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 (Surgery)

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.

CPT Surgical Package Definition

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 Surgical 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 (Surgery)

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 (Surgery)

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 (Surgery)

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).

Unlisted Service or Procedure (Surgery)

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 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 (Surgery)

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.

Imaging Guidance (Surgery)

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

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.

Foreign Body/Implant Definition (Surgery)

An object intentionally placed by a physician or other qualified health care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant. An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.

Graft Procurement

Codes that include obtaining or harvesting a graft include the work of procuring the graft from the patient during the same operative session.

All services that appear in the Musculoskeletal System section include the application and removal of the first cast, splint, or traction device, when performed. Supplies may be reported separately. If a cast is removed by someone other than the physician or other qualified health care professional who applied the cast, report a cast removal code (29700, 29705, 29710).

Subsequent replacement of cast, splint, or strapping (29000-29750) and/or traction device (eg, 20690, 20692) during or after the global period may be reported separately.

A cast, splint, or strapping is not considered part of the preoperative care; therefore, the use of modifier 56 for preoperative management only is not applicable.

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.

Fracture and/or Dislocation Treatment

Fracture and dislocation treatment codes appear throughout the Musculoskeletal System section. These codes are categorized by the type of treatment (closed, percutaneous, open) and type of stabilization (fixation, immobilization). There is no coding correlation between the type of fracture/dislocation (eg, open [compound], closed) and the type of treatment (eg, closed, percutaneous, open) provided. For example, a closed fracture may require open treatment.

Fracture/Dislocation Treatment Definitions

Manipulation: Reduction by the application of manually applied forces or traction to achieve satisfactory alignment of the fracture or dislocation. If satisfactory alignment (reduction) is not maintained and requires subsequent re-reduction of a fracture or dislocation by the same physician or same qualified health care professional, append modifier 76 to the fracture/dislocation treatment code.

Traction: The application of a distracting or traction force to the spine or a limb. Skeletal traction includes a wire, pin, screw, or clamp that is attached to (penetrates) bone. Skin traction is the application of force to a limb using strapping or a device that is applied directly to the skin only.

Closed treatment: The treatment site is not surgically opened (ie, not exposed to the external environment nor directly visualized). Closed treatment of a fracture/dislocation may be performed without manipulation (eg, application of cast, splint, or strapping), with manipulation, with skeletal traction, and/or with skin traction.

Casting, splinting, or strapping used solely to temporarily stabilize the fracture for patient comfort is not considered closed treatment.

Percutaneous skeletal fixation: Treatment that is neither open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (eg, pins, screws) is placed across the fracture site, typically with imaging guidance.

Open treatment: The site is opened surgically to expose the fracture/dislocation to the external environment for treatment, or the fracture/dislocation is treated through the traumatic wound or an extension thereof or is treated with an intramedullary nail or other internal fixation device placed through a surgical exposure that is remote from the fracture site with or without direct visualization of the fracture site.

External fixation: The use of pins and/or wires that penetrate the bone(s) and interconnection devices (eg, clamps, bars, rings) for fracture/dislocation treatment. External fixation may be used for temporary or long-term fracture/dislocation treatment. Uniplanar external fixation places all the pins in approximately the same plane but may also include triangular fixation across a joint. Multiplanar external fixation uses transosseous wires and threaded pins placed in several planes that are held with interconnected stabilizing and/or tensioning rings and/or half rings. External fixation may be used for all types of fracture/dislocation treatment (ie, closed, percutaneous, open). Codes for external fixation are reported separately only when external fixation is not listed in the code descriptor as inherent to the procedure.

Reporting Fracture and/or Dislocation Treatment Codes

The physician or other qualified health care professional providing fracture/dislocation treatment should report the appropriate fracture/dislocation treatment codes for the service he or she provided. If the person providing the initial treatment will not be providing subsequent treatment, modifier 54 should be appended to the fracture/dislocation treatment codes. If treatment of a fracture as defined above is not performed, report an evaluation and management code.

Excision/Resection Soft Tissue Tumors Definitions

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.

Including tibial plateaus.