Surgical Procedures CPT Codes and Descriptions

1 CPT CodesBody SystemDescription0652 TDIGESTIVE SYSTEMEGD DIAGNOSTIC TRANSNASAL0653 TDIGESTIVE SYSTEMEGD TRANSNASAL W/BIOPSY0654 TDIGESTIVE SYSTEMEGD TRANSNASAL/CATH INSERTION10060 INTEGUMENTARY SYSTEMDRAINAGE OF SKIN ABSCESS10061 INTEGUMENTARY SYSTEMDRAINAGE OF SKIN ABSCESS10080 INTEGUMENTARY SYSTEMDRAINAGE OF PILONIDAL CYST10081 INTEGUMENTARY SYSTEMDRAINAGE OF PILONIDAL CYST10120 INTEGUMENTARY SYSTEMREMOVE FOREIGN BODYS urgical Procedures CPT Codes and DescriptionsThis list of Codes applies to Anthem clinical guideline CG-Surg-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The following Codes for treatments and Procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.

2 Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual CodesBody SystemDescription10121 INTEGUMENTARY SYSTEMREMOVE FOREIGN BODY10140 INTEGUMENTARY SYSTEMDRAINAGE OF HEMATOMA/FLUID10160 INTEGUMENTARY SYSTEMPUNCTURE DRAINAGE OF LESION10180 INTEGUMENTARY SYSTEMCOMPLEX DRAINAGE WOUND11000 INTEGUMENTARY SYSTEMDEBRIDE INFECTED SKIN11010 INTEGUMENTARY SYSTEMDEBRIDE SKIN AT FX SITE11012 INTEGUMENTARY SYSTEMDEB SKIN BONE AT FX SITE11042 INTEGUMENTARY SYSTEMDEB SUBQ TISSUE 20 SQ CM/<11044 INTEGUMENTARY SYSTEMDEB BONE 20 SQ CM/<11200 INTEGUMENTARY SYSTEMREMOVAL OF SKIN TAGS <W/1511310 INTEGUMENTARY SYSTEMSHAVE SKIN LESION CM/<11402 INTEGUMENTARY SYSTEMEXC TR-EXT B9+MARG CM11403 INTEGUMENTARY SYSTEMEXC TR-EXT B9+MARG CodesBody SystemDescription11404 INTEGUMENTARY SYSTEMEXC TR-EXT B9+MARG CM11406 INTEGUMENTARY SYSTEMEXC TR-EXT B9+MARG > CM11420 INTEGUMENTARY SYSTEMEXC H-F-NK-SP B9+MARG <11421 INTEGUMENTARY SYSTEMEXC H-F-NK-SP B9+MARG SYSTEMEXC H-F-NK-SP B9+MARG SYSTEMEXC H-F-NK-SP B9+MARG SYSTEMEXC H-F-NK-SP B9+MARG SYSTEMEXC H-F-NK-SP B9+MARG >4 CM11440 INTEGUMENTARY SYSTEMEXC FACE-MM B9+MARG CM/<11441 INTEGUMENTARY SYSTEMEXC FACE-MM B9+MARG CM11442 INTEGUMENTARY SYSTEMEXC FACE-MM B9+MARG CM11443 INTEGUMENTARY SYSTEMEXC FACE-MM B9+MARG CM11444 INTEGUMENTARY SYSTEMEXC FACE-MM B9+MARG CMCPT CodesBody SystemDescription11446 INTEGUMENTARY SYSTEMEXC FACE-MM B9+MARG >4 CM11450 INTEGUMENTARY SYSTEMREMOVAL SWEAT GLAND LESION11451 INTEGUMENTARY SYSTEMREMOVAL SWEAT GLAND LESION11462 INTEGUMENTARY SYSTEMREMOVAL SWEAT GLAND LESION11463 INTEGUMENTARY SYSTEMREMOVAL SWEAT GLAND LESION11470 INTEGUMENTARY SYSTEMREMOVAL SWEAT GLAND LESION11471 INTEGUMENTARY

3 SYSTEMREMOVAL SWEAT GLAND LESION11601 INTEGUMENTARY SYSTEMEXC TR-EXT MAL+MARG CM11602 INTEGUMENTARY SYSTEMEXC TR-EXT MAL+MARG CM11603 INTEGUMENTARY SYSTEMEXC TR-EXT MAL+MARG CM11604 INTEGUMENTARY SYSTEMEXC TR-EXT MAL+MARG CM11606 INTEGUMENTARY SYSTEMEXC TR-EXT MAL+MARG >4 CM11620 INTEGUMENTARY SYSTEMEXC H-F-NK-SP MAL+MARG <CPT CodesBody SystemDescription11621 INTEGUMENTARY SYSTEMEXC S/N/H/F/G MAL+MRG SYSTEMEXC S/N/H/F/G MAL+MRG SYSTEMEXC S/N/H/F/G MAL+MRG SYSTEMEXC S/N/H/F/G MAL+MRG SYSTEMEXC S/N/H/F/G MAL+MRG >4 CM11640 INTEGUMENTARY SYSTEMEXC F/E/E/N/L MAL+MRG <11641 INTEGUMENTARY SYSTEMEXC F/E/E/N/L MAL+MRG SYSTEMEXC F/E/E/N/L MAL+MRG SYSTEMEXC F/E/E/N/L MAL+MRG SYSTEMEXC F/E/E/N/L MAL+MRG SYSTEMEXC F/E/E/N/L MAL+MRG >4 CM11730 INTEGUMENTARY SYSTEMREMOVAL OF NAIL PLATE11750 INTEGUMENTARY SYSTEMREMOVAL OF NAIL BEDCPT CodesBody SystemDescription11760 INTEGUMENTARY SYSTEMREPAIR OF NAIL BED11765 INTEGUMENTARY SYSTEMEXCISION OF NAIL FOLD TOE11770 INTEGUMENTARY SYSTEMREMOVE PILONIDAL CYST SIMPLE11772 INTEGUMENTARY SYSTEMREMOVE PILONIDAL CYST COMPL11900 INTEGUMENTARY SYSTEMINJECT SKIN LESIONS </W 712001 INTEGUMENTARY SYSTEMRPR S/N/AX/GEN/TRNK <12002 INTEGUMENTARY SYSTEMRPR S/N/AX/ SYSTEMRPR F/E/E/N/L/M CM/<12020 INTEGUMENTARY SYSTEMCLOSURE OF SPLIT WOUND12031 INTEGUMENTARY SYSTEMINTMD RPR S/A/T/EXT CM/<12032 INTEGUMENTARY SYSTEMINTMD RPR S/A/T/EXT SYSTEMINTMD RPR S/TR/EXT SYSTEMINTMD RPR S/A/T/EXT CodesBody SystemDescription12037 INTEGUMENTARY SYSTEMINTMD RPR S/TR/EXT > CM12041 INTEGUMENTARY SYSTEMINTMD RPR N-HF/GENIT <12042 INTEGUMENTARY SYSTEMINTMD RPR N- SYSTEMINTMD RPR FACE/MM CM/<12052 INTEGUMENTARY SYSTEMINTMD RPR FACE/MM CM13100 INTEGUMENTARY SYSTEMCMPLX RPR TRUNK CM13101 INTEGUMENTARY SYSTEMCMPLX RPR TRUNK CM13120 INTEGUMENTARY

4 SYSTEMCMPLX RPR S/A/L CM13121 INTEGUMENTARY SYSTEMCMPLX RPR S/A/L CM13131 INTEGUMENTARY SYSTEMCMPLX RPR F/C/C/M/N/AX/G/H/F13132 INTEGUMENTARY SYSTEMCMPLX RPR F/C/C/M/N/AX/G/H/F13151 INTEGUMENTARY SYSTEMCMPLX RPR E/N/E/L CM13152 INTEGUMENTARY SYSTEMCMPLX RPR E/N/E/L CMCPT CodesBody SystemDescription13160 INTEGUMENTARY SYSTEMLATE CLOSURE OF WOUND14020 INTEGUMENTARY SYSTEMTIS TRNFR S/A/L 10 SQ CM/<14301 INTEGUMENTARY SYSTEMTIS TRNFR ANY SQ CM15004 INTEGUMENTARY SYSTEMWOUND PREP F/N/HF/G15100 INTEGUMENTARY SYSTEMSKIN SPLT GRFT TRNK/ARM/LEG15120 INTEGUMENTARY SYSTEMSKN SPLT A-GRFT FAC/NCK/HF/G15220 INTEGUMENTARY SYSTEMSKIN FULL GRAFT SCLP/ARM/LEG15240 INTEGUMENTARY SYSTEMSKIN FULL GRFT FACE/GENIT/HF15260 INTEGUMENTARY SYSTEMSKIN FULL GRAFT EEN & LIPS15576 INTEGUMENTARY SYSTEMPEDICLE E/N/E/L/NTRORAL15760 INTEGUMENTARY SYSTEMCOMPOSITE SKIN GRAFT15770 INTEGUMENTARY SYSTEMDERMA-FAT-FASCIA GRAFT17000 INTEGUMENTARY SYSTEMDESTRUCT PREMALG LESIONCPT CodesBody SystemDescription17004 INTEGUMENTARY SYSTEMDESTROY PREMAL LESIONS 15/>17110 INTEGUMENTARY SYSTEMDESTRUCT B9 LESION 1-1417111 INTEGUMENTARY SYSTEMDESTRUCT LESION 15 OR MORE19020 INTEGUMENTARY SYSTEMINCISION OF BREAST LESION19101 INTEGUMENTARY SYSTEMBIOPSY OF BREAST OPEN19110 INTEGUMENTARY SYSTEMNIPPLE EXPLORATION19120 INTEGUMENTARY SYSTEMREMOVAL OF BREAST LESION19125 INTEGUMENTARY SYSTEMEXCISION BREAST LESION20220 MUSCULOSKELETAL SYSTEMBONE BIOPSY TROCAR/NEEDLE20225 MUSCULOSKELETAL SYSTEMBONE BIOPSY TROCAR/NEEDLE20240 MUSCULOSKELETAL SYSTEMBONE BIOPSY OPEN SUPERFICIAL20245 MUSCULOSKELETAL SYSTEMBONE BIOPSY OPEN DEEP20520 MUSCULOSKELETAL SYSTEMREMOVAL OF FOREIGN BODYCPT CodesBody SystemDescription20525 MUSCULOSKELETAL SYSTEMREMOVAL OF FOREIGN BODY20526 MUSCULOSKELETAL SYSTEMTHER INJECTION CARP TUNNEL20551 MUSCULOSKELETAL

5 SYSTEMINJ TENDON ORIGIN/INSERTION20552 MUSCULOSKELETAL SYSTEMINJ TRIGGER POINT 1/2 MUSCL20553 MUSCULOSKELETAL SYSTEMINJECT TRIGGER POINTS 3/>20600 MUSCULOSKELETAL SYSTEMDRAIN/INJ JOINT/BURSA W/O US20604 MUSCULOSKELETAL SYSTEMDRAIN/INJ JOINT/BURSA W/US20611 MUSCULOSKELETAL SYSTEMDRAIN/INJ JOINT/BURSA W/US20612 MUSCULOSKELETAL SYSTEMASPIRATE/INJ GANGLION CYST20680 MUSCULOSKELETAL SYSTEMREMOVAL OF SUPPORT IMPLANT21011 MUSCULOSKELETAL SYSTEMEXC FACE LES SC <2 CM21012 MUSCULOSKELETAL SYSTEMEXC FACE LES SBQ 2 CM/>21013 MUSCULOSKELETAL SYSTEMEXC FACE TUM DEEP < 2 CMCPT CodesBody SystemDescription21014 MUSCULOSKELETAL SYSTEMEXC FACE TUM DEEP 2 CM/>21029 MUSCULOSKELETAL SYSTEMCONTOUR OF FACE BONE LESION21030 MUSCULOSKELETAL SYSTEMEXCISE MAX/ZYGOMA B9 TUMOR21031 MUSCULOSKELETAL SYSTEMREMOVE EXOSTOSIS MANDIBLE21040 MUSCULOSKELETAL SYSTEMEXCISE MANDIBLE LESION21315 MUSCULOSKELETAL SYSTEMCLOSED TX NOSE FX W/O STABLJ21320 MUSCULOSKELETAL SYSTEMCLOSED TX NOSE FX W/ STABLJ21325 MUSCULOSKELETAL SYSTEMOPEN TX NOSE FX UNCOMPLICATD21330 MUSCULOSKELETAL SYSTEMOPEN TX NOSE FX W/SKELE FIXJ21335 MUSCULOSKELETAL SYSTEMOPEN TX NOSE & SEPTAL FX21336 MUSCULOSKELETAL SYSTEMOPEN TX SEPTAL FX W/WO STABJ21337 MUSCULOSKELETAL SYSTEMCLOSED TX SEPTAL&NOSE FX21356 MUSCULOSKELETAL SYSTEMOPN TX DPRSD ZYGOMATIC ARCHCPT CodesBody SystemDescription21550 MUSCULOSKELETAL SYSTEMBIOPSY OF NECK/CHEST21552 MUSCULOSKELETAL SYSTEMEXC NECK LES SC 3 CM/>21554 MUSCULOSKELETAL SYSTEMEXC NECK TUM DEEP 5 CM/>21555 MUSCULOSKELETAL SYSTEMEXC NECK LES SC < 3 CM21556 MUSCULOSKELETAL SYSTEMEXC NECK TUM DEEP < 5 CM21557 MUSCULOSKELETAL SYSTEMRESECT NECK THORAX TUMOR<5CM21920 MUSCULOSKELETAL SYSTEMBIOPSY SOFT TISSUE OF BACK21930 MUSCULOSKELETAL SYSTEMEXC BACK LES SC < 3 CM21931 MUSCULOSKELETAL SYSTEMEXC BACK LES SC 3 CM/>21932 MUSCULOSKELETAL

6 SYSTEMEXC BACK TUM DEEP < 5 CM21933 MUSCULOSKELETAL SYSTEMEXC BACK TUM DEEP 5 CM/>22900 MUSCULOSKELETAL SYSTEMEXC ABDL TUM DEEP < 5 CM22901 MUSCULOSKELETAL SYSTEMEXC ABDL TUM DEEP 5 CM/>CPT CodesBody SystemDescription22902 MUSCULOSKELETAL SYSTEMEXC ABD LES SC < 3 CM22903 MUSCULOSKELETAL SYSTEMEXC ABD LES SC 3 CM/>23030 MUSCULOSKELETAL SYSTEMDRAIN SHOULDER LESION23071 MUSCULOSKELETAL SYSTEMEXC SHOULDER LES SC 3 CM/>23075 MUSCULOSKELETAL SYSTEMEXC SHOULDER LES SC < 3 CM23076 MUSCULOSKELETAL SYSTEMEXC SHOULDER TUM DEEP < 5 CM23140 MUSCULOSKELETAL SYSTEMREMOVAL OF BONE LESION24066 MUSCULOSKELETAL SYSTEMBIOPSY ARM/ELBOW SOFT TISSUE24071 MUSCULOSKELETAL SYSTEMEXC ARM/ELBOW LES SC 3 CM/>24073 MUSCULOSKELETAL SYSTEMEX ARM/ELBOW TUM DEEP 5 CM/>24075 MUSCULOSKELETAL SYSTEMEXC ARM/ELBOW LES SC < 3 CM24076 MUSCULOSKELETAL SYSTEMEX ARM/ELBOW TUM DEEP < 5 CM24101 MUSCULOSKELETAL SYSTEMEXPLORE/TREAT ELBOW JOINTCPT CodesBody SystemDescription24102 MUSCULOSKELETAL SYSTEMREMOVE ELBOW JOINT LINING24105 MUSCULOSKELETAL SYSTEMREMOVAL OF ELBOW BURSA24110 MUSCULOSKELETAL SYSTEMREMOVE HUMERUS LESION24120 MUSCULOSKELETAL SYSTEMREMOVE ELBOW LESION24130 MUSCULOSKELETAL SYSTEMREMOVAL OF HEAD OF RADIUS24201 MUSCULOSKELETAL SYSTEMREMOVAL OF ARM FOREIGN BODY24310 MUSCULOSKELETAL SYSTEMREVISION OF ARM TENDON24340 MUSCULOSKELETAL SYSTEMREPAIR OF BICEPS TENDON24357 MUSCULOSKELETAL SYSTEMREPAIR ELBOW PERC24358 MUSCULOSKELETAL SYSTEMREPAIR ELBOW W/DEB OPEN24366 MUSCULOSKELETAL SYSTEMRECONSTRUCT HEAD OF RADIUS24515 MUSCULOSKELETAL SYSTEMTREAT HUMERUS FRACTURE24586 MUSCULOSKELETAL SYSTEMTREAT ELBOW FRACTURECPT CodesBody SystemDescription24665 MUSCULOSKELETAL SYSTEMTREAT RADIUS FRACTURE24666 MUSCULOSKELETAL SYSTEMTREAT RADIUS FRACTURE25000 MUSCULOSKELETAL SYSTEMINCISION OF TENDON SHEATH25071 MUSCULOSKELETAL SYSTEMEXC

7 FOREARM LES SC 3 CM/>25073 MUSCULOSKELETAL SYSTEMEXC FOREARM TUM DEEP 3 CM/>25075 MUSCULOSKELETAL SYSTEMEXC FOREARM LES SC < 3 CM25076 MUSCULOSKELETAL SYSTEMEXC FOREARM TUM DEEP < 3 CM25085 MUSCULOSKELETAL SYSTEMINCISION OF WRIST CAPSULE25105 MUSCULOSKELETAL SYSTEMREMOVE WRIST JOINT LINING25107 MUSCULOSKELETAL SYSTEMREMOVE WRIST JOINT CARTILAGE25109 MUSCULOSKELETAL SYSTEMEXCISE TENDON FOREARM/WRIST25110 MUSCULOSKELETAL SYSTEMREMOVE WRIST TENDON LESION25111 MUSCULOSKELETAL SYSTEMREMOVE WRIST TENDON LESIONCPT CodesBody SystemDescription25112 MUSCULOSKELETAL SYSTEMREREMOVE WRIST TENDON LESION25605 MUSCULOSKELETAL SYSTEMTREAT FRACTURE RADIUS/ULNA25606 MUSCULOSKELETAL SYSTEMTREAT FX DISTAL RADIAL25607 MUSCULOSKELETAL SYSTEMTREAT FX RAD EXTRA-ARTICUL25608 MUSCULOSKELETAL SYSTEMTREAT FX RAD INTRA-ARTICUL25609 MUSCULOSKELETAL SYSTEMTREAT FX RADIAL 3+ FRAG25624 MUSCULOSKELETAL SYSTEMTREAT WRIST BONE FRACTURE25628 MUSCULOSKELETAL SYSTEMTREAT WRIST BONE FRACTURE25635 MUSCULOSKELETAL SYSTEMTREAT WRIST BONE FRACTURE25645 MUSCULOSKELETAL SYSTEMTREAT WRIST BONE FRACTURE26160 MUSCULOSKELETAL SYSTEMREMOVE TENDON SHEATH LESION26180 MUSCULOSKELETAL SYSTEMREMOVAL OF FINGER TENDON26200 MUSCULOSKELETAL SYSTEMREMOVE HAND BONE LESIONCPT CodesBody SystemDescription26210 MUSCULOSKELETAL SYSTEMREMOVAL OF FINGER LESION27006 MUSCULOSKELETAL SYSTEMINCISION OF HIP TENDONS27043 MUSCULOSKELETAL SYSTEMEXC HIP PELVIS LES SC 3 CM/>27045 MUSCULOSKELETAL SYSTEMEXC HIP/PELV TUM DEEP 5 CM/>27047 MUSCULOSKELETAL SYSTEMEXC HIP/PELVIS LES SC < 3 CM27048 MUSCULOSKELETAL SYSTEMEXC HIP/PELV TUM DEEP < 5 CM27062 MUSCULOSKELETAL SYSTEMREMOVE FEMUR LESION/BURSA27345 MUSCULOSKELETAL SYSTEMREMOVAL OF KNEE CYST27347 MUSCULOSKELETAL SYSTEMREMOVE KNEE CYST27613 MUSCULOSKELETAL SYSTEMBIOPSY LOWER LEG SOFT TISSUE27614 MUSCULOSKELETAL

8 SYSTEMBIOPSY LOWER LEG SOFT TISSUE27618 MUSCULOSKELETAL SYSTEMEXC LEG/ANKLE TUM < 3 CM27619 MUSCULOSKELETAL SYSTEMEXC LEG/ANKLE TUM DEEP <5 CMCPT CodesBody SystemDescription27632 MUSCULOSKELETAL SYSTEMEXC LEG/ANKLE LES SC 3 CM/>27634 MUSCULOSKELETAL SYSTEMEXC LEG/ANKLE TUM DEP 5 CM/>30100 RESPIRATORY SYSTEMINTRANASAL BIOPSY30117 RESPIRATORY SYSTEMREMOVAL OF INTRANASAL LESION30118 RESPIRATORY SYSTEMREMOVAL OF INTRANASAL LESION30220 RESPIRATORY SYSTEMINSERT NASAL SEPTAL BUTTON30310 RESPIRATORY SYSTEMREMOVE NASAL FOREIGN BODY30630 RESPIRATORY SYSTEMREPAIR NASAL SEPTUM DEFECT30901 RESPIRATORY SYSTEMCONTROL OF NOSEBLEED30903 RESPIRATORY SYSTEMCONTROL OF NOSEBLEED30930 RESPIRATORY SYSTEMTHER FX NASAL INF TURBINATE31020 RESPIRATORY SYSTEMEXPLORATION MAXILLARY SINUS31030 RESPIRATORY SYSTEMEXPLORATION MAXILLARY SINUSCPT CodesBody SystemDescription31238 RESPIRATORY SYSTEMNASAL/SINUS ENDOSCOPY SURG31526 RESPIRATORY SYSTEMDX LARYNGOSCOPY W/OPER SCOPE31528 RESPIRATORY SYSTEMLARYNGOSCOPY AND DILATION31529 RESPIRATORY SYSTEMLARYNGOSCOPY AND DILATION31530 RESPIRATORY SYSTEMLARYNGOSCOPY W/FB REMOVAL31535 RESPIRATORY SYSTEMLARYNGOSCOPY W/BIOPSY31536 RESPIRATORY SYSTEMLARYNGOSCOPY W/BX & OP SCOPE31540 RESPIRATORY SYSTEMLARYNGOSCOPY W/EXC OF TUMOR31541 RESPIRATORY SYSTEMLARYNSCOP W/TUMR EXC + SCOPE31545 RESPIRATORY SYSTEMREMOVE VC LESION W/SCOPE31570 RESPIRATORY SYSTEMLARYNGOSCOPE W/VC INJ31571 RESPIRATORY SYSTEMLARYNGOSCOP W/VC INJ + SCOPE31575 RESPIRATORY SYSTEMDIAGNOSTIC LARYNGOSCOPYCPT CodesBody SystemDescription31576 RESPIRATORY SYSTEMLARYNGOSCOPY WITH BIOPSY31578 RESPIRATORY SYSTEMLARGSC W/REMOVAL LESION31622 RESPIRATORY SYSTEMDX BRONCHOSCOPE/WASH31623 RESPIRATORY SYSTEMDX BRONCHOSCOPE/BRUSH31624 RESPIRATORY SYSTEMDX BRONCHOSCOPE/LAVAGE31625 RESPIRATORY SYSTEMBRONCHOSCOPY W/BIOPSY(S)

9 31628 RESPIRATORY SYSTEMBRONCHOSCOPY/LUNG BX EA