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Preprosthetic Surgery__________________________________________________3REMOVAL OF TORI ____________________________________________________________3VESTIBULOPLASTY ____________________________________________________________3SURGERY OF THE FRENUM _______________________________________________________3
Excision, Destruction___________________________________________________3EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), DENTOALVEOLAR STRUCTURES ___________3OTHER PROCEDURES __________________________________________________________4
Incision and Drainage___________________________________________________5INTRAORAL DRAINAGE OF ABSCESS, CYST, HEMATOMA ___________________________________5EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA ______________________5
Palate and Uvula_______________________________________________________7BIOPSY ____________________________________________________________________7EXCISION ___________________________________________________________________7
Excision and Biopsy___________________________________________________12EXCISION OF PAROTID TUMOR OR PAROTID GLAND _____________________________________12EXCISION OF SUBMANDIBULAR GLAND ______________________________________________12EXCISION OF SUBLINGUAL GLAND _________________________________________________12
Repair of oral lacerations_______________________________________________20PALATE ___________________________________________________________________20VESTIBULE OF MOUTH _________________________________________________________20FLOOR OF MOUTH AND TONGUE __________________________________________________20
Skin Lacerations______________________________________________________20REPAIR - SIMPLE _____________________________________________________________20COMPLEX (SUM OF LENGTHS OF REPAIRS) ___________________________________________21LIP REPAIR (CHEILOPLASTY) ____________________________________________________21
Maxillofacial Fractures_________________________________________________21MAXILLARY FRACTURES ________________________________________________________21MANDIBULAR FRACTURES ______________________________________________________22HYOID BONE FRACTURES ______________________________________________________22NASAL FRACTURES ___________________________________________________________23NEC/FRONTAL BONE FRACTURES ________________________________________________23MALAR/ZMC FRACTURES ______________________________________________________23ORBITAL FRACTURES _________________________________________________________24
(42150 has been deleted. To report, see 21031, 21032)
42160 Destruction of lesion, palate or uvula (thermal, cryo or chemical)
VestibuleBIOPSY
40808 Biopsy, vestibule of mouth
EXCISION
40810 Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair
40812 With simple repair
40814 With complex repair
40816 Complex, with excision of underlying muscle
40818 Excision of mucosa of vestibule of mouth as donor graft
40819 Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
Skin Lesions
BIOPSY
11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed (separate procedure; single lesion
11101 each separate/additional lesion
REMOVAL OF SKIN TAGS
Removal by scissoring, or any sharp method or ligature strangulation including chemical or electrocauterization of wound, with or without local anesthesia.
11200* Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11201 each additional ten lesions
(For electrosurgical destruction, see 17200, 17201)
21151 any direction, requiring bone grafts (includes obtaining autografts)
21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I
21155 with LeFort I
21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I
21160 with LeFort I
Mandible21193 Reconstruction of mandibular rami, horizontal, vertical, “C”, or “L” osteotomy; without
bone graft
21194 with bone graft (includes obtaining graft)
21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
21196 with internal rigid fixation
21198 Osteotomy, mandible, segmental
21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)
(21207 has been deleted. To report, use 21209)
21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)
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21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)
21122 Sliding osteotomies, two or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)
21123 Sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
Bone Grafting20900 Bone graft, any donor area; minor or small (eg, dowel or button)
20902 Bone graft, any donor area; major or large
20910 Cartilage graft; costochondral
20912 Nasal septum
(For ear cartilage, see 21235)
20920 Fascia lata graft; by stripper
20922 Fascia lata graft; by incision and area exposure, complex or sheet
21230 Rib cartilage graft, autogenous, to face, chin, nose or ear (includes obtaining graft)
21235 Ear cartilage, autogenous, to nose or ear (includes obtaining graft)
21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209 Osteoplasty, facial bones; reduction
21210 Bone graft; nasal, maxillary or malar areas (includes obtaining graft)
(For cleft palate repair, see 42200-42225)
21215 Bone graft; mandible (includes obtaining graft)
20955 Bone graft with microvascular anastomosis; fibula
20960 Bone graft with microvascular anastomosis; rib
20962 Bone graft with microvascular anastomosis; other bone graft (specify)
20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, rib, metatarsal, or great toe
20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest
20971 Free osteocutaneous flap with microvascular anastomosis; rib
20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal
20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
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20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative)
Orbital Osteotomies21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes
obtaining autografts) (eg, micro-ophthalmia)
21260 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach
21261 Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach
21263 Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement
21267 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach
21268 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach
Fibrous Dysplasia/Asymmetry 21029 Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia)
21295 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach
21296 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach
Splint Construction21085 oral surgical splint
21110 application of interdental fixation (For conditions other than fracture)
21100* Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)
Craniofacial Surgery21172 Reconstruction superior-lateral orbital rim and lower forehead, advancement or
alteration, with or without grafts (includes obtaining autografts)
(For frontal or partial craniotomy performed for craniosynostosis, see 61556)
21175 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)
(For bifrontal craniotomy performed for craniosynostosis, see 61557)
21179 Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)
21180 Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)
(For extensive craniectomy for multiple suture craniosynostosis, use only 61558 or 61559)
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21181 Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial
Miscellaneous21125 Augmentation, mandibular body or angle; prosthetic material
21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)
21270 Malar augmentation, prosthetic material
(For malar augmentation with bone graft, see 21210)
21137 Reduction forehead; contouring only
21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
21139 Reduction forehead; contouring and setback of anterior frontal sinus wall
21182 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40cm2
21183 total area of bone grafting greater than 40 cm2 but less than 80 cm2
21184 total area of bone grafting greater than 80 cm2
(For excision of benign tumor of cranial bones, see 61563, 61564)
21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)
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Trauma
Repair of oral lacerationsPALATE
42180 Up to 2 cm
42182 Over 2 cm or complex
VESTIBULE OF MOUTH
40830 2.5 cm or less
40831 Over 2.5 cm or complex
FLOOR OF MOUTH AND TONGUE
41250* 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue
(For removal of internal or external fixation device, see 20670)
21436 complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft)
21440 Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21445 open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
MANDIBULAR FRACTURES
21440 Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21445 Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)
21450 Closed treatment of mandibular fracture; without manipulation
21451 Closed treatment of mandibular fracture; with manipulation
21452 Percutaneous treatment of mandibular fracture, with external fixation
21453 Closed treatment of mandibular fracture with interdental fixation
21454 Open treatment of mandibular fracture with external fixation
(2455 has been deleted. To report, see 21453)
21461 Open treatment of mandibular fracture; without interdental fixation
21462 Open treatment of mandibular fracture; with interdental fixation
21465 Open treatment of mandibular condylar fracture
21470 Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints
HYOID BONE FRACTURES
21493 Closed treatment of hyoid fracture; without manipulation
21494 Closed treatment of hyoid fracture; with manipulation
21495 Open treatment of hyoid fracture
NASAL FRACTURES
21310 Closed treatment of nasal bone fracture without manipulation
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21315* Closed treatment of nasal bone fracture; without stabilization
21320 Closed treatment of nasal bone fracture; with stabilization
21325 Open treatment of nasal fracture; uncomplicated
21330 Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation
21335 Open treatment of nasal fracture; with concomitant open treatment of fractured septum
21336 Open treatment of nasal septal fracture, with or without stabilization
21337 Closed treatment of nasal septal fracture, with or without stabilization
NEC/FRONTAL BONE FRACTURES
21338 Open treatment of nasoethmoid fracture; without external fixation
21339 Open treatment of nasoethmoid fracture; with external fixation
21340 Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus
21343 Open treatment of depressed frontal sinus fracture
21344 Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches
21345 Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint
21346 Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation
21347 requiring multiple open approaches
21348 with bone grafting (includes obtaining graft)
(21350 has been deleted. If necessary to report, use appropriate Evaluation and Management code)
21280 Medial canthopexy (separate procedure)
(For medical canthoplasty, see 67950)
21282 Lateral canthopexy
MALAR/ZMC FRACTURES
21355 * Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation
21356 Open treatment of depresses zygomatic arch fracture (eg, Gilles approach)
21360 Open treatment of depressed malar fracture, including zygomatic arch and malar tripod
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21365 Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar tripod; with internal fixation and multiple surgical approaches
21366 with bone grafting (includes obtaining graft)
(21380) has been deleted. If necessary to report, use appropriate Evaluation and Management code)
ORBITAL FRACTURES
OPEN TREATMENT OF ORBITAL FLOOR “BLOWOUT” FRACTURE
21385 Transantral approach (Caldwell-Luc type operation)
21386 Periorbital approach
21387 Combined approach
21390 Periorbital approach, with alloplastic or other implant
21395 Periorbital approach with bone graft (includes obtaining graft)
OTHER ORBITAL FRACTURES
21400 Closed treatment of fracture of orbit, except “blowout”; without manipulation
21401 Closed treatment of fracture of orbit, except “blowout”; with manipulation
21406 Open treatment of fracture of orbit, except “blowout”; without implant
21407 Open treatment of fracture of orbit, except “blowout”; with implant
41408 Open treatment of fracture of orbit, except “blowout”; with bone grafting (includes obtaining graft)
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Radiology
70350 Cephalogram, orthodontic
70355 Panoramic radiograph
70300 Radiologic examination, teeth; single view
70310 Partial examination, less than full mouth
70320 Complete, full mouth
70210 Radiologic examination, sinuses, paranasal, less than three views
70220 Radiologic examination, sinuses, paranasal, complete, minimum of three views
70100 Radiologic examination, mandible; partial, less than four views
70110 Complete, minimum of four views
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Cosmetic Surgery
Rhytidectomy15824 Forehead, brow or temporal lift
15824-22 Coronal forehead
15824-22 Mid-forehead
15825 Neck with platysmal tightening (platysmal flap, P-flap)
15826-22 Browplasty
15828 Cheek, chin, and neck
15829 Superficial musculoaponeurotic system (SMAS) flap
15876 Suction assisted lipectomy; head and neck
Otoplasty69300 Otoplasty protruding ear, with or without size reduction69320 Reconstruction external auditory canal for congenital atresia, single stage
21230 Graft; rib cartilage, autogenous, to ear, includes obtaining graft
21235 Ear cartilage graft to nose or ear, includes obtaining graft
Blepharoplasty15820 Lower eyelid; unilateral
15820-50 Lower eyelid; Bilateral
15821 With extensive herniated fat pad; unilateral
15821-50 With extensive herniated fat pad; bilateral
15822 Upper eyelid; unilateral
15822-50 Upper eyelid; bilateral
15823 With excessive skin weighting down lid
15823-50 With excessive skin weighting down lid; bilateral
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material
67903 Repair of blepharoptosis; (tarso)levator resection or advancement, internal approach
67914 Ectropion repair tarsal strip; suture
67914-50 Ectropion repair tarsal strip; bilateral
15822-22 Westernization of eyelid; unilateral
Rhinoplasty and Septal Surgery(If open structure technique, add modifier ‘-22’ and identify in operative report)
30400 Primary; lateral and alar cartilages and/or elevation of nasal tip
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30410 Complete, external part including bony pyramid, lateral and alar cartilage, and/or elevation of nasal tip
30420 Complete, external part including bony pyramid, lateral and alar cartilage, and/or elevation of nasal tip; including major septal repair
30430 Secondary; minor revision (small amount of nasal tip work)
30435 Secondary ;intermediate revision (bony work with osteotomies)
30450 Secondary; major revision (nasal tip work and osteotomies)
30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only
30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening, tip, septum, osteotomies
30620 Septal or other intranasal dermatoplasty (does not include obtaining graft)
30630 Repair nasal septal perforations
30520S Septoplasty, with or without cartilage scoring or graft
30520SR Submucous resection of turbinates, partial or complete
30801* Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method (separate procedure); superficial
30120 Excision or surgical planning of skin of nose for rhinophyma(For obtaining tissues for grafts refer to –J. OTHER GRAFTS)
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MODIFIERS
-20 MICROSURGERY: When the surgical services are performed using the techniques of microsurgery,
requiring the use of an operative microscope. (NOT to be used when a magnifying surgical loupe is used,
whether attached to the eyeglasses or on headband.)
-22 UNUSUAL PROCEDURE SERVICE: When the service(s) provided is greater than that usually
required for the listed procedure. A detailed report is appropriate.
-47 ANESTHESIA BY SURGEON: Regional or general anesthesia provided by the surgeon may be reported by using modifier ‘47’.
-50 BILATERAL PROCEDURE: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session, should be identified by the appropriate procedure code number. The second (bilateral) procedure is identified by adding the modifier ‘-50’ to the
procedure number.
-51 MULTIPLE PROCEDURES: When multiple procedures are performed on the same day or at the same session, the major procedure or service may be reported as listed. The additional, or lesser procedure(s) are identified with modifier ‘-51’ to the secondary procedure. The modifier may be
used to report multiple medical procedures performed at the same session, as well as a combination of medical
and surgical procedures, or several surgical procedures performed at the same operative session.
-52 REDUCED SERVICES: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s election. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier ‘-52’ signifying the service is
reduced.-54 SURGICAL CARE ONLY: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, services may be identified by adding the
modifier ‘-54.’-55 POSTOPERATIVE MANAGEMENT: When one physician performs the postoperative
management and another physician has performed the surgical procedure, the postoperative component is identified with modifier ‘-55.’
-58 STAGED OR RELATED PROCEDURE BY THE SAME PHYSICIAN DURING THE POSTOPERATIVE PERIOD: To indicate that the performance of a procedure or service during the postoperative period was: a. planned prospectively at time of original procedure, b. more extensive than original procedure; or c. for therapy following a diagnostic surgical procedure. NOTE: Not to be used for treatment of a problem requiring a return to operating room.
-62 TWO SURGEONS: Under certain circumstances the skills of two surgeons (usually with different
skills) may be required in the management of a specific surgical procedure. The separate service in identified with modifier ‘-62’ to the procedure number used by each surgeon for reporting his
services. An operative report MUST be indicated by each surgeon.-66 SURGICAL TEAM: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, of different specialties, plus other highly skilled, specially trained personnel, are carried out under the surgical team concept. Each participating physician can identify this service with the modifier ‘-66.’
-76 REPEAT PROCEDURE BY THE SAME PHYSICIAN: The physician may need to indicate that a procedure or service was repeated subsequent to the original service.
-77 REPEAT PROCEDURE BY ANOTHER PHYSICIAN: The physician may need to indicate that a basic procedure performed by another physician had to be reported.
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-78 RETURN TO THE OPERATING ROOM FOR A RELATED PROCEDURE DURING THE POSTOPERATIVE PERIOD: Indicates that another procedure was performed during the
postoperative period of the initial procedure. Subsequent procedure is related to the first.
-79 UNRELATED PROCEDURE OR SERVICE BY THE SAME PHYSICIAN DURING THE POSTOPERATIVE PERIOD: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.
-82 ASSISTANT SURGEON (When qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of the modifier appended to the usual procedure
code number(s).
STARRED (*) PROCEDURES: Because of the indefinite pre- and postoperative services the usual “package” concept for surgical services cannot be applied.
A22 Argon Laser: Identifies the use of the Argon Laser
C22 Carbon Dioxide Laser: Identifies the use of the Carbon Laser
Y22 Yag Laser: Identifies the use of the Yag Laser