ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT none ; operating room and anesthesia 77401 Radiation treatment delivery (Linear Accelerator) records are waived none ; operating room and anesthesia 77401 Radiation treatment delivery (Cobalt) records are waived Dialysis procedure other than hemodialysis (e.g. none ; operating room and anesthesia 90945 peritoneal, hemofiltration) records are waived none ; operating room and anesthesia 96408 Chemotherapy administration records are waived none ; operating room and anesthesia 79000 Radiopharmaceutical (radioactive iodine) therapy records are waived Simple repair of superficial wounds of scalp, neck, axillae, doctor's order and/or nurse's notes 12001 external genitalia, trunk and/or extremities (including indicating performance of the procedure hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, doctor's order and/or nurse's notes 12002 external genitalia, trunk and/or extremities (including indicating performance of the procedure hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of scalp, neck, axillae, doctor's order and/or nurse's notes 12004 external genitalia, trunk and/or extremities (including indicating performance of the procedure hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, axillae, doctor's order and/or nurse's notes 12005 external genitalia, trunk and/or extremities (including indicating performance of the procedure hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, axillae, doctor's order and/or nurse's notes 12006 external genitalia, trunk and/or extremities (including indicating performance of the procedure hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, axillae, doctor's order and/or nurse's notes 12007 external genitalia, trunk and/or extremities (including indicating performance of the procedure hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 12011 nose, lips and/or mucous membranes; 2.5 cm or less indicating performance of the procedure
Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 12013 nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm indicating performance of the procedure
Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 12014 nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm indicating performance of the procedure
Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 12015 nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm indicating performance of the procedure Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 12016 nose, lips and/or mucous membranes; 12.6 cm to 20.0 indicating performance of the procedure cm Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 12017 nose, lips and/or mucous membranes; 20.1 cm to 30.0 indicating performance of the procedure cm Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 12018 nose, lips and/or mucous membranes; over 30.0 cm indicating performance of the procedure
Page 1 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes 12031 extremities (excluding hands and feet); 2.5 cm or less indicating performance of the procedure
Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes 12032 extremities (excluding hands and feet); 2.6 cm to 7.5 cm indicating performance of the procedure
Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes 12034 extremities (excluding hands and feet); 7.6 cm to 12.5 cm indicating performance of the procedure Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes 12035 extremities (excluding hands and feet); 12.6 cm to 20.0 indicating performance of the procedure cm Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes 12036 extremities (excluding hands and feet); 20.1 cm to 30.0 indicating performance of the procedure cm Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes 12037 extremities (excluding hands and feet); over 30.0 cm indicating performance of the procedure
Layer closure of wounds of neck, hands, feet and/or doctor's order and/or nurse's notes 12041 external genitalia; 2.5 cm or less indicating performance of the procedure
Layer closure of wounds of neck, hands, feet and/or doctor's order and/or nurse's notes 12042 external genitalia; 2.6 cm to 7.5 cm indicating performance of the procedure
Layer closure of wounds of neck, hands, feet and/or doctor's order and/or nurse's notes 12044 external genitalia; 7.6 cm to 12.5 cm indicating performance of the procedure
Layer closure of wounds of neck, hands, feet and/or doctor's order and/or nurse's notes 12045 external genitalia; 12.6 cm to 20.0 cm indicating performance of the procedure
Layer closure of wounds of neck, hands, feet and/or doctor's order and/or nurse's notes 12046 external genitalia; 20.1 cm to 30.0 cm indicating performance of the procedure
Layer closure of wounds of neck, hands, feet and/or doctor's order and/or nurse's notes 12047 external genitalia; over 30.0 cm indicating performance of the procedure
Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes 12051 and/or mucous membrances; 2.5 cm or less indicating performance of the procedure
Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes 12052 and/or mucous membrances; 2.6 cm to 5.0 cm indicating performance of the procedure
Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes 12053 and/or mucous membrances; 5.1 cm to 7.5 cm indicating performance of the procedure
Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes 12054 and/or mucous membrances; 7.6 cm to 12.5 cm indicating performance of the procedure
Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes 12055 and/or mucous membrances; 12.6 cm to 20.0 cm indicating performance of the procedure
Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes 12056 and/or mucous membrances; 20.1 cm to 30.0 cm indicating performance of the procedure
Page 2 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes 12057 and/or mucous membrances; over 30.0 cm indicating performance of the procedure
doctor's order and/or nurse's notes 31600 Tracheostomy, planned ; indicating performance of the procedure
doctor's order and/or nurse's notes 31601 Tracheostomy, planned ; under two years indicating performance of the procedure
doctor's order and/or nurse's notes 31603 Tracheostomy, emergency procedure; transtracheal indicating performance of the procedure
Tracheostomy, emergency procedure; cricothyroid doctor's order and/or nurse's notes 31605 membrane indicating performance of the procedure
doctor's order and/or nurse's notes 31610 Tracheostomy, fenestration procedure with skin flaps indicating performance of the procedure
Thoracentesis, puncture of pleural cavity for aspiration, doctor's order and/or nurse's notes 32000 initial or subsequent indicating performance of the procedure
Thoracentesis w/ insertion of tube w/ or w/o water seal doctor's order and/or nurse's notes 32002 (e.g., for pneumothorax) indicating performance of the procedure
Tube thoracostomy w/ or w/o water seal (e.g., for doctor's order and/or nurse's notes 32020 abscess, hemothorax, empyema) indicating performance of the procedure
Arterial catheterization for prolonged infusion therapy doctor's order and/or nurse's notes 36640 (chemotherapy), cutdown indicating performance of the procedure Placement of central venous catheter (subclavian, jugular, or other vein) (e.g., for central venous pressure, doctor's order and/or nurse's notes 36488 hyperalimentation, hemodialysis, or chemotherapy); indicating performance of the procedure percutaneous or cutdown doctor's order and/or nurse's notes 38220 Bone marrow aspiration and/or biopsy indicating performance of the procedure
Peritoneocentesis, abdominal paracentesis, or peritoneal doctor's order and/or nurse's notes 49080 lavage (diagnostic or therapeutic) indicating performance of the procedure
doctor's order and/or nurse's notes 62270 Spinal puncture, lumbar, diagnostic indicating performance of the procedure 31231 Nasal endoscopy, diagnostic, unilateral or bilateral official report Nasal/sinus endoscopy, diagnostic w/ maxillary 31233 sinusoscopy (via inferior meatus or canine fossa official report puncture) Nasal/sinus endoscopy, diagnostic w/ sphenoid 31235 sinusoscopy (via puncture of sphenoidal face or official report cannulation of ostium) Nasal/sinus endoscopy, surgical; w/ biopsy, polypectomy 31237 official report or debridement 31238 Nasal/sinus endoscopy, surgical; w/ control of epistaxis official report
Page 3 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Nasal/sinus endoscopy, surgical; w/ 31239 official report dacrylocystorhinostomy Nasal/sinus endoscopy, surgical; w/ concha bullosa 31240 official report resection Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, 31254 official report partial (anterior) Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, 31255 official report total (anterior and posterior) 31256 Nasal/sinus endoscopy, surgical, w/ maxillary antrostomy official report Nasal/sinus endoscopy, surgical, w/ removal of tissue 31267 official report from maxillary sinus Nasal/sinus endoscopy, surgical w/ frontal sinus 31276 exploration, w/ or w/o removal of tissue from frontal official report sinus 31287 Nasal/sinus endoscopy, surgical, w/ sphenoidotomy official report Nasal/sinus endoscopy, surgical, w/ removal of tissure 31288 official report from the sphenoid sinus Nasal/sinus endoscopy, surgical, w/ repair of 31290 official report cerebrospinal fluid leak; ethmoid region 31291 Nasal/sinus endoscopy, surgical, sphenoid region official report Nasal/sinus endoscopy, surgical; w/ medial or inferior 31292 official report orbital wall decompression Nasal/sinus endoscopy, surgical; w/ medial orbital wall 31293 official report and inferior orbital wall decompression Nasal/sinus endoscopy, surgical; w/ optic nerve 31294 official report decompression Laryngoscopy direct, w/ or w/o tracheoscopy; for 31515 official report aspiration Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, 31520 official report newborn Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, 31525 official report except newborn Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, 31526 official report w/ operating microscope Laryngoscopy direct, w/ or w/o tracheoscopy; w/ 31527 official report insertion of obturator Laryngoscopy direct, w/ or w/o tracheoscopy; w/ 31528 official report dilatation, initial Laryngoscopy direct, w/ or w/o tracheoscopy; w/ 31529 official report dilatation, subsequent Laryngoscopy, direct, operative, w/ foreign body 31530 official report removal; Laryngoscopy, direct, operative, w/ foreign body 31531 official report removal; w/ operating microscope 31535 Laryngoscopy, direct, operative, w/ biopsy; official report Laryngoscopy, direct, operative, w/ biopsy; w/ operating 31536 official report microscope Laryngoscopy, direct, operative, w/ excision of tumor 31540 official report and/or stripping of vocal cords or epiglottis;
Page 4 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Laryngoscopy, direct, operative, w/ excision of tumor 31541 and/or stripping of vocal cords or epiglottis; w/ operating official report microscope 31560 Laryngoscopy, direct, operative, w/ arytenoidectomy; official report Laryngoscopy, direct, operative, w/ arytenoidectomy; w/ 31561 official report operating microscope Laryngoscopy, direct, w/ injection into vocal cord(s), 31570 official report therapeutic; Laryngoscopy, direct, w/ injection into vocal cord(s), 31571 official report therapeutic; w/ operating microscope 31575 Laryngoscopy, flexible fiberoptic; diagnostic official report 31576 Laryngoscopy, flexible fiberoptic; w/ biopsy official report Laryngoscopy, flexible fiberoptic; w/ removal of foreign 31577 official report body 31578 Laryngoscopy, flexible fiberoptic; w/ removal of lesion official report
31579 Laryngoscopy, flexible or rigid fiberoptic, w/ stroboscopy official report Bronchoscopy; diagnostic, (flexible or rigid), w/ or w/o 31622 official report cell washing or brushing 31625 Bronchoscopy; w/ biopsy official report Bronchoscopy; w/ transbronchial lung biopsy, w/ or w/o 31628 official report fluoroscopic guidance Bronchoscopy; w/ transbronchial needle aspiration 31629 official report biopsy Bronchoscopy; w/ tracheal or bronchial dilation or closed 31630 official report reduction of fracture Bronchoscopy; w/ tracheal dilation and placement of 31631 official report tracheal stent 31635 Bronchoscopy; w/ removal of foreign body official report Bronchoscopy; diagnostic, (flexible or rigid),w/ placement 31636 official report of bronchial stents 31640 Bronchoscopy; w/ excision of tumor official report Bronchoscopy; w/ destruction of tumor or relief of 31641 official report stenosis by any method other than excision (e.g., laser) Bronchoscopy; w/ placement of catheters for 31643 official report intracavitary radioelement application Bronchoscopy; w/ therapeutic aspiration of 31645 official report tracheobronchial tree, (e.g., drainage of lung abscess) Thoracoscopy, diagnostic ; lungs and pleural space, w/o 32601 official report biopsy Thoracoscopy, diagnostic ; lungs and pleural space, w/ 32602 official report biopsy 32603 Thoracoscopy, diagnostic ; pericardial sac, w/o biopsy official report
32604 Thoracoscopy, diagnostic ; pericardial sac, w/ biopsy official report
32605 Thoracoscopy, diagnostic ; mediastinal space, w/o biopsy official report
32606 Thoracoscopy, diagnostic ; mediastinal space, w/ biopsy official report
Page 5 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT 32650 Thoracoscopy, surgical; w/ pleurodesis, any method official report Thoracoscopy, surgical; w/ partial pulmonary 32651 official report decortication Thoracoscopy, surgical; w/ total pulmonary 32652 official report decortication, including intrapleural pneumonolysis Thoracoscopy, surgical; w/ removal of intrapleural 32653 official report foreign body or firbin deposit Thoracoscopy, surgical; w/ control of traumatic 32654 official report hemorrhage Thoracoscopy, surgical; w/ excision-plication of bullae, 32655 official report including any pleural procedure 32656 Thoracoscopy, surgical; w/ parietal pleurectomy official report Thoracoscopy, surgical; w/ removal of clot or foreign 32658 official report body from pericardial sac Thoracoscopy, surgical; w/ creation of percardial window 32659 official report or partial resection of pericardial sac for drainage 32660 Thoracoscopy, surgical; w/ total pericardiectomy official report Thoracoscopy, surgical; w/ excision of pericardial cyst, 32661 official report tumor, or mass Thoracoscopy, surgical; w/ excision of mediastinal cyst, 32662 official report tumor, or mass 32663 Thoracoscopy, surgical; w/ lobectomy, total or segmental official report 32664 Thoracoscopy, surgical; w/ thoracic sympathectomy official report Thoracoscopy, surgical; w/ esophagomyotomy (Heller 32665 official report type) Esophagoscopy, rigid or flexible; diagnostic, w/ or w/o 43200 official report collection of specimen(s) by brushing or washing Esophagoscopy, rigid or flexible; w/ biopsy, single or 43202 official report multiple Esophagoscopy, rigid or flexible; w/ injection sclerosis of 43204 official report esophageal varices Esophagoscopy, rigid or flexible; w/ band ligation of 43205 official report esophageal varices Esophagoscopy, rigid or flexible; w/ removal of foreign 43215 official report body Esophagoscopy, rigid or flexible; w/ removal of tumor(s), 43216 polyp(s), or other lesion(s) by hot biopsy forceps or official report bipolar cautery Esophagoscopy, rigid or flexible; w/ removal of tumor(s), 43217 official report polyp(s), or other lesion(s) by snare technique Esophagoscopy, rigid or flexible; w/ insertion of plastic 43219 official report tube or stent Esophagoscopy, rigid or flexible; w/ balloon dilation (less 43220 official report than 30 mm diameter) Esophagoscopy, rigid or flexible; w/ insertion of guide 43226 official report wire followed by dilation over guide wire Esophagoscopy, rigid or flexible; w/ control of bleeding, 43227 official report any method
Page 6 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Esophagoscopy, rigid or flexible; w/ ablation of tumor(s) 43228 polyp(s), or other lesion(s), not amenable to removal by official report hot biopsy forceps, bipolar cautery or snare technique
Upper gastrointestinal endoscopy, simple primary 43234 official report examination ( e.g. w/ small diameter flexible endoscope)
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43235 official report appropriate; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing
Upper gastrointestinal endoscopy including esophagus, 43239 stomach, and either the duodenum and/or jejunum as official report appropriate; w/ biopsy, single or multiple Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43241 official report appropriate; w/ transendoscopic tube or catheter placement Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43243 official report appropriate; w/ injection sclerosis of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43244 official report appropriate; w/ band ligation of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43245 official report appropriate; w/ dilation of gastric outlet for obstruction, any method Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43246 official report appropriate; w/ directed placement of percutaneous gastrostomy tube Upper gastrointestinal endoscopy including esophagus, 43247 stomach, and either the duodenum and/or jejunum as official report appropriate; w/ removal or foreign body
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43248 official report appropriate; w/ insertion of guide wire followed by dilation of esophagus over guide wire Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43249 official report appropriate; w/ ballon dilation of esophagus (less than 30 mm diameter)
Page 7 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43250 official report appropriate; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43251 official report appropriate; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique
Upper gastrointestinal endoscopy including esophagus, 43255 stomach, and either the duodenum and/or jejunum as official report appropriate; w/ control of bleeding, any method
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 43258 appropriate; w/ ablation of tumor(s), polyp(s), or other official report lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
Upper gastrointestinal endoscopy including esophagus, 43259 stomach, and either the duodenum and/or jejunum as official report appropriate; w/ endoscopic ultrasound examination
Small intestinal endoscopy, enteroscopy, beyond second 44360 portion of duodenum, not including ileum; diagnostic, w/ official report or w/o collection of specimen(s) by brushing or washing Small intestinal endoscopy, enteroscopy, beyond second 44361 portion of duodenum, not including ileum; w/ biopsy, official report single or multiple Small intestinal endoscopy, enteroscopy, beyond second 44363 portion of duodenum, not including ileum; w/ removal of official report foreign body Small intestinal endoscopy, enteroscopy, beyond second 44364 portion of duodenum, not including ileum; w/ removal of official report tumor(s), polyp(s), or other lesions(s) by snare technique Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ removal of 44365 official report tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Small intestinal endoscopy, enteroscopy, beyond second 44366 portion of duodenum, not including ileum; w/ control of official report bleeding, any method Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ ablation of 44369 tumor(s), polyp(s), or other lesion(s) not amenable to official report removal by hot biopsy forceps, bipolar cautery or snare tenchnique Small intestinal endoscopy, enteroscopy, beyond second 44372 portion of duodenum, not including ileum; w/ placement official report of percutaneous jejunostomy tube
Page 8 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ conversion 44373 official report of percutaneous gastrostomy tube to percutaneous jejunostomy tube Small intestinal endoscopy, enteroscopy beyond second 44376 portion of duodenum, including ileum; diagnostic, w/ or official report w/o collection of specimen(s) by brushing or washing Small intestinal endoscopy, enteroscopy beyond second 44377 portion of duodenum, including ileum;w/ biopsy, single official report or multiple Small intestinal endoscopy, enteroscopy beyond second 44378 portion of duodenum, including ileum;w/ control of official report bleeding, any method Ileoscopy, through stoma; diagnostic, w/ or w/o 44380 official report collection of specimen(s) by brushing or washing 44382 Ileoscopy, through stoma; w/ biopsy, single or multiple official report Endoscopic evaluation of small intestinal (abdominal or 44385 pelvic) pouch; diagnostic, w/ or w/o collection of official report specimen(s) by brushing or washing Endoscopic evaluation of small intestinal (abdominal or 44386 official report pelvic) pouch; w/ biopsy, single or multiple Colonoscopy through stoma; diagnostic, w/ or w/o 44388 official report collection of specimen(s) by brushing or washing 44389 Colonoscopy through stoma; w/ biopsy, single or multiple official report
44390 Colonoscopy through stoma; w/ removal of foreign body official report Colonoscopy through stoma; w/ control of bleeding, any 44391 official report method Colonoscopy through stoma; w/ removal of tumor(s), 44392 polyp(s), or other lesion(s) by hot biopsy forceps or official report bipolar cautery Colonoscopy through stoma; w/ ablation of tumor(s), 44393 polyp(s), or other lesion(s) not amenable to removal by official report hot biopsy forceps, bipolar caurtery or snare technique
Colonoscopy through stoma; w/ removal of tumor(s), 44394 official report polyp(s), or other lesion(s) by snare technique Colonoscopy, rigid or flexible, transabdominal via 45355 official report colotomy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; 45378 diagnostic, w/ or w/o collection of specimen(s) by official report brushing or washing, w/ or w/o colon decompression Colonoscopy, flexible, proximal to splenic flexure; w/ 45379 official report removal of foreign body Colonoscopy, flexible, proximal to splenic flexure; w/ 45380 official report biopsy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; w/ 45382 official report control of bleeding, any method
Page 9 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Colonoscopy, flexible, proximal to splenic flexure; w/ ablation of tumor(s), polyp(s), or other lesion(s) not 45383 official report amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Colonoscopy, flexible, proximal to splenic flexure; w/ 45384 removal of tumor(s), polyp(s), or other lesion(s) by hot official report biopsy forceps or bipolar cautery Colonoscopy, flexible, proximal to splenic flexure; w/ 45385 removal of tumor(s), polyp(s), or other lesion(s) by snare official report technique Anoscopy; diagnostic, w/ or w/o collection of 46600 official report specimen(s) by brushing or washing 46604 Anoscopy; w/ dilation, any method official report 46606 Anoscopy; w/ biopsy, single or multiple official report 46608 Anoscopy; w/ removal of foreign body official report Anoscopy; w/ removal of single tumor, polyp, or other 46610 official report lesion by hot biopsy forceps or bipolar cautery Anoscopy; w/ removal of single tumor, polyp or other 46611 official report lesion by snare technique Anoscopy; w/ removal of multiple tumor, polyps, or 46612 other lesions by hot biopsy forceps, bipolar cautery or official report snare technique 46614 Anoscopy; w/ control of bleeding, any method official report Anoscopy; w/ ablation of tumor(s), polyp(s), or other 46615 lesion(s) not amenable to removal by hot biopsy forceps, official report bipolar cautery or snare technique Biliary endoscopy, percutaneous via T- tube or other 47552 tract; diagnostic, w/ or w/o collection of specimen(s) by official report brushing and/or washing Biliary endoscopy, percutaneous via T- tube or other 47553 official report tract; w/ biopsy, single or multiple Biliary endoscopy, percutaneous via T- tube or other 47554 official report tract; w/ removal of stone(s) Biliary endoscopy, percutaneous via T- tube or other 47555 official report tract; w/ dilation of biliary duct stricture(s) w/o stent Biliary endoscopy, percutaneous via T- tube or other 47556 official report tract; w/ dilation of biliary duct stricture(s) w/ stent Renal endoscopy through established nephrostomy or 50551 pyelostomy, w/ or w/o irrigation, instillation, or official report ureteropyelography, exclusive of radiologic service; Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or 50553 official report ureteropyelography, exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or 50555 official report ureteropyelography, exclusive of radiologic service; w/ biopsy
Page 10 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or 50557 official report ureteropyelography, exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or 50559 ureteropyelography, exclusive of radiologic service; w/ official report insertion of radioactive substance w/ or w/out biopsy and/or fulguration Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or 50561 official report ureteropyelography, exclusive of radiologic service; w/ removal of foreign body or calculus Renal endoscopy through nephrotomy or pyelotomy, w/ 50570 or w/o irrigation, instillation, or ureteropyelography, official report exclusive of radiologic service; Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50572 official report exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter
Renal endoscopy through nephrotomy or pyelotomy, w/ 50574 or w/o irrigation, instillation, or ureteropyelography, official report exclusive of radiologic service; w/ biopsy
Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ endopyelotomy 50575 official report (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent) Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50576 official report exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50578 official report exclusive of radiologic service; w/ insertion of radioactive substance, w/ or w/o biopsy and/or fulguration Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50580 official report exclusive of radiologic service; w/ removal of foreign body or calculus Ureteral endoscopy through established ureterostomy, 50951 w/ or w/o irrigation, instillation, or ureteropyelography, official report exclusive of radiologic service; Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50953 official report exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter
Page 11 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Ureteral endoscopy through established ureterostomy, 50955 w/ or w/o irrigation, instillation, or ureteropyelography, official report exclusive of radiologic service; w/ biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50957 official report exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50959 exclusive of radiologic service; w/ insertion of radioactive official report substance, w/ or w/o biopsy and/or fulguration (not including provision of material) Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50961 official report exclusive of radiologic service; w/ removal of foreign body or calculus Ureteral endoscopy through ureterotomy, w/ or w/o 50970 irrigation, instillation, or ureteropyelography, exclusive of official report radiologic service; Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50972 official report exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter
Ureteral endoscopy through established ureterostomy, 50974 w/ or w/o irrigation, instillation, or ureteropyelography, official report exclusive of radiologic service; w/ biopsy
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50976 official report exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50978 exclusive of radiologic service; w/ insertion of radioactive official report substance, w/ or w/o biopsy and/or fulguration (not including provision of material) Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 50980 official report exclusive of radiologic service; w/ removal of foreign body or calculus 50590 Lithotripsy, extracorporeal shock wave official report Destruction of lesion(s), anus (e.g., condyloma, 46917 papilloma, molluscum contagiosum, herpetic vesicle), official report simple; laser surgery
Page 12 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, 52647 official report meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)
Contact laser vaporization w/ or w/o transurethral resection of prostate, including control of postoperative 52648 bleeding, complete (vasectomy, meatotomy, official report cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Trabeculoplasty by laser surgery, one or more sessions 65855 official report (defined treatment series)
65860 Severing adhesions of anterior segment, laser technique official report
Iridotomy/iridectomy by laser surgery (e.g., for 66761 official report glaucoma) ( one or more sessions)
Discission of secondary membranous cataract (opacified 66821 posterior lens capsule and/or anterior hyaloid) laser official report surgery (e.g., YAG laser) (one or more stages) 66998 Release of scleral flap suture by laser suture lysis official report Severing of vitreous strands, vitreous face adhesions, 67031 sheets, membranes or opacities, laser surgery (one or official report more stages) Vitrectomy, mechanical, pars plana approach; w/ focal 67039 official report endolaser photocoagulation Vitrectomy, mechanical, pars plana approach; w/ 67040 official report endolaser panretinal photocoagulation Destruction by any method, including laser, w/ or w/o surgical curettement, all benign facial lesions or 17000 premalignant lesions in any location, or benign lesions official report if laser specific surgery other than cutaneous vascular proliferative lesions, including local anesthesia; any number of lesions
Destruction by any method, including laser, of benign skin lesions other than cutaneous vascular proliferative 17100 official report if laser specific surgery lesions on any area other than the face, including local anesthesia; any number of lesions Destruction of cutaneous vascular proliferative lesions 17106 official report if laser specific surgery (e.g., laser technique) Excision or destruction, any method (including laser), 30117 official report if laser specific surgery intranasal lesion; internal approach Bronchoscopy; diagnostic, (flexible or rigid),w/ placement 31641 of bronchial stents w/ destruction of tumor or relief of official report if laser specific surgery stenosis by any method other than excision (e.g., laser)
Page 13 of 14 ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing; w/ 45320 ablation of tumor(s), polyp(s), or other lesion(s) not official report if laser specific surgery amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (e.g., laser) Cystourethroscopy, w/ fulguration (including cryosurgery 52214 or laser surgery) of trigone, bladder neck, prostatic fossa, official report if laser specific surgery urethra, or periurethral glands Cystourethroscopy, w/ fulguration (including cryosurgery 52224 or laser surgery) or treatment of MINOR (less than 0.5 official report if laser specific surgery cm) lesion(s) w/ or w/o biopsy Cystourethroscopy, w/ fulguration (including cryosurgery 52234 or laser surgery) and/or resection of; SMALL bladder official report if laser specific surgery tumor(s) (0.5 cm to 2.0 cm) Transurethral destruction of prostate tissue;by radiofrequncy ablation i.e., Transurethral Needle 53852 official report if laser specific surgery Ablation (TUNA), transurethral laser incision of the prostate (TULIP) Conization of cervix, w/ or w/o fulguration, w/ or w/o 57520 dilation and curettage, w/ or w/o repair; cold knife or official report if laser specific surgery laser
Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), w/ or w/o implant, w/ or w/o cryotherapy, photocoagulation, and drainage of subretinal fluid w/ 67108 official report if laser specific surgery vitrectomy, any method, w/ or w/o air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique
Destruction of localized lesion of retina (e.g., 67210 maculopathy, choroidopathy, small tumors), one or official report if laser specific surgery more sessions; photocoagulation (laser or xenon arc)
Destruction of localized lesion of choroid (e.g., choroidal 67220 neovascularization); photocoagulation (e.g., laser), one or official report if laser specific surgery more sessions Destruction of extensive or progressive retinopathy (e.g., 67228 diabetic retinopathy), one or more sessions; official report if laser specific surgery photocoagulation (laser or xenon arc) Repair of trichiasis; by electroepilation, electrosurgery, 67825 official report if laser specific surgery cryotherapy or laser surgery Closure of the lacrimal punctum; by thermocauterization, 68760 official report if laser specific surgery ligation, or laser surgery
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