
Pharynx, Adenoids, and Tonsils

Incision
42700 Incision and drainage abscess; peritonsillar
42720 retropharyngeal or parapharyngeal, intraoral approach
42725 retropharyngeal or parapharyngeal, external approach
42800 Biopsy; oropharynx
42804 nasopharynx, visible lesion, simple
42806 nasopharynx, survey for unknown primary lesion
(For laryngoscopic biopsy, see 31510, 31535, 31536)
42808 Excision or destruction of lesion of pharynx, any method
42809 Removal of foreign body from pharynx
42810 Excision branchial cleft cyst or vestige, confined to skin and
subcutaneous tissues
42815 Excision branchial cleft cyst, vestige, or fistula, extending
beneath subcutaneous tissues and/or into pharynx
42820 Tonsillectomy and adenoidectomy; younger than age 12
➲ CPT Assistant Feb 98:11, Mar 08:15, May 08:14
42821 age 12 or over

➲ CPT Assistant Aug 97:18, Feb 98:11, Mar 08:15,
May 08:14
42825 Tonsillectomy, primary or secondary; younger than age 12
➲ CPT Assistant Aug 97:18, Feb 98:11, Mar 08:15

➲ CPT Assistant Aug 97:18, Feb 98:11, Mar 08:15,
Apr 10:10
42830 Adenoidectomy, primary; younger than age 12
42835 Adenoidectomy, secondary; younger than age 12
42842 Radical resection of tonsil, tonsillar pillars, and/or

retromolar trigone; without closure
42844 closure with local flap (eg, tongue, buccal)

42845 closure with other flap

(For closure with other flap(s), use appropriate number for

flap(s))
(When combined with radical neck dissection, use also
38720)
42860 Excision of tonsil tags
42870 Excision or destruction lingual tonsil, any method (separate
procedure)
(For resection of the nasopharynx [eg, juvenile
angiofibroma] by bicoronal and/or transzygomatic approach,
see 61586 and 61600)
42890 Limited pharyngectomy
42892 Resection of lateral pharyngeal wall or pyriform sinus,
direct closure by advancement of lateral and posterior
pharyngeal walls

38720)
42894 Resection of pharyngeal wall requiring closure with
myocutaneous or fasciocutaneous flap or free muscle, skin,
or fascial flap with microvascular anastomosis

38720)
(For limited pharyngectomy with radical neck dissection,
use 38720 with 42890)
(For flap used for reconstruction, see 15730, 15733, 15734,
15756, 15757, 15758)
Repair
42900 Suture pharynx for wound or injury
42950 Pharyngoplasty (plastic or reconstructive operation on
pharynx)
(For pharyngeal flap, use 42225)

42953 Pharyngoesophageal repair
(For closure with myocutaneous or other flap, use
appropriate number in addition)
Other Procedures
42955 Pharyngostomy (fistulization of pharynx, external for
feeding)
42960 Control oropharyngeal hemorrhage, primary or secondary
(eg, post-tonsillectomy); simple
42961 complicated, requiring hospitalization
42962 with secondary surgical intervention
42970 Control of nasopharyngeal hemorrhage, primary or
secondary (eg, postadenoidectomy); simple, with posterior
nasal packs, with or without anterior packs and/or cautery
42971 complicated, requiring hospitalization

42972 with secondary surgical intervention
42999 Unlisted procedure, pharynx, adenoids, or tonsils
Esophagus
Incision
(For esophageal intubation with laparotomy, use 43510)
43020 Esophagotomy, cervical approach, with removal of foreign
body
43030 Cricopharyngeal myotomy
43045 Esophagotomy, thoracic approach, with removal of foreign
body
Excision
(For gastrointestinal reconstruction for previous
esophagectomy, see 43360, 43361)
43100 Excision of lesion, esophagus, with primary repair; cervical
approach
43101 thoracic or abdominal approach
(For wide excision of malignant lesion of cervical

esophagus, with total laryngectomy without radical neck
dissection, see 43107, 43116, 43124, and 31360)
(For wide excision of malignant lesion of cervical
esophagus, with total laryngectomy with radical neck
dissection, see 43107, 43116, 43124, and 31365)
43107 Total or near total esophagectomy, without thoracotomy;
with pharyngogastrostomy or cervical esophagogastrostomy,
with or without pyloroplasty (transhiatal)
43108 with colon interposition or small intestine reconstruction,

including intestine mobilization, preparation and
anastomosis(es)
43112 Total or near total esophagectomy, with thoracotomy; with

pharyngogastrostomy or cervical esophagogastrostomy, with
or without pyloroplasty (ie, McKeown esophagectomy or
tri-incisional esophagectomy)
➲ CPT Assistant Aug 13:14, Jul 18:7

including intestine mobilization, preparation, and
anastomosis(es)
43116 Partial esophagectomy, cervical, with free intestinal graft,

including microvascular anastomosis, obtaining the graft and
intestinal reconstruction
➲ CPT Assistant Nov 97:17, Nov 98:16, Aug 10:4

(Report 43116 with the modifier 52 appended if intestinal or
free jejunal graft with microvascular anastomosis is
performed by another physician)
(For free jejunal graft with microvascular anastomosis
performed by another physician, use 43496)
43117 Partial esophagectomy, distal two-thirds, with thoracotomy
and separate abdominal incision, with or without proximal
gastrectomy; with thoracic esophagogastrostomy, with or
without pyloroplasty (Ivor Lewis)
anastomosis(es)
(For total esophagectomy with gastropharyngostomy, see

43107, 43124)
(For esophagogastrectomy (lower third) and vagotomy, use
43122)
43121 Partial esophagectomy, distal two-thirds, with thoracotomy
only, with or without proximal gastrectomy, with thoracic
esophagogastrostomy, with or without pyloroplasty
43122 Partial esophagectomy, thoracoabdominal or abdominal
approach, with or without proximal gastrectomy; with
esophagogastrostomy, with or without pyloroplasty
anastomosis(es)
43124 Total or partial esophagectomy, without reconstruction (any

approach), with cervical esophagostomy
43130 Diverticulectomy of hypopharynx or esophagus, with or
without myotomy; cervical approach

(For endoscopic diverticulectomy of hypopharynx or

cervical esophagus, use 43180)
Endoscopy
When bleeding occurs as a result of an endoscopic procedure,
control of bleeding is not reported separately during the same
operative session.
Esophagoscopy includes examination from the cricopharyngeus
muscle (upper esophageal sphincter) to and including the
gastroesophageal junction. It may also include examination of the
proximal region of the stomach via retroflexion when performed.
Esophagoscopy
43180 Esophagoscopy, rigid, transoral with diverticulectomy of
hypopharynx or cervical esophagus (eg, Zenker’s
diverticulum), with cricopharyngeal myotomy, includes use
of telescope or operating microscope and repair, when
performed

(For diverticulectomy of hypopharynx or esophagus [open],
see 43130, 43135)
43191 Esophagoscopy, rigid, transoral; diagnostic, including
collection of specimen(s) by brushing or washing when
performed (separate procedure)
➲ CPT Assistant Dec 13:3, Feb 14:9, 11, Nov 15:8

43194, 43195, 43196, 43197, 43198, 43210)
(For diagnostic transnasal esophagoscopy, see 43197,
43198)
(For diagnostic flexible transoral esophagoscopy, use
43200)
43192 with directed submucosal injection(s), any substance

43198)
(For flexible transoral esophagoscopy with directed
submucosal injection(s), use 43201)
(For flexible transoral esophagoscopy with injection
sclerosis of esophageal varices, use 43204)
(For rigid transoral esophagoscopy with injection sclerosis
of esophageal varices, use 43499)
43193 with biopsy, single or multiple

43198)
(For flexible transoral esophagoscopy with biopsy, use
43202)

43198)
(If fluoroscopic guidance is performed, use 76000)
(For flexible transoral esophagoscopy with removal of
foreign body(s), use 43215)
43195 with balloon dilation (less than 30 mm diameter)
43198)
(For esophageal dilation with balloon 30 mm diameter or
larger, see 43214, 43233)
(For dilation without endoscopic visualization, see 43450,
43453)
(For flexible transoral esophagoscopy with balloon dilation
[less than 30 mm diameter], use 43220)
43196 with insertion of guide wire followed by dilation over
guide wire

43198)
(For flexible transoral esophagoscopy with insertion of
guide wire followed by dilation over guide wire, use
43226)
43197 Esophagoscopy, flexible, transnasal; diagnostic, including
collection of specimen(s) by brushing or washing, when
➲ CPT Assistant Dec 13:3, Feb 14:9, Nov 15:8

43192, 43193, 43194, 43195, 43196, 43198, 43200-43232,
43235-43259, 43266, 43270, 92511)
separate type of endoscope [eg, rigid endoscope] is used)
(For transoral esophagoscopy, see 43191, 43200)

43192, 43193, 43194, 43195, 43196, 43197, 43200-43232,
43235-43259, 43266, 43270, 92511)
separate type of endoscope [eg, rigid endoscope] is used)
(For transoral esophagoscopy with biopsy, see 43193,
43202)
43200 Esophagoscopy, flexible, transoral; diagnostic, including
➲ CPT Assistant Spring 91:7, Spring 94:1, Jun 98:10, Nov
99:21, Sep 03:3, Oct 08:6, Jan 13:11, Feb 13:16, Dec
13:3, Feb 14:9, Nov 15:8
43201-43232)
(For diagnostic rigid transoral esophagoscopy, use 43191)
(For diagnostic flexible transnasal esophagoscopy, use
43197)
(For diagnostic flexible esophagogastroduodenoscopy, use
43235)
➲ CPT Assistant Jun 10:4, Jan 13:11, Dec 13:3
43227 for the same lesion)
43200)
(For rigid transoral esophagoscopy with directed
submucosal injection[s], use 43192)
(For flexible transoral esophagoscopy with injection
sclerosis of esophageal varices, use 43204)
➲ CPT Assistant Spring 94:1, Oct 08:6, Jan 13:11, Dec
13:3
same lesion)
43200)
(For rigid transoral esophagoscopy with biopsy, use 43193)
(For flexible transnasal esophagoscopy with biopsy, use
43198)
43204 with injection sclerosis of esophageal varices
➲ CPT Assistant Spring 94:1, Oct 08:6, Jun 10:5, Jan
13:11, Dec 13:3
the same lesion)
43200)
43205 with band ligation of esophageal varices
13:3
same lesion)
43200)
(To report control of nonvariceal bleeding with band
ligation, use 43227)
43206 with optical endomicroscopy
➲ CPT Assistant Jan 13:11, Aug 13:5, Dec 13:3, Nov
17:10
(Report supply of contrast agent separately)
43200, 88375)
➲ CPT Assistant Spring 94:1, Oct 08:6, Dec 13:3

43200)
(For rigid transoral esophagoscopy with removal of foreign
body(s), use 43194)
43216 with removal of tumor(s), polyp(s), or other lesion(s) by
hot biopsy forceps
13:3
43200)
snare technique
13:3
same lesion)
43200)
(For esophagogastroduodenoscopy with removal of
tumor[s], polyp[s], or other lesion[s] by snare technique, use
43251)
(For endoscopic mucosal resection, use 43211)
# 43211 with endoscopic mucosal resection
➲ CPT Assistant Dec 13:3, Nov 17:10, Dec 19:14

43200)
# 43212 with placement of endoscopic stent (includes pre- and
post-dilation and guide wire passage, when performed)

43200, 43220, 43226, 43241)
43220 with transendoscopic balloon dilation (less than 30 mm
diameter)
➲ CPT Assistant Spring 94:2, Jan 97:10, May 05:3, Oct
08:6, Jan 13:11, Dec 13:3
43200, 43212, 43226, 43229)
(For rigid transoral esophagoscopy with balloon dilation
[less than 30 mm diameter], use 43195)
(For esophageal dilation with balloon 30 mm diameter or
larger, use 43214)
(For dilation without endoscopic visualization, see 43450,
43453)
# 43213 with dilation of esophagus, by balloon or dilator,
retrograde (includes fluoroscopic guidance, when
performed)

43200, 74360, 76000)
(For transendoscopic balloon dilation of multiple strictures
during the same session, report 43213 with modifier 59 for
each additional stricture dilated)
# 43214 with dilation of esophagus with balloon (30 mm diameter
or larger) (includes fluoroscopic guidance, when
performed)

43200, 74360, 76000)
43226 with insertion of guide wire followed by passage of
dilator(s) over guide wire

same lesion)
43200, 43212, 43220)
(For rigid transoral esophagoscopy with insertion of guide
wire followed by dilation over guide wire, use 43196)
43227 with control of bleeding, any method
➲ CPT Assistant Spring 94:2, Oct 08:6, Jun 10:4, Jan
13:11, Dec 13:3, Feb 14:11
43200)
43229 with ablation of tumor(s), polyp(s), or other lesion(s)
(includes pre- and post-dilation and guide wire passage,
when performed)
the same lesion)
43200)
(For esophagoscopic photodynamic therapy, report 43229 in
conjunction with 96570, 96571 as appropriate)
43231 with endoscopic ultrasound examination
➲ CPT Assistant Oct 01:4, May 04:6, Oct 08:6, Mar
09:8, Jan 13:11, Dec 13:3
43200, 43232, 76975)
43232 with transendoscopic ultrasound-guided intramural or
transmural fine needle aspiration/biopsy(s)
➲ CPT Assistant Oct 01:4, Mar 04:11, May 04:6, Oct
08:6, Mar 09:8, Jan 13:11, Dec 13:3, Feb 14:9
43200, 43231, 76942, 76975)
Esophagogastroduodenoscopy
(For examination of the esophagus from the cricopharyngeus
muscle [upper esophageal sphincter] to and including the
gastroesophageal junction, including examination of the
proximal region of the stomach via retroflexion when
performed, see 43197, 43198, 43200, 43201, 43202, 43204,
43205, 43206, 43211, 43212, 43213, 43214, 43215, 43216,
43217, 43220, 43226, 43227, 43229, 43231, 43232)
(Use 43233, 43235-43259, 43266, 43270 for examination of
a surgically altered stomach where the jejunum is examined
distal to the anastomosis [eg, gastric bypass,
gastroenterostomy {Billroth II}])
To report esophagogastroscopy where the duodenum is
deliberately not examined (eg, judged clinically not pertinent), or
because the clinical situation precludes such exam (eg, significant
gastric retention precludes safe exam of duodenum), append
modifier 52 if repeat examination is not planned, or modifier 53
if repeat examination is planned.
43235 Esophagogastroduodenoscopy, flexible, transoral;
diagnostic, including collection of specimen(s) by brushing
or washing, when performed (separate procedure)
➲ CPT Assistant Spring 94:4, Dec 97:11, Jun 03:11, Sep
03:3, Oct 08:6, May 09:8, Jan 13:11, Dec 13:3, Nov
15:8, Jul 17:10, Jul 18:14, Oct 19:10
43210, 43236-43259, 43266, 43270, 44360, 44361, 44363,
44364, 44365, 44366, 44369, 44370, 44372, 44373, 44376,
44377, 44378, 44379)
➲ CPT Assistant Jun 10:4, Jan 13:11, Dec 13:3

43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
(For flexible, transoral esophagogastroduodenoscopy with
injection sclerosis of esophageal and/or gastric varices, use
43243)
43237 with endoscopic ultrasound examination limited to the
esophagus, stomach or duodenum, and adjacent structures
➲ CPT Assistant Jan 13:11, Dec 13:3, Jan 16:11

43235, 43238, 43242, 43253, 43259, 44360, 44361, 44363,
44364, 44365, 44366, 44369, 44370, 44372, 44373, 44376,
44377, 44378, 44379, 76975)
43235
transmural fine needle aspiration/biopsy(s), (includes
endoscopic ultrasound examination limited to the
esophagus, stomach or duodenum, and adjacent
structures)

43235, 43237, 43242, 44360, 44361, 44363, 44364, 44365,
44366, 44369, 44370, 44372, 44373, 44376, 44377, 44378,
44379, 76942, 76975)
➲ CPT Assistant Spring 94:4, Apr 98:14, Feb 99:11,
Oct 01:4, Nov 07:9, Jan 13:11, Dec 13:3, Jul 18:14,
Jan 20:12
same lesion)
43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
43240 with transmural drainage of pseudocyst (includes
placement of transmural drainage catheter[s]/stent[s],
when performed, and endoscopic ultrasound, when
performed)
➲ CPT Assistant Oct 01:4, Jan 13:11, Dec 13:3

same lesion)
43235, 43242, 43259, 43266, 44360, 44361, 44363, 44364,
44365, 44366, 44369, 44370, 44372, 44373, 44376, 44377,
44378, 44379)
(For endoscopic pancreatic necrosectomy, use 48999)
43241 with insertion of intraluminal tube or catheter
➲ CPT Assistant Spring 94:4, Nov 01:7, Apr 09:3, Jan
13:11, Dec 13:3
43212, 43235, 43266, 44360, 44361, 44363, 44364, 44365,
44366, 44369, 44370, 44372, 44373, 44376, 44377, 44378,
44379)
(For naso- or oro-gastric tube placement requiring
physician’s or other qualified health care professional’s
skill and fluoroscopic guidance, use 43752)
(For nonendoscopic enteric tube placement, see 44500,
74340)
transmural fine needle aspiration/biopsy(s) (includes
endoscopic ultrasound examination of the esophagus,
stomach, and either the duodenum or a surgically altered
stomach where the jejunum is examined distal to the
anastomosis)
2017
➲ CPT Assistant Oct 01:4, Mar 09:8, Jan 13:11, Dec
13:3
43235, 43237, 43238, 43240, 43259, 44360, 44361, 44363,
44364, 44365, 44366, 44369, 44370, 44372, 44373, 44376,
44377, 44378, 44379, 76942, 76975)
(For transendoscopic ultrasound-guided transmural fine
needle aspiration/biopsy limited to the esophagus, stomach,
duodenum, or adjacent structure, use 43238)
43243 with injection sclerosis of esophageal/gastric varices
CPT Assistant Spring 94:4, Jun 10:5, Jan 13:11, Dec
➲ 13:3
the same lesion)
43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
43244 with band ligation of esophageal/gastric varices
➲ CPT Assistant Spring 94:4, Jun 11:13, Jan 13:11, Dec
13:3
43235, 43255, 44360, 44361, 44363, 44364, 44365, 44366,
44369, 44370, 44372, 44373, 44376, 44377, 44378, 44379)
(To report control of nonvariceal bleeding with band
ligation, use 43255)
43245 with dilation of gastric/duodenal stricture(s) (eg,
balloon, bougie)
2017
➲ CPT Assistant Spring 94:4, Oct 01:4, Jan 04:26, Jan
13:11, Dec 13:3
43235, 43266, 44360, 44361, 44363, 44364, 44365, 44366,
44369, 44370, 44372, 44373, 44376, 44377, 44378, 44379)
43246 with directed placement of percutaneous gastrostomy
tube
➲ CPT Assistant Spring 94:4, Feb 97:10, Mar 10:10,
Jan 13:11, May 13:12, Dec 13:3, Feb 19:5
43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44376, 44377, 44378, 44379)
(For percutaneous insertion of gastrostomy tube under
fluoroscopic guidance, use 49440)
(For percutaneous replacement of gastrostomy tube without
imaging or endoscopy, see 43762, 43763)

43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
43248 with insertion of guide wire followed by passage of
dilator(s) through esophagus over guide wire
➲ CPT Assistant Spring 94:4, Dec 97:11, Oct 08:6, Jan
13:11, Dec 13:3, Jul 17:10
43235, 43266, 43270, 44360, 44361, 44363, 44364, 44365,
44366, 44369, 44370, 44372, 44373, 44376, 44377, 44378,
44379)
43249 with transendoscopic balloon dilation of esophagus (less
than 30 mm diameter)
➲ CPT Assistant May 05:3, Jan 13:11, Dec 13:3, Jul
18:14
43235, 43266, 43270, 44360, 44361, 44363, 44364, 44365,
44366, 44369, 44370, 44372, 44373, 44376, 44377, 44378,
44379)
# 43233 with dilation of esophagus with balloon (30 mm diameter
or larger) (includes fluoroscopic guidance, when
performed)

43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379, 74360,
76000)
hot biopsy forceps
➲ CPT Assistant Spring 94:4, Feb 99:11, Nov 07:9, Jan
13:11, Dec 13:3
43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
snare technique
➲ CPT Assistant Spring 94:4, Oct 04:12, Nov 07:9, Jun
11:13, Jan 13:11, Dec 13:3
same lesion)
43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
43252 with optical endomicroscopy
➲ CPT Assistant Jan 13:11, Aug 13:5, Dec 13:3
(Report supply of contrast agent separately)

43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379, 88375)
43253 with transendoscopic ultrasound-guided transmural
injection of diagnostic or therapeutic substance(s) (eg,
anesthetic, neurolytic agent) or fiducial marker(s)
(includes endoscopic ultrasound examination of the
esophagus, stomach, and either the duodenum or a
surgically altered stomach where the jejunum is
examined distal to the anastomosis)
➲ CPT Assistant Dec 13:3, Apr 18:11

same lesion)
43235, 43237, 43259, 44360, 44361, 44363, 44364, 44365,
44366, 44369, 44370, 44372, 44373, 44376, 44377, 44378,
44379, 76942, 76975)
(For transendoscopic ultrasound-guided transmural fine
needle aspiration/biopsy, see 43238, 43242)
43254 with endoscopic mucosal resection
43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
➲ CPT Assistant Spring 94:4, Jun 10:4, Dec 13:3

43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
# 43266 with placement of endoscopic stent (includes pre- and

43235, 43240, 43241, 43245, 43248, 43249, 44360, 44361,
44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373,
44376, 44377, 44378, 44379)
43257 with delivery of thermal energy to the muscle of lower
esophageal sphincter and/or gastric cardia, for treatment
of gastroesophageal reflux disease
➲ CPT Assistant May 05:3, Jan 13:11, Dec 13:3

43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
(For ablation of metaplastic/dysplastic esophageal lesion
[eg, Barrett’s esophagus], see 43229, 43270)
# 43270 with ablation of tumor(s), polyp(s), or other lesion(s)
when performed)

the same lesion)
43235, 44360, 44361, 44363, 44364, 44365, 44366, 44369,
44370, 44372, 44373, 44376, 44377, 44378, 44379)
(For esophagoscopic photodynamic therapy, use 43270 in
conjunction with 96570, 96571 as appropriate)
43259 with endoscopic ultrasound examination, including the
esophagus, stomach, and either the duodenum or a
surgically altered stomach where the jejunum is
examined distal to the anastomosis
➲ CPT Assistant Spring 94:4, May 04:7, Mar 09:8, Jan
13:11, Dec 13:3, Jan 16:11, Oct 19:10
43235, 43237, 43240, 43242, 43253, 44360, 44361, 44363,
44364, 44365, 44366, 44369, 44370, 44372, 44373, 44376,
44377, 44378, 44379, 76975)
# 43210 with esophagogastric fundoplasty, partial or complete,
includes duodenoscopy when performed
43197, 43200, 43235)
Endoscopic Retrograde Cholangiopancreatography

(ERCP)
Report the appropriate code(s) for each service performed.

Therapeutic ERCP (43261, 43262, 43263, 43264, 43265, 43274,
43275, 43276, 43277, 43278) includes diagnostic ERCP (43260).
ERCP includes guide wire passage when performed. An ERCP is
considered complete if one or more of the ductal system(s),
(pancreatic/biliary) is visualized. To report ERCP attempted but
with unsuccessful cannulation of any ductal system, see 43235-
43259, 43266, 43270.
(For percutaneous biliary catheter procedures, see 47490-47544)
Codes 43274, 43275, 43276, and 43277 describe ERCP with stent
placement, removal or replacement (exchange) of stent(s), and
balloon dilation within the pancreatico-biliary system. For
reporting purposes, ducts that may be reported as stented or
subject to stent replacement (exchange) or to balloon dilation
include:
Pancreas: major and minor ducts
Biliary tree: common bile duct, right hepatic duct, left hepatic
duct, cystic duct/gallbladder
ERCP with stent placement includes any balloon dilation
performed in that duct. ERCP with more than one stent
placement (eg, different ducts or side by side in the same duct)
performed during the same day/session may be reported with
43274 more than once with modifier 59 appended to the
subsequent procedure(s). For ERCP with more than one stent
exchanged during the same day/session, 43276 may be reported
for the initial stent exchange, and 43276 with modifier 59 for
each additional stent exchange. ERCP with balloon dilation of
more than one duct during the same day/session may be reported
with modifier 59 appended to the subsequent procedure(s).
Sphincteroplasty, which is balloon dilation of the ampulla
(sphincter of Oddi), is reported with 43277, and includes
sphincterotomy (43262) when performed.
To report ERCP via altered postoperative anatomy, see 43260,
43262, 43263, 43264, 43265, 43273, 43274, 43275, 43276, 43277,
43278, for Billroth II gastroenterostomy. See 47999 (Unlisted
procedure, biliary tract) or 48999 (Unlisted procedure, pancreas)
for ERCP via gastrostomy (laparoscopic or open) or via Roux-
en-Y anatomy (eg, post-bariatric gastric bypass, post-total
gastrectomy).
To report optical endomicroscopy of the biliary tract and
pancreas, use 0397T. Do not report optical endomicroscopy more
than once per session.
Stone destruction includes any stone removal in the same ductal
system (biliary/pancreatic). Code 43277 may be separately
reported if sphincteroplasty or dilation of a ductal stricture is
required before proceeding to remove stones/debris from the
duct during the same session. Dilation that is incidental to the
passage of an instrument to clear stones or debris is not
(Do not report 43277 for use of a balloon catheter to clear
stones/debris from a duct. Any dilation of the duct that may
occur during this maneuver is considered inherent to the
work of 43264 and 43265)
(If imaging of the ductal systems is performed, including
images saved to the permanent record and report of the
imaging, see 74328, 74329, 74330)
43260 Endoscopic retrograde cholangiopancreatography (ERCP);
diagnostic, including collection of specimen(s) by brushing
or washing, when performed (separate procedure)
➲ CPT Assistant Spring 94:5, Oct 04:13, May 08:14, Aug
08:12, Jan 12:12, Jan 13:11, Dec 13:3
43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278)
➲ CPT Assistant Spring 94:5, Aug 08:12, Jun 11:13,
Jan 13:11
(For percutaneous endoluminal biopsy of biliary tree, use
47543)
43262 with sphincterotomy/papillotomy
➲ CPT Assistant Spring 94:5, Oct 04:13, Jul 09:10, Jan
13:11
(43262 may be reported when sphincterotomy is performed
in addition to 43261, 43263, 43264, 43265, 43275, 43278)
(Do not report 43262 in conjunction with 43274 for stent
placement or with 43276 for stent replacement [exchange] in
the same location)
(For percutaneous balloon dilation of biliary duct(s) or of
ampulla, use 47542)
43263 with pressure measurement of sphincter of Oddi
➲ CPT Assistant Spring 94:5, Oct 04:13, Jan 13:11,
Dec 13:3
Endoscopic Retrograde Cholangiopancreatography (ERCP)

43260
Examination of the hepatobiliary system (pancreatic ducts, hepatic ducts, common bile ducts, duodenal
papilla [ampulla of Vater] and gallbladder [if present]) is performed through a side-viewing flexible
fiberoptic endoscope.
43264 with removal of calculi/debris from biliary/pancreatic

duct(s)
(Do not report 43264 if no calculi or debris are found, even
if balloon catheter is deployed)
(For percutaneous removal of calculi/debris, use 47544)
43265 with destruction of calculi, any method (eg, mechanical,
electrohydraulic, lithotripsy)

# 43274 with placement of endoscopic stent into biliary or
pancreatic duct, including pre- and post-dilation and
guide wire passage, when performed, including
sphincterotomy, when performed, each stent

43276, 43277 for stent placement or replacement [exchange]
in the same duct)
(For stent placement in both the pancreatic duct and the
common bile duct during the same operative session,
placement of separate stents in both the right and left hepatic
ducts, or placement of two side-by-side stents in the same
duct, 43274 may be reported for each additional stent
placed, using modifier 59 with the subsequent procedure[s])
(To report naso-biliary or naso-pancreatic drainage tube
placement, use 43274)
(For percutaneous placement of biliary stent(s), see 47538,
47539, 47540)
# 43275 with removal of foreign body(s) or stent(s) from
biliary/pancreatic duct(s)

43276)
(For removal of stent from biliary or pancreatic duct without
ERCP, use 43247)
(Report 43275 only once for removal of one or more stents
or foreign bodies from biliary/pancreatic duct[s] during the
same session)
# 43276 with removal and exchange of stent(s), biliary or
pancreatic duct, including pre- and post-dilation and
guide wire passage, when performed, including
sphincterotomy, when performed, each stent exchanged
(43276 includes removal and replacement [exchange] of one

stent. For replacement [exchange] of additional stent[s]
each additional replacement [exchange])
stent placement or exchange in the same duct)
# 43277 with trans-endoscopic balloon dilation of
biliary/pancreatic duct(s) or of ampulla
(sphincteroplasty), including sphincterotomy, when
performed, each duct

same lesion)
(Do not report 43277 for incidental dilation using balloon
for stone/debris removal performed with 43264, 43265)
(If sphincterotomy without sphincteroplasty is performed on
a separate pancreatic duct orifice during the same session
[ie, pancreas divisum], report 43262 with modifier 59)
dilation and stent placement/replacement [exchange] in the
same duct)
during the same session, use 43277 with modifier 59 for
(For bilateral balloon dilation [both right and left hepatic
ducts], 43277 may be reported twice with modifier 59
appended to the second procedure)
(For percutaneous balloon dilation of biliary duct(s) or of
ampulla (sphincteroplasty), use 47542)
# 43278 with ablation of tumor(s), polyp(s), or other lesion(s),
including pre- and post-dilation and guide wire passage,
when performed

same lesion)
(For ampullectomy, use 43254)
✚ 43273 Endoscopic cannulation of papilla with direct visualization
of pancreatic/common bile duct(s) (List separately in
addition to code(s) for primary procedure)
(Report 43273 once per procedure)

43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278)
Laparoscopy
Surgical laparoscopy always includes diagnostic laparoscopy. To
report a diagnostic laparoscopy (peritoneoscopy) (separate
procedure), use 49320.
43279 Laparoscopy, surgical, esophagomyotomy (Heller type),
with fundoplasty, when performed
(For open approach, see 43330, 43331)

43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg,
Nissen, Toupet procedures)
➲ CPT Assistant Nov 99:22, Mar 00:8, Dec 02:2, Jun 11:8,
Feb 12:3, Dec 14:16, Nov 15:8
43282)
(For open esophagogastric fundoplasty, see 43327, 43328)
(For laparoscopy, surgical, esophageal sphincter
augmentation procedure, placement of sphincter
augmentation device, see 43284, 43285)
(For esophagogastroduodenoscopy fundoplasty, partial or
complete, transoral approach, use 43210)
43281 Laparoscopy, surgical, repair of paraesophageal hernia,
includes fundoplasty, when performed; without implantation
of mesh
➲ CPT Assistant Jun 11:9, Feb 12:3, Dec 14:16, Sep
18:14, Nov 18:11
43282 with implantation of mesh
➲ CPT Assistant Jun 11:9, Feb 12:3, Dec 14:16, Aug
16:9
(To report transabdominal paraesophageal hiatal hernia
repair, see 43332, 43333)
(To report transthoracic diaphragmatic hernia repair, see
43334, 43335)
43450, 43453)
Laparoscopic Fundoplasty
43280
With the esophagus and fundus held aside, sutures are placed in both crus diaphragmatis muscles below
the esophagus to bring them together to close the hiatal hernia, and the anterior and posterior walls of
the fundus are wrapped and stitched around the esophagus to complete the laparoscopic fundoplasty.
✚ 43283 Laparoscopy, surgical, esophageal lengthening procedure

(eg, Collis gastroplasty or wedge gastroplasty) (List
➲ CPT Assistant Jun 11:9, Feb 12:3

43284 Laparoscopy, surgical, esophageal sphincter augmentation
procedure, placement of sphincter augmentation device (ie,
magnetic band), including cruroplasty when performed
➲ CPT Assistant Aug 17:6, Sep 18:14, Apr 19:11

43281, 43282)
Laparoscopic Esophageal Sphincter Augmentation

43284
Implanted magnetic sphincter augmentation device
43285 Removal of esophageal sphincter augmentation device
43286 Esophagectomy, total or near total, with laparoscopic

mobilization of the abdominal and mediastinal esophagus
and proximal gastrectomy, with laparoscopic pyloric
drainage procedure if performed, with open cervical
pharyngogastrostomy or esophagogastrostomy (ie,
laparoscopic transhiatal esophagectomy)
43287 Esophagectomy, distal two-thirds, with laparoscopic

mobilization of the abdominal and lower mediastinal
esophagus and proximal gastrectomy, with laparoscopic
pyloric drainage procedure if performed, with separate
thoracoscopic mobilization of the middle and upper
mediastinal esophagus and thoracic esophagogastrostomy
(ie, laparoscopic thoracoscopic esophagectomy, Ivor Lewis
esophagectomy)
(Do not report 43287 in conjunction with 32551 for right

tube thoracostomy)
43288 Esophagectomy, total or near total, with thoracoscopic
mobilization of the upper, middle, and lower mediastinal
esophagus, with separate laparoscopic proximal
gastrectomy, with laparoscopic pyloric drainage procedure
if performed, with open cervical pharyngogastrostomy or
esophagogastrostomy (ie, thoracoscopic, laparoscopic and
cervical incision esophagectomy, McKeown
esophagectomy, tri-incisional esophagectomy)
(Do not report 43288 in conjunction with 32551 for right

tube thoracostomy)
43289 Unlisted laparoscopy procedure, esophagus
➲ CPT Assistant Nov 99:22, Mar 00:8, Dec 14:16, Jul
18:7
Repair
43300 Esophagoplasty (plastic repair or reconstruction), cervical
approach; without repair of tracheoesophageal fistula
43305 with repair of tracheoesophageal fistula
43310 Esophagoplasty (plastic repair or reconstruction), thoracic
approach; without repair of tracheoesophageal fistula
43312 with repair of tracheoesophageal fistula
43313 Esophagoplasty for congenital defect (plastic repair or
reconstruction), thoracic approach; without repair of
congenital tracheoesophageal fistula
43314 with repair of congenital tracheoesophageal fistula


43314)
Ivor Lewis Esophagectomy

43287
43320 Esophagogastrostomy (cardioplasty), with or without
vagotomy and pyloroplasty, transabdominal or transthoracic
approach
(For laparoscopic procedure, use 43280)
43325 Esophagogastric fundoplasty, with fundic patch (Thal-
Nissen procedure)
(For cricopharyngeal myotomy, use 43030)

43327 Esophagogastric fundoplasty partial or complete;
laparotomy
➲ CPT Assistant Jun 11:8, Feb 12:3, Nov 15:8
43328 thoracotomy
➲ CPT Assistant Jun 11:8, Feb 12:3, Nov 15:8
(For esophagogastroduodenoscopy fundoplasty, partial or

complete, transoral approach, use 43210)
Nissen Fundoplasty
43327, 43328
The lower esophagus is accessed through an upper abdominal or lower thoracic incision. The fundus of
the stomach is mobilized and wrapped around the lower esophageal sphincter, and the wrap is sutured
into place.
43330 Esophagomyotomy (Heller type); abdominal approach
(For laparoscopic esophagomyotomy procedure, use 43279)

(For thoracoscopic esophagomyotomy, use 32665)

43332 Repair, paraesophageal hiatal hernia (including
fundoplication), via laparotomy, except neonatal; without
implantation of mesh or other prosthesis
43333 with implantation of mesh or other prosthesis

(For neonatal diaphragmatic hernia repair, use 39503)

43334 Repair, paraesophageal hiatal hernia (including
fundoplication), via thoracotomy, except neonatal; without
implantation of mesh or other prosthesis


43336 Repair, paraesophageal hiatal hernia, (including
fundoplication), via thoracoabdominal incision, except
neonatal; without implantation of mesh or other prosthesis


✚ 43338 Esophageal lengthening procedure (eg, Collis gastroplasty
or wedge gastroplasty) (List separately in addition to code
(Use 43338 in conjunction with 43280, 43327-43337)

43340 Esophagojejunostomy (without total gastrectomy);
abdominal approach
43351 Esophagostomy, fistulization of esophagus, external;
thoracic approach
43352 cervical approach
43360 Gastrointestinal reconstruction for previous esophagectomy,

for obstructing esophageal lesion or fistula, or for previous
esophageal exclusion; with stomach, with or without
pyloroplasty
anastomosis(es)
43400 Ligation, direct, esophageal varices

43405 Ligation or stapling at gastroesophageal junction for pre-
existing esophageal perforation
43410 Suture of esophageal wound or injury; cervical approach
43415 transthoracic or transabdominal approach

43420 Closure of esophagostomy or fistula; cervical approach
43425 transthoracic or transabdominal approach
(To report transabdominal paraesophageal hiatal hernia
repair, see 43332, 43333. To report transthoracic
diaphragmatic hernia repair, see 43334, 43335)
Manipulation
(For associated esophagogram, use 74220)
43450 Dilation of esophagus, by unguided sound or bougie, single
or multiple passes
➲ CPT Assistant Spring 94:1, Jan 97:10, Apr 98:14, Jun
98:10, Dec 13:3, Jul 17:10
43453 Dilation of esophagus, over guide wire
(For dilation with endoscopic visualization, see 43195,

43226)
(For dilation of esophagus, by balloon or dilator, see 43214,
43220, 43233, 43249)
(For endoscopic dilation of esophagus with balloon less
than 30 mm diameter, see 43195, 43220, 43249)
(For endoscopic dilation of esophagus with balloon 30 mm
diameter or larger, see 43214, 43233)
43460 Esophagogastric tamponade, with balloon (Sengstaken type)
(For removal of esophageal foreign body by balloon

catheter, see 43499, 74235)
Other Procedures
43496 Free jejunum transfer with microvascular anastomosis
97:17, Nov 98:16
43499 Unlisted procedure, esophagus
➲ CPT Assistant May 07:10, Oct 10:12, Dec 10:12, May
11:9, Dec 11:19, Mar 13:13, Nov 15:8, 11, Jul 18:7
Stomach
Incision
43500 Gastrotomy; with exploration or foreign body removal
43501 with suture repair of bleeding ulcer
43502 with suture repair of pre-existing esophagogastric
laceration (eg, Mallory-Weiss)
43510 with esophageal dilation and insertion of permanent
intraluminal tube (eg, Celestin or Mousseaux-Barbin)
43520 Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt
type operation)
Excision
43605 Biopsy of stomach, by laparotomy
43610 Excision, local; ulcer or benign tumor of stomach

43611 malignant tumor of stomach
43620 Gastrectomy, total; with esophagoenterostomy
43621 with Roux-en-Y reconstruction
43622 with formation of intestinal pouch, any type
43631 Gastrectomy, partial, distal; with gastroduodenostomy
43632 with gastrojejunostomy
43633 with Roux-en-Y reconstruction
43634 with formation of intestinal pouch
✚ 43635 Vagotomy when performed with partial distal gastrectomy
(List separately in addition to code[s] for primary
procedure)

43634)
43640 Vagotomy including pyloroplasty, with or without
gastrostomy; truncal or selective
(For pyloroplasty, use 43800)
(For vagotomy, see 64755, 64760)
43641 parietal cell (highly selective)
(For upper gastrointestinal endoscopy, see 43235-43259)
Laparoscopy
(For upper gastrointestinal endoscopy including esophagus,
stomach, and either the duodenum and/or jejunum, see
43235-43259)
43644 Laparoscopy, surgical, gastric restrictive procedure; with
gastric bypass and Roux-en-Y gastroenterostomy (roux limb
150 cm or less)

(Esophagogastroduodenoscopy [EGD] performed for a
separate condition should be reported with modifier 59)
(For greater than 150 cm, use 43645)
43645 with gastric bypass and small intestine reconstruction to
limit absorption

43647 Laparoscopy, surgical; implantation or replacement of
gastric neurostimulator electrodes, antrum
43648 revision or removal of gastric neurostimulator

electrodes, antrum
(For open approach, see 43881, 43882)

(For insertion of gastric neurostimulator pulse generator, use
64590)
(For revision or removal of gastric neurostimulator pulse
generator, use 64595)
(For electronic analysis and programming of gastric
neurostimulator pulse generator, see 95980-95982)
(For laparoscopic implantation, revision, or removal of
gastric neurostimulator electrodes, lesser curvature [morbid
obesity], use 43659)
(For laparoscopic implantation, revision, replacement, or
removal of vagus nerve blocking neurostimulator electrode
array and/or pulse generator at the esophagogastric junction,
see 0312T-0317T)
43651 Laparoscopy, surgical; transection of vagus nerves, truncal
43652 transection of vagus nerves, selective or highly selective
43653 gastrostomy, without construction of gastric tube (eg,

Stamm procedure) (separate procedure)
43659 Unlisted laparoscopy procedure, stomach

➲ CPT Assistant Nov 99:22, Mar 00:8, Apr 06:19, Jun
06:16, Dec 07:12, Jun 11:8, Dec 11:19, Feb 13:13, Jun
13:13, Jul 18:7
Introduction
43752 Naso- or oro-gastric tube placement, requiring physician’s
skill and fluoroscopic guidance (includes fluoroscopy,
image documentation and report)
➲ CPT Assistant Jan 02:11, Apr 03:7, Oct 03:2, Jul 06:4,
Feb 07:10, Jul 07:1, Aug 08:7, Sep 11:4, May 14:4, Mar
18:11, Aug 19:8
(Do not report 43752 in conjunction with critical care codes
99291-99292, neonatal critical care codes 99468, 99469,
pediatric critical care codes 99471, 99472 or low birth
weight intensive care service codes 99478, 99479)
(For percutaneous placement of gastrostomy tube, use
49440)
(For enteric tube placement, see 44500, 74340)
43753 Gastric intubation and aspiration(s) therapeutic,
necessitating physician’s skill (eg, for gastrointestinal
hemorrhage), including lavage if performed
➲ CPT Assistant Sep 11:3, May 14:4, Aug 19:8
43754 Gastric intubation and aspiration, diagnostic; single
specimen (eg, acid analysis)
43755 collection of multiple fractional specimens with gastric

stimulation, single or double lumen tube (gastric
secretory study) (eg, histamine, insulin, pentagastrin,
calcium, secretin), includes drug administration
(For gastric acid analysis, use 82930)

(For naso- or oro-gastric tube placement by physician with
(Report the drug[s] or substance[s] administered. The fluid
used to administer the drug[s] is not separately reported)
Gastric Intubation
43753
A large-bore gastric lavage tube is inserted orally through the esophagus into the stomach for expedient
lavage and evacuation of stomach contents (eg, poisonings, hemorrhage).
43756 Duodenal intubation and aspiration, diagnostic, includes
image guidance; single specimen (eg, bile study for crystals
or afferent loop culture)
43757 collection of multiple fractional specimens with

pancreatic or gallbladder stimulation, single or double
lumen tube, includes drug administration
(For appropriate chemical analysis procedures, see 89049-

89240)
(Report the substances[s] or drug[s] administered. The fluid
used to administer the drug[s] is not separately reported)
(43760 has been deleted. To report replacement of
gastrostomy tube without imaging or endoscopy, see 43762,
43763)
(To report fluoroscopically guided replacement of
gastrostomy tube, use 49450)
(For endoscopic placement of gastrostomy tube, use 43246)
43761 Repositioning of a naso- or oro-gastric feeding tube, through
the duodenum for enteric nutrition
➲ CPT Assistant Oct 96:9, Nov 99:22, Jun 08:8, Aug 08:7

(For endoscopic conversion of a gastrostomy tube to
jejunostomy tube, use 44373)
(For placement of a long gastrointestinal tube into the
duodenum, use 44500)
43762 Replacement of gastrostomy tube, percutaneous, includes
removal, when performed, without imaging or endoscopic
guidance; not requiring revision of gastrostomy tract
43763 requiring revision of gastrostomy tract

(For percutaneous replacement of gastrostomy tube under

(For endoscopically directed placement of gastrostomy tube,
use 43246)
Bariatric Surgery
Bariatric surgical procedures may involve the stomach,
duodenum, jejunum, and/or the ileum.
Laparoscopy

report a diagnostic laparoscopy (separate procedure), use 49320.
Typical postoperative follow-up care (see Surgery Guidelines,
CPT Surgical Package Definition) after gastric restriction using
the adjustable gastric restrictive device includes subsequent
restrictive device adjustment(s) through the postoperative period
for the typical patient. Adjustment consists of changing the
gastric restrictive device component diameter by injection or
aspiration of fluid through the subcutaneous port component.
43770 Laparoscopy, surgical, gastric restrictive procedure;
placement of adjustable gastric restrictive device (eg,
gastric band and subcutaneous port components)
(For individual component placement, report 43770 with

modifier 52)
43771 revision of adjustable gastric restrictive device
component only
43772 removal of adjustable gastric restrictive device

component only
43773 removal and replacement of adjustable gastric restrictive

device component only
43774 removal of adjustable gastric restrictive device and
subcutaneous port components
(For removal and replacement of both gastric band and

subcutaneous port components, use 43659)
43775 longitudinal gastrectomy (ie, sleeve gastrectomy)
(For open gastric restrictive procedure, without gastric

bypass, for morbid obesity, other than vertical-banded
gastroplasty, use 43843)
(For laparoscopic implantation, revision, replacement,
removal or reprogramming of vagus nerve blocking
neurostimulator electrode array and/or pulse generator at the
esophagogastric junction, see 0312T-0317T)
Other Procedures
43800 Pyloroplasty
(For pyloroplasty and vagotomy, use 43640)
43810 Gastroduodenostomy
43820 Gastrojejunostomy; without vagotomy
43825 with vagotomy, any type
43830 Gastrostomy, open; without construction of gastric tube (eg,
Stamm procedure) (separate procedure)
43831 neonatal, for feeding

(For percutaneous replacement of gastrostomy tube with
removal when performed without imaging or endoscopy, see
43762, 43763)
(For percutaneous replacement of gastrostomy tube under
43832 with construction of gastric tube (eg, Janeway
procedure)
(For percutaneous endoscopic gastrostomy, use 43246)

43840 Gastrorrhaphy, suture of perforated duodenal or gastric
ulcer, wound, or injury
43842 Gastric restrictive procedure, without gastric bypass, for
morbid obesity; vertical-banded gastroplasty
43843 other than vertical-banded gastroplasty

(For laparoscopic longitudinal gastrectomy [ie, sleeve

gastrectomy], use 43775)
43845 Gastric restrictive procedure with partial gastrectomy,
pylorus-preserving duodenoileostomy and ileoileostomy (50
to 100 cm common channel) to limit absorption
(biliopancreatic diversion with duodenal switch)

44130, 49000)
43846 Gastric restrictive procedure, with gastric bypass for
morbid obesity; with short limb (150 cm or less) Roux-en-Y
gastroenterostomy
➲ CPT Assistant May 98:5, May 05:3
(For greater than 150 cm, use 43847)

Gastric Bypass for Morbid Obesity

43846
The stomach is partitioned with a staple line on the lesser curvature (no band, no gastric transection). A
short limb of small bowel (less than 100 cm) is divided and anastomosed to the small upper stomach
pouch.
43847 with small intestine reconstruction to limit absorption

➲ CPT Assistant May 98:5, May 02:7
43848 Revision, open, of gastric restrictive procedure for morbid

obesity, other than adjustable gastric restrictive device
➲ CPT Assistant May 98:5, Apr 06:1
(For laparoscopic adjustable gastric restrictive procedures,
see 43770-43774)
(For gastric restrictive port procedures, see 43886-43888)
43850 Revision of gastroduodenal anastomosis
(gastroduodenostomy) with reconstruction; without
vagotomy
43855 with vagotomy
43860 Revision of gastrojejunal anastomosis (gastrojejunostomy)
with reconstruction, with or without partial gastrectomy or
intestine resection; without vagotomy
43865 with vagotomy

43870 Closure of gastrostomy, surgical
43880 Closure of gastrocolic fistula

43881 Implantation or replacement of gastric neurostimulator
electrodes, antrum, open
43882 Revision or removal of gastric neurostimulator electrodes,

antrum, open
(For laparoscopic approach, see 43647, 43648)

(For insertion of gastric neurostimulator pulse generator, use
64590)
(For revision or removal of gastric neurostimulator pulse
generator, use 64595)
(For electronic analysis and programming of gastric
neurostimulator pulse generator, see 95980-95982)
(For open implantation, revision, or removal of gastric
neurostimulator electrodes, lesser curvature [morbid
obesity], use 43999)
(For laparoscopic implantation, revision, replacement,
removal or reprogramming of vagus nerve blocking
neurostimulator electrode array and/or pulse generator at the
esophagogastric junction, see 0312T-0317T)
(For open implantation, revision, or removal of gastric
lesser curvature or vagal trunk (EGJ) neurostimulator
electrodes, [morbid obesity], use 43999)
43886 Gastric restrictive procedure, open; revision of
subcutaneous port component only
43887 removal of subcutaneous port component only

43888 removal and replacement of subcutaneous port

component only

(For laparoscopic removal of both gastric restrictive device
and subcutaneous port components, use 43774)
(For removal and replacement of both gastric restrictive
device and subcutaneous port components, use 43659)
43999 Unlisted procedure, stomach
➲ CPT Assistant Mar 10:10, Jun 11:13, Feb 13:13, Jul
18:14, Dec 18:10
Intestines (Except Rectum)
Incision
44005 Enterolysis (freeing of intestinal adhesion) (separate
procedure)
➲ CPT Assistant Winter 90:6, Nov 97:17, Nov 99:23, Jan
00:11, Apr 00:10, Feb 18:11
(Do not report 44005 in addition to 45136)
(For laparoscopic approach, use 44180)
44010 Duodenotomy, for exploration, biopsy(s), or foreign body
removal
✚ 44015 Tube or needle catheter jejunostomy for enteral
alimentation, intraoperative, any method (List separately in
➲ CPT Assistant Mar 02:10, Jul 10:10
44020 Enterotomy, small intestine, other than duodenum; for

exploration, biopsy(s), or foreign body removal
44021 for decompression (eg, Baker tube)

44025 Colotomy, for exploration, biopsy(s), or foreign body
removal
(For exteriorization of intestine (Mikulicz resection with
crushing of spur), see 44602-44605)
44050 Reduction of volvulus, intussusception, internal hernia, by
laparotomy
44055 Correction of malrotation by lysis of duodenal bands and/or
reduction of midgut volvulus (eg, Ladd procedure)
Excision
Intestinal allotransplantation involves three distinct components
of physician work:
1. Cadaver donor enterectomy, which includes harvesting the
intestine graft and cold preservation of the graft (perfusing
with cold preservation solution and cold maintenance) (use
44132). Living donor enterectomy, which includes harvesting
the intestine graft, cold preservation of the graft (perfusing
with cold preservation solution and cold maintenance), and
care of the donor (use 44133).
2. Backbench work:
Standard preparation of an intestine allograft prior to
transplantation includes mobilization and fashioning of the
superior mesenteric artery and vein (see 44715).
Additional reconstruction of an intestine allograft prior to
transplantation may include venous and/or arterial
anastomosis(es) (see 44720-44721).
3. Recipient intestinal allotransplantation with or without
recipient enterectomy, which includes transplantation of
allograft and care of the recipient (see 44135, 44136).
44100 Biopsy of intestine by capsule, tube, peroral (1 or more
specimens)
44110 Excision of 1 or more lesions of small or large intestine not
requiring anastomosis, exteriorization, or fistulization;
single enterotomy
44111 multiple enterotomies

44120 Enterectomy, resection of small intestine; single resection
and anastomosis
➲ CPT Assistant Mar 04:3, Aug 08:7, Nov 18:11
✚ 44121 each additional resection and anastomosis (List

44125 with enterostomy
44126 Enterectomy, resection of small intestine for congenital
atresia, single resection and anastomosis of proximal
segment of intestine; without tapering
44127 with tapering

✚ 44128 each additional resection and anastomosis (List


44127, 44128)
44130 Enteroenterostomy, anastomosis of intestine, with or without
cutaneous enterostomy (separate procedure)
44132 Donor enterectomy (including cold preservation), open;
from cadaver donor
44133 partial, from living donor

(For backbench intestinal graft preparation or

reconstruction, see 44715, 44720, 44721)
44135 Intestinal allotransplantation; from cadaver donor
44136 from living donor
Enterectomy, Resection for Congenital Atresia

44127
44137 Removal of transplanted intestinal allograft, complete

(For partial removal of transplant allograft, see 44120,
44121, 44140)
✚ 44139 Mobilization (take-down) of splenic flexure performed in
conjunction with partial colectomy (List separately in
44140 Colectomy, partial; with anastomosis
➲ CPT Assistant Fall 92:23, Aug 08:7, Nov 08:7, Sep
10:7, Apr 20:10
44141 with skin level cecostomy or colostomy
➲ CPT Assistant Fall 92:24, Nov 08:7
Colectomy, Partial
44140
A segment of the colon is resected and an anastomosis is performed between the remaining ends of the
colon.
44143 with end colostomy and closure of distal segment
(Hartmann type procedure)

44144 with resection, with colostomy or ileostomy and creation
of mucofistula
44145 with coloproctostomy (low pelvic anastomosis)


44146 with coloproctostomy (low pelvic anastomosis), with
colostomy
➲ CPT Assistant Fall 92:24, Nov 08:7, Jun 18:11

44147 abdominal and transanal approach
44150 Colectomy, total, abdominal, without proctectomy; with

ileostomy or ileoproctostomy
44151 with continent ileostomy
Colectomy With Removal of Terminal Ileum and

Ileocolostomy
44160
A segment of the colon and terminal ileum is removed and an anastomosis is performed between the
remaining ileum and colon.
44155 Colectomy, total, abdominal, with proctectomy; with
ileostomy
44156 with continent ileostomy
44157 with ileoanal anastomosis, includes loop ileostomy, and
rectal mucosectomy, when performed
44158 with ileoanal anastomosis, creation of ileal reservoir (S

or J), includes loop ileostomy, and rectal mucosectomy,
when performed
44160 Colectomy, partial, with removal of terminal ileum with
ileocolostomy
Laparoscopy
Incision
44180 Laparoscopy, surgical, enterolysis (freeing of intestinal
adhesion) (separate procedure)
(For laparoscopy with salpingolysis, ovariolysis, use

58660)
Enterostomy—External Fistulization of Intestines
44186 Laparoscopy, surgical; jejunostomy (eg, for decompression

or feeding)
44187 ileostomy or jejunostomy, non-tube


44188 Laparoscopy, surgical, colostomy or skin level cecostomy
Excision
44202 Laparoscopy, surgical; enterectomy, resection of small
intestine, single resection and anastomosis
➲ CPT Assistant Nov 99:23, Mar 00:9, May 03:2, Apr
06:1
✚ 44203 each additional small intestine resection and anastomosis
procedure)

(For open procedure, see 44120, 44121)
44204 colectomy, partial, with anastomosis
➲ CPT Assistant May 03:3, Apr 06:1, 19, Dec 17:14

44205 colectomy, partial, with removal of terminal ileum with
ileocolostomy

44206 colectomy, partial, with end colostomy and closure of
distal segment (Hartmann type procedure)
44207 colectomy, partial, with anastomosis, with
coloproctostomy (low pelvic anastomosis)

44208 colectomy, partial, with anastomosis, with
coloproctostomy (low pelvic anastomosis) with
colostomy

44210 colectomy, total, abdominal, without proctectomy, with
ileostomy or ileoproctostomy

44211 colectomy, total, abdominal, with proctectomy, with
ileoanal anastomosis, creation of ileal reservoir (S or J),
with loop ileostomy, includes rectal mucosectomy, when
performed

44212 colectomy, total, abdominal, with proctectomy, with
ileostomy

✚ 44213 Laparoscopy, surgical, mobilization (take-down) of splenic
flexure performed in conjunction with partial colectomy
(List separately in addition to primary procedure)

Repair
44227 Laparoscopy, surgical, closure of enterostomy, large or
small intestine, with resection and anastomosis
Other Procedures
44238 Unlisted laparoscopy procedure, intestine (except rectum)
➲ CPT Assistant May 03:4, Jul 17:10, Oct 19:10
Enterostomy—External Fistulization of Intestines

44300 Placement, enterostomy or cecostomy, tube open (eg, for
feeding or decompression) (separate procedure)
(Do not report 44300 in conjunction with 44701 for

cannulation of the colon for intraoperative colonic lavage)
(For percutaneous placement of duodenostomy, jejunostomy,
gastro-jejunostomy or cecostomy [or other colonic] tube
including fluoroscopic imaging guidance, see 49441-49442)
44310 Ileostomy or jejunostomy, non-tube
(Do not report 44310 in conjunction with 44144, 44150-
44151, 44155, 44156, 45113, 45119, 45136)
44312 Revision of ileostomy; simple (release of superficial scar)
44314 complicated (reconstruction in-depth) (separate

procedure)
44316 Continent ileostomy (Kock procedure) (separate procedure)
(For fiberoptic evaluation, use 44385)
44320 Colostomy or skin level cecostomy;

44146, 44605, 45110, 45119, 45126, 45563, 45805, 45825,
50810, 51597, 57307, or 58240)
44322 with multiple biopsies (eg, for congenital megacolon)
44340 Revision of colostomy; simple (release of superficial scar)

44345 complicated (reconstruction in-depth) (separate
procedure)
44346 with repair of paracolostomy hernia (separate
procedure)
Endoscopy, Small Intestine

When bleeding occurs as the result of an endoscopic procedure,
operative session.
Antegrade transoral small intestinal endoscopy (enteroscopy) is
defined by the most distal segment of small intestine that is
examined. Codes 44360, 44361, 44363, 44364, 44365, 44366,
44369, 44370, 44372, 44373 are endoscopic procedures to
visualize the esophagus through the jejunum using an antegrade
approach. Codes 44376, 44377, 44378, 44379 are endoscopic
procedures to visualize the esophagus through the ileum using an
antegrade approach. If an endoscope cannot be advanced at least
50 cm beyond the pylorus, see 43233, 43235-43259, 43266,
43270; if an endoscope can be passed at least 50 cm beyond
pylorus but only into jejunum, see 44360, 44361, 44363, 44364,
44365, 44366, 44369, 44370, 44372, 44373.
To report retrograde examination of small intestine via anus or
colon stoma, use 44799, unlisted procedure, intestine.
(Do not report 44360, 44361, 44363, 44364, 44365, 44366,
44369, 44370, 44372, 44373 in conjunction with 43233,
43235-43259, 43266, 43270, 44376, 44377, 44378, 44379)
with 43233, 43235-43259, 43266, 43270, 44360, 44361,
44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373)
(For esophagogastroduodenoscopy, see 43233, 43235-
43259, 43266, 43270)
44360 Small intestinal endoscopy, enteroscopy beyond second
portion of duodenum, not including ileum; diagnostic,
including collection of specimen(s) by brushing or washing,
when performed (separate procedure)
➲ CPT Assistant Spring 94:7, Mar 11:10, Dec 13:3, Nov
14:3


snare technique

hot biopsy forceps or bipolar cautery
44366 with control of bleeding (eg, injection, bipolar cautery,

unipolar cautery, laser, heater probe, stapler, plasma
coagulator)
44369 with ablation of tumor(s), polyp(s), or other lesion(s) not

amenable to removal by hot biopsy forceps, bipolar
cautery or snare technique
44370 with transendoscopic stent placement (includes

predilation)
44372 with placement of percutaneous jejunostomy tube

➲ CPT Assistant Spring 94:7, Oct 19:10
44373 with conversion of percutaneous gastrostomy tube to
percutaneous jejunostomy tube
➲ CPT Assistant Spring 94:7, Dec 13:3, Oct 19:10
(For fiberoptic jejunostomy through stoma, use 43235)

44376 Small intestinal endoscopy, enteroscopy beyond second
portion of duodenum, including ileum; diagnostic, with or
without collection of specimen(s) by brushing or washing
➲ CPT Assistant Spring 94:7, Mar 11:10, Dec 13:3

44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373)

44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373)
coagulator)
➲ CPT Assistant Spring 94:7, Jun 10:4, Apr 12:17, Dec
13:3
44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373)
predilation)
44363, 44364, 44365, 44366, 44369, 44370, 44372, 44373)
Endoscopy, Stomal
Definitions
Proctosigmoidoscopy is the examination of the rectum and may
include examination of a portion of the sigmoid colon.
Sigmoidoscopy is the examination of the entire rectum, sigmoid
colon and may include examination of a portion of the
descending colon.
Colonoscopy is the examination of the entire colon, from the
rectum to the cecum, and may include examination of the
terminal ileum or small intestine proximal to an anastomosis.
Colonoscopy through stoma is the examination of the colon,
from the colostomy stoma to the cecum or colon-small intestine
anastomosis, and may include examination of the terminal ileum
or small intestine proximal to an anastomosis.
When performing a diagnostic or screening endoscopic
procedure on a patient who is scheduled and prepared for a total
colonoscopy, if the physician is unable to advance the
colonoscope to the cecum or colon-small intestine anastomosis
due to unforeseen circumstances, report 45378 (colonoscopy) or
44388 (colonoscopy through stoma) with modifier 53 and
provide appropriate documentation.
If a therapeutic colonoscopy (44389-44407, 45379, 45380, 45381,
45382, 45384, 45388, 45398) is performed and does not reach the
cecum or colon-small intestine anastomosis, report the
appropriate therapeutic colonoscopy code with modifier 52 and
Report ileoscopy through stoma (44380, 44381, 44382, 44384) for
endoscopic examination of a patient who has an ileostomy.
Report colonoscopy through stoma (44388-44408) for
endoscopic examination of a patient who has undergone
segmental resection of the colon (eg, hemicolectomy, sigmoid
colectomy, low anterior resection) and has a colostomy.
Coding Tip
For definitions of proctosigmoidoscopy, sigmoidoscopy, colonoscopy, and
guidelines for colonoscopies that do not reach the cecum or colon-small
intestine anastomosis, see Colon and Rectum/Endoscopy.
For colonoscopy per rectum, see 45378, 45390, 45392, 45393,

45398.
Report proctosigmoidoscopy (45300-45327), flexible
sigmoidoscopy (45330-45347), or anoscopy (46600, 46604,
46606, 46608, 46610, 46611, 46612, 46614, 46615), as appropriate
for endoscopic examination of the defunctionalized rectum or
distal colon in a patient who has undergone colectomy, in
addition to colonoscopy through stoma (44388-44408) or
ileoscopy through stoma (44380, 44381, 44382, 44384) if
appropriate.
When bleeding occurs as the result of an endoscopic procedure,
operative session.
For computed tomographic colonography, see 74261, 74262,
74263.
44380 Ileoscopy, through stoma; diagnostic, including collection of
specimen(s) by brushing or washing, when performed
➲ CPT Assistant Dec 13:3, Nov 14:3, Dec 14:3

44384)

# 44381 with transendoscopic balloon dilation

44384 with placement of endoscopic stent (includes pre- and

44385 Endoscopic evaluation of small intestinal pouch (eg, Kock
pouch, ileal reservoir [S or J]); diagnostic, including


Coding Tip
Definition of Colonoscopy through Stoma
Colonoscopy through stoma is the examination of the colon, from the stoma
to the cecum, and may include the examination of the terminal ileum or small
intestine proximal to an anastomosis. When performing an endoscopic
procedure on a patient who is scheduled and prepared for a colonoscopy
through stoma, if the physician is unable to advance the colonoscope to the
cecum or colon-small intestine anastomosis due to unforeseen circumstances,
report 44388 with modifier 53 and provide appropriate documentation.
44388 Colonoscopy through stoma; diagnostic, including collection

of specimen(s) by brushing or washing, when performed
➲ CPT Assistant Nov 07:8, Dec 13:3, Nov 14:3


same lesion)

same lesion)
hot biopsy forceps

(includes pre-and post-dilation and guide wire passage,
when performed)

same lesion)
snare technique

same lesion)
44402 with endoscopic stent placement (including pre- and



the same lesion)
44405 with transendoscopic balloon dilation

44402)
44406 with endoscopic ultrasound examination, limited to the
sigmoid, descending, transverse, or ascending colon and
cecum and adjacent structures

76975)
44407 with transendoscopic ultrasound guided intramural or
transmural fine needle aspiration/biopsy(s), includes
endoscopic ultrasound examination limited to the
cecum and adjacent structures

76942, 76975)
44408 with decompression (for pathologic distention) (eg,
volvulus, megacolon), including placement of
decompression tube, when performed

Introduction
⃠ 44500 Introduction of long gastrointestinal tube (eg, Miller-Abbott)

(For naso- or oro-gastric tube placement, use 43752)
Repair
44602 Suture of small intestine (enterorrhaphy) for perforated
ulcer, diverticulum, wound, injury or rupture; single
perforation
44603 multiple perforations

44604 Suture of large intestine (colorrhaphy) for perforated ulcer,
diverticulum, wound, injury or rupture (single or multiple
perforations); without colostomy
44605 with colostomy
44615 Intestinal stricturoplasty (enterotomy and enterorrhaphy)
with or without dilation, for intestinal obstruction
44620 Closure of enterostomy, large or small intestine;
44625 with resection and anastomosis other than colorectal

44626 with resection and colorectal anastomosis (eg, closure of

Hartmann type procedure)

44640 Closure of intestinal cutaneous fistula
44650 Closure of enteroenteric or enterocolic fistula
44660 Closure of enterovesical fistula; without intestinal or
bladder resection
44661 with intestine and/or bladder resection
(For closure of renocolic fistula, see 50525, 50526)

(For closure of gastrocolic fistula, use 43880)
(For closure of rectovesical fistula, see 45800, 45805)
44680 Intestinal plication (separate procedure)
Other Procedures
44700 Exclusion of small intestine from pelvis by mesh or other
prosthesis, or native tissue (eg, bladder or omentum)
(For therapeutic radiation clinical treatment, see Radiation

Oncology section)
✚ 44701 Intraoperative colonic lavage (List separately in addition to
(Use 44701 in conjunction with 44140, 44145, 44150, or

44604 as appropriate)
44705 Preparation of fecal microbiota for instillation, including
assessment of donor specimen

(For fecal instillation by oro-nasogastric tube or enema, use
44799)
44715 Backbench standard preparation of cadaver or living donor
intestine allograft prior to transplantation, including
mobilization and fashioning of the superior mesenteric
artery and vein
44720 Backbench reconstruction of cadaver or living donor

intestine allograft prior to transplantation; venous
anastomosis, each
44721 arterial anastomosis, each

44799 Unlisted procedure, small intestine
➲ CPT Assistant Dec 00:14, May 08:15, Nov 08:11, Mar
10:10, Jul 10:10, Mar 11:10, May 11:9, May 13:12, Nov
14:3
(For unlisted laparoscopic procedure, intestine except
rectum, use 44238)
(For unlisted procedure, colon, use 45399)
Meckel’s Diverticulum and the Mesentery

Excision
44800 Excision of Meckel’s diverticulum (diverticulectomy) or
omphalomesenteric duct
44820 Excision of lesion of mesentery (separate procedure)
(With intestine resection, see 44120 or 44140 et seq)
Suture
44850 Suture of mesentery (separate procedure)
(For reduction and repair of internal hernia, use 44050)
Other Procedures
44899 Unlisted procedure, Meckel’s diverticulum and the
mesentery
Appendix
Incision
44900 Incision and drainage of appendiceal abscess, open
(For percutaneous image-guided drainage by catheter of

appendiceal abscess, use 49406)
Excision
44950 Appendectomy;
➲ CPT Assistant Feb 92:22, Sep 96:4, Aug 02:2, Nov 08:7
(Incidental appendectomy during intra-abdominal surgery

does not usually warrant a separate identification. If
necessary to report, add modifier 52)
✚ 44955 when done for indicated purpose at time of other major
procedure (not as separate procedure) (List separately in
➲ CPT Assistant Fall 92:22, Sep 96:4, Apr 97:3, Nov
08:7, Jan 12:13
44960 for ruptured appendix with abscess or generalized
peritonitis
➲ CPT Assistant Fall 92:22, Nov 08:7, Dec 19:12
Laparoscopy
44970 Laparoscopy, surgical, appendectomy
➲ CPT Assistant Nov 99:23, Mar 00:9, Apr 06:1, 20, Mar
15:3, Dec 19:12
44979 Unlisted laparoscopy procedure, appendix
➲ CPT Assistant Nov 99:23, Mar 00:9, Jan 12:13
Colon and Rectum

Incision
45000 Transrectal drainage of pelvic abscess
(For transrectal image-guided fluid collection drainage by
catheter of pelvic abscess, use 49407)
45005 Incision and drainage of submucosal abscess, rectum
45020 Incision and drainage of deep supralevator, pelvirectal, or
retrorectal abscess
(See also 46050, 46060)
Excision
45100 Biopsy of anorectal wall, anal approach (eg, congenital
megacolon)
(For endoscopic biopsy, use 45305)
45108 Anorectal myomectomy
45110 Proctectomy; complete, combined abdominoperineal, with
colostomy
45111 partial resection of rectum, transabdominal approach
45112 Proctectomy, combined abdominoperineal, pull-through
procedure (eg, colo-anal anastomosis)
(For colo-anal anastomosis with colonic reservoir or pouch,
use 45119)
45113 Proctectomy, partial, with rectal mucosectomy, ileoanal
anastomosis, creation of ileal reservoir (S or J), with or
without loop ileostomy
45114 Proctectomy, partial, with anastomosis; abdominal and
transsacral approach
45116 transsacral approach only (Kraske type)
45119 Proctectomy, combined abdominoperineal pull-through
procedure (eg, colo-anal anastomosis), with creation of
colonic reservoir (eg, J-pouch), with diverting enterostomy
when performed

45120 Proctectomy, complete (for congenital megacolon),
abdominal and perineal approach; with pull-through
procedure and anastomosis (eg, Swenson, Duhamel, or
Soave type operation)
45121 with subtotal or total colectomy, with multiple biopsies
45123 Proctectomy, partial, without anastomosis, perineal
approach
45126 Pelvic exenteration for colorectal malignancy, with
proctectomy (with or without colostomy), with removal of
bladder and ureteral transplantations, and/or hysterectomy,
or cervicectomy, with or without removal of tube(s), with or
without removal of ovary(s), or any combination thereof
45130 Excision of rectal procidentia, with anastomosis; perineal

approach
45135 abdominal and perineal approach
45136 Excision of ileoanal reservoir with ileostomy

45150 Division of stricture of rectum
45160 Excision of rectal tumor by proctotomy, transsacral or
transcoccygeal approach
45171 Excision of rectal tumor, transanal approach; not including
muscularis propria (ie, partial thickness)
45172 including muscularis propria (ie, full thickness)

(For destruction of rectal tumor, transanal approach, use

45190)
(For transanal endoscopic microsurgical [ie, TEMS]
excision of rectal tumor, including muscularis propria [ie,
full thickness], use 0184T)
Rectal Tumor Excision

45171-45172
A rectal tumor is excised via transanal approach.
Destruction
45190 Destruction of rectal tumor (eg, electrodesiccation,
electrosurgery, laser ablation, laser resection, cryosurgery)
transanal approach
(For excision of rectal tumor, transanal approach, see

45171, 45172)
(For transanal endoscopic microsurgical [ie, TEMS]
excision of rectal tumor, including muscularis propria [ie,
full thickness], use 0184T)
Endoscopy
Definitions
Proctosigmoidoscopy is the examination of the rectum and may
include examination of a portion of the sigmoid colon.
Sigmoidoscopy is the examination of the entire rectum, sigmoid
colon and may include examination of a portion of the
descending colon.
Colonoscopy is the examination of the entire colon, from the
rectum to the cecum, and may include examination of the
terminal ileum or small intestine proximal to an anastomosis.
Colonoscopy through stoma is the examination of the colon,
from the colostomy stoma to the cecum, and may include
examination of the terminal ileum or small intestine proximal to
an anastomosis.
When performing a diagnostic or screening endoscopic
procedure on a patient who is scheduled and prepared for a total
colonoscopy, if the physician is unable to advance the
colonoscope to the cecum or colon-small intestine anastomosis
due to unforeseen circumstances, report 45378 (colonoscopy) or
44388 (colonoscopy through stoma) with modifier 53 and
If a therapeutic colonoscopy (44389-44407, 45379, 45380, 45381,
45382, 45384, 45388, 45398) is performed and does not reach the
cecum or colon-small intestine anastomosis, report the
appropriate therapeutic colonoscopy code with modifier 52 and
Report flexible sigmoidoscopy (45330-45347) for endoscopic
examination during which the endoscope is not advanced beyond
the splenic flexure.
Report flexible sigmoidoscopy (45330-45347) for endoscopic
examination of a patient who has undergone resection of the
colon proximal to the sigmoid (eg, subtotal colectomy) and has
an ileo-sigmoid or ileo-rectal anastomosis. Report pouch
endoscopy codes (44385, 44386) for endoscopic examination of a
patient who has undergone resection of colon with ileo-anal
anastomosis (eg, J-pouch).
Report colonoscopy (45378-45398) for endoscopic examination
of a patient who has undergone segmental resection of the colon
(eg, hemicolectomy, sigmoid colectomy, low anterior resection).
For colonoscopy through stoma, see 44388-44408.
Report proctosigmoidoscopy (45300-45327), flexible
sigmoidoscopy (45330-45347), or anoscopy (46600, 46604,
46606, 46608, 46610, 46611, 46612, 46614, 46615), as appropriate
for endoscopic examination of the defunctionalized rectum or
distal colon in a patient who has undergone colectomy, in
addition to colonoscopy through stoma (44388-44408) or
ileoscopy through stoma (44380, 44381, 44382, 44384) if
appropriate.
When bleeding occurs as a result of an endoscopic procedure,
operative session.
For computed tomographic colonography, see 74261-74263.
45300 Proctosigmoidoscopy, rigid; diagnostic, with or without
collection of specimen(s) by brushing or washing (separate
procedure)
➲ CPT Assistant Spring 94:8, Oct 97:6, Apr 06:1
45303 with dilation (eg, balloon, guide wire, bougie)


45308 with removal of single tumor, polyp, or other lesion by


snare technique
45315 with removal of multiple tumors, polyps, or other lesions

by hot biopsy forceps, bipolar cautery or snare technique

coagulator)

cautery or snare technique (eg, laser)
45321 with decompression of volvulus

predilation)
Coding Tip
Definition of Sigmoidoscopy
Sigmoidoscopy is the examination of the entire rectum, sigmoid colon and

may include examination of a portion of the descending colon.
CPT Coding Guidelines, Endoscopy
45330 Sigmoidoscopy, flexible; diagnostic, including collection of

➲ CPT Assistant Spring 94:9, May 05:3, May 07:10, Nov
07:8, Dec 13:3, Dec 14:3, 19, Sep 15:12, Feb 16:13
45346, 45347, 45349, 45350)
➲ CPT Assistant Spring 94:9, Sep 96:6, Jan 07:28

same lesion)
➲ CPT Assistant Winter 90:3, Spring 94:9, Dec 14:3
hot biopsy forceps
➲ CPT Assistant Winter 90:3, Spring 94:9, Dec 14:3

➲ CPT Assistant Spring 94:9, Sep 96:6, Jan 07:28, Jun
10:5, Dec 14:3
the same lesion)
➲ CPT Assistant Mar 03:22, Jun 10:5

the same lesion)
➲ CPT Assistant Spring 94:9, Dec 14:3

snare technique
same lesion)
when performed)

same lesion)

45347)
during the same session, use 45340 with modifier 59 for
45341 with endoscopic ultrasound examination
➲ CPT Assistant Oct 01:4, May 05:3, Dec 13:3

76872, 76975)
transmural fine needle aspiration/biopsy(s)
➲ CPT Assistant Oct 01:4, May 05:3, Dec 13:3

76872, 76942, 76975)
45347 with placement of endoscopic stent (includes pre- and


45338, 45350 for the same lesion)
45350 with band ligation(s) (eg, hemorrhoids)

same lesion)
46221)
(To report control of active bleeding with band ligation[s],
use 45334)
Coding Tip
Definition of Colonoscopy
Colonoscopy is the examination of the entire colon, from the rectum to the
cecum, and may include the examination of the terminal ileum or small
intestine proximal to an anastomosis. When performing a diagnostic or
screening endoscopic procedure on a patient who is scheduled and prepared
for a total colonoscopy, if the physician is unable to advance the colonoscope
to the cecum or colon-small intestine anastomosis due to unforeseen
circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through
stoma) with modifier 53 and provide appropriate documentation.
CPT Coding Guidelines, Endoscopy
Colonoscopy Decision Tree

45378 Colonoscopy, flexible; diagnostic, including collection of
➲ CPT Assistant Spring 94:9, Aug 99:3, Jan 02:12, Jan
04:4, May 05:3, Dec 10:3, Apr 11:12, Jan 13:11, Nov
14:3, Dec 14:3, Sep 15:12, Sep 17:14, Jan 18:7
45398)
(For colonoscopy with decompression [pathologic
distention], use 45393)
Colonoscopy
45378
A colonoscope is inserted in the anus and moved through the colon to the cecum in order to visualize the
lumen of the rectum and colon.
➲ CPT Assistant Spring 94:9, Aug 99:3, Dec 14:3

➲ CPT Assistant Spring 94:9, Jan 96:7, Feb 99:11, Aug
99:3, Jan 04:7, Jul 04:15, Dec 14:3
same lesion)
➲ CPT Assistant Mar 03:22, Jan 04:7, Jun 10:5, Jan
17:6
the same lesion)
➲ CPT Assistant Spring 94:9, Aug 99:3, Jun 10:5, Dec
14:3
the same lesion)
when performed)

same lesion)
Colonoscopy With Lesion Ablation or Removal

45385, 45388
Insertion and advancement of a colonoscope through the colon and to the cecum for ablation (45388) or
removal (45385) of tumors, polyps, or other lesions
hot biopsy forceps
➲ CPT Assistant Spring 94:9, Jul 98:10, Feb 99:11,
Aug 99:3, Jan 04:6, Jul 04:15, Apr 11:12, Dec 14:3,
Jun 15:10
snare technique
➲ CPT Assistant Spring 94:9, Jan 96:7, Jul 98:10, Aug
99:3, Jan 04:5, Jul 04:15, Jun 10:5, Jan 17:6
same lesion)

45389)
45389 with endoscopic stent placement (includes pre- and post-
dilation and guide wire passage, when performed)

45391 with endoscopic ultrasound examination limited to the
rectum, sigmoid, descending, transverse, or ascending
colon and cecum, and adjacent structures

76872, 76975)
transmural fine needle aspiration/biopsy(s), includes
endoscopic ultrasound examination limited to the rectum,
cecum, and adjacent structures

76872, 76942, 76975)
# 45390 with endoscopic mucosal resection
➲ CPT Assistant Dec 14:3, Jan 17:6, Dec 19:14

45385, 45398 for the same lesion)

# 45398 with band ligation(s) (eg, hemorrhoids)
➲ CPT Assistant Dec 14:3, Sep 17:14, Jan 18:7

same lesion)
46221)
(To report control of active bleeding with band ligation[s],
use 45382)
Laparoscopy
Excision
45395 Laparoscopy, surgical; proctectomy, complete, combined
abdominoperineal, with colostomy

45397 proctectomy, combined abdominoperineal pull-through
procedure (eg, colo-anal anastomosis), with creation of
colonic reservoir (eg, J-pouch), with diverting
enterostomy, when performed

Repair
45400 Laparoscopy, surgical; proctopexy (for prolapse)

(For open procedure, use 45540, 45541)

45402 proctopexy (for prolapse), with sigmoid resection
45499 Unlisted laparoscopy procedure, rectum
Repair
45500 Proctoplasty; for stenosis
45505 for prolapse of mucous membrane
➲ CPT Assistant Oct 13:19, Mar 15:10
45520 Perirectal injection of sclerosing solution for prolapse

45540 Proctopexy (eg, for prolapse); abdominal approach


45541 perineal approach
45550 with sigmoid resection, abdominal approach

45560 Repair of rectocele (separate procedure)
(For repair of rectocele with posterior colporrhaphy, use
57250)
45562 Exploration, repair, and presacral drainage for rectal injury;
45800 Closure of rectovesical fistula;
45820 Closure of rectourethral fistula;
(For rectovaginal fistula closure, see 57300-57308)
Manipulation
45900 Reduction of procidentia (separate procedure) under
anesthesia
45905 Dilation of anal sphincter (separate procedure) under
anesthesia other than local
45910 Dilation of rectal stricture (separate procedure) under
anesthesia other than local
45915 Removal of fecal impaction or foreign body (separate
procedure) under anesthesia
Other Procedures
Surgical diagnostic anorectal exam (45990) includes the
following elements: external perineal exam, digital rectal exam,
pelvic exam (when performed), diagnostic anoscopy, and
diagnostic rigid proctoscopy.
# 45399 Unlisted procedure, colon
45990 Anorectal exam, surgical, requiring anesthesia (general,

spinal, or epidural), diagnostic

46600, 57410, 99170)
45999 Unlisted procedure, rectum
(For unlisted laparoscopic procedure, rectum, use 45499)
Anus
For incision of thrombosed external hemorrhoid, use 46083. For
ligation of internal hemorrhoid(s), see 46221, 46945, 46946. For
excision of internal and/or external hemorrhoid(s), see 46250-
46262, 46320. For injection of hemorrhoid(s), use 46500. For
destruction of internal hemorrhoid(s) by thermal energy, use
46930. For destruction of hemorrhoid(s) by cryosurgery, use
46999. For transanal hemorrhoidal dearterialization, including
ultrasound guidance, with mucopexy, when performed, use
46948. For hemorrhoidopexy, use 46947. Do not report 46600 in
conjunction with 46020-46947, 0184T, during the same operative
session.
Incision
(For subcutaneous fistulotomy, use 46270)
46020 Placement of seton

46600)
46030 Removal of anal seton, other marker
46040 Incision and drainage of ischiorectal and/or perirectal
abscess (separate procedure)
46045 Incision and drainage of intramural, intramuscular, or
submucosal abscess, transanal, under anesthesia
46050 Incision and drainage, perianal abscess, superficial
(See also 45020, 46060)
Placement of Seton
46020
46060 Incision and drainage of ischiorectal or intramural abscess,
with fistulectomy or fistulotomy, submuscular, with or
without placement of seton
(See also 45020)
46070 Incision, anal septum (infant)
(For anoplasty, see 46700-46705)
46080 Sphincterotomy, anal, division of sphincter (separate
procedure)
46083 Incision of thrombosed hemorrhoid, external
Excision
46200 Fissurectomy, including sphincterotomy, when performed
(46210, 46211 have been deleted. To report, use 46999)

46221 Hemorrhoidectomy, internal, by rubber band ligation(s)
➲ CPT Assistant Oct 97:8, Dec 14:3, Apr 15:10, Sep
17:14, Jan 18:7
# 46945 Hemorrhoidectomy, internal, by ligation other than rubber
band; single hemorrhoid column/group, without imaging
guidance
➲ CPT Assistant Apr 15:10, Feb 20:11
# 46946 2 or more hemorrhoid columns/groups, without imaging

guidance

46948)
76942, 76998)
# 46948 Hemorrhoidectomy, internal, by transanal hemorrhoidal
dearterialization, 2 or more hemorrhoid columns/groups,
including ultrasound guidance, with mucopexy, when
performed
76998)
(For transanal hemorrhoidal dearterialization, single
hemorrhoid column/group, use 46999)
# 46220 Excision of single external papilla or tag, anus
46230 Excision of multiple external papillae or tags, anus

# 46320 Excision of thrombosed hemorrhoid, external

46250 Hemorrhoidectomy, external, 2 or more columns/groups

(For hemorrhoidectomy, external, single column/group, use

46999)
46255 Hemorrhoidectomy, internal and external, single
column/group;
46257 with fissurectomy

46258 with fistulectomy, including fissurectomy, when
performed
46260 Hemorrhoidectomy, internal and external, 2 or more

columns/groups;
Hemorrhoidectomy of Internal Prolapsed Hemorrhoid

Columns
46250-46262
46261 with fissurectomy
46262 with fistulectomy, including fissurectomy, when
performed

46270 Surgical treatment of anal fistula (fistulectomy/fistulotomy);
subcutaneous
46275 intersphincteric
46280 transsphincteric, suprasphincteric, extrasphincteric or

multiple, including placement of seton, when performed

46285 second stage
46288 Closure of anal fistula with rectal advancement flap
Introduction
46500 Injection of sclerosing solution, hemorrhoids
46505 Chemodenervation of internal anal sphincter

(For chemodenervation of other muscles, see 64612, 64616,

64617, 64642, 64643, 64644, 64645, 64646, 64647. For
destruction of nerve by neurolytic agent, use 64630)
(Report the specific service in conjunction with the specific
substance(s) or drug(s) provided)
Endoscopy
Surgical endoscopy always includes diagnostic endoscopy.
46600 Anoscopy; diagnostic, including collection of specimen(s)
by brushing or washing, when performed (separate
procedure)
➲ CPT Assistant Spring 94:9, Oct 97:6, Apr 06:1, Jun
10:3, Aug 11:9, Jan 18:7
0184T, during the same operative session)
(For diagnostic high-resolution anoscopy [HRA], use
46601)
46601 diagnostic, with high-resolution magnification (HRA)
(eg, colposcope, operating microscope) and chemical
agent enhancement, including collection of specimen(s)
by brushing or washing, when performed

46604 with dilation (eg, balloon, guide wire, bougie)

➲ CPT Assistant Spring 94:9, Oct 97:6, Sep 19:11
(For high-resolution anoscopy [HRA] with biopsy, use

46607)
46607 with high-resolution magnification (HRA) (eg,
colposcope, operating microscope) and chemical agent
enhancement, with biopsy, single or multiple


snare technique
46612 with removal of multiple tumors, polyps, or other lesions

by hot biopsy forceps, bipolar cautery or snare technique

coagulator)

cautery or snare technique
Repair
46700 Anoplasty, plastic operation for stricture; adult
46705 infant
(For simple incision of anal septum, use 46070)
46706 Repair of anal fistula with fibrin glue
46707 Repair of anorectal fistula with plug (eg, porcine small

intestine submucosa [SIS])
46710 Repair of ileoanal pouch fistula/sinus (eg, perineal or

vaginal), pouch advancement; transperineal approach
46712 combined transperineal and transabdominal approach
46715 Repair of low imperforate anus; with anoperineal fistula

(cut-back procedure)
46716 with transposition of anoperineal or anovestibular fistula
46716)
46730 Repair of high imperforate anus without fistula; perineal or
sacroperineal approach
46735 combined transabdominal and sacroperineal approaches
46735)
46740 Repair of high imperforate anus with rectourethral or
rectovaginal fistula; perineal or sacroperineal approach
46742 combined transabdominal and sacroperineal approaches
46742)
46744 Repair of cloacal anomaly by anorectovaginoplasty and
urethroplasty, sacroperineal approach
46746 Repair of cloacal anomaly by anorectovaginoplasty and
urethroplasty, combined abdominal and sacroperineal
approach;
46748 with vaginal lengthening by intestinal graft or pedicle
flaps
46750 Sphincteroplasty, anal, for incontinence or prolapse; adult
46751 child
46753 Graft (Thiersch operation) for rectal incontinence and/or
prolapse
46754 Removal of Thiersch wire or suture, anal canal
46760 Sphincteroplasty, anal, for incontinence, adult; muscle
transplant
46761 levator muscle imbrication (Park posterior anal repair)
# 46947 Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids)
by stapling
➲ CPT Assistant May 05:3, 14
Destruction
46900 Destruction of lesion(s), anus (eg, condyloma, papilloma,
molluscum contagiosum, herpetic vesicle), simple; chemical
46910 electrodesiccation
46916 cryosurgery
46917 laser surgery
46922 surgical excision
46924 Destruction of lesion(s), anus (eg, condyloma, papilloma,
molluscum contagiosum, herpetic vesicle), extensive (eg,
laser surgery, electrosurgery, cryosurgery, chemosurgery)
46930 Destruction of internal hemorrhoid(s) by thermal energy (eg,

infrared coagulation, cautery, radiofrequency)
(46934-46936 have been deleted)

46940 Curettage or cautery of anal fissure, including dilation of
anal sphincter (separate procedure); initial
46942 subsequent
Other Procedures
46999 Unlisted procedure, anus
➲ CPT Assistant Oct 97:8, Apr 15:10, Oct 18:11
Liver
Incision
47000 Biopsy of liver, needle; percutaneous

77012, 77021)
✚ 47001 when done for indicated purpose at time of other major
procedure (List separately in addition to code for
primary procedure)

(For fine needle aspiration biopsy in conjunction with
47000, 47001, see 10004, 10005, 10006, 10007, 10008,
10009, 10010, 10011, 10012, 10021)
(For evaluation of fine needle aspirate in conjunction with
47000, 47001, see 88172, 88173)
47010 Hepatotomy, for open drainage of abscess or cyst, 1 or 2
stages

catheter of hepatic abscess or cyst, use 49405)
47015 Laparotomy, with aspiration and/or injection of hepatic
parasitic (eg, amoebic or echinococcal) cyst(s) or
abscess(es)
Excision
47100 Biopsy of liver, wedge
47120 Hepatectomy, resection of liver; partial lobectomy
➲ CPT Assistant May 98:10, Sep 14:14, Oct 16:11
47122 trisegmentectomy
47125 total left lobectomy
47130 total right lobectomy
Liver Transplantation
Liver allotransplantation involves three distinct components of
physician work:
1. Cadaver donor hepatectomy, which includes harvesting the
graft and cold preservation of the graft (perfusing with cold
preservation solution and cold maintenance) (use 47133).
Living donor hepatectomy, which includes harvesting the
graft, cold preservation of the graft (perfusing with cold
preservation solution and cold maintenance), and care of the
donor (see 47140-47142).
2. Backbench work:
Standard preparation of the whole liver graft will include one
of the following:
Preparation of whole liver graft (including cholecystectomy, if
necessary, and dissection and removal of surrounding soft
tissues to prepare vena cava, portal vein, hepatic artery, and
common bile duct for implantation) (use 47143).
Preparation as described for whole liver graft, plus trisegment
split into two partial grafts (use 47144).
Preparation as described for whole liver graft, plus lobe split
into two partial grafts (use 47145).
Additional reconstruction of the liver graft may include venous
and/or arterial anastomosis(es) (see 47146, 47147).
3. Recipient liver allotransplantation, which includes recipient
hepatectomy (partial or whole), transplantation of the allograft
(partial or whole), and care of the recipient (use 47135).
47133 Donor hepatectomy (including cold preservation), from
cadaver donor
47135 Liver allotransplantation, orthotopic, partial or whole, from

cadaver or living donor, any age
47140 Donor hepatectomy (including cold preservation), from

living donor; left lateral segment only (segments II and III)
47141 total left lobectomy (segments II, III and IV)
47142 total right lobectomy (segments V, VI, VII and VIII)

47143 Backbench standard preparation of cadaver donor whole

liver graft prior to allotransplantation, including
cholecystectomy, if necessary, and dissection and removal
of surrounding soft tissues to prepare the vena cava, portal
vein, hepatic artery, and common bile duct for implantation;
without trisegment or lobe split
➲ CPT Assistant Apr 05:10, 12
47144 with trisegment split of whole liver graft into 2 partial

liver grafts (ie, left lateral segment [segments II and III]
and right trisegment [segments I and IV through VIII])
47145 with lobe split of whole liver graft into 2 partial liver
grafts (ie, left lobe [segments II, III, and IV] and right
lobe [segments I and V through VIII])
47146 Backbench reconstruction of cadaver or living donor liver

graft prior to allotransplantation; venous anastomosis, each


47125, 47600, 47610)
Repair
47300 Marsupialization of cyst or abscess of liver
47350 Management of liver hemorrhage; simple suture of liver
wound or injury
47360 complex suture of liver wound or injury, with or without
hepatic artery ligation
47361 exploration of hepatic wound, extensive debridement,
coagulation and/or suture, with or without packing of
liver
47362 re-exploration of hepatic wound for removal of packing
Laparoscopy
47370 Laparoscopy, surgical, ablation of 1 or more liver tumor(s);
radiofrequency
(For imaging guidance, use 76940)

47371 cryosurgical

47379 Unlisted laparoscopic procedure, liver
➲ CPT Assistant Aug 06:10, Dec 07:12, Dec 14:18, Aug
18:10
Other Procedures
47380 Ablation, open, of 1 or more liver tumor(s); radiofrequency

47381 cryosurgical

47382 Ablation, 1 or more liver tumor(s), percutaneous,
radiofrequency
➲ Clinical Examples in Radiology Spring 08:1, 2, Summer
08:3, Summer 12:11
(For imaging guidance and monitoring, see 76940, 77013,
77022)
47383 Ablation, 1 or more liver tumor(s), percutaneous,
cryoablation

77022)
47399 Unlisted procedure, liver
➲ CPT Assistant Dec 14:18, Mar 17:10
Biliary Tract
Incision
47400 Hepaticotomy or hepaticostomy with exploration, drainage,
or removal of calculus
47420 Choledochotomy or choledochostomy with exploration,
drainage, or removal of calculus, with or without
cholecystotomy; without transduodenal sphincterotomy or
sphincteroplasty
47425 with transduodenal sphincterotomy or sphincteroplasty
47460 Transduodenal sphincterotomy or sphincteroplasty, with or
without transduodenal extraction of calculus (separate
procedure)
47480 Cholecystotomy or cholecystostomy, open, with exploration,
drainage, or removal of calculus (separate procedure)
(For percutaneous cholecystostomy, use 47490)
Introduction
Percutaneous biliary procedures (eg, transhepatic,
transcholecystic) are described by 47490 and 47531-47544, and
are performed with imaging guidance. They are differentiated
from endoscopic procedures that utilize an access to the biliary
tree from a hollow viscus for diagnosis and therapy. Diagnostic
cholangiography is typically performed with percutaneous biliary
procedures, and is included in 47490, 47533, 47534, 47535,
47536, 47537, 47538, 47539, 47540, and 47541.
Codes 47531 and 47532 describe percutaneous diagnostic
cholangiography that includes injection(s) of contrast material, all
procedural imaging guidance (eg, ultrasound and/or
fluoroscopy). Code 47532 also includes accessing the biliary
system with a needle or catheter. Codes 47531 and 47532 may not
be reported with codes 47533, 47534, 47535, 47536, 47537,
47538, 47539, 47540, and 47541.
An external biliary drainage catheter is a catheter placed into a
bile duct that does not terminate in bowel, and that drains bile
externally only. An internal-external biliary drainage catheter is a
single, externally accessible catheter that terminates in the small
intestine, and may drain bile into the small intestine and/or
externally. A “stent,” as used in this code set, is a percutaneously
placed device (eg, self-expanding metallic mesh stent, plastic
tube) that is positioned within the biliary tree and is completely
internal, with no portion extending outside the patient.
Codes 47533, 47534, 47535, 47536, 47537, 47538, 47539, and
47540 describe percutaneous therapeutic biliary procedures that
include catheter or stent placement, catheter removal and
replacement (exchange), and/or catheter removal. These codes
include the elements of access, drainage catheter manipulations,
diagnostic cholangiography, imaging guidance (eg,
ultrasonography and/or fluoroscopy), and all associated
radiological supervision and interpretation. Codes 47533, 47534,
47538, 47539, 47540 may be reported once for each catheter or
stent placed (eg, bilobar placement, multi-segmental placement).
Codes 47535, 47536, and 47537 may be reported once for each
catheter conversion, exchange, or removal (eg, bilobar,
bisegmental).
Codes 47538, 47539, 47540 may be reported only once per
session to describe one or more overlapping or serial stent(s)
placed within a single bile duct, or bridging more than one ductal
segment (eg, left hepatic duct and common bile duct) through a
single percutaneous access. Codes 47538, 47539, 47540 may be
reported more than once in the same session using modifier 59
for the additional procedures in the following circumstances: (i)
placement of side-by-side (double-barrel) stents within a single
bile duct; (ii) placement of two or more stents into separate bile
ducts through a single percutaneous access; or (iii) placement of
stents through two or more percutaneous access sites (eg,
placement of one stent through the interstices of another stent).
Code 47538 describes biliary stent placement through an existing
access. Therefore, 47538 should not be reported together with
47536 if a biliary drainage catheter (eg, external or internal-
external) is replaced after the biliary stent is placed. Code 47540
describes biliary stent placement with the additional service of
placing a biliary drainage catheter (eg, external or internal-
external). Therefore, 47540 should not be reported with 47533,
47534 for the same ductal system.
Code 47541 describes a procedure to assist with endoscopic
procedures performed in conjunction with other physician
specialists. Access placed may include wire and/or catheter. Code
47541 may not be reported if a wire is placed through existing
percutaneous access.
Codes 47542, 47543, and 47544 describe procedures that may be
performed in conjunction with other codes in this family, are
add-on codes and do not include access, catheter placement, or
diagnostic imaging. Do not report 47542 with 47538, 47539,
47540 because balloon dilation is included in 47538, 47539, and
47540. Code 47544 should not be reported with 47531-47543 for
incidental removal of debris. Code 47542 should not be reported
with 47544, if a balloon is used for removal of calculi or debris
rather than for dilation.
47490 Cholecystostomy, percutaneous, complete procedure,
including imaging guidance, catheter placement,
cholecystogram when performed, and radiological
supervision and interpretation
11:10
75989, 76942, 77002, 77012, 77021)
47531 Injection procedure for cholangiography, percutaneous,
complete diagnostic procedure including imaging guidance
(eg, ultrasound and/or fluoroscopy) and all associated
radiological supervision and interpretation; existing access
47532 new access (eg, percutaneous transhepatic

cholangiogram)

47533, 47534, 47535, 47536, 47537, 47538, 47539, 47540,
47541 for procedures performed through the same
percutaneous access)
(For intraoperative cholangiography, see 74300, 74301)
47533 Placement of biliary drainage catheter, percutaneous,
including diagnostic cholangiography when performed,
imaging guidance (eg, ultrasound and/or fluoroscopy), and
all associated radiological supervision and interpretation;
external
47534 internal-external
47535 Conversion of external biliary drainage catheter to internal-

external biliary drainage catheter, percutaneous, including
diagnostic cholangiography when performed, imaging
guidance (eg, fluoroscopy), and all associated radiological
47536 Exchange of biliary drainage catheter (eg, external, internal-

external, or conversion of internal-external to external only),
percutaneous, including diagnostic cholangiography when
performed, imaging guidance (eg, fluoroscopy), and all
associated radiological supervision and interpretation

same access)
(47536 includes exchange of one catheter. For exchange of
additional catheter[s] during the same session, report 47536
with modifier 59 for each additional exchange)
Percutaneous Biliary Stent(s) and Drain Placement

47533, 47534, 47538, 47539, 47540
Biliary catheters (eg, external 47533, internal-external 47534) and multiple stents (eg, 47538, 47539,
47540)
Exchanges/Conversions
To
(Existing Access)
Do Not Report Exchange with Stent Internal-
for Same Percutaneous Access External External Stent
External Drain 47535 47536 47538
From Conversion Exchange Stent
Internal-External Drain 47536 47536 47538
Exchange Exchange Stent
47537 Removal of biliary drainage catheter, percutaneous,
requiring fluoroscopic guidance (eg, with concurrent
indwelling biliary stents), including diagnostic
cholangiography when performed, imaging guidance (eg,
fluoroscopy), and all associated radiological supervision
and interpretation

same access)
▶ (For removal of biliary drainage catheter not requiring
fluoroscopic guidance, see E/M services and report the
appropriate level of service provided [eg, 99202-99215,
99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224,
99225, 99226, 99231, 99232, 99233])◀
47538 Placement of stent(s) into a bile duct, percutaneous,
including diagnostic cholangiography, imaging guidance (eg,
fluoroscopy and/or ultrasound), balloon dilation, catheter
exchange(s) and catheter removal(s) when performed, and
all associated radiological supervision and interpretation;
existing access

the same percutaneous access)
47539 new access, without placement of separate biliary
drainage catheter
47540 new access, with placement of separate biliary drainage

catheter (eg, external or internal-external)
43277, 47542, 47555, 47556 for the same lesion in the same
session)
the same percutaneous access)
(47538, 47539, 47540 may be reported more than once per
session, when specific conditions described in the
Introduction within the Biliary Tract subsection guidelines
are met)
47541 Placement of access through the biliary tree and into small
bowel to assist with an endoscopic biliary procedure (eg,
rendezvous procedure), percutaneous, including diagnostic
cholangiography when performed, imaging guidance (eg,
ultrasound and/or fluoroscopy), and all associated
radiological supervision and interpretation, new access

47533, 47534, 47535, 47536, 47537, 47538, 47539, 47540)
(Do not report 47541 when there is existing catheter access)
(For use of existing access through the biliary tree into small
bowel to assist with an endoscopic biliary procedure, see
47535, 47536, 47537)
✚ 47542 Balloon dilation of biliary duct(s) or of ampulla
(sphincteroplasty), percutaneous, including imaging
guidance (eg, fluoroscopy), and all associated radiological
supervision and interpretation, each duct (List separately in
47534, 47535, 47536, 47537, 47541)
47538, 47539, 47540, 47555, 47556)
(Do not report 47542 in conjunction with 47544 if a balloon
is used for removal of calculi, debris, and/or sludge rather
than for dilation)
(For percutaneous balloon dilation of multiple ducts during
the same session, report an additional dilation once with
47542 and modifier 59, regardless of the number of
additional ducts dilated)
(For endoscopic balloon dilation, see 43277, 47555,
47556)
✚ 47543 Endoluminal biopsy(ies) of biliary tree, percutaneous, any
method(s) (eg, brush, forceps, and/or needle), including
imaging guidance (eg, fluoroscopy), and all associated
radiological supervision and interpretation, single or
multiple (List separately in addition to code for primary
procedure)

47534, 47535, 47536, 47537, 47538, 47539, 47540)
(Report 47543 once per session)
(For endoscopic brushings, see 43260, 47552)
(For endoscopic biopsy, see 43261, 47553)
✚ 47544 Removal of calculi/debris from biliary duct(s) and/or
gallbladder, percutaneous, including destruction of calculi
by any method (eg, mechanical, electrohydraulic,
lithotripsy) when performed, imaging guidance (eg,
and interpretation (List separately in addition to code for
primary procedure)

47534, 47535, 47536, 47537, 47538, 47539, 47540)
(Do not report 47544 if no calculi or debris are found, even
if removal device is deployed)
(Do not report 47544 in conjunction with 47531-47543 for
incidental removal of debris)
(For endoscopic removal of calculi, see 43264, 47554)
(For endoscopic destruction of calculi, use 43265)
Endoscopy
✚ 47550 Biliary endoscopy, intraoperative (choledochoscopy) (List
47552 Biliary endoscopy, percutaneous via T-tube or other tract;
diagnostic, with collection of specimen(s) by brushing
and/or washing, when performed (separate procedure)

47554 with removal of calculus/calculi
47555 with dilation of biliary duct stricture(s) without stent

47556 with dilation of biliary duct stricture(s) with stent
(For ERCP, see 43260-43278, 74328, 74329, 74330,
74363)
Laparoscopy
(For percutaneous cholangiography, see 47531 or 47532)
47562 Laparoscopy, surgical; cholecystectomy
➲ CPT Assistant Nov 99:23, Mar 00:9, Sep 03:3, Dec
07:12
47563 cholecystectomy with cholangiography
➲ CPT Assistant Nov 99:23, Mar 00:9, Dec 00:14, Dec
07:12, Mar 19:10
(For intraoperative cholangiography radiological
supervision and interpretation, see 74300, 74301)
(For percutaneous cholangiography, see 47531, 47532)
Laparoscopic Cholecystectomy
47562
The gallbladder is dissected and removed from the liver bed under laparoscopic guidance.
47564 cholecystectomy with exploration of common duct
47570 cholecystoenterostomy
47579 Unlisted laparoscopy procedure, biliary tract

Excision
47600 Cholecystectomy;
47605 with cholangiography

(For laparoscopic approach, see 47562-47564)

47610 Cholecystectomy with exploration of common duct;
(For cholecystectomy with exploration of common duct with

biliary endoscopy, use 47610 with 47550)
47612 with choledochoenterostomy
47620 with transduodenal sphincterotomy or sphincteroplasty,
with or without cholangiography
47700 Exploration for congenital atresia of bile ducts, without
repair, with or without liver biopsy, with or without
cholangiography
47701 Portoenterostomy (eg, Kasai procedure)
47711 Excision of bile duct tumor, with or without primary repair
of bile duct; extrahepatic
47712 intrahepatic
(For anastomosis, see 47760-47800)
47715 Excision of choledochal cyst
Repair
47720 Cholecystoenterostomy; direct
47721 with gastroenterostomy
47740 Roux-en-Y
47741 Roux-en-Y with gastroenterostomy
47760 Anastomosis, of extrahepatic biliary ducts and
gastrointestinal tract
47765 Anastomosis, of intrahepatic ducts and gastrointestinal tract
47780 Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and
47785 Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and
47800 Reconstruction, plastic, of extrahepatic biliary ducts with
end-to-end anastomosis
47801 Placement of choledochal stent
47802 U-tube hepaticoenterostomy

47900 Suture of extrahepatic biliary duct for pre-existing injury
Other Procedures
47999 Unlisted procedure, biliary tract
Pancreas
(For peroral pancreatic endoscopic procedures, see 43260-
43265, 43274-43278)
Incision
48000 Placement of drains, peripancreatic, for acute pancreatitis;
48001 with cholecystostomy, gastrostomy, and jejunostomy
48020 Removal of pancreatic calculus
Excision
48100 Biopsy of pancreas, open (eg, fine needle aspiration, needle
core biopsy, wedge biopsy)
48102 Biopsy of pancreas, percutaneous needle


77002, 77012, 77021)
10007, 10008, 10009, 10010, 10011, 10012)
48105 Resection or debridement of pancreas and peripancreatic
tissue for acute necrotizing pancreatitis
48120 Excision of lesion of pancreas (eg, cyst, adenoma)

48140 Pancreatectomy, distal subtotal, with or without
splenectomy; without pancreaticojejunostomy
48145 with pancreaticojejunostomy

48146 Pancreatectomy, distal, near-total with preservation of
duodenum (Child-type procedure)
48148 Excision of ampulla of Vater
48150 Pancreatectomy, proximal subtotal with total duodenectomy,
partial gastrectomy, choledochoenterostomy and
gastrojejunostomy (Whipple-type procedure); with
pancreatojejunostomy
48152 without pancreatojejunostomy

48153 Pancreatectomy, proximal subtotal with near-total
duodenectomy, choledochoenterostomy and
duodenojejunostomy (pylorus-sparing, Whipple-type
procedure); with pancreatojejunostomy
48154 without pancreatojejunostomy
48155 Pancreatectomy, total
48160 Pancreatectomy, total or subtotal, with autologous
transplantation of pancreas or pancreatic islet cells
(To report pancreatic islet cell transplantation via portal

vein catheterization and infusion, see 0584T, 0585T, 0586T)
Introduction
✚ 48400 Injection procedure for intraoperative pancreatography (List

74301)
(For intraoperative pancreatography radiological
supervision and interpretation, see 74300, 74301)
Repair
48500 Marsupialization of pancreatic cyst
48510 External drainage, pseudocyst of pancreas, open

catheter of pancreatic pseudocyst, use 49405)
48520 Internal anastomosis of pancreatic cyst to gastrointestinal
tract; direct
48540 Roux-en-Y
48545 Pancreatorrhaphy for injury
48547 Duodenal exclusion with gastrojejunostomy for pancreatic

injury
48548 Pancreaticojejunostomy, side-to-side anastomosis

(Puestow-type operation)
Pancreas Transplantation
Pancreas allotransplantation involves three distinct components
of physician work:
1. Cadaver donor pancreatectomy, which includes harvesting the
pancreas graft, with or without duodenal segment, and cold
preservation of the graft (perfusing with cold preservation
solution and cold maintenance) (use 48550).
2. Backbench work:
Standard preparation of a cadaver donor pancreas allograft
prior to transplantation includes dissection of the allograft
from surrounding soft tissues, splenectomy, duodenotomy,
ligation of bile duct, ligation of mesenteric vessels, and Y-graft
arterial anastomoses from the iliac artery to the superior
mesenteric artery and to the splenic artery (use 48551).
Additional reconstruction of a cadaver donor pancreas
allograft prior to transplantation may include venous
anastomosis(es) (use 48552).
3. Recipient pancreas allotransplantation, which includes
transplantation of allograft, and care of the recipient (use
48554).
48550 Donor pancreatectomy (including cold preservation), with
or without duodenal segment for transplantation
48551 Backbench standard preparation of cadaver donor pancreas

allograft from surrounding soft tissues, splenectomy,
duodenotomy, ligation of bile duct, ligation of mesenteric
vessels, and Y-graft arterial anastomoses from iliac artery to
superior mesenteric artery and to splenic artery
48552 Backbench reconstruction of cadaver donor pancreas

allograft prior to transplantation, venous anastomosis, each
(Do not report 48551 and 48552 in conjunction with 35531,

35563, 35685, 38100-38102, 44010, 44820, 44850, 47460,
47550-47556, 48100-48120, 48545)
48554 Transplantation of pancreatic allograft
48556 Removal of transplanted pancreatic allograft
Other Procedures
48999 Unlisted procedure, pancreas
➲ CPT Assistant Dec 07:12, May 11:9, Feb 13:13
Abdomen, Peritoneum, and Omentum

Incision
49000 Exploratory laparotomy, exploratory celiotomy with or
without biopsy(s) (separate procedure)
➲ CPT Assistant Fall 92:23, Mar 01:10, Nov 08:7, Sep
12:11, Jan 20:6
without laparotomy, use 20102)
49002 Reopening of recent laparotomy
➲ CPT Assistant Fall 92:23, Nov 08:7, Jan 20:6
(To report re-exploration of hepatic wound for removal of

packing, use 47362)
(To report re-exploration of pelvic wound for removal,
including repacking, when performed, use 49014)
49010 Exploration, retroperitoneal area with or without biopsy(s)

without laparotomy, use 20102)
49013 Preperitoneal pelvic packing for hemorrhage associated
with pelvic trauma, including local exploration
49014 Re-exploration of pelvic wound with removal of

preperitoneal pelvic packing, including repacking, when
performed
49020 Drainage of peritoneal abscess or localized peritonitis,
exclusive of appendiceal abscess, open
(For appendiceal abscess, use 44900)
(For percutaneous image-guided drainage of peritoneal
abscess or localized peritonitis by catheter, use 49406)
(For transrectal or transvaginal image-guided drainage of
peritoneal abscess by catheter, use 49407)
49040 Drainage of subdiaphragmatic or subphrenic abscess, open
(For percutaneous image-guided drainage of

subdiaphragmatic or subphrenic abscess by catheter, use
49406)
49060 Drainage of retroperitoneal abscess, open
➲ CPT Assistant Nov 97:18, Nov 99:24, Jul 01:11, Aug
01:10
(For percutaneous image-guided drainage of retroperitoneal
abscess by catheter, use 49406)
(For transrectal or transvaginal image-guided drainage of
retroperitoneal abscess by catheter, use 49407)
49062 Drainage of extraperitoneal lymphocele to peritoneal cavity,
open
➲ CPT Assistant Nov 97:19, Jul 01:11, Aug 01:10
(For laparoscopic drainage of lymphocele to peritoneal

cavity, use 49323)
(For percutaneous image-guided drainage of peritoneal or
retroperitoneal lymphocele by catheter, use 49406)
49082 Abdominal paracentesis (diagnostic or therapeutic); without
imaging guidance
➲ Clinical Examples in Radiology Fall 11:11, Spring
12:10, Winter 12:9
12:10, Winter 12:9
77012, 77021)
49084 Peritoneal lavage, including imaging guidance, when
performed

77012, 77021)
Code 49185 describes sclerotherapy of a fluid collection (eg,
lymphocele, cyst, or seroma) through a percutaneous access. It
includes contrast injection(s), sclerosant injection(s), sclerosant
dwell time, diagnostic study, imaging guidance (eg, ultrasound,
fluoroscopy), and radiological supervision and interpretation,
when performed. Code 49185 may be reported once per day for
each lesion treated through a separate catheter. Do not report
49185 more than once if treating multiple lesions through the
same catheter. Codes for access to and drainage of the collection
may be separately reportable according to location (eg, 10030,
10160, 49405, 49406, 49407, 50390).
(For lysis of intestinal adhesions, use 44005)
49180 Biopsy, abdominal or retroperitoneal mass, percutaneous
needle

77012, 77021)
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
49185 Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or
seroma), percutaneous, including contrast injection(s),
sclerosant injection(s), diagnostic study, imaging guidance
(eg, ultrasound, fluoroscopy) and radiological supervision
and interpretation when performed
(For treatment of multiple lesions in a single day requiring

separate access, use modifier 59 for each additional treated
lesion)
(For treatment of multiple interconnected lesions treated
through a single access, report 49185 once)
(For access/drainage with needle, see 10160, 50390)
(For access/drainage with catheter, see 10030, 49405,
49406, 49407, 50390)
(For exchange of existing catheter, before or after injection
of sclerosant, see 49423, 75984)
(For sclerotherapy of a lymphatic/vascular malformation,
use 37241)
(For sclerosis of veins or endovenous ablation of
incompetent extremity veins, see 36468, 36470, 36471,
36475, 36476, 36478, 36479)
(For pleurodesis, use 32560)
49203 Excision or destruction, open, intra-abdominal tumors, cysts
or endometriomas, 1 or more peritoneal, mesenteric, or
retroperitoneal primary or secondary tumors; largest tumor 5
cm diameter or less
➲ CPT Assistant Aug 08:7, Dec 10:16
49204 largest tumor 5.1-10.0 cm diameter

49205 largest tumor greater than 10.0 cm diameter


38780, 49000, 49010, 49215, 50010, 50205, 50225, 50236,
50250, 50290, 58920, 58925, 58940, 58943, 58951, 58952,
58953, 58954, 58956, 58957, 58958, 58960)
(For partial or total nephrectomy, use 50220 or 50240 in
conjunction with 49203-49205)
(For colectomy, use 44140 in conjunction with 49203-
49205)
(For small bowel resection, use 44120 in conjunction with
49203-49205)
(For vena caval resection with reconstruction, use 49203-
49205 in conjunction with 37799)
(For resection of recurrent ovarian, tubal, primary
peritoneal, or uterine malignancy, see 58957, 58958)
(For cryoablation of renal tumors, see 50250, 50593)
49215 Excision of presacral or sacrococcygeal tumor
49250 Umbilectomy, omphalectomy, excision of umbilicus
49255 Omentectomy, epiploectomy, resection of omentum (separate
procedure)
Laparoscopy
report a diagnostic laparoscopy (peritoneoscopy), (separate
For laparoscopic fulguration or excision of lesions of the ovary,
pelvic viscera, or peritoneal surface use 58662.
49320 Laparoscopy, abdomen, peritoneum, and omentum,
diagnostic, with or without collection of specimen(s) by
brushing or washing (separate procedure)
➲
CPT Assistant Nov 99:24, Mar 00:9, Apr 06:19, Mar
07:4, Nov 07:1, Dec 08:7, Jun 10:7, Dec 15:18, Apr
17:7
Laparoscopy
49320
The physician inserts a fiberoptic laparoscope to observe the necessary organs in these procedures.
49321 Laparoscopy, surgical; with biopsy (single or multiple)

➲ CPT Assistant Nov 99:24, Mar 00:9, Aug 18:10
49322 with aspiration of cavity or cyst (eg, ovarian cyst)

(single or multiple)
49323 with drainage of lymphocele to peritoneal cavity

➲ CPT Assistant Nov 99:24, Mar 00:9, May 00:4, Jul
01:11, Aug 01:10
(For open drainage of lymphocele to peritoneal cavity, use
49062)
49324 with insertion of tunneled intraperitoneal catheter
(For subcutaneous extension of intraperitoneal catheter with

remote chest exit site, use 49435 in conjunction with 49324)
(For open insertion of tunneled intraperitoneal catheter, use
49421)
49325 with revision of previously placed intraperitoneal
cannula or catheter, with removal of intraluminal
obstructive material if performed
✚ 49326 with omentopexy (omental tacking procedure) (List


✚ 49327 with placement of interstitial device(s) for radiation
therapy guidance (eg, fiducial markers, dosimeter), intra-
abdominal, intrapelvic, and/or retroperitoneum,
including imaging guidance, if performed, single or
multiple (List separately in addition to code for primary
procedure)
(Use 49327 in conjunction with laparoscopic abdominal,

pelvic, or retroperitoneal procedure[s] performed
concurrently)
(For placement of interstitial device[s] for intra-abdominal,
intrapelvic, and/or retroperitoneal radiation therapy
guidance concurrent with open procedure, use 49412)
49329 Unlisted laparoscopy procedure, abdomen, peritoneum and
omentum
➲ CPT Assistant Nov 99:24, Mar 00:9, Feb 06:16, Dec
11:16, Oct 13:18, Mar 19:10, Feb 20:13
Introduction, Revision, Removal

49400 Injection of air or contrast into peritoneal cavity (separate
procedure)

49402 Removal of peritoneal foreign body from peritoneal cavity
(For lysis of intestinal adhesions, use 44005)

(For open or percutaneous peritoneal drainage or lavage,
see 49406, 49020, 49040, 49082-49084, as appropriate)
(For percutaneous insertion of a tunneled intraperitoneal
catheter without subcutaneous port, use 49418)
49405 Image-guided fluid collection drainage by catheter (eg,
abscess, hematoma, seroma, lymphocele, cyst); visceral (eg,
kidney, liver, spleen, lung/mediastinum), percutaneous
16:10, Fall 18:15
77002, 77003, 77012, 77021)
(For pneumonostomy, use 32200)
(For thoracentesis, see 32554, 32555)
(For percutaneous pleural drainage, see 32556, 32557)
(For open visceral drainage, see 32200 [lung abscess or
cyst], 47010 [liver abscess or cyst], 48510 [pseudocyst of
pancreas], 50020 [perirenal or renal abscess])
49406 peritoneal or retroperitoneal, percutaneous
16:10, Fall 18:15
77002, 77003, 77012, 77021)
(For abdominal paracentesis [diagnostic or therapeutic], see
49082, 49083)
(For transrectal or transvaginal image-guided peritoneal or
retroperitoneal fluid collection drainage by catheter, use
49407)
(For open transrectal drainage of pelvic abscess, use
45000)
(For open peritoneal or retroperitoneal drainage, see 44900
[appendiceal abscess], 49020 [peritoneal abscess or
localized peritonitis], 49040 [subdiaphragmatic or
subphrenic abscess], 49060 [retroperitoneal abscess],
49062 [extraperitoneal lymphocele], 49084 [peritoneal
lavage], 50020 [perirenal or renal abscess], 58805 [ovarian
cyst], 58822 [ovarian abscess])
(For percutaneous paracentesis, see 49082, 49083)
(For percutaneous insertion of a tunneled intraperitoneal
catheter without subcutaneous port, use 49418)
49407 peritoneal or retroperitoneal, transvaginal or transrectal
16:10, Fall 18:15
77002, 77003, 77012, 77021)
(Report 49405, 49406, 49407 separately for each individual
collection drained with a separate catheter)
(For open transrectal or transvaginal drainage, see 45000
[pelvic abscess], 58800 [ovarian cyst], 58820 [ovarian
abscess])
catheter [eg, abscess, hematoma, seroma, lymphocele, cyst]
for soft tissue [eg, extremity, abdominal wall, neck], use
10030)
guidance (eg, fiducial markers, dosimeter), percutaneous,
intra-abdominal, intra-pelvic (except prostate), and/or
retroperitoneum, single or multiple
➲ CPT Assistant Feb 10:7, Jun 16:3

intra-thoracic radiation therapy guidance, use 32553)
✚ 49412 Placement of interstitial device(s) for radiation therapy
guidance (eg, fiducial markers, dosimeter), open, intra-
abdominal, intrapelvic, and/or retroperitoneum, including
image guidance, if performed, single or multiple (List
(Use 49412 in conjunction with open abdominal, pelvic, or
retroperitoneal procedure[s] performed concurrently)
(For placement of interstitial device[s] for intra-abdominal,
intrapelvic, and/or retroperitoneal radiation therapy
guidance concurrent with laparoscopic procedure, use
49327)
49418 Insertion of tunneled intraperitoneal catheter (eg, dialysis,
intraperitoneal chemotherapy instillation, management of
ascites), complete procedure, including imaging guidance,
catheter placement, contrast injection when performed, and
radiological supervision and interpretation, percutaneous
49419 Insertion of tunneled intraperitoneal catheter, with

subcutaneous port (ie, totally implantable)
(For removal, use 49422)

49421 Insertion of tunneled intraperitoneal catheter for dialysis,
open
➲ CPT Assistant Fall 93:2, Jul 06:19
(For laparoscopic insertion of tunneled intraperitoneal

catheter, use 49324)
(For subcutaneous extension of intraperitoneal catheter with
remote chest exit site, use 49435 in conjunction with 49421)
49422 Removal of tunneled intraperitoneal catheter
(For removal of a non-tunneled catheter, use appropriate
E/M code)
49423 Exchange of previously placed abscess or cyst drainage
catheter under radiological guidance (separate procedure)

49424 Contrast injection for assessment of abscess or cyst via
previously placed drainage catheter or tube (separate
procedure)

49425 Insertion of peritoneal-venous shunt
49426 Revision of peritoneal-venous shunt
(For shunt patency test, use 78291)
49427 Injection procedure (eg, contrast media) for evaluation of
previously placed peritoneal-venous shunt
78291)
49428 Ligation of peritoneal-venous shunt
49429 Removal of peritoneal-venous shunt
✚ 49435 Insertion of subcutaneous extension to intraperitoneal
cannula or catheter with remote chest exit site (List

49436 Delayed creation of exit site from embedded subcutaneous
segment of intraperitoneal cannula or catheter
Initial Placement
Do not additionally report 43752 for placement of a nasogastric

(NG) or orogastric (OG) tube to insufflate the stomach prior to
percutaneous gastrointestinal tube placement. NG or OG tube
placement is considered part of the procedure in this family of
codes.
49440 Insertion of gastrostomy tube, percutaneous, under
fluoroscopic guidance including contrast injection(s), image
documentation and report
➲ CPT Assistant Jan 08:8, Jun 08:8, Aug 08:7, Sep 10:9,
Sep 14:5, Dec 14:18
(For conversion to a gastro-jejunostomy tube at the time of
initial gastrostomy tube placement, use 49440 in conjunction
with 49446)
49441 Insertion of duodenostomy or jejunostomy tube,
percutaneous, under fluoroscopic guidance including
contrast injection(s), image documentation and report
➲ CPT Assistant Jan 08:8, Jun 08:8, Aug 08:7, Dec 14:18
(For conversion of gastrostomy tube to gastro-jejunostomy

tube, use 49446)
49442 Insertion of cecostomy or other colonic tube, percutaneous,
under fluoroscopic guidance including contrast injection(s),
➲ CPT Assistant Jan 08:8, Jun 08:8, Aug 08:7, Dec 14:18
Conversion
49446 Conversion of gastrostomy tube to gastro-jejunostomy tube,
(For conversion to a gastro-jejunostomy tube at the time of

initial gastrostomy tube placement, use 49446 in conjunction
with 49440)
Replacement
If an existing gastrostomy, duodenostomy, jejunostomy, gastro-

jejunostomy, or cecostomy (or other colonic) tube is removed
and a new tube is placed via a separate percutaneous access site,
the placement of the new tube is not considered a replacement
and would be reported using the appropriate initial placement
codes 49440-49442.
49450 Replacement of gastrostomy or cecostomy (or other colonic)
tube, percutaneous, under fluoroscopic guidance including
➲ CPT Assistant Sep 10:9, Dec 13:17, Feb 19:5
(For percutaneous replacement of gastrostomy tube with

removal when performed without imaging or endoscopy, see
43762, 43763)
49451 Replacement of duodenostomy or jejunostomy tube,
➲ CPT Assistant Jan 08:8, Jun 08:8, Aug 08:7, Jul 10:10,
Dec 14:18
49452 Replacement of gastro-jejunostomy tube, percutaneous,
under fluoroscopic guidance including contrast injection(s),
Mechanical Removal of Obstructive Material

49460 Mechanical removal of obstructive material from
gastrostomy, duodenostomy, jejunostomy, gastro-
jejunostomy, or cecostomy (or other colonic) tube, any
method, under fluoroscopic guidance including contrast
injection(s), if performed, image documentation and report

49465)
Other
49465 Contrast injection(s) for radiological evaluation of existing
jejunostomy, or cecostomy (or other colonic) tube, from a
percutaneous approach including image documentation and
report
Repair
Hernioplasty, Herniorrhaphy, Herniotomy
The hernia repair codes in this section are categorized primarily
by the type of hernia (inguinal, femoral, incisional, etc).
Some types of hernias are further categorized as “initial” or
“recurrent” based on whether or not the hernia has required
previous repair(s).
Additional variables accounted for by some of the codes include
patient age and clinical presentation (reducible vs. incarcerated or
strangulated).
With the exception of the incisional hernia repairs (see 49560-
49566) the use of mesh or other prostheses is not separately
reported.
The excision/repair of strangulated organs or structures such as
testicle(s), intestine, ovaries are reported by using the appropriate
code for the excision/repair (eg, 44120, 54520, and 58940) in
addition to the appropriate code for the repair of the strangulated
hernia.
(For reduction and repair of intra-abdominal hernia, use
44050)
(For debridement of abdominal wall, see 11042, 11043)
(Codes 49491-49651 are unilateral procedures. For
bilateral procedure, report 49491-49566, 49570-49651
with modifier 50. Report add-on code 49568 twice, when
performed biaterally. Do not report modifier 50 in
49491 Repair, initial inguinal hernia, preterm infant (younger than
37 weeks gestation at birth), performed from birth up to 50
weeks postconception age, with or without hydrocelectomy;
reducible
49492 incarcerated or strangulated

49492)
(Postconception age equals gestational age at birth plus age
of infant in weeks at the time of the hernia repair. Initial
inguinal hernia repairs that are performed on preterm infants
who are older than 50 weeks postconception age and
younger than age 6 months at the time of surgery, should be
reported using codes 49495, 49496)
49495 Repair, initial inguinal hernia, full term infant younger than
age 6 months, or preterm infant older than 50 weeks
postconception age and younger than age 6 months at the
time of surgery, with or without hydrocelectomy; reducible
➲ CPT Assistant Winter 93:6, Winter 94:13, Jan 04:27,
Mar 04:10, May 04:14, Nov 07:9, Jun 08:3

➲ CPT Assistant Winter 93:6, Winter 94:13, Jan 04:27,
Mar 04:10, May 04:14, Jun 08:3
49496)
(Postconception age equals gestational age at birth plus age
in weeks at the time of the hernia repair. Initial inguinal
hernia repairs that are performed on preterm infants who are
younger than or up to 50 weeks postconception age but
younger than 6 months of age since birth, should be reported
using codes 49491, 49492. Inguinal hernia repairs on infants
age 6 months to younger than 5 years should be reported
using codes 49500-49501)
49500 Repair initial inguinal hernia, age 6 months to younger than
5 years, with or without hydrocelectomy; reducible
➲ CPT Assistant Winter 94:13, Jan 04:27, Mar 04:10, Nov
07:9, Jun 08:3, Nov 14:14
➲ CPT Assistant Winter 94:13, Jan 04:27, Mar 04:12,
Jun 08:3
49505 Repair initial inguinal hernia, age 5 years or older;
reducible
➲ CPT Assistant Winter 94:13, Sep 00:10, Jan 04:27, Mar
04:12, Jun 08:3
Jun 08:3
(For inguinal hernia repair, with simple orchiectomy, see
49505 or 49507 and 54520)
(For inguinal hernia repair, with excision of hydrocele or
spermatocele, see 49505 or 49507 and 54840 or 55040)
49520 Repair recurrent inguinal hernia, any age; reducible
➲ CPT Assistant Winter 94:13, Sep 03:3, Jan 04:27, Mar
04:3, Jun 08:3
Jun 08:3
49525 Repair inguinal hernia, sliding, any age
➲ CPT Assistant Winter 94:14, Jan 04:27, Mar 04:10, Nov
07:9, Jun 08:3
(For incarcerated or strangulated inguinal hernia repair, see
49496, 49501, 49507, 49521)
49540 Repair lumbar hernia
49550 Repair initial femoral hernia, any age; reducible


49555 Repair recurrent femoral hernia; reducible


49560 Repair initial incisional or ventral hernia; reducible

➲ CPT Assistant Winter 93:6, Winter 94:14, Nov 97:19,
Jun 08:3, Jan 12:10, Oct 13:15
➲ CPT Assistant Winter 94:14, Jun 08:3, Jan 12:10, Oct
13:15, Mar 18:11, Jul 18:15, Nov 19:14
49565 Repair recurrent incisional or ventral hernia; reducible
➲ CPT Assistant Winter 94:14, Nov 97:19, Jun 08:3, Jan
12:10, Oct 13:15
➲ CPT Assistant Winter 94:14, Jun 08:3, Jan 12:10, Oct
13:15, Nov 19:14
Coding Tip
Restrictions for Reporting Insertion of Mesh and Other Prostheses with
Hernia Repairs
With the exception of the incisional hernia repairs (see 49560-49566) the use
of mesh or other prostheses is not separately reported.
CPT Coding Guidelines, Hernioplasty, Herniorrhaphy, Herniotomy
✚ 49568 Implantation of mesh or other prosthesis for open incisional

or ventral hernia repair or mesh for closure of debridement
for necrotizing soft tissue infection (List separately in
addition to code for the incisional or ventral hernia repair)
➲ CPT Assistant Winter 94:14, Nov 97:19, Sep 01:11, Nov
05:15, Nov 07:9, Jun 08:3, Jan 12:10, Oct 13:15, Nov
19:14
49566)
49570 Repair epigastric hernia (eg, preperitoneal fat); reducible

49580 Repair umbilical hernia, younger than age 5 years; reducible


49585 Repair umbilical hernia, age 5 years or older; reducible


49590 Repair spigelian hernia

➲ CPT Assistant Winter 94:15, Nov 19:14
49600 Repair of small omphalocele, with primary closure

49605 Repair of large omphalocele or gastroschisis; with or
without prosthesis
49606 with removal of prosthesis, final reduction and closure,

in operating room

49606)
49610 Repair of omphalocele (Gross type operation); first stage
49611 second stage


49611)
(For diaphragmatic or hiatal hernia repair, see 39503,
43332)
(For surgical repair of omentum, use 49999)
Laparoscopy

49650 Laparoscopy, surgical; repair initial inguinal hernia
➲ CPT Assistant Nov 99:24, Mar 00:9, Jul 14:5
49651 repair recurrent inguinal hernia

49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian
or epigastric hernia (includes mesh insertion, when
performed); reducible


49654 Laparoscopy, surgical, repair, incisional hernia (includes
mesh insertion, when performed); reducible


49656 Laparoscopy, surgical, repair, recurrent incisional hernia
(includes mesh insertion, when performed); reducible


49659 Unlisted laparoscopy procedure, hernioplasty,
herniorrhaphy, herniotomy
➲ CPT Assistant Nov 99:25, Mar 00:9, Sep 01:11, Nov
05:15, Feb 06:16, Jan 09:7, Jul 14:5, Dec 14:16, Jul
17:10
Suture
49900 Suture, secondary, of abdominal wall for evisceration or
dehiscence
(For suture of ruptured diaphragm, see 39540, 39541)

(For debridement of abdominal wall, see 11042, 11043)
Other Procedures
49904 Omental flap, extra-abdominal (eg, for reconstruction of
sternal and chest wall defects)
(Code 49904 includes harvest and transfer. If a second

surgeon harvests the omental flap, then the 2 surgeons should
code 49904 as co-surgeons, using modifier 62)
✚ 49905 Omental flap, intra-abdominal (List separately in addition to

49906 Free omental flap with microvascular anastomosis
➲ CPT Assistant Nov 96:8, Apr 97:8, Nov 98:16
(Do not report code 69990 in addition to 49906)

49999 Unlisted procedure, abdomen, peritoneum and omentum
➲ CPT Assistant Jul 06:19, Sep 07:10, Nov 07:9, Aug
08:7, Apr 10:10, Dec 10:13, Jun 11:13, Jan 14:9, Nov
19:14

Surgery
Urinary System (50010-53899)
Urinary System section of the CPT codebook. The subheadings or
guidelines will be presented preceding those procedural terminology listings
Kidney (50010-50593)
Incision (50010-50135)
Excision (50200-50290)
Renal Transplantation* (50300-50380)
Introduction (50382-50396, 50430-50437)
Renal Pelvis Catheter Procedures (50382-50389)
Internally Dwelling (50382-50386)
Externally Accessible (50387-50389)
Other Introduction (Injection/Change/Removal) Procedures*
(50390-50396, 50430-50437)
Repair (50400-50405, 50500-50540)
Endoscopy (50551-50580)
Ureter (50600-50980)
Incision/Biopsy* (50600-50630)
Excision (50650-50660)
Other Introduction (Injection/Change/Removal) Procedures*
(50684-50695)
Repair* (50700-50940)
Endoscopy (50951-50980)
Bladder (51020-52700)
Incision (51020-51080)
Removal (51100-51102)
Excision (51500-51597)
Urodynamics* (51725-51798)
Repair (51800-51980)
Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy* (52000-
52010)
Transurethral Surgery (52204-52356)
Urethra and Bladder (52204-52318)
Ureter and Pelvis* (52320-52356)
Vesical Neck and Prostate (52400-52700)
Urinary System
Urethra (53000-53899)
Incision (53000-53085)
Excision (53200-53275)
Repair (53400-53520)
Urinary System
(For provision of chemotherapeutic agents, report both the
specific service in addition to code(s) for the specific
substance(s) or drug(s) provided)
Kidney
Incision
(For retroperitoneal exploration, abscess, tumor, or cyst, see
49010, 49060, 49203-49205)
50010 Renal exploration, not necessitating other specific
procedures
(For laparoscopic ablation of renal mass lesion(s), use
50542)
50020 Drainage of perirenal or renal abscess, open
➲ CPT Assistant Nov 97:19, Oct 01:8, May 14:9
Drainage of Renal Abscess

50020
An incision is made to the abscess cavity and the site is irrigated and drained.
catheter of perirenal/renal abscess, use 49405)
50040 Nephrostomy, nephrotomy with drainage
50045 Nephrotomy, with exploration

(For renal endoscopy performed in conjunction with this

procedure, see 50570-50580)
50060 Nephrolithotomy; removal of calculus
Nephrolithotomy With Calculus Removal

50060-50075
A kidney stone (calculus) is removed by an incision in the kidney. Use 50070 if complicated by a
congenital kidney abnormality.
50065 secondary surgical operation for calculus

50070 complicated by congenital kidney abnormality

50075 removal of large staghorn calculus filling renal pelvis

and calyces (including anatrophic pyelolithotomy)
50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with

or without dilation, endoscopy, lithotripsy, stenting, or
basket extraction; up to 2 cm
➲ CPT Assistant Oct 01:8, Dec 08:7, Jun 09:10
50081 over 2 cm
➲ CPT Assistant Oct 01:8, Dec 08:7, Jun 09:10
(For establishment of nephrostomy without

nephrostolithotomy, see 50040, 50432, 50433, 52334)
(For fluoroscopic guidance, use 76000)
50437, when performed by the same physician or other
qualified health care professional)
50100 Transection or repositioning of aberrant renal vessels
50120 Pyelotomy; with exploration

(For renal endoscopy performed in conjunction with this

50125 with drainage, pyelostomy
50130 with removal of calculus (pyelolithotomy,

pelviolithotomy, including coagulum pyelolithotomy)
50135 complicated (eg, secondary operation, congenital kidney

abnormality)
(For supply of anticarcinogenic agents, use 99070 in

Excision
(For excision of retroperitoneal tumor or cyst, see 49203-
49205)
(For laparoscopic ablation of renal mass lesion(s), use
50542)
50200 Renal biopsy; percutaneous, by trocar or needle
➲ CPT Assistant Fall 93:13, Oct 01:8, Feb 10:7
77002, 77012, 77021)
10007, 10008, 10009, 10010, 10011, 10012)
50205 by surgical exposure of kidney
50220 Nephrectomy, including partial ureterectomy, any open

approach including rib resection;
➲ CPT Assistant Oct 01:8, Nov 02:3, Aug 08:7
50225 complicated because of previous surgery on same kidney

50230 radical, with regional lymphadenectomy and/or vena

caval thrombectomy
(When vena caval resection with reconstruction is

necessary, use 37799)
50234 Nephrectomy with total ureterectomy and bladder cuff;
through same incision
50236 through separate incision

50240 Nephrectomy, partial

➲ CPT Assistant Oct 01:8, Nov 02:3, Jan 03:20, Apr
05:10, 12, Aug 08:7
(For laparoscopic partial nephrectomy, use 50543)
50250 Ablation, open, 1 or more renal mass lesion(s),
cryosurgical, including intraoperative ultrasound guidance
and monitoring, if performed
(For laparoscopic ablation of renal mass lesions, use

50542)
(For percutaneous ablation of renal tumors, see 50592,
50593)
50280 Excision or unroofing of cyst(s) of kidney
(For laparoscopic ablation of renal cysts, use 50541)

50290 Excision of perinephric cyst
Renal Transplantation
Renal autotransplantation includes reimplantation of the
autograft as the primary procedure, along with secondary extra-
corporeal procedure(s) (eg, partial nephrectomy,
nephrolithotomy) reported with modifier 51 (see 50380 and
applicable secondary procedure(s)).
Renal allotransplantation involves three distinct components of
physician work:
1. Cadaver donor nephrectomy, unilateral or bilateral, which
includes harvesting the graft(s) and cold preservation of the
graft(s) (perfusing with cold preservation solution and cold
maintenance) (use 50300). Living donor nephrectomy, which
includes harvesting the graft, cold preservation of the graft
(perfusing with cold preservation solution and cold
maintenance), and care of the donor (see 50320, 50547).
2. Backbench work:
Standard preparation of a cadaver donor renal allograft prior to
transplantation including dissection and removal of perinephric
fat, diaphragmatic and retroperitoneal attachments; excision of
adrenal gland; and preparation of ureter(s), renal vein(s), and
renal artery(s), ligating branches, as necessary (use 50323).
Standard preparation of a living donor renal allograft (open or
laparoscopic) prior to transplantation including dissection and
removal of perinephric fat and preparation of ureter(s), renal
vein(s), and renal artery(s), ligating branches, as necessary (use
50325).
Additional reconstruction of a cadaver or living donor renal
allograft prior to transplantation may include venous, arterial,
and/or ureteral anastomosis(es) necessary for implantation (see
50327-50329).
3. Recipient renal allotransplantation, which includes
transplantation of the allograft (with or without recipient
nephrectomy) and care of the recipient (see 50360, 50365).
(For dialysis, see 90935-90999)
(For laparoscopic donor nephrectomy, use 50547)
cavity, use 49323)
50300 Donor nephrectomy (including cold preservation); from
cadaver donor, unilateral or bilateral
➲ CPT Assistant Nov 99:25, Apr 05:10-12
50320 open, from living donor

50323 Backbench standard preparation of cadaver donor renal
allograft prior to transplantation, including dissection and
removal of perinephric fat, diaphragmatic and
retroperitoneal attachments, excision of adrenal gland, and
preparation of ureter(s), renal vein(s), and renal artery(s),
ligating branches, as necessary

50325 Backbench standard preparation of living donor renal
allograft (open or laparoscopic) prior to transplantation,
including dissection and removal of perinephric fat and
preparation of ureter(s), renal vein(s), and renal artery(s),
ligating branches, as necessary
50327 Backbench reconstruction of cadaver or living donor renal

allograft prior to transplantation; venous anastomosis, each

50329 ureteral anastomosis, each

50340 Recipient nephrectomy (separate procedure)

50360 Renal allotransplantation, implantation of graft; without
recipient nephrectomy
50365 with recipient nephrectomy


50370 Removal of transplanted renal allograft
50380 Renal autotransplantation, reimplantation of kidney
➲ CPT Assistant Apr 05:10, 12, Sep 19:11
(For renal autotransplantation extra-corporeal [bench]

surgery, use autotransplantation as the primary procedure
and report secondary procedure[s] [eg, partial nephrectomy,
nephrolithotomy] with modifier 51)
Introduction
Renal Pelvis Catheter Procedures
Internally Dwelling
50382 Removal (via snare/capture) and replacement of internally

dwelling ureteral stent via percutaneous approach, including
➲ CPT Assistant Sep 06:1, 16, Oct 08:8, Dec 09:4, Jan
16:3
08:5
(For removal and replacement of an internally dwelling
ureteral stent via a transurethral approach, use 50385)
50384 Removal (via snare/capture) of internally dwelling ureteral
stent via percutaneous approach, including radiological
➲ CPT Assistant Sep 06:2, 16, Oct 08:8, Jan 16:3
08:5
50437)
(For removal of an internally dwelling ureteral stent via a
transurethral approach, use 50386)
50385 Removal (via snare/capture) and replacement of internally
dwelling ureteral stent via transurethral approach, without
use of cystoscopy, including radiological supervision and
interpretation
➲ CPT Assistant Oct 08:8, Dec 09:4, Jan 16:3
50386 Removal (via snare/capture) of internally dwelling ureteral

stent via transurethral approach, without use of cystoscopy,
including radiological supervision and interpretation
Externally Accessible
50387 Removal and replacement of externally accessible

nephroureteral catheter (eg, external/internal stent) requiring
fluoroscopic guidance, including radiological supervision
and interpretation
➲ CPT Assistant Sep 06:2, 4, 16, Dec 09:4, Mar 12:3, Jan
16:3, Mar 16:10
08:5, Fall 15:4
(For removal and replacement of externally accessible
ureteral stent via ureterostomy or ileal conduit, use 50688)
(For removal without replacement of an externally
accessible ureteral stent not requiring fluoroscopic
guidance, see Evaluation and Management services codes)
50389 Removal of nephrostomy tube, requiring fluoroscopic
guidance (eg, with concurrent indwelling ureteral stent)
➲ CPT Assistant Sep 06:1, 2, 4, Jan 16:3
(Removal of nephrostomy tube not requiring fluoroscopic

guidance is considered inherent to E/M services. Report the
appropriate level of E/M service provided)
Other Introduction (Injection/Change/Removal)

Procedures
Percutaneous genitourinary procedures are performed with

imaging guidance (eg, fluoroscopy and/or ultrasound).
Diagnostic nephrostogram and/or ureterogram are typically
performed with percutaneous genitourinary procedures and are
included in 50432, 50433, 50434, 50435, 50436, 50437, 50693,
50694, 50695.
Code 50436 describes enlargement of an existing percutaneous
tract to the renal collecting system to accommodate large
instruments used in an endourologic procedure. Code 50436
includes predilation urinary tract imaging, postprocedure
nephrostomy tube placement, when performed, and includes all
radiological supervision and interpretation and imaging guidance
(eg, ultrasound, fluoroscopy). Code 50436 may not be reported
with 50432, 50433, 52334 for basic dilation of a percutaneous
tract during initial placement of a catheter or device.
Code 50437 includes all elements of 50436, but also includes new
access into the renal collecting system performed in the same
session when a pre-existing tract is not present.
Codes 50430 and 50431 are diagnostic procedure codes that
include injection(s) of contrast material, all associated
radiological supervision and interpretation, and procedural
imaging guidance (eg, ultrasound and/or fluoroscopy). Code
50430 also includes accessing the collecting system and/or
associated ureter with a needle and/or catheter. Codes 50430 or
50431 may not be reported together with 50432, 50433, 50434,
50435, 50693, 50694, 50695.
Codes 50432, 50433, 50434, 50435 represent therapeutic
procedures describing catheter placement or exchange, and
include the elements of access, drainage catheter manipulations,
and imaging guidance (eg, ultrasonography and/or fluoroscopy),
as well as diagnostic imaging supervision and interpretation,
when performed.
Code 50433 describes percutaneous nephrostomy with the
additional accessing of the ureter/bladder to ultimately place a
nephroureteral catheter (a single transnephric catheter with
nephrostomy and ureteral components that allows drainage
internally, externally, or both).
For codes 50430, 50431, 50432, 50433, 50434, 50435,50606,
50693, 50694, 50695, 50705, and 50706, the renal pelvis and its
associated ureter are considered a single entity for reporting
purposes. Codes 50430, 50431, 50432, 50433, 50434,
50435,50606, 50693, 50694, 50695, 50705, and 50706 may be
reported once for each renal collecting system/ureter accessed
(eg, two separate codes would be reported for bilateral
nephrostomy tube placement or for unilateral duplicated
collecting system/ureter requiring two separate procedures).
50390 Aspiration and/or injection of renal cyst or pelvis by needle,
percutaneous
➲ CPT Assistant Fall 93:14, Dec 97:7, Oct 01:8, Oct
05:18, Oct 08:8
74470, 76942, 77002, 77012, 77021)
(For antegrade nephrostogram and/or antegrade pyelogram,
see 50430, 50431)
50391 Instillation(s) of therapeutic agent into renal pelvis and/or
ureter through established nephrostomy, pyelostomy or
ureterostomy tube (eg, anticarcinogenic or antifungal agent)

# 50436 Dilation of existing tract, percutaneous, for an endourologic
procedure including imaging guidance (eg, ultrasound and/or
fluoroscopy) and all associated radiological supervision
and interpretation, with postprocedure tube placement, when
performed
# 50437 including new access into the renal collecting system

(For nephrostolithotomy, see 50080, 50081)

(For retrograde percutaneous nephrostomy, use 52334)
(For endoscopic surgery, see 50551-50561)
50081, 50382, 50384, 50430, 50431, 50432, 50433, 52334,
74485)
50396 Manometric studies through nephrostomy or pyelostomy
tube, or indwelling ureteral catheter
➲ CPT Assistant Fall 93:16, Dec 97:7, Oct 01:8

# 50430 Injection procedure for antegrade nephrostogram and/or
ureterogram, complete diagnostic procedure including
imaging guidance (eg, ultrasound and fluoroscopy) and all
associated radiological supervision and interpretation; new
access
# 50431 existing access

16:12
50433, 50434, 50435, 50693, 50694, 50695, 74425 for the
same renal collecting system and/or associated ureter)
# 50432 Placement of nephrostomy catheter, percutaneous, including
diagnostic nephrostogram and/or ureterogram when
performed, imaging guidance (eg, ultrasound and/or
and interpretation
➲ CPT Assistant Oct 15:5, Jan 16:3, Mar 18:11
50433, 50436, 50437, 50694, 50695, 74425, for the same
renal collecting system and/or associated ureter)
dilation of the nephrostomy tube tract)
Introduction of Catheter Into Renal Pelvis

50432
The physician inserts a catheter into the renal pelvis in order to drain urine.
# 50433 Placement of nephroureteral catheter, percutaneous,

including diagnostic nephrostogram and/or ureterogram
when performed, imaging guidance (eg, ultrasound and/or
and interpretation, new access

50432, 50693, 50694, 50695, 74425 for the same renal
collecting system and/or associated ureter)
dilation of the nephroureteral catheter tract)
(For nephroureteral catheter removal and replacement, use
50387)
# 50434 Convert nephrostomy catheter to nephroureteral catheter,
percutaneous, including diagnostic nephrostogram and/or
ureterogram when performed, imaging guidance (eg,
ultrasound and/or fluoroscopy) and all associated
radiological supervision and interpretation, via pre-existing
nephrostomy tract

50435, 50684, 50693, 74425 for the same renal collecting
system and/or associated ureter)
# 50435 Exchange nephrostomy catheter, percutaneous, including
and interpretation

50434, 50693, 74425 for the same renal collecting system
and/or associated ureter)
(For removal of nephrostomy catheter requiring
Repair
50400 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on
renal pelvis, with or without plastic operation on ureter,
nephropexy, nephrostomy, pyelostomy, or ureteral splinting;
simple
➲ CPT Assistant Nov 99:25, May 00:4, Oct 01:8
50405 complicated (congenital kidney abnormality, secondary

pyeloplasty, solitary kidney, calycoplasty)

50500 Nephrorrhaphy, suture of kidney wound or injury
50520 Closure of nephrocutaneous or pyelocutaneous fistula
50525 Closure of nephrovisceral fistula (eg, renocolic), including
visceral repair; abdominal approach
50540 Symphysiotomy for horseshoe kidney with or without
pyeloplasty and/or other plastic procedure, unilateral or
bilateral (1 operation)
Laparoscopy
50541 Laparoscopy, surgical; ablation of renal cysts
➲ CPT Assistant Nov 99:25, May 00:4, Oct 01:8, Nov
02:3, Jan 03:20
50542 ablation of renal mass lesion(s), including intraoperative
ultrasound guidance and monitoring, when performed
➲ CPT Assistant Nov 02:3, Jan 03:21, Aug 04:12

(For percutaneous ablation of renal tumors, see 50592,
50593)
50543 partial nephrectomy

50544 pyeloplasty
50545 radical nephrectomy (includes removal of Gerota’s

fascia and surrounding fatty tissue, removal of regional
lymph nodes, and adrenalectomy)

50546 nephrectomy, including partial ureterectomy
50547 donor nephrectomy (including cold preservation), from
living donor

(For backbench renal allograft standard preparation prior to
transplantation, use 50325)
(For backbench renal allograft reconstruction prior to
transplantation, see 50327-50329)
Laparoscopic Radical Nephrectomy

50545
Radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of
regional lymph nodes, and adrenalectomy)
Laparoscopic Nephrectomy
50546
A kidney is dissected and removed under laparoscopic guidance.
50548 nephrectomy with total ureterectomy

50549 Unlisted laparoscopy procedure, renal
➲ CPT Assistant Nov 99:25, Mar 00:9, May 00:4, Feb
06:16
cavity, use 49323)
Endoscopy
(For supplies and materials, use 99070)
50551 Renal endoscopy through established nephrostomy or
pyelostomy, with or without irrigation, instillation, or
ureteropyelography, exclusive of radiologic service;
50553 with ureteral catheterization, with or without dilation of

ureter
(For image-guided dilation of ureter without endoscopic

guidance, use 50706)
50555 with biopsy
(For image-guided biopsy of ureter and/or renal pelvis

without endoscopic guidance, use 50606)
50557 with fulguration and/or incision, with or without biopsy
50561 with removal of foreign body or calculus

50562 with resection of tumor

(When procedures 50570-50580 provide a significant

identifiable service, they may be added to 50045 and
50120)
50570 Renal endoscopy through nephrotomy or pyelotomy, with or
without irrigation, instillation, or ureteropyelography,
exclusive of radiologic service;
(For nephrotomy, use 50045)

(For pyelotomy, use 50120)
ureter

50574 with biopsy

50575 with endopyelotomy (includes cystoscopy, ureteroscopy,
dilation of ureter and ureteral pelvic junction, incision of
ureteral pelvic junction and insertion of endopyelotomy
stent)


Other Procedures
50590 Lithotripsy, extracorporeal shock wave
➲ CPT Assistant Jul 01:11, Aug 01:10, Oct 01:8, Jul 03:16,
Aug 03:14
Lithotripsy
50590
The physician breaks up a kidney stone (calculus) by directing shock waves through a liquid surrounding
the patient.
50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral,
radiofrequency
12:11
(50592 is a unilateral procedure. For bilateral procedure,
report 50592 with modifier 50)
77022)
50593 Ablation, renal tumor(s), unilateral, percutaneous,
cryotherapy
(50593 is a unilateral procedure. For bilateral procedure,

(For imaging guidance and monitoring, see codes 76940,
77013, 77022)
Ureter
Incision/Biopsy
Code 50606 is an add-on code describing endoluminal biopsy
(eg, brush) using non-endoscopic imaging guidance, which may
be reported once per ureter per day. This code includes the work
of the biopsy and the imaging guidance and radiological
supervision and interpretation required to accomplish the biopsy.
The biopsy may be performed through de novo transrenal access,
an existing renal/ureteral access, transurethral access, an ileal
conduit, or ureterostomy. The service of gaining access may be
reported separately. Diagnostic pyelography/ureterography is not
included in the work of 50606 and may be reported separately.
Other interventions or catheter placements performed at the same
setting as the biopsy may be reported separately.
For codes 50430, 50431, 50432, 50433, 50434, 50435, 50606,
50693, 50694, 50695, 50705, and 50706, the renal pelvis and its
associated ureter are considered a single entity for reporting
purposes. Codes 50430, 50431, 50432, 50433, 50434, 50435,
50606, 50693, 50694, 50695, 50705, and 50706 may be reported
once for each renal collecting system/ureter accessed (eg, two
separate codes would be reported for bilateral nephrostomy tube
placement or for unilateral duplicated collecting system/ureter
requiring two separate procedures).
50600 Ureterotomy with exploration or drainage (separate
procedure)
(For ureteral endoscopy performed in conjunction with this
50605 Ureterotomy for insertion of indwelling stent, all types
➲ CPT Assistant Oct 01:8, Dec 09:4, Apr 12:18
Indwelling Ureteral Stent

50605
The physician makes an incision in the ureter (ureterotomy) and inserts a stent. For placement using
cystourethroscopic technique, use 52332.
✚ 50606 Endoluminal biopsy of ureter and/or renal pelvis, non-

endoscopic, including imaging guidance (eg, ultrasound
and/or fluoroscopy) and all associated radiological
supervision and interpretation (List separately in addition to
50386, 50387, 50389, 50430, 50431, 50432, 50433, 50434,
50435, 50684, 50688, 50690, 50693, 50694, 50695, 51610)
50955, 50974, 52007, 74425 for the same renal collecting
system and/or associated ureter)
50610 Ureterolithotomy; upper one-third of ureter
50620 middle one-third of ureter

50630 lower one-third of ureter


(For transvesical ureterolithotomy, use 51060)
(For cystotomy with stone basket extraction of ureteral
calculus, use 51065)
(For endoscopic extraction or manipulation of ureteral
calculus, see 50080, 50081, 50561, 50961, 50980, 52320-
52330, 52352, 52353, 52356)
Excision
(For ureterocele, see 51535, 52300)
50650 Ureterectomy, with bladder cuff (separate procedure)
50660 Ureterectomy, total, ectopic ureter, combination abdominal,
vaginal and/or perineal approach
Introduction
Other Introduction (Injection/Change/Removal)
Procedures
Codes 50693, 50694, 50695 are therapeutic procedure codes

describing percutaneous placement of ureteral stents. These
codes include access, drainage, catheter manipulations, diagnostic
nephrostogram and/or ureterogram, when performed, imaging
guidance (eg, ultrasonography and/or fluoroscopy), and all
associated radiological supervision and interpretation. When a
separate ureteral stent and a nephrostomy catheter are placed into
a ureter and its associated renal pelvis during the same session
through a new percutaneous renal access, use 50695 to report the
procedure.
50684 Injection procedure for ureterography or ureteropyelography
through ureterostomy or indwelling ureteral catheter

50693, 50694, 50695)
50686 Manometric studies through ureterostomy or indwelling
ureteral catheter
50688 Change of ureterostomy tube or externally accessible
ureteral stent via ileal conduit

50690 Injection procedure for visualization of ileal conduit and/or
ureteropyelography, exclusive of radiologic service
▶ (Forradiological supervision and interpretation, see

74420 for retrograde or 74425 for antegrade injection)◀
50693 Placement of ureteral stent, percutaneous, including
and interpretation; pre-existing nephrostomy tract
50694 new access, without separate nephrostomy catheter

16:12
50695 new access, with separate nephrostomy catheter
16:12
50430, 50431, 50432, 50433, 50434, 50435, 50684, 74425
for the same renal collecting system and/or associated
ureter)
Repair
Codes 50705, 50706 are add-on codes describing embolization
and balloon dilation of the ureter using non-endoscopic imaging
guidance, and each may be reported once per ureter per day.
These codes include embolization or dilation plus imaging
guidance and radiological supervision and interpretation required
to accomplish the embolization or dilation. These procedures
may be performed through de novo transrenal access, an existing
renal/ureteral access, transurethral access, an ileal conduit, or
ureterostomy. The service of gaining access may be reported
separately. Diagnostic pyelography/ureterography is not included
in 50705 and 50706 and may be reported separately. Other
interventions or catheter placements performed at the same
setting as the embolization/dilation may be reported separately.
50700 Ureteroplasty, plastic operation on ureter (eg, stricture)
✚ 50705 Ureteral embolization or occlusion, including imaging
guidance (eg, ultrasound and/or fluoroscopy) and all
associated radiological supervision and interpretation (List

50386, 50387, 50389, 50430, 50431, 50432, 50433, 50434,
50435, 50684, 50688, 50690, 50693, 50694, 50695, 51610)
✚ 50706 Balloon dilation, ureteral stricture, including imaging
guidance (eg, ultrasound and/or fluoroscopy) and all
associated radiological supervision and interpretation (List

50386, 50387, 50389, 50430, 50431, 50432, 50433, 50434,
50435, 50684, 50688, 50690, 50693, 50694, 50695, 51610)
50953, 50972, 52341, 52344, 52345, 74485)
(For percutaneous nephrostomy, nephroureteral catheter,
and/or ureteral catheter placement use 50385, 50387,
50432, 50433, 50434, 50435, 50693, 50694, 50695)
50715 Ureterolysis, with or without repositioning of ureter for
retroperitoneal fibrosis
50722 Ureterolysis for ovarian vein syndrome
50725 Ureterolysis for retrocaval ureter, with reanastomosis of
upper urinary tract or vena cava
50727 Revision of urinary-cutaneous anastomosis (any type
urostomy);
50728 with repair of fascial defect and hernia
50740 Ureteropyelostomy, anastomosis of ureter and renal pelvis
50750 Ureterocalycostomy, anastomosis of ureter to renal calyx

50760 Ureteroureterostomy
50770 Transureteroureterostomy, anastomosis of ureter to

contralateral ureter
(Codes 50780-50785 include minor procedures to prevent
vesicoureteral reflux)
50780 Ureteroneocystostomy; anastomosis of single ureter to
bladder
➲ CPT Assistant Oct 01:8, Feb 18:11

(When combined with cystourethroplasty or vesical neck
revision, use 51820)
50782 anastomosis of duplicated ureter to bladder
50783 with extensive ureteral tailoring

50785 with vesico-psoas hitch or bladder flap


50800 Ureteroenterostomy, direct anastomosis of ureter to intestine

50810 Ureterosigmoidostomy, with creation of sigmoid bladder
and establishment of abdominal or perineal colostomy,
including intestine anastomosis
50815 Ureterocolon conduit, including intestine anastomosis


50820 Ureteroileal conduit (ileal bladder), including intestine
anastomosis (Bricker operation)

(For combination of 50800-50820 with cystectomy, see
51580-51595)
50825 Continent diversion, including intestine anastomosis using
any segment of small and/or large intestine (Kock pouch or
Camey enterocystoplasty)
50830 Urinary undiversion (eg, taking down of ureteroileal

conduit, ureterosigmoidostomy or ureteroenterostomy with
ureteroureterostomy or ureteroneocystostomy)
50840 Replacement of all or part of ureter by intestine segment,

including intestine anastomosis

50845 Cutaneous appendico-vesicostomy
50860 Ureterostomy, transplantation of ureter to skin
50900 Ureterorrhaphy, suture of ureter (separate procedure)
50920 Closure of ureterocutaneous fistula
50930 Closure of ureterovisceral fistula (including visceral repair)
50940 Deligation of ureter
(For ureteroplasty, ureterolysis, see 50700-50860)
Ureteroileal Conduit
50820
The ureters are connected to a segment of intestine to divert urine flow through an opening in the skin.
Laparoscopy
50945 Laparoscopy, surgical; ureterolithotomy
➲ CPT Assistant Nov 99:26, May 00:4, Oct 01:8, Sep
06:13
50947 ureteroneocystostomy with cystoscopy and ureteral stent
placement
Laparoscopic Ureteroneocystostomy
50947
Ureteroneocystostomy with cystoscopy and ureteral stent placement
50948 ureteroneocystostomy without cystoscopy and ureteral

stent placement
(For open ureteroneocystostomy, see 50780-50785)

50949 Unlisted laparoscopy procedure, ureter
Endoscopy
50951 Ureteral endoscopy through established ureterostomy, with
or without irrigation, instillation, or ureteropyelography,

ureter

50955 with biopsy


➲ CPT Assistant Oct 01:8, Mar 07:10, Apr 07:12
50970 Ureteral endoscopy through ureterotomy, with or without

irrigation, instillation, or ureteropyelography, exclusive of
radiologic service;
(For ureterotomy, use 50600)

ureter

50974 with biopsy

Bladder
Incision
51020 Cystotomy or cystostomy; with fulguration and/or insertion
of radioactive material
51030 with cryosurgical destruction of intravesical lesion
51040 Cystostomy, cystotomy with drainage
51045 Cystotomy, with insertion of ureteral catheter or stent
51050 Cystolithotomy, cystotomy with removal of calculus, without
vesical neck resection
51060 Transvesical ureterolithotomy
51065 Cystotomy, with calculus basket extraction and/or ultrasonic
or electrohydraulic fragmentation of ureteral calculus
51080 Drainage of perivesical or prevesical space abscess

catheter of perivesicular or prevesicular space abscess, use
49406)
Removal
51100 Aspiration of bladder; by needle
51101 by trocar or intracatheter

51102 with insertion of suprapubic catheter

(For imaging guidance, see 76942, 77002, 77012)
Excision
51500 Excision of urachal cyst or sinus, with or without umbilical
hernia repair
51520 Cystotomy; for simple excision of vesical neck (separate
procedure)
51525 for excision of bladder diverticulum, single or multiple
51530 for excision of bladder tumor
(For transurethral resection, see 52234-52240, 52305)
51535 Cystotomy for excision, incision, or repair of ureterocele
(For transurethral excision, use 52300)
51550 Cystectomy, partial; simple
51555 complicated (eg, postradiation, previous surgery,
difficult location)
51565 Cystectomy, partial, with reimplantation of ureter(s) into
bladder (ureteroneocystostomy)
51570 Cystectomy, complete; (separate procedure)
51575 with bilateral pelvic lymphadenectomy, including

external iliac, hypogastric, and obturator nodes
51580 Cystectomy, complete, with ureterosigmoidostomy or

ureterocutaneous transplantations;
51590 Cystectomy, complete, with ureteroileal conduit or sigmoid
bladder, including intestine anastomosis;

51596 Cystectomy, complete, with continent diversion, any open
technique, using any segment of small and/or large intestine
to construct neobladder
51597 Pelvic exenteration, complete, for vesical, prostatic or

urethral malignancy, with removal of bladder and ureteral
transplantations, with or without hysterectomy and/or
abdominoperineal resection of rectum and colon and
colostomy, or any combination thereof
(For pelvic exenteration for gynecologic malignancy, use
58240)
Introduction
51600 Injection procedure for cystography or voiding
urethrocystography
74455)
51605 Injection procedure and placement of chain for contrast
and/or chain urethrocystography
51610 Injection procedure for retrograde urethrocystography

51700 Bladder irrigation, simple, lavage and/or instillation
(Codes 51701-51702 are reported only when performed
independently. Do not report 51701-51702 when catheter
insertion is an inclusive component of another procedure.)
51701 Insertion of non-indwelling bladder catheter (eg, straight
catheterization for residual urine)
➲ CPT Assistant Jul 06:4, Jan 07:31, Jul 07:1
51702 Insertion of temporary indwelling bladder catheter; simple

(eg, Foley)
➲ CPT Assistant Oct 03:10, Jul 06:4, Jan 07:31, Jul 07:1,
May 14:3
(Do not report 51702 in conjunction with 0071T, 0072T)

51703 complicated (eg, altered anatomy, fractured
catheter/balloon)
51705 Change of cystostomy tube; simple

51710 complicated

51715 Endoscopic injection of implant material into the
submucosal tissues of the urethra and/or bladder neck
51720 Bladder instillation of anticarcinogenic agent (including
retention time)
Urodynamics
The following section (51725-51798) lists procedures that may be
used separately or in many and varied combinations.
When multiple procedures are performed in the same
investigative session, modifier 51 should be employed.
All procedures in this section imply that these services are
performed by, or are under the direct supervision of, a physician
or other qualified health care professional and that all
instruments, equipment, fluids, gases, probes, catheters,
technician’s fees, medications, gloves, trays, tubing, and other
sterile supplies be provided by that individual. When the
individual only interprets the results and/or operates the
equipment, a professional component, modifier 26, should be
used to identify these services.
51725 Simple cystometrogram (CMG) (eg, spinal manometer)
➲ CPT Assistant Sep 02:6, Feb 10:7
51726 Complex cystometrogram (ie, calibrated electronic

equipment);
51727 with urethral pressure profile studies (ie, urethral
closure pressure profile), any technique
51728 with voiding pressure studies (ie, bladder voiding

pressure), any technique
51729 with voiding pressure studies (ie, bladder voiding

pressure) and urethral pressure profile studies (ie,
urethral closure pressure profile), any technique
#✚ 51797 Voiding pressure studies, intra-abdominal (ie, rectal, gastric,

intraperitoneal) (List separately in addition to code for
primary procedure)
➲ CPT Assistant Dec 01:7, Sep 02:6, Oct 09:7, Feb 10:7

51736 Simple uroflowmetry (UFR) (eg, stop-watch flow rate,
mechanical uroflowmeter)
51741 Complex uroflowmetry (eg, calibrated electronic

equipment)
➲ CPT Assistant Sep 02:6, Feb 10:7, Sep 14:14
51784 Electromyography studies (EMG) of anal or urethral

sphincter, other than needle, any technique
➲ CPT Assistant Sep 02:6, Feb 10:7, Feb 14:11, Sep 14:14

51785 Needle electromyography studies (EMG) of anal or urethral
sphincter, any technique
➲ CPT Assistant Apr 02:6, Sep 02:6, Jul 04:13, Feb 10:7
51792 Stimulus evoked response (eg, measurement of

bulbocavernosus reflex latency time)
➲ CPT Assistant Apr 02:6, Sep 02:6, Feb 10:7, Feb 14:11

51798 Measurement of post-voiding residual urine and/or bladder
capacity by ultrasound, non-imaging
➲ CPT Assistant Dec 05:3, Feb 10:7, Jun 18:11
Measurement of Postvoiding
51798
Repair
51800 Cystoplasty or cystourethroplasty, plastic operation on
bladder and/or vesical neck (anterior Y-plasty, vesical
fundus resection), any procedure, with or without wedge
resection of posterior vesical neck
51820 Cystourethroplasty with unilateral or bilateral
ureteroneocystostomy
51840 Anterior vesicourethropexy, or urethropexy (eg, Marshall-
Marchetti-Krantz, Burch); simple
➲ CPT Assistant Jan 97:1, Nov 97:19, Apr 98:15, Jun
02:7, May 06:17, Jun 10:6, Aug 12:13
51841 complicated (eg, secondary repair)
➲ CPT Assistant Jan 97:1, Jun 02:7, Jun 10:6, Aug
12:13
(For urethropexy (Pereyra type), use 57289)
51845 Abdomino-vaginal vesical neck suspension, with or without
endoscopic control (eg, Stamey, Raz, modified Pereyra)
51860 Cystorrhaphy, suture of bladder wound, injury or rupture;

simple
51865 complicated
51880 Closure of cystostomy (separate procedure)
51900 Closure of vesicovaginal fistula, abdominal approach
(For vaginal approach, see 57320-57330)
51920 Closure of vesicouterine fistula;
51925 with hysterectomy
(For closure of vesicoenteric fistula, see 44660, 44661)
(For closure of rectovesical fistula, see 45800-45805)
51940 Closure, exstrophy of bladder
(See also 54390)
51960 Enterocystoplasty, including intestinal anastomosis
51980 Cutaneous vesicostomy
Laparoscopy
51990 Laparoscopy, surgical; urethral suspension for stress
incontinence
➲ CPT Assistant Nov 99:26, May 00:4, Jun 10:6, Mar
12:10, Aug 12:13
51992 sling operation for stress incontinence (eg, fascia or
synthetic)
➲ CPT Assistant Nov 99:26, May 00:4, Mar 12:10, Aug
12:13
(For open sling operation for stress incontinence, use
57288)
(For reversal or removal of sling operation for stress
incontinence, use 57287)
51999 Unlisted laparoscopy procedure, bladder
Laparoscopic Sling Suspension Urinary Incontinence

51990
Nonabsorbable sutures are placed laparoscopically into the endopelvic fascia at the bladder neck region
on each side and secured to the ipsilateral pectineal ligament. The sutures are tied using extra vaginal-
urethral knots so as to create a hammock type suspension of the bladder neck, without urethral
occlusion.
Endoscopy—Cystoscopy, Urethroscopy,
Cystourethroscopy
Endoscopic descriptions are listed so that the main procedure can
be identified without having to list all the minor related functions
performed at the same time. For example: meatotomy, urethral
calibration and/or dilation, urethroscopy, and cystoscopy prior to
a transurethral resection of prostate; ureteral catheterization
following extraction of ureteral calculus; internal urethrotomy
and bladder neck fulguration when performing a
cystourethroscopy for the female urethral syndrome. When the
secondary procedure requires significant additional time and
effort, it may be identified by the addition of modifier 22.
For example: urethrotomy performed for a documented pre-
existing stricture or bladder neck contracture.
Because cutaneous urinary diversions utilizing ileum or colon
serve as functional replacements of a native bladder, endoscopy
of such bowel segments, as well as performance of secondary
procedures can be captured by using the cystourethroscopy
codes. For example, endoscopy of an ileal loop with removal of
ureteral calculus would be coded as cystourethroscopy (including
ureteral catheterization); with removal of ureteral calculus
(52320).
52000 Cystourethroscopy (separate procedure)
➲ CPT Assistant Oct 00:7, May 01:5, Sep 04:11, Oct
05:23, Nov 07:9, Mar 13:14, May 14:3, Oct 17:9, Nov
18:10
52325, 52327, 52330, 52332, 52334, 52341, 52342, 52343,
52356)
57265)
52001 Cystourethroscopy with irrigation and evacuation of
multiple obstructing clots
Coding Tip
Restrictions for Reporting Temporary Catheter Insertion and Removal
with Cystourethroscopy
The insertion and removal of a temporary ureteral catheter (52005) during

diagnostic or therapeutic cystourethroscopy with ureteroscopy and/or
pyeloscopy is included in 52320-52356 and should not be reported
separately.
CPT Coding Guidelines, Urinary System, Bladder Transurethral Surgery,
Ureter and Pelvis
52005 Cystourethroscopy, with ureteral catheterization, with or

without irrigation, instillation, or ureteropyelography,
➲ CPT Assistant Sep 00:11, Jan 01:13, May 01:5, Oct
01:8, Dec 10:15, Mar 19:11
52007 with brush biopsy of ureter and/or renal pelvis
➲ CPT Assistant May 01:5, Oct 01:8

52010 Cystourethroscopy, with ejaculatory duct catheterization,
with or without irrigation, instillation, or duct radiography,
exclusive of radiologic service
Cystourethroscopy With Ureteral Catheterization

52005
A cystourethroscope is passed through the urethra and bladder in order to view the urinary collecting
system.
Transurethral Surgery
Urethra and Bladder
52204 Cystourethroscopy, with biopsy(s)

➲ CPT Assistant May 01:5, Sep 01:1, Sep 03:16, Aug
09:6, May 16:12
52214 Cystourethroscopy, with fulguration (including cryosurgery
or laser surgery) of trigone, bladder neck, prostatic fossa,
urethra, or periurethral glands
➲ CPT Assistant May 01:5, Sep 01:1, Aug 09:6, May
16:12
(For transurethral fulguration of prostate tissue performed
within the postoperative period of 52601 or 52630
performed by the same physician, append modifier 78)
(For transurethral fulguration of prostate tissue performed
within the postoperative period of a related procedure
performed by the same physician, append modifier 78)
(For transurethral fulguration of prostate for postoperative
bleeding performed by the same physician, append modifier
78)
or laser surgery) or treatment of MINOR (less than 0.5 cm)
lesion(s) with or without biopsy
➲ CPT Assistant May 01:5, Sep 01:1, Dec 07:7, Jun 09:10,
Aug 09:6, May 16:12
or laser surgery) and/or resection of; SMALL bladder
tumor(s) (0.5 up to 2.0 cm)
➲ CPT Assistant May 01:5, Sep 01:1, Oct 02:12, Jan
03:21, Jun 09:10, Aug 09:6, May 16:12
52235 MEDIUM bladder tumor(s) (2.0 to 5.0 cm)
➲ CPT Assistant May 01:5, Sep 01:1, Oct 02:12, Jan
03:21, Jun 09:10, Aug 09:6, May 16:12
52240 LARGE bladder tumor(s)
➲ CPT Assistant May 01:5, Sep 01:1, Jun 09:10, Aug
09:6, May 16:12
52250 Cystourethroscopy with insertion of radioactive substance,
with or without biopsy or fulguration
➲ CPT Assistant May 01:5, Sep 01:1
52260 Cystourethroscopy, with dilation of bladder for interstitial

cystitis; general or conduction (spinal) anesthesia
➲ CPT Assistant May 01:5, Sep 01:1, Oct 05:23
52265 local anesthesia

52270 Cystourethroscopy, with internal urethrotomy; female
52275 male
52276 Cystourethroscopy with direct vision internal urethrotomy

➲ CPT Assistant May 01:5, Sep 01:1, May 09:8, Feb 10:7
52277 Cystourethroscopy, with resection of external sphincter

(sphincterotomy)
52281 Cystourethroscopy, with calibration and/or dilation of

urethral stricture or stenosis, with or without meatotomy,
with or without injection procedure for cystography, male or
female
➲ CPT Assistant Nov 97:20, May 01:5, Sep 01:1, Jun
07:10, Oct 17:9
(To report cystourethroscopy with urethral therapeutic drug
delivery, use 0499T)
52282 Cystourethroscopy, with insertion of permanent urethral
stent
➲ CPT Assistant Nov 97:20, May 01:5, Sep 01:1, Feb
10:7, Jun 15:5
(For placement of temporary prostatic urethral stent, use
53855)
52283 Cystourethroscopy, with steroid injection into stricture
➲ CPT Assistant May 01:5, Sep 01:1, Mar 15:9
52285 Cystourethroscopy for treatment of the female urethral

syndrome with any or all of the following: urethral
meatotomy, urethral dilation, internal urethrotomy, lysis of
urethrovaginal septal fibrosis, lateral incisions of the
bladder neck, and fulguration of polyp(s) of urethra, bladder
neck, and/or trigone
52287 Cystourethroscopy, with injection(s) for chemodenervation

of the bladder
(The supply of the chemodenervation agent is reported

separately)
52290 Cystourethroscopy; with ureteral meatotomy, unilateral or
bilateral
52300 with resection or fulguration of orthotopic ureterocele(s),

unilateral or bilateral
52301 with resection or fulguration of ectopic ureterocele(s),

52305 with incision or resection of orifice of bladder

diverticulum, single or multiple
Coding Tip
Instructions for Reporting Stent Removal
To report cystourethroscopic removal of a self-retaining, indwelling ureteral

stent, see 52310, 52315, and append modifier 58, if appropriate.
CPT Coding Guidelines, Urinary System, Bladder Transurethral Surgery,

Ureter and Pelvis
52310 Cystourethroscopy, with removal of foreign body, calculus,
or ureteral stent from urethra or bladder (separate
procedure); simple
52315 complicated
52317 Litholapaxy: crushing or fragmentation of calculus by any

means in bladder and removal of fragments; simple or small
(less than 2.5 cm)
➲ CPT Assistant May 01:5, Sep 01:1, Feb 12:11
52318 complicated or large (over 2.5 cm)

➲ CPT Assistant May 01:5, Sep 01:1, Feb 12:11
Ureter and Pelvis
Therapeutic cystourethroscopy always includes diagnostic

cystourethroscopy. To report a diagnostic cystourethroscopy, use
52000. Therapeutic cystourethroscopy with ureteroscopy and/or
pyeloscopy always includes diagnostic cystourethroscopy with
ureteroscopy and/or pyeloscopy. To report a diagnostic
cystourethroscopy with ureteroscopy and/or pyeloscopy, use
52351.
Do not report 52000 in conjunction with 52320-52343, 52356.
Do not report 52351 in conjunction with 52344-52346, 52352-
52356.
The insertion and removal of a temporary ureteral catheter
(52005) during diagnostic or therapeutic cystourethroscopy with
ureteroscopy and/or pyeloscopy is included in 52320-52356 and
should not be reported separately.
To report insertion of a self-retaining, indwelling stent performed
during diagnostic or therapeutic cystourethroscopy with
ureteroscopy and/or pyeloscopy, report 52332, in addition to
primary procedure(s) performed (52320-52330, 52334-52352,
52354, 52355), and append modifier 51. Code 52332 is used to
report a unilateral procedure unless otherwise specified.
For bilateral insertion of self-retaining, indwelling ureteral stents,
use code 52332, and append modifier 50.
To report cystourethroscopic removal of a self-retaining,
indwelling ureteral stent, see 52310, 52315, and append modifier
58, if appropriate.
52320 Cystourethroscopy (including ureteral catheterization); with
removal of ureteral calculus
➲ CPT Assistant Mar 96:1, May 96:11, Jan 01:13, May
01:5, Sep 01:1, Oct 01:8, May 14:3
52325 with fragmentation of ureteral calculus (eg, ultrasonic or
electro-hydraulic technique)
➲ CPT Assistant Mar 96:1, May 96:11, May 01:5, Sep
01:1, Oct 01:8, Dec 07:13
52327 with subureteric injection of implant material
01:1, Oct 01:8
52330 with manipulation, without removal of ureteral calculus
➲ CPT Assistant Mar 96:1, May 96:11, Sep 00:11, May
01:5, Sep 01:1, Oct 01:8, May 14:3
with 52000)
52332 Cystourethroscopy, with insertion of indwelling ureteral
stent (eg, Gibbons or double-J type)
➲ CPT Assistant Mar 96:1, May 96:11, Nov 96:8, Jan
01:13, May 01:5, Sep 01:1, Oct 01:8, Oct 05:18, Dec
09:4, 12, May 14:3
52356 when performed together on the same side)
52334 Cystourethroscopy with insertion of ureteral guide wire
through kidney to establish a percutaneous nephrostomy,
retrograde
01:1, Oct 01:8, May 14:3
(For percutaneous nephrostolithotomy, see 50080, 50081;
for establishment of percutaneous nephrostomy, see 50432,
50433)
(For cystourethroscopy, with ureteroscopy and/or
pyeloscopy, see 52351-52356)
(For cystourethroscopy with incision, fulguration, or
resection of congenital posterior urethral valves or
obstructive hypertrophic mucosal folds, use 52400)
52351)
52341 Cystourethroscopy; with treatment of ureteral stricture (eg,
balloon dilation, laser, electrocautery, and incision)
➲ CPT Assistant Nov 96:9, Apr 01:4, May 01:5, Sep 01:1,
Oct 01:8
52342 with treatment of ureteropelvic junction stricture (eg,
➲ CPT Assistant Apr 01:4, May 01:5, Sep 01:1, Oct
01:8, Aug 02:11
52343 with treatment of intra-renal stricture (eg, balloon
dilation, laser, electrocautery, and incision)
01:8, May 14:3
52000, 52351)
(For image-guided dilation of ureter, ureteropelvic junction
stricture without endoscopic guidance, use 50706)
52344 Cystourethroscopy with ureteroscopy; with treatment of
ureteral stricture (eg, balloon dilation, laser, electrocautery,
and incision)
➲ CPT Assistant Apr 01:4, May 01:5, Sep 01:1, Oct 01:8
52345 with treatment of ureteropelvic junction stricture (eg,

01:8
52346 with treatment of intra-renal stricture (eg, balloon
dilation, laser, electrocautery, and incision)
01:8, May 14:3
(For transurethral resection or incision of ejaculatory ducts,
use 52402)
52351)
(For image-guided dilation of ureter, ureteropelvic junction
stricture without endoscopic guidance, use 50706)
52351 Cystourethroscopy, with ureteroscopy and/or pyeloscopy;
diagnostic
➲ CPT Assistant Apr 01:4, May 01:5, Sep 01:1, Oct 01:8,
May 14:3
52343, 52344, 52345, 52346, 52352-52356)
52352 with removal or manipulation of calculus (ureteral
catheterization is included)
01:8, Jun 07:10, Feb 10:13, May 14:3, Dec 19:12
52353 with lithotripsy (ureteral catheterization is included)
01:8, Dec 07:13, Apr 09:8, May 14:3, Dec 19:12
(Do not report 52353 in conjunction with 52332, 52356
when performed together on the same side)
# 52356 with lithotripsy including insertion of indwelling ureteral
stent (eg, Gibbons or double-J type)

when performed together on the same side)
52354 with biopsy and/or fulguration of ureteral or renal pelvic
lesion
01:8, May 14:3
52355 with resection of ureteral or renal pelvic tumor
01:8, Jan 03:21, May 14:3
Vesical Neck and Prostate

52400 Cystourethroscopy with incision, fulguration, or resection of
congenital posterior urethral valves, or congenital
obstructive hypertrophic mucosal folds
52402 Cystourethroscopy with transurethral resection or incision

of ejaculatory ducts
52441 Cystourethroscopy, with insertion of permanent adjustable

transprostatic implant; single implant
✚ 52442 each additional permanent adjustable transprostatic

implant (List separately in addition to code for primary
procedure)

(To report removal of implant[s], use 52310)
(For insertion of a permanent urethral stent, use 52282. For
insertion of a temporary prostatic urethral stent, use 53855)
52450 Transurethral incision of prostate
➲ CPT Assistant Apr 01:4, Jul 05:15, Jun 15:5
52500 Transurethral resection of bladder neck (separate

procedure)
➲ CPT Assistant Apr 01:4, Jan 04:27, Jul 05:15, May 09:8
52601 Transurethral electrosurgical resection of prostate, including

control of postoperative bleeding, complete (vasectomy,
meatotomy, cystourethroscopy, urethral calibration and/or
dilation, and internal urethrotomy are included)
➲ CPT Assistant Nov 97:20, Apr 01:4, Jun 03:6, Oct
11:10, Jun 15:5
(For transurethral waterjet ablation of prostate, use 0421T)
(For other approaches, see 55801-55845)
Transurethral Resection of Prostate, Complete

52601
The physician removes the prostate gland using an electrocautery knife.
(52612, 52614, 52620 have been deleted. For first stage
transurethral partial resection of prostate, use 52601. For
second stage partial resection of prostate, use 52601 with
modifier 58. For transurethral resection of residual or
regrowth of obstructive prostate tissue, use 52630)
52630 Transurethral resection; residual or regrowth of obstructive
prostate tissue including control of postoperative bleeding,
complete (vasectomy, meatotomy, cystourethroscopy,
urethral calibration and/or dilation, and internal urethrotomy
are included)
(For resection of residual prostate tissue performed within

the postoperative period of a related procedure performed
by the same physician, append modifier 78)
(For transurethral waterjet ablation of prostate, use 0421T)
52640 of postoperative bladder neck contracture
52647 Laser coagulation of prostate, including control of

postoperative bleeding, complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or dilation, and
internal urethrotomy are included if performed)
➲ CPT Assistant Nov 97:20, Mar 98:11, Apr 01:4, Nov
06:21
52648 Laser vaporization of prostate, including control of
postoperative bleeding, complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or dilation,
internal urethrotomy and transurethral resection of prostate
are included if performed)
➲ CPT Assistant Mar 98:11, Apr 01:5, Jul 05:15, Nov
06:21, Jun 15:5
Contact Laser Vaporization of Prostate

52648
A laser is used to vaporize the prostate.
52649 Laser enucleation of the prostate with morcellation,

including control of postoperative bleeding, complete
(vasectomy, meatotomy, cystourethroscopy, urethral
calibration and/or dilation, internal urethrotomy and
transurethral resection of prostate are included if
performed)

52281, 52601, 52647, 52648, 53020, 55250)
52700 Transurethral drainage of prostatic abscess
(For litholapaxy, use 52317, 52318)
Urethra
(For endoscopy, see cystoscopy, urethroscopy,
cystourethroscopy, 52000-52700)
(For injection procedure for urethrocystography, see 51600-
51610)
Incision
53000 Urethrotomy or urethrostomy, external (separate procedure);
pendulous urethra
53010 perineal urethra, external
53020 Meatotomy, cutting of meatus (separate procedure); except
infant
53025 infant
53040 Drainage of deep periurethral abscess
(For subcutaneous abscess, see 10060, 10061)
53060 Drainage of Skene’s gland abscess or cyst
53080 Drainage of perineal urinary extravasation; uncomplicated
53085 complicated
Excision
53200 Biopsy of urethra
53210 Urethrectomy, total, including cystostomy; female
53215 male
53220 Excision or fulguration of carcinoma of urethra
53230 Excision of urethral diverticulum (separate procedure);
female
53235 male
53240 Marsupialization of urethral diverticulum, male or female
53250 Excision of bulbourethral gland (Cowper’s gland)
53260 Excision or fulguration; urethral polyp(s), distal urethra
(For endoscopic approach, see 52214, 52224)
53265 urethral caruncle
53270 Skene’s glands
53275 urethral prolapse
Repair
(For hypospadias, see 54300-54352)
53400 Urethroplasty; first stage, for fistula, diverticulum, or
stricture (eg, Johannsen type)
53405 second stage (formation of urethra), including urinary
diversion
53410 Urethroplasty, 1-stage reconstruction of male anterior
urethra
53415 Urethroplasty, transpubic or perineal, 1-stage, for
reconstruction or repair of prostatic or membranous urethra
53420 Urethroplasty, 2-stage reconstruction or repair of prostatic
or membranous urethra; first stage
53425 second stage
53430 Urethroplasty, reconstruction of female urethra
53431 Urethroplasty with tubularization of posterior urethra and/or
lower bladder for incontinence (eg, Tenago, Leadbetter
procedure)
53440 Sling operation for correction of male urinary incontinence

(eg, fascia or synthetic)
53442 Removal or revision of sling for male urinary incontinence

(eg, fascia or synthetic)
53444 Insertion of tandem cuff (dual cuff)

53445 Insertion of inflatable urethral/bladder neck sphincter,

including placement of pump, reservoir, and cuff
53446 Removal of inflatable urethral/bladder neck sphincter,

including pump, reservoir, and cuff
53447 Removal and replacement of inflatable urethral/bladder

neck sphincter including pump, reservoir, and cuff at the
same operative session
53448 Removal and replacement of inflatable urethral/bladder

neck sphincter including pump, reservoir, and cuff through
an infected field at the same operative session including
irrigation and debridement of infected tissue
(Do not report 11042, 11043 in addition to 53448)

53449 Repair of inflatable urethral/bladder neck sphincter,
including pump, reservoir, and cuff
53450 Urethromeatoplasty, with mucosal advancement
(For meatotomy, see 53020, 53025)

53460 Urethromeatoplasty, with partial excision of distal urethral
segment (Richardson type procedure)
53500 Urethrolysis, transvaginal, secondary, open, including
cystourethroscopy (eg, postsurgical obstruction, scarring)
(For urethrolysis by retropubic approach, use 53899)

53502 Urethrorrhaphy, suture of urethral wound or injury, female
53505 Urethrorrhaphy, suture of urethral wound or injury; penile
53510 perineal
53515 prostatomembranous
53520 Closure of urethrostomy or urethrocutaneous fistula, male
(For closure of urethrovaginal fistula, use 57310)
(For closure of urethrorectal fistula, see 45820, 45825)
Manipulation
53600 Dilation of urethral stricture by passage of sound or urethral
dilator, male; initial
53601 subsequent
53605 Dilation of urethral stricture or vesical neck by passage of
sound or urethral dilator, male, general or conduction
(spinal) anesthesia
(For dilation of urethral stricture, male, performed under
local anesthesia, see 53600, 53601, 53620, 53621)
53620 Dilation of urethral stricture by passage of filiform and
follower, male; initial
53621 subsequent
53660 Dilation of female urethra including suppository and/or
instillation; initial
53661 subsequent
53665 Dilation of female urethra, general or conduction (spinal)
anesthesia
(For urethral catheterization, see 51701-51703)
(For dilation of urethra performed under local anesthesia,
female, see 53660, 53661)
Other Procedures
(For 2 or 3 glass urinalysis, use 81020)
53850 Transurethral destruction of prostate tissue; by microwave
thermotherapy
➲ CPT Assistant Nov 97:20, Apr 01:6, Feb 10:7, Jun 15:5,
Nov 18:10
53852 by radiofrequency thermotherapy
18:10
53854 by radiofrequency generated water vapor thermotherapy
(For transurethral ablation of malignant prostate tissue by
high-energy water vapor thermotherapy, including
intraoperative imaging and needle guidance, use 0582T)
53855 Insertion of a temporary prostatic urethral stent, including
urethral measurement
(For insertion of permanent urethral stent, use 52282)
Temporary Prostatic Urethral Stent Insertion

53855
A temporary prostatic urethral stent is inserted.
53860 Transurethral radiofrequency micro-remodeling of the

female bladder neck and proximal urethra for stress urinary
incontinence
53899 Unlisted procedure, urinary system

➲
CPT Assistant Aug 04:12, Sep 04:11, Oct 05:18, 23-24,
Feb 06:14, May 10:10, Mar 15:9, Jun 15:5, Aug 19:10
➲ Clinical Examples in Radiology Summer 06:1-3

Surgery
Male Genital System (54000-55899)
Male Genital System section of the CPT codebook. The subheadings or
Penis (54000-54450)
Incision (54000-54015)
Excision (54100-54164)
Repair (54300-54440)
Testis (54500-54699)
Excision (54500-54535)
Exploration (54550-54560)
Repair (54600-54680)
Epididymis (54700-54901)
Incision (54700)
Excision (54800-54861)
Exploration (54865)
Repair (54900-54901)
Tunica Vaginalis (55000-55060)
Incision (55000)
Excision (55040-55041)
Repair (55060)
Scrotum (55100-55180)
Incision (55100-55120)
Excision (55150)
Repair (55175-55180)
Vas Deferens (55200-55400)
Incision (55200)
Excision (55250)
Repair (55400)
Suture
Spermatic Cord (55500-55559)
Excision (55500-55540)
Seminal Vesicles (55600-55680)
Incision (55600-55605)
Excision (55650-55680)
Prostate (55700-55899)
Incision (55700-55725)
Excision (55801-55865)
Laparoscopy* (55866)
Reproductive System Procedures (55920)
Intersex Surgery (55970-55980)
Male Genital System
Male Genital System
Penis
Incision
(For abdominal perineal gangrene debridement, see 11004-
11006)
54000 Slitting of prepuce, dorsal or lateral (separate procedure);
newborn
54001 except newborn
54015 Incision and drainage of penis, deep
(For skin and subcutaneous abscess, see 10060-10160)
Destruction
54050 Destruction of lesion(s), penis (eg, condyloma, papilloma,
molluscum contagiosum, herpetic vesicle), simple; chemical
54055 electrodesiccation
54056 cryosurgery
54057 laser surgery
54060 surgical excision
54065 Destruction of lesion(s), penis (eg, condyloma, papilloma,
molluscum contagiosum, herpetic vesicle), extensive (eg,
laser surgery, electrosurgery, cryosurgery, chemosurgery)
(For destruction or excision of other lesions, see
Integumentary System)
Excision
54100 Biopsy of penis; (separate procedure)
54105 deep structures

54110 Excision of penile plaque (Peyronie disease);
54111 with graft to 5 cm in length
54112 with graft greater than 5 cm in length

54115 Removal foreign body from deep penile tissue (eg, plastic
implant)
54120 Amputation of penis; partial
54125 complete
54130 Amputation of penis, radical; with bilateral inguinofemoral
lymphadenectomy
54135 in continuity with bilateral pelvic lymphadenectomy,
including external iliac, hypogastric and obturator nodes
(For lymphadenectomy [separate procedure], see 38760-
38770)
54150 Circumcision, using clamp or other device with regional
dorsal penile or ring block
➲ CPT Assistant Sep 96:11, May 98:11, Apr 03:27, Aug
03:6, May 07:10, Jul 07:5
(Report 54150 with modifier 52 when performed without
dorsal penile or ring block)
54160 Circumcision, surgical excision other than clamp, device, or
dorsal slit; neonate (28 days of age or less)
➲ CPT Assistant Sep 96:11, May 98:11, May 07:10, Jul
07:5
54161 older than 28 days of age
➲ CPT Assistant Sep 96:11, Dec 96:10, May 98:11, Jul
07:5
54162 Lysis or excision of penile post-circumcision adhesions
54163 Repair incomplete circumcision

54164 Frenulotomy of penis

(Do not report 54164 with circumcision codes 54150-

54161, 54162, 54163)
Introduction
54200 Injection procedure for Peyronie disease;
54205 with surgical exposure of plaque
54220 Irrigation of corpora cavernosa for priapism
54230 Injection procedure for corpora cavernosography
54231 Dynamic cavernosometry, including intracavernosal
injection of vasoactive drugs (eg, papaverine, phentolamine)
54235 Injection of corpora cavernosa with pharmacologic agent(s)
(eg, papaverine, phentolamine)
54240 Penile plethysmography

54250 Nocturnal penile tumescence and/or rigidity test
Repair
(For other urethroplasties, see 53400-53430)
(For penile revascularization, use 37788)
54300 Plastic operation of penis for straightening of chordee (eg,
hypospadias), with or without mobilization of urethra
54304 Plastic operation on penis for correction of chordee or for

first stage hypospadias repair with or without
transplantation of prepuce and/or skin flaps
54308 Urethroplasty for second stage hypospadias repair
(including urinary diversion); less than 3 cm
54312 greater than 3 cm
54316 Urethroplasty for second stage hypospadias repair
(including urinary diversion) with free skin graft obtained
from site other than genitalia
54318 Urethroplasty for third stage hypospadias repair to release
penis from scrotum (eg, third stage Cecil repair)
54322 1-stage distal hypospadias repair (with or without chordee
or circumcision); with simple meatal advancement (eg,
Magpi, V-flap)
54324 with urethroplasty by local skin flaps (eg, flip-flap,
prepucial flap)
54326 with urethroplasty by local skin flaps and mobilization of
urethra
54328 with extensive dissection to correct chordee and
urethroplasty with local skin flaps, skin graft patch,
and/or island flap
(For urethroplasty and straightening of chordee, use 54308)

54332 1-stage proximal penile or penoscrotal hypospadias repair
requiring extensive dissection to correct chordee and
urethroplasty by use of skin graft tube and/or island flap
54336 1-stage perineal hypospadias repair requiring extensive

dissection to correct chordee and urethroplasty by use of
skin graft tube and/or island flap
54340 Repair of hypospadias complications (ie, fistula, stricture,

diverticula); by closure, incision, or excision, simple
54344 requiring mobilization of skin flaps and urethroplasty
with flap or patch graft
54348 requiring extensive dissection and urethroplasty with
flap, patch or tubed graft (includes urinary diversion)
54352 Repair of hypospadias cripple requiring extensive
dissection and excision of previously constructed structures
including re-release of chordee and reconstruction of urethra
and penis by use of local skin as grafts and island flaps and
skin brought in as flaps or grafts
54360 Plastic operation on penis to correct angulation
54380 Plastic operation on penis for epispadias distal to external
sphincter;
54385 with incontinence
54390 with exstrophy of bladder
54400 Insertion of penile prosthesis; non-inflatable (semi-rigid)
54401 inflatable (self-contained)
(For removal or replacement of penile prosthesis, see
54415, 54416)
54405 Insertion of multi-component, inflatable penile prosthesis,
including placement of pump, cylinders, and reservoir
(For reduced services, report 54405 with modifier 52)

54406 Removal of all components of a multi-component, inflatable
penile prosthesis without replacement of prosthesis

54408 Repair of component(s) of a multi-component, inflatable
penile prosthesis
54410 Removal and replacement of all component(s) of a multi-

component, inflatable penile prosthesis at the same
operative session
54411 Removal and replacement of all components of a multi-

component inflatable penile prosthesis through an infected
field at the same operative session, including irrigation and
debridement of infected tissue

54415 Removal of non-inflatable (semi-rigid) or inflatable (self-
contained) penile prosthesis, without replacement of
prosthesis
54416 Removal and replacement of non-inflatable (semi-rigid) or
inflatable (self-contained) penile prosthesis at the same
operative session
54417 Removal and replacement of non-inflatable (semi-rigid) or

inflatable (self-contained) penile prosthesis through an
infected field at the same operative session, including
irrigation and debridement of infected tissue

54420 Corpora cavernosa-saphenous vein shunt (priapism
operation), unilateral or bilateral
54430 Corpora cavernosa-corpus spongiosum shunt (priapism
operation), unilateral or bilateral
54435 Corpora cavernosa-glans penis fistulization (eg, biopsy
needle, Winter procedure, rongeur, or punch) for priapism
54437 Repair of traumatic corporeal tear(s)
(For repair of urethra, see 53410, 53415)

54438 Replantation, penis, complete amputation including urethral
repair
(To report replantation of incomplete penile amputation, see

54437 for repair of corporeal tear[s], and 53410, 53415 for
repair of the urethra)
54440 Plastic operation of penis for injury
Manipulation
54450 Foreskin manipulation including lysis of preputial adhesions
and stretching
Testis
Excision
(For abdominal perineal gangrene debridement, see 11004-
11006)
54500 Biopsy of testis, needle (separate procedure)

10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
54505 Biopsy of testis, incisional (separate procedure)

(When combined with vasogram, seminal vesiculogram, or
epididymogram, use 55300)
54512 Excision of extraparenchymal lesion of testis
54520 Orchiectomy, simple (including subcapsular), with or

without testicular prosthesis, scrotal or inguinal approach
➲ CPT Assistant Winter 94:13, Oct 01:8, Mar 04:3

54522 Orchiectomy, partial
54530 Orchiectomy, radical, for tumor; inguinal approach

54535 with abdominal exploration
(For orchiectomy with repair of hernia, see 49505 or 49507

and 54520)
(For radical retroperitoneal lymphadenectomy, use 38780)
Exploration
54550 Exploration for undescended testis (inguinal or scrotal area)

54560 Exploration for undescended testis with abdominal
exploration
Repair
54600 Reduction of torsion of testis, surgical, with or without
fixation of contralateral testis
54620 Fixation of contralateral testis (separate procedure)

54640 Orchiopexy, inguinal or scrotal approach
➲ CPT Assistant Oct 01:8, Jan 04:27, Mar 04:10, Jun 08:4,
Mar 17:11
(For inguinal hernia repair performed in conjunction with
inguinal orchiopexy, see 49495-49525)
54650 Orchiopexy, abdominal approach, for intra-abdominal testis
(eg, Fowler-Stephens)

54660 Insertion of testicular prosthesis (separate procedure)

54670 Suture or repair of testicular injury
54680 Transplantation of testis(es) to thigh (because of scrotal

destruction)
Laparoscopy
54690 Laparoscopy, surgical; orchiectomy
➲ CPT Assistant Nov 99:26, Mar 00:5, Oct 01:8
54692 orchiopexy for intra-abdominal testis

Laparoscopic Orchiopexy
54692
Surgical fixation of an undescended testis in the scrotum under laparoscopic guidance
54699 Unlisted laparoscopy procedure, testis
Epididymis
Incision
54700 Incision and drainage of epididymis, testis and/or scrotal
space (eg, abscess or hematoma)
(For debridement of necrotizing soft tissue infection of

external genitalia, see 11004-11006)
Excision
54800 Biopsy of epididymis, needle
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
54830 Excision of local lesion of epididymis
54840 Excision of spermatocele, with or without epididymectomy

54860 Epididymectomy; unilateral

54861 bilateral
Exploration
54865 Exploration of epididymis, with or without biopsy
Repair
54900 Epididymovasostomy, anastomosis of epididymis to vas
deferens; unilateral
54901 bilateral
(For operating microscope, use 69990)
Tunica Vaginalis
Incision
55000 Puncture aspiration of hydrocele, tunica vaginalis, with or
without injection of medication
Excision
55040 Excision of hydrocele; unilateral
➲ CPT Assistant Jun 08:4, Nov 17:10
55041 bilateral
(With hernia repair, see 49495-49501)
Repair
55060 Repair of tunica vaginalis hydrocele (Bottle type)
Scrotum
Incision
55100 Drainage of scrotal wall abscess
(See also 54700)
(For debridement of necrotizing soft tissue infection of
external genitalia, see 11004-11006)
55110 Scrotal exploration
55120 Removal of foreign body in scrotum
Excision
(For excision of local lesion of skin of scrotum, see
Integumentary System)
55150 Resection of scrotum
Repair
55175 Scrotoplasty; simple
55180 complicated
Vas Deferens
Incision
55200 Vasotomy, cannulization with or without incision of vas,
unilateral or bilateral (separate procedure)
Excision
55250 Vasectomy, unilateral or bilateral (separate procedure),
including postoperative semen examination(s)
Introduction
55300 Vasotomy for vasograms, seminal vesiculograms, or
epididymograms, unilateral or bilateral
(When combined with biopsy of testis, see 54505 and use
modifier 51)
Repair
55400 Vasovasostomy, vasovasorrhaphy
➲ CPT Assistant Nov 98:16, Oct 01:8, Jun 04:11

(For operating microscope, use 69990)
Suture
Spermatic Cord
Excision
55500 Excision of hydrocele of spermatic cord, unilateral
55520 Excision of lesion of spermatic cord (separate procedure)

➲ CPT Assistant Sep 00:10, Oct 01:8
55530 Excision of varicocele or ligation of spermatic veins for

varicocele; (separate procedure)

55540 with hernia repair

Laparoscopy
55550 Laparoscopy, surgical, with ligation of spermatic veins for
varicocele
➲ CPT Assistant Nov 99:27, Mar 00:9, Oct 01:8
55559 Unlisted laparoscopy procedure, spermatic cord

Seminal Vesicles
Incision
55600 Vesiculotomy;
55605 complicated
Excision
55650 Vesiculectomy, any approach
55680 Excision of Mullerian duct cyst
(For injection procedure, see 52010, 55300)
Prostate
Incision
55700 Biopsy, prostate; needle or punch, single or multiple, any
approach
➲ CPT Assistant May 96:3, Nov 10:5, Jul 18:11
17:5
77012, 77021)
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
(For transperineal stereotactic template guided saturation
prostate biopsies, use 55706)
55705 incisional, any approach
55706 Biopsies, prostate, needle, transperineal, stereotactic
template guided saturation sampling, including imaging
guidance

55720 Prostatotomy, external drainage of prostatic abscess, any
approach; simple
55725 complicated
(For transurethral drainage, use 52700)
Excision
(For transurethral removal of prostate, see 52601-52640)
(For transurethral destruction of prostate, see 53850-53852)
(For limited pelvic lymphadenectomy for staging [separate
procedure], use 38562)
(For independent node dissection, see 38770-38780)
55801 Prostatectomy, perineal, subtotal (including control of
postoperative bleeding, vasectomy, meatotomy, urethral
calibration and/or dilation, and internal urethrotomy)
➲ CPT Assistant Jun 03:6-7
55810 Prostatectomy, perineal radical;

55812 with lymph node biopsy(s) (limited pelvic

lymphadenectomy)
external iliac, hypogastric and obturator nodes
(If 55815 is carried out on separate days, use 38770 with
modifier 50 and 55810)
55821 Prostatectomy (including control of postoperative bleeding,
vasectomy, meatotomy, urethral calibration and/or dilation,
and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages
55831 retropubic, subtotal

55840 Prostatectomy, retropubic radical, with or without nerve

sparing;

lymphadenectomy)

(If 55845 is carried out on separate days, use 38770 with

modifier 50 and 55840)
(For laparoscopic retropubic radical prostatectomy, use
55866)
55860 Exposure of prostate, any approach, for insertion of
radioactive substance;
(For application of interstitial radioelement, see 77770,
77771, 77772, 77778)
lymphadenectomy)
external iliac, hypogastric and obturator nodes
Laparoscopy
55866 Laparoscopy, surgical prostatectomy, retropubic radical,
including nerve sparing, includes robotic assistance, when
performed
Other Procedures
(For artificial insemination, see 58321, 58322)
55870 Electroejaculation
55873 Cryosurgical ablation of the prostate (includes ultrasonic
guidance and monitoring)
➲ CPT Assistant Apr 01:4, Sep 02:9, Jun 03:8, Feb 10:7,
Sep 15:12, Sep 19:11
55874 Transperineal placement of biodegradable material, peri-
prostatic, single or multiple injection(s), including image

55875 Transperineal placement of needles or catheters into
prostate for interstitial radioelement application, with or
without cystoscopy
(For placement of needles or catheters into pelvic organs
and/or genitalia [except prostate] for interstitial
77771, 77772, 77778)
(For ultrasonic guidance for interstitial radioelement
application, use 76965)
guidance (eg, fiducial markers, dosimeter), prostate (via
needle, any approach), single or multiple
➲ CPT Assistant May 07:1, Oct 07:1, Feb 10:7, 12, Jun
16:3
● 55880 Ablation of malignant prostate tissue, transrectal, with high
intensity–focused ultrasound (HIFU), including ultrasound
guidance
55899 Unlisted procedure, male genital system

➲ CPT Assistant Jun 03:8, May 07:11, Jun 15:5, Jan 17:6,
Jun 19:14, Dec 19:12
Reproductive System Procedures

55920 Placement of needles or catheters into pelvic organs and/or
genitalia (except prostate) for subsequent interstitial
radioelement application
(For placement of needles or catheters into prostate, use
55875)
(For insertion of uterine tandems and/or vaginal ovoids for
clinical brachytherapy, use 57155)
(For insertion of Heyman capsules for clinical
brachytherapy, use 58346)
Intersex Surgery
55970 Intersex surgery; male to female
55980 female to male
Notes

Surgery
Female Genital System (56405-58999)
Female Genital System section of the CPT codebook. The subheadings or
Vulva, Perineum, and Introitus* (56405-56821)

Incision (56405-56442)
Excision (56605-56740)
Repair (56800-56810)
Endoscopy (56820-56821)
Vagina (57000-57426)
Incision (57000-57023)
Excision (57100-57135)
Repair (57200-57335)
Endoscopy/Laparoscopy (57420-57426)
Cervix Uteri (57452-57800)
Endoscopy (57452-57465)
Excision (57500-57558)
Repair (57700-57720)
Corpus Uteri (58100-58579)
Excision (58100-58294)
Hysterectomy Procedures (58150-58294)
Repair (58400-58540)
Laparoscopy/Hysteroscopy* (58541-58579, 58674)
Oviduct/Ovary (58600-58770)
Incision (58600-58615)
Laparoscopy* (58660-58673, 58679)
Excision (58700-58720)
Repair (58740-58770)
Ovary (58800-58960)
Incision (58800-58825)
Excision (58900-58960)
In Vitro Fertilization (58970-58999)
Maternity Care and Delivery* (59000-59899)
Antepartum and Fetal Invasive Services (59000-59076)
Excision (59100-59160)
Repair (59300-59350)
Vaginal Delivery, Antepartum and Postpartum Care (59400-
59430)
Cesarean Delivery (59510-59525)
Delivery After Previous Cesarean Delivery* (59610-59622)
Abortion (59812-59857)
Endocrine System (60000-60699)
Thyroid Gland (60000-60300)
Incision (60000)
Excision (60100-60281)
Removal (60300)
Parathyroid, Thymus, Adrenal Glands, Pancreas, and
Carotid Body (60500-60699)
Excision (60500-60605)
(For pelvic laparotomy, use 49000)
(For excision or destruction of endometriomas, open
method, see 49203-49205, 58957, 58958)
(For paracentesis, see 49082, 49083, 49084)
(For secondary closure of abdominal wall evisceration or
disruption, use 49900)
(For fulguration or excision of lesions, laparoscopic
approach, use 58662)
(For chemotherapy, see 96401-96549)
Vulva, Perineum, and Introitus

Definitions
The following definitions apply to the vulvectomy codes (56620-
56640):
A simple procedure is the removal of skin and superficial
subcutaneous tissues.
A radical procedure is the removal of skin and deep
subcutaneous tissue.
A partial procedure is the removal of less than 80% of the vulvar
area.
A complete procedure is the removal of greater than 80% of the
vulvar area.
Incision
(For incision and drainage of sebaceous cyst, furuncle, or
abscess, see 10040, 10060, 10061)
56405 Incision and drainage of vulva or perineal abscess
56420 Incision and drainage of Bartholin’s gland abscess

(For incision and drainage of Skene’s gland abscess or cyst,
use 53060)
56440 Marsupialization of Bartholin’s gland cyst
56441 Lysis of labial adhesions
56442 Hymenotomy, simple incision

Destruction
56501 Destruction of lesion(s), vulva; simple (eg, laser surgery,
electrosurgery, cryosurgery, chemosurgery)
56515 extensive (eg, laser surgery, electrosurgery, cryosurgery,

chemosurgery)
(For destruction of Skene’s gland cyst or abscess, use

53270)
(For cautery destruction of urethral caruncle, use 53265)
Excision
56605 Biopsy of vulva or perineum (separate procedure); 1 lesion
➲ CPT Assistant Sep 00:9, Jun 08:6
✚ 56606 each separate additional lesion (List separately in

(For excision of local lesion, see 11420-11426, 11620-
11626)
56620 Vulvectomy simple; partial
56625 complete
(For skin graft, see 15002 et seq)
56630 Vulvectomy, radical, partial;
(For skin graft, if used, see 15004-15005, 15120, 15121,
15240, 15241)
56631 with unilateral inguinofemoral lymphadenectomy
56632 with bilateral inguinofemoral lymphadenectomy
(For partial radical vulvectomy with inguinofemoral lymph
node biopsy without complete inguinofemoral
lymphadenectomy, use 56630 in conjunction with 38531)
56633 Vulvectomy, radical, complete;
56634 with unilateral inguinofemoral lymphadenectomy
56637 with bilateral inguinofemoral lymphadenectomy
(For complete radical vulvectomy with inguinofemoral
lymph node biopsy without complete inguinofemoral
lymphadenectomy, use 56633 in conjunction with 38531)
56640 Vulvectomy, radical, complete, with inguinofemoral, iliac,
and pelvic lymphadenectomy
(For lymphadenectomy, see 38760-38780)
56700 Partial hymenectomy or revision of hymenal ring
56740 Excision of Bartholin’s gland or cyst
(For excision of Skene’s gland, use 53270)
(For excision of urethral caruncle, use 53265)
(For excision or fulguration of urethral carcinoma, use
53220)
(For excision or marsupialization of urethral diverticulum,
see 53230, 53240)
Repair
(For repair of urethra for mucosal prolapse, use 53275)
56800 Plastic repair of introitus
56805 Clitoroplasty for intersex state
56810 Perineoplasty, repair of perineum, nonobstetrical (separate
procedure)
(See also 56800)
(For repair of wounds to genitalia, see 12001-12007,
12041-12047, 13131-13133)
(For repair of recent injury of vagina and perineum,
nonobstetrical, use 57210)
(For anal sphincteroplasty, see 46750, 46751)
(For episiorrhaphy, episioperineorrhaphy for recent injury
of vulva and/or perineum, nonobstetrical, use 57210)
Endoscopy
56820 Colposcopy of the vulva;
56821 with biopsy(s)
(For colposcopic examinations/procedures involving the

vagina, see 57420, 57421; cervix, see 57452-57461)
Vagina
Incision
57000 Colpotomy; with exploration
57010 with drainage of pelvic abscess

57020 Colpocentesis (separate procedure)
57022 Incision and drainage of vaginal hematoma;
obstetrical/postpartum
57023 non-obstetrical (eg, post-trauma, spontaneous bleeding)

Destruction
57061 Destruction of vaginal lesion(s); simple (eg, laser surgery,
electrosurgery, cryosurgery, chemosurgery)
57065 extensive (eg, laser surgery, electrosurgery, cryosurgery,

chemosurgery)
Excision
57100 Biopsy of vaginal mucosa; simple (separate procedure)
57105 extensive, requiring suture (including cysts)
57106 Vaginectomy, partial removal of vaginal wall;
Vaginectomy, Partial Removal of Vaginal Wall

57106
A specific portion of the upper or lower vaginal wall is excised.
57107 with removal of paravaginal tissue (radical

vaginectomy)

vaginectomy) with bilateral total pelvic
lymphadenectomy and para-aortic lymph node sampling
(biopsy)
57110 Vaginectomy, complete removal of vaginal wall;


vaginectomy)
Vaginectomy, Complete Removal of Vaginal Wall (Radical

Vaginectomy)
57111
Removal of all of the vaginal wall and removal of paravaginal tissue (the highly vascular supporting
connective tissue next to the vagina)

57120 Colpocleisis (Le Fort type)
57130 Excision of vaginal septum
57135 Excision of vaginal cyst or tumor
Introduction
57150 Irrigation of vagina and/or application of medicament for
treatment of bacterial, parasitic, or fungoid disease
57155 Insertion of uterine tandem and/or vaginal ovoids for
clinical brachytherapy

(For insertion of radioelement sources or ribbons, see
77761-77763, 77770, 77771, 77772)
57156 Insertion of a vaginal radiation afterloading apparatus for
clinical brachytherapy
57160 Fitting and insertion of pessary or other intravaginal support

device
➲ CPT Assistant Nov 96:9, Oct 98:11, Jun 00:11, May
10:10
57170 Diaphragm or cervical cap fitting with instructions
57180 Introduction of any hemostatic agent or pack for spontaneous
or traumatic nonobstetrical vaginal hemorrhage (separate
procedure)
Repair
(For urethral suspension, Marshall-Marchetti-Krantz type,
abdominal approach, see 51840, 51841)
(For laparoscopic suspension, use 51990)
57200 Colporrhaphy, suture of injury of vagina (nonobstetrical)
57210 Colpoperineorrhaphy, suture of injury of vagina and/or
perineum (nonobstetrical)
57220 Plastic operation on urethral sphincter, vaginal approach
(eg, Kelly urethral plication)
57230 Plastic repair of urethrocele

57240 Anterior colporrhaphy, repair of cystocele with or without

repair of urethrocele, including cystourethroscopy, when
performed
➲ CPT Assistant Winter 90:7, Jan 97:3, Jun 02:5, Jun 10:6

57250 Posterior colporrhaphy, repair of rectocele with or without
perineorrhaphy
➲ CPT Assistant Winter 90:7, Jun 02:4, May 11:9
(For repair of rectocele [separate procedure] without

posterior colporrhaphy, use 45560)
57260 Combined anteroposterior colporrhaphy, including
cystourethroscopy, when performed;
➲ CPT Assistant Jun 02:5, Jun 10:6

57265 with enterocele repair

✚ 57267 Insertion of mesh or other prosthesis for repair of pelvic
floor defect, each site (anterior, posterior compartment),
vaginal approach (List separately in addition to code for
primary procedure)
➲ CPT Assistant Jul 05:16, May 11:9, Jan 12:10, Oct
13:15
57285)
57268 Repair of enterocele, vaginal approach (separate procedure)
57270 Repair of enterocele, abdominal approach (separate

procedure)
57280 Colpopexy, abdominal approach

57282 Colpopexy, vaginal; extra-peritoneal approach

(sacrospinous, iliococcygeus)
57283 intra-peritoneal approach (uterosacral, levator

myorrhaphy)

58270, 58280, 58292, 58294)
57284 Paravaginal defect repair (including repair of cystocele, if
performed); open abdominal approach
➲ CPT Assistant Jan 97:1, Jun 02:7, Jul 05:16, Jun 10:6
51990, 57240, 57260, 57265, 58152, 58267)
57285 vaginal approach

57260, 57265, 58267)
57287 Removal or revision of sling for stress incontinence (eg,
fascia or synthetic)
57288 Sling operation for stress incontinence (eg, fascia or

synthetic)
➲ CPT Assistant Nov 99:28, May 00:4, Oct 00:7, Apr
02:18, Jun 02:7
57289 Pereyra procedure, including anterior colporrhaphy
57291 Construction of artificial vagina; without graft

57292 with graft
57295 Revision (including removal) of prosthetic vaginal graft;
vaginal approach
57296 open abdominal approach


57300 Closure of rectovaginal fistula; vaginal or transanal
approach
57307 abdominal approach, with concomitant colostomy

57308 transperineal approach, with perineal body

reconstruction, with or without levator plication
57310 Closure of urethrovaginal fistula;

57311 with bulbocavernosus transplant
57320 Closure of vesicovaginal fistula; vaginal approach
(For concomitant cystostomy, see 51020-51040, 51101,
51102)
57330 transvesical and vaginal approach
(For abdominal approach, use 51900)
57335 Vaginoplasty for intersex state
Manipulation
57400 Dilation of vagina under anesthesia (other than local)
57410 Pelvic examination under anesthesia (other than local)

➲ CPT Assistant Spring 93:34, Apr 06:1, Nov 07:1
57415 Removal of impacted vaginal foreign body (separate

procedure) under anesthesia (other than local)
(For removal without anesthesia of an impacted vaginal

foreign body, use the appropriate E/M code)
Endoscopy/Laparoscopy
57420 Colposcopy of the entire vagina, with cervix if present;
57421 with biopsy(s) of vagina/cervix

➲ CPT Assistant Feb 03:5, Jun 03:11, Jun 06:16
(For colposcopic visualization of cervix and adjacent upper

vagina, use 57452)
(When reporting colposcopies of multiple sites, use
modifier 51 as appropriate. For colposcopic
examinations/procedures involving the vulva, see 56820,
56821; cervix, see 57452-57461)
▶ (Forcomputer-aided mapping of cervix uteri during
colposcopy, use 57465)◀
(For endometrial sampling [biopsy] performed in
conjunction with colposcopy, use 58110)
57423 Paravaginal defect repair (including repair of cystocele, if
performed), laparoscopic approach

51841, 51990, 57240, 57260, 58152, 58267)
57425 Laparoscopy, surgical, colpopexy (suspension of vaginal
apex)
57426 Revision (including removal) of prosthetic vaginal graft,

laparoscopic approach
(For vaginal approach, see 57295. For open abdominal
approach, see 57296)
Laparoscopic Revision of Prosthetic Vaginal Graft

57426
Location of prosthetic vaginal graft
Cervix Uteri
Endoscopy
(For colposcopic examinations/procedures involving the
vulva, see 56820, 56821; vagina, see 57420, 57421)
57452 Colposcopy of the cervix including upper/adjacent vagina;
➲ CPT Assistant Apr 00:5, Feb 03:5, Jun 03:10, Jul 19:6
(Do not report 57452 in addition to 57454-57461)
57454 with biopsy(s) of the cervix and endocervical curettage
➲ CPT Assistant Apr 00:5, Feb 03:5, Jun 03:10, Aug
11:9, Jul 19:6
57455 with biopsy(s) of the cervix
➲ CPT Assistant Apr 00:5, Feb 03:5, Jun 03:10, Jul
19:6
57456 with endocervical curettage
➲ CPT Assistant Apr 00:5, Jan 03:23, Feb 03:5, Jun
03:10, Jul 19:6
57460 with loop electrode biopsy(s) of the cervix
➲ CPT Assistant Apr 00:5, Jan 03:23, Feb 03:5, Jun
03:10, Jul 05:15, Jul 19:6
57461 with loop electrode conization of the cervix
➲ CPT Assistant Jan 03:23, Feb 03:5, Jun 03:10, Dec
06:15, Jul 19:6
▶ (Forcomputer-aided mapping of cervix uteri during
colposcopy, use 57465)◀
conjunction with colposcopy, use 58110)
✚● 57465 Computer-aided mapping of cervix uteri during colposcopy,
including optical dynamic spectral imaging and algorithmic
quantification of the acetowhitening effect (List separately in
57454, 57455, 57456, 57460, 57461)◀
Excision
(For radical surgical procedures, see 58200-58240)
57500 Biopsy of cervix, single or multiple, or local excision of
lesion, with or without fulguration (separate procedure)
57505 Endocervical curettage (not done as part of a dilation and

curettage)
57510 Cautery of cervix; electro or thermal

57511 cryocautery, initial or repeat

57513 laser ablation
57520 Conization of cervix, with or without fulguration, with or
without dilation and curettage, with or without repair; cold
knife or laser
(See also 58120)

57522 loop electrode excision
➲ CPT Assistant Apr 00:5, Mar 03:22, Jul 03:15
57530 Trachelectomy (cervicectomy), amputation of cervix

57531 Radical trachelectomy, with bilateral total pelvic
biopsy, with or without removal of tube(s), with or without
removal of ovary(s)
(For radical abdominal hysterectomy, use 58210)
57540 Excision of cervical stump, abdominal approach;
57545 with pelvic floor repair
57550 Excision of cervical stump, vaginal approach;
57555 with anterior and/or posterior repair
57556 with repair of enterocele
(For insertion of intrauterine device, use 58300)
(For insertion of any hemostatic agent or pack for control of
spontaneous non-obstetrical hemorrhage, see 57180)
57558 Dilation and curettage of cervical stump
Repair
57700 Cerclage of uterine cervix, nonobstetrical
57720 Trachelorrhaphy, plastic repair of uterine cervix, vaginal
approach
Manipulation
57800 Dilation of cervical canal, instrumental (separate
procedure)
Corpus Uteri
Excision
58100 Endometrial sampling (biopsy) with or without
endocervical sampling (biopsy), without cervical dilation,
any method (separate procedure)
(For endocervical curettage only, use 57505)
conjunction with colposcopy [57420, 57421, 57452-57461],
use 58110)
✚ 58110 Endometrial sampling (biopsy) performed in conjunction
with colposcopy (List separately in addition to code for
primary procedure)

57461)
58120 Dilation and curettage, diagnostic and/or therapeutic
(nonobstetrical)
➲ CPT Assistant Fall 95:16, Nov 97:21, May 03:19
(For postpartum hemorrhage, use 59160)

58140 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4
intramural myoma(s) with total weight of 250 g or less
and/or removal of surface myomas; abdominal approach
58145 vaginal approach

58146 Myomectomy, excision of fibroid tumor(s) of uterus, 5 or
more intramural myomas and/or intramural myomas with
total weight greater than 250 g, abdominal approach
(Do not report 58146 in addition to 58140-58145, 58150-

58240)
Hysterectomy Procedures
58150 Total abdominal hysterectomy (corpus and cervix), with or
without removal of tube(s), with or without removal of
ovary(s);
➲ CPT Assistant Dec 96:10, Apr 97:3, Nov 97:21, Sep
00:9, Aug 01:11
58152 with colpo-urethrocystopexy (eg, Marshall-Marchetti-
Krantz, Burch)
➲ CPT Assistant Jan 97:1, Nov 97:22, Jun 10:6
(For urethrocystopexy without hysterectomy, see 51840,

51841)
58180 Supracervical abdominal hysterectomy (subtotal
hysterectomy), with or without removal of tube(s), with or
without removal of ovary(s)
58200 Total abdominal hysterectomy, including partial
vaginectomy, with para-aortic and pelvic lymph node
sampling, with or without removal of tube(s), with or
58210 Radical abdominal hysterectomy, with bilateral total pelvic
(biopsy), with or without removal of tube(s), with or
➲ CPT Assistant Fall 92:21, May 12:14
(For radical hysterectomy with ovarian transposition, use

also 58825)
58240 Pelvic exenteration for gynecologic malignancy, with total
abdominal hysterectomy or cervicectomy, with or without
removal of tube(s), with or without removal of ovary(s),
with removal of bladder and ureteral transplantations,
and/or abdominoperineal resection of rectum and colon and
colostomy, or any combination thereof
(For pelvic exenteration for lower urinary tract or male
genital malignancy, use 51597)
58260 Vaginal hysterectomy, for uterus 250 g or less;
58262 with removal of tube(s), and/or ovary(s)

58263 with removal of tube(s), and/or ovary(s), with repair of
enterocele
58267 with colpo-urethrocystopexy (Marshall-Marchetti-Krantz
type, Pereyra type) with or without endoscopic control

(For repair of enterocele with removal of tubes and/or
ovaries, use 58263)
58275 Vaginal hysterectomy, with total or partial vaginectomy;

58285 Vaginal hysterectomy, radical (Schauta type operation)
58290 Vaginal hysterectomy, for uterus greater than 250 g;

58291 with removal of tube(s) and/or ovary(s)

58292 with removal of tube(s) and/or ovary(s), with repair of

enterocele

Introduction
(To report insertion of non-biodegradable drug delivery
implant for contraception, use 11981. To report removal of
implantable contraceptive capsules with subsequent
insertion of non-biodegradable drug delivery implant, use
11976 and 11981)
58300 Insertion of intrauterine device (IUD)
58301 Removal of intrauterine device (IUD)

58321 Artificial insemination; intra-cervical

58322 intra-uterine
58323 Sperm washing for artificial insemination
58340 Catheterization and introduction of saline or contrast

material for saline infusion sonohysterography (SIS) or
hysterosalpingography
(For radiological supervision and interpretation of saline

infusion sonohysterography, use 76831)
(For radiological supervision and interpretation of
hysterosalpingography, use 74740)
58345 Transcervical introduction of fallopian tube catheter for
diagnosis and/or re-establishing patency (any method), with
or without hysterosalpingography

58346 Insertion of Heyman capsules for clinical brachytherapy
(For insertion of radioelement sources or ribbons, see
77761-77763, 77770, 77771, 77772)
58350 Chromotubation of oviduct, including materials
(To report the supply of any materials, use 99070)

58353 Endometrial ablation, thermal, without hysteroscopic
guidance
(For hysteroscopic procedure, use 58563)

58356 Endometrial cryoablation with ultrasonic guidance,
including endometrial curettage, when performed

58340, 76700, 76856)
Repair
58400 Uterine suspension, with or without shortening of round
ligaments, with or without shortening of sacrouterine
ligaments; (separate procedure)
58410 with presacral sympathectomy
(For anastomosis of tubes to uterus, use 58752)

58520 Hysterorrhaphy, repair of ruptured uterus (nonobstetrical)
58540 Hysteroplasty, repair of uterine anomaly (Strassman type)
(For closure of vesicouterine fistula, use 51920)
Laparoscopy/Hysteroscopy
procedure), use 49320. To report a diagnostic hysteroscopy
(separate procedure), use 58555.
# 58674 Laparoscopy, surgical, ablation of uterine fibroid(s)
including intraoperative ultrasound guidance and
monitoring, radiofrequency

58554, 58570, 58571, 58572, 58573, 76998)
58541 Laparoscopy, surgical, supracervical hysterectomy, for
uterus 250 g or less;


57000, 57180, 57410, 58140-58146, 58545, 58546, 58561,
58661, 58670, 58671)
58543 Laparoscopy, surgical, supracervical hysterectomy, for
uterus greater than 250 g;

57000, 57180, 57410, 58140-58146, 58545, 58546, 58561,
58661, 58670, 58671)
58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4
intramural myomas with total weight of 250 g or less and/or
removal of surface myomas
➲ CPT Assistant Jun 03:5, 12, Jul 19:6
58546 5 or more intramural myomas and/or intramural myomas

with total weight greater than 250 g
➲ CPT Assistant Jun 03:12, Jan 04:26, Apr 17:7, Jul
19:6
58548 Laparoscopy, surgical, with radical hysterectomy, with
bilateral total pelvic lymphadenectomy and para-aortic
lymph node sampling (biopsy), with removal of tube(s) and
ovary(s), if performed
➲ CPT Assistant Nov 07:1, Sep 15:12, Apr 17:7, Mar
19:5, Jul 19:6
58210, 58285, 58550-58554)
58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus
250 g or less;
➲ CPT Assistant Nov 99:28, Mar 00:9, Apr 17:7, Jul 19:6

57000, 57180, 57410, 58140-58146, 58545, 58546, 58561,
58661, 58670, 58671)
58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus
greater than 250 g;


57000, 57180, 57410, 58140-58146, 58545, 58546, 58561,
58661, 58670, 58671)
58555 Hysteroscopy, diagnostic (separate procedure)
58558 Hysteroscopy, surgical; with sampling (biopsy) of

endometrium and/or polypectomy, with or without D & C
➲ CPT Assistant Nov 99:28, Mar 00:10, Sep 02:10, Jan
03:7, May 03:19
58559 with lysis of intrauterine adhesions (any method)
58560 with division or resection of intrauterine septum (any

method)
58561 with removal of leiomyomata

➲ CPT Assistant Nov 99:28, Mar 00:10, Jan 03:7
58562 with removal of impacted foreign body
58563 with endometrial ablation (eg, endometrial resection,

electrosurgical ablation, thermoablation)
➲ CPT Assistant Nov 99:28, Mar 00:10, Mar 02:11,
Apr 02:19, Jan 03:7, Feb 12:11, Jan 15:14
58565 with bilateral fallopian tube cannulation to induce
occlusion by placement of permanent implants

(For unilateral procedure, use modifier 52)
58570 Laparoscopy, surgical, with total hysterectomy, for uterus
250 g or less;

➲ CPT Assistant May 12:14, Aug 12:13, Apr 17:7, Feb
18:11, Jul 19:6
58572 Laparoscopy, surgical, with total hysterectomy, for uterus
greater than 250 g;

➲ CPT Assistant May 12:14, Aug 12:13, Apr 17:7, Feb
18:11, Apr 18:11, Mar 19:5, Jul 19:6
57000, 57180, 57410, 58140-58146, 58150, 58545, 58546,
58561, 58661, 58670, 58671)
Hysteroscopy
58563
58575 Laparoscopy, surgical, total hysterectomy for resection of

malignancy (tumor debulking), with omentectomy including
salpingo-oophorectomy, unilateral or bilateral, when
performed
➲ CPT Assistant Mar 19:5, Jul 19:6, Mar 20:14

49321, 58570, 58571, 58572, 58573, 58661)
58578 Unlisted laparoscopy procedure, uterus
➲ CPT Assistant Nov 99:28, Mar 00:10, Mar 07:9
58579 Unlisted hysteroscopy procedure, uterus

Oviduct/Ovary
Incision
58600 Ligation or transection of fallopian tube(s), abdominal or
vaginal approach, unilateral or bilateral
58605 Ligation or transection of fallopian tube(s), abdominal or

vaginal approach, postpartum, unilateral or bilateral, during
same hospitalization (separate procedure)
(For laparoscopic procedures, use 58670, 58671)

✚ 58611 Ligation or transection of fallopian tube(s) when done at the
time of cesarean delivery or intra-abdominal surgery (not a
separate procedure) (List separately in addition to code for
primary procedure)
58615 Occlusion of fallopian tube(s) by device (eg, band, clip,
Falope ring) vaginal or suprapubic approach

(For lysis of adnexal adhesions, use 58740)
Laparoscopy
58660 Laparoscopy, surgical; with lysis of adhesions
(salpingolysis, ovariolysis) (separate procedure)
➲ CPT Assistant Nov 99:28, Mar 00:10, Mar 03:22, Dec
11:16, Jul 19:6
58661 with removal of adnexal structures (partial or total
oophorectomy and/or salpingectomy)
➲ CPT Assistant Nov 99:28, Mar 00:10, Jan 02:11,
Nov 07:1, May 10:10, Jul 19:6, Jan 20:12
58662 with fulguration or excision of lesions of the ovary,
pelvic viscera, or peritoneal surface by any method
➲ CPT Assistant Nov 99:28, Mar 00:10, Dec 17:14, Jul
19:6
58670 with fulguration of oviducts (with or without transection)
➲ CPT Assistant Nov 99:29, Mar 00:10, Nov 07:2, Jul
19:6
58671 with occlusion of oviducts by device (eg, band, clip, or
Falope ring)
58672 with fimbrioplasty

58673 with salpingostomy (salpingoneostomy)

➲ CPT Assistant Nov 99:29, Mar 00:10, May 02:19,
Jul 19:6
(Codes 58672 and 58673 are used to report unilateral
procedures. For bilateral procedure, use modifier 50)
58679 Unlisted laparoscopy procedure, oviduct, ovary
(For laparoscopic aspiration of ovarian cyst, use 49322)

(For laparoscopic biopsy of the ovary or fallopian tube, use
49321)
Excision
58700 Salpingectomy, complete or partial, unilateral or bilateral
58720 Salpingo-oophorectomy, complete or partial, unilateral or

bilateral (separate procedure)
Repair
58740 Lysis of adhesions (salpingolysis, ovariolysis)

(For excision or destruction of endometriomas, open
method, see 49203-49205, 58957, 58958)
(For fulguration or excision of lesions, laparoscopic
58750 Tubotubal anastomosis
58752 Tubouterine implantation
58760 Fimbrioplasty

58770 Salpingostomy (salpingoneostomy)
Ovary
Incision
58800 Drainage of ovarian cyst(s), unilateral or bilateral (separate
procedure); vaginal approach
58820 Drainage of ovarian abscess; vaginal approach, open

(For transrectal image-guided fluid collection drainage by

catheter of pelvic abscess, use 49407)
58825 Transposition, ovary(s)
Excision
58900 Biopsy of ovary, unilateral or bilateral (separate procedure)
(For laparoscopic biopsy of the ovary or fallopian tube, use

49321)
58920 Wedge resection or bisection of ovary, unilateral or bilateral
58925 Ovarian cystectomy, unilateral or bilateral
58940 Oophorectomy, partial or total, unilateral or bilateral;
(For oophorectomy with concomitant debulking for ovarian

malignancy, use 58952)
58943 for ovarian, tubal or primary peritoneal malignancy, with
para-aortic and pelvic lymph node biopsies, peritoneal
washings, peritoneal biopsies, diaphragmatic
assessments, with or without salpingectomy(s), with or
without omentectomy
58950 Resection (initial) of ovarian, tubal or primary peritoneal

malignancy with bilateral salpingo-oophorectomy and
omentectomy;
58951 with total abdominal hysterectomy, pelvic and limited

para-aortic lymphadenectomy
➲ CPT Assistant Aug 01:11, Oct 10:16, Dec 10:16
58952 with radical dissection for debulking (ie, radical

excision or destruction, intra-abdominal or
retroperitoneal tumors)
➲ CPT Assistant Dec 96:10, Aug 01:11, Oct 10:16, Dec
10:16
(For resection of recurrent ovarian, tubal, primary
peritoneal, or uterine malignancy, see 58957, 58958)
58953 Bilateral salpingo-oophorectomy with omentectomy, total
abdominal hysterectomy and radical dissection for
debulking;
➲ CPT Assistant Feb 02:8, Oct 10:16, Dec 10:16, May
14:10
58954 with pelvic lymphadenectomy and limited para-aortic
lymphadenectomy
➲ CPT Assistant Feb 02:9, Oct 10:16, Dec 10:16
58956 Bilateral salpingo-oophorectomy with total omentectomy,

total abdominal hysterectomy for malignancy

58180, 58262, 58263, 58550, 58661, 58700, 58720, 58900,
58925, 58940, 58957, 58958)
58957 Resection (tumor debulking) of recurrent ovarian, tubal,
primary peritoneal, uterine malignancy (intra-abdominal,
retroperitoneal tumors), with omentectomy, if performed;
58958 with pelvic lymphadenectomy and limited para-aortic

lymphadenectomy

38780, 44005, 49000, 49203-49215, 49255, 58900-58960)
58960 Laparotomy, for staging or restaging of ovarian, tubal, or
primary peritoneal malignancy (second look), with or
without omentectomy, peritoneal washing, biopsy of
abdominal and pelvic peritoneum, diaphragmatic assessment
with pelvic and limited para-aortic lymphadenectomy
In Vitro Fertilization
58970 Follicle puncture for oocyte retrieval, any method
58974 Embryo transfer, intrauterine
58976 Gamete, zygote, or embryo intrafallopian transfer, any
method
(For laparoscopic adnexal procedures, see 58660-58673)
Other Procedures
58999 Unlisted procedure, female genital system (nonobstetrical)
➲ CPT Assistant Apr 09:9, 10, Jul 19:6
▶The services normally provided in uncomplicated maternity
cases include antepartum care, delivery, and postpartum care.
Pregnancy confirmation during a problem oriented or preventive
visit is not considered a part of antepartum care and should be
reported using the appropriate E/M service codes 99202, 99203,
99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242,
99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99384,
99385, 99386, 99394, 99395, 99396 for that visit.◀
Antepartum care includes the initial prenatal history and physical
examination; subsequent prenatal history and physical
examinations; recording of weight, blood pressures, fetal heart
tones, routine chemical urinalysis, and monthly visits up to 28
weeks gestation; biweekly visits to 36 weeks gestation; and
weekly visits until delivery. Any other visits or services within
this time period should be coded separately.
Delivery services include admission to the hospital, the admission
history and physical examination, management of uncomplicated
labor, vaginal delivery (with or without episiotomy, with or
without forceps), or cesarean delivery. When reporting delivery
only services (59409, 59514, 59612, 59620), report inpatient
postdelivery management and discharge services using
Evaluation and Management Services codes (99217-99239).
Delivery and postpartum services (59410, 59515, 59614, 59622)
include delivery services and all inpatient and outpatient
postpartum services. Medical complications of pregnancy (eg,
cardiac problems, neurological problems, diabetes, hypertension,
toxemia, hyperemesis, preterm labor, premature rupture of
membranes, trauma) and medical problems complicating labor
and delivery management may require additional resources and
may be reported separately.
Postpartum care only services (59430) include office or other
outpatient visits following vaginal or cesarean section delivery.
For surgical complications of pregnancy (eg, appendectomy,
hernia, ovarian cyst, Bartholin cyst), see services in the Surgery
section.
If all or part of the antepartum and/or postpartum patient care is
provided except delivery due to termination of pregnancy by
abortion or referral to another physician or other qualified health
care professional for delivery, see the antepartum and postpartum
care codes 59425, 59426, and 59430.
(For circumcision of newborn, see 54150, 54160)
Antepartum and Fetal Invasive Services

(For fetal intrauterine transfusion, use 36460)
(For unlisted fetal invasive procedure, use 59897)
59000 Amniocentesis; diagnostic
➲ CPT Assistant Apr 97:2, Feb 02:7, Aug 02:2, May 04:2,
Jul 19:6
59001 therapeutic amniotic fluid reduction (includes ultrasound
guidance)
➲ CPT Assistant Feb 02:7, Aug 02:2
Amniocentesis, Therapeutic Amniotic Fluid Reduction

59001
59012 Cordocentesis (intrauterine), any method

59015 Chorionic villus sampling, any method

59020 Fetal contraction stress test
59025 Fetal non-stress test

➲ CPT Assistant Apr 97:2, May 98:10, Oct 04:10, Dec
08:8
59030 Fetal scalp blood sampling
(For repeat fetal scalp blood sampling, use 59030 and see
modifiers 76 and 77)
59050 Fetal monitoring during labor by consulting physician (ie,
non-attending physician) with written report; supervision
and interpretation
59051 interpretation only

59070 Transabdominal amnioinfusion, including ultrasound

guidance
59072 Fetal umbilical cord occlusion, including ultrasound

guidance
59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis,

paracentesis), including ultrasound guidance
➲ CPT Assistant May 04:2, 4, Jun 04:11, Dec 04:19
59076 Fetal shunt placement, including ultrasound guidance

➲ CPT Assistant May 04:2, 4, Jun 04:11, Dec 04:19
Excision
59100 Hysterotomy, abdominal (eg, for hydatidiform mole,
abortion)
(When tubal ligation is performed at the same time as
hysterotomy, use 58611 in addition to 59100)
59120 Surgical treatment of ectopic pregnancy; tubal or ovarian,
requiring salpingectomy and/or oophorectomy, abdominal or
vaginal approach
59121 tubal or ovarian, without salpingectomy and/or
oophorectomy
59130 abdominal pregnancy
59135 interstitial, uterine pregnancy requiring total
hysterectomy
59136 interstitial, uterine pregnancy with partial resection of
uterus
59140 cervical, with evacuation
59150 Laparoscopic treatment of ectopic pregnancy; without
salpingectomy and/or oophorectomy
Laparoscopic Treatment of Ectopic Pregnancy

59150
The site of gestation is located with a laparoscope, and a small incision is made above the site. The
ectopic pregnancy is then removed.
59151 with salpingectomy and/or oophorectomy

59160 Curettage, postpartum
Introduction
(For intrauterine fetal transfusion, use 36460)
(For introduction of hypertonic solution and/or
prostaglandins to initiate labor, see 59850-59857)
59200 Insertion of cervical dilator (eg, laminaria, prostaglandin)
➲ CPT Assistant Fall 93:9, Apr 97:3, Jul 05:15, Dec 17:14
Repair
(For tracheloplasty, use 57700)
59300 Episiotomy or vaginal repair, by other than attending
59320 Cerclage of cervix, during pregnancy; vaginal

➲ CPT Assistant Aug 02:2, Nov 06:21, Feb 07:10
59325 abdominal
➲ CPT Assistant Aug 02:2, Nov 06:21, Feb 07:10
59350 Hysterorrhaphy of ruptured uterus

Vaginal Delivery, Antepartum and

Postpartum Care
Coding Tip
Instructions for Reporting Antepartum and Postpartum Care
The services normally provided in uncomplicated maternity cases include

antepartum care, delivery, and postpartum care.
CPT Coding Guidelines, Maternity Care and Delivery
59400 Routine obstetric care including antepartum care, vaginal

delivery (with or without episiotomy, and/or forceps) and
postpartum care
➲ CPT Assistant Feb 96:1, Mar 96:11, Feb 97:11, Apr
97:3, Apr 98:15, Jun 98:10, Aug 02:3, Feb 03:15
Vaginal Delivery
59400-59410
59409 Vaginal delivery only (with or without episiotomy and/or

forceps);
➲ CPT Assistant Feb 96:1, Mar 96:11, Jul 96:11, Sep 96:4,
Feb 97:11, Apr 97:1, Aug 02:3, Dec 07:13, Jun 09:10
59410 including postpartum care
59412 External cephalic version, with or without tocolysis
➲ CPT Assistant Fall 94:21, Feb 96:1, Aug 02:2-3
(Use 59412 in addition to code[s] for delivery)

59414 Delivery of placenta (separate procedure)
➲ CPT Assistant Jun 96:10, Jun 98:10, Aug 02:3
(For antepartum care only, see 59425, 59426 or appropriate

E/M code[s])
(For 1-3 antepartum care visits, see appropriate E/M
code[s])
59425 Antepartum care only; 4-6 visits
➲ CPT Assistant Fall 94:21, Apr 97:11, Aug 02:3
59426 7 or more visits

➲ CPT Assistant Fall 94:21, Apr 97:11, Aug 02:3
59430 Postpartum care only (separate procedure)

Cesarean Delivery
(For standby attendance for infant, use 99360)
(For low cervical cesarean section, see 59510, 59515,
59525)
Coding Tip
Instructions for Reporting Cesarean Delivery
Patients who have had a previous cesarean delivery and now present with
the expectation of a vaginal delivery are coded using codes 59610-59622. If
the patient has a successful vaginal delivery after a previous cesarean
delivery (VBAC), use codes 59610-59614. If the attempt is unsuccessful and
another cesarean delivery is carried out, use codes 59618-59622. To report
elective cesarean deliveries, use code 59510, 59514 or 59515.
CPT Coding Guidelines, Maternity Care and Delivery, Delivery After

Previous Cesarean Delivery
59510 Routine obstetric care including antepartum care, cesarean
delivery, and postpartum care
➲ CPT Assistant Jul 96:11, Sep 96:4, Oct 96:10, Feb
97:11, Apr 97:2, Aug 02:3, Mar 13:13
59514 Cesarean delivery only;
➲ CPT Assistant Oct 96:10, Feb 97:11, Mar 13:13

(For classic cesarean section, see 59510, 59515, 59525)

✚ 59525 Subtotal or total hysterectomy after cesarean delivery (List
59618, 59620, 59622)
(For extraperitoneal cesarean section, or cesarean section
with subtotal or total hysterectomy, see 59510, 59515,
59525)
Cesarean Delivery
59510-59515
Delivery After Previous Cesarean Delivery
Patients who have had a previous cesarean delivery and now
present with the expectation of a vaginal delivery are coded using
codes 59610-59622. If the patient has a successful vaginal
delivery after a previous cesarean delivery (VBAC), use codes
59610-59614. If the attempt is unsuccessful and another cesarean
delivery is carried out, use codes 59618-59622. To report elective
cesarean deliveries use code 59510, 59514 or 59515.
59610 Routine obstetric care including antepartum care, vaginal
delivery (with or without episiotomy, and/or forceps) and
postpartum care, after previous cesarean delivery
➲ CPT Assistant Feb 96:2, Apr 97:3, Aug 02:3
59612 Vaginal delivery only, after previous cesarean delivery
(with or without episiotomy and/or forceps);

59618 Routine obstetric care including antepartum care, cesarean

delivery, and postpartum care, following attempted vaginal
delivery after previous cesarean delivery
59620 Cesarean delivery only, following attempted vaginal

delivery after previous cesarean delivery;

Abortion
▶ (For medical treatment of spontaneous complete abortion,
any trimester, use E/M codes 99202-99233)◀
(For surgical treatment of spontaneous abortion, use 59812)
59812 Treatment of incomplete abortion, any trimester, completed
surgically
➲ CPT Assistant Fall 93:9, Fall 95:16
59820 Treatment of missed abortion, completed surgically; first

trimester
➲ CPT Assistant Fall 93:9, Fall 95:16, Feb 99:10
59821 second trimester

➲ CPT Assistant Fall 93:9, Fall 95:16
59830 Treatment of septic abortion, completed surgically

59840 Induced abortion, by dilation and curettage
59841 Induced abortion, by dilation and evacuation

59850 Induced abortion, by 1 or more intra-amniotic injections

(amniocentesis-injections), including hospital admission and
visits, delivery of fetus and secundines;
59851 with dilation and curettage and/or evacuation

59852 with hysterotomy (failed intra-amniotic injection)

(For insertion of cervical dilator, use 59200)

59855 Induced abortion, by 1 or more vaginal suppositories (eg,
prostaglandin) with or without cervical dilation (eg,
laminaria), including hospital admission and visits, delivery
of fetus and secundines;
59856 with dilation and curettage and/or evacuation
59857 with hysterotomy (failed medical evacuation)
Other Procedures
59866 Multifetal pregnancy reduction(s) (MPR)
59870 Uterine evacuation and curettage for hydatidiform mole
59871 Removal of cerclage suture under anesthesia (other than

local)
➲ CPT Assistant Nov 97:22, Nov 06:21, Feb 07:10
59897 Unlisted fetal invasive procedure, including ultrasound

59898 Unlisted laparoscopy procedure, maternity care and
delivery
59899 Unlisted procedure, maternity care and delivery

➲ CPT Assistant Jun 97:10, May 04:2, Oct 13:3, Jul 19:6
Endocrine System
(For pituitary and pineal surgery, see Nervous System)
Thyroid Gland
Incision
60000 Incision and drainage of thyroglossal duct cyst, infected
Excision
60100 Biopsy thyroid, percutaneous core needle
➲ Clinical Examples in Radiology Winter 17:5, Winter
19:3
77012, 77021)
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
60200 Excision of cyst or adenoma of thyroid, or transection of
isthmus
60210 Partial thyroid lobectomy, unilateral; with or without

isthmusectomy
➲ CPT Assistant Winter 94:7, Aug 11:9, Dec 12:3
60212 with contralateral subtotal lobectomy, including

isthmusectomy
60220 Total thyroid lobectomy, unilateral; with or without

isthmusectomy
➲ CPT Assistant Oct 10:13, Dec 10:13, Aug 11:10, Dec
12:3
Thyroid Lobectomy
60220
The thyroid is exposed via a transverse cervical incision. The superior and inferior thyroid vessels
serving the lobe are ligated, the isthmus is severed, and the entire thyroid lobe is resected.
60225 with contralateral subtotal lobectomy, including
isthmusectomy
60240 Thyroidectomy, total or complete

(For thyroidectomy, subtotal or partial, use 60271)

60252 Thyroidectomy, total or subtotal for malignancy; with
limited neck dissection
60254 with radical neck dissection

60260 Thyroidectomy, removal of all remaining thyroid tissue

following previous removal of a portion of thyroid
➲ CPT Assistant Oct 10:13, Dec 10:13, Dec 12:3

60270 Thyroidectomy, including substernal thyroid; sternal split or
transthoracic approach
60271 cervical approach

60280 Excision of thyroglossal duct cyst or sinus;

60281 recurrent
(For thyroid ultrasonography, use 76536)
Removal
60300 Aspiration and/or injection, thyroid cyst
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
Parathyroid, Thymus, Adrenal Glands,

Pancreas, and Carotid Body
Excision
(For pituitary and pineal surgery, see Nervous System)
60500 Parathyroidectomy or exploration of parathyroid(s);
60502 re-exploration
60505 with mediastinal exploration, sternal split or

transthoracic approach
✚ 60512 Parathyroid autotransplantation (List separately in addition

➲ CPT Assistant Aug 11:9, Dec 12:3, Jan 17:7

60212, 60225, 60240, 60252, 60254, 60260, 60270, 60271)
60520 Thymectomy, partial or total; transcervical approach
60521 sternal split or transthoracic approach, without radical

mediastinal dissection (separate procedure)
60522 sternal split or transthoracic approach, with radical

mediastinal dissection (separate procedure)
(For thoracoscopic [VATS] thymectomy, see 32673)
60540 Adrenalectomy, partial or complete, or exploration of
adrenal gland with or without biopsy, transabdominal,
lumbar or dorsal (separate procedure);
60545 with excision of adjacent retroperitoneal tumor


(For excision of remote or disseminated
pheochromocytoma, see 49203-49205)
Posterior View of the Pharynx

60512
60600 Excision of carotid body tumor; without excision of carotid
artery
60605 with excision of carotid artery
Laparoscopy
60650 Laparoscopy, surgical, with adrenalectomy, partial or
complete, or exploration of adrenal gland with or without
biopsy, transabdominal, lumbar or dorsal
Laparoscopic Adrenalectomy
60650
An adrenal gland is dissected and removed under laparoscopic guidance. Multiple small blood vessels
from the vena cava and the aorta do not follow standard anatomic pattern, requiring intricate dissection.
60659 Unlisted laparoscopy procedure, endocrine system
Other Procedures
60699 Unlisted procedure, endocrine system
➲ CPT Assistant Feb 06:16, Dec 07:12

Surgery
Nervous System (61000-64999)
Nervous System section of the CPT codebook. The subheadings or
Skull, Meninges, and Brain (61000-62258)
Injection, Drainage, or Aspiration (61000-61070)
Twist Drill, Burr Hole(s), or Trephine (61105-61253)
Craniectomy or Craniotomy (61304-61576)
Surgery of Skull Base* (61580-61619)
Approach Procedures (61580-61598)
Anterior Cranial Fossa (61580-61586)
Middle Cranial Fossa (61590-61592)
Posterior Cranial Fossa (61595-61598)
Definitive Procedures (61600-61616)
Base of Anterior Cranial Fossa (61600-61601)
Base of Middle Cranial Fossa (61605-61613)
Base of Posterior Cranial Fossa (61615-61616)
Repair and/or Reconstruction of Surgical Defects of Skull Base
(61618-61619)
Endovascular Therapy (61623-61651)
Surgery for Aneurysm, Arteriovenous Malformation, or Vascular
Disease* (61680-61711)
Stereotaxis (61720-61791)
Stereotactic Radiosurgery (Cranial)* (61796-61800)
Neurostimulators (Intracranial)* (61850-61888)
Repair (62000-62148)
Neuroendoscopy* (62160-62165)
Cerebrospinal Fluid (CSF) Shunt (62180-62258)
Spine and Spinal Cord (62263-63746)
Injection, Drainage, or Aspiration* (62263-62329)
Catheter Implantation (62350-62355)
Reservoir/Pump Implantation (62360-62370)
Endoscopic Decompression of Neural Elements and/or Excision of
Herniated Intervertebral Discs* (62380)
Posterior Extradural Laminotomy or Laminectomy for
Exploration/Decompression of Neural Elements or Excision of
Herniated Intervertebral Discs* (63001-63051)
Transpedicular or Costovertebral Approach for Posterolateral
Extradural Exploration/Decompression (63055-63066)
Anterior or Anterolateral Approach for Extradural
Exploration/Decompression* (63075-63091)
Lateral Extracavitary Approach for Extradural
Exploration/Decompression* (63101-63103)
Incision (63170-63200)
Excision by Laminectomy of Lesion Other Than Herniated Disc
(63250-63295)
Excision, Anterior or Anterolateral Approach, Intraspinal Lesion*
(63300-63308)
Stereotaxis (63600-63610)
Stereotactic Radiosurgery (Spinal)* (63620-63621)
Neurostimulators (Spinal)* (63650-63688)
Repair (63700-63710)
Shunt, Spinal CSF (63740-63746)
Nervous System
Extracranial Nerves, Peripheral Nerves, and Autonomic
Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic
or Therapeutic (64400-64530)
Somatic Nerves* (64400-64489)
Paravertebral Spinal Nerves and Branches (64490-64495)
Autonomic Nerves (64505-64530)
Neurostimulators (Peripheral Nerve)* (64553-64595)
Destruction by Neurolytic Agent (eg, Chemical, Thermal, Electrical
or Radiofrequency), Chemodenervation* (64600-64681)
Somatic Nerves (64600-64647)
Sympathetic Nerves (64650-64681)
Neuroplasty (Exploration, Neurolysis or Nerve Decompression)*
(64702-64727)
Transection or Avulsion (64732-64772)
Excision (64774-64823)
Somatic Nerves (64774-64795)
Sympathetic Nerves (64802-64823)
Neurorrhaphy (64831-64876)
Neurorrhaphy With Nerve Graft, Vein Graft, or Conduit (64885-
64913)
Brain Anatomy
Sagittal Section of Brain and Brain Stem

Nervous System
Skull, Meninges, and Brain
(For injection procedure for cerebral angiography, see
36100-36218)
(For injection procedure for ventriculography, see 61026,
61120)
(For injection procedure for pneumoencephalography, use
61055)
Injection, Drainage, or Aspiration

61000 Subdural tap through fontanelle, or suture, infant, unilateral
or bilateral; initial
61001 subsequent taps
61020 Ventricular puncture through previous burr hole, fontanelle,
suture, or implanted ventricular catheter/reservoir; without
injection
61026 with injection of medication or other substance for
diagnosis or treatment
61050 Cisternal or lateral cervical (C1-C2) puncture; without

injection (separate procedure)
61055 with injection of medication or other substance for
diagnosis or treatment
Clinical Examples in Radiology Fall 14:7, Fall
➲
15:10
62304, 62305)
(For radiological supervision and interpretation by a
different physician or qualified health care professional, see
Radiology)
61070 Puncture of shunt tubing or reservoir for aspiration or
injection procedure
Twist Drill, Burr Hole(s), or Trephine

61105 Twist drill hole for subdural or ventricular puncture
⃠ 61107 Twist drill hole(s) for subdural, intracerebral, or ventricular
puncture; for implanting ventricular catheter, pressure
recording device, or other intracerebral monitoring device
(For intracranial neuroendoscopic ventricular catheter

61108 for evacuation and/or drainage of subdural hematoma
61120 Burr hole(s) for ventricular puncture (including injection of
gas, contrast media, dye, or radioactive material)
61140 Burr hole(s) or trephine; with biopsy of brain or intracranial
lesion
61150 with drainage of brain abscess or cyst
61151 with subsequent tapping (aspiration) of intracranial
abscess or cyst
61154 Burr hole(s) with evacuation and/or drainage of hematoma,
extradural or subdural
61156 Burr hole(s); with aspiration of hematoma or cyst,
intracerebral
61210 for implanting ventricular catheter, reservoir, EEG
electrode(s), pressure recording device, or other
cerebral monitoring device (separate procedure)

61215 Insertion of subcutaneous reservoir, pump or continuous
infusion system for connection to ventricular catheter
(For refilling and maintenance of an implantable infusion

pump for spinal or brain drug therapy, use 95990)
(For chemotherapy, use 96450)
61250 Burr hole(s) or trephine, supratentorial, exploratory, not
followed by other surgery
61253 Burr hole(s) or trephine, infratentorial, unilateral or
bilateral
(If burr hole[s] or trephine are followed by craniotomy at

same operative session, use 61304-61321; do not use 61250
or 61253)
Craniectomy or Craniotomy
61304 Craniectomy or craniotomy, exploratory; supratentorial
61305 infratentorial (posterior fossa)
61312 Craniectomy or craniotomy for evacuation of hematoma,
supratentorial; extradural or subdural
61313 intracerebral
61314 Craniectomy or craniotomy for evacuation of hematoma,
infratentorial; extradural or subdural
61315 intracerebellar
✚ 61316 Incision and subcutaneous placement of cranial bone graft

61322, 61323, 61340, 61570, 61571, 61680-61705)
61320 Craniectomy or craniotomy, drainage of intracranial
abscess; supratentorial
61321 infratentorial
61322 Craniectomy or craniotomy, decompressive, with or without
duraplasty, for treatment of intracranial hypertension,
without evacuation of associated intraparenchymal
hematoma; without lobectomy

(For subtemporal decompression, use 61340)
61323 with lobectomy

(For subtemporal decompression, use 61340)
61330 Decompression of orbit only, transcranial approach
61333 Exploration of orbit (transcranial approach), with removal
of lesion
61340 Subtemporal cranial decompression (pseudotumor cerebri,
slit ventricle syndrome)

(For decompressive craniotomy or craniectomy for
intracranial hypertension, without hematoma evacuation, see
61322, 61323)
61343 Craniectomy, suboccipital with cervical laminectomy for
decompression of medulla and spinal cord, with or without
dural graft (eg, Arnold-Chiari malformation)
61345 Other cranial decompression, posterior fossa
(For orbital decompression by lateral wall approach,
Kroenlein type, use 67445)
61450 Craniectomy, subtemporal, for section, compression, or
decompression of sensory root of gasserian ganglion
61458 Craniectomy, suboccipital; for exploration or
decompression of cranial nerves
61460 for section of 1 or more cranial nerves
61500 Craniectomy; with excision of tumor or other bone lesion of
skull
61501 for osteomyelitis

61510 Craniectomy, trephination, bone flap craniotomy; for

excision of brain tumor, supratentorial, except meningioma
61512 for excision of meningioma, supratentorial
61514 for excision of brain abscess, supratentorial
61516 for excision or fenestration of cyst, supratentorial
(For excision of pituitary tumor or craniopharyngioma, see
61545, 61546, 61548)
✚ 61517 Implantation of brain intracavitary chemotherapy agent (List
(Use 61517 only in conjunction with 61510 or 61518)

(Do not report 61517 for brachytherapy insertion. For
intracavitary insertion of radioelement sources or ribbons,
see 77770, 77771, 77772)
61518 Craniectomy for excision of brain tumor, infratentorial or
posterior fossa; except meningioma, cerebellopontine angle
tumor, or midline tumor at base of skull
61519 meningioma
61520 cerebellopontine angle tumor
61521 midline tumor at base of skull
61522 Craniectomy, infratentorial or posterior fossa; for excision
of brain abscess
61524 for excision or fenestration of cyst
61526 Craniectomy, bone flap craniotomy, transtemporal (mastoid)
for excision of cerebellopontine angle tumor;
➲ CPT Assistant Summer 91:8, Mar 18:11
61530 combined with middle/posterior fossa

craniotomy/craniectomy
61531 Subdural implantation of strip electrodes through 1 or more
burr or trephine hole(s) for long-term seizure monitoring
(For stereotactic implantation of electrodes, use 61760)

(For craniotomy for excision of intracranial arteriovenous
malformation, see 61680-61692)
61533 Craniotomy with elevation of bone flap; for subdural
implantation of an electrode array, for long-term seizure
monitoring
(For continuous EEG monitoring, see 95700-95726)
61534 for excision of epileptogenic focus without
electrocorticography during surgery
61535 for removal of epidural or subdural electrode array,
without excision of cerebral tissue (separate procedure)
61536 for excision of cerebral epileptogenic focus, with

electrocorticography during surgery (includes removal of
electrode array)
61537 for lobectomy, temporal lobe, without
61538 for lobectomy, temporal lobe, with electrocorticography

during surgery
61539 for lobectomy, other than temporal lobe, partial or total,

with electrocorticography during surgery
61540 for lobectomy, other than temporal lobe, partial or total,

without electrocorticography during surgery
61541 for transection of corpus callosum

61543 for partial or subtotal (functional) hemispherectomy
61544 for excision or coagulation of choroid plexus

61545 for excision of craniopharyngioma
(For craniotomy for selective amygdalohippocampectomy,
use 61566)
(For craniotomy for multiple subpial transections during
surgery, use 61567)
61546 Craniotomy for hypophysectomy or excision of pituitary
tumor, intracranial approach
61548 Hypophysectomy or excision of pituitary tumor, transnasal
or transseptal approach, nonstereotactic
➲ CPT Assistant Nov 98:17, Jul 11:13, Dec 19:12

61550 Craniectomy for craniosynostosis; single cranial suture
61552 multiple cranial sutures

(For cranial reconstruction for orbital hypertelorism, see

21260-21263)
(For reconstruction, see 21172-21180)
61556 Craniotomy for craniosynostosis; frontal or parietal bone
flap
61557 bifrontal bone flap
61558 Extensive craniectomy for multiple cranial suture

craniosynostosis (eg, cloverleaf skull); not requiring bone
grafts
61559 recontouring with multiple osteotomies and bone

autografts (eg, barrel-stave procedure) (includes
obtaining grafts)
61563 Excision, intra and extracranial, benign tumor of cranial
bone (eg, fibrous dysplasia); without optic nerve
decompression
61564 with optic nerve decompression
61566 Craniotomy with elevation of bone flap; for selective
amygdalohippocampectomy
61567 for multiple subpial transections, with

61570 Craniectomy or craniotomy; with excision of foreign body

from brain
61571 with treatment of penetrating wound of brain
(For sequestrectomy for osteomyelitis, use 61501)
61575 Transoral approach to skull base, brain stem or upper spinal
cord for biopsy, decompression or excision of lesion;
61576 requiring splitting of tongue and/or mandible (including
tracheostomy)
(For arthrodesis, use 22548)
Surgery of Skull Base

The surgical management of lesions involving the skull base
(base of anterior, middle, and posterior cranial fossae) often
requires the skills of several surgeons of different surgical
specialties working together or in tandem during the operative
session. These operations are usually not staged because of the
need for definitive closure of dura, subcutaneous tissues, and
skin to avoid serious infections such as osteomyelitis and/or
meningitis.
The procedures are categorized according to:
(1) approach procedure necessary to obtain adequate exposure
to the lesion (pathologic entity), (2) definitive procedure(s)
necessary to biopsy, excise or otherwise treat the lesion, and (3)
repair/reconstruction of the defect present following the
definitive procedure(s).
The approach procedure is described according to anatomical
area involved, ie, anterior cranial fossa, middle cranial fossa,
posterior cranial fossa, and brain stem or upper spinal cord.
The definitive procedure(s) describes the repair, biopsy,
resection, or excision of various lesions of the skull base and,
when appropriate, primary closure of the dura, mucous
membranes, and skin.
The repair/reconstruction procedure(s) is reported separately if
extensive dural grafting, cranioplasty, local or regional
myocutaneous pedicle flaps, or extensive skin grafts are required.
For primary closure, see the appropriate codes (ie, 15730, 15733,
15756, 15757, 15758).
When one surgeon performs the approach procedure, another
surgeon performs the definitive procedure, and another surgeon
performs the repair/reconstruction procedure, each surgeon
reports only the code for the specific procedure performed.
If one surgeon performs more than one procedure (ie, approach
procedure and definitive procedure), then both codes are
reported, adding modifier 51 to the secondary, additional
procedure(s).
Approach Procedures
Anterior Cranial Fossa
61580 Craniofacial approach to anterior cranial fossa; extradural,

including lateral rhinotomy, ethmoidectomy,
sphenoidectomy, without maxillectomy or orbital
exenteration
➲ CPT Assistant Winter 93:17, Spring 94:11
61581 extradural, including lateral rhinotomy, orbital

exenteration, ethmoidectomy, sphenoidectomy and/or
maxillectomy
61582 extradural, including unilateral or bifrontal craniotomy,

elevation of frontal lobe(s), osteotomy of base of
anterior cranial fossa
61583 intradural, including unilateral or bifrontal craniotomy,

elevation or resection of frontal lobe, osteotomy of base
of anterior cranial fossa
➲ CPT Assistant Winter 93:17, Spring 94:11, Dec
17:13
61584 Orbitocranial approach to anterior cranial fossa, extradural,
including supraorbital ridge osteotomy and elevation of
frontal and/or temporal lobe(s); without orbital exenteration
61585 with orbital exenteration

61586 Bicoronal, transzygomatic and/or LeFort I osteotomy

approach to anterior cranial fossa with or without internal
fixation, without bone graft
Middle Cranial Fossa
61590 Infratemporal pre-auricular approach to middle cranial

fossa (parapharyngeal space, infratemporal and midline
skull base, nasopharynx), with or without disarticulation of
the mandible, including parotidectomy, craniotomy,
decompression and/or mobilization of the facial nerve
and/or petrous carotid artery
➲ CPT Assistant Winter 93:18, Apr 20:10
61591 Infratemporal post-auricular approach to middle cranial

fossa (internal auditory meatus, petrous apex, tentorium,
cavernous sinus, parasellar area, infratemporal fossa)
including mastoidectomy, resection of sigmoid sinus, with or
without decompression and/or mobilization of contents of
auditory canal or petrous carotid artery
61592 Orbitocranial zygomatic approach to middle cranial fossa

(cavernous sinus and carotid artery, clivus, basilar artery or
petrous apex) including osteotomy of zygoma, craniotomy,
extra- or intradural elevation of temporal lobe
Posterior Cranial Fossa
61595 Transtemporal approach to posterior cranial fossa, jugular

foramen or midline skull base, including mastoidectomy,
decompression of sigmoid sinus and/or facial nerve, with or
without mobilization
61596 Transcochlear approach to posterior cranial fossa, jugular

foramen or midline skull base, including labyrinthectomy,
decompression, with or without mobilization of facial nerve
and/or petrous carotid artery
61597 Transcondylar (far lateral) approach to posterior cranial

fossa, jugular foramen or midline skull base, including
occipital condylectomy, mastoidectomy, resection of C1-C3
vertebral body(s), decompression of vertebral artery, with
or without mobilization
61598 Transpetrosal approach to posterior cranial fossa, clivus or

foramen magnum, including ligation of superior petrosal
sinus and/or sigmoid sinus
Definitive Procedures
Base of Anterior Cranial Fossa
61600 Resection or excision of neoplastic, vascular or infectious

lesion of base of anterior cranial fossa; extradural
➲ CPT Assistant Winter 93:19, Spring 94:12, Nov 96:12
61601 intradural, including dural repair, with or without graft

Base of Middle Cranial Fossa

lesion of infratemporal fossa, parapharyngeal space, petrous
apex; extradural
➲ CPT Assistant Winter 93:19, Apr 20:10

lesion of parasellar area, cavernous sinus, clivus or midline
skull base; extradural

Code 61611 is reported in addition to code(s) for primary

procedure(s) 61605-61608. Report only one transection or
ligation of carotid artery code per operative session.
✚ 61611 Transection or ligation, carotid artery in petrous canal;
without repair (List separately in addition to code for
primary procedure)

61613 Obliteration of carotid aneurysm, arteriovenous
malformation, or carotid-cavernous fistula by dissection
within cavernous sinus
Base of Posterior Cranial Fossa

lesion of base of posterior cranial fossa, jugular foramen,
foramen magnum, or C1-C3 vertebral bodies; extradural

Repair and/or Reconstruction of Surgical Defects of

Skull Base
61618 Secondary repair of dura for cerebrospinal fluid leak,
anterior, middle or posterior cranial fossa following surgery
of the skull base; by free tissue graft (eg, pericranium,
fascia, tensor fascia lata, adipose tissue, homologous or
synthetic grafts)
➲ CPT Assistant Winter 93:20, Spring 94:19, Mar 00:11
61619 by local or regionalized vascularized pedicle flap or

myocutaneous flap (including galea, temporalis, frontalis
or occipitalis muscle)
➲ CPT Assistant Winter 93:20, Spring 94:19, Mar
00:11
Endovascular Therapy
61623 Endovascular temporary balloon arterial occlusion, head or
neck (extracranial/intracranial) including selective
catheterization of vessel to be occluded, positioning and
inflation of occlusion balloon, concomitant neurological
monitoring, and radiologic supervision and interpretation of
all angiography required for balloon occlusion and to
exclude vascular injury post occlusion
(If selective catheterization and angiography of arteries

other than artery to be occluded is performed, use
appropriate catheterization and radiologic supervision and
interpretation codes)
(If complete diagnostic angiography of the artery to be
occluded is performed immediately prior to temporary
occlusion, use appropriate radiologic supervision and
interpretation codes only)
61624 Transcatheter permanent occlusion or embolization (eg, for
tumor destruction, to achieve hemostasis, to occlude a
vascular malformation), percutaneous, any method; central
nervous system (intracranial, spinal cord)
➲ CPT Assistant Jun 99:10, Nov 06:8, Nov 13:6, Sep 19:6
➲ Clinical Examples in Radiology Summer 07:2, Summer
16:13, Winter 18:2
(For non-central nervous system and non-head or neck
embolization, see 37241-37244)
61626 non-central nervous system, head or neck (extracranial,
brachiocephalic branch)
(For non-central nervous system and non-head or neck

embolization, see 37241-37244)
61630 Balloon angioplasty, intracranial (eg, atherosclerotic
stenosis), percutaneous
61635 Transcatheter placement of intravascular stent(s),

intracranial (eg, atherosclerotic stenosis), including balloon
angioplasty, if performed
(61630 and 61635 include all selective vascular

catheterization of the target vascular territory, all diagnostic
imaging for arteriography of the target vascular territory, and
all related radiological supervision and interpretation.
When diagnostic arteriogram (including imaging and
selective catheterization) confirms the need for angioplasty
or stent placement, 61630 and 61635 are inclusive of these
services. If angioplasty or stenting are not indicated, then the
appropriate codes for selective catheterization and imaging
should be reported in lieu of 61630 and 61635)
(Do not report 61630 or 61635 in conjunction with 61645
for the same vascular territory)
(For definition of vascular territory, see the Nervous System
Endovascular Therapy guidelines)
61640 Balloon dilatation of intracranial vasospasm, percutaneous;
initial vessel
✚ 61641 each additional vessel in same vascular territory (List

✚ 61642 each additional vessel in different vascular territory (List

(Use 61641 and 61642 in conjunction with 61640)

(61640, 61641, 61642 include all selective vascular
catheterization of the target vessel, contrast injection[s],
vessel measurement, roadmapping, postdilatation
angiography, and fluoroscopic guidance for the balloon
dilatation)
(Do not report 61640, 61642 in conjunction with 61650 or
61651 for the same vascular territory)
(For definition of vascular territory, see the Nervous System
Endovascular Therapy guidelines)
Codes 61645, 61650, 61651 describe cerebral endovascular
therapeutic interventions in any intracranial artery. They include
selective catheterization, diagnostic angiography, and all
subsequent angiography including associated radiological
supervision and interpretation within the treated vascular
territory, fluoroscopic guidance, neurologic and hemodynamic
monitoring of the patient, and closure of the arteriotomy by
manual pressure, an arterial closure device, or suture.
For purposes of reporting services described by 61645, 61650,
61651, the intracranial arteries are divided into three vascular
territories: 1) right carotid circulation; 2) left carotid circulation;
3) vertebro-basilar circulation. Code 61645 may be reported once
for each intracranial vascular territory treated. Code 61650 is
reported once for the first intracranial vascular territory treated
with intra-arterial prolonged administration of pharmacologic
agent(s). If additional intracranial vascular territory(ies) is also
treated with intra-arterial prolonged administration of
pharmacologic agent(s) during the same session, the treatment of
each additional vascular territory(ies) is reported using 61651
(may be reported maximally two times per day).
Code 61645 describes endovascular revascularization of
thrombotic/embolic occlusion of intracranial arterial vessel(s) via
any method, including mechanical thrombectomy (eg, mechanical
retrieval device, aspiration catheter) and/or the administration of
any agent(s) for the purpose of revascularization, such as
thrombolytics or IIB/IIIA inhibitors.
Codes 61650, 61651 describe the cerebral endovascular
continuous or intermittent therapeutic prolonged administration
of any non-thrombolytic agent(s) (eg, spasmolytics or
chemotherapy) into an artery to treat non-iatrogenic central
nervous system diseases or sequelae thereof. These codes should
not be used to report administration of agents (eg, heparin,
nitroglycerin, saline) usually administered during endovascular
interventions. These codes are used for prolonged
administrations, ie, of at least 10 minutes continuous or
intermittent duration.
Do not report 61645, 61650, or 61651 in conjunction with 36221,
36226, 36228, 37184, or 37186 for the treated vascular territory.
Do not report 61645 in conjunction with 61650 or 61651 for the
same vascular distribution. Diagnostic angiography of a non-
treated vascular territory may be reported separately. For
example, angiography of the left carotid and/or the vertebral
circulations may be reported if the intervention is performed in
the right carotid circulation.
61645 Percutaneous arterial transluminal mechanical
thrombectomy and/or infusion for thrombolysis, intracranial,
any method, including diagnostic angiography, fluoroscopic
guidance, catheter placement, and intraprocedural
pharmacological thrombolytic injection(s)
➲ CPT Assistant Nov 15:3, Dec 15:17, Mar 16:3, Sep 19:6

36223, 36224, 36225, 36226, 37184, 61630, 61635, 61650,
(To report venous mechanical thrombectomy and/or
thrombolysis, see 37187, 37188, 37212, 37214)
61650 Endovascular intracranial prolonged administration of
pharmacologic agent(s) other than for thrombolysis, arterial,
including catheter placement, diagnostic angiography, and
imaging guidance; initial vascular territory
➲ CPT Assistant Nov 15:3, Mar 16:3, Sep 19:6
✚ 61651 each additional vascular territory (List separately in

➲ CPT Assistant Nov 15:3, Mar 16:3, Sep 19:6

36222, 36223, 36224, 36225, 36226, 61640, 61641, 61642,
96422, 96423, 96425 for the same vascular territory)
Surgery for Aneurysm, Arteriovenous

Malformation, or Vascular Disease
Includes craniotomy when appropriate for procedure.
61680 Surgery of intracranial arteriovenous malformation;
supratentorial, simple
61682 supratentorial, complex
61684 infratentorial, simple

61686 infratentorial, complex
61690 dural, simple
61692 dural, complex
61697 Surgery of complex intracranial aneurysm, intracranial

approach; carotid circulation
61698 vertebrobasilar circulation

(61697, 61698 involve aneurysms that are larger than 15

mm or with calcification of the aneurysm neck, or with
incorporation of normal vessels into the aneurysm neck, or a
procedure requiring temporary vessel occlusion, trapping,
or cardiopulmonary bypass to successfully treat the
aneurysm)
61700 Surgery of simple intracranial aneurysm, intracranial
approach; carotid circulation
➲ CPT Assistant Jun 99:11, Jul 99:10, Dec 17:13
Intracranial Aneurysm, Intracranial Approach

61700
Placement of ligating clip across the neck of an intracranial aneurysm
61702 vertebrobasilar circulation
61703 Surgery of intracranial aneurysm, cervical approach by

application of occluding clamp to cervical carotid artery
(Selverstone-Crutchfield type)
(For cervical approach for direct ligation of carotid artery,
see 37600-37606)
61705 Surgery of aneurysm, vascular malformation or carotid-
cavernous fistula; by intracranial and cervical occlusion of
carotid artery
61708 by intracranial electrothrombosis
(For ligation or gradual occlusion of internal/common
carotid artery, see 37605, 37606)
61710 by intra-arterial embolization, injection procedure, or
balloon catheter
61711 Anastomosis, arterial, extracranial-intracranial (eg, middle

cerebral/cortical) arteries
(For carotid or vertebral thromboendarterectomy, use
35301)
(Use 69990 when the surgical microscope is employed for
the microsurgical procedure. Do not use 69990 for
visualization with magnifying loupes or corrected vision)
Stereotaxis
61720 Creation of lesion by stereotactic method, including burr
hole(s) and localizing and recording techniques, single or
multiple stages; globus pallidus or thalamus
➲ CPT Assistant Jul 11:12, Jul 14:9
61735 subcortical structure(s) other than globus pallidus or

thalamus
61750 Stereotactic biopsy, aspiration, or excision, including burr

hole(s), for intracranial lesion;
61751 with computed tomography and/or magnetic resonance

guidance
➲ CPT Assistant Jun 96:10, Nov 99:30, Dec 04:20, Jul
11:12
computerized tomography, see 70450, 70460, or 70470 as
appropriate)
(For radiological supervision and interpretation of magnetic
resonance imaging, see 70551, 70552, or 70553 as
appropriate)
61760 Stereotactic implantation of depth electrodes into the
cerebrum for long-term seizure monitoring
61770 Stereotactic localization, including burr hole(s), with

insertion of catheter(s) or probe(s) for placement of
radiation source
✚ 61781 Stereotactic computer-assisted (navigational) procedure;

cranial, intradural (List separately in addition to code for
primary procedure)
➲ CPT Assistant Jul 11:12, Jul 14:9, Sep 14:14

61796-61799, 61863-61868, 62201, 77371-77373, 77432)
✚ 61782 cranial, extradural (List separately in addition to code
(Do not report 61781, 61782 by the same individual during

the same surgical session)
✚ 61783 spinal (List separately in addition to code for primary
procedure)
61790 Creation of lesion by stereotactic method, percutaneous, by
neurolytic agent (eg, alcohol, thermal, electrical,
radiofrequency); gasserian ganglion
61791 trigeminal medullary tract

Stereotactic Radiosurgery (Cranial)

Cranial stereotactic radiosurgery is a distinct procedure that
utilizes externally generated ionizing radiation to inactivate or
eradicate defined target(s) in the head without the need to make
an incision. The target is defined by and the treatment is
delivered using high-resolution stereotactic imaging. Stereotactic
radiosurgery codes and headframe application procedures are
reported by the neurosurgeon. The radiation oncologist reports
the appropriate code(s) for clinical treatment planning, physics
and dosimetry, treatment delivery, and management from the
Radiation Oncology section (77261-77790). Any necessary
planning, dosimetry, targeting, positioning, or blocking by the
neurosurgeon is included in the stereotactic radiation surgery
services. The same individual should not report stereotactic
radiosurgery services with radiation treatment management codes
(77427-77435).
Cranial stereotactic radiosurgery is typically performed in a single
planning and treatment session, using a rigidly attached
stereotactic guiding device, other immobilization technology
and/or a stereotactic image-guidance system, but can be
performed with more than one planning session and in a limited
number of treatment sessions, up to a maximum of five sessions.
Do not report stereotactic radiosurgery more than once per lesion
per course of treatment when the treatment requires more than
one session.
Codes 61796 and 61797 involve stereotactic radiosurgery for
simple cranial lesions. Simple cranial lesions are lesions less than
3.5 cm in maximum dimension that do not meet the definition of
a complex lesion provided below. Report code 61796 when all
lesions are simple.
Codes 61798 and 61799 involve stereotactic radiosurgery for
complex cranial lesions and procedures that create therapeutic
lesions (eg, thalamotomy or pallidotomy). All lesions 3.5 cm in
maximum dimension or greater are complex. When performing
therapeutic lesion creation procedures, report code 61798 only
once regardless of the number of lesions created. Schwannomas,
arterio-venous malformations, pituitary tumors, glomus tumors,
pineal region tumors and cavernous sinus/parasellar/petroclival
tumors are complex. Any lesion that is adjacent (5mm or less) to
the optic nerve/optic chasm/optic tract or within the brainstem is
complex. If treating multiple lesions, and any single lesion treated
is complex, use 61798.
Do not report codes 61796-61800 in conjunction with code
20660.
Codes 61796-61799 include computer-assisted planning. Do not
report codes 61796-61799 in conjunction with 61781-61783.
(For intensity modulated beam delivery plan and treatment,
see 77301, 77385, 77386. For stereotactic body radiation
therapy, see 77373, 77435)
61796 Stereotactic radiosurgery (particle beam, gamma ray, or
linear accelerator); 1 simple cranial lesion
➲ CPT Assistant Jul 11:12, Apr 12:11, Jul 14:9, Jun 15:6
(Do not report 61796 more than once per course of

treatment)
✚ 61797 each additional cranial lesion, simple (List separately in
➲ CPT Assistant Jul 11:12, Apr 12:11, Jun 15:6

(For each course of treatment, 61797 and 61799 may be
reported no more than once per lesion. Do not report any
combination of 61797 and 61799 more than 4 times for
entire course of treatment regardless of number of lesions
treated)
61798 1 complex cranial lesion
➲ CPT Assistant Jul 11:12, Apr 12:11, Jun 15:6

treatment)
✚ 61799 each additional cranial lesion, complex (List separately
➲ CPT Assistant Jul 11:12, Apr 12:11, Jul 14:9, Jun
15:6
(For each course of treatment, 61797 and 61799 may be
reported no more than once per lesion. Do not report any
combination of 61797 and 61799 more than 4 times for
entire course of treatment regardless of number of lesions
treated)
✚ 61800 Application of stereotactic headframe for stereotactic
radiosurgery (List separately in addition to code for primary
procedure)
Neurostimulators (Intracranial)
For electronic analysis with programming, when performed, of
cranial nerve and brain neurostimulator pulse
generator/transmitters, see codes 95970, 95976, 95977, 95983,
95984. Test stimulation to confirm correct target site placement of
the electrode array(s) and/or to confirm the functional status of
the system is inherent to placement and is not separately reported
as electronic analysis or programming of the neurostimulator
system. Electronic analysis (95970) at the time of implantation is
not separately reported.
Microelectrode recording, when performed by the operating
surgeon in association with implantation of neurostimulator
electrode arrays, is an inclusive service and should not be
reported separately. If another individual participates in
neurophysiological mapping during a deep brain stimulator
implantation procedure, this service may be reported by the
second individual with codes 95961-95962.
61850 Twist drill or burr hole(s) for implantation of
neurostimulator electrodes, cortical
61860 Craniectomy or craniotomy for implantation of
neurostimulator electrodes, cerebral, cortical
61863 Twist drill, burr hole, craniotomy, or craniectomy with

stereotactic implantation of neurostimulator electrode array
in subcortical site (eg, thalamus, globus pallidus,
subthalamic nucleus, periventricular, periaqueductal gray),
without use of intraoperative microelectrode recording; first
array
➲ CPT Assistant Sep 99:5, Oct 10:10, Jul 11:12, Jul 14:9
✚ 61864 each additional array (List separately in addition to

primary procedure)

61867 Twist drill, burr hole, craniotomy, or craniectomy with
stereotactic implantation of neurostimulator electrode array
in subcortical site (eg, thalamus, globus pallidus,
subthalamic nucleus, periventricular, periaqueductal gray),
with use of intraoperative microelectrode recording; first
array
✚ 61868 each additional array (List separately in addition to

primary procedure)

Placement of Cranial Neurostimulator
61867-61868, 61885
Placement of subcortical (eg, thalamic) neurostimulator electrode via burr hole (61867-61868) with
connection of the electrode to an implanted programmable pulse generator (61885) in the infraclavicular
area

61880 Revision or removal of intracranial neurostimulator
electrodes
61885 Insertion or replacement of cranial neurostimulator pulse
generator or receiver, direct or inductive coupling; with
connection to a single electrode array
➲ CPT Assistant Sep 99:5, Nov 99:30, Jun 00:3, Apr 01:8,
Sep 03:3, Dec 10:14, Feb 11:5, Sep 11:8
61886 with connection to 2 or more electrode arrays
➲ CPT Assistant Nov 99:30, Jun 00:3, Apr 01:8, Feb
11:5, Sep 11:8
(For percutaneous placement of cranial nerve (eg, vagus,
trigeminal) neurostimulator electrode(s), use 64553)
(For revision or removal of cranial nerve (eg, vagus,
trigeminal) neurostimulator electrode array, use 64569)
61888 Revision or removal of cranial neurostimulator pulse
generator or receiver
(Do not report 61888 in conjunction with 61885 or 61886

for the same pulse generator)
Repair
62000 Elevation of depressed skull fracture; simple, extradural
62005 compound or comminuted, extradural
62010 with repair of dura and/or debridement of brain
62100 Craniotomy for repair of dural/cerebrospinal fluid leak,
including surgery for rhinorrhea/otorrhea
(For repair of spinal dural/CSF leak, see 63707, 63709)

62115 Reduction of craniomegalic skull (eg, treated
hydrocephalus); not requiring bone grafts or cranioplasty
62117 requiring craniotomy and reconstruction with or without
bone graft (includes obtaining grafts)
62120 Repair of encephalocele, skull vault, including cranioplasty
62121 Craniotomy for repair of encephalocele, skull base
62140 Cranioplasty for skull defect; up to 5 cm diameter
62141 larger than 5 cm diameter
62142 Removal of bone flap or prosthetic plate of skull

62143 Replacement of bone flap or prosthetic plate of skull

62145 Cranioplasty for skull defect with reparative brain surgery

62146 Cranioplasty with autograft (includes obtaining bone grafts);

up to 5 cm diameter

✚ 62148 Incision and retrieval of subcutaneous cranial bone graft for

cranioplasty (List separately in addition to code for primary
procedure)
Neuroendoscopy
✚ 62160 Neuroendoscopy, intracranial, for placement or replacement
of ventricular catheter and attachment to shunt system or
external drainage (List separately in addition to code for
primary procedure)
(Use 62160 only in conjunction with 61107, 61210, 62220-
62230, 62258)
62161 Neuroendoscopy, intracranial; with dissection of adhesions,
fenestration of septum pellucidum or intraventricular cysts
(including placement, replacement, or removal of
ventricular catheter)
62162 with fenestration or excision of colloid cyst, including

placement of external ventricular catheter for drainage

62164 with excision of brain tumor, including placement of
external ventricular catheter for drainage
62165 with excision of pituitary tumor, transnasal or trans-

sphenoidal approach
Cerebrospinal Fluid (CSF) Shunt

62180 Ventriculocisternostomy (Torkildsen type operation)
62190 Creation of shunt; subarachnoid/subdural-atrial, -jugular, -
auricular
62192 subarachnoid/subdural-peritoneal, -pleural, other
terminus
62194 Replacement or irrigation, subarachnoid/subdural catheter
62200 Ventriculocisternostomy, third ventricle;

62201 stereotactic, neuroendoscopic method
➲ CPT Assistant Aug 07:15, Jul 11:12, Jul 14:9
(For intracranial neuroendoscopic procedures, see 62161-

62165)
62220 Creation of shunt; ventriculo-atrial, -jugular, -auricular

62223 ventriculo-peritoneal, -pleural, other terminus

62225 Replacement or irrigation, ventricular catheter

62230 Replacement or revision of cerebrospinal fluid shunt,
obstructed valve, or distal catheter in shunt system

(For replacement of only the valve and proximal catheter,
use 62230 in conjunction with 62225)
62252 Reprogramming of programmable cerebrospinal shunt
62256 Removal of complete cerebrospinal fluid shunt system;

without replacement
62258 with replacement by similar or other shunt at same

operation
(For percutaneous irrigation or aspiration of shunt reservoir,

use 61070)
Cerebrospinal Fluid (CSF) Shunt (Ventricular Peritoneal)

62223
A ventriculostomy is performed to drain CSF into the peritoneal cavity.
(For reprogramming of programmable CSF shunt, use

62252)

(For application of caliper or tongs, use 20660)
(For treatment of fracture or dislocation of spine, see
22310-22327)
Injection, Drainage, or Aspiration

Injection of contrast during fluoroscopic guidance and
localization is an inclusive component of 62263, 62264, 62267,
62273, 62280, 62281, 62282, 62302, 62303, 62304, 62305, 62321,
62323, 62325, 62327, 62328, 62329. Fluoroscopic guidance and
localization is reported with 77003, unless a formal contrast study
(myelography, epidurography, or arthrography) is performed, in
which case the use of fluoroscopy is included in the supervision
and interpretation codes or the myelography via lumbar injection
code. Image guidance and the injection of contrast are inclusive
components and are required for the performance of
myelography, as described by codes 62302, 62303, 62304, 62305.
For radiologic supervision and interpretation of epidurography,
use 72275. Code 72275 is only to be used when an epidurogram
is performed, images documented, and a formal radiologic report
is issued.
Code 62263 describes a catheter-based treatment involving
targeted injection of various substances (eg, hypertonic saline,
steroid, anesthetic) via an indwelling epidural catheter. Code
62263 includes percutaneous insertion and removal of an
epidural catheter (remaining in place over a several-day period),
for the administration of multiple injections of a neurolytic
agent(s) performed during serial treatment sessions (ie, spanning
two or more treatment days). If required, adhesions or scarring
may also be lysed by mechanical means. Code 62263 is not
reported for each adhesiolysis treatment, but should be reported
once to describe the entire series of injections/infusions spanning
two or more treatment days.
Code 62264 describes multiple adhesiolysis treatment sessions
performed on the same day. Adhesions or scarring may be lysed
by injections of neurolytic agent(s). If required, adhesions or
scarring may also be lysed mechanically using a percutaneously-
deployed catheter.
Codes 62263 and 62264 include the procedure of injections of
contrast for epidurography (72275) and fluoroscopic guidance
and localization (77003) during initial or subsequent sessions.
Fluoroscopy or CT and any injection of contrast are inclusive
components of 62321, 62323, 62325, 62327. For epidurography,
use 72275.
The placement and use of a catheter to administer one or more
epidural or subarachnoid injections on a single calendar day
should be reported in the same manner as if a needle had been
used, ie, as a single injection using either 62320, 62321, 62322, or
62323. Such injections should not be reported with 62324, 62325,
62326, or 62327.
Threading a catheter into the epidural space, injecting substances
at one or more levels and then removing the catheter should be
treated as a single injection (62320, 62321, 62322, 62323). If the
catheter is left in place to deliver substance(s) over a prolonged
period (ie, more than a single calendar day) either continuously
or via intermittent bolus, use 62324, 62325, 62326, 62327 as
appropriate.
When reporting 62320, 62321, 62322, 62323, 62324, 62325,
62326, 62327 code choice is based on the region at which the
needle or catheter entered the body (eg, lumbar). Codes 62320,
62321, 62322, 62323, 62324, 62325, 62326, 62327 should be
reported only once, when the substance injected spreads or
catheter tip insertion moves into another spinal region (eg, 62322
is reported only once for injection or catheter insertion at L3-4
with spread of the substance or placement of the catheter tip to
the thoracic region).
Percutaneous spinal procedures are done with indirect
visualization (eg, image guidance) (eg, 62287). Endoscopic
assistance during an open procedure with continuous and direct
visualization (light-based) is reported using excision codes (eg,
63020-63035).
(For transforaminal epidural injection, see 64479-64484)
(Report 01996 for daily hospital management of continuous
epidural or subarachnoid drug administration performed in
conjunction with 62324, 62325, 62326, 62327)
Definitions
For purposes of CPT coding, the following definitions of
approach and visualization apply. The primary approach and
visualization define the service, whether another method is
incidentally applied. Surgical services are presumed open, unless
otherwise specified.
Percutaneous: Image-guided procedures (eg, computer
tomography [CT] or fluoroscopy) performed with indirect
visualization of the spine without the use of any device that
allows visualization through a surgical incision.
Endoscopic: Spinal procedures performed with continuous direct
visualization of the spine through an endoscope.
Open: Spinal procedures performed with continuous direct
visualization of the spine through a surgical opening.
Indirect visualization: Image-guided (eg, CT or fluoroscopy),
not light-based visualization.
Direct visualization: Light-based visualization; can be performed
by eye, or with surgical loupes, microscope, or endoscope.
(For the techniques of microsurgery and/or use of microscope,
use 69990)
62263 Percutaneous lysis of epidural adhesions using solution
injection (eg, hypertonic saline, enzyme) or mechanical
means (eg, catheter) including radiologic localization
(includes contrast when administered), multiple
adhesiolysis sessions; 2 or more days
➲ CPT Assistant Nov 99:33, Dec 99:11, Mar 02:11, Dec
02:10, Nov 05:14, Jul 08:9, Oct 09:12, Nov 10:3, Jan
11:8, Jun 12:12
➲ Clinical Examples in Radiology Spring 11:10, Summer
16:4
(62263 includes codes 72275 and 77003)
62264 1 day
➲ CPT Assistant Nov 05:14, Jul 08:9, Oct 09:12, Nov
10:3, Jan 11:8, Jun 12:12
➲ Clinical Examples in Radiology Spring 11:10,
Summer 16:4
(Do not report 62264 with 62263)
(62264 includes codes 72275 and 77003)
62267 Percutaneous aspiration within the nucleus pulposus,
intervertebral disc, or paravertebral tissue for diagnostic
purposes
➲ CPT Assistant Nov 10:3, Jan 11:8, Jul 12:3
Winter 14:10, Summer 16:4
(For imaging, use 77003)
10007, 10008, 10009, 10010, 10011, 10012, 20225, 62287,
62290, 62291)
62268 Percutaneous aspiration, spinal cord cyst or syrinx

77002, 77012)
62269 Biopsy of spinal cord, percutaneous needle

77002, 77012)
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
62270 Spinal puncture, lumbar, diagnostic;
➲ CPT Assistant Nov 99:32-33, Oct 03:2, Jul 06:4, Jul
07:1, Oct 09:12, Nov 10:3, Jan 11:8, Mar 12:3
14:9-10, Summer 16:4, Summer 18:9
# 62328 with fluoroscopic or CT guidance

77012)
(If ultrasound or MRI guidance is performed, see 76942,
77021)
62272 Spinal puncture, therapeutic, for drainage of cerebrospinal
fluid (by needle or catheter);
➲ CPT Assistant Nov 99:32-33, Nov 10:3, Dec 13:14
14:9-10, Summer 16:4
# 62329 with fluoroscopic or CT guidance

77012)
(If ultrasound or MRI guidance is performed, see 76942,
77021)
62273 Injection, epidural, of blood or clot patch
➲ CPT Assistant Nov 99:32-34, Oct 09:12, Nov 10:3
14:10, Summer 16:4
(For injection of diagnostic or therapeutic substance[s], see
62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327)
62280 Injection/infusion of neurolytic substance (eg, alcohol,
phenol, iced saline solutions), with or without other
therapeutic substance; subarachnoid
➲ CPT Assistant Nov 99:32-34, Jan 00:2, Jul 08:9, Oct
09:12, Feb 10:11, Nov 10:3, Jan 11:8, Jun 12:12
➲
Clinical Examples in Radiology Spring 11:10, Winter
14:10, Summer 16:4
62281 epidural, cervical or thoracic
➲ CPT Assistant Apr 96:11, Nov 99:32-34, Jan 00:2,
Jul 08:9, Oct 09:12, Feb 10:11, May 10:10, Nov
10:3, Jan 11:8, Jun 12:12
62282 epidural, lumbar, sacral (caudal)
➲ CPT Assistant Apr 96:11, Nov 99:32-34, Jan 00:2,
Jul 08:9, Oct 09:12, Feb 10:11, Nov 10:3, Jan 11:8,
Jun 12:12
62284 Injection procedure for myelography and/or computed
tomography, lumbar
➲ Clinical Examples in Radiology Fall 06:5-6, 11-12,
Spring 11:9, Fall 14:6, 7, 11
62304, 62305, 72240, 72255, 72265, 72270)
(When both 62284 and 72240, 72255, 72265, 72270 are
performed by the same physician or other qualified health
care professional for myelography, see 62302, 62303,
62304, 62305)
(For injection procedure at C1-C2, use 61055)
Radiology)
62287 Decompression procedure, percutaneous, of nucleus
pulposus of intervertebral disc, any method utilizing needle
based technique to remove disc material under fluoroscopic
imaging or other form of indirect visualization, with
discography and/or epidural injection(s) at the treated
level(s), when performed, single or multiple levels, lumbar
2017
➲ CPT Assistant Nov 99:34, Mar 02:11, Oct 10:9, Jul
12:3, Oct 12:14, Apr 14:11, Mar 15:10, Feb 17:12, Dec
19:12
62322, 77003, 77012, 72295, when performed at same
level)
(For non-needle based technique for percutaneous
decompression of nucleus pulposus of intervertebral disc,
see 0274T, 0275T)
62290 Injection procedure for discography, each level; lumbar
➲ CPT Assistant Nov 99:35, Apr 03:27, Mar 11:7, Jul 12:3
62291 cervical or thoracic


72295)
62292 Injection procedure for chemonucleolysis, including
discography, intervertebral disc, single or multiple levels,
lumbar
62294 Injection procedure, arterial, for occlusion of arteriovenous

malformation, spinal
62302 Myelography via lumbar injection, including radiological
supervision and interpretation; cervical
➲ Clinical Examples in Radiology Fall 14:6, Fall 15:10,
Summer 16:4
62304, 62305, 72240, 72255, 72265, 72270)
62303 thoracic
➲ Clinical Examples in Radiology Fall 14:6, Fall
15:10, Summer 16:4
62304, 62305, 72240, 72255, 72265, 72270)
62304 lumbosacral
➲ Clinical Examples in Radiology Fall 14:3, 6, Fall
15:10, Summer 16:4
62303, 62305, 72240, 72255, 72265, 72270)
62305 2 or more regions (eg, lumbar/thoracic,
cervical/thoracic, lumbar/cervical,
lumbar/thoracic/cervical)
15:10, Summer 16:4
62303, 62304, 72240, 72255, 72265, 72270)
(For myelography lumbar injection and imaging performed
by different physicians or other qualified health care
professionals, see 62284 or 72240, 72255, 72265, 72270)
(For injection procedure at C1-C2, use 61055)
62320 Injection(s), of diagnostic or therapeutic substance(s) (eg,
anesthetic, antispasmodic, opioid, steroid, other solution),
not including neurolytic substances, including needle or
catheter placement, interlaminar epidural or subarachnoid,
cervical or thoracic; without imaging guidance
62321 with imaging guidance (ie, fluoroscopy or CT)


76942)
62322 Injection(s), of diagnostic or therapeutic substance(s) (eg,
anesthetic, antispasmodic, opioid, steroid, other solution),
not including neurolytic substances, including needle or
catheter placement, interlaminar epidural or subarachnoid,
lumbar or sacral (caudal); without imaging guidance


76942)
62324 Injection(s), including indwelling catheter placement,
continuous infusion or intermittent bolus, of diagnostic or
therapeutic substance(s) (eg, anesthetic, antispasmodic,
opioid, steroid, other solution), not including neurolytic
substances, interlaminar epidural or subarachnoid, cervical
or thoracic; without imaging guidance


76942)
62326 Injection(s), including indwelling catheter placement,
continuous infusion or intermittent bolus, of diagnostic or
therapeutic substance(s) (eg, anesthetic, antispasmodic,
opioid, steroid, other solution), not including neurolytic
substances, interlaminar epidural or subarachnoid, lumbar
or sacral (caudal); without imaging guidance


76942)
(Report 01996 for daily hospital management of continuous
epidural or subarachnoid drug administration performed in
conjunction with 62324, 62325, 62326, 62327)
Catheter Implantation
(For percutaneous placement of intrathecal or epidural
catheter, see 62270, 62272, 62273, 62280, 62281, 62282,
62284, 62320, 62321, 62322, 62323, 62324, 62325, 62326,
62327, 62328, 62329)
62350 Implantation, revision or repositioning of tunneled
intrathecal or epidural catheter, for long-term medication
administration via an external pump or implantable
reservoir/infusion pump; without laminectomy
62351 with laminectomy


pump for spinal or brain drug therapy, see 95990, 95991)
62355 Removal of previously implanted intrathecal or epidural
catheter
Reservoir/Pump Implantation
62360 Implantation or replacement of device for intrathecal or
epidural drug infusion; subcutaneous reservoir
62361 nonprogrammable pump
62362 programmable pump, including preparation of pump,
with or without programming
62365 Removal of subcutaneous reservoir or pump, previously

implanted for intrathecal or epidural infusion
Intrathecal or Epidural Drug Infusion Pump Implantation

62362
The reservoir is placed in the subcutaneous tissues and attached to a previously placed catheter for
intrathecal or epidural drug infusion.
62367 Electronic analysis of programmable, implanted pump for

intrathecal or epidural drug infusion (includes evaluation of
reservoir status, alarm status, drug prescription status);
without reprogramming or refill
➲ CPT Assistant Jul 12:5, 6, Aug 12:10, 11, 12, 15
62368 with reprogramming

➲ CPT Assistant Nov 02:10, Jul 06:1, Jul 12:5, 6, Aug
12:10, 11, 12, 15
pump for spinal or brain drug therapy, see 95990-95991)
62369 with reprogramming and refill
62370 with reprogramming and refill (requiring skill of a

physician or other qualified health care professional)

95991. For refilling and maintenance of a reservoir or an
implantable infusion pump for spinal or brain drug delivery
without reprogramming, see 95990, 95991)
Coding Tip
(when applicable) who performs a professional service within his or her
scope of practice and independently reports that professional service. These
health care professional, and who is allowed by law, regulation, and facility
policy to perform or assist in the performance of a specific professional
service, but does not individually report that professional service. Other
CPT Coding Guidelines, Introduction, Instructions for Use of the CPT

Codebook
Endoscopic Decompression of Neural Elements
and/or Excision of Herniated Intervertebral Discs
Definitions
(For the techniques of microsurgery and/or use of
microscope, use 69990)
(For percutaneous decompression, see 62287, 0274T,
0275T)
62380 Endoscopic decompression of spinal cord, nerve root(s),
including laminotomy, partial facetectomy, foraminotomy,
discectomy and/or excision of herniated intervertebral disc,
1 interspace, lumbar
(For open procedures, see 63030, 63056)
Posterior Extradural Laminotomy or

Laminectomy for Exploration/Decompression of
Neural Elements or Excision of Herniated
Intervertebral Discs
Definitions
(When 63001-63048 are followed by arthrodesis, see
22590-22614)
(For the techniques of microsurgery and/or use of
(For percutaneous decompression, see 62287, 0274T,
0275T)
63001 Laminectomy with exploration and/or decompression of
spinal cord and/or cauda equina, without facetectomy,
foraminotomy or discectomy (eg, spinal stenosis), 1 or 2
vertebral segments; cervical
➲ CPT Assistant Jan 01:12, Jun 07:1, Jul 11:13, Jul 12:3,
Jul 13:3
63003 thoracic
➲ CPT Assistant Jan 01:12, Jul 12:3, Jul 13:3
63005 lumbar, except for spondylolisthesis

➲ CPT Assistant Jan 01:12, Jul 12:3, Jul 13:3, Dec
13:17
Lumbar Laminectomy
63005
With the patient prone and under general anesthesia, the laminae and underlying ligamentum flavum are
removed.
63011 sacral
63012 Laminectomy with removal of abnormal facets and/or pars

inter-articularis with decompression of cauda equina and
nerve roots for spondylolisthesis, lumbar (Gill type
procedure)
➲ CPT Assistant Jan 01:12, Jul 13:3, Dec 19:12
63015 Laminectomy with exploration and/or decompression of

spinal cord and/or cauda equina, without facetectomy,
foraminotomy or discectomy (eg, spinal stenosis), more than
2 vertebral segments; cervical
63016 thoracic
63017 lumbar
63020 Laminotomy (hemilaminectomy), with decompression of

nerve root(s), including partial facetectomy, foraminotomy
and/or excision of herniated intervertebral disc; 1
interspace, cervical
➲ CPT Assistant Nov 99:36, Jan 01:12, Jul 12:4, Dec
12:13, Jul 13:3
63030 1 interspace, lumbar
➲ CPT Assistant Mar 96:7, Nov 99:36, Jan 01:12, Feb
01:10, Sep 02:10, Oct 04:12, Oct 08:10, Oct 09:9,
Nov 10:4, Mar 11:7, Jul 11:13, Jul 12:3, 4, Dec
12:13, Jul 13:3, Dec 13:17, May 16:13, Feb 17:13,
Nov 19:15
✚ 63035 each additional interspace, cervical or lumbar (List
➲ CPT Assistant Fall 91:8, Mar 96:7, Nov 99:36, Jan
01:12, Feb 01:10, Jul 12:4
(For percutaneous endoscopic approach, see 0274T, 0275T)
63040 Laminotomy (hemilaminectomy), with decompression of
nerve root(s), including partial facetectomy, foraminotomy
and/or excision of herniated intervertebral disc,
reexploration, single interspace; cervical
➲ CPT Assistant Jan 99:11, Jan 01:12, Jul 13:3

63042 lumbar
➲ CPT Assistant Jan 99:11, Jan 01:12, Oct 08:10, Oct
09:9, Jul 11:13, Jul 13:3
✚ 63043 each additional cervical interspace (List separately in

✚ 63044 each additional lumbar interspace (List separately in

63045 Laminectomy, facetectomy and foraminotomy (unilateral or
bilateral with decompression of spinal cord, cauda equina
and/or nerve root[s], [eg, spinal or lateral recess stenosis]),
➲ CPT Assistant Jan 01:12, Dec 12:13, Jul 13:3
63046 thoracic
➲ CPT Assistant Jan 99:11, Jan 01:12, Dec 12:13, Jul
13:3
63047 lumbar
➲ CPT Assistant Jan 99:11, Jan 01:12, Feb 01:10, Nov
02:11, Apr 08:11, Jul 08:7, Oct 08:10, Oct 09:9, Nov
10:4, Jul 11:13, Dec 12:13, Jul 13:3, Dec 13:17, Dec
14:16, Oct 16:11, Feb 17:13, May 18:9, Dec 19:12
✚ 63048 each additional segment, cervical, thoracic, or lumbar
procedure)
➲ CPT Assistant Fall 91:8, Jan 99:11, Jan 01:12, Dec
12:13
63050 Laminoplasty, cervical, with decompression of the spinal
cord, 2 or more vertebral segments;
63051 with reconstruction of the posterior bony elements

(including the application of bridging bone graft and non-
segmental fixation devices [eg, wire, suture, mini-
plates], when performed)

22614, 22840-22842, 63001, 63015, 63045, 63048, 63295
for the same vertebral segment(s))
Transpedicular or Costovertebral Approach for

Posterolateral Extradural
Exploration/Decompression
63055 Transpedicular approach with decompression of spinal
cord, equina and/or nerve root(s) (eg, herniated
intervertebral disc), single segment; thoracic
63056 lumbar (including transfacet, or lateral extraforaminal

approach) (eg, far lateral herniated intervertebral disc)
CPT Assistant Nov 99:36, Oct 09:9, Nov 11:10, Jul
➲ 12:3, Jul 13:3, Jan 14:9, Nov 19:15
✚ 63057 each additional segment, thoracic or lumbar (List

63064 Costovertebral approach with decompression of spinal cord
or nerve root(s) (eg, herniated intervertebral disc), thoracic;
single segment
➲ CPT Assistant Fall 92:19, Jul 13:3

(For excision of thoracic intraspinal lesions by
laminectomy, see 63266, 63271, 63276, 63281, 63286)
Anterior or Anterolateral Approach for

Extradural Exploration/Decompression
primary surgeons performing distinct part(s) of spinal cord
exploration/decompression operation, each surgeon should report
procedure code (and any associated add-on codes for that
procedure code as long as both surgeons continue to work
together as primary surgeons). In this situation, modifier 62 may
be appended to the definitive procedure code(s) 63075, 63077,
63081, 63085, 63087, 63090 and, as appropriate, to associated
additional interspace add-on code(s) 63076, 63078 or additional
segment add-on code(s) 63082, 63086, 63088, 63091 as long as
both surgeons continue to work together as primary surgeons.
For vertebral corpectomy, the term partial is used to describe
removal of a substantial portion of the body of the vertebra. In
the cervical spine, the amount of bone removed is defined as at
least one-half of the vertebral body. In the thoracic and lumbar
spine, the amount of bone removed is defined as at least one-
third of the vertebral body.
63075 Discectomy, anterior, with decompression of spinal cord
and/or nerve root(s), including osteophytectomy; cervical,
single interspace
➲ CPT Assistant Nov 98:18, Jan 01:12, Feb 02:4, Jul 13:3,
Apr 15:7
performed by separate individuals. To report anterior
✚ 63076 cervical, each additional interspace (List separately in
➲ CPT Assistant Nov 98:18, Jan 01:12, Feb 02:4

performed by separate individuals. To report anterior
63077 thoracic, single interspace
➲ CPT Assistant Nov 98:18, Jan 01:12, Feb 02:4, Jul
13:3
✚ 63078 thoracic, each additional interspace (List separately in

63078)
63081 Vertebral corpectomy (vertebral body resection), partial or
complete, anterior approach with decompression of spinal
cord and/or nerve root(s); cervical, single segment
➲ CPT Assistant Spring 93:37, Feb 02:4, Jul 13:3, Jun
15:10, Apr 16:8
✚ 63082 cervical, each additional segment (List separately in
➲ CPT Assistant Spring 93:37, Feb 02:4, Apr 16:8

(For transoral approach, see 61575, 61576)
complete, transthoracic approach with decompression of
spinal cord and/or nerve root(s); thoracic, single segment
➲ CPT Assistant Spring 93:37, Feb 02:4, Jul 13:3, Apr
16:8
✚ 63086 thoracic, each additional segment (List separately in

complete, combined thoracolumbar approach with
decompression of spinal cord, cauda equina or nerve
root(s), lower thoracic or lumbar; single segment
➲ CPT Assistant Spring 93:37, Feb 02:4, Jul 13:3, Apr
16:8

complete, transperitoneal or retroperitoneal approach with
decompression of spinal cord, cauda equina or nerve
root(s), lower thoracic, lumbar, or sacral; single segment
➲ CPT Assistant Spring 93:37, Mar 96:6, Feb 02:4, Jul
13:3, Apr 16:8
➲ CPT Assistant Spring 93:37, Mar 96:6, Feb 02:4,
Apr 16:8
(Procedures 63081-63091 include discectomy above and/or
below vertebral segment)
(If followed by arthrodesis, see 22548-22812)
(For reconstruction of spine, use appropriate vertebral
corpectomy codes 63081-63091, bone graft codes 20930-
20938, arthrodesis codes 22548-22812, and spinal
instrumentation codes 22840-22855, 22859)
Lateral Extracavitary Approach for Extradural
Exploration/Decompression
complete, lateral extracavitary approach with
decompression of spinal cord and/or nerve root(s) (eg, for
tumor or retropulsed bone fragments); thoracic, single
segment
63102 lumbar, single segment

✚ 63103 thoracic or lumbar, each additional segment (List

(Use 63103 in conjunction with 63101 and 63102)
Incision
63170 Laminectomy with myelotomy (eg, Bischof or DREZ type),
cervical, thoracic, or thoracolumbar
63172 Laminectomy with drainage of intramedullary cyst/syrinx; to

subarachnoid space
63173 to peritoneal or pleural space

▶ (63180, 63182 have been deleted)◀

63185 Laminectomy with rhizotomy; 1 or 2 segments
63190 more than 2 segments

63191 Laminectomy with section of spinal accessory nerve


(For resection of sternocleidomastoid muscle, use 21720)
63194 Laminectomy with cordotomy, with section of 1
spinothalamic tract, 1 stage; cervical
63195 thoracic
63196 Laminectomy with cordotomy, with section of both

spinothalamic tracts, 1 stage; cervical
63197 thoracic
63198 Laminectomy with cordotomy with section of both

spinothalamic tracts, 2 stages within 14 days; cervical
63199 thoracic
63200 Laminectomy, with release of tethered spinal cord, lumbar
Excision by Laminectomy of Lesion Other Than

Herniated Disc
63250 Laminectomy for excision or occlusion of arteriovenous
malformation of spinal cord; cervical
63251 thoracic
63252 thoracolumbar
63265 Laminectomy for excision or evacuation of intraspinal

lesion other than neoplasm, extradural; cervical
63266 thoracic
63267 lumbar
63268 sacral
63270 Laminectomy for excision of intraspinal lesion other than

neoplasm, intradural; cervical
63271 thoracic
63272 lumbar
63273 sacral
63275 Laminectomy for biopsy/excision of intraspinal neoplasm;

extradural, cervical
63276 extradural, thoracic

63277 extradural, lumbar

63278 extradural, sacral

63280 intradural, extramedullary, cervical

63281 intradural, extramedullary, thoracic

63282 intradural, extramedullary, lumbar

63283 intradural, sacral

63285 intradural, intramedullary, cervical

63286 intradural, intramedullary, thoracic

63287 intradural, intramedullary, thoracolumbar

63290 combined extradural-intradural lesion, any level

(For drainage of intramedullary cyst/syrinx, use 63172,
63173)
✚ 63295 Osteoplastic reconstruction of dorsal spinal elements,
following primary intraspinal procedure (List separately in

63190, 63200-63290)
22840-22844, 63050, 63051 for the same vertebral
segment(s))
Excision, Anterior or Anterolateral Approach,

Intraspinal Lesion
primary surgeons performing distinct part(s) of an anterior
approach for an intraspinal excision, each surgeon should report
single definitive procedure code. In this situation, modifier 62
may be appended to the definitive procedure code(s) 63300-
63307 and, as appropriate, to the associated additional segment
add-on code 63308 as long as both surgeons continue to work
(For arthrodesis, see 22548-22585)
(For reconstruction of spine, see 20930-20938)
complete, for excision of intraspinal lesion, single segment;
extradural, cervical
63301 extradural, thoracic by transthoracic approach

63302 extradural, thoracic by thoracolumbar approach

63303 extradural, lumbar or sacral by transperitoneal or

retroperitoneal approach
63304 intradural, cervical

63305 intradural, thoracic by transthoracic approach

63306 intradural, thoracic by thoracolumbar approach

63307 intradural, lumbar or sacral by transperitoneal or

retroperitoneal approach

codes for single segment)
Stereotaxis
63600 Creation of lesion of spinal cord by stereotactic method,
percutaneous, any modality (including stimulation and/or
recording)
63610 Stereotactic stimulation of spinal cord, percutaneous,
separate procedure not followed by other surgery
Stereotactic Radiosurgery (Spinal)

Spinal stereotactic radiosurgery is a distinct procedure that
utilizes externally generated ionizing radiation to inactivate or
eradicate defined target(s) in the spine without the need to make
an incision. The target is defined by and the treatment is
delivered using high-resolution stereotactic imaging. These codes
are reported by the surgeon. The radiation oncologist reports the
appropriate code(s) for clinical treatment planning, physics and
dosimetry, treatment delivery and management from the
Radiation Oncology section (77261-77790). Any necessary
planning, dosimetry, targeting, positioning, or blocking by the
neurosurgeon is included in the stereotactic radiation surgery
services. The same individual should not report stereotactic
radiosurgery services with radiation treatment management codes
(77427-77432).
Spinal stereotactic radiosurgery is typically performed in a single
planning and treatment session using a stereotactic image-
guidance system, but can be performed with a planning session
and in a limited number of treatment sessions, up to a maximum
of five sessions. Do not report stereotactic radiosurgery more
than once per lesion per course of treatment when the treatment
requires greater than one session.
Stereotactic spinal surgery is only used when the tumor being
treated affects spinal neural tissue or abuts the dura mater.
Arteriovenous malformations must be subdural. For other
radiation services of the spine, see Radiation Oncology services.
Codes 63620, 63621 include computer-assisted planning. Do not
report 63620, 63621 in conjunction with 61781-61783.
(For intensity modulated beam delivery plan and treatment,
see 77301, 77385, 77386. For stereotactic body radiation
therapy, see 77373, 77435)
63620 Stereotactic radiosurgery (particle beam, gamma ray, or
linear accelerator); 1 spinal lesion
➲ CPT Assistant Oct 10:3, Jul 11:12, Jun 15:6

treatment)
✚ 63621 each additional spinal lesion (List separately in addition
➲ CPT Assistant Oct 10:3, Jul 11:12, Jun 15:6

(For each course of treatment, 63621 may be reported no
more than once per lesion. Do not report 63621 more than 2
times for entire course of treatment regardless of number of
lesions treated)
Neurostimulators (Spinal)
spinal cord neurostimulator pulse generator/transmitters, see
codes 95970, 95971, 95972. Test stimulation to confirm correct
target site placement of the electrode array(s) and/or to confirm
the functional status of the system is inherent to placement, and is
not separately reported as electronic analysis or programming of
the neurostimulator system. Electronic analysis (95970) at the
time of implantation is not separately reported.
Codes 63650, 63655, and 63661-63664 describe the operative
placement, revision, replacement, or removal of the spinal
neurostimulator system components to provide spinal electrical
stimulation. A neurostimulator system includes an implanted
neurostimulator, external controller, extension, and collection of
contacts. Multiple contacts or electrodes (4 or more) provide the
actual electrical stimulation in the epidural space.
For percutaneously placed neurostimulator systems (63650,
63661, 63663), the contacts are on a catheter-like lead. An array
defines the collection of contacts that are on one catheter.
For systems placed via an open surgical exposure (63655, 63662,
63664), the contacts are on a plate or paddle-shaped surface.
Do not report 63661 or 63663 when removing or replacing a
temporary percutaneously placed array for an external generator.
63650 Percutaneous implantation of neurostimulator electrode
array, epidural
➲ CPT Assistant Jun 98:3-4, Nov 98:18, Mar 99:11, Apr
99:10, Sep 99:3, Dec 08:8, Feb 10:9, Aug 10:8, Dec
10:14, Apr 11:10, Oct 13:19, Dec 15:17, Jan 16:12, Dec
17:16, Oct 18:11
Percutaneous Implantation of Neurostimulator Electrodes

63650
Single catheter electrode array is inserted percutaneously into the epidural space. A simple or complex
receiver is subcutaneously implanted.
63655 Laminectomy for implantation of neurostimulator electrodes,
plate/paddle, epidural
➲ CPT Assistant Jun 98:3-4, Nov 98:18, Sep 99:3-4, Dec
08:8, Aug 10:8, Dec 10:14, Apr 11:10
63661 Removal of spinal neurostimulator electrode percutaneous
array(s), including fluoroscopy, when performed
➲ CPT Assistant Feb 10:9, Aug 10:8, Jan 11:8, Apr 11:10
63662 Removal of spinal neurostimulator electrode plate/paddle(s)

placed via laminotomy or laminectomy, including
fluoroscopy, when performed
63663 Revision including replacement, when performed, of spinal

neurostimulator electrode percutaneous array(s), including
fluoroscopy, when performed
the same spinal level)
Placement of Neurostimulator Electrodes Through

Laminectomy
63655
The electrode plate or paddle is placed in the epidural space via open exposure through large
laminotomy or small laminectomy. The simple or complex receiver is subcutaneously implanted.
63664 Revision including replacement, when performed, of spinal

neurostimulator electrode plate/paddle(s) placed via
laminotomy or laminectomy, including fluoroscopy, when
performed
the same spinal level)
63685 Insertion or replacement of spinal neurostimulator pulse
generator or receiver, direct or inductive coupling
➲ CPT Assistant Jun 98:3-4, Sep 99:5, Feb 10:9, Oct
10:14, Dec 10:14, Apr 11:10, Dec 17:16
same pulse generator or receiver)
63688 Revision or removal of implanted spinal neurostimulator
pulse generator or receiver
➲ CPT Assistant Jun 98:3-4, Sep 99:5, Feb 10:9, Apr
11:11
(For electronic analysis with programming, when
performed, of implanted spinal cord neurostimulator pulse
generator/transmitter, see 95970, 95971, 95972)
Repair
63700 Repair of meningocele; less than 5 cm diameter
(Do not use modifier 63 in conjunction with 63700, 63702)
63704 Repair of myelomeningocele; less than 5 cm diameter
(Do not use modifier 63 in conjunction with 63704, 63706)
(For complex skin closure, see Integumentary System)
63707 Repair of dural/cerebrospinal fluid leak, not requiring
laminectomy
63709 Repair of dural/cerebrospinal fluid leak or
pseudomeningocele, with laminectomy
63710 Dural graft, spinal
Shunt, Spinal CSF

63740 Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural,
or other; including laminectomy
63741 percutaneous, not requiring laminectomy

63744 Replacement, irrigation or revision of lumbosubarachnoid

shunt
63746 Removal of entire lumbosubarachnoid shunt system without
replacement
(For insertion of subarachnoid catheter with reservoir
and/or pump for intermittent or continuous infusion of drug
including laminectomy, see 62351 and 62360, 62361 or
62362)
(For insertion or replacement of subarachnoid or epidural
catheter, with reservoir and/or pump for drug infusion
without laminectomy, see 62350 and 62360, 62361 or
62362)
Extracranial Nerves, Peripheral Nerves,

and Autonomic Nervous System
(For intracranial surgery on cranial nerves, see 61450,
61460, 61790)
Introduction/Injection of Anesthetic Agent (Nerve
Block), Diagnostic or Therapeutic
(For destruction by neurolytic agent or chemodenervation,
see 62280-62282, 64600-64681)
(For epidural or subarachnoid injection, see 62320, 62321,
62322, 62323, 62324, 62325, 62326, 62327)
(64400-64455, 64461, 64462, 64463, 64479, 64480,
64483, 64484, 64490-64495 are unilateral procedures. For
bilateral procedures, report 64400, 64405, 64408, 64415,
64416, 64417, 64418, 64420, 64425-64455, 64461, 64463,
64479, 64483, 64490, 64493 with modifier 50. Report add-
on codes 64421, 64462, 64480, 64484, 64491, 64492,
64494, 64495 twice, when performed bilaterally. Do not
report modifier 50 in conjunction with 64421, 64462,
64480, 64484, 64491, 64492, 64494, 64495)
Somatic Nerves
Codes 64400-64489 describe the introduction/injection of an

anesthetic agent and/or steroid into the somatic nervous system
for diagnostic or therapeutic purposes. For injection or
destruction of genicular nerve branches, see 64454, 64624,
respectively.
Codes 64400-64450, 64454 describe the injection of an anesthetic
agent(s) and/or steroid into a nerve plexus, nerve, or branch.
These codes are reported once per nerve plexus, nerve, or branch
as described in the descriptor regardless of the number of
injections performed along the nerve plexus, nerve, or branch
described by the code.
Imaging guidance and localization may be reported separately for
64400-64450. Imaging guidance and any injection of contrast are
inclusive components of 64451 and 64454.
Codes 64455, 64479, 64480, 64483, 64484 are reported for single
or multiple injections on the same site. For 64479, 64480, 64483,
64484, imaging guidance (fluoroscopy or CT) and any injection
of contrast are inclusive components and are not reported
separately. For 64455, imaging guidance (ultrasound,
fluoroscopy, CT) and localization may be reported separately.
Codes 64461, 64462, 64463 describe injection of a paravertebral
block (PVB). Codes 64486, 64487, 64488, 64489 describe
injection of a transversus abdominis plane (TAP) block. Imaging
guidance and any injection of contrast are inclusive components
of 64461, 64462, 64463, 64486, 64487, 64488, 64489 and are not
64400 Injection(s), anesthetic agent(s) and/or steroid; trigeminal
nerve, each branch (ie, ophthalmic, maxillary, mandibular)
➲ CPT Assistant Jul 98:10, May 99:8, Nov 99:36, Apr
05:13, Feb 10:9, Jan 13:13
(64402 has been deleted. To report injection of anesthetic

agent and/or steroid to the facial nerve, use 64999)
64405 greater occipital nerve
➲ CPT Assistant Jul 98:10, Apr 05:13, Jan 13:13, Oct
16:11
64408 vagus nerve
➲ CPT Assistant Jul 98:10, Apr 05:13, Jan 13:13
(64410, 64413 have been deleted. To report injection of

anesthetic agent and/or steroid to the phrenic nerve, cervical
plexus, use 64999)
64415 brachial plexus
➲ CPT Assistant Fall 92:17, Jul 98:10, May 99:8, Oct
01:9, Feb 04:7, Apr 05:13, Nov 06:23, Jan 13:13
64416 brachial plexus, continuous infusion by catheter
(including catheter placement)
➲ CPT Assistant Feb 04:7, Apr 05:13, Jan 13:13

64417 axillary nerve
64418 suprascapular nerve

➲ CPT Assistant Jul 98:10, Apr 05:13, Aug 07:15, Jan
13:13
64420 intercostal nerve, single level
➲ CPT Assistant Jul 98:10, Apr 05:13, Aug 10:12, Nov
10:9, Jan 13:13, Jun 15:3
✚ 64421 intercostal nerve, each additional level (List separately
➲ CPT Assistant Jul 98:10, Apr 05:13, Aug 10:12, Nov
10:9, Jan 13:13, Jun 15:3, May 18:10
64425 ilioinguinal, iliohypogastric nerves
CPT Assistant Jul 98:10, Apr 05:13, Jan 13:13, Jun
➲ 15:3
64430 pudendal nerve
64435 paracervical (uterine) nerve

➲ CPT Assistant Jul 98:10, Mar 03:22, Jul 03:15, Apr
05:13, Feb 12:11, Jan 13:13
64445 sciatic nerve
➲ CPT Assistant Jul 98:10, May 99:8, Feb 04:8, Apr
05:13, Dec 11:8, Apr 12:19, Jan 13:13
64446 sciatic nerve, continuous infusion by catheter (including
catheter placement)
➲ CPT Assistant Feb 04:9, Apr 05:13, Jan 13:13

64447 femoral nerve
➲ CPT Assistant Feb 04:9, Apr 05:13, Jan 13:13, Nov
14:14, Dec 14:16, Sep 15:12
64448 femoral nerve, continuous infusion by catheter (including
catheter placement)
➲ CPT Assistant Feb 04:10, Apr 05:13, Jan 13:13, Nov
14:14, Dec 14:16, Sep 15:12
64449 lumbar plexus, posterior approach, continuous infusion
by catheter (including catheter placement)

64450 other peripheral nerve or branch
➲ CPT Assistant Jul 98:10, Nov 99:37, Dec 99:7, Oct
01:9, Aug 03:6, Apr 05:13, Jan 09:6, Jan 13:13, Sep
15:12, Nov 15:11, Oct 16:11, May 18:10, Nov 18:10,
Nov 19:15
(For injection, anesthetic agent, nerves innervating the

sacroiliac joint, use 64451)
64451 nerves innervating the sacroiliac joint, with image
guidance (ie, fluoroscopy or computed tomography)

64495, 77002, 77003, 77012, 95873, 95874)
sacroiliac joint, with ultrasound, use 76999)
64454 genicular nerve branches, including imaging guidance,
when performed

(64454 requires injecting all of the following genicular
nerve branches: superolateral, superomedial, and
inferomedial. If all 3 of these genicular nerve branches are
not injected, report 64454 with modifier 52)
▲ 64455 plantar common digital nerve(s) (eg, Morton’s neuroma)

(Imaging guidance [fluoroscopy or CT] and any injection of
contrast are inclusive components of 64479-64484. Imaging
guidance and localization are required for the performance
of 64479-64484)
(64470-64476 have been deleted. To report, see 64490-
64495)
▲ 64479 transforaminal epidural, with imaging guidance
(fluoroscopy or CT), cervical or thoracic, single level
➲ CPT Assistant Nov 99:33, 37, Feb 00:4, Jul 08:9,
Nov 08:11, Feb 10:9, Jan 11:8, Feb 11:4, Jul 11:16,
Jul 12:5, Jan 16:9
✚▲ 64480 transforaminal epidural, with imaging guidance
(fluoroscopy or CT), cervical or thoracic, each
additional level (List separately in addition to code for
primary procedure)
➲ CPT Assistant Nov 99:33, 37, Feb 00:4, Feb 05:14,
Jul 08:9, Feb 10:9, Jan 11:8, Feb 11:4, Jul 11:16, Jul
12:5
(For transforaminal epidural injection at the T12-L1 level,
use 64479)
▲ 64483 transforaminal epidural, with imaging guidance
(fluoroscopy or CT), lumbar or sacral, single level
➲ CPT Assistant Nov 99:33, 37, Feb 00:4, Jul 08:9,
Feb 10:9, Jan 11:8, Feb 11:4, Jul 11:16, May 12:14,
Jul 12:5, Oct 16:11
Winter 18:7
Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous

System
Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic
or Therapeutic
Code(s) Unit Image Image
Guidance Guidance
Included Separately
Reported,
When
Performed
Somatic Nerve
64400- 1 unit per plexus, nerve, or X
64450 branch injected regardless of
the number of injections
64451 1 unit for any number of nerves X
innervating the sacroiliac joint
injected regardless of the
number of injections
64454 1 unit for any number of X
genicular nerve branches, with
a required minimum of three
nerve branches
64455 1 or more injections per level X
✚64480 1 or more additional injections X
per level (add-on)
per level (add-on)
64461 1 injection site X
per code (add-on)
64463 1 or more injections per code X
64486- By injection site X
64489
Destruction by Neurolytic Agent (Eg, Chemical, Thermal, Electrical,
or Radiofrequency), Chemodenervation
Code(s) Unit Image Image
Guidance Guidance
Included Separately
Reported,
When
Performed
Somatic Nerves
64624 1 unit for any number of X
genicular nerve branches, with
a required minimum of three
nerve branches
✚▲ 64484 transforaminal epidural, with imaging guidance
(fluoroscopy or CT), lumbar or sacral, each additional
level (List separately in addition to code for primary
procedure)
➲ CPT Assistant Nov 99:33, 37, Feb 00:4, Feb 05:14,
Jul 08:9, Nov 08:11, Feb 10:9, Feb 11:4, Jul 11:16,
Jul 12:5, Jan 16:9
Winter 18:7
(64479-64484 are unilateral procedures. For bilateral
procedures, report 64479, 64483 with modifier 50. Report
add-on codes 64480, 64484 twice, when performed
bilaterally. Do not report modifier 50 in conjunction with
64480, 64484)
# 64461 Paravertebral block (PVB) (paraspinous block), thoracic;
single injection site (includes imaging guidance, when
performed)
#✚ 64462 second and any additional injection site(s) (includes

imaging guidance, when performed) (List separately in

(Do not report 64462 more than once per day)
# 64463 continuous infusion by catheter (includes imaging
guidance, when performed)

62320, 62324, 64420, 64421, 64479, 64480, 64490, 64491,
64492, 76942, 77002, 77003)
64486 Transversus abdominis plane (TAP) block (abdominal plane
block, rectus sheath block) unilateral; by injection(s)
(includes imaging guidance, when performed)
64487 by continuous infusion(s) (includes imaging guidance,

when performed)
64488 Transversus abdominis plane (TAP) block (abdominal plane

block, rectus sheath block) bilateral; by injections (includes
imaging guidance, when performed)
64489 by continuous infusions (includes imaging guidance,

when performed)
Paravertebral Spinal Nerves and Branches

(Image guidance [fluoroscopy or CT] and any injection of
contrast are inclusive components of 64490-64495. Imaging
of paravertebral facet joint injections described by codes
64490-64495. If imaging is not used, report 20552-20553. If
ultrasound guidance is used, report 0213T-0218T)
(For bilateral paravertebral facet injection procedures,
report 64490, 64493 with modifier 50. Report add-on codes
64491, 64492, 64494, 64495 twice, when performed
bilaterally. Do not report modifier 50 in conjunction with
64491, 64492, 64494, 64495)
(For paravertebral facet injection of the T12-L1 joint, or
nerves innervating that joint, use 64490)
64490 Injection(s), diagnostic or therapeutic agent, paravertebral
facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), cervical or
thoracic; single level
➲ CPT Assistant Feb 10:9, Aug 10:12, Dec 10:13, Jan
11:8, Feb 11:4, Jun 12:10, Oct 12:15
11:10, Winter 18:8
primary procedure)

✚ 64492 third and any additional level(s) (List separately in
11:4, Jun 12:10, Oct 12:15
➲
Clinical Examples in Radiology Winter 10:14,
64493 Injection(s), diagnostic or therapeutic agent, paravertebral
with image guidance (fluoroscopy or CT), lumbar or sacral;
single level
➲ CPT Assistant Feb 10:9, Aug 10:12, Jan 11:8, Feb 11:4,
Jun 12:10, Oct 12:15, May 18:10
11:10, Winter 18:8
sacroiliac joint, use 64451)
primary procedure)
11:4, Jun 12:10, May 18:10
✚ 64495 third and any additional level(s) (List separately in
11:4, Jun 12:10, Oct 12:15, May 18:10
Autonomic Nerves
64505 Injection, anesthetic agent; sphenopalatine ganglion
➲ CPT Assistant Jul 98:10, Apr 05:13, Jan 13:13, Jun
13:13, Jul 14:8

64510 stellate ganglion (cervical sympathetic)
64517 superior hypogastric plexus

➲ CPT Assistant Oct 04:11, Apr 05:13, Jan 13:13
64520 lumbar or thoracic (paravertebral sympathetic)

➲ CPT Assistant Jul 98:10, Apr 05:13, Dec 10:14, Jan
13:13
64530 celiac plexus, with or without radiologic monitoring
(For transendoscopic ultrasound-guided transmural

injection, anesthetic, celiac plexus, use 43253)
Neurostimulators (Peripheral Nerve)

peripheral nerve neurostimulator pulse generator/transmitters, see
codes 95970, 95971, 95972. An electrode array is a catheter or
other device with more than one contact. The function of each
contact may be capable of being adjusted during programming
services. Test stimulation to confirm correct target site placement
of the electrode array(s) and/or to confirm the functional status of
the system is inherent to placement, and is not separately reported
as electronic analysis or programming of the neurostimulator
system. Electronic analysis (95970) at the time of implantation is
not separately reported.
Codes 64553, 64555, and 64561 may be used to report both
temporary and permanent placement of percutaneous electrode
arrays.
(For transcutaneous nerve stimulation [TENS], use 97014
for electrical stimulation requiring supervision only or use
97032 for electrical stimulation requiring constant
attendance)
(For percutaneous implantation or replacement of integrated
neurostimulation system, posterior tibial nerve, use 0587T)
64553 Percutaneous implantation of neurostimulator electrode
array; cranial nerve
➲ CPT Assistant Nov 99:38, Apr 01:9, Oct 18:8
(For percutaneous electrical stimulation of a cranial nerve

using needle[s] or needle electrode[s] [eg, PENS, PNT], use
64999)
(For open placement of cranial nerve (eg, vagus, trigeminal)
neurostimulator pulse generator or receiver, see 61885,
61886, as appropriate)
64555 peripheral nerve (excludes sacral nerve)
➲ CPT Assistant Jan 15:14, Feb 16:13, Dec 17:16, Aug
18:10, Oct 18:8
(For percutaneous electrical stimulation of a peripheral
nerve using needle[s] or needle electrode[s] [eg, PENS,
PNT], use 64999)
64561 sacral nerve (transforaminal placement) including image
guidance, if performed

(For percutaneous electrical neuromuscular stimulation or
neuromodulation using needle[s] or needle electrode[s] [eg,
PENS, PNT], use 64999)
64566 Posterior tibial neurostimulation, percutaneous needle
electrode, single treatment, includes programming

95972)
64568 Incision for implantation of cranial nerve (eg, vagus nerve)
neurostimulator electrode array and pulse generator
➲ CPT Assistant Feb 11:5, Sep 11:8, 10, 12, Nov 16:6,
Mar 18:9
64570)
(For insertion of chest wall respiratory sensor electrode or
electrode array, including connection to pulse generator, use
0466T)
64569 Revision or replacement of cranial nerve (eg, vagus nerve)
neurostimulator electrode array, including connection to
existing pulse generator
➲ CPT Assistant Feb 11:5, Sep 11:8, Nov 16:6, Mar 18:9
(For replacement of pulse generator, use 61885)
(For revision or replacement of chest wall respiratory
sensor electrode or electrode array, including connection to
existing pulse generator, use 0467T)
64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator
electrode array and pulse generator
➲ CPT Assistant Feb 11:5, Sep 11:10, Nov 16:6, Mar 18:9

(For laparoscopic implantation, revision, replacement, or
removal of vagus nerve blocking neurostimulator electrode
array and/or pulse generator at the esophagogastric junction,
see 0312T-0317T)
(For removal of chest wall respiratory sensor electrode or
electrode array, use 0468T)
64575 Incision for implantation of neurostimulator electrode array;
peripheral nerve (excludes sacral nerve)
64580 neuromuscular
64581 sacral nerve (transforaminal placement)

64585 Revision or removal of peripheral neurostimulator electrode

array
64590 Insertion or replacement of peripheral or gastric

neurostimulator pulse generator or receiver, direct or
inductive coupling
➲ CPT Assistant Sep 99:4, Apr 01:8, Mar 07:4, Apr 07:7,
Sep 11:9, Dec 12:14, Jan 15:14, Dec 17:16, Aug 18:10
Implantation Neurostimulator Electrodes, Cranial Nerve

(Vagus Nerve Stimulation)
64568-64570
Implantation of a cranial nerve (eg, vagus nerve) neurostimulator electrode with connection of the
electrode to an implanted programmable pulse generator in the infraclavicular area (64568). Revision or
replacement of the cranial nerve electrode (64569). Replacement of the cranial nerve pulse generator
(61885).
Incisional Implantation of Sacral Nerve Neurostimulator

64581
64595 Revision or removal of peripheral or gastric
neurostimulator pulse generator or receiver
➲ CPT Assistant Sep 99:3, Mar 07:4, Jan 08:8
Destruction by Neurolytic Agent (eg, Chemical,

Thermal, Electrical or Radiofrequency),
Chemodenervation
Codes 64600-64681 include the injection of other therapeutic
agents (eg, corticosteroids). Do not report diagnostic/therapeutic
injections separately. Do not report a code labeled as destruction
when using therapies that are not destructive of the target nerve
(eg, pulsed radiofrequency), use 64999. For codes labeled as
chemodenervation, the supply of the chemodenervation agent is
(For chemodenervation of internal anal sphincter, use
46505)
(For chemodenervation of the bladder, use 52287)
(For chemodenervation for strabismus involving the
extraocular muscles, use 67345)
(For chemodenervation guided by needle electromyography
or muscle electrical stimulation, see 95873, 95874)
Somatic Nerves
64600 Destruction by neurolytic agent, trigeminal nerve;
supraorbital, infraorbital, mental, or inferior alveolar
branch
➲ CPT Assistant Aug 05:13, Feb 10:9, Sep 12:14, Apr
19:9
64605 second and third division branches at foramen ovale

19:9
64610 second and third division branches at foramen ovale
under radiologic monitoring
17:10, Apr 19:9
# 64624 Destruction by neurolytic agent, genicular nerve branches
including imaging guidance, when performed

(64624 requires the destruction of each of the following
genicular nerve branches: superolateral, superomedial, and
inferomedial. If a neurolytic agent for the purposes of
destruction is not applied to all of these nerve branches,
# 64625 Radiofrequency ablation, nerves innervating the sacroiliac
joint, with image guidance (ie, fluoroscopy or computed
tomography)

77003, 77012, 95873, 95874)
(For radiofrequency ablation, nerves innervating the
sacroiliac joint, with ultrasound, use 76999)
64611 Chemodenervation of parotid and submandibular salivary
glands, bilateral
➲ CPT Assistant Feb 11:10, Sep 12:14, Apr 19:9
(Report 64611 with modifier 52 if fewer than four salivary

glands are injected)
64612 Chemodenervation of muscle(s); muscle(s) innervated by
facial nerve, unilateral (eg, for blepharospasm, hemifacial
spasm)
➲ CPT Assistant Oct 98:10, Apr 01:2, Aug 05:13, Sep
06:5, Dec 08:9, Jan 09:8, Feb 10:9, 13, Dec 11:19, Sep
12:14, Apr 13:5, Dec 13:10, Jan 14:6, May 14:5, Apr
19:9
64615 muscle(s) innervated by facial, trigeminal, cervical
spinal and accessory nerves, bilateral (eg, for chronic
migraine)
➲ CPT Assistant Apr 13:5, Jan 14:6, Apr 19:9

64617, 64642, 64643, 64644, 64645, 64646, 64647)
(For guidance see 95873, 95874. Do not report more than
one guidance code for 64615)
64616 neck muscle(s), excluding muscles of the larynx,
unilateral (eg, for cervical dystonia, spasmodic
torticollis)
➲ CPT Assistant Jan 14:6, May 14:5, Apr 19:9

or muscle electrical stimulation, see 95873, 95874. Do not
report more than one guidance code for any unit of 64616)
64617 larynx, unilateral, percutaneous (eg, for spasmodic
dysphonia), includes guidance by needle
electromyography, when performed

(For diagnostic needle electromyography of the larynx, use
95865)
(For chemodenervation of the larynx performed with direct
laryngoscopy, see 31570, 31571)
64620 Destruction by neurolytic agent, intercostal nerve
➲ CPT Assistant Nov 99:38, Aug 05:13, Sep 12:14, Jan
14:6, Apr 19:9, Nov 19:15
(Imaging guidance [fluoroscopy or CT] are inclusive
components of 64633-64636)
(Image guidance [fluoroscopy or CT] and any injection of
contrast are inclusive components of 64633-64636. Image
of paravertebral facet joint nerve destruction by neurolytic
agent described by 64633-64636. If CT or fluoroscopic
imaging is not used, report 64999)
Report 64633, 64634, 64635, 64636 per joint, not per nerve.
Although two nerves innervate each facet joint, only one code
may be reported for each joint denervated, regardless of the
number of nerves treated. Use 64634 or 64636 to report each
additional facet joint at a different vertebral level in the same
spinal region.
For neurolytic destruction of the nerves innervating the T12-L1
paravertebral facet joint, use 64633.
Do not report 64633, 64634, 64635, 64636 for non-thermal facet
joint denervation including chemical, low-grade thermal energy
(<80 degrees Celsius), or any form of pulsed radiofrequency. To
appropriately report any of these modalities, use 64999.
# 64633 Destruction by neurolytic agent, paravertebral facet joint
nerve(s), with imaging guidance (fluoroscopy or CT);
cervical or thoracic, single facet joint
➲ CPT Assistant Jun 12:10, Jul 12:6, Sep 12:14, Apr
13:10, Feb 15:9, Apr 19:9
#✚ 64634 cervical or thoracic, each additional facet joint (List
➲ CPT Assistant Jun 12:10, Jul 12:6, Sep 12:14, Apr
13:10, Feb 15:9, Apr 19:9
# 64635 lumbar or sacral, single facet joint
➲ CPT Assistant Jun 12:10, Jul 12:6, 14, Sep 12:14,
Apr 13:10, Feb 15:9, Apr 19:9, Dec 19:8
#✚ 64636 lumbar or sacral, each additional facet joint (List
➲ CPT Assistant Jun 12:10, Jul 12:6, 14, Sep 12:14,
Apr 13:10, Feb 15:9, Apr 19:9
77012)
(For radiofrequency ablation of nerves innervating the
sacroiliac joint with image guidance, use 64625)
64630 Destruction by neurolytic agent; pudendal nerve
➲ CPT Assistant Aug 05:13, Feb 10:9, Sep 12:14, Oct
17:9, Apr 19:9
64632 plantar common digital nerve
➲ CPT Assistant Jan 09:6, Sep 12:14, Jan 13:13, Jul
15:11, Oct 17:9, Apr 19:9
64640 other peripheral nerve or branch
➲ CPT Assistant Aug 05:13, Dec 09:11, Feb 10:9, Jun
12:15, Sep 12:14, May 17:10, Oct 17:9, Jan 18:7,
Apr 19:9
Report 64642, 64643, 64644, 64645 once per extremity. Codes
64642, 64643, 64644, 64645 can be reported together up to a
combined total of four units of service per patient when all four
extremities are injected. Report only one base code (64642 or
64644) per session. Report one unit of additional extremity
code(s) (64643 or 64645) for each additional extremity injected.
Report 64646 or 64647 for chemodenervation of muscles of the
trunk.
Trunk muscles include the erector spinae and paraspinal muscles,
rectus abdominus and obliques. All other somatic muscles are
extremity muscles, head muscles, or neck muscles.
or muscle electrical stimulation, see 95873, 95874. Do not
report more than one guidance code for each corresponding
chemodenervation of extremity or trunk code)
64643, 64644, 64645, 64646, 64647)
Chemodenervation of Extremity
64642
64642 Chemodenervation of one extremity; 1-4 muscle(s)
➲ CPT Assistant Jan 14:6, Oct 14:15, Apr 19:9, Aug 19:10
✚ 64643 each additional extremity, 1-4 muscle(s) (List separately

➲ CPT Assistant Jan 14:6, Oct 14:15, Apr 19:9, Aug
19:10
64644 Chemodenervation of one extremity; 5 or more muscles
➲ CPT Assistant Jan 14:6, Oct 14:15, Apr 19:9, Aug 19:10
✚ 64645 each additional extremity, 5 or more muscles (List

➲ CPT Assistant Jan 14:6, Oct 14:15, Apr 19:9, Aug
19:10
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)
64647 6 or more muscles

(Report either 64646 or 64647 only once per session)
Sympathetic Nerves
64650 Chemodenervation of eccrine glands; both axillae
➲ CPT Assistant Jun 08:9, Feb 10:11, Sep 12:14, Apr 19:9
64653 other area(s) (eg, scalp, face, neck), per day

➲ CPT Assistant Jun 08:9, Sep 12:14, Apr 19:9
(Report the specific service in conjunction with code(s) for
the specific substance(s) or drug(s) provided)
(For chemodenervation of extremities (eg, hands or feet),
use 64999)
(For chemodenervation of bladder, use 52287)
64680 Destruction by neurolytic agent, with or without radiologic
monitoring; celiac plexus
➲ CPT Assistant Feb 99:10, Aug 05:13, Jun 08:9, Sep
12:14, Apr 19:9
(For transendoscopic ultrasound-guided transmural

injection, neurolytic agent, celiac plexus, use 43253)
64681 superior hypogastric plexus
➲ CPT Assistant Aug 05:13, Dec 07:13, Sep 12:14,
Apr 19:9
Neuroplasty (Exploration, Neurolysis or Nerve

Decompression)
Neuroplasty is the surgical decompression or freeing of intact
nerve from scar tissue, including external neurolysis and/or
transposition to repair or restore the nerve.
(For percutaneous neurolysis, see 62263, 62264, 62280-
62282)
(For internal neurolysis requiring use of operating
(For facial nerve decompression, use 69720)
(For neuroplasty with nerve wrapping, see 64702-64727,
64999)
64702 Neuroplasty; digital, 1 or both, same digit
64704 nerve of hand or foot

▶ (Do not report 64702, 64704 in conjunction with 11960)◀

64708 Neuroplasty, major peripheral nerve, arm or leg, open; other
than specified
➲ CPT Assistant Jun 01:11, Jun 12:12, Nov 17:10
64712 sciatic nerve

64713 brachial plexus

➲ CPT Assistant Jun 01:11, Jun 12:12, May 13:12
64714 lumbar plexus

➲ CPT Assistant Jun 97:11, Sep 98:16, Jun 01:11, Jun
12:12, Dec 13:17
▶ (Do not report 64708, 64712, 64713, 64714 in conjunction
with 11960)◀
64716 Neuroplasty and/or transposition; cranial nerve (specify)
64718 ulnar nerve at elbow

64719 ulnar nerve at wrist

64721 median nerve at carpal tunnel
➲ CPT Assistant Fall 92:17, Sep 97:10, Jun 01:11, Nov
06:23, Aug 09:11, Jun 12:15, Sep 12:16, Dec 13:14,
Jul 15:10
▶ (Do not report 64716, 64718, 64719, 64721 in conjunction
with 11960)◀
▶ (For endoscopic procedure, use 29848)◀
64722 Decompression; unspecified nerve(s) (specify)
➲ CPT Assistant Sep 98:16, May 99:11, Jun 01:11, Oct
04:12
64726 plantar digital nerve
▶ (Do not report 64722, 64726 in conjunction with 11960)◀

✚ 64727 Internal neurolysis, requiring use of operating microscope
(List separately in addition to code for neuroplasty)
(Neuroplasty includes external neurolysis)
➲ CPT Assistant Nov 98:19, Jun 01:11, Jun 12:13
Transection or Avulsion
(For stereotactic lesion of gasserian ganglion, use 61790)
64732 Transection or avulsion of; supraorbital nerve
64734 infraorbital nerve

64736 mental nerve
64738 inferior alveolar nerve by osteotomy
64740 lingual nerve
64742 facial nerve, differential or complete
64744 greater occipital nerve
64746 phrenic nerve
64755 vagus nerves limited to proximal stomach (selective
proximal vagotomy, proximal gastric vagotomy, parietal
cell vagotomy, supra- or highly selective vagotomy)

64760 vagus nerve (vagotomy), abdominal

64763 Transection or avulsion of obturator nerve, extrapelvic, with
or without adductor tenotomy
64766 Transection or avulsion of obturator nerve, intrapelvic, with
or without adductor tenotomy
64771 Transection or avulsion of other cranial nerve, extradural
64772 Transection or avulsion of other spinal nerve, extradural
(For excision of tender scar, skin and subcutaneous tissue,

with or without tiny neuroma, see 11400-11446, 13100-
13153)
Excision
Somatic Nerves
(For Morton neurectomy, use 28080)
64774 Excision of neuroma; cutaneous nerve, surgically
identifiable
64776 digital nerve, 1 or both, same digit
✚ 64778 digital nerve, each additional digit (List separately in
64782 hand or foot, except digital nerve
✚ 64783 hand or foot, each additional nerve, except same digit
procedure)
64784 major peripheral nerve, except sciatic
64786 sciatic nerve
✚ 64787 Implantation of nerve end into bone or muscle (List
separately in addition to neuroma excision)
64788 Excision of neurofibroma or neurolemmoma; cutaneous
nerve
64790 major peripheral nerve

64792 extensive (including malignant type)

(For destruction of extensive cutaneous neurofibroma, see

0419T, 0420T)
64795 Biopsy of nerve
Sympathetic Nerves
64802 Sympathectomy, cervical
64804 Sympathectomy, cervicothoracic
64809 Sympathectomy, thoracolumbar
64818 Sympathectomy, lumbar
64820 Sympathectomy; digital arteries, each digit
(Do not report 69990 in addition to code 64820)

64821 radial artery

64822 ulnar artery

64823 superficial palmar arch
Neurorrhaphy
64831 Suture of digital nerve, hand or foot; 1 nerve
➲ CPT Assistant Apr 00:6, Sep 14:13
✚ 64832 each additional digital nerve (List separately in addition

64834 Suture of 1 nerve; hand or foot, common sensory nerve
64835 median motor thenar

64836 ulnar motor

✚ 64837 Suture of each additional nerve, hand or foot (List

64840 Suture of posterior tibial nerve
64856 Suture of major peripheral nerve, arm or leg, except sciatic;
including transposition
64857 without transposition
64858 Suture of sciatic nerve
✚ 64859 Suture of each additional major peripheral nerve (List
64861 Suture of; brachial plexus
64862 lumbar plexus
64864 Suture of facial nerve; extracranial
64865 infratemporal, with or without grafting
64866 Anastomosis; facial-spinal accessory
64868 facial-hypoglossal
✚ 64872 Suture of nerve; requiring secondary or delayed suture (List
separately in addition to code for primary neurorrhaphy)
✚ 64874 requiring extensive mobilization, or transposition of
nerve (List separately in addition to code for nerve
suture)
✚ 64876 requiring shortening of bone of extremity (List separately
in addition to code for nerve suture)
Neurorrhaphy With Nerve Graft, Vein Graft, or

Conduit
64885 Nerve graft (includes obtaining graft), head or neck; up to 4
cm in length
64886 more than 4 cm length

64890 Nerve graft (includes obtaining graft), single strand, hand or

foot; up to 4 cm length
➲ CPT Assistant Apr 15:10, Aug 15:8, Dec 17:12

64892 Nerve graft (includes obtaining graft), single strand, arm or

leg; up to 4 cm length

64895 Nerve graft (includes obtaining graft), multiple strands

(cable), hand or foot; up to 4 cm length

64897 Nerve graft (includes obtaining graft), multiple strands

(cable), arm or leg; up to 4 cm length

✚ 64901 Nerve graft, each additional nerve; single strand (List


✚ 64902 multiple strands (cable) (List separately in addition to

64898)
64905 Nerve pedicle transfer; first stage
64907 second stage

64910 Nerve repair; with synthetic conduit or vein allograft (eg,

nerve tube), each nerve
➲ CPT Assistant Nov 07:4, Apr 15:10, Aug 15:8, Dec
17:12
64911 with autogenous vein graft (includes harvest of vein
graft), each nerve
64912 with nerve allograft, each nerve, first strand (cable)
✚ 64913 with nerve allograft, each additional strand (List


Other Procedures
64999 Unlisted procedure, nervous system
➲ CPT Assistant Apr 96:11, Sep 98:16, Oct 98:10, Jan
00:10, Aug 00:7, Sep 00:10, Feb 02:10, Nov 03:5, Oct
04:11, Apr 05:13, Aug 05:13, Sep 05:9, Sep 07:10, Nov
07:4, Dec 07:8, Jul 08:9, Sep 08:11, Aug 09:8, Dec
09:11, Jun 10:8, Sep 10:10, Nov 10:4, Apr 11:12, Jul
11:12, 16-17, Sep 11:12, Jan 12:14, Feb 12:11, May
12:14, Sep 12:16, Oct 12:14, Dec 12:13, Apr 13:5, 10,
Jun 13:13, Nov 13:14, Dec 13:14, Jan 14:8, 9, Feb
14:11, Jul 14:8, Feb 15:9, Apr 15:10, Jul 15:11, Aug
15:8, Oct 15:9, Feb 16:13, Oct 16:11, Nov 16:6, May
17:10, Dec 17:13, Jan 18:7, Mar 18:9, Aug 18:10, Oct
18:8, Dec 18:8, Apr 19:9, May 19:10, Jul 19:11, Dec
19:12, Jan 20:12, Feb 20:13
Surgery
Eye and Ocular Adnexa (65091-68899)
Eye and Ocular Adnexa section of the CPT codebook. The subheadings or
Eyeball (65091-65290)
Removal of Eye (65091-65114)
Secondary Implant(s) Procedures* (65125-65175)
Removal of Foreign Body (65205-65265)
Repair of Laceration (65270-65290)
Anterior Segment (65400-66999)
Cornea (65400-65785)
Excision (65400-65426)
Removal or Destruction (65430-65600)
Keratoplasty* (65710-65757)
Other Procedures* (65760-65785)
Anterior Chamber (65800-66030)
Incision (65800-65880)
Removal (65900-65930)
Anterior Sclera (66130-66250)
Excision (66130-66175)
Aqueous Shunt (66179-66185)
Repair or Revision (66225-66250)
Iris, Ciliary Body (66500-66770)
Incision (66500-66505)
Excision (66600-66635)
Repair (66680-66682)
Lens (66820-66940)
Incision (66820-66825)
Removal* (66830-66940)
Intraocular Lens Procedures (66982-66988)
Posterior Segment (67005-67299)
Vitreous (67005-67043)
Retina or Choroid (67101-67229)
Repair (67101-67121)
Prophylaxis* (67141-67145)
Posterior Sclera (67250-67255)
Repair (67250-67255)
Ocular Adnexa (67311-67999)
Extraocular Muscles (67311-67399)
Orbit (67400-67599)
Exploration, Excision, Decompression (67400-67450)
Eyelids (67700-67999)
Incision (67700-67715, 67810)
Excision, Destruction* (67800-67808, 67820-67850)
Tarsorrhaphy (67875-67882)
Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion,
Entropion) (67900-67924)
Reconstruction* (67930-67975)
Conjunctiva (68020-68899)
Incision and Drainage (68020-68040)
Excision and/or Destruction (68100-68135)
Injection (68200)
Conjunctivoplasty (68320-68340)
Lacrimal System (68400-68899)
Incision (68400-68440)
Excision (68500-68550)
Repair (68700-68770)
Probing and/or Related Procedures (68801-68850)
Eye Anatomy
Eye and Ocular Adnexa
(For diagnostic and treatment ophthalmological services,
see Medicine, Ophthalmology, and 92002 et seq)
68850)
Eyeball
Removal of Eye
65091 Evisceration of ocular contents; without implant
65093 with implant
65101 Enucleation of eye; without implant
65103 with implant, muscles not attached to implant
65105 with implant, muscles attached to implant
(For conjunctivoplasty after enucleation, see 68320 et seq)
65110 Exenteration of orbit (does not include skin graft), removal
of orbital contents; only
65112 with therapeutic removal of bone
65114 with muscle or myocutaneous flap
(For skin graft to orbit (split skin), see 15120, 15121; free,
full thickness, see 15260, 15261)
(For eyelid repair involving more than skin, see 67930 et
seq)
Secondary Implant(s) Procedures
An ocular implant is an implant inside muscular cone; an orbital
implant is an implant outside muscular cone.
65125 Modification of ocular implant with placement or
replacement of pegs (eg, drilling receptacle for prosthesis
appendage) (separate procedure)
65130 Insertion of ocular implant secondary; after evisceration, in
scleral shell
65135 after enucleation, muscles not attached to implant
65140 after enucleation, muscles attached to implant
65150 Reinsertion of ocular implant; with or without conjunctival
graft
65155 with use of foreign material for reinforcement and/or
attachment of muscles to implant
65175 Removal of ocular implant
(For orbital implant (implant outside muscle cone) insertion,
use 67550; removal, use 67560)
Removal of Foreign Body

(For removal of implanted material: ocular implant, use
65175; anterior segment implant, use 65920; posterior
segment implant, use 67120; orbital implant, use 67560)
(For diagnostic x-ray for foreign body, use 70030)
(For diagnostic echography for foreign body, use 76529)
(For removal of foreign body from orbit: frontal approach,
use 67413; lateral approach, use 67430)
(For removal of foreign body from eyelid, embedded, use
67938)
(For removal of foreign body from lacrimal system, use
68530)
65205 Removal of foreign body, external eye; conjunctival
superficial
➲ CPT Assistant Mar 05:17, Oct 13:19
65210 conjunctival embedded (includes concretions),

subconjunctival, or scleral nonperforating
65220 corneal, without slit lamp
65222 corneal, with slit lamp
(For repair of corneal laceration with foreign body, use
65275)
65235 Removal of foreign body, intraocular; from anterior chamber
of eye or lens
(For removal of implanted material from anterior segment,

use 65920)
65260 from posterior segment, magnetic extraction, anterior or
posterior route
65265 from posterior segment, nonmagnetic extraction
(For removal of implanted material from posterior segment,
use 67120)
Repair of Laceration
(For fracture of orbit, see 21385 et seq)
(For repair of wound of eyelid, skin, linear, simple, see
12011-12018; intermediate, layered closure, see 12051-
12057; linear, complex, see 13151-13160; other, see 67930,
67935)
(For repair of wound of lacrimal system, use 68700)
(For repair of operative wound, use 66250)
65270 Repair of laceration; conjunctiva, with or without
nonperforating laceration sclera, direct closure
65272 conjunctiva, by mobilization and rearrangement, without

hospitalization
65273 conjunctiva, by mobilization and rearrangement, with
hospitalization
65275 cornea, nonperforating, with or without removal foreign
body
65280 cornea and/or sclera, perforating, not involving uveal
tissue
65285 cornea and/or sclera, perforating, with reposition or

resection of uveal tissue
(65280 and 65285 are not used for repair of a surgical

wound)
65286 application of tissue glue, wounds of cornea and/or
sclera
(Repair of laceration includes use of conjunctival flap and

restoration of anterior chamber, by air or saline injection
when indicated)
(For repair of iris or ciliary body, use 66680)
65290 Repair of wound, extraocular muscle, tendon and/or Tenon’s
capsule
Anterior Segment
Cornea
Excision
65400 Excision of lesion, cornea (keratectomy, lamellar, partial),
except pterygium
65410 Biopsy of cornea
65420 Excision or transposition of pterygium; without graft
65426 with graft

Removal or Destruction
65430 Scraping of cornea, diagnostic, for smear and/or culture

65435 Removal of corneal epithelium; with or without
chemocauterization (abrasion, curettage)
(Do not report 65435 in conjunction with 0402T)

65436 with application of chelating agent (eg, EDTA)
65450 Destruction of lesion of cornea by cryotherapy,
photocoagulation or thermocauterization
Cryotherapy of Lesion on Cornea

65450
A freezing probe is applied directly to the corneal defect to destroy it.
65600 Multiple punctures of anterior cornea (eg, for corneal
erosion, tattoo)
Keratoplasty
Corneal transplant includes use of fresh or preserved grafts. The

preparation of donor material is included for penetrating or
anterior lamellar keratoplasty, but reported separately for
endothelial keratoplasty. Do not report 65710-65757 in
conjunction with 92025.
(Keratoplasty excludes refractive keratoplasty procedures,
65760, 65765, and 65767)
65710 Keratoplasty (corneal transplant); anterior lamellar
➲ CPT Assistant Oct 02:8, Apr 09:5, Dec 09:13, Aug
12:15
65730 penetrating (except in aphakia or pseudophakia)
➲ CPT Assistant Oct 02:8, Feb 06:1, Apr 09:5, Dec
09:13, Aug 12:15
65750 penetrating (in aphakia)
CPT Assistant Oct 02:8, Apr 09:5, Dec 09:13, Aug
➲ 12:15
65755 penetrating (in pseudophakia)
➲ CPT Assistant Winter 90:8, Oct 02:9, Apr 09:5, Dec
09:13, Aug 12:15
65756 endothelial
✚ 65757 Backbench preparation of corneal endothelial allograft prior

to transplantation (List separately in addition to code for
primary procedure)
Other Procedures
Do not report 65760-65771 in conjunction with 92025.

65760 Keratomileusis
65765 Keratophakia
65767 Epikeratoplasty
➲ CPT Assistant Winter 90:8, Oct 02:10
65770 Keratoprosthesis
65771 Radial keratotomy

65772 Corneal relaxing incision for correction of surgically

induced astigmatism
➲ CPT Assistant Oct 02:10, 12
65775 Corneal wedge resection for correction of surgically
induced astigmatism
➲ CPT Assistant Oct 02:10, 12, Aug 12:9
(For fitting of contact lens for treatment of disease, see

92071, 92072)
(For unlisted procedures on cornea, use 66999)
65778 Placement of amniotic membrane on the ocular surface;
without sutures
65779 single layer, sutured


65435, 65780)
(For placement of amniotic membrane using tissue glue, use
66999)
65780 Ocular surface reconstruction; amniotic membrane
transplantation, multiple layers
➲ CPT Assistant May 04:10, Jun 09:9, May 14:5, Feb
18:11
(For placement of amniotic membrane without
reconstruction using no sutures or single layer suture
technique, see 65778, 65779)
65781 limbal stem cell allograft (eg, cadaveric or living donor)
65782 limbal conjunctival autograft (includes obtaining graft)

➲ CPT Assistant Feb 04:11, May 04:10, Feb 05:15-16
(For harvesting conjunctival allograft, living donor, use
68371)
65785 Implantation of intrastromal corneal ring segments
Anterior Chamber
Incision
65800 Paracentesis of anterior chamber of eye (separate

procedure); with removal of aqueous
65810 with removal of vitreous and/or discission of anterior

hyaloid membrane, with or without air injection
65815 with removal of blood, with or without irrigation and/or

air injection
(For injection, see 66020-66030)

(For removal of blood clot, use 65930)
65820 Goniotomy
➲ CPT Assistant Sep 05:12, Jul 18:3, Dec 18:9, Sep 19:11

(For use of ophthalmic endoscope with 65820, use 66990)
Goniotomy
65820
65850 Trabeculotomy ab externo
65855 Trabeculoplasty by laser surgery

65870, 65875, 65880)
(For trabeculectomy, use 66170)
65860 Severing adhesions of anterior segment, laser technique
65865 Severing adhesions of anterior segment of eye, incisional
technique (with or without injection of air or liquid)
(separate procedure); goniosynechiae
(For trabeculoplasty by laser surgery, use 65855)
65870 anterior synechiae, except goniosynechiae
65875 posterior synechiae

65880 corneovitreal adhesions
(For laser surgery, use 66821)
Removal
65900 Removal of epithelial downgrowth, anterior chamber of eye
65920 Removal of implanted material, anterior segment of eye


65930 Removal of blood clot, anterior segment of eye
Introduction
66020 Injection, anterior chamber of eye (separate procedure); air
or liquid
66030 medication
(For unlisted procedures on anterior segment, use 66999)
Anterior Sclera
Excision
(For removal of intraocular foreign body, use 65235)
(For operations on posterior sclera, use 67250, 67255)
66130 Excision of lesion, sclera
66150 Fistulization of sclera for glaucoma; trephination with
iridectomy
66155 thermocauterization with iridectomy

66160 sclerectomy with punch or scissors, with iridectomy

66170 trabeculectomy ab externo in absence of previous

surgery
➲ CPT Assistant Jul 03:4, Nov 03:10, Dec 12:14, Jul
18:3, Dec 18:9
(For trabeculotomy ab externo, use 65850)
66172 trabeculectomy ab externo with scarring from previous
ocular surgery or trauma (includes injection of
antifibrotic agents)
➲ CPT Assistant Jul 03:4, Nov 03:10, Dec 12:14, Jul
18:3, Dec 18:10, Apr 19:7
66174 Transluminal dilation of aqueous outflow canal; without
retention of device or stent
Minimally Invasive Glaucoma Surgery (External Approach)

66150, 66155, 66160, 66170, 66172, 66183
66175 with retention of device or stent
Aqueous Shunt
66179 Aqueous shunt to extraocular equatorial plate reservoir,

external approach; without graft
66180 with graft

➲ CPT Assistant Winter 90:8, Aug 03:9, Sep 03:2, Jun
12:15, Jan 15:10, Jul 18:3
66183 Insertion of anterior segment aqueous drainage device,
without extraocular reservoir, external approach
66184 Revision of aqueous shunt to extraocular equatorial plate

reservoir; without graft
66185 with graft

➲ CPT Assistant Winter 90:8, Jan 15:10

(For removal of implanted shunt, use 67120)
Repair or Revision
(For scleral procedures in retinal surgery, see 67101 et seq)
66225 Repair of scleral staphyloma with graft
(For scleral reinforcement, see 67250, 67255)
66250 Revision or repair of operative wound of anterior segment,
any type, early or late, major or minor procedure
(For unlisted procedures on anterior sclera, use 66999)
Iris, Ciliary Body

Incision
66500 Iridotomy by stab incision (separate procedure); except
transfixion
66505 with transfixion as for iris bombe
(For iridotomy by photocoagulation, use 66761)
Excision
66600 Iridectomy, with corneoscleral or corneal section; for
removal of lesion
66605 with cyclectomy
66625 peripheral for glaucoma (separate procedure)
66630 sector for glaucoma (separate procedure)
66635 optical (separate procedure)
(For coreoplasty by photocoagulation, use 66762)
Repair
66680 Repair of iris, ciliary body (as for iridodialysis)

(For reposition or resection of uveal tissue with perforating
wound of cornea or sclera, use 65285)
66682 Suture of iris, ciliary body (separate procedure) with
retrieval of suture through small incision (eg, McCannel
suture)
Destruction
66700 Ciliary body destruction; diathermy
66710 cyclophotocoagulation, transscleral
66711 cyclophotocoagulation, endoscopic, without concomitant

removal of crystalline lens
➲ CPT Assistant Mar 05:20, Sep 05:5, 12, Dec 19:6
(For endoscopic cyclophotocoagulation performed at same
encounter as extracapsular cataract removal with intraocular
lens insertion, see 66987, 66988)
66720 cryotherapy
66740 cyclodialysis
66761 Iridotomy/iridectomy by laser surgery (eg, for glaucoma)
(per session)
66762 Iridoplasty by photocoagulation (1 or more sessions) (eg,

for improvement of vision, for widening of anterior chamber
angle)
66770 Destruction of cyst or lesion iris or ciliary body

(nonexcisional procedure)
(For excision lesion iris, ciliary body, see 66600, 66605;
for removal of epithelial downgrowth, use 65900)
(For unlisted procedures on iris, ciliary body, use 66999)
Lens
Incision
66820 Discission of secondary membranous cataract (opacified
posterior lens capsule and/or anterior hyaloid); stab incision
technique (Ziegler or Wheeler knife)
66821 laser surgery (eg, YAG laser) (1 or more stages)
66825 Repositioning of intraocular lens prosthesis, requiring an
incision (separate procedure)
Removal
Lateral canthotomy, iridectomy, iridotomy, anterior capsulotomy,

posterior capsulotomy, the use of viscoelastic agents, enzymatic
zonulysis, use of other pharmacologic agents, and
subconjunctival or sub-tenon injections are included as part of
the code for the extraction of lens.
66830 Removal of secondary membranous cataract (opacified
posterior lens capsule and/or anterior hyaloid) with corneo-
scleral section, with or without iridectomy
(iridocapsulotomy, iridocapsulectomy)
66840 Removal of lens material; aspiration technique, 1 or more
stages
➲ CPT Assistant Fall 92:4, Jan 09:7, Apr 09:9, Sep 09:5,
Apr 16:8, Jun 16:6, Sep 16:9
66850 phacofragmentation technique (mechanical or ultrasonic)
(eg, phacoemulsification), with aspiration
➲ CPT Assistant Fall 92:6, Jan 09:7, Apr 09:9, Sep
09:5, Jun 16:6
66852 pars plana approach, with or without vitrectomy
09:5, Jun 16:6
66920 intracapsular
66930 intracapsular, for dislocated lens

66940 extracapsular (other than 66840, 66850, 66852)

09:5, Jun 16:6
(For removal of intralenticular foreign body without lens
extraction, use 65235)
Intraocular Lens Procedures

66982 Extracapsular cataract removal with insertion of intraocular
lens prosthesis (1-stage procedure), manual or mechanical
technique (eg, irrigation and aspiration or
phacoemulsification), complex, requiring devices or
techniques not generally used in routine cataract surgery (eg,
iris expansion device, suture support for intraocular lens, or
primary posterior capsulorrhexis) or performed on patients
in the amblyogenic developmental stage; without endoscopic
cyclophotocoagulation
➲ CPT Assistant Feb 01:7, Nov 03:10, Sep 09:5, Mar
13:6, Mar 16:10, Dec 17:14, Dec 18:6, Dec 19:6
(For complex extracapsular cataract removal with
concomitant endoscopic cyclophotocoagulation, use 66987)
(For insertion of ocular telescope prosthesis including
removal of crystalline lens, use 0308T)
# 66987 with endoscopic cyclophotocoagulation
(For complex extracapsular cataract removal without

endoscopic cyclophotocoagulation, use 66982)
66983 Intracapsular cataract extraction with insertion of
intraocular lens prosthesis (1 stage procedure)
➲ CPT Assistant Fall 92:5, 8, Nov 03:10, Sep 09:5, Mar
13:6, Dec 19:6
66984 Extracapsular cataract removal with insertion of intraocular
lens prosthesis (1 stage procedure), manual or mechanical
technique (eg, irrigation and aspiration or
phacoemulsification); without endoscopic
cyclophotocoagulation
➲ CPT Assistant Fall 92:5, 8, Feb 01:7, Nov 03:10, Mar
05:11, Sep 09:5, Mar 13:6, Dec 18:6, Dec 19:6
(For complex extracapsular cataract removal, use 66982)
(For extracapsular cataract removal with concomitant
# 66988 with endoscopic cyclophotocoagulation
(For extracapsular cataract removal without endoscopic

cyclophotocoagulation, use 66984)
(For complex extracapsular cataract removal with
(For insertion of ocular telescope prosthesis, including
66985 Insertion of intraocular lens prosthesis (secondary implant),
not associated with concurrent cataract removal
➲ CPT Assistant Sep 05:12, Sep 09:5, Dec 11:16, Mar
13:6
(To code implant at time of concurrent cataract surgery, see
66982, 66983, 66984)
(To report supply of intraocular lens prosthesis, use 99070)
(For ultrasonic determination of intraocular lens power, use
76519)
(For removal of implanted material from anterior segment,
use 65920)
(For secondary fixation (separate procedure), use 66682)
66986 Exchange of intraocular lens

Other Procedures
✚ 66990 Use of ophthalmic endoscope (List separately in addition to
(66990 may be used only with codes 65820, 65875, 65920,

66985, 66986, 67036, 67039, 67040, 67041, 67042, 67043,
67113)
66999 Unlisted procedure, anterior segment of eye
Posterior Segment
Vitreous
67005 Removal of vitreous, anterior approach (open sky technique
or limbal incision); partial removal
67010 subtotal removal with mechanical vitrectomy

(For removal of vitreous by paracentesis of anterior

chamber, use 65810)
(For removal of corneovitreal adhesions, use 65880)
67015 Aspiration or release of vitreous, subretinal or choroidal
fluid, pars plana approach (posterior sclerotomy)
67025 Injection of vitreous substitute, pars plana or limbal
approach (fluid-gas exchange), with or without aspiration
67027 Implantation of intravitreal drug delivery system (eg,

ganciclovir implant), includes concomitant removal of
vitreous
➲ CPT Assistant Nov 97:23, Nov 98:1, Feb 18:3
(For removal, use 67121)
Intravitreal Drug Delivery System

67027
A drug delivery system that releases medication into the vitreous is implanted into the vitreous by pars
plana incision.
67028 Intravitreal injection of a pharmacologic agent (separate
procedure)
➲ CPT Assistant Winter 90:9, Oct 12:15, Feb 18:3
67030 Discission of vitreous strands (without removal), pars plana

approach
67031 Severing of vitreous strands, vitreous face adhesions,
sheets, membranes or opacities, laser surgery (1 or more
stages)
67036 Vitrectomy, mechanical, pars plana approach;
67039 with focal endolaser photocoagulation

➲ CPT Assistant Winter 90:9, Sep 05:12
67040 with endolaser panretinal photocoagulation

➲ CPT Assistant Winter 90:9, Sep 05:12, Jul 07:12
67041 with removal of preretinal cellular membrane (eg,

macular pucker)
67042 with removal of internal limiting membrane of retina (eg,

for repair of macular hole, diabetic macular edema),
includes, if performed, intraocular tamponade (ie, air,
gas or silicone oil)
67043 with removal of subretinal membrane (eg, choroidal
neovascularization), includes, if performed, intraocular
tamponade (ie, air, gas or silicone oil) and laser
photocoagulation
(For use of ophthalmic endoscope with 67036, 67039,

67040-67043, use 66990)
(For associated lensectomy, use 66850)
(For use of vitrectomy in retinal detachment surgery, see
67108, 67113)
(For associated removal of foreign body, see 65260, 65265)
(For unlisted procedures on vitreous, use 67299)
Retina or Choroid
Repair
(If diathermy, cryotherapy and/or photocoagulation are

combined, report under principal modality used)
67101 Repair of retinal detachment, including drainage of
subretinal fluid when performed; cryotherapy
➲ CPT Assistant Mar 98:7, Jun 16:6, Sep 16:5, Feb 17:14
67105 photocoagulation
➲ CPT Assistant Mar 98:7, Jun 16:6, Sep 16:5, Feb
17:14
67107 Repair of retinal detachment; scleral buckling (such as
lamellar scleral dissection, imbrication or encircling
procedure), including, when performed, implant,
cryotherapy, photocoagulation, and drainage of subretinal
fluid
➲ CPT Assistant Jun 16:6, Sep 16:5, Aug 19:11
67108 with vitrectomy, any method, including, when performed,

air or gas tamponade, focal endolaser photocoagulation,
cryotherapy, drainage of subretinal fluid, scleral
buckling, and/or removal of lens by same technique
➲ CPT Assistant Winter 90:9, Mar 12:9, Jun 16:6, Sep
16:5
67110 by injection of air or other gas (eg, pneumatic
retinopexy)
(For aspiration or drainage of subretinal or subchoroidal

fluid, use 67015)
Repair of Retinal Detachment

67107
The retinal tear is treated externally by placing a hot or cold probe over the sclera and then depressing
it. The burn seals the choroid to the retina at the site of the tear. The healing scar is supported by the
encircling band, which buckles the eye.
67113 Repair of complex retinal detachment (eg, proliferative
vitreoretinopathy, stage C-1 or greater, diabetic traction
retinal detachment, retinopathy of prematurity, retinal tear of
greater than 90 degrees), with vitrectomy and membrane
peeling, including, when performed, air, gas, or silicone oil
tamponade, cryotherapy, endolaser photocoagulation,
drainage of subretinal fluid, scleral buckling, and/or
removal of lens
(To report vitrectomy, pars plana approach, other than in

retinal detachment surgery, see 67036-67043)
67115 Release of encircling material (posterior segment)
67120 Removal of implanted material, posterior segment;
extraocular
67121 intraocular
(For removal from anterior segment, use 65920)

(For removal of foreign body, see 65260, 65265)
Prophylaxis
Codes 67141, 67145 include treatment at one or more sessions

that may occur at different encounters. These codes should be
reported once during a defined treatment period.
Repetitive services. The services listed below are often
performed in multiple sessions or groups of sessions. The
methods of reporting vary.
The following descriptors are intended to include all sessions in a
defined treatment period.
67141 Prophylaxis of retinal detachment (eg, retinal break, lattice
degeneration) without drainage, 1 or more sessions;
cryotherapy, diathermy
➲ CPT Assistant Mar 98:7, Oct 08:3, Sep 16:5
67145 photocoagulation (laser or xenon arc)

➲ CPT Assistant Fall 92:4, Mar 98:7, Sep 16:5
Destruction
Codes 67208, 67210, 67218, 67220, 67229 include treatment at

one or more sessions that may occur at different encounters.
These codes should be reported once during a defined treatment
period.
67208 Destruction of localized lesion of retina (eg, macular edema,
tumors), 1 or more sessions; cryotherapy, diathermy
➲ CPT Assistant Mar 98:7, Nov 98:19, Oct 08:3
67210 photocoagulation
➲ CPT Assistant Mar 98:7, Nov 98:19, Oct 08:3, Jan
12:3
67218 radiation by implantation of source (includes removal of
source)
67220 Destruction of localized lesion of choroid (eg, choroidal

neovascularization); photocoagulation (eg, laser), 1 or more
sessions
➲ CPT Assistant Nov 98:19, Nov 99:39, Feb 01:8, Oct
08:3, Jan 12:3
67221 photodynamic therapy (includes intravenous infusion)
➲ CPT Assistant Feb 01:8, Sep 01:10, Jun 02:10, Feb
18:10
✚ 67225 photodynamic therapy, second eye, at single session (List
separately in addition to code for primary eye treatment)

67227 Destruction of extensive or progressive retinopathy (eg,
diabetic retinopathy), cryotherapy, diathermy
67228 Treatment of extensive or progressive retinopathy (eg,

diabetic retinopathy), photocoagulation
67229 Treatment of extensive or progressive retinopathy, 1 or more

sessions, preterm infant (less than 37 weeks gestation at
birth), performed from birth up to 1 year of age (eg,
retinopathy of prematurity), photocoagulation or cryotherapy
(For bilateral procedure, use modifier 50 with 67208,
67210, 67218, 67220, 67227, 67228, 67229)
(For unlisted procedures on retina, use 67299)
Posterior Sclera
Repair
(For excision lesion sclera, use 66130)
67250 Scleral reinforcement (separate procedure); without graft
67255 with graft

(For repair scleral staphyloma, use 66225)
Other Procedures
67299 Unlisted procedure, posterior segment
Ocular Adnexa
Extraocular Muscles of Right Eye
Extraocular Muscles
67311 Strabismus surgery, recession or resection procedure; 1
horizontal muscle
➲ CPT Assistant Summer 93:20, Mar 97:5, Nov 98:19, Sep
02:10, Jan 17:7
Strabismus Surgery—Horizontal Muscles

67311-67312
In Figure A, the medial or lateral rectus muscle is made weaker by recession (retroplacement of the
muscle attachment). In Figure B, it is made stronger by resection (removal of a segment). Use 67311
for one horizontal muscle and 67312 for two muscles of the same eye.
67312 2 horizontal muscles
67314 1 vertical muscle (excluding superior oblique)
67316 2 or more vertical muscles (excluding superior oblique)

(For adjustable sutures, use 67335 in addition to codes

67311-67334 for primary procedure reflecting number of
muscles operated on)
Strabismus Surgery—Vertical Muscles

67314-67316
Either the superior or inferior rectus muscle is strengthened or weakened. Use 67316 for two muscles
of the same eye.
67318 Strabismus surgery, any procedure, superior oblique muscle

➲ CPT Assistant Summer 93:20, Mar 97:5, Nov 98:19
✚ 67320 Transposition procedure (eg, for paretic extraocular

muscle), any extraocular muscle (specify) (List separately in

✚ 67331 Strabismus surgery on patient with previous eye surgery or
injury that did not involve the extraocular muscles (List
Transposition Procedure
67320
The extraocular muscles are transposed.
✚ 67332 Strabismus surgery on patient with scarring of extraocular

muscles (eg, prior ocular injury, strabismus or retinal
detachment surgery) or restrictive myopathy (eg, dysthyroid
ophthalmopathy) (List separately in addition to code for
primary procedure)

✚ 67334 Strabismus surgery by posterior fixation suture technique,
with or without muscle recession (List separately in

✚ 67335 Placement of adjustable suture(s) during strabismus surgery,
including postoperative adjustment(s) of suture(s) (List
separately in addition to code for specific strabismus
surgery)
Strabismus Surgery—Adjustable Sutures

67335
Sutures are tied in such a way as to allow the tension on the muscle to be adjusted after the anesthetic
is not affecting the position of the globe.
✚ 67340 Strabismus surgery involving exploration and/or repair of

detached extraocular muscle(s) (List separately in addition

67343 Release of extensive scar tissue without detaching
extraocular muscle (separate procedure)
(Use 67343 in conjunction with 67311-67340, when such

procedures are performed other than on the affected muscle)
67345 Chemodenervation of extraocular muscle
➲ CPT Assistant Summer 93:20, Mar 97:5, Apr 00:2, Feb
10:13, Dec 13:10, May 14:5
(For chemodenervation for blepharospasm and other
neurological disorders, see 64612 and 64616)
67346 Biopsy of extraocular muscle
(For repair of wound, extraocular muscle, tendon or Tenon’s

capsule, use 65290)
Other Procedures
67399 Unlisted procedure, extraocular muscle
Orbit
Exploration, Excision, Decompression
67400 Orbitotomy without bone flap (frontal or transconjunctival
approach); for exploration, with or without biopsy
67405 with drainage only
67412 with removal of lesion
67414 with removal of bone for decompression
67415 Fine needle aspiration of orbital contents

(For exenteration, enucleation, and repair, see 65101 et seq;
for optic nerve decompression, use 67570)
67420 Orbitotomy with bone flap or window, lateral approach (eg,
Kroenlein); with removal of lesion
67440 with drainage
67445 with removal of bone for decompression
(For optic nerve sheath decompression, use 67570)

67450 for exploration, with or without biopsy
(For orbitotomy, transcranial approach, see 61330, 61333)
(For orbital implant, see 67550, 67560)
(For removal of eyeball or for repair after removal, see
65091-65175)
Other Procedures
67500 Retrobulbar injection; medication (separate procedure, does
not include supply of medication)
67505 alcohol
67515 Injection of medication or other substance into Tenon’s
capsule
(For subconjunctival injection, use 68200)

67550 Orbital implant (implant outside muscle cone); insertion
67560 removal or revision
(For ocular implant (implant inside muscle cone), see
65093-65105, 65130-65175)
(For treatment of fractures of malar area, orbit, see 21355 et
seq)
67570 Optic nerve decompression (eg, incision or fenestration of
optic nerve sheath)
67599 Unlisted procedure, orbit
Eyelids
Incision
67700 Blepharotomy, drainage of abscess, eyelid
67710 Severing of tarsorrhaphy

67715 Canthotomy (separate procedure)

(For canthoplasty, use 67950)

(For division of symblepharon, use 68340)
# 67810 Incisional biopsy of eyelid skin including lid margin
➲ CPT Assistant Dec 04:19, Feb 13:16, Mar 13:6
(For biopsy of skin of the eyelid, see 11102, 11103, 11104,

11105, 11106, 11107)
Codes for removal of lesion include more than skin (ie,

involving lid margin, tarsus, and/or palpebral conjunctiva).
(For removal of lesion, involving mainly skin of eyelid, see
11310-11313; 11440-11446, 11640-11646; 17000-17004)
(For repair of wounds, blepharoplasty, grafts, reconstructive
surgery, see 67930-67975)
67800 Excision of chalazion; single
67801 multiple, same lid

67805 multiple, different lids
67808 under general anesthesia and/or requiring hospitalization,

single or multiple
67820 Correction of trichiasis; epilation, by forceps only
Trichiasis
67820-67825
When the eyelashes are ingrown or misdirected (trichiasis), the physician uses a biomicroscope and
forceps to remove the offending eyelashes. Report 67825 when cryosurgery or electrosurgery is used to
destroy the follicles.
67825 epilation by other than forceps (eg, by electrosurgery,

cryotherapy, laser surgery)
67830 incision of lid margin
67835 incision of lid margin, with free mucous membrane graft
67840 Excision of lesion of eyelid (except chalazion) without
closure or with simple direct closure
(For excision and repair of eyelid by reconstructive surgery,
see 67961, 67966)
67850 Destruction of lesion of lid margin (up to 1 cm)
(For Mohs micrographic surgery, see 17311-17315)
(For initiation or follow-up care of topical chemotherapy
(eg, 5-FU or similar agents), see appropriate office visits)
Tarsorrhaphy
67875 Temporary closure of eyelids by suture (eg, Frost suture)
67880 Construction of intermarginal adhesions, median

tarsorrhaphy, or canthorrhaphy;
67882 with transposition of tarsal plate
(For severing of tarsorrhaphy, use 67710)
(For canthoplasty, reconstruction canthus, use 67950)
(For canthotomy, use 67715)
Repair (Brow Ptosis, Blepharoptosis, Lid Retraction,

Ectropion, Entropion)
67900 Repair of brow ptosis (supraciliary, mid-forehead or

coronal approach)
(For forehead rhytidectomy, use 15824)
67901 Repair of blepharoptosis; frontalis muscle technique with
suture or other material (eg, banked fascia)
➲ CPT Assistant Sep 00:7, Oct 06:11, Jul 17:10
67902 frontalis muscle technique with autologous fascial sling
(includes obtaining fascia)
67903 (tarso) levator resection or advancement, internal

approach
67904 (tarso) levator resection or advancement, external

approach
➲ CPT Assistant Sep 00:7, Oct 06:11, Aug 11:8
67906 superior rectus technique with fascial sling (includes

obtaining fascia)
67908 conjunctivo-tarso-Muller’s muscle-levator resection (eg,

Fasanella-Servat type)
67909 Reduction of overcorrection of ptosis

67911 Correction of lid retraction
(For obtaining autologous graft materials, see 15769, 20920,
20922)
(For correction of lid defects using fat harvested via
liposuction technique, see 15773, 15774)
(For correction of trichiasis by mucous membrane graft, use
67835)
67912 Correction of lagophthalmos, with implantation of upper
eyelid lid load (eg, gold weight)
➲ CPT Assistant May 04:12, Aug 04:10, Oct 06:11
67914 Repair of ectropion; suture
67915 thermocauterization
67916 excision tarsal wedge
➲ CPT Assistant Feb 04:11, May 04:12, Feb 05:16, Oct
06:11
67917 extensive (eg, tarsal strip operations)
➲ CPT Assistant Feb 04:11, May 04:12, Oct 06:11, Feb
20:13, Mar 20:14
(For correction of everted punctum, use 68705)
67921 Repair of entropion; suture
67922 thermocauterization
67923 excision tarsal wedge
67924 extensive (eg, tarsal strip or capsulopalpebral fascia

repairs operation)
(For repair of cicatricial ectropion or entropion requiring

scar excision or skin graft, see also 67961 et seq)
Reconstruction
Codes for blepharoplasty involve more than skin (ie, involving

lid margin, tarsus, and/or palpebral conjunctiva).
67930 Suture of recent wound, eyelid, involving lid margin, tarsus,
and/or palpebral conjunctiva direct closure; partial
thickness
67935 full thickness
67938 Removal of embedded foreign body, eyelid
(For repair of skin of eyelid, see 12011-12018, 12051-

12057, 13151-13153)
(For tarsorrhaphy, canthorrhaphy, see 67880, 67882)
(For repair of blepharoptosis and lid retraction, see 67901-
67911)
(For blepharoplasty for entropion, ectropion, see 67916,
67917, 67923, 67924)
(For correction of blepharochalasis (blepharorhytidectomy),
see 15820-15823)
(For repair of skin of eyelid, adjacent tissue transfer, see
14060, 14061; preparation for graft, use 15004; free graft,
see 15120, 15121, 15260, 15261)
(For excision of lesion of eyelid, use 67800 et seq)
(For repair of lacrimal canaliculi, use 68700)
67950 Canthoplasty (reconstruction of canthus)
67961 Excision and repair of eyelid, involving lid margin, tarsus,
conjunctiva, canthus, or full thickness, may include
preparation for skin graft or pedicle flap with adjacent
tissue transfer or rearrangement; up to one-fourth of lid
margin
67966 over one-fourth of lid margin
(For canthoplasty, use 67950)

(For free skin grafts, see 15120, 15121, 15260, 15261)
(For tubed pedicle flap preparation, use 15576; for delay,
use 15630; for attachment, use 15650)
67971 Reconstruction of eyelid, full thickness by transfer of
tarsoconjunctival flap from opposing eyelid; up to two-
thirds of eyelid, 1 stage or first stage
67973 total eyelid, lower, 1 stage or first stage
67974 total eyelid, upper, 1 stage or first stage
67975 second stage
Other Procedures
67999 Unlisted procedure, eyelids
Conjunctiva
(For removal of foreign body, see 65205 et seq)

68020 Incision of conjunctiva, drainage of cyst
68040 Expression of conjunctival follicles (eg, for trachoma)
(To report automated evacuation of meibomian glands, use

0207T)
(For manual evacuation of meibomian glands, use 0563T)
Excision and/or Destruction

68100 Biopsy of conjunctiva
68110 Excision of lesion, conjunctiva; up to 1 cm
68115 over 1 cm
68130 with adjacent sclera
68135 Destruction of lesion, conjunctiva
Injection
(For injection into Tenon’s capsule or retrobulbar injection,
see 67500-67515)
68200 Subconjunctival injection
Conjunctivoplasty
(For wound repair, see 65270-65273)
68320 Conjunctivoplasty; with conjunctival graft or extensive
rearrangement
68325 with buccal mucous membrane graft (includes obtaining

graft)
68326 Conjunctivoplasty, reconstruction cul-de-sac; with
conjunctival graft or extensive rearrangement
68328 with buccal mucous membrane graft (includes obtaining
graft)
68330 Repair of symblepharon; conjunctivoplasty, without graft
68335 with free graft conjunctiva or buccal mucous membrane
68340 division of symblepharon, with or without insertion of
conformer or contact lens
Other Procedures
68360 Conjunctival flap; bridge or partial (separate procedure)
68362 total (such as Gunderson thin flap or purse string flap)
(For conjunctival flap for perforating injury, see 65280,
65285)
(For removal of conjunctival foreign body, see 65205,
65210)
68371 Harvesting conjunctival allograft, living donor
68399 Unlisted procedure, conjunctiva
Lacrimal System
Incision
68400 Incision, drainage of lacrimal gland
68420 Incision, drainage of lacrimal sac (dacryocystotomy or
dacryocystostomy)
68440 Snip incision of lacrimal punctum
Excision
68500 Excision of lacrimal gland (dacryoadenectomy), except for

tumor; total
68505 partial
68510 Biopsy of lacrimal gland
68520 Excision of lacrimal sac (dacryocystectomy)
68525 Biopsy of lacrimal sac
68530 Removal of foreign body or dacryolith, lacrimal passages
68540 Excision of lacrimal gland tumor; frontal approach
68550 involving osteotomy
Repair
68700 Plastic repair of canaliculi
68705 Correction of everted punctum, cautery
68720 Dacryocystorhinostomy (fistulization of lacrimal sac to

nasal cavity)
➲ CPT Assistant Sep 01:10, Jul 03:15, Aug 03:14, Aug
09:11
68745 Conjunctivorhinostomy (fistulization of conjunctiva to nasal
cavity); without tube
68750 with insertion of tube or stent
68760 Closure of the lacrimal punctum; by thermocauterization,
ligation, or laser surgery
68761 by plug, each
(For insertion and removal of drug-eluting implant into

lacrimal canaliculus for intra-ocular pressure, use 0356T)
(For placement of drug-eluting insert under the eyelid[s],
see 0444T, 0445T)
Closure of Lacrimal Punctum by Plug

68761
The physician inserts a lacrimal duct implant into a lacrimal punctum.
68770 Closure of lacrimal fistula (separate procedure)
Probing and/or Related Procedures

68801 Dilation of lacrimal punctum, with or without irrigation
(To report a bilateral procedure, use 68801 with modifier
50)
68810 Probing of nasolacrimal duct, with or without irrigation;

68811 requiring general anesthesia

68815 with insertion of tube or stent
➲ CPT Assistant Nov 02:11, Oct 08:3, Aug 09:11, Nov
10:9
(See also 92018)
lacrimal canaliculus for intra-ocular pressure, use 0356T)
see 0444T, 0445T)
68816 with transluminal balloon catheter dilation
Probing of Nasolacrimal Duct

68816
A balloon catheter is in the nasolacrimal duct.

68815)
68840 Probing of lacrimal canaliculi, with or without irrigation
68850 Injection of contrast medium for dacryocystography

78660)
Other Procedures
68899 Unlisted procedure, lacrimal system
Notes

Surgery
Auditory System (69000-69979)
Auditory System and Operating Microscope sections of the CPT codebook.
The subheadings or subsections denoted with asterisks (*) below have
special instructions unique to that subsection. Where these are indicated,
special notes or guidelines will be presented preceding those procedural
terminology listings, referring to that subsection specifically.
Ear Anatomy
External Ear (69000-69399)

Incision (69000-69090)
Excision (69100-69155)
Removal (69200-69222)
Repair (69300-69320)
Middle Ear (69420-69799)
Incision (69420-69450)
Excision (69501-69554)
Repair (69601-69676)
Inner Ear (69801-69949)
Incision and/or Destruction (69801-69806)
Excision (69905-69915)
Temporal Bone, Middle Fossa Approach (69950-69979)
Operating Microscope* (69990)
Auditory System
(For diagnostic services (eg, audiometry, vestibular tests),
see 92502 et seq)
External Ear
Incision
69000 Drainage external ear, abscess or hematoma; simple
➲ CPT Assistant Oct 97:11, Oct 99:10
69005 complicated
69020 Drainage external auditory canal, abscess
69090 Ear piercing
Excision
69100 Biopsy external ear
69105 Biopsy external auditory canal
69110 Excision external ear; partial, simple repair
69120 complete amputation
(For reconstruction of ear, see 15120 et seq)
69140 Excision exostosis(es), external auditory canal
69145 Excision soft tissue lesion, external auditory canal
69150 Radical excision external auditory canal lesion; without
neck dissection
69155 with neck dissection
(For resection of temporal bone, use 69535)
(For skin grafting, see 15004-15261)
Removal
69200 Removal foreign body from external auditory canal; without
general anesthesia
69205 with general anesthesia
69209 Removal impacted cerumen using irrigation/lavage,

unilateral
➲ CPT Assistant Jan 16:7, Feb 16:14, Mar 16:11

performed on the same ear)
(For removal of impacted cerumen requiring
instrumentation, use 69210)
▶ (For cerumen removal that is not impacted, see E/M
service code, which may include new or established patient
office or other outpatient services [99202-99215], hospital
observation services [99217-99220, 99224-99226],
hospital care [99221-99223, 99231-99233], consultations
[99241-99255], emergency department services [99281-
99285], nursing facility services [99304-99318],
domiciliary, rest home, or custodial care services [99324-
99337], home services [99341-99350])◀
69210 Removal impacted cerumen requiring instrumentation,
unilateral
➲ CPT Assistant Apr 03:9, Jul 05:14, Oct 13:14, Nov
14:14, Jan 16:7, Feb 16:14, Mar 16:11
performed on the same ear)
(For removal of impacted cerumen achieved with irrigation
and/or lavage but without instrumentation, use 69209)
▶ (For cerumen removal that is not impacted, see E/M
service code, which may include new or established patient
office or other outpatient services [99202-99215], hospital
observation services [99217-99220, 99224-99226],
hospital care [99221-99223, 99231-99233], consultations
99337], home services [99341-99350])◀
69220 Debridement, mastoidectomy cavity, simple (eg, routine
cleaning)
69222 Debridement, mastoidectomy cavity, complex (eg, with
anesthesia or more than routine cleaning)
Repair
(For suture of wound or injury of external ear, see 12011-
14302)
69300 Otoplasty, protruding ear, with or without size reduction
69310 Reconstruction of external auditory canal (meatoplasty) (eg,
for stenosis due to injury, infection) (separate procedure)
69320 Reconstruction external auditory canal for congenital

atresia, single stage
(For combination with middle ear reconstruction, see
69631, 69641)
(For other reconstructive procedures with grafts (eg, skin,
cartilage, bone), see 13151-15760, 21230-21235)
Other Procedures
(For otoscopy under general anesthesia, use 92502)
69399 Unlisted procedure, external ear
Middle Ear
Incision
69420 Myringotomy including aspiration and/or eustachian tube
inflation
69421 Myringotomy including aspiration and/or eustachian tube

inflation requiring general anesthesia
69424 Ventilating tube removal requiring general anesthesia

➲ CPT Assistant Mar 05:17, Jun 10:11, Nov 10:9

(Do not report code 69424 in conjunction with 69205,
69210, 69420, 69421, 69433-69676, 69710-69745, 69801-
69930)
69433 Tympanostomy (requiring insertion of ventilating tube),
local or topical anesthesia

(For tympanostomy requiring insertion of ventilating tube,
with iontophoresis, using an automated tube delivery system,
use 0583T)
69436 Tympanostomy (requiring insertion of ventilating tube),
general anesthesia
➲ CPT Assistant May 11:8, May 12:14, Feb 18:11

69440 Middle ear exploration through postauricular or ear canal
incision
(For atticotomy, see 69601 et seq)
69450 Tympanolysis, transcanal
Tympanostomy
69433-69436
A ventilating tube is inserted into the opening of the tympanum.
Excision
69501 Transmastoid antrotomy (simple mastoidectomy)
69502 Mastoidectomy; complete
69505 modified radical
69511 radical
(For skin graft, see 15004 et seq)
(For mastoidectomy cavity debridement, see 69220, 69222)
69530 Petrous apicectomy including radical mastoidectomy
69535 Resection temporal bone, external approach
(For middle fossa approach, see 69950-69970)
69540 Excision aural polyp
69550 Excision aural glomus tumor; transcanal
69552 transmastoid
69554 extended (extratemporal)
Repair
69601 Revision mastoidectomy; resulting in complete
mastoidectomy
69602 resulting in modified radical mastoidectomy
69603 resulting in radical mastoidectomy
69604 resulting in tympanoplasty
(For planned secondary tympanoplasty after mastoidectomy,
see 69631, 69632)
(For skin graft, see 15120, 15121, 15260, 15261)
69610 Tympanic membrane repair, with or without site preparation
of perforation for closure, with or without patch
➲ CPT Assistant Mar 01:10, Mar 03:21, Aug 08:4, Apr
15:11, May 15:11
69620 Myringoplasty (surgery confined to drumhead and donor
area)
➲ CPT Assistant Mar 01:10, Aug 08:4, Apr 15:11, May
15:11
69631 Tympanoplasty without mastoidectomy (including
canalplasty, atticotomy and/or middle ear surgery), initial or
revision; without ossicular chain reconstruction
➲ CPT Assistant Jul 98:11, Mar 01:10, Mar 07:9, Aug
08:4, Dec 12:11
69632 with ossicular chain reconstruction (eg, postfenestration)
69633 with ossicular chain reconstruction and synthetic
prosthesis (eg, partial ossicular replacement prosthesis
[PORP], total ossicular replacement prosthesis [TORP])
69635 Tympanoplasty with antrotomy or mastoidotomy (including
canalplasty, atticotomy, middle ear surgery, and/or tympanic
membrane repair); without ossicular chain reconstruction
69636 with ossicular chain reconstruction
Tympanoplasty
69635-69646
A graft is used to repair the tympanic membrane perforation.
69637 with ossicular chain reconstruction and synthetic

prosthesis (eg, partial ossicular replacement prosthesis
[PORP], total ossicular replacement prosthesis [TORP])
69641 Tympanoplasty with mastoidectomy (including canalplasty,
middle ear surgery, tympanic membrane repair); without
ossicular chain reconstruction
69642 with ossicular chain reconstruction
69643 with intact or reconstructed wall, without ossicular chain
reconstruction
69644 with intact or reconstructed canal wall, with ossicular
chain reconstruction
69645 radical or complete, without ossicular chain
reconstruction
69646 radical or complete, with ossicular chain reconstruction
69650 Stapes mobilization
69660 Stapedectomy or stapedotomy with reestablishment of
ossicular continuity, with or without use of foreign material;
69661 with footplate drill out
69662 Revision of stapedectomy or stapedotomy
69666 Repair oval window fistula
69667 Repair round window fistula
69670 Mastoid obliteration (separate procedure)
69676 Tympanic neurectomy
Other Procedures
69700 Closure postauricular fistula, mastoid (separate procedure)
● 69705 Nasopharyngoscopy, surgical, with dilation of eustachian
tube (ie, balloon dilation); unilateral
● 69706 bilateral
▶ (Donot report 69705, 69706 in conjunction with 31231,

92511)◀
69710 Implantation or replacement of electromagnetic bone
conduction hearing device in temporal bone
(Replacement procedure includes removal of old device)
69711 Removal or repair of electromagnetic bone conduction
hearing device in temporal bone
69714 Implantation, osseointegrated implant, temporal bone, with
percutaneous attachment to external speech
processor/cochlear stimulator; without mastoidectomy
69715 with mastoidectomy

69717 Replacement (including removal of existing device),

osseointegrated implant, temporal bone, with percutaneous
attachment to external speech processor/cochlear stimulator;
without mastoidectomy

69720 Decompression facial nerve, intratemporal; lateral to

geniculate ganglion
69725 including medial to geniculate ganglion
69740 Suture facial nerve, intratemporal, with or without graft or
decompression; lateral to geniculate ganglion
69745 including medial to geniculate ganglion
(For extracranial suture of facial nerve, use 64864)
69799 Unlisted procedure, middle ear
Inner Ear
Incision and/or Destruction
69801 Labyrinthotomy, with perfusion of vestibuloactive drug(s),
transcanal

69433, 69436 when performed on the same ear)
69805 Endolymphatic sac operation; without shunt
69806 with shunt
Excision
69905 Labyrinthectomy; transcanal
69915 Vestibular nerve section, translabyrinthine approach
(For transcranial approach, use 69950)
Introduction
69930 Cochlear device implantation, with or without
mastoidectomy
Cochlear Device Implantation

69930
An internal coil is attached to the temporal bone and the ground wire attached to the internal coil is
connected to the temporalis muscle.
Other Procedures
69949 Unlisted procedure, inner ear
Temporal Bone, Middle Fossa Approach

(For external approach, use 69535)
69950 Vestibular nerve section, transcranial approach
69955 Total facial nerve decompression and/or repair (may
include graft)
69960 Decompression internal auditory canal
69970 Removal of tumor, temporal bone
Other Procedures
69979 Unlisted procedure, temporal bone, middle fossa approach
The surgical microscope is employed when the surgical services
are performed using the techniques of microsurgery. Code 69990
should be reported (without modifier 51 appended) in addition to
the code for the primary procedure performed. Do not use 69990
for visualization with magnifying loupes or corrected vision. Do
not report 69990 in addition to procedures where use of the
operating microscope is an inclusive component (15756-15758,
15842, 19364, 19368, 20955-20962, 20969-20973, 22551, 22552,
22856-22861, 26551-26554, 26556, 31526, 31531, 31536, 31541,
31545, 31546, 31561, 31571, 43116, 43180, 43496, 46601, 46607,
49906, 61548, 63075-63078, 64727, 64820-64823, 64912, 64913,
65091-68850, 0184T, 0308T, 0402T, 0583T).
✚ 69990 Microsurgical techniques, requiring use of operating
microscope (List separately in addition to code for primary
procedure)
➲ CPT Assistant Nov 98:20, Apr 99:11, Jun 99:11, Jul
99:10, Oct 99:10, Oct 00:3, Oct 02:8, Jan 04:28, Mar
05:11, Jul 05:14, Aug 05:1, Nov 07:4, Sep 08:10, Mar
09:10, Dec 11:14, Mar 12:9, Jun 12:17, Dec 12:13, Oct
13:14, Jan 14:8, Apr 14:10, Sep 14:13-14, Feb 16:12,
Dec 17:13, Feb 18:11
69990
A surgical operating microscope is used to obtain good visualization of the fine structures in the
operating field. The lens system may be operated by hand or foot controls to adjust to working distance,
with interchangeable oculars providing magnification as needed.
Notes

Radiology Guidelines (Including Nuclear
Medicine and Diagnostic Ultrasound)
Subject Listings
Separate Procedures
Special Report
Supervision and Interpretation, Imaging Guidance
Administration of Contrast Material(s)
Written Report(s)
Radiology
Radiology section of the CPT codebook. The subheadings or subsections
denoted with asterisks (*) below have special instructions unique to that
subsection. Where these are indicated, special notes or guidelines will be
presented preceding those procedural terminology listings, referring to that
Diagnostic Radiology (Diagnostic Imaging) (70010-76499)
Head and Neck (70010-70559)
Chest (71045-71555)
Spine and Pelvis (72020-72295)
Upper Extremities (73000-73225)
Lower Extremities (73501-73725)
Abdomen (74018-74190)
Gastrointestinal Tract (74210-74363)
Urinary Tract (74400-74485)
Gynecological and Obstetrical (74710-74775)
Heart (75557-75574)
Vascular Procedures (75600-75989)
Aorta and Arteries* (75600-75774)
Veins and Lymphatics* (75801-75893)
Transcatheter Procedures* (75894-75989)
Diagnostic Ultrasound* (76506-76999)
Head and Neck (76506-76536)
Chest* (76604-76642)
Abdomen and Retroperitoneum* (76700-76776)
Spinal Canal (76800)
Pelvis (76801-76857)
Obstetrical* (76801-76828)
Nonobstetrical* (76830-76857)
Genitalia (76870-76873)
Extremities* (76881-76886)
Ultrasonic Guidance Procedures (76932-76965)
Radiologic Guidance (77001-77022)
Fluoroscopic Guidance (77001-77003)
Computed Tomography Guidance (77011-77014)
Magnetic Resonance Imaging Guidance (77021-77022)
Breast, Mammography (77046-77067)
Bone/Joint Studies (77071-77086)
Radiation Oncology* (77261-77799)
Consultation: Clinical Management*
Clinical Treatment Planning (External and Internal
Sources)* (77261-77293, 77299)
Medical Radiation Physics, Dosimetry, Treatment Devices,
and Special Services (77295, 77300-77370)
Stereotactic Radiation Treatment Delivery (77371-77373)
Radiation Treatment Delivery* (77385-77387, 77401-77417,
77424-77425)
Neutron Beam Treatment Delivery (77423)
Radiation Treatment Management* (77427-77499)
Proton Beam Treatment Delivery* (77520-77525)
Hyperthermia* (77600-77615)
Clinical Intracavitary Hyperthermia (77620)
Clinical Brachytherapy* (77750-77799)
Nuclear Medicine* (78012-79999)
Diagnostic (78012-78999)
Endocrine System (78012-78099)
Hematopoietic, Reticuloendothelial and Lymphatic System (78102-
78199)
Gastrointestinal System (78201-78299)
Musculoskeletal System* (78300-78399)
Cardiovascular System* (78414-78499)
Respiratory System (78579-78599)
Genitourinary System (78700-78799)
Therapeutic* (79005-79999)
Endocrine System
Radiology Guidelines (Including
Nuclear Medicine and Diagnostic
Ultrasound)
for the convenience of those referring to this section on
Ultrasound). Other definitions and items unique to Radiology
are also listed.
Subject Listings
Subject listings apply when radiological services are performed
by or under the responsible supervision of a physician or other
qualified health care professional.
Separate Procedures
component.
session or patient encounter, different procedure or surgery,
different site or organ system, separate incision/excision, separate
lesion, separate injury, or area of injury in extensive injuries.

the service, identifying it by “Special Report” as discussed below.
The “Unlisted Procedures” and accompanying codes for
Ultrasound) are as follows:
76496 Unlisted fluoroscopic procedure (eg, diagnostic,
interventional)
76497 Unlisted computed tomography procedure (eg, diagnostic,
interventional)
76498 Unlisted magnetic resonance procedure (eg, diagnostic,
interventional)
76499 Unlisted diagnostic radiographic procedure
76999 Unlisted ultrasound procedure (eg, diagnostic,
interventional)
77299 Unlisted procedure, therapeutic radiology clinical treatment
planning
77399 Unlisted procedure, medical radiation physics, dosimetry
and treatment devices, and special services
77499 Unlisted procedure, therapeutic radiology treatment
management
77799 Unlisted procedure, clinical brachytherapy
78099 Unlisted endocrine procedure, diagnostic nuclear medicine
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic
procedure, diagnostic nuclear medicine
78299 Unlisted gastrointestinal procedure, diagnostic nuclear
medicine
78399 Unlisted musculoskeletal procedure, diagnostic nuclear
medicine
78499 Unlisted cardiovascular procedure, diagnostic nuclear
medicine
78599 Unlisted respiratory procedure, diagnostic nuclear medicine
78699 Unlisted nervous system procedure, diagnostic nuclear
medicine
78799 Unlisted genitourinary procedure, diagnostic nuclear
medicine
78999 Unlisted miscellaneous procedure, diagnostic nuclear
medicine
79999 Radiopharmaceutical therapy, unlisted procedure
Special Report
for the procedure; and the time, effort, and equipment necessary
Supervision and Interpretation,

Imaging Guidance
Imaging may be required during the performance of certain
procedures or certain imaging procedures may require surgical
procedures to access the imaged area. Many services include
image guidance, and imaging guidance is not separately
reportable when it is included in the base service. The CPT code
set typically defines in descriptors and/or guidelines when
imaging guidance is included. When imaging is not included in a
surgical procedure or procedure from the Medicine section,
image guidance codes or codes labeled “radiological supervision
and interpretation” (RS&I) may be reported for the portion of the
service that requires imaging. All imaging guidance codes
require: (1) image documentation in the patient record and (2)
description of imaging guidance in the procedure report. All
RS&I codes require: (1) image documentation in the patient’s
permanent record and (2) a procedure report or separate imaging
report that includes written documentation of interpretive
findings of information contained in the images and radiologic
supervision of the service.
(The RS&I codes are not applicable to the Radiation Oncology
subsection.)
Administration of Contrast
Material(s)
The phrase “with contrast” used in the codes for procedures
performed using contrast for imaging enhancement represents
contrast material administered intravascularly, intra-articularly, or
intrathecally.
For intra-articular injection, use the appropriate joint injection
code. If radiographic arthrography is performed, also use the
arthrography supervision and interpretation code for the
appropriate joint (which includes fluoroscopy). If computed
tomography (CT) or magnetic resonance (MR) arthrography are
performed without radiographic arthrography, use the
appropriate joint injection code, the appropriate CT or MR code
(“with contrast” or “without followed by contrast”), and the
appropriate imaging guidance code for needle placement for
contrast injection.
For spine examinations using computed tomography, magnetic
resonance imaging, magnetic resonance angiography, “with
contrast” includes intrathecal or intravascular injection. For
intrathecal injection, use also 61055 or 62284.
Injection of intravascular contrast material is part of the “with
contrast” CT, computed tomographic angiography (CTA),
magnetic resonance imaging (MRI), and magnetic resonance
angiography (MRA) procedures.
Oral and/or rectal contrast administration alone does not qualify
as a study “with contrast.”
Written Report(s)
A written report (eg, handwritten or electronic) signed by the
interpreting individual should be considered an integral part of a
radiologic procedure or interpretation.
With regard to CPT descriptors for imaging services, “images”
must contain anatomic information unique to the patient for
which the imaging service is provided. “Images” refer to those
acquired in either an analog (ie, film) or digital (ie, electronic)
manner.

Radiology
Diagnostic Radiology (Diagnostic

Imaging)
Head and Neck
70010 Myelography, posterior fossa, radiological supervision and
interpretation
70015 Cisternography, positive contrast, radiological supervision

and interpretation
70030 Radiologic examination, eye, for detection of foreign body
70100 Radiologic examination, mandible; partial, less than 4
views
70110 complete, minimum of 4 views
70120 Radiologic examination, mastoids; less than 3 views per
side
70130 complete, minimum of 3 views per side
70134 Radiologic examination, internal auditory meati, complete
70140 Radiologic examination, facial bones; less than 3 views
70160 Radiologic examination, nasal bones, complete, minimum of
3 views
70170 Dacryocystography, nasolacrimal duct, radiological
70190 Radiologic examination; optic foramina
70200 orbits, complete, minimum of 4 views
70210 Radiologic examination, sinuses, paranasal, less than 3
views
70220 Radiologic examination, sinuses, paranasal, complete,
minimum of 3 views
70240 Radiologic examination, sella turcica
70250 Radiologic examination, skull; less than 4 views

70300 Radiologic examination, teeth; single view

70310 partial examination, less than full mouth
70320 complete, full mouth
70328 Radiologic examination, temporomandibular joint, open and
closed mouth; unilateral
70330 bilateral
70332 Temporomandibular joint arthrography, radiological


70336 Magnetic resonance (eg, proton) imaging,
temporomandibular joint(s)
➲ CPT Assistant Jul 99:11, Jul 01:7, Aug 15:6
70350 Cephalogram, orthodontic

70355 Orthopantogram (eg, panoramic x-ray)
70360 Radiologic examination; neck, soft tissue

70370 pharynx or larynx, including fluoroscopy and/or
magnification technique
70371 Complex dynamic pharyngeal and speech evaluation by cine
or video recording
(For laryngeal computed tomography, see 70490, 70491,

70492)
70380 Radiologic examination, salivary gland for calculus
70390 Sialography, radiological supervision and interpretation
70450 Computed tomography, head or brain; without contrast

material
➲ Clinical Examples in Radiology Winter 08:6, Fall 14:8
70460 with contrast material(s)

14:8
70470 without contrast material, followed by contrast
material(s) and further sections
(To report 3D rendering, see 76376, 76377)

70480 Computed tomography, orbit, sella, or posterior fossa or
outer, middle, or inner ear; without contrast material


70486 Computed tomography, maxillofacial area; without contrast
material
➲ Clinical Examples in Radiology Winter 07:4-5, Spring
07:4, Fall 09:9
70490 Computed tomography, soft tissue neck; without contrast
material

70492 without contrast material followed by contrast
(For cervical spine, see 72125, 72126)
70496 Computed tomographic angiography, head, with contrast
material(s), including noncontrast images, if performed, and
image postprocessing
➲ CPT Assistant Jul 01:4, Dec 05:7, Jan 07:31
70498 Computed tomographic angiography, neck, with contrast
19:11
70540 Magnetic resonance (eg, proton) imaging, orbit, face, and/or
neck; without contrast material(s)
➲ CPT Assistant Jul 01:6, Mar 07:7, Sep 10:10
07:7, Summer 13:9
(For head or neck magnetic resonance angiography studies,
see 70544-70546, 70547-70549)
Summer 07:7, Summer 13:9
70543 without contrast material(s), followed by contrast
material(s) and further sequences
➲ Clinical Examples in Radiology Spring 05:2-3,
Winter 07:7, Summer 07:7, 11, Summer 13:9
(Report 70540-70543 once per imaging session)
70544 Magnetic resonance angiography, head; without contrast
material(s)
➲ CPT Assistant Sep 01:5, Dec 05:7, Jan 07:31
➲ CPT Assistant Jul 01:5, Dec 05:7

70547 Magnetic resonance angiography, neck; without contrast

material(s)


70551 Magnetic resonance (eg, proton) imaging, brain (including

brain stem); without contrast material
➲ CPT Assistant May 98:10, Mar 05:20, Feb 07:6

➲ CPT Assistant Jul 01:6, Mar 05:20, Feb 07:6
➲ CPT Assistant Nov 97:24, Jul 01:6, Mar 05:20, Feb
07:6
06:4-5, Spring 15:9, Summer 15:13
(For magnetic spectroscopy, use 76390)
Functional MRI involves identification and mapping of
stimulation of brain function. When neurofunctional tests are
administered by a technologist or other non-physician or non-
psychologist, use 70554. When neurofunctional tests are entirely
administered by a physician or psychologist, use 70555.
70554 Magnetic resonance imaging, brain, functional MRI;
including test selection and administration of repetitive body
part movement and/or visual stimulation, not requiring
physician or psychologist administration
➲ CPT Assistant Feb 07:6, Mar 07:7, Aug 08:13

70555 requiring physician or psychologist administration of
entire neurofunctional testing
(Do not report 70555 unless 96020 is performed)

(Do not report 70554, 70555 in conjunction with 70551-
70553 unless a separate diagnostic MRI is performed)
70557 Magnetic resonance (eg, proton) imaging, brain (including
brain stem and skull base), during open intracranial
procedure (eg, to assess for residual tumor or residual
vascular malformation); without contrast material

(For stereotactic biopsy of intracranial lesion with magnetic

resonance guidance, use 61751,70557, 70558, or 70559
may be reported only if a separate report is generated.
Report only 1 of the above codes once per operative
session. Do not use these codes in conjunction with 61751,
77021, 77022)
Chest
(For fluoroscopic or ultrasonic guidance for needle
placement procedures (eg, biopsy, aspiration, injection,
localization device) of the thorax, see 76942, 77002)
71048)
71045 Radiologic examination, chest; single view
➲
CPT Assistant Apr 18:7, Mar 19:10, May 19:10, Aug
19:8
19:14
71046 2 views
➲ CPT Assistant Apr 18:7, Mar 19:10, Aug 19:8
19:14
71047 3 views
19:14
71048 4 or more views
19:14
(For complete acute abdomen series that includes 2 or more
views of the abdomen [eg, supine, erect, decubitus], and a
single view chest, use 74022)
(For concurrent computer-aided detection [CAD] performed
in addition to 71045, 71046, 71047, 71048, use 0174T)
with 0175T for computer-aided detection [CAD] performed
remotely from the primary interpretation)
71100 Radiologic examination, ribs, unilateral; 2 views
71101 including posteroanterior chest, minimum of 3 views

71110 Radiologic examination, ribs, bilateral; 3 views
71111 including posteroanterior chest, minimum of 4 views

71120 Radiologic examination; sternum, minimum of 2 views

71130 sternoclavicular joint or joints, minimum of 3 views
▲ 71250 Computed tomography, thorax, diagnostic; without contrast
material
➲ CPT Assistant Jul 07:13, Aug 11:10, Fall 13:9, 10
18:17, Summer 19:10
▲ 71260 with contrast material(s)
➲ CPT Assistant Jul 01:4, Jun 09:9, Fall 13:9, 10
08:7, 11, 12
▲ 71270 without contrast material, followed by contrast
➲ Clinical Examples in Radiology Fall 08:7, Fall 13:9,
10
71271)◀
▶ (Do not report 71250, 71260, 71270 for breast CT
procedures)◀
(For cardiac computed tomography of the heart, see 75571-
75574)
● 71271 Computed tomography, thorax, low dose for lung cancer
screening, without contrast material(s)

71270)◀
▶ (Do not report 71271 for breast CT procedures)◀
▶ (Forcardiac computed tomography of the heart, see
75571, 75572, 75573, 75574)◀
71275 Computed tomographic angiography, chest (noncoronary),
with contrast material(s), including noncontrast images, if
performed, and image postprocessing
➲ CPT Assistant Jul 01:4, Jun 05:11, Dec 05:7, Jan 07:31,
Mar 07:7, Jun 09:9, Aug 11:10
12, Spring 09:11, Fall 09:10, Winter 10:2, Fall 13:9, 10,
Spring 16:13
(For coronary artery computed tomographic angiography
including calcification score and/or cardiac morphology,
use 75574)
71550 Magnetic resonance (eg, proton) imaging, chest (eg, for
evaluation of hilar and mediastinal lymphadenopathy);
without contrast material(s)
➲ CPT Assistant Jul 01:7, Apr 10:10, Sep 10:10


➲ CPT Assistant Jul 01:7, Apr 10:10, Sep 10:10
(For breast MRI, see 77046, 77047, 77048, 77049)

71555 Magnetic resonance angiography, chest (excluding
myocardium), with or without contrast material(s)
➲ CPT Assistant Fall 95:2, Dec 05:7, Jan 07:31
17:14
Spine and Pelvis

72020 Radiologic examination, spine, single view, specify level
➲ CPT Assistant Jul 13:10, Oct 15:9
➲ Clinical Examples in Radiology Spring 13:8, 9, Winter
18:15
(For a single view that includes the entire thoracic and
lumbar spine, use 72081)
72040 Radiologic examination, spine, cervical; 2 or 3 views
➲ CPT Assistant Sep 01:7, Jul 13:10, Aug 18:11
11:8, Fall 11:9, Spring 13:8, 9, Winter 18:15
72050 4 or 5 views
11:9, Spring 13:9, Winter 18:15
11:9, Spring 13:9, Winter 18:15
72070 Radiologic examination, spine; thoracic, 2 views
Winter 18:15
72072 thoracic, 3 views
13:9, Winter 18:15
72074 thoracic, minimum of 4 views
13:9, Winter 18:15
72080 thoracolumbar junction, minimum of 2 views
➲ CPT Assistant Sep 01:7, Oct 15:9, Sep 16:4
13:8, 9, Fall 15:7, Winter 18:15
(For a single view examination of the thoracolumbar
junction, use 72020)
72081 Radiologic examination, spine, entire thoracic and lumbar,
including skull, cervical and sacral spine if performed (eg,
scoliosis evaluation); one view
72082 2 or 3 views
18:15
72083 4 or 5 views
18:15
72084 minimum of 6 views
18:15
72100 Radiologic examination, spine, lumbosacral; 2 or 3 views
➲ Clinical Examples in Radiology Fall 11:9, 10, Spring
13:8, 9, Spring 14:10, Winter 18:15
13:9, Winter 18:15
72114 complete, including bending views, minimum of 6 views
72120 bending views only, 2 or 3 views
➲ Clinical Examples in Radiology Fall 11:9, 10,
Spring 13:8, 9, Spring 14:10, Winter 18:15
(Contrast material in CT of spine is either by intrathecal or
intravenous injection. For intrathecal injection, use also
61055 or 62284. IV injection of contrast material is part of
the CT procedure)
72125 Computed tomography, cervical spine; without contrast
material
72126 with contrast material

19:11
(For intrathecal injection procedure, see 61055, 62284)
72128 Computed tomography, thoracic spine; without contrast
material

➲ CPT Assistant Sep 14:3, Jan 19:15

72131 Computed tomography, lumbar spine; without contrast
material
12:10
➲ CPT Assistant Fall 93:13, Sep 14:3, Jan 19:15
➲ Clinical Examples in Radiology Fall 06:5-6, 11-12,
Fall 14:6, Fall 15:10

72141 Magnetic resonance (eg, proton) imaging, spinal canal and
contents, cervical; without contrast material

(For cervical spinal canal imaging without contrast material

followed by contrast material, use 72156)
▶ (For magnetic resonance spectroscopy, determination and
localization of discogenic pain, see 0609T, 0610T)◀
contents, thoracic; without contrast material
➲ CPT Assistant May 99:10, Apr 10:10, Jun 14:14

(For thoracic spinal canal imaging without contrast material

contents, lumbar; without contrast material
➲ Clinical Examples in Radiology Spring 06:6, 11
(For lumbar spinal canal imaging without contrast material
contents, without contrast material, followed by contrast
material(s) and further sequences; cervical
72157 thoracic
72158 lumbar
72159 Magnetic resonance angiography, spinal canal and contents,
with or without contrast material(s)
72170 Radiologic examination, pelvis; 1 or 2 views

➲ CPT Assistant Sep 01:7, Mar 03:23, Aug 16:7
➲ Clinical Examples in Radiology Spring 05:12, Fall
15:8, Winter 16:13, Summer 16:8
16:13, Summer 16:8
(For pelvimetry, use 74710)
(For a combined computed tomography [CT] or computed
tomographic angiography abdomen and pelvis study, see
74174, 74176-74178)
72191 Computed tomographic angiography, pelvis, with contrast
➲ CPT Assistant Jul 01:4, 6, Dec 05:7, Jan 07:31
09:10, Fall 11:9
(Do not report 72191 in conjunction with 73706 or 75635.
For CTA aorto-iliofemoral runoff, use 75635)
(Do not report 72191 in conjunction with 74175. For a
combined computed tomographic angiography abdomen and
pelvis study, use 74174)
72192 Computed tomography, pelvis; without contrast material
➲ CPT Assistant Mar 05:1, 4, Mar 07:10, Apr 10:9, Nov
11:6, Oct 12:12
07:3, 11, Summer 07:11, Fall 09:9, Winter 11:8-10, Fall
11:8, Spring 16:9
➲ CPT Assistant Mar 05:1, 4, Mar 07:10, Apr 10:9,
Nov 11:6, Oct 12:12
Spring 07:3, 11, Winter 11:8-10, Fall 11:8, Spring
16:9
➲ CPT Assistant Mar 05:1, 4, Mar 07:10, Apr 10:9,
Nov 11:6, Oct 12:12
➲ Clinical Examples in Radiology Spring 07:3, 11,
Winter 11:8-10, Fall 11:8, Spring 16:9
(For a combined CT abdomen and pelvis study, see 74176-
74178)
(For computed tomographic colonography, diagnostic, see
74261-74262. For computed tomographic colonography,
screening, use 74263)
74263)
72195 Magnetic resonance (eg, proton) imaging, pelvis; without
contrast material(s)
➲ CPT Assistant Jul 01:7, Jun 06:17, Jun 14:14, Jun 16:5,
Jul 18:11
➲ Clinical Examples in Radiology Spring 06:8-9, Fall
06:7-8, Summer 07:4, 5, Winter 16:12, Spring 18:12,
Spring 19:12
➲ CPT Assistant Jul 01:7, Jun 06:17, Jun 16:5, Jul
18:11
06:7-8, Winter 16:12, Spring 18:12, Spring 19:12
➲ CPT Assistant Jul 01:7, Jun 16:5, Jul 18:11
06:2-3, 7-8, Spring 15:10, Winter 16:12, Spring
18:12, Spring 19:12
74712, 74713)
(For magnetic resonance imaging of a fetus[es], see 74712,
74713)
72198 Magnetic resonance angiography, pelvis, with or without
72200 Radiologic examination, sacroiliac joints; less than 3 views

72220 Radiologic examination, sacrum and coccyx, minimum of 2
views
72240 Myelography, cervical, radiological supervision and
interpretation
➲ Clinical Examples in Radiology Fall 06:5-6, 11-12, Fall
14:6, 7, 11, Fall 15:10
62303, 62304, 62305)
(When both 62284 and 72240 are performed by the same
physician or other qualified health care professional for
cervical myelography, use 62302)
(For complete cervical myelography via injection procedure
at C1-C2, see 61055, 72240)
72255 Myelography, thoracic, radiological supervision and
interpretation
15:10
62303, 62304, 62305)
thoracic myelography, use 62303)
(For complete thoracic myelography via injection procedure
at C1-C2, see 61055, 72255)
72265 Myelography, lumbosacral, radiological supervision and
interpretation
➲ CPT Assistant Fall 93:13, Aug 00:7, Sep 14:3
15:10
62303, 62304, 62305)
lumbosacral myelography, use 62304)
(For complete lumbosacral myelography via injection
procedure at C1-C2, see 61055, 72265)
72270 Myelography, 2 or more regions (eg, lumbar/thoracic,
cervical/thoracic, lumbar/cervical,
lumbar/thoracic/cervical), radiological supervision and
interpretation
➲ Clinical Examples in Radiology Fall 14:6, 7, 11, Fall
15:10
62303, 62304, 62305)
myelography of 2 or more regions, use 62305)
(For complete myelography of 2 or more regions via
injection procedure at C1-C2, see 61055, 72270)
72275 Epidurography, radiological supervision and interpretation
CPT Assistant Nov 99:40, Jan 00:2, Aug 00:7, Jul 08:9,
➲ Oct 09:12, Feb 10:12, May 10:10, Jun 12:12, Jul 12:5,
May 17:3
(72275 includes 77003)
(For injection procedure, see 62280, 62281, 62282, 62320,
62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479,
64480, 64483, 64484)
(Use 72275 only when an epidurogram is performed, images
documented, and a formal radiologic report is issued)
Epidurography
72275
72285 Discography, cervical or thoracic, radiological supervision
and interpretation
➲ CPT Assistant Nov 99:35, 40, Mar 11:7
72295 Discography, lumbar, radiological supervision and

interpretation
➲ CPT Assistant Apr 03:27, Mar 11:7, Jul 12:3
Upper Extremities
(For stress views, any joint, use 77071)
73000 Radiologic examination; clavicle, complete
73010 scapula, complete
73020 Radiologic examination, shoulder; 1 view
73040 Radiologic examination, shoulder, arthrography,
➲ CPT Assistant Jul 01:7, Feb 07:11
09:6, 7, Summer 18:14
73050 Radiologic examination; acromioclavicular joints, bilateral,
with or without weighted distraction
73060 humerus, minimum of 2 views
73070 Radiologic examination, elbow; 2 views

73085 Radiologic examination, elbow, arthrography, radiological

73090 Radiologic examination; forearm, 2 views
73092 upper extremity, infant, minimum of 2 views
73100 Radiologic examination, wrist; 2 views
➲ CPT Assistant Winter 90:9, Sep 01:8, Oct 18:11

➲ CPT Assistant Mar 97:10, Nov 06:22, Oct 18:11
73115 Radiologic examination, wrist, arthrography, radiological


73120 Radiologic examination, hand; 2 views

11:8
73140 Radiologic examination, finger(s), minimum of 2 views
73200 Computed tomography, upper extremity; without contrast

material

Summer 18:14
73206 Computed tomographic angiography, upper extremity, with
contrast material(s), including noncontrast images, if
73218 Magnetic resonance (eg, proton) imaging, upper extremity,

other than joint; without contrast material(s)
➲ CPT Assistant Jul 01:7, Sep 10:10, Feb 11:9


73221 Magnetic resonance (eg, proton) imaging, any joint of upper

extremity; without contrast material(s)
➲ CPT Assistant Jul 01:7, Sep 10:10, Feb 11:9

➲ CPT Assistant Jul 01:7, Sep 10:10, Aug 15:6
Summer 13:9
Summer 13:9
73225 Magnetic resonance angiography, upper extremity, with or
Lower Extremities
(For stress views, any joint, use 77071)
73501 Radiologic examination, hip, unilateral, with pelvis when
performed; 1 view
➲ CPT Assistant Oct 15:9, Jun 16:9, Aug 16:7, Nov 16:10
16:14, Summer 16:9, 13
73502 2-3 views
➲ CPT Assistant Oct 15:9, Jun 16:9, Aug 16:7, Nov
16:10
16:14, Summer 16:8, 13
16:10
➲
Clinical Examples in Radiology Fall 15:9, Summer
16:9, 13
73521 Radiologic examination, hips, bilateral, with pelvis when
performed; 2 views
➲ CPT Assistant Oct 15:9, Jun 16:9, Aug 16:7, Nov 16:10
16:13, Summer 16:9, 13
73522 3-4 views
16:10
16:13, Summer 16:9, 13
16:10
16:13, Summer 16:9, 13
73525 Radiologic examination, hip, arthrography, radiological
➲ CPT Assistant Feb 07:11, Jun 12:14, Nov 16:10

73551 Radiologic examination, femur; 1 view
73552 minimum 2 views

➲ CPT Assistant Aug 16:7, Nov 16:10, Nov 17:10
73560 Radiologic examination, knee; 1 or 2 views
➲ CPT Assistant Feb 15:10, May 15:10
73562 3 views
73564 complete, 4 or more views

➲ CPT Assistant Jun 98:11, Nov 98:21, Feb 15:10, May
15:10
15:11
73565 both knees, standing, anteroposterior
➲ CPT Assistant Winter 90:9, Feb 15:10, May 15:10
15:11
73580 Radiologic examination, knee, arthrography, radiological
➲ CPT Assistant Feb 07:11, Aug 15:6, Aug 19:7
19:15
73590 Radiologic examination; tibia and fibula, 2 views
73592 lower extremity, infant, minimum of 2 views

73600 Radiologic examination, ankle; 2 views

➲ CPT Assistant Sep 01:8, Apr 02:15, Mar 03:9
73615 Radiologic examination, ankle, arthrography, radiological


73620 Radiologic examination, foot; 2 views
➲ CPT Assistant Sep 01:8, Apr 02:15, Mar 03:9

Summer 18:6
73650 Radiologic examination; calcaneus, minimum of 2 views
73660 toe(s), minimum of 2 views

73700 Computed tomography, lower extremity; without contrast

material
➲ Clinical Examples in Radiology Fall 08:10, Fall 10:6

➲ CPT Assistant Mar 07:10, Jul 11:17, Aug 19:7
Summer 18:12, Winter 19:14
73706 Computed tomographic angiography, lower extremity, with
contrast material(s), including noncontrast images, if
➲ CPT Assistant Jul 01:5-6, Dec 05:7, Jan 07:31, Apr
08:11, Apr 11:13
(For CTA aorto-iliofemoral runoff, use 75635)

73718 Magnetic resonance (eg, proton) imaging, lower extremity
other than joint; without contrast material(s)
➲ Clinical Examples in Radiology Spring 07:7-9, 12,
Summer 07:4, 5
Summer 07:4, 5
Summer 07:4, 5
73721 Magnetic resonance (eg, proton) imaging, any joint of lower
extremity; without contrast material
➲ CPT Assistant Jul 01:3, Jun 06:17
Summer 07:4, 5, Fall 18:11
➲ CPT Assistant Jul 01:3, Jun 06:17, Aug 15:6
Summer 07:4, 5, Spring 13:11, Winter 19:15
Summer 07:4, 5, Winter 19:14
73725 Magnetic resonance angiography, lower extremity, with or
Abdomen
74018 Radiologic examination, abdomen; 1 view
➲ CPT Assistant Apr 18:7, May 19:10, Apr 20:11
19:12, Summer 19:14
74019 2 views
Spring 19:12, Summer 19:14
Summer 19:14
74022 Radiologic examination, complete acute abdomen series,
including 2 or more views of the abdomen (eg, supine, erect,
decubitus), and a single view chest
74150 Computed tomography, abdomen; without contrast material

➲ CPT Assistant Oct 02:12, Mar 05:1, 4, Apr 10:9, Nov
11:6, Oct 12:12
➲ Clinical Examples in Radiology Spring 07:3, 11, Fall
08:7, Fall 09:9, Winter 11:8, 9, Fall 11:8, Spring 16:9
➲ CPT Assistant Mar 05:1, 4, Apr 10:9, Nov 11:6, Oct
12:12
Fall 08:7, Summer 10:10, Winter 11:8, 9, Fall 11:8,
Spring 16:9
➲ CPT Assistant Mar 05:4, Apr 10:9, Nov 11:6, Oct
12:12
➲ Clinical Examples in Radiology Winter 05:1, 7-8,
12, Spring 07:3, 11, Fall 08:7, Winter 11:8, 9, Fall
11:8, Spring 16:10
(For a combined CT abdomen and pelvis study, see 74176-
74178)
(For computed tomographic colonography, diagnostic, see
74261-74262. For computed tomographic colonography,
screening, use 74263)
74263)
74174 Computed tomographic angiography, abdomen and pelvis,
with contrast material(s), including noncontrast images, if

74175, 75635, 76376, 76377)
(For CTA aorto-iliofemoral runoff, use 75635)
74175 Computed tomographic angiography, abdomen, with contrast
➲ CPT Assistant Jul 01:6, Dec 05:7, Jan 07:31, Apr 11:13
09:10, Fall 11:8
(Do not report 74175 in conjunction with 73706 or 75635.
For CTA aorto-iliofemoral runoff, use 75635)
(Do not report 74175 in conjunction with 72191. For a
combined computed tomographic angiography abdomen and
pelvis study, use 74174)
For combinations of CT of the abdomen with CT of the pelvis
performed at the same session, use the following table. Do not
report more than one CT of the abdomen or CT of the pelvis for
any session.
Stand Alone 74150 CT 74160 CT 74170 CT

Code Abdomen WO Abdomen W Abdomen WO/W
Contrast Contrast Contrast
72192 CT 74176 74178 74178
Pelvis WO
Contrast
72193 CT 74178 74177 74178
Pelvis W
Contrast
72194 CT 74178 74178 74178
Pelvis WO/W
Contrast
74176 Computed tomography, abdomen and pelvis; without

contrast material
➲ Clinical Examples in Radiology Winter 11:9, Fall 11:8,
Spring 16:10, Spring 17:7
11:8, Spring 16:10, Spring 17:7
74178 without contrast material in one or both body regions,
followed by contrast material(s) and further sections in
one or both body regions
11:8, Spring 16:10, Spring 17:7
72194, 74150-74170)
(Report 74176, 74177, or 74178 only once per CT abdomen
and pelvis examination)
74181 Magnetic resonance (eg, proton) imaging, abdomen; without
➲ CPT Assistant Jul 01:3, Nov 07:9, May 09:9, Jul 09:10,
Mar 18:11

➲ CPT Assistant Jul 01:3, May 09:9, Jul 09:10, Mar
18:11
74183 without contrast material(s), followed by with contrast
➲ CPT Assistant Jul 01:3, May 09:9, Jul 09:10, Mar
18:11
74185 Magnetic resonance angiography, abdomen, with or without
74190 Peritoneogram (eg, after injection of air or contrast),

(For procedure, use 49400)
(For computed tomography, see 72192 or 74150)
Gastrointestinal Tract
(For percutaneous placement of gastrostomy tube, use
43246)
74210 Radiologic examination, pharynx and/or cervical esophagus,
including scout neck radiograph(s) and delayed image(s),
when performed, contrast (eg, barium) study
74220 Radiologic examination, esophagus, including scout chest

radiograph(s) and delayed image(s), when performed;
single-contrast (eg, barium) study

74246, 74248)
74221 double-contrast (eg, high-density barium and
effervescent agent) study

74246, 74248)
74230 Radiologic examination, swallowing function, with
cineradiography/videoradiography, including scout neck
radiograph(s) and delayed image(s), when performed,
contrast (eg, barium) study
➲ Clinical Examples in Radiology Summer 06:4-5, Spring
18:14
(For otorhinolaryngologic services fluoroscopic evaluation
of swallowing function, use 92611)
74235 Removal of foreign body(s), esophageal, with use of
balloon catheter, radiological supervision and interpretation
74240 Radiologic examination, upper gastrointestinal tract,
including scout abdominal radiograph(s) and delayed
image(s), when performed; single-contrast (eg, barium)
study

74246)
74246 double-contrast (eg, high-density barium and
effervescent agent) study, including glucagon, when
administered

74240)
✚ 74248 Radiologic small intestine follow-through study, including
multiple serial images (List separately in addition to code
for primary procedure for upper GI radiologic examination)

74250 Radiologic examination, small intestine, including multiple
serial images and scout abdominal radiograph(s), when
performed; single-contrast (eg, barium) study

74251 double-contrast (eg, high-density barium and air via
enteroclysis tube) study, including glucagon, when
administered
(For placement of enteroclysis tube, see 44500, 74340)

74261 Computed tomographic (CT) colonography, diagnostic,
including image postprocessing; without contrast material
74262 with contrast material(s) including non-contrast images,

if performed
➲ Clinical Examples in Radiology Winter 10:4-6

72194, 74150-74170, 74263, 76376, 76377)
74263 Computed tomographic (CT) colonography, screening,
including image postprocessing
74150-74170, 74261, 74262, 76376, 76377)
74270 Radiologic examination, colon, including scout abdominal
radiograph(s) and delayed image(s), when performed;
single-contrast (eg, barium) study

74280 double-contrast (eg, high density barium and air) study,
including glucagon, when administered

74283 Therapeutic enema, contrast or air, for reduction of
intussusception or other intraluminal obstruction (eg,
meconium ileus)
74290 Cholecystography, oral contrast

74300 Cholangiography and/or pancreatography; intraoperative,
✚ 74301 additional set intraoperative, radiological supervision

and interpretation (List separately in addition to code for
primary procedure)
74328 Endoscopic catheterization of the biliary ductal system,
(For procedure, see 43260-43278 as appropriate)
74329 Endoscopic catheterization of the pancreatic ductal system,
74330 Combined endoscopic catheterization of the biliary and
pancreatic ductal systems, radiological supervision and
interpretation
74340 Introduction of long gastrointestinal tube (eg, Miller-
Abbott), including multiple fluoroscopies and images,
(For tube placement, use 44500)

74355 Percutaneous placement of enteroclysis tube, radiological
➲ CPT Assistant Feb 07:11, Nov 10:3, Jan 11:8
74360 Intraluminal dilation of strictures and/or obstructions (eg,

esophagus), radiological supervision and interpretation

43233)
74363 Percutaneous transhepatic dilation of biliary duct stricture
with or without placement of stent, radiological supervision
and interpretation
(For procedure, see 47555, 47556)
Urinary Tract
74400 Urography (pyelography), intravenous, with or without
KUB, with or without tomography
74410 Urography, infusion, drip technique and/or bolus technique;
74415 with nephrotomography
74420 Urography, retrograde, with or without KUB
➲ CPT Assistant Sep 00:11, Dec 10:15
▲ 74425 Urography, antegrade, radiological supervision and

interpretation
➲ CPT Assistant Fall 93:14, Dec 97:7, Oct 05:18
➲ Clinical Examples in Radiology Summer 06:1-3, Fall
15:2, Spring 16:12
50690)◀
50432, 50433, 50434, 50435, 50693, 50694, 50695)
74430 Cystography, minimum of 3 views, radiological supervision
and interpretation
74440 Vasography, vesiculography, or epididymography,

74445 Corpora cavernosography, radiological supervision and
interpretation
74450 Urethrocystography, retrograde, radiological supervision

and interpretation
74455 Urethrocystography, voiding, radiological supervision and

interpretation
74470 Radiologic examination, renal cyst study, translumbar,
contrast visualization, radiological supervision and
interpretation
➲ CPT Assistant Oct 05:18, Feb 07:11, Nov 10:3, Jan 11:8
74485 Dilation of ureter(s) or urethra, radiological supervision and

interpretation
➲ CPT Assistant Oct 05:18, Dec 08:7, Jan 09:7, Oct 15:5
19:6
(For dilation of ureter without radiologic guidance, use
52341, 52344)
(For change of nephrostomy or pyelostomy tube, use 50435)
(For dilation of a nephrostomy tract for endourologic
procedure, see 50436, 50437)
Gynecological and Obstetrical

(For abdomen and pelvis, see 72170-72190, 74018, 74019,
74021, 74022, 74150, 74160, 74170)
74710 Pelvimetry, with or without placental localization
74712 Magnetic resonance (eg, proton) imaging, fetal, including
placental and maternal pelvic imaging when performed;
single or first gestation
✚ 74713 each additional gestation (List separately in addition to

72196, 72197)
(If only placenta or maternal pelvis is imaged without fetal
imaging, see 72195, 72196, 72197)
74740 Hysterosalpingography, radiological supervision and
interpretation
(For introduction of saline or contrast for

hysterosalpingography, see 58340)
74742 Transcervical catheterization of fallopian tube, radiological
74775 Perineogram (eg, vaginogram, for sex determination or
extent of anomalies)
Heart
Cardiac magnetic imaging differs from traditional magnetic
resonance imaging (MRI) in its ability to provide a physiologic
evaluation of cardiac function. Traditional MRI relies on static
images to obtain clinical diagnoses based upon anatomic
information. Improvement in spatial and temporal resolution has
expanded the application from an anatomic test and includes
physiologic evaluation of cardiac function. Flow and velocity
assessment for valves and intracardiac shunts is performed in
addition to a function and morphologic evaluation. Use 75559
with 75565 to report flow with pharmacologic wall motion stress
evaluation without contrast. Use 75563 with 75565 to report flow
with pharmacologic perfusion stress with contrast.
Cardiac MRI for velocity flow mapping can be reported in
conjunction with 75557, 75559, 75561, or 75563.
Listed procedures may be performed independently or in the
course of overall medical care. If the individual providing these
services is also responsible for diagnostic workup and/or follow-
up care of the patient, also see appropriate sections. Only one
procedure in the series 75557-75563 is appropriately reported per
session. Only one add-on code for flow velocity can be reported
per session.
Cardiac MRI studies may be performed at rest and/or during
pharmacologic stress. Therefore, the appropriate stress testing
code from the 93015-93018 series should be reported in addition
to 75559 or 75563.
▶Cardiac computed tomography (CT) and coronary computed
tomographic angiography (CTA) include the axial source images
of the pre-contrast, arterial phase sequence, and venous phase
sequence (if performed), as well as the two-dimensional and
three-dimensional reformatted images resulting from the study,
including cine review. Each of the contrast enhanced cardiac CT
and coronary CTA codes (75572, 75573, 75574) includes
conventional quantitative assessment(s) intrinsic to the service
listed in the code descriptor (ie, quantification of coronary
percentage stenosis, ventricular volume[s], ejection fraction[s],
and stroke volume[s]), when performed. Report only one
computed tomography heart service per encounter (75571, 75572,
75573, 75574).◀
(For separate injection procedures for vascular radiology,
see Surgery section, 36000-36299)
(For cardiac catheterization procedures, see 93451-93572)
(75552-75556 have been deleted. To report, see 75557,
75559, 75561, 75563, 75565)
75557 Cardiac magnetic resonance imaging for morphology and
function without contrast material;
75559 with stress imaging

75561 Cardiac magnetic resonance imaging for morphology and

function without contrast material(s), followed by contrast
material(s) and further sequences;
16:13, Spring 17:14
75563 with stress imaging
(75558, 75560, 75562, 75564 have been deleted. To report

flow velocity, use 75565)
✚ 75565 Cardiac magnetic resonance imaging for velocity flow
mapping (List separately in addition to code for primary
procedure)

75563)
(Do not report 75557, 75559, 75561, 75563, 75565 in
75571 Computed tomography, heart, without contrast material, with
quantitative evaluation of coronary calcium
75572 Computed tomography, heart, with contrast material, for

evaluation of cardiac structure and morphology (including
3D image postprocessing, assessment of cardiac function,
and evaluation of venous structures, if performed)
16:13
75573 Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology in the setting
of congenital heart disease (including 3D image
postprocessing, assessment of LV cardiac function, RV
structure and function and evaluation of venous structures, if
performed)
75574 Computed tomographic angiography, heart, coronary arteries

and bypass grafts (when present), with contrast material,
including 3D image postprocessing (including evaluation of
cardiac structure and morphology, assessment of cardiac
function, and evaluation of venous structures, if performed)
➲ Clinical Examples in Radiology Winter 10:1-3
▶ (Fornoninvasive estimated coronary fractional flow
reserve [FFR] derived from coronary computed tomography
angiography data, see 0501T, 0502T, 0503T, 0504T)◀
▶ (Forautomated quantification and characterization of
coronary atherosclerotic plaque, see 0623T, 0624T, 0625T,
0626T)◀
Vascular Procedures
Aorta and Arteries
Selective vascular catheterizations should be coded to include
introduction and all lesser order selective catheterizations used in
carotid arteries).
Additional second and/or third order arterial catheterizations
within the same family of arteries supplied by a single first order
artery should be expressed by 36218 or 36248. Additional first
order or higher catheterizations in vascular families supplied by a
first order vessel different from a previously selected and coded
family should be separately coded using the conventions
described above.
The lower extremity endovascular revascularization codes
describing services performed for occlusive disease (37220-
37235) include catheterization (36200, 36140, 36245-36248) in the
work described by the codes. Catheterization codes are not
additionally reported for diagnostic lower extremity angiography
when performed through the same access site as the therapy
(37220-37235) performed in the same session. However,
catheterization for the diagnostic lower extremity angiogram may
be reported separately if a different arterial puncture site is
necessary.
For angiography performed in conjunction with therapeutic
transcatheter radiological supervision and interpretation services,
see the radiology Transcatheter Procedures guidelines.
Diagnostic angiography (radiological supervision and
interpretation) codes should NOT be used with interventional
procedures for:
fluoroscopic guidance for the intervention,
2. Vessel measurement, and
3. Post-angioplasty/stent/atherectomy angiography, as this work is
captured in the radiological supervision and interpretation
code(s). In those therapeutic codes that include radiological
supervision and interpretation, this work is captured in the
therapeutic code.
Diagnostic angiography performed at the time of an
interventional procedure is separately reportable if:
1. No prior catheter-based angiographic study is available and a
full diagnostic study is performed, and the decision to
intervene is based on the diagnostic study, OR
record:
has changed since the prior study, OR
b. There is inadequate visualization of the anatomy and/or
pathology, OR
new evaluation outside the target area of intervention.
Diagnostic angiography performed at a separate sessions from an
interventional procedure is separately reported.
If diagnostic angiography is necessary, is performed at the same
session as the interventional procedure and meets the above
criteria, modifier 59 must be appended to the diagnostic
radiological supervision and interpretation code(s) to denote that
diagnostic work has been done following these guidelines.
Diagnostic angiography performed at the time of an
interventional procedure is NOT separately reportable if it is
specifically included in the interventional code descriptor.
(For intravenous procedure, see 36000, 36005-36015, and
for intra-arterial procedure, see 36100-36248)
(For radiological supervision and interpretation, see 75600-
75893)
75600 Aortography, thoracic, without serialography, radiological
(For supravalvular aortography performed at the time of
cardiac catheterization, use 93567, which includes imaging
supervision, interpretation, and report)
75605 Aortography, thoracic, by serialography, radiological
➲ CPT Assistant Spring 94:29, Dec 98:9, Jan 13:6
➲ Clinical Examples in Radiology Spring 13:4, 5, 6
(For supravalvular aortography performed at the time of

cardiac catheterization, use 93567, which includes imaging
75625 Aortography, abdominal, by serialography, radiological
➲ CPT Assistant Fall 93:16, Jan 01:14, Dec 07:14, Apr
08:11, Dec 09:13, Jan 13:6, Feb 13:16
➲ Clinical Examples in Radiology Winter 08:1, 2, 4, 5, 9,
Spring 13:11
75630 Aortography, abdominal plus bilateral iliofemoral lower
extremity, catheter, by serialography, radiological
➲ CPT Assistant Fall 93:16, Jan 01:14, Apr 08:11, Dec
09:13
75635 Computed tomographic angiography, abdominal aorta and

bilateral iliofemoral lower extremity runoff, with contrast
➲ CPT Assistant Jul 01:4-5, Dec 05:7, Jan 07:31, Apr
11:13
➲ Clinical Examples in Radiology Spring 06:1-3, Summer
08:7, 8, Summer 10:10, Summer 18:12
74174 or 74175)
75705 Angiography, spinal, selective, radiological supervision and
interpretation
Aortography
75600-75630
A radiographic contrast study is performed on the abdominal or thoracic aorta.
75710 Angiography, extremity, unilateral, radiological supervision

and interpretation
➲ CPT Assistant Apr 99:11, Jan 01:14, Mar 17:4
11:1, Spring 12:4
75716 Angiography, extremity, bilateral, radiological supervision
and interpretation
➲ CPT Assistant Fall 93:16, Jan 01:14, Dec 07:14, Apr
08:11, Dec 09:13
➲ Clinical Examples in Radiology Winter 08:1, 2, 4, 5, 9,
Winter 13:1, 2, 3, Spring 13:5, 6
75726 Angiography, visceral, selective or supraselective (with or
without flush aortogram), radiological supervision and
interpretation
➲ Clinical Examples in Radiology Summer 08:1, 2, 3, Fall
13:2, 3, 5, Summer 15:2, Winter 18:11, Summer 18:2,
Spring 19:2
(For selective angiography, each additional visceral vessel
studied after basic examination, use 75774)
75731 Angiography, adrenal, unilateral, selective, radiological
75733 Angiography, adrenal, bilateral, selective, radiological

75736 Angiography, pelvic, selective or supraselective,
08:4, 5, Winter 14:1-3, Summer 19:4
75741 Angiography, pulmonary, unilateral, selective, radiological
➲ CPT Assistant Mar 12:10, Jan 13:6, Jun 19:3
75743 Angiography, pulmonary, bilateral, selective, radiological

➲ CPT Assistant Spring 94:29, Apr 98:7, Jan 13:6, Jun
19:3
75746 Angiography, pulmonary, by nonselective catheter or venous
injection, radiological supervision and interpretation
(For pulmonary angiography by nonselective catheter or

venous injection performed at the time of cardiac
catheterization, use 93568, which includes imaging
75756 Angiography, internal mammary, radiological supervision
and interpretation
(For internal mammary angiography performed at the time of
cardiac catheterization, see 93455, 93457, 93459, 93461,
93564, which include imaging supervision, interpretation,
and report)
✚ 75774 Angiography, selective, each additional vessel studied after
basic examination, radiological supervision and
interpretation (List separately in addition to code for
primary procedure)
➲ CPT Assistant Fall 93:17, Spring 94:29, Apr 11:13, Fall
13:2, 3, 5, Feb 13:17, Jun 13:12, Oct 13:18, May 17:3
➲ Clinical Examples in Radiology Winter 08:1, 2, 4, 5,
Summer 08:1-3, Winter 13:1-3, Spring 13:6, Winter
15:4-6, Winter 18:2, Summer 18:2, Summer 19:4
(Use 75774 in addition to code for specific initial vessel
studied)
(Do not report 75774 as part of diagnostic angiography of
the extracranial and intracranial cervicocerebral vessels. It
may be appropriate to report 75774 for diagnostic
angiography of upper extremities and other vascular beds
performed in the same session)
(For angiography, see 75600-75756)
(For catheterizations, see codes 36215-36248)
(For cardiac catheterization procedures, see 93452-93462,
93531-93533, 93563-93568)
(For radiological supervision and interpretation of dialysis
circuit angiography performed through existing access[es] or
catheter-based arterial access, use 36901 with modifier 52)
Veins and Lymphatics

For venography performed in conjunction with therapeutic
transcatheter radiological supervision and interpretation services,
see the radiology Transcatheter Procedures guidelines.
Diagnostic venography (radiological supervision and
interpretation) codes should NOT be used with interventional
procedures for:
1. Contrast injections, venography, roadmapping, and/or
fluoroscopic guidance for the intervention,
3. Post-angioplasty/stent venography, as this work is captured in
the radiological supervision and interpretation code(s).
Diagnostic venography performed at the time of an interventional
procedure is separately reportable if:
1. No prior catheter-based venographic study is available and a
full diagnostic study is performed, and decision to intervene is
based on the diagnostic study, OR
record:
has changed since the prior study, OR
There is inadequate visualization of the anatomy and/or
b. pathology, OR

new evaluation outside the target area of intervention.
Diagnostic venography performed at a separate setting from an
interventional procedure is separately reported.
Diagnostic venography performed at the time of an interventional
procedure is NOT separately reportable if it is specifically
included in the interventional code descriptor.
(For injection procedure for venous system, see 36000-
36015, 36400-36510)
(For injection procedure for lymphatic system, use 38790)
75801 Lymphangiography, extremity only, unilateral, radiological
75803 Lymphangiography, extremity only, bilateral, radiological

75805 Lymphangiography, pelvic/abdominal, unilateral,

75807 Lymphangiography, pelvic/abdominal, bilateral,

75809 Shuntogram for investigation of previously placed

indwelling nonvascular shunt (eg, LeVeen shunt,
ventriculoperitoneal shunt, indwelling infusion pump),
CPT Assistant Feb 07:11, Jul 08:13, Aug 08:13, Sep
➲ 08:10, Nov 10:3, Jan 11:8
(For procedure, see 49427 or 61070)
75810 Splenoportography, radiological supervision and
interpretation
75820 Venography, extremity, unilateral, radiological supervision

and interpretation
➲ CPT Assistant Oct 97:10, May 08:14, May 15:3, May
16:5
08:12, Spring 14:7, Winter 16:2
75822 Venography, extremity, bilateral, radiological supervision
and interpretation
75825 Venography, caval, inferior, with serialography, radiological
➲ Clinical Examples in Radiology Winter 05:5-6, Winter
12:3, Winter 16:2
75827 Venography, caval, superior, with serialography,
75831 Venography, renal, unilateral, selective, radiological

75833 Venography, renal, bilateral, selective, radiological

75840 Venography, adrenal, unilateral, selective, radiological
75842 Venography, adrenal, bilateral, selective, radiological
Venography
75820-75822
A radiographic contrast study is performed on the veins of the lower extremities.
75860 Venography, venous sinus (eg, petrosal and inferior sagittal)
or jugular, catheter, radiological supervision and
interpretation
75870 Venography, superior sagittal sinus, radiological supervision

and interpretation
75872 Venography, epidural, radiological supervision and

interpretation
75880 Venography, orbital, radiological supervision and
interpretation
75885 Percutaneous transhepatic portography with hemodynamic
evaluation, radiological supervision and interpretation
➲ CPT Assistant Oct 96:4, Mar 02:10, Dec 03:2, Feb
07:11, Nov 10:3, Jan 11:8
75887 Percutaneous transhepatic portography without

hemodynamic evaluation, radiological supervision and
interpretation
➲ CPT Assistant Mar 02:10, Dec 03:2, Feb 07:11, Jan 11:8
75889 Hepatic venography, wedged or free, with hemodynamic

75891 Hepatic venography, wedged or free, without hemodynamic
75893 Venous sampling through catheter, with or without
angiography (eg, for parathyroid hormone, renin),

Transcatheter Procedures
Therapeutic transcatheter radiological supervision and
interpretation code(s) include the following services associated
with that intervention:
1. Contrast injections, angiography/venography, roadmapping,
and fluoroscopic guidance for the intervention,
3. Completion angiography/venography (except for those uses
permitted by 75898).
Unless specifically included in the code descriptor, diagnostic
angiography/venography performed at the time of transcatheter
therapeutic radiological and interpretation service(s) is separately
reportable (eg, no prior catheter-based diagnostic
angiography/venography study of the target vessel is available,
prior diagnostic study is inadequate, patient’s condition with
respect to the clinical indication has changed since the prior study
or during the intervention). See 75600-75893.
Codes 75956 and 75957 include all angiography of the thoracic
aorta and its branches for diagnostic imaging prior to deployment
of the primary endovascular devices (including all routine
components of modular devices), fluoroscopic guidance in the
delivery of the endovascular components, and intraprocedural
arterial angiography (eg, confirm position, detect endoleak,
evaluate runoff).
Code 75958 includes the analogous services for placement of
each proximal thoracic endovascular extension. Code 75959
includes the analogous services for placement of a distal thoracic
endovascular extension(s) placed during a procedure after the
primary repair.
75894 Transcatheter therapy, embolization, any method,
➲ CPT Assistant Sep 98:7, Feb 08:5, Apr 12:5, Fall 13:2,
3, 4, Nov 13:6, 7, 15, Oct 14:6
➲ Clinical Examples in Radiology Winter 07:1-3, Summer
07:2, Winter 08:4, 5, Summer 08:1, 2, 3, Fall 11:3,
Spring 14:8, Spring 16:5, Summer 16:13, Winter 18:2
36478, 36479, 37241-37244)
75898 Angiography through existing catheter for follow-up study
for transcatheter therapy, embolization or infusion, other
than for thrombolysis
➲ CPT Assistant Dec 07:11, Nov 11:11, Fall 13:2, 3, 4,
Nov 13:6, 15, Oct 14:6, Nov 15:3, Sep 19:6
08:4, 5, Summer 08:1, 2, 3, Summer 12:3, Spring 16:4,
Winter 18:2
(For thrombolysis infusion management other than coronary,
see 37211-37214, 61645)
(For non-thrombolysis infusion management other than
coronary, see 61650, 61651)
37241-37244, 61645, 61650, 61651)
75901 Mechanical removal of pericatheter obstructive material
(eg, fibrin sheath) from central venous device via separate
venous access, radiologic supervision and interpretation
75902 Mechanical removal of intraluminal (intracatheter)
obstructive material from central venous device through
device lumen, radiologic supervision and interpretation

(75952, 75953, 75954 have been deleted. To report, see
34701-34711, 34718)
75956 Endovascular repair of descending thoracic aorta (eg,
intramural hematoma, or traumatic disruption); involving
coverage of left subclavian artery origin, initial
endoprosthesis plus descending thoracic aortic extension(s),
if required, to level of celiac artery origin, radiological
(For implantation of endovascular graft, use 33880)

75957 not involving coverage of left subclavian artery origin,
initial endoprosthesis plus descending thoracic aortic
extension(s), if required, to level of celiac artery origin,
(For implantation of endovascular graft, use 33881)

75958 Placement of proximal extension prosthesis for
endovascular repair of descending thoracic aorta (eg,
intramural hematoma, or traumatic disruption), radiological
(Report 75958 for each proximal extension)

(For implantation of proximal endovascular extension, see
33883, 33884)
75959 Placement of distal extension prosthesis(s) (delayed) after
endovascular repair of descending thoracic aorta, as
needed, to level of celiac origin, radiological supervision
and interpretation

(Report 75959 once, regardless of number of modules
deployed)
(For implantation of distal endovascular extension, use
33886)
(Radiologic supervision for transcatheter placement of
stent[s] is included in the therapeutic service codes)
(For removal of a vena cava filter, use 37193)
75970 Transcatheter biopsy, radiological supervision and
interpretation
(For injection procedure only for transcatheter therapy or

biopsy, see 36100-36299)
(For transcatheter renal and ureteral biopsy, use 52007)
(For percutaneous needle biopsy of pancreas, use 48102; of
retroperitoneal lymph node or mass, use 49180)
transluminal balloon angioplasty within the peripheral
and/or central segments of a dialysis circuit performed
through the dialysis circuit, see 36902, 36905, 36907)
75984 Change of percutaneous tube or drainage catheter with
contrast monitoring (eg, genitourinary system, abscess),
15:2, Spring 16:12
(For percutaneous replacement of gastrostomy,
duodenostomy, jejunostomy, gastro-jejunostomy, or
cecostomy [or other colonic] tube including fluoroscopic
imaging guidance, see 49450-49452)
(To report exchange of a percutaneous nephrostomy catheter,
use 50435)
(For percutaneous biliary procedures, including
radiological supervision and interpretation, see 47531-
47544)
(For percutaneous nephrostolithotomy or pyelostolithotomy,
see 50080, 50081)
(For removal and/or replacement of an internally dwelling
ureteral stent via a transurethral approach, see 50385-
50386)
75989 Radiological guidance (ie, fluoroscopy, ultrasound, or
computed tomography), for percutaneous drainage (eg,
abscess, specimen collection), with placement of catheter,
➲ CPT Assistant Nov 97:24, Mar 98:8, Feb 07:11, Nov
10:3, Apr 11:12, Nov 12:3, Fall 13:5, 6, Nov 13:9, May
14:9
11:10, Summer 11:3, Winter 13:5, Spring 14:10, Spring
15:8, Winter 16:10
32555, 32556, 32557, 33017, 33018, 33019, 47490, 49405,
49406, 49407)
Other Procedures
(For computed tomography cerebral perfusion analysis, see
Category III code 0042T)
(For arthrography of shoulder, use 73040; elbow, use
73085; wrist, use 73115; hip, use 73525; knee, use 73580;
ankle, use 73615)
76000 Fluoroscopy (separate procedure), up to 1 hour physician or
other qualified health care professional time
➲ CPT Assistant Apr 96:11, Nov 99:32, Dec 00:14, Apr
03:7, Jul 03:16, Aug 03:14, Jul 08:9, Aug 08:7, Dec
08:7, 9, Aug 10:8, Oct 10:14, Nov 10:3, Dec 10:14, Jul
11:5, Nov 11:11, Feb 13:3, Mar 13:10, Sep 13:17, Sep
14:5, Oct 14:6, May 15:3, Sep 15:3, Jan 16:12, Mar
16:5, May 16:5, Aug 16:5, Mar 19:6, Jun 19:3, Sep
19:11

33957, 33958, 33959, 33962, 33963, 33964, 0515T, 0516T,
0517T, 0518T, 0519T, 0520T)
76010 Radiologic examination from nose to rectum for foreign
body, single view, child
76080 Radiologic examination, abscess, fistula or sinus tract study,

➲ CPT Assistant Nov 97:24, Mar 98:8, Nov 03:14, Dec
06:10, Jan 09:8
(For contrast injection[s] and radiological assessment of

jejunostomy, or cecostomy [or other colonic] tube including
fluoroscopic imaging guidance, use 49465)
76098 Radiological examination, surgical specimen
12:10, Fall 13:10, 11, Spring 14:10
76100 Radiologic examination, single plane body section (eg,
tomography), other than with urography
76101 Radiologic examination, complex motion (ie,
hypercycloidal) body section (eg, mastoid polytomography),
other than with urography; unilateral
76102 bilateral
(Do not report 76101, 76102 more than once per day)
(For panoramic X-ray, use 70355)
(For nephrotomography, use 74415)
76120 Cineradiography/videoradiography, except where
specifically included
➲ CPT Assistant Sep 00:4, Apr 04:15, Apr 11:13
✚ 76125 Cineradiography/videoradiography to complement routine
examination (List separately in addition to code for primary
procedure)
➲ CPT Assistant Oct 97:1, Sep 00:4
76140 Consultation on X-ray examination made elsewhere, written

report
➲ CPT Assistant Summer 91:13, Oct 97:1
(2D reformatting is no longer separately reported. To report

3D rendering, see 76376, 76377)
● 76145 Medical physics dose evaluation for radiation exposure that
exceeds institutional review threshold, including report
76376 3D rendering with interpretation and reporting of computed

tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality with image postprocessing
under concurrent supervision; not requiring image
postprocessing on an independent workstation
➲ CPT Assistant Dec 05:1, 7, Jan 07:31, Jul 08:3, May
09:9, Jun 09:9, Jul 09:10, Apr 10:5, Jul 10:7, May 13:3,
Jun 13:12, Apr 16:9, May 17:11, Jul 18:11, Aug 19:5,
Sep 19:11, Oct 19:11
06:8-9, Fall 06:9-10, Winter 07:4-5, Summer 08:8, Fall
08:12, Spring 09:4, Summer 09:14, Fall 09:9, Winter
10:6, Spring 10:2, Summer 10:10, Fall 10:6, Winter
13:10, Fall 14:8, 11, Winter 17:14, Spring 17:7, Spring
19:7
(Use 76376 in conjunction with code[s] for base imaging
procedure[s])
70496, 70498, 70544, 70545, 70546, 70547, 70548, 70549,
71275, 71555, 72159, 72191, 72198, 73206, 73225, 73706,
73725, 74174, 74175, 74185, 74261, 74262, 74263, 75557,
75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574,
75635, 76377, 77046, 77047, 77048, 77049, 77061, 77062,
77063, 78012-78999, 93355, 0523T, 0559T, 0560T, 0561T,
0562T, 0623T, 0624T, 0625T, 0626T, 0633T, 0634T,
0635T, 0636T, 0637T, 0638T)◀
76377 requiring image postprocessing on an independent
workstation
➲ CPT Assistant Dec 05:1, Jan 07:31, Jul 08:3, May
09:9, Jun 09:9, Jul 09:10, Dec 09:13, Feb 10:6, Apr
10:5, 9, Jul 10:7, May 13:3, Jun 13:12, Apr 16:9,
May 17:11, Jul 18:11, Aug 19:5, Sep 19:11, Oct
19:11
Spring 06:8-9, Fall 06:9-10, Winter 07:4-5, Summer
07:1, 2, Summer 08:8, Fall 08:12, Spring 09:5,
Summer 09:14, Fall 09:9, Winter 10:6, Spring 10:2,
Summer 10:10, Fall 10:6, Winter 13:10, Winter
17:14, Spring 17:7, Summer 18:13, Spring 19:7
(Use 76377 in conjunction with code[s] for base imaging
procedure[s])
70498, 70544, 70545, 70546, 70547, 70548, 70549, 71275,
71555, 72159, 72191, 72198, 73206, 73225, 73706, 73725,
74174, 74175, 74185, 74261, 74262, 74263, 75557, 75559,
75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635,
76376, 77046, 77047, 77048, 77049, 77061, 77062, 77063,
78012-78999, 93355, 0523T, 0559T, 0560T, 0561T, 0562T,
0623T, 0624T, 0625T, 0626T, 0633T, 0634T, 0635T,
0636T, 0637T, 0638T)◀
(76376, 76377 require concurrent supervision of image
postprocessing 3D manipulation of volumetric data set and
image rendering)
76380 Computed tomography, limited or localized follow-up study
76390 Magnetic resonance spectroscopy

(For magnetic resonance imaging, use appropriate MRI

body site code)
76391 Magnetic resonance (eg, vibration) elastography
76496 Unlisted fluoroscopic procedure (eg, diagnostic,

interventional)
76497 Unlisted computed tomography procedure (eg, diagnostic,

interventional)
18:13
76498 Unlisted magnetic resonance procedure (eg, diagnostic,
interventional)
Clinical Examples in Radiology Fall 08:11, Spring
➲
09:11, Winter 13:11, Spring 18:12, Fall 18:6, Spring
19:12, Summer 19:11
76499 Unlisted diagnostic radiographic procedure
➲ CPT Assistant Jul 99:10, Sep 00:4, Apr 04:15, Nov
06:22, Mar 08:15, Dec 11:17, Dec 13:17, Jul 16:8
Summer 15:8, Fall 18:5
All diagnostic ultrasound examinations require permanently
recorded images with measurements, when such measurements
are clinically indicated. For those codes whose sole diagnostic
goal is a biometric measure (ie, 76514, 76516, and 76519),
permanently recorded images are not required. A final, written
report should be issued for inclusion in the patient’s medical
record. The prescription form for the intraocular lens satisfies the
written report requirement for 76519. For those anatomic regions
that have “complete” and “limited” ultrasound codes, note the
elements that comprise a “complete” exam. The report should
contain a description of these elements or the reason that an
element could not be visualized (eg, obscured by bowel gas,
surgically absent).
If less than the required elements for a “complete” exam are
reported (eg, limited number of organs or limited portion of
region evaluated), the “limited” code for that anatomic region
should be used once per patient exam session. A “limited” exam
of an anatomic region should not be reported for the same exam
session as a “complete” exam of that same region.
Evaluation of vascular structures using both color and spectral
Doppler is separately reportable. To report, see Noninvasive
Vascular Diagnostic Studies (93880-93990). However, color
Doppler alone, when performed for anatomic structure
identification in conjunction with a real-time ultrasound
examination, is not reported separately.
Ultrasound guidance procedures also require permanently
recorded images of the site to be localized, as well as a
documented description of the localization process, either
separately or within the report of the procedure for which the
guidance is utilized.
Use of ultrasound, without thorough evaluation of organ(s) or
anatomic region, image documentation, and final, written report,
is not separately reportable.
Definitions
A-mode implies a one-dimensional ultrasonic measurement
procedure.
M-mode implies a one-dimensional ultrasonic measurement
procedure with movement of the trace to record amplitude and
velocity of moving echo-producing structures.
B-scan implies a two-dimensional ultrasonic scanning procedure
with a two-dimensional display.
Real-time scan implies a two-dimensional ultrasonic scanning
procedure with display of both two-dimensional structure and
motion with time.
(To report diagnostic vascular ultrasound studies, see
93880-93990)
(For focused ultrasound ablation treatment of uterine
leiomyomata, see Category III codes 0071T, 0072T)
Head and Neck

76506 Echoencephalography, real time with image documentation
(gray scale) (for determination of ventricular size,
delineation of cerebral contents, and detection of fluid
masses or other intracranial abnormalities), including A-
mode encephalography as secondary component where
indicated
76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative

A-scan performed during the same patient encounter
76511 quantitative A-scan only

➲ CPT Assistant Winter 93:12, Oct 96:9, Nov 99:42,
Jul 04:12, Dec 05:3
76512 B-scan (with or without superimposed non-quantitative
A-scan)
➲ CPT Assistant Winter 93:12, Oct 96:9, Dec 05:3
▲ 76513 anterior segment ultrasound, immersion (water bath) B-

scan or high resolution biomicroscopy, unilateral or
bilateral
➲ CPT Assistant Winter 93:12, Nov 99:42, Nov 09:9,
Apr 13:7
(For scanning computerized ophthalmic diagnostic imaging
of the anterior and posterior segments using technology other
than ultrasound, see 92132, 92133, 92134)
76514 corneal pachymetry, unilateral or bilateral (determination
of corneal thickness)
➲ CPT Assistant Jul 04:12, 15, Feb 05:13, Jun 05:11,
Dec 05:3, Feb 16:12
76516 Ophthalmic biometry by ultrasound echography, A-scan;
76519 with intraocular lens power calculation

➲ CPT Assistant Winter 93:12, Oct 03:10, Dec 05:3,
Sep 09:5
(For partial coherence interferometry, use 92136)
76529 Ophthalmic ultrasonic foreign body localization
76536 Ultrasound, soft tissues of head and neck (eg, thyroid,

parathyroid, parotid), real time with image documentation
➲ CPT Assistant Mar 07:7, May 09:7, Oct 17:10
15:4, Spring 18:13, Fall 18:4
Chest
Code 76641 represents a complete ultrasound examination of the
breast. Code 76641 consists of an ultrasound examination of all
four quadrants of the breast and the retroareolar region. It also
includes ultrasound examination of the axilla, if performed.
Code 76642 consists of a focused ultrasound examination of the
breast limited to the assessment of one or more, but not all of the
elements listed in code 76641. It also includes ultrasound
examination of the axilla, if performed.
anatomic region, image documentation, and final written report,
76604 Ultrasound, chest (includes mediastinum), real time with
image documentation
15:14, Winter 16:13, Fall 18:4, Spring 19:12
76641 Ultrasound, breast, unilateral, real time with image
documentation, including axilla when performed; complete
15:4, Fall 18:4
76642 limited
Spring 15:4, Winter 16:13, Spring 18:13, Fall 18:4
(Report 76641, 76642 only once per breast, per session)
(For axillary ultrasound only, use 76882)
Abdomen and Retroperitoneum

A complete ultrasound examination of the abdomen (76700)
consists of real time scans of the liver, gall bladder, common bile
duct, pancreas, spleen, kidneys, and the upper abdominal aorta
and inferior vena cava including any demonstrated abdominal
abnormality.
A complete ultrasound examination of the retroperitoneum
(76770) consists of real time scans of the kidneys, abdominal
aorta, common iliac artery origins, and inferior vena cava,
including any demonstrated retroperitoneal abnormality.
Alternatively, if clinical history suggests urinary tract pathology,
complete evaluation of the kidneys and urinary bladder also
comprises a complete retroperitoneal ultrasound.
anatomic region, image documentation and final, written report,
76700 Ultrasound, abdominal, real time with image documentation;
complete
➲ CPT Assistant Fall 93:13, Oct 01:3, Dec 05:3, Mar 07:7,
Oct 17:10
➲ Clinical Examples in Radiology Winter 05:9, 11, Fall
07:4, Spring 08:10, Summer 14:9, Spring 15:4, Winter
17:14
76705 limited (eg, single organ, quadrant, follow-up)
➲ CPT Assistant Fall 93:13, Oct 01:3, Apr 03:27, Dec
05:3, Feb 09:22, May 09:7, Mar 12:10, Dec 12:9,
Oct 17:10
Fall 07:4, Summer 11:11, Winter 12:10, Spring
12:10, Summer 14:8, 9, Spring 15:4, Summer 15:13,
Summer 16:10, Winter 17:14, Spring 18:13, Fall 18:2
76706 Ultrasound, abdominal aorta, real time with image
documentation, screening study for abdominal aortic
aneurysm (AAA)
(For ultrasound or duplex ultrasound of the abdominal aorta

other than screening, see 76770, 76775, 93978, 93979)
76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real
time with image documentation; complete
➲ CPT Assistant May 99:10, Jun 99:10, Mar 15:10, May
17:8, Oct 17:10
➲ Clinical Examples in Radiology Winter 05:9, 11, Fall
07:4, Winter 08:12, Summer 09:12, Summer 12:10,
Summer 13:10, Spring 15:4, Spring 17:5, Fall 18:4
76775 limited
➲ CPT Assistant May 99:10, Jun 99:10, Dec 05:3, Feb
09:22, Mar 15:10, May 17:8, Oct 17:10
Winter 07:8-10, Spring 07:5-6, Fall 07:4, Summer
09:12, Summer 12:10, Summer 13:10, Spring 15:4,
Summer 16:11, Spring 17:5, Fall 18:4
76776 Ultrasound, transplanted kidney, real time and duplex
Doppler with image documentation
(For ultrasound of transplanted kidney without duplex

Doppler, use 76775)
(For ultrasound and duplex Doppler of a transplanted
kidney, do not report 76776 in conjunction with 93975,
93976)
Spinal Canal
76800 Ultrasound, spinal canal and contents
Pelvis
Obstetrical
Codes 76801 and 76802 include determination of the number of
gestational sacs and fetuses, gestational sac/fetal measurements
appropriate for gestation (younger than 14 weeks 0 days), survey
of visible fetal and placental anatomic structure, qualitative
assessment of amniotic fluid volume/gestational sac shape and
examination of the maternal uterus and adnexa.
Codes 76805 and 76810 include determination of number of
fetuses and amniotic/chorionic sacs, measurements appropriate
for gestational age (older than or equal to 14 weeks 0 days),
survey of intracranial/spinal/abdominal anatomy, 4 chambered
heart, umbilical cord insertion site, placenta location and amniotic
fluid assessment and, when visible, examination of maternal
adnexa.
Codes 76811 and 76812 include all elements of codes 76805 and
76810 plus detailed anatomic evaluation of the fetal
brain/ventricles, face, heart/outflow tracts and chest anatomy,
abdominal organ specific anatomy, number/length/architecture of
limbs and detailed evaluation of the umbilical cord and placenta
and other fetal anatomy as clinically indicated.
Report should document the results of the evaluation of each
element described above or the reason for non-visualization.
Code 76815 represents a focused “quick look” exam limited to
the assessment of one or more of the elements listed in code
76815.
Code 76816 describes an examination designed to reassess fetal
size and interval growth or reevaluate one or more anatomic
abnormalities of a fetus previously demonstrated on ultrasound,
and should be coded once for each fetus requiring reevaluation
using modifier 59 for each fetus after the first.
Code 76817 describes a transvaginal obstetric ultrasound
performed separately or in addition to one of the transabdominal
examinations described above. For transvaginal examinations
performed for non-obstetrical purposes, use code 76830.
76801 Ultrasound, pregnant uterus, real time with image
documentation, fetal and maternal evaluation, first trimester
(< 14 weeks 0 days), transabdominal approach; single or
first gestation
10:8, Winter 19:7, Spring 19:9
(To report first trimester fetal nuchal translucency
measurement, use 76813)
➲ Clinical Examples in Radiology Winter 07:6-7,
Summer 11:10, Spring 19:10
measurement, use 76814)
documentation, fetal and maternal evaluation, after first
trimester (> or = 14 weeks 0 days), transabdominal
approach; single or first gestation
➲ CPT Assistant Apr 97:2, Nov 97:25, Oct 01:3, Aug 02:2,
Mar 03:7
12:11, Winter 14:11, Spring 19:9
➲ CPT Assistant Apr 97:2, Oct 01:3, Aug 02:2, Mar
03:7
documentation, fetal and maternal evaluation plus detailed
fetal anatomic examination, transabdominal approach; single
or first gestation
➲ Clinical Examples in Radiology Winter 05:4, Winter
14:11
Winter 14:11
documentation, first trimester fetal nuchal translucency
measurement, transabdominal or transvaginal approach;
single or first gestation

Summer 11:10
documentation, limited (eg, fetal heart beat, placental
location, fetal position and/or qualitative amniotic fluid
volume), 1 or more fetuses
➲ CPT Assistant Apr 97:2, Nov 97:25, Oct 01:3, Dec 01:6,
Aug 02:2, Mar 03:7, Nov 03:14, May 10:9
10:8, 9, Summer 12:11, Summer 14:7, 8, Summer 16:12,
Spring 19:9
(Use 76815 only once per exam and not per element)
measurement, see 76813, 76814)
documentation, follow-up (eg, re-evaluation of fetal size by
measuring standard growth parameters and amniotic fluid
volume, re-evaluation of organ system(s) suspected or
confirmed to be abnormal on a previous scan),
transabdominal approach, per fetus
➲ CPT Assistant Apr 97:2, Oct 01:3, Aug 02:2, Mar 03:7,
May 10:9, Nov 11:10
12:11, Summer 14:7, 8, Spring 16:13, Spring 19:9
(Report 76816 with modifier 59 for each additional fetus
examined in a multiple pregnancy)
documentation, transvaginal
11:10, Winter 14:11, Winter 16:13, Spring 19:9
(For non-obstetrical transvaginal ultrasound, use 76830)
(If transvaginal examination is done in addition to
transabdominal obstetrical ultrasound exam, use 76817 in
addition to appropriate transabdominal exam code)
76818 Fetal biophysical profile; with non-stress testing
➲ CPT Assistant Apr 97:2, May 98:10, Sep 01:4, Oct 01:3,
Dec 01:6, Nov 04:10
76819 without non-stress testing

➲ CPT Assistant Sep 01:8, Dec 01:6
(Fetal biophysical profile assessments for the second and
any additional fetuses, should be reported separately by
code 76818 or 76819 with the modifier 59 appended)
(For amniotic fluid index without non-stress test, use 76815)
76820 Doppler velocimetry, fetal; umbilical artery
76821 middle cerebral artery

76825 Echocardiography, fetal, cardiovascular system, real time

with image documentation (2D), with or without M-mode
recording;
➲ CPT Assistant Apr 97:2, Aug 02:2, Sep 17:15
76826 follow-up or repeat study

➲ CPT Assistant Apr 97:2, Aug 02:2, Sep 17:15
76827 Doppler echocardiography, fetal, pulsed wave and/or

continuous wave with spectral display; complete
76828 follow-up or repeat study

(To report the use of color mapping, use 93325)
Nonobstetrical
Code 76856 includes the complete evaluation of the female pelvic
anatomy. Elements of this examination include a description and
measurements of the uterus and adnexal structures, measurement
of the endometrium, measurement of the bladder (when
applicable), and a description of any pelvic pathology (eg,
ovarian cysts, uterine leiomyomata, free pelvic fluid).
Code 76856 is also applicable to a complete evaluation of the
male pelvis. Elements of the examination include evaluation and
measurement (when applicable) of the urinary bladder,
evaluation of the prostate and seminal vesicles to the extent that
they are visualized transabdominally, and any pelvic pathology
(eg, bladder tumor, enlarged prostate, free pelvic fluid, pelvic
abscess).
Code 76857 represents a focused examination limited to the
assessment of one or more elements listed in code 76856 and/or
the reevaluation of one or more pelvic abnormalities previously
demonstrated on ultrasound. Code 76857, rather than 76770,
should be utilized if the urinary bladder alone (ie, not including
the kidneys) is imaged, whereas code 51798 should be utilized if
a bladder volume or post-void residual measurement is obtained
without imaging the bladder.
anatomic region, image documentation, and final, written report,
76830 Ultrasound, transvaginal
➲ CPT Assistant Aug 96:10, Jul 99:8, Aug 02:2, Mar 03:7,
Dec 05:3, Feb 09:22, Nov 11:10, Oct 17:10
➲ Clinical Examples in Radiology Inaugural 04:6-7,
Spring 08:9, Summer 10:8, 9, Summer 12:7, Spring 15:4,
Summer 15:10, Winter 16:13, Fall 18:4
(For obstetrical transvaginal ultrasound, use 76817)
(If transvaginal examination is done in addition to
transabdominal non-obstetrical ultrasound exam, use 76830
in addition to appropriate transabdominal exam code)
76831 Saline infusion sonohysterography (SIS), including color
flow Doppler, when performed
➲ CPT Assistant Nov 97:25, Jul 99:8, Dec 05:3, Mar
09:11
(For introduction of saline for saline infusion
sonohysterography, use 58340)
76856 Ultrasound, pelvic (nonobstetric), real time with image
documentation; complete
➲ CPT Assistant Oct 01:3, Dec 05:3, Jan 06:47, Mar 07:7,
Feb 09:22, Aug 16:10, Oct 17:10
Spring 08:9, Summer 10:8, Summer 12:7, Summer 14:9,
Spring 15:4, Summer 15:10, Winter 18:15, Fall 18:4
76857 limited or follow-up (eg, for follicles)
➲ CPT Assistant Jun 97:10, Oct 01:3, Dec 05:3, Sep
07:10, May 09:7, Oct 17:10
Summer 10:8, Summer 12:7, Summer 13:11, Summer
14:8, 9, Spring 15:4, Summer 15:10, Winter 18:15,
Spring 18:13, Fall 18:4
Genitalia
76870 Ultrasound, scrotum and contents
18:15, Fall 18:4
76872 Ultrasound, transrectal;
➲ CPT Assistant May 96:3, Nov 99:42, Oct 17:10, Jul
18:11, Nov 18:10
45391, 45392, 46948, 0421T, 0619T)◀
76873 prostate volume study for brachytherapy treatment
planning (separate procedure)
Extremities
Code 76881 represents a complete evaluation of a specific joint in
an extremity. Code 76881 requires ultrasound examination of all
of the following joint elements: joint space (eg, effusion), peri-
articular soft-tissue structures that surround the joint (ie, muscles,
tendons, other soft-tissue structures), and any identifiable
abnormality. In some circumstances, additional evaluations such
as dynamic imaging or stress maneuvers may be performed as
part of the complete evaluation. Code 76881 also requires
permanently recorded images and a written report containing a
description of each of the required elements or reason that an
element(s) could not be visualized (eg, absent secondary to
surgery or trauma).
When fewer than all of the required elements for a “complete”
exam (76881) are performed, report the “limited” code (76882).
Code 76882 represents a limited evaluation of a joint or an
evaluation of a structure(s) in an extremity other than a joint (eg,
soft-tissue mass, fluid collection, or nerve[s]). Limited evaluation
of a joint includes assessment of a specific anatomic structure(s)
(eg, joint space only [effusion] or tendon, muscle, and/or other
soft-tissue structure[s] that surround the joint) that does not
assess all of the required elements included in 76881. Code 76882
also requires permanently recorded images and a written report
containing a description of each of the elements evaluated.
For spectral and color Doppler evaluation of the extremities, use
93925, 93926, 93930, 93931, 93970, or 93971 as appropriate.
76881 Ultrasound, complete joint (ie, joint space and peri-articular
soft-tissue structures), real-time with image documentation
Summer 14:8, Winter 15:8, 9, Spring 15:4, Spring 17:12,
Spring 18:12, Fall 18:4, Winter 19:13, Summer 19:8
76882 Ultrasound, limited, joint or other nonvascular extremity
structure(s) (eg, joint space, peri-articular tendon[s],
muscle[s], nerve[s], other soft-tissue structure[s], or soft-
tissue mass[es]), real-time with image documentation
11:11, Summer 14:8, 9, Winter 15:8-10, Spring 15:4,
Summer 15:13, Spring 17:12, Fall 18:4, Winter 19:7,
Summer 19:8
76885 Ultrasound, infant hips, real time with imaging
documentation; dynamic (requiring physician or other
qualified health care professional manipulation)
76886 limited, static (not requiring physician or other qualified

health care professional manipulation)
Ultrasonic Guidance Procedures

33018)
76932 Ultrasonic guidance for endomyocardial biopsy, imaging
76936 Ultrasound guided compression repair of arterial

pseudoaneurysm or arteriovenous fistulae (includes
diagnostic ultrasound evaluation, compression of lesion and
imaging)
✚ 76937 Ultrasound guidance for vascular access requiring
ultrasound evaluation of potential access sites,
documentation of selected vessel patency, concurrent
realtime ultrasound visualization of vascular needle entry,
with permanent recording and reporting (List separately in
➲ CPT Assistant Dec 04:13, Jan 09:7, Jul 10:6, Nov 10:3,
Jan 11:8, Apr 12:6, Feb 13:3, May 13:3, Jun 13:12, Sep
13:18, Oct 14:6, Jul 15:10, Mar 17:4, Jul 17:5
Winter 05:5-6, Summer 06:8-9, Spring 08:7, 8, Fall
08:5, 6, Winter 09:8, 9, Spring 09:10, Summer 10:1, 3, 4,
Winter 12:3, Spring 12:4, Summer 12:3, Winter 13:1-3,
Summer 13:4, Fall 13:1-4, Winter 14:1-5, 7, Summer
14:10, Winter 15:2-6, Summer 15:2, Winter 16:2, Winter
17:8, Spring 18:8, Summer 18:4, Fall 18:8, Spring 19:2,
Summer 19:4
36568, 36569, 36572, 36573, 36584, 37191, 37192, 37193,
37760, 37761, 76942)
▶ (Do not report 76937 in conjunction with 0505T, 0620T
for ultrasound guidance for vascular access)◀
(If extremity venous non-invasive vascular diagnostic study
is performed separate from venous access guidance, see
93970, 93971)
76940 Ultrasound guidance for, and monitoring of, parenchymal
tissue ablation
➲ CPT Assistant Oct 02:2, Mar 07:7, Jul 15:8, May 17:3,
Nov 17:8
12:11, Spring 15:3, Fall 17:3
32994, 32998, 50250, 50542, 76942, 76998, 0582T, 0600T,
0601T)◀
(For ablation, see 47370-47382, 47383, 50592, 50593)
76941 Ultrasonic guidance for intrauterine fetal transfusion or
cordocentesis, imaging supervision and interpretation
(For procedure, see 36460, 59012)

76942 Ultrasonic guidance for needle placement (eg, biopsy,
aspiration, injection, localization device), imaging
➲ CPT Assistant Fall 93:12, Fall 94:2, May 96:3, Jun 97:5,
Oct 01:2, May 04:7, Dec 04:12, Apr 05:15-16, Aug
08:7, Mar 09:8, Feb 10:6, Mar 10:9, Jul 10:6, Feb 11:4,
Mar 11:10, Apr 11:12, Nov 12:3, Dec 12:9, Nov 13:9,
Oct 14:6, Feb 15:6, Aug 15:8, Nov 15:10, Jan 16:9, Jun
16:3, Jun 17:10, Dec 17:16, Mar 18:3, Jul 18:11, Aug
19:10
➲ Clinical Examples in Radiology Summer 05:1, 2, 6, Fall
05:1, Summer 08:5, 6, Fall 08:2, 3, Winter 09:9, Fall
09:8, Summer 10:1, 3, 4, Fall 10:3, Summer 11:3, Spring
14:2-4, 7, Summer 14:9, Spring 15:10, Summer 15:7,
Winter 16:6, Winter 17:3, Winter 18:8, Spring 18:3,
Winter 19:2
10006, 10021, 10030, 19083, 19285, 20604, 20606, 20611,
27096, 32408, 32554, 32555, 32556, 32557, 37760, 37761,
43232, 43237, 43242, 45341, 45342, 46948, 55874, 64479,
64480, 64483, 64484, 64490, 64491, 64493, 64494, 64495,
76975, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T,
0232T, 0481T, 0582T)◀
(For harvesting, preparation, and injection[s] of platelet rich
plasma, use 0232T)
76945 Ultrasonic guidance for chorionic villus sampling, imaging

76946 Ultrasonic guidance for amniocentesis, imaging supervision
and interpretation
76948 Ultrasonic guidance for aspiration of ova, imaging

(For placement of interstitial device[s] for radiation therapy

guidance, see 31627, 32553, 49411, 55876)
76965 Ultrasonic guidance for interstitial radioelement application
Other Procedures
76975 Gastrointestinal endoscopic ultrasound, supervision and
interpretation
➲ CPT Assistant Spring 94:5, May 04:7, Mar 09:8

43237, 43238, 43240, 43242, 43259, 44406, 44407, 45341,
45342, 45391, 45392, 76942)
76977 Ultrasound bone density measurement and interpretation,
peripheral site(s), any method
76978 Ultrasound, targeted dynamic microbubble sonographic

contrast characterization (non-cardiac); initial lesion
✚ 76979 each additional lesion with separate injection (List


76981 Ultrasound, elastography; parenchyma (eg, organ)
76982 first target lesion

✚ 76983 each additional target lesion (List separately in addition

(Report 76981 only once per session for evaluation of the
same parenchymal organ)
(To report shear wave liver elastography without imaging,
use 91200)
(For evaluation of a parenchymal organ and lesion[s] in the
same parenchymal organ at the same session, report only
76981)
(Do not report 76983 more than two times per organ)
76998 Ultrasonic guidance, intraoperative
➲ CPT Assistant Mar 07:7, Jul 10:6, Jan 13:6, Jan 14:5,
Oct 14:6, Aug 15:8, Apr 17:7

37760, 37761, 46948, 47370, 47371, 47380, 47381, 47382,
0515T, 0516T, 0517T, 0518T, 0519T, 0520T)
(For ultrasound guidance for open and laparoscopic
radiofrequency tissue ablation, use 76940)
76999 Unlisted ultrasound procedure (eg, diagnostic,
interventional)
15:8, 9, Spring 15:10, Winter 19:7
Radiologic Guidance
Fluoroscopic Guidance
(Do not report guidance codes 77001, 77002, 77003 for
services in which fluoroscopic guidance is included in the
descriptor)
✚ 77001 Fluoroscopic guidance for central venous access device
placement, replacement (catheter only or complete), or
removal (includes fluoroscopic guidance for vascular
access and catheter manipulation, any necessary contrast
injections through access site or catheter with related
venography radiologic supervision and interpretation, and
radiographic documentation of final catheter position) (List
➲ CPT Assistant Mar 07:7, Jul 08:9, Nov 10:3, Jan 11:8
➲ Clinical Examples in Radiology Spring 08:7, 8, Fall
08:5, 6, Winter 09:8, 9, Summer 10:11, Winter 17:8, Fall
18:7
33959, 33962, 33963, 33964, 36568, 36569, 36572, 36573,
36584, 77002)
(If formal extremity venography is performed from separate
venous access and separately interpreted, use 36005 and
75820, 75822, 75825, or 75827)
✚ 77002 Fluoroscopic guidance for needle placement (eg, biopsy,
aspiration, injection, localization device) (List separately in
➲ CPT Assistant Feb 07:11, Mar 07:7, May 07:1, Jun
07:10, Jul 08:9, Aug 08:7, Dec 08:9, Dec 09:12, Feb
10:6, Nov 10:3, Jan 11:8, Apr 11:12, Feb 12:11, Apr
12:19, Jun 12:14, Nov 12:3, Dec 12:9, Nov 13:9, Jul
15:8, Aug 15:6, Jan 16:9, Jun 16:3, Sep 16:10, May
17:3, Jun 17:10, Nov 17:8, Dec 18:11, Dec 19:8
09:6, 7, Winter 09:9, Fall 09:7, Fall 10:10, Summer
11:3, Spring 13:11, Winter 14:9-10, Spring 14:4, 10,
Spring 15:3, Winter 16:6, Winter 17:5, Spring 18:3,
Summer 18:9, Fall 18:12, Winter 19:3
20225, 20520, 20525, 20526, 20550, 20551, 20552, 20553,
20555, 20600, 20605, 20610, 20612, 20615, 21116, 21550,
23350, 24220, 25246, 27093, 27095, 27369, 27648, 32400,
32553, 36002, 38220, 38221, 38222, 38505, 38794, 41019,
42400, 42405, 47000, 47001, 48102, 49180, 49411, 50200,
50390, 51100, 51101, 51102, 55700, 55876, 60100, 62268,
62269, 64400-64448, 64450, 64455, 64505, 64600,
64605)◀
(77002 is included in all arthrography radiological
supervision and interpretation codes. See Administration of
Contrast Material[s] introductory guidelines for reporting
of arthrography procedures)
✚ 77003 Fluoroscopic guidance and localization of needle or catheter
tip for spine or paraspinous diagnostic or therapeutic
injection procedures (epidural or subarachnoid) (List
2012, 2017
➲ CPT Assistant Mar 07:7, Jul 08:9, Feb 10:12, May
10:10, Aug 10:8, Oct 10:14, Nov 10:3, Dec 10:14, Jan
11:8, Feb 11:4, Mar 11:7, Jul 11:17, Jun 12:12, Jul 12:3,
5, 6, Sep 12:14, Nov 13:9, Dec 13:14, Jan 16:9, 12, May
17:3, Dec 17:13, Dec 19:8
Winter 09:9, Spring 11:9, Winter 14:9-10, Spring 14:4,
Fall 15:10, Summer 16:4, Winter 18:8, Summer 18:9
62273, 62280, 62281, 62282, 62284, 64449, 64510, 64517,
64520, 64610, 96450)
62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327,
62328, 62329, 0627T, 0628T)◀
Computed Tomography Guidance

77011 Computed tomography guidance for stereotactic localization
77012 Computed tomography guidance for needle placement (eg,

biopsy, aspiration, injection, localization device),
➲ CPT Assistant Mar 07:7, May 07:1, Jun 07:10, Aug
08:7, Feb 10:6, Feb 11:4, Apr 11:12, Jul 12:3, 6, Sep
12:14, Nov 12:3, Dec 12:9, Nov 13:9, Feb 15:6, Jun
16:3, Dec 19:8
➲ Clinical Examples in Radiology Summer 08:5, 6, Fall
08:3, Fall 09:6, Fall 10:3, Summer 11:3, Spring 14:4,
Spring 15:7, Winter 16:6, Summer 16:4, Winter 17:5,
Winter 18:8, Spring 18:3, Winter 19:3
10030, 27096, 32408, 32554, 32555, 32556, 32557, 62270,
62272, 62328, 62329, 64479, 64480, 64483, 64484, 64490,
64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635,
64636, 0232T, 0481T, 0629T, 0630T)◀
77013 Computed tomography guidance for, and monitoring of,
parenchymal tissue ablation
➲ CPT Assistant Mar 07:7, Jul 15:8, May 17:3, Nov 17:8
15:3, Fall 17:3
32994, 32998, 0600T)◀
(For percutaneous ablation, see 47382, 47383, 50592,
50593)
77014 Computed tomography guidance for placement of radiation
therapy fields
➲ CPT Assistant Mar 07:7, Apr 15:11, Feb 16:3
12:10, Winter 13:11
guidance, see 31627, 32553, 49411, 55876)
Magnetic Resonance Imaging Guidance

77021 Magnetic resonance imaging guidance for needle placement
(eg, for biopsy, needle aspiration, injection, or placement of
localization device) radiological supervision and
interpretation
➲ CPT Assistant Mar 07:7, May 07:1, Jun 07:10, Aug
08:7, Feb 10:6, Apr 11:12, Nov 12:3, Dec 12:9, Nov
13:9, Feb 15:6, Jun 16:3, Jun 17:10, Jul 18:11
➲ Clinical Examples in Radiology Summer 08:5, 6, 13,
Fall 08:3, Fall 10:3, Summer 11:3, Spring 14:4, Spring
15:7, Winter 16:6, Winter 17:5, Spring 18:3, Winter 19:3
(For procedure, see appropriate organ or site)
10030, 19085, 19287, 32408, 32554, 32555, 32556, 32557,
0232T, 0481T)◀
77022 Magnetic resonance imaging guidance for, and monitoring
of, parenchymal tissue ablation
➲ CPT Assistant Mar 07:7, Oct 14:6, Jul 15:8, May 17:3,
Sep 19:11
15:3, Fall 17:3
32994, 32998, 0071T, 0072T, 0600T)◀
(For percutaneous ablation, see 47382, 47383, 50592,
50593)
(For focused ultrasound ablation treatment of uterine
leiomyomata, see Category III codes 0071T, 0072T)
(To report stereotactic localization guidance for breast
biopsy or for placement of breast localization device[s], see
19081, 19283)
(To report mammographic guidance for placement of breast
localization device[s], use 19281)
Breast, Mammography
77046 Magnetic resonance imaging, breast, without contrast
material; unilateral
77047 bilateral
77048 Magnetic resonance imaging, breast, without and with

contrast material(s), including computer-aided detection
(CAD real-time lesion detection, characterization and
pharmacokinetic analysis), when performed; unilateral
77049 bilateral
77053 Mammary ductogram or galactogram, single duct,

(For mammary ductogram or galactogram injection, use

19030)
Screening Mammography
77067
77054 Mammary ductogram or galactogram, multiple ducts,

77061 Diagnostic digital breast tomosynthesis; unilateral
77062 bilateral

76377, 77067)
✚ 77063 Screening digital breast tomosynthesis, bilateral (List

77065, 77066)
77065 Diagnostic mammography, including computer-aided
detection (CAD) when performed; unilateral
18:3
77066 bilateral
Spring 18:12
77067 Screening mammography, bilateral (2-view study of each
breast), including computer-aided detection (CAD) when
performed
18:12
(For electrical impedance breast scan, use 76499)
Bone/Joint Studies
77071 Manual application of stress performed by physician or
other qualified health care professional for joint
radiography, including contralateral joint if indicated
(For radiographic interpretation of stressed images, see

appropriate anatomic site and number of views)
77072 Bone age studies
77073 Bone length studies (orthoroentgenogram, scanogram)

08:10, Fall 10:6
77074 Radiologic examination, osseous survey; limited (eg, for
metastases)
77075 complete (axial and appendicular skeleton)

77076 Radiologic examination, osseous survey, infant
77077 Joint survey, single view, 2 or more joints (specify)

77078 Computed tomography, bone mineral density study, 1 or

more sites, axial skeleton (eg, hips, pelvis, spine)
77080 Dual-energy X-ray absorptiometry (DXA), bone density

study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
10:6, Summer 15:12, Spring 19:14
77081 appendicular skeleton (peripheral) (eg, radius, wrist,
heel)
(For dual energy x-ray absorptiometry [DXA] body

composition study, use 76499)
# 77085 axial skeleton (eg, hips, pelvis, spine), including
vertebral fracture assessment
# 77086 Vertebral fracture assessment via dual-energy X-ray
absorptiometry (DXA)

77084 Magnetic resonance (eg, proton) imaging, bone marrow
blood supply

Radiation Oncology
Listings for Radiation Oncology provide for teletherapy and
brachytherapy to include initial consultation, clinical treatment
planning, simulation, medical radiation physics, dosimetry,
treatment devices, special services, and clinical treatment
management procedures. They include normal follow-up care
during course of treatment and for three months following its
completion.
When a service or procedure is provided that is not listed in this
edition of the CPT codebook it should be identified by a Special
Report (see page 513) and one of the following unlisted
procedure codes:
planning
management
For treatment by injectable or ingestible isotopes, see
subsection Nuclear Medicine.
Consultation: Clinical Management

Preliminary consultation, evaluation of patient prior to decision
to treat, or full medical care (in addition to treatment
management) when provided by the therapeutic radiologist may
be identified by the appropriate procedure codes from
Evaluation and Management, Medicine, or Surgery sections.
Clinical Treatment Planning (External and

Internal Sources)
The clinical treatment planning process is a complex service
including interpretation of special testing, tumor localization,
treatment volume determination, treatment time/dosage
determination, choice of treatment modality, determination of
number and size of treatment ports, selection of appropriate
treatment devices, and other procedures.
Definitions
Simple planning requires a single treatment area of interest
encompassed in a single port or simple parallel opposed ports
with simple or no blocking.
Intermediate planning requires 3 or more converging ports, 2
separate treatment areas, multiple blocks, or special time dose
constraints.
Complex planning requires highly complex blocking, custom
shielding blocks, tangential ports, special wedges or
compensators, three or more separate treatment areas, rotational
or special beam considerations, combination of therapeutic
modalities.
77261 Therapeutic radiology treatment planning; simple
➲ CPT Assistant Fall 91:12, 15, Oct 97:2, Oct 10:3, Feb
16:3
77262 intermediate
➲ CPT Assistant Fall 91:12, 15, Oct 97:2, Apr 09:3,
Nov 09:6, Oct 10:3, Feb 16:3
77263 complex
➲ CPT Assistant Fall 91:15, Oct 97:2, Apr 09:3, Nov
09:6, Oct 10:3, Feb 16:3
Summer 15:5
Simulation is the process of defining relevant normal and
abnormal target anatomy, and acquiring the images and data
necessary to develop the optimal radiation treatment process for
the patient. A simulation is defined as complex if any of these
criteria are met: particle, rotation or arc therapy, complex or
custom blocking, brachytherapy simulation, hyperthermia probe
verification, or any use of contrast material. If a simulation does
not meet any of these criteria, the complexity is defined by the
number of treatment areas: one treatment area is simple, two
treatment areas are intermediate, and three or more treatment
areas are complex.
A treatment area is a contiguous anatomic location that will be
treated with radiation therapy. Generally, this includes the
primary tumor organ or the resection bed and the draining lymph
node chains, if indicated. An example is a breast cancer patient
for whom a single treatment area could be the breast alone or the
breast, adjacent supraclavicular fossa, and internal mammary
nodes. In some cases, a patient might receive radiation therapy to
more than one discontinuous anatomic location. An example
would be a patient with multiple bone metastases in separate sites
(eg, femur and cervical spine); in this case, each distinct and
separate anatomic site to be irradiated is a separate treatment area.
Definitions
Simple: simulation of a single treatment area.
Intermediate: two separate treatment areas.
Complex: three or more treatment areas, or any number of
treatment areas if any of the following are involved: particle,
rotation or arc therapy, complex blocking, custom shielding
blocks, brachytherapy simulation, hyperthermia probe
verification, any use of contrast materials.
77280 Therapeutic radiology simulation-aided field setting; simple
➲ CPT Assistant Fall 91:15, Oct 97:2, Nov 97:26, Apr
09:10, Nov 09:6, Oct 10:3, Nov 13:11, Apr 15:11
09:2, 4, 5
77285 intermediate
➲ CPT Assistant Fall 91:15, Oct 97:3, Nov 09:6, Oct
10:3, Apr 15:11
Clinical Examples in Radiology Summer 08:12,
➲
Summer 09:4
77290 complex
➲ CPT Assistant Fall 91:12, 15, Oct 97:3, Apr 09:3,
10, Nov 09:6, Oct 10:3, Nov 13:11, Apr 15:11, Sep
16:10
Summer 09:4
✚ 77293 Respiratory motion management simulation (List separately

planning
Medical Radiation Physics, Dosimetry,

Treatment Devices, and Special Services
# 77295 3-dimensional radiotherapy plan, including dose-volume
histograms
➲ CPT Assistant Fall 91:15, Oct 97:3, Nov 97:26, May
05:7, Oct 07:1, Nov 09:3, Oct 10:3, Nov 13:11, Jun
15:6, Dec 15:16
09:2, 5
77300 Basic radiation dosimetry calculation, central axis depth
dose calculation, TDF, NSD, gap calculation, off axis factor,
tissue inhomogeneity factors, calculation of non-ionizing
radiation surface and depth dose, as required during course
of treatment, only when prescribed by the treating physician
➲ CPT Assistant Fall 91:14, Oct 97:3, Dec 08:9, Nov
09:3, Oct 10:3
09:2, 5, 6, Summer 15:5
77316, 77317, 77318, 77321, 77767, 77768, 77770, 77771,
77772, 0394T, 0395T)
77301 Intensity modulated radiotherapy plan, including dose-
volume histograms for target and critical structure partial
tolerance specifications
➲ CPT Assistant Mar 05:1, 6, May 05:7, Oct 07:1, Nov
09:3, Oct 10:3, Nov 13:11
(Dose plan is optimized using inverse or forward planning
technique for modulated beam delivery [eg, binary, dynamic
MLC] to create highly conformal dose distribution.
Computer plan distribution must be verified for positional
accuracy based on dosimetric verification of the intensity
map with verification of treatment set-up and interpretation
of verification methodology)
77306 Teletherapy isodose plan; simple (1 or 2 unmodified ports
directed to a single area of interest), includes basic
dosimetry calculation(s)
77307 complex (multiple treatment areas, tangential ports, the

use of wedges, blocking, rotational beam, or special
beam considerations), includes basic dosimetry
calculation(s)
(Only 1 teletherapy isodose plan may be reported for a
given course of therapy to a specific treatment area)
77316 Brachytherapy isodose plan; simple (calculation[s] made
from 1 to 4 sources, or remote afterloading brachytherapy, 1
channel), includes basic dosimetry calculation(s)
(For definition of source, see clinical brachytherapy

introductory guidelines)
77317 intermediate (calculation[s] made from 5 to 10 sources,
or remote afterloading brachytherapy, 2-12 channels),
includes basic dosimetry calculation(s)
77318 complex (calculation[s] made from over 10 sources, or

remote afterloading brachytherapy, over 12 channels),
includes basic dosimetry calculation(s)

77300)
77321 Special teletherapy port plan, particles, hemibody, total
body
➲ CPT Assistant Fall 91:14, Oct 97:4, Oct 10:3
77331 Special dosimetry (eg, TLD, microdosimetry) (specify),

only when prescribed by the treating physician
➲ CPT Assistant Fall 91:13, Oct 97:4, Jun 15:6
77332 Treatment devices, design and construction; simple (simple
block, simple bolus)
➲ CPT Assistant Oct 97:4, Oct 10:3, Feb 16:3
08:12, Summer 09:6
77333 intermediate (multiple blocks, stents, bite blocks, special
bolus)
➲ CPT Assistant Oct 97:3, Oct 10:3, Feb 16:3
77334 complex (irregular blocks, special shields,
compensators, wedges, molds or casts)
➲ CPT Assistant Fall 91:14, Oct 97:4, Dec 08:9, Nov
09:3, Oct 10:3, Dec 10:15, Dec 15:16, Feb 16:3, Sep
16:10
Summer 08:12, Summer 09:2, 6
77336 Continuing medical physics consultation, including
assessment of treatment parameters, quality assurance of
dose delivery, and review of patient treatment
documentation in support of the radiation oncologist,
reported per week of therapy
➲ CPT Assistant Fall 91:15, Oct 97:4, Nov 98:21, Oct
10:3, Feb 16:3
09:2, 6
77338 Multi-leaf collimator (MLC) device(s) for intensity
modulated radiation therapy (IMRT), design and
construction per IMRT plan
(Do not report 77338 in conjunction with 77385 for
compensator based IMRT)
(Do not report 77338 more than once per IMRT plan)
(For immobilization in IMRT treatment, see 77332-77334)
77370 Special medical radiation physics consultation
➲ CPT Assistant Fall 91:14, Oct 97:4, May 09:8, Oct 10:3,
Jun 15:6, Feb 16:3
09:6, 9
Stereotactic Radiation Treatment Delivery

77371 Radiation treatment delivery, stereotactic radiosurgery
(SRS), complete course of treatment of cranial lesion(s)
consisting of 1 session; multi-source Cobalt 60 based
2017
➲ CPT Assistant Mar 07:7, Oct 07:1, Oct 10:3, Jul 11:12,
Jul 14:9
77372 linear accelerator based

➲ CPT Assistant Mar 07:7, Oct 07:1, Oct 10:3, Jul
11:12
(For radiation treatment management, use 77432)

77373 Stereotactic body radiation therapy, treatment delivery, per
fraction to 1 or more lesions, including image guidance,
entire course not to exceed 5 fractions
➲ CPT Assistant Mar 07:7, Oct 07:1, Oct 10:3, Jul 11:12,
Jul 14:9, Jun 15:6
77401, 77402, 77407, 77412)
(For single fraction cranial lesion[s], see 77371, 77372)
Other Procedures
Radiation Treatment Delivery

Following dosimetry calculations, there are a number of
alternative methods to deliver external radiation treatments,
which are described with specific CPT codes:
■ X-ray (photon), including conventional and intensity
modulated radiation therapy (IMRT) beams;
■ Electron beams;
■ Neutron beams;
■ Proton beams.
All treatment delivery codes are reported once per treatment
session. The treatment delivery codes recognize technical-only
services and contain no physician work (the professional
component). In contrast, the treatment management codes
contain only the professional component.
Radiation treatment delivery with conventional X-ray or electron
beams is assigned levels of complexity based on the number of
treatment sites and complexity of the treatment fields, blocking,
wedges, and physical or virtual tissue compensators. A simple
block is straight-edged or an approximation of a straight edge
created by a multileaf collimator (MLC). Energy of the
megavoltage (≥ 1 MeV) beam does not contribute to complexity.
Techniques such as treating a field-in-field to ensure dose
homogeneity reflect added complexity.
Energies below the megavoltage range may be used in the
treatment of skin lesions. Superficial radiation energies (up to
200 kV) may be generated by a variety of technologies and
should not be reported with megavoltage (77402, 77407, 77412)
for surface application. Do not report clinical treatment planning
(77261, 77262, 77263), treatment devices (77332, 77333, 77334),
isodose planning (77306, 77307, 77316, 77317, 77318), physics
consultation (77336), or radiation treatment management (77427,
77431, 77432, 77435, 77469, 77470, 77499) with 77401, 0394T, or
0395T. When reporting 77401 alone, evaluation and management,
when performed, may be reported with the appropriate E/M
codes.
Intensity modulated radiation therapy (IMRT) uses computer-
based optimization techniques with non-uniform radiation beam
intensities to create highly conformal dose distributions that can
be delivered by a radiotherapy treatment machine. A number of
technologies, including spatially and temporally modulated
beams, cylindrical beamlets, dynamic MLC, single or multiple
fields or arcs, or compensators, may be used to generate IMRT.
The complexity of IMRT may vary depending on the area being
treated or the technique being used.
Image guided radiation therapy (IGRT) may be used to direct the
radiation beam and to reflect motion during treatment. A variety
of techniques may be used to perform this guidance including
imaging (eg, ultrasound, CT, MRI, stereoscopic imaging) and
non-imaging (eg, electromagnetic or infrared) techniques.
Guidance may be used with any radiation treatment delivery
technique and is typically used with IMRT delivery. IMRT
delivery codes include the technical component of guidance or
tracking, if performed. Because only the technical portion of
IGRT is bundled into IMRT, the physician involvement in
guidance or tracking may be reported separately. When guidance
is required with conventional radiation treatment delivery, both
the professional and technical components are reported because
neither component of guidance is bundled into conventional
radiation treatment delivery services.
The technical and professional components of guidance are
handled differently with each radiation delivery code depending
on the type of radiation being administered. The Radiation
Management and Treatment Table is provided for clarity.
Definitions
Radiation Treatment Delivery, megavoltage (≥ 1 MeV), any
energy
Simple: All of the following criteria are met (and none of the
complex or intermediate criteria are met): single treatment area,
one or two ports, and two or fewer simple blocks.
Intermediate: Any of the following criteria are met (and none of
the complex criteria are met): 2 separate treatment areas, 3 or
more ports on a single treatment area, or 3 or more simple
blocks.
Complex: Any of the following criteria are met: 3 or more
separate treatment areas, custom blocking, tangential ports,
wedges, rotational beam, field-in-field or other tissue
compensation that does not meet IMRT guidelines, or electron
beam.
IMRT, any energy, includes the technical services for guidance.
Simple: Any of the following: prostate, breast, and all sites using
physical compensator based IMRT.
Complex: Includes all other sites if not using physical
compensator based IMRT.
77401 Radiation treatment delivery, superficial and/or ortho
voltage, per day
➲ CPT Assistant Apr 03:14, Aug 03:10, Oct 07:1, Oct
10:3, Dec 15:14, Feb 16:3
09:7
77402 Radiation treatment delivery, ≥1 MeV; simple
➲ CPT Assistant Apr 03:14, Aug 03:10, Oct 07:1, Oct
10:3, Dec 15:14, Feb 16:3, Mar 16:7
77407 intermediate
➲ CPT Assistant Apr 03:14, Aug 03:10, Oct 07:1, Dec
15:14, Feb 16:3, Mar 16:7
77412 complex
➲ CPT Assistant Apr 03:14, Aug 03:10, Oct 07:1, Dec
15:14, Feb 16:3, Mar 16:7
Spring 07:7-9, 12, Summer 08:12, Summer 09:7
77417 Therapeutic radiology port image(s)
➲ CPT Assistant Fall 91:14, Dec 97:11, Feb 06:14, Oct
07:1, Dec 15:14, Dec 17:15
(For intensity modulated treatment planning, use 77301)

# 77385 Intensity modulated radiation treatment delivery (IMRT),
includes guidance and tracking, when performed; simple
(To report professional component [PC] of guidance and

tracking, use 77387 with modifier 26)
# 77386 complex
(To report professional component [PC] of guidance and

tracking, use 77387 with modifier 26)
77372, 77373)
# 77387 Guidance for localization of target volume for delivery of
radiation treatment, includes intrafraction tracking, when
performed
➲ CPT Assistant Dec 15:14, 17, Feb 16:3
(Do not report technical component [TC] with 77385,

77386, 77371, 77372, 77373)
guidance, see 31627, 32553, 49411, 55876)
# 77424 Intraoperative radiation treatment delivery, x-ray, single
treatment session
# 77425 Intraoperative radiation treatment delivery, electrons, single

treatment session
Neutron Beam Treatment Delivery

77423 High energy neutron radiation treatment delivery, 1 or more
isocenter(s) with coplanar or non-coplanar geometry with
blocking and/or wedge, and/or compensator(s)

Radiation Treatment Management

Radiation treatment management is reported in units of five
fractions or treatment sessions, regardless of the actual time
period in which the services are furnished. The services need not
be furnished on consecutive days. Multiple fractions representing
two or more treatment sessions furnished on the same day may
be counted separately as long as there has been a distinct break in
therapy sessions, and the fractions are of the character usually
furnished on different days. Code 77427 is also reported if there
are three or four fractions beyond a multiple of five at the end of
a course of treatment; one or two fractions beyond a multiple of
five at the end of a course of treatment are not reported
separately.
Radiation treatment management requires and includes a
minimum of one examination of the patient by the physician for
medical evaluation and management (eg, assessment of the
patient’s response to treatment, coordination of care and
treatment, review of imaging and/or lab test results with
documentation) for each reporting of the radiation treatment
management service. Code 77469 represents only the
intraoperative session management and does not include medical
evaluation and management outside of that session. The
professional services furnished during treatment management
typically include:
■ Review of port images;
■ Review of dosimetry, dose delivery, and treatment parameters;
■ Review of patient treatment set-up.
Stereotactic radiosurgery (SRS-[77432]) and stereotactic body
radiation treatment (SBRT-[77435]) management also include the
professional component of guidance for localization of target
volume for the delivery of radiation therapy (77387). See also the
Radiation Management and Treatment Table.
77427 Radiation treatment management, 5 treatments
➲ CPT Assistant Nov 99:42, Feb 00:7, Oct 07:1, Nov
09:6, Jun 15:6, Feb 16:3
09:2, 7, 8
77431 Radiation therapy management with complete course of
therapy consisting of 1 or 2 fractions only
➲ CPT Assistant Winter 90:10, Oct 97:4, Nov 09:6, Feb
16:3
09:7, 8
(77431 is not to be used to fill in the last week of a long
course of therapy)
77432 Stereotactic radiation treatment management of cranial
lesion(s) (complete course of treatment consisting of 1
session)
➲ CPT Assistant Oct 97:4, Nov 09:6, Jul 11:12, Jul 14:9,
Dec 15:14, 17, Feb 16:3
(The same physician should not report both stereotactic

radiosurgery services [61796-61800] and radiation
treatment management [77432 or 77435] for cranial lesions)
(For stereotactic body radiation therapy treatment, use
77435)
(To report the technical component of guidance for
localization of target volume, use 77387 with a technical
component modifier [TC])
77435 Stereotactic body radiation therapy, treatment management,
per treatment course, to 1 or more lesions, including image
guidance, entire course not to exceed 5 fractions
➲ CPT Assistant Mar 07:7, Oct 07:1, Nov 09:6, Jun 15:6,
Dec 15:14, Feb 16:3

(The same physician should not report both stereotactic
radiosurgery services [32701, 63620, 63621] and radiation
treatment management [77435])
(To report the technical component of guidance for
localization of target volume, use 77387 with a technical
component modifier [TC])
77469 Intraoperative radiation treatment management
11:11
77470 Special treatment procedure (eg, total body irradiation,
hemibody radiation, per oral or endocavitary irradiation)
➲ CPT Assistant Winter 91:22, Oct 97:1, Apr 09:3, Feb
16:3
09:7, 8, Spring 12:11
(77470 assumes that the procedure is performed 1 or more
times during the course of therapy, in addition to daily or
weekly patient management)
(For intraoperative radiation treatment delivery and
management, see 77424, 77425, 77469)
management
➲ CPT Assistant Nov 99:42, Feb 00:7, Nov 09:6, Jun 15:6,
Feb 16:3
Proton Beam Treatment Delivery

Definitions
Simple proton treatment delivery to a single treatment area
utilizing a single non-tangential/oblique port, custom block with
compensation (77522) and without compensation (77520).
Intermediate proton treatment delivery to one or more treatment
areas utilizing two or more ports or one or more
tangential/oblique ports, with custom blocks and compensators.
Complex proton treatment delivery to one or more treatment
areas utilizing two or more ports per treatment area with
matching or patching fields and/or multiple isocenters, with
custom blocks and compensators.
77520 Proton treatment delivery; simple, without compensation
77522 simple, with compensation

Radiation Management and Treatment Table
Category Code Descriptor IGRT IGRT PC Code Type

TC (77387- (Technical /
(77387- PC) Professional)
TC) Bundled
Bundled
into into
Code? Code?
SBRT: Stereotactic body radiation

SRS: Stereotactic radiosurgery
therapy
IMRT: Intensity modulated
IGRT: Image guided radiation therapy
radiation therapy
PC: Professional component
TC: Technical component
(modifier 26)
Treatment
Management,
77427 N N Professional
1-5
Treatments
Treatment
Management,
Radiation 77431 N N Professional
1-2
Treatment Fractions
Management
SRS
Management,
77432 N Y Professional
Cranial
Lesion(s)
SBRT
77435 N Y Professional
Management
SRS
SRS 77371 Multisource Y N Technical
Treatment 60 Based
Delivery
SRS Linear
77372 Y N Technical
Based
SBRT 77373 SBRT, 1 or Y N Technical

Treatment More
Delivery
Lesions, 1-5
Fractions
Superficial
77401 and/or Ortho N N Technical
Voltage
Radiation
Treatment
77402 N N Technical
Delivery,
Radiation Simple
Treatment
Radiation
Delivery
Treatment
77407 N N Technical
Delivery,
Intermediate
Radiation
Treatment
77412 N N Technical
Delivery,
Complex
IMRT
Treatment
77385 Y N Technical
Delivery,
IMRT Simple
Treatment
Delivery IMRT
Treatment
77386 Y N Technical
Delivery,
Complex
Neutron Neutron
Beam Beam
77423 N N Technical
Treatment Treatment,
Delivery Complex
Proton 77520 Proton N N Technical
Treatment Treatment,
Delivery Simple
Proton
77522 Treatment, N N Technical
Simple
Proton
Intermediate
Proton
Complex
77523 intermediate
77525 complex
Hyperthermia
Hyperthermia treatments as listed in this section include external
(superficial and deep), interstitial, and intracavitary.
Radiation therapy when given concurrently is listed separately.
Hyperthermia is used only as an adjunct to radiation therapy or
chemotherapy. It may be induced by a variety of sources (eg,
microwave, ultrasound, low energy radio-frequency conduction,
or by probes).
The listed treatments include management during the course of
therapy and follow-up care for three months after completion.
Preliminary consultation is not included (see Evaluation and
Management 99241-99255).
Physics planning and interstitial insertion of temperature sensors,
and use of external or interstitial heat generating sources are
included.
The following descriptors are included in the treatment schedule:
77600 Hyperthermia, externally generated; superficial (ie, heating
to a depth of 4 cm or less)
➲ CPT Assistant Winter 91:22, Dec 13:17
77605 deep (ie, heating to depths greater than 4 cm)

77610 Hyperthermia generated by interstitial probe(s); 5 or fewer

interstitial applicators
77615 more than 5 interstitial applicators

Clinical Intracavitary Hyperthermia

77620 Hyperthermia generated by intracavitary probe(s)
Clinical Brachytherapy
Clinical brachytherapy requires the use of either natural or man-
made radioelements applied into or around a treatment field of
interest. The supervision of radioelements and dose interpretation
are performed solely by the therapeutic radiologist.
Services 77750-77799 include admission to the hospital and daily
visits.
For insertion of ovoids and tandems, use 57155.
For insertion of Heyman capsules, use 58346.
Definitions
(Sources refer to intracavitary placement or permanent interstitial
placement; ribbons refer to temporary interstitial placement)
A simple application has one to four sources/ribbons.
An intermediate application has five to 10 sources/ribbons.
A complex application has greater than 10 sources/ribbons.
High dose-rate brachytherapy involves treatment with radiation
sources that cannot safely be handled manually. These systems
are remotely controlled and place a radionuclide source
(radioelement or radioisotope) within an applicator placed in or
near the target. These applicators may be placed in the body or
on the skin surface.
Small electronic X-ray sources placed into an applicator within or
close to the target may also be used to generate radiation at high-
dose rates. This is referred to as high dose-rate electronic
brachytherapy.
To report high dose-rate electronic brachytherapy, see 0394T,
0395T.
77750 Infusion or instillation of radioelement solution (includes 3-
month follow-up care)
(For administration of radiolabeled monoclonal antibodies,
use 79403)
(For non-antibody radiopharmaceutical therapy by
intravenous administration only, not including 3-month
follow-up care, use 79101)
77761 Intracavitary radiation source application; simple
➲ CPT Assistant Winter 91:23, Jan 96:7, Mar 99:3, Feb
02:7, Sep 05:1
77762 intermediate
➲ CPT Assistant Winter 91:23, Feb 02:7, Sep 05:1
77763 complex
➲ CPT Assistant Winter 91:23, Mar 99:3, Feb 02:7,
Sep 05:1
(Do not report 77761-77763 in conjunction with Category
III code 0394T, 0395T)
77767 Remote afterloading high dose rate radionuclide skin
surface brachytherapy, includes basic dosimetry, when
performed; lesion diameter up to 2.0 cm or 1 channel
77768 lesion diameter over 2.0 cm and 2 or more channels, or

multiple lesions
77770 Remote afterloading high dose rate radionuclide interstitial

or intracavitary brachytherapy, includes basic dosimetry,
when performed; 1 channel
77771 2-12 channels

77772 over 12 channels
(Do not report 77767, 77768, 77770, 77771, 77772 in

conjunction with 77300, 0394T, 0395T)
(For non-brachytherapy superficial [eg, ≤200 kV] radiation
treatment delivery, use 77401)
77778 Interstitial radiation source application, complex, includes
supervision, handling, loading of radiation source, when
performed
➲ CPT Assistant Winter 91:23, Apr 04:6, Sep 05:1, May
07:1
(Do not report 77778 in conjunction with Category III codes

0394T, 0395T)
(77782-77784 have been deleted. To report, see 77767,
77768, 77770, 77771, 77772)
77789 Surface application of low dose rate radionuclide source

77768, 0394T, 0395T)
77790 Supervision, handling, loading of radiation source

Nuclear Medicine
Listed procedures may be performed independently or in the
course of overall medical care. If the individual providing these
services is also responsible for diagnostic workup and/or follow-
up care of patient, see appropriate sections also.
Radioimmunoassay tests are found in the Clinical Pathology
section (codes 82009-84999). These codes can be appropriately
used by any specialist performing such tests in a laboratory
licensed and/or certified for radioimmunoassays. The reporting
of these tests is not confined to clinical pathology laboratories
alone.
The services listed do not include the radiopharmaceutical or
drug. To separately report supply of diagnostic and therapeutic
radiopharmaceuticals and drugs, use the appropriate supply
code(s), in addition to the procedure code.
Diagnostic
Endocrine System
78012 Thyroid uptake, single or multiple quantitative
measurement(s) (including stimulation, suppression, or
discharge, when performed)
78013 Thyroid imaging (including vascular flow, when

performed);
78014 with single or multiple uptake(s) quantitative
measurement(s) (including stimulation, suppression, or
discharge, when performed)
78015 Thyroid carcinoma metastases imaging; limited area (eg,

neck and chest only)
78016 with additional studies (eg, urinary recovery)

78018 whole body

➲ Clinical Examples in Radiology Fall 09:3-5
✚ 78020 Thyroid carcinoma metastases uptake (List separately in

➲ CPT Assistant Nov 98:21, Apr 99:4, Jan 07:31
(Use 78020 in conjunction with 78018 only)

78070 Parathyroid planar imaging (including subtraction, when
performed);
78071 with tomographic (SPECT)

78072 with tomographic (SPECT), and concurrently acquired

computed tomography (CT) for anatomical localization
78800, 78801, 78802, 78803, 78804, 78830, 78831, 78832,
78835)
78075 Adrenal imaging, cortex and/or medulla
78099 Unlisted endocrine procedure, diagnostic nuclear medicine

➲ CPT Assistant Dec 05:7, Jan 07:31, Dec 16:10
(For chemical analysis, see Chemistry section)
Hematopoietic, Reticuloendothelial and Lymphatic

System
78102 Bone marrow imaging; limited area

78104 whole body
78110 Plasma volume, radiopharmaceutical volume-dilution
technique (separate procedure); single sampling
78111 multiple samplings
78120 Red cell volume determination (separate procedure); single
sampling
78121 multiple samplings
78122 Whole blood volume determination, including separate
measurement of plasma volume and red cell volume
(radiopharmaceutical volume-dilution technique)
▲ 78130 Red cell survival study
78140 Labeled red cell sequestration, differential organ/tissue (eg,
splenic and/or hepatic)
78185 Spleen imaging only, with or without vascular flow
(If combined with liver study, use procedures 78215 and
78216)
78191 Platelet survival study
78195 Lymphatics and lymph nodes imaging
➲ CPT Assistant Nov 98:22, Jul 99:6, Nov 99:43, Dec
99:8, Sep 08:5, Feb 12:9
(For sentinel node identification without scintigraphy
imaging, use 38792)
(For sentinel node excision, see 38500-38542)
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic
procedure, diagnostic nuclear medicine
Gastrointestinal System
78201 Liver imaging; static only
78202 with vascular flow

(For spleen imaging only, use 78185)

78215 Liver and spleen imaging; static only
78226 Hepatobiliary system imaging, including gallbladder when
present;
78227 with pharmacologic intervention, including quantitative

measurement(s) when performed
78230 Salivary gland imaging;

78231 with serial images
78232 Salivary gland function study
78258 Esophageal motility
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264 Gastric emptying imaging study (eg, solid, liquid, or both);

78265 with small bowel transit

78266 with small bowel and colon transit, multiple days

(Report 78264, 78265, 78266 only once per imaging study)

78267 Urea breath test, C-14 (isotopic); acquisition for analysis
78268 analysis
(For breath hydrogen or methane testing and analysis, use

91065)
(78270, 78271, 78272 have been deleted)
78278 Acute gastrointestinal blood loss imaging
78282 Gastrointestinal protein loss

78290 Intestine imaging (eg, ectopic gastric mucosa, Meckel’s

localization, volvulus)
78291 Peritoneal-venous shunt patency test (eg, for LeVeen,

Denver shunt)
(For injection procedure, use 49427)

78299 Unlisted gastrointestinal procedure, diagnostic nuclear
medicine
Bone and joint imaging can be used in the diagnosis of a variety
of inflammatory processes (eg, osteomyelitis), as well as for
localization of primary and/or metastatic neoplasms.
78300 Bone and/or joint imaging; limited area
10:9
10:9
78306 whole body
➲ CPT Assistant Mar 97:11, Jan 02:10, Jun 03:11, Feb
12:10
Winter 09:3, 4, 5, Spring 10:9, Spring 13:10
78315 3 phase study
Winter 09:4, 5, Spring 10:9
78350 Bone density (bone mineral content) study, 1 or more sites;
single photon absorptiometry
78351 dual photon absorptiometry, 1 or more sites

78399 Unlisted musculoskeletal procedure, diagnostic nuclear

medicine
Myocardial perfusion (SPECT and PET) and cardiac blood pool
imaging studies may be performed at rest and/or during stress.
When performed during exercise and/or pharmacologic stress,
the appropriate stress testing code from the 93015-93018 series
may be reported in addition to 78430, 78431, 78432, 78433,
78451-78454, 78472, 78491, 78492. PET can be performed on
either a dedicated PET machine (which uses a PET source for
attenuation correction) or a combination PET/CT camera (78429,
78430, 78431, 78433). A cardiac PET study performed on a
PET/CT camera includes examination of the CT transmission
images for review of anatomy in the field of view.
78414 Determination of central c-v hemodynamics (non-imaging)
(eg, ejection fraction with probe technique) with or without
pharmacologic intervention or exercise, single or multiple
determinations
➲ CPT Assistant Dec 05:7, May 10:6, Feb 12:9
78428 Cardiac shunt detection


78445 Non-cardiac vascular flow imaging (ie, angiography,
venography)
78451 Myocardial perfusion imaging, tomographic (SPECT)
(including attenuation correction, qualitative or quantitative
wall motion, ejection fraction by first pass or gated
technique, additional quantification, when performed);
single study, at rest or stress (exercise or pharmacologic)
➲ CPT Assistant May 10:5, Feb 11:9, Feb 12:10
10:11
78802, 78803, 78804, 78830, 78831, 78832, 78835)
78452 multiple studies, at rest and/or stress (exercise or
pharmacologic) and/or redistribution and/or rest
reinjection
➲ CPT Assistant May 10:5, Feb 11:9, Feb 12:9
Spring 10:9
78802, 78803, 78804, 78830, 78831, 78832, 78835)
78453 Myocardial perfusion imaging, planar (including qualitative
or quantitative wall motion, ejection fraction by first pass or
gated technique, additional quantification, when performed);
single study, at rest or stress (exercise or pharmacologic)
78454 multiple studies, at rest and/or stress (exercise or

pharmacologic) and/or redistribution and/or rest
reinjection
78456 Acute venous thrombosis imaging, peptide
78457 Venous thrombosis imaging, venogram; unilateral

78458 bilateral
78459 Myocardial imaging, positron emission tomography (PET),

metabolic evaluation study (including ventricular wall
motion[s] and/or ejection fraction[s], when performed),
single study;
➲ CPT Assistant Jun 96:5, Nov 97:26, May 10:6
# 78429 with concurrently acquired computed tomography

transmission scan
(For CT coronary calcium scoring, use 75571)

(CT performed for other than attenuation correction and
anatomical localization is reported using the appropriate
site specific CT code with modifier 59)
78466 Myocardial imaging, infarct avid, planar; qualitative or
quantitative
78468 with ejection fraction by first pass technique

78469 tomographic SPECT with or without quantification

➲ CPT Assistant May 10:6, Nov 18:11
(For myocardial sympathetic innervation imaging, see
0331T, 0332T)
78802, 78803, 78804, 78830, 78831, 78832, 78835)
78472 Cardiac blood pool imaging, gated equilibrium; planar,
single study at rest or stress (exercise and/or
pharmacologic), wall motion study plus ejection fraction,
with or without additional quantitative processing
➲ CPT Assistant Nov 98:22, Nov 99:44, May 10:6
(For assessment of right ventricular ejection fraction by first

pass technique, use 78496)
78473 multiple studies, wall motion study plus ejection
fraction, at rest and stress (exercise and/or
pharmacologic), with or without additional
quantification

78454, 78481, 78483, 78494)
(78478, 78480 have been deleted. To report, see 78451-
78454)
78481 Cardiac blood pool imaging (planar), first pass technique;
single study, at rest or with stress (exercise and/or
with or without quantification
78483 multiple studies, at rest and with stress (exercise and/or

with or without quantification
(For cerebral blood flow study, use 78610)
78454)
78491 Myocardial imaging, positron emission tomography (PET),
perfusion study (including ventricular wall motion[s] and/or
ejection fraction[s], when performed); single study, at rest
or stress (exercise or pharmacologic)
# 78430 single study, at rest or stress (exercise or

pharmacologic), with concurrently acquired computed
tomography transmission scan
78492 multiple studies at rest and stress (exercise or

pharmacologic)
# 78431 multiple studies at rest and stress (exercise or

pharmacologic), with concurrently acquired computed
tomography transmission scan
# 78432 Myocardial imaging, positron emission tomography (PET),

combined perfusion with metabolic evaluation study
(including ventricular wall motion[s] and/or ejection
fraction[s], when performed), dual radiotracer (eg,
myocardial viability);
# 78433 with concurrently acquired computed tomography

transmission scan
(CT performed for other than attenuation correction and
anatomical localization is reported using the appropriate
site specific CT code with modifier 59)
#✚ 78434 Absolute quantitation of myocardial blood flow (AQMBF),
positron emission tomography (PET), rest and
pharmacologic stress (List separately in addition to code for
primary procedure)

(For CT coronary calcium scoring, use 75571)
(For myocardial imaging by planar or SPECT, see 78451,
78452, 78453, 78454)
78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at
rest, wall motion study plus ejection fraction, with or
without quantitative processing
➲ CPT Assistant Nov 98:22, Jun 99:3, May 10:6

78802, 78803, 78804, 78830, 78831, 78832, 78835)
✚ 78496 Cardiac blood pool imaging, gated equilibrium, single study,
at rest, with right ventricular ejection fraction by first pass
technique (List separately in addition to code for primary
procedure)
➲ CPT Assistant Nov 98:22, Jun 99:3, 11, May 10:6, Feb
12:9
78499 Unlisted cardiovascular procedure, diagnostic nuclear
medicine
Respiratory System
78579 Pulmonary ventilation imaging (eg, aerosol or gas)
78580 Pulmonary perfusion imaging (eg, particulate)

➲ CPT Assistant Mar 99:4, Dec 05:7, May 10:6
78582 Pulmonary ventilation (eg, aerosol or gas) and perfusion

imaging
78597 Quantitative differential pulmonary perfusion, including

imaging when performed
78598 Quantitative differential pulmonary perfusion and ventilation

(eg, aerosol or gas), including imaging when performed
(Report 78579, 78580, 78582-78598 only once per imaging

session)
(Do not report 78580, 78582-78598 in conjunction with
78451-78454)
78599 Unlisted respiratory procedure, diagnostic nuclear medicine
Nervous System
78600 Brain imaging, less than 4 static views;
78605 Brain imaging, minimum 4 static views;



78608 Brain imaging, positron emission tomography (PET);
metabolic evaluation
78609 perfusion evaluation

78610 Brain imaging, vascular flow only
78630 Cerebrospinal fluid flow, imaging (not including
introduction of material); cisternography
(For injection procedure, see 61000-61070, 62270-62327)

78635 ventriculography
78645 shunt evaluation
78650 Cerebrospinal fluid leakage detection and localization

78660 Radiopharmaceutical dacryocystography
78699 Unlisted nervous system procedure, diagnostic nuclear
medicine
Genitourinary System
78700 Kidney imaging morphology;
➲ CPT Assistant Dec 05:7, Mar 07:7, Feb 12:9

78707 with vascular flow and function, single study without

pharmacological intervention
78708 with vascular flow and function, single study, with

pharmacological intervention (eg, angiotensin converting
enzyme inhibitor and/or diuretic)
78709 with vascular flow and function, multiple studies, with

and without pharmacological intervention (eg,
angiotensin converting enzyme inhibitor and/or diuretic)
(For introduction of radioactive substance in association

with renal endoscopy, use 77778)
78725 Kidney function study, non-imaging radioisotopic study
✚ 78730 Urinary bladder residual study (List separately in addition


(For measurement of postvoid residual urine and/or bladder
capacity by ultrasound, nonimaging, use 51798)
(For ultrasound imaging of the bladder only, with
measurement of postvoid residual urine when performed,
use 76857)
78740 Ureteral reflux study (radiopharmaceutical voiding
cystogram)
(Use 78740 in conjunction with 78730 for urinary bladder

residual study)
(For catheterization, see 51701, 51702, 51703)
78761 Testicular imaging with vascular flow
78799 Unlisted genitourinary procedure, diagnostic nuclear

medicine
Other Procedures
(For specific organ, see appropriate heading)
78800 Radiopharmaceutical localization of tumor, inflammatory
process or distribution of radiopharmaceutical agent(s)
(includes vascular flow and blood pool imaging, when
performed); planar, single area (eg, head, neck, chest,
pelvis), single day imaging
➲ CPT Assistant Dec 05:7, Dec 11:17, Feb 12:9, Nov
18:11
➲ Clinical Examples in Radiology Summer 06:6, 10-11,
Spring 10:4, 8, Fall 10:11
(For specific organ, see appropriate heading)
78801 planar, 2 or more areas (eg, abdomen and pelvis, head
and chest), 1 or more days imaging or single area
imaging over 2 or more days
78802 planar, whole body, single day imaging

➲ Clinical Examples in Radiology Summer 06:6, 10-11
# 78804 planar, whole body, requiring 2 or more days imaging

78803 tomographic (SPECT), single area (eg, head, neck, chest,

pelvis), single day imaging
➲ CPT Assistant Jun 03:11, Feb 12:9, Oct 15:9, Dec
16:10, Nov 18:11
➲ Clinical Examples in Radiology Summer 06:6, 10-
11, Summer 12:8, Spring 15:10
78300, 78305, 78306, 78315, 78800, 78801, 78802, 78803,
78830, 78831, 78832)
(For imaging bone infectious or inflammatory disease with a
bone imaging radiopharmaceutical, see 78300, 78305,
78306, 78315)
# 78830 tomographic (SPECT) with concurrently acquired
computed tomography (CT) transmission scan for
anatomical review, localization and
determination/detection of pathology, single area (eg,
head, neck, chest, pelvis), single day imaging
# 78831 tomographic (SPECT), minimum 2 areas (eg, pelvis and

knees, abdomen and pelvis), single day imaging, or
single area imaging over 2 or more days
# 78832 tomographic (SPECT) with concurrently acquired

computed tomography (CT) transmission scan for
anatomical review, localization and
determination/detection of pathology, minimum 2 areas
(eg, pelvis and knees, abdomen and pelvis), single day
imaging, or single area imaging over 2 or more days
(For cerebrospinal fluid studies that require injection

procedure, see 61055, 61070, 62320, 62321, 62322, 62323)
#✚ 78835 Radiopharmaceutical quantification measurement(s) single
area (List separately in addition to code for primary
procedure)
(Report multiple units of 78835 if quantitation is more than
1 area or more than 1 day imaging)
(Report myocardial SPECT imaging with 78451, 78452,
78469, 78494)
(For all nuclear medicine codes, select the organ/system-
specific code[s] first; if there is no organ/system-specific
code[s], see 78800, 78801, 78802, 78803, 78830, 78831,
78832)
(For parathyroid imaging, see 78070, 78071, 78072)
78808 Injection procedure for radiopharmaceutical localization by
non-imaging probe study, intravenous (eg, parathyroid
adenoma)
(For sentinel lymph node identification, use 38792)

(For PET of brain, see 78608, 78609)
(For PET myocardial imaging, see 78459, 78491, 78492)
78811 Positron emission tomography (PET) imaging; limited area
(eg, chest, head/neck)
Spring 10:2, 7, Spring 13:10
78812 skull base to mid-thigh
➲ CPT Assistant Dec 05:7, Feb 12:9, Feb 13:16
Spring 10:1, 2
78813 whole body
➲ CPT Assistant Dec 05:7, Feb 12:9, Feb 13:16
Spring 10:2
78814 Positron emission tomography (PET) with concurrently
acquired computed tomography (CT) for attenuation
correction and anatomical localization imaging; limited area
(eg, chest, head/neck)
➲ CPT Assistant Feb 05:13, Jun 05:10, Dec 05:7, Feb
12:9, Feb 13:16
78815 skull base to mid-thigh
12:9, Feb 13:16
78816 whole body
12:9, Feb 13:16
Spring 10:2, Spring 13:10
(Report 78811-78816 only once per imaging session)
(Computed tomography [CT] performed for other than
attenuation correction and anatomical localization is
reported using the appropriate site specific CT code with
modifier 59)
78999 Unlisted miscellaneous procedure, diagnostic nuclear
medicine
➲ CPT Assistant Dec 05:7, Feb 12:9, Oct 15:9, Dec 16:16
10:2, 11, Spring 15:9
Therapeutic
The oral and intravenous administration codes in this section are
inclusive of the mode of administration. For intra-arterial, intra-
cavitary, and intra-articular administration, also use the
appropriate injection and/or procedure codes, as well as imaging
guidance and radiological supervision and interpretation codes,
when appropriate.
79005 Radiopharmaceutical therapy, by oral administration
09:5, Winter 12:8
(For monoclonal antibody therapy, use 79403)
79101 Radiopharmaceutical therapy, by intravenous administration
12:8
79403, 96360, 96374 or 96375, 96409)
(For radiolabeled monoclonal antibody by intravenous
infusion, use 79403)
(For infusion or instillation of non-antibody radioelement
solution that includes 3 months follow-up care, use 77750)
79200 Radiopharmaceutical therapy, by intracavitary
administration
79300 Radiopharmaceutical therapy, by interstitial radioactive

colloid administration
79403 Radiopharmaceutical therapy, radiolabeled monoclonal

antibody by intravenous infusion
(For pre-treatment imaging, see 78802, 78804)

79440 Radiopharmaceutical therapy, by intra-articular
administration
79445 Radiopharmaceutical therapy, by intra-arterial particulate

administration
➲ CPT Assistant Sep 05:1, Dec 06:10, Feb 12:9, Nov 13:6
18:12
(Use appropriate procedural and radiological supervision
and interpretation codes for the angiographic and
interventional procedures provided prerequisite to intra-
arterial radiopharmaceutical therapy)
79999 Radiopharmaceutical therapy, unlisted procedure
➲ CPT Assistant Mar 05:11, Sep 05:1, Jan 07:30, Feb 12:9

Pathology and Laboratory Guidelines
Special Report

The following is a listing of headings and subheadings that appear within the Pathology
and Laboratory section of the CPT code set. The subheadings or subsections denoted
with asterisks (*) below have special instructions unique to that subsection. Where these
are indicated, special notes or guidelines will be presented preceding those procedural
terminology listings, referring to that subsection specifically.
Organ or Disease-Oriented Panels* (80047-80081)
Drug Assay* (80305-80377, 83992)
Presumptive Drug Class Screening* (80305-80307)
Definitive Drug Testing* (80320-80377)
Definitive Drug Classes Listing* (80320-80373, 83992)
Therapeutic Drug Assays* (80143-80299)
Evocative/Suppression Testing* (80400-80439)
Consultations (Clinical Pathology)* (80500-80502)
Urinalysis* (81000-81099)
Molecular Pathology* (81105-81408, 81479)
Tier 1 Molecular Pathology Procedures* (81105-81383)
Tier 2 Molecular Pathology Procedures* (81400-81408, 81479)
Genomic Sequencing Procedures and Other Molecular Multianalyte
Assays* (81410-81471)
Multianalyte Assays with Algorithmic Analyses* (81490-81599)
Chemistry* (82009-84999)
Hematology and Coagulation (85002-85999)
Immunology (86000-86849)
Tissue Typing (86805-86849)
Transfusion Medicine (86850-86999)
Microbiology* (87003-87999)
Anatomic Pathology (88000-88099)
Postmortem Examination* (88000-88099)
Cytopathology (88104-88199)
Cytogenetic Studies* (88230-88299)
Surgical Pathology* (88300-88399)
In Vivo (eg, Transcutaneous) Laboratory Procedures (88720-88749)
Reproductive Medicine Procedures (89250-89398)
Proprietary Laboratory Analyses* (0001U-0222U)
Molecular Pathology Gene Table

Commonly
Associated
Claim Abbreviated CPT
Full Gene Name Proteins/Diseases
Designation Gene Name Code(s)
(Not a complete
list)
ABCA4 ABCA4 ATP-binding cassette, sub- Stargardt disease, age- 81408,
family A (ABC1), member 4 related macular 81434
degeneration, hereditary
retinal disorders
ABCC8 ABCC8 ATP-binding cassette, sub- Familial hyperinsulinism 81401,
family C (CFTR/MRP), 81407
member 8
ABCD1 ABCD1 ATP-binding cassette, sub- Adrenoleukodystrophy 81405
family D (ALD), member 1
ABL1 ABL1 ABL proto-oncogene 1 non- Acquired imatinib 81401
receptor tyrosine kinase resistance
ABL1 ABL proto-oncogene 1, non- Acquired imatinib 81170
receptor tyrosine kinase tyrosine kinase inhibitor
resistance
ACADM ACADM Acyl-CoA dehydrogenase, C- Medium chain acyl 81400,
4 to C-12 straight chain, dehydrogenase 81401,
MCAD deficiency, severe 81443
inherited conditions
ACADS ACADS Acyl-CoA dehydrogenase, C- Short chain acyl-CoA 81404,
2 to C-3 short chain dehydrogenase deficiency 81405
ACADVL ACADVL Acyl-CoA dehydrogenase, Very long chain acyl- 81406
very long chain coenzyme A
dehydrogenase deficiency
ACE ACE Angiotensin converting Hereditary blood pressure 81400
enzyme regulation
ACTA2 ACTA2 Actin, alpha 2, smooth Thoracic aortic 81405,
muscle, aorta aneurysms and aortic 81410
dissections, aortic
dysfunction or dilation
ACTC1 ACTC1 Actin, alpha, cardiac muscle 1 Familial hypertrophic 81405
cardiomyopathy
ACTN4 ACTN4 Actinin, alpha 4 Focal segmental 81406
glomerulosclerosis
ADRB2 ADRB2 Adrenergic beta-2 receptor Drug metabolism 81401
surface
AFF2 AFF2 AF4/FMR2 family, member 2 Fragile X mental 81171,
(FMR2) retardation 2 (FRAXE) 81172,
AFG3L2 AFG3L2 AFG3 ATPase family gene 3- Spinocerebellar ataxia 81406
like 2 (S. cerevisiae)
AGL AGL Amylo-alpha-1, 6-glucosidase, Glycogen storage disease 81407
4-alpha-glucanotransferase type III
AGTR1 AGTR1 Angiotensin II receptor, type Essential hypertension 81400
1
AHI1 AHI1 Abelson helper integration Joubert syndrome 81407
site 1
AIRE AIRE Autoimmune regulator Autoimmune 81406
polyendocrinopathy
syndrome type 1
ALDH7A1 ALDH7A1 Aldehyde dehydrogenase 7 Pyridoxine-dependent 81406,
family, member A1 epilepsy, epilepsy 81419
ALK ALK Anaplastic lymphoma Solid organ neoplasm or 81445,
receptor tyrosine kinase hematolymphoid 81455
neoplasm
ANG ANG Angiogenin, ribonuclease, Amyotrophic lateral 81403
RNase A family, 5 sclerosis
ANK2 ANK2 Ankyrin-2 Cardiac ion 81413
channelopathies
ANKRD1 ANKRD1 Ankyrin repeat domain 1 Dilated cardiomyopathy 81405
ANO5 ANO5 Anoctamin 5 Limb-girdle muscular 81406
dystrophy
ANOS1 ANOS1 Anosmin- 1 Kallmann syndrome 1 81406
APC Adenomatous polyposis coli Familial adenomatosis 81201,
polyposis (FAP), 81202,
attenuated FAP, 81203,
hereditary colon cancer 81435
disorders
APOB APOB Apolipoprotein B Familial 81401,
hypercholesterolemia 81407
type B
APOE APOE Apolipoprotein E Hyperlipoproteinemia 81401
type III, cardiovascular
disease, Alzheimer
disease
APP APP Amyloid beta (A4) precursor Alzheimer disease 81406
protein
APTX APTX Aprataxin Ataxia with oculomotor 81405
apraxia 1
AQP2 AQP2 Aquaporin 2 (collecting duct) Nephrogenic diabetes 81404
insipidus
AR AR Androgen receptor Spinal and bulbar 81173,
muscular atrophy, 81174,
Kennedy disease, X 81204
chromosome inactivation,
androgen insensitivity
syndrome
ARSA ARSA Arylsulfatase A Arylsulfatase A 81405,
deficiency, severe 81443
ARX ARX Aristaless related homeobox X-linked lissencephaly 81403,
with ambiguous genitalia, 81404,
X-linked mental 81470,
retardation, X-linked 81471
intellectual disability
(XLID)
ASPA Aspartoacylase Canavan disease, 81200,
Ashkenazi Jewish- 81412,
associated disorders, 81443
severe inherited
conditions
ASPM ASPM Asp (abnormal spindle) Primary microcephaly 81407
homolog, microcephaly
associated (Drosophila)
ASS1 ASS1 Argininosuccinate synthase 1 Citrullinemia type I 81406
ASXL1 ASXL1 Additional sex combs like 1, Myelodysplastic 81175,
transcriptional regulator syndrome, 81176
myeloproliferative
neoplasms, chronic
myelomonocytic leukemia
ATL1 ATL1 Atlastin GTPase 1 Spastic paraplegia 81406
ATM ATM Ataxia telangiectasia mutated Ataxia telangiectasia 81408
ATN1 ATN1 Atrophin 1 Dentatorubral- 81177
pallidoluysian atrophy
ATP1A2 ATP1A2 ATPase, Na+/K+ Familial hemiplegic 81406
transporting, alpha 2 migraine
polypeptide
ATP7B ATP7B ATPase, Cu++ transporting, Wilson disease, severe 81406,
beta polypeptide inherited conditions 81443
ATRX ATRX Alpha thalassemia/mental X-linked intellectual 81470,
retardation syndrome X- disability (XLID) 81471
linked
ATXN1 ATXN1 Ataxin 1 Spinocerebellar ataxia 81178
ATXN3 ATXN3 Ataxin 3 Spinocerebellar ataxia, 81180
Machado-Joseph disease
ATXN8OS ATXN8OS ATXN8 opposite strand (non- Spinocerebellar ataxia 81182
protein coding)
AVPR2 AVPR2 Arginine vasopressin receptor Nephrogenic diabetes 81404
2 insipidus
BBS1 BBS1 Bardet-Biedl syndrome 1 Bardet-Biedl syndrome 81406
BCKDHA BCKDHA Branched-chain keto acid Maple syrup urine 81400,
dehydrogenase E1, alpha disease type 1A, severe 81405,
polypeptide inherited conditions 81443
BCKDHB BCKDHB Branched-chain keto acid Maple syrup urine 81205,
dehydrogenase E1, beta disease, maple syrup 81406,
polypeptide urine disease type 1B, 81443
severe inherited
conditions
BCR/ABL1 t(9;22) Chronic myelogenous 81206,
leukemia 81207,
81208
BCS1L BCS1L BCS1-like (S. cerevisiae) Leigh syndrome, 81405,
mitochondrial complex III 81440
deficiency, GRACILE
syndrome, mitochondrial
disorders
BEST1 BEST1 Bestrophin 1 Vitelliform macular 81406
dystrophy
BLM Bloom syndrome, RecQ Bloom syndrome, 81209,
helicase-like Ashkenazi Jewish- 81412,
severe inherited
conditions
BMPR1A BMPR1A Bone morphogenetic protein Hereditary colon cancer 81435
receptor, type IA disorders
BMPR2 BMPR2 Bone morphogenetic protein Heritable pulmonary 81405,
receptor, type II arterial hypertension 81406
(serine/threonine kinase)
BRAF V-raf murine sarcoma viral Colon cancer 81210
oncogene homolog B1
BRAF BRAF B-Raf proto-oncogene, Noonan syndrome, 81406,
serine/threonine kinase Noonan spectrum 81442,
disorders, solid organ 81445,
neoplasm, 81450,
hematolymphoid 81455
neoplasm or disorder
BRCA1 BRCA1, DNA repair Hereditary breast and 81165,
associated ovarian cancer, hereditary 81166,
breast cancer-related 81215,
disorders 81432,
81433
BRCA2 BRCA2, DNA repair Hereditary breast and 81167,
associated ovarian cancer, hereditary 81216,
disorders 81432,
81433
BRCA1 and BRCA1, DNA repair Hereditary breast and 81162,
BRCA2 associated ovarian cancer 81163,
BRCA2, DNA repair 81164,
associated 81212
BSCL2 BSCL2 Berardinelli-Seip congenital Berardinelli-Seip 81406,
lipodystrophy 2 (seipin) congenital lipodystrophy, 81448
hereditary peripheral
neuropathies
BTD BTD Biotinidase Biotinidase deficiency 81404
BTK BTK Bruton agammaglobulinemia X-linked 81406,
tyrosine kinase agammaglobulinemia, 81233
chronic lymphocytic
leukemia
C10ORF2 C10orf2 Chromosome 10 open reading Mitochondrial DNA 81404,
frame 2 depletion syndrome, 81440
mitochondrial disorders
C1P19Q Chromosome N/A Glial tumors 81402
1p-/19q- deletion
analysis
CACNA1A CACNA1A Calcium channel, voltage- Spinocerebellar ataxia, 81184,
dependent, P/Q type, alpha epilepsy 81185,
1A subunit 81186,
81419
CACNB2 CACNB2 Calcium channel, voltage- Brugada syndrome 81406
dependent, beta 2 subunit
CALR Calreticulin Myeloproliferative 81219
disorders
CAPN3 CAPN3 Calpain 3 Limb-girdle muscular 81406
dystrophy (LGMD) type
2A, calpainopathy
CASQ2 CASQ2 Calsequestrin 2 (cardiac Catecholaminergic 81405,
muscle) polymorphic ventricular 81413
tachycardia, cardiac ion
channelopathies
CASR CASR Calcium-sensing receptor Hypocalcemia 81405
CAV3 CAV3 Caveolin 3 CAV3-related distal 81404,
myopathy, limb-girdle 81413
muscular dystrophy type
1C, cardiac ion
channelopathies
CBFBMYH11 CBFB/MYH11 Inv(16) Acute myeloid leukemia 81401
CBL CBL Cbl proto-oncogene, E3 Noonan spectrum 81442
ubiquitin protein ligase disorders
CBS CBS Cystathionine-beta-synthase Homocystinuria, 81401,
cystathionine beta- 81406
synthase deficiency
CCND1IGH CCND1/IGH t(11;14) Mantle cell lymphoma 81168
CCR5 CCR5 Chemokine C-C motif HIV resistance 81400
receptor 5
CD40LG CD40LG CD40 ligand X-linked hyper IgM 81404
syndrome
CDH1 CDH1 Cadherin 1, type 1, E- Hereditary diffuse gastric 81406,
cadherin (epithelial) cancer, hereditary breast 81432,
cancer-related disorders, 81435
hereditary colon cancer
disorders
CDH23 CDH23 Cadherin-related 23 Usher syndrome, type 1, 81408,
hearing loss 81430
CDKL5 CDKL5 Cyclin-dependent kinase-like Early infantile epileptic 81405,
5 encephalopathy, X-linked 81406,
intellectual disability 81419,
(XLID), epilepsy 81470,
81471
CDKN2A CDKN2A Cyclin-dependent kinase CDKN2A-related 81404,
inhibitor 2A cutaneous malignant 81445,
melanoma, solid organ 81455
neoplasm or
hematolymphoid
neoplasm
CEBPA CCAAT/enhancer binding Acute myeloid leukemia, 81218,
protein (C/EBP), alpha hematolymphoid 81450,
neoplasm or disorder, 81455
solid organ neoplasm
CEL CEL Carboxyl ester lipase (bile Maturity-onset diabetes 81403
salt-stimulated lipase) of the young (MODY)
CEP290 CEP290 Centrosomal protein 290kDa Joubert syndrome 81408
CFHARMS2 CFH/ARMS2 Complement factor H/age- Macular degeneration 81401
related maculopathy
susceptibility 2
CFTR Cystic fibrosis Cystic fibrosis, Ashkenazi 81220,
transmembrane conductance Jewish-associated 81221,
regulator disorders, severe 81222,
inherited conditions 81223,
81224,
81412,
81443
Ch22Q13 Cytogenomic N/A N/A 81405
constitutional
targeted microarray
analysis of
chromosome 22q13
by interrogation of
genomic regions for
copy number and
single nucleotide
polymorphism
variants
CHD2 Chromodomain helicase Epilepsy 81419
DNA binding protein 2
CHD7 CHD7 Chromodomain helicase CHARGE syndrome 81407
DNA binding protein 7
Chimerism N/A Post transplantation 81267,
engraftment specimen (eg, 81268
analysis hematopoietic stem cell)
CHRNA4 CHRNA4 Cholinergic receptor, nicotinic, Nocturnal frontal lobe 81405
alpha 4 epilepsy
CHRNB2 CHRNB2 Cholinergic receptor, nicotinic, Nocturnal frontal lobe 81405
beta 2 (neuronal) epilepsy
CHROM18Q Chromosome 18q- Colon cancer 81402
CLCN1 CLCN1 Chloride channel 1, skeletal Myotonia congenita 81406
muscle
CLCNKB CLCNKB Chloride channel, voltage- Bartter syndrome 3 and 81406
sensitive Kb 4b
CLRN1 CLRN1 Clarin 1 Usher syndrome, type 3, 81400,
hearing loss 81404,
81430
CNBP CNBP CCHC-type zinc finger, Myotonic dystrophy type 81187
nucleic acid binding protein 2
CNGA1 CNGA1 Cyclic nucleotide gated Hereditary retinal 81434
channel alpha 1 disorders
CNTNAP2 CNTNAP2 Contactin associated protein- Pitt-Hopkins-like 81406
like 2 syndrome 1
COL1A1 COL1A1 Collagen, type I, alpha 1 Osteogenesis imperfecta, 81408
type I
COL1A1PDGFB COL1A1/PDGFB t(17;22) Dermatofibrosarcoma 81402
protuberans
COL1A2 COL1A2 Collagen, type I, alpha 2 Osteogenesis imperfecta, 81408
type I
COL3A1 COL3A1 Collagen, type III, alpha 1 Aortic dysfunction or 81410,
dilation 81411
COL4A1 COL4A1 Collagen, type IV, alpha 1 Brain small-vessel 81408
disease with hemorrhage
COL4A3 COL4A3 Collagen, type IV, alpha 3 Alport syndrome 81408
(Goodpasture antigen)
COL4A4 COL4A4 Collagen, type IV, alpha 4 Alport syndrome 81407
COL4A5 COL4A5 Collagen, type IV, alpha 5 Alport syndrome 81407,
81408
COL6A1 COL6A1 Collagen, type VI, alpha 1 Collagen type VI-related 81407
disorders
COL6A2 COL6A2 Collagen, type VI, alpha 2 Collagen type VI-related 81406,
disorders 81407
COL6A3 COL6A3 Collagen, type VI, alpha 3 Collagen type VI-related 81407
disorders
COQ2 COQ2 Coenzyme Q2, Mitochondrial disorders 81440
polyprenyltransferase
COX10 COX10 COX10 homolog, cytochrome Mitochondrial respiratory 81405,
c oxidase assembly protein chain complex IV 81440
deficiency, mitochondrial
disorders
COX15 COX15 COX15 homolog, cytochrome Mitochondrial respiratory 81405
c oxidase assembly protein chain complex IV
deficiency
COX6B1 COX6B1 Cytochrome c oxidase subunit Mitochondrial respiratory 81404
VIb polypeptide 1 chain complex IV
deficiency
CPOX CPOX Coproporphyrinogen oxidase Hereditary 81405
coproporphyria
CPT1A CPT1A Carnitine palmitoyltransferase Carnitine 81406
1A (liver) palmitoyltransferase 1A
(CPT1A) deficiency
CPT2 CPT2 Carnitine palmitoyltransferase Carnitine 81404
2 palmitoyltransferase II
deficiency
CRB1 CRB1 Crumbs homolog 1 Leber congenital 81406,
(Drosophila) amaurosis, hereditary 81434
retinal disorders
CREBBP CREBBP CREB binding protein Rubinstein-Taybi 81406,
syndrome 81407
CRX CRX Cone-rod homeobox Cone-rod dystrophy 2, 81404
Leber congenital
amaurosis
CSTB CSTB Cystatin B (stefin B) Unverricht-Lundborg 81188,
disease 81189,
81190
CTNNB1 CTNNB1 Catenin (cadherin-associated Desmoid tumors 81403
protein), beta 1, 88kDa
CTRC CTRC Chymotrypsin C Hereditary pancreatitis 81405
CYP11B1 CYP11B1 Cytochrome P450, family 11, Congenital adrenal 81405
subfamily B, polypeptide 1 hyperplasia
CYP17A1 CYP17A1 Cytochrome P450, family 17, Congenital adrenal 81405
subfamily A, polypeptide 1 hyperplasia
CYP1B1 CYP1B1 Cytochrome P450, family 1, Primary congenital 81404
subfamily B, polypeptide 1 glaucoma
CYP21A2 CYP21A2 Cytochrome P450, family 21, Congenital adrenal 81402,
subfamily A, polypeptide 2 hyperplasia, 21- 81405
hydroxylase deficiency,
steroid 21-hydroxylase
isoform
CYP2C9 Cytochrome P450, family 2, Drug metabolism 81227
subfamily C, polypeptide 9
CYP2C19 Cytochrome P450, family 2, Drug metabolism 81225
subfamily C, polypeptide 19
CYP2D6 Cytochrome P450, family 2, Drug metabolism 81226
subfamily D, polypeptide 6
CYP3A4 CYP3A4 Cytochrome P450 family 3 Drug metabolism 81230
subfamily A member 4
CYP3A5 CYP3A5 Cytochrome P450 family 3 Drug metabolism 81231
subfamily A member 5
Cytogenomic N/A N/A 81228,
constitutional 81229
(genome-wide)
microarray analysis
Cytogenomic N/A N/A 81277
neoplasia (genome-
wide) microarray
analysis
DAZSRY DAZ/SRY Deleted in azoospermia and Male infertility 81403
sex determining region Y
DBT DBT Dihydrolipoamide branched Maple syrup urine 81405,
chain transacylase E2 disease, type 2 81406
DCX DCX Doublecortin X-linked lissencephaly 81405
DEKNUP214 DEK/NUP214 t(6;9) Acute myeloid leukemia 81401
DES DES Desmin Myofibrillar myopathy 81405
DFNB1 DFNB1 N/A Hearing loss 81431
DFNB59 DFNB59 Deafness, autosomal Autosomal recessive 81405
recessive 59 nonsyndromic hearing
impairment
DGUOK DGUOK Deoxyguanosine kinase Hepatocerebral 81405,
mitochondrial DNA 81440
depletion syndrome,
DHCR7 DHCR7 7-dehydrocholesterol Smith-Lemli-Opitz 81405,
reductase syndrome, severe 81443
DLAT DLAT Dihydrolipoamide S- Pyruvate dehydrogenase 81406
acetyltransferase E2 deficiency
DLD DLD Dihydrolipoamide Maple syrup urine 81406
dehydrogenase disease, type III
DMD Dystrophin Duchenne/Becker 81161
muscular dystrophy
DMD DMD Dystrophin Duchenne/Becker 81408
muscular dystrophy
DMPK DMPK Dystrophia myotonica-protein Myotonic dystrophy, type 81234,
kinase 1 81239
DNMT3A DNMT3A DNA (cytosine-5-)- Acute myeloid leukemia, 81403,
methyltransferase 3 alpha hematolymphoid 81450,
DPYD DPYD Dihydropyrimidine 5-fluorouracil/5-FU and 81232
dehydrogenase capecitabine drug
metabolism
DSC2 DSC2 Desmocollin Arrhythmogenic right 81406
ventricular
dysplasia/cardiomyopathy
11
DSG2 DSG2 Desmoglein 2 Arrhythmogenic right 81406,
ventricular 81439
10, hereditary
cardiomyopathy
DSP DSP Desmoplakin Arrhythmogenic right 81406
ventricular
8
DYSF DYSF Dysferlin, limb-girdle Limb-girdle muscular 81408
muscular dystrophy 2B dystrophy
(autosomal recessive)
E2APBX1 E2A/PBX1 t(1;19) Acute lymphocytic 81401
leukemia
EFHC1 EFHC1 EF-hand domain (C-terminal) Juvenile myoclonic 81406
containing 1 epilepsy
EGFR Epidermal growth factor Non-small cell lung 81235,
receptor cancer, solid organ 81445,
neoplasm or 81455
hematolymphoid
neoplasm
EGR2 EGR2 Early growth response 2 Charcot-Marie-Tooth 81404
disease
EIF2B2 EIF2B2 Eukaryotic translation Leukoencephalopathy 81405
initiation factor 2B, subunit 2 with vanishing white
beta, 39kDa matter
gamma, 58kDa matter
delta, 67kDa matter
EIF2B5 EIF2B5 Eukaryotic translation Childhood ataxia with 81406
initiation factor 2B, subunit 5 central nervous system
epsilon, 82kDa hypomyelination/vanishing
white matter
EMD EMD Emerin Emery-Dreifuss muscular 81404,
dystrophy 81405
EML4ALK EML4/ALK Inv(2) Non-small cell lung 81401
cancer
ENG ENG Endoglin Hereditary hemorrhagic 81405,
telangiectasia, type 1 81406
EPCAM EPCAM Epithelial cell adhesion Lynch syndrome, 81403,
molecule hereditary colon cancer 81436
disorders
EPM2A EPM2A Epilepsy, progressive Progressive myoclonus 81404
myoclonus type 2A, Lafora epilepsy
disease (laforin)
ERBB2 ERBB2 V-Erb-B2 avian erythroblastic Solid organ neoplasm or 81445,
leukemia viral oncogene hematolymphoid 81455
homolog 2 neoplasm
ESR1PGR ESR1/PGR Receptor 1/progesterone Breast cancer 81402
receptor
ETV6RUNX1 ETV6/RUNX1 t(12;21) Acute lymphocytic 81401
leukemia
EWSR1ATF1 EWSR1/ATF1 t(12;22) Clear cell sarcoma 81401
EWSR1ERG EWSR1/ERG t(21;22) Ewing 81401
sarcoma/peripheral
neuroectodermal tumor
EWSR1FLI1 EWSR1/FLI1 t(11;22) Ewing 81401
sarcoma/peripheral
neuroectodermal tumor
EWSR1WT1 EWSR1/WT1 t(11;22) Desmoplastic small round 81401
cell tumor
EYA1 EYA1 Eyes absent homolog 1 Branchio-oto-renal 81405,
(Drosophila) (BOR) spectrum 81406
disorders
EYS EYS Eyes shut homolog Hereditary retinal 81434
(Drosophila) disorders
EZH2 EZH2 Enhancer of zeste 2 Myelodysplastic 81236,
polycomb repressive complex syndrome, 81237,
2 subunit myeloproliferative 81450,
neoplasms, diffuse large 81455
B-cell lymphoma
F2 Prothrombin, coagulation Hereditary 81240
factor II hypercoagulability
F2 F2 Prothrombin, coagulation Hereditary 81400
factor II hypercoagulability
F5 Coagulation factor V Hereditary 81241
hypercoagulability
F5 F5 Coagulation factor V Hereditary 81400
hypercoagulability
F7 F7 Coagulation factor VII Hereditary 81400
(serum prothrombin hypercoagulability
conversion accelerator)
F8 F8 Coagulation factor VIII Hemophilia A 81403,
81406,
81407
F9 F9 Coagulation factor IX Hemophilia B 81238
F11 F11 Coagulation factor XI Coagulation disorder 81401
F12 F12 Coagulation factor XII Angioedema, hereditary, 81403
(Hageman factor) type III; factor XII
deficiency
F13B F13B Coagulation factor XIII, B Hereditary 81400
polypeptide hypercoagulability
FAH FAH Fumarylacetoacetate Tyrosinemia, type 1 81406
hydrolase
(fumarylacetoacetase)
FANCC Fanconi anemia, Fanconi anemia, type C, 81242,
complementation group C Ashkenazi Jewish- 81412,
severe inherited
conditions
FASTKD2 FASTKD2 FAST kinase domains 2 Mitochondrial respiratory 81406
chain complex IV
deficiency
FBN1 FBN1 Fibrillin 1 Marfan syndrome, aortic 81408,
dysfunction or dilation 81410
FGB FGB Fibrinogen beta chain Hereditary ischemic heart 81400
disease
FGD1 FGD1 FYVE, RhoGEF and PH X-linked intellectual 81470,
domain containing 1 disability (XLID) 81471
FGF23 FGF23 Fibroblast growth factor 23 Hypophosphatemic 81404
rickets
FGFR1 FGFR1 Fibroblast growth factor Pfeiffer syndrome type 1, 81400,
receptor 1 craniosynostosis, 81405
Kallmann syndrome
FGFR2 FGFR2 Fibroblast growth factor Craniosynostosis, Apert 81404
receptor 2 syndrome, Crouzon
syndrome
FGFR3 FGFR3 Fibroblast growth factor Muenke syndrome, 81400,
receptor 3 achondroplasia, 81401,
hypochondroplasia, 81403,
isolated craniosynostosis 81404
FH FH Fumarate hydratase Fumarate Hydratase 81405
Deficiency, Hereditary
Leiomyomatosis with
renal cell cancer
FHL1 FHL1 Four and a half LIM domains Emery-Dreifuss muscular 81404
1 dystrophy
FIG4 FIG4 FIG4 homolog, SAC1 lipid Charcot-Marie-Tooth 81406
phosphatase domain disease
containing (S. cerevisiae)
FIP1L1PDGFRA FIP1L1/PDGFRA Del(4q12) Imatinib-sensitive chronic 81401
eosinophilic leukemia
FKRP FKRP Fukutin related protein Congenital muscular 81404
dystrophy type 1C
(MDC1C), limb-girdle
muscular dystrophy
(LGMD) type 2I
FKTN FKTN Fukutin Fukuyama congenital 81400,
muscular dystrophy, limb- 81405
girdle muscular dystrophy
(LGMD) type 2M or 2L
FLG FLG Filaggrin Ichthyosis vulgaris 81401
FLT3 Fms-related tyrosine kinase 3 Acute myeloid leukemia, 81245,
hematolymphoid 81246,
neoplasm or disorder, 81450,
solid organ neoplasm 81455
FMR1 Fragile X mental retardation 1 Fragile X mental 81243,
retardation, X-linked 81244,
(XLID) 81471
FOXG1 FOXG1 Forkhead box G1 Rett syndrome 81404
FOXO1PAX3 FOXO1/PAX3 t(2;13) Ewing 81401
sarcoma/peripheral
neuroectodermal tumor,
alveolar
rhabdomyosarcoma
FOXO1PAX7 FOXO1/PAX7 t(1;13) Ewing 81401
sarcoma/peripheral
neuroectodermal tumor,
alveolar
rhabdomyosarcoma
FSHMD1A FSHMD1A Facioscapulohumeral Facioscapulohumeral 81404
muscular dystrophy 1A muscular dystrophy
FTSJ1 FTSJ1 FtsJ RNA methyltransferase X-linked mental 81405,
homolog 1 (E. coli) retardation 9 81406
FUS FUS Fused in sarcoma Amyotrophic lateral 81406
sclerosis
FUSDDIT3 FUS/DDIT3 t(12;16) Myxoid liposarcoma 81401
FXN FXN Frataxin Friedreich ataxia 81284,
81285,
81286,
81289
G6PC G6PC Glucose-6-phosphatase, Glycogen storage disease, 81250,
catalytic subunit type 1a, von Gierke 81443
disease, severe inherited
conditions
G6PD G6PD Glucose-6-phosphate Hemolytic anemia, 81247,
dehydrogenase jaundice 81248,
81249
GAA GAA Glucosidase, alpha; acid Glycogen storage disease 81406,
type II (Pompe disease), 81443
severe inherited
conditions
GABRG2 GABRG2 Gamma-aminobutyric acid Generalized epilepsy with 81405,
(GABA) A receptor, gamma febrile seizures, epilepsy 81419
2
GALC GALC Galactosylceramidase Krabbe disease 81401,
81406
GALT GALT Galactose-1-phosphate Galactosemia, severe 81401,
uridylyltransferase inherited conditions 81406,
81443
GARS GARS Glycyl-tRNA synthetase Charcot-Marie-Tooth 81406
disease
GBA Glucosidase, beta, acid Gaucher disease, 81251,
severe inherited
conditions
GBE1 1,4-alpha-glucan branching Severe inherited 81443
enzyme 1 conditions
GCDH GCDH Glutaryl-CoA dehydrogenase Glutaricacidemia type 1 81406
GCH1 GCH1 GTP cyclohydrolase 1 Autosomal dominant 81405
dopa-responsive dystonia
GCK GCK Glucokinase (hexokinase 4) Maturity-onset diabetes 81406
of the young (MODY)
GDAP1 GDAP1 Ganglioside-induced Charcot-Marie-Tooth 81405
differentiation-associated disease
protein 1
GFAP GFAP Glial fibrillary acidic protein Alexander disease 81405
GH1 GH1 Growth hormone 1 Growth hormone 81404
deficiency
GHR GHR Growth hormone receptor Laron syndrome 81405
GHRHR GHRHR Growth hormone releasing Growth hormone 81405
hormone receptor deficiency
GJB1 GJB1 Gap junction protein, beta 1 Charcot-Marie-Tooth X- 81403,
linked, hereditary 81448
peripheral neuropathies
GJB2 Gap junction protein, beta 2, Nonsyndromic hearing 81252,
26kDa, connexin 26 loss 81253,
81430,
81431
GJB6 Gap junction protein, beta 6, Nonsyndromic hearing 81254,
30kDa, connexin 30 loss 81431
GLA GLA Galactosidase, alpha Fabry disease 81405
GLUD1 GLUD1 Glutamate dehydrogenase 1 Familial hyperinsulinism 81406
GNAQ GNAQ Guanine nucleotide-binding Uveal melanoma 81403
protein G(q) subunit alpha
GNE GNE Glucosamine (UDP-N- Inclusion body myopathy 81400,
acetyl)-2-epimerase/N- 2 (IBM2), Nonaka 81406
acetyl-mannosamine kinase myopathy
GP1BB GP1BB Glycoprotein Ib (platelet), Bernard-Soulier 81404
beta polypeptide syndrome type B
GPR98 GPR98 G-protein coupled receptor 98 Hearing loss 81430
GRIN2A Glutamate ionotropic receptor Epilepsy 81419
NMDA type subunit 2A
GRN GRN Granulin Frontotemporal dementia 81406
H19 H19 Imprinted maternally Beckwith-Wiedemann 81401
expressed transcript (non- syndrome
protein coding)
HADHA HADHA Hydroxyacyl-CoA Long chain acyl- 81406
dehydrogenase/3-ketoacyl- coenzyme A
CoA thiolase/enoyl-CoA dehydrogenase deficiency
hydratase (trifunctional
protein) alpha subunit
HADHB HADHB Hydroxyacyl-CoA Trifunctional protein 81406
dehydrogenase/3-ketoacyl- deficiency
CoA thiolase/enoyl-CoA
hydratase (trifunctional
protein), beta subunit
HBA1/HBA2 HBA1/HBA2 Alpha globin 1 and alpha Alpha thalassemia, 81257,
globin 2 thalassemia, Hb Bart 81258,
hydrops fetalis syndrome, 81259,
HbH disease 81269
HBB HBB Hemoglobin, subunit beta Sickle cell anemia, beta 81361,
thalassemia, 81362,
hemoglobinopathy, severe 81363,
inherited conditions 81364,
81443
HEA HEA Human erythrocyte antigen Sickle-cell disease, 81403
thalassemia, hemolytic
transfusion reactions,
hemolytic disease of the
fetus or newborn
HEXA Hexosaminidase A (alpha Tay-Sachs disease, 81255,
polypeptide) Ashkenazi Jewish- 81406,
associated disorders, 81412,
severe inherited 81443
conditions
HFE Hemochromatosis Hereditary 81256
hemochromatosis
HLA Human leukocyte antigen Pretransplant and drug 81370-
genes therapy testing 81383
HLCS HLCS HLCS holocarboxylase Holocarboxylase 81406
synthetase synthetase deficiency
HMBS HMBS Hydroxymethylbilane Acute intermittent 81406
synthase porphyria
HNF1A HNF1A HNF1 homeobox A Maturity-onset diabetes 81405
of the young (MODY)
HNF1B HNF1B HNF1 homeobox B Maturity-onset diabetes 81404,
of the young (MODY) 81405
HNF4A HNF4A Hepatocyte nuclear factor 4, Maturity-onset diabetes 81406
alpha of the young (MODY)
HPA1 Human Platelet Integrin, beta 3 (platelet Neonatal alloimmune 81105
Antigen 1 glycoprotein IIIa), antigen thrombocytopenia
genotyping (HPA- CD61 (GPIIIa) (NAIT), post-transfusion
1), ITGB3 purpura
HPA2 Human Platelet Glycoprotein Ib (platelet), Neonatal alloimmune 81106
Antigen 2 alpha polypeptide (GPIba) thrombocytopenia
genotyping (HPA- (NAIT), post-transfusion
2), GP1BA purpura
HPA3 Human Platelet Integrin, alpha 2b (platelet Neonatal alloimmune 81107
Antigen 3 glycoprotein IIb of IIb/IIIa thrombocytopenia
genotyping (HPA- complex), antigen CD41 (NAIT), post-transfusion
3), ITGA2B (GPIIb) purpura
Antigen 4 glycoprotein IIIa), antigen thrombocytopenia
CD61 (GPIIIa)
4), ITGB3 purpura
HPA5 Human Platelet Integrin, alpha 2 (CD49B, Neonatal alloimmune 81109
Antigen 5 alpha 2 subunit of VLA-2 thrombocytopenia
genotyping (HPA- receptor) (GPIa) (NAIT), post-transfusion
5), ITGA2 purpura
Antigen 6 glycoprotein IIIa, antigen thrombocytopenia
genotyping (HPA- CD61) (GPIIIa) (NAIT), post-transfusion
6w), ITGB3 purpura
HPA9 Human Platelet Integrin, alpha 2b (platelet Neonatal alloimmune 81111
Antigen 9 glycoprotein IIb of IIb/IIIa thrombocytopenia
genotyping (HPA- complex, antigen CD41) (NAIT), post-transfusion
9w), ITGA2B (GPIIb) purpura
HPA15 Human Platelet CD109 molecule Neonatal alloimmune 81112
Antigen 15 thrombocytopenia
15), CD109 purpura
HRAS HRAS V-Ha-ras Harvey rat Costello syndrome, 81403,
sarcoma viral oncogene Noonan spectrum 81404,
homolog disorders 81442
HSD3B2 HSD3B2 Hydroxy-delta-5-steroid 3-beta-hydroxysteroid 81404
dehydrogenase, 3 beta- and dehydrogenase type II
steroid delta-isomerase 2 deficiency
HSD11B2 HSD11B2 Hydroxysteroid (11-beta) Mineralocorticoid excess 81404
dehydrogenase 2 syndrome
HSPB1 HSPB1 Heat shock 27kDa protein 1 Charcot-Marie-Tooth 81404
disease
HTRA1 HTRA1 HtrA serine peptidase 1 Macular degeneration 81405
HTT HTT Huntingtin Huntington disease 81271,
81274
HUWE1 HUWE1 HECT, UBA and WWE X-linked intellectual 81470,
domain containing 1, E3 disability (XLID) 81471
ubiquitin protein ligase
IDH1 IDH1 Isocitrate dehydrogenase 1 Glioma, hematolymphoid 81120,
(NADP+), soluble neoplasm or disorder, 81450,
IDH2 IDH2 Isocitrate dehydrogenase 2 Glioma, hematolymphoid 81121,
(NADP+), mitochondrial neoplasm or disorder, 81450,
IDS IDS Iduronate 2-sulfatase Mucopolysaccharidosis, 81405
type II
IDUA IDUA Iduronidase, alpha-L- Mucopolysaccharidosis 81406
type I
IFNL3 IFNL3 Interferon, lambda 3 Drug response 81283
IGH@ Immunoglobulin heavy chain Leukemias and 81261,
locus lymphomas, B-cell 81262,
81263
IGHBCL2 IGH@/BCL2 t(14;18) Follicular lymphoma 81278,
81401
IGK@ Immunoglobulin kappa light Leukemia and lymphoma, 81264
chain locus B-cell
IKBKAP Inhibitor of kappa light Familial dysautonomia, 81260,
polypeptide gene enhancer in Ashkenazi Jewish- 81412,
B-cells, kinase complex- associated disorders, 81443
associated protein severe inherited
conditions
IL1RAPL IL1RAPL Interleukin 1 receptor X-linked intellectual 81470,
accessory protein disability (XLID) 81471
IL2RG IL2RG Interleukin 2 receptor, gamma X-linked severe combined 81405
immunodeficiency
INF2 INF2 Inverted formin, FH2 and Focal segmental 81406
WH2 domain containing glomerulosclerosis
INS INS Insulin Diabetes mellitus 81404
ISPD ISPD Isoprenoid synthase domain Muscle-eye-brain 81405
containing disease, Walker-Warburg
syndrome
ITPR1 ITPR1 Inositol 1,4,5-trisphosphate Spinocerebellar ataxia 81408
receptor, type 1
IVD IVD Isovaleryl-CoA Isovaleric acidemia 81400,
dehydrogenase 81406
JAG1 JAG1 Jagged 1 Alagille syndrome 81406,
81407
JAK2 Janus kinase 2 Myeloproliferative 81270,
disorder, hematolymphoid 81279,
neoplasm or disorder, 81450,
JUP JUP Junction plakoglobin Arrhythmogenic right 81406
ventricular
11
KCNC3 KCNC3 Potassium voltage-gated Spinocerebellar ataxia 81403
channel, Shaw-related
subfamily, member 3
KCNE1 KCNE1 Potassium voltage-gated Cardiac ion 81413
channel, subfamily E, member channelopathies
1
KCNE2 KCNE2 Potassium voltage-gated Cardiac ion 81413
channel, subfamily E, member channelopathies
2
KCNH2 KCNH2 Potassium voltage-gated Short QT syndrome, long 81406,
channel, subfamily H (eag- QT syndrome, cardiac ion 81413,
related), member 2 channelopathies 81414
KCNJ1 KCNJ1 Potassium inwardly-rectifying Bartter syndrome 81404
channel, subfamily J, member
1
KCNJ2 KCNJ2 Potassium inwardly-rectifying Andersen-Tawil 81403,
channel, subfamily J, member syndrome, cardiac ion 81413
2 channelopathies
KCNJ10 KCNJ10 Potassium inwardly-rectifying SeSAME syndrome, 81404
channel, subfamily J, member EAST syndrome,
10 sensorineural hearing loss
KCNJ11 KCNJ11 Potassium inwardly-rectifying Familial hyperinsulinism 81403
channel, subfamily J, member
11
KCNQ1 KCNQ1 Potassium voltage-gated Short QT syndrome, long 81406,
channel, KQT-like subfamily, QT syndrome, cardiac ion 81413,
member 1 channelopathies 81414
KCNQ1OT1 KCNQ1OT1 KCNQ1 overlapping Beckwith-Wiedemann 81401
transcript 1 (non-protein syndrome
coding)
KCNQ2 KCNQ2 Potassium voltage-gated Epileptic encephalopathy, 81406,
channel, KQT-like subfamily, epilepsy 81419
member 2
KDM5C KDM5C Lysine (K)-specific X-linked mental 81407,
demethylase 5C retardation, X-linked 81470,
intellectual disability 81471
(XLID)
KIAA0196 KIAA0196 KIAA0196 Spastic paraplegia 81407
KIR KIR Killer cell immunoglobulin-like Hematopoietic stem cell 81403
receptor transplantation
KIT v-kit Hardy-Zuckerman 4 Gastrointestinal stromal 81272,
feline sarcoma viral oncogene tumor, acute myeloid 81273,
homolog leukemia, melanoma, solid 81445,
organ neoplasm, 81450,
KRAS v-Ki-ras2 Kirsten rat Carcinoma, Noonan 81275,
sarcoma viral oncogene syndrome 81276
homolog
KRAS KRAS Kirsten rat sarcoma viral Noonan syndrome, 81405,
oncogene homolog Noonan spectrum 81442,
neoplasm, 81450,
L1CAM L1CAM L1 cell adhesion molecule MASA syndrome, X- 81407,
linked hydrocephaly, X- 81470,
linked intellectual 81471
disability (XLID)
LAMA2 LAMA2 Laminin, alpha 2 Congenital muscular 81408
dystrophy
LAMB2 LAMB2 Laminin, beta 2 (laminin S) Pierson syndrome 81407
LAMP2 LAMP2 Lysosomal-associated Danon disease 81405
membrane protein 2
LCT LCT Lactase-phlorizin hydrolase Lactose intolerance 81400
LDB3 LDB3 LIM domain binding 3 Familial dilated 81406
cardiomyopathy,
myofibrillar myopathy
LDLR LDLR Low density lipoprotein Familial 81405,
receptor hypercholesterolemia 81406
LEPR LEPR Leptin receptor Obesity with 81406
hypogonadism
LHCGR LHCGR Luteinizing Precocious male puberty 81406
hormone/choriogonadotropin
receptor
LINC00518 LINC00518 Long intergenic non-protein Melanoma 81401
coding RNA 518
LITAF LITAF Lipopolysaccharide-induced Charcot-Marie-Tooth 81404
TNF factor disease
LMNA LMNA Lamin A/C Emery-Dreifuss muscular 81406
dystrophy (EDMD1, 2,
and 3) limb-girdle
muscular dystrophy
(LGMD) type 1B, dilated
cardiomyopathy
(CMD1A), familial partial
lipodystrophy (FPLD2)
LRP5 LRP5 Low density lipoprotein Osteopetrosis 81406
receptor-related protein 5
LRRK2 LRRK2 Leucine-rich repeat kinase 2 Parkinson disease 81401,
81408
MAP2K1 MAP2K1 Mitogen-activated protein Cardiofaciocutaneous 81406,
kinase 1 syndrome, Noonan 81442
spectrum disorders
MAP2K2 MAP2K2 Mitogen-activated protein Cardiofaciocutaneous 81406,
kinase 2 syndrome, Noonan 81442
spectrum disorders
MAPT MAPT Microtubule-associated Frontotemporal dementia 81406
protein tau
MAX MAX MYC-associated factor X Hereditary 81437
neuroendocrine tumor
disorders
MC4R MC4R Melanocortin 4 receptor Obesity 81403
MCCC1 MCCC1 Methylcrotonoyl-CoA 3-methylcrotonyl-CoA 81406
carboxylase 1 (alpha) carboxylase deficiency
MCCC2 MCCC2 Methylcrotonoyl-CoA 3-methylcrotonyl 81406
carboxylase 2 (beta) carboxylase deficiency
MCOLN1 Mucolipin 1 Mucolipidosis, type IV, 81290,
severe inherited
conditions
MECP2 Methyl CpG binding protein 2 Rett syndrome, X-linked 81302,
(XLID), epilepsy 81304,
81419,
81470,
81471
MED12 MED12 Mediator complex subunit 12 FG syndrome type 1, 81401,
Lujan syndrome, X-linked 81470,
intellectual disability 81471
(XLID)
MEFV MEFV Mediterranean fever Familial Mediterranean 81402,
fever 81404
MEG3DLK1 MEG3/DLK1 Maternally expressed 3 (non- Intrauterine growth 81401
protein coding)/delta-like 1 retardation
homolog (Drosophila)
MEN1 MEN1 Multiple endocrine neoplasia Multiple endocrine 81404,
1 neoplasia type 1, Wermer 81405
syndrome
MET MET Met proto-oncogene Solid organ neoplasm or 81445,
neoplasm
MFN2 MFN2 Mitofusin 2 Charcot-Marie-Tooth 81406,
disease, hereditary 81448
MGMT O-6-methylguanine-DNA Glioblastoma multiforme 81287
methyltransferase
MICA MICA MHC class I polypeptide- Solid organ 81403
related sequence A transplantation
Microsatellite N/A Hereditary nonpolyposis 81301
instability analysis colorectal cancer, Lynch
syndrome
MID1 MID1 Midline 1 X-linked intellectual 81470,
disability (XLID) 81471
MLH1 mutL homolog 1, colon Hereditary nonpolyposis 81288,
cancer, nonpolyposis type 2 colorectal cancer, Lynch 81292,
syndrome, hereditary 81293,
disorders, hereditary 81432,
colon cancer disorders 81433,
81435,
81436
MLL MLL N/A Hematolymphoid 81450,
MLLAFF1 MLL/AFF1 t(4;11) Acute lymphoblastic 81401
leukemia
MLLMLLT3 MLL/MLLT3 t(9;11) Acute myeloid leukemia 81401
MMAA MMAA Methylmalonic aciduria MMAA-related 81405
(cobalamine deficiency) type methylmalonic acidemia
A
MMAB MMAB Methylmalonic aciduria MMAA-related 81405
(cobalamine deficiency) type methylmalonic acidemia
B
MMACHC MMACHC Methylmalonic aciduria Methylmalonic acidemia 81404
(cobalamin deficiency) cblC and homocystinuria
type, with homocystinuria
MPI MPI Mannose phosphate Congenital disorder of 81405
isomerase glycosylation 1b
MPL MPL MPL proto-oncogene, Myeloproliferative 81338,
thrombopoietin receptor disorder 81339
MPV17 MPV17 MpV17 mitochondrial inner Mitochondrial DNA 81404,
membrane protein depletion syndrome, 81405,
mitochondrial disorders 81440
MPZ MPZ Myelin protein zero Charcot-Marie-Tooth 81405,
disease, hereditary 81448
MSH2 mutS homolog 2, colon Hereditary nonpolyposis 81295,
cancer, nonpolyposis type 1 colorectal cancer, Lynch 81296,
colon cancer disorders 81435,
81436
MSH6 mutS homolog 6 (E. coli) Hereditary nonpolyposis 81298,
colorectal cancer, Lynch 81299,
disorders, hereditary 81435
colon cancer disorders
MTATP6 MT-ATP6 Mitochondrially encoded ATP Neuropathy with ataxia 81401
synthase 6 and retinitis pigmentosa
(NARP), Leigh syndrome
MTHFR 5,10- Hereditary 81291
methylenetetrahydrofolate hypercoagulability
reductase
MTM1 MTM1 Myotubularin 1 X-linked centronuclear 81405,
myopathy 81406
MTND4ND6 MT-ND4, MT-ND6 Mitochondrially encoded Leber hereditary optic 81401
NADH dehydrogenase 4, neuropathy (LHON)
mitochondrially encoded
NADH dehydrogenase 6
MTND5 MT-ND5 Mitochondrially encoded Mitochondrial 81401
tRNA leucine 1 (UUA/G), encephalopathy with
mitochondrially encoded lactic acidosis and stroke-
NADH dehydrogenase 5 like episodes (MELAS)
MTRNR1 MT-RNR1 Mitochondrially encoded 12S Nonsyndromic hearing 81401,
RNA loss 81403,
81430
MTTK MT-TK Mitochondrially encoded Myoclonic epilepsy with 81401
tRNA lysine ragged-red fibers
(MERRF)
MTTL1 MT-TL1 Mitochondrially encoded Diabetes and hearing loss 81401
tRNA leucine 1 (UUA/G)
MTTS1 MT-TS1 Mitochondrially encoded Nonsyndromic hearing 81403
tRNA serine 1 loss
MTTS1RNR1 MT-TS1, MT- Mitochondrially encoded Nonsyndromic 81401
RNR1 tRNA serine 1 (UCN), sensorineural deafness
mitochondrially encoded 12S (including
RNA aminoglycoside-induced
nonsyndromic deafness)
MUT MUT Methylmalonyl CoA mutase Methylmalonic acidemia 81406
MUTYH MUTYH mutY homolog (E. coli) MYH-associated 81401,
polyposis, hereditary 81406,
colon cancer disorders 81435
MYBPC3 MYBPC3 Myosin binding protein C, Familial hypertrophic 81407,
cardiac cardiomyopathy, 81439
hereditary
cardiomyopathy
MYD88 MYD88 Myeloid differentiation Waldenstrom’s 81305
primary response 88 macroglobulinemia,
lymphoplasmacytic
leukemia
MYH6 MYH6 Myosin, heavy chain 6, Familial dilated 81407
cardiac muscle, alpha cardiomyopathy
MYH7 MYH7 Myosin, heavy chain 7, Familial hypertrophic 81407,
cardiac muscle, beta cardiomyopathy, Laing 81439
distal myopathy,
hereditary
cardiomyopathy
MYH11 MYH11 Myosin, heavy chain 11, Thoracic aortic 81408,
smooth muscle aneurysms and aortic 81410,
dissections, aortic 81411
dysfunction or dilation
MYL2 MYL2 Myosin, light chain 2, Familial hypertrophic 81405
regulatory, cardiac, slow cardiomyopathy
MYL3 MYL3 Myosin, light chain 3, alkali, Familial hypertrophic 81405
ventricular, skeletal, slow cardiomyopathy
MYLK MYLK Myosin light chain kinase Aortic dysfunction or 81410
dilation
MYO7A MYO7A Myosin VIIA Usher syndrome, type 1, 81407,
hearing loss 81430
MYO15A MYO15A Myosin XVA Hearing loss 81430
MYOT MYOT Myotilin Limb-girdle muscular 81405
dystrophy
NDP NDP Norrie disease Norrie disease 81403,
(pseudoglioma) 81404
NDUFA1 NDUFA1 NADH dehydrogenase Leigh syndrome, 81404
(ubiquinone) 1 alpha mitochondrial complex I
subcomplex, 1, 7.5kDa deficiency
NDUFAF2 NDUFAF2 NADH dehydrogenase Leigh syndrome, 81404
(ubiquinone) 1 alpha mitochondrial complex I
subcomplex, assembly factor deficiency
2
NDUFS1 NDUFS1 NADH dehydrogenase Leigh syndrome, 81406
(ubiquinone) Fe-S protein 1, mitochondrial complex I
75kDa (NADH-coenzyme Q deficiency
reductase)
reductase)
reductase)
reductase)
NDUFV1 NDUFV1 NADH dehydrogenase Leigh syndrome, 81405
(ubiquinone) flavoprotein 1, mitochondrial complex I
51kDa deficiency
NEB NEB Nebulin Nemaline myopathy 2 81400,
81408
NEFL NEFL Neurofilament, light Charcot-Marie-Tooth 81405
polypeptide disease
NF1 NF1 Neurofibromin 1 Neurofibromatosis, type 1 81408
NF2 NF2 Neurofibromin 2 (merlin) Neurofibromatosis, type 2 81405,
81406
NHLRC1 NHLRC1 NHL repeat containing 1 Progressive myoclonus 81403
epilepsy
NIPA1 NIPA1 Non-imprinted in Prader- Spastic paraplegia 81404
Willi/Angelman syndrome 1
NLGN3 NLGN3 Neuroligin 3 Autism spectrum 81405
disorders
NLGN4X NLGN4X Neuroligin 4, X-linked Autism spectrum 81404,
disorders 81405
NOD2 NOD2 Nucleotide-binding Crohn’s disease, Blau 81401
oligomerization domain syndrome
containing 2
NOS Known familial N/A N/A 81403
variant NOS
NOTCH1 NOTCH1 Notch 1 Aortic valve disease, 81407,
neoplasm or disorder or 81455
NOTCH3 NOTCH3 Notch 3 Cerebral autosomal 81406
dominant arteriopathy
with subcortical infarcts
and leukoencephalopathy
(CADASIL)
NPC1 NPC1 Niemann-Pick disease, type Niemann-Pick disease 81406
C1
NPC2 NPC2 Niemann-Pick disease, type Niemann-Pick disease 81404
C2 (epididymal secretory type C2
protein E1)
NPHP1 NPHP1 Nephronophthisis 1 (juvenile) Joubert syndrome 81405,
81406
NPHS1 NPHS1 Nephrosis 1, congenital, Congenital Finnish 81407
Finnish type (nephrin) nephrosis
NPHS2 NPHS2 Nephrosis 2, idiopathic, Steroid-resistant 81405
steroid-resistant (podocin) nephrotic syndrome
NPM1 Nucleophosmin Acute myeloid leukemia, 81310,
81455
neoplasm or disorder or
NPM1ALK NPM1/ALK t(2;5) Anaplastic large cell 81401
lymphoma
NR0B1 NR0B1 Nuclear receptor subfamily 0, Congenital adrenal 81404
group B, member 1 hypoplasia
NRAS Neuroblastoma RAS viral (v- Colorectal carcinoma, 81311,
ras) oncogene homolog Noonan spectrum 81442,
neoplasm, 81450,
NSD1 NSD1 Nuclear receptor binding SET Sotos syndrome 81405,
domain protein 1 81406
NTRK Neurotrophic-tropomyosin Solid tumors 81194
receptor tyrosine kinase 1, 2,
and 3
NTRK1 Neurotrophic receptor Solid tumors 81191
tyrosine kinase 1
tyrosine kinase 2
tyrosine kinase 3
NUDT15 Nudix hydrolase 15 Drug metabolism 81306
OCRL OCRL Oculocerebrorenal syndrome X-linked intellectual 81470,
of Lowe disability (XLID) 81471
OPA1 OPA1 Optic atrophy 1 Optic atrophy, 81406,
mitochondrial disorders 81407,
81440
OPTN OPTN Optineurin Amyotrophic lateral 81406
sclerosis
OTC OTC Ornithine Ornithine 81405
carbamoyltransferase transcarbamylase
deficiency
OTOF OTOF Otoferlin Hearing loss 81430
PABPN1 PABPN1 Poly(A) binding protein, Oculopharyngeal 81312
nuclear 1 muscular dystrophy
PAFAH1B1 PAFAH1B1 Platelet-activating factor Lissencephaly, Miller- 81405,
acetylhydrolase 1b, regulatory Dieker syndrome 81406
subunit 1 (45kDa)
PAH PAH Phenylalanine hydroxylase Phenylketonuria, severe 81406,
inherited conditions 81443
PALB2 PALB2 Partner and localizer of Breast and pancreatic 81307,
BRCA2 cancer, hereditary breast 81308,
cancer-related disorders 81432
PARK2 PARK2 Parkinson protein 2, E3 Parkinson disease 81405,
ubiquitin protein ligase 81406
(parkin)
PAX2 PAX2 Paired box 2 Renal coloboma 81406
syndrome
PAX8PPARG PAX8/PPARG t(2;3) (q13;p25) Follicular thyroid 81401
carcinoma
PC PC Pyruvate carboxylase Pyruvate carboxylase 81406
deficiency
PCA3/KLK3 Prostate cancer antigen Prostate cancer 81313
3/kallikrein-related peptidase
3
PCCA PCCA Propionyl CoA carboxylase, Propionic acidemia, type 81405,
alpha polypeptide 1 81406
PCCB PCCB Propionyl CoA carboxylase, Propionic acidemia 81406
beta polypeptide
PCDH15 PCDH15 Protocadherin-related 15 Usher syndrome type 1F, 81400,
Usher syndrome type 1, 81406,
hearing loss 81407,
81430
PCDH19 PCDH19 Protocadherin 19 Epileptic encephalopathy, 81405,
epilepsy 81419
PCSK9 PCSK9 Proprotein convertase Familial 81406
subtilisin/kexin type 9 hypercholesterolemia
PDE6A PDE6A Phosphodiesterase 6A, Hereditary retinal 81434
CGMP-specific, rod, alpha disorders
PDE6B PDE6B Phosphodiesterase 6B, Hereditary retinal 81434
CGMP-specific, rod, beta disorders
PDGFRA Platelet-derived growth factor Gastrointestinal stromal 81314,
receptor, alpha polypeptide tumor, solid organ 81445,
neoplasm or 81455
hematolymphoid
neoplasm
PDGFRB Platelet-derived growth factor Solid organ neoplasm or 81445,
receptor, beta polypeptide hematolymphoid 81455
neoplasm
PDHA1 PDHA1 Pyruvate dehydrogenase Lactic acidosis 81405,
(lipoamide) alpha 1 81406
PDHB PDHB Pyruvate dehydrogenase Lactic acidosis 81405
(lipoamide) beta
PDHX PDHX Pyruvate dehydrogenase Lactic acidosis 81406
complex, component X
PDSS2 PDSS2 Decaprenyl diphosphate Mitochondrial disorders 81440
synthase subunit 2
PDX1 PDX1 Pancreatic and duodenal Maturity-onset diabetes 81404
homeobox 1 of the young (MODY)
PGR PGR Progesterone receptor Solid organ or 81445,
neoplasm
PHEX PHEX Phosphate regulating Hypophosphatemic 81406
endopeptidase homolog, X- rickets
linked
PHOX2B PHOX2B Paired-like homeobox 2b Congenital central 81403,
hypoventilation syndrome 81404
PIK3CA PIK3CA Phosphatidylinositol-4,5- Colorectal cancer, breast 81309,
bisphosphate 3-kinase, cancer, solid organ 81445,
catalytic subunit alpha neoplasm or 81455
hematolymphoid
neoplasm
PINK1 PINK1 PTEN induced putative Parkinson disease 81405
kinase 1
PKD1 PKD1 Polycystic kidney disease 1 Polycystic kidney disease 81407
(autosomal dominant)
PKD2 PKD2 Polycystic kidney disease 2 Polycystic kidney disease 81406
(autosomal dominant)
PKHD1 PKHD1 Polycystic kidney and hepatic Autosomal recessive 81408
disease 1 polycystic kidney disease
PKLR PKLR Pyruvate kinase, liver and Pyruvate kinase 81405
RBC deficiency
PKP2 PKP2 Plakophilin 2 Arrhythmogenic right 81406,
ventricular 81439
9, hereditary
cardiomyopathy
PLCE1 PLCE1 Phospholipase C, epsilon 1 Nephrotic syndrome type 81407
3
PLCG2 Phospholipase C gamma 2 Chronic lymphocytic 81320
leukemia
PLN PLN Phospholamban Dilated cardiomyopathy, 81403
hypertrophic
cardiomyopathy
PLP1 PLP1 Proteolipid protein 1 Pelizaeus-Merzbacher 81404,
disease, spastic 81405
paraplegia
PML/RARalpha t(15;17) promyelocytic Promyelocytic leukemia 81315,
leukemia/retinoic acid 81316
receptor alpha
PMP22 Peripheral myelin protein 22 Charcot-Marie-Tooth 81324,
disease, hereditary 81325,
neuropathy with liability 81326
to pressure palsies
PMS2 Postmeiotic segregation Hereditary nonpolyposis 81317,
increased 2 (S. cerevisiae) colorectal cancer, Lynch 81318,
syndrome 81319
PNKD PNKD Paroxysmal nonkinesigenic Paroxysmal 81406
dyskinesia nonkinesigenic dyskinesia
POLG POLG Polymerase (DNA directed), Alpers-Huttenlocher 81406,
gamma syndrome, autosomal 81419,
dominant progressive 81440
external ophthalmoplegia,
mitochondrial disorders,
epilepsy
POLG2 POLG2 Polymerase (DNA directed), Mitochondrial disorders 81440
gamma 2
POMGNT1 POMGNT1 Protein O-linked mannose Muscle-eye-brain 81406
beta1,2-N disease, Walker-Warburg
acetylglucosaminyltransferase syndrome
POMT1 POMT1 Protein-O- Limb-girdle muscular 81406
mannosyltransferase 1 dystrophy (LGMD) type
2K, Walker-Warburg
syndrome
POMT2 POMT2 Protein-O- Limb-girdle muscular 81406
mannosyltransferase 2 dystrophy (LGMD) type
2N, Walker-Warburg
syndrome
POU1F1 POU1F1 POU class 1 homeobox 1 Combined pituitary 81405
hormone deficiency
PPOX PPOX Protoporphyrinogen oxidase Variegate porphyria 81406
PPP2R2B PPP2R2B Protein phosphatase 2, Spinocerebellar ataxia 81343
regulatory subunit B, beta
PQBP1 PQBP1 Polyglutamine binding protein Renpenning syndrome 81404,
1 81405
PRAME PRAME Preferentially expressed Melanoma 81401
antigen in melanoma
PRKAG2 PRKAG2 Protein kinase, AMP- Familial hypertrophic 81406
activated, gamma 2 non- cardiomyopathy with
catalytic subunit Wolff-Parkinson-White
syndrome, lethal
congenital glycogen
storage disease of heart
PRKCG PRKCG Protein kinase C, gamma; Spinocerebellar ataxia; 81406
(sodium channel, voltage- hyperkalemic periodic
gated, type IV, alpha subunit) paralysis
PRNP PRNP Srion protein Genetic prion disease 81404
PROP1 PROP1 PROP paired-like homeobox Combined pituitary 81404
1 hormone deficiency
PRPF31 PRPF31 Pre-MRNA processing factor Hereditary retinal 81434
31 disorders
PRPH2 PRPH2 Peripherin 2 (retinal Retinitis pigmentosa, 81404,
degeneration, slow) hereditary retinal 81434
disorders
PRRT2 Proline rich transmembrane Epilepsy 81419
protein 2
PRSS1 PRSS1 Protease, serine, 1 (trypsin 1) Hereditary pancreatitis 81401,
81404
PRX PRX Periaxin Charcot-Marie-Tooth 81405
disease
PSEN1 PSEN1 Presenilin 1 Alzheimer disease 81405
PSEN2 PSEN2 Presenilin 2 (Alzheimer Alzheimer disease 81406
disease 4)
PTEN Phosphatase and tensin Cowden syndrome, 81321
homolog PTEN hamartoma tumor 81322,
colon cancer disorders, 81445,
solid organ neoplasm or 81455
hematolymphoid
neoplasm
PTPN11 PTPN11 Protein tyrosine phosphatase, Noonan syndrome, 81406,
non-receptor type 11 LEOPARD syndrome, 81442
Noonan spectrum
disorders
PYGM PYGM Phosphorylase, glycogen, Glycogen storage disease 81401,
muscle type V, McArdle disease 81406
RAB7A RAB7A RAB7A, member RAS Charcot-Marie-Tooth 81405
oncogene family disease
RAF1 RAF1 v-raf-1 murine leukemia viral LEOPARD syndrome, 81404,
oncogene homolog 1 Noonan spectrum 81406,
disorder 81442
RAI1 RAI1 Retinoic acid induced 1 Smith-Magenis syndrome 81405
RDH12 RDH12 Retinol dehydrogenase 12 Hereditary retinal 81434
(All-Trans/9-Cis/11-Cis) disorders
REEP1 REEP1 Receptor accessory protein 1 Spastic paraplegia, 81405,
hereditary peripheral 81448
neuropathies
RET RET Ret proto-oncogene Multiple endocrine 81404,
neoplasia, type 2A and 81405,
familial medullary thyroid 81406,
carcinoma, Hirschsprung 81445,
disease, solid organ 81455
neoplasm or
hematolymphoid
neoplasm
RHDDA RHD, deletion Rh blood group, D antigen Hemolytic disease of the 81403
analysis fetus and newborn, Rh
maternal/fetal
compatibility
RHDDAMB RHD, deletion Rh blood group, D antigen Hemolytic disease of the 81403
analysis, cell-free fetus and newborn, Rh
fetal DNA in maternal/fetal
maternal blood compatibility
RHO RHO Rhodopsin Retinitis pigmentosa, 81404,
hereditary retinal 81434
disorders
RIT1 RIT1 Ras-like without CAAX 1 Noonan spectrum 81442
disorders
RP1 RP1 Retinitis pigmentosa 1 Retinitis pigmentosa, 81404,
hereditary retinal 81434
disorders
RP2 RP2 Retinitis pigmentosa 2 Hereditary retinal 81434
disorders
RPE65 RPE65 Retinal pigment epithelium- Retinitis pigmentosa, 81406,
specific protein 65kDa Leber congenital 81434
amaurosis, hereditary
retinal disorders
RPGR RPGR Retinitis pigmentosa GTPase Hereditary retinal 81434
regulator disorders
RPS19 RPS19 Ribosomal protein S19 Diamond-Blackfan 81405
anemia
RPS6KA3 RPS6KA3 Ribosomal protein S6 kinase, X-linked intellectual 81470,
90kDa, polypeptide 3 disability (XLID) 81471
RRM2B RRM2B Ribonucleotide reductase M2 Mitochondrial DNA 81405,
B (TP53 inducible) depletion, mitochondrial 81440
disorders
RUNX1 RUNX1 Runt related transcription Acute myeloid leukemia, 81334
factor 1 familial platelet disorder
with associated myeloid
malignancy
RUNX1RUNX1T1 RUNX1/RUNX1T1 t(8;21) Acute myeloid leukemia 81401
RYR1 RYR1 Ryanodine receptor 1, skeletal Malignant hyperthermia 81406,
81408
RYR2 RYR2 Ryanodine receptor 2 Catecholaminergic 81408,
(cardiac) polymorphic ventricular 81413
tachycardia,
arrhythmogenic right
ventricular dysplasia,
cardiac ion
channelopathies
SCN1A SCN1A Sodium channel, voltage- Generalized epilepsy with 81407,
gated, type 1, alpha subunit febrile seizures, epilepsy 81419
SCN1B SCN1B Sodium channel, voltage- Brugada syndrome, 81404,
gated, type I, beta epilepsy 81419
SCN2A Sodium voltage-gated channel Epilepsy 81419
alpha subunit 2
SCN4A SCN4A Sodium channel, voltage- Hyperkalemic periodic 81406
gated, type IV, alpha subunit paralysis
SCN8A Sodium voltage-gated channel Epilepsy 81419
alpha subunit 8
SCN5A SCN5A Sodium channel, voltage- Familial dilated 81407,
gated, type V, alpha subunit cardiomyopathy, cardiac 81413
ion channelopathies
SCNN1A SCNN1A Sodium channel, nonvoltage- Pseudohypoaldosteronism 81406
gated 1 alpha
SCNN1B SCNN1B Sodium channel, nonvoltage- Liddle syndrome, 81406
gated 1, beta pseudohypoaldosteronism
SCNN1G SCNN1G Sodium channel, nonvoltage- Liddle syndrome, 81406
gated 1, gamma pseudohypoaldosteronism
SCO1 SCO1 SCO cytochrome oxidase Mitochondrial respiratory 81405,
deficient homolog 1 chain complex IV 81440
disorders
SCO2 SCO2 SCO cytochrome oxidase Mitochondrial respiratory 81404,
deficient homolog 2 (SCO1L) chain complex IV 81440
disorders
SDHA SDHA Succinate dehydrogenase Leigh syndrome, 81406
complex, subunit A, mitochondrial complex II
flavoprotein (Fp) deficiency
SDHB SDHB Succinate dehydrogenase Hereditary 81405,
complex, subunit B, iron paraganglioma, hereditary 81437,
sulfur neuroendocrine tumor 81438
disorders
SDHC SDHC Succinate dehydrogenase Hereditary 81404,
complex, subunit C, integral paraganglioma- 81405,
membrane protein, 15kDa pheochromocytoma 81437,
syndrome, hereditary 81438
disorders
SDHD SDHD Succinate dehydrogenase Hereditary 81404,
complex, subunit D, integral paraganglioma, hereditary 81437,
membrane protein neuroendocrine tumor 81438
disorders
SEPT9 SEPT9 Septin 9 Colorectal cancer 81327
SERPINA1 Serpin peptidase inhibitor, Alpha-1-antitrypsin 81332
clade A, alpha-1 deficiency
antiproteinase, antitrypsin,
member 1
SERPINE1 SERPINE1 Serpine peptidase inhibitor Thrombophilia 81400
clade E, member 1,
plasminogen activator
inhibitor -1, PAI-1
SETX SETX Senataxin Ataxia 81406
SF3B1 Splicing factor [3b] subunit Myelodysplastic 81347
B1 syndrome/acute myeloid
leukemia
SGCA SGCA Sarcoglycan, alpha (50kDa Limb-girdle muscular 81405
dystrophin-associated dystrophy
glycoprotein)
SGCB SGCB Sarcoglycan, beta (43kDa Limb-girdle muscular 81405
glycoprotein)
SGCD SGCD Sarcoglycan, delta (35kDa Limb-girdle muscular 81405
glycoprotein)
SGCE SGCE Sarcoglycan, epsilon Myoclonic dystonia 81405,
81406
SGCG SGCG Sarcoglycan, gamma (35kDa Limb-girdle muscular 81404,
dystrophin-associated dystrophy 81405
glycoprotein)
SH2D1A SH2D1A SH2 domain containing 1A X-linked 81403,
lymphoproliferative 81404
syndrome
SH3TC2 SH3TC2 SH3 domain and Charcot-Marie-Tooth 81406
tetratricopeptide repeats 2 disease
SHOC2 SHOC2 Soc-2 suppressor of clear Noonan-like syndrome 81400,
homolog with loose anagen hair, 81405,
Noonan spectrum 81442
disorders
Short Tandem N/A Pre-transplant recipient, 81265,
Repeat (STR) donor germline testing, 81266
post-transplant recipient
SHOX SHOX Short stature homeobox Langer mesomelic 81405
dysplasia
SIL1 SIL1 SIL1 homolog, endoplasmic Ataxia 81405
reticulum chaperone (S.
cerevisiae)
SLC2A1 SLC2A1 Solute carrier family 2 Glucose transporter type 81405,
(facilitated glucose 1 (GLUT 1) deficiency 81419
transporter), member 1 syndrome, epilepsy
SLC2A10 SLC2A10 Solute carrier family 2 Aortic dysfunction or 81410
(facilitated glucose dilation
transporter), member 10
SLC9A6 SLC9A6 Solute carrier family 9 Christianson syndrome, 81406,
(sodium/hydrogen epilepsy 81419
exchanger), member 6
SLC12A1 SLC12A1 Solute carrier family 12 Bartter syndrome 81407
(sodium/potassium/chloride
transporters), member 1
SLC12A3 SLC12A3 Solute carrier family 12 Gitelman syndrome 81407
(sodium/chloride
transporters), member 3
SLC16A2 SLC16A2 Solute carrier family 16, Specific thyroid hormone 81404,
member 2 (thyroid hormone cell transporter 81405,
transporter) deficiency, Allan- 81470,
Herndon-Dudley 81471
syndrome, X-linked
intellectual disability
(XLID)
SLC22A5 SLC22A5 Solute carrier family 22 Systemic primary 81405
(organic cation/carnitine carnitine deficiency
SLC25A4 SLC25A4 Solute carrier family 25 Progressive external 81404,
(mitochondrial carrier; ophthalmoplegia, 81440
adenine nucleotide mitochondrial disorders
translocator), member 4
SLC25A20 SLC25A20 Solute carrier family 25 Carnitine-acylcarnitine 81404,
(carnitine/acylcarnitine translocase deficiency 81405
translocase), member 20
SLC26A4 SLC26A4 Solute carrier family 26, Pendred syndrome, 81406,
member 4 hearing loss 81430
SLC37A4 SLC37A4 Solute carrier family 37 Glycogen storage disease 81406
(glucose-6-phosphate type Ib
SLCO1B1 SLCO1B1 Solute carrier organic anion Adverse drug reaction 81328
transporter family, member
1B1
SMAD3 SMAD3 SMAD family member 3 Aortic dysfunction or 81410
dilation
SMAD4 SMAD4 SMAD family member 4 Hemorrhagic 81405,
telangiectasia syndrome, 81406,
juvenile polyposis, 81435,
hereditary colon cancer 81436
disorders
SMN1 SMN1 Survival of motor neuron 1, Spinal muscular atrophy 81329,
telomeric 81336,
81337
SMN1SMN2 SMN1/SMN2 Survival of motor neuron 1, Spinal muscular atrophy 81329
telomeric/survival of motor
neuron 2, centromeric
SMPD1 Sphingomyelin Niemann-Pick disease, 81330,
phosphodiesterase 1, acid type A, Ashkenazi 81412
lysosomal Jewish-associated
disorders
SNRPN/UBE3A Small nuclear Prader-Willi syndrome 81331
ribonucleoprotein polypeptide and/or Angelman
N and ubiquitin protein ligase syndrome
E3A
SOD1 SOD1 Superoxide dismutase 1, Amyotrophic lateral 81404
soluble sclerosis
SOS1 SOS1 Son of sevenless homolog 1 Noonan syndrome, 81406,
gingival fibromatosis, 81442
Noonan spectrum
disorders
SPAST SPAST Spastin Spastic paraplegia, 81405,
hereditary peripheral 81406,
neuropathies 81448
SPG11 SPG11 Spastic paraplegia 11 Spastic paraplegia, 81407,
(autosomal recessive) hereditary peripheral 81448
neuropathies
SPG7 SPG7 Spastic paraplegia 7 (pure Spastic paraplegia 81405,
and complicated autosomal 81406
recessive)
SPINK1 SPINK1 Serine peptidase inhibitor, Hereditary pancreatitis 81404
Kazal type 1
SPRED1 SPRED1 Sprouty-related, EVH1 Legius syndrome 81405
domain containing 1
SPTBN2 SPTBN2 Spectrin, beta, non- Spinocerebellar ataxia 81407
erythrocytic 2
SPTLC1 SPTLC1 Serine palmitoyltransferase, Hereditary peripheral 81448
long chain base subunit 1 neuropathies
SRSF2 Serine and arginine-rich Myelodysplastic 81348
splicing factor 2 syndrome, acute myeloid
leukemia
SRY SRY Sex determining region Y 46, XX testicular disorder 81400
of sex development,
gonadal dysgenesis
SS18SSX1 SS18/SSX1 t(X;18) Synovial sarcoma 81401
SS18SSX2 SS18/SSX2 t(X;18) Synovial sarcoma 81401
STAT3 STAT3 Signal transducer and Autosomal dominant 81405
activator of transcription 3 hyper-IgE syndrome
(acute-phase response factor)
STK11 STK11 Serine/threonine kinase 11 Peutz-Jeghers syndrome, 81404,
hereditary breast cancer- 81405,
related disorders, 81432,
hereditary colon cancer 81433,
disorders 81435,
81436
STRC STRC Stereocilin Hearing loss 81431
STXBP1 STXBP1 Syntaxin binding protein 1 Epileptic encephalopathy, 81406,
epilepsy 81419
SUCLA2 SUCLA2 Succinate-CoA ligase ADP- Mitochondrial disorders 81440
forming beta subunit
SUCLG1 SUCLG1 Succinate-CoA ligase alpha Mitochondrial disorders 81440
subunit
SURF1 SURF1 Surfeit 1 Mitochondrial respiratory 81405
chain complex IV
deficiency
SYNGAP1 Synaptic Ras GTPase Epilepsy 81419
activating protein 1
TACO1 TACO1 Translational activator of Mitochondrial respiratory 81404
mitochondrial encoded chain complex IV
cytochrome c oxidase I deficiency
TARDBP TARDBP TAR DNA binding protein Amyotrophic lateral 81405
sclerosis
TAZ TAZ Tafazzin Methylglutaconic aciduria 81406,
type 2, Barth syndrome, 81440
TBP TBP TATA box binding protein Spinocerebellar ataxia 81344
TBX5 TBX5 T-box 5 Holt-Oram syndrome 81405
TCF4 TCF4 Transcription factor 4 Pitt-Hopkins syndrome, 81405,
epilepsy 81406,
81419
TERT Telomerase reverse Thyroid carcinoma, 81345
transcriptase glioblastoma multiforme
TGFBI Transforming growth factor Corneal dystrophy 81333
beta-induced
TGFBR1 TGFBR1 Transforming growth factor, Marfan syndrome, aortic 81405,
beta receptor 1 dysfunction or dilation 81410,
81411
TGFBR2 TGFBR2 Transforming growth factor, Marfan syndrome, aortic 81405,
beta receptor 2 dysfunction or dilation 81410,
81411
TH TH Tyrosine hydroxylase Segawa syndrome 81406
THAP1 THAP1 THAP domain containing, Torsion dystonia 81404
apoptosis associated protein 1
THRB THRB Thyroid hormone receptor, Thyroid hormone 81405
beta resistance, thyroid
hormone beta receptor
deficiency
TK2 TK2 Thymidine kinase 2, Mitochondrial DNA 81405,
mitochondrial depletion syndrome, 81440
TMC1 TMC1 Transmembrane channel-like Hearing loss 81430
1
TMEM43 TMEM43 Transmembrane protein 43 Arrhythmogenic right 81406
ventricular
cardiomyopathy
TMEM67 TMEM67 Transmembrane protein 67 Joubert syndrome 81407
TMEM127 TMEM127 Transmembrane protein 127 Hereditary 81437
disorders
TMPRSS3 TMPRSS3 Transmembrane protease, Hearing loss 81430
serine 3
TNNC1 TNNC1 Troponin C type 1 (slow) Hypertrophic 81405
cardiomyopathy or dilated
cardiomyopathy
TNNI3 TNNI3 Troponin I, type 3 (cardiac) Familial hypertrophic 81405
cardiomyopathy
TNNT2 TNNT2 Troponin T, type 2 (cardiac) Familial hypertrophic 81406
cardiomyopathy
TOR1A TOR1A Torsin family 1, member A Early-onset primary 81400,
(torsin A) dystonia (DYT1), torsion 81404
dystonia
TP53 TP53 Tumor protein 53 Li-Fraumeni syndrome, 81351,
hereditary breast cancer– 81352,
related disorders 81353,
81432
TPM1 TPM1 Tropomyosin 1 (alpha) Familial hypertrophic 81405
cardiomyopathy
TPMT TPMT Thiopurine S- Drug metabolism 81335
methyltransferase
TPP1 Tripeptidyl peptidase 1 Epilepsy 81419
TRB@ T cell antigen receptor, beta Leukemia and lymphoma 81340,
81341
TRD TRD@ T cell antigen receptor, delta Leukemia and lymphoma 81402
TRG@ T cell antigen receptor, Leukemia and lymphoma 81342
gamma
TRPC6 TRPC6 Transient receptor potential Focal segmental 81406
cation channel, subfamily C, glomerulosclerosis
member 6
TSC1 TSC1 Tuberous sclerosis 1 Tuberous sclerosis, 81405,
epilepsy 81406,
81419
TSC2 TSC2 Tuberous sclerosis 2 Tuberous sclerosis, 81406,
epilepsy 81407,
81419
TTN TTN Titin Hereditary 81439
cardiomyopathy
TTPA TTPA Tocopherol (alpha) transfer Ataxia 81404
protein
TTR TTR Transthyretin Familial transthyretin 81404
amyloidosis
TWIST1 TWIST1 Twist homolog 1 (Drosophila) Saethre-Chotzen 81403,
syndrome 81404
TYMP TYMP Thymidine phosphorylase Mitochondrial DNA 81405,
depletion syndrome, 81440
TYMS TYMS Thymidylate synthetase 5-fluorouracil/5-FU drug 81346
metabolism
TYR TYR Tyrosinase (oculocutaneous Oculocutaneous albinism 81404
albinism IA) IA
U2AF1 U2 small nuclear RNA Myelodysplastic 81357
auxiliary factor 1 syndrome, acute myeloid
leukemia
UBA1 UBA1 Ubiquitin-like modifier Spinal muscular atrophy, 81403
activating enzyme 1 X-linked
UBE3A UBE3A Ubiquitin protein ligase E3A Angelman syndrome 81406
UGT1A1 UGT1A1 UDP glucuronosyltransferase Drug metabolism, Gilbert 81350,
1 family, polypeptide A1 syndrome, Crigler-Najjar 81404
syndrome
UMOD UMOD Uromodulin Glomerulocystic kidney 81406
disease with
hyperuricemia and
isosthenuria
UPD Uniparental disomy UPD Russell-Silver syndrome, 81402
Prader-Willi/Angelman
syndrome
USH1C USH1C Usher syndrome 1C Usher syndrome, type 1, 81407,
(autosomal recessive, severe) hearing loss 81430
USH1G USH1G Usher syndrome 1G Usher syndrome, type 1, 81404,
(autosomal recessive) hearing loss 81430
USH2A USH2A Usher syndrome 2A Usher syndrome, type 2, 81408,
(autosomal recessive, mild) hearing loss, hereditary 81430,
retinal disorders 81434
VHL VHL Von Hippel-Lindau tumor Von Hippel-Lindau 81403,
suppressor familial cancer syndrome, 81404,
hereditary 81437,
neuroendocrine tumor 81438
disorders
VKORC1 Vitamin K epoxide reductase Warfarin metabolism 81355
complex, subunit 1
VPS13B VPS13B Vacuolar protein sorting 13 Cohen syndrome 81407,
homolog B (yeast) 81408
VWF VWF Von Willebrand factor Von Willebrand disease 81401,
types 1, 1C, 2A, 2B, 2M, 81403,
2N, 3 81404,
81405,
81406,
81408
WAS WAS Wiskott-Aldrich syndrome Wiskott-Aldrich 81406
(eczema-thrombocytopenia) syndrome
WDR62 WDR62 WD repeat domain 62 Primary autosomal 81407
recessive microcephaly
WFS1 WFS1 Wolfram syndrome 1 Hearing loss 81430
WT1 WT1 Wilms tumor 1 Denys-Drash syndrome, 81405
familial Wilms tumor
ZEB2 ZEB2 Zinc finger E-box binding Mowat-Wilson syndrome, 81404,
homeobox 2 epilepsy 81405,
81419
ZNF41 ZNF41 Zinc finger protein 41 X-linked mental 81404
retardation 89
ZRSR2 Zinc finger CCCH type, Myelodysplastic 81360
RNA-binding motif and syndrome, acute myeloid
serine/arginine rich 2 leukemia
Guidelines
for the convenience of those referring to this section on
Pathology and Laboratory. Other definitions and items unique
to Pathology and Laboratory are also listed.

Services in Pathology and Laboratory are provided by a
physician or by technologists under responsible supervision of a
physician.

It is appropriate to designate multiple procedures that are
rendered on the same date by separate entries.

the service, identifying it by “Special Report” as discussed below.
The “Unlisted Procedures” and accompanying codes for
Pathology and Laboratory are as follows:
81099 Unlisted urinalysis procedure
# 81479 Unlisted molecular pathology procedure
81599 Unlisted multianalyte assay with algorithmic analysis
84999 Unlisted chemistry procedure
85999 Unlisted hematology and coagulation procedure
86486 unlisted antigen, each
86849 Unlisted immunology procedure
86999 Unlisted transfusion medicine procedure
87999 Unlisted microbiology procedure
88099 Unlisted necropsy (autopsy) procedure
88199 Unlisted cytopathology procedure
88299 Unlisted cytogenetic study
88399 Unlisted surgical pathology procedure
88749 Unlisted in vivo (eg, transcutaneous) laboratory service
89240 Unlisted miscellaneous pathology test
89398 Unlisted reproductive medicine laboratory procedure
Special Report
Organ or Disease-Oriented Panels

These panels were developed for coding purposes only and
should not be interpreted as clinical parameters. The tests listed
with each panel identify the defined components of that panel.
These panel components are not intended to limit the
performance of other tests. If one performs tests in addition to
those specifically indicated for a particular panel, those tests
should be reported separately in addition to the panel code.
Do not report two or more panel codes that include any of the
same constituent tests performed from the same patient
collection. If a group of tests overlaps two or more panels, report
the panel that incorporates the greater number of tests to fulfill
the code definition and report the remaining tests using
individual test codes (eg, do not report 80047 in conjunction with
80053).
80047 Basic metabolic panel (Calcium, ionized)
This panel must include the following:
Calcium, ionized (82330)
Carbon dioxide (bicarbonate) (82374)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Potassium (84132)
Sodium (84295)
Urea Nitrogen (BUN) (84520)
80048 Basic metabolic panel (Calcium, total)

Calcium, total (82310)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Potassium (84132)
Sodium (84295)
Urea nitrogen (BUN) (84520)
➲ CPT Assistant Jan 98:6, Sep 99:11, Nov 99:44, Jan 00:7,
Aug 05:9
80050 General health panel
Comprehensive metabolic panel (80053)
Blood count, complete (CBC), automated and automated
differential WBC count (85025 or 85027 and 85004)
OR
Blood count, complete (CBC), automated (85027) and
appropriate manual differential WBC count (85007 or
85009)
Thyroid stimulating hormone (TSH) (84443)
➲ CPT Assistant Winter 92:14, Summer 93:14, Jun 97:10,
Nov 97:28, Jan 98:6, Sep 99:11
80051 Electrolyte panel
Chloride (82435)
Potassium (84132)
Sodium (84295)
80053 Comprehensive metabolic panel

Albumin (82040)
Bilirubin, total (82247)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Phosphatase, alkaline (84075)
Potassium (84132)
Protein, total (84155)
Sodium (84295)
Transferase, alanine amino (ALT) (SGPT) (84460)
Transferase, aspartate amino (AST) (SGOT) (84450)
➲ CPT Assistant Jan 98:6, Nov 98:23, Sep 99:11, Nov
99:44, May 00:11, Jan 05:46, Apr 08:5, Apr 10:11, Apr
13:10
80055 Obstetric panel
Blood count, complete (CBC), automated and automated
differential WBC count (85025 or 85027 and 85004)
OR
85009)
Hepatitis B surface antigen (HBsAg) (87340)
Antibody, rubella (86762)
Syphilis test, non-treponemal antibody; qualitative (eg,
VDRL, RPR, ART) (86592)
Antibody screen, RBC, each serum technique (86850)
Blood typing, ABO (86900) AND
Blood typing, Rh (D) (86901)
Apr 99:6, Sep 99:11
(When syphilis screening is performed using a treponemal
antibody approach [86780], do not use 80055. Use the
individual codes for the tests performed in the obstetric
panel)
# 80081 Obstetric panel (includes HIV testing)
Blood count, complete (CBC), and automated differential
WBC count (85025 or 85027 and 85004)
OR
85009)
HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single
result (87389)
Antibody, rubella (86762)
Syphilis test, non-treponemal antibody; qualitative (eg,
VDRL, RPR, ART) (86592)
Antibody screen, RBC, each serum technique (86850)
Blood typing, ABO (86900) AND
Blood typing, Rh (D) (86901)
(When syphilis screening is performed using a treponemal

antibody approach [86780], do not use 80081. Use the
individual codes for the tests performed in the Obstetric
panel)
80061 Lipid panel
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement, high density cholesterol
(HDL cholesterol) (83718)
Triglycerides (84478)
Sep 99:11, Mar 00:11, Feb 05:9, Sep 17:12
80069 Renal function panel
Albumin (82040)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Phosphorus inorganic (phosphate) (84100)
Potassium (84132)
Sodium (84295)
80074 Acute hepatitis panel

Hepatitis A antibody (HAAb), IgM antibody (86709)
Hepatitis B core antibody (HBcAb), IgM antibody (86705)
Hepatitis C antibody (86803)
80076 Hepatic function panel

Albumin (82040)
Bilirubin, total (82247)
Bilirubin, direct (82248)
Phosphatase, alkaline (84075)
Protein, total (84155)
Transferase, alanine amino (ALT) (SGPT) (84460)
Transferase, aspartate amino (AST) (SGOT) (84450)
Jan 98:6, Apr 99:6, Sep 99:11, Nov 99:45, Jan 00:7, Aug
05:9
Drug Assay
Drug procedures are divided into three subsections:
Therapeutic Drug Assay, Drug Assay, and Chemistry—with
code selection dependent on the purpose and type of patient
results obtained. Therapeutic Drug Assays are performed to
monitor clinical response to a known, prescribed medication. The
two major categories for drug testing in the Drug Assay
subsection are:
1. Presumptive Drug Class procedures are used to identify
possible use or non-use of a drug or drug class. A presumptive
test may be followed by a definitive test in order to specifically
identify drugs or metabolites.
2. Definitive Drug Class procedures are qualitative or
quantitative test to identify possible use or non-use of a drug.
These test identify specific drugs and associated metabolites, if
performed. A presumptive test is not required prior to a
definitive drug test.
The material for drug class procedures may be any specimen type
unless otherwise specified in the code descriptor (eg, urine,
blood, oral fluid, meconium, hair). Procedures can be qualitative
(eg, positive/negative or present/absent), semi-quantitative, or
quantitative (measured) depending on the purpose of the testing.
Therapeutic drug assay (TDA) procedures are typically
quantitative tests and the specimen type is whole blood, serum,
plasma, or cerebrospinal fluid.
When the same procedure(s) is performed on more than one
specimen type (eg, blood and urine), the appropriate code is
reported separately for each specimen type using modifier 59.
Drugs or classes of drugs may be commonly assayed first by a
presumptive screening method followed by a definitive drug
identification method. Presumptive methods include, but are not
limited to, immunoassays (IA, EIA, ELISA, RIA, EMIT, FPIA,
etc), enzymatic methods (alcohol dehydrogenase, etc),
chromatographic methods without mass spectrometry (TLC,
HPLC, GC, etc), or mass spectrometry without adequate drug
resolution by chromatography (MS-TOF, DART, DESI, LDTD,
MALDI). LC-MS, LCMS/MS, or mass spectrometry without
adequate drug resolution by chromatography may also be used
for presumptive testing if the chromatographic phase is not
adequate to identify individual drugs and distinguish between
structural isomers or isobaric compounds. All drug class
immunoassays are considered presumptive, whether qualitative,
semi-quantitative, or quantitative. Methods that cannot
distinguish between structural isomers (such as morphine and
hydromorphone or methamphetamine and phentermine) are also
considered presumptive.
DEFINITIONS AND ACRONYM CONVERSION LISTING

Drug Testing
Definition
Term/Acronym
6-MAM Acronym for the heroin drug metabolite 6-
monacetylmorphine
Acid Descriptor for classifying drug/drug metabolite molecules
based upon chemical ionization properties. Laboratory
procedures for drug isolation and identification may
include acid, base, or neutral groupings.
AM A category of synthetic marijuana drugs discovered by and
named after Alexandros Makriyannis at Northeastern
University
Analog A structural derivative of a parent chemical compound that
often differs from it by a single element
Analyte The substance or chemical constituent that is of interest in
an analytical procedure
Base Descriptor for classifying drug/drug metabolite molecules
Card(s) Multiplexed presumptive drug class(es) immunoassay
product that is read by visual observation, including
instrumented when performed
Cassette(s) Multiplexed presumptive drug class immunoassay
product(s) that is read by visual observation, including
CEDIA Acronym for Cloned-Enzyme-Donor-Immuno-Assay.
CEDIA immunoassay is a competitive antibody binding
procedure that utilizes enzyme donor fragment-labeled
antigens (drugs) to compete for antigens (drugs) contained
in the patient sample. Recombination of enzyme donor
fragment and enzyme acceptor fragment produces a
functional enzyme. CEDIA immunoassay enzyme activity is
proportional to concentration of drug(s) detected.
Chromatography An analytical technique used to separate components of a
mixture. See thin layer chromatography, gas
chromatography, and high performance chromatography.
Confirmatory Term used to describe definitive identification/quantitation
procedures that are secondary to presumptive screening
methods
DART Acronym for Direct-Analysis-in-Real-Time. DART is an
atmospheric pressure ionization method for mass
spectrometry analysis
Definitive Drug A procedure that provides specific identification of
Procedure individual drugs and drug metabolites
DESI Acronym for Desorption-ElectroSpray-Ionization. DESI is
a combination of electrospray ionization and desorption
ionization methods for mass spectrometry analysis.
Dipstick A multiplexed presumptive drug class immunoassay
Drug test cup A multiplexed presumptive drug class immunoassay
EDDP Acronym for the methadone drug metabolite 2-ethylidene-
1,5-dimethyl-3,3-diphenylpyrrolidine
EIA Acronym for Enzyme-Immuno-Assay. Enzyme immunoassay
is a competitive antibody binding procedure that utilizes
enzyme-labeled antigens (drugs) to compete for antigens
(drugs) contained in the patient sample. Enzyme
immunoassay enzyme activity is proportional to
concentration of drug(s) detected
ELISA Acronym for Enzyme-Linked Immunosorbent Assay. ELISA
is a competitive binding immunoassay that is designed to
measure antigens (drugs) or antibodies. ELISA
immunoassay results are proportional to concentration of
drug(s) detected.
EMIT Acronym for Enzyme-Multiplied-Immunoassay-Test. EMIT
is a trade name for a type of enzyme immunoassay (EIA).
FPIA Acronym for Fluorescence-Polarization-Immuno-Assay.
FPIA is a competitive binding immunoassay that utilizes
fluorescein-labeled antigens (drugs) to compete for
antigens (drugs) contained in the patient sample. The
measure of polarized light emission is inversely
proportional to the concentration of drug(s) detected.
Gas Gas chromatography is a chromatography technique in
chromatography which patient sample preparations are vaporized into a gas
(mobile phase) which flows through a tubular column
(containing a stationary phase) and into a detector. The
retention time of a drug on the column is determined by
partitioning characteristics of the drug into the mobile and
stationary phases. Chromatography column detectors may
be non-specific (eg, flame ionization) or specific (eg, mass
spectrometry). The combination of column retention time
and specific detector response provides a definitive
identification of the drug or drug metabolite.
GC Acronym for gas chromatography
GC-MS Acronym for gas chromatography mass spectrometry
GC-MS/MS Acronym for gas chromatography mass spectrometry/mass
spectrometry
High High performance liquid chromatography is a
performance chromatography technique in which patient sample
liquid preparations are injected into a liquid (mobile phase)
chromatography which flows through a tubular column (containing a
stationary phase) and into a detector. The retention time of
a drug on the column is determined by partitioning
characteristics of the drug into the mobile and stationary
phases. Chromatography column detectors may be non-
specific (eg, ultra-violet spectrophotometry) or specific
(eg, mass spectrometry). The combination of column
retention time and specific detector response provides a
definitive identification of the drug or drug metabolite.
High performance liquid chromatography is also called
high pressure liquid chromatography.
HPLC Acronym for high performance liquid chromatography
HU A category of synthetic marijuana drugs discovered by and
named after Raphael Mechoulam at Hebrew University
IA Acronym for immunoassay
Immunoassay Antigen-antibody binding procedures utilized to detect
antigens (eg, drugs and/or drug metabolites) in patient
samples. Immunoassay designs include competitive or non-
competitive with various mechanisms for detection.
Isobaric In mass spectrometry, ions with the same mass
Isomers Compounds that have the same molecular formula but differ
in structural formula
JWH A category of synthetic marijuana drugs discovered by and
named after John W. Huffman at Clemson University.
KIMS Acronym for kinetic interaction of microparticles in
solution. KIMS immunoassay is a competitive antibody
binding procedure that utilizes microparticle-labeled
antigens (drugs) to compete for antigens (drugs) contained
in the patient sample. Microparticle immunoassay
absorbance increase is inversely proportional to
concentration of drug(s) detected.
LC-MS Acronym for liquid chromatography mass spectrometry
LC-MS/MS Acronym for liquid chromatography mass
spectrometry/mass spectrometry
LDTD Acronym for laser diode thermal desorption. LDTD is a
combination of atmospheric pressure chemical ionization
and laser diode thermal desorption methods for mass
spectrometry analysis.
MALDI Acronym for matrix assisted laser desorption/Ionization
mass spectrometry. MALDI is a soft ionization technique
that reduces molecular fragmentation.
MDA Acronym for the drug 3,4-methylenedioxyamphetamine.
MDA is also a drug metabolite of MDMA.
MDEA Acronym for the drug 3,4-methylenedioxy-N-
ethylamphetamine
MDMA Acronym for the drug 3,4-methylenedioxy-N-
methylamphetamine
MDPV Acronym for the drug methylenedioxypyrovalerone
MS Acronym for mass spectrometry. MS is an identification
technique that measures the charge-to-mass ratio of charged
particles. There are several types of mass spectrometry
instruments, such as magnetic sectoring, time of flight,
quadrupole mass filter, ion traps, and Fourier
transformation. Mass spectrometry is used as part of the
process to assign definitive identification of drugs and drug
metabolites.
MS/MS Acronym for mass spectrometry/mass spectrometry.
MS/MS instruments combine multiple units of mass
spectrometry filters into a single instrument. MS/MS is also
called tandem mass spectrometry.
MS-TOF Acronym for mass spectrometry time of flight. Time of
flight is a mass spectrometry identification technique that
utilizes ion velocity to determine the mass-to-charge ratio.
Multiplexed Descriptor for a multiple component test device that
simultaneously measures multiple analytes (drug classes) in
a single analysis.
Neutral Descriptor for classifying drug/drug metabolite molecules
ng/mL Unit of measure for weight per volume calculated as
nanograms per milliliter. The ng/mL unit of measure is
equivalent to the ug/L unit of measure.
Optical Optical observation refers to procedure results that are
observation interpreted visually with or without instrumentation
assistance.
Opiate Medicinal category of narcotic alkaloid drugs that are
natural products in the opium poppy plant Papaver
somniferum. This immunoassay class of drugs typically
includes detection of codeine, dihydrocodeine,
hydrocodone, hydromorphone, and morphine.
Opioids A category of medicinal synthetic or semi-synthetic
narcotic alkaloid opioid receptor stimulating drugs
including butorphanol, desomorphine, dextromethorphan,
dextrorphan, levorphanol, meperidine, naloxone,
naltrexone, normeperidine, and pentazocine.
Presumptive Drug test results that indicate possible, but not definitive,
presence of drugs and/or drug metabolites
QTOF Acronym for quadrupole-time of flight mass spectrometry.
QTOF is a hybrid mass spectrometry identification
technique that combines ion velocity with tandem
quadrupole mass spectrometry (MS or MS/MS) to
determine the mass-to-charge ratio.
RCS A category of synthetic marijuana drugs that are analogs of
JHW compounds. See JWH.
RIA Acronym for radio-immuno-assay. Radioimmunoassay is a
competitive antibody binding procedure that utilizes
radioactive-labeled antigens (drugs) to compete for
antigens (drugs) contained in the patient sample. The
measure of radioactivity is inversely proportional to
concentration of drug(s) detected.
Stereoisomers Isomeric molecules that have the same molecular formula
and sequence of bonded atoms (constitution), but that differ
only in the three-dimensional orientations of their atoms in
space
Substance A substance is a drug that does not have an established
therapeutic use as distinguished from other analytes listed
in the Chemistry section (82009-84999).
TDM Acronym for therapeutic drug monitoring
THC Acronym for marijuana active drug ingredient
tetrahydrocannabinol
Therapeutic Analysis of blood (serum, plasma) drug concentration to
Drug monitor clinical response to therapy
Monitoring
Time of flight Time of flight is a mass spectrometry technique that utilizes
ion velocity to determine the mass-to-charge ratio
TLC Acronym for thin layer chromatography
TOF Acronym for time of flight
ug/L Unit of measure for mass per volume calculated as
micrograms per liter. The ug/L unit of measure is
equivalent to the ng/mL unit of measure.
Definitive drug identification methods are able to identify

individual drugs and distinguish between structural isomers but
not necessarily stereoisomers. Definitive methods include, but are
not limited to, gas chromatography with mass spectrometry (any
type, single or tandem) and liquid chromatography mass
spectrometry (any type, single or tandem) and excludes
immunoassays (eg, IA, EIA, ELISA, RIA, EMIT, FPIA), and
enzymatic methods (eg, alcohol dehydrogenase).
For chromatography, each combination of stationary and mobile
phase is to be counted as one procedure.
Presumptive Drug Class Screening

Drugs or classes of drugs may be commonly assayed first by a
presumptive screening method followed by a definitive drug
identification method. The methodology is considered when
coding presumptive procedures. Each code (80305, 80306,
80307) represents all drugs and drug classes performed by the
respective methodology per date of service. Each code also
includes all sample validation procedures performed. Examples
of sample validation procedures may include, but are not limited
to, pH, specific gravity, and nitrite. The codes (80305, 80306,
80307) represent three different method categories:
1. Code 80305 is used to report procedures in which the results
are read by direct optical observation. The results are visually
read. Examples of these procedures are dipsticks, cups, cards,
and cartridges. Report 80305 once, irrespective of the number
of direct observation drug class procedures performed or
results on any date of service.
2. Code 80306 is used to report procedures when an instrument is
used to assist in determining the result of a direct optical
observation methodology. Examples of these procedures are
dipsticks, cards, and cartridges inserted into an instrument that
determines the final result of an optical observation
methodology. Report 80306 once, irrespective of the number
of drug class procedures or results on any date of service.
3. Code 80307 is used to report any number of devices or
procedures by instrumented chemistry analyzers. There are
many different instrumented methodologies available to
perform presumptive drug assays. Examples include
immunoassay (eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA),
chromatography (eg, GC, HPLC), and mass spectrometry,
either with or without chromatography (eg, DART, DESI, GC-
MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF).
Some of these methodologies may be used for definitive drug
testing also, but, for the purpose of presumptive drug testing,
the presumptive method is insufficient to provide definitive
drug identification. Report 80307 once, irrespective of the
number of drug class procedures or results on any date of
service.
# 80305 Drug test(s), presumptive, any number of drug classes, any
number of devices or procedures; capable of being read by
direct optical observation only (eg, utilizing immunoassay
[eg, dipsticks, cups, cards, or cartridges]), includes sample
validation when performed, per date of service
# 80306 read by instrument assisted direct optical observation

(eg, utilizing immunoassay [eg, dipsticks, cups, cards, or
cartridges]), includes sample validation when
performed, per date of service
# 80307 by instrument chemistry analyzers (eg, utilizing

immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS,
RIA]), chromatography (eg, GC, HPLC), and mass
spectrometry either with or without chromatography, (eg,
DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-
MS/MS, LDTD, MALDI, TOF) includes sample
validation when performed, per date of service
Definitive Drug Testing

Definitive drug identification methods are able to identify
individual drugs and distinguish between structural isomers but
not necessarily stereoisomers. Definitive methods include, but are
not limited to, gas chromatography with mass spectrometry (any
type, single or tandem) and liquid chromatography mass
spectrometry (any type, single or tandem) and exclude
immunoassays (eg, IA, EIA, ELISA, RIA, EMIT, FPIA) and
enzymatic methods (eg, alcohol dehydrogenase).
Use 80320-80377 to report definitive drug class procedures.
Definitive testing may be qualitative, quantitative, or a
combination of qualitative and quantitative for the same patient
on the same date of service.
The Definitive Drug Classes Listing provides the drug classes,
their associated CPT codes, and the drugs included in each class.
Each category of a drug class, including metabolite(s) if
performed (except stereoisomers), is reported once per date of
service. Metabolites not listed in the table may be reported using
the code for the parent drug. Drug class metabolite(s) is not
reported separately unless the metabolite(s) is listed as a separate
category in Definitive Drug Classes Listing (eg, heroin
metabolite).
Drug classes may contain one or more codes based on the
number of analytes. For example, an analysis in which five or
more amphetamines and/or amphetamine metabolites would be
reported with 80326. The code is based on the number of
reported analytes and not the capacity of the analysis.
▶Definitive drug procedures that are not specified in 80320-
80373 should be reported using the unlisted definitive procedure
codes 80375, 80376, 80377, unless the specific analyte is listed in
the Therapeutic Drug Assays (80143-80203) or Chemistry
(82009-84830) sections.◀
See the Definitive Drug Classes Listing table for a listing of the
more common analytes within each drug class.
# 80320 Alcohols
▶ (Foralcohol [ethanol] by immunoassay and enzymatic

methods, use 82077)◀
# 80321 Alcohol biomarkers; 1 or 2
# 80322 3 or more
# 80323 Alkaloids, not otherwise specified

# 80324 Amphetamines; 1 or 2
# 80325 3 or 4
# 80326 5 or more
# 80327 Anabolic steroids; 1 or 2

# 80328 3 or more
(For dihydrotestosterone analysis for endogenous hormone
levels or therapeutic monitoring, use 82642)
# 80329 Analgesics, non-opioid; 1 or 2
# 80330 3-5
# 80331 6 or more
▶ (Foracetaminophen by immunoassay or enzymatic

▶ (Forsalicylate by immunoassay or enzymatic methods, use
80179)◀
# 80332 Antidepressants, serotonergic class; 1 or 2
# 80333 3-5
# 80334 6 or more
# 80335 Antidepressants, tricyclic and other cyclicals; 1 or 2

# 80336 3-5
# 80337 6 or more
# 80338 Antidepressants, not otherwise specified

# 80339 Antiepileptics, not otherwise specified; 1-3
# 80340 4-6
# 80341 7 or more
(To report definitive drug testing for antihistamines, see

80375, 80376, 80377)
▶ (Toreport therapeutic drug assay for carbamazepine, see
80156, 80157, 80161)◀
# 80342 Antipsychotics, not otherwise specified; 1-3
# 80343 4-6
# 80344 7 or more
# 80345 Barbiturates
# 80346 Benzodiazepines; 1-12

# 80347 13 or more
# 80348 Buprenorphine
# 80349 Cannabinoids, natural

# 80350 Cannabinoids, synthetic; 1-3

# 80351 4-6
# 80352 7 or more
# 80353 Cocaine
# 80354 Fentanyl
# 80355 Gabapentin, non-blood

(For therapeutic drug assay, use 80171)

# 80356 Heroin metabolite
# 80357 Ketamine and norketamine

# 80358 Methadone
# 80359 Methylenedioxyamphetamines (MDA, MDEA, MDMA)

# 80360 Methylphenidate
# 80361 Opiates, 1 or more

# 80362 Opioids and opiate analogs; 1 or 2

# 80363 3 or 4
# 80364 5 or more
# 80365 Oxycodone
# 83992 Phencyclidine (PCP)

(Phenobarbital, use 80345)

# 80366 Pregabalin
# 80367 Propoxyphene
# 80368 Sedative hypnotics (non-benzodiazepines)

# 80369 Skeletal muscle relaxants; 1 or 2

# 80370 3 or more
# 80371 Stimulants, synthetic

# 80372 Tapentadol
# 80373 Tramadol
# 80374 Stereoisomer (enantiomer) analysis, single drug class

(Use 80374 in conjunction with an index drug analysis,

when performed)
# 80375 Drug(s) or substance(s), definitive, qualitative or
quantitative, not otherwise specified; 1-3
# 80376 4-6
# 80377 7 or more
(To report definitive drug testing for antihistamines, see

80375, 80376, 80377)
For Example:
To report amphetamine and methamphetamine using any number
of definitive procedures, report 80324 once per facility per date
of service.
To report codeine, hydrocodone, hydromorphone, morphine
using any number of definitive procedures, report 80361 once
per facility per date of service.
To report codeine, hydrocodone, hydromorphone, morphine,
oxycodone, oxymorphone, naloxone, naltrexone performed using
any number of definitive procedures report 80361 X 1, 80362 X
1, and 80365 X 1 per facility per date of service.
To report benzoylecgonine, cocaine, carboxy-THC, meperidine,
normeperidine using any number of definitive procedures, report
80349 X 1, 80353 X 1, and 80362 X 1 per facility per date of
service.
Definitive Drug Classes Listing

▶Drugs and metabolites included in each definitive drug class are
listed in the Definitive Drug Classes Listing table. This is not a
comprehensive list. FDA classification of drugs not listed should
be used where possible within the defined drug classes. Any
metabolites that are not listed should be categorized with the
parent drug. Drugs and metabolites not listed may be reported
using codes from the Therapeutic Drug Assay (80143-80299) or
Chemistry (82009-84999) sections.◀
DEFINITIVE DRUG CLASSES LISTING
Codes Classes Drugs

80320 Alcohol(s) Acetone, ethanol, ethchlorvynol,
ethylene glycol, isopropanol,
isopropyl alcohol, methanol
80321- Alcohol biomarkers Ethanol conjugates (ethyl glucuronide
80322 [ETG], ethyl sulfate [ETS], fatty acid
ethyl esters, phosphatidylethanol)
80323 Alkaloids, not otherwise 7-Hydroxymitragynine, atropine,
specified cotinine, lysergic acid diethylamide
(LSD), mescaline, mitragynine,
nicotine, psilocin, psilocybin,
scopolamine
80324- Amphetamines Amphetamine, ephedrine,
80326 lisdexamphetamine,
methamphetamine, phentermine,
phenylpropanolamine,
pseudoephedrine
80327- Anabolic steroids 1-Androstenediol, 1-
80328 androstenedione, 1-testosterone, 4-
hydroxy-testosterone, 6-oxo, 19-
norandrostenedione,
androstenedione, androstanolone,
bolandiol, bolasterone, boldenone,
boldione, calusterone, clostebol,
danazol,
dehydrochlormethyltestosterone,
dihydrotestosterone, drostanolone,
epiandrosterone, epitestosterone,
fluoxymesterone, furazabol,
mestanolone, mesterolone,
methandienone, methandriol,
methenolone, methydienolone,
methyl-1-testosterone,
methylnortestosterone,
methyltestosterone, mibolerone,
nandrolone, norbolethone,
norclostebol, norethandrolone,
norethindrone, oxabolone,
oxandrolone, oxymesterone,
oxymetholone, stanozolol,
stenbolone, tibolone, trenbolone,
zeranol
80329- Analgesics, non-opioid Acetaminophen, diclofenac
80331 ibuprofen, ketoprofen, naproxen,
oxaprozin, salicylate
80332- Antidepressants, serotonergic Citalopram, duloxetine,
80334 class escitalopram, fluoxetine,
fluvoxamine, paroxetine, sertraline
80335- Antidepressants, tricyclic and Amitriptyline, amoxapine,
80337 other cyclicals clomipramine, demexiptiline,
desipramine, doxepin, imipramine,
maprotiline, mirtazapine,
nortriptyline, protriptyline
80338 Antidepressants, not Bupropion, desvenlafaxine,
otherwise specified isocarboxazid, nefazodone,
phenelzine, selegiline,
tranylcypromine, trazodone,
venlafaxine
80339- Antiepileptics, not otherwise Carbamazepine, clobazam,
80341 specified dimethadione, ethosuximide,
ezogabine, lamotrigine,
levetiracetam, methsuximide,
oxcarbazepine, phenytoin, primidone,
rufinamide, tiagabine, topiramate,
trimethadione, valproic acid,
zonisamide
80342- Antipsychotics, not otherwise Aripiprazole, chlorpromazine,
80344 specified clozapine, fluphenazine, haloperidol,
loxapine, mesoridazine, molindone,
olanzapine, paliperidone,
perphenazine, phenothiazine,
pimozide, prochlorperazine,
quetiapine, risperidone,
trifluoperazine, thiothixene,
thioridazine, ziprasidone
80345 Barbiturates Amobarbital, aprobarbital,
butalbital, cyclobarbital,
mephobarbital, pentobarbital,
phenobarbital, secobarbital, talbutal,
thiopental
80346, Benzodiazepines Alprazolam, chlordiazepoxide,
80347 clonazepam, clorazepate, diazepam,
estazolam, flunitrazepam,
flurazepam, halazepam, lorazepam,
midazolam, nitrazepam, nordazepam,
oxazepam, prazepam, quazepam,
temazepam
80348 Buprenorphine Buprenorphine
80349 Cannabinoids, natural Marijuana, dronabinol carboxy-THC
80350- Cannabinoids, synthetic CP-47,497, CP497 C8-homolog,
80352 JWH-018 and AM678, JWH-073,
JWH-019, JWH-200, JWH-210,
JWH-250, JWH-081, JWH-122,
HWH-398, AM-2201, AM-694, SR-
19 and RCS-4, SR-18 and RCS-8,
JWH-203, UR-144, XLR-11, MAM-
2201, AKB-48
80353 Cocaine Benzoylecgonine, cocaethylene,
cocaine, ecgonine methyl ester,
norcocaine
80354 Fentanyls Acetylfentanyl, alfentanil, fentanyl,
remifentanil, sufentanil
80355 Gabapentin, non-blood Gabapentin
80356 Heroin metabolite 6-acetylmorphine, acetylcodeine,
diacetylmorphine
80368 Hypnotics, sedative (non- See Sedative Hypnotics
benzodiazepines)
80357 Ketamine and Norketamine Ketamine, norketamine
80358 Methadone Methadone and EDDP
80359 Methylenedioxyamphetamines MDA, MDEA, MDMA
80360 Methylphenidate Methylphenidate, ritalinic acid
80357 Norketamine See Ketamine
80368 Non-Benzodiazepines See Hypnotics, sedative
80361 Opiates Codeine, dihydrocodeine,
hydrocodone, hydromorphone,
morphine
80362- Opioids and opiate analogs Butorphanol, desomorphine,
80364 dextromethorphan, dextrorphan,
levorphanol, meperidine, naloxone,
naltrexone, normeperidine,
pentazocine
80365 Oxycodone Oxycodone, oxymorphone
83992 Phencyclidine Phencyclidine
80366 Pregabalin Pregabalin
80367 Propoxyphene Norpropoxyphene, propoxyphene
80368 Sedative Hypnotics (non- Eszopiclone, zaleplon, zolpidem
benzodiazepines)
80369, Skeletal muscle relaxants Baclofen, carisoprodol,
80370 cyclobenzaprine, meprobamate,
metaxalone, methocarbamol,
orphenadrine, tizanidine
80371 Stimulants, synthetic 2C-B, 2C-E, 2C-I, 2C-H, 3TFMPP,
4-methylethcathinone, alpha-PVP,
benzylpiperazine, bromodragonfly,
cathinone, m-CPP, MDPBP, MDPPP,
MDPV, mephedrone, methcathinone,
methylone, phenethylamines,
salvinorin, tryptamines
80372 Tapentadol Tapentadol
80373 Tramadol Tramadol
Therapeutic Drug Assays

▶Therapeutic drug assays are performed to monitor levels of a
known, prescribed, or over-the-counter medication.◀
The material for examination is whole blood, serum, plasma, or
cerebrospinal fluid. Examination is quantitative. Coding is by
parent drug; measured metabolites of the drug are included in the
code, if performed.
● 80143 Acetaminophen
▶ (Fordefinitive drug testing for acetaminophen, see 80329,

80330, 80331)◀
80145 Adalimumab
80150 Amikacin
➲ CPT Assistant Aug 05:9, Oct 10:7, Dec 10:7, Mar 11:10,
Apr 15:3
● 80151 Amiodarone
80155 Caffeine
80156 Carbamazepine; total

80157 free
#● 80161 -10,11-epoxide
80158 Cyclosporine
80159 Clozapine
80162 Digoxin; total
80163 free

80168 Ethosuximide
80169 Everolimus
#● 80167 Felbamate
#● 80181 Flecainide
# 80171 Gabapentin, whole blood, serum, or plasma

80170 Gentamicin

80173 Haloperidol
# 80230 Infliximab
#● 80189 Itraconazole
# 80235 Lacosamide
80175 Lamotrigine

#● 80193 Leflunomide
80177 Levetiracetam
# 80176 Lidocaine
80178 Lithium
#● 80204 Methotrexate

80180 Mycophenolate (mycophenolic acid)

80183 Oxcarbazepine
80184 Phenobarbital
80185 Phenytoin; total

80186 free
80187 Posaconazole
80188 Primidone

80190 Procainamide;
80192 with metabolites (eg, n-acetyl procainamide)


80194 Quinidine
#● 80210 Rufinamide
#● 80179 Salicylate
▶ (Fordefinitive drug testing for salicylate, see 80329,

80330, 80331)◀
80195 Sirolimus
➲ CPT Assistant Mar 06:6, Oct 10:7, Mar 11:10
80197 Tacrolimus
80198 Theophylline
80199 Tiagabine
80200 Tobramycin
80201 Topiramate
➲ CPT Assistant Nov 97:28, Oct 10:7, Mar 11:10
# 80164 Valproic acid (dipropylacetic acid); total

# 80165 free
80202 Vancomycin
# 80280 Vedolizumab
# 80285 Voriconazole
80203 Zonisamide

80299 Quantitation of therapeutic drug, not elsewhere specified
➲ CPT Assistant Mar 00:3, Oct 04:14, Aug 05:9, Oct 10:7,
Dec 10:3, Mar 11:10, Apr 15:3
80305 Code is out of numerical sequence. See Presumptive Drug
Class Screening subsection
80320 Code is out of numerical sequence. See Definitive Drug
Testing subsection
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Evocative/Suppression Testing
The following test panels involve the administration of evocative
or suppressive agents and the baseline and subsequent
measurement of their effects on chemical constituents. These
codes are to be used for the reporting of the laboratory
component of the overall testing protocol. For the administration
of the evocative or suppressive agents, see Hydration,
Therapeutic, Prophylactic, Diagnostic Injections and Infusions,
and Chemotherapy and Other Highly Complex Drug or Highly
Complex Biologic Agent Administration (eg, 96365, 96366,
96367, 96368, 96372, 96374, 96375, 96376). In the code
descriptors where reference is made to a particular analyte (eg,
Cortisol: 82533 x 2) the “x 2” refers to the number of times the
test for that particular analyte is performed.
80400 ACTH stimulation panel; for adrenal insufficiency
Cortisol (82533 x 2)
➲ CPT Assistant Summer 94:1, Fall 94:10, Aug 05:9
80402 for 21 hydroxylase deficiency

17 hydroxyprogesterone (83498 x 2)
➲ CPT Assistant Summer 94:1, Fall 94:10
80406 for 3 beta-hydroxydehydrogenase deficiency

17 hydroxypregnenolone (84143 x 2)
80408 Aldosterone suppression evaluation panel (eg, saline

infusion)
Aldosterone (82088 x 2)
Renin (84244 x 2)
80410 Calcitonin stimulation panel (eg, calcium, pentagastrin)

Calcitonin (82308 x 3)
80412 Corticotropic releasing hormone (CRH) stimulation panel

Adrenocorticotropic hormone (ACTH) (82024 x 6)
80414 Chorionic gonadotropin stimulation panel; testosterone

response
Testosterone (84403 x 2 on 3 pooled blood samples)
▲ 80415 estradiol response
Estradiol, total (82670 x 2 on 3 pooled blood samples)
80416 Renal vein renin stimulation panel (eg, captopril)

Renin (84244 x 6)
80417 Peripheral vein renin stimulation panel (eg, captopril)

Renin (84244 x 2)
80418 Combined rapid anterior pituitary evaluation panel
Adrenocorticotropic hormone (ACTH) (82024 x 4)
Luteinizing hormone (LH) (83002 x 4)
Follicle stimulating hormone (FSH) (83001 x 4)
Prolactin (84146 x 4)
Human growth hormone (HGH) (83003 x 4)
Thyroid stimulating hormone (TSH) (84443 x 4)
80420 Dexamethasone suppression panel, 48 hour

Free cortisol, urine (82530 x 2)
Volume measurement for timed collection (81050 x 2)
(For single dose dexamethasone, use 82533)

80422 Glucagon tolerance panel; for insulinoma
Glucose (82947 x 3)
Insulin (83525 x 3)
80424 for pheochromocytoma

Catecholamines, fractionated (82384 x 2)
80426 Gonadotropin releasing hormone stimulation panel

Follicle stimulating hormone (FSH) (83001 x 4)
Luteinizing hormone (LH) (83002 x 4)
80428 Growth hormone stimulation panel (eg, arginine infusion, l-

dopa administration)
80430 Growth hormone suppression panel (glucose administration)

Glucose (82947 x 3)
80432 Insulin-induced C-peptide suppression panel

Insulin (83525)
C-peptide (84681 x 5)
Glucose (82947 x 5)
80434 Insulin tolerance panel; for ACTH insufficiency

Glucose (82947 x 5)
80435 for growth hormone deficiency

Glucose (82947 x 5)
80436 Metyrapone panel

11 deoxycortisol (82634 x 2)
80438 Thyrotropin releasing hormone (TRH) stimulation panel; 1

hour
80439 2 hour
Consultations (Clinical Pathology)

A clinical pathology consultation is a service, including a written
report, rendered by the pathologist in response to a request from
a physician or qualified health care professional in relation to a
test result(s) requiring additional medical interpretive judgment.
Reporting of a test result(s) without medical interpretive
judgment is not considered a clinical pathology consultation.
80500 Clinical pathology consultation; limited, without review of
patient’s history and medical records
➲ CPT Assistant Apr 97:9, Nov 02:9, Aug 05:9
80502 comprehensive, for a complex diagnostic problem, with

review of patient’s history and medical records
➲ CPT Assistant Apr 97:9, Nov 02:9, Aug 05:9
(These codes may also be used for pharmacokinetic

consultations)
(For consultations involving the examination and evaluation
of the patient, see 99241-99255)
Urinalysis
For specific analyses, see appropriate section.
81000 Urinalysis, by dip stick or tablet reagent for bilirubin,
glucose, hemoglobin, ketones, leukocytes, nitrite, pH,
protein, specific gravity, urobilinogen, any number of these
constituents; non-automated, with microscopy
➲ CPT Assistant Winter 90:, Winter 91:10, Fall 93:25, Aug
05:9, Jul 18:15
81001 automated, with microscopy
81002 non-automated, without microscopy
81003 automated, without microscopy

81005 Urinalysis; qualitative or semiquantitative, except

immunoassays
➲ CPT Assistant Winter 90:, Winter 91:10, Fall 93:25
(For non-immunoassay reagent strip urinalysis, see 81000,

81002)
(For immunoassay, qualitative or semiquantitative, use
83518)
(For microalbumin, see 82043, 82044)
81007 bacteriuria screen, except by culture or dipstick
(For culture, see 87086-87088)

(For dipstick, use 81000 or 81002)
81015 microscopic only
(For sperm evaluation for retrograde ejaculation, use

89331)
81020 2 or 3 glass test
➲ CPT Assistant Winter 90:, Winter 91:10
81025 Urine pregnancy test, by visual color comparison methods
81050 Volume measurement for timed collection, each

81099 Unlisted urinalysis procedure
Molecular Pathology
Molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid (ie, DNA,
RNA) to detect variants in genes that may be indicative of
germline (eg, constitutional disorders) or somatic (eg, neoplasia)
conditions, or to test for histocompatibility antigens (eg, HLA).
Code selection is typically based on the specific gene(s) that is
being analyzed. Genes are described using Human Genome
Organization (HUGO) approved gene names and are italicized in
the code descriptors. Gene names were taken from tables of the
HUGO Gene Nomenclature Committee (HGNC) at the time the
CPT codes were developed. For the most part, Human Genome
Variation Society (HGVS) recommendations were followed for
the names of specific molecular variants. The familiar name is
used for some variants because defined criteria were not in place
when the variant was first described or because HGVS
recommendations were changed over time (eg, intronic variants,
processed proteins). When the gene name is represented by an
abbreviation, the abbreviation is listed first, followed by the full
gene name italicized in parentheses (eg, “F5 [coagulation Factor
V]”), except for the HLA series of codes. Proteins or diseases
commonly associated with the genes are listed as examples in the
code descriptors. The examples do not represent all conditions in
which testing of the gene may be indicated.
Codes that describe tests to assess for the presence of gene
variants (see definitions) use common gene variant names.
Typically, all of the listed variants would be tested. However,
these lists are not exclusive. If other variants are also tested in the
analysis, they would be included in the procedure and not
reported separately. Full gene sequencing should not be reported
using codes that assess for the presence of gene variants unless
specifically stated in the code descriptor.
The molecular pathology codes include all analytical services
performed in the test (eg, cell lysis, nucleic acid stabilization,
extraction, digestion, amplification, and detection). Any
procedures required prior to cell lysis (eg, microdissection, codes
88380 and 88381) should be reported separately.
The results of the procedure may require interpretation by a
physician or other qualified health care professional. When only
the interpretation and report are performed, modifier 26 may be
appended to the specific molecular pathology code.
All analyses are qualitative unless otherwise noted.
For microbial identification, see 87149-87153 and 87471-87801,
and 87900-87904. For in situ hybridization analyses, see 88271-
88275 and 88365-88368.
Molecular pathology procedures that are not specified in 81161,
81200-81383 should be reported using either the appropriate Tier
2 code (81400-81408) or the unlisted molecular pathology
procedure code, 81479.
Definitions
For purposes of CPT reporting, the following definitions apply:
Abnormal allele: an alternative form of a gene that contains a
disease-related variation from the normal sequence.
Breakpoint: the region at which a chromosome breaks during a
translocation (defined elsewhere). These regions are often
consistent for a given translocation.
Codon: a discrete unit of three nucleotides of a DNA or mRNA
sequence that encodes a specific amino acid within, or signals the
termination of, a polypeptide.
Common variants: variants (as defined elsewhere) that are
associated with compromised gene function and are interrogated
in a single round of laboratory testing (in a single, typically
multiplex, assay format or using more than one assay to
encompass all variants to be tested). These variants typically fit
the definition of a “mutation,” and are usually the predominant
ones causing disease. Testing for additional uncommon variants
may provide additional limited value in assessment of a patient.
Often there are professional society recommendations or
guidelines for which variants are most appropriate to test (eg,
American College of Medical Genetics/American College of
Obstetrics and Gynecology guidelines for variants used in
population screening for cystic fibrosis).
Constitutional: synonymous with germline, often used in
reference to the genetic code that is present at birth.
Copy number variants (CNVs): structural changes in the genome
composed of large deletions or duplications. CNVs can be found
in the germline, but can also occur in somatic cells. See also
Duplication/Deletion (Dup/Del).
Cytogenomic: chromosome analysis using molecular techniques.
DNA methylation: the process of adding methyl groups to a
DNA sequence, specifically adenine and cytosine nucleotides,
thereby affecting transcription of that sequence. DNA hyper-
methylation in a gene promoter typically represses gene
transcription. DNA methylation serves as a regulatory mechanism
in numerous scenarios including development, chromosome
inactivation, and carcinogenesis.
DNA methylation analysis: analytical protocols are designed to
evaluate the degree of DNA methylation related to specific
disease processes. This analysis has various applications,
qualitative or quantitative, and could be gene specific or
encompass global degrees of methylation. All assays employ
specific maneuvers (eg, chemical, enzymatic) that allow for
distinguishable evaluation of methylated and non-methylated
sequences.
Duplication/Deletion (Dup/Del): terms that are usually used
together with the “/” to refer to molecular testing, which assesses
the dosage of a particular genomic region. The region tested is
typically of modest to substantial size—from several dozen to
several million or more nucleotides. Normal gene dosage is two
copies per cell, except for the sex chromosomes (X and Y). Thus,
zero or one copy represents a deletion, and three (or more)
copies represent a duplication.
Dynamic mutation: polynucleotide (eg, trinucleotide) repeats that
are in or associated with genes that can undergo disease-
producing increases or decreases in the numbers of repeats
within tissues and across generations.
Exome: DNA sequences within the human genome that code for
proteins (coding regions).
Exon: typically, one of multiple nucleic acid sequences used to
encode information for a gene product (polypeptide or protein).
Exons are separated from each other by non-protein-coding
sequences known as introns. Exons at the respective ends of a
gene also contain nucleic acid sequence that does not code for the
gene’s protein product.
Gene: a nucleic acid sequence that typically contains information
for coding a protein as well as for the regulated expression of that
protein. Human genes usually contain multiple protein coding
regions (exons) separated by non-protein coding regions
(introns). See also exon, intron, and polypeptide.
Gene expression: the sequence of events that results in the
production and assembly of a protein product corresponding to
the information encoded in a specific gene. The process begins
with the transcription of gene sequences to produce an mRNA
intermediary, which is subsequently translated to produce a
specific protein product.
Genome: the total (nuclear) human genetic content.
Heteroplasmy: the copy number of a variant within a cell; it is
expressed as a percent. It reflects the varied distribution and
dosage of mutant mitochondria in tissues and organs (mitotic
segregation).
Intron: a nucleic acid sequence found between exons in human
genes. An intron contains essential sequences for its proper
removal (by a process known as splicing) to join exons together
and thus facilitate production of a functional protein from a gene.
An intron is sometimes referred to as an intervening sequence
(IVS).
Inversion: a defect in a chromosome in which a segment breaks
and reinserts in the same place but in the opposite orientation.
Loss of heterozygosity (LOH, allelic imbalance): an event that
can occur in dividing cells that are heterozygous for one or more
alleles, in which a daughter cell becomes hemizygous or
homozygous for the allele(s) through mitotic recombination,
deletion, or other chromosomal event.
Microarray: surface(s) on which multiple specific nucleic acid
sequences are attached in a known arrangement. Sometimes
referred to as a “gene chip.” Examples of uses of microarrays
include evaluation of a patient specimen for gains or losses of
DNA sequences (copy number variants, CNVs), identification of
the presence of specific nucleotide sequence variants (also
known as single nucleotide polymorphisms, SNPs), mRNA
expression levels, or DNA sequence analysis.
Mitochondrial DNA (mtDNA): DNA located in the
mitochondria, which are cytoplasmic organelles involved with
energy production. MtDNA contains 37 genes coding for
oxidative phosphorylation enzymes, transfer RNAs (tRNAs) and
ribosomal RNAs (rRNAs).
Mutations: typically are variants associated with altered gene
function that lead to functional deficits or disease (pathogenic).
Mutation scanning: a technique (eg, single strand conformation
polymorphism, temperature gradient gel electrophoresis, etc.)
typically employed on multiple PCR amplicons to indicate the
presence of DNA sequence variants by differences in physical
properties compared to normal. Variants are then further
characterized by DNA sequence analysis only in amplicons which
demonstrate differences.
Nuclear DNA: DNA located in the nucleus of a cell, generally
packaged in chromosomes.
Polymorphisms: typically are variants that do not compromise
gene function or produce disease (benign).
Polypeptide: a sequence of amino acids covalently linked in a
specified order. Polypeptides alone or in combination with other
polypeptide subunits are the building blocks of proteins.
Promoter: a region of DNA associated with a gene (on the same
strand) which regulates gene expression. Promoter regions can
affect gene transcription through the binding of specific
transcription factors.
Short tandem repeat (STR): a region of DNA where a pattern of
two or more nucleotides are repeated. The number of repeating
segments can be used as genetic markers for human identity
testing.
Single-nucleotide polymorphism (SNP): a DNA sequence
variation existing at a significant frequency in the population, in
which a single nucleotide (A, T, C, or G) differs between
individuals and/or within an individual’s paired chromosomes.
Somatic: synonymous with acquired, referring to genetic code
alterations that develop after birth (eg, occurring in neoplastic
cells).
Translocation: an abnormality resulting from the breakage of a
chromosome and the relocation of a portion of that
chromosome’s DNA sequence to the same or another
chromosome. Most common translocations involve a reciprocal
exchange of DNA sequences between two differently numbered
(ie, non-homologous) chromosomes, with or without a clinically
significant loss of DNA.
Uniparental disomy (UPD): abnormal inheritance of both
members of a chromosome pair from one parent, with absence of
the other parent’s chromosome for the pair.
Variant: a nucleotide sequence difference from the “normal”
(predominant) sequence for a given region. Variants are typically
of two types: substitutions of one nucleotide for another, and
deletions or insertions of nucleotides. Occasionally, variants
reflect several nucleotide sequence changes in reasonably close
proximity on the same chromosomal strand of DNA (a
haplotype). These nucleotide sequence variants often result in
amino acid changes in the protein made by the gene. The term
variant does not itself carry a functional implication for those
protein changes.
Variants in introns are typically described in one of two ways.
The altered nucleotide(s) within a defined intervening sequence
(eg, IVS3-2A>G) of a gene is listed with a “+” or “-” sign, which
indicates the position relative to the first or last nucleotide of the
intron. Or, the variant position is indicated relative to the last
nucleotide of the preceding exon or first nucleotide of the
following exon (eg, c.171+1G>A c.172-1G>T are single
nucleotide changes at the first and last nucleotide of a given
intron for a specific gene).
The majority of the variants described here are listed by the
amino acid change using the single letter amino acid code for the
original amino acid followed by the numerical position in the
protein product and the amino acid substitution, eg, for ASPA
E285A, Glutamic acid (E) at position 285 is replaced with an
alanine (A). A few of the variants are described by the DNA
change using the numerical position followed by the original
nucleotide, a greater than sign (>) and the new nucleotide, eg,
MTHFR. 677C>T.
A known familial variant is a specific mutation that has
previously been identified within a patient’s family.
Tier 1 Molecular Pathology Procedures

The following codes represent gene-specific and genomic
procedures:
81170 ABL1 (ABL proto-oncogene 1, non-receptor tyrosine
kinase) (eg, acquired imatinib tyrosine kinase inhibitor
resistance), gene analysis, variants in the kinase domain
81171 AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile

X mental retardation 2 [FRAXE]) gene analysis; evaluation
to detect abnormal (eg, expanded) alleles
81172 characterization of alleles (eg, expanded size and

methylation status)

# 81201 APC (adenomatous polyposis coli) (eg, familial
adenomatosis polyposis [FAP], attenuated FAP) gene
analysis; full gene sequence
➲ CPT Assistant May 12:4, Sep 13:3, Aug 16:10, Nov
18:9
# 81202 known familial variants
18:9
# 81203 duplication/deletion variants
18:9
# 81204 AR (androgen receptor) (eg, spinal and bulbar muscular
atrophy, Kennedy disease, X chromosome inactivation) gene
analysis; characterization of alleles (eg, expanded size or
methylation status)
# 81173 full gene sequence

# 81174 known familial variant

# 81200 ASPA (aspartoacylase) (eg, Canavan disease) gene analysis,

common variants (eg, E285A, Y231X)
➲ CPT Assistant May 12:4, Aug 16:10, Nov 18:9
81175 ASXL1 (additional sex combs like 1, transcriptional

regulator) (eg, myelodysplastic syndrome,
myeloproliferative neoplasms, chronic myelomonocytic
leukemia), gene analysis; full gene sequence
81176 targeted sequence analysis (eg, exon 12)

81177 ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian

atrophy) gene analysis, evaluation to detect abnormal (eg,
expanded) alleles
81178 ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis,

evaluation to detect abnormal (eg, expanded) alleles

81180 ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-
Joseph disease) gene analysis, evaluation to detect abnormal
(eg, expanded) alleles

81182 ATXN8OS (ATXN8 opposite strand [non-protein coding])

(eg, spinocerebellar ataxia) gene analysis, evaluation to
detect abnormal (eg, expanded) alleles
81183 ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene

analysis, evaluation to detect abnormal (eg, expanded)
alleles

# 81205 BCKDHB (branched-chain keto acid dehydrogenase E1,
beta polypeptide) (eg, maple syrup urine disease) gene
analysis, common variants (eg, R183P, G278S, E422X)
# 81206 BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia)

translocation analysis; major breakpoint, qualitative or
quantitative
# 81207 minor breakpoint, qualitative or quantitative

# 81208 other breakpoint, qualitative or quantitative

# 81209 BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom
syndrome) gene analysis, 2281del6ins7 variant
# 81210 BRAF (B-Raf proto-oncogene, serine/threonine kinase)

(eg, colon cancer, melanoma), gene analysis, V600
variant(s)
# 81162 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2,

DNA repair associated) (eg, hereditary breast and ovarian
cancer) gene analysis; full sequence analysis and full
duplication/deletion analysis (ie, detection of large gene
rearrangements)

81165, 81166, 81167, 81215, 81216, 81217, 81432)
# 81163 full sequence analysis
# 81164 full duplication/deletion analysis (ie, detection of large

gene rearrangements)
(To report BRCA1, BRCA2 full sequence analysis and full

duplication/deletion analysis on the same date of service,
use 81162)
(For analysis of common duplication/deletion variant(s) in
BRCA1 [ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-
20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb], use
81479)
81165, 81216, 81432)
81166, 81167, 81217)
81212 185delAG, 5385insC, 6174delT variants
➲ CPT Assistant May 12:4, Aug 16:10, Nov 18:9, May
19:5
(81211, 81213 have been deleted. To report see 81162,
81163, 81164)
# 81165 BRCA1 (BRCA1, DNA repair associated) (eg, hereditary
breast and ovarian cancer) gene analysis; full sequence
analysis

81215 known familial variant

19:5
(For analysis of common duplication/deletion variant(s) in
BRCA1 [ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-
20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb], use
81479)
81432)
81216 BRCA2 (BRCA2, DNA repair associated) (eg, hereditary
breast and ovarian cancer) gene analysis; full sequence
analysis
19:5

19:5
81432)
81217)
81167)
# 81233 BTK (Bruton’s tyrosine kinase) (eg, chronic lymphocytic
leukemia) gene analysis, common variants (eg, C481S,
C481R, C481F)
# 81184 CACNA1A (calcium voltage-gated channel subunit alpha1

A) (eg, spinocerebellar ataxia) gene analysis; evaluation to
detect abnormal (eg, expanded) alleles

# 81219 CALR (calreticulin) (eg, myeloproliferative disorders),

gene analysis, common variants in exon 9
#● 81168 CCND1/IGH (t(11;14)) (eg, mantle cell lymphoma)

translocation analysis, major breakpoint, qualitative and
quantitative, if performed
81218 CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha)

(eg, acute myeloid leukemia), gene analysis, full gene
sequence

81220 CFTR (cystic fibrosis transmembrane conductance
regulator) (eg, cystic fibrosis) gene analysis; common
variants (eg, ACMG/ACOG guidelines)
(When Intron 8 poly-T analysis is performed in conjunction

with 81220 in a R117H positive patient, do not report
81224)
81221 known familial variants
81222 duplication/deletion variants
81223 full gene sequence

81224 intron 8 poly-T analysis (eg, male infertility)

# 81267 Chimerism (engraftment) analysis, post transplantation

specimen (eg, hematopoietic stem cell), includes
comparison to previously performed baseline analyses;
without cell selection
# 81268 with cell selection (eg, CD3, CD33), each cell type
(If comparative STR analysis of recipient [using buccal

swab or other germline tissue sample] and donor are
performed after hematopoietic stem cell transplantation,
report 81265, 81266 in conjunction with 81267, 81268 for
chimerism testing)
# 81187 CNBP (CCHC-type zinc finger nucleic acid binding
protein) (eg, myotonic dystrophy type 2) gene analysis,
# 81265 Comparative analysis using Short Tandem Repeat (STR)

markers; patient and comparative specimen (eg, pre-
transplant recipient and donor germline testing, post-
transplant non-hematopoietic recipient germline [eg, buccal
swab or other germline tissue sample] and donor testing,
twin zygosity testing, or maternal cell contamination of fetal
cells)
#✚ 81266 each additional specimen (eg, additional cord blood

donor, additional fetal samples from different cultures, or
additional zygosity in multiple birth pregnancies) (List

# 81188 CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene
analysis; evaluation to detect abnormal (eg, expanded)
alleles

# 81190 known familial variant(s)

# 81227 CYP2C9 (cytochrome P450, family 2, subfamily C,

polypeptide 9) (eg, drug metabolism), gene analysis,
common variants (eg, *2, *3, *5, *6)
81225 CYP2C19 (cytochrome P450, family 2, subfamily C,

common variants (eg, *2, *3, *4, *8, *17)
81226 CYP2D6 (cytochrome P450, family 2, subfamily D,

common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19,
*29, *35, *41, *1XN, *2XN, *4XN)

# 81230 CYP3A4 (cytochrome P450 family 3 subfamily A member
4) (eg, drug metabolism), gene analysis, common variant(s)
(eg, *2, *22)
# 81231 CYP3A5 (cytochrome P450 family 3 subfamily A member

5) (eg, drug metabolism), gene analysis, common variants
(eg, *2, *3, *4, *5, *6, *7)
81228 Cytogenomic constitutional (genome-wide) microarray

analysis; interrogation of genomic regions for copy number
variants (eg, bacterial artificial chromosome [BAC] or
oligo-based comparative genomic hybridization [CGH]
microarray analysis)
➲ CPT Assistant May 12:4, Sep 13:4, 6, Aug 16:10, Nov
18:9
81229 interrogation of genomic regions for copy number and
single nucleotide polymorphism (SNP) variants for
chromosomal abnormalities
18:9
(When performing cytogenomic constitutional microarray
analysis that is not genome-wide [ie, regionally targeted],
report the specific code for the targeted analysis if available
[eg, 81405] or the unlisted molecular pathology code
[81479])
(Do not report analyte-specific molecular pathology
procedures separately in conjunction with 81228, 81229
when the specific analytes are included as part of the
(Do not report 88271 when performing cytogenomic
(For genomic sequencing procedures or other molecular
multianalyte assays for copy number analysis using
circulating cell-free fetal DNA in maternal blood, see
81420, 81422, 81479)
# 81277 Cytogenomic neoplasia (genome-wide) microarray analysis,
interrogation of genomic regions for copy number and loss-
of-heterozygosity variants for chromosomal abnormalities

procedures separately when the specific analytes are
included as part of the cytogenomic microarray analysis for
neoplasia)
# 81161 DMD (dystrophin) (eg, Duchenne/Becker muscular
dystrophy) deletion analysis, and duplication analysis, if
performed
# 81234 DMPK (DM1 protein kinase) (eg, myotonic dystrophy type
1) gene analysis; evaluation to detect abnormal (expanded)
alleles
# 81239 characterization of alleles (eg, expanded size)

81232 DPYD (dihydropyrimidine dehydrogenase) (eg, 5-

fluorouracil/5-FU and capecitabine drug metabolism), gene
analysis, common variant(s) (eg, *2A, *4, *5, *6)

81235 EGFR (epidermal growth factor receptor) (eg, non-small
cell lung cancer) gene analysis, common variants (eg, exon
19 LREA deletion, L858R, T790M, G719A, G719S,
L861Q)
➲ CPT Assistant Sep 13:3, Aug 16:10, Nov 18:9
81236 EZH2 (enhancer of zeste 2 polycomb repressive complex 2

subunit) (eg, myelodysplastic syndrome, myeloproliferative
neoplasms) gene analysis, full gene sequence
81237 EZH2 (enhancer of zeste 2 polycomb repressive complex 2

subunit) (eg, diffuse large B-cell lymphoma) gene analysis,
common variant(s) (eg, codon 646)
81240 F2 (prothrombin, coagulation factor II) (eg, hereditary
hypercoagulability) gene analysis, 20210G>A variant
81241 F5 (coagulation factor V) (eg, hereditary

hypercoagulability) gene analysis, Leiden variant
# 81238 F9 (coagulation factor IX) (eg, hemophilia B), full gene

sequence
81242 FANCC (Fanconi anemia, complementation group C) (eg,

Fanconi anemia, type C) gene analysis, common variant (eg,
IVS4+4A>T)
# 81245 FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid

leukemia), gene analysis; internal tandem duplication (ITD)
variants (ie, exons 14, 15)
➲ CPT Assistant May 12:4, Jan 15:3, Aug 16:10, Nov 18:9
# 81246 tyrosine kinase domain (TKD) variants (eg, D835, I836)

➲ CPT Assistant Jan 15:3, Aug 16:10, Nov 18:9
81243 FMR1 (fragile X mental retardation 1) (eg, fragile X

mental retardation) gene analysis; evaluation to detect
abnormal (eg, expanded) alleles
(For evaluation to detect and characterize abnormal alleles,

see 81243, 81244)
(For evaluation to detect and characterize abnormal alleles
using a single assay [eg, PCR], use 81243)
81244 characterization of alleles (eg, expanded size and
promoter methylation status)
➲ CPT Assistant May 12:4, Aug 16:10, Nov 18:9, Jul
19:3
# 81284 FXN (frataxin) (eg, Friedreich ataxia) gene analysis;
evaluation to detect abnormal (expanded) alleles



# 81250 G6PC (glucose-6-phosphatase, catalytic subunit) (eg,

Glycogen storage disease, type 1a, von Gierke disease) gene
analysis, common variants (eg, R83C, Q347X)
81247 G6PD (glucose-6-phosphate dehydrogenase) (eg,
hemolytic anemia, jaundice), gene analysis; common
variant(s) (eg, A, A-)
81248 known familial variant(s)

81249 full gene sequence


81251 GBA (glucosidase, beta, acid) (eg, Gaucher disease) gene
analysis, common variants (eg, N370S, 84GG, L444P,
IVS2+1G>A)
81252 GJB2 (gap junction protein, beta 2, 26kDa, connexin 26)

(eg, nonsyndromic hearing loss) gene analysis; full gene
sequence

81254 GJB6 (gap junction protein, beta 6, 30kDa, connexin 30)

(eg, nonsyndromic hearing loss) gene analysis, common
variants (eg, 309kb [del(GJB6-D13S1830)] and 232kb
[del(GJB6-D13S1854)])
# 81257 HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha
thalassemia, Hb Bart hydrops fetalis syndrome, HbH
disease), gene analysis; common deletions or variant (eg,
Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7,
alpha4.2, alpha20.5, Constant Spring)



# 81361 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia,

beta thalassemia, hemoglobinopathy); common variant(s)
(eg, HbS, HbC, HbE)

# 81363 duplication/deletion variant(s)


81255 HEXA (hexosaminidase A [alpha polypeptide]) (eg, Tay-
Sachs disease) gene analysis, common variants (eg,
1278insTATC, 1421+1G>C, G269S)
81256 HFE (hemochromatosis) (eg, hereditary hemochromatosis)

gene analysis, common variants (eg, C282Y, H63D)

# 81271 HTT (huntingtin) (eg, Huntington disease) gene analysis;

# 81105 Human Platelet Antigen 1 genotyping (HPA-1), ITGB3

(integrin, beta 3 [platelet glycoprotein IIIa], antigen
CD61 [GPIIIa]) (eg, neonatal alloimmune
thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant, HPA-1a/b (L33P)
# 81106 Human Platelet Antigen 2 genotyping (HPA-2), GP1BA

(glycoprotein Ib [platelet], alpha polypeptide [GPIba])
(eg, neonatal alloimmune thrombocytopenia [NAIT], post-
transfusion purpura), gene analysis, common variant, HPA-
2a/b (T145M)
# 81107 Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B
(integrin, alpha 2b [platelet glycoprotein IIb of IIb/IIIa
complex], antigen CD41 [GPIIb]) (eg, neonatal
alloimmune thrombocytopenia [NAIT], post-transfusion
purpura), gene analysis, common variant, HPA-3a/b (I843S)
# 81108 Human Platelet Antigen 4 genotyping (HPA-4), ITGB3

(integrin, beta 3 [platelet glycoprotein IIIa], antigen
CD61 [GPIIIa]) (eg, neonatal alloimmune
analysis, common variant, HPA-4a/b (R143Q)
# 81109 Human Platelet Antigen 5 genotyping (HPA-5), ITGA2

(integrin, alpha 2 [CD49B, alpha 2 subunit of VLA-2
receptor] [GPIa]) (eg, neonatal alloimmune
analysis, common variant (eg, HPA-5a/b [K505E])
# 81110 Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3

(integrin, beta 3 [platelet glycoprotein IIIa, antigen
CD61] [GPIIIa]) (eg, neonatal alloimmune
analysis, common variant, HPA-6a/b (R489Q)
# 81111 Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B

(integrin, alpha 2b [platelet glycoprotein IIb of IIb/IIIa
complex, antigen CD41] [GPIIb]) (eg, neonatal
alloimmune thrombocytopenia [NAIT], post-transfusion
purpura), gene analysis, common variant, HPA-9a/b
(V837M)
# 81112 Human Platelet Antigen 15 genotyping (HPA-15), CD109
(CD109 molecule) (eg, neonatal alloimmune
analysis, common variant, HPA-15a/b (S682Y)
# 81120 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg,

glioma), common variants (eg, R132H, R132C)
# 81121 IDH2 (isocitrate dehydrogenase 2 [NADP+],

mitochondrial) (eg, glioma), common variants (eg, R140W,
R172M)
# 81283 IFNL3 (interferon, lambda 3) (eg, drug response), gene

analysis, rs12979860 variant
# 81261 IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias

and lymphomas, B-cell), gene rearrangement analysis to
detect abnormal clonal population(s); amplified
methodology (eg, polymerase chain reaction)
18:9
# 81262 direct probe methodology (eg, Southern blot)
# 81263 IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia

and lymphoma, B-cell), variable region somatic mutation
analysis
#● 81278 IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma)
translocation analysis, major breakpoint region (MBR) and
minor cluster region (mcr) breakpoints, qualitative or
quantitative
# 81264 IGK@ (Immunoglobulin kappa light chain locus) (eg,

leukemia and lymphoma, B-cell), gene rearrangement
analysis, evaluation to detect abnormal clonal population(s)
(For immunoglobulin lambda gene [IGL@] rearrangement

or immunoglobulin kappa deleting element, [IGKDEL]
analysis, use 81479)
81260 IKBKAP (inhibitor of kappa light polypeptide gene
enhancer in B-cells, kinase complex-associated protein)
(eg, familial dysautonomia) gene analysis, common variants
(eg, 2507+6T>C, R696P)

81270 JAK2 (Janus kinase 2) (eg, myeloproliferative disorder)
gene analysis, p.Val617Phe (V617F) variant
#● 81279 JAK2 (Janus kinase 2) (eg, myeloproliferative disorder)
targeted sequence analysis (eg, exons 12 and 13)

81272 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral
oncogene homolog) (eg, gastrointestinal stromal tumor
[GIST], acute myeloid leukemia, melanoma), gene analysis,
targeted sequence analysis (eg, exons 8, 11, 13, 17, 18)
81273 KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral

oncogene homolog) (eg, mastocytosis), gene analysis, D816
variant(s)

81275 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg,
carcinoma) gene analysis; variants in exon 2 (eg, codons 12
and 13)
18:9
81276 additional variant(s) (eg, codon 61, codon 146)

81290 MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type IV) gene
analysis, common variants (eg, IVS3-2A>G, del6.4kb)
# 81302 MECP2 (methyl CpG binding protein 2) (eg, Rett

syndrome) gene analysis; full sequence analysis


# 81287 MGMT (O-6-methylguanine-DNA methyltransferase) (eg,

glioblastoma multiforme) promoter methylation analysis
➲ CPT Assistant Aug 16:10, Nov 18:9, Dec 18:10, Jul
19:3
# 81301 Microsatellite instability analysis (eg, hereditary non-
polyposis colorectal cancer, Lynch syndrome) of markers
for mismatch repair deficiency (eg, BAT25, BAT26),
includes comparison of neoplastic and normal tissue, if
performed
# 81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type
2) (eg, hereditary non-polyposis colorectal cancer, Lynch
➲ CPT Assistant May 12:4, Jan 15:3, Aug 16:10, Nov 18:9
# 81288 promoter methylation analysis

➲ CPT Assistant Jan 15:3, Aug 16:10, Nov 18:9
# 81293 known familial variants


#● 81338 MPL (MPL proto-oncogene, thrombopoietin receptor) (eg,

myeloproliferative disorder) gene analysis; common
variants (eg, W515A, W515K, W515L, W515R)
#● 81339 sequence analysis, exon 10

# 81295 MSH2 (mutS homolog 2, colon cancer, nonpolyposis type

1) (eg, hereditary non-polyposis colorectal cancer, Lynch


81298 MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-

polyposis colorectal cancer, Lynch syndrome) gene analysis;
full sequence analysis



# 81291 MTHFR (5,10-methylenetetrahydrofolate reductase) (eg,
hereditary hypercoagulability) gene analysis, common
variants (eg, 677T, 1298C)
81305 MYD88 (myeloid differentiation primary response 88) (eg,

Waldenstrom’s macroglobulinemia, lymphoplasmacytic
leukemia) gene analysis, p.Leu265Pro (L265P) variant

81310 NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene
analysis, exon 12 variants
81311 NRAS (neuroblastoma RAS viral [v-ras] oncogene

homolog) (eg, colorectal carcinoma), gene analysis,
variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg,
codon 61)

#● 81191 NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid
tumors) translocation analysis


#● 81194 NTRK (neurotrophic-tropomyosin receptor tyrosine kinase

1, 2, and 3) (eg, solid tumors) translocation analysis
▶ (For translocation analysis NTRK1, NTRK2, and NTRK3
using a single assay, use 81194)◀
# 81306 NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene
analysis, common variant(s) (eg, *2, *3, *4, *5, *6)
# 81312 PABPN1 (poly[A] binding protein nuclear 1) (eg,

oculopharyngeal muscular dystrophy) gene analysis,
# 81307 PALB2 (partner and localizer of BRCA2) (eg, breast and

pancreatic cancer) gene analysis; full gene sequence

81313 PCA3/KLK3 (prostate cancer antigen 3 [non-protein

coding]/kallikrein-related peptidase 3 [prostate specific
antigen]) ratio (eg, prostate cancer)
➲ CPT Assistant Jan 15:3, Aug 16:10
81314 PDGFRA (platelet-derived growth factor receptor, alpha

polypeptide) (eg, gastrointestinal stromal tumor [GIST]),
gene analysis, targeted sequence analysis (eg, exons 12, 18)
# 81309 PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase,

catalytic subunit alpha) (eg, colorectal and breast cancer)
gene analysis, targeted sequence analysis (eg, exons 7, 9,
20)
# 81320 PLCG2 (phospholipase C gamma 2) (eg, chronic
lymphocytic leukemia) gene analysis, common variants (eg,
R665W, S707F, L845F)
81315 PML/RARalpha, (t(15;17)), (promyelocytic

leukemia/retinoic acid receptor alpha) (eg, promyelocytic
leukemia) translocation analysis; common breakpoints (eg,
intron 3 and intron 6), qualitative or quantitative
➲ CPT Assistant May 12:4, Aug 16:10
81316 single breakpoint (eg, intron 3, intron 6 or exon 6),

qualitative or quantitative
(For intron 3 and intron 6 [including exon 6 if performed]

(If both intron 6 and exon 6 are analyzed, without intron 3,
use one unit of 81316)
# 81324 PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-
Tooth, hereditary neuropathy with liability to pressure
palsies) gene analysis; duplication/deletion analysis
# 81325 full sequence analysis

➲ CPT Assistant Sep 13:3, Aug 16:10, May 18:6, Nov
18:9
81317 PMS2 (postmeiotic segregation increased 2 [S.
cerevisiae]) (eg, hereditary non-polyposis colorectal
cancer, Lynch syndrome) gene analysis; full sequence
analysis



# 81343 PPP2R2B (protein phosphatase 2 regulatory subunit
Bbeta) (eg, spinocerebellar ataxia) gene analysis,
81321 PTEN (phosphatase and tensin homolog) (eg, Cowden

syndrome, PTEN hamartoma tumor syndrome) gene analysis;
full sequence analysis

81323 duplication/deletion variant

# 81334 RUNX1 (runt related transcription factor 1) (eg, acute
myeloid leukemia, familial platelet disorder with associated
myeloid malignancy) gene analysis, targeted sequence
analysis (eg, exons 3-8)
81327 SEPT9 (Septin9) (eg, colorectal cancer) promoter

methylation analysis
# 81332 SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1

antiproteinase, antitrypsin, member 1) (eg, alpha-1-
antitrypsin deficiency), gene analysis, common variants (eg,
*S and *Z)
#● 81347 SF3B1 (splicing factor [3b] subunit B1) (eg,

myelodysplastic syndrome/acute myeloid leukemia) gene
analysis, common variants (eg, A672T, E622D, L833F,
R625C, R625L)
81328 SLCO1B1 (solute carrier organic anion transporter

family, member 1B1) (eg, adverse drug reaction), gene
analysis, common variant(s) (eg, *5)
81329 SMN1 (survival of motor neuron 1, telomeric) (eg, spinal

muscular atrophy) gene analysis; dosage/deletion analysis
(eg, carrier testing), includes SMN2 (survival of motor
neuron 2, centromeric) analysis, if performed

# 81337 known familial sequence variant(s)

81330 SMPD1(sphingomyelin phosphodiesterase 1, acid

lysosomal) (eg, Niemann-Pick disease, Type A) gene
analysis, common variants (eg, R496L, L302P, fsP330)
81331 SNRPN/UBE3A (small nuclear ribonucleoprotein

polypeptide N and ubiquitin protein ligase E3A) (eg,
Prader-Willi syndrome and/or Angelman syndrome),

#● 81348 SRSF2 (serine and arginine-rich splicing factor 2) (eg,
myelodysplastic syndrome, acute myeloid leukemia) gene
analysis, common variants (eg, P95H, P95L)
# 81344 TBP (TATA box binding protein) (eg, spinocerebellar

ataxia) gene analysis, evaluation to detect abnormal (eg,
expanded) alleles
# 81345 TERT (telomerase reverse transcriptase) (eg, thyroid
carcinoma, glioblastoma multiforme) gene analysis, targeted
sequence analysis (eg, promoter region)
81333 TGFBI (transforming growth factor beta-induced) (eg,

corneal dystrophy) gene analysis, common variants (eg,
R124H, R124C, R124L, R555W, R555Q)

#● 81351 TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene
analysis; full gene sequence
#● 81352 targeted sequence analysis (eg, 4 oncology)

#● 81353 known familial variant

81335 TPMT (thiopurine S-methyltransferase) (eg, drug

metabolism), gene analysis, common variants (eg, *2, *3)

81340 TRB@ (T cell antigen receptor, beta) (eg, leukemia and
lymphoma), gene rearrangement analysis to detect abnormal
clonal population(s); using amplification methodology (eg,
polymerase chain reaction)
81341 using direct probe methodology (eg, Southern blot)

81342 TRG@ (T cell antigen receptor, gamma) (eg, leukemia and

lymphoma), gene rearrangement analysis, evaluation to
detect abnormal clonal population(s)
(For T cell antigen alpha [TRA@] gene rearrangement

(For T cell antigen delta [TRD@] gene rearrangement
81346 TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU
drug metabolism), gene analysis, common variant(s) (eg,
tandem repeat variant)

#● 81357 U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg,
myelodysplastic syndrome, acute myeloid leukemia) gene
analysis, common variants (eg, S34F, S34Y, Q157R,
Q157P)
81350 UGT1A1 (UDP glucuronosyltransferase 1 family,
polypeptide A1) (eg, drug metabolism, hereditary
unconjugated hyperbilirubinemia [Gilbert syndrome]) gene
analysis, common variants (eg, *28, *36, *37)
➲ CPT Assistant May 12:4, Aug 16:10, Nov 18:9, Apr
20:9
81355 VKORC1 (vitamin K epoxide reductase complex, subunit
1) (eg, warfarin metabolism), gene analysis, common
variant(s) (eg, -1639G>A, c.173+1000C>T)

● 81360 ZRSR2 (zinc finger CCCH-type, RNA binding motif and
serine/arginine-rich 2) (eg, myelodysplastic syndrome,
acute myeloid leukemia) gene analysis, common variant(s)
(eg, E65fs, E122fs, R448fs)

Human leukocyte antigen (HLA) typing is performed to assess
compatibility of recipients and potential donors as a part of solid
organ and hematopoietic stem cell pretransplant testing. HLA
testing is also performed to identify HLA alleles and allele groups
(antigen equivalents) associated with specific diseases and
individualized responses to drug therapy (eg, HLA-B*27 and
ankylosing spondylitis and HLA-B*57:01 and abacavir
hypersensitivity), as well as other clinical uses. One or more HLA
genes may be tested in specific clinical situations (eg, HLA-DQB1
for narcolepsy and HLA-A, -B, -C, -DRB1, and -DQB1 for
kidney transplantation). Each HLA gene typically has multiple
variant alleles or allele groups that can be identified by typing.
For HLA result reporting, a low resolution HLA type is denoted
by a two digit HLA name (eg, A*02) and intermediate resolution
typing by a string of alleles or an NMDP (National Marrow
Donor Program) code (eg, B*14:01/07N/08/12/14, B*39CKGN).
Both low and intermediate resolutions are considered low
resolution for code assignment. High resolution typing resolves
the common well defined (CWD) alleles and is usually denoted
by at least 4 digits (eg, A*02:02, *03:01:01:01, A*26:01:01G, and
C*03:04P), however, high resolution typing may include some
ambiguities for rare alleles, which may be reported as a string of
alleles or an NMDP code.
If additional testing is required to resolve ambiguous allele
combinations for high resolution typing, this is included in the
base HLA typing codes below. The gene names have been
italicized similar to the other molecular pathology codes.
(For HLA antigen typing by non-molecular pathology
techniques, see 86812, 86813, 86816, 86817, 86821)
81370 HLA Class I and II typing, low resolution (eg, antigen
equivalents); HLA-A, -B, -C, -DRB1/3/4/5, and -DQB1
81371 HLA-A, -B, and -DRB1 (eg, verification typing)

(When HLA typing includes a determination of the presence
or absence of the DRB3/4/5 genes, that service is included
in the typing and is not separately reported)
81372 HLA Class I typing, low resolution (eg, antigen
equivalents); complete (ie, HLA-A, -B, and -C)
(When performing both Class I and II low resolution HLA

typing for HLA-A,-B,-C, -DRB1/3/4/5, and -DQB1, use
81370)
81373 one locus (eg, HLA-A, -B, or -C), each
➲ CPT Assistant May 12:4, Jun 12:16, Aug 16:10, Nov
18:9
(When performing a complete Class I [HLA-A,-B, and -C]
low resolution HLA typing, use 81372)
(When the presence or absence of a single antigen
equivalent is reported using low resolution testing, use
81374)
81374 one antigen equivalent (eg, B*27), each
18:9
(When testing for presence or absence of more than 2
antigen equivalents at a locus, use 81373 for each locus
tested)
81375 HLA Class II typing, low resolution (eg, antigen
equivalents); HLA-DRB1/3/4/5 and -DQB1
(When performing both Class I and II low resolution HLA
typing for HLA-A,-B,-C, -DRB1/3/4/5, and –DQB1, use
81370)
81376 one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1,
-DPB1, or -DPA1), each
18:9
(When low resolution typing is performed for HLA-
DRB1/3/4/5 and -DQB1, use 81375)
(When HLA typing includes a determination of the presence
or absence of the DRB3/4/5 genes, that service is included
in the typing and is not separately reported. When low or
intermediate resolution typing of any or all of the DRB3/4/5
genes is performed, treat as one locus)
81377 one antigen equivalent, each
18:9
(When testing for presence or absence of more than 2
antigen equivalents at a locus, use 81376 for each locus)
81378 HLA Class I and II typing, high resolution (ie, alleles or
allele groups), HLA-A, -B, -C, and -DRB1
18:9
81379 HLA Class I typing, high resolution (ie, alleles or allele
groups); complete (ie, HLA-A, -B, and -C)
81380 one locus (eg, HLA-A, -B, or -C), each
18:9
(When a complete Class I high resolution typing for HLA-A,-
B, and -C is performed, use 81379)
(When the presence or absence of a single allele or allele
group is reported using high resolution testing, use 81381)
81381 one allele or allele group (eg, B*57:01P), each
18:9
(When testing for the presence or absence of more than 2
alleles or allele groups at a locus, use 81380 for each locus)
81382 HLA Class II typing, high resolution (ie, alleles or allele
groups); one locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -
DQA1, -DPB1, or -DPA1), each
➲ CPT Assistant May 12:4, Jun 12:16, Nov 18:9
(When only the presence or absence of a single allele or

allele group is reported using high resolution testing, use
81383)
(When high resolution typing of any or all of the DRB3/4/5
genes is performed, treat as one locus)
81383 one allele or allele group (eg, HLA-DQB1*06:02P),
each
➲ CPT Assistant May 12:4, Jun 12:16, Nov 18:9
(When testing for the presence or absence of more than 2

alleles or allele groups at a locus, use 81382 for each locus)
Tier 2 Molecular Pathology Procedures
The following molecular pathology procedure (Tier 2) codes are
used to report procedures not listed in the Tier 1 molecular
pathology codes (81161, 81200-81383). They represent medically
useful procedures that are generally performed in lower volumes
than Tier 1 procedures (eg, the incidence of the disease being
tested is rare). They are arranged by level of technical resources
and interpretive work by the physician or other qualified health
care professional. The individual analyses listed under each code
(ie, level of procedure) utilize the definitions and coding
principles as described in the introduction preceding the Tier 1
molecular pathology codes. The parenthetical examples of
methodologies presented near the beginning of each code
provide general guidelines used to group procedures for a given
level and are not all-inclusive.
▶Use the appropriate molecular pathology procedure level code
that includes the specific analyte listed after the code descriptor.
If the analyte tested is not listed under one of the Tier 2 codes or
is not represented by a Tier 1 code, use the unlisted molecular
pathology procedure code, 81479. See the Introduction section of
the CPT code set for a complete list of the dates of release and
implementation.◀
81400 Molecular pathology procedure, Level 1 (eg, identification
of single germline variant [eg, SNP] by techniques such as
restriction enzyme digestion or melt curve analysis)
ACADM (acyl-CoA dehydrogenase, C-4 to C-12 straight
chain, MCAD) (eg, medium chain acyl dehydrogenase
deficiency), K304E variant
ACE (angiotensin converting enzyme) (eg, hereditary blood
pressure regulation), insertion/deletion variant
AGTR1 (angiotensin II receptor, type 1) (eg, essential
hypertension), 1166A>C variant
BCKDHA (branched chain keto acid dehydrogenase E1,
alpha polypeptide) (eg, maple syrup urine disease, type
1A), Y438N variant
CCR5 (chemokine C-C motif receptor 5) (eg, HIV
resistance), 32-bp deletion mutation/794 825del32 deletion
CLRN1 (clarin 1) (eg, Usher syndrome, type 3), N48K
variant
F2 (coagulation factor 2) (eg, hereditary
hypercoagulability), 1199G>A variant
F5 (coagulation factor V) (eg, hereditary
hypercoagulability), HR2 variant
F7 (coagulation factor VII [serum prothrombin conversion
accelerator]) (eg, hereditary hypercoagulability), R353Q
variant
F13B (coagulation factor XIII, B polypeptide) (eg,
hereditary hypercoagulability), V34L variant
FGB (fibrinogen beta chain) (eg, hereditary ischemic heart
disease), -455G>A variant
FGFR1 (fibroblast growth factor receptor 1) (eg, Pfeiffer
syndrome type 1, craniosynostosis), P252R variant
FGFR3 (fibroblast growth factor receptor 3) (eg, Muenke
syndrome), P250R variant
FKTN (fukutin) (eg, Fukuyama congenital muscular
dystrophy), retrotransposon insertion variant
GNE (glucosamine [UDP-N-acetyl]-2-epimerase/N-
acetylmannosamine kinase) (eg, inclusion body myopathy 2
[IBM2], Nonaka myopathy), M712T variant
IVD (isovaleryl-CoA dehydrogenase) (eg, isovaleric
acidemia), A282V variant
LCT (lactase-phlorizin hydrolase) (eg, lactose intolerance),
13910 C>T variant
NEB (nebulin) (eg, nemaline myopathy 2), exon 55 deletion
variant
PCDH15 (protocadherin-related 15) (eg, Usher syndrome
type 1F), R245X variant
SERPINE1 (serpine peptidase inhibitor clade E, member
1, plasminogen activator inhibitor -1, PAI-1) (eg,
thrombophilia), 4G variant
SHOC2 (soc-2 suppressor of clear homolog) (eg, Noonan-
like syndrome with loose anagen hair), S2G variant
SRY (sex determining region Y) (eg, 46,XX testicular
disorder of sex development, gonadal dysgenesis), gene
analysis
TOR1A (torsin family 1, member A [torsin A]) (eg, early-
onset primary dystonia [DYT1]), 907_909delGAG
(904_906delGAG) variant
2018, 2019
➲ CPT Assistant May 12:4, Jul 13:12, Sep 13:4, 5, 8, Jan
15:3, Aug 16:10, Nov 18:9, Jul 19:3
▲ 81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1
methylated variant, or 1 somatic variant [typically using
nonsequencing target variant analysis], or detection of a
dynamic mutation disorder/triplet repeat)
ABCC8 (ATP-binding cassette, sub-family C [CFTR/MRP],
member 8) (eg, familial hyperinsulinism), common variants
(eg, c.3898-9G>A [c.3992-9G>A], F1388del)
ABL1 (ABL proto-oncogene 1, non-receptor tyrosine
kinase) (eg, acquired imatinib resistance), T315I variant
ACADM (acyl-CoA dehydrogenase, C-4 to C-12 straight
chain, MCAD) (eg, medium chain acyl dehydrogenase
deficiency), commons variants (eg, K304E, Y42H)
ADRB2 (adrenergic beta-2 receptor surface) (eg, drug
metabolism), common variants (eg, G16R, Q27E)
APOB (apolipoprotein B) (eg, familial
hypercholesterolemia type B), common variants (eg,
R3500Q, R3500W)
APOE (apolipoprotein E) (eg, hyperlipoproteinemia type
III, cardiovascular disease, Alzheimer disease), common
variants (eg, *2, *3, *4)
CBFB/MYH11 (inv(16)) (eg, acute myeloid leukemia),
qualitative, and quantitative, if performed
CBS (cystathionine-beta-synthase) (eg, homocystinuria,
cystathionine beta-synthase deficiency), common variants
(eg, I278T, G307S)
CFH/ARMS2 (complement factor H/age-related
maculopathy susceptibility 2) (eg, macular degeneration),
common variants (eg, Y402H [CFH], A69S [ARMS2])
DEK/NUP214 (t(6;9)) (eg, acute myeloid leukemia),
translocation analysis, qualitative, and quantitative, if
performed
E2A/PBX1 (t(1;19)) (eg, acute lymphocytic leukemia),
performed
EML4/ALK (inv(2)) (eg, non-small cell lung cancer),
translocation or inversion analysis
ETV6/RUNX1 (t(12;21)) (eg, acute lymphocytic leukemia),
performed
EWSR1/ATF1 (t(12;22)) (eg, clear cell sarcoma),
performed
EWSR1/ERG (t(21;22)) (eg, Ewing sarcoma/peripheral
neuroectodermal tumor), translocation analysis, qualitative,
and quantitative, if performed
EWSR1/FLI1 (t(11;22)) (eg, Ewing sarcoma/peripheral
neuroectodermal tumor), translocation analysis, qualitative,
and quantitative, if performed
EWSR1/WT1 (t(11;22)) (eg, desmoplastic small round cell
tumor), translocation analysis, qualitative, and quantitative,
if performed
F11 (coagulation factor XI) (eg, coagulation disorder),
common variants (eg, E117X [Type II], F283L [Type III],
IVS14del14, and IVS14+1G>A [Type I])
FGFR3 (fibroblast growth factor receptor 3) (eg,
achondroplasia, hypochondroplasia), common variants (eg,
1138G>A, 1138G>C, 1620C>A, 1620C>G)
FIP1L1/PDGFRA (del[4q12]) (eg, imatinib-sensitive
chronic eosinophilic leukemia), qualitative, and
FLG (filaggrin) (eg, ichthyosis vulgaris), common variants
(eg, R501X, 2282del4, R2447X, S3247X, 3702delG)
FOXO1/PAX3 (t(2;13)) (eg, alveolar rhabdomyosarcoma),
performed
FOXO1/PAX7 (t(1;13)) (eg, alveolar rhabdomyosarcoma),
performed
FUS/DDIT3 (t(12;16)) (eg, myxoid liposarcoma),
performed
GALC (galactosylceramidase) (eg, Krabbe disease),
common variants (eg, c.857G>A, 30-kb deletion)
GALT (galactose-1-phosphate uridylyltransferase) (eg,
galactosemia), common variants (eg, Q188R, S135L,
K285N, T138M, L195P, Y209C, IVS2-2A>G, P171S,
del5kb, N314D, L218L/N314D)
H19 (imprinted maternally expressed transcript [non-
protein coding]) (eg, Beckwith-Wiedemann syndrome),
IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma),
translocation analysis; single breakpoint (eg, major
breakpoint region [MBR] or minor cluster region [mcr]),
qualitative or quantitative
▶ (When both MBR and mcr breakpoints are performed, use
81278)◀
KCNQ1OT1 (KCNQ1 overlapping transcript 1 [non-
protein coding]) (eg, Beckwith-Wiedemann syndrome),
LINC00518 (long intergenic non-protein coding RNA 518)
(eg, melanoma), expression analysis
LRRK2 (leucine-rich repeat kinase 2) (eg, Parkinson
disease), common variants (eg, R1441G, G2019S, I2020T)
MED12 (mediator complex subunit 12) (eg, FG syndrome
type 1, Lujan syndrome), common variants (eg, R961W,
N1007S)
MEG3/DLK1 (maternally expressed 3 [non-protein
coding]/delta-like 1 homolog [Drosophila]) (eg,
intrauterine growth retardation), methylation analysis
MLL/AFF1 (t(4;11)) (eg, acute lymphoblastic leukemia),
performed
MLL/MLLT3 (t(9;11)) (eg, acute myeloid leukemia),
performed
MT-ATP6 (mitochondrially encoded ATP synthase 6) (eg,
neuropathy with ataxia and retinitis pigmentosa [NARP],
Leigh syndrome), common variants (eg, m.8993T>G,
m.8993T>C)
MT-ND4, MT-ND6 (mitochondrially encoded NADH
dehydrogenase 4, mitochondrially encoded NADH
dehydrogenase 6) (eg, Leber hereditary optic neuropathy
[LHON]), common variants (eg, m.11778G>A, m.3460G>A,
m.14484T>C)
MT-ND5 (mitochondrially encoded tRNA leucine 1
[UUA/G], mitochondrially encoded NADH dehydrogenase
5) (eg, mitochondrial encephalopathy with lactic acidosis
and stroke-like episodes [MELAS]), common variants (eg,
m.3243A>G, m.3271T>C, m.3252A>G, m.13513G>A)
MT-RNR1 (mitochondrially encoded 12S RNA) (eg,
nonsyndromic hearing loss), common variants (eg,
m.1555A>G, m.1494C>T)
MT-TK (mitochondrially encoded tRNA lysine) (eg,
myoclonic epilepsy with ragged-red fibers [MERRF]),
common variants (eg, m.8344A>G, m.8356T>C)
MT-TL1 (mitochondrially encoded tRNA leucine 1
[UUA/G]) (eg, diabetes and hearing loss), common variants
(eg, m.3243A>G, m.14709 T>C) MT-TL1
MT-TS1, MT-RNR1 (mitochondrially encoded tRNA serine
1 [UCN], mitochondrially encoded 12S RNA) (eg,
nonsyndromic sensorineural deafness [including
aminoglycoside-induced nonsyndromic deafness]), common
variants (eg, m.7445A>G, m.1555A>G)
MUTYH (mutY homolog [E. coli]) (eg, MYH-associated
polyposis), common variants (eg, Y165C, G382D)
NOD2 (nucleotide-binding oligomerization domain
containing 2) (eg, Crohn’s disease, Blau syndrome),
common variants (eg, SNP 8, SNP 12, SNP 13)
NPM1/ALK (t(2;5)) (eg, anaplastic large cell lymphoma),
translocation analysis
PAX8/PPARG (t(2;3) (q13;p25)) (eg, follicular thyroid
carcinoma), translocation analysis
PRAME (preferentially expressed antigen in melanoma)
(eg, melanoma), expression analysis
PRSS1 (protease, serine, 1 [trypsin 1]) (eg, hereditary
pancreatitis), common variants (eg, N29I, A16V, R122H)
PYGM (phosphorylase, glycogen, muscle) (eg, glycogen
storage disease type V, McArdle disease), common variants
(eg, R50X, G205S)
RUNX1/RUNX1T1 (t(8;21)) (eg, acute myeloid leukemia)
performed
SS18/SSX1 (t(X;18)) (eg, synovial sarcoma), translocation
analysis, qualitative, and quantitative, if performed
SS18/SSX2 (t(X;18)) (eg, synovial sarcoma), translocation
analysis, qualitative, and quantitative, if performed
VWF (von Willebrand factor) (eg, von Willebrand disease
type 2N), common variants (eg, T791M, R816W, R854Q)
2016, 2017, 2018, 2019, 2021
➲ CPT Assistant May 12:4, Jul 13:12, Sep 13:5, Jan 15:3,
Aug 16:10, Nov 18:9, Jul 19:3
▲ 81402 Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-
10 methylated variants, or 2-10 somatic variants [typically
using non-sequencing target variant analysis],
immunoglobulin and T-cell receptor gene rearrangements,
duplication/deletion variants of 1 exon, loss of
heterozygosity [LOH], uniparental disomy [UPD])
Chromosome 1p-/19q- (eg, glial tumors), deletion analysis
Chromosome 18q- (eg, D18S55, D18S58, D18S61,
D18S64, and D18S69) (eg, colon cancer), allelic imbalance
assessment (ie, loss of heterozygosity)
COL1A1/PDGFB (t(17;22)) (eg, dermatofibrosarcoma
protuberans), translocation analysis, multiple breakpoints,
CYP21A2 (cytochrome P450, family 21, subfamily A,
polypeptide 2) (eg, congenital adrenal hyperplasia, 21-
hydroxylase deficiency), common variants (eg, IVS2-13G,
P30L, I172N, exon 6 mutation cluster [I235N, V236E,
M238K], V281L, L307FfsX6, Q318X, R356W, P453S,
G110VfsX21, 30-kb deletion variant)
ESR1/PGR (receptor 1/progesterone receptor) ratio (eg,
breast cancer)
MEFV (Mediterranean fever) (eg, familial Mediterranean
fever), common variants (eg, E148Q, P369S, F479L,
M680I, I692del, M694V, M694I, K695R, V726A, A744S,
R761H)
TRD@ (T cell antigen receptor, delta) (eg, leukemia and
lymphoma), gene rearrangement analysis, evaluation to
detect abnormal clonal population
Uniparental disomy (UPD) (eg, Russell-Silver syndrome,
Prader-Willi/Angelman syndrome), short tandem repeat
(STR) analysis
2015, 2016, 2021
➲ CPT Assistant May 12:4, Jul 13:12, Sep 13:5, 9, Jan
15:3, Aug 16:10, Nov 18:9
▲ 81403 Molecular pathology procedure, Level 4 (eg, analysis of
single exon by DNA sequence analysis, analysis of >10
amplicons using multiplex PCR in 2 or more independent
reactions, mutation scanning or duplication/deletion variants
of 2-5 exons)
ANG (angiogenin, ribonuclease, RNase A family, 5) (eg,
amyotrophic lateral sclerosis), full gene sequence
ARX (aristaless-related homeobox) (eg, X-linked
lissencephaly with ambiguous genitalia, X-linked mental
retardation), duplication/deletion analysis
CEL (carboxyl ester lipase [bile salt-stimulated lipase])
(eg, maturity-onset diabetes of the young [MODY]), targeted
sequence analysis of exon 11 (eg, c.1785delC, c.1686delT)
CTNNB1 (catenin [cadherin-associated protein], beta 1,
88kDa) (eg, desmoid tumors), targeted sequence analysis
(eg, exon 3)
DAZ/SRY (deleted in azoospermia and sex determining
region Y) (eg, male infertility), common deletions (eg,
AZFa, AZFb, AZFc, AZFd)
DNMT3A (DNA [cytosine-5-]-methyltransferase 3 alpha)
(eg, acute myeloid leukemia), targeted sequence analysis
(eg, exon 23)
EPCAM (epithelial cell adhesion molecule) (eg, Lynch
syndrome), duplication/deletion analysis
F8 (coagulation factor VIII) (eg, hemophilia A), inversion
analysis, intron 1 and intron 22A
F12 (coagulation factor XII [Hageman factor]) (eg,
angioedema, hereditary, type III; factor XII deficiency),
targeted sequence analysis of exon 9
FGFR3 (fibroblast growth factor receptor 3) (eg, isolated
craniosynostosis), targeted sequence analysis (eg, exon 7)
(For targeted sequence analysis of multiple FGFR3 exons,
use 81404)
GJB1 (gap junction protein, beta 1) (eg, Charcot-Marie-
Tooth X-linked), full gene sequence
GNAQ (guanine nucleotide-binding protein G[q] subunit
alpha) (eg, uveal melanoma), common variants (eg, R183,
Q209)
Human erythrocyte antigen gene analyses (eg, SLC14A1
[Kidd blood group], BCAM [Lutheran blood group],
ICAM4 [Landsteiner-Wiener blood group], SLC4A1
[Diego blood group], AQP1 [Colton blood group], ERMAP
[Scianna blood group], RHCE [Rh blood group, CcEe
antigens], KEL [Kell blood group], DARC [Duffy blood
group], GYPA, GYPB, GYPE [MNS blood group], ART4
[Dombrock blood group]) (eg, sickle-cell disease,
thalassemia, hemolytic transfusion reactions, hemolytic
disease of the fetus or newborn), common variants
HRAS (v-Ha-ras Harvey rat sarcoma viral oncogene
homolog) (eg, Costello syndrome), exon 2 sequence
KCNC3 (potassium voltage-gated channel, Shaw-related
subfamily, member 3) (eg, spinocerebellar ataxia), targeted
sequence analysis (eg, exon 2)
KCNJ2 (potassium inwardly-rectifying channel, subfamily
J, member 2) (eg, Andersen-Tawil syndrome), full gene
sequence
KCNJ11 (potassium inwardly-rectifying channel,
subfamily J, member 11) (eg, familial hyperinsulinism), full
gene sequence
Killer cell immunoglobulin-like receptor (KIR) gene family
(eg, hematopoietic stem cell transplantation), genotyping of
KIR family genes
Known familial variant not otherwise specified, for gene
listed in Tier 1 or Tier 2, or identified during a genomic
sequencing procedure, DNA sequence analysis, each variant
exon
(For a known familial variant that is considered a common
variant, use specific common variant Tier 1 or Tier 2 code)
MC4R (melanocortin 4 receptor) (eg, obesity), full gene
sequence
MICA (MHC class I polypeptide-related sequence A) (eg,
solid organ transplantation), common variants (eg, *001,
*002)
MT-RNR1 (mitochondrially encoded 12S RNA) (eg,
nonsyndromic hearing loss), full gene sequence
MT-TS1 (mitochondrially encoded tRNA serine 1) (eg,
nonsyndromic hearing loss), full gene sequence
NDP (Norrie disease [pseudoglioma]) (eg, Norrie
disease), duplication/deletion analysis
NHLRC1 (NHL repeat containing 1) (eg, progressive
myoclonus epilepsy), full gene sequence
PHOX2B (paired-like homeobox 2b) (eg, congenital central
hypoventilation syndrome), duplication/deletion analysis
PLN (phospholamban) (eg, dilated cardiomyopathy,
hypertrophic cardiomyopathy), full gene sequence
RHD (Rh blood group, D antigen) (eg, hemolytic disease of
the fetus and newborn, Rh maternal/fetal compatibility),
deletion analysis (eg, exons 4, 5, and 7, pseudogene)
RHD (Rh blood group, D antigen) (eg, hemolytic disease of
the fetus and newborn, Rh maternal/fetal compatibility),
deletion analysis (eg, exons 4, 5, and 7, pseudogene),
performed on cell-free fetal DNA in maternal blood
(For human erythrocyte gene analysis of RHD, use a
separate unit of 81403)
SH2D1A (SH2 domain containing 1A) (eg, X-linked
lymphoproliferative syndrome), duplication/deletion
analysis
TWIST1 (twist homolog 1 [Drosophila]) (eg, Saethre-
Chotzen syndrome), duplication/deletion analysis
UBA1 (ubiquitin-like modifier activating enzyme 1) (eg,
spinal muscular atrophy, X-linked), targeted sequence
analysis (eg, exon 15)
VHL (von Hippel-Lindau tumor suppressor) (eg, von
Hippel-Lindau familial cancer syndrome),
deletion/duplication analysis
types 2A, 2B, 2M), targeted sequence analysis (eg, exon 28)
2015, 2016, 2017, 2018, 2019, 2021
Aug 16:10, May 18:6, Nov 18:9, Jul 19:3
▲ 81404 Molecular pathology procedure, Level 5 (eg, analysis of 2-5
exons by DNA sequence analysis, mutation scanning or
duplication/deletion variants of 6-10 exons, or
characterization of a dynamic mutation disorder/triplet
repeat by Southern blot analysis)
ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain)
(eg, short chain acyl-CoA dehydrogenase deficiency),
targeted sequence analysis (eg, exons 5 and 6)
AQP2 (aquaporin 2 [collecting duct]) (eg, nephrogenic
diabetes insipidus), full gene sequence
ARX (aristaless related homeobox) (eg, X-linked
lissencephaly with ambiguous genitalia, X-linked mental
retardation), full gene sequence
AVPR2 (arginine vasopressin receptor 2) (eg, nephrogenic
diabetes insipidus), full gene sequence
BBS10 (Bardet-Biedl syndrome 10) (eg, Bardet-Biedl
syndrome), full gene sequence
BTD (biotinidase) (eg, biotinidase deficiency), full gene
sequence
C10orf2 (chromosome 10 open reading frame 2) (eg,
mitochondrial DNA depletion syndrome), full gene
sequence
CAV3 (caveolin 3) (eg, CAV3-related distal myopathy, limb-
girdle muscular dystrophy type 1C), full gene sequence
CD40LG (CD40 ligand) (eg, X-linked hyper IgM
CDKN2A (cyclin-dependent kinase inhibitor 2A) (eg,
CDKN2A-related cutaneous malignant melanoma, familial
atypical mole-malignant melanoma syndrome), full gene
sequence
CLRN1 (clarin 1) (eg, Usher syndrome, type 3), full gene
sequence
COX6B1 (cytochrome c oxidase subunit VIb polypeptide 1)
(eg, mitochondrial respiratory chain complex IV
deficiency), full gene sequence
CPT2 (carnitine palmitoyltransferase 2) (eg, carnitine
palmitoyltransferase II deficiency), full gene sequence
CRX (cone-rod homeobox) (eg, cone-rod dystrophy 2, Leber
congenital amaurosis), full gene sequence
CYP1B1 (cytochrome P450, family 1, subfamily B,
polypeptide 1) (eg, primary congenital glaucoma), full gene
sequence
EGR2 (early growth response 2) (eg, Charcot-Marie-
Tooth), full gene sequence
EMD (emerin) (eg, Emery-Dreifuss muscular dystrophy),
duplication/deletion analysis
EPM2A (epilepsy, progressive myoclonus type 2A, Lafora
disease [laforin]) (eg, progressive myoclonus epilepsy),
full gene sequence
FGF23 (fibroblast growth factor 23) (eg,
hypophosphatemic rickets), full gene sequence
craniosynostosis, Apert syndrome, Crouzon syndrome),
targeted sequence analysis (eg, exons 8, 10)
achondroplasia, hypochondroplasia), targeted sequence
analysis (eg, exons 8, 11, 12, 13)
FHL1 (four and a half LIM domains 1) (eg, Emery-
Dreifuss muscular dystrophy), full gene sequence
FKRP (fukutin related protein) (eg, congenital muscular
dystrophy type 1C [MDC1C], limb-girdle muscular
dystrophy [LGMD] type 2I), full gene sequence
FOXG1 (forkhead box G1) (eg, Rett syndrome), full gene
sequence
FSHMD1A (facioscapulohumeral muscular dystrophy 1A)
(eg, facioscapulohumeral muscular dystrophy), evaluation to
detect abnormal (eg, deleted) alleles
FSHMD1A (facioscapulohumeral muscular dystrophy 1A)
(eg, facioscapulohumeral muscular dystrophy),
characterization of haplotype(s) (ie, chromosome 4A and 4B
haplotypes)
GH1 (growth hormone 1) (eg, growth hormone deficiency),
full gene sequence
GP1BB (glycoprotein Ib [platelet], beta polypeptide) (eg,
Bernard-Soulier syndrome type B), full gene sequence
(For common deletion variants of alpha globin 1 and alpha
globin 2 genes, use 81257)
HNF1B (HNF1 homeobox B) (eg, maturity-onset diabetes of
the young [MODY]), duplication/deletion analysis
HRAS (v-Ha-ras Harvey rat sarcoma viral oncogene
homolog) (eg, Costello syndrome), full gene sequence
HSD3B2 (hydroxy-delta-5-steroid dehydrogenase, 3 beta-
and steroid delta-isomerase 2) (eg, 3-beta-hydroxysteroid
dehydrogenase type II deficiency), full gene sequence
HSD11B2 (hydroxysteroid [11-beta] dehydrogenase 2) (eg,
mineralocorticoid excess syndrome), full gene sequence
HSPB1 (heat shock 27kDa protein 1) (eg, Charcot-Marie-
Tooth disease), full gene sequence
INS (insulin) (eg, diabetes mellitus), full gene sequence
KCNJ1 (potassium inwardly-rectifying channel, subfamily
J, member 1) (eg, Bartter syndrome), full gene sequence
KCNJ10 (potassium inwardly-rectifying channel,
subfamily J, member 10) (eg, SeSAME syndrome, EAST
syndrome, sensorineural hearing loss), full gene sequence
LITAF (lipopolysaccharide-induced TNF factor) (eg,
Charcot-Marie-Tooth), full gene sequence
MEFV (Mediterranean fever) (eg, familial Mediterranean
fever), full gene sequence
MEN1 (multiple endocrine neoplasia I) (eg, multiple
endocrine neoplasia type 1, Wermer syndrome),
MMACHC (methylmalonic aciduria [cobalamin
deficiency] cblC type, with homocystinuria) (eg,
methylmalonic acidemia and homocystinuria), full gene
sequence
MPV17 (MpV17 mitochondrial inner membrane protein)
(eg, mitochondrial DNA depletion syndrome),
NDP (Norrie disease [pseudoglioma]) (eg, Norrie
disease), full gene sequence
NDUFA1 (NADH dehydrogenase [ubiquinone] 1 alpha
subcomplex, 1, 7.5kDa) (eg, Leigh syndrome, mitochondrial
complex I deficiency), full gene sequence
NDUFAF2 (NADH dehydrogenase [ubiquinone] 1 alpha
subcomplex, assembly factor 2) (eg, Leigh syndrome,
mitochondrial complex I deficiency), full gene sequence
NDUFS4 (NADH dehydrogenase [ubiquinone] Fe-S
protein 4, 18kDa [NADH-coenzyme Q reductase]) (eg,
Leigh syndrome, mitochondrial complex I deficiency), full
gene sequence
NIPA1 (non-imprinted in Prader-Willi/Angelman syndrome
1) (eg, spastic paraplegia), full gene sequence
NLGN4X (neuroligin 4, X-linked) (eg, autism spectrum
disorders), duplication/deletion analysis
NPC2 (Niemann-Pick disease, type C2 [epididymal
secretory protein E1]) (eg, Niemann-Pick disease type C2),
full gene sequence
NR0B1 (nuclear receptor subfamily 0, group B, member 1)
(eg, congenital adrenal hypoplasia), full gene sequence
PDX1 (pancreatic and duodenal homeobox 1) (eg,
maturity-onset diabetes of the young [MODY]), full gene
sequence
PHOX2B (paired-like homeobox 2b) (eg, congenital central
hypoventilation syndrome), full gene sequence
PLP1 (proteolipid protein 1) (eg, Pelizaeus-Merzbacher
disease, spastic paraplegia), duplication/deletion analysis
PQBP1 (polyglutamine binding protein 1) (eg, Renpenning
PRNP (prion protein) (eg, genetic prion disease), full gene
sequence
PROP1 (PROP paired-like homeobox 1) (eg, combined
pituitary hormone deficiency), full gene sequence
PRPH2 (peripherin 2 [retinal degeneration, slow]) (eg,
retinitis pigmentosa), full gene sequence
PRSS1 (protease, serine, 1 [trypsin 1]) (eg, hereditary
pancreatitis), full gene sequence
RAF1 (v-raf-1 murine leukemia viral oncogene homolog 1)
(eg, LEOPARD syndrome), targeted sequence analysis (eg,
exons 7, 12, 14, 17)
RET (ret proto-oncogene) (eg, multiple endocrine
neoplasia, type 2B and familial medullary thyroid
carcinoma), common variants (eg, M918T,
2647_2648delinsTT, A883F)
RHO (rhodopsin) (eg, retinitis pigmentosa), full gene
sequence
RP1 (retinitis pigmentosa 1) (eg, retinitis pigmentosa), full
gene sequence
SCN1B (sodium channel, voltage-gated, type I, beta) (eg,
Brugada syndrome), full gene sequence
SCO2 (SCO cytochrome oxidase deficient homolog 2
[SCO1L]) (eg, mitochondrial respiratory chain complex IV
SDHC (succinate dehydrogenase complex, subunit C,
integral membrane protein, 15kDa) (eg, hereditary
paraganglioma-pheochromocytoma syndrome),
SDHD (succinate dehydrogenase complex, subunit D,
integral membrane protein) (eg, hereditary paraganglioma),
full gene sequence
SGCG (sarcoglycan, gamma [35kDa dystrophin-associated
glycoprotein]) (eg, limb-girdle muscular dystrophy),
SH2D1A (SH2 domain containing 1A) (eg, X-linked
lymphoproliferative syndrome), full gene sequence
SLC16A2 (solute carrier family 16, member 2 [thyroid
hormone transporter]) (eg, specific thyroid hormone cell
transporter deficiency, Allan-Herndon-Dudley syndrome),
SLC25A20 (solute carrier family 25
[carnitine/acylcarnitine translocase], member 20) (eg,
carnitine-acylcarnitine translocase deficiency),
SLC25A4 (solute carrier family 25 [mitochondrial carrier;
adenine nucleotide translocator], member 4) (eg,
progressive external ophthalmoplegia), full gene sequence
SOD1 (superoxide dismutase 1, soluble) (eg, amyotrophic
lateral sclerosis), full gene sequence
SPINK1 (serine peptidase inhibitor, Kazal type 1) (eg,
hereditary pancreatitis), full gene sequence
STK11 (serine/threonine kinase 11) (eg, Peutz-Jeghers
TACO1 (translational activator of mitochondrial encoded
cytochrome c oxidase I) (eg, mitochondrial respiratory
chain complex IV deficiency), full gene sequence
THAP1 (THAP domain containing, apoptosis associated
protein 1) (eg, torsion dystonia), full gene sequence
TOR1A (torsin family 1, member A [torsin A]) (eg, torsion
dystonia), full gene sequence
TTPA (tocopherol [alpha] transfer protein) (eg, ataxia), full
gene sequence
TTR (transthyretin) (eg, familial transthyretin amyloidosis),
full gene sequence
TWIST1 (twist homolog 1 [Drosophila]) (eg, Saethre-
Chotzen syndrome), full gene sequence
TYR (tyrosinase [oculocutaneous albinism IA]) (eg,
oculocutaneous albinism IA), full gene sequence
UGT1A1 (UDP glucuronosyltransferase 1 family,
polypeptide A1) (eg, hereditary unconjugated
hyperbilirubinemia [Crigler-Najjar syndrome]) full gene
sequence
USH1G (Usher syndrome 1G [autosomal recessive]) (eg,
Usher syndrome, type 1), full gene sequence
VHL (von Hippel-Lindau tumor suppressor) (eg, von
Hippel-Lindau familial cancer syndrome), full gene
sequence
type 1C), targeted sequence analysis (eg, exons 26, 27, 37)
ZEB2 (zinc finger E-box binding homeobox 2) (eg, Mowat-
Wilson syndrome), duplication/deletion analysis
ZNF41 (zinc finger protein 41) (eg, X-linked mental
retardation 89), full gene sequence
2015, 2016, 2018, 2019, 2020, 2021
15:3, Aug 16:10, May 18:6, Nov 18:9, Jul 19:3, Apr
20:9
▲ 81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-
10 exons by DNA sequence analysis, mutation scanning or
duplication/deletion variants of 11-25 exons, regionally
targeted cytogenomic array analysis)
ABCD1 (ATP-binding cassette, sub-family D [ALD],
member 1) (eg, adrenoleukodystrophy), full gene sequence
ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain)
(eg, short chain acyl-CoA dehydrogenase deficiency), full
gene sequence
ACTA2 (actin, alpha 2, smooth muscle, aorta) (eg, thoracic
aortic aneurysms and aortic dissections), full gene sequence
ACTC1 (actin, alpha, cardiac muscle 1) (eg, familial
ANKRD1 (ankyrin repeat domain 1) (eg, dilated
cardiomyopathy), full gene sequence
APTX (aprataxin) (eg, ataxia with oculomotor apraxia 1),
full gene sequence
ARSA (arylsulfatase A) (eg, arylsulfatase A deficiency), full
gene sequence
BCKDHA (branched chain keto acid dehydrogenase E1,
alpha polypeptide) (eg, maple syrup urine disease, type
1A), full gene sequence
BCS1L (BCS1-like [S. cerevisiae]) (eg, Leigh syndrome,
mitochondrial complex III deficiency, GRACILE syndrome),
full gene sequence
BMPR2 (bone morphogenetic protein receptor, type II
[serine/threonine kinase]) (eg, heritable pulmonary arterial
hypertension), duplication/deletion analysis
CASQ2 (calsequestrin 2 [cardiac muscle]) (eg,
catecholaminergic polymorphic ventricular tachycardia),
full gene sequence
CASR (calcium-sensing receptor) (eg, hypocalcemia), full
gene sequence
CDKL5 (cyclin-dependent kinase-like 5) (eg, early infantile
epileptic encephalopathy), duplication/deletion analysis
CHRNA4 (cholinergic receptor, nicotinic, alpha 4) (eg,
nocturnal frontal lobe epilepsy), full gene sequence
CHRNB2 (cholinergic receptor, nicotinic, beta 2
[neuronal]) (eg, nocturnal frontal lobe epilepsy), full gene
sequence
COX10 (COX10 homolog, cytochrome c oxidase assembly
protein) (eg, mitochondrial respiratory chain complex IV
COX15 (COX15 homolog, cytochrome c oxidase assembly
protein) (eg, mitochondrial respiratory chain complex IV
CPOX (coproporphyrinogen oxidase) (eg, hereditary
coproporphyria), full gene sequence
CTRC (chymotrypsin C) (eg, hereditary pancreatitis), full
gene sequence
CYP11B1 (cytochrome P450, family 11, subfamily B,
polypeptide 1) (eg, congenital adrenal hyperplasia), full
gene sequence
polypeptide 1) (eg, congenital adrenal hyperplasia), full
gene sequence
polypeptide2) (eg, steroid 21-hydroxylase isoform,
congenital adrenal hyperplasia), full gene sequence
Cytogenomic constitutional targeted microarray analysis of
chromosome 22q13 by interrogation of genomic regions for
copy number and single nucleotide polymorphism (SNP)
variants for chromosomal abnormalities
(When performing genome-wide cytogenomic constitutional
microarray analysis, see 81228, 81229)
procedures separately when the specific analytes are
included as part of the microarray analysis of chromosome
22q13)
DBT (dihydrolipoamide branched chain transacylase E2)
(eg, maple syrup urine disease, type 2), duplication/deletion
analysis
DCX (doublecortin) (eg, X-linked lissencephaly), full gene
sequence
DES (desmin) (eg, myofibrillar myopathy), full gene
sequence
DFNB59 (deafness, autosomal recessive 59) (eg, autosomal
recessive nonsyndromic hearing impairment), full gene
sequence
DGUOK (deoxyguanosine kinase) (eg, hepatocerebral
sequence
DHCR7 (7-dehydrocholesterol reductase) (eg, Smith-
Lemli-Opitz syndrome), full gene sequence
EIF2B2 (eukaryotic translation initiation factor 2B,
subunit 2 beta, 39kDa) (eg, leukoencephalopathy with
vanishing white matter), full gene sequence
EMD (emerin) (eg, Emery-Dreifuss muscular dystrophy),
full gene sequence
ENG (endoglin) (eg, hereditary hemorrhagic telangiectasia,
type 1), duplication/deletion analysis
EYA1 (eyes absent homolog 1 [Drosophila]) (eg, branchio-
oto-renal [BOR] spectrum disorders), duplication/deletion
analysis
FGFR1 (fibroblast growth factor receptor 1) (eg, Kallmann
syndrome 2), full gene sequence
FH (fumarate hydratase) (eg, fumarate hydratase
deficiency, hereditary leiomyomatosis with renal cell
cancer), full gene sequence
FKTN (fukutin) (eg, limb-girdle muscular dystrophy
[LGMD] type 2M or 2L), full gene sequence
FTSJ1 (FtsJ RNA methyltransferase homolog 1 [E. coli])
(eg, X-linked mental retardation 9), duplication/deletion
analysis
GABRG2 (gamma-aminobutyric acid [GABA] A receptor,
gamma 2) (eg, generalized epilepsy with febrile seizures),
full gene sequence
GCH1 (GTP cyclohydrolase 1) (eg, autosomal dominant
dopa-responsive dystonia), full gene sequence
GDAP1 (ganglioside-induced differentiation-associated
protein 1) (eg, Charcot-Marie-Tooth disease), full gene
sequence
GFAP (glial fibrillary acidic protein) (eg, Alexander
GHR (growth hormone receptor) (eg, Laron syndrome), full
gene sequence
GHRHR (growth hormone releasing hormone receptor)
(eg, growth hormone deficiency), full gene sequence
GLA (galactosidase, alpha) (eg, Fabry disease), full gene
sequence
HNF1A (HNF1 homeobox A) (eg, maturity-onset diabetes of
the young [MODY]), full gene sequence
HNF1B (HNF1 homeobox B) (eg, maturity-onset diabetes of
the young [MODY]), full gene sequence
HTRA1 (HtrA serine peptidase 1) (eg, macular
degeneration), full gene sequence
IDS (iduronate 2-sulfatase) (eg, mucopolysacchridosis,
type II), full gene sequence
IL2RG (interleukin 2 receptor, gamma) (eg, X-linked
severe combined immunodeficiency), full gene sequence
ISPD (isoprenoid synthase domain containing) (eg,
muscle-eye-brain disease, Walker-Warburg syndrome), full
gene sequence
KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg,
Noonan syndrome), full gene sequence
LAMP2 (lysosomal-associated membrane protein 2) (eg,
Danon disease), full gene sequence
LDLR (low density lipoprotein receptor) (eg, familial
hypercholesterolemia), duplication/deletion analysis
MEN1 (multiple endocrine neoplasia I) (eg, multiple
endocrine neoplasia type 1, Wermer syndrome), full gene
sequence
MMAA (methylmalonic aciduria [cobalamine deficiency]
type A) (eg, MMAA-related methylmalonic acidemia), full
gene sequence
MMAB (methylmalonic aciduria [cobalamine deficiency]
type B) (eg, MMAA-related methylmalonic acidemia), full
gene sequence
MPI (mannose phosphate isomerase) (eg, congenital
disorder of glycosylation 1b), full gene sequence
MPV17 (MpV17 mitochondrial inner membrane protein)
(eg, mitochondrial DNA depletion syndrome), full gene
sequence
MPZ (myelin protein zero) (eg, Charcot-Marie-Tooth), full
gene sequence
MTM1 (myotubularin 1) (eg, X-linked centronuclear
myopathy), duplication/deletion analysis
MYL2 (myosin, light chain 2, regulatory, cardiac, slow)
(eg, familial hypertrophic cardiomyopathy), full gene
sequence
MYL3 (myosin, light chain 3, alkali, ventricular, skeletal,
slow) (eg, familial hypertrophic cardiomyopathy), full gene
sequence
MYOT (myotilin) (eg, limb-girdle muscular dystrophy), full
gene sequence
gene sequence
gene sequence
NDUFV1 (NADH dehydrogenase [ubiquinone]
flavoprotein 1, 51kDa) (eg, Leigh syndrome, mitochondrial
complex I deficiency), full gene sequence
NEFL (neurofilament, light polypeptide) (eg, Charcot-
Marie-Tooth), full gene sequence
NF2 (neurofibromin 2 [merlin]) (eg, neurofibromatosis,
type 2), duplication/deletion analysis
NLGN3 (neuroligin 3) (eg, autism spectrum disorders), full
gene sequence
NLGN4X (neuroligin 4, X-linked) (eg, autism spectrum
disorders), full gene sequence
NPHP1 (nephronophthisis 1 [juvenile]) (eg, Joubert
syndrome), deletion analysis, and duplication analysis, if
performed
NPHS2 (nephrosis 2, idiopathic, steroid-resistant
[podocin]) (eg, steroid-resistant nephrotic syndrome), full
gene sequence
NSD1 (nuclear receptor binding SET domain protein 1)
(eg, Sotos syndrome), duplication/deletion analysis
OTC (ornithine carbamoyltransferase) (eg, ornithine
transcarbamylase deficiency), full gene sequence
PAFAH1B1 (platelet-activating factor acetylhydrolase 1b,
regulatory subunit 1 [45kDa]) (eg, lissencephaly, Miller-
Dieker syndrome), duplication/deletion analysis
PARK2 (Parkinson protein 2, E3 ubiquitin protein ligase
[parkin]) (eg, Parkinson disease), duplication/deletion
analysis
PCCA (propionyl CoA carboxylase, alpha polypeptide) (eg,
propionic acidemia, type 1), duplication/deletion analysis
PCDH19 (protocadherin 19) (eg, epileptic
encephalopathy), full gene sequence
PDHA1 (pyruvate dehydrogenase [lipoamide] alpha 1)
(eg, lactic acidosis), duplication/deletion analysis
PDHB (pyruvate dehydrogenase [lipoamide] beta) (eg,
lactic acidosis), full gene sequence
PINK1 (PTEN induced putative kinase 1) (eg, Parkinson
PKLR (pyruvate kinase, liver and RBC) (eg, pyruvate
kinase deficiency), full gene sequence
PLP1 (proteolipid protein 1) (eg, Pelizaeus-Merzbacher
disease, spastic paraplegia), full gene sequence
POU1F1 (POU class 1 homeobox 1) (eg, combined
pituitary hormone deficiency), full gene sequence
PRX (periaxin) (eg, Charcot-Marie-Tooth disease), full
gene sequence
PQBP1 (polyglutamine binding protein 1) (eg, Renpenning
PSEN1 (presenilin 1) (eg, Alzheimer disease), full gene
sequence
RAB7A (RAB7A, member RAS oncogene family) (eg,
Charcot-Marie-Tooth disease), full gene sequence
RAI1 (retinoic acid induced 1) (eg, Smith-Magenis
REEP1 (receptor accessory protein 1) (eg, spastic
paraplegia), full gene sequence
RET (ret proto-oncogene) (eg, multiple endocrine
neoplasia, type 2A and familial medullary thyroid
carcinoma), targeted sequence analysis (eg, exons 10, 11,
13-16)
RPS19 (ribosomal protein S19) (eg, Diamond-Blackfan
anemia), full gene sequence
RRM2B (ribonucleotide reductase M2 B [TP53 inducible])
(eg, mitochondrial DNA depletion), full gene sequence
SCO1 (SCO cytochrome oxidase deficient homolog 1) (eg,
mitochondrial respiratory chain complex IV deficiency), full
gene sequence
SDHB (succinate dehydrogenase complex, subunit B, iron
sulfur) (eg, hereditary paraganglioma), full gene sequence
SDHC (succinate dehydrogenase complex, subunit C,
integral membrane protein, 15kDa) (eg, hereditary
paraganglioma-pheochromocytoma syndrome), full gene
sequence
SGCA (sarcoglycan, alpha [50kDa dystrophin-associated
glycoprotein]) (eg, limb-girdle muscular dystrophy), full
gene sequence
SGCB (sarcoglycan, beta [43kDa dystrophin-associated
gene sequence
SGCD (sarcoglycan, delta [35kDa dystrophin-associated
gene sequence
SGCE (sarcoglycan, epsilon) (eg, myoclonic dystonia),
SGCG (sarcoglycan, gamma [35kDa dystrophin-associated
gene sequence
SHOC2 (soc-2 suppressor of clear homolog) (eg, Noonan-
like syndrome with loose anagen hair), full gene sequence
SHOX (short stature homeobox) (eg, Langer mesomelic
dysplasia), full gene sequence
SIL1 (SIL1 homolog, endoplasmic reticulum chaperone [S.
cerevisiae]) (eg, ataxia), full gene sequence
SLC2A1 (solute carrier family 2 [facilitated glucose
transporter], member 1) (eg, glucose transporter type 1
[GLUT 1] deficiency syndrome), full gene sequence
SLC16A2 (solute carrier family 16, member 2 [thyroid
hormone transporter]) (eg, specific thyroid hormone cell
transporter deficiency, Allan-Herndon-Dudley syndrome),
full gene sequence
SLC22A5 (solute carrier family 22 [organic
cation/carnitine transporter], member 5) (eg, systemic
primary carnitine deficiency), full gene sequence
[carnitine/acylcarnitine translocase], member 20) (eg,
carnitine-acylcarnitine translocase deficiency), full gene
sequence
SMAD4 (SMAD family member 4) (eg, hemorrhagic
telangiectasia syndrome, juvenile polyposis),
SPAST (spastin) (eg, spastic paraplegia),
SPG7 (spastic paraplegia 7 [pure and complicated
autosomal recessive]) (eg, spastic paraplegia),
SPRED1 (sprouty-related, EVH1 domain containing 1) (eg,
Legius syndrome), full gene sequence
STAT3 (signal transducer and activator of transcription 3
[acute-phase response factor]) (eg, autosomal dominant
hyper-IgE syndrome), targeted sequence analysis (eg, exons
12, 13, 14, 16, 17, 20, 21)
STK11 (serine/threonine kinase 11) (eg, Peutz-Jeghers
SURF1 (surfeit 1) (eg, mitochondrial respiratory chain
complex IV deficiency), full gene sequence
TARDBP (TAR DNA binding protein) (eg, amyotrophic
lateral sclerosis), full gene sequence
TBX5 (T-box 5) (eg, Holt-Oram syndrome), full gene
sequence
TCF4 (transcription factor 4) (eg, Pitt-Hopkins syndrome),
TGFBR1 (transforming growth factor, beta receptor 1) (eg,
Marfan syndrome), full gene sequence
TGFBR2 (transforming growth factor, beta receptor 2) (eg,
Marfan syndrome), full gene sequence
THRB (thyroid hormone receptor, beta) (eg, thyroid
hormone resistance, thyroid hormone beta receptor
deficiency), full gene sequence or targeted sequence
analysis of >5 exons
TK2 (thymidine kinase 2, mitochondrial) (eg,
sequence
TNNC1 (troponin C type 1 [slow]) (eg, hypertrophic
cardiomyopathy or dilated cardiomyopathy), full gene
sequence
TNNI3 (troponin I, type 3 [cardiac]) (eg, familial
TPM1 (tropomyosin 1 [alpha]) (eg, familial hypertrophic
cardiomyopathy), full gene sequence
TSC1 (tuberous sclerosis 1) (eg, tuberous sclerosis),
TYMP (thymidine phosphorylase) (eg, mitochondrial DNA
depletion syndrome), full gene sequence
type 2N), targeted sequence analysis (eg, exons 18-20, 23-
25)
WT1 (Wilms tumor 1) (eg, Denys-Drash syndrome, familial
Wilms tumor), full gene sequence
ZEB2 (zinc finger E-box binding homeobox 2) (eg, Mowat-
Wilson syndrome), full gene sequence
2015, 2016, 2018, 2019, 2021
➲ CPT Assistant May 12:4, Jul 13:12, Sep 13:8, 10, Jan
15:3, Aug 16:10, May 18:6, Sep 18:15, Nov 18:9, Jul
19:3
81406 Molecular pathology procedure, Level 7 (eg, analysis of 11-
duplication/deletion variants of 26-50 exons)
ACADVL (acyl-CoA dehydrogenase, very long chain) (eg,
very long chain acyl-coenzyme A dehydrogenase
ACTN4 (actinin, alpha 4) (eg, focal segmental
glomerulosclerosis), full gene sequence
AFG3L2 (AFG3 ATPase family gene 3-like 2 [S.
cerevisiae]) (eg, spinocerebellar ataxia), full gene sequence
AIRE (autoimmune regulator) (eg, autoimmune
polyendocrinopathy syndrome type 1), full gene sequence
ALDH7A1 (aldehyde dehydrogenase 7 family, member A1)
(eg, pyridoxine-dependent epilepsy), full gene sequence
ANO5 (anoctamin 5) (eg, limb-girdle muscular dystrophy),
full gene sequence
ANOS1 (anosmin-1) (eg, Kallmann syndrome 1), full gene
sequence
APP (amyloid beta [A4] precursor protein) (eg, Alzheimer
ASS1 (argininosuccinate synthase 1) (eg, citrullinemia type
I), full gene sequence
ATL1 (atlastin GTPase 1) (eg, spastic paraplegia), full gene
sequence
ATP1A2 (ATPase, Na+/K+ transporting, alpha 2
polypeptide) (eg, familial hemiplegic migraine), full gene
sequence
ATP7B (ATPase, Cu++ transporting, beta polypeptide)
(eg, Wilson disease), full gene sequence
BCKDHB (branched-chain keto acid dehydrogenase E1,
beta polypeptide) (eg, maple syrup urine disease, type 1B),
full gene sequence
BEST1 (bestrophin 1) (eg, vitelliform macular dystrophy),
full gene sequence
BMPR2 (bone morphogenetic protein receptor, type II
[serine/threonine kinase]) (eg, heritable pulmonary arterial
hypertension), full gene sequence
BRAF (B-Raf proto-oncogene, serine/threonine kinase)
(eg, Noonan syndrome), full gene sequence
BSCL2 (Berardinelli-Seip congenital lipodystrophy 2
[seipin]) (eg, Berardinelli-Seip congenital lipodystrophy),
full gene sequence
BTK (Bruton agammaglobulinemia tyrosine kinase) (eg, X-
linked agammaglobulinemia), full gene sequence
CACNB2 (calcium channel, voltage-dependent, beta 2
subunit) (eg, Brugada syndrome), full gene sequence
CAPN3 (calpain 3) (eg, limb-girdle muscular dystrophy
[LGMD] type 2A, calpainopathy), full gene sequence
CBS (cystathionine-beta-synthase) (eg, homocystinuria,
cystathionine beta-synthase deficiency), full gene sequence
CDH1 (cadherin 1, type 1, E-cadherin [epithelial]) (eg,
hereditary diffuse gastric cancer), full gene sequence
CDKL5 (cyclin-dependent kinase-like 5) (eg, early infantile
epileptic encephalopathy), full gene sequence
CLCN1 (chloride channel 1, skeletal muscle) (eg, myotonia
congenita), full gene sequence
CLCNKB (chloride channel, voltage-sensitive Kb) (eg,
Bartter syndrome 3 and 4b), full gene sequence
CNTNAP2 (contactin-associated protein-like 2) (eg, Pitt-
Hopkins-like syndrome 1), full gene sequence
COL6A2 (collagen, type VI, alpha 2) (eg, collagen type VI-
related disorders), duplication/deletion analysis
CPT1A (carnitine palmitoyltransferase 1A [liver]) (eg,
carnitine palmitoyltransferase 1A [CPT1A] deficiency), full
gene sequence
CRB1 (crumbs homolog 1 [Drosophila]) (eg, Leber
congenital amaurosis), full gene sequence
CREBBP (CREB binding protein) (eg, Rubinstein-Taybi
DBT (dihydrolipoamide branched chain transacylase E2)
(eg, maple syrup urine disease, type 2), full gene sequence
DLAT (dihydrolipoamide S-acetyltransferase) (eg, pyruvate
dehydrogenase E2 deficiency), full gene sequence
DLD (dihydrolipoamide dehydrogenase) (eg, maple syrup
urine disease, type III), full gene sequence
DSC2 (desmocollin) (eg, arrhythmogenic right ventricular
dysplasia/cardiomyopathy 11), full gene sequence
DSG2 (desmoglein 2) (eg, arrhythmogenic right ventricular
DSP (desmoplakin) (eg, arrhythmogenic right ventricular
EFHC1 (EF-hand domain [C-terminal] containing 1) (eg,
juvenile myoclonic epilepsy), full gene sequence
subunit 3 gamma, 58kDa) (eg, leukoencephalopathy with
subunit 4 delta, 67kDa) (eg, leukoencephalopathy with
subunit 5 epsilon, 82kDa) (eg, childhood ataxia with
central nervous system hypomyelination/vanishing white
matter), full gene sequence
ENG (endoglin) (eg, hereditary hemorrhagic telangiectasia,
type 1), full gene sequence
EYA1 (eyes absent homolog 1 [Drosophila]) (eg, branchio-
oto-renal [BOR] spectrum disorders), full gene sequence
F8 (coagulation factor VIII) (eg, hemophilia A),
FAH (fumarylacetoacetate hydrolase
[fumarylacetoacetase]) (eg, tyrosinemia, type 1), full gene
sequence
FASTKD2 (FAST kinase domains 2) (eg, mitochondrial
respiratory chain complex IV deficiency), full gene
sequence
FIG4 (FIG4 homolog, SAC1 lipid phosphatase domain
containing [S. cerevisiae]) (eg, Charcot-Marie-Tooth
FTSJ1 (FtsJ RNA methyltransferase homolog 1 [E. coli])
(eg, X-linked mental retardation 9), full gene sequence
FUS (fused in sarcoma) (eg, amyotrophic lateral sclerosis),
full gene sequence
GAA (glucosidase, alpha; acid) (eg, glycogen storage
disease type II [Pompe disease]), full gene sequence
GALC (galactosylceramidase) (eg, Krabbe disease), full
gene sequence
GALT (galactose-1-phosphate uridylyltransferase) (eg,
galactosemia), full gene sequence
GARS (glycyl-tRNA synthetase) (eg, Charcot-Marie-Tooth
GCDH (glutaryl-CoA dehydrogenase) (eg, glutaricacidemia
GCK (glucokinase [hexokinase 4]) (eg, maturity-onset
diabetes of the young [MODY]), full gene sequence
GLUD1 (glutamate dehydrogenase 1) (eg, familial
hyperinsulinism), full gene sequence
GNE (glucosamine [UDP-N-acetyl]-2-epimerase/N-
acetylmannosamine kinase) (eg, inclusion body myopathy 2
[IBM2], Nonaka myopathy), full gene sequence
GRN (granulin) (eg, frontotemporal dementia), full gene
sequence
HADHA (hydroxyacyl-CoA dehydrogenase/3-ketoacyl-CoA
thiolase/enoyl-CoA hydratase [trifunctional protein]
alpha subunit) (eg, long chain acyl-coenzyme A
dehydrogenase deficiency), full gene sequence
HADHB (hydroxyacyl-CoA dehydrogenase/3-ketoacyl-CoA
thiolase/enoyl-CoA hydratase [trifunctional protein], beta
subunit) (eg, trifunctional protein deficiency), full gene
sequence
HEXA (hexosaminidase A, alpha polypeptide) (eg, Tay-
Sachs disease), full gene sequence
HLCS (HLCS holocarboxylase synthetase) (eg,
holocarboxylase synthetase deficiency), full gene sequence
HMBS (hydroxymethylbilane synthase) (eg, acute
intermittent porphyria), full gene sequence
HNF4A (hepatocyte nuclear factor 4, alpha) (eg, maturity-
onset diabetes of the young [MODY]), full gene sequence
IDUA (iduronidase, alpha-L-) (eg, mucopolysaccharidosis
type I), full gene sequence
INF2 (inverted formin, FH2 and WH2 domain containing)
(eg, focal segmental glomerulosclerosis), full gene sequence
IVD (isovaleryl-CoA dehydrogenase) (eg, isovaleric
acidemia), full gene sequence
JAG1 (jagged 1) (eg, Alagille syndrome),
JUP (junction plakoglobin) (eg, arrhythmogenic right
ventricular dysplasia/cardiomyopathy 11), full gene
sequence
KCNH2 (potassium voltage-gated channel, subfamily H
[eag-related], member 2) (eg, short QT syndrome, long QT
KCNQ1 (potassium voltage-gated channel, KQT-like
subfamily, member 1) (eg, short QT syndrome, long QT
KCNQ2 (potassium voltage-gated channel, KQT-like
subfamily, member 2) (eg, epileptic encephalopathy), full
gene sequence
LDB3 (LIM domain binding 3) (eg, familial dilated
cardiomyopathy, myofibrillar myopathy), full gene sequence
LDLR (low density lipoprotein receptor) (eg, familial
hypercholesterolemia), full gene sequence
LEPR (leptin receptor) (eg, obesity with hypogonadism),
full gene sequence
LHCGR (luteinizing hormone/choriogonadotropin
receptor) (eg, precocious male puberty), full gene sequence
LMNA (lamin A/C) (eg, Emery-Dreifuss muscular dystrophy
[EDMD1, 2 and 3] limb-girdle muscular dystrophy [LGMD]
type 1B, dilated cardiomyopathy [CMD1A], familial partial
lipodystrophy [FPLD2]), full gene sequence
LRP5 (low density lipoprotein receptor-related protein 5)
(eg, osteopetrosis), full gene sequence
MAP2K1 (mitogen-activated protein kinase 1) (eg,
cardiofaciocutaneous syndrome), full gene sequence
MAP2K2 (mitogen-activated protein kinase 2) (eg,
cardiofaciocutaneous syndrome), full gene sequence
MAPT (microtubule-associated protein tau) (eg,
frontotemporal dementia), full gene sequence
MCCC1 (methylcrotonoyl-CoA carboxylase 1 [alpha]) (eg,
3-methylcrotonyl-CoA carboxylase deficiency), full gene
sequence
MCCC2 (methylcrotonoyl-CoA carboxylase 2 [beta]) (eg,
3-methylcrotonyl carboxylase deficiency), full gene
sequence
MFN2 (mitofusin 2) (eg, Charcot-Marie-Tooth disease), full
gene sequence
MTM1 (myotubularin 1) (eg, X-linked centronuclear
myopathy), full gene sequence
MUT (methylmalonyl CoA mutase) (eg, methylmalonic
acidemia), full gene sequence
MUTYH (mutY homolog [E. coli]) (eg, MYH-associated
polyposis), full gene sequence
gene sequence
NF2 (neurofibromin 2 [merlin]) (eg, neurofibromatosis,
NOTCH3 (notch 3) (eg, cerebral autosomal dominant
arteriopathy with subcortical infarcts and
leukoencephalopathy [CADASIL]), targeted sequence
analysis (eg, exons 1-23)
NPC1 (Niemann-Pick disease, type C1) (eg, Niemann-Pick
NPHP1 (nephronophthisis 1 [juvenile]) (eg, Joubert
NSD1 (nuclear receptor binding SET domain protein 1)
(eg, Sotos syndrome), full gene sequence
OPA1 (optic atrophy 1) (eg, optic atrophy),
OPTN (optineurin) (eg, amyotrophic lateral sclerosis), full
gene sequence
PAFAH1B1 (platelet-activating factor acetylhydrolase 1b,
regulatory subunit 1 [45kDa]) (eg, lissencephaly, Miller-
Dieker syndrome), full gene sequence
PAH (phenylalanine hydroxylase) (eg, phenylketonuria), full
gene sequence
PARK2 (Parkinson protein 2, E3 ubiquitin protein ligase
[parkin]) (eg, Parkinson disease), full gene sequence
PAX2 (paired box 2) (eg, renal coloboma syndrome), full
gene sequence
PC (pyruvate carboxylase) (eg, pyruvate carboxylase
PCCA (propionyl CoA carboxylase, alpha polypeptide) (eg,
propionic acidemia, type 1), full gene sequence
PCCB (propionyl CoA carboxylase, beta polypeptide) (eg,
propionic acidemia), full gene sequence
PCDH15 (protocadherin-related 15) (eg, Usher syndrome
type 1F), duplication/deletion analysis
PCSK9 (proprotein convertase subtilisin/kexin type 9) (eg,
familial hypercholesterolemia), full gene sequence
PDHA1 (pyruvate dehydrogenase [lipoamide] alpha 1)
(eg, lactic acidosis), full gene sequence
PDHX (pyruvate dehydrogenase complex, component X)
(eg, lactic acidosis), full gene sequence
PHEX (phosphate-regulating endopeptidase homolog, X-
linked) (eg, hypophosphatemic rickets), full gene sequence
PKD2 (polycystic kidney disease 2 [autosomal dominant])
(eg, polycystic kidney disease), full gene sequence
PKP2 (plakophilin 2) (eg, arrhythmogenic right ventricular
PNKD (paroxysmal nonkinesigenic dyskinesia) (eg,
paroxysmal nonkinesigenic dyskinesia), full gene sequence
POLG (polymerase [DNA directed], gamma) (eg, Alpers-
Huttenlocher syndrome, autosomal dominant progressive
external ophthalmoplegia), full gene sequence
POMGNT1 (protein O-linked mannose beta1,2-N
acetylglucosaminyltransferase) (eg, muscle-eye-brain
disease, Walker-Warburg syndrome), full gene sequence
POMT1 (protein-O-mannosyltransferase 1) (eg, limb-
girdle muscular dystrophy [LGMD] type 2K, Walker-
Warburg syndrome), full gene sequence
POMT2 (protein-O-mannosyltransferase 2) (eg, limb-
girdle muscular dystrophy [LGMD] type 2N, Walker-
Warburg syndrome), full gene sequence
PPOX (protoporphyrinogen oxidase) (eg, variegate
porphyria), full gene sequence
PRKAG2 (protein kinase, AMP-activated, gamma 2 non-
catalytic subunit) (eg, familial hypertrophic
cardiomyopathy with Wolff-Parkinson-White syndrome,
lethal congenital glycogen storage disease of heart), full
gene sequence
PRKCG (protein kinase C, gamma) (eg, spinocerebellar
ataxia), full gene sequence
PSEN2 (presenilin 2 [Alzheimer disease 4]) (eg, Alzheimer
PTPN11 (protein tyrosine phosphatase, non-receptor type
11) (eg, Noonan syndrome, LEOPARD syndrome), full gene
sequence
PYGM (phosphorylase, glycogen, muscle) (eg, glycogen
storage disease type V, McArdle disease), full gene
sequence
RAF1 (v-raf-1 murine leukemia viral oncogene homolog 1)
(eg, LEOPARD syndrome), full gene sequence
RET (ret proto-oncogene) (eg, Hirschsprung disease), full
gene sequence
RPE65 (retinal pigment epithelium-specific protein
65kDa) (eg, retinitis pigmentosa, Leber congenital
amaurosis), full gene sequence
RYR1 (ryanodine receptor 1, skeletal) (eg, malignant
hyperthermia), targeted sequence analysis of exons with
functionally-confirmed mutations
SCN4A (sodium channel, voltage-gated, type IV, alpha
subunit) (eg, hyperkalemic periodic paralysis), full gene
sequence
SCNN1A (sodium channel, nonvoltage-gated 1 alpha) (eg,
pseudohypoaldosteronism), full gene sequence
SCNN1B (sodium channel, nonvoltage-gated 1, beta) (eg,
Liddle syndrome, pseudohypoaldosteronism), full gene
sequence
SCNN1G (sodium channel, nonvoltage-gated 1, gamma)
(eg, Liddle syndrome, pseudohypoaldosteronism), full gene
sequence
SDHA (succinate dehydrogenase complex, subunit A,
flavoprotein [Fp]) (eg, Leigh syndrome, mitochondrial
complex II deficiency), full gene sequence
SETX (senataxin) (eg, ataxia), full gene sequence
SGCE (sarcoglycan, epsilon) (eg, myoclonic dystonia), full
gene sequence
SH3TC2 (SH3 domain and tetratricopeptide repeats 2) (eg,
Charcot-Marie-Tooth disease), full gene sequence
SLC9A6 (solute carrier family 9 [sodium/hydrogen
exchanger], member 6) (eg, Christianson syndrome), full
gene sequence
SLC26A4 (solute carrier family 26, member 4) (eg,
Pendred syndrome), full gene sequence
SLC37A4 (solute carrier family 37 [glucose-6-phosphate
transporter], member 4) (eg, glycogen storage disease type
Ib), full gene sequence
SMAD4 (SMAD family member 4) (eg, hemorrhagic
telangiectasia syndrome, juvenile polyposis), full gene
sequence
SOS1 (son of sevenless homolog 1) (eg, Noonan syndrome,
gingival fibromatosis), full gene sequence
SPAST (spastin) (eg, spastic paraplegia), full gene sequence
SPG7 (spastic paraplegia 7 [pure and complicated
autosomal recessive]) (eg, spastic paraplegia), full gene
sequence
STXBP1 (syntaxin-binding protein 1) (eg, epileptic
encephalopathy), full gene sequence
TAZ (tafazzin) (eg, methylglutaconic aciduria type 2, Barth
TCF4 (transcription factor 4) (eg, Pitt-Hopkins syndrome),
full gene sequence
TH (tyrosine hydroxylase) (eg, Segawa syndrome), full gene
sequence
TMEM43 (transmembrane protein 43) (eg, arrhythmogenic
right ventricular cardiomyopathy), full gene sequence
TNNT2 (troponin T, type 2 [cardiac]) (eg, familial
TRPC6 (transient receptor potential cation channel,
subfamily C, member 6) (eg, focal segmental
glomerulosclerosis), full gene sequence
TSC1 (tuberous sclerosis 1) (eg, tuberous sclerosis), full
gene sequence
TSC2 (tuberous sclerosis 2) (eg, tuberous sclerosis),
UBE3A (ubiquitin protein ligase E3A) (eg, Angelman
UMOD (uromodulin) (eg, glomerulocystic kidney disease
with hyperuricemia and isosthenuria), full gene sequence
VWF (von Willebrand factor) (von Willebrand disease type
2A), extended targeted sequence analysis (eg, exons 11-16,
24-26, 51, 52)
WAS (Wiskott-Aldrich syndrome [eczema-
thrombocytopenia]) (eg, Wiskott-Aldrich syndrome), full
gene sequence
2016, 2017, 2018, 2020
➲ CPT Assistant May 12:4, Jul 13:12, Sep 13:5, 6, 8, 11,
Jan 15:3, Aug 16:10, Apr 17:10, May 18:6, Nov 18:9,
Feb 20:10, Mar 20:13
81407 Molecular pathology procedure, Level 8 (eg, analysis of 26-
duplication/deletion variants of >50 exons, sequence
analysis of multiple genes on one platform)
ABCC8 (ATP-binding cassette, sub-family C [CFTR/MRP],
member 8) (eg, familial hyperinsulinism), full gene
sequence
AGL (amylo-alpha-1, 6-glucosidase, 4-alpha-
glucanotransferase) (eg, glycogen storage disease type III),
full gene sequence
AHI1 (Abelson helper integration site 1) (eg, Joubert
APOB (apolipoprotein B) (eg, familial
hypercholesterolemia type B) full gene sequence
ASPM (asp [abnormal spindle] homolog, microcephaly
associated [Drosophila]) (eg, primary microcephaly), full
gene sequence
CHD7 (chromodomain helicase DNA binding protein 7)
(eg, CHARGE syndrome), full gene sequence
COL4A4 (collagen, type IV, alpha 4) (eg, Alport syndrome),
full gene sequence
related disorders), full gene sequence
CREBBP (CREB binding protein) (eg, Rubinstein-Taybi
F8 (coagulation factor VIII) (eg, hemophilia A), full gene
sequence
JAG1 (jagged 1) (eg, Alagille syndrome), full gene
sequence
KDM5C (lysine [K]-specific demethylase 5C) (eg, X-
linked mental retardation), full gene sequence
KIAA0196 (KIAA0196) (eg, spastic paraplegia), full gene
sequence
L1CAM (L1 cell adhesion molecule) (eg, MASA syndrome,
X-linked hydrocephaly), full gene sequence
LAMB2 (laminin, beta 2 [laminin S]) (eg, Pierson
MYBPC3 (myosin binding protein C, cardiac) (eg, familial
MYH6 (myosin, heavy chain 6, cardiac muscle, alpha) (eg,
familial dilated cardiomyopathy), full gene sequence
MYH7 (myosin, heavy chain 7, cardiac muscle, beta) (eg,
familial hypertrophic cardiomyopathy, Liang distal
myopathy), full gene sequence
MYO7A (myosin VIIA) (eg, Usher syndrome, type 1), full
gene sequence
NOTCH1 (notch 1) (eg, aortic valve disease), full gene
sequence
NPHS1 (nephrosis 1, congenital, Finnish type [nephrin])
(eg, congenital Finnish nephrosis), full gene sequence
OPA1 (optic atrophy 1) (eg, optic atrophy), full gene
sequence
PCDH15 (protocadherin-related 15) (eg, Usher syndrome,
PKD1 (polycystic kidney disease 1 [autosomal dominant])
(eg, polycystic kidney disease), full gene sequence
PLCE1 (phospholipase C, epsilon 1) (eg, nephrotic
syndrome type 3), full gene sequence
SCN1A (sodium channel, voltage-gated, type 1, alpha
subunit) (eg, generalized epilepsy with febrile seizures),
full gene sequence
SCN5A (sodium channel, voltage-gated, type V, alpha
subunit) (eg, familial dilated cardiomyopathy), full gene
sequence
[sodium/potassium/chloride transporters], member 1) (eg,
Bartter syndrome), full gene sequence
SLC12A3 (solute carrier family 12 [sodium/chloride
transporters], member 3) (eg, Gitelman syndrome), full
gene sequence
SPG11 (spastic paraplegia 11 [autosomal recessive]) (eg,
spastic paraplegia), full gene sequence
SPTBN2 (spectrin, beta, non-erythrocytic 2) (eg,
spinocerebellar ataxia), full gene sequence
TMEM67 (transmembrane protein 67) (eg, Joubert
TSC2 (tuberous sclerosis 2) (eg, tuberous sclerosis), full
gene sequence
USH1C (Usher syndrome 1C [autosomal recessive,
severe]) (eg, Usher syndrome, type 1), full gene sequence
VPS13B (vacuolar protein sorting 13 homolog B [yeast])
(eg, Cohen syndrome), duplication/deletion analysis
WDR62 (WD repeat domain 62) (eg, primary autosomal
recessive microcephaly), full gene sequence
2019, 2020
Aug 16:10, May 18:6, Nov 18:9, Jul 19:3
81408 Molecular pathology procedure, Level 9 (eg, analysis of
>50 exons in a single gene by DNA sequence analysis)
ABCA4 (ATP-binding cassette, sub-family A [ABC1],
member 4) (eg, Stargardt disease, age-related macular
degeneration), full gene sequence
ATM (ataxia telangiectasia mutated) (eg, ataxia
telangiectasia), full gene sequence
CDH23 (cadherin-related 23) (eg, Usher syndrome, type 1),
full gene sequence
CEP290 (centrosomal protein 290kDa) (eg, Joubert
COL1A1 (collagen, type I, alpha 1) (eg, osteogenesis
imperfecta, type I), full gene sequence
COL1A2 (collagen, type I, alpha 2) (eg, osteogenesis
imperfecta, type I), full gene sequence
COL4A1 (collagen, type IV, alpha 1) (eg, brain small-
vessel disease with hemorrhage), full gene sequence
COL4A3 (collagen, type IV, alpha 3 [Goodpasture
antigen]) (eg, Alport syndrome), full gene sequence
full gene sequence
DMD (dystrophin) (eg, Duchenne/Becker muscular
dystrophy), full gene sequence
DYSF (dysferlin, limb girdle muscular dystrophy 2B
[autosomal recessive]) (eg, limb-girdle muscular
FBN1 (fibrillin 1) (eg, Marfan syndrome), full gene
sequence
ITPR1 (inositol 1,4,5-trisphosphate receptor, type 1) (eg,
spinocerebellar ataxia), full gene sequence
LAMA2 (laminin, alpha 2) (eg, congenital muscular
LRRK2 (leucine-rich repeat kinase 2) (eg, Parkinson
MYH11 (myosin, heavy chain 11, smooth muscle) (eg,
thoracic aortic aneurysms and aortic dissections), full gene
sequence
NEB (nebulin) (eg, nemaline myopathy 2), full gene
sequence
NF1 (neurofibromin 1) (eg, neurofibromatosis, type 1), full
gene sequence
PKHD1 (polycystic kidney and hepatic disease 1) (eg,
autosomal recessive polycystic kidney disease), full gene
sequence
RYR1 (ryanodine receptor 1, skeletal) (eg, malignant
hyperthermia), full gene sequence
RYR2 (ryanodine receptor 2 [cardiac]) (eg,
catecholaminergic polymorphic ventricular tachycardia,
arrhythmogenic right ventricular dysplasia), full gene
sequence or targeted sequence analysis of > 50 exons
USH2A (Usher syndrome 2A [autosomal recessive, mild])
(eg, Usher syndrome, type 2), full gene sequence
VPS13B (vacuolar protein sorting 13 homolog B [yeast])
(eg, Cohen syndrome), full gene sequence
types 1 and 3), full gene sequence
15:3, Aug 16:10, May 18:6, Nov 18:9
# 81479 Unlisted molecular pathology procedure
➲ CPT Assistant Jul 13:12, Sep 13:4-8, Jan 15:3, Apr
16:4, Aug 16:10, Sep 16:10, Apr 17:10, Jun 18:8, Sep
18:15, Nov 18:9, Dec 18:10, May 19:5, Jun 19:11
Genomic Sequencing Procedures and

Other Molecular Multianalyte Assays
Genomic sequencing procedures (GSPs) and other molecular
multianalyte assays GSPs are DNA or RNA sequence analysis
methods that simultaneously assay multiple genes or genetic
regions relevant to a clinical situation. They may target specific
combinations of genes or genetic material, or assay the exome or
genome. The technology used for genomic sequencing is
commonly referred to as next generation sequencing (NGS) or
massively parallel sequencing (MPS). GSPs are performed on
nucleic acids from germline or neoplastic samples. Examples of
applications include aneuploidy analysis of cell-free circulating
fetal DNA, gene panels for somatic alterations in neoplasms, and
sequence analysis of the exome or genome to determine the cause
of developmental delay. The exome and genome procedures are
designed to evaluate the genetic material in totality or near
totality. Although commonly used to identify sequence (base)
changes, they can also be used to identify copy number,
structural changes, and abnormal zygosity patterns. Another
unique feature of GSPs is the ability to “re-query” or re-evaluate
the sequence data (eg, complex phenotype such as developmental
delay is reassessed when new genetic knowledge is attained, or
for a separate unrelated clinical indication). The analyses listed
below represent groups of genes that are often performed by
GSPs; however, the analyses may also be performed by other
molecular techniques (polymerase chain reaction [PCR] methods
and microarrays). These codes should be used when the
components of the descriptor(s) are fulfilled regardless of the
technique used to provide the analysis, unless specifically noted
in the code descriptor. When a GSP assay includes gene(s) that is
listed in more than one code descriptor, the code for the most
specific test for the primary disorder sought should be reported,
rather than reporting multiple codes for the same gene(s). When
all of the components of the descriptor are not performed, use
individual Tier 1 codes, Tier 2 codes, or 81479 (Unlisted
molecular pathology procedure).
The assays in this section represent discrete genetic values,
properties, or characteristics in which the measurement or
analysis of each analyte is potentially of independent medical
significance or useful in medical management. In contrast to
multianalyte assays with algorithmic analyses (MAAAs), the
assays in this section do not represent algorithmically combined
results to obtain a risk score or other value, which in itself
represents a new and distinct medical property that is of
independent medical significance relative to the individual,
component test results.
(For cytogenomic microarray analyses, see 81228, 81229,
81405, 81406)
81410 Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys
Dietz syndrome, Ehler Danlos syndrome type IV, arterial
tortuosity syndrome); genomic sequence analysis panel, must
include sequencing of at least 9 genes, including FBN1,
TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10,
SMAD3, and MYLK
81411 duplication/deletion analysis panel, must include

analyses for TGFBR1, TGFBR2, MYH11, and COL3A1
81412 Ashkenazi Jewish associated disorders (eg, Bloom

syndrome, Canavan disease, cystic fibrosis, familial
dysautonomia, Fanconi anemia group C, Gaucher disease,
Tay-Sachs disease), genomic sequence analysis panel, must
include sequencing of at least 9 genes, including ASPA,
BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and
SMPD1
➲ CPT Assistant Apr 16:4, Nov 18:9
81413 Cardiac ion channelopathies (eg, Brugada syndrome, long

QT syndrome, short QT syndrome, catecholaminergic
polymorphic ventricular tachycardia); genomic sequence
analysis panel, must include sequencing of at least 10 genes,
including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2,
KCNJ2, KCNQ1, RYR2, and SCN5A
81414 duplication/deletion gene analysis panel, must include

analysis of at least 2 genes, including KCNH2 and
KCNQ1
(For genomic sequencing panel testing for

cardiomyopathies, use 81439)
(Do not report 81413, 81414 in conjunction with 81439
when performed on the same date of service)
#● 81419 Epilepsy genomic sequence analysis panel, must include
analyses for ALDH7A1, CACNA1A, CDKL5, CHD2,
GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG,
PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1,
SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2,
and ZEB2
81415 Exome (eg, unexplained constitutional or heritable disorder

or syndrome); sequence analysis
✚ 81416 sequence analysis, each comparator exome (eg, parents,
siblings) (List separately in addition to code for primary
procedure)

81417 re-evaluation of previously obtained exome sequence
(eg, updated knowledge or unrelated
condition/syndrome)
(Do not report 81417 for incidental findings)

(For exome-wide copy number assessment by microarray,
see 81228, 81229)
81420 Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy
X) genomic sequence analysis panel, circulating cell-free
fetal DNA in maternal blood, must include analysis of
chromosomes 13, 18, and 21
➲ CPT Assistant Jan 15:3, Dec 15:17, Apr 18:11
(Do not report 81228, 81229, 88271 when performing

genomic sequencing procedures or other molecular
multianalyte assays for copy number analysis)
81422 Fetal chromosomal microdeletion(s) genomic sequence
analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome),
circulating cell-free fetal DNA in maternal blood

# 81443 Genetic testing for severe inherited conditions (eg, cystic
fibrosis, Ashkenazi Jewish-associated disorders [eg, Bloom
syndrome, Canavan disease, Fanconi anemia type C,
mucolipidosis type VI, Gaucher disease, Tay-Sachs
disease], beta hemoglobinopathies, phenylketonuria,
galactosemia), genomic sequence analysis panel, must
include sequencing of at least 15 genes (eg, ACADM, ARSA,
ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7,
FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA,
IKBKAP, MCOLN1, PAH)
(If spinal muscular atrophy testing is performed separately,

use 81329)
(If testing is performed only for Ashkenazi Jewish-
associated disorders, use 81412)
(If FMR1 [expanded allele] testing is performed separately,
use 81243)
(If hemoglobin A testing is performed separately, use
81257)
81425 Genome (eg, unexplained constitutional or heritable
disorder or syndrome); sequence analysis
✚ 81426 sequence analysis, each comparator genome (eg, parents,

siblings) (List separately in addition to code for primary
procedure)
81427 re-evaluation of previously obtained genome sequence
(eg, updated knowledge or unrelated
condition/syndrome)
(Do not report 81427 for incidental findings)

(For genome-wide copy number assessment by microarray,
see 81228, 81229)
81430 Hearing loss (eg, nonsyndromic hearing loss, Usher
syndrome, Pendred syndrome); genomic sequence analysis
panel, must include sequencing of at least 60 genes,
including CDH23, CLRN1, GJB2, GPR98, MTRNR1,
MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1,
TMPRSS3, USH1C, USH1G, USH2A, and WFS1
81431 duplication/deletion analysis panel, must include copy

number analyses for STRC and DFNB1 deletions in
GJB2 and GJB6 genes
81432 Hereditary breast cancer-related disorders (eg, hereditary

breast cancer, hereditary ovarian cancer, hereditary
endometrial cancer); genomic sequence analysis panel, must
include sequencing of at least 10 genes, always including
BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2,
PTEN, STK11, and TP53

analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11
81434 Hereditary retinal disorders (eg, retinitis pigmentosa, Leber
congenital amaurosis, cone-rod dystrophy), genomic
sequence analysis panel, must include sequencing of at least
15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A,
PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2,
RPE65, RPGR, and USH2A
81435 Hereditary colon cancer disorders (eg, Lynch syndrome,

PTEN hamartoma syndrome, Cowden syndrome, familial
adenomatosis polyposis); genomic sequence analysis panel,
must include sequencing of at least 10 genes, including APC,
BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN,
SMAD4, and STK11

analysis of at least 5 genes, including MLH1, MSH2,
EPCAM, SMAD4, and STK11
81437 Hereditary neuroendocrine tumor disorders (eg, medullary

thyroid carcinoma, parathyroid carcinoma, malignant
pheochromocytoma or paraganglioma); genomic sequence
including MAX, SDHB, SDHC, SDHD, TMEM127, and
VHL

analyses for SDHB, SDHC, SDHD, and VHL
# 81448 Hereditary peripheral neuropathies (eg, Charcot-Marie-

Tooth, spastic paraplegia), genomic sequence analysis
panel, must include sequencing of at least 5 peripheral
neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ,
REEP1, SPAST, SPG11, SPTLC1)
81439 Hereditary cardiomyopathy (eg, hypertrophic

cardiomyopathy, dilated cardiomyopathy, arrhythmogenic
right ventricular cardiomyopathy), genomic sequence
analysis panel, must include sequencing of at least 5
cardiomyopathy-related genes (eg, DSG2, MYBPC3, MYH7,
PKP2, TTN)
➲ CPT Assistant Apr 17:3, Sep 18:15

when performed on the same date of service)
(For genomic sequencing panel testing for cardiac ion
channelopathies, see 81413, 81414)
81440 Nuclear encoded mitochondrial genes (eg, neurologic or
myopathic phenotypes), genomic sequence panel, must
include analysis of at least 100 genes, including BCS1L,
C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2,
POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2,
SUCLG1, TAZ, TK2, and TYMP
81442 Noonan spectrum disorders (eg, Noonan syndrome, cardio-

facio-cutaneous syndrome, Costello syndrome, LEOPARD
syndrome, Noonan-like syndrome), genomic sequence
including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2,
NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1

81445 Targeted genomic sequence analysis panel, solid organ
neoplasm, DNA analysis, and RNA analysis when
performed, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR,
ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB,
PGR, PIK3CA, PTEN, RET), interrogation for sequence
variants and copy number variants or rearrangements, if
performed
(For copy number assessment by microarray, use 81406)

81450 Targeted genomic sequence analysis panel, hematolymphoid
neoplasm or disorder, DNA analysis, and RNA analysis
when performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A,
EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS,
NPM1, NOTCH1), interrogation for sequence variants, and
copy number variants or rearrangements, or isoform
expression or mRNA expression levels, if performed

81455 Targeted genomic sequence analysis panel, solid organ or
hematolymphoid neoplasm, DNA analysis, and RNA
analysis when performed, 51 or greater genes (eg, ALK,
BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2,
FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS,
MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA,
PTEN, RET), interrogation for sequence variants and copy
number variants or rearrangements, if performed

81460 Whole mitochondrial genome (eg, Leigh syndrome,
mitochondrial encephalomyopathy, lactic acidosis, and
stroke-like episodes [MELAS], myoclonic epilepsy with
ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis
pigmentosa [NARP], Leber hereditary optic neuropathy
[LHON]), genomic sequence, must include sequence
analysis of entire mitochondrial genome with heteroplasmy
detection
81465 Whole mitochondrial genome large deletion analysis panel

(eg, Kearns-Sayre syndrome, chronic progressive external
ophthalmoplegia), including heteroplasmy detection, if
performed
81470 X-linked intellectual disability (XLID) (eg, syndromic and

non-syndromic XLID); genomic sequence analysis panel,
must include sequencing of at least 60 genes, including ARX,
ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL,
KDM5C, L1CAM, MECP2, MED12, MID1, OCRL,
RPS6KA3, and SLC16A2
81471 duplication/deletion gene analysis, must include analysis

of at least 60 genes, including ARX, ATRX, CDKL5,
FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM,
MECP2, MED12, MID1, OCRL, RPS6KA3, and
SLC16A2
Multianalyte Assays with Algorithmic

Analyses
Multianalyte Assays with Algorithmic Analyses (MAAAs) are
procedures that utilize multiple results derived from panels of
analyses of various types, including molecular pathology assays,
fluorescent in situ hybridization assays, and non-nucleic acid
based assays (eg, proteins, polypeptides, lipids, carbohydrates).
Algorithmic analysis using the results of these assays as well as
other patient information (if used) is then performed and
typically reported as a numeric score(s) or as a probability.
MAAAs are typically unique to a single clinical laboratory or
manufacturer. The results of individual component procedure(s)
that are inputs to the MAAAs may be provided on the associated
laboratory report; however, these assays are not separately
reported using additional codes.
The format for the code descriptors of MAAAs usually include
(in order):
• Disease type (eg, oncology, autoimmune, tissue rejection),
• Material(s) analyzed (eg, DNA, RNA, protein, antibody),
• Number of markers (eg, number of genes, number of
proteins),
• Methodology(ies) (eg, microarray, real-time [RT]-PCR, in situ
hybridization [ISH], enzyme linked immunosorbent assays
[ELISA]),
• Number of functional domains (if indicated),
• Specimen type (eg, blood, fresh tissue, formalin-fixed
paraffin-embedded),
• Algorithm result type (eg, prognostic, diagnostic),
• Report (eg, probability index, risk score)
In contrast to GSPs and other molecular multianalyte assays, the
assays in this section represent algorithmically combined results
of analyses of multiple analytes to obtain a risk score or other
value which in itself represents a new and distinct medical
property that is of independent medical significance relative to
the individual component test results in clinical context in which
the assay is performed.
MAAAs, including those that do not have a Category I code, may
be found in Appendix O. MAAAs that do not have a Category I
code are identified in Appendix O by a four-digit number
followed by the letter “M.” The Category I MAAA codes that are
included in this subsection are also included in Appendix O. All
MAAA codes are listed in Appendix O along with the
procedure’s proprietary name. In order to report a MAAA code,
the analysis performed must fulfill the code descriptor and, if
proprietary, must be the test represented by the proprietary name
listed in Appendix O.
When a specific MAAA procedure is not listed below or in
Appendix O, the procedure must be reported using the Category I
MAAA unlisted code (81599).
These codes encompass all analytical services required (eg, cell
lysis, nucleic acid stabilization, extraction, digestion,
amplification, hybridization, and detection) in addition to the
algorithmic analysis itself. Procedures that are required prior to
cell lysis (eg, microdissection, codes 88380 and 88381) should be
81490 Autoimmune (rheumatoid arthritis), analysis of 12
biomarkers using immunoassays, utilizing serum, prognostic
algorithm reported as a disease activity score

# 81595 Cardiology (heart transplant), mRNA, gene expression
profiling by real-time quantitative PCR of 20 genes (11
content and 9 housekeeping), utilizing subfraction of
peripheral blood, algorithm reported as a rejection risk
score
81493 Coronary artery disease, mRNA, gene expression profiling

by real-time RT-PCR of 23 genes, utilizing whole peripheral
blood, algorithm reported as a risk score

81506 Endocrinology (type 2 diabetes), biochemical assays of
seven analytes (glucose, HbA1c, insulin, hs-CRP,
adiponectin, ferritin, interleukin 2-receptor alpha), utilizing
serum or plasma, algorithm reporting a risk score
(Do not report 81506 in conjunction with constituent
components [ie, 82728, 82947, 83036, 83525, 86141],
84999 [for adopectin], and 83520 [for interleukin 2-
receptor alpha])
81507 Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence
analysis of selected regions using maternal plasma,
algorithm reported as a risk score for each trisomy

81508 Fetal congenital abnormalities, biochemical assays of two
proteins (PAPP-A, hCG [any form]), utilizing maternal
serum, algorithm reported as a risk score

81509 Fetal congenital abnormalities, biochemical assays of three
proteins (PAPP-A, hCG [any form], DIA), utilizing maternal

86336)
81510 Fetal congenital abnormalities, biochemical assays of three
analytes (AFP, uE3, hCG [any form]), utilizing maternal

84702)
81511 Fetal congenital abnormalities, biochemical assays of four
analytes (AFP, uE3, hCG [any form], DIA) utilizing maternal
serum, algorithm reported as a risk score (may include
additional results from previous biochemical testing)

84702, 86336)
81512 Fetal congenital abnormalities, biochemical assays of five
analytes (AFP, uE3, total hCG, hyperglycosylated hCG,
DIA) utilizing maternal serum, algorithm reported as a risk
score

84702, 86336)
● 81513 Infectious disease, bacterial vaginosis, quantitative real-
time amplification of RNA markers for Atopobium vaginae,
Gardnerella vaginalis, and Lactobacillus species, utilizing
vaginal-fluid specimens, algorithm reported as a positive or
negative result for bacterial vaginosis
● 81514 Infectious disease, bacterial vaginosis and vaginitis,

quantitative real-time amplification of DNA markers for
Gardnerella vaginalis, Atopobium vaginae, Megasphaera
type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-
2), and Lactobacillus species (L. crispatus and L. jensenii),
utilizing vaginal-fluid specimens, algorithm reported as a
positive or negative for high likelihood of bacterial
vaginosis, includes separate detection of Trichomonas
vaginalis and/or Candida species (C. albicans, C. tropicalis,
C. parapsilosis, C. dubliniensis), Candida glabrata, Candida
krusei, when reported

87482, 87510, 87511, 87512, 87660, 87661)◀
# 81596 Infectious disease, chronic hepatitis C virus (HCV)
infection, six biochemical assays (ALT, A2-macroglobulin,
apolipoprotein A-1, total bilirubin, GGT, and haptoglobin)
utilizing serum, prognostic algorithm reported as scores for
fibrosis and necroinflammatory activity in liver
81518 Oncology (breast), mRNA, gene expression profiling by

real-time RT-PCR of 11 genes (7 content and 4
housekeeping), utilizing formalin-fixed paraffin-embedded
tissue, algorithms reported as percentage risk for metastatic
recurrence and likelihood of benefit from extended
endocrine therapy
# 81522 Oncology (breast), mRNA, gene expression profiling by RT-

PCR of 12 genes (8 content and 4 housekeeping), utilizing
formalin-fixed paraffin-embedded tissue, algorithm reported
as recurrence risk score
81519 Oncology (breast), mRNA, gene expression profiling by

real-time RT-PCR of 21 genes, utilizing formalin-fixed
paraffin-embedded tissue, algorithm reported as recurrence
score
81520 Oncology (breast), mRNA gene expression profiling by

hybrid capture of 58 genes (50 content and 8 housekeeping),
utilizing formalin-fixed paraffin-embedded tissue, algorithm
reported as a recurrence risk score
81521 Oncology (breast), mRNA, microarray gene expression

profiling of 70 content genes and 465 housekeeping genes,
utilizing fresh frozen or formalin-fixed paraffin-embedded
tissue, algorithm reported as index related to risk of distant
metastasis

81525 Oncology (colon), mRNA, gene expression profiling by
tissue, algorithm reported as a recurrence score
81528 Oncology (colorectal) screening, quantitative real-time
target and signal amplification of 10 DNA markers (KRAS
mutations, promoter methylation of NDRG4 and BMP3) and
fecal hemoglobin, utilizing stool, algorithm reported as a
positive or negative result

● 81529 Oncology (cutaneous melanoma), mRNA, gene expression
profiling by real-time RT-PCR of 31 genes (28 content and 3
tissue, algorithm reported as recurrence risk, including
likelihood of sentinel lymph node metastasis
81535 Oncology (gynecologic), live tumor cell culture and

chemotherapeutic response by DAPI stain and morphology,
predictive algorithm reported as a drug response score; first
single drug or drug combination
✚ 81536 each additional single drug or drug combination (List

81538 Oncology (lung), mass spectrometric 8-protein signature,
including amyloid A, utilizing serum, prognostic and
predictive algorithm reported as good versus poor overall
survival
# 81500 Oncology (ovarian), biochemical assays of two proteins

(CA-125 and HE4), utilizing serum, with menopausal status,
algorithm reported as a risk score

# 81503 Oncology (ovarian), biochemical assays of five proteins
(CA-125, apolipoprotein A1, beta-2 microglobulin,
transferrin, and pre-albumin), utilizing serum, algorithm
reported as a risk score

84134, 84466, 86304)
81539 Oncology (high-grade prostate cancer), biochemical assay
of four proteins (Total PSA, Free PSA, Intact PSA, and
human kallikrein-2 [hK2]), utilizing plasma or serum,
prognostic algorithm reported as a probability score

81541 Oncology (prostate), mRNA gene expression profiling by
tissue, algorithm reported as a disease-specific mortality
risk score
81542 Oncology (prostate), mRNA, microarray gene expression
profiling of 22 content genes, utilizing formalin-fixed
paraffin-embedded tissue, algorithm reported as metastasis
risk score

81551 Oncology (prostate), promoter methylation profiling by real-
time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing
formalin-fixed paraffin-embedded tissue, algorithm reported
as a likelihood of prostate cancer detection on repeat biopsy
#● 81546 Oncology (thyroid), mRNA, gene expression analysis of

10,196 genes, utilizing fine needle aspirate, algorithm
reported as a categorical result (eg, benign or suspicious)
# 81504 Oncology (tissue of origin), microarray gene expression

profiling of > 2000 genes, utilizing formalin-fixed paraffin-
embedded tissue, algorithm reported as tissue similarity
scores
# 81540 Oncology (tumor of unknown origin), mRNA, gene

expression profiling by real-time RT-PCR of 92 genes (87
content and 5 housekeeping) to classify tumor into main
cancer type and subtype, utilizing formalin-fixed paraffin-
embedded tissue, algorithm reported as a probability of a
predicted main cancer type and subtype
81552 Oncology (uveal melanoma), mRNA, gene expression
profiling by real-time RT-PCR of 15 genes (12 content and 3
housekeeping), utilizing fine needle aspirate or formalin-
fixed paraffin-embedded tissue, algorithm reported as risk
of metastasis
● 81554 Pulmonary disease (idiopathic pulmonary fibrosis [IPF]),

mRNA, gene expression analysis of 190 genes, utilizing
transbronchial biopsies, diagnostic algorithm reported as
categorical result (eg, positive or negative for high
probability of usual interstitial pneumonia [UIP])

81599 Unlisted multianalyte assay with algorithmic analysis
➲ CPT Assistant Apr 18:11, Jun 18:8, Jun 19:11
(Do not use 81599 for multianalyte assays with algorithmic

analyses listed in Appendix O)
Chemistry
The material for examination may be from any source unless
otherwise specified in the code descriptor. When an analyte is
measured in multiple specimens from different sources, or in
specimens that are obtained at different times, the analyte is
reported separately for each source and for each specimen. The
examination is quantitative unless specified. To report an organ
or disease oriented panel, see codes 80048-80076.
Clinical information or mathematically calculated values, which
are not specifically requested by the ordering physician and are
derived from the results of other ordered or performed
laboratory tests, are considered part of the ordered test
procedure(s) and therefore are not separately reportable
service(s).
When the requested analyte result is derived using a calculation
that requires values from nonrequested laboratory analyses, only
the requested analyte code should be reported.
When the calculated analyte determination requires values
derived from other requested and nonrequested laboratory
analyses, the requested analyte codes (including those calculated)
should be reported.
An exception to the above is when an analyte (eg, urinary
creatinine) is performed to compensate for variations in urine
concentration (eg, microalbumin, thromboxane metabolites) in
random urine samples; the appropriate CPT code is reported for
both the ordered analyte and the additional required analyte.
When the calculated result(s) represent an algorithmically derived
numeric score or probability, see the appropriate multianalyte
assay with algorithmic analyses (MAAA) code or the MAAA
unlisted code (81599).
82009 Ketone body(s) (eg, acetone, acetoacetic acid, beta-
hydroxybutyrate); qualitative
82010 quantitative
82013 Acetylcholinesterase
(Acid phosphatase, see 84060-84066)
82016 Acylcarnitines; qualitative, each specimen
82017 quantitative, each specimen

(For carnitine, use 82379)

82024 Adrenocorticotropic hormone (ACTH)
82030 Adenosine, 5-monophosphate, cyclic (cyclic AMP)
82040 Albumin; serum, plasma or whole blood

82043 urine (eg, microalbumin), quantitative
82044 urine (eg, microalbumin), semiquantitative (eg, reagent

strip assay)
➲ CPT Assistant Summer 94:2, Mar 98:3, Sep 02:10
(For prealbumin, use 84134)

82045 ischemia modified
# 82042 other source, quantitative, each specimen

(For total protein, see 84155, 84156, 84157, 84160)

▲ 82075 Alcohol (ethanol); breath
● 82077 any specimen except urine and breath, immunoassay (eg,
IA, EIA, ELISA, RIA, EMIT, FPIA) and enzymatic
methods (eg, alcohol dehydrogenase)
▶ (Fordefinitive drug testing for alcohol [ethanol], use

80320)◀
82085 Aldolase
82088 Aldosterone
(Alkaline phosphatase, see 84075, 84080)

(Alphaketoglutarate, see 82009, 82010)
(Alpha tocopherol [Vitamin E], use 84446)
82103 Alpha-1-antitrypsin; total
82104 phenotype
82105 Alpha-fetoprotein (AFP); serum
82106 amniotic fluid
82107 AFP-L3 fraction isoform and total AFP (including ratio)
82108 Aluminum
82120 Amines, vaginal fluid, qualitative
(For combined pH and amines test for vaginitis, use 82120

and 83986)
82127 Amino acids; single, qualitative, each specimen
82128 multiple, qualitative, each specimen

82131 single, quantitative, each specimen
82135 Aminolevulinic acid, delta (ALA)

82136 Amino acids, 2 to 5 amino acids, quantitative, each
specimen
82139 Amino acids, 6 or more amino acids, quantitative, each

specimen
82140 Ammonia
82143 Amniotic fluid scan (spectrophotometric)
(For L/S ratio, use 83661)
(Amobarbital, use 80345)
82150 Amylase
82154 Androstanediol glucuronide
82157 Androstenedione
82160 Androsterone
82163 Angiotensin II
82164 Angiotensin I - converting enzyme (ACE)
(Antidiuretic hormone (ADH), use 84588)
(Antimony, use 83015)
(Antitrypsin, alpha-1-, see 82103, 82104)
82172 Apolipoprotein, each
82175 Arsenic
(For heavy metal screening, use 83015)
82180 Ascorbic acid (Vitamin C), blood
(Aspirin, see acetylsalicylic acid, 80329, 80330, 80331)
80179)◀
(Atherogenic index, blood, ultracentrifugation, quantitative,
use 83701)
82190 Atomic absorption spectroscopy, each analyte
82232 Beta-2 microglobulin

(Bicarbonate, use 82374)
82239 Bile acids; total
82240 cholylglycine
(For bile pigments, urine, see 81000-81005)
82247 Bilirubin; total
➲ CPT Assistant Nov 98:24, Apr 99:6, Dec 99:1, Jan 00:7,
Dec 08:5, Apr 10:11
82248 direct
➲ CPT Assistant Nov 98:24, Apr 99:6, Dec 99:1, Apr
10:11
82252 feces, qualitative
82261 Biotinidase, each specimen
82270 Blood, occult, by peroxidase activity (eg, guaiac),

qualitative; feces, consecutive collected specimens with
single determination, for colorectal neoplasm screening (ie,
patient was provided 3 cards or single triple card for
consecutive collection)
➲ CPT Assistant Sep 03:15, Feb 06:7, Apr 08:5
82271 other sources
82272 Blood, occult, by peroxidase activity (eg, guaiac),

qualitative, feces, 1-3 simultaneous determinations,
performed for other than colorectal neoplasm screening
➲ CPT Assistant Feb 06:7, Apr 08:5, Jun 09:10
(Blood urea nitrogen [BUN], see 84520, 84525)

82274 Blood, occult, by fecal hemoglobin determination by
immunoassay, qualitative, feces, 1-3 simultaneous
determinations
82286 Bradykinin
82300 Cadmium
82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed

# 82652 1, 25 dihydroxy, includes fraction(s), if performed

82308 Calcitonin
82310 Calcium; total
82330 ionized
82331 after calcium infusion test

82340 urine quantitative, timed specimen
82355 Calculus; qualitative analysis
82360 quantitative analysis, chemical

82365 infrared spectroscopy
82370 X-ray diffraction
(Carbamates, see individual listings)

82373 Carbohydrate deficient transferrin
82374 Carbon dioxide (bicarbonate)

(See also 82803)

82375 Carboxyhemoglobin; quantitative
82376 qualitative
(For transcutaneous measurement of carboxyhemoglobin,

use 88740)
82378 Carcinoembryonic antigen (CEA)
➲ CPT Assistant Fall 93:25, Aug 96:11
82379 Carnitine (total and free), quantitative, each specimen

(For acylcarnitine, see 82016, 82017)

82380 Carotene
82382 Catecholamines; total urine
82383 blood
82384 fractionated
(For urine metabolites, see 83835, 84585)
82387 Cathepsin-D
82390 Ceruloplasmin
82397 Chemiluminescent assay
82415 Chloramphenicol
82435 Chloride; blood

82436 urine
82438 other source
(For sweat collection by iontophoresis, use 89230)

82441 Chlorinated hydrocarbons, screen
(Cholecalciferol [Vitamin D], use 82306)
82465 Cholesterol, serum or whole blood, total
(For high density lipoprotein [HDL], use 83718)

82480 Cholinesterase; serum
82482 RBC
82485 Chondroitin B sulfate, quantitative
(Chorionic gonadotropin, see gonadotropin, 84702, 84703)
82495 Chromium
82507 Citrate
(Cocaine, qualitative analysis, use 80353)
(Codeine, qualitative analysis, use 80361)
(Complement, see 86160-86162)
82523 Collagen cross links, any method
82525 Copper
(Coproporphyrin, see 84119, 84120)
(Corticosteroids, use 83491)
82528 Corticosterone
82530 Cortisol; free
82533 total
(C-peptide, use 84681)

82540 Creatine
82542 Column chromatography, includes mass spectrometry, if
performed (eg, HPLC, LC, LC/MS, LC/MS-MS, GC,
GC/MS-MS, GC/MS, HPLC/MS), non-drug analyte(s) not
elsewhere specified, qualitative or quantitative, each
specimen
➲ CPT Assistant Nov 98:24-25, Apr 15:3
(Do not report more than one unit of 82542 for each
specimen)
(For column chromatography/mass spectrometry of drugs or
substances, see 80305, 80306, 80307, 80320-80377, or
specific analyte code[s] in the Chemistry section)
82550 Creatine kinase (CK), (CPK); total
82552 isoenzymes
82553 MB fraction only

82554 isoforms
82565 Creatinine; blood

82570 other source

82575 clearance
82585 Cryofibrinogen
82595 Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit)
(For quantitative, cryoglobulin, see 82784, 82785)

(Crystals, pyrophosphate vs urate, use 89060)
82600 Cyanide
82607 Cyanocobalamin (Vitamin B-12);

82608 unsaturated binding capacity
(Cyclic AMP, use 82030)
(Cyclosporine, use 80158)
82610 Cystatin C
82615 Cystine and homocystine, urine, qualitative

82626 Dehydroepiandrosterone (DHEA)
(Do not report 82626 in conjunction with 80327, 80328 to
identify anabolic steroid testing for testosterone)
82627 Dehydroepiandrosterone-sulfate (DHEA-S)
(Delta-aminolevulinic acid (ALA), use 82135)

82633 Desoxycorticosterone, 11-
82634 Deoxycortisol, 11-
(Dexamethasone suppression test, use 80420)
(Diastase, urine, use 82150)
82638 Dibucaine number
(Dichloroethane, use 82441)
(Dichloromethane, use 82441)
(Diethylether, use 84600)
82642 Dihydrotestosterone (DHT)
(For dihydrotestosterone analysis for anabolic drug testing,

see 80327, 80328)
(Dipropylacetic acid, use 80164)
(Dopamine, see 82382-82384)
(Duodenal contents, see individual enzymes; for intubation
and collection, see 43756, 43757)
82656 Elastase, pancreatic (EL-1), fecal, qualitative or semi-
quantitative
82657 Enzyme activity in blood cells, cultured cells, or tissue, not
elsewhere specified; nonradioactive substrate, each
specimen
82658 radioactive substrate, each specimen

82664 Electrophoretic technique, not elsewhere specified

(Endocrine receptor assays, see 84233-84235)
82668 Erythropoietin
▲ 82670 Estradiol; total
#● 82681 free, direct measurement (eg, equilibrium dialysis)

82671 Estrogens; fractionated

82672 total
(Estrogen receptor assay, use 84233)
82677 Estriol
82679 Estrone
▶ (Fordefinitive drug testing for alcohol [ethanol], use
80320)◀
▶ (Foralcohol [ethanol] by immunoassay or enzymatic
82693 Ethylene glycol
82696 Etiocholanolone
(For fractionation of ketosteroids, use 83593)

82705 Fat or lipids, feces; qualitative
82710 quantitative
82715 Fat differential, feces, quantitative
82725 Fatty acids, nonesterified
82726 Very long chain fatty acids
82728 Ferritin
(Fetal hemoglobin, see hemoglobin 83030, 83033, and
85460)
(Fetoprotein, alpha-1, see 82105, 82106)
82731 Fetal fibronectin, cervicovaginal secretions, semi-
quantitative
82735 Fluoride
(Foam stability test, use 83662)
82746 Folic acid; serum
82747 RBC
(Follicle stimulating hormone [FSH], use 83001)
82757 Fructose, semen
(Fructosamine, use 82985)
(Fructose, TLC screen, use 84375)
82759 Galactokinase, RBC
82760 Galactose
82775 Galactose-1-phosphate uridyl transferase; quantitative
82776 screen
82777 Galectin-3
82784 Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each

➲ CPT Assistant Spring 94:31, Aug 00:11
82785 IgE
(For allergen specific IgE, see 86003, 86005)

82787 immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each
(Gamma-glutamyltransferase [GGT], use 82977)

82800 Gases, blood, pH only
82803 Gases, blood, any combination of pH, pCO2, pO2, CO2,

HCO3 (including calculated O2 saturation);
(Use 82803 for 2 or more of the above listed analytes)
82805 with O2 saturation, by direct measurement, except pulse
oximetry
82810 Gases, blood, O2 saturation only, by direct measurement,
except pulse oximetry
(For pulse oximetry, use 94760)
82820 Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin
saturation with oxygen)

82930 Gastric acid analysis, includes pH if performed, each
specimen
➲ CPT Assistant Oct 10:7, Dec 10:7, Sep 11:3
82938 Gastrin after secretin stimulation

82941 Gastrin
(Gentamicin, use 80170)

(GGT, use 82977)
(For a qualitative column chromatography procedure [eg,
gas liquid chromatography], use the appropriate specific
analyte code, if available, or 82542)
82943 Glucagon
82945 Glucose, body fluid, other than blood
82946 Glucagon tolerance test

82947 Glucose; quantitative, blood (except reagent strip)
➲ CPT Assistant Summer 93:14, Summer 94:5, Sep 99:10,
Dec 99:2, Jun 02:3, Feb 05:9, Apr 13:10
82948 blood, reagent strip
➲ CPT Assistant Summer 94:5, Jan 99:10, Nov 10:10,
Oct 11:8
82950 post glucose dose (includes glucose)
➲ CPT Assistant Sep 99:10, Jun 02:3, Feb 05:9
82951 tolerance test (GTT), 3 specimens (includes glucose)
➲ CPT Assistant Feb 01:10, Feb 05:9, Oct 10:7
✚ 82952 tolerance test, each additional beyond 3 specimens (List

➲ CPT Assistant Feb 01:10, Oct 10:7, Dec 10:7

(For insulin tolerance test, see 80434, 80435)
(For leucine tolerance test, use 80428)
(For semiquantitative urine glucose, see 81000, 81002,
81005, 81099)
82955 Glucose-6-phosphate dehydrogenase (G6PD); quantitative
82960 screen
(For glucose tolerance test with medication, use 96374 in
addition)
82962 Glucose, blood by glucose monitoring device(s) cleared by
the FDA specifically for home use
➲ CPT Assistant Summer 94:4, Jan 99:10, Nov 10:10, Oct
11:8
82963 Glucosidase, beta
82965 Glutamate dehydrogenase
82977 Glutamyltransferase, gamma (GGT)
82978 Glutathione
82979 Glutathione reductase, RBC
(Glycohemoglobin, use 83036)
82985 Glycated protein
(Gonadotropin, chorionic, see 84702, 84703)
83001 Gonadotropin; follicle stimulating hormone (FSH)
83002 luteinizing hormone (LH)

(For luteinizing releasing factor [LRH], use 83727)
83003 Growth hormone, human (HGH) (somatotropin)
(For antibody to human growth hormone, use 86277)
83006 Growth stimulation expressed gene 2 (ST2, Interleukin 1
receptor like-1)
83009 Helicobacter pylori, blood test analysis for urease activity,

non-radioactive isotope (eg, C-13)
(For H. pylori, breath test analysis for urease activity, see

83013, 83014)
83010 Haptoglobin; quantitative
83012 phenotypes
83013 Helicobacter pylori; breath test analysis for urease activity,
non-radioactive isotope (eg, C-13)
➲ CPT Assistant Nov 98:25, Feb 99:8, Nov 99:45
83014 drug administration

➲ CPT Assistant Nov 98:25, Feb 99:8, Nov 99:45
(For H. pylori, stool, use 87338. For H. pylori, liquid

scintillation counter, see 78267, 78268. For H. pylori,
immunoassay, use 87339)
(For H. pylori, blood test analysis for urease activity, use
83009)
83015 Heavy metal (eg, arsenic, barium, beryllium, bismuth,
antimony, mercury); qualitative, any number of analytes
83018 quantitative, each, not elsewhere specified

(Use an analyte-specific heavy metal quantitative code,

instead of 83018, when available)
83020 Hemoglobin fractionation and quantitation; electrophoresis
(eg, A2, S, C, and/or F)
83021 chromatography (eg, A2, S, C, and/or F)

(For glycosylated [A1c] hemoglobin analysis, by

electrophoresis or chromatography, in the absence of an
identified hemoglobin variant, use 83036)
83026 Hemoglobin; by copper sulfate method, non-automated
83030 F (fetal), chemical
83033 F (fetal), qualitative
83036 glycosylated (A1C)

➲ CPT Assistant Summer 94:2, Feb 06:7, Oct 06:15
(For glycosylated [A1C] hemoglobin analysis, by

electrophoresis or chromatography, in the setting of an
identified hemoglobin variant, see 83020, 83021)
(For fecal hemoglobin detection by immunoassay, use
82274)
83037 glycosylated (A1C) by device cleared by FDA for home
use
83045 methemoglobin, qualitative

83050 methemoglobin, quantitative
(For transcutaneous quantitative methemoglobin
determination, use 88741)
83051 plasma
83060 sulfhemoglobin, quantitative
83065 thermolabile
83068 unstable, screen
83069 urine
83070 Hemosiderin, qualitative
(HIAA, use 83497)
(For a qualitative column chromatography procedure [eg,
high performance liquid chromatography], use the
appropriate specific analyte code, if available, or 82542)
83080 b-Hexosaminidase, each assay
83088 Histamine
(Hollander test, see 43754, 43755)
83090 Homocysteine
83150 Homovanillic acid (HVA)

(Hormones, see individual alphabetic listings in Chemistry
section)
(For hydrogen/methane breath test, use 91065)
83491 Hydroxycorticosteroids, 17- (17-OHCS)
(For cortisol, see 82530, 82533. For deoxycortisol, use

82634)
83497 Hydroxyindolacetic acid, 5-(HIAA)
(For urine qualitative test, use 81005)
(5-Hydroxytryptamine, use 84260)
83498 Hydroxyprogesterone, 17-d
83500 Hydroxyproline; free
83505 total
83516 Immunoassay for analyte other than infectious agent antibody
or infectious agent antigen; qualitative or semiquantitative,
multiple step method
83518 qualitative or semiquantitative, single step method (eg,

reagent strip)
83519 quantitative, by radioimmunoassay (eg, RIA)

➲ CPT Assistant Fall 93:26, Summer 94:2
83520 quantitative, not otherwise specified

(For immunoassays for antibodies to infectious agent
antigens, see analyte and method specific codes in the
Immunology section)
(For immunoassay of tumor antigen not elsewhere specified,
use 86316)
(Immunoglobulins, see 82784, 82785)
83525 Insulin; total
(For proinsulin, use 84206)
83527 free
83528 Intrinsic factor

(For intrinsic factor antibodies, use 86340)
83540 Iron
83550 Iron binding capacity

83570 Isocitric dehydrogenase (IDH)
(Isonicotinic acid hydrazide, INH, see code for specific
method)
(Isopropyl alcohol, use 80320)
83582 Ketogenic steroids, fractionation
(Ketone bodies, for serum, see 82009, 82010; for urine, see
81000-81003)
83586 Ketosteroids, 17- (17-KS); total
83593 fractionation
83605 Lactate (lactic acid)
83615 Lactate dehydrogenase (LD), (LDH);

➲ CPT Assistant Fall 93:25, Feb 98:1, Dec 99:2
83625 isoenzymes, separation and quantitation

➲ CPT Assistant Fall 93:25, Feb 98:1
83630 Lactoferrin, fecal; qualitative

83631 quantitative
83632 Lactogen, human placental (HPL) human chorionic

somatomammotropin
83633 Lactose, urine, qualitative
(For tolerance, see 82951, 82952)
(For breath hydrogen/methane test for lactase deficiency, use
91065)
83655 Lead
83661 Fetal lung maturity assessment; lecithin sphingomyelin (L/S)
ratio
83662 foam stability test

83663 fluorescence polarization
83664 lamellar body density

(For phosphatidylglycerol, use 84081)

83670 Leucine aminopeptidase (LAP)
83690 Lipase
83695 Lipoprotein (a)
83698 Lipoprotein-associated phospholipase A2 (Lp-PLA2)

(For secretory type II phospholipase A2 [sPLA2-IIA], use

0423T)
83700 Lipoprotein, blood; electrophoretic separation and
quantitation
83701 high resolution fractionation and quantitation of

lipoproteins including lipoprotein subclasses when
performed (eg, electrophoresis, ultracentrifugation)
83704 quantitation of lipoprotein particle number(s) (eg, by

nuclear magnetic resonance spectroscopy), includes
lipoprotein particle subclass(es), when performed
83718 Lipoprotein, direct measurement; high density cholesterol

(HDL cholesterol)
➲ CPT Assistant Oct 99:11, Mar 00:11, Feb 05:9
83719 VLDL cholesterol

83721 LDL cholesterol

83722 small dense LDL cholesterol
(For fractionation by high resolution electrophoresis or

ultracentrifugation, use 83701)
(For lipoprotein particle numbers and subclasses analysis
by nuclear magnetic resonance spectroscopy, use 83704)
83727 Luteinizing releasing factor (LRH)
(Luteinizing hormone [LH], use 83002)
(Macroglobulins, alpha-2, use 86329)
83735 Magnesium
83775 Malate dehydrogenase
(Maltose tolerance, see 82951, 82952)
(Mammotropin, use 84146)
83785 Manganese
83789 Mass spectrometry and tandem mass spectrometry (eg, MS,
MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not
elsewhere specified, qualitative or quantitative, each
specimen
(Do not report more than one unit of 83789 for each
specimen)
(For column chromatography/mass spectrometry of drugs or
substances, see 80305, 80306, 80307, 80320-80377, or
specific analyte code[s] in the Chemistry section)
83825 Mercury, quantitative
(Mercury screen, use 83015)
83835 Metanephrines
(For catecholamines, see 82382-82384)
(Methamphetamine, see 80324, 80325, 80326)
(Methane breath test, use 91065)
83857 Methemalbumin
(Methemoglobin, see hemoglobin 83045, 83050)
(Methyl alcohol, use 80320)
(Microalbumin, see 82043 for quantitative, see 82044 for
semiquantitative)
83861 Microfluidic analysis utilizing an integrated collection and
analysis device, tear osmolarity
(Microglobulin, beta-2, use 82232)

(For microfluidic tear osmolarity of both eyes, report 83861
twice)
83864 Mucopolysaccharides, acid, quantitative
83872 Mucin, synovial fluid (Ropes test)
83873 Myelin basic protein, cerebrospinal fluid
(For oligoclonal bands, use 83916)

83874 Myoglobin
83876 Myeloperoxidase (MPO)

83880 Natriuretic peptide

83883 Nephelometry, each analyte not elsewhere specified
83885 Nickel
83915 Nucleotidase 5’-
83916 Oligoclonal immune (oligoclonal bands)
83918 Organic acids; total, quantitative, each specimen

83919 qualitative, each specimen

83921 Organic acid, single, quantitative

83930 Osmolality; blood

83935 urine
(For tear osmolarity using microfluidic analysis, use 83861)
83937 Osteocalcin (bone g1a protein)
83945 Oxalate
83950 Oncoprotein; HER-2/neu
(For tissue, see 88342, 88365)

83951 des-gamma-carboxy-prothrombin (DCP)
83970 Parathormone (parathyroid hormone)

(Pesticide, quantitative, see code for specific method. For
screen for chlorinated hydrocarbons, use 82441)
83986 pH; body fluid, not otherwise specified
➲ CPT Assistant Sep 13:13, May 16:14
83987 exhaled breath condensate
(For blood pH, see 82800, 82803)

(Phenobarbital, use 80345)
Testing subsection
83993 Calprotectin, fecal
84030 Phenylalanine (PKU), blood

(Phenylalanine-tyrosine ratio, see 84030, 84510)
84035 Phenylketones, qualitative
84060 Phosphatase, acid; total
84066 prostatic
84075 Phosphatase, alkaline;
84078 heat stable (total not included)

84080 isoenzymes
84081 Phosphatidylglycerol
(Phosphates inorganic, use 84100)
(Phosphates, organic, see code for specific method. For
cholinesterase, see 82480, 82482)
84085 Phosphogluconate, 6-, dehydrogenase, RBC
84087 Phosphohexose isomerase
84100 Phosphorus inorganic (phosphate);
➲ CPT Assistant Dec 99:2, Aug 05:9, Oct 10:7
84105 urine
(Pituitary gonadotropins, see 83001-83002)
(PKU, see 84030, 84035)
84106 Porphobilinogen, urine; qualitative
84110 quantitative
84112 Evaluation of cervicovaginal fluid for specific amniotic
fluid protein(s) (eg, placental alpha microglobulin-1
[PAMG-1], placental protein 12 [PP12], alpha-fetoprotein),
qualitative, each specimen
84119 Porphyrins, urine; qualitative

84120 quantitation and fractionation
84126 Porphyrins, feces, quantitative
(Porphyrin precursors, see 82135, 84106, 84110)
(For protoporphyrin, RBC, see 84202, 84203)
84132 Potassium; serum, plasma or whole blood
➲ CPT Assistant Dec 99:2, Jun 02:3, Apr 13:10
84133 urine
84134 Prealbumin
(For microalbumin, see 82043, 82044)
84135 Pregnanediol
84138 Pregnanetriol
84140 Pregnenolone
84143 17-hydroxypregnenolone
84144 Progesterone
(Progesterone receptor assay, use 84234)
(For proinsulin, use 84206)
84145 Procalcitonin (PCT)
84146 Prolactin
84150 Prostaglandin, each
84152 Prostate specific antigen (PSA); complexed (direct
measurement)
84153 total
➲ CPT Assistant Fall 93:26, May 96:10, Aug 96:10,
Jan 97:10, Nov 98:26, Aug 99:5, Dec 99:10
84154 free
➲ CPT Assistant Nov 98:26, Aug 99:5, Dec 99:10
84155 Protein, total, except by refractometry; serum, plasma or

whole blood
84156 urine
84157 other source (eg, synovial fluid, cerebrospinal fluid)

84160 Protein, total, by refractometry, any source

(For urine total protein by dipstick method, use 81000-
81003)
84163 Pregnancy-associated plasma protein-A (PAPP-A)
84165 Protein; electrophoretic fractionation and quantitation,

serum
84166 electrophoretic fractionation and quantitation, other

fluids with concentration (eg, urine, CSF)
84181 Western Blot, with interpretation and report, blood or

other body fluid
84182 Western Blot, with interpretation and report, blood or
other body fluid, immunological probe for band
identification, each
(For Western Blot tissue analysis, use 88371)

84202 Protoporphyrin, RBC; quantitative
84203 screen
84206 Proinsulin
(Pseudocholinesterase, use 82480)
84207 Pyridoxal phosphate (Vitamin B-6)
84210 Pyruvate
84220 Pyruvate kinase
84228 Quinine
84233 Receptor assay; estrogen
84234 progesterone
84235 endocrine, other than estrogen or progesterone (specify
hormone)
84238 non-endocrine (specify receptor)
84244 Renin
84252 Riboflavin (Vitamin B-2)
(Salicylates, see 80329, 80330, 80331)
80179)◀
(Secretin test, see 99070, 43756, 43757 and appropriate
analyses)
84255 Selenium
84260 Serotonin
(For urine metabolites (HIAA), use 83497)
84270 Sex hormone binding globulin (SHBG)
84275 Sialic acid

(Sickle hemoglobin, use 85660)
84285 Silica
84295 Sodium; serum, plasma or whole blood
➲ CPT Assistant Dec 99:2, Oct 10:7, Apr 13:10
84300 urine
84302 other source
(Somatomammotropin, use 83632)

(Somatotropin, use 83003)
84305 Somatomedin
84307 Somatostatin
84311 Spectrophotometry, analyte not elsewhere specified

84315 Specific gravity (except urine)
(For specific gravity, urine, see 81000-81003)
(Stone analysis, see 82355-82370)
(For suppression of growth stimulation expressed gene 2
[ST2] testing, use 83006)
84375 Sugars, chromatographic, TLC or paper chromatography
84376 Sugars (mono-, di-, and oligosaccharides); single
qualitative, each specimen
➲ CPT Assistant Nov 98:26-27, Dec 99:7
84377 multiple qualitative, each specimen

➲ CPT Assistant Nov 98:26-27, Jul 03:7
84378 single quantitative, each specimen

84379 multiple quantitative, each specimen

➲ CPT Assistant Nov 98:26-27, Dec 99:7, Jul 03:7
84392 Sulfate, urine

(Sulfhemoglobin, use hemoglobin, 83060)
(T-3, see 84479-84481)
(T-4, see 84436-84439)
84402 Testosterone; free
84403 total
84410 bioavailable, direct measurement (eg, differential
precipitation)

80328 to identify anabolic steroid testing for testosterone)
84425 Thiamine (Vitamin B-1)
84430 Thiocyanate
84431 Thromboxane metabolite(s), including thromboxane if
performed, urine
(For concurrent urine creatinine determination, use 84431 in

84432 Thyroglobulin
(Thyroglobulin, antibody, use 86800)

(Thyrotropin releasing hormone [TRH] test, see 80438,
80439)
84436 Thyroxine; total
84437 requiring elution (eg, neonatal)

84439 free
84442 Thyroxine binding globulin (TBG)
84443 Thyroid stimulating hormone (TSH)
84445 Thyroid stimulating immune globulins (TSI)

(Tobramycin, use 80200)

84446 Tocopherol alpha (Vitamin E)
84449 Transcortin (cortisol binding globulin)
84450 Transferase; aspartate amino (AST) (SGOT)

84460 alanine amino (ALT) (SGPT)

84466 Transferrin
(Iron binding capacity, use 83550)

84478 Triglycerides
84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone

binding ratio (THBR)
84480 Triiodothyronine T3; total (TT-3)

84481 free
84482 reverse
84484 Troponin, quantitative

(For troponin, qualitative assay, use 84512)

84485 Trypsin; duodenal fluid
84488 feces, qualitative
84490 feces, quantitative, 24-hour collection
84510 Tyrosine
(Urate crystal identification, use 89060)

84512 Troponin, qualitative
(For troponin, quantitative assay, use 84484)

84520 Urea nitrogen; quantitative
84525 semiquantitative (eg, reagent strip test)

84540 Urea nitrogen, urine

84545 Urea nitrogen, clearance
84550 Uric acid; blood
84560 other source

84577 Urobilinogen, feces, quantitative
84578 Urobilinogen, urine; qualitative
84580 quantitative, timed specimen
84583 semiquantitative
(Uroporphyrins, use 84120)
(Valproic acid [dipropylacetic acid], use 80164)
84585 Vanillylmandelic acid (VMA), urine
84586 Vasoactive intestinal peptide (VIP)
84588 Vasopressin (antidiuretic hormone, ADH)

84590 Vitamin A
(Vitamin B-1, use 84425)

(Vitamin C, use 82180)
(Vitamin D, see 82306, 82652)
(Vitamin E, use 84446)
84591 Vitamin, not otherwise specified
84597 Vitamin K
(VMA, use 84585)

84600 Volatiles (eg, acetic anhydride, diethylether)
(For carbon tetrachloride, dichloroethane, dichloromethane,

use 82441)
(For isopropyl alcohol and methanol, use 80320)
(Volume, blood, RISA or Cr-51, see 78110, 78111)
84620 Xylose absorption test, blood and/or urine
(For administration, use 99070)
84630 Zinc
84681 C-peptide
84702 Gonadotropin, chorionic (hCG); quantitative

84703 qualitative
(For urine pregnancy test by visual color comparison, use
81025)
84704 free beta chain
➲ CPT Assistant Apr 08:5, Aug 08:13, Oct 10:7
84830 Ovulation tests, by visual color comparison methods for

human luteinizing hormone
84999 Unlisted chemistry procedure

➲ CPT Assistant Oct 00:24, Aug 05:9, Oct 10:7, Dec 10:7,
Apr 15:3
(For definitive testing of a drug, not otherwise specified, see
80299, 80375, 80376, 80377)

(For blood banking procedures, see Transfusion Medicine)
(Agglutinins, see Immunology)
(Antiplasmin, use 85410)
(Antithrombin III, see 85300, 85301)
85002 Bleeding time
85004 Blood count; automated differential WBC count
85007 blood smear, microscopic examination with manual

differential WBC count
85008 blood smear, microscopic examination without manual

differential WBC count
(For other fluids [eg, CSF], see 89050, 89051)

85009 manual differential WBC count, buffy coat
(Eosinophils, nasal smear, use 89190)

85013 spun microhematocrit
85014 hematocrit (Hct)
85018 hemoglobin (Hgb)

(For other hemoglobin determination, see 83020-83069)

(For immunoassay, hemoglobin, fecal, use 82274)
(For transcutaneous hemoglobin measurement, use 88738)
85025 complete (CBC), automated (Hgb, Hct, RBC, WBC and
platelet count) and automated differential WBC count
➲ CPT Assistant Jul 00:11, Jul 03:7, Jan 04:26, Jul
11:16
85027 complete (CBC), automated (Hgb, Hct, RBC, WBC and
platelet count)
85032 manual cell count (erythrocyte, leukocyte, or platelet)

each
85041 red blood cell (RBC), automated

(Do not report code 85041 in conjunction with 85025 or

85027)
85044 reticulocyte, manual
85045 reticulocyte, automated

85046 reticulocytes, automated, including 1 or more cellular

parameters (eg, reticulocyte hemoglobin content [CHr],
immature reticulocyte fraction [IRF], reticulocyte volume
[MRV], RNA content), direct measurement
85048 leukocyte (WBC), automated

85049 platelet, automated
85055 Reticulated platelet assay

85060 Blood smear, peripheral, interpretation by physician with

written report
85097 Bone marrow, smear interpretation
➲ CPT Assistant Winter 92:17, Jul 98:4, Mar 03:22
(For special stains, see 88312, 88313)

(For bone biopsy, see 20220, 20225, 20240, 20245, 20250,
20251)
85130 Chromogenic substrate assay
(Circulating anti-coagulant screen [mixing studies], see

85611, 85732)
85170 Clot retraction
85175 Clot lysis time, whole blood dilution
(Clotting factor I [fibrinogen], see 85384, 85385)
85210 Clotting; factor II, prothrombin, specific
(See also 85610-85613)

85220 factor V (AcG or proaccelerin), labile factor
85230 factor VII (proconvertin, stable factor)
85240 factor VIII (AHG), 1-stage
85244 factor VIII related antigen
85245 factor VIII, VW factor, ristocetin cofactor
85246 factor VIII, VW factor antigen
85247 factor VIII, von Willebrand factor, multimetric analysis
85250 factor IX (PTC or Christmas)
85260 factor X (Stuart-Prower)
85270 factor XI (PTA)
85280 factor XII (Hageman)
85290 factor XIII (fibrin stabilizing)
85291 factor XIII (fibrin stabilizing), screen solubility
85292 prekallikrein assay (Fletcher factor assay)
85293 high molecular weight kininogen assay (Fitzgerald factor
assay)
85300 Clotting inhibitors or anticoagulants; antithrombin III,
activity
85301 antithrombin III, antigen assay

85302 protein C, antigen
85303 protein C, activity
85305 protein S, total
85306 protein S, free
85307 Activated Protein C (APC) resistance assay
85335 Factor inhibitor test

85337 Thrombomodulin
(For mixing studies for inhibitors, use 85732)
85345 Coagulation time; Lee and White
85347 activated
85348 other methods
(Differential count, see 85007 et seq)
(Duke bleeding time, use 85002)
(Eosinophils, nasal smear, use 89190)
85360 Euglobulin lysis
(Fetal hemoglobin, see 83030, 83033, 85460)
85362 Fibrin(ogen) degradation (split) products (FDP) (FSP);
agglutination slide, semiquantitative
(Immunoelectrophoresis, use 86320)
85366 paracoagulation
85370 quantitative
85378 Fibrin degradation products, D-dimer; qualitative or
semiquantitative
85379 quantitative
(For ultrasensitive and standard sensitivity quantitative D-
dimer, use 85379)
85380 ultrasensitive (eg, for evaluation for venous
thromboembolism), qualitative or semiquantitative
85384 Fibrinogen; activity

85385 antigen
85390 Fibrinolysins or coagulopathy screen, interpretation and
report
85396 Coagulation/fibrinolysis assay, whole blood (eg,
viscoelastic clot assessment), including use of any
pharmacologic additive(s), as indicated, including
interpretation and written report, per day
85397 Coagulation and fibrinolysis, functional activity, not

otherwise specified (eg, ADAMTS-13), each analyte
85400 Fibrinolytic factors and inhibitors; plasmin

85410 alpha-2 antiplasmin

85415 plasminogen activator
85420 plasminogen, except antigenic assay
85421 plasminogen, antigenic assay
(Fragility, red blood cell, see 85547, 85555-85557)
85441 Heinz bodies; direct
85445 induced, acetyl phenylhydrazine
(Hematocrit [PCV], see 85014, 85025, 85027)
(Hemoglobin, see 83020-83068, 85018, 85025, 85027)
85460 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage;
differential lysis (Kleihauer-Betke)
(See also 83030, 83033)

(Hemolysins, see 86940, 86941)
85461 rosette
85475 Hemolysin, acid
(See also 86940, 86941)
85520 Heparin assay
85525 Heparin neutralization

85530 Heparin-protamine tolerance test

85536 Iron stain, peripheral blood
(For iron stains on bone marrow or other tissues with

physician evaluation, use 88313)
85540 Leukocyte alkaline phosphatase with count
85547 Mechanical fragility, RBC
85549 Muramidase
(Nitroblue tetrazolium dye test, use 86384)
85555 Osmotic fragility, RBC; unincubated
85557 incubated
(Packed cell volume, use 85013)
(Partial thromboplastin time, see 85730, 85732)
(Parasites, blood [eg, malaria smears], use 87207)
(Plasmin, use 85400)
(Plasminogen, use 85420)
(Plasminogen activator, use 85415)
85576 Platelet, aggregation (in vitro), each agent
(For thromboxane metabolite[s], including thromboxane, if

performed, measurement[s] in urine, use 84431)
85597 Phospholipid neutralization; platelet
85598 hexagonal phospholipid

85610 Prothrombin time;

85611 substitution, plasma fractions, each

85612 Russell viper venom time (includes venom); undiluted
85613 diluted
(Red blood cell count, see 85025, 85027, 85041)
85635 Reptilase test
(Reticulocyte count, see 85044, 85045)
85651 Sedimentation rate, erythrocyte; non-automated
85652 automated
85660 Sickling of RBC, reduction
(Hemoglobin electrophoresis, use 83020)
(Smears [eg, for parasites, malaria], use 87207)
85670 Thrombin time; plasma
85675 titer
85705 Thromboplastin inhibition, tissue
(For individual clotting factors, see 85245-85247)

85730 Thromboplastin time, partial (PTT); plasma or whole blood
85732 substitution, plasma fractions, each
85810 Viscosity
(von Willebrand factor assay, see 85245-85247)
(WBC count, see 85025, 85027, 85048, 89050)
85999 Unlisted hematology and coagulation procedure
➲ CPT Assistant Aug 05:9, Oct 09:12, Aug 17:10
Immunology
(Acetylcholine receptor antibody, see 83519, 86255, 86256)
(Actinomyces, antibodies to, use 86602)
(Adrenal cortex antibodies, see 86255, 86256)
86000 Agglutinins, febrile (eg, Brucella, Francisella, Murine
typhus, Q fever, Rocky Mountain spotted fever, scrub
typhus), each antigen
(For antibodies to infectious agents, see 86602-86804)

86001 Allergen specific IgG quantitative or semiquantitative, each
allergen
(Agglutinins and autohemolysins, see 86940, 86941)

86003 Allergen specific IgE; quantitative or semiquantitative,
crude allergen extract, each
(For total quantitative IgE, use 82785)

86005 qualitative, multiallergen screen (eg, disk, sponge, card)
86008 quantitative or semiquantitative, recombinant or purified
component, each
(For total qualitative IgE, use 83518)

(Alpha-1 antitrypsin, see 82103, 82104)
(Alpha-1 feto-protein, see 82105, 82106)
(Anti-AChR [acetylcholine receptor] antibody titer, see
86255, 86256)
(Anticardiolipin antibody, use 86147)
(Anti-DNA, use 86225)
(Anti-deoxyribonuclease titer, use 86215)
86021 Antibody identification; leukocyte antibodies
86022 platelet antibodies
86023 platelet associated immunoglobulin assay
86038 Antinuclear antibodies (ANA);
86039 titer
(Antistreptococcal antibody, ie, anti-DNAse, use 86215)
(Antistreptokinase titer, use 86590)
86060 Antistreptolysin 0; titer
86063 screen
(Blastomyces, antibodies to, use 86612)
86077 Blood bank physician services; difficult cross match and/or
evaluation of irregular antibody(s), interpretation and
written report
86078 investigation of transfusion reaction including suspicion
of transmissible disease, interpretation and written
report
86079 authorization for deviation from standard blood banking
procedures (eg, use of outdated blood, transfusion of Rh
incompatible units), with written report
(Brucella, antibodies to, use 86622)
(Candida, antibodies to, use 86628. For skin testing, use
86485)
86140 C-reactive protein;
(Candidiasis, use 86628)

86141 high sensitivity (hsCRP)
86146 Beta 2 Glycoprotein I antibody, each

86147 Cardiolipin (phospholipid) antibody, each Ig class

# 86152 Cell enumeration using immunologic selection and

identification in fluid specimen (eg, circulating tumor cells
in blood);
(For physician interpretation and report, use 86153. For cell

enumeration with interpretation and report, use 86152 and
86153)
# 86153 physician interpretation and report, when required
(For cell enumeration, use 86152. For cell enumeration with

interpretation and report, use 86152 and 86153)
(For flow cytometric immunophenotyping, see 88184-
88189)
(For flow cytometric quantitation, see 86355, 86356, 86357,
86359, 86360, 86361, 86367)
86148 Anti-phosphatidylserine (phospholipid) antibody
➲ CPT Assistant Nov 97:30, Jul 03:8, Nov 03:5
(To report antiprothrombin [phospholipid cofactor]

antibody, use 86849)
86155 Chemotaxis assay, specify method
(Clostridium difficile toxin, use 87230)
(Coccidioides, antibodies to, see 86635. For skin testing,
use 86490)
86156 Cold agglutinin; screen
86157 titer
86160 Complement; antigen, each component
86161 functional activity, each component
86162 total hemolytic (CH50)
86171 Complement fixation tests, each antigen
(Coombs test, see 86880-86886)
86200 Cyclic citrullinated peptide (CCP), antibody
86215 Deoxyribonuclease, antibody

86225 Deoxyribonucleic acid (DNA) antibody; native or double
stranded
(Echinococcus, antibodies to, see code for specific method)
(For HIV antibody tests, see 86701-86703)
86226 single stranded
(Anti D.S., DNA, IFA, eg, using C.Lucilae, see 86255 and
86256)
86235 Extractable nuclear antigen, antibody to, any method (eg,
nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody
86255 Fluorescent noninfectious agent antibody; screen, each
antibody
86256 titer, each antibody

(Fluorescent technique for antigen identification in tissue,
use 88346; for indirect fluorescence, see 88346, 88350)
(FTA, use 86780)
(Gel [agar] diffusion tests, use 86331)
86277 Growth hormone, human (HGH), antibody
86280 Hemagglutination inhibition test (HAI)
(For rubella, use 86762)
86294 Immunoassay for tumor antigen, qualitative or
semiquantitative (eg, bladder tumor antigen)
(For qualitative NMP22 protein, use 86386)

86300 Immunoassay for tumor antigen, quantitative; CA 15-3
(27.29)
86301 CA 19-9
86304 CA 125
(For measurement of serum HER-2/neu oncoprotein, see

83950)
(For hepatitis delta agent, antibody, use 86692)
86305 Human epididymis protein 4 (HE4)
86308 Heterophile antibodies; screening

86309 titer
86310 titers after absorption with beef cells and guinea pig
kidney
(Histoplasma, antibodies to, use 86698. For skin testing, use
86510)
(Human growth hormone antibody, use 86277)
86316 Immunoassay for tumor antigen, other antigen, quantitative
(eg, CA 50, 72-4, 549), each
➲ CPT Assistant May 96:11, Aug 96:11, Apr 98:15, Aug
99:5, Dec 99:10
86317 Immunoassay for infectious agent antibody, quantitative, not
otherwise specified
(For immunoassay techniques for antigens, see 83516,
83518, 83519, 83520, 87301-87450, 87810-87899)
(For particle agglutination procedures, use 86403)
▲ 86318 Immunoassay for infectious agent antibody(ies), qualitative
or semiquantitative, single-step method (eg, reagent strip);
#● 86328 severe acute respiratory syndrome coronavirus 2

(SARS-CoV-2) (Coronavirus disease [COVID-19])
▶ (For severe acute respiratory syndrome coronavirus 2

[SARS-CoV-2] [Coronavirus disease {COVID-19}]
antibody testing using multiple-step method, use 86769)◀
86320 Immunoelectrophoresis; serum
86325 other fluids (eg, urine, cerebrospinal fluid) with
concentration
86327 crossed (2-dimensional assay)

86329 Immunodiffusion; not elsewhere specified
86331 gel diffusion, qualitative (Ouchterlony), each antigen or

antibody
86332 Immune complex assay
86334 Immunofixation electrophoresis; serum
86335 other fluids with concentration (eg, urine, CSF)

86336 Inhibin A
86337 Insulin antibodies

86340 Intrinsic factor antibodies
(Leptospira, antibodies to, use 86720)
(Leukoagglutinins, use 86021)
86341 Islet cell antibody
86343 Leukocyte histamine release test (LHR)

86344 Leukocyte phagocytosis
86352 Cellular function assay involving stimulation (eg, mitogen or
antigen) and detection of biomarker (eg, ATP)
86353 Lymphocyte transformation, mitogen (phytomitogen) or

antigen induced blastogenesis
(Malaria antibodies, use 86750)
(For cellular function assay involving stimulation and
detection of biomarker, use 86352)
86355 B cells, total count
86356 Mononuclear cell antigen, quantitative (eg, flow cytometry),

not otherwise specified, each antigen
(Do not report 88187-88189 for interpretation of 86355,

86356, 86357, 86359, 86360, 86361, 86367)
86357 Natural killer (NK) cells, total count
86359 T cells; total count
86360 absolute CD4 and CD8 count, including ratio

➲ CPT Assistant Nov 97:30, Jan 07:29, Apr 08:5
86361 absolute CD4 count

86367 Stem cells (ie, CD34), total count

➲ CPT Assistant Mar 06:6, Apr 08:5, Oct 13:3
(For flow cytometric immunophenotyping for the assessment

of potential hematolymphoid neoplasia, see 88184-88189)
86376 Microsomal antibodies (eg, thyroid or liver-kidney), each
86382 Neutralization test, viral
86384 Nitroblue tetrazolium dye test (NTD)
86386 Nuclear Matrix Protein 22 (NMP22), qualitative
(Ouchterlony diffusion, use 86331)

(Platelet antibodies, see 86022, 86023)
86403 Particle agglutination; screen, each antibody
86406 titer, each antibody

(Pregnancy test, see 84702, 84703)
(Rapid plasma reagin test (RPR), see 86592, 86593)
86430 Rheumatoid factor; qualitative
86431 quantitative
(Serologic test for syphilis, see 86592, 86593)
86480 Tuberculosis test, cell mediated immunity antigen response
measurement; gamma interferon
➲ CPT Assistant Mar 06:6, Oct 10:7, Dec 10:8, Dec 19:13
86481 enumeration of gamma interferon-producing T-cells in

cell suspension
86485 Skin test; candida

(For antibody, candida, use 86628)
86486 unlisted antigen, each
86490 coccidioidomycosis
86510 histoplasmosis
(For histoplasma, antibody, use 86698)

86580 tuberculosis, intradermal
(For tuberculosis test, cell mediated immunity measurement
of gamma interferon antigen response, use 86480)
(For skin tests for allergy, see 95012-95199)
(Smooth muscle antibody, see 86255, 86256)
(Sporothrix, antibodies to, see code for specific method)
86590 Streptokinase, antibody
(Streptolysin O antibody, see antistreptolysin O, 86060,
86063)
86592 Syphilis test, non-treponemal antibody; qualitative (eg,
VDRL, RPR, ART)

86593 quantitative

(Tetanus antibody, use 86774)
(Thyroglobulin antibody, use 86800)
(Thyroglobulin, use 84432)
(Thyroid microsomal antibody, use 86376)
(For toxoplasma antibody, see 86777-86778)
▶The following codes (86602-86804) are qualitative or
semiquantitative immunoassays performed by multiple-step
methods for the detection of antibodies to infectious agents. For
immunoassays by single-step method (eg, reagent strips), see
codes 86318, 86328. Procedures for the identification of
antibodies should be coded as precisely as possible. For example,
an antibody to a virus could be coded with increasing specificity
for virus, family, genus, species, or type. In some cases, further
precision may be added to codes by specifying the class of
immunoglobulin being detected. When multiple tests are done to
detect antibodies to organisms classified more precisely than the
specificity allowed by available codes, it is appropriate to code
each as a separate service. For example, a test for antibody to an
enterovirus is coded as 86658. Coxsackie viruses are
enteroviruses, but there are no codes for the individual species of
enterovirus. If assays are performed for antibodies to coxsackie
A and B species, each assay should be separately coded.
Similarly, if multiple assays are performed for antibodies of
different immunoglobulin classes, each assay should be coded
separately. When a coding option exists for reporting IgM
specific antibodies (eg, 86632), the corresponding nonspecific
code (eg, 86631) may be reported for performance of either an
antibody analysis not specific for a particular immunoglobulin
class or for an IgG analysis.◀
(For the detection of antibodies other than those to infectious
agents, see specific antibody [eg, 86021-86023, 86376,
86800, 86850-86870] or specific method [eg, 83516,
86255, 86256]).
(For infectious agent/antigen detection, see 87260-87899)
86602 Antibody; actinomyces
86603 adenovirus
86606 Aspergillus
86609 bacterium, not elsewhere specified
86611 Bartonella
86612 Blastomyces
86615 Bordetella
86617 Borrelia burgdorferi (Lyme disease) confirmatory test
(eg, Western Blot or immunoblot)
86618 Borrelia burgdorferi (Lyme disease)
86619 Borrelia (relapsing fever)
86622 Brucella
86625 Campylobacter
86628 Candida
(For skin test, candida, use 86485)
86631 Chlamydia
86632 Chlamydia, IgM
(For chlamydia antigen, see 87270, 87320. For fluorescent

antibody technique, see 86255, 86256)
86635 Coccidioides
antibody testing, see 86328, 86769)◀
86638 Coxiella burnetii (Q fever)
86641 Cryptococcus
86644 cytomegalovirus (CMV)
86645 cytomegalovirus (CMV), IgM
86648 Diphtheria
86651 encephalitis, California (La Crosse)
86652 encephalitis, Eastern equine
86653 encephalitis, St. Louis
86654 encephalitis, Western equine
86658 enterovirus (eg, coxsackie, echo, polio)
(Trichinella, antibodies to, use 86784)
(Trypanosoma, antibodies to, see code for specific method)
(Tuberculosis, use 86580 for skin testing)
(Viral antibodies, see code for specific method)
86663 Epstein-Barr (EB) virus, early antigen (EA)
86664 Epstein-Barr (EB) virus, nuclear antigen (EBNA)
86665 Epstein-Barr (EB) virus, viral capsid (VCA)
86666 Ehrlichia
86668 Francisella tularensis

86671 fungus, not elsewhere specified
86674 Giardia lamblia
86677 Helicobacter pylori
86682 helminth, not elsewhere specified

86684 Haemophilus influenza
86687 HTLV-I
86688 HTLV-II
86689 HTLV or HIV antibody, confirmatory test (eg, Western
Blot)
86692 hepatitis, delta agent

(For hepatitis delta agent, antigen, use 87380)

86694 herpes simplex, non-specific type test
86695 herpes simplex, type 1
86696 herpes simplex, type 2
86698 histoplasma
86701 HIV-1
➲ CPT Assistant Aug 05:9, Mar 08:3, Apr 08:5
86702 HIV-2
86703 HIV-1 and HIV-2, single result
(For HIV-1 antigen(s) with HIV-1 and HIV-2 antibodies,

single result, use 87389)
(When HIV immunoassay [HIV testing 86701-86703 or
87389] is performed using a kit or transportable instrument
that wholly or in part consists of a single use, disposable
analytical chamber, the service may be identified by adding
modifier 92 to the usual code)
(For HIV-1 antigen, use 87390)
(For HIV-2 antigen, use 87391)
(For confirmatory test for HIV antibody (eg, Western Blot),
use 86689)
86704 Hepatitis B core antibody (HBcAb); total
86705 IgM antibody

86706 Hepatitis B surface antibody (HBsAb)

86707 Hepatitis Be antibody (HBeAb)

86708 Hepatitis A antibody (HAAb)

86709 Hepatitis A antibody (HAAb), IgM antibody

86710 Antibody; influenza virus
86711 JC (John Cunningham) virus
86713 Legionella
86717 Leishmania
86720 Leptospira
86723 Listeria monocytogenes
86727 lymphocytic choriomeningitis
86732 mucormycosis
86735 mumps
86738 mycoplasma
86741 Neisseria meningitidis
86744 Nocardia
86747 parvovirus
86750 Plasmodium (malaria)
86753 protozoa, not elsewhere specified
86756 respiratory syncytial virus
86757 Rickettsia
86759 rotavirus
86762 rubella
86765 rubeola
86768 Salmonella
● 86769 severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) (Coronavirus disease [COVID-19])

antibody testing using single-step method, use 86328)◀
86771 Shigella
86774 tetanus
86777 Toxoplasma
86778 Toxoplasma, IgM
86780 Treponema pallidum
(For syphilis testing by non-treponemal antibody analysis,

see 86592-86593)
86784 Trichinella
86787 varicella-zoster
86788 West Nile virus, IgM
86789 West Nile virus

86790 virus, not elsewhere specified

86793 Yersinia
86794 Zika virus, IgM
86800 Thyroglobulin antibody

(For thyroglobulin, use 84432)

86803 Hepatitis C antibody;
86804 confirmatory test (eg, immunoblot)
Tissue Typing
86805 Lymphocytotoxicity assay, visual crossmatch; with titration
86806 without titration
86807 Serum screening for cytotoxic percent reactive antibody
(PRA); standard method
86808 quick method

86812 HLA typing; A, B, or C (eg, A10, B7, B27), single antigen

86813 A, B, or C, multiple antigens

86816 DR/DQ, single antigen

86817 DR/DQ, multiple antigens

86821 lymphocyte culture, mixed (MLC)


86825 Human leukocyte antigen (HLA) crossmatch, non-cytotoxic
(eg, using flow cytometry); first serum sample or dilution
✚ 86826 each additional serum sample or sample dilution (List

separately in addition to primary procedure)
86359, 88184-88189 for antibody surface markers integral
to crossmatch testing)
(For autologous HLA crossmatch, see 86825, 86826)
(For lymphocytotoxicity visual crossmatch, see 86805,
86806)
86828 Antibody to human leukocyte antigens (HLA), solid phase
assays (eg, microspheres or beads, ELISA, flow cytometry);
qualitative assessment of the presence or absence of
antibody(ies) to HLA Class I and Class II HLA antigens
86829 qualitative assessment of the presence or absence of

antibody(ies) to HLA Class I or Class II HLA antigens
(If solid phase testing is performed to assess presence or

absence of antibody to both HLA classes, use 86828)
86830 antibody identification by qualitative panel using
complete HLA phenotypes, HLA Class I
86831 antibody identification by qualitative panel using

complete HLA phenotypes, HLA Class II
86832 high definition qualitative panel for identification of

antibody specificities (eg, individual antigen per bead
methodology), HLA Class I
86833 high definition qualitative panel for identification of

antibody specificities (eg, individual antigen per bead
methodology), HLA Class II
(If solid phase testing is performed to test for HLA Class I

or II antibody after treatment [eg, to remove IgM antibodies
or other interfering substances], report 86828-86833 once
for each panel with the untreated serum and once for each
panel with the treated serum)
86834 semi-quantitative panel (eg, titer), HLA Class I
86835 semi-quantitative panel (eg, titer), HLA Class II

86849 Unlisted immunology procedure

(For apheresis, use 36511, 36512)
(For therapeutic phlebotomy, use 99195)
86850 Antibody screen, RBC, each serum technique
➲ CPT Assistant Fall 93:25, Aug 05:9, Apr 08:5
86860 Antibody elution (RBC), each elution

86870 Antibody identification, RBC antibodies, each panel for
each serum technique
➲ CPT Assistant Fall 93:25, Mar 01:10
86880 Antihuman globulin test (Coombs test); direct, each

antiserum
86885 indirect, qualitative, each reagent red cell
86886 indirect, each antibody titer
(For indirect antihuman globulin [Coombs] test for RBC

antibody screening, use 86850)
(For indirect antihuman globulin [Coombs] test for RBC
antibody identification using reagent red cell panels, use
86870)
86890 Autologous blood or component, collection processing and
storage; predeposited
86891 intra- or postoperative salvage

86900 Blood typing, serologic; ABO
86901 Rh (D)
86902 antigen testing of donor blood using reagent serum, each

antigen test
(If multiple blood units are tested for the same antigen,
86902 should be reported once for each antigen for each unit
tested)
86904 antigen screening for compatible unit using patient serum,
per unit screened
86905 RBC antigens, other than ABO or Rh (D), each

86906 Rh phenotyping, complete
(For human erythrocyte antigen typing by molecular

pathology techniques, use 81403)
86910 Blood typing, for paternity testing, per individual; ABO, Rh
and MN
86911 each additional antigen system
86920 Compatibility test each unit; immediate spin technique
86921 incubation technique

86922 antiglobulin technique

86923 electronic
(Do not use 86923 in conjunction with 86920-86922 for

same unit crossmatch)
86927 Fresh frozen plasma, thawing, each unit
86930 Frozen blood, each unit; freezing (includes preparation)
86931 thawing
86932 freezing (includes preparation) and thawing

86940 Hemolysins and agglutinins; auto, screen, each
86941 incubated
86945 Irradiation of blood product, each unit
86950 Leukocyte transfusion

(For allogeneic lymphocyte infusion, use 38242)

(For leukapheresis, use 36511)
86960 Volume reduction of blood or blood product (eg, red blood
cells or platelets), each unit
86965 Pooling of platelets or other blood products

(For harvesting, preparation, and injection[s] of platelet rich

plasma, use 0232T)
(For harvesting, preparation, and injection[s] of autologous
white blood cell/autologous protein solution, use 0481T)
86970 Pretreatment of RBCs for use in RBC antibody detection,
identification, and/or compatibility testing; incubation with
chemical agents or drugs, each
86971 incubation with enzymes, each
86972 by density gradient separation
86975 Pretreatment of serum for use in RBC antibody
identification; incubation with drugs, each
86976 by dilution
86977 incubation with inhibitors, each
86978 by differential red cell absorption using patient RBCs or
RBCs of known phenotype, each absorption
86985 Splitting of blood or blood products, each unit
86999 Unlisted transfusion medicine procedure

➲ CPT Assistant Aug 05:9, Nov 05:14, Mar 09:10, Apr
09:9, May 12:11
Microbiology
Includes bacteriology, mycology, parasitology, and virology.
Presumptive identification of microorganisms is defined as
identification by colony morphology, growth on selective media,
Gram stains, or up to three tests (eg, catalase, oxidase, indole,
urease). Definitive identification of microorganisms is defined as
an identification to the genus or species level that requires
additional tests (eg, biochemical panels, slide cultures). If
additional studies involve molecular probes, nucleic acid
sequencing, chromatography, or immunologic techniques, these
should be separately coded using 87140-87158, in addition to
definitive identification codes. The molecular diagnostic codes
(eg, 81161, 81200-81408) are not to be used in combination with
or instead of the procedures represented by 87140-87158. For
multiple specimens/sites use modifier 59. For repeat laboratory
tests performed on the same day, use modifier 91.
87003 Animal inoculation, small animal, with observation and
dissection
87015 Concentration (any type), for infectious agents

87040 Culture, bacterial; blood, aerobic, with isolation and
presumptive identification of isolates (includes anaerobic
culture, if appropriate)
➲ CPT Assistant Aug 97:18, Jun 02:2, Oct 10:17, Dec
10:17
87045 stool, aerobic, with isolation and preliminary
examination (eg, KIA, LIA), Salmonella and Shigella
species
87046 stool, aerobic, additional pathogens, isolation and

presumptive identification of isolates, each plate
2005
87070 any other source except urine, blood or stool, aerobic,
with isolation and presumptive identification of isolates
➲ CPT Assistant Aug 97:18, Nov 01:10, Oct 03:10,
Nov 11:11
(For urine, use 87088)
87071 quantitative, aerobic with isolation and presumptive
identification of isolates, any source except urine, blood
or stool
(For urine, use 87088)

87073 quantitative, anaerobic with isolation and presumptive
identification of isolates, any source except urine, blood
or stool
(For definitive identification of isolates, use 87076 or
87077. For typing of isolates see 87140-87158)
87075 any source, except blood, anaerobic with isolation and
presumptive identification of isolates
87076 anaerobic isolate, additional methods required for

definitive identification, each isolate
87077 aerobic isolate, additional methods required for

definitive identification, each isolate
87081 Culture, presumptive, pathogenic organisms, screening only;

87084 with colony estimation from density chart

87086 Culture, bacterial; quantitative colony count, urine
87088 with isolation and presumptive identification of each

isolate, urine
87101 Culture, fungi (mold or yeast) isolation, with presumptive

identification of isolates; skin, hair, or nail
87102 other source (except blood)

87103 blood
87106 Culture, fungi, definitive identification, each organism; yeast
87107 mold
87109 Culture, mycoplasma, any source

87110 Culture, chlamydia, any source
(For immunofluorescence staining of shell vials, use 87140)

87116 Culture, tubercle or other acid-fast bacilli (eg, TB, AFB,
mycobacteria) any source, with isolation and presumptive
identification of isolates
(For concentration, use 87015)

87118 Culture, mycobacterial, definitive identification, each
isolate
87140 Culture, typing; immunofluorescent method, each antiserum

87143 gas liquid chromatography (GLC) or high pressure liquid

chromatography (HPLC) method
87147 immunologic method, other than immunofluorescence

(eg, agglutination grouping), per antiserum
87149 identification by nucleic acid (DNA or RNA) probe,

direct probe technique, per culture or isolate, each
organism probed
➲ CPT Assistant Nov 01:10, May 12:5, Sep 13:3
81408)
87150 identification by nucleic acid (DNA or RNA) probe,
amplified probe technique, per culture or isolate, each
organism probed

81408)
87152 identification by pulse field gel typing

81408)
87153 identification by nucleic acid sequencing method, each
isolate (eg, sequencing of the 16S rRNA gene)
87158 other methods

87164 Dark field examination, any source (eg, penile, vaginal,

oral, skin); includes specimen collection
87166 without collection
87168 Macroscopic examination; arthropod
87169 parasite
87172 Pinworm exam (eg, cellophane tape prep)
87176 Homogenization, tissue, for culture

87177 Ova and parasites, direct smears, concentration and

identification

(For direct smears from a primary source, use 87207)
(For coccidia or microsporidia exam, use 87207)
(For complex special stain (trichrome, iron hematoxylin),
use 87209)
(For nucleic acid probes in cytologic material, use 88365)
87181 Susceptibility studies, antimicrobial agent; agar dilution
method, per agent (eg, antibiotic gradient strip)
87184 disk method, per plate (12 or fewer agents)

87185 enzyme detection (eg, beta lactamase), per enzyme

87186 microdilution or agar dilution (minimum inhibitory

concentration [MIC] or breakpoint), each multi-
antimicrobial, per plate
✚ 87187 microdilution or agar dilution, minimum lethal

concentration (MLC), each plate (List separately in
(Use 87187 in conjunction with 87186 or 87188)

87188 macrobroth dilution method, each agent
87190 mycobacteria, proportion method, each agent

(For other mycobacterial susceptibility studies, see 87181,

87184, 87186, or 87188)
87197 Serum bactericidal titer (Schlichter test)
87205 Smear, primary source with interpretation; Gram or Giemsa
stain for bacteria, fungi, or cell types
87206 fluorescent and/or acid fast stain for bacteria, fungi,

parasites, viruses or cell types
87207 special stain for inclusion bodies or parasites (eg,

malaria, coccidia, microsporidia, trypanosomes, herpes
viruses)
(For direct smears with concentration and identification, use

87177)
(For thick smear preparation, use 87015)
(For fat, meat, fibers, nasal eosinophils, and starch, see
miscellaneous section)
87209 complex special stain (eg, trichrome, iron hemotoxylin)
for ova and parasites
87210 wet mount for infectious agents (eg, saline, India ink,
KOH preps)
(For KOH examination of skin, hair or nails, see 87220)

87220 Tissue examination by KOH slide of samples from skin,
hair, or nails for fungi or ectoparasite ova or mites (eg,
scabies)
87230 Toxin or antitoxin assay, tissue culture (eg, Clostridium

difficile toxin)
87250 Virus isolation; inoculation of embryonated eggs, or small
animal, includes observation and dissection
87252 tissue culture inoculation, observation, and presumptive

identification by cytopathic effect
87253 tissue culture, additional studies or definitive

identification (eg, hemabsorption, neutralization,
immunofluorescence stain), each isolate
(Electron microscopy, use 88348)

(Inclusion bodies in tissue sections, see 88304-88309; in
smears, see 87207-87210; in fluids, use 88106)
87254 centrifuge enhanced (shell vial) technique, includes
identification with immunofluorescence stain, each virus
(Report 87254 in addition to 87252 as appropriate)

87255 including identification by non-immunologic method,
other than by cytopathic effect (eg, virus specific
enzymatic activity)
These codes are intended for primary source only. For similar
studies on culture material, refer to codes 87140-87158.
Infectious agents by antigen detection, immunofluorescence
microscopy, or nucleic acid probe techniques should be reported
as precisely as possible. The molecular pathology procedures
codes (81161, 81200-81408) are not to be used in combination
with or instead of the procedures represented by 87471-87801.
The most specific code possible should be reported. If there is no
specific agent code, the general methodology code (eg, 87299,
87449, 87450, 87797, 87798, 87799, 87899) should be used. For
identification of antibodies to many of the listed infectious
agents, see 86602-86804. When separate results are reported for
different species or strain of organisms, each result should be
coded separately. Use modifier 59 when separate results are
reported for different species or strains that are described by the
same code.
87260 Infectious agent antigen detection by immunofluorescent
technique; adenovirus
87265 Bordetella pertussis/parapertussis

87267 Enterovirus, direct fluorescent antibody (DFA)
87269 giardia
87270 Chlamydia trachomatis

87271 Cytomegalovirus, direct fluorescent antibody (DFA)

87272 cryptosporidium
87273 Herpes simplex virus type 2

87274 Herpes simplex virus type 1

87275 influenza B virus

87276 influenza A virus


87278 Legionella pneumophila
87279 Parainfluenza virus, each type


87281 Pneumocystis carinii
87283 Rubeola
87285 Treponema pallidum

87290 Varicella zoster virus

87299 not otherwise specified, each organism

87300 Infectious agent antigen detection by immunofluorescent

technique, polyvalent for multiple organisms, each
polyvalent antiserum
(For physician evaluation of infectious disease agents by

immunofluorescence, use 88346)
87301 Infectious agent antigen detection by immunoassay
technique, (eg, enzyme immunoassay [EIA], enzyme-linked
immunosorbent assay [ELISA], immunochemiluminometric
assay [IMCA]) qualitative or semiquantitative, multiple-step
method; adenovirus enteric types 40/41
87305 Aspergillus

87324 Clostridium difficile toxin(s)
87327 Cryptococcus neoformans

(For Cryptococcus latex agglutination, use 86403)

87328 cryptosporidium
87329 giardia
87332 cytomegalovirus
87335 Escherichia coli 0157

(For giardia antigen, use 87329)

87336 Entamoeba histolytica dispar group
87337 Entamoeba histolytica group

87338 Helicobacter pylori, stool

87339 Helicobacter pylori

(For H. pylori, stool, use 87338. For H. pylori, breath and
blood by mass spectrometry, see 83013, 83014. For H.
pylori, liquid scintillation counter, see 78267, 78268)
87340 hepatitis B surface antigen (HBsAg)
87341 hepatitis B surface antigen (HBsAg) neutralization

87350 hepatitis Be antigen (HBeAg)

87380 hepatitis, delta agent

87385 Histoplasma capsulatum

87389 HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies,

single result
87390 HIV-1
87391 HIV-2
87400 Influenza, A or B, each

➲ CPT Assistant Jun 01:11, Dec 01:6, Aug 05:9, May
09:6
87425 rotavirus
87427 Shiga-like toxin

87430 Streptococcus, group A

87449 Infectious agent antigen detection by immunoassay

technique, (eg, enzyme immunoassay [EIA], enzyme-linked
immunosorbent assay [ELISA], immunochemiluminometric
assay [IMCA]), qualitative or semiquantitative; multiple-
step method, not otherwise specified, each organism
➲ CPT Assistant Nov 97:32, Jan 00:11, Nov 01:10
87450 single-step method, not otherwise specified, each

organism
87451 multiple-step method, polyvalent for multiple organisms,

each polyvalent antiserum
87471 Infectious agent detection by nucleic acid (DNA or RNA);

Bartonella henselae and Bartonella quintana, amplified
probe technique
87472 Bartonella henselae and Bartonella quintana,
quantification
87475 Borrelia burgdorferi, direct probe technique

87476 Borrelia burgdorferi, amplified probe technique


87480 Candida species, direct probe technique
87481 Candida species, amplified probe technique

87482 Candida species, quantification

87483 central nervous system pathogen (eg, Neisseria

meningitidis, Streptococcus pneumoniae, Listeria,
Haemophilus influenzae, E. coli, Streptococcus
agalactiae, enterovirus, human parechovirus, herpes
simplex virus type 1 and 2, human herpesvirus 6,
cytomegalovirus, varicella zoster virus, Cryptococcus),
includes multiplex reverse transcription, when
performed, and multiplex amplified probe technique,
multiple types or subtypes, 12-25 targets
87485 Chlamydia pneumoniae, direct probe technique

87486 Chlamydia pneumoniae, amplified probe technique

87487 Chlamydia pneumoniae, quantification
87490 Chlamydia trachomatis, direct probe technique
87491 Chlamydia trachomatis, amplified probe technique

87492 Chlamydia trachomatis, quantification

87493 Clostridium difficile, toxin gene(s), amplified probe

technique
➲ CPT Assistant Sep 10:8, May 12:5, Sep 13:3
87495 cytomegalovirus, direct probe technique

87496 cytomegalovirus, amplified probe technique

87497 cytomegalovirus, quantification

87498 enterovirus, amplified probe technique, includes reverse

transcription when performed
87500 vancomycin resistance (eg, enterococcus species van A,

van B), amplified probe technique
➲ CPT Assistant Apr 08:5, May 12:5, Sep 13:3
87501 influenza virus, includes reverse transcription, when

performed, and amplified probe technique, each type or
subtype
➲ CPT Assistant Oct 10:8, Dec 10:8, May 12:5, Sep
13:3
87502 influenza virus, for multiple types or sub-types, includes
multiplex reverse transcription, when performed, and
multiplex amplified probe technique, first 2 types or sub-
types
2016
✚ 87503 influenza virus, for multiple types or sub-types, includes

multiplex amplified probe technique, each additional
influenza virus type or sub-type beyond 2 (List

87505 gastrointestinal pathogen (eg, Clostridium difficile, E.
coli, Salmonella, Shigella, norovirus, Giardia), includes
multiplex amplified probe technique, multiple types or
subtypes, 3-5 targets


87510 Gardnerella vaginalis, direct probe technique

➲ CPT Assistant Aug 05:9, May 12:5, Sep 13:3
87511 Gardnerella vaginalis, amplified probe technique

87512 Gardnerella vaginalis, quantification


87516 hepatitis B virus, amplified probe technique
87517 hepatitis B virus, quantification

87520 hepatitis C, direct probe technique

87521 hepatitis C, amplified probe technique, includes reverse

87522 hepatitis C, quantification, includes reverse transcription

when performed
87525 hepatitis G, direct probe technique

87526 hepatitis G, amplified probe technique

87527 hepatitis G, quantification
87528 Herpes simplex virus, direct probe technique

87529 Herpes simplex virus, amplified probe technique

87530 Herpes simplex virus, quantification

87531 Herpes virus-6, direct probe technique

87532 Herpes virus-6, amplified probe technique

87533 Herpes virus-6, quantification

87534 HIV-1, direct probe technique

87535 HIV-1, amplified probe technique, includes reverse

87536 HIV-1, quantification, includes reverse transcription

when performed
87537 HIV-2, direct probe technique

87538 HIV-2, amplified probe technique, includes reverse

87539 HIV-2, quantification, includes reverse transcription
when performed
# 87623 Human Papillomavirus (HPV), low-risk types (eg, 6, 11,

42, 43, 44)
# 87624 Human Papillomavirus (HPV), high-risk types (eg, 16,

18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
(When both low-risk and high-risk HPV types are performed

in a single assay, use only 87624)
# 87625 Human Papillomavirus (HPV), types 16 and 18 only,
includes type 45, if performed
(For Human Papillomavirus [HPV] detection of five or

greater separately reported high-risk HPV types [ie,
genotyping], use 0500T)
87540 Legionella pneumophila, direct probe technique
87541 Legionella pneumophila, amplified probe technique

87542 Legionella pneumophila, quantification

87550 Mycobacteria species, direct probe technique

87551 Mycobacteria species, amplified probe technique
87552 Mycobacteria species, quantification

87555 Mycobacteria tuberculosis, direct probe technique

87556 Mycobacteria tuberculosis, amplified probe technique

87557 Mycobacteria tuberculosis, quantification

87560 Mycobacteria avium-intracellulare, direct probe

technique
87561 Mycobacteria avium-intracellulare, amplified probe

technique
87562 Mycobacteria avium-intracellulare, quantification

87563 Mycoplasma genitalium, amplified probe technique

87580 Mycoplasma pneumoniae, direct probe technique

87581 Mycoplasma pneumoniae, amplified probe technique

87582 Mycoplasma pneumoniae, quantification

87590 Neisseria gonorrhoeae, direct probe technique

87591 Neisseria gonorrhoeae, amplified probe technique
87592 Neisseria gonorrhoeae, quantification


87631 respiratory virus (eg, adenovirus, influenza virus,
coronavirus, metapneumovirus, parainfluenza virus,
respiratory syncytial virus, rhinovirus), includes


(Use 87631-87633 for nucleic acid assays which detect
multiple respiratory viruses in a multiplex reaction [ie,
single procedure with multiple results])
(For assays that are used to type or subtype influenza viruses
only, see 87501-87503)
(For assays that include influenza viruses with additional
respiratory viruses, see 87631-87633)
(For detection of multiple infectious agents not otherwise
specified which report a single result, see 87800, 87801)
87634 respiratory syncytial virus, amplified probe technique
(For assays that include respiratory syncytial virus with

additional respiratory viruses, see 87631, 87632, 87633)
● 87635 severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) (Coronavirus disease [COVID-19]),
amplified probe technique
87640 Staphylococcus aureus, amplified probe technique

➲ CPT Assistant Aug 07:7, May 12:5, Sep 13:3
87641 Staphylococcus aureus, methicillin resistant, amplified

probe technique
(For assays that detect methicillin resistance and identify

Staphylococcus aureus using a single nucleic acid sequence,
use 87641)
87650 Streptococcus, group A, direct probe technique
87651 Streptococcus, group A, amplified probe technique
87652 Streptococcus, group A, quantification

87653 Streptococcus, group B, amplified probe technique

87660 Trichomonas vaginalis, direct probe technique

87661 Trichomonas vaginalis, amplified probe technique

87662 Zika virus, amplified probe technique

87797 Infectious agent detection by nucleic acid (DNA or RNA),

not otherwise specified; direct probe technique, each
organism
➲ CPT Assistant Nov 97:34, Nov 01:10, Aug 05:9, May
12:5, Sep 13:3, Aug 16:10
87798 amplified probe technique, each organism
➲ CPT Assistant Nov 97:34, Nov 01:10, Aug 07:7, Sep
13:3
87799 quantification, each organism
87800 Infectious agent detection by nucleic acid (DNA or RNA),

multiple organisms; direct probe(s) technique
➲ CPT Assistant Aug 05:9, May 12:5, Sep 13:3, Aug 16:10
87801 amplified probe(s) technique
➲ CPT Assistant May 12:5, Jun 13:14, Sep 13:3
(For each specific organism nucleic acid detection from a

primary source, see 87471-87660. For detection of specific
infectious agents not otherwise specified, see 87797, 87798,
or 87799 1 time for each agent)
(For detection of multiple infectious agents not otherwise
specified which report a single result, see 87800, 87801)
(Do not use 87801 for nucleic acid assays that detect
multiple respiratory viruses in a multiplex reaction [ie,
single procedure with multiple results], see 87631-87633)
87802 Infectious agent antigen detection by immunoassay with
direct optical observation; Streptococcus, group B
87803 Clostridium difficile toxin A

# 87806 HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies

87804 Influenza
➲ CPT Assistant Jun 03:11-12, May 09:6

87808 Trichomonas vaginalis
87809 adenovirus

87850 Neisseria gonorrhoeae

87880 Streptococcus, group A

➲ CPT Assistant Nov 97:34, Jan 98:6, Dec 98:8
87899 not otherwise specified

87900 Infectious agent drug susceptibility phenotype prediction

using regularly updated genotypic bioinformatics
➲ CPT Assistant Mar 06:6, May 12:5, Sep 13:3, Dec 15:17
# 87910 Infectious agent genotype analysis by nucleic acid (DNA or

RNA); cytomegalovirus
(For infectious agent drug susceptibility phenotype

prediction for HIV-1, use 87900)
(For Human Papillomavirus [HPV] for high-risk types [ie,
genotyping], of five or greater separately reported HPV
types, use 0500T)
87901 HIV-1, reverse transcriptase and protease regions
2013
➲ CPT Assistant Aug 05:9, Mar 06:6, Oct 10:9, Dec
10:9, May 12:5, Sep 13:3
# 87906 HIV-1, other region (eg, integrase, fusion)
(For infectious agent drug susceptibility phenotype

prediction for HIV-1, use 87900)
# 87912 Hepatitis B virus
87902 Hepatitis C virus

➲ CPT Assistant May 12:5, Sep 13:3, Nov 15:11, Dec
15:17
87903 Infectious agent phenotype analysis by nucleic acid (DNA or
RNA) with drug resistance tissue culture analysis, HIV 1;
first through 10 drugs tested
➲ CPT Assistant Apr 04:15, Mar 06:6, May 12:3, Sep 13:3
✚ 87904 each additional drug tested (List separately in addition to

➲ CPT Assistant Apr 04:15, Mar 06:6, May 12:3, Sep
13:3
87905 Infectious agent enzymatic activity other than virus (eg,
sialidase activity in vaginal fluid)
(For virus isolation including identification by non-

immunologic method, other than by cytopathic effect, use
87255)
87999 Unlisted microbiology procedure
Anatomic Pathology
Postmortem Examination
Procedures 88000 through 88099 represent physician services
only. Use modifier 90 for outside laboratory services.
88000 Necropsy (autopsy), gross examination only; without CNS
88005 with brain

88007 with brain and spinal cord
88012 infant with brain
88014 stillborn or newborn with brain
88016 macerated stillborn
88020 Necropsy (autopsy), gross and microscopic; without CNS
88025 with brain
88027 with brain and spinal cord
88028 infant with brain
88029 stillborn or newborn with brain
88036 Necropsy (autopsy), limited, gross and/or microscopic;
regional
88037 single organ
88040 Necropsy (autopsy); forensic examination
88045 coroner’s call
88099 Unlisted necropsy (autopsy) procedure
Cytopathology
88104 Cytopathology, fluids, washings or brushings, except
cervical or vaginal; smears with interpretation
➲ CPT Assistant Spring 91:6, Fall 94:3, Aug 05:9
88106 simple filter method with interpretation


(For nongynecological selective cellular enhancement
including filter transfer techniques, use 88112)
88108 Cytopathology, concentration technique, smears and
interpretation (eg, Saccomanno technique)
➲ CPT Assistant Fall 94:3, Nov 97:34, Jan 98:6
(For cervical or vaginal smears, see 88150-88155)

(For gastric intubation with lavage, see 43754, 43755)
(For x-ray localization, use 74340)
88112 Cytopathology, selective cellular enhancement technique
with interpretation (eg, liquid based slide preparation
method), except cervical or vaginal
(Do not report 88112 with 88108)

88120 Cytopathology, in situ hybridization (eg, FISH), urinary tract
specimen with morphometric analysis, 3-5 molecular
probes, each specimen; manual
88121 using computer-assisted technology

(For morphometric in situ hybridization on cytologic

specimens other than urinary tract, see 88367, 88368)
(For more than 5 probes, use 88399)
88125 Cytopathology, forensic (eg, sperm)
88130 Sex chromatin identification; Barr bodies
88140 peripheral blood smear, polymorphonuclear drumsticks
(For Guard stain, use 88313)

Codes 88141-88155, 88164-88167, 88174-88175 are used to
report cervical or vaginal screening by various methods and to
report physician interpretation services. Use codes 88150, 88152,
88153 to report conventional Pap smears that are examined using
non-Bethesda reporting. Use codes 88164-88167 to report
conventional Pap smears that are examined using the Bethesda
System of reporting. Use codes 88142-88143 to report liquid-
based specimens processed as thin-layer preparations that are
examined using any system of reporting (Bethesda or non-
Bethesda). Use codes 88174-88175 to report automated screening
of liquid-based specimens that are examined using any system of
reporting (Bethesda or non-Bethesda).Within each of these three
code families choose the one code that describes the screening
method(s) used. Codes 88141 and 88155 should be reported in
addition to the screening code chosen when the additional
services are provided. Manual rescreening requires a complete
visual reassessment of the entire slide initially screened by either
an automated or manual process. Manual review represents an
assessment of selected cells or regions of a slide identified by
initial automated review.
88141 Cytopathology, cervical or vaginal (any reporting system),
requiring interpretation by physician
➲ CPT Assistant Nov 97:35, Jan 98:6, Jan 99:11, May
99:6, Nov 99:46, Mar 04:6, Mar 05:16, May 11:10, Dec
11:17
88148, 88150, 88152, 88153, 88164-88167, 88174-88175)
collected in preservative fluid, automated thin layer
preparation; manual screening under physician supervision
➲ CPT Assistant Nov 97:34-35, Jan 98:6, Nov 98:28, May
99:6, Jul 03:7, Mar 04:4
88143 with manual screening and rescreening under physician
supervision
➲ CPT Assistant Nov 97:34-35, Nov 98:28, May 99:6,
Jul 03:7, Mar 04:4, Mar 05:16
(For automated screening of automated thin layer
preparation, see 88174, 88175)
88147 Cytopathology smears, cervical or vaginal; screening by
automated system under physician supervision
➲ CPT Assistant Nov 97:35, Nov 98:28, Jan 99:11, May
99:6, Nov 99:46, Mar 04:6
88148 screening by automated system with manual rescreening
under physician supervision
➲ CPT Assistant Jan 99:1, May 99:6, Nov 99:46, Mar
04:6
88150 Cytopathology, slides, cervical or vaginal; manual screening
under physician supervision
➲ CPT Assistant Winter 91:19, Nov 97:34-35, Nov 98:28,
May 99:6, Mar 04:5
88152 with manual screening and computer-assisted
rescreening under physician supervision
➲ CPT Assistant Nov 97:35, Jan 98:6, May 99:6, Mar
04:5
supervision
➲ CPT Assistant Nov 97:34-35, Nov 98:28, May 99:6,
Mar 04:5, Mar 05:16
✚ 88155 Cytopathology, slides, cervical or vaginal, definitive
hormonal evaluation (eg, maturation index, karyopyknotic
index, estrogenic index) (List separately in addition to
code[s] for other technical and interpretation services)
➲ CPT Assistant Nov 97:35, Nov 98:28, May 99:6, Nov
99:46, Mar 04:5, May 11:10
88148, 88150, 88152, 88153, 88164-88167, 88174-88175)
88160 Cytopathology, smears, any other source; screening and
interpretation
88161 preparation, screening and interpretation

➲ CPT Assistant Aug 97:18, Jan 98:6
88162 extended study involving over 5 slides and/or multiple

stains
(For aerosol collection of sputum, use 89220)
(For special stains, see 88312-88314)
88164 Cytopathology, slides, cervical or vaginal (the Bethesda
System); manual screening under physician supervision
➲ CPT Assistant Nov 98:28, May 99:6, Mar 04:5

supervision
➲ CPT Assistant Nov 98:28, May 99:6, Mar 04:5, Mar
05:16
rescreening under physician supervision
➲ CPT Assistant Nov 98:28, May 99:6, Mar 04:5

rescreening using cell selection and review under
physician supervision
➲ CPT Assistant Nov 98:28, May 99:6, Jul 03:7, Mar
04:5
(For collection of specimen via fine needle aspiration
biopsy, see 10004, 10005, 10006, 10007, 10008, 10009,
10010, 10011, 10012, 10021)
88172 Cytopathology, evaluation of fine needle aspirate; immediate
cytohistologic study to determine adequacy for diagnosis,
first evaluation episode, each site
➲ CPT Assistant Fall 93:26, Fall 94:2, Dec 98:8, Aug
07:15, Oct 10:9, Dec 10:9, Jan 16:12, Apr 19:4
(The evaluation episode represents a complete set of
cytologic material submitted for evaluation and is
independent of the number of needle passes or slides
prepared. A separate evaluation episode occurs if the
proceduralist provider obtains additional material from the
same site, based on the prior immediate adequacy
assessment, or a separate lesion is aspirated)
88173 interpretation and report
➲ CPT Assistant Fall 93:26, Fall 94:2, Dec 98:8, Oct
10:9, Dec 10:9, Apr 19:4
(Report one unit of 88173 for the interpretation and report
from each anatomic site, regardless of the number of passes
or evaluation episodes performed during the aspiration
procedure)
(For fine needle aspirate biopsy, see 10004, 10005, 10006,
10007, 10008, 10009, 10010, 10011, 10012, 10021)
(Do not report 88172, 88173 in conjunction with 88333 and
88334 for the same specimen)
#✚ 88177 immediate cytohistologic study to determine adequacy
for diagnosis, each separate additional evaluation
episode, same site (List separately in addition to code
➲ CPT Assistant Oct 10:9, Dec 10:9, Jan 16:12, Apr
19:4
(When repeat immediate evaluation episode(s) is required
on subsequent cytologic material from the same site, eg,
following determination the prior sampling that was not
adequate for diagnosis, use 1 unit of 88177 for each
additional evaluation episode)
collected in preservative fluid, automated thin layer
preparation; screening by automated system, under physician
supervision
88175 with screening by automated system and manual
rescreening or review, under physician supervision
➲ CPT Assistant Jul 03:9, Mar 04:4, Mar 06:6, May
11:10
(For manual screening, see 88142, 88143)
88182 Flow cytometry, cell cycle or DNA analysis
(For DNA ploidy analysis by morphometric technique, use

88358)
88184 Flow cytometry, cell surface, cytoplasmic, or nuclear
marker, technical component only; first marker
✚ 88185 each additional marker (List separately in addition to

code for first marker)

88187 Flow cytometry, interpretation; 2 to 8 markers
88188 9 to 15 markers
88189 16 or more markers

(Do not report 88187-88189 for interpretation of 86355,
86356, 86357, 86359, 86360, 86361, 86367)
(For assessment of circulating antibodies by flow cytometric
techniques, see analyte and method-specific codes in the
Chemistry section [83516-83520] or Immunology section
[86000-86849])
(For cell enumeration using immunologic selection and
identification in fluid specimen [eg, circulating tumor cells
in blood], see 86152, 86153)
88199 Unlisted cytopathology procedure
(For electron microscopy, use 88348)
Cytogenetic Studies
Molecular pathology procedures should be reported using the
appropriate code from Tier 1 (81161, 81200-81383), Tier 2
(81400-81408), Genomic Sequencing Procedures and Other
Molecular Multianalyte Assays (81410-81471), or Multianalyte
Assays with Algorithmic Analyses (81500-81512) sections. If no
specific code exists, one of the unlisted codes (81479 or 81599)
should be used.
(For acetylcholinesterase, use 82013)
(For alpha-fetoprotein, serum or amniotic fluid, see 82105,
82106)
(For laser microdissection of cells from tissue sample, see
88380)
88230 Tissue culture for non-neoplastic disorders; lymphocyte
➲ CPT Assistant Nov 98:29, Oct 99:2, Aug 05:9, May 08:5
88233 skin or other solid tissue biopsy

88235 amniotic fluid or chorionic villus cells
88237 Tissue culture for neoplastic disorders; bone marrow, blood

cells
88239 solid tumor

88240 Cryopreservation, freezing and storage of cells, each cell

line
➲ CPT Assistant Nov 98:29, Oct 99:2, Jul 03:9, May 08:5,
Oct 13:3
(For therapeutic cryopreservation and storage, use 38207)
88241 Thawing and expansion of frozen cells, each aliquot
➲ CPT Assistant Nov 98:29, Oct 99:2, Jul 03:9, May 08:5,
Oct 13:3
(For therapeutic thawing of previous harvest, use 38208)
88245 Chromosome analysis for breakage syndromes; baseline
Sister Chromatid Exchange (SCE), 20-25 cells
➲ CPT Assistant Nov 98:29, Oct 99:2, Jul 05:1, May 08:5
88248 baseline breakage, score 50-100 cells, count 20 cells, 2

karyotypes (eg, for ataxia telangiectasia, Fanconi anemia,
fragile X)
➲ CPT Assistant Nov 98:29, Oct 99:2, Jul 05:1, May
08:5
88249 score 100 cells, clastogen stress (eg, diepoxybutane,
mitomycin C, ionizing radiation, UV radiation)
08:5
88261 Chromosome analysis; count 5 cells, 1 karyotype, with
banding
88262 count 15-20 cells, 2 karyotypes, with banding
➲ CPT Assistant Nov 98:29, Oct 99:2, May 08:5, May
11:10, Aug 19:11
88263 count 45 cells for mosaicism, 2 karyotypes, with banding
08:5
88264 analyze 20-25 cells
08:5, Aug 19:11
88267 Chromosome analysis, amniotic fluid or chorionic villus,
count 15 cells, 1 karyotype, with banding
88269 Chromosome analysis, in situ for amniotic fluid cells, count

cells from 6-12 colonies, 1 karyotype, with banding
88271 Molecular cytogenetics; DNA probe, each (eg, FISH)

➲ CPT Assistant Nov 98:29, Mar 99:10, Oct 99:3, Jun
02:11, Jul 05:1, May 08:5, May 12:5, Sep 13:3, Feb
20:10
(For cytogenomic microarray analysis, see 81228, 81229,
81405, 81406, 81479)
(For genomic sequencing procedures or other molecular
multianalyte assays for copy number analysis using
circulating cell-free fetal DNA in maternal blood, see
81420, 81422, 81479)
88272 chromosomal in situ hybridization, analyze 3-5 cells (eg,
for derivatives and markers)
02:11, Jul 05:1, May 08:5, May 12:5, Sep 13:3
88273 chromosomal in situ hybridization, analyze 10-30 cells
(eg, for microdeletions)
02:11, Jul 05:1, May 08:5, May 12:5, Sep 13:3
88274 interphase in situ hybridization, analyze 25-99 cells
02:11, Jul 05:1, May 08:5, May 12:5, Sep 13:3
88275 interphase in situ hybridization, analyze 100-300 cells
02:11, Jul 05:1, May 08:5, May 12:5, Sep 13:3
88280 Chromosome analysis; additional karyotypes, each study
➲ CPT Assistant Jul 05:1, May 08:5
88283 additional specialized banding technique (eg, NOR, C-

banding)
➲ CPT Assistant Jul 05:1, May 08:5
88285 additional cells counted, each study

➲ CPT Assistant Jul 05:1, Dec 07:14, May 08:5, May
11:10
88289 additional high resolution study
➲ CPT Assistant Oct 99:3, Jul 05:1
88291 Cytogenetics and molecular cytogenetics, interpretation and

report
88299 Unlisted cytogenetic study

Surgical Pathology
Services 88300 through 88309 include accession, examination,
and reporting. They do not include the services designated in
codes 88311 through 88365 and 88399, which are coded in
addition when provided.
The unit of service for codes 88300 through 88309 is the
specimen.
A specimen is defined as tissue or tissues that is (are) submitted
for individual and separate attention, requiring individual
examination and pathologic diagnosis. Two or more such
specimens from the same patient (eg, separately identified
endoscopic biopsies, skin lesions) are each appropriately
assigned an individual code reflective of its proper level of
service.
Service code 88300 is used for any specimen that in the opinion
of the examining pathologist can be accurately diagnosed without
microscopic examination. Service code 88302 is used when gross
and microscopic examination is performed on a specimen to
confirm identification and the absence of disease. Service codes
88304 through 88309 describe all other specimens requiring gross
and microscopic examination, and represent additional ascending
levels of physician work. Levels 88302 through 88309 are
specifically defined by the assigned specimens.
Any unlisted specimen should be assigned to the code which
most closely reflects the physician work involved when
compared to other specimens assigned to that code.
(Do not report 88302-88309 on the same specimen as part
of Mohs surgery)
88300 Level I - Surgical pathology, gross examination only
➲ CPT Assistant Winter 91:18, Sep 00:10, Aug 05:9
88302 Level II - Surgical pathology, gross and microscopic

examination
Appendix, incidental
Fallopian tube, sterilization
Fingers/toes, amputation, traumatic
Foreskin, newborn
Hernia sac, any location
Hydrocele sac
Nerve
Skin, plastic repair
Sympathetic ganglion
Testis, castration
Vaginal mucosa, incidental
Vas deferens, sterilization
➲ CPT Assistant Winter 91:18, Sep 00:10, Nov 06:1, Jan
07:29, Dec 11:17, Feb 14:10
88304 Level III - Surgical pathology, gross and microscopic
examination
Abortion, induced
Abscess
Aneurysm - arterial/ventricular
Anus, tag
Appendix, other than incidental
Artery, atheromatous plaque
Bartholin’s gland cyst
Bone fragment(s), other than pathologic fracture
Bursa/synovial cyst
Carpal tunnel tissue
Cartilage, shavings
Cholesteatoma
Colon, colostomy stoma
Conjunctiva - biopsy/pterygium
Cornea
Diverticulum - esophagus/small intestine
Dupuytren’s contracture tissue
Femoral head, other than fracture
Fissure/fistula
Foreskin, other than newborn
Gallbladder
Ganglion cyst
Hematoma
Hemorrhoids
Hydatid of Morgagni
Intervertebral disc
Joint, loose body
Meniscus
Mucocele, salivary
Neuroma - Morton’s/traumatic
Pilonidal cyst/sinus
Polyps, inflammatory - nasal/sinusoidal
Skin - cyst/tag/debridement
Soft tissue, debridement
Soft tissue, lipoma
Spermatocele
Tendon/tendon sheath
Testicular appendage
Thrombus or embolus
Tonsil and/or adenoids
Varicocele
Vas deferens, other than sterilization
Vein, varicosity
➲ CPT Assistant Spring 91:2, Winter 91:18, Aug 97:18,
Sep 00:10, Jan 07:29, Dec 11:17
88305 Level IV - Surgical pathology, gross and microscopic
examination
Abortion - spontaneous/missed
Artery, biopsy
Bone marrow, biopsy
Bone exostosis
Brain/meninges, other than for tumor resection
Breast, biopsy, not requiring microscopic evaluation of
surgical margins
Breast, reduction mammoplasty
Bronchus, biopsy
Cell block, any source
Cervix, biopsy
Colon, biopsy
Duodenum, biopsy
Endocervix, curettings/biopsy
Endometrium, curettings/biopsy
Esophagus, biopsy
Extremity, amputation, traumatic
Fallopian tube, biopsy
Fallopian tube, ectopic pregnancy
Femoral head, fracture
Fingers/toes, amputation, non-traumatic
Gingiva/oral mucosa, biopsy
Heart valve
Joint, resection
Kidney, biopsy
Larynx, biopsy
Leiomyoma(s), uterine myomectomy - without uterus
Lip, biopsy/wedge resection
Lung, transbronchial biopsy
Lymph node, biopsy
Muscle, biopsy
Nasal mucosa, biopsy
Nasopharynx/oropharynx, biopsy
Nerve, biopsy
Odontogenic/dental cyst
Omentum, biopsy
Ovary with or without tube, non-neoplastic
Ovary, biopsy/wedge resection
Parathyroid gland
Peritoneum, biopsy
Pituitary tumor
Placenta, other than third trimester
Pleura/pericardium - biopsy/tissue
Polyp, cervical/endometrial
Polyp, colorectal
Polyp, stomach/small intestine
Prostate, needle biopsy
Prostate, TUR
Salivary gland, biopsy
Sinus, paranasal biopsy
Skin, other than cyst/tag/debridement/plastic repair
Small intestine, biopsy
Soft tissue, other than tumor/mass/lipoma/debridement
Spleen
Stomach, biopsy
Synovium
Testis, other than tumor/biopsy/castration
Thyroglossal duct/brachial cleft cyst
Tongue, biopsy
Tonsil, biopsy
Trachea, biopsy
Ureter, biopsy
Urethra, biopsy
Urinary bladder, biopsy
Uterus, with or without tubes and ovaries, for prolapse
Vagina, biopsy
Vulva/labia, biopsy
➲ CPT Assistant Winter 90:2, Spring 91:6, Winter 91:18,
Winter 92:17, Aug 97:18, Jul 98:4, Nov 98:29-30, Jul
00:4, Sep 00:10, Dec 00:15, Jul 05:13, Nov 06:1, Jan
07:29, Dec 11:17
88307 Level V - Surgical pathology, gross and microscopic
examination
Adrenal, resection
Bone - biopsy/curettings
Bone fragment(s), pathologic fracture
Brain, biopsy
Brain/meninges, tumor resection
Breast, excision of lesion, requiring microscopic evaluation
of surgical margins
Breast, mastectomy - partial/simple
Cervix, conization
Colon, segmental resection, other than for tumor
Extremity, amputation, non-traumatic
Eye, enucleation
Kidney, partial/total nephrectomy
Larynx, partial/total resection
Liver, biopsy - needle/wedge
Liver, partial resection
Lung, wedge biopsy
Lymph nodes, regional resection
Mediastinum, mass
Myocardium, biopsy
Odontogenic tumor
Ovary with or without tube, neoplastic
Pancreas, biopsy
Placenta, third trimester
Prostate, except radical resection
Salivary gland
Sentinel lymph node
Small intestine, resection, other than for tumor
Soft tissue mass (except lipoma) - biopsy/simple excision
Stomach - subtotal/total resection, other than for tumor
Testis, biopsy
Thymus, tumor
Thyroid, total/lobe
Ureter, resection
Urinary bladder, TUR
Uterus, with or without tubes and ovaries, other than
neoplastic/prolapse
➲ CPT Assistant Winter 91:18, Winter 92:18, Jul 98:4,
Nov 98:29-30, Jul 99:10, Jul 00:4, Sep 00:10, Dec
00:15, Dec 03:11, Nov 06:1, Jan 07:29, Dec 11:17
88309 Level VI - Surgical pathology, gross and microscopic
examination
Bone resection
Breast, mastectomy - with regional lymph nodes
Colon, segmental resection for tumor
Colon, total resection
Esophagus, partial/total resection
Extremity, disarticulation
Fetus, with dissection
Larynx, partial/total resection - with regional lymph nodes
Lung - total/lobe/segment resection
Pancreas, total/subtotal resection
Prostate, radical resection
Small intestine, resection for tumor
Soft tissue tumor, extensive resection
Stomach - subtotal/total resection for tumor
Testis, tumor
Tongue/tonsil -resection for tumor
Urinary bladder, partial/total resection
Uterus, with or without tubes and ovaries, neoplastic
Vulva, total/subtotal resection
➲ CPT Assistant Spring 91:2, Winter 91:18, Fall 93:2, 26,
Jul 00:4, Sep 00:10, Dec 03:11, Nov 06:1, Jan 07:29,
Dec 11:18, Feb 14:10
10006, 10007, 10008, 10009, 10010, 10011, 10012, 10021)
(For evaluation of fine needle aspirate, see 88172-88173)
(Do not report 88302-88309 on the same specimen as part
of Mohs surgery)
✚ 88311 Decalcification procedure (List separately in addition to
code for surgical pathology examination)
➲ CPT Assistant Winter 92:18, Jul 98:4, Jun 02:11, Nov
02:7, Nov 06:1, Dec 11:18
88312 Special stain including interpretation and report; Group I for
microorganisms (eg, acid fast, methenamine silver)
➲ CPT Assistant Winter 91:19, Jun 02:11, Nov 02:7, Nov
06:1, Dec 11:18
(Report one unit of 88312 for each special stain, on each
surgical pathology block, cytologic specimen, or
hematologic smear)
88313 Group II, all other (eg, iron, trichrome), except stain for
microorganisms, stains for enzyme constituents, or
immunocytochemistry and immunohistochemistry
➲ CPT Assistant Jun 02:11, Nov 02:7, Mar 03:22, Nov
03:15, Jun 06:17, Nov 06:1, Dec 11:18
(Report one unit of 88313 for each special stain, on each
surgical pathology block, cytologic specimen, or
hematologic smear)
(For immunocytochemistry and immunohistochemistry, use
88342)
✚ 88314 histochemical stain on frozen tissue block (List
➲ CPT Assistant Nov 02:7, Nov 06:1, Dec 11:18

88309, 88331, 88332)
(Do not report 88314 with 17311-17315 for routine frozen
section stain [eg, hematoxylin and eosin, toluidine blue],
performed during Mohs surgery. When a nonroutine
histochemical stain on frozen tissue during Mohs surgery is
utilized, report 88314 with modifier 59)
(Report one unit of 88314 for each special stain on each
frozen surgical pathology block)
(For a special stain performed on frozen tissue section
material to identify enzyme constituents, use 88319)
(For determinative histochemistry to identify chemical
components, use 88313)
88319 Group III, for enzyme constituents
(For each stain on each surgical pathology block, cytologic

specimen, or hematologic smear, use one unit of 88319)
(For detection of enzyme constituents by
immunohistochemical or immunocytochemical technique,
use 88342)
88321 Consultation and report on referred slides prepared
elsewhere
➲ CPT Assistant Winter 91:19, Apr 97:9, Oct 00:7, Dec
02:10, Jan 10:11, Dec 11:18, Jun 13:15
88323 Consultation and report on referred material requiring
preparation of slides
➲ CPT Assistant Winter 91:19, Apr 97:9, Oct 00:7, Dec
02:10, Dec 11:18, Jun 13:15
88325 Consultation, comprehensive, with review of records and
specimens, with report on referred material
➲ CPT Assistant Winter 91:19, Apr 97:9, Dec 02:10, Dec
11:18, Jun 13:15
88329 Pathology consultation during surgery;
➲ CPT Assistant Winter 91:19, Apr 97:12, Aug 97:18, Jan
07:29, Dec 11:18
88331 first tissue block, with frozen section(s), single specimen
➲ CPT Assistant Spring 91:2, Winter 91:19, Apr 97:12,
Aug 97:18, Jul 00:4, Nov 02:7, Mar 06:6, Nov 06:1,
Jan 07:29, Oct 10:9, Dec 10:9, Dec 11:18
✚ 88332 each additional tissue block with frozen section(s) (List
➲ CPT Assistant Winter 91:19, Apr 97:12, Aug 97:18,
Jul 00:4, Mar 06:6, Jan 07:29, Oct 10:9, Dec 10:9,
Dec 11:18
88333 cytologic examination (eg, touch prep, squash prep),
initial site
➲ CPT Assistant Mar 06:6, Jan 07:29, Jun 08:15, Dec
10:9, Dec 11:18
✚ 88334 cytologic examination (eg, touch prep, squash prep),
each additional site (List separately in addition to code
➲ CPT Assistant Mar 06:6, Jan 07:29, Oct 10:9, Dec
11:18
(For intraoperative consultation on a specimen requiring
both frozen section and cytologic evaluation, use 88331 and
88334)
(For percutaneous needle biopsy requiring intraprocedural
cytologic examination, use 88333)
(Do not report 88333 and 88334 for non-intraoperative
cytologic examination, see 88160-88162)
(Do not report 88333 and 88334 for intraprocedural
cytologic evaluation of fine needle aspirate, see 88172)
88342 Immunohistochemistry or immunocytochemistry, per
specimen; initial single antibody stain procedure
➲ CPT Assistant Winter 91:17, Jul 00:10, Nov 02:6-7, Nov
06:1, Dec 11:18, Jun 14:15, Jun 15:11
(For quantitative or semiquantitative immunohistochemistry,
see 88360, 88361)
#✚ 88341 each additional single antibody stain procedure (List

(For multiplex antibody stain procedure, use 88344)
88344 each multiplex antibody stain procedure
(Do not use more than one unit of 88341, 88342, or 88344
for the same separately identifiable antibody per specimen)
88360, 88361 unless each procedure is for a different
antibody)
(When multiple separately identifiable antibodies are
applied to the same specimen [ie, multiplex antibody stain
procedure], use one unit of 88344)
(When multiple antibodies are applied to the same slide that
are not separately identifiable, [eg, antibody cocktails], use
88342, unless an additional separately identifiable antibody
is also used, then use 88344)
88346 Immunofluorescence, per specimen; initial single antibody
stain procedure
#✚ 88350 each additional single antibody stain procedure (List


(Do not report 88346 and 88350 for fluorescent in situ
hybridization studies, see 88364, 88365, 88366, 88367,
88368, 88369, 88373, 88374, and 88377)
(Do not report 88346 and 88350 for multiplex
immunofluorescence analysis, use 88399)
88348 Electron microscopy, diagnostic

88355 Morphometric analysis; skeletal muscle
88356 nerve
88358 tumor (eg, DNA ploidy)

➲ CPT Assistant Jul 98:4, Jul 99:11, Jun 02:11, Jun
06:17, Dec 11:18
(Do not report 88358 with 88313 unless each procedure is
for a different special stain)
88360 Morphometric analysis, tumor immunohistochemistry (eg,
Her-2/neu, estrogen receptor/progesterone receptor),
quantitative or semiquantitative, per specimen, each single
antibody stain procedure; manual
88361 using computer-assisted technology


88342, or 88344 unless each procedure is for a different
antibody)
(Morphometric analysis of a multiplex antibody stain should
be reported with one unit of 88360 or 88361, per specimen)
(For morphometric analysis using in situ hybridization
techniques, see 88367, 88368)
(When semi-thin plastic-embedded sections are performed
in conjunction with morphometric analysis, only the
morphometric analysis should be reported; if performed as
an independent procedure, see codes 88300-88309 for
surgical pathology.)
88362 Nerve teasing preparations
88363 Examination and selection of retrieved archival (ie,

previously diagnosed) tissue(s) for molecular analysis (eg,
KRAS mutational analysis)

88365 In situ hybridization (eg, FISH), per specimen; initial single
probe stain procedure
➲ CPT Assistant Jun 02:11, Mar 05:16, Dec 11:18, May
12:3, Sep 13:3, Nov 18:11
#✚ 88364 each additional single probe stain procedure (List

88366 each multiplex probe stain procedure

88368, 88374, 88377 for the same probe)
88367 Morphometric analysis, in situ hybridization (quantitative or
semi-quantitative), using computer-assisted technology, per
specimen; initial single probe stain procedure
➲ CPT Assistant Mar 05:16, Oct 10:9, Dec 11:18, May
12:5, Sep 13:3
#✚ 88373 each additional single probe stain procedure (List

# 88374 each multiplex probe stain procedure

88368 Morphometric analysis, in situ hybridization (quantitative or
semi-quantitative), manual, per specimen; initial single
probe stain procedure
➲ CPT Assistant Mar 05:16, Oct 10:9, Dec 11:18, May
12:5, Sep 13:3
✚ 88369 each additional single probe stain procedure (List

# 88377 each multiplex probe stain procedure

(For morphometric in situ hybridization evaluation of
urinary tract cytologic specimens, see 88120, 88121)
88371 Protein analysis of tissue by Western Blot, with
interpretation and report;
88372 immunological probe for band identification, each


88375 Optical endomicroscopic image(s), interpretation and
report, real-time or referred, each endoscopic session

0397T)
88380 Microdissection (ie, sample preparation of microscopically
identified target); laser capture
CPT Assistant Apr 02:17, Apr 08:5, Dec 11:18, May
➲
12:8, 10, Sep 13:3
88381 manual
➲ CPT Assistant Apr 08:5, Dec 11:18, May 12:8, 10,
Sep 13:3
88387 Macroscopic examination, dissection, and preparation of
tissue for non-microscopic analytical studies (eg, nucleic
acid-based molecular studies); each tissue preparation (eg,
a single lymph node)
(Do not report 88387 for tissue preparation for

microbiologic cultures or flow cytometric studies)
88334)
✚ 88388 in conjunction with a touch imprint, intraoperative
consultation, or frozen section, each tissue preparation
(eg, a single lymph node) (List separately in addition to

(Do not report 88387 or 88388 for tissue preparation for
microbiologic cultures or flow cytometric studies)
88399 Unlisted surgical pathology procedure
In Vivo (eg, Transcutaneous)
Laboratory Procedures
(For all in vivo measurements not specifically listed, use
88749)
(For wavelength fluorescent spectroscopy of advanced
glycation end products [skin], use 88749)
(For transcutaneous oxyhemoglobin measurement in a lower
extremity wound by near infrared spectroscopy, use 0493T)
88720 Bilirubin, total, transcutaneous
(For transdermal oxygen saturation, see 94760-94762)

88738 Hemoglobin (Hgb), quantitative, transcutaneous
(For in vitro hemoglobin measurement, use 85018)

88740 Hemoglobin, quantitative, transcutaneous, per day;
carboxyhemoglobin
(For in vitro carboxyhemoglobin measurement, use 82375)

88741 methemoglobin
(For in vitro quantitative methemoglobin determination, use

83050)
88749 Unlisted in vivo (eg, transcutaneous) laboratory service
Other Procedures
89049 Caffeine halothane contracture test (CHCT) for malignant
hyperthermia susceptibility, including interpretation and
report
➲ CPT Assistant Mar 06:6, May 06:19, Sep 11:4
89050 Cell count, miscellaneous body fluids (eg, cerebrospinal

fluid, joint fluid), except blood;
89051 with differential count

89055 Leukocyte assessment, fecal, qualitative or semiquantitative

89060 Crystal identification by light microscopy with or without

polarizing lens analysis, tissue or any body fluid (except
urine)
(Do not report 89060 for crystal identification on paraffin-

embedded tissue)
89125 Fat stain, feces, urine, or respiratory secretions
89160 Meat fibers, feces

89190 Nasal smear for eosinophils

(Occult blood, feces, use 82270)
(Paternity tests, use 86910)
89220 Sputum, obtaining specimen, aerosol induced technique
89230 Sweat collection by iontophoresis

89240 Unlisted miscellaneous pathology test

Reproductive Medicine Procedures

89250 Culture of oocyte(s)/embryo(s), less than 4 days;
➲ CPT Assistant Nov 97:35-36, Jan 98:6, Oct 98:1, Apr
04:2, May 04:16, Jun 04:9, Sep 11:4
89251 with co-culture of oocyte(s)/embryos
➲ CPT Assistant Nov 97:35-36, Jan 98:6, Oct 98:1,
Apr 04:2
(For extended culture of oocyte[s]/embryo[s], see 89272)
89253 Assisted embryo hatching, microtechniques (any method)
04:2, May 04:16, Jun 04:9
89254 Oocyte identification from follicular fluid
04:2, May 04:16, Jun 04:9
89255 Preparation of embryo for transfer (any method)
04:2, May 04:16, Jun 04:9
89257 Sperm identification from aspiration (other than seminal
fluid)
➲ CPT Assistant Nov 97:35-36, Jan 98:6, Oct 98:1, Nov
98:30, Apr 04:2
(For semen analysis, see 89300-89320)
(For sperm identification from testis tissue, use 89264)
89258 Cryopreservation; embryo(s)
➲ CPT Assistant Nov 97:36, Jan 98:6, Oct 98:1, Apr 04:2,
4
89259 sperm
➲ CPT Assistant Nov 97:36, Jan 98:6, Oct 98:1, Apr
04:2, 4
(For cryopreservation of reproductive tissue, testicular, use
89335)
89260 Sperm isolation; simple prep (eg, sperm wash and swim-up)
for insemination or diagnosis with semen analysis
➲ CPT Assistant Nov 97:36, Jan 98:6, Oct 98:1, Apr 04:3-
4
89261 complex prep (eg, Percoll gradient, albumin gradient) for
insemination or diagnosis with semen analysis
➲ CPT Assistant Nov 97:36, Jan 98:6, Oct 98:1, Apr
04:3-4
(For semen analysis without sperm wash or swim-up, use
89320)
89264 Sperm identification from testis tissue, fresh or
cryopreserved
➲ CPT Assistant Nov 98:30, Apr 04:3-4
(For biopsy of testis, see 54500, 54505)
(For sperm identification from aspiration, use 89257)
(For semen analysis, see 89300-89320)
89268 Insemination of oocytes
89272 Extended culture of oocyte(s)/embryo(s), 4-7 days

89280 Assisted oocyte fertilization, microtechnique; less than or

equal to 10 oocytes
89281 greater than 10 oocytes

89290 Biopsy, oocyte polar body or embryo blastomere,

microtechnique (for pre-implantation genetic diagnosis);
less than or equal to 5 embryos
89291 greater than 5 embryos

89300 Semen analysis; presence and/or motility of sperm including

Huhner test (post coital)
➲ CPT Assistant Nov 97:36, Jul 98:10, Oct 98:4, Apr
04:3, Aug 05:9
89310 motility and count (not including Huhner test)
89320 volume, count, motility, and differential

(Skin tests, see 86485-86580 and 95012-95199)

89321 sperm presence and motility of sperm, if performed
(To report Hyaluronan binding assay [HBA], use 89398)

89322 volume, count, motility, and differential using strict
morphologic criteria (eg, Kruger)
89325 Sperm antibodies

(For medicolegal identification of sperm, use 88125)
89329 Sperm evaluation; hamster penetration test
89330 cervical mucus penetration test, with or without
spinnbarkeit test
89331 Sperm evaluation, for retrograde ejaculation, urine (sperm

concentration, motility, and morphology, as indicated)
(For semen analysis on concurrent semen specimen, see

89300-89322 in conjunction with 89331)
(For detection of sperm in urine, use 81015)
89335 Cryopreservation, reproductive tissue, testicular
▶ (Forcryopreservation of embryo[s], use 89258. For
cryopreservation of sperm, use 89259; for mature oocytes,
use 89337)◀
89337 Cryopreservation, mature oocyte(s)
89342 Storage (per year); embryo(s)

89343 sperm/semen
89344 reproductive tissue, testicular/ovarian

89346 oocyte(s)
89352 Thawing of cryopreserved; embryo(s)

89353 sperm/semen, each aliquot

89354 reproductive tissue, testicular/ovarian

89356 oocytes, each aliquot

89398 Unlisted reproductive medicine laboratory procedure

Proprietary laboratory analyses (PLA) codes describe proprietary
clinical laboratory analyses and can be either provided by a single
(“sole-source”) laboratory or licensed or marketed to multiple
providing laboratories (eg, cleared or approved by the Food and
Drug Administration [FDA]).
This subsection includes advanced diagnostic laboratory tests
(ADLTs) and clinical diagnostic laboratory tests (CDLTs), as
defined under the Protecting Access to Medicare Act (PAMA) of
2014. These analyses may include a range of medical laboratory
tests including, but not limited to, multianalyte assays with
algorithmic analyses (MAAA) and genomic sequencing
procedures (GSP). The descriptor nomenclature follows, where
possible, existing code conventions (eg, MAAA, GSP).
Unless specifically noted, even though the Proprietary Laboratory
Analyses section of the code set is located at the end of the
Pathology and Laboratory section of the code set, a PLA code
does not fulfill Category I code criteria. PLA codes are not
required to fulfill the Category I criteria. The standards for
inclusion in the PLA section are:
■ The test must be commercially available in the United States
for use on human specimens and
■ The clinical laboratory or manufacturer that offers the test must
request the code.
For similar laboratory analyses that fulfill Category I criteria, see
codes listed in the numeric 80000 series.
When a PLA code is available to report a given proprietary
laboratory service, that PLA code takes precedence. The service
should not be reported with any other CPT code(s) and other
CPT code(s) should not be used to report services that may be
reported with that specific PLA code. These codes encompass all
analytical services required for the analysis (eg, cell lysis, nucleic
acid stabilization, extraction, digestion, amplification,
hybridization and detection). For molecular analyses, additional
procedures that are required prior to cell lysis (eg,
microdissection [codes 88380 and 88381]) may be reported
separately.
▶Codes in this subsection are released on a quarterly basis to
expedite dissemination for reporting. PLA codes will be
published electronically on the AMA CPT website (ama-
assn.org/cpt-pla-codes), distributed via CPT data files on a
quarterly basis, and, at a minimum, made available in print
annually in the CPT codebook. See the Introduction section of
the CPT code set for a complete list of the dates of release and
implementation.◀
All codes that are included in this section are also included in
Appendix O, with the procedure’s proprietary name. In order to
report a PLA code, the analysis performed must fulfill the code
descriptor and must be the test represented by the proprietary
name listed in Appendix O. In some instances, the descriptor
language of PLA codes may be identical and the code may only
be differentiated by the listed proprietary name in Appendix O.
When more than one PLA has an identical descriptor, the codes
will be denoted by the symbol “ .”
All PLA tests will have assigned codes in the PLA section of the
code set. Any PLA coded test(s) that satisfies Category I criteria
and has been accepted by the CPT Editorial Panel will be
designated by the addition of the symbol “⇅” to the existing PLA
code and will remain in the PLA section of the code set.
If a proprietary test has already been accepted for a Category I
code and a code has not been published, subsequent application
for a PLA code will take precedence. The code will only be
placed in the PLA section.
▶The accuracy of a PLA code is to be maintained by the original
applicant, or the current owner of the test kit or laboratory
performing the proprietary test.
A new PLA code is required when:
1. Additional nucleic acid (DNA or RNA) and/or protein
analysis(es) are added to the current PLA test, or
2. The name of the PLA test has changed in association with
changes in test performance or test characteristics.
The addition or modification of the therapeutic applications of
the test require submission of a code change application, but it
may not require a new code number.◀
0001U Red blood cell antigen typing, DNA, human erythrocyte
antigen gene analysis of 35 antigens from 11 blood groups,
utilizing whole blood, common RBC alleles reported
0002U Oncology (colorectal), quantitative assessment of three

urine metabolites (ascorbic acid, succinic acid and
carnitine) by liquid chromatography with tandem mass
spectrometry (LC-MS/MS) using multiple reaction
monitoring acquisition, algorithm reported as likelihood of
adenomatous polyps
0003U Oncology (ovarian) biochemical assays of five proteins

(apolipoprotein A-1, CA 125 II, follicle stimulating
hormone, human epididymis protein 4, transferrin), utilizing
serum, algorithm reported as a likelihood score
(0004U has been deleted)

0005U Oncology (prostate) gene expression profile by real-time
RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine,
algorithm reported as risk score
▶ (0006U has been deleted)◀

0007U Drug test(s), presumptive, with definitive confirmation of
positive results, any number of drug classes, urine, includes
specimen verification including DNA authentication in
comparison to buccal DNA, per date of service
0008U Helicobacter pylori detection and antibiotic resistance,

DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA, and rpoB,
next generation-sequencing, formalin-fixed paraffin-
embedded or fresh tissue or fecal sample, predictive,
reported as positive or negative for resistance to
clarithromycin, fluoroquinolones, metronidazole,
amoxicillin, tetracycline, and rifabutin
0009U Oncology (breast cancer), ERBB2 (HER2) copy number by

FISH, tumor cells from formalin-fixed paraffin-embedded
tissue isolated using image-based dielectrophoresis (DEP)
sorting, reported as ERBB2 gene amplified or non-amplified
0010U Infectious disease (bacterial), strain typing by whole

genome sequencing, phylogenetic-based report of strain
relatedness, per submitted isolate
0011U Prescription drug monitoring, evaluation of drugs present by

LC-MS/MS, using oral fluid, reported as a comparison to an
estimated steady-state range, per date of service including
all drug compounds and metabolites
0012U Germline disorders, gene rearrangement detection by whole

genome next-generation sequencing, DNA, whole blood,
report of specific gene rearrangement(s)
0013U Oncology (solid organ neoplasia), gene rearrangement

detection by whole genome next-generation sequencing,
DNA, fresh or frozen tissue or cells, report of specific gene
rearrangement(s)
0014U Hematology (hematolymphoid neoplasia), gene

rearrangement detection by whole genome next-generation
sequencing, DNA, whole blood or bone marrow, report of
specific gene rearrangement(s)

0016U Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1
major and minor breakpoint fusion transcripts, quantitative
PCR amplification, blood or bone marrow, report of fusion
not detected or detected with quantitation
0017U Oncology (hematolymphoid neoplasia), JAK2 mutation,
DNA, PCR amplification of exons 12-14 and sequence
analysis, blood or bone marrow, report of JAK2 mutation
not detected or detected
0018U Oncology (thyroid), microRNA profiling by RT-PCR of 10

microRNA sequences, utilizing fine needle aspirate,
algorithm reported as a positive or negative result for
moderate to high risk of malignancy
0019U Oncology, RNA, gene expression by whole transcriptome

sequencing, formalin-fixed paraffin-embedded tissue or
fresh frozen tissue, predictive algorithm reported as
potential targets for therapeutic agents

0021U Oncology (prostate), detection of 8 autoantibodies (ARF 6,
NKX3-1, 5’-UTR-BMI1, CEP 164, 3’-UTR-Ropporin,
Desmocollin, AURKAIP-1, CSNK2A2), multiplexed
immunoassay and flow cytometry serum, algorithm reported
as risk score
0022U Targeted genomic sequence analysis panel, non-small cell

lung neoplasia, DNA and RNA analysis, 23 genes,
interrogation for sequence variants and rearrangements,
reported as presence/absence of variants and associated
therapy(ies) to consider
0023U Oncology (acute myelogenous leukemia), DNA, genotyping

of internal tandem duplication, p.D835, p. I836, using
mononuclear cells, reported as detection or non-detection of
FLT3 mutation and indication for or against the use of
midostaurin
0024U Glycosylated acute phase proteins (GlycA), nuclear

magnetic resonance spectroscopy, quantitative
0025U Tenofovir, by liquid chromatography with tandem mass

spectrometry (LC-MS/MS), urine, quantitative
0026U Oncology (thyroid), DNA and mRNA of 112 genes, next-

generation sequencing, fine needle aspirate of thyroid
nodule, algorithmic analysis reported as a categorical result
(“Positive, high probability of malignancy” or “Negative,
low probability of malignancy”)
0027U JAK2 (Janus kinase 2) (eg, myeloproliferative disorder)

gene analysis, targeted sequence analysis exons 12-15

0029U Drug metabolism (adverse drug reactions and drug
response), targeted sequence analysis (ie, CYP1A2,
CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2,
SLCO1B1, VKORC1 and rs12777823)
0030U Drug metabolism (warfarin drug response), targeted

sequence analysis (ie, CYP2C9, CYP4F2, VKORC1,
rs12777823)
0031U CYP1A2 (cytochrome P450 family 1, subfamily A, member

2) (eg, drug metabolism) gene analysis, common variants
(ie, *1F, *1K, *6, *7)
0032U COMT (catechol-O-methyltransferase) (eg, drug
metabolism) gene analysis, c.472G>A (rs4680) variant
0033U HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-

hydroxytryptamine receptor 2C) (eg, citalopram
metabolism) gene analysis, common variants (ie, HTR2A
rs7997012 [c.614-2211T>C], HTR2C rs3813929
[c.-759C>T] and rs1414334 [c.551-3008C>G])
0034U TPMT (thiopurine S-methyltransferase), NUDT15 (nudix

hydroxylase 15) (eg, thiopurine metabolism) gene analysis,
common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6,
*8, *12; NUDT15 *3, *4, *5)
0035U Neurology (prion disease), cerebrospinal fluid, detection of

prion protein by quaking-induced conformational
conversion, qualitative
0036U Exome (ie, somatic mutations), paired formalin-fixed

paraffin-embedded tumor tissue and normal specimen,
sequence analyses
0037U Targeted genomic sequence analysis, solid organ neoplasm,

DNA analysis of 324 genes, interrogation for sequence
variants, gene copy number amplifications, gene
rearrangements, microsatellite instability and tumor
mutational burden
0038U Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum

microsample, quantitative
0039U Deoxyribonucleic acid (DNA) antibody, double stranded,
high avidity
0040U BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia)

translocation analysis, major breakpoint, quantitative
0041U Borrelia burgdorferi, antibody detection of 5 recombinant

protein groups, by immunoblot, IgM
0042U Borrelia burgdorferi, antibody detection of 12 recombinant

protein groups, by immunoblot, IgG
0043U Tick-borne relapsing fever Borrelia group, antibody

detection to 4 recombinant protein groups, by immunoblot,
IgM
0044U Tick-borne relapsing fever Borrelia group, antibody

detection to 4 recombinant protein groups, by immunoblot,
IgG
0045U Oncology (breast ductal carcinoma in situ), mRNA, gene

expression profiling by real-time RT-PCR of 12 genes (7
content and 5 housekeeping), utilizing formalin-fixed
paraffin-embedded tissue, algorithm reported as recurrence
score
0046U FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid

leukemia) internal tandem duplication (ITD) variants,
quantitative
0047U Oncology (prostate), mRNA, gene expression profiling by
tissue, algorithm reported as a risk score
0048U Oncology (solid organ neoplasia), DNA, targeted

sequencing of protein-coding exons of 468 cancer-
associated genes, including interrogation for somatic
mutations and microsatellite instability, matched with
normal specimens, utilizing formalin-fixed paraffin-
embedded tumor tissue, report of clinically significant
mutation(s)
0049U NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene

analysis, quantitative
0050U Targeted genomic sequence analysis panel, acute

myelogenous leukemia, DNA analysis, 194 genes,
interrogation for sequence variants, copy number variants or
rearrangements
0051U Prescription drug monitoring, evaluation of drugs present by

LC-MS/MS, urine, 31 drug panel, reported as quantitative
results, detected or not detected, per date of service
0052U Lipoprotein, blood, high resolution fractionation and

quantitation of lipoproteins, including all five major
lipoprotein classes and subclasses of HDL, LDL, and VLDL
by vertical auto profile ultracentrifugation
0053U Oncology (prostate cancer), FISH analysis of 4 genes

(ASAP1, HDAC9, CHD1 and PTEN), needle biopsy
specimen, algorithm reported as probability of higher tumor
grade
0054U Prescription drug monitoring, 14 or more classes of drugs

and substances, definitive tandem mass spectrometry with
chromatography, capillary blood, quantitative report with
therapeutic and toxic ranges, including steady-state range for
the prescribed dose when detected, per date of service
0055U Cardiology (heart transplant), cell-free DNA, PCR assay of

96 DNA target sequences (94 single nucleotide
polymorphism targets and two control targets), plasma
0056U Hematology (acute myelogenous leukemia), DNA, whole

genome next-generation sequencing to detect gene
rearrangement(s), blood or bone marrow, report of specific
gene rearrangement(s)

0058U Oncology (Merkel cell carcinoma), detection of antibodies
to the Merkel cell polyoma virus oncoprotein (small T
antigen), serum, quantitative
0059U Oncology (Merkel cell carcinoma), detection of antibodies

to the Merkel cell polyoma virus capsid protein (VP1),
serum, reported as positive or negative
0060U Twin zygosity, genomic-targeted sequence analysis of

chromosome 2, using circulating cell-free fetal DNA in
maternal blood
0061U Transcutaneous measurement of five biomarkers (tissue
oxygenation [StO2], oxyhemoglobin [ctHbO2],
deoxyhemoglobin [ctHbR], papillary and reticular dermal
hemoglobin concentrations [ctHb1 and ctHb2]), using
spatial frequency domain imaging (SFDI) and multi-spectral
analysis
0062U Autoimmune (systemic lupus erythematosus), IgG and IgM

analysis of 80 biomarkers, utilizing serum, algorithm
reported with a risk score
0063U Neurology (autism), 32 amines by LC-MS/MS, using

plasma, algorithm reported as metabolic signature
associated with autism spectrum disorder
0064U Antibody, Treponema pallidum, total and rapid plasma

reagin (RPR), immunoassay, qualitative
0065U Syphilis test, non-treponemal antibody, immunoassay,

qualitative (RPR)
0066U Placental alpha-micro globulin-1 (PAMG-1), immunoassay

with direct optical observation, cervico-vaginal fluid, each
specimen
0067U Oncology (breast), immunohistochemistry, protein

expression profiling of 4 biomarkers (matrix
metalloproteinase-1 [MMP-1], carcinoembryonic antigen-
related cell adhesion molecule 6 [CEACAM6],
hyaluronoglucosaminidase [HYAL1], highly expressed in
cancer protein [HEC1]), formalin-fixed paraffin-embedded
precancerous breast tissue, algorithm reported as carcinoma
risk score
0068U Candida species panel (C. albicans, C. glabrata, C.

parapsilosis, C. kruseii, C. tropicalis, and C. auris),
amplified probe technique with qualitative report of the
presence or absence of each species
0069U Oncology (colorectal), microRNA, RT-PCR expression

profiling of miR-31-3p, formalin-fixed paraffin-embedded
tissue, algorithm reported as an expression score
0070U CYP2D6 (cytochrome P450, family 2, subfamily D,

polypeptide 6) (eg, drug metabolism) gene analysis,
common and select rare variants (ie, *2, *3, *4, *4N, *5, *6,
*7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29,
*35, *36, *41, *57, *61, *63, *68, *83, *xN)
✚ 0071U CYP2D6 (cytochrome P450, family 2, subfamily D,

polypeptide 6) (eg, drug metabolism) gene analysis, full
gene sequence (List separately in addition to code for
primary procedure)
(Use 0071U in conjunction with 0070U)

polypeptide 6) (eg, drug metabolism) gene analysis, targeted
sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List

sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List

sequence analysis (ie, non-duplicated gene when
duplication/multiplication is trans) (List separately in

sequence analysis (ie, 5’ gene duplication/multiplication)

sequence analysis (ie, 3’ gene duplication/multiplication)

0077U Immunoglobulin paraprotein (M-protein), qualitative,
immunoprecipitation and mass spectrometry, blood or urine,
including isotype
0078U Pain management (opioid-use disorder) genotyping panel,

16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR,
DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR,
MTHFR, MUOR, OPRK1, OPRM1), buccal swab or other
germline tissue sample, algorithm reported as positive or
negative risk of opioid-use disorder
0079U Comparative DNA analysis using multiple selected single-

nucleotide polymorphisms (SNPs), urine and buccal DNA,
for specimen identity verification
0080U Oncology (lung), mass spectrometric analysis of galectin-3-

binding protein and scavenger receptor cysteine-rich type 1
protein M130, with five clinical risk factors (age, smoking
status, nodule diameter, nodule-spiculation status and nodule
location), utilizing plasma, algorithm reported as a
categorical probability of malignancy
(0081U has been deleted. To report, use 81552)

0082U Drug test(s), definitive, 90 or more drugs or substances,
definitive chromatography with mass spectrometry, and
presumptive, any number of drug classes, by instrument
chemistry analyzer (utilizing immunoassay), urine, report of
presence or absence of each drug, drug metabolite or
substance with description and severity of significant
interactions per date of service
0083U Oncology, response to chemotherapy drugs using motility

contrast tomography, fresh or frozen tissue, reported as
likelihood of sensitivity or resistance to drugs or drug
combinations
0084U Red blood cell antigen typing, DNA, genotyping of 10 blood

groups with phenotype prediction of 37 red blood cell
antigens
0086U Infectious disease (bacterial and fungal), organism
identification, blood culture, using rRNA FISH, 6 or more
organism targets, reported as positive or negative with
phenotypic minimum inhibitory concentration (MIC)-based
antimicrobial susceptibility
0087U Cardiology (heart transplant), mRNA gene expression

profiling by microarray of 1283 genes, transplant biopsy
tissue, allograft rejection and injury algorithm reported as a
probability score
0088U Transplantation medicine (kidney allograft rejection),

microarray gene expression profiling of 1494 genes,
utilizing transplant biopsy tissue, algorithm reported as a
probability score for rejection
0089U Oncology (melanoma), gene expression profiling by

RTqPCR, PRAME and LINC00518, superficial collection
using adhesive patch(es)
0090U Oncology (cutaneous melanoma), mRNA gene expression

profiling by RT-PCR of 23 genes (14 content and 9
tissue, algorithm reported as a categorical result (ie, benign,
indeterminate, malignant)
0091U Oncology (colorectal) screening, cell enumeration of

circulating tumor cells, utilizing whole blood, algorithm, for
the presence of adenoma or cancer, reported as a positive or
negative result
0092U Oncology (lung), three protein biomarkers, immunoassay
using magnetic nanosensor technology, plasma, algorithm
reported as risk score for likelihood of malignancy
0093U Prescription drug monitoring, evaluation of 65 common

drugs by LC-MS/MS, urine, each drug reported detected or
not detected
0094U Genome (eg, unexplained constitutional or heritable

disorder or syndrome), rapid sequence analysis
0095U Inflammation (eosinophilic esophagitis), ELISA analysis of

eotaxin-3 (CCL26 [C-C motif chemokine ligand 26]) and
major basic protein (PRG2 [proteoglycan 2, pro eosinophil
major basic protein]), specimen obtained by swallowed
nylon string, algorithm reported as predictive probability
index for active eosinophilic esophagitis
0096U Human papillomavirus (HPV), high-risk types (ie, 16, 18,

31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68), male urine
0097U Gastrointestinal pathogen, multiplex reverse transcription

and multiplex amplified probe technique, multiple types or
subtypes, 22 targets (Campylobacter [C. jejuni/C. coli/C.
upsaliensis], Clostridium difficile [C. difficile] toxin A/B,
Plesiomonas shigelloides, Salmonella, Vibrio [V.
parahaemolyticus/V. vulnificus/V. cholerae], including
specific identification of Vibrio cholerae, Yersinia
enterocolitica, Enteroaggregative Escherichia coli [EAEC],
Enteropathogenic Escherichia coli [EPEC], Enterotoxigenic
Escherichia coli [ETEC] lt/st, Shiga-like toxin-producing
Escherichia coli [STEC] stx1/stx2 [including specific
identification of the E. coli O157 serogroup within STEC],
Shigella/Enteroinvasive Escherichia coli [EIEC],
Cryptosporidium, Cyclospora cayetanensis, Entamoeba
histolytica, Giardia lamblia [also known as G. intestinalis
and G. duodenalis], adenovirus F 40/41, astrovirus,
norovirus GI/GII, rotavirus A, sapovirus [Genogroups I, II,
IV, and V])
0098U Respiratory pathogen, multiplex reverse transcription and

subtypes, 14 targets (adenovirus, coronavirus, human
metapneumovirus, influenza A, influenza A subtype H1,
influenza A subtype H3, influenza A subtype H1-2009,
influenza B, parainfluenza virus, human
rhinovirus/enterovirus, respiratory syncytial virus,
Bordetella pertussis, Chlamydophila pneumoniae,
Mycoplasma pneumoniae)

subtypes, 20 targets (adenovirus, coronavirus 229E,
coronavirus HKU1, coronavirus, coronavirus OC43, human
metapneumovirus, influenza A, influenza A subtype,
influenza A subtype H3, influenza A subtype H1-2009,
influenza, parainfluenza virus, parainfluenza virus 2,
parainfluenza virus 3, parainfluenza virus 4, human
rhinovirus/enterovirus, respiratory syncytial virus,
Bordetella pertussis, Chlamydophila pneumonia,

subtypes, 21 targets (adenovirus, coronavirus 229E,
coronavirus HKU1, coronavirus NL63, coronavirus OC43,
human metapneumovirus, human rhinovirus/enterovirus,
influenza A, including subtypes H1, H1-2009, and H3,
influenza B, parainfluenza virus 1, parainfluenza virus 2,
parainfluenza virus 3, parainfluenza virus 4, respiratory
syncytial virus, Bordetella parapertussis [IS1001],
Bordetella pertussis [ptxP], Chlamydia pneumoniae,
0101U Hereditary colon cancer disorders (eg, Lynch syndrome,

adenomatosis polyposis), genomic sequence analysis panel
utilizing a combination of NGS, Sanger, MLPA, and array
CGH, with mRNA analytics to resolve variants of unknown
significance when indicated (15 genes [sequencing and
deletion/duplication], EPCAM and GREM1
[deletion/duplication only])
0102U Hereditary breast cancer-related disorders (eg, hereditary

endometrial cancer), genomic sequence analysis panel
utilizing a combination of NGS, Sanger, MLPA, and array
CGH, with mRNA analytics to resolve variants of unknown
significance when indicated (17 genes [sequencing and
deletion/duplication])
0103U Hereditary ovarian cancer (eg, hereditary ovarian cancer,

hereditary endometrial cancer), genomic sequence analysis
panel utilizing a combination of NGS, Sanger, MLPA, and
array CGH, with mRNA analytics to resolve variants of
unknown significance when indicated (24 genes [sequencing
and deletion/duplication], EPCAM [deletion/duplication
only])

0105U Nephrology (chronic kidney disease), multiplex
electrochemiluminescent immunoassay (ECLIA) of tumor
necrosis factor receptor 1A, receptor superfamily 2
(TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1)
combined with longitudinal clinical data, including APOL1
genotype if available, and plasma (isolated fresh or frozen),
algorithm reported as probability score for rapid kidney
function decline (RKFD)
0106U Gastric emptying, serial collection of 7 timed-breath

specimens, non-radioisotope carbon-13 (13C) spirulina
substrate, analysis of each specimen by gas isotope ratio
mass spectrometry, reported as rate of 13CO2 excretion
0107U Clostridium difficile toxin(s) antigen detection by
immunoassay technique, stool, qualitative, multiple-step
method
0108U Gastroenterology (Barrett’s esophagus), whole slide–digital

imaging, including morphometric analysis, computer-
assisted quantitative immunolabeling of 9 protein
biomarkers (p16, AMACR, p53, CD68, COX-2, CD45RO,
HIF1a, HER-2, K20) and morphology, formalin-fixed
paraffin-embedded tissue, algorithm reported as risk of
progression to high-grade dysplasia or cancer
0109U Infectious disease (Aspergillus species), real-time PCR for

detection of DNA from 4 species (A. fumigatus, A. terreus,
A. niger, and A. flavus), blood, lavage fluid, or tissue,
qualitative reporting of presence or absence of each species
0110U Prescription drug monitoring, one or more oral oncology

drug(s) and substances, definitive tandem mass spectrometry
with chromatography, serum or plasma from capillary blood
or venous blood, quantitative report with steady-state range
for the prescribed drug(s) when detected)
0111U Oncology (colon cancer), targeted KRAS (codons 12, 13,

and 61) and NRAS (codons 12, 13, and 61) gene analysis,
utilizing formalin-fixed paraffin-embedded tissue
0112U Infectious agent detection and identification, targeted

sequence analysis (16S and 18S rRNA genes) with drug-
resistance gene
0113U Oncology (prostate), measurement of PCA3 and TMPRSS2-

ERG in urine and PSA in serum following prostatic
massage, by RNA amplification and fluorescence-based
detection, algorithm reported as risk score
0114U Gastroenterology (Barrett’s esophagus), VIM and CCNA1

methylation analysis, esophageal cells, algorithm reported
as likelihood for Barrett’s esophagus
0115U Respiratory infectious agent detection by nucleic acid (DNA

and RNA), 18 viral types and subtypes and 2 bacterial
targets, amplified probe technique, including multiplex
reverse transcription for RNA targets, each analyte reported
as detected or not detected
0116U Prescription drug monitoring, enzyme immunoassay of 35 or
more drugs confirmed with LC-MS/MS, oral fluid,
algorithm results reported as a patient-compliance
measurement with risk of drug to drug interactions for
prescribed medications
0117U Pain management, analysis of 11 endogenous analytes

(methylmalonic acid, xanthurenic acid, homocysteine,
pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic
acid, hydroxymethylglutarate, ethylmalonate, 3-
hydroxypropyl mercapturic acid (3-HPMA), quinolinic
acid, kynurenic acid), LC-MS/MS, urine, algorithm reported
as a pain-index score with likelihood of atypical
biochemical function associated with pain
0118U Transplantation medicine, quantification of donor-derived

cell-free DNA using whole genome next-generation
sequencing, plasma, reported as percentage of donor-
derived cell-free DNA in the total cell-free DNA
0119U Cardiology, ceramides by liquid chromatography–tandem

mass spectrometry, plasma, quantitative report with risk
score for major cardiovascular events
0120U Oncology (B-cell lymphoma classification), mRNA, gene

expression profiling by fluorescent probe hybridization of
58 genes (45 content and 13 housekeeping genes), formalin-
fixed paraffin-embedded tissue, algorithm reported as
likelihood for primary mediastinal B-cell lymphoma
(PMBCL) and diffuse large B-cell lymphoma (DLBCL) with
cell of origin subtyping in the latter
0121U Sickle cell disease, microfluidic flow adhesion (VCAM-1),

whole blood
0122U Sickle cell disease, microfluidic flow adhesion (P-

Selectin), whole blood
0123U Mechanical fragility, RBC, shear stress and spectral

analysis profiling

0129U Hereditary breast cancer–related disorders (eg, hereditary
endometrial cancer), genomic sequence analysis and
deletion/duplication analysis panel (ATM, BRCA1, BRCA2,
CDH1, CHEK2, PALB2, PTEN, and TP53)
✚ 0130U Hereditary colon cancer disorders (eg, Lynch syndrome,

adenomatosis polyposis), targeted mRNA sequence analysis
panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6,
MUTYH, PMS2, PTEN, and TP53) (List separately in
(Use 0130U in conjunction with 81435, 0101U)

✚ 0131U Hereditary breast cancer–related disorders (eg, hereditary
endometrial cancer), targeted mRNA sequence analysis
panel (13 genes) (List separately in addition to code for
primary procedure)
(Use 0131U in conjunction with 81162, 81432, 0102U)

✚ 0132U Hereditary ovarian cancer–related disorders (eg, hereditary
endometrial cancer), targeted mRNA sequence analysis
panel (17 genes) (List separately in addition to code for
primary procedure)
(Use 0132U in conjunction with 81162, 81432, 0103U)

✚ 0133U Hereditary prostate cancer–related disorders, targeted
mRNA sequence analysis panel (11 genes) (List separately
(Use 0133U in conjunction with 81162)

✚ 0134U Hereditary pan cancer (eg, hereditary breast and ovarian
cancer, hereditary endometrial cancer, hereditary colorectal
cancer), targeted mRNA sequence analysis panel (18 genes)
(Use 0134U in conjunction with 81162, 81432, 81435)

✚ 0135U Hereditary gynecological cancer (eg, hereditary breast and
ovarian cancer, hereditary endometrial cancer, hereditary
colorectal cancer), targeted mRNA sequence analysis panel
(12 genes) (List separately in addition to code for primary
procedure)

✚ 0136U ATM (ataxia telangiectasia mutated) (eg, ataxia
telangiectasia) mRNA sequence analysis (List separately in

✚ 0137U PALB2 (partner and localizer of BRCA2) (eg, breast and
pancreatic cancer) mRNA sequence analysis (List

✚ 0138U BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2,
DNA repair associated) (eg, hereditary breast and ovarian
cancer) mRNA sequence analysis (List separately in

● 0139U Neurology (autism spectrum disorder [ASD]), quantitative
measurements of 6 central carbon metabolites (ie, α-
ketoglutarate, alanine, lactate, phenylalanine, pyruvate, and
succinate), LC-MS/MS, plasma, algorithmic analysis with
result reported as negative or positive (with metabolic
subtypes of ASD)
● 0140U Infectious disease (fungi), fungal pathogen identification,

DNA (15 fungal targets), blood culture, amplified probe
technique, each target reported as detected or not detected
● 0141U Infectious disease (bacteria and fungi), gram-positive

organism identification and drug resistance element
detection, DNA (20 gram-positive bacterial targets, 4
resistance genes, 1 pan gram-negative bacterial target, 1 pan
Candida target), blood culture, amplified probe technique,
each target reported as detected or not detected
● 0142U Infectious disease (bacteria and fungi), gram-negative
bacterial identification and drug resistance element
detection, DNA (21 gram-negative bacterial targets, 6
resistance genes, 1 pan gram-positive bacterial target, 1 pan
Candida target), amplified probe technique, each target
reported as detected or not detected
● 0143U Drug assay, definitive, 120 or more drugs or metabolites,

urine, quantitative liquid chromatography with tandem mass
monitoring (MRM), with drug or metabolite description,
comments including sample validation, per date of service
▶ (For additional PLA code with identical clinical

descriptor, see 0150U. See Appendix O to determine
appropriate code assignment)◀


urine, by quantitative liquid chromatography with tandem
mass spectrometry (LC-MS/MS) using multiple reaction




▶ (For additional PLA code with identical clinical

descriptor, see 0143U. See Appendix O to determine
appropriate code assignment)◀
● 0151U Infectious disease (bacterial or viral respiratory tract
infection), pathogen specific nucleic acid (DNA or RNA),
33 targets, real-time semi-quantitative PCR,
bronchoalveolar lavage, sputum, or endotracheal aspirate,
detection of 33 organismal and antibiotic resistance genes
with limited semi-quantitative results
● 0152U Infectious disease (bacteria, fungi, parasites, and DNA

viruses), DNA, PCR and next-generation sequencing,
plasma, detection of >1,000 potential microbial organisms
for significant positive pathogens
● 0153U Oncology (breast), mRNA, gene expression profiling by

next-generation sequencing of 101 genes, utilizing formalin-
fixed paraffin-embedded tissue, algorithm reported as a
triple negative breast cancer clinical subtype(s) with
information on immune cell involvement
▲ 0154U Oncology (urothelial cancer), RNA, analysis by real-time

RT-PCR of the FGFR3 (fibroblast growth factor receptor
3) gene analysis (ie, p.R248C [c.742C>T], p.S249C
[c.746C>G], p.G370C [c.1108G>T], p.Y373C
[c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3),
utilizing formalin-fixed paraffin-embedded urothelial cancer
tumor tissue, reported as FGFR gene alteration status
▲ 0155U Oncology (breast cancer), DNA, PIK3CA

(phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic
subunit alpha) (eg, breast cancer) gene analysis (ie, p.
C420R, p.E542K, p.E545A, p.E545D [g.1635G>T only], p.
E545G, p.E545K, p.Q546E, p.Q546R, p.H1047L,
p.H1047R, p.H1047Y), utilizing formalin-fixed paraffin-
embedded breast tumor tissue, reported as PIK3CA gene
mutation status
● 0156U Copy number (eg, intellectual disability, dysmorphology),
sequence analysis
✚● 0157U APC (APC regulator of WNT signaling pathway) (eg,

familial adenomatosis polyposis [FAP]) mRNA sequence
analysis (List separately in addition to code for primary
procedure)
▶ (Use 0157U in conjunction with 81201)◀

✚● 0158U MLH1 (mutL homolog 1) (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) mRNA sequence
analysis (List separately in addition to code for primary
procedure)

✚● 0159U MSH2 (mutS homolog 2) (eg, hereditary colon cancer,
Lynch syndrome) mRNA sequence analysis (List separately

✚● 0160U MSH6 (mutS homolog 6) (eg, hereditary colon cancer,

✚● 0161U PMS2 (PMS1 homolog 2, mismatch repair system
component) (eg, hereditary non-polyposis colorectal cancer,
✚● 0162U Hereditary colon cancer (Lynch syndrome), targeted mRNA
sequence analysis panel (MLH1, MSH2, MSH6, PMS2)
▶ (Use0162U in conjunction with 81292, 81295, 81298,

81317, 81435)◀
● 0163U Oncology (colorectal) screening, biochemical enzyme-
linked immunosorbent assay (ELISA) of 3 plasma or serum
proteins (teratocarcinoma derived growth factor-1 [TDGF-
1, Cripto-1], carcinoembryonic antigen [CEA], extracellular
matrix protein [ECM]), with demographic data (age, gender,
CRC-screening compliance) using a proprietary algorithm
and reported as likelihood of CRC or advanced adenomas
● 0164U Gastroenterology (irritable bowel syndrome [IBS]),

immunoassay for anti-CdtB and anti-vinculin antibodies,
utilizing plasma, algorithm for elevated or not elevated
qualitative results
▲ 0165U Peanut allergen-specific quantitative assessment of multiple

epitopes using enzyme-linked immunosorbent assay
(ELISA), blood, individual epitope results and probability
of peanut allergy
● 0166U Liver disease, 10 biochemical assays (α2-macroglobulin,

haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST,
triglycerides, cholesterol, fasting glucose) and biometric
and demographic data, utilizing serum, algorithm reported as
scores for fibrosis, necroinflammatory activity, and steatosis
with a summary interpretation
● 0167U Gonadotropin, chorionic (hCG), immunoassay with direct
optical observation, blood
● 0168U Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence
analysis of selected regions using maternal plasma without
fetal fraction cutoff, algorithm reported as a risk score for
each trisomy
● 0169U NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-

methyltransferase) (eg, drug metabolism) gene analysis,
common variants
● 0170U Neurology (autism spectrum disorder [ASD]), RNA, next-

generation sequencing, saliva, algorithmic analysis, and
results reported as predictive probability of ASD diagnosis
● 0171U Targeted genomic sequence analysis panel, acute myeloid

leukemia, myelodysplastic syndrome, and
myeloproliferative neoplasms, DNA analysis, 23 genes,
interrogation for sequence variants, rearrangements and
minimal residual disease, reported as presence/absence
● 0172U Oncology (solid tumor as indicated by the label), somatic

mutation analysis of BRCA1 (BRCA1, DNA repair
associated), BRCA2 (BRCA2, DNA repair associated) and
analysis of homologous recombination deficiency pathways,
DNA, formalin-fixed paraffin-embedded tissue, algorithm
quantifying tumor genomic instability score
● 0173U Psychiatry (ie, depression, anxiety), genomic analysis panel,

includes variant analysis of 14 genes
● 0174U Oncology (solid tumor), mass spectrometric 30 protein
targets, formalin-fixed paraffin-embedded tissue, prognostic
and predictive algorithm reported as likely, unlikely, or
uncertain benefit of 39 chemotherapy and targeted
therapeutic oncology agents
● 0175U Psychiatry (eg, depression, anxiety), genomic analysis

panel, variant analysis of 15 genes
● 0176U Cytolethal distending toxin B (CdtB) and vinculin IgG

antibodies by immunoassay (ie, ELISA)
● 0177U Oncology (breast cancer), DNA, PIK3CA

(phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic
subunit alpha) gene analysis of 11 gene variants utilizing
plasma, reported as PIK3CA gene mutation status
● 0178U Peanut allergen-specific quantitative assessment of multiple

epitopes using enzyme-linked immunosorbent assay
(ELISA), blood, report of minimum eliciting exposure for a
clinical reaction
● 0179U Oncology (non-small cell lung cancer), cell-free DNA,

targeted sequence analysis of 23 genes (single nucleotide
variations, insertions and deletions, fusions without prior
knowledge of partner/breakpoint, copy number variations),
with report of significant mutation(s)
● 0180U Red cell antigen (ABO blood group) genotyping (ABO),

gene analysis Sanger/chain termination/conventional
sequencing, ABO (ABO, alpha 1-3-N-
acetylgalactosaminyltransferase and alpha 1-3-
galactosyltransferase) gene, including subtyping, 7 exons
● 0181U Red cell antigen (Colton blood group) genotyping (CO),

gene analysis, AQP1 (aquaporin 1 [Colton blood group])
exon 1
● 0182U Red cell antigen (Cromer blood group) genotyping

(CROM), gene analysis, CD55 (CD55 molecule [Cromer
blood group]) exons 1-10
● 0183U Red cell antigen (Diego blood group) genotyping (DI), gene
analysis, SLC4A1 (solute carrier family 4 member 1 [Diego
blood group]) exon 19
● 0184U Red cell antigen (Dombrock blood group) genotyping (DO),

gene analysis, ART4 (ADP-ribosyltransferase 4 [Dombrock
blood group]) exon 2
● 0185U Red cell antigen (H blood group) genotyping (FUT1), gene

analysis, FUT1 (fucosyltransferase 1 [H blood group])
exon 4
● 0186U Red cell antigen (H blood group) genotyping (FUT2), gene

analysis, FUT2 (fucosyltransferase 2) exon 2
● 0187U Red cell antigen (Duffy blood group) genotyping (FY), gene
analysis, ACKR1 (atypical chemokine receptor 1 [Duffy
blood group]) exons 1-2
● 0188U Red cell antigen (Gerbich blood group) genotyping (GE),

gene analysis, GYPC (glycophorin C [Gerbich blood
group]) exons 1-4
● 0189U Red cell antigen (MNS blood group) genotyping (GYPA),

gene analysis, GYPA (glycophorin A [MNS blood group])
introns 1, 5, exon 2
● 0190U Red cell antigen (MNS blood group) genotyping (GYPB),

gene analysis, GYPB (glycophorin B [MNS blood group])
introns 1, 5, pseudoexon 3
● 0191U Red cell antigen (Indian blood group) genotyping (IN), gene
analysis, CD44 (CD44 molecule [Indian blood group])
exons 2, 3, 6
● 0192U Red cell antigen (Kidd blood group) genotyping (JK), gene
analysis, SLC14A1 (solute carrier family 14 member 1
[Kidd blood group]) gene promoter, exon 9
● 0193U Red cell antigen (JR blood group) genotyping (JR), gene
analysis, ABCG2 (ATP binding cassette subfamily G
member 2 [Junior blood group]) exons 2-26
● 0194U Red cell antigen (Kell blood group) genotyping (KEL), gene
analysis, KEL (Kell metallo-endopeptidase [Kell blood
group]) exon 8
● 0195U KLF1 (Kruppel-like factor 1), targeted sequencing (ie, exon

13)
● 0196U Red cell antigen (Lutheran blood group) genotyping (LU),

gene analysis, BCAM (basal cell adhesion molecule
[Lutheran blood group]) exon 3
● 0197U Red cell antigen (Landsteiner-Wiener blood group)

genotyping (LW), gene analysis, ICAM4 (intercellular
adhesion molecule 4 [Landsteiner-Wiener blood group])
exon 1
● 0198U Red cell antigen (RH blood group) genotyping (RHD and
RHCE), gene analysis Sanger/chain
termination/conventional sequencing, RHD (Rh blood group
D antigen) exons 1-10 and RHCE (Rh blood group CcEe
antigens) exon 5
● 0199U Red cell antigen (Scianna blood group) genotyping (SC),

gene analysis, ERMAP (erythroblast membrane associated
protein [Scianna blood group]) exons 4, 12
● 0200U Red cell antigen (Kx blood group) genotyping (XK), gene
analysis, XK (X-linked Kx blood group) exons 1-3
● 0201U Red cell antigen (Yt blood group) genotyping (YT), gene
analysis, ACHE (acetylcholinesterase [Cartwright blood
group]) exon 2
● 0202U Infectious disease (bacterial or viral respiratory tract

infection), pathogen-specific nucleic acid (DNA or RNA),
22 targets including severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), qualitative RT-PCR,
nasopharyngeal swab, each pathogen reported as detected or
not detected
● 0203U Autoimmune (inflammatory bowel disease), mRNA, gene
expression profiling by quantitative RT-PCR, 17 genes (15
target and 2 reference genes), whole blood, reported as a
continuous risk score and classification of inflammatory
bowel disease aggressiveness
● 0204U Oncology (thyroid), mRNA, gene expression analysis of 593

genes (including BRAF, RAS, RET, PAX8, and NTRK) for
sequence variants and rearrangements, utilizing fine needle
aspirate, reported as detected or not detected
● 0205U Ophthalmology (age-related macular degeneration), analysis

of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR
and MALDI-TOF, buccal swab, reported as positive or
negative for neovascular age-related macular-degeneration
risk associated with zinc supplements
● 0206U Neurology (Alzheimer disease); cell aggregation using

morphometric imaging and protein kinase C-epsilon (PKCe)
concentration in response to amylospheroid treatment by
ELISA, cultured skin fibroblasts, each reported as positive
or negative for Alzheimer disease
✚● 0207U quantitative imaging of phosphorylated ERK1 and ERK2

in response to bradykinin treatment by in situ
immunofluorescence, using cultured skin fibroblasts,
reported as a probability index for Alzheimer disease
procedure)
▶ (Use 0207U in conjunction with 0206U)◀

● 0208U Oncology (medullary thyroid carcinoma), mRNA, gene
expression analysis of 108 genes, utilizing fine needle
aspirate, algorithm reported as positive or negative for
medullary thyroid carcinoma
● 0209U Cytogenomic constitutional (genome-wide) analysis,

interrogation of genomic regions for copy number, structural
changes and areas of homozygosity for chromosomal
abnormalities
● 0210U Syphilis test, non-treponemal antibody, immunoassay,

quantitative (RPR)
● 0211U Oncology (pan-tumor), DNA and RNA by next-generation

sequencing, utilizing formalin-fixed paraffin-embedded
tissue, interpretative report for single nucleotide variants,
copy number alterations, tumor mutational burden, and
microsatellite instability, with therapy association
● 0212U Rare diseases (constitutional/heritable disorders), whole

genome and mitochondrial DNA sequence analysis,
including small sequence changes, deletions, duplications,
short tandem repeat gene expansions, and variants in non-
uniquely mappable regions, blood or saliva, identification
and categorization of genetic variants, proband
▶ (Do not report 0212U in conjunction with 81425)◀

genome and mitochondrial DNA sequence analysis,
including small sequence changes, deletions, duplications,
short tandem repeat gene expansions, and variants in non-
uniquely mappable regions, blood or saliva, identification
and categorization of genetic variants, each comparator
genome (eg, parent, sibling)

exome and mitochondrial DNA sequence analysis, including
small sequence changes, deletions, duplications, short
tandem repeat gene expansions, and variants in non-uniquely
mappable regions, blood or saliva, identification and
categorization of genetic variants, proband

exome and mitochondrial DNA sequence analysis, including
small sequence changes, deletions, duplications, short
tandem repeat gene expansions, and variants in non-uniquely
mappable regions, blood or saliva, identification and
categorization of genetic variants, each comparator exome
(eg, parent, sibling)

● 0216U Neurology (inherited ataxias), genomic DNA sequence
analysis of 12 common genes including small sequence
changes, deletions, duplications, short tandem repeat gene
expansions, and variants in non-uniquely mappable regions,
blood or saliva, identification and categorization of genetic
variants
● 0217U Neurology (inherited ataxias), genomic DNA sequence

analysis of 51 genes including small sequence changes,
deletions, duplications, short tandem repeat gene
expansions, and variants in non-uniquely mappable regions,
blood or saliva, identification and categorization of genetic
variants
● 0218U Neurology (muscular dystrophy), DMD gene sequence

analysis, including small sequence changes, deletions,
duplications, and variants in non-uniquely mappable
regions, blood or saliva, identification and characterization
of genetic variants
● 0219U Infectious agent (human immunodeficiency virus), targeted

viral next-generation sequence analysis (ie, protease [PR],
reverse transcriptase [RT], integrase [INT]), algorithm
reported as prediction of antiviral drug susceptibility
● 0220U Oncology (breast cancer), image analysis with artificial

intelligence assessment of 12 histologic and
immunohistochemical features, reported as a recurrence
score
● 0221U Red cell antigen (ABO blood group) genotyping (ABO),

gene analysis, next-generation sequencing, ABO (ABO,
alpha 1-3-N-acetylgalactosaminyltransferase and alpha 1-
3-galactosyltransferase) gene
● 0222U Red cell antigen (RH blood group) genotyping (RHD and
RHCE), gene analysis, next-generation sequencing, RH
proximal promoter, exons 1-10, portions of introns 2-3
Medicine Guidelines
Add-on Codes
Separate Procedures
Special Report
Imaging Guidance
Supplied Materials
Medicine
Medicine section of the CPT codebook. The subheadings or subsections
denoted with asterisks (*) below have special instructions unique to that
subsection. Where these are indicated, special notes or guidelines will be
presented preceding those procedural terminology listings, referring to that
Immune Globulins, Serum or Recombinant Products*
(90281-90399)
Immunization Administration for Vaccines/Toxoids* (90460-
90474)
Vaccines, Toxoids* (90476-90749)
Psychiatry* (90785-90899)
Interactive Complexity* (90785)
Psychiatric Diagnostic Procedures* (90791-90899)
Psychotherapy* (90832-90838)
Psychotherapy for Crisis* (90839-90840)
Other Psychotherapy (90845-90853)
Other Psychiatric Services or Procedures (90863-90899)
Biofeedback (90901-90913)
Dialysis (90935-90999)
Hemodialysis* (90935-90940)
Miscellaneous Dialysis Procedures* (90945-90947)
End-Stage Renal Disease Services* (90951-90970)
Other Dialysis Procedures (90989-90999)
Gastroenterology (91010-91299)
Gastric Physiology (91132-91133)
Ophthalmology* (92002-92499)
General Ophthalmological Services (92002-92014)
Special Ophthalmological Services (92015-92287)
Ophthalmoscopy* (92201-92260)
Other Specialized Services* (92265-92287)
Contact Lens Services* (92310-92326)
Spectacle Services (Including Prosthesis for Aphakia)*
(92340-92499)
Special Otorhinolaryngologic Services* (92502-92700)
Vestibular Function Tests, Without Electrical Recording
(92531-92534)
Vestibular Function Tests, With Recording (eg, ENG)
(92517-92519, 92537-92549)
Audiologic Function Tests* (92550-92596, 92650-92653)
Evaluative and Therapeutic Services* (92597, 92601-92633)
Special Diagnostic Procedures (92640)
Cardiovascular (92920-93799)
Therapeutic Services and Procedures (92920-92998)
Other Therapeutic Services and Procedures (92950-92971, 92986-
92998)
Coronary Therapeutic Services and Procedures* (92920-92944,
92973-92979)
Cardiography* (93000-93050)
Cardiovascular Monitoring Services* (93224-93229, 93241-
93248, 93268-93278)
Implantable, Insertable, and Wearable Cardiac Device
Evaluations* (93260-93261, 93264, 93279-93298)
Echocardiography* (93303-93356)
Cardiac Catheterization* (93451-93592)
Injection Procedures* (93561-93572)
Repair of Structural Heart Defect (93580-93592)
Transcatheter Closure of Paravalvular Leak* (93590-93592)
Intracardiac Electrophysiological Procedures/Studies*
(93600-93662)
Peripheral Arterial Disease Rehabilitation* (93668)
Noninvasive Physiologic Studies and Procedures (93701-
93790)
Home and Outpatient International Normalized Ratio (INR)
Monitoring Services* (93792-93793)
Noninvasive Vascular Diagnostic Studies* (93880-93998)
Cerebrovascular Arterial Studies* (93880-93895)
Extremity Arterial Studies (Including Digits) (93922-93931)
Extremity Venous Studies (Including Digits) (93970-93971)
Visceral and Penile Vascular Studies (93975-93981)
Extremity Arterial-Venous Studies* (93985-93990)
Other Noninvasive Vascular Diagnostic Studies (93998)
Pulmonary (94002-94799)
Ventilator Management (94002-94005)
Pulmonary Diagnostic Testing and Therapies* (94010-94799)
Allergy and Clinical Immunology* (95004-95199)
Allergy Testing (95004-95070)
Ingestion Challenge Testing* (95076-95079)
Allergen Immunotherapy* (95115-95199)
Endocrinology* (95249-95251)
Neurology and Neuromuscular Procedures* (95700-96020)
Sleep Medicine Testing* (95782, 95783, 95800-95811)
Routine Electroencephalography (EEG)* (95812-95824,
95830)
Electrocorticography* (95829, 95836)
Range of Motion Testing (95851-95857)
Electromyography* (95860-95872, 95885-95887)
Ischemic Muscle Testing and Guidance for
Chemodenervation (95873-95875)
Nerve Conduction Tests* (95905-95913)
Intraoperative Neurophysiology* (95940-95941)
Autonomic Function Tests* (95921-95924, 95943)
Evoked Potentials and Reflex Tests (95925-95939)
Special EEG Tests* (95954-95967, 95700-95726)
Long-term EEG Setup (95700)
Monitoring (95705-95726)
Neurostimulators, Analysis-Programming* (95970-95984)
Motion Analysis* (96000-96004)
Functional Brain Mapping* (96020)
Medical Genetics and Genetic Counseling Services* (96040)
Adaptive Behavior Services* (97151-97158)
Adaptive Behavior Assessments* (97151-97152)
Adaptive Behavior Treatment* (97153-97158)
Central Nervous System Assessments/Tests (eg, Neuro-
Cognitive, Mental Status, Speech Testing)* (96105-96146)
Assessment of Aphasia and Cognitive Performance Testing
(96105, 96125)
Developmental/Behavioral Screening and Testing (96110-
96113, 96127)
Psychological/Neuropsychological Testing (96116, 96121,
96130-96139, 96146)
Neurobehavioral Status Examination (96116, 96121)
Testing Evaluation Services (96130-96133)
Test Administration and Scoring (96136-96139)
Automated Testing and Result (96146)
Health Behavior Assessment and Intervention* (96156-
96161, 96164-96171)
Hydration, Therapeutic, Prophylactic, Diagnostic Injections
and Infusions, and Chemotherapy and Other Highly
Complex Drug or Highly Complex Biologic Agent
Administration* (96360-96549)
Hydration* (96360-96361)
Therapeutic, Prophylactic, and Diagnostic Injections and
Infusions (Excludes Chemotherapy and Other Highly
Administration)* (96365-96379)
Chemotherapy and Other Highly Complex Drug or Highly
Complex Biologic Agent Administration* (96401-96549)
Injection and Intravenous Infusion Chemotherapy and Other Highly
Complex Drug or Highly Complex Biologic Agent Administration*
(96401-96417)
Intra-Arterial Chemotherapy and Other Highly Complex Drug or
Highly Complex Biologic Agent Administration (96420-96425)
Other Injection and Infusion Services* (96440-96549)
Photodynamic Therapy* (96567-96574)
Special Dermatological Procedures* (96900-96999)
Physical Medicine and Rehabilitation* (97161-97799)
Physical Therapy Evaluations* (97161-97164)
Occupational Therapy Evaluations* (97165-97168)
Athletic Training Evaluations* (97169-97172)
Modalities* (97010-97039)
Supervised* (97010-97028)
Constant Attendance* (97032-97039)
Therapeutic Procedures* (97110-97150, 97530-97546)
Active Wound Care Management* (97597-97610)
Tests and Measurements* (97750-97755)
Orthotic Management and Training and Prosthetic Training
(97760-97763)
Medical Nutrition Therapy (97802-97804)
Acupuncture* (97810-97814)
Osteopathic Manipulative Treatment* (98925-98929)
Chiropractic Manipulative Treatment* (98940-98943)
Education and Training for Patient Self-Management*
(98960-98962)
Non-Face-to-Face Nonphysician Services (98966-98972)
Telephone Services* (98966-98968)
Qualified Nonphysician Health Care Professional Online
Digital Assessment and Management Service* (98970-
98972)
Special Services, Procedures and Reports* (99000-99082)
Miscellaneous Services (99000-99082)
Qualifying Circumstances for Anesthesia (99100-99140)
Moderate (Conscious) Sedation* (99151-99157)
Other Services and Procedures (99170-99199)
Home Health Procedures/Services* (99500-99602)
Home Infusion Procedures/Services (99601-99602)
Medication Therapy Management Services* (99605-99607)
Medicine Guidelines
In addition to the definitions and commonly used terms
presented in the Introduction, several other items unique to this
section on Medicine are defined or identified here.
Add-on Codes
Some of the listed procedures are commonly carried out in
addition to the primary procedure performed. All add-on codes
found in the CPT codebook are exempt from the multiple
procedure concept. They are exempt from the use of modifier 51,
as these procedures are not reported as stand-alone codes. These
additional or supplemental procedures are designated as “add-on”
codes. Add-on codes in the CPT codebook can be readily
identified by specific descriptor nomenclature which includes
phrases such as “each additional” or “(List separately in addition
to primary procedure).”
Separate Procedures
component.
session or patient encounter, different procedure or surgery,
different site or organ system, separate incision/excision, separate
lesion, or separate injury (or area of injury in extensive injuries).

the service, identifying it by “Special Report” as discussed on the
following page. The “Unlisted Procedures” and accompanying
codes for Medicine are as follows:
90399 Unlisted immune globulin
90749 Unlisted vaccine/toxoid
90899 Unlisted psychiatric service or procedure
90999 Unlisted dialysis procedure, inpatient or outpatient
91299 Unlisted diagnostic gastroenterology procedure
92499 Unlisted ophthalmological service or procedure
92700 Unlisted otorhinolaryngological service or procedure
93799 Unlisted cardiovascular service or procedure
93998 Unlisted noninvasive vascular diagnostic study
94799 Unlisted pulmonary service or procedure
95199 Unlisted allergy/clinical immunologic service or procedure
95999 Unlisted neurological or neuromuscular diagnostic
procedure
96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous
or intra-arterial injection or infusion
96549 Unlisted chemotherapy procedure
96999 Unlisted special dermatological service or procedure
97039 Unlisted modality (specify type and time if constant
attendance)
97139 Unlisted therapeutic procedure (specify)
97799 Unlisted physical medicine/rehabilitation service or
procedure
99199 Unlisted special service, procedure or report
99600 Unlisted home visit service or procedure
Special Report
Imaging Guidance
When imaging guidance or imaging supervision and
interpretation is included in a procedure, guidelines for image
documentation and report, included in the guidelines for
Radiology (including Nuclear Medicine and Diagnostic
Ultrasound) will apply. Imaging guidance should not be reported
for use of a non-imaging guided tracking or localizing system
(eg, radar signals, electromagnetic signals). Imaging guidance
should only be reported when an imaging modality (eg,
radiography, fluoroscopy, ultrasonography, magnetic resonance
imaging, computed tomography, or nuclear medicine) is used and
is appropriately documented.
Supplied Materials
Supplies and materials (eg, trays, drug supplies, and materials)
over and above those usually included with the procedure(s)
rendered are reported separately using code 99070 or a specific
supply code.

Medicine
Immune Globulins, Serum or

Recombinant Products
▶Codes 90281-90399 identify the serum globulins, extracted
from human blood; or recombinant immune globulin products
created in a laboratory through genetic modification of human
and/or animal proteins. Both are reported in addition to the
administration codes 96365, 96366, 96367, 96368, 96369, 96370,
96371, 96372, 96374, 96375, as appropriate. Modifier 51 should
not be reported with this section of products codes when
performed with another procedure. The serum or recombinant
globulin products listed here include broad-spectrum anti-
infective immune globulins, antitoxins, various isoantibodies,
and monoclonal antibodies. See the Introduction section of the
CPT code set for a complete list of the dates of release and
implementation.◀
90281 Immune globulin (Ig), human, for intramuscular use
90283 Immune globulin (IgIV), human, for intravenous use

90284 Immune globulin (SCIg), human, for use in subcutaneous

infusions, 100 mg, each
90287 Botulinum antitoxin, equine, any route
90288 Botulism immune globulin, human, for intravenous use

90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for

intravenous use
90296 Diphtheria antitoxin, equine, any route

90371 Hepatitis B immune globulin (HBIg), human, for

intramuscular use
90375 Rabies immune globulin (RIg), human, for intramuscular

and/or subcutaneous use
90376 Rabies immune globulin, heat-treated (RIg-HT), human, for

intramuscular and/or subcutaneous use
● 90377 Rabies immune globulin, heat- and solvent/detergent-treated

(RIg-HT S/D), human, for intramuscular and/or
subcutaneous use
90378 Respiratory syncytial virus, monoclonal antibody,
recombinant, for intramuscular use, 50 mg, each
2010
➲ CPT Assistant Jan 99:3, Nov 99:47, Jun 00:10
90384 Rho(D) immune globulin (RhIg), human, full-dose, for

intramuscular use
90385 Rho(D) immune globulin (RhIg), human, mini-dose, for

intramuscular use
90386 Rho(D) immune globulin (RhIgIV), human, for intravenous

use
90389 Tetanus immune globulin (TIg), human, for intramuscular use

90393 Vaccinia immune globulin, human, for intramuscular use

90396 Varicella-zoster immune globulin, human, for intramuscular

use
90399 Unlisted immune globulin

➲ CPT Assistant Nov 98:30, Jan 99:3, Feb 99:11, Sep
99:10
Immunization Administration for
Vaccines/Toxoids
Report vaccine immunization administration codes 90460, 90461,
90471-90474 in addition to the vaccine and toxoid code(s) 90476-
90749.
Report codes 90460 and 90461 only when the physician or
qualified health care professional provides face-to-face
counseling of the patient/family during the administration of a
vaccine. For immunization administration of any vaccine that is
not accompanied by face-to-face physician or qualified health
care professional counseling to the patient/family or for
administration of vaccines to patients over 18 years of age, report
codes 90471-90474. (See also Instructions for Use of the CPT
Codebook for definition of reporting qualifications.)
▶If a significant separately identifiable evaluation and
management service (eg, new or established patient office or
other outpatient services [99202-99215], office or other outpatient
consultations [99241-99245], emergency department services
[99281-99285], preventive medicine services [99381-99429]) is
performed, the appropriate E/M service code should be reported
in addition to the vaccine and toxoid administration codes.◀
A component refers to all antigens in a vaccine that prevent
disease(s) caused by one organism (90460 and 90461). Multi-
valent antigens or multiple serotypes of antigens against a single
organism are considered a single component of vaccines.
Combination vaccines are those vaccines that contain multiple
vaccine components. Conjugates or adjuvants contained in
vaccines are not considered to be component parts of the vaccine
as defined above.
(For allergy testing, see 95004 et seq)
(For skin testing of bacterial, viral, fungal extracts, see
86485-86580)
(For therapeutic or diagnostic injections, see 96372-96379)
90460 Immunization administration through 18 years of age via any
route of administration, with counseling by physician or
other qualified health care professional; first or only
component of each vaccine or toxoid administered
➲ CPT Assistant Mar 11:3, Jun 11:14, Jan 12:43, Jul 12:7,
Aug 13:10, Mar 14:10, Apr 15:9, 11, May 15:6, Oct
16:7, Nov 18:7, Jan 20:11
✚ 90461 each additional vaccine or toxoid component
administered (List separately in addition to code for
primary procedure)
➲ CPT Assistant Mar 11:3, Jun 11:14, Jan 12:43, Jul
12:7, Aug 13:10, Mar 14:10, Apr 15:4, May 15:6,
Oct 16:7, Nov 18:7
(Use 90460 for each vaccine administered. For vaccines
with multiple components [combination vaccines], report
90460 in conjunction with 90461 for each additional
component in a given vaccine)
90471 Immunization administration (includes percutaneous,
intradermal, subcutaneous, or intramuscular injections); 1
vaccine (single or combination vaccine/toxoid)
➲ CPT Assistant Nov 98:31, Jan 99:2, Apr 99:10, Oct
99:9, Nov 99:47-48, Nov 00:10, Feb 01:5, Jul 01:2, Nov
02:11, Mar 04:11, Apr 04:14, Apr 05:1-3, 5, Nov 05:1,
Jan 09:8, Jul 09:7, Aug 09:9, Sep 09:7, Oct 09:3, Mar
11:3, Jun 11:14, Jul 12:7, Aug 13:10, Mar 14:10, Apr
15:9, 11, May 15:6, Oct 16:7, Nov 18:7, Jun 19:11, Jan
20:11
✚ 90472 each additional vaccine (single or combination
vaccine/toxoid) (List separately in addition to code for
primary procedure)
➲ CPT Assistant Nov 98:31, Jan 99:2, Apr 99:10, Oct
99:9, Nov 99:47-48, Nov 00:10, Feb 01:5, Jul 01:2,
Nov 02:11, Mar 04:11, Apr 04:14, Apr 05:1-3, Nov
05:1, Jan 09:3, 8, Jul 09:7, Aug 09:9, Sep 09:7, Oct
09:3, Mar 11:3, Jun 11:14, Jul 12:7, Aug 13:10, Mar
14:10, Apr 15:9, 11, May 15:6, Oct 16:7, Nov 18:7,
Jan 20:11
(For immune globulins, see 90281-90399. For
administration of immune globulins, see 96365, 96366,
96367, 96368, 96369, 96370, 96371, 96374)
(For intravesical administration of BCG vaccine, see
51720, 90586)
90473 Immunization administration by intranasal or oral route; 1
vaccine (single or combination vaccine/toxoid)
➲ CPT Assistant Feb 01:5, Nov 02:11, Apr 04:14, Apr
05:1-3, Jan 09:3, 8, Jul 09:7, Aug 09:9, Oct 09:3, Mar
11:3, Jun 11:14, Jul 12:7, Aug 13:10, Mar 14:10, Apr
15:9, May 15:6, Nov 18:7
✚ 90474 each additional vaccine (single or combination
vaccine/toxoid) (List separately in addition to code for
primary procedure)
➲ CPT Assistant Feb 01:5, Nov 02:11, Apr 04:14, Apr
05:1-3, Jan 09:3, 8, Jul 09:7, Aug 09:9, Oct 09:3,
Mar 11:3, Jun 11:14, Jul 12:7, Aug 13:10, Mar 14:10,
Apr 15:9, May 15:6, Nov 18:7
Vaccines, Toxoids
▶To assist users to report the most recent new or revised vaccine
product codes, the American Medical Association (AMA)
currently uses the CPT website (ama-assn.org/cpt-cat-i-vaccine-
codes), which features updates of CPT Editorial Panel actions
regarding these products. See the Introduction section of the CPT
code set for a complete list of the dates of release and
implementation.◀
The CPT Editorial Panel, in recognition of the public health
interest in vaccine products, has chosen to publish new vaccine
product codes prior to approval by the US Food and Drug
Administration (FDA). These codes are indicated with the ⚡
symbol and will be tracked by the AMA to monitor FDA
approval status. Once the FDA status changes to approval, the ⚡
symbol will be removed. CPT users should refer to the AMA
CPT website (ama-assn.org/cpt-cat-i-vaccine-codes) for the most
up-to-date information on codes with the ⚡ symbol.
Codes 90476-90749 identify the vaccine product only. To report
the administration of a vaccine/toxoid, the vaccine/toxoid product
codes 90476-90749 must be used in addition to an immunization
administration code(s) 90460, 90461, 90471, 90472, 90473, 90474.
Modifier 51 should not be reported with vaccine/toxoid codes
90476-90749, when reported in conjunction with administration
codes 90460, 90461, 90471, 90472, 90473, 90474.
If a significantly separately identifiable Evaluation and
Management (E/M) service (eg, office or other outpatient
services, preventive medicine services) is performed, the
appropriate E/M service code should be reported in addition to
the vaccine and toxoid administration codes.
To meet the reporting requirements of immunization registries,
vaccine distribution programs, and reporting systems (eg,
Vaccine Adverse Event Reporting System) the exact vaccine
product administered needs to be reported. Multiple codes for a
particular vaccine are provided in the CPT codebook when the
schedule (number of doses or timing) differs for two or more
products of the same vaccine type (eg, hepatitis A, Hib) or the
vaccine product is available in more than one chemical
formulation, dosage, or route of administration.
The “when administered to” age descriptions included in CPT
vaccine codes are not intended to identify a product’s licensed
age indication. The term “preservative free” includes use for
vaccines that contain no preservative and vaccines that contain
trace amounts of preservative agents that are not present in a
sufficient concentration for the purpose of preserving the final
vaccine formulation. The absence of a designation regarding a
preservative does not necessarily indicate the presence or absence
of preservative in the vaccine. Refer to the product’s prescribing
information (PI) for the licensed age indication before
administering vaccine to a patient.
Separate codes are available for combination vaccines (eg, Hib-
HepB, DTap-IPV/Hib). It is inappropriate to code each
component of a combination vaccine separately. If a specific
vaccine code is not available, the unlisted procedure code should
be reported, until a new code becomes available.
The vaccine/toxoid abbreviations listed in codes 90476-90748
reflect the most recent US vaccine abbreviations references used
in the Advisory Committee on Immunization Practices (ACIP)
recommendations at the time of CPT code set publication.
Interim updates to vaccine code descriptors will be made
following abbreviation approval by the ACIP on a timely basis
via the AMA CPT website (ama-assn.org/cpt-cat-i-vaccine-
codes). The accuracy of the ACIP vaccine abbreviation
designations in the CPT code set does not affect the validity of
the vaccine code and its reporting function.
(For immune globulins, see 90281-90399. For
administration of immune globulins, see 96365-96375)
90476 Adenovirus vaccine, type 4, live, for oral use
➲ CPT Assistant Nov 98:31-33, Jan 99:2, Sep 99:10, Oct
99:9, Nov 99:48, Mar 11:4, Aug 13:10, May 15:6, Oct
16:6
90477 Adenovirus vaccine, type 7, live, for oral use
➲ CPT Assistant Nov 98:31-33, Jan 99:2, Oct 99:9, Mar
11:4, Aug 13:10
90581 Anthrax vaccine, for subcutaneous or intramuscular use
11:4, Aug 13:10
90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis,
live, for percutaneous use
11:4, Aug 13:10
90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder
cancer, live, for intravesical use
➲ CPT Assistant Nov 98:31-33, Jan 99:2, Oct 99:9, Nov
02:11, Mar 11:4, Aug 13:10
90587 Dengue vaccine, quadrivalent, live, 3 dose schedule, for
subcutaneous use

90632 Hepatitis A vaccine (HepA), adult dosage, for intramuscular
use
11:4, Aug 13:10
90633 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2
dose schedule, for intramuscular use
11:4, Aug 13:10
90634 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3
11:4, Aug 13:10
90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult
dosage, for intramuscular use
11:4, Aug 13:10
90647 Haemophilus influenzae type b vaccine (Hib), PRP-OMP
conjugate, 3 dose schedule, for intramuscular use
11:4, Aug 13:10
90648 Haemophilus influenzae type b vaccine (Hib), PRP-T
conjugate, 4 dose schedule, for intramuscular use
➲ CPT Assistant Nov 98:31-33, Jan 99:2, Oct 99:9, Sep
09:7, Mar 11:4, Aug 13:10
90649 Human Papillomavirus vaccine, types 6, 11, 16, 18,
quadrivalent (4vHPV), 3 dose schedule, for intramuscular
use
➲ CPT Assistant Dec 05:9, Jun 06:8, Sep 06:14, Jul 07:13,
Mar 11:4, Aug 13:10
90650 Human Papillomavirus vaccine, types 16, 18, bivalent
(2vHPV), 3 dose schedule, for intramuscular use
90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33,
45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for
intramuscular use
90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for
intramuscular use
➲ CPT Assistant Aug 13:10, Oct 16:6, Jun 19:11
90654 Influenza virus vaccine, trivalent (IIV3), split virus,

preservative-free, for intradermal use
➲ CPT Assistant Aug 13:10, Apr 15:9, May 15:6, Oct 16:6
# 90630 Influenza virus vaccine, quadrivalent (IIV4), split virus,

preservative free, for intradermal use

preservative free, 0.25 mL dosage, for intramuscular use
2013, 2016, 2017
➲ CPT Assistant Oct 99:9, Feb 04:2, Apr 07:12, Apr 08:8,
Oct 09:3, Mar 11:4, Aug 13:10, May 16:9, Oct 16:6
2013, 2016, 2017
➲ CPT Assistant Apr 08:8, Oct 09:3, Mar 11:4, Aug 13:10,
May 16:9, Oct 16:6
90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL
2013, 2016, 2017
➲ CPT Assistant Nov 98:31-33, Jan 99:2, Oct 99:9, Feb
02:10, Feb 04:2, Apr 05:5, Apr 08:8, Oct 09:3, Mar
11:4, Aug 13:10, May 16:9, Oct 16:6
90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL
2013, 2016, 2017
➲ CPT Assistant Nov 98:31-33, Jan 99:2, Oct 99:9, Feb
04:2, Apr 07:12, Apr 08:8, Oct 09:3, Mar 11:4, Aug
13:10, May 16:9, Oct 16:6
90660 Influenza virus vaccine, trivalent, live (LAIV3), for
intranasal use
04:11, Apr 04:14, Oct 09:3, Mar 11:4, Aug 13:10
# 90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for
intranasal use
90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell

cultures, subunit, preservative and antibiotic free, 0.5 mL
➲ CPT Assistant Apr 08:8, Oct 09:3, Mar 11:4, Aug 13:10,
Oct 16:6
# 90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from
cell cultures, subunit, preservative and antibiotic free, 0.5
mL dosage, for intramuscular use
# 90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from

cell cultures, subunit, antibiotic free, 0.5 mL dosage, for
intramuscular use
# 90673 Influenza virus vaccine, trivalent (RIV3), derived from
recombinant DNA, hemagglutinin (HA) protein only,
preservative and antibiotic free, for intramuscular use
90662 Influenza virus vaccine (IIV), split virus, preservative free,

enhanced immunogenicity via increased antigen content, for
intramuscular use
➲ CPT Assistant Apr 08:8, Oct 09:3, 6, Mar 11:4, Aug
13:10
90664 Influenza virus vaccine, live (LAIV), pandemic formulation,
for intranasal use
⚡ 90666 Influenza virus vaccine (IIV), pandemic formulation, split

virus, preservative free, for intramuscular use

virus, adjuvanted, for intramuscular use

virus, for intramuscular use
90670 Pneumococcal conjugate vaccine, 13 valent (PCV13), for

intramuscular use
90675 Rabies vaccine, for intramuscular use
11:4, Aug 13:10
90676 Rabies vaccine, for intradermal use
11:4, Jul 12:7, Aug 13:10
90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live,
for oral use
➲ CPT Assistant Nov 98:31-33, Jan 99:2, Oct 99:9, Jun
05:6, Dec 05:9, Jun 06:8, Mar 11:4, Aug 13:10
90681 Rotavirus vaccine, human, attenuated (RV1), 2 dose
schedule, live, for oral use
90682 Influenza virus vaccine, quadrivalent (RIV4), derived from

recombinant DNA, hemagglutinin (HA) protein only,
preservative and antibiotic free, for intramuscular use
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus,


0.25 mL dosage, for intramuscular use
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5

mL dosage, for intramuscular use
90689 Influenza virus vaccine, quadrivalent (IIV4), inactivated,

adjuvanted, preservative free, 0.25 mL dosage, for
intramuscular use
# 90694 Influenza virus vaccine, quadrivalent (aIIV4), inactivated,

adjuvanted, preservative free, 0.5 mL dosage, for
intramuscular use
90690 Typhoid vaccine, live, oral

11:4, Aug 13:10
90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for
intramuscular use
11:4, Aug 13:10
90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and
inactivated poliovirus vaccine (DTaP-IPV), when
administered to children 4 through 6 years of age, for
intramuscular use
90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine,

inactivated poliovirus vaccine, Haemophilus influenzae type
b PRP-OMP conjugate vaccine, and hepatitis B vaccine
(DTaP-IPV-Hib-HepB), for intramuscular use

Haemophilus influenzae type b, and inactivated poliovirus
vaccine, (DTaP-IPV/Hib), for intramuscular use
➲ CPT Assistant Oct 99:9, Dec 05:9, Jun 06:8, Mar 11:4,
Aug 13:10
90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine
(DTaP), when administered to individuals younger than 7
years, for intramuscular use
➲ CPT Assistant Jan 96:5, Apr 97:10, Nov 98:31-33, Jan
99:2, Oct 99:9, Nov 03:13, Mar 11:4, Jul 12:7, Aug
13:10
90702 Diphtheria and tetanus toxoids adsorbed (DT) when
administered to individuals younger than 7 years, for
intramuscular use
2016
➲ CPT Assistant Jan 96:6, Aug 96:10, Apr 97:10, Nov
98:31-33, Jan 99:2, Sep 99:10, Oct 99:9, Jun 00:10, Feb
07:11, Mar 11:4, Aug 13:10
90707 Measles, mumps and rubella virus vaccine (MMR), live, for
subcutaneous use
➲ CPT Assistant Jan 96:6, May 96:10, Apr 97:10, Nov
98:31-33, Jan 99:2, Oct 99:9, Apr 05:1, 5, Mar 11:4, Jul
12:7, Aug 13:10
90710 Measles, mumps, rubella, and varicella vaccine (MMRV),
live, for subcutaneous use
➲ CPT Assistant May 96:10, Apr 97:10, Nov 98:31-33,
Jan 99:2, Oct 99:9, Dec 05:9, Jun 06:8, Mar 11:4, Aug
13:10
90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or
intramuscular use
➲ CPT Assistant Apr 97:10, Nov 98:31-33, Jan 99:2, Oct
99:9, Jun 05:6, Mar 11:4, Aug 13:10
90714 Tetanus and diphtheria toxoids adsorbed (Td), preservative
free, when administered to individuals 7 years or older, for
intramuscular use
2016
➲ CPT Assistant Jun 05:6, Mar 11:4, Aug 13:10
90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine

(Tdap), when administered to individuals 7 years or older,
for intramuscular use
➲ CPT Assistant Oct 99:9, Jun 05:6, Dec 05:9, Jun 06:8,
Mar 11:4, Aug 13:10
90716 Varicella virus vaccine (VAR), live, for subcutaneous use
➲ CPT Assistant Jan 96:6, May 96:10, Apr 97:10, Nov
98:31-33, Jan 99:2, Oct 99:9, Mar 11:4, Aug 13:10
90717 Yellow fever vaccine, live, for subcutaneous use
99:9, Mar 11:4, Aug 13:10
hepatitis B, and inactivated poliovirus vaccine (DTaP-
HepB-IPV), for intramuscular use
➲ CPT Assistant Apr 97:10, Oct 99:9, Mar 11:4, Aug
13:10, May 15:6
# 90625 Cholera vaccine, live, adult dosage, 1 dose schedule, for
oral use
90732 Pneumococcal polysaccharide vaccine, 23-valent

(PPSV23), adult or immunosuppressed patient dosage, when
administered to individuals 2 years or older, for
subcutaneous or intramuscular use
2016
99:9, Mar 11:4, Aug 13:10
# 90644 Meningococcal conjugate vaccine, serogroups C & Y and
Haemophilus influenzae type b vaccine (Hib-MenCY), 4
dose schedule, when administered to children 6 weeks-18
months of age, for intramuscular use
2017
90733 Meningococcal polysaccharide vaccine, serogroups A, C, Y,

W-135, quadrivalent (MPSV4), for subcutaneous use
2016
99:9, Dec 99:7, Mar 11:4, Aug 13:10
90734 Meningococcal conjugate vaccine, serogroups A, C, W, Y,
quadrivalent, diphtheria toxoid carrier (MenACWY-D) or
CRM197 carrier (MenACWY-CRM), for intramuscular use
2017, 2020
➲ CPT Assistant Oct 99:9, Mar 11:4, Aug 13:10, May
15:6, Oct 16:6, Jan 20:11
# 90619 Meningococcal conjugate vaccine, serogroups A, C, W, Y,
quadrivalent, tetanus toxoid carrier (MenACWY-TT), for
intramuscular use
# 90620 Meningococcal recombinant protein and outer membrane

vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule,
# 90621 Meningococcal recombinant lipoprotein vaccine, serogroup

B (MenB-FHbp), 2 or 3 dose schedule, for intramuscular
use
90736 Zoster (shingles) vaccine (HZV), live, for subcutaneous

injection
➲ CPT Assistant Dec 05:9, Jun 06:8, Jul 07:13, Mar 11:4,
Aug 13:10, Nov 18:7
# 90750 Zoster (shingles) vaccine (HZV), recombinant, subunit,
adjuvanted, for intramuscular use
90738 Japanese encephalitis virus vaccine, inactivated, for
intramuscular use
90739 Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule,

90740 Hepatitis B vaccine (HepB), dialysis or immunosuppressed

patient dosage, 3 dose schedule, for intramuscular use
➲ CPT Assistant Apr 97:10, Oct 99:9, Apr 01:10, Mar
11:4, Aug 13:10
90743 Hepatitis B vaccine (HepB), adolescent, 2 dose schedule,
➲ CPT Assistant Apr 97:10, Oct 99:9, Mar 11:4, Aug
13:10
90744 Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3
2016
➲ CPT Assistant Jan 96:5, Apr 97:10, Jun 97:10, Nov
98:31-33, Jan 99:2, Oct 99:9, Nov 99:48-49, Jun 00:10,
Mar 11:4, Aug 13:10
90746 Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule,
➲ CPT Assistant Jan 96:5, Apr 97:10, Nov 98:31-33, Jan
99:2, Oct 99:9, Mar 11:4, Aug 13:10
90747 Hepatitis B vaccine (HepB), dialysis or immunosuppressed
patient dosage, 4 dose schedule, for intramuscular use
98:31-33, Jan 99:2, Oct 99:9, Jun 00:10, Apr 01:10, Mar
11:4, Aug 13:10
90748 Hepatitis B and Haemophilus influenzae type b vaccine
(Hib-HepB), for intramuscular use
➲ CPT Assistant Apr 97:10, Nov 97:37, Nov 98:31-33,
Jan 99:2, Sep 99:10, Oct 99:9, Mar 11:4, Jul 12:7, Aug
13:10, Oct 16:6
90749 Unlisted vaccine/toxoid
98:31-33, Jan 99:2, Oct 99:9, Nov 02:11, Mar 11:4, May
15:6
Psychiatry
▶Psychiatry services include diagnostic services, psychotherapy,
and other services to an individual, family, or group. Patient
condition, characteristics, or situational factors may require
services described as being with interactive complexity. Services
may be provided to a patient in crisis. Services are provided in all
settings of care and psychiatry services codes are reported
without regard to setting. Services may be provided by a
physician or other qualified health care professional. Some
psychiatry services may be reported with evaluation and
management services (99202-99255, 99281-99285, 99304-
99337, 99341-99350) or other services when performed.
Evaluation and management services (99202-99285, 99304-
99337, 99341-99350) may be reported for treatment of psychiatric
conditions, rather than using psychiatry services codes, when
appropriate.◀
Hospital care in treating a psychiatric inpatient or partial
hospitalization may be initial or subsequent in nature (see 99221-
99233).
Some patients receive hospital evaluation and management
services only and others receive hospital evaluation and
management services and other procedures. If other procedures
such as electroconvulsive therapy or psychotherapy are rendered
in addition to hospital evaluation and management services, these
may be listed separately (eg, hospital care services [99221-99223,
99231-99233] plus electroconvulsive therapy [90870]), or when
psychotherapy is done, with appropriate code(s) defining
psychotherapy services.
Consultation for psychiatric evaluation of a patient includes
examination of a patient and exchange of information with the
primary physician and other informants such as nurses or family
members, and preparation of a report. These services may be
reported using consultation codes (see Consultations).
90840, 97151, 97152, 97153, 97154, 97155, 97156, 97157,
97158, 0362T, 0373T)
Interactive Complexity
▶Code 90785 is an add-on code for interactive complexity to be
reported in conjunction with codes for diagnostic psychiatric
evaluation (90791, 90792), psychotherapy (90832, 90834, 90837),
psychotherapy when performed with an evaluation and
management service (90833, 90836, 90838, 99202-99255, 99304-
99337, 99341-99350), and group psychotherapy (90853).◀
Interactive complexity refers to specific communication factors
that complicate the delivery of a psychiatric procedure. Common
factors include more difficult communication with discordant or
emotional family members and engagement of young and
verbally undeveloped or impaired patients. Typical patients are
those who have third parties, such as parents, guardians, other
family members, interpreters, language translators, agencies,
court officers, or schools involved in their psychiatric care.
These factors are typically present with patients who:
■ Have other individuals legally responsible for their care, such
as minors or adults with guardians, or
■ Request others to be involved in their care during the visit,
such as adults accompanied by one or more participating
family members or interpreter or language translator, or
■ Require the involvement of other third parties, such as child
welfare agencies, parole or probation officers, or schools.
Psychiatric procedures may be reported “with interactive
complexity” when at least one of the following is present:
1. The need to manage maladaptive communication (related to,
eg, high anxiety, high reactivity, repeated questions, or
disagreement) among participants that complicates delivery of
care.
2. Caregiver emotions or behavior that interferes with the
caregiver’s understanding and ability to assist in the
implementation of the treatment plan.
3. Evidence or disclosure of a sentinel event and mandated report
to third party (eg, abuse or neglect with report to state agency)
with initiation of discussion of the sentinel event and/or report
with patient and other visit participants.
4. Use of play equipment, other physical devices, interpreter, or
translator to communicate with the patient to overcome
barriers to therapeutic or diagnostic interaction between the
physician or other qualified health care professional and a
patient who:
■ Is not fluent in the same language as the physician or other
qualified health care professional, or
■ Has not developed, or has lost, either the expressive
language communication skills to explain his/her symptoms
and response to treatment, or the receptive communication
skills to understand the physician or other qualified health
care professional if he/she were to use typical language for
communication.
▶When provided in conjunction with the psychotherapy services
(90832-90838), the amount of time spent by a physician or other
qualified health care professional providing interactive
complexity services should be reflected in the timed service code
for psychotherapy (90832, 90834, 90837) or the psychotherapy
add-on code performed with an evaluation and management
service (90833, 90836, 90838) and must relate to the
psychotherapy service only. Interactive complexity is not a factor
for evaluation and management services selection (99202-99255,
99281-99285, 99304-99337, 99341-99350), except as it directly
affects key components as defined in the Evaluation and
Management Services Guidelines (ie, history, examination, and
medical decision making).◀
✚ 90785 Interactive complexity (List separately in addition to the
➲ CPT Assistant May 13:12, Jun 13:3, Apr 14:6, Nov 18:3
▶ (Use 90785 in conjunction with codes for diagnostic

psychiatric evaluation [90791, 90792], psychotherapy
[90832, 90834, 90837], psychotherapy when performed
with an evaluation and management service [90833, 90836,
90838, 99202-99255, 99304-99337, 99341-99350], and
group psychotherapy [90853])◀
(Do not report 90785 in conjunction with 90839, 90840, or
in conjunction with E/M services when no psychotherapy
service is also reported)
97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158,
0362T, 0373T)
Psychiatric Diagnostic Procedures

Psychiatric diagnostic evaluation is an integrated biopsychosocial
assessment, including history, mental status, and
recommendations. The evaluation may include communication
with family or other sources and review and ordering of
diagnostic studies.
Psychiatric diagnostic evaluation with medical services is an
integrated biopsychosocial and medical assessment, including
history, mental status, other physical examination elements as
indicated, and recommendations. The evaluation may include
communication with family or other sources, prescription of
medications, and review and ordering of laboratory or other
diagnostic studies.
In certain circumstances one or more other informants (family
members, guardians, or significant others) may be seen in lieu of
the patient. Codes 90791, 90792 may be reported more than once
for the patient when separate diagnostic evaluations are
conducted with the patient and other informants. Report services
as being provided to the patient and not the informant or other
party in such circumstances. Codes 90791, 90792 may be
reported once per day and not on the same day as an evaluation
and management service performed by the same individual for
the same patient.
The psychiatric diagnostic evaluation may include interactive
complexity services when factors exist that complicate the
delivery of the psychiatric procedure. These services should be
reported with add-on code 90785 used in conjunction with the
diagnostic psychiatric evaluation codes 90791, 90792.
Codes 90791, 90792 are used for the diagnostic assessment(s) or
reassessment(s), if required, and do not include
psychotherapeutic services. Psychotherapy services, including for
crisis, may not be reported on the same day.
90840, 97151, 97152, 97153, 97154, 97155, 97156, 97157,
97158, 0362T, 0373T)
★ 90791 Psychiatric diagnostic evaluation
➲ CPT Assistant May 13:12, Jun 13:3, Dec 13:18, Jun
14:3, Nov 17:3, Nov 18:3
★ 90792 Psychiatric diagnostic evaluation with medical services
➲ CPT Assistant Jun 13:3, Dec 13:18, Jun 14:3, Nov 17:3,
Nov 18:3, Dec 19:15
▶ (Donot report 90791 or 90792 in conjunction with 99202-
99337, 99341-99350, 99366-99368, 99401-99443, 97151,
97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T,
0373T)◀
(Use 90785 in conjunction with 90791, 90792 when the
diagnostic evaluation includes interactive complexity
services)
Psychotherapy
Psychotherapy is the treatment of mental illness and behavioral
disturbances in which the physician or other qualified health care
professional, through definitive therapeutic communication,
attempts to alleviate the emotional disturbances, reverse or
change maladaptive patterns of behavior, and encourage
personality growth and development.
The psychotherapy service codes 90832-90838 include ongoing
assessment and adjustment of psychotherapeutic interventions,
and may include involvement of informants in the treatment
process.
Codes 90832, 90833, 90834, 90836, 90837, 90838 describe
psychotherapy for the individual patient, although times are for
face-to-face services with patient and may include informant(s).
The patient must be present for all or a majority of the service.
See codes 90846, 90847 when utilizing family psychotherapy
techniques, such as focusing on family dynamics. Do not report
90846, 90847 for family psychotherapy services less than 26
minutes. Codes 90832, 90833, 90834, 90836, 90837, 90838 may
be reported on the same day as codes 90846, 90847, when the
services are separate and distinct.
In reporting, choose the code closest to the actual time (ie, 16-37
minutes for 90832 and 90833, 38-52 minutes for 90834 and
90836, and 53 or more minutes for 90837 and 90838). Do not
report psychotherapy of less than 16 minutes duration. (See
instructions for the usage of time in the Introduction of the CPT
code set.)
Psychotherapy provided to a patient in a crisis state is reported
with codes 90839 and 90840 and cannot be reported in addition
to the psychotherapy codes 90832-90838. For psychotherapy for
crisis, see “Other Psychotherapy.”
Code 90785 is an add-on code to report interactive complexity
services when provided in conjunction with the psychotherapy
codes 90832-90838. For family psychotherapy, see 90846, 90847.
The amount of time spent by a physician or other qualified health
care professional providing interactive complexity services
should be reflected in the timed service code for psychotherapy
(90832, 90834, 90837) or the psychotherapy add-on code
performed with an evaluation and management service (90833,
90836, 90838).
Some psychiatric patients receive a medical evaluation and
management (E/M) service on the same day as a psychotherapy
service by the same physician or other qualified health care
professional. To report both E/M and psychotherapy, the two
services must be significant and separately identifiable. These
services are reported by using codes specific for psychotherapy
when performed with evaluation and management services
(90833, 90836, 90838) as add-on codes to the evaluation and
management service.
Medical symptoms and disorders inform treatment choices of
psychotherapeutic interventions, and data from therapeutic
communication are used to evaluate the presence, type, and
severity of medical symptoms and disorders. For the purposes of
reporting, the medical and psychotherapeutic components of the
service may be separately identified as follows:
1. The type and level of E/M service is selected first based upon
the key components of history, examination, and medical
decision-making.
2. Time associated with activities used to meet criteria for the E/M
service is not included in the time used for reporting the
psychotherapy service (ie, time spent on history, examination
and medical decision making when used for the E/M service
is not psychotherapy time). Time may not be used as the basis
of E/M code selection and Prolonged Services may not be
reported when psychotherapy with E/M (90833, 90836, 90838)
are reported.
3. A separate diagnosis is not required for the reporting of E/M
and psychotherapy on the same date of service.
★ 90832 Psychotherapy, 30 minutes with patient
➲ CPT Assistant Jan 13:3, May 13:12, Jun 13:3, Aug
13:14, Feb 14:3, Aug 14:5, Oct 15:9, Dec 16:11, Sep
17:12, Nov 18:3
★✚ 90833 Psychotherapy, 30 minutes with patient when performed
with an evaluation and management service (List separately
in addition to the code for primary procedure)
13:14, Aug 14:5, Oct 15:9, Dec 16:11, Nov 18:3
▶ (Use90833 in conjunction with 99202-99255, 99304-
99337, 99341-99350)◀
13:14, Jun 14:3, Oct 15:9, Dec 16:11, Nov 18:3
13:14, Oct 15:9, Dec 16:11, Nov 18:3
99337, 99341-99350)◀
13:14, Apr 14:6, Oct 15:3, 9, Dec 16:11, Nov 18:3
(Use the appropriate prolonged services code [99354,
99355, 99356, 99357] for psychotherapy services not
performed with an E/M service of 90 minutes or longer
face-to-face with the patient)
13:14, Feb 14:3, Apr 14:6, Oct 15:9, Dec 16:11, Nov
18:3
99337, 99341-99350)◀
90836, 90837, 90838 when psychotherapy includes
interactive complexity services)
Psychotherapy for Crisis
Psychotherapy for crisis is an urgent assessment and history of a
crisis state, a mental status exam, and a disposition. The treatment
includes psychotherapy, mobilization of resources to defuse the
crisis and restore safety, and implementation of
psychotherapeutic interventions to minimize the potential for
psychological trauma. The presenting problem is typically life
threatening or complex and requires immediate attention to a
patient in high distress.
Codes 90839, 90840 are used to report the total duration of time
face-to-face with the patient and/or family spent by the physician
or other qualified health care professional providing
psychotherapy for crisis, even if the time spent on that date is not
continuous. For any given period of time spent providing
psychotherapy for crisis state, the physician or other qualified
health care professional must devote his or her full attention to
the patient and, therefore, cannot provide services to any other
patient during the same time period. The patient must be present
for all or some of the service. Do not report with 90791 or 90792.
Code 90839 is used to report the first 30-74 minutes of
psychotherapy for crisis on a given date. It should be used only
once per date even if the time spent by the physician or other
health care professional is not continuous on that date.
Psychotherapy for crisis of less than 30 minutes total duration on
a given date should be reported with 90832 or 90833 (when
provided with evaluation and management services).
Code 90840 is used to report additional block(s) of time, of up to
30 minutes each beyond the first 74 minutes.
90839 Psychotherapy for crisis; first 60 minutes
➲ CPT Assistant Jun 13:3, Aug 14:5, Oct 15:9, Nov 18:3
➲ CPT Assistant Jun 13:3, Aug 14:5, Oct 15:9, Nov
18:3
90792, psychotherapy codes 90832-90838 or other
psychiatric services, or 90785-90899)
Other Psychotherapy
★ 90845 Psychoanalysis
➲ CPT Assistant Summer 92:15, Nov 97:40-41, Mar 01:8,
Mar 02:4, May 05:1, Feb 06:15, Mar 10:6, Oct 15:9,
Nov 18:3
★ 90846 Family psychotherapy (without the patient present), 50
minutes
Mar 02:4, May 05:1, Sep 09:11, Mar 10:6, Jun 13:3, Dec
13:18, Oct 15:9, Dec 16:11, Mar 17:11, Nov 18:3
★ 90847 Family psychotherapy (conjoint psychotherapy) (with
patient present), 50 minutes
Mar 02:4, May 05:1, Mar 10:6, Jun 13:3, Dec 13:18, Oct
15:9, Dec 16:11, Nov 18:3
(Do not report 90846, 90847 for family psychotherapy
services less than 26 minutes)
97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T,
0373T)
(For family psychotherapy services [90847] of 80 minutes
or more, see the appropriate prolonged services code
[99354, 99355, 99356, 99357])
90849 Multiple-family group psychotherapy
Mar 02:4, May 05:1, Mar 10:6, Aug 14:15, Oct 15:9,
Nov 18:3
90853 Group psychotherapy (other than of a multiple-family group)
Mar 02:4, May 05:1, Mar 10:6, Jun 13:3, Jun 14:3, Aug
14:15, Oct 15:9, Mar 17:11, Nov 18:3
(Use 90853 in conjunction with 90785 for the specified
patient when group psychotherapy includes interactive
complexity)
97153, 97154, 97155, 97156, 97157, 97158, 0362T,
0373T)
Other Psychiatric Services or Procedures

performed, of vagal nerve neurostimulators, see 95970,
95976, 95977)
★✚ 90863 Pharmacologic management, including prescription and
review of medication, when performed with psychotherapy
services (List separately in addition to the code for primary
procedure)
▶ (For pharmacologic management with psychotherapy
services performed by a physician or other qualified health
care professional who may report evaluation and
management codes, use the appropriate evaluation and
management codes 99202-99255, 99281-99285, 99304-
99337, 99341-99350 and the appropriate psychotherapy
with evaluation and management service 90833, 90836,
90838)◀
(Do not count time spent on providing pharmacologic
management services in the time used for selection of the
psychotherapy service)
90865 Narcosynthesis for psychiatric diagnostic and therapeutic
purposes (eg, sodium amobarbital (Amytal) interview)
➲ CPT Assistant Nov 97:41, Mar 01:5, Mar 02:4, May
05:1, Nov 18:3
90867 Therapeutic repetitive transcranial magnetic stimulation
(TMS) treatment; initial, including cortical mapping, motor
threshold determination, delivery and management
(Report only once per course of treatment)

95860, 95870, 95928, 95929, 95939)
90868 subsequent delivery and management, per session
90869 subsequent motor threshold re-determination with

delivery and management
95860-95870, 95928, 95929, 95939)
(If a significant, separately identifiable evaluation and
management, medication management, or psychotherapy
service is performed, the appropriate E/M or psychotherapy
code may be reported in addition to 90867-90869.
Evaluation and management activities directly related to
cortical mapping, motor threshold determination, delivery
and management of TMS are not separately reported)
90870 Electroconvulsive therapy (includes necessary monitoring)
➲ CPT Assistant Summer 92:16, Mar 01:5, Mar 02:4, May
05:1, Mar 10:6, Feb 13:3, Nov 18:3
90875 Individual psychophysiological therapy incorporating
biofeedback training by any modality (face-to-face with the
patient), with psychotherapy (eg, insight oriented, behavior
modifying or supportive psychotherapy); 30 minutes
➲ CPT Assistant Nov 96:15, Sep 97:11, Nov 97:41, Apr
98:14, Jun 99:5, Mar 01:5, Mar 02:4, Mar 05:16, May
05:1, Nov 18:3
90876 45 minutes
➲ CPT Assistant Nov 96:15, Sep 97:11, Nov 97:41, Jun
99:5, Mar 01:5, Mar 05:16, May 05:1, Nov 18:3
90880 Hypnotherapy
➲ CPT Assistant Summer 92:16, Nov 97:41, Mar 01:5,
Mar 02:4, May 05:1, Nov 18:3
90882 Environmental intervention for medical management
purposes on a psychiatric patient’s behalf with agencies,
employers, or institutions
05:1, Nov 18:3
90885 Psychiatric evaluation of hospital records, other psychiatric
reports, psychometric and/or projective tests, and other
accumulated data for medical diagnostic purposes
➲ CPT Assistant Nov 97:41, Mar 01:5, Mar 02:4, Oct
04:10, May 05:1, Nov 18:3
90887 Interpretation or explanation of results of psychiatric, other
medical examinations and procedures, or other accumulated
data to family or other responsible persons, or advising
them how to assist patient
➲ CPT Assistant Summer 92:17, Mar 01:5, Mar 02:4, Oct
02:11, May 05:1, Nov 18:3
97153, 97154, 97155, 97156, 97157, 97158, 0362T,
0373T)
90889 Preparation of report of patient’s psychiatric status, history,
treatment, or progress (other than for legal or consultative
purposes) for other individuals, agencies, or insurance
carriers
05:1, Nov 18:3
90899 Unlisted psychiatric service or procedure
➲ CPT Assistant Mar 01:5, Mar 02:4, May 05:1, Jan
10:11, Apr 14:6, Nov 18:3
Biofeedback
(For psychophysiological therapy incorporating biofeedback
training, see 90875, 90876)
90901 Biofeedback training by any modality
➲ CPT Assistant Sep 97:11, Apr 98:14, Jun 98:10, Jun
99:5, May 02:18, Sep 04:13, Mar 05:16
90912 Biofeedback training, perineal muscles, anorectal or
urethral sphincter, including EMG and/or manometry, when
performed; initial 15 minutes of one-on-one physician or
other qualified health care professional contact with the
patient
✚ 90913 each additional 15 minutes of one-on-one physician or

other qualified health care professional contact with the
patient (List separately in addition to code for primary
procedure)

(For testing of rectal sensation, tone and compliance, use
91120)
(For incontinence treatment by pulsed magnetic
neuromodulation, use 53899)
Dialysis
(For therapeutic apheresis for white blood cells, red blood
cells, platelets and plasma pheresis, see 36511, 36512,
36513, 36514)
(For therapeutic apheresis extracorporeal adsorption
(90918, 90922 have been deleted. To report ESRD-related
services for patients younger than 2 years of age, see 90951-
90953, 90963, 90967)
services for patients between 2 and 11 years of age, see
90954-90956, 90964, 90968)
services for patients between 12 and 19 years of age, see
90957-90959, 90965, 90969)
services for patients 20 years of age and older, see 90960-
90962, 90966, 90970)
Hemodialysis
▶Codes 90935, 90937 are reported to describe the hemodialysis
procedure with all evaluation and management services related to
the patient’s renal disease on the day of the hemodialysis
procedure. These codes are used for inpatient end-stage renal
disease (ESRD) and non-ESRD procedures or for outpatient non-
ESRD dialysis services. Code 90935 is reported if only one
evaluation of the patient is required related to that hemodialysis
procedure. Code 90937 is reported when patient re-evaluation(s)
is required during a hemodialysis procedure. Use modifier 25
with evaluation and management codes including new or
99215), office or other outpatient consultations (99241-99245),
observation care (99217-99220, 99224-99226), observation or
inpatient care including admission and discharge (99234-99236),
initial hospital care (99221-99226, 99231-99239), new or
established patient emergency department services (99281-
99285), critical care services (99291, 99292), inpatient neonatal
intensive care services and pediatric and neonatal critical care
services (99466-99480), nursing facility services (99304-99318),
domiciliary, rest home services, or custodial care (99324-99337),
and home services (99341-99350), for separately identifiable
services unrelated to the dialysis procedure or renal failure which
cannot be rendered during the dialysis session.◀
(For home visit hemodialysis services performed by a non-
physician health care professional, use 99512)
(For cannula declotting, see 36831, 36833, 36860, 36861)
(For declotting of implanted vascular access device or
catheter by thrombolytic agent, use 36593)
(For collection of blood specimen from a partially or
completely implantable venous access device, use 36591)
(For prolonged attendance by a physician or other qualified
health care professional, see 99354-99360)
90935 Hemodialysis procedure with single evaluation by a
physician or other qualified health care professional
➲ CPT Assistant Fall 93:2, May 02:17, Jan 03:22
90937 Hemodialysis procedure requiring repeated evaluation(s)

with or without substantial revision of dialysis prescription
➲ CPT Assistant Fall 93:2, May 02:17, Jan 03:22
90940 Hemodialysis access flow study to determine blood flow in

grafts and arteriovenous fistulae by an indicator method
(For duplex scan of hemodialysis access, use 93990)
Miscellaneous Dialysis Procedures

▶Codes 90945, 90947 describe dialysis procedures other than
hemodialysis (eg, peritoneal dialysis, hemofiltration or
continuous renal replacement therapies), and all evaluation and
management services related to the patient’s renal disease on the
day of the procedure. Code 90945 is reported if only one
evaluation of the patient is required related to that procedure.
Code 90947 is reported when patient re-evaluation(s) is required
during a procedure. Use modifier 25 with evaluation and
management codes including office or other outpatient services
(99202-99215), office or other outpatient consultations (99241-
99245), observation care (99217-99220, 99224-99226),
observation or inpatient care including admission and discharge
(99234-99239), hospital care (99221-99226, 99231-99239), new or
established patient emergency department services (99281-
99285), critical care services (99291, 99292), inpatient neonatal
intensive care services and pediatric and neonatal critical care
services (99466-99480), nursing facility services (99304-99318),
domiciliary, rest home, or custodial care services (99324-99337),
and home services (99341-99350) for separately identifiable
services unrelated to the procedure or the renal failure which
cannot be rendered during the dialysis session.◀
(For percutaneous insertion of intraperitoneal tunneled
catheter, use 49418. For open insertion of tunneled
intraperitoneal catheter, use 49421)
(For prolonged attendance by a physician or other qualified
health care professional, see 99354-99360)
90945 Dialysis procedure other than hemodialysis (eg, peritoneal
dialysis, hemofiltration, or other continuous renal
replacement therapies), with single evaluation by a
➲ CPT Assistant Fall 93:2, Nov 97:41, Jul 98:10, Oct
01:11, Jan 03:22
(For home infusion of peritoneal dialysis, use 99601,
99602)
90947 Dialysis procedure other than hemodialysis (eg, peritoneal
dialysis, hemofiltration, or other continuous renal
replacement therapies) requiring repeated evaluations by a
physician or other qualified health care professional, with
or without substantial revision of dialysis prescription
➲ CPT Assistant Fall 93:2, Nov 97:41, Jul 98:10, Oct
01:11, Jan 03:22
End-Stage Renal Disease Services

Codes 90951-90962 are reported once per month to distinguish
age-specific services related to the patient’s ESRD performed in
an outpatient setting with three levels of service based on the
number of face-to-face visits. ESRD-related services by a
physician or other qualified health care professional include
establishment of a dialyzing cycle, outpatient evaluation and
management of the dialysis visits, telephone calls, and patient
management during the dialysis provided during a full month. In
the circumstances in which the patient has had a complete
assessment visit during the month and services are provided over
a period of less than a month, 90951-90962 may be used
according to the number of visits performed.
Codes 90963-90966 are reported once per month for a full month
of service to distinguish age-specific services for end-stage renal
disease (ESRD) services for home dialysis patients.
For ESRD and non-ESRD dialysis services performed in an
inpatient setting, and for non-ESRD dialysis services performed
in an outpatient setting, see 90935-90937 and 90945-90947.
Evaluation and management services unrelated to ESRD services
that cannot be performed during the dialysis session may be
Codes 90967-90970 are reported to distinguish age-specific
services for end-stage renal disease (ESRD) services for less than
a full month of service, per day, for services provided under the
following circumstances: transient patients, partial month where
there was one or more face-to-face visits without the complete
assessment, the patient was hospitalized before a complete
assessment was furnished, dialysis was stopped due to recovery
or death, or the patient received a kidney transplant. For
reporting purposes, each month is considered 30 days.
Examples:
ESRD-related services:
ESRD-related services are initiated on July 1 for a 57-year-old
male. On July 11, he is admitted to the hospital as an inpatient
and is discharged on July 27. He has had a complete assessment
and the physician or other qualified health care professional has
performed two face-to-face visits prior to admission. Another
face-to-face visit occurs after discharge during the month.
In this example, 90961 is reported for the three face-to-face
outpatient visits. Report inpatient E/M services as appropriate.
Dialysis procedures rendered during the hospitalization (July 11-
27) should be reported as appropriate (90935-90937, 90945-
90947).
If the patient did not have a complete assessment during the
month or was a transient or dialysis was stopped due to recovery
or death, 90970 would be used to report each day outside the
inpatient hospitalization as described in the home dialysis
example below.
ESRD-related services for the home dialysis patient:
Home ESRD-related services are initiated on July 1 for a 57-year-
old male. On July 11, he is admitted to the hospital as an inpatient
and is discharged on July 27.
Report inpatient E/M services as appropriate. Dialysis procedures
rendered during the hospitalization (July 11-27) should be
reported as appropriate (90935-90937, 90945-90947).
▶ (Do not report 90951-90970 during the same month in
conjunction with 99439, 99487, 99489, 99490, 99491)◀
★ 90951 End-stage renal disease (ESRD) related services monthly,
for patients younger than 2 years of age to include
monitoring for the adequacy of nutrition, assessment of
growth and development, and counseling of parents; with 4
or more face-to-face visits by a physician or other qualified
health care professional per month
➲ CPT Assistant Apr 13:3, Nov 13:3, Oct 14:3, Feb 18:12
★ 90952 with 2-3 face-to-face visits by a physician or other

qualified health care professional per month
90953 with 1 face-to-face visit by a physician or other qualified


for patients 2-11 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and
development, and counseling of parents; with 4 or more
face-to-face visits by a physician or other qualified health
care professional per month



for patients 12-19 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and
development, and counseling of parents; with 4 or more
face-to-face visits by a physician or other qualified health
care professional per month



for patients 20 years of age and older; with 4 or more face-
to-face visits by a physician or other qualified health care
professional per month


90963 End-stage renal disease (ESRD) related services for home

dialysis per full month, for patients younger than 2 years of
age to include monitoring for the adequacy of nutrition,
assessment of growth and development, and counseling of
parents

dialysis per full month, for patients 2-11 years of age to
include monitoring for the adequacy of nutrition, assessment
of growth and development, and counseling of parents

dialysis per full month, for patients 12-19 years of age to
include monitoring for the adequacy of nutrition, assessment
of growth and development, and counseling of parents

dialysis per full month, for patients 20 years of age and
older
90967 End-stage renal disease (ESRD) related services for

dialysis less than a full month of service, per day; for
patients younger than 2 years of age
90968 for patients 2-11 years of age

90969 for patients 12-19 years of age

90970 for patients 20 years of age and older

➲ CPT Assistant Apr 13:3, Nov 13:3, Oct 14:3, Feb
18:12
Other Dialysis Procedures

90989 Dialysis training, patient, including helper where
applicable, any mode, completed course
90993 Dialysis training, patient, including helper where

applicable, any mode, course not completed, per training
session
➲ CPT Assistant Winter 90:11, Fall 93:5, Jun 01:10
90997 Hemoperfusion (eg, with activated charcoal or resin)

90999 Unlisted dialysis procedure, inpatient or outpatient
Gastroenterology
91010 Esophageal motility (manometric study of the esophagus
and/or gastroesophageal junction) study with interpretation
and report;
✚ 91013 with stimulation or perfusion (eg, stimulant, acid or

alkali perfusion) (List separately in addition to code for
primary procedure)

(To report esophageal motility studies with high resolution
esophageal pressure topography, use 91299)
91020 Gastric motility (manometric) studies
91022 Duodenal motility (manometric) study

(If gastrointestinal endoscopy is performed, use 43235)

(If fluoroscopy is performed, use 76000)
(If gastric motility study is performed, use 91020)
91030 Esophagus, acid perfusion (Bernstein) test for esophagitis
91034 Esophagus, gastroesophageal reflux test; with nasal catheter
pH electrode(s) placement, recording, analysis and
interpretation
Esophageal Acid Reflux Test

91034
A catheter with a pH electrode is placed into the esophagus, either through the nares or swallowed, to
measure intraesophageal pH (an indicator of gastric reflux).
91035 with mucosal attached telemetry pH electrode placement,

recording, analysis and interpretation
91037 Esophageal function test, gastroesophageal reflux test with

nasal catheter intraluminal impedance electrode(s)
placement, recording, analysis and interpretation;
91038 prolonged (greater than 1 hour, up to 24 hours)

91040 Esophageal balloon distension study, diagnostic, with
provocation when performed
➲ CPT Assistant May 05:3, Jan 17:7

91065 Breath hydrogen or methane test (eg, for detection of lactase
deficiency, fructose intolerance, bacterial overgrowth, or
oro-cecal gastrointestinal transit)
(Report 91065 once for each administered challenge)

(For H. pylori breath test analysis, use 83013 for non-
radioactive (C-13) isotope or 78268 for radioactive (C-14)
isotope)
(To report placement of an esophageal tamponade tube for
management of variceal bleeding, use 43460. To report
placement of a long intestinal Miller-Abbott tube, use
44500)
(For abdominal paracentesis, see 49082, 49083, 49084;
with instillation of medication, see 96440, 96446)
(For peritoneoscopy, use 49320; with biopsy, use 49321)
(For splenoportography, see 38200, 75810)
91110 Gastrointestinal tract imaging, intraluminal (eg, capsule
endoscopy), esophagus through ileum, with interpretation
and report
➲ CPT Assistant Oct 04:15, Aug 05:14, May 09:8, Sep
13:13
(Do not report 91110 in conjunction with 91111, 0355T)
(Visualization of the colon is not reported separately)
(Append modifier 52 if the ileum is not visualized)
91111 Gastrointestinal tract imaging, intraluminal (eg, capsule
endoscopy), esophagus with interpretation and report

(For measurement of gastrointestinal tract transit times or
pressure using wireless capsule, use 91112)
91112 Gastrointestinal transit and pressure measurement, stomach
through colon, wireless capsule, with interpretation and
report

91022, 91117)
91117 Colon motility (manometric) study, minimum 6 hours
continuous recording (including provocation tests, eg, meal,
intracolonic balloon distension, pharmacologic agents, if
performed), with interpretation and report
(For wireless capsule pressure measurements, use 91112)

91120 Rectal sensation, tone, and compliance test (ie, response to
graded balloon distention)
(For biofeedback training, see 90912, 90913)

(For anorectal manometry, use 91122)
91122 Anorectal manometry
Gastric Physiology
91132 Electrogastrography, diagnostic, transcutaneous;
91133 with provocative testing

Other Procedures
91200 Liver elastography, mechanically induced shear wave (eg,
vibration), without imaging, with interpretation and report

76983)
91299 Unlisted diagnostic gastroenterology procedure
Ophthalmology
(For surgical procedures, see Surgery, Eye and Ocular
Adnexa, 65091 et seq)
Definitions
Intermediate ophthalmological services describes an evaluation
of a new or existing condition complicated with a new diagnostic
or management problem not necessarily relating to the primary
diagnosis, including history, general medical observation,
external ocular and adnexal examination and other diagnostic
procedures as indicated; may include the use of mydriasis for
ophthalmoscopy.
For example:
a. Review of history, external examination, ophthalmoscopy,
biomicroscopy for an acute complicated condition (eg, iritis)
not requiring comprehensive ophthalmological services.
b. Review of interval history, external examination,
ophthalmoscopy, biomicroscopy and tonometry in established
patient with known cataract not requiring comprehensive
ophthalmological services.
Comprehensive ophthalmological services describes a general
evaluation of the complete visual system. The comprehensive
services constitute a single service entity but need not be
performed at one session. The service includes history, general
medical observation, external and ophthalmoscopic
examinations, gross visual fields and basic sensorimotor
examination. It often includes, as indicated: biomicroscopy,
examination with cycloplegia or mydriasis and tonometry. It
always includes initiation of diagnostic and treatment programs.
Intermediate and comprehensive ophthalmological services
constitute integrated services in which medical decision making
cannot be separated from the examining techniques used.
Itemization of service components, such as slit lamp examination,
keratometry, routine ophthalmoscopy, retinoscopy, tonometry, or
motor evaluation is not applicable.
For example:
The comprehensive services required for diagnosis and treatment
of a patient with symptoms indicating possible disease of the
visual system, such as glaucoma, cataract or retinal disease, or to
rule out disease of the visual system, new or established patient.
Initiation of diagnostic and treatment program includes the
prescription of medication, and arranging for special
ophthalmological diagnostic or treatment services, consultations,
laboratory procedures and radiological services.
Special ophthalmological services describes services in which a
special evaluation of part of the visual system is made, which
goes beyond the services included under general
ophthalmological services, or in which special treatment is given.
Special ophthalmological services may be reported in addition to
the general ophthalmological services or evaluation and
management services.
For example:
Fluorescein angioscopy, quantitative visual field examination,
refraction or extended color vision examination (such as Nagel’s
anomaloscope) should be separately reported.
Prescription of lenses, when required, is included in 92015. It
includes specification of lens type (monofocal, bifocal, other),
lens power, axis, prism, absorptive factor, impact resistance, and
other factors.
Interpretation and report by the physician or other qualified
health care professional is an integral part of special
ophthalmological services where indicated. Technical procedures
(which may or may not be performed personally) are often part
of the service, but should not be mistaken to constitute the
service itself.
General Ophthalmological Services

New Patient
(For distinguishing between new and established patients,
see Evaluation and Management guidelines)
92002 Ophthalmological services: medical examination and
evaluation with initiation of diagnostic and treatment
program; intermediate, new patient
➲ CPT Assistant Feb 97:6, Aug 98:3, Jun 05:11, Dec
05:10, Jan 07:30, Jan 08:1, Sep 08:7, Feb 11:10, Aug
12:9, Oct 12:9, Sep 17:15, Feb 18:3
99177, 0469T)
92004 comprehensive, new patient, 1 or more visits
05:10, Jan 07:30, Jan 08:1, Sep 08:7, Nov 10:8, Jan
11:9, Feb 11:10, Aug 12:9, Nov 16:9, Sep 17:15, Feb
18:3
99177, 0469T)
Established Patient
(For distinguishing between new and established patients,
see Evaluation and Management guidelines)
92012 Ophthalmological services: medical examination and
evaluation, with initiation or continuation of diagnostic and
treatment program; intermediate, established patient
05:10, Jan 07:30, Jan 08:1, Sep 08:7, Feb 11:10, Aug
12:9, Sep 17:15, Feb 18:3
99177, 0469T)
92014 comprehensive, established patient, 1 or more visits
➲ CPT Assistant Feb 97:6, Aug 98:3, Dec 99:10, Jun
05:11, Dec 05:10, Jan 07:30, Jan 08:1, Sep 08:7,
Nov 10:8, Jan 11:9, Feb 11:10, Aug 12:9, Oct 12:9,
Nov 16:9, Sep 17:15, Feb 18:3
99177, 0469T)
(For surgical procedures, see Surgery, Eye and Ocular
Adnexa, 65091 et seq)
Special Ophthalmological Services

92015 Determination of refractive state
➲ CPT Assistant Mar 96:11, Feb 97:6, Aug 98:3, Aug
06:11, Mar 13:6, Mar 16:11
99177)
(For instrument-based ocular screening, use 99174, 99177)
92018 Ophthalmological examination and evaluation, under general
anesthesia, with or without manipulation of globe for
passive range of motion or other manipulation to facilitate
diagnostic examination; complete
92019 limited
92020 Gonioscopy (separate procedure)

▶ (Do not report 92020 in conjunction with 0621T, 0622T)◀

(For gonioscopy under general anesthesia, use 92018)
92025 Computerized corneal topography, unilateral or bilateral,
with interpretation and report
➲ CPT Assistant Oct 10:10, Oct 12:9
(92025 is not used for manual keratoscopy, which is part of
a single system Evaluation and Management or
ophthalmological service)
92060 Sensorimotor examination with multiple measurements of
ocular deviation (eg, restrictive or paretic muscle with
diplopia) with interpretation and report (separate
procedure)
92065 Orthoptic and/or pleoptic training, with continuing medical

direction and evaluation
➲ CPT Assistant Feb 97:6, Jun 98:10, Aug 98:3
92071 Fitting of contact lens for treatment of ocular surface disease


(Report supply of lens separately with 99070 or appropriate
supply code)
92072 Fitting of contact lens for management of keratoconus, initial
fitting
(For subsequent fittings, report using evaluation and

management services or general ophthalmological services)
(Report supply of lens separately with 99070 or appropriate
supply code)
92081 Visual field examination, unilateral or bilateral, with
interpretation and report; limited examination (eg, tangent
screen, Autoplot, arc perimeter, or single stimulus level
automated test, such as Octopus 3 or 7 equivalent)
➲ CPT Assistant Feb 97:6, Aug 98:3, Sep 10:10, Oct 12:9
92082 intermediate examination (eg, at least 2 isopters on

Goldmann perimeter, or semiquantitative, automated
suprathreshold screening program, Humphrey
suprathreshold automatic diagnostic test, Octopus
program 33)
➲ CPT Assistant Feb 97:6, Aug 98:3, Oct 12:9
92083 extended examination (eg, Goldmann visual fields with

at least 3 isopters plotted and static determination within
the central 30°, or quantitative, automated threshold
perimetry, Octopus program G-1, 32 or 42, Humphrey
visual field analyzer full threshold programs 30-2, 24-2,
or 30/60-2)
➲ CPT Assistant Feb 97:6, Aug 98:3, Oct 12:9
(Gross visual field testing (eg, confrontation testing) is a

part of general ophthalmological services and is not
reported separately)
(For visual field assessment by patient activated data
transmission to a remote surveillance center, see 0378T,
0379T)
92100 Serial tonometry (separate procedure) with multiple
measurements of intraocular pressure over an extended time
period with interpretation and report, same day (eg, diurnal
curve or medical treatment of acute elevation of intraocular
pressure)
➲ CPT Assistant Feb 97:6, Jun 98:10, Aug 98:3, Aug 12:9,
15, Oct 12:9, May 14:5
(For monitoring of intraocular pressure for 24 hours or
longer, use 0329T)
(Ocular blood flow measurements are reported with 0198T.
Single-episode tonometry is a component of general
ophthalmological service or E/M service)
92132 Scanning computerized ophthalmic diagnostic imaging,
anterior segment, with interpretation and report, unilateral
or bilateral
➲ CPT Assistant Feb 11:6, Oct 12:9, Mar 13:6, Apr 13:7,
May 14:5
(For specular microscopy and endothelial cell analysis, use
92286)
(For tear film imaging, use 0330T)
92133 Scanning computerized ophthalmic diagnostic imaging,
posterior segment, with interpretation and report, unilateral
or bilateral; optic nerve
➲ CPT Assistant Feb 11:6, Oct 12:9, Nov 14:10
92134 retina
➲ CPT Assistant Feb 11:6, Oct 12:9, Nov 14:10
(Do not report 92133 and 92134 at the same patient

encounter)
(For scanning computerized ophthalmic diagnostic imaging
of the optic nerve and retina, see 92133, 92134)
92136 Ophthalmic biometry by partial coherence interferometry
with intraocular lens power calculation
➲ CPT Assistant Aug 98:3, Apr 02:18, Sep 09:5, May 14:5

92145 Corneal hysteresis determination, by air impulse
stimulation, unilateral or bilateral, with interpretation and
report
Ophthalmoscopy
Routine ophthalmoscopy is part of general and special
ophthalmologic services whenever indicated. It is a non-itemized
service and is not reported separately.
92201 Ophthalmoscopy, extended; with retinal drawing and scleral
depression of peripheral retinal disease (eg, for retinal tear,
retinal detachment, retinal tumor) with interpretation and
report, unilateral or bilateral
92202 with drawing of optic nerve or macula (eg, for glaucoma,

macular pathology, tumor) with interpretation and report,

92202)
★▲ 92227 Imaging of retina for detection or monitoring of disease;
with remote clinical staff review and report, unilateral or
bilateral
2021
➲ CPT Assistant Feb 11:7, May 11:9, Oct 12:9, Jul 16:9,
Aug 19:11
92228, 92229, 92250)◀
★▲ 92228 with remote physician or other qualified health care
professional interpretation and report, unilateral or
bilateral
➲ CPT Assistant Feb 11:7, May 11:9, Oct 12:9

92227, 92229, 92250)◀
● 92229 point-of-care automated analysis and report, unilateral or
bilateral

92227, 92228, 92250)◀
92230 Fluorescein angioscopy with interpretation and report
Extended Ophthalmoscopy
92201, 92202
Example of clinical drawing of peripheral retinal disease

Example of clinical drawing of optic nerve or macular (posterior pole) pathology
92235 Fluorescein angiography (includes multiframe imaging) with

interpretation and report, unilateral or bilateral
➲ CPT Assistant Feb 97:6, Feb 11:6, Jun 17:8
(When fluorescein and indocyanine-green angiography are

performed at the same patient encounter, use 92242)
Fluorescein Angiography
92235
Fluorescein dye is injected in a peripheral vein to enhance imaging. Serial multiframe angiography is
performed to evaluate choroidal and retinal circulation. In this illustration, arteries display an even
fluorescence, while veins appear striped from the laminar dye flow.
92240 Indocyanine-green angiography (includes multiframe

imaging) with interpretation and report, unilateral or
bilateral
➲ CPT Assistant Feb 11:6, Oct 12:9, Jun 17:8
(When indocyanine-green and fluorescein angiography are

performed at the same patient encounter, use 92242)
92242 Fluorescein angiography and indocyanine-green angiography
(includes multiframe imaging) performed at the same patient
encounter with interpretation and report, unilateral or
bilateral
(To report fluorescein angiography and indocyanine-green

angiography not performed at the same patient encounter, see
92235, 92240)
92250 Fundus photography with interpretation and report
➲ CPT Assistant Feb 97:6, Apr 99:10, Feb 11:6, Oct 12:9,
Nov 14:10, Dec 14:17, May 15:9, Jul 16:9
92260 Ophthalmodynamometry
(For ophthalmoscopy under general anesthesia, use 92018)
Other Specialized Services

▶For prescription, fitting, and/or medical supervision of ocular
prosthetic (artificial eye) adaptation by a physician, see evaluation
and management services including office or other outpatient
services (99202-99215), office or other outpatient consultations
(99241-99245), or general ophthalmological service codes 92002-
92014.◀
Electroretinography (ERG) is used to evaluate function of the
retina and optic nerve of the eye, including photoreceptors and
ganglion cells. A number of techniques are used which target
different areas of the eye, including full field (flash and flicker)
(92273) for a global response of photoreceptors of the retina,
multifocal (92274) for photoreceptors in multiple separate
locations in the retina including the macula, and pattern (0509T)
for retinal ganglion cells. Multiple additional terms and
techniques are used to describe various types of ERG. If the
technique used is not specifically named in the code descriptors
for 92273, 92274, or 0509T, use the unlisted procedure code
92499.
92265 Needle oculoelectromyography, 1 or more extraocular
muscles, 1 or both eyes, with interpretation and report
92270 Electro-oculography with interpretation and report

➲ CPT Assistant Feb 97:6, Aug 08:12, May 09:9, Oct 12:9,
Sep 15:7, Apr 20:7
(For vestibular function tests with recording, see 92537,
92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547,
92548)
92540, 92541, 92542, 92544, 92545, 92546, 92547, 92548,
92549)
(To report saccadic eye movement testing with recording,
use 92700)
92273 Electroretinography (ERG), with interpretation and report;
full field (ie, ffERG, flash ERG, Ganzfeld ERG)
92274 multifocal (mfERG)

(For pattern ERG, use 0509T)

(92275 has been deleted. To report electroretinography, see
92273, 92274, 0509T)
(For electronystagmography for vestibular function studies,
see 92541 et seq)
(For ophthalmic echography (diagnostic ultrasound), see
76511-76529)
92283 Color vision examination, extended, eg, anomaloscope or
equivalent
(Color vision testing with pseudoisochromatic plates [such

as HRR or Ishihara] is not reported separately. It is included
in the appropriate general or ophthalmological service, or
99172)
92284 Dark adaptation examination with interpretation and report
92285 External ocular photography with interpretation and report

for documentation of medical progress (eg, close-up
photography, slit lamp photography, goniophotography,
stereo-photography)
➲ CPT Assistant Feb 97:6, Sep 97:10, Oct 12:9, May 14:5

(For meibomian gland imaging, use 0507T)
92286 Anterior segment imaging with interpretation and report;
with specular microscopy and endothelial cell analysis
➲ CPT Assistant Feb 97:6, Oct 12:9, Mar 13:6
92287 with fluorescein angiography

Contact Lens Services

The prescription of contact lens includes specification of optical
and physical characteristics (such as power, size, curvature,
flexibility, gas-permeability). It is not a part of the general
ophthalmological services.
The fitting of contact lens includes instruction and training of the
wearer and incidental revision of the lens during the training
period.
Follow-up of successfully fitted extended wear lenses is reported
as part of a general ophthalmological service (92012 et seq).
The supply of contact lenses may be reported as part of the
service of fitting. It may also be reported separately by using the
appropriate supply codes.
(For therapeutic or surgical use of contact lens, see 68340,
92071, 92072)
92310 Prescription of optical and physical characteristics of and
fitting of contact lens, with medical supervision of
adaptation; corneal lens, both eyes, except for aphakia
(For prescription and fitting of 1 eye, add modifier 52)

92311 corneal lens for aphakia, 1 eye
92312 corneal lens for aphakia, both eyes

92313 corneoscleral lens

92314 Prescription of optical and physical characteristics of

contact lens, with medical supervision of adaptation and
direction of fitting by independent technician; corneal lens,
both eyes except for aphakia
(For prescription and fitting of 1 eye, add modifier 52)

92315 corneal lens for aphakia, 1 eye
92316 corneal lens for aphakia, both eyes

92317 corneoscleral lens

92325 Modification of contact lens (separate procedure), with

medical supervision of adaptation
92326 Replacement of contact lens

Spectacle Services (Including Prosthesis

for Aphakia)
Prescription of lenses, when required, is included in 92015,
Determination of refractive state. It includes specification of lens
type (monofocal, bifocal, other), lens power, axis, prism,
absorptive factor, impact resistance, and other factors.
When provided, fitting of spectacles is a separate service and is
reported as indicated by 92340-92371.
Fitting includes measurement of anatomical facial characteristics,
the writing of laboratory specifications, and the final adjustment
of the spectacles to the visual axes and anatomical topography.
Presence of the physician or other qualified health care
professional is not required.
Supply of materials is a separate service component; it is not part
of the service of fitting spectacles.
92340 Fitting of spectacles, except for aphakia; monofocal
➲ CPT Assistant Feb 97:7, Aug 98:4, Mar 13:6
92341 bifocal
92342 multifocal, other than bifocal

92352 Fitting of spectacle prosthesis for aphakia; monofocal

92353 multifocal
92354 Fitting of spectacle mounted low vision aid; single element

system
92355 telescopic or other compound lens system

92358 Prosthesis service for aphakia, temporary (disposable or

loan, including materials)
92370 Repair and refitting spectacles; except for aphakia

92371 spectacle prosthesis for aphakia

Other Procedures
92499 Unlisted ophthalmological service or procedure
Special Otorhinolaryngologic Services

Diagnostic or treatment procedures that are reported as evaluation
and management services (eg, otoscopy, anterior rhinoscopy,
tuning fork test, removal of non-impacted cerumen) are not
▶Special otorhinolaryngologic services are those diagnostic and
treatment services not included in an evaluation and management
service, including office or other outpatient services (99202-
99215) or office or other outpatient consultations (99241-
99245).◀
Codes 92507, 92508, 92520, 92521, 92522, 92523, 92524, and
92526 are used to report evaluation and treatment of speech
sound production, receptive language, and expressive language
abilities, voice and resonance production, speech fluency, and
swallowing. Evaluations may include examination of speech
sound production, articulatory movements of oral musculature,
oral-pharyngeal swallowing function, qualitative analysis of
voice and resonance, and measures of frequency, type, and
duration of stuttering. Evaluations may also include the patient’s
ability to understand the meaning and intent of written and verbal
expressions, as well as the appropriate formulation and utterance
of expressive thought. In contrast, 92626 and 92627 are reported
for an evaluation of auditory rehabilitation status determining the
patient’s ability to use residual hearing in order to identify the
acoustic characteristics of sounds associated with speech
communication.
(For laryngoscopy with stroboscopy, use 31579)
92502 Otolaryngologic examination under general anesthesia
92504 Binocular microscopy (separate diagnostic procedure)

➲ CPT Assistant Jul 05:14, Oct 11:10, Oct 13:14, Sep 16:6
92507 Treatment of speech, language, voice, communication,

and/or auditory processing disorder; individual
➲ CPT Assistant Dec 04:14, Jan 06:7, Oct 13:7, Sep 16:6,
Nov 18:3, Dec 18:7
92508 group, 2 or more individuals
➲ CPT Assistant Dec 04:14, Oct 13:7, Sep 16:6, Nov
18:3
(For auditory rehabilitation, prelingual hearing loss, use
92630)
(For auditory rehabilitation, postlingual hearing loss, use
92633)
(For cochlear implant programming, see 92601-92604)
92511 Nasopharyngoscopy with endoscope (separate procedure)

43198)
▶ (For nasopharyngoscopy, surgical, with dilation of
eustachian tube, see 69705, 69706)◀
92512 Nasal function studies (eg, rhinomanometry)
92516 Facial nerve function studies (eg, electroneuronography)


92520 Laryngeal function studies (ie, aerodynamic testing and
acoustic testing)
➲ CPT Assistant Dec 04:17, Jan 06:7, Sep 16:6
(For performance of a single test, use modifier 52)

(To report flexible fiberoptic laryngeal evaluation of
swallowing and laryngeal sensory testing, see 92611-
92617)
(To report other testing of laryngeal function (eg,
electroglottography), use 92700)
92521 Evaluation of speech fluency (eg, stuttering, cluttering)
92522 Evaluation of speech sound production (eg, articulation,

phonological process, apraxia, dysarthria);
92523 with evaluation of language comprehension and

expression (eg, receptive and expressive language)
92524 Behavioral and qualitative analysis of voice and resonance

92526 Treatment of swallowing dysfunction and/or oral function

for feeding
Vestibular Function Tests, Without

Electrical Recording
92531 Spontaneous nystagmus, including gaze
92532 Positional nystagmus test
▶ (Do not report 92531, 92532 with evaluation and

management services including office or other outpatient
services [99202-99215], observation care [99218-99220,
99224-99226], observation or inpatient care including
admission and discharge [99234-99236], hospital care
[99221-99223, 99231-99233], office or other outpatient
consultations [99241-99245], nursing facility services
[99304-99318], and domiciliary, rest home, or custodial
care services [99324-99337])◀
92533 Caloric vestibular test, each irrigation (binaural, bithermal
stimulation constitutes 4 tests)
92534 Optokinetic nystagmus test

Vestibular Function Tests, With Recording

(eg, ENG)
92537 Caloric vestibular test with recording, bilateral; bithermal
(ie, one warm and one cool irrigation in each ear for a total
of four irrigations)

(For three irrigations, use modifier 52)
(For monothermal caloric vestibular testing, use 92538)
92538 monothermal (ie, one irrigation in each ear for a total of
two irrigations)

(For one irrigation, use modifier 52)
(For bilateral, bithermal caloric vestibular testing, use
92537)
92540 Basic vestibular evaluation, includes spontaneous nystagmus
test with eccentric gaze fixation nystagmus, with recording,
positional nystagmus test, minimum of 4 positions, with
recording, optokinetic nystagmus test, bidirectional foveal
and peripheral stimulation, with recording, and oscillating
tracking test, with recording

92542, 92544, 92545)
92541 Spontaneous nystagmus test, including gaze and fixation
nystagmus, with recording
➲ CPT Assistant Feb 05:13, Aug 08:12, May 11:10, Sep
15:7
(Do not report 92541 in conjunction with 92270, 92540 or
the set of 92542, 92544, and 92545)
92542 Positional nystagmus test, minimum of 4 positions, with
recording
➲ CPT Assistant Feb 05:13, Aug 08:12, Sep 10:9, Sep
15:7
the set of 92541, 92544, and 92545)
92544 Optokinetic nystagmus test, bidirectional, foveal or
peripheral stimulation, with recording
➲ CPT Assistant Feb 05:13, Aug 08:12, Sep 15:7

the set of 92541, 92542, and 92545)
92545 Oscillating tracking test, with recording
➲ CPT Assistant Feb 05:13, Aug 08:12, May 11:10, Sep
15:7
the set of 92541, 92542, and 92544)
92546 Sinusoidal vertical axis rotational testing
CPT Assistant Sep 04:13, Feb 05:13, Aug 08:12, May
➲ 11:10, Jun 13:14, Sep 15:7
✚ 92547 Use of vertical electrodes (List separately in addition to
➲ CPT Assistant May 04:14, Feb 05:13, Aug 08:12, Sep
15:7
(For unlisted vestibular tests, use 92700)
92548 Computerized dynamic posturography sensory organization
test (CDP-SOT), 6 conditions (ie, eyes open, eyes closed,
visual sway, platform sway, eyes closed platform sway,
platform and visual sway), including interpretation and
report;
➲ CPT Assistant May 11:10, Sep 15:7, Apr 20:7
92549 with motor control test (MCT) and adaptation test (ADT)

#● 92517 Vestibular evoked myogenic potential (VEMP) testing, with
interpretation and report; cervical (cVEMP)

92519)◀
#● 92518 ocular (oVEMP)

92519)◀
#● 92519 cervical (cVEMP) and ocular (oVEMP)

92518)◀
Audiologic Function Tests

The audiometric tests listed below require the use of calibrated
electronic equipment, recording of results and a report with
interpretation. Hearing tests (such as whispered voice, tuning
fork) that are otorhinolaryngologic Evaluation and Management
services are not reported separately. All services include testing
of both ears. Use modifier 52 if a test is applied to one ear instead
of two ears. All codes (except 92559) apply to testing of
individuals. For testing of groups, use 92559 and specify test(s)
used.
(For evaluation of speech, language, and/or hearing
problems through observation and assessment of
performance, see 92521, 92522, 92523, 92524)
92550 Tympanometry and reflex threshold measurements

92551 Screening test, pure tone, air only
92552 Pure tone audiometry (threshold); air only

92553 air and bone

92555 Speech audiometry threshold;

92556 with speech recognition
92557 Comprehensive audiometry threshold evaluation and speech

recognition (92553 and 92556 combined)
➲ CPT Assistant Sep 07:11, Mar 11:8, Aug 14:3
(For hearing aid evaluation and selection, see 92590-

92595)
(For automated audiometry, see 0208T-0212T)
Coding Tip
Instructions for Reporting Group Testing
For testing of groups, use 92559 and specify test(s) used.
CPT Coding Guidelines, Special Otorhinolaryngologic Service, Audiologic

Function Tests

92559 Audiometric testing of groups
92560 Bekesy audiometry; screening

92561 diagnostic
92562 Loudness balance test, alternate binaural or monaural

➲ CPT Assistant Mar 05:7, 9, Aug 14:3
92563 Tone decay test

92564 Short increment sensitivity index (SISI)
92565 Stenger test, pure tone

92567 Tympanometry (impedance testing)

➲ CPT Assistant Winter 90:11, Aug 14:3
92568 Acoustic reflex testing, threshold

➲ CPT Assistant Jan 06:7, Sep 07:11, Jun 09:10, Aug 14:3
92570 Acoustic immittance testing, includes tympanometry

(impedance testing), acoustic reflex threshold testing, and
acoustic reflex decay testing

92571 Filtered speech test
92572 Staggered spondaic word test

92575 Sensorineural acuity level test

92576 Synthetic sentence identification test

92577 Stenger test, speech

92579 Visual reinforcement audiometry (VRA)

92582 Conditioning play audiometry

92583 Select picture audiometry
92584 Electrocochleography
▶ (92585 has been deleted. To report, see 92652, 92653)◀

▶ (92586 has been deleted. To report, see 92650, 92651)◀
#● 92650 Auditory evoked potentials; screening of auditory potential
with broadband stimuli, automated analysis
#● 92651 for hearing status determination, broadband stimuli, with

interpretation and report
#● 92652 for threshold estimation at multiple frequencies, with


#● 92653 neurodiagnostic, with interpretation and report
# 92558 Evoked otoacoustic emissions, screening (qualitative

measurement of distortion product or transient evoked
otoacoustic emissions), automated analysis
92587 Distortion product evoked otoacoustic emissions; limited

evaluation (to confirm the presence or absence of hearing
disorder, 3-6 frequencies) or transient evoked otoacoustic
emissions, with interpretation and report
92588 comprehensive diagnostic evaluation (quantitative

analysis of outer hair cell function by cochlear mapping,
minimum of 12 frequencies), with interpretation and
report
(For central auditory function evaluation, see 92620, 92621)

92590 Hearing aid examination and selection; monaural
92591 binaural
92592 Hearing aid check; monaural
92593 binaural
92594 Electroacoustic evaluation for hearing aid; monaural
92595 binaural
92596 Ear protector attenuation measurements

Evaluative and Therapeutic Services

Codes 92601 and 92603 describe post-operative analysis and
fitting of previously placed external devices, connection to the
cochlear implant, and programming of the stimulator. Codes
92602 and 92604 describe subsequent sessions for measurements
and adjustment of the external transmitter and re-programming of
the internal stimulator.
(For placement of cochlear implant, use 69930)
92601 Diagnostic analysis of cochlear implant, patient younger
than 7 years of age; with programming
CPT Assistant Mar 03:1, Jan 06:7, Jul 11:17, Oct 13:7,
➲ Jul 14:4, Mar 20:15
92602 subsequent reprogramming
➲ CPT Assistant Mar 03:1, 21, Jan 06:7, Oct 13:7, Mar
20:15
(For aural rehabilitation services following cochlear
implant, including evaluation of rehabilitation status, see
92626-92627, 92630-92633)
92603 Diagnostic analysis of cochlear implant, age 7 years or
older; with programming
➲ CPT Assistant Mar 03:2, 4, Jan 06:7, Jul 11:17, Oct
13:7, Mar 20:15
92604 subsequent reprogramming
➲ CPT Assistant Mar 03:2, 21, Jan 06:7, Jul 11:17, Oct
13:7, Jul 14:4, Mar 20:15
A View of the Outer Cochlear Implant

92601-92604
An example of the elements that are addressed in the diagnostic analysis and reprogramming of the
cochlear implant
# 92597 Evaluation for use and/or fitting of voice prosthetic device
to supplement oral speech
(To report augmentative and alternative communication
device services, see 92605, 92607, 92608, 92618)
92605 Evaluation for prescription of non-speech-generating
augmentative and alternative communication device, face-
to-face with the patient; first hour
➲ CPT Assistant Mar 03:2, 4, Oct 13:7
(To report evaluation for use and/or fitting of voice

prosthetic device, use 92597)

92606 Therapeutic service(s) for the use of non-speech-generating
device, including programming and modification
➲ CPT Assistant Mar 03:2, 4
92607 Evaluation for prescription for speech-generating
augmentative and alternative communication device, face-
to-face with the patient; first hour
➲ CPT Assistant Mar 03:2, 4, Dec 04:16, Oct 13:7
(To report evaluation for use and/or fitting of voice

prosthetic device, use 92597)
(For evaluation for prescription of a non-speech-generating
device, use 92605)
➲ CPT Assistant Mar 03:2, 5, Dec 04:16, Oct 13:7

92609 Therapeutic services for the use of speech-generating
device, including programming and modification
➲ CPT Assistant Mar 03:2, 4, Dec 04:16
(For therapeutic service(s) for the use of a non-speech-

generating device, use 92606)
92610 Evaluation of oral and pharyngeal swallowing function
(For motion fluoroscopic evaluation of swallowing function,

use 92611)
(For flexible endoscopic examination, use 92612-92617)
92611 Motion fluoroscopic evaluation of swallowing function by
cine or video recording
➲ CPT Assistant Mar 03:2, 5, Dec 04:17, Jan 06:7, Jul
14:5, Apr 17:8
18:14
(For evaluation of oral and pharyngeal swallowing function,
use 92610)
(For flexible diagnostic laryngoscopy, use 31575)
92612 Flexible endoscopic evaluation of swallowing by cine or
video recording;
➲ CPT Assistant Mar 03:6, Jan 06:7, Apr 17:8
(If flexible endoscopic evaluation of swallowing is

performed without cine or video recording, use 92700)
92613 interpretation and report only
(To report an evaluation of oral and pharyngeal swallowing

function, use 92610)
(To report motion fluoroscopic evaluation of swallowing
function, use 92611)
92614 Flexible endoscopic evaluation, laryngeal sensory testing by
cine or video recording;

92616 Flexible endoscopic evaluation of swallowing and laryngeal

sensory testing by cine or video recording;


92620 Evaluation of central auditory function, with report; initial
60 minutes
➲ CPT Assistant Mar 05:7-8, Aug 14:3


92522, 92523, 92524)
92625 Assessment of tinnitus (includes pitch, loudness matching,
and masking)
➲ CPT Assistant Mar 05:7-10, Aug 14:3
(For unilateral assessment, use modifier 52)
92626 Evaluation of auditory function for surgically implanted
device(s) candidacy or postoperative status of a surgically
implanted device(s); first hour
➲ CPT Assistant Jan 06:7, May 14:10, Jul 14:4, Sep 16:7,
Mar 20:15
➲ CPT Assistant Jan 06:7, Jul 14:4, Sep 16:7, Mar
20:15
(When reporting 92626, 92627, use the face-to-face time
with the patient or family)
92591, 92592, 92593, 92594, 92595 for hearing aid
evaluation, fitting, follow-up, or selection)
92630 Auditory rehabilitation; prelingual hearing loss
92633 postlingual hearing loss

Special Diagnostic Procedures

92640 Diagnostic analysis with programming of auditory brainstem
implant, per hour
(Report nonprogramming services separately [eg, cardiac
monitoring])
Other Procedures
92700 Unlisted otorhinolaryngological service or procedure
➲ CPT Assistant Sep 04:14, Oct 04:10, Jan 06:7, Sep
06:13, Sep 07:11, Mar 11:10, Jul 11:17, May 14:10, Sep
15:15, Apr 17:8
Cardiovascular
Therapeutic Services and Procedures
Other Therapeutic Services and Procedures
92950 Cardiopulmonary resuscitation (eg, in cardiac arrest)
➲ CPT Assistant Jan 96:7, Oct 04:14, Nov 07:5, Jul 12:13, Sep 12:17
(See also critical care services, 99291, 99292)

92953 Temporary transcutaneous pacing
➲ CPT Assistant Nov 99:49, Feb 07:10, Jul 07:1, May 14:4, Aug 19:8
(For direction of ambulance or rescue personnel outside the hospital by a physician or other
qualified health care professional, use 99288)
92960 Cardioversion, elective, electrical conversion of arrhythmia; external
➲ CPT Assistant Summer 93:13, Nov 99:49, Jun 00:5, Nov 00:9, Jul 01:11, Jan 12:13
92961 internal (separate procedure)

➲ CPT Assistant Summer 93:13, Nov 99:49, Jun 00:5, Jul 00:5, Nov 00:9, Feb 15:3
(Do not report 92961 in conjunction with 93282-93284, 93287, 93289, 93295, 93296, 93618-
93624, 93631, 93640-93642, 93650, 93653-93657, 93662)
92970 Cardioassist-method of circulatory assist; internal
92971 external
▶ (For balloon atrial septostomy, use 33741)◀
(For placement of catheters for use in circulatory assist devices such as intra-aortic balloon pump,
use 33970)
92986 Percutaneous balloon valvuloplasty; aortic valve
92987 mitral valve

92990 pulmonary valve

➲ CPT Assistant Winter 91:3, Feb 15:3, Jul 15:11
▶ (92992, 92993 have been deleted)◀

▶ (For atrial septectomy or septostomy, transvenous method, balloon or blade, use 33741)◀
92997 Percutaneous transluminal pulmonary artery balloon angioplasty; single vessel
➲ CPT Assistant Nov 97:44, Feb 15:3, Mar 16:5
✚ 92998 each additional vessel (List separately in addition to code for primary procedure)
➲ CPT Assistant Nov 97:44, Feb 15:3, Mar 16:5
Coronary Therapeutic Services and Procedures

Codes 92920-92944 describe percutaneous revascularization services performed for occlusive
disease of the coronary vessels (major coronary arteries, coronary artery branches, or coronary
artery bypass grafts). These percutaneous coronary intervention (PCI) codes are built on
progressive hierarchies with more intensive services inclusive of lesser intensive services. These
PCI codes all include the work of accessing and selectively catheterizing the vessel, traversing the
lesion, radiological supervision and interpretation directly related to the intervention(s) performed,
closure of the arteriotomy when performed through the access sheath, and imaging performed to
document completion of the intervention in addition to the intervention(s) performed. These codes
include angioplasty (eg, balloon, cutting balloon, wired balloons, cryoplasty), atherectomy (eg,
directional, rotational, laser), and stenting (eg, balloon expandable, self-expanding, bare metal,
drug eluting, covered). Each code in this family includes balloon angioplasty, when performed.
Diagnostic coronary angiography may be reported separately under specific circumstances.
Diagnostic coronary angiography codes (93454-93461) and injection procedure codes (93563-
93564) should not be used with percutaneous coronary revascularization services (92920-92944) to
report:
1. Contrast injections, angiography, roadmapping, and/or fluoroscopic guidance for the coronary
intervention,
2. Vessel measurement for the coronary intervention, or
3. Post-coronary angioplasty/stent/atherectomy angiography, as this work is captured in the
percutaneous coronary revascularization services codes (92920-92944).
Diagnostic angiography performed at the time of a coronary interventional procedure may be
separately reportable if:
1. No prior catheter-based coronary angiography study is available, and a full diagnostic study is
performed, and a decision to intervene is based on the diagnostic angiography, or
2. A prior study is available, but as documented in the medical record:
a. The patient’s condition with respect to the clinical indication has changed since the prior
study, or
b. There is inadequate visualization of the anatomy and/or pathology, or
c. There is a clinical change during the procedure that requires new evaluation outside the target
area of intervention.
Diagnostic coronary angiography performed at a separate session from an interventional procedure
is separately reportable.
Major coronary arteries: The major coronary arteries are the left main, left anterior descending,
left circumflex, right, and ramus intermedius arteries. All PCI procedures performed in all
segments (proximal, mid, distal) of a single major coronary artery through the native coronary
circulation are reported with one code. When one segment of a major coronary artery is treated
through the native circulation and treatment of another segment of the same artery requires access
through a coronary artery bypass graft, the intervention through the bypass graft is reported
separately.
Coronary artery branches: Up to two coronary artery branches of the left anterior descending
(diagonals), left circumflex (marginals), and right (posterior descending, posterolaterals) coronary
arteries are recognized. The left main and ramus intermedius coronary arteries do not have
recognized branches for reporting purposes. All PCI(s) performed in any segment (proximal, mid,
distal) of a coronary artery branch is reported with one code. PCI is reported for up to two
branches of a major coronary artery. Additional PCI in a third branch of the same major coronary
artery is not separately reportable.
Coronary artery bypass grafts: Each coronary artery bypass graft represents a coronary vessel. A
sequential bypass graft with more than one distal anastomosis represents only one graft. A
branching bypass graft (eg, Y graft) represents a coronary vessel for the main graft, and each
branch off the main graft constitutes an additional coronary vessel. PCI performed on major
coronary arteries or coronary artery branches by access through a bypass graft is reported using the
bypass graft PCI codes. All bypass graft PCI codes include the use of coronary artery embolic
protection devices when performed.
Only one base code from this family may be reported for revascularization of a major coronary
artery and its recognized branches. Only one base code should be reported for revascularization of
a coronary artery bypass graft, its subtended coronary artery, and recognized branches of the
subtended coronary artery. If one segment of a major coronary artery and its recognized branches
is treated through the native circulation, and treatment of another segment of the same vessel
requires access through a coronary artery bypass graft, an additional base code is reported to
describe the intervention performed through the bypass graft. The PCI base codes are 92920,
92924, 92928, 92933, 92937, 92941, and 92943. The PCI base code that includes the most intensive
service provided for the target vessel should be reported. The hierarchy of these services is built on
an intensity of service ranked from highest to lowest as 92943 = 92941 = 92933 > 92924 > 92937 =
92928 > 92920.
PCI performed during the same session in additional recognized branches of the target vessel
should be reported using the applicable add-on code(s). The add-on codes are 92921, 92925,
92928, 92934, 92938, and 92944 and follow the same principle in regard to reporting the most
intensive service provided. The intensity of service is ranked from highest to lowest as 92944 =
92938 > 92934 > 92925 > 92929 > 92921.
PCI performed during the same session in additional major coronary or in additional coronary
artery bypass grafts should be reported using the applicable additional base code(s). PCI
performed during the same session in additional coronary artery branches should be reported using
the applicable additional add-on code(s).
If a single lesion extends from one target vessel (major coronary artery, coronary artery bypass
graft, or coronary artery branch) into another target vessel, but can be revascularized with a single
intervention bridging the two vessels, this PCI should be reported with a single code despite
treating more than one vessel. For example, if a left main coronary lesion extends into the proximal
left circumflex coronary artery and a single stent is placed to treat the entire lesion, this PCI should
be reported as a single vessel stent (92928). In this example, a code for additional vessel treatment
(92929) would not be additionally reported.
When bifurcation lesions are treated, PCI is reported for both vessels treated. For example, when a
bifurcation lesion involving the left anterior descending artery and the first diagonal artery is
treated by stenting both vessels, 92928 and 92929 are both reported.
Target vessel PCI for acute myocardial infarction is inclusive of all balloon angioplasty,
atherectomy, stenting, manual aspiration thrombectomy, distal protection, and intracoronary
rheolytic agent administration performed. Mechanical thrombectomy is reported separately.
Chronic total occlusion of a coronary vessel is present when there is no antegrade flow through the
true lumen, accompanied by suggestive angiographic and clinical criteria (eg, antegrade “bridging”
collaterals present, calcification at the occlusion site, no current presentation with ST elevation or
Q wave acute myocardial infarction attributable to the occluded target lesion). Current presentation
with ST elevation or Q wave acute myocardial infarction attributable to the occluded target lesion,
subtotal occlusion, and occlusion with dye staining at the site consistent with fresh thrombus are
not considered chronic total occlusion.
Codes 92973 (percutaneous transluminal coronary thrombectomy, mechanical), 92974 (coronary
brachytherapy), 92978 and 92979 (intravascular ultrasound/optical coherence tomography), and
93571 and 93572 (intravascular Doppler velocity and/or pressure [fractional flow reserve (FFR) or
coronary flow reserve (CFR)]) are add-on codes for reporting procedures performed in addition to
coronary and bypass graft diagnostic and interventional services, unless included in the base code.
Non-mechanical, aspiration thrombectomy is not reported with 92973, and is included in the PCI
code for acute myocardial infarction (92941), when performed.
(To report transcatheter placement of radiation delivery device for coronary intravascular
(For intravascular radioelement application, see 77770, 77771, 77772)
(For nonsurgical septal reduction therapy [eg, alcohol ablation], use 93799)
# 92920 Percutaneous transluminal coronary angioplasty; single major coronary artery or branch
#✚ 92921 each additional branch of a major coronary artery (List separately in addition to code for
primary procedure)
➲ CPT Assistant Jan 13:3, Sep 14:14, Dec 14:6
(Use 92921 in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943)
# 92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single
major coronary artery or branch
primary procedure)
(Use 92925 in conjunction with 92924, 92928, 92933, 92937, 92941, 92943)
# 92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when
performed; single major coronary artery or branch
➲ CPT Assistant Jan 13:3, Jan 14:3, Mar 14:14, Sep 14:14, Dec 14:6, Jan 17:7, Feb 17:15
primary procedure)
➲ CPT Assistant Jan 13:3, Sep 14:14, Dec 14:6, Jan 17:7
(Use 92929 in conjunction with 92928, 92933, 92937, 92941, 92943)

# 92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary
angioplasty when performed; single major coronary artery or branch
primary procedure)
(Use 92934 in conjunction with 92933, 92937, 92941, 92943)

# 92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal
mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and
angioplasty, including distal protection when performed; single vessel
➲ CPT Assistant Jan 13:3, Mar 14:14, Dec 14:6, Feb 17:15
#✚ 92938 each additional branch subtended by the bypass graft (List separately in addition to code for
primary procedure)
➲ CPT Assistant Jan 13:3, Mar 14:14, Sep 14:14, Dec 14:6

# 92941 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute
myocardial infarction, coronary artery or coronary artery bypass graft, any combination of
intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when
performed, single vessel
➲ CPT Assistant Jan 13:3, Jan 14:3, Mar 14:14, Dec 14:6, Feb 17:14
(For additional vessels treated, see 92920-92938, 92943, 92944)

# 92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary
artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy
and angioplasty; single vessel
#✚ 92944 each additional coronary artery, coronary artery branch, or bypass graft (List separately in
(Use 92944 in conjunction with 92924, 92928, 92933, 92937, 92941, 92943)
(To report transcatheter placement of radiation delivery device for coronary intravascular
#✚ 92973 Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition to code
➲ CPT Assistant Mar 02:2, 10, Mar 04:10, Dec 14:6, Feb 17:14
(Use 92973 in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975, 93454-
93461, 93563, 93564)
(Do not report 92973 for aspiration thrombectomy)
#✚ 92974 Transcatheter placement of radiation delivery device for subsequent coronary intravascular
brachytherapy (List separately in addition to code for primary procedure)
(Use 92974 in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 93454-93461)
# 92975 Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography
# 92977 by intravenous infusion

(For thrombolysis of vessels other than coronary, see 37211-37214)
(For cerebral thrombolysis, use 37195)
#✚ 92978 Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical
coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including
imaging supervision, interpretation and report; initial vessel (List separately in addition to code for
primary procedure)
➲ CPT Assistant Nov 97:43-44, Nov 99:49, Dec 13:18, Dec 14:6

93461, 93563, 93564)
Intravascular Ultrasound (Coronary Vessel or Graft)

92978
A catheter with a transducer at its tip is inserted and threaded through a selected coronary artery(s) or coronary bypass graft(s).
#✚ 92979 each additional vessel (List separately in addition to code for primary procedure)
➲ CPT Assistant Nov 97:43-44, Nov 99:49, Dec 13:18, Dec 14:6
(Report 92979 once per additional vessel)

(Intravascular ultrasound and optical coherence tomography services include all transducer
manipulations and repositioning within the specific vessel being examined, both before and after
therapeutic intervention [eg, stent placement])
Cardiography
Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm
strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.
There must be a specific order for an electrocardiogram or rhythm strip followed by a separate,
signed, written, and retrievable report. It is not appropriate to use these codes for reviewing the
telemetry monitor strips taken from a monitoring system. The need for an electrocardiogram or
rhythm strip should be supported by documentation in the patient medical record.
(For echocardiography, see 93303-93350)
(For acoustic cardiography services, use 93799)
93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
➲ CPT Assistant Aug 97:9, Feb 05:9, Mar 05:1, 11, Jul 08:3
93005 tracing only, without interpretation and report

➲ CPT Assistant Aug 97:9, Mar 05:1, Apr 16:8

➲ CPT Assistant Aug 97:9, Mar 05:1, Apr 07:1, Apr 16:8
(For ECG monitoring, see 99354-99360)

(Do not report 93000, 93005, 93010 in conjunction with, 0525T, 0526T, 0527T, 0528T, 0529T,
0530T, 0531T, 0532T)
93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous
electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation
and report
➲ CPT Assistant Apr 96:11, Jun 96:10, Aug 02:10, Jul 08:3, Jan 10:8, May 10:6
93016 supervision only, without interpretation and report

➲ CPT Assistant Apr 96:11, Aug 02:10, Jul 08:3, Jan 10:8, May 10:6
93017 tracing only, without interpretation and report

➲ CPT Assistant Aug 02:10, Jul 08:3, Jan 10:8, May 10:6

➲ CPT Assistant Apr 96:11, Jun 96:10, Jul 08:3, Jan 10:8, May 10:6
93024 Ergonovine provocation test

93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias
Coding Tip
Instructions for Reporting Electrocardiographic Recording
Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to
help diagnose the presence or absence of an arrhythmia, and a report is generated. There must be a specific order for
an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report. It is not
appropriate to use these codes for reviewing the telemetry monitor strips taken from a monitoring system. The need
for an electrocardiogram or rhythm strip should be supported by documentation in the patient medical record.
CPT Coding Guidelines, Cardiovascular, Cardiography
93040 Rhythm ECG, 1-3 leads; with interpretation and report

➲ CPT Assistant Apr 04:8, Oct 10:10, Nov 12:6
93041 tracing only without interpretation and report


➲ CPT Assistant Apr 04:8, Oct 10:10, Oct 11:7
Coding Tip
Instructions for Reporting Electrocardiographic Recording
Do not report 93268-93272 when performing 93260, 93261, 93279-93289, 93291-93296, or 93298. Do not report
93040, 93041, 93042 when performing 93260, 93261, 93279-93289, 93291-93296, or 93298.
CPT Coding Guidelines, Cardiovascular, Implantable, Insertable, and Wearable Cardiac Device Evaluations
93050 Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining
waveform(s), digitization and application of nonlinear mathematical transformations to determine
central arterial pressures and augmentation index, with interpretation and report, upper extremity
artery, non-invasive
(Do not report 93050 in conjunction with diagnostic or interventional intra-arterial procedures)
Cardiovascular Monitoring Services

▶Cardiovascular monitoring services are diagnostic medical procedures using in-person and
remote technology to assess cardiovascular rhythm (ECG) data. Holter monitors (93224-93227)
include up to 48 hours of continuous recording. Mobile cardiac telemetry monitors (93228, 93229)
have the capability of transmitting a tracing at any time, always have internal ECG analysis
algorithms designed to detect major arrhythmias, and transmit to an attended surveillance center.
Event monitors (93268-93272) record segments of ECGs with recording initiation triggered either
by patient activation or by an internal automatic, pre-programmed detection algorithm (or both)
and transmit the recorded electrocardiographic data when requested (but cannot transmit
immediately based upon the patient or algorithmic activation rhythm) and require attended
surveillance. Long-term continuous recorders (93241, 93242, 93243, 93244, 93245, 93246, 93247,
93248) continuously record and store for greater than 48 hours and up to 7 days or for greater than
7 days up to 15 days.◀
Attended surveillance: is the immediate availability of a remote technician to respond to rhythm or
device alert transmissions from a patient, either from an implanted or wearable monitoring or
therapy device, as they are generated and transmitted to the remote surveillance location or center.
Electrocardiographic rhythm derived elements: elements derived from recordings of the electrical
activation of the heart including, but not limited to heart rhythm, rate, ST analysis, heart rate
variability, T-wave alternans.
▶Long-term continuous recorders: Continuously record the electrocardiographic rhythm from a
device applied to the patient. The electrocardiographic rhythm recording data collected is analyzed
and annotated with frequency, duration, and symptomatic rhythm correlations. The processing
center technician reviews the data and notifies the physician or other qualified health care
professional depending on the prescribed criteria. An initial findings report is generated for
physician review and final interpretation.◀
Mobile cardiovascular telemetry (MCT): continuously records the electrocardiographic rhythm
from external electrodes placed on the patient’s body. Segments of the ECG data are automatically
(without patient intervention) transmitted to a remote surveillance location by cellular or landline
telephone signal. The segments of the rhythm, selected for transmission, are triggered automatically
(MCT device algorithm) by rapid and slow heart rates or by the patient during a symptomatic
episode. There is continuous real time data analysis by preprogrammed algorithms in the device
and attended surveillance of the transmitted rhythm segments by a surveillance center technician to
evaluate any arrhythmias and to determine signal quality. The surveillance center technician
reviews the data and notifies the physician or other qualified health care professional depending on
the prescribed criteria.
ECG rhythm derived elements are distinct from physiologic data, even when the same device is
capable of producing both. Implantable cardiovascular physiologic monitor device services are
always separately reported from implantable cardioverter-defibrillator (ICD) service.
93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage;
includes recording, scanning analysis with report, review and interpretation by a physician or other
➲ CPT Assistant Oct 05:14, Apr 07:3, Mar 08:4, Mar 09:5, Oct 11:5, Nov 11:11
93225 recording (includes connection, recording, and disconnection)

➲ CPT Assistant Oct 05:14, Apr 07:3, Mar 09:5, Oct 11:5
93226 scanning analysis with report

➲ CPT Assistant Oct 05:14, Apr 07:3, Mar 09:5, Oct 11:5
93227 review and interpretation by a physician or other qualified health care professional
➲ CPT Assistant Apr 07:3, Mar 09:5, Apr 09:7, Oct 11:5, Mar 18:5
(For less than 12 hours of continuous recording, use modifier 52)

▶ (Forgreater than 48 hours of monitoring, see 93241, 93242, 93243, 93244, 93245, 93246, 93247,
93248)◀
#● 93241 External electrocardiographic recording for more than 48 hours up to 7 days by continuous rhythm
recording and storage; includes recording, scanning analysis with report, review and interpretation
#● 93242 recording (includes connection and initial recording)

#● 93243 scanning analysis with report

#● 93244 review and interpretation

▶ (Donot report 93241, 93242, 93243, 93244 in conjunction with 93224, 93225, 93226, 93227,
93228, 93229, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 99091, 99453, 99454,
0497T, 0498T, for the same monitoring period)◀
#● 93245 External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm
recording and storage; includes recording, scanning analysis with report, review and interpretation
#● 93246 recording (includes connection and initial recording)

#● 93247 scanning analysis with report

#● 93248 review and interpretation

▶ (Donot report 93245, 93246, 93247, 93248 in conjunction with 93224, 93225, 93226, 93227,
93228, 93229, 93241, 93242, 93243, 93244, 93268, 93270, 93271, 93272, 99091, 99453, 99454,
0497T, 0498T, for the same monitoring period)◀
★ 93228 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent
computerized real time data analysis and greater than 24 hours of accessible ECG data storage
(retrievable with query) with ECG triggered and patient selected events transmitted to a remote
attended surveillance center for up to 30 days; review and interpretation with report by a physician
or other qualified health care professional
➲ CPT Changes: An Insider’s View 2009, 2011, 2013, 2017
(Report 93228 only once per 30 days)

★ 93229 technical support for connection and patient instructions for use, attended surveillance, analysis
and transmission of daily and emergent data reports as prescribed by a physician or other

(For external cardiovascular monitors that do not perform automatic ECG triggered transmissions to
an attended surveillance center, see 93224-93227, 93268-93272)
★ 93268 External patient and, when performed, auto activated electrocardiographic rhythm derived event
recording with symptom-related memory loop with remote download capability up to 30 days, 24-
hour attended monitoring; includes transmission, review and interpretation by a physician or other
➲ CPT Changes: An Insider’s View 2003, 2009, 2011, 2013, 2017
➲ CPT Assistant Jun 96:2, Nov 99:49-50, Oct 05:14, Apr 07:3, Mar 08:4, Mar 09:5, Oct 11:5
★ 93270 recording (includes connection, recording, and disconnection)

➲ CPT Assistant Jun 96:2, Oct 05:14, Apr 07:3, Mar 09:5, Aug 10:13, Oct 11:5
★ 93271 transmission and analysis

➲ CPT Assistant Jun 96:2, Oct 05:14, Apr 07:3, Mar 09:5, Oct 11:5
★ 93272 review and interpretation by a physician or other qualified health care professional
➲ CPT Assistant Jun 96:2, Apr 98:14, Nov 99:49-50, Oct 05:14, Apr 07:3, Mar 09:5, Apr
09:7, Oct 11:5, Mar 18:5
(For subcutaneous cardiac rhythm monitoring, see 33285, 93285, 93291, 93298)
93278 Signal-averaged electrocardiography (SAECG), with or without ECG
(For interpretation and report only, use 93278 with modifier 26)
(For unlisted cardiographic procedure, use 93799)
Implantable, Insertable, and Wearable Cardiac Device

Evaluations
Cardiac device evaluation services are diagnostic medical procedures using in-person and remote
technology to assess device therapy and cardiovascular physiologic data. Codes 93260, 93261,
93279-93298 describe this technology and technical/professional and service center practice. Codes
93260, 93261, 93279-93292 are reported per procedure. Codes 93293, 93294, 93295, 93296 are
reported no more than once every 90 days. Do not report 93293, 93294, 93295, 93296, if the
monitoring period is less than 30 days. Codes 93297, 93298 are reported no more than once up to
every 30 days, per patient. Do not report 93297, 93298, if the monitoring period is less than 10
days. Do not report 93264 if the monitoring period is less than 30 days. Code 93264 is reported no
more than once up to every 30 days, per patient.
A service center may report 93296 during a period in which a physician or other qualified health
care professional performs an in-person interrogation device evaluation. The same individual may
not report an in-person and remote interrogation of the same device during the same period.
Report only remote services when an in-person interrogation device evaluation is performed
during a period of remote interrogation device evaluation. A period is established by the initiation
of the remote monitoring or the 91st day of a pacemaker or implantable defibrillator monitoring or
the 31st day of monitoring a subcutaneous cardiac rhythm monitor or implantable cardiovascular
physiologic monitor, and extends for the subsequent 90 or 30 days respectively, for which remote
monitoring is occurring. Programming device evaluations and in-person interrogation device
evaluations may not be reported on the same date by the same individual. Programming device
evaluations and remote interrogation device evaluations may both be reported during the remote
interrogation device evaluation period.
For monitoring by wearable devices, see 93224-93272.
ECG rhythm derived elements are distinct from physiologic data, even when the same device is
capable of producing both. Implantable cardiovascular physiologic monitor services are always
separately reported from implantable defibrillator services. When cardiac rhythm data are derived
from an implantable defibrillator or pacemaker, do not report subcutaneous cardiac rhythm
monitor services with pacemaker or implantable defibrillator services.
Do not report 93268-93272 when performing 93260, 93261, 93279-93289, 93291-93296, or 93298.
Do not report 93040, 93041, 93042 when performing 93260, 93261, 93279-93289, 93291-93296, or
93298.
The pacemaker and implantable defibrillator interrogation device evaluations, peri-procedural
device evaluations and programming, and programming device evaluations may not be reported in
conjunction with pacemaker or implantable defibrillator device and/or lead insertion or revision
services by the same individual.
The following definitions and instructions apply to codes 93260, 93261, 93279-93298.
Attended surveillance: the immediate availability of a remote technician to respond to rhythm or
device alert transmissions from a patient, either from an implanted, inserted, or wearable
monitoring or therapy device, as they are generated and transmitted to the remote surveillance
location or center.
Device, leadless: a leadless cardiac pacemaker system that includes a pulse generator with built-in
battery and electrode for implantation into the cardiac chamber via a transcatheter approach.
Device, single lead: a pacemaker or implantable defibrillator with pacing and sensing function in
only one chamber of the heart or a subcutaneous electrode.
Device, dual lead: a pacemaker or implantable defibrillator with pacing and sensing function in
only two chambers of the heart.
Device, multiple lead: a pacemaker or implantable defibrillator with pacing and sensing function in
three or more chambers of the heart.
Electrocardiographic rhythm derived elements: elements derived from recordings of the electrical
activation of the heart including, but not limited to heart rhythm, rate, ST analysis, heart rate
variability, T-wave alternans.
Implantable cardiovascular physiologic monitor: an implantable cardiovascular device used to
assist the physician or other qualified health care professional in the management of non-rhythm
related cardiac conditions such as heart failure. The device collects longitudinal physiologic
cardiovascular data elements from one or more internal sensors (such as right ventricular pressure,
pulmonary artery pressure, left atrial pressure, or an index of lung water) and/or external sensors
(such as blood pressure or body weight) for patient assessment and management. The data are
stored and transmitted by either local telemetry or remotely to an Internet-based file server or
surveillance technician. The function of the implantable cardiovascular physiologic monitor may
be an additional function of an implantable cardiac device (eg, implantable defibrillator) or a
function of a stand-alone device. When implantable cardiovascular physiologic monitor
functionality is included in an implantable defibrillator device or pacemaker, the implantable
cardiovascular physiologic monitor data and the implantable defibrillator or pacemaker, heart
rhythm data such as sensing, pacing, and tachycardia detection therapy are distinct and, therefore,
the monitoring processes are distinct.
Implantable defibrillator: two general categories of implantable defibrillators exist: transvenous
implantable pacing cardioverter-defibrillator (ICD) and subcutaneous implantable defibrillator
(SICD). An implantable pacing cardioverter-defibrillator device provides high-energy and low-
energy stimulation to one or more chambers of the heart to terminate rapid heart rhythms called
tachycardia or fibrillation. Implantable pacing cardioverter-defibrillators also have pacemaker
functions to treat slow heart rhythms called bradycardia. In addition to the tachycardia and
bradycardia functions, the implantable pacing cardioverter-defibrillator may or may not include the
functionality of an implantable cardiovascular physiologic monitor or a subcutaneous cardiac
rhythm monitor. The subcutaneous implantable defibrillator uses a single subcutaneous electrode
to treat ventricular tachyarrhythmias. Subcutaneous implantable defibrillators differ from
transvenous implantable pacing cardioverter-defibrillators in that subcutaneous implantable
defibrillators do not provide antitachycardia pacing or chronic pacing. For subcutaneous
implantable defibrillator device evaluation, see 93260, 93261.
Interrogation device evaluation: an evaluation of an implantable device such as a cardiac
pacemaker, implantable defibrillator, implantable cardiovascular physiologic monitor, or
subcutaneous cardiac rhythm monitor. Using an office, hospital, or emergency room instrument or
via a remote interrogation system, stored and measured information about the lead(s) when
present, sensor(s) when present, battery and the implanted device function, as well as data
collected about the patient’s heart rhythm and heart rate is retrieved. The retrieved information is
evaluated to determine the current programming of the device and to evaluate certain aspects of the
device function such as battery voltage, lead impedance, tachycardia detection settings, and rhythm
treatment settings.
The components that must be evaluated for the various types of implantable or insertable cardiac
devices are listed below. (The required components for both remote and in-person interrogations
are the same.)
Pacemaker: programmed parameters, with or without lead(s), battery, capture and sensing
function and heart rhythm.
Implantable defibrillator: programmed parameters, lead(s), battery, capture and sensing
function, presence or absence of therapy for ventricular tachyarrhythmias and underlying heart
rhythm.
Implantable cardiovascular physiologic monitor: programmed parameters and analysis of at
least one recorded physiologic cardiovascular data element from either internal or external
sensors.
Subcutaneous cardiac rhythm monitor: programmed parameters and the heart rate and rhythm
during recorded episodes from both patient initiated and device algorithm detected events, when
present.
Interrogation device evaluation (remote): a procedure performed for patients with pacemakers,
implantable defibrillators, or subcutaneous cardiac rhythm monitors using data obtained remotely.
All device functions, including the programmed parameters, lead(s), battery, capture and sensing
function, presence or absence of therapy for ventricular tachyarrhythmias (for implantable
defibrillators) and underlying heart rhythm are evaluated.
The components that must be evaluated for the various types of implantable or insertable cardiac
devices are listed below. (The required components for both remote and in person interrogations
are the same.)
Pacemaker: programmed parameters, with or without lead(s), battery, capture and sensing
function, and heart rhythm.
function, presence or absence of therapy for ventricular tachyarrhythmias, and underlying heart
rhythm.
Implantable cardiovascular physiologic monitor: programmed parameters and analysis of at least
one recorded physiologic cardiovascular data element from either internal or external sensors.
Subcutaneous cardiac rhythm monitor: programmed parameters and the heart rate and rhythm
during recorded episodes from both patient-initiated and device algorithm detected events, when
present.
Pacemaker: an implantable device that provides low energy localized stimulation to one or more
chambers of the heart to initiate contraction in that chamber. Two general categories of pacemakers
exist: (1) pacemakers with a subcutaneous generator plus transvenous/epicardial lead(s); and (2)
leadless pacemakers. A leadless pacemaker does not require a subcutaneous pocket for the
generator. It combines a miniaturized generator with an integrated electrode for implantation in a
heart chamber via a transcatheter approach.
Peri-procedural device evaluation and programming: an evaluation of an implantable device
system (either a pacemaker or implantable defibrillator) to adjust the device to settings appropriate
for the patient prior to a surgery, procedure, or test. The device system data are interrogated to
evaluate the lead(s) when present, sensor(s), and battery in addition to review of stored
information, including patient and system measurements. The device is programmed to settings
appropriate for the surgery, procedure, or test, as required. A second evaluation and programming
are performed after the surgery, procedure, or test to provide settings appropriate to the post
procedural situation, as required. If one performs both the pre- and post-evaluation and
programming service, the appropriate code, either 93286 or 93287, would be reported two times. If
one performs the pre-surgical service and a separate individual performs the post-surgical service,
each reports either 93286 or 93287 only one time.
Physiologic cardiovascular data elements: data elements from one or more internal sensors (such
as right ventricular pressure, left atrial pressure or an index of lung water) and/or external sensors
(such as blood pressure or body weight) for patient assessment and management. It does not
include ECG rhythm derived data elements.
Programming device evaluation (in person): a procedure performed for patients with a
pacemaker, implantable defibrillator, or subcutaneous cardiac rhythm monitor. All device
functions, including the battery, programmable settings and lead(s), when present, are evaluated.
To assess capture thresholds, iterative adjustments (eg, progressive changes in pacing output of a
pacing lead) of the programmable parameters are conducted. The iterative adjustments provide
information that permits the operator to assess and select the most appropriate final program
parameters to provide for consistent delivery of the appropriate therapy and to verify the
function of the device. The final program parameters may or may not change after evaluation.
The programming device evaluation includes all of the components of the interrogation device
evaluation (remote) or the interrogation device evaluation (in person), and it includes the selection
of patient specific programmed parameters depending on the type of device.
The components that must be evaluated for the various types of programming device evaluations
are listed below. (See also required interrogation device evaluation [remote and in person]
components above.)
Pacemaker: programmed parameters, lead(s) when present, battery, capture and sensing
function, and heart rhythm. Often, but not always, the sensor rate response, lower and upper
heart rates, AV intervals, pacing voltage and pulse duration, sensing value, and diagnostics will
be adjusted during a programming evaluation.
function, presence or absence of therapy for ventricular tachyarrhythmias and underlying heart
rhythm. Often, but not always, the sensor rate response, lower and upper heart rates, AV
intervals, pacing voltage and pulse duration, sensing value, and diagnostics will be adjusted
during a programming evaluation. In addition, ventricular tachycardia detection and therapies
are sometimes altered depending on the interrogated data, patient’s rhythm, symptoms, and
condition.
Subcutaneous cardiac rhythm monitor: programmed parameters and the heart rhythm during
recorded episodes from both patient initiated and device algorithm detected events. Often, but
not always, the tachycardia and bradycardia detection criteria will be adjusted during a
programming evaluation.
Subcutaneous cardiac rhythm monitor: an implantable or insertable device that continuously
records the electrocardiographic rhythm triggered automatically by rapid, irregular, and/or slow
heart rates or by the patient during a symptomatic episode. The cardiac rhythm monitor function
may be the only function of the device or it may be part of a pacemaker or implantable defibrillator
device. The data are stored and transmitted by either local telemetry or remotely to an Internet-
based file server or surveillance technician. Extraction of data and compilation or report for
physician or qualified health care professional interpretation is usually performed in the office
setting.
Transtelephonic rhythm strip pacemaker evaluation: service of transmission of an
electrocardiographic rhythm strip over the telephone by the patient using a transmitter and
recorded by a receiving location using a receiver/recorder (also commonly known as
transtelephonic pacemaker monitoring). The electrocardiographic rhythm strip is recorded both
with and without a magnet applied over the pacemaker. The rhythm strip is evaluated for heart rate
and rhythm, atrial and ventricular capture (if observed) and atrial and ventricular sensing (if
observed). In addition, the battery status of the pacemaker is determined by measurement of the
paced rate on the electrocardiographic rhythm strip recorded with the magnet applied. For remote
monitoring of an implantable wireless pulmonary artery pressure sensor, use 93264.
Implantable wireless pulmonary artery sensor: an implantable cardiovascular device used to assist
the physician or other qualified health care professional in monitoring heart failure. The device
collects longitudinal physiologic cardiovascular data elements from an internal sensor located in
the pulmonary artery. The data are transmitted and stored remotely to an Internet-based file server.
# 93264 Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at
least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis,
and report(s) by a physician or other qualified health care professional

(Do not report 93264 if download[s], interpretation[s], trend analysis, and report[s] do not occur at
least weekly during the 30-day time period)
(Do not report 93264 if review does not occur at least weekly during the 30-day time period)
(Do not report 93264 if monitoring period is less than 30 days)
93279 Programming device evaluation (in person) with iterative adjustment of the implantable device to
test the function of the device and select optimal permanent programmed values with analysis,
review and report by a physician or other qualified health care professional; single lead pacemaker
system or leadless pacemaker system in one cardiac chamber
➲ CPT Assistant Jun 12:4, Jun 13:6, Jul 13:7, Apr 14:3, Jul 14:3, Nov 14:5, Aug 16:5, Mar 19:6

93280 dual lead pacemaker system
➲ CPT Assistant Jun 12:4, Jun 13:6, Jul 13:7, Apr 14:3, Aug 16:5
93281 multiple lead pacemaker system
➲ CPT Assistant Jun 12:4, Jun 13:6, Jul 13:7, Apr 14:3, Aug 16:5

93282 single lead transvenous implantable defibrillator system
➲ CPT Assistant Jun 13:6, Jul 13:7, Apr 14:3, Aug 16:5
93283 dual lead transvenous implantable defibrillator system

93284 multiple lead transvenous implantable defibrillator system

# 93260 implantable subcutaneous lead defibrillator system

(Do not report 93260 in conjunction with pulse generator and lead insertion or repositioning codes
33240, 33241, 33262, 33270, 33271, 33272, 33273)
93285 subcutaneous cardiac rhythm monitor system
(Do not report 93285 in conjunction with 33285, 93279-93284, 93291)

93286 Peri-procedural device evaluation (in person) and programming of device system parameters before
or after a surgery, procedure, or test with analysis, review and report by a physician or other
qualified health care professional; single, dual, or multiple lead pacemaker system, or leadless
pacemaker system
➲ CPT Assistant Jun 13:6, Jul 13:7, Apr 14:3, Aug 16:5, Mar 19:6
(Report 93286 once before and once after surgery, procedure, or test, when device evaluation and
programming is performed before and after surgery, procedure, or test)
(Do not report 93286 in conjunction with 93279-93281, 93288, 0408T, 0409T, 0410T, 0411T,
0414T, 0415T)
93287 single, dual, or multiple lead implantable defibrillator system
➲ CPT Assistant Jun 13:6, Jul 13:7, Apr 14:3, Jul 14:3, Aug 16:5
(Report 93287 once before and once after surgery, procedure, or test, when device evaluation and
programming is performed before and after surgery, procedure, or test)
(Do not report 93287 in conjunction with 93260, 93261, 93282, 93283, 93284, 93289, 0408T,
0409T, 0410T, 0411T, 0414T, 0415T)
93288 Interrogation device evaluation (in person) with analysis, review and report by a physician or other
qualified health care professional, includes connection, recording and disconnection per patient
encounter; single, dual, or multiple lead pacemaker system, or leadless pacemaker system
➲ CPT Assistant Jun 12:4, Jun 13:6, Jul 13:7, Apr 14:3, Aug 16:5, Mar 19:6
(Do not report 93288 in conjunction with 93279-93281, 93286, 93294, 93296)
93289 single, dual, or multiple lead transvenous implantable defibrillator system, including analysis of
heart rhythm derived data elements
(For monitoring physiologic cardiovascular data elements derived from an implantable

defibrillator, use 93290)
(Do not report 93289 in conjunction with 93261, 93282, 93283, 93284, 93287, 93295, 93296)
# 93261 implantable subcutaneous lead defibrillator system

(Do not report 93261 in conjunction with pulse generator and lead insertion or repositioning codes
33240, 33241, 33262, 33270, 33271, 33272, 33273)
93290 implantable cardiovascular physiologic monitor system, including analysis of 1 or more
recorded physiologic cardiovascular data elements from all internal and external sensors
➲ CPT Assistant Feb 10:13, Apr 13:11, Aug 16:5, Feb 20:7
(For heart rhythm derived data elements, use 93289)

93291 subcutaneous cardiac rhythm monitor system, including heart rhythm derived data analysis
(Do not report 93291 in conjunction with 33285, 93288-93290, 93298)

93292 wearable defibrillator system
Coding Tip
Instructions for Reporting Pacemaker and Interrogation Device Evaluations
Codes 93293-93296 are reported no more than once every 90 days. Do not report 93293-93296 if the monitoring
period is less than 30 days.
CPT Coding Guidelines, Cardiovascular, Cardiography Implantable and Wearable Cardiac Device Evaluations
93293 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker
system, includes recording with and without magnet application with analysis, review and report(s)
by a physician or other qualified health care professional, up to 90 days

(For in person evaluation, see 93040, 93041, 93042)
93294 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker
system, or leadless pacemaker system with interim analysis, review(s) and report(s) by a physician
➲ CPT Assistant Jun 12:4, Aug 16:5, Mar 19:6

93295 single, dual, or multiple lead implantable defibrillator system with interim analysis, review(s)
and report(s) by a physician or other qualified health care professional
(For remote monitoring of physiologic cardiovascular data elements derived from an ICD, use
93297)
(For remote interrogation device evaluation[s] of implantable cardioverter-defibrillator with
substernal lead, see 0578T, 0579T)
93296 single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable
defibrillator system, remote data acquisition(s), receipt of transmissions and technician review,
technical support and distribution of results

(For remote interrogation device evaluation[s] of implantable cardioverter-defibrillator with
substernal lead, see 0578T, 0579T)
93297 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic
monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements
from all internal and external sensors, analysis, review(s) and report(s) by a physician or other
➲ CPT Assistant Feb 09:9-12, Apr 13:11, Aug 16:5, Oct 19:3, Feb 20:12
(For heart rhythm derived data elements, use 93295)

93298 subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data,
analysis, review(s) and report(s) by a physician or other qualified health care professional
➲ CPT Assistant Feb 09:9-12, Aug 16:5, Oct 19:3, Feb 20:12
(For remote monitoring of an implantable wireless pulmonary artery pressure sensor, use 93264)
Echocardiography
Echocardiography includes obtaining ultrasonic signals from the heart and great vessels, with real
time image and/or Doppler ultrasonic signal documentation, with interpretation and report. When
interpretation is performed separately, use modifier 26.
A complete transthoracic echocardiogram without spectral or color flow Doppler (93307) is a
comprehensive procedure that includes 2-dimensional and, when performed, selected M-mode
examination of the left and right atria, left and right ventricles, the aortic, mitral, and tricuspid
valves, the pericardium, and adjacent portions of the aorta. Multiple views are required to obtain a
complete functional and anatomic evaluation, and appropriate measurements are obtained and
recorded. Despite significant effort, identification and measurement of some structures may not
always be possible. In such instances, the reason that an element could not be visualized must be
documented. Additional structures that may be visualized (eg, pulmonary veins, pulmonary artery,
pulmonic valve, inferior vena cava) would be included as part of the service.
A complete transthoracic echocardiogram with spectral and color flow Doppler (93306) is a
comprehensive procedure that includes spectral Doppler and color flow Doppler in addition to the
2-dimensional and selected M-mode examinations, when performed. Spectral Doppler (93320,
93321) and color flow Doppler (93325) provide information regarding intracardiac blood flow and
hemodynamics.
A follow-up or limited echocardiographic study (93308) is an examination that does not evaluate or
document the attempt to evaluate all the structures that comprise the complete echocardiographic
exam. This is typically limited to, or performed in follow-up of a focused clinical concern.
In stress echocardiography, echocardiographic images are recorded from multiple cardiac windows
before, after, and in some protocols, during stress. The stress is achieved by (1) walking on a
treadmill; (2) using a bicycle (supine or upright); or (3) the administration of pharmacological
agents that either simulate exercise (by increasing heart rate, blood pressure, or myocardial
contractility) or alter coronary flow (vasodilation). The patient’s ECG, heart rate, and blood
pressure are monitored at baseline, throughout the procedure and during recovery. Reports are
prepared to evaluate (1) the duration of stress, the reason for stopping, and the hemodynamic
response to stress; (2) the electrocardiographic response to stress; and (3) the echocardiographic
response to stress.
When a stress echocardiogram is performed with a complete cardiovascular stress test (continuous
electrocardiographic monitoring, supervision, interpretation and report by a physician or other
qualified health care professional), use 93351. When only the professional components of a
complete stress test and a stress echocardiogram are provided (eg, in a facility setting) by the same
physician, use 93351 with modifier 26. When all professional services of a stress test are not
performed by the same physician performing the stress echocardiogram, use 93350 in conjunction
with the appropriate codes (93016-93018) for the components of the cardiovascular stress test that
are provided.
When left ventricular endocardial borders cannot be adequately identified by standard
echocardiographic imaging, echocardiographic contrast may be infused intravenously both at rest
and with stress to achieve that purpose. Code 93352 is used to report the administration of
echocardiographic contrast agent in conjunction with the stress echocardiography codes (93350 or
93351). Supply of contrast agent and/or drugs used for pharmacological stress is reported
separately in addition to the procedure code.
Code 93355 is used to report transesophageal echocardiography (TEE) services during
transcatheter intracardiac therapies. Code 93355 is reported once per intervention and only by an
individual who is not performing the interventional procedure. Code 93355 includes the work of
passing the endoscopic ultrasound transducer through the mouth into the esophagus, when
performed by the individual performing the TEE, diagnostic transesophageal echocardiography
and ongoing manipulation of the transducer to guide sizing and/or placement of implants,
determination of adequacy of the intervention, and assessment for potential complications. Real-
time image acquisition, measurements, and interpretation of image(s), documentation of
completion of the intervention, and final written report are included in this code.
A range of intracardiac therapies may be performed with TEE guidance. Code 93355 describes TEE
during advanced transcatheter structural heart procedures (eg, transcatheter aortic valve
replacement [TAVR], left atrial appendage closure [LAA], or percutaneous mitral valve repair).
See 93313 for separate reporting of the probe insertion by a physician other than the physician
performing the TEE.
Report of an echocardiographic study, whether complete or limited, includes an interpretation of
all obtained information, documentation of all clinically relevant findings including quantitative
measurements obtained, plus a description of any recognized abnormalities. Pertinent images,
videotape, and/or digital data are archived for permanent storage and are available for subsequent
review. Use of echocardiography not meeting these criteria is not separately reportable.
Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image
documentation and final, written report, is not separately reportable.
(For fetal echocardiography, see 76825-76828)
93303 Transthoracic echocardiography for congenital cardiac anomalies; complete
➲ CPT Assistant Nov 97:44, Dec 97:5, Sep 05:10-11, Mar 08:4, Oct 10:17, Dec 10:17, Aug 13:3,
Dec 13:15, May 15:10, Apr 20:11
93304 follow-up or limited study

➲ CPT Assistant Nov 97:44, Dec 97:5, Jan 10:8, Oct 10:17, Dec 10:17, Aug 13:3, Dec 13:15,
May 15:10
93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode
recording, when performed, complete, with spectral Doppler echocardiography, and with color
flow Doppler echocardiography
➲ CPT Assistant Oct 10:17, Dec 10:17, Aug 13:3, May 15:10, Apr 16:9, Dec 18:11
(For transthoracic echocardiography without spectral and color Doppler, use 93307)
recording, when performed, complete, without spectral or color Doppler echocardiography
➲ CPT Assistant Dec 97:5, Sep 05:11, Oct 10:17, Dec 10:17, Aug 13:3, May 15:10, Apr 16:9

recording, when performed, follow-up or limited study
➲ CPT Assistant Dec 97:5, Sep 05:11, Jan 10:8, Oct 10:17, Dec 10:17, Mar 12:10, Aug 13:3, May
15:10, Apr 16:9, Dec 18:11
93312 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-
mode recording); including probe placement, image acquisition, interpretation and report
➲ CPT Assistant Dec 97:5, Jan 00:10, Jan 10:8, Oct 12:15, Aug 13:3, Jul 14:9

93313 placement of transesophageal probe only
➲ CPT Assistant Dec 97:5, Mar 08:4, Jan 10:8, Aug 13:3
(The same individual may not report 93313 in conjunction with 93355)
Transesophageal Echocardiography (TEE)

93312-93318
An endoscopic ultrasound transducer is passed through the mouth into the esophagus and 2-dimensional images are obtained from the posterior aspect of the
heart.
93314 image acquisition, interpretation and report only

➲ CPT Assistant Dec 97:5, Jan 00:10, Jan 10:8, Aug 13:3
93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement,
image acquisition, interpretation and report
➲ CPT Assistant Nov 97:44, Dec 97:5, Jan 10:8, Aug 13:3, Dec 13:15, Jul 14:9

93316 placement of transesophageal probe only
➲ CPT Assistant Nov 97:44, Dec 97:5, Jan 10:8, Aug 13:3

93317 image acquisition, interpretation and report only
➲ CPT Assistant Nov 97:44, Dec 97:5, Jan 10:8, Aug 13:3, Dec 13:15

93318 Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real
time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment
of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate
time basis
➲ CPT Assistant Jan 10:8, Apr 10:6, Aug 13:3

✚ 93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List
separately in addition to codes for echocardiographic imaging); complete
➲ CPT Assistant Nov 97:44, Dec 97:5, Aug 13:3
(Use 93320 in conjunction with 93303, 93304, 93312, 93314, 93315, 93317, 93350, 93351)
✚ 93321 follow-up or limited study (List separately in addition to codes for echocardiographic imaging)
➲ CPT Assistant Nov 97:44, Dec 97:5, Jan 10:8, Aug 13:3
(Use 93321 in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 93317, 93350, 93351)
✚ 93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for
echocardiography)
➲ CPT Assistant Nov 97:44, Dec 97:5, Aug 13:3, Jul 16:9
(Use 93325 in conjunction with 76825, 76826, 76827, 76828, 93303, 93304, 93308, 93312, 93314,
93315, 93317, 93350, 93351)
recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle
exercise and/or pharmacologically induced stress, with interpretation and report;
➲ CPT Assistant Aug 02:11, Jan 10:8, Oct 10:17, Dec 10:17, Aug 13:3, Jul 14:9, Apr 16:9
(Stress testing codes 93016-93018 should be reported, when appropriate, in conjunction with
93350 to capture the cardiovascular stress portion of the study)
93351 including performance of continuous electrocardiographic monitoring, with supervision by a
➲ CPT Assistant Jan 10:8, Oct 10:17, Dec 10:17, Aug 13:3, Jul 14:9, Apr 16:9
(Do not report 93351 in conjunction with 93015-93018, 93350. Do not report 93351-26 in
conjunction with 93016, 93018, 93350-26)
#✚ 93356 Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics
(List separately in addition to codes for echocardiography imaging)
✚ 93352 Use of echocardiographic contrast agent during stress echocardiography (List separately in addition
➲ CPT Assistant Jan 10:8, Oct 10:17, Dec 10:17, Aug 13:3
(Do not report 93352 more than once per stress echocardiogram)
93355 Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great
vessel(s) structural intervention(s) (eg, TAVR, transcatheter pulmonary valve replacement, mitral
valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular
septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation,
guidance with quantitative measurements, probe manipulation, interpretation, and report, including
diagnostic transesophageal echocardiography and, when performed, administration of ultrasound
contrast, Doppler, color flow, and 3D
(To report placement of transesophageal probe by separate physician, use 93313)

(Do not report 93355 in conjunction with 76376, 76377, 93312, 93313, 93314, 93315, 93316,
93317, 93318, 93320, 93321, 93325)
Cardiac Catheterization
Cardiac catheterization is a diagnostic medical procedure which includes introduction, positioning
and repositioning, when necessary, of catheter(s), within the vascular system, recording of
intracardiac and/or intravascular pressure(s), and final evaluation and report of procedure. There
are two code families for cardiac catheterization: one for congenital heart disease and one for all
other conditions. Anomalous coronary arteries, patent foramen ovale, mitral valve prolapse, and
bicuspid aortic valve are to be reported with 93451-93464, 93566-93568.
Right heart catheterization includes catheter placement in one or more right-sided cardiac
chamber(s) or structures (ie, the right atrium, right ventricle, pulmonary artery, pulmonary wedge),
obtaining blood samples for measurement of blood gases, and cardiac output measurements (Fick
or other method), when performed. Left heart catheterization involves catheter placement in a left-
sided (systemic) cardiac chamber(s) (left ventricle or left atrium) and includes left ventricular
injection(s) when performed. Do not report 93503 in conjunction with other diagnostic cardiac
catheterization codes. When right heart catheterization is performed in conjunction with other
cardiac catheterization services, report 93453, 93456, 93457, 93460, or 93461. For placement of a
flow directed catheter (eg, Swan-Ganz) performed for hemodynamic monitoring purposes not in
conjunction with other catheterization services, use 93503. Right heart catheterization does not
include right ventricular or right atrial angiography (93566). When left heart catheterization is
performed using either transapical puncture of the left ventricle or transseptal puncture of an intact
septum, report 93462 in conjunction with 93452, 93453, 93458-93461, 93653, 93654. Catheter
placement(s) in coronary artery(ies) involves selective engagement of the origins of the native
coronary artery(ies) for the purpose of coronary angiography. Catheter placement(s) in bypass
graft(s) (venous, internal mammary, free arterial graft[s]) involve selective engagement of the
origins of the graft(s) for the purpose of bypass angiography. It is typically performed only in
conjunction with coronary angiography of native vessels.
The cardiac catheterization codes (93452-93461), other than those for congenital heart disease,
include contrast injection(s), imaging supervision, interpretation, and report for imaging typically
performed. Codes for left heart catheterization (93452, 93453, 93458-93461), other than those for
congenital heart disease, include intraprocedural injection(s) for left ventricular/left atrial
angiography, imaging supervision, and interpretation, when performed. Codes for coronary
catheter placement(s) (93454-93461), other than those for congenital heart disease, include
intraprocedural injection(s) for coronary angiography, imaging supervision, and interpretation.
Codes for catheter placement(s) in bypass graft(s) (93455, 93457, 93459, 93461), other than those
for congenital heart disease, include intraprocedural injection(s) for bypass graft angiography,
imaging supervision, and interpretation. Do not report 93563-93565 in conjunction with 93452-
93461.
For cardiac catheterization for congenital cardiac anomalies, see 93530-93533. When contrast
injection(s) are performed in conjunction with cardiac catheterization for congenital anomalies, see
93563-93568.
Cardiac catheterization (93451-93461) includes all roadmapping angiography in order to place the
catheters, including any injections and imaging supervision, interpretation, and report. It does not
include contrast injection(s) and imaging supervision, interpretation, and report for imaging that is
separately identified by specific procedure code(s). For right ventricular or right atrial angiography
performed in conjunction with cardiac catheterization for congenital or noncongenital heart disease
(93451-93461, 93530-93533), use 93566. For aortography, use 93567. For pulmonary angiography,
use 93568. For angiography of noncoronary arteries and veins, performed as a distinct service, use
appropriate codes from the Radiology section and the Vascular Injection Procedures section.
When cardiac catheterization is combined with pharmacologic agent administration with the
specific purpose of repeating hemodynamic measurements to evaluate hemodynamic response, use
93463 in conjunction with 93451-93453 and 93456-93461. Do not report 93463 for intracoronary
administration of pharmacologic agents during percutaneous coronary interventional procedures,
during intracoronary assessment of coronary pressure, flow or resistance, or during intracoronary
imaging procedures. Do not report 93463 in conjunction with 92920-92944, 92975, 92977.
When cardiac catheterization is combined with exercise (eg, walking or arm or leg ergometry
protocol) with the specific purpose of repeating hemodynamic measurements to evaluate
hemodynamic response, report 93464 in conjunction with 93451-93453, 93456-93461, and 93530-
93533.
Contrast injection to image the access site(s) for the specific purpose of placing a closure device is
inherent to the catheterization procedure and not separately reportable. Closure device placement at
the vascular access site is inherent to the catheterization procedure and not separately reportable.
Please see the cardiac catheterization table located on page 682.
93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when
performed
➲ CPT Assistant Aug 11:5, Mar 12:10, May 13:12, Jul 14:3, Sep 15:3, Mar 16:5, Dec 17:16, Dec
18:11, Mar 19:6, Jun 19:3
▶ (Donot report 93451 in conjunction with 33289, 93453, 93456, 93457, 93460, 93461, 0613T,
0632T)◀
(Do not report 93451 in conjunction with 33418, 0345T, 0483T, 0484T, 0544T, 0545T for
diagnostic right heart catheterization procedures intrinsic to the valve repair or annulus
reconstruction procedure)
93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging
supervision and interpretation, when performed
➲ CPT Assistant Aug 11:3, Mar 12:10, Jan 13:6, May 13:12, Sep 15:3
(Do not report 93452 in conjunction with 93453, 93458-93461, 0408T, 0409T, 0410T, 0411T,
0414T, 0415T)
diagnostic left heart catheterization procedures intrinsic to the valve repair or annulus
93453 Combined right and left heart catheterization including intraprocedural injection(s) for left
ventriculography, imaging supervision and interpretation, when performed
➲ CPT Assistant Aug 11:3, Mar 12:10, Jan 13:6, May 13:12, Sep 15:3, Mar 16:5, Mar 19:6, Jun
19:3
(Do not report 93453 in conjunction with 93451, 93452, 93456-93461, 0408T, 0409T, 0410T,
0411T, 0414T, 0415T)
diagnostic left and right heart catheterization procedures intrinsic to the valve repair or annulus
93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural
injection(s) for coronary angiography, imaging supervision and interpretation;
➲ CPT Assistant Aug 11:3, Mar 12:10, May 13:12, Dec 14:6, Mar 16:5, Feb 17:15
(Do not report 93454 in conjunction with 33418, 0345T, 0483T, 0484T, 0544T, 0545T for coronary
angiography intrinsic to the valve repair or annulus reconstruction procedure)
Right Heart Catheterization

93451
The physician introduces a cardiac catheter into the venous system. The catheter is directed into the right atrium, right ventricle, and pulmonary artery.
Right Heart Catheterization—Infant

Catheter is advanced retrograde through the arterial system to the ascending aorta; pressures are measured in the aortic root; the catheter is manipulated
using fluoroscopic guidance into the ostium of a coronary artery, arterial bypass conduit, or venous coronary bypass graft.
Left Heart Catheterization

93452
A catheter is inserted into the arterial system and then into the left ventricle.
Coronary Angiography Without Concomitant Left Heart Catheterization
93454
Cardiac catheterization procedure performed wherein the catheter does not cross the aortic valve into the left ventricle (left heart catheterization).
93455 with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts)
including intraprocedural injection(s) for bypass graft angiography
➲ CPT Assistant Aug 11:3, Dec 11:9, Mar 12:10, May 13:12, Mar 16:5
(Do not report 93455 in conjunction with 33418, 0345T, 0483T, 0484T, 0544T, 0545T for coronary
angiography intrinsic to the valve repair or annulus reconstruction procedure)
93456 with right heart catheterization
➲ CPT Assistant Aug 11:3, Mar 12:10, May 13:12, Sep 15:3, Mar 16:5, Mar 19:6, Jun 19:3
diagnostic coronary angiography or right heart catheterization procedures intrinsic to the valve
repair or annulus reconstruction procedure)
93457 with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts)
including intraprocedural injection(s) for bypass graft angiography and right heart catheterization
➲ CPT Assistant Aug 11:3, Dec 11:9, Mar 12:10, May 13:12, Sep 15:3, Mar 16:5, Mar 19:6,
Jun 19:3
diagnostic coronary angiography or right heart catheterization procedures intrinsic to the valve
repair or annulus reconstruction procedure)
93458 with left heart catheterization including intraprocedural injection(s) for left ventriculography,
when performed
➲ CPT Assistant Aug 11:3, Mar 12:10, Jan 13:6, May 13:12, Sep 15:3, Mar 16:5
diagnostic coronary angiography or left heart catheterization procedures intrinsic to the valve repair
or annulus reconstruction procedure)
(Do not report 93458 in conjunction with 0408T, 0409T, 0410T, 0411T, 0414T, 0415T)
93459 with left heart catheterization including intraprocedural injection(s) for left ventriculography,
when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial,
venous grafts) with bypass graft angiography
➲ CPT Assistant Aug 11:3, Dec 11:11, Mar 12:10, Jan 13:6, May 13:12, Sep 15:3, Mar 16:5
diagnostic coronary angiography or left heart catheterization procedures intrinsic to the valve repair
or annulus reconstruction procedure)
93460 with right and left heart catheterization including intraprocedural injection(s) for left
ventriculography, when performed
➲ CPT Assistant Aug 11:3, Mar 12:10, Jan 13:6, May 13:12, Sep 15:3, Mar 16:5, Mar 19:6,
Jun 19:3
diagnostic coronary angiography or left and right heart catheterization procedures intrinsic to the
valve repair or annulus reconstruction procedure)
93461 with right and left heart catheterization including intraprocedural injection(s) for left
ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary,
free arterial, venous grafts) with bypass graft angiography
➲ CPT Assistant Aug 11:3, Dec 11:9, Mar 12:10, Jan 13:6, May 13:12, Jul 14:3, Dec 14:6, Sep
15:3, Mar 16:5, Mar 19:6, Jun 19:3
diagnostic coronary angiography or left and right heart catheterization procedures intrinsic to the
valve repair or annulus reconstruction procedure)
✚ 93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture
➲ CPT Assistant Aug 11:3, Mar 12:10, May 13:12, Jun 13:6, Jul 14:3, Sep 15:3, Jul 17:3, Sep
17:3
(Use 93462 in conjunction with 33477, 93452, 93453, 93458, 93459, 93460, 93461, 93582, 93653,
93654)
(Use 93462 in conjunction with 93590, 93591 for transapical puncture performed for left heart
catheterization and percutaneous transcatheter closure of paravalvular leak)
(Do not report 93462 in conjunction with 93590 for transeptal puncture through intact septum
performed for left heart catheterization and percutaneous transcatheter closure of paravalvular leak)
(Do not report 93462 in conjunction with 0345T, 0544T unless transapical puncture is performed)
✚ 93463 Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside,
dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before,
during, after and repeat pharmacologic agent administration, when performed (List separately in
➲ CPT Assistant Aug 11:3, Mar 12:10, Dec 14:6
(Use 93463 in conjunction with 33477, 93451-93453, 93456-93461, 93530, 93531, 93532, 93533,
93580, 93581)
(Report 93463 only once per catheterization procedure)
(Do not report 93463 for pharmacologic agent administration in conjunction with coronary
interventional procedure 92920-92944, 92975, 92977)
✚ 93464 Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic
measurements before and after (List separately in addition to code for primary procedure)
➲ CPT Assistant Aug 11:3, Mar 12:10, Jul 14:3
(Use 93464 in conjunction with 33477, 93451-93453, 93456-93461, 93530-93533)

(Report 93464 only once per catheterization procedure)
(For pharmacologic agent administration, use 93463)
(For bundle of His recording, use 93600)
93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes
➲ CPT Assistant Winter 91:3, Fall 95:8, Feb 97:5, Apr 98:2, Mar 08:4, Aug 11:3, Dec 11:18
▶ (Do not report 93503 in conjunction with 0632T)◀

(For subsequent monitoring, see 99356-99357)
93505 Endomyocardial biopsy
➲ CPT Assistant Apr 98:2, Apr 00:10, Aug 11:3, Dec 17:16
93530 Right heart catheterization, for congenital cardiac anomalies

➲ CPT Assistant Nov 97:45, Jan 98:11, Mar 98:11, Apr 98:3, 6-7, Aug 11:3, Dec 11:11, Mar
12:10, May 13:12, Jul 14:3, Sep 15:3, Mar 16:5, Mar 19:6, Jun 19:3
93531 Combined right heart catheterization and retrograde left heart catheterization, for congenital cardiac
anomalies
CPT Assistant Nov 97:45, Jan 98:11, Mar 98:11, Apr 98:8, 10-11, Aug 11:3, Dec 11:11, Mar
➲
12:10, Sep 15:3, Mar 16:5, Mar 19:6, Jun 19:3
93532 Combined right heart catheterization and transseptal left heart catheterization through intact septum
with or without retrograde left heart catheterization, for congenital cardiac anomalies
➲ CPT Assistant Nov 97:45, Jan 98:11, Mar 98:11, Apr 98:10-11, Aug 11:3, Dec 11:11, Mar
12:10, Sep 15:3, Mar 16:5, Mar 19:6, Jun 19:3
93533 Combined right heart catheterization and transseptal left heart catheterization through existing septal
opening, with or without retrograde left heart catheterization, for congenital cardiac anomalies
➲ CPT Assistant Nov 97:45, Jan 98:11, Mar 98:11, Apr 98:12-13, Aug 11:3, Dec 11:11, Mar
12:10, Jul 14:3, Sep 15:3, Mar 16:5, Mar 19:6, Jun 19:3
Injection Procedures
All injection codes include radiological supervision, interpretation, and report. Cardiac
catheterization codes (93452-93461), other than those for congenital heart disease, include contrast
injection(s) for imaging typically performed during these procedures (see Cardiac Catheterization
above). Do not report 93563-93565 in conjunction with 93452-93461. When injection procedures
for right ventricular, right atrial, aortic, or pulmonary angiography are performed in conjunction
with cardiac catheterization, these services are reported separately (93566-93568). When right
ventricular or right atrial angiography is performed at the time of heart catheterization, use 93566
with the appropriate catheterization code (93451, 93453, 93456, 93457, 93460, or 93461). Use 93567
when supravalvular ascending aortography is performed at the time of heart catheterization. Use
93568 with the appropriate right heart catheterization code when pulmonary angiography is
performed. Separately reported injection procedures do not include introduction of catheters but
do include repositioning of catheters when necessary and use of automatic power injectors, when
performed.
When contrast injection(s) are performed in conjunction with cardiac catheterization for congenital
cardiac anomalies (93530-93533), see 93563-93568. Injection procedure codes 93563-93568 include
imaging supervision, interpretation, and report.
Injection procedures 93563-93568 represent separate identifiable services and may be coded in
conjunction with one another when appropriate. The technical details of angiography, supervision
of imaging and processing, interpretation, and report are included.
93561 Indicator dilution studies such as dye or thermodilution, including arterial and/or venous
catheterization; with cardiac output measurement (separate procedure)
➲ CPT Assistant Winter 91:25, Summer 95:2, Aug 00:2, Feb 07:10, Jul 07:1, Aug 11:3, Jul 14:3,
Aug 19:8
93562 subsequent measurement of cardiac output
➲ CPT Assistant Winter 91:25, Summer 95:2, Aug 00:2, Feb 07:10, Jul 07:1, Aug 11:3, May
14:4, Jul 14:3, Aug 19:8
(Do not report 93561, 93562 in conjunction with 93451-93462, 93582)
(For radioisotope method of cardiac output, see 78472, 78473, or 78481)
✚ 93563 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and
report; for selective coronary angiography during congenital heart catheterization (List separately in
➲ CPT Assistant Aug 11:3, Dec 11:11, Jan 13:6, Dec 14:6, Mar 16:5
✚ 93564 for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary
saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary
arteries and in situ arterial conduits (eg, internal mammary), whether native or used for bypass to
one or more coronary arteries during congenital heart catheterization, when performed (List
➲ CPT Assistant Aug 11:3, Dec 11:11, Jan 13:6, Dec 14:6, Mar 16:5
(Do not report 93563, 93564 in conjunction with 33418, 0345T, 0483T, 0484T, 0544T, 0545T for
coronary angiography intrinsic to the valve repair or annulus reconstruction procedure)
✚ 93565 for selective left ventricular or left atrial angiography (List separately in addition to code for
primary procedure)
➲ CPT Assistant Aug 11:3, Dec 11:9, Jan 13:6
(Do not report 93563-93565 in conjunction with 93452-93461)

(Use 93563-93565 in conjunction with 93530-93533)
✚ 93566 for selective right ventricular or right atrial angiography (List separately in addition to code for
primary procedure)
➲ CPT Assistant Aug 11:3, Dec 11:9, Jan 13:6, May 15:3, Mar 16:5, May 16:5, Mar 19:6
(Use 93566 in conjunction with 93451, 93453, 93456, 93457, 93460, 93461, 93530-93533)
(Do not report 93566 in conjunction with 33274 for right ventriculography performed during
leadless pacemaker insertion)
(Do not report 93566 in conjunction with 0545T for right ventricular or right atrial angiography
procedures intrinsic to the annulus reconstruction procedure)
✚ 93567 for supravalvular aortography (List separately in addition to code for primary procedure)
➲ CPT Assistant Aug 11:3, Dec 11:9, Jan 13:6, Mar 16:5
(Use 93567 in conjunction with 93451-93461, 93530-93533)

(For non-supravalvular thoracic aortography or abdominal aortography performed at the time of
cardiac catheterization, use the appropriate radiological supervision and interpretation codes
[36221, 75600-75630])
✚ 93568 for pulmonary angiography (List separately in addition to code for primary procedure)
➲ CPT Assistant Aug 11:3, Dec 11:9, Jan 13:6, Mar 16:5, Jun 19:3
(Use 93568 in conjunction with 93451, 93453, 93456, 93457, 93460, 93461, 93530-93533, 93582,
93583)
▶ (Do not report 93568 in conjunction with 0632T)◀
✚ 93571 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement
(coronary vessel or graft) during coronary angiography including pharmacologically induced stress;
initial vessel (List separately in addition to code for primary procedure)
➲ CPT Assistant Nov 98:33, Apr 00:2, Mar 08:4, Aug 11:3, Dec 14:6, May 15:10, Dec 15:17
93461, 93563, 93564)
✚ 93572 each additional vessel (List separately in addition to code for primary procedure)
➲ CPT Assistant Nov 98:34, Apr 00:2, Aug 11:5, Dec 14:6, May 15:10, Dec 15:17

(Intravascular distal coronary blood flow velocity measurements include all Doppler transducer
manipulations and repositioning within the specific vessel being examined, during coronary
angiography or therapeutic intervention [eg, angioplasty])
(For unlisted cardiac catheterization procedure, use 93799)
Intravascular Distal Blood Flow Velocity

93571
A Doppler guidewire is positioned in a proximal coronary artery with the transducer beam parallel to blood flow to measure blood flow velocity.
Repair of Structural Heart Defect

93580 Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration,
atrial septal defect) with implant
(Percutaneous transcatheter closure of atrial septal defect includes a right heart catheterization
procedure. Code 93580 includes injection of contrast for atrial and ventricular angiograms. Codes
93451-93453, 93455-93461, 93530-93533, 93564-93566 should not be reported separately in
addition to code 93580)
93581 Percutaneous transcatheter closure of a congenital ventricular septal defect with implant
(Percutaneous transcatheter closure of ventricular septal defect includes a right heart catheterization
procedure. Code 93581 includes injection of contrast for atrial and ventricular angiograms. Codes
93451-93453, 93455-93461, 93530-93533, 93564-93566 should not be reported separately in
addition to code 93581)
(For echocardiographic services performed in addition to 93580, 93581, see 93303-93317, 93662
as appropriate)
93582 Percutaneous transcatheter closure of patent ductus arteriosus
(93582 includes congenital right and left heart catheterization, catheter placement in the aorta, and
aortic arch angiography, when performed)
(Do not report 93582 in conjunction with 36013, 36014, 36200, 75600, 75605, 93451-93461,
93530, 93531, 93532, 93533, 93567)
(For other cardiac angiographic procedures performed at the time of transcatheter PDA closure, see
93563, 93564, 93565, 93566, 93568 as appropriate)
(For left heart catheterization by transseptal puncture through intact septum or by transapical
puncture performed at the time of transcatheter PDA closure, use 93462)
(For repair of patent ductus arteriosus by ligation, see 33820, 33822, 33824)
(For intracardiac echocardiographic services performed at the time of transcatheter PDA closure,
use 93662. Other echocardiographic services provided by a separate individual are reported using
the appropriate echocardiography service codes, 93315, 93316, 93317)
93583 Percutaneous transcatheter septal reduction therapy (eg, alcohol septal ablation) including
temporary pacemaker insertion when performed
(93583 includes insertion of temporary pacemaker, when performed, and left heart catheterization)
93531, 93532, 93533, 93565)
Cardiac Catheterization Codes

Catheter Placement Type Add-on Procedures (Can Be Reporte
Injection
Procedure
With for
Coronary Transseptal With With Selective
CPT Bypass
Code Descriptor RHC LHC Artery or Pharmacological Exercise Right
Code Graft(s)
Placement Transapical Study Study Ventricular
Puncture or Right
Atrial
Angiography
93462 93463 93464 93566
93451 Right heart X X X X

catheterization
including
measurement(s)
of oxygen
saturation and
cardiac output,
when performed
93452 Left heart X X X X

catheterization
including
intraprocedural
injection(s) for
left
ventriculography,
imaging
supervision and
interpretation,
when performed
93453 Combined right X X X X X X

and left heart
catheterization
including
intraprocedural
injection(s) for
left
ventriculography,
imaging
supervision and
interpretation,
when performed
93454 Catheter X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
93455 Catheter X X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
with catheter
placement(s) in
bypass graft(s),
(internal
mammary, free
arterial, venous
grafts) including
intraprocedural
injection(s) for
bypass graft
angiography
93456 Catheter X X X X X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
with right heart
catheterization
93457 Catheter X X X X X X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
with catheter
placement(s) in
bypass graft(s)
(internal
mammary, free
arterial, venous
grafts) including
intraprocedural
injection(s) for
bypass graft
angiography and
right heart
catheterization
93458 Catheter X X X X X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
with left heart
catheterization
including
intraprocedural
injection(s) for
left
ventriculography,
when performed
93459 Catheter X X X X X X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
with left heart
catheterization
including
intraprocedural
injection(s) for
left
ventriculography,
when performed,
catheter
placement(s) in
bypass graft(s)
(internal
mammary, free
arterial, venous
grafts) with
bypass graft
angiography
93460 Catheter X X X X X X X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
with right and
left heart
catheterization
including
intraprocedural
injection(s) for
left
ventriculography,
when performed
93461 Catheter X X X X X X X X
placement in
coronary
artery(s) for
coronary
angiography,
including
intraprocedural
injection(s) for
coronary
angiography,
imaging
supervision and
interpretation;
with right and
left heart
catheterization
including
intraprocedural
injection(s) for
left
ventriculography,
when performed,
catheter
placement(s) in
bypass graft(s)
(internal
mammary, free
arterial, venous
grafts) with
bypass graft
angiography
(93583 includes left anterior descending coronary angiography for the purpose of roadmapping to
guide the intervention. Do not report 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461,
93563 for coronary angiography performed during alcohol septal ablation for the purpose of
roadmapping, guidance of the intervention, vessel measurement, and completion angiography)
(Diagnostic cardiac catheterization procedures may be separately reportable when no prior
catheter-based diagnostic study of the treatment zone is available, the prior diagnostic study is
inadequate, or the patient’s condition with respect to the clinical indication has changed since the
prior study or during the intervention. Use the appropriate codes from 93451, 93454, 93455, 93456,
93457, 93530, 93563, 93564, 93566, 93567, 93568)
(Do not report 93463 for the injection of alcohol for this procedure)
(For intracardiac echocardiographic services performed at the time of alcohol septal ablation, use
93662)
(Other echocardiographic services provided by a separate physician are reported using the
appropriate echocardiography services codes, 93312, 93313, 93314, 93315, 93316, 93317)
(For surgical ventriculomyotomy [-myectomy] for idiopathic hypertrophic subaortic stenosis, use
33416)
Transcatheter Closure of Paravalvular Leak
Codes 93590, 93591, 93592 are used to report transcatheter closure of paravalvular leak (PVL).
Codes 93590 and 93591 include, when performed, percutaneous access, placing the access
sheath(s), advancing the delivery system to the paravalvular leak, positioning the closure device,
repositioning the closure device as needed, and deploying the device.
Codes 93590 and 93591 include, when performed, fluoroscopy (76000), angiography, radiological
supervision and interpretation services performed to guide the PVL closure (eg, guiding the device
placement and documenting completion of the intervention).
Code 93590 includes transseptal puncture, and left heart catheterization/left ventriculography
(93452, 93453, 93458, 93459, 93460, 93461, 93531, 93532, 93533, 93565), when performed.
Transapical left heart catheterization (93462) may be reported separately, when performed.
Code 93591 includes, when performed, supravalvular aortography (93567), left heart
catheterization/left ventriculography (93452, 93453, 93458, 93459, 93460, 93461, 93531, 93532,
93533, 93565). Transapical left heart catheterization (93462) may be reported separately, when
performed.
Diagnostic right heart catheterization codes (93451, 93456, 93457, 93530) and diagnostic coronary
angiography codes (93454, 93455, 93456, 93457, 93563, 93564) may be reported with 93590,
93591, representing separate and distinct services from PVL closure, if:
1. No prior study is available and a full diagnostic study is performed, or
2. A prior study is available, but as documented in the medical record:
a. there is inadequate visualization of the anatomy and/or pathology, or
b. the patient’s condition with respect to the clinical indication has changed since the prior study,
or
c. there is a clinical change during the procedure that requires new evaluation.
Other cardiac catheterization services may be reported separately, when performed for diagnostic
purposes not intrinsic to PVL closure.
For same session/same day diagnostic cardiac catheterization services, report the appropriate
diagnostic cardiac catheterization code(s) appended with modifier 59 indicating separate and
distinct procedural service from PVL closure.
93590 Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve
(Do not report 93590 in conjunction with 93462 for transseptal puncture)
(For transapical puncture performed in conjunction with 93590, use 93462)
93591 initial occlusion device, aortic valve
(For transseptal or transapical puncture performed in conjunction with 93591, use 93462)
✚ 93592 each additional occlusion device (List separately in addition to code for primary procedure)
Intracardiac Electrophysiological Procedures/Studies

Intracardiac electrophysiologic studies (EPS) are invasive diagnostic medical procedures which
include the insertion and repositioning of electrode catheters, recording of electrograms before and
during pacing, programmed stimulation of multiple locations in the heart, analysis of recorded
information, and report of the procedure. In many circumstances, patients with arrhythmias are
evaluated and treated at the same encounter. In this situation, a diagnostic electrophysiologic study
is performed, induced tachycardia(s) are mapped, and on the basis of the diagnostic and mapping
information, the tissue is ablated.
Definitions
Arrhythmia Induction: In most electrophysiologic studies, an attempt is made to induce
arrhythmia(s) from single or multiple sites within the heart. Arrhythmia induction may be achieved
by multiple techniques, eg, by performing pacing at different rates or programmed stimulation
(introduction of critically timed electrical impulses). Because arrhythmia induction occurs via the
same catheter(s) inserted for the electrophysiologic study(ies), catheter insertion and temporary
pacemaker codes are not additionally reported. Codes 93600-93603, 93610, 93612, and 93618 are
used to describe unusual situations where there may be recording, pacing, or an attempt at
arrhythmia induction from only one site in the heart. Code 93619 describes only evaluation of the
sinus node, atrioventricular node, and His-Purkinje conduction system, without arrhythmia
induction. Codes 93620-93624, 93640-93642, 93653, 93654, and 93656 all include recording,
pacing, and attempted arrhythmia induction from one or more site(s) in the heart.
Mapping: When a tachycardia is induced, the site of tachycardia origination or its electrical path
through the heart is often defined by mapping. Mapping creates a multidimensional depiction of a
tachycardia by recording multiple electrograms obtained sequentially or simultaneously from
multiple catheter sites in the heart. Depending upon the technique, certain types of mapping
catheters may be repositioned from point-to-point within the heart, allowing sequential recording
from the various sites to construct maps. Other types of mapping catheters allow mapping without
a point-to-point technique by allowing simultaneous recording from many electrodes on the same
catheter and computer-assisted three-dimensional reconstruction of the tachycardia activation
sequence.
Mapping is a distinct procedure performed in addition to a diagnostic electrophysiologic study or
ablation procedure and may be separately reported using 93609 or 93613. Do not report standard
mapping (93609) in addition to 3-dimensional mapping (93613).
Ablation: Once the part of the heart involved in the tachycardia is localized, the tachycardia may be
treated by ablation (the delivery of a radiofrequency or cryo-energy to the area to selectively
destroy cardiac tissue). Ablation procedures (93653-93657) are performed at the same session as
electrophysiology studies and therefore represent a combined code description. When reporting
ablation therapy codes (93653-93657), the single site electrophysiology studies (93600-93603,
93610, 93612, 93618) and the comprehensive electrophysiology studies (93619, 93620) may not be
reported separately. Code 93622 may be reported separately with 93653 and 93656. Code 93623
may be reported separately with 93653, 93654, and 93656. However, 93621 for left atrial pacing and
recording from coronary sinus or left atrium should not be reported in conjunction with 93656, as
this procedure is a component of 93656. Codes 93653 and 93654 include right ventricular pacing
and recording and His bundle recording when clinically indicated. When performance of one or
more components is not possible or indicated, document the reason for not performing. Code
93656 includes each of left atrial pacing/recording, right ventricular pacing/recording, and His
bundle recording when clinically indicated. When performance of one or more components is not
possible or indicated, document the reason for not performing.
The differences in the techniques involved for ablation of supraventricular arrhythmias, ventricular
arrhythmias, and atrial fibrillation are reflected within the descriptions for 93653-93657. Code
93653 is a primary code for catheter ablation for treatment of supraventricular tachycardia caused
by dual atrioventricular nodal pathways, accessory atrioventricular connections, or other atrial foci.
Code 93654 describes catheter ablation for treatment of ventricular tachycardia or focus of
ventricular ectopy. Code 93656 is a primary code for reporting treatment of atrial fibrillation by
ablation to achieve complete pulmonary vein electrical isolation. Codes 93653, 93654, and 93656
are distinct primary procedure codes and may not be reported together.
Codes 93655 and 93657 are add-on codes listed in addition to the primary ablation code to report
ablation of sites distinct from the primary ablation site. After ablation of the primary target site,
post-ablation electrophysiologic evaluation is performed as part of those ablation services (93653,
93654, 93656) and additional mechanisms of tachycardia may be identified. For example, if the
primary tachycardia ablated was atrioventricular nodal reentrant tachycardia and during post-
ablation testing an atrial tachycardia, atrial flutter, or accessory pathway with orthodromic reentry
tachycardia was identified, this would be considered a separate mechanism of tachycardia. Pacing
maneuvers are performed to define the mechanism(s) of the new tachycardia(s). Catheter ablation
of this distinct mechanism of tachycardia is then performed at the newly discovered atrial or
ventricular origin. Appropriate post-ablation attempts at re-induction and observation are again
performed. Code 93655 is listed in conjunction with 93653 when repeat ablation is for treatment of
an additional supraventricular tachycardia mechanism and with 93654 when the repeat ablation is
for treatment of an additional ventricular tachycardia mechanism. Code 93655 may be reported
with 93656 when an additional non-atrial fibrillation tachycardia is separately diagnosed after
pulmonary vein isolation. Code 93657 is reported in conjunction with 93656 when successful
pulmonary vein isolation is achieved, attempts at re-induction of atrial fibrillation identify an
additional left or right atrial focus for atrial fibrillation, and further ablation of this new focus is
performed.
In certain circumstances, depending on the chamber of origin, a catheter or catheters may be
maneuvered into the left ventricle to facilitate arrhythmia diagnosis. This may be accomplished via
a retrograde aortic approach by means of the arterial access or through a transseptal puncture. For
ablation treatment of supraventricular tachycardia (93653) and ventricular tachycardia (93654), the
left heart catheterization by transseptal puncture through intact septum (93462) may be reported
separately as an add-on code. However, for ablation treatment of atrial fibrillation (93656), the
transseptal puncture (93462) is a standard component of the procedure and may not be reported
separately. Do not report 93462 in conjunction with 93656.
Modifier 51 should not be appended to 93600-93603, 93610, 93612, 93615-93618.
⃠ 93600 Bundle of His recording
➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Jul 04:13, Aug 05:13, Dec 07:16, Mar 08:4,
Jun 13:6, Jul 13:7, Apr 14:3
⃠ 93602 Intra-atrial recording
➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Jul 04:13, Aug 05:13, Jun 13:6, Jul 13:7,
Apr 14:3
⃠ 93603 Right ventricular recording
➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Jul 04:13, Aug 05:13, Jun 13:6, Jul 13:7,
Apr 14:3
✚ 93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to
record from multiple sites to identify origin of tachycardia (List separately in addition to code for
primary procedure)
➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Aug 05:13, Jun 13:6, Jul 13:7, Apr 14:3

⃠ 93610 Intra-atrial pacing
➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Jul 04:13, Jun 13:6, Jul 13:7, Apr 14:3
⃠ 93612 Intraventricular pacing
➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Jul 04:13, Jun 13:6, Jul 13:7, Apr 14:3
✚ 93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for
primary procedure)
➲ CPT Assistant Apr 04:8, Aug 05:13, Jun 13:6, Jul 13:7, Apr 14:3

⃠ 93615 Esophageal recording of atrial electrogram with or without ventricular electrogram(s);
➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Aug 05:13, Apr 14:3
⃠ 93616 with pacing

➲ CPT Assistant Summer 94:12, Aug 97:9, Apr 04:9, Aug 05:13, Apr 14:3
⃠ 93618 Induction of arrhythmia by electrical pacing

➲ CPT Assistant Summer 94:12, Aug 97:9, Oct 97:10, Apr 99:10, Jun 00:5, Nov 00:9, Apr 04:9,
Jul 04:13, Aug 05:13, Dec 07:16, Jun 13:6, Jul 13:7, Apr 14:3
(For intracardiac phonocardiogram, use 93799)
93619 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right
ventricular pacing and recording, His bundle recording, including insertion and repositioning of
multiple electrode catheters, without induction or attempted induction of arrhythmia
➲ CPT Assistant Aug 97:9, Oct 97:10, Nov 00:9, Apr 04:9, Jul 04:13, Aug 05:13, Dec 07:16, Nov
12:6, Jun 13:6, Jul 13:7, Apr 14:3
93621, 93622, 93653, 93654, 93655, 93656, 93657)
93620 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple
electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and
recording, right ventricular pacing and recording, His bundle recording
➲ CPT Assistant Summer 94:12, Aug 97:9, Oct 97:10, Jul 98:10, Aug 98:7, Nov 00:9, Apr 04:9,
Jul 04:13, Aug 05:13, Dec 07:16, Oct 08:10, Nov 12:6, Jun 13:6, Jul 13:7, Apr 14:3
93653, 93654, 93655, 93656, 93657)
✚ 93621 with left atrial pacing and recording from coronary sinus or left atrium (List separately in
➲ CPT Assistant Summer 94:12, Aug 97:9, Oct 97:10, Jul 98:10, Aug 98:7, Nov 98:34, Nov
00:9, Apr 04:9, Jul 04:13, Aug 05:13, Dec 07:16, Oct 08:10, Nov 12:6, Jun 13:6, Jul 13:7,
Apr 14:3
✚ 93622 with left ventricular pacing and recording (List separately in addition to code for primary
procedure)
➲ CPT Assistant Summer 94:14, Aug 97:9, Oct 97:10, Jul 98:10, Aug 98:7, Nov 98:34, Nov
00:9, Apr 04:9, Jul 04:13, Aug 05:13, Dec 07:16, Mar 08:4, Nov 12:6, Jun 13:6, Jul 13:7,
Apr 14:3
✚ 93623 Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to
➲ CPT Assistant Summer 94:14, Aug 97:9, Nov 00:9, Aug 05:13, Dec 07:16, Oct 08:10, Apr 14:3
93624 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy,
including induction or attempted induction of arrhythmia
➲ CPT Assistant Summer 94:14, Aug 97:9, Nov 00:9, Aug 05:13, Dec 07:16
93631 Intra-operative epicardial and endocardial pacing and mapping to localize the site of tachycardia or
zone of slow conduction for surgical correction
➲ CPT Assistant Summer 94:14, Aug 97:9, Nov 00:9, Aug 05:13, Dec 07:16
(For operative ablation of an arrhythmogenic focus or pathway by a separate individual, see 33250-
33261)
93640 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads
including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and
pacing for arrhythmia termination) at time of initial implantation or replacement;
➲ CPT Assistant Summer 94:14, Aug 97:9, Apr 99:10, Nov 99:50, Nov 00:9, Aug 05:13, Jun 12:3
93641 with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator
➲ CPT Assistant Summer 94:14, Aug 97:9, Apr 99:10, Nov 99:50, Jun 00:5, Jul 00:5, Nov
00:9, Aug 05:13, Jun 12:3, Apr 14:3
(For subsequent or periodic electronic analysis and/or reprogramming of single or dual chamber
pacing cardioverter-defibrillators, see 93282, 93283, 93289, 93292, 93295, 93642)
93642 Electrophysiologic evaluation of single or dual chamber transvenous pacing cardioverter-
defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of
sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or
therapeutic parameters)
➲ CPT Assistant Summer 94:14, Aug 97:9, Nov 99:50, Jun 00:5, Nov 00:9, Aug 05:13, Jun 13:6,
Jul 13:7, Apr 14:3
93644 Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation
threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and
programming or reprogramming of sensing or therapeutic parameters)
(Do not report 93644 in conjunction with 33270 at the time of subcutaneous implantable
defibrillator device insertion)
(For subsequent or periodic electrophysiologic evaluation of a subcutaneous implantable
defibrillator device, see 93260, 93261)
(For electrophysiological evaluation of subcutaneous implantable defibrillator system, with
substernal electrode, use 0577T)
93650 Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for
creation of complete heart block, with or without temporary pacemaker placement
➲ CPT Assistant Summer 94:15, Aug 97:9, Nov 00:9, Aug 05:13, Apr 12:18, May 12:15
93653 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple

electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing
and recording, right ventricular pacing and recording (when necessary), and His bundle recording
(when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of
supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory
atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-
entry
➲ CPT Assistant Jun 13:6, Jul 13:7, Apr 14:3
(Do not report 93653 in conjunction with 93600-93603, 93610, 93612, 93618-93620, 93642,
93654, 93656)
93654 with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac
electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording,
when performed
➲ CPT Assistant Jun 13:6, Jul 13:7, Apr 14:3
(Do not report 93654 in conjunction with 93279-93284, 93286-93289, 93600-93603, 93609,
93610, 93612, 93613, 93618-93620, 93622, 93642, 93653, 93656)
✚ 93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the
primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or
induced arrhythmia (List separately in addition to code for primary procedure)

93656 Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and
repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia
including left or right atrial pacing/recording when necessary, right ventricular pacing/recording
when necessary, and His bundle recording when necessary with intracardiac catheter ablation of
atrial fibrillation by pulmonary vein isolation
➲ CPT Assistant Jun 13:6, Jul 13:7, Apr 14:3, Sep 19:10
(Do not report 93656 in conjunction with 93279-93284, 93286-93289, 93462, 93600, 93602,
93603, 93610, 93612, 93618, 93619, 93620, 93621, 93653, 93654)
✚ 93657 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of
atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition
➲ CPT Assistant Jun 13:6, Jul 13:7, Apr 14:3, Sep 19:10

93660 Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring
and intermittent blood pressure monitoring, with or without pharmacological intervention
(For testing of autonomic nervous system function, see 95921, 95924, 95943)
✚ 93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging
supervision and interpretation (List separately in addition to code for primary procedure)
(Use 93662 in conjunction with 92987, 93453, 93460-93462, 93532, 93580, 93581, 93582, 93583,
93620, 93621, 93622, 93653, 93654, 93656 as appropriate)
▶ (Do not report 93662 in conjunction with 92961, 0569T, 0570T, 0613T)◀
Peripheral Arterial Disease Rehabilitation

▶Peripheral arterial disease (PAD) rehabilitative physical exercise consists of a series of sessions,
lasting 45-60 minutes per session, involving use of either a motorized treadmill or a track to permit
each patient to achieve symptom-limited claudication. Each session is supervised by an exercise
physiologist or nurse. The supervising provider monitors the individual patient’s claudication
threshold and other cardiovascular limitations for adjustment of workload. During this supervised
rehabilitation program, the development of new arrhythmias, symptoms that might suggest angina
or the continued inability of the patient to progress to an adequate level of exercise may require
review and examination of the patient by a physician or other qualified health care professional.
These services would be separately reported with an appropriate level E/M service code including
office or other outpatient services (99202-99215), initial hospital care (99221-99223), subsequent
hospital care (99231-99233), critical care services (99291-99292).◀
93668 Peripheral arterial disease (PAD) rehabilitation, per session
Noninvasive Physiologic Studies and Procedures

(For arterial cannulization and recording of direct arterial pressure, use 36620)
(For radiographic injection procedures, see 36000-36299)
(For vascular cannulization for hemodialysis, see 36800-36821)
(For chemotherapy for malignant disease, see 96409-96549)
(For penile plethysmography, use 54240)
93701 Bioimpedance-derived physiologic cardiovascular analysis
(For bioelectrical impedance analysis whole body composition, use 0358T. For left ventricular
filling pressure indirect measurement by computerized calibration of the arterial waveform
response to Valsalva, use 93799)
93702 Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)
(For bioelectrical impedance analysis whole body composition, use 0358T)

(For bioimpedance-derived physiological cardiovascular analysis, use 93701)
93724 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording,
programming of device, induction and termination of tachycardia via implanted pacemaker, and
interpretation of recordings)
93740 Temperature gradient studies

93745 Initial set-up and programming by a physician or other qualified health care professional of
wearable cardioverter-defibrillator includes initial programming of system, establishing baseline
electronic ECG, transmission of data to data repository, patient instruction in wearing system and
patient reporting of problems or events

93750 Interrogation of ventricular assist device (VAD), in person, with physician or other qualified health
care professional analysis of device parameters (eg, drivelines, alarms, power surges), review of
device function (eg, flow and volume status, septum status, recovery), with programming, if
performed, and report
(Do not report 93750 in conjunction with 33975, 33976, 33979, 33981-33983)
93770 Determination of venous pressure
(For central venous cannulization see 36555-36556, 36500)
93784 Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn
continuously for 24 hours or longer; including recording, scanning analysis, interpretation and report
93786 recording only

93788 scanning analysis with report

93790 review with interpretation and report

(For self-measured blood pressure monitoring, see 99473, 99474)
Home and Outpatient International Normalized Ratio (INR)

Monitoring Services
Home and outpatient international normalized ratio (INR) monitoring services describe the
management of warfarin therapy, including ordering, review, and interpretation of new INR test
result(s), patient instructions, and dosage adjustments as needed.
If a significantly, separately identifiable evaluation and management (E/M) service is performed on
the same day as 93792, the appropriate E/M service may be reported using modifier 25.
Do not report 93793 on the same day as an E/M service.
▶Do not report 93792, 93793 in conjunction with 98966, 98967, 98968, 98970, 98971, 98972,
99421, 99422, 99423, 99441, 99442, 99443, when telephone or online digital evaluation and
management services address home and outpatient INR monitoring.
Do not count time spent in 93792, 93793 in the time of 99439, 99487, 99489, 99490, 99491, when
reported in the same calendar month.◀
93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring
under the direction of a physician or other qualified health care professional, face-to-face, including
use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test
results, and documentation of patient’s/caregiver’s ability to perform testing and report results
(For provision of test materials and equipment for home INR monitoring, see 99070 or the
appropriate supply code)
93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a
new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage
adjustment (as needed), and scheduling of additional test(s), when performed
➲ CPT Assistant Nov 17:11, Mar 18:7, Feb 20:7
▶ (Donot report 93793 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99241, 99242, 99243, 99244, 99245)◀
(Report 93793 no more than once per day, regardless of the number of tests reviewed)
Other Procedures
93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation;
without continuous ECG monitoring (per session)
93798 with continuous ECG monitoring (per session)

93799 Unlisted cardiovascular service or procedure

➲ CPT Assistant Mar 98:11, Mar 02:10, Nov 05:15, Apr 09:9, Jul 10:10, Oct 11:7, Nov 11:11,
Dec 13:18, Aug 18:11, Sep 18:10, Dec 18:11
Noninvasive Vascular Diagnostic Studies

Vascular studies include patient care required to perform the studies, supervision of the studies and
interpretation of study results with copies for patient records of hard copy output with analysis of
all data, including bidirectional vascular flow or imaging when provided.
The use of a simple hand-held or other Doppler device that does not produce hard copy output, or
that produces a record that does not permit analysis of bidirectional vascular flow, is considered to
be part of the physical examination of the vascular system and is not separately reported. The
Ankle-Brachial Index (or ABI) is reportable with 93922 or 93923 as long as simultaneous Doppler
recording and analysis of bidirectional blood flow, volume plethysmography, or transcutaneous
oxygen tension measurements are also performed.
Duplex scan (eg, 93880, 93882) describes an ultrasonic scanning procedure for characterizing the
pattern and direction of blood flow in arteries or veins with the production of real-time images
integrating B-mode two-dimensional vascular structure, Doppler spectral analysis, and color flow
Doppler imaging.
Physiologic studies Noninvasive physiologic studies are performed using equipment separate and
distinct from the duplex ultrasound imager. Codes 93922, 93923, 93924 describe the evaluation of
non-imaging physiologic recordings of pressures with Doppler analysis of bi-directional blood
flow, plethysmography, and/or oxygen tension measurements appropriate for the anatomic area
studied.
Limited studies for lower extremity require either:
(1) ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus
bidirectional Doppler waveform recording and analysis at 1-2 levels; or (2) ankle/brachial indices
at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-
2 levels; or (3) ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis
arteries with transcutaneous oxygen tension measurements at 1-2 levels. Potential levels include
high thigh, low thigh, calf, ankle, metatarsal and toes.
Limited studies for upper extremity require either:
(1) Doppler-determined systolic pressures and bidirectional Doppler waveform recording and
analysis at 1-2 levels; or (2) Doppler-determined systolic pressures and volume plethysmography at
1-2 levels; or (3) Doppler-determined systolic pressures and transcutaneous oxygen tension
measurements at 1-2 levels. Potential levels include arm, forearm, wrist, and digits.
Complete studies for lower extremity require either:
(1) ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus
bidirectional Doppler waveform recording and analysis at 3 or more levels; or (2) ankle/brachial
indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume
plethysmography at 3 or more levels; or (3) ankle/brachial indices at distal posterior tibial and
anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 3 or
more levels. Alternatively, a complete study may be reported with measurements at a single level if
provocative functional maneuvers (eg, measurements with postural provocative tests, or
measurements with reactive hyperemia) are performed.
Complete studies for upper extremity require either:
(1) Doppler-determined systolic pressures and bidirectional Doppler waveform recording and
analysis at 3 or more levels; or (2) Doppler-determined systolic pressures and volume
plethysmography at 3 or more levels; or (3) Doppler-determined systolic pressures and
transcutaneous oxygen tension measurements at 3 or more levels. Potential levels include arm,
forearm, wrist, and digits. Alternatively, a complete study may be reported with measurements at a
single level if provocative functional maneuvers (eg, measurements with postural provocative tests,
or measurements with cold stress) are performed.
Cerebrovascular Arterial Studies

A complete transcranial Doppler (TCD) study (93886) includes ultrasound evaluation of the right
and left anterior circulation territories and the posterior circulation territory (to include vertebral
arteries and basilar artery). In a limited TCD study (93888) there is ultrasound evaluation of two or
fewer of these territories. For TCD, ultrasound evaluation is a reasonable and concerted attempt to
identify arterial signals through an acoustic window.
▶Code 93895 includes the acquisition and storage of images of the common carotid arteries,
carotid bulbs, and internal carotid arteries bilaterally with quantification of intima media thickness
(common carotid artery mean and maximal values) and determination of presence of
atherosclerotic plaque.◀
93880 Duplex scan of extracranial arteries; complete bilateral study
➲ Clinical Examples in Radiology Fall 07:6, Winter 09:2, Winter 13:8, Winter 18:15

93882 unilateral or limited study
➲ Clinical Examples in Radiology Fall 07:6, Winter 09:2, Winter 13:8, Winter 18:15

93886 Transcranial Doppler study of the intracranial arteries; complete study
93888 limited study

93890 vasoreactivity study

93892 emboli detection without intravenous microbubble injection

93893 emboli detection with intravenous microbubble injection

93895 Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral

Extremity Arterial Studies (Including Digits)

93922 Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for
lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis
arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or
ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus
volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and
anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2
levels)
➲ CPT Assistant Jun 96:9, Dec 05:3, Aug 09:3, Jun 12:16, Jun 13:14, Jan 14:10
➲ Clinical Examples in Radiology Spring 11:5, 6, Summer 11:11, Winter 18:15
(When only 1 arm or leg is available for study, report 93922 with modifier 52 for a unilateral study
when recording 1-2 levels. Report 93922 when recording 3 or more levels or performing
provocative functional maneuvers)
(Report 93922 only once in the upper extremity(s) and/or once in the lower extremity(s). When both
the upper and lower extremities are evaluated in the same setting, 93922 may be reported twice by
adding modifier 59 to the second procedure)
(For transcutaneous oxyhemoglobin measurement in a lower extremity wound by near infrared
spectroscopy, use 0493T)
▶ (Fortranscutaneous visible light hyperspectral imaging measurement of oxyhemoglobin,
deoxyhemoglobin, and tissue oxygenation, use 0631T)◀
93923 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more
levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior
tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional
Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal
posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at
3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis
pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or
single level study with provocative functional maneuvers (eg, measurements with postural
provocative tests, or measurements with reactive hyperemia)
➲ CPT Assistant Jun 96:9, Jun 01:10, Dec 05:3, Aug 09:3, Jun 12:16, Jan 14:10
➲ Clinical Examples in Radiology Spring 11:5, 6, Summer 11:11, Winter 18:15
(When only 1 arm or leg is available for study, report 93922 for a unilateral study when recording 3
or more levels or when performing provocative functional maneuvers)
(Report 93923 only once in the upper extremity(s) and/or once in the lower extremity(s). When both
the upper and lower extremities are evaluated in the same setting, 93923 may be reported twice by
adding modifier 59 to the second procedure)
▶ (Fortranscutaneous visible light hyperspectral imaging measurement of oxyhemoglobin,
deoxyhemoglobin, and tissue oxygenation, use 0631T)◀
93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress
testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at
rest with ankle/brachial indices immediately after and at timed intervals following performance of a
standardized protocol on a motorized treadmill plus recording of time of onset of claudication or
other symptoms, maximal walking time, and time to recovery) complete bilateral study
➲ CPT Assistant Jun 96:9, Dec 05:3, Aug 09:3, Jun 12:16, Jan 14:10

93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study
➲ CPT Assistant Jun 96:9, Dec 05:3, Sep 16:9
(Do not report 93925 in conjunction with 93985 for the same extremities)
➲ CPT Assistant Jun 96:9, Oct 01:2, Dec 05:3, Sep 16:9
➲ Clinical Examples in Radiology Fall 09:4, 5, Winter 18:15
(Do not report 93926 in conjunction with 93986 for the same extremity)
93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study
➲ CPT Assistant Jun 96:9, Dec 05:3, Sep 16:9
(Do not report 93930 in conjunction with 93985, 93986 for the same extremity[ies])
➲ CPT Assistant Jun 96:9, Oct 01:2, Dec 05:3, Sep 16:9
(Do not report 93931 in conjunction with 93985, 93986 for the same extremity)
Extremity Venous Studies (Including Digits)

93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete
bilateral study
➲ CPT Assistant Jun 96:9, Dec 05:3, Jan 12:13, Feb 12:11, Oct 14:6, Sep 16:9
➲ Clinical Examples in Radiology Spring 12:8, Spring 17:11, Winter 18:15
(Do not report 93970 in conjunction with 93985, 93986 for the same extremity[ies])
➲ CPT Assistant Jun 96:9, Oct 01:2, Mar 03:21, Dec 05:3, Jul 10:6, Apr 11:13, Jan 12:13, Feb
12:11, Oct 14:6, Aug 15:8, Sep 16:9
➲ Clinical Examples in Radiology Winter 08:11, Fall 09:4, 5, Spring 17:11, Winter 18:15
(Do not report 93971 in conjunction with 93985, 93986 for the same extremity)
Visceral and Penile Vascular Studies

93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or
retroperitoneal organs; complete study
➲ CPT Assistant Apr 96:11, Jun 96:9, Dec 05:3, Jun 14:15, Mar 15:10, Aug 16:10
➲ Clinical Examples in Radiology Spring 08:9, Winter 08:10, Summer 09:12, Summer 12:7,
Summer 15:10, Winter 15:11, Winter 18:15
93976 limited study
➲ CPT Assistant Apr 96:11, Jun 96:9, Dec 05:3, Mar 15:10, Aug 16:10
➲ Clinical Examples in Radiology Spring 08:10, Summer 09:12, Summer 12:7, Summer 15:10,
Winter 18:15
93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study
➲ Clinical Examples in Radiology Spring 07:5-6, Spring 17:5, Winter 18:15

➲ CPT Assistant Jun 96:9, Dec 05:3, Jun 14:15
(For ultrasound screening study for abdominal aortic aneurysm [AAA], real time with image
documentation, use 76706)
93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study
93981 follow-up or limited study

Extremity Arterial-Venous Studies

A complete extremity duplex scan (93985, 93986) includes evaluation of both arterial inflow and
venous outflow for preoperative vessel assessment prior to creation of hemodialysis access. If only
an arterial extremity duplex scan is performed, see 93925, 93926, 93930, 93931. If only a venous
extremity duplex scan is performed, see 93970, 93971. If a physiologic arterial evaluation of
extremities is performed, see 93922, 93923, 93924.
93985 Duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to
creation of hemodialysis access; complete bilateral study
(Do not report 93985 in conjunction with 93925, 93930, 93970 for the same extremity[ies])
(Do not report 93985 in conjunction with 93990 for the same extremity)
93986 complete unilateral study
(Do not report 93986 in conjunction with 93926, 93931, 93971, 93990 for the same extremity)
93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)
➲ Clinical Examples in Radiology Spring 07:5-6, Winter 18:15
(For measurement of hemodialysis access flow using indicator dilution methods, use 90940)
Other Noninvasive Vascular Diagnostic Studies

93998 Unlisted noninvasive vascular diagnostic study
➲ CPT Assistant Sep 12:9, Jan 14:10
Pulmonary
Ventilator Management
94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or
controlled breathing; hospital inpatient/observation, initial day
➲ CPT Assistant Feb 07:10, Mar 07:10, Apr 07:3, Jul 07:1, Nov 08:5, May 14:4, Oct 14:9, Aug
19:8
94003 hospital inpatient/observation, each subsequent day
➲ CPT Assistant Feb 07:10, Apr 07:3, Jul 07:1, Nov 08:5, May 14:4, Aug 19:8
94004 nursing facility, per day
➲ CPT Assistant Feb 07:10, Apr 07:3, Jul 07:1, Nov 08:5, Aug 19:8
▶ (Donot report 94002-94004 in conjunction with evaluation and management services 99202-
99499)◀
94005 Home ventilator management care plan oversight of a patient (patient not present) in home,
domiciliary or rest home (eg, assisted living) requiring review of status, review of laboratories and
other studies and revision of orders and respiratory care plan (as appropriate), within a calendar
month, 30 minutes or more
➲ CPT Assistant Mar 07:11, Apr 07:3, Nov 08:5, Oct 14:9
(Do not report 94005 in conjunction with 99339, 99340, 99374-99378)

(Ventilator management care plan oversight is reported separately from home or domiciliary, rest
home [eg, assisted living] services. A physician or other qualified health care professional may
report 94005, when performed, including when a different individual reports 99339, 99340, 99374-
99378 for the same 30 days)
Pulmonary Diagnostic Testing and Therapies

▶Codes 94010-94799 include laboratory procedure(s) and interpretation of test results. If a
separate identifiable evaluation and management service is performed, the appropriate E/M service
code including new or established patient office or other outpatient services (99202-99215), office
or other outpatient consultations (99241-99245), emergency department services (99281-99285),
nursing facility services (99304-99318), domiciliary, rest home, or custodial care services (99324-
99337), and home services (99341-99350) may be reported in addition to 94010-94799.◀
Spirometry (94010) measures expiratory airflow and volumes and forms the basis of most
pulmonary function testing. When spirometry is performed before and after administration of a
bronchodilator, report 94060. Measurement of vital capacity (94150) is a component of spirometry
and is only reported when performed alone. The flow-volume loop (94375) is used to identify
patterns of inspiratory and/or expiratory obstruction in central or peripheral airways. Spirometry
(94010, 94060) includes maximal breathing capacity (94200) and flow-volume loop (94375), when
performed.
Measurement of lung volumes may be performed using plethysmography, helium dilution or
nitrogen washout. Plethysmography (94726) is utilized to determine total lung capacity, residual
volume, functional residual capacity, and airway resistance. Nitrogen washout or helium dilution
(94727) may be used to measure lung volumes, distribution of ventilation and closing volume.
Oscillometry (94728) assesses airway resistance and may be reported in addition to gas dilution
techniques. Spirometry (94010, 94060) and bronchial provocation (94070) are not included in
94726 and 94727 and may be reported separately.
Diffusing capacity (94729) is most commonly performed in conjunction with lung volumes or
spirometry and is an add-on code to 94726-94728, 94010, 94060, 94070, and 94375.
Pulmonary function tests (94011-94013) are reported for measurements in infants and young
children through 2 years of age.
Pulmonary function testing measurements are reported as actual values and as a percent of
predicted values by age, gender, height, and race.
Chest wall manipulation for the mobilization of secretions and improvement in lung function can
be performed using manual (94667, 94668) or mechanical (94669) methods. Manual techniques
include cupping, percussing, and use of a hand-held vibration device. A mechanical technique is
the application of an external vest or wrap that delivers mechanical oscillation.
94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow
rate measurement(s), with or without maximal voluntary ventilation
➲ CPT Assistant Summer 91:16, Summer 95:4, Feb 96:9, Mar 96:10, Nov 97:45,
Nov 98:35, Jan 99:8, Feb 99:9, Aug 03:15, Jul 05:11, Nov 08:5, Oct 10:15, Dec
10:15, Aug 12:6, 7, Nov 12:14, Dec 13:12, Mar 14:11, Sep 15:9, Mar 19:11, Apr
19:11, May 19:10
94011 Measurement of spirometric forced expiratory flows in an infant or child through 2
years of age
➲ CPT Assistant May 10:7, Aug 12:6, Dec 13:12
94012 Measurement of spirometric forced expiratory flows, before and after bronchodilator,
in an infant or child through 2 years of age
94013 Measurement of lung volumes (ie, functional residual capacity [FRC], forced vital
capacity [FVC], and expiratory reserve volume [ERV]) in an infant or child through 2
years of age
➲ CPT Assistant May 10:7, Aug 12:6, Dec 13:12
94014 Patient-initiated spirometric recording per 30-day period of time; includes reinforced
education, transmission of spirometric tracing, data capture, analysis of transmitted
data, periodic recalibration and review and interpretation by a physician or other
➲ CPT Assistant Summer 95:4, Nov 98:34, Jan 99:8, Jul 05:11, Nov 08:5
94015 recording (includes hook-up, reinforced education, data transmission, data capture,
trend analysis, and periodic recalibration)
94016 review and interpretation only by a physician or other qualified health care
professional
94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator

administration
➲ CPT Assistant Summer 95:4, Feb 96:9, Feb 97:10, Nov 98:34, Jan 99:8, Feb 99:9,
Jul 05:11, Nov 08:5, Dec 10:15, Aug 12:6, 7, Mar 14:11, Sep 15:9, Apr 19:11
(Report bronchodilator supply separately with 99070 or appropriate supply code)
▶ (Forexercise test for bronchospasm with pre- and postspirometry, see 94617,
94619)◀
94070 Bronchospasm provocation evaluation, multiple spirometric determinations as in
94010, with administered agents (eg, antigen[s], cold air, methacholine)
➲ CPT Assistant Summer 91:16, Summer 95:4, Feb 96:9, Nov 97:45, Jan 99:8, Jul
05:11, Nov 08:5, Aug 12:6, Nov 12:11, Sep 15:9
(Report antigen[s] administration separately with 99070 or appropriate supply code)
94150 Vital capacity, total (separate procedure)
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 05:11, Nov 08:5, Dec 10:15, Aug 12:6,
Mar 14:11, Sep 18:14
(Do not report 94150 in conjunction with 94010, 94060, 94728. To report thoracic gas
volumes, see 94726, 94727)
94200 Maximum breathing capacity, maximal voluntary ventilation
➲ CPT Assistant Summer 95:4, Feb 96:9, Aug 03:15, Jul 05:11, Nov 08:5, Dec
10:15, Aug 12:6, 7, Mar 14:11
94375 Respiratory flow volume loop
➲ CPT Assistant Summer 95:4, Feb 96:9, Oct 03:2, Jul 05:11, Jul 06:4, Jul 07:1, Nov
08:5, Aug 12:6, 7, Mar 14:11
94450 Breathing response to hypoxia (hypoxia response curve)
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 05:11, Nov 08:5
(For high altitude simulation test [HAST], see 94452, 94453)

94452 High altitude simulation test (HAST), with interpretation and report by a physician or
other qualified health care professional;
(For obtaining arterial blood gases, use 36600)

94453 with supplemental oxygen titration
(For obtaining arterial blood gases, use 36600)

⃠ 94610 Intrapulmonary surfactant administration by a physician or other qualified health care
professional through endotracheal tube
➲ CPT Assistant Apr 07:3, Jul 08:7, Nov 08:5, Dec 10:15

(Report 94610 once per dosing episode)
▲ 94617 Exercise test for bronchospasm, including pre- and post-spirometry and pulse
oximetry; with electrocardiographic recording(s)
➲ CPT Assistant Oct 17:3, Mar 19:11, May 19:10
#● 94619 without electrocardiographic recording(s)

94618 Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate,
oximetry, and oxygen titration, when performed
➲ CPT Assistant Oct 17:3, Mar 19:11, May 19:10

(94620 has been deleted. To report pulmonary stress testing, use 94618)
94621 Cardiopulmonary exercise testing, including measurements of minute ventilation, CO2
production, O2 uptake, and electrocardiographic recordings
➲ CPT Assistant Summer 95:4, Nov 98:35, Jan 99:8, Aug 02:10, Jul 05:11, Nov
08:5, Nov 12:14, Oct 17:3, May 19:10
▶ (Donot report 94617, 94619, 94621 in conjunction with 93000, 93005, 93010,
93040, 93041, 93042 for ECG monitoring performed during the same session)◀
▶ (Donot report 94617, 94619, 94621 in conjunction with 93015, 93016, 93017,
93018)◀
▶ (Do not report 94621 in conjunction with 94680, 94681, 94690)◀
▶ (Do not report 94617, 94618, 94619, 94621 in conjunction with 94760, 94761)◀
94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction for
therapeutic purposes and/or for diagnostic purposes such as sputum induction with an
aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure
breathing (IPPB) device
➲ CPT Assistant Summer 95:4, Feb 96:9, May 98:10, Apr 00:11, Jul 05:11, Apr
07:3, Nov 08:5, Sep 10:3, Dec 13:12, Mar 14:11, Sep 15:9
(For more than 1 inhalation treatment performed on the same date, append modifier
76)
(For continuous inhalation treatment of 1 hour or more, see 94644, 94645)
94642 Aerosol inhalation of pentamidine for pneumocystis carinii pneumonia treatment or
prophylaxis
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 05:11, Nov 08:5
94644 Continuous inhalation treatment with aerosol medication for acute airway obstruction;
first hour
➲ CPT Assistant Apr 07:3, Nov 08:5, Mar 14:11, Sep 15:9
(For services of less than 1 hour, use 94640)

✚ 94645 each additional hour (List separately in addition to code for primary procedure)
➲ CPT Assistant Apr 07:3, Nov 08:5, Mar 14:11, Sep 15:9

94660 Continuous positive airway pressure ventilation (CPAP), initiation and management
➲ CPT Assistant Fall 92:30, Spring 95:4, Summer 95:4, Feb 96:9, Jan 99:10, Aug
00:2, Oct 03:2, Jul 05:11, Jul 06:4, Feb 07:10, Jul 07:1, Nov 08:5, May 14:4, Oct
14:9, Aug 19:8
94662 Continuous negative pressure ventilation (CNP), initiation and management
➲ CPT Assistant Fall 92:30, Spring 94:4, Summer 95:4, Feb 96:9, Aug 00:2, Jul
05:11, Feb 07:10, Jul 07:1, Nov 08:5, May 14:4, Aug 19:8
94664 Demonstration and/or evaluation of patient utilization of an aerosol generator,
nebulizer, metered dose inhaler or IPPB device
➲ CPT Assistant Summer 95:4, Feb 96:9, May 98:10, Apr 00:11, Jul 05:11, Nov
08:5, Sep 10:3, Dec 13:12
(94664 can be reported 1 time only per day of service)
94667 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung
function; initial demonstration and/or evaluation
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 05:11, Nov 08:5, Sep 10:3, Dec 13:12,
Mar 14:11, Sep 15:9
94668 subsequent
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 05:11, Sep 10:3, Dec 13:12, Mar
14:11, Sep 15:9
94669 Mechanical chest wall oscillation to facilitate lung function, per session
94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 05:11
94681 including CO2 output, percentage oxygen extracted

94690 rest, indirect (separate procedure)
(For single arterial puncture, use 36600)

(Do not report 94680, 94681, 94690 in conjunction with 94621)
94726 Plethysmography for determination of lung volumes and, when performed, airway
resistance
➲ CPT Assistant Jan 12:3, Aug 12:6, May 13:11

94727 Gas dilution or washout for determination of lung volumes and, when performed,
distribution of ventilation and closing volumes
➲ CPT Assistant Jan 12:3, Aug 12:6, May 13:11

94728 Airway resistance by oscillometry
➲ CPT Assistant Jan 12:3, Aug 12:6, May 13:11, Mar 14:11
✚ 94729 Diffusing capacity (eg, carbon monoxide, membrane) (List separately in addition to
➲ CPT Assistant Jan 12:3, Aug 12:6, Dec 13:12
(Report 94729 in conjunction with 94010, 94060, 94070, 94375, 94726-94728)

94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination
➲ CPT Assistant Summer 95:4, Feb 96:9, Feb 97:10, Jul 98:2, Oct 03:2, Jul 05:11,
Feb 06:9, Jul 06:4, Feb 07:10, Apr 07:1, Jul 07:1, Dec 10:15, May 14:4, Aug 19:8
(For blood gases, see 82803-82810)
94761 multiple determinations (eg, during exercise)
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 98:2, Jun 99:10, Jul 05:11, Feb
06:9, Jul 06:4, Feb 07:10, Apr 07:1, Jun 07:11, Jul 07:1, Dec 08:5, May 14:4,
Aug 19:8
▶ (Do not report 94760, 94761 in conjunction with 94617, 94618, 94619, 94621)◀
94762 by continuous overnight monitoring (separate procedure)
➲ CPT Assistant Summer 95:4, Feb 96:9, Jul 98:2, Oct 03:2, Jul 05:11, Feb 06:9,
Jul 06:4, Feb 07:10, Apr 07:1, Jul 07:1, Dec 08:5, May 14:4, Aug 19:8
(For other in vivo laboratory procedures, see 88720-88741)
94772 Circadian respiratory pattern recording (pediatric pneumogram), 12-24 hour
continuous recording, infant
(Separate procedure codes for electromyograms, EEG, ECG, and recordings of

respiration are excluded when 94772 is reported)
94774 Pediatric home apnea monitoring event recording including respiratory rate, pattern
and heart rate per 30-day period of time; includes monitor attachment, download of
data, review, interpretation, and preparation of a report by a physician or other
(Do not report 94774 in conjunction with 94775-94777 during the same reporting
period)
94775 monitor attachment only (includes hook-up, initiation of recording and
disconnection)
94776 monitoring, download of information, receipt of transmission(s) and analyses by

computer only
94777 review, interpretation and preparation of report only by a physician or other

(When oxygen saturation monitoring is used in addition to heart rate and respiratory
monitoring, it is not reported separately)
(Do not report 94774-94777 in conjunction with 93224-93272)
(Do not report apnea recording device separately)
(For sleep study, see 95805-95811)
94780 Car seat/bed testing for airway integrity, for infants through 12 months of age, with
continual clinical staff observation and continuous recording of pulse oximetry, heart
rate and respiratory rate, with interpretation and report; 60 minutes
(Do not report 94780 for less than 60 minutes)

(Do not report 94780 in conjunction with 93040-93042, 94760, 94761, 99468-99472,
99477-99480)
✚ 94781 each additional full 30 minutes (List separately in addition to code for primary
procedure)
94799 Unlisted pulmonary service or procedure
➲ CPT Assistant Summer 95:4, Feb 96:9, Mar 96:10, Jul 05:11, Dec 10:15, Nov
12:14, Dec 13:12, May 15:11, Dec 15:17, Sep 18:14, Mar 19:11
Allergy and Clinical Immunology

Definitions
Immunotherapy (desensitization, hyposensitization): is the parenteral administration of
allergenic extracts as antigens at periodic intervals, usually on an increasing dosage
scale to a dosage which is maintained as maintenance therapy. Indications for
immunotherapy are determined by appropriate diagnostic procedures coordinated with
clinical judgment and knowledge of the natural history of allergic diseases.
Other therapy: for medical conferences on the use of mechanical and electronic devices
(precipitators, air conditioners, air filters, humidifiers, dehumidifiers), climatotherapy,
physical therapy, occupational and recreational therapy, see Evaluation and
Management services.
▶Do not report evaluation and management (E/M) services for test interpretation and
report. If a significant separately identifiable E/M service is performed, the appropriate
E/M service code, which may include new or established patient office or other
outpatient services (99202-99215), hospital observation services (99217-99220, 99224-
99226), hospital care (99221-99223, 99231-99233), consultations (99241-99255),
emergency department services (99281-99285), nursing facility services (99304-99318),
domiciliary, rest home, or custodial care services (99324-99337), home services (99341-
99350), or preventive medicine services (99381-99429), should be reported using
modifier 25.◀
Allergy Testing
(For allergy laboratory tests, see 86000-86999)
(For administration of medications [eg, epinephrine, steroidal agents, antihistamines]
for therapy for severe or intractable allergic reaction, use 96372)
95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type
reaction, including test interpretation and report, specify number of tests
➲ CPT Assistant Summer 91:15, May 10:3, Jan 13:9
95012 Nitric oxide expired gas determination

➲ CPT Assistant Mar 07:11, Apr 07:6, Jan 13:9, Mar 14:11
95017 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and
intracutaneous (intradermal), sequential and incremental, with venoms, immediate type
reaction, including test interpretation and report, specify number of tests
95018 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and
intracutaneous (intradermal), sequential and incremental, with drugs or biologicals,
immediate type reaction, including test interpretation and report, specify number of
tests
95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction,
including test interpretation and report, specify number of tests
95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts
for airborne allergens, immediate type reaction, including test interpretation and
report, specify number of tests
➲ CPT Assistant Summer 91:15, Jun 97:10, Dec 07:9, May 10:3, Jan 13:9
95028 Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction,
including reading, specify number of tests
95044 Patch or application test(s) (specify number of tests)

➲ CPT Assistant Summer 91:15, Spring 94:31, Jan 13:9
95052 Photo patch test(s) (specify number of tests)

➲ CPT Assistant Spring 94:31, Jan 13:9
95056 Photo tests

➲ CPT Assistant Summer 91:16, Jan 13:9
95060 Ophthalmic mucous membrane tests

95065 Direct nasal mucous membrane test

▲ 95070 Inhalation bronchial challenge testing (not including necessary pulmonary function
tests), with histamine, methacholine, or similar compounds
➲ CPT Assistant Summer 91:16, Nov 12:11, Jan 13:9
(For pulmonary function tests, see 94060, 94070)

Ingestion Challenge Testing
Codes 95076 and 95079 are used to report ingestion challenge testing. Report 95076 for
initial 120 minutes of testing time (ie, not physician face-to-face time). Report 95079 for
each additional 60 minutes of testing time (ie, not physician face-to-face time). For total
testing time less than 61 minutes (eg, positive challenge resulting in cessation of
testing), report an evaluation and management service, if appropriate. Patient
assessment/monitoring activities for allergic reaction (eg, blood pressure testing, peak
flow meter testing) are not separately reported. Intervention therapy (eg, injection of
steroid or epinephrine) may be reported separately as appropriate.
For purposes of reporting testing times, if an evaluation and management service is
required, then testing time ends.
95076 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food,
drug or other substance); initial 120 minutes of testing
✚ 95079 each additional 60 minutes of testing (List separately in addition to code for
primary procedure)
Allergen Immunotherapy
Codes 95115-95199 include the professional services necessary for allergen
immunotherapy. Office visit codes may be used in addition to allergen immunotherapy
if other identifiable services are provided at that time.
95115 Professional services for allergen immunotherapy not including provision of
allergenic extracts; single injection
➲ CPT Assistant Fall 91:19, Spring 94:30, Summer 95:4, May 96:1, Nov 98:35, Apr
00:4, Feb 05:10-12, Nov 05:1, Nov 06:23, Dec 07:9, Jan 13:9, Jun 19:15
95117 2 or more injections
➲ CPT Assistant Fall 91:19, Spring 94:30, Summer 95:4, May 96:1, Aug 96:10,
Nov 98:35, Apr 00:4, Feb 05:10-12, Nov 05:1, Nov 06:23, Dec 07:9, Jan 13:9,
Jun 19:15
95120 Professional services for allergen immunotherapy in the office or institution of the
prescribing physician or other qualified health care professional, including provision
of allergenic extract; single injection
➲ CPT Assistant Fall 91:19, Spring 94:30, Summer 95:4, May 96:2, Nov 98:35, Feb
05:10-12, Jan 13:9
95125 2 or more injections
➲ CPT Assistant Fall 91:19, Spring 94:30, Summer 95:4, May 96:2, Aug 96:10,
Nov 98:35, Feb 05:10, 12, Jan 13:9
95130 single stinging insect venom
➲ CPT Assistant Fall 91:19, Summer 95:4, May 96:2, Jun 96:10, Nov 98:35, Sep
99:10, Feb 05:10, 12, Jan 13:9
95131 2 stinging insect venoms
➲ CPT Assistant Fall 91:19, Summer 95:4, May 96:2, Jun 96:10, Nov 98:35, Sep
99:10, Feb 05:10, 12, Jan 13:9
➲ CPT Assistant Fall 91:19, Summer 95:4, May 96:2, Nov 98:35, Sep 99:11, Feb
05:10, 12, Jan 13:9
05:10, 12, Jan 13:9
05:10, 12, Jan 13:9
95144 Professional services for the supervision of preparation and provision of antigens for
allergen immunotherapy, single dose vial(s) (specify number of vials)
➲ CPT Assistant Fall 91:19, Spring 94:30, Summer 95:4, May 96:11, Nov 98:35,
Feb 05:10-11, Jan 13:9
(A single dose vial contains a single dose of antigen administered in 1 injection)
allergen immunotherapy (specify number of doses); single stinging insect venom
➲ CPT Assistant Fall 91:19, Summer 95:4, May 96:11, Nov 98:35, Feb 05:10-12,
Jan 13:9
95146 2 single stinging insect venoms
Jan 13:9
Jan 13:9
Jan 13:9
Jan 13:9
allergen immunotherapy; single or multiple antigens (specify number of doses)
➲ CPT Assistant Fall 91:19, Spring 94:30, Summer 95:4, May 96:11, Nov 98:35,
Apr 00:4, Apr 01:11, Feb 05:10-12, Jun 05:9, Jan 13:9
95170 whole body extract of biting insect or other arthropod (specify number of doses)
➲ CPT Assistant Fall 91:19, Spring 94:30, Summer 95:4, May 96:12, Apr 01:11,
Feb 05:10-12, Jun 05:9, Jan 13:9
(For allergy immunotherapy reporting, a dose is the amount of antigen[s] administered
in a single injection from a multiple dose vial)
95180 Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum)
➲ CPT Assistant Summer 95:4, Jan 13:9, Jun 19:15
95199 Unlisted allergy/clinical immunologic service or procedure

➲ CPT Assistant Summer 95:4, Nov 98:35, Jan 13:9
(For skin testing of bacterial, viral, fungal extracts, see 86485-86580, 95028)
(For special reports on allergy patients, use 99080)
(For testing procedures such as radioallergosorbent testing [RAST], rat mast cell
technique [RMCT], mast cell degranulation test [MCDT], lymphocytic transformation
test [LTT], leukocyte histamine release [LHR], migration inhibitory factor test [MIF],
transfer factor test [TFT], nitroblue tetrazolium dye test [NTD], see Immunology
section in Pathology or use 95199)
Endocrinology
Codes 95249 and 95250 are used to report the service for subcutaneous interstitial
sensor placement, hook-up of the sensor to the transmitter, calibration of continuous
glucose monitoring (CGM) device, patient training on CGM device functions and
management, removal of the interstitial sensor, and the print-out of captured data
recordings. For the CGM device owned by the physician’s or other qualified health care
professional’s office, use 95250 for the data capture occurring over a minimum period
of 72 hours.
Code 95249 may be reported only once during the time that a patient owns a given data
receiver, including the initial episode of data collection.
Code 95249 may not be reported for subsequent episodes of data collection, unless the
patient obtains a new and/or different model of data receiver. Obtaining a new sensor
and/or transmitter without a change in receiver may not be reported with 95249.
Code 95249 may not be reported unless the patient brings the data receiver to the
physician’s or other qualified health care professional’s office with the entire initial data
collection procedure conducted in the physician’s or other qualified health care
professional’s office.
95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a
subcutaneous sensor for a minimum of 72 hours; physician or other qualified health
care professional (office) provided equipment, sensor placement, hook-up, calibration
of monitor, patient training, removal of sensor, and printout of recording
➲ CPT Changes: An Insider’s View 2002, 2006, 2009, 2016, 2018
(Do not report 95250 more than once per month)

# 95249 patient-provided equipment, sensor placement, hook-up, calibration of monitor,
patient training, and printout of recording
(Do not report 95249 more than once for the duration that the patient owns the data
receiver)
95251 analysis, interpretation and report
(Do not report 95251 more than once per month)

Neurology and Neuromuscular Procedures

Neurologic services are typically consultative, and any of the levels of consultation
(99241-99255) may be appropriate.
In addition, services and skills outlined under Evaluation and Management levels of
service appropriate to neurologic illnesses should be reported similarly.
The electroencephalogram (EEG), video electroencephalogram (VEEG), autonomic
function, evoked potential, reflex tests, electromyography (EMG), nerve conduction
velocity (NCV), and magnetoencephalography (MEG) services (95700-95726, 95812-
95829, and 95860-95967) include recording, interpretation, and report by a physician or
other qualified health care professional. For interpretation only, use modifier 26 with
95812-95829, 95860-95967. For interpretation only for long-term EEG services, report
95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726.
Codes 95700-95726 and 95812-95822 use EEG/VEEG recording time as a basis for code
use. Recording time is when the recording is underway and diagnostic EEG data is
being collected. Recording time excludes set up and take down time. If diagnostic EEG
recording is disrupted, recording time stops until diagnostic EEG recording is resumed.
Codes 95961-95962 use physician or other qualified health care professional attendance
time as a basis for code use.
(Do not report codes 95860-95875 in addition to 96000-96004)
Sleep Medicine Testing

Sleep medicine services include procedures that evaluate adult and pediatric patients for
a variety of sleep disorders. Sleep medicine testing services are diagnostic procedures
using in-laboratory and portable technology to assess physiologic data and therapy.
All sleep services (95800-95811) include recording, interpretation, and report. (Report
with modifier 52 if less than 6 hours of recording for 95800, 95801 and 95806, 95807,
95810, 95811; if less than 7 hours of recording for 95782, 95783, or if less than four nap
opportunities are recorded for 95805).
Definitions
For purposes of CPT reporting of sleep medicine testing services, the following
definitions apply:
Actigraphy: the use of a portable, non-invasive, device that continuously records gross
motor movement over an extended period of time. The periods of activity and rest are
indirect parameters for estimates of the periods of wakefulness and sleep of an
individual.
Attended: a technologist or qualified health care professional is physically present (ie,
sufficient proximity such that the qualified health care professional can physically
respond to emergencies, to other appropriate patient needs or to technical problems at
the bedside) throughout the recording session.
Electrooculogram (EOG): a recording of electrical activity indicative of eye
movement.
Maintenance of wakefulness test (MWT): a standardized objective test used to
determine a person’s ability to stay awake. MWT requires sleep staging of the trials that
are performed at defined intervals and is attended by a qualified health care
professional.
Multiple sleep latency test (MSLT): a standardized objective test of the tendency to fall
asleep. MSLT requires sleep staging of the nap opportunities that are performed at
defined intervals and is attended by a technologist or qualified health care professional.
Peripheral arterial tonometry (PAT): a plethysmography technique that continuously
measures pulsatile volume changes in a digit. This reflects the relative change of blood
volume as an indirect measure of sympathetic nervous system activity which is used in
respiratory analysis.
Physiological measurements of sleep as used in 95805: the parameters measured are a
frontal, central and occipital lead of EEG (3 leads), submental EMG lead and a left and
right EOG. These parameters are used together for staging sleep.
Polysomnography: a sleep test involving the continuous, simultaneous, recording of
physiological parameters for a period of at least 6 hours that is performed in a sleep
laboratory and attended by a technologist or qualified health care professional. The
parameters measured are a frontal, central and occipital lead of EEG (3 leads),
submental EMG lead and a left and right EOG, (from which sleep is staged), plus four
or more additional parameters. The additional parameters typically required in
polysomnography are listed below:
a. Electrocardiogram (ECG)
b. Nasal and/or oral airflow
c. Respiratory effort
d. Oxyhemoglobin saturation, SpO 2
e. Bilateral anterior tibialis EMG
Positive airway pressure (PAP): a device used to treat sleep-related breathing disorders
with the use of non-invasive delivery of positive pressure to the airway. Examples
include but are not limited to: CPAP (continuous positive airway pressure), bilevel PAP,
AutoPAP (autotitrating or adjusting PAP), ASV (adaptive-servo ventilation).
Remote: the site of service is distant from the monitoring center. Neither a technologist
nor a qualified health care professional is physically present at the testing site.
Respiratory airflow (ventilation): the movement of air during inhaled and exhaled
breaths. This is typically assessed using thermistor and nasal pressure sensors.
Respiratory analysis: generation of derived parameters that describe components of
respiration obtained by using direct or indirect parameters, eg, by airflow or peripheral
arterial tone.
Respiratory effort: contraction of the diaphragmatic and/or intercostal muscles to cause
(or attempt to cause) respiratory airflow. This is typically measured using transducers
that estimate motion of the thorax and abdomen such as respiratory inductive
plethysmography, transducers that estimate pressures generated by breathing muscles
such as esophageal manometry, or by contraction of breathing muscles, such as
diaphragmatic/intercostal EMG.
Respiratory (thoracoabdominal) movement: movement of the chest and abdomen
during respiratory effort.
Sleep latency: the length of time it takes to transition from wakefulness to sleep. In the
sleep laboratory it is the time from “lights out” to the first epoch scored as any stage of
sleep.
Sleep staging: the delineation of the distinct sleep levels through the simultaneous
evaluation of physiologic measures including a frontal, central and occipital lead of
EEG (3 leads), submental EMG lead and a left and right EOG.
Sleep testing (or sleep study): the continuous, simultaneous monitoring of
physiological parameters during sleep (eg, polysomnography, EEG).
Total sleep time: a derived parameter obtained by sleep staging or may be estimated
indirectly using actigraphy or other methods.
Unattended: a technologist or qualified health care professional is not physically
present with the patient during the recording session.
(Report with modifier 52 if less than 6 hours of recording or in other cases of reduced
services as appropriate)
(For unattended sleep study, use 95806)
95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72
hours to 14 consecutive days of recording)
(Do not report 95803 more than once in any 14 day period)
95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and
interpretation of physiological measurements of sleep during multiple trials to assess
sleepiness
➲ CPT Assistant Nov 97:45-46, Nov 98:35, Dec 01:3, Sep 02:2-3, Mar 08:4, Nov
11:3
95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation,
respiratory airflow, and respiratory effort (eg, thoracoabdominal movement)
➲ CPT Assistant Nov 97:45-46, Aug 98:10, Nov 98:35, Jan 11:7, Nov 11:3, Feb
13:14, Jul 13:11
95800, 95801)
(For unattended sleep study that measures heart rate, oxygen saturation, respiratory
analysis, and sleep time, use 95800)
(For unattended sleep study that measures a minimum heart rate, oxygen saturation, and
respiratory analysis, use 95801)
# 95800 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation,
respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time
➲ CPT Assistant Jan 11:6, Nov 11:3, Feb 13:14
95801, 95803, 95806)
(For unattended sleep study that measures a minimum of heart rate, oxygen saturation,
and respiratory analysis, use 95801)
# 95801 minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow
or peripheral arterial tone)
➲ CPT Assistant Jan 11:7, Nov 11:3, Feb 13:14
95800, 95806)
(For unattended sleep study that measures heart rate, oxygen saturation, respiratory
analysis and sleep time, use 95800)
95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart
rate, and oxygen saturation, attended by a technologist
➲ CPT Assistant Nov 97:46, Nov 98:35, Mar 08:4, Nov 11:3, Feb 13:14
95808 Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep,
attended by a technologist
➲ CPT Assistant Sep 96:11, Nov 97:46, Feb 98:6, Nov 98:35, Sep 02:2-3, Mar 08:4,
Nov 11:3, Feb 13:14
95810 age 6 years or older, sleep staging with 4 or more additional parameters of sleep,
➲ CPT Assistant Feb 98:6, Nov 98:35, Sep 02:2-3, Nov 11:3, Feb 13:14
95811 age 6 years or older, sleep staging with 4 or more additional parameters of sleep,
with initiation of continuous positive airway pressure therapy or bilevel
ventilation, attended by a technologist
➲ CPT Assistant Nov 97:46, Feb 98:6, Nov 98:35, Sep 02:2-3, Mar 08:4, Nov
11:3, Feb 13:14, Oct 14:9
# 95782 younger than 6 years, sleep staging with 4 or more additional parameters of sleep,
# 95783 younger than 6 years, sleep staging with 4 or more additional parameters of sleep,
with initiation of continuous positive airway pressure therapy or bi-level
ventilation, attended by a technologist
Routine Electroencephalography (EEG)

EEG codes 95812-95822 include hyperventilation and/or photic stimulation when
appropriate. Routine EEG codes 95816-95822 include 20 to 40 minutes of recording.
Extended EEG codes 95812-95813 include reporting times longer than 40 minutes.
95812 Electroencephalogram (EEG) extended monitoring; 41-60 minutes
➲ CPT Assistant Winter 94:18, Nov 98:35, May 11:3, 10, Dec 18:3

95813 61-119 minutes
➲ CPT Assistant Winter 94:18, Nov 98:35, May 11:3, 10, Dec 18:3

(For long-term EEG services [2 hours or more], see 95700-95726)
95816 Electroencephalogram (EEG); including recording awake and drowsy
➲ CPT Assistant Sep 96:11, Nov 98:35, Nov 99:51, Jul 00:1, May 11:3, Dec 15:17,
Dec 18:3
95819 including recording awake and asleep
➲ CPT Assistant Nov 98:35, Nov 99:51, Jul 00:1, May 11:3, Dec 15:17, Dec
18:3
95822 recording in coma or sleep only
➲ CPT Assistant Nov 98:35, May 11:3, May 13:8, Dec 14:19, Dec 18:3

95824 cerebral death evaluation only
(95827 has been deleted. To report all night EEG recording, see 95705, 95706,
95707, 95711, 95712, 95713, 95717, 95718)
(For long-term EEG monitoring, see 95700-95726)
(For EEG during nonintracranial surgery, use 95955)
(For Wada test, use 95958)
95830 Insertion by physician or other qualified health care professional of sphenoidal
electrodes for electroencephalographic (EEG) recording
Electrocorticography
Electrocorticography (ECoG) is the recording of EEG from electrodes directly on or in
the brain.
Code 95829 describes intraoperative recordings of ECoG from electrode arrays
implanted in or placed directly on the brain exposed during surgery. Code 95829
includes review and interpretation during surgery.
Code 95836 describes recording of ECoG from electrodes chronically implanted on or
in the brain. Chronically implanted electrodes allow for intracranial recordings to
continue after the patient has been discharged from the hospital. Code 95836 includes
unattended ECoG recording with storage for later review and interpretation during a
single 30-day period. Code 95836 may be reported only once for each 30-day period.
The dates encompassed by the 30-day period must be documented in the report.
For report of programming for a brain neurostimulator pulse generator/transmitter
during the ECoG (95836) 30-day period, see 95983, 95984.
# 95829 Electrocorticogram at surgery (separate procedure)
# 95836 Electrocorticogram from an implanted brain neurostimulator pulse

generator/transmitter, including recording, with interpretation and written report, up to
30 days

(For programming a brain neurostimulator pulse generator/transmitter when performed
in conjunction with ECoG [95836], see 95983, 95984)
Intraoperative Electrocorticography (ECoG)

95829
Intraoperative ECoG device and surgical exposure.
Extraoperative ECoG
95836
Extraoperative ECoG device with wand placed above head and laptop.
Range of Motion Testing

(95831, 95832, 95833, 95834 have been deleted. To report manual muscle testing, see
Physical Medicine and Rehabilitation services 97161-97172)
95851 Range of motion measurements and report (separate procedure); each extremity
(excluding hand) or each trunk section (spine)
➲ CPT Assistant Sep 99:10, Nov 01:5, Apr 03:28, Dec 03:7, Feb 04:5, Dec 07:16,
May 08:9, Aug 13:7, Dec 16:16
95852 hand, with or without comparison with normal side
➲ CPT Assistant Nov 01:5, Apr 03:28, Dec 03:7, May 08:9, Aug 13:7
95857 Cholinesterase inhibitor challenge test for myasthenia gravis

Electromyography
Needle electromyographic (EMG) procedures include the interpretation of electrical
waveforms measured by equipment that produces both visible and audible components
of electrical signals recorded from the muscle(s) studied by the needle electrode.
Use 95870 or 95885 when four or fewer muscles are tested in an extremity. Use 95860-
95864 or 95886 when five or more muscles are tested in an extremity.
Use EMG codes (95860-95864 and 95867-95870) when no nerve conduction studies
(95907-95913) are performed on that day. Use 95885, 95886, and 95887 for EMG
services when nerve conduction studies (95907-95913) are performed in conjunction
with EMG on the same day.
Report either 95885 or 95886 once per extremity. Codes 95885 and 95886 can be
reported together up to a combined total of four units of service per patient when all
four extremities are tested.
Report 95887 once per anatomic site (ie, cervical paraspinal muscle[s], thoracic
paraspinal muscle[s], lumbar paraspinal muscle[s], chest wall muscle[s], and abdominal
wall muscle[s]). Use 95887 for a unilateral study of the cranial nerve innervated
muscles (excluding extra-ocular and larynx); when performed bilaterally, 95887 may be
reported twice.
Use 95887 when a study of the cervical paraspinal muscle(s), or the lumbar paraspinal
muscle(s) is performed with no corresponding limb study (95885 or 95886) on the
same day.
(For needle electromyography of anal or urethral sphincter, use 51785)
(For non-needle electromyography of anal or urethral sphincter, use 51784)
(For needle electromyography of larynx, use 95865)
(For needle electromyography of hemidiaphragm, use 95866)
(For needle electromyography of extra-ocular muscles, use 92265)
95860 Needle electromyography; 1 extremity with or without related paraspinal areas
➲ CPT Assistant Nov 97:46, Jul 00:2, Apr 02:2, May 03:20, Jun 03:3, Feb 04:4, Jul
04:6, Oct 04:15, Jun 06:8, Sep 06:5, Aug 08:12, Jan 09:8, Oct 10:15, Dec 10:15,
Feb 12:8, Mar 13:3, May 13:8, Mar 15:6
95861 2 extremities with or without related paraspinal areas
➲ CPT Assistant Nov 97:46, Jul 00:2, Apr 02:2, May 03:20, Jun 03:3, Feb 04:4,
Jul 04:6, Oct 04:15, Jun 05:9, Jun 06:8, Sep 06:5, Aug 08:12, Jan 09:8, Oct
10:15, Dec 10:15, Feb 12:8, Mar 13:3, May 13:8
(For dynamic electromyography performed during motion analysis studies, see 96002-
96003)
➲ CPT Assistant Nov 97:46, Jul 00:2, Apr 02:2, May 03:20, Jun 03:3, Feb 04:4,
Jul 04:6, Oct 04:15, Jun 06:8, Sep 06:5, Oct 10:15, Dec 10:15, Feb 12:8, Mar
13:3, May 13:8
➲ CPT Assistant Nov 97:46, Jul 00:2, Jan 02:11, Apr 02:2, May 03:20, Jun 03:3,
Feb 04:4, Jul 04:6, Oct 04:15, Jun 06:8, Sep 06:5, Aug 08:12, Jan 09:8, Oct
10:15, Dec 10:15, Feb 12:8, Mar 13:3, May 13:8
95865 larynx
➲ CPT Assistant Sep 06:5, Dec 07:16, Jan 09:8, May 13:8, Jan 14:6

(For unilateral procedure, report modifier 52 in conjunction with 95865)
95866 hemidiaphragm
95867 cranial nerve supplied muscle(s), unilateral

➲ CPT Assistant Apr 02:2, May 03:20, Jun 03:3, Jun 06:8, Sep 06:5, Dec 07:16,
Aug 08:12, Jan 09:8, Feb 12:8, Mar 13:3, May 13:8
95868 cranial nerve supplied muscles, bilateral
➲ CPT Assistant Apr 02:2, May 03:20, Jun 03:3, Jun 06:8, Sep 06:5, Dec 07:16,
Jan 09:8, Feb 12:8, Mar 13:3, May 13:8
95869 thoracic paraspinal muscles (excluding T1 or T12)
➲ CPT Assistant Nov 97:46, Apr 02:2, May 03:20, Jun 03:3, Feb 04:4, Jun 06:8,
Sep 06:5, Jan 09:8, May 10:9, Feb 12:8, Mar 13:3, May 13:8
95870 limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or
bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or
sphincters
➲ CPT Assistant Nov 97:46, Nov 99:51, Jul 00:2, Apr 02:2, May 03:20, Jun
03:3, Feb 04:4, Jul 04:6, Jun 05:9, Jun 06:8, Sep 06:5, Jan 09:8, Feb 12:8, Mar
13:3, May 13:8
(To report a complete study of the extremities, see 95860-95864)
(For anal or urethral sphincter, detrusor, urethra, perineum musculature, see 51785-
51792)
(For eye muscles, use 92265)
95872 Needle electromyography using single fiber electrode, with quantitative measurement
of jitter, blocking and/or fiber density, any/all sites of each muscle studied
➲ CPT Assistant Apr 02:2, May 03:20, Jun 03:3, Sep 06:5, Jan 09:8
#✚ 95885 Needle electromyography, each extremity, with related paraspinal areas, when
performed, done with nerve conduction, amplitude and latency/velocity study; limited
➲ CPT Assistant Feb 12:8, Mar 13:3, May 13:8, Sep 13:18, Mar 15:6, Jul 17:10
#✚ 95886 complete, five or more muscles studied, innervated by three or more nerves or four
or more spinal levels (List separately in addition to code for primary procedure)
➲ CPT Assistant Feb 12:8, Mar 13:3, May 13:8, Sep 13:18, Mar 15:6, Jul 17:10
(Use 95885, 95886 in conjunction with 95907-95913)

(Do not report 95885, 95886 in conjunction with 95860-95864, 95870, 95905)
#✚ 95887 Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s)
done with nerve conduction, amplitude and latency/velocity study (List separately in
➲ CPT Assistant Feb 12:8, Jul 12:12, Mar 13:3, Jan 14:8, Mar 15:6, Jul 17:11

(Do not report 95887 in conjunction with 95867-95870, 95905)
Ischemic Muscle Testing and Guidance for

Chemodenervation
✚ 95873 Electrical stimulation for guidance in conjunction with chemodenervation (List
(Do not report 95873 in conjunction with 64451, 64617, 64625, 95860-95870, 95874)
✚ 95874 Needle electromyography for guidance in conjunction with chemodenervation (List
➲ CPT Assistant Apr 13:5, Jan 14:6, Oct 14:15
(Use 95873, 95874 in conjunction with 64612, 64615, 64616, 64642, 64643, 64644,
64645, 64646, 64647)
(Do not report more than one guidance code for each corresponding chemodenervation
code)
(Do not report 95874 in conjunction with 64451, 64617, 64625, 95860-95870, 95873)
95875 Ischemic limb exercise test with serial specimen(s) acquisition for muscle(s)
metabolite(s)
(For listing of nerves considered for separate study, see Appendix J)

Nerve Conduction Tests

The following applies to nerve conduction tests (95907-95913): Codes 95907-95913
describe nerve conduction tests when performed with individually placed stimulating,
recording, and ground electrodes. The stimulating, recording, and ground electrode
placement and the test design must be individualized to the patient’s unique anatomy.
Nerves tested must be limited to the specific nerves and conduction studies needed for
the particular clinical question being investigated. The stimulating electrode must be
placed directly over the nerve to be tested, and stimulation parameters properly adjusted
to avoid stimulating other nerves or nerve branches. In most motor nerve conduction
studies, and in some sensory and mixed nerve conduction studies, both proximal and
distal stimulation will be used. Motor nerve conduction study recordings must be made
from electrodes placed directly over the motor point of the specific muscle to be tested.
Sensory nerve conduction study recordings must be made from electrodes placed
directly over the specific nerve to be tested. Waveforms must be reviewed on site in real
time, and the technique (stimulus site, recording site, ground site, filter settings) must
be adjusted, as appropriate, as the test proceeds in order to minimize artifact, and to
minimize the chances of unintended stimulation of adjacent nerves and the unintended
recording from adjacent muscles or nerves. Reports must be prepared on site by the
examiner, and consist of the work product of the interpretation of numerous test
results, using well-established techniques to assess the amplitude, latency, and
configuration of waveforms elicited by stimulation at each site of each nerve tested.
This includes the calculation of nerve conduction velocities, sometimes including
specialized F-wave indices, along with comparison to normal values, summarization of
clinical and electrodiagnostic data, and physician or other qualified health care
professional interpretation. Codes 95907-95913 describe one or more nerve conduction
studies. For the purposes of coding, a single conduction study is defined as a sensory
conduction test, a motor conduction test with or without an F wave test, or an H-reflex
test. Each type of study (sensory, motor with or without F wave, H-reflex) for each
nerve includes all orthodromic and antidromic impulses associated with that nerve and
constitutes a distinct study when determining the number of studies in each grouping
(eg, 1-2 or 3-4 nerve conduction studies). Each type of nerve conduction study is
counted only once when multiple sites on the same nerve are stimulated or recorded.
The numbers of these separate tests should be added to determine which code to use.
For a list of nerves, see Appendix J. Use 95885-95887 in conjunction with 95907-95913
when performing electromyography with nerve conduction studies.
Code 95905 describes nerve conduction tests when performed with preconfigured
electrodes customized to a specific anatomic site.
⃠ 95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s),
amplitude and latency/velocity study, each limb, includes F-wave study when
performed, with interpretation and report
(Report 95905 only once per limb studied)

(Do not report 95905 in conjunction with 95885, 95886, 95907-95913)
95907 Nerve conduction studies; 1-2 studies
➲ CPT Assistant Mar 13:3, May 13:8, Sep 13:18, Dec 17:15, Aug 18:11
95908 3-4 studies

➲ CPT Assistant Mar 13:3, May 13:8, Sep 13:18, Mar 15:6, Aug 18:11
95909 5-6 studies

➲ CPT Assistant Mar 13:3, May 13:8, Sep 13:18, Aug 18:11
95910 7-8 studies

95911 9-10 studies

95912 11-12 studies
95913 13 or more studies

Intraoperative Neurophysiology
Codes 95940, 95941 describe ongoing neurophysiologic monitoring, testing, and data
interpretation distinct from performance of specific type(s) of baseline
neurophysiologic study(s) performed during surgical procedures. When the service is
performed by the surgeon or anesthesiologist, the professional services are included in
the surgeon’s or anesthesiologist’s primary service code(s) for the procedure and are
not reported separately. Do not report these codes for automated monitoring devices
that do not require continuous attendance by a professional qualified to interpret the
testing and monitoring.
Recording and testing are performed either personally or by a technologist who is
physically present with the patient during the service. Supervision is performed either
in the operating room or by real time connection outside the operating room. The
monitoring professional must be solely dedicated to performing the intraoperative
neurophysiologic monitoring and must be available to intervene at all times during the
service as necessary, for the reported time period(s). For any given period of time spent
providing these services, the service takes full attention and, therefore, other clinical
activities beyond providing and interpreting of monitoring cannot be provided during
the same period of time.
Throughout the monitoring, there must be provisions for continuous and immediate
communication directly with the operating room team in the surgical suite. One or more
simultaneous cases may be reported (95941). When monitoring more than one
procedure, there must be the immediate ability to transfer patient monitoring to another
monitoring professional during the surgical procedure should that individual’s
exclusive attention be required for another procedure. Report 95941 for all remote or
non-one-on-one monitoring time connected to each case regardless of overlap with
other cases.
Codes 95940, 95941 include only the ongoing neurophysiologic monitoring time
distinct from performance of specific type(s) of baseline neurophysiologic study(s), or
other services such as intraoperative functional cortical or subcortical mapping. Codes
95940 and 95941 are reported based upon the time spent monitoring only, and not the
number of baseline tests performed or parameters monitored. The time spent
performing or interpreting the baseline neurophysiologic study(ies) should not be
counted as intraoperative monitoring, but represents separately reportable procedures.
When reporting 95940 and 95941, the same neurophysiologic study(ies) performed at
baseline should be reported not more than once per operative session. Baseline study
reporting is based upon the total unique studies performed. For example, if during the
course of baseline testing and one-on-one monitoring, two separate nerves have motor
testing performed in conjunction with limited single extremity EMG, then 95885 and
95907 would be reported in addition to 95940. Time spent monitoring (95940, 95941)
excludes time to set up, record, and interpret the baseline studies, and to remove
electrodes at the end of the procedure. To report time spent waiting on standby for a
case to start, use 99360. For procedures that last beyond midnight, report services using
the day on which the monitoring began and using the total time monitored.
Code 95940 is reported per 15 minutes of service. Code 95940 requires reporting only
the portion of time the monitoring professional was physically present in the operating
room providing one-on-one patient monitoring, and no other cases may be monitored
at the same time. Time spent in the operating room is cumulative. To determine units of
service of 95940, use the total minutes monitoring in the operating room one-on-one.
Monitoring may begin prior to incision (eg, when positioning on the table is a time of
risk). Report continuous intraoperative neurophysiologic monitoring in the operating
room (95940) in addition to the services related to monitoring from outside the
operating room (95941).
Code 95941 should be used once per hour even if multiple methods of
neurophysiologic monitoring are used during the time. Code 95941 requires the
monitoring of neurophysiological data that is collected from the operating room
continuously on-line in real time via a secure data link. When reporting 95941, real-time
ability must be available through sufficient data bandwidth transfer rates to view and
interrogate the neurophysiologic data contemporaneously.
Report 95941 for all cases in which there was no physical presence by the monitoring
professional in the operating room during the monitoring time or when monitoring
more than one case in an operating room. It is also used to report the time of
monitoring physically performed outside of the operating room in those cases where
monitoring occurred both within and outside the operating room. Do not report 95941
if the monitoring lasts 30 minutes or less.
Intraoperative neurophysiology monitoring codes 95940 and 95941 are each used to
report the total duration of respective time spent providing each service, even if that
time is not in a single continuous block.
#✚ 95940 Continuous intraoperative neurophysiology monitoring in the operating room, one on
one monitoring requiring personal attendance, each 15 minutes (List separately in
➲ CPT Assistant May 13:8, 9, 10, Apr 14:5, 11, Aug 17:8
▶ (Use95940 in conjunction with the study performed, 92653, 95822, 95860-95870,
95907-95913, 95925, 95926, 95927, 95928, 95929, 95930-95937, 95938, 95939)◀
#✚ 95941 Continuous intraoperative neurophysiology monitoring, from outside the operating
room (remote or nearby) or for monitoring of more than one case while in the
operating room, per hour (List separately in addition to code for primary procedure)
➲ CPT Assistant Feb 13:16, May 13:8, Apr 14:5, 11, Dec 14:19, Aug 17:8
▶ (Use95941 in conjunction with the study performed, 92653, 95822, 95860-95870,

95907-95913, 95925, 95926, 95927, 95928, 95929, 95930-95937, 95938, 95939)◀
(For time spent waiting on standby before monitoring, use 99360)
(For electrocorticography, use 95829)
(For intraoperative EEG during nonintracranial surgery, use 95955)
(For intraoperative functional cortical or subcortical mapping, see 95961-95962)
(For intraoperative neurostimulator programming, see 95971, 95972, 95976, 95977,
95983, 95984)
Autonomic Function Tests

The purpose of autonomic nervous system function testing is to determine the presence
of autonomic dysfunction, the site of autonomic dysfunction, and the various
autonomic subsystems that may be disordered.
Code 95921 should be reported only when electrocardiographic monitoring of heart
rate derived from the time elapsing between two consecutive R waves in the
electrocardiogram, or the R-R interval, is displayed on a monitor and stored for
subsequent analysis of waveforms. Testing is typically performed in the prone position.
A tilt table may be used, but is not required equipment for testing of the
parasympathetic function. At least two of the following components need to be
included in testing:
1. Heart rate response to deep breathing derived from a visual quantitative analysis of
recordings with subject breathing at a rate of 5-6 breaths per minute.
2. Valsalva ratio determined by dividing the maximum heart rate by the lowest heart
rate. The initial heart rate responses to sustained oral pressure (blowing into a tube
with an open glottis) consist of tachycardia followed by a bradycardia at 15-45
seconds after the Valsalva pressure has been released. A minimum of two Valsalva
maneuvers are to be performed. The initial cardioacceleration is an exercise reflex
while the subsequent tachycardia and bradycardia are baroreflex-mediated.
3. A 30:15 ratio (R-R interval at beat 30)/(R-R interval at beat 15) used as an index of
cardiovascular function.
Code 95922 should be reported only when all of the following components are
included in testing:
1. Continuous recording of beat-to-beat BP and heart rate. The heart rate needs to be
derived from an electrocardiogram (ECG) unit such that an accurate quantitative
graphical measurement of the R-R interval is obtained.
2. A period of supine rest of at least 20 minutes prior to testing.
3. The performance and recording of beat-to-beat blood pressure and heart rate during
a minimum of two (2) Valsalva maneuvers.
4. The performance of passive head-up tilt with continuous recording of beat-to-beat
blood pressure and heart rate for a minimum of five minutes, followed by passive
tilt-back to the supine position. This must be performed using a tilt table.
Code 95924 should be reported only when both the parasympathetic function and the
adrenergic function are tested together with the use of a tilt table.
(To report autonomic function testing that does not include beat-to-beat recording or
for testing without use of a tilt table, use 95943)
95921 Testing of autonomic nervous system function; cardiovagal innervation
(parasympathetic function), including 2 or more of the following: heart rate response
to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio
➲ CPT Assistant Nov 98:35-36, Apr 02:2, Oct 03:11, Feb 06:15, Nov 12:6
95922 vasomotor adrenergic innervation (sympathetic adrenergic function), including

beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver
and at least 5 minutes of passive tilt
➲ CPT Assistant Nov 98:35-36, Apr 02:2, Jun 03:11, Feb 06:15, Nov 06:23, Dec
08:4, Nov 12:6
95923 sudomotor, including 1 or more of the following: quantitative sudomotor axon
reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and
changes in sympathetic skin potential
➲ CPT Assistant Nov 98:35-36, Apr 02:2, Feb 06:15, Nov 12:6
95924 combined parasympathetic and sympathetic adrenergic function testing with at least
5 minutes of passive tilt

# 95943 Simultaneous, independent, quantitative measures of both parasympathetic function and
sympathetic function, based on time-frequency analysis of heart rate variability
concurrent with time-frequency analysis of continuous respiratory activity, with mean
heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva
maneuvers, and head-up postural change
Evoked Potentials and Reflex Tests

95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral
nerves or skin sites, recording from the central nervous system; in upper limbs
➲ CPT Assistant Nov 98:35-36, Apr 02:2, Apr 12:17, May 13:8

95926 in lower limbs
➲ CPT Assistant May 01:11, Apr 02:2, Apr 12:17, May 13:8

# 95938 in upper and lower limbs
➲ CPT Assistant Apr 12:17, 18, Feb 13:17, May 13:8

95927 in the trunk or head
(To report a unilateral study, use modifier 52)

▶ (For auditory evoked potentials, use 92653)◀
95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs

95929 lower limbs

# 95939 in upper and lower limbs
➲ CPT Assistant Apr 12:17, 18, May 13:8

95930 Visual evoked potential (VEP) checkerboard or flash testing, central nervous system
except glaucoma, with interpretation and report
➲ CPT Assistant May 13:8, Aug 14:8, Feb 18:3
(For visual evoked potential testing for glaucoma, use 0464T)

(For screening of visual acuity using automated visual evoked potential devices, use
0333T)
95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing
➲ CPT Assistant Nov 98:35-36, May 13:8, Jul 17:10
95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any
1 method
➲ CPT Assistant Nov 98:35-36, Apr 02:2, Jun 06:8, Mar 13:3, May 13:8, Feb 16:14

Special EEG Tests

Codes 95961 and 95962 use physician or other qualified health care professional time as
a basis for unit of service. Report 95961 for the first hour of attendance. Use modifier
52 with 95961 for 30 minutes or less. Report 95962 for each additional hour of
attendance. Codes 95961, 95962 may be reported with 95700-95726 when functional
cortical or subcortical mapping is performed with long-term EEG monitoring.
Codes 95700-95726 describe long-term continuous recording services for
electroencephalography (EEG), which are performed to differentiate seizures from
other abnormalities, determine type or location of seizures, monitor treatment of
seizures and status epilepticus, establish if the patient is a candidate for epilepsy
surgery, and/or screen for adverse change in critically ill patients.
The set of codes that describe long-term continuous recording EEG services (95700-
95726) is divided into two major groups: (1) technical services, and (2) professional
services. Codes 95700-95726 may be reported for any site of service. The technical
component of the services is reported with 95700-95716. The professional component
of the services is reported with 95717, 95718, 95719, 95720, 95721, 95722, 95723,
95724, 95725, 95726. Diagnostic EEG recording time of less than 2 hours (ie, 1 minute,
up to 1 hour and 59 minutes) is not reported separately as a long-term EEG service.
Long-term continuous recording EEG services (95700-95726) are different than routine
EEGs (95812, 95813, 95816, 95819, 95822). Routine EEGs capture brain-wave activity
within a short duration of testing, defined as less than 2 hours. Long-term continuous
recording EEGs capture brain-wave activity for durations of time equal to or greater
than 2 hours. The length of recording is based on a number of factors, including the
clinical indication for the test and the frequency of seizures.
Use of automated spike and seizure detection and trending software is included in
95700-95726, when performed. Do not report 95957 for use of automated software.
Definitions
EEG technologist: An individual who is qualified by education, training,
licensure/certification/regulation (when applicable) in seizure recognition. An EEG
technologist(s) performs EEG setup, takedown when performed, patient education,
technical description, maintenance, and seizure recognition when within his or her
scope of practice and as allowed by law, regulation, and facility policy (when
applicable).
Unmonitored: Services that have no real-time monitoring by an EEG technologist(s)
during the continuous recording. If the criteria for intermittent or continuous
monitoring are not met, then the study is an unmonitored study.
Intermittent monitoring (remote or on-site): Requires an EEG technologist(s) to
perform and document real-time review of data at least every 2 hours during the entire
recording period to assure the integrity and quality of the recording (ie, EEG, VEEG),
identify the need for maintenance, and, when necessary, notify the physician or other
qualified health care professional of clinical issues. For intermittent monitoring, a single
EEG technologist may monitor a maximum of 12 patients concurrently. If the number
of intermittently monitored patients exceeds 12, then all of the studies are reported as
unmonitored.
Continuous real-time monitoring (may be provided remotely): Requires all elements of
intermittent monitoring. In addition, the EEG technologist(s) performs and documents
real-time concurrent monitoring of the EEG data and video (when performed) during
the entire recording period. The EEG technologist(s) identifies when events occur and
notifies, as instructed, the physician or other qualified health care professional. For
continuous monitoring, a single EEG technologist may monitor a maximum of four
patients concurrently. If the number of concurrently monitored patients exceeds four,
then all of the studies are reported as either unmonitored or intermittent studies. If there
is a break in the real-time monitoring of the EEG recording, the study is an intermittent
study.
Technical description: The EEG technologist(s)’s written documentation of the
reviewed EEG/VEEG data, including technical interventions. The technical description
is based on the EEG technologist(s)’s review of data and includes the following
required elements: uploading and/or transferring EEG/VEEG data from EEG equipment
to a server or storage device; reviewing raw EEG/VEEG data and events and automated
detection, as well as patient activations; and annotating, editing, and archiving
EEG/VEEG data for review by the physician or other qualified health care professional.
For unmonitored services, the EEG technologist(s) annotates the recording for review
by the physician or other qualified health care professional and creates a single
summary.
Maintenance of long-term EEG equipment: Performed by the EEG technologist(s) and
involves ensuring the integrity and quality of the recording(s) (eg, camera position,
electrode placement, and impedances).
Setup: Performed in person by the EEG technologist(s) and includes preparing supplies
and equipment and securing electrodes using the 10/20 system. Code 95700 is reported
only once per recording period on the date the setup was performed. “In person” means
that the EEG technologist(s) must be physically present with the patient.
Technical Component Services
Code 95700 describes any long-term continuous EEG/VEEG recording setup, takedown
when performed, and patient/caregiver education by the EEG technologist(s). To report
95700, the setup must include a minimum of eight channels of EEG. Services with
fewer than eight channels may be reported using 95999. Eight to 15 channels are
typically used for neonates and when electrodes cannot be placed on certain regions of
the scalp that are sterile. Twenty or more channels are typically used for children and
adults. If setup is performed by someone who does not meet the definition of an EEG
technologist(s), report 95999.
Codes 95705-95716 describe monitoring, maintenance, review of data, and creating a
summary technical description. These codes are divided into four groups based on
duration and whether video is utilized. Key elements in determining the appropriate
technical code (95705-95716) for long-term EEG continuous recording are: (1) whether
diagnostic video recording is captured in conjunction and simultaneously with the EEG
service, which is referred to as video-EEG (VEEG), and (2) technologist monitoring for
the study (ie, unmonitored, intermittently monitored, or continuously monitored).
Codes 95711, 95712, 95713, 95714, 95715, 95716 are reported if diagnostic video of the
patient is recorded a minimum of 80% of the time of the entire long-term VEEG
service, concurrent with diagnostic EEG recording (ie, the entire study is reported as an
EEG without video if concurrent diagnostic video occurs less than 80% of the entire
study). Diagnostic EEG recording is an essential component of all long-term EEG
services. If diagnostic EEG recording stops, timing stops until the diagnostic EEG is
resumed.
Codes 95705, 95706, 95707, 95711, 95712, 95713 are reported when total diagnostic
recording time is between 2 and 12 hours, or to capture the final increment of a
multiple-day service when the final increment extends 2 to 12 hours beyond the time
reported by the appropriate greater-than-12-hour-up-to-26-hour code(s) (95708, 95709,
95710, 95714, 95715, 95716). A maximum of one 2-12 hour code may be reported for
an entire long-term EEG service. For example, if the testing lasts 48 hours, but
diagnostic recording occurs only in the initial 11 hours and the final 11 hours of the
testing period, a single greater-than-12-hour-up-to-26-hour technical code is reported,
rather than two 2-12 hour code for the 48-hour service (see the Long-Term EEG
Monitoring Table).
Professional Component Services
Codes 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726 describe
the professional services performed by a physician or other qualified health care
professional for reviewing, analyzing, interpreting, and reporting the results of the
continuous recording EEG/VEEG with recommendations based on the findings of the
studies. These codes do not include E/M services, which may be reported separately.
Codes 95719, 95720 are used for greater than 12 hours (ie, 12 hours and 1 minute) up
to 26 hours of recording. Code selection for professional interpretation for long-term
EEG is based on: (1) length of the recording being interpreted, and (2) when the
physician or other qualified health care professional reports are generated (ie, whether
diagnostic interpretations and reports are made daily during the study, or whether the
entire professional interpretation is performed after the entire study is completed).
Codes 95717, 95718, 95719, 95720 are reported when: (1) daily professional reports are
generated during the long-term recording, even if the entire study extends over multiple
days or (2) the time of recording for the entire study is between 2 hours and 36 hours.
Codes 95717, 95718 are reported once for each 2-12 hour recording and reported a
maximum of once for an entire long-term EEG service. Codes 95719, 95720 are
reported once for each greater-than-12-hours-up-to-26-hours recording period. Studies
lasting 26 to 36 hours or longer are reported using building blocks and reported using
one or more of the greater-than-12-hours-up-to-26-hour code with one 2-12 hour code.
The recorded data are reviewed, interpreted, and reported daily by the physician or
other qualified health care professional, and summary reports are made for the entire
multiple-day study. The summary reports are included in each code (95717, 95718,
95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726) and not reported separately
(see the Long-Term EEG Monitoring Table).
For 95721, 95722, 95723, 95724, 95725, 95726, the entire professional interpretation
(including retrospective daily reports and a summary report) is made after the entire
study is recorded and downloaded at the completion of the study. When the entire
professional interpretation is provided for a multiple-day study that is greater than 36
hours, 95721, 95722, 95723, 95724, 95725, 95726 are used to report the entire
professional service with the appropriate code determined by the span of diagnostic
recording time, as defined by the codes. A single code (95721, 95722, 95723, 95724,
95725, 95726) is reported for the multiple-day study. For example, a long-term EEG
recording that spans three days with a total of 50 hours of VEEG recording would be
reported with 95722. Sixty hours and one minute of diagnostic VEEG recording is
reported with 95724 (see the Long-Term EEG Monitoring Table).
(95950, 95951, 95953 have been deleted. To report, see 95700-95726. See Long-
Term EEG Monitoring Table for guidance)
95954 Pharmacological or physical activation requiring physician or other qualified health
care professional attendance during EEG recording of activation phase (eg, thiopental
activation test)
95955 Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)

(95956 has been deleted. To report, see 95700-95726. See Long-Term EEG
Monitoring Table for guidance)
95957 Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)
➲ CPT Assistant Winter 94:18, Nov 98:35, Nov 10:6, Dec 18:3, Mar 20:8
(Do not report 95957 for use of automated software. For use of automated spike and
seizure detection and trending software when performed with long-term EEG, see
95700-95726)
95958 Wada activation test for hemispheric function, including electroencephalographic
(EEG) monitoring
95961 Functional cortical and subcortical mapping by stimulation and/or recording of

electrodes on brain surface, or of depth electrodes, to provoke seizures or identify
vital brain structures; initial hour of attendance by a physician or other qualified health
care professional
➲ CPT Assistant Winter 94:18, Nov 98:35, Nov 99:52-53, Apr 10:10, Aug 10:13,
Feb 11:3, Dec 18:3
Long-Term EEG Monitoring Table

Professional Services Technical Services
Duration of Long- With With Report at Unmonitored Intermittent Continuous
Term EEG/VEEG Report Conclusion of Entire
Recording Each 24 Recording Period
Hours
Less than 120 Not See 95812/95813 Not reported Not reported Not
minutes (w/video reported separately separately reported
or w/out video) separately separately
2 to 12 hours 95717 x 1 95705 x 1 95706 x 1 95707 x 1
(w/out video)
2 to 12 hours 95718 x 1 95711 x 1 95712 x 1 95713 x 1
(w/video)
12 hours and 1 95719 x 1 95708 x 1 95709 x 1 95710 x 1
minute to 26 hours
(w/out video)
12 hours and 1 95720 x 1 95714 x 1 95715 x 1 95716 x 1
minute to 26 hours
(w/video)
26 hours and 1 95719 x 1 and 95717 x 1 95708 x 1 95709 x 1 95710 x 1
minute to 36 hours and 95705 x and 95706 x and 95707
(w/out video) 1 1 x1
26 hours and 1 95720 x 1 and 95718 x 1 95714 x 1 95715 x 1 95716 x 1
minute to 36 hours and 95711 x and 95712 x and 95713
(w/video) 1 1 x1
36 hours and 1 95719 x 2 95721 x 1 95708 x 2 95709 x 2 95710 x 2
minute to 50 hours
(w/out video)
36 hours and 1 95720 x 2 95722 x 1 95714 x 2 95715 x 2 95716 x 2
minute to 50 hours
(w/video)
50 hours and 1 95719 x 2 95721 x 1 95708 x 2 95709 x 2 95710 x 2
minute to 60 hours and 95717 and 95705 x and 95706 x and 95707
(w/out video) x1 1 1 x1
50 hours and 1 95720 x 2 95722 x 1 95714 x 2 95715 x 2 95716 x 2
(w/video) x1 1 1 x1
60 hours and 1 95719 x 3 95723 x 1 95708 x 3 95709 x 3 95710 x 3
minute to 74 hours
(w/out video)
60 hours and 1 95720 x 3 95724 x 1 95714 x 3 95715 x 3 95716 x 3
minute to 74 hours
(w/video)
74 hours and 1 95719 x 3 95723 x 1 95708 x 3 95709 x 3 95710 x 3
(w/out video) x1 1 1 x1
74 hours and 1 95720 x 3 95724 x 1 95714 x 3 95715 x 3 95716 x 3
(w/video) x1 1 1 x1
84 hours and 1 95719 x 4 95725 x 1 95708 x 4 95709 x 4 95710 x 4
minute to 98 hours
(w/out video)
84 hours and 1 95720 x 4 95726 x 1 95714 x 4 95715 x 4 95716 x 4
minute to 98 hours
(w/video)
✚ 95962 each additional hour of attendance by a physician or other qualified health care
professional (List separately in addition to code for primary procedure)
➲ CPT Assistant Winter 94:18, Nov 98:35, Nov 99:52-53, Apr 10:10, Aug 10:13,
Feb 11:3
95965 Magnetoencephalography (MEG), recording and analysis; for spontaneous brain
magnetic activity (eg, epileptic cerebral cortex localization)
95966 for evoked magnetic fields, single modality (eg, sensory, motor, language, or visual
cortex localization)
✚ 95967 for evoked magnetic fields, each additional modality (eg, sensory, motor, language,
or visual cortex localization) (List separately in addition to code for primary
procedure)

(For electroencephalography performed in addition to magnetoencephalography, see
95812-95824)
▶ (Forsomatosensory evoked potentials, auditory evoked potentials, and visual
evoked potentials performed in addition to magnetic evoked field responses, see
92653, 95925, 95926, and/or 95930)◀
(For computerized tomography performed in addition to magnetoencephalography, see
70450-70470, 70496)
(For magnetic resonance imaging performed in addition to magnetoencephalography,
see 70551-70553)
Long-term EEG Setup

# 95700 Electroencephalogram (EEG) continuous recording, with video when performed,
setup, patient education, and takedown when performed, administered in person by
EEG technologist, minimum of 8 channels
(95700 should be reported once per recording period)

(For EEG using patient-placed electrode sets, use 95999)
(For setup performed by non-EEG technologist or remotely supervised by an EEG
technologist, use 95999)
Monitoring
# 95705 Electroencephalogram (EEG), without video, review of data, technical description by
EEG technologist, 2-12 hours; unmonitored
# 95706 with intermittent monitoring and maintenance

# 95707 with continuous, real-time monitoring and maintenance

# 95708 Electroencephalogram (EEG), without video, review of data, technical description by

EEG technologist, each increment of 12-26 hours; unmonitored


# 95711 Electroencephalogram with video (VEEG), review of data, technical description by

EEG technologist, 2-12 hours; unmonitored


# 95714 Electroencephalogram with video (VEEG), review of data, technical description by

EEG technologist, each increment of 12-26 hours; unmonitored


(95705, 95706, 95707, 95711, 95712, 95713 may be reported a maximum of once for
an entire longer-term EEG service to capture either the entire time of service or the
final 2-12 hour increment of a service extending beyond 26 hours)
# 95717 Electroencephalogram (EEG), continuous recording, physician or other qualified
health care professional review of recorded events, analysis of spike and seizure
detection, interpretation and report, 2-12 hours of EEG recording; without video
# 95718 with video (VEEG)

(For recording greater than 12 hours, see 95719, 95720, 95721, 95722, 95723, 95724,
95725, 95726)
(95717, 95718 may be reported a maximum of once for an entire long-term EEG
service to capture either the entire time of service or the final 2-12 hour increment of a
service extending beyond 24 hours)
detection, each increment of greater than 12 hours, up to 26 hours of EEG recording,
interpretation and report after each 24-hour period; without video
# 95720 with video (VEEG)

(95719, 95720 may be reported only once for a recording period greater than 12 hours
up to 26 hours. For multiple-day studies, 95719, 95720 may be reported after each 24-
hour period during the extended recording period. 95719, 95720 describe reporting
for a 26-hour recording period, whether done as a single report or as multiple reports
during the same time)
(95717, 95718 may be reported in conjunction with 95719, 95720 for studies lasting
greater than 26 hours)
(Do not report 95717, 95718, 95719, 95720 for professional interpretation of long-
term EEG studies when the recording is greater than 36 hours and the entire
professional report is retroactively generated, even if separate daily reports are
rendered after the completion of recording)
(When the entire study includes recording greater than 36 hours, and the professional
interpretation is performed after the entire recording is completed, see 95721, 95722,
95723, 95724, 95725, 95726)
detection, interpretation, and summary report, complete study; greater than 36 hours,
up to 60 hours of EEG recording, without video
# 95722 greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG)
# 95723 greater than 60 hours, up to 84 hours of EEG recording, without video

# 95724 greater than 60 hours, up to 84 hours of EEG recording, with video (VEEG)
# 95725 greater than 84 hours of EEG recording, without video

# 95726 greater than 84 hours of EEG recording, with video (VEEG)

(When the entire study includes recording greater than 36 hours, and the professional
interpretation is performed after the entire recording is completed, see 95721, 95722,
95723, 95724, 95725, 95726)
(Do not report 95721, 95722, 95723, 95724, 95725, 95726 in conjunction with 95717,
95718, 95719, 95720)
Neurostimulators, Analysis-Programming
Electronic analysis of an implanted neurostimulator pulse generator/transmitter involves
documenting settings and electrode impedances of the system parameters prior to
programming. Programming involves adjusting the system parameter(s) to address
clinical signs and patient symptoms. Parameters available for programming can vary
between systems and may need to be adjusted multiple times during a single
programming session. The iterative adjustments to parameters provide information that
is required for the physician or other qualified health care professional to assess and
select the most appropriate final program parameters to provide for consistent delivery
of appropriate therapy. The values of the final program parameters may differ from the
starting values after the programming session.
Examples of parameters include: contact group(s), interleaving, amplitude, pulse width,
frequency (Hz), on/off cycling, burst, magnet mode, dose lockout, patient-selectable
parameters, responsive neurostimulation, detection algorithms, closed-loop parameters,
and passive parameters. Not all parameters are available for programming in every
neurostimulator pulse generator/transmitter.
For coding purposes, a neurostimulator system is considered implanted when the
electrode array(s) is inserted into the target area for either permanent or trial placement.
There are several types of implantable neurostimulator pulse generator/transmitters and
they are differentiated by the nervous system region that is stimulated. A brain
neurostimulator may stimulate either brain surface regions (cortical stimulation) or deep
brain structures (deep brain stimulation). A brain neurostimulation system consists of
array(s) that targets one or more of these regions.
A cranial nerve neurostimulator targets the fibers of the cranial nerves or their branches
and divisions. There are 12 pairs of cranial nerves (see nerve anatomy figure on page
780 [of the codebook]). Each cranial nerve has its origin in the brain and passes
through one or more foramina in the skull to innervate extracranial structures. A cranial
nerve neurostimulator stimulates the nerve fibers of either the extracranial or
intracranial portion(s) of one or more cranial nerve(s) (eg, vagus nerve, trigeminal
nerve).
Cranial Nerves
Illustration of the 12 cranial nerves and their areas of innervation.
A spinal cord or peripheral nerve neurostimulator targets nerve(s) that originate in the
spinal cord and exit the spine through neural foramina and gives rise to peripheral
nerves. The peripheral nervous system consists of the nerves and ganglia outside of the
brain and spinal cord. Peripheral nerves may give rise to independent branches or
branches that combine with other peripheral nerves in neural plexuses (ie, brachial
plexus, lumbosacral plexus). Under the lumbosacral plexus, the sacral nerves
(specifically S2, S3, S4) are located in the lower back just above the tailbone.
Neurostimulation of the sacral nerves affect pelvic floor muscles and urinary organs
(eg, bladder, urinary sphincter).
Cranial nerve, spinal cord, peripheral nerve, and sacral nerve neurostimulator analysis
with programming (95971, 95972, 95976, 95977) are reported based on the number of
parameters adjusted during a programming session. Brain neurostimulator analysis with
programming (95983, 95984) is reported based on physician or other qualified health
care professional face-to-face time.
Physician or Other Qualified Health Care Professional Face-to-Face Time for

Code(s)
Brain Neurostimulator Analysis With Programming
Less than 8 minutes Not reported
8-22 minutes 95983 X 1
23-37 minutes 95983 X 1 +
95984 X 1
38-52 minutes 95983 X 1 +
95984 X 2
53-67 minutes 95983 X 1 +
95984 X 3
68 minutes or longer add units of
95984
▶Code 95970 describes electronic analysis of the implanted brain, cranial nerve, spinal
cord, peripheral nerve, or sacral nerve neurostimulator pulse generator/transmitter
without programming. Electronic analysis is inherent to implantation codes 43647,
43648, 43881, 43882, 61850, 61860, 61863, 61864, 61867, 61868, 61880, 61885, 61886,
61888, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 64553, 64555, 64561,
64566, 64568, 64569, 64570, 64575, 64580, 64581, 64585, 64590, 64595, and is not
separately reportable at the same operative session.◀
Codes 95971, 95972, 95976, 95977 describe electronic analysis with simple or complex
programming of the implanted neurostimulator pulse generator/transmitter. Simple
programming of a neurostimulator pulse generator/transmitter includes adjustment of
one to three parameter(s). Complex programming includes adjustment of more than
three parameters. For purposes of counting the number of parameters being
programmed, a single parameter that is adjusted two or more times during a
programming session counts as one parameter.
Code 95971 describes electronic analysis with simple programming of an implanted
spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse
generator/transmitter.
Code 95972 describes electronic analysis with complex programming of an implanted
spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse
generator/transmitter.
Code 95976 describes electronic analysis with simple programming of an implanted
cranial nerve neurostimulator pulse generator/transmitter.
Code 95977 describes electronic analysis with complex programming of an implanted
cranial nerve neurostimulator pulse generator/transmitter.
Codes 95983, 95984 describe electronic analysis with programming of an implanted
brain neurostimulator pulse generator/transmitter. Code 95983 is reported for the first
15 minutes of physician or other qualified health care professional face-to-face time for
analysis and programming. Code 95984 is reported for each additional 15 minutes. A
unit of service is attained when the mid-point is passed. Physician or other qualified
health care professional face-to-face time of less than eight minutes is not separately
reportable.
Code 95980 describes intraoperative electronic analysis of an implanted gastric
neurostimulator pulse generator system, with programming; code 95981 describes
subsequent analysis of the device; code 95982 describes subsequent analysis and
reprogramming. For electronic analysis and reprogramming of gastric neurostimulator,
lesser curvature, see 95980-95982.
Codes 95971, 95972, 95976, 95977, 95983, 95984 are reported when programming a
neurostimulator is performed by a physician or other qualified health care professional.
Programming may be performed in the operating room, postoperative care unit,
inpatient, and/or outpatient setting. Programming a neurostimulator in the operating
room is not inherent in the service represented by the implantation code and may be
reported by either the implanting surgeon or other qualified health care professional,
when performed.
▶Test stimulations are typically performed during an implantation procedure (43647,
43648, 43881, 43882, 61850, 61860, 61863, 61864, 61867, 61868, 61880, 61885, 61886,
61888, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 64553, 64555, 64561,
64566, 64568, 64569, 64570, 64575, 64580, 64581, 64585, 64590, 64595) to confirm
correct target site placement of the electrode array(s) and/or to confirm the functional
status of the system. Test stimulation is not considered electronic analysis or
programming of the neurostimulator system (test stimulation is included in the service
described by the implantation code) and should not be reported with 95970, 95971,
95972, 95980, 95981, 95982, 95983, 95984. Electronic analysis of a device (95970) is not
reported separately at the time of implantation.◀
(For insertion of neurostimulator pulse generator, see 61885, 61886, 63685, 64568,
64590)
(For revision or removal of neurostimulator pulse generator or receiver, see 61888,
63688, 64569, 64570, 64595)
▶ (Forimplantation of neurostimulator electrodes, see 43647, 43881, 61850-61868,
63650, 63655, 64553-64581. For revision or removal of neurostimulator electrodes,
see 43648, 43882, 61880, 63661, 63662, 63663, 63664, 64569, 64570, 64585)◀
(For analysis and programming of implanted integrated neurostimulation system,
posterior tibial nerve, see 0589T, 0590T)
95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg,
contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling,
burst, magnet mode, dose lockout, patient selectable parameters, responsive
neurostimulation, detection algorithms, closed loop parameters, and passive
parameters) by physician or other qualified health care professional; with brain,
cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse
generator/transmitter, without programming
➲ CPT Assistant Nov 98:36-37, Sep 99:1, Nov 99:53-54, Aug 05:7, Sep 05:10, Oct
12:15, Jul 16:7, Oct 18:8
▶ (Do not report 95970 in conjunction with 43647, 43648, 43881, 43882, 61850,
61860, 61863, 61864, 61867, 61868, 61880, 61885, 61886, 61888, 63650, 63655,
63661, 63662, 63663, 63664, 63685, 63688, 64553, 64555, 64561, 64566, 64568,
64569, 64570, 64575, 64580, 64581, 64585, 64590, 64595, during the same operative
session)◀
(Do not report 95970 in conjunction with 95971, 95972, 95976, 95977, 95983,
95984)
95971 with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator
pulse generator/transmitter programming by physician or other qualified health care
professional
➲ CPT Assistant Nov 98:36-37, Sep 99:1, Nov 99:53-54, Aug 05:7, Oct 10:14,
Dec 10:14, Apr 11:11, Oct 12:15, Jul 16:7, Oct 18:8
95972 with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator
pulse generator/transmitter programming by physician or other qualified health care
professional
➲ CPT Changes: An Insider’s View 2000, 2005, 2012, 2015, 2016, 2019
➲ CPT Assistant Nov 98:36-37, Sep 99:1, Nov 99:53-54, Aug 05:7, Apr 11:10,
Oct 12:15, Aug 14:5, Jul 16:7, Oct 18:8
(For percutaneous implantation or replacement of integrated neurostimulation system,
posterior tibial nerve, use 0587T)
(95974, 95975 have been deleted. To report, see 95976, 95977)
95976 with simple cranial nerve neurostimulator pulse generator/transmitter programming
by physician or other qualified health care professional

95977 with complex cranial nerve neurostimulator pulse generator/transmitter
programming by physician or other qualified health care professional
# 95983 with brain neurostimulator pulse generator/transmitter programming, first 15

minutes face-to-face time with physician or other qualified health care professional
#✚ 95984 with brain neurostimulator pulse generator/transmitter programming, each

additional 15 minutes face-to-face time with physician or other qualified health
care professional (List separately in addition to code for primary procedure)

(Do not report 95970, 95971, 95972, 95976, 95977, 95983, 95984 in conjunction with
0587T, 0588T, 0589T, 0590T)
(For percutaneous implantation or replacement of integrated neurostimulation system,
posterior tibial nerve, use 0587T)
(95978, 95979 have been deleted. To report, see 95983, 95984)
95980 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate,
pulse amplitude and duration, configuration of wave form, battery status, electrode
selectability, output modulation, cycling, impedance and patient measurements) gastric
neurostimulator pulse generator/transmitter; intraoperative, with programming
➲ CPT Assistant Jan 08:8, Nov 10:8, Jul 16:7
95981 subsequent, without reprogramming

95982 subsequent, with reprogramming

(For intraoperative or subsequent analysis, with programming, when performed, of

vagus nerve trunk stimulator used for blocking therapy [morbid obesity], see 0312T,
0317T)
Other Procedures
95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal
(intrathecal, epidural) or brain (intraventricular), includes electronic analysis of
pump, when performed;
➲ CPT Assistant Nov 02:4, Nov 05:1, Jul 06:1, Jul 12:6, Aug 12:10, 11, 12, 15
95991 requiring skill of a physician or other qualified health care professional

➲ CPT Assistant Nov 05:1, Jul 06:1, Jul 12:6, Aug 12:10, 11, 12, 15
(Do not report 95990, 95991 in conjunction with 62367-62370. For analysis and/or
reprogramming of implantable infusion pump, see 62367-62370)
(For refill and maintenance of implanted infusion pump or reservoir for systemic drug
therapy [eg, chemotherapy], use 96522)
Coding Tip
When advanced practice nurses and physician assistants are working with physicians, they are
considered as working in the exact same specialty and exact same subspecialties as the physician. A
“physician or other qualified health care professional” is an individual who is qualified by education,
training, licensure/regulation (when applicable), and facility privileging (when applicable) who
performs a professional service within his or her scope of practice and independently reports that
professional service. These professionals are distinct from “clinical staff.” A clinical staff member is a
person who works under the supervision of a physician or other qualified health care professional, and
who is allowed by law, regulation, and facility policy to perform or assist in the performance of a
specific professional service, but does not individually report that professional service. Other policies
may also affect who may report specific services.
CPT Coding Guidelines, Introduction, Instructions for Use of the CPT Codebook
95992 Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day

95999 Unlisted neurological or neuromuscular diagnostic procedure
➲ CPT Assistant Feb 99:11, Jan 02:11, Mar 07:4, Apr 07:7, Dec 08:10, Aug 15:8,
Aug 18:11, Mar 20:8
Motion Analysis
Codes 96000-96004 describe services performed as part of a major therapeutic or
diagnostic decision making process. Motion analysis is performed in a dedicated
motion analysis laboratory (ie, a facility capable of performing videotaping from the
front, back and both sides, computerized 3D kinematics, 3D kinetics, and dynamic
electromyography). Code 96000 may include 3D kinetics and stride characteristics.
Codes 96002-96003 describe dynamic electromyography.
Code 96004 should only be reported once regardless of the number of study(ies)
reviewed/interpreted.
(For performance of needle electromyography procedures, see 95860-95870, 95872,
95885-95887)
(For gait training, use 97116)
96000 Comprehensive computer-based motion analysis by video-taping and 3D kinematics;
➲ CPT Assistant Aug 02:5, Jun 03:2
96001 with dynamic plantar pressure measurements during walking

96002 Dynamic surface electromyography, during walking or other functional activities, 1-12
muscles
➲ CPT Assistant Aug 02:5, Jun 03:3, Aug 15:8
96003 Dynamic fine wire electromyography, during walking or other functional activities, 1
muscle
(Do not report 96002, 96003 in conjunction with 95860-95866, 95869-95872, 95885-
95887)
96004 Review and interpretation by physician or other qualified health care professional of
comprehensive computer-based motion analysis, dynamic plantar pressure
measurements, dynamic surface electromyography during walking or other functional
activities, and dynamic fine wire electromyography, with written report
➲ CPT Assistant Aug 02:5, Jun 03:3, Aug 15:8
Functional Brain Mapping

Code 96020 includes selection and administration of testing of language, memory,
cognition, movement, sensation, and other neurological functions when conducted in
association with functional neuroimaging, monitoring of performance of this testing,
and determination of validity of neurofunctional testing relative to separately
interpreted functional magnetic resonance images.
96020 Neurofunctional testing selection and administration during noninvasive imaging
functional brain mapping, with test administered entirely by a physician or other
qualified health care professional (ie, psychologist), with review of test results and
report
(For functional magnetic resonance imaging [fMRI], brain, use 70555)

(Do not report 96020 in conjunction with 96112, 96113, 96116, 96121, 96130, 96131,
96132, 96133)
(Evaluation and Management services codes should not be reported on the same day
as 96020)
Medical Genetics and Genetic Counseling Services

These services are provided by trained genetic counselors and may include obtaining a
structured family genetic history, pedigree construction, analysis for genetic risk
assessment, and counseling of the patient and family. These activities may be provided
during one or more sessions and may include review of medical data and family
information, face-to-face interviews, and counseling services.
Code 96040 is reported for each 30-minute increment of face-to-face time. Do not
report 96040 for 15 minutes or less of face-to-face time. Report 96040 once for 16 to 30
minutes of face-to-face time.
★ 96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with
patient/family
(For genetic counseling and education provided to an individual by a physician or

other qualified health care professional who may report evaluation and management
services, see the appropriate Evaluation and Management codes)
(For genetic counseling and education to a group by a physician or other qualified
health care professional, use 99078)
(For education regarding genetic risks by a nonphysician to a group, see 98961,
98962)
(For genetic counseling and/or risk factor reduction intervention provided to patient(s)
without symptoms or established disease, by a physician or other qualified health care
professional who may report evaluation and management services, see 99401-99412)
Adaptive Behavior Services

Adaptive behavior services address deficient adaptive behaviors (eg, impaired social,
communication, or self-care skills), maladaptive behaviors (eg, repetitive and
stereotypic behaviors, behaviors that risk physical harm to the patient, others, and/or
property), or other impaired functioning secondary to deficient adaptive or maladaptive
behaviors, including, but not limited to, instruction-following, verbal and nonverbal
communication, imitation, play and leisure, social interactions, self-care, daily living,
and personal safety.
Definitions
Functional behavior assessment: comprises descriptive assessment procedures
designed to identify environmental events that occur just before and just after
occurrences of potential target behaviors and that may influence those behaviors. That
information may be gathered by interviewing the patient’s caregivers; having caregivers
complete checklists, rating scales, or questionnaires; and/or observing and recording
occurrences of target behaviors and environmental events in everyday situations.
Functional analysis: an assessment procedure for evaluating the separate effects of
each of several environmental events on a potential target behavior by systematically
presenting and withdrawing each event to a patient multiple times and observing and
measuring occurrences of the behavior in response to those events. Graphed data are
analyzed visually to determine which events produced relatively high and low
occurrences of the behavior.
Standardized instruments and procedures: include, but not limited to, behavior
checklists, rating scales, and adaptive skill assessment instruments that comprise a fixed
set of items and are administered and scored in a uniform way with all patients (eg,
Pervasive Developmental Disabilities Behavior Inventory, Brigance Inventory of Early
Development, Vineland Adaptive Behavior Scales).
Nonstandardized instruments and procedures: include, but not limited to, curriculum-
referenced assessments, stimulus preference assessment procedures, and other
procedures for assessing behaviors and associated environmental events that are
specific to the individual patient and behaviors.
Adaptive Behavior Assessments

Behavior identification assessment (97151) is conducted by the physician or other
qualified health care professional and may include analysis of pertinent past data
(including medical diagnosis), a detailed behavioral history, patient observation,
administration of standardized and/or non-standardized instruments and procedures,
functional behavior assessment, functional analysis, and/or guardian/caregiver
interview to identify and describe deficient adaptive behaviors, maladaptive behaviors,
and other impaired functioning secondary to deficient adaptive or maladaptive
behaviors. Code 97151 includes the physician’s or other qualified health care
professional’s scoring of assessments, interpretation of results, discussion of findings
and recommendations with the primary guardian(s)/caregiver(s), preparation of report,
and development of plan of care, which may include behavior identification supporting
assessment (97152) or behavior identification–supporting assessment with four
required components (0362T).
Behavior identification supporting assessment (97152) is administered by a
technician under the direction of a physician or other qualified health care professional.
The physician or other qualified health care professional may or may not be on site
during the face-to-face assessment process. Code 97152 includes the physician’s or
other qualified health care professional’s interpretation of results and may include
functional behavior assessment, functional analysis, and other structured observations
and/or standardized and/or nonstandardized instruments and procedures to determine
levels of adaptive and maladaptive behavior.
Codes 97152, 0362T may be reported separately with 97151 based on the time that the
patient is face-to-face with one or more technician(s). Only count the time of one
technician when two or more are present.
For behavior identification–supporting assessment with four required components, use
0362T.
Coding Tip
If the physician or other qualified health care professional personally performs the technician
activities, his or her time engaged in these activities should be included as part of the required
technician time to meet the components of the code.
# 97151 Behavior identification assessment, administered by a physician or other qualified

health care professional, each 15 minutes of the physician’s or other qualified health
care professional’s time face-to-face with patient and/or guardian(s)/caregiver(s)
administering assessments and discussing findings and recommendations, and non-
face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the
report/treatment plan
Guide to Selection of Codes 97152 and 0362T

97152 0362T
Physician or other qualified health care professional required to be on site ✓
Physician or other qualified health care professional not required to be on site ✓
Number of technicians 1 2 or
more
Deficient adaptive behavior(s), maladaptive behavior(s), or other impaired functioning ✓
secondary to deficient adaptive or maladaptive behaviors
Destructive behavior(s) ✓
May include functional behavior assessment ✓ ✓
May include functional analysis ✓ ✓
Environment customized to patient and behavior ✓
# 97152 Behavior identification-supporting assessment, administered by one technician
under the direction of a physician or other qualified health care professional, face-to-
face with the patient, each 15 minutes
(97151, 97152, 0362T may be repeated on the same or different days until the
behavior identification assessment [97151] and, if necessary, supporting assessment[s]
[97152, 0362T], is complete)
(For psychiatric diagnostic evaluation, see 90791, 90792)
(For speech evaluations, see 92521, 92522, 92523, 92524)
(For occupational therapy evaluation, see 97165, 97166, 97167, 97168)
(For medical team conference, see 99366, 99367, 99368)
(For health and behavior assessment/intervention, see 96156, 96158, 96159, 96164,
96165, 96167, 96168, 96170, 96171)
(For neurobehavioral status exam, see 96116, 96121)
(For neuropsychological testing, see 96132, 96133, 96136, 96137, 96138, 96139,
96146)
Adaptive Behavior Treatment

Adaptive behavior treatment codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T
describe services that address specific treatment targets and goals based on results of
previous assessments (see 97151, 97152, 0362T), and include ongoing assessment and
adjustment of treatment protocols, targets, and goals.
Adaptive behavior treatment by protocol (97153) and group adaptive behavior
treatment by protocol (97154) are administered by a technician under the direction of
a physician or other qualified health care professional, utilizing a treatment protocol
designed in advance by the physician or other qualified health care professional, who
may or may not provide direction during the treatment. Code 97153 describes face-to-
face services with one patient and code 97154 describes face-to-face services with two
or more patients. Do not report 97154 if the group is larger than eight patients.
Adaptive behavior treatment with protocol modification (97155) is administered by
a physician or other qualified health care professional face-to-face with a single patient.
The physician or other qualified health care professional resolves one or more
problems with the protocol and may simultaneously direct a technician in administering
the modified protocol while the patient is present. Physician or other qualified health
care professional direction to the technician without the patient present is not reported
separately.
Family adaptive behavior treatment guidance and multiple-family group adaptive
behavior treatment guidance (97156, 97157) are administered by a physician or other
qualified health care professional face-to-face with guardian(s)/caregiver(s) and involve
identifying potential treatment targets and training guardian(s)/caregiver(s) of one
patient (97156) or multiple patients (97157) to implement treatment protocols designed
to address deficient adaptive or maladaptive behaviors. Services described by 97156
may be performed with or without the patient present. Services described by 97157 are
performed without the patient present. Do not report 97157 if the group has more than
eight patients’ guardian(s)/caretaker(s).
Group adaptive behavior treatment with protocol modification (97158) is
administered by a physician or other qualified health care professional face-to-face with
multiple patients. The physician or other qualified health care professional monitors the
needs of individual patients and adjusts the treatment techniques during the group
sessions, as needed. In contrast to group adaptive behavior treatment by protocol
(97154), protocol adjustments are made in real time rather than for a subsequent
service. Do not report 97158 if the group has more than eight patients.
For adaptive behavior treatment with protocol modification with four required
components, use 0373T.
Coding Tip
If the physician or other qualified health care professional personally performs the technician
activities, his or her time engaged in these activities should be reported as technician time.
# 97153 Adaptive behavior treatment by protocol, administered by technician under the

direction of a physician or other qualified health care professional, face-to-face with
one patient, each 15 minutes
(Do not report 97153 in conjunction with 90785-90899, 92507, 96105-96171, 97129)
# 97154 Group adaptive behavior treatment by protocol, administered by technician under
the direction of a physician or other qualified health care professional, face-to-face
with two or more patients, each 15 minutes
(Do not report 97154 if the group has more than 8 patients)
# 97155 Adaptive behavior treatment with protocol modification, administered by physician
or other qualified health care professional, which may include simultaneous direction
of technician, face-to-face with one patient, each 15 minutes
# 97156 Family adaptive behavior treatment guidance, administered by physician or other
qualified health care professional (with or without the patient present), face-to-face
with guardian(s)/caregiver(s), each 15 minutes
Guide to Selection of Codes 97153, 97155, and 0373T
97153 97155 0373T

By protocol ✓
With protocol modification ✓ ✓
Physician or other qualified health care professional face-to-face with patient ✓
Physician or other qualified health care professional required to be on site ✓
Physician or other qualified health care professional not required to be on site ✓
Number of technicians 1 0-1 2 or
more
Deficient adaptive behavior(s), maladaptive behavior(s), or other impaired ✓ ✓
functioning secondary to deficient adaptive or maladaptive behaviors
Destructive behavior(s) ✓ ✓
Environment customized to patient and behavior ✓
(Do not report 97156 in conjunction with 90785-90899, 96105-96171)
# 97157 Multiple-family group adaptive behavior treatment guidance, administered by
physician or other qualified health care professional (without the patient present),
face-to-face with multiple sets of guardians/caregivers, each 15 minutes
(Do not report 97157 if the group has more than 8 families)
(Do not report 97156, 97157 in conjunction with 90785-90899, 96105-96171)
# 97158 Group adaptive behavior treatment with protocol modification, administered by
physician or other qualified health care professional, face-to-face with multiple
patients, each 15 minutes
(Do not report 97158 if the group has more than 8 patients)
(Do not report 97158 in conjunction with 90785-90899, 96105-96171, 92508, 97150)
Central Nervous System Assessments/Tests (eg,

Neuro-Cognitive, Mental Status, Speech Testing)
The following codes are used to report the services provided during testing of the
central nervous system functions. The central nervous system assessments include, but
are not limited to, memory, language, visual motor responses, and abstract
reasoning/problem-solving abilities. It is accomplished by the combination of several
types of testing procedures. Testing procedures include assessment of aphasia and
cognitive performance testing, developmental screening and behavioral assessments
and testing, and psychological/neuropsychological testing. The administration of these
tests will generate material that will be formulated into a report or an automated result.
(For development of cognitive skills, see 97129, 97533)
(For dementia screens, [eg, Folstein Mini-Mental State Examination, by a physician or
other qualified health care professional], see Evaluation and Management services
codes)
(Do not report assessment of aphasia and cognitive performance testing services
[96105, 96125], developmental/behavioral screening and testing services [96110,
96112, 96113, 96127], and psychological/neuropsychological testing services [96116,
96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146] in
conjunction with 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T,
0373T)
Definitions
Codes in this family (96105-96146) describe a number of services that are defined
below:
Cognitive performance testing: assesses the patient’s ability to complete specific
functional tasks applicable to the patient’s environment in order to identify or quantify
specific cognitive deficits. The results are used to determine impairments and develop
therapeutic goals and objectives.
Central Nervous System Assessments/Tests (eg, Neuro-Cognitive, Mental Status,

Speech Testing) Tables
Assessment of Aphasia and Cognitive Performance Testing
Cognitive Services Test Interpretation and
Administration/Scoring Report or Automated
Result
Code Unit Evaluation Interactive Physician or Technician Physician or Automated
Feedback Qualified Qualified Result
Health Health
Care Care
Professional Professional
96105 Per hour X X X
Developmental/Behavioral Screening and Testing
Result
Code Unit Evaluation Interactive Physician or Clinical Physician or Automated
Feedback Qualified Staff Qualified Result
Health Health
Care Care
96110 Per X
instrument
✚96113 Per 30 X X X
min (add-
on)
96127 Per X
instrument
Psychological/Neuropsychological Testing
Result
Code Unit Evaluation Interactive Physician or Technician Physician or Automated
Feedback Qualified Qualified Result
Health Health
Care Care
Neurobehavioral Status Examination
✚96121 Per hour X X X
(add-on)
Testing Evaluation Services
96130 Per hour X X Not included Not X
in Code included in
Code
✚96131 Per hour X X Not included Not X
(add-on) in Code included in
Code
96132 Per hour X X Not included Not X
in Code included in
Code
✚96133 Per hour X X Not included Not X
(add-on) in Code included in
Code
Test Administration & Scoring
96136 Per 30 Not Not X Not included Not
min included in included in in Code included in
Code Code Code
✚96137 Per 30 Not Not X Not included Not
min (add- included in included in in Code included in
on) Code Code Code
96138 Per 30 Not Not X Not included Not
min included in included in in Code included in
Code Code Code
✚96139 Per 30 Not Not X Not included Not
min (add- included in included in in Code included in
on) Code Code Code
Automated Testing and Result
96146 Automated Not Not X
report(s) included in included in
Code Code
Interactive feedback: used to convey the implications of psychological or

neuropsychological test findings and diagnostic formulation. Based on patient-specific
cognitive and emotional strengths and weaknesses, interactive feedback may include
promoting adherence to medical and/or psychological treatment plans; educating and
engaging the patient about his or her condition to maximize patient collaboration in
their care; addressing safety issues; facilitating psychological coping; coordinating care;
and engaging the patient in planning given the expected course of illness or condition,
when performed.
Interpretation and report: performed by a physician or other qualified health care
professional. In some circumstances, a result is generated through the use of a
“computer,” tablet(s), or other device(s).
Neurobehavioral status examination: a clinical assessment of cognitive functions and
behavior, and may include an interview with the patient, other informant(s), and/or
staff, as well as integration of prior history and other sources of clinical data with
clinical decision making, further assessment and/or treatment planning and report.
Evaluation domains may include acquired knowledge, attention, language, memory,
planning and problem solving, and visual spatial abilities.
Neuropsychological testing evaluation services: typically include integration of patient
data with other sources of clinical data, interpretation, clinical decision making, and
treatment planning and report. It may include interactive feedback to the patient, family
member(s) or caregiver(s), when performed. Evaluation domains for
neuropsychological evaluation may include intellectual function, attention, executive
function, language and communication, memory, visual-spatial function, sensorimotor
function, emotional and personality features, and adaptive behavior.
Psychological testing evaluation services: typically include integration of patient data
with other sources of clinical data, interpretation, clinical decision making, and
treatment planning and report. It may include interactive feedback to the patient, family
member(s) or caregiver(s) when performed. Evaluation domains for psychological
evaluation may include emotional and interpersonal functioning, intellectual function,
thought processes, personality, and psychopathology.
Standardized instruments: used in the performance of these services. Standardized
instruments are validated tests that are administered and scored in a consistent or
“standard” manner consistent with their validation.
Testing: administered by a physician, other qualified health care professional, and
technician, or completed by the patient. The mode of completion can be manual (eg,
paper and pencil) or via automated means.
Assessment of aphasia and cognitive performance testing, which includes interpretation
and report, are described by 96105, 96125.
Developmental screening services are described by 96110. Developmental/behavioral
testing services, which include interpretation and report, are described by 96112, 96113.
Neurobehavioral status examination, which includes interpretation and report, is
described by 96116, 96121.
Psychological and neuropsychological test evaluation services, which include
integration of patient data, interpretation of test results and clinical data, treatment
planning and report, and interactive feedback, are described by 96130, 96131, 96132,
96133.
Testing and administration services (96136, 96137) are performed by a physician or
other qualified health care professional. For 96136, 96137, do not include time for
evaluation services (eg, integration of patient data or interpretation of test results). This
time is included with psychological and neuropsychological test evaluation services
(96130, 96131, 96132, 96133). Testing and administration services (96138, 96139) are
performed by a technician. The tests selected, test administration and method of testing
and scoring are the same, regardless whether the testing is performed by a physician,
other qualified health care professional, or a technician, for 96136, 96137, 96138,
96139. Automated testing and result code 96146 describes testing performed by a single
automated instrument with an automated result.
Some of these services are typically performed together. For example,
psychological/neuropsychological testing evaluation services (96130, 96131, 96132,
96133) may be reported with psychological/neuropsychological test administration and
scoring services (96136, 96137, 96138, 96139).
A requirement of testing services (96105, 96125, 96112, 96113, 96130, 96131, 96132,
96133, 96146) is that there is an interpretation and report when performed by a
qualified health care professional, or a result when generated by automation. These
services follow standard CPT time definitions (ie, a minimum of 16 minutes for 30
minutes codes and 31 minutes for 1-hour codes must be provided to report any per
hour code). The time reported in 96116, 96121, 96130, 96131, 96132, 96133, 96125 is
the face-to-face time with the patient and the time spent integrating and interpreting
data.
Report the total time at the completion of the entire episode of evaluation.
(To report psychological testing evaluation and administration and scoring services,
see 96130, 96131, 96136, 96137, 96138, 96139, 96146)
(To report psychological test administration using a single automated instrument, use
96146)
Assessment of Aphasia and Cognitive
Performance Testing
96105 Assessment of aphasia (includes assessment of expressive
and receptive speech and language function, language
comprehension, speech production ability, reading, spelling,
writing, eg, by Boston Diagnostic Aphasia Examination)
with interpretation and report, per hour
➲ CPT Assistant Jul 96:8, May 05:1, Nov 09:10, Oct 18:5,
Nov 18:3
# 96125 Standardized cognitive performance testing (eg, Ross
Information Processing Assessment) per hour of a qualified
health care professional’s time, both face-to-face time
administering tests to the patient and time interpreting these
test results and preparing the report
➲ CPT Assistant Oct 11:4, Oct 18:5, Nov 18:3
(To report neuropsychological testing evaluation and

administration and scoring services, see 96132, 96133,
96136, 96137, 96138, 96139, 96146)
Developmental/Behavioral Screening and

Testing
96110 Developmental screening (eg, developmental milestone
survey, speech and language delay screen), with scoring and
documentation, per standardized instrument
➲ CPT Assistant Jul 96:9, May 05:1, Nov 09:10, Jun 14:3,
Aug 15:5, Feb 17:15, Nov 18:3
(For an emotional/behavioral assessment, use 96127)
(To report developmental testing, see 96112, 96113)
96112 Developmental test administration (including assessment of
fine and/or gross motor, language, cognitive level, social,
memory and/or executive functions by standardized
developmental instruments when performed), by physician
or other qualified health care professional, with
interpretation and report; first hour

# 96127 Brief emotional/behavioral assessment (eg, depression

inventory, attention-deficit/hyperactivity disorder [ADHD]
scale), with scoring and documentation, per standardized
instrument
➲ CPT Assistant Aug 15:5, Feb 17:15, Nov 18:3
(For developmental screening, use 96110)
Neurobehavioral Status Examination
★ 96116 Neurobehavioral status exam (clinical assessment of
thinking, reasoning and judgment, [eg, acquired knowledge,
attention, language, memory, planning and problem solving,
and visual spatial abilities]), by physician or other qualified
health care professional, both face-to-face time with the
patient and time interpreting test results and preparing the
report; first hour
➲ CPT Assistant Oct 11:4, Jun 14:3, Oct 18:5, Nov 18:3
(To report neuropsychological testing evaluation and
administration and scoring services, see 96132, 96133,
96136, 96137, 96138, 96139, 96146)
(To report psychological test administration using a single
automated instrument, use 96146)
✚ 96121 each additional hour (List separately in addition to code

Testing Evaluation Services

96130 Psychological testing evaluation services by physician or
other qualified health care professional, including
integration of patient data, interpretation of standardized test
results and clinical data, clinical decision making, treatment
planning and report, and interactive feedback to the patient,
family member(s) or caregiver(s), when performed; first
hour
➲ CPT Assistant Nov 18:3, Sep 19:12, Dec 19:15

96132 Neuropsychological testing evaluation services by physician

or other qualified health care professional, including
integration of patient data, interpretation of standardized test
results and clinical data, clinical decision making, treatment
planning and report, and interactive feedback to the patient,
family member(s) or caregiver(s), when performed; first
hour

Test Administration and Scoring

96136 Psychological or neuropsychological test administration and
scoring by physician or other qualified health care
professional, two or more tests, any method; first 30 minutes

(96136, 96137 may be reported in conjunction with 96130,

96131, 96132, 96133 on the same or different days)
96138 Psychological or neuropsychological test administration and
scoring by technician, two or more tests, any method; first
30 minutes

(96138, 96139 may be reported in conjunction with 96130,

96131, 96132, 96133 on the same or different days)
(For 96136, 96137, 96138, 96139, do not include time for
evaluation services [eg, integration of patient data or
interpretation of test results]. This time is included in
96130, 96131, 96132, 96133)
Automated Testing and Result

96146 Psychological or neuropsychological test administration,
with single automated, standardized instrument via
electronic platform, with automated result only
(If test is administered by physician, other qualified health

care professional, or technician, do not report 96146. To
report, see 96127, 96136, 96137, 96138, 96139)
Health Behavior Assessment and

Intervention
Health behavior assessment and intervention services are used to
identify and address the psychological, behavioral, emotional,
cognitive, and interpersonal factors important to the assessment,
treatment, or management of physical health problems.
The patient’s primary diagnosis is physical in nature and the
focus of the assessment and intervention is on factors
complicating medical conditions and treatments. These codes
describe assessments and interventions to improve the patient’s
health and well-being utilizing psychological and/or psychosocial
interventions designed to ameliorate specific disease-related
problems.
Health behavior assessment: includes evaluation of the patient’s
responses to disease, illness or injury, outlook, coping strategies,
motivation, and adherence to medical treatment. Assessment is
conducted through health-focused clinical interviews,
observation, and clinical decision making.
Health behavior intervention: includes promotion of functional
improvement, minimizing psychological and/or psychosocial
barriers to recovery, and management of and improved coping
with medical conditions. These services emphasize active
patient/family engagement and involvement. These interventions
may be provided individually, to a group (two or more patients),
and/or to the family, with or without the patient present.
Codes 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170,
96171 describe services offered to patients who present with
primary physical illnesses, diagnoses, or symptoms and may
benefit from assessments and interventions that focus on the
psychological and/or psychosocial factors related to the patient’s
health status. These services do not represent preventive
medicine counseling and risk factor reduction interventions.
For patients that require psychiatric services (90785-90899),
adaptive behavior services (97151, 97152, 97153, 97154, 97155,
97156, 97157, 97158, 0362T, 0373T) as well as health behavior
assessment and intervention (96156, 96158, 96159, 96164, 96165,
96167, 96168, 96170, 96171), report the predominant service
performed. Do not report 96156, 96158, 96159, 96164, 96165,
96167, 96168, 96170, 96171 in conjunction with 90785-90899 on
the same date.
Evaluation and management services codes (including counseling
risk factor reduction and behavior change intervention [99401-
99412]) should not be reported on the same day as health
behavior assessment and intervention codes 96156, 96158, 96159,
96164, 96165, 96167, 96168, 96170, 96171 by the same provider.
Health behavior assessment and intervention services (96156,
96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171) can
occur and be reported on the same date of service as evaluation
and management services (including counseling risk factor
reduction and behavior change intervention [99401, 99402,
99403, 99404, 99406, 99407, 99408, 99409, 99411, 99412]), as
long as the health behavior assessment and intervention service is
reported by a physician or other qualified health care
professional and the evaluation and management service is
performed by a physician or other qualified health care
professional who may report evaluation and management
services.
Do not report 96158, 96164, 96167, 96170 for less than 16
minutes of service.
(For health behavior assessment and intervention services
[96156, 96158, 96159, 96164, 96165, 96167, 96168,
96170, 96171] performed by a physician or other qualified
health care professional who may report evaluation and
management services, see Evaluation and Management or
Preventive Medicine Services codes)
(Do not report 96156, 96158, 96159, 96164, 96165, 96167,
96168, 96170, 96171 in conjunction with 97151, 97152,
97153, 97154, 97155, 97156, 97157, 97158, 0362T,
0373T)
96156, 96158, 96159)
96156 Health behavior assessment, or re-assessment (ie, health-
focused clinical interview, behavioral observations, clinical
decision making)
96158 Health behavior intervention, individual, face-to-face;

initial 30 minutes


# 96164 Health behavior intervention, group (2 or more patients),
face-to-face; initial 30 minutes


# 96167 Health behavior intervention, family (with the patient
present), face-to-face; initial 30 minutes

# 96170 Health behavior intervention, family (without the patient
present), face-to-face; initial 30 minutes


96160 Administration of patient-focused health risk assessment
instrument (eg, health hazard appraisal) with scoring and
documentation, per standardized instrument
96161 Administration of caregiver-focused health risk assessment

instrument (eg, depression inventory) for the benefit of the
patient, with scoring and documentation, per standardized
instrument

Hydration, Therapeutic, Prophylactic,

Diagnostic Injections and Infusions,
and Chemotherapy and Other Highly
Complex Drug or Highly Complex
Biologic Agent Administration
Physician or other qualified health care professional work related
to hydration, injection, and infusion services predominantly
involves affirmation of treatment plan and direct supervision of
staff.
▶Codes 96360-96379, 96401, 96402, 96409-96425, 96521-96523
are not intended to be reported by the physician in the facility
setting. If a significant, separately identifiable office or other
outpatient evaluation and management (E/M) service is
performed, the appropriate E/M service (99202-99215, 99241-
99245, 99354-99355) should be reported using modifier 25 in
addition to 96360-96549. For same day E/M service, a different
diagnosis is not required.◀
If performed to facilitate the infusion or injection, the following
services are included and are not reported separately:
a. Use of local anesthesia
b. IV start
c. Access to indwelling IV, subcutaneous catheter or port
d. Flush at conclusion of infusion
e. Standard tubing, syringes, and supplies
(For declotting a catheter or port, use 36593)
When multiple drugs are administered, report the service(s) and
the specific materials or drugs for each.
When administering multiple infusions, injections or
combinations, only one “initial” service code should be reported
for a given date, unless protocol requires that two separate IV
sites must be used. Do not report a second initial service on the
same date due to an intravenous line requiring a re-start, an IV
rate not being able to be reached without two lines, or for
accessing a port of a multi-lumen catheter. If an injection or
infusion is of a subsequent or concurrent nature, even if it is the
first such service within that group of services, then a subsequent
or concurrent code from the appropriate section should be
reported (eg, the first IV push given subsequent to an initial one-
hour infusion is reported using a subsequent IV push code).
Initial infusion: For physician or other qualified health care
professional reporting, an initial infusion is the key or primary
reason for the encounter reported irrespective of the temporal
order in which the infusion(s) or injection(s) are administered.
For facility reporting, an initial infusion is based using the
hierarchy. For both physician or other qualified health care
professional and facility reporting, only one initial service code
(eg, 96365) should be reported unless the protocol or patient
condition requires that two separate IV sites must be utilized. The
difference in time and effort in providing this second IV site
access is also reported using the initial service code with
modifier 59 appended (eg, 96365, 96365-59).
Sequential infusion: A sequential infusion is an infusion or IV
push of a new substance or drug following a primary or initial
service. All sequential services require that there be a new
substance or drug, except that facilities may report a sequential
intravenous push of the same drug using 96376.
Concurrent infusion: A concurrent infusion is an infusion of a
new substance or drug infused at the same time as another
substance or drug. A concurrent infusion service is not time
based and is only reported once per day regardless of whether an
additional new drug or substance is administered concurrently.
Hydration may not be reported concurrently with any other
service. A separate subsequent concurrent administration of
another new drug or substance (the third substance or drug) is
not reported.
In order to determine which service should be reported as the
initial service when there is more than one type of service,
hierarchies have been created. These vary by whether the
physician or other qualified health care professional or a facility
is reporting. The order of selection for reporting is based upon
the physician’s or other qualified health care professional’s
knowledge of the clinical condition(s) and treatment(s). The
hierarchy that facilities are to use is based upon a structural
algorithm. When these codes are reported by the physician or
other qualified health care professional, the “initial” code that
best describes the key or primary reason for the encounter should
always be reported irrespective of the order in which the
infusions or injections occur.
When these codes are reported by the facility, the following
instructions apply. The initial code should be selected using a
hierarchy whereby chemotherapy services are primary to
therapeutic, prophylactic, and diagnostic services which are
primary to hydration services. Infusions are primary to pushes,
which are primary to injections. This hierarchy is to be followed
by facilities and supersedes parenthetical instructions for add-on
codes that suggest an add-on of a higher hierarchical position
may be reported in conjunction with a base code of a lower
position. (For example, the hierarchy would not permit reporting
96376 with 96360, as 96376 is a higher order code. IV push is
primary to hydration.)
When reporting multiple infusions of the same drug/substance on
the same date of service, the initial code should be selected. The
second and subsequent infusion(s) should be reported based on
the individual time(s) of each additional infusion(s) of the same
drug/substance using the appropriate add-on code.
Example: In the outpatient observation setting, a patient receives
one-hour intravenous infusions of the same antibiotic every 8
hours on the same date of service through the same IV access.
The hierarchy for facility reporting permits the reporting of code
96365 for the first one-hour dose administered. Add-on 96366
would be reported twice (once for the second and third one-hour
infusions of the same drug).
When reporting codes for which infusion time is a factor, use the
actual time over which the infusion is administered. Intravenous
or intra-arterial push is defined as: (a) an injection in which the
individual who administers the drug/substance is continuously
present to administer the injection and observe the patient, or (b)
an infusion of 15 minutes or less. If intravenous hydration
(96360, 96361) is given from 11 PM to 2 AM, 96360 would be
reported once and 96361 twice. For continuous services that last
beyond midnight, use the date in which the service began and
report the total units of time provided continuously. However, if
instead of a continuous infusion, a medication was given by
intravenous push at 10 PM and 2 AM, as the service was not
continuous, the two administrations would be reported as an
initial service (96374) and sequential (96376) as: (1) no other
infusion services were performed; and (2) the push of the same
drug was performed more than 30 minutes beyond the initial
administration. A “keep open” infusion of any type is not
Hydration
Codes 96360-96361 are intended to report a hydration IV
infusion to consist of a pre-packaged fluid and electrolytes (eg,
normal saline, D5-1/2 normal saline+30mEq KCl/liter), but are
not used to report infusion of drugs or other substances.
Hydration IV infusions typically require direct supervision for
purposes of consent, safety oversight, or intraservice supervision
of staff. Typically such infusions require little special handling to
prepare or dispose of, and staff that administer these do not
typically require advanced practice training. After initial set-up,
infusion typically entails little patient risk and thus little
monitoring. These codes are not intended to be reported by the
physician or other qualified health care professional in the facility
setting.
Some chemotherapeutic agents and other therapeutic agents
require pre- and/or post-hydration to be given in order to avoid
specific toxicities. A minimum time duration of 31 minutes of
hydration infusion is required to report the service. However, the
hydration codes 96360 or 96361 are not used when the purpose
of the intravenous fluid is to “keep open” an IV line prior or
subsequent to a therapeutic infusion, or as a free-flowing IV
during chemotherapy or other therapeutic infusion.
96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
➲ CPT Assistant May 10:8, May 11:7, Oct 11:3, Dec 11:3,
Oct 13:3, May 14:11, Jun 19:5
(Do not report 96360 if performed as a concurrent infusion
service)
(Do not report intravenous infusion for hydration of 30
minutes or less)
➲ CPT Assistant May 10:8, May 11:7, Oct 11:3, Dec
11:3, Oct 13:3, May 14:11, Jun 19:5
(Report 96361 for hydration infusion intervals of greater
than 30 minutes beyond 1 hour increments)
(Report 96361 to identify hydration if provided as a
secondary or subsequent service after a different initial
service [96360, 96365, 96374, 96409, 96413] is
administered through the same IV access)
Therapeutic, Prophylactic, and Diagnostic

Injections and Infusions (Excludes
Chemotherapy and Other Highly Complex
Drug or Highly Complex Biologic Agent
Administration)
A therapeutic, prophylactic, or diagnostic IV infusion or injection
(other than hydration) is for the administration of
substances/drugs. When fluids are used to administer the drug(s),
the administration of the fluid is considered incidental hydration
and is not separately reportable. These services typically require
direct supervision for any or all purposes of patient assessment,
provision of consent, safety oversight, and intra-service
supervision of staff. Typically, such infusions require special
consideration to prepare, dose or dispose of, require practice
training and competency for staff who administer the infusions,
and require periodic patient assessment with vital sign monitoring
during the infusion. These codes are not intended to be reported
by the physician or other qualified health care professional in the
facility setting.
See codes 96401-96549 for the administration of chemotherapy
or other highly complex drug or highly complex biologic agent
services. These highly complex services require advanced
practice training and competency for staff who provide these
services; special considerations for preparation, dosage or
disposal; and commonly, these services entail significant patient
risk and frequent monitoring. Examples are frequent changes in
the infusion rate, prolonged presence of nurse administering the
solution for patient monitoring and infusion adjustments, and
frequent conferring with the physician or other qualified health
care professional about these issues.
(Do not report 96365-96379 with codes for which IV push
or infusion is an inherent part of the procedure [eg,
administration of contrast material for a diagnostic imaging
study])
Coding Tip
Instructions for Reporting Medication Administration With
Chemotherapy and Other Highly Complex Drug or Highly Complex
Biologic Agent Administration
The administration of medications (eg, antibiotics, steroidal agents,

antiemetics, narcotics, analgesics) administered independently or
sequentially as supportive management of chemotherapy administration,
should be separately reported using 96360, 96361, 96365, 96379 as
appropriate.
CPT Coding Guidelines, Chemotherapy and Other Highly Complex Drug

or Highly Complex Biologic Agent Administration
96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis

(specify substance or drug); initial, up to 1 hour
➲ CPT Assistant May 10:8, May 11:7, Oct 11:4, Dec 11:3,
May 18:10, Sep 18:15, Dec 18:9

➲ CPT Assistant May 11:7, Dec 11:3, Sep 18:15
(Report 96366 in conjunction with 96365, 96367)

(Report 96366 for additional hour[s] of sequential infusion)
(Report 96366 for infusion intervals of greater than 30
minutes beyond 1 hour increments)
(Report 96366 in conjunction with 96365 to identify each
second and subsequent infusions of the same drug/substance)
✚ 96367 additional sequential infusion of a new drug/substance,
up to 1 hour (List separately in addition to code for
primary procedure)

96413 to identify the infusion of a new drug/substance
provided as a secondary or subsequent service after a
different initial service is administered through the same IV
access. Report 96367 only once per sequential infusion of
same infusate mix)
✚ 96368 concurrent infusion (List separately in addition to code
➲ CPT Assistant May 10:8, May 11:7, Dec 11:3
(Report 96368 only once per date of service)

96415, 96416)
96369 Subcutaneous infusion for therapy or prophylaxis (specify
substance or drug); initial, up to 1 hour, including pump set-
up and establishment of subcutaneous infusion site(s)
(For infusions of 15 minutes or less, use 96372)


(Use 96370 for infusion intervals of greater than 30 minutes
beyond 1 hour increments)
✚ 96371 additional pump set-up with establishment of new
subcutaneous infusion site(s) (List separately in addition

(Use 96369, 96371 only once per encounter)
96372 Therapeutic, prophylactic, or diagnostic injection (specify
substance or drug); subcutaneous or intramuscular
➲ CPT Assistant May 10:9, May 11:7, Jan 13:9, Jan 14:10,
Oct 16:9, Dec 18:11
(For administration of vaccines/toxoids, see 90460, 90461,
90471, 90472)
(Report 96372 for non-antineoplastic hormonal therapy
injections)
(Report 96401 for anti-neoplastic nonhormonal injection
therapy)
(Report 96402 for anti-neoplastic hormonal injection
therapy)
(Do not report 96372 for injections given without direct
supervision. To report, use 99211. Hospitals may report
96372 when the physician or other qualified health care
professional is not present)
(96372 does not include injections for allergen
immunotherapy. For allergen immunotherapy injections, see
95115-95117)
96373 intra-arterial
96374 intravenous push, single or initial substance/drug

➲ CPT Assistant May 10:8, May 11:7, Oct 11:3, Dec
11:4, Feb 13:3, Jun 13:9, Jun 19:9
Summer 16:10, Fall 18:13
✚ 96375 each additional sequential intravenous push of a new
substance/drug (List separately in addition to code for
primary procedure)
➲ CPT Assistant May 10:8, May 11:7, Feb 13:3
18:13
96413)
(Report 96375 to identify intravenous push of a new
substance/drug if provided as a secondary or subsequent
service after a different initial service is administered
through the same IV access)
✚ 96376 each additional sequential intravenous push of the same
substance/drug provided in a facility (List separately in
➲ CPT Assistant May 10:6, May 11:7, Dec 11:3, Nov
14:15, Dec 18:9
18:13
(Do not report 96376 for a push performed within 30
minutes of a reported push of the same substance or drug)
(96376 may be reported by facilities only)
96413)
96377 Application of on-body injector (includes cannula insertion)
for timed subcutaneous injection
96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous

or intra-arterial injection or infusion
(For allergy immunology, see 95004 et seq)
Chemotherapy and Other Highly Complex

Drug or Highly Complex Biologic Agent
Administration
Chemotherapy administration codes 96401-96549 apply to
parenteral administration of non-radionuclide anti-neoplastic
drugs; and also to anti-neoplastic agents provided for treatment
of noncancer diagnoses (eg, cyclophosphamide for auto-immune
conditions) or to substances such as certain monoclonal antibody
agents, and other biologic response modifiers. The highly
complex infusion of chemotherapy or other drug or biologic
agents requires physician or other qualified health care
professional work and/or clinical staff monitoring well beyond
that of therapeutic drug agents (96360-96379) because the
incidence of severe adverse patient reactions are typically greater.
These services can be provided by any physician or other
qualified health care professional. Chemotherapy services are
typically highly complex and require direct supervision for any or
all purposes of patient assessment, provision of consent, safety
oversight, and intraservice supervision of staff. Typically, such
chemotherapy services require advanced practice training and
competency for staff who provide these services; special
considerations for preparation, dosage, or disposal; and
commonly, these services entail significant patient risk and
frequent monitoring. Examples are frequent changes in the
infusion rate, prolonged presence of the nurse administering the
solution for patient monitoring and infusion adjustments, and
frequent conferring with the physician or other qualified health
care professional about these issues. When performed to facilitate
the infusion of injection, preparation of chemotherapy agent(s),
highly complex agent(s), or other highly complex drugs is
included and is not reported separately. To report infusions that
do not require this level of complexity, see 96360-96379. Codes
96401-96402, 96409-96425, 96521-96523 are not intended to be
reported by the individual physician or other qualified health care
professional in the facility setting.
The term “chemotherapy” in 96401-96549 includes other highly
complex drugs or highly complex biologic agents.
Report separate codes for each parenteral method of
administration employed when chemotherapy is administered by
different techniques. The administration of medications (eg,
antibiotics, steroidal agents, antiemetics, narcotics, analgesics)
administered independently or sequentially as supportive
management of chemotherapy administration, should be
separately reported using 96360, 96361, 96365, 96379 as
appropriate.
Report both the specific service as well as code(s) for the specific
substance(s) or drug(s) provided. The fluid used to administer
the drug(s) is considered incidental hydration and is not
separately reportable.
Regional (isolation) chemotherapy perfusion should be reported
using the codes for arterial infusion (96420-96425). Placement of
the intra-arterial catheter should be reported using the appropriate
code from the Cardiovascular Surgery section. Placement of
arterial and venous cannula(s) for extracorporeal circulation via a
membrane oxygenator perfusion pump should be reported using
36823. Code 36823 includes dose calculation and administration
of the chemotherapy agent by injection into the perfusate. Do not
report 96409-96425 in conjunction with 36823.
(For home infusion services, see 99601-99602)
Injection and Intravenous Infusion Chemotherapy

and Other Highly Complex Drug or Highly
Complex Biologic Agent Administration
Intravenous or intra-arterial push is defined as: (a) an injection in
which the healthcare professional who administers the
substance/drug is continuously present to administer the injection
and observe the patient, or (b) an infusion of 15 minutes or less.
96401 Chemotherapy administration, subcutaneous or
intramuscular; non-hormonal anti-neoplastic
➲ CPT Assistant Nov 05:1, Jan 06:47, Jan 07:30, May
07:3, Jun 07:4, Feb 09:17, Aug 11:9, Dec 11:3
18:12
96402 hormonal anti-neoplastic
➲ CPT Assistant Nov 05:1, Jan 07:30, May 07:3, Feb
09:17, Dec 11:3
Winter 18:12
96405 Chemotherapy administration; intralesional, up to and
including 7 lesions
➲ CPT Assistant Sep 96:5, Aug 97:19, Feb 01:10, Jul 01:2,
Nov 05:1, Jan 07:30, May 07:3, Feb 09:17
96406 intralesional, more than 7 lesions
➲ CPT Assistant Sep 96:5, Aug 97:19, Feb 01:10, Jul
01:2, Nov 05:1, Jan 07:30, May 07:3, Feb 09:17
96409 intravenous, push technique, single or initial

substance/drug
09:17, May 10:8, May 11:17, Dec 11:3
Winter 18:12
✚ 96411 intravenous, push technique, each additional
substance/drug (List separately in addition to code for
primary procedure)
09:17, Dec 11:3
Winter 18:12
96413 Chemotherapy administration, intravenous infusion
technique; up to 1 hour, single or initial substance/drug
➲ CPT Assistant Nov 05:1, Jan 07:30, May 07:3, Sep 07:3,
Dec 07:15, Feb 09:17, May 10:8, May 11:7, Dec 11:4
18:12
(Report 96361 to identify hydration if administered as a
secondary or subsequent service in association with 96413
through the same IV access)
(Report 96366, 96367, 96375 to identify therapeutic,
prophylactic, or diagnostic drug infusion or injection, if
administered as a secondary or subsequent service in
association with 96413 through the same IV access)
➲ CPT Assistant Nov 05:1, Jan 07:30, May 07:3, Sep
07:3, Dec 07:15, Feb 09:17, Dec 11:3
Winter 18:12
minutes beyond 1-hour increments)
96416 initiation of prolonged chemotherapy infusion (more than
8 hours), requiring use of a portable or implantable pump
➲ CPT Assistant Nov 05:1, Jan 07:30, May 07:3, Sep
07:3, Dec 07:15, Feb 09:17, Dec 11:3
Winter 18:12
(For refilling and maintenance of a portable pump or an
implantable infusion pump or reservoir for drug delivery,
see 96521-96523)
✚ 96417 each additional sequential infusion (different
substance/drug), up to 1 hour (List separately in addition
➲ CPT Assistant Nov 05:1, Jan 07:30, May 07:3, Jun
07:4, Feb 09:17, Aug 11:9, Dec 11:3
Winter 18:12
(Report only once per sequential infusion. Report 96415 for
additional hour(s) of sequential infusion)
Intra-Arterial Chemotherapy and Other Highly

Administration
96420 Chemotherapy administration, intra-arterial; push technique
➲ CPT Assistant Aug 97:19, Nov 98:37, Nov 99:54, Feb
01:10, Jul 01:2, Nov 05:1, Jan 07:30, May 07:3, Jun
07:4, Feb 09:17, Aug 11:9, Dec 11:3, Nov 13:6
➲ Clinical Examples in Radiology Summer 08:1, 2, 4,
96422 infusion technique, up to 1 hour
➲ CPT Assistant Dec 96:10, Aug 97:19, Nov 98:37,
Feb 01:10, Jul 01:2, Nov 05:1, Jan 07:30, May 07:3,
Dec 07:15, Feb 09:17, Aug 11:9, Dec 11:3
Winter 18:12
✚ 96423 infusion technique, each additional hour (List separately
➲ CPT Assistant Dec 96:10, Nov 98:37, Feb 01:10, Jul
01:2, Nov 05:1, Jan 07:30, May 07:3, Dec 07:15,
Feb 09:17, Dec 11:3
Winter 18:12
minutes beyond 1-hour increments)
(For regional chemotherapy perfusion via membrane
oxygenator perfusion pump to an extremity, use 36823)
96425 infusion technique, initiation of prolonged infusion (more
than 8 hours), requiring the use of a portable or
implantable pump
➲ CPT Assistant Nov 99:54, Feb 01:10, Jul 01:2, Nov
05:1, Jan 07:30, May 07:3, Jun 07:4, Feb 09:17, Aug
11:9, Dec 11:3
Winter 18:12
(For refilling and maintenance of a portable pump or an
implantable infusion pump or reservoir for drug delivery,
see 96521-96523)
Other Injection and Infusion Services

Code 96523 does not require direct supervision. Codes 96521-
96523 may be reported when these devices are used for
therapeutic drugs other than chemotherapy.
(For collection of blood specimen from a completely
implantable venous access device, use 36591)
96440 Chemotherapy administration into pleural cavity, requiring
and including thoracentesis
➲ CPT Assistant Feb 01:10, Jul 01:2, Nov 05:1, Jan 07:30,
May 07:3, Jun 07:4, Feb 09:17
96446 Chemotherapy administration into the peritoneal cavity via

indwelling port or catheter
96450 Chemotherapy administration, into CNS (eg, intrathecal),

requiring and including spinal puncture
➲ CPT Assistant Feb 01:10, Jul 01:2, Nov 05:1, Jan 07:30,
May 07:3, Feb 09:17
14:10, Summer 18:9
(For intravesical (bladder) chemotherapy administration,
use 51720)
(For insertion of subarachnoid catheter and reservoir for
infusion of drug, see 62350, 62351, 62360-62362; for
insertion of intraventricular catheter and reservoir, see
61210, 61215)
96521 Refilling and maintenance of portable pump
09:17, Dec 11:3
18:12
96522 Refilling and maintenance of implantable pump or reservoir
for drug delivery, systemic (eg, intravenous, intra-arterial)
➲ CPT Assistant Jul 06:1, Jan 07:30, May 07:3, Feb 09:17,
Dec 11:3
18:12
pump for spinal or brain drug infusion, use 95990-95991)
96523 Irrigation of implanted venous access device for drug
delivery systems
➲ CPT Assistant Jan 07:30, May 07:3, Feb 09:17, Jul
11:16, Dec 11:3
18:12
(Do not report 96523 in conjunction with other services. To
report collection of blood specimen, use 36591)
96542 Chemotherapy injection, subarachnoid or intraventricular
via subcutaneous reservoir, single or multiple agents
➲ CPT Assistant Aug 97:19, Jul 01:2, Nov 05:1, Jan 07:30,
May 07:3, Feb 09:17
(For radioactive isotope therapy, use 79005)

96549 Unlisted chemotherapy procedure
➲ CPT Assistant Aug 97:19, Jul 01:2, Nov 05:1, Jan 07:30,
May 07:3, Jun 07:4, Oct 10:16, Dec 10:16
Codes 96573, 96574 should be used to report nonsurgical
treatment of cutaneous lesions using photodynamic therapy by
external application of light to destroy premalignant lesion(s) of
the skin and adjacent mucosa (eg, face, scalp) by activation of
photosensitizing drug(s).
A treatment session is defined as an application of photosensitizer
to all lesions within an anatomic area (eg, face, scalp), with or
without debridement of all premalignant hyperkeratotic lesions in
that area, followed by illumination/activation with an appropriate
light source to the same area.
Do not report codes for debridement (11000, 11001, 11004,
11005), lesion shaving (11300-11313), biopsy (11102, 11103,
11104, 11105, 11106, 11107), or lesion excision (11400-11471)
within the treatment area(s) on the same day as photodynamic
therapy (96573, 96574).
(To report ocular photodynamic therapy, use 67221)
96567 Photodynamic therapy by external application of light to
destroy premalignant lesions of the skin and adjacent
mucosa with application and illumination/activation of
photosensitive drug(s), per day
(Use 96567 for reporting photodynamic therapy when

physician or other qualified health care professional is not
directly involved in the delivery of the photodynamic
therapy service)
✚ 96570 Photodynamic therapy by endoscopic application of light to
ablate abnormal tissue via activation of photosensitive
drug(s); first 30 minutes (List separately in addition to code
for endoscopy or bronchoscopy procedures of lung and
gastrointestinal tract)
➲ CPT Assistant Nov 99:54, Sep 00:5, Oct 11:11, Apr
13:8
(Report 96570 with modifier 52 for service of less than 23
minutes with report)
code for endoscopy or bronchoscopy procedures of lung
and gastrointestinal tract)
➲ CPT Assistant Nov 99:54, Sep 00:5, Oct 11:11, Apr
13:8
(For 23-37 minutes of service, use 96570. For 38-52
minutes of service, use 96570 in conjunction with 96571)
(96570, 96571 are to be used in addition to bronchoscopy,
endoscopy codes)
(Use 96570, 96571 in conjunction with 31641, 43229 as
appropriate)
96573 Photodynamic therapy by external application of light to
destroy premalignant lesions of the skin and adjacent
mucosa with application and illumination/activation of
photosensitizing drug(s) provided by a physician or other
qualified health care professional, per day

the same anatomic area)
96574 Debridement of premalignant hyperkeratotic lesion(s) (ie,
targeted curettage, abrasion) followed with photodynamic
therapy by external application of light to destroy
premalignant lesions of the skin and adjacent mucosa with
application and illumination/activation of photosensitizing
drug(s) provided by a physician or other qualified health
care professional, per day

the same anatomic area)
Special Dermatological Procedures

See the Evaluation and Management coding guidelines for
further instructions on reporting that is appropriate for
management of dermatologic illnesses.
(For intralesional injections, see 11900, 11901)
(For Tzanck smear, see 88160-88161)
96900 Actinotherapy (ultraviolet light)
➲ CPT Assistant Jul 12:9, Sep 16:3, Nov 16:9
(For rhinophototherapy, intranasal application of ultraviolet

and visible light, use 30999)
96902 Microscopic examination of hairs plucked or clipped by the
examiner (excluding hair collected by the patient) to
determine telogen and anagen counts, or structural hair shaft
abnormality
96904 Whole body integumentary photography, for monitoring of

high risk patients with dysplastic nevus syndrome or a
history of dysplastic nevi, or patients with a personal or
familial history of melanoma
96910 Photochemotherapy; tar and ultraviolet B (Goeckerman

treatment) or petrolatum and ultraviolet B
96912 psoralens and ultraviolet A (PUVA)

96913 Photochemotherapy (Goeckerman and/or PUVA) for severe

photoresponsive dermatoses requiring at least 4-8 hours of
care under direct supervision of the physician (includes
application of medication and dressings)
96920 Laser treatment for inflammatory skin disease (psoriasis);

total area less than 250 sq cm
➲ CPT Assistant Oct 10:9, Jul 12:9, May 13:12, Sep 16:3
96921 250 sq cm to 500 sq cm
➲ CPT Assistant Oct 10:9, Jul 12:9, May 13:12, Sep
16:3
96922 over 500 sq cm
➲ CPT Assistant Oct 10:9, Jul 12:9, May 13:12, Sep
16:3
(For laser destruction of premalignant lesions, see 17000-
17004)
(For laser destruction of cutaneous vascular proliferative
lesions, see 17106-17108)
(For laser destruction of benign lesions, see 17110-17111)
(For laser destruction of malignant lesions, see 17260-
17286)
Codes 96931, 96932, 96933, 96934, 96935, 96936 describe the
acquisition and/or diagnostic interpretation of the device
generated stitched image mosaics related to a single lesion. Do
not report 96931, 96932, 96933, 96934, 96935, 96936 for a
reflectance confocal microscopy examination that does not
produce mosaic images. For services rendered using reflectance
confocal microscopy not generating mosaic images, use 96999.
(For optical coherence tomography [OCT] for
microstructural and morphological imaging of skin, see
0470T, 0471T)
96931 Reflectance confocal microscopy (RCM) for cellular and
sub-cellular imaging of skin; image acquisition and
interpretation and report, first lesion
96932 image acquisition only, first lesion
96933 interpretation and report only, first lesion

✚ 96934 image acquisition and interpretation and report, each

additional lesion (List separately in addition to code for
primary procedure)

✚ 96935 image acquisition only, each additional lesion (List

✚ 96936 interpretation and report only, each additional lesion
procedure)

96999 Unlisted special dermatological service or procedure
➲ CPT Assistant Jul 12:9, May 13:12, Sep 17:9
Physical Medicine and Rehabilitation

Codes 97010-97763 should be used to report each distinct
procedure performed. Do not append modifier 51 to 97010-
97763.
The work of the physician or other qualified health care
professional consists of face-to-face time with the patient (and
caregiver, if applicable) delivering skilled services. For the
purpose of determining the total time of a service, incremental
intervals of treatment at the same visit may be accumulated.
▶The meanings of terms in the Physical Medicine and
Rehabilitation section are not the same as those in the Evaluation
and Management Services section (99202-99350). Do not use the
Definitions of Commonly Used Terms in the Evaluation and
Management (E/M) Guidelines for physical medicine and
rehabilitation services.◀
(For range of joint motion, see 95851, 95852)
(For biofeedback training by EMG, use 90901)
(For transcutaneous nerve stimulation [TENS], use 97014
for electrical stimulation requiring supervision only, or use
97032 for electrical stimulation requiring constant
attendance)
Physical Therapy Evaluations

Physical therapy evaluations include a patient history and an
examination with development of a plan of care, conducted by
the physician or other qualified health care professional, which is
based on the composite of the patient’s presentation.
Coordination, consultation, and collaboration of care with
physicians, other qualified health care professionals, or agencies
is provided consistent with the nature of the problem(s) and the
needs of the patient, family, and/or other caregivers.
At a minimum, each of the following components noted in the
code descriptors must be documented, in order to report the
selected level of physical therapy evaluation.
Physical therapy evaluations include the following components:
■ History
■ Examination
■ Clinical decision making
■ Development of plan of care
Report 97164 for performance of patient re-evaluation that is
based on an established and ongoing plan of care.
Definitions
The level of the physical therapy evaluation performed is
dependent on clinical decision making and on the nature of the
patient’s condition (severity). For the purpose of reporting
physical therapy evaluations, the body regions and body systems
are defined as follows:
Body regions: head, neck, back, lower extremities, upper
extremities, and trunk.
Body systems: musculoskeletal, neuromuscular, cardiovascular
pulmonary, and integumentary.
A review of body systems include the following:
■ For the musculoskeletal system: the assessment of gross
symmetry, gross range of motion, gross strength, height, and
weight
■ For the neuromuscular system: a general assessment of gross
coordinated movement (eg, balance, gait, locomotion,
transfers, and transitions) and motor function (motor control
and motor learning)
■ For the cardiovascular pulmonary system: the assessment of
heart rate, respiratory rate, blood pressure, and edema
■ For the integumentary system: the assessment of pliability
(texture), presence of scar formation, skin color, and skin
integrity
A review of any of the body systems also includes the assessment
of the ability to make needs known, consciousness, orientation
(person, place, and time), expected emotional/behavioral
responses, and learning preferences (eg, learning barriers,
education needs)
Body structures: The structural or anatomical parts of the body,
such as organs, limbs, and their components, classified according
to body systems.
Personal factors: Factors that include sex, age, coping styles,
social background, education, profession, past and current
experience, overall behavior pattern, character, and other factors
that influence how disability is experienced by the individual.
Personal factors that exist but do not impact the physical therapy
plan of care are not to be considered, when selecting a level of
service.
# 97161 Physical therapy evaluation: low complexity, requiring these
components:
■ A history with no personal factors and/or comorbidities
that impact the plan of care;
■ An examination of body system(s) using standardized
tests and measures addressing 1-2 elements from any of
the following: body structures and functions, activity
limitations, and/or participation restrictions;
■ A clinical presentation with stable and/or uncomplicated
characteristics; and
■ Clinical decision making of low complexity using
standardized patient assessment instrument and/or
measurable assessment of functional outcome.
and/or family.
# 97162 Physical therapy evaluation: moderate complexity, requiring

these components:
■ A history of present problem with 1-2 personal factors
and/or comorbidities that impact the plan of care;
■ An examination of body systems using standardized tests
and measures in addressing a total of 3 or more elements
from any of the following: body structures and functions,
activity limitations, and/or participation restrictions;
■ An evolving clinical presentation with changing
■ Clinical decision making of moderate complexity using
and/or family.
# 97163 Physical therapy evaluation: high complexity, requiring

these components:
■ A history of present problem with 3 or more personal
factors and/or comorbidities that impact the plan of care;
■ An examination of body systems using standardized tests
and measures addressing a total of 4 or more elements
from any of the following: body structures and functions,
activity limitations, and/or participation restrictions;
■ A clinical presentation with unstable and unpredictable
■ Clinical decision making of high complexity using
and/or family.
# 97164 Re-evaluation of physical therapy established plan of care,

requiring these components:
■ An examination including a review of history and use of
standardized tests and measures is required; and
■ Revised plan of care using a standardized patient
assessment instrument and/or measurable assessment of
functional outcome
and/or family.
Occupational Therapy Evaluations

Occupational therapy evaluations include an occupational profile,
medical and therapy history, relevant assessments, and
development of a plan of care, which reflects the therapist’s
clinical reasoning and interpretation of the data.
needs of the patient, family and/or other caregivers.
selected level of occupational therapy evaluation.
Occupational therapy evaluations include the following
components:
■ Occupational profile and client history (medical and therapy)
■ Assessments of occupational performance
Report 97168 for performance of a re-evaluation that is based on
an established and ongoing plan of care.
Definitions
The level of the occupational therapy evaluation performed is
determined by patient condition, complexity of clinical decision
making, and the scope and nature of the patient’s performance
deficits relating to physical, cognitive, or psychosocial skills to be
assessed. The patient’s plan of treatment should reflect
assessment of each of the identified performance deficits.
Performance deficits: performance deficits refer to the inability
to complete activities due to the lack of skills in one or more of
the categories below (ie, relating to physical, cognitive, or
psychosocial skills):
■ Physical skills: Physical skills refer to impairments of body
structure or body function (eg, balance, mobility, strength,
endurance, fine or gross motor coordination, sensation,
dexterity).
■ Cognitive skills: Cognitive skills refer to the ability to attend,
perceive, think, understand, problem solve, mentally sequence,
learn, and remember resulting in the ability to organize
occupational performance in a timely and safe manner. These
skills are observed when: (1) a person attends to and selects,
interacts with, and uses task tools and materials; (2) carries out
individual actions and steps; and (3) modifies performance
when problems are encountered.
■ Psychosocial skills: Psychosocial skills refer to interpersonal
interactions, habits, routines and behaviors, active use of
coping strategies, and/or environmental adaptations to develop
skills necessary to successfully and appropriately participate in
everyday tasks and social situations.
# 97165 Occupational therapy evaluation, low complexity, requiring
these components:
■ An occupational profile and medical and therapy history,
which includes a brief history including review of
medical and/or therapy records relating to the presenting
problem;
■ An assessment(s) that identifies 1-3 performance deficits
(ie, relating to physical, cognitive, or psychosocial skills)
that result in activity limitations and/or participation
restrictions; and
■ Clinical decision making of low complexity, which
includes an analysis of the occupational profile, analysis
of data from problem-focused assessment(s), and
consideration of a limited number of treatment options.
Patient presents with no comorbidities that affect
occupational performance. Modification of tasks or
assistance (eg, physical or verbal) with assessment(s) is
not necessary to enable completion of evaluation
component.
and/or family.
# 97166 Occupational therapy evaluation, moderate complexity,

which includes an expanded review of medical and/or
therapy records and additional review of physical,
cognitive, or psychosocial history related to current
functional performance;
■ An assessment(s) that identifies 3-5 performance deficits
(ie, relating to physical, cognitive, or psychosocial skills)
that result in activity limitations and/or participation
restrictions; and
■ Clinical decision making of moderate analytic
complexity, which includes an analysis of the
occupational profile, analysis of data from detailed
assessment(s), and consideration of several treatment
options. Patient may present with comorbidities that affect
occupational performance. Minimal to moderate
modification of tasks or assistance (eg, physical or
verbal) with assessment(s) is necessary to enable patient
to complete evaluation component.
and/or family.
# 97167 Occupational therapy evaluation, high complexity, requiring

these components:
which includes review of medical and/or therapy records
and extensive additional review of physical, cognitive, or
psychosocial history related to current functional
performance;
■ An assessment(s) that identifies 5 or more performance
deficits (ie, relating to physical, cognitive, or
psychosocial skills) that result in activity limitations
and/or participation restrictions; and
■ Clinical decision making of high analytic complexity,
which includes an analysis of the patient profile, analysis
of data from comprehensive assessment(s), and
consideration of multiple treatment options. Patient
presents with comorbidities that affect occupational
performance. Significant modification of tasks or
assistance (eg, physical or verbal) with assessment(s) is
necessary to enable patient to complete evaluation
component.
and/or family.
# 97168 Re-evaluation of occupational therapy established plan of

care, requiring these components:
■ An assessment of changes in patient functional or medical
status with revised plan of care;
■ An update to the initial occupational profile to reflect
changes in condition or environment that affect future
interventions and/or goals; and
■ A revised plan of care. A formal reevaluation is
performed when there is a documented change in
functional status or a significant change to the plan of care
is required.
and/or family.
Athletic Training Evaluations

Athletic training evaluations include a patient history and an
examination with development of a plan of care, conducted by
the physician or other qualified health care professional.
needs of the patient, family, and/or other caregivers.
selected level of athletic training evaluation.
Athletic training evaluations include the following components:
■ History and physical activity profile
■ Examination
Report 97172 for performance of patient re-evaluation that is
based on an established and ongoing plan of care.
Definitions
For the purpose of reporting athletic training evaluations, the
body areas and body systems are defined as follows:
Body areas: head, neck, back, lower extremities, upper
extremities, and trunk.
Body systems: musculoskeletal, neuromuscular, cardiovascular
pulmonary, and integumentary.
The body systems review includes the following:
■ For the musculoskeletal system: the assessment of gross
symmetry, gross range of motion, gross strength, height, and
weight
■ For the neuromuscular system: a general assessment of gross
coordinated movement (eg, balance, gait, locomotion,
transfers, and transitions) and motor function (motor control
and motor learning)
■ For the cardiovascular pulmonary system: the assessment of
heart rate, respiratory rate, blood pressure, and edema
■ For the integumentary system: the assessment of pliability
(texture), presence of scar formation, skin color, and skin
integrity
# 97169 Athletic training evaluation, low complexity, requiring these
components:
■ A history and physical activity profile with no
comorbidities that affect physical activity;
■ An examination of affected body area and other
symptomatic or related systems addressing 1-2 elements
from any of the following: body structures, physical
activity, and/or participation deficiencies; and
■ Clinical decision making of low complexity using
and/or family.
➲ CPT Assistant Jun 17:6, May 18:5
# 97170 Athletic training evaluation, moderate complexity, requiring

these components:
■ A medical history and physical activity profile with 1-2
comorbidities that affect physical activity;
■ An examination of affected body area and other
symptomatic or related systems addressing a total of 3 or
more elements from any of the following: body structures,
physical activity, and/or participation deficiencies; and
■ Clinical decision making of moderate complexity using
and/or family.
# 97171 Athletic training evaluation, high complexity, requiring these

components:
■ A medical history and physical activity profile, with 3 or
more comorbidities that affect physical activity;
■ A comprehensive examination of body systems using
standardized tests and measures addressing a total of 4 or
more elements from any of the following: body structures,
physical activity, and/or participation deficiencies;
■ Clinical presentation with unstable and unpredictable
■ Clinical decision making of high complexity using
and/or family.
# 97172 Re-evaluation of athletic training established plan of care

■ An assessment of patient’s current functional status when
there is a documented change; and
■ A revised plan of care using a standardized patient
assessment instrument and/or measurable assessment of
functional outcome with an update in management options,
goals, and interventions.
and/or family.
Modalities
Any physical agent applied to produce therapeutic changes to
biologic tissue; includes but not limited to thermal, acoustic, light,
mechanical, or electric energy.
Supervised
The application of a modality that does not require direct (one-
on-one) patient contact.
97010 Application of a modality to 1 or more areas; hot or cold
packs
➲ CPT Assistant Summer 95:5, Apr 96:11, Nov 97:47, Dec
98:1, Nov 01:5, Aug 02:11, Aug 06:11, Nov 09:10, Jun
10:8, Aug 10:13, Nov 10:8, Jun 16:9, May 18:5
97012 traction, mechanical
➲ CPT Assistant Summer 95:5, Apr 96:11, Nov 97:47,
Dec 98:1, May 99:11, Nov 01:5, Aug 02:11, Dec
03:4, Oct 04:9, Jun 10:8, Aug 10:13, Nov 10:8, Jun
16:9, May 18:5
97014 electrical stimulation (unattended)
➲ CPT Assistant Summer 95:5, Apr 96:11, Nov 97:47,
May 98:10, Nov 01:5, Jan 02:11, Apr 02:18, Aug
02:11, Dec 03:4, Nov 09:10, Jun 10:8, Aug 10:13,
Nov 10:8, Aug 11:6, May 18:5, Oct 18:8, Jul 19:11
(For acupuncture with electrical stimulation, see 97813,
97814)
97016 vasopneumatic devices
➲ CPT Assistant Summer 95:6, Apr 96:11, Dec 98:1,
Nov 01:5, Aug 02:11, May 05:14, Jun 10:8, Aug
10:13, Nov 10:8, May 18:5
97018 paraffin bath
Nov 01:5, Aug 02:11, Nov 09:10, Jun 10:8, Aug
10:13, Nov 10:8, May 18:5
97022 whirlpool
➲ CPT Assistant Summer 95:6, Apr 96:11, May 98:10,
Dec 98:1, Nov 01:5, Aug 02:11, Nov 09:10, Jun
10:8, Aug 10:13, Nov 10:8, May 18:5
97024 diathermy (eg, microwave)
10:13, Nov 10:8, May 18:5
97026 infrared
Nov 01:5, Aug 02:11, Nov 09:10, Feb 10:12, Jun
10:8, Aug 10:13, Nov 10:8, May 18:5
97028 ultraviolet
10:13, Nov 10:8, May 18:5
Constant Attendance
The application of a modality that requires direct (one-on-one)
patient contact.
97032 Application of a modality to 1 or more areas; electrical
stimulation (manual), each 15 minutes
➲ CPT Assistant Summer 95:6, Dec 98:1, Nov 01:5, Apr
02:18, Jul 04:14, Nov 09:10, Jun 10:8, Aug 10:13, Nov
10:8, May 18:5, Oct 18:8, Jul 19:11
(For transcutaneous electrical modulation pain reprocessing
[TEMPR/scrambler therapy], use 0278T)
97033 iontophoresis, each 15 minutes
➲ CPT Assistant Summer 95:7, Dec 98:1, Nov 01:5,
Nov 09:10, Jun 10:8, Aug 10:13, Nov 10:8, May 18:5
97034 contrast baths, each 15 minutes
Jun 10:8, Aug 10:13, Nov 10:8, May 18:5
97035 ultrasound, each 15 minutes
➲ CPT Assistant Summer 95:7, Sep 96:10, Dec 98:1,
Nov 01:5, Nov 09:10, Jun 10:8, Aug 10:13, Nov
10:8, May 18:5
97036 Hubbard tank, each 15 minutes
Nov 09:10, Jun 10:8, Aug 10:13, Nov 10:8, May 18:5
97039 Unlisted modality (specify type and time if constant
attendance)
➲ CPT Assistant Summer 95:7, May 98:10, Dec 98:1, Jan
00:10, Nov 01:5, May 05:14, Nov 09:10, Feb 10:12, Jun
10:8, Aug 10:13, Nov 10:8, Jun 16:9, Nov 16:10, May
18:5
Therapeutic Procedures
A manner of effecting change through the application of clinical
skills and/or services that attempt to improve function.
Physician or other qualified health care professional (ie,
therapist) required to have direct (one-on-one) patient contact.
97110 Therapeutic procedure, 1 or more areas, each 15 minutes;
therapeutic exercises to develop strength and endurance,
range of motion and flexibility
➲ CPT Assistant Summer 95:7, Feb 97:10, Nov 98:37, Dec
99:11, Mar 05:11, Apr 05:14, Aug 05:11, Dec 05:8, Mar
06:15, Aug 06:11, May 08:13, Dec 09:15, May 10:9,
Mar 12:9, Mar 14:15, Aug 14:6, Jun 16:9, Dec 17:15,
May 18:5, Dec 18:7, Jun 19:15
97112 neuromuscular reeducation of movement, balance,
coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities
➲ CPT Assistant Summer 95:7, Feb 97:10, Apr 05:14,
Aug 05:11, Mar 06:15, Aug 06:11, May 08:13, Oct
09:10, May 10:9, Mar 12:9, Mar 14:15, May 18:5
97113 aquatic therapy with therapeutic exercises
➲ CPT Assistant Summer 95:7, Feb 97:10, Apr 05:14,
Mar 06:15, Aug 06:11, Oct 09:10, May 10:9, Mar
14:15, May 18:5
97116 gait training (includes stair climbing)
➲ CPT Assistant Summer 95:8, Sep 96:7, Feb 97:10,
Jun 03:3, Apr 05:14, Mar 06:15, Aug 06:11, Oct
09:10, May 10:9, Mar 14:15, May 18:5
(Use 96000-96003 to report comprehensive gait and motion
analysis procedures)
97124 massage, including effleurage, petrissage and/or
tapotement (stroking, compression, percussion)
➲ CPT Assistant Summer 95:8, May 96:10, Feb 97:10,
Dec 99:7, Apr 05:14, May 05:14, Mar 06:15, Aug
06:11, Oct 09:10, May 10:9, Mar 14:15, Jun 16:9,
May 18:5, Jun 19:15
(For myofascial release, use 97140)
97129 Therapeutic interventions that focus on cognitive function
(eg, attention, memory, reasoning, executive function,
problem solving, and/or pragmatic functioning) and
compensatory strategies to manage the performance of an
activity (eg, managing time or schedules, initiating,
organizing, and sequencing tasks), direct (one-on-one)
patient contact; initial 15 minutes
(Report 97129 only once per day)

97155)
97139 Unlisted therapeutic procedure (specify)
➲ CPT Assistant Summer 95:8, Feb 97:10, Apr 05:14, Aug
06:11, Mar 14:15, May 18:5
97140 Manual therapy techniques (eg, mobilization/manipulation,

manual lymphatic drainage, manual traction), 1 or more
regions, each 15 minutes
➲ CPT Assistant Nov 98:37, Feb 99:10, Mar 99:1, Jul
99:11, Aug 01:10, Dec 03:5, May 09:9, Oct 09:10, Mar
14:15, Mar 15:10, Aug 16:11, Sep 16:11, Nov 16:9, May
18:5, Jun 19:15, Feb 20:9
(For needle insertion[s] without injection[s] [eg, dry
needling, trigger-point acupuncture], see 20560, 20561)
97150 Therapeutic procedure(s), group (2 or more individuals)
➲ CPT Assistant Summer 95:8, Dec 96:10, Feb 97:10, Oct
99:10, Nov 99:54-55, Dec 99:11, Apr 05:14, Aug 06:11,
Mar 14:15, Nov 16:9, May 18:5, Nov 18:3
(Report 97150 for each member of group)
(Group therapy procedures involve constant attendance of
the physician or other qualified health care professional [ie,
therapist], but by definition do not require one-on-one
patient contact by the same physician or other qualified
health care professional)
(For manipulation under general anesthesia, see appropriate
anatomic section in Musculoskeletal System)
(For osteopathic manipulative treatment [OMT], see 98925-
98929)
97161 Code is out of numerical sequence. See Physical Therapy
Evaluations subsection
97165 Code is out of numerical sequence. See Occupational
Therapy Evaluations subsection
97169 Code is out of numerical sequence. See Athletic Training
97530 Therapeutic activities, direct (one-on-one) patient contact
(use of dynamic activities to improve functional
performance), each 15 minutes
➲ CPT Assistant Summer 95:9, Dec 01:6, Apr 03:26, Jul
03:15, Aug 05:11, May 08:13, Mar 14:15, May 18:5,
Dec 18:7
97533 Sensory integrative techniques to enhance sensory
processing and promote adaptive responses to
environmental demands, direct (one-on-one) patient contact,
each 15 minutes
➲ CPT Assistant Dec 01:1, Mar 14:15, May 18:5
97535 Self-care/home management training (eg, activities of daily

living (ADL) and compensatory training, meal preparation,
safety procedures, and instructions in use of assistive
technology devices/adaptive equipment) direct one-on-one
contact, each 15 minutes
➲ CPT Assistant Sep 96:7, Apr 00:11, Dec 03:6, Mar
14:15, Mar 15:10, Jun 15:11, Aug 16:3, May 18:5
97537 Community/work reintegration training (eg, shopping,
transportation, money management, avocational activities
and/or work environment/modification analysis, work task
analysis, use of assistive technology device/adaptive
equipment), direct one-on-one contact, each 15 minutes
➲ CPT Assistant Sep 96:7, Dec 03:6, Mar 14:15, May 18:5
(For wheelchair management/propulsion training, use

97542)
97542 Wheelchair management (eg, assessment, fitting, training),
each 15 minutes
➲ CPT Assistant Sep 96:8, Mar 14:15, Jun 15:11, May
18:5
97545 Work hardening/conditioning; initial 2 hours
➲ CPT Assistant Apr 03:26, Jul 03:15, May 08:13, Mar
14:15, May 18:5
Active Wound Care Management

Active wound care procedures are performed to remove
devitalized and/or necrotic tissue and promote healing. Chemical
cauterization (17250) to achieve wound hemostasis is included in
active wound care procedures (97597, 97598, 97602) and should
not be separately reported for the same lesion. Services require
direct (one-on-one) contact with the patient.
(For debridement of burn wounds, see 16020-16030)
97597 Debridement (eg, high pressure waterjet with/without
suction, sharp selective debridement with scissors, scalpel
and forceps), open wound, (eg, fibrin, devitalized epidermis
and/or dermis, exudate, debris, biofilm), including topical
application(s), wound assessment, use of a whirlpool, when
performed and instruction(s) for ongoing care, per session,
total wound(s) surface area; first 20 sq cm or less
➲ CPT Assistant Jun 05:1, 10, Nov 09:10, Jun 10:8, Nov
10:9, May 11:3, Sep 11:11, Jan 12:8, Mar 12:11, Oct
12:3, Jun 14:11, Aug 16:9, Oct 16:3, May 18:5
✚ 97598 each additional 20 sq cm, or part thereof (List separately
➲ CPT Assistant Jun 05:1, 10, May 11:3, Sep 11:11, Jan
12:8, Mar 12:11, Jun 14:11, Aug 16:9, Oct 16:3, May
18:5
97602 Removal of devitalized tissue from wound(s), non-selective
debridement, without anesthesia (eg, wet-to-moist dressings,
enzymatic, abrasion, larval therapy), including topical
application(s), wound assessment, and instruction(s) for
ongoing care, per session
➲ CPT Assistant May 02:5, Jun 05:1, 10, Sep 08:11, May
11:4, Aug 11:7, Jan 12:9, Mar 12:11, Dec 12:15, Jun
14:11, Oct 16:3, May 18:5
97605 Negative pressure wound therapy (eg, vacuum assisted
drainage collection), utilizing durable medical equipment
(DME), including topical application(s), wound assessment,
and instruction(s) for ongoing care, per session; total
wound(s) surface area less than or equal to 50 square
centimeters
➲ CPT Assistant Apr 05:13, Jun 05:1, 10, May 11:4, Nov
14:8, Feb 16:14, May 18:5
97606 total wound(s) surface area greater than 50 square
centimeters
➲ CPT Assistant Apr 05:13, Jun 05:1, 10, May 11:4,
Nov 14:8, Feb 16:14, May 18:5
97607 Negative pressure wound therapy, (eg, vacuum assisted
drainage collection), utilizing disposable, non-durable
medical equipment including provision of exudate
management collection system, topical application(s),
wound assessment, and instructions for ongoing care, per
session; total wound(s) surface area less than or equal to 50
square centimeters
97608 total wound(s) surface area greater than 50 square

centimeters

97606)
97610 Low frequency, non-contact, non-thermal ultrasound,
including topical application(s), when performed, wound
assessment, and instruction(s) for ongoing care, per day
Tests and Measurements

Requires direct one-on-one patient contact.
(For joint range of motion, see 95851, 95852; for
electromyography, see 95860-95872, 95885, 95886, 95887;
for nerve velocity determination, see 95905, 95907, 95908,
95909, 95910, 95911, 95912, 95913)
97750 Physical performance test or measurement (eg,
musculoskeletal, functional capacity), with written report,
each 15 minutes
➲ CPT Assistant Summer 95:5, Feb 97:10, Aug 98:11, Mar
00:11, Nov 01:5, May 02:18, Apr 03:28, Dec 03:7, Feb
04:5, Feb 07:12, May 08:9, Aug 13:7, May 18:5
97755 Assistive technology assessment (eg, to restore, augment or
compensate for existing function, optimize functional tasks
and/or maximize environmental accessibility), direct one-
on-one contact, with written report, each 15 minutes
(To report augmentative and alternative communication

devices, see 92605, 92607)
Orthotic Management and Training and

Prosthetic Training
97760 Orthotic(s) management and training (including assessment
and fitting when not otherwise reported), upper
extremity(ies), lower extremity(ies) and/or trunk, initial
orthotic(s) encounter, each 15 minutes
➲ CPT Assistant Dec 05:8, 11, Feb 07:8, May 18:5
(Code 97760 should not be reported with 97116 for the

same extremity[ies])
97761 Prosthetic(s) training, upper and/or lower extremity(ies),
initial prosthetic(s) encounter, each 15 minutes
➲ CPT Assistant Dec 05:8, 11, Feb 07:8, May 18:5

97763 Orthotic(s)/prosthetic(s) management and/or training, upper
extremity(ies), lower extremity(ies), and/or trunk,
subsequent orthotic(s)/prosthetic(s) encounter, each 15
minutes
Other Procedures
(For extracorporeal shock wave musculoskeletal therapy,
see 0101T, 0102T)
97799 Unlisted physical medicine/rehabilitation service or
procedure
➲ CPT Assistant Summer 95:5, Oct 99:10, Nov 16:10, May
18:5
Medical Nutrition Therapy

★ 97802 Medical nutrition therapy; initial assessment and
intervention, individual, face-to-face with the patient, each
15 minutes
➲ CPT Assistant Apr 03:10, Nov 03:1, Feb 09:13
★ 97803 re-assessment and intervention, individual, face-to-face

with the patient, each 15 minutes
★ 97804 group (2 or more individual(s)), each 30 minutes
(Physicians and other qualified health care professionals

who may report evaluation and management services should
use the appropriate evaluation and management codes)
Acupuncture
Acupuncture is reported based on 15-minute increments of
personal (face-to-face) contact with the patient, not the duration
of acupuncture needle(s) placement.
If no electrical stimulation is used during a 15-minute increment,
use 97810, 97811. If electrical stimulation of any needle is used
during a 15-minute increment, use 97813, 97814.
Only one code may be reported for each 15-minute increment.
Use either 97810 or 97813 for the initial 15-minute increment.
Only one initial code is reported per day.
▶Evaluation and management services may be reported in
addition to acupuncture procedures when performed by
physicians or other health care professionals, who may report
evaluation and management (E/M) services, including new or
99215), hospital observation care (99217-99220, 99224-99226),
hospital care (99221-99223, 99231-99233), office or other
outpatient consultations (99241-99245), inpatient consultations
(99251-99255), critical care services (99291, 99292), inpatient
neonatal intensive care services and pediatric and neonatal critical
care services (99466-99480), emergency department services
(99281-99285), nursing facility services (99304-99318),
domiciliary, rest home, or custodial care services (99324-99337),
and home services (99341-99350) may be reported separately
using modifier 25 if the patient’s condition requires a significant,
separately identifiable E/M service above and beyond the usual
preservice and postservice work associated with the acupuncture
services. The time of the E/M service is not included in the time
of the acupuncture service.◀
For needle insertion(s) without injection(s) (eg, dry needling,
trigger point acupuncture), see 20560, 20561.
97810 Acupuncture, 1 or more needles; without electrical
stimulation, initial 15 minutes of personal one-on-one
contact with the patient
➲ CPT Assistant Jan 05:16-17, Jun 05:5, Jun 06:20, Aug
06:4, Feb 20:9
✚ 97811 without electrical stimulation, each additional 15 minutes
of personal one-on-one contact with the patient, with re-
insertion of needle(s) (List separately in addition to code
➲ CPT Assistant Jan 05:16, Jun 05:5, Aug 06:4, Feb
20:9
97813 with electrical stimulation, initial 15 minutes of personal
one-on-one contact with the patient
➲ CPT Assistant Jan 05:16-18, Jun 05:5, Jun 06:20,
Aug 06:4, Feb 20:9
✚ 97814 with electrical stimulation, each additional 15 minutes of
personal one-on-one contact with the patient, with re-
insertion of needle(s) (List separately in addition to code
➲ CPT Assistant Jan 05:16, Jun 05:5, Aug 06:4, Feb
20:9
with 20560, 20561. When both time-based acupuncture
services and needle insertion[s] without injection[s] are
performed, report only the time-based acupuncture codes)
Acupuncture, Needle
97810-97811
Osteopathic Manipulative Treatment
Osteopathic manipulative treatment (OMT) is a form of manual
treatment applied by a physician or other qualified health care
professional to eliminate or alleviate somatic dysfunction and
related disorders. This treatment may be accomplished by a
variety of techniques.
▶Evaluation and management (E/M) services including new or
99215), hospital observation care (99217-99220, 99224-99226),
hospital care (99221-99223, 99231-99233), critical care services
(99291, 99292), observation or inpatient care services (99234-
99236), office or other outpatient consultations (99241-99245),
emergency department services (99281-99285), nursing facility
services (99304-99318), domiciliary, rest home, or custodial care
services (99324-99337), and home services (99341-99350) may
be reported separately using modifier 25 if the patient’s condition
requires a significant, separately identifiable E/M service above
and beyond the usual preservice and postservice work associated
with the procedure. The E/M service may be caused or prompted
by the same symptoms or condition for which the OMT service
was provided. As such, different diagnoses are not required for
the reporting of the OMT and E/M service on the same date.◀
Body regions referred to are: head region; cervical region;
thoracic region; lumbar region; sacral region; pelvic region; lower
extremities; upper extremities; rib cage region; abdomen and
viscera region.
98925 Osteopathic manipulative treatment (OMT); 1-2 body
regions involved
➲ CPT Assistant May 96:10, Jan 97:8, 10, Jul 98:10, Aug
00:11, Dec 00:15, Oct 09:10, Dec 17:15, Aug 18:9
98926 3-4 body regions involved
➲ CPT Assistant May 96:10, Jan 97:8, Aug 00:11, Dec
00:15, Oct 09:10, Aug 18:9
00:15, Oct 09:10, Aug 18:9
00:15, Oct 09:10, Mar 12:14, May 12:14, Aug 18:9
➲ CPT Assistant May 96:10, Jan 97:8, 10, Aug 00:11,
Oct 09:10, Aug 18:9
Chiropractic Manipulative Treatment

Chiropractic manipulative treatment (CMT) is a form of manual
treatment to influence joint and neurophysiological function. This
treatment may be accomplished using a variety of techniques.
▶The chiropractic manipulative treatment codes include a pre-
manipulation patient assessment. Additional evaluation and
management (E/M) services including office or other outpatient
services (99202-99215), subsequent observation care (99224-
99226), subsequent hospital care (99231-99233), office or other
outpatient consultations (99241-99245), subsequent nursing
custodial care services (99324-99337), and home services (99341-
99350) may be reported separately using modifier 25 if the
patient’s condition requires a significant, separately identifiable
E/M service above and beyond the usual preservice and
postservice work associated with the procedure. The E/M service
may be caused or prompted by the same symptoms or condition
for which the CMT service was provided. As such, different
diagnoses are not required for the reporting of the CMT and E/M
service on the same date.◀
For purposes of CMT, the five spinal regions referred to are:
cervical region (includes atlanto-occipital joint); thoracic region
(includes costovertebral and costotransverse joints); lumbar
region; sacral region; and pelvic (sacro-iliac joint) region. The
five extraspinal regions referred to are: head (including
temporomandibular joint, excluding atlanto-occipital) region;
lower extremities; upper extremities; rib cage (excluding
costotransverse and costovertebral joints) and abdomen.
98940 Chiropractic manipulative treatment (CMT); spinal, 1-2
regions
➲ CPT Assistant Jan 97:7, 11, Feb 99:10, Dec 00:15, Mar
06:15, Dec 07:16, 17, Oct 09:10, May 10:9, Dec 13:15,
Nov 18:12
98941 spinal, 3-4 regions
➲ CPT Assistant Jan 97:7, 11, Mar 97:10, Feb 99:10,
Dec 00:15, Mar 06:15, Dec 07:16, 17, Oct 09:10,
May 10:9, Nov 18:12
98942 spinal, 5 regions
➲ CPT Assistant Jan 97:7, 11, Feb 99:10, Dec 00:15,
Mar 06:15, Dec 07:16, 17, Oct 09:10, May 10:9, Nov
18:12
98943 extraspinal, 1 or more regions
➲ CPT Assistant Jan 97:7, 11, Mar 97:10, Feb 99:10,
Dec 00:15, Mar 06:15, Dec 07:16, 17, Oct 09:10,
May 10:9, Dec 13:15, Nov 18:12
Education and Training for Patient
Self-Management
The following codes are used to report educational and training
services prescribed by a physician or other qualified health care
professional and provided by a qualified, nonphysician health
care professional using a standardized curriculum to an
individual or a group of patients for the treatment of established
illness(s)/disease(s) or to delay comorbidity(s). Education and
training for patient self-management may be reported with these
codes only when using a standardized curriculum as described
below. This curriculum may be modified as necessary for the
clinical needs, cultural norms and health literacy of the individual
patient(s).
The purpose of the educational and training services is to teach
the patient (may include caregiver[s]) how to effectively self-
manage the patient’s illness(s)/disease(s) or delay disease
comorbidity(s) in conjunction with the patient’s professional
healthcare team. Education and training related to subsequent
reinforcement or due to changes in the patient’s condition or
treatment plan are reported in the same manner as the original
education and training. The type of education and training
provided for the patient’s clinical condition will be identified by
the appropriate diagnosis code(s) reported.
The qualifications of the nonphysician healthcare professionals
and the content of the educational and training program must be
consistent with guidelines or standards established or recognized
by a physician society, nonphysician healthcare professional
society/association, or other appropriate source.
▶ (For counseling and education provided by a physician to
an individual, see the appropriate evaluation and
management codes including office or other outpatient
services [99202-99215], hospital observation care [99217-
99220, 99224-99226], hospital care [99221-99223, 99231-
99233], new or established patient office or other outpatient
consultations [99241-99245], inpatient consultations
99337], home services [99341-99350], and counseling risk
factor reduction and behavior change intervention [99401-
99429]. See also Instructions for Use of the CPT
Codebook for definition of reporting qualifications)◀
(For counseling and education provided by a physician to a
group, use 99078)
(For counseling and/or risk factor reduction intervention
provided by a physician to patient[s] without symptoms or
established disease, see 99401-99412)
(For medical nutrition therapy, see 97802-97804)
(For health behavior assessment and intervention that is not
part of a standardized curriculum, see 96156, 96158, 96159,
96164, 96165, 96167, 96168, 96170, 96171)
(For education provided as genetic counseling services, use
96040. For education to a group regarding genetic risks, see
98961, 98962)
★ 98960 Education and training for patient self-management by a
qualified, nonphysician health care professional using a
standardized curriculum, face-to-face with the patient (could
include caregiver/family) each 30 minutes; individual
patient
➲ CPT Assistant Apr 13:3, Nov 13:3, Oct 14:3
★ 98961 2-4 patients
➲ CPT Assistant Aug 07:9, Aug 08:3, Feb 09:13, Apr
13:3
★ 98962 5-8 patients
➲ CPT Assistant Aug 07:9, Aug 08:3, Feb 09:13, Apr
13:3, Nov 13:3, Oct 14:3
Non-Face-to-Face Nonphysician
Services
Telephone Services
Telephone services are non-face-to-face assessment and
management services provided by a qualified health care
professional to a patient using the telephone. These codes are
used to report episodes of care by the qualified health care
professional initiated by an established patient or guardian of an
established patient. If the telephone service ends with a decision
to see the patient within 24 hours or the next available urgent visit
appointment, the code is not reported; rather the encounter is
considered part of the preservice work of the subsequent
assessment and management service, procedure, and visit.
Likewise, if the telephone call refers to a service performed and
reported by the qualified health care professional within the
previous seven days (either qualified health care professional
requested or unsolicited patient follow-up) or within the
postoperative period of the previously completed procedure, then
the service(s) are considered part of that previous service or
procedure. (Do not report 98966-98968 if reporting 98966-98968
performed in the previous seven days.)
(For telephone services provided by a physician, see
99441-99443)
98966 Telephone assessment and management service provided by
a qualified nonphysician health care professional to an
established patient, parent, or guardian not originating from
a related assessment and management service provided
within the previous 7 days nor leading to an assessment and
management service or procedure within the next 24 hours
or soonest available appointment; 5-10 minutes of medical
discussion
➲ CPT Assistant Apr 13:3, Oct 13:11, Nov 13:3, Oct 14:3,
Mar 18:7
➲ CPT Assistant Apr 13:3, Oct 13:11, Mar 18:7

➲ CPT Assistant Apr 13:3, Oct 13:11, Nov 13:3, Oct
14:3, Mar 18:7
▶ (Donot report 98966-98968 during the same month with
99439, 99487, 99489, 99490, 99491)◀
93792, 93793)
Qualified Nonphysician Health Care

Professional Online Digital Assessment and
Management Service
Qualified nonphysician health care professional online digital
assessment and management services are patient-initiated digital
services with qualified nonphysician health care professionals
that require qualified nonphysician health care professional
patient evaluation and decision making to generate an assessment
and subsequent management of the patient. These services are
not for the nonevaluative electronic communication of test
results, scheduling of appointments, or other communication that
does not include E/M. While the patient’s problem may be new to
the qualified nonphysician health care professional, the patient is
an established patient. Patients initiate these services through
Health Insurance Portability and Accountability Act (HIPAA)-
compliant, secure platforms, such as through the electronic health
record (EHR) portal, email, or other digital applications, which
allow digital communication with the qualified nonphysician
health care professional.
Qualified nonphysician health care professional online digital
assessments are reported once for the qualified nonphysician
health care professional’s cumulative time devoted to the service
during a seven-day period. The seven-day period begins with the
qualified nonphysician health care professional’s initial, personal
review of the patient-generated inquiry. Qualified nonphysician
health care professional cumulative service time includes review
of the initial inquiry, review of patient records or data pertinent to
assessment of the patient’s problem, personal qualified
nonphysician health care professional interaction with clinical
staff focused on the patient’s problem, development of
management plans, including qualified nonphysician health care
professional generation of prescriptions or ordering of tests, and
subsequent communication with the patient through online,
telephone, email, or other digitally supported communication. All
qualified nonphysician health care professionals in the same
group practice who are involved in an online digital assessment
contribute to the cumulative service time devoted to the patient’s
online digital assessment. Qualified nonphysician health care
professional online digital assessments require visit
documentation and permanent storage (electronic or hard copy)
of the encounter.
If the patient generates the initial online digital inquiry within
seven days of a previous treatment or E/M service and both
services relate to the same problem, or the online digital inquiry
occurs within the postoperative period of a previously completed
procedure, then the qualified nonphysician health care
professional’s online digital assessment may not be reported
separately. If the patient generates an initial online digital inquiry
for a new problem within seven days of a previous service that
addressed a different problem, then the qualified nonphysician
health care professional online digital assessment is reported
separately. If a separately reported evaluation service occurs
within seven days of the qualified nonphysician health care
professional’s initial review of the online digital assessment,
codes 98970, 98971, 98972 may not be reported. If the patient
presents a new, unrelated problem during the seven-day period
of an online digital assessment, then the qualified nonphysician
health care professional’s time spent assessing the additional
problem is added to the cumulative service time of the online
digital assessment for that seven-day period.
(For an online digital E/M service provided by a physician
or other qualified health care professional, see 99421,
99422, 99423)
98972)
98970 Qualified nonphysician health care professional online
digital assessment and management, for an established
patient, for up to 7 days, cumulative time during the 7 days;
5-10 minutes
98971 11-20 minutes

98972 21 or more minutes

(Report 98970, 98971, 98972 once per 7-day period)

(Do not report online digital E/M services for cumulative
visit time less than 5 minutes)
(Do not count 98970, 98971, 98972 time otherwise reported
with other services)
(Do not report 98970, 98971, 98972 for home and outpatient
INR monitoring when reporting 93792, 93793)
▶ (Donot report 98970, 98971, 98972 when using 99091,
99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380,
99439, 99487, 99489, 99490, 99491, for the same
communication[s])◀
Special Services, Procedures and

Reports
The procedures with code numbers 99000 through 99082 provide
the reporting physician or other qualified health care professional
with the means of identifying the completion of special reports
and services that are an adjunct to the basic services rendered.
The specific number assigned indicates the special circumstances
under which a basic procedure is performed.
Codes 99050-99060 are reported in addition to an associated
basic service. Do not append modifier 51 to 99050-99060.
Typically only a single adjunct code from among 99050-99060
would be reported per patient encounter. However, there may be
circumstances in which reporting multiple adjunct codes per
patient encounter may be appropriate.
Miscellaneous Services
99000 Handling and/or conveyance of specimen for transfer from
the office to a laboratory
➲ CPT Assistant Winter 94:26, Feb 99:10, Oct 99:11, May
02:19, Aug 06:6, Sep 06:15, Jan 07:30
99001 Handling and/or conveyance of specimen for transfer from
the patient in other than an office to a laboratory (distance
may be indicated)
➲ CPT Assistant Winter 94:26, May 02:19, Aug 06:6, Sep
06:15, Jan 07:30
99002 Handling, conveyance, and/or any other service in
connection with the implementation of an order involving
devices (eg, designing, fitting, packaging, handling, delivery
or mailing) when devices such as orthotics, protectives,
prosthetics are fabricated by an outside laboratory or shop
but which items have been designed, and are to be fitted and
adjusted by the attending physician or other qualified health
care professional
06:15, Jan 07:30
(For routine collection of venous blood, use 36415)
99024 Postoperative follow-up visit, normally included in the
surgical package, to indicate that an evaluation and
management service was performed during a postoperative
period for a reason(s) related to the original procedure
➲ CPT Assistant Winter 94:26, Sep 97:10, Aug 98:5, May
02:19, Nov 03:13, Aug 06:6, Sep 06:15, Jan 07:30, Mar
15:3, Jan 17:3, Jul 17:9
(As a component of a surgical “package,” see Surgery
Guidelines)
99026 Hospital mandated on call service; in-hospital, each hour
➲ CPT Assistant Jun 03:10, Aug 06:6, Sep 06:15, Jan
07:30
99027 out-of-hospital, each hour
➲ CPT Assistant Jun 03:10, Aug 06:6, Sep 06:15, Jan
07:30
(For standby services requiring prolonged attendance, use
99360, as appropriate. Time spent performing separately
reportable procedure(s) or service(s) should not be
included in the time reported as mandated on-call service)
99050 Services provided in the office at times other than regularly
scheduled office hours, or days when the office is normally
closed (eg, holidays, Saturday or Sunday), in addition to
basic service
➲ CPT Assistant Winter 94:27, May 02:19, Jun 03:10, May
06:18, Aug 06:6, Sep 06:15, Jan 07:30, Aug 10:9
99051 Service(s) provided in the office during regularly scheduled
evening, weekend, or holiday office hours, in addition to
basic service
➲ CPT Assistant May 06:18, Aug 06:6, Sep 06:15, Jan
07:30, Aug 10:9
99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service
07:30
99056 Service(s) typically provided in the office, provided out of
the office at request of patient, in addition to basic service
➲ CPT Assistant Winter 94:27, May 02:19, May 06:18,
Aug 06:6, Sep 06:15, Jan 07:30
99058 Service(s) provided on an emergency basis in the office,
which disrupts other scheduled office services, in addition
to basic service
➲ CPT Assistant Winter 94:27, May 02:19, May 06:18,
Aug 06:6, Sep 06:15, Jan 07:30, Aug 10:9
99060 Service(s) provided on an emergency basis, out of the
office, which disrupts other scheduled office services, in
addition to basic service
07:30
99070 Supplies and materials (except spectacles), provided by the
physician or other qualified health care professional over
and above those usually included with the office visit or
other services rendered (list drugs, trays, supplies, or
materials provided)
➲ CPT Assistant Winter 94:28, May 98:10, Jun 99:10, Jun
00:11, Jul 01:2, May 02:19, Aug 02:11, Jun 05:1, Jul
06:1, Aug 06:6, Sep 06:15, Jan 07:30, 31, Feb 07:8, Sep
08:11, May 09:8, Sep 09:5, May 10:10, Jun 10:8, Sep
10:11, Apr 12:10, Nov 12:11, Mar 13:6, Dec 13:12, Mar
14:11, Jan 17:6, Sep 17:15, Jan 18:3, Mar 18:7, Jun
18:11, Apr 19:11
(For supply of spectacles, use the appropriate supply codes)
99071 Educational supplies, such as books, tapes, and pamphlets,
for the patient’s education at cost to physician or other
06:15, Jan 07:30, Apr 13:3, Nov 13:3, Oct 14:3
99075 Medical testimony
06:15, Jan 07:30
qualified by education, training, licensure/regulation (when
applicable) educational services rendered to patients in a
group setting (eg, prenatal, obesity, or diabetic instructions)
➲ CPT Assistant Winter 94:28, Jan 98:12, May 02:19, Aug
06:6, Sep 06:15, Jan 07:30, Aug 07:9, Apr 13:3, Nov
13:3, Oct 14:3
99080 Special reports such as insurance forms, more than the
information conveyed in the usual medical communications
or standard reporting form
06:15, Jan 07:30, Apr 13:3, Nov 13:3, Oct 14:3
the completion of Workmen’s Compensation forms)
99082 Unusual travel (eg, transportation and escort of patient)
➲ CPT Assistant May 02:19, Jan 03:24, Nov 03:14, Aug
06:6, Sep 06:15, Jan 07:30
Qualifying Circumstances for

Anesthesia
(For explanation of these services, see Anesthesia
Guidelines)
✚ 99100 Anesthesia for patient of extreme age, younger than 1 year
and older than 70 (List separately in addition to code for
primary anesthesia procedure)
➲ CPT Assistant Apr 08:3, Dec 17:8, Oct 19:10
(For procedure performed on infants younger than 1 year of

age at time of surgery, see 00326, 00561, 00834, 00836)
✚ 99116 Anesthesia complicated by utilization of total body
hypothermia (List separately in addition to code for primary
✚ 99135 Anesthesia complicated by utilization of controlled

hypotension (List separately in addition to code for primary
✚ 99140 Anesthesia complicated by emergency conditions (specify)

(List separately in addition to code for primary anesthesia
procedure)
➲ CPT Assistant Mar 01:10, Apr 08:3, Dec 17:8, Oct
19:10
(An emergency is defined as existing when delay in
treatment of the patient would lead to a significant increase
in the threat to life or body part)

Moderate (also known as conscious) sedation is a drug-induced
depression of consciousness during which patients respond
purposefully to verbal commands, either alone or accompanied
by light tactile stimulation. No interventions are required to
maintain cardiovascular function or a patent airway, and
spontaneous ventilation is adequate.
Moderate sedation codes 99151, 99152, 99153, 99155, 99156,
99157 are not used to report administration of medications for
pain control, minimal sedation (anxiolysis), deep sedation, or
monitored anesthesia care (00100-01999).
For purposes of reporting, intraservice time of moderate sedation
is used to select the appropriate code(s). The following
definitions are used to determine intraservice time (compared to
pre- and postservice time).
An independent trained observer is an individual who is qualified
to monitor the patient during the procedure, who has no other
duties (eg, assisting at surgery) during the procedure.
Preservice Work
The preservice activities required for moderate sedation are
included in the work described by each of these codes (99151,
99152, 99153, 99155, 99156, 99157) and are not reported
separately. The following preservice work components are not
included when determining intra-service time for reporting:
■ Assessment of the patient’s past medical and surgical history
with particular emphasis on cardiovascular, pulmonary, airway,
or neurological conditions;
■ Review of the patient’s previous experiences with anesthesia
and/or sedation;
■ Family history of sedation complications;
■ Summary of the patient’s present medication list;
■ Drug allergy and intolerance history;
■ Focused physical examination of the patient with emphasis on:
• Mouth, jaw, oropharynx, neck and airway for Mallampati
score assessment;
• Chest and lungs;
• Heart and circulation;
■ Vital signs, including heart rate, respiratory rate, blood
pressure, and oxygenation with end tidal CO 2 when indicated;
■ Review of any pre-sedation diagnostic tests;
■ Completion of a pre-sedation assessment form (with an
American Society of Anesthesiologists [ASA] Physical Status
classification);
■ Patient informed consent;
■ Immediate pre-sedation assessment prior to first sedating
doses; and
■ Initiation of IV access and fluids to maintain patency.
Intraservice Work
Intraservice time is used to determine the appropriate CPT code
to report moderate sedation services:
■ Begins with the administration of the sedating agent(s);
■ Ends when the procedure is completed, the patient is stable for
recovery status, and the physician or other qualified health care
professional providing the sedation ends personal continuous
face-to-face time with the patient;
■ Includes ordering and/or administering the initial and
subsequent doses of sedating agents;
■ Requires continuous face-to-face attendance of the physician
or other qualified health care professional;
■ Requires monitoring patient response to the sedating agents,
including:
• Periodic assessment of the patient;
• Further administration of agent(s) as needed to maintain
sedation; and
• Monitoring of oxygen saturation, heart rate, and blood
pressure.
If the physician or other qualified health care professional who
provides the sedation services also performs the procedure
supported by sedation (99151, 99152, 99153), the physician or
other qualified health care professional will supervise and direct
an independent trained observer who will assist in monitoring the
patient’s level of consciousness and physiological status
throughout the procedure.
Postservice Work
The postservice activities required for moderate sedation are
included in the work described by each of these codes (99151,
99152, 99153, 99155, 99156, 99157) and are not reported
separately. Once continuous face-to-face time with the patient has
ended, additional face-to-face time with the patient is not added
to the intraservice time, however, it is considered as part of the
postservice work. The following postservice work components
are not included, when determining intraservice time for
reporting:
■ Assessment of the patient’s vital signs, level of consciousness,
neurological, cardiovascular, and pulmonary stability in the
post-sedation recovery period;
■ Assessment of the patient’s readiness for discharge following
the procedure;
■ Preparation of documentation regarding sedation service; and
■ Communication with family/caregiver regarding sedation
service.
Postservice work/times are not used to select the appropriate
code.
Do not report 99151, 99152, 99153, 99155, 99156, 99157 in
conjunction with 94760, 94761, 94762.
Codes 99151, 99152, 99155, 99156 are reported for the first 15
minutes of intraservice time providing moderate sedation. Codes
99153, 99157 are reported for each additional 15 minutes, in
addition to the code for the primary service.
⃠ 99151 Moderate sedation services provided by the same physician
or other qualified health care professional performing the
diagnostic or therapeutic service that the sedation supports,
requiring the presence of an independent trained observer to
assist in the monitoring of the patient’s level of
consciousness and physiological status; initial 15 minutes of
intraservice time, patient younger than 5 years of age
➲ CPT Assistant Jan 17:3, May 17:3, Jun 17:3, Sep 17:11
18:8, Winter 18:11
⃠ 99152 initial 15 minutes of intraservice time, patient age 5
years or older
➲ CPT Assistant Jan 17:3, May 17:3, Jun 17:3, Sep
17:11, May 19:10
17:2, Winter 17:5, Spring 18:4, Summer 18:2, Winter
18:3, Spring 19:2, Summer 19:4
✚ 99153 each additional 15 minutes intraservice time (List
separately in addition to code for primary service)
17:11, May 19:10
17:2, Fall 17:2, Winter 18:3, Spring 18:4, Summer
18:2, Spring 19:2, Summer 19:4
Moderate sedation (MS) MS provided by

provided by physician or different physician or
other qualified health other qualified health
care professional (same care professional (not
physician or qualified the physician or
health care professional qualified health care
also performing the professional who is
procedure MS is performing the
supporting)
procedure MS is
supporting)
Total
Intra-
service
Time for
Moderate Patient
Sedation Age Code(s) Code(s)
Less than Any Not reported separately Not reported separately
10 age
minutes
10-22 <5 99151 99155
minutes years
10-22 5 years 99152 99156
minutes or
older
23-37 <5 99151 + 99153 X 1 99155 + 99157 X 1
minutes years
23-37 5 years 99152 + 99153 X 1 99156 + 99157 X 1
minutes or
older
38-52 <5 99151 + 99153 X 2 99155 + 99157 X 2
minutes years
38-52 5 years 99152 + 99153 X 2 99156 + 99157 X 2
minutes or
older
53-67 <5 99151 + 99153 X 3 99155 + 99157 X 3
minutes years
(53 min. -
1 hr. 7
min.)
53-67 5 years 99152 + 99153 X 3 99156 + 99157 X 3
minutes or
(53 min. - older
1 hr. 7
min.)
68-82 <5 99151 + 99153 X 4 99155 + 99157 X 4
minutes years
(1 hr. 8
min. - 1 hr.
22 min.)
68-82 5 years 99152 + 99153 X 4 99156 + 99157 X 4
minutes or
(1 hr. 8 older
min. - 1 hr.
22 min.)
83 <5 99153 Add 99157
minutes or years
longer
(1 hr. 23
min. - etc.)
83 5 years Add 99153 Add 99157
minutes or or
longer older
(1 hr. 23
min. - etc.)
99155 Moderate sedation services provided by a physician or
other qualified health care professional other than the
performing the diagnostic or therapeutic service that the
sedation supports; initial 15 minutes of intraservice time,
patient younger than 5 years of age
➲ CPT Assistant Jan 17:3, May 17:3, Jun 17:3, Sep 17:11
18:10
99156 initial 15 minutes of intraservice time, patient age 5
years or older
17:11
18:10
✚ 99157 each additional 15 minutes intraservice time (List
separately in addition to code for primary service)
17:11
18:10
Other Services and Procedures

99170 Anogenital examination, magnified, in childhood for
suspected trauma, including image recording when
performed
➲ CPT Assistant Nov 99:55, Apr 06:1, Sep 14:7
(For moderate sedation, see 99151, 99152, 99153, 99155,

99156, 99157)
99172 Visual function screening, automated or semi-automated
bilateral quantitative determination of visual acuity, ocular
alignment, color vision by pseudoisochromatic plates, and
field of vision (may include all or some screening of the
determination[s] for contrast sensitivity, vision under glare)
➲ CPT Assistant Feb 01:7, Mar 05:1, 3
(This service must employ graduated visual acuity stimuli

that allow a quantitative determination of visual acuity [eg,
Snellen chart]. This service may not be used in addition to a
general ophthalmological service or an E/M service)
99177, 0469T)
99173 Screening test of visual acuity, quantitative, bilateral
➲ CPT Assistant Nov 99:55, May 02:2, Mar 05:1, 3
(The screening test used must employ graduated visual

acuity stimuli that allow a quantitative estimate of visual
acuity [eg, Snellen chart]. Other identifiable services
unrelated to this screening test provided at the same time
may be reported separately [eg, preventive medicine
services]. When acuity is measured as part of a general
ophthalmological service or of an E/M service of the eye, it
is a diagnostic examination and not a screening test.)
99177)
99174 Instrument-based ocular screening (eg, photoscreening,
automated-refraction), bilateral; with remote analysis and
report
➲ CPT Assistant Mar 13:6, Mar 16:11, Feb 18:3

99172, 99173, 99177)
# 99177 with on-site analysis

99172, 99173, 99174)
(For retinal polarization scan, use 0469T)
99175 Ipecac or similar administration for individual emesis and
continued observation until stomach adequately emptied of
poison
(For diagnostic intubation, see 43754, 43755)
(For gastric lavage for diagnostic purposes, see 43754,
43755)
attendance and supervision of hyperbaric oxygen therapy,
per session
(Evaluation and Management services and/or procedures

[eg, wound debridement] provided in a hyperbaric oxygen
treatment facility in conjunction with a hyperbaric oxygen
therapy session should be reported separately)
99184 Initiation of selective head or total body hypothermia in the
critically ill neonate, includes appropriate patient selection
by review of clinical, imaging and laboratory data,
confirmation of esophageal temperature probe location,
evaluation of amplitude EEG, supervision of controlled
hypothermia, and assessment of patient tolerance of cooling
(Do not report 99184 more than once per hospital stay)
99188 Application of topical fluoride varnish by a physician or
other qualified health care professional
99190 Assembly and operation of pump with oxygenator or heat

exchanger (with or without ECG and/or pressure
monitoring); each hour
99191 45 minutes
99192 30 minutes
99195 Phlebotomy, therapeutic (separate procedure)
99199 Unlisted special service, procedure or report

➲ CPT Assistant Nov 99:55, Jun 12:16, Sep 12:9
Home Health Procedures/Services

These codes are used by non-physician health care professionals.
Physicians should utilize the home visit codes 99341-99350 and
utilize CPT codes other than 99500-99600 for any additional
procedure/service provided to a patient living in a residence.
The following codes are used to report services provided in a
patient’s residence (including assisted living apartments, group
homes, nontraditional private homes, custodial care facilities, or
schools).
Health care professionals who are authorized to use Evaluation
and Management (E/M) Home Visit codes (99341-99350) may
report 99500-99600 in addition to 99341-99350 if both services
are performed. E/M services may be reported separately, using
modifier 25, if the patient’s condition requires a significant
separately identifiable E/M service, above and beyond the home
health service(s)/procedure(s) codes 99500-99600.
99500 Home visit for prenatal monitoring and assessment to
include fetal heart rate, non-stress test, uterine monitoring,
and gestational diabetes monitoring
99501 Home visit for postnatal assessment and follow-up care

99502 Home visit for newborn care and assessment

99503 Home visit for respiratory therapy care (eg, bronchodilator,

oxygen therapy, respiratory assessment, apnea evaluation)
99504 Home visit for mechanical ventilation care

99505 Home visit for stoma care and maintenance including

colostomy and cystostomy
99506 Home visit for intramuscular injections

99507 Home visit for care and maintenance of catheter(s) (eg,

urinary, drainage, and enteral)
99509 Home visit for assistance with activities of daily living and
personal care
(To report self-care/home management training, see 97535)

(To report home medical nutrition assessment and
intervention services, see 97802-97804)
(To report home speech therapy services, see 92507-92508)
99510 Home visit for individual, family, or marriage counseling
99511 Home visit for fecal impaction management and enema

administration
99512 Home visit for hemodialysis

(For home infusion of peritoneal dialysis, use 99601,

99602)
99600 Unlisted home visit service or procedure
Home Infusion Procedures/Services

99601 Home infusion/specialty drug administration, per visit (up to
2 hours);
Medication Therapy Management

Services
Medication therapy management service(s) (MTMS) describe
face-to-face patient assessment and intervention as appropriate,
by a pharmacist, upon request. MTMS is provided to optimize the
response to medications or to manage treatment-related
medication interactions or complications.
MTMS includes the following documented elements: review of
the pertinent patient history, medication profile (prescription and
nonprescription), and recommendations for improving health
outcomes and treatment compliance. These codes are not to be
used to describe the provision of product-specific information at
the point of dispensing or any other routine dispensing-related
activities.
99605 Medication therapy management service(s) provided by a
pharmacist, individual, face-to-face with patient, with
assessment and intervention if provided; initial 15 minutes,
new patient
99606 initial 15 minutes, established patient


Category II Codes
The following section of Current Procedural Terminology (CPT)
contains a set of supplemental tracking codes that can be used for
performance measurement. It is anticipated that the use of
Category II codes for performance measurement will decrease
the need for record abstraction and chart review, and thereby
minimize administrative burden on physicians, other health care
professionals, hospitals, and entities seeking to measure the
quality of patient care. These codes are intended to facilitate data
collection about the quality of care rendered by coding certain
services and test results that support nationally established
performance measures and that have an evidence base as
contributing to quality patient care.
The use of these codes is optional. The codes are not required for
correct coding and may not be used as a substitute for Category I
codes.
These codes describe clinical components that may be typically
included in evaluation and management services or clinical
services and, therefore, do not have a relative value associated
with them. Category II codes may also describe results from
clinical laboratory or radiology tests and other procedures,
identified processes intended to address patient safety practices,
or services reflecting compliance with state or federal law.
Category II codes described in this section make use of
alphabetical characters as the 5th character in the string (ie, 4
digits followed by the letter F). These digits are not intended to
reflect the placement of the code in the regular (Category I) part
of the CPT code set. To promote understanding of these codes
and their associated measures, users are referred to the
Alphabetical Clinical Topics Listing, which contains information
about performance measurement exclusion modifiers, measures,
and the measure’s source.
Cross-references to the measures associated with each Category
II code and their source are included for reference in the
Alphabetical Clinical Topics Listing. In addition, acronyms for
the related diseases or clinical condition(s) have been added at
the end of each code descriptor to identify the topic or clinical
category in which that code is included. A complete listing of the
diseases/clinical conditions, and their acronyms are provided in
alphabetical order in the Alphabetical Clinical Topics Listing. The
Alphabetical Clinical Topics Listing can be accessed on the
website at www.ama-assn.org, under the Category II link. Users
should review the complete measure(s) associated with each code
prior to implementation.
Requests for Category II CPT codes will be reviewed by the
CPT/HCPAC Advisory Committee just as requests for Category I
CPT codes are reviewed. In developing new and revised
performance measurement codes, requests for codes are
considered from:
■ measurements that were developed and tested by a national
organization;
■ evidenced-based measurements with established ties to health
outcomes;
■ measurements that address clinical conditions of high
prevalence, high risk, or high cost; and
■ well-established measurements that are currently being used by
large segments of the health care industry across the country.
In addition, all of the following are required:
■ Definition or purpose of the measure is consistent with its
intended use (quality improvement and accountability, or
solely quality improvement)
■ Aspect of care measured is substantially influenced by the
physician (or other qualified health care professional or entity
for which the code may be relevant)
■ Reduces data collection burden on physicians (or other
qualified health care professional or entities)
■ Significant
• Affects a large segment of health care community
• Tied to health outcomes
• Addresses clinical conditions of high prevalence, high costs,
high risks
■ Evidence-based
• Agreed upon
• Definable
• Measurable
■ Risk-adjustment specifications and instructions for all outcome
measures submitted or compelling evidence as to why risk
adjustment is not relevant
■ Sufficiently detailed to make it useful for multiple purposes
■ Facilitates reporting of performance measure(s)
■ Inclusion of select patient history, testing (eg,
glycohemoglobin), other process measures, cognitive or
procedure services within CPT, or physiologic measures (eg,
blood pressure) to support performance measurements
■ Performance measure-development process that includes
• Nationally recognized expert panel
• Multidisciplinary
• Vetting process
▶See the Introduction section of the CPT code set for a complete
list of the dates of release and implementation.◀
The superscripted numbers included at the end of each code
descriptor direct users to the measure developers that are
associated with these footnotes, whose names and Web addresses
are listed below.
1 Physician Consortium for Performance Improvement®(PCPI),
www.physicianconsortium.org.
2 National Committee on Quality Assurance (NCQA), Health
Employer Data Information Set (HEDIS®), www.ncqa.org.
3 The Joint Commission (TJC), ORYX Initiative Performance
Measures,
www.jointcommission.org/performancemeasurement/aspx.
4 National Diabetes Quality Improvement Alliance (NDQIA),
www.nationaldiabetesalliance.org.
5 Joint measure from The Physician Consortium for
Performance Improvement, www.physicianconsortium.org,
and National Committee on Quality Assurance (NCQA),
www.ncqa.org.
6 The Society of Thoracic Surgeons at www.sts.org and National
Quality Forum, www.qualityforum.org.
7 Optum, www.optum.com.
8 American Academy of Neurology,
www.aan.com/go/practice/quality/measurements or
[email protected].
9 College of American Pathologists (CAP),
www.cap.org/apps/docs/advocacy/pathology_performance_me
asurement.pdf.
10 American Gastroenterological Association (AGA),
www.gastro.org/quality.
11 American Society of Anesthesiologists (ASA),
www.asahq.org.
12 American College of Gastroenterology (ACG), www.gi.org;
American Gastroenterological Association (AGA),
www.gastro.org; and American Society for Gastrointestinal
Endoscopy (ASGE), www.asge.org.
Modifiers
The following performance measurement modifiers may be used
for Category II codes to indicate that a service specified in the
associated measure(s) was considered but, due to either medical,
patient, or system circumstance(s) documented in the medical
record, the service was not provided. These modifiers serve as
denominator exclusions from the performance measure. The user
should note that not all listed measures provide for exclusions
(see Alphabetical Clinical Topics Listing for more discussion
regarding exclusion criteria).
Category II modifiers should only be reported with Category II
codes—they should not be reported with Category I or Category
III codes. In addition, the modifiers in the Category II section
should only be used where specified in the guidelines, reporting
instructions, parenthetic notes, or code descriptor language listed
in the Category II section (code listing and the Alphabetical
Clinical Topics Listing).
1P Performance Measure Exclusion Modifier due to Medical
Reasons
Reasons include:
■ Not indicated (absence of organ/limb, already
received/performed, other)
■ Contraindicated (patient allergic history, potential adverse drug
interaction, other)
■ Other medical reasons
2P Performance Measure Exclusion Modifier due to Patient
Reasons
Reasons include:
■ Patient declined
■ Economic, social, or religious reasons
■ Other patient reasons
Performance Measure Exclusion Modifier due to System
3P Reasons
Reasons include:
■ Resources to perform the services not available
■ Insurance coverage/payor-related limitations
■ Other reasons attributable to health care delivery system
Modifier 8P is intended to be used as a “reporting modifier” to
allow the reporting of circumstances when an action described in
a measure’s numerator is not performed and the reason is not
8P Performance measure reporting modifier–action not
performed, reason not otherwise specified
Composite Codes
Composite codes combine several measures grouped within a
single code descriptor to facilitate reporting for a clinical
condition when all components are met. If only some of the
components are met or if services are provided in addition to
those included in the composite code, they may be reported
individually using the corresponding CPT Category II codes for
those services.
0001F Heart failure assessed (includes assessment of all the
following components) (CAD)1:
Blood pressure measured (2000F)1
Level of activity assessed (1003F)1
Clinical symptoms of volume overload (excess) assessed
(1004F)1
Weight, recorded (2001F)1
Clinical signs of volume overload (excess) assessed
(2002F)1
(To report blood pressure measured, use 2000F)

0005F Osteoarthritis assessed (OA)1
Includes assessment of all the following components:
Osteoarthritis symptoms and functional status assessed
(1006F)1
Use of anti-inflammatory or over-the-counter (OTC)
analgesic medications assessed (1007F)1
Initial examination of the involved joint(s) (includes visual
inspection, palpation, range of motion) (2004F)1
(To report tobacco use cessation intervention, use 4001F)

0012F Community-acquired bacterial pneumonia assessment
(includes all of the following components) (CAP)1:
Co-morbid conditions assessed (1026F)1
Vital signs recorded (2010F)1
Mental status assessed (2014F)1
Hydration status assessed (2018F)1
0014F Comprehensive preoperative assessment performed for

cataract surgery with intraocular lens (IOL) placement
(includes assessment of all of the following components)
(EC)5:
Dilated fundus evaluation performed within 12 months prior
to cataract surgery (2020F)5
Pre-surgical (cataract) axial length, corneal power
measurement and method of intraocular lens power
calculation documented (must be performed within 12
months prior to surgery) (3073F)5
Preoperative assessment of functional or medical
indication(s) for surgery prior to the cataract surgery with
intraocular lens placement (must be performed within 12
months prior to cataract surgery) (3325F)5
0015F Melanoma follow up completed (includes assessment of all

of the following components) (ML)5:
History obtained regarding new or changing moles (1050F)5
Complete physical skin exam performed (2029F)5
Patient counseled to perform a monthly self skin examination
(5005F)5
Patient Management
Patient management codes describe utilization measures or
measures of patient care provided for specific clinical purposes
(eg, prenatal care, pre- and post-surgical care).
0500F Initial prenatal care visit (report at first prenatal encounter
with health care professional providing obstetrical care.
Report also date of visit and, in a separate field, the date of
the last menstrual period [LMP]) (Prenatal)2
0501F Prenatal flow sheet documented in medical record by first
prenatal visit (documentation includes at minimum blood
pressure, weight, urine protein, uterine size, fetal heart
tones, and estimated date of delivery). Report also: date of
visit and, in a separate field, the date of the last menstrual
period [LMP] (Note: If reporting 0501F Prenatal flow sheet,
it is not necessary to report 0500F Initial prenatal care visit)
(Prenatal)1
0502F Subsequent prenatal care visit (Prenatal)2

[Excludes: patients who are seen for a condition unrelated
to pregnancy or prenatal care (eg, an upper respiratory
infection; patients seen for consultation only, not for
continuing care)]
0503F Postpartum care visit (Prenatal)2

0505F Hemodialysis plan of care documented (ESRD, P-ESRD)1

0507F Peritoneal dialysis plan of care documented (ESRD)1

0509F Urinary incontinence plan of care documented (GER)5

0513F Elevated blood pressure plan of care documented (CKD)1

0514F Plan of care for elevated hemoglobin level documented for

patient receiving Erythropoiesis-Stimulating Agent therapy
(ESA) (CKD)1
0516F Anemia plan of care documented (ESRD)1

0517F Glaucoma plan of care documented (EC)5

0518F Falls plan of care documented (GER)5

0519F Planned chemotherapy regimen, including at a minimum:

drug(s) prescribed, dose, and duration, documented prior to
initiation of a new treatment regimen (ONC)1
0520F Radiation dose limits to normal tissues established prior to

the initiation of a course of 3D conformal radiation for a
minimum of 2 tissue/organ (ONC)1
0521F Plan of care to address pain documented (COA)2 (ONC)1

0525F Initial visit for episode (BkP)2

0526F Subsequent visit for episode (BkP)2

0528F Recommended follow-up interval for repeat colonoscopy of

at least 10 years documented in colonoscopy report
(End/Polyp)5
0529F Interval of 3 or more years since patient’s last colonoscopy,

documented (End/Polyp)5
Dyspnea management plan of care, documented (Pall Cr)5
0535F
0540F Glucorticoid Management Plan Documented (RA)5

0545F Plan for follow-up care for major depressive disorder,

documented (MDD ADOL)1
0550F Cytopathology report on routine nongynecologic specimen

finalized within two working days of accession date
(PATH)9
0551F Cytopathology report on nongynecologic specimen with

documentation that the specimen was non-routine (PATH)9
0555F Symptom management plan of care documented (HF)1

0556F Plan of care to achieve lipid control documented (CAD)1

0557F Plan of care to manage anginal symptoms documented

(CAD)1
0575F HIV RNA control plan of care, documented (HIV)5

0580F Multidisciplinary care plan developed or updated (ALS)8

0581F Patient transferred directly from anesthetizing location to

critical care unit (Peri2)11
0582F Patient not transferred directly from anesthetizing location to
critical care unit (Peri2)11
0583F Transfer of care checklist used (Peri2)11

0584F Transfer of care checklist not used (Peri2)11

Patient History
Patient history codes describe measures for select aspects of
patient history or review of systems.
1000F Tobacco use assessed (CAD, CAP, COPD, PV)1 (DM)4
1002F Anginal symptoms and level of activity assessed (NMA–No

Measure Associated)
1003F Level of activity assessed (NMA–No Measure Associated)

1004F Clinical symptoms of volume overload (excess) assessed

(NMA–No Measure Associated)
1005F Asthma symptoms evaluated (includes documentation of

numeric frequency of symptoms or patient completion of an
asthma assessment tool/survey/questionnaire) (NMA–No
Measure Associated)
1006F Osteoarthritis symptoms and functional status assessed (may
include the use of a standardized scale or the completion of
an assessment questionnaire, such as the SF-36, AAOS Hip
& Knee Questionnaire) (OA)1
[Instructions: Report when osteoarthritis is addressed during
the patient encounter]
1007F Use of anti-inflammatory or analgesic over-the-counter

(OTC) medications for symptom relief assessed (OA)1
1008F Gastrointestinal and renal risk factors assessed for patients

on prescribed or OTC non-steroidal anti-inflammatory drug
(NSAID) (OA)1
1010F Severity of angina assessed by level of activity (CAD)1

1011F Angina present (CAD)1

1012F Angina absent (CAD)1

1015F Chronic obstructive pulmonary disease (COPD) symptoms

assessed (Includes assessment of at least 1 of the following:
dyspnea, cough/sputum, wheezing), or respiratory symptom
assessment tool completed (COPD)1
1018F Dyspnea assessed, not present (COPD)1
1019F Dyspnea assessed, present (COPD)1

1022F Pneumococcus immunization status assessed (CAP, COPD)1

1026F Co-morbid conditions assessed (eg, includes assessment for

presence or absence of: malignancy, liver disease,
congestive heart failure, cerebrovascular disease, renal
disease, chronic obstructive pulmonary disease, asthma,
diabetes, other co-morbid conditions) (CAP)1
1030F Influenza immunization status assessed (CAP)1

1031F Smoking status and exposure to second hand smoke in the

home assessed (Asthma)1
1032F Current tobacco smoker or currently exposed to secondhand

smoke (Asthma)1
1033F Current tobacco non-smoker and not currently exposed to

secondhand smoke (Asthma)1
1034F Current tobacco smoker (CAD, CAP, COPD, PV)1 (DM)4

1035F Current smokeless tobacco user (eg, chew, snuff) (PV)1

1036F Current tobacco non-user (CAD, CAP, COPD, PV)1 (DM)4

(IBD)10
1038F Persistent asthma (mild, moderate or severe) (Asthma)1
1039F Intermittent asthma (Asthma)1

1040F DSM-5 criteria for major depressive disorder documented

at the initial evaluation (MDD, MDD ADOL)1
2015
1050F History obtained regarding new or changing moles (ML)5
1052F Type, anatomic location, and activity all assessed (IBD)10

1055F Visual functional status assessed (EC)5

1060F Documentation of permanent or persistent or paroxysmal

atrial fibrillation (STR)5
1061F Documentation of absence of permanent and persistent and

paroxysmal atrial fibrillation (STR)5
1065F Ischemic stroke symptom onset of less than 3 hours prior to

arrival (STR)5
1066F Ischemic stroke symptom onset greater than or equal to 3

hours prior to arrival (STR)5
1070F Alarm symptoms (involuntary weight loss, dysphagia, or
gastrointestinal bleeding) assessed; none present (GERD)5
1071F 1 or more present (GERD)5

1090F Presence or absence of urinary incontinence assessed

(GER)5
1091F Urinary incontinence characterized (eg, frequency, volume,

timing, type of symptoms, how bothersome) (GER)5
1100F Patient screened for future fall risk; documentation of 2 or

more falls in the past year or any fall with injury in the past
year (GER)5
1101F documentation of no falls in the past year or only 1 fall

without injury in the past year (GER)5
1110F Patient discharged from an inpatient facility (eg, hospital,

skilled nursing facility, or rehabilitation facility) within the
last 60 days (GER)5
1111F Discharge medications reconciled with the current

medication list in outpatient medical record (COA)2 (GER)5
1116F Auricular or periauricular pain assessed (AOE)1

1118F GERD symptoms assessed after 12 months of therapy

(GERD)5
1119F Initial evaluation for condition (HEP C)1(EPI, DSP)8
1121F Subsequent evaluation for condition (HEP C)1(EPI)8

1123F Advance Care Planning discussed and documented advance

care plan or surrogate decision maker documented in the
medical record (DEM)1 (GER, Pall Cr)5
1124F Advance Care Planning discussed and documented in the

medical record, patient did not wish or was not able to
name a surrogate decision maker or provide an advance
care plan (DEM)1 (GER, Pall Cr)5
1125F Pain severity quantified; pain present (COA)2 (ONC)1

1126F no pain present (COA)2 (ONC)1

1127F New episode for condition (NMA–No Measure Associated)

1128F Subsequent episode for condition (NMA–No Measure

Associated)
1130F Back pain and function assessed, including all of the

following: Pain assessment and functional status and patient
history, including notation of presence or absence of “red
flags” (warning signs) and assessment of prior treatment and
response, and employment status (BkP)2
1134F Episode of back pain lasting 6 weeks or less (BkP)2
1135F Episode of back pain lasting longer than 6 weeks (BkP)2

1136F Episode of back pain lasting 12 weeks or less (BkP)2

1137F Episode of back pain lasting longer than 12 weeks (BkP)2

1150F Documentation that a patient has a substantial risk of death

within 1 year (Pall Cr)5
1151F Documentation that a patient does not have a substantial risk

of death within one year (Pall Cr)5
1152F Documentation of advanced disease diagnosis, goals of care

prioritize comfort (Pall Cr)5
1153F Documentation of advanced disease diagnosis, goals of care

do not prioritize comfort (Pall Cr)5
1157F Advance care plan or similar legal document present in the

medical record (COA)2
1158F Advance care planning discussion documented in the

medical record (COA)2
1159F Medication list documented in medical record (COA)2

1160F Review of all medications by a prescribing practitioner or
clinical pharmacist (such as, prescriptions, OTCs, herbal
therapies and supplements) documented in the medical
record (COA)2
1170F Functional status assessed (COA)2 (RA)5

1175F Functional status for dementia assessed and results

reviewed (DEM)1
1180F All specified thromboembolic risk factors assessed (AFIB)1

1181F Neuropsychiatric symptoms assessed and results reviewed

(DEM)1
1182F Neuropsychiatric symptoms, one or more present (DEM)1

1183F Neuropsychiatric symptoms, absent (DEM)1

1200F Seizure type(s) and current seizure frequency(ies)

documented (EPI)8
1205F Etiology of epilepsy or epilepsy syndrome(s) reviewed and

documented (EPI)8
1220F Patient screened for depression (SUD)5

1400F Parkinson’s disease diagnosis reviewed (Prkns)8

Symptoms improved or remained consistent with treatment
1450F
goals since last assessment (HF)1
1451F Symptoms demonstrated clinically important deterioration

since last assessment (HF)1
1460F Qualifying cardiac event/diagnosis in previous 12 months

(CAD)1
1461F No qualifying cardiac event/diagnosis in previous 12

months (CAD)1
1490F Dementia severity classified, mild (DEM)1

1491F Dementia severity classified, moderate (DEM)1

1493F Dementia severity classified, severe (DEM)1

1494F Cognition assessed and reviewed (DEM)1

1500F Symptoms and signs of distal symmetric polyneuropathy

reviewed and documented (DSP)8
1501F Not initial evaluation for condition (DSP)8

1502F Patient queried about pain and pain interference with

function using a valid and reliable instrument (DSP)8
1503F Patient queried about symptoms of respiratory insufficiency
(ALS)8
1504F Patient has respiratory insufficiency (ALS)8

1505F Patient does not have respiratory insufficiency (ALS)8

Physical examination codes describe aspects of physical
examination or clinical assessment.
2000F Blood pressure measured (CKD)1(DM)2,4
2001F Weight recorded (PAG)1

2002F Clinical signs of volume overload (excess) assessed

(NMA–No Measure Associated)
2004F Initial examination of the involved joint(s) (includes visual

inspection, palpation, range of motion) (OA)1
[Instructions: Report only for initial osteoarthritis visit or
for visits for new joint involvement]
2010F Vital signs (temperature, pulse, respiratory rate, and blood

pressure) documented and reviewed (CAP)1 (EM)5
2014F Mental status assessed (CAP)1 (EM)5

2015F Asthma impairment assessed (Asthma)1

2016F Asthma risk assessed (Asthma)1

2018F Hydration status assessed (normal/mildly

dehydrated/severely dehydrated) (CAP)1
2019F Dilated macular exam performed, including documentation

of the presence or absence of macular thickening or
hemorrhage and the level of macular degeneration severity
(EC)5
2020F Dilated fundus evaluation performed within 12 months prior

to cataract surgery (EC)5
2021F Dilated macular or fundus exam performed, including

documentation of the presence or absence of macular edema
and level of severity of retinopathy (EC)5
2022F Dilated retinal eye exam with interpretation by an

ophthalmologist or optometrist documented and reviewed;
with evidence of retinopathy (DM)2
2023F without evidence of retinopathy (DM)2

2024F 7 standard field stereoscopic retinal photos with
interpretation by an ophthalmologist or optometrist
documented and reviewed; with evidence of retinopathy
(DM)2
2025F without evidence of retinopathy (DM)2

2026F Eye imaging validated to match diagnosis from 7 standard

field stereoscopic retinal photos results documented and
reviewed; with evidence of retinopathy (DM)2
# 2033F without evidence of retinopathy (DM)2

2027F Optic nerve head evaluation performed (EC)5

2028F Foot examination performed (includes examination through

visual inspection, sensory exam with monofilament, and
pulse exam – report when any of the 3 components are
completed) (DM)4
2029F Complete physical skin exam performed (ML)5

2030F Hydration status documented, normally hydrated (PAG)1

2031F Hydration status documented, dehydrated (PAG)1

2033F Code is out of numerical sequence. See 2025F-2028F

2035F Tympanic membrane mobility assessed with pneumatic
otoscopy or tympanometry (OME)1
2040F Physical examination on the date of the initial visit for low
back pain performed, in accordance with specifications
(BkP)2
2044F Documentation of mental health assessment prior to

intervention (back surgery or epidural steroid injection) or
for back pain episode lasting longer than 6 weeks (BkP)2
2050F Wound characteristics including size and nature of wound

base tissue and amount of drainage prior to debridement
documented (CWC)5
2060F Patient interviewed directly on or before date of diagnosis

of major depressive disorder (MDD ADOL)1
Diagnostic/Screening Processes or
Results
Diagnostic/screening processes or results codes describe results
of tests ordered (clinical laboratory tests, radiological or other
procedural examinations, and conclusions of medical decision-
making).
3006F Chest X-ray results documented and reviewed (CAP)1
3008F Body Mass Index (BMI), documented (PV)1

3011F Lipid panel results documented and reviewed (must include
total cholesterol, HDL-C, triglycerides and calculated LDL-
C) (CAD)1
3014F Screening mammography results documented and reviewed

(PV)1,2
3015F Cervical cancer screening results documented and reviewed

(PV)1
3016F Patient screened for unhealthy alcohol use using a systematic

screening method (PV)1 (DSP)8
3017F Colorectal cancer screening results documented and

reviewed (PV)12
3018F Pre-procedure risk assessment and depth of insertion and

quality of the bowel prep and complete description of
polyp(s) found, including location of each polyp, size,
number and gross morphology and recommendations for
follow-up in final colonoscopy report documented
(End/Polyp)5
3019F Left ventricular ejection fraction (LVEF) assessment

planned post discharge (HF)1
3020F Left ventricular function (LVF) assessment (eg,

echocardiography, nuclear test, or ventriculography)
documented in the medical record (Includes quantitative or
qualitative assessment results) (NMA–No Measure
Associated)
3021F Left ventricular ejection fraction (LVEF) less than 40% or
documentation of moderately or severely depressed left
ventricular systolic function (CAD, HF)1
3022F Left ventricular ejection fraction (LVEF) greater than or

equal to 40% or documentation as normal or mildly
depressed left ventricular systolic function (CAD, HF)1
3023F Spirometry results documented and reviewed (COPD)1

3025F Spirometry test results demonstrate FEV1/FVC less than

70% with COPD symptoms (eg, dyspnea, cough/sputum,
wheezing) (CAP, COPD)1
3027F Spirometry test results demonstrate FEV1/FVC greater than

or equal to 70% or patient does not have COPD symptoms
(COPD)1
3028F Oxygen saturation results documented and reviewed

(includes assessment through pulse oximetry or arterial
blood gas measurement) (CAP, COPD)1 (EM)5
3035F Oxygen saturation less than or equal to 88% or a PaO2 less

than or equal to 55 mm Hg (COPD)1
3037F Oxygen saturation greater than 88% or PaO2 greater than 55

mm Hg (COPD)1
3038F Pulmonary function test performed within 12 months prior to
surgery (Lung/Esop Cx)6
3040F Functional expiratory volume (FEV1) less than 40% of

predicted value (COPD)1
3042F Functional expiratory volume (FEV1) greater than or equal

to 40% of predicted value (COPD)1
3044F Most recent hemoglobin A1c (HbA1c) level less than 7.0%
(DM)2,4
(3045F has been deleted. To report control of HbA1c, see

3051F, 3052F)
# 3051F Most recent hemoglobin A1c (HbA1c) level greater than or
equal to 7.0% and less than 8.0% (DM)2
# 3052F Most recent hemoglobin A1c (HbA1c) level greater than or

equal to 8.0% and less than or equal to 9.0% (DM)2
3046F Most recent hemoglobin A1c level greater than 9.0% (DM)4
(To report most recent hemoglobin A1c level less than or

equal to 9.0%, see 3044F, 3051F, 3052F)
3048F Most recent LDL-C less than 100 mg/dL (CAD)1 (DM)4
3049F Most recent LDL-C 100-129 mg/dL (CAD)1 (DM)4

3050F Most recent LDL-C greater than or equal to 130 mg/dL
(CAD)1 (DM)4

3055F Left ventricular ejection fraction (LVEF) less than or equal
to 35% (HF)1
3056F Left ventricular ejection fraction (LVEF) greater than 35%

or no LVEF result available (HF)1
3060F Positive microalbuminuria test result documented and

reviewed (DM)2,4
3061F Negative microalbuminuria test result documented and

reviewed (DM)2,4
3062F Positive macroalbuminuria test result documented and

reviewed (DM)2,4
3066F Documentation of treatment for nephropathy (eg, patient

receiving dialysis, patient being treated for ESRD, CRF,
ARF, or renal insufficiency, any visit to a nephrologist)
(DM)2,4
3072F Low risk for retinopathy (no evidence of retinopathy in the

prior year) (DM)2
3073F Pre-surgical (cataract) axial length, corneal power

measurement and method of intraocular lens power
calculation documented within 12 months prior to surgery
(EC)5
3074F Most recent systolic blood pressure less than 130 mm Hg

(DM)2,4 (HTN, CKD, CAD)1
3075F Most recent systolic blood pressure 130-139 mm Hg

(DM)2,4(HTN, CKD, CAD)1
3077F Most recent systolic blood pressure greater than or equal to

140 mm Hg (HTN, CKD, CAD)1 (DM)2,4
3078F Most recent diastolic blood pressure less than 80 mm Hg

(HTN, CKD, CAD)1 (DM)2,4
3079F Most recent diastolic blood pressure 80-89 mm Hg (HTN,

CKD, CAD)1 (DM)2,4
3080F Most recent diastolic blood pressure greater than or equal to

90 mm Hg (HTN, CKD, CAD)1 (DM)2,4
3082F Kt/V less than 1.2 (Clearance of urea [Kt]/volume [V])

(ESRD, P-ESRD)1
3083F Kt/V equal to or greater than 1.2 and less than 1.7
(Clearance of urea [Kt]/volume [V]) (ESRD, P-ESRD)1
3084F Kt/V greater than or equal to 1.7 (Clearance of urea

[Kt]/volume [V]) (ESRD, P-ESRD)1
3085F Suicide risk assessed (MDD, MDD ADOL)1

3088F Major depressive disorder, mild (MDD)1

3089F Major depressive disorder, moderate (MDD)1

3090F Major depressive disorder, severe without psychotic

features (MDD)1
3091F Major depressive disorder, severe with psychotic features

(MDD)1
3092F Major depressive disorder, in remission (MDD)1

3093F Documentation of new diagnosis of initial or recurrent

episode of major depressive disorder (MDD)1
3095F Central dual-energy X-ray absorptiometry (DXA) results

documented (OP)5(IBD)10
3096F Central dual-energy X-ray absorptiometry (DXA) ordered

(OP)5(IBD)10
3100F Carotid imaging study report (includes direct or indirect

reference to measurements of distal internal carotid
diameter as the denominator for stenosis measurement)
(STR, RAD)5
3110F Documentation in final CT or MRI report of presence or
absence of hemorrhage and mass lesion and acute infarction
(STR)5
3111F CT or MRI of the brain performed in the hospital within 24

hours of arrival or performed in an outpatient imaging
center, to confirm initial diagnosis of stroke, TIA or
intracranial hemorrhage (STR)5
3112F CT or MRI of the brain performed greater than 24 hours

after arrival to the hospital or performed in an outpatient
imaging center for purpose other than confirmation of initial
diagnosis of stroke, TIA, or intracranial hemorrhage (STR)5
3115F Quantitative results of an evaluation of current level of

activity and clinical symptoms (HF)1
3117F Heart failure disease specific structured assessment tool

completed (HF)1
3118F New York Heart Association (NYHA) Class documented

(HF)1
3119F No evaluation of level of activity or clinical symptoms

(HF)1
3120F 12-Lead ECG Performed (EM)5

3126F Esophageal biopsy report with a statement about dysplasia
(present, absent, or indefinite, and if present, contains
appropriate grading) (PATH)9
3130F Upper gastrointestinal endoscopy performed (GERD)5

3132F Documentation of referral for upper gastrointestinal

endoscopy (GERD)5
3140F Upper gastrointestinal endoscopy report indicates suspicion

of Barrett’s esophagus (GERD)5
3141F Upper gastrointestinal endoscopy report indicates no

suspicion of Barrett’s esophagus (GERD)5
3142F Barium swallow test ordered (GERD)1

(To report documentation of barium swallow study, use

3142F)
3150F Forceps esophageal biopsy performed (GERD)5
3155F Cytogenetic testing performed on bone marrow at time of

diagnosis or prior to initiating treatment (HEM)1
3160F Documentation of iron stores prior to initiating

erythropoietin therapy (HEM)1
Baseline flow cytometry studies performed at time of

▲ 3170F diagnosis or prior to initiating treatment (HEM)1
3200F Barium swallow test not ordered (GERD)5

3210F Group A Strep Test Performed (PHAR)2

3215F Patient has documented immunity to Hepatitis A (HEP-C)1

3216F Patient has documented immunity to Hepatitis B (HEP-

C)1(IBD)10
3218F RNA testing for Hepatitis C documented as performed

within 6 months prior to initiation of antiviral treatment for
Hepatitis C (HEP-C)1
3220F Hepatitis C quantitative RNA testing documented as

performed at 12 weeks from initiation of antiviral treatment
(HEP-C)1
3230F Documentation that hearing test was performed within 6

months prior to tympanostomy tube insertion (OME)1
3250F Specimen site other than anatomic location of primary tumor

(PATH)1
3260F pT category (primary tumor), pN category (regional lymph

nodes), and histologic grade documented in pathology report
(PATH)1
3265F Ribonucleic acid (RNA) testing for Hepatitis C viremia
ordered or results documented (HEP C)1
3266F Hepatitis C genotype testing documented as performed prior

to initiation of antiviral treatment for Hepatitis C (HEP C)1
3267F Pathology report includes pT category, pN category,

Gleason score, and statement about margin status (PATH)9
3268F Prostate-specific antigen (PSA), and primary tumor (T)

stage, and Gleason score documented prior to initiation of
treatment (PRCA)1
3269F Bone scan performed prior to initiation of treatment or at

any time since diagnosis of prostate cancer (PRCA)1
3270F Bone scan not performed prior to initiation of treatment nor

at any time since diagnosis of prostate cancer (PRCA)1
3271F Low risk of recurrence, prostate cancer (PRCA)1

3272F Intermediate risk of recurrence, prostate cancer (PRCA)1

3273F High risk of recurrence, prostate cancer (PRCA)1

3274F Prostate cancer risk of recurrence not determined or neither

low, intermediate nor high (PRCA)1
3278F Serum levels of calcium, phosphorus, intact Parathyroid

Hormone (PTH) and lipid profile ordered (CKD)1
3279F Hemoglobin level greater than or equal to 13 g/dL (CKD,

ESRD)1
3280F Hemoglobin level 11 g/dL to 12.9 g/dL (CKD, ESRD)1

3281F Hemoglobin level less than 11 g/dL (CKD, ESRD)1

3284F Intraocular pressure (IOP) reduced by a value of greater

than or equal to 15% from the pre-intervention level (EC)5
3285F Intraocular pressure (IOP) reduced by a value less than 15%

from the pre-intervention level (EC)5
3288F Falls risk assessment documented (GER)5

3290F Patient is D (Rh) negative and unsensitized (Pre-Cr)1

3291F Patient is D (Rh) positive or sensitized (Pre-Cr)1

3292F HIV testing ordered or documented and reviewed during the

first or second prenatal visit (Pre-Cr)1
3293F ABO and Rh blood typing documented as performed (Pre-

Cr)7
3294F Group B Streptococcus (GBS) screening documented as

performed during week 35-37 gestation (Pre-Cr)7
3300F American Joint Committee on Cancer (AJCC) stage

documented and reviewed (ONC)1
3301F Cancer stage documented in medical record as metastatic

and reviewed (ONC)1
(To report measures for cancer staging, see 3321F-3390F)

3315F Estrogen receptor (ER) or progesterone receptor (PR)
positive breast cancer (ONC)1
3316F Estrogen receptor (ER) and progesterone receptor (PR)

negative breast cancer (ONC)1
3317F Pathology report confirming malignancy documented in the

medical record and reviewed prior to the initiation of
chemotherapy (ONC)1
3318F Pathology report confirming malignancy documented in the

medical record and reviewed prior to the initiation of
radiation therapy (ONC)1
3319F 1 of the following diagnostic imaging studies ordered: chest

x-ray, CT, Ultrasound, MRI, PET, or nuclear medicine scans
(ML)5
3320F None of the following diagnostic imaging studies ordered:

chest X-ray, CT, Ultrasound, MRI, PET, or nuclear medicine
scans (ML)5
3321F AJCC Cancer Stage 0 or IA Melanoma, documented (ML)5
3322F Melanoma greater than AJCC Stage 0 or IA (ML)5

3323F Clinical tumor, node and metastases (TNM) staging

documented and reviewed prior to surgery (Lung/Esop Cx)6
3324F MRI or CT scan ordered, reviewed or requested (EPI)8

3325F Preoperative assessment of functional or medical

indication(s) for surgery prior to the cataract surgery with
intraocular lens placement (must be performed within 12
months prior to cataract surgery) (EC)5
3328F Performance status documented and reviewed within 2

weeks prior to surgery (Lung/Esop Cx)6
3330F Imaging study ordered (BkP)2

3331F Imaging study not ordered (BkP)2

3340F Mammogram assessment category of “incomplete: need

additional imaging evaluation” documented (RAD)5
3341F Mammogram assessment category of “negative,”

documented (RAD)5
3342F Mammogram assessment category of “benign,” documented
(RAD)5
3343F Mammogram assessment category of “probably benign,”

documented (RAD)5
3344F Mammogram assessment category of “suspicious,”

documented (RAD)5
3345F Mammogram assessment category of “highly suggestive of

malignancy,” documented (RAD)5
3350F Mammogram assessment category of “known biopsy proven

malignancy,” documented (RAD)5
3351F Negative screen for depressive symptoms as categorized by

using a standardized depression screening/assessment tool
(MDD)2
3352F No significant depressive symptoms as categorized by using

a standardized depression assessment tool (MDD)2
3353F Mild to moderate depressive symptoms as categorized by

using a standardized depression screening/assessment tool
(MDD)2
3354F Clinically significant depressive symptoms as categorized

by using a standardized depression screening/assessment
tool (MDD)2
3370F AJCC Breast Cancer Stage 0 documented (ONC)1
3372F AJCC Breast Cancer Stage I: T1mic, T1a or T1b (tumor

size ≤ 1 cm) documented (ONC)1
3374F AJCC Breast Cancer Stage I: T1c (tumor size > 1 cm to 2

cm) documented (ONC)1
3376F AJCC Breast Cancer Stage II documented (ONC)1

3378F AJCC Breast Cancer Stage III documented (ONC)1

3380F AJCC Breast Cancer Stage IV documented (ONC)1

3382F AJCC colon cancer, Stage 0 documented (ONC)1

3384F AJCC colon cancer, Stage I documented (ONC)1

3386F AJCC colon cancer, Stage II documented (ONC)1

3388F AJCC colon cancer, Stage III documented (ONC)1

3390F AJCC colon cancer, Stage IV documented (ONC)1

3394F Quantitative HER2 immunohistochemistry (IHC) evaluation

of breast cancer consistent with the scoring system defined
in the ASCO/CAP guidelines (PATH)9
3395F Quantitative non-HER2 immunohistochemistry (IHC)
evaluation of breast cancer (eg, testing for estrogen or
progesterone receptors [ER/PR]) performed (PATH)9
3450F Dyspnea screened, no dyspnea or mild dyspnea (Pall Cr)5

3451F Dyspnea screened, moderate or severe dyspnea (Pall Cr)5

3452F Dyspnea not screened (Pall Cr)5

3455F TB screening performed and results interpreted within six

months prior to initiation of first-time biologic disease
modifying anti-rheumatic drug therapy for RA (RA)5
3470F Rheumatoid arthritis (RA) disease activity, low (RA)5

3471F Rheumatoid arthritis (RA) disease activity, moderate (RA)5

3472F Rheumatoid arthritis (RA) disease activity, high (RA)5

3475F Disease prognosis for rheumatoid arthritis assessed, poor

prognosis documented (RA)5
3476F Disease prognosis for rheumatoid arthritis assessed, good

prognosis documented (RA)5
3490F History of AIDS-defining condition (HIV)5

3491F HIV indeterminate (infants of undetermined HIV status born
of HIV-infected mothers) (HIV)5
3492F History of nadir CD4+ cell count <350 cells/mm3 (HIV)5

3493F No history of nadir CD4+ cell count <350 cells/mm3 and no

history of AIDS-defining condition (HIV)5
3494F CD4+ cell count <200 cells/mm3 (HIV)5

3495F CD4+ cell count 200 – 499 cells/mm3 (HIV)5

3496F CD4+ cell count ≥500 cells/mm3 (HIV)5

3497F CD4+ cell percentage <15% (HIV)5

3498F CD4+ cell percentage ≥15% (HIV)5

3500F CD4+ cell count or CD4+ cell percentage documented as

performed (HIV)5
3502F HIV RNA viral load below limits of quantification (HIV)5

3503F HIV RNA viral load not below limits of quantification

(HIV)5
3510F Documentation that tuberculosis (TB) screening test

performed and results interpreted (HIV)5 (IBD)10
3511F Chlamydia and gonorrhea screenings documented as
performed (HIV)5
3512F Syphilis screening documented as performed (HIV)5

3513F Hepatitis B screening documented as performed (HIV)5

3514F Hepatitis C screening documented as performed (HIV)5

3515F Patient has documented immunity to Hepatitis C (HIV)5

3517F Hepatitis B Virus (HBV) status assessed and results

interpreted within one year prior to receiving a first course
of anti-TNF (tumor necrosis factor) therapy (IBD)10
3520F Clostridium difficile testing performed (IBD)10

3550F Low risk for thromboembolism (AFIB)1

3551F Intermediate risk for thromboembolism (AFIB)1

3552F High risk for thromboembolism (AFIB)1

3555F Patient had International Normalized Ratio (INR)

measurement performed (AFIB)1
3570F Final report for bone scintigraphy study includes correlation

with existing relevant imaging studies (eg, X ray, MRI, CT)
corresponding to the same anatomical region in question
(NUC_MED)1
3572F Patient considered to be potentially at risk for fracture in a

weight-bearing site (NUC_MED)1
3573F Patient not considered to be potentially at risk for fracture in

a weight-bearing site (NUC_MED)1
3650F Electroencephalogram (EEG) ordered, reviewed or

requested (EPI)8
3700F Psychiatric disorders or disturbances assessed (Prkns)8

3720F Cognitive impairment or dysfunction assessed (Prkns)8

3725F Screening for depression performed (DEM)1

3750F Patient not receiving dose of corticosteroids greater than or

equal to 10mg/day for 60 or greater consecutive days
(IBD)10
3751F Electrodiagnostic studies for distal symmetric

polyneuropathy conducted (or requested), documented, and
reviewed within 6 months of initial evaluation for condition
(DSP)8
3752F Electrodiagnostic studies for distal symmetric

polyneuropathy not conducted (or requested), documented,
or reviewed within 6 months of initial evaluation for
condition (DSP)8
3753F Patient has clear clinical symptoms and signs that are highly
suggestive of neuropathy AND cannot be attributed to
another condition, AND has an obvious cause for the
neuropathy (DSP)8
3754F Screening tests for diabetes mellitus reviewed, requested, or

ordered (DSP)8
3755F Cognitive and behavioral impairment screening performed

(ALS)8
3756F Patient has pseudobulbar affect, sialorrhea, or ALS-related

symptoms (ALS)8
3757F Patient does not have pseudobulbar affect, sialorrhea, or

ALS-related symptoms (ALS)8
3758F Patient referred for pulmonary function testing or peak cough

expiratory flow (ALS)8
3759F Patient screened for dysphagia, weight loss, and impaired

nutrition, and results documented (ALS)8
3760F Patient exhibits dysphagia, weight loss, or impaired

nutrition (ALS)8
3761F Patient does not exhibit dysphagia, weight loss, or impaired
nutrition (ALS)8
3762F Patient is dysarthric (ALS)8

3763F Patient is not dysarthric (ALS)8

3775F Adenoma(s) or other neoplasm detected during screening

colonoscopy (SCADR)
3776F Adenoma(s) or other neoplasm not detected during

screening colonoscopy (SCADR)
Therapeutic, Preventive, or Other

Interventions
Therapeutic, preventive, or other interventions codes describe
pharmacologic, procedural, or behavioral therapies, including
preventive services such as patient education and counseling.
4000F Tobacco use cessation intervention, counseling (COPD,
CAP, CAD, Asthma)1 (DM)4 (PV)2
4001F Tobacco use cessation intervention, pharmacologic therapy

(COPD, CAD, CAP, PV, Asthma)1 (DM)4 (PV)2
4003F Patient education, written/oral, appropriate for patients with

heart failure, performed (NMA–No Measure Associated)1
4004F Patient screened for tobacco use and received tobacco

cessation intervention (counseling, pharmacotherapy, or
both), if identified as a tobacco user (PV, CAD)1
4005F Pharmacologic therapy (other than minerals/vitamins) for

osteoporosis prescribed (OP)5 (IBD)10
4008F Beta-blocker therapy prescribed or currently being taken

(CAD,HF)1
4010F Angiotensin Converting Enzyme (ACE) Inhibitor or

Angiotensin Receptor Blocker (ARB) therapy prescribed or
currently being taken (CAD, CKD, HF)1 (DM)2
4011F Oral antiplatelet therapy prescribed (CAD)1

4012F Warfarin therapy prescribed (NMA–No Measure

Associated)
4013F Statin therapy prescribed or currently being taken (CAD)1

4014F Written discharge instructions provided to heart failure

patients discharged home (Instructions include all of the
following components: activity level, diet, discharge
medications, follow-up appointment, weight monitoring,
what to do if symptoms worsen) (NMA–No Measure
Associated)
4015F Persistent asthma, preferred long term control medication or

an acceptable alternative treatment, prescribed (NMA–No
Measure Associated)
(Note: There are no medical exclusion criteria)

(Do not report modifier 1P with 4015F)
(To report patient reasons for not prescribing, use modifier
2P)
4016F Anti-inflammatory/analgesic agent prescribed (OA)1
(Use for prescribed or continued medication[s], including
over-the-counter medication[s])
4017F Gastrointestinal prophylaxis for NSAID use prescribed

(OA)1
4018F Therapeutic exercise for the involved joint(s) instructed or

physical or occupational therapy prescribed (OA)1
4019F Documentation of receipt of counseling on exercise and

either both calcium and vitamin D use or counseling
regarding both calcium and vitamin D use (OP)5
4025F Inhaled bronchodilator prescribed (COPD)1

4030F Long-term oxygen therapy prescribed (more than 15 hours
per day) (COPD)1
4033F Pulmonary rehabilitation exercise training recommended

(COPD)1
(Report 4033F with 1019F)

4035F Influenza immunization recommended (COPD)1 (IBD)10
4037F Influenza immunization ordered or administered (COPD, PV,

CKD, ESRD)1(IBD)10
4040F Pneumococcal vaccine administered or previously received

(COPD)1 (PV)1,2 (IBD)10
4041F Documentation of order for cefazolin OR cefuroxime for

antimicrobial prophylaxis (PERI 2)5
4042F Documentation that prophylactic antibiotics were neither

given within 4 hours prior to surgical incision nor given
intraoperatively (PERI 2)5
4043F Documentation that an order was given to discontinue

prophylactic antibiotics within 48 hours of surgical end
time, cardiac procedures (PERI 2)5
4044F Documentation that an order was given for venous

thromboembolism (VTE) prophylaxis to be given within 24
hours prior to incision time or 24 hours after surgery end
time (PERI 2)5
4045F Appropriate empiric antibiotic prescribed (CAP)1, (EM)5
4046F Documentation that prophylactic antibiotics were given

within 4 hours prior to surgical incision or given
intraoperatively (PERI 2)5
4047F Documentation of order for prophylactic parenteral

antibiotics to be given within 1 hour (if fluoroquinolone or
vancomycin, 2 hours) prior to surgical incision (or start of
procedure when no incision is required) (PERI 2)5
4048F Documentation that administration of prophylactic

parenteral antibiotic was initiated within 1 hour (if
fluoroquinolone or vancomycin, 2 hours) prior to surgical
incision (or start of procedure when no incision is required)
as ordered (PERI 2)5
4049F Documentation that order was given to discontinue

prophylactic antibiotics within 24 hours of surgical end
time, non-cardiac procedure (PERI 2)5
4050F Hypertension plan of care documented as appropriate

(NMA–No Measure Associated)1
4051F Referred for an arteriovenous (AV) fistula (ESRD, CKD)1

4052F Hemodialysis via functioning arteriovenous (AV) fistula

(ESRD)1
4053F Hemodialysis via functioning arteriovenous (AV) graft
(ESRD)1
4054F Hemodialysis via catheter (ESRD)1

4055F Patient receiving peritoneal dialysis (ESRD)1

4056F Appropriate oral rehydration solution recommended (PAG)1

4058F Pediatric gastroenteritis education provided to caregiver

(PAG)1
4060F Psychotherapy services provided (MDD, MDD ADOL)1

4062F Patient referral for psychotherapy documented (MDD, MDD

ADOL)1
4063F Antidepressant pharmacotherapy considered and not

prescribed (MDD ADOL)1
4064F Antidepressant pharmacotherapy prescribed (MDD, MDD

ADOL)1
4065F Antipsychotic pharmacotherapy prescribed (MDD)1

4066F Electroconvulsive therapy (ECT) provided (MDD)1

4067F Patient referral for electroconvulsive therapy (ECT)

documented (MDD)1
4069F Venous thromboembolism (VTE) prophylaxis received

(IBD)10
4070F Deep vein thrombosis (DVT) prophylaxis received by end

of hospital day 2 (STR)5
4073F Oral antiplatelet therapy prescribed at discharge (STR)5

4075F Anticoagulant therapy prescribed at discharge (STR)5

4077F Documentation that tissue plasminogen activator (t-PA)

administration was considered (STR)5
4079F Documentation that rehabilitation services were considered

(STR)5
4084F Aspirin received within 24 hours before emergency

department arrival or during emergency department stay
(EM)5
4086F Aspirin or clopidogrel prescribed or currently being taken

(CAD)1
4090F Patient receiving erythropoietin therapy (HEM)1

4095F Patient not receiving erythropoietin therapy (HEM)1

Bisphosphonate therapy, intravenous, ordered or received
4100F
(HEM)1
4110F Internal mammary artery graft performed for primary,

isolated coronary artery bypass graft procedure (CABG)6
4115F Beta blocker administered within 24 hours prior to surgical

incision (CABG)6
4120F Antibiotic prescribed or dispensed (URI, PHAR)2, (A-

BRONCH)2
4124F Antibiotic neither prescribed nor dispensed (URI, PHAR)2,

(A-BRONCH)2
4130F Topical preparations (including OTC) prescribed for acute

otitis externa (AOE)1
4131F Systemic antimicrobial therapy prescribed (AOE)1

4132F Systemic antimicrobial therapy not prescribed (AOE)1

4133F Antihistamines or decongestants prescribed or

recommended (OME)1
4134F Antihistamines or decongestants neither prescribed nor

recommended (OME)1
Systemic corticosteroids prescribed (OME)1

4135F ➲ CPT Changes: An Insider’s View 2009
4136F Systemic corticosteroids not prescribed (OME)1
4140F Inhaled corticosteroids prescribed (Asthma)1

4142F Corticosteroid sparing therapy prescribed (IBD)10

4144F Alternative long-term control medication prescribed

(Asthma)1
4145F Two or more anti-hypertensive agents prescribed or

currently being taken (CAD, HTN)1
4148F Hepatitis A vaccine injection administered or previously

received (HEP-C)1
4149F Hepatitis B vaccine injection administered or previously

received (HEP-C, HIV)1 (IBD)10
4150F Patient receiving antiviral treatment for Hepatitis C (HEP-

C)1
4151F Patient did not start or is not receiving antiviral treatment

for Hepatitis C during the measurement period (HEP-C)1
4153F Combination peginterferon and ribavirin therapy prescribed

(HEP-C)1
4155F Hepatitis A vaccine series previously received (HEP-C)1
4157F Hepatitis B vaccine series previously received (HEP-C)1

4158F Patient counseled about risks of alcohol use (HEP-C)1

4159F Counseling regarding contraception received prior to

initiation of antiviral treatment (HEP-C)1
4163F Patient counseling at a minimum on all of the following

treatment options for clinically localized prostate cancer:
active surveillance, and interstitial prostate brachytherapy,
and external beam radiotherapy, and radical prostatectomy,
provided prior to initiation of treatment (PRCA)1
4164F Adjuvant (ie, in combination with external beam

radiotherapy to the prostate for prostate cancer) hormonal
therapy (gonadotropin-releasing hormone [GnRH] agonist or
antagonist) prescribed/administered (PRCA)1
4165F 3-dimensional conformal radiotherapy (3D-CRT) or

intensity modulated radiation therapy (IMRT) received
(PRCA)1
4167F Head of bed elevation (30-45 degrees) on first ventilator

day ordered (CRIT)1
4168F Patient receiving care in the intensive care unit (ICU) and
receiving mechanical ventilation, 24 hours or less (CRIT)1
4169F Patient either not receiving care in the intensive care unit
(ICU) OR not receiving mechanical ventilation OR
receiving mechanical ventilation greater than 24 hours
(CRIT)1
4171F Patient receiving erythropoiesis-stimulating agents (ESA)

therapy (CKD)1
4172F Patient not receiving erythropoiesis-stimulating agents

(ESA) therapy (CKD)1
4174F Counseling about the potential impact of glaucoma on visual

functioning and quality of life, and importance of treatment
adherence provided to patient and/or caregiver(s) (EC)5
4175F Best-corrected visual acuity of 20/40 or better (distance or

near) achieved within the 90 days following cataract surgery
(EC)5
4176F Counseling about value of protection from UV light and lack

of proven efficacy of nutritional supplements in prevention
or progression of cataract development provided to patient
and/or caregiver(s) (NMA–No Measure Associated)
4177F Counseling about the benefits and/or risks of the Age-

Related Eye Disease Study (AREDS) formulation for
preventing progression of age-related macular degeneration
(AMD) provided to patient and/or caregiver(s) (EC)5
4178F Anti-D immune globulin received between 26 and 30 weeks

gestation (Pre-Cr)1
4179F Tamoxifen or aromatase inhibitor (AI) prescribed (ONC)1
4180F Adjuvant chemotherapy referred, prescribed, or previously

received for Stage III colon cancer (ONC)1
4181F Conformal radiation therapy received (NMA–No Measure

Associated)
4182F Conformal radiation therapy not received (NMA–No

Measure Associated)
4185F Continuous (12-months) therapy with proton pump inhibitor

(PPI) or histamine H2 receptor antagonist (H2RA) received
(GERD)5
4186F No continuous (12-months) therapy with either proton pump

inhibitor (PPI) or histamine H2 receptor antagonist (H2RA)
received (GERD)5
4187F Disease modifying anti-rheumatic drug therapy prescribed

or dispensed (RA)2
4188F Appropriate angiotensin converting enzyme

(ACE)/angiotensin receptor blockers (ARB) therapeutic
monitoring test ordered or performed (AM)2
4189F Appropriate digoxin therapeutic monitoring test ordered or

performed (AM)2
Appropriate diuretic therapeutic monitoring test ordered or
4190F
performed (AM)2
4191F Appropriate anticonvulsant therapeutic monitoring test

ordered or performed (AM)2
4192F Patient not receiving glucocorticoid therapy (RA)5

4193F Patient receiving <10 mg daily prednisone (or equivalent),

or RA activity is worsening, or glucocorticoid use is for
less than 6 months (RA)5
4194F Patient receiving ≥10 mg daily prednisone (or equivalent)

for longer than 6 months, and improvement or no change in
disease activity (RA)5
4195F Patient receiving first-time biologic disease modifying anti-

rheumatic drug therapy for rheumatoid arthritis (RA)5
4196F Patient not receiving first-time biologic disease modifying

anti-rheumatic drug therapy for rheumatoid arthritis (RA)5
4200F External beam radiotherapy as primary therapy to prostate

with or without nodal irradiation (PRCA)1
4201F External beam radiotherapy with or without nodal

irradiation as adjuvant or salvage therapy for prostate
cancer patient (PRCA)1
Angiotensin converting enzyme (ACE) or angiotensin

4210F receptor blockers (ARB) medication therapy for 6 months or
more (MM)2
4220F Digoxin medication therapy for 6 months or more (MM)2

4221F Diuretic medication therapy for 6 months or more (MM)2

4230F Anticonvulsant medication therapy for 6 months or more

(MM)2
4240F Instruction in therapeutic exercise with follow-up provided

to patients during episode of back pain lasting longer than
12 weeks (BkP)2
4242F Counseling for supervised exercise program provided to

patients during episode of back pain lasting longer than 12
weeks (BkP)2
4245F Patient counseled during the initial visit to maintain or

resume normal activities (BkP)2
4248F Patient counseled during the initial visit for an episode of

back pain against bed rest lasting 4 days or longer (BkP)2
4250F Active warming used intraoperatively for the purpose of

maintaining normothermia, or at least 1 body temperature
equal to or greater than 36 degrees Centigrade (or 96.8
degrees Fahrenheit) recorded within the 30 minutes
immediately before or the 15 minutes immediately after
anesthesia end time (CRIT)1
4255F Duration of general or neuraxial anesthesia 60 minutes or
longer, as documented in the anesthesia record (CRIT)5
(Peri2)11
4256F Duration of general or neuraxial anesthesia less than 60

minutes, as documented in the anesthesia record (CRIT)5
(Peri2)11
4260F Wound surface culture technique used (CWC)5

4261F Technique other than surface culture of the wound exudate

used (eg, Levine/deep swab technique, semi-quantitative or
quantitative swab technique) or wound surface culture
technique not used (CWC)5
4265F Use of wet to dry dressings prescribed or recommended

(CWC)5
4266F Use of wet to dry dressings neither prescribed nor

recommended (CWC)5
4267F Compression therapy prescribed (CWC)5

4268F Patient education regarding the need for long term

compression therapy including interval replacement of
compression stockings received (CWC)5
4269F Appropriate method of offloading (pressure relief)

prescribed (CWC)5
4270F Patient receiving potent antiretroviral therapy for 6 months
or longer (HIV)5
4271F Patient receiving potent antiretroviral therapy for less than 6

months or not receiving potent antiretroviral therapy (HIV)5
4274F Influenza immunization administered or previously received

(HIV)5 (P-ESRD)1
4276F Potent antiretroviral therapy prescribed (HIV)5

4279F Pneumocystis jiroveci pneumonia prophylaxis prescribed

(HIV)5
4280F Pneumocystis jiroveci pneumonia prophylaxis prescribed

within 3 months of low CD4+ cell count or percentage
(HIV)5
4290F Patient screened for injection drug use (HIV)5

4293F Patient screened for high-risk sexual behavior (HIV)5

4300F Patient receiving warfarin therapy for nonvalvular atrial

fibrillation or atrial flutter (AFIB)1
4301F Patient not receiving warfarin therapy for nonvalvular atrial

fibrillation or atrial flutter (AFIB)1
4305F Patient education regarding appropriate foot care and daily
inspection of the feet received (CWC)5
4306F Patient counseled regarding psychosocial and

pharmacologic treatment options for opioid addiction
(SUD)1
4320F Patient counseled regarding psychosocial and

pharmacologic treatment options for alcohol dependence
(SUD)5
4322F Caregiver provided with education and referred to

additional resources for support (DEM)1
4324F Patient (or caregiver) queried about Parkinson’s disease

medication related motor complications (Prkns)8
4325F Medical and surgical treatment options reviewed with

patient (or caregiver) (Prkns)8
4326F Patient (or caregiver) queried about symptoms of autonomic

dysfunction (Prkns)8
4328F Patient (or caregiver) queried about sleep disturbances

(Prkns)8
4330F Counseling about epilepsy specific safety issues provided to

patient (or caregiver(s)) (EPI)8
Counseling for women of childbearing potential with

4340F epilepsy (EPI)8
4350F Counseling provided on symptom management, end of life

decisions, and palliation (DEM)1
4400F Rehabilitative therapy options discussed with patient (or

caregiver) (Prkns)8
4450F Self-care education provided to patient (HF)1

4470F Implantable cardioverter-defibrillator (ICD) counseling

provided (HF)1
4480F Patient receiving ACE inhibitor/ARB therapy and beta-

blocker therapy for 3 months or longer (HF)1
4481F Patient receiving ACE inhibitor/ARB therapy and beta-

blocker therapy for less than 3 months or patient not
receiving ACE inhibitor/ARB therapy and beta-blocker
therapy (HF)1
4500F Referred to an outpatient cardiac rehabilitation program

(CAD)1
4510F Previous cardiac rehabilitation for qualifying cardiac event

completed (CAD)1
4525F Neuropsychiatric intervention ordered (DEM)1

4526F Neuropsychiatric intervention received (DEM)1
4540F Disease modifying pharmacotherapy discussed (ALS)8

4541F Patient offered treatment for pseudobulbar affect, sialorrhea,

or ALS-related symptoms (ALS)8
4550F Options for noninvasive respiratory support discussed with

patient (ALS)8
4551F Nutritional support offered (ALS)8

4552F Patient offered referral to a speech language pathologist

(ALS)8
4553F Patient offered assistance in planning for end of life issues

(ALS)8
4554F Patient received inhalational anesthetic agent (Peri2)11

4555F Patient did not receive inhalational anesthetic agent

(Peri2)11
4556F Patient exhibits 3 or more risk factors for post-operative

nausea and vomiting (Peri2)11
4557F Patient does not exhibit 3 or more risk factors for post-
operative nausea and vomiting (Peri2)11
Patient received at least 2 prophylactic pharmacologic anti-
4558F
emetic agents of different classes preoperatively and
intraoperatively (Peri2)11
4559F At least 1 body temperature measurement equal to or greater

than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit)
recorded within the 30 minutes immediately before or the 15
minutes immediately after anesthesia end time (Peri2)11
4560F Anesthesia technique did not involve general or neuraxial

anesthesia (Peri2)11
4561F Patient has a coronary artery stent (Peri2)11

4562F Patient does not have a coronary artery stent (Peri2)11

4563F Patient received aspirin within 24 hours prior to anesthesia

start time (Peri2)11

Follow-up or other outcomes codes describe review and
communication of test results to patients, patient satisfaction or
experience with care, patient functional status, and patient
morbidity and mortality.
5005F Patient counseled on self-examination for new or changing
moles (ML)5
Findings of dilated macular or fundus exam communicated

5010F to the physician or other qualified health care professional
managing the diabetes care (EC)5
5015F Documentation of communication that a fracture occurred

and that the patient was or should be tested or treated for
osteoporosis (OP)5
5020F Treatment summary report communicated to physician(s) or

other qualified health care professional(s) managing
continuing care and to the patient within 1 month of
completing treatment (ONC)1
5050F Treatment plan communicated to provider(s) managing

continuing care within 1 month of diagnosis (ML)5
5060F Findings from diagnostic mammogram communicated to

practice managing patient’s on-going care within 3 business
days of exam interpretation (RAD)5
5062F Findings from diagnostic mammogram communicated to the

patient within 5 days of exam interpretation (RAD)5
5100F Potential risk for fracture communicated to the referring

physician or other qualified health care professional within
24 hours of completion of the imaging study (NUC_MED)1
5200F Consideration of referral for a neurological evaluation of

appropriateness for surgical therapy for intractable epilepsy
within the past 3 years (EPI)8
5250F Asthma discharge plan provided to patient (Asthma)1
Patient Safety
Patient safety codes that describe patient safety practices.
6005F Rationale (eg, severity of illness and safety) for level of
care (eg, home, hospital) documented (CAP)1
6010F Dysphagia screening conducted prior to order for or receipt

of any foods, fluids, or medication by mouth (STR)5
6015F Patient receiving or eligible to receive foods, fluids, or

medication by mouth (STR)5
6020F NPO (nothing by mouth) ordered (STR)5

6030F All elements of maximal sterile barrier technique, hand

hygiene, skin preparation and, if ultrasound is used, sterile
ultrasound techniques followed (CRIT)1
6040F Use of appropriate radiation dose reduction devices OR

manual techniques for appropriate moderation of exposure,
documented (RAD)5
6045F Radiation exposure or exposure time in final report for

procedure using fluoroscopy, documented (RAD)5
11:2, 9-10, Summer 11:2, Fall 11:2-3, Winter 11:2,
Spring 13:2, 3, 6, Summer 13:2, 3, 5, 6, Spring 14:7, Fall
14:6
6070F Patient queried and counseled about anti-epileptic drug
(AED) side effects (EPI)8
6080F Patient (or caregiver) queried about falls (Prkns, DSP)8

6090F Patient (or caregiver) counseled about safety issues

appropriate to patient’s stage of disease (Prkns)8
6100F Timeout to verify correct patient, correct site, and correct

procedure, documented (PATH)9
6101F Safety counseling for dementia provided (DEM)1

6102F Safety counseling for dementia ordered (DEM)1

6110F Counseling provided regarding risks of driving and the

alternatives to driving (DEM)1
6150F Patient not receiving a first course of anti-TNF (tumor

necrosis factor) therapy (IBD)10
Structural Measures
Structural measures codes are used to identify measures that
address the setting or system of the delivered care. These codes
also address aspects of the capabilities of the organization or
health care professional providing the care.
7010F Patient information entered into a recall system that
includes: target date for the next exam specified and a
process to follow up with patients regarding missed or
unscheduled appointments (ML)5
7020F Mammogram assessment category (eg, Mammography

Quality Standards Act [MQSA], Breast Imaging Reporting
and Data System [BI-RADS®], or FDA approved equivalent
categories) entered into an internal database to allow for
analysis of abnormal interpretation (recall) rate (RAD)5
7025F Patient information entered into a reminder system with a

target due date for the next mammogram (RAD)5
Nonmeasure Code Listing

The following codes are included for reporting of certain aspects
of care. These factors are not represented by measures developed
by existing measures organizations or recognized measures-
development processes at the time they are placed in the CPT
code set, but may ultimately be associated with measures
approved by an appropriate quality improvement organization.
9001F Aortic aneurysm less than 5.0 cm maximum diameter on
centerline formatted CT or minor diameter on axial
formatted CT (NMA–No Measure Associated)
9002F Aortic aneurysm 5.0 - 5.4 cm maximum diameter on
9003F Aortic aneurysm 5.5 - 5.9 cm maximum diameter on

9004F Aortic aneurysm 6.0 cm or greater maximum diameter on

9005F Asymptomatic carotid stenosis: No history of any transient

ischemic attack or stroke in any carotid or vertebrobasilar
territory (NMA–No Measure Associated)
9006F Symptomatic carotid stenosis: Ipsilateral carotid territory

TIA or stroke less than 120 days prior to procedure (NMA–
No Measure Associated)
9007F Other carotid stenosis: Ipsilateral TIA or stroke 120 days or

greater prior to procedure or any prior contralateral carotid
territory or vertebrobasilar TIA or stroke (NMA–No
Measure Associated)

Category III Codes
The following section contains a set of temporary codes for
emerging technology, services, procedures, and service
paradigms. Category III codes allow data collection for these
services/procedures. Use of unlisted codes does not offer the
opportunity for the collection of specific data. If a Category III
code is available, this code must be reported instead of a
Category I unlisted code. This is an activity that is critically
important in the evaluation of health care delivery and the
formation of public and private policy. The use of the codes in
this section allows physicians and other qualified health care
professionals, insurers, health services researchers, and health
policy experts to identify emerging technology, services,
procedures, and service paradigms for clinical efficacy, utilization
and outcomes.
The inclusion of a service or procedure in this section does not
constitute a finding of support, or lack thereof, with regard to
clinical efficacy, safety, applicability to clinical practice, or payer
coverage. The codes in this section may not conform to the usual
requirements for CPT Category I codes established by the
Editorial Panel. For Category I codes, the Panel requires that the
service/procedure be performed by many health care
professionals in clinical practice in multiple locations and that
FDA approval, as appropriate, has already been received. The
nature of emerging technology, services, procedures, and service
paradigms is such that these requirements may not be met. For
these reasons, temporary codes for emerging technology,
services, procedures, and service paradigms have been placed in
a separate section of the CPT code set and the codes are
differentiated from Category I CPT codes by the use of
alphanumeric characters.
▶Services and procedures described in this section make use of
alphanumeric characters. These codes have an alpha character as
the 5th character in the string (ie, four digits followed by the
letter T). The digits are not intended to reflect the placement of
the code in the Category I section of CPT nomenclature. Codes in
this section may or may not eventually receive a Category I CPT
code. In either case, in general, a given Category III code will be
archived five years from the date of initial publication or
extension unless a modification of the archival date is specifically
noted at the time of a revision or change to a code (eg, addition
of parenthetical instructions, reinstatement). Services and
procedures described by Category III codes which have been
archived after five years, without conversion, must be reported
using the Category I unlisted code unless another specific cross-
reference is established at the time of archiving. New codes or
revised codes in this section are released semi-annually via the
AMA CPT website to expedite dissemination for reporting.
Codes approved for deletion are published annually with the full
set of temporary codes for emerging technology, services,
procedures, and service paradigms in the CPT code set. See the
Introduction section of the CPT code set for a complete list of the
dates of release and implementation.◀
(For destruction of localized lesion of choroid by
transpupillary thermotherapy, use 67299)
(For destruction of macular drusen, photocoagulation, use
67299)
(For extracorporeal shock wave involving musculoskeletal
system, not otherwise specified, low energy, use 20999)
(For application of high energy extracorporeal shock wave
involving musculoskeletal system not otherwise specified,
use 0101T)
(For application of high energy extracorporeal shock wave
involving lateral humeral epicondyle, use 0102T)
(For non-surgical septal reduction therapy, use 93799)
(For lipoprotein, direct measurement, intermediate density
lipoproteins [IDL] [remnant lipoprotein], use 84999)
(For endoscopic lysis of epidural adhesions with direct
visualization using mechanical means or solution injection
[eg, normal saline], use 64999)
(For dual energy x-ray absorptiometry [DXA] body
composition study, use 76499)
(For pulsed magnetic neuromodulation incontinence
treatment, use 53899)
(To report antiprothrombin [phospholipid cofactor]
antibody, use 86849)
(0031T, 0032T have been deleted)
(For speculoscopy, including sampling, use 58999)
(For urinalysis infectious agent detection, semi-quantitative
analysis of volatile compounds, use 81099)
0042T Cerebral perfusion analysis using computed tomography
with contrast administration, including post-processing of
parametric maps with determination of cerebral blood flow,
cerebral blood volume, and mean transit time
Sunset January 2024
(For carbon monoxide, expired gas analysis [eg,
ETCOc/hemolysis breath test], use 84999)
(For mammary duct[s] catheter lavage, use 19499)
(0051T, 0052T, 0053T have been deleted. To report, see
33927, 33928, 33929)
✚ 0054T Computer-assisted musculoskeletal surgical navigational
orthopedic procedure, with image-guidance based on
fluoroscopic images (List separately in addition to code for
primary procedure)
Sunset January 2024
✚ 0055T Computer-assisted musculoskeletal surgical navigational
orthopedic procedure, with image-guidance based on
CT/MRI images (List separately in addition to code for
primary procedure)
Sunset January 2024
(When CT and MRI are both performed, report 0055T only
once)
▶ (0058T has been deleted)◀
▶ (Forcryopreservation, reproductive tissue, ovarian, use
89398)◀
(For cryopreservation of mature oocyte(s), use 89337)
(0357T has been deleted)
(For cryopreservation of immature oocyte[s], use 89398)
(For cryopreservation of embryo(s), sperm and testicular
reproductive tissue, see 89258, 89259, 89335)
(For electrical impedance breast scan, use 76499)
(For destruction/reduction of malignant breast tumor,
microwave phased array thermotherapy, use 19499)
(For percutaneous intradiscal annuloplasty, any method
other than electrothermal, use 22899)
(For intradiscal electrothermal annuloplasty, see 22526,
22527)
(To report CT colon, screening, use 74263)
(To report CT colon, diagnostic, see 74261-74262)
(0068T-0070T have been deleted)
(For acoustic heart sound recording and computer analysis,
use 93799)
0071T Focused ultrasound ablation of uterine leiomyomata,
including MR guidance; total leiomyomata volume less than
200 cc of tissue
Sunset January 2025
0072T total leiomyomata volume greater or equal to 200 cc of
tissue
Sunset January 2025
(Do not report 0071T, 0072T in conjunction with 51702 or
77022)
0075T Transcatheter placement of extracranial vertebral artery
stent(s), including radiologic supervision and interpretation,
open or percutaneous; initial vessel
Sunset January 2025
✚ 0076T each additional vessel (List separately in addition to
Sunset January 2025
(Use 0076T in conjunction with 0075T)
(When the ipsilateral extracranial vertebral arteriogram
(including imaging and selective catheterization) confirms
the need for stenting, then 0075T and 0076T include all
ipsilateral extracranial vertebral catheterization, all
diagnostic imaging for ipsilateral extracranial vertebral
artery stenting, and all related radiologic supervision and
interpretation. If stenting is not indicated, then the
appropriate codes for selective catheterization and imaging
should be reported in lieu of 0075T or 0076T)
▶ (For breath test for heart transplant rejection, use 84999)◀
(To report total disc lumbar arthroplasty, use 22857)
✚ 0095T Removal of total disc arthroplasty (artificial disc), anterior
approach, each additional interspace, cervical (List
Sunset January 2024
(Use 0095T in conjunction with 22864)
(To report revision of total disc lumbar arthroplasty, use
22862)
✚ 0098T Revision including replacement of total disc arthroplasty
(artificial disc), anterior approach, each additional
interspace, cervical (List separately in addition to code for
primary procedure)
Sunset January 2024
(Do not report 0098T in conjunction with 0095T)
(Do not report 0098T in conjunction with 22853, 22854,
22859 when performed at the same level)
0100T Placement of a subconjunctival retinal prosthesis receiver
and pulse generator, and implantation of intraocular retinal
electrode array, with vitrectomy
Sunset January 2026
➲ CPT Assistant Jun 05:6, Feb 06:1, Jun 11:13, Feb 18:3
(For initial programming of implantable intraocular retinal
electrode array device, use 0472T)
0101T Extracorporeal shock wave involving musculoskeletal
system, not otherwise specified, high energy
Sunset January 2026
➲ CPT Assistant Jun 05:6, Mar 06:1, Jun 11:13, Dec 18:5
integumentary system not otherwise specified, see 0512T,
0513T)
(Do not report 0101T in conjunction 0512T, 0513T, when
treating same area)
0102T Extracorporeal shock wave, high energy, performed by a
physician, requiring anesthesia other than local, involving
lateral humeral epicondyle
Sunset January 2026
➲ CPT Assistant Jun 05:6, Mar 06:1, Jun 11:13, Dec 18:5,
Jun 19:11
# 0512T Extracorporeal shock wave for integumentary wound
healing, high energy, including topical application and
dressing care; initial wound
Sunset January 2024
#✚ 0513T each additional wound (List separately in addition to
Sunset January 2024
(For holotranscobalamin, quantitative, use 84999)
(For inert gas rebreathing for cardiac output measurement
during rest, use 93799)
(For inert gas rebreathing for cardiac output measurement
during exercise, use 93799)
0106T Quantitative sensory testing (QST), testing and interpretation
per extremity; using touch pressure stimuli to assess large
diameter sensation
Sunset January 2026
➲ CPT Assistant Jun 05:6, Mar 06:1, May 11:10, Jun 11:13
0107T using vibration stimuli to assess large diameter fiber
sensation
Sunset January 2026
➲ CPT Assistant Jun 05:6, Mar 06:1, May 11:10, Jun
11:13
0108T using cooling stimuli to assess small nerve fiber
sensation and hyperalgesia
Sunset January 2026
11:13
0109T using heat-pain stimuli to assess small nerve fiber
sensation and hyperalgesia
Sunset January 2026
11:13
0110T using other stimuli to assess sensation
Sunset January 2026
11:13
(For very long chain fatty acids, use 82726)
▶ (For long-chain [C20-22] omega-3 fatty acids in red blood
cell [RBC] membranes, use 84999)◀
(For fistulization of sclera for glaucoma, through ciliary
body, use 66999)
(For conjunctival incision with posterior extrascleral
placement of pharmacological agent, use 68399)
▶ (For common carotid intima-media thickness [IMT] study
for evaluation of atherosclerotic burden or coronary heart
disease risk factor assessment, use 93998)◀
(For bilateral quantitative carotid intima media thickness
and carotid atheroma evaluation that includes all required
elements, use 93895)
(For validated, statistically reliable, randomized,
controlled, single-patient clinical investigation of FDA
approved chronic care drugs, provided by a pharmacist,
interpretation and report to the prescribing health care
professional, use 99199)
(0144T-0151T have been deleted. To report, see 75571-
75574)
(For laparoscopic implantation, replacement, revision, or
removal of gastric stimulation electrodes, lesser curvature,
use 43659)
(For open implantation, replacement, revision, or removal
of gastric stimulation electrodes, lesser curvature, use
43999)
(0159T has been deleted. To report, see 77048, 77049)
✚ 0163T Total disc arthroplasty (artificial disc), anterior approach,
including discectomy to prepare interspace (other than for
decompression), each additional interspace, lumbar (List
Sunset January 2024
✚ 0164T Removal of total disc arthroplasty, (artificial disc), anterior
approach, each additional interspace, lumbar (List
Sunset January 2024
✚ 0165T Revision including replacement of total disc arthroplasty
(artificial disc), anterior approach, each additional
interspace, lumbar (List separately in addition to code for
primary procedure)
Sunset January 2024
(Do not report 0163T, 0164T, 0165T in conjunction with
level)
(For transmyocardial transcatheter closure of ventricular
septal defect, with implant, including cardiopulmonary
bypass if performed, use 33999)
(For rhinophototherapy, intranasal application of ultraviolet
and visible light, use 30999)
(For stereotactic placement of infusion catheter[s] in the
brain for delivery of therapeutic agent[s], use 64999)
(To report insertion of interlaminar/interspinous process
lumbar, single level, use 22867. To report insertion of
interlaminar/interspinous process stabilization/distraction
device, without open decompression or fusion, including
image guidance when performed, lumbar, single level, use
22869)
(To report insertion of interlaminar/interspinous process
lumbar, second level, use 22868. To report insertion of
interlaminar/interspinous process stabilization/distraction
device, without open decompression or fusion, including
image guidance when performed, lumbar, second level use,
22870)
✚ 0174T Computer-aided detection (CAD) (computer algorithm
analysis of digital image data for lesion detection) with
further physician review for interpretation and report, with
or without digitization of film radiographic images, chest
radiograph(s), performed concurrent with primary
interpretation (List separately in addition to code for
primary procedure)
Sunset January 2022
(Use 0174T in conjunction with 71045, 71046, 71047,
71048)
0175T Computer-aided detection (CAD) (computer algorithm
analysis of digital image data for lesion detection) with
further physician review for interpretation and report, with
or without digitization of film radiographic images, chest
radiograph(s), performed remote from primary
interpretation
Sunset January 2022
71047, 71048)
(0178T, 0179T, 0180T have been deleted)
(For electrocardiogram, 64 leads or greater, with graphic
presentation and analysis, use 93799)
(For electrocardiogram routine, with at least 12 leads
separately performed, see 93000-93010)
(0182T has been deleted. To report, see 0394T, 0395T)
0184T Excision of rectal tumor, transanal endoscopic
microsurgical approach (ie, TEMS), including muscularis
propria (ie, full thickness)
Sunset January 2024
(For non-endoscopic excision of rectal tumor, see 45160,
45171, 45172)
45309, 45315, 45317, 45320, 69990)
(For multivariate analysis of patient-specific findings with
quantifiable computer probability assessment, including
report, use 99199)
(For suprachoroidal delivery of pharmacologic agent, use
67299)
(For remote real-time interactive video-conferenced critical
care, evaluation and management of the critically ill or
critically injured patient, use 99499)
(For placement of intraocular radiation source applicator,
use 67299)
(For application of the source by radiation oncologist, see
Clinical Brachytherapy section)
0191T Insertion of anterior segment aqueous drainage device,
without extraocular reservoir, internal approach, into the
trabecular meshwork; initial insertion
Sunset January 2024
➲ CPT Assistant Dec 12:14, Feb 18:3, Jul 18:3
#✚ 0376T each additional device insertion (List separately in
Sunset January 2024
# 0253T Insertion of anterior segment aqueous drainage device,
without extraocular reservoir, internal approach, into the
suprachoroidal space
Sunset January 2024
(To report insertion of drainage device by external
(For arthrodesis, pre-sacral interbody technique, disc space
preparation, discectomy, without instrumentation, with
image guidance, includes bone graft when performed, L4-L5
interspace, L5-S1 interspace, use 22899)
0198T Measurement of ocular blood flow by repetitive intraocular
pressure sampling, with interpretation and report
Sunset January 2025
(For tremor measurement with accelerometer(s) and/or
gyroscope(s), use 95999)
0200T Percutaneous sacral augmentation (sacroplasty), unilateral
injection(s), including the use of a balloon or mechanical
device, when used, 1 or more needles, includes imaging
guidance and bone biopsy, when performed
Sunset January 2025
Minimally Invasive Glaucoma Surgery (Internal Approach)

0191T, 0376T, 0253T, 0449T, 0450T, 0474T
0201T Percutaneous sacral augmentation (sacroplasty), bilateral

injections, including the use of a balloon or mechanical
device, when used, 2 or more needles, includes imaging
guidance and bone biopsy, when performed
Sunset January 2025
(Do not report 0200T, 0201T in conjunction with 20225
when performed at the same level)
0202T Posterior vertebral joint(s) arthroplasty (eg, facet joint[s]
replacement), including facetectomy, laminectomy,
foraminotomy, and vertebral column fixation, injection of
bone cement, when performed, including fluoroscopy, single
level, lumbar spine
Sunset January 2025
22840, 22853, 22854, 22857, 22859, 63005, 63012, 63017,
63030, 63042, 63047, 63056 at the same level)
(For intravascular catheter-based coronary vessel or graft
spectroscopy [eg, infrared] during diagnostic evaluation
and/or therapeutic intervention including imaging
supervision, interpretation, and report, each vessel, use
93799)
(For computerized database analysis of multiple cycles of
digitized cardiac electrical data from 2 or more ECG leads,
including transmission to a remote center, application of
multiple nonlinear mathematical transformations, with
coronary artery obstruction severity assessment, use 93799)
0207T Evacuation of meibomian glands, automated, using heat and
intermittent pressure, unilateral
Sunset January 2025
(For evacuation of meibomian glands using heat-delivered
through wearable, open-eye eyelid treatment devices and
manual gland expression, use 0563T. For evacuation of
meibomian gland using manual gland expression only, use
the appropriate evaluation and management code)
# 0563T Evacuation of meibomian glands, using heat delivered
through wearable, open-eye eyelid treatment devices and
manual gland expression, bilateral
Sunset January 2025
(For evacuation of meibomian gland using manual gland
expression only, use the appropriate evaluation and
management code)
0208T Pure tone audiometry (threshold), automated; air only
Sunset January 2026
0209T air and bone
Sunset January 2026
0210T Speech audiometry threshold, automated;
Sunset January 2026
0211T with speech recognition
Sunset January 2026
0212T Comprehensive audiometry threshold evaluation and speech
recognition (0209T, 0211T combined), automated
Sunset January 2026
(For audiometric testing using audiometers performed
manually by a qualified health care professional, see 92551-
92557)
0213T Injection(s), diagnostic or therapeutic agent, paravertebral
with ultrasound guidance, cervical or thoracic; single level
Sunset January 2026
(To report bilateral procedure, use 0213T with modifier 50)
✚ 0214T second level (List separately in addition to code for
primary procedure)
Sunset January 2026
(For bilateral procedure, report 0214T twice. Do not report
modifier 50 in conjunction with 0214T)
✚ 0215T third and any additional level(s) (List separately in
Sunset January 2026
(Do not report 0215T more than once per day)
(Use 0215T in conjunction with 0213T, 0214T)
0216T Injection(s), diagnostic or therapeutic agent, paravertebral
with ultrasound guidance, lumbar or sacral; single level
Sunset January 2026
(To report bilateral procedure, use 0216T with modifier 50)
✚ 0217T second level (List separately in addition to code for
primary procedure)
Sunset January 2026
✚ 0218T third and any additional level(s) (List separately in
Sunset January 2026
(Do not report 0218T more than once per day)
(Use 0218T in conjunction with 0216T, 0217T)
(If injection(s) are performed using fluoroscopy or CT, see
64490-64495)
0219T Placement of a posterior intrafacet implant(s), unilateral or
bilateral, including imaging and placement of bone graft(s)
or synthetic device(s), single level; cervical
Sunset January 2026
0220T thoracic
Sunset January 2026
0221T lumbar
Sunset January 2026
(Do not report 0219T-0221T in conjunction with any
radiological service)
20930, 20931, 22600-22614, 22840, 22853, 22854, 22859
at the same level)
✚ 0222T each additional vertebral segment (List separately in
Sunset January 2026
(Use 0222T in conjunction with 0219T-0221T)
(For posterior or posterolateral arthrodesis technique, see
22600-22614)
▶ (0228T, 0229T, 0230T, 0231T have been deleted)◀
▶ (For injection[s], anesthetic agent and/or steroid,
transforaminal epidural, with ultrasound guidance, cervical
or thoracic, single level, use 64999)◀
(For transforaminal epidural injections performed under
fluoroscopy or CT, see 64479–64484)
0232T Injection(s), platelet rich plasma, any site, including image
guidance, harvesting and preparation when performed
Sunset January 2022
➲ CPT Assistant Oct 10:8, Dec 10:8, May 12:11, Oct
12:14, May 18:3, Apr 19:10
15772, 15773, 15774, 20550, 20551, 20600, 20604, 20605,
20606, 20610, 20611, 36415, 36592, 76942, 77002, 77012,
77021, 86965, 0481T)
(Do not report 38220-38230 for bone marrow aspiration for
platelet rich stem cell injection. For bone marrow aspiration
for platelet rich stem cell injection, use 0232T)
Atherectomy (Open or Percutaneous) for Supra-

Inguinal Arteries
Codes 0234T-0238T describe atherectomy performed by any
method (eg, directional, rotational, laser) in arteries above the
inguinal ligaments. These codes are structured differently than
the codes describing atherectomy performed below the inguinal
ligaments (37225, 37227, 37229, 37231, 37233, 37235).
These supra-inguinal atherectomy codes all include the surgical
work of performing the atherectomy plus the radiological
supervision and interpretation of the atherectomy. Unlike the
atherectomy codes for infra-inguinal arteries, this set of Category
III codes does not include accessing and selectively catheterizing
the vessel, traversing the lesion, embolic protection if used, other
intervention used to treat the same or other vessels, or closure of
the arteriotomy by any method. These codes describe
endovascular procedures performed percutaneously and/or
through an open surgical exposure.
0234T Transluminal peripheral atherectomy, open or percutaneous,
including radiological supervision and interpretation; renal
artery
Sunset January 2026
0235T visceral artery (except renal), each vessel
Sunset January 2026
0236T abdominal aorta
Sunset January 2026
0237T brachiocephalic trunk and branches, each vessel
Sunset January 2026
0238T iliac artery, each vessel
Sunset January 2026
(To report esophageal motility studies without high
resolution esophageal pressure topography, use 91010 and
with stimulant or perfusion, use 91013)
(0249T has been deleted. To report, use 46948)
0253T Code is out of numerical sequence. See 0184T-0200T
0263T Intramuscular autologous bone marrow cell therapy, with
preparation of harvested cells, multiple injections, one leg,
including ultrasound guidance, if performed; complete
procedure including unilateral or bilateral bone marrow
harvest
Sunset January 2022
(Do not report 0263T in conjunction with 38204-38242,
76942, 93925, 93926)
0264T complete procedure excluding bone marrow harvest
Sunset January 2022
76942, 93925, 93926, 0265T)
0265T unilateral or bilateral bone marrow harvest only for
intramuscular autologous bone marrow cell therapy
Sunset January 2022
0264T. For complete procedure, use 0263T)
0266T Implantation or replacement of carotid sinus baroreflex
activation device; total system (includes generator
placement, unilateral or bilateral lead placement, intra-
operative interrogation, programming, and repositioning,
when performed)
Sunset January 2022
0267T lead only, unilateral (includes intra-operative
interrogation, programming, and repositioning, when
performed)
Sunset January 2022
(For bilateral lead implantation or replacement, use 0267T
with modifier 50)
0268T pulse generator only (includes intra-operative
performed)
Sunset January 2022
(Do not report 0267T, 0268T in conjunction with 0266T,
0269T-0273T)
0269T Revision or removal of carotid sinus baroreflex activation
device; total system (includes generator placement,
unilateral or bilateral lead placement, intra-operative
performed)
Sunset January 2022
(Do not report 0269T in conjunction with 0266T-0268T,
0270T-0273T)
0270T lead only, unilateral (includes intra-operative
performed)
Sunset January 2022
0271T-0273T)
(For bilateral lead removal, use 0270T with modifier 50)
(For removal of total carotid sinus baroreflex activation
device, use 0269T)
0271T pulse generator only (includes intra-operative
performed)
Sunset January 2022
0272T, 0273T)
(For removal and replacement, see 0266T, 0267T, 0268T)
0272T Interrogation device evaluation (in person), carotid sinus
baroreflex activation system, including telemetric iterative
communication with the implantable device to monitor
device diagnostics and programmed therapy values, with
interpretation and report (eg, battery status, lead impedance,
pulse amplitude, pulse width, therapy frequency, pathway
mode, burst mode, therapy start/stop times each day);
Sunset January 2022
0273T)
0273T with programming
Sunset January 2022
(Do not report 0273T in conjunction with 0266T-0272T)
0274T Percutaneous laminotomy/laminectomy (interlaminar
approach) for decompression of neural elements, (with or
without ligamentous resection, discectomy, facetectomy
and/or foraminotomy), any method, under indirect image
guidance (eg, fluoroscopic, CT), single or multiple levels,
unilateral or bilateral; cervical or thoracic
Sunset January 2022
➲ CPT Assistant Jan 12:14, Jul 12:3, 4, Feb 17:12
0275T lumbar
Sunset January 2022
➲ CPT Assistant Jan 12:14, Jul 12:3, 4, Feb 17:12
(For percutaneous decompression of the nucleus pulposus of
intervertebral disc utilizing needle based technique, use
62287)
0278T Transcutaneous electrical modulation pain reprocessing (eg,
scrambler therapy), each treatment session (includes
placement of electrodes)
Sunset January 2022
(For implantation of trial or permanent electrode arrays or
pulse generators for peripheral subcutaneous field
stimulation, use 64999)
(For delivery of thermal energy to the muscle of the anal
canal, use 46999)
✚ 0290T Corneal incisions in the recipient cornea created using a
laser, in preparation for penetrating or lamellar keratoplasty
Sunset January 2022
65755)
▶ (0295T, 0296T, 0297T, 0298T have been deleted)◀
(For extracorporeal shock wave for integumentary wound
healing, high energy, use 28899)
▶ (For greater than 48 hours of monitoring of external
electrocardiographic recording, see 93241, 93242, 93243,
93244, 93245, 93246, 93247, 93248)◀
(For focused microwave thermotherapy of the breast, use
19499)
(0302T, 0303T, 0304T, 0305T, 0306T, 0307T have been
deleted)
0308T Insertion of ocular telescope prosthesis including removal
of crystalline lens or intraocular lens prosthesis
Sunset January 2026
66020, 66030, 66600-66635, 66761, 66825, 66982-66986,
69990)
(For arthrodesis, pre-sacral interbody technique, including
disc space preparation, discectomy, with posterior
instrumentation, with image guidance, including bone graft,
when performed, lumbar, L4-L5 interspace, use 22899)
(For motor function mapping using non-invasive navigated
transcranial magnetic stimulation [nTMS] for therapeutic
treatment planning, upper and lower extremity, use 64999)
0312T Vagus nerve blocking therapy (morbid obesity);
laparoscopic implantation of neurostimulator electrode
array, anterior and posterior vagal trunks adjacent to
esophagogastric junction (EGJ), with implantation of pulse
generator, includes programming
Sunset January 2023
0313T laparoscopic revision or replacement of vagal trunk
neurostimulator electrode array, including connection to
Sunset January 2023
0314T laparoscopic removal of vagal trunk neurostimulator
electrode array and pulse generator
Sunset January 2023
0315T removal of pulse generator
Sunset January 2023
0316T replacement of pulse generator
Sunset January 2023
0317T neurostimulator pulse generator electronic analysis,
includes reprogramming when performed
Sunset January 2023
(For implantation, revision, replacement, and/or removal of
vagus [cranial] nerve neurostimulator electrode array and/or
pulse generator for vagus nerve stimulation performed other
than at the EGJ [eg, epilepsy], see 64568-64570)
performed, of vagal nerve neurostimulators, see 95970,
95976, 95977. Test stimulation to confirm correct target site
placement of the electrode array[s] and/or to confirm the
functional status of the system is inherent to placement, and
is not separately reported as electronic analysis or
programming of the neurostimulator system. Electronic
analysis [95970] at the time of implantation is not separately
reported.)
0329T Monitoring of intraocular pressure for 24 hours or longer,
unilateral or bilateral, with interpretation and report
Sunset January 2024
0330T Tear film imaging, unilateral or bilateral, with interpretation
and report
Sunset January 2024
0331T Myocardial sympathetic innervation imaging, planar
qualitative and quantitative assessment;
Sunset January 2024
0332T with tomographic SPECT
Sunset January 2024
(For myocardial infarct avid imaging, see 78466, 78468,
78469)
0333T Visual evoked potential, screening of visual acuity,
automated, with report
Sunset January 2024
➲ CPT Assistant Aug 14:8, Feb 18:3
(For visual evoked potential testing for glaucoma, use
0464T)
# 0464T Visual evoked potential, testing for glaucoma, with
Sunset January 2023
(To report percutaneous/minimally invasive [indirect
visualization] arthrodesis of the sacroiliac joint with image
(For visual evoked potential screening of visual acuity, use
0333T)
0335T Insertion of sinus tarsi implant
Sunset January 2024
29907)
# 0510T Removal of sinus tarsi implant
Sunset January 2024
# 0511T Removal and reinsertion of sinus tarsi implant
Sunset January 2024
(For unilateral or bilateral endothelial function assessments,
using peripheral vascular response to reactive hyperemia,
noninvasive [eg, brachial artery ultrasound, peripheral
artery tonometry], use 93998)
0338T Transcatheter renal sympathetic denervation, percutaneous
approach including arterial puncture, selective catheter
placement(s) renal artery(ies), fluoroscopy, contrast
injection(s), intraprocedural roadmapping and radiological
supervision and interpretation, including pressure gradient
measurements, flush aortogram and diagnostic renal
angiography when performed; unilateral
Sunset January 2024
0339T bilateral
Sunset January 2024
(Do not report 0338T, 0339T in conjunction with 36251,
36252, 36253, 36254)
(For quantitative pupillometry with interpretation and
report, unilateral or bilateral, use 92499)
0342T Therapeutic apheresis with selective HDL delipidation and
plasma reinfusion
Sunset January 2024
Fluoroscopy (76000) and radiologic supervision and
interpretation are inherent to the transcatheter mitral valve repair
(TMVR) procedure and are not separately reportable. Diagnostic
cardiac catheterization (93451, 93452, 93453, 93454, 93455,
93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532,
93533) should not be reported with transcatheter mitral valve
repair (0345T) for:
■ Contrast injections, angiography, roadmapping, and/or
fluoroscopic guidance for the transcatheter mitral valve repair
(TMVR),
■ Left ventricular angiography to assess mitral regurgitation, for
guidance of TMVR, or
■ Right and left heart catheterization for hemodynamic
measurements before, during, and after TMVR for guidance of
TMVR.
Diagnostic right and left heart catheterization (93451, 93452,
93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531,
93532, 93533), and diagnostic coronary angiography (93454,
93455, 93456, 93457, 93458, 93459, 93460, 93461, 93563, 93564)
not inherent to the TMVR, may be reported with 0345T,
appended with modifier 59 if:
performed, or
record:
pathology, or
new evaluation.
Other cardiac catheterization services may be reported separately,
when performed for diagnostic purposes not intrinsic to the
TMVR.
▶When transcatheter ventricular support is required, the
appropriate code may be reported with the appropriate
ventricular assist device (VAD) procedure (33990, 33991, 33992,
33993, 33995, 33997) or balloon pump insertion (33967, 33970,
33973).◀
0345T Transcatheter mitral valve repair percutaneous approach via
the coronary sinus
Sunset January 2025
(For transcatheter mitral valve repair percutaneous
approach including transseptal puncture when performed,
see 33418, 33419)
93453, 93456, 93457, 93458, 93459, 93460, 93461 for
diagnostic left and right heart catheterization procedures
intrinsic to the valve repair procedure)
93563, 93564 for coronary angiography intrinsic to the
valve repair procedure)
[TMVI], see 0483T, 0484T)
0544T)
(0346T has been deleted. To report, see 76981, 76982,
76983)
0347T Placement of interstitial device(s) in bone for
radiostereometric analysis (RSA)
Sunset January 2025
0348T Radiologic examination, radiostereometric analysis (RSA);
spine, (includes cervical, thoracic and lumbosacral, when
performed)
Sunset January 2025
0349T upper extremity(ies), (includes shoulder, elbow, and
wrist, when performed)
Sunset January 2025
0350T lower extremity(ies), (includes hip, proximal femur,
knee, and ankle, when performed)
Sunset January 2025
0351T Optical coherence tomography of breast or axillary lymph
node, excised tissue, each specimen; real-time
intraoperative
Sunset January 2025
0352T interpretation and report, real-time or referred
Sunset January 2025
(Do not report 0352T in conjunction with 0351T, when
performed by the same physician)
0353T Optical coherence tomography of breast, surgical cavity;
real-time intraoperative
Sunset January 2025
(Report 0353T once per session)
0354T interpretation and report, real-time or referred
Sunset January 2025
(Do not report 0354T in conjunction with 0353T, when
performed by the same physician)
0355T Gastrointestinal tract imaging, intraluminal (eg, capsule
endoscopy), colon, with interpretation and report
Sunset January 2025
(Use 0355T for imaging of distal ileum, when performed)
(Do not report 0355T in conjunction with 91110, 91111)
0356T Insertion of drug-eluting implant (including punctal dilation
and implant removal when performed) into lacrimal
canaliculus, each
Sunset January 2025
see 0444T, 0445T)
0358T Bioelectrical impedance analysis whole body composition
assessment, with interpretation and report
Sunset January 2025
(For bioimpedance-derived physiological cardiovascular
(For bioimpedance spectroscopy (BIS), use 93702)
Adaptive Behavior Assessments and Treatment

Behavior identification supporting assessment (0362T) and
adaptive behavior treatment with protocol modification
(0373T) include the following required components:
■ administration by the physician or other qualified health care
professional who is on-site but not necessarily face-to-face
with the patient;
■ with the assistance of two or more technicians;
■ for a patient with destructive behavior that requires the
presence of a team;
■ completion in an environment that is customized to the
patient’s behavior.
“On-site” is defined as immediately available and interruptible to
provide assistance and direction throughout the performance of
the procedure, however, the physician or other qualified health
care professional does not need to be present in the room when
the procedure is performed.
Typical patients for 0362T and 0373T present with one or more
specific destructive behavior(s) (ie, maladaptive behaviors
associated with high risk of medical consequences or property
damage [eg, elopement, pica, or self-injury requiring medical
attention, aggression with injury to other{s}, or breaking
furniture, walls, or windows]). Code 0362T may include
functional behavior assessment, functional analysis, other
structured observations, and standardized and/or nonstandardized
instruments and procedures to determine levels of adaptive and
maladaptive behavior as well as other impairments in
functioning.
Only count the time of one technician when two or more are
present. For assistance with code selection of 97152, 0362T, see
the Guide to Selection of Codes 97152 and 0362T on page 785.
For assistance with code selection of 97153, 97155, 0373T, see
Guide to Selection of Codes 97153, 97155, 0373T on page 787.
97151, 97152)
0362T Behavior identification supporting assessment, each 15
minutes of technicians’ time face-to-face with a patient,
requiring the following components:
■ administration by the physician or other qualified health
care professional who is on site;
■ for a patient who exhibits destructive behavior;
Sunset January 2024
(0362T is reported based on a single technician’s face-to-
face time with the patient and not the combined time of
multiple technicians [eg, one hour with three technicians
equals one hour of service])
(0362T may be repeated on different days until the behavior
identification assessment [97151] and, if necessary,
supporting assessment[s] [97152, 0362T], is complete)
(For psychiatric diagnostic evaluation, see 90791, 90792)
(For speech evaluations, see 92521, 92522, 92523, 92524)
(For occupational therapy evaluation, see 97165, 97166,
97167, 97168)
(For medical team conference, see 99366, 99367, 99368)
(For health behavior assessment and intervention, see
96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170,
96171)
(For neurobehavioral status examination, see 96116, 96121)
(For neuropsychological testing, see 96132, 96133, 96136,
96137, 96138, 96139, 96146)
(0363T, 0364T, 0365T, 0366T, 0367T, 0368T, 0369T,
0370T, 0371T, 0372T have been deleted. To report, see
97153, 97154, 97155, 97156, 97157, 97158, 0373T)
0373T Adaptive behavior treatment with protocol modification,
each 15 minutes of technicians’ time face-to-face with a
patient, requiring the following components:
■ administration by the physician or other qualified health
care professional who is on site;
■ for a patient who exhibits destructive behavior;
Sunset January 2024
➲ CPT Assistant Jun 14:4, 6, 9, Nov 18:3
(0373T is reported based on a single technician’s face-to-
face time with the patient and not the combined time of
multiple technicians)
96105, 96110, 96116, 96121, 96156, 96158, 96159, 96164,
96165, 96167, 96168, 96170, 96171)
(0374T has been deleted. To report, use 0373T)
(For total disc arthroplasty [artificial disc], anterior
approach, including discectomy with end-plate preparation
[includes osteophytectomy for nerve root or spinal cord
decompression and microdissection], cervical, 3 or more
levels, use 22899)
(For anoscopy with directed submucosal injection of
bulking agent for fecal incontinence, use 46999)
0378T Visual field assessment, with concurrent real time data
analysis and accessible data storage with patient initiated
data transmitted to a remote surveillance center for up to 30
days; review and interpretation with report by a physician
Sunset January 2025
0379T technical support and patient instructions, surveillance,
analysis, and transmission of daily and emergent data
reports as prescribed by a physician or other qualified
health care professional
Sunset January 2025
(For computer-aided animation and analysis of time series
retinal images for the monitoring of disease progression,
unilateral or bilateral, with interpretation and report, use
92499)
▶ (0381T, 0382T, 0383T, 0384T, 0385T, 0386T have been
deleted)◀
▶ (For external heart rate and 3-axis accelerometer data
recording up to 14 days to assess changes in heart rate and
to monitor motion analysis for the purposes of diagnosing
nocturnal epilepsy seizure events, including report, scanning
analysis with report, review and interpretation by a
physician or other qualified health care professional, use
95999)◀
Pacemaker-Leadless and Pocketless System

(0387T, 0388T have been deleted. To report, see 33274,
33275)
33274, 33275, 93279, 93286, 93288, 93294, 93296)
(Electronic brachytherapy is a form of radiation therapy in
which an electrically generated X-ray source of ionizing
radiation is placed inside or in close proximity to the tumor
or target tissue to deliver therapeutic radiation dosage)
0394T High dose rate electronic brachytherapy, skin surface
application, per fraction, includes basic dosimetry, when
performed
Sunset January 2026
77263, 77300, 77306, 77307, 77316, 77317, 77318, 77332,
77333, 77334, 77336, 77427, 77431, 77432, 77435, 77469,
77470, 77499, 77761, 77762, 77763, 77767, 77768, 77770,
77771, 77772, 77778, 77789)
(For high dose rate radionuclide surface brachytherapy, see
77767, 77768)
(For non-brachytherapy superficial [eg, ≤200 kV] radiation
treatment delivery, use 77401)
0395T High dose rate electronic brachytherapy, interstitial or
intracavitary treatment, per fraction, includes basic
dosimetry, when performed
Sunset January 2026
77263, 77300, 77306, 77307, 77316, 77317, 77318, 77332,
77333, 77334, 77336, 77427, 77431, 77432, 77435, 77469,
77470, 77499, 77761, 77762, 77763, 77767, 77768, 77770,
77771, 77772, 77778, 77789)
(For skin surface application of high dose rate electronic
brachytherapy, use 0394T)
▶ (Forintraoperative use of kinetic balance sensor for
implant stability during knee replacement arthroplasty, use
27599)◀
✚ 0397T Endoscopic retrograde cholangiopancreatography (ERCP),
with optical endomicroscopy (List separately in addition to
Sunset January 2026
43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278)
(Do not report 0397T in conjunction with 88375)
(Do not report optical endomicroscopy more than once per
session)
0398T Magnetic resonance image guided high intensity focused
ultrasound (MRgFUS), stereotactic ablation lesion,
intracranial for movement disorder including stereotactic
navigation and frame placement when performed
Sunset January 2026
▶ (0400T, 0401T have been deleted)◀
▶ (For multispectral digital skin lesion analysis of clinically
atypical cutaneous pigmented lesions for detection of
melanomas and high risk melanocytic atypia, use 96999)◀
0402T Collagen cross-linking of cornea, including removal of the
corneal epithelium and intraoperative pachymetry, when
performed (Report medication separately)
Sunset January 2025
76514)
A diabetes prevention program consists of intensive behavioral
counseling that is provided in person, online, or via electronic
technology, or a combination of both modalities.
Intensive behavioral counseling consists of care management,
lifestyle coaching, facilitation of a peer-support group, and
provision of clinically validated educational lessons based on a
standardized curriculum that is focused on nutrition, exercise,
stress, and weight management. Lifestyle coaches must complete
a nationally recognized training program. The lifestyle coach is
available to interact with the participants.
Codes 0403T and 0488T describe diabetes prevention programs
that use a standardized diabetes prevention curriculum. For
educational services that use a standardized curriculum provided
to patients with an established illness/disease, see 98960, 98961,
98962. Use 0403T for diabetes prevention programs that are
provided only in-person. Use 0488T for programs that are
provided online or via electronic technology. Code 0488T
includes in person components, if provided.
0403T Preventive behavior change, intensive program of
prevention of diabetes using a standardized diabetes
prevention program curriculum, provided to individuals in a
group setting, minimum 60 minutes, per day
Sunset January 2026
98962, 0488T)
# 0488T Preventive behavior change, online/electronic structured
intensive program for prevention of diabetes using a
standardized diabetes prevention program curriculum,
provided to an individual, per 30 days
Sunset January 2023
98962, 0403T)
0404T Transcervical uterine fibroid(s) ablation with ultrasound
guidance, radiofrequency
Sunset January 2026
▶ (For oversight of the care of an extracorporeal liver-assist
system patient requiring review of status, review of
laboratory and other studies, and revision of orders and
liver-assist care plan [as appropriate], within a calendar
month, 30 minutes or more of non-face-to-face time, use
99499)◀
(To report endoscopic placement of a drug-eluting implant
in the ethmoid sinus without any other nasal/sinus
endoscopic surgical service, use 31299. To report
endoscopic placement of a drug-eluting implant in the
ethmoid sinus in conjunction with biopsy, polypectomy, or
Codes 0408T-0418T describe procedures related to cardiac
contractility modulation systems (CCM). These systems consist
of a pulse generator plus one atrial and two ventricular
pacemaker electrodes (leads). In contrast to a pacemaker or a
defibrillator, which modulate the heart’s rhythm, the CCM
system’s impulses are designed to modulate the strength of
contraction of the heart muscle. Unlike pacemakers, these
systems stimulate for specific time intervals in order to improve
myocardial function.
All catheterization and imaging guidance required to complete a
CCM procedure are included in the work of each code. Left heart
catheterization with a high fidelity transducer is intrinsic to the
CCM procedure. Left heart catheterization codes (93452, 93453,
93458, 93459, 93460, 93461) at the time of CCM placement,
replacement, or revision may not be reported separately. Removal
of only the CCM pulse generator is reported with 0412T. If only
the pulse generator is removed and replaced at the same session
without any right atrial and/or right ventricular lead(s) inserted or
replaced, report 0414T. For removal and replacement of the pulse
generator and leads, individual codes for removal of the
generator (0412T) and removal of the leads (0413T for each lead
removed) are used in conjunction with the insertion/replacement
system code (0408T). When individual transvenous electrodes
are inserted or replaced, report using 0410T and 0411T, as
appropriate. When the entire system is inserted or replaced,
report with 0408T.
Revision of the CCM generator skin pocket is included in 0408T,
0412T, 0414T. Relocation of a skin pocket for a CCM may be
necessary for various clinical situations such as infection or
erosion. Relocation is reported with 0416T, and follows
conventions for pacemaker skin pocket relocation.
Repositioning of a CCM electrode is reported using 0415T.
CCM device evaluation codes 0417T, 0418T may not be reported
in conjunction with pulse generator and lead insertion or revision
codes.
0408T Insertion or replacement of permanent cardiac contractility
modulation system, including contractility evaluation when
performed, and programming of sensing and therapeutic
parameters; pulse generator with transvenous electrodes
Sunset January 2022
0409T pulse generator only
Sunset January 2022
0410T atrial electrode only
Sunset January 2022
0411T ventricular electrode only
Sunset January 2022
(Report 0410T, 0411T once for each transvenous electrode
inserted or replaced)
(If the entire system is inserted or replaced, report 0408T)
0412T Removal of permanent cardiac contractility modulation
system; pulse generator only
Sunset January 2022
0413T transvenous electrode (atrial or ventricular)
Sunset January 2022
(Report 0413T once for each transvenous electrode
removed)
(For removal of the pulse generator and all 3 leads, use
0412T plus 0413T once for each electrode removed)
(If transvenous electrodes are removed and replaced, report
0413T once for each electrode removed in conjunction with
0410T, 0411T, as appropriate)
0414T Removal and replacement of permanent cardiac contractility
modulation system pulse generator only
Sunset January 2022
(For removal and replacement of the pulse generator plus all
three electrodes, report 0408T in conjunction with 0412T,
0413T once for each transvenous electrode removed)
0415T Repositioning of previously implanted cardiac contractility
modulation transvenous electrode (atrial or ventricular lead)
Sunset January 2022
(Do not report 0408T, 0409T, 0410T, 0411T, 0414T, 0415T
in conjunction with 93286, 93287, 93452, 93453, 93458,
93459, 93460, 93461)
(Do not report 0415T in conjunction with 0408T, 0410T,
0411T)
0416T Relocation of skin pocket for implanted cardiac contractility
modulation pulse generator
Sunset January 2022
0417T Programming device evaluation (in person) with iterative
adjustment of the implantable device to test the function of
the device and select optimal permanent programmed values
with analysis, including review and report, implantable
cardiac contractility modulation system
Sunset January 2022
0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0418T)
0418T Interrogation device evaluation (in person) with analysis,
review and report, includes connection, recording and
disconnection per patient encounter, implantable cardiac
contractility modulation system
Sunset January 2022
0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0417T)
0419T Destruction of neurofibroma, extensive (cutaneous, dermal
extending into subcutaneous); face, head and neck, greater
than 50 neurofibromas
Sunset January 2022
(For excision of neurofibroma, use 64792)
(Report 0419T once per session regardless of the number of
lesions treated)
0420T trunk and extremities, extensive, greater than 100
neurofibromas
Sunset January 2022
(For excision of neurofibroma, use 64792)
(Report 0420T once per session regardless of the number of
lesions treated)
0421T Transurethral waterjet ablation of prostate, including control
of post-operative bleeding, including ultrasound guidance,
complete (vasectomy, meatotomy, cystourethroscopy,
urethral calibration and/or dilation, and internal urethrotomy
are included when performed)
Sunset January 2022
76872)
0422T Tactile breast imaging by computer-aided tactile sensors,
Sunset January 2022
0423T Secretory type II phospholipase A2 (sPLA2-IIA)
Sunset January 2022
(For lipoprotein-associated phospholipase A2 [Lp-PLA2],
use 83698)
Phrenic Nerve Stimulation System
A phrenic nerve stimulation system includes a pulse generator
(containing electronics and a battery), one stimulation lead
(electrode), and one sensing lead (electrode). Pulse generators are
placed in a submuscular or subcutaneous “pocket” in the pectoral
region. The stimulation lead is placed transvenously into the right
brachiocephalic vein or left pericardiophrenic vein. The sensing
lead is placed transvenously into the azygos vein.
If replacing less than a complete system, report 0425T, 0426T,
and/or 0427T (for sensing lead, stimulation lead or pulse
generator respectively). If all three components are replaced,
report only 0424T in conjunction with codes for removal of each
of the components (0428T, 0429T, 0430T).
Codes 0424T-0433T include vessel catheterization, all image
guidance required for the procedure, and interrogation and
programming, when performed. Interrogation device evaluation
and programming device evaluation include parameters of rate,
pulse amplitude, pulse duration, configuration of waveform,
battery status, electrode selectability, output modulation, cycling,
impedance, and patient compliance measurements. For patients
that require programming during an overnight sleep study, report
0436T once, regardless of how many programming changes are
made during the sleep study.
0424T Insertion or replacement of neurostimulator system for
treatment of central sleep apnea; complete system
(transvenous placement of right or left stimulation lead,
sensing lead, implantable pulse generator)
Sunset January 2022
0425T sensing lead only
Sunset January 2022
0426T stimulation lead only
Sunset January 2022
0427T pulse generator only
Sunset January 2022
0424T)
0428T Removal of neurostimulator system for treatment of central
sleep apnea; pulse generator only
Sunset January 2022
Sunset January 2022
0430T stimulation lead only
Sunset January 2022
(Report 0429T, 0430T once for each transvenous sensing or
stimulation lead removed)
(For removal of the entire system, report 0428T for pulse
generator removal plus 0429T or 0430T for each
transvenous lead removal)
0431T Removal and replacement of neurostimulator system for
treatment of central sleep apnea, pulse generator only
Sunset January 2022
(For removal and replacement of the pulse generator plus all
three leads, report 0424T in conjunction with 0428T,
0429T, 0430T)
0432T Repositioning of neurostimulator system for treatment of
central sleep apnea; stimulation lead only
Sunset January 2022
Sunset January 2022
0425T, 0426T, 0427T)
0434T Interrogation device evaluation implanted neurostimulator
pulse generator system for central sleep apnea
Sunset January 2022
0435T Programming device evaluation of implanted
neurostimulator pulse generator system for central sleep
apnea; single session
Sunset January 2022
0436T during sleep study
Sunset January 2022
0424T, 0425T, 0426T, 0427T, 0428T, 0429T, 0430T,
0431T, 0432T, 0433T)
(Report 0436T once per sleep study)
✚ 0437T Implantation of non-biologic or synthetic implant (eg,
polypropylene) for fascial reinforcement of the abdominal
wall (List separately in addition to code for primary
procedure)
Sunset January 2022
(For implantation of mesh or other prosthesis for open
incisional or ventral hernia repair, use 49568 in conjunction
with 49560, 49561, 49565, 49566)
(For insertion of mesh or other prosthesis for closure of a
necrotizing soft tissue infection wound, use 49568 in
conjunction with 11004, 11005, 11006)
✚ 0439T Myocardial contrast perfusion echocardiography, at rest or
with stress, for assessment of myocardial ischemia or
viability (List separately in addition to code for primary
procedure)
Sunset January 2022
93350, 93351)
0440T Ablation, percutaneous, cryoablation, includes imaging
guidance; upper extremity distal/peripheral nerve
Sunset January 2022
17:3
0441T lower extremity distal/peripheral nerve
Sunset January 2022
17:13
0442T nerve plexus or other truncal nerve (eg, brachial plexus,
pudendal nerve)
Sunset January 2022
17:13
✚ 0443T Real-time spectral analysis of prostate tissue by
fluorescence spectroscopy, including imaging guidance (List
Sunset January 2022
(Report 0443T only once per session)
0444T Initial placement of a drug-eluting ocular insert under one or
more eyelids, including fitting, training, and insertion,
Sunset January 2022
0445T Subsequent placement of a drug-eluting ocular insert under
one or more eyelids, including re-training, and removal of
existing insert, unilateral or bilateral
Sunset January 2022
lacrimal canaliculus, use 0356T)
0446T Creation of subcutaneous pocket with insertion of
implantable interstitial glucose sensor, including system
activation and patient training
Sunset January 2022
(Do not report 0446T in conjunction with 95251, 0447T,
0448T)
0447T Removal of implantable interstitial glucose sensor from
subcutaneous pocket via incision
Sunset January 2022
0448T Removal of implantable interstitial glucose sensor with
creation of subcutaneous pocket at different anatomic site
and insertion of new implantable sensor, including system
activation
Sunset January 2022
(Do not report 0448T in conjunction with 0446T, 0447T)
(For placement of non-implantable interstitial glucose
sensor without pocket, use 95250)
0449T Insertion of aqueous drainage device, without extraocular
reservoir, internal approach, into the subconjunctival space;
initial device
Sunset January 2022
✚ 0450T each additional device (List separately in addition to
Sunset January 2022
(For removal of aqueous drainage device without
extraocular reservoir, placed into the subconjunctival space
via internal approach, use 92499)
Codes 0451T-0463T describe a family of services related to the
placement and maintenance of permanent aortic counterpulsation
ventricular assistance devices. These devices are used to treat
congestive heart failure, and they employ a counterpulsation
device that is implanted in the aorta, which inflates during
diastole to reduce end diastolic ventricular pressure on a long-
term basis without rerouting blood flow. The counterpulsation
assistance device implantation is achieved by surgically placing a
subclavian arterial graft and creating of a subcutaneous pocket to
implant a mechano-electrical interface, without requiring access
to the heart. The counterpulsation device’s mechano-electrical
skin interface receives ECG signals from the subcutaneous
electrodes and digitizes and transmits a signal through an external
driveline to an external “driver,” which is carried by the patient.
The “driver” receives the ECG signal and determines the location
of the dicrotic notch. The “driver” then activates a bellows,
which sends compressed air through the external driveline to the
mechano-electrical skin interface in which the compressed air
enters the internal driveline and inflates the balloon. After
diastole, the bellows creates suction that deflates the balloon
through the same pathway.
These services differ from those performed for the implantation,
revision, and removal of existing aortic balloon pumps in several
ways in that they: (1) use a permanently implanted balloon that is
intended for long-term use; (2) require surgical placement of a
vascular graft; (3) use a vascular hemostatic seal; (4) implant a
mechano-electrical skin interface that contains a programmable
processor; and (5) implant subcutaneous electrodes. In addition,
they also differ from procedures to insert, revise, and remove
extracorporeal and intracorporeal ventricular assist devices
because these procedures require access to the heart and include
inflow or outflow grafts into the heart, which divert blood flow
from either the left and/or right cardiac chambers into a pump
that then pumps blood directly into the corresponding artery
(either aorta and/or pulmonary artery).
Codes 0451T-0463T are inclusive of all vessel catheterization,
diagnostic angiography, radiological supervision and
interpretation, and imaging guidance. Removal of a
counterpulsation assistance device at the same session as
insertion is not separately reportable.
0451T Insertion or replacement of a permanently implantable aortic
counterpulsation ventricular assist system, endovascular
approach, and programming of sensing and therapeutic
parameters; complete system (counterpulsation device,
vascular graft, implantable vascular hemostatic seal,
mechano-electrical skin interface and subcutaneous
electrodes)
Sunset January 2022
▶ (Donot report 0451T in conjunction with 33973, 33979,
33990, 33991, 33995, 33997, 0452T, 0453T, 0454T,
0455T, 0456T, 0457T, 0458T)◀
(For insertion of intra-aortic balloon assist device, see
33967, 33970, 33973)
(For insertion or replacement of extracorporeal ventricular
assist device, see 33975, 33976, 33981)
(For insertion or replacement of intracorporeal ventricular
▶ (Forpercutaneous insertion of ventricular assist device,
see 33990, 33991, 33995)◀
0452T aortic counterpulsation device and vascular hemostatic
seal
Sunset January 2022
33990, 33991, 33995, 33997, 0451T, 0455T, 0456T)◀
0453T mechano-electrical skin interface
Sunset January 2022
33990, 33991, 33995, 33997, 0451T, 0455T, 0457T)◀
0454T subcutaneous electrode
Sunset January 2022
(Report 0454T once for each subcutaneous electrode
inserted or replaced)
(If the entire system is inserted or replaced, use 0451T)
33990, 33991, 33995, 33997, 0451T, 0455T, 0458T)◀
0455T Removal of permanently implantable aortic counterpulsation
ventricular assist system; complete system (aortic
counterpulsation device, vascular hemostatic seal, mechano-
electrical skin interface and electrodes)
Sunset January 2022
33992, 0451T, 0452T, 0453T, 0454T, 0456T, 0457T,
0458T)
(For removal of intra-aortic balloon assist device, see
33968, 33971, 33974)
(For removal of extracorporeal ventricular assist device,
see 33977, 33978)
(For removal of intracorporeal ventricular assist device, use
33980)
(For removal of percutaneous ventricular assist device, use
33992)
0456T aortic counterpulsation device and vascular hemostatic
seal
Sunset January 2022
33992, 0451T, 0452T, 0455T)
0457T mechano-electrical skin interface
Sunset January 2022
33992, 0451T, 0453T, 0455T)
0458T subcutaneous electrode
Sunset January 2022
removed)
33992, 0451T, 0454T, 0455T)
0459T Relocation of skin pocket with replacement of implanted
aortic counterpulsation ventricular assist device, mechano-
electrical skin interface and electrodes
Sunset January 2022
(For repositioning of percutaneous ventricular assist device,
use 33993)
0460T Repositioning of previously implanted aortic
counterpulsation ventricular assist device; subcutaneous
electrode
Sunset January 2022
repositioned)
(Do not report 0460T in conjunction with 33993, 0451T,
0454T)
use 33993)
0461T aortic counterpulsation device
Sunset January 2022
use 33993)
adjustment of the implantable mechano-electrical skin
interface and/or external driver to test the function of the
device and select optimal permanent programmed values
with analysis, including review and report, implantable
aortic counterpulsation ventricular assist system, per day
Sunset January 2022
0463T)
review and report, includes connection, recording and
disconnection per patient encounter, implantable aortic
counterpulsation ventricular assist system, per day
Sunset January 2022
(Do not report 0463T in conjunction with 0451T-0462T)
(Do not report 0451T-0463T in conjunction with 36000,
36002, 36005, 36010, 36200-36228, 75600-75774, 76000,
76936, 76937, 77001, 77002, 77011, 77012, 77021, 93451-
93533, 93561-93572)
0465T Suprachoroidal injection of a pharmacologic agent (does not
include supply of medication)
Sunset January 2023
(To report intravitreal injection/implantation, see 67025,
67027, 67028)
✚ 0466T Insertion of chest wall respiratory sensor electrode or
electrode array, including connection to pulse generator
Sunset January 2023
0467T Revision or replacement of chest wall respiratory sensor
electrode or electrode array, including connection to
Sunset January 2023
(For revision or replacement of cranial nerve [eg, vagus
nerve] neurostimulator electrode array, including connection
to existing pulse generator, use 64569)
0468T Removal of chest wall respiratory sensor electrode or
electrode array
Sunset January 2023
(For removal of cranial nerve [eg, vagus nerve]
neurostimulator electrode array and pulse generator, use
64570)
0469T Retinal polarization scan, ocular screening with on-site
automated results, bilateral
Sunset January 2023
92012, 92014)
(For ocular photoscreening, see 99174, 99177)
0470T Optical coherence tomography (OCT) for microstructural
and morphological imaging of skin, image acquisition,
interpretation, and report; first lesion
Sunset January 2023
✚ 0471T each additional lesion (List separately in addition to
Sunset January 2023
(For optical coherence tomography for coronary vessel or
graft, see 92978, 92979)
(For reflectance confocal microscopy [RCM] of the skin,
see 96931, 96932, 96933, 96934, 96935, 96936)
0472T Device evaluation, interrogation, and initial programming of
intraocular retinal electrode array (eg, retinal prosthesis), in
person, with iterative adjustment of the implantable device
to test functionality, select optimal permanent programmed
values with analysis, including visual training, with review
and report by a qualified health care professional
Sunset January 2023
0473T Device evaluation and interrogation of intraocular retinal
electrode array (eg, retinal prosthesis), in person, including
reprogramming and visual training, when performed, with
review and report by a qualified health care professional
Sunset January 2023
(For implantation of intraocular electrode array, use 0100T)
(For reprogramming of implantable intraocular retinal
electrode array device, use 0473T)
0474T Insertion of anterior segment aqueous drainage device, with
creation of intraocular reservoir, internal approach, into the
supraciliary space
Sunset January 2023
➲ CPT Assistant Feb 18:3, Jul 18:3, Dec 18:9
0475T Recording of fetal magnetic cardiac signal using at least 3
channels; patient recording and storage, data scanning with
signal extraction, technical analysis and result, as well as
supervision, review, and interpretation of report by a
Sunset January 2023
0476T patient recording, data scanning, with raw electronic
signal transfer of data and storage
Sunset January 2023
0477T signal extraction, technical analysis, and result
Sunset January 2023
0478T review, interpretation, report by physician or other
Sunset January 2023
0479T Fractional ablative laser fenestration of burn and traumatic
scars for functional improvement; first 100 cm2 or part
thereof, or 1% of body surface area of infants and children
Sunset January 2023
✚ 0480T each additional 100 cm2, or each additional 1% of body
surface area of infants and children, or part thereof (List
Sunset January 2023
(Report 0479T, 0480T only once per day)
(Do not report 0479T, 0480T in conjunction with 0492T)
(For excision of cicatricial lesion[s] [eg, full thickness
excision, through the dermis], see 11400-11446)
0481T Injection(s), autologous white blood cell concentrate
(autologous protein solution), any site, including image
guidance, harvesting and preparation, when performed
Sunset January 2023
15772, 15773, 15774, 20550, 20551, 20600, 20604, 20605,
20606, 20610, 20611, 36415, 36592, 76942, 77002, 77012,
77021, 86965, 0232T)
(Do not report 38220, 38221, 38222, 38230 for bone
marrow aspiration for autologous white blood cell
concentrate [autologous protein solution] injection. For bone
marrow aspiration for autologous white blood cell
concentrate [autologous protein solution] injection, use
0481T)
(For absolute quantitation of myocardial blood flow
[AQMBF] for cardiac PET, use 78434)
Codes 0483T, 0484T include vascular access, catheterization,
balloon valvuloplasty, deploying the valve, repositioning the
valve as needed, temporary pacemaker insertion for rapid pacing,
and access site closure, when performed.
Angiography, radiological supervision and interpretation,
intraprocedural roadmapping (eg, contrast injections,
fluoroscopy) to guide the TMVI, left ventriculography (eg, to
assess mitral regurgitation for guidance of TMVI), and
completion angiography are included in codes 0483T, 0484T.
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530,
93531, 93532, 93533) should not be used with 0483T, 0484T to
report:
1. contrast injections, angiography, roadmapping, and/or
fluoroscopic guidance for the transcatheter mitral valve
implantation (TMVI),
2. left ventricular angiography to assess or confirm valve
positioning and function,
3. right and left heart catheterization for hemodynamic
measurements before, during, and after TMVI for guidance of
TMVI.
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530,
(93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93563,
93564) performed at the time of TMVI may be separately
reportable, if:
1. no prior study is available and a full diagnostic study is
performed, or
2. a prior study is available, but as documented in the medical
record:
a. there is inadequate visualization of the anatomy and/or
pathology, or
b. the patient’s condition with respect to the clinical indication
c. there is a clinical change during the procedure that requires
new evaluation.
code(s) appended with modifier 59, indicating separate and
distinct procedural service from TMVI.
TMVI, 0483T, 0484T may be reported with the appropriate add-
on code for percutaneous peripheral bypass (33367), open
For percutaneous transcatheter tricuspid valve annulus
reconstruction, with implantation of adjustable annulus
reconstruction device, use 0545T.
0483T Transcatheter mitral valve implantation/replacement
(TMVI) with prosthetic valve; percutaneous approach,
including transseptal puncture, when performed
Sunset January 2023
0544T)
see 33418, 33419)
0484T transthoracic exposure (eg, thoracotomy, transapical)
Sunset January 2023
0485T Optical coherence tomography (OCT) of middle ear, with
interpretation and report; unilateral
Sunset January 2023
0486T bilateral
Sunset January 2023
0487T Biomechanical mapping, transvaginal, with report
Sunset January 2023
0489T Autologous adipose-derived regenerative cell therapy for
scleroderma in the hands; adipose tissue harvesting,
isolation and preparation of harvested cells including
incubation with cell dissociation enzymes, removal of non-
viable cells and debris, determination of concentration and
dilution of regenerative cells
Sunset January 2023
15772, 15773, 15774, 15876, 15877, 15878, 15879, 20600,
20604)
0490T multiple injections in one or both hands
Sunset January 2023
15772, 15773, 15774, 15876, 15877, 15878, 15879, 20600,
20604)
(Do not report 0490T for a single injection)
(For complete procedure, use 0490T in conjunction with
0489T)
0491T Ablative laser treatment, non-contact, full field and
fractional ablation, open wound, per day, total treatment
surface area; first 20 sq cm or less
Sunset January 2023
✚ 0492T each additional 20 sq cm, or part thereof (List separately
Sunset January 2023
0493T Near-infrared spectroscopy studies of lower extremity
wounds (eg, for oxyhemoglobin measurement)
Sunset January 2023
0494T Surgical preparation and cannulation of marginal (extended)
cadaver donor lung(s) to ex vivo organ perfusion system,
including decannulation, separation from the perfusion
system, and cold preservation of the allograft prior to
implantation, when performed
Sunset January 2023
0495T Initiation and monitoring marginal (extended) cadaver donor
lung(s) organ perfusion system by physician or qualified
health care professional, including physiological and
laboratory assessment (eg, pulmonary artery flow,
pulmonary artery pressure, left atrial pressure, pulmonary
vascular resistance, mean/peak and plateau airway pressure,
dynamic compliance and perfusate gas analysis), including
bronchoscopy and X ray when performed; first two hours in
sterile field
Sunset January 2023
✚ 0496T each additional hour (List separately in addition to code
Sunset January 2023
(Report 0496T in conjunction with 0495T)
0497T External patient-activated, physician- or other qualified
health care professional-prescribed, electrocardiographic
rhythm derived event recorder without 24-hour attended
monitoring; in-office connection
Sunset January 2023
0498T review and interpretation by a physician or other
qualified health care professional per 30 days with at
least one patient-generated triggered event
Sunset January 2023
▶ (Donot report 0497T, 0498T in conjunction with 93040,
93041, 93042, 93228, 93229, 93268, 93271, 93272)◀
0499T Cystourethroscopy, with mechanical dilation and urethral
therapeutic drug delivery for urethral stricture or stenosis,
including fluoroscopy, when performed
Sunset January 2023
0500T Infectious agent detection by nucleic acid (DNA or RNA),
Human Papillomavirus (HPV) for five or more separately
reported high-risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45,
51, 52, 56, 58, 59, 68) (ie, genotyping)
Sunset January 2023
(For reporting four or fewer separately reported high-risk
HPV types, see 87624, 87625)
(For reporting of separately reported high-risk Human
Papillomavirus [HPV] types 16, 18 and 45, if performed,
use 87625)
(Do not report 0500T in conjunction with 87624 or 87625
for the same procedure)
0501T Noninvasive estimated coronary fractional flow reserve
(FFR) derived from coronary computed tomography
angiography data using computation fluid dynamics
physiologic simulation software analysis of functional data
to assess the severity of coronary artery disease; data
preparation and transmission, analysis of fluid dynamics and
simulated maximal coronary hyperemia, generation of
estimated FFR model, with anatomical data review in
comparison with estimated FFR model to reconcile
discordant data, interpretation and report
Sunset January 2023
0502T data preparation and transmission
Sunset January 2023
0503T analysis of fluid dynamics and simulated maximal
coronary hyperemia, and generation of estimated FFR
model
Sunset January 2023
0504T anatomical data review in comparison with estimated
FFR model to reconcile discordant data, interpretation
and report
Sunset January 2023
(Report 0501T, 0502T, 0503T, 0504T one time per
coronary CT angiogram)
0504T, 0523T)
▶ (Forautomated quantification and characterization of
coronary plaque using coronary computed tomographic
#● 0623T Automated quantification and characterization of coronary
atherosclerotic plaque to assess severity of coronary
disease, using data from coronary computed tomographic
angiography; data preparation and transmission,
computerized analysis of data, with review of computerized
analysis output to reconcile discordant data, interpretation
and report
Sunset January 2026
#● 0624T data preparation and transmission
Sunset January 2026
#● 0625T computerized analysis of data from coronary computed
tomographic angiography
Sunset January 2026
#● 0626T review of computerized analysis output to reconcile
discordant data, interpretation and report
Sunset January 2026
▶ (Use0623T, 0624T, 0625T, 0626T one time per coronary
computed tomographic angiogram)◀
▶ (Donot report 0623T in conjunction with 0624T, 0625T,
0626T)◀
▶ (Do not report 0623T, 0624T, 0625T, 0626T in
conjunction with 76376, 76377)◀
▶ (Fornoninvasive estimated coronary fractional flow
reserve [FFR] derived from coronary computed tomography
#✚ 0523T Intraprocedural coronary fractional flow reserve (FFR) with
3D functional mapping of color-coded FFR values for the
coronary tree, derived from coronary angiogram data, for
real-time review and interpretation of possible
atherosclerotic stenosis(es) intervention (List separately in
Sunset January 2024
93457, 93458, 93459, 93460, 93461)
(Do not report 0523T more than once per session)
93571, 93572, 0501T, 0502T, 0503T, 0504T)
0505T Endovenous femoral-popliteal arterial revascularization,
with transcatheter placement of intravascular stent graft(s)
and closure by any method, including percutaneous or open
vascular access, ultrasound guidance for vascular access
when performed, all catheterization(s) and intraprocedural
roadmapping and imaging guidance necessary to complete
the intervention, all associated radiological supervision and
interpretation, when performed, with crossing of the
occlusive lesion in an extraluminal fashion
Sunset January 2024
(0505T includes all ipsilateral selective arterial and venous
catheterization, all diagnostic imaging for ipsilateral, lower
extremity arteriography, and all related radiological
supervision and interpretation)
37226, 37227, 37238, 37239, 37248, 37249, within the
femoral-popliteal segment)
(Do not report 0505T in conjunction with 76937, for
ultrasound guidance for vascular access)
#● 0620T Endovascular venous arterialization, tibial or peroneal vein,
with transcatheter placement of intravascular stent graft(s)
and closure by any method, including percutaneous or open
vascular access, ultrasound guidance for vascular access
when performed, all catheterization(s) and intraprocedural
roadmapping and imaging guidance necessary to complete
the intervention, all associated radiological supervision and
interpretation, when performed
Sunset January 2026
▶ (0620T includes all ipsilateral selective arterial and
venous catheterization, all diagnostic imaging for ipsilateral,
lower extremity arteriography, and all related radiological
supervision and interpretation)◀
▶ (Do not report 0620T in conjunction with 37228, 37229,
37230, 37231, 37238, 37239, 37248, 37249 within the
tibial-peroneal segment)◀
0506T Macular pigment optical density measurement by
heterochromatic flicker photometry, unilateral or bilateral,
with interpretation and report
Sunset January 2024
0507T Near infrared dual imaging (ie, simultaneous reflective and
transilluminated light) of meibomian glands, unilateral or
bilateral, with interpretation and report
Sunset January 2024
(For external ocular photography, use 92285)
0508T Pulse-echo ultrasound bone density measurement resulting in
indicator of axial bone mineral density, tibia
Sunset January 2024
Electroretinography (ERG) is used to evaluate function of the
retina and optic nerve of the eye, including photoreceptors and
ganglion cells. A number of techniques that target different areas
of the eye, including full field (flash and flicker) (92273) for a
global response of photoreceptors of the retina, multifocal
(92274) for photoreceptors in multiple separate locations in the
retina, including the macula, and pattern (0509T) for retinal
ganglion cells, are used. Multiple additional terms and techniques
are used to describe various types of ERG. If the technique used
is not specifically named in the code descriptors for 92273,
92274, 0509T, use the unlisted procedure code 92499.
0509T Electroretinography (ERG) with interpretation and report,
pattern (PERG)
Sunset January 2024
(For full-field ERG, use 92273)
(For multifocal ERG, use 92274)
✚ 0514T Intraoperative visual axis identification using patient
fixation (List separately in addition to code for primary
procedure)
Sunset January 2024
(Use 0514T in conjunction with 66982, 66984)
Wireless Cardiac Stimulation System for Left

Ventricular Pacing
A wireless cardiac stimulator system provides biventricular
pacing by sensing right ventricular pacing output from a
previously implanted conventional device (pacemaker or
defibrillator, with univentricular or biventricular leads), and then
transmitting an ultrasound pulse to a wireless electrode implanted
on the endocardium of the left ventricle, which then emits a left
ventricular pacing pulse.
The complete system consists of two components: a wireless
endocardial left ventricle electrode and a pulse generator. The
pulse generator has two components: a transmitter and a battery.
The electrode is implanted transarterially into the left ventricular
wall and powered wirelessly using ultrasound delivered by a
subcutaneously implanted transmitter. Two subcutaneous pockets
are created on the chest wall, one for the battery and one for the
transmitter, and these two components are connected by a
subcutaneously tunneled cable.
Patients with a wireless cardiac stimulator require
programming/interrogation of their existing conventional device,
as well as the wireless device. The wireless cardiac stimulator is
programmed and interrogated with its own separate programmer
and settings.
Code 0515T describes insertion of a complete wireless cardiac
stimulator system (electrode and pulse generator, which includes
transmitter and battery), including interrogation, programming,
pocket creation, revision and repositioning, and all
echocardiography and other imaging to guide the procedure,
when performed. Use 0516T only when insertion of the electrode
is a stand-alone procedure. For insertion of only a new generator
or generator component (battery and/or transmitter), use 0517T.
For removal of only the generator or a generator component
(battery and/or transmitter) without replacement, use 0518T. For
removal and replacement of a generator or a generator
component (battery and/or transmitter), use 0519T. For battery
and/or generator removal and reinsertion performed together
with a new electrode insertion, use 0520T.
All catheterization and imaging guidance (including transthoracic
or transesophageal echocardiography) required to complete a
wireless cardiac stimulator procedure is included in 0515T,
0516T, 0517T, 0518T, 0519T, 0520T. Do not report 76000, 76998,
93303-93355 in conjunction with 0515T, 0516T, 0517T, 0518T,
0519T, 0520T.
Do not report left heart catheterization codes (93452, 93453,
93458, 93459, 93460, 93461, 93531, 93532, 93533) for delivery of
a wireless cardiac stimulator electrode into the left ventricle.
0515T Insertion of wireless cardiac stimulator for left ventricular
pacing, including device interrogation and programming,
and imaging supervision and interpretation, when
performed; complete system (includes electrode and
generator [transmitter and battery])
Sunset January 2024
0516T electrode only
Sunset January 2024
0517T pulse generator component(s) (battery and/or transmitter)
only
Sunset January 2024
0518T, 0519T, 0520T, 0521T, 0522T)
0518T Removal of only pulse generator component(s) (battery
and/or transmitter) of wireless cardiac stimulator for left
ventricular pacing
Sunset January 2024
0517T, 0519T, 0520T, 0521T, 0522T)
0519T Removal and replacement of wireless cardiac stimulator for
left ventricular pacing; pulse generator component(s)
(battery and/or transmitter)
Sunset January 2024
0520T pulse generator component(s) (battery and/or
transmitter), including placement of a new electrode
Sunset January 2024
0516T, 0517T, 0518T, 0521T, 0522T)
review and report, includes connection, recording, and
disconnection per patient encounter, wireless cardiac
stimulator for left ventricular pacing
Sunset January 2024
0517T, 0518T, 0519T, 0520T, 0522T)
adjustment of the implantable device to test the function of
the device and select optimal permanent programmed values
with analysis, including review and report, wireless cardiac
stimulator for left ventricular pacing
Sunset January 2024
0517T, 0518T, 0519T, 0520T, 0521T)
0524T Endovenous catheter directed chemical ablation with
balloon isolation of incompetent extremity vein, open or
percutaneous, including all vascular access, catheter
manipulation, diagnostic imaging, imaging guidance and
monitoring
Sunset January 2024
0525T Insertion or replacement of intracardiac ischemia monitoring
system, including testing of the lead and monitor, initial
system programming, and imaging supervision and
interpretation; complete system (electrode and implantable
monitor)
Sunset January 2024
Sunset January 2024
0527T implantable monitor only
Sunset January 2024
93000, 93005, 93010, 0528T, 0529T)
(For removal and replacement of intracardiac ischemia
monitoring system or its components, see 0525T, 0526T,
0527T in conjunction with 0530T, 0531T, 0532T, as
appropriate)
0528T Programming device evaluation (in person) of intracardiac
ischemia monitoring system with iterative adjustment of
programmed values, with analysis, review, and report
Sunset January 2024
93010, 0525T, 0526T, 0527T, 0529T, 0530T, 0531T,
0532T)
0529T Interrogation device evaluation (in person) of intracardiac
ischemia monitoring system with analysis, review, and
report
Sunset January 2024
93010, 0525T, 0526T, 0527T, 0528T, 0530T, 0531T,
0532T)
0530T Removal of intracardiac ischemia monitoring system,
including all imaging supervision and interpretation;
complete system (electrode and implantable monitor)
Sunset January 2024
Sunset January 2024
0532T implantable monitor only
Sunset January 2024
0528T, 0529T)
0533T Continuous recording of movement disorder symptoms,
including bradykinesia, dyskinesia, and tremor for 6 days up
to 10 days; includes set-up, patient training, configuration of
monitor, data upload, analysis and initial report
configuration, download review, interpretation and report
Sunset January 2024
0534T set-up, patient training, configuration of monitor
Sunset January 2024
0535T data upload, analysis and initial report configuration
Sunset January 2024
0536T download review, interpretation and report
Sunset January 2024
Cellular and Gene Therapy
Cellular and gene therapies involve the collection, processing and
handling of cells or other tissues, genetic modification of those
cells or tissues, and administration of the genetically modified
cells or tissues with the intent to treat, modify, reverse or cure a
serious or life-threatening disease or condition.
Codes 0537T, 0538T, 0539T, 0540T describe the various steps
required to collect, prepare, transport, receive, and administer
genetically modified T cells. The collection and handling code
(0537T) may be reported only once per day, regardless of the
number of collections or quantity of cells collected. Similarly, the
administration code (0540T) may only be reported once per day,
regardless of the number of units administered. The development
of genetically modified cells is not reported with this family of
codes.
Chimeric antigen receptor therapy (CAR-T) with genetically
modified T cells begins with the collection of cells from the
patient by peripheral blood leukocyte cell harvesting. The cells
are then cryopreserved and/or otherwise prepared for processing
or shipping to a manufacturing or cell processing facility, if
applicable, where gene modification and expansion of the cells is
performed. When gene modification and expansion of the cells
by the manufacturer is complete, the genetically modified cells
are returned to the physician or other qualified health care
professional in which additional preparation occurs including
thawing of the cryopreserved CAR-T cells, if necessary, before
the cells are administered to the patient.
The procedure to administer CAR-T cells includes physician
monitoring of multiple physiologic parameters, physician
verification of cell processing, evaluation of the patient during, as
well as immediately before and after the administration of the
CAR-T cells, physician presence during the administration and
direct supervision of clinical staff, and management of any
adverse events during the administration. Care on the same date
of service that is not directly related to the service of
administration of the CAR-T cells (eg, care provided after the
administration is complete, care for the patient’s underlying
condition or for other medical problems) may be separately
reported using the appropriate evaluation and management code
with modifier 25. Management of uncomplicated adverse events
(eg, nausea, urticaria) during the infusion is not reported
separately.
The fluid used to administer the cells and other infusions for
incidental hydration (eg, 96360, 96361) are not reported
separately. Similarly, infusion(s) of any supportive medication(s)
(eg, steroids) concurrently with the CAR-T cell administration are
not reported separately. However, hydration or administration of
medications (eg, antibiotics, opioids) unrelated to the CAR-T
administration may be reported separately with modifier 59.
0537T Chimeric antigen receptor T-cell (CAR-T) therapy;
harvesting of blood-derived T lymphocytes for development
of genetically modified autologous CAR-T cells, per day
Sunset January 2024
0538T preparation of blood-derived T lymphocytes for
transportation (eg, cryopreservation, storage)
Sunset January 2024
0539T receipt and preparation of CAR-T cells for
administration
Sunset January 2024
0540T CAR-T cell administration, autologous
Sunset January 2024
0541T Myocardial imaging by magnetocardiography (MCG) for
detection of cardiac ischemia, by signal acquisition using
minimum 36 channel grid, generation of magnetic-field time-
series images, quantitative analysis of magnetic dipoles,
machine learning–derived clinical scoring, and automated
report generation, single study;
Sunset January 2024
0542T interpretation and report
Sunset January 2024
0543T Transapical mitral valve repair, including transthoracic
echocardiography, when performed, with placement of
artificial chordae tendineae
Sunset January 2025
(For transesophageal echocardiography image guidance, use
93355)
Codes 0544T and 0545T include vascular access, catheterization,
deploying and adjusting the reconstruction device(s), temporary
pacemaker insertion for rapid pacing if required, and access site
closure, when performed.
Angiography, radiological supervision and interpretation,
intraprocedural roadmapping (eg, contrast injections,
fluoroscopy) to guide the device implantation, ventriculography
(eg, to assess target valve regurgitation for guidance of device
implantation and adjustment), and completion angiography are
included in 0544T and 0545T.
93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460,
93461, 93530, 93531, 93532, 93533, 93565, 93566) may not be
used in conjunction with 0544T, 0545T to report:
1. contrast injections, angiography, road-mapping, and/or
fluoroscopic guidance for the implantation and adjustment of
the transcatheter mitral or tricuspid valve annulus
reconstruction device, or
2. right or left ventricular angiography to assess or confirm
transcatheter mitral or tricuspid valve annulus reconstruction
device positioning and function, or
3. right and left heart catheterization for hemodynamic
measurements before, during, and after transcatheter mitral or
tricuspid valve annulus reconstruction for guidance.
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530,
(93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93563,
93564) performed at the time of transcatheter mitral or tricuspid
valve annulus reconstruction may be separately reportable if:
1. no prior study is available and a full diagnostic study is
performed, or
2. a prior study is available, but as documented in the medical
record:
a. there is inadequate visualization of the anatomy and/or
pathology, or
b. the patient’s condition with respect to the clinical indication
c. there is a clinical change during the procedure that requires
new evaluation.
Other cardiac catheterization services may be reported separately,
when performed for diagnostic purposes not intrinsic to the
transcatheter mitral valve annulus reconstruction.
code(s) appended with modifier 59 indicating separate and
distinct procedural service from transcatheter mitral or tricuspid
valve annulus reconstruction.
transcatheter mitral valve or tricuspid valve annulus
reconstruction, 0544T, 0545T should be reported with the
appropriate add-on code for percutaneous peripheral bypass
(33367), open peripheral bypass (33368), or central bypass
(33369).
When transcatheter ventricular support is required, the
appropriate code may be reported with the appropriate
ventricular assist device (VAD) procedure (33990, 33991, 33992,
33993) or balloon pump insertion (33967, 33970, 33973).
For percutaneous transcatheter mitral valve repair, use 0345T. For
percutaneous transcatheter mitral valve implantation/replacement
(TMVI) with prosthetic valve, use 0483T.
0544T Transcatheter mitral valve annulus reconstruction, with
implantation of adjustable annulus reconstruction device,
percutaneous approach including transseptal puncture
Sunset January 2025
see 33418, 33419)
[TMVI] with prosthetic valve percutaneous approach, use
0483T)
0545T Transcatheter tricuspid valve annulus reconstruction with
implantation of adjustable annulus reconstruction device,
percutaneous approach
Sunset January 2025
(Do not report 0544T, 0545T in conjunction with 76000)
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461,
93530, 93531, 93532, 93533, 93565, 93566 for diagnostic
left and right heart catheterization procedures intrinsic to the
annular repair procedure)
93455, 93456, 93457, 93458, 93459, 93460, 93461, 93563,
93564 for coronary angiography procedures intrinsic to the
annular repair procedure)
0546T Radiofrequency spectroscopy, real time, intraoperative
margin assessment, at the time of partial mastectomy, with
report
Sunset January 2025
(Use 0546T only once for each partial mastectomy site)
(Do not report 0546T for re-excision)
0547T Bone-material quality testing by microindentation(s) of the
tibia(s), with results reported as a score
Sunset January 2025
0548T Transperineal periurethral balloon continence device;
bilateral placement, including cystoscopy and fluoroscopy
Sunset January 2025
0549T unilateral placement, including cystoscopy and
fluoroscopy
Sunset January 2025
0550T removal, each balloon
Sunset January 2025
0551T adjustment of balloon(s) fluid volume
Sunset January 2025
0550T)
0552T Low-level laser therapy, dynamic photonic and dynamic
thermokinetic energies, provided by a physician or other
Sunset January 2025
0553T Percutaneous transcatheter placement of iliac arteriovenous
anastomosis implant, inclusive of all radiological
supervision and interpretation, intraprocedural
roadmapping, and imaging guidance necessary to complete
the intervention
Sunset January 2025
36012, 36140, 36245, 36246, 37220, 37221, 37224, 37226,
37238, 37248, 75710, 75820)
0554T Bone strength and fracture risk using finite element analysis
of functional data and bone-mineral density utilizing data
from a computed tomography scan; retrieval and
transmission of the scan data, assessment of bone strength
and fracture risk and bone-mineral density, interpretation
and report
Sunset January 2025
0557T)
0555T retrieval and transmission of the scan data
Sunset January 2025
0556T assessment of bone strength and fracture risk and bone-
mineral density
Sunset January 2025
0557T interpretation and report
Sunset January 2025
0558T Computed tomography scan taken for the purpose of
biomechanical computed tomography analysis
Sunset January 2025
71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130,
72131, 72132, 72133, 72191, 72192, 72193, 72194, 74150,
74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261,
74262, 74263, 75571, 75572, 75573, 75574, 75635, 78816)
Codes 0559T, 0560T represent production of 3D-printed models
of individually prepared and processed components of structures
of anatomy. These individual components of structures of
anatomy include, but are not limited to, bones, arteries, veins,
nerves, ureters, muscles, tendons and ligaments, joints, visceral
organs, and brain. Each 3D-printed anatomic model of a structure
can be made up of one or more separate components. The 3D
anatomic printings can be 3D printed in unique colors and/or
materials.
Codes 0561T, 0562T represent the production of 3D-printed
cutting or drilling guides using individualized imaging data. 3D-
printed guides are cutting or drilling tools used during surgery
and are 3D printed so that they precisely fit an individual patient’s
anatomy to guide the surgery. A cutting guide does not have
multiple parts, but instead is a unique single tool. It may be
necessary to make a 3D-printed model and a 3D-printed cutting
or drilling guide on the same patient to assist with surgery.
0559T Anatomic model 3D-printed from image data set(s); first
individually prepared and processed component of an
anatomic structure
Sunset January 2025
✚ 0560T each additional individually prepared and processed
component of an anatomic structure (List separately in
Sunset January 2025
76377)
0561T Anatomic guide 3D-printed and designed from image data
set(s); first anatomic guide
Sunset January 2025
✚ 0562T each additional anatomic guide (List separately in
Sunset January 2025
76377)
0564T Oncology, chemotherapeutic drug cytotoxicity assay of
cancer stem cells (CSCs), from cultured CSCs and primary
tumor cells, categorical drug response reported based on
percent of cytotoxicity observed, a minimum of 14 drugs or
drug combinations
Sunset January 2025
0565T Autologous cellular implant derived from adipose tissue for
the treatment of osteoarthritis of the knees; tissue harvesting
and cellular implant creation
Sunset January 2025
15772, 15773, 15774)
0566T injection of cellular implant into knee joint including
ultrasound guidance, unilateral
Sunset January 2025
76942, 77002)
(For bilateral procedure, report 0566T with modifier 50)
0567T Permanent fallopian tube occlusion with degradable
biopolymer implant, transcervical approach, including
transvaginal ultrasound
Sunset January 2025
74740, 74742, 76830, 76856, 76857)
0568T Introduction of mixture of saline and air for
sonosalpingography to confirm occlusion of fallopian tubes,
transcervical approach, including transvaginal ultrasound
and pelvic ultrasound
Sunset January 2025
74742, 76830, 76831, 76856, 76857)
Tricuspid Valve Repair

Codes 0569T, 0570T include the work of percutaneous vascular
access, placing the access sheath, cardiac catheterization,
advancing the repair device system into position, repositioning
the prosthesis as needed, deploying the prosthesis, and vascular
closure. Code 0569T may only be reported once per session.
Add-on code 0570T is reported in conjunction with 0569T for
each additional prosthesis placed.
For open tricuspid valve procedures, see 33460, 33463, 33464,
33465, 33468.
Angiography, radiological supervision and interpretation
performed to guide transcatheter tricuspid valve repair (TTVr)
(eg, guiding device placement and documenting completion of
the intervention) are included in these codes.
Intracardiac echocardiography (93662), when performed, is
included in 0569T, 0570T. Transesophageal echocardiography
(93355) performed by a separate operator for guidance of the
procedure may be separately reported.
Fluoroscopy (76000) and diagnostic right and left heart
catheterization codes (93451, 93452, 93453, 93456, 93457, 93458,
93459, 93460, 93461, 93530, 93531, 93532, 93533, 93566) may
not be used with 0569T, 0570T to report the following techniques
for guidance of TTVr:
fluoroscopic guidance for the TTVr,
2. Right ventricular angiography to assess tricuspid regurgitation
for guidance of TTVr, or
3. Right and left heart catheterization for hemodynamic
measurements before, during, and after TTVr for guidance of
TTVr.
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461, 93530,
93531, 93532, 93533, 93566) and diagnostic coronary
angiography codes (93454, 93455, 93456, 93457, 93458, 93459,
93460, 93461, 93563, 93564) may be reported with 0569T, 0570T,
representing separate and distinct services from TTVr, if:
1. No prior study is available, and a full diagnostic study is
performed, or
record:
a. There is inadequate evaluation of the anatomy and/or
pathology, or
new diagnostic evaluation.
when performed for diagnostic purposes not intrinsic to TTVr.
code(s) with modifier 59 indicating separate and distinct
procedural service from TTVr.
When transcatheter ventricular support is required in conjunction
with TTVr, the procedure may be reported with the appropriate
ventricular assist device (VAD) procedure code (33990, 33991,
33992, 33993) or balloon pump insertion code (33967, 33970,
33973).
TTVr, 0569T, 0570T may be reported with the appropriate add-on
code for percutaneous peripheral bypass (33367), open
0569T Transcatheter tricuspid valve repair, percutaneous approach;
initial prosthesis
Sunset January 2025
✚ 0570T each additional prosthesis during same session (List
Sunset January 2025
93452, 93453, 93456, 93457, 93458, 93459, 93460, 93461,
93566 for diagnostic left and right heart catheterization
procedures intrinsic to the valve repair procedure)
93563, 93564 for coronary angiography intrinsic to the
valve repair procedure)
Implantable Cardioverter-Defibrillator with

Substernal Electrode
▶An implantable cardioverter-defibrillator system with
substernal electrode (substernal implantable cardioverter-
defibrillator) consists of a pulse generator and at least one
substernal electrode. The generator is placed in a subcutaneous
pocket over the lateral rib cage. The electrode is tunneled
subcutaneously and placed into the substernal anterior
mediastinum, without entering the pericardial cavity. The
electrode performs defibrillation and antitachycardia pacing, but
not chronic pacing. The system requires programming and
interrogation of the device.◀
All imaging guidance (eg, fluoroscopy) required to complete the
substernal implantable defibrillator procedure is included in
0571T, 0572T, 0573T, 0574T. The work of implantation, removal,
repositioning, interrogation, or programming of substernal
implantable cardioverter-defibrillator systems, generators, or
leads may not be reported using 33202-33275, 93260-93298,
93640, 93641, 93642, 93644.
0571T Insertion or replacement of implantable cardioverter-
defibrillator system with substernal electrode(s), including
all imaging guidance and electrophysiological evaluation
(includes defibrillation threshold evaluation, induction of
arrhythmia, evaluation of sensing for arrhythmia termination,
and programming or reprogramming of sensing or
therapeutic parameters), when performed
Sunset January 2025
(Use 0571T in conjunction with 0573T, 0580T for removal
and replacement of an implantable defibrillator pulse
generator and substernal electrode)
93644, 0572T, 0575T, 0576T, 0577T)
(For insertion or replacement of permanent subcutaneous
implantable defibrillator system with subcutaneous
electrode, use 33270)
0572T Insertion of substernal implantable defibrillator electrode
Sunset January 2025
93644, 0571T, 0575T, 0576T, 0577T, 0580T)◀
(For insertion of subcutaneous implantable defibrillator
0573T Removal of substernal implantable defibrillator electrode
Sunset January 2025
▶ (Use 0573T in conjunction with 0580T for removal of
substernal electrode in conjunction with removal of
implantable defibrillator pulse generator without
replacement)◀
93644, 0575T, 0576T, 0577T)
(For removal of subcutaneous implantable defibrillator
0574T Repositioning of previously implanted substernal
implantable defibrillator-pacing electrode
Sunset January 2025
93644, 0572T, 0575T, 0576T, 0577T)◀
(For repositioning of previously implanted subcutaneous
implantable defibrillator electrode, use 33273)
0575T Programming device evaluation (in person) of implantable
cardioverter-defibrillator system with substernal electrode,
with iterative adjustment of the implantable device to test
the function of the device and select optimal permanent
programmed values with analysis, review and report by a
Sunset January 2025
▶ (Do not report 0575T in conjunction with pulse generator
or lead insertion, removal or repositioning codes 0571T,
0572T, 0573T, 0574T, 0580T, 0614T)◀
93287, 0576T)
0576T Interrogation device evaluation (in person) of implantable
cardioverter-defibrillator system with substernal electrode,
with analysis, review and report by a physician or other
qualified health care professional, includes connection,
recording and disconnection per patient encounter
Sunset January 2025
▶ (Do not report 0576T in conjunction with pulse generator
or lead insertion, removal or repositioning codes 0571T,
0572T, 0573T, 0574T, 0580T, 0614T)◀
0575T)
▲ 0577T Electrophysiologic evaluation of implantable cardioverter-
defibrillator system with substernal electrode (includes
defibrillation threshold evaluation, induction of arrhythmia,
evaluation of sensing for arrhythmia termination, and
programming or reprogramming of sensing or therapeutic
parameters)
Sunset January 2025
93642, 93644, 0571T at the time of insertion or replacement
of implantable defibrillator system with substernal lead)
▶ (Donot report 0577T in conjunction with 0580T,
0614T)◀
▶ (For electrophysiologic evaluation of subcutaneous
implantable defibrillator system with subcutaneous
electrode, use 93644)◀
0578T Interrogation device evaluation(s) (remote), up to 90 days,
substernal lead implantable cardioverter-defibrillator
system with interim analysis, review(s) and report(s) by a
Sunset January 2025
93297, 93298, 0576T)
(Report 0578T only once per 90 days)
0579T Interrogation device evaluation(s) (remote), up to 90 days,
substernal lead implantable cardioverter-defibrillator
system, remote data acquisition(s), receipt of transmissions
and technician review, technical support and distribution of
results
Sunset January 2025
(Do not report 0579T in conjunction with 93296, 0576T)
(Report 0579T only once per 90 days)
0580T Removal of substernal implantable defibrillator pulse
generator only
Sunset January 2025
▶ (Use 0580T in conjunction with 0573T for removal of
substernal electrode in conjunction with removal of
implantable defibrillator pulse generator without
replacement)◀
(Use 0580T in conjunction with 0571T, 0573T for removal
and replacement of an implantable cardioverter-defibrillator
and substernal electrode[s])
▶ (Donot report 0580T in conjunction with 0575T, 0576T,
0577T, 0614T)◀
#● 0614T Removal and replacement of substernal implantable
defibrillator pulse generator
Sunset January 2026
▶ (Donot report 0614T in conjunction with 33262, 0571T,
0572T, 0575T, 0576T, 0577T, 0580T)◀
0581T Ablation, malignant breast tumor(s), percutaneous,
cryotherapy, including imaging guidance when performed,
unilateral
Sunset January 2025
(Report 0581T only once per breast treated)
76940, 76942)
(For cryoablation of breast fibroadenoma[s], use 19105)
0582T Transurethral ablation of malignant prostate tissue by high-
energy water vapor thermotherapy, including intraoperative
imaging and needle guidance
Sunset January 2025
72196, 72197, 76376, 76377, 76872, 76940, 76942, 77021,
77022)
(For transurethral destruction of prostate tissue by
radiofrequency-generated water vapor thermotherapy for
benign prostatic hypertrophy [BPH], use 53854)
0583T Tympanostomy (requiring insertion of ventilating tube),
using an automated tube delivery system, iontophoresis local
anesthesia
Sunset January 2025
69420, 69421, 69433, 69436, 69990, 92504, 97033)
(For bilateral procedure, report 0583T with modifier 50)
0584T Islet cell transplant, includes portal vein catheterization and
infusion, including all imaging, including guidance, and
radiological supervision and interpretation, when
performed; percutaneous
Sunset January 2025
0585T laparoscopic
Sunset January 2025
0586T open
Sunset January 2025
0587T Percutaneous implantation or replacement of integrated
single device neurostimulation system including electrode
array and receiver or pulse generator, including analysis,
programming, and imaging guidance when performed,
posterior tibial nerve
Sunset January 2025
64575, 64590, 95970, 95971, 95972, 0588T, 0589T,
0590T)
0588T Revision or removal of integrated single device
neurostimulation system including electrode array and
receiver or pulse generator, including analysis,
programming, and imaging guidance when performed,
posterior tibial nerve
Sunset January 2025
64575, 64590, 95970, 95971, 95972, 0587T, 0589T,
0590T)
0589T Electronic analysis with simple programming of implanted
integrated neurostimulation system (eg, electrode array and
receiver), including contact group(s), amplitude, pulse
width, frequency (Hz), on/off cycling, burst, dose lockout,
patient-selectable parameters, responsive neurostimulation,
detection algorithms, closed-loop parameters, and passive
parameters, when performed by physician or other qualified
health care professional, posterior tibial nerve, 1-3
parameters
Sunset January 2025
43881, 43882, 61850-61888, 63650, 63655, 63661, 63662,
63663, 63664, 63685, 63688, 64553-64595, 95970, 95971,
95972, 95976, 95977, 95983, 95984, 0587T, 0588T,
0590T)
0590T Electronic analysis with complex programming of implanted
integrated neurostimulation system (eg, electrode array and
receiver), including contact group(s), amplitude, pulse
width, frequency (Hz), on/off cycling, burst, dose lockout,
patient-selectable parameters, responsive neurostimulation,
detection algorithms, closed-loop parameters, and passive
parameters, when performed by physician or other qualified
health care professional, posterior tibial nerve, 4 or more
parameters
Sunset January 2025
43881, 43882, 61850-61888, 63650, 63655, 63661, 63662,
63663, 63664, 63685, 63688, 64553-64595, 95970, 95971,
95972, 95976, 95977, 95983, 95984, 0587T, 0588T,
0589T)
Health and Well-Being Coaching

Health and well-being coaching is a patient-centered approach
wherein patients determine their goals, use self-discovery or
active learning processes together with content education to work
toward their goals, and self-monitor behaviors to increase
accountability, all within the context of an interpersonal
relationship with a coach. The coach is a nonphysician health
care professional certified by the National Board for Health and
Wellness Coaching or National Commission for Health Education
Credentialing, Inc. Coaches’ training includes behavioral change
theory, motivational strategies, communication techniques, health
education and promotion theories, which are used to assist
patients to develop intrinsic motivation and obtain skills to create
sustainable change for improved health and well-being.
0591T Health and well-being coaching face-to-face; individual,
initial assessment
Sunset January 2025
0592T individual, follow-up session, at least 30 minutes
Sunset January 2025
96159, 98960, 0488T, 0591T)
(For medical nutrition therapy, see 97802, 97803, 97804)
0593T group (2 or more individuals), at least 30 minutes
Sunset January 2025
97150, 98961, 98962, 0403T)
● 0594T Osteotomy, humerus, with insertion of an externally
controlled intramedullary lengthening device, including
intraoperative imaging, initial and subsequent alignment
assessments, computations of adjustment schedules, and
management of the intramedullary lengthening device
Sunset January 2026
24410, 24420, 24516)◀
▶ (For revision of externally controlled intramedullary
lengthening device, use 24999)◀
● 0596T Temporary female intraurethral valve-pump (ie, voiding
prosthesis); initial insertion, including urethral measurement
Sunset January 2026
● 0597T replacement
Sunset January 2026
▶ (Donot report 0596T, 0597T in conjunction with 51610,
51700, 51701, 51702, 51703, 51705)◀
● 0598T Noncontact real-time fluorescence wound imaging, for
bacterial presence, location, and load, per session; first
anatomic site (eg, lower extremity)
Sunset January 2026
✚● 0599T each additional anatomic site (eg, upper extremity) (List
Sunset January 2026
▶ (Use 0599T in conjunction with 0598T)◀
● 0600T Ablation, irreversible electroporation; 1 or more tumors per
organ, including imaging guidance, when performed,
percutaneous
Sunset January 2026
77013, 77022)◀
● 0601T 1 or more tumors per organ, including fluoroscopic and
ultrasound guidance, when performed, open
Sunset January 2026
▶ (Do not report 0601T in conjunction with 76940, 77002)◀
● 0602T Glomerular filtration rate (GFR) measurement(s),
transdermal, including sensor placement and administration
of a single dose of fluorescent pyrazine agent
Sunset January 2026
● 0603T Glomerular filtration rate (GFR) monitoring, transdermal,
including sensor placement and administration of more than
one dose of fluorescent pyrazine agent, each 24 hours
Sunset January 2026
▶ (Do not report 0603T in conjunction with 0602T)◀
● 0604T Optical coherence tomography (OCT) of retina, remote,
patient-initiated image capture and transmission to a remote
surveillance center, unilateral or bilateral; initial device
provision, set-up and patient education on use of equipment
Sunset January 2026
● 0605T remote surveillance center technical support, data
analyses and reports, with a minimum of 8 daily
recordings, each 30 days
Sunset January 2026
● 0606T review, interpretation and report by the prescribing
physician or other qualified health care professional of
remote surveillance center data analyses, each 30 days
Sunset January 2026
▶ (Donot report 0604T, 0605T, 0606T in conjunction with
99457, 99458)◀
● 0607T Remote monitoring of an external continuous pulmonary
fluid monitoring system, including measurement of
radiofrequency-derived pulmonary fluid levels, heart rate,
respiration rate, activity, posture, and cardiovascular rhythm
(eg, ECG data), transmitted to a remote 24-hour attended
surveillance center; set-up and patient education on use of
equipment
Sunset January 2026
93226, 93227, 93228, 93229, 93264, 93268, 93270, 93271,
93272, 93297, 99453, for same monitoring period)◀
● 0608T analysis of data received and transmission of reports to
the physician or other qualified health care professional
Sunset January 2026
▶ (Report 0608T only once per 30 days)◀
93226, 93227, 93228, 93229, 93264, 93268, 93270, 93271,
93272, 93297, 99454, for same monitoring period)◀
● 0609T Magnetic resonance spectroscopy, determination and
localization of discogenic pain (cervical, thoracic, or
lumbar); acquisition of single voxel data, per disc, on
biomarkers (ie, lactic acid, carbohydrate, alanine, laal,
propionic acid, proteoglycan, and collagen) in at least 3
discs
Sunset January 2026
● 0610T transmission of biomarker data for software analysis
Sunset January 2026
● 0611T postprocessing for algorithmic analysis of biomarker
data for determination of relative chemical differences
between discs
Sunset January 2026
● 0612T interpretation and report
Sunset January 2026
▶ (Do not report 0609T, 0610T, 0611T, 0612T in
conjunction with 72141, 72142, 72146, 72147, 72148,
72149, 72156, 72157, 72158, 72159, 76390)◀
● 0613T Percutaneous transcatheter implantation of interatrial septal
shunt device, including right and left heart catheterization,
intracardiac echocardiography, and imaging guidance by the
proceduralist, when performed
Sunset January 2026
93314, 93318, 93355, 93451, 93452, 93453, 93456, 93457,
93458, 93459, 93460, 93461, 93462, 93530, 93531, 93532,
93533, 93662)◀
▶ (Fortranscatheter atrial septostomy for congenital cardiac
abnormality, use 33741)◀
▶ (Fortranscatheter intracardiac shunt creation by stent
placement for congenital cardiac abnormality, see 33745,
33746)◀
▶ (Fortransvenous atrial balloon septectomy or septostomy,
see 33741, 33745, 33746)◀
● 0615T Eye-movement analysis without spatial calibration, with
Sunset January 2026
92542, 92544, 92545, 92546, 92547)◀
● 0616T Insertion of iris prosthesis, including suture fixation and
repair or removal of iris, when performed; without removal
of crystalline lens or intraocular lens, without insertion of
intraocular lens
Sunset January 2026
● 0617T with removal of crystalline lens and insertion of
intraocular lens
Sunset January 2026
66984)◀
● 0618T with secondary intraocular lens placement or intraocular
lens exchange
Sunset January 2026
66600, 66680, 66682)◀
● 0619T Cystourethroscopy with transurethral anterior prostate
commissurotomy and drug delivery, including transrectal
ultrasound and fluoroscopy, when performed
Sunset January 2026
52442, 52450, 52500, 52601, 52630, 52640, 52647, 52648,
52649, 53850, 53852, 53854, 76872, 0499T)◀
● 0621T Trabeculostomy ab interno by laser;
Sunset January 2026
● 0622T with use of ophthalmic endoscope
Sunset January 2026
▶ (Do not report 0621T, 0622T in conjunction with 92020)◀
● 0627T Percutaneous injection of allogeneic cellular and/or tissue-
based product, intervertebral disc, unilateral or bilateral
injection, with fluoroscopic guidance, lumbar; first level
Sunset January 2026
✚● 0628T each additional level (List separately in addition to code
Sunset January 2026
● 0629T Percutaneous injection of allogeneic cellular and/or tissue-
based product, intervertebral disc, unilateral or bilateral
injection, with CT guidance, lumbar; first level
Sunset January 2026
✚● 0630T each additional level (List separately in addition to code
Sunset January 2026
● 0631T Transcutaneous visible light hyperspectral imaging
measurement of oxyhemoglobin, deoxyhemoglobin, and
tissue oxygenation, with interpretation and report, per
extremity
Sunset January 2026
94762, 0061U)◀
● 0632T Percutaneous transcatheter ultrasound ablation of nerves
innervating the pulmonary arteries, including right heart
catheterization, pulmonary artery angiography, and all
imaging guidance
Sunset January 2026
36015, 75741, 75743, 75746, 93451, 93453, 93456, 93460,
93503, 93505, 93568)◀
● 0633T Computed tomography, breast, including 3D rendering, when
performed, unilateral; without contrast material
Sunset January 2026
● 0634T with contrast material(s)
Sunset January 2026
● 0635T without contrast, followed by contrast material(s)
Sunset January 2026
76376, 76377, 76380, 76497)◀
● 0636T Computed tomography, breast, including 3D rendering, when
performed, bilateral; without contrast material(s)
Sunset January 2026
● 0637T with contrast material(s)
Sunset January 2026
● 0638T without contrast, followed by contrast material(s)
Sunset January 2026
76376, 76377, 76380, 76497)◀
● 0639T Wireless skin sensor thermal anisotropy measurement(s) and
assessment of flow in cerebrospinal fluid shunt, including
ultrasound guidance, when performed
Sunset January 2026

Appendix A
Modifiers
This list includes all of the modifiers applicable to CPT 2021
codes.
A modifier provides the means to report or indicate that a service
or procedure that has been performed has been altered by some
specific circumstance but not changed in its definition or code.
Modifiers also enable health care professionals to effectively
respond to payment policy requirements established by other
entities.
22 Increased Procedural Services: When the work required to provide
a service is substantially greater than typically required, it may be
identified by adding modifier 22 to the usual procedure code.
Documentation must support the substantial additional work and the
reason for the additional work (ie, increased intensity, time, technical
difficulty of procedure, severity of patient’s condition, physical and
mental effort required). Note: This modifier should not be appended
to an E/M service.
➲ CPT Assistant Jan 09:8, Apr 09:8, Jun 09:8,10, Aug 13:4
23 Unusual Anesthesia: Occasionally, a procedure, which usually

requires either no anesthesia or local anesthesia, because of unusual
circumstances must be done under general anesthesia. This
circumstance may be reported by adding modifier 23 to the procedure
code of the basic service.
24 Unrelated Evaluation and Management Service by the Same
Physician or Other Qualified Health Care Professional During a
Postoperative Period: The physician or other qualified health care
professional may need to indicate that an evaluation and management
service was performed during a postoperative period for a reason(s)
unrelated to the original procedure. This circumstance may be
reported by adding modifier 24 to the appropriate level of E/M
service.
25 Significant, Separately Identifiable Evaluation and Management

Service by the Same Physician or Other Qualified Health Care
Professional on the Same Day of the Procedure or Other Service:
It may be necessary to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient’s condition
required a significant, separately identifiable E/M service above and
beyond the other service provided or beyond the usual preoperative
and postoperative care associated with the procedure that was
performed. A significant, separately identifiable E/M service is
defined or substantiated by documentation that satisfies the relevant
criteria for the respective E/M service to be reported (see Evaluation
and Management Services Guidelines for instructions on
determining level of E/M service). The E/M service may be prompted
by the symptom or condition for which the procedure and/or service
reporting of the E/M services on the same date. This circumstance
may be reported by adding modifier 25 to the appropriate level of
E/M service. Note: This modifier is not used to report an E/M
service that resulted in a decision to perform surgery. See modifier
57. For significant, separately identifiable non-E/M services, see
modifier 59.
➲ CPT Assistant Feb 09:22, Mar 09:3, Apr 09:4; Jun 09:11
26 Professional Component: Certain procedures are a combination of a

physician or other qualified health care professional component and a
technical component. When the physician or other qualified health
care professional component is reported separately, the service may
be identified by adding modifier 26 to the usual procedure number.
➲ CPT Assistant Jan 09:7, Apr 09:4, May 09:7
32 Mandated Services: Services related to mandated consultation

and/or related services (eg, third party payer, governmental,
legislative or regulatory requirement) may be identified by adding
modifier 32 to the basic procedure.
33 Preventive Services: When the primary purpose of the service is the

delivery of an evidence based service in accordance with a US
Preventive Services Task Force A or B rating in effect and other
preventive services identified in preventive services mandates
(legislative or regulatory), the service may be identified by adding 33
to the procedure. For separately reported services specifically
identified as preventive, the modifier should not be used.
47 Anesthesia by Surgeon: Regional or general anesthesia provided by

the surgeon may be reported by adding modifier 47 to the basic
service. (This does not include local anesthesia.) Note: Modifier 47
would not be used as a modifier for the anesthesia procedures.
50 Bilateral Procedure: Unless otherwise identified in the listings,
bilateral procedures that are performed at the same session, should be
identified by adding modifier 50 to the appropriate 5 digit code.
Note: This modifier should not be appended to designated “add-on”
codes (see Appendix D).
51 Multiple Procedures: When multiple procedures, other than E/M

services, Physical Medicine and Rehabilitation services or provision
of supplies (eg, vaccines), are performed at the same session by the
same individual, the primary procedure or service may be reported as
listed. The additional procedure(s) or service(s) may be identified by
appending modifier 51 to the additional procedure or service code(s).
➲ CPT Assistant Feb 09:6, Mar 09:10, Apr 09:8
52 Reduced Services: Under certain circumstances a service or

procedure is partially reduced or eliminated at the discretion of the
physician or other qualified health care professional. Under these
circumstances the service provided can be identified by its usual
procedure number and the addition of modifier 52, signifying that the
service is reduced. This provides a means of reporting reduced
services without disturbing the identification of the basic service.
Note: For hospital outpatient reporting of a previously scheduled
procedure/service that is partially reduced or cancelled as a result of
extenuating circumstances or those that threaten the well-being of the
patient prior to or after administration of anesthesia, see modifiers 73
and 74 (see modifiers approved for ASC hospital outpatient use).
➲ CPT Assistant Mar 09:11, Apr 09:5, May 09:8, Jun 09:10, Jun
13:7
53 Discontinued Procedure: Under certain circumstances, the physician
or other qualified health care professional may elect to terminate a
surgical or diagnostic procedure. Due to extenuating circumstances or
those that threaten the well being of the patient, it may be necessary to
indicate that a surgical or diagnostic procedure was started but
discontinued. This circumstance may be reported by adding modifier
53 to the code reported by the individual for the discontinued
procedure. Note: This modifier is not used to report the elective
cancellation of a procedure prior to the patient’s anesthesia induction
and/or surgical preparation in the operating suite. For outpatient
hospital/ambulatory surgery center (ASC) reporting of a previously
scheduled procedure/service that is partially reduced or cancelled as
a result of extenuating circumstances or those that threaten the well
being of the patient prior to or after administration of anesthesia, see
modifiers 73 and 74 (see modifiers approved for ASC hospital
outpatient use).
54 Surgical Care Only: When 1 physician or other qualified health care

professional performs a surgical procedure and another provides
preoperative and/or postoperative management, surgical services may
be identified by adding modifier 54 to the usual procedure number.
55 Postoperative Management Only: When 1 physician or other

qualified health care professional performed the postoperative
management and another performed the surgical procedure, the
postoperative component may be identified by adding modifier 55 to
the usual procedure number.
56 Preoperative Management Only: When 1 physician or other

qualified health care professional performed the preoperative care
and evaluation and another performed the surgical procedure, the
preoperative component may be identified by adding modifier 56 to
the usual procedure number.
57 Decision for Surgery: An evaluation and management service that

resulted in the initial decision to perform the surgery may be
identified by adding modifier 57 to the appropriate level of E/M
service.
58 Staged or Related Procedure or Service by the Same Physician or

Other Qualified Health Care Professional During the
Postoperative Period: It may be necessary to indicate that the
performance of a procedure or service during the postoperative
period was: (a) planned or anticipated (staged); (b) more extensive
than the original procedure; or (c) for therapy following a surgical
procedure. This circumstance may be reported by adding modifier 58
to the staged or related procedure. Note: For treatment of a problem
that requires a return to the operating/procedure room (eg,
unanticipated clinical condition), see modifier 78.
59 Distinct Procedural Service: Under certain circumstances, it may be

necessary to indicate that a procedure or service was distinct or
independent from other non-E/M services performed on the same day.
Modifier 59 is used to identify procedures/services, other than E/M
services, that are not normally reported together, but are appropriate
under the circumstances. Documentation must support a different
session, different procedure or surgery, different site or organ system,
separate incision/excision, separate lesion, or separate injury (or area
of injury in extensive injuries) not ordinarily encountered or
performed on the same day by the same individual. However, when
another already established modifier is appropriate it should be used
rather than modifier 59. Only if no more descriptive modifier is
available, and the use of modifier 59 best explains the circumstances,
should modifier 59 be used. Note: Modifier 59 should not be
appended to an E/M service. To report a separate and distinct E/M
service with a non-E/M service performed on the same date, see
modifier 25.
➲ CPT Assistant Feb 09:17, Apr 09:4,8, May 09:6, Jun 09:8
62 Two Surgeons: When 2 surgeons work together as primary surgeons

performing distinct part(s) of a procedure, each surgeon should report
his/her distinct operative work by adding modifier 62 to the
procedure code and any associated add-on code(s) for that procedure
as long as both surgeons continue to work together as primary
surgeons. Each surgeon should report the co-surgery once using the
same procedure code. If additional procedure(s) (including add-on
procedure[s]) are performed during the same surgical session,
separate code(s) may also be reported with modifier 62 added. Note:
If a co-surgeon acts as an assistant in the performance of additional
procedure(s), other than those reported with the modifier 62, during
the same surgical session, those services may be reported using
separate procedure code(s) with modifier 80 or modifier 82 added, as
appropriate.
63 Procedure Performed on Infants less than 4 kg: Procedures

performed on neonates and infants up to a present body weight of 4 kg
may involve significantly increased complexity and physician or other
qualified health care professional work commonly associated with
these patients. This circumstance may be reported by adding modifier
63 to the procedure number. Note: Unless otherwise designated, this
modifier may only be appended to procedures/services listed in the
20100-69990 code series and 92920, 92928, 92953, 92960, 92986,
92987, 92990, 92997, 92998, 93312, 93313, 93314, 93315, 93316,
93317, 93318, 93452, 93505, 93530, 93531, 93532, 93533, 93561,
93562, 93563, 93564, 93568, 93580, 93582, 93590, 93591, 93592,
93615, 93616 from the Medicine/Cardiovascular section. Modifier 63
should not be appended to any CPT codes listed in the Evaluation
and Management Services, Anesthesia, Radiology,
Pathology/Laboratory, or Medicine sections (other than those
identified above from the Medicine/Cardiovascular section).
66 Surgical Team: Under some circumstances, highly complex

procedures (requiring the concomitant services of several physicians
or other qualified health care professionals, often of different
specialties, plus other highly skilled, specially trained personnel,
various types of complex equipment) are carried out under the
“surgical team” concept. Such circumstances may be identified by
each participating individual with the addition of modifier 66 to the
basic procedure number used for reporting services.
76 Repeat Procedure or Service by Same Physician or Other
Qualified Health Care Professional: It may be necessary to indicate
that a procedure or service was repeated by the same physician or
other qualified health care professional subsequent to the original
procedure or service. This circumstance may be reported by adding
modifier 76 to the repeated procedure or service. Note: This modifier
should not be appended to an E/M service.
77 Repeat Procedure by Another Physician or Other Qualified

Health Care Professional: It may be necessary to indicate that a
basic procedure or service was repeated by another physician or
78 Unplanned Return to the Operating/Procedure Room by the Same

Physician or Other Qualified Health Care Professional Following
Initial Procedure for a Related Procedure During the
Postoperative Period: It may be necessary to indicate that another
procedure was performed during the postoperative period of the
initial procedure (unplanned procedure following initial procedure).
When this procedure is related to the first, and requires the use of an
operating/procedure room, it may be reported by adding modifier 78
to the related procedure. (For repeat procedures, see modifier 76.)
79 Unrelated Procedure or Service by the Same Physician or Other

Qualified Health Care Professional During the Postoperative
Period: The individual may need to indicate that the performance of a
procedure or service during the postoperative period was unrelated to
the original procedure. This circumstance may be reported by using
modifier 79. (For repeat procedures on the same day, see modifier
76.)
80 Assistant Surgeon: Surgical assistant services may be identified by

adding modifier 80 to the usual procedure number(s).
81 Minimum Assistant Surgeon: Minimum surgical assistant services
are identified by adding modifier 81 to the usual procedure number.
82 Assistant Surgeon (when qualified resident surgeon not available):
The unavailability of a qualified resident surgeon is a prerequisite for
use of modifier 82 appended to the usual procedure code number(s).
90 Reference (Outside) Laboratory: When laboratory procedures are
performed by a party other than the treating or reporting physician or
other qualified health care professional, the procedure may be
identified by adding modifier 90 to the usual procedure number.
91 Repeat Clinical Diagnostic Laboratory Test: In the course of

treatment of the patient, it may be necessary to repeat the same
laboratory test on the same day to obtain subsequent (multiple) test
results. Under these circumstances, the laboratory test performed can
be identified by its usual procedure number and the addition of
modifier 91. Note: This modifier may not be used when tests are
rerun to confirm initial results; due to testing problems with
specimens or equipment; or for any other reason when a normal, one-
time, reportable result is all that is required. This modifier may not be
used when other code(s) describe a series of test results (eg, glucose
tolerance tests, evocative/suppression testing). This modifier may
only be used for laboratory test(s) performed more than once on the
same day on the same patient.
92 Alternative Laboratory Platform Testing: When laboratory testing

is being performed using a kit or transportable instrument that wholly
or in part consists of a single use, disposable analytical chamber, the
service may be identified by adding modifier 92 to the usual
laboratory procedure code (HIV testing 86701-86703, and 87389).
The test does not require permanent dedicated space, hence by its
design may be hand carried or transported to the vicinity of the patient
for immediate testing at that site, although location of the testing is not
in itself determinative of the use of this modifier.
95 Synchronous Telemedicine Service Rendered Via a Real-Time

Interactive Audio and Video Telecommunications System:
Synchronous telemedicine service is defined as a real-time
interaction between a physician or other qualified health care
professional and a patient who is located at a distant site from the
physician or other qualified health care professional. The totality of
the communication of information exchanged between the physician or
other qualified health care professional and the patient during the
course of the synchronous telemedicine service must be of an amount
and nature that would be sufficient to meet the key components and/or
requirements of the same service when rendered via a face-to-face
interaction. Modifier 95 may only be appended to the services listed
in Appendix P. Appendix P is the list of CPT codes for services that
are typically performed face-to-face, but may be rendered via a real-
time (synchronous) interactive audio and video telecommunications
system.
96 Habilitative Services: When a service or procedure that may be

either habilitative or rehabilitative in nature is provided for
habilitative purposes, the physician or other qualified health care
professional may add modifier 96 to the service or procedure code to
indicate that the service or procedure provided was a habilitative
service. Habilitative services help an individual learn skills and
functioning for daily living that the individual has not yet developed,
and then keep and/or improve those learned skills. Habilitative
services also help an individual keep, learn, or improve skills and
functioning for daily living.
97 Rehabilitative Services: When a service or procedure that may be

either habilitative or rehabilitative in nature is provided for
rehabilitative purposes, the physician or other qualified health care
professional may add modifier 97 to the service or procedure code to
indicate that the service or procedure provided was a rehabilitative
service. Rehabilitative services help an individual keep, get back, or
improve skills and functioning for daily living that have been lost or
impaired because the individual was sick, hurt, or disabled.
99 Multiple Modifiers: Under certain circumstances 2 or more modifiers

may be necessary to completely delineate a service. In such situations
modifier 99 should be added to the basic procedure, and other
applicable modifiers may be listed as part of the description of the
service.
Anesthesia Physical Status Modifiers

The Physical Status modifiers are consistent with the American
Society of Anesthesiologists ranking of patient physical status,
and distinguishing various levels of complexity of the anesthesia
service provided. All anesthesia services are reported by use of
the anesthesia five-digit procedure code (00100-01999) with the
appropriate physical status modifier appended.
Example: 00100-P1
Under certain circumstances, when another established
modifier(s) is appropriate, it should be used in addition to the
physical status modifier.
Example: 00100-P4-53
Physical Status Modifier P1: A normal healthy patient
Physical Status Modifier P2: A patient with mild systemic
disease
Physical Status Modifier P3: A patient with severe systemic
disease
Physical Status Modifier P4: A patient with severe systemic
disease that is a constant threat to life
Physical Status Modifier P5: A moribund patient who is not
expected to survive without the operation
Physical Status Modifier P6: A declared brain-dead patient
whose organs are being removed for donor purposes
Modifiers Approved for Ambulatory

Surgery Center (ASC) Hospital Outpatient
Use
CPT Level I Modifiers
25 Significant, Separately Identifiable Evaluation and Management
Service by the Same Physician or Other Qualified Health Care
Professional on the Same Day of the Procedure or Other Service:
It may be necessary to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient’s condition
required a significant, separately identifiable E/M service above and
beyond the other service provided or beyond the usual preoperative
and postoperative care associated with the procedure that was
performed. A significant, separately identifiable E/M service is
defined or substantiated by documentation that satisfies the relevant
criteria for the respective E/M service to be reported (see Evaluation
and Management Services Guidelines for instructions on
determining level of E/M service). The E/M service may be prompted
by the symptom or condition for which the procedure and/or service
reporting of the E/M services on the same date. This circumstance
may be reported by adding modifier 25 to the appropriate level of
E/M service. Note: This modifier is not used to report an E/M
service that resulted in a decision to perform surgery. See modifier
57. For significant, separately identifiable non-E/M services, see
modifier 59.
27 Multiple Outpatient Hospital E/M Encounters on the Same Date:

For hospital outpatient reporting purposes, utilization of hospital
resources related to separate and distinct E/M encounters performed
in multiple outpatient hospital settings on the same date may be
reported by adding modifier 27 to each appropriate level outpatient
and/or emergency department E/M code(s). This modifier provides a
means of reporting circumstances involving evaluation and
management services provided by physician(s) in more than one
(multiple) outpatient hospital setting(s) (eg, hospital emergency
department, clinic). Note: This modifier is not to be used for
physician reporting of multiple E/M services performed by the same
physician on the same date. For physician reporting of all outpatient
evaluation and management services provided by the same physician
on the same date and performed in multiple outpatient setting(s) (eg,
hospital emergency department, clinic), see Evaluation and
Management, Emergency Department, or Preventive Medicine
Services codes.
33 Preventive Services: When the primary purpose of the service is the
delivery of an evidence based service in accordance with a US
Preventive Services Task Force A or B rating in effect and other
preventive services identified in preventive services mandates
(legislative or regulatory), the service may be identified by adding 33
to the procedure. For separately reported services specifically
identified as preventive, the modifier should not be used.
50 Bilateral Procedure: Unless otherwise identified in the listings,
bilateral procedures that are performed at the same session, should be
identified by adding modifier 50 to the appropriate 5 digit code.
52 Reduced Services: Under certain circumstances a service or

procedure is partially reduced or eliminated at the discretion of the
physician or other qualified health care professional. Under these
circumstances the service provided can be identified by its usual
procedure number and the addition of modifier 52, signifying that the
service is reduced. This provides a means of reporting reduced
services without disturbing the identification of the basic service.
Note: For hospital outpatient reporting of a previously scheduled
procedure/service that is partially reduced or cancelled as a result of
extenuating circumstances or those that threaten the well-being of the
patient prior to or after administration of anesthesia, see modifiers 73
and 74 (see modifiers approved for ASC hospital outpatient use).
58 Staged or Related Procedure or Service by the Same Physician or

Other Qualified Health Care Professional During the
Postoperative Period: It may be necessary to indicate that the
performance of a procedure or service during the postoperative
period was: (a) planned or anticipated (staged); (b) more extensive
than the original procedure; or (c) for therapy following a surgical
procedure. This circumstance may be reported by adding modifier 58
to the staged or related procedure. Note: For treatment of a problem
that requires a return to the operating/procedure room (eg,
unanticipated clinical condition), see modifier 78.
59 Distinct Procedural Service: Under certain circumstances, it may be
necessary to indicate that a procedure or service was distinct or
independent from other non-E/M services performed on the same day.
Modifier 59 is used to identify procedures/services, other than E/M
services, that are not normally reported together, but are appropriate
under the circumstances. Documentation must support a different
session, different procedure or surgery, different site or organ system,
separate incision/excision, separate lesion, or separate injury (or area
of injury in extensive injuries) not ordinarily encountered or
performed on the same day by the same individual. However, when
another already established modifier is appropriate it should be used
rather than modifier 59. Only if no more descriptive modifier is
available, and the use of modifier 59 best explains the circumstances,
should modifier 59 be used. Note: Modifier 59 should not be
appended to an E/M service. To report a separate and distinct E/M
service with a non-E/M service performed on the same date, see
modifier 25.
73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center
(ASC) Procedure Prior to the Administration of Anesthesia: Due
to extenuating circumstances or those that threaten the well being of
the patient, the physician may cancel a surgical or diagnostic
procedure subsequent to the patient’s surgical preparation (including
sedation when provided, and being taken to the room where the
procedure is to be performed), but prior to the administration of
anesthesia (local, regional block(s) or general). Under these
circumstances, the intended service that is prepared for but cancelled
can be reported by its usual procedure number and the addition of
modifier 73. Note: The elective cancellation of a service prior to the
administration of anesthesia and/or surgical preparation of the patient
should not be reported. For physician reporting of a discontinued
procedure, see modifier 53.
74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center
(ASC) Procedure After Administration of Anesthesia: Due to
extenuating circumstances or those that threaten the well being of the
patient, the physician may terminate a surgical or diagnostic
procedure after the administration of anesthesia (local, regional
block(s), general) or after the procedure was started (incision made,
intubation started, scope inserted, etc). Under these circumstances, the
procedure started but terminated can be reported by its usual
procedure number and the addition of modifier 74. Note: The elective
cancellation of a service prior to the administration of anesthesia
and/or surgical preparation of the patient should not be reported. For
physician reporting of a discontinued procedure, see modifier 53.
76 Repeat Procedure or Service by Same Physician or Other

Qualified Health Care Professional: It may be necessary to indicate
that a procedure or service was repeated by the same physician or
77 Repeat Procedure by Another Physician or Other Qualified

Health Care Professional: It may be necessary to indicate that a
basic procedure or service was repeated by another physician or
78 Unplanned Return to the Operating/Procedure Room by the Same

Physician or Other Qualified Health Care Professional Following
Initial Procedure for a Related Procedure During the
Postoperative Period: It may be necessary to indicate that another
procedure was performed during the postoperative period of the
initial procedure (unplanned procedure following initial procedure).
When this procedure is related to the first, and requires the use of an
operating/procedure room, it may be reported by adding modifier 78
to the related procedure. (For repeat procedures, see modifier 76.)
79 Unrelated Procedure or Service by the Same Physician or Other

Qualified Health Care Professional During the Postoperative
Period: The individual may need to indicate that the performance of a
procedure or service during the postoperative period was unrelated to
the original procedure. This circumstance may be reported by using
modifier 79. (For repeat procedures on the same day, see modifier
76.)
91 Repeat Clinical Diagnostic Laboratory Test: In the course of

treatment of the patient, it may be necessary to repeat the same
laboratory test on the same day to obtain subsequent (multiple) test
results. Under these circumstances, the laboratory test performed can
be identified by its usual procedure number and the addition of
modifier 91. Note: This modifier may not be used when tests are
rerun to confirm initial results; due to testing problems with
specimens or equipment; or for any other reason when a normal, one-
time, reportable result is all that is required. This modifier may not be
used when other code(s) describe a series of test results (eg, glucose
tolerance tests, evocative/suppression testing). This modifier may
only be used for laboratory test(s) performed more than once on the
same day on the same patient.
Category II Modifiers
The following performance measurement modifiers may be used
for Category II codes to indicate that a service specified in the
associated measure(s) was considered but, due to either medical,
patient, or system circumstance(s) documented in the medical
record, the service was not provided. These modifiers serve as
denominator exclusions from the performance measure. The user
should note that not all listed measures provide for exclusions
(see Alphabetical Clinical Topics Listing for more discussion
regarding exclusion criteria).
Category II modifiers should only be reported with Category II
codes—they should not be reported with Category I or Category
III codes. In addition, the modifiers in the Category II section
should only be used where specified in the guidelines, reporting
instructions, parenthetic notes, or code descriptor language listed
in the Category II section (code listing and the Alphabetical
Clinical Topics Listing).
1P Performance Measure Exclusion Modifier due to Medical Reasons:
Reasons include:
■ Not indicated (absence of organ/limb, already received/performed, other)
■ Contraindicated (patient allergic history, potential adverse drug
interaction, other)
■ Other medical reasons
2P Performance Measure Exclusion Modifier due to Patient Reasons:
Reasons include:
■ Patient declined
■ Economic, social, or religious reasons
■ Other patient reasons
3P Performance Measure Exclusion Modifier due to System Reasons:
Reasons include:
■ Resources to perform the services not available
■ Insurance coverage/payor-related limitations
■ Other reasons attributable to health care delivery system
Modifier 8P is intended to be used as a “reporting modifier” to
allow the reporting of circumstances when an action described in
a measure’s numerator is not performed and the reason is not
8P Performance measure reporting modifier–action not
performed, reason not otherwise specified
Level II (HCPCS/National) Modifiers

E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
GG Performance and payment of a screening mammogram and
diagnostic mammogram on the same patient, same day
GH Diagnostic mammogram converted from screening mammogram
on same day
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LM Left main coronary artery
LT Left side (used to identify procedures performed on the left side
of the body)
QM Ambulance service provided under arrangement by a provider of
services
QN Ambulance service furnished directly by a provider of services
RC Right coronary artery
RI Ramus intermedius coronary artery
RT Right side (used to identify procedures performed on the right
side of the body)
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
XE Separate Encounter*
XP Separate Practitioner*
XS Separate Organ/Structure*
XU Unusual Separate Service*
(*HCPCS modifiers for selective identification of subsets of Distinct
Procedural Services [59 modifier])

Appendix B
Summary of Additions, Deletions, and

Revisions
Appendix B shows the actual changes that were made to the code
descriptors. New codes appear with a bullet (●) and are indicated
as “Code added.” Revised codes are preceded with a triangle (▲).
Within revised codes, the deleted language appears with a
strikethrough, while new text appears underlined. The symbol ⚡
is used to identify codes for vaccines that are pending FDA
approval (see Appendix K).The symbol # is used to identify
codes that have been resequenced (see Appendix N). The
symbol is used to identify codes that are duplicate PLA tests.
CPT add-on codes are annotated by the symbol ✚ (see Appendix
D). The symbol ⃠ is used to identify codes that are exempt from
the use of modifier 51 (see Appendix E). The symbol ★ is used
to identify codes that may be used for reporting telemedicine
services (see Appendix P). The symbol ⇅ is used to identify
Category I PLA codes.

99201 Office or other outpatient visit for the evaluation and
components:
and/or family.
components:a medically appropriate history and/or
examination and straightforward medical decision making.
physicians, other qualified health care professionalsWhen
using time for code selection, or agencies are provided
consistent with the nature15-29 minutes of the problem(s)
and the patient’s and/or family’s needstotal time is spent on
the date of the encounter.
examination and low level of medical decision making.
and/or family.

examination and moderate level of medical decision making.
examination and high level of medical decision making.
▲ 99211 Office or other outpatient visit for the evaluation and
management of an established patient, that may not require
the presence of a physician or other qualified health care
professional. Usually, the presenting problem(s) are
minimal. Typically, 5 minutes are spent performing or
supervising these services.
least 2 of these 3 key components: medically appropriate
history and/or examination and straightforward medical
decision making.
and/or family.
history and/or examination and low level of medical
decision making.
Counseling and coordination of care with other physicians,
other qualified health care professionalsWhen using time for
code selection, or agencies are provided consistent with the
nature20-29 minutes of the problem(s) and the patient’s
and/or family’s needstotal time is spent on the date of the
encounter.
history and/or examination and moderate level of medical
decision making.
history and/or examination and high level of medical
decision making.
★✚▲ 99354 Prolonged evaluation and management or psychotherapy
service(s) (beyond the typical service time of the primary
procedure) in the office or other outpatient setting requiring
direct patient contact beyond the time of the usual service;
first hour (List separately in addition to code for office or
other outpatient Evaluation and Management or
psychotherapy service, except with office or other outpatient
services [99202, 99203, 99204, 99205, 99212, 99213,
99214, 99215])
★✚▲ 99355 each additional 30 minutes (List separately in addition to
✚▲ 99356 Prolonged service in the inpatient or observation setting,
requiring unit/floor time beyond the usual service; first hour
(List separately in addition to code for inpatient or
observation Evaluation and Management service)
#✚▲ 99415 Prolonged clinical staff service (the service beyond
the highest time in the range of total typical service time of
the service) during an evaluation and management service in
the office or outpatient setting, direct patient contact with
physician supervision; first hour (List separately in addition
to code for outpatient Evaluation and Management
service)
#✚▲ 99416 each additional 30 minutes (List separately in addition to
#★✚● 99417 Code added
#▲ 99490 Chronic care management services, at least 20 minutes of
clinical staff time directed by a physician or other qualified
health care professional, per calendar month, with the
last at least 12 months, or until the death of the patient;,
decline;,
revised, or monitored.;
month.
#✚● 99439 Code added
▲ 99487 Complex chronic care management services, with the
decline,
■ establishment or substantial revision of a comprehensive
care plancomprehensive care plan established,
implemented, revised, or monitored,
■ moderate or high complexity medical decision making;
■ 60 minutes of clinical staff time directed by a physician
month.
month.
✚▲ 99489 each additional 30 minutes of clinical staff time directed by
a physician or other qualified health care professional, per
calendar month (List separately in addition to code for
primary procedure)
Surgery
▲ 11970 Replacement of tissue expander with permanent
prosthesisimplant
▲ 11971 Removal of tissue expander(s) without insertion of
prosthesisimplant
▲ 19318 Breast Rreduction mammaplasty
19324 Mammaplasty, augmentation; without prosthetic implant
▲ 19325 Mammaplasty, augmentation Breast augmentation with
implant; with prosthetic implant
▲ 19328 Removal of intact mammarybreast implant
▲ 19330 Removal of mammaryruptured breast implant material,
including implant contents (eg, saline, silicone gel)
▲ 19340 Immediate iInsertion of breast implant prosthesis following
mastopexy, mastectomy or in reconstruction on same day of
mastectomy (ie, immediate)
▲ 19342 Delayed iInsertion or replacement of breast prosthesis
following mastopexy, mastectomy or in
reconstruction implant on separate day from mastectomy
▲ 19357 Breast reconstruction, immediate or delayed, with tissue
expanderTissue expander placement in breast
reconstruction, including subsequent expansion(s)
▲ 19361 Breast reconstruction; with latissimus dorsi flap, without
prosthetic implant
▲ 19364 Breast reconstruction with free flap (eg, fTRAM, DIEP,
SIEA, GAP flap)
19366 Breast reconstruction with other technique
▲ 19367 Breast reconstruction with single-pedicled transverse rectus
abdominis myocutaneous (TRAM) flap (TRAM), single
pedicle, including closure of donor site;
▲ 19368 with single-pedicled transverse rectus abdominis
myocutaneous (TRAM) flap, requiring
separate microvascular anastomosis (supercharging)
▲ 19369 with bipedicled transverse rectus abdominis myocutaneous
(TRAM) flap Breast reconstruction with transverse rectus
abdominis myocutaneous flap (TRAM), double pedicle,
including closure of donor site
▲ 19370 Open periprostheticRevision of peri-implant capsule,
breast, including capsulotomy, capsulorrhaphy, breastand/or
partial capsulectomy
▲ 19371 Periprosthetic-implant capsulectomy, breast, complete,
including removal of all intracapsular contents
▲ 19380 Revision of reconstructed breast (eg, significant removal of
tissue, re-advancement and/or re-inset of flaps in autologous
reconstruction or significant capsular revision combined
with soft tissue excision in implant-based reconstruction)
▲ 29822 debridement, limited, 1 or 2 discrete structures (eg, humeral
bone, humeral articular cartilage, glenoid bone, glenoid
articular cartilage, biceps tendon, biceps anchor complex,
labrum, articular capsule, articular side of the rotator cuff,
bursal side of the rotator cuff, subacromial bursa, foreign
body[ies])
▲ 29823 debridement, extensive, 3 or more discrete structures (eg,
humeral bone, humeral articular cartilage, glenoid bone,
glenoid articular cartilage, biceps tendon, biceps anchor
complex, labrum, articular capsule, articular side of the
rotator cuff, bursal side of the rotator cuff, subacromial
bursa, foreign body[ies])
● 30468 Code added
32405 Biopsy, lung or mediastinum, percutaneous needle
✚● 33746 Code added
#● 33995 Code added
▲ 33990 left heart, arterial access only
▲ 33991 left heart, both arterial and venous access, with transseptal
puncture
▲ 33992 Removal of percutaneous left heart ventricular assist device,
arterial or arterial and venous cannula(s), at separate and
distinct session from insertion
▲ 33993 Repositioning of percutaneous right or left heart ventricular
assist device with imaging guidance at separate and distinct
session from insertion
49220 Staging laparotomy for Hodgkins disease or lymphoma
(includes splenectomy, needle or open biopsies of both liver
lobes, possibly also removal of abdominal nodes,
abdominal node and/or bone marrow biopsies, ovarian
repositioning)
57112 with removal of paravaginal tissue (radical vaginectomy)
with bilateral total pelvic lymphadenectomy and para-aortic
lymph node sampling (biopsy)
✚● 57465 Code added
58293 with colpo-urethrocystopexy (Marshall-Marchetti-Krantz
type, Pereyra type) with or without endoscopic control
61870 Craniectomy for implantation of neurostimulator electrodes,
cerebellar, cortical
62163 with retrieval of foreign body
63180 Laminectomy and section of dentate ligaments, with or
without dural graft, cervical; 1 or 2 segments
63182 more than 2 segments
▲ 64455 plantar common digital nerve(s) (eg, Morton’s neuroma)
▲ 64479 transforaminal epidural, with imaging guidance (fluoroscopy
or CT), cervical or thoracic, single level
✚▲ 64480 transforaminal epidural, with imaging guidance (fluoroscopy
or CT), cervical or thoracic, each additional level (List
▲ 64483 transforaminal epidural, with imaging guidance (fluoroscopy
or CT), lumbar or sacral, single level
✚▲ 64484 transforaminal epidural, with imaging guidance (fluoroscopy
or CT), lumbar or sacral, each additional level (List
69605 with apicectomy
Radiology
▲ 71250 Computed tomography, thorax, diagnostic; without contrast
material
▲ 71260 with contrast material(s)
▲ 71270 without contrast material, followed by contrast material(s)
and further sections
▲ 74425 Urography, antegrade (pyelostogram, nephrostogram,
loopogram), radiological supervision and interpretation
▲ 76513 anterior segment ultrasound, immersion (water bath) B-scan
or high resolution biomicroscopy, unilateral or bilateral
76970 Ultrasound study follow-up (specify)
▲ 78130 Red cell survival study;
78135 differential organ/tissue kinetics (eg, splenic and/or hepatic
sequestration)

▲ 80415 estradiol response
This panel must include the following: Estradiol, total
(82670 x 2 on 3 pooled blood samples)
▲ 81401 Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1
methylated variant, or 1 somatic variant [typically using
nonsequencing target variant analysis], or detection of a
dynamic mutation disorder/triplet repeat)
CCND1/IGH (BCL1/IgH, t(11;14)) (eg, mantle cell
lymphoma) translocation analysis, major breakpoint,
ETV6/NTRK3 (t(12;15)) (eg, congenital/infantile
fibrosarcoma), translocation analysis, qualitative, and
▲ 81402 Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-
10 methylated variants, or 2-10 somatic variants [typically
using non-sequencing target variant analysis],
immunoglobulin and T-cell receptor gene rearrangements,
duplication/deletion variants of 1 exon, loss of
heterozygosity [LOH], uniparental disomy [UPD])
IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma),
translocation analysis; major breakpoint region (MBR) and
minor cluster region (mcr) breakpoints, qualitative or
quantitative
MPL (myeloproliferative leukemia virus oncogene,
thrombopoietin receptor, TPOR) (eg, myeloproliferative
disorder), common variants (eg, W515A, W515K, W515L,
W515R)
▲ 81403 Molecular pathology procedure, Level 4 (eg, analysis of
single exon by DNA sequence analysis, analysis of >10
amplicons using multiplex PCR in 2 or more independent
reactions, mutation scanning or duplication/deletion variants
of 2-5 exons)
JAK2 (Janus kinase 2) (eg, myeloproliferative disorder),
exon 12 sequence and exon 13 sequence, if performed
MPL (myeloproliferative leukemia virus oncogene,
thrombopoietin receptor, TPOR) (eg, myeloproliferative
disorder), exon 10 sequence
▲ 81404 Molecular pathology procedure, Level 5 (eg, analysis of 2-5
exons by DNA sequence analysis, mutation scanning or
duplication/deletion variants of 6-10 exons, or
characterization of a dynamic mutation disorder/triplet
repeat by Southern blot analysis)
TP53 (tumor protein 53) (eg, tumor samples), targeted
sequence analysis of 2-5 exons
▲ 81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-
duplication/deletion variants of 11-25 exons, regionally
targeted cytogenomic array analysis)
TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome, tumor
samples), full gene sequence or targeted sequence analysis
of >5 exons
81545 Oncology (thyroid), gene expression analysis of 142 genes,
utilizing fine needle aspirate, algorithm reported as a
categorical result (eg, benign or suspicious)
▲ 82075 Alcohol (ethanol), breath; breath
▲ 82670 Estradiol; total
▲ 86318 Immunoassay for infectious agent antibody(ies), qualitative
or semiquantitative, single-step method (eg, reagent strip);
0006U Detection of interacting medications, substances,
supplements and foods, 120 or more analytes, definitive
chromatography with mass spectrometry, urine, description
and severity of each interaction identified, per date of
service
0085U Cytolethal distending toxin B (CdtB) and vinculin IgG
antibodies by immunoassay (ie, ELISA)
0124U Fetal congenital abnormalities, biochemical assays of 3
analytes (free beta-hCG, PAPP-A, AFP), time-resolved
fluorescence immunoassay, maternal dried-blood spot,
algorithm reported as risk scores for fetal trisomies 13/18
and 21
0125U Fetal congenital abnormalities and perinatal complications,
biochemical assays of 5 analytes (free beta-hCG, PAPP-A,
AFP, placental growth factor, and inhibin-A), time-resolved
fluorescence immunoassay, maternal serum, algorithm
reported as risk scores for fetal trisomies 13/18, 21, and
preeclampsia
0126U Fetal congenital abnormalities and perinatal complications,
biochemical assays of 5 analytes (free beta-hCG, PAPP-A,
AFP, placental growth factor, and inhibin-A), time-resolved
fluorescence immunoassay, includes qualitative assessment
of Y chromosome in cell-free fetal DNA, maternal serum
and plasma, predictive algorithm reported as risk scores for
fetal trisomies 13/18, 21, and preeclampsia
0127U Obstetrics (preeclampsia), biochemical assays of 3 analytes
(PAPP-A, AFP, and placental growth factor), time-resolved
fluorescence immunoassay, maternal serum, predictive
algorithm reported as a risk score for preeclampsia
0128U Obstetrics (preeclampsia), biochemical assays of 3 analytes
(PAPP-A, AFP, and placental growth factor), time-resolved
fluorescence immunoassay, includes qualitative assessment
of Y chromosome in cell-free fetal DNA, maternal serum
and plasma, predictive algorithm reported as a risk score
for preeclampsia
● 0139U Code added
▲ 0154U Oncology (urothelial cancer), RNA, analysis by real-time
RT-PCR of the FGFR3 (fibroblast growth factor receptor
3) gene analysis (ie, p.R248C [c.742C>T], p.S249C
[c.746C>G], p.G370C [c.1108G>T], p.Y373C
[c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3),
utilizing formalin-fixed paraffin-embedded urothelial cancer
tumor tissue, reported as FGFR gene alteration status
▲ 0155U Oncology (breast cancer), DNA, PIK3CA
(phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic
subunit alpha) (eg, breast cancer) gene analysis (ie,
p.C420R, p.E542K, p.E545A, p.E545D [g.1635G>T only],
p.E545G, p.E545K, p.Q546E, p.Q546R, p. H1047L,
p.H1047R, p.H1047Y), utilizing formalin-fixed paraffin-
embedded breast tumor tissue, reported as PIK3CA gene
mutation status
✚● 0157U Code added
▲ 0165U Peanut allergen-specific IgE and quantitative assessment of
64 multiple epitopes using enzyme-linked immunosorbent
assay (ELISA), blood, individual epitope results and
interpretation probability of peanut allergy
Medicine
★▲ 92227 Remote imagingImaging of retina for detection or
monitoring of retinal disease (eg, retinopathy in a patient
with diabetes) with analysis and report under physician
supervision, unilateral or bilateral; with remote clinical
staff review and report, unilateral or bilateral
★▲ 92228 Remote imaging for monitoring and management of active
retinal disease (eg, diabetic retinopathy) with remote
physician review or other qualified health care professional
interpretation and report, unilateral or bilateral
92585 Auditory evoked potentials for evoked response audiometry
and/or testing of the central nervous system; comprehensive
92586 limited
92992 Atrial septectomy or septostomy; transvenous method,
balloon (eg, Rashkind type) (includes cardiac
catheterization)
92993 blade method (Park septostomy) (includes cardiac
catheterization)
94250 Expired gas collection, quantitative, single procedure
94400 Breathing response to CO2 (CO2 response curve)
▲ 94617 Exercise test for bronchospasm, including pre- and post-
spirometry, electrocardiographic recording(s), and pulse
oximetry; with electrocardiographic recording(s)
94750 Pulmonary compliance study (eg, plethysmography, volume
and pressure measurements)
94770 Carbon dioxide, expired gas determination by infrared
analyzer
▲ 95070 Inhalation bronchial challenge testing (not including
necessary pulmonary function tests);, with histamine,
methacholine, or similar compounds
95071 with antigens or gases, specify
Category II Codes
▲ 3170F FlowBaseline flow cytometry studies performed at time of
diagnosis or prior to initiating treatment (HEM)1
Category III Codes

0058T Cryopreservation; reproductive tissue, ovarian
0085T Breath test for heart transplant rejection
0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell
(RBC) membranes
0126T Common carotid intima-media thickness (IMT) study for
evaluation of atherosclerotic burden or coronary heart
disease risk factor assessment
0228T Injection(s), anesthetic agent and/or steroid, transforaminal
epidural, with ultrasound guidance, cervical or thoracic;
single level
0229T each additional level (List separately in addition to code for
primary procedure)
0230T Injection(s), anesthetic agent and/or steroid, transforaminal
epidural, with ultrasound guidance, lumbar or sacral; single
level
0231T each additional level (List separately in addition to code for
primary procedure)
0295T External electrocardiographic recording for more than 48
hours up to 21 days by continuous rhythm recording and
storage; includes recording, scanning analysis with report,
review and interpretation
0296T recording (includes connection and initial recording)
0297T scanning analysis with report
0298T review and interpretation
0381T External heart rate and 3-axis accelerometer data recording
up to 14 days to assess changes in heart rate and to monitor
motion analysis for the purposes of diagnosing nocturnal
epilepsy seizure events; includes report, scanning analysis
with report, review and interpretation by a physician or
other qualified health care professional
0382T review and interpretation only
from 15 to 30 days to assess changes in heart rate and to
monitor motion analysis for the purposes of diagnosing
nocturnal epilepsy seizure events; includes report, scanning
more than 30 days to assess changes in heart rate and to
monitor motion analysis for the purposes of diagnosing
nocturnal epilepsy seizure events; includes report, scanning
0396T Intra-operative use of kinetic balance sensor for implant
stability during knee replacement arthroplasty (List
0400T Multi-spectral digital skin lesion analysis of clinically
atypical cutaneous pigmented lesions for detection of
melanomas and high risk melanocytic atypia; one to five
lesions
0401T six or more lesions
0405T Oversight of the care of an extracorporeal liver assist
system patient requiring review of status, review of
laboratories and other studies, and revision of orders and
liver assist care plan (as appropriate), within a calendar
month, 30 minutes or more of non-face-to-face time
#● 0623T Code added
▲ 0577T Electrophysiological evaluation of implantable
cardioverter-defibrillator system with substernal electrode
(includes defibrillation threshold evaluation, induction of
arrhythmia, evaluation of sensing for arrhythmia termination,
and programming or reprogramming of sensing or
therapeutic parameters)
● 0594T Code added
0595T Removal of humeral externally controlled intramedullary
lengthening device
✚● 0599T Code added
Administrative Multianalyte Assays with

Algorithmic Analyses (MAAA)
● 0014M Code added

Appendix C
Clinical Examples
▶As described in the CPT 2021 code set, clinical examples of the
CPT codes for the evaluation and management (E/M) services
included in this Appendix are intended to be an important
element of the coding system. The clinical examples, when used
with the E/M descriptors contained in the full text of the CPT
code set, provide a useful tool and guidance for individuals to
report the services provided to their patients. Clinical examples of
the codes for the E/M services included in this Appendix are
provided to assist physicians in understanding the meaning of the
descriptors and selecting the correct code. Each example was
developed by physicians in the specialties shown.◀
The same problem, when seen by physicians in different
specialties, may involve different amounts of work. Therefore,
the appropriate level of encounter should be reported using the
descriptors rather than the examples.
▶The American Medical Association is pleased to provide you
with these clinical examples for the CPT 2021 code set. The
clinical examples that are provided in this supplement are limited
to Hospital Inpatient Services, Subsequent Hospital Care,
Consultations, Emergency Department Services, Critical Care,
Prolonged Services, Care Plan Oversight, and Inpatient Neonatal
Intensive Care Services and Pediatric and Neonatal Critical Care
Services. Due to the substantial revisions to the guidelines and
code descriptors for the Office or Other Outpatient Services
section of E/M in the CPT 2021 code set, the clinical examples for
Office or Other Outpatient Services in Appendix C have been
removed. The CPT Editorial Panel, with input from interested
stakeholders, will continue to monitor the impacts to the revised
Office or Other Outpatient Services and may include revised
clinical examples in future editions of the CPT code set.◀
These clinical examples are used to describe presenting problems
that are frequently encountered in a given specialty. Typical
patients with such problems may commonly require the listed
E/M service. Therefore, these examples are not appropriately
used for any review of correct coding or estimating physician or
qualified health care professional work. These clinical examples
do not encompass the entire scope of medical practice. Inclusion
or exclusion of any particular specialty group does not infer any
judgment of importance or lack thereof; nor does it limit the
applicability of the example to any particular specialty. We
present these examples to provide additional educational context
when used in conjunction with the E/M descriptors and
guidelines
▶Of utmost importance is that these clinical examples are just
that: examples. A particular patient encounter, depending on the
specific circumstances, must be judged by the services provided
by the physician or other qualified health care professional for
that particular patient. Simply because the patient’s complaints,
symptoms, or diagnoses match those of a particular clinical
example does not automatically assign that patient encounter to
that particular level of service. Moreover, simply because the
patient’s complaints, symptoms, or diagnoses do not match those
of a particular clinical example does not automatically exclude
that patient encounter from a particular level of service. Ensure
that the required elements, as defined in the relevant E/M
guideline section, are met and documented in the medical record
to report a particular level of service.◀

Initial Hospital Care
99221 Initial hospital visit following admission for a 42-year-old
male for observation following institution of IV antibiotics
for a cellulitis of the forearm. (Plastic Surgery/Oral &
Maxillofacial Surgery)
Initial hospital visit for a 40-year-old patient with a
thrombosed synthetic arteriovenous conduit. (Nephrology)
Initial hospital visit for a healthy 24-year-old male with an
acute onset of low back pain following a lifting injury.
(Internal Medicine/Anesthesiology/Pain Medicine)
Initial hospital visit for a 69-year-old female with
controlled hypertension, scheduled for surgery. (Internal
Medicine/Cardiology)
Initial hospital visit for a 24-year-old healthy female with
benign tumor of palate. (Oral & Maxillofacial Surgery)
Initial hospital visit for a 14-year-old female with infectious
mononucleosis and dehydration. (Internal Medicine)
Initial hospital visit for a 62-year-old female with stable
rheumatoid arthritis, admitted for total joint replacement.
(Rheumatology)
Initial hospital visit for a 6-month-old infant admitted for
observation for apnea after craniofacial CT scan with
sedation. (Plastic Surgery)
controlled hypertension, scheduled for surgery. (Cardiology)
Hospital admission, examination, and initiation of treatment
program for a 67-year-old male with uncomplicated
pneumonia who requires IV antibiotic therapy. (Internal
Medicine)
Hospital admission for a 12-year-old with a laceration of
the upper eyelid involving the lid margin admitted prior to
surgery for IV antibiotic therapy. (Ophthalmology)
Hospital admission for a 32-year-old female with severe
flank pain, hematuria, and presumed diagnosis of ureteral
calculus as determined by Emergency Department physician.
(Urology)
Initial hospital visit for a patient with several large venous
stasis ulcers not responding to outpatient therapy.
(Dermatology)
Initial hospital visit for 21-year-old pregnant patient (nine-
weeks gestation) with hyperemesis gravidarum. (Obstetrics
& Gynecology)
Initial hospital visit for a 73-year-old female with acute
pyelonephritis who is otherwise generally healthy.
(Geriatrics)
Initial hospital visit for 62-year-old patient with cellulitis of
the foot requiring bedrest and intravenous antibiotics.
(Orthopaedic Surgery)
Initial hospital visit for a 55-year-old female admitted to the
hospital with nausea and vomiting, has a benign exam and a
nonspecific bowel gas pattern on X ray. (General Surgery)
99222 Hospital admission for an 18-month-old with 10%
dehydration. (Pediatrics)
Initial hospital visit for a 65-year-old female with right
upper quadrant pain, mild jaundice, and gallstones. (General
Surgery/Abdominal Surgery/Colon & Rectal Surgery)
Initial hospital visit for airway management, due to a benign
laryngeal mass. (Otolaryngology/Head & Neck Surgery)
Initial hospital visit for a 66-year-old female with an L-2
vertebral compression fracture with acute onset of paralytic
ileus; seen in the office two days previously. (Orthopaedic
Surgery)
Initial hospital visit and evaluation of a 15-year-old male
admitted with peritonsillar abscess or cellulitis requiring
intravenous antibiotic therapy. (Otolaryngology/Head &
Neck Surgery)
Initial hospital visit for a 42-year-old male with vertebral
compression fracture following a motor vehicle accident.
Initial hospital evaluation of a patient with a diffuse
erythematous maculopapular eruption of new onset. Patient
has multiple medical problems requiring various
medications. (Dermatology)
Initial hospital visit for a 3-year-old patient with high
temperature, limp, and painful hip motion of 18 hours’
duration. (Pediatrics/Orthopaedic Surgery)
Initial hospital visit for an 18-year-old male who has
suppurative sialadenitis and dehydration. (Oral &
Initial hospital visit for a 65-year-old female for acute onset
of thrombotic cerebrovascular accident with contralateral
paralysis and aphasia. (Neurology)
Initial hospital visit for a 50-year-old male chronic
paraplegic patient with pain and spasm below the lesion.
(Anesthesiology)
Partial hospital admission for an adolescent patient from
chaotic blended family, transferred from inpatient setting,
for continued treatment to maintain symptomatic control of
hostility and depression. (Psychiatry)
Initial hospital visit for a 61-year-old male with history of
previous myocardial infarction, who now complains of
chest pain. (Internal Medicine)
Initial hospital visit of a 15-year-old on medications for a
sore throat over the last two weeks. The sore throat has
worsened and patient now has dysphagia. The exam shows
large necrotic tonsils with an adequate airway and small
palpable nodes. The initial mono test was negative.
(Otolaryngology/Head & Neck Surgery)
Initial hospital evaluation of a 23-year-old allergy patient
admitted with eyelid edema and pain on fifth day of oral
antibiotic therapy. (Otolaryngology/Head & Neck Surgery)
Hospital admission for a 30-year-old female with epilepsy,
not compliant with medication, admitted after three seizures.
(Neurology)
program for a 66-year-old chronic hemodialysis patient with
fever. (Nephrology)
Hospital admission for a 40-year-old male with
submaxillary cellulitis and trismus from infected lower
molar. (Oral & Maxillofacial Surgery)
Initial hospital visit following admission for a 42-year-old
male for observation following an uncomplicated mandible
fracture. (Oral & Maxillofacial Surgery)
Initial hospital visit for a 24-year-old healthy female with
benign tumor of palate. (Oral & Maxillofacial Surgery)
Initial hospital visit for a 15-year-old male with acute status
asthmaticus, unresponsive to outpatient therapy. (Internal
Medicine)
99223 Hospital admission of a 62-year-old smoker, established
patient, with bronchitis in acute respiratory distress.
(Internal Medicine/Pulmonary Medicine)
Initial hospital visit for a 45-year-old female, who has a
history of rheumatic fever as a child and now has anemia,
fever, and congestive heart failure. (Cardiology)
Initial hospital visit for a 50-year-old male with acute chest
pain and diagnostic electrocardiographic changes of an
acute anterior myocardial infarction. (Cardiology/Family
Medicine/Internal Medicine)
Initial hospital visit of a 75-year-old with progressive
stridor and dysphagia with history of cancer of the larynx
treated by radiation therapy in the past. Exam shows a large
recurrent tumor of the glottis with a mass in the neck.
Initial hospital visit for a 70-year-old male admitted with
chest pain, complete heart block, and congestive heart
failure. (Cardiology)
Initial hospital visit for an 82-year-old male who presents
with syncope, chest pain, and ventricular arrhythmias.
(Cardiology)
arteriosclerotic coronary vascular disease, who is severely
dehydrated, disoriented, and confused. (Psychiatry)
Initial hospital visit for a 70-year-old male with alcohol and
sedative-hypnotic dependence, admitted by family for
severe withdrawal, hypertension, and diabetes mellitus.
(Psychiatry)
Initial hospital visit for a persistently suicidal latency-aged
child whose parents have requested admission to provide
safety but are anxious about separation from her.
(Psychiatry)
Initial psychiatric visit for an adolescent patient without
previous psychiatric history, who was transferred from the
medical ICU after an overdose. (Psychiatry)
Initial hospital visit for a 35-year-old female with severe
systemic lupus erythematosus on corticosteroid and
cyclophosphamide, with new onset of fever, chills, rash, and
chest pain. (Rheumatology)
Initial hospital visit for a 52-year-old male with known
rheumatic heart disease who presents with anasarca,
hypertension, and history of alcohol abuse. (Cardiology)
Initial hospital visit for a 55-year-old female with a history
of congenital heart disease; now presents with cyanosis.
(Cardiology)
Initial hospital visit for a psychotic, hostile, violently
combative adolescent, involuntarily committed for his and
other’s safety. (Psychiatry)
Initial hospital visit for a now subdued and sullen teenage
male with six-month history of declining school
performance, increasing self-endangerment, and resistance
of parental expectations, including running away past
weekend after physical fight with father. (Psychiatry)
Initial partial hospital admission for a 17-year-old female
with history of borderline mental retardation who has
developed auditory hallucinations. Parents are known to
abuse alcohol, and Child Protective Services is
investigating allegations of sexual abuse of a younger
sibling. (Psychiatry)
Initial hospital visit of a 67-year-old male admitted with a
large neck mass, dysphagia, and history of myocardial
infarction three months before. (Otolaryngology/Head &
Neck Surgery)
Initial hospital visit for a patient with suspected
cerebrospinal fluid rhinorrhea that developed two weeks
after head injury. (Otolaryngology/Head & Neck Surgery)
Initial hospital visit for a 25-year-old female with history of
poly-substance abuse and psychiatric disorder. The patient
appears to be psychotic with markedly elevated vital signs.
(Psychiatry)
Initial hospital visit for a 70-year-old male with cutaneous
T-cell lymphoma who has developed fever and
lymphadenopathy. (Internal Medicine)
Initial hospital visit for a 62-year-old female with known
coronary artery disease, for evaluation of increasing edema,
dyspnea on exertion, confusion, and sudden onset of fever
with productive cough. (Internal Medicine)
Initial hospital visit for a 3-year-old female with 36-hour
history of sore throat and high fever; now with sudden onset
of lethargy, irritability, photophobia, and nuchal rigidity.
(Pediatrics)
Initial hospital visit for a 26-year-old female for evaluation
of severe facial fractures (LeFort’s II/III). (Plastic Surgery)
Initial hospital visit for a 55-year-old female for bilateral
mandibular fractures resulting in flail mandible and airway
obstruction. (Plastic Surgery)
Initial hospital visit for a 71-year-old patient with a red
painful eye four days following uncomplicated cataract
surgery due to endophthalmitis. (Ophthalmology)
Initial hospital visit for a 45-year-old patient involved in a
motor vehicle accident who suffered a perforating
corneoscleral laceration with loss of vision.
(Ophthalmology)
Initial hospital visit for a 58-year-old male who has
Ludwig’s angina and progressive airway compromise. (Oral
& Maxillofacial Surgery)
Initial hospital visit for an adult with multiple cutaneous
blisters, denuded secondarily infected ulcerations, oral
lesions, weight loss, and increasing weakness refractory to
high-dose corticosteroid. Initiation of new
immunosuppressive therapy. (Dermatology)
Initial hospital visit for an 82-year-old male who presents
with syncope, chest pain, and ventricular arrhythmias.
(Cardiology)
previous myocardial infarction, comes in with recurrent,
sustained ventricular tachycardia. (Cardiology)
Initial hospital visit for a chronic dialysis patient with
infected PTFE fistula, septicemia, and shock. (Nephrology)
Initial hospital visit for a 1-year-old male, victim of child
abuse, with central nervous system depression, skull
fracture, and retinal hemorrhage. (Neurology)
Initial hospital visit for a 25-year-old female with recent
C4-C5 quadriplegia, admitted for rehabilitation. (Physical
Medicine & Rehabilitation)
Initial hospital visit for an 18-year-old male, post-traumatic
brain injury with multiple impairment. (Physical Medicine
& Rehabilitation)
Initial partial hospital admission for 16-year-old male,
sullen and subdued, with six-month history of declining
school performance, increasing self-endangerment, and
resistance to parental expectations. (Psychiatry)
Initial hospital visit for a 16-year-old primigravida at 32
weeks gestation with severe hypertension (200/110),
thrombocytopenia, and headache. (Obstetrics &
Gynecology)
Initial hospital visit for a 49-year-old male with cirrhosis of
liver with hematemesis, hepatic encephalopathy, and fever.
(Gastroenterology)
Initial hospital visit for a 55-year-old female in chronic pain
who has attempted suicide. (Psychiatry)
Initial hospital visit for a 70-year-old male, with multiple
organ system disease, admitted with history of being anuric
and septic for 24 hours prior to admission. (Urology)
Initial hospital visit for a 3-year-old female with 36-hour
history of sore throat and high fever, now with sudden onset
of lethargy, irritability, photophobia, and nuchal rigidity.
(Pediatrics/Critical Care)
Initial hospital visit for a 78-year-old male, transfers from
nursing home with dysuria and pyuria, increasing confusion,
and high fever. (Internal Medicine)
Initial hospital visit for a 1-day-old male with cyanosis,
respiratory distress, and tachypnea. (Cardiology)
Initial hospital visit for a 3-year-old female with recurrent
tachycardia and syncope. (Cardiology)
Initial hospital visit for a thyrotoxic patient who presents
with fever, atrial fibrillation, and delirium. (Endocrinology)
Initial hospital visit for a 50-year-old Type I diabetic who
presents with diabetic ketoacidosis with fever and
obtundation. (Endocrinology)
anatomical stage 3, ARA functional class 3 rheumatoid
arthritis on methotrexate, corticosteroid, and nonsteroidal
anti-inflammatory drugs. Patient presents with severe
arthritis flare, new oral ulcers, abdominal pain, and
leukopenia. (Rheumatology)
Initial hospital exam of a pediatric patient with high fever
and proptosis. (Otolaryngology/Head & Neck Surgery)
Initial hospital visit for a 25-year-old patient admitted for
the first time to the rehab unit, with recent C4-C5
quadriplegia. (Physical Medicine & Rehabilitation)
program for a previously unknown 58-year-old male who
presents with acute chest pain. (Cardiology)
Hospital admission, examination, and initiation of induction
chemotherapy for a 42-year-old patient with newly
diagnosed acute myelogenous leukemia.
(Hematology/Oncology)
Hospital admission following a motor vehicle accident of a
24-year-old male with fracture dislocation of C5-C6;
neurologically intact. (Neurosurgery)
Hospital admission for a 78-year-old female with left lower
lobe pneumonia and a history of coronary artery disease,
congestive heart failure, osteoarthritis, and gout. (Family
Medicine)
program for a 65-year-old immunosuppressed male with
confusion, fever, and a headache. (Infectious Disease)
Hospital admission for a 9-year-old with vomiting,
dehydration, fever, tachypnea, and an admitting diagnosis of
diabetic ketoacidosis. (Pediatrics)
Initial hospital visit for a 65-year-old male who presents
with acute myocardial infarction, oliguria, hypotension, and
altered state of consciousness. (Cardiology)
asthmaticus, unresponsive to outpatient therapy. (Internal
Medicine/Pediatrics/Pulmonary Medicine)
Initial hospital visit for a hostile/resistant adolescent patient
who is severely depressed and involved in poly-substance
abuse. Patient is experiencing significant conflict in his
chaotic family situation and was suspended from school
following an attack on a teacher with a baseball bat.
(Psychiatry)
Initial hospital visit for 89-year-old female with fulminant
hepatic failure and encephalopathy. (Gastroenterology)
Initial hospital visit for a patient with congestive heart
failure, type 1 diabetes mellitus, and renal failure who has
developed an acute onset of fever and a generalized bullous
erythematous and purpuric eruption. (Dermatology)
Hospital admission for a 50-year-old male with new-onset
left hemiparesis (Neurology)
Hospital admission for an 18-year-old male admitted to the
trauma service following a motor vehicle accident for
treatment of a closed head injury, liver laceration, and long
bone fractures. (General Surgery)
First hour of critical care of a 15-year-old with acute
respiratory failure from asthma. (Pulmonary Medicine)
Hospital admission of a 62-year-old smoker, established
patient, with bronchitis in acute respiratory distress.
(Pulmonary Medicine/Critical Care)
asthmaticus, unresponsive to outpatient therapy.
(Cardiology/Family Practice/General Surgery/Pulmonary
Medicine/Critical Care)
Initial hospital visit for a 42-year-old female with rapidly
progressing scleroderma, malignant hypertension, digital
infarcts, and oliguria. (Cardiology/Family Practice/General
Surgery/Pulmonary Medicine/Rheumatology/Critical Care)

99231 Subsequent hospital visit for a 65-year-old female, post-
open reduction and internal fixation of a fracture. (Physical
Subsequent hospital visit for a 33-year-old patient with
pelvic pain who is responding to pain medication and
observation. (Obstetrics & Gynecology)
Subsequent hospital visit for a 21-year-old female with
hyperemesis who has responded well to intravenous fluids.
(Obstetrics & Gynecology)
Subsequent hospital visit to re-evaluate postoperative pain
and titrate patient-controlled analgesia for a 27-year-old
female. (Anesthesiology)
Follow-up hospital visit for a 35-year-old female, status
post-epidural analgesia. (Anesthesiology/Pain Medicine)
Subsequent hospital visit for a 56-year-old male, post-
gastrectomy, for maintenance of analgesia using an
intravenous Dilaudid infusion. (Anesthesiology)
Subsequent hospital visit for a male with improving venous
stasis ulcers. (Dermatology)
otitis externa, seen two days before in consultation, now to
have otic wick removal. (Otolaryngology/Head & Neck
Surgery)
resolving cellulitis of the foot. (Orthopaedic Surgery)
Subsequent hospital visit for a 25-year-old male admitted
for supra-ventricular tachycardia and converted on medical
therapy. (Cardiology)
Subsequent hospital visit for a 27-year-old male with nasal
fracture who was intoxicated and uncooperative on
admission exam. Patient confirms no difficulty breathing and
no change in nasal appearance, exam normal other than mild
tenderness. (Plastic Surgery)
Subsequent hospital visit for a 76-year-old male with
venous stasis ulcers. (Geriatrics)
Subsequent hospital visit for a 67-year-old female admitted
three days ago with bleeding gastric ulcer; now stable.
(Gastroenterology)
Subsequent hospital visit for stable 33-year-old male
following a motor vehicle accident who is stable with
bruised ribs and improving dyspnea. (General
Surgery/Gastroenterology)
Subsequent hospital visit for a 29-year-old male with effort
thrombosis of left upper extremity. (General Surgery)
Subsequent hospital visit for a 14-year-old female in middle
phase of residential or day treatment who is now
behaviorally stable and making satisfactory progress in
treatment. (Psychiatry)
rheumatoid arthritis, two days following an uncomplicated
total joint replacement. (Rheumatology)
Subsequent hospital visit for a 60-year-old dialysis patient
with an access infection, now afebrile on antibiotic.
(Nephrology)
for cellulitis following dog bite to hand, redness, pain, and
swelling resolving. (Plastic Surgery)
Subsequent hospital visit for a 66-year-old female with L-2
vertebral compression fracture with resolving ileus.
Subsequent hospital visit for an 18-year-old female
responding to intravenous antibiotic therapy for ear or sinus
infection. (Otolaryngology/Head & Neck Surgery)
with congestive heart failure who has responded to therapy.
(Cardiology)
Follow-up hospital visit for a 32-year-old female with left
ureteral calculus; being followed in anticipation of
spontaneous passage. (Urology)
Subsequent hospital visit for a 42-year-old female, admitted
for acute gastroenteritis and dehydration, requiring IV
hydration; now stable but refusing oral intake. (Family
Medicine/Pediatrics)
Subsequent hospital visit for a 50-year-old Type II diabetic
who is clinically stable and without complications requiring
regulation of a single dose of insulin daily. (Endocrinology)
Subsequent hospital visit to reassesses the status of a 65-
year-old patient post-open reduction and internal fixation of
hip fracture, on the rehab unit. (Physical Medicine &
Rehabilitation)
cholangiocarcinoma managed by biliary drainage.
(Interventional Radiology)
uncomplicated myocardial infarction who is clinically
stable and without chest pain. (Family
Medicine/Cardiology/Internal Medicine)
Subsequent hospital visit for a stable 72-year-old lung
cancer patient undergoing a five-day course of infusion
chemotherapy. (Hematology/Oncology)
Subsequent hospital visit, two days post admission for a 65-
year-old male with a CVA (cerebral vascular accident) and
left hemiparesis, who is clinically stable.
(Neurology/Physical Medicine & Rehabilitation)
Subsequent hospital visit for now stable, 33-year-old male,
status post lower gastrointestinal bleeding. (General
Surgery)
Subsequent hospital visit for a 3-year-old patient in traction
for a congenital dislocation of the hip. (Orthopaedic
Surgery)
Subsequent hospital visit for a 4-year-old female, admitted
for acute gastroenteritis and dehydration, requiring IV
hydration; now stable. (Family Medicine/Internal Medicine)
Subsequent hospital visit for 50-year-old female with
resolving uncomplicated acute pancreatitis.
(Gastroenterology)
Subsequent hospital visit for a 30-day-old male admitted for
sepsis evaluation and IV antibiotics due to fever; afebrile
now with cultures pending. (Family Medicine/Pediatrics)
for lobar pneumonia with vomiting and dehydration; is
becoming afebrile and tolerating oral fluids. (Pulmonary
Medicine)
Subsequent visit on third day of hospitalization for a 60-
year-old female recovering from an uncomplicated lower
extremity cellulitis. (Infectious Disease/Internal
Medicine/Pulmonary Medicine)
Subsequent visit for a 75-year-old female, now three days
after onset of left hemiparesis, awaiting placement in a
rehabilitation unit. (Neurology)
99232 Subsequent visit on third day of hospitalization for a 60-
year-old female recovering from an uncomplicated
pneumonia. (Infectious Disease/Internal
Subsequent hospital visit for a patient with peritonsillar
cellulitis, with slow response to antibiotic therapy, with
consideration for additional testing and changes in treatment
plan. (Otolaryngology/Head & Neck Surgery)
Subsequent hospital visit for a 27-year-old with acute
vertigo, with review of laboratory and imaging studies.
Subsequent hospital visit for a patient with venous stasis
ulcers who developed fever and red streaks adjacent to the
ulcer. (Dermatology/Internal Medicine/Family Medicine)
for IV antibiotics for cellulitis post dog bite to hand.
Increased redness and fluctuance found. (Plastic Surgery)
for myocardial infarction, but who is now having frequent
premature ventricular contractions. (Internal Medicine)
Subsequent hospital visit for an 80-year-old patient with a
pelvic rim fracture, inability to walk, and severe pain; now
36 hours post-injury, experiencing urinary retention.
fever, pharyngitis, and airway obstruction, who after 48
hours develops a maculopapular rash. (Pediatrics/Family
Medicine)
Follow-up visit for a 67-year-old male with congestive
heart failure who has responded to antibiotics and diuretics
and has now developed a monoarthropathy. (Internal
Medicine)
Follow-up hospital visit for a 58-year-old male receiving
continuous opioids who is experiencing severe nausea and
vomiting. (Pain Medicine)
Subsequent hospital visit for a patient after an auto accident
who is slow to respond to ambulation training. (Physical
Subsequent hospital visit for a 50-year-old diabetic,
hypertensive male with back pain not responding to
conservative inpatient management with continued radiation
of pain to the lower left extremity. (Orthopaedic Surgery)
Subsequent hospital visit for a 37-year-old female on day
five of antibiotics for bacterial endocarditis, who still has
low-grade fever. (Cardiology)
Subsequent hospital visit for a 54-year-old patient, post MI
(myocardial infarction), who is out of the CCU (coronary
care unit) but is now having frequent premature ventricular
contractions on telemetry. (Cardiology/Internal Medicine)
Subsequent hospital visit for a patient with neutropenia, a
fever responding to antibiotics, and continued slow
gastrointestinal bleeding on platelet support.
two days ago for sub-acute renal allograft rejection.
(Nephrology)
Subsequent hospital visit for a 35-year-old drug addict, not
responding to initial antibiotic therapy for pyelonephritis.
(Urology)
worsening jaundice and a pancreatic mass. (General
Surgery)
Subsequent hospital care for a 62-year-old female with
congestive heart failure, who remains dyspneic and febrile.
(Internal Medicine)
recently diagnosed lung cancer, who complains of unsteady
gait. (Pulmonary Medicine)
Subsequent hospital visit for a 20-month-old male with
bacterial meningitis treated one week with antibiotic
therapy; has now developed a temperature of 101 degrees.
(Pediatrics)
Subsequent hospital visit for 13-year-old male admitted
with left lower quadrant abdominal pain and fever, not
responding to therapy. (General Surgery)
hemiplegia and painful paretic shoulder. (Physical Medicine
& Rehabilitation)
Subsequent hospital visit for a patient admitted for treatment
of congestive heart failure, on multiple medications, whose
previous pale, diffuse rash has now generalized, brightened,
and is intensely pruritic. (Dermatology)
Subsequent hospital visit for a 41-year-old female whose
altered mental status improved. (General Surgery)
Subsequent hospital visit for adolescent female who
continues to struggle with suicidal thoughts and has multiple
questions about her antidepressant medication. (Psychiatry)
Subsequent partial hospital visit for a child with depression
and severe anxiety. (Psychiatry)
Subsequent hospital visit for 59-year-old male with
depression, anxiety, and medication side effects.
(Psychiatry)
Subsequent partial hospital visit for a 25-year-old female
with body image ruminations and high anxiety about
following the prescribed meal plan. (Psychiatry)
99233 Subsequent hospital visit for a 38-year-old male,
quadriplegic with acute autonomic hyperreflexia, who is not
responsive to initial care. (Physical Medicine &
Rehabilitation)
Follow-up hospital visit for a teenage female who continues
to experience severely disruptive, violent, and life-
threatening symptoms in a complicated multi-system illness.
Family/social circumstances also a contributing factor.
(Psychiatry)
progressive systemic sclerosis (scleroderma), renal failure
on dialysis, congestive heart failure, cardiac arrhythmias,
and digital ulcers. (Allergy & Immunology)
Subsequent hospital visit for a 50-year-old diabetic,
hypertensive male with nonresponding back pain and
radiating pain to the lower left extremity, who develops
chest pain, cough, and bloody sputum. (Orthopaedic
Surgery)
Subsequent hospital visit for a 64-year-old female, status
post-abdominal aortic aneurysm resection, with non-
responsive coagulopathy, who has now developed lower GI
bleeding. (Abdominal Surgery/Colon & Rectal
Surgery/General Surgery)
Follow-up hospital care of a patient with pansinusitis
infection complicated by a brain abscess and asthma; no
response to current treatment. (Otolaryngology/Head &
Neck Surgery)
Subsequent hospital visit for a patient with a laryngeal
neoplasm who develops airway compromise, suspected
metastasis. (Otolaryngology/Head & Neck Surgery)
significant rectal bleeding, etiology undetermined, not
responding to treatment. (Abdominal Surgery/General
Surgery/Colon & Rectal Surgery)
aortocoronary bypass surgery; now develops hypotension
and oliguria. (Cardiology)
Subsequent hospital visit for an adolescent patient who is
violent, unsafe, and noncompliant, with multiple
expectations for participation in treatment plan and behavior
on the treatment unit. (Psychiatry)
Subsequent hospital visit for an 18-year-old male being
treated for presumed PCP-induced psychosis. Patient still
has moderate auditory hallucinations and is insisting on
signing out against medical advice. (Psychiatry)
Subsequent hospital visit for an 8-year-old female with
caustic ingestion, who now has fever, dyspnea, and dropping
hemoglobin. (Gastroenterology)
electrical burns to the left arm with ascending infection.
Subsequent hospital visit for a type 1 diabetes mellitus
patient with a new onset of fever, change in mental status,
and a diffuse petechial, purpuric eruption. (Internal
Medicine)
Subsequent hospital visit for a 65-year-old female, status
postoperative resection of abdominal aortic aneurysm, with
suspected ischemic bowel. (General Surgery)
aortocoronary bypass surgery, now develops hypotension
and oliguria. (Cardiology)
Subsequent hospital visit for a 65-year-old male, following
an acute myocardial infarction, who complains of shortness
of breath and new chest pain. (Cardiology)
rheumatoid arthritis (stage 3, class 3) admitted for
urosepsis. On the third hospital day, chest pain, dyspnea,
and fever develop. (Rheumatology)
Follow-up hospital care of a pediatric case with stridor,
laryngomalacia, established tracheostomy, complicated by
multiple medical problems in PICU. (Otolaryngology/Head
& Neck Surgery)
Subsequent hospital visit for a 60-year-old female, four
days post uncomplicated inferior myocardial infarction who
has developed severe chest pain, dyspnea, diaphoresis, and
nausea. (Family Medicine)
Subsequent hospital visit for a patient with AML (acute
myelogenous leukemia), fever, elevated white count and uric
acid undergoing induction chemotherapy.
Subsequent hospital visit for a 38-year-old quadriplegic
male with acute autonomic hyperreflexia, who is not
responsive to initial care. (Physical Medicine &
Rehabilitation)
Subsequent hospital visit for a 65-year-old female
postoperative resection of abdominal aortic aneurysm, with
suspected ischemic bowel. (General Surgery)
persistent leukocytosis, fever, abdominal pain, and
hypotension seven days after a sigmoid colon resection for
carcinoma. (Infectious Disease)
Subsequent hospital visit for a chronic renal failure patient
on dialysis, who develops chest pain, shortness of breath.
(Nephrology)
Subsequent hospital visit for a 65-year-old male with acute
myocardial infarction who now demonstrates complete heart
block and congestive heart failure. (Cardiology)
Subsequent hospital visit for a 55-year-old male with severe
chronic obstructive pulmonary disease and bronchospasm;
initially admitted for acute respiratory distress requiring
ventilatory support in the ICU. The patient was stabilized,
extubated, and transferred to the floor but has now
developed acute fever, dyspnea, left lower lobe rhonchi, and
laboratory evidence of carbon dioxide retention and
hypoxemia. (Family Medicine/Internal Medicine)
Subsequent hospital visit for 46-year-old female, known
liver cirrhosis patient, with recent upper gastrointestinal
hemorrhage from varices; now with worsening ascites and
encephalopathy. (Gastroenterology)
Subsequent hospital visit for 62-year-old female admitted
with acute subarachnoid hemorrhage, negative cerebral
arteriogram, increased lethargy, and hemiparesis with fever.
(Neurosurgery)
Subsequent partial hospital visit for an adolescent female
who cut herself over the weekend following an intense
family argument. (Psychiatry)
Subsequent hospital visit for an adolescent patient who is
actively suicidal and experiencing significant medication
side effects. (Psychiatry)
depression who had a syncopal episode on the unit.
(Psychiatry)
Subsequent hospital visit for a 43-year-old male with new
onset foot drop after removing a cast from his leg.
(Neurology)
Consultations
Office or Other Outpatient Consultations
99241 Initial office consultation for a 40-year-old female in pain
from blister on lip following a cold. (Oral & Maxillofacial
Surgery)
Initial office consultation for a 62-year-old construction
worker with olecranon bursitis. (Orthopaedic Surgery)
Office consultation with 25-year-old postpartum female
with suspected hemorrhoids. (General Surgery)
Office consultation with 58-year-old male, referred for
follow-up of creatinine level and evaluation of obstructive
uropathy, relieved two months ago. (Nephrology)
Office consultation for 30-year-old female tennis player
with sprain or contusion of the forearm. (Orthopaedic
Surgery)
Office consultation for a 45-year-old male, requested by his
internist, with asymptomatic torus palatinus requiring no
further treatment. (Oral & Maxillofacial Surgery)
99242 Initial office consultation for a 29-year-old soccer player
with painful proximal thigh/groin injury. (Orthopaedic
Surgery)
Initial office consultation for an 8-year-old female with a
five-day-old second-degree scald burn of the foot. (Plastic
Surgery)
Initial office consultation for a patient with a history of
discoid lupus erythematosus who has developed a new
erythematous nodule on a cheek. (Dermatology)
Office consultation for management of systolic hypertension
in a 70-year-old male scheduled for elective prostate
resection. (Geriatrics)
Office consultation with 27-year-old female, with old
amputation, for evaluation of existing above-knee
prosthesis. (Physical Medicine & Rehabilitation)
Office consultation with 66-year-old female with wrist and
hand pain, and finger numbness, secondary to suspected
carpal tunnel syndrome. (Orthopaedic Surgery)
Office consultation for 61-year-old female, recently on
antibiotic therapy, now with diarrhea and leukocytosis.
(Abdominal Surgery)
Office consultation for a patient with papulosquamous
eruption of elbow with pitting of nails and itchy scalp.
(Dermatology)
Office consultation for a 25-year-old female seen in
consultation for complaints of breast pain, with no nipple
discharge, mass, or family history of breast cancer. (General
Surgery)
Initial office consultation for a 60-year-old female with
ptosis, muscle weakness, and thymic tumor who was
referred by her neurologist for possible therapeutic
plasmapheresis. (Pathology)
99243 Initial office consultation for a 60-year-old male with
avascular necrosis of the left femoral head with increasing
pain. (Orthopaedic Surgery)
Office consultation for a 31-year-old female complaining of
palpitations and chest pains. Her internist had described a
mild systolic click. (Cardiology)
Office consultation for a 65-year-old female with recurrent
upper extremity cellulitis following axillary lymph node
dissection for breast carcinoma. (Infectious Disease)
Office consultation for a 65-year-old male with chronic
low-back pain radiating to the leg. (Neurosurgery)
Office consultation for 23-year-old female with Crohn’s
disease not responding to therapy. (Abdominal
Office consultation for 25-year-old patient with
symptomatic knee pain and swelling, with torn anterior
cruciate ligament and/or torn meniscus. (Orthopaedic
Surgery)
Office consultation for a 67-year-old patient with
osteoporosis and mandibular atrophy with regard to
reconstructive alternatives. (Oral & Maxillofacial Surgery)
Office consultation for 39-year-old patient referred at a
perimenopausal age for irregular menses and menopausal
symptoms. (Obstetrics & Gynecology)
Office consultation for a patient with a papulosquamous
eruption of the elbows, pitting of the nails, an itchy, scaly
scalp, and localized joint pains. (Dermatology)
Initial office consultation for a 40-year-old female in pain
from blister on lip following a cold. (Oral & Maxillofacial
Surgery)
Office consultation for a 45-year-old male, requested by his
internist, with asymptomatic torus palatinus requiring no
further treatment. (Oral & Maxillofacial Surgery)
Office consultation for a 16-year-old male who suffered a
concussion a week ago, now fully recovered, needing an
evaluation to return to playing football. (Neurology)
99244 Initial office consultation for a 28-year-old male, HIV+,
with a recent change in visual acuity. (Ophthalmology)
Initial office consultation for a 15-year-old male with failing
grades, suspected drug abuse. (Pediatrics)
Initial office consultation for a 36-year-old factory worker,
status four months post-occupational low back injury and
requires management of intractable low back pain. (Pain
Medicine)
Initial office consultation for a 45-year-old female with a
history of chronic arthralgia of TMJ and associated myalgia
and sudden progressive symptomatology over last two to
three months. (Oral & Maxillofacial Surgery)
developmental facial skeletal anomaly and subsequent
abnormal relationship of jaw(s) to cranial base. (Oral &
Initial office consultation for a 45-year-old myopic patient
with a one-week history of floaters and a partial retinal
detachment. (Ophthalmology)
moderate dementia, mild unsteadiness, back pain fatigue on
ambulation, intermittent urinary incontinence.
(Neurosurgery)
Initial office consultation for a 33-year-old female referred
by endocrinologist with amenorrhea and galactorrhea, for
evaluation of pituitary tumor. (Neurosurgery)
Initial office consultation for a 34-year-old male with new
onset nephrotic syndrome. (Nephrology)
Initial office consultation for a patient with multiple giant
tumors of jaws. (Oral & Maxillofacial Surgery)
Initial office consultation for a patient with a failed total hip
replacement with loosening and pain upon walking.
three-year history of intermittent tic-like unilateral facial
pain; now constant pain for six weeks without relief by
adequate carbamazepine dosage. (Neurosurgery)
Initial office consultation for a 45-year-old male heavy
construction worker with prior lumbar disk surgery two
years earlier; now gradually recurring low back and
unilateral leg pain for three months, unable to work for two
weeks. (Neurosurgery)
Office consultation with 38-year-old female with
inflammatory bowel disease, complaints of pain in the right
lower quadrant, and suspected intra-abdominal abscess.
(General Surgery/Colon & Rectal Surgery)
Office consultation with 72-year-old male with esophageal
carcinoma, symptoms of dysphagia and reflux. (Thoracic
Surgery)
Office consultation for discussion of treatment options for a
40-year-old female with a 2 cm adenocarcinoma of the
breast. (Radiation Oncology)
Office consultation for 66-year-old female, history of colon
resection for adenocarcinoma six years earlier, now with
severe mid-back pain; X-rays showing osteoporosis and
multiple vertebral compression fractures. (Neurosurgery)
Office consultation for a patient with chronic pelvic
inflammatory disease who now has left lower quadrant pain
with a palpable pelvic mass. (Obstetrics & Gynecology)
Office consultation for a patient with long-standing psoriasis
with acute onset of erythroderma, pustular lesions, chills,
and fever. Combinations of topical and systemic treatments
discussed and instituted. (Dermatology)
Office consultation for a 39-year-old female with persistent
migraines failing medications prescribed by her primary
care provider. (Neurology)
99245 Office consultation for young patient referred by
pediatrician because of patient’s short attention span, easy
distractibility, and hyperactivity after a failed stimulant trial.
(Psychiatry)
Initial office consultation for evaluation of a 70-year-old
male with multiple medical problems and recent
unexplained appetite loss and diminished energy.
(Psychiatry)
Initial office consultation for an elementary school-aged
patient, referred by pediatrician, with multiple somatic
complaints and recent onset of behavioral discontrol.
(Psychiatry)
Initial office consultation of a patient who presents with a
30-year history of smoking, hypertension, chronic
obstructive pulmonary disease, and a hard, fixed right neck
mass. Patient on other meds for conditions. Patient presents
with CT ordered by PCP. (Otolaryngology/Head & Neck
Surgery)
Initial office consultation for a 35-year-old multiple-trauma
male patient with complex pelvic fractures, for evaluation
and formulation of management plan. (Orthopaedic Surgery)
Initial emergency room consultation for 10-year-old male in
status epilepticus, recent closed head injury, information
about medication not available. (Neurosurgery)
Initial emergency room consultation for a 23-year-old
patient with severe abdominal pain, guarding, febrile, and
unstable vital signs. (Obstetrics & Gynecology)
Office consultation for a 67-year-old female longstanding
uncontrolled diabetic who presents with retinopathy,
nephropathy, and a foot ulcer. (Endocrinology)
Office consultation for a 37-year-old male for initial
evaluation and management of Cushing’s disease.
(Endocrinology)
Office consultation for a 60-year-old male who presents
with thyrotoxicosis, exophthalmos, frequent premature
ventricular contractions, and congestive heart failure.
(Endocrinology)
Initial office consultation for a 36-year-old patient, one year
status post occupational herniated cervical disk treated by
laminectomy, requiring management of multiple sites of
intractable pain, depression, and narcotic dependence. (Pain
Medicine)
Office consultation for a 58-year-old male with a history of
MI and CHF who complains of the recent onset of rest
angina and shortness of breath. The patient has a systolic
blood pressure of 90 mmHG and is in Class IV heart failure.
(Cardiology)
Emergency room consultation for a 1-year-old with a three-
day history of fever with increasing respiratory distress who
is thought to have cardiac tamponade by the ER physician.
(Cardiology)
Office consultation in the emergency room for a 25-year-old
male with severe, acute, closed head injury. (Neurosurgery)
Office consultation for a 53-year-old female with advanced
head and neck cancer. (Radiation Oncology)
Office consultation for a 27-year-old juvenile diabetic
patient with severe diabetic retinopathy, gastric atony,
nephrotic syndrome, and progressive renal failure, now with
a serum creatinine of 2.7, and a blood pressure of 170/114.
(Nephrology)
Office consultation for independent medical evaluation of a
patient with a history of complicated low back and neck
problems with previous multiple failed back surgeries.
Office consultation for an adolescent referred by
pediatrician PCP for recent onset of violent and self-
injurious behavior. (Psychiatry)
Office consultation for a 6-year-old male for evaluation of
severe muscle and joint pain and a diffuse rash. Patient well
until 4-6 weeks earlier, when he developed arthralgia,
myalgias, and a fever of 102 degrees for one week.
(Rheumatology)
Office consultation for a 70-year-old male with COPD,
congestive heart failure, and diabetes, who presents with
rectal bleeding and pain, and worsening constipation. The
patient has a fixed, partially obstructing rectal mass.
(General Surgery)
Office consultation for a 57-year-old male with recent onset
of three events of left arm weakness lasting 30 minutes each.
(Neurology)
Initial office consultation of a patient who presents with a
30 year history of smoking and hard, fixed right neck mass,
HTN, COPD for which he is on other meds and/or a
suspicious epiglottic lesion on indirect laryngoscopy. He
brings a CT ordered by his PCP. (Otolaryngology)
99251 Initial hospital consultation for a 27-year-old female with
fractured incisor post-intubation. (Oral & Maxillofacial
Surgery)
Initial hospital consultation for an orthopaedic patient on IV
antibiotics who has developed an apparent candida infection
of the oral cavity. (Oral & Maxillofacial Surgery)
Initial inpatient consultation for a 30-year-old female
complaining of vaginal itching, post orthopaedic surgery.
Initial inpatient consultation for a 36-year-old male on
orthopaedic service with complaint of localized dental pain.
(Oral & Maxillofacial Surgery)
Initial hospital consultation for a 20-year-old male
following a motor vehicle accident who developed cellulitis
around a laceration that was sutured in the emergency room.
(General Surgery)
Initial inpatient consultation for a 64-year-old bedridden
male with skin irritation and pain in posterior heel.
(Podiatry Surgery)
99252 Initial hospital consultation for a 45-year-old male,
previously abstinent alcoholic, who relapsed and was
admitted for management of gastritis. The patient readily
accepts the need for further treatment. (Addiction Medicine)
Inpatient consultation for a 28-year-old female with
thrombocytopenia and neurologic symptoms who was
referred by her hematologist for possible therapeutic
plasmapheresis for thrombotic thrombocytopenic purpura.
(Pathology)
Initial hospital consultation for a 35-year-old dialysis
patient with episodic oral ulcerations. (Oral &
Initial inpatient preoperative consultation for a 43-year-old
female with cholecystitis and well-controlled hypertension.
(Cardiology)
Initial inpatient consultation for recommendation of
antibiotic prophylaxis for a patient with a synthetic heart
valve who will undergo urologic surgery. (Internal
Medicine)
Initial inpatient consultation for possible drug induced skin
eruption in 50-year-old male. (Dermatology)
Preoperative inpatient consultation for evaluation of
hypertension in a 60-year-old male who will undergo a
cholecystectomy. Patient had a normal annual check-up in
your office four months ago. (Internal Medicine)
Initial inpatient consultation for 66-year-old patient with
wrist and hand pain and finger numbness, secondary to
carpal tunnel syndrome. (Orthopaedic Surgery/Plastic
Surgery)
Initial inpatient consultation for a 66-year-old male smoker
referred for pain management immediately status post-
biliary tract surgery done via sub-costal incision.
(Anesthesiology/Pain Medicine)
Initial inpatient consultation for an asymptomatic patient
with an established diagnosis of allergic rhinitis, who has
gone six weeks since last allergy injection and needs a dose
adjustment before the next dose is given. (Allergy &
Immunology)
Initial office visit for an 86-year old male with a 2 cm
lipoma on back that he is concerned is infected. (General
Surgery)
Initial inpatient consultation for a 70-year-old female who
has had no bowel sounds for two days following an
orthopedic operation. (General Surgery)
Initial hospital consultation for a 56-year-old stroke patient
with ankle venous stasis ulcerations. (Podiatry Surgery)
Initial consultation for 66-year-old patient with a grade 1
sacral decubitus following a six-hour abdominal surgical
procedure. (Orthopaedic Surgery/Plastic Surgery)
99253 Initial hospital consultation for a 50-year-old female with
incapacitating knee pain due to generalized rheumatoid
arthritis. (Orthopaedic Surgery)
Initial hospital consultation for a 60-year-old male with
avascular necrosis of the left femoral heel with increasing
pain. (Orthopaedic Surgery)
Initial hospital consultation for a 45-year-old female with
compound mandibular fracture and concurrent head,
abdominal, and/or orthopaedic injuries. (Oral &
Initial hospital consultation for a 22-year-old female,
paraplegic, to evaluate wrist and hand pain. (Orthopaedic
Surgery)
Initial hospital consultation for a 40-year-old male with 10-
day history of incapacitating unilateral sciatica, unable to
walk now, not improved by bed rest. (Neurosurgery)
Initial hospital consultation, requested by pediatrician, for
treatment recommendations for a patient admitted with
persistent inability to walk following soft tissue injury to
ankle. (Physiatry)
Initial hospital consultation for a 27-year-old previously
healthy male who vomited during IV sedation and may have
aspirated gastric contents. (Anesthesiology)
Initial hospital consultation for a 33-year-old female, post-
abdominal surgery, who now has a fever. (Internal
Medicine)
Initial inpatient consultation for a 57-year-old male admitted
for severe abdominal pain and fever two days post lower
endoscopy. (General Surgery)
Initial inpatient consultation for rehabilitation of a 73-year-
old female one week after surgical management of a hip
fracture. (Physical Medicine & Rehabilitation)
Initial inpatient consultation for diagnosis/management of
fever following abdominal surgery. (Internal Medicine)
Initial inpatient consultation for a 42-year-old non-diabetic
patient, postoperative cholecystectomy, now with an acute
urinary tract infection. (Nephrology)
Initial inpatient consultation for 53-year-old female with
moderate uncomplicated pancreatitis. (Gastroenterology)
Initial inpatient consultation for 45-year-old patient with
chronic neck pain with radicular pain of the left arm.
Initial inpatient consultation for a 43-year-old male with
new onset foot drop after removing a cast from his leg.
(Neurology)
Initial hospital consultation for an orthopaedic patient on IV
antibiotics who has developed an apparent candida infection
of the oral cavity. (Oral & Maxillofacial Surgery)
Initial inpatient consultation for a 36-year-old male on
orthopaedic service with complaint of localized dental pain.
Initial hospital consultation for a 35-year-old dialysis
patient with episodic oral ulcerations. (Oral &
Initial hospital consultation for a 55-year-old diabetic
patient on dialysis with infected ingrown toenail. (Podiatry
Surgery)
99254 Initial inpatient consultation for a 35-year-old female with a
fever and pulmonary infiltrate following cesarean section.
(Pulmonary Medicine)
Initial hospital consultation for a 15-year-old patient with
painless swelling of proximal humerus with lytic lesion by
X-ray. (Orthopaedic Surgery)
Initial hospital consultation for evaluation of a 29-year-old
female with a diffusely positive medical review of systems
and history of multiple surgeries. (Psychiatry)
female with gangrene of the foot. (Orthopaedic Surgery)
Initial inpatient consultation for a 47-year-old female with
progressive pulmonary infiltrate, hypoxemia, and
diminished urine output. (Anesthesiology)
Initial hospital consultation for a patient with failed total hip
replacement with loosening and pain upon walking.
metastatic breast cancer to the femoral neck and thoracic
vertebra. (Orthopaedic Surgery)
nephrolithiasis requiring extensive opioid analgesics, whose
vital signs are now elevated. She initially denied any drug
use but today gives history of multiple substance abuse,
including opioids and prior treatment for a personality
disorder. (Psychiatry)
Initial inpatient consultation for evaluation of a 63-year-old
in the ICU with diabetes and chronic renal failure who
develops acute respiratory distress syndrome 36 hours after
a mitral valve replacement. (Anesthesiology)
enlarged supraclavicular lymph nodes, found on biopsy to
be malignant. (Hematology/Oncology)
Initial inpatient consultation for a 43-year-old female for
evaluation of sudden painful visual loss, optic neuritis, and
episodic paresthesia. (Ophthalmology)
Initial inpatient consultation for evaluation of a 71-year-old
male with hyponatremia (serum sodium 114) who was
admitted to the hospital with pneumonia. (Nephrology)
emergency admission for possible bowel obstruction.
(Internal Medicine/General Surgery)
fever, swollen joints, and rash of one-week duration.
(Rheumatology)
compound mandibular fracture and concurrent head,
abdominal, and/or orthopaedic injuries. (Oral &
female with gangrene of the foot. (Podiatry Surgery)
myasthenia admitted for a thymectomy surgery tomorrow.
(Neurology)
99255 Initial hospital consultation for a 70-year-old female without
previous psychiatric history who is now experiencing
nocturnal confusion and visual hallucinations following hip
replacement surgery. (Psychiatry)
massive, life-threatening gastrointestinal hemorrhage and
chest pain. (Gastroenterology)
Initial inpatient consultation for a 75-year-old female,
admitted to intensive care with acute respiratory distress
syndrome, who is hypersensitive, and has a moderate
metabolic acidosis, and a rising serum creatinine.
(Nephrology)
Initial hospital consultation for patient with a history of
complicated low back pain and neck problems with
previous multiple failed back surgeries. (Orthopaedic
Surgery/Neurosurgery)
Initial hospital consultation for a 66-year-old female, two
days post-abdominal aneurysm repair, with oliguria and
hypertension of one-day duration. (Nephrology/Internal
Medicine)
Initial hospital consultation for a patient with shotgun wound
to face with massive facial trauma and airway obstruction.
Initial hospital consultation for patient with severe
pancreatitis complicated by respiratory insufficiency, acute
renal failure, and abscess formation. (General
Initial hospital consultation for a 35-year-old multiple-
trauma male patient with complex pelvic fractures to
evaluate and formulate management plan. (Orthopaedic
Surgery)
Initial inpatient consultation for adolescent patient with
fractured femur and pelvis who pulled out IVs and
disconnected traction in attempt to elope from hospital.
(Psychiatry)
Initial hospital consultation for a 16-year-old primigravida
at 32-weeks gestation requested by a family practitioner for
evaluation of severe hypertension, thrombocytopenia, and
headache. (Obstetrics & Gynecology)
Initial hospital consultation for a 58-year-old insulin-
dependent diabetic with multiple antibiotic allergies, now
with multiple fascial plane abscesses and airway
obstruction. (Oral & Maxillofacial Surgery)
known cirrhosis and ascites, now with jaundice,
encephalopathy, and massive hematemesis.
(Gastroenterology)
Initial hospital consultation for a 25-year-old male, seen in
emergency room with severe, closed head injury.
(Neurosurgery)
Initial hospital consultation for a 2-day-old male with single
ventricle physiology and subaortic obstruction. Family
counseling following evaluation for multiple, staged
surgical procedures. (Thoracic Surgery)
Initial hospital consultation for a 45-year-old male admitted
with subarachnoid hemorrhage and intracranial aneurysm on
angiogram. (Neurosurgery)
Initial inpatient consultation for myxedematous patient who
is hypoventilating and obtunded. (Endocrinology)
Initial hospital consultation for a 45-year-old patient with
widely metastatic lung carcinoma, intractable back pain, and
a history that includes substance dependence, NSAID
allergy, and two prior laminectomies with fusion for low
back pain. (Pain Medicine)
Initial hospital consultation for evaluation of treatment
options in a 50-year-old patient with cirrhosis, known
peptic ulcer disease, hypotension, encephalopathy, and
massive acute upper gastrointestinal bleeding that cannot be
localized by endoscopy. (Interventional Radiology)
Initial inpatient consultation in the ICU for a 70-year-old
male who experienced a cardiac arrest during surgery and
was resuscitated. (Cardiology)
Initial inpatient consultation for a patient with severe
pancreatitis complicated by respiratory insufficiency, acute
renal failure, and abscess formation. (Gastroenterology)
Initial inpatient consultation for a 70-year-old cirrhotic male
admitted with ascites, jaundice, encephalopathy, and
massive hematemesis. (Gastroenterology)
Initial inpatient consultation in the ICU for a 51-year-old
patient who has a fever, respiratory failure requiring
mechanical ventilation, and bilateral pulmonary infiltrates
on chest radiograph two weeks after a renal transplantation.
(Infectious Disease)
Initial inpatient consultation for evaluation and formulation
of plan for management of multiple-trauma patient with
complex pelvic fracture, 35-year-old male. (General
Surgery/Orthopaedic Surgery)
Initial inpatient consultation for a 50-year-old male with a
history of previous myocardial infarction, now with acute
pulmonary edema and hypotension. (Cardiology)
Initial inpatient consultation for 45-year-old male with
recent, acute subarachnoid hemorrhage, hesitant speech,
mildly confused, drowsy. High risk group for HIV+ status.
(Neurosurgery)
Initial inpatient consultation for 36-year-old female referred
by her internist to evaluate a patient being followed for
abdominal pain and fever. The patient has developed diffuse
abdominal pain, guarding, rigidity, and increased fever.
Initial inpatient consultation for adolescent patient with
fractured femur and pelvis who expressed feeling hopeless
and suicidal. (Psychiatry)
closed head injury, pulmonary contusion, liver laceration,
and complex pelvic fracture. (General Surgery)
Initial hospital consultation for a 35-year-old male patient
with acute partial traumatic amputation of the forefoot for
evaluation and formulation of a management plan. (Podiatry
Surgery)
Initial hospital consultation for a 57-year-old male with
new-onset right hemiparesis and aphasia. (Neurology)

99281 Emergency department visit for a patient for removal of
sutures from a well-healed, uncomplicated laceration.
(Emergency Medicine)
Emergency department visit for a patient for tetanus toxoid
immunization. (Emergency Medicine)
Emergency department visit for a patient with several
uncomplicated insect bites. (Pediatrics)
99282 Emergency department visit for a 20-year-old student who
presents with a painful sunburn with blister formation on the
back. (Emergency Medicine)
Emergency department visit for a child presenting with
impetigo localized to the face. (Emergency Medicine)
Emergency department visit for a patient with a minor
traumatic injury of an extremity with localized pain,
swelling, and bruising. (Emergency Medicine)
Emergency department visit for an otherwise healthy patient
whose chief complaint is a red, swollen cystic lesion on
his/her back. (Emergency Medicine)
Emergency department visit for a patient presenting with a
rash on both legs after exposure to poison ivy. (Emergency
Medicine)
Emergency department visit for a child presenting with
impetigo localized to the face with use of topical OTC
treatment. (Pediatrics)
Emergency department visit for a patient with a minor
traumatic injury of an extremity with localized pain,
swelling, and bruising (no imaging done). (Pediatrics)
99283 Emergency department visit for a sexually active female
complaining of vaginal discharge who is afebrile and denies
experiencing abdominal or back pain. (Emergency
Medicine)
Emergency department visit for a well-appearing 8-year-old
who has a fever, diarrhea, and abdominal cramps; is
tolerating oral fluids and is not vomiting. (Pediatrics)
Emergency department visit for a patient with an inversion
ankle injury, who is unable to bear weight on the injured
foot and ankle. (Emergency Medicine)
Emergency department visit for a patient who has a
complaint of acute pain associated with a suspected foreign
body in the painful eye. (Emergency Medicine)
Emergency department visit for a healthy, young adult
patient who sustained a blunt head injury with local
swelling and bruising without subsequent confusion, loss of
consciousness, or memory deficit. (Emergency Medicine)
99284 Emergency department visit for a 4-year-old who fell off a
bike sustaining a head injury with brief loss of
consciousness. (Emergency Medicine)
Emergency department visit for a patient with flank pain and
hematuria. (Emergency Medicine)
Emergency department visit for a female presenting with
lower abdominal pain and a vaginal discharge. (Emergency
Medicine)
99285 Emergency department visit for a patient with a complicated
overdose requiring aggressive management to prevent side
effects from the ingested materials. (Emergency Medicine)
Emergency department visit for a patient exhibiting active,
upper gastrointestinal bleeding. (Emergency Medicine)
Emergency department visit for a previously healthy young
adult patient who is injured in an automobile accident and is
brought to the emergency department immobilized and has
symptoms compatible with intra-abdominal injuries or
multiple extremity injuries. (Emergency Medicine)
Emergency department visit for a patient with an acute onset
of chest pain compatible with symptoms of cardiac ischemia
and/or pulmonary embolus. (Emergency Medicine)
Emergency department visit for a patient who presents with
a sudden onset of “the worst headache of her life,” and
complains of a stiff neck, nausea, and inability to
concentrate. (Emergency Medicine)
Emergency department visit for a patient with a new onset of
a cerebral vascular accident. (Emergency Medicine)
Emergency department visit for acute febrile illness in an
adult, associated with shortness of breath and an altered
level of alertness. (Emergency Medicine)

99291 First hour of critical care of a 65-year-old male with septic
shock following relief of ureteral obstruction caused by a
stone. (Cardiology/Emergency Medicine/Family
Practice/General Surgery/Internal Medicine/Pulmonary
Medicine)
First hour of critical care of a 15-year-old with acute
respiratory failure from asthma. (Cardiology/Emergency
Medicine/Family Practice/General Surgery/Internal
First hour of critical care of a 45-year-old who sustained a
liver laceration, cerebral hematoma, flailed chest, and
pulmonary contusion after being struck by an automobile.
(Cardiology/Emergency Medicine/Family Practice/General
Surgery/Internal Medicine/Pulmonary Medicine)
First hour of critical care of a 65-year-old female who,
following a hysterectomy, suffered a cardiac arrest
associated with a pulmonary embolus.
Surgery/Internal Medicine/Pulmonary Medicine)
First hour of critical care of a 6-month-old with
hypovolemic shock secondary to diarrhea and dehydration.
Surgery/Internal Medicine/Pulmonary Medicine/Critical
Care)
First hour of critical care of a 3-year-old with respiratory
failure secondary to pneumocystis carinii pneumonia.
Surgery/Internal Medicine/Pulmonary Medicine/Critical
Care)
First hour of critical care of a 13-year-old with
hypovolemic shock secondary to diarrhea and dehydration.
Surgery/Internal Medicine/Pediatrics/Pulmonary
Medicine/Critical Care)
First hour of critical care of a 13-year-old with respiratory
failure secondary to pneumocystis carinii pneumonia
(Pediatrics)
Subsequent hospital visit for a 55-year-old male with severe
chronic obstructive pulmonary disease and bronchospasm;
initially admitted for acute respiratory distress requiring
ventilatory support in the ICU. The patient was stabilized,
extubated, and transferred to the floor but has now
developed acute fever, dyspnea, left lower lobe rhonchi, and
laboratory evidence of carbon dioxide retention and
hypoxemia. (Family Medicine)
asthmaticus, unresponsive to outpatient therapy. (Pulmonary
Medicine)
previous myocardial infarction, comes in with recurrent,
sustained ventricular tachycardia. (Cardiology)
Prolonged Services
Prolonged Service With Direct Patient
Contact
Office or Other Outpatient
99354 A 20-year-old female with history of asthma presents with
acute bronchospasm and moderate respiratory distress.
Initial evaluation shows respiratory rate 30, labored
breathing and wheezing heard in all lung fields. Office
treatment is initiated which includes intermittent bronchial
dilation and subcutaneous epinephrine. Requires intermittent
time with patient over a period of 2-3 hours. (Family
99355 A 20-year-old female with history of asthma presents with
acute bronchospasm and moderate respiratory distress.
Initial evaluation shows respiratory rate 30, labored
breathing, and wheezing heard in all lung fields. Office
treatment is initiated that includes intermittent bronchial
dilation and subcutaneous epinephrine. Requires intermittent
time with patient over a period of 2-3 hours. (Family
Medicine/Internal Medicine/Pulmonary Medicine)
Inpatient
99356 A 34-year-old primigravida female presents to hospital in
early labor. Admission history and physical reveals severe
preeclampsia. Physician supervises management of
preeclampsia, IV magnesium initiation and maintenance,
labor augmentation with Pitocin, and close maternal-fetal
monitoring. Involvement includes 40 minutes of continuous
bedside care until the patient is stable, then is intermittent
over several hours until the delivery. (Family
Medicine/Internal Medicine/Obstetrics & Gynecology)
Prolonged Service Without Direct Patient

Contact
99358 An 85-year-old new patient with multiple complicated
medical problems has moved to the area to live closer to her
daughter. She is brought to the primary care office by her
daughter and has been seen and examined by the physician.
The physician indicated that past medical records would be
obtained from the patient’s prior physicians’ and that he will
communicate further with the daughter upon review of them.
(Family Medicine/Internal Medicine)
99359 An 85-year-old new patient with multiple complicated
medical problems has moved to the area to live closer to her
daughter. She is brought to the primary care office by her
daughter and has been seen and examined by the physician.
The physician indicated that past medical records would be
obtained from the patient’s prior physicians’ and that he will
communicate further with the daughter upon review of them.
Physician Standby Services
99360 A 24-year-old patient is admitted to OB unit attempting
VBAC. Fetal monitoring shows increasing fetal distress.
Patient’s blood pressure is rising and labor progressing
slowly. A primary care physician is requested by the
OB/GYN to standby in the unit for possible cesarean
delivery and neonatal resuscitation. (Family

99375 First month of care plan oversight for terminal care of a 58-
year-old female with advanced intraabdominal ovarian
cancer. Care plan includes home oxygen, diuretics IV for
edema and ascites control and pain control management
involving IV morphine infusion when progressive ileus
occurred. Physician phone contacts with nurse, family, and
MSW. Discussion with MSW concerning plans to withdraw
supportive measures per patient wishes. Documentation
includes review and modification of care plan and
certifications from nursing, MSW, pharmacy, and DME.
Prolonged Clinical Staff Services with

Physician or Other Qualified Health
Care Professional Supervision
99415 A 52-year-old female presents with gastroenteritis and
persistent vomiting. She is unable to tolerate food or liquid
by mouth. She presents with signs and symptoms of clinical
dehydration. Evaluation and management is performed by
the physician. The decision is made to begin IV hydration in
the office. A hydration IV is initiated, consisting of normal
saline. Prolonged monitoring and observation for 2 hours
ensues with intermittent evaluation of the patient by the
physician. (Allergy/Immunology/Gastroenterology/General
Practice/Nephrology/Obstetrics
Gynecology/Orthopaedics/Pediatrics)
Inpatient Neonatal Intensive Care

Service and Pediatric and Neonatal
99477 Initial hospital visit for a 1-day-old male with cyanosis,
respiratory distress, and tachypnea. (Cardiology)

Appendix D
Summary of CPT Add-on Codes

This listing is a summary of CPT add-on codes for CPT 2021.
The codes listed below are identified in CPT 2021 with a ✚
symbol.
01953
01968
01969
10004
10006
10008
10010
10012
10036
11001
11008
11045
11046
11047
11103
11105
11107
11201
11732
11922
13102
13122
13133
13153
14302
15003
15005
15101
15111
15116
15121
15131
15136
15151
15152
15156
15157
15201
15221
15241
15261
15272
15274
15276
15278
15772
15774
15777
15787
15847
16036
17003
17312
17314
17315
19001
19082
19084
19086
19126
19282
19284
19286
19288
19294
19297
20700
20701
20702
20703
20704
20705
20930
20931
20932
20933
20934
20936
20937
20938
20939
20985
22103
22116
22208
22216
22226
22328
22512
22515
22527
22534
22552
22585
22614
22632
22634
22840
22841
22842
22843
22844
22845
22846
22847
22848
22853
22854
22858
22859
22868
22870
26125
26861
26863
27358
27692
29826
31627
31632
31633
31637
31649
31651
31654
32501
32506
32507
32667
32668
32674
33141
33225
33257
33258
33259
33367
33368
33369
33419
33508
33517
33518
33519
33521
33522
33523
33530
33572
33746
33768
33866
33884
33924
33929
33987
34709
34711
34713
34714
34715
34716
34717
34808
34812
34813
34820
34833
34834
35306
35390
35400
35500
35572
35600
35681
35682
35683
35685
35686
35697
35700
36218
36227
36228
36248
36474
36476
36479
36483
36907
36908
36909
37185
37186
37222
37223
37232
37233
37234
37235
37237
37239
37247
37249
37252
37253
38102
38746
38747
38900
43273
43283
43338
43635
44015
44121
44128
44139
44203
44213
44701
44955
47001
47542
47543
47544
47550
48400
49326
49327
49412
49435
49568
49905
50606
50705
50706
51797
52442
56606
57267
57465
58110
58611
59525
60512
61316
61517
61611
61641
61642
61651
61781
61782
61783
61797
61799
61800
61864
61868
62148
62160
63035
63043
63044
63048
63057
63066
63076
63078
63082
63086
63088
63091
63103
63295
63308
63621
64421
64462
64480
64484
64491
64492
64494
64495
64634
64636
64643
64645
64727
64778
64783
64787
64832
64837
64859
64872
64874
64876
64901
64902
64913
65757
66990
67225
67320
67331
67332
67334
67335
67340
69990
74248
74301
74713
75565
75774
76125
76802
76810
76812
76814
76937
76979
76983
77001
77002
77003
77063
77293
78020
78434
78496
78730
78835
81266
81416
81426
81536
82952
86826
87187
87503
87904
88155
88177
88185
88311
88314
88332
88334
88341
88350
88364
88369
88373
88388
0071U
0072U
0073U
0074U
0075U
0076U
0130U
0131U
0132U
0133U
0134U
0135U
0136U
0137U
0138U
0157U
0158U
0159U
0160U
0161U
0162U
0207U
90461
90472
90474
90785
90833
90836
90838
90840
90863
90913
91013
92547
92608
92618
92621
92627
92921
92925
92929
92934
92938
92944
92973
92974
92978
92979
92998
93320
93321
93325
93352
93356
93462
93463
93464
93563
93564
93565
93566
93567
93568
93571
93572
93592
93609
93613
93621
93622
93623
93655
93657
93662
94645
94729
94781
95079
95873
95874
95885
95886
95887
95940
95941
95962
95967
95984
96113
96121
96131
96133
96137
96139
96159
96165
96168
96171
96361
96366
96367
96368
96370
96371
96375
96376
96411
96415
96417
96423
96570
96571
96934
96935
96936
97130
97546
97598
97811
97814
99100
99116
99135
99140
99153
99157
99292
99354
99355
99356
99357
99359
99415
99416
99417
99439
99458
99467
99486
99489
99494
99498
99602
99607
0054T
0055T
0076T
0095T
0098T
0163T
0164T
0165T
0174T
0214T
0215T
0217T
0218T
0222T
0290T
0376T
0397T
0437T
0439T
0443T
0450T
0466T
0471T
0480T
0492T
0496T
0513T
0514T
0523T
0560T
0562T
0570T
0599T
0628T
0630T
Appendix E
Summary of CPT Codes Exempt from

Modifier 51
This listing is a summary of CPT codes that are exempt from the
use of modifier 51. Procedures on this list are typically
performed with another procedure but may be a stand-alone
procedure and not always performed with other specified
procedures. For add-on codes, see Appendix D. This is not an
exhaustive list of procedures that are typically exempt from
multiple procedure reductions. The codes listed below are
identified in CPT 2021 with a ⃠ symbol.
20697
20974
20975
44500
61107
93600
93602
93603
93610
93612
93615
93616
93618
94610
95905
99151
99152

Appendix F
Summary of CPT Codes Exempt from

Modifier 63
The listing is a summary of CPT codes that are exempt from the
use of modifier 63. The codes listed below are additionally
identified in CPT 2021 with the parenthetical instruction “(Do not
report modifier 63 in conjunction with…).”
30540
30545
31520
33470
33502
33503
33505
33506
33610
33611
33619
33647
33670
33690
33694
33730
33732
33735
33736
33750
33755
33762
33778
33786
33922
33946
33947
33948
33949
36415
36420
36450
36456
36460
36510
36660
39503
43313
43314
43520
43831
44055
44126
44127
44128
46070
46705
46715
46716
46730
46735
46740
46742
46744
47700
47701
49215
49491
49492
49495
49496
49600
49605
49606
49610
49611
53025
54000
54150
54160
63700
63702
63704
63706
65820

Appendix G
Summary of CPT Codes That Include

The summary of CPT codes that include moderate (conscious)
sedation (formerly Appendix G) has been removed from the CPT
code set.
The codes that were previously included in the former Appendix
G have been revised with the removal of the moderate
(conscious) sedation symbol. For information/guidance on
reporting moderate (conscious) sedation services with codes
formerly listed in Appendix G, please refer to the guidelines for
codes 99151, 99152, 99153, 99155, 99156, 99157.

Appendix H
Alphabetical Clinical Topics Listing

(AKA – Alphabetical Listing)
The Alphabetical Clinical Topics Listing (formerly Appendix H)
has been removed from the CPT codebook. Since this document
is a dynamic and rapidly expanding source of information to link
CPT Category II codes, clinical conditions, and measure
abstracts, the Alphabetical Listing is now solely accessed on the
AMA CPT website at https://www.ama-
assn.org/system/files/2020-01/cpt-cat2-codes-alpha-listing-
clinical-topics.pdf.
In addition, new codes for the publication cycle (ie, the Update
to the List of Category II Codes) will continue to be located on
the AMA CPT website prior to publication in the next edition of
the CPT codebook (subsequent to its listing on the Web).

Appendix I
Genetic Testing Code Modifiers

The Genetic Testing Code Modifiers (formerly Appendix I) has
been removed from the CPT code set.
The addition of more than 100 molecular pathology codes to the
2012 code set and still more codes to the 2013 CPT code set
resulted in the deletion of the stacking codes (83890–83914). The
genetic testing code modifiers formerly described in Appendix I
applied to those stacking codes, and therefore, the Appendix and
modifiers have been removed from the code set.
For the most up-to-date information on future updates for
molecular pathology coding in the CPT code set, see the AMA
CPT website (https://www.ama-assn.org/practice-
management/cpt/molecular-pathology-tier-2-codes).

Appendix J
Electrodiagnostic Medicine Listing of Sensory,

Motor, and Mixed Nerves
This summary assigns each sensory, motor, and mixed nerve with its
appropriate nerve conduction study code in order to enhance accurate
reporting of codes 95907-95913. Each nerve constitutes one unit of service.
Motor Nerves Assigned to Codes 95907-95913

I. Upper extremity, cervical plexus, and brachial plexus motor nerves
A. Axillary motor nerve to the deltoid
B. Long thoracic motor nerve to the serratus anterior
C. Median nerve
1. Median motor nerve to the abductor pollicis brevis
2. Median motor nerve, anterior interosseous branch, to the flexor
pollicis longus
3. Median motor nerve, anterior interosseous branch, to the pronator
quadratus
4. Median motor nerve to the first lumbrical
5. Median motor nerve to the second lumbrical
D. Musculocutaneous motor nerve to the biceps brachii
E. Radial nerve
1. Radial motor nerve to the extensor carpi ulnaris
2. Radial motor nerve to the extensor digitorum communis
3. Radial motor nerve to the extensor indicis proprius
4. Radial motor nerve to the brachioradialis
F. Suprascapular nerve
1. Suprascapular motor nerve to the supraspinatus
2. Suprascapular motor nerve to the infraspinatus
G. Thoracodorsal motor nerve to the latissimus dorsi
H. Ulnar nerve
1. Ulnar motor nerve to the abductor digiti minimi
2. Ulnar motor nerve to the palmar interosseous
3. Ulnar motor nerve to the first dorsal interosseous
4. Ulnar motor nerve to the flexor carpi ulnaris
I. Other
II. Lower extremity motor nerves
A. Femoral motor nerve to the quadriceps
1. Femoral motor nerve to vastus medialis
2. Femoral motor nerve to vastus lateralis
3. Femoral motor nerve to vastus intermedialis
4. Femoral motor nerve to rectus femoris
B. Ilioinguinal motor nerve
C. Peroneal (fibular) nerve
1. Peroneal motor nerve to the extensor digitorum brevis
2. Peroneal motor nerve to the peroneus brevis
3. Peroneal motor nerve to the peroneus longus
4. Peroneal motor nerve to the tibialis anterior
D. Plantar motor nerve
E. Sciatic nerve
F. Tibial nerve
1. Tibial motor nerve, inferior calcaneal branch, to the abductor digiti
minimi
2. Tibial motor nerve, medial plantar branch, to the abductor hallucis
3. Tibial motor nerve, lateral plantar branch, to the flexor digiti minimi
brevis
G. Other
III. Cranial nerves and trunk
A. Cranial nerve VII (facial motor nerve)
1. Facial nerve to the frontalis
2. Facial nerve to the nasalis
3. Facial nerve to the orbicularis oculi
4. Facial nerve to the orbicularis oris
B. Cranial nerve XI (spinal accessory motor nerve)
C. Cranial nerve XII (hypoglossal motor nerve)
D. Intercostal motor nerve
E. Phrenic motor nerve to the diaphragm
F. Recurrent laryngeal nerve
G. Other
IV. Nerve Roots
A. Cervical nerve root stimulation
1. Cervical level 5 (CT)
2. Cervical level 6 (C6)
B. Thoracic nerve root stimulation
1. Thoracic level 1 (T1)
C. Lumbar nerve root stimulation
1. Lumbar level 1 (L1)
D. Sacral nerve root stimulation
1. Sacral level 1 (S1)
Sensory and Mixed Nerves Assigned to Codes 95907-95913

I. Upper extremity sensory and mixed nerves
A. Lateral antebrachial cutaneous sensory nerve
B. Medial antebrachial cutaneous sensory nerve
C. Medial brachial cutaneous sensory nerve
D. Median nerve
1. Median sensory nerve to the first digit
2. Median sensory nerve to the second digit
3. Median sensory nerve to the third digit
4. Median sensory nerve to the fourth digit
5. Median palmar cutaneous sensory nerve
6. Median palmar mixed nerve
E. Posterior antebrachial cutaneous sensory nerve
F. Radial sensory nerve
1. Radial sensory nerve to the base of the thumb
2. Radial sensory nerve to digit 1
G. Ulnar nerve
1. Ulnar dorsal cutaneous sensory nerve
2. Ulnar sensory nerve to the fourth digit
3. Ulnar sensory nerve to the fifth digit
4. Ulnar palmar mixed nerve
H. Intercostal sensory nerve
I. Other
II. Lower extremity sensory and mixed nerves
A. Lateral femoral cutaneous sensory nerve
B. Medial calcaneal sensory nerve
C. Medial femoral cutaneous sensory nerve
D. Peroneal nerve
1. Deep peroneal sensory nerve
2. Superficial peroneal sensory nerve, medial dorsal cutaneous branch
3. Superficial peroneal sensory nerve, intermediate dorsal cutaneous
branch
E. Posterior femoral cutaneous sensory nerve
F. Saphenous nerve
1. Saphenous sensory nerve (distal technique)
2. Saphenous sensory nerve (proximal technique)
G. Sural nerve
1. Sural sensory nerve, lateral dorsal cutaneous branch
2. Sural sensory nerve
H. Tibial sensory nerve (digital nerve to toe 1)
I. Tibial sensory nerve (medial plantar nerve)
J. Tibial sensory nerve (lateral plantar nerve)
K. Other
III. Head and trunk sensory nerves
A. Dorsal nerve of the penis
B. Greater auricular nerve
C. Ophthalmic branch of the trigeminal nerve
D. Pudendal sensory nerve
E. Suprascapular sensory nerves
F. Other
The following table provides a reasonable maximum number of studies
performed per diagnostic category necessary for a physician to arrive at a
diagnosis in 90% of patients with that final diagnosis. The numbers in each
column represent the number of studies recommended. The appropriate
number of studies to be performed is based upon the physician’s discretion.
Type of Study/Maximum Number of Studies

Limbs
Studied
by
Needle Nerve
EMG Conduction
(95860- Studies Neuromuscular
95864, (Total Junction
95867- Nerves Testing
95870, Studied, (Repetitive
95885- 95907- Stimulation,
Indication 95887) 95913) 95937)
Carpal Tunnel (Unilateral) 1 7 —
Carpal Tunnel (Bilateral) 2 10 —
Radiculopathy 2 7 —
Mononeuropathy 1 8 —
Polyneuropathy/Mononeuropathy
Multiplex 3 10 —
Myopathy 2 4 2
Motor Neuronopathy (eg, ALS) 4 6 2
Plexopathy 2 12 —
Neuromuscular Junction 2 4 3
Tarsal Tunnel Syndrome 1 8 —
(Unilateral)
Tarsal Tunnel Syndrome
(Bilateral) 2 11 —
Weakness, Fatigue, Cramps, or
Twitching (Focal) 2 7 2
Weakness, Fatigue, Cramps, or
Twitching (General) 4 8 2
Pain, Numbness, or Tingling
(Unilateral) 1 9 —
Pain, Numbness, or Tingling
(Bilateral) 2 12 —

details ▲ = Revised code ● = New code ▶◀ = Contains new or
revised text = Duplicate PLA test ⇅ = Category I PLA
Appendix K
Product Pending FDA Approval

Some vaccine products have been assigned a CPT Category I
code in anticipation of future approval from the Food and Drug
Administration (FDA). Following is a list of the vaccine product
codes pending FDA approval status that are identified in the CPT
code set with the (⚡) symbol. Upon revision of the approval
status by the FDA, notation of this revision will be provided via
the AMA CPT “Category I Vaccine Codes” website listing (ama-
assn.org/cpt-cat-i-vaccine-codes) and in subsequent publications
of the CPT code set.
90666
90667
90668

Appendix L
Vascular Families
Appendix L is a vascular branching model that assumes the aorta,
vena cava, pulmonary artery, or portal vein is the starting point of
catheterization. Accordingly, branches have been categorized into
first, second, third order, and beyond. (Note that this
categorization does not apply, for instance, if a femoral or carotid
artery were catheterized directly in an antegrade direction.)
Common branching patterns of typical anatomy are shown in the
charts and illustrations.
No specific coding instructions should be inferred from
Appendix L. End-users must deter-mine how best to code any
specific procedure based on variant anatomy and different
vascular access point relative to vessel(s) selectively catheterized
(eg, antegrade femoral artery, radial artery, retrograde femoral to
ipsilateral internal iliac artery catheterization, transsplenic splenic
vein access to portal venous system, etc).
Appendix M
Renumbered CPT Codes–Citations

Crosswalk
This listing is a summary of crosswalked deleted and renumbered
codes and descriptors with the associated CPT Assistant
references for the deleted codes. This listing includes codes
deleted and renumbered from 2007 to 2009. Additional codes will
not be added, since the principle of deleting and renumbering is
no longer being utilized in the CPT code set.
Citations
Year Referencing
Current Deleted/Former
Code Former Code—
Code(s) Code
Deleted Applicable to
Current Code(s)
89240 0058T 2009 Jun 04:8 CPT Changes:
An Insider’s View 2004
89240 0059T 2009 CPT Changes: An
Insider’s View 2004
41530 0088T 2009 May 05:7, Sep 05:9 CPT
Changes: An Insider’s
View 2005
95803 0089T 2009 Jun 05:6, Feb 06:1 CPT
View 2006
22856 0090T 2009 Jun 05:6, Feb 06:1 CPT
View 2006, 2007
22864 0093T 2009 Jun 05:6, Feb 06:1 CPT
View 2006, 2007
22861 0096T 2009 Jun 05:6, Feb 06:1 CPT
View 2006, 2007
95980- 0162T 2009 CPT Changes: An
95982 Insider’s View 2007
1123F, 1080F 2009 CPT Changes: An
1124F Insider’s View 2008
0054T, 20986 2009 CPT Changes: An
0055T Insider’s View 2008
0054T, 20987 2009 CPT Changes: An
0055T Insider’s View 2008
4177F 4007F 2009 CPT Changes: An
52214 52606 2009 Apr 01:4
52601 52612 2009 Apr 01:4
52601 52614 2009 Apr 01:4
52630 52620 2009 Apr 01:4
61796- 61793 2009 Nov 97:23, May 03:19,
61800, Apr 04:15, Jan 06:46
63620,
63621
88720 88400 2009 Aug 05:9
96360 90760 2009 Nov 05:1, Jul 06:4, Sep
06:14, Dec 06:14 CPT
View 2006, 2008
96361 90761 2009 Nov 05:1, Jul 06:4, Sep
06:14, Dec 06:14, Mar
07:10 CPT Changes: An
Insider’s View 2006,
2007
96365 90765 2009 Nov 05:1, Sep 06:14,
Nov 06:22, Dec 06:14
CPT Changes: An
96366 90766 2009 Nov 05:1, Sep 06:14,
Dec 06:14, Mar 07:10
CPT Changes: An
2007
96367 90767 2009 Nov 05:1, Sep 06:14,
Nov 06:22, Dec 06:14
CPT Changes: An
96368 90768 2009 Nov 05:1, Aug 06:11,
Sep 06:14, Nov 06:22,
Dec 06:14 CPT Changes:
96369 90769 2009 CPT Changes: An
96370 90770 2009 CPT Changes: An
96371 90771 2009 CPT Changes: An
96372 90772 2009 Nov 05:1, Sep 06:14,
96373 90773 2009 Nov 05:1, Sep 06:14,
96374 90774 2009 Nov 05:1, Sep 06:14,
96375 90775 2009 Nov 05:1, Sep 06:14,
96376 90776 2009 CPT Changes: An
96379 90779 2009 Nov 05:1, Sep 06:14,
90951- 90918 2009 Fall 93:5, May 96:4,
90953, May 02:17, Jan 03:22
90963,
90967
90954- 90919 2009 Fall 93:5, May 96:5,
90956, May 02:17, Jan 03:22
90964,
90968
90957- 90920 2009 Fall 93:5, May 96:5,
90959, May 02:17, Jan 03:22
90965,
90969
90960- 90921 2009 Fall 93:5, May 96:5,
90962, May 02:17, Jan 03:22
90966,
90970
90951- 90922 2009 Fall 93:5, May 96:5,
90953, May 02:17, Jan 03:22
90963,
90967
90954- 90923 2009 May 96:5, May 02:17,
90956, Jan 03:22
90964,
90968
90957- 90924 2009 May 96:5, May 02:17,
90959, Jan 03:22
90965,
90969
90960- 90925 2009 May 96:5, May 02:17,
90962, Jan 03:22
90966,
90970
93285, 93727 2009 Nov 99:50, Jul 00:5,
93291, CPT Changes: An
93280, 93731 2009 Summer 94:23, Feb
93288, 98:11
93294
93280, 93732 2009 Summer 94:23, Feb
93288, 98:11, Mar 00:10
93294
93293 93733 2009 Summer 94:23
93279, 93734 2009 Summer 94:23, Feb
93288, 98:11
93294
93279, 93735 2009 Summer 94:23, Feb
93288, 98:11
93294
93293 93736 2009 Summer 94:23
93282, 93741 2009 Nov 99:50-51, Jul 00:5,
93289, Nov 00:9, Sep 05:8 CPT
93292, Changes: An Insider’s
93295 View 2000, 2005
93282, 93742 2009 Nov 99:50-51, Jul 00:5,
93289, Nov 00:9 CPT Changes:
93292, An Insider’s View 2000,
93295 2005
93283, 93743 2009 Nov 99:50-51, Jul 00:5,
93289, Nov 00:9, Sep 05:8 CPT
93295 Changes: An Insider’s
View 2000
93283, 93744 2009 Nov 99:50-51, Jul 00:5,
93289, Nov 00:9 CPT Changes:
93295 An Insider’s View 2000
99466 99289 2009 May 05:1, Jul 06:4 CPT
View 2002, 2003
99467 99290 2009 CPT Changes: An
99468 99295 2009 Summer 93:1, Nov 97:4-
5, Mar 98:11, Nov 99:5-
6, Dec 00:14, Feb 03:15,
Oct 03:1, May 05:1, Nov
05:10, CPT Changes: An
2003, 2004, 2005
99469 99296 2009 Summer 93:1, Nov 97:4-
5, Mar 98:11, Nov 99:5-
6, Dec 00:14, Feb 03:15,
Oct 03:1, Nov 05:10,
CPT Changes: An
2003, 2004, 2005, 2008
99471 99293 2009 Feb 03:15, Oct 03:2,
Aug 04:7, 10, May 05:1,
Nov 05:10, Jul 06:4, Apr
2004, 2005
99472 99294 2009 Feb 03:15, Oct 03:2,
Aug 04:7, Nov 05:10, Jul
06:4, Apr 07:3 CPT
View 2003, 2004, 2005
99478 99298 2009 Nov 98:2-3, Nov 99: 5-
6, Aug 00:4, Dec 00:15,
Oct 03:2, May 05:1, Nov
05:10; CPT Changes: An
2003
99479 99299 2009 Oct 03:2, Nov 05:10;
CPT Changes: An
99480 99300 2009 CPT Changes: An
99460 99431 2009 Apr 97:10, Nov 97:9,
Sep 98:5, Apr 04:14,
May 05:1
99461 99432 2009 Sep 98:5, May 99:11,
Apr 04:14
99462 99433 2009 Sep 98:5, Apr 03:27
99463 99435 2009 Sep 98:5, Apr 04:14
99464 99436 2009 Nov 97:9-10, Sep 98:5,
Nov 99:5-6, Aug 00:3,
Aug 04:9, Nov 05:15
99465 99440 2009 Summer 93:3, Mar
96:10, Nov 97:9, Sep
98:5, Nov 99:5-6, Aug
00:3, Oct 03:3, Aug
04:9, Apr 07:3
20985 0054T 2008 May 04:14, Jun 04:8
CPT Changes: An
20985 0055T 2008 May 04:14, Jun 04:8
CPT Changes: An
2005
20985 0056T 2008 May 04:14, Jun 04:8
CPT Changes: An
99174 0065T 2008 Mar 05:1, 3-4 CPT
View 2005
99605- 0115T 2008 CPT Changes: An
99605- 0116T 2008 CPT Changes: An
99605- 0117T 2008 CPT Changes: An
Clinical Examples in
Radiology Winter 06:18
01935, 01905 2008 Mar 06:15 CPT
01936 Changes: An Insider’s
View 2002
24357- 24350 2008
24359
24357- 24351 2008
24359
24357- 24352 2008
24359
24357- 24354 2008
24359
24357- 24356 2008
24359
3044F 3047F 2008 CPT Changes: An
3074F- 3076F 2008 CPT Changes: An
3075F Insider’s View 2007
32560 32005 2008
32550 32019 2008 CPT Changes: An
32551 32020 2008 Fall 92:13, Nov 03:14
36591 36540 2008 Jan 02:11, Nov 02:3,
Apr 03:26, Nov 05:1
CPT Changes: An
2003
36593 36550 2008 Nov 99:20, Nov 05:1
CPT Changes: An
49203- 49200 2008 CPT Changes: An
49205, Insider’s View 2003
58957,
58958
49203- 49201 2008
49205,
58957,
58958
51100 51000 2008 Nov 99:32-33, Aug 00:3,
Oct 03:2
51101 51005 2008
51102 51010 2008
60300 60001 2008
67041, 67038 2008 Aug 03:15, Sep 05:12
67042,
67043
75557, 75552 2008 Fall 95:2
75559,
75561,75563
75557, 75553 2008 Fall 95:2
75559,
75561,75563
75557, 75554 2008 Fall 95:2
75559,
75561,75563
75557, 75555 2008 Fall 95:2
75559,
75561,75563
75557, 75556 2008 Fall 95:2
75559,
75561,75563
78610 78615 2008 CPT Changes: An
86356, 86586 2008 Jul 98:11
86486
99366- 99361 2008 May 05:1
99368
99366- 99362 2008
99368
99441- 99371 2008 Spring 94:34, May
99443 00:11, May 05:1, Nov
05:10
99441- 99372 2008 Spring 94:34, May
99443 00:11, Nov 05:10
99441- 99373 2008 Spring 94:34, May
99443 00:11, Nov 05:10
2004
96904 0045T 2007 Jul 04:7 CPT Changes:
77371- 0082T 2007 CPT Changes: An
77371- 0083T 2007 CPT Changes: An
15002, 15000 2007 Fall 93:7, Apr 97:4, Aug
15004 97:6, Sep 97:2, Nov
98:5, Jan 99:4, Apr
99:10, May 99:10, Nov
02:7, Aug 03:14 CPT
View 2001, 2006
15003, 15001 2007 Nov 98:5-6, Jan 99:4,
15005 May 99:10, Aug 03:14
15830, 15831 2007 May 01:11 CPT
15847, Changes: An Insider’s
17999 View 2007
17311 17304 2007 Winter 94:19, Mar
99:11, Jun 99:10, Nov
02:7, Nov 03:15, Feb
04:11, Jul 04:2 CPT
View 2003
17312, 17305 2007 Winter 94:19, Mar
17314 99:11, Jun 99:10, Nov
02:7, Feb 04:11, Jul 04:3
17312, 17306 2007 Winter 94:19, Mar
17314 99:11, Jun 99:10, Nov
02:7, Feb 04:11, Jul 04:4
17312, 17307 2007 Winter 94:19, Mar
17314 99:11, Jun 99:10, Nov
02:7, Nov 03:15, Feb
04:11, Jul 04:4
17315 17310 2007 Winter 94:19, Mar
99:11, Jun 99:10, Nov
02:7, Feb 04:11, May
04:14, Jul 04:4 CPT
View 2003
19300 19140 2007 Feb 96:9, Apr 05:13
19301 19160 2007 Apr 05:7 CPT Changes:
19302 19162 2007 Jun 00:11, Apr 05:7
19303 19180 2007 Apr 05:7
19305 19200 2007 Apr 05:7
19306 19220 2007 Apr 05:7
19307 19240 2007 Apr 05:7
25606 25611 2007 Fall 93:23, Oct 99:5
25607- 25620 2007
25609
26390 26504 2007
27325 27315 2007
27326 27320 2007
28055 28030 2007
33254- 33253 2007
33256
35302- 35381 2007
35306
35506 35507 2007
35537, 35541 2007
35538
35539, 35546 2007
35540
35637, 35641 2007 Dec 01:7
35638
44799 44152 2007
44799 44153 2007
48105 48005 2007
48548 48180 2007
49402 49085 2007
54150 54152 2007 Sep 96:11, Dec 96:10,
May 98:11, Apr 03:27
CPT Changes: An
54865 54820 2007 Oct 01:8
55875 55859 2007 Apr 04:6
56442 56720 2007
57558 57820 2007
67346 67350 2007
77001 75998 2007 Dec 04:12-13 CPT
View 2004 Clinical
Examples in Radiology
Inaugural 04:1-2, Winter
05:9
77002 76003 2007 Fall 93:14, Jul 01:7 CPT
View 2001 Clinical
Examples in Radiology
Spring 05:5-6
77003 76005 2007 Nov 99:32, 34, 41, Jan
00:2, Feb 00:6, Aug
00:8, Sep 02:11, Sep
77071 76006 2007 Nov 98:21 CPT
View 2003
77072 76020 2007
77073 76040 2007
77074 76061 2007
77075 76062 2007
77076 76065 2007
77077 76066 2007 CPT Changes: An
77078 76070 2007 Nov 97:24 CPT
View 2002, 2003
77080 76075 2007 Nov 97:24, Jun 03:11
CPT Changes: An
77081 76076 2007 Nov 97:24
77053 76086 2007
77054 76088 2007
77011 76355 2007 CPT Changes: An
2003
77012 76360 2007 Fall 93:12, Fall 94:2,
Jan 01:9-10, Mar 05:2
CPT Changes: An
2002, 2003
77013 76362 2007 Oct 02:4 CPT Changes:
An Insider’s View 2002,
2004
77014 76370 2007 Fall 91:12 CPT Changes:
An Insider’s View 2002,
2003
77021 76393 2007 Jan 01:10, Mar 05:2
CPT Changes: An
2002
77022 76394 2007 Oct 02:4, Mar 05:5 CPT
View 2002, 2004
77084 76400 2007
76775, 76778 2007 CPT Changes: An
76998 76986 2007 CPT Changes: An
78707- 78704 2007
78709
78701, 78715 2007
78707,
78708,
78709
78761 78760 2007
92700 92573 2007
94002, 94656 2007 Fall 92:30, Spring 95:4,
94004 Summer 95:4, Feb 96:9,
Aug 00:2, Oct 03:2
94003, 94657 2007 Fall 92:30, Spring 95:4,
94004 Summer 95:4, Feb 96:9,
Aug 00:2, Oct 03:2

Appendix N
Summary of Resequenced CPT Codes

This is a table of CPT codes that do not appear in numeric
sequence in the listing of CPT codes and the code ranges with
their corresponding locations. Rather than deleting and
renumbering, resequencing allows existing codes to be relocated
to an appropriate location for the code concept, regardless of the
numeric sequence. The codes listed below are identified in the
CPT 2021 code set with a # symbol for the location of the
resequenced number within the family of related concepts.
Numerically placed references (eg, Code is out of numerical
sequence. See…) are used as navigational alerts to direct the
user to the location of an out-of-sequence code.
Resequenced Corresponding Locations of Resequenced Code

Code
10004 10021-10035
10005 10021-10035
10006 10021-10035
10007 10021-10035
10008 10021-10035
10009 10021-10035
10010 10021-10035
10011 10021-10035
10012 10021-10035
11045 11012-11047
11046 11012-11047
15769 15760-15772
20560 20552-20600
20561 20552-20600
21552 21550-21558
21554 21550-21558
22858 22853-22861
22859 22853-22861
23071 23066-23078
23073 23066-23078
24071 24066-24079
24073 24066-24079
25071 25066-25078
25073 25066-25078
26111 26110-26118
26113 26110-26118
27043 27041-27052
27045 27041-27052
27059 27041-27052
27329 27358-27365
27337 27326-27331
27339 27326-27331
27632 27616-27625
27634 27616-27625
28039 28035-28047
28041 28035-28047
28295 28292-28298
29914 29862-29867
29915 29862-29867
29916 29862-29867
31253 31254-31267
31257 31254-31267
31259 31254-31267
31551 31579-31587
31552 31579-31587
31553 31579-31587
31554 31579-31587
31572 31577-31580
31573 31577-31580
31574 31577-31580
31651 31646-31649
32994 32997-32999
33221 33212-33215
33227 33226-33244
33228 33226-33244
33229 33226-33244
33230 33226-33244
33231 33226-33244
33262 33226-33244
33263 33226-33244
33264 33226-33244
33270 33244-33251
33271 33244-33251
33272 33244-33251
33273 33244-33251
33274 33244-33251
33275 33244-33251
33440 33406-33412
33962 33958-33968
33963 33958-33968
33964 33958-33968
33965 33958-33968
33966 33958-33968
33969 33958-33968
33984 33958-33968
33985 33958-33968
33986 33958-33968
33987 33958-33968
33988 33958-33968
33989 33958-33968
33995 33982-33991
33997 33991-33993
34717 34707-34711
34718 34707-34711
34812 34712-34716
34820 34712-34716
34833 34712-34716
34834 34712-34716
36465 36470-36474
36466 36470-36474
36482 36478-36500
36483 36478-36500
36572 36568-36571
36573 36568-36571
37246 37234-37237
37247 37234-37237
37248 37234-37237
37249 37234-37237
38243 38240-38300
43210 43254-43261
43211 43216-43227
43212 43216-43227
43213 43216-43227
43214 43216-43227
43233 43248-43251
43266 43254-43261
43270 43254-43261
43274 43264-43279
43275 43264-43279
43276 43264-43279
43277 43264-43279
43278 43264-43279
44381 44380-44385
44401 44391-44402
45346 45337-45341
45388 45381-45385
45390 45391-45397
45398 45391-45397
45399 45910-45999
46220 46200-46255
46320 46200-46255
46945 46200-46255
46946 46200-46255
46947 46760-46910
46948 46200-46255
50430 50390-50405
50431 50390-50405
50432 50390-50405
50433 50390-50405
50434 50390-50405
50435 50390-50405
50436 50390-50405
50437 50390-50405
51797 51728-51741
52356 52352-52355
58674 58520-58542
62328 62269-62280
62329 62269-62280
64461 64483-64487
64462 64483-64487
64463 64483-64487
64624 64605-64612
64625 64605-64612
64633 64617-64632
64634 64617-64632
64635 64617-64632
64636 64617-64632
66987 66940-66984
66988 66983-66986
67810 67710-67801
77085 77080-77261
77086 77080-77261
77295 77293-77301
77385 77412-77427
77386 77412-77427
77387 77412-77427
77424 77412-77427
77425 77412-77427
78429 78458-78468
78430 78483-78496
78431 78483-78496
78432 78483-78496
78433 78483-78496
78434 78483-78496
78804 78801-78811
78830 78801-78811
78831 78801-78811
78832 78801-78811
78835 78801-78811
80081 80053-80069
80161 80156-80159
80164 80200-80203
80165 80200-80203
80167 80168-80173
80171 80168-80173
80176 80170-80183
80179 80192-80197
80181 80168-80173
80189 80173-80175
80193 80170-80183
80204 80170-80183
80210 80192-80195
80230 80170-80183
80235 80170-80183
80280 80201-80299
80285 80201-80299
80305 See Presumptive Drug Class Screening
subsection
subsection
subsection
80320 See Definitive Drug Testing subsection
81105 81255-81270
81106 81255-81270
81107 81255-81270
81108 81255-81270
81109 81255-81270
81110 81255-81270
81111 81255-81270
81112 81255-81270
81120 81255-81270
81121 81255-81270
81161 81228-81235
81162 81182-81220
81163 81182-81220
81164 81182-81220
81165 81182-81220
81166 81182-81220
81167 81182-81220
81168 81216-81220
81173 81171-81176
81174 81171-81176
81184 81182-81220
81185 81182-81220
81186 81182-81220
81187 81223-81226
81188 81223-81226
81189 81223-81226
81190 81223-81226
81191 81310-81314
81192 81310-81314
81193 81310-81314
81194 81310-81314
81200 81171-81176
81201 81171-81176
81202 81171-81176
81203 81171-81176
81204 81171-81176
81205 81182-81220
81206 81182-81220
81207 81182-81220
81208 81182-81220
81209 81182-81220
81210 81182-81220
81219 81182-81220
81227 81223-81226
81230 81225-81229
81231 81225-81229
81233 81182-81220
81234 81228-81235
81238 81240-81248
81239 81228-81235
81245 81240-81248
81246 81240-81248
81250 81243-81248
81257 81253-81256
81258 81253-81256
81259 81253-81256
81261 81255-81270
81262 81255-81270
81263 81255-81270
81264 81255-81270
81265 81223-81226
81266 81223-81226
81267 81223-81226
81268 81223-81226
81269 81253-81256
81271 81255-81270
81274 81255-81270
81277 81228-81235
81278 81255-81260
81279 81260-81273
81283 81255-81270
81284 81243-81248
81285 81243-81248
81286 81243-81248
81287 81276-81297
81288 81276-81297
81289 81243-81248
81291 81299-81310
81292 81276-81297
81293 81276-81297
81294 81276-81297
81295 81276-81297
81301 81276-81297
81302 81276-81297
81303 81276-81297
81304 81276-81297
81306 81310-81316
81307 81310-81316
81308 81310-81316
81309 81310-81316
81312 81310-81316
81320 81310-81316
81324 81310-81318
81325 81310-81318
81326 81310-81318
81332 81318-81335
81334 81318-81335
81336 81318-81335
81337 81318-81335
81338 81276-81297
81339 81276-81297
81343 81318-81335
81344 81318-81335
81345 81318-81335
81347 81327-81329
81348 81330-81340
81351 81330-81340
81352 81330-81340
81353 81330-81340
81357 81342-81355
81361 81253-81256
81362 81253-81256
81363 81253-81256
81364 81253-81256
81419 81413-81416
81443 81420-81426
81448 81437-81440
81479 81407-81411
81500 81536-81541
81503 81536-81541
81504 81542-81554
81522 81513-81520
81540 81542-81554
81546 81542-81554
81595 81490-81506
81596 81513-81520
82042 82044-82077
82652 82300-82310
82681 82668-82672
86152 86146-86155
86153 86146-86155
86328 86317-86325
87623 87538-87541
87624 87538-87541
87625 87538-87541
87806 87802-87903
87906 87802-87903
87910 87802-87903
87912 87802-87903
88177 88172-88175
88341 88334-88372
88350 88334-88372
88364 88334-88372
88373 88334-88372
88374 88334-88372
88377 88334-88372
90619 90717-90739
90620 90717-90739
90621 90717-90739
90625 90717-90739
90630 90653-90656
90644 90717-90739
90672 90658-90664
90673 90658-90664
90674 90658-90664
90694 90688-90691
90750 90717-90739
90756 90658-90664
92517 92548-92551
92518 92548-92551
92519 92548-92551
92558 92583-92588
92597 92603-92607
92618 92603-92607
92650 92583-92588
92651 92583-92588
92652 92583-92588
92653 92583-92588
92920 92997-93005
92921 92997-93005
92924 92997-93005
92925 92997-93005
92928 92997-93005
92929 92997-93005
92933 92997-93005
92934 92997-93005
92937 92997-93005
92938 92997-93005
92941 92997-93005
92943 92997-93005
92944 92997-93005
92973 92997-93005
92974 92997-93005
92975 92997-93005
92977 92997-93005
92978 92997-93005
92979 92997-93005
93241 93226-93229
93242 93226-93229
93243 93226-93229
93244 93226-93229
93245 93226-93229
93246 93226-93229
93247 93226-93229
93248 93226-93229
93260 93283-93291
93261 93283-93291
93264 93272-93280
93356 93350-93355
94619 94610-94621
95249 95199-95803
95700 95966-95971
95705 95966-95971
95706 95966-95971
95707 95966-95971
95708 95966-95971
95709 95966-95971
95710 95966-95971
95711 95966-95971
95712 95966-95971
95713 95966-95971
95714 95966-95971
95715 95966-95971
95716 95966-95971
95717 95966-95971
95718 95966-95971
95719 95966-95971
95720 95966-95971
95721 95966-95971
95722 95966-95971
95723 95966-95971
95724 95966-95971
95725 95966-95971
95726 95966-95971
95782 95805-95813
95783 95805-95813
95800 95805-95813
95801 95805-95813
95829 95824-95852
95836 95824-95852
95885 95870-95874
95886 95870-95874
95887 95870-95874
95938 95912-95933
95939 95912-95933
95940 95912-95933
95941 95912-95933
95943 95912-95933
95983 95976-95981
95984 95976-95981
96125 96020-96121
96127 96020-96121
96164 96158-96161
96165 96158-96161
96167 96158-96161
96168 96158-96161
96170 96158-96161
96171 96158-96161
97151 96020-96112
97152 96020-96112
97153 96020-96112
97154 96020-96112
97155 96020-96112
97156 96020-96112
97157 96020-96112
97158 96020-96112
97161 See Physical Therapy Evaluations subsection
97165 See Occupational Therapy Evaluations
subsection
subsection
subsection
subsection
97169 See Athletic Training Evaluations subsection
99091 99448-99455
99177 99173-99183
99224 99219-99222
99225 99219-99222
99226 99219-99222
99415 99358-99366
99416 99358-99366
99417 99358-99366
99421 99442-99447
99422 99442-99447
99423 99442-99447
99439 99480-99489
99451 99448-99455
99452 99448-99455
99453 99448-99455
99454 99448-99455
99457 99448-99455
99458 99448-99455
99473 99448-99455
99474 99448-99455
99484 99497-99499
99485 99466-99469
99486 99466-99469
99490 99480-99489
99491 99480-99489
2033F 2025F-2028F
3051F 3042F-3048F
3052F 3042F-3048F
0253T 0184T-0200T
0376T 0184T-0200T
0464T 0332T-0339T
0488T 0402T-0408T
0510T 0332T-0339T
0511T 0332T-0339T
0512T 0101T-0107T
0513T 0101T-0107T
0523T 0503T-0507T
0563T 0202T-0209T
0614T 0579T-0582T
0620T 0503T-0507T
0623T 0503T-0507T
0624T 0503T-0507T
0625T 0503T-0507T
0626T 0503T-0507T

Appendix O

and Proprietary Laboratory Analyses
The following list includes three types of CPT codes:
1. Multianalyte assays with algorithmic analyses (MAAA) administrative codes
2. Category I MAAA codes
3. Proprietary laboratory analyses (PLA) codes
1. Multianalyte assays with algorithmic analyses (MAAAs) are procedures that
utilize multiple results derived from assays of various types, including
molecular pathology assays, fluorescent in situ hybridization assays and non-
nucleic acid based assays (eg, proteins, polypeptides, lipids, carbohydrates).
Algorithmic analysis using the results of these assays as well as other patient
information (if used) is then performed and reported typically as a numeric
score(s) or as a probability. MAAAs are typically unique to a single clinical
laboratory or manufacturer. The results of individual component procedure(s)
that are inputs to the MAAAs may be provided on the associated laboratory
report, however these assays are not reported separately using additional codes.
MAAAs, by nature, are typically unique to a single clinical laboratory or
manufacturer.
The list includes a proprietary name and clinical laboratory or manufacturer in
the first column, an alpha-numeric code in the second column and code
descriptor in the third column. The format for the code descriptor usually
includes (in order):
• Disease type (eg, oncology, autoimmune, tissue rejection),
• Chemical(s) analyzed (eg, DNA, RNA, protein, antibody),
• Number of markers (eg, number of genes, number of proteins),
• Methodology(s) (eg, microarray, real-time [RT]-PCR, in situ hybridization
[ISH], enzyme linked immunosorbent assays [ELISA]),
• Number of functional domains (if indicated),
• Specimen type (eg, blood, fresh tissue, formalin-fixed paraffin-embedded),
• Algorithm result type (eg, prognostic, diagnostic),
• Report (eg, probability index, risk score).
MAAA procedures that have been assigned a Category I code are noted in the
list below and additionally listed in the Category I MAAA section (81490-
81599). The Category I MAAA section introductory language and associated
parenthetical instruction(s) should be used to govern the appropriate use for
Category I MAAA codes. If a specific MAAA procedure has not been assigned
a Category I code, it is indicated as a four-digit number followed by the letter
M.
When a specific MAAA procedure is not included in either the list below or in
the Category I MAAA section, report the analysis using the Category I MAAA
unlisted code (81599). The codes below are specific to the assays identified in
Appendix O by proprietary name. In order to report an MAAA code, the
analysis performed must fulfill the code descriptor and, if proprietary, must be
the test represented by the proprietary name listed in Appendix O. When an
analysis is performed that may potentially fall within a specific descriptor,
however the proprietary name is not included in the list below, the MAAA
unlisted code (81599) should be used.
▶Additions in this section may be released tri-annually (or quarterly for PLA
codes) via the AMA CPT website to expedite dissemination for reporting. See
the Introduction section of the CPT code set for a complete list of the dates of
release and implementation.◀
These administrative codes encompass all analytical services required for the
algorithmic analysis (eg, cell lysis, nucleic acid stabilization, extraction,
digestion, amplification, hybridization and detection) in addition to the
algorithmic analysis itself, when applicable. Procedures that are required prior
to cell lysis (eg, microdissection, codes 88380 and 88381) should be reported
separately.
The codes in this list are provided as an administrative coding set to facilitate
accurate reporting of MAAA services. The minimum standard for inclusion in
this list is that an analysis is generally available for patient care. The AMA has
not reviewed procedures in the administrative coding set for clinical utility. The
list is not a complete list of all MAAA procedures.
2. Category I MAAA codes are included below along with their proprietary names.
These codes are also listed in the Pathology and Laboratory section of the CPT
code set (81490-81599).
3. PLA codes created in response to the Protecting Access to Medicare Act
(PAMA) of 2014 are listed along with their proprietary names. These codes are
also located at the end of the Pathology and Laboratory section of the CPT code
set. In some instances, the descriptor language of PLA codes may be identical,
which are differentiated only by the listed propriety names.
▶The accuracy of a PLA code is to be maintained by the original applicant, or the
current owner of the test kit or laboratory performing the proprietary test.
A new PLA code is required when:
1. Additional nucleic acid (DNA or RNA) and/or protein analysis(es) are added to
the current PLA test, or
2. The name of the PLA test has changed in association with changes in test
performance or test characteristics.
The addition or modification of the therapeutic applications of the test require
submission of a code change application, but it may not require a new code
number.◀
Proprietary Name and Alpha- Code Descriptor

Clinical Laboratory or Numeric
Manufacturer Code
Administrative Codes for Multianalyte Assays with Algorithmic Analyses
(MAAA)
— (0001M —
has been
deleted.
To report,
use
81596)
ASH FibroSURE™, 0002M Liver disease, ten biochemical
BioPredictive S.A.S assays (ALT, A2-macroglobulin,
apolipoprotein A-1, total bilirubin,
GGT, haptoglobin, AST, glucose,
total cholesterol and triglycerides)
utilizing serum, prognostic
algorithm reported as quantitative
scores for fibrosis, steatosis and
alcoholic steatohepatitis (ASH)
NASH FibroSURE™, 0003M Liver disease, ten biochemical
BioPredictive S.A.S assays (ALT, A2-macroglobulin,
apolipoprotein A-1, total bilirubin,
GGT, haptoglobin, AST, glucose,
total cholesterol and triglycerides)
algorithm reported as quantitative
scores for fibrosis, steatosis and
nonalcoholic steatohepatitis
(NASH)
ScoliScore™ Transgenomic 0004M Scoliosis, DNA analysis of 53
single nucleotide polymorphisms
(SNPs), using saliva, prognostic
HeproDX™, GoPath 0006M Oncology (hepatic), mRNA
Laboratories, LLC expression levels of 161 genes,
utilizing fresh hepatocellular
carcinoma tumor tissue, with
alpha-fetoprotein level, algorithm
reported as a risk classifier
NETest, Wren Laboratories, 0007M Oncology (gastrointestinal
LLC neuroendocrine tumors), real-time
PCR expression analysis of 51
genes, utilizing whole peripheral
blood, algorithm reported as a
nomogram of tumor disease index
— (0009M —
has been
deleted)
NeoLAB™ Prostate Liquid 0011M Oncology, prostate cancer, mRNA
Biopsy, NeoGenomics expression assay of 12 genes (10
Laboratories content and 2 housekeeping),
RT-PCR test utilizing blood
plasma and urine, algorithms to
predict high-grade prostate
cancer risk
Cxbladder™ Detect, Pacific 0012M Oncology (urothelial), mRNA,
Edge Diagnostics USA, Ltd gene expression profiling by real-
time quantitative PCR of five
genes (MDK, HOXA13, CDC2
[CDK1], IGFBP5, and CXCR2),
utilizing urine, algorithm reported
as a risk score for having
urothelial carcinoma
Cxbladder™ Monitor, Pacific 0013M Oncology (urothelial), mRNA,
Edge Diagnostics USA, Ltd gene expression profiling by real-
time quantitative PCR of five
genes (MDK, HOXA13, CDC2
[CDK1], IGFBP5, and CXCR2),
utilizing urine, algorithm reported
as a risk score for having recurrent
urothelial carcinoma
▶Enhanced Liver Fibrosis™ ●0014M ▶Liver disease, analysis of 3
(ELF™) Test, Siemens biomarkers (hyaluronic acid
Healthcare Diagnostics [HA], procollagen III amino
Inc/Siemens Healthcare terminal peptide [PIIINP], tissue
Laboratory LLC◀ inhibitor of metalloproteinase 1
[TIMP-1]), using
immunoassays, utilizing serum,
prognostic algorithm reported as
a risk score and risk of liver
fibrosis and liver-related clinical
events within 5 years◀
▶Adrenal Mass Panel, 24 ●0015M ▶Adrenal cortical tumor,
Hour, Urine, Mayo Clinic biochemical assay of 25 steroid
Laboratories (MCL), Mayo markers, utilizing 24-hour urine
Clinic◀ specimen and clinical
parameters, prognostic algorithm
reported as a clinical risk and
integrated clinical steroid risk
for adrenal cortical carcinoma,
adenoma, or other adrenal
malignancy◀
▶Decipher Bladder TURBT®, ●0016M ▶Oncology (bladder), mRNA,
Decipher Biosciences, Inc◀ microarray gene expression
profiling of 209 genes, utilizing
formalin-fixed paraffin-
embedded tissue, algorithm
reported as molecular subtype
(luminal, luminal infiltrated,
basal, basal claudin-low,
neuroendocrine-like)◀
Category I Codes for Multianalyte Assays with Algorithmic Analyses
(MAAA)
Vectra® DA, Crescendo 81490 Autoimmune (rheumatoid
Bioscience, Inc arthritis), analysis of 12
biomarkers using immunoassays,
algorithm reported as a disease
activity score
(Do not report 81490 in
AlloMap ®, CareDx, Inc #81595 Cardiology (heart transplant),
mRNA, gene expression profiling
by real-time quantitative PCR of
20 genes (11 content and 9
housekeeping), utilizing
subfraction of peripheral blood,
algorithm reported as a rejection
risk score
Corus® CAD, CardioDx, Inc 81493 Coronary artery disease, mRNA,
gene expression profiling by real-
time RT-PCR of 23 genes, utilizing
whole peripheral blood, algorithm
PreDx Diabetes Risk Score™, 81506 Endocrinology (type 2 diabetes),
Tethys Clinical Laboratory biochemical assays of seven
analytes (glucose, HbA1c, insulin,
hs-CRP, adiponectin, ferritin,
interleukin 2-receptor alpha),
utilizing serum or plasma,
algorithm reporting a risk score
Harmony™ Prenatal Test, 81507 Fetal aneuploidy (trisomy 21, 18,
Ariosa Diagnostics and 13) DNA sequence analysis of
selected regions using maternal
plasma, algorithm reported as a
risk score for each trisomy
No proprietary name and 81508 Fetal congenital abnormalities,
clinical laboratory or biochemical assays of two proteins
manufacturer. (PAPP-A, hCG [any form]),
utilizing maternal serum, algorithm
Maternal serum screening
procedures are well-
established procedures and are 81509 Fetal congenital abnormalities,
performed by many biochemical assays of three
laboratories throughout the proteins (PAPP-A, hCG [any
country. The concept of form], DIA), utilizing maternal
prenatal screens has existed serum, algorithm reported as a risk
and evolved for over 10 years score
and is not exclusive to any 81510 Fetal congenital abnormalities,
one facility. biochemical assays of three
analytes (AFP, uE3, hCG [any
form]), utilizing maternal serum,
81511 Fetal congenital abnormalities,
biochemical assays of four
analytes (AFP, uE3, hCG [any
form], DIA) utilizing maternal
serum, algorithm reported as a risk
score (may include additional
results from previous biochemical
testing)
81512 Fetal congenital abnormalities,
biochemical assays of five analytes
(AFP, uE3, total hCG,
hyperglycosylated hCG, DIA)
utilizing maternal serum, algorithm
▶Aptima® BV Assay, Hologic, ●81513 ▶Infectious disease, bacterial
Incb vaginosis, quantitative real-time
amplification of RNA markers
for Atopobium vaginae,
Gardnerella vaginalis, and
Lactobacillus species, utilizing
vaginal-fluid specimens,
algorithm reported as a positive
or negative result for bacterial
vaginosis◀
▶BD MAX™ Vaginal Panel, ●81514 ▶Infectious disease, bacterial
Becton Dickson and vaginosis and vaginitis,
Company◀ quantitative real-time
amplification of DNA markers
for Gardnerella vaginalis,
Atopobium vaginae,
Megasphaera type 1, Bacterial
Vaginosis Associated Bacteria-2
(BVAB-2), and Lactobacillus
species (L. crispatus and L.
jensenii), utilizing vaginal-fluid
specimens, algorithm reported as
a positive or negative for high
likelihood of bacterial vaginosis,
includes separate detection of
Trichomonas vaginalis and/or
Candida species (C. albicans, C.
tropicalis, C. parapsilosis, C.
dubliniensis), Candida glabrata,
Candida krusei, when reported ◀
HCV FibroSURE™, #81596 Infectious disease, chronic
FibroTest™, BioPredictive hepatitis C virus (HCV) infection,
S.A.S. six biochemical assays (ALT, A2-
macroglobulin, apolipoprotein A-
1, total bilirubin, GGT, and
haptoglobin) utilizing serum,
prognostic algorithm reported as
scores for fibrosis and
necroinflammatory activity in liver
Breast Cancer Index, 81518 Oncology (breast), mRNA, gene
Biotheranostics, Inc expression profiling by real-time
RT-PCR of 11 genes (7 content
and 4 housekeeping), utilizing
formalin-fixed paraffin-embedded
tissue, algorithms reported as
percentage risk for metastatic
recurrence and likelihood of
benefit from extended endocrine
therapy
EndoPredict®, Myriad Genetic #81522 Oncology (breast), mRNA, gene
Laboratories, Inc expression profiling by RT-PCR of
housekeeping), utilizing formalin-
fixed paraffin-embedded tissue,
algorithm reported as recurrence
risk score
Oncotype DX®, Genomic 81519 Oncology (breast), mRNA, gene
Health expression profiling by real-time
RT-PCR of 21 genes, utilizing
tissue, algorithm reported as
recurrence score
Prosigna® Breast Cancer 81520 Oncology (breast), mRNA gene
Assay, NanoString expression profiling by hybrid
Technologies, Inc capture of 58 genes (50 content
tissue, algorithm reported as a
recurrence risk score
MammaPrint®, Agendia, Inc 81521 Oncology (breast), mRNA,
microarray gene expression
profiling of 70 content genes and
465 housekeeping genes, utilizing
fresh frozen or formalin-fixed
paraffin-embedded tissue,
algorithm reported as index related
to risk of distant metastasis
Oncotype DX® Colon Cancer 81525 Oncology (colon), mRNA, gene
Assay, Genomic Health expression profiling by real-time
recurrence score
Cologuard™, Exact Sciences, 81528 Oncology (colorectal) screening,
Inc quantitative real-time target and
signal amplification of 10 DNA
markers (KRAS mutations,
promoter methylation of NDRG4
and BMP3) and fecal hemoglobin,
utilizing stool, algorithm reported
as a positive or negative result
(Do not report 81528 in
▶DecisionDx® Melanoma, ●81529 ▶Oncology (cutaneous
Castle Biosciences, Inc◀ melanoma), mRNA, gene
expression profiling by real-time
reported as recurrence risk,
including likelihood of sentinel
lymph node metastasis◀
ChemoFX®, Helomics, Corp 81535 Oncology (gynecologic), live
tumor cell culture and
chemotherapeutic response by
DAPI stain and morphology,
predictive algorithm reported as a
drug response score; first single
drug or drug combination
✚81536 each additional single drug or
drug combination (List
separately in addition to code
(Use 81536 in conjunction with
81535)
VeriStrat, Biodesix, Inc 81538 Oncology (lung), mass
spectrometric 8-protein signature,
including amyloid A, utilizing
serum, prognostic and predictive
algorithm reported as good versus
poor overall survival
Risk of Ovarian Malignancy #81500 Oncology (ovarian), biochemical
Algorithm (ROMA)™, assays of two proteins (CA-125
Fujirebio Diagnostics and HE4), utilizing serum, with
menopausal status, algorithm
OVA1™, Vermillion, Inc #81503 Oncology (ovarian), biochemical
assays of five proteins (CA-125,
apolipoprotein A1, beta-2
microglobulin, transferrin, and
pre-albumin), utilizing serum,
4Kscore test, OPKO Health, 81539 Oncology (high-grade prostate
Inc cancer), biochemical assay of four
proteins (Total PSA, Free PSA,
Intact PSA and human kallikrein-2
[hK2]), utilizing plasma or serum,
prognostic algorithm reported as a
probability score
Prolaris®, Myriad Genetic 81541 Oncology (prostate), mRNA gene
Laboratories, Inc expression profiling by real-time
disease-specific mortality risk
score
Decipher® Prostate, Decipher® 81542 Oncology (prostate) mRNA,
Biosciences microarray gene expression
profiling of 22 content genes,
utilizing formalin-fixed paraffin-
reported as metastasis risk score
— ▶(81545 —
has been
deleted)◀
ConfirmMDx® for Prostate 81551 Oncology (prostate), promoter
Cancer, MDxHealth, Inc methylation profiling by real-time
PCR of 3 genes (GSTP1, APC,
RASSF1), utilizing formalin-fixed
algorithm reported as a likelihood
of prostate cancer detection on
repeat biopsy
▶Afirma® Genomic #●81546 ▶Oncology (thyroid), mRNA,
SequencingClassifier, gene expression analysis of
Veracyte, Inc◀ 10,196 genes, utilizing fine
needle aspirate, algorithm
reported as a categorical result
(eg, benign or suspicious)◀
Tissue of Origin Test Kit- #81504 Oncology (tissue of origin),
FFPE, Cancer Genetics, Inc microarray gene expression
profiling of >2000 genes, utilizing
tissue, algorithm reported as tissue
similarity scores
CancerTYPE ID, #81540 Oncology (tumor of unknown
bioTheranostics, Inc origin), mRNA, gene expression
profiling by real-time RT-PCR of
housekeeping) to classify tumor
into main cancer type and subtype,
reported as a probability of a
predicted main cancer type and
subtype
DecisionDx®-UM test, Castle 81552 Oncology (uveal melanoma),
Biosciences, Inc mRNA, gene expression profiling
by real-time RT-PCR of 15 genes
(12 content and 3 housekeeping),
utilizing fine needle aspirate or
tissue, algorithm reported as risk
of metastasis
▶Envisia® Genomic ●81554 ▶Pulmonary disease (idiopathic
Classifier,Veracyte, Inc◀ pulmonary fibrosis [IPF]),
mRNA, gene expression analysis
of 190 genes, utilizing
transbronchial biopsies,
diagnostic algorithm reported as
categorical result (eg, positive or
negative for high probability of
usual interstitial pneumonia
[UIP])◀
— 81599 Unlisted multianalyte assay with
algorithmic analysis
Proprietary Laboratory Analyses (PLA)
PreciseType® HEA Test, 0001U Red blood cell antigen typing,
Immucor, Inc DNA, human erythrocyte antigen
gene analysis of 35 antigens from
11 blood groups, utilizing whole
blood, common RBC alleles
reported
PolypDX™, Atlantic 0002U Oncology (colorectal), quantitative
Diagnostic Laboratories, LLC, assessment of three urine
Metabolomic Technologies, metabolites (ascorbic acid,
Inc succinic acid and carnitine) by
liquid chromatography with
tandem mass spectrometry (LC-
MS/MS) using multiple reaction
monitoring acquisition, algorithm
reported as likelihood of
adenomatous polyps
Overa (OVA1 Next 0003U Oncology (ovarian) biochemical
Generation), Asprira Labs, assays of five proteins
Inc, Vermillion, Inc (apolipoprotein A-1, CA 125 II,
follicle stimulating hormone,
human epididymis protein 4,
transferrin), utilizing serum,
algorithm reported as a likelihood
score
— (0004U —
has been
deleted)
ExosomeDx® Prostate 0005U Oncology (prostate) gene
(IntelliScore), Exosome expression profile by real-time RT-
Diagnostics, Inc, Exosome PCR of 3 genes (ERG, PCA3, and
Diagnostics, Inc SPDEF), urine, algorithm reported
as risk score
— ▶(0006U —
has been
deleted)◀
ToxProtect, Genotox 0007U Drug test(s), presumptive, with
Laboratories Ltd definitive confirmation of positive
results, any number of drug
classes, urine, includes specimen
verification including DNA
authentication in comparison to
buccal DNA, per date of service
AmHPR® H. pylori Antibiotic 0008U Helicobacter pylori detection and
Resistance Panel, American antibiotic resistance, DNA, 16S
Molecular Laboratories, Inc and 23S rRNA, gyrA, pbp1, rdxA
and rpoB, next generation
sequencing, formalin-fixed
paraffin-embedded or fresh tissue
or fecal sample, predictive,
reported as positive or negative
for resistance to clarithromycin,
fluoroquinolones, metronidazole,
amoxicillin, tetracycline, and
rifabutin
DEPArray™ HER2, PacificDx 0009U Oncology (breast cancer), ERBB2
(HER2) copy number by FISH,
tumor cells from formalin-fixed
paraffin-embedded tissue isolated
using image-based
dielectrophoresis (DEP) sorting,
reported as ERBB2 gene amplified
or non-amplified
Bacterial Typing by Whole 0010U Infectious disease (bacterial),
Genome Sequencing, Mayo strain typing by whole genome
Clinic sequencing, phylogenetic-based
report of strain relatedness, per
submitted isolate
Cordant CORE™, Cordant 0011U Prescription drug monitoring,
Health Solutions evaluation of drugs present by LC-
MS/MS, using oral fluid, reported
as a comparison to an estimated
steady-state range, per date of
service including all drug
compounds and metabolites
MatePair Targeted 0012U Germline disorders, gene
Rearrangements, Congenital, rearrangement detection by whole
Mayo Clinic genome next-generation
sequencing, DNA, whole blood,
report of specific gene
rearrangement(s)
MatePair Targeted 0013U Oncology (solid organ neoplasia),
Rearrangements, Oncology, gene rearrangement detection by
Mayo Clinic whole genome next-generation
sequencing, DNA, fresh or frozen
tissue or cells, report of specific
gene rearrangement(s)
MatePair Targeted 0014U Hematology (hematolymphoid
Rearrangements, Hematologic, neoplasia), gene rearrangement
Mayo Clinic detection by whole genome next-
generation sequencing, DNA,
whole blood or bone marrow,
report of specific gene
rearrangement(s)
— (0015U —
has been
deleted)
BCR-ABL1 major and minor 0016U Oncology (hematolymphoid
breakpoint fusion transcripts, neoplasia), RNA, BCR/ABL1
University of Iowa, major and minor breakpoint
Department of Pathology, fusion transcripts, quantitative
Asuragen PCR amplification, blood or bone
marrow, report of fusion not
detected or detected with
quantitation
JAK2 Mutation, University of 0017U Oncology (hematolymphoid
Iowa, Department of neoplasia), JAK2 mutation, DNA,
Pathology PCR amplification of exons 12-14
and sequence analysis, blood or
bone marrow, report of JAK2
mutation not detected or detected
ThyraMIR™, Interpace 0018U Oncology (thyroid), microRNA
Diagnostics profiling by RT-PCR of 10
microRNA sequences, utilizing
fine needle aspirate, algorithm
reported as a positive or negative
result for moderate to high risk of
malignancy
OncoTarget/OncoTreat, 0019U Oncology, RNA, gene expression
Columbia University by whole transcriptome
Department of Pathology and sequencing, formalin-fixed
Cell Biology, Darwin Health paraffin-embedded tissue or fresh
frozen tissue, predictive algorithm
reported as potential targets for
therapeutic agents
— (0020U —
has been
deleted)
Apifiny®, Armune BioScience, 0021U Oncology (prostate), detection of
Inc 8 autoantibodies (ARF 6, NKX3-1,
5’-UTR-BMI1, CEP 164, 3’-UTR-
Ropporin, Desmocollin,
AURKAIP-1, CSNK2A2),
multiplexed immunoassay and
flow cytometry serum, algorithm
reported as risk score
Oncomine™ Dx Target Test, 0022U Targeted genomic sequence
Thermo Fisher Scientific analysis panel, non-small cell lung
neoplasia, DNA and RNA
analysis, 23 genes, interrogation
for sequence variants and
rearrangements, reported as
presence/absence of variants and
associated therapy(ies) to consider
LeukoStrat® CDx FLT3 0023U Oncology (acute myelogenous
Mutation Assay, LabPMM leukemia), DNA, genotyping of
LLC, an Invivoscribe internal tandem duplication,
Technologies, Inc Company, p.D835, p.I836, using
Invivoscribe Technologies, mononuclear cells, reported as
Inc detection or non-detection of
FLT3 mutation and indication for
or against the use of midostaurin
GlycA, Laboratory 0024U Glycosylated acute phase proteins
Corporation of America, (GlycA), nuclear magnetic
Laboratory Corporation of resonance spectroscopy,
America quantitative
UrSure Tenofovir 0025U Tenofovir, by liquid
Quantification Test, Synergy chromatography with tandem
Medical Laboratories, UrSure mass spectrometry (LC-MS/MS),
Inc urine, quantitative
Thyroseq Genomic Classifier, 0026U Oncology (thyroid), DNA and
CBLPath, Inc, University of mRNA of 112 genes, next-
Pittsburgh Medical Center generation sequencing, fine needle
aspirate of thyroid nodule,
algorithmic analysis reported as a
categorical result (“Positive, high
probability of malignancy” or
“Negative, low probability of
malignancy”)
JAK2 Exons 12 to 15 0027U JAK2 (Janus kinase 2) (eg,
Sequencing, Mayo Clinic, myeloproliferative disorder) gene
Mayo Clinic analysis, targeted sequence
analysis exons 12-15
— (0028U —
has been
deleted)
Focused Pharmacogenomics 0029U Drug metabolism (adverse drug
Panel, Mayo Clinic, Mayo reactions and drug response),
Clinic targeted sequence analysis (ie,
CYP1A2, CYP2C19, CYP2C9,
CYP2D6, CYP3A4, CYP3A5,
CYP4F2, SLCO1B1, VKORC1
and rs12777823)
Warfarin Response Genotype, 0030U Drug metabolism (warfarin drug
Mayo Clinic, Mayo Clinic response), targeted sequence
analysis (ie, CYP2C9, CYP4F2,
VKORC1, rs12777823)
Cytochrome P450 1A2 0031U CYP1A2 (cytochrome P450 family
Genotype, Mayo Clinic, Mayo 1, subfamily A, member 2) (eg,
Clinic drug metabolism) gene analysis,
common variants (ie, *1F, *1K,
*6, *7)
Catechol-O-Methyltransferase 0032U COMT (catechol-O-
(COMT) Genotype, Mayo methyltransferase) (eg, drug
Clinic, Mayo Clinic metabolism) gene analysis,
c.472G>A (rs4680) variant
Serotonin Receptor Genotype 0033U HTR2A (5-hydroxytryptamine
(HTR2A and HTR2C), Mayo receptor 2A), HTR2C (5-
Clinic, Mayo Clinic hydroxytryptamine receptor 2C)
(eg, citalopram metabolism) gene
analysis, common variants (ie,
HTR2A rs7997012 [c.614-
2211T>C], HTR2C rs3813929
[c.-759C>T] and rs1414334
[c.551-3008C>G])
Thiopurine Methyltransferase 0034U TPMT (thiopurine S-
(TPMT) and Nudix Hydrolase methyltransferase), NUDT15
(nudix hydroxylase 15) (eg,
(NUDT15) Genotyping, Mayo thiopurine metabolism) gene
Clinic, Mayo Clinic analysis, common variants (ie,
TPMT *2, *3A, *3B, *3C, *4, *5,
*6, *8, *12; NUDT15 *3, *4, *5)
Real-time quaking-induced 0035U Neurology (prion disease),
conversion for prion detection cerebrospinal fluid, detection of
(RT-QuIC), National Prion prion protein by quaking-induced
Disease Pathology conformational conversion,
Surveillance Center qualitative
EXaCT-1 Whole Exome 0036U Exome (ie, somatic mutations),
Testing, Lab of Oncology- paired formalin-fixed paraffin-
Molecular Detection, Weill embedded tumor tissue and
Cornell Medicine-Clinical normal specimen, sequence
Genomics Laboratory analyses
FoundationOne CDx™ 0037U Targeted genomic sequence
(F1CDx), Foundation analysis, solid organ neoplasm,
Medicine, Inc, Foundation DNA analysis of 324 genes,
Medicine, Inc interrogation for sequence
variants, gene copy number
amplifications, gene
rearrangements, microsatellite
instability and tumor mutational
burden
Sensieva™ Droplet 25OH 0038U Vitamin D, 25 hydroxy D2 and D3,
Vitamin D2/D3 Microvolume by LC-MS/MS, serum
LC/MS Assay, InSource microsample, quantitative
Diagnostics, InSource
Diagnostics
Anti-dsDNA, High 0039U Deoxyribonucleic acid (DNA)
Salt/Avidity, University of antibody, double stranded, high
Washington, Department of avidity
Laboratory Medicine, Bio-Rad
MRDx BCR-ABL Test, 0040U BCR/ABL1 (t(9;22)) (eg, chronic
MolecularMD, MolecularMD myelogenous leukemia)
translocation analysis, major
breakpoint, quantitative
Lyme ImmunoBlot IgM, 0041U Borrelia burgdorferi, antibody
IGeneX Inc, ID-FISH detection of 5 recombinant protein
Technology Inc (ASR) (Lyme groups, by immunoblot, IgM
ImmunoBlot IgM Strips Only)
Lyme ImmunoBlot IgG, 0042U Borrelia burgdorferi, antibody
IGeneX Inc, ID-FISH detection of 12 recombinant
Technology Inc (ASR) (Lyme protein groups, by immunoblot,
ImmunoBlot IgG Strips Only) IgG
Tick-Borne Relapsing Fever 0043U Tick-borne relapsing fever
(TBRF) Borrelia ImmunoBlots Borrelia group, antibody detection
IgM Test, IGeneX Inc, ID- to 4 recombinant protein groups,
FISH Technology (Provides by immunoblot, IgM
TBRF ImmunoBlot IgM
Strips)
Tick-Borne Relapsing Fever 0044U Tick-borne relapsing fever
(TBRF) Borrelia ImmunoBlots Borrelia group, antibody detection
IgG Test, IGeneX Inc, ID- to 4 recombinant protein groups,
FISH Technology Inc by immunoblot, IgG
(Provides TBRF ImmunoBlot
IgG Strips)
The Oncotype DX® Breast 0045U Oncology (breast ductal carcinoma
DCIS Score™ Test, Genomic in situ), mRNA, gene expression
Health, Inc, Genomic Health, profiling by real-time RT-PCR of
Inc 12 genes (7 content and 5
housekeeping), utilizing formalin-
fixed paraffin-embedded tissue,
algorithm reported as recurrence
score
FLT3 ITD MRD by NGS, 0046U FLT3 (fms-related tyrosine kinase
LabPMM LLC, an 3) (eg, acute myeloid leukemia)
Invivoscribe Technologies, internal tandem duplication (ITD)
Inc Company variants, quantitative
Oncotype DX Genomic 0047U Oncology (prostate), mRNA, gene
Prostate Score, Genomic expression profiling by real-time
Health, Inc, Genomic Health, RT-PCR of 17 genes (12 content
Inc and 5 housekeeping), utilizing
tissue, algorithm reported as a risk
score
MSK-IMPACT (Integrated 0048U Oncology (solid organ neoplasia),
Mutation Profiling of DNA, targeted sequencing of
Actionable Cancer Targets), protein-coding exons of 468
Memorial Sloan Kettering cancer-associated genes, including
Cancer Center interrogation for somatic
mutations and microsatellite
instability, matched with normal
specimens, utilizing formalin-fixed
paraffin-embedded tumor tissue,
report of clinically significant
mutation(s)
NPM1 MRD by NGS, 0049U NPM1 (nucleophosmin) (eg, acute
LabPMM LLC, an myeloid leukemia) gene analysis,
Invivoscribe Technologies, quantitative
Inc Company
MyAML NGS Panel, LabPMM 0050U Targeted genomic sequence
LLC, an Invivoscribe analysis panel, acute myelogenous
Technologies, Inc Company leukemia, DNA analysis, 194
genes, interrogation for sequence
variants, copy number variants or
rearrangements
UCompliDx, Elite Medical 0051U Prescription drug monitoring,
Laboratory Solutions, LLC, evaluation of drugs present by LC-
Elite Medical Laboratory MS/MS, urine, 31 drug panel,
Solutions, LLC (LDT) reported as quantitative results,
detected or not detected, per date
of service
VAP Cholesterol Test, VAP 0052U Lipoprotein, blood, high
Diagnostics Laboratory, Inc, resolution fractionation and
VAP Diagnostics Laboratory, quantitation of lipoproteins
Inc including all five major
lipoprotein classes and the
subclasses of HDL, LDL, and
VLDL by vertical auto profile
ultracentrifugation
Prostate Cancer Risk Panel, 0053U Oncology (prostate cancer), FISH
Mayo Clinic, Laboratory analysis of 4 genes (ASAP1,
Developed Test HDAC9, CHD1 and PTEN),
needle biopsy specimen, algorithm
reported as probability of higher
tumor grade
AssuranceRx Micro Serum, 0054U Prescription drug monitoring, 14
Firstox Laboratories, LLC, or more classes of drugs and
Firstox Laboratories, LLC substances, definitive tandem
mass spectrometry with
chromatography, capillary blood,
quantitative report with
therapeutic and toxic ranges,
including steady-state range for
the prescribed dose when
detected, per date of service
myTAIHEART, TAI 0055U Cardiology (heart transplant), cell-
Diagnostics, Inc, TAI free DNA, PCR assay of 96 DNA
Diagnostics, Inc target sequences (94 single
nucleotide polymorphism targets
and two control targets), plasma
MatePair Acute Myeloid 0056U Hematology (acute myelogenous
Leukemia Panel, Mayo Clinic, leukemia), DNA, whole genome
Laboratory Developed Test next-generation sequencing to
detect gene rearrangement(s),
blood or bone marrow, report of
specific gene rearrangement(s)
— (0057U —
has been
deleted)
Merkel SmT Oncoprotein 0058U Oncology (Merkel cell carcinoma),
Antibody Titer, University of detection of antibodies to the
Washington, Department of Merkel cell polyoma virus
Laboratory Medicine oncoprotein (small T antigen),
serum, quantitative
Merkel Virus VP1 Capsid 0059U Oncology (Merkel cell carcinoma),
Antibody, University of detection of antibodies to the
Washington, Department of Merkel cell polyoma virus capsid
Laboratory Medicine protein (VP1), serum, reported as
positive or negative
Twins Zygosity PLA, Natera, 0060U Twin zygosity, genomic-targeted
Inc, Natera, Inc sequence analysis of chromosome
2, using circulating cell-free fetal
DNA in maternal blood
Transcutaneous multispectral 0061U Transcutaneous measurement of
measurement of tissue five biomarkers (tissue
oxygenation and hemoglobin oxygenation [StO 2],
using spatial frequency oxyhemoglobin [ctHbO 2],
domain imaging (SFDI), deoxyhemoglobin [ctHbR],
Modulated Imaging, Inc, papillary and reticular dermal
Modulated Imaging, Inc hemoglobin concentrations [ctHb1
and ctHb2]), using spatial
frequency domain imaging (SFDI)
and multi-spectral analysis
SLE-key® Rule Out, Veracis 0062U Autoimmune (systemic lupus
Inc Veracis Inc erythematosus), IgG and IgM
analysis of 80 biomarkers, utilizing
serum, algorithm reported with a
risk score
NPDX ASD ADM Panel I, 0063U Neurology (autism), 32 amines by
Stemina Biomarker Discovery, LC-MS/MS, using plasma,
Inc, Stemina Biomarker algorithm reported as metabolic
Discovery, Inc d/b/a signature associated with autism
NeuroPointDX spectrum disorder
BioPlex 2200 Syphilis Total & 0064U Antibody, Treponema pallidum,
RPR Assay, Bio-Rad total and rapid plasma reagin
Laboratories, Bio-Rad (RPR), immunoassay, qualitative
Laboratories
BioPlex 2200 RPR Assay, Bio- 0065U Syphilis test, non-treponemal
Rad Laboratories, Bio-Rad antibody, immunoassay,
Laboratories qualitative (RPR)
PartoSure™ Test, Parsagen 0066U Placental alpha-micro globulin-1
Diagnostics, Inc, Parsagen (PAMG-1), immunoassay with
Diagnostics, Inc, a QIAGEN direct optical observation, cervico-
Company vaginal fluid, each specimen
BBDRisk Dx™, Silbiotech, 0067U Oncology (breast),
Inc, Silbiotech, Inc immunohistochemistry, protein
expression profiling of 4
biomarkers (matrix
metalloproteinase-1 [MMP-1],
carcinoembryonic antigen-related
cell adhesion molecule 6
[CEACAM6],
hyaluronoglucosaminidase
[HYAL1], highly expressed in
cancer protein [HEC1]), formalin-
fixed paraffin-embedded
precancerous breast tissue,
algorithm reported as carcinoma
risk score
▶MYCODART-PCR™ Dual 0068U Candida species panel (C.
Amplification Real Time albicans, C. glabrata, C.
PCR Panel for 6 Candida parapsilosis, C. kruseii, C.
species, RealTime tropicalis, and C. auris), amplified
Laboratories, probe technique with qualitative
Inc/MycoDART, Inc, report of the presence or absence
RealTime Laboratories, of each species
Inc◀
miR-31now™, GoPath 0069U Oncology (colorectal), microRNA,
Laboratories, GoPath RT-PCR expression profiling of
Laboratories miR-31-3p, formalin-fixed
algorithm reported as an
expression score
CYP2D6 Common Variants 0070U CYP2D6 (cytochrome P450,
and Copy Number, Mayo family 2, subfamily D, polypeptide
Clinic, Laboratory Developed 6) (eg, drug metabolism) gene
Test analysis, common and select rare
variants (ie, *2, *3, *4, *4N, *5,
*6, *7, *8, *9, *10, *11, *12, *13,
*14A, *14B, *15, *17, *29, *35,
*36, *41, *57, *61, *63, *68, *83,
*xN)
CYP2D6 Full Gene ✚0071U CYP2D6 (cytochrome P450,
Sequencing, Mayo Clinic, family 2, subfamily D, polypeptide
Laboratory Developed Test 6) (eg, drug metabolism) gene
analysis, full gene sequence (List
separately in addition to code for
primary procedure)
(Use 0071U in conjunction with
0070U)
CYP2D6-2D7 Hybrid Gene ✚0072U CYP2D6 (cytochrome P450,
Targeted Sequence Analysis, family 2, subfamily D, polypeptide
Mayo Clinic, Laboratory 6) (eg, drug metabolism) gene
Developed Test analysis, targeted sequence
analysis (ie, CYP2D6-2D7 hybrid
gene) (List separately in addition
0070U)
CYP2D7-2D6 Hybrid Gene ✚0073U CYP2D6 (cytochrome P450,
Targeted Sequence Analysis, family 2, subfamily D, polypeptide
Mayo Clinic, Laboratory 6) (eg, drug metabolism) gene
Developed Test analysis, targeted sequence
analysis (ie, CYP2D7-2D6 hybrid
gene) (List separately in addition
0070U)
CYP2D6 trans- ✚0074U CYP2D6 (cytochrome P450,
duplication/multiplication family 2, subfamily D, polypeptide
non-duplicated gene targeted 6) (eg, drug metabolism) gene
sequence analysis, Mayo analysis, targeted sequence
Clinic, Laboratory Developed analysis (ie, non-duplicated gene
Test when duplication/multiplication is
trans) (List separately in addition
0070U)
CYP2D6 5’ gene ✚0075U CYP2D6 (cytochrome P450,
targeted sequence analysis, 6) (eg, drug metabolism) gene
Mayo Clinic, Laboratory analysis, targeted sequence
Developed Test analysis (ie, 5’ gene
duplication/multiplication) (List
primary procedure)
0070U)
CYP2D6 3’ gene ✚0076U CYP2D6 (cytochrome P450,
targeted sequence analysis, 6) (eg, drug metabolism) gene
Mayo Clinic, Laboratory analysis, targeted sequence
Developed Test analysis (ie, 3’ gene
duplication/multiplication) (List
primary procedure)
0070U)
M-Protein Detection and 0077U Immunoglobulin paraprotein (M-
Isotyping by MALDI-TOF protein), qualitative,
Mass Spectrometry, Mayo immunoprecipitation and mass
Clinic, Laboratory Developed spectrometry, blood or urine,
Test including isotype
INFINITI® Neural Response 0078U Pain management (opioid-use
Panel, PersonalizeDx Labs, disorder) genotyping panel, 16
AutoGenomics Inc common variants (ie, ABCB1,
COMT, DAT1, DBH, DOR,
DRD1, DRD2, DRD4, GABA,
GAL, HTR2A, HTTLPR, MTHFR,
MUOR, OPRK1, OPRM1), buccal
swab or other germline tissue
sample, algorithm reported as
positive or negative risk of opioid-
use disorder
ToxLok™, InSource 0079U Comparative DNA analysis using
Diagnostics, InSource multiple selected single-nucleotide
Diagnostics polymorphisms (SNPs), urine and
buccal DNA, for specimen identity
verification
BDX-XL2, Biodesix®, Inc, 0080U Oncology (lung), mass
Biodesix®, Inc spectrometric analysis of galectin-
3-binding protein and scavenger
receptor cysteine-rich type 1
protein M130, with five clinical
risk factors (age, smoking status,
nodule diameter, nodule-
spiculation status and nodule
location), utilizing plasma,
algorithm reported as a categorical
probability of malignancy
— (0081U —
has been
deleted.
To report,
use
81552)
NextGen Precision™ Testing, 0082U Drug test(s), definitive, 90 or more
Precision Diagnostics, drugs or substances, definitive
Precision Diagnostics LBN chromatography with mass
Precision Toxicology, LLC spectrometry, and presumptive,
any number of drug classes, by
instrument chemistry analyzer
(utilizing immunoassay), urine,
report of presence or absence of
each drug, drug metabolite or
substance with description and
severity of significant interactions
per date of service
Onco4D™, Animated 0083U Oncology, response to
Dynamics, Inc, Animated chemotherapy drugs using motility
Dynamics, Inc contrast tomography, fresh or
frozen tissue, reported as
likelihood of sensitivity or
resistance to drugs or drug
combinations
BLOODchip ® ID CORE 0084U Red blood cell antigen typing,
XT™, Grifols Diagnostic DNA, genotyping of 10 blood
Solutions Inc groups with phenotype prediction
of 37 red blood cell antigens
— ▶(0085U —
has been
deleted)◀
Accelerate PhenoTest™ BC 0086U Infectious disease (bacterial and
kit, Accelerate Diagnostics, fungal), organism identification,
Inc blood culture, using rRNA FISH,
6 or more organism targets,
with phenotypic minimum
inhibitory concentration (MIC)-
based antimicrobial susceptibility
Molecular Microscope® 0087U Cardiology (heart transplant),
MMDx—Heart, Kashi Clinical mRNA gene expression profiling
Laboratories by microarray of 1283 genes,
transplant biopsy tissue, allograft
rejection and injury algorithm
reported as a probability score
Molecular Microscope® 0088U Transplantation medicine (kidney
MMDx—Kidney, Kashi allograft rejection), microarray
Clinical Laboratories gene expression profiling of 1494
genes, utilizing transplant biopsy
probability score for rejection
Pigmented Lesion Assay 0089U Oncology (melanoma), gene
(PLA), DermTech expression profiling by RTqPCR,
PRAME and LINC00518,
superficial collection using
adhesive patch(es)
myPath ® Melanoma, Myriad 0090U Oncology (cutaneous melanoma),
Genetic Laboratories mRNA gene expression profiling
by RT-PCR of 23 genes (14
content and 9 housekeeping),
reported as a categorical result (ie,
benign, indeterminate, malignant)
FirstSightCRC, CellMax Life 0091U Oncology (colorectal) screening,
cell enumeration of circulating
tumor cells, utilizing whole blood,
algorithm, for the presence of
adenoma or cancer, reported as a
positive or negative result
REVEAL Lung Nodule 0092U Oncology (lung), three protein
Characterization, MagArray, biomarkers, immunoassay using
Inc magnetic nanosensor technology,
plasma, algorithm reported as risk
score for likelihood of malignancy
ComplyRX, Claro Labs 0093U Prescription drug monitoring,
evaluation of 65 common drugs
by LC-MS/MS, urine, each drug
reported detected or not detected
RCIGM Rapid Whole Genome 0094U Genome (eg, unexplained
Sequencing, Rady Children’s constitutional or heritable disorder
Institute for Genomic or syndrome), rapid sequence
Medicine (RCIGM) analysis
Esophageal String Test™ 0095U Inflammation (eosinophilic
(EST), Cambridge esophagitis), ELISA analysis of
Biomedical, Inc eotaxin-3 (CCL26 [C-C motif
chemokine ligand 26]) and major
basic protein (PRG2
[proteoglycan 2, pro eosinophil
major basic protein]), specimen
obtained by swallowed nylon
string, algorithm reported as
predictive probability index for
active eosinophilic esophagitis
HPV, High-Risk, Male Urine, 0096U Human papillomavirus (HPV),
Molecular Testing Labs high-risk types (ie, 16, 18, 31, 33,
35, 39, 45, 51, 52, 56, 58, 59, 66,
68), male urine
BioFire® FilmArray® 0097U Gastrointestinal pathogen,
Gastrointestinal (GI) Panel, multiplex reverse transcription and
BioFire® Diagnostics multiplex amplified probe
technique, multiple types or
subtypes, 22 targets
(Campylobacter [C. jejuni/C.
coli/C. upsaliensis], Clostridium
difficile [C. difficile] toxin A/B,
Plesiomonas shigelloides,
Salmonella, Vibrio [V.
parahaemolyticus/V. vulnificus/V.
cholerae], including specific
identification of Vibrio cholerae,
Yersinia enterocolitica,
Enteroaggregative Escherichia coli
[EAEC], Enteropathogenic
Escherichia coli [EPEC],
Enterotoxigenic Escherichia coli
[ETEC] lt/st, Shiga-like toxin-
producing Escherichia coli [STEC]
stx1/stx2 [including specific
identification of the E. coli O157
serogroup within STEC],
Shigella/Enteroinvasive
Escherichia coli [EIEC],
Cryptosporidium, Cyclospora
cayetanensis, Entamoeba
histolytica, Giardia lamblia [also
known as G. intestinalis and G.
duodenalis], adenovirus F 40/41,
astrovirus, norovirus GI/GII,
rotavirus A, sapovirus
[Genogroups I, II, IV, and V])
BioFire® FilmArray® 0098U Respiratory pathogen, multiplex
Respiratory Panel (RP) EZ, reverse transcription and multiplex
BioFire® Diagnostics amplified probe technique,
multiple types or subtypes, 14
targets (adenovirus, coronavirus,
human metapneumovirus,
influenza A, influenza A subtype
H1, influenza A subtype H3,
influenza A subtype H1-2009,
influenza B, parainfluenza virus,
human rhinovirus/enterovirus,
respiratory syncytial virus,
Bordetella pertussis,
Chlamydophila pneumoniae,
Respiratory Panel (RP), reverse transcription and multiplex
targets (adenovirus, coronavirus
229E, coronavirus HKU1,
coronavirus, coronavirus OC43,
human metapneumovirus,
influenza A, influenza A subtype,
influenza A subtype H3, influenza
A subtype H1-2009, influenza,
parainfluenza virus, parainfluenza
virus 2, parainfluenza virus 3,
parainfluenza virus 4, human
rhinovirus/enterovirus, respiratory
syncytial virus, Bordetella
pertussis, Chlamydophila
pneumonia, Mycoplasma
pneumoniae)
Respiratory Panel 2 (RP2), reverse transcription and multiplex
targets (adenovirus, coronavirus
229E, coronavirus HKU1,
coronavirus NL63, coronavirus
OC43, human metapneumovirus,
human rhinovirus/enterovirus,
influenza A, including subtypes
H1, H1-2009, and H3, influenza B,
parainfluenza virus 1,
parainfluenza virus 4, respiratory
syncytial virus, Bordetella
parapertussis [IS1001], Bordetella
pertussis [ptxP], Chlamydia
pneumoniae, Mycoplasma
pneumoniae)
ColoNext®, Ambry Genetics®, 0101U Hereditary colon cancer disorders
Ambry Genetics® (eg, Lynch syndrome, PTEN
hamartoma syndrome, Cowden
syndrome, familial adenomatosis
polyposis), genomic sequence
analysis panel utilizing a
combination of NGS, Sanger,
MLPA, and array CGH, with
mRNA analytics to resolve
variants of unknown significance
when indicated (15 genes
[sequencing and
deletion/duplication], EPCAM and
GREM1 [deletion/duplication
only])
BreastNext®, Ambry 0102U Hereditary breast cancer-related
Genetics®, Ambry Genetics® disorders (eg, hereditary breast
cancer, hereditary ovarian cancer,
hereditary endometrial cancer),
genomic sequence analysis panel
utilizing a combination of NGS,
Sanger, MLPA, and array CGH,
with mRNA analytics to resolve
[sequencing and
deletion/duplication])
OvaNext®, Ambry Genetics®, 0103U Hereditary ovarian cancer (eg,
Ambry Genetics® hereditary ovarian cancer,
genomic sequence analysis panel
utilizing a combination of NGS,
Sanger, MLPA, and array CGH,
with mRNA analytics to resolve
[sequencing and
deletion/duplication], EPCAM
[deletion/duplication only])
— (0104U —
has been
deleted)
KidneyIntelX™, RenalytixAI, 0105U Nephrology (chronic kidney
RenalytixAI disease), multiplex
electrochemiluminescent
immunoassay (ECLIA) of tumor
necrosis factor receptor 1A,
receptor superfamily 2 (TNFR1,
TNFR2), and kidney injury
molecule-1 (KIM-1) combined
with longitudinal clinical data,
including APOL1 genotype if
available, and plasma (isolated
fresh or frozen), algorithm
reported as probability score for
rapid kidney function decline
(RKFD)
13C-Spirulina Gastric 0106U Gastric emptying, serial collection
Emptying Breath Test (GEBT), of 7 timed breath specimens, non-
Cairn Diagnostics d/b/a radioisotope carbon-13 (13C)
Advanced Breath Diagnostics, spirulina substrate, analysis of
LLC, Cairn Diagnostics d/b/a each specimen by gas isotope ratio
Advanced Breath Diagnostics, mass spectrometry, reported as
LLC rate of 13CO 2 excretion
Singulex Clarity C.diff toxins 0107U Clostridium difficile toxin(s)
A/B Assay, Singulex antigen detection by immunoassay
technique, stool, qualitative,
multiple-step method
TissueCypher® Barrett’s 0108U Gastroenterology (Barrett’s
Esophagus Assay, Cernostics, esophagus), whole slide–digital
Cernostics imaging, including morphometric
analysis, computer-assisted
quantitative immunolabeling of 9
protein biomarkers (p16, AMACR,
p53, CD68, COX-2, CD45RO,
HIF1a, HER-2, K20) and
morphology, formalin-fixed
algorithm reported as risk of
progression to high-grade
dysplasia or cancer
MYCODART Dual 0109U Infectious disease (Aspergillus
Amplification Real Time PCR species), real-time PCR for
Panel for 4 Aspergillus detection of DNA from 4 species
species, RealTime (A. fumigatus, A. terreus, A. niger,
Laboratories, Inc/MycoDART, and A. flavus), blood, lavage fluid,
Inc or tissue, qualitative reporting of
presence or absence of each
species
Oral OncolyticAssuranceRX, 0110U Prescription drug monitoring, one
Firstox Laboratories, LLC, or more oral oncology drug(s) and
Firstox Laboratories, LLC substances, definitive tandem
mass spectrometry with
chromatography, serum or plasma
from capillary blood or venous
blood, quantitative report with
steady-state range for the
prescribed drug(s) when detected
Praxis(TM) Extended RAS 0111U Oncology (colon cancer), targeted
Panel, Illumina, Illumina KRAS (codons 12, 13, and 61) and
NRAS (codons 12, 13, and 61)
gene analysis, utilizing formalin-
fixed paraffin-embedded tissue
MicroGenDX qPCR & NGS 0112U Infectious agent detection and
For Infection, MicroGenDX, identification, targeted sequence
MicroGenDX analysis (16S and 18S rRNA
genes) with drug-resistance gene
MiPS (Mi-Prostate Score), 0113U Oncology (prostate), measurement
MLabs, MLabs of PCA3 and TMPRSS2-ERG in
urine and PSA in serum following
prostatic massage, by RNA
amplification and fluorescence-
based detection, algorithm
reported as risk score
EsoGuard™, Lucid 0114U Gastroenterology (Barrett’s
Diagnostics, Lucid Diagnostics esophagus), VIM and CCNA1
methylation analysis, esophageal
cells, algorithm reported as
likelihood for Barrett’s esophagus
ePlex Respiratory Pathogen 0115U Respiratory infectious agent
(RP) Panel, GenMark detection by nucleic acid (DNA
Diagnostics, Inc, GenMark and RNA), 18 viral types and
Diagnostics, Inc subtypes and 2 bacterial targets,
amplified probe technique,
including multiplex reverse
transcription for RNA targets, each
analyte reported as detected or not
detected
Snapshot Oral Fluid 0116U Prescription drug monitoring,
Compliance, Ethos enzyme immunoassay of 35 or
Laboratories more drugs confirmed with LC-
MS/MS, oral fluid, algorithm
results reported as a patient-
compliance measurement with risk
of drug to drug interactions for
prescribed medications
Foundation PISM, Ethos 0117U Pain management, analysis of 11
Laboratories endogenous analytes
(methylmalonic acid, xanthurenic
acid, homocysteine, pyroglutamic
acid, vanilmandelate, 5-
hydroxyindoleacetic acid,
hydroxymethylglutarate,
ethylmalonate, 3-hydroxypropyl
mercapturic acid (3-HPMA),
quinolinic acid, kynurenic acid),
LC-MS/MS, urine, algorithm
reported as a pain-index score
with likelihood of atypical
biochemical function associated
with pain
Viracor TRAC™ dd-cfDNA, 0118U Transplantation medicine,
Viracor Eurofins, Viracor quantification of donor-derived
Eurofins cell-free DNA using whole
genome next-generation
sequencing, plasma, reported as
percentage of donor-derived cell-
free DNA in the total cell-free
DNA
MI-HEART Ceramides, 0119U Cardiology, ceramides by liquid
Plasma, Mayo Clinic, chromatography–tandem mass
Laboratory Developed Test spectrometry, plasma, quantitative
report with risk score for major
cardiovascular events
Lymph3Cx Lymphoma 0120U Oncology (B-cell lymphoma
Molecular Subtyping Assay, classification), mRNA, gene
Mayo Clinic, Laboratory expression profiling by fluorescent
Developed Test probe hybridization of 58 genes
(45 content and 13 housekeeping
genes), formalin-fixed paraffin-
reported as likelihood for primary
mediastinal B-cell lymphoma
(PMBCL) and diffuse large B-cell
lymphoma (DLBCL) with cell of
origin subtyping in the latter
Flow Adhesion of Whole 0121U Sickle cell disease, microfluidic
Blood on VCAM-1 (FAB-V), flow adhesion (VCAM-1), whole
Functional Fluidics, blood
Functional Fluidics
Flow Adhesion of Whole 0122U Sickle cell disease, microfluidic
Blood to P-SELECTIN (WB- flow adhesion (P-Selectin), whole
blood
PSEL), Functional Fluidics,
Functional Fluidics
Mechanical Fragility, RBC by 0123U Mechanical fragility, RBC, shear
shear stress profiling and stress and spectral analysis
spectral analysis, Functional profiling
Fluidics, Functional Fluidics
— ▶(0124U —
has been
deleted)◀
— ▶(0125U —
has been
deleted)◀
— ▶(0126U —
has been
deleted)◀
— ▶(0127U —
has been
deleted)◀
— ▶(0128U —
has been
deleted)◀
BRCAplus, Ambry Genetics 0129U Hereditary breast cancer–related
disorders (eg, hereditary breast
genomic sequence analysis and
deletion/duplication analysis panel
(ATM, BRCA1, BRCA2, CDH1,
CHEK2, PALB2, PTEN, and
TP53)
+RNAinsight™ for ✚0130U Hereditary colon cancer disorders
ColoNext®, Ambry Genetics (eg, Lynch syndrome, PTEN
hamartoma syndrome, Cowden
syndrome, familial adenomatosis
polyposis), targeted mRNA
sequence analysis panel (APC,
CDH1, CHEK2, MLH1, MSH2,
MSH6, MUTYH, PMS2, PTEN,
and TP53) (List separately in
addition to code for primary
procedure)
81435, 0101U)
+RNAinsight™ for ✚0131U Hereditary breast cancer–related
BreastNext®, Ambry Genetics disorders (eg, hereditary breast
targeted mRNA sequence analysis
panel (13 genes) (List separately in
procedure)
81162, 81432, 0102U)
+RNAinsight™ for OvaNext®, ✚0132U Hereditary ovarian cancer–related
Ambry Genetics disorders (eg, hereditary breast
targeted mRNA sequence analysis
panel (17 genes) (List separately in
procedure)
81162, 81432, 0103U)
+RNAinsight™ for ✚0133U Hereditary prostate cancer–related
ProstateNext®, Ambry disorders, targeted mRNA
Genetics sequence analysis panel (11 genes)
(List separately in addition to code
81162)
+RNAinsight™ for ✚0134U Hereditary pan cancer (eg,
CancerNext®, Ambry Genetics hereditary breast and ovarian
cancer, hereditary endometrial
cancer, hereditary colorectal
cancer), targeted mRNA sequence
analysis panel (18 genes) (List
primary procedure)
81162, 81432, 81435)
+RNAinsight™ for ✚0135U Hereditary gynecological cancer
GYNPlus®, Ambry Genetics (eg, hereditary breast and ovarian
cancer, hereditary endometrial
cancer, hereditary colorectal
cancer), targeted mRNA sequence
analysis panel (12 genes) (List
primary procedure)
81162)
+RNAinsight™ for ATM, ✚0136U ATM (ataxia telangiectasia
Ambry Genetics mutated) (eg, ataxia telangiectasia)
mRNA sequence analysis (List
primary procedure)
81408)
+RNAinsight™ for PALB2, ✚0137U PALB2 (partner and localizer of
Ambry Genetics BRCA2) (eg, breast and pancreatic
cancer) mRNA sequence analysis
(List separately in addition to code
81307)
+RNAinsight™ for BRCA1/2, ✚0138U BRCA1 (BRCA1, DNA repair
Ambry Genetics associated), BRCA2 (BRCA2, DNA
repair associated) (eg, hereditary
breast and ovarian cancer) mRNA
sequence analysis (List separately
in addition to code for primary
procedure)
81162)
▶NPDX ASD Energy ●0139U ▶Neurology (autism spectrum
Metabolism, Stemina disorder [ASD]), quantitative
Biomarker Discovery, Inc, measurements of 6 central
Stemina Biomarker carbon metabolites (ie, α-
Discovery, Inc◀ ketoglutarate, alanine, lactate,
phenylalanine, pyruvate, and
succinate), LC-MS/MS, plasma,
algorithmic analysis with result
reported as negative or positive
(with metabolic subtypes of
ASD)◀
▶ePlex® BCID Fungal ●0140U ▶Infectious disease (fungi),
Pathogens Panel, GenMark fungal pathogen identification,
Diagnostics, Inc, GenMark DNA (15 fungal targets), blood
Diagnostics, Inc◀ culture, amplified probe
technique, each target reported
as detected or not detected ◀
▶ePlex® BCID Gram-Positive ●0141U ▶Infectious disease (bacteria and
Panel, GenMark fungi), gram-positive organism
Diagnostics, Inc, GenMark identification and drug
Diagnostics, Inc◀ resistance element detection,
DNA (20 gram-positive bacterial
targets, 4 resistance genes, 1 pan
gram-negative bacterial target, 1
pan Candida target), blood
culture, amplified probe
technique, each target reported
as detected or not detected ◀
▶ePlex® BCID Gram-Negative ●0142U ▶Infectious disease (bacteria and
Panel, GenMark fungi), gramnegative bacterial
Diagnostics, Inc, GenMark identification and drug
Diagnostics, Inc◀ resistance element detection,
DNA (21 gram-negative bacterial
targets, 6 resistance genes, 1 pan
gram-positive bacterial target, 1
pan Candida target), amplified
probe technique, each target
reported as detected or not
detected ◀
▶CareViewRx, Newstar ●0143U ▶Drug assay, definitive, 120 or
Medical Laboratories, LLC, more drugs or metabolites,
Newstar Medical urine, quantitative liquid
Laboratories, LLC◀ chromatography with tandem
mass spectrometry (LC-MS/MS)
using multiple reaction
monitoring (MRM), with drug or
metabolite description,
comments including sample
validation, per date of service◀
▶(For additional PLA code with
identical clinical descriptor, see
0150U. See Appendix O to
determine appropriate code
assignment)◀
▶CareViewRx Plus, Newstar ●0144U ▶Drug assay, definitive, 160 or
▶PainViewRx, Newstar ●0145U ▶Drug assay, definitive, 65 or
▶PainViewRx Plus, Newstar ●0146U ▶Drug assay, definitive, 80 or
Newstar Medical urine, by quantitative liquid
▶RiskViewRx, Newstar ●0147U ▶Drug assay, definitive, 85 or
▶RiskViewRx Plus, Newstar ●0148U ▶Drug assay, definitive, 100 or
▶PsychViewRx, Newstar ●0149U ▶Drug assay, definitive, 60 or
▶PsychViewRx Plus, Newstar ●0150U ▶Drug assay, definitive, 120 or
▶(For additional PLA code with
identical clinical descriptor, see
0143U. See Appendix O to
determine appropriate code
assignment)◀
▶BioFire® FilmArray® ●0151U ▶Infectious disease (bacterial or
Pneumonia Panel, BioFire ® viral respiratory tract infection),
Diagnostics, BioFire® pathogen specific nucleic acid
Diagnostics◀ (DNA or RNA), 33 targets, real-
time semi-quantitative PCR,
bronchoalveolar lavage, sputum,
or endotracheal aspirate,
detection of 33 organismal and
antibiotic resistance genes with
limited semi-quantitative
results◀
▶Karius® Test, Karius Inc, ●0152U ▶Infectious disease (bacteria,
Karius Inc◀ fungi, parasites, and DNA
viruses), DNA, PCR and next-
generation sequencing, plasma,
detection of >1,000 potential
microbial organisms for
significant positive pathogens◀
▶Insight TNBCtype™, Insight ●0153U ▶Oncology (breast), mRNA, gene
Molecular Labs◀ expression profiling by next-
generation sequencing of 101
genes, utilizing formalin-fixed
algorithm reported as a triple
negative breast cancer clinical
subtype(s) with information on
immune cell involvement◀
▶therascreen ® FGFR RGQ ▲0154U ▶Oncology (urothelial cancer),
RT-PCR Kit, QIAGEN, RNA, analysis by real-time RT-
QIAGEN GmbH◀ PCR of the FGFR3 (fibroblast
growth factor receptor 3) gene
analysis (ie, p.R248C
[c.742C>T], p.S249C
[c.746C>G], p.G370C
[c.1108G>T], p.Y373C
[c.1118A>G], FGFR3-TACC3v1,
and FGFR3-TACC3v3), utilizing
embedded urothelial cancer
tumor tissue, reported as FGFR
gene alteration status◀
▶therascreen PIK3CA RGQ ▲0155U ▶Oncology (breast cancer), DNA,
PCR Kit, QIAGEN, PIK3CA (phosphatidylinositol-
QIAGEN GmbH◀ 4,5-bisphosphate 3-kinase,
catalytic subunit alpha) (eg,
breast cancer) gene analysis (ie,
p.C420R, p.E542K, p.E545A, p.
E545D [g.1635G>T only],
p.E545G, p.E545K, p. Q546E,
p.Q546R, p.H1047L, p.H1047R,
p. H1047Y), utilizing formalin-
fixed paraffin-embedded breast
tumor tissue, reported as
PIK3CA gene mutation status◀
▶SMASH™, New York ●0156U ▶Copy number (eg, intellectual
Genome Center, Marvel disability, dysmorphology),
Genomics™ ◀ sequence analysis◀
▶CustomNext + RNA: APC, ✚●0157U ▶APC (APC regulator of WNT
® signaling pathway) (eg, familial
Ambry Genetics , Ambry
Genetics®◀ adenomatosis polyposis [FAP])
mRNA sequence analysis (List
primary procedure)◀
▶(Use 0157U in conjunction with
81201)◀
▶CustomNext + RNA: MLH1, ✚●0158U ▶MLH1 (mutL homolog 1) (eg,
® hereditary nonpolyposis
Genetics®◀ colorectal cancer, Lynch
syndrome) mRNA sequence
analysis (List separately in
procedure)◀
81292)◀
▶CustomNext + RNA: MSH2, ✚●0159U ▶MSH2 (mutS homolog 2) (eg,
® hereditary colon cancer, Lynch
Genetics®◀ syndrome) mRNA sequence
procedure)◀
81295)◀
▶CustomNext + RNA: MSH6, ✚●0160U ▶MSH6 (mutS homolog 6) (eg,
® hereditary colon cancer, Lynch
Genetics®◀ syndrome) mRNA sequence
procedure)◀
81298)◀
▶CustomNext + RNA: PMS2, ✚●0161U ▶PMS2 (PMS1 homolog 2,
® mismatch repair system
Genetics®◀ component) (eg, hereditary non-
polyposis colorectal cancer,
Lynch syndrome) mRNA
sequence analysis (List
81317)◀
▶CustomNext + RNA: Lynch ✚●0162U ▶Hereditary colon cancer (Lynch
(MLH1, MSH2, MSH6, syndrome), targeted mRNA
PMS2), Ambry Genetics®, sequence analysis panel (MLH1,
Ambry Genetics®◀ MSH2, MSH6, PMS2) (List
81292, 81295, 81298, 81317,
81435)◀
▶BeScreened™-CRC, Beacon ●0163U ▶Oncology (colorectal) screening,
Biomedical Inc, Beacon biochemical enzyme-linked
Biomedical Inc◀ immunosorbent assay (ELISA)
of 3 plasma or serum proteins
(teratocarcinoma derived growth
factor-1 [TDGF-1, Cripto-1],
carcinoembryonic antigen
[CEA], extracellular matrix
protein [ECM]), with
demographic data (age, gender,
CRC-screening compliance)
using a proprietary algorithm
and reported as likelihood of
CRC or advanced adenomas◀
▶ibs-smart™, Gemelli ●0164U ▶Gastroenterology (irritable
Biotech, Gemelli Biotech ◀ bowel syndrome [IBS]),
immunoassay for anti-CdtB and
anti-vinculin antibodies, utilizing
plasma, algorithm for elevated
or not elevated qualitative
results◀
▶VeriMAP™ Peanut Dx – ▲0165U ▶Peanut allergen-specific
Bead-based Epitope Assay, quantitative assessment of
AllerGenis™ Clinical multiple epitopes using enzyme-
Laboratory, AllerGenis™ linked immunosorbent assay
LLC◀ (ELISA), blood, individual
epitope results and probability
of peanut allergy◀
▶LiverFASt™, Fibronostics, ●0166U ▶Liver disease, 10 biochemical
Fibronostics◀ assays (α2-macroglobulin,
haptoglobin, apolipoprotein A1,
bilirubin, GGT, ALT, AST,
triglycerides, cholesterol, fasting
glucose) and biometric and
demographic data, utilizing
serum, algorithm reported as
scores for fibrosis,
necroinflammatory activity, and
steatosis with a summary
interpretation ◀
▶ADEXUSDx hCG Test, ●0167U ▶Gonadotropin, chorionic (hCG),
NOWDiagnostics, immunoassay with direct optical
NOWDiagnostics◀ observation, blood ◀
▶Vanadis® NIPT, ●0168U ▶Fetal aneuploidy (trisomy 21, 18,
PerkinElmer, Inc, and 13) DNA sequence analysis
PerkinElmer Genomics◀ of selected regions using
maternal plasma without fetal
fraction cutoff, algorithm
reported as a risk score for each
trisomy◀
▶NT (NUDT15 and TPMT) ●0169U ▶NUDT15 (nudix hydrolase 15)
genotyping panel, RPRD and TPMT (thiopurine S-
Diagnostics◀ methyltransferase) (eg, drug
metabolism) gene analysis,
common variants◀
▶Clarifi™, Quadrant ●0170U ▶Neurology (autism spectrum
Biosciences, Inc, Quadrant disorder [ASD]), RNA, next-
Biosciences, Inc◀ generation sequencing, saliva,
algorithmic analysis, and results
reported as predictive
probability of ASD diagnosis◀
▶MyMRD® NGS Panel, ●0171U ▶Targeted genomic sequence
Laboratory for Personalized analysis panel, acute myeloid
Molecular Medicine, leukemia, myelodysplastic
Laboratory for Personalized syndrome, and
Molecular Medicine◀ myeloproliferative neoplasms,
DNA analysis, 23 genes,
interrogation for sequence
variants, rearrangements and
minimal residual disease,
reported as presence/absence◀
▶myChoice® CDx, Myriad ●0172U ▶Oncology (solid tumor as
Genetics Laboratories, Inc, indicated by the label), somatic
Myriad Genetics mutation analysis of BRCA1
Laboratories, Inc◀ (BRCA1, DNA repair
associated), BRCA2 (BRCA2,
DNA repair associated) and
analysis of homologous
recombination deficiency
pathways, DNA, formalin-fixed
algorithm quantifying tumor
genomic instability score◀
▶Psych HealthPGx Panel, ●0173U ▶Psychiatry (ie, depression,
RPRD Diagnostics, RPRD anxiety), genomic analysis panel,
Diagnostics◀ includes variant analysis of 14
genes◀
▶LC-MS/MS Targeted ●0174U ▶Oncology (solid tumor), mass
Proteomic Assay, spectrometric 30 protein targets,
OncoOmicDx Laboratory, formalin-fixed paraffin-
LDT◀ embedded tissue, prognostic and
predictive algorithm reported as
likely, unlikely, or uncertain
benefit of 39 chemotherapy and
targeted therapeutic oncology
agents◀
▶Genomind ® Professional ●0175U ▶Psychiatry (eg, depression,
PGx Express™ CORE, anxiety), genomic analysis panel,
Genomind, Inc, Genomind, variant analysis of 15 genes◀
Inc◀
▶IBSchek®, Commonwealth ●0176U ▶Cytolethal distending toxin B
Diagnostics International, (CdtB) and vinculin IgG
Inc, Commonwealth antibodies by immunoassay (ie,
Diagnostics International, ELISA)◀
Inc◀
▶therascreen ® PIK3CA RGQ ●0177U ▶Oncology (breast cancer), DNA,
PCR Kit, QIAGEN, PIK3CA (phosphatidylinositol-
QIAGEN GmbH◀ 4,5-bisphosphate 3-kinase
catalytic subunit alpha) gene
analysis of 11 gene variants
utilizing plasma, reported as
PIK3CA gene mutation status◀
▶VeriMAP™ Peanut ●0178U ▶Peanut allergen-specific
Sensitivity – Bead Based quantitative assessment of
Epitope Assay, AllerGenis™ multiple epitopes using enzyme-
Clinical Laboratory, linked immunosorbent assay
AllerGenis™ LLC◀ (ELISA), blood, report of
minimum eliciting exposure for
a clinical reaction ◀
▶Resolution ctDx Lung™, ●0179U ▶Oncology (non-small cell lung
Resolution Bioscience, cancer), cell-free DNA, targeted
Resolution Bioscience, Inc◀ sequence analysis of 23 genes
(single nucleotide variations,
insertions and deletions, fusions
without prior knowledge of
partner/breakpoint, copy
number variations), with report
of significant mutation(s)◀
▶Navigator ABO Sequencing, ●0180U ▶Red cell antigen (ABO blood
Grifols Immunohematology group) genotyping (ABO), gene
Center, Grifols analysis Sanger/chain
Immunohematology termination/conventional
Center◀ sequencing, ABO (ABO, alpha
1-3-N-
acetylgalactosaminyltransferase
and alpha 1-3-
galactosyltransferase) gene,
including subtyping, 7 exons◀
▶Navigator CO Sequencing, ●0181U ▶Red cell antigen (Colton blood
Grifols Immunohematology group) genotyping (CO), gene
Center, Grifols analysis, AQP1 (aquaporin 1
Immunohematology [Colton blood group]) exon 1◀
Center◀
▶Navigator CROM ●0182U ▶Red cell antigen (Cromer blood
Sequencing, Grifols group) genotyping (CROM),
Immunohematology Center, gene analysis, CD55 (CD55
Grifols Immunohematology molecule [Cromer blood
Center◀ group]) exons 1-10◀
▶Navigator DI Sequencing, ●0183U ▶Red cell antigen (Diego blood
Grifols Immunohematology group) genotyping (DI), gene
Center, Grifols analysis, SLC4A1 (solute carrier
Immunohematology family 4 member 1 [Diego
Center◀ blood group]) exon 19◀
▶Navigator DO Sequencing, ●0184U ▶Red cell antigen (Dombrock
Grifols Immunohematology blood group) genotyping (DO),
Center, Grifols gene analysis, ART4
Immunohematology (ADPribosyltransferase 4
Center◀ [Dombrock blood group]) exon
2◀
▶Navigator FUT1 ●0185U ▶Red cell antigen (H blood group)
Sequencing, Grifols genotyping (FUT1), gene
Immunohematology Center, analysis, FUT1
Grifols (fucosyltransferase 1 [H blood
ImmunohematologyCenter◀ group]) exon 4◀
▶Navigator FUT2 ●0186U ▶Red cell antigen (H blood group)
Sequencing, Grifols genotyping (FUT2), gene
Immunohematology Center, analysis, FUT2
Grifols Immunohematology (fucosyltransferase 2) exon 2◀
Center◀
▶Navigator FY Sequencing, ●0187U ▶Red cell antigen (Duffy blood
Grifols Immunohematology group) genotyping (FY), gene
Center, Grifols analysis, ACKR1 (atypical
Immunohematology chemokine receptor 1 [Duffy
Center◀ blood group]) exons 1-2◀
▶Navigator GE Sequencing, ●0188U ▶Red cell antigen (Gerbich blood
Grifols Immunohematology group) genotyping (GE), gene
Center, Grifols analysis, GYPC (glycophorin C
Immunohematology [Gerbich blood group]) exons
Center◀ 1-4◀
▶Navigator GYPA ●0189U ▶Red cell antigen (MNS blood
Sequencing, Grifols group) genotyping (GYPA),
Immunohematology Center, gene analysis, GYPA
Grifols Immunohematology (glycophorin A [MNS blood
Center◀ group]) introns 1, 5, exon 2◀
▶Navigator GYPB ●0190U ▶Red cell antigen (MNS blood
Sequencing, Grifols group) genotyping (GYPB),
Immunohematology Center, gene analysis, GYPB
Grifols Immunohematology (glycophorin B [MNS blood
Center◀ group]) introns 1, 5,
pseudoexon 3◀
▶Navigator IN Sequencing, ●0191U ▶Red cell antigen (Indian blood
Grifols Immunohematology group) genotyping (IN), gene
Center, Grifols analysis, CD44 (CD44 molecule
Immunohematology [Indian blood group]) exons 2,
Center◀ 3, 6◀
▶Navigator JK Sequencing, ●0192U ▶Red cell antigen (Kidd blood
Grifols Immunohematology group) genotyping (JK), gene
Center, Grifols analysis, SLC14A1 (solute
Immunohematology carrier family 14 member 1
Center◀ [Kidd blood group]) gene
promoter, exon 9◀
▶Navigator JR Sequencing, ●0193U ▶Red cell antigen (JR blood
Grifols Immunohematology group) genotyping (JR), gene
Center, Grifols analysis, ABCG2 (ATP binding
Immunohematology cassette subfamily G member 2
Center◀ [Junior blood group]) exons 2-
26◀
▶Navigator KEL Sequencing, ●0194U ▶Red cell antigen (Kell blood
Grifols Immunohematology group) genotyping (KEL), gene
Center, Grifols analysis, KEL (Kell
Immunohematology metalloendopeptidase [Kell
▶Navigator KLF1 ●0195U ▶KLF1 (Kruppel-like factor 1),
Sequencing, Grifols targeted sequencing (ie, exon
Immunohematology Center, 13)◀
Grifols Immunohematology
Center◀
▶Navigator LU Sequencing, ●0196U ▶Red cell antigen (Lutheran blood
Grifols Immunohematology group) genotyping (LU), gene
Center, Grifols analysis, BCAM (basal cell
Immunohematology adhesion molecule [Lutheran
▶Navigator LW Sequencing, ●0197U ▶Red cell antigen (Landsteiner-
Grifols Immunohematology Wiener blood group) genotyping
Center, Grifols (LW), gene analysis, ICAM4
Immunohematology (intercellular adhesion molecule
Center◀ 4 [Landsteiner-Wiener blood
group]) exon 1◀
▶Navigator RHD/CE ●0198U ▶Red cell antigen (RH blood
Sequencing, Grifols group) genotyping (RHD and
Immunohematology Center, RHCE), gene analysis
Grifols Immunohematology Sanger/chain
Center◀ termination/conventional
sequencing, RHD (Rh blood
group D antigen) exons 1-10
and RHCE (Rh blood group
CcEe antigens) exon 5◀
▶Navigator SC Sequencing, ●0199U ▶Red cell antigen (Scianna blood
Grifols Immunohematology group) genotyping (SC), gene
Center, Grifols analysis, ERMAP (erythroblast
Immunohematology membrane associated protein
Center◀ [Scianna blood group]) exons
4, 12◀
▶Navigator XK Sequencing, ●0200U ▶Red cell antigen (Kx blood
Grifols Immunohematology group) genotyping (XK), gene
Center, Grifols analysis, XK (X-linked Kx blood
Immunohematology group) exons 1-3◀
Center◀
▶Navigator YT Sequencing, ●0201U ▶Red cell antigen (Yt blood
Grifols Immunohematology group) genotyping (YT), gene
Center, Grifols analysis, ACHE
Immunohematology (acetylcholinesterase
Center◀ [Cartwright blood group]) exon
2◀
▶BioFire® Respiratory Panel ●0202U ▶Infectious disease (bacterial or
2.1 (RP2.1), BioFire® viral respiratory tract infection),
Diagnostics, BioFire® pathogen-specific nucleic acid
Diagnostics, LLC◀ (DNA or RNA), 22 targets
including severe acute
respiratory syndrome
coronavirus 2 (SARS-CoV-2),
qualitative RT-PCR,
nasopharyngeal swab, each
pathogen reported as detected or
not detected ◀
▶PredictSURE IBD™ Test, ●0203U ▶Autoimmune (inflammatory
KSL Diagnostics, bowel disease), mRNA, gene
PredictImmune Ltd ◀ expression profiling by
quantitative RT-PCR, 17 genes
(15 target and 2 reference
genes), whole blood, reported as
a continuous risk score and
classification of inflammatory
bowel disease aggressiveness◀
▶Afirma Xpression Atlas, ●0204U ▶Oncology (thyroid), mRNA,
Veracyte, Inc, Veracyte, gene expression analysis of 593
Inc◀ genes (including BRAF, RAS,
RET, PAX8, and NTRK) for
sequence variants and
rearrangements, utilizing fine
needle aspirate, reported as
detected or not detected ◀
▶Vita Risk ®, Arctic Medical ●0205U ▶Ophthalmology (age-related
Laboratories, Arctic Medical macular degeneration), analysis
Laboratories◀ of 3 gene variants (2 CFH gene,
1 ARMS2 gene), using PCR and
MALDI-TOF, buccal swab,
for neovascular age-related
macular-degeneration risk
associated with zinc
supplements◀
▶DISCERN™, ●0206U ▶Neurology (Alzheimer disease);
NeuroDiagnostics, cell aggregation using
NeuroDiagnostics◀ morphometric imaging and
protein kinase C-epsilon (PKCe)
concentration in response to
amylospheroid treatment by
ELISA, cultured skin fibroblasts,
each reported as positive or
negative for Alzheimer disease◀
✚●0207U ▶quantitative imaging of
phosphorylated ERK1 and
ERK2 in response to
bradykinin treatment by in
situ immunofluorescence,
using cultured skin
fibroblasts, reported as a
probability index for
Alzheimer disease (List
separately in addition to code
for primary procedure)◀
0206U)◀
▶Afirma Medullary Thyroid ●0208U ▶Oncology (medullary thyroid
Carcinoma (MTC) carcinoma), mRNA, gene
Classifier, Veracyte, Inc, expression analysis of 108
Veracyte, Inc◀ genes, utilizing fine needle
aspirate, algorithm reported as
positive or negative for
medullary thyroid carcinoma◀
▶CNGnome™, PerkinElmer ●0209U ▶Cytogenomic constitutional
Genomics, PerkinElmer (genome-wide) analysis,
Genomics◀ interrogation of genomic regions
for copy number, structural
changes and areas of
homozygosity for chromosomal
abnormalities◀
▶BioPlex 2200 RPR Assay – ●0210U ▶Syphilis test, non-treponemal
Quantitative, Bio-Rad antibody, immunoassay,
Laboratories, Bio-Rad quantitative (RPR)◀
Laboratories◀
▶MI Cancer Seek™ – NGS ●0211U ▶Oncology (pan-tumor), DNA
Analysis, Caris MPI d/b/a and RNA by next-generation
Caris Life Sciences, Caris sequencing, utilizing formalin-
MPI d/b/a Caris Life fixed paraffin-embedded tissue,
Sciences◀ interpretative report for single
nucleotide variants, copy
number alterations, tumor
mutational burden, and
microsatellite instability, with
therapy association ◀
▶Genomic Unity® Whole ●0212U ▶Rare diseases
Genome Analysis – (constitutional/heritable
Proband, Variantyx Inc, disorders), whole genome and
Variantyx Inc◀ mitochondrial DNA sequence
analysis, including small
sequence changes, deletions,
duplications, short tandem
repeat gene expansions, and
variants in non-uniquely
mappable regions, blood or
saliva, identification and
categorization of genetic
variants, proband ◀
▶(Do not report 0212U with
81425)◀
▶Genomic Unity® Whole ●0213U ▶Rare diseases
Genome Analysis – (constitutional/heritable
Comparator, Variantyx Inc, disorders), whole genome and
Variantyx Inc◀ mitochondrial DNA sequence
variants, each comparator
genome (eg, parent, sibling)◀
▶(Do not report 0213U in
conjunction with 81426)◀
▶Genomic Unity® Exome Plus ●0214U ▶Rare diseases
Analysis – Proband, (constitutional/heritable
Variantyx Inc, Variantyx disorders), whole exome and
Inc◀ mitochondrial DNA sequence
variants, proband ◀
▶Genomic Unity® Exome Plus ●0215U ▶Rare diseases
Analysis – Comparator, (constitutional/heritable
Variantyx Inc, Variantyx disorders), whole exome and
Inc◀ mitochondrial DNA sequence
variants, each comparator exome
(eg, parent, sibling)◀
▶Genomic Unity® Ataxia ●0216U ▶Neurology (inherited ataxias),
Repeat Expansion and genomic DNA sequence analysis
Sequence Analysis, of 12 common genes including
Variantyx Inc, Variantyx small sequence changes,
Inc◀ deletions, duplications, short
tandem repeat gene expansions,
and variants in non-uniquely
variants◀
▶Genomic Unity® ●0217U ▶Neurology (inherited ataxias),
Comprehensive Ataxia genomic DNA sequence analysis
Repeat Expansion and of 51 genes including small
Sequence Analysis, sequence changes, deletions,
Variantyx Inc, Variantyx duplications, short tandem
Inc◀ repeat gene expansions, and
variants◀
▶Genomic Unity® DMD ●0218U ▶Neurology (muscular
Analysis, Variantyx Inc, dystrophy), DMD gene sequence
Variantyx Inc◀ analysis, including small
duplications, and variants in
non-uniquely mappable regions,
blood or saliva, identification
and characterization of genetic
variants◀
▶Sentosa ® SQ HIV-1 ●0219U ▶Infectious agent (human
Genotyping Assay, Vela immunodeficiency virus),
Diagnostics USA, Inc, Vela targeted viral next-generation
Operations Singapore Pte sequence analysis (ie, protease
Ltd ◀ [PR], reverse transcriptase [RT],
integrase [INT]), algorithm
reported as prediction of
antiviral drug susceptibility◀
▶PreciseDx™ Breast Cancer ●0220U ▶Oncology (breast cancer), image
Test, PreciseDx, PreciseDx◀ analysis with artificial
intelligence assessment of 12
histologic and
immunohistochemical features,
reported as a recurrence score◀
▶Navigator ABO Blood ●0221U ▶Red cell antigen (ABO Blood
Group NGS, Grifols Group) genotyping (ABO), gene
Immunohematology Center, analysis, next-generation
Grifols Immunohematology sequencing, ABO (ABO, alpha
Center◀ 1-3-N-
acetylgalactosaminyltransferase
and alpha 1-3-
galactosyltransferase) gene◀
▶Navigator Rh Blood Group ●0222U ▶Red cell antigen (RH Blood
NGS, Grifols Group) genotyping (RHD and
Immunohematology Center, RHCE), gene analysis, next-
Grifols Immunohematology generation sequencing, RH
Center◀ proximal promoter, exons 1-10,
portions of introns 2-3◀

details ▲ = Revised code ● = New code ▶◀ = Contains new or revised
text = Duplicate PLA test ⇅ = Category I PLA
Appendix P
CPT Codes That May Be Used For

Synchronous Telemedicine Services
This listing is a summary of CPT codes that may be used for
reporting synchronous (real-time) telemedicine services when
appended by modifier 95. Procedures on this list involve
electronic communication using interactive telecommunications
equipment that includes, at a minimum, audio and video. The
codes listed below are identified in CPT 2021 with the ★ symbol.
90791
90792
90832
90833
90834
90836
90837
90838
90845
90846
90847
90863
90951
90952
90954
90955
90957
90958
90960
90961
92227
92228
93228
93229
93268
93270
93271
93272
96040
96116
97802
97803
97804
98960
98961
98962
99202
99203
99204
99205
99212
99213
99214
99215
99231
99232
99233
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99307
99308
99309
99310
99354
99355
99406
99407
99408
99409
99417
99495
99496

Index
Instructions for the Use of the CPT

Index
The alphabetic index is not a substitute for the main text of the
CPT codebook. Even if only one code is present, the user must
refer to the main text to ensure that the code selected accurately
identifies the service(s) performed.
Main Terms
The index is organized by main terms. Each main term can stand
alone or can be followed by up to three modifying terms. There
are four primary classes of main entries:
1. Procedure or service.
For example: Endoscopy; Anastomosis; Splint
2. Organ or other anatomical site.
For example: Tibia; Colon; Salivary Gland
3. Condition.
For example: Abscess; Entropion; Tetralogy of Fallot
4. Synonyms, Eponyms, and Abbreviations.
For example: EEG; Brock Operation; Clagett Procedure
The Anesthesia-section codes are indexed under the Anesthesia
main entry and are not double-entered under the anatomical sites.
Only codes within the Surgery, Medicine, Category II, and
Category III sections that specifically reference the service of
anesthesia are indexed under the anatomical sites.
Modifying Terms
A main term may be followed by up to three indented terms that
modify the terms they follow. For example, the main term
Endoscopy is subdivided by the anatomical sites in which the
procedure is used, and within these anatomical sites, the specific
purpose of the procedure is identified. In the following example,
the code for an endoscopic removal of a foreign body from the
bile duct could be located:
Bile Duct
Removal
Foreign Body 43275
Note that in this entry, the inclusion of a subentry under

“Removal” implies the reading “Removal [of]” the term that
follows it. If no subheads followed “Removal,” the procedure
would relate to the subhead that preceded it, as in this entry for
the endoscopic removal of the spleen:
Spleen
Removal 38120
When modifying terms appear, one should review the list, as

these subterms further qualify the selection of the appropriate
code for the procedure.
Code Ranges
Whenever more than one code applies to a given index entry, a
code range is listed. If several nonsequential codes apply, they
will be separated by a comma. In the following example, three
nonsequential codes apply:
Esophagus
Reconstruction 43300, 43310, 43313
If three or more sequential codes apply, they will be separated by

a hyphen. If more than one code range applies, the code ranges
will be separated by a comma as in the following example:
Anesthesia
Forearm 01810-01820, 01830-01860
Conventions
As a space-saving convention, certain terms carry meaning
inferred from the context. This convention is primarily used
when a procedure or service is listed as a subterm. For example:
Knee
Exploration [of] 27310, 27331
In this example, the bracketed qualifier “[of]” does not appear in

the index; “of” is understood in the context of the term
“Exploration.” As another example:
Pelvis
Halo [Application of] 20662
In this example, as there is no such entity as “pelvis halo,” the

bracketed words are inferred.

The Pathology and Laboratory listing in the index presents the
headings, subheadings, procedures, and analytes in the Pathology
and Laboratory section of the CPT codebook. Analytes are either
listed alphabetically (for example, the Chemistry analytes) or
cross-referenced to the index main heads where they are
alphabetically listed (for example, to reference infectious agent
analytes, the entry will indicate “See Infectious Agents”).
A
Abbe-Estlander Procedure
Lip Reconstruction 40527, 40761
Abdomen
See also Abdominal
Abdominal Wall
Debridement
Infected 11005, 11006
Fascial Reinforcement
with Implant 0437T
Implantation
Non-Biologic or Synthetic Implant 0437T
Removal
Mesh 11008
Prosthesis 11008
Repair
Hernia 49491-49496, 49501, 49507, 49521, 49590
Tumor
Excision 22900-22903
Radical Resection 22904, 22905
Abscess
Open 49020, 49040
Anesthesia
See Anesthesia, Abdomen
Angiography 74174, 74175, 74185, 75635
Aorta
See Aorta, Abdominal
Aortic Aneurysm
See Aorta, Abdominal, Aneurysm
Artery
Ligation 37617
Biopsy 49000
Bypass Graft
Excision 35907
Catheter
Removal 49422
Celiotomy
Exploratory 49000
CT Scan 74150, 74160, 74170, 74174-74178, 75635
Cyst
Destruction/Excision 49203-49205
Deliveries
See Cesarean Delivery
Drainage
Fluid 49082, 49083
Ectopic Pregnancy 59130
Endometrioma
Exploration 49000, 49010
Blood Vessel 35840
Staging 58960
Hysterectomy
See Hysterectomy, Abdominal
Incision 49000-49084
Staging 58960
Pancreatitis 48000
Infraumbilical Panniculectomy 15830
Injection
Air 49400
Contrast Material 49400
Insertion
Catheter 49324, 49418, 49419, 49421
Venous Shunt 49425
Intraperitoneal
Catheter Exit Site 49436
Catheter Insertion 49418-49421, 49435
Catheter Removal 49422
Catheter Revision 49325
Shunt
Insertion 49425
Ligation 49428
Removal 49429
Revision 49426
Laparoscopy 49320-49327, 49329
Laparotomy
Exploratory 49000
Reopening 49002
Staging 58960
Lymphangiogram
See Lymphangiography, Abdomen
Magnetic Resonance Imaging (MRI) 74181-74183
Needle Biopsy (Mass) 49180
Paracentesis 49082, 49083
Radiation Therapy
Placement of Guidance Devices 49411, 49412
Radical Resection 51597
Radiographies
See Abdomen, X ray
Repair
Blood Vessel 35221
with Other Graft 35281
with Vein Graft 35251
Hernia 49491-49525, 49560-49587, 49590
Suture 49900
Revision
Venous Shunt 49426
Suture 49900
Tumor
Ultrasound 76700-76705
Unlisted Services and Procedures 49999
Wall
See Abdomen, Abdominal Wall
Wound Exploration
Penetrating 20102
X ray 74018, 74019, 74021, 74022
Abdominal
See also Abdomen
Aorta
Aortic Aneurysm
See Aorta, Abdominal, Aneurysm
Deliveries
Hysterectomy
Lymphangiogram
See Lymphangiography, Abdomen
Paracentesis
See Abdomen, Drainage
Radiographies
See Abdomen, X ray
Wall
See Abdomen, Abdominal Wall
Abdominohysterectomy
Abdominopelvic Amputation
See Amputation, Interpelviabdominal
Abdominoplasty
Excision, Skin and Tissue 15830, 15847
Unlisted Procedure 17999
Ablation
Anus
Polyp 46615
Tumor 46615
Bone
Tumor
with Adjacent Soft Tissue 20982, 20983
Breast
Malignant Tumor 0581T
Colon
Lesion 44401, 45346, 45388
Polyp 44401, 45346, 45388
Tumor 44401, 45346, 45388
Cryosurgical
Breast Tumor 0581T
Fibroadenoma 19105
Liver Tumor 47381, 47383
Renal Mass 50250
Renal Tumor
Percutaneous 50593
CT Scan Guidance 77013
Electroporation 0600T-0601T
Endometrial 58353, 58356, 58563
with Ultrasound Guidance 58356
Heart
Arrhythmogenic Focus 33250, 33251, 33261, 93653, 93654, 93655
Atrioventricular 93650, 93653, 93654
High Intensity Focused Ultrasound (HIFU)
Prostate Tissue 55880
Larynx
Lesion 31572
Laser
Wound 0491T, 0492T
Liver (Tumor)
Cryosurgical 47381, 47383
Laparoscopic 47370, 47371
Radiofrequency 47380-47382
Lung
Tumor
Radiofrequency 32998
Nerve
Percutaneous 0440T-0442T
Ultrasound 0632T
Parenchymal Tissue
Magnetic Resonance Imaging Guidance 77022
Ultrasound Guidance 76940
Prostate
Cryosurgical 55873
High Intensity Focused Ultrasound (HIFU) 55880
Transurethral Water Vapor Thermotherapy 0582T
Waterjet 0421T
Pulmonary Tumor 32994, 32998
Radiofrequency
Liver Tumor 47382
Lung Tumor 32998
Renal Tumor 50592
Tongue Base 41530
Uterine Fibroid 0404T
Rectum
Lesion 45346
Polyp 45346
Tumor 45346
Renal Cyst 50541
Renal Mass 50542
Renal Tumor
Cryotherapy
Percutaneous 50593
Stereotactic
Intracranial Lesion
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) 0398T
Tongue Base
Turbinate Mucosa 30801, 30802
Uterine Fibroids
Laparoscopic 58674
Radiofrequency 0404T
Uterine Tumor
Ultrasound, Focused 0071T, 0072T
Vein
Endovenous
Chemical Adhesive 36482, 36483
Laser 36478, 36479
Mechanochemical 36473, 36474
Radiofrequency 36475, 36476
Abortion
Incomplete 59812
Induced
by Dilation and Curettage 59840
by Dilation and Evacuation 59841
with Hysterotomy 59100, 59852, 59857
by Saline 59850, 59851
by Vaginal Suppositories 59855, 59856
Missed
First Trimester 59820
Second Trimester 59821
Septic 59830
Spontaneous
Complete 59812
Incomplete 59812
Therapeutic
by Saline 59850
with Dilation and Curettage 59851
with Hysterotomy 59852
Abrasion (Skin)
Chemical Peel 15788, 15789, 15792, 15793
Dermabrasion 15780-15783
Lesion 15786, 15787
Abscess
Bone
Ankle
Incision 27607
Clavicle
Sequestrectomy 23170
Elbow
Incision 23930, 23935
Facial
Excision 21026
Femur
Incision 27303
Finger
Incision 26034
Foot
Incision 28005
Forearm
Incision 25035
Humeral Head
Incision 23174
Humerus
Excision 24134
Incision and Drainage 23935
Incision 26992
Knee
Incision 27303
Leg, Lower
Incision 27607
Olecranon Process 24138
Pelvis
Incision 26992
Radius
Incision, Deep 25035
Scapula
Shoulder
Incision 23035
Thorax
Incision 21510
Wrist
Incision 25035
Drainage
with X ray 75989
Localization
Nuclear Medicine 78830-78832
Tissue
Abdomen 49040
Ankle
Anus
Incision and Drainage 46045-46060
Appendix
Arm, Lower
Auditory Canal, External
Bartholin’s Gland
Bladder
Brain
Drainage via Burr Hole 61150, 61151
Drainage via Craniotomy 61320, 61321
Excision 61514
Breast
Ear, External
Incision and Drainage 69000, 69005
Elbow
Epididymis
Excision 61522
Eyelid
Finger
Forearm
Gums
Hand
Hip
Kidney
Knee
Leg, Lower
Liver
Drainage
Open 47010
Injection 47015
Marsupialization 47300
Lung
Percutaneous Drainage 32200
Lymph Node
Mandible
Excision 21025
Mouth 41015-41018
Dentoalveolar 41800
Lingual 41000
Masticator Space 41009, 41018
Sublingual 41005, 41006, 41015
Submandibular 41008, 41017
Submental 41007, 41016
Vestibular 40800, 40801
Nasal
Neck
Olecranon Process
Excision 24138
Ovary
Abdominal Approach 58822
Vaginal Approach 58820
Palate
Paraurethral Gland
Parotid Gland
Drainage 42300, 42305
Pelvis
Incision and Drainage 26990, 26992, 45000
Perineum
Perirenal or Renal
Peritoneum
Pharynx
Prostate
Transurethral Drainage 52700
Rectum
Incision and Drainage 45005, 45020, 46040, 46060
Renal
Retroperitoneal
Salivary Gland
Drainage 42300-42320
Scrotum
Shoulder
Skene’s Gland
Skin/Superficial
Puncture Aspiration 10160
Spine
Subdiaphragmatic
Drainage 49040
Sublingual Gland
Submaxillary Gland
Drainage 42310, 42320
Subphrenic
Drainage 49040
Testis
Thigh
Thorax
Throat
Tongue
Tonsil
Urethra
Uvula
Vagina
Vulva
Wrist
X ray 76080
Abscess, Nasal
See Nose, Abscess
Abscess, Parotid Gland
See Parotid Gland, Abscess
Absorptiometry, X ray (DXA)

Bone Density Study
Dual Photon 78351
Dual-Energy
Axial Skeleton 77080
Vertebral 77085, 77086
Single Photon 78350
Diagnostic Screening 3095F, 3096F
Dual
Dual-Energy
Appendicular 77081
Accessory, Toe
See Polydactyly, Toe
Accessory Nerve, Spinal

Anastomosis, Facial-Spinal 64866
Avulsion 64772
Chemodenervation, Muscles 64615
Laminectomy 63191
Transection 64772
ACE
See Angiotensin Converting Enzyme (ACE)
Acetabuloplasty 27120-27122, 29915

Acetabulum
Fracture
Closed Treatment 27220-27222
with Manipulation 27222
without Manipulation 27220
Open Treatment 27226-27228
Reconstruction 27120
with Resection, Femoral Head 27122
Tumor
Excision 27076
Acetic Anhydride
Analyte 84600
Acetylcholinesterase
Blood or Urine 82013
AcG (Accelerator Globulin)

Labile Factor 85220
Achilles Tendon
Incision 27605, 27606
Lengthening 27612
Repair 27650-27654
Achillotomy
See Tenotomy, Achilles Tendon
Acid
Gastric 82930
Acid, Adenylic
See Adenosine Monophosphate (AMP)
Acid, Aminolevulinic
See Aminolevulinic Acid (ALA)
Acid, Ascorbic
See Ascorbic Acid
Acid, Deoxyribonucleic (DNA)
See Deoxyribonucleic Acid (DNA)
Acid, Folic
See Folic Acid
Acid, Glycocholic
See Cholylglycine
Acid, Lactic
See Lactic Acid
Acid, N-Acetylneuraminic
See Sialic Acid
Acid, Phenylethylbarbituric
See Phenobarbital
Acid, Uric
See Uric Acid
Acid Diethylamide, Lysergic

See Lysergic Acid Diethylamide
Acid Perfusion Study
Esophagus 91013, 91030
Acid Phosphatase 84060, 84066

Acid Reflux Test
Esophagus 91034, 91035, 91037, 91038
Gastroesophageal 91034, 91035, 91037, 91038
Acid-Fast Bacilli (AFB)

Culture 87116
Acid-Fast Bacillus Culture 87116
Acid-Fast Stain
Analysis 88312
Acidity/Alkalinity
See Blood Gases, pH
Acids, Amino
See Amino Acids
Acids, Bile
See Bile Acids
Acids, Fatty
See Fatty Acid
Acne Surgery
Abscess 10060, 10061
Comedones 10040
Cyst 10040
Milia, Multiple 10040
Pustules 10040
Acne Treatment
Abrasion 15786, 15787
Chemical Peel 15788-15793
Cryotherapy 17340
Exfoliation
Chemical 17360
Acoustic Cardiography 93799
Acoustic Evoked Brain Stem Potential
See Evoked Potentials, Auditory Brainstem
Acoustic Recording
Heart Sounds
with Computer Analysis 93799
Acoustic Respiratory Measurements

for Wheeze Rate 94799
Acromioclavicular Joint
Arthrocentesis 20605, 20606
Arthrotomy 23044
with Biopsy 23101
Dislocation 23540-23552
X ray 73050
Acromion
Excision 23130
Acromionectomy
Partial 23130
Acromioplasty 23415-23420
Partial 23130
ACTH
See Adrenocorticotropic Hormone (ACTH)
ACTH Releasing Factor

See Corticotropic Releasing Hormone (CRH)
Actigraphy
Sleep Study 95803
Actinomyces
Antibody Detection 86602
Actinomycosis
Actinomycotic Infection
See Actinomycosis
Actinotherapy 96900
Activated Factor X
See Stuart-Prower Factor
Activated Partial Thromboplastin Time (aPTT)
See Thromboplastin, Partial Thromboplastin Time (PTT)
Activation, Lymphocyte
See Blastogenesis
Activities of Daily Living
In-Home Assistance 99509
Training 97535
Activity, Glomerular Procoagulant

See Thromboplastin
Acupuncture
with Electrical Stimulation 97813, 97814
without Electrical Stimulation 97810, 97811
Acute Poliomyelitis
See Polio
Acylcarnitines 82016, 82017
Adamantinoma, Pituitary
See Craniopharyngioma
Adaptive Behavior Treatment
Assessment
Administered by Physician/QHP 0362T, 97151
Supporting, Administered by Technician 0362T, 97152
Treatment
Group 97154, 97158
Individual 0373T, 97153, 97155
Treatment Guidance 97156, 97157
Adductor Tenotomy of Hip

See Tenotomy, Hip, Adductor
Adenoidectomy
See Adenoids, Excision
Adenoids
with Tonsils 42820, 42821
Adenoma
Pancreas
Excision 48120
Parathyroid
Localization
Injection Procedure 78808
Thyroid Gland Excision 60200
Adenosine 3’5’ Monophosphate
See Cyclic AMP
Adenosine Diphosphate
Blood 82030
Adenosine Monophosphate (AMP)
5-Monophosphate, Cyclic
Blood 82030
Adenovirus
Antigen Detection
Immunoassay 87301
Immunofluorescence 87260
Adenovirus Vaccine 90476, 90477
Adenylic Acid
ADH
See Antidiuretic Hormone
ADH (Antidiuretic Hormone)

Measurement
Vasopressin 84588
Adhesions
Construction 67880
Transposition of Tarsal Plate 67882
Epidural 62263, 62264
Eye
Corneovitreal 65880
Incision
Anterior Segment 65860, 65870
Posterior Segment 65875
Intestinal
Enterolysis 44005
Laparoscopic 44180
Intracranial
Dissection 62161
Intrauterine
Lysis 58559
Labial
Lysis 56441
Liver
Lysis 58660
Lungs
Pneumonolysis 32124, 32940
Nose
Lysis 30560
Pelvic
Lysis 58660, 58740
Penile
Lysis
Post-circumcision 54162
Preputial
Lysis 54450
Urethral
Lysis 53500
Adipectomy
See Lipectomy
ADL
See Activities of Daily Living
Administration
Immunization
Each Additional Vaccine/Toxoid 90472, 90474
with Counseling 90461
One Vaccine/Toxoid 90471, 90473
Occlusive Substance 31634
Pharmacologic Agent 93463
ADP
See Adenosine Diphosphate
ADP Phosphocreatine Phosphotransferase

See CPK
Adrenal Cortex Hormone
See Corticosteroids
Adrenal Gland
Biopsy 60540-60545
Excision 60540
Laparoscopy 60650
Retroperitoneal Tumor 60545
Nuclear Medicine
Imaging 78075
Adrenal Medulla
See Medulla
Adrenalectomy
Anesthesia 00866
Complete 60540, 60545, 60650
Laparoscopic 50545
Partial 60540, 60545, 60650
Adrenalin 80424, 82382-82384

Adrenaline-Noradrenaline 80424, 82382-82384
Adrenocorticotropic Hormone (ACTH)
Evaluation Panel 80418
Stimulation Panel 80400-80406, 80412
Adrenogenital Syndrome
See Intersex State
Adult T Cell Leukemia Lymphoma Virus I

See HTLV-I
Advanced Life Support
Physician/Health Care Professional Direction 99288
Advancement
Genioglossus 21199
Tendon
Tibia 28238
Advancement Flap
See Skin, Adjacent Tissue Transfer
Aerosol Inhalation
Pentamidine 94642
AFB
See Acid-Fast Bacilli (AFB)
Afferent Nerve
See Sensory Nerve
AFP
See Alpha-Fetoprotein (AFP)
After Hours Medical Services 99050
Agents, Anticoagulant
See Clotting Inhibitors
Agglutinin
Cold 86156, 86157
Febrile 86000
Aggregation
Platelet 85576
AHG
See Clotting Factor, Factor VIII
AICD (Automated Implantable Cardioverter-Defibrillator)

See Cardiac Assist Devices, Implantable Defibrillators
Aid, Hearing
See Hearing Aid
AIDS Antibodies
See Antibody, Detection, Human Immunodeficiency Virus (HIV)
AIDS Virus
See HIV-1; HIV-2
A-II
See Angiotensin II
Airway
Air Leak Assessment 31634, 31647, 31647-31649
Obstruction
Inhalation Treatment 94640
ALA
See Aminolevulinic Acid (ALA)
Alanine 2 Oxoglutarate Aminotransferase
See Transaminase, Glutamic-Pyruvic
Alanine Amino Transferase (ALT) 84460

Alanine Transaminase
Albumin
Ischemia Modified 82045
Other Source 82042
Serum, Plasma or Whole Blood 82040
Urine 82043, 82044
Alcohol
Breath 82075
Ethylene Glycol 82693
Alcohol Dehydrogenase
Gene Analysis 81205, 81400, 81401
Alcohol (Ethanol)
Any Specimen, Except Breath, Urine 82077
Breath 82075
Alcohol, Methyl
Definitive Drug Identification 80320
Aldolase
Blood 82085
Aldosterone
Blood 82088
Suppression Evaluation 80408
Urine 82088
Alimentary Canal
See Gastrointestinal Tract
Alkaline Phosphatase 84075, 84078, 84080
Leukocyte 85540
WBC 85540
Allergen Bronchial Provocation Tests

Inhalation Bronchial Challenge Testing 95070
Allergen Challenge, Endobronchial
Inhalation Bronchial Challenge Testing 95070
Allergen Immunotherapy
Allergen
IgE 86003, 86005, 86008
IgG 86001
Multiallergen Screen 86005
Allergenic Extracts
Injection 95115, 95117
Injection and Provision 95120-95134
Insect Venom 95130-95134
Antigens
Preparation and Provision 95144-95165
Insect, Whole Body Extract 95170
Rapid Desensitization 95180
Allergy Services/Procedures
See Office and/or Other Outpatient Services
Immunotherapy
See Allergen Immunotherapy
Allergy Tests
Challenge Test
Bronchial 95070
Ingestion 95076, 95079
Eye Allergy 95060
Food Allergy 95076, 95079
Intradermal
Allergen Extract 95024-95028
Biologicals 95018
Drugs 95018
Incremental 95027
Venoms 95017
Nasal Mucous Membrane Test 95065
Nose Allergy 95065
Patch
Application Tests 95044
Photo Patch 95052
Photosensitivity 95056
Skin Tests
Allergen Extract 95004, 95024, 95027
Biologicals 95018
Drugs 95018
Venoms 95017
Allogeneic Donor
Lymphocyte Infusion 38242
Allogeneic Transplantation
See also Homograft
Hematopoietic Progenitor Cells (HPCs) 38240
Allogenic Transplantation
Cellular Product
Intervertebral Disc 0627T-0630T
Allograft
Aortic Valve 33406, 33413
Bone
Elbow Joint 24370, 24371
Hemicortical/Hemicylindrical 20933
Intercalary 20933, 20934
Osteoarticular 20932
Shoulder Joint 23473, 23474
Spine Surgery
Morselized 20930
Structural 20931
Cartilage
Knee 27415
Cornea
Amniotic Membrane 65780
Endothelial 65756
Lamellar 65710
Penetrating 65730, 65750, 65755
for Aphakia 65750
Lung Transplant 32850
Nerve 64910, 64912, 64913
Skin Substitute
Arms 15271-15274
Digits 15275-15278
Eyelids 15275-15278
Face 15275-15278
Feet 15275-15278
Genitalia 15275-15278
Hands 15275-15278
Legs 15271-15274
Mouth 15275-15278
Orbits 15275-15278
Scalp 15275-15278
Trunk 15271-15274
Allograft Preparation
Cornea 65757
Heart 33933, 33944
Intestines 44715-44721
Kidney 50323-50329
Liver 47143-47147
Lung 32855, 32856, 33933
Pancreas 48551, 48552
Renal 50323-50329
Allotransplantation
Intestines 44135, 44136
Removal 44137
Renal 50360-50365
Removal 50370
Almen Test
See Blood, Feces
Alpha-1 Antitrypsin 82103, 82104

Alpha-2 Antiplasmin 85410
Alpha-Fetoprotein (AFP)
Amniotic Fluid 82106
Serum 82105, 82107
Alpha-tocopherol 84446
ALT
Altemeier Procedure
See Rectum, Prolapse, Excision
Aluminum
Blood 82108
Alveola
Fracture
Closed Treatment 21421
Open Treatment 21422, 21423
Alveolar Cleft
Ungrafted Bilateral 21147
Ungrafted Unilateral 21146
Alveolar Nerve
Avulsion 64738
Incision 64738
Transection 64738
Alveolar Ridge
Fracture
Open Treatment 21445
Alveolectomy 41830
Alveoloplasty 41874
Alveolus
Excision 41830
Amide, Procaine
See Procainamide
Amikacin
Assay 80150
Amine
Vaginal Fluid 82120
Amino Acids 82127-82139
Aminolevulinic Acid (ALA)
Aminotransferase
See Transaminase
Aminotransferase, Alanine
Aminotransferase, Aspartate
See Transaminase, Glutamic-Oxaloacetic
Ammonia
Blood 82140
Amniocenteses
See Amniocentesis
Amniocentesis
Diagnostic 59000
Induced Abortion 59850
with Dilation and Curettage 59851
with Dilation and Evacuation 59851
with Hysterotomy 59852
Therapeutic
Amniotic Fluid Reduction 59001
Amnioinfusion
Transabdominal 59070
Amnion
Amniocentesis 59000
with Amniotic Fluid Reduction 59001
Amnioinfusion
Membrane Placement
Eye 65778, 65779
Amniotic Fluid
Alpha-Fetoprotein 82106
Scan 82143
Testing 83661, 83663, 83664
Amniotic Membrane
See Amnion
AMP
AMP, Cyclic
See Cyclic AMP
Amputation
See also Radical Resection; Replantation
Ankle 27888
Arm, Lower 25900-25905, 25915
Revision 25907, 25909
Arm, Upper 24900-24920
Cineplasty 24940
with Implant 24931-24935
Revision 24925-24930
and Shoulder 23900-23921
Cervix
Total 57530
Ear
Partial 69110
Total 69120
Finger 26910-26952
Foot 28800-28805
Hand at Metacarpal 25927
Revision 25924, 25929, 25931
at Wrist 25920
Revision 25922
Hip Disarticulation 27295
Interpelviabdominal 27290
Interthoracoscapular 23900
Leg, Lower 27598, 27880-27882
Revision 27884, 27886
Leg, Upper 27590-27592
at Hip 27290, 27295
Revision 27594, 27596
Metacarpal 26910
Metatarsal 28810
Penis
Partial 54120
Radical 54130, 54135
Total 54125
Thumb 26910, 26951, 26952
Toe 28810, 28820, 28825
Upper Extremity 24900-24940
Cineplasty 24940
Revision 24925, 24930, 24935
Amputation, Nose
See Resection, Nose
Amputation through Hand
See Hand, Amputation
Amylase
Blood 82150
Urine 82150
ANA
See Antinuclear Antibodies (ANA)
Anabolic Steroid
See Androstenedione
Anal Abscess
See Abscess, Tissue, Anus
Anal Bleeding
See Anus, Hemorrhage
Anal Fistula
Closure 46288
Fissurectomy 46200, 46257, 46258, 46261, 46262
Fistulectomy 46060, 46258, 46262, 46270
Fistulotomy 46060, 46270
Repair 46706
Anal Fistulectomy 46060, 46258, 46262, 46270

Anal Fistulotomy 46060, 46270
Anal Sphincter
Dilation 45905
Incision 46080
Anal Ulceration
See Anus, Fissure
Analgesia
See Anesthesia; Sedation
Analgesic Cutaneous Electrostimulation
Needle Electrode 64566
TENS 97014
Analysis, Spectrum
See Spectrometry
Anaspadias
See Epispadias
Anastomosis
Aortic 33866
with Bypass Graft 35686
Direct 36821
with Graft 36825, 36830, 36832
Artery
Extracranial-Intracranial 61711
Iliac Arteriovenous Implant Placement 0553T
Pulmonary Artery to Aorta 33606
Atria to Pulmonary Artery 33615
Bile Duct
to Bile Duct 47800
to Intestines 47760, 47780
Bile Duct to Gastrointestinal Tract 47780, 47785
Broncho-Bronchial 32486
Caval to Mesenteric 37160
Cavopulmonary 33622, 33768
Colorectal 44626
Damus-Kaye-Stansel Procedure 33606
Epididymis
to Vas Deferens
Bilateral 54901
Unilateral 54900
Excision
Trachea 31780, 31781
Fallopian Tube 58750
Gallbladder to Intestines 47720-47740
Hepatic Duct to Intestines 47765, 47802
Ileum to Anus 45113
Intestine to Intestine 44130
Intestines
Colon to Anus 45119
Cystectomy 51590
Enterocystoplasty 51960
Ileoanal 44157, 44158
Resection
Laparoscopic 44202-44205
Intrahepatic Portosystemic 37182, 37183
Jejunum 43820-43825
Microvascular
Free Transfer
Jejunum 43496
Nerve
Facial to Hypoglossal 64868
Oviduct 58750
Pancreas to Intestines 48520, 48540, 48548
Portocaval 37140
Pulmonary 33606
Renoportal 37145
Splenorenal 35636, 37180, 37181
Stomach
to Duodenum 43810, 43855
Revision 43850
to Jejunum 43820-43825, 43860-43865
Tubotubal 58750
Ureter
to Bladder 50780-50785
to Colon 50810-50815
Removal 50830
to Intestine 50800, 50820, 50825
Removal 50830
to Kidney 50727-50750
to Ureter 50725-50727, 50760, 50770
Vein
Saphenopopliteal 34530
Vein to Vein 37140-37160, 37182, 37183
Vena Cava to Pulmonary Artery 33615
Anastomosis, Aorta-Pulmonary Artery

See Aorta, Anastomosis, to Pulmonary Artery
Anastomosis, Bladder, to Intestine
See Enterocystoplasty
Anastomosis, Hepatic Duct

See Hepatic Duct, Anastomosis
Anastomosis of Lacrimal Sac to Conjunctival Sac
See Conjunctivorhinostomy
Anastomosis of Pancreas
See Pancreas, Anastomosis
Anderson Tibial Lengthening 27715
Androstanediol Glucuronide 82154
Androstenedione
Androstenolone
See Dehydroepiandrosterone
Androsterone
Anesthesia
Abbe-Estlander Procedure 00102
Abdomen
Abdominal Wall 00700, 00730, 00800-00802, 00820, 00836
Blood Vessels 00770, 00880-00882
Endoscopy 00731, 00732, 00811-00813
Extraperitoneal 00860-00870
Hernia Repair 00750-00756, 00830-00836
Intraperitoneal 00790-00797, 00840-00851
Abdominoperineal Resection 00844
Abortion
Incomplete 01965
Induced 01966
Achilles Tendon Repair 01472
Acromioclavicular Joint 01620
Adrenalectomy 00866
Amniocentesis 00842
Aneurysm
Axillary-Brachial 01652
Knee 01444
Popliteal Artery 01444
Angiography 01920
Ankle 00400, 01462-01522
Anorectal Procedure 00902
Anus 00902
Arm
Lower 00400, 01810-01820, 01830-01860
Upper 00400, 01710-01782
Arrhythmias 00410
Arteriography 01916
Arteriovenous Fistula 01432
Arthroplasty
Hip 01214, 01215
Knee 01402
Arthroscopic Procedures
Ankle 01464
Elbow 01732-01740
Foot 01464
Hip 01202
Knee 01382, 01400
Shoulder 01622-01638
Wrist 01829, 01830
Axilla 00400, 01610, 01650, 01652, 01654, 01656, 01670
Back Skin 00300
Batch-Spittler-McFaddin Operation 01404
Biopsy
Ear 00120
Liver 00702
Salivary Glands 00100
Bladder 00870, 00912
Brain 00210-00218, 00220-00222
Breast 00402-00406
Bronchi 00542
Intrathoracic Repair of Trauma 00548
Bronchoscopy 00520
Burns
Debridement and/or Excision 01951-01953
Burr Hole 00214
Bypass Graft
Leg, Lower 01500
Leg, Upper 01270
Shoulder, Axillary 01654, 01656
Cardiac Catheterization 01920
Cast
Knee 01420
Cast Application
Forearm, Wrist, and Hand 01860
Leg 01490
Pelvis 01130
Shoulder 01680
Central Venous Circulation 00532
Cervical Cerclage 00948
Cervix 00948
Cesarean Delivery 01961, 01963
Chest 00410, 00470-00474, 00522, 00530-00539, 00542-00548, 00550
Chest Skin 00400
Childbirth
Cesarean Delivery 01961, 01963, 01968, 01969
External Cephalic Version 01958
Vaginal Delivery 01960, 01967
Clavicle 00450, 00454
Cleft Lip Repair 00102
Cleft Palate Repair 00172
Colonoscopy, Screening 00812
Colpectomy 00942
Colporrhaphy 00942
Colpotomy 00942
Corneal Transplant 00144
Craniectomy 00211
Cranioplasty 00215
Craniotomy 00211
Culdoscopy 00950
Cystectomy 00864
Cystolithotomy 00870
Decortication 00542
Defibrillator 00534, 00560
Diaphragm 00540, 00541
Disarticulation
Hip 01212
Knee 01404
Shoulder 01634
Drug Administration
Epidural or Subarachnoid 01996
Ear 00120-00126
Elbow 00400, 01710-01782
Electrocoagulation
Intracranial Nerve 00222
Electroconvulsive Therapy 00104
Embolectomy
Arm, Upper 01772
Femoral 01274
Femoral Artery 01274
Leg, Lower 01502
Endoscopy
Arm, Lower 01830
Gastrointestinal 00731, 00732, 00813
Uterus 00952
Vagina 00950
Eye 00140-00148
Cornea 00144
Iridectomy 00147
Iris 00147
Lens 00142
Eyelid 00103
Facial Bones 00190, 00192
Fallopian Tube
Ligation 00851
Femoral Artery
Embolectomy 01274
Ligation 01272
Femur 01220-01234, 01340, 01360
Fibula 01390-01392
Foot 01462-01522
Forearm 01810-01820, 01830-01860
Fowler-Stephens Orchiopexy 00930
Gastrocnemius Recession 01474
Gastrointestinal Endoscopy 00731, 00732, 00813
Genitalia
Female 00940-00952
Male 00920-00938
Great Vessels of Chest 00560-00563
Hand 00400, 01810-01820, 01830-01860
Harrington Rod Technique 00670
Head 00210-00222, 00300
Muscles 00300
Nerves 00300
Heart 00560-00567, 00580
Coronary Artery Bypass Grafting 00566, 00567
Electrophysiology/Ablation 00537
Transplant 00580
Hepatectomy
Partial 00792
Hernia Repair
Abdomen
Lower 00830-00836
Upper 00750-00752, 00756
Hip 01200-01215
Humerus 01620, 01730, 01742-01744, 01758
Hysterectomy 01962
Cesarean 01963, 01969
Radical 00846
Vaginal 00944
Hysterosalpingography 00952
Hysteroscopy 00952
Inferior Vena Cava Ligation 00882
Nerve 01991, 01992
Anterior Trunk 00400
Arm, Upper 00400
Axilla 00400
Elbow 00400
Extremity 00400
Forearm 00400
Hand 00400
Head 00300
Knee 00400
Leg, Lower 00400
Leg, Upper 00400
Neck 00300
Perineum 00400
Popliteal Area 00400
Posterior Pelvis 00300
Posterior Trunk 00300
Shoulder 00400
Wrist 00400
Intestines
Endoscopy 00811-00813
Intracranial Procedures 00210-00218, 00220-00222
Intraoral Procedures 00170-00176
Intrathoracic Procedures
Bronchi 00539, 00548
Trachea 00539, 00548
Intrathoracic System 00500, 00520-00529, 00530-00539, 00540-00548, 00550, 00560-00567, 00580
Iridectomy 00147
Keen Operation 00604
Kidney 00862, 00868, 00872, 00873
Knee 00400, 01320, 01340, 01360, 01380-01404, 01420, 01430-01432, 01440-01444
Knee Skin 00400
Laminectomy 00604
Laparoscopy 00790-00792, 00840
Larynx 00320, 00326
Leg
Lower 01462-01522
Upper 01200-01274
Life Support for Organ Donor 01990
Ligation
Lithotripsy 00872, 00873
Liver 00702, 00796
Transplant 00796
Liver Hemorrhage 00792
Lumbar Puncture 00635
Lungs 00522, 00539, 00540-00548
Transplant 00580
Lymphadenectomy 00934, 00936
Lymphatic System 00320
Mammoplasty 00402
Manipulation of Temporomandibular Joint(s) (TMJ)
Therapeutic 21073
Mediastinoscopy 00528, 00529
Mediastinum 00528, 00529, 00540, 00541
Mouth 00170, 00172
Neck 00300, 00320-00322, 00350-00352
Nephrectomy 00862
Neuraxial
Cesarean Delivery 01968, 01969
Labor 01967-01969
Vaginal Delivery 01967
Nose 00160-00164
Removal
Foreign Body 30310
Omphalocele 00754
Ophthalmoscopy 00148
Orchiectomy 00926, 00928
Orchiopexy 00930
Torek Procedure 00930
Organ Harvesting
Brain-Dead Patient 01990
Osteoplasty
Tibia/Fibula 01484
Osteotomy
Humerus 01742
Tibia/Fibula 01484
Other Procedures 01990, 01996-01999
Otoscopy 00124
Pacemaker Insertion 00530
Pacing Cardioverter-Defibrillator Insertion/Replacement 00534
Pancreas 00794
Pancreatectomy 00794
Panniculectomy 00802
Patella 01390-01392
Pectus Excavatum 00474
Pelvic Exenteration 00848
Pelvis 00400, 00865, 01112
Amputation 01140
Bone 01120
Bone Marrow 01112
Examination 57400
Extraperitoneal 00864
Intraperitoneal 00844-00848
Repair 01173
Skin 00300, 00400
Penis 00932-00938
Pericardial Sac 00560-00563
Perineum 00904-00908
Pharynx 00174, 00176
Phleborrhaphy
Arm, Upper 01782
Pleura 00540, 00541
Needle Biopsy 00522
Pneumocentesis 00524
Popliteal Area 00400, 01320, 01430-01444
Prognathism 00192
Prostate 00865, 00908, 00914
Prostatectomy
Perineal 00908
Radical 00865
Radiological Procedures 01916-01936
Arterial
Therapeutic 01924-01926
Percutaneous Image Guided 01935, 01936
Venous/Lymphatic
Renal Procedures 00862
Repair of Skull 00215
Replacement
Ankle 01486
Elbow 01760
Hip 01212, 01214, 01215
Knee 01402
Shoulder 01638
Wrist 01832
Restriction
Gastric
for Obesity 00797
Retropharyngeal Tumor Excision 00174
Rib Resection 00470, 00472, 00474
Sacroiliac Joint 01160, 01170
Scapula 00450
Sedation
Moderate 99151-99153, 99155-99157
with Independent Observation 99151-99153
Seminal Vesicles 00922
Shoulder
Arteries 01650, 01652, 01654, 01656
Arthroscopic Procedures 01622, 01630, 01634, 01636, 01638
Bursae 01610
Fascia 01610
Integumentary System 00400
Joint 01620
Muscles 01610
Nerves 01610
Tendons 01610
Veins 01670
Shunt
Spinal Fluid 00220
Sinuses
Accessory 00160-00164
Skull 00190
Skull Fracture
Elevation 00215
Special Circumstances
Emergency 99140
Extreme Age 99100
Hypotension 99135
Hypothermia 99116
Spinal Instrumentation 00670
Spinal Manipulation 00640
Spine and Spinal Cord 00600-00604, 00620, 00670
Cervical 00600-00604, 00640, 00670
Injection 62320-62327
Lumbar 00630-00635, 00640, 00670
Percutaneous Image Guided 01935, 01936
Thoracic 00620-00626, 00640, 00670
Vascular 00670
Sternoclavicular Joint 01620
Sternum 00550
Stomach
Restriction
for Obesity 00797
Strayer Procedure 01474
Subdural Taps 00212
Sympathectomy
Lumbar 00632
Symphysis Pubis 01160, 01170
Tenodesis 01716
Tenoplasty 01714
Tenotomy 01712
Testis 00924-00928, 00930
Thoracoplasty 00472
Thoracoscopy 00528, 00529, 00540, 00541
Thoracotomy 00540, 00541
Thorax 00400-00410, 00450, 00454, 00470-00474
Thromboendarterectomy 01442
Thyroid 00320-00322
Tibia 01390-01392, 01484
Trachea 00320, 00326, 00542
Transplantation
Cornea 00144
Heart 00580
Kidney 00868
Liver 00796, 01990
Lungs 00580
Organ Harvesting 01990
Transurethral Procedures 00910-00918
Tubal Ligation 00851
TURP 00914
Tympanostomy 00120
Urethra 00910, 00918-00920, 00942
Urethrocystoscopy 00910
Urinary Bladder 00864, 00870, 00912
Urinary Tract 00860
Uterus 00952
Vagina 00940-00942, 00950
Vas Deferens
Excision 00921
Vascular Access 00532
Vascular Shunt 01844
Vascular Surgery
Abdomen, Lower 00880-00882
Abdomen, Upper 00770
Arm, Lower 01840-01852
Arm, Upper 01770-01782
Brain 00216
Elbow 01770-01782
Hand 01840-01852
Knee 01430-01444
Leg, Lower 01500-01522
Leg, Upper 01260, 01270-01274
Neck 00350-00352
Wrist 01840-01852
Vasectomy 00921
Venography 01916
Ventriculography 00214, 01920
Vertebroplasty 01936
Vitrectomy 00145
Vitreoretinal Surgery 00145
Vitreous Body 00145
Vulva 00906
Vulvectomy 00906
Wrist 00400, 01810-01860
Anesthesia, Local
See Injection, Anesthetic Agent
Aneurysm Repair
Abdominal Aorta 34830-34832, 34845-34848, 35081-35103
Axillary Artery 35011, 35013
Basilar Artery 61698, 61702
Brachial Artery 35011, 35013
Carotid Artery 35001, 35002, 61613, 61697, 61700, 61703
Celiac Artery 35121, 35122
Femoral Artery 35141, 35142
Hepatic Artery 35121, 35122
Iliac Artery 34703-34708, 34717, 34718, 35131, 35132
Infrarenal Aorta 34701-34706, 34709-34711
Innominate Artery 35021, 35022
Intracranial Artery 61705-61708
Mesenteric Artery 35121, 35122
Popliteal Artery 35151, 35152
Radial Artery 35045
Renal Artery 35121, 35122
Splenic Artery 35111, 35112
Subclavian Artery 35001, 35002, 35021, 35022
Thoracoabdominal Aorta 33877
Ulnar Artery 35045
Vertebral Artery 61698, 61702
Angina Assessment
Performance Measures 1002F
Coronary Artery Disease 0557F, 1010F-1012F
Angiocardiographies
See Angiography
Angiography
See also Aortography
Abdomen 74174, 74175, 74185, 75635, 75726
Adrenal 75731, 75733
Arm Artery 73206, 75710, 75716
Brain 70496
Bypass Graft 93455, 93457, 93459, 93461
Carotid Artery 36221-36228
Cervicocerebral Arch 36221-36226
Chest 71275, 71555
Common Carotid
Selective Catheterization 36222, 36223
Endovascular Repair 75956, 75957
Extracranial Carotid
Non-selective 36221
Selective 36222, 36223, 36224
Extremity, Lower 73725
Extremity, Upper 73225
Fluorescein 92235, 92242
Head 70496, 70544-70546
Heart
Abdominal Aorta 75635
Aorta
Injection 93567
Atrial 93565, 93566
Congenital Heart 93563, 93564
Coronary Artery 93454-93461, 93563
Flow Velocity Measurement 93571, 93572
Left Heart
Injection 93565
Right Heart
Injection 93566
Indocyanine-green 92240, 92242
Injection 93454-93461, 93563, 93565, 93566
Innominate Artery 36222, 36223, 36225
Intracranial 36221, 36223, 36224
with Endovascular Infusion 61640, 61650, 61651
with Thrombectomy 61645
Leg Artery 73706, 75635, 75710-75716
Lung
Injection 93568
Magnetic Resonance (MRA)
See Magnetic Resonance Angiography (MRA)
Mammary Artery 75756
Neck 70498, 70547-70549
Non-Cardiac Vascular Flow 78445
Other Artery 75774
Pelvis 72191, 72198, 74174, 75736
Pulmonary 75741-75746, 93568
Renal Artery 36251-36254
Selective Catheterization
See Selective Catheterization
Spinal Artery 75705
Spinal Canal 72159
Subclavian Artery 36225
Thorax 71275
Transcatheter Therapy
Embolization 75894, 75898
Infusion 75898
Ventricular 93565, 93566
Vertebral Artery 36221, 36225, 36226, 36228
Angioma
See Lesion, Skin
Angioplasty
Aorta
Intraoperative 37246, 37247
Percutaneous 37246, 37247
Axillary Artery
Brachiocephalic Artery
Coronary Artery
with Atherectomy 92937, 92938, 92941, 92943, 92944
Percutaneous Transluminal 92920, 92921
with Stent Placement 92928, 92929, 92937, 92938, 92941, 92943, 92944
with Endovascular Repair 34841-34848
Femoral Artery
Intraoperative 37224
Iliac Artery
Intracranial
Percutaneous 61630
with Intravascular Stent Placement 37215-37218, 37236-37239
Patch
Blood Vessel 35201-35286
Vein 35879
Percutaneous Transluminal
See Percutaneous Transluminal Angioplasty
Perineal Artery 37228
Popliteal Artery
Pulmonary Artery
Percutaneous Transluminal 92997, 92998
Renal Artery
Open 37246-37249
Percutaneous 37246-37249
for Revascularization
Intracoronary 92937, 92938, 92941, 92943, 92944
Subclavian Artery
Tibial/Peroneal Artery
Balloon
Open 37246-37249
Dialysis Circuit 36902, 36907
Venous 37248, 37249
Venous
Open 37248, 37249
Visceral Artery
Open 37246, 37247
Angioplasty, Coronary Balloon

See Balloon Angioplasty, Coronary
Angioscopy
Noncoronary Vessels 35400
Angiotensin Converting Enzyme (ACE)

Angiotensin I
Quantitative 82164
Angiotensin II
Quantitative 82163
Receptor, Gene Analysis 81400
Therapy
Performance Measures 4188F, 4210F
Angiotensin Converting Enzyme Inhibitor 4010F, 4480F, 4481F
Angiotensin Receptor Blocker (ARB) 4010F, 4188F, 4210F, 4480F, 4481F
Angiotensin Forming Enzyme

See Renin
Angiotensin I 84244
Riboflavin 84252
Angiotensin II
Angle Deformity
Toe
Anhydride, Carbonic
See Carbon Dioxide
Anhydrides, Acetic
See Acetic Anhydride
Animal Inoculation 87003, 87250

Ankle
See also Fibula; Leg, Lower; Tibia; Tibiofibular Joint
Abscess
Amputation 27888
Arthrodesis 27870
Arthrography 73615
Arthroplasty 27700, 27702, 27703
Arthroscopy
Surgical 29891, 29894-29899
Arthrotomy 27610-27612, 27620-27626
Biopsy 27613, 27614, 27620
Bursa
Disarticulation 27889
Dislocation
Closed Treatment 27840, 27842
Fracture
Bimalleolar 27808-27814
Lateral 27786-27814
Medial 27760-27766, 27808-27814
Posterior 27767-27769, 27808-27814
Trimalleolar 27816-27823
Fusion 27870
Hematoma
Incision 27607
Injection
Radiological 27648
Lesion
Excision 27630
Manipulation 27860
Removal
Foreign Body 27610, 27620
Implant 27704
Loose Body 27620
Repair
Achilles Tendon 27650-27654
Ligament 27695-27698
Tendon 27612, 27680-27687
Strapping 29540
Synovium
Excision 27625, 27626
Tenotomy 27605, 27606
Tumor
Excision 27618, 27619, 27630, 27632, 27634
X ray 73600-73610
with Contrast 73615
Ankylosis (Surgical)
See Arthrodesis
Annuloplasty
Intradiscal
Anogenital Region
See Perineum
Anoplasty
Stricture 46700, 46705
Anorectal Biofeedback 90912, 90913
Anorectal Exam (Surgical) 45990
Anorectal Fistula
Repair 46706, 46707
Anorectal Myectomy
See Myomectomy, Anorectal
Anorectovaginoplasty 46744-46746
Anoscopy
Ablation
Polyp 46615
Tumor 46615
Biopsy 46606
Collection of Specimen 46600, 46601
Dilation 46604
Exploration 46600
Hemorrhage 46614
High Resolution Anoscopy (HRA)
with Biopsy(ies) 46607
Diagnostic 46601
Removal
Foreign Body 46608
Polyp 46610-46612
Tumor 46610-46612
Antebrachium
See Forearm
Antecedent, Plasma Thromboplastin

See Plasma Thromboplastin, Antecedent
Antepartum Care
Cesarean Delivery 59510
Previous 59610, 59618
Vaginal Delivery 59400, 59425, 59426
Anterior Chamber Fluid, Eye

See Paracentesis, Eye
Anterior Ramus of Thoracic Nerve
See Intercostal Nerve
Anthrax Vaccine
See Vaccines and Toxoids
Anthrogon
See Follicle Stimulating Hormone (FSH)
Antiactivator, Plasmin
See Alpha-2 Antiplasmin
Anti-Australia Antigens
See Hepatitis B Surface Antigen (HBsAg)
Antibiotic Administration
Prescribed or Dispensed 4120F, 4124F
Antibiotic Sensitivity
Susceptibility Studies 87181-87184, 87188
Enzyme Detection 87185
Minimum Inhibitory Concentration (MIC) 87186
Minimum Lethal Concentration (MLC) 87187
Antibodies, Thyroid-Stimulating
See Immunoglobulin, Thyroid Stimulating
Antibodies, Viral
See Viral Antibodies
Antibody
See also Antibody Identification; Microsomal Antibody
Detection
Actinomyces 86602
Adenovirus 86603
Antinuclear 86038, 86039
Anti-phosphatidylserine (Phospholipid) 86148
Antistreptolysin O 86060, 86063
Aspergillus 86606
Bacterium 86609
Bartonella 86611
Beta-2 Glycoprotein I 86146
Blastomyces 86612
Blood Crossmatch 86920-86923
Bordetella 86615
Borrelia 86617-86619
Brucella 86622
Campylobacter 86625
Candida 86628
Cardiolipin 86147
Chlamydia 86631, 86632
Coccidioides 86635
Coxiella Burnetii 86638
C-Reactive Protein (CRP) 86140, 86141
Cryptococcus 86641
Cyclic Citrullinated Peptide (CCP) 86200
Cytomegalovirus (CMV) 86644, 86645
Cytotoxic Screen 86807, 86808
Deoxyribonuclease 86215
Deoxyribonucleic Acid (DNA) 86225, 86226
Diphtheria 86648
Ehrlichia 86666
Encephalitis 86651-86654
Enterovirus 86658
Epstein-Barr Virus 86663-86665
Fluorescent 86255, 86256
Francisella Tularensis 86668
Fungus, Other 86671
Giardia Lamblia 86674
Growth Hormone 86277
Haemophilus Influenzae 86684
Helicobacter Pylori 86677
Helminth 86682
Hepatitis
Delta Agent 86692
Hepatitis A (HAAb) 86708, 86709
Hepatitis B
Core (HBcAb) 86704
IgM 86705
Surface (HBsAb) 86706
Hepatitis Be (HBeAb) 86707
Hepatitis C Virus (HCV) 86803, 86804
Herpes Simplex 86694-86696
Heterophile 86308-86310
Histoplasma 86698
HTLV-I 86687, 86689
HTLV-II 86688
Human Immunodeficiency Virus (HIV)
HIV 86689, 86701-86703
HIV-1 86701, 86703, 87389
HIV-2 86702, 86703, 87389
Human Leukocyte Antigens (HLA) 86828-86835
Infectious Agent, Other 86317
Influenza Virus 86710
Insulin 86337
Intrinsic Factor 86340
Islet Cell 86341
JC (John Cunningham) Virus 86711
Legionella 86713
Leishmania 86717
Leptospira 86720
Listeria Monocytogenes 86723
Lyme Disease 86617
Lymphocytic Choriomeningitis 86727
Malaria 86750
Microsomal 86376
Mucormycosis 86732
Mumps 86735
Mycoplasma 86738
Neisseria Meningitidis 86741
Nocardia 86744
Nuclear Antigen 86235
Parvovirus 86747
Phospholipid 85597, 86147
Neutralization 85597, 85598
Plasmodium 86750
Platelet 85597, 86022, 86023
Protozoa 86753
Red Blood Cell 86850, 86860, 86870
Respiratory Syncytial Virus 86756
Rickettsia 86757
Rotavirus 86759
Rubella 86762
Rubeola 86765
Salmonella 86768
Shigella 86771
Sperm 89325
Streptokinase 86590
Tetanus 86774
Thyroglobulin 86800
Toxoplasma 86777, 86778
Treponema Pallidum 86780
Trichinella 86784
Tuberculosis 86580
Varicella-Zoster 86787
Virus, Other 86790
West Nile Virus 86788, 86789
White Blood Cell 86021
Yersinia 86793
Zika Virus, IgM 86794
Antibody Identification
Fluorescent 86255, 86256
Immunoassay 83516, 83518-83520
Immunocytochemistry 88341, 88342, 88344
Immunoelectrophoresis 86320, 86325, 86327, 86334, 86335
Leukocyte Antibodies 86021, 86828-86835
Platelet 86022, 86023
Red Blood Cell 86850, 86860, 86870
Pretreatment 86970-86972, 86975-86978
Solid Phase Assay 86828-86835
Antibody Neutralization Test
See Neutralization Test
Antibody Screening
Cytotoxic Percent Reactive Antibody (PRA) 86807, 86808
Fluorescent Noninfectious 86255
Anticoagulant
Home and Outpatient 93793
Anti-D Immunoglobulin
See Immune Globulins, Rho(D)
Antidiabetic Hormone
See Glucagon
Antidiuretic Hormone (ADH)
Measurement
Vasopressin 84588
AntiDNA Autoantibody
See Antinuclear Antibodies (ANA)
Antigen
See also Antigen Detection
Allergen Immunotherapy 95144-95149, 95165, 95170
Carcinoembryonic 82378
Prostate Specific 84152, 84153
Antigen, Australia
Antigen, CD4
See CD4
Antigen, CD8
See CD8
Antigen, CD142
See Thromboplastin
Antigen, CD143
Antigen Bronchial Provocation Tests
See Bronchial Challenge Test
Antigen Detection
Direct Fluorescence
Cytomegalovirus 87271
Enterovirus 87267
Immunoassay
Adenovirus 87301
Aspergillus 87305
Chlamydia Trachomatis 87320
Clostridium Difficile 87324
Cryptococcus Neoformans 87327
Cryptosporidium 87328
Entamoeba Histolytica Dispar Group 87336
Entamoeba Histolytica Group 87337
Escherichia coli 0157 87335
Giardia 87329
Helicobacter Pylori 87338, 87339
Hepatitis B Surface Antigen (HBsAg) 87340
Neutralization 87341
Hepatitis Be Antigen (HBeAg) 87350
Hepatitis Delta Agent 87380
Histoplasma capsulatum 87385
HIV-1 87389, 87390
HIV-2 87391
Infectious Agent, Otherwise 87449, 87450
Influenza A 87400
Influenza B 87400
Polyvalent 87451
Rotavirus 87425
Shiga-like Toxin 87427
Streptococcus, Group A 87430
Immunoassay with Direct Optical Observation
Clostridium Difficile Toxin A 87803
Influenza 87804
Streptococcus, Group B 87802
Trichomonas Vaginalis 87808
Immunofluorescence
Adenovirus 87260
Bordetella Pertussis 87265
Giardia 87269
Herpes Simplex 87273, 87274
Influenza A 87276
Influenza B 87275
Legionella Pneumophila 87278
Organism, Other 87299
Parainfluenza Virus 87279
Pneumocystis Carinii 87281
Polyvalent 87300
Rubeola 87283
Varicella Zoster 87290
Antigens, E
See Hepatitis Antigen, Detection, Immunoassay, Be (HBeAg)
Antigens, Hepatitis
See Hepatitis Antigen
Antigens, Hepatitis B
See Hepatitis Antigen, Detection, Nucleic Acid, B
Antihemophilic Factor B
See Christmas Factor
Antihemophilic Factor C
See Plasma Thromboplastin, Antecedent
Antihemophilic Globulin (AHG) 85240
Antihuman Globulin 86880-86886
Antihuman Globulin Consumption Test
See Coombs Test
Antinuclear Antibodies (ANA) 86038, 86039

Antiphospholipid Antibody
See Antibody, Detection, Anti-phosphatidylserine (Phospholipid)
Antiplasmin, Alpha-2 85410

Antiplatelet Therapy
Performance Measures
Coronary Artery Disease 4011F
Stroke and Stroke Rehabilitation 4073F
Antiprotease, Alpha-1
See Alpha-1 Antitrypsin
Antistreptococcal Antibody 86215
Antistreptokinase Titer 86590
Antistreptolysin O 86060-86063
Antithrombin III 85300, 85301
Antithrombin VI
See Fibrin Degradation Products
Antitoxin Assay 87230

Antiviral Antibody
See Viral Antibodies
Antrostomy
Sinus
Maxillary 31256, 31267
Antrotomy
Sinus
Maxillary 31020, 31030, 31032
Transmastoid 69501
Antrum of Highmore
See Nasal Sinuses, Maxillary
Antrum Puncture
Sinus
Maxillary 31000
Sphenoid 31002
Anus
See also Hemorrhoids; Rectum
Ablation 46615
Abscess
Anoscopy
See Anoscopy
Biofeedback 90912, 90913
Biopsy
Endoscopy 46606
Crypt
Excision 46999
Dilation
Endoscopy 46604
Endoscopy
Biopsy 46606
Dilation 46604
Exploration 46600
Hemorrhage 46614
High Resolution Anoscopy (HRA) 46601, 46607
Removal
Foreign Body 46608
Polyp 46610, 46612
Tumor 46610, 46612
Excision
Tag 46220, 46230
Exploration
Endoscopy 46600
Surgical 45990
Fissure
Destruction 46940, 46942
Excision 46200
Fistula
Closure 46288
Repair 46706
Hemorrhage
Endoscopic Control 46614
Hemorrhoids
Clot Excision 46320
Destruction 46930
Injection 46500
Ligation 46221, 46945, 46946, 46948
Stapling 46947
Suture 46945, 46946, 46948
Transanal Hemorrhoidal Dearterialization (THD) 46948
Imperforated
Repair 46715-46742
Incision
Septum 46070
Sphincterotomy 46200
Lesion
Destruction 46900-46917, 46924
Excision 45108, 46922
Manometry 91122
Placement
Seton 46020
Reconstruction
Congenital Absence 46730-46740
with Graft 46753
Sphincter 46750, 46751, 46760-46761
Removal
Foreign Body 46608
Seton 46030
Suture 46754
Wire 46754
Repair
Anoperineal Fistula 46715, 46716
Cloacal Anomaly 46744, 46746, 46748
Fistula 46706
Sphincter
Chemodenervation 46505
Electromyography 51784, 51785
Needle 51785
Aorta
Abdominal
Aneurysm
Endovascular Repair 34845-34848
Screening 76706
Angiography 75635
Anastomosis
with Excision of Coarctation 33840
to Pulmonary Artery 33606
Angiogram
Radiological Injection 93567
See Cardiac Catheterization, Injection
Angioplasty 37246, 37247
Aortography 75600, 75605, 75625, 75630
Ascending
Graft 33858, 33859, 33864
Balloon Assist Device
Insertion 33967, 33970, 33973
Removal 33968, 33971, 33974
Catheterization
Catheter 36200
Intracatheter/Needle 36160
Circulation Assist Device
Insertion 33967, 33970, 33973
Removal 33968, 33971, 33974
Conduit to Heart 33404
Endograft
Fenestrated 34839, 34841-34848
Excision
Coarctation 33840, 33845, 33851
Graft
Descending Thoracic 33875
Hemiarch 33866
Transverse Arch 33871
Implantable Counterpulsation Ventricular Assist System
Insertion 0451T-0454T
Interrogation Device Evaluation 0463T
Programming Device Evaluation 0462T
Relocation 0459T
Removal 0455T-0458T
Replacement 0451T-0454T
Repositioning 0460T, 0461T
Infrarenal Abdominal
Repair
Endovascular 34701-34706, 34709-34711, 34845-34848
Insertion
Balloon Device 33967, 33970, 33973
Catheter 36200
Graft 33330, 33335, 33864, 33866
Removal
Balloon Assist Device 33968, 33971, 33974
Repair 33320-33322, 33802, 33803
Aneurysm
Ascending 33859, 33863, 33864
Sinus of Valsalva 33720
Thoracic 33875, 33877
Transverse Arch 33871
Coarctation 33840, 33845, 33851
Hypoplastic or Interrupted Aortic Arch 33852, 33853
Sinus of Valsalva 33702, 33710, 33720
Suspension 33800
Suture 33320-33322
Thoracic
Catheterization 36221
Repair 33875, 33877, 75956-75959
Endovascular 33880, 33881, 33883, 33884, 33886, 33889, 33891
Translocation
Aortic Root 33782, 33783
Valve
Implantation 33361-33369
Incision 33415
Repair 33390, 33391
Left Ventricle 33414
Supravalvular Stenosis 33417
Replacement
See Aortic Valve Replacement
Visceral
Repair
Endovascular 34839, 34841-34848
X ray with Contrast 75600, 75605, 75625, 75630
Aortic Sinus
See Sinus, Heart, Sinus of Valsalva
Aortic Stenosis
Repair 33415
Nikaidoh Procedure 33782, 33783
Supravalvular 33417
Aortic Valve
Closure
Paravalvular Leak 93591, 93592
Construction
Apical-Aortic Conduit 33404
Implantation
Transcatheter 33361-33369
Occlusion
Repair
Gusset Aortoplasty 33417
Outflow Tract Obstruction
Left Ventricle 33414
Stenosis
Idiopathic Hypertrophic 33416
Subvalvular 33415
Supravalvular 33417
Valvuloplasty
Open, with Cardiopulmonary Bypass 33390, 33391
Replacement
See Aortic Valve Replacement
Aortic Valve Replacement
with Allograft Valve 33406
with Aortic Annulus Enlargement 33411, 33412
with Cardiopulmonary Bypass 33367-33369, 33405, 33406, 33410
Open
with Allograft Valve 33406
with Cardiopulmonary Bypass 33405, 33406, 33410
with Prosthesis 33405
with Stentless Tissue Valve 33410
with Prosthesis 33361-33369, 33405
Ross Procedure 33413
Ross-Konno Procedure 33440
with Stentless Tissue Valve 33410
Transcatheter
See Transcatheter Aortic Valve Replacement (TAVR/TAVI)
with Translocation, Pulmonary Valve 33413
Aortocoronary Bypass
See Coronary Artery Bypass Graft (CABG)
Aortocoronary Bypass for Heart Revascularization

See Artery, Coronary, Bypass
Aortography
Aorta Imaging 75600-75630, 93567
with Iliofemoral Artery 75630, 75635
Serial 75625
Aortoiliac
Embolectomy 34151, 34201
Thrombectomy 34151, 34201
Aortopexy
Tracheal Decompression 33800
Aortoplasty
Supravalvular Stenosis 33417
Aortopulmonary Transposition
See Transposition, Great Arteries
AP (Abdominal Pressure)
See Voiding Pressure Studies
Apert-Gallais Syndrome
See Intersex State
Aphasia Testing
Speech and Language Function 96105
Apheresis
Therapeutic 0342T, 36511-36516

Apicectomy
with Mastoidectomy
Petrous 69530
Apoaminotransferase, Aspartate
Apolipoprotein
Appendectomy
Appendix Excision 44950, 44955, 44960
Laparoscopic 44970
Appendiceal Abscess
See Appendix, Abscess
Appendico-Vesicostomy
Cutaneous 50845
Appendix
Abscess
Open 44900
Excision 44950, 44955, 44960, 44970
Application
Allergy (Percutaneous) Tests 95044
Bone Fixation Device
Multiplane 20692
Stereotactic Computer Assisted 20696, 20697
Uniplane 20690
Caliper 20660
Cranial Tongs 20660
Fixation Device
See Application of External Fixation Device
Halo
Cranial 20661
Thin Skull Osteology 20664
Femoral 20663
Maxillofacial Fixation
See Fixation (Device), Maxillofacial
Pelvic 20662
Injector Device
for Timed Subcutaneous Injection 96377
Interdental Fixation Device 21110
Neurostimulation
TENS 97014
Radioelement
Infusion or Instillation 77750
Interstitial 77770-77772, 77778
Intracavitary 77761-77763, 77770-77772, 77790, 77799
Surface 77767, 77768, 77789
with Ultrasound 76965
Stereotactic Frame 20660
Headframe 61800
Strapping
Multi-layer Compression System
Arm 29584
Leg 29581
Application of External Fixation Device
See also External Fixation Device, Removal
Caliper 20660
Cranial Tongs 20660
External Fixation System
Multiplane 20692, 20693, 20696, 20697
Uniplane 20690
Halo 20661-20664
APPT (Activated Partial Thromboplastin Time)

See Thromboplastin, Partial Thromboplastin Time (PTT)
Aquatic Therapy
See Physical Medicine/Therapy/Occupational Therapy
Aqueous Shunt
to Extraocular Equatorial Plate Reservoir 66179, 66180
without Extraocular Reservoir 0376T, 66183
Revision 66184, 66185
Arch, Zygomatic
See Zygomatic Arch
Arch Ligament
See Coracoacromial Ligament
Arm
See also Radius; Ulna; Wrist
Lower
Abscess 25028
Amputation 25900, 25905, 25909, 25915
Cineplasty 24940
Revision 25907, 25909
Angiography 73206
Artery
Ligation 37618
Biopsy 25065, 25066
Bursa
Bypass Graft 35903
Cast 29075
CT Scan 73200-73202, 73206
Decompression 25020, 25023-25025
Exploration
Blood Vessel 35860
Fasciotomy 24495, 25020, 25023-25025
Hematoma 25028
Implant 24931
Lesion, Tendon Sheath
Excision 25110
Magnetic Resonance Imaging (MRI) 73218-73220, 73221-73223, 73225
Reconstruction
Ulna 25337
Removal
Foreign Body 25248
Repair
Blood Vessel with Other Graft 35266
Blood Vessel with Vein Graft 35236
Decompression 24495
Muscle 25260-25263, 25270
Secondary 25265
Secondary
Muscle 25272-25274
Tendon 25272-25274
Tendon 25260-25263, 25270, 25280-25295, 25310-25316
Secondary 25265
Tendon Sheath 25275
Replantation 20805
Splint 29125, 29126
Tendon
Excision 25109
Lengthening 25280
Shortening 25280
Transplantation 25310-25312
Tenotomy 25290
Tumor
Ultrasound
Complete 76881
Limited 76882
X ray 73090
with Upper Arm 73092
Removal
Foreign Body
Forearm or Wrist 25248
Repair
Muscle 24341
Tendon 24341
Strapping
Multi-layer Compression System 29584
Upper
Abscess
Amputation 23900-23920, 24900, 24920, 24930, 24931
Cineplasty 24940
with Implant 24931
Revision 23921, 24925, 24935
Angiography 73206
Artery
Ligation 37618
Biopsy 24065, 24066
Bypass Graft 35903
Cast 29065
CT Scan 73200-73206
Exploration
Blood Vessel 35860
Hematoma
Muscle Revision 24330, 24331
Removal
Cast 29705
Repair
Muscle Transfer 24301, 24320
Tendon 24332
Tendon Lengthening 24305
Tendon Revision 24320
Tendon Transfer 24301
Tenotomy 24310
Replantation 20802
Splint 29105
Tumor
Soft Tissue
Radical Resection 24077-24079
Ultrasound
Complete 76881
Limited 76882
Wound Exploration
Penetrating 20103
X ray
Infant 73092
Arnold-Chiari Malformation Repair

See Decompression, Skull
Arrest, Epiphyseal
See Epiphyseal Arrest
Arrhythmogenic Focus
Heart
Ablation 33250, 33251, 33261, 93653, 93654, 93656
Catheter 93655
Arsenic
Qualitative 83015
Quantitative 82175, 83018
ART (Automated Reagin Test)
See Syphilis Test
Arterial Catheterization
See Cannulation, Arterial
Arterial Grafting for Coronary Artery Bypass
See Bypass Graft, Arterial, Coronary
Arterial Infusion, Thrombolysis

See Transcatheter, Therapy, Infusion (Arterial or Venous)
Arterial Pressure
See Blood Pressure
Arterial Puncture
for Diagnosis 36600
Arterialization, Venous
Transcatheter Stent Placement
Peroneal Vein 0620T
Tibial Vein 0620T
Arteriography, Aorta
See Aortography, Aorta Imaging
Arteriosus, Ductus
Closure
Transcatheter Percutaneous 93582
Repair 33820-33824
Arteriosus, Truncus
Repair 33786
Arteriotomy
See Incision, Artery; Transection, Artery
Arteriovenous Anastomosis
for Increased Blood Flow 36818-36821
Cannulization
Vein 36815
Creation 36825-36830
Hemodialysis via Fistula 4052F
Referral 4051F
Repair
Abdomen 35182, 35189
Head 35180, 35188
Lower Extremity 35184, 35190
Neck 35180, 35188
Thorax 35182, 35189
Upper Extremity 35184, 35190
Revision
without Thrombectomy 36832
Thrombectomy
Dialysis Graft
without Revision 36831
Arteriovenous Malformation
Carotid
Obliteration 61613
Occlusion 61705
Cranial
Repair
Carotid Artery Occlusion 61705
Dural 61690, 61692
Electrothrombosis 61708
Infratentorial 61684, 61686
Supratentorial 61680, 61682
Iliac Artery
Repair 34707, 34708, 34717, 34718
Spinal
Occlusion 62294, 63250-63252
Arteriovenous Shunt
Aorta to Pulmonary Artery 33755, 33762
Blalock-Taussig Shunt 33750
Intrahepatic Portosystemic
Insertion 37182
Revision 37183
Patency 78291
Peritoneal-Venous
Evaluation 49427
Insertion 49425
Ligation 49428
Removal 49429
Revision 49426
Potts-Smith Shunt 33762
Subclavian to Pulmonary Artery 33750
Thomas Shunt 36835
Waterston Shunt 33755
Artery
Abdomen
Angiography 75726
Catheterization 36245-36248
Ligation 37617
Adrenal
Angiography 75731-75733
Anastomosis
See Anastomosis, Artery
Angioplasty
See Angioplasty
Aorta
Aortobifemoral
Bypass Graft 35540
Aortobi-iliac
Bypass Graft 35538, 35638
Aortocarotid
Aortofemoral
Bypass Graft 35539
Aortoiliac
Embolectomy 34151-34201
Thrombectomy 34151-34201
Aortoiliofemoral
Aortoinnominate
Aortosubclavian
Arm
Harvest 35600
Atherectomy
Brachiocephalic 0237T
Coronary 92924, 92925, 92933, 92934, 92937, 92938, 92941, 92943, 92944
Femoral 37225, 37227
Iliac 0238T
Peroneal 37229, 37231
Popliteal 37225, 37227
Renal 0234T
Tibial 37229, 37231
Transluminal 0234T-0238T, 92924, 92925, 92933, 92934, 92937, 92938, 92941, 92943, 92944
Visceral 0235T
Axillary
Aneurysm 35011-35013
Bypass Graft 35616, 35621, 35623, 35650, 35654
Embolectomy 34101
Exploration 35702
Thrombectomy 34101
Basilar
Aneurysm 61698, 61702
Biopsy 75970
Brachial
Bypass Graft 35510, 35512, 35522-35525
Embolectomy 34101
Exposure 34834
Thrombectomy 34101
Brachiocephalic
Atherectomy 0237T
Bypass Graft
with Composite Graft 35681-35683
Cannulization
for Extracorporeal Circulation 36823
to Vein 36810-36815
Carotid
Aneurysm 35001, 35002, 61697, 61700, 61703, 61705, 61708, 61710
Baroreflex Activation Device
Implantation/Replacement 0266T-0268T
Interrogation Evaluation 0272T, 0273T
Revision/Removal 0269T-0271T
Bypass Graft 33891, 35501-35510, 35601-35606, 35642
Carotid Cavernous Fistula 61705, 61708, 61710
Catheterization 36100, 36221-36224, 36227, 36228
Decompression 61590, 61591, 61596
Embolectomy 34001
Evaluation
Atheroma 93895
Intima Media Thickness 93895
Excision 60605
Exploration 35701
Ligation 37600-37606, 61611
Reimplantation 35691, 35694-36595
Stenosis
Imaging Study Measurement 3100F
Stent Placement
Transcatheter 37217, 37218
Thrombectomy 34001
Thromboendarterectomy 35301, 35390
Transection 61611
Transposition 33889, 35691, 35694, 35695
Vascular Malformation 61705, 61708, 61710
Celiac
Aneurysm 35121, 35122
Embolectomy 34151
Endoprosthesis 34841-34848
Thrombectomy 34151
Chest
Ligation 37616
Coronary
Angioplasty 92924, 92925, 92933, 92934
Atherectomy 92924, 92925, 92933, 92934
Bypass 33510-33536
Internal Mammary Artery Graft 4110F
Fractional Flow Reserve 0501T-0504T, 0523T
Graft 33503, 33504
Ligation 33502
Repair 33500-33507
Thrombectomy 92973
Thrombolysis 92975, 92977
Translocation 33506, 33507
Unroofing 33507
Digital
Sympathectomy 64820
Endothelial Function Assessment
Noninvasive 93998
Ethmoidal
Ligation 30915
Extracorporeal Circulation
for Regional Chemotherapy of Extremity 36823
Extracranial
Anastomosis 61711
Extremities
Bypass Graft Revision 35879-35884
Catheterization 36140, 36245-36248
Ligation 37618
Vascular Studies 93922-93931
Bypass Grafts 93925-93931
Femoral
Aneurysm 35141, 35142
Angiography 73706
Angioplasty 37224
Approach
Transcatheter Aortic Valve Replacement 33361-33366
Atherectomy 37225, 37227
Bypass Graft 35621, 35646, 35647, 35654, 35656, 35661, 35665, 35666
Revision 35883, 35884
Bypass In-Situ 35583-35585
Embolectomy 34201
Exploration 35703
Exposure 34812
Thrombectomy 34201
Great Vessel
Repair 33770-33781
Hepatic
Aneurysm 35121, 35122
Bypass Graft 35535
Iliac
Anastomosis Implant Placement 0553T
Aneurysm
Direct Repair 35001, 35131, 35132
Endovascular Repair 34703-34711, 34717, 34718
Atherectomy 0238T
Bypass Graft 35563, 35632-35634, 35637, 35663
Endograft 34717, 34718
Exposure 34820, 34833
Occlusion Device 34808
Revascularization 37220-37222
Thromboendarterectomy 35351, 35361-35363
Ilio-celiac
Bypass Graft 35632
Iliofemoral
Bypass Graft 35565
X ray with Contrast 75630
Ilio-mesenteric
Bypass Graft 35633
Iliorenal
Bypass Graft 35634
Innominate
Aneurysm 35021, 35022
Catheterization 36222, 36223, 36225
Stent Placement
Transcatheter 37217
Intracranial
Anastomosis 33606
Aneurysm 61705, 61708
Angiography
Angioplasty 61630
Infusion
for Other Than Thrombolysis 61650, 61651
for Thrombolysis 61645
Thrombectomy 61645
Leg
Angiography 73706, 75710-75716
Mammary
Angiography 75756
Maxillary
Ligation 30920
Mesenteric
Aneurysm 35121, 35122
Embolectomy 34151
Thrombectomy 34151
Middle Cerebral Artery, Fetal
Ligation 37615
Vascular Studies 76821
Nose
Other Angiography 75774
Other Artery
Angiography 75774
Pelvic
Angiography 72198, 75736
Peripheral Arterial Rehabilitation 93668
Peroneal
Angioplasty 37228-37235
Bypass Graft 35566-35571, 35666-35671
Embolectomy 34203
Exploration 35703
Thrombectomy 34203
Popliteal
Aneurysm 35151, 35152
Angioplasty 37224
Bypass Graft 35623, 35656, 35671
Bypass In-Situ 35583, 35587
Exploration 35703
Pressure
Waveform Analysis 93050
Pulmonary
Anastomosis 33606
Banding 33620, 33622, 33690
Embolectomy 33910, 33915, 33916
Endarterectomy 33916
Ligation 33924
Repair
Arborization Anomalies 33925, 33926
Atresia 33920
Stenosis 33917
Radial
Aneurysm 35045
Bypass Graft 35523
Embolectomy 34111
Exploration 35702
Sympathectomy 64821
Thrombectomy 34111
Rehabilitation 93668
Reimplantation
Carotid 35691, 35694, 35695
Subclavian 35693-35695
Vertebral 35691-35693
Visceral 35697
Renal
Aneurysm 35121, 35122
Atherectomy 0234T
Bypass Graft 35631, 35634, 35636
Embolectomy 34151
Fluoroscopy (included) 36251-36254
Thrombectomy 34151
Repair
Angioplasty
Radiological Supervision 37246, 37247
Revision
Hemodialysis Graft or Fistula 36831-36833
Spine
Angiography 75705
Splenic
Aneurysm 35111, 35112
Stent Placement
Carotid 37215-37218, 37236, 37237
Coronary 37236, 37237, 92928, 92929
Dialysis Circuit 36903, 36906, 36908
Extracranial Vertebral 0075T, 0076T, 37236, 37237
Femoral-Popliteal 0505T, 37226, 37227
Iliac 37221, 37223
Innominate 37217, 37218
Intracranial 61635
Tibial-Peroneal 37230, 37231, 37234, 37235
Subclavian
Aneurysm 35001, 35002, 35021, 35022
Bypass Graft 35506, 35511-35516, 35606-35616, 35645
Exploration 35701
Reimplantation 35693-35695
Transposition 33889, 35693-35695
Superficial Femoral
Superficial Palmar Arch
Sympathectomy 64823
Temporal
Biopsy 37609
Ligation 37609
Thoracic
Catheterization 33621, 36215-36218
Thrombectomy
Coronary 92973
Dialysis Circuit 36904-36906
Hemodialysis Graft or Fistula 36831
Intracranial 61645
Noncoronary 37184-37186
Other than Hemodialysis Graft or Fistula 35875, 36830-36833
Thrombolysis
Intracranial 61645
Noncoronary 37211, 37213, 37214
Tibial
Angiography 73706
Angioplasty 37228
Bypass Graft 35566-35571, 35623, 35666-35671
Embolectomy 34203
Exploration 35703
Thrombectomy 34203
Tibial/Peroneal Trunk-Tibial Bypass Graft 35570
Tibial-Tibial Bypass Graft 35570
Tibioperoneal
Angioplasty 37228-37235
Atherectomy 37233-37235
Tibioperoneal Trunk
with Angiography 75894-75898
Transposition
Carotid 33889, 35691, 35694, 35695
Subclavian 33889, 35693-35695
Ulnar
Aneurysm 35045
Bypass Graft 35523
Embolectomy 34111
Exploration 35702
Sympathectomy 64822
Thrombectomy 34111
Umbilical
Vascular Study 76820
Upper Extremity
Exploration 35702
Vertebral
Aneurysm 35005, 61698, 61702
Bypass Graft 35508, 35515, 35642-35645
Catheterization 36100, 36221, 36225, 36226, 36228
Decompression 61597
Reimplantation 35691-35693
Transposition 35691-35693
Visceral
Atherectomy 0235T
Reimplantation 35697
Artery Catheterization, Pulmonary

See Catheterization, Pulmonary Artery
Arthrectomy
Elbow 24155
Arthrocentesis
Bursa 20600
with Recording and Reporting 20604, 20606, 20611
with Ultrasound Guidance 20604, 20606, 20611
Intermediate Joint 20605, 20606
Large Joint 20610, 20611
Small Joint 20600, 20604
Arthrodeses
See Arthrodesis
Arthrodesis
Ankle 27870
with Bunionectomy 28295, 28296, 28298, 28299
Carpometacarpal Joint
Hand 26843, 26844
Thumb 26841, 26842
Cervical
Atlas-Axis 22548, 22585, 22595
below C2 22551-22554, 22585, 22595, 22600
Clivus-C1-C2 22548, 22585, 22595
Occiput-C2 22590
Elbow 24800-24802
Finger Joint 26850-26852
Interphalangeal 26860-26863
Metacarpophalangeal 26850
Foot Joint 28730-28735, 28740
with Advancement 28737
with Lengthening 28737
Pantalar 28705
Subtalar 28725
Triple 28715
Hand Joint 26843, 26844
Hip Joint 27284-27286
Intercarpal Joint 25800-25820
with Autograft 25825
Interphalangeal Joint 26860-26863
Great Toe 28755
with Tendon Transfer 28760
Knee 27580
Metacarpophalangeal Joint 26850-26852
Metatarsophalangeal Joint
Great Toe 28750
Pubic Symphysis 27282
Radioulnar Joint 25830
Sacroiliac Joint
Minimally Invasive 27279
Open 27280
Percutaneous 27279
Shoulder
See Shoulder, Arthrodesis
Shoulder Joint 23800-23802
Subtalar Joint 28725, 29907
Talus
Pantalar 28705
Subtalar 28725
Triple 28715
Tarsal Joint 28730-28737, 28740
Tarsometatarsal Joint 28730-28735, 28740
Thumb Joint 26841, 26842
Tibiofibular Joint 27871
Vertebra
Additional Interspace
Anterior/Anterolateral Approach 22585
Lateral Extracavitary 22534
Posterior 22614, 22634
Cervical
Posterior/Posterolateral/Lateral Transverse 22590-22600
with Insertion of Biomechanical Device 22853, 22854
Lumbar
Lateral Extracavitary 22533, 22534
Posterior/Interbody 22630
Posterior/Posterolateral and/or Lateral Transverse Technique 22612, 22633, 22634
Presacral Interbody 22586, 22899
Sacroiliac
Presacral Interbody 22899
Spinal Deformity
Anterior Approach 22808-22812
Posterior Approach 22800-22804
Spinal Fusion
Exploration 22830
Thoracic
Lateral Extracavitary 22532, 22534
Posterior/Posterolateral/Lateral Transverse 22610
Wrist 25800-25825
Arthrography
Ankle 73615
Injection 27648
Elbow 73085
Injection 24220
Hip 73525
Knee 73580
Injection 27369
Sacroiliac Joint
Injection 27096
Shoulder 73040
Injection 23350
Temporomandibular Joint (TMJ) 70332
Injection 21116
Wrist 73115
Injection 25246
Arthroplasties, Knee Replacement
See Prosthesis, Knee, Arthroplasty
Arthroplasty
Ankle 27700-27703
Elbow 24360-24363
Revision 24370, 24371
Hip 27132
Partial Replacement 27125
Total Replacement 27130
Implant
Radiostereometric Analysis (RSA) 0348T-0350T
Interphalangeal Joint 26535, 26536
Intervertebral Disc
Cervical 22856, 22858
Removal 0095T, 22864
Revision 0098T, 22861
Lumbar 0163T, 22857
Knee 27437-27447
Revision 27486, 27487
Metacarpophalangeal Joint 26530, 26531
Radius 24365, 24366
Shoulder Joint 23470, 23472-23474
Subtalar Joint
Sinus Tarsi Implant
Insertion 0335T
Removal 0510T
Removal and Reinsertion 0511T
Temporomandibular Joint 21240-21243
Vertebral Joint
Lumbar Spine 0202T
Wrist 25332
Carpal 25443
Carpometacarpal Joint 25447
Lunate 25444
Navicular 25443
Radius 25441
Revision 25449
Trapezium 25445
Ulna 25442
Arthroplasty, Hip, Total

See Hip, Total Replacement
Arthroplasty, Shoulder
See Repair, Shoulder
Arthropods
Examination 87168
Arthroscopy
Diagnostic
Elbow 29830
Hip 29860
Knee 29870
Metacarpophalangeal Joint 29900
Shoulder 29805
Temporomandibular Joint 29800
Wrist 29840
Surgical
Ankle 29891-29899
Elbow 29834-29838
Hip 29861-29916
Knee 29866-29868, 29871-29889
Subtalar Joint 29904-29907
with Acetabuloplasty 29915
Wrist 29843-29847
Arthroscopy of Ankle
See Ankle, Arthroscopy
Arthrotomy
Ankle 27610-27612, 27620
Ankle Joint 27625, 27626
with Biopsy
Glenohumeral Joint 23100
Hip Joint 27052-27054
Knee Joint 27330
Sacroiliac Joint 27050
Carpometacarpal Joint 26070, 26100
Elbow 24000
Capsular Release 24006
with Joint Exploration 24101
with Synovectomy 24102
with Synovial Biopsy 24100
Finger Joint 26075
Interphalangeal 26110
Glenohumeral Joint 23040, 23100, 23105, 23800
Hip 27030, 27033, 27054
Toe 28024, 28054
Intertarsal Joint 28020, 28050
Knee 27310, 27330-27335, 27403, 29868
Metatarsophalangeal Joint 28022, 28052
Shoulder 23044, 23105-23107
Shoulder Joint 23100, 23101
Sternoclavicular Joint 23044, 23101, 23106
with Synovectomy
Tarsometatarsal Joint 28020, 28050
Wrist 25040, 25100-25107
Arthrotomy for Removal of Prosthesis of Ankle

See Ankle, Removal, Implant
Arthrotomy for Removal of Prosthesis of Hip
See Hip, Removal, Prosthesis
Arthrotomy for Removal of Prosthesis of Wrist
See Wrist, Removal, Prosthesis
Articular Ligament
See Ligament
Artificial Abortion
See Abortion
Artificial Cardiac Pacemaker

See Cardiac Assist Devices, Pacemaker System
Artificial Eye
See Eye, Prosthesis
Artificial Genitourinary Sphincter

See Prosthesis, Urethral Sphincter
Artificial Insemination
Intracervical 58321
Intrauterine 58322
Sperm Washing 58323
Artificial Knee Joints

See Prosthesis, Knee
Artificial Penis
See Penile Prosthesis
Artificial Pneumothorax
See Pneumothorax, Therapeutic
Arytenoid
Excision 31400, 31560
Fixation 31400
Arytenoidectomy
Arytenoid Excision 31400
Endoscopic 31560
Arytenoidopexy
Arytenoid Fixation 31400
Ascorbic Acid
Blood 82180
Aspartate Aminotransferase
Aspergillus
Detection
Antibody 86606
Antigen 87305
Aspiration
Abdomen 49322
Amniotic Fluid
Diagnostic 59000
Therapeutic 59001
Aspirate Evaluation 88172, 88173, 88177
Bladder 51100-51102
Bone Marrow 38220, 38222
Spine Surgery 20939
Brain Lesion 61750, 61751
Breast 19000, 19001
Bronchi 31629, 31633, 31645, 31646, 31725
Bursa 20600, 20604, 20605, 20606, 20610, 20611
Catheter
Nasotracheal 31720
Tracheobronchial 31725
Cyst
Bone 20615
Breast 19000, 19001
Ganglion 20612
Kidney 50390
Pelvis 50390
Spinal Cord 62268
Thyroid 60300
Duodenum 43756, 43757
Fetal Fluid 59074
Fine Needle 67415
Aspirate Evaluation 88172, 88173, 88177
Fine Needle, Biopsy
See Fine Needle Aspiration (FNA) Biopsy
Gastric 43753, 43754
Hydrocele
Tunica Vaginalis 55000
Joint 20600, 20604-20606, 20610, 20611
Laryngoscopy 31515
Lens Material 66840
Liver 47015
Orbital Contents 67415
Pericardium 33016
Pleural Cavity 32554, 32555
with Imaging Guidance 32555
Puncture
See Puncture Aspiration
Spinal Cord
Syrinx 62268
Stomach
Diagnostic 43754, 43755
Therapeutic 43753
Syrinx
Spinal Cord 62268
Thyroid 60300
Trachea 31612, 31629
Nasotracheal 31720
Tracheobronchial 31645, 31646, 31725
Tunica Vaginalis
Hydrocele 55000
Vertebral
Disc 62267
Nucleus Pulposus 62267
Tissue 62267
Vitreous 67015
Aspiration, Chest
Thoracentesis 32554, 32555
Aspiration, Nail
See Evacuation, Hematoma, Subungual
Aspiration, Spinal Puncture

Lumbar 62272, 62328
Aspiration Lipectomies
Liposuction 15876-15879
Aspiration of Bone Marrow from Donor for Transplant

See Bone Marrow, Harvesting
Assay, Tobramycin
See Tobramycin
Assay, Very Long Chain Fatty Acids

See Fatty Acid, Very Long Chain
Assisted Circulation
See Circulation Assist
AST
Astragalectomy
Talectomy 28130
Astragalus
See Talus
Asymmetry, Face
See Hemifacial Microsomia
Ataxia Telangiectasia
Chromosome Analysis 88248
Cytogenetic Study 88248
Gene Test 0136U, 81408
Ataxy, Telangiectasia
See Ataxia Telangiectasia
Atherectomies, Coronary
See Artery, Coronary, Atherectomy
Atherectomy
See also Revascularization, Artery
Abdominal Aorta 0236T
Brachiocephalic 0237T
Coronary 92924, 92925, 92937, 92938, 92941, 92943, 92944
Femoral 37225, 37227
Iliac 0238T
Peroneal 37229, 37231, 37233, 37235
Renal 0234T
Tibial 37229, 37231, 37233, 37235
Visceral 0235T
Athletic Training
Evaluation 97169-97171
Re-evaluation 97172
ATLV (Adult T Cell Leukemia Virus)
See HTLV-I
ATLV Antibodies
See HTLV-I, Antibody
Atomic Absorption Spectroscopy
Each Analyte 82190
ATP Creatine Phosphotransferase

See CPK
Atresia
Choanal 30540-30545
Congenital
Auditory Canal, External 69320
Bile Duct 47700
Small Intestine 44126, 44127
Pulmonary Artery 33920
Tetralogy of Fallot 33697
Tricuspid 33615
Atria
Ablation
Operative Tissue 33254-33256, 33265, 33266
Anastomosis
Baffle Procedure 33774
Blalock-Hanlon Operation 33735
Cor Triatriatum
Repair 33732
Cuff Preparation 32855, 32856
Electrogram 93615, 93616
Endoscopy 33265, 33266
Fibrillation
See Fibrillation, Atrial
Left Atrial Appendage
Closure 33340
Membrane Resection 33732
Pacemaker
Electrode
Removal 33229, 33236
Repositioning 33215
Insertion 33206, 33208
Rashkind Procedure 33741
Reconstruction 33254-33256, 33265, 33266
Septum
Interatrial Septal Shunt Device
Implantation 0613T
Septal Defect
See Atrial Septal Defect
Septectomy 33735-33737
Septostomy 33735-33737
Transcatheter, for Congenital Anomaly 33741
Thrombus 33310
Atrial Electrogram
Esophageal Recording 93615, 93616
Atrial Fibrillation
Atrial Septal Defect
Closure 33615, 33647
Repair 33641, 33660
Atrioseptopexy
See Atrial Septal Defect, Repair
Atrioseptoplasty
See Atrial Septal Defect, Repair
Attachment
See Fixation
Atticotomy
Tympanic Incision 69631, 69635

Acoustic Immittance 92570
Acoustic Reflex 92568, 92570
Audiometry
Automated 0208T-0212T
Bekesy 92560, 92561
Comprehensive 0212T, 92557
Conditioning Play 92582
Groups 92559
Pure Tone 0208T, 0209T, 92552, 92553
Select Picture 92583
Speech 0210T, 0211T, 92555, 92556
Visual Reinforcement (VRA) 92579
Auditory Brainstem Implant 92640
Auditory Processing
Treatment 92507, 92508
Central Auditory Function 92620, 92621
Ear Protector Attenuation 92596
Electrocochleography 92584
Evoked Otoacoustic Emission 92558, 92587, 92588
Filtered Speech 92571
Hearing Aid Evaluation 92590-92595
Loudness Balance 92562
Screening 92551
Sensorineural Acuity 92575
Short Increment Sensitivity Index (SISI) 92564
Staggered Spondaic Word Test 92572
Stenger Test 92565, 92577
Synthetic Sentence Test 92576
Tinnitus Assessment 92625
Tone Decay 92563
Tympanometry 92550, 92567, 92570
Audiometry
Bekesy 92560, 92561
Comprehensive 0212T, 92557
Conditioning Play 92582
Groups 92559
Pure Tone 92552, 92553
Automated 0208T, 0209T
Select Picture 92583
Speech 0210T, 0211T, 92555, 92556
Tympanometry 92550, 92567, 92570
Voice Prosthesis Fitting 92597
Auditory Brainstem Evoked Response

Auditory Canal
Decompression 61591
External Ear
Abscess
Incision and Drainage 69000, 69005, 69020
Biopsy 69105
Excision 69110, 69120
Lesion 69140, 69145, 69150, 69155
Hematoma 69000, 69005
Reconstruction
for Congenital Atresia 69320
for Stenosis 69310
Removal
Cerumen 69209, 69210
Ear Wax 69209, 69210
Foreign Body 69200-69205
Middle Ear
Canalplasty 69631-69633, 69635-69637, 69641-69646
Decompression 69960
Excision
Aural Glomus Tumor 69550
Exploration 69440
Tympanolysis 69450
Auditory Canal Atresia, External

Auditory Evoked Otoacoustic Emission
Screening 92558, 92587, 92588
Auditory Evoked Potentials

See Audiometry, Brainstem Evoked Response
Auditory Labyrinth
See Labyrinth
Auditory Meatus
X ray 70134
Auditory Tube
See Eustachian Tube
Augmentation
Breast
See Breast, Augmentation
Chin 21120, 21123
Cruciate Ligament 29888, 29889
Facial Bones 21208
Knee Ligament 27427, 27556-27558
Larynx 31574
Malar 21210, 21270
Mandibular Body 21125, 21127
Palate 21082
Pulmonary Valve Outflow 33478
Spine
Lumbar 22514, 22515
Thoracic 22513, 22515
Augmentation Mammoplasty
See Breast, Augmentation
Aural Rehabilitation
Evaluation for Auditory Implant Candidacy 92626, 92627
Evaluation of Function of Auditory Implant 92626, 92627
Status Evaluation 92630, 92633
Auricle (Heart)
See Atria
Auricular Fibrillation
Auricular Prosthesis
Custom Preparation 21086
Australia Antigen
Autograft
Adipose Cellular Implant
for Knee Osteoarthritis 0565T, 0566T
Bone 20936-20938
Bone Marrow 20939
Chondrocytes
Knee 27412
Fat 15771-15774
Hematopoietic Progenitor Cells
See Hematopoietic Progenitor Cell (HPC), Transplantation
Osteochondral
Knee 27416
Talus 28446
Skin
Dermal 15130-15136
Epidermal 15110-15116
Soft Tissue 15769
Tissue Cultured 15150-15157
Harvesting 15040
Spine 20936-20939
Autologous Blood Transfusion

See Autotransfusion
Autologous Transplantation
See Autograft
Autonomic Nervous System Function

See Neurology, Diagnostic, Autonomic Function Tests
Autoprothrombin C
See Thrombokinase
Autoprothrombin I
See Proconvertin
Autoprothrombin II
Autoprothrombin III
See Stuart-Prower Factor
Autopsy
Coroner’s Exam 88045
Forensic Exam 88040
Gross and Micro Exam 88020-88037
Gross Exam 88000-88016
Organ 88037
Regional 88036
Autotransfusion
Blood 86890, 86891
Autotransplant
See Autograft
Autotransplantation
Renal 50380
AV Fistula
See Arteriovenous Fistula
AV Shunt
See Arteriovenous Shunt
Avulsion
Nails 11730-11732
Nerve 64732-64772
Axilla
Artery
See Artery, Axillary
Lymph Nodes
See Lymph Nodes, Axillary
Nerve
Injection
Anesthetic 64417
Steroid 64417
Skin Graft
Dermal 15130, 15131
Full-thickness 15200, 15201
Tissue Cultured 15150-15152
Tissue Transfer
Adjacent 14040, 14041
Flap 15574, 15620
Wound Repair 13131-13133
Axillary Nerve
Injection
Anesthetic 64417
Steroid 64417
Axis, Dens
See Odontoid Process
B
B Antibodies, Hepatitis
See Hepatitis Antibody, B
B Antigens, Hepatitis
See Hepatitis Antigen, Detection, Nucleic Acid, B
B Cells
Count 86355
B Complex Vitamins
See Vitamins, B Complex
B-1 Vitamin
See Thiamine
B-6 Vitamin
See Vitamins, B-6
B-12 Vitamin
See Cyanocobalamin
Bacillus Calmette Guerin Vaccine

See BCG Vaccine
Backbone
See Spine
Back/Flank
Biopsy 21920-21925
Penetrating Wound
Exploration 20102
Repair
Hernia 49540
Tumor
Bacteria Culture
Aerobic 87040-87071, 87077
Anaerobic 87073-87076
Mycobacterial 87118
Screening 87081
Specimen
Blood 87040
Other Source 87070, 87071, 87073, 87075
Stool 87045, 87046
Urine 87086-87088
Typing 87140, 87143, 87147, 87149, 87150, 87152, 87153, 87158
Bacterial Endotoxins 87176, 87205

Bacterial Overgrowth Breath Test 91065
Bactericidal Titer, Serum 87197
Bacterium
Antibody 86609
BAER
Baker Tube
Intestine Decompression 44021
Baker’s Cyst 27345

Balanoplasty
See Penis, Repair
Balkan Grippe
See Q Fever
Balloon Angioplasty
Aorta 34841-34848
Coronary Artery
See Balloon Angioplasties, Coronary
Femoral Artery 37224-37227
Iliac Artery 37220-37223
Intracranial Artery 61630, 61635
Peroneal Artery 37228-37235
Popliteal Artery 37224-37227
Pulmonary Artery 92977, 92998
Tibial Artery 37228-37235
Visceral Artery 34841-34848
Balloon Angioplasty, Coronary

with Atherectomy 92924, 92925, 92933, 92934, 92937, 92938, 92941, 92943, 92944
Percutaneous Transluminal 92920, 92921, 92937, 92938
with Revascularization 92937, 92938, 92941, 92943, 92944
with Stent Placement 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944
Balloon Assisted Device
Aorta 33967-33974
Bronchoscopy 31647, 31648, 31649, 31651
Band, Pulmonary Artery

See Banding, Artery, Pulmonary
Banding
Artery
Fistula 37607
Pulmonary 33610, 33622, 33690
Bank, Blood
See Blood Banking
Bankart Procedure
See Capsulorrhaphy, Anterior
Barany Caloric Test

See Caloric Vestibular Test
Bardenheurer Operation
See Ligation, Artery, Chest
Bariatric Surgery
Gastric Bypass 43644, 43645, 43846, 43847
Gastric Restriction 43644, 43645, 43842, 43843, 43845, 43846, 43847, 43848
Device
Placement 43770
Removal 43772-43774
Replacement 43773
Revision 43771
Port Component 43886-43888
Sleeve Gastrectomy 43775
Surgically Altered Stomach
Ultrasound Examination 43242
Barium Enema 74270, 74280
Revision/Removal 0269T-0271T
Barr Bodies 88130
Barr Procedure
See Tendon, Transfer, Leg, Lower
Bartholin’s Gland
Abscess
Cyst
Excision 56740
Bartonella Detection
Antibody 86611
Nucleic Acid Probe 87471, 87472
Basic Proteins, Myelin
See Myelin Basic Protein
Basilar Arteries
See Artery, Basilar
Batch-Spittler-McFaddin Operation
See Disarticulation, Knee
BCG Vaccine 90585, 90586

B-DNA
Be Antigens, Hepatitis
See Hepatitis Antigen, Detection, Immunoassay, Be (HBeAg)
Bed Sores
See Pressure, Ulcer (Decubitus)
Bed Testing
See Pulmonology, Diagnostic, Bed Testing
Bekesy Audiometry
See Audiometry, Bekesy
Benedict Test for Urea

See Urinalysis, Qualitative
Benign Cystic Mucinous Tumor
See Ganglion
Benign Neoplasm of Cranial Nerves

See Nerves, Neurofibroma
Bennett Fracture
Treatment 26645, 26650, 26665
Bennett Procedure
Quadricepsplasty 27430
Benzidine Test
Occult Blood Tests 82270-82272, 82274
Benzoyl Cholinesterase
See Cholinesterase
Bernstein Test
See Acid Perfusion Study, Esophagus
Beta 2 Glycoprotein I Antibody 86146

Beta Glucosidase 82963
Beta Hypophamine
Beta Lipoproteins
See Lipoprotein, LDL
Beta-2-Microglobulin
Blood 82232
Urine 82232
Beta-Blocker Therapy
Coronary Artery Disease 4008F
Heart Failure 4008F, 4480F, 4481F
Beta-hydroxydehydrogenase 80406
Bethesda System 88164-88167
b-Hexosaminidase 83080
Bicarbonate 82374
Biceps Tendon
Reinsertion 24342
Resection 23440
Tenodesis 23430, 29828
Transplantation 23440
Bichloride, Methylene
See Dichloromethane
Bicuspid Valve
See Mitral Valve
Bifrontal Craniotomy
for Craniosynostosis 61557
Bilaminate Skin Substitute/Neodermis

See Tissue, Substitute
Bile Acids 82239
Blood 82240
Bile Duct
Anastomosis
with Intestines 47760, 47780-47785
Biopsy
Endoluminal 47543
Endoscopy 47553
Cholangiography
with Catheterization 47533-47537
with Placement of Access to Small Bowel 47541
with Stent Placement 47538-47540
Cyst
Excision 47715
Destruction
Calculus (Stone) 43265, 47544
Dilation
Endoscopy 43277, 47555, 47556
Percutaneous 47542
X ray 74360
Drainage
Catheter
Change 75984
Conversion of External to Internal-External 47535
Exchange 47536
Placement 47533, 47534
Removal 47537
with Optical Endomicroscopy 0397T
Endoscopy
Biopsy 47553
Cannulation 43273
Destruction
Calculus (Stone) 43265
Dilation 43277, 47555, 47556
Exploration 47552
Placement
Stent 43274
Removal
Calculus (Stone) 43264, 47554
Foreign Body 43275
Specimen Collection 43260
Sphincter Pressure 43263
Sphincterotomy 43262, 43274
Exploration
Atresia 47700
Endoscopy 47552
Incision
Sphincter 43262, 47460
Nuclear Medicine
Imaging 78226, 78227
Pharmacologic Intervention 78227
Placement
Access to Small Bowel 47541
Catheter
Drainage 47533, 47534
Stent 43274, 47801
Reconstruction
Anastomosis 47800
Removal
Calculus (Stone) 43264, 47420, 47425, 47544
Foreign Body 43275
Stent 43275
Repair 47701
Gastrointestinal Tract 47785
with Intestines 47760, 47780
Stent Placement 47538-47540, 47801
Tumor
Ablation 43278
Excision 47711, 47712
X ray
with Contrast 47532, 74300, 74301
Calculus Removal 47544
Guide Catheter 74328, 74330
Guide Dilation 74360
Bile Duct, Common, Cystic Dilatation

See Cyst, Choledochal
Bilirubin
Blood 82247, 82248
Feces 82252
Total
Direct 82247, 82248
Transcutaneous 88720
Billroth I or II
See Gastrectomy, Partial
Bilobectomy 32482
Thoracoscopic 32670
Bimone
See Testosterone
Binding Globulin, Testosterone-Estradiol
See Globulin, Sex Hormone Binding
Binocular Microscopy 92504

Biofeedback
See Biofeedback Training
Biofeedback Training
Anorectal 90912, 90913
Psychophysiological 90875, 90876
Bioimpedance
Body Composition Analysis 0358T
Cardiovascular Analysis 93701
Biological Skin Grafts

See Skin Substitute Graft
Biomechanical Mapping
Transvaginal 0487T
Biometry
Eye 76516-76519, 92136
Biopsies, Needle
See Needle Biopsy
Biopsy
See also Brush Biopsy; Needle Biopsy
Abdomen 49000, 49321
Mass 49180
Adrenal Gland 60540-60545, 60650
Anal
Endoscopy 46606
High-Resolution Magnification (HRA) 46607
Ankle 27613, 27614, 27620
Arm, Lower 25065, 25066
Arm, Upper 24065, 24066
Artery
Temporal 37609
with Arthrotomy
Glenohumeral Joint 23100, 23105
Back/Flank 21920-21925
Bile Duct
Endoluminal 47543
Endoscopy 47553
with Transhepatic Guided Cholangiography
Laparoscopic 47579
Bladder 52354
Cystourethroscopy 52204, 52224, 52250
Blood Vessel
Transcatheter 75970
Bone 0200T, 0201T, 20220-20245, 22510-22512
Bone Marrow 38221, 38222, 88305
Brain 61140
Stereotactic 61750, 61751
Brainstem 61575, 61576
Breast 19100, 19101
Imaging of Specimen with Localization Device Placement 19081-19086
with Magnetic Resonance Guidance 19085, 19086
with Stereotactic Guidance 19081, 19082
with Ultrasound Guidance 19083, 19084
Bronchi
Endoscopic 31625-31629, 31632, 31633
Brush
Bronchi 31717
with Cystourethroscopy 52204
Renal Pelvis 52007
Ureter 52007
Synovium 26100
Cervix 57421, 57454, 57455, 57460, 57500
Chorionic Villus 59015
Colon 44025, 44100
Endoscopy 44389, 45380, 45392
Multiple
with Colostomy, Cecostomy 44322
Colon-Sigmoid
Conjunctiva 68100
Core Needle
Lung 32408
Mediastinum 32408
Thyroid 60100
Cornea 65410
Duodenum 44010
Ear, External 69100
Elbow 24065, 24066, 24101, 29830
Synovium 24100
Embryo Blastomere 89290, 89291
Endometrium 58100-58110, 58558
Epididymis 54800, 54865
Esophagus
Endoscopy 43193, 43198, 43202, 43238, 43239, 43242
Forceps 3150F
Eye Muscle 67346
Eyelid 67810
Margin 67810
Femur 27323, 27324
Foot
Interphalangeal Joint 28054
Intertarsal Joint 28050
Metatarsophalangeal Joint 28052
Tarsometatarsal Joint 28050
Forearm 25065, 25066
Gallbladder
Endoscopy 43261
Gastrointestinal, Upper
Endoscopy 43239
Hand
Synovium 26100
Heart 93505
Hip 27040, 27041
Joint 27052
Synovium 29860
Ileum
Endoscopy 44382
Interphalangeal Joint
Finger 26110
Toe 28054
Intervertebral Disc 62267
Intestines 44010, 44020, 44100
Endoscopy 44361, 44377, 44382, 44386
Intracranial Lesion 61140, 61750
Kidney 50200-50205
Endoscopic 50555-50557, 50574, 50576, 52354
Knee 27323, 27324, 29870
Synovium 27330
Knee Joint
Synovium 27331
Lacrimal Gland 68510
Lacrimal Sac 68525
Larynx
Endoscopy 31510, 31535, 31536, 31576
Leg
Lower 27613, 27614
Upper 27323, 27324
Lip 40490
Liver 47000, 47001, 47100, 47700
Lung
Thoracoscopy 32607, 32608
Lymph Nodes
Endobronchial Ultrasound (EBUS) Guided 31652, 31653
Injection Procedure
Radioactive Tracer 38792
Needle 38505
Open 38500, 38510, 38520, 38525, 38530, 38531
Superficial 38500
Para-aortic 57109, 57531, 58210, 58548
Prostate 55812, 55842, 55862
Transbronchial 31652, 31653
Transtracheal 31652, 31653
Mediastinum
Mediastinoscopy 39401, 39402
Mediastinotomy 39000, 39010
Mouth 40808, 41108
Muscle 20200-20206
Nail 11755
Nasopharynx 42804-42806
Neck 21550
Nerve 64795
Nose
Endoscopic 31237
Intranasal 30100
Omentum 49321
Oocyte Polar Body 89290, 89291
Orbit
Oropharynx 42800
Ovary 49321, 58900
Palate 42100
Pancreas 48100-48102
Paravertebral Tissue 62267
Pelvis 27040, 27041
Penis 54100
Deep Structures 54105
Pericardial Sac
Thorascopic 32604
Pericardium 39010
Perineum 56605, 56606
Peritoneum
Endoscopic 49321
Pharynx 42800-42806
Pleura
Needle 32400
Thoracoscopic 32609
Thoracotomy 32098
Prostate
Incisional 55705
Lymph Nodes 55812, 55842, 55862
Needle or Punch 55700, 55706
Stereotactic 55706
Rectum 45100, 45305, 45331
Renal Pelvis
Endoluminal, Non-endoscopic 50606
Retroperitoneal Area 49010, 49180
Salivary Gland 42400, 42405
Shoulder 23065, 23066
Shoulder Joint 23100, 23101, 23106, 29805
Sinus 31237
Sphenoid 31050
Skin Lesion
Fine Needle Aspiration (FNA) 10004-10012, 10021
Incisional 11106, 11107
Punch 11104, 11105
Tangential 11102, 11103
Skull Base 61575, 61576
Spinal Cord
Needle 62269
Neoplasm 63275-63290
Percutaneous 62269
Transoral 61575, 61576
Stomach 43605
Tarsometatarsal Joint
Synovium 28050
Testis 54500-54505
Thigh 27323, 27324
Thorax 21550
Throat 42800-42806
Thyroid 60100
Tongue 41100-41105
Transcatheter 37200
Ureter 52354
Endoluminal, Non-endoscopic 50606
Endoscopic 50955-50957, 50974-50976
Urethra 52204, 52250, 52354, 53200
Uterus
Endometrial 58100-58110
Endoscopic 58558
Uvula 42100
Vagina 57100-57105, 57109, 57421
Vein 37200, 75970
Vertebral Body
Open 20250, 20251
Vulva 56605, 56606, 56821
Wrist 25065, 25066, 25100, 25101, 29840
Biopsy, Skin
See Skin, Biopsy
Biopsy, Vein
See Vein, Biopsy
Biostatistics
See Biometry
Biosterol
See Vitamins, A
Biotinidase 82261
Birthing Room
Newborn Care 99460, 99463
Attendance at Delivery 99464
Resuscitation 99465
Bischof Procedure
See Laminectomy, with Myelotomy
Bizzozero’s Corpuscle/Cell
See Blood, Platelet
Bladder
Abscess
Anastomosis 50780-50782, 51960
Aspiration 51100-51102
Biopsy 52204
Calculus
Litholapaxy 52317, 52318
Manipulation 52352
Removal 51050, 51065, 52310-52315, 52352
Catheterization 51045, 51102, 51701-51703
Cuff 50234, 50650
Cyst
Urachal
Excision 51500
Cystostomy Tube 51705-51710
Cystourethroscopy
See Cystourethroscopy
Destruction
Lesion 51030
Dilation 52260-52265
Ureter
See Ureter, Dilation
Diverticulum
Excision 51525
Incision 52305
Resection 52305
Endoscopy 52000
Biopsy 52204, 52224, 52250, 52354
Diverticulum 52305
Evacuation
Clot 52001
Excision
Tumor 52234, 52235, 52240, 52355
Exploration 52351
Fulguration 52214-52224, 52400
Tumor 52234, 52235, 52240
Injection, Steroid 52283
Instillation 52005, 52010
Irrigation
Clot 52001
Lithotripsy 52353
Radiotracer 52250
Removal
Calculus 52310-52315, 52352
Tumor
Excision 52234-52240, 52355
Fulguration 52234, 52235, 52240
Excision
Partial 51550-51565
Total 45126, 51570, 51580, 51590-51597
with Nodes 51575, 51585, 51595
Transurethral 52640
Ureterocele 51535
Flap 50785
Fulguration 52214-52224, 52354
Injection
Radiological 51600-51610
Insertion
Stent 51045, 52334
Instillation 51700
Anticarcinogenic Agent 51720
Interstitial Cystitis
Irrigation 51700
Laparoscopy 51999
Lesion
Destruction 51030
Fulguration 52224
Neck
Excision 51520
Injection of Implant Material 51715
Remodel for Urinary Incontinence 53860
Nuclear Medicine
Residual Study 78730
Pressure
Cystometrogram (CMG) 51725-51729
Uroflowmetry 51736-51741
Voiding Study 51728, 51729, 51797
Radiotracer 51020, 52250
Reconstruction
with Intestines 51960
and Urethra 51800-51820
Radiofrequency Micro-Remodeling 53860
Removal
Calculus 51050, 51065, 52310-52315, 52352
Urethral Stent 52310-52315
Repair 51800-51980
Diverticulum 52305
Exstrophy 51940
Fistula 44660, 44661, 45800-45805, 51880-51925
Neck 51845
Wound 51860-51865
Resection 52500
Tumor
Excision 51530
Fulguration 52234-52240
Resection 52234-52240
Ureterocele 51535
Urethrocystography 74450-74455
Urethrotomy 52270-52276
Urinary Incontinence Procedures
Neck Micro-remodel 53860
Plan of Care 0509F
Sling Operation 51992
Urethral Suspension 51990
X ray 74430, 74450-74455
Bladder Voiding Pressure Studies 51728, 51729

Blalock-Hanlon Procedure 33735
See Septostomy, Atrial
Blalock-Taussig Procedure
Shunt, Great Vessel 33750
Blast Cells
See Stem Cell
Blast Transformation
See Blastogenesis
Blastocyst Implantation
See Implantation, Embryo
Blastocyst Transfer
See Embryo Transfer
Blastogenesis 86353
Blastomyces
Antibody 86612
Blastomycosis, European
See Cryptococcus
Bleeding
See Hemorrhage
Disorder
See Coagulopathy
Time 85002
Uterine
Postpartum 59160
Vaginal 57180
Blepharoplasty 15820-15823
Anesthesia 00103
Canthoplasty 67950
Eyelid Reconstruction 15820-15823
Blepharoptosis
Repair 67901-67909
Frontalis Muscle Technique 67901
with Fascial Sling 67902
Superior Rectus Technique with Fascial Sling 67906
Tarso Levator Resection/Advancement
External Approach 67904
Internal Approach 67903
Blepharorrhaphy
See Tarsorrhaphy
Blepharospasm
Blepharotomy
Drainage of Abscess 67700
Blister
See Bulla
Blom-Singer Prosthesis 31611
Blood
Apheresis
See Apheresis
Banking
See Blood Banking
Bleeding Time 85002
Blood Cell Count
See Blood Cell Count, Complete (CBC)
Blood-derived Peripheral Stem Cells
See Hematopoietic Progenitor Cell (HPC)
Carboxyhemoglobin 88740
Clot (Thrombus)
See Clot (Thrombus)
Clotting
See Coagulation, Tests
Collection, for Autotransfusion
Preoperative 86890
Feces 82270, 82272-82274
Hemoglobin
Carboxyhemoglobin 88740
Concentration 85046
Methemoglobin 88741
Quantitative 88740
Hemoglobin A1c (HbA1c) Level 3044F-3046F
Injection
Plasma 0232T
Methemoglobin 88741
Nuclear Medicine
Flow Imaging 78445
Red Cell 78140
Red Cell Survival 78130
Osmolality 83930
Plasma
Exchange 36514-36516
Frozen Preparation 86927
Injection 0232T
Reinfusion 0342T
Volume 78110, 78111
Platelet
Aggregation 85576
Automated Count 85049
Count 85008
Manual Count 85032
Stem Cell
Count 86367
Donor Search 38204
Erythropoietin Therapy 3160F, 4090F-4095F
Harvesting 38205, 38206
Cell Concentration 38215
Cryopreservation 38207, 88240
Plasma Depletion 38214
Platelet Depletion 38213
Preparation 38207-38209
Red Blood Cell Depletion 38212
T-cell Depletion 38210
Thawing 38208, 38209, 88241
Tumor Cell Depletion 38211
Washing 38209
Transfusion 36430
Exchange 36455
Newborn 36450, 36456
Fetal 36460
Push
Infant to 2 years old 36440
Urine 83491
Viscosity 85810
Volume
Plasma 78110, 78111
Red Blood Cells 78120, 78121
Whole Blood 78122
Blood, Occult
See Occult Blood
Blood Banking
Frozen Blood Preparation 86930-86932, 88240
Frozen Plasma Preparation 86927
Physician Services 86077-86079
Blood Cell
Apheresis 36511-36514, 36516
CD4 and CD8
Including Ratio 86360
Enzyme Activity 82657
Photopheresis 36522
Sedimentation Rate
Automated 85652
Manual 85651
Blood Cell Count
Automated 85049
B Cells 86355
Blood Smear 85007, 85008
Complete (CBC) 85025-85027
Differential WBC Count 85004-85007, 85009
Hematocrit 85014
Hemoglobin 85018
Hemogram
Added Indices 85025-85027
Automated 85025-85027
Manual 85032
Microhematocrit 85013
Natural Killer (NK) Cells 86357
Red Blood Cells 85032-85041
Reticulocyte 85044-85046
Stem Cells 86367
T Cells 86359-86361
White Blood Cells 85032, 85048, 89055
Blood Cell Count, Red

See Red Blood Cell (RBC), Count
Blood Cell Count, White
See White Blood Cell, Count
Blood Cell, Red

See Red Blood Cell (RBC)
Blood Cell, White
See Leukocyte
Blood Coagulation
See Blood, Clotting
Clot
See Clot
Defect
See Coagulopathy
Disorders
See Coagulopathy
Factor
See Clotting Factor
Test
See Blood, Clotting
Blood Component Removal

See Apheresis
Blood Count, Complete
Blood Flow
Graft Check 15860, 90940
Myocardial
Absolute Quantitation 78434
Blood Gases
CO2 82803
HCO3 82803
O2 Saturation 82805, 82810
pCO2 82803
pH 82800, 82803, 82930
pO2 82803, 82820
Blood Letting
See Phlebotomy
Blood Lipoprotein
See Lipoprotein
Blood Pool Imaging

Cardiac
First Pass 78481-78483, 78496
Gated Equilibrium 78472, 78473, 78496
SPECT 78494
Blood Pressure
Determination
Central Arterial
Noninvasive Waveform Analysis 93050
Patient Self-Measurement 99473, 99474
Monitoring
Ambulatory, Using Wearable Software 93784, 93786, 93788, 93790
Ocular
Measurement 0198T
Monitoring 0329T
Chronic Kidney Disease 0513F, 2000F, 3074F, 3075F, 3077F-3080F
Coronary Artery Disease 0001F, 3074F
Hypertension 3074F, 3075F, 3077F-3080F
Venous 93770
Blood Products
Irradiation 86945
Pooling 86965
Splitting 86985
Volume Reduction 86960
Blood Sample
Fetal 59030
Blood Serum
See Serum
Blood Smear
Microorganism Identification 87205-87207
Microscopic Examination 85007, 85008
Peripheral 85060
Sex Chromatin 88140
Surgical Pathology 88312, 88313, 88319
Blood Syndrome
Chromosome Analysis 88245, 88248, 88249
Blood Tests
Cell Count
See Blood Cell Count
Coagulation
See Blood, Clotting
Culture, Bacteria
See Bacteria Culture
Gas Analysis
See Blood Gases
Iron Stores 3160F
Kt/V 3082F-3084F
Nuclear Medicine
Plasma Volume 78110, 78111
Platelet Survival 78191
Red Cell Volume 78120, 78121
Whole Blood Volume 78122
Panels
Acute Hepatitis 80074
Electrolyte 80051
General Health 80050
Hepatic Function 80076
Hepatitis, Acute 80074
Lipid 80061
Metabolic
Basic 80047, 80048
Comprehensive 80053
Obstetric 80055, 80081
Renal Function 80069
Typing
See Blood Typing, Serologic
Urea Nitrogen 84520-84525
Volume Determination 78122
Blood Transfusion, Autologous

See Autotransfusion
Blood Typing, Serologic
ABO Only 86900
Antigen Screen 86904
Antigen Testing, Donor Blood 86902
Compatibility 86920-86923
Other RBC Antigens 86905
Paternity Testing 86910, 86911
Rh (D) 86901
Rh Phenotype 86906
Blood Urea Nitrogen 84520-84525

Blood Vessels
Angioscopy 35400
Endothelial Function Assessment
Noninvasive 93998
Excision
Carotid Artery 60605
Saphenous Vein 37718, 37722, 37735
Exploration
Abdomen 35840
Chest 35820
Extremity 35702, 35703, 35860
Femoral Artery 35703
Neck 35701, 35800
Popliteal Artery 35703
Harvest
See Bypass Graft, Harvest
Repair
Aneurysm
See Aneurysm Repair
Aorta 33320-33322
Direct 35201-35226
Finger 35207
Hand 35207
Intra-abdominal 35221, 35281
Intrathoracic 35211, 35216, 35271, 35276
Neck 35201, 35231, 35261
Fistula
Great Vessel 33320-33322
Kidney 50100
Malformation
See Arteriovenous Malformation
Shunt Creation
with Bypass Graft 35686
Direct 36818, 36821
with Graft 36825-36830
Thomas Shunt 36835
with Transposition 36818-36820
Shunt Revision
with Graft 36832
Stripping
Saphenous Vein 37718, 37722, 37735
Bloom Syndrome
Gene Analysis 81209
Blotting, Western
See Western Blot
Blow-Out Fracture
Orbital Floor 21385-21395
Blue Dome Cyst
See Breast, Cyst
BMT
See Hematopoietic Progenitor Cell (HPC), Transplantation
Boarding Home Care
Established Patient 99334-99337
New Patient 99324-99328
Bodies
Acetone
See Drug Assay, Drug Procedure, Definitive Drug Class, Alcohols
Barr
See Barr Bodies
Carotid
See Carotid Body
Ciliary
See Ciliary Body
Heinz
See Heinz Bodies
Inclusion
See Inclusion Bodies
Ketone
See Ketone Body
Body Cast
Halo 29000
Removal 29700
Repair 29720
Risser Jacket 29010
Shoulder to Hips 29035
Body Fluid
Abdominal
See Paracentesis
Amniotic
See Amniotic Fluid
Blood
See Blood
Cerebrospinal Fluid
See Cerebrospinal Fluid
Fetal
Procedures and Testing
See Fetal Procedure; Fetal Testing
Pleural
See Pleura
Semen
See Semen Analysis
Spinal
Urine
See Urinalysis
Body of Vertebra
See Vertebral, Body
Boil
See Furuncle
Boil, Vulva
See Vulva, Incision and Drainage, Boil
Bone
Abscess
See Abscess, Bone
Biopsy
Needle 20220, 20225
Open 20240, 20245, 20250, 20251
Trocar 20220, 20225
with Vertebroplasty
Cervicothoracic 22510, 22512
Lumbosacral 22511, 22512
Cast
See Cast
Cyst
Drainage 20615
Injection 20615
Debridement 11044, 11047
Density Study
See Bone Density Study
Disease
See Performance Measures, Osteoarthritis; Performance Measures, Osteoporosis
Excision
See Amputation; Artherectomy
Fixation
See External Fixation Device
Fracture
See Fracture
Implant Removal 20670, 20680
Insertion
Intraosseous Infusion 36680
Osseointegrated Implant 69714-69718
Marrow
See Bone Marrow
Nuclear Medicine Imaging
Density Study 78350, 78351
Imaging 78300, 78305, 78306, 78315
SPECT 78803
Unlisted Musculoskeletal Services and Procedures 78399
Protein
Osteocalcin 83937
Quality Testing
Microindentation 0547T
Radiography
Age Study 77072
Dual Energy X ray Absorptiometry (DXA) 77080, 77081, 77085, 77086
Joint Stress 77071
Length Study 77073
Osseous Survey 77074-77077
Scan
See Bone, Nuclear Medicine Imaging
Skeletal Traction
See Skeletal Traction
Spur
See Exostosis
Tumor
Ablation
with Adjacent Soft Tissue 20982, 20983
Bone 4-Carboxyglutamic Protein

See Osteocalcin
Bone Analysis
CT Scan for Fracture Risk 0554T-0557T
CT Scan for Strength Assessment 0554T-0557T
Microindentation for Quality Testing 0547T
Bone Conduction Hearing Device, Electromagnetic

Implantation/Replacement 69710
Removal/Repair 69711
Bone Density Study
Appendicular Skeleton 77081
Axial Skeleton 77078, 77080
Dual Energy X ray Absorptiometry (DXA) 77080, 77081, 77085
Vertebral Fracture Assessment 77085, 77086
CT Scan 0554T-0557T
Ultrasound 0508T, 76977
Bone Graft
Allograft
See Allograft, Bone
Any Donor Area 20900, 20902
Autograft
See Autograft, Bone
Calcaneal Fracture 28420
Clavicle 23485
Craniofacial Separation 21436
Cranium 61316, 61559, 62146-62148
Femur 27170, 27177, 27470
Harvesting 20900-20902
Knee Drilling 29885
Malar Area 21210, 21366
Mandible 21127, 21194, 21215
Mandibular Ramus 21194
Maxilla 21210
Metacarpal Nonunion 26546
Metatarsal Nonunion 28322
Microvascular Anastomosis
Fibula 20955
Iliac Crest 20956
Metatarsal 20957
Other Site 20962
Midface 21182-21184, 21188
LeFort I 21145-21147, 21155, 21160
LeFort II 21151
LeFort III 21154, 21155, 21159, 21160
Nasal Area 21210
Nasomaxillary Complex Fracture 21348
Orbit
Blowout Fracture 21395
Fracture 21408
Hypertelorism 21260
Reconstruction 21182-21184, 21256
Repositioning 21267
Osteocutaneous Flap 20969-20973
Palate, Cleft 42210
Phalanx Nonunion 26546
Spine Surgery 20930, 20931, 22586, 22899
Bone Marrow Aspiration 20939
Toe Transfer 26551
Ulna 25830
Vertebra 0222T
Cervical 0219T, 63051
Lumbar 0221T
Thoracic 0220T
Wrist 25810, 25825
Bone Healing
Electrical Stimulation 20974, 20975
Ultrasound Stimulation 20979
Bone Infection
See Osteomyelitis
Bone Marrow
Aspiration 38220, 38222
Biopsy 38221, 38222, 88305
Blood Supply Magnetic Resonance Imaging (MRI) 77084
Blood-derived Peripheral Stem Cell
Cell Therapy 0263T-0265T
Cryopreservation 38207
Cytogenic Testing 3155F
Donor Cell Acquisition 38204
Harvesting 0265T, 38230, 38232
Magnetic Resonance Imaging (MRI) 77084
Nuclear Medicine
Imaging 78102-78104
Smear Interpretation 85097
T-Cell Transplantation 38240-38242
Transplant Preparation 38207-38215
Bone Plate
Mandible 21244
Bone Wedge Reversal
Osteotomy 21122
Bordetella
Antibody 86615
Antigen Detection
Direct Fluorescence 87265
Borrelia
Antibody Detection 86617-86619
Borrelia burgdorferi ab
See Antibody, Detection, Lyme Disease
Borreliosis, Lyme
See Lyme Disease
Bost Fusion
See Arthrodesis, Wrist
Bosworth Operation
See Acromioclavicular Joint, Dislocation
Bottle Procedure
Repair of Tunica Vaginalis Hydrocele 55060
Botulinum Toxin
See Chemodenervation
Boutonniere Deformity 26426-26428

Bowel
See Intestines
Bowleg Repair 27455-27457
Brace
Long Leg Cast 29358
Vertebral Fracture 22310, 22315
Brachial Arteries
See Artery, Brachial
Brachial Plexus
Decompression 64713
Injection
Anesthetic 64415, 64416
Steroid 64415, 64416
Neuroplasty 64708, 64713
Release 64713
Repair/Suture 64861
Brachiocephalic Artery
See Artery, Brachiocephalic
Brachycephaly
Brachytherapy
High Dose Electronic 0394T, 0395T
Remote Afterloading 77770-77772
Interstitial Application 0395T, 77778
Device Placement
Breast 19296-19298
Genitalia 55920
Head 41019
Intraocular 67299
Neck 41019
Pelvis 55920
Uterus 57155
Vagina 57155, 57156
Heyman Capsule Insertion 58346
Remote Afterloading 77770-77772
Intracavitary Application 0395T, 77761-77763
Loading 77790
Planning
Isodose Plan 77316-77318
Prostate Volume Study 76873
Radioelement Solution
Infusion 77750
Instillation 77750
Remote Afterloading
Interstitial 77770-77772
Intracavitary 77770-77772
Surface 77767, 77768
Surface Application 0394T, 77789
Remote Afterloading 77767, 77768
Unlisted Clinical Procedures 77799
Bradykinin
Brain
See also Brainstem; Skull Base Surgery
Abscess
Drainage 61150, 61151
Excision 61514, 61522
Adhesions 62161
Biopsy 61140
Stereotactic 61750, 61751
Catheter
Insertion 61210
Irrigation 62194, 62225
Replacement 62160, 62194, 62225
Catheter Placement
for Radiation Source 61770
Computer Assisted
Procedure 61781, 61782
Cortex
Magnetic Stimulation 64999, 90867-90869
Mapping 90867, 96020
Motor Function 64999
Cyst
Drainage 61150, 61151, 62161, 62162
Excision 61516, 61524, 62162
Debridement 62010
Diagnostic Radiology
CT Scan 0042T, 70450, 70460, 70470, 70496
Doppler Study 93886, 93888, 93890, 93892, 93893
Imaging 70010-70015, 78600, 78601, 78605-78610
Cerebrospinal Fluid 78630-78650
Cisternography 70015
Vascular Flow 78601, 78606, 78610
Ventriculography 78635
Magnetic Resonance Imaging 70551-70555, 70557-70559
Perfusion Analysis 0042T
Positron Emission Tomography (PET) 78608, 78609
Electrocorticography 61536, 61538
Electroencephalography
See Electroencephalography (EEG)
Epileptogenic Focus
Excision 61534, 61536
Monitoring 61531, 61533, 61535, 61760
Excision
Amygdala 61566
Choroid Plexus 61544
Craniopharyngioma 61545
Hemisphere 61543
Hippocampus 61566
Meningioma 61512, 61519
Other Lobe 61323, 61539, 61540
Temporal Lobe 61537, 61538
Tumor 61510, 61518, 61520, 61521, 61526-61530, 61545, 62164
Exploration
Infratentorial 61305
Supratentorial 61304
Hematoma
Drainage 61154
Implantation
Chemotherapy Agent 61517
Electrode 61210, 61533, 61850, 61860, 61863, 61864, 61867, 61868
Pulse Generator 61885, 61886
Reservoir 61210, 61215
Infusion 95990, 95991
Lesion
Aspiration, Stereotactic 61750, 61751
Excision 61600, 61601, 61605-61608, 61615, 61616
Lobectomy 61537-61540
Magnetoencephalography 95965-95967
Mapping 90867-90869, 95961, 95962, 96020
Meningioma
Excision 61512, 61519
Neurostimulation
Analysis
Brain 95970, 95983, 95984
Cranial Nerve 95970, 95976, 95977
Gastric 95980-95982
Peripheral Nerve 95970-95972
Spinal Cord 95970-95972
with Vagus Nerve Blocking Therapy 0317T
Electrode
Implantation 61210, 61850, 61860, 61863, 61864
Removal 61880
Revision 61880
Pulse Generator
Removal 61880
Revision 61880
Radiosurgery
for Lesion 61796-61800
Radiation Treatment Delivery 77371-77373
Removal
Electrode 61535, 61880
Foreign Body 61570
Pulse Generator 61888
Shunt 62256-62258
Repair
Dura 61618
Wound 61571
Shunt
Creation 62190, 62192, 62200, 62223
Removal 62256-62258
Replacement 62160, 62194, 62225, 62230, 62256, 62258
Reprogramming 62252
Skull Surgery
See Skull Base Surgery
Stereotaxis-aided Procedures
Biopsy 61750, 61751
Catheter Placement 61770
Create Lesion 61720, 61735, 61790, 61791
Navigation 61781, 61782
Procedure 61781, 61782
Radiation Treatment 77432
Radiosurgery 61796-61800, 77371-77373
Trigeminal Tract 61791
Transcranial Magnetic Stimulation (TMS) 90867-90869
Transection
Corpus Callosum 61541
Subpial 61567
Tumor
Excision
Cerebellopontine Angle 61520, 61526
Ventriculocisternostomy 62200, 62201
Torkildsen Type 62180
Brain Coverings
See Meninges
Brain Death
Determination 95824
Brain Stem
See Brainstem
Brain Stem Auditory Evoked Potential

Brain Surface Electrode
Stimulation 95961, 95962
Brain Tumor
Cerebellopontine Angle 61520, 61526, 61530
Midline 61521
Pituitary Tumor 61546, 61548, 62165
Posterior Fossa 61518
Brain Ventriculography
See Ventriculography
Brainstem
See Brain; Skull Base Surgery
Biopsy 61575, 61576
Decompression 61575, 61576
Diagnostic Tests
Auditory Implant 92640
Lesion
Excision 61575, 61576
Branchial Cleft
Cyst
Branchioma
See Branchial Cleft, Cyst
Breast
Ablation
Fibroadenoma 19105
Malignant Tumor 0581T
Abscess
Aspiration
Cyst 19000, 19001
Augmentation with Implant 19325
Biopsy 19100, 19101
with Imaging of Specimen 19081-19086
with Localization Device Placement
Magnetic Resonance Guided 19085, 19086
Stereotactic Guidance 19081, 19082
Ultrasound Guided 19083, 19084
Cancer Gene Analysis
BRCA1 (BRCA1, DNA repair associate)
185delAG, 5385insC, 6174delT Variants 81212
Duplication/Deletion 81162, 81164
Full Sequence 81162, 81165
Known Familial Variant 81215
BRCA2 (BRCA2, DNA repair associated)
185delAG, 5385insC, 6174delT Variants 81212
Duplication/Deletion 81162, 81167
Full Sequence 81162, 81216
Known Familial Variant 81217
ERBB2 (HER2) 0009U
Cryosurgical Ablation 19105
Cyst
Excision 19120
Puncture Aspiration 19000, 19001
Diagnostic Imaging
Axillary Lymph Node 0351T, 0352T
CT Scan 0633T-0638T
Ductogram 19030, 77053, 77054
Galactogram 77053, 77054
Injection 19030
Magnetic Resonance Imaging (MRI)
with Computer-Aided Detection 77048, 77049
without Contrast 77046, 77047
Mammogram, Screening 3014F, 77067
Mammography, Diagnostic 77065, 77066
Ultrasound 76641, 76642
Excision
Biopsy 19100, 19101
Chest Wall Tumor 21601-21603
Cyst 19120
Lactiferous Duct 19110
Fistula 19112
Lesion 19120, 19125, 19126, 19301
by Needle Localization 19125, 19126
Mastectomy 19300-19307
Tissue 19120
Tumor 19120, 21601-21603
Exploration
Abscess 19020
Nipple 19110
Imaging
Mammogram, Screening 3014F, 77067
Optical Coherence Tomography 0351T-0354T
Tactile 0422T
Implant
for Augmentation 19325
Biological
Preparation of Moulage 19396
Soft Tissue Reinforcement 15777
Supply 19396
Implant, Intact
Removal 19328
Implant, Ruptured
Removal 19330
Lesion
Localization Device Placement
with Magnetic Resonance Guidance 19287, 19288
with Mammographic Guidance 19281, 19282
with Stereotactic Guidance 19283, 19284
Mastectomy
with Axillary Lymphadenectomy 19302
Complete 19303
Gynecomastia 19300
Modified Radical 19307
Partial 19301, 19302
Radical 19303-19306
Mastopexy 19316
Peri-Implant Capsule Revision 19370
Peri-Implant Capsulectomy 19371
Peri-Implant Capsulotomy 19370
Radiation Therapy
Interstitial Radioelement Application
Catheter Placement 19296-19298
Preparation of Tumor Cavity 19294
Reconstruction
Augmentation 19325
with Free Flap 19364
with Latissimus Dorsi Flap 19361
Nipple 19350, 19355
Areola 19350
Revision 19380
Tissue Expander Placement/Expansion 19357
with Transverse Rectus Abdominis Myocutaneous (TRAM) Flap 19367-19369
Reduction 19318
Removal
Capsules 19371
Partial 19300-19302
Radical 19305, 19306
Simple, Complete 19303
Suspension 19316
Tissue Expander
Removal without Implant Insertion 11971
Replacement with Implant 11970
Tumor
Ablation 0581T
Destruction/Reduction
Microwave Thermotherapy 19499
Excision
Benign 19120
Chest Wall 21601-21603
Involving Ribs 21601-21603
Malignant 19120
Breath Odor, Alcohol

See Alcohol (Ethanol), Breath
Breath Test
Alcohol, Ethyl 82075
Helicobacter Pylori 78267, 78268, 83013
Hydrogen 91065
Methane 91065
Urea 78267, 78268
Breathing, Inspiratory Positive-Pressure

See Inhalation Treatment
Device
Intermittent Positive Pressure Breathing (IPPB) Patient Utilization Demonstration/Evaluation 94664
Bricker Procedure
Intestinal Anastomosis 50820
Brock Operation
See Valvotomy, Pulmonary Valve
Broken Nose
See Fracture, Nasal Bone
Bronchi
Allograft Preparation 32855, 32856
Aspiration
Catheter 31720, 31725
Endoscopic 31629, 31633, 31645, 31646
Biopsy 31625-31629, 31632, 31633
Bronchial Valve
Removal 31648, 31649
Bronchodilator
Home Care 99503
Spirometry 94012, 94060
Bronchoscopy
Alveolar Lavage 31624
Aspiration 31629, 31633, 31645, 31646
Biopsy 31625-31629, 31632, 31633
Catheter Placement for Radiotherapy 31643
Cell Brushing 31623
Cell Washing 31622
Computer-assisted/Image-guided Navigation 31627
Dilation 31630, 31631, 31636, 31638
Endobronchial Ultrasound (EBUS) 31652-31654
via Existing Tracheostomy 31615
Exploration 31622
with Balloon Occlusion 31634, 31647, 31651
Fiducial Marker Placement 31626
Foreign Body Removal 31635
Fracture Reduction 31630
Stenosis Relief 31641
Stent Placement 31631, 31636-31638
Thermoplasty 31660, 31661
Tumor Destruction 31641
Tumor Excision 31640
Catheterization
Aspiration 31725
Bronchial Brush Biopsy 31717
for Intracavitary Radioelement Application 31643
Endoscopy
Ablation
Photodynamic Therapy 96570, 96571
Exploration 31622, 31634, 31647, 31651
Insertion
Bronchial Valve 31647, 31651
Needle Biopsy 31629, 31633
Reconstruction
Anastomosis 31775, 32486
Graft Repair 31770
Stenosis 31775
Removal 32501
Foreign Body 31635
Repair 32501
Fistula 32815, 32906
Stenosis 31641, 96570, 96571
Stent
Revision 31638
Tests
Air Leak Assessment 31647, 31651
Airway Sizing 31647, 31651
Bronchospasm Evaluation 94070, 94617, 94619
Wheeze Rate 94799
Thermoplasty 31660, 31661
Tumor
Destruction 31641
Excision 31640
Bronchial Allergen Challenge

Bronchial Alveolar Lavage 31624
Bronchial Brush Biopsy
with Catheterization 31717
Bronchial Brushings/Protected Brushing 31623
Bronchial Challenge Test
See also Allergy Tests
Bronchospasm Evaluation 94070, 94617, 94619
with Chemicals 95070
with Histamine 95070
with Methacholine 95070
for Wheeze Rate 94799
Bronchial Provocation Tests
Bronchial Thermoplasty 31660, 31661

Bronchioalveolar Lavage
See Lung, Lavage
Broncho-Bronchial Anastomosis 32486

Bronchoplasty
Excision Stenosis and Anastomosis 31775
Graft Repair 31770
with Lobectomy/Segmentectomy 32501
Bronchopneumonia, Hiberno-Vernal
See Q Fever
Bronchopulmonary Lavage
See Lung, Lavage
Bronchoscopy
Ablation
Air Leak Assessment 31647-31649
Airway Resizing 31647, 31648, 31649
Alveolar Lavage 31624
Aspiration 31629, 31633, 31645, 31646
Balloon Occlusion 31634, 31647-31649, 31651
Biopsy 31625-31629, 31632, 31633
with Bronchial Thermoplasty 31660, 31661
Brushing/Protected Brushing 31623
Catheter Placement
Aspiration 31725
Intracavitary Radioelement 31643
Computer-assisted Navigation 31627
Dilation 31630, 31631, 31636-31638
with Endobronchial Ultrasound (EBUS) 31652-31654
Exploration 31622, 31634, 31647, 31651
Fiducial Marker Placement 31626
Insertion of Bronchial Valve(s) 31647
with Insertion of Bronchial Valves 31647, 31648, 31649
Insertion of Bronchial Valve(s) 31651
Removal
Foreign Body 31635
Tumor 31640, 31641
Stenosis 31641
Stent Placement 31631, 31636, 31637
Stent Revision 31638
Bronchospasm Evaluation
See Pulmonology, Diagnostic, Spirometry
Bronkodyl
See Theophylline
Brow Ptosis
Repair 67900, 67909
Brucella
Antibody 86622
Antigen 86000
Bruise
See Hematoma
Brush Biopsy
Bronchi 31717
Brush Border Ab
See Antibody, Detection, Heterophile
Bucca
See Cheek
Buccal Mucosa
See Mouth, Mucosa
Bulbourethral Gland
Excision 53250
Bulla
Lung
Resection-plication 32141, 32655
BUN
See Blood Urea Nitrogen; Urea Nitrogen
Bunion Repair
Bunionectomy 28292
Concentric Procedure 28296
with Metatarsal Osteotomy 28295, 28296
by Phalanx Osteotomy 28298, 28299
with Sesamoidectomy 28292
Burgess Amputation
See Disarticulation, Ankle
Burkitt Herpesvirus
See Epstein-Barr Virus
Burns
Debridement 15002-15005, 16020, 16025, 16030
Dressings 16020, 16025, 16030
Escharotomy 15002-15005, 16035, 16036
Fenestration
Body Surface 0479T, 0480T
First Degree, Initial Treatment 16000
Tissue Cultured Skin Grafts 15150-15152, 15155-15157
Total Body Surface Area (TBSA) Calculation 16000
Burr Hole
for Aspiration
Cyst 61156
Hematoma 61156
for Biopsy
Brain 61140
Lesion 61140, 61750, 61751
for Catheterization 61210
for Drainage
Abscess 61150, 61151
Cyst 61150, 61151
Hematoma 61154-61156
for Exploration
for Implantation
Catheter 61210
Cerebral Monitoring Device 61210
EEG Electrode 61210
Neurostimulator Array 61850, 61863, 61864, 61867, 61868
Pressure Recording Device 61210
Reservoir 61210
Strip Electrodes 61531
for Insertion
Pump 61210
Reservoir 61210
for Lesion Creation 61720
for Stereotactic Localization 61770
for Ventricular Puncture 61020
with Injection, Contrast Media 61120
with Injection, Diagnostic or Therapeutic Substance 61026
Bursa
Ankle
Arm, Lower
Arm, Upper
Arthrocentesis
Intermediate 20605, 20606
Major 20610, 20611
Small 20600, 20604
Elbow
Excision 24105
Femur
Excision 27062
Finger
Foot
Hand
Hip
Injection 20600, 20604-20606, 20610, 20611
Ischial
Excision 27060
Joint
Aspiration 20600, 20604-20606, 20610, 20611
Drainage 20600, 20604-20606, 20610, 20611
Injection 20600, 20604-20606, 20610, 20611
Knee
Excision 27340
Leg, Lower 27604
Leg, Upper
Palm
Pelvis
Shoulder
Drainage 23031
Toe
Wrist
Excision 25115, 25116
Bursectomy
See Excision, Bursa
Bursitis, Radiohumeral
See Tennis Elbow
Bursocentesis
See Aspiration, Bursa
Button
Bone Graft 20900
Prosthesis
Nasal Septal 30220
Voice 31611
Butyrylcholine Esterase
See Cholinesterase
Bypass, Cardiopulmonary
See Cardiopulmonary Bypass
Bypass Graft
Arterial
Coronary 33533-33536, 35600
Arterial-Venous
Coronary 33517-33519, 33521-33523, 33530
with Composite Graft 35681
Harvest
Artery 35600
Endoscopic 33508
Vein 35500, 35572
Placement
Vein Patch 35685
Reoperation 35700
Repair
Abdomen 35907
Extremity 35903
Lower Extremity
with Composite Graft 35681-35683
Neck 35901
Thorax 35905
Revascularization
Extremity 35903
Neck 35901
Thorax 35905
Revision
Lower Extremity
with Angioplasty 35879
Femoral Artery 35883, 35884
with Vein Interposition 35881
Secondary Repair 35870
In-Situ
See Bypass In-Situ
Thrombectomy
Coronary 92973
Other than Hemodialysis Graft or Fistula 35875, 35876
Venous
Aortobifemoral 35540, 35646
Aortobi-iliac 35538, 35638
Aortocarotid 35526, 35626
Aortoceliac 35531, 35631
Aortofemoral 35539, 35647
Aortoiliac 35537, 35637
Aortoinnominate 35526, 35626
Aortomesenteric 35531, 35631
Aortorenal 35560, 35631
Aortosubclavian 35526, 35626
Axillary-Axillary 35518, 35650
Axillary-Brachial 35522
Axillary-Femoral 35521, 35621
Axillary-Femoral-Femoral 35533, 35654
Axillary-Popliteal 35623
Axillary-Tibial 35623
Brachial-Brachial 35525
Brachial-Radial 35523
Brachial-Ulnar 35523
Carotid-Brachial 35510
Carotid-Contralateral Carotid 35509
Carotid-Subclavian 35506, 35606
Carotid-Vertebral 35508, 35642
Common Carotid-Ipsilateral Internal Carotid 35501, 35601
Coronary 33510-33514, 33516
Femoral-Femoral 35558, 35661
Femoral-Peroneal 35566
Femoral-Popliteal 35556, 35572, 35656
Femoral-Tibial 35566, 35666
Hepatorenal 35535
Ilioceliac 35632
Iliofemoral 35565, 35665
Ilioiliac 35563, 35663
Iliomesenteric 35633
Iliorenal 35634
Mesenteric 35531, 35631
Peroneal 35566-35571, 35666-35671
Peroneal-Tibial 35570
Popliteal-Peroneal 35571, 35671
Popliteal-Tibial 35571, 35671
Splenorenal 35536, 35636
Subclavian-Axillary 35516, 35616
Subclavian-Brachial 35512
Subclavian-Carotid 35506
Subclavian-Subclavian 35511, 35612
Subclavian-Vertebral 35515, 35645
Tibial/Peroneal Trunk-Tibial 35570
Tibial-Tibial 35570
Bypass In-Situ
Femoral-Peroneal 35585
Femoral-Popliteal 35583
Femoral-Tibial 35585
Popliteal-Peroneal 35587
Popliteal-Tibial 35587
Tibial Artery 35585-35587
Ventricular Restoration 33548
C
C Vitamin
See Ascorbic Acid
C-13
Urea Breath Test 83013, 83014
Urease Activity 83013, 83014
C-14
CABG
Cadmium
Urine 82300
Caffeine
Drug Assay 80155
Halothane Contracture Test (CHCT) 89049
Calcaneal Spur
See Heel Spur
Calcaneus
Bone Graft 28420
Craterization 28120
Cyst
Diaphysectomy 28120
Fracture
with Bone Graft 28420
with Manipulation 28405, 28406
Percutaneous Fixation 28406
Heel Spur 28119
Repair
Osteotomy 28300
Saucerization 28120
Tumor
X ray 73650
Calcareous Deposits
Subdeltoid
Removal 23000
Calcifediol
See Vitamins, D
Calciferol
See Vitamins, D
Calcification
See Calcium, Deposits
Calciol
See Vitamins, D, Blood Serum Level, 25 hydroxy
Calcitonin
Stimulation Panel 80410
Calcium
Blood
Infusion Test 82331
Deposits
See Calculus, Removal
Ionized 82330
Total 82310
Urine 82340
Calcium-Binding Protein, Vitamin K-Dependent
See Osteocalcin
Calcium-Pentagastrin Stimulation 80410

Calculus
Analysis 82355, 82360, 82365, 82370
Destruction
Bile Duct 43265, 47544
Extracorporeal Shock Wave Lithotripsy 50590
Gallbladder 47544
Pancreatic Duct 43265
Extraction
Bladder 51065
Kidney 50080, 50081
Liver 50080, 50081
Transduodenal 47460
Fragmentation
Bile Duct 43265
Bladder 52317, 52318
Kidney 50080, 50081
Liver 50080, 50081
Ureter 51065, 52325, 52353
Removal
Bile Duct 43264, 47544, 47554
Biliary Tract 47400, 47420, 47425, 47480
Bladder 51050, 52310, 52315, 52352
Gallbladder 47544
Kidney 50060, 50065, 50070, 50075, 50080, 50081, 50130, 50561, 50580, 52352
Liver 47400
Pancreatic Duct 43264, 48020
Renal Pelvis 50075, 50080, 50081, 50130
Salivary Duct 42330, 42335, 42340
Ureter 50610, 50620, 50630, 50945, 50961, 50980, 52310, 52315, 52320, 52352
Calculus of Kidney
See Calculus, Removal, Kidney
Caldwell-Luc Procedure
Orbital Floor Blowout Fracture 21385
Sinusotomy 21385
Caliper
Application/Removal 20660
Callander Knee Disarticulation
See Disarticulation, Knee
Callosum, Corpus
See Corpus Callosum
Calmette-Guerin Bacillus Vaccine
See BCG Vaccine
Caloric Vestibular Test 92533

Calprotectin
Fecal 83993
Calycoplasty 50405
Camey Enterocystoplasty 50825
CAMP
See Cyclic AMP
Campbell Procedure 27422
Campylobacter
Antibody 86625
Campylobacter Pylori
See Helicobacter Pylori
Canal, Ear
See Auditory Canal
Canalith Repositioning 95992
Canaloplasty 69631, 69635
Candida
Antibody 86628
Skin Test 86485
Cannulation
Arterial 36620, 36625
Arteriovenous 36810, 36815
Common Bile Duct 43273
Sinus
Maxillary 31000
Ostium 31235
Sphenoid 31002
Thoracic Duct 38794
with Transcatheter Aortic Valve Replacement (TAVR/TAVI)
Arterial and Venous 33367-33369
Vas Deferens 55200
Vein to Vein 36800
Cannulation, Renoportal
See Anastomosis, Renoportal
Cannulization
See also Cannulation
Arteriovenous 36810-36815
Declotting 36593, 36860, 36861
ECMO
See Extracorporeal Membrane Oxygenation (ECMO)
External
Declotting 36860, 36861
Vas Deferens 55200
Vein to Vein 36800
Canthocystostomy
Canthopexy
Lateral 21282
Medial 21280
Canthoplasty 67950
Canthorrhaphy 67880-67882
Canthotomy 67715
Canthus
Cap, Cervical
See Cervical Cap
Capsule (Drug)
Drug Delivery Implants
Clinical Brachytherapy 58346
Contraception 11976, 11981
Heyman 58346
Capsule (Tissue)
See also Capsulectomy; Capsulodesis; Capsulorrhaphy; Capsulotomy; Cataract
Ankle 27612, 27630
Biopsy 44100
Elbow 24006, 24149
Eye 66830
Finger 26160, 26520
Foot 28090, 28264, 28289, 28291
Hand 26160, 26520
Hip 27036
Injection 67515
Knee 27347, 27405, 27435
Leg 27630
Shoulder 23020
Tenon’s 67515
Toe 28270, 28272
Wrist 25320
Capsulectomy
Breast
Peri-Implant 19370, 19371
Elbow 24149
Foot 28090
Hand 26160, 26520
Hip 27036
Knee 27347
Capsulodesis
Wrist 25320
Capsulorrhaphy
Ankle 27630
Anterior 23450, 23455, 23460, 23462
Bankart Procedure 23455
Magnuson Type 23450
Putti-Platt Procedure 23450
Breast
Peri-Implant Capsule Revision 19370
Glenohumeral Joint 23465, 23466
Multi-Directional Instability 23466
Posterior 23465
Shoulder 29806
Thermal 29999
Wrist 25320
Capsulotomy
Breast 19370
Eye 66830
Foot 28260-28262, 28264
Hip 27036
Knee 27435
Leg 27630
Shoulder 23020
Toe 28270-28272
Wrist 25085, 25320
Captopril 80416, 80417

Car Seat Testing 94780, 94781
Carbamazepine
Assay 80156, 80157
Carbazepin
See Carbamazepine
Carbinol
See Methanol
Carbohydrate Deficient Transferrin 82373
Carbon Dioxide
Blood or Urine 82374, 82803
Carbon Tetrachloride 82441
Carboxycathepsin
See Angiotensin II
Carboxyhemoglobin 82375, 82376, 88740
Carbuncle
Carcinoembryonal Antigen
See Carcinoembryonic Antigen
Carcinoembryonic Antigen
Detection 82378
Cardiac
Aorta
See Aorta
Arteries and Veins
See under Artery; Vein
Atrium
See Atria
Catheterization
See Cardiac Catheterization
Devices
See Cardiac Assist Devices
Diagnostic Imaging
See Cardiology, Diagnostic; Vascular Studies
Heart
See Heart
Myocardium
See Myocardium
Pacemaker
See Cardiac Assist Devices, Pacemaker System
Pericardium
See Pericardium
Tumor
See Heart, Tumor
Valves
See Aortic Valve; Mitral Valve; Pulmonary Valve; Tricuspid Valve
Cardiac Arrhythmia, Tachycardia

See Tachycardia
Cardiac Assist Devices
Cardiac Contractility Modulation System
Device Evaluation 0417T, 0418T
Relocation of Skin Pocket 0416T
Removal 0412T, 0413T
Replacement 0414T
Repositioning 0415T
Cardiovascular Physiologic Monitor System
Device Evaluation 93290, 93297
Implantable Defibrillators
Subcutaneous Implantable Defibrillator (SICD)
Device Evaluation 93260, 93261, 93287, 93295, 93296, 93644
Insertion
Electrode 33202, 33203, 33271
Pulse Generator 33230, 33231, 33240
System 33270
Relocation of Skin Pocket 33223
Removal 33241, 33262, 33272
Repair, Electrode 33218, 33220
Replacement, Pulse Generator 33262
Repositioning, Electrode 33215, 33273
Transvenous Implantable Pacing Defibrillator (ICD)
Device Evaluation 93282-93284, 93287, 93289, 93295, 93296
Insertion
Electrode 33202, 33203, 33216, 33217, 33224, 33225
System 33249
Removal
Electrodes 33244
Pulse Generator 33241, 33262-33264
Replacement, Pulse Generator 33262-33264
Ischemia Monitoring System
Insertion or Replacement 0525T-0527T
Removal 0530T-0532T
Pacemaker System
Device Evaluation 93279-93281, 93286, 93288, 93293, 93294, 93296, 93724
Insertion
Electrode 33202, 33203, 33210, 33211, 33216, 33217, 33224, 33225
Lead 33206-33208, 33216, 33217
System 33206-33208
Removal 33233-33237
Repair, Electrode 33218-33220
Replacement
Catheter/Electrode 33210, 33211
Pulse Generator 33227-33229
Single-to-Dual Chamber System Upgrade 33214
Pacemaker System, Leadless
Device Evaluation 93279, 93286, 93288, 93294, 93296
Transcatheter Insertion 33274
Transcatheter Removal 33275
Transcatheter Replacement 33274
Subcutaneous Cardiac Rhythm Monitor System
Device Evaluation 93285, 93291, 93298
Insertion 33285
Removal 33286
Substernal Implantable Cardioverter-Defibrillator
Electrophysiological Evaluation 0577T
Insertion 0571T, 0572T
Interrogation Device Evaluation 0576T, 0578T, 0579T
Removal and Replacement of Pulse Generator 0614T
Removal of Electrode 0573T
Removal of Pulse Generator 0580T
Replacement 0571T
Repositioning of Electrode 0574T
Wireless Cardiac Stimulation System
Removal 0518T
Replacement 0519T, 0520T
Cardiac Atria
See Atria
Cardiac Catheterization
for Angiography
Bypass Graft(s) 93455, 93457, 93459, 93461
Congenital Heart 93563, 93564
Coronary 93454-93461, 93563, 93571
Left Atrial 93565
Left Ventricular 93565
Pulmonary 93568
Right Atrial 93566
Right Ventricular 93566
for Biopsy 93505
Combined Left and Right Heart 93460, 93461
with Left Ventriculography 93453, 93460, 93461
Combined Right and Retrograde Left
Congenital Cardiac Anomalies 93531
Combined Right and Transseptal Left
Congenital Cardiac Anomalies 93532, 93533
Congenital Cardiac Anomalies 93530-93533
for Congenital Prosthetic Valve Implantation 33477
for Dilution Studies 93561, 93562
for Flow Measurement 93571, 93572
Imaging 93452-93461, 93563-93568
Injection 93454-93461, 93563-93568
Insertion
Flow Directed Catheter
Swan-Ganz 93503
Left Heart
by Transapical Puncture 93462
by Transseptal Puncture through Intact Septum 93462
with Ventriculography 93452, 93458, 93459, 93565
for Measurement of Oxygen/Cardiac Output 93451
for Opacification
Bypass Grafts 93564
Pacemaker 33210
Right Heart 93451, 93456, 93503
for Supravalvular Aortography 93567
Cardiac Electroversion 92960, 92961

Cardiac Event Recorder
See Subcutaneous Cardiac Rhythm Monitor System
Cardiac Magnetic Resonance Imaging (CMRI)

Morphology and Function 75557, 75559, 75561, 75563
Stress 75559, 75563
Velocity Flow Mapping 75565
Cardiac Massage
Thoracotomy 32160
Cardiac Output
Indicator Dilution 93561, 93562
Cardiac Rehabilitation 93797, 93798
Cardiac Transplantation
See Heart, Transplantation
Cardiectomy
Donor 33930, 33940
Cardioassist 92970, 92971

Cardiography
Acoustic 93799
Arterial Pressure Waveform Analysis 93050
Magnetocardiography 0541T, 0542T
Cardiolipin Antibody 86147

Cardiology
Diagnostic
Arrhythmia Induction 93618-93624, 93640, 93641, 93653-93656
Arterial Pressure Waveform Analysis 93050
Atrial Electrogram 93615, 93616
Bioimpedance-derived Analysis 93701
Blood Pool Imaging 78472, 78473, 78481, 78483, 78494, 78496
Echocardiography
See Echocardiography
Electrocardiography
See Electrocardiography
Ergonovine Provocation Test 93024
Heart Imaging
Computed Tomography 75572, 75573
Computed Tomographic Angiography 75574
Magnetic Resonance 75557, 75559, 75561, 75563, 75565
Intracardiac Pacing and Mapping
3D Mapping 93613, 93654
Follow-up Study 93624
Localization 93631
Slow Conduction Zone 93631
Stimulation and Pacing 93623
Tachycardia Sites 93631
Intracardiac Pacing and Recording
Arrhythmia Induction 93618-93624, 93653, 93654, 93656
Bundle of His 93600, 93619, 93620, 93653, 93654, 93656
Comprehensive 93619-93622
Intra-Atrial 93602, 93610, 93616, 93656
Right Ventricular 93603, 93653, 93656
Ventricular 93612
Intravascular Ultrasound 92978, 92979
Myocardial Imaging
CT Scan 78429, 78433
Magnetocardiography (MCG) 0541T, 0542T
PET Metabolic Study 78429, 78432, 78433, 78459
PET Perfusion Studies 78430-78434, 78491, 78492
Planar Infarct Avid 78466, 78468, 78469
Planar Perfusion Studies 78453, 78454
SPECT Studies 0332T, 78451, 78452, 78469
Sympathetic Innervation 0331T, 0332T
Stress Tests
Cardiovascular 93015-93018
Drug Induced 93024
Multiple Gated Acquisition (MUGA) 78473
Temperature Gradient Studies 93740
Tilt Table Evaluation 93660
Venous Pressure Determination 93784, 93786, 93788, 93790
Therapeutic
Ablation 93650, 93653-93656
Cardioassist 92970, 92971
Cardioversion 92960, 92961
Intravascular Ultrasound 92978, 92979
Pacing 92953
Rehabilitation 93668, 93797, 93798
Thrombolysis 92975-92977
Thrombolysis, Coronary 92977
Valvuloplasty 92986-92990
Cardiomyotomy
See Esophagomyotomy
Cardioplasty 43320
Cardiopulmonary Bypass
with Aortic Aneurysm Repair 33877
with Ascending Aorta Graft 33858, 33859, 33863, 33864
with Atrial Septectomy/Septostomy 33736
with Chamber Fistula Repair 33500
with Descending Thoracic Aorta Graft 33875
with Lung Transplant 32852, 32854
with Operative Ablation 33251, 33256, 33259, 33261
with Pericardiectomy 33031
with Pulmonary Artery Repair 33910, 33916, 33922, 33926
with Replacement of Ventricular Assist
Device 33983
with Septal Defect Repair
See Septal Defect
with Sinus of Valsalva Repair 33702, 33720
with Transcatheter Aortic Valve Replacement (TAVR/TAVI) 33367-33369
with Transverse Arch Graft 33871
with Tumor Excision/Resection 33120
with Valve Repair
See Aortic Valve; Mitral Valve; Pulmonary Valve; Tricuspid Valve
with Wound Repair 33305
Cardiopulmonary Resuscitation 92950

Cardiotomy 33310-33315
Cardiovascular Stress Test
See Exercise Stress Tests, Cardiovascular
Care
Custodial
See Nursing Facility Services
Intensive
See Intensive Care
Neonatal Intensive
See Neonatal Critical Care
Self
See Self-Care
See Physician Services, Care Plan Oversight
Carinal Reconstruction
See Trachea, Reconstruction
Carneous Mole
See Abortion, Incomplete
Carnitine 82379
Carotene 82380
Caroticum, Glomus
See Carotid Body
Carotid Artery
See Artery, Carotid
Carotid Body
Tumor
Carpal Bone
See also Wrist
Arthroplasty
with Implant 25443
Cyst
Dislocation
Excision 25210, 25215
Partial 25145
Fracture
Closed Treatment 25622, 25630, 25635, 25645
Insertion
Vascular Pedicle 25430
Ligament Release 29848
Osteoplasty
Shortening 25394
Prosthetic Placement 25443
Repair
with Fixation 25628
Nonunion 25431, 25440
with Styloidectomy 25440
Scaphoid (Navicular)
Fracture 25622, 25624, 25628
Nonunion Repair 25440
Tumor
Excision 25130, 25135, 25136
Tunnel
See Carpal Tunnel
Carpal Tunnel
Injection
Therapeutic 20526
Median Nerve Neuroplasty 64721
Carpal Tunnel Syndrome

Decompression 64721
Carpals
Carpectomy 25210, 25215

Arthrodesis 25800
Finger 26843, 26844
Thumb 26841, 26842
Arthrotomy 26070
Biopsy 26100
Dislocation
Drainage 26070
Exploration 26070
Fusion
Hand 26843, 26844
Thumb 26841, 26842
Magnetic Resonance Imaging 73221-73225
Removal
Foreign Body 26070
Repair 25447
Synovectomy 26130
Cartilage, Arytenoid
See Arytenoid
Cartilage, Ear
See Ear Cartilage
Cartilage Graft
Costochondral 20910
Ear 21235
for Mandibular Condyle Reconstruction 21247
Nasal Septum 20912
Rib 21230
for Zygomatic Arch Reconstruction 21255
Cartilaginous Exostoses
See Exostosis

Online 98970-98972, 99421-99423
Team Conferences 99366-99368
Telephone Calls 98966-98968, 99441-99443
Cast
See also Brace; Splint
Ambulatory 29355, 29425, 29440
Below Knee to Toes 29405
Body
Halo 29000
Removal 29700
Repair 29720
Risser Jacket 29010
Shoulder to Hips 29035
Club Foot 29450, 29750
Cylinder 29365
Elbow to Finger 29075
Figure-of-eight 29049
Finger 29086
Gauntlet 29085, 29750
Halo
Body Cast 29000
Cranial 20661
Femur 20663
Maxillofacial 21100
Pelvic 20662
Removal 20665
for Thin Skull Osteology 20664
Hand and Lower Forearm 29085
Hip Spica
1 and one-half 29325
1 Leg 29305
Both Legs 29325
Leg 29445, 29450
Long Arm 29065
Long Leg 29358, 29450
Minerva 29040
Patella Tendon Bearing (PTB) 29435
Removal 29700, 29705, 29710
Repair 29720
Rigid Total Contact 29445
Risser Jacket
Body 29010
with Head 29015
Short Arm 29075
Short Leg 29405, 29450
Shoulder Spica 29055
Shoulder to Hand 29065
Shoulder to Hip 29035
with 1 Thigh 29044
with Both Thighs 29046
with Head 29040
Spica 29055, 29305, 29720
Thigh to Ankle 29365
Thigh to Toes 29345, 29355
Velpeau 29058
Walker 29355, 29425, 29440
Wedging 29740, 29750
Windowing 29730
Casting
Castration
See Orchiectomy
Castration, Female
See Oophorectomy
CAT Scan
See CT Scan
Cataract
Discission 66820, 66821
Excision 66830
Dilated Fundus Evaluation 2020F
Extraction/Removal
Extracapsular 66982, 66984
with Endoscopic Cyclophotocoagulation 66987, 66988
Intracapsular (ICCE) 66983
Incision 66820, 66821
Laser 66821
Stab Incision 66820
Intraoperative Visual Axis Identification
Patient Fixation 0514T
Presurgical Measurement and Calculations 3073F
Catecholamines 80424, 82382-82384
Blood 82383
Panel for Pheochromocytoma 80424
Urine 82382
Cathepsin-D 82387
Catheter
See also Cannulation; Catheterization; Venipuncture
Aspiration
Nasotracheal 31720
Balloon
See Balloon Angioplasty
Biopsy 37200
Bladder 51701-51703
Irrigation 51700
Blood Specimen Collection 36592, 37799
Conversion
Biliary Drainage
External to Internal-External 47535
Nephrostomy to Nephroureteral 50434
for Cystourethroscopy 52320-52356
Declotting 36593, 36861
Drainage
Biliary
Conversion 47535
Exchange 47536
Removal 47537
Pericardial 33017-33019
Peritoneal 49406, 49407
Pleural 32556, 32557
Retroperitoneal 49406, 49407
Spinal 62272, 62329
Ureteral 50693
Ventricular 62162, 62164
Visceral 49405
Electrode Array 63650
for Embolectomy 34001, 34051, 34101-34111, 34151, 34201, 34203
Embolization 61624, 61626
Peritoneal 49423
for Enteral Alimentation 44015
Exchange
with Biliary Stent Placement 47538-47540
Nephrostomy 50435
Flow Directed 93503
Home Visit for Care 99507
for Infusion
Brachial Plexus 64416
Femoral Nerve 64448
Lumbar Plexus 64449
Saline 58340
Sciatic Nerve 64446
for Instillation
Fibrinolysis 32561, 32562
Pleurodesis 32560
Intraperitoneal, Tunneled
Insertion
Laparoscopic 49324
Open 49421
Obstruction Clearance 36595, 36596
Occlusion 61624, 61626
Placement
See Catheterization
for Radiation Source Placement 61770
Removal
with Biliary Stent Placement 47538-47540
Central Venous 36589
Foreign Body 37197
Peritoneal 49422
Spinal Cord 62355
Repair
Intraperitoneal 49325
Replacement
Central Venous 36580, 36581, 36584
Nephroureteral, Externally Accessible 50387
Shunt System 62230
Subarachnoid 62194
Subdural 62194
Ventricular 62225
Repositioning
for Stent Placement 33621, 61635
for Thrombectomy 34001, 34051, 34101-34111, 34151, 34201, 34203, 34401, 34421, 34451
Arterial, for Chemotherapy 36640
Arterial, Intracranial 61650, 61651
Epidural or Subarachnoid 62320-62327
Newborn 36660
Thrombolysis 37211-37214
Ureteral
Manometric Studies 50396, 50686
Ureterography 50684
Ureteropyelography 50684
Catheterization
See also Catheter
Abdomen 49421
Abdominal Artery 36245-36248
Aorta 36160, 36200
Arterial System 36215, 36245-36248
Cutdown 36625
Intracatheter/Needle 36100-36140
Percutaneous 36620
Bile Duct
Percutaneous
Conversion 47535
Exchange 47536
Removal 47537
Bladder 51045, 51102, 51702, 51703
Brachiocephalic Artery 36215-36218
Brain 61210
Replacement 62160, 62194, 62225
Breast
for Interstitial Radioelement Application 19296-19298, 20555, 41019
Bronchus
Cardiac
Carotid Artery 36100, 36221-36224, 36227, 36228
Central Venous
See Central Venous Catheter Placement
Cerebral Artery 36215
Cholecystostomy 47490
Coronary Artery 93455
Cystourethroscopy
Ejaculatory Duct 52010
Ureteral 52005
Dialysis 36901-36903, 49418, 49419, 49421
Extremity Artery 36140
Fallopian Tube 58345, 74742
Gastrointestinal 43241
Hepatic Vein 37182, 37183
Intracardiac
Ablation 93650, 93653-93657
Intracranial Neuroendoscopic Ventricular 62160
Intraperitoneal Tunneled 49324, 49421
Jejunum
for Enteral 44015
Kidney
Percutaneous
for Nephrostomy 50432
Nephroureteral 50433
Legs 36245-36248
Nasotracheal 31720
Newborn
Umbilical Vein 36510
Pelvic Artery 36245-36248
Pericardium 33017-33019
Peripherally Inserted 36568-36573
Pleural Cavity 32550-32552
Portal Vein 36481, 37182, 37183
Pulmonary Artery 36013-36015
Radioelement Application 19296, 19297, 20555, 31643, 55875
Genitalia 55920
Head 41019
Neck 41019
Pelvic Organs 55920
Prostate 55875
Salivary Duct 42660
Selective
See Selective Catheterization
Skull 61107
Spinal Cord 62350, 62351
Thoracic Artery 36215-36218
Umbilical Artery 36660
Ureter
Endoscopic 50553, 50572, 50953, 50972, 52005
Injection 50684
Manometric Studies 50396, 50686
via Kidney 50693
Uterus
Radiology 58340
Vena Cava 36010
Venous
Central Line
See Central Venous Catheter Placement
First Order 36011
for Organ Blood Sampling 36500
Second Order 36012
Ventricular 61020-61026, 61210-61215, 62160-62162, 62164, 62225
Vertebral Artery 36100, 36221, 36225, 36226, 36228
Cauda Equina
See also Spinal Cord
Decompression
Cervical 63001, 63015, 63045, 63048
Lumbar 63005, 63012, 63017, 63047, 63048, 63056, 63057, 63087, 63088, 63090, 63091
Sacral 63011, 63090, 63091
Thoracic 63003, 63016, 63046, 63048, 63055, 63057, 63087, 63088, 63090, 63091
Exploration
Cervical 63001, 63015
Lumbar 63005, 63012, 63017
Sacral 63011
Thoracic 63003, 63016
Cauterization
Anus
Control of Bleeding 46614
Fissure 46940, 46942
Hemorrhoid Destruction 46930
Tumor Removal 46610, 46612
Cervix 57522
Cryocautery 57511
Electro or Thermal 57510
Laser Ablation 57513
Chemical
Corneal Epithelium 65435, 65436
Granulation Tissue 17250
Colon
Control of Bleeding 45334, 45382
Lesion Removal 45384
Polyp Removal 45384
Cornea 65450
Ectropion Repair 67915
Entropion Repair 67922
Esophagus
Everted Punctum 68705
Intrarenal Stricture 52343, 52346
Iris 66155
Lacrimal Punctum Closure 68760
Nasopharyngeal Hemorrhage 42970
Nose
Hemorrhage 30901, 30903, 30905, 30906
Prostate Resection 52601
Rectum
Skin Lesion 11055-11057, 17000-17004
Skin Tags 11200, 11201
Small Intestine
Control of Bleeding 44366, 44378, 44391
Turbinate Mucosa
Electrocautery 30801, 30802
Ureteral Stricture 52341, 52344
Ureteropelvic Junction Stricture 52342, 52345
Urethral Caruncle 53265
Cavernitides, Fibrous
See Peyronie Disease
Cavernosography
Corpora 54230
Cavernosometry 54231
Cavities, Pleural
See Pleural Cavity
Cavus Foot Correction 28309

CBC
CCL4
See Carbon Tetrachloride
CCU Visit
See Critical Care Services
CD4 86360
CD8 86360
CD142 Antigens
See Thromboplastin
CD143 Antigens
CEA
See Carcinoembryonic Antigen
Cecil Repair
See Urethroplasty
Cecostomy
with Colectomy 44141
Laparoscopic 44188
Obstructive Material Removal 49460
Skin Level 44320
Tube
Insertion
Open 44300
Percutaneous 49442
Radiological Evaluation 49465
Replacement 49450
Celiac Plexus
Destruction 64680
Injection
Anesthetic 64530
Neurolytic 64680
Celiac Trunk Artery

See Artery, Celiac
Celioscopy
See Endoscopy, Peritoneum
Celiotomy 49000
Cell, Blood
See Blood Cell
Cell, Islet
See Islet Cell
Cell, Mother
See Stem Cell
Cell Count
B Cells 86355
Bacterial Colony 87086
Body Fluid 86152, 86153
Other than Blood 89050, 89051
CD4 86360, 86361
CD8 86360
CD34 86367
Chromosome Analysis
See Chromosome Analysis
Natural Killer (NK) 86357
Sperm 89310, 89320, 89322
Stem 86367
T Cells 86359-86361
Cellobiase
See Beta Glucosidase
Cell-Stimulating Hormone, Interstitial

See Luteinizing Hormone (LH)
Cellular Inclusion
See Inclusion Bodies
Central Shunt 33764

Central Venous Catheter Placement
Insertion
Central
Non-tunneled 36555, 36556
Tunneled with Port 36560, 36561, 36566
Tunneled with Pump 36563
Tunneled without Port or Pump 36557, 36558, 36565
Peripheral
with Port 36570, 36571
without Port or Pump 36568, 36569
Repair
with Port or Pump 36576
without Port or Pump 36575
Replacement
Catheter Only 36578
Complete
Central 36580-36583
Peripheral 36584, 36585
Repositioning 36597
Central Venous Catheter Removal 36589

Cephalic Version
of Fetus
Anesthesia 01958
External 59412
Cephalocele
See Encephalocele
Cephalogram, Orthodontic
See Orthodontic Cephalogram
Cerclage
Cervix 57700
Abdominal 59325
Removal under Anesthesia 59871
Vaginal 59320
Femoral Fracture 27244, 27245, 27506, 27507
Humeral Shaft Fracture 24515, 24516
Tibial Shaft Fracture 27758, 27759
Cerebellopontine Angle Tumor
Excision 61520, 61526, 61530
Cerebral Death
See Brain Death
Cerebral Hernia
See Encephalocele
Cerebral Perfusion Analysis

CT Scan 0042T
Cerebral Ventriculographies
Cerebral Vessels
Anastomosis 61711
Aneurysm Surgery
Carotid Artery Occlusion 61705, 61708, 61710
Cervical Approach 61703
Intracranial Approach 61697, 61698, 61700, 61702
Angioplasty 61630
Arteriovenous Malformation Surgery
Dural 61690, 61692
Fistula 61705
Infratentorial 61684, 61686
Supratentorial 61680-61682
Dilation
Intracranial Vasospasm 61640-61642
Occlusion 61623
Placement
Stent
Intravascular 61635
Thrombolysis 37195
Cerebrose
See Galactose
Cerebrospinal Fluid
Drainage
Spinal Puncture 62272, 62329
Flow Imaging
Cisternography 78630
Leakage Detection and Localization 78650
Shunt Evaluation 78645
Tomographic (SPECT) 78803
Ventriculography 78635
Leak
See Cerebrospinal Fluid Leak
Shunt
See Cerebrospinal Fluid Shunt
Test
Cell Count 89050
Immunoelectrophoresis 86325
Myelin Basic Protein 83873
Protein, Total 84157
Cerebrospinal Fluid Leak
Repair
Craniotomy 62100
with Nasal/Sinus Endoscopy 31290, 31291
with Skull Base Surgery 61618, 61619
Cerebrospinal Fluid Shunt

Creation 62190, 62192, 62220, 62223
Lumbar 63740, 63741
Flow Monitoring
Skin Sensor 0639T
Removal 62256, 62258, 63746
Replacement 62160, 62258, 63744
Catheter 62194, 62225, 62230
Valve 62230
Reprogramming 62252
Torkildsen Operation 62180
Ventriculocisternostomy 62180, 62200, 62201
Ceruloplasmin 82390
Cerumen
Removal
with Instrumentation 69210
with Irrigation/Lavage 69209
Cervical Cap 57170
Cervical Lymphadenectomy 38720-38724
Cervical Mucus Penetration Test 89330
Cervical Plexus
Nerve Conduction Studies 64999
Cervical Pregnancy 59140
Cervical Puncture 61050-61055
Cervical Smears
Cytopathology
Automated Screen 88174
Hormone Evaluation 88155
Manual Screen 88150, 88153, 88164, 88165
Partially Automated Screen 88147, 88148, 88152, 88166, 88167, 88175
Physician Interpretation 88141
Pap
Any Reporting System 88174, 88175
Non-Bethesda 88150, 88152, 88153
Cervical Spine
See Vertebra, Cervical
Cervical Sympathectomy
See Sympathectomy, Cervical
Cervicectomy
Amputation of Cervix 57530
Pelvic Exenteration 45126, 58240
Cervicocerebral Arch
Angiography
See Angiography, Cervicocerebral Arch
Cervicoplasty 15819
Cervicothoracic Ganglia
See Stellate Ganglion
Cervix
See Cytopathology
Acetowhitening Effect
Imaging/Quantification 57465
Amputation
Total 57530
Biopsy 57500, 57520
Colposcopy 57454, 57455, 57460
Cauterization
Cryocautery 57511
Electro or Thermal 57510
Laser Ablation 57513
Cerclage 57700
Abdominal 59325
Removal under Anesthesia 59871
Vaginal 59320
Colposcopy 57452, 57454-57456, 57460, 57461
with Computer-aided Mapping 57465
Conization 57461, 57520, 57522
Curettage
Endocervical 57454, 57456, 57505
Dilation
Canal 57800
Stump 57558
Dilation and Curettage 57520, 57558
Excision
Radical 57531
Stump
Abdominal Approach 57540, 57545
Vaginal Approach 57550, 57555, 57556
Total 57530
Exploration
Endoscopy 57452
Insertion
Dilator 59200
Laminaria 59200
Prostaglandin 59200
Repair
Cerclage 57700
Abdominal 59325
Suture 57720
Vaginal 59320
Unlisted Nonobstetrical Services and Procedures 58999
Cesarean Delivery
Antepartum Care 59610, 59618
Delivery Only 59514
Delivery with Postpartum Care 59515
with Hysterectomy 59525
Previous Cesarean Delivery
Unsuccessful Attempted Vaginal Delivery
Cesarean Delivery Only 59620
Routine Care 59618
Vaginal Delivery
Delivery Only 59612
Routine Care 59610
Routine Care 59510
with Tubal Ligation during Delivery 58611
Chalazion
Excision 67800
under Anesthesia 67808
Multiple
Different Lids 67805
Same Lid 67801
Single 67800
Challenge Tests
Bronchial Inhalation 95070
Cholinesterase Inhibitor 95857
Ingestion 95076, 95079
Chambers Procedure 28300
Change
Catheter
Percutaneous Drainage, with Contrast Monitoring 75984
Dressing, under Anesthesia 15852
Fetal Position
by Manipulation 59412
Stent
Bile or Pancreatic Duct 43276
Ureteral 50688
Tube
Percutaneous, with Contrast Monitoring 75984
Tracheotomy 31502
Ureterostomy 50688
Change of, Dressing

See Dressings, Change
CHCT
See Caffeine, Halothane Contracture Test (CHCT)
Cheek
Bone
Excision 21030, 21034
Fracture
Closed Treatment with Manipulation 21355
Fascia Graft 15840
Muscle Graft 15841-15845
Muscle Transfer 15845
Rhytidectomy 15828
Skin Graft 15240, 15241
Tissue Transfer
Adjacent 14040, 14041
Flap 15574, 15620
Cheilectomy
Metatarsophalangeal Joint Release 28289, 28291
Cheiloplasty
See Lip, Repair
Cheiloschisis
See Cleft Lip
Cheilotomy
See Incision, Lip
Chemical Cauterization
Granulation Tissue 17250
Chemical Exfoliation 17360

Chemical Peel 15788-15793
Chemiluminescent Assay 82397
Chemistry Tests
See Pathology and Laboratory, Chemistry
Unlisted Chemistry Procedure 84999
Chemocauterization
Corneal Epithelium 65435
with Chelating Agent 65436
Chemodenervation
Anal Sphincter 46505
Bladder 52287
Eccrine Glands
Axillae 64650
Other Area 64653
Extraocular Muscle 67345
Extremity Muscle 64642-64645
Facial Muscle 64612, 64615
Guidance
Electrical Stimulation 95873
Needle Electromyography 64617, 95874
Larynx 64617
Neck Muscle 64615, 64616
Trunk Muscle 64646, 64647
Chemonucleolysis 62292
Chemosurgery
Destruction of Benign Lesions 17110, 17111
Skin Lesion 17000-17004, 17110, 17111, 17270, 17280
Chemotaxis Assay 86155

Chemotherapy
Bladder Instillation 51720
Brain Implantation 61517
CNS Administration 96450
Extremity 36823
Home Infusion Procedures 99601, 99602
Intra-Arterial
Cannulation 36823
Infusion 96422, 96423, 96425
Insertion Infusion Pump 36260
Push 96420
Intralesional 96405, 96406
Intramuscular 96401, 96402
Intravenous
Infusion 96413, 96415, 96416, 96417
Infusion Pump 96416
Push 96409, 96411
Kidney Instillation 50391
Peritoneal Cavity 96446
Pleural Cavity 96440
Pump Services
Implantable 96522
Maintenance 95990, 95991
Portable 96521
Reservoir Filling 96542
Response Assessment
Cytotoxicity Assay of Cancer Stem Cells (CSCs) 0564T
Subcutaneous 96401, 96402
Ureteral Instillation 50391
Venous Cannulation 36823
Chest
See also Mediastinum; Thorax
Artery
Ligation 37616
Diagnostic Imaging
Angiography 71275
CT Angiography 71275
CT Scan 71250, 71260, 71270
Magnetic Resonance Angiography 71555
PET Imaging 78811, 78814
Ultrasound 76604
X ray
See X ray, Chest
Exit Site, Intraperitoneal Cannula/Catheter 49435
Exploration
Penetrating Wound 20101
Postoperative
Hemorrhage 35820
Infection 35820
Thrombosis 35820
Repair
Blood Vessel 35211, 35216
with Other Graft 35271-35276
with Vein Graft 35241, 35246
Tube
See Thoracostomy, Tube
Tumor
See Chest Wall, Tumor
Chest, Funnel
See Pectus Excavatum
Chest Cavity
Bypass Graft 35905
Thoracoscopy
See Thoracoscopy
Chest Wall
See also Pulmonology, Therapeutic
Manipulation 94667, 94668
Mechanical Oscillation 94669
with Lung Tumor Resection 32504
Trauma 32820
Repair 32905
Closure 32810
Fistula 32906
Lung Hernia 32800
Resection 32503
Tumor
Ablation
Cryoablation 32994
Radiofrequency Ablation 32998
Chiari Osteotomy of the Pelvis
See Osteotomy, Pelvis
Chicken Pox Vaccine

Varicella Virus (VAR) 90716
Child Procedure
Pancreatectomy 48146
Chimerism 81267, 81268

Chin
Cartilage Graft 21230
Repair
Augmentation 21120
Osteotomy 21121-21123
Rhytidectomy 15828
Skin Graft 15240, 15241
Tissue Transfer
Adjacent 14040, 14041
Flap 15574, 15620
Chinidin
See Quinidine
Chiropractic Manipulation
Extraspinal 98943
Spinal 98940-98942
Chiropractic Treatment
Extraspinal 98943
Spinal 98940-98942
Chlamydia
Antibody 86631, 86632
Antigen Detection
Amplified Nucleic Acid Probe 87486, 87491
Direct Nucleic Acid Probe 87485, 87490
Direct Optical 87810
Immunoassay 87320
Nucleic Acid Quantification 87487, 87492
Culture 87110
Chloramphenicol 82415
Chloride
Blood 82435
Other Source 82438
Panels
Basic Metabolic 80047, 80048
Comprehensive Metabolic 80053
Electrolyte 80051
Spinal Fluid 82438
Urine 82436
Chloride, Methylene
See Dichloromethane
Chlorinated Hydrocarbons 82441
Chlorohydrocarbon
See Chlorinated Hydrocarbons
Choanal Atresia
Repair 30540-30545
Cholangiography
with Conversion of Drainage Catheter 47535
with Exchange of Drainage Catheter 47536
with Placement of Access to Small Bowel 47541
with Placement of Drainage Catheter 47533, 47534
with Placement of Stent 47538-47540
Postoperative 47531
with Removal of Drainage Catheter 47537
Repair
with Bile Duct Exploration 47700
with Cholecystectomy 47563, 47605, 47620
Transhepatic
Laparoscopically Guided 47579
Cholangiopancreatography
with Ablation
Lesion 43278
Polyp 43278
Tumor 43278
with Biopsy 43261
with Collection of Specimen(s) 43260
with Exchange
Stent 43276
with Papillotomy 43262
with Placement
Stent 43274
with Pressure Measurement Sphincter of Oddi 43263
with Removal
Foreign Body 43275
Stent 43275, 43276
with Removal/Destruction of Calculus 43264, 43265
with Sphincterotomy 43262, 43274, 43276, 43277
with Transendoscopic Balloon Dilation 43277
Postoperative 47531
Cholangiostomy
See Hepaticostomy
Cholangiotomy
See Hepaticotomy
Cholecalciferol
See Vitamins, D, Blood Serum Level, 25 hydroxy
Cholecystectomy
Any Method
with Cholangiography 47563, 47605, 47620
with Choledochoenterostomy 47612
with Exploration Common Duct 47564, 47610
Donor Liver 47143
Cholecystenterostomy
Direct 47720
with Gastroenterostomy 47721, 47741
Laparoscopic 47570
Roux-en-Y 47740, 47741
Cholecystography 47490, 74290
Cholecystostomy
Open 47480
Percutaneous 47490
with Peripancreatic Drain Placement 48000
Cholecystotomy
with Choledochostomy 47420
with Choledochotomy 47420
Open 47480
Choledochoplasty
See Bile Duct, Repair
Choledochoscopy
Biliary Endoscopy 47550
Choledochostomy
Biliary Tract 47420, 47425
Choledochotomy
Biliary Tract 47420, 47425
Choledochus, Cyst
See Cyst, Choledochal
Cholera Vaccine
Live, for Oral Use 90625
Cholesterol
Measurement
HDL 83718
LDL 83721
Panel
Lipid 80061
Serum 82465
VLDL 83719
Choline Esterase I
See Acetylcholinesterase
Choline Esterase II
See Cholinesterase
Cholinesterase
Blood 82480, 82482
Cholylglycine
Blood 82240
Chondroitin Sulfate
Detection 82485
Chondromalacia Patella
Repair 27418
Chondropathia Patellae
See Chondromalacia Patella
Chopart Procedure
Amputation, Foot 28800-28805
Chordotomies
See Cordotomy
Choriogonadotropin
See Chorionic Gonadotropin
Choriomeningitides, Lymphocytic
See Lymphocytic Choriomeningitis
Chorionic Gonadotropin
Qualitative 84703
Quantitative 84702
Stimulation Panel 80414, 80415
Chorionic Growth Hormone

Lactogen, Human Placental 83632
Chorionic Tumor
See Hydatidiform Mole
Chorionic Villi
See Biopsy, Chorionic Villus
Chorionic Villus
Biopsy 59015
Choroid
Aspiration 67015
Lesion 67220, 67221, 67225
Neovascularization 67043
Choroid Plexus
Excision 61544
Christmas Factor 85250
Chromaffinoma, Medullary
See Pheochromocytoma
Chromatin, Sex
See Barr Bodies
Chromatography
Column
See Drug Assay; Pathology and Laboratory, Chemistry
Unspecified Non-Drug Analyte(s) 82542
Column/Mass Spectrometry
See Pathology and Laboratory, Chemistry; specific analyte in Drug Assay
Drug Screen 80305-80307, 80320-80377
Gas Liquid or HPLC
See specific analyte in Pathology and Laboratory, Chemistry
Typing 87143
Hemoglobin 83021, 83036
Paper
Sugars 84375
Thin-Layer
Chromium 82495
Chromogenic Substrate Assay 85130
Chromosome Analysis
See also Amniocentesis
Added Study 88280, 88283, 88285, 88289
Amniotic Fluid 88267, 88269
Culture 88235
Biopsy Culture
Tissue 88233
Bone Marrow Culture 88237
Breakage Syndromes 88245, 88248, 88249
Ataxia Telangiectasia 88248
Clastogen Stress 88249
Fanconi Anemia 88248
Fragile-X 88248
Chorionic Villus 88267
5 Cells 88261
15-20 Cells 88262
20-25 Cells 88264
45 Cells 88263
Culture 88235
Cytogenomic Constitutional Microarray 81228, 81229
Cytogenomic Neoplasia Microarray 81277
Lymphocyte Culture 88230
Molecular Pathology, Level 5 81404
Pregnancy Associated Plasma Protein-A 84163
In Situ Hybridization 88272, 88273
Tissue Culture
Amniotic Fluid Cells 88325
Blood Cells 88237
Bone Marrow Cells 88237
Chorionic Villus Cells 88235
Skin 88233
Tumor 88239
Unlisted Cytogenic Study 88299
Chromotubation
Oviduct 58350
Chronic Erection
See Priapism
Chronic Interstitial Cystitides

See Cystitis, Interstitial
Ciliary Body
Cyst
Destruction 66770
Excision 66500, 66505
Destruction
Cryotherapy 66720
Cyclodialysis 66740
Cyclophotocoagulation 66710, 66711
Diathermy 66700
Endoscopic 66711
Lesion
Destruction 66770
Excision 66500, 66505
Repair 66680
Suture 66682
Cimino Type Procedure 36821

Cinefluorographies
See Cineradiography
Cineplasty
Arm, Lower or Upper 24940
Cineradiography
Esophagus 74230
Pharynx 70371, 74230
Site Unspecified 76120, 76125
Speech Evaluation 70371
Swallowing Evaluation 74230
Circulation, Extracorporeal
See Extracorporeal Circulation
Circulation Assist
See Ventricular Assist Device (VAD)
Aortic 33967, 33970
Balloon 33967, 33970
Circulatory Assist
See Circulation Assist
Circumcision
Repair
Adhesions 54162
Incomplete 54163
Surgical Excision 54161
Neonate 54150, 54160
Cisternal Puncture 61050, 61055

Cisternography
Cerebrospinal Fluid Flow Imaging 78630
Study 70015
Citrate
Clagett Procedure
Chest Wall Closure 32810
Clavicle
Arthrocentesis
Acromioclavicular Joint 20605, 20606
Arthrotomy
Acromioclavicular Joint 23044, 23101
Sternoclavicular Joint 23044, 23101, 23106
Bone Graft 23485
Craterization 23180
Cyst
Excision 23140
with Graft 23145, 23146
Diaphysectomy 23180
Dislocation
Sternoclavicular Joint
Excision 23170
Partial 23120, 23180
Total 23125
Fracture
Closed Treatment
Pinning, Wiring 23490
Prophylactic Treatment 23490
Repair
Malunion/Nonunion 23485
Osteotomy 23480
Saucerization 23180
Tumor
Excision 23140, 23145, 23146, 23200
with Graft 23145, 23146
X ray 73000
Clavicula
See Clavicle
Claviculectomy
Arthroscopic 29824
Open
Partial 23120
Total 23125
Claw Finger Repair 26499

Cleft, Branchial
See Branchial Cleft
Cleft Cyst, Branchial

See Branchial Cleft, Cyst
Cleft Foot
Cleft Hand
Repair 26580
Cleft Lip
Repair
with Pedicle Flap 40761
Primary 40700-40702
Secondary 40720
Rhinoplasty 30460-30462
Cleft Palate
Repair 42200-42225
Rhinoplasty 30460-30462
Clinical Act of Insertion
See Insertion
Clinical Chemistry Test

Clinical Pathology
Consultation 80500, 80502
Clitoroplasty
Intersex State 56805
Closed [Transurethral] Biopsy of Bladder
See Biopsy, Bladder, Cystourethroscopy
Clostridial Tetanus
See Tetanus
Clostridium Botulinum Toxin
See Chemodenervation
Clostridium Difficile
Antigen Detection
Immunoassay 87324
Immunoassay
with Direct Optical Observation 87803
Tissue Culture 87230
Toxin Genes Detection 87493
Clostridium Tetani ab
See Antibody, Detection, Tetanus
Closure 12001-13160
See also Repair, Wound
Anal Fistula 46288
Atrioventricular Valve 33600
Cystostomy 51880
Enterostomy 44227, 44620, 44625, 44626
Laparoscopic 44227
Lacrimal Fistula 68770
Lacrimal Punctum
Plug 68761
Thermocauterization, Ligation or Laser Surgery 68760
Left Atrial Appendage
with Implant 33340
Paravalvular Leak
Percutaneous Transcatheter
Mitral Valve 93590, 93592
Rectovaginal Fistula 57300, 57305, 57307, 57308
Semilunar Valve 33602
Septal Defect
Ventricular 33776, 33780, 93581
Ventricular Tunnel 33722
Closure, Atrial Septal Defect

See Atrial Septal Defect, Closure
Closure, Cranial Sutures, Premature
See Craniosynostosis
Closure, Fistula, Vesicouterine

See Fistula, Closure, Vesicouterine
Closure, Meningocele Spinal
See Meningocele Repair
Closure, Vagina
See Vagina, Closure
Closure of Esophagostomy
See Esophagostomy, Closure
Closure of Gastrostomy
See Gastrostomy, Closure
Clot (Thrombus)
Clotting
See Blood Coagulation, Test; Clotting Factor
Declotting
Artery
Balloon Catheter 36861
External Cannula 36860
Central Venous Access Device 36593
Eye 65930
Pericardium 32658, 33020
Ureter
Cystourethroscopic 52001
Dissolution
See Thrombolysis
Excision
See Thrombectomy; Thromboendarterectomy
Clot Lysis Time
Euglobin Lysis 85360
Whole Blood Dilution 85175
Clot Retraction
Coagulation Test 85170
Clotting
Clotting Disorders
See Coagulopathy
Clotting Factor
Factor I
See Fibrinogen
Factor II (Prothrombin) 85210
Factor III (Thromboplastin)
Inhibition Test 85347
Partial Time 85730, 85732
Factor IV
See Calcium
Factor IX (Christmas Factor) 85250
Factor VII (Proconvertin) 85230
Factor VIII
AHG 85240
Related Antigen 85244
von Willebrand factor 85247
VW factor 85245, 85246
Factor X (Stuart-Prower) 85260
Factor X (Thrombokinase) 85260
Factor XI (Plasma Thromboplastin, Antecedent [PTA]) 85270
Factor XII (Hageman Factor) 85280
Factor XIII (Fibrin Stabilizing) 85290, 85291
Inhibition 85705
Clotting Inhibitors
Tests
Factor Inhibitor 85335
Mixed Screen 85611, 85732
Protein C 85302, 85303, 85307
Protein S 85305, 85306
Thrombomodulin 85337
Thromboplastin Inhibition 85705
Clotting Test
Clot Lysis Time 85175
Clot Retraction 85170
Clotting Factors
See Clotting Factors
Inhibitors
Protein C 85303, 85307
Protein S 85305, 85306
Clotting Time
Coagulation Time 85345, 85347, 85348
Clozapine
Drug Assay 80159
Clubfoot Cast 29450

Wedging 29750
CMG
See Cystometrogram
CMRI
See Cardiac Magnetic Resonance Imaging (CMRI)
CMV
See Cytomegalovirus
CNPB
See Continuous Negative Pressure Breathing (CNPB); Pulmonology, Therapeutic
CO2
See Carbon Dioxide
Coagulation
Tests
ADAMTS-13 85397
Anticoagulants
Coagulation/Fibrinolysis Assay 85396
Coagulation/Fibrinolysis Functional
Activity 85397
Factor Inhibitor Test 85335
Factors
Inhibitors
Paracoagulation 85366
Unlisted Coagulation Procedures 85999
Coagulation, Blood
See Coagulation
Coagulation, Light
See Photocoagulation
Coagulation Defect
See Coagulopathy
Coagulation Factor
See Clotting Factor
Coagulation Time 85345-85348

Coagulin
See Thromboplastin
Coagulopathy
Assay 85130
Screen 85390
Coccidioides
Antibody 86635
Coccidioidin Test
See Streptokinase, Antibody
Coccidioidomycosis
Skin Test 86490
Coccygeal Spine Fracture

See Coccyx, Fracture
Coccygectomy 15920-15922, 27080

Coccyx
Excision 27080
Coccygeal Approach, Rectal Tumor 45160
Pressure Ulcer 15920-15922
Fracture
Tumor
Excision 49215
X ray 72220
Cochlear Device
Candidacy Evaluation 92626, 92627
Diagnostic Analysis 92601, 92603
Function Evaluation 92626, 92627
Implantation 69930
Interface with Osseointegrated Implant 69714, 69715, 69717
Programming 92602, 92604
Co-Factor I, Heparin
See Antithrombin III
Cofactor Protein S
See Protein S
Coffey Operation
See Uterus, Repair, Suspension
Cognitive Function Tests

See Neurology, Diagnostic
Cognitive Skills Development
Therapeutic Interventions 97129, 97130
Cold Agglutinin 86156, 86157

Cold Pack Treatment 97010
Cold Preservation
See Cryopreservation
Cold Therapies
See Cryotherapy
Colectomy
Partial 44140
with Anastomosis 44140
Laparoscopic 44204, 44207, 44208
with Coloproctostomy 44145, 44146
with Colostomy 44141-44144
with Ileocolostomy
Laparoscopic 44205
with Ileostomy 44144
with Ileum Removal 44160
Laparoscopic 44213
with Splenic Flexure Mobilization 44139
Laparoscopic 44213
with Transanal Approach 44147
Total
with Creation of Ileal Reservoir 44211
with Ileoanal Anastomosis 44211
with Ileoproctostomy 44210
with Ileostomy 44210-44212
with Proctectomy 44211, 44212
with Rectal Mucosectomy 44211
without Proctectomy 44210
Open
with Complete Proctectomy 45121
with Ileoproctostomy 44150
with Ileostomy 44150, 44151
with Proctectomy 44155-44158
Collagen Cross Links

Any Method 82523
Cornea 0402T
Collagen Injection 11950-11954
Collar Bone
See Clavicle
Collateral Ligament
Reconstruction
Elbow 24346
Reduction
Ulna 29902
Repair
Ankle 27695, 27696, 27698
Elbow 24345
Knee 27405, 27409
Collection and Processing
Aspirate
See Aspiration
Brushings
Abdomen 49320
Anus 46600, 46601
Biliary Tract 47552
Colon 44388, 45300, 45330, 45378
Duodenum 43235, 44360, 44376
Esophagus 43197, 43200, 43235
Hepatobiliary System 43260
Ileum 44376, 44380
Jejunum 43235
Omentum 49320
Peritoneum 49320
Rectum 45300, 45330
Small Intestine
Pouch 44385
Stomach 43235
Radiological Guidance 75989
Specimen
Capillary Blood 36416
for Dark Field Examination 87164
Duodenum 43756, 43757
Ear 36416
Hematoma 10140
Sputum 89220
Stomach 43754
Sweat 89230
Tears 83861
Venous Access Device 36591
Venous Blood 36415, 36591, 36592
Venous Catheter 36592
Stem Cells
Harvesting
Allogenic Blood 38205
Autologous Blood 38206, 86890, 86891
Processing 38210-38215
Washings
Abdomen 49320
Anus 46600, 46601
Biliary Tract 47552
Colon 44388, 45300, 45330, 45378
Duodenum 43235, 44360, 44376
Esophagus 43197, 43200, 43235
Hepatobiliary System 43260
Ileum 44376, 44380
Jejunum 43235
Omentum 49320
Peritoneum 49320
Rectum 45300, 45330
Small Intestine
Pouch 44385
Stomach 43235
Colles Fracture 25600-25605

Colles Fracture Reversed
See Smith Fracture
Collins Syndrome, Treacher

See Treacher-Collins Syndrome
Collis Procedure
See Gastroplasty with Esophagogastric Fundoplasty
Colon
See also Colon-Sigmoid
Ablation/Removal
Lesion 44392, 44394, 44401, 45384, 45388
Polyp 44392, 44394, 44401, 45384, 45388
Tumor 44392, 44394, 44401, 45384, 45388
Biopsy 44025, 44100, 44322, 44389, 44407, 45380, 45392
Endoscopic 44389, 45380, 45392
Closure
Fistula 44650, 44660, 44661
Stoma 44620, 44625, 44626
Colonoscopy
See Colonoscopy
Colostomy
See Colostomy
Colotomy
See Colotomy
CT Scan
Colonography 74261-74263
Endoscopy via Stoma
Biopsy 44389, 44407
Decompression 44408
Destruction
Lesion 44401
Polyp 44401
Tumor 44401
Dilation 44405
Exploration 44388
Hemorrhage Control 44391
Injection, Submucosal 44404
Removal
Foreign Body 44390
Lesion 44392, 44394
Polyp 44392, 44394
Tumor 44392, 44394
Stent Placement 44402
Ultrasound 44406
Excision
Partial 44140, 44141, 44143-44147, 44160
Total 44150, 44151, 44155-44158
Exploration 44025
Hemorrhage Control 44391, 45382
Intraluminal Imaging 0355T
Lavage
Lesion
Ablation 45388
Excision 44110, 44111
Lysis
Adhesions 44005
Motility Study 91117
Mucosal Resection 45390
Obstruction 44025-44050
Plication 44680
Reduction
Hernia 44050
Volvulus 44050
Removal
Foreign Body 44025, 44390, 45379
Polyp 44384
Repair
Intussusception 44050
Malrotation 44055
Volvulus 44050
Splenic Flexure Mobilization
Laparoscopic 44213
Open 44139
Suture
Diverticula 44602-44605
Injury 44602-44605
Rupture 44602-44605
Ulcer 44602-44605
Wound 44602-44605
Tumor
Ablation 45388
Removal 45384, 45385
Ultrasound
Endoscopic 45391, 45392
X ray with Contrast
Barium Enema 74270, 74280
Colonna Procedure
See Acetabulum, Reconstruction
Colonography
CT Scan
Screening 74263
Colonoscopy
Flexible
Ablation
Lesion 45388
Polyp 45388
Tumor 45388
Band Ligation 45398
Biopsy 45380, 45392
Collection of Specimen 45378
Decompression 45393
Diagnostic 45378
Dilation 45388
Transendoscopic Balloon 45386
Injection
Any Substance 45381
Placement
Stent 45389
Removal
Foreign Body 45379
Lesion 45384, 45385
Polyp 45384, 45385
Tumor 45384, 45385
Follow-up Intervals 0528F, 0529F
through Stoma
Ablation
Lesion 44401
Polyp 44401
Tumor 44401
Biopsy 44389, 44407
Decompression 44408
Diagnostic 44388
Dilation
Exploration 44388
Placement
Decompression Tube 44408
Stent 44402
Removal
Foreign Body 44390
Lesion 44392, 44394
Polyp 44392, 44394
Tumor 44392, 44394
Submucosal Injection 44404
Ultrasound
Biopsy 44407
Examination 44406
Colon-Sigmoid
See also Colon
Biopsy
Endoscopy 45331
Decompression 45337
Volvulus 45337
Endoscopy
Ablation
Lesion 45346
Polyp 45346
Tumor 45346
Band Ligation 45350
Biopsy 45331
Dilation 45340
Exploration
Needle Biopsy 45342
Placement
Stent 45327, 45347
Removal
Foreign Body 45332
Polyp 45333, 45338
Tumor 45333, 45338
Reconstruction
Bladder from Sigmoid Colon 50810
Color Vision Examination 92283

Colorrhaphy 44604
Colostomy
Abdominal 50810, 57307
Abdominoperineal 51597, 58240
with Colorrhaphy 44605
External Fistulization 44320
Paracolostomy Hernia 44346
Revision 44340
Home Visit 99505
Ileocolostomy 44160, 44205
Laparoscopic 44188, 44206, 44208
with Partial Colectomy 44141, 44143, 44144, 44146
Hartmann Type 44143
with Pelvic Exenteration 45126, 51597, 58240
Perineal 50810
with Proctectomy 45110
Laparoscopic 45395
with Rectal Repair 45563, 45805, 45825
Revision 44340, 44345, 44346
Colotomy
Biopsy 44025
Exploration 44025
Colpectomy
See Vaginectomy
Colpocentesis 57020
Colpoceliocentesis
See Colpocentesis
Colpocleisis Complete
See Vagina, Closure
Colpocleisis 57120
Colpohysterectomies
See Hysterectomy, Vaginal
Colpoperineorrhaphy 57210
Colpopexy
Abdominal 57280
Laparoscopic 57425
Vaginal 57282, 57283
Colpoplasty
See Repair, Vagina
Colporrhaphy
Anterior 57240, 57289
with Insertion of Mesh 57267
with Insertion of Prosthesis 57267
Anteroposterior 57260-57265
with Enterocele Repair 57265
Nonobstetrical 57200
Posterior 57250
Colposcopy
Biopsy
Cervix 57421, 57454, 57455
Loop Electrode Biopsy 57460
Loop Electrode Conization 57461
Endometrium 58110
Cervix 57420, 57421, 57454-57456, 57460, 57461
with Computer-aided Mapping 57465
and Upper/Adjacent Vagina 57452
Endometrium 58110
Exploration 57452
Vagina 57420, 57421, 57452
Vulva 56820
Biopsy 56821
Colpotomy
Exploration 57000
Pelvic Abscess Drainage 57010
Colpo-Urethrocystopexy
with Hysterectomy 58152, 58267
Marshall-Marchetti-Krantz Type 58152, 58267
Pereyra Type 58267
Colprosterone
See Progesterone
Column Chromatography/Mass Spectrometry

Unspecified Non-Drug Analyte 82542
Columna Vertebralis
See Spine
Combined Heart-Lung Transplantation

See Transplantation, Heart-Lung
Combined Right and Left Heart Cardiac Catheterization
See Cardiac Catheterization, Combined Left and Right Heart
Comedones
Removal 10040
Commissurotomy
Right Ventricle 33476, 33478
Common Sensory Nerve

Repair/Suture 64834
Common Truncus
See Truncus Arteriosus
Communication Device
Non-Speech-Generating 92605, 92606, 92618
Speech-Generating 92607-92609
Community/Work Reintegration
Training 97537
Comparative Analysis (Short Tandem Repeat)

Patient and Comparative Specimen 81265, 81266
Compatibility Test
Blood 86920, 86923
Specimen Pretreatment 86970-86972
Complement
Antigen 86160
Fixation Test 86171
Functional Activity 86161
Total Hemolytic 86162
Complete Blood Count (CBC)
Complete Colectomy
See Colectomy, Total
Complete Pneumonectomy
See Pneumonectomy, Completion
Complete Transposition of Great Vessels

Complex, Factor IX
Component Removal, Blood
See Apheresis
Composite Graft 15760-15770, 35681-35683

Compound B
See Corticosterone
Compound F
See Cortisol
Compression, Nerve, Median
See Carpal Tunnel Syndrome
Computed Tomographic Angiography (CTA)

Abdomen 74174, 74175
Abdominal Aorta 75635
Arm 73206
Chest 71275
Automated Data Analysis
for Atherosclerotic Plaque 0623T-0626T
Software Analysis
for Fractional Flow Reserve (FFR) 0501T-0504T
Head 70496
Heart 75571-75574
Leg 73706
Neck 70498
Pelvis 72191, 74174
Computed Tomographic Scintigraphy
See SPECT
Computed Tomography (CT)

See CT Scan
Computer Analysis
Acoustic Recording
Heart Sounds 93799
Digital Image Data
Mammography 77065-77067
Electrocardiographic Data 93228
Morphometric Analysis 88121
Motion Analysis 96000-96004
Pediatric Home Apnea Monitor 94776
Computer Data Analysis
Electrocardiographic 93228
Computer-Aided Detection (CAD)

Lesion
Chest Radiograph 0174T, 0175T
Magnetic Resonance Imaging (MRI) 77048, 77049
Computer-Assisted Navigation
Bronchoscopy 31627
Cranial Procedure 61781, 61782
Musculoskeletal Procedure 0054T, 0055T, 20985
Spinal Procedure 61783
Computer-Assisted Testing 96146

Cytopathology 88121
Morphometric Analysis 88121
Motion Analysis 96000-96004
Neuropsychological 96146
Psychological 96146
Computerized Emission Tomography
See SPECT
Concentration, Hydrogen-Ion
See Blood Gases, pH
Concentration, Minimum Inhibitory
See Minimum Inhibitory Concentration
Concentration of Specimen
Cytopathology 88108
Electrophoretic Fractionation and Quantitation 84166
Immunofixation Electrophoresis 86335
Infectious Agent 87015
Ova and Parasites 87177
Concentric Procedure 28296
Concha Bullosa Resection
with Nasal/Sinus Endoscopy 31240
Conchae Nasale
See Nasal Turbinate
Conduction, Nerve
See Nerve Conduction
Conduit, Ileal
See Ileal Conduit
Condyle
Excision
See Condylectomy
Femur 27508-27510, 27514
Humerus
Fracture
Percutaneous 24582
Knee 27446
Femoral, Arthroplasty 27442
Mandible
Metatarsal
Excision 28288
Toe
Resection 28153
Condyle, Mandibular
See Mandibular Condyle
Condylectomy
Metatarsal Head 28288
Posterior Cranial Fossa 61597
Condyloma
Anus 46900
Penis 54050, 54055-54057, 54060, 54065
Conference
Face-to-Face with Patient/Family 99366
Interdisciplinary Medical Team 99367, 99368
Congenital Arteriovenous Malformation
Congenital Cardiac Anomaly

Atrial Septostomy 33741
Closure
Interatrial Communication 93580
Ventricular Septal Defect 93581
Echocardiography
for Congenital Anomalies
Transesophageal 93315-93317
Transthoracic 93303, 93304
Doppler, Fetal 76827, 76828
Fetal 76825, 76826
Ectopy
Ventricular
Treatment 93654
Transcatheter Intracardiac Shunt (TIS) 33745, 33746
Congenital Elevation of Scapula

See Sprengel’s Deformity
Congenital Heart Septum Defect
See Congenital Cardiac Anomaly
Congenital Kidney Abnormality

Nephrolithotomy 50070
Pyeloplasty 50405
Pyelotomy 50135
Congenital Laryngocele
See Laryngocele
Congenital Obstructive Hypertrophic Mucosal Folds

Cystourethroscopy, with Fulguration, Lesion 52400
Congenital Posterior Urethral Valves
Cystourethroscopy, with Fulguration, Lesion 52400
Congenital Vascular Anomaly

See Vascular Malformation
Conisation
See Cervix, Conization
Conization
Cervix 57461, 57520, 57522
Conjoint Psychotherapy
See Psychiatric Treatment, Family
Conjunctiva
Biopsy 68100
Cyst
Fistulization for Drainage 68745, 68750
Follicle Expression 68040
Graft 65150, 65782
Harvesting, Living Donor 68371
Injection 68200
Insertion
Aqueous Drainage Device 0449T, 0450T, 0474T
Stent 68750
Lesion
Destruction 68135
Excision 68110, 68115
with Adjacent Sclera 68130
Reconstruction 68320, 68325, 68326, 68328
with Flap 67971, 68360, 68362
Removal
Repair
Eyelid Wound 67961, 67966
Direct Closure 65270, 67930, 67935
Mobilization and Rearrangement 65272, 65273
Symblepharon
Division 68340
with Graft 68335
without Graft 68330
Conjunctivocystorhinostomy
Conjunctivodacryocystostomy
Conjunctivoplasty 68320-68330
Reconstruction Cul-de-Sac
with Extensive Rearrangement 68326
with Graft 68326
Buccal Mucous Membrane 68328
Repair of Symblepharon 68330, 68335, 68340
Conjunctivorhinostomy
with Tube 68750
without Tube 68745
Conjunctivo-Tarso-Muller Resection 67908

Conscious Sedation
See Sedation
Construction
Arterial
Conduit 33608, 33920
Tunnel 33505
Bladder from Sigmoid Colon 50810
Eye Adhesions 67880
Finger
Toe to Hand Transfer 26551-26556
Gastric Tube 43832
Neobladder 51596
Tracheoesophageal Fistula 31611
Vagina
with Graft 57292
without Graft 57291
Valve
Consultation
Clinical Pathology 80500, 80502
Inpatient
New or Established Patient 99251-99255
Interprofessional
Telephone/Internet Electronic Health Record 99446-99449, 99451, 99452
Office or Other Outpatient
Psychiatric, with Family 90887
Radiation Therapy
Radiation Physics 77336, 77370
Surgical Pathology 88321, 88323, 88325
Intraoperative 88329, 88331-88334
X ray 76140
Consumption Test, Antiglobulin
See Coombs Test

Fittings and Prescription 92071, 92072, 92310-92317
Modification 92325
Prescription 92314-92317
Replacement 92326
Continuous Negative Pressure Breathing (CNPB) 94662
Continuous Positive Airway Pressure (CPAP) 94660
Contouring
Cranial
Bones 21181
Sutures 61559
Forehead 21137, 21138
Frontal Sinus Wall 21139
Septoplasty 30520
Subcutaneous Injections 11950-11952, 11954
Tumor
Facial Bone 21029
Contraception
Cervical Cap
Fitting 57170
Diaphragm
Fitting 57170
Intrauterine Device (IUD)
Insertion 58300
Removal 58301
Contraceptive Capsules, Implantable

Removal 11976
Contraceptive Device, Intrauterine
See Intrauterine Device (IUD)
Contracture
Bladder Neck
Resection 52640
Elbow
Release
with Radical Resection of Capsule 24149
Finger Cast 29086
Palm
Release 26121-26125
Scar
Release 15002-15005
Shoulder
Thumb
Thenar Muscle Release 26508
Volkmann 25315
Wrist
Capsulotomy 25085
Contracture of Palmar Fascia
See Dupuytren’s Contracture
Contralateral Ligament
Repair
Knee 27405
Contrast Aortogram
See Aortography
Contrast Bath Therapy

Application 97034
Contrast Material
Injection
Colonic Tube
for Insertion 49440-49442
for Radiological Evaluation 49465
for Removal of Obstruction 49460
for Replacement 49446, 49450-49452
Cranial
for Ventricular Puncture 61120
Dacryocystography 68850
Peritoneal
for Assessment of Abscess or Cyst 49424
for Evaluation of Venous Shunt 49427
for Insertion of Tunneled Catheter 49418
Renal Angiography 36251-36254
Saline Infusion Sonohysterography (SIS) 58340
Spine
for Localization 62263
Urethrocystography 51605
Contrast Phlebogram
See Venography
Contusion
See Hematoma
Converting Enzyme, Angiotensin

Coombs Test
Direct 86880
Indirect 86885, 86886
RBC Antibody Screen 86850, 86860
Copper 82525
Coprobilinogen
Feces Test 84577
Coproporphyrin 84119, 84120

Coracoacromial Ligament
Release 23415, 29826
Coracoid Process Transfer 23462

Cord, Spermatic
See Spermatic Cord
Cord, Spinal
See Spinal Cord
Cord, Vocal
See Vocal Cords
Cordectomy 31300
Cordocenteses
See Cordocentesis
Cordocentesis 59012
Cordotomy
Cervical 63194, 63196, 63198
Thoracic 63195, 63197, 63199
Corectomy
See Iridectomy
Coreoplasty 66762
Cornea
Astigmatism
Relaxing Incision 65772
Wedge Resection 65775
Biopsy 65410
Collagen Cross Links 0402T
with Pachymetry 0402T
with Removal of Epithelium 0402T
Curettage 65435, 65436
with Chelating Agent Application 65436
Epithelium
Excision 65435, 65436
with Chelating Agent 65436
Hysteresis Determination 92145
Implantation
Corneal Ring Segments 65785
Incision
for Astigmatism Correction 65772
for Keratoplasty 0290T
Lesion
Destruction 65450
Excision 65400
with Graft 65426
without Graft 65420
Pachymetry 76514
Prosthesis 65770
Pterygium
Excision 65420
Puncture 65600
Relaxing Incision 65772
Removal
Lesion 66600
Repair
with Amniotic Membrane 65778-65780
with Glue 65286
Incision 65772
Wound
Nonperforating 65275
Perforating 65280-65285
Tissue Glue 65286
Reshape
Epikeratoplasty 65767
Keratomileusis 65760
Keratophakia 65765
Keratoprosthesis 65767
Scraping
Smear 65430
Tattoo 65600
Tear Film Imaging 0330T
Tear Osmolarity 83861
Thickness Measurement 76514
Transplantation
for Aphakia 65750
Autograft or Homograft
Allograft Preparation 0290T, 65757
Endothelial 65756
Lamellar 65710
Penetrating 65730, 65750, 65755
Unlisted Procedures 66999
Coronary Angioplasty, Transluminal Balloon

See Balloon Angioplasty, Coronary
Coronary Anomaly
Graft 33503, 33504
Repair 33500-33507
Coronary Artery
with Atherectomy 92933, 92934, 92937, 92938, 92941, 92943, 92944
with Stent Placement 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944
with Angioplasty 92933, 92934, 92937, 92938, 92941, 92943, 92944
with Stent 92933, 92934, 92937, 92938, 92941, 92943, 92944
Computed Tomographic Angiography (CTA)
Automated Data Analysis
for Atherosclerotic Plaque 0623T-0626T
Endarterectomy 33572
Fractional Flow Reserve 0501T-0504T, 0523T
Graft
Anomaly 33503, 33504
Arterial Bypass 33533-33536
Harvest 35600
Arterial-Venous Bypass 33517-33519, 33521-33523
Venous Bypass 33510-33516
Harvest 35500
Insertion
Stent 92928, 92929
Ligation 33502
Placement
Radiation Delivery Device 92974
Reconstruction 33863, 33864
Repair
Anomaly 33500-33507
Revascularization 92937, 92938, 92941, 92943, 92944
Thrombectomy 92973
Thrombolysis 92975, 92977
Translocation 33506, 33507
Unroofing 33507
Coronary Artery Bypass Graft (CABG)

Anomalous Artery 33503, 33504
Arterial Bypass 33533-33536
Harvest 35600
Arterial-Venous Bypass 33517-33519, 33521-33523
Harvest 35500
Beta Blocker Administered 4115F
Harvest
Upper Extremity Artery 35600
Upper Extremity Vein 35500
Reoperation 33530
Revascularization 92937, 92938, 92941, 92943, 92944
Venous Bypass 33510-33516
Harvest 35500
Coronary Endarterectomy 33572
Coronavirus Disease (COVID-19)
Antibody Detection
Immunoassay, Multiple-Step 86769
Immunoassay, Single-Step 86328
Infectious Agent Detection
Nucleic Acid Probe 87635
Pathogen Detection
Pathogen-Specific Nucleic Acid 0202U

Coronoidectomy
Corpectomy 63101-63103
Corpora Cavernosa
Corpora Cavernosography 74445
Injection 54230
Corpus Spongiosum Shunt 54430
Dynamic Cavernosometry 54231
Glans Penis Fistulization 54435
Injection
for Peyronie Disease 54200
Irrigation 54220
Peyronie Disease 54200-54205
Priapism 54220, 54430
Saphenous Vein Shunt 54420
Corpora Cavernosa, Plastic Induration

Corpora Cavernosography
Imaging with Contrast 74445
Injection 54230
Corpus Callosum
Transection 61541
Corpus Vertebrae (Vertebrale)
See Vertebral, Body
Correction of Cleft Palate

See Cleft Palate, Repair
Correction of Lid Retraction
See Repair, Eyelid, Retraction
Correction of Malrotation of Duodenum

Ladd Procedure 44055
Correction of Syndactyly
See Syndactyly, Repair
Correction of Ureteropelvic Junction
Cortical Mapping
by Electric Stimulation 95961, 95962
Initial TMS Treatment 90867
Noninvasive 96020
Corticoids
See Corticosteroids
Corticoliberin
Corticosteroid Binding Globulin
See Transcortin
Corticosteroid Binding Protein

See Transcortin
Corticosteroids
Blood 83491
Urine 83491
Corticosterone
Corticotropic Releasing Hormone (CRH)
Cortisol 80400, 80402, 80406, 80418, 80420, 80436, 82530

Stimulation 80412
Total 82533
Cortisol Binding Globulin 84449
Costectomy
See Rib, Excision
Costen Syndrome
See Temporomandibular Joint (TMJ)
Costotransversectomy 21610
Cothromboplastin
See Proconvertin
Counseling
See also Preventive Medicine, Counseling; Psychiatric Treatment
End-Stage Renal Disease (ESRD) 90951-90959, 90963-90965
Evaluation and Management Care Coordination
Consultations 99241-99245, 99251-99255
Domiciliary/Rest Home Services 99324-99328, 99334-99337
Emergency Department Services 99281-99285
Home Visit 99341-99345, 99347-99350, 99510
Hospital Inpatient Services 99221-99223, 99231-99236
Hospital Observation Services 99218-99220, 99224-99226
Nursing Facility Services 99304-99310, 99318
Medical Genetics 96040
Preventive Medicine 99381-99387, 99391-99397
Risk Factor Reduction 99401-99404, 99411, 99412
Smoking and Tobacco Use Cessation 99406, 99407
Counseling for Risk Factor Reduction and Preventive Medicine

Preventive Medicine 99381-99387, 99391-99397
Risk Factor Reduction 99401-99404, 99411, 99412
Smoking and Tobacco Use Cessation 99406, 99407
Count
Blood Cell
Blood Platelet
See Blood, Platelet, Count
Cell
See Cell Count
Complete Blood
See Complete Blood Count (CBC)
Erythrocyte
Leukocyte
Reticulocyte
See Reticulocyte, Count
Counters, Cell
See Cell Count
Countershock, Electric
See Cardioversion
Coventry Tibial Wedge Osteotomy

See Osteotomy, Tibia
COVID-19 (Coronavirus Disease)
Antibody Detection
Pathogen Detection
Cowper’s Gland
Excision 53250
Coxa
See Hip
Coxiella Burnetii
Antibody 86638
Coxsackie
Antibody 86658
CPAP (Continuous Positive Airway Pressure) 94660

C-Peptide 80432, 84681
CPK
Blood 82550-82552
CPR (Cardiopulmonary Resuscitation)
Cardiac Arrest 92950
Cranial Bone
See also Skull
Burr Hole
See Burr Hole
Craniectomy
See Craniectomy
Craniosynostosis
Craniotomy
See Craniotomy
Frontal Bone Flap 61556, 61557
Graft
See Bone Graft, Cranium
Halo Application
Thin Skull Osteology 20664
Parietal Bone Flap 61556
Reconstruction
Extracranial 21181-21184
Temporal Bone
Implantation
Cochlear Device 69930
Hearing Device 69710, 69711
Osseointegrated Implant 69714, 69715
Removal of Tumor 69970
Resection 69535
Trephination
See Trephine Procedure
Tumor
Excision 61563, 61564
Cranial Halo 20661

Cranial Nerve
Avulsion 64732-64760, 64771
Cranial Nerve II
See Optic Nerve
Cranial Nerve V
See Trigeminal Nerve
Cranial Nerve VII
See Facial Nerve
Cranial Nerve X
See Vagus Nerve
Cranial Nerve XI
See Accessory Nerve, Spinal
Cranial Nerve XII
See Hypoglossal Nerve
Decompression 61458, 61460, 64716
Injection
Anesthetic
Trigeminal Nerve 64400
Vagus Nerve 64408
Neurolytic 64600, 64605, 64610
Steroid 64400
Neuroplasty 64716
Neurostimulator
See Neurostimulators, Cranial Nerve
Release 64716
Repair
Suture, with or without Graft 64864, 64865
Transection 64732-64760, 64771
Transposition 64716
Cranial Tongs
Removal 20665
Craniectomy
Abscess Drainage 61320, 61321
Anesthesia 00211
Compression 61450
Craniosynostosis
Multiple Sutures 61552, 61558, 61559
Single Suture 61550
with Craniotomy 61316, 61530
Decompression 61322, 61323, 61340, 61343
Cranial Nerves 61458
Sensory Root of Gasserian Ganglion 61450
Drainage 61320, 61321
for Electrode
Cortical 61860
Subcortical 61863, 61864, 61867, 61868
Evacuation of Hematoma 61312-61315
Excision
Abscess 61514, 61522
Bone Lesion 61500
Fenestration of Cyst 61516, 61524
Tumor 61500, 61510, 61518, 61520, 61521
Exploratory 61304, 61305, 61458
for Osteomyelitis 61501
Release Stenosis 61550-61552
Section 61450, 61460
Wound Treatment 61571
Craniofacial Procedures
Craniofacial Separation
Bone Graft 21436
External Fixation 21435
Open Treatment 21432, 21433, 21435, 21436
Wire Fixation 21431, 21432
Craniomegalic Skull
Reduction 62115, 62117
Craniopharyngioma
Excision 61545
Cranioplasty
Autograft 62146, 62147
Bone Graft 61316, 62146, 62147
Bone Graft Retrieval 62148
Encephalocele Repair 62120
Skull Defect 62140, 62141, 62145
Craniostenosis
Craniosynostosis
Bifrontal Craniotomy 61557
Extensive Craniectomy 61558, 61559
Front or Parietal 61556
Multiple Sutures 61552
Single Suture 61550
Craniotomy
See also Burr Hole; Drill Hole; Trephine Procedure
Anesthesia 00211
Bifrontal 61557
with Bone Flap 61510-61516, 61526-61530, 61533-61545, 61566, 61567
for Craniosynostosis 61556, 61557
Drainage 61320, 61321
for Encephalocele 62121
Evacuation of Hematoma 61312-61315
for Excision
Epileptogenic Focus 61534, 61536
Foreign Body 61570
Tumor 61546
Exploratory 61304, 61305
Frontal 61556
for Hemispherectomy 61543
for Implant of Neurostimulators 61533, 61860, 61863, 61864, 61867, 61868
for Lobectomy 61537-61540
Parietal 61556
Removal
Skull Base Surgery 61582, 61583, 61590, 61592
for Transection of Corpus Callosum 61541
for Wound Treatment 61571
Cranium
See Skull
Craterization
Calcaneus 28120
Clavicle 23180
Femur 27070, 27071, 27360
Fibula 27360, 27641
Hip 27070
Humerus 23184, 24140
Ileum 27070
Metacarpal 26230
Metatarsal 28122
Phalanges
Finger 26235, 26236
Toe 28124
Pubis 27070
Radius 24145, 25151
Scapula 23182
Talus 28120
Tarsal 28122
Tibia 27360, 27640
Ulna 25150
C-Reactive Protein 86140, 86141

Creatine 82553, 82554
Creatine Kinase
Total 82550
Creatine Phosphokinase
Blood 82552
Total 82550
Creatinine
Blood 82565
Clearance 82575
Other Source 82570
Urine 82570-82575
Creation
Arteriovenous Fistula 35686, 36825, 36830
Catheter Exit Site 49436
Cavopulmonary Anastomosis 33622
Colonic Reservoir 45119, 45397
Complete Heart Block 93650
Defect 40720
Ileal Reservoir 44158, 44211, 45113
Iliac Artery Conduit 34833
Lesion 61720, 61735, 61790, 63600
Mucofistula 44144
Pericardial Window 32659, 33025
Recipient Site 15002-15005
Shunt
Cerebrospinal Fluid
See Cerebrospinal Fluid Shunt
Sigmoid Bladder 50810
Speech Prosthesis 31611
Stoma
Bladder 51980
Tympanic Membrane 0583T, 69433, 69436
Ureter 50860
Subcutaneous Pocket
with Glucose Sensor Insertion 0446T, 0448T
Ventral Hernia 39503
Vertebral Cavity 22513-22515
CRF
CRH
Cricoid Cartilage Split

Laryngoplasty 31587
Cricothyroid Membrane
Incision for Tracheostomy 31605
Cristobalite
See Silica
Cardiopulmonary Resuscitation 92950
Evaluation and Management 99291, 99292
Interfacility Transport 99466, 99467
Ipecac Administration for Poison 99175
Neonatal
Initial 99468
Intensive 99477
Low Birth Weight Infant 99478, 99479
Subsequent 99469
Pediatric
Initial 99471, 99475
Interfacility Transport 99466, 99467
Supervision 99485, 99486
Subsequent 99472, 99476
Cross Finger Flap 15574

Crossmatch
Tissue Typing 86805, 86806, 86825, 86826
Transfusion Compatibility Testing 86920-86923
Crossmatching, Tissue Typing

Human Leukocyte Antigen (HLA) 86825, 86826
Lymphocytotoxicity Assay 86805, 86806
Cruciate Ligament
Repair 27407, 27409
Arthroscopic Repair 29888, 29889
Knee
with Collateral Ligament 27409
Cryoablation
Nerve
Cryofibrinogen 82585
Cryofixation
Cryoglobulin 82595
Cryopreservation
Bone Marrow 38207-38209
Cells 38207-38209, 88240, 88241
Embryo 89258, 89352
Freezing and Storage
Cells 88240
Embryo 89258
Reproductive Tissue
Oocyte(s) 89337
Sperm 89259
Testicular 89335
Stem Cells 38207
Thawing
Cells 88241
Embryo 89352
Oocytes 89356
Reproductive Tissue 89354
Sperm 89353
Stem Cells 38208, 38209
for Transplantation 32850, 33930, 33940, 44132, 47133, 47140, 48550, 50300-50320, 50547
Cryosurgery 17000-17286, 47371, 47381

See also Cryotherapy
Ablation
Fibroadenoma
Breast 19105
Lesion/Tumor
Chest Wall 32994
Liver 47371, 47381, 47383, 50250
Pleura 32994
Pulmonary 32994
Bladder 52214
Tumor 52234, 52235, 52240
Hemorrhoids 46999
Lesion
Anus 46916, 46924
Bladder 51030, 52224
Ear 17280-17284, 17286
Eyelid 17280-17284, 17286
Face 17280-17284, 17286
Kidney 50250
Lips 17280-17284, 17286
Mouth 17280-17284, 17286, 40820
Nose 17280-17284, 17286
Penis 54056, 54065
Skin 17000, 17003, 17004, 17106-17108, 17110, 17111
Urethra 52224
Vagina 57061, 57065
Vulva 56501, 56515
Prostate 52214, 55873
Trichiasis 67825
Tumor
Bladder 52234, 52235, 52240
Rectum 45190
Urethra 52214
Cryotherapy
Ablation
Renal Tumor 50593
Acne 17340
Bronchial Stenosis 31641
Destruction
Bronchial Tumor 31641
Ciliary Body 66720
Retinopathy 67227
Lesion
Cornea 65450
Retina 67208
Retinal Detachment
Prophylaxis 67141
Repair 67101, 67107, 67108, 67113
Retinopathy
Destruction 67227
Treatment
Preterm Infant 67229
Trichiasis 67825
Cryptectomy
Unlisted Procedure, Anus 46999
Cryptococcus
Antibody 86641
Antigen Detection
Immunoassay 87327
Cryptococcus Neoformans
Antigen Detection
Immunoassay 87327
Cryptorchism
See Testis, Undescended
Cryptosporidium
Antigen Detection
Immunoassay 87328
Crystal Identification
Any Body Fluid 89060
Tissue 89060
C-Section
CSF
CT Scan
3D Rendering 76376, 76377
Angiography
See Computed Tomographic Angiography
Biomechanical CT Analysis 0558T
Bone
Density Study 0554T-0557T, 77078
Fracture Risk Assessment 0554T-0557T
Strength Assessment 0554T-0557T
Brain 70450-70470
Stroke Diagnosis 3110F-3112F
Breast 0633T-0638T
with Contrast 70460
Abdomen 74160, 74177
Arm 73201
Brain 0042T, 70460
Cerebral Blood Flow/Volume 0042T
Ear 70481
Face 70487
Head 70460
Leg 73701
Maxilla 70487
Neck 70491
Orbit 70481
Pelvis 72193, 74177
Sella Turcica 70481
Spine
Cervical 72126
Lumbar 72132
Thoracic 72129
Thorax 71260
Guidance
Drainage 75989
Localization 77011
Needle Placement 77012
Parenchymal Tissue Ablation 77013
Radiation Therapy 77014
Visceral Tissue Ablation 77013
Heart
Evaluation
Angiography 75574
for Coronary Calcium 75571
for Structure and Morphology 75572, 75573
Optical Coherence Tomography (OCT)
Breast 0351T-0354T
Intravascular 92978, 92979
Parathyroid Gland 78072
Radiopharmaceutical Localization
of Inflammation 78830, 78832
of Radiopharmaceutical Agent Distribution 78830, 78832
of Tumor 78830, 78832
without and with Contrast
Abdomen 74170, 74174, 74175, 74178, 75635
Arm 73202
Brain 70470, 70496
Breast 0635T, 0638T
Chest 71275
Ear 70482
Face 70488
Head 70470, 70496
Leg 73702-73706, 75635
Maxilla 70488
Neck 70492, 70498
Orbit 70482
Pelvis 72194, 74174, 74178
Sella Turcica 70482
Spine
Cervical 72127
Lumbar 72133
Thoracic 72130
Thorax 71270
without Contrast 70450
Abdomen 74150, 74176, 74178
Arm 73200
Brain 70450
Colon
Colonography 74261-74263
Ear 70480
Face 70486
Head 70450
Leg 73700
Maxilla 70486
Neck 70490
Orbit 70480
Pelvis 72192, 74176, 74178
Sella Turcica 70480
Spine
Cervical 72125
Lumbar 72131
Thoracic 72128
Thorax 71250, 71271
CT Scan, Radionuclide
See SPECT
Cuff, Rotator
Repair 23410-23420
Culdocentesis
See Colpocentesis
Culture
Acid-Fast Bacilli 87116
Amniotic Fluid
Bacteria
Aerobic 87040-87071, 87077
Anaerobic 87073-87076
Blood 87040
Other 87070-87075
Screening 87081
Stool 87045, 87046
Urine 87086, 87088
Bone Marrow
Neoplastic Disorders 88237
Cancer Stem Cells (CSCs)
Cytotoxicity Assay 0564T
Chlamydia 87110
Chorionic Villus
Fertilized Oocytes
for In Vitro Fertilization 89250
Co-Culture of Embryo 89251
Fungus
Blood 87103
Hair 87101
Nail 87101
Skin 87101
Source Other than Blood 87102
Lymphocyte
HLA Typing 86821
Mold 87107
Mycobacteria 87118
Mycoplasma 87109
Oocyte/Embryo 89250
Co-Culture of Oocyte/Embryo 89251
Extended Culture 89272
Pathogen
Presumptive 87081-87084
Skin
Tissue
Homogenization 87176
Infectious Agent Drug Resistance 87903, 87904
Toxin/Antitoxin 87230
Virus 87252, 87253
Tubercle Bacilli 87116
Tumor Tissue
Typing 87140-87158
Yeast 87106
Curettage
See also Dilation and Curettage
Anal Fissure 46940
Cervix
Endocervical 57454, 57456, 57505
Cornea 65435, 65436
Dentoalveolar 41830
Hydatidiform Mole 59870
Uterus
Endometrial 58356
Postpartum 59160
Curettage, Uterus
Endometrial 58356
Postpartum 59160
Curettage and Dilatation

See Dilation and Curettage
Curettement
Skin Lesion
Malignant 17270-17274, 17280-17284, 17286
Premalignant 17000, 17003, 17004, 17110, 17111
Curietherapy
See Brachytherapy
Custodial Care
See Domiciliary Services; Nursing Facility Services
Cutaneolipectomy
See Lipectomy
Cutaneous Electrostimulation, Analgesic

See Application, Neurostimulation
Cutaneous Tag
See Skin, Tags
Cutaneous Tissue
See Integumentary System
Cutaneous-Vesicostomy
See Vesicostomy, Cutaneous
CVS (Chorionic Villus Sampling)

See Biopsy, Chorionic Villus
Cyanacobalamin
See Cyanocobalamin
Cyanide
Blood 82600
Tissue 82600
Cyanocobalamin 82607, 82608
Cyclic AMP 82030
Cyclic Somatostatin
Somatostatin 84307
Cyclocryotherapy
See Cryotherapy, Destruction, Ciliary Body
Cyclodialysis
Destruction
Ciliary Body 66740
Cyclophotocoagulation
Destruction
Ciliary Body 66710, 66711
Cyclosporine
Assay 80158
Cyst
See also Pseudocyst
Abdomen
Abdominal Laparoscopy
Aspiration 49322
Ankle
Capsule 27630
Tendon Sheath 27630
Bartholin’s Gland
Excision 56740
Bile Duct 47715
Bladder
Excision 51500
Bone
Curettage
Calcaneus 28100-28103
Carpal 25130, 25135, 25136
Clavicle 23140, 23145, 23146
Femur 27355, 27356, 27357
Finger 26210, 26215
Humerus 24110, 24115, 24116
Proximal 23150, 23155, 23156
Mandible 21040
Maxilla 21030
Metacarpal 26200, 26205
Olecranon Process 24120, 24125, 24126
Radius 24120, 24125, 24126
Talus 28100-28103
Tibia 27635, 27637, 27638
Toe 28108
Zygoma 21030
Drainage 20615, 63172
Enucleation
Mandible 21040
Maxilla 21030
Zygoma 21030
Injection 20615
Brain
Drainage 61150, 61151, 61156, 62161, 62162
Excision 61516, 61524, 62162
Branchial Cleft
Excision 42810, 42815
Breast
Excision 19120
Puncture Aspiration 19000, 19001
Carpal 25130, 25135, 25136
Choledochal 47715
Ciliary Body
Destruction 66770
Clavicle
Excision 23140, 23145, 23146
Conjunctiva 68020
Dermoid
Nose
Excision 30124, 30125
Drainage
Contrast Injection 49424
with X ray 76080
Excision
Cheekbone 21030
Clavicle 23140
with Allograft 23146
Femur 27065-27067, 27355-27358
Ganglion
See Ganglion
Humerus 23150, 24110
Hydatid
See Echinococcosis
Lymphatic
See Lymphocele
Maxilla 21030
Mediastinum 32662
Ovarian 58925
Pericardial 32661
Pilonidal 11770-11772
Radius 24120
Salivary Gland 42408
Scapula 23140
Symphysis Pubis 27065-27067
Facial Bones
Excision 21030
Femur 27065-27067, 27355-27358
Fibula 27635, 27637, 27638
Foot
Excision 28090
Ganglion
Aspiration/Injection 20612
Gums
Hand
Capsule 26160
Tendon Sheath 26160
Hip 27065-27067
Humerus
Excision 23150, 24110
with Allograft 23156, 24116
with Autograft 23155, 24115
Ilium 27065-27067
Lung 32200
Mouth
Dentoalveolar 41800
Lingual 41000
Sublingual 41005, 41006, 41015
Ovarian 58800, 58805
Pilonidal 10080, 10081
Skin 10060, 10061
Iris
Destruction 66770
Kidney
Ablation 50541
Aspiration 50390
Excision 50280, 50290
Injection 50390
X ray 74470
Knee
Baker’s 27345
Excision 27347
Leg, Lower
Capsule 27630
Tendon Sheath 27630
Liver
Aspiration 47015
Drainage 47010
Lung
Removal 32140
Lymph Node
Axillary/Cervical
Excision 38550, 38555
Mandible
Excision 21040, 21046, 21047
Maxilla
Excision 21030, 21048, 21049
Mediastinal
Excision 32662
Resection 39200
Metatarsal 28104, 28106, 28107
Mouth 41000, 41005-41009, 41015-41018
Mullerian Duct
Excision 55680
Nose
Excision 30124, 30125
Olecranon 24120, 24125, 24126
Ovarian
Excision 58925
Pancreas 48500
Excision 48120
Pelvis
Aspiration 50390
Injection 50390
Pericardial
Excision 32661
Resection 33050
Phalanges
Finger 26210, 26215
Toe 28108
Pilonidal
Pubis 27065-27067
Radius 24120, 25120, 25125, 25126
Rathke’s Pouch
See Craniopharyngioma
Removal
Skin 10040
Retroperitoneal
Salivary Gland
Excision 42408
Scapula
Excision 23140, 23145, 23146
Seminal Vesicle
Excision 55680
Skene’s Gland
Destruction 53270
Drainage 53060
Skin
Removal 10040
Spinal Cord
Aspiration 62268
Sublingual Gland
Drainage 42409
Excision 42408
Symphysis Pubis 27065-27067
Talus 28100-28103
Tarsal 28104, 28106, 28107
Thyroglossal Duct
Excision 60280, 60281
Thyroid Gland
Aspiration 60300
Excision 60200
Injection 60300
Tibia 27635, 27637, 27638
Tongue 41000, 41005-41009
Ulna 24120, 25120, 25125, 25126
Urachal
Bladder
Excision 51500
Vaginal
Biopsy 57105
Excision 57135
Wrist
Excision 25111, 25112, 25130, 25135, 25136
Zygoma
Excision 21030
Cyst, Ovary
Excision 58925
Cystatin C
Blood 82610
Cystatins, Kininogen
See Kininogen
Cystectomy
Complete 51570
with Bilateral Pelvic Lymphadenectomy 51575, 51585, 51595
with Continent Diversion 51596
with Ureteroileal Conduit 51590
with Ureterosigmoidostomy 51580
Ovarian 58925
Laparoscopic 58662
Partial
Complicated 51555
Reimplantation of Ureters 51565
Simple 51550
Cystic Hygroma
See Hygroma
Cystine
Urine 82615
Cystitis
Interstitial 52260, 52265
Cystography
Bladder 74430
Cystolithotomy 51050
Cystometrogram 51725-51729
Cystoplasty 51800
Cystorrhaphy 51860-51865
Cystoscopy
with Endopyelotomy 50545
with Ureteroneocystostomy 50947
Cystoscopy, with Biopsy
See Cystourethroscopy, Biopsy
Cystostomy
Change Tube 51705, 51710
Closure 51880
with Drainage 51040
with Fulguration 51020
Home Visit 99505
with Insertion Radioactive Material 51020
with Tumor Destruction 51030
with Urethrectomy
Female 53210
Male 53215
Cystotomy
with Calculus Basket Extraction 51065
with Destruction Intravesical Lesion 51030
with Drainage 51040
Excision
Bladder Diverticulum 51525
Bladder Tumor 51530
Vesical Neck 51520
with Fulguration 51020
with Insertion
Radioactive Material 51020
Ureteral Catheter 51045
with Removal Calculus 51050, 51065
Repair Ureterocele 51535
Cystourethrogram, Retrograde
See Urethrocystography, Retrograde
Cystourethropexy
See Vesicourethropexy
Cystourethroplasty
Bladder/Vesical Neck 51800, 51820
Cystourethroscopy
Anterior Colporrhaphy 57240, 57260, 57265
Biopsy 52204, 52224, 52250, 52354
Brush 52007
Calibration and/or Dilation
Urethral Stricture or Stenosis 52281, 52630, 52647-52649
Catheterization
Ureteral 52005, 52320
Chemodenervation
Bladder 52287
Dilation
Bladder 52260, 52265
Intra-Renal Stricture 52343, 52346
Ureter 52341, 52342, 52344, 52345
Urethra 0499T, 52281, 52285
Direct Vision Internal Urethrotomy 52276
Drug Delivery
Urethral 0499T
Duct Radiography 52010
Ejaculatory Duct Catheterization 52010
Evacuation
Clot 52001
Examination 52000
Female Urethral Syndrome 52285
Fulguration 52214
Lesion 52224, 52354
Polyps 52285
Tumor 52234, 52235, 52240
Ureterocele(s) 52300, 52301
Urethral Valves 52400
Incision
Bladder Neck 52285
Congenital Obstructive Hypertrophic Mucosal Folds 52400
Diverticulum 52305
Injection
for Cystography 52281
Implant Material 52327
Insertion
Indwelling Ureteral Stent 50947, 52332
Radioactive Substance 52250
Transprostatic Implant 52441, 52442
Ureteral Guide Wire 52334
Urethral Stent 52282
Instillation 52005, 52010
Internal Urethrotomy 52630, 52647-52649
Female 52270, 52285
Male 52275
Lithotripsy 52353
Lysis
Urethra 53500
Urethrovaginal Septal Fibrosis 52285
Manipulation of Ureteral Calculus 52330, 52352
Meatotomy
Ureteral 52290
Urethral 52281, 52285, 52630, 52647-52649
Prostate
Laser Coagulation 52647
Laser Enucleation 52649
Laser Vaporization 52648
Transurethral Commissurotomy 0619T
Pyeloscopy 52351
Removal
Calculus 52310, 52315, 52320, 52325, 52352
Urethral Stent 52310, 52315
Resection
Congenital Obstructive Hypertrophic Mucosal Folds 52400
Diverticulum 52305
External Sphincter 52277
Prostate 52601, 52630
Tumor 52234, 52235, 52240, 52355
Ureterocele(s) 52300, 52301
Steroid Injection 52283
Treatment
Lesion(s) 52224
Ureteral Stricture 52341
Ureteral Catheterization 52005
Ureteral Meatotomy 52290
Ureteropyelography 52005
Ureteroscopy 52351
Urethral Syndrome 52285
Vasectomy
Transurethral 52402, 52630, 52647-52649
Vasotomy
Transurethral 52402
Cytochrome Reductase, Lactic

See Lactic Dehydrogenase
Cytogenetic Study
Bone Marrow
Diagnostic 3155F
Neoplastic Disorder 88237
Breakage Syndromes
Chromosome Analysis
Interpretation and Report 88291
Molecular
DNA Probe 88271-88275, 88364-88366
Neoplastic Disorders
Bone Marrow 88237
Tumor 88239
Non-neoplastic Disorders
Chorionic Villus Cells 88235
Lymphocyte 88230
Skin or Tissue Biopsy 88233
Cytogenomic Constitutional (Genome-Wide) Microarray Analysis

Interrogation of Genomic Regions 81228, 81229, 81406
Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis
Interrogation of Genomic Regions 81277
Cytomegalovirus
Antibody 86644, 86645
Antigen Detection
Immunoassay 87332
Nucleic Acid 87495-87497
Cytometries, Flow
See Flow Cytometry
Cytopathology
Cervical or Vaginal
Definitive Hormone Evaluation 88155
Pap 88164-88167
Requiring Interpretation by Physician 88141
Thin Layer Prep 88142, 88143, 88174, 88175
Evaluation 88172, 88177
Needle Aspirate 88172, 88177
Flow Cytometry
See Flow Cytometry
Fluids, Washings, Brushings
Simple Filter 88106
Smears 88104
Forensic 88125
Other Source 88160-88162
Sex Chromatin Identification
Barr Bodies 88130
Polymorphonuclear Drumsticks 88140
Smears
Any Other Source 88160-88162
Brushings 88104
Cervical or Vaginal
Automated Screen 88174
Hormone Evaluation 88155
Manual Screen 88150, 88153, 88164, 88165
Partially Automated Screen 88147, 88148, 88152, 88166, 88167, 88175
Physician Interpretation 88141
Concentration Technique 88108
Fluids 88104
Washings 88104
Techniques
Concentration 88108
Saccomanno Technique 88108
Selective Cellular Enhancement 88112
In Situ Hybridization 88120, 88121
Morphometric Analysis
Computer-Assisted 88367, 88373, 88374
Manual 88368, 88369, 88377
Unlisted Cytopathology Procedure 88199
Urinary Tract Specimen 88120, 88121
Cytosol Aminopeptidase
See Leucine Aminopeptidase
Cytotoxic Screen
Lymphocyte 86805, 86806
Percent Reactive Antibody (PRA) 86807, 86808
Serum Antibodies 86807, 86808
D
D, Vitamin
See Vitamins, D
D & C Yellow No. 7

See Fluorescein
D and C
See Dilation and Curettage
D and E
See Dilation and Evacuation
D Galactose
See Galactose
D Glucose
See Glucose
D-2, Vitamin
See Vitamins, D
Dacryoadenectomy
Partial 68505
Total 68500
Dacryocystectomy 68520
Dacryocystogram
See Dacryocystography
Dacryocystography
Injection of Contrast 68850
Nuclear Imaging 78660
Radiological Examination 70170
Dacryocystorhinostomy
Lacrimal Sac/Nasal Cavity Fistulization 68720
Dacryocystostomies
See Dacryocystotomy
Dacryocystotomy 68420
Daily Living Activities
Damus-Kaye-Stansel Procedure
See Anastomosis, Pulmonary
Dana Operation
See Rhizotomy
Dark Adaptation Examination 92284

Dark Field Examination 87164-87166
Darkroom Test
See Glaucoma, Visual Evoked Potential
Darrach Procedure
See Excision, Ulna
David Procedure
See Aorta, Ascending, Graft
Day Test
See Blood, Feces
de Quervain’s Disease Treatment 25000
Death, Brain
Determination 95824
Debridement
Ankle 29897, 29898
Bone 11044, 11047
with Open Fracture and/or Dislocation 11012
Brain 62010
Burns 01951-01953, 16020-16030
Cartilage 29862, 29877, 29880, 29881, 29885
Elbow 29837, 29838
with Prosthesis Removal 24160, 24164
Forearm 25023, 25025
Knee 27441, 27443, 27497, 27499
Leg 27892-27894
Lesion, Premalignant 96574
Liver 47361
Mastoid Cavity
Complex 69222
Simple 69220
Metatarsophalangeal Joint 28289, 28291, 29901, 29902
Muscle 11043, 11044, 11046, 11047
Infected 11004-11006, 11008
with Open Fracture and/or Dislocation 11011, 11012
Nails 11720, 11721
Nonviable Tissue 25023, 25025, 27497, 27892-27894
Nose
Endoscopic 31237
Pancreatic Tissue 48105
Pathology Analysis 88304, 88305
Penile Prosthesis Infected Field 54411, 54417
Shoulder 29822, 29823
with Prosthesis Removal 23334, 23335
Skin
Eczematous 11000, 11001
Infected 11000-11006
with Open Fracture and/or Dislocation 11010-11012
Subcutaneous Tissue 11042-11047
Infected 11004-11006, 11008
Necrotized 49568
Sternum 21627, 21750
Thigh 27497, 27499
Urethral/Bladder Infected Inflatable Sphincter Field 53448
Wound
Non-Selective 97602
Selective 97597, 97598
Wrist
Joint 29846
Nonviable Tissue 25023, 25025
Debulking Procedure
Ovary/Pelvis 58952-58958
Decompression
Arm, Lower 24495, 25020-25025
Auditory Canal, Internal 61591, 69960
Carotid Artery 61590, 61591
Cauda Equina 63011, 63017, 63045-63048, 63056, 63057, 63087-63091
Colon 45337, 45393
Cranial Nerve 61458
Esophagogastric Varices 37181
Facial Nerve
Intratemporal 61590
Lateral to Geniculate Ganglion 69720, 69740
Medial to Geniculate Ganglion 69725, 69745
Total 69955
Transtemporal 61595
Fasciotomy
Leg 27892-27894
Pelvic/Buttock 27027
with Debridement 27057
Thigh/Knee 27496-27499
Finger 26035
Gasserian Ganglion
Sensory Root 61450
Hand 26035-26037
Intestines
Small 44021
Jejunostomy
Leg
Fasciotomy 27600-27602
with Nasal/Sinus Endoscopy
Optic Nerve 31294
Orbit Wall 31292, 31293
Nerve 64702-64727
Laminotomy/Laminectomy 0274T, 0275T
Root 22551, 22552, 63020-63048, 63055-63103
Optic Nerve 61564, 67570
Orbit 61330
Removal of Bone 67414, 67445
Pelvis/Buttock
Fasciotomy 27027
Sigmoid Sinus 61595
Skull 61322, 61323, 61340-61345
Spinal Cord 22856, 22858, 62287, 62380, 63001-63017, 63045-63103
with Arthrodesis 22551, 22552
Cauda Equina 63005
Osteophytectomy 22551, 22552, 22856, 22858
Tarsal Tunnel Release 28035
Trachea 33800
Volvulus 45321, 45337
Wrist 25020-25025
Decortication
Lung
with Parietal Pleurectomy 32320
Partial 32225
Total 32220
Decubiti
See Decubitus Ulcers (Pressure Ulcers)
Decubitus Ulcers (Pressure Ulcers)

Excision
Coccygeal 15920, 15922
Ischial 15940, 15941, 15944-15946
Sacral 15931, 15933-15937
Trochanteric 15950-15953, 15956, 15958
Deetjen’s Body
See Blood, Platelet
Defect, Coagulation
See Coagulopathy
Defect, Heart Septal
See Septal Defect
Defect, Septal Closure, Atrial

See Atrial Septal Defect, Closure
Deferens, Ductus
See Vas Deferens
Defibrillation
See Cardioversion
Defibrillator, Heart
Cardioverter-Defibrillator
Implantable Device
See Cardiac Assist Devices, Implantable
Defibrillators
Wearable Device
Data Analysis 93292
Initial Set Up and Programming 93745
Deformity, Boutonniere
Repair of Finger Extensor Tendon 26426, 26428
Deformity, Sprengel’s
Scapulopexy 23400
Degenerative, Articular Cartilage, Patella

See Chondromalacia Patella
Degradation Products, Fibrin
Dehydroepiandrosterone 82626
Dehydroepiandrosterone Sulfate 82627
Dehydrogenase, 6-Phosphogluconate 84085
Dehydrogenase, Alcohol
Dehydrogenase, Glucose-6-Phosphate 82955, 82960

Dehydrogenase, Glutamate 82965
Dehydrogenase, Isocitrate 83570
Dehydrogenase, Lactate 83615, 83625
Dehydrogenase, Malate 83775
Dehydroisoandrosterone Sulfate
See Dehydroepiandrosterone Sulfate
Delay of Flap
Skin Graft 15600-15630
Deligation
Ureter 50940
Deliveries, Abdominal
Delivery
See Cesarean Delivery; Vaginal Delivery
Delorme Operation
Pericardiectomy 33030, 33031
Denervation
Hip
Femoral 27035
Obturator 27035
Sciatic 27035
Denervation, Sympathetic
Chemodenervation 64650, 64653
Neurolytic Agent 64680, 64681
Transcatheter Percutaneous 0338T, 0339T
Dens Axis
See Odontoid Process
Denver Shunt
Patency Test 78291
Deoxycorticosterone
See Desoxycorticosterone
Deoxycortisol 80436, 82634
Deoxyribonuclease
Antibody 86215
Deoxyribonuclease I
See DNAse
Deoxyribonucleic Acid (DNA)

Antibody 86225, 86226
Depilation
See Removal, Hair
Depletion
Bone Marrow/Stem Cells
Plasma 38214
Platelet 38213
T-Cell 38210
Tumor Cell 38211
Deposit Calcium
Depth Electrode
Cerebral Implantation 61760
Electrode Array, Intracranial 61760
Derma-Fat-Fascia Graft 15770
Dermatology
Actinotherapy 96900
Microscopic Examination of Hair 96902
Photochemotherapy
Ultraviolet A Treatment 96912, 96913
Ultraviolet B Treatment 96910, 96913
Psoriasis Laser Treatment 96920-96922
Reflectance Confocal Microscopy (RCM)
Skin Imaging 96931-96936
Whole Body Photography 96904
Dermatoplasty
Intranasal 30620
Septal 30620
Dermoid
See Cyst, Dermoid
Derrick-Burnet Disease
See Q Fever
Descending Abdominal Aorta

Desmotomy
Ligament Release
Coracoacromial 23130, 23415, 29826
Transverse Carpal 29848
Desoxycorticosterone 82633
Desoxycortone
See Desoxycorticosterone
Desoxyphenobarbital
See Primidone
Desquamation
See Exfoliation
Destruction
Ablation
See Ablation
Acne
See Acne Treatment
Calculus
See Calculus
Chemosurgery
See Chemosurgery
Cryosurgery
See Cryosurgery
Cyst
Abdomen 49203-49205
Ciliary Body 66740, 66770
Iris 66770
Electrosurgery
See Electrosurgery
Endometriomas
See Endometrioma
Fulguration
See Fulguration
Hemorrhoids
Thermal 46930
Laser Surgery
See Laser Surgery
Lesion
Anal 46900-46917, 46924
Bladder 51030
Choroid 67220, 67221, 67225
Ciliary Body 66770
Conjunctiva 68135
Cornea 65450
Eyelid 67850
Facial 17000-17004, 17280-17286
Gums 41850
Iris 66770
Larynx 31572
Mouth 40820
Nerve
Plantar 64632
Nose
Intranasal 30117, 30118
Palate 42160
Penis
Cryosurgery 54056
Electrodesiccation 54055
Extensive 54065
Laser Surgery 54057
Simple 54050-54060
Pharynx 42808
Prostate
Radio Frequency Thermotherapy 53852, 53854
Retina
Cryotherapy, Diathermy 67208-67218, 67227
Photocoagulation 67210, 67228, 67229
Radiation by Implantation of Source 67218
Skin
Benign 17110, 17111
Malignant 17260-17286
Premalignant 17000-17004, 96567, 96573, 96574
Uvula 42160
Vagina
Extensive 57065
Simple 57061
Vascular, Cutaneous 17106-17108
Vulva
Extensive 56515
Simple 56501
Nerve
See Nerves, Destruction
Neurofibroma
Extensive 0419T, 0420T
Prostate 55873
Prostate Tissue
Transurethral
Thermotherapy 53850, 53852, 53854
Sinus
Frontal 31080-31085
Tonsil
Lingual 42870
Tumor
Abdomen 49203-49205
Breast
Colon 45388
Intestines
Large 44401
Small 44369
Mesentery 49203-49205
Peritoneum 49203-49205
Rectum 45190, 45320
Retroperitoneal 49203-49205
Urethra 53220
Turbinate Mucosa 30801, 30802
Ureter 50976, 52354
Fulguration 50957
Urethra 53220, 53260
Fulguration 52285
Warts
Flat 17110, 17111
Determination, Blood Pressure

See Blood Pressure, Determination
Determination, Lung Volume
by Gas Dilution or Washout 94727
by Oscillometry 94728
by Plethysmography 94726
Developmental Cognitive Testing

Standardized Screening and Scoring 96110
by Physician 96112, 96113
Device
Adjustable Gastric Band 43770-43774
Annulus Reconstruction Device 0544T, 0545T
Balloon Continence Device
Placement 0548T, 0549T
Removal 0550T
Volume Adjustment 0551T
Cardiac
Evaluation
See Device Evaluation Services
Iliac Artery Occlusion Device
Insertion 34808
Subcutaneous Port
for Gastric Restrictive Procedure 43770, 43774, 43886-43888
Venous Access
Collection of Blood Specimen 36591, 36592
Implanted Device 36591
Fluoroscopic Guidance 36598, 77001
Insertion
Central 36560-36566
Irrigation 96523
Obstruction Clearance 36595, 36596
Imaging 75901, 75902
Removal 36590
Repair 36576
Replacement 36582, 36583, 36585
Catheter 36578
Ventricular Assist
Device, Intrauterine
Device, Orthotic
See Orthotics
Device Evaluation Services

Cardiac Contractility Modulation System
Interrogation 0418T
Programming 0417T
Cardiac Pacemaker
Interrogation 93288, 93294, 93296
Programming 93279-93281, 93286
Cardiovascular Physiologic Monitor System
Interrogation 93290, 93297
Implantable Counterpulsation Aortic System
Interrogation 0463T
Programming 0462T
Implantable Defibrillator System
Interrogation 93289, 93295, 93296
Programming 93282-93284
Implanted Neurostimulator Pulse Generator for Sleep Apnea
Interrogation 0434T
Programming 0435T, 0436T
Intracardiac Ischemia Monitoring System
Interrogation 0529T
Programming 0528T
Intraocular Retinal Electrode Array 0472T, 0473T
Interrogation Device Evaluation 93298
Programming Device Evaluation 93285
Subcutaneous Lead Implantable Defibrillator System 93261
Interrogation 0576T, 0578T, 0579T
Programming 0575T
Ventricular Assist Device (VAD)
Interrogation and Programming 93750
Wireless Cardiac Stimulator
Interrogation 0521T
Programming 0522T
Device Handling
Order Expediting 99002
Dexamethasone
Suppression Panel 80420
DHA Sulfate
DHEA
See Dehydroepiandrosterone
DHEA Sulfate
Diagnosis, Psychiatric
See Psychiatric Diagnosis
Diagnostic Amniocentesis
See Amniocentesis
Diagnostic Aspiration, Eye
See Paracentesis, Eye, Anterior Chamber Fluid Removal
Diagnostic Radiological Examination

See X ray
Diagnostic Skin and Sensitization Tests
See Allergy Tests
See Ultrasound
Diagnostic Ultrasound of Heart
See Echocardiography
Dialyses, Peritoneal
See Dialysis, Peritoneal
Dialysis
Anesthesia 01844
Arteriovenous Fistula 36831-36833
End-Stage Renal Disease
See End-Stage Renal Disease Services, Dialysis
Hemodialysis
See Hemodialysis
Hemoperfusion 90997
Hepatitis B Vaccine (HepB) 90740, 90747
Introduction
with Transcatheter Placement of Stent 36906
Kt/V Level 3082F-3084F
Nephropathy Treatment Documented 3066F
Patient Training
Completed Course 90989
Per Session 90993
Peritoneal 4055F, 90945, 90947
Catheter Insertion 49418, 49419, 49421
Home Infusion 99601, 99602
Plan of Care Documented 0507F
Thrombectomy
with Transcatheter Stent Placement
via Dialysis Circuit 36908
with Transluminal Balloon Angioplasty
via Dialysis Circuit 36907
with Vascular Embolization/Occlusion 36909
Dialysis, Extracorporeal
See Hemodialysis
Diaphragm
Assessment 58943, 58960
Contraception 57170
Imbrication
for Eventration 39545
Repair
Hernia 39540, 39541
Esophageal Hiatal 43280-43282, 43325
Neonatal 39503
Laceration 39501
Resection 39560, 39561
Unlisted Diaphragm Procedures 39599
Diaphragm Contraception
See Contraception, Diaphragm
Diaphysectomy
Calcaneus 28120
Clavicle 23180
Femur 27360
Fibula 27360, 27641
Humerus 23184, 24140
Metacarpal 26230
Metatarsal 28122
Phalanges
Finger 26235, 26236
Toe 28124
Radius 24145, 25151
Scapula 23182
Talus 28120
Tarsal 28122
Tibia 27360, 27640
Ulna 24147, 25150
Diastase
See Amylase
Diastasis
Pelvic Ring
Diathermy
Destruction
Ciliary Body 66700
Lesion
Retina 67208, 67227
Retinal Detachment
Prophylaxis 67141
Treatment 97024
Diathermy, Surgical
See Electrocautery
Dibucaine Number 82638

Dichloride, Methylene
See Dichloromethane
Dichlorides, Ethylene
See Dichloroethane
Dichloroethane 82441
Dichloromethane 82441
Diethylamide, Lysergic Acid
See Lysergic Acid Diethylamide
Diethylether 84600
Differential Count
Differentiation Reversal Factor

See Prothrombin
Diffusion Test, Gel
See Immunodiffusion
Digestive Tract
Digit
See also Finger; Toe
Destruction 64632
Injection 64455
Replantation 20816-20822
Digital Artery Sympathectomy 64820
Digital Slit-Beam Radiograph
See Scanogram
Digits
See Digit
Dihydroxyethanes
Dihydroxyvitamin D 82652
Dilatation, Transluminal Arterial
See Balloon Angioplasty
Dilation
See also Dilation and Curettage; Dilation and Evacuation
Anal
Endoscopy 46604
Bile Duct
Balloon 47542
Endoscopy 43277, 47555, 47556
with Stent Placement 47538-47540
Stricture 74363
Biliary Ampulla
Balloon 47542
Bladder
Cystourethroscopy 52260, 52265
Bronchi
Cerebral Vessels
Intracranial Vasospasm 61640-61642
Cervix
Canal 57800
Stump 57558
Colon
Endoscopy 45386
Colon-Sigmoid
Endoscopy 45340
Balloon 43195, 43213, 43214, 43220, 43233, 43249
Endoscopy 43195, 43196, 43212, 43213, 43220, 43226, 43229, 43233, 43453
Eustachian Tube 69705, 69706
Gastric/Duodenal Stricture 43245
Surgical 43510
Intestines 44615
Endoscopy 44370
Stent Placement 44379, 44384, 44402
Kidney 50080, 50081
Lacrimal Punctum 68801
Larynx
Nasolacrimal Duct
Balloon Catheter 68816
Nose
Balloon 31295-31297
Pancreatic Duct
Endoscopy 43277
Passage of Dilator
Esophagus 43248
Rectum
Endoscopy 45303, 45327, 45340, 45347, 45388, 45389
Sphincter 45910
Renal Tract
Salivary Duct 42650, 42660
Sclera
Aqueous Outflow Canal 66174, 66175
Sinus Ostium 31295-31297
Sphincter of Oddi
Balloon 47542
Trachea
Endoscopy 31630, 31631, 31636, 31638
Ureter
Balloon 50706
with Cystourethroscopy 52341-52343
with Ureteroscopy 52344-52346
Endoscopy 50553, 50572, 50575, 50953, 50972
Urethra 52285, 52601, 52630, 52647-52649, 53660, 53661, 53665, 55801, 55821
Stenosis 52281
Stricture 52281, 53600, 53601, 53605, 53620, 53621, 53665
Vagina 57400
Dilation and Curettage
See also Curettage; Dilation
with Amniotic Injections 59851
Cervical Stump 57558
Cervix 57520, 57558
Corpus Uteri 58120
with Vaginal Suppository 59856
Postpartum 59160
with Vaginal Suppositories 59856
Dilation and Evacuation 59841

with Vaginal Suppository 59856
Dioxide, Carbon
See Carbon Dioxide
Dioxide, Silicon
See Silica
Dipeptidyl Peptidase A
Diphenylhydantoin
See Phenytoin
Diphosphate, Adenosine
See Adenosine Diphosphate
Diphtheria
Antibody 86648
Toxoids
Diphtheria, Tetanus Toxoids, Acellular Pertussis, Inactivated Poliovirus, Haemophilus Influenzae
type b PRP-OMP Conjugate, and Hepatitis B (DTaP-IPV-Hib-HepB) 90697
Diphtheria, Tetanus Toxoids, Acellular Pertussis, Haemophilus Influenza type b, and Inactivated
Poliovirus (DTaP-IPV/Hib) 90698
Diphtheria and Tetanus Toxoids (DT) 90702
Vaccines
Diphtheria, Tetanus, Acellular Pertussis, and Inactivated Poliovirus (DtaP-IPV) 90696
Diphtheria, Tetanus, Acellular Pertussis (DtaP) (Tdap) 90700, 90715
Diphtheria, Tetanus, Acellular Pertussis, Hepatitis B, and Inactivated Poliovirus (DtaP-HepB-IPV)
90723
Dipropylacetic Acid
Assay 80164, 80165
Direct Pedicle Flap
Formation 15570, 15572, 15574, 15576
Transfer 15570, 15572, 15574, 15576, 15650
Disability Evaluation Services

Basic Life and/or Disability Examination 99450
Work-Related or Medical Disability Examination 99455, 99456
Disarticulation
Ankle 27889
Hip 27295
Knee 27598
Mandible 61590
Shoulder 23920, 23921
Wrist 25920, 25922, 25924
Disc, Intervertebral
See Intervertebral Disc
Disc Chemolyses, Intervertebral 62292
Discectomies
See Discectomy
Discectomies, Percutaneous
See Discectomy, Percutaneous
Discectomy
Additional Segment 22226
Arthrodesis
Additional Interspace 22534, 22585, 22634
Cervical 22551, 22552, 22554, 22585
Lumbar 22533, 22534, 22558, 22585, 22630, 22899, 62380
Sacral 22586, 22899
Thoracic 22532, 22534, 22556, 22585, 63077, 63078
Cervical 22220, 22551, 22552, 22554, 22856-22858, 63075, 63076
with End Plate Preparation 22856, 22858
with Osteophytectomy 22856, 22858
Lumbar 0163T, 0164T, 22224, 22630, 22633, 22634, 22857, 22899
Percutaneous 0274T, 0275T
Sacral 22586, 22899
Thoracic 22222
Discharge, Body Substance
See Drainage
Discharge Services
Hospital 99238, 99239
Newborn 99463
Nursing Facility 99315, 99316
Observation Care 99217, 99234, 99236
Discission
Cataract
Laser Surgery 66821
Stab Incision 66820
Hyaloid Membrane 65810
Vitreous Strands 67030
Discography
Cervical Disc 72285
Lumbar Disc 62287, 72295
Thoracic 72285
Discolysis
See Chemonucleolysis
Disease
Erb-Goldflam
See Myasthenia Gravis
Heine-Medin
See Polio
Hydatid
See Echinococcosis
Lyme
See Lyme Disease
Ormond
See Retroperitoneal Fibrosis
Peyronie
Posada-Wernicke
See Coccidioidomycosis
Disease/Organ Panel
See Organ or Disease-Oriented Panel
Dislocated Elbow
See Dislocation, Elbow
Dislocated Hip
See Dislocation, Hip Joint
Dislocated Jaw
See Dislocation, Temporomandibular Joint
Dislocated Joint
See Dislocation
Dislocated Shoulder
See Dislocation, Shoulder
Dislocation
Ankle
Carpal
Thumb 26641
Bennett Fracture 26650, 26665
Elbow
Monteggia 24620, 24635
Open Treatment 24586, 24587, 24615
Hip Joint
Closed Treatment 27250-27252, 27265, 27266
Congenital 27256-27259
Open Treatment 27253, 27254, 27258, 27259
without Trauma 27265, 27266
Percutaneous Fixation 26776, 28666
Knee 27560-27562
Open Treatment 27556-27558, 27566, 27730
Recurrent 27420-27424
Leg
Knee 27560-27562
Open Treatment 27556-27558, 27566, 27730
Recurrent 27420-27424
Patella
Recurrent 27420, 27424
Tibiofibular Joint
Lunate
Metacarpophalangeal Joint
Patella
Recurrent 27420, 27424
Pelvic Ring
Percutaneous 26705
Peroneal Tendons 27675, 27676
Radiocarpal
Radioulnar
Radioulnar Joint
Galeazzi 25520, 25525, 25526
Radius
with Fracture
Shoulder
Closed Treatment with Manipulation 23650, 23655
with Greater Tuberosity Fracture
with Surgical or Anatomical Neck Fracture
Skin
Debridement 11010-11012
Sternoclavicular Joint
Closed Treatment
Talotarsal Joint
Tarsal
Tarsometatarsal Joint
Temporomandibular Joint
Thumb
with Fracture 26645
with Manipulation 26641, 26645, 26650
Tibiofibular Joint
Toe
Closed Treatment 26770, 26775, 28630-28635
Trans-Scaphoperilunar
Vertebra
Additional Segment
Cervical
Open Treatment 22318, 22319, 22326
Closed Treatment
with Manipulation, Casting and/or Bracing 22315
Lumbar
Thoracic
Wrist
Closed Treatment 25660, 25675, 25680
with Fracture
Intercarpal 25660
with Manipulation 25660, 25675, 25680
Radiocarpal 25660
Radioulnar
Disorder
Auditory Processing
Gene
See Gene Analysis
Hearing
Evoked Otoacoustic Emissions
Movement
Lesion Ablation 0398T
Symptom Recording 0533T-0536T
Displacement Therapy
Nose 30210
Dissection
Axial Vessel
for Island Pedicle 15740
Cavernous Sinus 61613
Cranial Adhesions 62161
for Debulking 58952, 58953
Donor Organ
Heart 33944
Heart/Lung 33933
Kidney 50323, 50325
Liver 47143
Lung 32855
Pancreas 48551
Facial Nerve 42420
Hygroma, Cystic
Axillary/Cervical 38550, 38555
Infrarenal Aneurysm 34701-34706, 34709-34711, 34830-34832
Lymph Nodes 38542
Mediastinal 60521, 60522
Neck
See Radical Neck Dissection
Neurovascular 32503
Sclera 67107
Urethra 54328, 54332, 54336, 54348, 54352
Dissection, Neck, Radical

Distention
See Dilation
Diverticula, Meckel’s
See Diverticulum, Meckel’s
Diverticulectomy 44800
Cervical Esophagus 43180
Esophagus 43130, 43135, 43180
Hypopharynx 43180
Diverticulectomy, Meckel’s
See Meckel’s Diverticulum, Excision
Diverticulum
Bladder
Excision 51525
Incision 52305
Resection 52305
Large Intestine 44604, 44605
Meckel’s
Excision 44800
Urethra
Excision 53230, 53235
Urethroplasty 53400, 53405
Division
Flap 15600, 15610, 15620, 15630
Intrauterine Septum 58560
Muscle
Foot 28250
Neck
Scalenus Anticus 21700, 21705
Sternocleidomastoid 21720, 21725
Plantar Fascia
Foot 28250
Rectal Stricture 45150
Saphenous Vein 37700, 37722, 37735
Symblepharon 68340
Division, Isthmus, Horseshoe Kidney

Symphysiotomy, Horseshoe Kidney 50540
Division, Scalenus Anticus Muscle 21700, 21705
DNA
DNA Endonuclease
See DNAse
DNA Probe
See Cytogenetic Study, Molecular, DNA Probe
DNAse
Antibody 86215
Domiciliary Services
Care Plan Oversight 99339, 99340
Discharge Services 99315, 99316
Donor Procedures
See also Harvesting
Bone Harvesting 20900-20902
Bone Marrow Harvesting 38230, 38232
Conjunctival Graft 68371
Heart Excision 33940
Heart/Lung Excision 33930
Intestine Excision 44132, 44133
Kidney Excision 50300, 50320
Liver Excision 47133
Segment 47140-47142
Lung Excision 32850
Mucosa of Vestibule of Mouth Excision 40818
Pancreas Excision 48550
Preparation of Fecal Microbiota 44705
Stem Cells 38204
Donor Search 38204
Dopamine
See Catecholamines
Doppler Echocardiography 76827, 76828, 93306-93308, 93320-93350
Intracardiac 93662
Transesophageal 93318
Transthoracic 93303-93317
Doppler Scan
Arterial Studies
Coronary Flow Reserve 93571, 93572
Extremities 93922-93924
Fetal
Middle Cerebral Artery 76821
Duplex
Transplanted Kidney 76776
Intracranial Arteries
Complete Study 93886
Emboli Detection 93892, 93893
Limited Study 93888
Vasoreactivity Study 93890
Transplanted Kidney 76776
Dorsal Vertebra
See Vertebra, Thoracic
Dose Plan
See Dosimetry
Dosimetry
Radiation Therapy
Basic Calculation 77300
Oncology 0520F
Brachytherapy 77316-77318
Intensity Modulated Radiation Treatment (IMRT) 77301, 77338, 77385, 77386
Special 77331
Teletherapy 77306, 77307, 77321
Unlisted Radiation Dosimetry Procedure 77399
Double-Stranded DNA
DPH
Phenytoin Assay 80185, 80186
Drainage
See also Incision and Drainage; Paracentesis; Puncture Aspiration
Abscess
Anal 46045, 46050, 46060
Ankle 27603
Appendix 44900
Arm, Upper 23930
Auditory Canal 69020
Bartholin’s Gland 56420
Brain 61150, 61151, 61320, 61321
Breast 19020
Dentoalveolar Structures 41800
Ear, External 69000, 69005
Elbow 23930
Eyelid 67700
Finger 26010, 26011
Tendon Sheath 26020
Forearm 25028
Knee 27301
Leg 27603
Liver 47010
Lung 31645, 31646, 32200
Lymph Node 38300, 38305
Mouth
Lingual 41000
Sublingual 41005, 41006, 41015, 42310
Submandibular Space 41008, 41017
Submaxillary 42310, 42320
Submental Space 41007, 41016
Nasal 30000
Nasal Septum 30020
Neck 21501, 21502
Ovary 58820, 58822
Palate 42000
Parotid 42300, 42305
Pelvic 45000
Supralevator 45020
Perineal 56405
Perirenal 50020
Peritoneal 49020
Peritonsillar 42700
Pharyngeal 42720, 42725
Prostate 52700, 55720, 55725
Rectum 45005, 46040
Supralevator 45020
Renal 50020
Retroperitoneal 49060, 49323
Shoulder 23030
Skene’s Gland 53060
Soft Tissue
Percutaneous 10030
Subfascial 22010, 22015
Spine
Subdiaphragmatic 49040
Subphrenic 49040
Thigh 27301
Thorax 21501, 21502
Urethra 53040
Uvula 42000
Vestibule of Mouth 40800, 40801
Vulva 56405
Wrist 25028
with X ray 75989
Abscess, Superficial 10060, 10061
Bile Duct 47533-47540
Biliary Tract 47400, 47420, 47425, 47480
Catheterization 47533, 47534
Bladder 51040, 51080
Brain 62160, 62162, 62164
Bursa
Arm, Upper 23930
Elbow 23930
Foot 28001-28003
Forearm 25028
Hip 26990
Knee 27301
Leg 27604
Palm 26025, 26030
Pelvis 26990
Shoulder 23031
Thigh 27301
Wrist 25028
Catheter
See Catheter, Drainage
Cyst
Brain 61150, 61151, 62162
Breast 19000, 19001
Conjunctiva 68020
Intramedullary 63172, 63173
Liver 47010
Lung 32200
Mouth
Lingual 41000
Sublingual 41005, 41006, 41015
Ovary 58800, 58805
Elbow 23930
Empyema
Chest 32036, 32810
Eye 0191T, 0253T, 0376T, 66183
Lacrimal Sac 68420
Paracentesis
See Paracentesis, Eye
Fluid
Cerebrospinal 62272, 62329
Fetal 59074
Hand (Finger or Palm)
Tendon Sheath 26020
Peritoneal
Percutaneous 49406
Transrectal 49407
Transvaginal 49407
Retinal 67108, 67113
Retroperitoneal
Percutaneous 49406
Transrectal 49407
Transvaginal 49407
Visceral
Percutaneous 49405
Hematoma
Ankle 27603
Brain 61108, 61154, 61156
Ear, External 69000, 69005
Forearm 25028
Knee 27301
Leg 27603
Mouth
Lingual 41000
Sublingual 41005, 41006, 41015
Nasal 30000
Nasal Septum 30020
Shoulder 23030
Subungual 11740
Vagina 57022, 57023
Wrist 25028
Hematoma, Superficial 10140
Joint
Acromioclavicular 23040
Ankle 27610
Carpometacarpal 26070
Glenohumeral 23040
Hip 26990, 27030
Interphalangeal 26080, 28024
Intertarsal 28022
Knee 29871
Metatarsophalangeal 28022
Midcarpal 25040
Pelvis 26990
Radiocarpal 25040
Sternoclavicular 23044
Thigh 27301
Wrist 29843
Kidney 50040
Knee 27310
Lymph Node 38300, 38305
Lymphocele
Peritoneal 49062, 49323
Mediastinum 39000
Onychia 10060, 10061
Orbit 67405, 67440
Pancreas
to Intestines 48520, 48540, 48548
Pseudocyst 48510
Paronychia 10060, 10061
Pelvis 50125, 50433
Penis 54015
Pericardial Sac 32659
Pericardium 33017-33019, 33025
Peritonitis 49020
Pleura 32556, 32557
Postoperative Wound Infection 10180
Pseudocyst
Gastrointestinal, Upper 43240
Pancreas 48510
Radiological Guidance 75989
Rectum
Injury 45562
Seroma
Skin 10140
Syrinx
Intramedullary 63172, 63173
via Tube Thoracostomy 32551
Ureter 50600
Urethra
Extravasation 53080-53085
Venous
Sinus Venosus 33645
Drainage Implant, Glaucoma

See Aqueous Shunt
Dressings
Burns 16020, 16025, 16030
Change
Anesthesia 15852
DREZ Procedure
Spinal Laminectomy with Myelotomy 63170
DRIL (Distal Revascularization and Interval Ligation)
Steal Syndrome 36838
Drill Hole
Skull 61105
for Catheter 61107
for Drainage of Hematoma 61108
for Implantation of Electrode 61850, 61863, 61864
for Implantation of Electrode Array 61867, 61868
for Intracerebral Monitoring Device 61107
for Pressure Recording Device 61107
Drug
Administration
Allergenic Extracts
for Cancer
See Chemotherapy
for Cardiac Assessments 93463
for Helicobacter Pylori Breath Test 83014
Infusion
Epidural 62360-62362
Home 99601, 99602
Intravenous 4100F, 96365-96368
Instillation
See Instillation, Drugs
Unlisted Injection or Infusion 96379
Analysis
See specific analytes
Monitoring
Prescription Drug 0011U, 0051U, 0054U
Procedure
See Drug Assay, Drug Procedure
Resistance Analysis
HIV 1 87903, 87904
Susceptibility Prediction
Quantitative
See Drug Assay
Drug Assay
Drug Procedure
Definitive Drug Class
6-Acetylmorphine 80356
Acetaminophen 80329-80331
Acetylcodeine 80356
Alcohol Biomarkers 80321, 80322
Alcohols 80320
Alkaloids, Not Otherwise Specified 80323
Amphetamines 80324-80326
Anabolic Steroids 80327, 80328
Analgesics, Non-Opioid 80329-80331
Antidepressants
Not Otherwise Specified 80338
Serotonergic Class 80332-80334
Tricyclic and Other Cyclicals 80335-80337
Antiepileptics, Not Otherwise Specified 80339-80341
Antipsychotics, Not Otherwise Specified 80342-80344
Barbiturates 80345
Benzodiazepines 80346, 80347
Buprenorphine 80348
Cannabinoids
Natural 80349
Synthetic 80350-80352
Cocaine 80353
Codeine 80361
Diacetylmorphine 80356
Drug(s) or Substance(s), Definitive, Qualitative or Quantitative, Not Otherwise Specified 80375-
80377
Fentanyl 80354
Gabapentin, Non-blood 80355
Heroin Metabolite 80356
Ketamine and Norketamine 80357
Methadone 80358
Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80359
Methylphenidate 80360
Opiates, 1 or more 80361
Opioids and Opiate Analogs 80362-80364
Oxycodone 80365
Pregabalin 80366
Propoxyphene 80367
Salicylate 80329-80331
Sedative Hypnotics (non-benzodiazepines) 80368
Skeletal Muscle Relaxants 80369, 80370
Stereoisomer (Enantiomer) Analysis, Single Drug Class 80374
Stimulants, Synthetic 80371
Tapentadol 80372
Tramadol 80373
Presumptive Drug Class 0007U, 80305-80307
Therapeutic Drug Assay
See Therapeutic Drug Assay
Drug Delivery Systems

See also Infusion Pump
Drug Delivery Device
Muscular
Insertion 20700, 20702, 20704
Removal 20701, 20703, 20705
Implantation
Contraceptive 11976
Intravitreal 67027
Insertion 11981
for Clinical Brachytherapy 58346
Irrigation 96523
Maintenance and Refill
Implant 11983
Implantable Drug Pump/Reservoir
Brain 95990, 95991
Epidural 95990, 95991
Intra-arterial 96522
Intrathecal 95990, 95991
Intravenous 96522
Intraventricular 95990, 95991
Spinal 95990, 95991
Reinsertion
Implant 11983
Removal
Device 20701, 20703, 20705
Implant 11982, 11983
Drug Instillation
See Instillation, Drugs
Drug Management
by Pharmacist 99605-99607
Psychiatric 90863
Drug Screen
Chromatography 80307
Direct Optical Observation 80305
Instrument Assisted Direct Optical Observation 80306
Instrument Chemistry Analyzers 80307
Mass Spectrometry 80307
Drugs, Anticoagulant
See Anticoagulant Management; Clotting Inhibitors
DST
Dexamethasone, Suppression Panel 80420
DT Shots
Diphtheria and Tetanus Toxoids, Acellular Pertussis, Inactivated Poliovirus, Haemophilus Influenzae
type b PRP-OMP Conjugate, and Hepatitis B (DTaP-IPV-Hib-HepB) 90697
Diphtheria and Tetanus Toxoids, Acellular Pertussis, Haemophilus Influenza Type b, and Inactivated
Poliovirus (DTaP-IPV/Hib) 90698
Diphtheria and Tetanus Toxoids (DT) 90702
DTaP Immunization 90700
DTaP-HepB-IPV Immunization 90723
Dual Photon Absorptiometry
Bone Density Study 78351
Dual X-ray Absorptiometry (DXA)

Appendicular 77081
Axial Skeleton 77080
Vertebral Fracture 77085, 77086
Duct, Bile
See Bile Duct
Duct, Hepatic
See Hepatic Duct
Duct, Nasolacrimal
See Nasolacrimal Duct
Duct, Omphalomesenteric
See Omphalomesenteric Duct
Duct, Pancreatic
See Pancreatic Duct
Duct, Salivary
See Salivary Duct
Duct, Stensen
See Parotid Duct
Duct, Thoracic
See Thoracic, Duct
Ductogram, Mammary
See Galactogram
Ductus Arteriosus
Closure
Repair 33820, 33824
Ductus Deferens
See Vas Deferens
Duhamel Procedure
See Proctectomy, Total
Duodenectomy
Partial 48153, 48154
Total 48150, 48152
Duodenostomy
Insertion 49441
Replacement 49451
Duodenotomy
Biopsy 43239, 44010
Fine Needle Aspiration 43242
Exploration 44010
Duodenum
Bariatric Surgery
See Bariatric Surgery
Biopsy 43239, 44010
Fine Needle Aspiration 43242
Donor Transplant 48550, 48551
Duodenostomy
See Duodenostomy
Catheter Placement 43241
Cholangiopancreatography 43260
with Control of Bleeding 43255
Diagnostic 43235
Dilation 43245
Drainage, Pseudocyst 43240
Examination 43259
Ultrasound 43253
Foreign Body Removal 43247, 43275
with Injection
Sclerotic Varix 43243
Submucosal 43236, 43253
with Ligation
Sclerotic Varix 43244
with Lithotripsy 43265
Excision 48150, 48152-48154
Exclusion 48547
Exploration 44010
Incision 44010
Intubation and Aspiration 43756, 43757
Lysis 44055
Motility Study 91022
Naso- or Oro-gastric Feeding Tube
Repositioning 43761
Removal
Lesion 43250, 43251
Polyp 43250, 43251
Tumor 43250, 43251
Duplex Scan
See Vascular Studies
Arterial Studies
Aorta 93978, 93979
Penile 93980, 93981
Visceral 93975-93979
Doppler
See Doppler Scan, Duplex
Hemodialysis Access 93990
Hemodialysis Preoperative Assessment 93985, 93986
Venous Studies
Extremity 93970, 93971
Penile 93980, 93981
Dupuy-Dutemps Operation
See Reconstruction, Eyelid
Dupuytren’s Contracture
Fasciotomy
Open, Partial 26045
Percutaneous 26040
Injection
Enzyme 20527
Manipulation 26341
Palmar Fascial Cord
Injection
Enzyme 20527
Manipulation 26341
Surgical Pathology 88304
DXA
See Dual X-ray Absorptiometry (DXA)
D-Xylose Absorption Test 84620
Dynamometry
Ophthalmodynamometry 92260
E
E Antigens
Hepatitis Be (HBeAg) Antigen Detection 87350
E B Virus
Epstein-Barr Virus Antibody
Detection 86663-86665
E Vitamin
Tocopherol 84446
E1
See Estrone
E2
See Estradiol
E3
See Estriol
Ear
Collection of Blood 36416
Drum
See Tympanic Membrane
External Ear
Biopsy 69100, 69105
Blood Specimen Collection 36416
Debridement
Mastoidectomy Cavity 69220-69222
Drainage
Abscess 69000, 69005
Hematoma 69000, 69005
Excision
Partial 69110
Total 69120
Exostosis Excision 69140
Graft
See Graft, Ear
Lesion
Destruction, Malignant 17280
Excision 11400-11444, 11446, 69145, 69150, 69155
Excision, Malignant 11640-11644, 11646
Shaving 11310
Mastoid
See Mastoid
Piercing 69090
Prosthesis, Custom 21086
Reconstruction
External Auditory Canal 69310, 69320
Protruding Ear 69300
with Tissue Transfer 14060, 14061
Removal
Impacted Cerumen 69209, 69210
Repair
Complex 13151, 13152, 13153
Intermediate 12051
Simple 12011
Superficial 12011
Tympanic Membrane
Inner Ear
CT Scan 70480-70482
Endolymphatic Sac 69805, 69806
Evoked Potentials
See Evoked Potentials, Auditory
Insertion
Labyrinth
Excision 69905, 69910
Incision for Perfusion 69801
Vertigo
Canalith Repositioning 95992
Vestibular Nerve Section 69915
Meatoplasty 69310
for Congenital Atresia 69320
Middle Ear
CT Scan 70480-70482
Eustachian Tube Dilation 69705, 69706
Excision
Glomus Tumor 69550, 69552, 69554
Polyp 69540
Exploration 69440
Facial Nerve Decompression 69720, 69725
Facial Nerve Suture 69740, 69745
Nasopharyngoscopy
Surgical 69705, 69706
Optical Coherence Tomography 0485T, 0486T
Repair
Fistula 69666, 69667
Stapes
Mobilization 69650
Stapedectomy 69660-69662
Stapedotomy 69660-69662
Tumor
Excision 69550, 69552, 69554
Tympanostomy 0583T, 69433, 69436
Temporal Bone
Bone Conduction Hearing Device
Implantation 69710
Removal 69711
Repair 69711
Osseointegrated Implant
Implantation 69714, 69715
Removal 69717
Replacement 69717
Resection 69535
Vestibular Function
See Vestibular Function Tests
Ear, Nose, and Throat

See Audiologic Function Tests
Audiometry
See Audiometry
Binocular Microscopy 92504
Diagnostic Analysis
Auditory Brainstem Implant 92640
Cochlear Implant 92601-92604
Evaluation
Auditory Rehabilitation Status 92630, 92633
Candidacy for Auditory Implant 92626, 92627
Function of Auditory Implant 92626, 92627
Language Comprehension and Expression 92523
Laryngeal Sensory Testing 92614-92617
Prescription of Communication Device
Non-speech-generating 92605, 92618
Speech-generating 92607, 92608
Speech Fluency 92521
Speech Sound Production 92522
Swallowing 92610-92613, 92616
Voice and Resonance
Behavioral Analysis 92524
Examination under Anesthesia 92502
Facial Nerve Function Study 92516
Laryngeal Function Study 92520
Nasal Function Study 92512
Nasopharyngoscopy 92511
Treatment
Hearing, Language and Speech Disorder 92507, 92508
Oral Function for Feeding 92526
Swallowing Dysfunction 92526
Use and Programming of Communication Device
Non-speech-generating 92606
Speech-generating 92609
Unlisted Otorhinolaryngological Service/Procedure 92700
Vestibular Function Tests
Ear Canal
See Auditory Canal
Ear Cartilage
Graft
Autogenous
Ear Cartilage to Nose or Ear 21235
Rib Cartilage to Ear 21230
Ear Lobes
Pierce 69090
Ear Protector Attenuation
See Hearing Aid Services
Measurements 92596
Ear Wax
See Cerumen
Ebstein Anomaly Repair
Tricuspid Valve 33468
Eccrine Glands
Chemodenervation
Axillae 64650
Feet 64999
Hands 64999
Other Area 64653
ECG
Echinococcosis 86171, 86280
Echocardiography
Congenital Cardiac Anomaly
Doppler, Fetal 76827, 76828
Fetal 76825, 76826
Transesophageal 93315-93317
Doppler
See Doppler Echocardiography
Intracardiac 93662
Myocardial
Contrast Perfusion 0439T
Strain Imaging 93356
Speckle Tracking Assessment 93356
Transesophageal 93312-93318, 93355
Transthoracic 93306-93308, 93350-93352
Congenital Cardiac Anomalies 93303, 93304
with Stress Test 93350-93352
Echoencephalography
Intracranial 76506
Echography
See Ultrasound
Echotomography
See Ultrasound
ECLS (Extracorporeal Life Support)

ECMO
ECS
See SPECT
ECSF (Erythrocyte Colony Stimulating Factor)
Erythropoietin 82668
ECT
See SPECT
Ectasia
See Dilation
Ectopic Pregnancy
Abdominal 59130
Cervix 59140
Laparoscopic Treatment 59150
with Salpingectomy and/or Oophorectomy 59151
Ovarian 59121
Tubal 59121
Uterine
with Partial Uterine Resection 59136
Ectropion
Repair
Excision Tarsal Wedge 67916
Extensive 67917
Suture 67914
Thermocauterization 67915
Education Services
Group 98961, 98962, 99078
Individual
Pediatric Gastroenteritis Education 4058F
Education Supplies
Provided to Patient 99071
EEG
Egg
See Ova
Ehrlichia
Antibody 86666
EKG
Elastase 82656
Elastography
Magnetic Resonance 76391
Ultrasound 76979, 76981-76983
Elbow
See also Humerus; Radius; Ulna
Abscess
Anesthesia
See Anesthesia, Elbow
Arthrectomy 24155
Arthrodesis 24800, 24802
Arthrography 73085
Arthroplasty 24360
Total Replacement 24361-24363, 24365, 24366
with Implant 24361, 24362
Prosthesis Removal 24160, 24164
Revision 24370, 24371
Arthroscopy
Diagnostic 29830
Surgical 29834-29838
Arthrotomy 24000
Drainage 24000
Removal of Foreign Body 24000
Synovectomy 24102
Synovial Biopsy 24100
Biopsy 24065, 24066, 24101
Synovial 24100, 29830
Bone Cortex Incision 23935
Capsule
Excision 24006
Contracture Release 24149
Dislocation
Nursemaid Elbow 24640
Subluxate 24640
Epicondylitis 24357-24359
Excision
Bursa 24105
Soft Tissue 24077, 24079
Subfascial 24076
Synovium 24102, 29835, 29836
Fracture
Hematoma
Abscess, Deep 23930
Bursa 23931
Hematoma 23930
Injection
Arthrography
Radiological 24220
Magnetic Resonance Imaging (MRI) 73221
Manipulation 24300
Prosthesis
Removal
Humeral and Ulnar Components 24160
Radial Head 24164
Removal
Foreign Body 24000, 24101, 24200, 24201, 29834
Loose Body 24101, 29834
Prosthesis 24160
Repair
Advancement 24330, 24331
Epicondylitis 24357-24359
Flexorplasty 24330
Graft 24320
Hemiepiphyseal Arrest 24470
Muscle 24341
Tendon 24340-24342, 24357-24359
Lengthening 24305
Repair 24341, 24359
Tenodesis 24340
Tenotomy 24310, 24357-24359
Transfer 24301
Tennis Elbow 24357-24359
Resection
Capsule 24149
Heterotropic Bone 24149
Joint 24155
Soft Tissue 24149
with Contracture Release 24149
Seddon-Brookes Procedure 24320
Steindler Advancement 24330
Strapping 29260
Tumor
Soft Tissue
Ulnar Neuroplasty 64718
Unlisted Elbow Procedure 24999
X ray 73070, 73080
with Contrast 73085
Elbow, Golfer
Tenotomy, Lateral or Medial 24357-24359
Elbow, Tennis
Tenotomy, Lateral or Medial 24357-24359
Electric Countershock
See Cardioversion
Electric Stimulation
See Electrical Stimulation
Electric Stimulation, Transcutaneous
Electrical Modulation Pain Reprocessing, Transcutaneous 0278T

Electrical Stimulation
Acupuncture 97813, 97814
Arrhythmia Induction 93618
Bone Healing
Invasive 20975
Noninvasive 20974
Brain Surface 95961, 95962
Guidance
for Chemodenervation 95873
Physical Therapy
Attended, Manual 97032
Unattended 97014
Spine 63650, 63655, 63661-63664, 63685, 63688
Electroanalgesia
Electrocardiography
12 Lead 3120F, 93000
Evaluation 93000, 93010, 93660
External Recording
Auto Activated 93268, 93270-93272
Duration
More than 7 Days Up to 15 Days 93245-93248
More than 48 Hours Up to 7 Days 93241-93244
Up to 30 Days 93268, 93270-93272
Up to 48 Hours 93224-93227
Mobile
More than 24 Hours 93228, 93229
Patient-Activated 0497T, 0498T, 93268, 93270-93272
Transmission and Evaluation 93268, 93270, 93271
Interpretation
Auto Activated 93268, 93272
External Recording
More than 7 Days Up to 15 Days 93245, 93248
More than 48 Hours Up to 7 Days 93241, 93244
Up to 48 Hours 93224, 93227
Rhythm
Evaluation 93042
Microvolt T-wave Alternans 93025
Tracing 93005, 93041
Tracing and Evaluation 93040
Signal Averaged 93278
Symptom-Related Memory Loop 93268, 93270-93272
Electrocautery
Inferior Turbinates Soft Tissue 30801, 30802
Prostate Resection 52601
Ureteral Stricture 52341-52346
Electrochemistry
See Electrolysis
Electroconvulsive Therapy 90870

Electrocorticogram
from Implanted Brain Neurostimulator 95836
Intraoperative 61536, 61538, 95829
Electrode, Depth
Cerebral Implantation 61760
Electrode Array Intracranial 64553
Electrodesiccation 17000-17286
Lesion
Penis 54055
Electroejaculation
Reproductive 55870
Electroencephalography (EEG)
with Data Review 95705-95716
Digital Analysis for Epileptic Spike 95957
by Health Professional 95954
Monitoring
Continuous 95707, 95710, 95713
Extended 95812, 95813
Intermittent 95706, 95709
In-Person Administration by Technologist 95700
Unmonitored 95705, 95708
with Wada Activation 95958
Recording
Awake and Asleep 95819
Awake and Drowsy 95816
for Brain Death Evaluation 95824
Coma Only 95822
Complete Study 95721-95726
Continuous for Seizure Detection 95717-95726
In-Person Administration by Technologist 95700
Sleep Only 95822
Wada 95958
Electroencephalography with Video (VEEG)

Data Review 95711-95715
Monitoring
Continuous 95713, 95716
Intermittent 95712, 95715
Unmonitored 95711, 95714
with In-Person Administration by Technologist 95700
Recording
Complete Study 95722, 95724, 95726
Continuous for Seizure Detection 95718, 95720, 95722, 95724, 95726
Electrogastrography 91132, 91133
Electrogram, Atrial
Electro-Hydraulic Procedure 52325
Electrolysis 17380
Electromyographs
See Electromyography, Needle
Electromyography
Anorectal with Biofeedback 90912, 90913
Fine Wire
Dynamic 96004
Needle
Cranial Nerve Supplied Muscle 95867, 95868
Extremities 95860-95864
Extremity 95860, 95885, 95886
Face and Neck Muscles 95867, 95868
Guidance
for Chemodenervation 64617, 95874
Hemidiaphragm 95866
Larynx 95865
Non-extremity 95887
Ocular 92265
Other than Thoracic Paraspinal 95870
Single Fiber Electrode 95872
Thoracic Paraspinal Muscles 95869
Sphincter Muscles
Anus 51784, 51785
Needle 51785
Urethra 51784, 51785
Needle 51785
Surface
Dynamic 96002, 96004
Electron Microscopy
Diagnostic 88348
Electronic Analysis
Cardiac Assist Devices
Cardiac Contractility Modulation System 0417T, 0418T
Cardiovascular Physiologic Monitor System 93290, 93297
Pacemaker System, Leadless 93279, 93286, 93288, 93294, 93296
Pacemaker System 93279-93281, 93286, 93288, 93293, 93294, 93296, 93724
Subcutaneous Cardiac Rhythm Monitor System 93285, 93291, 93298
Subcutaneous Implantable Defibrillator (SICD) 93260, 93261, 93287, 93295, 93296, 93644
Transvenous Implantable Pacing Defibrillator (ICD) 93282-93284, 93287, 93289, 93295, 93296
Wireless Cardiac Stimulation System 0521T-0522T
Drug Infusion Pump 62367-62370
Integrated Neurostimulation System 0589T, 0590T
Neurostimulators
Brain 95970-95972, 95983, 95984
Cranial Nerve 95970, 95976, 95977
Gastric 95980-95982
Peripheral Nerve 95970-95972
Posterior Tibial 0589T, 0590T
with Vagus Nerve Blocking Therapy 0317T
Electro-Oculography 92270
Electrophoresis
Hemoglobin 83020
High Resolution 83701
Immuno- 86320, 86325, 86327
Immunofixation 86334, 86335
Protein 84165, 84166
Unlisted Electrophoretic Technique 82664
Electrophysiology Procedure
Intracardiac Pacing and Mapping
3D Mapping 93613, 93654
Localization 93631
Slow Conduction Zone 93631
Stimulation and Pacing 93623
Intracardiac Pacing and Recording
Arrhythmia Induction 93618-93624, 93653, 93654, 93656
Bundle of His 93600, 93619, 93620, 93653, 93654, 93656
Comprehensive 93619-93622
Intra-Atrial 93602, 93610, 93616, 93656
Right Ventricular 93603, 93653, 93656
Ventricular 93612
Electroretinogram
See Electroretinography (ERG)
Electroretinography (ERG)
Full Field (ffERG, Flash ERG, Ganzfeld ERG) 92273
Multifocal (mfERG) 92274
Pattern (PERG) 0509T
Electrostimulation, Analgesic Cutaneous

Electrosurgery
Lesions
Anal 46924
Penile 54065
Proliferative 17106-17108
Skin, Benign 17110, 17111
Skin, Malignant 17266
Arms, Legs, or Trunk 17260-17264
Face, Ears, Eyelids, Nose, Lips, Mucous Membrane 17280-17284, 17286
Scalp, Neck, Hands, Feet, or Genitalia 17270-17274, 17276
Skin, Premalignant 17000, 17003, 17004
Vaginal 57061, 57065
Vulva 56501, 56515
Trichiasis
Epilation 67825
Tumor
Rectal 45190
Electroversion, Cardiac
See Cardioversion
Elevation, Scapula, Congenital
Scapulopexy 23400
Elliot Operation
Excision of Scleral Lesion 66130
Eloesser Procedure
Thoracostomy for Empyema 32035, 32036
Eloesser Thoracoplasty
Thoracoplasty 32905, 32906
Embolectomy
Aortoiliac Artery 34151, 34201
Axillary Artery 34101
Brachial Artery 34101
Celiac Artery 34151
Femoral 34201
Iliac 34151-34201
Innominate Artery 34001-34101
Mesentery Artery 34151
Peroneal Artery 34203
Popliteal Artery 34201, 34203
Pulmonary Artery 33910, 33915, 33916
Radial Artery 34111
Renal Artery 34151
Subclavian Artery 34001, 34101
Tibial Artery 34203
Ulnar Artery 34111
Embolization
Central Nervous System 61624
Intra-arterial
for Aneurysm 61710
for Carotid-Cavernous Fistula 61710
for Vascular Malformation 61710
Non-Central Nervous System
Head or Neck 61626
Ureteral 50705
Vascular
Arterial 37242
Dialysis Circuit 36909
for Hemorrhage 37244
for Infarction 37243
for Lymphatic Extravasation 37244
for Organ Ischemia 37243
for Tumors 37243
Venous 37241
Embryo
Biopsy 89290, 89291
Carcinoembryonic Antigen 82378
Thawing 89352
Culture 89250
with Co-Culture Oocyte 89251, 89272
Hatching, Assisted 89253
Implantation 58974
Preparation
for Transfer 89255
Storage 89342
Transfer
See Embryo Transfer
Embryo Implantation
Intrauterine Embryo Transfer 58974
Embryo Transfer
Intrafallopian 58976
Intrauterine 58974
Preparation
for Transfer 89255
In Vitro Fertilization 58970, 58974, 58976
Embryo/Fetus Monitoring
See Monitoring, Fetal
Embryonated Eggs
Inoculation 87250

Anesthesia 99140
Critical Care
See Critical Care Services
Physician Direction of Advanced Life Support 99288
Emesis Induction 99175
EMG
EMI Scan
See CT Scan
Emission-Computed Tomography, Single-Photon

See SPECT
Emmet Operation
Trachelorrhaphy 57720
Empyema
Drainage
Chest Wall Closure 32810
Thoracostomy 32035, 32036
Empyemectomy 32540
Enucleation 32540
Empyemectomy 32540
Encephalitis
Antibody
California 86651
Eastern Equine 86652
St. Louis 86653
Western Equine 86654
Encephalitis Virus Vaccine 90738

Encephalocele
Repair
Skull Base 62121
Skull Vault 62120
Encephalon
See Brain
Endarterectomy
Aneurysm Repair
See Aneurysm Repair
Anomaly 33500-33507
Pulmonary 33916
See Thromboendarterectomy
Endemic Flea-Borne Typhus

Murine Typhus 86000
End-Expiratory Pressure, Positive
Continuous Positive Airway Pressure
Ventilation 94660
Endobronchial Challenge Tests

Endobronchial Ultrasound (EBUS)
with Bronchoscopy 31652-31654
Endocavitary Fulguration
See Electrocautery
Endocrine, Pancreas
See Islet Cell
Endocrine System
Unlisted Services and Procedures 60699, 78099
Endolymphatic Sac
Exploration
with Shunt 69806
without Shunt 69805
Endometrial Ablation
Cryoablation 58356
Curettage 58356
with Surgical Hysteroscopy 58563
Thermal 58353
Endometrioma
Abdomen
Mesenteric
Peritoneal
Retroperitoneal
Endometriosis, Adhesive
See Adhesions, Intrauterine
Endometrium
Ablation 58353, 58356, 58563
Biopsy 58100, 58110, 58558
Curettage 58356
Endomicroscopy
Esophageal 43206
Endomyocardial Biopsy 93505

Endonuclease, DNA
DNAse Antibody 86215
Endoscopic Retrograde Cannulation of Pancreatic Duct

See Cholangiopancreatography
Endoscopies, Pleural
See Thoracoscopy
Endoscopy
See also Arthroscopy; Thoracoscopy
Adrenal Gland 60650
Anus
Ablation
Polyp 46615
Tumor 46615
Biopsy 46606
Dilation 46604
Exploration 46600
Hemorrhage 46614
High Resolution Anoscopy (HRA) 46601, 46607
Removal
Foreign Body 46608
Polyp 46610-46612
Tumor 46610-46612
Atria
Surgical 33265, 33266
Bile Duct 43273
Biopsy 47553
Cannulation 43273
Catheterization 47533-47537, 74328, 74330
Destruction
Calculi (Stone) 43265
Dilation 43277, 47555, 47556
Exploration 47552
Placement
Stent 43274
Removal
Calculi (Stone) 43264, 47554
Foreign Body 43275
Stent 43275
Bladder 52000
Biopsy 52204, 52250, 52354
Polyps 52285
Dilation 52260, 52265
Lesion 52224, 52234, 52235, 52240, 52400
Evacuation
Clot 52001
Excision
Tumor 52355
Exploration 52351
Insertion
Instillation 52010
Irrigation 52010
Lithotripsy 52353
Removal
Calculus 52310, 52315, 52352
Stent 52310
Urethral Stent 52282
Bladder Neck
Destruction 52214
Polyps 52285
Resection 52500
Contracture 52640
Brain
Dissection
Adhesions 62161
Cyst 62162
Drainage 62162
Excision
Cyst 62162
Pituitary Tumor 62165
Tumor 62164
Bronchi
with Alveolar Lavage 31624
Biopsy 31625-31629, 31632, 31633
with Brushing 31623
with Cell Washing 31622
Computer-assisted Image-guided 31627
Destruction
Lesion 31641, 96570, 96571
Tumor 31641, 96570, 96571
Dilation 31630, 31631, 31636-31638
with Endobronchial Ultrasound (EBUS) Sampling 31652, 31653
Excision
Tumor 31640
Exploration 31622
Lesion
Destruction 31641, 96570, 96571
Occlusion 31634
Placement
Fiducial Markers 31626
Radioelement Catheter 31643
Stent 31636, 31637
Removal
Foreign Body 31635
Revision
Stent 31638
Specimen Collection 31623, 31624
Stenosis 31641, 96570, 96571
through Tracheostomy 31615
Tumor
Destruction 31641, 96570, 96571
Cervix 57452
Biopsy 57421, 57454, 57455, 57460
Exploration 57452
Loop Electrode Biopsy 57460
Chest Cavity
Diagnostic 32601, 32604, 32606
Surgical 32650-32674
Colon
Ablation
Lesion 45388
Polyp 45388
Tumor 45388
Band Ligation 45350, 45398
Biopsy 44389, 45380, 45392
Decompression 45337
Destruction
Lesion 44401
Tumor 44401
Dilation 45386, 45388
Hemorrhage Control 44391, 45382
Injection 45381
Placement
Stent 45389
Removal
Polyp 44392, 45384, 45385
Tumor 44392, 45384, 45385
via Stoma 44388-44394, 44402
Colon-Sigmoid
Ablation
Lesion 45346
Polyp 45346
Tumor 45346
Band Ligation 45350
Biopsy 45331
Decompression 45337
Dilation
Exploration 45330
Hemorrhage 45334
Injection 45335
Needle Biopsy 45342
Placement
Stent 45327, 45347
Removal
Foreign Body 45332
Polyp 45333, 45338
Tumor 45333, 45338
Volvulus 45321, 45337
Duodenum
Endomicroscopy
Esophageal 43206
Esophagus
Biopsy 43198, 43202
Collection of Specimen 43197, 43200
Dilation 43195, 43196, 43212-43214, 43220, 43226, 43229, 43233, 43248, 43249
Exploration 43200
Hemorrhage 43227
Injection 43192, 43201, 43204
Injection Varices 43243
Insertion Stent 43212
Needle Biopsy 43232
with Optical Endomicroscopy 43206
Removal
Polyp 43216, 43217, 43229
Tumor 43216, 43217, 43229
Ultrasound 43231, 43232, 43237, 43238, 43242, 43253
Vein Ligation 43205
Eye 66990
Foot
Plantar Fasciotomy 29893
Gastrointestinal
See also Laparoscopy
Ablation
Lesion 43270
Polyp 43270
Tumor 43270
Capsule 91110, 91111
Upper 3130F, 3132F, 3140F, 3141F
Biopsy 43239
Dilation 43245, 43248, 43249
Drainage of Pseudocyst 43240
Foreign Body 43247
Hemorrhage 43255
Inject Varices 43243
Referral 3132F
Removal 43247, 43250, 43251
Thermal Radiation 43257
Tube Placement 43246
Ultrasound 43237-43242, 43253, 43259, 76975
Vein Ligation 43244
Heart
Atria 33265, 33266
Ileum
Biopsy 44382
via Stoma 44384
Intestines, Small
Ablation
Polyp 44369
Tumor 44369
Biopsy 44361, 44377
Destruction
Lesion 44369
Tumor 44369
Diagnostic 44376
Exploration 44360
Hemorrhage 44366, 44378
Placement
Stent 44370, 44379
Tube 44372, 44373, 44379
Removal
Foreign Body 44363
Lesion 44365
Polyp 44364, 44365
Tumor 44364, 44365
via Stoma 44380, 44382, 44384
Tube Revision 44373
Intracranial 62160-62165
Intraluminal Imaging
Colon 0355T
Gastrointestinal Tract 91110, 91111
Jejunum
Kidney 50551, 50570
Biopsy 50555, 50557, 50574-50576, 52354
Destruction 50557, 50576, 52354
Dilation
Excision
Tumor 50562, 52355
Exploration 52351
via Incision 50570, 50572, 50574-50576, 50580
Lithotripsy 52353
Removal
Calculus 50561, 50580, 52352
via Stoma 50551, 50553, 50555, 50557, 50561, 50562
Larynx
Ablation, Lesion 31572
Arytenoidectomy 31560, 31561
Aspiration 31515
Biopsy 31510, 31535, 31536
Dilation 31528, 31529
Direct 31515, 31520, 31525-31529
Diagnostic 31520, 31525, 31526
Operative 31530, 31531, 31535, 31536, 31540, 31541, 31545, 31546, 31560, 31561
Epiglottis Stripping 31540, 31541
Excision
Tumor 31540
Flexible 31575-31579
Indirect 31505, 31510-31513
Insertion
Obturator 31527
Laser Destruction, Lesion 31572
Newborn, Diagnostic 31525
Removal
Foreign Body 31511, 31530, 31531
Lesion 31512, 31545, 31546
Rigid Telescopic 31579
Vocal Cord
Injection 31513, 31570, 31571
Lesion Removal 31545
Stripping 31540, 31541
Lung
Biopsy 31628, 31632
Mediastinoscopy
Biopsy 39401, 39402
Nose
Diagnostic 31231, 31233, 31235
Surgical 31237-31241, 31253-31257, 31259, 31267, 31276, 31287, 31288, 31290-31298
Otorhinolaryngologic Evaluation
Cine or Video Recording
Swallowing 92612, 92613, 92616, 92617
Pancreatic Duct
Cannulation 43273
Destruction
Dilation 43277
Placement
Stent 43274
Removal
Foreign Body 43275
Stent 43275
Pelvis 52351
Aspiration 49322
Destruction of Lesion 52354, 58662
Lysis of Adhesions 58660
Oviduct Surgery 58670, 58671
Removal of Adnexal Structures 58661
Resection
Tumor 52355
Peritoneum
Drainage
Lymphocele 49323, 54690
Pleural Cavity
Ablation
Prostate
Coagulation with Laser 52647
Destruction 52214
Drainage
Abscess 52700
Enucleation with Laser 52649
Incision 52450
Resection
Complete 52601
Obstructive Tissue 52630
Vaporization with Laser 52647
Rectum
Ablation
Polyp 45320
Tumor 45320
Biopsy 45305
Destruction
Tumor 45320
Dilation 45303
Exploration 45300
Hemorrhage 45317
Removal
Foreign Body 45307
Polyp 45308, 45309, 45315
Tumor 45308, 45309, 45315
Volvulus 45321
Sinuses
Surgical 31237-31240, 31254-31256, 31267, 31276, 31287, 31288, 31290-31297
Spinal Cord Nerve Root
Decompression 62380
Spleen
Removal 38120
Stomach
Testis
Removal 54690
Trachea
Biopsy 31629
Dilation 31630, 31631, 31636-31638
Placement
Stent 31631
via Tracheostomy 31615
Ureter 50575, 52351
Biopsy 50955, 50957, 50974, 50976, 52007, 52354
Catheterization 50572, 50953, 50972, 52005
Destruction 50957, 50976, 52354
Lesion 52354
Ureterocele 52300, 52301
Dilation 50572, 50575, 50953
Stricture 52341, 52342, 52344, 52345
Excision
Tumor 52355
Exploration 52351
Incision 52290
Insertion
Guide Wire 52334
Manipulation of Ureteral Calculus 52330
Placement
Stent 50947, 52332
Removal
Calculus 50961, 50980, 52320, 52352
via Incision 50970, 50972, 50974, 50976, 50980
via Stoma 50951, 50953, 50955, 50957, 50961
Ureteral
Biopsy 52007
Urethra 52000
Biopsy 52204, 52354
Congenital Posterior Valves 52400
Lesion 52214, 52224, 52234, 52235, 52240
Polyps 52285
Dilation 52281, 52285
Evacuation
Clot 52001
Excision
Tumor 52355
Exploration 52351
Incision 52285
Internal 52270, 52275, 52276
Meatotomy 52281, 52285
Injection
for Cystography 52281
Implant Material 51715
Steroid 52283
Insertion
Stent 52282
Lithotripsy 52353
Lysis
Fibrosis 52285
Removal
Calculus 52310, 52315, 52352
Stent 52310
Resection
Sphincter 52277
Vasectomy 52402
Vasotomy 52402
Uterus
See Laparoscopy, Uterus
Vagina 57420
Anesthesia 00950
Biopsy 57421, 57454
Exploration 57452
Vascular
Surgical 33508, 37500, 37501
Vulva 56820
Biopsy 56821
Endosteal Implant
Reconstruction
Mandible 21248, 21249
Maxilla 21248, 21249
Endothelioma, Dural
Excision of Meningioma 61512, 61519
Endotracheal Intubation
Emergency 31500
Endotracheal Tube
Emergency Intubation 31500
Endovascular Repair
Abdominal Aorta
See Aneurysm Repair, Abdominal Aorta
Delivery of Endograft 34712, 34713
Delivery of Endovascular Prosthesis 34714-34716
Iliac Artery
with Endograft 34703-34708, 34717, 34718
with Prosthesis 34709-34711
Infrarenal Abdominal Aorta
with Endograft 34701-34706, 34845-34848
Revascularization
See Revascularization
Thoracic Aorta
See Aorta, Thoracic, Repair
Vena Cava
Filter Insertion 37191
Repositioning 37192
Retrieval 37193
Visceral Aorta
with Fenestrated Endograft 34839, 34841-34848
Endovascular Therapy
Ablation
Vein 36473-36476, 36478, 36479, 36482, 36483
Balloon Angioplasty 61630
Intracranial
Dilatation 61640-61642
Infusion
Injection 61645
Thrombectomy 61645
Occlusion
Arterial Balloon 61623
Transcatheter 61624, 61626
Vascular Catheterization 61630, 61635
End-Stage Renal Disease Services
Dialysis 90951-90970
Home 90963-90966
Inpatient 90935, 90937, 90945, 90947
Outpatient 90951-90962
Less Than a Full Month 90967-90970
Monthly 90951-90966
Enema
Contrast 74270, 74280
Home Visit for Fecal Impaction 99511
Therapeutic
for Intussusception 74283
Energies, Electromagnetic
Irradiation of Blood Product 86945
ENT
See Ear, Nose, and Throat
Entamoeba Histolytica
Antigen Detection
Immunoassay 87336, 87337
Enterectomy
Donor 44132, 44133
Partial 44133
for Congenital Atresia 44126-44128
with Enterostomy 44125
Transplanted Allograft 44137
Enterocele
Repair
with Colporrhaphy 57265
with Hysterectomy 58263, 58270, 58280, 58292, 58294
Vaginal Approach 57268, 57556
Enterocystoplasty
Camey 50825
with Intestinal Anastomosis 51960
Enteroenterostomy
See Anastomosis, Intestines
Enterolysis 44005
Laparoscopic 44180
Enteropancreatostomy
Anastomosis, Pancreas to Intestines 48520, 48540, 48548
Enterorrhaphy 44602, 44603, 44615
Enterostomy
Closure 44227, 44620, 44625, 44626
with Enterectomy
Intestine, Small 44125
with Enteroenterostomy 44130
Placement 44300
with Proctectomy 45119, 45397
Enterotomy
Biopsy 44020
Decompression 44021
Excision
Lesion 44110, 44111
Exploration 44020
Intestinal Stricturoplasty 44615
Enterovirus
Antibody 86658, 87267, 87498
Entropion
Repair 67921-67924
Suture 67921
Enucleation
Cyst
Mandible 21040
Maxilla 21030
Zygoma 21030
Empyema
Pleural 32540
Eye 65101, 65103, 65105
Prostate 52649
Tumor, Benign
Mandible 21040
Maxilla 21030
Zygoma 21030
Enucleation, Cyst, Ovarian
Cystectomy, Ovarian 58925
Enucleation, Prostate
Laser 52649
Environmental Intervention
for Psychiatric Patients 90882
Enzyme, Angiotensin Converting

Enzyme, Angiotensin-Forming
See Renin
Enzyme Activity
Constituents 88319
Detection 87185
Immunoassay
See Infectious Agent, Antigen Detection, Immunoassay
Incubation 86977
Specific Analytes
See Pathology and Laboratory, Enzymes
EOG
Electro-Oculography 92270
Eosinocyte
Eosinophils 89190
Eosinophils
Nasal Smear 89190
Epicondylitis, Radiohumeral
Tennis Elbow Tenotomy 24357-24359
Epicondylitises, Lateral Humeral

Epidemic Parotitis
See Mumps
Epididymectomy
Bilateral 54861
with Excision of Spermatocele 54840
Unilateral 54860
Epididymis
Anastomosis
to Vas Deferens
Bilateral 54901
Unilateral 54900
Biopsy 54800, 54865
Excision
Bilateral 54861
Unilateral 54860
Exploration
Biopsy 54865
Lesion
Excision
Local 54830
Spermatocele 54840
Needle Biopsy 54800
Spermatocele
Excision 54840
Epididymograms 55300
Epididymoplasty
Epididymis Repair 54900, 54901
Epididymovasostomy
Bilateral 54901
Unilateral 54900
Epidural
Administration
Device 62360-62362, 62365
Analysis 62367
Drug 62320-62327
Hospital Management 01996
Anesthesia
See Epidural Anesthesia
Removal 62355
Electrode
Insertion 61531, 63650, 63655
Removal 61535
Injection 62281, 62282, 62320-62327
Blood or Clot Patch 62273
with Disc Decompression 62287
Neurolytic Substance 62281, 62282
Transforaminal 64479, 64480, 64483, 64484
Lysis 62263, 62264
Epidural Anesthesia
Infusion
with Imaging Guidance 62325, 62327
without Imaging Guidance 62324, 62326
Injection
Epidurography 72275
Epigastric
Hernia Repair 49570, 49572
Laparoscopic 49652
Epiglottidectomy 31420
Epiglottis
Excision 31420
Epikeratoplasty
Eye 65767
Epilation
Electrolytic Hair Removal 17380
Epinephrine
Blood 82383, 82384
Urine 82384
Epiphyseal Arrest
Femur 20150, 27185, 27475, 27479-27485, 27742
Fibula 20150, 27477-27485, 27730-27742
Radius 20150, 25450-25455
Tibia 20150, 27477-27485, 27730, 27734-27742
Ulna 20150, 25450-25455
Epiphyseal Separation
Femur
Percutaneous Treatment 27509
Radius
Epiphysiodesis
Epiphysis
See Repair, Epiphysis
Epiploectomy 49255
Episiotomy 59300, 59610, 59612
Epispadias
Penis
Repair 54380, 54385, 54390
with Exstrophy of Bladder 54390
with Incontinence 54385, 54390
Epistaxis
Control 30901, 30903, 30905, 30906
EPO
Epstein-Barr Virus
Antibody 86663-86665
Equina, Cauda
See Cauda Equina
ERCP
Endoscopic Retrograde
Cholangiopancreatography 0397T
ERG
See Electroretinography (ERG)
Ergocalciferol
See Vitamins, D
Ergonovine Provocation Test

Cardiovascular Assessment 93024
Erythrocyte
Erythrocyte ab
See Antibody, Detection, Red Blood Cell
Erythrocyte Count
Escharotomy
Burns 16035, 16036
Graft Site 15002-15005
Escherichia coli 0157

Antigen Detection
Immunoassay 87335
Esophageal Acid Infusion Test
Acid Perfusion Study, Esophagus 91013, 91030
Esophageal Polyp
See Esophagus, Polyp
Esophageal Tumor
See Esophagus, Tumor
Esophageal Varices
Decompression 37181
Ligation 43205, 43244, 43400
Sclerosis Injection 43204, 43243
Esophagectomy
Ivor Lewis 43287
Laparoscopic Thoracoscopic 43287
Laparoscopic Transhiatal 43286
McKeown 43112, 43288
Partial 43116-43118, 43121-43124, 43287
Total 43107, 43108, 43112, 43113, 43124, 43286, 43288
Tri-incisional 43112, 43288
Esophagoenterostomy
with Total Gastrectomy 43620
Flexible Transoral
Ablation
Lesion 43270
Polyp 43270
Tumor 43270
Band Ligation 43244
Biopsy 43239
Delivery of Thermal Energy 43257
Dilation of Esophagus 43233, 43249
Passage of Dilator over Guide Wire 43248
Dilation of Gastric/Duodenal Stricture 43245
Drainage of Pseudocyst 43240
Esophagogastric Fundoplasty 43210
Examination
Ultrasound Guided 43237, 43238, 43253, 43259
Injection 43236, 43243, 43253
Insertion
Catheter or Tube 43241
Guide Wire 43248
Needle Aspiration 43238, 43242
Placement
Gastrostomy Tube 43246
Stent 43266
Removal
Foreign Body 43247
Lesion 43250, 43251
Polyp 43250, 43251
Tumor 43250, 43251
Resection
Mucosal 43254
Esophagogastromyotomy
See Esophagomyotomy
Esophagogastrostomy 43320
Esophagojejunostomy 43340, 43341
Esophagomyotomy
with Fundoplasty 43279
Heller Type 32665, 43279, 43330
Laparoscopic 43279
Thoracic Approach 43331
Thoracoscopic 32665
Esophagorrhaphy
See Esophagus, Suture
Esophagoscopy
Transnasal
Biopsy 43198
Transoral
Ablation
Lesion 43229
Biopsy 43193, 43198, 43202
Collection of Specimen 43191, 43197, 43200
with Cricopharyngeal Myotomy 43180
Dilation 43195, 43196, 43212-43214, 43220, 43226, 43229, 43233
with Diverticulectomy 43180
Exploration 43200
Hemorrhage 43227
Injection 43192, 43201, 43204
Insertion Guide Wire 43196, 43212, 43226, 43229
Ligation Varices 43205
Needle Biopsy 43232
Removal
Polyp 43216, 43217, 43229
Tumor 43216, 43217, 43229
with Ultrasound Examination 43231, 43232
with Vein Ligation 43205
Esophagostomy
Closure 43420, 43425
with Esophagectomy 43124
External Fistulization 43351, 43352
Esophagotomy 43020, 43045
Esophagotracheal Fistula
Repair 43305, 43312, 43314
Esophagus
Ablation
Lesion 43229
Polyp 43229
Tumor 43229
Acid Perfusion Test 91030
Acid Reflux Tests 91034, 91035, 91037, 91038
Balloon Distension Study 91040
with Provocation 91040
Biopsy
Forceps 3150F
Cricopharyngeal Myotomy 43030, 43180
Dilation 43450, 43453
Endoscopic 43195, 43196, 43212-43214, 43220, 43226, 43229, 43233, 43248, 43249
Surgical 43510
Endoscopy
See Endoscopy, Esophagus; Esophagogastroduodenoscopy
Esophagoscopy
See Esophagoscopy
Excision
Diverticula 43130, 43135
Exploration
Endoscopy 43200
Hemorrhage 43227
Imaging Studies 91110, 91111
Motility 78258
Obstructions 74360
Reflux 78262
Strictures 74360
Swallowing Function Cineradiography 74230
X ray 74210, 74220, 74221
Incision 43020, 43045
Muscle 43030
Injection
Sclerosis Agent 43204
Submucosal 43192, 43201
Insertion
Sengstaken Tamponade 43460
Stent 43212
Tamponade 43460
Tube 43510
Ivor Lewis 43287
Laparoscopy, Thoracoscopic 43287
Laparoscopy, Transhiatal 43286
Lengthening 43283, 43338
Lesion
Excision 43100, 43101
Ligation 43405
McKeown 43112, 43288
Partial 43116-43118, 43121-43124, 43287
Total 43107, 43108, 43112, 43113, 43124, 43286, 43288
Tri-incisional 43112, 43288
Motility Study 78258, 91010, 91013
with Perfusion 91013
with Pressure Topography 91299
with Stimulation 91013
Needle Biopsy
Endoscopy 43232
Nuclear Medicine
Imaging (Motility) 78258
Reflux Study 78262
Polyp
Ablation 43229
Removal 43216, 43217
Creation
Stoma 43351, 43352
Esophagostomy 43351, 43352
Fistula 43305, 43312, 43314
Gastrointestinal 43360, 43361
Removal
Foreign Bodies 43020, 43045, 43194, 43215, 74235
Lesion 43216
Polyp 43216, 43217
Repair 43300, 43310, 43313
Esophagogastric Fundoplasty 43325, 43327, 43328
Esophagogastroduodenoscopic 43210
Laparoscopic 43280
Esophagogastroduodenoscopy 43235-43259
Esophagomyotomy 43279
Esophagoplasty 43300, 43305, 43310, 43312
Fistula 43305, 43312, 43314, 43420, 43425
Heller Esophagomyotomy 32665
Muscle 43330, 43331
Nissen Procedure 43280
Paraesophageal Hernia
via Laparotomy 43332, 43333
via Thoracoabdominal Incision 43336, 43337
via Thoracotomy 43334, 43335
Pre-existing Perforation 43405
Thal-Nissen Procedure 43325
Toupet Procedure 43280
Wound 43410, 43415
Sphincter Augmentation
Device Placement 43284
Device Removal 43285
Suture 43405
Wound 43410, 43415
Tumor
Ablation 43270, 43278
Removal 43216, 43217, 43250, 43251
Ultrasound
Vein
Ligation 43205, 43400
Esophagus, Varix
See Esophageal Varices
Esophagus Neoplasm
See Esophagus, Tumor
Established Patient Evaluation and Management Services

Critical Care 99291, 99292
Domiciliary or Rest Home Visit 99334-99337, 99339, 99340
Evaluation Services
Basic Life and/or Disability 99450
Work-related or Medical Disability 99455
Home Services 99347-99350, 99606
Hospital Inpatient Services 99221-99223, 99231-99236, 99238, 99239
Hospital Observation Services 99217-99220, 99224-99226, 99235, 99236
Inpatient Consultations 99251-99255
Nursing Facility 99304-99310, 99315, 99316, 99318
Office and/or Other Outpatient Consultations 99241-99245
Office Visit 99211-99215
Online Medical Evaluation 98970-98972, 99421-99423
Ophthalmological Services 92012, 92014
Outpatient Visit 99211-99215
Preventive Medicine 99391-99397
Prolonged Services
with Patient Contact 99354-99357
with Physician Supervision 99415, 99416
without Patient Contact 99358, 99359
Telephone Services 98966-98968, 99441-99443
Establishment
Colostomy
Abdominal 50810
Perineal 50810
Estlander Procedure 40525

Estradiol
Free 82681
Response
Total 80415
Total 82670
Estriol
Estrogen
Receptor Assay 84233
Estrone
Ethanediols
Ethanol
Any Specimen, Except Breath, Urine 82077
Breath 82075
Ethmoid
Artery Ligation 30915
Excision
See Ethmoidectomy
Nasoethmoid
See Nasoethmoid Complex
Repair
Leak, Cerebrospinal Fluid 31290
Sinus
See Nasal Sinuses, Ethmoid
Ethmoid, Sinus
See Nasal Sinuses, Ethmoid
Ethmoidectomy
Anterior 31200
Partial 31254
Skull Base Surgery 61580, 61581
Total 31201, 31205, 31255
Ethosuccimid
Ethosuximide Assay 80168
Ethosuximide
Assay 80168
Ethyl Alcohol
Ethanol 82075
Ethylene Dichlorides
Ethylmethylsuccimide
Ethosuximide Assay 80168
Etiocholanalone Measurement
Etiocholanolone 82696
ETOH
Drug Assay, Alcohols 80320
Euglobulin Lysis 85360
European Blastomycosis
See Cryptococcus
Eustachian Tube
Inflation
Myringotomy 69420
Anesthesia 69421
Eutelegenesis
See Artificial Insemination
Evacuation
Clots
Endoscopic 52001
Hematoma
Brain 61108, 61154, 61312-61315
Anesthesia 00211
Subungual 11740
Intraspinal Lesion 63265
Meibomian Glands 0207T, 0563T
Pregnancy
See Dilation and Evacuation
Cervical 59140
Stomach 43753
Evaluation
Auditory Function
Candidacy for Auditory Implant 92626, 92627
Function of Auditory Implant 92626, 92627
Cardiac Devices
See Electronic Analysis, Cardiac Assist Devices
Carotid Artery
Atheroma 93895
Intima Media Thickness 93895
Cine 74230
Electrophysiologic 0577T, 93653, 93654, 93656
Physical Therapy 97161-97164
Radiation Exposure 76145
Treatment 92526
Video 74230

Advance Care Planning 99497, 99498
Assistive Technology
Assessment 97755
Basic Life and/or Disability Evaluation Services 99450
Care Management
Behavioral Health Conditions 99484
Psychiatric Collaborative Care 99492-99494
Care Plan Oversight Services 99339, 99340, 99374-99380
Home Health Agency Care 99374, 99375
Home or Rest Home Care 99339, 99340
Hospice 99377, 99378
Care Planning
Cognitive Impairment 99483
Case Management Services 99366-99368
Chronic Care 99439, 99490, 99491
Complex Chronic Care 99487, 99489
Consultation 99241-99255
Critical Care 99291, 99292
Interfacility Pediatric Transport 99466, 99467, 99485, 99486
Domiciliary or Rest Home
Emergency Department 99281-99288
Health Behavior
Assessment 96156
Family Intervention 96167, 96168, 96170, 96171
Group Intervention 96164, 96165
Individual Intervention 96158, 96159
Home Services 99341-99350
Hospital 99221-99233
Discharge 99238, 99239
Hospital Services
Observation Care 99217-99220, 99224-99226, 99234-99236
Hyperbaric Oxygen Treatment Facility 99183
Insurance Exam 99455, 99456
Low Birthweight Infant 99478, 99479
Medical Team Conferences 99366-99368
Neonatal Critical Care 99468, 99469
Newborn Care 99460-99465
Nursing Facility
Annual Assessment 99318
Discharge 99315, 99316
Initial Care 99304-99306
Other 99318
Subsequent Care 99307-99310
Occupation Therapy Evaluation 97166, 97167
Re-evaluation 97168
Office and Other Outpatient Visit
Prolonged Service(s) 99417
Online Services 98970-98972, 99421-99423
Pediatric Critical Care 99471, 99472
Pediatric Interfacility Transport 99466-99476, 99485, 99486
Post-discharge Transitional Care 99495, 99496
Preventive Services 99381-99429
Prolonged Services 99415, 99416
with Psychotherapy 90833, 90836, 90838
Remote
Physiologic Monitoring of Physiologic Parameters 99453, 99454
Physiologic Monitoring Treatment Services 99457, 99458
Standby Services 99360
Team Conferences 99366-99368
Telephone Services 98966-98968, 99441-99443
Transitional Care 99495, 99496
Work-Related and/or Medical Disability Evaluation 99455
Evaluation Studies, Drug, Pre-Clinical

See Drug Screen
Everolimus
Drug Assay 80169
Evisceration
Ocular Contents
with Implant 65093
without Implant 65091
Suture
Abdominal Wall 49900
Evisceration, Pelvic
See Exenteration, Pelvis
Evocative/Suppression Test
Agent Administration 96360, 96361, 96372-96375
Analytes
Evaluation Panel
Anterior Pituitary 80418
Metyrapone Panel 80436
Stimulation Panel
ACTH 80400, 80402, 80406
Calcitonin 80410
Chorionic Gonadotropin 80414, 80415
Corticotropic Releasing Hormone (CRH) 80412
Gonadotropin Releasing Hormone 80426
Renin, Peripheral Vein 80417
Renin, Renal Vein 80416
Thyrotropin Releasing Hormone (TRH) 80438, 80439
Suppression Panel
Dexamethasone 80420
Insulin-induced C-peptide 80432
Tolerance Panel
Glucagon 80422, 80424
Insulin 80434, 80435
Evoked Potentials
Auditory
See Evoked Potentials, Auditory
Central Nervous System
Somatosensory Testing 95925-95927, 95938
Transcranial Motor Stimulation 95928, 95929, 95939
Visual 95930
Visual
Acuity 0333T
Glaucoma Test 0464T
Evoked Potentials, Auditory
Evoked Otoacoustic Emissions
Screening 92558
Frequency Threshold Estimations 92652
Hearing Status Determination 92651
Neurodiagnostic Testing 92653
Screening of Auditory Potential 92650
Vestibular Evoked Myogenic Potential (VEMP) Testing 92517-92519
Ewart Procedure
Palate, Reconstruction, Lengthening 42226, 42227
Excavatum, Pectus
Reconstructive Repair 21740, 21742
with Thoracoscopy 21743
Exchange
Drainage Catheter
under Radiological Guidance 49423
Fluid-Gas, Vitreous 67025
Intraocular Lens 66986
Strut
External Fixation System 20697
Exchange Transfusion
Blood Transfusion, Exchange 36455
Newborn 36450, 36456
Excision
Abdomen
Tumor 49203-49205
Abdominal Wall
Tumor 22900-22903
Abscess
Brain 61514, 61522
Clavicle 23170
Facial Bones 21026
Femur 27070, 27071, 27360
Fibula 27360
Forearm 25145
Humerus 23174, 24134
Ilium 27070, 27071
Mandible 21025
Pubic Symphysis 27070, 27071
Radial Head or Neck 24136
Scapula 23172
Tibia 27360
Wrist 25145
Acetabulum
Tumor 27076
Acromion 23130
Adenoids 42820, 42821, 42830, 42831, 42835, 42836
Adenoma
Thyroid Gland 60200
Adrenal Gland 60540, 60545, 60650
Ankle
Tumor 27618, 27619, 27632, 27634
Anus
Crypt 46999
Fissure 46200
Lesion 45108, 46922
Tag 46220, 46230
Aorta
Coarctation 33840-33851
Appendix 44950-44960
Arm, Lower
Tumor 25071, 25073, 25075, 25076
Arm, Upper
Tumor 24071, 24073, 24075, 24076
Spinal 63250-63252
Arytenoid Cartilage 31400, 31560
Atrial Septum 33735-33737
Lesion 69145, 69150, 69155
Back/Flank
Tumor 21930, 21933
Bile Duct
Cyst 47715
Tumor 47711, 47712
Bladder
Cyst 51500
Diverticulum 51525
Neck Contracture 52640
Partial 51550-51565
Total 51570, 51580, 51590-51597
with Nodes 51575, 51585, 51595
Transurethral 52640
Tumor 51530
Bone
Abscess
Facial 21026
Mandible 21025
Epiphyseal Bar
Femur 20150
Fibula 20150
Radius 20150
Tibia 20150
Ulna 20150
Brain
Abscess 61514, 61522
Amygdala 61566
Cyst 61516, 61524, 62162
Epileptogenic Focus 61534, 61536
Hemisphere 61543
Hippocampus 61566
Lesion 61600-61608, 61615, 61616
Other Lobe 61323, 61539, 61540
Tumor 61510, 61518, 61520, 61521, 61526-61530, 61545, 62164
Brain Lobe
See Lobectomy, Brain
Brainstem
Lesion 61575, 61576
Breast
See Mastectomy
Chest Wall Tumor 21601-21603
Cyst 19120-19126
Fibroadenoma 19120-19126
Fistula 19112
Lesion 19120-19126
Tumor 19120-19126
Bronchi
Tumor 31640
Bulbourethral Gland 53250
Burn Eschar 15002-15005
Bursa
Elbow 24105
Femur 27062
Forearm Tendon Sheath 25115, 25116
Hip 27060, 27062
Knee 27340
Synovium Wrist 25115, 25116
Bypass Graft 35901-35907
Cyst 28100-28103
Tumor 28100-28103
Carotid Body
Tumor 60600, 60605
Carpal 25210, 25215
Cyst 25130-25136
Tumor 25130-25136
Cartilage
Knee Joint 27332, 27333, 27335
Shoulder Joint 23101
Caruncle
Urethra 53265
Cervix
Radical 57531
Stump
Abdominal Approach 57540, 57545
Vaginal Approach 57550, 57555, 57556
Total 57530
Tumor 58550, 58555
Chalazion
with Anesthesia 67808
Multiple
Different Lids 67805
Same Lid 67801
Single 67800
Cheekbone
Cyst 21030
Tumor 21030, 21034
Chest Wall
Tumor 21601-21603
Clavicle
Cyst 23140, 23145, 23146
Diaphysectomy 23180
Partial 23120, 23180
Total 23125
Tumor 23140, 23145, 23146
Coccyx 27080
Colon
See Colectomy
Colorectal
Tumor 45126
Condyle
See Condylectomy
Conjunctiva
Lesion 68110-68130
Constricting Ring
Finger 26596
Cornea
Lesion 65400
Pterygium 65420, 65426
Coronoid Process 21070
Cowper’s Gland 53250
Cranial Bone
Tumor 61563, 61564
Cyst
Bile Duct 47715
Bladder 51500
Brain 61516, 61524, 62162
Breast 19120-19126
Carpal 25130-25136
Cheekbone 21030
Clavicle 23140, 23145, 23146
Epididymis 54840
Facial Bones 21030
Femur 27355-27358
Greater Trochanter 27065-27067
Fibula 27635-27638
Finger 26160, 26210, 26215
Foot
Tendon/Tendon Sheath 28090
Toe 28108
Ganglion 20612, 25111, 25112
Hand 26160
Hip 27065-27067
Humerus 23150, 23155, 23156, 24110, 24115, 24116
Ileum
Wing 27065-27067
Kidney 50280, 50290
Knee 27345
Mandible 21040, 21046, 21047
Maxilla 21030, 21048, 21049
Mediastinum 32662, 39200
Metatarsal 28104, 28106, 28107
Mullerian Duct 55680
Nose 30124, 30125
Ovary 58925
Pericardium 32661
Phalanges
Foot 28108
Hand 26210, 26215
Pharynx 42810-42815
Pilonidal 11770-11772
Pubic Symphysis 27065-27067
Radius 25120, 25125, 25126
Head or Neck 24120, 24125, 24126
Ranula 42408
Salivary Gland Duct 42408
Scapula 23140, 23145, 23146
Seminal Vesicle 55680
Sublingual 42408
Talus 28100-28103
Tarsal 28104, 28106, 28107
Thyroglossal Duct 60280, 60281
Thyroid Gland 60200
Tibia 27635, 27637, 27638
Toe
Tendon/Tendon Sheath 28092
Ulna 25120, 25125, 25126
Urachal 51500
Vaginal 57135
Zygoma 21030
Defect
Osteochondral 29891
Talus 29891
Tibia 29891
Dentoalveolar Structures
Alveolar Mucosa 41828
Alveolectomy 41830
Gingivectomy 41820
Operculectomy 41821
Tuberosities 41822, 41823
Tumor 41825-41827
Diverticulum
Bladder 51525
Hypopharynx 43130, 43135
Mesentery (Meckel’s) 44800
Urethra 53230, 53235, 53240
Ear
External 69110, 69120
Inner 69905, 69910
Vestibular Nerve 69915
Middle
Polyp 69540
Tumor 69550, 69552, 69554
Elbow
Tumor 24071, 24073, 24075, 24076
Elbow Joint 24155
Electrode 57522
Embolism
See Embolectomy
Cyst 54840
Lesion 54830
Spermatocele 54840
Epiglottis 31420
Epiphyseal Bar 20150
Esophagus
See Esophagectomy
Lesion 43100, 43101
Eyelid
Lesion 67800, 67801, 67805, 67808, 67840
Face
Bone Tumor 21029, 21030, 21034-21040, 21044-21049
Cyst 21030
Soft Tissue Tumor 21011-21014
Fallopian Tube
Salpingectomy 58700
Salpingo-Oophorectomy 58720
Fascia
See Fasciectomy
Femur 27070, 27071, 27360
Cyst 27065-27067, 27355-27358
Tumor 27065-27067, 27327, 27328, 27337-27339, 27355-27358
Fibroadenoma
Breast 19120-19126
Fibula 27360, 27455, 27457, 27641
Cyst 27635-27638
Tumor 27635, 27637, 27638
Finger
Cyst 26160, 26210, 26215
Lesion 26160
Tumor 26111-26118, 26200, 26205
Vascular Malformation 26111, 26113, 26115, 26116
Fistula
Anal 46270, 46275, 46280, 46285, 46288
Foot
Cyst 28090, 28100-28103, 28108
Fasciectomy 28060
Radical 28060-28062
Lesion 28090
Tumor 28039, 28041, 28043, 28045, 28100-28103
Forearm
Tumor 25071, 25073, 25075, 25076
Gallbladder
See Cholecystectomy
Ganglion
Finger or Hand 26160
Foot 28090
Toe 28092
Wrist 25111, 25112
Gingiva 41820
Gums 41820
Alveolus 41830
Lesion 41825-41827
Operculum 41821
Tumor 41825-41827
Hand
Cyst 26160
Lesion 26160
Tumor 26111, 26113, 26115, 26116
Vascular Malformation 26111, 26113, 26115, 26116
Heart
Donor 33940
Tumor 33130, 33210
Heart/Lung, Donor 33930
Hemorrhoids
See Hemorrhoidectomy
Hip 27070, 27071
Bone Cyst 27065-27067
Bursa 27060, 27062
Tumor 27043-27048, 27065-27067
Hippocampus 61566
Humerus
Cyst 23150, 23155, 23156, 24110, 24115, 24116
Diaphysectomy 23184, 24140
Head 23174, 23195
Tumor 23150, 23155, 23156, 24110, 24115, 24116
Hydrocele
Spermatic Cord 55500
Tunica Vaginalis 55040, 55041
Hygroma, Cystic 38550-38555
Hymenal Ring 56700
Ileum
Cyst 27065-27067
Ileoanal Reservoir 45136
Partial 27070, 27071
Ilium
Tumor 27065-27067, 27075, 27076
Innominate
Tumor 27077
Toe, Proximal End 28160
Intervertebral Disc
See Discectomy; Hemilaminectomy
Intestines
See Enterectomy
Lesion 44110, 44111
Iris
See Iridectomy
Ischium
Tumor 27075, 27076, 27078
Kidney
See Nephrectomy
Cyst 50280, 50290
Knee
Cyst 27345
Kneecap 27350
Lesion, Meniscus or Capsule 27347
Tumor 27327, 27328, 27337-27339
Labyrinth
with Mastoidectomy 69910
Transcanal 69905
Lacrimal Gland 68500, 68505
Tumor 68540, 68550
Larynx
See Laryngectomy
with Pharynx 31395
Tumor 31300, 31540, 31541
Leg, Lower
Tumor 27615, 27616, 27618, 27619, 27632, 27634, 27645, 27646
Leg, Upper
Tumor 27327-27329, 27337-27339, 27365
Lesion
Anal 45108, 46922
Ankle Tendon Sheath 27630
Auditory Canal, External 69145, 69150, 69155
Exostosis 69140
Brain 61600-61608, 61615, 61616
Breast 19120, 19125, 19126
Colon 44110, 44111
Conjunctiva 68110-68130
Cornea 65400
Ear, Middle 69540
Epididymis 54830
Eyelid 67800, 67801, 67805, 67808, 67840
Finger Tendon Sheath 26160
Foot 28080, 28090
Forearm Tendon Sheath 25110
Gums 41825-41827
Hand 26160
Intraspinal 63300-63308
Knee Meniscus or Capsule 27347
Leg Tendon/Sheath 27630
Mesentery 44820
Mouth 40810-40816, 41116
Nerve 64774-64792
Neuroma 28080, 64774, 64776, 64778
Nose
Intranasal 30117, 30118
Orbit 61333, 67412, 67420
Palate 42104, 42106, 42107
Pancreas 48120
Penis 54060
Pharynx 42808
Rectum 45108
Sclera 66130
Skin
Benign 11400-11404, 11406, 11420-11424, 11426, 11440-11444, 11446, 11450, 11451, 11462, 11463,
11470, 11471
Malignant 11600-11604, 11606, 11620-11624, 11626, 11640-11644, 11646
Skull 61500, 61615, 61616
Anterior 61600, 61601
Base 61575, 61576
Middle 61605-61608
Spinal Cord
Intraspinal 63265-63268, 63270-63273, 63300-63308
Upper 61575, 61576
Tendon Sheath
Ankle and/or Leg 27630
Forearm or Wrist 25110
Testis 54512
Toe 28092
Tongue 41110, 41112-41114
Urethra 52224
Uterus 58140, 58545, 58546, 58561, 59100
Uvula 42104, 42106, 42107
Vertebral Column 22100-22103
without Decompression 22110, 22112, 22114, 22116
Wrist Tendon Sheath 25110
Lip 40500, 40510, 40520, 40525
Liver
See Hepatectomy
Lung
Bronchus Resection 32486
Completion 32488
Lobe 32480-32482
Pleurectomy 32310, 32320
Pneumonectomy 32440-32445
Segment 32484
Tumor, Apical 32503, 32504
Lung/Heart, Donor 33930
Lymphatic System
See Lymphadenectomy
Hygroma, Cystic 38550, 38555
Nodes 38500, 38510, 38520, 38525, 38530, 38531
Mandible
Cyst 21040, 21046, 21047
Mandibular Torus
Exostosis 21031
Tumor 21040, 21044-21047
Mass
Mediastinum 32662
Pericardium 32661
Mastoid Process
See Mastoidectomy
Maxilla
Cyst 21030, 21048, 21049
Tumor 21030, 21034, 21048, 21049
Maxillary Torus Palatinus 21032
Mediastinum
Cyst 32662, 39200
Tumor 32662
Meningioma
Brain 61512, 61519
Meniscus
Mesentery
Lesion 44820
Meckel’s Diverticulum 44800
Metacarpal 26230
Cyst 26200, 26205
Tumor 26200-26205
Metatarsal
Cyst 28104, 28106, 28107
Head 28110-28114, 28122, 28140, 28288
Tumor 28104, 28106, 28107
Mouth
Frenum 40819, 41115
Lesion 40810-40816, 41116
Mucosa 40818
Ranula 42408
Mucosa
Gums 41828
Vestibule of Mouth 40818
Nail Fold 11765
Nails 11750
Neck
Tumor 21552, 21554-21556
Neoplasm
Spine 63275-63290
Nerve
Foot 28055
Hamstring Muscle 27325
Neurofibroma 64788-64792
Neurolemmoma 64788-64792
Neuroma 64774-64786
Popliteal 27326
Sympathetic
See Sympathectomy
Neurofibroma 64788-64790
Neurolemmoma 64788-64792
Neuroma 64774-64786
Nose
Cyst 30124, 30125
Lesion 30117, 30118
Polyp 30110-30115
Rhinectomy 30150, 30160
Skin 30120
Turbinate, Inferior 30130, 30140
Odontoid Process 22548
Cyst 24120, 24125, 24126
Tumor 24120, 24125, 24126
Omentum 49255
Operculum 41821
Orbit
Lesion 61333, 67412, 67420
Ovary
Cystectomy 58925
Oophorectomy 58940, 58943
Salpingo-oophorectomy 58720
Wedge Resection/Bisection 58920
Oviduct 58700, 58720
Palate 42120, 42145
Lesion 42104, 42106, 42107
Pancreas
See Pancreatectomy
Ampulla of Vater 48148
Lesion 48120
Peripancreatic Tissue 48105
Parathyroid Gland 60500, 60502, 60505
Tumor 42410, 42415, 42420, 42425, 42426
Parotid Gland
Partial 42410-42415
Total 42420-42426
Patella 27350
Pelvis
Tumor 27043, 27045, 27047, 27048, 27049, 27059
Penis
Amputation 54120, 54125, 54130, 54135
Circumcision 54150, 54160, 54161, 54163
Frenulotomy 54164
Lesion 54060
Plaque 54110-54112
Post-Circumcision Adhesion 54162
Pericardium 33030, 33031
Cyst 32661
Mass 32661
Tumor 32661
Peritoneum
Tumor 49203-49205
Petrous Temporal Apex 69530
Phalanges
Cyst
Finger 26210, 26215
Toe 28108
Finger 26235, 26236
Hemiphalangectomy 28160
Toe 28124, 28126, 28150, 28153
Tumor 26210, 26215, 26260, 26262, 28108, 28175
Pharynx 42145, 42890, 42892, 42894
Cyst 42810, 42815
with Larynx 31390, 31395
Lesion 42808
Pituitary Gland 61546, 61548
Tumor 61546, 61548, 62165
Plaque
Penis 54110-54112
Pleura 32310-32320
Thoracoscopic 32656
Polyp
Nose 30110, 30115
Endoscopic 31237
Urethra 53260
Caruncle 53265
Presacral
Tumor 49215
Prostate
See Proctectomy
Pubic Symphysis 27070, 27071
Cyst 27065-27067
Tumor 27065-27067
Pulmonary Artery 33910, 33915, 33916
Radius 24130, 24145, 25151
Cyst 24120, 24125, 24126, 25120, 25125, 25126
Styloid Process 25230
Tumor 24120, 24125, 25120, 25125, 25126
Rectum
See Proctectomy
Lesion 45108
Prolapse 45130, 45135
Stricture 45150
Tumor 45160, 45171, 45172
Redundant Skin of Eyelid
Retroperitoneal
Tumor 49203-49205
Ribs 21600, 21610, 21615, 21616
Sacrococcygeal
Tumor 49215
Salivary Gland Duct
Cyst 42408
Scalp
Tumor 21011-21014
Scapula 23172, 23182, 23190
Cyst 23140, 23145, 23146
Tumor 23140, 23145, 23146
Sclera 66150, 66155, 66160, 66170
Lesion 66130
Scrotum 55150
Semilunar Cartilage of Knee 27332, 27333
Seminal Vesicle 55650
Mullerian Duct Cyst 55680
Sesamoid Bone
Toe 28315
Shoulder
Tumor 23071, 23073, 23075, 23076
Sinus
Ethmoid 31200, 31201, 31205
Maxilla 31225, 31230
Skene’s Glands 53270
Skin
Excess 15830, 15832-15839, 15847
Lesion, Benign 11400-11404, 11406, 11420-11424, 11426, 11440-11444, 11446, 11450, 11451, 11462,
11463, 11470, 11471
Lesion, Malignant 11600-11604, 11606, 11620-11624, 11626, 11640-11644, 11646
Nose 30120
Skin Graft
Infected
Abdomen 35907
Extremity 35903
Neck 35901
Thorax 35905
Site Preparation 15002-15005
Skull 61501
Lesion 61500
Anterior 61600, 61601
Base 61575, 61576
Middle 61605-61608
Tumor 61500
Spermatic Cord
Lesion 55520
Varicocele 55530, 55535, 55540
Spermatocele 54840
Spinal Cord
Lesion 61575, 61576, 63265-63268, 63270-63273, 63300-63308
Spine
Lesion 63300-63308
Neoplasm 63275-63278, 63280-63283, 63285-63287, 63290
Spleen 38100-38102
Stapes 69660, 69661
Sternum 21620, 21627, 21630, 21632
Stomach
See Gastrectomy
Tumor 43610, 43611
Sublingual Gland 42450
Cyst 42408
Submandibular (Submaxillary) Gland 42440, 42509
Sweat Glands
Axillary 11450, 11451
Inguinal 11462, 11463
Perianal 11470, 11471
Perineal 11470, 11471
Umbilical 11470, 11471
Synovium
See Synovectomy
Talus 28120, 28130
Cyst 28100, 28102, 28103
Osteochondral Defect 29891
Tumor 28100, 28102, 28103
Tarsal 28116, 28122
Cyst 28104, 28106, 28107
Tumor 28104, 28106, 28107
Temporal Bone 69530, 69535
Tendon
Finger 26180, 26390, 26415
Forearm 25109
Hand 26390, 26415
Palm 26170
Wrist 25109
Tendon Sheath
Cyst 28092
Finger 26145
Foot 28086-28088
Forearm 25115, 25116
Bursa 25115, 25116
Cyst 25120, 25125, 25126
Lesion 25110
Synovia 25115, 25116
Tumor 25120, 25125, 25126
Leg
Lesion 27630
Palm 26145
Wrist
Bursa 25115, 25116
Ganglion 25111, 25112
Lesion 25110
Synovectomy 25118, 25119
Synovia 25115, 25116
Testis
See Orchiectomy
Lesion 54512
Tumor 54530, 54535
Thigh
Tumor 27327, 27328, 27337, 27339
Thorax
Tumor 21552, 21554-21556
See Thromboendarterectomy
Thrombus
See Thrombectomy
Thymus Gland 60520-60522
Thyroglossal Duct
Cyst 60280, 60281
Thyroid Gland
See Thyroidectomy
Lobectomy
Partial 60210, 60212
Total 60220, 60225
Tumor 60200
Tibia 27360, 27640
Cyst 27635, 27637, 27638
Osteochondral Defect 29891
Tumor 27635, 27637, 27638
Toe
Lesion 28092
Tumor 28039, 28041, 28043, 28045, 28175
Tongue
See Glossectomy
Lesion 41110, 41112-41114
Lingual Frenum 41115
Tonsils 42820, 42821, 42825, 42826
Lingual 42870
Radical Resection 42842, 42844, 42845
Tag 42860
Torus Mandibularis 21031
Trachea
Stenosis and Anastomosis 31780, 31781
Tumor 31785, 31786
Tumor
Abdomen 49203-49205
Abdominal Wall 22900-22903
Acetabulum 27076
Ankle 27618, 27619, 27632, 27634
Arm, Lower 25071, 25073, 25075, 25076
Arm, Upper 24071, 24073, 24075, 24076
Back/Flank 21930, 21933
Bile Duct 47711, 47712
Bladder 51530
Brain 61510, 61518, 61520, 61521, 61526-61530, 61545, 62164
Breast 19120, 19125, 19126
Bronchi 31640
Carotid Body 60600, 60605
Carpal 25130-25136
Cervix 58550, 58555
Cheekbone 21030, 21034
Clavicle 23140, 23145, 23146
Colorectal 45126
Cranial Bone 61563, 61564
Dentoalveolar Structures 41825-41827
Ear, Middle 69550, 69552, 69554
Elbow 24071, 24073, 24075, 24076
Face
Bone 21029, 21030, 21034, 21040, 21046-21049
Soft Tissue 21011-21014
Femur 27065-27067, 27327, 27328, 27337-27339, 27355-27358
Fibula 27635, 27637, 27638
Finger 26111-26118
Flank 21930, 21933
Foot
Soft Tissue 28039, 28041, 28043, 28045
Forearm 25071, 25073, 25075, 25076
Greater Trochanter, Femur 27065-27067
Gums 41825-41827
Hand 26111-26118
Heart 33120-33130
Hip 27043-27048, 27065-27067
Humerus 23150, 23155, 23156, 24110, 24115, 24116
Ilium 27065-27067, 27075, 27076
Innominate 27077
Ischium
Radical Resection Including Acetabulum 27076
Ramus
Tuberosity
Knee 27327, 27328, 27337-27339
Lacrimal Gland 68540, 68550
Larynx 31300, 31540, 31541
Leg, Lower 27615-27619, 27632, 27634, 27645, 27646
Leg, Upper 27327-27329, 27337-27339, 27365
Lung 32503, 32504
Mandible 21040, 21044-21047
Maxilla 21030, 21034, 21048, 21049
Mediastinum 32662
Mesentery 49203-49205
Metacarpal 26200-26205
Metatarsal 28104, 28106, 28107
Neck 21552, 21554-21556
Parotid Gland 42410-42426
Pelvis 27043, 27045, 27047, 27048, 27049, 27059
Pericardium 32661
Peritoneum 49203-49205
Phalanges 26210-26215, 26260, 26262
Toe 26215, 28108, 28175
Pituitary Gland 61546, 61548, 62165
Presacral 49215
Pubis 27065-27067, 27075, 27076
Radius 24120-24125, 25120, 25125, 25126
Rectum 45160-45172
Retroperitoneal 49203-49205
Sacrococcygeal 49215
Scalp 21011-21016
Scapula 23140, 23145, 23146
Skull 61500
Stomach 43610, 43611
Talus 28100, 28102, 28103
Tarsal Bones 28104, 28106, 28107
Testis 54530, 54535
Thigh 27327, 27328, 27337, 27339
Thorax 21552, 21554-21556
Thyroid 60200
Tibia 27635, 27637, 27638
Toe 28039-28045, 28175
Trachea 31785, 31786
Ulna 25120, 25125, 25126
Ureter
Urethra 53220
Uterus
Fibroid 58140, 58145, 58146
Intramural Myoma 58545, 58546
Leiomyomata 58561
Turbinate, Inferior 30130, 30140
Tympanic Nerve 69676
Ulcer
Pressure
Coccyx 15920, 15922
Ischium 15940, 15941, 15944-15946
Sacrum 15931, 15933-15937
Trochanter 15950-15953, 15956, 15958
Stomach 43610
Ulna 24147, 25150, 25240
Cyst 25120, 25125, 25126
Darrach Procedure 25240
Tumor 25120, 25125, 25126
Umbilicus 49250
Urachus
Cyst 51500
Ureter
See Ureterectomy
Ureterocele 51535
Urethra
Bulbourethral Gland 53250
Diverticulum 53230, 53235, 53240
Lesion 52224
Prolapse 53275
Skene’s Glands 53270
Tumor 53220
Urethrectomy 53210, 53215
Uterus
Fibroid 58140, 58145, 58146
Intramural Myoma 58545, 58546
Hysterectomy
See Hysterectomy
Leiomyomata 58561
Myoma 58545, 58546
Tumor 58140, 58145, 58146
Uvula 42140, 42145
Lesion 42104, 42106, 42107
Vagina
Cyst 57135
Lumen 57120
Septum 57130
Vaginectomy
Complete 58275, 58280
Partial 57106, 57107, 57109
Vaginal Wall 57110, 57111
Varicocele
Spermatic Cord 55530, 55535, 55540
Vas Deferens 55250
Vascular Malformation
Finger 26111, 26113, 26115, 26116
Hand 26111, 26113, 26115, 26116
Vein
Varicose 37765, 37766
Vertebra
Additional Segment 22103, 22116
Cervical 22110
for Tumor 22100, 22110
Lumbar 22102
for Tumor 22114
Thoracic 22112
for Tumor 22101
Vertebral Body 63081-63103
Corpectomy 63081, 63082, 63085-63088, 63090, 63091
Vitreous
See Vitrectomy
Vulva
See Vulvectomy
Wrist
Radial Styloidectomy 25230
Tendon Sheath 25109
Zygoma
Cyst 21030
Exclusion
Duodenum 48547
Small Intestine 44700
Exenteration
Orbit
Anterior Cranial Fossa
Craniofacial 61581
Orbitocranial 61585
with Maxillectomy 31230
Removal Orbital Contents 65110
with Muscle or Myocutaneous Flap 65114
with Therapeutic Removal of Bone 65112
Pelvis 45126, 51597, 58240
Exercise Stress Tests

Cardiovascular 93015-93018, 93464
Pulmonary 94617, 94618, 94619
Exercise Test
Cardiopulmonary 94621
Ischemic Limb 95875
Exercise Therapy 97110-97113, 97116, 97530

Exfoliation
Chemical 17360
Exomphalos
See Omphalocele
Exostectomy
Foot 28288
Exostosis
Excision
Calcaneus 28119
External Auditory Canal 69140
Fibula 27635
Foot 28288
Mandibular Torus 21031
Palate 21031, 21032
Tibia 27635
Expander, Skin, Inflatable

See Tissue, Expander
Expired Gas Analysis
NO 95012
O2 and CO2 94681
O2 Update, Direct 94680
O2 Uptake, Indirect 94690
Exploration
Abdomen 49000, 49002, 54535, 54560
Staging 58960
Adrenal Gland 60540, 60545, 60650
Anal
Endoscopy 46600
Ankle 27610, 27620
Anus
Surgical 45990
Arm, Lower 25248
Artery
Brachial 24495
Carotid 35701
Femoral 35703
Neck 35701
Popliteal 35703
Upper Extremity 35702
Back
Bile Duct 47420, 47425, 47480
Atresia 47700
Endoscopy 47552
Blood Vessel
Abdomen 35840
Chest 35820
Extremity 35860
Neck 35800
Brain
via Burr Hole
Breast 19020
Nipple 19110
Bronchi
Endoscopy 31622
Bronchoscopy 31622
Cardiotomy 33310, 33315
Cauda Equina 63005, 63011, 63017
Chest 32100, 32601
Colon
Colotomy 44025
Colon-Sigmoid
Common Bile Duct
with Cholecystectomy 47564, 47610
Duodenum 44010
Ear, Middle 69440
Elbow 24000, 24101
Epididymis 54865
Esophagus
Endoscopy 43200
Extremity
Flank
Forearm 25248
Gallbladder 47480
Gastrointestinal Tract, Upper
Hand Joint 26070
Heart 33310, 33315
Hepatic Duct 47400
Hip 27033
Intestines, Small
Endoscopy 44360
Enterotomy 44020
Joint
See Joint, Exploration
Kidney 50010, 50045, 50120
Lacrimal Duct 68810, 68811, 68815, 68816
Canaliculi 68840
Laparoscopic
Surgical
Pelvis 49321-49327
Larynx
Endoscopy 31505, 31510-31513, 31520, 31525, 31526, 31575
Liver 47400
Wound 47361, 47362
Mediastinum 39000, 39010, 60505
Nasolacrimal Duct 68810, 68811, 68815, 68816
Neck
Nerves
Cranial 61458, 61460
Nose
Endoscopy 31231, 31233, 31235
Ocular
for Strabismus 67340
Orbit 61333
with/without Biopsy 67450
without Bone Flap 67400
Parathyroid Gland 60500, 60502, 60505
Pelvis 49320
Wound 49014
Preperitoneal Area 49014
Rectum
Injury 45562, 45563
Surgical 45990
Retroperitoneal Area 49010
Scrotum 55110
Shoulder Joint 23040-23044, 23107
Sinus
Frontal 31070-31075, 31255
Maxillary 31020-31030
Spinal Cord 63001, 63003, 63005, 63011, 63015-63017, 63040, 63042-63044
Spine Fusion 22830
Stomach 43500
Testis
Undescended 54550, 54560
Toe Joint 28024
Ureter 50600
Vagina 57000
Endocervical 57452
Wound
See Wound, Exploration
Wrist 25101, 25248
Joint 25040
Exploratory Laparotomy 49000

Expression
Conjunctiva 68040
Exteriorization, Small Intestine
See Enterostomy
External Auditory Canal

See Auditory Canal
External Ear
See Ear, External Ear
External Exostoses
See Exostosis
External Fixation Device

Adjustment/Revision
External Fixation System 20693, 20697
Application
Caliper 20660
Cranial Tong 20660
External Fixation System
Multiplane 20692, 20693, 20696, 20697
Uniplane 20690
Halo 20661-20664
Removal
Cranial Tongs 20665
Halo 20665
Extirpation, Lacrimal Sac
Dacryocystectomy 68520
Cannulation
Chemotherapy Perfusion 36823
Extremity 36823
Extracorporeal Dialyses
See Hemodialysis
Extracorporeal Life Support (ECLS)

Extracorporeal Membrane Oxygenation (ECMO)
Arterial Exposure with Graft Conduit Creation 33987
Daily Management
Veno-Arterial 33949
Veno-Venous 33948
Initiation
Veno-Arterial 33947
Veno-Venous 33946
Insertion of Cannula(e)
Open 33953, 33954
Sternotomy/Thoracotomy 33955, 33956
Left Heart Vent
Insertion 33988
Removal 33989
Removal of Cannula(e)
Open 33969, 33984
Repositioning of Cannula(e)
Open 33959, 33962
Birth through 5 Years 33963
Six Years and Older 33964
Extracorporeal Photochemotherapies
Extracorporeal Photopheresis 36522
Extracorporeal Shock Wave Therapy
Humeral Epicondyle 0102T
Integumentary 0512T, 0513T
Lithotripsy 50590
Anesthesia 00872, 00873
Plantar Fascia 28890
Unspecified Musculoskeletal
High Energy 0101T
Low Energy 20999
Extraction
Calculus
See Calculus, Extraction
Cataract
See Cataract, Extraction/Removal
Foreign Body
Eye 65260, 65265
Thrombus
Mechanical 36904
Extraction, Cataract
Extradural Anesthesia
Infusion
Injection
Extradural Injection
See Epidural, Injection
Extraocular Muscle
See Eye Muscles
Extrauterine Pregnancy
See Ectopic Pregnancy
Extravasation Blood
See Hemorrhage
Extremity
Lower
Harvest of Vein for Bypass Graft 35500
Harvest of Vein for Vascular Reconstruction 35572
Upper
Harvest of Artery for Coronary Artery Bypass Graft 35600
Harvest of Vein for Bypass Graft 35500
Repair
Blood Vessel 35206
Wound Exploration
Eye
See also Ciliary Body; Conjunctiva; Cornea; Iris; Lens; Orbit; Retina; Sclera; Vitreous
Age-Related Eye Disease Study (AREDS) Counseling 4177F
Aspiration
Biopsy
Cornea 65410, 65430
Orbit 67400
Chemodenervation
Contact Lens
See Contact Lens Services
Decompression
Orbit
See Orbit, Decompression
Destruction
Ciliary Body
See Ciliary Body, Destruction
Cyst
Ciliary Body 66770
Iris 66770
Lesion
Choroid 67220, 67221, 67225
Ciliary Body 66770
Cornea 65450
Iris 66770
Retina 67208, 67210, 67218
Retinopathy 67227-67229
Diagnostic and Monitoring Studies
Biometry 76516, 76519, 92136
Blood Flow Measurement 0198T
Computerized Corneal Topography 92025
Corneal Hysteresis Determination 92145
Corneal Pachymetry 76514
Dilated Fundus Evaluation 2020F, 2021F
Dilated Macular Exam 2019F, 2021F
Dilated Retinal Exam 2022F
Field Stereoscopic Photos 2024F
Eye Imaging Validation 2026F
Foreign Body Localization 76529
Heterochromatic Flicker Photometry 0506T
Interferometry
Biometry 92136
Intraocular Pressure
Measurement 0198T, 92100
Monitoring 0329T
Movement Analysis 0615T
Optic Nerve Head Evaluation 2027F
Biometry 76516-76519
Foreign Body 76529
Visual Field
Assessment 0378T, 0379T
Exam 92081-92083
X ray 70030
Diagnostic Ophthalmology
See Ophthalmology, Diagnostic
Dilation
Outflow Canal 66174, 66175
Discission
Anterior Hyaloid Membrane 65810
Cataract
Laser Surgery 66821
Stab Incision 66820
Vitreous Strands 67030
Drainage
Anterior Segment 0191T, 0253T, 0376T, 66183
with Aqueous Removal 65800
with Aspiration
Choroidal Fluid 67015
Subretinal Fluid 67015
Vitreous 67015
with Discission of Anterior Hyaloid Membrane 65810
Orbit 67405, 67440
with Removal
Blood 65815
Vitreous 65810
Endoscopy 66990
Enucleation 65101-65105
with Implant 65103, 65105, 65135, 65140
Evacuation
Evaluation
Dilated Fundus 2021F
Evisceration
Ocular 65091, 65093
Excision
Iris
See Iridectomy
Lesion 65400, 65900, 66130
Vitreous
See Vitrectomy
Exenteration
Orbital 65110, 65112, 65114
Exploration
Orbit 67400, 67450
Fistulization
Sclera 66150, 66155, 66160, 66170
Goniotomy 65820
Implant
Lacrimal Canaliculus 0356T
Ocular
Insertion 65093, 65103, 65105, 65130, 65135, 65140
Modification 65125
Reinsertion 65150, 65155
Removal 65175, 65920, 67120
Orbital 67550
Incision
Adhesions
Anterior Synechiae 65860, 65870
Corneovitreal Adhesions 65880
Goniosynechiae 65865
Posterior Synechiae 65875
Cornea, Relaxing 65772
Iris 66500, 66505, 66761
Laser 65860, 66761, 66821, 67031
Orbit
See Orbitotomy
to Reposition Lens Prosthesis 66825
Trabeculae 65820, 65850
Injection
Air or Liquid 66020
Alcohol 67505
Medication 66030, 67500
Pharmacologic Agent 0465T, 67028
into Tenon’s Capsule 67515
Vitreous Substitute 67025
Insertion
Aqueous Drainage Device
to Extraocular Reservoir 66179, 66180
without Extraocular Reservoir 0376T, 0449T, 0450T, 66183
Drug-Eluting Ocular Insert
Eyelid 0444T, 0445T
Implantation
Drainage Device 0191T, 0253T
Drug Delivery System 67027
Electrode Array 0100T
Foreign Material for Reinforcement 65155
Ganciclovir Implant 67027
Muscles, Attached 65140
Muscles, Not Attached 65135
Reinsertion 65150
Scleral Shell 65130
Prosthetic Lens
See Lens, Prosthesis, Insertion
Lesion
Choroid
Destruction 67220, 67221, 67225
Ciliary Body
Destruction 66770
Cornea
Destruction 65450
Excision 65400, 65900
Iris
Destruction 66770
Orbit
Removal 67412, 67420
Retina
Destruction 67208, 67210, 67218
Sclera
Excision 66130
Macula
Dilated Macular Exam 2019F, 2021F
Meibomian Glands
Evacuation 0207T, 0563T
Near Infrared Dual Imaging 0507T
Nerve
Destruction 67345
Paracentesis
with Discission of Anterior Hyaloid Membrane 65810
with Removal
Blood 65815
Vitreous 65810
Placement
Amniotic Membrane Graft 65778-65780
Limbal Conjunctival Graft 65782
Limbal Stem Cell Graft 65781
Radiation Source Applicator 67299
Prophylaxis
Retinal Detachment 67141, 67145
Prosthesis
Custom Preparation 21077
Intraocular Lens
Exchange 66986
Insertion 66985
Removal 0308T
Repositioning 66825
Iris 0616T-0618T
Ocular Telescope 0308T
Retinal Receiver and Pulse Generator
Implantation Electrode Array 0100T
Placement 0100T
Pterygium
Excision 65420, 65426
Transposition 65420, 65426
Puncture
Cornea 65600
Radial Keratotomy 65771
Reconstruction
Graft
Conjunctiva 65782
Stem Cell 65781
Transplantation
Amniotic Membrane 65778-65780
Removal
Blood 65815
Blood Clot 65930
Bone 65112, 67445
Cataract
Epithelial Downgrowth 65900
Foreign Body
Conjunctival Embedded 65210
Conjunctival Superficial 65205
Corneal 65220, 65222, 65275
Intraocular 65235, 65260, 65265
Orbit 67413, 67430
Implant
Anterior Segment 65920
Ocular 65175
Posterior Segment 67120, 67121
Lens Material
See Lens, Removal
Lesion
Orbit 67412, 67420
Membrane 65810
Vitreous
See Vitreous, Removal
Repair
Astigmatism, Surgical 65772, 65775
Conjunctiva 65270, 65272, 65273
Cornea
See Cornea, Repair
Iris 66680, 66682
Iridoplasty 66762
Muscles 65290
Retina
See Retina, Repair
Sclera
See Sclera, Repair
Trabeculae 65855
Wound
Direct Closure 65270
Operative 66250
Rearrangement 65272, 65273
Scraping
Cornea, Diagnostic 65430
Severing
Vitreous 67031
Adhesions 67031
Membranes 67031
Opacities 67031
Strands 67031
Shunt, Aqueous
Revision 66184, 66185
Strabismus Surgery
See Strabismus, Repair
Trabeculectomy Ab Externo
See Trabeculectomy ab Externo
Trabeculostomy ab Interno
Laser 0621T, 0622T
Transluminal Dilation
Aqueous Outflow Canal 66174, 66175
Transplant
See Keratoplasty
Keratophakia 65765
Unlisted Services and Procedures
Posterior Segment 67299
Eye Allergy Test

Ophthalmic Mucous Membrane Test 95060
Eye Evisceration
Evisceration, Ocular Contents 65091, 65093
Eye Exam
with Anesthesia 92018, 92019
Radiological 70030
Eye Exercises
Training 92065
Eye Muscles
Attached to Implant 65105, 65140, 65155
Biopsy 67346
Flap Graft 65114
Repair
Strabismus
See Strabismus
Wound 65290
Transposition 67320
Eye Prosthesis
Intraocular Lens Prosthesis 66982-66987
Ocular Telescope Prosthesis 0308T
Eye Socket
See Orbit
Eyebrow
Osteoplastic Flap Incision 31080, 31084, 31086
Repair
Ptosis 67900
Eyeglasses
See Spectacle Services
Eyelashes
Trichiasis Correction
Epilation
by Forceps Only 67820
by Other than Forceps 67825
Incision of Lid Margin 67830, 67835
for Biopsy 67810
Eyelid
Abscess
Biopsy
Incisional 67810
Blepharoplasty 15820-15823, 67914
Chalazion
Excision
Multiple 67801, 67805
Single 67800
Closure by Suture 67875
Evacuation
Incision
Canthus 67715
Severing of Tarsorrhaphy 67710
Injection
Subconjunctival 68200
Lesion
Destruction 67850
Excision 67840
Skin, Benign 11440-11444, 11446
Skin, Malignant 11640-11644, 11646, 17280-17284, 17286
Shaving
Dermal/Epidermal 11310-11313
Meibomian Glands
Evacuation 0207T, 0563T
Near Infrared Dual Imaging 0507T
Placement
Drug-Eluting Ocular Insert 0444T, 0445T
Reconstruction
Canthus 67950
Superficial
Adjacent Tissue Transfer 14060, 14061
Total 67973-67975
Total Eyelid
Lower 67973-67975
Second Stage 67975
Upper 67974
Transfer of Tarsoconjunctival Flap from Opposing Eyelid 67971
Removal
Foreign Body 67938
Repair 21280-21282
Blepharoptosis
See Blepharoptosis
Ectropion
Blepharoplasty 15820-15823, 67914
Suture 67914
Entropion
Extensive 67924
Suture 67921
Excisional 67961
over One-Fourth of Lid Margin 67966
Lagophthalmos 67912
Lashes
Epilation, by Forceps Only 67820
Epilation, by Other than Forceps 67825
Lid Margin 67830, 67835
Lid Retraction 67911
Overcorrection of Ptosis 67909
Skin
Complex 13151-13153
Intermediate 12051-12057
Wound
Full Thickness 67935
Partial Thickness 67930
Superficial 12011, 12013-12018
Repair with Graft
Retraction 67911
Skin Graft
Delayed/Sectioned Flap 15630
Dermal Autograft 15135, 15136
Epidermal Autograft 15115, 15116
Full-Thickness 15260, 15261, 67961
Pedicle 15576
Skin Substitute 15275-15278
Split-Thickness 15120, 15121, 67961
Superficial
Recipient Site Preparation 15004, 15005
Tissue-cultured Autograft 15155-15157
Suture
for Intermarginal Adhesions 67880
for Temporary Closure of Eyelids 67875
with Transposition of Tarsal Plate 67882
Tissue Transfer, Adjacent 67961
Eyelid Ptoses
See Blepharoptosis
F
Face
CT Scan 70486-70488
Lesion
Destruction 17000-17004, 17280-17286
Reconstruction
Facial Bones
Secondary 21275
Forehead 21172-21180, 21182-21184
Lip 40525-40527, 40761
Malar Augmentation 21210, 21270
Mandible 21244-21246, 21248, 21249
Mandibular Condyle 21247
Mandibular Rami 21193-21196
Maxilla 21245, 21246, 21248, 21249
Midface
Forehead Advancement 21159, 21160
with Bone Graft 21145-21160, 21188
without Bone Graft 21141-21143
LeFort I 21141-21147, 21155, 21160
LeFort II 21150, 21151
LeFort III 21154, 21155, 21159, 21160
Mouth 40840-40845
Nose 30400-30420, 30430-30450, 30620
Cleft Lip/Cleft Palate 30460-30462
Septum 30520
Orbit 21172-21180, 21182-21184, 21256, 21275
Orbitocraniofacial 21275
Periorbital Region 21267, 21268
Tumor Resection 21011-21016
Face Lift
See Rhytidectomy
Facial Asymmetries
See Hemifacial Microsomia
Facial Bones
Malar Bone
See Cheek Bone
Mandible
See Mandible
Maxilla
See Maxilla
Nasal Bones
See Nasal Bones
Orbit
See Orbit
Zygoma
See Zygomatic Arch
Facial Nerve
Anastomosis
to Hypoglossal 64868
to Spinal Accessory 64866
Avulsion 64742
Intratemporal
Lateral to Geniculate Ganglion 69720, 69740
Medial to Geniculate Ganglion 69725, 69745
Total 69955
Function Study 92516
Incision 64742
Injection
Anesthetic 64400
Steroid 64400
Mobilization 61590, 61595, 61596
Repair
Lateral to Geniculate Ganglion 69740
Medial to Geniculate Ganglion 69745
Repair/Suture
with or without Graft 64864, 64865
Suture
Lateral to Geniculate Ganglion 69740
Medial to Geniculate Ganglion 69745
Transection 64742
Facial Nerve Paralysis

Graft 15840-15842, 15845
Repair 15840-15842, 15845
Facial Prosthesis
Impression 21088
Facial Rhytidectomy
Face Lift 15824-15826, 15828, 15829
Factor, ACTH-Releasing
Corticotropic Releasing Hormone (CRH)
Factor, Antinuclear
Antinuclear Antibodies (ANA) 86038, 86039
Factor, Blood Coagulation
See Clotting Factor
Factor, Fitzgerald
Kininogen Assay 85293
Factor, Fletcher
Prekallikrein Assay 85292
Factor, Hyperglycemic-Glycogenolytic
See Glucagon
Factor, Intrinsic
See Intrinsic Factor
Factor, Rheumatoid
Qualitative 86430
Quantitative 86431
Factor, Sulfation
Somatomedin 84305
Factor Inhibitor Tests

See Pathology and Laboratory, Factor Inhibitor
Tests
Fallopian Tube
Anastomosis 58750
Biopsy 49321
Cannulation 58565
Destruction
Endoscopic 58670
with Salpingectomy and/or Oophorectomy 59120, 59151
Excision 58661, 58700, 58720, 58943, 58950, 58953, 58956
Imaging
Sonosalpingography 0568T
Ligation 58600, 58611
Lysis
Adhesions 58740
Occlusion
by Biopolymer Implant 0567T
by Cannulation 58565
by Device 58615, 58671
Sonosalpingography to Confirm 0568T
Repair 58752
Anastomosis 58750
Create Stoma 58673, 58770
Tumor
Resection 58950, 58952-58954, 58956-58958
Fallopian Tube Pregnancy

Ectopic Pregnancy, Tubal 59121
Fallot, Tetralogy of
Repair 33692, 33694, 33697
Family Adaptive Behavior Treatment Guidance 97156, 97157

Family Psychotherapy
See Psychotherapy, Family of Patient
Fanconi Anemia
Chromosome Analysis 81242, 88248
Farnsworth-Munsell Color Test
Color Vision Examination 92283
Farr Test
Gammaglobulin 82784, 82785, 82787
Fasanella-Servat Procedure 67908
Fascia Graft 15840
Fascia Lata Graft
Harvesting 20920-20922
Fascial Defect
Leg 27656
Urostomy 50728
Fascial Graft
Cheek 15840
Fascia and Skin
Flap 15733, 15734, 15736, 15738
Free
Microvascular Anastomosis 15758
Harvest 20920, 20922
Reconstruction
Collateral Ligament 26541
Infrapatellar Tendon 27381
Quadriceps Muscle 27386
Tendon Pulley 26502
Sternoclavicular Dislocation 23532
Fasciectomy
Foot 28060-28062
Palm 26121-26125
Fasciocutaneous Flaps
Muscle 15733-15738
Pharyngeal Wall 42894
Fasciotomy
Arm, Lower 24495, 25020-25025
Buttock
Decompression 27027
Foot 28008
Hand Decompression 26037
Hip 27025
Knee 27305, 27496-27499
Leg, Lower 27600-27602, 27892-27894
Leg, Upper 27305, 27496-27499, 27892-27894
Palm 26040-26045
Pelvis
Decompression 27027
Plantar
Endoscopic 29893
Thigh 27025
Toe 28008
Wrist 25020-25025
FAST (Food Allergy Specific Immunotherapy)

Fat
Feces 82705-82715
Removal
Lipectomy 15876-15879
Fat Stain
Feces 89125
Respiratory Secretions 89125
Sputum 89125
Urine 89125
Fatty Acid
Blood 82725
Very Long Chain 82726
FDP
Fecal Microbiota Transplant 44705
Feedback, Psychophysiologic
Therapy 90875, 90876
Training 90901, 90912, 90913
Female Castration
See Oophorectomy
Female Gonad
See Ovary
Femoral Arteries
See Artery, Femoral
Femoral Nerve
Injection
Steroid 64447, 64448
Femoral Stem Prosthesis
Hip Hemiarthroplasty, Partial 27125
Femoral Vein
Ligation 37650
Valvuloplasty 34501
Femur
Abscess
Incision 27303
Amputation 27590
Bone Graft 27170, 27177, 27470
Bursa
Excision 27062
Craterization 27070, 27071, 27360
Cyst
Excision 27065-27067, 27355-27358
Diaphysectomy 27360
Drainage 27303
Excision 27070, 27071, 27360
Femoroplasty 29914
Fracture 27244
Closed Treatment 27267, 27268, 27501-27503
Distal 27508, 27510, 27514
Distal, Medial or Lateral Condyle 27509
Epiphysis 27516-27519
Intertrochanteric 27244
with Implant 27245
Treatment with Implant 27244
Neck
Open Treatment 27177-27179, 27181, 27236
Open Treatment 27245, 27269, 27506, 27507, 27511-27513
Peritrochanteric 27244
with Implant 27245
Proximal End, Head
Shaft 27500, 27502, 27506, 27507
Subtrochanteric 27244
with Implant 27245
Supracondylar 27501-27503, 27509, 27511-27513
Transcondylar 27501-27503, 27509, 27511-27513
Trochanteric
Halo 20663
Osteoplasty
Lengthening 27466-27468
Shortening 27465, 27468
Osteotomy
without Fixation 27448
Prophylactic Treatment 27187, 27495
Radiostereometric Analysis (RSA) 0350T
Realignment 27454
at Knee 27442, 27443, 27446
Repair 27470-27472
Epiphysis 27181, 27475-27479, 27742
Arrest 27185
with Graft 27170
Osteotomy 27140, 27151-27156, 27161-27165, 27450-27454
Saucerization 27070, 27071, 27360
Tumor
Excision 27065-27067, 27078, 27355-27358, 27365
X ray 73551, 73552
Fenestration, Pericardium
Creation of Pericardial Window 32659, 33025
Fenestration Procedure
Burn and Scar Laser Ablation 0479T, 0480T
Tracheostomy 31610
Ferric Chloride
Urine 81005
Ferrihemoglobin
Methemoglobin 83045, 83050
Ferritin
Ferroxidase
Ceruloplasmin 82390
Fertility Control
See Contraception
Fertility Test
Huhner Test 89310
Male Infertility
Gene Analysis
CFTR intron 8 poly-T Analysis 81224
DAZ/SRY Deletion 81403
Semen Analysis 89300, 89310, 89320-89322
Sperm Analysis 89331
Antibodies 89325
Hamster Penetration 89329
Sperm Evaluation 89331
Fertilization
Assisted
Oocyte
Microtechnique 89280, 89281
Oocyte Culture 89250
with Co-Culture 89251
In Vitro 58321, 58322
Fertilization in Vitro 58321, 58322

Fetal Biophysical Profile 76818, 76819
Fetal Contraction Stress Test 59020
Fetal Hemoglobin
for Fetal-Maternal Hemorrhage 85460, 85461
Hemoglobin F 83030, 83033
Kleihauer-Betke 85460
Fetal Lung Maturity Assessment; Lecithin Sphingomyelin Ratio 83661

Fetal Monitoring
See Monitoring, Fetal
Fetal Non-Stress Test

Antepartum 59025
Fetal Procedure
Amniocentesis 59000
Amnioinfusion 59070
Amniotic Fluid Reduction 59001
Cord Occlusion 59072
Cordocentesis 59012
Fluid Drainage 59074
Intrauterine Transfusion 36460
Magnetic Cardiac Signal Recording 0475T-0478T
Non-stress Test 59025
Shunt Placement 59076
Stress Test 59020
Unlisted Fetal Invasive Procedure 59897
Unlisted Laparoscopy Procedure 59898
Unlisted Procedure, Maternity Care and Delivery 59899
Fetal Testing
Amniocentesis 59000
Amniotic Fluid
Lung Maturity 83661, 83663, 83664
Blood 59030
Heart 76825, 76826
Doppler
Complete 76827
Follow-up or Repeat Study 76828
Hemoglobin 83030-83033, 85460
Home Visit 99500
Non-Stress Test 59025
Ultrasound
Biophysical Profile 76818, 76819
Fetal 76813-76816
Fetal and Maternal 76801, 76802, 76805, 76810-76812, 76817
Heart 76825-76828
Middle Cerebral Artery 76821
Fetuin
See Alpha-Fetoprotein (AFP)
Fever, Australian Q
Q Fever 86000, 86638
Fever, Japanese River
Scrub Typhus 86000
Fibrillation
Atrial
Performance Measures 1060F, 1061F
Documentation 1060F, 1061F
Fibrillation, Heart
Fibrin Degradation Products

Agglutination 85362
D-dimer 85378, 85379
Quantitative 85379
Fibrin Deposit
Removal 32150, 32653
Fibrin Stabilizing Factor

Clotting Test 85290, 85291
Fibrinase
Plasmin 85400
Fibrinogen
Activity 85384
Antigen 85385
Fibrinolysins
Plasmin 85400
Screen 85390
Fibrinolysis
Assay 85396
Activity 85397
ADAMTS-13 85397
Plasmin 85400
Plasminogen 85420, 85421
Plasminogen Activator 85415
Pleural Cavity
Instillation of Agent 32561, 32562
Fibroadenoma
Ablation
Cryosurgical 19105
Excision 19120
Fibroblastoma, Arachnoidal
Meningioma
Excision 61512, 61519
Fibrocutaneous Tags
Removal 11200, 11201
Fibromatosis, Dupuytren’s
Fibromatosis, Penile
Fibromyoma
See Leiomyomata
Fibronectin, Fetal 82731

Fibrosis, Penile
Fibrosis, Retroperitoneal
Ureterolysis 50715
Fibrous Cavernitides
Fibrous Dysplasia
Cranial Bone 21181-21184
Facial Bone 21029
Fibula
Bone Graft with Microvascular Anastomosis 20955
Craterization 27360, 27641
Cyst
Excision 27635, 27637, 27638
Excision 27360, 27455, 27457, 27641
Proximal 27832
Fracture
with Distal Tibia Fracture 27826, 27828
Malleolus 27786, 27788, 27792, 27814
Shaft 27780, 27781, 27784
with Tibial Shaft Fracture 27750, 27752, 27756, 27758, 27759
Proximal
Incision 27607
Osteoplasty
Lengthening 27715
Shortening 27715
Repair
Epiphysis 27477, 27479, 27485, 27732, 27734, 27740, 27742
Nonunion or Malunion 27726
Osteotomy 27676, 27707, 27709, 27712
Saucerization 27360, 27641
Tibiofibular Joint
Arthrodesis 27871
Disruption 27829
Tumor
Excision
Bone 27635, 27637, 27638
X ray 73590
Figure of Eight Cast
Application 29049
Filariasis 86280, 86682
Filtering Operation
Scleral Fistulization
Sclerectomy 66160
Trabeculectomy ab externo 66170, 66172
Trephination 66150
Filtration Implant, Glaucoma
See Aqueous Shunt
Fimbrioplasty
Laparoscopic 58672
Uterus 58760
Fine Needle Aspiration
Diagnostic 10021
Evaluation 88172, 88173, 88177
Transendoscopic 43232, 43242
Colon 45392
Esophagus 43238
Fine Needle Aspiration (FNA) Biopsy

Lesion
with CT Guidance 10009, 10010
with Fluoroscopic Guidance 10007, 10008
with MR Guidance 10011, 10012
without Guidance 10004, 10021
Finger
Abscess
Amputation 26910, 26951, 26952
Blood Specimen, Finger Stick 36416
Blood Vessel Repair 35207
Bone
Bone Graft 26546
Cyst
Excision 26235, 26236
Partial 28114, 28285
Fracture
Articular
Distal 26755, 26756
Distal 26765
Shaft 26720-26727
Nonunion 26546
Ostectomy
Radical
for Tumor 26260-26262
Repair
Lengthening 26568
Nonunion 26546
Osteotomy 26567
Sesamoidectomy 26185
Thumb
Fracture
Shaft 26720-26727
Tumor
Cast 29086
Claw Finger Correction 26499
Collateral Ligament
with Graft 26541, 26545
Repair 26540
Decompression 26035
Diagnostic Imaging
Joint, Magnetic Resonance Imaging (MRI) 73221
X ray 73140
Excision
Constricting Ring 26596
Fascia 26123, 26125
Vascular Malformation 26111, 26113, 26115-26118
Fracture, Phalanges
See Fracture, Phalanges
Implant
Removal 26320
Joint
Arthrodesis
Interphalangeal Joint 26860-26863
Arthroplasty
with Prosthetic Implant 26536
with Prosthetic Implant 26531
Biopsy 26105, 26110
Capsulectomy 26520-26525
Capsulodesis 26516-26518
Capsulotomy 26520-26525
Dislocation 26770, 26775, 26785
Drainage 26075, 26080
Fracture 26740, 26742, 26746
Lesion Excision 26160
Manipulation 26340
Release 26123, 26125
Removal of Foreign Body 26075, 26080
Macrodactylia Repair 26590
Pollicization 26550
Polydactylous Digit Reconstruction 26587
Replantation 20816, 20822
Reposition 26555
Skin Replacement
Filleted Flap 14350
Split-Thickness 15120, 15121
Splint 29130, 29131
Strapping 29280, 29584
Syndactyly Repair 26560-26562
Tendon
Extensor
Delayed Tendon Graft 26416
Excision 26180, 26415
Lengthening 26476
Repair 26418, 26420, 26426, 26428, 26432-26434
Shortening 26477
Synthetic Rod Implantation 26415
Tenolysis 26445, 26449
Tenotomy 26460
Flexor
Excision 26180, 26390
Lengthening 26478
Repair 26350, 26352, 26356-26358
Shortening 26479
Tenosynovectomy 26145
Tenotomy 26455
Grafts 26502
Extensor 26412, 26420, 26428, 26434
Flexor 26352, 26358
Profundus 26372
Replace Rod Implant 26392, 26416
Profundus
Repair 26370, 26372, 26373
Pulley Reconstruction 26500, 26502
Sheath
Incision 26055, 26060
Tenotomy 26060
Transfer 26497, 26498, 26510
Transfer
Finger to Another Position 26555
Toe Joint 26556
Toe to Hand 26551, 26553, 26554
Tumor, Soft Tissue
Excision 26111, 26113, 26115-26118
Radical Resection 26117, 26118, 26260, 26262
Volar Plate Reconstruction 26548
Web Finger Repair 26560-26562
Finger Flap
Filleted 14350
Finger Joint
See Finger, Joint
Finney Operation
Gastroduodenostomy 43631, 43810, 43850, 43855
FISH (Fluorescent In Situ Hybridization)
Cytogenetics 88271-88275
Cytopathology 88120, 88121
Probe 88364-88366
Computer-Assisted 88367, 88374
Manual 88368, 88369, 88377
Fissure in Ano
See Anus, Fissure
Fissurectomy
Anus 46200
with Hemorrhoidectomy 46257, 46261
with Fistulectomy 46258, 46262
Fissurectomy, Anal
See Fissurectomy, Anus
Fistula
Closure
Anal 46288
Bronchi 32815
Bronchopleural 32906
Enterocolic 44650
Enteroenteric 44650
Enterovesical 44660, 44661
Esophageal 43420, 43425
Gastrocolic 43880
Intestinal Cutaneous 44640
Kidney 50520-50526
Lacrimal 68770
Nephrocutaneous 50520
Nephrovisceral 50525, 50526
Postauricular Mastoid 69700
Pyelocutaneous 50520
Rectourethral 45820, 45825
Rectovaginal 57300, 57305, 57307, 57308
Rectovesical 45800, 45805
Renocolic 50525, 50526
Salivary 42600
Trachea 31820
Ureter 50920-50930
Ureterocutaneous 50920, 53520
Ureterovisceral 50930
Urethrorectal 45820, 45825
Urethrovaginal 57310, 57311
Vesicoenteric 44660, 44661
Vesicouterine 51920, 51925
Vesicovaginal 51900, 57320, 57330
Creation
See Fistulization
Excision
Anal 46270, 46275, 46280, 46285
Branchial Cleft 42815
Repair
Anal 46288, 46706
Anorectal 46707
Anovestibular 46716
Arteriovenous
Carotid-Cavernous 61613, 61705, 61708, 61710
Esophageal 43360
Esophagotracheal 43305, 43312, 43314
Graft-enteric 35870
Ileoanal Pouch 46710, 46712
Mouth 30580, 30600
Nasolabial 42260
Nose 30580, 30600
Oval Window, Ear 69666
Penis 54340, 54344, 54348
Round Window, Ear 69667
Tracheoesophageal 43305, 43312, 43314
Urethra 53400, 53405
Suture
Kidney 50520-50526
Ureter 50920-50930
Ultrasound 76936
X ray 76080
Fistula, Arteriovenous
Fistulectomy
Anal 46060, 46270-46285
with Hemorrhoidectomy 46258, 46262
Fistulization
Anoperineal 46715, 46716
Arteriovenous
Colon
See Colostomy
Conjunctiva to Nasal Cavity 68745, 68750
Dacryocystorhinostomy 68720
Intestinal 44144
See Enterostomy
Penis 54435
Pharynx 42955
Rectourethral 46740, 46742
Rectovaginal 46740, 46742
Sclera
See Sclera, Fistulization
Tracheoesophageal 43305, 43312, 43314
Tracheopharyngeal 31755
Fistulization, Interatrial
See Septostomy, Atrial
Fistulotomy
Anal 46270, 46280
Fitting
Amputation
Leg 27881
Thigh 27591
Cervical Cap 57170
Contact Lens 92071, 92072, 92310-92317
See also Contact Lens Services
Diaphragm 57170
Intravaginal Support Device 57160
Low Vision Aid 92354, 92355
See also Spectacle Services
Orthotics 97760
Spectacle Prosthesis 92352, 92353
Spectacles 92340-92342
Voice Prosthetic 92597
Wheelchair 97542
Fitzgerald Factor
Kininogen Assay 85293
Fixation
Arthrodesis
Finger 26843, 26850, 26860
Thumb 26841, 26850, 26860
Arthroplasty
Wrist 25332
Arthroscopy
Knee 29885, 29887, 29892
Dislocation
Ankle 27842, 27846, 27848
Finger 26706, 26715
Finger Joint 26776, 26785
Foot
Metatarsophalangeal 28636, 28645
Talotarsal 28576, 28585
Tarsal 28546, 28555
Tarsometatarsal 28606, 28615
Hip 27216-27218
Knee 27556
Pelvis 27216-27218
Temporomandibular 21485
Thumb 26650, 26665
Thumb Joint 26776, 26785
Tibiofibular Syndesmosis 27829
Femur, Cyst Excision 27358
Fracture
Ankle
Bimalleolar 27814
Malleolar 27766, 27769
Manipulation 27860
Trimalleolar 27822, 27823
Carpal Scaphoid 25628
Clavicle 23515
Craniofacial 21432, 21435, 21436
Elbow 24635
Femur
Condylar 27509
Head Fracture 27254, 27269
Neck Fracture 27235, 27236
Shaft Fracture 27506
Trochanteric Fracture 27248
Fibula 27780, 27792, 27826, 27828
Finger 26607, 26608, 26615, 26756, 26765
Finger Joint 26746
Foot
Calcaneus 28406, 28415
Great Toe 28496, 28505
Metatarsal 28476, 28485
Sesamoid 28531
Talus 28436, 28445
Tarsus 28456, 28465
Hand
Carpometacarpal 26676, 26685, 26706, 26715
Hip 27226-27228
Interdental 21421, 21431
Knee 27524, 27540, 29850
Larynx 31584
Malar 21365
Mandibular 21196, 21452-21454, 21462, 21470
Maxillofacial 21100, 21110, 21345, 21346, 21421, 21435
Nasal 21330, 21339, 21340, 21345, 21346
Odontoid Process 22318
Pelvis 27216-27218
Radius 24665, 25606-25609, 25671
Shaft 25515, 25525, 25526, 25574, 25575
Rib 21811-21813
Scapula 23585
Shoulder 23670, 23680, 23700
Spine
See Spinal Instrumentation
Sternum 21825
Thumb 26727, 26735, 26756, 26765
Thumb Joint 26746
Tibia 27535, 27536, 27827, 27828, 29855, 29856
Tibial Shaft 27756, 27758
Ulna 24685, 25671
Ulnar Shaft 25545, 25574, 25575
Ulnar Styloid 25651
Wrist 29847
Fracture, Epiphyseal Separation 27509, 27519
Humerus 23615, 23630, 24400, 24538
Condylar 24545, 24546, 24566, 24579, 24582
Interdental 21110, 21421, 21431, 21462
without Fracture 21497
Knee
Dislocation 27556
Fracture 27524, 27540, 29850
Osteotomy
Femur 27165, 27181, 27450
Foot
Calcaneus 28300
Talar 28302
Tarsal 28304
Repair of Nonunion 25628
Carpal Bone 25431, 25440
Clavicle 23485
Fibula 27726
without Fracture
Interdental 21497
Fixation, External
Fixation, Kidney
Nephropexy 50400-50405
Fixation, Rectum
See Proctopexy
Fixation, Tongue
Tongue Base Suspension 41512
Tongue-to-Lip Suturing 41510
Fixation Test, Complement

See Complement, Fixation Test
Flank
See Back/Flank
Flap
See Skin Graft and Flap
Flatfoot Correction 28735
Flea Typhus
Murine Typhus 86000
Fletcher Factor
Flow Cytometry
Baseline 3170F
Cell Cycle Analysis 88182
Cell Surface Marker 88184, 88185
Cytoplasmic Marker 88184, 88185
DNA Analysis 88182
Interpretation 88187-88189
Nuclear Marker 88184, 88185
Flow-Volume Loop 94375
Flu Vaccines
See Vaccines and Toxoids, Influenza
Fluid, Amniotic
See Amniotic Fluid
Fluid, Body
See Body Fluid
Fluid, Cerebrospinal
Fluid Collection
Amniocentesis
See Amniocentesis
Arterial Catheter 37799
Catheter
Percutaneous 10030
Image Guided 10030
Transrectal 49407
Transvaginal 49407
Cerebrospinal Fluid 62272, 62329
Hematoma 10140
Skin 10140
Soft Tissue
Percutaneous 10030
Sputum 89220
Sweat 89230
Tears 83861
Venipuncture 36415
Fluorescein
Angiography, Ocular 92230, 92235, 92242, 92287
Intravenous Injection
Vascular Flow Check, Graft 15860
Fluorescein Angiography 92235, 92242
Fluorescent In Situ Hybridization (FISH)
Cytogenetics 88271-88275
Probe 88364-88366
Manual 88368, 88369, 88377
Fluoride
Chemistry 82735
Varnish
Application 99188
Fluoroscopy
Examination
Angiography 36901, 36902, 36903
GI Tract 74340
Larynx 70370
Pharynx 70370
Guidance
Abscess Drainage 75989
Bile Duct
Calculus Removal 47544
Catheterization
Dialysis Circuit 36901, 36902, 36903
Spine/Paraspinous 77003
Chest
Bronchoscopy 31622-31638, 31640, 31641, 31643, 31645, 31646, 31647-31649, 31651, 31660,
31661
Disc Decompression 62287
Electrothermal Annuloplasty 22526, 22527
Esophagoscopy 43213, 43214
Intubation
Colonic 49442, 49450
Duodenostomy 49441, 49451
Gastro-jejunostomy 49446, 49452
Gastrostomy 49440, 49446, 49450
GI Tract 74340
Jejunostomy 49441, 49446, 49451
Nasogastric 43752
Nephrostomy 50389
Orogastric 43752
Nephroureteral Catheter
Replacement 50387
Spinal Neurostimulator Electrode
Removal 63661, 63662
Revision/Replacement 63663, 63664
Stoma
Creation 49465
Thrombectomy
Arterial
Coronary 92973
Intracranial 61645
Venous 37187, 37188
Vena Cava Filter
Insertion 37191
Removal 37193
Repositioning 37192
Venous Access Device 36598, 77001
Hourly 76000
Needle Biopsy 77002
FNA
Foam Stability Test 83662
Fold, Vocal
See Vocal Cords
Foley Operation Pyeloplasty
See Pyeloplasty
Foley Y-Pyeloplasty 50400-50405

Folic Acid
Blood 82746
Serum 82747
Follicle Stimulating Hormone (FSH) 80418, 80426, 83001

Folliculin
Estrone 82679
Follitropin
See Follicle Stimulating Hormone (FSH)
Follow-up Inpatient Consultations
See Consultation, Inpatient
Follow-up Services
See Hospital Services; Office and/or Other Outpatient Services
Post-Op 99024
Fontan Procedure
Cardiac Anomaly Repair 33615, 33617
Food Allergy Test

Allergen-specific IgE 86003, 86005, 86008
Challenge Test 95076, 95079
Foot
See also Calcaneus; Metatarsal Bone; Tarsal Bone; Toe
Abscess
Bone Cortex 28005
Amputation 28800-28805
Bone
See Calcaneus; Metatarsal Bone; Tarsal Bone; Toe, Bone
Bursa
Capsulotomy 28260-28262, 28264
Casts and Strapping
Clubfoot Cast 29450
Compression System 29581
Strapping 29540
Unna Boot 29580
Cleft Foot Reconstruction 28360
Clubfoot Repair 28262
Cast 29450
Wedging 29750
Fasciectomy 28060
Radical 28060-28062
Fasciotomy 28008
Endoscopic 29893
Incision 28002, 28003, 28005
Joint
Arthrodesis 28705, 28715, 28725, 28730, 28735, 28740, 28750, 28755, 28760
Arthrotomy 28020, 28050
Biopsy 28050
Dislocation
Interphalangeal 28660, 28665, 28666, 28675
Metatarsophalangeal 28630, 28635, 28636, 28645
Talotarsal 28570, 28575, 28576, 28585
Tarsometatarsal 28600, 28605, 28606, 28615
Drainage 28020, 28022, 28024
Exploration 28020, 28022, 28024
Fusion 28730, 28735, 28740
Removal of Foreign Body 28020, 28022, 28024
Lesion
Excision 28080, 28090
Nerve
Destruction
Neurolytic 64632
Excision 28055
Graft 64890, 64891, 64895, 64896
Incision 28035
Neuroma
Excision 28080, 64782
Injection of Anesthetic or Steroid 64455
Morton’s 64455, 64632
Neuroplasty 64702
Suture
Common Sensory 64834
Digital 64831, 64832
Each Additional 64837
Median Motor Thenar 64835
Ulnar Motor 64836
Plantar Fascia
Division 28250
Extracorporeal Shock Wave 28890
Fasciectomy 28060, 28062
Release 28119
Removal
Foreign Body 28190, 28192, 28193
Muscle 28250
Tendon 28200-28230, 28234-28238
Replantation 20838
Sesamoid
Excision 28315
Skin Graft
Suture
Tendon 28200-28210
Tendon
Extensor
Repair 28208, 28210
Tenotomy 28234
Flexor
Repair 28200, 28202
Tenotomy 28230, 28232
Lengthening/Advancement 28261, 28262, 28737
Tendon Sheath
Synovectomy 28086, 28088, 28090
Tenotomy 28010, 28011, 28230, 28234
Transfer 27690-27692
Tissue Transfer
Adjacent 14040, 14041
Flap 15574, 15620
Tumor
Soft Tissue
Excision 28039, 28041, 28043, 28045
X ray 73620, 73630
Foot Abscess
Incision 28005
Foot Navicular Bone
See Navicular Bone, Tarsal
Forearm 20805
See Arm, Lower
Forehead
Flap 15731
Reconstruction 21179, 21180, 21182-21184
Midface 15730, 21159, 21160
Reduction 21137-21139
Forehead and Orbital Rim

Reconstruction 21172-21180
Forensic Exam
Autopsy 88040
Cytopathology 88125
Foreskin of Penis
See Penis, Prepuce
Formycin Diphosphate
Fournier’s Gangrene
Debridement, Necrotizing Infection 11004, 11006
Fowler-Stephens Orchiopexy
Orchiopexy, Abdominal Approach 54650
Fowler-Stephens Procedure 54650

Fraction, Factor IX 85250
Fracture
Acetabulum
Alveolar Ridge
Ankle
Bimalleolar 27808, 27810, 27814
Lateral 27786, 27788, 27792, 27808, 27810, 27814
Medial 27760, 27762, 27766, 27808, 27810, 27814
Posterior 27767-27769, 27808, 27810, 27814
Trimalleolar 27816, 27818, 27822, 27823
Ankle Bone
Medial 27760-27762
Bennett 26645, 26650, 26665
Blow-Out Fracture
Orbital Floor 21385-21387, 21390, 21395
Bronchi
Reduction 31630
Calcaneus
Carpal
Closed Treatment
without Manipulation 25622, 25630
Carpal Scaphoid
Cheekbone
Clavicle
Closed Treatment
Coccyx
Colles 25600, 25605
Colles-Reversed
Smith Fracture 25600, 25605
Elbow
Monteggia
Femur
Closed Treatment 27230, 27238-27240, 27246, 27267, 27268, 27500-27503, 27508, 27510, 27516,
27517
Distal 27508, 27510, 27514
Epiphysis 27516-27519
Intertrochanteric
Intramedullary Implant 27245
Plate/Screw Implant 27244
Treatment with Implant 27244, 27245
Neck
Open Treatment 27245, 27248, 27269, 27506, 27507, 27511-27514, 27519
Peritrochanteric
Intramedullary Implant Shaft 27245, 27500, 27502, 27506, 27507
Proximal
Subtrochanteric
Intramedullary Implant 27245
Supracondylar 27501-27503, 27509, 27511-27513
Transcondylar 27501-27503, 27509, 27511-27513
Trochanteric
with Manipulation 27232, 27502, 27503, 27510
without Manipulation 27230, 27238, 27246, 27500, 27501, 27508, 27516, 27517, 27520
Fibula
Bimalleolar
Closed Treatment 27780, 27781, 27786-27788, 27808-27810
Malleolus 27786-27814
Open Treatment 27784, 27792, 27814
Shaft 27780-27786, 27808
Fixation
See Fixation, Fracture
Frontal Sinus
Great Toe
Heel
Humerus
Condyle
Percutaneous 24582
with Dislocation
Epicondyle
Skeletal Fixation
Percutaneous 24566
Greater Tuberosity Fracture
Closed Treatment without Manipulation 23620
Shaft 24500-24505, 24516
with Shoulder Dislocation
Supracondylar
Transcondylar
Hyoid Bone
Ilium
Knee 27520
Arthroscopic Treatment 29850, 29851
Larynx
Fixation 31584
Malar Area
Mandible
Closed Treatment
Interdental Fixation 21453
with Interdental Fixation 21462
without Interdental Fixation 21461
Maxilla
Metacarpal
with Fixation 26607
with Manipulation 26605-26607
Metatarsal
Nasal Bone
Nasal Septum
Nasal Turbinate
Therapeutic 30930
Nasoethmoid
with Fixation 21340
Nasomaxillary
with Bone Grafting 21348
with Fixation 21345-21347
Navicular
Odontoid
Open Treatment
with Graft 22319
without Graft 22318
Orbit
Closed Treatment
Blowout Fracture 21385-21395
Orbital Floor
Blow Out 21385-21395
Palate
Patella
Closed Treatment
Pelvic Ring
Open Treatment
Anterior 27217
Posterior 27218
Phalanges
Articular
Articular 26740
Distal 26750
Distal 26755, 26756
Finger or Thumb 26765
Finger/Thumb
Shaft 26720, 26727
Great Toe 28490
Distal 26765
Shaft
Toe
Radius
Colles 25600-25605
Distal 25600-25609
Smith 25600-25605
Head/Neck
Open Treatment 25515, 25607-25609
Internal Fixation 25607-25609
with Radioulnar Joint
Dislocation 25525, 25526
Shaft 25500, 25525, 25526
Closed Treatment 25500-25505, 25520
Open Treatment 25515, 25525, 25526, 25574
with Ulna 25560-25565
Rib
with Internal Fixation 21811-21813
Risk Assessment
CT Scan 0554T-0557T
Scaphoid
with Dislocation
Scapula
Closed Treatment
Sesamoid
Foot 28530, 28531
Skeletal Traction 20650
Acetabulum Fracture 27220
Femoral Fracture 27232, 27240, 27502, 27503, 27517
Hip Socket 27220
Humerus Fracture 23605, 24505, 24535
Phalangeal Fracture 26725
Scapula Fracture 23575
Tibia Fracture 27532, 27752, 27762, 27825
Skin
Skull 62000-62010
Smith Fracture 25600, 25605
Sternum
Talus
Tarsal
Thumb
with Dislocation 26645-26650
Tibia 27759
Plateau
Bicondylar 29856
Unicondylar 29855
Bimalleolar
Closed Treatment 27530-27532, 27538, 27750-27752, 27760-27762, 27808-27810, 27824, 27825
Distal 27824-27828
Articular 27826-27828
Intercondylar 27538-27540
Malleolus 27760-27769, 27808-27814
with Manipulation 27752, 27760-27762, 27810
without Manipulation 27530, 27750, 27760-27762, 27808, 27825
Open Treatment 27535, 27536, 27540, 27758, 27766, 27814, 27826-27828
Plateau 27530-27536
Unicondylar
Shaft 27750-27759
Trachea
Endoscopy 31630
Ulna
with Dislocation
Monteggia 24620-24635
Olecranon
with Radius 25560-25565
Shaft
Styloid Process
Ulna and Radius
Vertebra
Additional Segment
Cervical
Closed Treatment
with Manipulation, Casting and/or Bracing 22315
Lumbar
Posterior
Thoracic
Vertebral Fracture Assessment 77085, 77086
Wrist
with Dislocation
Zygomatic Arch
Fractured Catheter Retrieval 37197

Fragile-X
FMR1 Gene Analysis 81243
Fragility
Red Blood Cell
Mechanical 85547
Osmotic 85555, 85557
Frames, Stereotactic
Francisella 86000
Antibody 86668
Fredet-Ramstedt Procedure 43520
Free E3
Estriol 82677
Free Skin Graft
See Skin, Grafts, Free
Free T4
See Thyroxine, Free
Frenectomy
Lip 40819
Tongue 41115
Frenectomy, Lingual
Tongue 41115
Frenotomy
Lip 40806
Tongue 41010
Frenulectomy
See Frenectomy
Frenuloplasty 41520
Frenum
Lip
Excision 40819
Incision 40806
Revision 41520
Tongue
Excision 41115
Incision 41010
Frenumectomy 40819
Frickman Operation
See Proctopexy
Frontal Craniotomy 61556
Frontal Sinus
See Nasal Sinuses, Frontal
Frontal Sinusotomy
See Exploration, Sinus, Frontal
Frost Suture
Temporary Closure of Eyelids 67875
Frozen Blood Preparation
Freezing 86930, 86932
Thawing 86931
Fructose
Semen 82757
TLC Screen 84375
Fructose Intolerance Breath Test 91065
Fruit Sugar
See Fructose
FSF 85290, 85291
FSH (Follicle Stimulating Hormone) 80418, 80426, 83001
FSP (Fibrinogram Split Products)
FT-4
Free Thyroxine 84439
Fulguration
Bladder 51020, 52285
Cervix 57500, 57520
Cystourethroscopy with 52214, 52400
Lesion 52224
Tumor 52234, 52235, 52240, 52250
Kidney
Lesion
Ovary 58662
Pelvis 58662
Peritoneal 58662
Oviducts 58670
Ureter 50957, 50976, 52354
Ureterocele
Ectopic 52301
Orthotopic 52300
Urethra 52285, 53220, 53260
Fulguration, Endocavitary
See Electrocautery
Full Thickness Graft 15200-15261

Function Study, Nasal 92512
Function Test, Lung
See Pulmonology, Diagnostic
Function Test, Vestibular
Functional Ability
Fundoplasty
Esophagogastric 43325, 43327, 43328
Esophagogastroduodenoscopic 43210
Laparoscopic 43279, 43280, 43283
Esophagomyotomy
Laparoscopic 43279
Paraesophageal Hiatal Hernia Repair
with Fundoplication
Laparotomy 43332, 43333
Thoracoabdominal Incisional 43336, 43337
Fundoplication
Paraesophageal Hiatal Hernia Repair
via Laparotomy 43332, 43333
via Thoracoabdominal Incision 43336, 43337
via Thoracotomy 43334, 43335
Fungus
Antibody 86671
Culture
Blood 87103
Hair 87101
Identification 87106
Nail 87101
Other 87102
Skin 87101
Tissue Exam 87220
Funnel Chest
See Pectus Excavatum
Furuncle
Furuncle, Vulva
Fusion
See also Arthrodesis
Great Toe 28760
Metatarsocuneiform 28297
Pleural Cavity
Instillation of Agent for Pleurodesis 32560
Spine
Exploration 22830
Thumb
in Opposition 26820
Fusion, Epiphyseal-Diaphyseal
Fusion, Joint
See Arthrodesis
Fusion, Joint, Ankle

Arthrodesis 27870
Fusion, Joint, Interphalangeal, Finger
Arthrodesis 26860-26863
G
Gabapentin
Assay 80171
Gait Training 97116

Galactogram 77053, 77054
Injection 19030
Galactokinase
Blood 82759
Galactose
Blood 82760
Urine 82760
Galactose-1-Phosphate
Uridyl Transferase 82775, 82776
Galeazzi Fracture/Dislocation
Radial Shaft 25520, 25525, 25526
Gall Bladder
See Gallbladder
Gallbladder
Anastomosis
with Intestines 47720, 47721, 47740, 47741
Biopsy 43261
Destruction
Diagnostic Imaging
Nuclear Medicine 78226, 78227
Excision
See Cholecystectomy
Exploration 47480
Endoscopic Retrograde Cholangiopancreatography (ERCP) 43260
Fistulization 47480, 47490
Incision 47480
Removal
Repair
with Gastroenterostomy 47741
with Intestines 47720, 47721, 47740, 47741
Stimulation 43757
Galvanocautery
See Electrocautery
Galvanoionization
See Iontophoresis
Gamete Intrafallopian Transfer (GIFT) 58976

Gamete Transfer
In Vitro Fertilization 58976
Gamma Camera Imaging

See Nuclear Medicine, Diagnostic
Gamma Glutamyl Transferase 82977
Gamma Seminoprotein
Prostate Specific Antigen 84152, 84153
Gammacorten
Gammaglobulin
Blood 82784, 82785, 82787
Gamulin Rh
Immune Globulins, Rho(D) 90384-90386
Ganglia, Trigeminal
See Gasserian Ganglion
Ganglion
Cyst
Aspiration/Injection 20612
Drainage 20612
Wrist
Excision 25111, 25112
Gasserian
Geniculate
Facial Nerve
Suture 69740, 69745
Injection
Anesthetic
Sphenopalatine 64505
Stellate 64510
Stellate
Injection
Anesthetic 64510
Ganglion, Gasser’s
Ganglion Cervicothoracicum
Stellate Ganglion
Anesthetic Injection 64510
Ganglion Pterygopalatinum
Sphenopalatine Ganglion
Anesthetic Injection 64505
Gardner Operation
Gardnerella Vaginalis Detection 87510-87512

Gasser Ganglion
Gasserian Ganglion
Creation of Lesion
Stereotactic 61790
Sensory Root
Compression 61450
Decompression 61450
Section 61450
Gastrectomy
with Gastroduodenostomy 43631
Longitudinal 43775
Partial 43631-43635, 43845, 48150, 48152
with Gastrojejunostomy 43632
Proximal 43117, 43118, 43121-43123
Sleeve 43775
Total 43620-43622
with Esophagoenterostomy 43620
Gastric Acid
Analysis 82930
Gastric Analysis Test
Secretory Study 43754, 43755
Gastric Electrodes
Neurostimulator
Implantation
Laparoscopic 43647
Open 43881
Removal
Laparoscopic 43648
Open 43882
Replacement
Laparoscopic 43647
Open 43881
Revision
Laparoscopic 43648
Open 43882
Gastric Intubation
Diagnostic 43754-43757
Therapeutic 43753
Gastric Lavage, Therapeutic
Intubation 43753
Gastric Tests
Acid Reflux 91034, 91035, 91037, 91038
Motility 91020
Gastric Ulcer Disease
See Stomach, Ulcer
Gastrin 82938-82941
Gastrocnemius Recession
Leg, Lower 27687
Gastroduodenostomy
Establishment 43810
with Gastrectomy 43631
Revision 43850, 43855
Gastroenterology, Diagnostic
Breath Test
Hydrogen 91065
Methane 91065
Urea 78267, 78268
Esophagus Tests
Acid Perfusion 91030
Acid Reflux 91034-91038
Balloon Distension Study 91040
with Provocation 91040
Intubation with Specimen Collection 43754, 43755
Motility Study 91010, 91013
Gastric Tests
Emptying Imaging Study 78264
with Small Bowel and Colon Transit 78266
with Small Bowel Transit 78265
Motility 91020
Gastroesophageal Reflux Test 91034, 91035, 91037, 91038
Imaging
See Gastrointestinal Tract, Imaging
Manometry 91010, 91013, 91020, 91022
Motility Study
Colon 91117
Gastric 91020
Rectum
Sensation, Tone, and Compliance Test 91120
Rectum/Anus
Manometry 91122
Stomach
Stimulation of Secretion 43755
Gastroenterostomy
for Obesity
for Repair 47721, 47741
Gastroesophageal Reflux Test
with Electrode Placement 91034, 91035, 91037, 91038
Gastrointestinal Endoscopies
See Endoscopy, Gastrointestinal
Gastrointestinal Exam
Capsule Endoscopy
Colon 0355T
CT Scan
Colon 74261-74263
Endoscopic Imaging
Intraluminal
Colon 0355T
Nuclear Medicine
Blood Loss Study 78278
Esophageal Motility 78258
Gastric Emptying Imaging Study 78264
with Small Bowel and Colon Transit 78266
with Small Bowel Transit 78265
Gastric Mucosa Imaging 78261
Gastroesophageal Reflux Study 78262
Hepatobiliary 78226, 78227
Intestine 78290
Liver 78201, 78215, 78216
SPECT 78803
with Vascular Flow 78202
Peritoneal-Venous Shunt Patency 78291
Protein Loss Study 78282
Salivary Gland 78230-78232
Spleen 78215
Unlisted Diagnostic Nuclear Medicine
Procedure 78299
Radiological Imaging
Bile Ducts 47531, 47532, 74300, 74301
Colon 74270, 74280
Esophagus 74210, 74220, 74221
Swallowing Function 74230
Gallbladder 74290, 78226
See Gastrointestinal Tract, Imaging, Radiological
Pharynx 74210
Protein Loss 78282
Small Intestine 74248, 74250, 74251
Ultrasound
Endoscopic 76975
Gastrointestinal Pathogen 87505-87507

Imaging
CT Scan
Colon 74261-74263
Endoscopic
Radiological 74340
Colon 74270, 74280
Small Intestine 74248, 74250, 74251
Upper 74240, 74246
Measurements
Pressure 91112
Transit 91112
Upper
Dilation 43249, 74360
X ray 74240, 74246
with Contrast 74246
Guide Dilator 74360
Guide Intubation 74340
Gastrointestinal Tract, Upper

Biopsy 43239
Dilation
Endoscopy 43245
Esophagus 43249
Passage of Dilator 43248
Endoscopy
Ablation
Lesion 43270
Polyp 43270
Tumor 43270
Biopsy 43239
Dilation 43245, 43248, 43249
Drainage
Pseudocyst 43240
Esophageal Ultrasound 43237, 43238, 43253
Examination 43235, 43252
Ultrasound 43253
Hemorrhage 43255
Injection, Varices 43243
Ligation, Varices 43244
Removal
Foreign Body 43247
Lesion 43251
Polyp 43251
Tumor 43251
Thermal Radiation 43257
Ultrasound 43237, 43238, 43242, 43253, 43259, 76975
Exploration
Hemorrhage
Imaging
Radiological 74240, 74246
Ultrasound Endoscopy 43237, 43238, 43242, 43259, 76975
Injection
Submucosal 43236
Transmural 43253
Varices 43243
Lesion
Ablation 43270
Ligation of Vein 43244
Needle Biopsy
Reconstruction
Esophageal 43360
Removal
Foreign Body 43247
Lesion 43250
Polyp 43250, 43251
Tumor 43250
Tube Placement
Endoscopy 43246
Ultrasound
Endoscopy 43237, 43238, 43242, 43259, 76975
Gastrojejunostomy
Conversion from Gastrostomy Tube 49446
with Duodenal Exclusion 48547
with Pancreatectomy 48150
with Partial Gastrectomy 43632
Removal of Obstructive Material 49460
Replacement of Tube 49452
Revision of Gastrojejunal Anastomosis 43860, 43865
with Vagotomy 43825
without Vagotomy 43820
Whipple Procedure 48150
Gastroplasty
Collis 43338
Esophageal Lengthening 43283, 43338
Laparoscopic 43279, 43280, 43283
Revision
for Obesity 43644, 43645, 43842, 43843, 43845-43848
Wedge 43338
Gastroplasty with Esophagogastric Fundoplasty

Laparoscopic 43820
Gastrorrhaphy
Injury 43840
Perforated Ulcer 43840
Wound 43840
Gastroschises
See Gastroschisis
Gastroschisis
Removal of Prosthesis 49606
Repair 49605
Gastrostomy
Closure 43870
Laparoscopic 43653
Neonatal 43831
with Pancreatic Drain 48001
with Pyloroplasty 43640
Radiological Assessment 49465
Revision of Tract
with Replacement of Gastrostomy Tube 43763
Temporary 43830
Tube
See Gastrostomy Tube
with Vagotomy 43640, 43641
Gastrostomy Tube
Conversion
to Gastro-jejunostomy Tube 49446
to Jejunostomy Tube 44373
Placement
with Conversion to Gastro-jejunostomy Tube 49446
Endoscopic 43246
Percutaneous 49440
Replacement 49450
Percutaneous
with Fluoroscopic Guidance 49450
without Imaging/Endoscopic
Guidance 43762, 43763
Requiring Revision of Gastrostomy Tract 43763
Repositioning
Feeding Tube 43761
Gastrotomy
with Esophageal Tube Insertion 43510
Exploration 43500
Suture Repair
Bleeding Ulcer 43501
Esophagogastric Laceration 43502
GDH
Glutamate Dehydrogenase 82965
Gel Diffusion
Detection 86331
Gel Diffusion Test

See Immunodiffusion
Gene Analysis
Analytes
ABCA4 (ATP-binding cassette, sub-family A [ABC1], member 4) 81408
ABCC8 (ATP-binding cassette, sub-family C [CFTR/MRP], member 8) 81400, 81401, 81407
ABCD1 (ATP-binding cassette, sub-family D [ALD], member 1) 81405
ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) 81170, 81401
ACADM (acyl-CoA dehydrogenase, C-4 to C-12 straight chain) 81400, 81401
ACADS (acyl-CoA dehydrogenase, C-2 to C-3 short chain) 81404, 81405
ACADVL (acyl-CoA dehydrogenase, very long chain) 81406
ACE (angiotensin I converting enzyme [peptidyl-dipeptidase A] 1) 81400
ACTA2 (actin, alpha 2, smooth muscle, aorta) 81405
ACTC1 (actin, alpha, cardiac muscle 1) 81405
ACTN4 (actinin, alpha 4) 81406
ADRB2 (adrenergic, beta-2-, receptor, surface) 81401
AFF2 (AF4/FMR2 family, member 2 [FMR2]) 81171, 81172
AFG3L2 (AFG3 ATPase family gene 3 like 2 [S. cerevisiae]) 81406
AGL (amylo-alpha-1, 6-glucosidase, 4-alpha-glucanotransferase) 81407
AGTR1 (angiotensin II receptor, type 1) 81400
AHI1 (Abelson helper integration site 1) 81407
AIRE (autoimmune regulator) 81406
ALDH7A1 (aldehyde dehydrogenase 7 family, member A1) 81406
ANG (angiogenin, ribonuclease, RNase A family, 5) 81403
ANKRD1 (ankyrin repeat domain 1) 81405
ANO5 (anoctamin 5) 81406
ANOS1 (anosmin-1) 81406
APC (adenomatous polyposis coli) 81201, 81202
APOB (apolipoprotein B) 81401, 81407
APOE (apolipoprotein E) 81401
APP (amyloid beta [A4] precursor protein) 81406
APTX (aprataxin) 81405
AQP2 (aquaporin 2 [collecting duct]) 81404
AR (androgen receptor) 81173, 81174, 81204
ARSA (arylsulfatase A) 81405
ARX (aristaless related homeobox) 81403, 81404
ASPA (aspartoacylase) 81200
ASPM (asp [abnormal spindle] homolog, microcephaly associated [Drosophila]) 81407
ASS1 (argininosuccinate synthase 1) 81406
ASXL1 (additional sex combs like 1, transcriptional regulator) 81175, 81176
ATL1 (atlastin GTPase 1) 81406
ATM (ataxia telangiectasia mutated) 81408
ATN1 (atrophin 1) 81177
ATP1A2 (ATPase, Na+/K+ transporting, alpha 2 polypeptide) 81406
ATP7B (ATPase, Cu++ transporting, beta polypeptide) 81406
ATXN1 (ataxin 1) 81178
ATXN8OS (ATXN8 opposite strand [non-protein coding]) 81182
AVPR2 (arginine vasopressin receptor 2) 81404
BBS1 (Bardet-Biedl syndrome 1) 81406
BCKDHA (branched chain keto acid dehydrogenase E1, alpha polypeptide) 81400, 81405
BCKDHB (branched chain keto acid dehydrogenase E1, beta polypeptide) 81205, 81406
BCL1/IgH, t(11;14) 81401
BCR/ABL1 (chronic myelogenous leukemia) Translocation 81206-81208
BCS1L (BCS1-like [S. cerevisiae]) 81405
BEST1 (bestrophin 1) 81406
BLM (Bloom syndrome, RecQ helicase-like) 81209
BMPR2 (bone morphogenetic protein receptor, type II [serine/threonine kinase]) 81405, 81406
BRAF (B-Raf proto-oncogene, serine/threonine kinase) 81210, 81406
BRCA1 (BRCA1, DNA repair associated) 81162-81166, 81212, 81215
BRCA2 (BRCA2, DNA repair associated) 81162-81164, 81167, 81212, 81216, 81217
BSCL2 (Berardinelli-Seip congenital lipodystrophy 2 [seipin]) 81406
BTD (biotinidase) 81404
BTK (Bruton agammaglobulinemia tyrosine kinase) 81406
BTK (Bruton’s tyrosine kinase) 81233
C10orf2 (chromosome 10 open reading frame 2) 81404
CACNA1A (calcium voltage-gated channel subunit alpha 1A) 81184-81186
CACNB2 (calcium channel, voltage-dependent, beta 2 subunit) 81406
CALR (calreticulin) (eg, myeloproliferative disorders) 81219
CAPN3 (calpain 3) 81406
CASQ2 (calsequestrin 2 [cardiac muscle]) 81405
CASR (calcium-sensing receptor) 81405
CAV3 (caveolin 3) 81404
CBFB/MYH11 (inv (16)) 81401
CBS (cystathionine-beta-synthase) 81401, 81406
CCND1/IGH (t(11;14)) 81168
CCR5 (chemokine C-C motif receptor 5) 81400
CD40LG (CD40 ligand) 81404
CDH1 (cadherin 1, type 1, E-cadherin [epithelial]) 81406
CDH23 (cadherin-related 23) 81408
CDKL5 (cyclin-dependent kinase-like 5) 81405, 81406
CDKN2A (cyclin-dependent kinase inhibitor 2A) 81404
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) 81218
CEL (carboxyl ester lipase [bile salt stimulated lipase]) 81403
CEP290 (centrosomal protein 290kDa) 81408
CFH/ARMS2 (complement factor H/age-related maculopathy susceptibility 2) 81401
CFTR (cystic fibrosis transmembrane conductance regulator) 81220-81224
CHD7 (chromodomain helicase DNA binding protein 7) 81407
CHRNA4 (cholinergic receptor, nicotinic, alpha 4) 81405
CHRNB2 (cholinergic receptor, nicotinic, beta 2 [neuronal]) 81405
Chromosome 1p-/19q- 81402
Chromosome 18q- 81402
CLCN1 (chloride channel 1, skeletal muscle) 81406
CLCNKB (chloride channel, voltage-sensitive Kb) 81406
CLRN1 (clarin 1) 81400, 81404
CNBP (CCHC-type zinc finger nucleic acid binding protein) 81187
CNTNAP2 (contactin associated protein-like 2) 81406
COL1A1 (collagen, type I, alpha 1) 81408
COL1A1/PDGFB (t(17;22)) 81402
COL1A2 (collagen, type I, alpha 2) 81408
COL4A1 (collagen, type IV, alpha 1) 81408
COL4A3 (collagen, type IV, alpha 3 [Goodpasture antigen]) 81408
COL4A4 (collagen, type IV, alpha 4) 81407
COL4A5 (collagen, type IV, alpha 5) 81407, 81408
COL6A1 (collagen, type VI, alpha 1) 81407
COL6A2 (collagen, type VI, alpha 2) 81406, 81407
COL6A3 (collagen, type VI, alpha 3) 81407
Constitution 81228, 81229
COX6B1 (cytochrome c oxidase subunit VIb polypeptide 1) 81404
COX10 (COX10 homolog, cytochrome c oxidase assembly protein) 81405
COX15 (COX15 homolog, cytochrome c oxidase assembly protein) 81405
CPOX (coproporphyrinogen oxidase) 81405
CPT1A (carnitine palmitoyltransferase 1A [liver]) 81406
CPT2 (carnitine palmitoyltransferase 2) 81404
CRB1 (crumbs homolog 1 [Drosophila]) 81406
CREBBP (CREB binding protein) 81406, 81407
CRX (cone-rod homeobox) 81404
CSTB (cystatin B) 81188-81190
CTNNB1 (catenin [cadherin-associated protein], beta 1, 88kDa) 81403
CTRC (chymotrypsin C) (eg, hereditary pancreatitis) 81405
CYP1B1 (cytochrome P450, family 1, subfamily B, polypeptide 1) 81404
CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) 81227
CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) 81225
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) 81226
CYP3A4 (cytochrome P450, family 3, subfamily A member 4) 81230
CYP3A5 (cytochrome P450, family 3, subfamily A member 5) 81231
CYP11B1 (cytochrome P450, family 11, subfamily B, polypeptide 1) 81405
CYP17A1 (cytochrome P450, family 17, subfamily A, polypeptide 1) 81405
CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) 81402, 81405
DAZ/SRY (deleted in azoospermia and sex determining region Y) 81403
DBT (dihydrolipoamide branched chain transacylase E2) 81405, 81406
DCX (doublecortin) 81405
DEK/NUP214 (t(6;9)) 81401
DES (desmin) 81405
DFNB59 (deafness, autosomal recessive 59) 81405
DGUOK (deoxyguanosine kinase) 81405
DHCR7 (7-dehydrocholesterol reductase) 81405
DLAT (dihydrolipoamide S-acetyltransferase) 81406
DLD (dihydrolipoamide dehydrogenase) 81406
DMD (dystrophin) 81161, 81408
DMPK (DM1 protein kinase) 81234, 81239
DNMT3A (DNA [cytosine-5-]-methyltransferase 3 alpha) 81403
DPYD (dihydropyrimidine dehydrogenase) 81232
DSC2 (desmocollin) 81406
DSG2 (desmoglein 2) 81406
DSP (desmoplakin) 81406
DYSF (dysferlin, limb girdle muscular dystrophy 2B [autosomal recessive]) 81408
E2A/PBX1 (t(1;19)) 81401
EFHC1 (EF-hand domain [C terminal] containing 1) 81406
EGFR (epidermal growth factor receptor) 81235
EGR2 (early growth response 2) 81404
EIF2B2 (eukaryotic translation initiation factor 2B, subunit 2 beta, 39kDa) 81405
EIF2B3 (eukaryotic translation initiation factor 2B, subunit 3 gamma, 58kDa) 81406
EIF2B4 (eukaryotic translation initiation factor 2B, subunit 4 delta, 67kDa) 81406
EIF2B5 (eukaryotic translation initiation factor 2B, subunit 5 epsilon, 82kDa) 81406
EMD (emerin) 81404, 81405
EML4/ALK (inv(2)) 81401
ENG (endoglin) 81405, 81406
EPCAM (epithelial cell adhesion molecule) 81403
EPM2A (epilepsy, progressive myoclonus type 2A, Lafora disease [laforin]) 81404
ESR1/PGR (receptor 1/progesterone receptor) 81402
ETV6/RUNX1 (t(12;21)) 81401
EWSR1/ATF1 (t1(2;22)) 81401
EWSR1/ERG (t(21;22)) 81401
EWSR1/FLI1 (t(11;22)) 81401
EWSR1/WT1 (t(11;22)) 81401
EYA1 (eyes absent homolog 1 [Drosophila]) 81405, 81406
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) 81236, 81237
F2 (prothrombin, coagulation factor II) 81240, 81400
F5 (coagulation factor V) 81241, 81400
F7 (coagulation factor VII [serum prothrombin conversion accelerator]) 81400
F8 (coagulation factor VIII) 81403, 81406, 81407
F9 (coagulation factor IX) 81238
F11 (coagulation factor XI) 81401
F12 (coagulation factor XII [Hageman factor]) 81403
F13B (coagulation factor XIII, B polypeptide) 81400
FAH (fumarylacetoacetate hydrolase [fumarylacetoacetase]) 81406
FANCC (Fanconi anemia, complementation group C) 81242
FASTKD2 (FAST kinase domains 2) 81406
FBN1 (fibrillin 1) 81408
FGB (fibrinogen beta chain) 81400
FGF23 (fibroblast growth factor 23) 81404
FGFR1 (fibroblast growth factor receptor 1) 81400, 81405
FGFR2 (fibroblast growth factor receptor 2) 81404
FGFR3 (fibroblast growth factor receptor 3) 81400, 81401, 81403, 81404
FH (fumarate hydratase) 81405
FHL1 (four and a half LIM domains 1) 81404
FIG4 (FIG4 homolog, SAC1 lipid phosphatase domain containing [S. cerevisiae]) 81406
FIP1L1/PDGFRA (del(4q12)) 81401
FKRP (fukutin related protein) 81404
FKTN (fukutin) 81400, 81405
FLG (filaggrin) 81401
FLT3 (fms-related tyrosine kinase 3) 81245, 81246
FMR1 (fragile X mental retardation 1) 81243, 81244
FOXG1 (forkhead box G1) 81404
FOXO1/PAX3 (t(2;13)) 81401
FOXO1/PAX7 (t(1;13)) 81401
FSHMD1A (facioscapulohumeral muscular dystrophy 1A) 81404
FTSJ1 (FtsJ RNA methyltransferase homolog 1 [E. coli]) 81405, 81406
FUS (fused in sarcoma) 81406
FUS/DDIT3 (t(12;16)) 81401
FXN (frataxin) 81284-81286, 81289
G6PC (glucose-6-phosphatase, catalytic subunit) 81250
G6PD (glucose-6-phosphate dehydrogenase) 81247-81249
GAA (glucosidase, alpha; acid) 81406
GABRG2 (gamma-aminobutyric acid [GABA] A receptor, gamma 2) 81405
GALC (galactosylceramidase) 81401, 81406
GALT (galactose-1-phosphate uridylyltransferase) 81401, 81406
GARS (glycyl-tRNA synthetase) 81406
GBA (glucosidase, beta, acid) 81251
GCDH (glutaryl-CoA dehydrogenase) 81406
GCH1 (GTP cyclohydrolase 1) 81405
GCK (glucokinase [hexokinase 4]) 81406
GDAP1 (ganglioside-induced differentiation-associated protein 1) 81405
GFAP (glial fibrillary acidic protein) 81405
GH1 (growth hormone 1) 81404
GHR (growth hormone receptor) 81405
GHRHR (growth hormone releasing hormone receptor) 81405
GJB1 (gap junction protein, beta 1) 81403
GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) 81252, 81253
GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) 81254
GLA (galactosidase, alpha) 81405
GLUD1 (glutamate dehydrogenase 1) 81406
GNAQ (guanine nucleotide-binding protein G[q] subunit alpha) 81403
GNE (glucosamine [UDP-N-acetyl]-2-epimerase/N-acetylmannosamine kinase) 81400, 81406
GP1BB (glycoprotein Ib [platelet], beta polypeptide) 81404
GRN (granulin) 81406
H19 (imprinted maternally expressed transcript [non-protein coding]) 81401
HADHA (hydroxyacyl-CoA dehydrogenase/3-ketoacyl-CoA thiolase/enoyl-CoA hydratase
[trifunctional protein] alpha subunit) 81406
HADHB (hydroxyacyl-CoA dehydrogenase/3 ketoacyl-CoA thiolase/enoyl-CoA hydratase
[trifunctional protein], beta subunit) 81406
HBA1/HBA2 (alpha globin 1 and alpha globin 2) 81257-81259, 81269
HBB (hemoglobin, beta, beta-Globin) 81361-81364
HEXA (hexosaminidase A [alpha polypeptide]) 81255, 81406
HFE (hemochromatosis) 81256
HLA Class I and II Typing, High Resolution 81378
HLA Class I and II Typing, Low Resolution 81370, 81371
HLA Class I Typing, High Resolution 81379-81381
HLA Class I Typing, Low Resolution 81372-81374
HLA Class II Typing, High Resolution 81382, 81383
HLA Class II Typing, Low Resolution 81375-81377
HLCS (HLCS holocarboxylase synthetase) 81406
HMBS (hydroxymethylbilane synthase) 81406
HNF1A (HNF1 homeobox A) 81405
HNF1B (HNF1 homeobox B) 81404, 81405
HNF4A (hepatocyte nuclear factor 4, alpha) 81406
HPA (Human Platelet Antigen) 81105-81112
HRAS (v-Ha-ras Harvey rat sarcoma viral oncogene homolog) 81403, 81404
HSD3B2 (hydroxyl-delta-5-steroid dehydrogenase, 3 beta- and steroid-delta isomerase 2) 81404
HSD11B2 (hydroxysteroid [11-beta] dehydrogenase 2) 81404
HSPB1 (heat shock 27kDa protein 1) 81404
HTRA1 (HtrA serine peptidase 1) 81405
HTT (huntingtin) 81271, 81274
Human Erythrocyte Antigen 81403
Human Platelet Antigen 1 (HPA-1) 81105
Human Platelet Antigen 6 (HPA-6w) 81110
Human Platelet Antigen 9 (HPA-9w) 81111
IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) 81120
IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) 81121
IDS (iduronate 2-sulfatase) 81405
IDUA (iduronidase, alpha L-) 81406
IFNL3 (interferon, lambda 3) 81283
IGH@ (immunoglobulin heavy chain locus) 81261-81263
IGH@/BCL2 (t(14;18)) 81278, 81401
IGK@ (immunoglobulin kappa light chain locus) 81264
IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase complex-associated
protein) 81260
IL2RG (interleukin 2 receptor, gamma) 81405
INF2 (inverted formin, FH2 and WH2 domain containing) 81406
INS (insulin) 81404
ISPD (isoprenoid synthase domain containing) 81405
ITPR1 (inositol 1,4,5-trisphosphate receptor, type 1) 81408
IVD (isovaleryl-CoA dehydrogenase) 81400, 81406
JAG1 (jagged 1) 81406, 81407
JAK2 (Janus kinase 2) 81270, 81279
JUP (junction plakoglobin) 81406
KCNC3 (potassium voltage-gated channel, Shaw-related subfamily, member 3) 81403
KCNH2 (potassium voltage-gated channel, subfamily H [eag-related], member 2) 81406
KCNJ1 (potassium inwardly-rectifying channel, subfamily J, member 1) 81404
KCNQ1 (potassium voltage-gated channel, KQT-like subfamily, member 1) 81406
KCNQ1OT1 (KCNQ1 overlapping transcript 1 [non-protein coding]) 81401
KCNQ2 (potassium voltage-gated channel, KQT-like subfamily, member 2) 81406
KDM5C (lysine [K]-specific demethylase 5C) 81407
KIAA0196 (KIAA0196) 81407
Killer cell immunoglobulin-like receptor (KIR) gene family 81403
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) 81272, 81273
Known familial variant not otherwise specified 81403
KRAS (Kirsten rat sarcoma viral oncogene homolog) 81275, 81276, 81405
L1CAM (L1 cell adhesion molecule) 81407
LAMA2 (laminin, alpha 2) 81408
LAMB2 (laminin, beta 2 [laminin S]) 81407
LAMP2 (lysosomal-associated membrane protein 2) 81405
LCT (lactase-phlorizin hydrolase) 81400
LDB3 (LIM domain binding 3) 81406
LDLR (low density lipoprotein receptor) 81405, 81406
LEPR (leptin receptor) 81406
LHCGR (luteinizing hormone/choriogonadotropin receptor) 81406
LINC00518 (long intergenic non-protein coding RNA 518) 81401
LITAF (lipopolysaccharide-induced TNF factor) 81404
LMNA (lamin A/C) 81406
LRP5 (low density lipoprotein receptor-related protein 5) 81406
LRRK2 (leucine-rich repeat kinase 2) 81401, 81408
MAP2K1 (mitogen-activated protein kinase 1) 81406
MAP2K2 (mitogen-activated protein kinase 2) 81406
MAPT (microtubule-associated protein tau) 81406
MC4R (melanocortin 4 receptor) 81403
MCCC1 (methylcrotonoyl-CoA carboxylase 1 [alpha]) 81406
MCCC2 (methylcrotonoyl-CoA carboxylase 2 [beta]) 81406
MCOLN1 (mucolipin 1) 81290
MECP2 (methyl CpG binding protein 2 [Rett syndrome]) 81302-81304
MED12 (mediator complex subunit 12) 81401
MEFV (Mediterranean fever) 81402, 81404
MEG3/DLK1 (maternally expressed 3 [non-protein coding]/delta-like 1 homolog [Drosophila])
81401
MEN1 (multiple endocrine neoplasia I) 81404, 81405
MFN2 (mitofusin 2) 81406
MGMT (O-6-methylguanine-DNA methyltransferase) 81287
MICA (MHC class I polypeptide-related sequence A) 81403
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) 81288, 81292-81294
MLL/AFF1 (t(4;11)) 81401
MLL/MLLT3 (t(9;11)) 81401
MMAA (methylmalonic aciduria [cobalamine deficiency] type A) 81405
MMAB (methylmalonic aciduria [cobalamine deficiency] type B) 81405
MMACHC (methylmalonic aciduria [cobalamin deficiency] cblC type, with homocystinuria) 81404
MPI (mannose phosphate isomerase) 81405
MPL (MPL proto-oncogene, thrombopoietin receptor) 81338, 81339
MPV17 (MpV17 mitochondrial inner membrane protein) 81404, 81405
MPZ (myelin protein zero) 81405
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) 81295-81297
MSH6 (mutS homolog 6 [E. coli]) 81298-81300
MT-ATP6 (mitochondrially encoded ATP synthase 6) 81401
MTHFR (5, 10-methylenetetrahydrofolate reductase) 81291
MTM1 (myotubularin 1) 81405, 81406
MT-ND4, MT-ND6 (mitochondrially encoded NADH dehydrogenase 4, mitochondrially encoded
NADH dehydrogenase 6) 81401
MT-RNR1 (mitochondrially encoded 12S RNA) 81401, 81403
MT-TK (mitochondrially encoded tRNA lysine) 81401
MT-TL1 (mitochondrially encoded tRNA leucine 1 [UUA/G]) 81401
MT-TL1, MT-ND5 (mitochondrially encoded tRNA leucine 1 [UUA/G], mitochondrially encoded
NADH dehydrogenase 5) 81401
MT-TS1 (mitochondrially encoded tRNA serine 1) 81403
MT-TS1, MT-RNR1 (mitochondrially encoded tRNA serine 1 [UCN], mitochondrially encoded 12S
RNA) 81401
MUT (methylmalonyl CoA mutase) 81406
MUTYH (mutY homolog [E. coli]) 81401, 81406
MYBPC3 (myosin binding protein C, cardiac) 81407
MYD88 (myeloid differentiation primary response 88) 81305
MYH6 (myosin, heavy chain 6, cardiac muscle, alpha) 81407
MYH7 (myosin, heavy chain 7, cardiac muscle, beta) 81407
MYH11 (myosin, heavy chain 11, smooth muscle) 81408
MYL2 (myosin, light chain 2, regulatory, cardiac, slow) 81405
MYL3 (myosin, light chain 3, alkali, ventricular, skeletal, slow) 81405
MYO7A (myosin VIIA) 81407
MYOT (myotilin) 81405
NDP (Norrie disease [pseudoglioma]) 81403, 81404
NDUFA1 (NADH dehydrogenase [ubiquinone] 1 alpha subcomplex, 1, 7.5kDa) 81404
NDUFAF2 (NADH dehydrogenase [ubiquinone] 1 alpha subcomplex, assembly factor 2) 81404
NDUFS1 (NADH dehydrogenase [ubiquinone] Fe-S protein 1, 75kDa [NADH-coenzyme Q
reductase]) 81406
reductase]) 81404
reductase]) 81405
reductase]) 81405
NDUFV1 (NADH dehydrogenase [ubiquinone] flavoprotein 1, 51kDa) 81405
NEB (nebulin) 81400, 81408
NEFL (neurofilament, light polypeptide) 81405
Neoplasia 81277, 81406
NF1 (neurofibromin 1) 81408
NF2 (neurofibromin 2 [merlin]) 81405, 81406
NHLRC1 (NHL repeat containing 1) 81403
NIPA1 (non-imprinted in Prader-Willi/Angelman syndrome 1) 81404
NLGN3 (neuroligin 3) 81405
NLGN4X (neuroligin 4, X-linked) 81404, 81405
NOD2 (nucleotide-binding oligomerization domain containing 2) 81401
NOTCH1 (notch 1) 81407
NOTCH3 (notch 3) 81406
NPC1 (Niemann-Pick disease, type C1) 81406
NPC2 (Niemann-Pick disease, type C2 [epididymal secretory protein E1]) 81404
NPHP1 (nephronophthisis 1 [juvenile]) 81405, 81406
NPHS1 (nephrosis 1, congenital, Finnish type [nephrin]) 81407
NPHS2 (nephrosis 2, idiopathic, steroid resistant [podocin]) 81405
NPM1 (nucleophosmin [nucleolar phosphoprotein B23, numatrin]) 81310
NPM1/ALK (t(2;5)) 81401
NR0B1 (nuclear receptor subfamily 0, group B, member 1) 81404
NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) 81311
NSD1 (nuclear receptor binding SET domain protein 1) 81405, 81406
NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) 81194
NTRK1 (neurotrophic receptor tyrosine kinase 1) 81191
NUDT15 (nudix hydrolase 15) 81306
OPA1 (optic atrophy 1) 81406, 81407
OPTN (optineurin) 81406
OTC (ornithine carbamoyltransferase) 81405
PABPN1 (poly[A] binding protein nuclear 1) 81312
PAFAH1B1 (platelet-activating factor acetylhydrolase 1b, regulatory subunit 1 [45kDa]) 81405,
81406
PAH (phenylalanine hydroxylase) 81406
PALB2 (partner and localizer of BRCA2) 81307, 81308
PARK2 (Parkinson protein 2, E3 ubiquitin protein ligase [parkin]) 81405, 81406
PAX2 (paired box 2) 81406
PAX8/PPARG (t(2;3) (q13;p25)) 81401
PC (pyruvate carboxylase) 81406
PCA3/KLK3 (prostate cancer antigen 3 [non_protein coding]/kallikrein_related peptidase 3
[prostate specific antigen]) 81313
PCCA (propionyl CoA carboxylase, alpha polypeptide) 81405, 81406
PCCB (propionyl CoA carboxylase, beta polypeptide) 81406
PCDH15 (protocadherin-related 15) 81400, 81406, 81407
PCDH19 (protocadherin 19) 81405
PCSK9 (proprotein convertase subtilisin/kevin type 9) 81406
PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) 81314
PDHA1 (pyruvate dehydrogenase [lipoamide] alpha 1) 81405, 81406
PDHB (pyruvate dehydrogenase [lipoamide] beta) 81405
PDHX (pyruvate dehydrogenase complex, component X) 81406
PDX1 (pancreatic and duodenal homeobox 1) 81404
PHEX (phosphate regulating endopeptidase homolog, X-linked) 81406
PHOX2B (paired-like homeobox 2b) 81403, 81404
PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) 81309
PINK1 (PTEN induced putative kinase 1) 81405
PKD1 (polycystic kidney disease 1 [autosomal dominant]) 81407
PKD2 (polycystic kidney disease 2 [autosomal dominant]) 81406
PKHD1 (polycystic kidney and hepatic disease 1) 81408
PKLR (pyruvate kinase, liver and RBC) (eg, pyruvate kinase deficiency) 81405
PKP2 (plakophilin 2) 81406
PLCE1 (phospholipase C, epsilon 1) 81407
PLCG2 (phospholipase C gamma 2) 81320
PLN (phospholamban) 81403
PLP1 (proteolipid protein 1) 81404, 81405
PML/RARalpha, (t(15;17)) (promyelocytic leukemia/retinoic acid receptor alpha) 81315, 81316
PMP22 (peripheral myelin protein 22) 81324-81326
PMS2 (PMS2 postmeiotic segregation increased 2 [S. cerevisiae]) 81317-81319
PNKD (paroxysmal nonkinesigenic dyskinesia) 81406
POLG (polymerase [DNA directed], gamma) 81406
POMGNT1 (protein O-linked mannose beta1, 2-N-acetylglucosaminyltransferase) 81406
POMT1 (protein-O-mannosyltransferase 1) 81406
POMT2 (protein-O-mannosyltransferase 2) 81406
POU1F1 (POU class 1 homeobox 1) 81405
PPOX (protoporphyrinogen oxidase) 81406
PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) 81343
PQBP1 (polyglutamine binding protein 1) 81404, 81405
PRAME (preferentially expressed antigen in melanoma) 81401
PRKAG2 (protein kinase, AMP-activated, gamma 2 non-catalytic subunit) 81406
PRKCG (protein kinase C, gamma) 81406
PRNP (prion protein) 81404
PROP1 (PROP paired-like homeobox 1) 81404
PRPH2 (peripherin 2 [retinal degeneration, slow]) 81404
PRSS1 (protease, serine, 1 [trypsin 1]) 81401, 81404
PRX (periaxin) 81405
PSEN1 (presenilin 1) 81405
PSEN2 (presenilin 2 [Alzheimer disease 4]) 81406
PTEN (phosphatase and tensin homolog) 81321-81323
PTPN11 (protein tyrosine phosphatase, non-receptor type 11) 81406
PYGM (phosphorylase, glycogen, muscle) 81401, 81406
RAB7A (RAB7A, member RAS oncogene family) 81405
RAF1 (v-raf-1 murine leukemia viral oncogene homolog 1) 81404, 81406
RAI1 (retinoic acid induced 1) 81405
REEP1 (receptor accessory protein 1) 81405
RET (ret proto-oncogene) 81404-81406
RHD (Rh blood group, D antigen) 81403
RHO (rhodopsin) 81404
RP1 (retinitis pigmentosa 1) 81404
RPE65 (retinal pigment epithelium specific protein 65kDa) 81406
RPS19 (ribosomal protein S19) 81405
RRM2B (ribonucleotide reductase M2 B [TP53 inducible]) 81405
RUNX1 (runt related transcription factor 1) 81334
RUNX1/RUNX1T1(t(8;21)) 81401
RYR1 (ryanodine receptor 1, skeletal) 81406, 81408
RYR2 (ryanodine receptor 2 [cardiac]) 81408
SCN1A (sodium channel, voltage-gated, type I, alpha subunit) 81407
SCN1B (sodium channel, voltage-gated, type I, beta) 81404
SCN4A (sodium channel, voltage-gated, type IV, alpha subunit) 81406
SCN5A (sodium channel, voltage-gated, type V, alpha subunit) 81407
SCNN1A (sodium channel, nonvoltage-gated 1 alpha) 81406
SCNN1B (sodium channel, nonvoltage-gated 1, beta) 81406
SCNN1G (sodium channel, nonvoltage-gated 1, gamma) 81406
SCO1 (SCO cytochrome oxidase deficient homolog 1) 81405
SCO2 (SCO cytochrome oxidase deficient homolog 2 [SCO1L]) 81404
SDHA (succinate dehydrogenase complex, subunit A, flavoprotein [Fp]) 81406
SDHB (succinate dehydrogenase complex, subunit B, iron sulfur) 81405
SDHC (succinate dehydrogenase complex, subunit C, integral membrane protein, 15kDa) 81404,
81405
SDHD (succinate dehydrogenase complex, subunit D, integral membrane protein) 81404
SEPT9 (Septin9) 81327
SERPINA1 (serpin peptidase inhibitor, clade A [alpha-1 antiproteinase, antitrypsin], member 1)
81332
SERPINE1 (serpine peptidase inhibitor clade E, member 1, plasminogen activator inhibitor 1, PAI 1)
81400
SETX (senataxin) 81406
SF3B1 (splicing factor [3b] subunit B1) 81347
SGCA (sarcoglycan, alpha [50kDa dystrophin-associated glycoprotein]) 81405
SGCB (sarcoglycan, beta [43kDa dystrophin-associated glycoprotein]) 81405
SGCD (sarcoglycan, delta [35kDa dystrophin-associated glycoprotein]) 81405
SGCE (sarcoglycan, epsilon) 81405, 81406
SGCG (sarcoglycan, gamma [35kDa dystrophin-associated glycoprotein]) 81404, 81405
SH2D1A (SH2 domain containing 1A) 81403, 81404
SH3TC2 (SH3 domain and tetratricopeptide repeats 2) 81406
SHOC2 (soc-2 suppressor of clear homolog) 81400, 81405
SHOX (short stature homeobox) 81405
SIL1 (SIL1 homolog, endoplasmic reticulum chaperone [S. cerevisiae]) 81405
SLC2A1 (solute carrier family 2 [facilitated glucose transporter], member 1) 81405
SLC9A6 (solute carrier family 9 [sodium/hydrogen exchanger], member 6) 81406
SLC12A1 (solute carrier family 12 [sodium/potassium/chloride transporters], member 1) 81407
SLC12A3 (solute carrier family 12 [sodium/chloride transporters], member 3) 81407
SLC16A2 (solute carrier family 16, member 2 [thyroid hormone transporter]) 81404, 81405
SLC22A5 (solute carrier family 22 [organic cation/carnitine transporter], member 5) 81405
SLC25A4 (solute carrier family 25 [mitochondrial carrier; adenine nucleotide translocator], member
4) 81404
SLC25A20 (solute carrier family 25 [carnitine/acylcarnitine translocase], member 20) 81404, 81405
SLC26A4 (solute carrier family 26, member 4) 81406
SLC37A4 (solute carrier family 37 [glucose-6-phosphate transporter], member 4) 81406
SLCO1B1 (solute carrier organic anion transporter family, member 1B1) 81328
SMAD4 (SMAD family member 4) 81405, 81406
SMN1 (survival of motor neuron 1, telomeric) 81329, 81336, 81337
SMN2 (survival of motor neuron 2, centromeric) 81329, 81336, 81337
SMPD1 (sphingomyelin phosphodiesterase 1, acid lysosomal) 81330
SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N/ubiquitin protein ligase E3A) 81331
SOD1 (superoxide dismutase 1, soluble) 81404
SOS1 (son of sevenless homolog 1) 81406
SPAST (spastin) 81405, 81406
SPG7 (spastic paraplegia 7 [pure and complicated autosomal recessive]) 81405, 81406
SPG11 (spastic paraplegia 11 [autosomal recessive]) 81407
SPINK1 (serine peptidase inhibitor, Kazal type 1) 81404
SPRED1 (sprouty-related, EVH1 domain containing 1) 81405
SPTBN2 (spectrin, beta, non-erythrocytic 2) 81407
SRSF2 (serine and arginine-rich splicing factor 2) 81348
SRY (sex determining region Y) 81400
SS18/SSX1 (t(X;18)) 81401
SS18/SSX2 (t(X;18)) 81401
STAT3 (signal transducer and activator of transcription 3 [acute-phase response factor]) 81405
STK11 (serine/threonine kinase 11) 81404, 81405
STXBP1 (syntaxin binding protein 1) 81406
SURF1 (surfeit 1) 81405
TACO1 (translational activator of mitochondrial encoded cytochrome c oxidase I) 81404
TARDBP (TAR DNA binding protein) 81405
TAZ (tafazzin) 81406
TBP (TATA box binding protein) 81344
TBX5 (T-box 5) 81405
TCF4 (transcription factor 4) 81405, 81406
TERT (telomerase reverse transcriptase) 81345
TGFBI (transforming growth factor beta-induced) 81333
TGFBR1 (transforming growth factor, beta receptor 1) 81405
TGFBR2 (transforming growth factor, beta receptor 2) 81405
TH (tyrosine hydroxylase) 81406
THAP1 (THAP domain containing, apoptosis associated protein 1) 81404
THRB (thyroid hormone receptor, beta) 81405
TK2 (thymidine kinase 2, mitochondrial) 81405
TMEM43 (transmembrane protein 43) 81406
TMEM67 (transmembrane protein 67) 81407
TNNC1 (troponin C type 1 [slow]) 81405
TNNI3 (troponin I, type 3 [cardiac]) 81405
TNNT2 (troponin T, type 2 [cardiac]) 81406
TOR1A (torsin family 1, member A [torsin A]) 81400, 81404
TP53 (tumor protein 53) 81351-81353
TPM1 (tropomyosin 1 [alpha]) 81405
TPMT (thiopurine S-methyltransferase) 81335
TRB@ (T cell receptor beta locus) 81340, 81341
TRD@ (T cell antigen receptor, delta) Rearrangement 81402
TRG@ (T cell receptor gamma locus) 81342
TRPC6 (transient receptor potential cation channel, subfamily C, member 6) 81406
TSC1 (tuberous sclerosis 1) 81405, 81406
TSC2 (tuberous sclerosis 2) 81406, 81407
TTPA (tocopherol [alpha] transfer protein) 81404
TTR (transthyretin) 81404
TWIST1 (twist homolog 1 [Drosophila]) 81403, 81404
TYMP (thymidine phosphorylase) 81405
TYMS (thymidylate synthetase) 81346
TYR (tyrosinase [oculocutaneous albinism IA]) 81404
U2AF1 (U2 small nuclear RNA auxiliary factor 1) 81357
UBA1 (ubiquitin-like modifier activating enzyme 1) 81403
UBE3A (ubiquitin protein ligase E3A) 81406
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) 81350
UMOD (uromodulin) 81406
Uniparental disomy (UPD) 81402
USH1C (Usher syndrome 1C [autosomal recessive, severe]) 81407
USH1G (Usher syndrome 1G [autosomal recessive]) 81404
USH2A (Usher syndrome 2A [autosomal recessive, mild]) 81408
VHL (von Hippel-Lindau tumor suppressor) 81403, 81404
VKORC1 (vitamin K epoxide reductase complex, subunit 1) 81355
VPS13B (vacuolar protein sorting 13 homolog B [yeast]) 81407, 81408
VWF (von Willebrand factor) 81401, 81403-81406, 81408
WAS (Wiskott-Aldrich syndrome [eczema-thrombocytopenia]) 81406
WDR62 (WD repeat domain 62) 81407
WT1 (Wilms tumor 1) 81405
ZEB2 (zinc finger E-box binding homeobox 2) 81404, 81405
ZNF41 (zinc finger protein 41) 81404
ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) 81360
Chimerism Analysis 81267, 81268
Comparative Analysis Using Short Tandem Repeat (STR) Markers 81265, 81266
Cytogenomic Constitutional Targeted Microarray Analysis
Chromosome 22q13 81405
Cytogenomic Microarray Analysis, Neoplasia 81406
Human Platelet Antigen Genotyping 81105-81112
Microsatellite Instability Analysis 81301
Short Tandem Repeat (STR) Analysis 81265, 81266, 81402
Translocation Analysis
BCR/ABL1 (t(9;22)) 81206-81208
CCND1/IGH (t(11;14)) 81168
COL1A1/PDGFB (t(17;22)) 81402
E2A/PBX1 (t(1;19)) 81401
EML4/ALK (inv(2)) 81401
ETV6/RUNX1 (t(12;21)) 81401
EWSR1/ATF1 (t(12;22)) 81401
EWSR1/ERG (t(21;22) 81401
EWSR1/FLI1 (t(11;22)) 81401
EWSR1/WT1 (t(11;22)) 81401
FOXO1/PAX3 (t(2;13)) 81401
FOXO1/PAX7 (t(1;13)) 81401
FUS/DDIT3 (t(12;16)) 81401
IGH@/BCL2 (t(14;18) 81278
MLL/AFF1 (t(4;11)) 81401
MLL/MLLT3 (t(9;11)) 81401
NPM1/ALK (t(2;5)) 81401
NTRK 81194
NTRK1 81191
NTRK2 81192
NTRK3 81193
PAX8/PPARG (t(2;3)) (q13;p25)) 81401
PML/RARalpha (t(15;17)) 81315, 81316
RUNX1/RUNX1T1 (t(8;21)) 81401
SS18/SSX1 (t(X;18)) 81401
SS18/SSX2 (t(X;18)) 81401
Gene Product
See Protein
Genioplasty
Augmentation 21120, 21123
Genitourinary Sphincter, Artificial

See Prosthesis, Urethral Sphincter
Genomic Sequencing Procedures (GSPs)

Acute Myelogenous Leukemia 0023U
Aortic Dysfunction or Dilation 81410, 81411
Ashkenazi Jewish Associated Disorders 81412
Cardiac Ion Channelopathies 81413, 81414
COMT (catechol-O-methyltransferase) 0032U
CYP1A2 (cytochrome P450 family 1, subfamily A, member 2) 0031U
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) 0070U
Drug Metabolism 0029U, 0030U
Epilepsy 81419
Exome 0036U, 81415-81417
Fetal Chromosomal Aneuploidy 81420
Fetal Chromosomal Microdeletion(s) 81422
Gene Rearrangement Detection 0012U
Genome 81425-81427
Germline Disorders 0012U
Hearing Loss 81430, 81431
Helicobacter Pylori Detection and Antibiotic Resistance 0008U
Hematolymphoid Neoplasia 0014U, 0016U, 0017U
Hereditary Breast Cancer-Related Disorders 81432, 81433
Hereditary Cardiomyopathy 81439
Hereditary Colon Cancer Disorders 81435, 81436
Hereditary Neuroendocrine Tumor Disorders 81437, 81438
Hereditary Peripheral Neuropathies 81448
Hereditary Retinal Disorders 81434
HTR2A (5-hydroxytryptamine receptor 2A) 0033U
HTR2C (5-hydroxytryptamine receptor 2C) 0033U
JAK2 (Janus kinase 2) 0027U
Non-small Cell Lung Neoplasia 0022U
Noonan Spectrum Disorders 81442
Nuclear Encoded Mitochondrial Genes 81440
NUDT15 (nudix hydroxlase 15) 0034U
Severe Inherited Conditions 81443
Solid Organ Neoplasia 0013U, 0037U
Targeted Genomic Sequence Analysis Panel 81445, 81450, 81455
Thyroid DNA and RNA 0026U
TPMT (thiopurine S-methyltransferase) 0034U
Whole Mitochondrial Genome 81460, 81465
X-linked Intellectual Disability (XLID) 81470, 81471
Genotype Analysis
Human Platelet Antigen 81105-81112
by Nucleic Acid
Hepatitis C Virus 87902
HIV-1 87901, 87906
Protease/Reverse Transcriptase Regions 87901
Vancomycin Resistance 87500
Gentamicin
Assay 80170
Gentamycin Level
Gentamicin 80170
Gentiobiase 82963
Genus: Human Cytomegalovirus Group
See Cytomegalovirus
GERD
Gastroesophageal Reflux Test 91034, 91035, 91037, 91038
German Measles
See Rubella
Gestational Trophoblastic Tumor
GGT
Gamma Glutamyl Transferase 82977
GI Tract
Giardia
Antigen Detection
Immunoassay 87329
Giardia Lamblia
Antibody 86674
Gibbons Stent
Ureteral 52332
GIF
Somatostatin 84307
GIFT
Gamete Intrafallopian Transfer 58976
Gill Operation
Laminectomy 63012
Gillies Approach
Fracture
Zygomatic Arch 21356
Gingiva
See Gums
Gingiva, Abscess
Gingivectomy
Each Quadrant 41820
Gingivoplasty
Each Quadrant 41872
Girdlestone Procedure
Acetabulum Resection, Femoral Head 27122
Gla Protein (Bone)
Osteocalcin 83937
Gland, Adrenal
See Adrenal Gland
Gland, Bartholin’s
See Bartholin’s Gland
Gland, Bulbourethral
See Bulbourethral Gland
Gland, Lacrimal
See Lacrimal Gland
Gland, Mammary
See Breast
Gland, Parathyroid
See Parathyroid Gland
Gland, Parotid
See Parotid Gland
Gland, Pituitary
See Pituitary Gland
Gland, Salivary
See Salivary Gland
Gland, Sublingual
See Sublingual Gland
Gland, Sweat
See Sweat Glands, Excision
Gland, Thymus
See Thymus Gland
Gland, Thyroid
See Thyroid Gland
Glasses
Glaucoma
Counseling 4174F
Cryotherapy 66720
Diathermy 66700
Filtration Implant
See Aqueous Shunt
Fistulization of Sclera
Sclerectomy 66160
Through Ciliary Body 66999
Trabeculectomy ab externo 66170, 66172
Trephination 66150
Genetic Analysis 81404
Iridectomy 66150, 66155, 66160, 66625, 66630, 66761
Plan of Care 0517F
Visual Evoked Potential 0464T
Glaucoma Drainage Implant

See Aqueous Shunt
Glenn Procedure 33766, 33767
Glenohumeral Joint
Arthroplasty 23470, 23472-23474
Arthrotomy 23040
with Biopsy 23100
with Drainage 23040
with Exploration 23040, 23107
with Synovectomy 23105
Capsulorrhaphy 23465, 23466
Removal
Foreign or Loose Body 23040, 23107
Glenoid Fossa
Allograft 23473, 23474
Arthroplasty 23473, 23474
Globulin
Antihuman
Coombs Test
Direct 86880, 86885, 86886
Indirect 86850, 86870
Immune
Administration 96365-96368
Product
Botulinum Antitoxin 90288
Botulism 90288
Cytomegalovirus (CMV-IgIV) 90291
Diphtheria Antitoxin 90296
Gammaglobulin 82784, 82785
Hepatitis B (HBIg) 90371
Ig 90281
IgIV 90283
Rabies (RIg) 90375
Rabies (RIg-HT) 90376
Rabies (RIg-HT S/D) 90377
Rho(D) (RhIg/RhIgIV) 90384-90386
SCIg 90284
Tetanus (TIg) 90389
Unlisted 90399
Vaccinia 90393
Varicella-zoster 90396
Sex Hormone Binding 84270
Globulin, Corticosteroid-Binding
Transcortin 84449
Globulin, Rh Immune
Globulin, Thyroxine-Binding
Thyroxine Binding Globulin 84442
Glomerular Filtration Rate (GFR)
Measurement 0602T
Monitoring 0603T
Glomerular Procoagulant Activity

See Thromboplastin
Glomus Caroticum
Carotid Body Tumor Excision 60600-60605
Glossectomy
Complete 41140, 41145
Composite 41150, 41153, 41155
Partial 41135
Half 41130
Less than Half 41120
Glossopexy
Glossorrhaphy
Glucagon
Measurement 82943
Tolerance Panel 80422, 80424
Tolerance Test 82946
Glucose
Blood Test 82947, 82948, 82950
Home Test 82962
Body Fluid 82945
Interstitial Fluid
Continuous Monitoring 95249-95251
Data Interpretation 99091
Panel
Glucagon Tolerance 80422, 80424
Growth Hormone Suppression 80430
Insulin Tolerance 80434, 80435
Insulin-induced C-peptide Suppression 80432
Sensor
Insertion
Subcutaneous Pocket 0446T, 0448T
Tolerance Test 82951, 82952
Intravenous Push 96374
Urinalysis 81000-81003, 81005
Glucose Phosphate Isomerase

Phosphohexose Isomerase 84087
Glucose-6-Phosphate
Dehydrogenase 82955-82960
Glucosidase 82963
Glucuronide Androstanediol 82154
Glue
Anal Fistula Repair 46706
Bronchoscopy
Balloon Occlusion 31634
Cornea Wound 65286
Sclera Wound 65286
Glukagon
See Glucagon
Glutamate Dehydrogenase
Blood 82965
Glutamate Pyruvate Transaminase 84460
Glutamic Alanine Transaminase
Glutamic-Pyruvic Transaminase 84460
Glutamic Aspartic Transaminase
Glutamic-Oxaloacetic 84450
Glutamic Dehydrogenase
Glutamyltransferase, Gamma 82977
Glutathione 82978
Glutathione Reductase 82979
Glycanhydrolase, N-Acetylmuramide
Lysozyme 85549
Glycated Hemoglobins
Glycosylated Hemoglobin 83036
Glycated Protein 82985

Glycerol, Phosphatidyl
Phosphatidylglycerol 84081
Glycerol Phosphoglycerides
Glycerophosphatase
See Alkaline Phosphatase
Glycinate, Theophylline Sodium
Theophylline 80198
Glycocholic Acid
Cholylglycine 82240
Glycohemoglobin
Glycosylated Hemoglobin 83036
Glycosaminoglycan
Mucopolysaccharides 83864
Goeckerman Treatment
Photochemotherapy 96910, 96912, 96913
Goldwaite Procedure
Knee 27422
Golfer’s Elbow
Tenotomy 24357-24359
Gol-Vernet Operation
Pyelotomy, Exploration 50120
Gonadectomy, Female
See Oophorectomy
Gonadectomy, Male
See Orchiectomy
Gonadotropin
Chorionic 84702-84704
FSH 83001
ICSH 83002
LH 83002
Gonadotropin Panel
Stimulation 80426
Gonioscopy
Ophthalmic 92020
Goniotomy
Congenital Glaucoma 65820
Gonococcus
Neisseria Gonorrhoeae 87590-87592, 87850
GOTT
Transaminase, Glutamic-Oxaloacetic 84450
GPUT
Galactose-1-Phosphate, Uridyl Transferase 82776
Uridyl Transferase 82775
Graft
Allograft
See Allograft
Anal 46753
Aorta
See Aorta, Graft
Artery
Bypass Graft
See Bypass Graft, Arterial; Bypass Graft, Arterial-Venous
Coronary 33503
Bone and Skin 20969, 20970, 20972, 20973
Bone Marrow
Aspiration 20939
Cartilage
See Cartilage Graft
Conjunctiva 65782
Harvesting 68371
Cornea
with Lesion Excision 65426
Cornea Transplant
See Cornea, Transplantation
Dura
Cranial
Anterior Cranial Fossa 61601
Middle Cranial Fossa 61606, 61608
Posterior Cranial Fossa 61616
Suboccipital Craniectomy 61343
Spinal Cord 63710
Ear
Fat Autograft 15773, 15774
Full-thickness Graft, Free 15260, 15261
Preparation of Recipient Site 15004, 15005
Skin Substitute Graft 15275-15278
Split-thickness Autograft 15120, 15121
Tissue Cultured Skin Autograft 15155-15157
Eye
Conjunctiva 65782
Stem Cell 65781
for Facial Nerve Paralysis
Fascia 15840
Muscle 15841, 15842, 15845
Fascia
See Fascial Graft
Fascia Lata
Fat 15771-15774
Gum Mucosa 41870
Intestine 43116, 46748
Muscle
See Muscle Flaps; Muscle Grafts
Nail Bed
Nerve
See Nerve Graft
Oral Mucosa 40818
Organ
See Transplantation
Pancreas
See Pancreas, Transplantation
Patency
Blood Flow Check 15860
Vascular Flow Check 15860
Skin
Skin Substitute
Tendon
Finger 26392, 26416, 26420, 26428, 26434
Hand 26392, 26412, 26416
Harvesting 20924
Vein
Bypass Graft
See Bypass Graft, Venous
Cross-Over 34520
Grain Alcohol
Granulation Tissue
Cauterization, Chemical 17250
Gravis, Myasthenia
Cholinesterase Inhibitor Challenge Test 95857
Gravities, Specific
Specific Gravity 84315
Great Toe
Arthrodesis
Fracture
Skeletal Fixation 28496
Osteocutaneous Flap 20973
Toe-to-Hand Transfer 20973
Wrap-around with Bone Graft 26551
Great Vessels
Graft Insertion 33330, 33335
Shunt
Aorta to Pulmonary Artery
Ascending 33755
Descending 33762
Central 33764
Subclavian to Pulmonary Artery 33750
Vena Cava to Pulmonary Artery 33766, 33767
Suture Repair 33320-33322
Translocation
Aortic Root 33782, 33783
Transposition Repair
Aortic Pulmonary Artery Reconstruction 33778-33781
Atrial Baffle Procedure 33774-33777
with Subpulmonary Stenosis 33770, 33771
with Ventricular Septal Defect 33770, 33771
Great Vessels Transposition

Humeral
Greater Vestibular Gland
Grippe, Balkan
Q Fever 86000, 86638
Gritti Operation
Amputation, Thigh, through Femur 27590
Groin Area
Incision
Femoral Artery Exposure 34812
Repair
Hernia 49550-49557
Revision
Femoral Arterial Bypass Graft 35883
Group Adaptive Behavior Treatment 97154, 97158
Group Health Education
Genetic 98961, 98962, 99078
Physical 99078
Preventive Medicine 99411
Self-Management, Condition or Treatment 98961, 98962
Well-being Coaching 0593T
Grouping, Blood
Growth Factors, Insulin-Like

Somatomedin 84305
Growth Hormone Stimulation Panel 80428
Growth Hormone Suppression Panel 80430
Human
Antibody 86277
Measurement 83003
Insulin Tolerance Panel 80435
Pituitary Evaluation Panel 80418
Growth Hormone Release Inhibiting Factor

Somatostatin 84307
Growth Stimulation Expressed Gene 2 83006
GTT
Glucose Tolerance Test 82951, 82952
Guaiac Test
Occult Blood 82270-82272
Guard Stain
Special Stain, Group II 88313
Gullet
See Esophagus
Gums
Abscess
Alveolus
Excision 41830
Cyst
Excision
Gingiva 41820
Operculum 41821
Graft
Mucosa 41870
Hematoma
Lesion
Destruction 41850
Mucosa
Excision 41828
Graft 41870
Reconstruction
Alveolus 41874
Gingiva 41872
Removal
Bone 41806
Foreign Body 41805
Tuberosities
Excision 41822, 41823
Tumor
Gunning-Lieben Test
Guthrie Test
Phenylalanine (PKU) 84030
H
H Flu
See Haemophilus Influenza (H Flu)
HAA (Hepatitis Associated Antigen)

Hepatitis Antigen, B Surface (HBsAg) 87340, 87341
HAAb
Haemoglobin F
Haemophilus Influenza (H Flu)
Antibody 86684
Antigen Detection 87275
Immunoassay 87804
Nucleic Acid Detection
Reverse Transcription, Amplified Probe 87501-87503
Vaccines
Hib, PRP-OMP Conjugate 90647
Hib, PRP-T Conjugate 90648, 90748
Hib-HepB 90748
Hib-MenCY 90644
Haemorrhage
See Hemorrhage
Haemorrhage, Rectum
See Hemorrhage, Endoscopic Control, Rectum
Hageman Factor
Clotting Factor XII 85280
HAI Test
Hemagglutination Inhibition Test 86280
Hair
Cell
Ear, Function Analysis 92588
Electrolysis 17380
Fungi Isolation 87101
KOH Examination 87220
Microscopic Evaluation 96902
Transplant
Punch Graft 15775, 15776
Strip Graft 15220, 15221
Hair Removal
Electrolysis 17380
Hallux
See Great Toe
Halo
Body Cast 29000
Cranial 20661
for Thin Skull Osteology 20664
Femur 20663
Maxillofacial 21100
Pelvic 20662
Removal 20665
Haloperidol
Assay 80173
Halstead-Reitan Neuropsychological Battery

Administration and Scoring 96139
Evaluation Services 96132, 96133
Ham Test
See Hemolysins
Hammertoe Repair
Correction 28285, 28286
Hamster Penetration Test
Sperm Evaluation 89329
Hand
Amputation
at Metacarpal 25927, 26910
Ray Amputation 26910
Revision 25924, 25929, 25931
at Wrist 25920
Revision 25922
Bone
Cyst
Excision 26210, 26215
Osteotomy, Metacarpal 26565
Casts, Splints, and Strapping 29065, 29085
Compression System 29584
Gauntlet Cast 29085
Long Arm Cast 29065
Long Arm Splint 29105
Short Arm Cast 29075
Short Arm Splint 29125, 29126
Strapping 29280
Decompression 26035
Diagnostic Imaging
Angiography 73225
X ray 73120, 73130
Drainage
Bursa 26025, 26030
Fasciectomy 26121, 26123, 26125
Fasciotomy
Decompressive 26037
Injection, Enzyme 20527, 26341
Open 26045
Percutaneous 26040
Fracture
Carpometacarpal 26645, 26650
Interphalangeal
See Interphalangeal Joint, Fracture
Metacarpal
Skeletal Fixation 26608
Metacarpophalangeal 26740-26746
Phalangeal 26720-26735, 26750-26765
Injection
Cell Therapy for Scleroderma 0490T
Insertion
Tendon Graft 26392
Joint
See Carpometacarpal Joint; Intercarpal Joint
Manipulation
Carpometacarpal Fracture 26645, 26650
Dupuytren’s Cord 26341
Joint Dislocation
See Carpometacarpal Joint, Dislocation; Intercarpal Joint, Dislocation
Metacarpal Fracture 26605, 26607
Palmar Fascial Cord 26341
Nerve
Graft 64890, 64891, 64895, 64896
Neuroma, Excision 64782, 64783
Neuroplasty 64704
Suture
Additional Nerve 64837
Common Sensory 64834
Digital 64831
Reconstruction
Tendon Pulley 26500-26502
Removal
Implantation 26320
Tube/Rod 26390-26392, 26416
Repair
Blood Vessel 35207
Cleft Hand 26580
Muscle 26591-26593
Release, Thenar 26508
Transfer, Hypothenar 26494
Non-Union, Metacarpal 26546
Replantation 20808
Skin Graft 15240, 15241
Strapping 29280
Tendon
Extensor
Excision 26170, 26415
Lengthening 26476
Realignment 26437
Repair 26410
Shortening 26477
Tenolysis 26445
Tenotomy 26460
Flexor
Excision 26390
Lengthening 26478
Repair 26350, 26352, 26356-26358
Shortening 26479
Tenosynovectomy 26145
Tenotomy 26450
Grafts 26502
Extensor 26412, 26420, 26428, 26434
Flexor 26352, 26358
Profundus 26372
Replace Rod Implant 26392, 26416
Opponensplasty 26490, 26492, 26494, 26496
Palm
Excision 26170
Profundus
Repair 26370, 26372, 26373
Pulley Reconstruction 26500, 26502
Sheath
Synovectomy 26145
Tenotomy 26060
Transfer
Carpometacarpal Area 26480, 26483
Cross Intrinsic 26510
Dorsum 26480, 26483
with Graft 26492
Palmar 26485, 26489
Superficialis 26490
Tenotomy 26450, 26460
Tissue Transfer
Adjacent 14040, 14041
Flap 15574, 15620
Toe-to-Hand Transfer 20973
Tumor
Excision 26111, 26113, 26115, 26116, 26200
Vascular Malformation
Excision 26111, 26113, 26115, 26116
Hand Abscess
Hand Phalanges
See Phalanx, Finger
Handling
Device Order Implementation 99002
Radioelement 77790
Specimen Transport 99000, 99001
Hand(s) Dupuytren’s Contracture(s)
Hanganutziu-Deicher Antibodies
Heterophile Antibody 86308-86310
Haptoglobin
Measurement 83010-83012
Hard Palate
See Palate
Harelip Operation
See Cleft Lip, Repair
Harii Procedure
Carpal Bone 25430
Harrington Rod
Insertion 22840
Removal 22850
Hartmann Procedure
Colectomy with Colostomy
Closure 44626
Laparoscopic 44206
Open 44143
Harvest of Upper Extremity Artery for Coronary Artery Bypass 35600
Harvesting
Adipose Tissue Cells
for Cellular Knee Implant 0565T
Bone Graft 20900-20902
Spine Surgery
Allograft 20930-20934
Autograft 20936-20938
Bone Marrow
Allogeneic 38230
Autologous 0265T, 20939, 38232
Cartilage Graft
Ear 21235
Glenoid Fossa 21255
Rib 21230
Conjunctival Graft 68371
Eggs
Fascia Lata Graft 20920-20922
Fat
by Liposuction 15876-15879
Lower Extremity Vein
for Vascular Reconstruction 35572
Mucosa 40818
Organs
Duodenum 48550
Heart 33940
Heart/Lung 33930
Kidney 50300, 50320, 50547
Liver 47133, 47140-47142
Lung 32850
Pancreas 48550
Skin
for Tissue-Cultured Autograft 15040
Stem Cell
Blood-derived 38205, 38206
Limbal 65781
Tendon Graft 20924
Upper Extremity Artery
for Coronary Artery Bypass Graft 35600
Upper Extremity Vein
for Bypass Graft 35500
Endoscopic 33508
Multiple 35681-35683
Hauser Procedure
Patella 27420
Hayem’s Elementary Corpuscle
See Blood, Platelet
Haygroves Procedure 27120

HBcAb (Hepatitis B Core Antibody)
Detection 86704
HBeAb (Hepatitis Be Antibody)

Detection 86707
HBeAg (Hepatitis Be Antigen)
Detection 87350
HBsAb (Hepatitis B Surface Antibody)

Detection 86706
HBsAg (Hepatitis B Surface Antigen)
Detection 87340
HCG
HCO3
Bicarbonate 82374
HCV (Hepatitis C Virus) Antibodies

Detection 86803, 86804
HDL
See Lipoprotein
Head
Dislocation
Temporomandibular Joint 21480, 21485, 21490
Excision
Bone, Facial 21025, 21026
Tumor, Soft Tissue 21011-21016
Fracture
Malar Area 21355, 21360-21366, 21366
Mandible 21450, 21451, 21452, 21453, 21454, 21454-21470, 21461, 21462
Maxilla 21421, 21422, 21423
Nasal Bone 21310, 21310-21320, 21315-21320, 21325-21335
Nasal Septum 21336, 21337
Nasal Turbinate 30930
Nasoethmoid 21338, 21339, 21340
Nasomaxillary 21345, 21345-21347, 21346-21348, 21348
Orbit 21385-21395, 21400, 21401, 21406-21408
Palate 21422, 21423
Skull 62000, 62005, 62010
Zygomatic Arch 21355, 21356-21366
Halo Appliance 21100
Imaging
Angiography 70496, 70544-70546
CT Scan 70450, 70460, 70470, 70496
Magnetic Resonance Angiography (MRA) 70544-70546
Positron Emission Tomography (PET) 78811, 78814
Ultrasound Exam 76506, 76536
X ray 70350
Lipectomy, Suction Assisted 15876
Nerve
Graft 64885, 64886
Other Procedures 21299, 21499
Prosthesis
Custom Preparation
See Impression, Maxillofacial
Cheekbone
Malar Augmentation 21270
Chin 21120
Cornea 65770
Ear
Ossicle Reconstruction 69633, 69637
Facial
Osteoplasty 21208
Lens 66825, 66982-66985, 66987
Mandible 21125
Nasal Septum 30220
Ocular 65770, 66982-66985, 66987
Telescope Prosthesis 0308T
Temporary 92358
Orbital 21179
Ossicle Reconstruction
Chain 69633
Palate 42280, 42281
Retina 0100T
Skull Plate 62142, 62143
Spectacle
Fitting 92352, 92353
Repair 92371
Speech Aid 31611
Voice 31611
Unlisted Maxillofacial Prosthetic Procedure 21089
Repair/Revision and/or Reconstruction
See Cranioplasty; Face; Mandible
Rhytidectomy
See Rhytidectomy
Head Rings, Stereotactic

Stereotactic Frame Application 20660
Headbrace
See Halo
Heaf Test
Intradermal Tuberculosis Test 86580
Health Behavior
Assessment 96156
Coaching 0591T-0593T
Intervention
Family 96167, 96168, 96170, 96171
Group 96164, 96165
Individual 96158, 96159
Health Risk Assessment Instrument

Administration
Caregiver-Focused 96161
Patient-Focused 96160
Hearing Aid
Device
Attenuation Measurements 92596
Check 92592, 92593
Evaluation, Electroacoustic 92594, 92595
Examination and Selection 92590, 92591
Implants
Bone Conduction
Implantation 69710
Removal 69711
Repair 69711
Replacement 69710
Brainstem
Programming 92640
Cochlear
Evaluation for Auditory Implant Candidacy 92626, 92627
Evaluation of Function of Auditory Implant 92626, 92627
Implantation 69930
Programming 92601-92604
Osseointegrated
Replacement 69717, 69718
Hearing Aid Check 92592, 92593

Hearing Aid Services
Attenuation Measurements
Ear Protector 92596
Electroacoustic Test 92594, 92595
Examination 92590, 92591
Hearing Tests
See Audiologic Function Tests
Hearing Therapy
Cochlear Implant
Analysis and Programming 92601-92604
Candidacy Evaluation 92626, 92627
Function Evaluation 92626, 92627
Evaluation
for Auditory Implant Candidacy 92626, 92627
of Function of Auditory Implant 92626, 92627
Group 92508
for Hearing Loss
Postlingual 92633
Prelingual 92630
Individual 92507
Heart
Ablation
Arrhythmogenic Focus 33250, 33251, 33261
Atrial Tissue 33254-33259
Anomaly
Congenital
See Congenital Cardiac Anomaly
Repair 33615, 33617
Aorta
See Aorta
Arrhythmia
See Tachycardia
Artificial Heart
Implantation 33927
Removal 33929
Replacement 33928
Atria
See Atria
Balloon Device
Insertion 33973
Removal 33974
Biopsy 93505
Ultrasonic Guidance 76932
Blood Vessel
Repair 33320-33322
Cardiac Contractility Modulation
Electrode
Reposition 0415T
Cardiac Event Recorder
Device Evaluation 93285, 93291, 93298
Insertion 33285
Removal 33286
Cardiac Output Measurements 93451, 93561, 93562
Cardiac Rehabilitation 93797, 93798
Cardioassist
Circulation 92970, 92971
Cardiopulmonary Bypass
Catheterization
Chordae Tendineae, Artificial
Placement 0543T
Cor Triatriatum
Repair 33732
Coronary Artery Bypass Graft
Cyst
Pericardial
Resection 33050
Diagnostic Imaging
Angiography
See Angiography, Heart
Blood Pool 78472, 78473, 78481, 78483, 78496
SPECT 78494
CT Scan 75571-75573
Angiography 75574
Magnetic Resonance
See Cardiac Magnetic Resonance Imaging (CMRI)
Myocardial Imaging
Infarct Avid 78466, 78468, 78469
Perfusion 78451-78454
Perfusion Study 78430-78433, 78491, 78492
PET Metabolic Evaluation 78429, 78432, 78433, 78459
Speckle-Tracking Assessment of Mechanics 93356
SPECT 0332T, 78451, 78452, 78469
Shunt Detection 78428
Unlisted Cardiovascular Diagnostic Nuclear Medicine Procedure 78499
Ventriculography
Electrical Recording
See Electrophysiology Procedure
Electrode
Insertion 33202, 33203, 33210, 33211, 33216, 33217, 33224, 33225
Removal 33238
Single/Dual Chamber 33243, 33244
Electrophysiologic Study
See Electrophysiology Procedure
Exploration 33310-33315
Great Vessels
See Great Vessels
Heart-Lung Bypass
Heart-Lung Transplantation 33935
Hemodynamic Monitoring
Duplex Scan
Extracranial Arteries 93880, 93882
Extremity Arteries 93925-93931, 93970, 93971
Hemodialysis Access 93985, 93986, 93990
Penile Vessels 93980, 93981
Viscera 93975, 93976, 93978, 93979
Noninvasive 93922-93924, 93998
with Pharmacologic Agent 93463
with Physiologic Exercise Study 93464
See Cardiac Assist Devices, Implantable
Defibrillators
Infundibular Stenosis 33476-33478
Injection
Radiological 93454-93461, 93563-93568
Intraoperative Pacing and Mapping 93631
Ischemia Monitoring System 0525T-0532T
Ligation
Fistula 37607
Myocardium
Imaging 78466-78469
Infarction
Revascularization 92941, 92943, 92944
Tissue Plasminogen Activator (tPA) Therapy 4077F
Perfusion Study 78451-78454
Revascularization 33140, 33141
Speckle-Tracking Assessment of Mechanics 93356
SPECT 0332T, 78451, 78452, 78469
Open Chest Massage 32160
Output
Pacemaker
See Pacemaker
Pacing
Arrhythmia Induction 93618
Atria 93610
Left Ventricular Wireless Stimulator System 0515T-0522T
Rate Increase
See Tachycardia
Transcutaneous
Temporary 92953
Ventricular 33224-33226, 93612
Pericardium
Drainage 33017-33019, 33025
Pericardiectomy 33030, 33031
Pericardiocentesis 33016
Pericardiotomy
for Removal of Clot 33020
for Removal of Foreign Body 33020
Wound 33300-33305
Resuscitation 92950
Septal Defect
See Septal Defect
Sinus of Valsalva
Repair 33702-33722
Sinus Venosus
Repair 33645
Sounds
See Heart Sounds
Tetralogy of Fallot
Repair 33692-33697, 33924
Thrombectomy
See Thrombectomy
Total Replacement Heart System
Implantation 33927
Removal 33929
Replacement 33928
Transplantation 33935, 33945
Allograft Preparation 33933, 33944
Harvest 33940
Tumor
Cardiac
Pericardial
Resection 33050
Valve
Aortic
See Aortic Valve
Bicuspid
See Mitral Valve
Mitral
See Mitral Valve
Pulmonary
See Pulmonary Valve
Tricuspid
See Tricuspid Valve
Valve Closure
Atrioventricular 33600
Semilunar 33602
Vena Cava
Ventricle
Commissurotomy
Right Ventricle 33476-33478
Leadless Pacemaker System
Device Evaluation
Interrogation 93288, 93294, 93296
Peri-procedural 93286
Programming 93279
Obstruction Removal 33619
Pacing 33224-33226, 93612
Repair 33548, 33611, 33612
Ventricular Tunnel Repair 33722
Ventriculomyectomy 33416
Ventricular Assist Device (VAD)
Wound
Repair 33300-33305
Heart Sounds
Acoustic Recording
with Computer Analysis 93799
Heart Vessels
See Great Vessels
Angioplasty
See Angioplasty
Heat Unstable Haemoglobin

Hemoglobin, Thermolabile 83065, 83068
Heavy Lipoproteins
See Lipoprotein
Heavy Metal
Qualitative 83015
Quantitative 83018
Heel
Bone
See Calcaneus
Dual-energy X-ray Absorptiometry 77080
Fracture
See Calcaneus, Fracture
Spur
Excision 28119
Stick, for Collection of Blood 36416
X ray 73650
Heel Bone
See Calcaneus
Heel Fracture
Heel Spur
Excision 28119
Heine-Medin Disease
See Polio
Heinz Bodies
Assessment 85441, 85445
Helicobacter Pylori
Antibody 86677
Antigen Detection
Blood Test 83009
Breath Test
Urea, Liquid Scintillation Counter
Acquisition 78267
Analysis 78268
Urease Activity 83013
Injection for Breath Test 83014
Stool 87338
Urease Activity 83009, 83013, 83014
Heller Operation
See Heller Procedure
Heller Procedure
Esophagomyotomy
Laparoscopic 43279
Open 43330, 43331
Thoracoscopic 32665
Helminth
Antibody 86682
Hemagglutination Inhibition Test
by Antibody 86280
Hemangioma
Benign Lesion Excision 11400-11406, 11420-11424, 11426, 11440-11446
Hemapheresis
Therapeutic Apheresis 0342T, 36511-36516
Hematochezia
Blood, Feces 82270, 82272-82274
Hematologic Test
See Blood Tests

Blood
Hemoglobin, Concentration 85046
Platelet
Aggregation 85576
Automated Count 85049
Count 85008
Manual Count 85032
Sedimentation Rate 85651, 85652
Viscosity 85810
Blood Cell Count
Automated 85049
B Cells 86355
Complete (CBC) 85025-85027
Differential WBC Count 85004-85007, 85009
Hematocrit 85014
Hemoglobin 85018
Hemogram
Manual 85032
Microhematocrit 85013
Red Blood Cells 85032-85041
Reticulocyte 85044-85046
White Blood Cells 85032, 85048
Blood Smear
Microscopic Examination 85007, 85008
Peripheral 85060
Coagulation Tests
ADAMTS-13 85397
Anticoagulants
Bleeding Time 85002
Coagulation/Fibrinolysis Assay 85396
Coagulation/Fibrinolysis Functional Activity 85397
Factors
Inhibitors
Hematoma
Ankle
Aorta, Intramural
Endovascular Repair 34841-34848
Arm, Lower
Arm, Upper
Brain
Aspiration via Burr Hole 61156
Drainage via Burr Hole 61154-61156
Evacuation via Burr Hole 61108, 61154
Evacuation via Craniotomy 61312-61315
Chest
Ear, External
Elbow
Epididymis
Gums
Hip 26990
Integumentary System/Superficial
Knee 27301
Leg, Lower
Leg, Upper 27301
Mouth 41015-41018
Dentoalveolar 41800
Lingual 41000
Sublingual 41005, 41006, 41015
Nail
Evacuation 11740
Nasal Septum
Neck
Nose
Pelvis
Scrotum
Shoulder
Skin
Subdural 61108
Subungual
Evacuation 11740
Testis
Thigh
Thorax
Tongue 41000, 41005, 41006, 41015
Vagina
Wrist 25028
Hematopoietic Progenitor Cell (HPC)

Donor Search and Cell Acquisition 38204
HPC Boost 38243
Transplant Preparation
Cell Concentration 38215
Cell Depletion 38210-38214
Cryopreservation and Storage 38207
Thawing 38208, 38209
Hematopoietic Stem Cell Transplantation
Transplantation 38240, 38241
Hematopoietin
Hematuria
Blood, Urine 83491
Hemic System
Unlisted Procedure, Hemic System 38999
Unlisted Procedure, Spleen
Laparoscopic 38129
Hemiepiphyseal Arrest
Elbow 24470
Hemifacial Microsomia
Reconstruction
Hemilaminectomy 63020-63044
Hemilaryngectomy 31370-31382
Hemipelvectomies
Amputation, Interpelviabdominal 27290
Hemiphalangectomy
Toe 28160
Hemispherectomy
Brain
Partial 61543
Hemocytoblast
See Stem Cell
Hemodialyses
See Hemodialysis
Hemodialysis
Access
Anastomosis
Cannulation
Arteriovenous 36810
Closure 36815
Preoperative Vessel Assessment 93985, 93986
Revision 36815
Vein to Vein 36800
Blood Flow Study 90940
Duplex Scan of Access 93985, 93986, 93990
Home Visit 99512
Procedure 90935-90937
with Evaluation 90935, 90937
via Catheter 4054F
via Functioning Arteriovenous Fistula 4052F
Thrombectomy 36831
via Functioning Arteriovenous Graft 4053F
Hemofiltration
Dialysis Procedure 90945, 90947
Hemoglobin
A1c (HbA1c) Level 3044F, 3051F, 3052F
Analysis
O2 Affinity 82820
Carboxyhemoglobin 82375, 82376, 88740
Concentration 85046
Electrophoresis 83020
Fetal 83030-83033, 85460, 85461
Fractionation and Quantitation 83020
Glycosylated (A1C) 83036, 83037
Hgb
Transcutaneous Testing 88738
Methemoglobin 83045-83050
Non-Automated 83026
Plasma 83051
Sulfhemoglobin 83060
Thermolabile 83065-83068
Urine 83069
Hemoglobin, Glycosylated 83036

Hemoglobin F
Fetal Hemoglobin
Copper Sulfate 83030-83033
Differential Lysis 85460, 85461
Hemogram
Complete Blood Count
Manual 85014-85018, 85032
Hemolysins
Acid 85475
with Agglutinins 86940, 86941
Hemolytic Complement
Hemolytic Complement, Total
Hemoperfusion
Dialysis 90997
Hemophil
See Clotting Factor
Hemorrhage
Control
Liver 47350
Lung 32110
Nasal (Epistaxis)
Complex 30903
Initial 30905
Simple 30901
Subsequent 30906
Nasopharynx 42970-42972
Neck 35800
Oropharynx 42960-42962
Preperitoneal Pelvis 49013, 49014
Prostate, Transurethral Fulguration 52214
Throat 42960-42962
Uterus
Postpartum 59160
Vagina 57180
Endoscopic Control
Anus 46614
Chest Cavity 32654
Colon 44391, 45382
Colon-Sigmoid 45334
Intestines, Small 44366, 44378
Nose 31238
Rectum 45317
Vascular 37244
Hemorrhoidectomy
Complex 46260
with Fissurectomy 46261, 46262
External Complete 46250
Ligation 46221, 46945, 46946, 46948
with Mucopexy 46948
Simple 46255
with Fissurectomy 46257, 46258
Hemorrhoidopexy
Stapling 46947
Hemorrhoids
Band Ligation
with Colonoscopy 45398
with Sigmoidoscopy 45350
Destruction 46930
Excision
See Hemorrhoidectomy
Incision
External 46083
Injection
Sclerosing Solution 46500
Ligation 46945, 46946, 46948
Stapling 46947
Suture 46945, 46946, 46948
Hemosiderin
Qualitative 83070
Heparin
Assay 85520
Protamine Tolerance Test 85530
Heparin Cofactor I
Hepatectomy
Extensive 47122
Left Lobe 47125
Partial
Donor 47140-47142
Lobe 47120
Right Lobe 47130
Total
Donor 47133
Hepatic Abscess
See Abscess, Tissue, Liver
Hepatic Arteries
See Artery, Hepatic
Hepatic Artery Aneurysm

See Artery, Hepatic, Aneurysm
Hepatic Duct
Anastomosis
with Gastrointestinal Tract 47765
U-Tube Hepaticoenterostomy 47802
Nuclear Medicine
Imaging 78226, 78227
Removal
Repair
Hepatic Haemorrhage
Liver Hemorrhage, Control 47350
Hepatic Portal Vein
See Vein, Hepatic Portal
Hepatic Portoenterostomies
Hepaticoenterostomy 47802
Hepatic Transplantation
See Liver, Transplantation
Hepaticodochotomy
See Hepaticostomy
Hepaticoenterostomy
U-Tube 47802
Hepaticostomy
Drainage 47400
Exploration 47400
Removal of Calculus 47400
Hepaticotomy
Drainage 47400
Exploration 47400
Removal of Calculus 47400
Hepatitis A and Hepatitis B

Antibody
See Hepatitis Antibody
Vaccine
HepA-HepB 90636
Hepatitis A Vaccine (HepA)
Adolescent/Pediatric
2 Dose Schedule 90633
Adult Dosage 90632
and Hepatitis B Vaccine 90636
Hepatitis Antibody
B
B Core (HBcAb) 86704, 86705
B Surface (HBsAb) 86706
Be (HBeAb) 86707
C 86803, 86804
Delta Agent 86692
A (HAAb) 86708, 86709
IgG 86704
IgM 86704, 86705, 86709
Panel
Hepatitis Antigen
Detection
Drug Susceptibility 87902
Immunoassay
B Surface (HBsAg) 87340, 87341
Be (HBeAg) 87350
Delta Agent 87380
Nucleic Acid
B 87516, 87517
C 87520-87522
G 87525-87527
Hepatitis B and Hib Vaccine (Hib-HepB)
Intramuscular 90748
Hepatitis B Surface Antigen (HBsAg)

Hepatitis B Vaccine (HepB)
Dosage
Adolescent 90743
Adult 90739, 90746
Immunosuppressed 90740, 90747
Pediatric/Adolescent 90744
and Haemophilus Influenza b Vaccine (Hib-HepB) 90748
and Hepatitis A Vaccine 90636
Hepatitis B Virus E Antigen (HBeAg)

Detection 87350
Hepatitis B Virus Surface ab (HBsAb)
Detection 86706
Hepatorrhaphy
Liver Suture 47350, 47360, 47361
Hepatotomy
Drainage
Abscess
Open 47010
Cyst 47010
Hernia, Cerebral
See Encephalocele
Hernia, Rectovaginal
Rectocele Repair 45560, 57250
Hernia, Umbilical
Omphalocele Repair 49600-49611
Hernia Repair
Abdominal
Reduction by Laparotomy 44050
Diaphragmatic 39540, 39541
Neonatal 39503
Epigastric 49570
Incarcerated 49572
Laparoscopic 49652
Incarcerated 49653
Strangulated 49653
Strangulated 49572
Femoral
Initial 49550
Incarcerated 49553
Strangulated 49553
Recurrent 49555
Incarcerated 49557
Strangulated 49557
Incisional
Implantation, Mesh or Prosthesis 49568
Initial 49560
Incarcerated 49561
Strangulated 49561
Laparoscopic
Incarcerated 49655, 49657
Strangulated 49655, 49657
Recurrent 49565
Incarcerated 49566
Strangulated 49566
Thoracoabdominal 43336, 43337
Inguinal
Incarcerated 49492, 49496, 49501, 49507, 49521
Infant Gestation, Surgery Age
Full Term, Birth to 6 Months 49495, 49496
Preterm, 37 Weeks Gestational Age to 50 Weeks 49491, 49492
Preterm, 50 Weeks Gestational Age to 6 Months 49495, 49496
Initial, Child 5 Years or Older 49505, 49507
Initial, Child under 5 Years 49500, 49501
Laparoscopic
Initial 49650
Recurrent 49651
Recurrent, Any Age 49520, 49521
Sliding, Any Age 49525
Strangulated 49492, 49496, 49507, 49521
Intestinal 44050
Lumbar 49540
Lung 32800
Neonatal 39503
Paracolostomy 44346
Paraesophageal
Hiatal
Laparotomy 43332, 43333
Thoracoabdominal Incision 43336, 43337
with Spermatic Cord Repair 55540
Spigelian 49590
Laparoscopic 49652
Incarcerated 49653
Strangulated 49653
Umbilicus
Child, 5 Years and Up 49585
Incarcerated 49587
Strangulated 49587
Child, under 5 Years 49580
Incarcerated 49582
Strangulated 49582
Laparoscopic 49652
Incarcerated 49653
Strangulated 49653
Reducible 49580, 49585
with Urachal Cyst or Sinus Excision 51500
Ventral
Implantation, Mesh or Prosthesis 49568
Laparoscopic 49652
Incarcerated 49653
Strangulated 49653
Recurrent 49565
Incarcerated 49566
Strangulated 49566
Heroin Screen
Heroin Metabolite Assay 80356
Herpes Simplex
Antigen Detection
Immunofluorescence 87273, 87274
Identification
Smear and Stain 87207
Herpes Smear and Stain

Inclusion Bodies 87207
Herpes Virus-4 (Gamma), Human
Herpes Virus-6
Quantification 87533
Herpetic Vesicle
Destruction
Anus 46900, 46910, 46916, 46917, 46922, 46924
Penis 54050, 54055-54057, 54060, 54065
Heteroantibodies
Heterophile Antibody 86308-86310
Heterophile Antibody
Screening 86308-86310
Heterotropia
See Strabismus
Hex B
Hexadecadrol
Dexamethasone Suppression Panel 80420
Hexosephosphate Isomerase
Heyman Procedure
Femoral Neck 27179
Midtarsal 28264
Hg Factor
See Glucagon
HGB
Hemoglobin, Concentration 85046
HGH
See Growth Hormone, Human
HHV-4
HIAA
Hydroxyindoleacetic Acid, Urine 83497
Hib Vaccine
4 Dose Schedule
PRP-T 90648
PRP-OMP
Hidradenitis
Suppurative
High Altitude Simulation Test

HAST 94452, 94453
High Density Lipoprotein
See Lipoprotein
High Intensity Focused Ultrasound (HIFU)

Ablation
Prostate Tissue 55880
High Molecular Weight Kininogen
Fitzgerald Factor 85293
High Resolution Anoscopy (HRA)

Biopsy 46607
Diagnostic 46601
Highly Selective Vagotomy 43641
Highmore Antrum
See Nasal Sinuses, Maxillary
Hill Procedure
Gastroplasty with Esophagogastric
Fundoplasty 43820
Hinton Positive
Syphilis Test 86592
Hip
See also Femur; Pelvis
Abscess
Arthrography 73525
Arthroplasty 27130-27132
Arthroscopy 29860-29863, 29914-29916
Arthrotomy 27030-27033
Biopsy 27040-27045
Bone
Drainage 26992
Bursa
Capsulectomy
with Release, Flexor Muscles 27036
Cast 29305-29325
Craterization 27070
Cyst
Denervation 27035
Echography
Infant 76885, 76886
Endoprosthesis
See Prosthesis, Hip
Excision 27070
Exploration 27033
Fasciotomy 27025
Fusion 27284-27286
Hematoma
Injection
Reconstruction
Removal
Cast 29710
Foreign Body 27033, 27086, 27087
Arthroscopic 29861-29863
Loose Body
Prosthesis 27090, 27091
Repair
Muscle Transfer 27100-27105, 27110, 27111
Tendon 27097
Replacement
Partial 27125
Total 27130, 27132
Saucerization 27070
Stem Prostheses 27125
Strapping 29520
Tenotomy
Abductor Tendon 27006
Adductor Tendon 27000-27003
Iliopsoas 27005
Total Replacement 27130-27132
Tumor
Excision 27047, 27048, 27065-27067
Ultrasound
Infant 76885, 76886
X ray
Bilateral 73521-73523
with Contrast 73525
Unilateral 73501-73503
Hip Joint
Arthroplasty 27132
Biopsy 27052
Capsulotomy
with Release, Flexor Muscles 27036
Congenital 27256-27259
without Trauma 27265, 27266
Manipulation 27275
Reconstruction
Synovium
Excision 27054
Hip Stem Prostheses
Hemiarthroplasty 27125
Hippocampus
Excision 61566
Histamine
Measurement 83088
Histamine Release Test

Leukocyte 86343
Histochemistry
Enzyme Constituents 88319
Stain on Frozen Tissue Block 88314
Histocompatibility Testing
See Tissue, Typing
Histoplasma
Detection
Immunoassay
Antibody 86698
Antigen 87385
Histoplasma capsulatum
Antigen Detection
Immunoassay 87385
Histoplasmin Test
Histoplasmosis Skin Test 86510
Histoplasmoses
Histoplasmosis Skin Test 86510
Histoplasmosis
Skin Test 86510
History and Physical

See Evaluation and Management, Office and Other Outpatient
HIV
Confirmation Test 86689
HIV-1
Antibody Detection
Immunoassay 86701, 86703, 87389
Immunoassay with Direct Optical Observation 87806
Antigen Detection
Genotype Analysis 87901, 87906
Amplified Probe 87535
Direct Probe 87534
HIV-2
Antibody Detection
Immunoassay 86702, 86703, 87389
Antigen Detection
Direct Probe 87537
HK3 Kallikrein
Prostate-Specific Antigen 84152, 84153
HLA
See Human Leukocyte Antigen (HLA)
HMRK
See Fitzgerald Factor
HMW Kininogen
See Fitzgerald Factor
Hoffman Apparatus 20690
Hofmeister Operation
See Gastrectomy, Total
Holotranscobalamin
Quantitative 84999
Holten Test
Creatinine, Urine 82570, 82575
Holter Monitor 93224-93227
Home Services
Activities of Daily Living 99509
Anticoagulant Management 93793
Apnea Monitoring 94774-94777
Catheter Care 99507
Enema Administration 99511
Hemodialysis 99512
Individual or Family Counseling 99510
Intramuscular Injections 99506
Mechanical Ventilation 99504
Newborn Care 99502
Postnatal Assessment 99501
Prenatal Monitoring 99500
Respiratory Therapy 99503
Sleep Studies 95805-95811
Actigraphy Testing 95803
Stoma Care 99505
Ventilation Assist 94005
Home Visit
See House Calls
Homocyst(e)ine 83090
Urine 82615
Homogenization, Tissue
for Culture 87176
Homograft
Cornea
for Aphakia 65750
Autograft or Homograft
Allograft Preparation 0290T, 65757
Endothelial 65756
Lamellar 65710
Penetrating 65730, 65750, 65755
Skin Substitute
Arms 15271-15274
Digits 15275-15278
Eyelids 15275-15278
Face 15275-15278
Feet 15275-15278
Genitalia 15275-15278
Hands 15275-15278
Legs 15271-15274
Mouth 15275-15278
Orbits 15275-15278
Scalp 15275-15278
Trunk 15271-15274
Homologous Grafts
See Allograft
Homologous Transplantation
See Allograft
Homovanillic Acid
Urine 83150
Hormone, Adrenocorticotrophic
See Adrenocorticotropic Hormone (ACTH)
Hormone, Corticotropin-Releasing
Hormone, Growth
See Growth Hormone
Hormone, Human Growth
See Growth Hormone, Human
Hormone, Interstitial Cell-Stimulating

Hormone, Parathyroid
Parathormone 83970
Hormone, Pituitary Lactogenic

Prolactin 80418, 84146
Hormone, Placental Lactogen
Hormone, Somatotropin Release-Inhibiting

Somatostatin 84307
Hormone, Thyroid-Stimulating 80418, 80438, 80439, 84443
Hormone Assay
ACTH 82024
Aldosterone
Androstenedione
Androsterone
Angiotensin II 82163
Corticosterone 82528
Cortisol
Total 82533
Estradiol, Total 82670
Estriol 82677
Estrogen 82671, 82672
Estrone 82679
Follicle Stimulating Hormone
Gonadotropin 83001
Gonadotropin Releasing Hormone Panel 80426
Pituitary Evaluation Panel 80418
Hydroxyprogesterone 83498
Luteinizing Hormone 83002
Somatotropin 83003
Testosterone
Bioavailable 84410
Free 84402
Response 80414
Total 84403
Vasopressin 84588
Hormone Pellet Implantation

Estradiol 11980
Testosterone 11980
Hormone-Binding Globulin, Sex
Globulin, Sex Hormone Binding 84270
Hormones, Adrenal Cortex

See Corticosteroids
Hormones, Antidiuretic
Vasopressin 84588
Horseshoe Kidney
Symphysiotomy 50540
Hospital Discharge Services
See Discharge Services, Hospital
Hospital Services
Advance Care Planning 99497, 99498
Inpatient Services 99238, 99239
Chronic Care Management 99490, 99491
Complex 99487, 99489
Discharge Services 1110F, 1111F, 99238, 99239
Initial Care
Initial Hospital Care 99221-99223
Newborn 99460-99462, 99477
Prolonged Services 99356, 99357
Subsequent Hospital Care 99231-99233
Observation
Discharge Services 99234-99236
Post-discharge Transitional Care Management
Services 99495, 99496
Same Day Admission
Discharge Services 99234-99236
Subsequent Newborn Care 99462
Hot Pack Treatment

Application 97010
House Calls
HPC
HPL
Human Placental Lactogen 83632
HTLV-I
Antibody
Confirmatory Test 86689
Detection 86687
HTLV-II
Antibody 86688
Hubbard Tank Therapy

Each 15 minutes 97036
Hue Test
Color Vision Exam 92283
Huggin Operation
Orchiectomy, Simple 54520
Huhner Test
Semen Analysis 89300, 89320
Human Chorionic Gonadotropin

Human Chorionic Somatomammotropin
Human Cytomegalovirus Group

See Cytomegalovirus
Human Epididymis Protein 86305
Human Growth Hormone (HGH)
Anterior Pituitary Evaluation Panel 80418
Antibody 86277
Insulin Tolerance Panel 80435
Measurement 83003
Human Herpes Virus 4

Human Immunodeficiency Virus
See HIV
Human Immunodeficiency Virus 1

See HIV-1
Human Immunodeficiency Virus 2
See HIV-2
Human Leukocyte Antigen (HLA)

Antibody Analysis 86828-86835
Crossmatch 86825, 86826
Tissue Typing 86812, 86813, 86816, 86817, 86821
Typing 81370-81383
Human Papillomavirus
Vaccine
See Vaccines and Toxoids, Human Papillomavirus (HPV)
Human Papillomavirus Detection

Nucleic Acid Probe 0500T, 87623-87625
Human T Cell Leukemia Virus I Antibodies
HTLV-I Detection 86687, 86689
Human T Cell Leukemia Virus I
See HTLV-I
Human T Cell Leukemia Virus II

HTLV-II Detection 86688
Human T Cell Leukemia Virus II Antibodies
HTLV-II Detection 86688
Humeral Epicondylitises, Lateral

See Tennis Elbow
Humeral Fracture
See Fracture, Humerus
Humerus
See also Arm, Upper; Shoulder
Abscess
Cyst
Excision 23150, 24110
Excision 23174, 23184, 23195, 24134, 24140, 24150
Fracture
Condyle
with Dislocation 23665-23670
Epicondyle
Skeletal Fixation
Percutaneous 24566
Closed Treatment without Manipulation 23620
Shaft 24500-24505, 24516
Supracondylar
Transcondylar
Osteomyelitis 24134
Osteotomy
Insertion, Intramedullary Lengthening Device 0594T
Intramedullary Rod Realignment 24410
Sofield Procedure 24410
Pinning, Wiring 23491, 24498
Radial Head or Neck 24152
Repair 24430
with Graft 24435
Nonunion, Malunion 24430-24435
Osteoplasty 24420
Resection Head 23195
Sequestrectomy 23174, 24134
Tumor
Excision 23150, 23220, 24071-24076, 24110
X ray 73060
Hummelshein Operation
See Strabismus, Repair
Humor Shunt, Aqueous
See Aqueous Shunt
HVA
Homovanillic Acid 83150
Hybridization Probes, DNA
See Nucleic Acid Probe
Hydatid Disease
Echinococcosis 86171, 86280
Hydatid Mole
Hydatidiform Mole
Evacuation and Curettage 59870
Excision 59100
Hydration
Intravenous 96360, 96361
Rehydration Oral Solution 4056F
Status 2030F, 2031F
Hydrocarbons, Chlorinated 82441

Hydrocele
Aspiration 55000
Excision
Bilateral
Unilateral
Repair 55060
Hydrochloric Acid, Gastric 82930

Hydrochloride, Vancomycin
See Vancomycin
Hydrocodon
Dihydrocodeinone 80361
Hydrogen Ion Concentration
Blood Gases, pH 82800, 82803, 82930
Hydrolase, Acetylcholine
Acetylcholinesterase 82103
Hydrolase, Triacylglycerol
Lipase 83690
Hydrolases, Phosphoric Monoester

See Phosphatase
Hydrotherapy (Hubbard Tank)
Application 97036
Hydrotubation
Chromotubation, Oviduct 58350
Hydroxycorticosteroid 83491
Hydroxyindoleacetic Acid
Urine 83497
Qualitative 81005
Hydroxypregnenolone
3 Beta-hydroxydehydrogenase Deficiency Panel 80406
Quantitative 84143
Hydroxyprogesterone
ACTH Stimulation Panel 80402, 80406
Quantitative 83498
Hydroxyproline
Free 83500
Total 83505
Hydroxytyramine
See Catecholamines
Hygroma
Cystic
Axillary/Cervical
Hymen
Excision 56700
Incision 56442
Hymenal Ring
Revision 56700
Hymenectomy 56700
Hymenotomy 56442
Hyoid
Bone
Fracture 31584
Muscle
Incision and Suspension 21685
Hyperbaric Oxygen Pressurization 99183
Hypercycloidal X ray 76101, 76102
Hyperdactylies
See Supernumerary Digit
Hyperglycemic Glycogenolytic Factor

See Glucagon
Hyperhidrosis 64650-64653
Hypertelorism of Orbit
Osteotomy 21260, 21261, 21263
Hyperthermia Therapy
See Thermotherapy
Hyperthermia Treatment 77600-77620

Hypnotherapy 90880
Hypodermis
See Subcutaneous Tissue
Hypogastric Plexus
Destruction 64681
Injection
Anesthetic 64517
Neurolytic 64680, 64681
Hypoglossal Nerve
Anastomosis
Facial-Hypoglossal 64868
Facial-Spinal 64866
Hypoglossal-Facial Anastomosis
See Hypoglossal Nerve, Anastomosis, Facial-Hypoglossal
Hypopharynges
See Hypopharynx
Hypopharynx
Diverticulectomy 43130, 43180
Hypophysectomy 61546-61548, 62165
Hypophysis
See Pituitary Gland
Hypopyrexia
See Hypothermia
Hypospadias
Repair 54300, 54352
Complications 54340-54348
First Stage 54304
Proximal Penile or Penoscrotal 54332
One Stage
Meatal Advancement 54322
Perineal 54336
Urethroplasty
Local Skin Flaps 54324
Local Skin Flaps and Mobilization of Urethra 54326
Local Skin Flaps, Skin Graft Patch and/or Island Flap 54328
Urethroplasty for Second Stage 54308, 54312, 54316
Free Skin Graft 54316
Urethroplasty for Third Stage 54318
Hypothermia
Treatment
Neonatal
Selective 99184
Total 99184
Hypoxia
Breathing Response 94450
High Altitude Simulation Test 94452, 94453
Hysterectomy
Abdominal
Radical 58210
Resection of Ovarian Malignancy 58951, 58953, 58954, 58956
Supracervical 58180
Total 58150, 58200, 58956
with Colpo-Urethrocystopexy 58152
with Omentectomy 58956
with Partial Vaginectomy 58200
Cesarean
after Cesarean Delivery 59525
with Closure of Vesicouterine Fistula 51925
Radical 58548
Total 58570-58573, 58575
Removal
Lesion 59100
Supracervical
Vaginal 58260-58270, 58290-58294, 58550-58554
with Colpectomy 58275-58280
with Colpo-Urethrocystopexy 58267
Laparoscopic 58550, 58570-58573, 58575
Radical 58285
Removal Tubes/Ovaries 58262, 58263, 58291, 58292, 58552, 58554
Repair of Enterocele 58263, 58292, 58294
Hysterolysis
Uterine Adhesions 58559
Hysteroplasty 58540
Hysterorrhaphy 58520, 59350
Hysterosalpingostomy
Implantation, Tubouterine 58752
Hysteroscopy
Ablation
Endometrial 58563
Diagnostic 58555
Lysis
Adhesions 58559
Placement
Fallopian Tube Implants 58565
Removal
Impacted Foreign Body 58562
Leiomyomata 58561
Resection
of Intrauterine Septum 58560
Surgical with Biopsy 58558
Hysterosonography
Introduction of Saline 58340
Hysterotomy
Abdominal 59100
with Failed Abortion 59852, 59857
with Tubal Ligation 58611
Hysterotrachelectomy
Amputation, Cervix 57530
I
ICCE (Intracapsular Cataract Extraction) 66983
Ichthyosis, Sex Linked
Syphilis Test 86592, 86593
ICSH
Identification
Antibody
See Antibody Identification
Antigen
See Antigen Detection
Axial Vessel
for Island Pedicle 15740
Crystal, Light Microscopy 89060
Microbe
See Bacteria Culture; Infectious Agent; Ova; Parasites
Oocyte
from Follicular Fluid 89254
Sex Chromatin 88130, 88140
Sperm
from Aspiration 89257
Medicolegal 88125
from Tissue 89264
Urate Crystal 89060
IDH (Isocitric Dehydrogenase) 83570

IG
See Immune Globulins
IgA 82784
IgD 82784
IgE 82785, 86003, 86005, 86008
IgG 82784, 82787, 86001
IgM 82784
Ileal Conduit
Visualization 50690
Ileoscopy
via Stoma 44380-44382, 44384
Ileostomy 45136
Continent (Kock Procedure) 44316
Ileoanal Reservoir 45136
Non-Tube 44187, 44310
Iliac Arteries
See Artery, Iliac
Iliac Crest
Bone Graft 20956
Free Osteocutaneous Flap 20970
Iliohypogastric Nerve
Injection
Anesthetic 64425
Steroid 64425
Ilioinguinal Nerve
Injection
Anesthetic 64425
Steroid 64425
Ilium
Craterization 27070
Cyst
Excision 27070
Fracture
Saucerization 27070
Tumor
Excision 27065-27067, 27075, 27076
Ilizarov Procedure
Monticelli Type 20692
IM Injection
See Injection, Intramuscular
Imaging
Anatomic Model 3D Printing 0559T-0562T
Blood Vessels
Imaging, Gamma Camera
Imaging, Magnetic Resonance

See Magnetic Resonance Imaging (MRI)
Imaging, Ultrasonic
See Ultrasound
Imbrication
Diaphragm 39545
Immune Complex Assay 86332
Immune Globulin Administration
Injection 96372
Intravenous Infusion 96365-96368, 96374, 96375
Immune Globulin E 82785, 86003, 86005, 86008
Immune Globulins
Antitoxin
Botulinum 90287
Diphtheria 90296
Botulism 90288
Hepatitis B 90371
Human 90281, 90283, 90284
Rabies
RIg 90375
RIg-HT 90376
RIg-HT S/D 90377
Rho(D) 90384-90386
Tetanus 90389
Unlisted Immune Globulin 90399
Vaccinia 90393
Immunization, Mumps 90707, 90710

Immunization Administration
Each Additional Vaccine/Toxoid 90472, 90474
One Vaccine/Toxoid 90471, 90473
Immunoassay
Amniotic Fluid Protein 84112
Analyte 83516, 83518-83520
Calprotectin, Fecal 83993
Hemoglobin, Fecal 82274
Cellular Function
Detection of Biomarker 86352
Infectious Agent
See Infectious Agent
Other than Infectious Agent Antibody/Antigen 83516, 83518, 83519
Tumor Antigen
Human Epididymis Protein 4 (HE4) 86305
Qualitative/Semiquantitative 86294
Quantitative
CA 15-3 86300
CA 19-9 86301
CA-125 86304
Other Antigen 86316
Immunoblotting, Western
See Western Blot
Immunochemical, Lysozyme (Muramidase) 85549

Immunocytochemistry
Antibody 88341, 88342, 88344
Immunodeficiency Virus, Human

See HIV
Immunodeficiency Virus Type 1, Human
See HIV-1
Immunodeficiency Virus Type 2, Human

See HIV-2
Immunodiffusion
Gel Diffusion
Antibody or Antigen 86331
Ouchterlony 86331
Unspecified 86329
Immunoelectrophoresis
Crossed/2-dimensional Assay 86320
Fluids Other Than Serum 86325
Serum 86320
Immunofixation Electrophoresis
Fluids Other Than Serum 86335
Serum 86334
Immunofluorescence Microscopy
Antibody Stain Procedure 88346, 88350
Antiserum Culture Typing 87140
Infectious Agent Antigen Detection
See Infectious Agent, Antigen Detection, Immunofluorescence
Immunogen
See Antigen
Immunoglobulin 82784-82787
Platelet Associated Antibody 86023
Thyroid Stimulating 84445
Immunoglobulin E 82785, 86003, 86005, 86008
Immunohistochemistry
Antibody Stain Procedure 88341, 88342, 88344
Immunologic Skin Tests
Candida 86485
Coccidioidomycosis 86490
Histoplasmosis 86510
Other Antigen 86486
Tuberculosis 86580
Immunology 86000-86849
Tissue Typing
See Tissue, Typing
Unlisted Immunology Procedure 86849
Immunotherapies, Allergen
Impedance Testing
Bioelectrical Impedance Analysis
Whole Body Composition 0358T
Bioimpedance Spectroscopy (BIS)
Lymphedema Assessments 93702
Bioimpedance-derived Physiologic Analysis
Cardiovascular System 93701
Tympanometry 92567, 92570
Imperfectly Descended Testis

Implant, Breast
See Breast, Implant
Implant, Glaucoma Drainage

See Aqueous Shunt
Implant, Orbital 67550, 67560
Implant, Penile
Implant, Penile Prosthesis, Inflatable
See Penile Prosthesis, Insertion, Inflatable
Implant, Subperiosteal
See Subperiosteal Implant
Implant, Ureters into, Bladder
See Ureteroneocystostomy
Implant Removal
See Removal, Implant
Implantable Defibrillators
Subcutaneous Implantable Defibrillator (SICD)
Device Evaluation 93260, 93261, 93287, 93295, 93296, 93644
Insertion
Electrode 33202, 33203, 33271
System 33270
Removal 33241, 33262, 33272
Repair, Electrode 33218, 33220
Replacement, Pulse Generator 33262
Electrophysiological Evaluation 0577T
Insertion 0571T, 0572T
Interrogation Device Evaluation 0576T, 0578T, 0579T
Removal and Replacement of Pulse Generator 0614T
Removal of Electrode 0573T
Removal of Pulse Generator 0580T
Replacement 0571T
Repositioning of Electrode 0574T
Transvenous Implantable Pacing Defibrillator (ICD)
Device Evaluation 93282-93284, 93287, 93289, 93295, 93296
Insertion
Electrode 33202, 33203, 33216, 33217, 33224, 33225
System 33249
Removal
Electrode 33243, 33244
Pulse Generator 33241, 33262-33264
Replacement of Pulse Generator 33262-33264
Implantable Loop Recorder System

Implantation
Abdominal Wall
Non-Biologic or Synthetic Implant 0437T
Annulus Reconstruction Device
Mitral Valve 0544T
Tricuspid Valve 0545T
Aortic Valve
Transcatheter 33361-33369
Artificial Heart 33927
Baroreflex Activation Device 0266T-0268T
Lead 0267T
Pulse Generator 0268T
Total System 0266T
Biological Implant
Bone
for External Speech Processor/Cochlear Stimulator 69714-69718
Brain
Chemotherapy 61517
Drug Delivery Device 11981, 11983, 61517
Drug-Eluting Device
Embryo 58974
Ethmoid Sinus
Drug-Eluting Implant 31237, 31299
Eye
Aqueous Shunt to Extraocular Placement or Replacement of Pegs 65125
Posterior Segment
Extraocular 67120
Intraocular 67121
Replacement of Pegs 65125
Reservoir 66179, 66180
Vitreous
Hearing Aid Hormone Pellet(s)
Bone Conduction 69710
Hip Prosthesis
See Arthroplasty, Hip
Hormone Pellet 11980
Interatrial Septal Shunt Device 0613T
Intraocular Lens
See Insertion, Intraocular Lens
Joint
See Arthroplasty
Left Atrial Appendage 33340
Load
Upper Eyelid 67912
Mesh 49568
Hernia Repair 43333, 43335, 43337, 49568, 49652-49657
Vaginal Repair 57267
Nerve
into Bone 64787
into Muscle 64787
Neurostimulator Systems
See Neurostimulators
Ovum 58976
Pressure Sensor
Pulmonary Valve
Radiostereometric Analysis (RSA)
Interstitial 0347T
Removal 20670-20680
Ankle 27704
Contraceptive Capsules 11976
Disc 22865
Eye 67120, 67121
Finger 26320
Hand 26320
Wrist 25449
Reservoir Vascular Access Device
Declotting 36593
Retinal Electrode Array 0100T
Total Replacement Heart System 33927
Trunk
Biological Implant 15777
Tubouterine 58752
Ventricular Assist Device
Impression, Maxillofacial
Auricular Prosthesis 21086
Definitive Obturator Prosthesis 21080
Facial Prosthesis 21088
Interim Obturator 21079
Mandibular Resection Prosthesis 21081
Nasal Prosthesis 21087
Oral Surgical Splint 21085
Orbital Prosthesis 21077
Palatal Augmentation Prosthesis 21082
Palatal Lift Prosthesis 21083
Speech Aid Prosthesis 21084
Surgical Obturator 21076
IMRT (Intensity Modulated Radiation Treatment) 77385, 77386
In Situ Hybridization
Chromosome Analysis 88272, 88273
Fluorescent
See Fluorescent In Situ Hybridization (FISH)
Nucleic Acid Probe 88120, 88121, 88364-88366
In Vitro Fertilization 58321, 58322
In Vivo Laboratory Procedures
Unlisted Service 88749
In Vivo NMR Spectroscopy
Magnetic Resonance Spectroscopy 76390
Incision
See also Incision and Drainage
Abdomen 49000
Exploration 58960
Accessory Nerve 63191
Anal
Fistula 46270, 46280
Septum 46070
Sphincter 46080
Ankle 27607
Tendon 27605, 27606
Anus
See Anus, Incision
Aortic Valve
for Stenosis 33415
Artery
Nose 30915-30920
Atrial Septum 33735-33737
Bile Duct
Bladder
with Destruction 51020-51030
with Radiotracer 51020
Brachial Artery
Exposure 34834
Brain
Amygdalohippocampectomy 61566
Subpial 61567
Burn Scab 16035, 16036
Buttock 27027, 27057
Cataract
Secondary
Laser Surgery 66821
Stab Incision Technique 66820
Chest
Biopsy 32096-32098
with Therapeutic Wedge Resection 32505, 32506
Colon
Exploration 44025
Stoma
Creation 44320-44322
Cornea
for Astigmatism 65772
Laser
for Keratoplasty 0290T
Corpus Callosum 61541
Cricothyroid Membrane 31605
Duodenum 44010
Ear, Inner
Labyrinth
Transcanal 69801
Elbow 24000
Muscle 43030
Exploration
Heart 33310-33315
Kidney 50010
Eye
Adhesions 65880
Anterior Segment 65860-65865
Anterior Synechiae 65870
Corneovitreal 65880
Posterior 65875
Anterior Chamber 65820
Trabeculae 65850
Eyelid
Canthus 67715
Margin
for Biopsy 67810
Sutures 67710
Femoral Artery
Exposure 34812, 34813
Fibula 27607
Finger
Decompression 26035
Tendon 26060, 26455-26460
Tendon Sheath 26055
Foot 28005
Capsule 28260-28264
Fasciotomy 28008
for Infection 28002, 28003
Tendon 28230, 28234
Gallbladder 47490
Hand Decompression 26035-26037
Tendon 26450, 26460
Heart
Hemorrhoids
External 46083
Hepatic Ducts
See Hepaticostomy
Hip
Denervation 27035
Exploration 27033
Fasciotomy 27025
Joint Capsule
for Flexor Release 27036
Tendon
Abductor 27006
Adductor 27000-27003
Iliopsoas 27005
Hymen
See Hymen, Incision
Hymenotomy 56442
Hyoid
Muscle 21685
Iliac Artery
Exposure 34820, 34833
Intercarpal Joint
Dislocation 25670
Capsule 26525
Intestines (Except Rectum)
See Enterotomy
Intestines, Small 44010
Biopsy 44020
Creation
Pouch 44316
Stoma 44300-44310, 44314
Decompression 44021
Exploration 44020
Incision 44020
Removal
Foreign Body 44020
Revision
Stoma 44312
Iris 66500-66505
Kidney 50010, 50045
Knee
Capsule 27435
Exploration 27310
Fasciotomy 27305
Lacrimal Sac
Dacryocystotomy 68420
Larynx 31300
Leg, Lower
Leg, Upper
Fasciotomy 27305
Tenotomy 27306, 27307, 27390-27392
Lip
Frenum 40806
Liver
See Hepatotomy
Lung
Biopsy 32096, 32097
Decortication
Partial 32225
Total 32220
Lymphatic Channels 38308
Mastoid
See Mastoidotomy
Capsule 26520
Mitral Valve 33420-33422
Muscle
See Myotomy
Nerve 64568, 64575-64580, 64595, 64702-64772
Foot 28035
Root 63185-63190
Sacral 64581
Vagus 43640, 43641
Nose
Rhinotomy 30118, 30320
Orbit
See Orbitotomy
Palm
Pancreas
Sphincter 43262
Pelvis
Fasciotomy 27027, 27057
Penis
Prepuce 54000, 54001
Newborn 54000
Pericardium
with Clot Removal 33020
with Foreign Body Removal 33020
Pharynx
Stoma 42955
Pleura
Biopsy 32098
Pleural Cavity
Empyema 32035, 32036
Prostate
Exposure
Bilateral Pelvic Lymphadenectomy 55865
Insertion Radioactive Substance 55860
Lymph Node Biopsy 55862
Transurethral 52450
Pterygomaxillary Fossa 31040
Pulmonary Valve 33470, 33471, 33474
Pyloric Sphincter 43520
Retina
Encircling Material 67115
Sclera
Fistulization
Sclerectomy with Punch or Scissors with Iridectomy 66160
Thermocauterization with Iridectomy 66155
Trabeculectomy ab Externo in Absence Previous Surgery 66170
Trephination with Iridectomy 66150
Seminal Vesicle 55600-55605
Complicated 55605
Shoulder
Bone 23035
Capsular Contracture Release 23020
Removal
Calcareous Deposits 23000
Tenomyotomy 23405, 23406
Shoulder Joint 23040-23044
Sinus
Frontal 31070-31087
Maxillary 31020-31032
Endoscopic 31256-31267
Multiple 31090
Sphenoid
Sinusotomy 31050, 31051
Skin 10040, 10060, 10061, 10080, 10081, 10120-10180
Skull 61316, 62148
Suture 61550-61552
Spinal Cord 63200
Tract 63170, 63194-63199
Stomach
Creation
Stoma 43830-43832
Exploration 43500
Synovectomy 26140
Tendon
Arm, Upper 24310
Thigh
Fasciotomy 27025
Thoracoabdominal
Paraesophageal Hiatal Hernia Repair 43336, 43337
Thorax
Empyema 32035, 32036
Thyroid Gland
Thyrotomy 31300
Tibia 27607
Toe
Capsule 28270-28272
Fasciotomy 28008
Tendon 28232-28234
Tenotomy 28010, 28011
Tongue
Frenum 41010
Trachea
Emergency 31603-31605
Fenestration with Flaps 31610
Planned 31600, 31601
Tympanic Membrane 69420
Ureter 50600
Ureterocele 51535
Urethra 53000-53010
Meatus 53020-53025
Uterus
Remove Lesion 59100
Vagina
Exploration 57000
Vas Deferens 55200
for X ray 55300
Vitreous Strands
Laser Surgery 67031
Pars Plana Approach 67030
Wrist 25100-25105
Capsule 25085
Decompression 25020-25025
Tendon Sheath 25000, 25001

See also Drainage; Incision
Abdomen
Fluid 49082, 49083
Pancreatitis 48000
Abscess
Abdomen 49020, 49040
Open 49040
Anal 46045-46050
Ankle 27603
Appendix 44900
Arm, Lower 25028
Arm, Upper 23930, 23931
Bladder 51080
Brain 61320, 61321
Breast 19020
Ear, External
Complicated 69005
Simple 69000
Elbow 23930
Epididymis 54700
Eyelid 67700
Finger 26010, 26011
Gums 41800
Hip 26990
Kidney 50020
Knee 27301
Leg, Lower 27603
Leg, Upper 27301
Liver 47010
Lung 32200
Lymph Node 38300-38305
Mouth 40800, 40801, 41005-41009, 41015-41018
Nasal Septum 30020
Neck 21501, 21502
Nose 30000-30020
Ovary 58820-58822
Palate 42000
Paraurethral Gland 53060
Pelvis 26990, 45000
Perineum 56405
Peritoneum 49020
Prostate 55720-55725
Rectum 45005-45020, 46040, 46050-46060
Retroperitoneal 49060
Open 49060
Salivary Gland 42300-42320
Scrotum 54700, 55100
Skin 10060, 10061
Subdiaphragmatic 49040
Sublingual Gland 42310-42320
Submaxillary Gland 42310-42320
Subphrenic 49040
Testis 54700
Thorax 21501, 21502
Throat 42700-42725
Tongue 41000-41006, 41015
Tonsil 42700
Urethra 53040
Uvula 42000
Vagina 57010
Vestibule of the Mouth 40800, 40801
Vulva 56405
Wrist 25028
Ankle 27610
Bile Duct 47420-47425
Bladder 51040
Bulla
Skin
Bursa
Ankle 27604
Arm, Lower 25031
Elbow 23931
Foot 28001
Hip 26991
Knee 27301
Leg, Lower 27604
Leg, Upper 27301
Palm 26025-26030
Pelvis 26991
Wrist 25031
Carbuncle
Skin 10060, 10061
Carpals 25035, 26034
Comedones
Skin 10040
Cyst
Conjunctiva 68020
Gums 41800
Liver 47010
Lung 32200
Mouth 40800, 40801, 41005-41009, 41015-41018
Ovarian 58800-58805
Skin 10040, 10060, 10061
Thyroid Gland 60000
Tongue 41000-41006, 41015, 60000
Elbow
Abscess 23935
Arthrotomy 24000
Femur 27303
Fluid Collection
Skin 10140
Foreign Body
Skin 10120, 10121
Furuncle 10060, 10061
Gallbladder 47480
Hematoma
Ankle 27603
Arm, Lower 25028
Arm, Upper 23930
Brain 61312-61315
Ear, External
Complicated 69005
Simple 69000
Elbow 23930
Epididymis 54700
Gums 41800
Hip 26990
Knee 27301
Leg, Lower 27603
Leg, Upper 27301
Mouth 40800, 40801, 41005-41009, 41015-41018
Nasal Septum 30020
Neck 21501, 21502
Nose 30000-30020
Pelvis 26990
Scrotum 54700
Skin 10140
Skull 61312-61315
Testis 54700
Thorax 21501, 21502
Tongue 41000-41006, 41015
Vagina 57022, 57023
Wrist 25028
Hepatic Duct 47400
Hip
Bone 26992, 27030
Humerus
Abscess 23935
Toe 28024
Kidney 50040, 50125
Knee 27303, 27310
Lacrimal Sac 68420
Liver
Abscess or Cyst 47010
Mediastinum 39000-39010
Onychia 10060, 10061
Orbit 67405, 67440
Paronychia 10060, 10061
Pelvic
Bone 26992
Penis 54015
Pericardium 33025
Phalanges
Finger 26034
Pilonidal Cyst 10080, 10081
Pustules
Skin 10040
Radius 25035
Seroma
Skin 10140
Shoulder
Abscess 23030
Arthrotomy
Bursa 23031
Hematoma 23030
Shoulder Joint
Arthrotomy
Spine
Abscess 22010-22015
Tendon Sheath
Finger 26020
Palm 26020
Thorax
Deep 21510
Toe 28024
Ulna 25035
Ureter 50600
Vagina 57020
Wound Infection
Skin 10180
Wrist 25028, 25040
Incisional Hernia Repair

See Hernia Repair, Incisional
Inclusion Bodies
Fluid 88106
Smear 87207, 87210
Incomplete Abortion 59812

Indicator Dilution Studies
Cardiac Output 93562
Thermodilution 93561
Induced Abortion
See Abortion, Induced
Induced Hyperthermia
See Thermotherapy
Induced Hypothermia 99184
Induratio Penis Plastica
Indwelling Catheter
Percutaneous, Lung
See Pleural Cavity, Catheterization
Infant, Newborn, Intensive Care

See Intensive Care, Neonate
Infantile Paralysis
See Polio
Infection
Diagnosis
Group A Strep Test 3210F
Rapid Test 86403, 86406
Treatment
Antibiotic Prescribed 4045F
Infection, Actinomyces
See Actinomycosis
Infection, Bone
See Osteomyelitis
Infection, Filarioidea
See Filariasis
Infection, Postoperative Wound

Infection, Wound
Infectious Agent
Antibody Detection
Immunoassay, Multiple-Step
Actinomyces 86602
Adenovirus 86603
Aspergillus 86606
Bacterium 86609
Bartonella 86611
Blastomyces 86612
Bordetella 86615
Borrelia 86617-86619
Brucella 86622
Campylobacter 86625
Candida 86628
Chlamydia 86631, 86632
Coccidioides 86635
Coronavirus Disease (COVID-19) 86769
Cryptococcus 86641
Cytomegalovirus (CMV) 86644, 86645
Delta Agent 86692
Diphtheria 86648
Ehrlichia 86666
Encephalitis 86651-86654
Enterovirus 86658, 87498
Francisella Tularensis 86668
Fungus, Other 86671
Haemophilus Influenzae 86684
Helicobacter Pylori 86677
Helminth 86682
Hepatitis Delta Agent 86692
Hepatitis B
Core 86704
IgM 86705
Surface 86706
Hepatitis Be 86707
Hepatitis C 86803, 86804
Herpes Simplex 86694-86696
Histoplasma 86698
HIV 86689, 86701-86703
HIV-1 86701, 86703, 87389, 87806
HIV-2 86702, 86703, 87389, 87806
HTLV-I 86687, 86689
HTLV-II 86688
Influenza Virus 86710
Legionella 86713
Leishmania 86717
Leptospira 86720
Listeria Monocytogenes 86723
Lyme Disease 86617
Malaria 86750
Mucormycosis 86732
Mumps 86735
Mycoplasma 86738
Nocardia 86744
Parvovirus 86747
Plasmodium 86750
Protozoa 86753
Rickettsia 86757
Rotavirus 86759
Rubella 86762
Rubeola 86765
Salmonella 86768
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) 86769
Shigella 86771
Tetanus 86774
Thyroglobulin 86800
Toxoplasma 86777, 86778
Trichinella 86784
Tuberculosis 86580
Virus, Other 86790
West Nile Virus 86788, 86789
Yersinia 86793
Immunoassay, Other Antibody
Quantitative 86317
Immunoassay, Single-Step
Qualitative/Semiquantitative 86318
Antigen Detection
Direct Fluorescence
Bordetella 87265
Enterovirus 87267
Giardia 87269
Influenza A 87276
Immunoassay
Adenovirus 87301, 87809
Aspergillus 87305
Cryptococcus Neoformans 87327
Entamoeba Histolytica Dispar Group 87336
Entamoeba Histolytica Group 87337
Escherichia coli 0157 87335
Giardia 87329
Helicobacter Pylori 87338, 87339
Hepatitis, Delta Agent 87380
Hepatitis B Surface Antigen (HBsAg) 87340
Hepatitis B Surface Antigen (HBsAg) Neutralization 87341
Hepatitis Be Antigen (HBeAg) 87350
Histoplasma capsulatum 87385
HIV-1 87389, 87390
HIV-2 87391
Influenza A 87400
Influenza B 87400
Multiple Step Method 87301-87449, 87451
Not Otherwise Specified 87449, 87450
Polyvalent 87451
Rotavirus 87425
Shiga-like Toxin 87427
Single Step Method 87450
Immunoassay, with Direct Optical Observation
Gonorrhea 87850
HIV-1 87806
Influenza 87804
Neisseria Gonorrhoeae 87850
Trichomonas Vaginalis 87808
Immunofluorescence
Adenovirus 87260
Herpes Simplex 87273, 87274
Influenza B 87275
Parainfluenza Virus 87279
Pneumocystis Carinii 87281
Polyvalent 87300
Rubeola 87283
Nucleic Acid Probe
Bartonella Henselae 87471-87472
Bartonella Quintana 87471-87472
Borrelia Burgdorferi 87475, 87476
Candida Species 87480-87482
Chlamydia Pneumoniae 87485-87487
Chlamydia Trachomatis 87490-87492
Cytomegalovirus 87495-87497
Gardnerella Vaginalis 87510-87512
Gonorrhea 87850
Hepatitis B Virus 87516, 87517
Hepatitis C 87520-87522
Hepatitis G 87525-87527
Herpes Simplex Virus 87528-87530
Herpes Virus-6 87531-87533
HIV-1 87534-87536
HIV-2 87537-87539
Influenza 87501-87503
Legionella Pneumophila 87540-87542
Multiple Organisms 87800, 87801
Mycobacteria Avium-Intracellulare 87560-87562
Mycobacteria Species 87550-87552
Mycobacteria Tuberculosis 87555-87557
Mycoplasma Pneumoniae 87580-87582
Neisseria Gonorrhoeae 87590-87592
Not Otherwise Specified 87797-87799
Papillomavirus, Human 0500T, 87623-87625
Respiratory Virus 87631-87634
Staphylococcus Aureus 87640, 87641
Streptococcus, Group A 87650-87652
Trichomonas Vaginalis 87660, 87661
Vancomycin Resistance 87500
Zika Virus 87662
Concentration 87015
Detection by Nucleic Acid Probe
Central Nervous System Pathogen 87483
Enzymatic Activity 87905
Genotype Analysis
by Nucleic Acid
Hepatitis B Virus 87912
HIV-1 Regions 87901, 87906
Phenotype Analysis
by Nucleic Acid
HIV-1 Drug Resistance 87903, 87904
Phenotype Prediction
by Genetic Database 87900
Infectious Mononucleosis Virus

Inflammatory Process
Localization
Nuclear Medicine 78800-78804, 78830-78832
Inflation
Eustachian Tube
Myringotomy 69420
Anesthesia 69424
Influenza A
Antigen Detection
Immunoassay 87400
Influenza B
Antigen Detection
Immunoassay 87400
Influenza Vaccine
See Vaccines and Toxoids, Influenza
Influenza Virus
Antibody 86710
Detection
by Immunoassay
by Nucleic Acid 87501-87503
Infraorbital Nerve
Avulsion 64734
Incision 64734
Transection 64734
Infrared Light Treatment

Application 97026
Infratentorial Craniectomy
Evacuation of Hematoma 61314, 61315
Excision of Abscess 61522
Excision of Cyst 61524
Excision of Tumor 61518, 61519, 61521
Exploratory 61305
Infusion
Amnion
Anesthetic
Paravertebral Block (PVB) 64463
Cerebral
for Thrombolysis
Intravenous 37195
Percutaneous Transluminal 61645
Hydration 96360, 96361
Status Documented 2030F, 2031F
Intra-Arterial 96373
Unlisted 96379
Intraosseous 36680
Intravenous Unlisted 96379
Diagnostic/Prophylactic/Therapeutic 96365-96368, 96379
Nerves
See Nerves, Infusion
Radioelement 77750
Spinal
Diagnostic/Therapeutic 62324-62327
Device Implantation/Replacement 62360-62362
Subcutaneous 96369-96371
for Thrombolysis
Percutaneous Transluminal 61645
Transcatheter Therapy 37211-37214
Transcatheter Therapy 37211-37214
Infusion Pump
Electronic Analysis
Insertion
Intra-Arterial
Removal 36262
Revision 36261
Intravenous
Insertion 36563
Repair 36576
Replacement 36583
Maintenance 95990, 95991, 96521, 96522
See Chemotherapy, Pump Services
Refill 62369, 62370
Reprogramming 62368-62370
Ventricular Catheter 61215
Infusion Therapy
Arterial Catheterization 36640
Intravenous 96365-96368, 96379
Chemotherapy 96413, 96415-96417, 96422, 96423, 96425
by Pump
See Infusion Pump
Spinal 62324-62327, 62350, 62351
Subcutaneous 96369-96371, 96379
Unlisted Therapeutic Infusion 96379
Ingestion Challenge Test
Incremental/Sequential 95076, 95079
Inguinal Hernia Repair

See Hernia Repair, Inguinal
INH (Isonicotinic Acid Hydrazide)
See Isocitric dehydrogenase (IDH)
Inhalation
Pentamidine 94642
Inhalation Provocation Tests
Inhalation Treatment
for Airway Obstruction
Pressurized or Nonpressurized 94640
Continuous 94644, 94645
Home Visit 99503
Nebulizer 94664
Inhibin A 86336
Inhibition, Fertilization
See Contraception
Inhibition Test, Hemagglutination 86280
Inhibitor, Alpha 1-Protease
See Alpha-1 Antitrypsin
Inhibitor, Alpha 2-Plasmin

See Alpha-2 Antiplasmin
Inhibitory Concentration, Minimum
See Minimum Inhibitory Concentration
Initial Inpatient Consultations

Injection
See also Allergen Immunotherapy; Infusion
Abdomen
Air 49400
Contrast Material 49400
Knee Joint 0566T
Air
Anesthetic Agent
Nerves
See Nerves, Injection, Anesthetic/Steroid
Angiography
Pulmonary 75746
Ankle
Radial 27648
Antibiotic
See Antibiotic Administration
Antigen (Allergen) 95115-95125
Anus
Aorta (Aortography)
Radiological 93567
Aponeurosis 20550
Arthrography
Bile Duct
Cholangiography 47531, 47532
Bladder
for Chemodenervation 52287
Brain Canal 61070
Bursa 20600, 20604, 20605, 20610, 20611
Cardiac Catheterization 93454-93464, 93563-93568
Carpal Tunnel
Therapeutic 20526
Chemotherapy 96401-96542, 96549
Cistern
Medication or Other 61055
Contrast 49465
via Catheter 36598, 49424
Corpora Cavernosa 54235
Cyst
Bone 20615
Kidney 50390
Pelvis 50390
Thyroid 60300
Diagnostic
Additional Sequential, Each Push 96376
Elbow
Arthrography
Radiological 24220
Epidural
Esophageal Varices
Esophagus
Sclerosing Agent 43204
Submucosal 43192, 43201, 43236
Extremity
Pseudoaneurysm 36002
Eye
Anterior Segment
Air 66020
Medication 66030
Pharmacologic Agent 0465T, 67028
Posterior Segment
Intravitreal 67028
Suprachoroidal 0465T
Eyelid
Subconjunctival 68200
Fluid Collection
Sclerosant 49185
Foot
Nerve 64455
Ganglion
Ganglion Cyst 20612
Gastric Secretion Stimulant 43755
Gastric Varices
Endoscopy 43243
Hand
Heart Vessels
Hemorrhoids
Hip
Intervertebral Disc
Allogenic Cellular/Tissue-based Product 0627T-0630T
Chemonucleolysis Agent 62292
Radiological 62290, 62291
Intra-amniotic 59852
Intra-arterial 96373, 96379
Thrombolytic 37184-37186, 61645
Intradermal
for Tattooing 11920-11922
Intralesional
Skin 11900, 11901
Intramuscular 96372
Therapeutic 96372, 99506
Intravenous 96379
Nuclear Diagnostic Localization 78808
Thrombolytic 37187, 37188
Unlisted 96379
Vascular Flow Check, Graft 15860
Intravenous Push 96374-96376
Joint 20600, 20604-20606, 20610, 20611
Kidney
Drugs 50391
for Nephrostogram 50430, 50431
Knee
Adipose Cellular Implant 0566T
Radiological 27369
Lacrimal Gland
Radiological 68850
Larynx
Endoscopic 31570, 31573, 31574
Left Heart
Radiological 93565
Lesion
Skin 11900, 11901
Ligament 20550
Liver 47015
Mammary Ductogram/Galactogram 19030
Muscle Endplate
Facial 64612
Nerve
Anesthetic 01991, 01992, 64400-64530
Neurolytic Agent 64600-64640, 64680, 64681
Steroid 64400
Orbit
Retrobulbar
Alcohol 67505
Medication 67500
Tenon’s Capsule 67515
Pancreatography 48400
Paravertebral Facet Joint/Nerve
with Image Guidance 64490-64495
with Ultrasound Guidance 0213T-0218T
Penis
for Erection 54235
Peyronie Disease 54200
with Surgical Exposure of Plaque 54205
Radiology 54230
Vasoactive Drugs 54231
Peritoneal Cavity
Air 49400
Platelet Rich Plasma 0232T
Prophylactic
Radiological
Breast 19030
Cholangiography 47531, 47532
Rectum
Right Heart 93454-93461, 93563-93568
Radiological 93566
Sacroiliac Joint
for Arthrography 27096
Salivary Duct 42660
Salivary Gland
Radiological 42550
Sclerosant
Esophagus 43204
Intravenous 36465, 36466, 36468, 36470, 36471
Sentinel Node
Identification 38792, 38900
Shoulder
Arthrography
Radiological 23350
Shunt
Peritoneal
Venous 49427
Sinus Tract 20500
Diagnostic 20501
Spider Veins
Sclerosant 36468
Spinal Artery 62294
Spinal Cord
Anesthetic 62320-62327
Blood 62273
Neurolytic Agent 62280-62282
Other 62320-62327
Radiological 62284
Steroids
Spine
Cervical 62320, 62321, 62324, 62325
Lumbar 62322, 62323, 62326, 62327
Sacral 62322, 62323, 62326, 62327
Thoracic 62320, 62321, 62324, 62325
Urethral Stricture 52283
Subcutaneous 96372
Silicone 11950-11954
Therapeutic 96372
Timed
Application of On-Body Injection Device 96377
Arthrography 21116
Tendon Origin, Insertion 20551
Tendon Sheath 20550
Therapeutic
Extremity Pseudoaneurysm 36002
Lung 32960
Thyroid 60300
Turbinate 30200
Thoracic Cavity
Instillation of Agent 32560
Thoracoscopic 32650
Trachea 31612
Puncture 31612
Trigger Point(s)
One or Two Muscles 20552
Three or More Muscles 20553
Turbinate 30200
Ureter
Drugs 50391
Radiological 50684
for Ureterogram 50430, 50431
Vein
Sclerosant 36465, 36466, 36468, 36470, 36471
Venography 36005
Ventricle
Dye 61120
Medication or Other 61026
Vitreous 67028
Fluid Substitute 67025
Vocal Cords
Therapeutic 31513, 31570, 31571
White Blood Cells
Autologous Concentrate 0481T
Wrist
Carpal Tunnel
Therapeutic 20526
Radiological 25246
Inner Ear
See Ear, Inner Ear
Innominate
Artery
Bone
Osteotomy 27146
Innominate Arteries
Inorganic Sulfates
See Sulfate
INR Test Review
with Anticoagulant Management 93793
Insemination
Artificial
Intra-cervical 58321
Intra-uterine 58322
of Oocytes 89268
Sperm Washing 58323
Insertion
See also Implantation; Intubation; Transplantation
without Extraocular Reservoir 0376T, 0449T, 0450T, 66183
Balloon
Intra-Aortic 33967, 33973
Breast
Implant 19340, 19342
Cannula
for On-Body Injector 96377
ECMO
See Extracorporeal Membrane Oxygenation (ECMO), Insertion of Cannula(e)
Extra Corporeal Circulation
for Regional Chemotherapy of Extremity 36823
Thoracic Duct 38794
Vein to Vein 36800
Cardiac Contractility Modulation System 0408T-0411T
Catheter
See also Placement, Catheter
Abdomen 49324, 49418, 49419, 49421, 49435
Abdominal Artery 36245-36248
Aorta 36200
Bladder 51045, 51701-51703
Brachiocephalic Artery 36215-36218
Brain 61770
Bronchi 31717
Bronchus
Cardiac
Flow Directed 93503
Jejunum 44015
Lower Extremity Artery 36245-36248
Nasotracheal 31720
Pelvic Artery 36245-36248
Pericardium 33017-33019
Pleural Cavity 32550, 32556
Portal Vein 36481
Prostate 55875
Pulmonary Artery 36013-36015
Right Heart 36013
Skull 61107
Suprapubic 51045, 51102
Thoracic Artery 36215-36218
Transthoracic 33621
Urethra 51701-51703
Vena Cava 36010
Venous
See Catheterization, Venous
Cecostomy Tube 49442
Cervical Dilation 59200
Colonic Tube 49442
Defibrillator System
Distraction Device
Interlaminar/Interspinous Process, Lumbar 22867-22870
Drug Delivery Device
Muscle 20700, 20702, 20704
Drug Delivery Implant 11981, 11983
Drug-Eluting Implant
Duodenostomy Tube 49441
Electrode
Brain 61531-61533, 61760, 61863, 61864, 61867, 61868
Chest Wall
Respiratory Sensor 0466T
Heart 33202, 33203, 33210, 33211, 33216, 33217, 33224, 33225, 33271, 93620-93622
Nerve 64553-64581
Retina 0100T
Sphenoidal 95830
Stomach
Neurostimulator
Laparoscopic 43647
Open 43881
Endotracheal Tube
Filter
Vena Cava 37191
Gastrostomy Tube
Laparoscopic 43653
Percutaneous 43246
Glucose Sensor
with Subcutaneous Pocket Creation 0446T, 0448T
Graft
Aorta 33330-33335
Heart Vessel 33330-33335
Guide Wire
Endoscopy 43248
Esophagoscopy 43248
with Dilation 43196, 43212, 43226, 43229
Heyman Capsule
Uterus
for Brachytherapy 58346
Iliac Artery
Occlusion Device 34808
Implant
Bone
for External Speech Processor/Cochlear Stimulator 69714-69718
Implantable Cardioverter-Defibrillator (ICD)
Infusion Pump
Intravenous 36563
Intracatheter/Needle
Aorta 36160
Intra-Arterial 36100-36140
Intravenous 36000
Intramedullary Lengthening Device
Humeral Osteotomy 0594T
Intraocular Lens 66983
Manual or Mechanical Technique 66982, 66984, 66987, 66988
Not Associated with Concurrent Cataract Removal 66985
Intrauterine Device (IUD) 58300
Jejunostomy Tube
Endoscopy 44372
Percutaneous 49441
Keel
Laryngoplasty 31580
Laminaria 59200
Left Ventricular Wireless Stimulator System 0515T-0517T
Mesh
Pelvic Floor 57267
Needle
Bone 36680
Intraosseous 36680
Muscle 20560, 20561
Prostate 55875
Needle Wire
Trachea 31730
Neurostimulator
Nose
Septal Prosthesis 30220
Obturator
Larynx 31527
Ocular Implant
with Foreign Material 65155
with/without Conjunctival Graft 65150
in Scleral Shell 65130
Orbital Transplant 67550
Oviduct
Chromotubation 58350
Hydrotubation 58350
Ovoid
Vagina
Pacemaker, Heart
See Pacemaker
Packing
Vagina 57180
Penile Prosthesis, Inflatable 54401-54405
Pessary
Vagina 57160
Pin
Probe
Brain 61770
Prostaglandin 59200
Prostate
Prosthesis
Knee 27438, 27445
Nasal Septal 30220
Palate 42281
Pelvic Floor 57267
Penis
Inflatable 54401-54405
Noninflatable 54400
Speech 31611
Testis 54660
Urethral Sphincter 53444, 53445
Pulse Generator
See Pulse Generator
Radiation Afterloading Apparatus 57156
Vagina
Radioactive Material
Bladder 51020
Cystourethroscopy 52250
Receiver
Brain 61885, 61886
Spinal Cord 63685
Reservoir
Brain 61210-61215
Spinal Cord 62360
Subcutaneous 49419
Shunt 36835
Abdomen
Vein 49425
Venous 49426
Eye
to Suprachoroidal Space 0253T
Intrahepatic Portosystemic 37182
Spinal Instrument 22849
Spinous Process 22841
Anterior 22845-22847
Biomechanical Device 22853, 22854, 22859
Internal Spinal Fixation 22841
Pelvic Fixation 22848
Posterior Nonsegmental
Harrington Rod Technique 22840
Posterior Segmental 22842-22844
Stabilization/Distraction Device 22869, 22870
Stent
Bile Duct 43274, 47801
Bladder 51045
Conjunctiva 68750
Coronary 92928, 92929
Esophagus 43212
Ileum 44384
Indwelling 50605
Lacrimal Duct 68815
Larynx 31580
Small Intestines 44370, 44379
Ureter 50688
Ureter via Kidney 50693
Ureteral 50947, 52332
Urethral 52282
System 33285
Substernal Implantable Cardioverter-Defibrillator 0571T, 0572T
Tamponade
Esophagus 43460
Tandem
Uterus
Tendon Graft
Finger 26392
Hand 26392
Testicular Prosthesis 54520, 54660
Tissue Expander
Breast 19357
Other than Breast 11960
Tube
Esophagus 43510
Ileum 44384
Small Intestines 44379
Trachea 31730
Ureter 50688
Ureteral Guide Wire 52334
Urethra
Female Intraurethral Valve-Pump 0596T
Valve
Bronchial 31647, 31651
Vascular Pedicle
Carpal Bone 25430
Venous Access Device
Central 36560-36566
Ventilating Tube 0583T, 69433
Wire
Inspiratory Positive Pressure Breathing

See Intermittent Positive Pressure Breathing (IPPB)
Instillation
Agent for Fibrinolysis 32561, 32562
Agent for Pleurodesis 32560
Drugs
Bladder 51700
Anticarcinogenic Agent 51720
Endoscopic
Bladder 52005, 52010
Kidney 50551, 50570
Renal Pelvis 50551, 50570
Ureter 50951, 50970
Urethra 52005, 52010, 53660
Kidney 50391
Ureter 50391
Radioelement Solution 77750
Instillation, Bladder
See Bladder, Instillation
Instrumentation
Spinal
with Arthrodesis 22586
Insertion 22840-22848, 22853, 22854, 22859, 22869, 22870
Reinsertion 22849
Removal 22850, 22852, 22855
Insufflation, Eustachian Tube 69420, 69421

Insulin
Antibody 86337
Blood 83525
Free 83527
Panels
for ACTH Insufficiency 80434
Glucagon Tolerance 80422
Insulin Tolerance 80434, 80435
Insulin-induced C-peptide Suppression 80432
for Insulinoma 80422
Insulin C-Peptide Measurement 80432, 84681

Insulin-Like Growth Factors
Somatomedin 84305
Insurance
Basic Life and/or Disability Evaluation Services 99450
Disability Examination
Basic Life and/or Disability 99450
Work Related or Medical Disability 99455, 99456
Ablation
Breast 19105
Biopsy
Lesion
Punch 11104, 11105
Breast
See Breast
Replacement
Tissue Expander with Implant 11970
Burns
See Burns
Debridement 11000-11006, 11010-11047
Destruction
Actinotherapy 96900
Benign Lesion 17000, 17003, 17004, 17110, 17111
Cryotherapy 17340
Cutaneous Vascular Proliferative Lesion 17106-17108
Electrolysis Epilation 17380
Malignant Lesion 17260-17286
Mohs Micrographic Surgery 17311-17315
Premalignant Lesion 17000, 17003, 17004
by Photodynamic Therapy 96567, 96573, 96574
Drainage
Image Guided 10030
Dressing Change
Excision
Benign Lesion 11400-11404, 11406, 11420-11424, 11426, 11440-11444, 11446
Excessive Skin/Tissue 15830, 15832-15839
for Hidradenitis
Axillary 11450, 11451
Inguinal 11462, 11463
Perianal 11470, 11471
Perineal 11470, 11471
Lipectomy 15830, 15832-15839
Suction Assisted 15771-15774, 15876-15879
Malignant Lesion 11600-11604, 11606, 11620-11624, 11626, 11640-11644, 11646
Nail 11750
Pressure Ulcer
Ischial 15940, 15941, 15944-15946
Sacral 15931, 15933-15937
Trochanteric 15950-15953, 15956, 15958
Fluid Collection
Image Guided 10030
Graft
See Autograft; Skin Graft and Flap
Implantation
Hormone Pellet, Subcutaneous 11980
Abscess 10060, 10061
Acne 10040
Fluid 10140
Hematoma 10140
Pilonidal Cyst 10080, 10081
Postoperative Wound Infection 10180
by Puncture Aspiration
Abscess 10160
Bulla 10160
Cyst 10160
Hematoma 10160
Seroma 10140
Insertion
Permanent Implant 11970
Tissue Expander 11960
Introduction
Filling Material 11950-11954
Pigment for Tattooing 11920-11922
Nail 11720-11765
See Nails
Paring
Benign Hyperkeratotic Lesion 11055-11057
Photography 96904
Pilonidal Cyst
Incision 10080, 10081
Pressure Ulcers 15920-15999
Removal
Contraceptive Capsules Implant 11976
Sutures
with Anesthesia 15850-15852
Repair
Adjacent Tissue Transfer/Rearrangement
See Tissue, Transfer
with Grafts and Flaps
Other Procedures 15780-15879
Skin and/or Deep Tissue 15570-15738
Wounds
See Wound, Repair
Rhytidectomy
See Rhytidectomy
Shaving
Epidermal or Dermal Lesion 11300-11313
Skin Replacement Surgery and Skin Substitutes
Autograft/Tissue Cultured Autograft 15040-15157
Skin Substitute Graft
Surgical Preparation 15002-15005
Skin Tags
Removal 11200, 11201
Tattooing 11920-11922
Tissue Expander
Removal 11971
Replacement
with Implant 11970
Treatment
Superficial Wound Dehiscence 12020, 12021
Trunk
Unlisted Skin, Mucous Membrane, Subcutaneous Tissue Procedure 17999
Integumentum Commune
See Integumentary System
Intensity Modulated Radiation Treatment (IMRT)
Complex 77386
Simple 77385
Intensive Care
Low Birthweight Infant
Neonate
Initial 99477
Interbody
Arthrodesis
Presacral 22586
Intercarpal Joint
Arthrodesis 25800, 25805, 25810, 25820, 25825
Dislocation
Magnetic Resonance Imaging 73221-73225
Repair 25447
Intercostal Nerve
Destruction 64620
Injection
Neurolytic 64421, 64620
Steroid 64420, 64421
Interdental Fixation
Device
Application 21110
Removal 20670, 20680
without Fracture 21497
Mandibular Fracture
Maxillary Fracture
Nasomaxillary Complex Fracture
Palatal Fracture
Interdental Papilla
See Gums
Interdental Wire Fixation
without Fracture 21110, 21497
Mandibular Fracture
Maxillary Fracture
Nasomaxillary Complex Fracture
Palatal Fracture
Interferometry
Ophthalmic Biometry 92136
Intermediate Care Facilities (ICFs)
Intermittent Positive Pressure Breathing (IPPB)

Device
Inhalation Treatment for Airway Obstruction 94640
Patient Utilization
Demonstration 94664
Evaluation 94664
Internal Breast Prostheses
See Prosthesis, Breast
Internal Ear
See Ear, Inner Ear
Internal Rigid Fixation
Femoral Neck Fracture 27236
Reconstruction
Mandibular Rami 21196
International Normalized Ratio

Patient/Caregiver Training 93792
Test Review 93793
Internet E/M Service
Interprofessional Consultation 99446-99449, 99451, 99452
Online Evaluation and Management 98970-98972, 99421-99423
Amputation 28825
Arthrodesis 26860-26863, 28755, 28760
Arthrotomy 26080
with Biopsy 28054
with Drainage 28024
with Exploration 28024
with Removal of Foreign Body 28024
Biopsy 28054
Synovium 26110
Capsule
Excision 26525
Incision 28272
Dislocation
without Anesthesia 28660
with Internal Fixation 28675
Excision
Toe, Proximal End 28160
Fasciectomy with Release 26123, 26125
Fracture
Fusion 26860-26863
Great Toe
Arthrodesis 28755
Fusion 28755
Repair
Collateral Ligament 26540, 26545
Volar Plate 26548
Synovectomy 26140
Toe 28272
Arthrotomy 28024
Dislocation 28660-28665, 28675
Excision 28160
Exploration 28024
Removal
Foreign Body 28024
Loose Body 28024
Synovial
Biopsy 28054
Interprofessional Telephone/Internet/Electronic Health Record

Consultation 99446-99449, 99451, 99452
Interrogation
Device
See Device Evaluation Services
Genomic Regions
Acute Myelogenous Leukemia 0050U
Chromosome 22q13 81405
Copy Number Variants 81228-81229, 81277, 81445, 81450, 81455
Isoform Expression 81450
Loss-of-Heterozygosity Variants 81277
mRNA Expression Levels 81450
Non-Small Cell Lung Neoplasia 0022U
Sequence Variants 81445, 81450, 81455
Single Nucleotide Polymorphism (SNP) 81229
Solid Organ Neoplasm 0037U, 0048U
Interruption
Vein
Femoral 37650
Iliac 37660
Lower Leg 37735
Saphenous Vein 37700
Intersex State
Clitoroplasty 56805
Vaginoplasty 57335
Intersex Surgery
Female to Male 55980
Male to Female 55970
Interspace, Vertebral
Arthrodesis
See Arthrodesis, Vertebra
Arthroplasty, Disc 22856-22858, 22861, 22862, 22864, 22865
Decompression 62380
Discectomy
See Discectomy
Laminotomy
Cervical 63020, 63035, 63040, 63043
Lumbar 63030, 63042, 63044
Spinal Instrumentation 22840, 22853
Vertebral
Arthrodesis
See Arthrodesis, Vertebra
Interstitial Cell Stimulating Hormone

Interstitial Cystitides, Chronic
See Interstitial Cystitis
Interstitial Cystitis
Bladder Dilation 52260, 52265
Interstitial Fluid Pressure
Monitoring 20950
Interstitial Radiation Therapy

Radioelement Application 77778
Device Placement
Breast 19296-19298
Genitalia 55920
Head 41019
Neck 41019
Pelvis 55920
Uterus 57155
Vagina 57155, 57156
Heyman Capsules Insertion 58346
Intertarsal Joint
Biopsy 28050
Drainage 28020
Exploration 28020
Removal
Foreign Body 28020
Loose Body 28020
Synovectomy 28070
Interthoracoscapular Amputation 23900
Intertrochanteric Femur Fracture
See Femur, Fracture, Intertrochanteric
Intervertebral Chemonucleolysis 62292
Intervertebral Disc
Annuloplasty 22526, 22527
Arthroplasty
Artificial Disc 0163T, 22856-22858
Removal 0095T, 0164T, 22864, 22865
Revision 0098T, 0165T, 22861, 22862
Aspiration 62267
Biopsy 62267
by Needle 62287
Discectomy
See Discectomy
Discogenic Pain Determination/Localization
Magnetic Resonance
Spectroscopy 0609T-0612T
Discography
Cervical 72285
Injection 62291
Lumbar 62292, 72295
Injection 62290
Thoracic 72285
Injection 62291
Herniated
Excision
Cervical 63020, 63035, 63040, 63043
Lumbar 62380, 63030, 63035, 63042-63044, 63056, 63057
Thoracic 63055, 63057, 63064, 63066
Injection
Allogenic Cellular/Tissue-based
Product 0627T-0630T
Chemonucleolysis Agent 62292
X ray 62290, 62291
Insertion
Biomechanical Device 22853, 22854, 22859
Removal
Artificial Disc 0095T, 0164T, 22864, 22865
by Needle 62287
Revision
Artificial Disc Arthroplasty 0098T, 0165T, 22861, 22862
Intestinal Anastomosis
See Anastomosis, Intestines
Intestinal Invagination
See Intussusception
Intestinal Peptide, Vasoactive 84586

Intestines
Alimentation 44015
Allotransplantation 44135, 44136
Removal 44137
Anastomosis 44130, 44625, 44626
Closure 44227
with Cystectomy 51590
with Intestinal Replacement of Ureter 50840
Koch Pouch 50825
Laparoscopic 44227
Biopsy 44100
Closure
Enterostomy 44620, 44625, 44626
Large or Small 44227, 44625, 44626
Fistula 44640, 44650, 44660
with Resection 44661
Stoma 44620-44625
Construction
Neobladder 51596
Ureter 50840
Enteroenterostomy 44130
Enterolysis 44005
Laparoscopic 44180
Enterostomy
Closure 44620, 44625, 44626
Laparoscopic 44227, 44625, 44626
Excision
Donor 44132, 44133
Exteriorization 44602-44605
Fecal Microbiota Transplantation
Preparation of Specimen 44705
Graft 43116, 46748
Laparoscopic Resection
with Anastomosis 44202, 44203
Lesion
Excision 44110, 44111
Lysis
of Adhesions 44005
of Duodenal Bands 44050
Laparoscopic 44180
Malrotation
Correction 44055
Mobilization 43108, 43113, 43118, 43123, 43361
Nuclear Medicine
Imaging 78290
Obstruction
Stricturoplasty 44615
Plication 44680
Reconstruction
Bladder 50820
Colonic Reservoir 45119
for Obstruction 44615
Pouch 43622, 43634
Resection 44661
Laparoscopic 44227
Transplantation
Allograft Preparation 44715-44721
Donor Enterectomy 44132, 44133
Removal of Allograft 44137
Laparoscopic 44238
Ureteroenterostomy 50800
Volvulus
Reduction 44050
Intestines, Large
See Anus; Colon; Rectum
Intestines, Small
Closure 44227
Laparoscopic Resection 44202
Biopsy 44020
Endoscopy 44361
Catheterization
Jejunum 44015
Decompression 44021
Destruction
Lesion 44369
Tumor 44369
Endoscopy 44364
Ablation
Lesion 44369
Polyp 44369
Tumor 44369
Biopsy 44361, 44377, 44382, 44386
Collection of Specimen 44360, 44376, 44380, 44385
Control of Bleeding 44366, 44378
via Stoma 44382
Destruction
Lesion 44369
Tumor 44369
Diagnostic 44360, 44376, 44380
Evaluation
Pouch
Ileal Reservoir 44385
Kock 44385, 44386
Exploration 44360
Hemorrhage 44366, 44378
Ileal Reservoir 44385, 44386
Insertion
Stent 44370, 44379
Tube 44372
Kock Pouch 44385, 44386
Removal
Foreign Body 44363
Lesion 44364, 44365
Polyp 44364, 44365
Tumor 44364, 44365
Repair
Fistula 46707
via Stoma
Balloon Dilation 44381
Biopsy 44382
Diagnostic 44380
Tube Revision 44373
Enterostomy
Placement 44300
Excision 44120, 44121, 44125-44128
Partial with Anastomosis 44140
Exclusion 44700
Exploration 44020
Hemorrhage 44378
Ileostomy 44310-44314, 45136
Continent 44316
Incision 44020
Creation
Pouch 44316
Stoma 44300-44310, 44314
Decompression 44021
Exploration 44020
Revision
Stoma 44312
Stoma Closure 44620-44626
Insertion
Catheter 44015
Jejunostomy Tube 44372, 49441
Jejunostomy 44310
Laparoscopic Resection 44203
Lysis
Adhesions 44005
Removal
Repair
Enterocele
Fistula 44640-44661
Hernia 44050
Malrotation 44055
Obstruction 44050
Ulcer 44602, 44603
Volvulus 44050
Wound 44602, 44603
Revision
Jejunostomy Tube 44373, 49451, 49452
Specimen Collection 43756, 43757
Suture
Fistula 44640-44661
Plication 44680
Ulcer 44602, 44603
Wound 44602, 44603
Tumor
Destruction 44369
X ray 74248, 74250, 74251
Guide Intubation 74355
Intestinovesical Fistula
Enterovesical
Closure 44660, 44661
Intimectomy
See Endarterectomy
Intra-Abdominal Voiding Pressure Studies

Gastric 51797
Intraperitoneal 51797
Rectal 51797
Intra-Arterial Injections
Therapeutic, Prophylactic, or Diagnostic 96373, 96379
Thrombolytic 37184-37186, 61645
Intracapsular Extraction of Lens 66920-66930

Intracardiac Echocardiography 93662
Intracranial
Biopsy 61140
Extracranial 61623
Microdissection 69990
Intracranial Arterial Perfusion
Thrombolysis 61624
Intracranial Neoplasm, Cerebellopontine Angle Tumor

Excision 61520, 61526
Intracranial Neoplasm, Craniopharyngioma
Excision 61545
Intracranial Neoplasm, Meningioma

Excision 61512, 61519
Intrafallopian Transfer, Gamete 58976
Intraluminal Angioplasty
See Angioplasty
Intramuscular Injection
Therapeutic 96372, 99506
Intraocular Lens
Cataract Removal
Exchange 66986
Insertion 66983
Manual or Mechanical Technique 66982, 66984, 66987, 66988
Intra-Osseous Infusion 36680

Intratracheal Intubation
Intrauterine Contraceptive Device

Intrauterine Device (IUD)
Insertion 58300
Removal 58301
Intrauterine Synechiae
See Adhesions, Intrauterine
Intravascular Foreign Body Removal (Fractured Catheter) 37197
Intravascular Stent
Placement
See Transcatheter, Placement, Intravascular Stent
Intravascular Ultrasound
Coronary Vessel or Graft
Endoluminal Imaging 92978, 92979
Noncoronary Vessel 37252, 37253
Intravenous Infusion
Diagnostic 96365-96368, 96379
Intravenous Unlisted 96379
Prophylactic 96365-96368, 96379
Therapeutic 96365-96368, 96379
Cerebral
Chemotherapy 96413, 96415-96417, 96422, 96423, 96425
Unlisted Therapeutic Infusion 96379
Intravenous Injection
See Injection, Intravenous
Intravenous Pyelogram
Urography, Intravenous 74400-74415
Intravenous Therapy
Cerebral
Chemotherapy 96413, 96415-96417, 96422, 96423, 96425
Infusion 96365-96368, 96379
Pain Management 96365-96368, 96374, 96379
Spinal
Unlisted Intravenous 96379
Intravesical Instillation
See Bladder, Instillation
Intravitreal Injection
Intrinsic Factor
Antibody 86340
Quantitative 83528
Introduction
Breast
Localization Device Placement 19081-19086
Gastrointestinal Tube 44500
with Fluoroscopic Guidance 74340
Intubation
Endotracheal Tube 31500
Esophageal
with Laparotomy 43510
Eustachian Tube
See Eustachian Tube, Inflation
Gastric
Therapeutic 43753
Specimen Collection
Duodenal 43756, 43757
Gastric 43754-43757
Intubation Tube
See Endotracheal Tube
Intussusception
Reduction
Enema 74283
Laparotomy 44050
Invagination, Intestinal
See Intussusception
Inversion, Nipple 19355
Iodide Test
Thyroid Uptake 78012, 78014
Ionization, Medical
See Iontophoresis
Iontophoreses
See Iontophoresis
Iontophoresis
Application 97033
Sweat Collection 89230
Ipecac Administration
for Poisoning 99175
IPPB (Intermittent Positive Pressure Breathing)
Device
Inhalation Treatment for Airway Obstruction 94640
Patient Utilization
Demonstration 94664
Evaluation 94664
Iridectomy
with Cataract Removal 66830
with Corneoscleral or Corneal Section 66600
with Cyclectomy 66605
for Glaucoma 66625, 66630
by Laser Surgery 66761
Optical 66635
with Sclerectomy 66160
with Thermocauterization 66155
with Trephination 66150
Iridodialysis
Ciliary Body Repair 66680
Iridoplasty
Photocoagulation 66762
Iridotomy
by Stab Incision 66500
with Transfixion as for Iris Bombe 66505
Iris
Cyst
Destruction 66770
Excision
with Cataract Removal 66830
with Corneoscleral or Corneal Section 66600
with Cyclectomy 66605
Optical 66635
Peripheral 66625
with Sclerectomy 66160
Sector 66630
with Thermocauterization 66155
with Trephination 66150
Incision
Stab 66500
with Transfixion as for Iris Bombe 66505
Lesion
Destruction 66770
Prosthesis 0616T-0618T
Repair
with Ciliary Body 66680
Suture 66682
Revision
Laser Surgery 66761
Suture
Iron
Blood 83540
Iron Binding Capacity

Blood 83550
Iron Hematoxylin Stain
for Microorganisms 87209, 88312
Iron Stain
Blood 85536, 88313
Irradiation
Blood Products 86945
Irrigation
Bladder 51700, 52005, 52010, 53448
Bronchus 31624
Caloric Vestibular Test 92537, 92538
Catheter
Brain 62194, 62225
Corpora Cavernosa
for Priapism 54220
Eye
Lung 32997
Nasolacrimal Duct 68810
Penis 54411, 54417
for Priapism 54220
Peritoneal
Lavage 49084
Shunt
Cerebrospinal Fluid 61070
Spinal Cord 63744
Sinus
Maxillary 31000
Sphenoid 31002
Ureter
Vagina 57150
Ventricular Catheter 62225
Wrist
Arthroscopy 29843
Irving Sterilization
See Ligation, Fallopian Tube, Oviduct
Ischemic Stroke
History of Onset 1065F, 1066F
Tissue Plasminogen Activator (tPA) Administration 4077F
Ischiectomy
with Pressure Ulcer Excision 15941
Ischium
Biopsy 20245
Bursa
Excision 27060
Pressure Ulcer
Excision 15940, 15941, 15944-15946
Tumor
Island Pedicle Flaps

Graft 15740
Islands of Langerhans
See Islet Cell
Islet Cell
Antibody 86341
Transplant 0584T-0586T
Isocitrate Dehydrogenase
Isocitric Dehydrogenase 83570
Isocitric Dehydrogenase
Blood 83570
Isolation
Sperm 89260, 89261
Virus
Centrifuge Enhanced 87254
Inoculation 87250, 87252
Non-immunologic Method 87255
Tissue Culture 87253
Isomerase, Glucose 6 Phosphate

Isopropyl Alcohol 80320
Isthmusectomy
Thyroid Gland 60210, 60212, 60220, 60225
IUD
IV (Intravenous)
See Intravenous Therapy
IV Infusion Therapy
See Intravenous Infusion, Therapeutic
IV Injection
See Injection, Intravenous
IVF (In Vitro Fertilization)
Intracervical 58321
Intrauterine 58322
Sperm Washing 58323
Ivy Bleeding Time

Bleeding Time 85002
J
Japanese Encephalitis Virus
Vaccine 90738
Japanese River Fever

Scrub Typhus Antigen 86000
Jatene Type Procedure 33770-33781
Jaw Joint
See Mandible; Maxilla; Temporomandibular Joint (TMJ)
Jaws
Muscle Reduction 21295, 21296
Orthopantogram X ray
for Orthodontics 70355
Jejunostomy
Contrast 49465
Conversion
from Gastrostomy Tube 44373
Endoscopic 44373
Percutaneous 49446
Insertion
Catheter 44015
Endoscopic 44372
Percutaneous 49441
Non-Tube 44187, 44310
with Pancreatic Drain 48001
Replacement 49451
Jejunum
Endoscopy
Examination 43242
Needle Aspiration 43242
Needle Biopsy 43242
Ultrasound 43259
Stoma
See Jejunostomy
Transfer
with Microvascular Anastomosis
Free 43496
Johannsen Procedure
Urethroplasty 53400
Joint
Acromioclavicular
See Acromioclavicular Joint
Arthrocentesis
Bursa 20600, 20604
Large Joint 20610, 20611
Aspiration 20600, 20604, 20605, 20606, 20610, 20611
Dislocation
See Dislocation
Drainage 20600, 20604, 20605, 20606, 20610, 20611
Exploration
Ankle 27610, 27620
Elbow 24101
Finger 26075-26080
Glenohumeral 23040, 23107
Hand 26070
Hip 27033
Interphalangeal
Finger 26080
Toe 28024
Intertarsal 28020
Knee 27310, 27331
Metatarsophalangeal 28022
Midcarpal 25040
Radiocarpal 25040
Tarsometatarsal 28020
Wrist 25101
Finger
See Finger, Joint
Fixation (Surgical)
See Arthrodesis
Foot
See Intertarsal Joint; Metatarsophalangeal Joint; Talotarsal Joint; Tarsal Joint; Tarsometatarsal Joint
Hip
See Hip Joint
Injection 0213T-0218T, 20600, 20604, 20605, 20610, 20611
Intertarsal
See Intertarsal Joint
Knee
See Knee Joint
Ligament
See Ligament
Magnetic Resonance Imaging
Extremity, Lower 73721
Extremity, Upper 73221
Metacarpophalangeal
See Metacarpophalangeal Joint
Metatarsophalangeal
See Metatarsophalangeal Joint
Nuclear Medicine
Imaging 78300, 78305, 78306, 78315
SPECT 78803
Radiology
Stress Views 77071
Survey Views 77077
Replacement
Temporomandibular 21243
Vertebral 0202T, 20931, 20938, 22554, 22556, 22854, 63081, 63085, 63087, 63090
Sacroiliac
See Sacroiliac Joint
Shoulder
See Glenohumeral Joint
Sternoclavicular
See Sternoclavicular Joint
Survey 77077
Temporomandibular
Arthrography 70332
Dislocation Temporomandibular
See Dislocation, Temporomandibular Joint
Implant
See Prosthesis, Temporomandibular Joint
Magnetic Resonance Imaging 70336
Radiology 70328
Wrist
See Radiocarpal Joint
Joint Syndrome, Temporomandibular

Jones and Cantarow Test
Urea Nitrogen Clearance 84545
Jones Procedure
Arthrodesis 28760
Jugal Bone
See Zygomatic Arch
Jugular Vein
Venography 75860
K
Kala Azar Smear 87207
Kallidin I /Kallidin 9
Bradykinin 82286
Kallikrein HK3
Prostate-specific Antigen 84152, 84153
Kallikreinogen
Fletcher Factor Assay 85292
Kasai Procedure 47701

Kedani Fever
Scrub Typhus 86000
Keel
Insertion/Removal
Laryngoplasty 31580
Kelikian Procedure 28280
Kelly Urethral Plication 57220
Keratectomy
Partial
for Lesion 65400
Keratophakia 65765
Keratoplasty
Endothelial 65756
Allograft Preparation 65757
Lamellar
Anterior 65710
Laser Preparation 0290T
Penetrating 65730
in Aphakia 65750
in Pseudophakia 65755
Keratotomy
Radial 65771
Ketogenic Steroids 83582
Ketone Body 82009, 82010
Ketosteroids 83586, 83593
Kidner Procedure 28238
Kidney
Abscess
Open 50020
Anesthesia 00862
Biopsy 50200, 50205
Endoscopic 50555, 50557, 52354
Catheterization
Endoscopic 50572
Cyst
Ablation 50541
Aspiration 50390
Excision 50280, 50290
Injection 50390
X ray 74470
Destruction
Calculus 50590
Endoscopic 50557, 50576, 52354
Endoscopy
Biopsy 50555, 50574-50576, 52354
Destruction 50557, 50576, 52354
Dilation
Ureter 50553
Excision
Tumor 52355
Exploration 52351
via Incision 50562, 50570, 50572, 50574-50576, 50580
Lithotripsy 52353
Removal
Calculus 50060-50075
via Stoma 50551, 50553, 50555, 50557, 50561
Excision
Donor 50300, 50320, 50547
Partial 50240
Laparoscopic 50543
Recipient 50340
with Ureters 50220, 50225, 50230, 50234, 50236
Exploration 50010, 50045, 50120
Incision 50010, 50045
Injection
Drugs 50391
for Nephrostogram 50430, 50431
Insertion
Stoma 50400
Instillation
Drugs 50391
Lithotripsy 50590
Mass
Ablation 50542
Cryosurgical 50250
Needle Biopsy 50200
Nuclear Medicine
Imaging 78700, 78701, 78707-78709, 78803
Placement
Catheter
Nephrostomy 50432
Removal
Calculus 50060, 50065, 50070, 50075, 50080, 50130, 50561
Tube
Nephrostomy 50389
Renal Function
Glomerular Filtration Rate (GFR) 0602T-0603T
Manometric Studies 50396
Repair
Blood Vessels 50100
Fistula 50520, 50525, 50526
Fixation 50400, 50405
Horseshoe Kidney 50540
Wound 50500
Solitary 50405
Suture
Fistula 50520, 50525, 50526
Transplantation
Anesthesia
Donor 00862
Recipient 00868
Donor 00862
Donor Nephrectomy 50300, 50320, 50547
Implantation of Graft 50360
Recipient Nephrectomy 50340, 50365
Reimplantation Kidney 50380
Removal Transplant Renal Autograft 50370
Tumor
Ablation
Cryotherapy 50593
Ultrasound 76770, 76775, 76776
X ray with Contrast
Guide Catheter 50433
Kidney Stone
See Calculus, Removal, Kidney
Calculus 50060, 50065, 50070, 50075, 50080, 50130, 50561
Killian Operation
See Sinusotomy, Frontal Sinus
Kinase, Creatine
CPK 82550-82552
Kineplasty
Cineplasty 24940
Kinetic Therapy 97530

Kininase A
Kininogen 85293
Kininogen, High Molecular Weight 85293
Kleihauer-Betke Test 85460
Kloramfenikol
Chloramphenicol 82415
Knee
Abscess 27301
for Osteoarthritis 0565T, 0566T
Arthrodesis 27580
Arthroplasty 27440-27445, 27447
Revision 27486, 27487
Arthroscopy
Diagnostic 29870
Surgical 29866-29868, 29871, 29873-29877, 29879-29889
Arthrotomy 27310, 27330-27335, 27403
Autograft, Osteochondral, Open 27416
Biopsy 27323, 27324, 27330, 27331
Synovium 27330
Bone
Drainage 27303
Graft 29885
Bone Graft 29885
Bursa 27301
Excision 27340
Cyst
Dislocation 27550-27552, 27556-27558, 27560-27562, 27566
Open Treatment 27556-27558, 27566
Drainage 27310
Excision
Cartilage 27332, 27333
Ganglion 27347
Lesion 27347
Patella 27350, 27424
Synovium 27334, 27335
Fasciotomy 27305, 27496-27499
Fracture 27520-27524, 27538, 27540
Fusion 27580
Hematoma 27301
Incision
Capsule 27435
Injection
X ray, CT-MRI 27369
Manipulation 27570
Meniscectomy 27332, 27333
Patella
See Patella
Removal
Foreign Body 27310, 27331, 27372
Loose Body 27331
Prosthesis 27488
Repair
Collateral 27405
Collateral and Cruciate 27409
Cruciate 27407-27409
Meniscus 27403
Tendon 27380, 27381
Replacement 27447
Retinacular
Release 27425
Strapping 29530
Suture
Tendon 27380, 27381
Transplantation
Chondrocytes 27412
Meniscus 29868
Osteochondral
Allograft 27415, 29867
Autograft 27412, 29866
Tumor
Excision 27327, 27328, 27337-27339
X ray 73560-73564
Arthrography 73580
Bilateral 73565
X ray with Contrast
Arthrography 73580
Injection, Contrast 27369
Knee Joint
Arthroplasty 27437, 27438, 27440-27443, 27445-27447
Revision 27486
Biopsy 27331
Debridement 27441
Drainage 27310
Excision
Semilunar Cartilage 27332, 27333
Synovium 27334, 27335
Fusion 27580
Manipulation 27570
Removal
Repair
Condyle 27446, 27447
Debridement 27441
Dislocation
Patella 27420, 27424, 27425
Plateau 27446, 27447
with Prosthesis
Resurfacing 27447
Synovectomy
Partial 27443
Knee Prosthesis
Kneecap
Excision 27350, 27424
Repair
Instability 27420-27424
Knock-Knee Repair 27455-27457

Kock Pouch
Continent Ileostomy 44316, 50825
Endoscopic Evaluation 44385, 44386
Kock Procedure 44316

KOH
Slide Tissue Examination
Ectoparasite Ova 87220
Fungus 87220
Mite 87220
Kraske Procedure 45116

Kroenlein Procedure 67420
Krukenberg Procedure 25915
Kyphectomy
More than Two Segments 22819
Up to Two Segments 22818
Kyphoplasty 22513-22515
L
L Ascorbic Acid 82180
L Aspartate 2 Oxoglutarate Aminotransferase
Transaminase, Glutamic-Oxaloacetic 84450
Labial Adhesions
Lysis 56441
Labyrinth
Excision 69905, 69910
Incision for Perfusion 69801
Labyrinthectomy 69905
with Mastoidectomy 69910
with Skull Base Surgery 61596
Labyrinthotomy
Transcanal 69801
Laceration Repair
See Repair, Laceration
Lacrimal Duct
Balloon 68816
Canaliculi
Insertion
Drug-Eluting Implant 0356T
Repair 68700
Dilation 68816
Exploration 68810
Canaliculi 68840
Stent 68815
Insertion
Stent 68815
Nasolacrimal Duct Probing 68816
Removal
Dacryolith 68530
Foreign Body 68530
Lacrimal Gland
Biopsy 68510
Close Fistula 68770
Excision
Partial 68505
Total 68500
Fistulization 68720
Injection
X ray 68850
Removal
Dacryolith 68530
Foreign Body 68530
Repair
Fistula 68770
Tear Flow Diagnostic Procedure
Microfluidic Analysis 83861
Nuclear Medicine 78660
Tumor
Excision
Frontal Approach 68540
with Osteotomy 68550
X ray 70170
Lacrimal Punctum
Closure
by Plug 68761
by Thermocauterization, Ligation or Laser Surgery 68760
Dilation 68801
Incision 68440
Repair 68705
Lacrimal Sac
Biopsy 68525
Excision 68520
Lacrimal System
Lactase Deficiency Breath Test 91065
Lactate 83605
Lactate Dehydrogenase 83615, 83625
Lactic Acid 83605
Lactic Cytochrome Reductase
Lactic Dehydrogenase
Lactiferous Duct
Excision 19110
Fistula 19112
Mammary Ductogram 77053, 77054
Lactoferrin
Fecal 83630, 83631
Lactogenic Hormone
Lactose
Urine 83633

Lagophthalmos
Correction 67912
Laki-Lorand Factor
Fibrin Stabilizing Factor XIII 85290, 85291
L-Alanine
Aminolevulinic Acid (ALA) 82135
Lamblia Intestinalis
Lambrinudi Operation
Triple Arthrodesis, Foot Joint 28715
Lamellar Keratoplasties
Anterior 65710
Laminaria
Insertion
for Cervical Dilation 59200
for Abortion 59855
Laminectomy
Arthrodesis 22630, 22632-22634
with Cordotomy 63194-63199
with Creation of Shunt 63740
for Decompression
Cervical 0274T, 61343, 63001, 63015, 63045, 63048
Lumbar 0275T, 63005, 63012, 63017, 63047, 63048
Sacral 63011
Thoracic 0274T, 63003, 63016, 63046, 63048
with Diagnostic/Therapeutic Injection 62351
with Discectomy 0274T, 0275T, 63020
with Drainage 63172, 63173
with Dural/Cerebrospinal Fluid Leak Repair 63709
for Excision
Arteriovenous Malformation 63250-63252
Intraspinal Lesion 63300-63308
Neoplasm 63275-63278, 63280-63283, 63285-63287, 63290
Other than Neoplasm 63265-63268, 63270-63273
with Exploration
Cervical 63001, 63015, 63045, 63048
Lumbar 63005, 63017, 63047, 63048
Sacral 63011
Thoracic 63003, 63016, 63046, 63048
with Facetectomy 0202T, 0274T, 0275T, 63045-63048
with Foraminotomy 0202T, 0274T, 0275T, 63045-63048
for Implantation of Electrodes 63655
with Ligamentous Resection 0274T, 0275T
Lumbar 0202T, 22630, 63012
with Myelotomy 63170
with Nerve Resection 63191
with Rhizotomy 63185, 63190
with Spinal Cord Release 63200
Laminoplasty
Cervical 63050, 63051
Lamotrigine
Drug Assay 80175
Langerhans Islands
See Islet Cell
Language Evaluation
Language Comprehension and Expression 92523
Speech Fluency 92521
Speech Sound Production 92522
Voice and Resonance
Behavioral Analysis 92524
Language Therapy
Group 92508
Individual 92507
LAP (Leucine Aminopeptidase) 83670
Laparoscopic Appendectomy 44970
Laparoscopic Biopsy of Ovary 49321
Laparoscopy
Abdomen
Aspiration
Cavity 49322
Cyst 49322
Biopsy 49321
Diagnostic 49320
Drainage
Lymphocele 49323
Placement
Interstitial Radiation Device 49327
Adrenal Gland
Biopsy 60650
Excision 60650
Appendix
Appendectomy 44970
Aspiration 49322
Biliary Tract
Cholangiography 47563
with Biopsy 47579
Cholecystectomy 47562-47564
Cholecystenterostomy 47570
Biopsy 49321
Lymph Nodes 38570
Bladder
Laparoscopic 44188
Repair
Sling Operation 51992
Unlisted 51999
Colon
Cecostomy 44188
Colectomy
Partial 44204-44208, 44213
Total 44210-44212
Colostomy 44188
Destruction
Lesion 58662
Esophagus
Esophagogastric Fundoplasty 43280
Esophagomyotomy Fundoplasty 43279
Heller Type Esophagomyotomy 43279
Hernia Repair 43281, 43282
Lengthening 43283
Sphincter Augmentation
Device Placement 43284
Device Removal 43285
Gastric Restrictive Procedures 43644, 43645, 43770-43775
Hernia Repair
Epigastric
Incarcerated or Strangulated 49653
Reducible 49652
Incisional
Reducible 49654
Incisional Recurrent
Reducible 49656
Inguinal
Initial 49650
Recurrent 49651
Paraesophageal 43281, 43282
Spigelian
Reducible 49652
Umbilical
Reducible 49652
Ventral
Reducible 49652
Intestines
Enterectomy 44202, 44203
Enterolysis 44180
Enterostomy
Closure 44227
Ileostomy 44187
Jejunostomy 44186, 44187
Reconstruction with Gastric Bypass 43645
Resection
with Anastomosis 44202, 44203
Kidney
Ablation
Cysts 50541
Lesions 50542
Allograft Preparation 50325
Nephrectomy 50544-50548
Donor 50547
Liver
Ablation
Tumor 47370, 47371
Lymph System
Biopsy 38570
Lymphadenectomy 38571-38573
Lysis of Intestinal Adhesions 44180
Nephrectomy 50545-50548
Partial 50543
Omentum
Diagnostic 49320
Omentopexy 49326
Ovary/Oviduct
Excision of Lesions 58662
Fimbrioplasty 58672
Fulguration
Lesions 58662
Oviducts 58670
Occlusion of Oviducts 58671
Oophorectomy 58661
Oviduct Surgery 58670, 58671, 58679
Removal
Ovary(s) 58544, 58552, 58554
Tube(s) 58544, 58552, 58554
Salpingectomy 58661
Salpingostomy 58673
Pelvis 49320
Placement
Pyeloplasty 50544
Peritoneum
Catheter Insertion 49324
Diagnostic 49320
Placement
Removal of Obstructive Material 49325
Prostate
Prostatectomy 55866
Rectum
Proctectomy
Complete 45395
with Creation of Colonic Reservoir 45397
Proctopexy
for Prolapse 45400, 45402
Unlisted 45499
Removal
Leiomyomata 58545, 58546
Ovaries 58661
Spleen 38120
Testis 54690
Spermatic Cord
Ligation
Veins 55550
Spleen
Mobilization 44213
Splenectomy 38120, 38129
Stomach
Gastrectomy
Longitudinal/Sleeve 43775
Gastric Bypass 43644, 43645
Gastric Restrictive Procedures 43770-43775, 43848, 43886-43888
Gastroenterostomy 43644, 43645
Gastrostomy, Temporary 43653
Neurostimulator Electrode
Implantation 0312T, 43647
Replacement 0313T, 43647
Roux-En-Y 43644
Vagus Nerves Transection 43651, 43652
Testis
Orchiectomy 54690
Orchiopexy 54692
Transplantation
Donor Allograft Preparation
Kidney 50325
Abdomen, Peritoneum, and Omentum 49329
Appendix 44979
Biliary Tract 47579
Bladder 51999
Endocrine System 60659
Esophagus 43289
Hernioplasty, Herniorrhaphy, Herniotomy 49659
Intestine 44238
Liver 47379
Lymphatic System 38589
Maternity Care and Delivery 59898, 59899
Oviduct, Ovary 58679
Rectum 45499
Renal 50549
Spleen 38129
Stomach 43659
Testis 54699
Ureter 50949
Uterus 58578, 58579
Ureter
Ureterectomy 50546, 50548
Ureterolithotomy 50945
Ureteroneocystostomy 50947, 50948
Urethra
Incontinence Repair 51990, 51992
Uterus
Ablation
Fibroids 58674
Biopsy 57421
Endometrium 58558
Hysterectomy 58541-58544
Radical 58548
Total 58570-58573, 58575
Vaginal 58550, 58552-58554
Hysteroscopy
Diagnostic 58555
with Division/Resection Intrauterine Septum 58560
with Endometrial Ablation 58563
with Endometrial Biopsy 58558
with Lysis of Intrauterine Adhesions 58559
with Polypectomy 58558
with Removal
Impacted Foreign Body 58562
Leiomyomata 58561
Unlisted Hysteroscopy Procedure 58578
Myomectomy 58545, 58546
Placement
Fallopian Tube Cannulation 58565
Retrieve Oocyte 58970
Transfer Embryo 58974
Transfer Gamete 58976
Vagina
Biopsy 57421
Colpopexy 57425
Colposcopy 57420
Paravaginal Defect Repair 57423
Prosthetic Graft Revision 57426
Vaginal Hysterectomy 58550-58554
Vaginal Suspension 57425
Laparotomy
Abdominal
Esophagogastric
Fundoplasty 43327, 43328
Hiatal Hernia Repair 43332, 43333
Gastric
Electrode
Implantation 43881
Removal 43882
Replacement 43881
Revision 43882
Intestinal
Reduction
Internal Hernia 44050
Volvulus 44050
Liver
Aspiration/Injection
Parasitic Abscess 47015
Parasitic Cyst 47015
Staging
Ovarian Malignancy 58960
Peritoneal Malignancy 58960
Tubal Malignancy 58960
Stomach
Biopsy 43605
Laparotomy, Exploratory
Peritoneal 49000, 49010, 58960
Large Bowel
See Anus; Rectum
Laroyenne Operation
Abscess, Incision and Drainage 57010
Larval Therapy 97602

Laryngeal Function Study 92520
Laryngectomy 31360-31382
Partial 31367-31382
Subtotal 31367, 31368
Total 31360, 31365
Laryngocele
Removal 31300
Laryngofissure 31300
Laryngography
Contrast 76499
Laryngopharyngectomy
Pharyngolaryngectomy 31390, 31395
Laryngopharynx
Hypopharynx Diverticulectomy 43130, 43180
Laryngoplasty
Cricoid Split 31587
for Fracture
Fixation 31584
Open Reduction 31584
for Laryngeal Stenosis 31551-31554
Laryngeal Web 31580
Medialization 31591
Laryngoscopy
Direct 31515-31571
Aspiration 31515
Biopsy 31535, 31536
Dilation 31528, 31529
Exploration 31520-31526, 31575
Newborn 31520
Biopsy 31576
Diagnostic 31575
Injection
Vocal Cord 31570, 31571, 31573, 31574
Operative 31530-31561
Arytenoidectomy 31560, 31561
Excision of Tumor 31540, 31541
Removal
Foreign Body 31577
Lesion 31578
Stripping of Vocal Cords 31540, 31541
Removal
Lesion 31545, 31546
Indirect 31505-31513
Biopsy 31510
Diagnostic 31505
Exploration 31505
Injection
Vocal Cord 31513
Insertion
Obturator 31527
Removal
Foreign Body 31511
Lesion 31512
Newborn 31520
with Operating Microscope or Telescope 31526, 31531, 31536, 31541, 31545, 31546, 31561, 31571
Rigid Telescopic 31579
with Stroboscopy 31579
Laryngotomy 31300
Larynx
Aspiration
Endoscopy 31515
Biopsy
Endoscopy 31510, 31535, 31536, 31576
Dilation
Electromyography
Needle 95865
Endoscopy
Direct 31515-31571
Excision 31545, 31546
Exploration 31505, 31520-31526, 31575
with Stroboscopy 31579
Indirect 31505-31513
Operative 31530-31561
Removal, Lesion 31512, 31578
Excision
Lesion 31512, 31578
Partial 31367-31382
with Pharynx 31390-31395
Total 31360-31365
Exploration
Endoscopic 31505, 31520-31526, 31575
Fracture
Fixation 31584
Open Reduction 31584
Insertion
Keel 31580
Obturator 31527
Stent 31580
Lesion
Ablation 31572
Laser Destruction 31572
Removal 31512, 31578
Medialization 31591
Muscle
Reconstruction
Cricoid Split 31587
Stenosis 31551-31554
Web 31580
Removal
Foreign Body
Endoscopic 31511, 31530, 31531, 31577
Lesion
Endoscopic 31512, 31545, 31546, 31578
Repair
Reinnervation Neuromuscular Pedicle 31590
Stroboscopy 31579
Tumor
Excision 31300
Vocal Cord(s)
Injection 31513, 31570, 31571, 31573, 31574
X ray 70370
Laser Surgery
Anus 46614, 46917
Bladder 52214, 52224
Bronchi
Stenosis 31641
Tumor 31641
Cataract 66821
Cautery
Anus 46614
Cervix 57513, 57520
Colon 44391, 45317, 45382
Esophagus 43227
Hemorrhoids 46930
Rectum 45317, 45334
Fenestration
Body Surface 0479T, 0480T
Incompetent Vein 0524T, 36478, 36479
Iridectomy 66761
Iridotomy 66761
Lens, Posterior 66821
Lesion
Anus 46917, 46924
Bladder 52224
Choroid 67220
Colon 45320
Larynx 31572
Mouth 40820
Nose 30117, 30118
Penis 54057, 54065
Rectum 45320
Skin 17000-17111, 17260-17286
Vagina 57061, 57065
Vulva 56501, 56515
Myocardium 33140, 33141
Ocular Adhesion 65860
Polyp
Colon 45320
Prostate 52647, 52648, 52649
Retina 67108, 67113, 67145
Trabeculoplasty 65855
Trichiasis 67825
Tumors
Bladder 52234, 52235, 52240
Bronchi 31641
Colon 45320
Rectum 45190
Ureter 52341-52346
Urethra and Bladder 52214
Vitreous 67031, 67039, 67040, 67043
Laser Treatment
See also Laser Surgery
Inflammatory Skin Disease 96920-96922
Photonic Dynamic Therapy 0552T
Thermokinetic Dynamic Therapy 0552T
Lateral Epicondylitis
Latex Fixation 86403-86406
LATS (Long-Acting Thyroid Stimulation Hormone)
Latzko Operation
Vesicovaginal Fistula Repair 57320
LAV (Lymphadenopathy-associated Virus)

See HIV; HIV-1
LAV Antibodies
See Antibody, Detection, Human Immunodeficiency Virus (HIV)
LAV-2
See HIV-2
Lavage
Bladder 51700
Colon 44701
Knee Joint 29871
Lung
Bronchial 31624
Total 32997
Maxillary Sinus 31000
Peritoneal 49084
Sphenoid Sinus 31002
Stomach 43753
Wrist Joint 29843
LCM
LD (Lactic Dehydrogenase) 83615, 83625
LDH (Lactate Dehydrogenase) 83615-83625
LDL
Low Density Lipoproteins 83700-83704, 83721, 83722
Lead 83655
Leadbetter Procedure 53431
Lecithinase C
See Tissue, Typing
Lecithin-Sphingomyelin Ratio 83661

Lee and White Test 85345
LEEP Procedure 57460
Loop Electrode Excision 57522
LeFort I Procedure
Midface Reconstruction 21141-21147, 21155, 21160
Palatal or Maxillary Fracture 21421-21423
LeFort II Procedure
Midface Reconstruction 21150, 21151
Nasomaxillary Complex Fracture 21345-21348
LeFort III Procedure
Craniofacial Separation 21431-21436
Midface Reconstruction 21154-21160
LeFort Procedure
Vagina 57120
Left Atrioventricular Valve
See Mitral Valve
Left Heart Cardiac Catheterization

See Cardiac Catheterization, Left Heart
Leg
Bone Procedures
See Femur; Fibula; Tibia
Cast
Full Leg 29705
Rigid Total Contact 29445
Dislocation
See Dislocation, Leg
Fracture
See Femur, Fracture; Fibula, Fracture; Tibia, Fracture
Incision
Embolectomy 34201, 34203
Thrombectomy 34201, 34203, 34421, 34451
Injection
Sclerosant 36465, 36466, 36468, 36470, 36471
Joint
See Ankle; Knee
Lipectomy 15833
Lower
See also Ankle; Fibula; Knee; Tibia
Abscess
Amputation 27598, 27880-27882
Angiography 73706
Artery
Ligation 37618
Biopsy 27613, 27614
Bursa
Bypass Graft 35903
Cast 29405-29435, 29450
CT Scan 73700-73706
Decompression 27600-27602, 27892-27894
Exploration
Blood Vessel 35860
Fasciotomy 27600-27602, 27892-27894
Hematoma
Incision 27607
Lesion
Excision 27630
Neurectomy 27325, 27326
Repair
Blood Vessel 35226
Fascia 27656
Tendon 27612, 27650, 27652, 27654, 27656, 27658-27692
Splint 29515
Strapping
Compression 29581
Unna Boot 29580
Suture
Nerve 64856, 64857, 64859
Tendon 27658-27665
Tenotomy 27605, 27606
Tumor
Excision 27618, 27619, 27632, 27634
Ultrasound
Complete 76881
Limited 76882
Unna Boot 29580
Vein
Division 37718
Ligation 37718, 37760, 37761
Stripping 37718
X ray 73592
Nerve Graft 64892, 64897, 64898
Neuroplasty 64708, 64712
Splint 29505
Strapping
Multi-layer Compression System 29581
Upper
See also Femur
Abscess
Amputation 27590-27592
at Hip 27290-27295
Artery
Ligation 37618, 37650
Biopsy 27323, 27324
Body Cast 29044, 29046
Bursa 27301
Bypass Graft 35903
Cast 29345-29355, 29365, 29450
Cast Brace 29358
CT Scan 73700-73706, 75635
Exploration
Blood Vessel 35860
Fasciotomy 27025, 27305, 27496-27499, 27892-27894
Halo Application 20663
Hematoma 27301
Lipectomy 15832
Neurectomy 27325, 27326
Removal
Cast 29705
Foreign Body 27372
Repair
Muscle 27385, 27386, 27400, 27430
Tendon 27393-27400
Splint 29505
Strapping
Unna Boot 29580
Suture
Muscle 27385, 27386
Nerve 64856-64859
Tendon Transfer/Transplant 27396, 27397, 27400
Tenotomy 27306, 27307, 27390-27392
Transplantation
Testis to Thigh 54680
Tumor
Excision 27327, 27328, 27337-27339
Resection 27329, 27364, 27365
Ultrasound
Complete 76881
Limited 76882
Unna Boot 29580
X ray 73592
Varicose Vein
Division 37785
Excision 37785
Ligation 37785
Phlebectomy 37765, 37766
Vein
Division 37700, 37722, 37735
Ligation
Great Saphenous 37700, 37722, 37735
Perforator 37760, 37761
Wound Exploration
Penetrating 20103
Leg Length Measurement X ray

Scanogram 77073
Legionella
Antibody 86713
Antigen 87278, 87540-87542
Legionella Pneumophila
Antigen Detection
Direct Probe 87540
Leiomyomata
Removal 58140, 58145, 58545, 58546, 58561
Leishmania
Antibody 86717
Lengthening, Tendon
See Tendon, Lengthening
Lens
Contact
Extracapsular 66940
Incision 66821, 66825
Intracapsular 66920
Dislocated 66930
Intraocular
Exchange 66986
Reposition 66825
Laser 66821
Prosthesis
Insertion 66983
Manual or Mechanical Technique 66982, 66984, 66988
Ocular Telescope 0308T
Removal
Crystalline 0308T
Intraocular Lens 0308T
Repositioning 66825
Removal 67108, 67113
Cataract
Foreign Body 65235
Lens Material
Aspiration Technique 66840
Extracapsular 66940
Intracapsular 66920-66930
Phacofragmentation Technique 66850
Lens Material
Removal
Aspiration Technique 66840
Extracapsular 66940
Intracapsular 66920-66930
Phacofragmentation Technique 66850
Leptomeningioma
Leptospira
Antibody 86720
Lesion
See also Tumor
Ablation
Endoscopic Retrograde Cholangiopancreatography (ERCP) 43278
Stereotactic
Anal
Destruction 46900-46917, 46924
Excision 45108, 46922
Ankle
Tendon Sheath
Excision 27630
Arm, Lower
Tendon Sheath
Excision 25110
Excision
Exostosis 69140
Radical with Neck Dissection 69155
Radical without Neck Dissection 69150
Soft Tissue 69145
Biopsy
Fine Needle Aspiration
Punch 11104, 11105
Bladder
Destruction 51030
Fulguration 52224, 52234, 52235, 52240
Resection 52234, 52235, 52240
Treatment 52224
Brain
Excision 61534, 61536, 61600-61608, 61615, 61616
Brainstem
Excision 61575, 61576
Breast
Detection
Localization Device Placement
with Magnetic Resonance Guidance 19085, 19086, 19287, 19288
with Stereotactic Guidance 19081, 19082, 19283, 19284
with Ultrasound Guidance 19083, 19084, 19285, 19286
Chemotherapy 96405, 96406
Choroid 67220, 67221, 67225
Ciliary Body
Destruction 66770
Colon
Ablation 44401, 45388
Excision 44110, 44111
Conjunctiva
Destruction 68135
with Adjacent Sclera 68130
over 1 cm 68115
Cornea
Destruction 65450
Excision 65400
of Pterygium 65420-65426
Cranium
Radiosurgery 61796-61800
Stereotactic Radiation Therapy 77432
Ear, Middle
Excision 69540
Epididymis
Excision 54830
Esophagus
Ablation 43229
Excision 43100, 43101
Removal 43216, 43217
Eyelid
Destruction 67850
Excision
without Closure 67840
Multiple, Different Lids 67805
Multiple, Same Lid 67801
Single 67800
Facial
Destruction 17000-17004, 17280-17286
Finger
Tendon Sheath
Excision 26160
Foot
Excision 28080, 28090
Gums
Destruction 41850
Hand Tendon Sheath 26160
Intestines
Excision 44110
Intestines, Small
Ablation 44369
Excision 44111
Iris
Destruction 66770
Larynx
Ablation 31572
Laser Destruction 31572
Removal 31512, 31545, 31546, 31578
Leg, Lower
Tendon Sheath
Excision 27630
Mesentery
Excision 44820
Mouth
Destruction 40820
Excision 40810-40816, 41116
Vestibule
Destruction 40820
Repair 40830
Nose
Intranasal
Excision 30117, 30118
Orbit
Excision 61333, 67412, 67420
Ovary
Excision 58662
Palate
Destruction 42160
Excision 42104, 42106, 42107
Pancreas
Excision 48120
Pelvis
Excision 58662
Penis
Destruction
Cryosurgery 54056
Extensive 54065
Laser Surgery 54057
Simple 54050-54060
Excision 54060
Penile Plaque 54110-54112
Peritoneum
Excision 58662
Pharynx
Destruction 42808
Excision 42808
Radiosurgery
Cranial 61796-61800
Rectum
Excision 45108
Renal Pelvis
Biopsy 52354
Fulguration 52354
Retina
Destruction
Extensive 67227, 67228
Localized 67208-67210
Radiation by Implantation of Source 67218
Sclera
Excision 66130
Skin
Abrasion 15786, 15787
Biopsy
Punch 11104, 11105
Destruction
Benign 17110, 17111, 17250
Premalignant 17000-17004
Excision
Benign 11400-11471
Paring or Curettement 11055-11057
Reflectance Confocal Microscopic Imaging 96931
Shaving 11300-11313
Skin Tags
Removal 11200, 11201
Skull
Excision 61500, 61600-61608, 61615, 61616
Spermatic Cord
Excision 55520
Spinal Cord
Destruction 62280-62282
Excision 61575, 61576, 63265-63273, 63300-63308
Stereotactic Radiation Therapy 77432, 77435
Testis
Excision 54512
Toe
Excision 28092
Tongue
Ureter
Biopsy 52354
Destruction 52341, 52342, 52344, 52345, 52354
Fulguration 52354
Urethra
Fulguration 52224, 53265
Treatment 52224
Uvula
Destruction 42160
Vagina
Vulva
Destruction
Extensive 56515
Simple 56501
Wrist Tendon
Excision 25110
Leu 2 Antigens
CD8 86360
Leucine Aminopeptidase 83670
Leukemia Lymphoma Virus I, Adult T Cell
Antibody
Confirmatory Test 86689
Detection 86687
Leukemia Lymphoma Virus I Antibodies, Human T Cell

HTLV-I Antibody Detection 86687, 86689
Leukemia Lymphoma Virus II Antibodies, Human T Cell

HTLV-II Antibody Detection 86688
Leukemia Virus II, Hairy Cell Associated, Human T Cell
HTLV-II Antibody Detection 86688
Leukoagglutinins 86021
Leukocyte
See White Blood Cell
Alkaline Phosphatase 85540
Antibody 86021
Count 85032, 85048, 89055
Fecal Assessment 89055
Histamine Release Test 86343
Human Leukocyte Antigen (HLA)
See Human Leukocyte Antigen (HLA)
Phagocytosis 86344
Transfusion 86950
Urinalysis 81000
Levarterenol
See Noradrenalin
Levator Muscle Repair
See Blepharoptosis, Repair
LeVeen Shunt
Insertion 49425
Patency Test 78291
Revision 49426
Levetiracetam
Drug Assay 80177
Levulose
See Fructose
LH
LHR
Leukocyte Histamine Release Test 86343
Lid Suture
See Blepharoptosis, Repair
Lidocaine
Assay 80176
Lift, Face
See Rhytidectomy
Ligament
Ankle
Collateral Ligament Repair 27695, 27696
Augmentation
Knee 29888, 29889
Collateral
Reconstruction
Elbow 24344, 24346, 24362
Reduction
Ulna 29902
Repair
Ankle 27695, 27696, 27698
Elbow 24343, 24345
Knee 27405, 27409
Coracoacromial
Release 23130, 23415, 29826
Cruciate
Repair
Knee 27407, 27409, 29888, 29889
Elbow
Collateral Ligament
Repair 24343, 24345
Injection 20550
Knee 27557, 27558
Collateral Ligament Repair 27405, 27409
Cruciate Ligament Repair 27407, 27409
Reconstruction
Elbow 24344, 24346, 24362
Knee 27427-27429, 29888, 29889
Reduction
Ulna
Release
Repair
Ankle 27695, 27696, 27698
Elbow 24343-24346
Knee Joint 27405-27409
Wrist 25320
Transverse Carpal
Release 29848
Ulna
Collateral Ligament Reduction 29902
Wrist
Release 29848
Repair 25320
Ligation
Artery
Abdomen 37617
Carotid 37600-37606, 61611
Chest 37616
Coronary 33502
Ethmoidal 30915
Extremity 37618
Fistula 37607
Hepatic 47360
Maxillary 30920
Neck 37615
Temporal 37609
Cranial Sinus 61598
Esophageal Varices 43205, 43244, 43400
Fallopian Tube
Oviduct 58600-58611, 58670
Gastric Varices 43244
Gastroesophageal 43405
Hemorrhoids 46945, 46946, 46948
Oviducts 59100
Salivary Duct 42665
Shunt
Aorta
Pulmonary 33924
Peritoneal
Venous 49428
Submandibular Duct 42510
Thoracic Duct 38380
Thoracic Approach 38381
Tubal 58600
Vein
Clusters 37785
Esophagus 43205, 43244, 43400
Femoral 37650
Gastric 43244
Iliac 37660
Jugular, Internal 37565
Perforate 37500, 37760, 37761
Saphenous 37700-37735, 37780
Spermatic 55530, 55535, 55540, 55550
Vena Cava 37619
Wharton’s Ducts 42510
Ligature Strangulation
Skin Tags 11200, 11201
Light Coagulation
See Photocoagulation
Light Scattering Measurement

Nephelometry 83883
Light Therapy, UV
Actinotherapy 96900
Limb
See Extremity
Limited Lymphadenectomy for Staging
See Lymphadenectomy, Limited, for Staging
Limited Neck Dissection

with Thyroidectomy 60252
Limited Resection Mastectomies
See Breast, Excision, Lesion
Lindholm Operation
Repair, Ruptured Achilles Tendon 27650
Lingual Bone
Hyoid Bone
Fracture 31584
Lingual Frenectomy 41115
Lingual Nerve
Avulsion 64740
Transection 64740
Lingual Tonsil
Destruction 42870
Linton Procedure 37760

Lip
Biopsy 40490
Excision
Frenum 40819
Full Thickness 40525, 40527
Transverse Wedge 40510
V 40520
Incision
Frenum 40806
Malleolus
Fixation 27823
Repair 40650-40654
Cleft Lip 40700-40761
Complex 13151-13153
Fistula 42260
Resection 40530
Shave 40500
Suture
Tongue to Lip 41510
Vermilionectomy 40500
Lip, Cleft
See Cleft Lip
Lipase 83690
Lipectomy
Excision 15830-15839, 15847
Suction Assisted 15876-15879
Lipectomy, Aspiration
Lipids
Feces 82705-82710
Panel 80061
Phospholipid
Antibody 86147, 86148
Neutralization 85597, 85598
Lipo-Lutin
Progesterone 84144
Lipolysis, Aspiration
Lipophosphodiesterase I
See Tissue, Typing
Lipoprotein
(a) 83695
Apolipoprotein 82172
Blood 83695, 83700-83721
Delipidation
HDL 0342T
HDL 83718
LDL 83700-83704, 83721, 83722
Phospholipase A2 83698
VLDL 83719
Lipoprotein, Alpha
See Lipoprotein
Lipoprotein, Pre-Beta
See Lipoprotein, Blood
Liposuction
for Autologous Fat Grafting 15876-15879
Listeria Monocytogenes
Antibody 86723
Lithium
Assay 80178
Lithotripsy
Bile Duct Calculi (Stone)
Endoscopy 43265
Bladder 52353
with Indwelling Ureteral Stent Insertion 52356
Kidney 50080, 50081, 50590, 52353
Pancreatic Duct Calculi (Stone)
Endoscopy 43265
Ureter 52353
Urethra 52353
Lithotrity
Liver
See also Hepatic Duct
Ablation
Tumor 47380-47383
Abscess
Aspiration 47015
Open 47010
Injection 47015
Aspiration 47015
Biopsy 47700
Needle 47000, 47001
Wedge 47100
Cyst
Aspiration 47015
Open 47010
Injection 47015
Drainage 47400
Image Guided Fluid Collection 49405
Excision
Extensive 47122
Partial 47120, 47125-47130
Donor 47140-47142
Total
Donor 47133
Exploration 47400
Hemorrhage 47350-47362
Injection 47015
Lobectomy 47125-47130
Partial 47120
Nuclear Medicine
Imaging 78201-78216
Vascular Flow 78202
Removal
Calculus 47400
Repair
Abscess 47300
Cyst 47300
Wound 47350-47362
Suture
Wound 47350-47362
Transplantation
Lobe Split 47145
Trisegment Split 47144
Partial 47135, 47144, 47145
Whole 47135
Trisegmentectomy 47122
Ultrasound
Elastography, Shear Wave 91200
Living Activities, Daily

L-Leucylnaphthylamidase
Lobectomy
Brain 61323, 61537-61540
Partial 61539, 61540
Contralateral Subtotal
Thyroid Gland 60212, 60225
Liver 47120-47130
Donor 47141, 47142
Lung 32480-32482
Sleeve 32486
Thoracoscopic 32663, 32670
Sleeve 32486
Thoracoscopic
Lung 32663, 32670
Thyroid Gland
Partial 60210-60212
Total 60220-60225
Local Excision Mastectomies
See Breast, Excision, Lesion
Local Excision of Lesion or Tissue of Femur

See Tumor, Femur
Localization of Nodule
Breast
Device Placement
with Magnetic Resonance Guidance 19085, 19086, 19287, 19288
with Stereotactic Guidance 19081, 19082, 19283, 19284
with Ultrasound Guidance 19083, 19084, 19285, 19286
Soft Tissue
Device Placement 10035, 10036
Log Hydrogen Ion Concentration

Blood Gases, pH 82800, 82803, 82930
Long-Acting Thyroid Stimulator
Longmire Operation
Anastomosis, Hepatic Duct to Intestines 47765, 47802
Long-Term Care Facility Visits
Loop Recorder System, Implantable

Loose Body
Removal
Carpometacarpal Joint 26070
Elbow Joint 24101, 29834
Hip Joint 27033
Knee Joint 27331
Shoulder Joint 29819
Subtalar Joint 29904
Toe 28022
Wrist Joint 25101
Lord Procedure
Anal Sphincter Dilation 45905
Louis Bar Syndrome
Ataxia Telangiectasia Chromosome Analysis 88248
Low Birth Weight Intensive Care Services 99478-99480

Low Density Lipoprotein 83700-83704, 83721, 83722
Low Frequency Ultrasound 97610
Low Vision Aids
Fitting 92354, 92355
Lower Extremities
See Extremity, Lower
Lower GI Series
Barium Enema Radiological Examination 74270, 74280
LRH
Luteinizing Releasing Factor 83727
L/S Ratio
LSD
Lysergic Acid Diethylamide 80323
LTH
Lumbar Plexus
Decompression 64714
Infusion
Anesthetic 64449
Steroid 64449
Neuroplasty 64714
Repair/Suture 64862
Lumbar Puncture
Lumbar Spine Fracture
Open Treatment/Reduction 22325
Lumbar Sympathectomy 64818

Lumbar Vertebra
See Vertebra, Lumbar
Lumen Dilation 74360

Lumpectomy 19301, 19302
Lunate
Arthroplasty
with Implant 25444
Dislocation
Lung
Ablation
Tumor 32994, 32998
Abscess
Open 32200
Biopsy 32096, 32097
Bronchoscopic 31628, 31629, 31632, 31633
Core Needle 32408
Thoracoscopic 32607, 32608
Infiltrate 32607
Mass 32608
Nodule 32608
Bullae
Resection-Plication
Thoracoscopic 32655
Thoracotomy 32141
Cancer Screening
Thoracic CT Scan 71271
Collapse
See Lung Collapse Therapy
Cyst
Open 32200
Removal 32140
Decortication
with Parietal Pleurectomy 32320
Partial 32225, 32651
Total 32220, 32652
Drainage
Empyema 32035, 32036
Closure, Chest Wall 32810
Empyema
Drainage 32035, 32036
Excision 32540
Excision
Bronchus Resection 32486
Completion 32488
Donor
Heart-Lung 33930
Lung 32850
Empyema 32540
Lobe 32480-32482
Segment 32484
Tumor 32503, 32504
Exploration 32100
Foreign Body
Removal 32151
Thoracoscopic 32654
Insertion
Lavage
Bronchial 31624
Total 32997
Lysis
Adhesions 32124, 32940
Nuclear Medicine
Imaging, Perfusion 78580, 78597, 78598
Imaging, Ventilation 78579, 78582, 78598
Placement
Interstitial Device 32553
Pleura
See Pleura
Pneumolysis 32652, 32940
Pneumonostomy 32200
Pneumothorax
Repeat 32215
Therapeutic 32960
Pulmonary Fluid Monitoring System
Remote Monitoring 0607T-0608T
Removal 32440-32445
Bilobectomy 32482
Thoracoscopic 32670
Bronchoplasty 32501
Completion Pneumonectomy 32488
Extrapleural 32445
Thoracoscopic 32671
Segmentectomy
Thoracoscopic 32669
Single Lobe 32480
Single Segment 32484
Sleeve Lobectomy 32486
Sleeve Pneumonectomy 32442
Two Lobes 32482, 32670
Repair
Hernia 32800
Resection
Anatomic Lung 32507
Diagnostic Wedge 32507
Pancoast Tumor 32503, 32504
Therapeutic Wedge 32505, 32506
Tumor 32503, 32504
Resection-Plication
Bullae 32141, 32655
Thoracoscopic 32672
Emphysematous 32491
Thoracoscopic 32672
Segmentectomy 32484, 32669
Tear
Repair 32110
Thoracoscopy
See Thoracoscopy
Thoracostomy
Empyema 32035, 32036
Thoracotomy
Biopsy 32096, 32097
Cardiac Massage 32160
Exploration 32100
with Open Intrapleural Pneumonolysis 32124
for Post-Op Complications 32120
Removal
Bullae 32141
Cyst 32140
Fibrin Deposit 32150
Intrapleural Foreign Body 32150
Intrapulmonary Foreign Body 32151
Repair 32110
with Resection-Plication of Bullae 32141
Transplantation
Allograft Preparation
Heart/Lung 33933
Lung 32855, 32856
Marginal (Extended) Lung 0494T-0496T
Donor Pneumonectomy
Heart/Lung 33930
Lung 32850
Heart/Lung 33935
Lung 32851-32854
Tumor
Thoracoscopic 32672
Lung Collapse Therapy

Air Injection 32960
Pneumonolysis 32940
Rib Resection 32900
Schede Thoracoplasty 32905
Thoracoplasty 32905
Closure, Bronchopleural Fistula 32906
Lung Function Tests
Lung Volume Reduction (LVRS)

Emphysematous 32491, 32672
Lupus Anticoagulant Assay 85705
Lupus Band Test
Antibody Stain Procedure 88346, 88350
Luteinizing Hormone (LH)
Gonadotropin 83002
Ovulation Tests 84830
Panels
Gonadotropin Releasing Hormone Stimulation 80426
Pituitary Evaluation 80418
Luteinizing Releasing Factor 83727

Luteotropic Hormone
Luteotropin
Luteotropin, Placental
Lyme Disease ab
Antibody 86617
Lyme Disease 86617, 86618
Lymph Duct
Injection
for Lymphangiography 38790
Thoracic
Cannulation 38794
Ligation 38380-38382
Suture 38380-38382
Lymph Nodes
Abdominal
Excision 38747
Abscess
Aortic
Excision 38780
Axillary
Hygroma, Cystic
Lymphadenectomy
Complete 19305-19307, 38745
Superficial 38740
Optical Coherence Tomography 0351T, 0352T
Biopsy
Needle 38505
Open 38500, 38510, 38520, 38525, 38530, 38531
Celiac
Excision 38747
Cervical
Hygroma, Cystic
Lymphadenectomy
Complete 38720
Modified 38724
Dissection
Jugular 38542
Drainage
Manual 97140
Excision 38500, 38510, 38520, 38525, 38530, 38531
Abdominal 38747
Aortic 38780
Celiac 38747
Gastric 38747
Hypogastric 38770, 55845, 55865
Iliac 38770, 55845, 55865
Inguinofemoral 38531, 38760-38765
Limited, for Staging
Para-Aortic 38562, 38747
Mediastinal 21632, 32674, 38746
Obturator 38770, 55845, 55865
Pelvic 38562
Pelvic 38562, 38770, 38780, 57531
Peripancreatic 38747
Portal 38747
Radical
Axillary 19305-19307, 38740-38745
Cervical 38720-38724
Suprahyoid 38700
Renal 38780
Retroperitoneal Transabdominal 38780
Thoracic 38746
Vena Caval 38747
Exploration
Jugular 38542
Gastric
Excision 38747
Hilar
Sampling
Endobronchial Ultrasound (EBUS) Guided 31652, 31653
Hygroma
Axillary/Cervical
Hypogastric
Excision 38770, 55845, 55865
Identification
Sentinel
Injection, Radioactive Tracer 38792
Iliac
Excision 38770, 55845, 55865
Inguinofemoral
Jugular
Dissection 38542
Mediastinal
Excision 21632
Thoracoscopic 32674
by Thoracotomy 38746
Mediastinoscopy 39402
Sampling
Guided 31652, 31653
Nuclear Medicine
Imaging 78195
Obturator
Excision 38770, 55845, 55865
Para-Aortic
Biopsy 57531, 58200, 58210, 58548, 58943
Excision 38562, 38747, 58951, 58954, 58960
Pelvic
Biopsy 55812, 55842, 55862, 58200, 58943, 58954
Excision 38562, 38770, 38780, 55845, 55865, 58210, 58548, 58951, 58954, 58960
Peripancreatic
Excision 38747
Portal
Excision 38747
Removal
Regional
with Nephrectomy 50545
Renal
Excision 38780
Suprahyoid
Excision 38700
Therapy 97140
Thoracic
Excision 38746
Vena Caval
Excision 38747
Lymph Vessels
Imaging
Lymphangiography
Abdomen 75805-75807
Arm 75801-75803
Leg 75801-75803
Pelvis 75805-75807
Incision 38308
Lymphadenectomy
Abdominal 38747
Aortic 38780
Axillary 38740-38745
Bilateral Inguinofemoral 54130, 56632, 56637
Bilateral Pelvic 51575, 51585, 51595, 54135, 55845, 55865
Total 38571-38573, 57531, 58210
Celiac 38747
Diaphragmatic Assessment 58960
Gastric 38747
Hypogastric 38770, 55845, 55865
Iliac 38770, 55845, 55865
Inguinofemoral 38760-38765
Inguinofemoral, Iliac and Pelvic 56640
Injection
Sentinel Node 38792, 38900
Limited
Para-Aortic, Resection of Ovarian Malignancy 58951, 58954
Pelvic 55842, 55862, 58954
for Staging
Para-Aortic 38562
Pelvic 38562
Mediastinal 21632
Thoracoscopic 32674
Obturator 38770, 55845, 55865
Para-Aortic 58958
Pelvic 38770, 38780, 55845, 55865, 57531, 58210, 58548, 58958
Peripancreatic 38747
Portal 38747
Radical
Pelvic 54135, 55845, 58548
Suprahyoid 38700
Regional 50230
Thoracoscopic 32674
Renal 38780
Retroperitoneal Transabdominal 38780
Suprahyoid 38700
Thoracic
Unilateral Inguinofemoral 56631, 56634
Vena Caval 38747
Lymphadenitis
Lymphadenopathy-Associated Antibodies/Virus
Human Immunodeficiency Virus (HIV)
HIV 86689, 86701-86703
HIV-1 86701, 86703, 87389
HIV-2 86702, 86703, 87389
Lymphangiogram
See Lymphangiography
Lymphangiography
Abdomen 75805-75807
Arm 75801-75803
Injection 38790
Leg 75801-75803
Pelvis 75805-75807
Lymphangioma, Cystic 38550-38555

Lymphangiotomy 38308
Lymphatic Channels
Incision 38308
Lymphatic Cyst
See Lymphocele
Lymphatic System
Lymphatics
See Lymph Nodes; Lymph Vessels
Imaging
Lymphoblast Transformation
Blastogenesis 86353
Lymphocele
Drainage
Laparoscopic 49323
Open 49062
Lymphocoele
See Lymphocele
Lymphocyte
Culture 86821
Tissue 88230
Toxicity Assay 86805, 86806
Transformation 86353
Lymphocyte, Thymus-Dependent
See T Cells
Lymphocytes, CD4 86360
Lymphocytes, CD8 86360
Lymphocytic Choriomeningitis
Antibody 86727
Lymphocytotoxicity 86805, 86806

Lymphoma Virus, Burkitt
Lynch Procedure 31075
Lysergic Acid Diethylamide
Drug Assay
Alkaloids, Not Otherwise Specified 80323
Lysis
Adhesions
Epidural 62263, 62264
Foreskin 54450
Intestinal 44005, 44180
Labial 56441
Lung 32124, 32940
Nose 30560
Ovary 58660, 58740
Oviduct 58660, 58740
Penile
Post-Circumcision 54162
Ureter 50715-50725
Urethra 53500
Uterus 58559
Clot
Time 85175
Euglobulin 85360
Fibrosis
Urethral 52285
Intranasal Synechia 30560
Lysozyme 85549
M
Macrodactylia
Repair 26590
Macroscopic Examination
Arthropod 87168
Parasite 87169
Tissue 88387, 88388
Magnesium 83735
Magnet Operation
Magnetic Extraction
Foreign Body
Eye 65260
Magnetic Resonance Angiography (MRA)

Abdomen 74185
Arm 73225
Chest 71555
Head 70544-70546
Leg 73725
Neck 70547-70549
Pelvis 72198
Spine 72159
Diagnostic
3D Rendering 76376, 76377
Abdomen 74181-74183
Ankle 73721-73723
Arm 73218-73220
Joint 73221-73223
Bone Marrow Study 77084
Brain 70551-70555
Intraoperative 70557-70559
Chest 71550-71552
Elbow 73221
Face 70540-70543
Fetal 74712, 74713
Foot 73718, 73719
Foot Joints 73721-73723
Hand 73218-73220, 73223
Heart 75557-75565
Joint
Lower Extremity 73721-73723
Upper Extremity 73221-73223
Knee 73721-73723
Leg 73718-73720
Joint 73721-73723
Neck 70540-70543
Obstetrical
Maternal Pelvis 74712, 74713
Orbit 70540-70543
Pelvis 72195-72197
Spectroscopy 76390
Spine
Cervical 72141, 72142, 72156
Lumbar 72148, 72149, 72158
Thoracic 72146, 72147, 72157
Temporomandibular Joint (TMJ) 70336
Toe 73721-73723
Wrist 73221
Guidance
Arthrography, Enhanced
Shoulder
Injection 23350
Brain
Stereotactic Lesion Ablation
Stereotactic Lesion Biopsy 61751
Breast
Biopsy 19085, 19086
Lesion Localization Device Placement 19085, 19086, 19287, 19288
Needle Placement 77021
Orthopedic Procedure
Computer-assisted Navigation 0055T
Parenchymal Tissue Ablation 77022
Magnetic Resonance Spectroscopy

Discogenic Pain Determination/Localization 0609T-0612T
Glycosylated Acute Phase Proteins (GlycA) Quantitation 0024U
Lipoprotein Particle Quantitation 83704
Scan 76390
Magnetic Stimulation
Transcranial 90867-90869
Magnetoencephalography (MEG) 95965-95967

Magnuson Procedure 23450
MAGPI Operation 54322
MAGPI Procedure
See Hypospadias, Repair
Major Vestibular Gland

Malar Area
Augmentation 21270
Bone Graft 21210
Fracture
Malar Bone
See Cheek, Bone
Malaria Antibody 86750
Malaria Smear 87207
Malate Dehydrogenase 83775
Maldescent, Testis
Male Circumcision
See Circumcision
Malformation, Arteriovenous
Malic Dehydrogenase
Malignant Hyperthermia Susceptibility

Caffeine Halothane Contracture Test (CHCT) 89049
Malleolus
Fracture
Bimalleolar 27808, 27810, 27814
Lateral 27786, 27788, 27792
Medial 27760, 27762, 27766
Posterior 27767-27769
Trimalleolar 27816, 27818, 27822, 27823
Mallet Finger Repair 26432, 26433

Maltose
Malunion Repair
Clavicle 23485
Femur
with Graft 27472
without Graft 27470
Fibula 27726
Humerus
with Graft 24435
without Graft 24430
Metatarsal Bone 28322
Radius
with Graft 25405, 25420
without Graft 25400, 25415
Tarsal Bone 28320
Tibia
with Graft 27722, 27724
by Synostosis with Fibula 27725
without Graft 27720
Ulna
with Graft 25405, 25420
without Graft 25400, 25415
Mammalian Oviduct
See Fallopian Tube
Mammary Abscess
Mammary Arteries
Angiography 75756
Mammary Duct
X ray 77053, 77054
Mammary Ductogram
X ray 77053, 77054
Mammary Stimulating Hormone
Mammillaplasty
Nipple/Areola Reconstruction 19350
Mammogram 77065-77067
with Computer-Aided Detection (CAD) 77065-77067
Localization, Lesion
Device Placement 19281, 19282
Screening Mammography 77067
Tomosynthesis 77061-77063
Mammoplasty
See Mammaplasty
Mammotomy
Mastotomy
Exploration 19020
Mammotropic Hormone, Pituitary

Mammotropic Hormone, Placental
Mammotropin
Mandated Services
On Call Services 99026, 99027
Mandible
See also Facial Bones; Maxilla; Temporomandibular Joint (TMJ)
Abscess
Excision 21025
Bone Graft 21215
Condyle
See Mandibular Condyle
Cyst
Excision 21040, 21046, 21047
Excision
Abscess 21025
Bone 21025
Cyst 21040, 21046, 21047
Torus Mandibularis 21031
Tumor 21040, 21044, 21045, 21046, 21047
Fracture
Closed Treatment
Alveolar Ridge 21440
Alveolar Ridge 21445
Condylar Fracture 21465
without Interdental Fixation 21461
Osteotomy 21198, 21199
with Cyst Excision 21046, 21047
with Tumor Excision 21046, 21047
Prosthesis
Impression 21081
Rami
See Mandibular Rami
Reconstruction
with Implant 21244-21246, 21248, 21249
Removal
Foreign Body 41806
Resection
with Glossectomy 41150, 41155
Splitting 61576
Torus Mandibularis
Excision 21031
Tumor
X ray 70100-70110
Mandibular Body
Augmentation
Mandibular Condyle
Fracture
Mandibular Condylectomy
See Condylectomy
Mandibular Fracture
See Fracture, Mandible
Mandibular Rami
Reconstruction
with Internal Rigid Fixation 21196
without Bone Graft 21193
without Internal Rigid Fixation 21195
Mandibular Staple Bone Plate
Reconstruction
Mandible 21244
Manganese 83785
Manipulation
Chest Wall 94667, 94668
Chiropractic 98940-98943
Clubfoot Cast Application 29450
Dislocation and/or Fracture
Acetabulum 27222
Ankle 27810, 27818, 27860
Calcaneal 28405, 28406
Carpal 25635
Carpal Scaphoid 25624
Carpometacarpal 26670-26676
Thumb Dislocation 26641, 26645, 26650
Clavicular 23505
Elbow 24300, 24620, 24640
Femoral 27232, 27268, 27503, 27510, 27517
Peritrochanteric 27240
Femoral Shaft 27502
Fibula 27781, 27788
Finger 26725-26727, 26742, 26755
Joint 26340
Greater Tuberosity
Humeral 23625
Hand 26670-26676
Heel 28405, 28406
Hip 27257
Hip Socket 27222
Humeral 23605, 24505, 24535
Condyle 24577, 24582
Epicondyle 24565, 24566
Tuberosity 23625
Intercarpal 25660
Interphalangeal Joint 26340, 26742, 26770-26776, 28666
Knee 27538, 29850
Lunate 25690
Malar Area 21355
Mandibular 21451
Metacarpal 26605-26607
Metacarpophalangeal 26700-26706, 26742
Metacarpophalangeal Joint 26340, 26700-26706, 26742
Metatarsal 28475, 28476
Monteggia 24620
Navicular 25624
Orbit 21401
Pelvic Ring 27198
Pelvis 27275
Phalangeal Shaft 26727
Distal, Finger or Thumb 26755
Finger/Thumb 26725, 26727
Phalanges 28495, 28496, 28510
Finger 26742, 26755, 26770-26776
Finger/Thumb 26727
Great Toe 28495, 28496
Toes 28515
Radial 24655, 25565, 25605
Radial Shaft 25505, 25565
Radiocarpal 25660
Radioulnar 25675
Scapular 23575
with Greater Tuberosity 23665
Joint 23700
with Neck Fracture 23675
Talotarsal 28576
Talus 28435, 28436
Tarsal 28455, 28456, 28546
Thumb 26641-26650
Tibial 27532, 27752, 27762, 27768, 27825
Trans-Scaphoperilunar 25680
Ulnar 24675, 25605
Ulnar Shaft 25535, 25565
Vertebral 22315
Wrist 25259, 25624, 25635, 25660, 25675, 25680, 25690
Dupuytren’s Cord 26341
Foreskin 54450
Globe 92018, 92019
Hip 27275
Finger 26340
Proximal 26742
Knee Joint 27570
Adhesions 29884
Lymphatic Drainage 97140
Manual Therapy 97140
Osteopathic 98925-98929
Palmar Fascial Cord 26341
Rectal
Dilation 45905, 45910
Reduction, Procidentia 45900
Removal, Fecal Impaction 45915
Shoulder
Adhesions 29825
Application of Fixation Apparatus 23700
Slipped Epiphysis
Femur 27178
Spine
without Anesthesia 97140
Temporomandibular Joint(s) (TMJ) 21073
Ureter 52330, 52352
Manometric Studies
Abdominal Voiding Pressure 51797
Bladder Voiding Pressure 51728, 51729
Blood Pressure
See Blood Pressure
Colon 91117
Cranial Pressure 61107, 61210
Duodenal Motility 91022
Esophagus 91010
Gastric Motility 91020
Gastrointestinal Tract 91112
Interstitial Fluid Pressure 20950
Intraocular Pressure 0198T, 92100
Kidney Pressure 50396
Plantar Pressure 96001-96004
Rectum/Anus 91122
Sphincter of Oddi 43263
Ureter Pressure 50686
Ureterostomy 50686
Urethra Voiding Pressure 51727, 51729
Manometry
Anorectal 91122
with Biofeedback Training 90912, 90913
Rectum 90912, 90913
Mantoux Test
TB Skin Test 86580
Maquet Procedure 27418
Marrow, Bone
See Bone Marrow
Marshall-Marchetti-Krantz Procedure 51840, 51841, 58152, 58267

Marsupialization
Abscess
Liver 47300
Acne 10040
Cyst
Liver 47300
Pancreatic 48500
Sublingual Salivary 42409
Urethral Diverticulum 53240
Mass
Abdomen
Biopsy 49180
Kidney
Ablation 50542
Cryosurgical 50250
Lung
Biopsy 32097, 32608
Resection 32505, 32506, 32666, 32667
Mediastinum
Excision 32662
Pericardium
Excision 32661
Renal
Ablation 50250, 50542
Retroperitoneal
Biopsy 49180
Soft Tissue
Mass Spectrometry and Tandem Mass Spectrometry
Analyte
Drug, Presumptive Screening 80307
Non-Drug
Unspecified Non-Drug Analyte 83789
Massage
Cardiac 32160
Therapy 97124
Masseter Muscle/Bone
Bone and Muscle
Muscle Flap 15733
Massively Parallel Sequencing (MPS)

See Next Generation Sequencing (NGS) and Other Molecular Multianalyte Assays
Mastectomy
with Axillary Lymphadenectomy 19302
for Gynecomastia 19300
Intraoperative Margin Assessment
Radiofrequency Spectroscopy 0546T
Partial 19301, 19302
Radical 19303-19306
Simple, Complete 19303
Mastoid
Excision
Complete 69502
Debridement 69220
Radical 69511
Modified 69505
Petrous Apicectomy 69530
Simple 69501
Obliteration 69670
Repair
by Excision 69601-69603
Fistula 69700
with Tympanoplasty 69604
Mastoid Cavity
Mastoidectomy
with Labyrinthectomy 69910
Osseointegrated Implant
for External Speech Processor/Cochlear Stimulator 69715, 69718
with Skull Base Surgery 61591, 61597
Decompression 61595
Facial Nerve 61595
with Tympanoplasty 69604, 69641-69646
Cochlear Device Implantation 69930
Complete 69502
Revision 69601
with Labyrinthectomy 69910
with Petrous Apicectomy 69530
Radical 69511
Modified 69505
Revision 69602, 69603
Simple 69501
Mastoidotomy 69635-69637
Ossicular Chain Reconstruction 69636
and Synthetic Prosthesis 69636
Mastoids
Polytomography 76101, 76102
X ray 70120-70130
Mastopexy 19316
Mastotomy
Exploration 19020
Maternity Care
See Abortion; Cesarean Delivery; Ectopic Pregnancy; Obstetrical Care
See Obstetrical Care
Maxilla
Bone Graft 21210, 21348
CT Scan 70486-70488
Cyst
Excision 21030, 21048, 21049
Excision 21030, 21032-21034
Cyst 21030, 21048, 21049
Torus Palatinus 21032
Tumor 21030, 21034, 21048, 21049
Fracture
with Fixation 21345-21347, 21435, 21485
Open Treatment 21346-21348, 21422, 21423
Osteotomy 21206
Reconstruction
with Implant 21245, 21246, 21248, 21249
Tumor
Excision 21030, 21048, 21049
Maxillary Arteries
Ligation 30920
Maxillary Sinus
Antrostomy 31256-31267
Caldwell-Luc Operation 21385
Dilation 31295
Excision 31225-31230, 61581
Incision 31020-31032, 31256-31267
Irrigation 31000
Maxillary Torus Palatinus
Excision 21032
Maxillectomy 31225-31230
with Craniofacial Procedures 61581
Partial 21049
Maxillofacial Fixation
See Fixation, Fracture, Maxillofacial
Maxillofacial Impressions
Auricular Prosthesis 21086
Facial Prosthesis 21088
Nasal Prosthesis 21087
Obturator Prosthesis
Definitive 21080
Interim 21079
Surgical 21076
Palatal Prosthesis
Augmentation 21082
Lift 21083
Speech Aid Prosthesis 21084
Maxillofacial Procedures
Fixation
See Fixation (Device), Maxillofacial
Reconstruction
See Face, Reconstruction
Maxillofacial Prosthetics 21076-21088
Impressions
See Maxillofacial Impressions
Maze Procedure
Open 33254-33256
McCannel Procedure 66682
Measles, German
Antibody 86762
Vaccine 90707, 90710
Measles, Uncomplicated
Antibody 86765
Measles Vaccine
Measles, Mumps, and Rubella (MMR) 90707
Measles, Mumps, Rubella, and Varicella (MMRV) 90710
Meat Fibers
Feces 89160
Meatoplasty
External Auditory Canal 69310
Urethra 53450, 53460
Meatotomy
Cystourethroscopy 52281
Infant 53025
Prostate
Laser Coagulation 52647
Laser Enucleation 52649
Laser Vaporization 52648
with Prostatectomy 55801, 55821
Transurethral Resection 52630
Electrosurgical 52601
Ureter 52290
Urethral 52285, 53020
Infant 53025
Meckel’s Diverticulum
Excision 44800
Median Nerve
Decompression 64721
Neuroplasty 64721
Release 64721
Repair/Suture
Motor Thenar 64835
Transposition 64721
Median Nerve Compression
Carpal Tunnel Syndrome 64721
Mediastinal Cyst
Excision 32662
Resection 39200
Mediastinoscopy
Biopsy
Mediastinal Lymph Node 39402
Mediastinal Mass 39401
Mediastinotomy
Cervical Approach 39000
Transthoracic Approach 39010
Mediastinum
Biopsy
Core Needle 32408
Cyst
Excision 32662
Resection 39200
Drainage
Endoscopy
Biopsy 39401, 39402
Excision
Cyst 32662
Lymph Node 21603, 21632, 32674, 38746
Mass 32662
Tumor 32662
Exploration 39000-39010, 60505
Lymph Node
Biopsy
Medianoscopy 39402
Lymphadenectomy 21603, 21632, 32674, 38746
Sampling
Guided 31652, 31653
Mass
Biopsy
Medianoscopy 39401
Excision 32662
Radical Dissection 60522
Removal
Resection
Cyst 39200
Tumor 39220
Thoracoscopy
Biopsy 32606
Diagnostic 32601
Excision
Cyst 32662
Mass 32662
Tumor 32662
Tumor
Excision 32662
Resection 39220
Medical Disability Evaluation Services 99455, 99456

Medical Genetics
Genetic Counseling 96040
Medical Team Conference 99366-99368

Medical Testimony 99075
Medication Therapy Management
Pharmacist Provided 99605-99607
Psychiatric 90863
Medicine, Preventive
See Preventive Medicine
Medicine, Pulmonary
See Pulmonology
Medulla
Creation of Lesion
Stereotactic 61791
Decompression
Craniectomy 61343
Megacolon
Decompression
with Colonoscopy 45393
with Sigmoidoscopy 45337
Meibomian Cyst
See Chalazion
Membrane, Mucous
See Mucosa
Membrane, Tympanic
Membrane Oxygenation, Extracorporeal

Meninges
Excision
Tumor 61512, 61519
Meningitis, Meningococcal
Antibody 86741
Vaccine 90619, 90620, 90621, 90644, 90733, 90734
Repair
Meningocele 63700, 63702
Myelomeningocele 63704, 63706
Pseudomeningocele 63709
Meningioma
Excision 61512, 61519
Meningitis, Lymphocytic Benign

Meningocele Repair
Meningocele 63700, 63702
Myelomeningocele 63704, 63706
Pseudomeningocele 63709
Meningococcal Meningitis
Antibody 86741
Vaccine 90619, 90620, 90621, 90644, 90733, 90734
Meningococcal Vaccine
Meningococcal Conjugate
Serogroups A, C, W, Y, Quadrivalent, CRM197
Carrier (MenACWY-CRM) 90734
Serogroups A, C, W, Y, Quadrivalent, Diphtheria Toxid Carrier (MenACWY-D) 90734
Serogroups A, C, W, Y, Quadrivalent, Tetanus Toxoid Carrier (MenACWY-TT) 90619
Serogroups C and Y, Haemophilus Influenza type b (Hib-MenCY) 90644
Meningococcal Polysaccharide Quadrivalent (MPSV4) 90733
Meningococcal Recombinant Lipoprotein Vaccine
Serogroup B (MenB-FHbp) 90621
Meningococcal Recombinant Protein Vaccine
Serogroup B (MenB-4C) 90620
Meningococcus
Meningomyelocele
Myelomeningocele
Repair 63704-63706
Meniscectomy
Knee Joint 27332, 27333
Arthroscopic 29880, 29881
Meniscus
Knee
Excision 27332, 27333
Lesion
Excision 27347
Repair 27403
Mental Nerve
Avulsion 64736
Incision 64736
Transection 64736
Mercury
Qualitative 83015
Quantitative 83825
Mesenteric Arteries
See Artery, Mesenteric
Mesentery
Lesion
Excision 44820
Repair 44850
Suture 44850
Mesh
for Exclusion
Small Intestine from Pelvis 44700
Implantation
Hernia Repair 43282, 43333, 43335, 43337, 49568, 49652-49654, 49652-49657
Insertion
Pelvic Floor 57267
Removal
Abdominal, Infected 11008
Metabisulfite Test
Red Blood Cell (RBC), Sickling 85660
Metabolite
Thromboxane 84431
Metacarpal Bone
Amputation 26910
Craterization 26230
Cyst
Excision 26200, 26205
Diaphysectomy 26230
Excision
Bone 26230
Cyst 26200-26205
Tumor 26200-26205
Fracture
with Fixation 26607
Graft 26546
Ray Amputation 26910
Repair
Lengthening 26568
Non-union 26546
Osteotomy 26565
Resection
Tumor 26250
Saucerization 26230
Tumor
Arthroscopy
Diagnostic 29900
Surgical 29901, 29902
Arthrotomy 26075
Biopsy
Synovium 26105, 29900
Capsule
Excision 26520
Fixation 26516-26518
Incision 26520
Dislocation
Drainage 26075
Exploration 26075
Fracture, Articular
Fusion 26516-26518, 26850-26852
Implantation
Prosthetic
Joint 26531
Reconstruction
Repair
Synovectomy 26135
Metadrenaline
Metanephrines 83835
Metals, Heavy
Qualitative 83015
Quantitative 83018
Metanephrines 83835
Metatarsal Bone
See also Foot
Amputation 28810
Bone Graft 20957
Osteocutaneous 20972
Condyle
Excision 28288
Craterization 28122
Cyst
Diaphysectomy 28122
Excision 28110-28114, 28122, 28140
Fracture
Closed Treatment
Bone Graft 20957
Free Osteocutaneous Flap 20972
Repair
Shortening 28306-28309
Saucerization 28122
Tumor
Metatarsectomy 28140
Amputation 28820
Biopsy 28052
Capsulotomy 28270
Cheilectomy 28289, 28291
Dislocation
Drainage 28022
Exploration 28022
Great Toe
Arthrodesis 28750
Fusion 28750
Removal
of Foreign Body 28022
of Loose Body 28022
Repair
Hallux Rigidus 28289, 28291
Synovial
Biopsy 28052
Excision 28072
Methaemoglobin
Methemoglobin 83045, 83050
Methane Test 91065
Methanol 80320
Methbipyranone
Metyrapone
Panel 80436
Methemalbumin 83857
Methemoglobin 83045-83050
Methenamine Silver Stain 88312
Methopyrapone
Metyrapone
Panel 80436
Methoxyhydroxymandelic Acid
Vanillylmandelic Acid 84585
Methyl Alcohol
Methanol 80320
Methylene Bichloride
Methylfluorprednisolone
Dexamethasone
Metroplasty
Hysteroplasty 58540
Metyrapone
Panel 80436
MIC
Minimum Inhibitory Concentration 87186
Microalbumin
Urine 82043, 82044
Microbiology 87003-87999
Microbiota, Transplantation Fecal Matter 44705
Microdissection 88380, 88381
Microfluorometries, Flow
See Flow Cytometry
Microglobulin, Beta 2
Blood 82232
Urine 82232
Micrographic Surgery
Mohs Technique 17311-17315
Micrographic Surgery, Mohs

See Mohs Micrographic Surgery
Micro-ophthalmia
Orbit Reconstruction 21256
Micropigmentation
Correction 11920-11922
Microscope, Surgical
Operating Microscope 69990
Microscopic Evaluation
Hair 96902
Necropsy 88020, 88025, 88027-88029, 88036, 88037
Surgical Pathology 88302, 88304, 88305, 88307, 88309, 88399
Urinalysis 81015
Microscopies, Electron
Electron Microscopy 88348
Microscopy
Binocular
Ear Exam 92504
Reflectance Confocal Microscopy (RCM)
Lesion 96932
Skin Imaging 96931-96936
Specular
Endothelial Cell Analysis 92286
Microsomal Antibody 86376

Microsomia, Hemifacial
Reconstruction
Microsurgery
Bone Graft
Fibula 20955
Iliac Crest 20956
Metatarsal 20957
Other Site 20962
Breast Reconstruction TRAM Flap 19367-19369
Fascial Flap, Free 15758
Finger Transfer 26555
Intestinal Graft, Free 43116
Jejunum Transfer, Free 43496
Muscle Flap, Free 15756
Myocutaneous Flap
Pharyngeal Wall Resection with Closure 42894
Omental Flap, Free 49906
Osteocutaneous Flap 20969
Great Toe with Web 20973
Iliac Crest 20970
Metatarsal 20972
Skin Flap, Free 15757
Toe Joint, Free 26556
Toe-to-Hand Transfer 26551, 26553, 26554
Microvite A
Vitamin A 84590
Microwave Therapy 97024

Midcarpal Medioccipital Joint
Arthrotomy 25040
Middle Cerebral Artery Velocimetry 76821

Middle Ear
See Ear, Middle Ear
Midface
Reconstruction
Forehead
Advancement 21159, 21160, 21172, 21175, 21263
Alteration 21175
with Bone Graft 21145-21160, 21188
Entire/Majority 21179, 21180
LeFort I 21141-21143, 21145-21147, 21155, 21160
LeFort II 21150, 21151
LeFort III 21154, 21155, 21159, 21160
Milia, Multiple
Removal 10040
Miller Procedure 28737

Miller-Abbott Intubation
Introduction 44500
with Radiological Guidance 74340
Minerva Cast
Application 29040
Removal 29710
Minimum Inhibitory Concentration 87186
Minimum Lethal Concentration 87187
Minnesota Multiphasic Personality Inventory (MMPI)
Psychological Test Administration/Scoring 96136-96139, 96146
Miscarriage
Incomplete Abortion 59812
Missed Abortion
Septic Abortion 59830
Missed Abortion
Mitogen Blastogenesis 86353
Mitral Valve
Annulus
Transcatheter Reconstruction 0544T
Closure
Incision 33420, 33422
Occlusion
Repair
with Cardiopulmonary Bypass 33425-33427
Transapical 0543T
Transcatheter 0345T, 33418, 33419
Replacement 33430
Transcatheter Mitral Valve Implantation/Replacement (TMVI) 0483T, 0484T
Miyagawanella
See Chlamydia
MLC (Mixed Lymphocyte Culture) 86821

MMPI (Minnesota Multiphasic Personality Inventory)
Psychological Test Administration/Scoring 96136-96139, 96146
MMR Shots 90707

Measles, Mumps, and Rubella (MMR) 90707
Measles, Mumps, Rubella, and Varicella (MMRV) 90710
Mobilization
Conjunctiva 65272, 65273
Cranium 61590, 61591, 61595-61597
Intestine 43108, 43113, 43118, 43123, 43361
Nerve 64874
Splenic Flexure 44139
Laparoscopic 44213
Stapes 69650
Urethra 54300, 54326, 54344
Modeling, 3D Anatomic
Printed from Image Data Set 0559T-0562T
Moderate Sedation 99151-99153, 99155-99157
Modified Radical Mastectomy 19307
Molar Pregnancy
Mold
Cast 29450
Culture 87107
Mole, Carneous
See Abortion, Missed
Mole, Hydatid
Molecular Cytogenetics 88271-88275
Interpretation and Report 88291
Molecular Diagnostics
Reverse Transcription and Amplified Probe
Enterovirus 87498
Hepatitis C 87521
HIV-1 87535
HIV-2 87538
Reverse Transcription and Quantification
Hepatitis C 87522
HIV-1 87536
HIV-2 87539
Molecular Oxygen Saturation 82805-82810
Molecular Pathology
See Gene Analysis
Molecular Probes 88120
Molluscum Contagiosum
Destruction 17110, 17111, 46900, 46910, 46916, 46917, 54050-54065
Excision
Anus 46922
Penis 54060
Monilia
See Candida
Monitoring
Ablation Therapy
Incompetent Vein 0524T, 36473-36476, 36478, 36479, 36482, 36483
Parenchymal Tissue
Computed Tomography 77013
Ultrasound 76940
Renal Mass 50250, 50542
ACE/ARB Therapy 4188F
Anticonvulsant Therapy 4191F
by Arterial Catheterization 36620
Blood Pressure
See Blood Pressure, Monitoring
Cardiac
Cardiovascular Physiologic Monitor System 93290, 93297
System 93285, 93291, 93298
Cerebrospinal Shunt Flow
Skin Sensor 0639T
with Contrast
Biliary Drainage 47533-47540
Catheter 75984, 93503
Digoxin Therapy 4189F
Diuretic Therapy 4190F
Electrocardiogram
Electroencephalogram
ESRD 90951-90959, 90963-90965
Fetal
During Labor 59050, 59051, 99500
Interpretation Only 59051
Magnetic Cardiac Signal 0475T-0478T
Glomerular Filtration Rate (GFR)
Transdermal Sensor Placement and Agent Administration 0603T
Glucose
Home Device 82962
Interstitial Fluid 95249-95251
Hemodynamic
Pulmonary Artery Pressure 33289, 93264
Interstitial Fluid Pressure 20950
Intraocular Pressure 0329T
Neurological
Arterial Occlusion 61623
Neurophysiologic
Pediatric Apnea 94774-94777
Physiologic Parameters
Remote 99453, 99454
Treatment Management Services 99457, 99458
Pulmonary Fluid Monitoring System 0607T-0608T
Retinal Disease 92227-92229
Seizure 61531-61533, 61760
Monitoring, Sleep
Polysomnography 95782, 95783, 95808, 95810, 95811
Sleep Study 95800, 95801, 95807
Monoethylene Glycol
Mononuclear Cell Antigen 86356

Mononucleosis Virus, Infectious
Monophosphate, Adenosine
5-Monophosphate, Cyclic 82030
Monophosphate, Adenosine Cyclic
Cyclic AMP 82030
Monospot Test 86308

Monoxide, Carbon
Diffusing Capacity 94729
Monteggia Fracture 24620, 24635

Monticelli Procedure
Application, Bone Fixation Device 20692
Morbilli
Rubeola
Antibody 86765
Manual 88368, 88369, 88377
Nerve 88356
Skeletal Muscle 88355
Tumor 88358-88361
Urinary Tract Specimen 88120, 88121
Morton’s Neuroma
Excision 28080
Mosaicplasty 27416
Mosenthal Test
Urinalysis, Routine 81002
Mother Cell
See Stem Cell
Motility Study
Colon 91117
Duodenal 91022
Esophagus 91010
Imaging 78258
Sperm 89300
Motion Analysis
Computer-based 96000, 96004
Movement Disorder Monitoring 0533T-0536T
by Video and 3D Kinematics 96000, 96004
Motion Management Simulation

Respiratory 77293
Mouth
Abscess
Incision and Drainage 40800, 40801, 41005-41009, 41015-41018
Biopsy 40808, 41108
Cyst
Excision
Frenum 40819
Gums
See Gums
Hematoma
Lesion
Destruction 40820
Excision 40810-40816, 41116
Vestibule
Destruction 40820
Lips
See Lip
Mucosa
Donor Excision 40818
Lesion
Excision 40810, 40812, 40814, 40816
Removal
Repair
Laceration 40830, 40831, 41250, 41252
Resection
with Glossectomy 41150, 41153, 41155
Skin Graft
Tongue
See Tongue
Vestibule
Biopsy 40808
Destruction
Lesion 40820
Scar 40820
Excision
Frenum 40819
Abscess 40800, 40801
Cyst 40800, 40801
Hematoma 40800, 40801
Removal
Repair 40830-40845
Move
See also Transfer
Finger 26555
Toe Joint 26556
Toe to Hand 26551-26554
MPD Syndrome
MPR
Multifetal Pregnancy Reduction 59866
MR Spectroscopy
MRA
See Magnetic Resonance Angiography (MRA)
MRI
Mucin
Synovial Fluid 83872
Mucocele
Sinusotomy
Frontal 31075
Mucopolysaccharides 83864
Mucormycoses
Antibody 86732
Mucormycosis
Antibody 86732
Mucosa
Ablation
Turbinates 30801, 30802
Advancement
Lip 40500
Urethra 53450
Biopsy
Gross and Microscopic Examination
Nasal 88305
Oral 88305
Vaginal 88302
Vaginal 57100-57105
Ectopic Gastric Imaging 78290
Excision
Alveolar, Hyperplastic 41828
Vestibule of Mouth, Donor 40818
Fulguration
Hypertrophic Folds
Urethra 52400
Lesion
Ablation
Vestibule of Mouth 40810-40818
Photodynamic Therapy 96567, 96573, 96574
Periodontal Grafting 41870
Polyp
Sinus
Removal 31051
Resection
Endoscopy 43211
Hypertrophic Folds
Urethra 52400
Stripping
Sinus 31051
Turbinates
Ablation 30801, 30802
Vaginal
Biopsy 57100, 57105
Mucosa, Buccal
See Mouth, Mucosa
Mucous Cyst
Tendon Sheath/Joint Capsule
Hand or Finger
Excision 26160
Mucous Membrane
Excision
Benign Lesion 11440-11446
Malignant Lesion 11640-11646
Sphenoid Sinus 31288
Graft
Buccal 67835, 68325, 68328, 68335
Layer Closure
Wounds 12051-12057
Lesion
Destruction 17000-17004, 17280-17286
Excision
Benign 11440-11446
Shaving 11310-11313
Rectum
Proctoplasty for Prolapse 45505
Repair
Trichiasis 67835
Wound
Superficial 12011, 12013-12018
Simple Repair
Wounds 12011-12018
Tests
Nasal 95065
Ophthalmic 95060
Mucus Cyst
See Mucous Cyst
MUGA (Multiple Gated Acquisition) 78472, 78473, 78483
Autoimmune Disease
Rheumatoid Arthritis 81490
Cardiology
Heart Transplant 81595
Coronary Artery Disease 81493
Endocrinology 81506
Fetal Aneuploidy 81507
Fetal Congenital Abnormalities 81508-81512
Infectious Disease
Bacterial Vaginosis 81513
Bacterial Vaginosis/Vaginitis 81514
Mycoplasma Genitalium 87563
Liver Disease 0002M, 0003M, 0014M
Oncology
Adrenal Cortical Tumor 0015M
Bladder Cancer 0016M
Breast
mRNA Gene Expression Profiling 81518-81521
Colon 81525
Colorectal 81528
Cutaneous Melanoma 81529
Gastrointestinal Neuroendocrine 0007M
Gynecologic 81535, 81536
Liver 0006M
Lung 81538
Ovarian 81500, 81503
Prostate 0011M, 81539, 81541, 81542, 81551
Thyroid 81546
Tissue of Origin 81504
Tumor of Unknown Origin 81540
Urothelial Carcinoma 0012M, 0013M
Uveal Melanoma 81552
Pulmonary Disease
Idiopathic Pulmonary Fibrosis (IPF) 81554
Scoliosis 0004M
Unlisted Multianalyte Assay with Algorithmic
Analysis 81599
Multifetal Pregnancy Reduction 59866

Multiple Sleep Latency Testing (MSLT) 95805
Multiple Valve Procedures
See Valvuloplasty
Mumford Operation
Claviculectomy, Open, Partial 23120
Mumford Procedure 29824

Mumps
Antibody 86735
Immunization 90707, 90710
Vaccine
MMR 90707
MMRV 90710
Muramidase 85549
Murine Typhus 86000
Muscle, General Procedures
See also Muscle-specific Procedures
Biofeedback Training 90912, 90913
Biopsy 20200-20206, 67346
Chemodenervation 64612, 64615-64617, 64642-64647, 67345
Guidance 95873, 95874
Compartment Syndrome
Detection 20950
Cutting
Pyloric 43520
Debridement 11011, 11012, 11043, 11044, 11046, 11047
Infected 11004-11006
Nonviable 25023, 25025, 27057, 27497, 27499
Leg 27892-27894
Delivery
Thermal Energy
for Gastroesophageal Reflux
Disease 43257
Division
See Muscle Division
Excision
Lip 40816
Pectoral 19305-19307
Flaps
Fasciocutaneous 15733, 15734, 15736, 15738
Muscle, Free 15842
with Microvascular
Myocutaneous 15733, 15734, 15736, 15738, 61619
Grafts
Muscle, Free 15841, 25265, 25274
Imaging
Myocardium
See Myocardial Imaging
Imbrication
Anus 46761
Implantation
Eye 65105, 65140, 65155
Nerve to Muscle 64787
Incision
Esophagus 32665, 43130, 43279, 43330, 43331
Hyoid 21685
Pharynx 43030, 43130
Pylorus 43520
Insertion
Needle 20560, 20561
Interstitial Fluid Pressure
Monitoring 20950
Myopathy
Studies
Electromyography 95860-95864, 95867-95870, 95885-95887
Nerve Conduction 95907-95913
Neuromuscular Junction 95937
Neoplasms
Leiomata Ablation 0071T, 0072T
Myomectomy 58140, 58145, 58146
Neurectomy
Hamstring 27325
Placement
Catheter
Interstitial Radioelement Application 20555
Range of Motion
See Range of Motion Test
Redirection/Rerouting/Repositioning
Extraocular 67320
Leg, Upper 27396, 27397
Leg. Lower 27690, 27691
Mouth 40845
Release
Foot 28240
Hand 26508, 26593
Hip 27036
Knee 27422
Removal
Repair
Arm, Upper 24341
Blepharoptosis 67901-67908
Elbow 24341
Extraocular 65290, 67311-67316, 67334, 67340, 67346
Forearm 25260-25274
Frontalis Technique 67901, 67902
Hand 26591, 26593
Wrist 25260-25274
Revision
Arm, Upper 24330, 24331
Suspension
Hyoid 21685
Suture
Hamstring 27385
Quadriceps 27385
Testing
See Muscle Testing
Transfer
Arm, Upper 24301, 24320
Elbow 24301
Femur 27110
Hand 26494
Hip 27100-27105, 27111
Regional 15845
Rotator Cuff 23410, 23412
Shoulder 23395-23397, 23410, 23412, 24301, 24320
Thigh 27400
Transplant
Anus 46760
Muscle, Oculomotor
See Eye Muscles
Muscle Compartment Syndrome
Detection 20950
Muscle Denervation
See Denervation
Muscle Division
Plantar 28250
Scalenus Anticus 21700-21705
Sternocleidomastoid 21720-21725
Muscle Flaps 15731-15738
Fasciocutaneous 15733, 15734, 15736, 15738
Muscle, Free 15842
with Microvascular Anastomosis 15756, 42894
Myocutaneous 15733, 15734, 15736, 15738, 61619
Muscle Grafts
Free 15841, 25265, 25274
Muscle Testing
Dynamometry, Eye 92260
Electromyography
See Electromyography
Extraocular Multiple Muscles 92265
Ischemic Limb 95875
Oculoelectromyography 92265
Range of Motion
See Range of Motion Test
Reflex
See Reflex Test
Muscle-specific Procedures
Arm
Biceps
Resection 23440
Tendon Reinsertion 24342
Tendon Reconstruction
Excision 25109
Revision 24320
Shortening 25280
Transfer 24301
Tenotomy 24310
Triceps
Tendon Reinsertion 24342
Tenolysis 24332
Eye
Extraocular
Transposition 67318
Wound Repair 65290
Strabismus Surgery 67318
Inferior Rectus 67314, 67316
Lateral Rectus 67311, 67312
Medial Rectus 67311, 67312
Superior Oblique 67318
Superior Rectus 67314, 67316
Head
Buccinators
Flap with Vascular Pedicle 15733
Genioglossus
Masseter
Reduction 21295
Temporalis
Hip
Abductor
Tenotomy 27006
Adductor
Tenotomy 27000-27003
Fasciotomy 27027
Hip Extensor
Tenotomy 27006
Hip Flexor
Release 27036
Tenotomy 27005
Iliopsoas
Tenotomy 27005
Leg
Gastrocnemius
Neurectomy 27326
Recession 27687
Hamstring
Neurectomy 27325
Neck
Hyoid
Myotomy 21685
Suspension 21685
Levator Scapulae
Scalenus Anticus
Division 21700, 21705
Sternocleidomastoid
Division 21720, 21725
Musculoplasty
See Muscle, Repair
Musculotendinous (Rotator) Cuff
Repair 23410-23412
Mustard Procedure
Repair, Great Arteries Transposition 33774
Myasthenia Gravis
Myasthenic, Gravis
See Myasthenia Gravis
Mycobacteria
Culture 87116
Sensitivity Studies 87190
Mycophenolate (mycophenolic acid)

Drug Assay 80180
Mycoplasma
Antibody 86738
Culture 87109
Mycota
See Fungus
Myectomy, Anorectal
See Myomectomy, Anorectal
Myelencephalon
See Medulla
Myelin Basic Protein
Myelography
Brain 70010
Spine
Cervical 62302, 62305, 72240
Lumbosacral 62304, 62305, 72265
Thoracic 62303, 62305, 72255
Total 72270
Myelomeningocele
Repair 63704-63706
Myeloperoxidase (MPO) 83876
Myelotomy 63170
Myocardial Imaging
Blood Flow
Echocardiography
Contrast Perfusion 0439T
Infarct Avid 78466-78469
Metabolic Evaluation
PET 78429, 78432, 78433, 78459
Perfusion Study
Nuclear Medicine
PET 78430-78433, 78491, 78492
Planar 78453, 78454
SPECT 78451, 78452
Repair
Postinfarction 33542
for Strain
Speckle-Tracking Assessment of Myocardial Mechanics 93356
Myocardium
Biopsy 93505
Blood Flow
Ischemia Assessment
Echocardiography 0439T
Mechanical Assessment 93356
Perfusion Imaging 78451-78454
Echocardiography 0439T
Positron Emission Tomography (PET) 78429, 78432, 78433, 78459
Resection 33542
Myocutaneous Flaps 15731-15738, 15756
Myofascial Pain Dysfunction Syndrome
Myofibroma
Leiomyomata, Removal 58140, 58145, 58545, 58546, 58561
Myoglobin 83874
Myomectomy
Anorectal 45108
Uterus 58140-58146
Myoplasty
See Muscle, Repair
Myotomy
Cricopharyngeal 43180
Esophagus 32665, 43130, 43180, 43279, 43330, 43331
Hyoid 21685
Pharynx 43030, 43130
Pylorus 43520
Myringoplasty 69620
Myringostomy
See Myringotomy
Myringotomy 69420, 69421
Myxoid Cyst
See Ganglion
N
N. Meningitidis
Naffziger Operation 67414
Nagel Test 92283
Nail Bed
Repair 11760
Nail Fold
Excision
Wedge 11765
Nail Plate Separation
Avulsion 11730-11732
Nails
Biopsy 11755
Drainage 10060, 10061
Evacuation
Hematoma, Subungual 11740
Excision 11750
KOH Examination 87220
Removal 11730-11732, 11750
Trimming 11719
Narcosynthesis
Diagnostic and Therapeutic 90865
Nasal Abscess
Drainage 30000, 30020
Nasal Area
Bone Graft 21210
Nasal Bleeding
Control 30901, 30903, 30905, 30906
Nasal Bones
Bone Graft 21210
Fracture
Reconstruction
See Rhinoplasty
X ray 70160
Nasal Deformity
Repair 40700-40761
Nasal Function Study 92512

Nasal Polyp
See Nose, Polyp
Nasal Prosthesis
Impression 21087
Nasal Septum
Abscess
Fracture
Hematoma
Insertion
Button Prosthesis 30220
Repair 30630
Septoplasty 30520
Submucous Resection 30520
Nasal Sinuses
Endoscopy
Biopsy 31237
Debridement 31237
Diagnostic 31231, 31233, 31235
Exploration 31276
Polypectomy 31237
Surgical 31237-31241, 31253-31257, 31259, 31267, 31276, 31287, 31288, 31290-31298
Ethmoid
Drug-Eluting Implant
Repair of Cerebrospinal Leak 31290
Ethmoidectomy 31254, 31255
Excision
See Excision, Sinus
Frontal
Dilation 31296
Fracture
Injection 20500
Diagnostic 20501
Maxillary
Antrostomy 31256-31267
Caldwell-Luc Operation 21385
Dilation 31295
Excision 31225-31230, 61581
Incision 31020-31032, 31256-31267
Irrigation 31000
Multiple
Incision 31090
Paranasal
Incision 31090
Sphenoid
Biopsy 31050, 31051
Incision 31050, 31051
with Nasal/Sinus Endoscopy 31257, 31259, 31287, 31288
Irrigation 31002
Repair of Cerebrospinal Leak 31291
Sinusotomy 31050, 31051
Skull Base Surgery 61580, 61581
X ray 70210-70220
Nasal Smear
Eosinophils 89190
Nasal Turbinate
Fracture
Therapeutic 30930
Nasal Valve
Collapse
Repair with Implant 30468
Nasoethmoid Complex
Fracture
Nasogastric Tube
Placement 43752
Nasolacrimal Duct
Dilation 68816
Exploration 68810
Insertion
Catheter 68816
Stent 68815
Tube 68815
Repair 21340
X ray
with Contrast 70170
Nasomaxillary
Fracture
with Bone Grafting 21348
Nasopharynges
See Nasopharynx
Nasopharyngoscopy
Endoscopic 92511
Surgical
with Eustachian Tube Dilation 69705, 69706
Nasopharynx
See also Pharynx
Biopsy
Lesion 42804-42806
Hemorrhage 42970-42972
Natriuretic Peptide 83880

Natural Killer (NK) Cells
Count 86357
Natural Ostium
Sinus
Maxillary 31000
Sphenoid 31002
Navicular Bone
Carpal
Arthroplasty
with Implant 25443
Fracture
Repair
Nonunion 25431, 25440
Tarsal
Arthrodesis 28737
Excision 28238
Navigation
Computer-Assisted Procedures
Bronchoscopy 31627
Cranial 61781, 61782
Musculoskeletal 20985
Orthopedic 0054T, 0055T
Spinal 61783
Neck
Angiography 70498, 70547-70549
Artery
Ligation 37615
Biopsy 21550
Bypass Graft 35901
CT Scan 70490-70492, 70498
with PET Scan 78814
Dissection, Radical
Exploration
Blood Vessel 35800
Lymph Nodes 38542
Abscess 21501, 21502
Hematoma 21501, 21502
Lipectomy, Suction Assisted 15876
Magnetic Resonance Angiography (MRA) 70547-70549
Muscle
Nerve
Graft 64885, 64886
Nuclear Medicine
Thyroid Carcinoma Imaging 78015
PET Scan 78811
with CT Scan 78814
Repair
Blood Vessel 35201
Rhytidectomy 15828
Skin
Graft 15240, 15241
Revision 15819
Tissue Transfer
Adjacent 14040, 14041
Flap 15574, 15620
Tumor
Ultrasound Exam 76536
Unlisted Services and Procedures, Surgery 21899
Urinary Bladder
See Bladder, Neck
Wound
Exploration 20100
Repair 13131-13133
X ray 70360
Neck Muscle
Division
Necropsy
Forensic Exam 88040
Gross Exam 88000-88016
Gross and Micro Exam 88020-88029
Organ 88037
Regional 88036
Needle Biopsy
See also Biopsy
Abdomen Mass 49180
Bone 20220-20225
Bone Marrow 38221, 38222
Breast 19100
Bronchi 31629, 31633
Colon
Endoscopy 45392
Colon-Sigmoid
Endoscopy 45342
Epididymis 54800
Esophagus
Endoscopy 43232
Fluoroscopic Guidance 77002
Gastrointestinal, Upper
Intervertebral Disc 62267
Kidney 50200
Liver 47000, 47001
Lung
Core 32408
Lymph Nodes 38505
Mediastinum
Core 32408
Muscle 20206
Pancreas 48102
Paravertebral Tissue 62267
Pleura 32400
Prostate 55700
Transperineal 55706
Retroperitoneal Mass 49180
Salivary Gland 42400
Spinal Cord 62269
Testis 54500
Thyroid Gland 60100
Transbronchial 31629, 31633
Needle Localization
Breast
with Lesion Excision 19125, 19126
CT Guidance 77012
Fluoroscopic Guidance 77002
Spine 77003
Magnetic Resonance Imaging Guidance 77021
Needle Manometer Technique 20950
Needle Wire
Introduction
Trachea 31730
Neer Procedure 23470
Negative Pressure Wound Therapy 97605-97608
Neisseria Gonorrhoeae 87590-87592, 87850
Neisseria Meningitidis
Antibody 86741
Neobladder
Construction 51596
Neonatal Critical Care

See also Newborn Care
Initial 99468
Subsequent 99469
Neoplasm
Cancer Photoradiation Therapy
See Photochemotherapy
Cardiac
See Heart, Tumor
Colon
See Colon, Tumor
Esophageal
See Tumor, Esophagus
Spinal Cord
Unspecified Nature of Brain
See Brain, Tumor
Neoplastic Growth
See Tumor
Nephelometry 83883
Nephrectomy
Donor 50300-50320, 50547
Partial 50240
Laparoscopic 50543
Recipient 50340
with Ureters 50220-50236, 50546, 50548
Nephrolith
Endoscopic Removal 50561, 50580
Nephrolithotomy 50060, 50065, 50070, 50075
Nephrostolithotomy 50080, 50081
Pyelolithotomy 50130
Nephrolithotomy 50060-50075
Nephropexy 50400-50405
Nephroplasty
See Kidney, Repair
Nephropyeloplasty
See Pyeloplasty
Nephrorrhaphy 50500
Nephroscopy
See Endoscopy, Kidney
Nephrostogram
with Catheter Conversion
Nephrostomy to Nephroureteral 50434
Injection Procedure 50430, 50431
with Nephrostomy Catheter Exchange 50435
with Placement of Ureteral Stent 50693-50695
Nephrostolithotomy
Nephrostomy
Change Catheter 50434, 50435
with Drainage 50040
Insertion
Guide Wire 52334
Placement of Catheter 50432
with Pyeloplasty 50400
Nephrostomy Tract
Establishment 52334
Nephrotomogram
See Nephrotomography
Nephrotomography 74415
Nephrotomy 50040-50045
with Drainage 50040
Nerve Block
Anesthesia Administration 01991, 01992
Injection
Axillary 64417
Brachial Plexus 64415, 64416
Celiac Plexus 64530
Femoral 64448
Genicular 64454
Greater Occipital 64405
Iliohypogastric 64425
Ilioinguinal 64425
Intercostal 64420, 64421
Lumbar Plexus 64449
Paracervical 64435
Paravertebral Block (PVB) 64461-64463
Paravertebral Facet Joint 64490-64495
Paravertebral Sympathetic, Lumbar 64520
Paravertebral Sympathetic, Thoracic 64520
Peripheral 64450
Plantar Common Digital 64455
Pudendal 64430
Sciatic 64445, 64446
Sphenopalatine Ganglion 64505
Stellate Ganglion 64510
Superior Hypogastric Plexus 64517
Suprascapular 64418
Transforaminal Epidural 64479, 64480, 64483, 64484
Transverse Abdominis Plane (TAP) 64486-64489
Trigeminal 64400
Vagus 64408
Paravertebral Block (PVB) 64461-64463
Transverse Abdominis Plane (TAP) 64486-64489
Nerve Conduction
Motor/Sensory Nerve 95905, 95907-95913
Nerve Graft
Additional Nerve 64901, 64902
Arm or Leg 64892, 64893, 64897, 64898
Foot or Hand 64890, 64891, 64895, 64896
Head or Neck 64885, 64886
Neurovascular Pedicle 15750
Pedicle 64905, 64907
Nerve II, Cranial

See Optic Nerve
Nerve Root
See Cauda Equina; Spinal Cord
Decompression 22856, 22858, 63020-63048, 63055-63103
Section 63185-63190
Nerve Stimulation, Transcutaneous

Nerve Teasing 88362
Nerve V, Cranial
See Trigeminal Nerve
Nerve VII, Cranial
See Facial Nerve
Nerve X, Cranial
See Vagus Nerve
Nerve XI, Cranial
See Accessory Nerve, Spinal
Nerve XII, Cranial

See Hypoglossal Nerve
Nerves
Ablation, Radiofrequency 64625
Anastomosis
Facial to Hypoglossal 64868
Facial to Spinal Accessory 64866
Axillary
See Axillary Nerve
Biopsy 64795
Closure
Amputation, Ankle 27888
Cranial
See Cranial Nerve
Cryoablation
Cranial 61458, 61460
Laminotomy/Laminectomy 0274T, 0275T
Denervation 27035
Destruction
by Neurolytic Agent
Celiac Plexus 64680
Genicular 64624
Intercostal 64620
Other Peripheral 64640
Paravertebral Facet Joint 64633-64636
Plantar Common Digital 64632
Pudendal 64630
Superior Hypogastric Plexus 64681
Trigeminal 64600, 64605, 64610
Excision
See Neurectomy
Facial
See Facial Nerve
Graft 64885-64902
Implantation
to Bone 64787
Electrode Array 64553-64581
to Muscle 64787
Incision 28035, 43640, 43641, 64732-64772
Infusion
Femoral 64448
Lumbar Plexus 64449
Sciatic 64446
Injection
Anesthetic/Steroid
Axillary 64417
Femoral 64447
Genicular 64454
Greater Occipital 64405
Iliohypogastric 64425
Ilioinguinal 64425
Intercostal 64420
for Nerve Blocks 01991, 01992
Other Peripheral 64450
Paracervical (Uterine) 64435
Pudendal 64430
Sciatic 64445
Suprascapular 64418
Trigeminal 64400
Vagus 64408
Diagnostic Agent 0213T, 64493-64495
Neurolytic Agent 64600-64681
Therapeutic Agent 0213T, 64490-64495
Insertion
Electrode Array 64553-64581
Intercostal
Lesion
Lingual
See Lingual Nerve
Median
See Median Nerve
Neurofibroma
Neurolemmoma
Neurolytic
Internal 64727
Neuroma
Destruction 64632
Cutaneous 64774
Digital 64776, 64778
Foot, Other than Digital 64782, 64783
Hand, Other than Digital 64782, 64783
Peripheral 64784
Sciatic 64786
Injection 64455
Neuroplasty 64702-64721
Obturator
See Obturator Nerve
Pedicle Transfer 64905, 64907
Peripheral
See Peripheral Nerve
Phrenic
See Phrenic Nerve
Removal
Repair
Allograft 64910, 64912, 64913
Autogenous Graft 64911
Microdissection 69990
Suture 64831-64876
Synthetic Conduit 64910
Revision
Sciatic
See Sciatic Nerve
Spinal
See Spinal Nerve
Spinal Accessory
Incision 63191
Section 63191
Suture 64831-64876
Sympathectomy
Tibial
See Tibial, Nerve
Transection 64732-64772
Transposition 64718-64721
Ulnar
See Ulnar Nerve
Vagus Nerve 43640, 43641
Vestibular
See Vestibular Nerve
Nervous System
Central Nervous System Pathogen
Nucleic Acid Detection 87483
Extracranial, Peripheral Nerves and Autonomic Nervous System
Neuroplasty 64702-64727
Neurorrhaphy 64831-64911
Neurostimulation
Nuclear Medicine
Skull, Meninges, and Brain 61000-62258
Spine and Spinal Cord 62263-63746
Nesidioblast
See Islet Cell
Neural Conduction
Motor/Sensory Nerve 95905, 95907-95913
Neural Ganglion
See Ganglion
Neurectomy
Foot 28055
Gastrocnemius 27326
Hip
Obturator 27003
Leg, Lower 27326
Leg, Upper 27325
Morton 28080
Popliteal 27326
Tympanic 69676
Neuroendoscopy
Neurofibroma
Destruction
Extensive 0419T, 0420T
Excision
Cutaneous Nerve 64788
Extensive 64792
Peripheral Nerve 64790
Neurolemmoma
Excision
Extensive 64792
Neurologic System
See Nervous System
Neurology
Brain Cortex Magnetic Stimulation 90867-90869
Brain Mapping 90867, 96020
Brain Surface Electrode Stimulation 95961, 95962
Central Motor
Motor Function Mapping 64999
Transcranial Motor Stimulation 95928, 95929
Cognitive Performance 96125
Diagnostic
Auditory Evoked Potentials 92653
Autonomic Function Tests
Heart Rate Response 95921, 95943
Parasympathetic 95943
Pseudomotor Response 95921-95924
Sympathetic Function 95921-95924, 95943
Valsalva Maneuvers 95922, 95943
Electrocorticogram
from Implanted Brain Neurostimulator 95836
Intraoperative 61536, 61538, 95829
Electroencephalogram (EEG)
Electromyography
Fine Wire
Dynamic 96004
Ischemic Limb Exercise Test 95875
Needle 51785, 95860-95872
Surface
Dynamic 96002-96004
Evoked Potentials
Central Motor 95928, 95929, 95939
Somatosensory Testing 95925-95927, 95938
Visual 0333T, 0464T, 95930
Higher Cerebral Function
Aphasia Test 96105
Cognitive Performance 96125
Developmental Tests 96110, 96112, 96113
Neurobehavioral Status 96116, 96121
Neuropsychological Testing
Automated Testing and Result 96146
Evaluation Services 96132, 96133
Neurobehavioral Status 96116, 96121
Magnetoencephalography (MEG) 95965-95967
Motion Analysis
Computer-based 96000, 96004
Movement Disorder Monitoring 0533T-0536T
by Video and 3D Kinematics 96000, 96004
Nerve Conduction
Motor and Sensory Nerve 95905-95913
Neurofunctional Testing 96020
Neuromuscular Junction Tests 95937
Neurophysiological Monitoring
Plantar Pressure Measurements
Dynamic 96001, 96004
Polysomnography
See Polysomnography
Range of Motion 95851, 95852
Reflex
Blink Reflex 95933
Sleep Study 95801, 95805-95811
Actigraphy Testing 95803
Somatosensory Testing 95925-95927, 95938, 95939
Therapeutic
Magnetic Stimulation
Transcranial 90867-90869
Urethral Sphincter 51785
Neurolysis
Internal 64727
with Neuroplasty 64702-64721
Neuroma
Excision
Digital Nerve 64776-64778
Foot 28080
Foot Nerve 64782, 64783
Hand Nerve 64782, 64783
Sciatic Nerve 64786
Injection
Anesthetic Agent 64455
Steroid 64455
Interdigital
Morton
Excision 28080
Neuromuscular Junction Tests 95937

Neuromuscular Pedicle
Reinnervation
Larynx 31590
Neuromuscular Reeducation 97112

Neurophysiologic Testing
Autonomic Nervous Function
Heart Rate Response 95921-95924
Pseudomotor Response 95921-95924
Sympathetic Function 95921-95924
Neuroplasty
Cranial Nerve 64716
Digital Nerve 64702, 64704
Peripheral Nerve 64708, 64712-64714, 64716, 64718, 64719, 64721
Arm 64708
Cranial 64716
Leg 64708
Lumbar Plexus 64714
Median at Carpal Tunnel 64721
Sciatic 64712
Ulnar at Elbow 64718
Ulnar at Wrist 64719
Neuropsychological Testing
Automated Testing and Result 96146
Computer-Assisted 96146
Evaluation Services 96130-96133
Neurorrhaphy 64831-64876
Peripheral Nerve
Conduit 64910
with Graft 64885-64907
Neurostimulators
Brain
Electronic Analysis 95970, 95983, 95984
Implantation 61863, 61864, 61867, 61868, 61885, 61886
Removal 61880
Replacement 61885, 61886, 61888
Revision 61880, 61888
Cranial Nerve
Electronic Analysis 95970, 95977
Removal 64570
Replacement 64569
Revision 64569
Gastric Nerve
Electronic Analysis 95980-95982
Implantation/Replacement 43647, 43881, 64590
Revision/Removal 43648, 43882, 64595
Integrated Neurostimulation System
Electronic Analysis 0589T, 0590T
Implantation 0587T
Programming 0589T, 0590T
Removal 0588T
Replacement 0587T
Revision 0588T
Peripheral Nerve
Implantation 64555, 64575, 64580
Removal 64585, 64595
Replacement 64590
Revision 64585, 64595
Phrenic Nerve System for Sleep Apnea
Device Evaluation 0434T-0436T
Removal 0428T-0430T
Replacement 0424T-0427T, 0431T
Revision 63663, 63664, 63688
Sacral Nerve
Spinal Cord
Removal 63661, 63662, 63688
Replacement 63663, 63664, 63685
Tibia
Percutaneous 64566
Vagus Nerve System for Morbid Obesity
Electronic Analysis/Programming 0317T
Implantation 0312T
Replacement 0313T, 0316T
Revision 0313T
Neurotomy, Sympathetic
See Gasserian Ganglion, Sensory Root, Decompression
Neurovascular Pedicle Flaps 15750
Neutralization Test
Virus 86382
New Patient
Domiciliary or Rest Home Visit 99324-99328
Home Services 99341-99345
Hospital Inpatient Services 99221-99239
Hospital Observation Services 99217-99220
Initial Office Visit 99202-99205
Inpatient Consultations 99251-99255
Office and/or Other Outpatient Consultations 99241-99245
Newborn Care 99460-99465, 99502

Attendance at Delivery 99464
Blood Transfusion
Exchange 36450, 36456
Push 36440
Circumcision
Clamp or Other Device 54150
History and Examination 99460, 99463
Home Visit 99502
Initial Care
Birthing Room 99460, 99463
Hospital 99460, 99463
Other Site 99461
Laryngoscopy 31520
Normal 99460-99463
Prepuce Slitting 54000
Preventive
Office 99461
Resuscitation 99465
Standby for Cesarean Delivery 99360
Subsequent Hospital Care 99462
Umbilical Artery Catheterization 36660
Next Generation Sequencing (NGS) and Other Molecular Multianalyte
Assays
Aortic Dysfunction or Dilation 81410, 81411
Exome 81415-81417
Fetal Chromosomal Aneuploidy 81420
Genome 81425-81427
Hearing Loss 81430, 81431
Hereditary Breast Cancer-Related Disorders 81432, 81433
Hereditary Colon Cancer Disorders 81435, 81436
Hereditary Neuroendocrine Tumor Disorders 81437, 81438
Hereditary Retinal Disorders 81434
Noonan Spectrum Disorders 81442
Nuclear Encoded Mitochondrial Genes 81440
Severe Inherited Conditions 81443
Targeted Genomic Sequence Analysis Panel 81445, 81450, 81455
Whole Mitochondrial Genome 81460, 81465
X-linked Intellectual Disability (XLID) 81470, 81471
Nickel 83885
Nidation
See Implantation
Nikaidoh Procedure
Aortic Root Translocation 33782, 33783
Nipples
See also Breast
Exploration 19110
Inverted 19355
Lesion
Excision 19120
Nissen Operation
Esophagogastric Fundoplasty 43327, 43328
Nissen Procedure
Gastroplasty with Esophagogastric
Nitrate Reduction Test

See Urinalysis
Nitric Oxide
Administration 93463
Expired Gas Determination 95012
Nitroblue Tetrazolium Dye Test 86384

Nitrogen, Blood Urea 84520-84525
NMR Imaging
NMR Spectroscopies
See Magnetic Resonance Spectroscopy
No Man’s Land
Tendon Repair 26356-26358
Nocardia
Antibody 86744
Nocturnal Penile Rigidity Test 54250

Nocturnal Penile Tumescence Test 54250
Node, Lymph
See Lymph Nodes
Nodes
See Lymph Nodes
Non-Invasive Vascular Imaging

Non-Office Medical Services 99056
Emergency Care 99060
Non-Stress Test, Fetal 59025

with Biophysical Profile 76818
Nonunion Repair
with Bone Graft 23485, 25405, 25420, 26546, 27470, 27722, 27724, 28322
Carpal 25431, 25440
Clavicle 23485
Femur
with Graft 27472
without Graft 27470
Fibula 27726
Humerus 24430-24435
Metacarpal 26546
Metatarsal 28322
Phalanx 26546
Radius 25400, 25405, 25415, 25420
Tarsal 28320
Tibia 27720, 27722, 27724, 27725
Ulna 25400, 25405, 25415, 25420
Noradrenalin
Blood 82383, 82384
Urine 82384
Norepinephrine
Blood 82383, 82384
Urine 82384
Norwood Procedure 33611, 33612, 33619

Nose
Abscess
Artery
Biopsy
Endoscopic 31237
Intranasal 30100
Debridement
Endoscopic 31237
Dermoid Cyst
Excision
Complex 30125
Simple 30124
Displacement Therapy 30210
Endoscopy
Surgical 31237-31241, 31253-31257, 31259, 31267, 31276, 31287, 31288, 31290-31298
Excision
Rhinectomy 30150-30160
Turbinate 30140
Fracture
with Fixation 21330, 21340, 21345-21347
Open Treatment 21325-21336, 21338, 21339, 21346, 21347
Hematoma
Hemorrhage Control
Cauterization 30901-30906
Packs 30901-30906
Endoscopic 31237
Insertion
Septal Prosthesis 30220
Lesion
Destruction or Excision
External Approach 30118
Internal Approach 30117
Polyp
Excision
Endoscopic 31237
Extensive 30115
Simple 30110
Reconstruction
Complete 30410
Dermatoplasty 30620
Primary 30400, 30420
Secondary 30430-30450
Septum 30520
Removal
Foreign Body 30300
by Lateral Rhinotomy 30320
Repair
Adhesions 30560
Choanal Atresia 30540, 30545
Cleft Lip 40700-40761
Complex 13151-13153
Fistula 30580-30600, 42260
Nasal Valve Collapse 30468
Rhinophyma 30120
Septum 30540-30545, 30630
Synechia 30560
Vestibular Stenosis 30465
Skin
Excision 30120
Surgical Planing 30120
Submucous Resection Turbinate
Excision 30140
Turbinate
Fracture 30930
Injection 30200
Turbinate Mucosa
Cauterization 30801, 30802
Nose Bleed
Cauterization 30901-30906
Packs 30901-30906
Endoscopic 31237
NTD
Nitroblue Tetrazolium Dye Test 86384
Nuclear Antigen
Antibody 86235
Nuclear Imaging
See Nuclear Medicine
Nuclear Magnetic Resonance Imaging

Nuclear Magnetic Resonance Spectroscopy
See Magnetic Resonance Spectroscopy
Nuclear Matrix Protein 22 86386

Nuclear Medicine
Diagnostic
Adrenal Gland Imaging 78075
Bile Duct
Imaging 78226, 78227
Bladder
Residual Study 78730
Blood Pool Imaging 78472, 78473, 78481, 78483
Bone and Joint
Bone Density Study 78350, 78351
Imaging 78300, 78305, 78306, 78315, 78803
SPECT 78803
Ultrasound 76977
Bone Marrow
Imaging 78102-78104
Brain
Blood Flow 78610
Cerebrospinal Fluid Imaging 78630-78650
Imaging 78600-78609
PET Imaging 78608, 78609
Vascular Flow 78601, 78606, 78610
Endocrine System
Parathyroid Gland Imaging 78070-78072
Esophagus
Imaging (Motility) 78258
Reflux Study 78262
Flow Imaging 78445
Plasma Volume 78110-78121
Platelet Survival 78191
Red Cell Sequestration 78140
Red Cell Volume 78120, 78121
Whole Blood Volume 78122
Imaging 78700-78709
Imaging, SPECT 78803
Gallbladder
Imaging 78226, 78227
Gastric
Emptying Imaging Study 78264-78266
Mucosa Imaging 78261
Gastroesophageal Reflux Study 78262
Gastrointestinal
Blood Loss Imaging 78278
Intestine Imaging 78290
Peritoneal-Venous Shunt Patency 78291
Protein Loss Study 78282
Genitourinary System
Heart
Angiography 78445
Blood Flow 78414
Blood Pool Imaging 78472, 78473, 78481-78483
Blood Pool SPECT Imaging 78494-78496
Myocardial Imaging 78459, 78466-78469
Myocardial Perfusion Imaging 78451-78454
Myocardial PET Imaging 78429-78434, 78459, 78491, 78492
Shunt Detection 78428
Vascular Flow Imaging 78445
Venography 78445
Venous Thrombosis Imaging 78456-78458
Hepatic Duct
Imaging 78226, 78227
Inflammatory Process 78800-78804, 78830-78832
Intestines
Imaging 78290
Lacrimal Gland Tear Flow 78660
Liver
Imaging 78201-78216
Vascular Flow 78202, 78216
Lung
Imaging, Perfusion 78580, 78597, 78598
Imaging, Ventilation 78579, 78582, 78598
Unlisted Respiratory Procedure 78599
Lymphatics and Lymph Nodes
Imaging 78195
Positron Emission Tomography (PET) 78811-78816
with Computed Tomography 78814-78816
Pulmonary Perfusion 78580, 78597, 78598
Pulmonary Ventilation 78579, 78582
Quantification Measurement 78835
Salivary Gland
Imaging 78230, 78231
Spleen
Imaging 78185, 78215, 78216
Testes
Imaging 78761
Thyroid
Imaging for Metastases 78015-78018
Imaging with Flow 78013
Metastases Uptake 78020
Uptake 78012, 78014
Tumor Localization
by Radiopharmaceuticals 78800-78804, 78808, 78830-78832
by SPECT 78803, 78830-78832
Unlisted Diagnostic Procedures
Cardiovascular 78499
Endocrine 78099
Genitourinary 78799
Hematopoietic, Reticuloendothelial, and Lymphatic 78199
Miscellaneous 78999
Musculoskeletal 78399
Nervous System 78699
Respiratory 78599
Ureter
Reflux Study 78740
Vascular Flow 78701-78709
Vein
Thrombosis Imaging 78456-78458
Therapeutic
Radiopharmaceutical, Administration
Interstitial Radioactive Colloid 79300
Intra-Articular 79440
Intracavitary 79200
Intravenous 79101
Intravenous Infusion 79403
Oral 79005
Thyroid 79200-79300
Unlisted Radiopharmaceutical
Procedure 79999
Nucleases, DNA
DNAse Antibody 86215
Nucleic Acid Probe
Amplified Probe Detection
Infectious Agent
Bartonella Henselae 87471
Bartonella Quintana 87471
Borrelia Burgdorferi 87476
Candida Species 87481
Chlamydia Pneumoniae 87486
Gardnerella Vaginalis 87511
Hepatitis C 87521, 87522
Hepatitis G 87526
Herpes Simplex Virus 87529
Herpes Virus-6 87532
HIV-1 87535, 87536
HIV-2 87538, 87539
Multiple Organisms 87801
Mycobacteria Avium-Intracellulare 87561
Mycobacteria Species 87551
Mycobacteria Tuberculosis 87556
Mycoplasma Pneumoniae 87581
Not Otherwise Specified 87798, 87801
Staphylococcus Aureus 87640, 87641
Zika Virus 87662
Direct Probe Detection
Infectious Agent
Borrelia Burgdorferi 87475
Hepatitis C 87520
Hepatitis G 87525
HIV-1 87534
HIV-2 87537
Multiple Organisms 87800
Papillomavirus, Human 0500T, 87623-87625
Trichomonas Vaginalis 87660, 87661
Genotype Analysis
Infectious Agent
HIV-1 Regions 87901, 87906
Phenotype Analysis
Infectious Agent
HIV-1 Drug Resistance 87903, 87904
Quantification
Infectious Agent
Bartonella Henselae 87472
Bartonella Quintana 87472
Hepatitis C 87522
Hepatitis G 87527
HIV-1 87536
HIV-2 87539
In Situ Hybridization 88120, 88121, 88364-88366
Manual 88368, 88369, 88377
Nucleolysis, Intervertebral Disc

Chemonucleolysis 62292
Nucleotidase 83915
Nursing Facility Discharge Services 99315, 99316
Annual Assessment 99318
Care Plan Oversight Services 99379, 99380
Discharge Services 1110F, 1111F, 99315, 99316
Nuss Procedure
without Thoracoscopy 21742
Nutrition Therapy
Group 97804
Initial Assessment 97802
Reassessment 97803
Nystagmus Tests
Optokinetic 92534, 92544
Positional 92532, 92542
Spontaneous 92531, 92541
O
Ober-Yount Procedure 27025
Obliteration
Mastoid 69670
Vagina
Vault 57120
Oblongata, Medulla
See Medulla
Observation
Hospital Services 99217-99220, 99224-99226, 99234-99236, 99356, 99357
Observational Behavioral Follow-Up Assessment

Behavior Identification Assessment 97151, 97152
Obstetrical Care
Abortion
Induced
by Amniocentesis Injection 59850-59852
Missed
Spontaneous 59812
Cesarean Delivery 59618-59622
Only 59514
Routine 59510
Curettage
Diagnostic Imaging
Fetal
Biophysical Profile 76818, 76819
Doppler Velocimetry 76820, 76821
Echocardiography 76825-76828
Pregnant Uterus
Ultrasound 76801, 76802, 76805, 76810-76817
Fetal and Maternal
Ectopic Pregnancy
See Ectopic Pregnancy
Evacuation
Miscarriage
Surgical Completion 59812-59821
Placenta Delivery 59414
Postpartum Care 59430, 59514
Septic Abortion 59830
Total (Global) 59400, 59610, 59618
Vaginal
after Cesarean (VBAC) 59610-59614
Delivery after Cesarean 59610-59614
Obstruction
See Occlusion
Obstruction, Colon
Foreign Body
Removal 44025, 45307, 45332, 45379
Intussusception
Reduction 44050
Malrotation 44055
Volvulus
Decompression 45321
Obstruction Clearance
Venous Access Device 36595, 36596
Obturator Nerve
Obturator Prosthesis 21076

Definitive 21080
Insertion
Larynx 31527
Interim 21079
Occipital Nerve, Greater
Avulsion 64744
Incision 64744
Injection
Anesthetic 64405
Steroid 64405
Transection 64744
Occlusion
Bronchi
Balloon 31634, 31647, 31651
Fallopian Tube
by Biopolymer Implant 0567T
by Cannulation 58565
by Device 58615, 58671
Paravalvular Leak
Mitral Valve 93590, 93592
Penis
Vein 37790
Umbilical Cord 59072
Ureteral 50705
Vascular
Arterial, other than Hemorrhage or
Tumor 37242
Carotid Artery 37606, 61705
Dialysis Circuit 36909
during Endovascular Therapy 34820
for Hemorrhage 37244
for Infarction 37243
with Ligation 37606
for Lymphatic Extravasation 37244
Nervous System
Cranial 61623, 61624, 61626
Spinal 61624, 61626, 62294, 63250-63252
for Organ Ischemia 37243
Placement of Occlusion Device 34808
for Tumors 37243
Venous, other than Hemorrhage 37241
Occlusive Disease of Artery
Direct Repair
See Repair, Artery
Revascularization
See Revascularization, Artery

Guaiac Test 82270-82272
by Hemoglobin Immunoassay 82274
Occupational Therapy
Cognitive Skills 97129, 97130
Evaluation 97165, 97166, 97167
Physical Skills 97110, 97112, 97113, 97116, 97124
Psychosocial Skills
See Adaptive Behavior Treatment
Re-evaluation 97168
Ocular Implant
See also Orbital Implant
Insertion
Drainage Device 0191T, 0253T, 0376T, 66183
Drug-Eluting Insert
Eyelid 0444T, 0445T
Scleral Shell 65130
Modification 65125
Reinsertion 65150
with Foreign Material 65155
Removal 65175
Ocular Muscle
See Eye Muscles
Ocular Orbit
See Orbit
Ocular Prostheses
See Prosthesis, Ocular
Ocular Prosthesis
Intraocular Lens 0308T, 66985
Temporary 92358
Ocular Screening
Instrument Based 99174, 99177
Retinal Polarization Scan 0469T
Oddi Sphincter
See Sphincter of Oddi
Odontoid Dislocation
with Grafting 22319
Odontoid Fracture
with Grafting 22319
Odontoid Process
Excision 22548
Oesophageal Neoplasm
See Tumor, Esophagus
Oesophageal Varices
See Esophageal Varices
Oesophagus
See Esophagus
Oestradiol
See Estradiol
Office or Other Outpatient Visit
Office Medical Services

After Hours 99050
Emergency Care 99058
Extended Hours 99051
Office or Other Outpatient Consultations 99241-99245
Olecranon
Bursa
Cyst
Excision 24125, 24126
Tumor
Cyst 24120
Excision 24125, 24126
Olecranon Process
Craterization 24147
Diaphysectomy 24147
Excision 24147
Abscess 24138
Fracture
Osteomyelitis 24138, 24147
Saucerization 24147
Oligoclonal Immunoglobulins 83916

Omentectomy
with Laparotomy 58960
with Lymph Node Laparoscopy 38573
with Oophorectomy 58943
Separate Procedure 49255
with Tumor Debulking 58575, 58950-58954, 58956-58958, 58960
Omentum
Excision 49255, 58950-58958
Flap 49904, 49905
Free
with Microvascular Anastomosis 49906
Omentopexy 49326
Omphalectomy 49250
Omphalocele
Repair 49600-49611
Omphalomesenteric Duct
Excision 44800
Omphalomesenteric Duct, Persistent

Oncoprotein
Des-gamma-carboxyprothrombin (DCP) 83951
HER-2/neu 83950
One Stage Prothrombin Time 85610, 85611

Online Digital Evaluation and Management
Nonphysician 98970-98972
Physician 99421-99423
Onychectomy
Excision, Nails 11750
Onychia
Drainage 10060, 10061
Oocyte
Assisted Fertilization
Microtechnique 89280, 89281
Biopsy 89290, 89291
Culture
with Co-Culture 89251
Extended 89272
Less than 4 Days 89250
Identification
Follicular Fluid 89254
Insemination 89268
Retrieval
for In Vitro Fertilization 58970
Storage 89346
Thawing 89356
Oophorectomy
Ectopic Pregnancy
Laparoscopic Treatment 59120
Surgical Treatment 59120
Laparoscopic 58548, 58552, 58554, 58661
Open 58940, 58943
Salpingo-Oophorectomy 58950-58954, 58956
Vaginal 58262, 58263, 58291, 58292
Oophorectomy, Partial 58661, 58940
Oophorocystectomy 58925
Open Biopsy, Adrenal Gland 60540, 60545
Operation/Procedure
Abbe-Estlander 40527, 40761
Bankart 23455
Bischof 63170
Blalock-Hanlon 33735
Blalock-Taussig 33750
Campbell 27422
Chambers 28300
Clagett 32810
Colles Fracture 25600
Conjunctivo-Tarso-Muller Resection 67908
Coombs Test 86880
Damus-Kaye-Stansel Procedure 33606
Darrach Procedure 25240
de Quervains Disease Treatment 25000
Dwyer-type Procedures 28300
Ebstein Anomaly Repair 33468
Fasanella-Servat Procedure 67908
Foley Y-pyeloplasty 50400, 50405
Fontan 33615, 33617
Fowler-Stephens Orchiopexy 54650
Fowler-Stephens Procedure 54650
Fredet-Ramstedt Procedure 43520
Frost Suture 67875
Gibbons Stent 52332
Gill Operation 63012
Glenn Procedure 33766, 33767
Goeckerman Treatment 96910, 96912, 96913
Goldwaite Procedure 27422
Harrington Rod Technique 22840, 22850
Hauser Procedure 27420
Haygroves Procedure 27120
Heller Operation 32665
Heller Procedure 32665, 43330, 43331
Heyman Procedure 27179, 28264
Hori Procedure 25430
Ilizarov Procedure, Monticelli Type 20692
Jatene Type 33770-33781
Johannsen Procedure 53400
Jones Procedure 28760
Kasai Procedure 47701
Kelikian Procedure 28280
Kelly Urethral Plication 57220
Kock Pouch 44316
Kock Procedure 44316
Kraske Procedure 45116
Kroenlein Procedure 67420
Leadbetter Procedure 53431
Linton Procedure 37760
Lynch Procedure 31075
Magnuson Procedure 23450
Maquet Procedure 27418
Marshall-Marchetti-Krantz Procedure 51840, 51841, 58152, 58267
Maze Procedure 33254-33256, 33265, 33266
McCannel Procedure 66682
Meckel’s Excision 44800
Miller Procedure 28737
Miller-Abbott Intubation 44500, 74340
Monteggia Fracture 24620-24635
Monticelli Procedure 20690
Mumford Procedure 29824
Nissen Procedure 43327, 43328
Norwood Procedure 33619, 33622
Nuss Procedure 21742, 21743
Ober-Yount Procedure 27025
Pereyra Procedure 51845, 57289, 58267
Pirogoff Procedure 27888
Potts-Smith Procedure 33762
Puestow Procedure 48548
Ramstedt 43520
Raz Procedure 51845
Richardson Procedure 53460
Ross-Konno Procedure 33440
Roux-En-Y Procedure 43621, 43633, 43634, 43644, 43846, 47740, 47741, 47780-47785, 48540
Schede Procedure 32905, 32906
Scribner Cannulization 36810
Sengstaaken Tamponade, Esophagus 43460
Senning Procedure 33774-33777
Senning Type 33774-33777
Soave Procedure 45120
Stamey Procedure 51845
Steindler Flexor-Plasty 24330
Steindler Stripping 28250
Stenger Test 92565, 92577
Strassman Procedure 58540
Strayer Procedure 01474
Swanson Procedure 28309
Swenson Procedure 45120
Syme Procedure 27888
Takeuchi Procedure 33505
Tenago Procedure 53431
Thal-Nissen Procedure 43325
Thiersch Procedure 46753
Thompson Procedure 27430
Tompkins Metroplasty 58540
Torkildsen Procedure 62180
Waterston Procedure 33755
Watson-Jones Procedure 27695-27698
Whipple Procedure 48150
Whitman Procedure 27120
Winter Procedure 54435
Operculectomy 41821
Operculum
See Gums
Ophthalmic Mucous Membrane Test 95060

Ophthalmology, Diagnostic
Color Vision Exam 92283
Computerized Scanning
Anterior 92132
Corneal Pachymetry 76514
Dark Adaptation 92284
Electromyography, Needle 92265
Electro-oculography 92270
Electroretinography 0509T, 92273, 92274
Endoscopy 66990
Evoked Potentials
Acuity 0333T
Glaucoma Test 0464T
Eye Exam
with Anesthesia 92018, 92019
Gonioscopy 92020
Heterochromatic Flicker Photometry 0506T
Instrument-based Screening 99172, 99174
Ocular Photography
External 92285
Ophthalmoscopy
See Ophthalmoscopy
Refractive Determination 92015
Sensorimotor Exam 92060
Tonometry
Serial 92100
Biometric Echography 76516, 76519
B-Scan 76510, 76512, 76513
Foreign Body Localization 76529
A-Scan 76510-76512
Visual Acuity Screen 99172, 99173
Visual Field Exam 0378T, 0379T, 92081-92083
Visual Function Screen 99172, 99174, 99177
Ophthalmology, Therapeutic
General Services, Medical Examination and
Evaluation
Established Patient 92012, 92014
New Patient 92002, 92004
Special Services, Diagnosis
See Ophthalmology, Diagnostic
Spectacle Services
Unlisted Ophthalmological Service or
Procedure 92499
Ophthalmoscopy
Drawing of Macula 92202
Drawing of Optic Nerve 92202
Dynamometry 92260
Fluorescein Angioscopy 92230
Fundus Photography 92250
Indocyanine-Green Angiography 92240, 92242
Retinal Drawing 92201
Retinal Imaging
for Disease Detection 92227-92229
for Disease Monitoring 92227-92229
Scleral Depression 92201
Opponensplasty 26490, 26492, 26494, 26496
Optic Nerve
Decompression 67570
Diagnostic Imaging
Computerized Scanning 92133
Opthalmoscopy 92202
Head Evaluation 2027F
Breast 0351T-0354T
Intravascular 92978, 92979
Middle Ear 0485T, 0486T
Retina
Remote 0604T-0606T
Skin Lesion 0470T, 0471T
Optical Endomicroscopy
with Endoscopic Retrograde
Cholangiopancreatography (ERCP) 0397T
Esophageal 43206
Optokinetic Nystagmus Test 92534, 92544
Oral Lactose Tolerance Test 82951, 82952
Oral Mucosa
See Mouth, Mucosa

Orbit
Aspiration of Contents 67415
Biopsy
Orbitotomy without Bone Flap 67400
Bone Graft 21182-21184, 21256, 21260, 21267, 21395, 21408
Bone Removal 67414, 67445
CT Scan 70480-70482
Decompression 61330, 67414, 67445
Exploration 61333, 67400, 67450
Fracture
Blowout Fracture 21385-21395
Hypertelorism
Osteotomies 21260, 21261, 21263
Implant
Insertion 67550
Removal 67560
Injection
Retrobulbar 67500-67505
Tenon’s Capsule 67515
Insertion
Implant 67550
Lesion
Removal 67412, 67420
Nerve Decompression 67570
Orbitotomy
See Orbitotomy
Prosthesis 21077
Reconstruction
Orbitocraniofacial 21275
Rims 21172, 21175, 21179, 21180
Walls 21182-21184
Removal
Bone 67445
Lesion 61333
Repositioning 21267, 21268
Sella Turcica 70482
Walls
X ray 70190-70200
Orbital Contents
Aspiration 67415
Orbital Floor Blowout Fracture
Open Treatment
Combined Periorbital and Transantral Approaches 21387
Periorbital Approach 21386, 21390, 21395
Transantral Approach 21385
Orbital Hypertelorism
Orbital Implant
Insertion 67550
Removal 67560

Orbitocraniofacial Reconstruction
Secondary 21275
Orbitotomy
with Bone Flap
with Drainage 67440
for Exploration 67450
Lateral Approach 67420
with Removal Foreign Body 67430
with Removal of Bone for
Decompression 67445
without Bone Flap
with Drainage Only 67405
for Exploration 67400
with Removal Lesion 67412
with Removal Foreign Body 67413
with Removal of Bone for Decompression 67414
Orchidectomies
See Orchiectomy
Orchidopexy
See Orchiopexy
Orchidoplasty
See Repair, Testis
Orchiectomy
Laparoscopic 54690
Partial 54522
Radical
Abdominal Exploration 54535
Inguinal Approach 54530
Simple 54520
Orchiopexy
Inguinal Approach 54640
Intra-Abdominal Testis 54692
Scrotal Approach 54640
Orchioplasty
See Repair, Testis
Organ Grafting
See Transplantation
Organ or Disease-Oriented Panel
Electrolyte 80051
General Health Panel 80050
Hepatic Function Panel 80076
Hepatitis Panel 80074
Lipid Panel 80061
Metabolic
Basic 80047, 80048
Comprehensive 80053
Obstetric Panel 80055, 80081
Organ System, Neurologic

See Nervous System
Organic Acids 83918-83921
Ormond Disease
Ureterolysis 50715
Orogastric Tube
Placement 43752
Oropharynx
Biopsy 42800
Orthodontic Cephalogram 70350
Orthomyxoviridae
See Influenza Virus
Orthomyxovirus
See Influenza Virus
Orthopantogram 70355
Orthopedic Cast
See Cast
Orthopedic Surgery
Computer Assisted Navigation 20985
Stereotaxis
Computer Assisted 20985
Orthoptic Training 92065

Orthoroentgenogram 77073
Orthosis
See Orthotics
Orthotics
Fitting 97760
Management and Training 97760, 97763
Os Calcis Fracture
Oscillation
Chest Wall 94669
Osmolality
Blood 83930
Urine 83935
Osseous Survey 77074-77076
Osseous Tissue
See Bone
Ossicles
Excision
Stapes
with Footplate Drill Out 69661
without Foreign Material 69660, 69661
Mobilization
Stapes 69650
Reconstruction
Ossicular Chain
Tympanoplasty with Antrotomy or Mastoidotomy 69636, 69637
Tympanoplasty with Mastoidectomy 69642, 69644, 69646
Tympanoplasty without Mastoidectomy 69632, 69633
Replacement
with Prosthesis 69633, 69637
Revision
Stapedectomy 69662
Stapedotomy 69662
Ostectomy
Metacarpal 26250
Metatarsal 28110-28114, 28122, 28140, 28288
Phalanges
Finger 26260-26262
Toe 28124, 28150
Pressure Ulcer
Coccygeal 15920
Ischial 15941, 15945, 15946
Sacral 15933, 15935, 15937
Trochanteric 15951, 15953, 15958
Rib 21502
Scapula 23190
Sternum 21620
Talus 28120, 28130
Tarsal 28116, 28122
Osteocalcin 83937
Osteocartilaginous Exostoses
See Exostosis
Osteochondroma
See Exostosis
Osteocutaneous Flap
with Microvascular Anastomosis 20969-20973
Osteoma
Sinusotomy
Frontal 31075
Osteomyelitis
Calcaneus
Partial Excision 28120
Clavicle
Craterization
See Craterization
Diaphysectomy
See Diaphysectomy
Elbow
Excision
Facial 21026
Mandible 21025
Skull 61501
Femur/Knee
Finger
Incision 26034
Partial Excision 26235, 26236
Hand Incision 26034
Hip
Humerus 24134
Incision
Ankle 27607
Elbow 23935
Femur 27303
Finger 26034
Foot 28005
Forearm 25035
Hand 26034
Hip 26992, 27070, 27071
Humerus 23935
Knee 27303
Leg 27607
Shoulder 23035
Thorax 21510
Wrist 25035
Metacarpal
Metatarsal
Olecranon Process
Pelvis
Radius 24136, 24145
Saucerization
See Saucerization
Scapula
Sequestrectomy
Calcaneus 28120
Clavicle 23170
Forearm 24145
Humerus 23174, 24134
Metatarsal 28122
Radius 24136
Scapula 23172
Skull 61501
Talus 28120
Tarsal 28122
Wrist 24145
Talus
Tarsal
Tibia
Ulna
Osteopathic Manipulation 98925-98929

Osteoplasty
Carpal Bone 25394
Facial Bones
Augmentation 21208
Reduction 21209
Femoral Neck 27179
Femur 27179
Fibula
Lengthening 27715
Humerus 24420
Metacarpal 26568
Phalanges, Finger 26568
Radius 25390-25393
Tibia
Lengthening 27715
Ulna 25390-25393
Vertebra
Cervicothoracic 22510, 22512
Lumbosacral 22511, 22512
Osteotomy
with Bunionectomy 28295, 28296, 28298, 28299
Calcaneus 28300
Chin 21121-21123
Clavicle 23480-23485
Femur 27140, 27151
Femoral Neck 27161
with Fixation 27165
without Fixation 27448-27450
with Open Reduction of Hip 27156
with Realignment 27454
for Slipped Epiphysis 27181
Fibula 27707-27712
Hip 27146-27151
Femoral
with Open Reduction 27156
Femur 27151
Humerus 24400
Insertion, Intramedullary Lengthening
Device 0594T
Intramedullary Rod Realignment 24410
Mandible 21198, 21199
Extra-Oral 21047
Intra-Oral 21046
Mandibular Rami 21193, 21194
Maxilla 21206
Extra-Oral 21049
Intra-Oral 21048
Metacarpal 26565
Metatarsal 28306-28309
Orbit Reconstruction 21256
Pelvis 27158
Periorbital
Orbital Hypertelorism 21260-21263
Osteotomy with Graft 21267, 21268
Phalanges
Finger 26567
Toe 28299, 28310-28312
with Bunionectomy 28298
Radius
Distal Third 25350
Middle or Proximal Third 25355
Multiple 25370
and Ulna 25365, 25375
Skull Base 61582-61585, 61592
Spine
Anterior 22220-22226
Posterior
Posterolateral 22210-22214
Posterior or Posterolateral
Three-Column 22206-22208
Talus 28302
Tarsal 28304, 28305
Tibia 27455-27457, 27705, 27709-27712
Ulna 25360
Multiple 25370
and Radius 25365, 25375
Vertebra
Additional Segment
Anterior Approach 22226
Posterior/Posterolateral Approach 22216
Cervical
Lumbar
Thoracic
Otolaryngology
Diagnostic
Exam under Anesthesia 92502
Otomy
See Incision
Otoplasty 69300
Otorhinolaryngology
See Ear, Nose, and Throat
Ouchterlony Immunodiffusion 86331

Outer Ear
Outpatient Visit
See History and Physical; Office or Other Outpatient Services
Output, Cardiac
Ova
Smear 87177
Oval Window
Repair Fistula 69666
Oval Window Fistula

Repair 69666
Ovarian Cyst
Excision 58925
Ovarian Vein Syndrome
Ureterolysis 50722
Ovariectomies
See Oophorectomy
Ovariolysis 58740
Ovary
Abscess
Biopsy 49321, 58900
Cyst
Excision 58925
Excision 58662, 58720
Cyst 58925
Partial
Oophorectomy 58661, 58940, 58953, 58954
Ovarian Malignancy 58943
Peritoneal Malignancy 58943
Tubal Malignancy 58943
Total 58940-58943
Laparoscopy 58660-58662, 58679
Lesion
Excision 58662
Fulguration 58662
Lysis
Adhesions 58660, 58740
Malignancy
Resection 58950-58952, 58957, 58958
Staging Laparotomy 58960
Oncology
Biochemical Assay
Apolipoprotein A1 81503
Beta-2 Microglobulin 81503
CA-125 81500, 81503
HE4 81500
Menopausal Status 81500
Pre-albumin 81503
Transferrin 81503
Pregnancy
Surgical Treatment 59120, 59121
Removal
with Hysterectomy
Abdominal 58150, 58152, 58180, 58200, 58210
Laparoscopic 58542, 58544, 58548, 58552, 58554, 58571, 58573, 58575
Vaginal 58262, 58263, 58291, 58292
with Pelvic Exenteration 45126, 58240
with Radical Trachelectomy 57531
Transposition 58825
Tumor
Oviduct
Anastomosis 58750
Chromotubation 58350
Ectopic Pregnancy 59120, 59121
Fulguration
Laparoscopic 58670
Laparoscopy 58679
Lysis
Adhesions 58740
Occlusion 58615
Laparoscopic 58671
Repair 58752
Anastomosis 58750
Create Stoma 58770
Ovocyte
See Oocyte

Ovum Implantation 58976
Ovum Transfer Surgery
Gamete Intrafallopian Transfer (GIFT) 58976
Oxalate 83945
Oxcarbazepine
Drug Assay 80183
Oxidase, Ceruloplasmin 82390

Oxidoreductase, Alcohol-Nad+
Vasopressin 84588
Oximetry (Noninvasive)
Blood O2 Saturation Determination
Ear or Pulse 94760-94762
with Pulmonary Stress Testing 94618
Pulse, Recording
Car Seat/Bed Testing 94780, 94781
Oxoisomerase
Oxosteroids 83593
Oxygen Saturation 82805-82810
Oxygenation, Extracorporeal Membrane
Oxyproline
Hydroxyproline 83500, 83505
Oxytocin Stress Test, Fetal 59020
P
P B Antibodies
See Antibody, Detection, Heterophile
P&P
Proconvertin 85230
Pacemaker
Pacemaker System, Leadless
Device Evaluation 93279, 93286, 93288, 93294, 93296
Pacemaker System with Leads
Device Evaluation 93279-93281, 93286, 93288, 93293, 93294, 93296, 93724
Insertion
Electrode 33202, 33203, 33210, 33211, 33216, 33217, 33224, 33225
Lead 33206-33208, 33216, 33217
System 33206-33208
Removal 33233-33237
Repair, Electrode 33218-33220
Replacement
Catheter/Electrode 33210, 33211
Pulse Generator 33227-33229
Single-to-Dual Chamber System
Upgrade 33214
Pachymetry
Cornea 76514
with Collagen Cross-Linking 0402T
Packing
for Nasal Hemorrhage 30901-30906
for Preperitoneal Pelvic Hemorrhage 49013, 49014
Pain Management
Electrical Reprocessing 0278T
Epidural/Intrathecal 62350, 62351, 62360-62362, 99601, 99602
Intravenous Therapy 96365-96368, 96374-96379
Palate
Abscess
Biopsy 42100
Bone Graft 42210
Excision
Lesion 42120
Fracture
Lesion
Destruction 42160
Prosthesis
Augmentation 21082
Impression 42280
Insertion 42281
Lift 21083
Reconstruction
Repair
Cleft Palate 42200-42225
Laceration 42180-42182
Vomer Flap 42235
Palate, Cleft
Palatoplasty 42200, 42205, 42210
Revision 42215, 42220, 42225
Rhinoplasty 30460, 30462
Palatoplasty 42145, 42200-42225
Anterior Palate Repair with Vomer Flap 42235
Cleft Palate 42200, 42205, 42210, 42215, 42220, 42225
Palate Lengthening 42226, 42227
Palatoschisis
See Palate, Cleft
Palm
Arch
Sympathectomy 64823
Bursa
Dupuytren’s Contracture
Injection 20527
Manipulation 26341
Fascial Cord
Enzyme Injection 20527
Manipulation 26341
Fasciectomy 26121-26123
Injection, Enzyme
Dupuytren’s Contracture 20527
Fascial Cord 20527
Tendon
Excision 26170
Incision 26450
Lysis 26440, 26442
Transfer 26485, 26489
Tendon Sheath
Excision 26145
Palsy, Seventh Nerve

See Facial Nerve Paralysis
Pancreas
Anastomosis
with Intestines 48520-48540, 48548
Biopsy 48100
Needle Biopsy 48102
Cyst
Anastomosis 48520-48540
Repair 48500
Debridement
Dilation
Ampulla of Vater 43277, 47542
Endoscopy
See Endoscopy, Pancreatic Duct
Excision
Ampulla of Vater 48148
Duct 48148
Partial 48140-48146, 48150, 48154, 48160
Total 48155-48160
Lesion
Ablation 43278
Excision 48120
Needle Biopsy 48102
Placement
Drainage 48000, 48001
Polyp
Ablation 43278
Pseudocyst
Drainage
Open 48510
Percutaneous 49405
Removal
Removal Transplanted Allograft 48556
Repair
Cyst 48500
Resection 48105
Suture 48545
Transplantation 48160, 48550, 48554-48556
Tumor
Ablation 43278
X ray 74300, 74301
Pancreas, Endocrine Only

See Islet Cell
Pancreatectomy
Donor 48550
Partial 48140-48146, 48150-48154, 48160
Total 48155-48160
with Transplantation 48160
Pancreatic DNAse
Antibody 86215
Pancreatic Duct
Destruction
Dilation
Endoscopy 43277
Endoscopy 43273
Ablation 43278
Collection
Specimen 43260
Destruction
Dilation 43277
Placement
Stent 43274
Removal (Endoscopic)
Foreign Body 43275
Stent 43275
Incision
Sphincter 43262
Removal
Foreign Body 43275
Stent 43275
Tube Placement
Nasopancreatic 43274
Stent 43274
Tumor
Ablation 43278
X ray
Injection Procedure 47531, 47532, 48400
Intra-operative 74300, 74301
Pancreatic Elastase 1 (PE1) 82656

Pancreatic Islet Cell AB 86341
Pancreaticojejunostomy 48145, 48150, 48153, 48548
Pancreatography
Postoperative 47531, 47532
Pancreatorrhaphy 48545
Pancreatotomy
Papillotomy 43262
Pancreozymin-Secretin Test 82938

Panel
Evaluation
Metyrapone 80436
Electrolyte 80051
General Health 80050
Hepatic Function 80076
Lipid 80061
Stimulation Panel
ACTH 80400, 80402, 80406
Calcitonin 80410
Estradiol Response, Total 80415
Testosterone Response 80414
Peripheral Vein Renin 80417
Renal Vein Renin 80416
Thyropopin Releasing Hormone (TRH) 80438, 80439
Suppression Panel
Aldosterone 80408
Dexamethasone, Suppression Panel 80420
Insulin-Induced C-Peptide 80432
Tolerance Panel
Glucagon
Insulinoma 80422
Pheochromocytoma 80424
Insulin
ACTH Insufficiency 80434
Growth Hormone Deficiency 80435
Panniculectomy
See Lipectomy
Pap Smears
Any Reporting System 88174, 88175
Non-Bethesda 88150, 88152, 88153
Paper, Chromatography
See Chromatography, Paper
Papilla, Interdental
See Gums
Papilloma
Destruction
Anus 46900-46924
Penis 54050-54065
Excision
Breast 19110
PAPP D
Paracentesis
Abdomen 49082, 49083
Eye
Anterior Chamber Fluid Removal 65800
with Discission of Anterior Hyaloid
Membrane 65810
with Removal
Blood 65815
Vitreous 65810
Fetal 59074
Thorax 32554, 32555
Paracervical Nerve
Injection
Anesthetic 64435
Steroid 64435
Paraffin Bath Therapy 97018

Paraganglioma, Medullary
Glucagon Tolerance Panel, Pheochromocytoma 80424
Parainfluenza Virus
Paralysis, Facial Nerve
Graft 15840-15842, 15845
Repair 15840-15842, 15845
Paralysis, Infantile
Polio
Vaccine 90713
Paranasal Sinuses
See Nasal Sinuses
Parasites
Blood 87206-87209
Macroscopic Examination 87169
Smear 87177
from Primary Source 87206, 87207
Stain 87207, 87209
Tissue 87220
Parasitic Worms
Helminth, Antibody 86682
Parathormone 83970
Parathyrin
Parathormone 83970
Parathyroid Autotransplantation 60512

Parathyroid Gland
Autotransplant 60512
Nuclear Medicine
Imaging, Planar 78070-78072
with SPECT 78071
with SPECT and CT Scan 78072
Parathyroid Hormone 83970

Parathyroid Transplantation 60512
Parathyroidectomy 60500-60505
Para-Tyrosine 84510
Paraurethral Gland
See Skene’s Gland
Paravertebral Nerve
Infusion
Anesthetic 64463
Injection
Anesthetic 64461, 64462, 64490-64495
Diagnostic Agent 64490-64495
Neurolytic 64633-64636
Therapeutic Agent 64490-64495
Parietal Cell Vagotomy 43641
Parietal Craniotomy
for Craniosynostosis 61556, 61557
Paring
Skin Lesion
Benign Hyperkeratotic 11055-11057
Paronychia
Parotid Duct
Diversion 42507-42510
Parotid Gland
Abscess
Calculi (Stone)
Excision 42330, 42340
Excision
Partial 42410-42415
Total 42420-42426
Tumor
Parotitises, Epidemic
See Mumps
Pars Abdominalis Aortae

Partial
Colectomy
See Colectomy, Partial
Cystectomy 51550, 51555, 51565
Esophagectomy 43116-43118, 43121-43124, 43287
Gastrectomy 43631-43635, 43845, 48150, 48152
with Gastrojejunostomy 43632
Glossectomy 41120, 41130, 41135
Hepatectomy 47120, 47140-47142
Mastectomy 19301, 19302
Nephrectomy 50240, 50543
Pancreatectomy 48140-48146, 48150-48154, 48160
Splenectomy 38101, 38115
Thromboplastin Time
Partial Thromboplastin Time (PTT) 85730, 85732
Ureterectomy 50220, 50546
Particle Agglutination 86403-86406

Particle Beam 61796, 63620
Stereotactic Radiosurgery (Cranial) (Spinal) 61796-61799, 63620, 63621
Parvovirus
Antibody 86747
Patch
Allergy Tests 95044, 95052
Patella
See also Knee
Application
Patellar Tendon Bearing Cast 29435
Repair 27420, 27422, 27424
Excision 27350
Prepatellar Bursa 27340
with Reconstruction 27424
Fracture
with Internal Fixation 27524
with Patellectomy 27524, 27566
Repair
Chondromalacia 27418
Resurfacing 27447
Suture
Infrapatellar Tendon 27380, 27381
Patella, Chondromalacia
Repair 27418
Patellar Tendon Bearing (PTB) Cast
Application 29435
Patellectomy
Complete 27524, 27566
Partial 27524, 27566
with Reconstruction 27424, 27524, 27566
Patent Ductus Arteriosus (PDA)
Repair 33820, 33822, 33824, 93582

Anatomic Pathology
See Autopsy
Antibody Identification
See Antibody; Antibody Identification
Antigen Detection
Atomic Absorption Spectroscopy 82190
Blood Tests
Cell Count
Coagulation
Gas Analysis
See Blood Gases
Smear
See Blood Smear
Typing
Urea Nitrogen 84520-84525
Breath Test
Alcohol, Ethyl 82075
Helicobacter Pylori 78267, 78268, 83013, 83014
Hydrogen 91065
Methane 91065
Urea 78267, 78268
Caffeine Halothane Contracture Test (CHCT) 89049
Cell Count
Blood
Body Fluid 86152, 86153, 89050, 89051
Crystal Identification 89060
with Immunologic Selection and
Identification 86152, 86153
Cerebrospinal Fluid
Cell Count 89050
Myelin Basic Protein 83873
Protein, Total 84157
Cervical Smears
See Cervical Smears
Chemistry 82009-84999
Acetaminophen 80329-80331
Acetic Anhydride 84600
Acetylcholinesterase
Acetylsalicylic Acid 80329-80331
Acid
Bile 82239
Gastric 82930
Acid Phosphatase 84060, 84066
Acid Probes, Nucleic
Acylcarnitines 82016, 82017
Adenosine Diphosphate
Blood 82030
Adenosine Monophosphate (AMP)
Blood 82030
Adrenalin
See Catecholamines
Blood 82383
Urine 82382, 82384
Adrenaline-Noradrenaline 82382-82384
Adrenocorticotropic Hormone (ACTH) 80400-80406, 80412, 80418, 82024
Alanine Amino Transferase 84460
Albumin
Ischemia modified 82045
Other Source 82042
Serum, Plasma or Whole Blood 82040
Urine 82043, 82044
Alcohol
Ethanol
Any Specimen, Except Breath 80320-80322
Breath 82075
Urine 80320-80322
Alcohol, Isopropyl 80320
Alcohol, Methyl 80320
Aldolase
Blood 82085
Aldosterone
Blood 82088
Suppression Evaluation 80408
Urine 82088
Alkaline Phosphatase 84075, 84078, 84080
Alkaloids 80323
Alpha-Fetoprotein (AFP)
Serum 82105, 82107
Alpha-tocopherol 84446
Aluminum
Blood 82108
Amine
Vaginal Fluid 82120
Amino Acids 82127-82139
Aminolevulinic Acid (ALA)
Aminotransferase
Glutamic-Oxaloacetic 84450
Glutamic-Pyruvic 84460
Aminotransferase, Alanine 84460
Aminotransferase, Aspartate 84450
Ammonia
Blood 82140
Amobarbital 80345
Amphetamine 80324-80326
Amylase
Blood 82150
Urine 82150
Androstanediol Glucuronide 82154
Androstenedione
Androstenolone 82626
Androsterone
Angiotensin Forming Enzyme 82164
Angiotensin I-converting Enzyme 82164
Angiotensin II 82163
Antimony 83018
Qualitative 83015
Apolipoprotein
Arsenic 82175, 83018
Qualitative 83015
Ascorbic Acid
Blood 82180
Aspartate Aminotransferase (AST) 84450
Aspirin 80329-80331
Atomic Absorption Spectroscopy 82190
B-1 Vitamin 84425
B-6 Vitamin 84207
B-12 Vitamin 82607, 82608
Barbiturates 80345
Barium 83018
Qualitative 83015
Beryllium 83018
Qualitative 83015
Beta Glucosidase 82963
Beta-2-Microglobulin
Blood 82232
Urine 82232
Bicarbonate 82374
Bile Acids 82239
Bilirubin
Blood 82247, 82248
Feces 82252
Total
Direct 82247, 82248
Biotinidase 82261
Bismuth 83018
Qualitative 83015
Blood, Occult 82270-82274
Blood Gases
CO2 82803
HCO3 82803
pCO2 82803
pH 82800, 82803, 82930
pO2 82803, 82820
Blood Urea Nitrogen 84520-84525
Bone g1a Protein 83937
Bradykinin
Blood or Urine Test 82286
C-13
C-14
Cadmium 82300
Calcitonin 82308
Calcium
Blood
Infusion Test 82331
Ionized 82330
Total 82310
Urine 82340
Calculus
Analysis 82355, 82360, 82365, 82370
Calprotectin
Fecal 83993
Carbohydrate Deficient Transferrin 82373
Carbon Dioxide 82374, 82803
Carbon Tetrachloride 82441
Carboxyhemoglobin 82375, 82376
Carcinoembryonic Antigen 82378
Carnitine 82379
Carotene 82380
Catecholamines 80424, 82382-82384
Blood 82383
Panel for Pheochromocytoma 80424
Urine 82382
Cathepsin-D 82387
Ceruloplasmin 82390
Cervicovaginal Fluid Evaluation
Amniotic Fluid Proteins 84112
Chloride
Blood 82435
Other Source 82438
Spinal Fluid 82438
Urine 82436
Chloride, Methylene 82441
Chlorohydrocarbon 82441
Cholesterol
HDL 83718
LDL 83721, 83722
Serum or Whole Blood 82465
Choline Esterase I 82013
Choline Esterase II 82480, 82482
Cholinesterase
Blood 82480, 82482
Cholylglycine 82240
Chondroitin B Sulfate 82485
VLDL 83719
Chorionic Gonadotropin (hCG) 84702-84704
Chorionic Growth Hormone 83632
Chromatography
Sugars 84375
Chromium 82495
Citrate 82507
Cocaine 80353
Screen 80305-80307
Collagen Cross Links 82523
Copper 82525
Coproporphyrin
Blood 84119, 84120
Feces 84126
Corticosteroids
Corticosterone 82528
Cortisol
Free 82530
Total 82533
Cortisol Binding Globulin 84449
C-Peptide 84681
Creatine 82540
Creatine Kinase (CK), (CPK) 82550-82554
Creatinine
Blood 82565
Other Source 82570
Screen 82575
CRF
CRH
Cristobalite 84285
Cryofibrinogen 82585
Cryoglobulin 82784, 82785
Qualitative 82595
Cyanacobalamin 82607, 82608
Cyanide 82600
Cyanocobalamin 82607, 82608
Cyclic AMP 82030
Cyclic Somatostatin 84307
Cyclosporine 80158
Cystatin C
Blood 82610
Cystatins, Kininogen 85293
Cystine
Urine 82615
Dehydroepiandrosterone Sulfate 82627
Delta-aminolevulinic Acid (ALA) 82135
Deoxycortisol 82634
Des-Gamma-Carboxy-Prothrombin (DCP)
Oncoprotein 83951
Desoxycorticosterone 82633
Diastase
Dibucaine Number 82638
Diethylether 84600
Dihydrocodeinone 80361
Dihydrotestosterone (DHT) 80327, 80328, 82642
Dihydroxyvitamin D 82652
Dimethadione 80339-80341
Dopamine 82383, 82384
D-Xylose Absorption Test 84620
Elastase 82656
Electrophoresis
Electrophoretic Technique, Unspecified 82664
Hemoglobin 83020
High Resolution 83701
Protein 84165, 84166
Enzyme Activity
Unspecified
Nonradioactive Substrate 82657
Radioactive Substrate 82658
Epiandrosterone 80327, 80328
Epinephrine
Blood or Urine 82382-82384
Estradiol
Free 82681
Total 82670
Estriol 82677
Estrogen Receptor Assay 84233
Estrogens
Estrone 82679
Ethanol
Any Source, Except Breath 80320-80322
Any Source, Except Breath and Urine 82077
Breath 82075
Ethchlorvynol
Ethyl Alcohol 80320
Breath 82075
Etiocholanolone 82696
Fat Differential, Fecal 82715
Fat or Lipids, Fecal 82710
Qualitative 82705
Fatty Acids, Nonesterified 82725
Fatty Acids, Very Long Chain 82726
Ferritin 82728
Fetal Fibronectin 82731
Fetal Hemoglobin
See Hemoglobin
Fetal Lung Maturity Assessment
Fluorescence Polarization 83663
Foam Stability Test 83662
Lamellar Body Density 83664
Lecithin Sphingomyelin (L/S) Ratio 83661
Fetoprotein, Alpha-1
Serum 82105
Fibronectin, Fetal 82731
Fluoride 82735
Flurazepam 80346, 80347
Folic Acid
RBC 82747
Serum 82746
Follicle Stimulating Hormone (FSH) 83001
Fructosamine 82985
Fructose
Semen 82757
TLC Screen 84375
FT-4 84439
Galactokinase
RBC 82759
Galactose 82760
Galactose-1-Phosphate Uridyl
Transferase 82775
Screen 82776
Galectin-3 82777
Gammaglobulin, IgA 82784, 82787
Gammaglobulin, IgD 82784, 82787
Gammaglobulin, IgE 82785, 82787
Allergen Specific 86003, 86005, 86008
Gammaglobulin, IgG 82784, 82787
Gammaglobulin, IgM 82784, 82787
Gamma-Glutamyltransferase (GGT) 82977
Gases, Blood
CO2 82803
HCO3 82803
O2 82803, 82805, 82810
pCO2 82803
pH 82800, 82803, 82930
pO2 82803, 82820
Gastric Acid Analysis 82930
Gastrin 82941
Post Secretin Stimulation 82938
Gentamicin 80170
GGT 82977
Glucagon 82943
Tolerance 82946
Glucose
Blood 82947, 82948
Home Monitoring Device 82962
Other than Blood 82945
Post Glucose Dose 82950
Tolerance 82951, 82952
Glucose-6-Phosphate Dehydrogenase (G6PD) 82955
Screen 82960
Glucosidase 82963
Glucuronide Androstanediol 82154
Glutamine 82127, 82128, 82131
Glutamyltransferase, Gamma 82977
Glutathione 82978
Glutathione Reductase
RBC 82979
Glycated Protein 82985
Glycohemoglobin 83036
Glycosylated (A1c) Hemoglobin 83021, 83036, 83037
Gonadotropin, Chorionic 84702
Follicle Stimulating Hormone (FSH) 83001
Free Beta Chain 84704
Luteinizing Hormone (LH) 83002
Qualitative 84703
Growth Stimulation Expressed Gene 2 83006
H. (Helicobacter) Pylori
Blood, Urease Activity 83009
Breath, Urease Activity 83013, 83014
Infectious Agent Antigen 87339
Stool 87338
Haptoglobin 83010
Phenotypes 83012
HDL Cholesterol 83718
Heavy Metal 83015, 83018
Hemoglobin
Copper Sulfate Method 83026, 83030, 83033, 83036
Electrophoresis 83020
Fecal, Immunoassay 82274
Plasma 83051
Thermolabile 83065
Unstable 83068
Urine 83069
Hemoglobin A1c (Glycosylated) 83021, 83036, 83037
Hemoglobin-Oxygen Affinity 82820
Hemosiderin
Qualitative 83070
HER-2/neu Oncoprotein 83950
Heroin 80305-80307, 80356
HGH (Human Growth Hormone) 83003
HIAA (5-Hydroxyindolacetic Acid) 83497
Urine, Qualitative 81005
Histamine 83088
Holotranscobalamin 84999
Homocysteine 83090
Homocystine
Urine 82615
Homovanillic Acid (HVA) 83150
Human Growth Hormone (HGH) 83003
HVA (Homovanillic Acid) 83150
Hydroxycorticosteroid, 17- (17-OHCS) 83491
Hydroxyindoleacetic Acid, 5- (HIAA) 83497
Hydroxypregnenolone, 17- 84143
Hydroxyprogesterone
17-d 83498
Hydroxyproline
Free 83500
Total 83505
Hydroxytryptamine, 5- 84260
IgA 82784
IgD 82784
IgE 82785, 82787, 86003, 86005, 86008
IgG 82784, 82787
IgM 82784, 82787
Immunoassay, Unspecified Analyte 83516, 83518-83520
Immunoglobulins 82784, 82785
Insulin 83525, 83527
Insulin Tolerance Test 80434, 80435
Intrinsic Factor 83528
Iron 83540
Binding Capacity 83550
Isocitric Dehydrogenase (IDH) 83570
Ketogenic Steroids 83582
Ketone Body 82009, 82010
Ketosteroids, 17- (17-KS) 83586, 83593
Lactate 83605
Lactic Acid 83605
Lactoferrin, Fecal 83631
Qualitative 83630
Lactose, Urine
Qualitative 83633
LAP 83670
LD 83615-83625
LDH 83615-83625
LDL Cholesterol 83721, 83722
Lead 83655
Lecithin-Sphingomyelin Ratio 83661
Leucine Aminopeptidase (LAP) 83670
LH 83002
Lipase 83690
Lipoprotein (a), Blood
Electrophoretic Fractionation 83700
HDL Cholesterol 83718
High-resolution Fractionation 83701
LDL Cholesterol 83721, 83722
Quantitation 83704
VLDL Cholesterol 83719
Lipoprotein-associated Phospholipase A2 (Lp-PLA2) 83698
LRH 83727
Luteinizing Hormone (LH) 83002
Luteinizing Releasing Factor (LRH) 83727
Macroglobulins, Alpha-2 86329
Magnesium 83735
Maltose Tolerance 82951, 82952
Mammotropin 84146
Manganese 83785
Marijuana 80305-80307
Mass Spectrometry, Unspecified Analyte 83789
Qualitative 80305-80307
Mercury 83018, 83825
Qualitative 83015
Metanephrines 83835
Methadone 80358
Methamphetamine 80324-80326
Methanol 80320
Methemalbumin 83857
Methemoglobin 83050
Qualitative 83045
Methsuximide 80339-80341
Methyl Alcohol 80320
Microalbumin 82043, 82044
Microglobulin, Beta-2 82232
MPO 83876
Mucin
Synovial Fluid 83872
Mucopolysaccharides, Acid 83864
Myelin Basic Protein
Myeloperoxidase (MPO) 83876
Myoglobin 83874
Natriuretic Peptide 83880
Nephelometry, Unspecified Analyte 83883
Nickel 83885
Nicotine 80323
Nucleotidase 83915
Oligoclonal Bands 83916
Oligoclonal Immunoglobulins 83916
Oncoprotein 83950, 83951
Des-Gamma-Carboxy-Prothrombin (DCP) 83951
HER-2/neu 83950
Opiates 80361-80364
Oral Lactose Tolerance Test 82951, 82952
Organic Acids 83918-83921
Osmolality
Blood 83930
Urine 83935
Osteocalcin 83937
Oxalate 83945
Oxygen Saturation 82805, 82810
PAMG-1 84112
Pancreatic Elastase 1 (PE1) 82656
Pancreozymin-Secretin Test 82938
Parathormone 83970
Parathyroid Hormone 83970
pH
Blood 82800, 82803
Body Fluid 83986
Exhaled Breath Condensate 83987
Phencyclidine (PCP) 83992
Phenobarbital 80345
Phenothiazine 80342-80344
Phenylalanine (PKU)
Blood 84030
Phenylalanine-Tyrosine Ratio 84030, 84510
Phenylketones
Qualitative 84035
Phosphatase, Acid 84060, 84066
Phosphatase, Alkaline 84075, 84078, 84080
Phosphates, Inorganic 84100
Phosphates, Organic
See specific method
Phosphogluconate, 6-, Dehydrogenase
RBC 84085
Phospholipase A2
Lipoprotein-associated (Lp-PLA2) 83698
Secretory Type II (sPLA2-IIA) 0423T
Phosphorus, Inorganic 84100
Urine 84105
Pituitary Gonadotropins 83001, 83002
PKU 84030
Placenta Alpha Microglobulin-1 (PAMG-1) 84112
Plasma Protein-A, Pregnancy-Associated (PAPP-A) 84163
Porphobilinogen, Urine 84110
Qualitative 84106
Porphyrin Precursors 82135, 84106, 84110
Porphyrins
Feces, Quantitative 84126
Urine, Quantitation and Fractionation 84120
Potassium
Blood 84132
Urine 84133
Prealbumin 84134
Pregnancy Associated Plasma Protein-A 84163
Pregnancy Test
Blood 84702-84704
Urine 81025
Pregnanediol 84135
Pregnanetriol 84138
Pregnenolone 84140
Procalcitonin (PCT) 84145
Progesterone 84144
Progesterone Receptors 84234
Proinsulin 84206
Prolactin 84146
Prostaglandin 84150
Prostate Specific Antigen 84152-84154
Protein
See Protein
Protoporphyrin
RBC 84202
RBC, Screen 84203
Pyridoxal Phosphate 84207
Pyruvate 84210
Pyruvate Kinase 84220
Quinine 84228
Receptor Assay
Estrogen 84233
Non-endocrine 84238
Progesterone 84234
Unspecified Hormone 84235
Reinsch Test 83015
Renin 84244
Renin-Converting Enzyme 82164
Riboflavin 84252
Ropes Test 83872
Salicylates 80329-80331
Selenium 84255
Serotonin 84260
Serum Glutamic Oxalacetic Transaminase (SGOT) 84450
Serum Glutamic Pyruvate Transaminase (SGPT) 84460
Sex Hormone Binding Globulin 84270
Sialic Acid 84275
Sickle Hemoglobin 85660
Silica 84285
Sodium
Blood 84295
Unspecified Source 84302
Urine 84300
Somatomammotropin, Chorionic 83632
Somatomedin 84305
Somatostatin 84307
Somatotropin 83003
Specific Gravity
Other than Urine 84315
Urine 81000-81003
Spectrophotometry
Unspecified Analyte 84311
Stone Analysis 82355, 82360, 82365, 82370
Sugars 84375-84379
Sulfate
Urine 84392
Sulfhemoglobin 83060
Sweat Test 82435
T-3 84479-84482
T-4 84436, 84437, 84439, 84479
Testosterone 84402, 84403, 84410
Thiamine 84425
Thiocyanate 84430
Thromboxane
Urine 84431
Thyroglobulin 84432
Thyroid Hormone Binding Ratio 84479
Thyroid Hormone Uptake 84479
Thyroid Stimulating Hormone (TSH) 84443
Thyroid Stimulating Immune Globulins (TSI) 84445
Thyroxine 84436, 84437, 84439
Thyroxine Binding Globulin (TBG) 84442
Tobramycin 80200
Tocopherol, Alpha 84446
Transcortin 84449
Transferase
Alanine Amino 84460
Aspartate Amino 84450
Transferrin 84466
Triglycerides 84478
Triiodothyronine 84480-84482
Troponin 84484
Qualitative 84512
Trypsin
Duodenal Fluid 84485
Feces 84488, 84490
Tyrosine 84510
Urea Nitrogen 84520, 84525
Screen 84545
Urine 84540
Uric Acid
Blood 84550
Other Source 84560
Urobilinogen
Feces 84577
Urine 84578, 84580, 84583
Uroporphyrin 84120
Valproic Acid (Dipropylacetic Acid) 80164, 80165
Vanillylmandelic Acid (VMA)
Urine 84585
Vasoactive Intestinal Peptide (VIP) 84586
Vasopressin 84588
Vitamins
See Vitamins
Volatiles 84600
Xylose Absorption 84620
Zinc 84630
Cholesterol
HDL 83718
LDL 83721
Lipid Panel 80061
Serum 82465
VLDL 83719
Detection 84703
Free Beta Chain 84704
Measurement 84702
Stimulation Panel 80414, 80415
Chromatography
See Chromatography
Chromium 82495
Chromogenic Substrate Assay
Chromosome Analysis
Clinical Consultation 80500-80502
Coagulation
Cryopreservation
Cells 88240, 88241
Oocyte(s)
Mature 89337
Testicular 89335
Cytogenetic Studies 88230-88299
Cytopathology 88104-88140
Cervical or Vaginal
Requiring Interpretation by Physician 88141
Thin Layer Prep 88142, 88143, 88174, 88175
Concentration Technique 88108
Immediate Cytohistologic Study 88172, 88177
Fluids, Washings, Brushings 46600, 46601, 88104-88108
Forensic 88125
Other Source 88160-88162
Selective Cellular Enhancement
Technique 88112
Smears
Cervical or Vaginal 88141-88167, 88174, 88175
Nasal 89190
Urinary Tract Specimen
In Situ Hybridization Technique 88120, 88121
Cytotoxicity Assay
Cancer Stem Cells (CSCs) 0564T
Drug Assay (Testing)
See Drug Assay
Enzymes
Specific Analytes
3 Beta-Hydroxydehydrogenase 80406
6-Phosphoglutonate Dehydrogenase 84085
21 Hydroxylase 80402, 81402, 81405
Acetylcholinesterase 82013
Acetylglucosaminyltransferase 81406
Aldolase 82085
Alpha-1 Antiproteinase 81332
Amylase 82150
Angiotensin Converting Enzyme (ACE) 81400, 82164
Antistreptokinase 86590
Aspartoacylase 81200
Biotinidase 81404, 82261
Cholinesterase 82480, 82482
Creatine Kinase 82550, 82552-82554
Dehydrogenase 81205, 81400, 81401, 81404, 81405
Deoxyribonuclease Antibody 86215
Diastase 82150
Elastase 82656
Galactokinase 82759
Galactose-1-phosphate Uridyl Transferase 82775, 82776
Gamma-glutamyltransferase 82977
Glucose-6-phosphate Dehydrogenase 82955, 82960
Glucosidase 81251, 82963
Glucuronosyltransferase 1 81350
Glutamyltransferase 82977
Glutathione Reductase 82979
Hexosaminidase 81255, 81406
Hydroxylase 81406
Isocitric Dehydrogenase 83570
Kinase 81245, 81246, 81270, 81401, 81404
Lactate Dehydrogenase 83615
Leukocyte Alkaline Phosphatase 85540
Ligase 81331
Lipase 83690
Lipoprotein-associated Phospholipase A2 83698
Mannosyltransferase 81406
Methyltransferase 81401
Muramidase 85549
Myeloperoxidase 83876
Peptidase 81400
Peroxidase 82270-82272
Phosphatase 80053, 80076, 81250, 84060, 84066, 84075, 84078, 84080
Phosphodiesterase 81330
Polymerase 81406
Pseudocholinesterase 82480
Pyruvate Kinase 84220
Reductase 81291, 81355
Reptilase 85635
Streptokinase Antibody 86590
Transferase 80053, 80076, 84450, 84460
Urease 83009, 83013, 83014
Uridylyltransferase 81401, 81406
Evocative/Suppression Test
Agent Administration 96360, 96361, 96372-96375
Analytes
Evaluation Panel
Metyrapone Panel 80436
Stimulation Panel
ACTH 80400, 80402, 80406
Calcitonin 80410
Chorionic Gonadotropin 80414, 80415
Renin, Peripheral Vein 80417
Renin, Renal Vein 80416
Suppression Panel
Dexamethasone 80420
Insulin-induced C-peptide 80432
Tolerance Panel
Glucagon 80422, 80424
Insulin 80434, 80435
Factor Inhibitor Tests
Activated Protein C Resistance Assay 85307
Antithrombin III Activity 85300
Antithrombin III Antigen Assay 85301
Protein C
Activity 85303
Antigen 85302
Protein S
Free 85306
Total 85305
Fibrin Degradation Products
Agglutination 85362
D-dimer 85378, 85379
Quantitative 85379
Fibrinolysis
See Fibrinolysis
Flow Cytometry 88182-88189
See Flow Cytometry
Gene Analysis
Analytes
See Gene Analysis, Analytes
Chimerism Analysis 81267, 81268
Comparative Analysis Using Short Tandem Repeat (STR) Markers 81265, 81266
Cytogenomic Microarray Analysis 81406
Human Platelet Antigen Genotyping 81105-81112
Translocation
See Gene Analysis, Translocation Analysis
Genetic Testing
See Gene Analysis
Genomic Sequencing Procedures
See Genomic Sequencing Procedures (GSPs)
Globulin
See Globulin
Hematology and Coagulation 85002-85999
Blood Cell Count
Blood Tests
See Blood Tests
Blood Typing
Compatibility 86920-86923
Coagulation
See Coagulation
Disorders
Anemia 0516F
Coagulopathy 85130, 85390
Hemodynamic Evaluation
Central Cardiovascular 78414
Exercise Study 93464
Pharmacologic Agent Study 93463
Portography 37182, 37183, 75885
Venography 75889
Hemoglobin
See Hemoglobin
Hormone Assay
See Hormone Assay
Human Growth Hormone (HGH)
See Human Growth Hormone (HGH)
Immunology
See Immunology
Infectious Agent
Amplified Probe Detection
See Nucleic Acid Probe, Amplified Probe Detection, Infectious Agent
Antibody Detection
See Antibody; Antibody Identification
Antigen Detection
Concentration 87015
Enzyme Activity 87905
Genotype Analysis
See Infectious Agent, Genotype Analysis
Immunoassay Detection
See Infectious Agent, Antibody Detection
Nucleic Acid Detection
See Infectious Agent, Antigen Detection, Nucleic Acid Probe
Phenotype Analysis
See Infectious Agent, Phenotype Analysis
Quantification
See Nucleic Acid Probe, Quantification, Infectious Agent
Iontophoresis
Sweat Collection 89230
Meat Fibers
Feces 89160
Microbiology 87003-87999
Microorganism Identification
by Animal Inoculation 87003, 87250
by Culture
See Bacteria Culture
by Dark Field Examination 87164-87166
by Examination 87168-87172
by Nucleic Acid Probe
by Nucleic Acid Sequencing 87153
Sensitivity Studies 87181-87190
Serum Bactericidal Titer 87197
by Smear or Stain 87177, 87205-87210
by Tissue
Culture 87230, 87252, 87253
Virus Isolation 87250-87255
Molecular Pathology 81105-81408, 81479
Adoponectin 81506
AFP 81510-81512
Apoliproprotein A1 81503
CA-125 81500, 81503
DIA 81509, 81511, 81512
Ferritin 81506
Glucose 81506
HbA1c 81506
hCG 81508-81512
HE4 81500
hs-CRP 81506
Insulin 81506
Interleukin 2-receptor Alpha 81506
mRNA 81518-81521
Oncological Gene Profiling 81504
PAPP-A 81508, 81509
Prealbumin 81503
Transferrin 81503
Trisomy 21, 18, and 13 81507
uE3 81510-81512
Unlisted 81599
Nucleic Acids
Optical Endomicroscopy 88375
See Organ or Disease-Oriented Panel
Panels
See Panel
Particle Agglutination 86403-86406
pH
See pH
Postmortem 88000-88099
Proprietary Laboratory Analyses (PLAs)
See Proprietary Laboratory Analyses (PLAs)
Protein
See Protein
Radioimmunoassay 82009-84999
Receptor Assay
See Receptor Assay
Red Blood Cell (RBC)
Reproductive Medicine 89250-89398
Cryopreservation
Embryo
See Embryo
Oocyte
See Oocyte
Reproductive Tissue
See Reproductive Tissue
Sperm Analysis/Evaluation
See Sperm Analysis
Respiratory Syncytial Virus
See Respiratory Syncytial Virus
Reticulocyte
Count 85044-85046
Smear and Stain
See Smear and Stain
Spectrometry, Mass
See Pathology and Laboratory, Chemistry; specific analyte in Drug Assay
Column Chromatography
Unspecified Non-drug Analyte(s) 82542
Non-drug Analytes 83789
Spectrophotometry 84311
Spectroscopy
Atomic Absorption 82190
Bioimpedance Spectroscopy (BIS) 93702
Fluorescent
Advanced Glycation Endproducts (AGE) 88749
Infrared 82365
Lipoprotein 83704
Sperm
Analysis
Antibodies 89325
Evaluation from Semen
Count 89310, 89320, 89322
Differential 89320, 89322
Motility 89300, 89310, 89320-89322
Presence 89300, 89321
Forensic 88125
Hamster Penetration Test 89329
Huhner Test 89300
for Retrograde Ejaculation 89331
Storage 89343
Thawing 89353
Identification
Aspiration 89257
from Testis Tissue 89264
Isolation 89260, 89261
Sputum 89220
Stem Cell
See Stem Cell
Storage
See Storage
Streptococcus, Group A
Antigen Detection
Immunoassay 87430
Streptococcus, Group B
by Immunoassay
Sugars 84375-84379
Surgical Pathology 88300-88399
Antibody Stain Procedure
Immunofluorescence 88346, 88350
Archived Tissue Examination 88363
Intraoperative 88329-88334
Decalcification Procedure 88311
Electron Microscopy 88348
Gross and Micro Exam
Level II 88302
Level III 88304
Level IV 88305
Level V 88307
Level VI 88309
Gross Exam
Level I 88300
Histochemistry 88313-88319
Immunocytochemistry 88313, 88341, 88342, 88344
Immunofluorescent Study 88346, 88350
Immunohistochemistry 88341, 88342, 88344
Macroscopic Tissue Examination 88387, 88388
Microdissection 88380, 88381
Morphometry
See Morphometric Analysis
Nerve Teasing 88362
Optical Endomicroscopy 88375
Protein Analysis 88371, 88372
Special Stain 88312-88314, 88319
Staining 88312-88314
Tissue Hybridization 88364-88366
Unlisted Services and
Procedures 88399, 89240
Sweat Collection
Iontophoresis 89230
T Cells
See T Cells
Therapeutic Drug Assay
See Therapeutic Drug Assay
Thrombin Time 85670-85675
Thrombomodulin 85337
Thromboplastin
See Thromboplastin
Tolerance Test
See Tolerance Test
Toxicology Screen 80305-80307
Antibody
Elution 86860
Screen 86850
Antihuman Globulin Test
See Coombs Test
Blood Processing
Autologous 86890, 86891
Frozen 86927, 86930-86932
Irradiation 86945
Pooling 86965
Pretreatment 86970-86972, 86975-86978
Splitting 86985
Blood Typing
Leukocyte Transfusion 86950
Urea Nitrogen
Blood 84520-84525
Clearance 84545
Quantitative 84520
Semiquantitative 84525
Urine 84540
Urinalysis
See Urinalysis
Vitamin
See Vitamins
In Vivo Procedures 88720-88749
Western Blot
HIV 86689
Protein 84181, 84182
Tissue Analysis 88371, 88372
White Blood Cell
Alkaline Phosphatase 85540
Antibody 86021
Count 85032, 85048, 89055
Differential 85004-85007, 85009
Histamine Release Test 86343
Phagocytosis 86344
Transfusion 86950
PBG
Porphobilinogen 84106, 84110
PCP
Phencyclidine 83992
PCR (Polymerase Chain Reaction) Molecular Analysis

Coronary Artery Disease 81493
Heart Transplant 0055U, 81595
Infectious Disease, Aspergillus Species 0109U
Molecular Pathology Procedure, Level 4 81403
Oncology Profiling
Breast 0045U, 81518, 81519, 81522
Colon 81525
Colorectal 0069U
Cutaneous Melanoma 0090U
Hematolymphoid Neoplasia 0016U, 0017U
Prostate 0005U, 0047U, 81541, 81551
Thyroid 0018U
Tumor of Unknown Origin 81540
Uveal Melanoma 81552
Péans’ Operation 27290, 27295
Pectoral Cavity
See Chest Cavity
Pectus Carinatum
Reconstructive Repair 21740-21743
Pectus Excavatum
Reconstructive Repair 21740-21742
Pediatric Critical Care 99471, 99472

Pediatric Intensive Care 99478
Pedicle Fixation
Insertion 22840, 22842-22844
Pedicle Flap
Abbe-Estlander Type 40761
for Breast Reconstruction
Bipedicle, TRAM 19369
Single, TRAM 19367, 19368
for Cerebrospinal Fluid Leak 61619
for Eyelid Repair 67961
Formation 15570-15576
Island 15740
for Lip Repair 40761
Neurovascular 15750
Transfer 15650
for Vaginal Lengthening 46748
Vascular 15730, 15731, 15733
Zygomaticofacial Flap 15730
PEEP (Positive End-Expiratory Pressure)

Therapy
Ventilation (CPAP) 94660
Pelvic Adhesions
Lysis 58660, 58740
Pelvic Exam
Preventive 99397
Pelvic Exenteration 45126, 51597, 58240
Pelvic Fixation
See Spinal Instrumentation
Pelvic Lymphadenectomy 38770, 55845, 55865, 57531, 58210, 58548, 58958
with Aortic Nodes 38780
with External Iliac Nodes 38765, 38770, 51575, 51585, 51595, 54135, 55815, 55845, 55865
with Hypogastric Nodes 38765, 38770, 51575, 51585, 51595, 54135, 55815, 55845, 55865
Limited 38562, 55812, 55842, 55862
with Obdurator Nodes 38765, 38770, 51575, 51585, 51595, 54135, 55815, 55845, 55865
with Renal Nodes 38780
with Salpingo-Oophorectomy 58950, 58951, 58954
Total 57109, 57531, 58210, 58548
with Vulvectomy 56640
Pelvimetry 74710
Pelviolithotomy 50130
Pelvis
See also Hip
Abscess
Biopsy 27040, 27041
Bone
Drainage 26992
Brace Application 20662
Bursa
CT Scan 72191-72194, 74174, 74176-74178
Destruction
Lesion 58662
Endoscopy
Destruction of Lesion 58662
Exclusion
Exenteration 45126, 51597, 58240
Fasciotomy
Decompression 27027
Halo 20662
Hematoma
Lysis
Adhesions 58660
Magnetic Resonance Angiography 72198
Removal
Repair
Osteotomy 27158
Tendon 27098
Ring Dislocation/Fracture
with Internal Fixation 27217, 27218
Percutaneous Skeletal Fixation 27216
Tumor
Unlisted Services and Procedures for Hips and Hip Joint 27299
Wound
Exploration 49014
Packing 49013
X ray 72170-72190
with Hip(s) 73501-73503, 73521-73523
Manometry 74710
Pelvi-Ureteroplasty
See Pyeloplasty
Penectomy
See Penis, Amputation
Penetrating Keratoplasties
See Keratoplasty, Penetrating
Penile Induration
Penile Prosthesis
Insertion
Noninflatable 54400
Removal
Inflatable 54406, 54410-54417
Semi-rigid 54415-54417
Repair
Inflatable 54408
Replacement
Inflatable 54410, 54411, 54416, 54417
Semi-rigid 54416, 54417
Penile Rigidity Test 54250
Penile Tumescence Test 54250
Penis
Amputation
Complete 54125
Partial 54120
Radical 54130-54135
Replanted 54438
Biopsy 54100-54105
Circumcision
Repair 54163
Surgical Excision
Newborn 54150, 54160, 54161
Destruction
Lesion 54050, 54055-54057, 54060, 54065
Drainage 54015
Excision
Partial 54120
Prepuce 54150-54161, 54163
Total 54125-54135
Frenulotomy 54164
Incision
Frenulum 54164
Prepuce 54000, 54001
Injection
for Erection 54235
Peyronie Disease 54200
Surgical Exposure Plaque 54205
Vasoactive Drugs 54231
X ray 54230
Insertion
Prosthesis
Noninflatable 54400
Irrigation
Priapism 54220
Lesion
Destruction
Cryosurgery 54056
Extensive 54065
Laser Surgery 54057, 54065
Simple 54050-54060
Excision 54060
Nocturnal Penile Tumescence Test 54250
Occlusion
Vein 37790
Plaque
Plethysmography 54240
Prepuce
Adhesions
Lysis 54450
Slitting 54000, 54001
Stretching 54450
Prosthesis
Removal
Foreign Body 54115
Prosthesis
Inflatable 54406, 54410-54417
Semi-rigid 54415-54417
Repair
Angulation 54360
Chordee 54300-54304, 54328
Corporeal Tear(s) 54437
Epispadias 54380-54390
Fistulization 54435
Hypospadias 54328-54352
Injury 54440
Priapism with Shunt 54420-54430
Prosthesis
Inflatable 54408
Replacement
Prosthesis
Inflatable 54410, 54411, 54416, 54417
Semi-rigid 54416, 54417
Replantation 54438
Revascularization 37788
Rigidity Test 54250
Suture
Urethral Injury 53505
Test Erection 54250
Venous Studies 93980, 93981
Penis Adhesions
Lysis
Post-circumcision 54162
Penis Prostheses
Pentagastrin Test
Secretory Study 43754, 43755
Pentamidine
Peptidase P
Peptidase S
Peptide, Connecting
C-Peptide 80432, 84681
Peptide, Vasoactive Intestinal 84586
Peptidyl Dipeptidase A
Percutaneous Abdominal Paracentesis 49082, 49083
Percutaneous Atherectomies
See Artery, Atherectomy
Percutaneous Biopsy, Gallbladder/ Bile Ducts 47543, 47553
Percutaneous Catheter Retrieved 37197
Percutaneous Discectomies 0274T, 0275T
Percutaneous Electric Nerve Stimulation
TENS 97014
Percutaneous Insertion—Ventricular Assist Device
Arterial Access 33990, 33991
Venous Access 33991, 33995
Percutaneous Lumbar Discectomy

See Discectomy, Lumbar
Percutaneous Lysis
Epidural Adhesions 62263, 62264
Percutaneous Nephrostomies
See Nephrostomy
Percutaneous Pleural Fluid Drainage

with Imaging 32557
without Imaging 32556
Percutaneous Transluminal Angioplasty
Artery
Aortic 37246, 37247
Brachiocephalic 37246, 37247
Coronary 92920, 92921
Pulmonary 92997, 92998
Renal 37246, 37247
Visceral 37246, 37247
Vein 36902, 36905, 36907, 37248, 37249
Percutaneous Transluminal Coronary Angioplasty

Pereyra Procedure 51845, 57289, 58267
Acute Bronchitis
Interventions
Antibiotic Prescribed 4120F-4124F
Acute Otitis Externa/Otitis Media with Effusion
Hearing Testing 3230F
History
Auricular Pain 1116F
Periauricular Pain 1116F
Interventions
Antimicrobial Therapy 4131F, 4132F
Effusion Antihistamines/Decongestants 4133F, 4134F
Systemic Antimicrobials 4131F, 4132F
Systemic Steroids 4135F, 4136F
Topical Therapy 4130F
Membrane Mobility 2035F
Amyotrophic Lateral Sclerosis (ALS)
Cognitive Behavioral Impairment Screening 3755F
Dysarthria Evaluation 3762F, 3763F
Impaired Nutrition Screening 3759F-3761F
Pulmonary Function Testing 3758F
Symptom Evaluation 3756F, 3757F
Interventions
End-of-Life Planning Assistance 4553F
Nutritional Support Offered 4551F
Pharmacotherapy 4540F, 4541F
Respiratory Support Options 4550F
Speech Pathologist Referral 4552F
Patient History
Respiratory Insufficiency 1503F-1505F
Patient Management
Care Planning 0580F
Anesthesiology/Critical Care
Interventions
Active Warming 4250F
Anesthesia 4255F, 4256F
Head of Bed Elevation 4167F
Mechanical Ventilation 4168F, 4169F
Patient Safety
Maximal Sterile Barrier Technique 6030F
Annual Monitoring
Interventions
Angiotensin Converting Enzyme (ACE)/Angiotensin Receptor Blockers (ARB) 4188F, 4210F
Anticonvulsant 4191F, 4230F
Digoxin 4189F, 4220F
Diuretic 4190F, 4221F
Aortic Aneurysm 9001F-9004F
Asthma
Discharge Plan 5250F
History 1005F
Assessment of Tobacco Use or Exposure to Second-hand Smoke 1031F-1033F
Intermittent 1039F
Persistent 1038F
Interventions
Alternative Long-term Control Medication Prescribed 4144F
Inhaled Corticosteroids 4140F
Pharmacologic Therapy 4015F
Impairment Assessment 2015F
Risk Assessment 2016F
Therapeutic, Preventive or Other Interventions
Tobacco Use Cessation
Counseling 4000F, 4004F
Pharmacologic Therapy 4001F, 4004F
Atrial Fibrillation/Flutter
International Normalized Ratio (INR) Measured 3555F
Thromboembolism Risk 3550F-3552F
History
Thromboembolism Risk Assessed 1180F
Interventions
Warfarin Therapy 4300F, 4301F
Back Pain
Imaging Study 3330F, 3331F
History
Back Pain and Function 1130F
Employment Status 1130F
Exercise 1136F, 1137F
Mental Health Assessment 1134F, 1135F
Prior Treatment Response 1130F
Warning Signs 1130F
Interventions
Bed Rest Counseling 4248F
Exercise Regimen 4240F, 4242F
Range of Activity Counseling 4245F
Patient Management
Episode Initial Visit 0525F
Episode Subsequent Visit 0526F
Initial Visit 2040F
Mental Health Documented 2044F
Care for Older Adults
History
Advance Care Plan 1157F, 1158F
Functional Status Assessment 1170F
Medication Review 1111F, 1159F, 1160F
Pain Severity Assessed 1125F, 1126F
Patient Management
Pain Plan of Care 0521F
Carotid Stenosis 9005F-9007F
Chronic Kidney Disease
Blood Pressure, Diastolic 3078F-3080F
Blood Pressure, Systolic 3074F-3079F
Hemoglobin 3279F-3281F
Serum Levels 3278F
Interventions
Erythropoieses-Stimulating Agents (ESA) Therapy 4171F, 4172F
Patient Management
Blood Pressure Management 0513F
Elevated Hemoglobin 0514F
Chronic Obstructive Pulmonary Disease
Functional Expiratory Volume 3040F-3042F
Oxygen Saturation 3035F
Spirometry 3023F, 3025F
History
Dyspnea 1018F, 1019F
Pneumococcus Immunization 1022F
Symptom Assessment 1015F
Tobacco Use 1034F-1036F
Interventions
Angiotensin Converting Enzyme (ACE)/Angiotensin Receptor Blockers (ARB) 4188F, 4210F
Bronchodilator Prescription 4025F
Influenza Immunization 4035F, 4037F
Oxygen Therapy 4030F
Pulmonary Rehabilitation 4033F
Tobacco Use Cessation Intervention
Chronic Wound Care
Interventions
Compression Therapy 4267F, 4268F
Diabetic Foot Care 4305F
Dressings 4265F, 4266F
Pressure Offloading 4269F
Wound Surface Culture 4260F, 4261F
Blood Pressure 2000F
Wound Characteristics 2050F
Community Acquired Bacterial Pneumonia
Chest X ray 3006F
History
Co-Morbid Conditions 1026F
Influenza Immunization 1030F
Pneumonia Assessment 0012F
Tobacco Use 1000F, 1034F-1036F
Interventions
Antibiotic Prescription 4045F
Counseling 4000F
Patient Safety
Level of Care Rationale 6005F
Hydration Status 2018F
Mental Status 2014F
Vital Signs 2010F
Composite Codes
Community-acquired Bacterial Pneumonia Assessment 0012F
Heart Failure Assessment 0001F
Intraocular Lens (IOL) Placement Assessment 0014F
Melanoma Follow-up 0015F
Osteoarthritis Assessment 0005F
Coronary Artery Bypass Graft
Interventions
Mammary Artery Graft 4110F, 4115F
Coronary Artery Disease
Anti-Hypertensive Agents 4145F
Antiplatelet Therapy 4011F
Aspirin or Clopidogrel 4086F
Beta-Blocker Therapy 4008F
Cardiac Rehabilitation Program 4500F, 4510F
Counseling 4000F
Statin Therapy 4013F
Tobacco Use Cessation
Left Ventricular Ejection Fraction 3021F, 3022F
Lipid Panel 3011F, 3048F-3050F
History
Angina Assessed by Activity 1002F, 1010F
Angina Occurrence 1011F, 1012F
Qualifying Cardiac Event 1460F, 1461F
Smokeless Tobacco Use 1035F
Tobacco Non-Use 1036F
Tobacco Smoker 1034F
Tobacco Use 1000F
Interventions
Angiotensin Converting Enzyme (ACE)/Angiotensin Receptor Blockers (ARB) 4010F
Patient Management
Anginal Symptoms Plan of Care 0557F
Lipid Control Plan of Care 0556F
Dementia
Depression Screening 3725F
History
Advance Care Plan 1123F
Cognition Assessment 1494F
Functional Status Assessment 1175F
Neuropsychiatric Symptoms Assessment 1181F-1183F
Severity Classification 1490F-1493F
Interventions
Caregiver Education and Support 4322F
Counseling on Symptoms, End of Life Decisions 4350F
Neuropsychiatric Intervention 4525F, 4526F
Patient Safety
Safety Counseling 6101F, 6102F, 6110F
Diabetes
Hemoglobin
A1c 3046F
Lipids 3048F-3050F
Macroalbuminuria 3060F-3062F
Nephropathy Treatment 3066F
Retinopathy Risk 3072F
Urine Protein 3060F-3062F
Distal Symmetric Polyneuropathy (DSP) 3751F-3754F
Electrodiagnostic Studies 3751F, 3752F
Screening Test 3754F
Symptom and Signs Present 3753F
History
Tobacco Use 1034F-1036F
Interventions
Pharmacologic 4001F
Dilated Retinal Exam 2022F, 2023F
Foot Examination 2028F
Stereoscopic Retinal Photos 2024F-2026F, 2033F
Distal Symmetric Polyneuropathy (DSP)
Diagnostic Screening Processes or Results 3016F, 3751F-3754F
Patient History 1119F, 1501F, 1502F
Patient Safety 6080F
Emergency Medicine
Electrocardiogram 3120F
Interventions
Antibiotic 4045F
Aspirin at Arrival 4084F
Mental Status 2014F
Vital Signs 2010F
End Stage Renal Disease
Hemoglobin Level 3279F-3281F
Interventions
Arteriovenous (AV) Fistula Referral 4051F
Hemodialysis 4052F-4054F
Peritoneal Dialysis 4055F
Patient Management
Anemia Plan of Care 0516F
Hemodialysis Plan of Care 0505F
Peritoneal Dialysis Plan of Care 0507F
Endoscopy and Polyp Surveillance
Colonoscopy Intervals 0528F, 0529F
Epilepsy
Electroencephalogram (EEG) 3650F
MRI/CT Scan 3324F
Follow-Up or Other Outcomes
Surgical Therapy Considered 5200F
History
Etiology Reviewed and Documented 1205F
Seizure Type and Frequency Documented 1200F
Interventions
Childbearing Counseling 4340F
Safety Counseling 4330F
Patient Safety
Anti-Epileptic Drug (AED) Side Effects Counseling 6070F
Eye Care
Intraocular Pressure (IOP) 3284F, 3285F
Presurgical Calculations 3073F, 3325F
Interventions
Age Related Eye Disease Study (AREDS) Formulation 4177F
Glaucoma Counseling 4174F
Visual Acuity 4175F
Patient Management
Glaucoma Plan of Care 0517F
Dilated Fundus 2020F
Gastroesophageal Reflux Disease (GERD)
Barium Swallow 3140F-3142F, 3150F, 3200F
Barrett’s Esophagus Biopsy 3140F-3142F, 3150F, 3200F
Upper Endoscopy 3130F, 3132F
History
Alarm Symptoms 1070F, 1071F
Assessment of Therapy at 12 months 1118F
Interventions
Histamine H2 Receptor Antagonist (H2RA) 4185F, 4186F
Proton Pump Inhibitor (PPI) 4185F, 4186F
Geriatrics
Falls Risk 3288F
History
Medication Reconciliation 1111F
Patient Discharge 1110F
Urinary Incontinence 1090F, 1091F
Patient Management
Falls Plan 0518F
Urinary Incontinence Plan 0509F
Fall Screening 1100F, 1101F
Heart Failure
Composite Measures
Heart Failure Assessment 0001F
Activity Level Evaluation 3115F, 3119F
Clinical Symptoms Evaluation 3115F, 3119F
Disease-specific Structured Assessment Tool Completed 3117F
Left Ventricular Ejection Fraction 3019F, 3021F, 3022F, 3055F, 3056F
New York Heart Association (NYHA) Class Documented 3118F
History
Activity Level 1003F
Status of Symptoms 1450F, 1451F
Symptoms of Volume Overload 1004F
Interventions
Angiotensin Converting Enzyme (ACE)/Angiotensin Receptor Blockers (ARB) 4010F, 4480F,
4481F
Beta-Blocker Therapy 4008F
Implantable Defibrillator Counseling 4470F
Patient Education 4003F, 4450F
Warfarin Therapy 4012F
Patient Management
Symptom Management Plan of Care 0555F
Clinical Signs of Volume Overload 2002F
Weight 2001F
Hematology
Baseline Flow Cytometry Studies 3170F
Bone Marrow 3155F
Iron Stores 3160F
Interventions
Erythropoietin Therapy 4090F, 4095F
Multiple Myeloma: Treatment with Bisphosphonates 4100F
Hepatitis C
Genotype Testing 3266F
Hepatitis A Immunity 3215F
Hepatitis B Immunity 3216F
RNA Testing 3218F, 3220F, 3265F
History
Initial Evaluation 1119F
Subsequent Evaluation 1121F
Interventions
Antiviral Therapy 4150F, 4151F
Education, Alcohol 4158F
Education, Contraception 4159F
Hepatitis A Vaccination 4148F, 4155F
Hepatitis B Vaccination 4149F, 4157F
Peginterferon and Ribavirin Therapy 4153F
RNA Testing 4150F, 4151F
HIV/AIDS
CD4+ Cell Count 3492F-3500F
Chlamydia Screening 3511F
Gonorrhea Screening 3511F
Hepatitis B Screening 3216F, 3513F
Hepatitis C Screening 3514F, 3515F
History of AIDS-defining Condition 3490F
Infants of Undetermined HIV Status 3491F
Nadir CD4+ Cell Count 3492F, 3493F
RNA Viral Load 3502F, 3503F
Syphilis Screening 3512F
Tuberculosis Screening 3510F
Interventions
Antiretroviral Therapy 4276F
Antiviral Therapy 4270F, 4271F
High Risk Sexual Behavior Screening 4293F
Injection Drug Use Screening 4290F
Pneumococcal Immunization 4040F
Pneumocystis Jiroveci Pneumonia Prophylaxis 4279F, 4280F
Patient Management
RNA Control Plan of Care 0575F
Hydration 2030F, 2031F
Hypertension
Plan of Care 3074F, 3075F, 3077F-3080F
Interventions
Anti-Hypertensive Agents 4145F
Hypertension Plan of Care 4050F
Inflammatory Bowel Disease
Clostridium Difficile Testing 3520F
Corticosteroid Dose Monitoring 3750F
Hepatitis B Virus Status Assessed 3517F
X-ray Absorptiometry (DXA) 3095F, 3096F
History
Assessment of Type, Location, Activity 1052F
Interventions
Corticosteroid Sparing Therapy 4142F
Venous Thromboembolism (VTE) Prophylaxis 4069F
Patient Safety
First Course of Anti-TNF (Tumor Necrosis Factor) Therapy Not Received 6150F
Lung Cancer/Esophageal Cancer
Pre-Surgery Performance Status Review 3328F
Pulmonary Function Test 3038F
Tumor, Node and Metastases (TNM) Staging Documented 3323F
Major Depressive Disorder
Depression 3351F-3354F
Severity Classification 3088F-3093F
Suicide Risk 3085F, 3092F
History
Diagnostic Status 1040F
Interventions
Electroconvulsive Therapy 4066F, 4067F
Psychotherapy 4060F-4062F
Psychotropic Medication 4063F-4065F
Patient Management
Plan of Follow-up Care Documented 0545F
Clinical Interview 2060F
Melanoma
Cancer Stage 3321F, 3322F
Imaging Studies 3319F, 3320F
History
Moles 1050F
Outcomes
Counseling 5005F
Scheduled Patient Follow Up 7010F
Treatment Plan 5050F
Skin Exam 2029F
Nuclear Medicine
Bone Scintigraphy Study Report 3570F
Fracture Risk Assessment 3572F, 3573F
Fracture Risk Conveyed to Referring Physician 5100F
Oncology
Cancer Stage 3370F-3390F
Estrogen Receptor 3315F, 3316F
Malignancy Report 3317F, 3318F
Progesterone Receptor 3315F, 3316F
Interventions
Adjuvant Chemotherapy for Colon Cancer 4180F
Aromatase Inhibitor (AI) 4179F
Tamoxifen Inhibitor 4179F
Outcomes
Oncological Treatment Summary Report 5020F
Patient Management
Chemotherapy Regimen 0519F
Pain Plan of Care 0521F
Radiation Dose Limits 0520F
Pain Level 1125F, 1126F
Osteoarthritis
History
Anti-inflammatory Risk 1008F
Assessment 0005F
Symptom and Functional 1006F
OTC Medication Use 1007F
Interventions
Anti-inflammatory/Analgesic 4016F
Gastrointestinal Prophylaxis 4017F
Therapeutic Exercise 4018F
Therapy 4016F
Involved Joint 2004F
Osteoporosis
Screening 3095F, 3096F
Interventions
Counseling 4019F
Pharmacologic 4005F
Outcomes
Care Coordination 5015F
Palliative/End of Life Care
Dyspnea Screening 3450F-3452F
History
Disease Prognosis 1152F, 1153F
Risk of Death Assessment 1150F, 1151F
Patient Management
Dyspnea Plan of Care 0535F
Parkinson Disease
Cognitive Impairment/Dysfunction Assessed 3720F
Psychiatric Disorders/Disturbances Assessed 3700F
Interventions
Autonomic Dysfunction Symptoms Queried with Patient 4326F
Medication-related Motor Complications 4324F
Rehabilitation Options Discussed with Patient 4400F
Sleep Disturbances Queried with Patient 4328F
Treatment Options Reviewed with Patient 4325F
Patient History
Diagnosis Reviewed 1400F
Patient Safety
Falls Incidence Queried with Patient 6080F
Stage-Specific Safety Counseling 6090F
Pathology
Cancer Resection (Colon/Breast) 3260F
Esophageal Biopsy Report for Dysplasia 3126F
Gleason Score Pathology Report 3267F
Histologic Grade 3260F
Immunohistochemistry (IHC) Evaluation of HER2 3394F, 3395F
Margin Status Pathology Report 3267F
pN Category Report 3260F, 3267F
pT Category Report 3260F, 3267F
Specimen Site Other than Primary Tumor Site 3250F
Patient Management
Cytopathology Report 0550F, 0551F
Timeout Verification 6100F
Pediatric Acute Gastroenteritis
Interventions
Education 4058F
Oral Rehydration 4056F
Hydration Status 2030F, 2031F
Oral Rehydration 2030F, 2031F
Weight Measurement 2001F
Pediatric End Stage Renal Disease
Interventions
Patient Management
Hemodialysis Plan of Care 0505F
Pediatric Pharyngitis
Strep Test as Appropriate 3210F
Interventions
Antibiotic 4120F, 4124F
Perioperative Care 2
Interventions
Antibiotic Prophylaxis
Discontinuation 4042F, 4043F, 4046F, 4049F
Selection 4041F
Timing 4047F, 4048F
Aspirin Prophylaxis 4563F
Coronary Artery Stent Status Confirmed 4561F, 4562F
Body Temperature Recorded 4559F, 4560F
Inhalational Anesthetic 4554F, 4555F
Postoperative Nausea and Emesis
Administration of Anti-Emetic 4558F
Assessment 4556F, 4557F
Venous Thromboembolism 4044F
Patient Management
Transfer of Care 0581F-0584F
Prenatal Care
ABO and Rh Typing 3293F
D RH Status 3290F, 3291F
Interventions
Anti-D Immune Globulin Received 4178F
Prenatal-Postpartum Care
Anti-D Immune Globulin Status 3290F, 3291F
HIV 3292F
Interventions
Anti-D Immune Globulin 4178F
Patient Management 0500F-0503F
Preventive Care and Screening
Alcohol Misuse 3016F
Body Mass Index (BMI) Documented 3008F
Cervical Cancer Screening 3015F
Colorectal Screening 3017F
Screening Mammography 3014F
History
Tobacco Use 1000F, 1034F-1036F
Interventions
Pneumococcal Vaccination 4040F
Prostate Cancer
Bone Scan 3269F, 3270F
Gleason Score 3268F
Primary Tumor Stage 3268F
Prostate-Specific Antigen (PSA) 3268F
Risk of Recurrence 3271F-3274F
Interventions
3D Conformal Radiotherapy 4165F
Counseling on Treatment Options 4163F
External Beam Radiotherapy 4200F, 4201F
Hormonal Therapy Adjuvant 4164F
Intensity Modulated Radiation Therapy 4165F
Radiology
Mammogram Assessment Documented 3340F-3345F, 3350F
Outcomes
Diagnostic Mammogram 5062F
Patient Safety
Controlled Dosage 6040F
Fluoroscopic Radiation Exposure 6045F
Structural Measures
Mammogram Assessment Categories 7020F
Mammogram Reminder 7025F
Rheumatoid Arthritis
Post-therapy TB Screening 3455F
Rheumatoid Arthritis Disease Activity Assessment 3470F-3472F
Rheumatoid Arthritis Prognosis Assessment 3475F, 3476F
Interventions
Anti-Rheumatic Drug Therapy 4187F, 4195F, 4196F
Glucocorticoid Therapy 4192F-4194F
Screening Colonoscopy Adenoma Detection Rate
Adenoma/Neoplasm Detection 3775F, 3776F
Stroke and Stroke Rehabilitation
Carotid Imaging 3100F
CT/MRI Assessment 3111F, 3112F
Lesion Screening 3110F-3112F
History
Anticoagulant Therapy 1060F, 1061F
Tissue Plasminogen 1065F, 1066F
Interventions
Anticoagulant Therapy 4075F
Antiplatelet Therapy 4073F
Rehabilitation Services 4079F
Thrombosis Prophylaxis 4070F
Tissue Plasminogen 4077F
Patient Safety
Dysphagia Screening 6010F
NPO Order 6020F
Swallowing Eligibility 6015F
Substance Abuse Disorders
Interventions
Alcohol Dependency Treatment Options 4320F
Opioid Addiction Treatment Options 4306F
Upper Respiratory Infection in Children
Interventions
Antibiotic Prescribed 4120F-4124F
Performance Test
Cognitive 96125
Physical 97750
Perfusion
for Esophageal Motility Study 91013
Imaging
Brain
CT Scan 0042T
PET Scan 78609
Myocardial 78451-78454
PET Scan 78430-78433, 78491, 78492
Pulmonary 78580, 78582, 78597, 78598
Test
Esophageal Acid 91030
Therapeutic
Hemoperfusion, Dialysis 90997
Vestibuloactive Drugs 69801
Perfusion, Intracranial Arterial

Thrombolysis 61624
Perfusion Pump
See Infusion Pump
Pericardectomy 33030, 33031

Pericardial Cyst
Excision 32661
Resection 33050
Pericardial Sac
Drainage 32659
Thoracoscopy
Biopsy 32604
Diagnostic 32601
Removal
Clot 32658
Foreign Body 32658
Pericardial Window
Creation
for Drainage 32659, 33025
Pericardiectomy
Complete 33030, 33031
Subtotal 33030, 33031
Pericardiocentesis 33016
Pericardiotomy
Removal
Clot 33020
Foreign Body 33020
Pericardium
Biopsy
Endoscopic 32604
Cyst
Excision 32661
Resection 33050
Diagnostic Thoracoscopy 32601
Drainage
Insertion of Indwelling Catheter 33017-33019
Window or Partial Resection 32659, 33025
Excision 33030, 33031
Window, for Drainage 32659, 33025
Incision
Removal
Clot 33020
Foreign Body 33020
Mass
Excision 32661
Removal
Endoscopic
Clot 32658
Foreign Body 32658
Tumor
Excision 32661
Resection 33050
Peridural Anesthesia
Infusion 62324-62327
Peridural Injection
Perineal Prostatectomy
Partial 55801
Radical 55810, 55812, 55815
Perineoplasty 56810
Perineorrhaphy
Repair
Rectocele 57250
Perineum
Abscess
Anogenital Examination
with Magnification and Image Recording 99170
Biopsy
Lesion 56605, 56606
Colostomy 50810
Debridement
Infected 11004, 11006
Removal
Prosthesis 53442
Repair 56810
Perionychia
See Paronychia
Periorbital Region
Reconstruction
Repair, Osteotomy 21260-21263
Treatment
Orbital Floor Blowout Fracture 21386, 21390, 21395
Peripheral Artery Disease (PAD) Rehabilitation 93668

Peripheral Nerve
Repair/Suture
Major 64856, 64857, 64859
Peripherally Inserted Central Catheter (PICC)

Insertion
with Port 36570, 36571
Periprosthetic Capsulectomy
Breast 19371
Peristaltic Pumps
See Infusion Pump
Peritoneal Dialysis 4055F, 90945-90947
Catheter Insertion 49418, 49419, 49421
Peritoneal Free Air

Injection of Air 49400
Peritoneal Lavage 49084
Peritoneoscopy
See Peritoneum, Endoscopy
Peritoneum
Abscess
Percutaneous 49406
Chemotherapy Administration 96446
Drainage
Image Guided Fluid Collection 49406, 49407
Intramedullary Cyst/Syrinx 63173
Lymphocele 49062, 49323
Endoscopy
Biopsy 49321
Diagnostic 49320
Drainage
Lymphocele 49323
Insertion
Catheter 49324
Revision
Cannula/Catheter 49326
Exchange
Drainage Catheter 49423
Injection
Air 49400
Contrast 49400
via Catheter 49424
Insertion
Catheter 49418, 49419
for Dialysis 49421
Shunt
Peritoneal-Venous 49425
Subarachnoid/Subdural-Peritoneal 62192, 63740, 63741
Ventriculo-Peritoneal 62223
Lavage 49084
Lesion
Excision
Laparoscopic 58662
Fulguration
Laparoscopic 58662
Ligation
Shunt 49428
Removal
Catheter 49422
Foreign Body 49402
Shunt 49429
Shunt, Peritoneal-Venous
Insertion 49425
Ligation 49428
Injection, Contrast 49427
Removal 49429
Revision 49426
Tumor
Laparoscopic 49329
Venous Shunt
Injection 49427
X ray 74190
Injection
Air/Contrast 49400
Persistent, Omphalomesenteric Duct

Persistent Truncus Arteriosus
Repair 33786
Personal Care
Training 97535, 98960-98962, 99509
Pessary
Insertion 57160
Pesticides
PET
See Positron Emission Tomography (PET)
Petrous Temporal
Excision
Apex 69530
Peyronie Disease
Excision
Injection 54200
Surgical Exposure 54205
pH
Blood Gases 82800, 82803
Exhaled Breath Condensate 83987
Gastric Acid 82930
Other Fluid 83986
Urine 81000-81003, 83986
Phacoemulsification
Removal
Extracapsular Cataract 66982, 66984, 66988
Secondary Membranous Cataract 66850
Phagocytosis
White Blood Cells 86344
Phalangectomy
Toe 28150
Partial 28160
Phalanges (Foot)
See Toe
Phalanges (Hand)
See Finger
Phalanx, Finger
See Finger
Phalanx, Great Toe
See Great Toe
Pharmaceutic Preparations
See Drug
Pharyngeal Tonsil
See Adenoids
Pharyngectomy
Limited 42890
Pharyngolaryngectomy 31390-31395
Pharyngoplasty 42950
Pharyngorrhaphy
Pharynx, Suture 42900
Pharyngostomy 42955
Pharyngotomy 42955
Pharyngotympanic Tube
See Eustachian Tube
Pharynx
See also Nasopharynx; Throat
Abscess
Biopsy 42800-42806
Cineradiography 70371, 74230
Creation
Stoma 42955
Cyst, Brachial Cleft
Excision 42815
Excision
with Larynx 31390-31395
Partial 42890
Fistulization
External for Feeding 42955
Hemorrhage Control 42960-42962
Lesion
Destruction 42808
Excision 42808
with Palate 42145
Removal
Foreign Body 42809
Repair
with Esophagus 42953
Suture
Wound 42900
Video Study 70371, 74230
X ray 70370, 74210
Phencyclidine 80305-80307, 83992

Phenobarbital 80345
Phenothiazine 80342-80344
Phenotype Analysis
Alpha-1-antitrypsin 82104
by Genotypic Bioinformatics 87900
by Nucleic Acid 87901-87904, 87906
Infectious Agent
HIV-1 Drug Resistance 87903, 87904, 87906
Phenotype Prediction
by Genetic Database
HIV-1 Drug Susceptibility 87900
Phenylalanine 84030
Phenylalanine-Tyrosine Ratio 84030
Phenylketones 84035
Phenylketonuria
Phenylalanine 84030
Phenytoin
Assay 80185, 80186
Pheochromocytoma 80424
Pheresis
Apheresis 0342T, 36511-36516
Phlebectasia
See Varicose Vein
Phlebectomy
Varicose Veins 37765, 37766
Phlebographies
See Venography
Phleborrhaphy
See Suture, Vein
Phlebotomy
Therapeutic 99195
Phoria
See Strabismus
Phosphatase
Alkaline 84075, 84080
Blood 84078
Phosphatase Acid 84060
Blood 84066
Phosphate, Pyridoxal 84207

Phosphatidyl Glycerol 84081
Phosphatidylcholine Cholinephosphohydrolase
See Tissue, Typing
Phosphocreatine Phosphotransferase, ADP
Creatine Kinase (CPK) 82550, 82552-82554
Phosphogluconate-6
Dehydrogenase 84085
Phosphoglycerides, Glycerol 84081

Phosphohydrolases 84075, 84078, 84080
Phosphokinase, Creatine
Creatine Kinase (CPK) 82550, 82552
Phospholipase C
See Tissue, Typing
Phospholipid, Neutralization 85597, 85598
Phospholipid Antibody 86147
Phosphorus 84100
Urine 84105
Phosphotransferase, ADP Phosphocreatine

Creatine Kinase (CPK) 82550, 82552
Photo Patch
Allergy Test 95052
Photochemotherapies, Extracorporeal
Photopheresis 36522
See also Photodynamic Therapy
Photocoagulation
Endolaser Panretinal
Vitrectomy 67040
Focal Endolaser
Vitrectomy 67040
Iridoplasty 66762
Lesion
Choroid 67220
Cornea 65450
Retina 67210, 67227, 67228
Retinal Detachment
Prophylaxis 67145
Repair 67105, 67107
Treatment
Retinopathy 67228, 67229
Preterm Infant, at Birth 67229
for Lesion 67221, 67225, 96567, 96573, 96574
for Tissue Ablation 96570, 96571
Photography
Fundus 92250
Ocular 92285
Skin
Monitoring 96904
Photography, Ocular 92285
Photon Beam Therapy
See Radiation Therapy, Treatment Delivery
Photopheresis
Blood 36522
Photoradiation Therapies
Actinotherapy 96900
Photosensitivity Testing 95056
Phototherapies
Actinotherapy 96900
Phototherapy, Ultraviolet
Actinotherapy 96900
Phrenic Nerve
Anastomosis 61711
Avulsion 64746
Incision 64746
Neurostimulator System for Sleep Apnea
Device Evaluation 0434T-0436T
Removal 0428T-0430T
Replacement 0424T-0427T, 0431T
Transection 64746
Physical Medicine/Therapy/Occupational Therapy

Activities of Daily Living 97535, 99509
Aquatic Therapy
with Exercises 97113
Athletic Training
Orthotic/Prosthetic 97763
Re-Evaluation 97172
Cognitive Skills Development 97129, 97130
Community/Work Reintegration 97537
Evaluation
Athletic Training 97169-97171
Re-evaluation 97172
Occupational Therapy 97165-97167
Re-evaluation 97168
Physical Therapy 97161-97163
Re-evaluation 97164
Kinetic Therapy 97530
Modalities
Contrast Baths 97034
Diathermy Treatment 97024
Unattended 97014
Hot or Cold Pack 97010
Hydrotherapy (Hubbard Tank) 97036
Infrared Light Treatment 97026
Iontophoresis 97033
Paraffin Bath 97018
Traction 97012
Ultrasound 97035
Ultraviolet Light 97028
Unlisted Modality 97039
Vasopneumatic Device 97016
Whirlpool Therapy 97022
Orthotics Training 97760, 97763
Osteopathic Manipulation 98925-98929
Procedures
Aquatic Therapy 97113
Direct 97032-97039
Gait Training 97116
Group Therapeutic 97150
Massage Therapy 97124
Physical Performance Test 97750
Supervised 97010-97028
Therapeutic Exercises 97110
Traction Therapy 97140
Work Hardening 97545, 97546
Prosthetic Training 97761
Self-care Training 97535
Sensory Integration 97533
Therapeutic Activities
One-on-one Patient Contact 97530
Wheelchair Management 97542
Work Reintegration 97537
Physical Therapy
Re-evaluation 97164
Therapeutic Modalities
Contrast Baths 97034
Diathermy Treatment 97024
Unattended 97014
Hot or Cold Pack 97010
Hydrotherapy (Hubbard Tank) 97036
Infrared Light Treatment 97026
Iontophoresis 97033
Paraffin Bath 97018
Traction 97012
Ultrasound 97035
Ultraviolet Light 97028
Unlisted Modality 97039
Vasopneumatic Device 97016
Whirlpool Therapy 97022
Therapeutic Procedures
Aquatic Therapy 97113
Direct 97032-97039
Gait Training 97116
Group Therapeutic 97150
Massage Therapy 97124
Physical Performance Test 97750
Supervised 97010-97028
Therapeutic Exercises 97110
Traction Therapy 97140
Work Hardening 97545, 97546
Physician Services
Care Management
Behavioral Health Conditions 99484
Psychiatric Collaborative Care 99492-99494
Care Plan Oversight
Domiciliary Facility 99339, 99340
Home Health Agency 99374, 99375
Home or Rest Home 99339, 99340
Hospice 99377, 99378
Care Planning
Cognitive Impairment 99483
Case Management Services 99366-99368
Consultation, Interprofessional
Electronic Health Record Assessment and Report 99446-99449, 99451, 99452
Telephone/Internet Assessment and Report 99446-99449, 99451, 99452
Direction, Advanced Life Support 99288
Online 99421-99423
Prolonged
with Direct Patient Contact
Inpatient 99356, 99357
Outpatient/Office 99354, 99355, 99417
without Direct Patient Contact 99358, 99359
Standby 99360
Supervision, Care Plan Oversight 99339, 99340, 99374-99380
Team Conference 99367
Telephone 99441-99443
PICC Line
Insertion
with Port 36570, 36571
Piercing of Ear Lobe 69090
Piles
See Hemorrhoids
Pilonidal Cyst
Pin
See also Wire
Application, External Fixation System
Insertion
with Skeletal Traction 20650
Prophylactic Pinning
Femur 27187
Humerus 24498
Shoulder 23490, 23491
Removal 20650, 20670, 20680
Retention, Palatal Prosthesis 42281
Pinch Graft 15050
Pinna
Pinworms
Examination 87172
Pirogoff Procedure 27888

Pituitary Epidermoid Tumor
Craniopharyngioma, Excision 61545
Pituitary Gland
Tumor
Excision 61546-61548, 62165
Pituitary Growth Hormone
See Growth Hormone
Pituitary Lactogenic Hormone

Pituitectomy
Pituitary Gland, Excision 61546, 61548
PKU
Phenylalanine 84030
PLA
See Proprietary Laboratory Analyses (PLAs)
Placement
Adjustable Gastric Restrictive Device 43770
Artificial Chordae Tendineae 0543T
Balloon Continence Device 0548T, 0549T
Biodegradable Material
Peri-prostatic 55874
Breast Localization Device
Imaging Guided
with Biopsy 19081-19086
without Biopsy 19281-19288
Catheter
Aneurysm Sac
See Aneurysm Repair
Breast
for Interstitial Radioelement Application 19296-19298, 20555, 41019
Bronchus
Cardiac
Head
Kidney
Nephrostomy 50432
Neck
Pelvic Organs
Prostate 55875
Renal Artery
Selective 36251, 36252
Superselective 36253, 36254
Ureter via Kidney 50695
Cecostomy Tube 44300, 49442
Dosimeter
Prostate 55876
Drainage
Pancreas 48001
Drug-Eluting Ocular Insert
Eyelid 0444T, 0445T
Endoscopic Access
Biliary Tract 47541
Endovascular Prosthesis
Aorta 33883-33886, 34709-34711
Iliac Artery 34709-34711
Enterostomy Tube 44300
Esophageal Sphincter Augmentation Device 43284
Fiducial Markers
Bronchus 31626
Prostate 55876
Gastrostomy Tube 43246, 49440
Guidance
Catheter
Abscess 75989
Specimen 75989
Prosthesis
Thoracic Aorta 75958, 75959
Implant
Vertebra
Intrafacet 0219T-0222T
Interstitial Device
Abdomen 49411, 49412
Lungs 32553
Omentum 49411, 49412
Pelvis 49411, 49412
Peritoneum 49411, 49412
Pleura 32553
Prostate 55876
Retroperitoneum 49411, 49412
Jejunostomy Tube
Endoscopic 44372
Percutaneous 49441
Lesion Localization Device
Breast
Imaging Guided 19081-19086, 19281-19288
Nasogastric Tube 43752
Needle
Bone 36680
Interstitial Radioelement Application
Genitalia 55920
Head 41019
Muscle 20555
Neck 41019
Pelvic Organs 55920
Soft Tissue 20555
Prostate 55875
Orogastric Tube 43752
Osteopromotive Material 20930
Radiation Delivery Device
Intracoronary Artery 92974
Radiation Therapy Applicator
Breast 19294
Seton
Anal 46020
Stent
Biliary 47538-47540
Bronchial 31636, 31637
Cardiac 33621
Colonic 44402, 45327, 45347, 45389
Intravascular
Coronary 92928, 92929
Intracranial 61635
Tracheal 31631
for Transcatheter Intracardiac Shunt (TIS) 33745, 33746
Ureteral 50947
Subconjunctival Retinal Prosthesis 0100T
Synthetic Device
Vertebra 0220T-0222T
Placenta
Delivery 59414
Placenta Alpha Microglobulin-1 84112
Placental Lactogen
Placental Villi
See Chorionic Villus
Plagiocephaly 21175
Planing
Nose
Skin 30120
Plantar Common Digital Nerve

Destruction
Neurolytic 64632
Injection
Anesthetic Agent 64455
Plantar Digital Nerve
Decompression 64726
Plantar Pressure Measurements

Dynamic 96001, 96004
Plasma
Exchange 36514-36516
Frozen Preparation 86927
Injection 0232T
Volume 78110, 78111
Plasma Prekallikrein
Plasma Protein-A, Pregnancy-Associated (PAPP-A) 84163
Plasma Test
Volume Determination 78110, 78111
Plasma Thromboplastin
Antecedent 85270
Component 85250
Plasmin 85400
Plasmin Antiactivator

Plasmodium
Antibody 86750
Plastic Repair of Mouth

Laceration 40830, 40831, 41250, 41252
Plate, Bone
Mandible 21244
Platelet Cofactor I
See Clotting Factor
Platelet
Aggregation 85576
Antibody 86022, 86023
Assay 85055
Blood 85025, 85027
Count 85032, 85049
Human Platelet Antigen
Genotyping 81105-81112
Platelet Test
Survival Test 78191
Platysmal Flap 15825
PLC (Primed Lymphocyte Culture) 86821
Pleoptic Training 92065
Plethysmography
Extremities 93922, 93923
Penis 54240
Pulmonary 94726
Pleura
Biopsy 32098, 32400, 32609
Decortication 32320
Empyema
Excision 32540
Thoracoscopic 32656
Fibrinolysis
Agent 32561, 32562
Foreign Body
Removal 32150, 32151
Insertion
Catheter 32550
Tube 32551
Needle Biopsy 32400
Placement
Pleurodesis
by Agent 32560
Thoracoscopic 32650
Removal
Catheter 32552
Foreign Body 32653
Repair 32215
Scarification 32215
Thoracoscopy
Biopsy 32609
Exploration 32601
Pleurodesis 32650
Removal
Foreign Body 32653
Biopsy 32098
Excision 32656
Exploration 32100
Lysis 32124
Removal
Cyst 32140
Tumor
Cryoablation 32994
Pleural Cavity
Ablation
Aspiration 32554
Chemotherapy Administration 96440
Incision
Empyema 32035, 32036
Instillation of Agent for Fibrinolysis 32561, 32562
Instillation of Agent for Pleurodesis 32560
Puncture and Drainage 32554-32557
Pleural Endoscopies
See Pleura, Thoracoscopy
Pleural Scarification
for Repeat Pneumothorax 32215
Pleural Tap
Drainage, Indwelling Catheter 32556, 32557
Pleurectomy
Parietal 32310-32320
Thoracotomy
Endoscopic 32656
Pleuritis, Purulent
Thoracostomy for Empyema 32035, 32036
Pleurocentesis
Pleurodesis
Thoracoscopic 32650
Pleurosclerosis
Pleurodesis
Thoracoscopy 32650
Pleurosclerosis, Chemical
Pleurodesis, Instillation of Agent 32560
Plexectomy, Choroid
Excision, Choroid Plexus 61544
Plexus
Brachialis
See Brachial Plexus
Cervicalis
See Cervical Plexus
Choroid
See Choroid Plexus
Coeliacus
See Celiac Plexus
Lumbalis
See Lumbar Plexus
PLGN
Plication, Sphincter, Urinary Bladder
Bladder Neck Repair 51845
Pneumocisternogram
Cisternography
Cerebrospinal Fluid Flow Imaging 78630
Study 70015
Pneumococcal Vaccine
13-valent (PCV13) 90670
23-valent (PPSV23) 90732
Pneumocystis Carinii
Antigen Detection
Pneumogastric Nerve
See Vagus Nerve
Pneumogram
Infant 94772
Pneumolysis
See Pneumonolysis
Completion 32488
Donor 32850, 33930
Sleeve 32442
Thoracoscopic 32671
Pneumonology
See Pulmonology
Pneumonolysis 32940
Intrapleural 32652
Open Intrapleural 32124
Pneumonostomy 32200
Pneumonotomy
See Incision, Lung
Pneumoperitoneum
Pneumothorax
Pleural Scarification for Repeat 32215
Pleurodesis 32560
Therapeutic
Injection Intrapleural Air 32960
Polio
Vaccine 90713
Poliovirus Vaccine 90713
Pollicization
Digit 26550
Polydactylism
See Polydactyly
Polydactyly
Finger
Repair 26587
Toe 28344
Polyp
Ablation
Endoscopic
Anus 46615
Colon 44401, 45388
Esophagus 43229
Rectum 45320, 45346
Upper Gastrointestinal Tract 43270, 43278
Antrochoanal
Removal 31032
Anus
Ablation
Endoscopic 46615
Removal
Colon
Ablation 44401, 45388
Removal 44392, 44394, 45384, 45385
Esophagus
Ablation 43229
Removal 43216, 43217
Excision
Ear 69540
Nose
Extensive 30115
Simple 30110
Urethra 53260
Uterus 58558
Fulguration
Endoscopic
Bladder 52285
Urethra 52285
Urethra 53260
Nose
Excision
Extensive 30115
Simple 30110
Rectum
Ablation
Removal
Endoscopic 45308, 45309, 45315, 45333
Removal
Endoscopic
Anus 46610-46612
Colon 44392, 44394, 45384, 45385
Rectum 45308, 45309, 45315, 45333
Upper Gastrointestinal Tract 43250, 43251
Small Intestine
Ablation
Endoscopic 44369
Removal
Sphenoid Sinus
Removal 31051
Urethra
Excision 53260
Fulguration 53260
Uterus
Excision 58558
Polypectomy
Nose
Extensive 30115
Simple 30110
Urethra 53260
Uterus 58558
Polypeptide, Vasoactive Intestinal 84586
Polysomnography
5 Years and Under 95782, 95783
6 Years or Older 95810, 95811
Any Age 95808
Pomeroy’s Operation
Tubal Ligation 58600, 58605, 58611
Pooling
Cardiac Blood Pool Imaging
First Pass 78481-78483, 78496
Gated Equilibrium 78472, 78473, 78496
SPECT 78494
Popliteal Artery
See Artery, Popliteal
Popliteal Synovial Cyst

Excision 27345
PORP (Partial Ossicular Replacement Prosthesis) 69633, 69637
Porphobilinogen
Urine 84106-84110
Porphyrin Precursors 82135
Porphyrins
Feces 84126
Urine 84119, 84120
Port Image(s) 77417
Portal Vein
Hepatic Portal
Splenoportography 75810
Venography 75885, 75887
Portoenterostomies, Hepatic
Hepaticoenterostomy 47802
Portoenterostomy 47701
Positional Nystagmus Test 92532, 92542
Positive End-Expiratory Pressure (PEEP)
Therapy
Ventilation (CPAP) 94660
Positive-Pressure Breathing, Inspiratory

See Intermittent Positive Pressure Breathing (IPPB)
Positron Emission Tomography (PET)
Brain 78608, 78609
Chest 78811
with Computed Tomography (CT) 78814, 78815
Head/Neck 78811
Heart 78429-78434, 78459, 78491, 78492
Myocardial Imaging
Blood Flow Absolute Quantitation 78434
Metabolic Evaluation Study 78429, 78432, 78433, 78459
Perfusion Study 78430-78433, 78491, 78492
Skull Base to Mid-thigh 78812
Whole Body 78813
Postauricular Fistula
Closure 69700
Postcaval Ureter
Retrocaval Ureterolysis 50725
Postmortem
See Autopsy
Postop Vas Reconstruction
Vasovasorrhaphy 55400
Post-Op Visit 99024

Postoperative Wound Infection
Postpartum Care
Cesarean Delivery 59515
after Attempted Vaginal Delivery 59622
Previous 59610, 59614-59618, 59622
after Previous Cesarean Delivery 59614
Potassium 84132
Urine 84133
Potential, Evoked
See Evoked Potentials
Potts-Smith Procedure 33762

Pouch, Kock
Continent Ileostomy 44316, 50825
Endoscopic Evaluation 44385, 44386
PPP
PRA (Percent Reactive Antibody)
Cytotoxic Screen 86807, 86808
Prealbumin 84134
Prebeta Lipoproteins
See Lipoprotein, Blood
Pregnancy
Abortion
Induced 59855-59857
by Amniocentesis Injection 59850-59852
Septic 59830
Therapeutic
by Hysterectomy 59852
by Saline 59850
Cesarean Delivery 59618-59622
Only 59514
Postpartum Care 59515
Routine Care 59510
Vaginal Birth After 59610-59614
Ectopic
Abdominal 59130
Cervix 59140
Interstitial
Partial Resection Uterus 59136
Total Hysterectomy 59135
Laparoscopy
without Salpingectomy and/or Oophorectomy 59150
Tubal 59121
Imaging
See Obstetrical Care, Diagnostic Imaging
Miscarriage
Surgical Completion
Any Trimester 59812
Molar
Multifetal Reduction 59866
Placenta Delivery 59414
after Cesarean Delivery 59610-59614
Postpartum Care 59430
Total Obstetrical Care 59400, 59610, 59618
Pregnancy Test 84702-84704

Urinalysis 81025
Pregnanediol 84135
Pregnanetriol 84138
Pregnenolone 84140
Prekallikrein
Assay 85292
Prekallikrein, Plasma
Prekallikrein Factor 85292

Premature Closure, Cranial Suture
Prenatal Procedure 59897

Amnioinfusion
Drainage
Fluid 59074
Occlusion
Umbilical Cord 59072
Shunt 59076
Prenatal Testing
Amniocentesis 59000
with Amniotic Fluid Reduction 59001
Amniotic Fluid Proteins
Cervicovaginal Fluid Evaluation 84112
Chorionic Villus Sampling 59015
Congenital Abnormalities
Biochemical Assays 81508-81512
Cordocentesis 59012
Fetal Blood Sample 59030
Fetal Monitoring 59050
Interpretation Only 59051
Non-Stress Test, Fetal 59025, 99500
Oxytocin Stress Test 59020
Placental Alpha Microglobulin-1 (PAMG-1) 84112
Stress Test
Oxytocin 59020
Fetal Biophysical Profile 76818, 76819
Fetal Heart 76825
Preparation
Custom Breast Implant 19396
Custom Prostheses
Recipient Site
Skin Graft 15002-15005
Thawing
Embryo
Cryopreserved 89352
Oocytes
Cryopreserved 89356
Reproductive Tissue
Cryopreserved 89354
Sperm
Cryopreserved 89353
for Transfer
Embryo 89255
for Transplantation
Fecal Microbiota 44705
Heart 33933, 33944
Heart/Lung 33933
Kidney 50323-50329
Liver 47143-47147
Lung 32855, 32856, 33933
Pancreas 48551, 48552
Renal 50323-50329
Stem Cells 38207-38215
Presacral Interbody
Presacral Sympathectomy 58410
Prescription
Contact Lens 92310-92317
Spectacle Lenses 92015
Pressure
Anorectal 91122
Blood
See Blood Pressure
Esophageal Pressure Topography Study 91013, 91299
Measurement 91112
Interstitial Fluid 20950
Intraocular
Measurement 0198T, 0329T, 92100
Monitoring 0329T
Sphincter of Oddi 43263
Ulcer (Decubitus)
Excision
Ischial 15940, 15941, 15944-15946
Sacral 15931, 15933-15937
Trochanteric 15950-15953, 15956, 15958
Venous 93770
Voiding
See Voiding Pressure Studies
Pressure Breathing
Continuous Negative (CNP) 94662
Continuous Positive (CPAP) 94660
Pressure Ulcers (Decubitus Ulcers)
Excision
Ischial 15940, 15941, 15944-15946
Sacral 15931, 15933-15937
Trochanteric 15950-15953, 15956, 15958
Unlisted Pressure Ulcer Excision Procedure 15999
Pretreatment
Red Blood Cell
Antibody Identification 86970-86972
Serum
Antibody Identification 86975-86978
Prevention & Control
See Prophylaxis
Preventive Medicine
Behavior Change Intervention
Group
Diabetes Prevention 0403T
Risk Factor Reduction 99411, 99412
Individual
Substance Abuse Other Than Tobacco 99408, 99409
Tobacco Use Cessation 99406, 99407
Comprehensive
Counseling
Group Counseling 99411, 99412
Individual
Behavior Change 99406-99408
Exercise 4019F
Risk Factor Reduction Intervention 99401-99404
Self-Examination for Moles 5005F
Fluoride Varnish Application 99188
Health and Well-being Coaching 0591T-0593T
Health Risk Assessment 96160, 96161
Priapism
Repair
Fistulization 54435
with Shunt 54420-54430
Primidone
Assay 80188
PRL
Proalbumin
Prealbumin 84134
Probes, DNA
Probes, Nucleic Acid

Procainamide
Assay 80190-80192
Procalcitonin (PCT) 84145

Procedure
See Abdominoplasty
Process
Coracoid
Transfer 23462
Coronoid
Coronoidectomy 21070
Odontoid
Excision 22548
Fracture 22318
Olecranon
Craterization 24147
Diaphysectomy 24147
Excision, Cyst or Tumor 24120, 24125, 24126
Saucerization 24147
Spinous
Wiring 22841
Styloid
Fracture 25650, 25652
Styloidectomy 25230, 25440
Vertebral
Excision 22100-22103, 22110, 22116
Procidentia
Rectum
Proctopexy 45400, 45402, 45540, 45541
Reduction 45900
Procoagulant Activity, Glomerular

See Thromboplastin
Proconvertin 85230
Proctectasia
See Dilation, Rectum
Proctectomy
with Colectomy 44155-44158, 45121
with Colectomy/Ileostomy
Laparoscopic 44212
Open 44155
Partial
Open 45113-45116, 45123
with Pelvic Exenteration 45126
Total 45110-45112, 45119-45121
Open 45110, 45112, 45119, 45120
Proctocele
Rectocele, Repair 45560, 57250
Proctopexy
with Sigmoid Resection 45402
Open 45540, 45541
with Sigmoid Excision 45550
Proctoplasty 45500-45505
Proctorrhaphy
See Rectum, Suture
Proctoscopies
See Anoscopy
Proctosigmoidoscopy
Ablation
Polyp or Lesion 45320
Biopsy 45305
Destruction
Tumor 45320
Diagnostic 45300
Dilation 45303
Exploration 45300
Placement
Stent 45327
Removal
Foreign Body 45307
Polyp 45308-45315
Tumor 45315
Volvulus Repair 45321
Products, Gene
See Protein
Proetz Therapy
Nose 30210
Profibrinolysin
Progenitor Cell
See Stem Cell
Progesterone 84144
Progesterone Receptors 84234
Progestin Receptors 84234
Proinsulin 84206
Pro-Insulin C Peptide 80432, 84681
Projective Test
Psychiatric Evaluation 90885
Prokinogenase

Prolapse
Rectum
Proctopexy 45400, 45402, 45540, 45541
Reduction 45900
Prolapse, Rectal
Proctopexy 45400, 45402, 45540, 45541
Reduction 45900
Prolastin
Prolonged Services
with Direct Patient Contact
Inpatient 99356, 99357
Observation Setting 99356, 99357
Outpatient Setting 99354, 99355
Office or Other Outpatient Visit 99417
Clinical Staff with Physician
without Direct Patient Contact 99358, 99359, 99417
Prophylactic Treatment
Antibiotic 4042F, 4045F, 4046F-4049F
Antimicrobial
Cefazolin or Cefuroxime 4041F, 4043F
Clavicle
Methylmethacrylate 23490
Nailing 23490
Pinning 23490
Plating 23490
Wiring 23490
Deep Vein Thrombosis 4070F
Femoral Neck and Proximal Femur
Nailing 27187
Pinning 27187
Wiring 27187
Femur 27495
Nailing 27495
Pinning 27495
Wiring 27495
Humerus
Methylmethacrylate 23490, 24498
Pinning, Wiring 23491, 24498
NSAID 4017F
Pneumocystis Jiroveci Pneumonia 4279F, 4280F
Radius 25490, 25492
Nailing 25490, 25492
Pinning 25490, 25492
Plating 25490, 25492
Wiring 25490, 25492
Shoulder
Clavicle 23490
Humerus 23491
Tibia 27745
Nailing 27745
Pinning 27745
Plating 27745
Wiring 27745
Ulna 25491, 25492
Nailing 25491, 25492
Pinning 25491, 25492
Plating 25491, 25492
Wiring 25491, 25492
Venous Thromboembolism (VTE) 4044F
Prophylaxis
Anticoagulant Therapy 4075F
Deep Vein Thrombosis (DVT) 4070F
Retina
Detachment
Cryotherapy, Diathermy 67141
Proprietary Laboratory Analyses (PLAs)
Acute Myeloid Leukemia
Myelodysplastic Syndrome 0171U
Myeloproliferative Neoplasms 0171U
Ataxia Telangiectasia Mutated (ATM) mRNA Sequence Analysis 0136U
Autoimmune Disease
Deoxyribonucleic Acid (DNA) Antibody, High Avidity 0039U
Inflammatory Bowel Disease
Gene Expression Profiling 0203U
Systemic Lupus Erythematosus 0062U
Cardiology
Ceramide Quantification 0119U
Heart Transplant 0055U, 0087U
Chemistry
Glycosylated Acute Phase Proteins 0024U
Tenofovir 0025U
Vitamin D, 25 Hydroxy D2 and D3 0038U
Chromosomal Abnormalities
Cytogenomic Constitutional Analysis 0209U
Clostridium Difficile Toxin(s) Antigen Detection 0107U
Drug Assay
Multiple Reaction Monitoring (MRM) 0143U-0150U
Drug Testing
Drug Metabolism 0029U, 0030U
Drug Test, Presumptive 0007U
Interactions 0082U
Opioid-Use Disorder 0078U
Prescription Drug Monitoring 0011U, 0051U, 0054U, 0093U, 0110U
Prescription Drug-to-Drug Interactions 0116U
Fetal Aneuploidy 0168U
Gastroenterology
Barrett’s Esophagus 0108U, 0114U
Gastric Emptying Rate 0106U
Irritable Bowel Syndrome (IBS)
Anti-CdtB and Anti-Vinculin Antibodies 0164U
Cytolethal Distending Toxin B (CdtB) and Vinculin IgG Antibodies 0176U
Gene Analysis
APC (APC regulator of WNT signaling pathway) 0157U
MLH1 (mutL homolog 1) 0158U
MSH2 (mutS homolog 2) 0159U
MSH6 (mutS homolog 6) 0160U
NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) 0169U
PMS2 (PMS1 homolog 2, mismatch repair system component) 0161U
Genome Rapid Sequence Analysis 0094U
Genomic Copy Number Sequence Analysis 0156U
Germline Disorders
COMT (catechol-O-methyltransferase) 0032U
CYP1A2 (cytochrome P450 family 1, subfamily A, member 2) 0031U
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) 0070U-0076U
Exome (Somatic Mutations) 0036U
FLT3 (fms-related tyrosine kinase 3) 0046U
Gene Rearrangement Detection 0012U
HTR2A (5-hydroxytryptamine receptor 2A) 0033U
JAK2 (Janus kinase 2) 0027U
NPM1 (nucleophosmin) 0049U
TPMT (thiopurine S-methyltransferase) 0034U
Gonadotropin, Chorionic (hCG) 0167U
Hematology
ctHb1, ctHb2, ctHbO2, ctHbR, StO2 0061U
Hematolymphoid Neoplasia 0014U
RBC Antigen Typing 0001U, 0084U
RBC Mechanical Fragility Profiling 0123U
Red Cell Antigen Genotyping 0180U-0201U, 0221U, 0222U
Infectious Agent
Human Immunodeficiency Virus
Antiviral Drug Susceptibility Prediction 0219U
Infectious Disease
Agent Detection and Identification 0112U
Aspergillus Species Detection 0109U
Bacteria and Fungi Identification 0141U, 0142U
Bacterial, Strain Typing 0010U
Borrelia burgdorferi, Antibody Detection 0041U-0044U
Fungal Pathogen Identification 0140U
Gastrointestinal Pathogen 0097U
Human Papillomavirus (HPV) 0096U
Microbial Organism Detection 0152U
Organism Identification 0086U
Respiratory Pathogen 0098U-0100U, 0115U
Respiratory Tract Infection 0151U
Pathogen Detection including SARS-CoV-2 0202U
Syphilis, Non-Treponemal Antibody 0065U, 0210U
Treponema pallidum Antibody 0064U
Inflammation
Eosinophilic Esophagitis 0095U
Lipoprotein 0052U
Liver Disease 0166U
Microbiology
Candida Species Panel 0068U
Helicobacter Pylori Detection 0008U
Specimen Identity DNA Analysis 0079U
Nephrology
Chronic Kidney Disease Rapid Kidney Function Decline (RKFD) Probability 0105U
Neurology
Alzheimer Disease
Cell Aggregation 0206U
Quantitative Imaging of Phosphorylated ERK1 and ERK2 0207U
Autism 0063U
Autism Spectrum Disorder (ASD) 0139U, 0170U
Inherited Ataxias
Identification/Categorization of Genetic Variants 0216U, 0217U
Muscular Dystrophy
DMD Gene Sequence Analysis 0218U
Prion Disease 0035U
Oncology
Acute Myelogenous Leukemia 0023U, 0050U, 0056U
B-cell Lymphoma Classification by mRNA Gene Expression Profiling 0120U
BRCA1 and BRCA2
Homologous Recombination Deficiency Pathways 0172U
mRNA Sequence Analysis 0138U
Somatic Mutation Analysis 0172U
Breast Cancer
Breast Ductal Carcinoma In Situ Profiling 0045U
ERBB2 Analysis 0009U
Hereditary Disorders 0102U, 0129U, 0131U
Histologic and Immunohistochemical Features Assessment 0220U
Immunohistochemistry 0067U
PIK3CA Gene Mutation Status 0155U, 0177U
Triple Negative Subtype Identification 0153U
Colon Cancer
Hereditary Disorders 0130U
KRAS and NRAS Gene Analysis 0111U
Colorectal Cancer 0002U, 0069U, 0091U
CRC/Advanced Adenoma Likelihood 0163U
Gynecological Cancer
Hereditary Gene Analysis 0135U
Hematolymphoid Neoplasia 0016U
Hematolymphoidneoplasia 0017U
Hereditary Gene Analysis
Colon Cancer (Lynch Syndrome) 0162U
Gynecological Cancer 0135U
Ovarian Cancer 0103U
Pan Cancer 0134U
Immunoglobulin Paraprotein (M-protein) 0077U
Leukemia
BCR/ABL1 Analysis 0040U
Lung Cancer
Malignancy Probability 0080U, 0092U
Non-Small Cell Lung Neoplasia Treatment 0022U
Medullary Thyroid Carcinoma
Gene Expression Analysis 0208U
Merkel Cell Carcinoma 0058U, 0059U
Non-Small Cell Lung Cancer
Genetic Mutations Analysis 0179U
Ovarian Cancer
Hereditary Gene Analysis 0103U, 0132U
Likelihood Score 0003U
PALB2 mRNA Sequence Analysis 0137U
Pan Tumor
Gene Analysis with Therapy Association 0211U
Prostate Cancer
Hereditary Related Disorders 0133U
Higher-Grade Probability 0053U
Risk Score 0005U, 0021U, 0047U, 0113U
Response to Chemotherapy Drugs 0083U
RNA 0019U
Solid Organ Neoplasm 0037U, 0048U
Solid Tumor
Targeted Oncology Agents 0174U
Thyroid 0018U, 0026U
Thyroid Cancer
Gene Expression Analysis 0204U
Urothelial Cancer
FGFR Gene Alteration Status 0154U
Ophthalmology
Age-Related Macular Degeneration
Risk Associated with Zinc Supplements 0205U
Pain Management 0117U
Peanut Allergy
Clinical Reaction Threshold 0178U
Probability 0165U
Placental Alpha-Micro Globulin-1 (PAMG-1) 0066U
Psychiatry
Anxiety, Depression
Genomic Analysis Panel 0173U, 0175U
Rare Diseases (Constitutional/Heritable Disorders)
Exome and Mitochondrial DNA Sequence Analysis 0214U, 0215U
Genome and Mitochondrial DNA Sequence Analysis 0212U, 0213U
Sickle Cell Disease Microfluidic Flow Adhesion Analysis 0121U, 0122U
Transplantation Medicine
Donor-derived Cell-free DNA 0118U
Kidney Allograft Rejection 0088U
Twin Zygosity 0060U
Prostaglandin 84150
Prostanoids
Prostaglandin 84150
Prostate
Ablation
Cryosurgery 55873
Waterjet 0421T
Abscess
Drainage 52700
Biopsy
Incisional 55705
Needle or Punch 55700, 55706
Stereotactic 55706
Transperineal 55706
Brachytherapy
Needle Insertion 55875
Cancer Performance Measures
See Performance Measures, Prostate Cancer
Coagulation
Laser 52647
Cystourethroscopy
Transurethral Commissurotomy 0619T
Destruction
Cryosurgery 55873
Thermotherapy
Microwave 53850
Radio Frequency 53852, 53854
Enucleation
Laser 52649
Excision
Partial 55801, 55821-55831
Perineal 55801-55815
Radical 55810-55815, 55840-55845
Retropubic 55831-55845
Laparoscopic 55866
Suprapubic 55821
Transurethral 52402, 52601, 52630
Exploration
Exposure 55860
with Nodes 55862-55865
Incision
Exposure 55860-55865
Transurethral 52450
Insertion
Catheter 55875
Needle 55875
Needle Biopsy 55700
Transperineal 55706
Placement
Biodegradable Material
Transperineal 55874
Catheter 55875
Dosimeter 55876
Fiducial Marker 55876
Needle 55875
Resection
Transurethral 52601, 52630
Spectral Analysis, Real-Time 0443T
Thermotherapy
Transurethral 0582T, 53850, 53852, 53854
Urinary System 53899
Vaporization
Laser 52648
Prostate Specific Antigen 84152-84154

Prostatectomy
Electrosurgical 52601
Laparoscopic 55866
Perineal
Partial 55801
Radical 55810-55815
Retropubic
Partial 55831
Radical 55840-55845, 55866
Suprapubic
Partial 55821
Transurethral 52601, 52630
Prostatic Abscess
Transurethral Drainage 52700
Prostatotomy 55720-55725
Prosthesis
Arm
Removal 24160, 24164
Breast
Supply 19396
Button
Bone Graft 20900
Nasal Septum 30220
Voice 31611
Cheekbone
Malar Augmentation 21270
Chin 21120
Cornea 65770
Diaphragm
Complex Repair 39561
Ear
Ossicle Reconstruction 69633, 69637
PORP 69633, 69637
TORP 69633, 69637
Elbow
Removal
Radial Head 24164
Endovascular
Bypass
Composite, with Vein 35681
Endoprosthesis
Abdominal Aortic 34845-34848
Aorto-bifemoral 34832
Aorto-bi-iliac 34831
Brachial 34834
Celiac Artery 34841-34848
Femoral 34812, 34813
Iliac 34709, 34710, 34711, 34820, 34833
Ilio-iliac 34707, 34708
Infrarenal Abdominal Aortic 34709, 34710, 34711, 34845-34848
Infrarenal Aortic 34830, 35697
Mesenteric 34841-34848
Visceral Aortic 34841-34848
Visceral Artery 34841-34848
Thoracic Aorta 33883-33886
Facial
Osteoplasty 21208
Femur 27236
Finger Joint 26531, 26536
Forehead 21138
Head
Impression and Custom Preparation
Heart
Aortic Arch Repair 33852
Aortic Enlargement 33851
Aortic Valve 33361-33365, 33367-33369, 33405
Atrioventricular Valve 33670
Mitral Valve 33426
Repair 0345T, 33418, 33419
Pulmonary Valve 33475, 33477
Shunt 33764
Valve Prosthesis Repair 33496
Ventricular Patch 33548
Hernia
Gastroschisis 49605, 49606
Hiatal 43333, 43335, 43337
Omphalocele 49605, 49606
Ventral 49568, 49652-49657
Hip
Insertion 27125, 27130, 27236
Removal 27090, 27091
Infected
Removal
Intestines 44700
Joint
Humeral 23616, 24361, 24363
Revision 24370, 24371
Lunate 25444
Radial Head 24666
Radius, Distal 25441, 25446
Scaphoid Carpal 25443
Trapezium 25445
Ulnar 24363, 25442
Revision 24370, 24371
Wrist 25446
Knee
Arthroplasty
Removal 27488
Lens
without Cataract Removal 66985
Insertion 66982-66985
Repositioning 66825
Mandible 21125
Nasal Septum
Insertion 30220
Ocular
Intraocular Lens 0308T, 66985
Temporary 92358
Orbital 21179
Orthotic
Training 97761
Ossicle Reconstruction
Chain 69633
Palate 42280, 42281
Penis
Removal 54406, 54415
Repair 54408
Replacement 54410, 54411, 54416, 54417
Perineum
Removal 53442
Retina
Placement
Pulse Generator 0100T
Receiver 0100T
Shoulder
Removal 23334, 23335
Skull Plate
Removal 62142
Replacement 62143
Spectacle
Fitting 92352, 92353
Repair 92371
Speech Aid
Insertion 31611
Spine
Insertion 22853, 22854, 22859
Synthetic 69633, 69637
Arthroplasty 21243
Testis
Tissue Expander, Other than Breast
Insertion 11960
Training 97761
Unlisted Maxillofacial Prosthetic Procedure 21089
Urethral Sphincter
Removal 53446, 53447
Repair 53449
Replacement 53448
Urethral Voiding Valve-Pump
Insertion 0596T
Replacement 0597T
Vagina
Insertion 57267
Removal 57295, 57296, 57426
Revision 57295, 57296, 57426
Voiding
Female Intraurethral Valve-Pump
Insertion 0596T
Replacement 0597T
Wrist
Removal 25250, 25251
Prosthetic Valve, Aortic Valve Replacement 33361-33369, 33405

Protease F
Plasmin 85400
Protein
A, Plasma (PAPP-A) 84163
S
Free 85306
Total 85305
C
Activated (APC) 85307
Activator 85337
Activity 85303
Antigen 85302
Reactive 86140, 86141
Resistance Assay 85307
CA-125 81500, 81503
Analysis, Tissue
Western Blot 88371
Apoliproprotein A1 81503
DIA 81509
Electrophoresis 84165, 84166
Other Fluids 84166
Western Blot 84181, 84182
Glycated 82985
hCG 81508, 81509
HE4 81500
Human Epididymis Protein 4 86305
Myelin Basic 83873
Nuclear Matrix Protein 22 (NMP22) 86386
Osteocalcin 83937
PAPP-A 81508, 81509
Prealbumin 81503, 84134
Serum, Plasma or Whole Blood 84155, 84165
Total 84155-84157
by Refractometry 84160
Transferrin 81503
Urine 84156
Urine 84156
Dipstick 81000
Western Blot 84181, 84182, 88371, 88372
Protein Analysis, Tissue

Western Blot 88371
Protein Blotting
Western Blot 88371
Protein C Activator 85337

Protein C Antigen 85302
Protein C Assay 85303
Protein C Resistance Assay 85307
Protein S
Assay 85306
Total 85305
Prothrombase
Thrombokinase 85260
Prothrombin Time 85610, 85611

Prothrombin 85210
Prothrombinase
See Thromboplastin
Prothrombokinase 85230
Protime
See Prothrombin Time
Proton Treatment Delivery
Complex 77525
Intermediate 77523
Simple 77520-77522
Protoporphyrin 84202, 84203

Protozoa
Antibody 86753
Provitamin A
Vitamin A 84590
Provocation Test
Allergy
Bronchial Challenge Tests 95070
Ingestion Challenge Tests 95076, 95079
Bronchospasm, Evaluation 94070
with Electrogastrography 91133
Ergonovine 93024
Esophageal Balloon Distension Study 91040
Prower Factor 85260
PSA (Prostate Specific Antigen) 84152-84154
Pseudocyst
Esophagus
Drainage 43240
Pancreas
Drainage 48510
Pseudophakia
See Keratoplasty
PSG
See Polysomnography
Psoriasis Treatment
Laser Treatment 96920-96922
Psychiatric Diagnosis
Assessment
Behavior Identification 0362T, 97151, 97152
Brief Emotional/Behavioral 96127
Evaluation 90791
with Medical Services 90792
Evaluation of Records or Reports 90885
Interactive Complexity 90785
Neurobehavioral Status Exam 96116, 96121
Dementia
See Performance Measures, Dementia
Major Depressive Disorder (MDD)
See Performance Measures, Major Depressive Disorder
Psychological Testing 96130-96133, 96136-96139, 96146
Suicide Risk Assessment 3085F
Psychiatric Treatment
See also Adaptive Behavior Treatment
Biofeedback Training 90875, 90876
Consultation with Family 90887
Drug Management 90863
Electroconvulsive Therapy 4066F, 90870
Referral, Documented 4067F
Environmental Intervention 90882
Family 90846-90849, 99510
Group 90853
Hypnotherapy 90880
Narcosynthesis Analysis 90865
Pharmacotherapy
Antidepressant 4063F, 4064F
Antipsychotic 4065F
Drug Management 90863
Psychoanalysis 90845
Psychotherapy
See Psychotherapy
Report Preparation 90889
Suicide Risk Assessment 3085F
Transcranial Magnetic Stimulation (TMS) 90867-90869
Psychoanalysis 90845
Neurobehavioral Status Exam 96116, 96121
Test Administration 96136-96139, 96146
Testing Evaluation 96130-96133
Psychophysiologic Feedback
See Biofeedback Training
Psychotherapy
for Crisis 90839, 90840
Family of Patient 90846, 90847
Group Other Than Multifamily 90853
Individual Patient 90832-90834, 90836-90838
Interactive Complexity 90785
Major Depressive Disorder 4060F-4062F
Multifamily 90849
with Pharmacologic Management 90863
Prolonged Services, Outpatient
with Patient Contact 99354, 99355
Referral, Documented 4062F
PTA (Factor XI) 85270

PTC (Factor IX) 85250
PTCA
Pteroylglutamic Acid
Folic Acid 82746, 82747
Pterygium
Excision 65420
with Graft 65426
Pterygomaxillary Fossa
Incision 31040
Pterygopalatine Ganglion
See Sphenopalatine Ganglion
PTH
Parathormone 83970
Ptosis
See Blepharoptosis; Procidentia
PTT
Partial Thromboplastin Time (PTT) 85730, 85732
Ptyalectasis
Dilation, Salivary Duct 42650, 42660
Pubic Symphysis
Arthrodesis 27282
Cyst
Dislocation/Fracture
Excision
Partial 27070, 27071
Tumor
Pubis
See Pubic Symphysis
Pudendal Nerve
Destruction 64630
Injection
Anesthetic 64430
Neurolytic 64630
Steroid 64430
Puestow Procedure 48548

Pulled Elbow
Pulmonary Artery
Angiography 75741, 75743, 75746
Banding 33690
Application 33620
Removal 33622
Embolism 33910-33916
Monitoring
with Pressure Sensor 33289, 93264
Nerves
Ultrasound Ablation 0632T
Percutaneous Transluminal
Repair 33620, 33690, 33917-33920
Shunt
from Aorta 33755-33762, 33924
Subclavian 33750
from Vena Cava 33766, 33767
Transection 33922
Pulmonary Function Test
Pulmonary Hemorrhage
Lung Hemorrhage, Control 32110
Pulmonary Perfusion Imaging 78580, 78582, 78597, 78598
Pulmonary Valve
Incision 33470, 33471, 33474
Repair 33470, 33471, 33474
Replacement 33475
with Aortic Valve 33440
Transcatheter Pulmonary Valve Implantation (TVPI) 33477
Pulmonary Vein
Isolation 93656
Repair
Complete 33730
Partial 33724
Stenosis 33726
Stenosis
Repair 33726
Pulmonology
Diagnostic
Airway Closing Volume 94727
Airway Obstruction
Apnea Monitoring
Pediatric 94774-94777
Bed Testing
Infant through 12 months 94780, 94781
Bronchodilation 94060, 94664
Bronchospasm Provocation 94070
Car Seat Testing
Infant through 12 months 94780, 94781
Carbon Monoxide Diffusion Capacity 94729
Circadian Respiratory Pattern 94772
Exercise Test 94621
Expired Gas Analysis
NO 95012
O2 and CO2 94681
O2 Update, Direct 94680
O2 Uptake, Indirect 94690
Flow-Volume Loop 94375
Hemoglobin O2 Affinity 82820
High Altitude Simulation Test (HAST) 94452, 94453
Hypoxia Response Curve 94450
Maximum Breathing Capacity 94200
Maximum Voluntary Ventilation 94200
Membrane Diffusion Capacity 94729
Oximetry
Ear or Pulse 94760-94762
Pediatric Pneumogram 94772
Plethysmography 94726
Pulmonary Fluid Monitoring System
Remote Monitoring 0607T-0608T
Resistance to Airflow 94726, 94728
Spirometry
Evaluation 94010-94015, 94060, 94070
Evaluation Only 94016
Patient Initiated 94014
Sputum Mobilization with Inhalants 94664
Stress Test, Pulmonary 94618
Vital Capacity 94150
Wheeze Rate 94799
Therapeutic
Airway Obstruction
Inhalation
Pentamidine 94642
Inhalation Treatment
Intrapulmonary Surfactant Administration 94610
Manipulation of Chest Wall 94667, 94668
Mechanical Oscillation of Chest Wall 94669
Pressure Ventilation
Negative (CNP) 94662
Positive (CPAP) 94660
Ventilation Assist 94002-94005, 99504
Pulse Generator
Implantation/Replacement 0268T
Revision/Removal 0271T
Implantable Defibrillator
Insertion 33230, 33231, 33240
Removal 33241
Removal with Replacement 33262-33264
Neurostimulator
Insertion 61885, 61886, 64568, 64590
Removal/Revision 61888, 64570, 64595
Pacemaker
Insertion 33212, 33213, 33221
Removal 33233
Replacement 33227-33229
Respiratory Sensor Electrode/Electrode Array
Insertion 0466T
Removal 0468T
Replacement 0467T
Revision 0467T
Removal 0580T
Removal and Replacement 0614T
Pulse Rate Increased
See Tachycardia
Pump
See Chemotherapy, Pump Services; Infusion Pump
Pump, Infusion
See Infusion Pump
Pump Services
Drug Delivery Pump 95990, 95991, 96521-96523
Oxygenator/Heat Exchanger 99190-99192
Punch Graft 15775, 15776
Puncture
Artery
Diagnosis 36600
Chest
Cisternal 61050, 61055
Cornea 65600
Follicle
Oocyte Retrieval 58970
Lumbar 62272, 62328
Pericardium 33016
Pleural Cavity
Drainage 32556, 32557
Sinus
for Endoscopy 31233, 31235
Skull
Drain Fluid 61000-61020
Cistern 61050
Inject Cistern 61055
Inject Ventricle 61026
Shunt
Drain Fluid 61070
Injection 61070
Spinal Cord
Drain Fluid 62272, 62329
Lumbar 62270, 62328
Tracheal
Aspiration and/or Injection 31612
Vein
See Venipuncture
Ventricle
Existing Burr Hole Access 61020, 61026
Twist Drill Hole Access 61105, 61107, 61108, 61120
Puncture Aspiration
Abscess
Skin 10160
Bulla 10160
Cyst
Breast 19000, 19001
Skin 10160
Hematoma 10160
Hydrocele 55000
Puncturing
See Puncture
Pure-Tone Audiometry
Attended 92552, 92553
Automated 0208T, 0209T
Pustules
Removal 10040
PUVA (Psoralens and Ultraviolet A)
Photochemotherapy 96912, 96913
Pyelogram 74400
Pyelography 74400
Pyelolithotomy 50130
Anatrophic 50075
Coagulum 50130
Pyeloplasty 50400-50405, 50544

Foley-Y 50400
Repair
Secondary 50405
Pyeloscopy
Biopsy 52354
Destruction 52354
Lithotripsy 52353
Removal
Calculus 52352
Pyelostolithotomy
Pyelostomy
Change Tube 50435
with Drainage 50125
with Pyeloplasty 50400, 50405
Pyelotomy
Complicated 50135
with Drainage 50125
Exploration 50120
with Removal of Calculus 50130
with Renal Endoscopy 50570
Pyeloureteroplasty
See Pyeloplasty
Pyloric Sphincter
Incision 43520
Pyloromyotomy 43520
Pyloroplasty 43800
with Vagotomy 43640
Pyothorax
Thoracic Abscess, Incision 21510
Pyridoxal Phosphate 84207

Pyrophosphate, Adenosine
Adenosine Diphosphate 82030
Pyrophosphorylase, Udp Galactose

Uridyl Transferase 82775, 82776
Pyruvate 84210-84220
Q
Q Fever 86000, 86638
Q Fever ab
QST
See Quantitative Sensory Testing (QST)
Quadrantectomy 19301, 19302

Quadriceps Repair 27430
Suture 27385, 27386
Quantitative Sensory Testing (QST)

Cooling Stimuli 0108T
Heat-Pain Stimuli 0109T
Other Stimuli 0110T
Touch Pressure Stimuli 0106T
Vibration Stimuli 0107T
Quick Test
Prothrombin Time 85610, 85611
Quinidine
Assay 80194
Quinine 84228
R
Rabies Immune Globulin (RIg)
Human 90375
Human, Heat- and Solvent-Treated
(RIg-HT S/D) 90377
Human, Heat-Treated (RIg-HT) 90376
Rabies Vaccine 90675, 90676

Rachicentesis
Lumbar Puncture 62272, 62328
Radial Artery
See Artery, Radial
Radial Head, Subluxation
Radial Keratotomy 65771

Radiation, Transfusion Medicine
Irradiation of Blood Product 86945
Radiation, X
See X ray
Radiation Physics
Radiation Exposure Evaluation 76145
Radiation Therapy
Consultation
Radiation Physics 77336-77370
Dose Plan 77300, 77301, 77306, 77307, 77331
Brachytherapy 0394T, 0395T, 77316-77318
Intensity Modulated Radiation Treatment (IMRT) 77338
Multi-leaf Collimator (MLC) Device 77338
Radiotherapy
3-Dimensional 77295
Teletherapy 77306, 77307, 77321
Field Set-up 77280, 77285, 77290
Guidance
CT 77014
Interstitial Devices, Placement 49411, 49412
for Localization of Target Volume 77387
Intraoperative Radiation Therapy
Breast
Preparation of Tumor Cavity 19294
Planning 77261-77263, 77299
Port Image(s) 77417
Radiosurgery 77371-77373
Respiratory Motion Management
Simulation 77293
Special Treatment Procedure 77470
Stereotactic Body 77373
Cerebral Lesions 77371, 77372
Guidance 77387
Target Delineation
Thoracic 32701
Treatment Delivery 77401, 77402, 77407, 77412
Brachytherapy
See Brachytherapy
High Energy Neutron Radiation 77423
Intensity Modulation 77385, 77386
Interstitial Radiation Therapy
See Interstitial Radiation Therapy
Localization 77387
Proton Beam 77520-77525
Stereotactic 77371-77373
Body 77373
Superficial 77401
Tracking 77387
Treatment Device 77332-77334
Treatment Management
1 or 2 Fractions Only 77431
Stereotactic
Body 77435
Cerebral 77432
Weekly 77427
Radical Excision of Lymph Nodes

Axillary 19305-19307, 38740-38745
Suprahyoid 38700
Radical Mastectomy, Modified 19307
Radical Neck Dissection
with Auditory Canal Surgery 69155
Laryngectomy 31365-31368
Pharyngolaryngectomy 31390-31395
with Thyroidectomy 60254
with Tongue Excision 41135, 41145, 41153-41155
Radical Resection
Abdomen 51597
Elbow
Capsule, Soft Tissue, Bone
with Contracture Release 24149
Mediastinum 60522
Sternum 21630-21632
Tonsil 42842-42845
Tumor
Abdominal Wall 22904, 22905
Acetabulum 27076
Ankle 27615, 27616
Arm, Lower 25077, 25078
Arm, Upper 24077, 24079
Back/Flank 21935, 21936
Calcaneus 27647
Clavicle 23200
Elbow 24077, 24079
Face 21015, 21016
Femur 27078, 27365
Fibula 27646
Finger 26117, 26118
Foot 28046, 28047
Forearm 25077, 25078
Hand 26117, 26118
Hip 27075, 27076
Humerus 23220, 24150
Ilium 27076
Ischial Ramus 27075, 27076
Knee 27329, 27364, 27365
Leg, Lower 27615, 27616
Leg, Upper 27329, 27364, 27365
Lymph Nodes
See Lymphadenectomy
Mandible 21045
Metacarpal 26250
Metatarsal 28173
Neck 21557, 21558
Ovarian 58950-58954, 58957
Pelvis 27049, 27059
Peritoneal 58950-58954, 58957
Phalanges
Finger 26260, 26262
Toe 28175
Pubic Ramus 27075, 27076
Radius 24152, 25170
Scalp 21015, 21016
Scapula 23210
Shoulder 23077, 23078
Symphysis Pubis 27075
Talus 27647
Tarsal 28171
Thigh 27329, 27364
Thorax 21557, 21558
Tibia 27645
Toe 28046, 28047
Ulna 25170
Wing of Ilium 27075, 27076
Wrist 25077, 25078
Radical Vaginal Hysterectomy 58285

Radical Vulvectomy 56630-56634, 56637, 56640
Radioactive Colloid Therapy 79300
Radioactive Substance
Injection
Sentinel Node 38792
Insertion
Bladder 51020, 52250
Prostate 55860
Urethra 52250
Radiocarpal Joint
Arthrotomy 25040
Dislocation
Radiocinematographies
See Cineradiography
Radioelement
Application 77761-77763, 77767, 77768, 77770-77772, 77778, 77789
Device Placement
Breast 19296-19298
Genitalia 55920
Head 41019
Heyman Capsules Insertion 58346
Intracavitary 31643
Muscle 20555
Neck 41019
Pelvis 55920
Prostate 55875
Soft Tissue 20555
Uterus 57155
Vagina 57155, 57156
Handling 77790
Infusion 77750
Radioelement Substance
Catheter Placement
Breast 19296-19298
Bronchus 31643
Muscle 20555
Prostate 55875
Soft Tissue 20555
Needle Placement
Muscle 20555
Prostate 55875
Soft Tissue 20555
Radiography
See X ray
Radioimmunosorbent Test
Gammaglobulin 82784, 82785, 82787
Radioisotope Brachytherapy
See Brachytherapy
Radioisotope Scan
Radiological Marker
Preoperative Placement
Excision of Breast Lesion 19125, 19126
Radiology
Bone/Joint Studies
Dual-Energy X-ray Absorptiometry (DXA) 77080, 77081, 77085, 77086
Radiography 77071-77077
Diagnostic Imaging
3D Rendering, Tomographic 76376, 76377
Abdomen 74018, 74019, 74021
Abscess, Fistula or Sinus Tract, Study 76080
Chest 71045-71048
Cineradiography 76120, 76125
Complex Body Motion Section 76101, 76102
Computed Tomography Follow-up Study 76380
Fluoroscopy 76000, 76496
Gastrointestinal Tract 74210-74363
Gynecological and Obstetrical Imaging 74710-74775
Head and Neck 70010-70559
Heart 75557-75574
Lower Extremities 73501-73725
Nose to Abdomen, for Foreign Body 76010
Single Plane Body Section 76100
Spine and Pelvis 72020-72295
Surgical Specimen 76098
Upper Extremities 73000-73225
Urinary Tract 74018-74485
Vascular Procedures
Aorta and Arteries 36901-36906, 75600-75774
Transcatheter Procedures 75894-75989
Veins and Lymphatics 75801-75893
Videoradiography 76120, 76125
X ray Examination Consultation 76140
See Ultrasound
Mammography
See Mammography
Nuclear Medicine
Radiation Oncology
Device Design/Construction 77332-77334, 77338
Dosimetry
See Dosimetry
Medical Physics Consultation 77336, 77370
Treatment Delivery
See Radiation Therapy, Treatment Delivery
Treatment Planning 77261-77263, 77299
Field Setting 77280, 77285, 77290, 77293
Radiation Therapy
See Radiation Therapy
Radiological Guidance
Computed Tomography 77011-77014
Fluoroscopy 77001-77003
Magnetic Resonance Imaging 77021, 77022
Brachytherapy 77799
Fluoroscopy 76496
Nuclear Medicine 78099, 78199, 78299, 78399, 78499, 78599, 78699, 78799, 78999
Radiation Physics 77399
Radiographic 76499
Radiopharmaceutical 79999
Treatment Management 77499
Treatment Planning 77299
Ultrasound 76999
X ray
See X ray
Radionuclide CT Scan
See SPECT
Radionuclide Imaging
Radionuclide Therapy
See Radiopharmaceutical Therapy
Radionuclide Tomography, Single-Photon Emission-Computed
See SPECT
Radiopharmaceutical Localization
of Inflammatory Process 78800-78804, 78830-78832
Injection for 78808
of Radiopharmaceutical Agent 78800-78804, 78830-78832
of Tumor 78800-78804, 78830-78832
Radiopharmaceutical Therapy
Interstitial 79300
Intra-Articular 79440
Intracavitary 79200
Intravenous 79101, 79403
Oral 79005
Radiostereometric Analysis (RSA) 0347T-0350T

Radiosurgery
Brain
Lesion 61796-61800
Treatment Delivery 77371, 77372
Radiotherapeutic
Radiotherapies
Radiotherapy, Surface 77767, 77768, 77789

Radioulnar Joint
Arthrodesis
with Resection of Ulna 25830
Arthrotomy 25107
Dislocation
Radius
See also Arm, Lower; Elbow; Ulna
Amputation
Radius and Ulna 25900, 25905, 25909
Secondary Closure/Scar Revision 25907
Arthroplasty 24365
Cyst
Excision 24125, 24126, 25120-25126
Dislocation
with Fracture
Partial 24640
Subluxate 24640
Excision
Head 24130
Partial 24136, 25145, 25151
Styloid Process 25230, 25440
Fracture
Colles
Treatment 25600
Distal 25600-25609
Head/Neck
Shaft
Closed Treatment 25500-25505, 25520, 25560, 25565
Manipulation 25505, 25565
Open Treatment 25515, 25525, 25526, 25574, 25575
with Ulna 25560-25565, 25574, 25575
Smith Type
with Ulna
Implant
Removal 24164
Osteomyelitis 24136, 24145
Osteoplasty
Osteotomy 25350, 25355, 25365, 25370, 25375
Sofield Type 25370
Repair
Defect, with Graft 25425, 25426
Epiphyseal Arrest 25450-25455
Epiphyseal Separation
Closed 25600
Closed with Manipulation 25605
with Graft 25405, 25420-25426
Malunion or Nonunion 25400, 25405, 25415, 25420
Osteotomy 25350-25355, 25370-25375
and Ulna 25365
Replacement with Prosthesis
Distal 25441, 25446
Radial Head 24666
Replantation 20805
Sequestrectomy 24136, 25145
Styloidectomy 25230, 25440
Tumor
Cyst 24120
Excision 24125, 24126, 25120-25126, 25170
Ramstedt Operation
Pyloromyotomy 43520
Ramus Anterior, Nervus Thoracicus
Range of Motion Test

Cholinesterase Inhibitor Challenge 95857
Extremities or Trunk
with Hand 95852
without Hand 95851
Eye 92018, 92019
Hand 95852
for Myasthenia Gravis 95857
Rapid Heart Rate
See Tachycardia
Rapid Plasma Reagin Test 86592, 86593

Rapid Test for Infection 86308, 86403-86406
Monospot Test 86308
Rapoport Test 52005

Rat Typhus
Murine Typhus 86000
Rathke Pouch Tumor

Craniopharyngioma, Excision 61545
Rays, Roentgen
See X ray
Raz Procedure
Abdomino-Vaginal Vesical Neck Suspension 51845
RBC
RBC ab
Red Blood Cell Antibody 86850, 86860, 86870
Reaction, Polymerase Chain
See Genomic Sequencing Procedures (GSPs)
Realignment
Femur
Shaft 27454
Hand
Extensor Tendon 26437
Humeral Shaft
Intramedullary Rod 24410
Knee
Extensor Tendon 27422
Radius
Intramedullary Rod 25370, 25375
Tibia
Intramedullary Rod 27712
Ulna
Intramedullary Rod 25370, 25375
Receptor
CD4 86360
Estrogen 84233
Progesterone 84234
Receptor Assay
Hormone
Estrogen 84233
Progesterone 84234
Unspecified 84235
Nonendocrine 84238
Recession
Gastrocnemius
Leg, Lower 27687
Hamstring 27097
Strabismus Surgery 67311-67314, 67316, 67334
Reconstruction
See also Revision
Abdominal Wall
Omental Flap 49905
Acetabulum 27120-27122
Anal
Congenital Absence 46730-46740
Fistula 46742
Graft 46753
Sphincter 46750, 46751, 46760-46761
Ankle 27700-27703
Atrial 33257-33259
Open 33254-33259
Auditory Canal, External 69310-69320
Bile Duct
Anastomosis 47800
Bladder
from Colon 50810
from Intestines 50820, 51960
and Urethra 51800-51820
Breast
Augmentation 19325
with Free Flap 19364
with Latissimus Dorsi Flap 19361
Nipple 19350-19355
Revision 19380
Tissue Expander Placement/Expansion 19357
Transverse Rectus Abdominis Myocutaneous (TRAM) Flap 19367-19369
Bronchi 32501
Graft Repair 31770
Stenosis 31775
Canthus 67950
Carpal 25443
Carpal Bone 25394, 25430
Cheekbone 21270
Chest Wall 21602, 21603, 32504
Omental Flap 49904
Trauma 32820
Conduit
Apical-Aortic 33404
with Flap
Bridge or Partial 68360
Total 68362
Cranial Bone
Ear, Middle
Tympanoplasty with Antrotomy or Mastoidotomy
with Ossicular Chain Reconstruction 69636, 69637
Tympanoplasty with Mastoidectomy 69641
with Intact or Reconstructed Wall 69643, 69644
with Ossicular Chain Reconstruction 69642
Radical or Complete 69644, 69645
Tympanoplasty without Mastoidectomy 69631
with Ossicular Chain Reconstruction 69632, 69633
Elbow 24360
Fascia Lata Ligament 24362
Revision 24370, 24371
Esophagus 43300, 43310, 43313
Creation
Stoma 43351, 43352
Esophagostomy 43351, 43352
Fistula 43305, 43312, 43314
Gastrointestinal 43360, 43361
Eye
Graft
Conjunctiva 65782
Stem Cell 65781
Transplantation
Eyelid
Canthus 67950
Second Stage 67975
Tarsoconjunctival Flap Transfer 67971
Total 67973-67975
Total Eyelid
Lower, One Stage 67973
Upper, One Stage 67974
Facial Bones
Secondary 21275
Fallopian Tube
Tubotubal Anastomosis 58750
Tubouterine Implantation 58752
Femur
Fibula
Lengthening 27715
Finger 26548
Polydactylous 26587
Foot
Cleft 28360
Forehead 21172-21180, 21182-21184
Glenoid Fossa 21255
Gums
Alveolus 41874
Gingiva 41872
Hand
Tendon Pulley 26390, 26500-26502
Toe to Finger Transfer 26551-26556
Heart
Atrial 33257-33259
Open 33254-33256
for Hypoplasia 33622
for Obstruction 33622
Pulmonary Artery Shunt 33924
Vena Cava 34502
Hip
Replacement 27130-27132
Hip Joint
Intestines, Small
Knee 27437, 27438
Femur 27442, 27443, 27446
Replacement 27447
Revision 27486, 27487
Tibia 27440-27443, 27446
Kneecap
Larynx
Cricoid Split 31587
with Fracture Repair 31584
Medialization 31591
Stenosis 31551-31554
Web 31580
LeFort I 21141-21147, 21155, 21160
LeFort II 21150, 21151
LeFort III 21154, 21155, 21159, 21160
Lip 40525-40527, 40761
Lunate 25444
Malar Augmentation
Prosthetic Material 21270
Mandible
with Implant 21244-21246, 21248, 21249
Mandibular Rami
with Internal Rigid Fixation 21196
without Bone Graft 21193
without Internal Rigid Fixation 21195
Maxilla
with Implant 21245, 21246, 21248, 21249
Metacarpophalangeal Joint 26135, 26140, 26530, 26531, 26541
Midface
with Bone Graft 21145-21160, 21188
Forehead Advancement 21159, 21160
Mouth 40840-40845
Nail Bed 11762
Nasoethmoid Complex 21182-21184
Navicular 25443
Nose
Dermatoplasty 30620
Primary 30400-30420
Septum 30520
Orbit 21256
Orbit Area
Secondary 21275
Orbit with Bone Grafting 21182-21184
Orbital Rim 21172-21180
Orbital Rims 21182-21184
Orbital Walls 21182-21184
Orbitocraniofacial
Secondary Revision 21275
Oviduct
Fimbrioplasty 58760
Palate
Parotid Duct
Patella 27437, 27438
Penis
Angulation 54360
Chordee 54300-54304
Hypospadias 54332, 54352
One Stage Distal with Urethroplasty 54324-54328
One Stage Perineal 54336
Periorbital Region
Pharynx 42950
Radius 24365, 25390-25393, 25441
Arthroplasty
with Implant 24366
Shoulder
Joint
with Implant 23470, 23472-23474
Rotator Cuff 23420
Skull 21172-21180
Defect 62140, 62141, 62145
Spinal Elements 63051, 63295
Sternum 21740-21742
Stomach
with Duodenum 43810, 43850-43855, 43865
Gastric Bypass 43644, 43645, 43846
with Jejunum 43820-43825, 43860
for Obesity 43644, 43645, 43845-43848
Roux-En-Y 43644, 43846
Superior-Lateral Orbital Rim and Forehead 21172-21175
Supraorbital Rim and Forehead 21179, 21180
Symblepharon 68335
Arthroplasty 21240-21243
Throat 42950
Thumb
from Finger 26550
Opponensplasty 26490-26496
Tibia
Lengthening 27715
Tubercle 27418
Toe
Angle Deformity 28313
Extra Toes 28344
Hammertoe 28285, 28286
Macrodactyly 28340, 28341
Polydactylous 26587
Syndactyly 28345
Webbed Toe 28345
Tongue
Frenum 41520
Trachea
Carina 31766
Cervical 31750
Fistula 31755
Intrathoracic 31760
Trapezium 25445
Tympanic Membrane 69620
Ulna 25390-25393, 25442
Radioulnar 25337
Ureter 50700
Urethra 53410-53440, 53445
Hypospadias
One Stage Distal with Meatal Advancement 54322
One Stage Distal with Urethroplasty 54324-54328
Suture to Bladder 51840, 51841
Urethroplasty for Second Stage 54308-54316
Urethroplasty for Third Stage 54318
Uterus 58540
Vas Deferens 55400
Vena Cava 34502
with Resection 37799
Wrist 25320
Rectal Bleeding
Rectal Prolapse
Excision 45130
Proctopexy 45400, 45402, 45540, 45541
Reduction 45900
Rectal Sphincter
Dilation 45910
Rectocele
Repair 45560, 57250
Rectopexy
See Proctopexy
Rectoplasty
See Proctoplasty
Rectorrhaphy
See Rectum, Suture
Rectovaginal Fistula
Closure 57300, 57305, 57307, 57308
Rectovaginal Hernia
Rectocele Repair 45560, 57250
Rectum
See also Anus
Abscess
Incision and Drainage 45005-45020, 46040, 46060
Advancement Flap 46288
Biopsy 45100
Dilation
Endoscopy 45303
Endoscopy
Biopsy 45305
Destruction
Tumor 45320
Dilation 45910
Endoscopic 45303
Exploration 45300
Hemorrhage 45317
Removal
Foreign Body 45307
Polyp 45308-45315
Tumor 45308-45315
Volvulus Decompression 45321
Excision
with Colon 45121
Muscularis Propria 45172
Partial 45111, 45113-45116, 45123
Total 45110, 45112, 45119, 45120
Exploration
Endoscopic 45300
Surgical 45990
Hemorrhage
Endoscopic 45317
Hemorrhoid
See Hemorrhoids
Incontinence
Graft 46753
Thiersch Procedure 46753
Injection
Laparoscopy 45499
Lesion
Excision 45108
Manometry 91122
Mucosectomy 44157, 44158, 44211, 45113
Procidentia
Prolapse
Proctopexy 45400, 45402, 45540, 45541
Removal
Fecal Impaction 45915
Repair
Fistula 45800-45825, 46707
Incontinence 46753
Injury 45562, 45563
Prolapse 45505-45541, 45900
Rectocele 45560
Stenosis 45500
Sensation, Tone, and Compliance Test 91120
Stricture
Dilation 45910
Division 45150
Excision 45150
Suture
Fistula 45800-45825
Prolapse 45540, 45541
Tumor
Transanal Endoscopic 0184T
Laparoscopic 45499
Voiding Pressure 51797
Red Blood Cell ab

Red Blood Cell Antibody 86850, 86860, 86870
Red Blood Cell (RBC)
Pretreatment 86970-86972
Count 85032-85041
Fetal 85460, 85461
Fetomaternal Hemorrhage 85460, 85461
Fragility
Mechanical 85547
Osmotic 85555, 85557
Hematocrit 85014
Sedimentation Rate
Automated 85652
Manual 85651
Sequestration 78140
Sickling 85660
Survival Test 78130
Volume Determination 78120, 78121
Reductase, Glutathione 82979

Reductase, Lactic Cytochrome
Reduction
Breast 19318
Collateral Ligament
Ulnar 29902
Craniomegalic Skull 62115, 62117
for Dislocation
Ear, Protruding 69300
Forehead 21137-21139
for Fracture
Laryngeal 31584
Odontoid 22318, 22319
Tracheal 31630
Internal Hernia
Mesentery 44050
Masseter Muscle/Bone 21295, 21296
Osteoplasty
Facial Bones 21209
Overcorrection of Ptosis 67909
Pregnancy
Multifetal 59866
Procidentia 45900
with Reconstruction
Hip 27147, 27156
Wrist 25230
Skull
Craniomegalic 62115, 62117
Tissue 30801
Torsion
Testis 54600
Tumor
Bone
Ablation Therapy 20982, 20983
Volume
Lung 32491
Volvulus 44050, 44055
Reflex Test
Blink Reflex 95933
Reflux Study 78262
Gastroesophageal 91034-91038
Refraction
Ophthalmological 92015
Rehabilitation
Artery
Occlusive Disease 93668
Auditory
Post-Lingual Hearing Loss 92633
Pre-Lingual Hearing Loss 92630
Cardiac 93797, 93798
Rehabilitation Facility
Discharge Services 1110F, 1111F
Rehabilitative Procedures
See Rehabilitation
Reimplantation
Arteries
Aorta
Prosthesis 35697
Carotid 35691, 35694, 35695
Coronary Ostium 33783
Subclavian 35693-35695
Visceral 35697
Kidney 50380
Ureters 51565
Reinnervation
Larynx
Neuromuscular Pedicle 31590
Reinsch Test 83015

Reinsertion
Drug Delivery Implant 11983
Ocular Implant 65150, 65155
Spinal Fixation Device 22849
Tendon
Biceps 24342
Triceps 24342
Relative Density
Specific Gravity 84315
Release
Capsule
Ankle 27612
Elbow 24149
Foot 28260
Knee 27435
Metatarsophalangeal Joint 28289, 28291
Shoulder 23020
Carpal Tunnel 64721
Choroidal Fluid 67015
Fascia
Finger/Thumb 26123
Heel 28119
Flexor Muscles
Hip 27036
Knee Joint 29873
Ligament
Knee
Retinacular 27425
Muscle
Abductor Hallucis 28240
Hamstring 27097
Hand 26508, 26593
Hip 27036
Knee 27422
Nerve 64702-64726
Neurolytic 64727
Penis
Chordee 54352
from Scrotum 54318
Retina
Fluid 67015
Scar 11042, 14040, 14041
Colostomy 44340
Eye 67343
Ileostomy 44312
Spinal Cord 63200
Stapes 69650
Tarsal Tunnel 28035
Tendon 24332, 25295
Vitreous 67015
Release-Inhibiting Hormone, Somatotropin 84307

Relocation
Skin Pocket
Implantable Defibrillator 33223
Pacemaker 33222
Removal
Adjustable Gastric Restrictive Device 43772-43774
Allograft
Intestinal 44137
Artificial Intervertebral Disc
Cervical Interspace 0095T, 22864
Lumbar Interspace 0164T, 22865
Balloon
Intra-Aortic 33974
Balloon Assist Device
Intra-Aortic 33968, 33971
Balloon Continence Device 0550T
Blood Clot
Eye 65930
Blood Component
Apheresis 36511-36516
Breast
See Mastectomy
Calcareous Deposits
Subdeltoid 23000
Calculi (Stone)
Capsules
Breast 19371
Cardiac Event Recorder 33286
Cast 29700, 29705, 29710
Cataract
Catheter
Peritoneum 49422
Spinal Cord 62355
Cerclage
Cervix 59871
Cerumen
Auditory Canal, External 69209, 69210
Clot
Pericardium 33020
Endoscopic 32658
Comedones 10040
Cranial Tongs 20665
Cyst 10040
Dacryolith
Lacrimal Duct 68530
Drug-Delivery Device 20701, 20703, 20705
Ear Wax
Auditory Canal, External 69209, 69210
Electrode
Array
Nerve 64585
Brain 61535, 61880
Chest Wall
Heart 33238
Stomach 43648, 43882
Embolus
See Embolectomy
Esophageal Sphincter Augmentation Device 43285
Eye
with Bone 65112
Bone 67414, 67445
Epithelium 65435, 65436
with Implant
Muscles Attached 65105
with Muscle or Myocutaneous Flap 65114
Ocular Contents
with Implant 65093
Orbital Contents Only 65110
Fallopian Tube
Laparoscopy 58661
with Hysterectomy 58542, 58544, 58548
Fat
Lipectomy 15876-15879
Fecal Impaction
Rectum 45915
Filter
Vena Cava 37193
Fixation Device 20670-20680
Foreign Body
Anal 46608
Arm
Lower 25248
Upper 24200, 24201
Bile Duct 43275
Bladder 52310-52315
Brain 61570
Bronchi 31635
Colon 44025, 44390, 45379
Colon-Sigmoid 45332
Conjunctival Embedded 65210
Cornea
with Slit Lamp 65222
without Slit Lamp 65220
Duodenum 44010
Elbow 24000, 24101, 24200, 24201
Esophagus 43020, 43045, 43215, 74235
Eye
Corneal 65220, 65222
External Eye 65205-65222
Eyelid 67938
Posterior Segment 65260, 65265
Finger 26075-26080
Foot 28190-28193
Gum 41805
Hand 26070
Hip 27033, 27086, 27087
Hysteroscopy 58562
Toe 28024
Intestines, Small 44020, 44363
Intraocular 65235-65265
Kidney 50561, 50580
Knee Joint 27310, 27331, 27372
Lacrimal Duct 68530
Larynx 31511, 31530, 31531, 31577
Leg, Upper 27372
Lung 32151
Mandible 41806
Mediastinum 39000-39010
Mouth 40804, 40805
Muscle 20520, 20525
Nose 30300
Anesthesia 30310
Lateral Rhinotomy 30320
Orbit 67413, 67430
with Bone Flap 67430
without Bone Flap 67413
Patella
See Patellectomy
Pelvis 27086, 27087
Penile Tissue 54115
Penis 54115
Pericardium 33020
Endoscopic 32658
Peritoneum 49402
Pharynx 42809
Pleura 32150, 32151
Endoscopic 32653
Rectum 45307, 45915
Scrotum 55120
Deep 23333
Subcutaneous 23330
Skin
with Debridement 11010-11012
Stomach 43500
Subcutaneous Tissue 10120, 10121
with Debridement 11010-11012
Tendon Sheath 20520-20525
Toe 28022
Ureter 50961, 50980
Urethra 52310-52315
Uterus 58562
Vagina 57415
Wrist 25040, 25101, 25248
Hair
Electrolysis 17380
Halo 20665
Hearing Aid
Hematoma
Brain 61312-61315
Implant 20670-20680
Ankle 27704
Breast 19328, 19330
Disc 22865
Eye 67120, 67121
Finger 26320
Hand 26320
Radius 24164
Shoulder 23334, 23335
Wrist 25449
Infusion Pump
Intravenous 36590
Spinal Cord 62365
Interstitial Glucose Sensor 0447T, 0448T
Intra-Aortic Balloon 33974
Assist Device 33968, 33971
Intrauterine Device (IUD) 58301
Keel
Laryngoplasty 31580
Lacrimal Gland
Partial 68505
Total 68500
Lacrimal Sac
Excision 68520
Laryngocele 31300
Leiomyomata 58545, 58546, 58561
Lens 66920-66940
Lens Material 66840-66852
Lesion
Conjunctiva 68040
Larynx 31512, 31578
Loose Body
See Loose Body, Removal
Lung
Apical Tumor 32503, 32504
Bronchoplasty 32501
Completion Pneumonectomy 32488
Cyst 32140
Extrapleural 32445
Single Lobe 32480
Single Segment 32484
Sleeve Lobectomy 32486
Sleeve Pneumonectomy 32442
Two Lobes 32482
Lymph Nodes
Abdominal 38747
Inguinofemoral 38760-38765
Pelvic 38770
Retroperitoneal
Thoracic 38746
Mastoid
Air Cells 69670
Mesh
Nails 11730-11732, 11750
Neurostimulators
Pulse Generator 64595
Receiver 64595
Ocular Implant 65175, 65920
Orbital Implant 67560
Ovary
Laparoscopy 58661
with Hysterectomy 58542, 58544, 58548
Pacemaker System
Electrodes
Pulse Generator Only 33233
Patella, Complete 27424
Percutaneous Ventricular Assist Device 33992
Plate
Skull 62142
Polyp
Anal 46610, 46612
Antrochoanal 31032
Colon 44392, 45385
Colon-Sigmoid 45333
Endoscopy 44364, 44365, 44394
Gastrointestinal, Upper 43250, 43251
Rectum 45315
Sinus 31032, 31051
Prosthesis
Abdomen 49606
Elbow
Radial Head 24164
Glenoid Component 23334, 23335
Hip 27090, 27091
Humeral Component 23334, 23335, 24160
Knee 27488
Penis 54406, 54410-54417
Perineum 53442
Radial Head 24164
Shoulder 23334, 23335
Skull 62142
Ulnar Component 24160
Urethral Sphincter 53446, 53447
Wrist 25250, 25251
Pulse Generator
Brain 61888
Spinal Cord 63688
Pustules 10040
Receiver
Brain 61888
Spinal Cord 63688
Reservoir
Spinal Cord 62365
Seton
Anal 46030
Shoulder Joint
Foreign or Loose Body 23107
Shunt
Brain 62256-62258
Heart 33924
Peritoneum 49429
Spinal Cord 63746
Skin Tags 11200, 11201
Sling
Urethra 53442
Vagina 57287
Anterior 22855
Posterior Nonsegmental
Harrington Rod 22850
Posterior Segmental 22852
Stent
Bile Duct 43275
Ureteral 50382-50386
Subcutaneous Port
for Gastric Restrictive Procedure 43887, 43888
Substernal Implantable Cardioverter-Defibrillator Electrode 0573T
Substernal Implantable Cardioverter-Defibrillator Pulse Generator 0580T
Suture
Anal 46754
Anesthesia 15850, 15851
Thrombus
See Thrombectomy
Tissue Expander 11971
Total Replacement Heart System 33929
Transplant
Intestines 44137
Kidney 50370
Tube
Ear, Middle 69424
Nephrostomy 50389
Tumor
Larynx 31578
Temporal Bone 69970
Ureter
Ligature 50940
Urethral Stent
Bladder 52310-52315
Urethra 52310-52315
Uterus
Laparoscopy 58541, 58543, 58548
Vein
Clusters 37785
Perforation 37760, 37761
Saphenous 37718-37735, 37780
Varicose 37765, 37766
Obstruction 75901, 75902
Ventilating Tube
Ear, Middle 69424
Ventricular Assist Device 33977, 33978
Intracorporeal 33980
Vitreous
Anterior Approach 67005-67010
Wire
Anal 46754
Renal Abscess
Renal Arteries
See Artery, Renal
Renal Autotransplantation 50380

Renal Calculus
Basket Extraction 50080, 50081
Removal
Nephrolithotomy 50060, 50065, 50075
Pyelotomy 50130
Renal Cyst
See Cyst, Kidney
Renal Dialyses
See Hemodialysis
Renal Disease Services

See Dialysis; End-Stage Renal Disease Services
Renal Transplantation
See Kidney, Transplantation
Renin 80408, 80416, 80417, 84244

Renin-Converting Enzyme 82164
Reoperation
Carotid
Coronary Artery Bypass
Valve Procedure 33530
Distal Vessel Bypass 35700
Repair
See also Revision
Abdomen 49900
Hernia 49491-49525, 49565, 49570, 49582-49590
Omphalocele 49600-49611
Suture 49900
Aneurysm
Aorta
Abdominal 34845-34848
Thoracic 33877-33886
Ankle
Tendon 27612, 27650-27654, 27680-27687
Anorectum
Fistula 46707
Anus
Anomaly 46744-46748
Fistula 46288, 46706, 46715, 46716
Stricture 46700-46705
Aorta 33320-33322, 33802, 33803
Coarctation 33840-33851
Graft 33858, 33859, 33877
Infrarenal Abdominal Endovascular 34701-34706, 34845-34848
Sinus of Valsalva 33702-33720
Thoracic 75956-75959
Endovascular 33880-33891
Visceral
Endovascular 34841-34848
Physician Planning 34839
Aortic Arch
with Cardiopulmonary Bypass 33853
without Cardiopulmonary Bypass 33852
Obstruction
Outflow Tract 33414
Septic Hypertrophy 33416
Stenosis 33415
Arm
Lower 25260-25263, 25270
Fasciotomy 24495
Secondary 25265, 25272-25274
Tendon 25290
Tendon Sheath 25275
Muscle 24341
Tendon 24332, 24341, 25280, 25295, 25310-25316
Upper
Muscle Revision 24330, 24331
Tendon Revision 24320
Tenotomy 24310
Abdomen
Acquired or Traumatic 35189
Congenital 35182
Extremity
Congenital 35184
Head
Congenital 35180
Neck
Congenital 35180
Thorax
Congenital 35182
Spinal Artery 62294
Artery
Angioplasty
Aorta 37246-37247
Brachiocephalic 37246-37247
Bypass Graft 35501-35571, 35601-35683, 35691-35695, 35700
Bypass Venous Graft 33510-33516, 35510-35525
Coronary 33507
Direct Repair for Aneurysm
Axillary-Brachial 35011, 35013
Carotid 35001, 35002
Celiac 35121, 35122
Femoral 35141, 35142
Hepatic 35121, 35122
Iliac 35131, 35132
Innominate 35021, 35022
Mesenteric 35121, 35122
Radial 35045
Renal 35121, 35122
Splenic 35111, 35112
Subclavian 35001, 35002, 35021, 35022
Ulnar 35045
Vertebral 35005
Femoral 37224
Iliac 37220-37222, 37227
Popliteal 37224
Pulmonary 33690
Renal 37246, 37247
Renal or Visceral 37246, 37247
Subclavian 37246, 37247
Thromboendarterectomy 35301-35321, 35341-35390
Tibioperoneal 37228-37235
Viscera 37246, 37247
Arytenoid Cartilage 31400
Atria
Open 33254-33256
Bile Duct 47701
with Intestines 47760, 47780-47785
Wound 47900
Bladder
Exstrophy 51940
Fistula 44660, 44661, 45800-45805, 51880-51925
Neck 51845
Resection 52500
Wound 51860-51865
Blepharoptosis
Frontalis Muscle Technique with Fascial Sling 67902
Blood Vessel
Abdomen 35221
Chest 35211-35216
with Other Graft 35271-35276
with Vein Graft 35241-35246
Finger 35207
Graft Defect 35870
Hand 35207
Kidney 50100
Lower Extremity 35226
Neck 35201
Upper Extremity 35206
Body Cast 29720
Brain
Wound 61571
Breast
Suspension 19316
Bronchi
Fistula 32815
Brow Ptosis 67900
Bunion 28292, 28295-28299
Bypass Graft 35901-35907
Fistula 35870
Calcaneus
Osteotomy 28300
Cannula 36860, 36861
Carpal 25440
Carpal Bone 25431
Cervix
Cerclage 57700
Abdominal 59320-59325
Suture 57720
Chest Wall 32905
Closure 32810
Fistula 32906
Chin
Augmentation 21120, 21123
Clavicle
Cleft Hand 26580
Cleft Lip 40525-40527, 40700-40761
Nasal Deformity 40700, 40701, 40720-40761
Cleft Palate 42200, 42205, 42210, 42215, 42220, 42225
Colon
Fistula 44650-44661
Hernia 44050
Malrotation 44055
Obstruction 44050
Cornea
See Cornea, Repair
Coronary Chamber Fistula 33500, 33501
Cyst
Liver 47300
Diaphragm
for Eventration 39545
Hernia 39503, 39540, 39541
Laceration 39501
Ductus Arteriosus 33820-33824, 93582
Ear, Middle
Oval Window Fistula 69666
Round Window Fistula 69667
Elbow
Muscle 24341
Tendon 24340-24342
Each 24341
Tennis Elbow 24357-24359
Encephalocele 62121
Endovascular
See Endovascular Repair
Enterocele
Hysterectomy 58270, 58294
Epiphysis
Femur 27177-27181, 27475, 27479, 27485, 27516-27519, 27742
Fibula 27477, 27479, 27485, 27732, 27734, 27740, 27742
Tibia 27477-27485, 27730-27742
Esophagus 43300, 43310, 43313
Fistula 43305, 43312, 43314, 43420-43425
Laparotomy 43327
Thoracotomy 43328
Muscle 43330, 43331
Pre-Existing Perforation 43405
Wound 43410-43415
Eye
Ciliary Body 66680
Suture 66682
Wound 65270-65273
Cornea 65275
with Amniotic Membrane 65778-65780
Astigmatism 65772-65775
with Glue 65286
Wound 65275-65285
Fistula
Iris
Suture 66682
Lacrimal Duct
Canaliculi 68700
Retina
Detachment 67101, 67105, 67107, 67108, 67110, 67113
Sclera
with Glue 65286
with Graft 66225
Reinforcement 67250-67255
Staphyloma 66225
Wound 65286, 66250
Strabismus
Symblepharon
Division 68340
with Graft 68335
without Graft 68330
Trabeculae 65855
Eye Muscles
Strabismus
Adjustable Sutures 67335
One Horizontal Muscle 67311
One Vertical Muscle 67314
Posterior Fixation Suture Technique 67334, 67335
Previous Surgery, Not Involving Extraocular Muscles 67331
Release Extensive Scar Tissue 67343
Superior Oblique Muscle 67318
Two Horizontal Muscles 67312
Two or More Vertical Muscles 67316
Wound
Eyebrow
Ptosis 67900
Eyelashes
Epilation
by Forceps 67820
by Other than Forceps 67825
Incision of Lid Margin 67830
with Free Mucous Membrane Graft 67835
Eyelid 21280-21282
Ectropion 67916, 67917
Suture 67914
Entropion 67924
Suture 67921-67924
Excisional 67961-67966
Lagophthalmos 67912
Ptosis
Conjunctivo-Tarso-Muller’s Muscle-Levator Resection 67908
Frontalis Muscle Technique 67901, 67902
Levator Resection 67903, 67904
Reduction of Overcorrection 67909
Superior Rectus Technique 67906
Retraction 67911
Wound
Suture 67930-67935
Facial Bones 21208, 21209
Facial Nerve
Paralysis 15840-15845
Suture
Intratemporal, Lateral to Geniculate Ganglion 69740
Intratemporal, Medial to Geniculate Ganglion 69745
Anastomosis 58750
Create Stoma 58770
Fascial Defect 50728
Femur 27470-27472
Epiphysis 27475-27485, 27742
Arrest 27185
Osteoplasty 27179
Osteotomy 27181
by Pinning 27176
by Traction 27175
with Graft 27170
Osteotomy 27140, 27151, 27450-27454
Femoral Neck 27161
with Fixation 27165
with Open Reduction 27156
Fibula
Epiphysis 27477-27485, 27730-27742
Finger
Claw Finger 26499
Macrodactylia 26590
Polydactylous 26587
Syndactyly 26560-26562
Tendon
Extensor 26415-26434, 26445-26449
Flexor 26356-26358, 26440-26442
Joint Stabilization 26474
PIP Joint 26471
Toe Transfer 26551-26556
Trigger 26055
Volar Plate 26548
Web Finger 26560-26562
Fistula
Anorectal 46707
Carotid-Cavernous 61710
Ileoanal Pouch 46710-46712
Mastoid 69700
Rectovaginal 57308
Foot
Fascia 28250
Muscle 28250
Tendon 28200-28226, 28238
Gallbladder
with Gastroenterostomy 47741
with Intestines 47720-47740
Great Arteries 33770-33781
Great Vessel 33320-33322
Hallux Valgus 28292, 28295-28299
Hamstring 27097
Hand
Cleft Hand 26580
Muscle 26591-26593
Tendon
Extensor 26410-26416, 26426-26428, 26433-26437
Flexor 26350-26358, 26440
Profundus 26370-26373
Hearing Aid
Heart
Anomaly 33600-33617
Aortic Sinus 33702-33722
Atria
Open 33254-33256
Atrioventricular Canal 33660-33665
Complete 33670
Atrioventricular Valve 33660-33665
Blood Vessel 33320-33322
Cor Triatriatum 33732
Infundibular 33476-33478
Mitral Valve
with Cardiopulmonary Bypass 33425-33427
Transapical 0543T
Transcatheter 0345T, 0544T, 33418, 33419
Myocardium 33542
Outflow Tract 33476-33478
Patent Ductus Arteriosus 33820, 33822, 33824, 93582
Postinfarction 33542-33545
Prosthetic Valve 33670, 33852, 33853
Prosthetic Valve Dysfunction 33496
Pulmonary Artery Shunt 33924
Pulmonary Valve 33470-33474
Septal Defect 33545, 33608-33610, 33681-33688, 33692-33697, 33782, 33783
Atrial and Ventricular 33647
Atrium 33641
Septal Reduction Therapy 93583
Sinus Venosus 33645
Tetralogy of Fallot 33692-33697
Ventricle 33548, 33611, 33612
Obstruction 33619
Ventricular Tunnel 33722
Wound 33300-33305
Hepatic Duct
Hernia
Epigastric
Incarcerated 49572
Reducible 49570
Femoral
Initial
Incarcerated 49553
Reducible 49550
Recurrent
Incarcerated 49557
Reducible 49555
Incisional
Initial
Reducible 49560
Recurrent
Reducible 49565
Inguinal 49491-49525
Intestinal 44025-44050
Lumbar 49540
Lung 32800
Paraesophageal Hiatal 43332-43337
Sliding 49525
with Spermatic Cord 54640
Spigelian 49590
Reducible 49652
Incarcerated 49582, 49587, 49653
Reducible 49580, 49652
Ventral
Reducible 49652
Hip
Muscle Transfer 27100-27105, 27111
Tendon 27097
Humerus 24420-24430
with Graft 24435
Ileum
See Ileostomy
See Integumentary System, Repair
Volar Plate 26548
Intestine
Large
Ulcer 44605
Wound 44605
Intestines
Enterocele
Large
Closure Enterostomy 44620-44626
Diverticula 44605
Obstruction 44615
Intestines, Small
Closure Enterostomy 44620-44626
Fistula 44640-44661
Hernia 44050
Malrotation 44055
Obstruction 44025-44050
Ulcer 44602, 44603
Wound 44602, 44603
Introitus
Vagina 56800
Iris, Ciliary Body 66680
Jejunum
Free Transfer
with Microvascular Anastomosis 43496
Kidney
Fistula 50520-50526
Horseshoe 50540
Renal Pelvis 50400-50405
Wound 50500
Knee
Cartilage 27403
Instability 27420
Collateral 27405
Collateral and Cruciate 27409
Cruciate 27407-27409
Meniscus 27403
Tendon 27380, 27381
Laceration
Diaphragm 39501
Esophagogastric 43502
Mouth 40830, 40831
Palate 42180, 42182
Stomach 43501, 43502
Tongue 41250, 41252
Larynx
Fracture 31584
Reinnervation
Neuromuscular Pedicle 31590
Leg
Lower
Fascia 27656
Tendon 27658-27692
Upper
Muscle 27385, 27386, 27400, 27430
Tendon 27393-27400
Ligament
See Ligament, Repair
Lip 40650-40654
Cleft Lip 40700-40761
Fistula 42260
Liver
Abscess 47300
Cyst 47300
Wound 47350-47361
Lung
Hernia 32800
Pneumolysis 32940
Tear 32110
Mastoidectomy
Complete 69601
Radical 69603
Maxilla
Osteotomy 21206
Mesentery 44850
Metacarpal
Lengthening 26568
Nonunion 26546
Osteotomy 26565
Collateral Ligament 26540-26542
Fusion 26516-26518
Metatarsal 28322
Microsurgery 69990
Mitral Valve 0345T, 33418-33420, 33422, 33425-33427
Mouth
Laceration 40830, 40831
Vestibule of 40830-40845
Musculotendinous Cuff 23410-23412
Nail Bed 11760
Nasal Deformity
Cleft Lip 40700-40761
Nasal Septum 30630
Nasal Valve Collapse
with Implant 30468
Navicular 25440
Neck Muscles
Nerve 64876
Graft 64885-64902, 64910-64913
Microrepair 69990
Pedicle Transfer 64905, 64907
Suture 64831-64876
Synthetic Conduit 64910
Nose
Adhesions 30560
Fistula 30580-30600, 42260
Rhinophyma 30120
Septum 30540-30545, 30630
Synechia 30560
Vestibular Stenosis 30465
Osteotomy
Femoral Neck 27161
Radius
and Ulna 25365
Ulna
and Radius 25365
Vertebra
Additional Segment 22216, 22226
Cervical 22210, 22220
Lumbar 22214, 22224
Thoracic 22212, 22222
Oviduct 58752
Create Stoma 58770
Pacemaker
Heart
Electrode 33218-33220
Palate
Vomer Flap 42235
Pancreas
Cyst 48500
Pseudocyst 48510
Percutaneous 49405
Paravaginal Defect 57284, 57285, 57423
Pectus Carinatum 21740-21742
Pectus Excavatum 21740-21742
Pelvic Floor
Prosthetic Insertion 57267
Pelvis
Osteotomy 27158
Tendon 27098
Penis
Corporeal Tear(s) 54437
Fistulization 54435
Injury 54440
Priapism 54420-54435
Shunt 54420-54430
Perineum 56810
Periorbital Region
Phalanx
Finger
Lengthening 26568
Osteotomy 26567
Nonunion 26546
Toe
Pharynx
with Esophagus 42953
Pleura 32215
Prosthesis
Penis 54408
Pulmonary Artery 33917-33920, 33925, 33926
Pulmonary Valve 33470, 33471, 33474
Pulmonary Venous Return 33724
Pulmonary Venous Stenosis 33726
Quadriceps
See Quadriceps Repair
Radius
Epiphyseal 25450-25455
with Graft 25405, 25420, 25425, 25426
Osteotomy 25350-25355, 25370-25375
Rectocele 45560, 57250
Rectovaginal Fistula 57308
Rectum
Fistula 45800-45825
Injury 45562, 45563
Prolapse 45505-45541, 45900
Rectocele 45560
Stenosis 45500
Retina
Detachment 67101, 67105, 67107, 67108, 67110, 67113
Rotator Cuff 23410, 23412, 23420
Salivary Duct 42500-42505
Fistula 42600
Scapula
Fixation 23400
Scapulopexy 23400
Sclera
See Sclera, Repair
Scrotum 55175-55180
Septal Defect 33782, 33783, 33813, 33814
Shoulder
Capsule 23450-23466
Cuff 23410-23412
Ligament Release 23415
Muscle Transfer 23395-23397
Musculotendinous Rotator Cuff 23415-23420
Tendon 23410-23412, 23430-23440
Tenomyotomy 23405, 23406
Sinus
Ethmoid
Cerebrospinal Fluid Leak 31290
Sphenoid
Skin
Wound
Complex 13100-13160
Simple 12020, 12021
Skull
Encephalocele 62120
Spica Cast 29720
Spinal Cord 63700
Cerebrospinal Fluid Leak 63707-63709
Meningocele 63700-63702
Myelomeningocele 63704-63706
Spinal Meningocele
Spine
Lumbar Vertebra 22514, 22515
Thoracic Vertebra 22513, 22515
Spleen 38115
Stomach
Fistula 43880
Fundoplasty 43325, 43327, 43328
Laceration 43501, 43502
Stoma 43870
Ulcer 43501
Talus
Osteotomy 28302
Tarsal 28320
Osteotomy 28304, 28305
Testis
Orchiopexy 54640
Reduction of Torsion 54600
Suspension 54620, 54640
Suture of Injury 54670
Throat
Pharyngoesophageal 42953
Wound 42900
Thumb
Muscle 26508
Tendon 26510
Tibia 27720-27725
Epiphysis 27477-27485, 27730-27742
Osteotomy 27455-27457, 27705, 27709-27712
Pseudoarthrosis 27727
Toe
Bunion 28292, 28295-28299
Muscle 28240
Tendon 28240
Webbing 28280, 28345
Toes
Macrodactylia 26590
Polydactylous 26587
Tongue 41250-41252
Suture 41510
Trachea
Fistula 31755
with Plastic Repair 31825
without Plastic Repair 31820
Stenosis 31780, 31781
Stoma 31613, 31614
with Plastic Repair 31825
without Plastic Repair 31820
Scar 31830
Wound
Cervical 31800
Intrathoracic 31805
Tricuspid Valve 33463-33465
Transcatheter Tricuspid Valve Repair (TTVr) 0569T, 0570T
Truncus Arteriosus
Rastelli Type 33786
Tunica Vaginalis
Hydrocele 55060
Tympanic Membrane 69450, 69610
Ulna
Epiphyseal 25450-25455
with Graft 25405, 25420
Osteotomy 25360, 25370-25375, 25425, 25426
Umbilicus
Ureter
Anastomosis 50740-50825
Continent Diversion 50825
Deligation 50940
Fistula 50920-50930
Lysis Adhesions 50715-50725
Suture 50900
Urinary Undiversion 50830
Ureterocele 51535
Urethra
Artificial Sphincter 53449
Diverticulum 53240, 53400-53405
Fistula 45820-45825, 53400-53405, 53520
with Replantation of Penis 54438
Stoma 53520
Stricture 53400-53405
Urethrocele 57230
Wound 53502-53515
Urinary Incontinence 53431-53440, 57284, 57285, 57423
Uterus
Fistula 51920-51925
Rupture 58520, 59350
Suspension 58400-58410
Vagina
Colporrhaphy 57200, 57210, 57240, 57250, 57260, 57265, 57289
Cystocele 57240, 57260, 57284, 57285, 57423
Enterocele 57265
Fistula 46715, 46716, 51900
Rectovaginal 57300-57307
Transvesical and Vaginal Approach 57330
Urethrovaginal 57310, 57311
Vesicovaginal 57320-57330
Hysterectomy 58267
Incontinence 57284, 57285, 57288, 57423
Pereyra Procedure 57289
Postpartum 59300
Prolapse 57282, 57284
Rectocele 57250-57260
Suspension 57280-57284
Vaginal Wall Prolapse
See Colporrhaphy
Wound 57200-57210
Vas Deferens
Suture 55400
Vein
Femoral 34501
Graft 34520
Pulmonary 33730
Transposition 34510
Vulva
Postpartum 59300
Wound
Complex 13100-13160
Simple 12001-12021
Wound Dehiscence
Complex 13160
Simple 12020, 12021
Wrist 25260-25263, 25270, 25447
Bone 25440
Carpal Bone 25431
Cartilage 25107
Removal
Implant 25449
Secondary 25265, 25272-25274
Tendon 25280-25316
Tendon Sheath 25275
Repeat Surgeries
See Reoperation
Replacement
Adjustable Gastric Band 43773
Aortic Valve 33361-33365, 33367-33369, 33405, 33406, 33410-33413
Arthroplasties, Hip
See Arthroplasty, Hip
Artificial Heart
Intracorporeal 33928
Cardiac Devices, Implanted
Catheter
See Catheter, Replacement
Cecostomy Tube 49450
Cerebrospinal Fluid Shunt 62160, 62194, 62225-62230
Colonic Tube 49450
Contact Lens
Elbow
Total 24363
Revision 24370, 24371
Electrode
Chest Wall
Heart 33210, 33211, 33216, 33217
Stomach 43647, 43881
Eye
Gastro-Jejunostomy Tube 49452
Gastrostomy Tube 43762, 43763, 49450
Hearing Aid
Hip 27130-27132
Implant
Bone
for External Speech Processor/Cochlear Stimulator 69717, 69718
Implantable Defibrillator
Intervertebral Disc
Cervical Interspace 0098T, 22861
Lumbar Interspace 0165T, 22862
Jejunostomy Tube 49451
Joint
See Prosthesis, Joint
Knee
Arthroplasty
Partial 27446
Total 27447
Mitral Valve 33430
Nephrostomy Tube 50434, 50435
Nerve 64726
Neurostimulator
Pulse Generator/Receiver
Intracranial 61885
Spinal 63685
Ossicles
Ossicular Replacement 69633, 69637
Pacemaker
See Pacemaker
Penile
Prosthesis 54410, 54411, 54416, 54417
Prosthesis
Skull 62143
Pulmonary Valve 33475
Pulse Generator
See Pulse Generator
Receiver
Brain 61885
Spinal Cord 63685
Shoulder 23472
Revision 23473, 23474
Skin
Skin Substitute Graft 15271-15278
Skull Plate 62143
Spinal Cord
Reservoir 62360
Stent
Ureteral 50382-50386
Strut
Subcutaneous Port
for Gastric Restrictive Procedure 43888
Tissue Expander with Implant 11970
Total
Hip 27130
Ureter
Valve
Aortic 33405, 33406, 33410-33413
Mitral 33430
Venous Access Device 36582, 36583, 36585
Catheter 36578
Venous Catheter
Central 36580, 36581, 36584
Pump 33981-33983
Replantation
Arm
Lower 20805
Upper 20802
Digit 20816-20822
Foot 20838
Forearm 20805
Hand 20808
Penis 54438
Thumb 20824-20827
Report Preparation
Arthrocentesis
Major Joint 20610, 20611
Extended, Medical 99080
Bone Scintigraphy Study 3570F
Carotid Image Study 3100F
Esophageal Biopsy 3126F
Oncology Treatment Summary 5020F
Pathology 0550F, 0551F
Prenatal 0500F, 0501F
Psychiatric 90889
Repositioning
Central Venous Catheter 36597
Electrode
Cardiac Contractility Modulation 0415T
Heart 33215, 33226
Epidural Catheter 62350
Filter
Vena Cava 37192
Heart
Defibrillator
Leads 33215, 33226
Intraocular Lens Prosthesis 66825
Intrathecal Catheter 62350
Muscle
Vestibule of Mouth 40845
Orbital 21267, 21268
Renal Vessels 50100
Substernal Implantable Cardioverter-Defibrillator Electrode 0574T
Ureter 50715
Uveal Tissue 65285
Ventricular Assist Device 33993
Reproductive Tissue
Ovarian
Storage 89344
Thawing 89354
Testicular
Sperm Identification 89264
Storage 89344
Thawing 89354
Reprogramming
Cardiac Pacing Device
Implantable Defibrillator 33270, 93642
Cochlear Implant 92602, 92604
Implanted Drug Infusion Pump 62368-62370
Implanted Neurostimulator Pulse Generator System 95971, 95982
Shunt
Cerebrospinal 62252
Reptilase Test 85635

Reptilase Time
Thrombin Time 85670, 85675
Resection
Anatomic
Lung 32668
Aortic Valve
Stenosis 33415
Bladder Neck
Transurethral 52500
Brain Lobe
See Lobectomy, Brain
Chest
Diagnostic Wedge 32507, 32668
Therapeutic Wedge 32505, 32506, 32666, 32667
Clavicle
Tumor 23200
Cricotracheal 31592
Cyst
Mediastinal 39200
Pericardial 33050
Diaphragm 39560, 39561
Endaural
Temporal Bone 69535
Vestibular Nerve 69915, 69950
Esophagus
Mucosal 43211
Gastrointestinal
Mucosal 43254
Humeral Head 23195
Intestines, Small
Lip 40530
Lung 32503, 32504
Anatomic 32507, 32668
Bullae 32141, 32655
Emphysematous 32491, 32672
Mouth
with Tongue Excision 41153
Myocardium
Aneurysm 33542
Septal Defect 33545
Nasal Septum Submucous 30520
Nose
Septum 30520
Ovary, Wedge 58920
Palate 42120
Pericardium
Cyst 33050
Sac 32659
Tumor 33050
Phalangeal Head
Toe 28153
Prostate Transurethral 52601, 52630
Radical
Tumor
Soft Tissue
Ankle 27615, 27616
Arm, Lower 25077, 25078
Arm, Upper 24077, 24079
Back 21935, 21936
Elbow 24077
Face 21015, 21016
Femur 27329, 27364
Fibula 27646
Finger 26117, 26118
Foot 28046, 28047
Hand 26117, 26118
Hip 27049, 27059
Knee 27329, 27364
Leg, Lower 27615, 27616
Leg, Upper 27329, 27364
Neck 21557, 21558
Pelvis 27049, 27059
Scalp 21015, 21016
Shoulder 23077, 23078
Thigh 27329, 27364
Toe 28046, 28047
Wrist 25077, 25078
Synovial Membrane
See Synovectomy
Temporal Bone 69535
Thymus
Thoracoscopic 32673
Trachea
Cricotracheal 31592
Tumor
Bladder 52234, 52235, 52240
Calcaneus 27647
Cardiac 33130
Clavicle 23200
Femur 27365
Fibula 27646
Finger 26260, 26262
Humerus 23220
Kidney 52355
Knee 27365
Mediastinum 39220
Metatarsal 28173
Ovary 58957, 58958
Pericardium 33050
Peritoneum 58957, 58958
Radius 25170
Scapula 23210
Sternum 21630
Talus 27647
Tarsal 28171
Tibia 27645
Toe 28175
Ulna 25170
Ureter 52355
Urethra 52240, 52235-52334, 52355
Ulna
Arthrodesis
Ureterocele
Ectopic 52301
Orthotopic 52300
Vena Cava
with Reconstruction 37799
Respiration, Positive-Pressure
Continuous Positive Airway Pressure (CPAP) 94660
Respiratory Motion Management Simulation
for Radiation Treatment 77293
Respiratory Pattern Recording

Preventive
Home Apnea Monitoring 94774, 94775
Infant 94772
Sleep Study 94799, 95800, 95801, 95806, 95807
Wheeze Rate 94799
Respiratory Syncytial Virus
Antibody 86756
Antigen Detection
Immunoassay 87420
Respiratory Syncytial Virus Immune Globulin 90378

Rest Home Visit
See Domiciliary Services
Resuscitation
Cardiac Massage 32160
Cardiopulmonary 92950
Newborn 99465
Reticulocyte
Count 85044-85046
Retina
Diagnostic Imaging
Computerized Scanning 92134
Electroretinography 0509T, 92273, 92274
Imaging
for Disease Detection 92227-92229
for Disease Monitoring 92227-92229
Incision
Intra-Ocular Retinal Electrode Array
Initial Programming 0472T
Interrogation 0472T, 0473T
Lesion
Destruction
Extensive 67227, 67228
Localized 67208-67218
Macular/Fundus Exam, Dilated 2019F-2021F
Findings Communicated for Diabetes Management 5010F
Remote 0604T-0606T
Prophylaxis
Prosthesis 0100T
Release
Removal
Implanted Material 67120
Repair
Detachment 67113
Cryotherapy 67101, 67107, 67108, 67113
with Drainage of Subretinal Fluid 67101, 67105, 67107, 67108, 67113
Encircling 67107
Imbrication 67107
Photocoagulation 67105, 67107, 67108
with Removal of Lens 67113
by Scleral Buckling 67107, 67108, 67113
Scleral Dissection 67107
Tamponade 67108, 67113
with Vitrectomy 67108, 67113
Prophylaxis
Detachment 67141-67145
Retinopathy
Destruction
Detection 92201
Macular Degeneration
Dilated Macular Exam 2019F
Treatment
Cryotherapy 67229
Photocoagulation 67228, 67229
Retinacular
Knee
Release 27425
Retinopathy
Destruction
Detection 92201, 92227-92229
Macular Degeneration
Dilated Macular Exam 2019F
Monitoring 92227-92229
Treatment
Cryotherapy 67229
Photocoagulation 67228, 67229
Retraction, Clot
Retrieval
Cranial Bone Graft 62148
Filter
Vena Cava 37193
Foreign Body
Intravascular 37197
Oocyte 58970
Suture
from Iris 66682
Retrocaval Ureter
Ureterolysis 50725
Retrograde Cholangiopancreatography, Endoscopic
See Cholangiopancreatography
Retrograde Cystourethrogram 51610

Retrograde Pyelogram 74420
Retroperitoneal Area
Abscess
Open 49060
Percutaneous 49406
Biopsy 49010
Cyst
Endometriomas
Exploration 49010
Needle Biopsy
Mass 49180
Tumor
Retroperitoneal Fibrosis
Ureterolysis 50715
Retropubic Prostatectomy 55831, 55840-55845, 55866

Revascularization
Artery
Coronary 92937, 92938, 92941, 92943, 92944
Femoral/Popliteal 0505T, 37224-37227
Iliac 37220-37223
Tibial/Peroneal 37228-37235
Coronary Artery Bypass Graft 92937, 92938, 92941, 92943, 92944
Distal Revascularization and Interval Ligation (DRIL) 36838
Distal Upper Extremity
with Interval Ligation 36838
Interval Ligation
Distal Revascularization and Interval Ligation (DRIL) 36838
Penis 37788
Transmyocardial 33140, 33141
Reversal, Vasectomy
Vasovasorrhaphy 55400
Reverse T3
Triiodothyronine, Reverse 84482
Reverse Triiodothyronine
Revision
See also Reconstruction
Abdomen
Intraperitoneal Catheter 49325
Adjustable Gastric Restrictive Device 43771
Aorta 33404
Breast
Peri-Implant Capsule 19370
Bronchial Stent 31638
Bronchus 32501
Bypass Graft
Vein Patch 35685
Cervicoplasty 15819
Colostomy
See Colostomy, Revision
Cornea
Prosthesis 65770
Reshaping
Keratophakia 65765
Ear, Middle 69662
Electrode
Chest Wall
Eye
Aqueous Shunt 66184, 66185
Gastric Restrictive Procedure
Other than Adjustable Gastric Restrictive Device 43848
Hip Replacement 27134, 27137, 27138
Hymenal Ring 56700
Ileostomy 44312, 44314
Infusion Pump
Intra-arterial 36261
Intravenous 36576-36578, 36582, 36583
Iris
Iridoplasty 66762
Iridotomy 66761
Jejunostomy Tube 44373
Lower Extremity Arterial Bypass 35879-35881
Rhytidectomy 15824-15829
Shoulder Joint 23470, 23472-23474
Shunt
Intrahepatic Portosystemic 37183
Sling 53442
Stapedectomy 69662
Stomach
for Obesity 43848
Subcutaneous Port
for Gastric Restrictive Procedure 43886
Tracheostomy
Scar 31830
Urinary-Cutaneous Anastomosis 50727, 50728
Vagina
Prosthetic Graft 57295, 57296, 57426
Sling
Stress Incontinence 57287
Venous Access Device 36576-36578, 36582, 36583, 36585
Ventricle
Ventriculomyectomy 33416
Ventriculomyotomy 33416
Rh (D)
Rh Immune Globulin
Rheumatoid Factor 86430, 86431

Rhinectomy
Partial 30150
Total 30160
Rhinomanometry 92512
Rhinopharynx
See Nasopharynx
Rhinophyma
Repair 30120
Rhinoplasty
Primary 30400-30420
Rhinoscopy
See Endoscopy, Nose
Rhinotomy
Lateral 30118, 30320
Rhizotomy 63185-63190
Rho Variant Du 86905
Rhomboid Flap 14000-14302
Rhytidectomy
Cheek, Chin, and Neck 15828
Forehead 15824
Glabellar Frown Lines 15826
Neck 15825
Superficial Musculoaponeurotic System (SMAS) Flap 15829
Rhytidoplasties
See Rhytidectomy
Rib
Excision 21600-21616, 32900
Fracture
Open Treatment
with Internal Fixation 21811-21813
Graft
to Face 21230
Resection 21601-21603, 32900
X ray 71100-71111
Riboflavin 84252
Richardson Procedure
Urethromeatoplasty 53460
Rickettsia
Antibody 86757
Ridge, Alveolar
Fracture
Right Atrioventricular Valve

See Tricuspid Valve
Right Heart Cardiac Catheterization 93451, 93456, 93503
Risk Factor Reduction Intervention
Group 99411, 99412
Individual 99401-99404
Risser Jacket
Application 29010-29015
Removal 29710
Rocky Mountain Spotted Fever 86000

Roentgen Rays
See X ray
Roentgenographic
See X ray
Roentgenography
See X ray
Ropes Test 83872

Ross Information Processing Assessment 96125
Rotation Flap
Adjacent Tissue Transfer 14000-14350
Rotator Cuff
Repair 23410-23420
Rotavirus
Antibody 86759
Antigen Detection
Immunoassay 87425
Rotavirus Vaccine
2 Dose 90681
3 Dose 90680
Round Window Fistula
Repair 69667
Round Window
Repair Fistula 69667
Roux-En-Y Procedure
Anastomosis
Biliary Ducts and Gastrointestinal Tract 47780, 47785
Pancreatic Cysts to Gastrointestinal Tract 48540
Cholecystoenterostomy 47740, 47741
Gastrectomy 43621, 43633
Laparoscopic Gastroenterostomy 43644, 43846
RPR (Rapid Plasma Reagin)
RSV
See Respiratory Syncytial Virus
RT3
Rubbing Alcohol
Rubella
Antibody 86762
Vaccine 90707, 90710
Rubella HI Test
Hemagglutination Inhibition Test 86280
Rubella/Mumps
Vaccines 90707, 90710
Rubeola
Antibody 86765
Antigen Detection
Rubeolla
See Rubeola
Russell Viper Venom Time 85612, 85613
S
Sac, Endolymphatic
Sacral, Pre-
Presacral Interbody Arthrodesis 22586, 22899
Sacral Nerve
Implantation
Electrode Array 64561, 64581
Sacroiliac Joint
Arthrodesis
Open 27280
Percutaneous 27279
Arthrotomy 27050
Biopsy 27050
Dislocation
Fusion 27280
Injection, Anesthetic/Steroid
for Arthrography 27096
Nerves 64451
X ray 72200-72202
Sacrum
Augmentation
Bone Biopsy 0200T, 0201T
Sacroplasty
Tumor
Excision 49215
X ray 72220
Sahli Test
Gastric Secretory Study 43755
Salicylate
Assay 80329-80331
Saline-Solution Abortion 59850, 59851

Salivary Duct
Ligation 42510, 42665
Repair 42500-42505
Fistula 42600
Salivary Gland
Abscess
Parotid 42300-42305
Sublingual 42310
Submaxillary 42310-42320
Biopsy 42405
Calculi (Stone)
Cyst
Excision 42408
Duct
See Salivary Duct
Excision
Parotid Gland 42410, 42415, 42420, 42425, 42426
Sublingual Gland 42450
Submandibular Gland 42440, 42509
Injection
X ray 42550
Needle Biopsy 42400
Nuclear Medicine
Imaging 78230, 78231
Tumor
Parotid
Excision 42410, 42415, 42420, 42425, 42426
X ray 70380-70390
with Contrast 70390
Salivary Gland Virus

See Cytomegalovirus
Salmonella
Antibody 86768
Salpingectomy
Complete or Partial 58700
Laparoscopic 58661
for Ectopic Pregnancy 59120
Laparoscopic 59151
with Oophorectomy 58943
with Vaginal Hysterectomy 58262, 58263, 58291, 58292
Salpingohysterostomy 58752
Salpingolysis 58740
Laparoscopic 58660
Salpingoneostomy 58673, 58770

Salpingo-Oophorectomy 58720
Laparoscopic 58571, 58573, 58575
Resection Ovarian Malignancy 58950-58958
Resection Peritoneal Malignancy 58950-58958
Resection Tubal Malignancy 58950-58958
Salpingoplasty 58752
Salpingostomy 58673, 58770
Laparoscopic 58673
Salter Osteotomy of the Pelvis 27158

Sampling
See also Biopsy; Brush Biopsy; Needle Biopsy
Blood
Arterial 36620
Fetal Scalp 59030
Ocular 0198T
Organ 36500
Plasma 78110, 78111
Red Cell 78120, 78121
Venous 75893
Chorionic Villus 59015, 76945
Endometrium 58100, 58558
Lymph Node
Endobronchial Ultrasound (EBUS) Guided
Hilar 31652, 31653
Mediastinal 31652, 31653
Para-Aortic 57109, 57531, 58200, 58210, 58548
Pelvic 58200
Periaortic 38572, 38573
Stereotactic Template Guided 55706
Sao Paulo Typhus 86000

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)
Antibody Detection
Pathogen Detection
Saucerization
Calcaneus 28120
Clavicle 23180
Femur 27070, 27360
Fibula 27360, 27641
Hip 27070
Humerus 23184, 24140
Ileum 27070
Metacarpal 26230
Metatarsal 28122
Phalanges
Finger 26235, 26236
Toe 28124
Pubis 27070
Radius 24145, 25151
Scapula 23182
Talus 28120
Tarsal 28122
Tibia 27360, 27640
Ulna 25150
Saundby Test
See Occult Blood
Scabies
Examination for Ectoparasites 87220
Scalenotomy
Division, Scalenus Anticus 21700, 21705
Scalenus Anticus
Division 21700, 21705
Scaling
Scalp
Lesion
Destruction 17270-17274, 17276
Excision
Benign 11420-11424, 11426
Malignant 11620-11624, 11626
Shaving 11305-11308
Skin Graft
Flap 15610
Pedicle Formation 15572
Tissue Transfer
Adjacent 14020, 14021
Tumor
Venipuncture
Child 36405
Wound
Repair 12001, 12002, 12004-12007, 12031, 12032, 12034-12037, 13120-13122
Scalp Blood Sampling

Fetal 59030
Scan
Abdomen
See Abdomen, CT Scan
CT
See CT Scan
MRI
PET
See Positron Emission Tomography (PET)
Radionuclide
See SPECT
SPECT
See SPECT
Scanning, Radioisotope
Scanogram 77073
Scaphoid
Fracture
Nonunion
Repair 25440
Replacement 25443
Scapula Bone
Craterization 23182
Cyst
Excision 23140
Diaphysectomy 23182
Excision
Partial 23172, 23182, 23190
Fracture
Closed Treatment
Ostectomy 23190
Repair
Fixation 23400
Scapulopexy 23400
Saucerization 23182
Tumor
Excision 23140, 23210
X ray 73010
Scapulopexy 23400
Scarification
Pleural 32215
Scarification of Pleura 32215

Schanz Operation
Femur, Osteotomy 27448
Schauta Operation
Vaginal Hysterectomy, Radical 58285
Schede Procedure 32905, 32906
Schlicter Test 87197
Schuchard Procedure
Maxilla, Osteotomy 21206
Sciatic Nerve
Administration, Anesthetic or Steroid
Infusion 64446
Decompression 64712
Neuroma
Excision 64786
Neuroplasty 64712
Release 64712
Repair/Suture 64858
Scintigraphy
Scissoring
Skin Tags 11200, 11201
Sclera
Diagnostic Imaging
Excision
Sclerectomy with Punch or Scissors 66160
Fistulization
for Glaucoma
Through Ciliary Body 66999
Sclerectomy with Punch or Scissors with Iridectomy 66160
Thermocauterization with Iridectomy 66155
Trabeculectomy ab Externo 66170, 66172
Trephination with Iridectomy 66150
Lesion
Excision 66130
Repair
with Glue 65286
Reinforcement
with Graft 67255
without Graft 67250
Staphyloma
with Graft 66225
Wound
Operative 66250
Tissue Glue 65286
Scleral Buckling Operation 67107, 67108, 67113
Scleral Ectasia
Scleral Staphyloma Repair 66225
Sclerectomy 66160
Sclerotherapy
Esophageal Varices 43204, 43243
Fluid Collection 49185
Gastric Varices 43243
Hemorrhoids 46500
Perirectal 45520
Venous 36465, 36466, 36468, 36470, 36471
Sclerotomy
See Incision, Sclera
Screening
for Abdominal Aortic Aneurysm (AAA)
Ultrasound 76706
Alcohol and/or Substance Abuse 99408, 99409
Audiology
Bekesy Audiometry 92560
Evoked Otoacoustic Emissions 92558
Colonography CT 74263
Cytopathology
See Cytopathology
Developmental Tests 96110
Drug
See Drug Screen
Ocular 99174, 99177
Oncology
Colorectal
DNA Testing 81528
for Lung Cancer
CT Scan 71271
Ophthalmology
Suprathreshold 92082
See specific clinical topic, Performance Measures
Visual Acuity 99173
Visual Function 99172
Scribner Cannulization 36810

Scrotal Varices
See Varicocele
Scrotoplasty 55175-55180
Scrotum
Abscess
Exploration 55110
Hematoma
Removal
Foreign Body 55120
Repair 55175-55180
Resection 55150
Ultrasound 76870
Scrub Typhus 86000

Second Look Surgery
See Reoperation
Section
See also Decompression
Cesarean
Cranial Nerve 61460
Spinal Access 63191
Gasserian Ganglion
Sensory Root 61450
Nerve Root 63185-63190
Spinal Accessory Nerve 63191
Spinal Cord Tract 63194-63199
Vestibular Nerve
Transcranial Approach 69950
Translabyrinthine Approach 69915
Sedation
Moderate 99151-99153, 99155-99157
with Independent Observation 99151-99153

Sedimentation Rate
Blood Cell
Automated 85652
Manual 85651
Segmentectomy
Breast 19301, 19302
Lung 32484
Thoracoscopic 32669
Seidlitz Powder Test
Radiologic Study with Effervescent Agent Contrast 74221, 74246
Selective Catheterization
with Angiography
Carotid Arch 36223, 36224
Carotid Artery 36222-36224, 36227, 36228
Cervicocerebral Arch 36222-36226
Vertebral Vessels 36225, 36226, 36228
Arterial
First Order
Abdominal 36245
Brachiocephalic Branch 36215
Pelvic 36245
Renal 36251, 36252
Thoracic Branch 36215
Second Order
Abdominal 36246
Brachiocephalic Branch 36216
Pelvic 36246
Thoracic Branch 36216
Superselective
Brachiocephalic Branch 36217, 36218
Pelvic 36247, 36248
Renal 36253, 36254
Thoracic Branch 36217, 36218
Venous
First Order Branch 36011
Second Order Branch 36012
Sel

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Symbols

Modifiers (See Appendix A for definitions)

Anesthesia Physical Status Modifiers

Modifiers Approved for Hospital Outpatient

Printed in the United States of America. 20 21 22/ BD-RD / 9 8 7 6 5 4 3 2

Professional ISBN: 978-1-64016-049-1

1st Edition printed 1966

No part of this publication may be reproduced, stored in a retrieval system,

To purchase additional CPT products, contact the American Medical

To request a license for distribution of products containing or reprinting CPT

*Member of the CPT Executive Committee

Illustrated Anatomical and Procedural Review

Evaluation and Management (E/M) Services Guidelines

Evaluation and Management

Radiology Guidelines (Including Nuclear Medicine and Diagnostic

Pathology and Laboratory Guidelines

Pathology and Laboratory

Category III Codes

Appendix B—Summary of Additions, Deletions, and Revisions

Appendix C—Clinical Examples

Appendix E—Summary of CPT Codes Exempt from Modifier 51

Appendix F—Summary of CPT Codes Exempt from Modifier 63

Appendix G—Summary of CPT Codes That Include Moderate

Appendix H—Alphabetical Clinical Topics Listing (AKA – Alphabetical

Appendix I—Genetic Testing Code Modifiers

Appendix J—Electrodiagnostic Medicine Listing of Sensory, Motor, and

Appendix K—Product Pending FDA Approval

Appendix L—Vascular Families

Appendix M—Renumbered CPT Codes–Citations Crosswalk

Appendix N—Summary of Resequenced CPT Codes

Appendix O—Multianalyte Assays with Algorithmic Analyses and

Appendix P—CPT Codes That May Be Used For Synchronous

Current Procedural Terminology (CPT®), Fourth Edition, is a set of codes,

▶ Release of CPT Codes◀

▶ CPT Code Set Update Calendar◀

Section Numbers and Their Sequences

Instructions for Use of the CPT

Format of the Terminology

Requests to Update the CPT Nomenclature

Application Submission Requirements

General Criteria for Category I, II, and III

Place of Service and Facility Reporting

Results, Testing, Interpretation, and

Alphabetical Reference Index

Use of Anti-Piracy Technology in CPT

References to AMA Resources

▶◀ = Contains new or revised text

Prefixes, Suffixes, and Roots

Suffix Meaning Example

Directions and Positions

Evaluation and Management

▶ E/M Guidelines Overview◀

▶Summary of Guideline Differences◀

▶ Component(s) Office or Other Other E/M Services (Hospital Observation,

Definitions of Commonly Used Terms

▶ Guidelines Common to All E/M Services◀

New and Established Patient

Decision Tree for New vs Established Patients

Concurrent Care and Transfer of Care

▶ Services Reported Separately◀

History of Present Illness

Nature of Presenting Problem