Incision and drainage of infected or noninfected sebaceous cyst

Incision and drainage of furuncle

Acne surgery; marsupialization, opening, or removal of multiple milia, comedones, cysts, pustules, etc.

Incision and drainage of carbuncle, suppurative hidradenitis and other cutaneous or subcutaneous abscesses simple

extensive

Drainage of pilonidal cyst

Drainage of onychia or paronychia

multiple or complicated

Incision and removal of foreign body, subcutaneous tissues, simple

complicated by

Drainage of hematoma, simple

complicated

Puncture aspiration of abscess or hematoma

Debridement of extensively eczematized or infected skin up to 10% of the body surface

for each additional 10% of body surface, add

Debridement of nails, any method, five or less

for each additional five or major portion thereof

Debridement of abrasions

Biopsy; excision of skin, subcutaneous tissue or mucous membrane for biopsy (including simple closure) (independent procedure)

lesion

up to

¼

inch

lesion

¼

to

½

lesion

½

to

¾

lesion

more than

¾

inch or complicated

lesion diameter up to

¼

inch

lesion

¼

to

½

inch

lesion

½

to

¾

inch

lesion

up to

¼

inch

lesion

up to

½

inch

lesion

½

to

¾

inch

lesion

up to

¼

inch

lesion

¼

to

½

inch

lesion

½

to

¾

inch

Lesions over

¾

inch, complicated or unusually located

Avulsion, nail, partial, or complete, simple

Excision of nail or nail matrix, partial or complete, e.g., ingrown or deformed nail for permanent removal

Excision of pilonidal cyst or sinus

Injection, intralesional (up to and including seven lesions)

more than seven

Wounds, recent, up to 2

½

inches

for each additional inch add

up to

½

inch, forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

½

inch to 1 inch, trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

1 inch to 3 inches, trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, none, ears and lips

Unusual, complicated or over 3 inch linear repair

for defect up to 1 square inch, trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

defect size between 1 square inch and 3 square inches, trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

more than 3 square inches, unusual or complicated

by advancement flaps, up to

¼

eyelid margin

over

¼

of eyelid margin

by transfer flaps of tarso–conjunctivea from opposing eyelid, up to

²/₃

of eyelid

total eyelid, one or more stages, lower lid

upper lid

Pinch, split or full thickness skin to cover small ulcer, tip of digit or other minimal open area (except on face, use 0301–0304) up to defect size

¾

inch diameter

Split skin graft, up to 16 square inches (except 0300), trunk, scalp, arms, legs, hands and feet (except multiple digits)

each additional 16 square inches or part thereof

face, neck, ears, genitalia or multiple digits

each additional 16 square inches or part thereof

Full thickness, free, up to 3 square inches, including direct closure of donor site, trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

Pedicle flap, direct flap, direct or tubed, (including direct closure of donor site) trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

delay, intermediate transfer or sectioning of pedicle of tubed or direct flap, trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

excision of lesion and/or preparation of recipient site and attachment of direct or tubed pedicle flap, trunk

scalp, arms and legs

forehead, cheeks, chin, mouth, neck, axilla, genitalia, hands and feet

eyelids, nose, ears and lips

Composite graft (full thickness of external ear or nasal ala)

Derma–fat–fascia–graft (except to breast–0484)

Abrasion of skin, total face, for removal of scars, tattoos, etc. primary

secondary, total face

regional (

¼

face, cheeks, chin, forehead or elsewhere) primary

secondary, regional

Rhytidectomy, lower eyelids

upper eyelids

forehead

glabellar frown

cheeks, chin and neck

Facial nerve paralysis, free fascia grafts

re-animation–muscle transfers

Initial treatment, first degree, where no more than local treatment necessary

Dressings, initial or subsequent under anesthesia, small

under anesthesia, large or with major debridement, per hour

without anesthesia, small, office or hospital

without anesthesia, medium (whole face or whole extremity, etc.)

without anesthesia, large (more than one extremity, etc.)

Electro–surgical destruction with or without surgical curettement of facial nevi, leukoplakia, actinic or senile keratoses, or keratoacanthomas, to include local anesthesia, one lesion

complicated lesion(s)

Electro–surgical destruction (except 0401 and 0402) or chemocautery (Mono–, Bi–, Tricholoracetic acid, phenol, etc.) or cryocautery (liquid N

, CO

, etc.) of benign or pre–malignant lesions of skin or mucous membrane (except 0405 and 0406) with or without curettement one lesion

complicated lesion(s)

flat (plane, juvenile) warts, up to fifteen

Electro–surgical destruction of multiple fibro–cutaneous tags, up to fifteen

Chemosurgery, (Mohs type technique), malignancies of skin, includes removal of growth and microscopic delineation of margins and base,

—fulguration and application of chemicals

each subsequent treatment, up to five sections

each additional section over five

Cryotherapy—(CO

slush, liquid N

)

Electrolysis epilation, each

½

hour

Puncture aspiration of cyst

Mastotomy with exploration or drainage of abscess, deep

Biopsy of breast

Excision of cyst, fibro–adenoma or other benign tumor, aberrant breast tissue, duct lesion (including gynecomastia) or nipple lesion (including any other partial mastectomy) male or female, unilateral

bilateral

Excision of chest wall tumor involving ribs

Excision of chest wall tumor involving ribs plus plastic reconstruction

Complete (simple) mastectomy

Radical mastectomy, including breast, pectoral muscles and axillary lymph nodes

Mammoplasty, plastic operation on breasts, reduction or repositioning, bilateral, one stage

two stage

augmentation, prosthetic, unilateral

bilateral

derma–fat fascia, unilateral

Aspiration or curette biopsy of bone marrow

Needle (trocar) biopsy vertebra

Incision of superficial soft tissue abscess secondary to osteomyelitis

deep or complicated

Sequestrectomy for osteomyelitis or bone abscess

Removal of metal band, plate, screw or nail (independent procedure)

Clavicle

Humerus

Radius

Ulna

Femur, neck, under age 8

over age 8

subtrochanteric

supracondylar

Tibia

Smaller bones (fibula, metacarpals, metatarsals, etc.)

Correction of bowlegs or knock–knees, unilateral

bilateral

Multiple osteotomies, single bones for realignment on intrameduliary rod, Scofield type procedure, humerus

radius or ulna

femur

tibia

Biopsy bone, radius, ulna, fibula, skull, sternum

humerus, pelvis, femur, tibia

vertebra

Claviculectomy, partial

total

Astragalectomy

Excision of head of radius

Carpectomy

Coccygectomy

Patellectomy or hemipatellectomy

Metatarsectomy

Excision of chondroma, osteochondroma, or exostosis; humerus, pelvis, femur, tibia, radius, fibula, ulna

small bones

Excision of bone cyst, simple, large bones

small bones

Partial ostectomy; partial excision of bone, craterization, guttering or saucerization of bone; diaphysectomy; humerus, pelvis, femur, tibia, fibula, radius, ulna

small bones

Excision of tumor of mandible without replacement

Radical resection of bones for tumor with bone graft; scapula, humerus, pelvis, femur, tibia

other bones

Insertion of wire, pin, caliper or tongs (independent procedure)

Removal buried wire or pin (independent procedure)

Removal of caliper or tongs (independent procedure)

Osteoplasty; shortening of bone, femur, tibia, humerus

radius, ulna

other bones

lengthing of bone

mandible for prognathism or micrognathism, one or two stages

Bone graft; femur, tibia, humerus

radius, ulna

skull or significant portion of mandible

other bones, including chin, nose, malar prominences

Cartilage graft, autogenous, to face, nose, ear or skull

Spinal fusion, cervical region, posterior technique

anterior technique

thoracic region, posterior or posterior-lateral technique

interbody technique, anterior, lateral or posterior

lumbar region, posterior or posterior–laterial technique

Spinal fusion with removal of intervertebral disc, cervical region, posterior, technique

anterior interbody technique

lumbar or thoracic region, posterior, posterior–lateral, or posterior interbody technique

anterior interbody technique

Spinal fusion for scoliosis, child or young adult (less than 18 years of age), up to and including five interspaces

Harrington rod technique

Halo technique

Scapulopexy

Patellapexy

Pectus excavatum, infants, plastic repair

Pectus excavatum (major) plastic repair

Epiphyseal–diaphyseal fusion; epiphyseal arrest; epiphysiodesis or stapling; femur

tibia and fibula, proximal or distal

combined distal femur and proximal tibia and fibula (knee)

combined proximal and distal, tibia and fibula

combined distal femur and proximal and distal tibia and fibula

Hemi–epiphyseal arrest (e.g., for genu varus or genu valgus) distal femur

Skull, non–operative

Nasal, simple or compound, no reduction

uncomplicated (digital) closed reduction

complicated (instrumental) closed reduction

open reduction, uncomplicated

complicated with either internal and/or external skeletal fixation

with concomitant open reduction of fractured septum

Malar, simple or compound, no reduction

closed reduction (including towel clip technique)

depressed, open reduction

complicated, depressed, open reduction with internal skeletal fixation and multiple surgical approaches

Maxilla, simple or compound, no reduction

closed reduction, with wiring of teeth

open reduction, with wiring of teeth and/or local fixation

complicated, open reduction, fixation by head cap, multiple surgical approaches, internal fixation, wiring teeth, etc

Mandible, simple or compound, no reduction

closed reduction and wiring of teeth

open reduction with or without wiring of teeth

skeletal pinning with external fixation

Vertebral process, one or more

Vertebral body, one or more not requiring reduction

requiring reduction

Sacrum, simple not requiring reduction

compound or complex

Coccyx, simple, not requiring reduction

compound or complicated

Clavicle, simple, no reduction

simple, closed reduction

compound, including uncomplicated soft tissue closure

simple or compound, open reduction

Scapula, simple, no reduction

simple or compound, open reduction

Sternum, simple

compound or complicated

Ribs, simple

compound or complicated

Fracture, simple, no reduction

complicated, closed reduction

compound, open reduction

Acetabulum, with or without other fractures of pelvis, simple, no reduction

central, with displacement, requiring closed reduction

simple or compound, open reduction

Humerus, surgical neck, simple, not requiring reduction

requiring manipulative reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

shaft, simple, not requiring reduction

simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

simple or compound, open reduction, skeletal pinning with external fixation

supracondylar or dicondylar, not requiring reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

medial or lateral condyle, simple, not requiring reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Elbow, proximal end of ulna with dislocation of radial head simple, (Monteggia fracture) closed reduction

simple or compound, open reduction (See also 1292.)

Radius, head, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction or excision (See also 0556.)

shaft, simple, no reduction

simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

distal end (e.g., Colle's type), simple, no reduction

closed reduction

with severe comminution and impaction, closed reduction

simple or compound, open reduction

skeletal pinning, with external fixation

Ulna, proximal end, olecranon process, simple, no reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction and/or resection

shaft, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

skeletal pinning with external fixation

Radius and ulna shaft, simple, no reduction

simple, closed reduction

compound, with uncomplicated soft tissue closure

simple compound, open reduction

skeletal pinning with external fixation

Carpal bones, one or more, simple reduction

simple or compound, open reduction

Metacarpal, simple, no reduction

one, simple or compound, closed reduction with uncomplicated soft tissue closure

more than one, simple or compound, closed reduction, with uncomplicated soft tissue closure

one or more, simple or compound, open reduction

skeletal pinning with external fixation

Phalanx or phalanges, finger, proximal, middle or thumb, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Phalanx or phalanges, distal, simple, no reduction

simple or compound, closed reduction with uncomplicated soft tissue closure

simple or compound, open reduction

Femur, neck, simple, no reduction

with fixation or traction

simple or compound, open reduction

multiple pinning, with or without external fixation

treatment with replacement prosthesis

intertrochanteric, simple, no reduction

with fixation or traction

simple or compound, open reduction

slipped epiphysis, no reduction, treatment by traction, bed rest or cast application

open reduction, single or multiple pinning or bone graft

reconstruction

shaft, including supracondylar, simple, no reduction

simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

skeletal pinning with external fixation

distal end, medial or lateral condyle, simple, no reduction

condyle or condyles, simple, closed reduction

simple or compound, open reduction

Patella, simple, no reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Tibia, proximal end, tibial plateaus, condyle, condyles or intercondylar spines, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

shaft, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compounded, open reduction

simple or compound, open or "blind" insertion of intramedullary rod (e.g., Lottes nail)

distal end, malleolus, simple, no reduction

simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Fibula, shaft, simple, no reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

distal end, malleolus, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Tibia and fibula, shafts, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

skeletal pinning with external fixation

Ankle, bimalleolar (including Potts) simple, no reduction

simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

trimalleolar, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Tarsal (except astragalus and os calcis) one or more, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Astragalus, simple, no reduction

simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Os calcis, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

skeletal pinning with external fixation

Metatarsal, simple, no reduction

closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Phalanx or phalanges, great toe, simple, no reduction

simple, closed reduction

simple or compound, open reduction

other than great toe, simple, no reduction

closed reduction

simple or compound, open reduction

Shoulder

Elbow

Wrist

Other joints of upper extremity

Finger, one

Hip

Knee

Ankle

Other joints of lower extremity

Toe, great toe

other

Arthrocentesis; puncture for aspiration of hemarthrosis, initial

subsequent

puncture for aspiration of joint effusion (not traumatic), or injection of medication, initial or subsequent

Sesamoid bone, excision, one or more, unilateral

Temporomandibular joint, unilateral

Excision of intervertebral disc

Meniscectomy: excision of semilunar cartilage of knee joint

temporomandibular joint

Synovectomy elbow

hip

knee

ankle

Injection procedure for arthography

Shoulder (See also 1200, 1201.)

Elbow

Wrist

Finger, one joint

Hip, cup

replacement prosthesis, primary for fracture

secondary reconstruction

Knee

Ankle

Toe, one joint

Metatarsal—phalangeal joint; bunion operation, Silver type

Keller, McBride, etc., types

Joplin type

Club foot corrective procedure, medial release, Brockman type

Shoulder

Elbow

Wrist

Finger, thumb, one joint

Hip

Knee

Ankle

Toe, one or more joints

Hammer toe operation, one toe (

inter–phalangeal fusion, filleting, phalanectomy)

Tarsal joints, one or more (

Grice procedure)

Other joints, lower extremity

Foot, triple arthrodesis, unilateral under age 14 years

over age 14 years

Shoulder, suture or repair of joint capsule for recurrent dislocation (independent procedure), Putti–Platt, Magnusen types

Bankart type

Patella (See also 0561, 1352, 1632.)

Knee, suture of a torn, ruptured or severed collateral ligament

suture of a torn, ruptured or severed cruciate ligament

suture of torn, ruptured or severed collateral and cruciate ligaments

reconstruction of a collateral or cruciate ligament

both collateral or cruciate ligaments

Ankle, reconstruction of a collateral ligament, ankle

both ligaments

Hand, reconstruction, metacarpophalangeal or interphalangeal ligaments

Shoulder

Elbow

Wrist

Digits, one or more, under anesthesia, where no other surgical procedure is performed

Hip

Knee

Ankle

Spine

Temporomandibular, simple, closed reduction, initial

subsequent

Vertebra, cervical, simple, closed reduction, using traction

closed reduction with anesthesia

thoracic, simple, closed reduction with anesthesia

simple or compound, open reduction

lumbar, simple, closed reduction with anesthesia

simple or compound, open reduction

Clavicle, sternoclavicular, simple, no reduction

closed reduction with anesthesia

simple or compound, open reduction

acromioclavicular, simple, no reduction

closed reduction with anesthesia

simple or compound, open reduction

Shoulder (humerus), simple, closed reduction without anesthesia

with anesthesia

simple or compound, open reduction

Elbow, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Wrist, carpal, one bone, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

more than one bone, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Metacarpal, one bone, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Finger, one, one or more joints, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Thumb, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Hip (femur), simple, closed reduction

simple or compound, open reduction

congenital, abduction splinting or traction in any form

congenital, closed reduction with anesthesia

congenital, open reduction and replacement of femoral head in acetabulum

iliac or acetabular osteotomy, (

Pemberton or Salter type), under age 8

over age 8

Knee (femoral–tibial joint), simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Patella, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction (with or without partial or total patellectomy)

Distal tibial–fibular joint (ankle mortise), open reduction and fixation

Ankle, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Tarsal, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Astragalo–tarsal, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Metatarsal, one bone, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Toe, one, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

multiple joints and/or toes, simple, closed reduction

compound, with uncomplicated soft tissue closure

simple or compound, open reduction

Drainage of infected bursa

Removal of subdeltoid calcium deposits

Removal of subtrochanteric calcium deposits

Needle puncture of bursa, with or without aspiration, injection or irregation, initial or subsequent

Radical excision of bursa, hand, wrist or forearm, (

tenosynovitis fungosa, Tbc., and other granulomas)

Excision of bursa, olecranon

prepatellar

subacromial (subdeltoid)

peritrochanteric, femur

Removal of foreign body in muscle, with anesthesia

Division of scalenus anticus, without resection of cervical rib

with resection of cervical rib

Division of sternocleidomastoid for torticollis open operation

Muscle biopsy, superficial

deep

Suture of ruptured diaphragm, chronic, transabdominal

transthoracic or combined

acute, traumatic

Drainage of tendon sheath, acute suppurative tenosynovitis, one digit

single palmar and/or ulnar or radial bursa

multiple or complicated

Injection of medication, tendon sheath

Incision of fibrous sheath of tendon for stenosing tenosynovitis, including freeing of tendons or removal of foreign body

Division of iliotibial band, open operation

Stripping of ilium (Soutter operation)

Tenotomy, subcutaneous, corrective, single digit

multiple digits

adductor, hip

open, elbow to shoulder, single

multiple

elbow to wrist, single

multiple

knee to hip, single

multiple

knee to thigh, single

multiple

Excision of lesion of tendon or fibrous sheath, or ganglion, digits only

in other locations

Excision of synovial cyst of popliteal space (Baker's cyst)

Fasciotomy, palmar plantar, subcutaneous

Fasciectomy, for Dupuytren's contracture, partial

radical, including finger extensions and vertical bands

Repair or suture of an extensor tendon, primary or late, hand or foot, distal to wrist or ankle

forearm or leg

Repair or suture of a flexor tendon, primary or late, finger, hand or forearm foot or leg

Transfer, transplant or free tendon graft, distal to elbow, or distal to knee, single

multiple

elbow to shoulder or knee to hip, single

multiple

Tenolysis, single

multiple (any number through same incision)

Lengthening or shortening of tendon (

Achilles' tendon)

Multiple tendons and/or other structures through same incision or wound

Free fascial graft for reconstruction of tendon pulley or gliding surface, etc.

Abdominal fascial transplants, bilateral (Lowman type procedure)

Fascia lata transplants, other

Patellar (extensor mechanism) advancement, with or without patellectomy

Ruptured quadirceps insertion

Ruptured Achilles' tendon from insertion at heel

Ruptured long head of biceps, proximal

Ruptured biceps tendon from insertion at elbow

Flexor–plasty, elbow (e.g., Steindler type advancement or extensor release)

Repair ruptured supraspinatus tendon or musculotendinous cuff shoulder, acute

Repair of complete shoulder cuff avulsion, chronic

Drainage of felon, superficial

in hospital

Interthoracoscapular

Disarticulation of shoulder

Arm through humerus

Forearm, through radius and ulna

Open (Guillotine) arm

secondary closure or minor scar revision

reamputation

Cineplasty, complete procedure

Disarticulation through wrist or amputation of hand through metacarpal bones

Metacarpal, with finger or thumb, one, with or without split or Wolff graft, or skin–plasty and/or tenodesis, with or without resection of digital nerves

Digit (finger or thumb), any joint or phalanx, one, with or without split or Wolff graft, or skin–plasty and/or tenodesis, with or without resection of digital nerves

Interpelviabdominal

Disarticulation of hip

Disarticulation of knee

Thigh, through femur, including supracondylar

open (Guillotine)

secondary closure or minor revision

reamputation

Leg, through tibia and fibula

open (Guillotine)

secondary closure or minor revision

re-amputation

Ankle (Syme, Pirogoff types), with skin–plasty and resection of nerves

Midtarsal

Foot, transmetatarsal

Metatarsal with toe, with or without split or Wolff graft, or skin–plasty and/or tenodesis, with or without resection of digital nerves

Toe, one, with or without split or Wolff graft, or skin–plasty and/or tenodesis, with or without resection of digital nerves

more than one

Freeing of web fingers, with flaps

with skin graft

complex

with molding or manipulation, long or short leg, under age of 24 months, single

bilateral

Wedging

single

bilateral

Molded plaster to forearm (splint)

Elbow to fingers (short arm)

Hand and wrist (gauntlet)

Shoulder to hand (full arm)

Shoulder spica

Thigh–foot, molded splint

Leg–foot, molded splint

Ankle (foot to midleg) (short leg)

Knee (foot to thigh) (long leg)

Ambulatory leg cast (walking boot cast)

Hip spica, unilateral

bilateral

Body, shoulder to hips

including head

Risser jacket, localizer, body only

including head

Turnbuckle jacket, body only for scoliosis

including head

"Halo" type fixation and cast

Unna boot

large, (e.g., long leg, shoulder or hip spica, Minerva, Calot jacket, turnbuckle, etc.)

Repair of spica, body cast or jacket

Drainage of nasal abscess or hematoma

Drainage of septal abscess or hematoma

Biopsy, soft tissue, nose

Excision of nasal polyp(s) one or more, unilateral or bilateral, one or more stages, office

complicated, requiring hospitalization

Excision or surgical planning of skin of nose for rhinophyma

Submucous resection, classic, nasal septum

Resection of inferior turbinate (submucous), complete or partial, unilateral or bilateral (independent procedure)

Removal of intranasal foreign body by rhinoscopy

by lateral rhinotomy

Rhinoplasty, lateral and alar cartilages and/or elevation of nasal tip

complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip

including major septal repair

secondary minor revision

Septoplasty, (not 1928) independent procedure

Repair choanal altresia, intranasal

transpalantine

Lysis of synechia

Repair of oromaxillary fistula

with radical antrotomy

Repair oronasal fistula

Reconstruction, functional, of the internal nose

Cauterization of turbinates, unilateral or bilateral (independent procedure)

Nasal hemorrhage, anterior, control of, unilateral or bilateral, with or without cauterization or anterior packs

posterior, with cauterzation or posterior nasal packs, with or without anterior pack, initial

subsequent

by ligation of anterior ethmoidal artery

Antrum lavage. puncture or natural ostium, unilateral

bilateral

Antroscopy

Antrotomy, intranasal, unilateral

bilateral

Radical (Caldwell–Luc), unilateral

bilateral

Sphenoid sinusotomy

Frontal sinusotomy, external, simple (trephine operation)

transorbital, unilateral

radical, obliterative

Combined external frontal, ethmoidal and sphenoidal sinusotomy, unilateral

Ethmoidectomy, intranasal or external, unilateral

Maxillectomy, unilateral, with or without orbital exenteration and/or lateral rhinotomy

Hypophisectomy, transeptal

Laryngofissure with removal of tumor or laryngocele

Thyrotomy, diagnostic

for laryngeal web, two stage, with Keel insertion, (McNaught type)

for laryngeal stenosis with graft or core mold, including tracheotomy

Laryngectomy, without neck dissection

with neck dissection

Hemilaryngectomy

Arytenoidectomy, external approach (See also 2084.)

Epiglottidectomy, external approach

endoral approach

Injection procedure for bronchography, indirect method

with insertion of catheter, (independent procedure)

Endotracheal intubation, emergency procedure

Laryngoscopy, indirect with biopsy

direct, diagnostic (independent procedure)

operative, including foreign body removal

with biopsy

including excision of tumor

with Lynch suspension

Endoscopic arytenoidectomy

Tracheotomy (independent procedure)

Tracheal fenestration

Bronchoscopy, diagnostic

with biopsy

with removal of foreign body

with excision of tumor

with therapeutic aspiration of bronchus

with drainage of lung abscess or cavity, initial

with injection of contrast media

subsequent

Catheterization for bronchospirometry (independent procedure) (exclusive of gas analysis)

Tracheal aspiration (independent procedure) under direct vision

indirect

Tracheoplasty: plastic operation on trachea, cervical

intrathoracic

Bronchoplasty, graft repair

excision of stenosis and anastomosis

with lobectomy and anastomosis

Tracheorrhaphy: suture of external tracheal wound or injury, depending on structure and extent of injury, cervical

intrathoracic

Closure of tracheostomy or tracheal fistula

Closure of tracheo–esophageal fistula

complicated

Thoracotomy, exploratory, including biopsy

including control of hemorrhage and/or repair of lung fistula

for postoperative complications

with open drainage of empyema cavity by rib resection (independent procedure)

with cyst removal

with closed drainage of empyema cavity; tube drainage with negative pressure (independent procedure), in hospital

with removal of intrapleural foreign body or fibrin body

with cardiac massage

with open intrapleural pneumonolysis (See also 2207.)

Pneumonotomy, with open drainage of pulmonary abscess or cyst

with removal of foreign body from lung

Decortication, pulmonary, total

Pneumonocentesis: puncture of lung for aspiration biopsy

Thoracentesis: puncture of pleural cavity for aspiration, initial or subsequent

Pneumonectomy, total

Lobectomy, total, subtotal or segmental

with concomitant decortication

Wedge resection, single or multiple

Pulmonary resection with concomitant thoracoplasty

Pleurectomy, any type (independent procedure)

Thoracoscopy, exploratory (independent procedure)

with biopsy

Closed intrapleural pneumonolysis

Extrapleural resection of ribs, any type, first stage

second stage

third stage

Extrapleural pneumonolysis, including associated filling or packing procedures

Extraperiosteal pneumonolysis, including associated filling or packing procedures

Pneumothorax: intrapleural injection of air, initial

subsequent

Cardiotomy, exploratory (includes removal of foreign body)

Pericardiotomy with exploration, drainage or removal of foreign body

pericardiocentesis, initial

subsequent

Blalock–Hanlon procedure (creation of atrial–septal defect) (closed)

Pericardiectomy, extensive

Excision intracardiac tumor

Infundibular stenosis

Catheterization of heart, including recording of intracardiac pressures where indicated (independent procedure) right

left, percutaneous

trans–septal

retrograde

combined left and right

final evaluation and report only

Cardiorrhaphy: suture of heart wound or injury

Aortic valve, valvotomy (commissurotomy) (closed)

valvuloplasty for stenosis or insufficiency (open)

replacement (open)

Pulmonic valve, valvotomy (commissurotomy) (closed)

valvotomy; infundibular stenosis (open)

Mitral valve, valvotomy (commissurotomy) (closed)

valvuloplasty for stenosis or insufficiency (open)

replacement (open)

Tricuspid valve

Coronary endarterectomy, myocardial revascularization by implantation or anastomosis

Myocardial aneurysm

Atrial septal defect (secundum type; endocardial cushion defect) (open)

Ventricular septal defect (open)

Tetralogy of Fallot (with or without previous shunt) (open)

Aortic sinus of Valsalva fistula (open)

Repair anomaleus pulmonary venous connection, total (open)

Insert internal pacemaker with myocardial electrodes, initial

replacement or repair

Pervenous or transvenous insertion of a pacemaker and subcutaneous implantation of a battery

Subcutaneous implantation of a battery (used with code 2330, right heart catheterization, currently in fee schedule)

Trunk

Neck

Extremity

Trunk

Extremity

Thromboendarterectomy, abdominal aorta and iliac arteries and/or femoral arteries

femoral and/or popliteal arteries

carotid artery

Excision and graft or bypass graft of arch of aorta

Excision and graft, thoracic aorta

abdominal aorta

extremity

Excision of arteriovenous fistula (See also 2474.)

Venopuncture, withdrawal of venous blood, intravenous injection (femoral, internal or external jugular or sagittal sinus) for diagnostic study or introduction of intravenous therapy, up to three years of age

scalp vein, for fluid therapy or indirect transfusion, up to three years of age

Exposure of and incision into vein ("cutdown") for fluid therapy or indirect transfusion, under one year of age

Blood transfusion, indirect method

replacement type, infant, initial or subsequent

direct method

"push" transfusion, given under two years of age

Injection of sclerosing solution into vein of leg, one

two or more injections, same leg

Repair aneurysm of aorta, lateral repair

dissecting ("window" operation)

Banding of pulmonary artery

Repair of aortic arch anomalies (vascular ring)

Repair of atrial septal defect

Repair of arterio–venous fistula, plastic procedure

Excision of coarctation of aorta with primary anastomosis (See also 2400–2408.)

Pulmonary–subclavian anastomosis, Potts

Blalock

Pulmonary–superiorcaval anastomosis, Glenn

Baffes procedure: inferior cava to left atrium–right pulmonary vein to right antrium

Portocaval anastomosis

Splenorenal anastomosis

Arteriorrhaphy: suture of wound or injury of artery (independent procedure), trunk

extremity

Phleborrhaphy: suture of wound or injury of vein (independent procedure), trunk

extremity

Ligation and division of ductus arteriosus

Ligation of carotid artery

Ligation and division of inferior vena cava

Ligation of femoral vein

Ligation and division of common iliac vein

Ligation and division of long saphenous vein at saphenofemoral junction, with or without retrograde injection or distal interruptions

Ligation and division and complete stripping of long or short saphenous veins, unilateral

bilateral

long and short saphenous veins, unilateral

bilateral

Ligation and division of short saphenous vein at saphenopopliteal junction (independent procedure)

minor varicose vein of leg, initial

subsequent

Insertion of initial arterio–venous shunt (Including revisions during 21 follow–up days)

Revision of either arterial or venous cannula

Construction of arterio–venous fistula

Splenectomy

Injection procedure for splenoportography

Drainage of lymph node abscess or lymphadenitis, simple

extensive

Biopsy or excision of lymph node (independent procedure) (except 2642)

anterior scalene

Supra–hyoid, unilateral

bilateral

Cervical (complete), unilateral

Axilla

Groin, superficial

deep, with common iliac dissection

Retroperitoneal, extensive, including pelvic, aortic and renal dissection

Injection procedure for lymph–angiography, unilateral

bilateral

Mediastinotomy with exploration or drainage, cervical approach

transthoracic

Foreign body removal, cervical approach

transthoracic

Excision of mediastinal cyst

Excision of mediastinal tumor

Ligation or repair, thoracic duct

Drainage of sublingual abscess

Drainage of Ludwig's angina

Vermilionectomy ("lip peel")

Transverse wedge excision, lip

V–excision of large lesion of lip up to one–half lip

Resection of more than one–half lip without plastic closure

Plastic repair of cleft lip, primary, unilateral

bilateral, one stage

bilateral, two stages, per stage

Plastic repair (secondary) of unilateral cleft lip by recreation of defect and reclosure

Plastic repair (secondary) of bilateral harelip by recreation of defect and reclosure—per major stage

Drainage of lingual abscess

Biopsy of tongue, anterior third

posterior two–thirds

Partial glossectomy or hemiglossectomy

Complete or total glossectomy

Drainage of alveolar abscess, acute with cellulitis, intraoral

Incision and drainage of abscess of palate

Biopsy of palate

Resection of palate or extensive excision of lesion of palate

Uvulectomy: excision of uvula

Palatoplasty: plastic operation for cleft palate, partial

complete, including alveolar ridge

major revision

secondary lengthening procedure

attachment pharyngeal flap

alveolar ridge, anterior palate defect

Drainage of parotid abscess

Drainage of submaxillary abscess

Sialolithotomy, submaxillary or parotid, uncomplicated

Sialolithotomy, submaxillary, complicated

Sialolithotomy, parotid extraoral

Biopsy of salivary gland

Excision of parotid tumor or gland, superficial without nerve dissection

with nerve dissection

Excision of parotid gland, total, with dissection of facial nerve

with sacrifice of facial nerve

Excision of submaxillary tumor and/or gland

Plastic repair of salivary duct, simple

complicated

Injection procedure for sialography

Closure of salivary fistula

Dilation of salivary duct; ptyalectasis

Drainage of peritonsillar abscess

Drainage of retropharyngeal or parapharyngeal abscess, intraoral

external approach

Biopsy of oropharynx

hypopharynx

nasopharynx

Excision of pharyngoesophageal diverticulum, single stage

multiple stages

Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues

extending beneath subcutaneous tissues

Tonsillectomy, with or without adenoidectomy, under age 18 years

18 years or over

Adenoidectomy (independent procedure), primary or secondary

Excision of tonsil tag(s), hospital

office

Excision of lingual tonsil (independent procedure)

Excision of nasopharyngeal fibroma

Suture of wound or injury of pharynx

Pharyngoplasty: plastic or reconstructive operation on pharynx

Esophagotomy, cervical

for removal of foreign body, cervical

thoracic

Esophagectomy: resection of esophagus, transpleural or extrapleural (upper two–thirds)

Esophagogastrectomy, combined thoraco–abdominal

Local excision, end–to–end anastomosis

Esophagoscopy, diagnostic

with insertion of radioactive substance

with biopsy

with foreign body removal

with dilation, direct

subsequent dilation

Esophagoplasty: plastic repair or reconstruction of esophagus

Esophagogastrostomy (cardioplasty)

Esophagomyotomy (Heller type)

Esophagoduodenostomy (including total gastrectomy)

Esophagojejunostomy, including total gastrectomy

Esophagostomy: fistulization of esophagus, external

Direct ligation of esophageal varices

Suture of esophageal wound, injury or rupture, cervical approach

transthoracic

Closure of esophagostomy or other external esophageal fistula, cervical

thoracic

Dilation of esophagus by sound, bougie or bag, indirect, initial

subsequent

Gastrotomy with exploration or foreign body removal

Pyloromyotomy: cutting of pyloric muscle (Fredet–Ramstedt type operation)

Biopsy by laparotomy

Local excision of ulcer or tumor

Total gastrectomy

Subtotal or hemi–gastrectomy, without vagotomy

with vagotomy

Vagotomy and pylorplasty

Gastroscopy, diagnostic

with biopsy

Pyloroplasty

Gastroduodenostomy

Gastrojejunostomy

with vagotomy

Gastrostomy

Gastrorrhaphy: suture of perforated duodenal or gastric ulcer, wound or injury

Revision of gastroduodenal anatomosis (gastroduodenostomy) with reconstruction, without vagotomy

with vagotomy

Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, without vagotomy

with vagotomy

Closure of gastrostomy, surgical

Enterotomy with exploration or foreign body removal, small bowel

large bowel

Exteriorization of intestine (Mikulicz resection of colon, with or without crushing of spur)

Excision of one or more lesions of small or large bowel not requiring anastomosis, exteriorization or fistulization, single enterotomy

multiple enterotomies

Enterectomy: resection of small intestine with anastomosis

with enterostomy

Colectomy, partial resection of large intestine in two stages, including first stage colostomy or cecostomy

Colectomy, partial, with anastomosis with or without concomitant proximal colostomy

total, with ileostomy or ilioproctostomy

with proctectomy and ileostomy

Enteroenterostomy; anastomosis of intestine

small bowel (ileostomy or jejunostomy)

large bowel, (colostomy or cecostomy)

small or large bowel, for ulcerative colitis

Reduction of volvulus, intussusception, internal hernia, by laparotomy

Revision of colostomy, simple, (release of superficial scar)

complicated (reconstruction in depth)

Enterolysis (freeing of intestinal adhesion)

with acute bowel obstruction

Intestinal plication (Noble type)

Suture of intestine (enterorrhaphy), large or small, for perforated ulcer, wound, injury or rupture, single

multiple

Suture of intestine with colostomy

Closure of enterostomy, large or small intestine

Closure of fecal fistula

Excision of Meckel's diverticulum (diverticulectomy)

Excision of lesion of mesentery

Suture of mesentery

Incision and drainage of appendicular abscess, transabdominal

Appendectomy

Transrectal drainage of pelvic abscess

Incision and drainage of deep supralevator, pelvirectal or retrorectal abscess

Complete proctectomy, combined abdomino–perineal, one or two stages

Complete proctectomy for congenital megacolon (Swenson type procedure)

Excision of rextal procidentia, with anastomosis, perineal approach

abdominal and perineal approach

Division of stricture in rectum

Perineal excision of primary or recurrent malignant tumor (Kraske type)

Local excision of extensive villous papilloma of rectum

Proctosigmoidoscopy, diagnostic, initial

subsequent

with biopsy, initial

subsequent for same lesion

with removal of papilloma or polyp, initial

subsequent for same lesion

with removal of multiple papillomas or polyps

complicated

Endoscopic control of hemmorrhage

Endoscopic removal of foreign body, anus or rectum

Proctoplasty, for stenosis

for prolapse of mucous membrane

Perirectal injection of sclerosing solution for prolapse, in hospital

Proctopexy for prolapse, abdominal approach

Proctopexy combined with sigmoid resection, abdominal approach

Closure of rectovesical fistula

Closure of rectourethral fistula

Closure of rectovaginal fistula

Reduction of procidentia (independent procedure)

Fistulotomy or fistulectomy, subcutaneous

submuscular

complex or multiple

second stage

Remove seton, office

Incision and drainage of ischiorectal abscess (independent procedure)

Incision and drainage, perianal abscess (See also 3283.)

Incision and drainage of ischiorectal abscess with fistulotomy or fistulectomy, submuscular (See also 3283.)

Sphincterotomy, anal: division of anal sphincter (independent procedure)

Fissurectomy, with or without sphincterotomy

Cryptectomy, single, office

multiple, hospital procedure

Papillectomy or excision of single tab (independent procedure), office

Excision of external hemorrhoidal tags and/or multple papillae, office

Hemorrhoidectomy, external, complete

internal and external

radical (Buie or amputative type)

Fistulotomy or fistulectomy, submuscular, and hemorrhoidectomy

Fissurectomy and hemorrhoidectomy

Enucleation or excision of external thrombotic hemorrhoid

Hemorrhoids, injection of sclerosing solution

Anoscopy, diagnostic with or without biopsy

Anoplasty: plastic operation for stricture

infant, minor thin septum

Construction of anus for congenital absence, perineal approach

combined abdominal and perineal approach

Sphincteroplasty, anal, for incontinence

muscle transplant

Thiersch procedure for incontinence and/or prolapse

Condyloma, single or multiple, internal and external, in hospital

external, electrodesiccation, initial

subsequent

Aspiration biopsy of liver

Hepatectomy, partial: resection of liver

Marsupialization of cyst or abscess of liver

Hepatorrhaphy: suture of liver wound or injury

Hepaticotomy or hepaticostomy with exploration, drainage or removal of calculus

Choledochotomy or choledochostomy with exploration, drainage or removal of calculus, with or without cholecystotomy

Duodenocholedochotomy: transduodenal choledocholithotomy

Transduodenal sphincterotomy

Cholecystotomy or cholecystostomy with exploration, drainage or removal of calculus

Injection procedure for percutaneous trans–hepatic cholangiography (independent procedure)

Cholecystectomy

with open exploration of common duct

Exploration for congenital atresia of bile ducts

Direct anastomosis of gallbladder and gastrointestinal tract

Roux–en–y anastomosis of gallbladder and gastrointestinal tract

Direct anastomosis of extrahepatic biliary ducts and gastrointestinal tract

Roux–en–y anastomosis of extrahepatic biliary ducts and gastrointestinal tract

Plastic reconstruction of extrahepatic biliary ducts with end–to–end anastomosis

Abdominal drainage of pancreatitis

Removal of calculus

Pancreatectomy, subtotal

subtotal (Whipple type)

Pancreatico–jejunostomy

Marsupialization of cyst of pancreas

Internal direct anastomosis of cyst to gastrointestinal tract

Roux–en–y internal anastomosis, cyst to gastrointestinal tract

Exploratory laparotomy: exploratory celiotomy

Drainage of peritoneal abscess or localized peritonitis exclusive of appendicular abscess

Subdiaphragmatic or subphrenic abscess

Retroperitoneal abscess

Peritoneocentesis: abdominal paracentesis, initial

subsequent

Trans–peritoneal excision of intra–abdominal or retroperitoneal tumors or cysts

Peritoneoscopy

Pneumoperitoneum: intraperitoneal injection of air, initial

subsequent

Injection procedure for retroperitoneal pneumography, unilateral or bilateral (independent procedure)

Injection procedure for pelvic pneumography (independent procedure)

Inguinal, unilateral

with orchiectomy

with excision of hydrocele

recurrent

Femoral, unilateral

recurrent

Ventral, incisional

recurrent

Epigastric

recurrent

Umbilical, under age five years

over age five years

Omphalocele, in newborn, one stage

Gross type procedure, first stage

second stage

Secondary suture of abdominal wall for evisceration or disruption