Longevity Health Plan

tumor mutational burden

Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on

Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less

Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume

score

Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or

Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or

rearrangements, and copy number variations

genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements

microsatellite instability and tumor mutational burden

gene rearrangements, microsatellite instability and tumor mutational burden

variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6

0394T High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when

High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when

High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic

variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6

Relocation of skin pocket for implanted cardiac contractility modulation pulse generator

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording

Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); face, head and

Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and

Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound

Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral Prior Authorization Required Only if POS is 22 (On Campus-Outpatient Hospital)

Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the

Myocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia

Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve

Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve

Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg

Real-time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance (List Prior Authorization Required Only if POS is 22 (On Campus-Outpatient Hospital)

Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and

Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and

Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system

Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision

Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic

Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the

Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the

Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion

Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or

Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or

Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and

Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and

Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and

Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; battery component only

Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing

Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing

Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or

Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development

Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for

Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration

Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous

Removal and replacement of substernal implantable defibrillator pulse generator

Debridement of extensive eczematous or infected skin; up to 10% of body surface

Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external

Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh

Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation

Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation

Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation

Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first

Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed)

Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or

Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each

Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed)

Subcutaneous injection of filling material (eg, collagen); 1 cc or less

Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc

Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc

Subcutaneous injection of filling material (eg, collagen); over 10.0 cc

Insertion of tissue expander(s) for other than breast, including subsequent expansion

Removal of tissue expander without insertion of implant

Insertion, drug-delivery implant (ie, bioresorbable, biodegradable, non-biodegradable)

Removal with reinsertion, non-biodegradable drug delivery implant

Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less

Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm

and/or feet; defect 10 sq cm or less

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm

Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

digits; first 100 sq cm or less, or 1% of body area of infants and children (except )

digits; first 100 sq cm or less, or 1% of body area of infants and children (except )

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq

genitalia, hands, and/or feet; 20 sq cm or less

15730 Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)

Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)

Muscle, myocutaneous, or fasciocutaneous flap; trunk

Muscle, myocutaneous, or fasciocutaneous flap; lower extremity

Flap; neurovascular pedicle

Free skin flap with microvascular anastomosis

Free fascial flap with microvascular anastomosis

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each

Punch graft for hair transplant; 1 to 15 punch grafts

Punch graft for hair transplant; more than 15 punch grafts

Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk)

Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)

Dermabrasion; segmental, face

Dermabrasion; regional, other than face

Dermabrasion; superficial, any site (eg, tattoo removal)

Abrasion; single lesion (eg, keratosis, scar)

Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)

Chemical peel, facial; epidermal

Chemical peel, facial; dermal

Chemical peel, nonfacial; epidermal

Chemical peel, nonfacial; dermal

Blepharoplasty, lower eyelid

Blepharoplasty, lower eyelid; with extensive herniated fat pad

Blepharoplasty, upper eyelid

Blepharoplasty, upper eyelid; with excessive skin weighting down lid

Rhytidectomy; forehead

Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)

Rhytidectomy; glabellar frown lines

Rhytidectomy; cheek, chin, and neck

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical

Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh

Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg

Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip

Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad

Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty)

Suction assisted lipectomy; head and neck

Suction assisted lipectomy; trunk

Suction assisted lipectomy; upper extremity

Suction assisted lipectomy; lower extremity

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm

nerves, or vessels; first stage, up to 5 tissue blocks

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens

arms, or legs; first stage, up to 5 tissue blocks

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens

Electrolysis epilation, each 30 minutes

Unlisted procedure, skin, mucous membrane and subcutaneous tissue

imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance

Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple

or areolar lesion (except ), open, male or female, 1 or more lesions

Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion

Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation

Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for

Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for

Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the

or areolar lesion (except ), open, male or female, 1 or more lesions

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)

lymphadenectomy

Mastectomy, simple, complete

excluding pectoralis major muscle

Mastopexy

Breast reduction

Breast augmentation with implant

Removal of intact breast implant

Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)

Insertion of breast implant on same day of mastectomy (ie, immediate)

Insertion or replacement of breast implant on separate day from mastectomy

Nipple/areola reconstruction

Correction of inverted nipples

Tissue expander placement in breast reconstruction, including subsequent expansion(s)

Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)

Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy

Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents

Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in

Preparation of moulage for custom breast implant

Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)

Cartilage graft; nasal septum

Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in

Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure)

Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List

Electrical stimulation to aid bone healing; noninvasive (nonoperative)

Electrical stimulation to aid bone healing; invasive (operative)

Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)

Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent

Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent

Arthrotomy, temporomandibular joint

Condylectomy, temporomandibular joint (separate procedure)

Meniscectomy, partial or complete, temporomandibular joint (separate procedure)

Coronoidectomy (separate procedure)

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or

Genioplasty; augmentation (autograft, allograft, prosthetic material)

Genioplasty; sliding osteotomy, single piece

Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for

Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

Augmentation, mandibular body or angle; prosthetic material

Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining

Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face

Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft

Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft

Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts

Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts

Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts

Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)

Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc)

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc)

Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without

Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg

Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic

Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining

Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial

Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining

Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation

Osteotomy, mandible, segmental

Osteotomy, mandible, segmental; with genioglossus advancement

Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)

Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

Osteoplasty, facial bones; reduction

Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

Graft, bone; mandible (includes obtaining graft)

Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

Arthroplasty, temporomandibular joint, with allograft

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate)

Reconstruction of mandible or maxilla, subperiosteal implant; partial

Reconstruction of mandible or maxilla, subperiosteal implant; complete

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for

Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial

Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts)

Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach

Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach

Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement

Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach

Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial

Malar augmentation, prosthetic material

Secondary revision of orbitocraniofacial reconstruction

Unlisted craniofacial and maxillofacial procedure

Closed treatment of temporomandibular dislocation; initial or subsequent

Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary

Open treatment of temporomandibular dislocation

Interdental wiring, for condition other than fracture

Reconstructive repair of pectus excavatum or carinatum; open

Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure)

Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with

Unlisted procedure, neck or thorax

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve

Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg

Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg

Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical

Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic

Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar

Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical

Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic

Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than

Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for

Arthrodesis, posterior technique, craniocervical (occiput-C2)

Arthrodesis, posterior technique, atlas-axis (C1-C2)

Arthrodesis, posterior or posterolateral technique, single interspace; cervical below C2 segment

Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse

Arthrodesis, posterior or posterolateral technique, single interspace; lumbar (with lateral transverse

Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including

Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments

Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments

Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments

Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments

Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and

Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and

Exploration of spinal fusion

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace

Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar

Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)

Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)

Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary

Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List

Reinsertion of spinal fixation device

Removal of posterior nonsegmental instrumentation (eg, Harrington rod)

Removal of posterior segmental instrumentation

Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior

Removal of anterior instrumentation

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace

Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image

Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression

Unlisted procedure, spine

Arthroplasty, glenohumeral joint; hemiarthroplasty

Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total

Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Arthroplasty, elbow; with membrane (eg, fascial)

Arthroplasty, elbow; with distal humeral prosthetic replacement

Arthroplasty, elbow; with implant and fascia lata ligament reconstruction

Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow)

Arthroplasty, radial head

nonviable muscle and/or nerve

Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon

Arthroplasty with prosthetic replacement; distal radius

Arthroplasty with prosthetic replacement; distal ulna

Arthroplasty with prosthetic replacement; lunate

Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)

Revision of arthroplasty, including removal of implant, wrist joint

carpometacarpal joints)

Arthrodesis, wrist; with autograft (includes obtaining graft)

Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon

Tenotomy, flexor, finger, open, each tendon

Arthroplasty, metacarpophalangeal joint; each joint

direct closure

Arthrotomy, hip, with drainage (eg, infection)

(eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular)

Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)

Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)

Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)

Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without

Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft

Revision of total hip arthroplasty; both components, with or without autograft or allograft

Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

Revision of total hip arthroplasty; femoral component only, with or without allograft

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance

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

Autologous chondrocyte implantation, knee

Osteochondral allograft, knee, open

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

Arthroplasty, knee, condyle and plateau; medial OR lateral compartment

Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing

Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg]

Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique)

Revision of total knee arthroplasty, with or without allograft; 1 component

Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

Amputation, thigh, through femur, any level; re-amputation

to midfoot or hindfoot)

Arthroplasty, ankle

Arthrodesis, ankle, open

osteotomy, any method

Reconstruction, toe(s); polydactyly

Amputation, foot; transmetatarsal

Amputation, toe; metatarsophalangeal joint

Amputation, toe; interphalangeal joint

Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional,

Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)

Arthroscopy, temporomandibular joint, surgical

Arthroscopy, elbow, surgical; with removal of loose body or foreign body

Arthroscopy, elbow, surgical; debridement, limited

Arthroscopy, elbow, surgical; debridement, extensive

Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure)

Arthroscopy, wrist, surgical; synovectomy, partial

Arthroscopy, wrist, surgical; synovectomy, complete

Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement

Arthroscopy, wrist, surgical; internal fixation for fracture or instability

Endoscopy, wrist, surgical, with release of transverse carpal ligament

without manipulation; with internal or external fixation (includes arthroscopy)

Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)

Arthroscopy, hip, surgical; with removal of loose body or foreign body

Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion

Arthroscopy, hip, surgical; with synovectomy

Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the

Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or

Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the

Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond

Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body

Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial

Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited

Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive

Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis

Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)

Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)

Arthroscopy, hip, surgical; with labral repair

Excision or destruction (eg, laser), intranasal lesion; internal approach

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

Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or

Rhinoplasty, primary; including major septal repair

Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)

Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar

Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar

Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

Repair choanal atresia; intranasal

Repair choanal atresia; transpalatine

Lysis intranasal synechia

Septal or other intranasal dermatoplasty (does not include obtaining graft)

Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)

Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus

Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)

Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)

Nasal/sinus endoscopy, surgical, with maxillary antrostomy

Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy

Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy

Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus

Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus

Nasal/sinus endoscopy, surgical, with sphenoidotomy

Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via

Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium

Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); sphenoid sinus ostium

Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia

Unlisted procedure, accessory sinuses

Laryngoscopy, direct, operative, with biopsy

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

Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), unilateral

Unlisted procedure, larynx

washing, when performed (separate procedure)

aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)

dilation or closed reduction of fracture

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of

two mediastinal and/or hilar lymph node stations or structures

more mediastinal and/or hilar lymph node stations or structures

Unlisted procedure, trachea, bronchi

Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed

procedure)

Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter)

Donor pneumonectomy(s) (including cold preservation), from cadaver donor

Lung transplant, single; without cardiopulmonary bypass

Lung transplant, single; with cardiopulmonary bypass

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

Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass

Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection

Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection

Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial

Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular

Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and

Insertion of pacemaker pulse generator only; with existing single lead

Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system

Insertion of pacemaker pulse generator only; with existing multiple leads

Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously

Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of

Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single

Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead

Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple

Insertion of implantable defibrillator pulse generator only; with existing dual leads

Insertion of implantable defibrillator pulse generator only; with existing multiple leads

Insertion of implantable defibrillator pulse generator only; with existing single lead

Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction

Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or

Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse

Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse

Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse

Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous

Insertion of subcutaneous implantable defibrillator electrode

Removal of subcutaneous implantable defibrillator electrode

Repositioning of previously implanted subcutaneous implantable defibrillator electrode

Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging

Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (eg

Insertion, subcutaneous cardiac rhythm monitor, including programming

Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic

angiography, when performed, and radiological supervision and interpretation

Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy

Removal and replacement of total replacement heart system (artificial heart)

Removal of a total replacement heart system (artificial heart) for heart transplantation (List separately in

Donor cardiectomy-pneumonectomy (including cold preservation)

Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including

Heart-lung transplant with recipient cardiectomy-pneumonectomy

Donor cardiectomy (including cold preservation)

Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection

Heart transplant, with or without recipient cardiectomy

Insertion of ventricular assist device; extracorporeal, single ventricle

Insertion of ventricular assist device; extracorporeal, biventricular

Removal of ventricular assist device; extracorporeal, single ventricle

Removal of ventricular assist device; extracorporeal, biventricular

Insertion of ventricular assist device, implantable intracorporeal, single ventricle

Removal of ventricular assist device, implantable intracorporeal, single ventricle

Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without

Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with

Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left

Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left

Removal of percutaneous left heart ventricular assist device, arterial or arterial and venous cannula(s), at

Repositioning of percutaneous right or left heart ventricular assist device with imaging guidance at separate

Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right

Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and distinct session

patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision

Thromboendarterectomy, including patch graft, if performed; axillary-brachial

Excision of infected graft; extremity

Injection procedure for extremity venography (including introduction of needle or intracatheter)

Introduction of catheter, superior or inferior vena cava

Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein)

Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein

Introduction of needle or intracatheter, upper or lower extremity artery

Introduction of catheter, aorta

vascular family

Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery

branch, within a vascular family

Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower

great saphenous vein, accessory saphenous vein)

saphenous vein, accessory saphenous vein), same leg

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive

Therapeutic apheresis; for plasma pheresis

Arteriovenous anastomosis, open; by upper arm cephalic vein transposition

Arteriovenous anastomosis, open; by upper arm basilic vein transposition

Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure)

nonautogenous graft (eg, biological collagen, thermoplastic graft)

(separate procedure)

(separate procedure)

(separate procedure)

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal

Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional

Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease

Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease

Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision

Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision

same vessel, when performed; initial artery

Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision

(List separately in addition to code for primary procedure)

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural

Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and

Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention

Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention

Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS)

Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions

Ligation, division, and stripping, short saphenous vein

Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or

Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and

Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open,1 leg

Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg

Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions

Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions

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

Ligation, division, and/or excision of varicose vein cluster(s), 1 leg

Unlisted procedure, vascular surgery

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic

Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous

Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage

Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without

Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing

Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell

Transplant preparation of hematopoietic progenitor cells; tumor cell depletion

Transplant preparation of hematopoietic progenitor cells; red blood cell removal

Transplant preparation of hematopoietic progenitor cells; platelet depletion

Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion

Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy

Bone marrow harvesting for transplantation; autologous

Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor

Hematopoietic progenitor cell (HPC); autologous transplantation

Allogeneic lymphocyte infusions

Biopsy or excision of lymph node(s); open, superficial

Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary)

Biopsy or excision of lymph node(s); open, deep cervical node(s)

Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral

Glossectomy; less than one-half tongue

Alveoloplasty, each quadrant (specify)

Uvulectomy, excision of uvula

Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Unlisted procedure, palate, uvula

Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete

Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)

or washing, when performed (separate procedure)

Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance

the anastomosis)

bougie)

Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less

than 30 mm diameter)

snare technique

Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method

Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower

distal to the anastomosis

brushing or washing, when performed (separate procedure)

Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy