ANNEX 10.

LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
77401 77401 90945 96408 79000 12001

DESCRIPTION
Radiation treatment delivery (Linear Accelerator) Radiation treatment delivery (Cobalt) Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) Chemotherapy administration Radiopharmaceutical (radioactive iodine) therapy Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm

REQUIREMENT
none ; operating room and anesthesia records are waived none ; operating room and anesthesia records are waived none ; operating room and anesthesia records are waived none ; operating room and anesthesia records are waived none ; operating room and anesthesia records are waived doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure

12002

12004

Simple repair of superficial wounds of scalp, neck, axillae, doctor's order and/or nurse's notes 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 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 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 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 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 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 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 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, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure

12005

12006

12007

12011

12013

12014

12015

12016

12017

12018

Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes 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
12031

DESCRIPTION
Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 2.5 cm or less Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm

REQUIREMENT
doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure

12032

12034

Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes 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 extremities (excluding hands and feet); 12.6 cm to 20.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); over 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; over 30.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 2.5 cm or less Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 2.6 cm to 5.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 5.1 cm to 7.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 7.6 cm to 12.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 12.6 cm to 20.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 20.1 cm to 30.0 cm doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure

12035

12036

12037

12041

12042

12044

12045

12046

12047

12051

12052

12053

12054

12055

12056

Page 2 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
12057

DESCRIPTION
Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; over 30.0 cm Tracheostomy, planned ;

REQUIREMENT
doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure doctor's order and/or nurse's notes indicating performance of the procedure

31600

31601

Tracheostomy, planned ; under two years

31603

Tracheostomy, emergency procedure; transtracheal Tracheostomy, emergency procedure; cricothyroid membrane Tracheostomy, fenestration procedure with skin flaps Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent Thoracentesis w/ insertion of tube w/ or w/o water seal (e.g., for pneumothorax) Tube thoracostomy w/ or w/o water seal (e.g., for abscess, hemothorax, empyema) Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown Placement of central venous catheter (subclavian, jugular, or other vein) (e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy); percutaneous or cutdown Bone marrow aspiration and/or biopsy

31605

31610

32000

32002

32020

36640

36488

38220

49080

Peritoneocentesis, abdominal paracentesis, or peritoneal doctor's order and/or nurse's notes lavage (diagnostic or therapeutic) indicating performance of the procedure Spinal puncture, lumbar, diagnostic Nasal endoscopy, diagnostic, unilateral or bilateral Nasal/sinus endoscopy, diagnostic w/ maxillary sinusoscopy (via inferior meatus or canine fossa puncture) Nasal/sinus endoscopy, diagnostic w/ sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) Nasal/sinus endoscopy, surgical; w/ biopsy, polypectomy or debridement Nasal/sinus endoscopy, surgical; w/ control of epistaxis doctor's order and/or nurse's notes indicating performance of the procedure official report official report

62270 31231 31233

31235 31237 31238

official report official report official report

Page 3 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
31239 31240 31254 31255 31256 31267 31276 31287 31288 31290 31291 31292 31293 31294 31515 31520 31525 31526 31527 31528 31529 31530 31531 31535 31536 31540

DESCRIPTION
Nasal/sinus endoscopy, surgical; w/ dacrylocystorhinostomy Nasal/sinus endoscopy, surgical; w/ concha bullosa resection Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, partial (anterior) Nasal/sinus endoscopy, surgical; w/ ethmoidectomy, total (anterior and posterior)

REQUIREMENT
official report official report official report official report

Nasal/sinus endoscopy, surgical, w/ maxillary antrostomy official report Nasal/sinus endoscopy, surgical, w/ removal of tissue from maxillary sinus Nasal/sinus endoscopy, surgical w/ frontal sinus exploration, w/ or w/o removal of tissue from frontal sinus Nasal/sinus endoscopy, surgical, w/ sphenoidotomy Nasal/sinus endoscopy, surgical, w/ removal of tissure from the sphenoid sinus Nasal/sinus endoscopy, surgical, w/ repair of cerebrospinal fluid leak; ethmoid region Nasal/sinus endoscopy, surgical, sphenoid region Nasal/sinus endoscopy, surgical; w/ medial or inferior orbital wall decompression Nasal/sinus endoscopy, surgical; w/ medial orbital wall and inferior orbital wall decompression Nasal/sinus endoscopy, surgical; w/ optic nerve decompression Laryngoscopy direct, w/ or w/o tracheoscopy; for aspiration Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, newborn Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, except newborn Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, w/ operating microscope Laryngoscopy direct, w/ or w/o tracheoscopy; w/ insertion of obturator Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, initial Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, subsequent Laryngoscopy, direct, operative, w/ foreign body removal; Laryngoscopy, direct, operative, w/ foreign body removal; w/ operating microscope Laryngoscopy, direct, operative, w/ biopsy; Laryngoscopy, direct, operative, w/ biopsy; w/ operating microscope Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of vocal cords or epiglottis; official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report

Page 4 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
31541 31560 31561 31570 31571 31575 31576 31577 31578 31579 31622 31625 31628 31629 31630 31631 31635 31636 31640 31641 31643 31645 32601 32602 32603 32604 32605 32606

DESCRIPTION

REQUIREMENT

Laryngoscopy, direct, operative, w/ excision of tumor and/or stripping of vocal cords or epiglottis; w/ operating official report microscope Laryngoscopy, direct, operative, w/ arytenoidectomy; Laryngoscopy, direct, operative, w/ arytenoidectomy; w/ operating microscope Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic; Laryngoscopy, direct, w/ injection into vocal cord(s), therapeutic; w/ operating microscope Laryngoscopy, flexible fiberoptic; diagnostic Laryngoscopy, flexible fiberoptic; w/ biopsy Laryngoscopy, flexible fiberoptic; w/ removal of foreign body Laryngoscopy, flexible fiberoptic; w/ removal of lesion official report official report official report official report official report official report official report official report

Laryngoscopy, flexible or rigid fiberoptic, w/ stroboscopy official report Bronchoscopy; diagnostic, (flexible or rigid), w/ or w/o cell washing or brushing Bronchoscopy; w/ biopsy Bronchoscopy; w/ transbronchial lung biopsy, w/ or w/o fluoroscopic guidance Bronchoscopy; w/ transbronchial needle aspiration biopsy Bronchoscopy; w/ tracheal or bronchial dilation or closed reduction of fracture Bronchoscopy; w/ tracheal dilation and placement of tracheal stent Bronchoscopy; w/ removal of foreign body Bronchoscopy; diagnostic, (flexible or rigid),w/ placement of bronchial stents Bronchoscopy; w/ excision of tumor Bronchoscopy; w/ destruction of tumor or relief of stenosis by any method other than excision (e.g., laser) Bronchoscopy; w/ placement of catheters for intracavitary radioelement application Bronchoscopy; w/ therapeutic aspiration of tracheobronchial tree, (e.g., drainage of lung abscess) Thoracoscopy, diagnostic ; lungs and pleural space, w/o biopsy Thoracoscopy, diagnostic ; lungs and pleural space, w/ biopsy Thoracoscopy, diagnostic ; pericardial sac, w/o biopsy Thoracoscopy, diagnostic ; pericardial sac, w/ biopsy official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report official report

Thoracoscopy, diagnostic ; mediastinal space, w/o biopsy official report 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
32650 32651 32652 32653 32654 32655 32656 32658 32659 32660 32661 32662 32663 32664 32665 43200 43202 43204 43205 43215 43216

DESCRIPTION
Thoracoscopy, surgical; w/ pleurodesis, any method Thoracoscopy, surgical; w/ partial pulmonary decortication Thoracoscopy, surgical; w/ total pulmonary decortication, including intrapleural pneumonolysis Thoracoscopy, surgical; w/ removal of intrapleural foreign body or firbin deposit Thoracoscopy, surgical; w/ control of traumatic hemorrhage Thoracoscopy, surgical; w/ excision-plication of bullae, including any pleural procedure Thoracoscopy, surgical; w/ parietal pleurectomy Thoracoscopy, surgical; w/ removal of clot or foreign body from pericardial sac

REQUIREMENT
official report official report official report official report official report official report official report official report

Thoracoscopy, surgical; w/ creation of percardial window official report or partial resection of pericardial sac for drainage Thoracoscopy, surgical; w/ total pericardiectomy Thoracoscopy, surgical; w/ excision of pericardial cyst, tumor, or mass Thoracoscopy, surgical; w/ excision of mediastinal cyst, tumor, or mass official report official report official report

Thoracoscopy, surgical; w/ lobectomy, total or segmental official report Thoracoscopy, surgical; w/ thoracic sympathectomy Thoracoscopy, surgical; w/ esophagomyotomy (Heller type) Esophagoscopy, rigid or flexible; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Esophagoscopy, rigid or flexible; w/ biopsy, single or multiple Esophagoscopy, rigid or flexible; w/ injection sclerosis of esophageal varices Esophagoscopy, rigid or flexible; w/ band ligation of esophageal varices Esophagoscopy, rigid or flexible; w/ removal of foreign body Esophagoscopy, rigid or flexible; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery official report official report official report official report official report official report official report official report

43217 43219 43220 43226 43227

Esophagoscopy, rigid or flexible; w/ removal of tumor(s), official report polyp(s), or other lesion(s) by snare technique Esophagoscopy, rigid or flexible; w/ insertion of plastic tube or stent Esophagoscopy, rigid or flexible; w/ balloon dilation (less than 30 mm diameter) Esophagoscopy, rigid or flexible; w/ insertion of guide wire followed by dilation over guide wire Esophagoscopy, rigid or flexible; w/ control of bleeding, any method official report official report official report official report

Page 6 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
43228

DESCRIPTION
Esophagoscopy, rigid or flexible; w/ ablation of tumor(s) polyp(s), or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

REQUIREMENT
official report

43234

Upper gastrointestinal endoscopy, simple primary official report examination ( e.g. w/ small diameter flexible endoscope) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ biopsy, single or multiple Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ transendoscopic tube or catheter placement Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ injection sclerosis of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ band ligation of esophageal and/or gastric varices Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ dilation of gastric outlet for obstruction, any method Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ directed placement of percutaneous gastrostomy tube Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ removal or foreign body Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ insertion of guide wire followed by dilation of esophagus over guide wire

43235

official report

43239

official report

43241

official report

43243

official report

43244

official report

43245

official report

43246

official report

43247

official report

43248

official report

43249

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 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
43250

DESCRIPTION
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 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 appropriate; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; w/ control of bleeding, any method

REQUIREMENT
official report

43251

official report

43255

official report

43258

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as 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, stomach, and either the duodenum and/or jejunum as appropriate; w/ endoscopic ultrasound examination

43259

official report

44360

Small intestinal endoscopy, enteroscopy, beyond second 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 official report portion of duodenum, not including ileum; w/ biopsy, single or multiple Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ removal of official report foreign body Small intestinal endoscopy, enteroscopy, beyond second 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 tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ control of bleeding, any method Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare tenchnique Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ placement of percutaneous jejunostomy tube

44361

44363

44364

44365

official report

44366

official report

44369

official report

44372

official report

Page 8 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
44373

DESCRIPTION

REQUIREMENT

Small intestinal endoscopy, enteroscopy, beyond second portion of duodenum, not including ileum; w/ conversion official report of percutaneous gastrostomy tube to percutaneous jejunostomy tube Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum;w/ biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum;w/ control of bleeding, any method Ileoscopy, through stoma; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Ileoscopy, through stoma; w/ biopsy, single or multiple Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; w/ biopsy, single or multiple Colonoscopy through stoma; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing official report

44376

44377

official report

44378 44380 44382 44385

official report official report official report official report

44386 44388 44389 44390 44391 44392

official report official report

Colonoscopy through stoma; w/ biopsy, single or multiple official report Colonoscopy through stoma; w/ removal of foreign body official report Colonoscopy through stoma; w/ control of bleeding, any official report method Colonoscopy through stoma; w/ removal of tumor(s), official report polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma; w/ ablation of tumor(s), 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), polyp(s), or other lesion(s) by snare technique Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing, w/ or w/o colon decompression Colonoscopy, flexible, proximal to splenic flexure; w/ removal of foreign body Colonoscopy, flexible, proximal to splenic flexure; w/ biopsy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; w/ control of bleeding, any method official report official report

44393

44394 45355

45378

official report

45379 45380 45382

official report official report official report

Page 9 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
45383

DESCRIPTION
Colonoscopy, flexible, proximal to splenic flexure; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy, flexible, proximal to splenic flexure; w/ removal of tumor(s), polyp(s), or other lesion(s) by snare technique Anoscopy; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Anoscopy; w/ dilation, any method Anoscopy; w/ biopsy, single or multiple Anoscopy; w/ removal of foreign body Anoscopy; w/ removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Anoscopy; w/ removal of single tumor, polyp or other lesion by snare technique Anoscopy; w/ removal of multiple tumor, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique Anoscopy; w/ control of bleeding, any method Anoscopy; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Biliary endoscopy, percutaneous via T- tube or other tract; diagnostic, w/ or w/o collection of specimen(s) by brushing and/or washing Biliary endoscopy, percutaneous via T- tube or other tract; w/ biopsy, single or multiple Biliary endoscopy, percutaneous via T- tube or other tract; w/ removal of stone(s) Biliary endoscopy, percutaneous via T- tube or other tract; w/ dilation of biliary duct stricture(s) w/o stent Biliary endoscopy, percutaneous via T- tube or other tract; w/ dilation of biliary duct stricture(s) w/ stent Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or 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 ureteropyelography, exclusive of radiologic service; w/ biopsy

REQUIREMENT
official report

45384

official report

45385 46600 46604 46606 46608 46610 46611 46612 46614 46615

official report official report official report official report official report official report official report official report official report official report

47552 47553 47554 47555 47556

official report official report official report official report official report

50551

official report

50553

official report

50555

official report

Page 10 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
50557

DESCRIPTION
Renal endoscopy through established nephrostomy or pyelostomy, w/ or w/o irrigation, instillation, or 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 ureteropyelography, exclusive of radiologic service; w/ 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 ureteropyelography, exclusive of radiologic service; w/ removal of foreign body or calculus Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service;

REQUIREMENT
official report

50559

official report

50561

official report

50570

official report

50572

Renal endoscopy through nephrotomy or pyelotomy, w/ or w/o irrigation, instillation, or ureteropyelography, official report exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter Renal endoscopy through nephrotomy or pyelotomy, w/ 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 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, 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, 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, official report exclusive of radiologic service; w/ removal of foreign body or calculus Ureteral endoscopy through established ureterostomy, 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, exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter

50574

50575

50576

50578

50580

50951

50953

official report

Page 11 of 14

ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
50955

DESCRIPTION
Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy

REQUIREMENT
official report

50957

official report

50959

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 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, official report exclusive of radiologic service; w/ removal of foreign body or calculus Ureteral endoscopy through ureterotomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of official report radiologic service; Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ ureteral catheterization, w/ or w/o dilation of ureter Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ biopsy Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, exclusive of radiologic service; w/ fulguration and/or incision, w/ or w/o biopsy

50961

50970

50972

official report

50974

official report

50976

official report

50978

Ureteral endoscopy through established ureterostomy, w/ or w/o irrigation, instillation, or ureteropyelography, 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, exclusive of radiologic service; w/ removal of foreign body or calculus Lithotripsy, extracorporeal shock wave Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery

50980 50590 46917

official report official report official report

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ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL TECHNIQUE RVS CODE
52647

DESCRIPTION

REQUIREMENT

Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, 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 bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) Severing adhesions of anterior segment, laser technique Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) ( one or more sessions)

52648

official report

65855 65860 66761

official report official report official report

66821 66998 67031 67039 67040

Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) laser official report surgery (e.g., YAG laser) (one or more stages) Release of scleral flap suture by laser suture lysis Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (one or more stages) Vitrectomy, mechanical, pars plana approach; w/ focal endolaser photocoagulation Vitrectomy, mechanical, pars plana approach; w/ endolaser panretinal photocoagulation Destruction by any method, including laser, w/ or w/o surgical curettement, all benign facial lesions or premalignant lesions in any location, or benign lesions 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 lesions on any area other than the face, including local anesthesia; any number of lesions Destruction of cutaneous vascular proliferative lesions (e.g., laser technique) Excision or destruction, any method (including laser), intranasal lesion; internal approach official report official report official report official report

17000

official report if laser specific surgery

17100

official report if laser specific surgery

17106 30117

official report if laser specific surgery official report if laser specific surgery

31641

Bronchoscopy; diagnostic, (flexible or rigid),w/ placement 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
45320

DESCRIPTION
Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing; w/ ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (e.g., laser)

REQUIREMENT
official report if laser specific surgery

52214

Cystourethroscopy, w/ fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, official report if laser specific surgery urethra, or periurethral glands Cystourethroscopy, w/ fulguration (including cryosurgery 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 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 Ablation (TUNA), transurethral laser incision of the prostate (TULIP) Conization of cervix, w/ or w/o fulguration, w/ or w/o dilation and curettage, w/ or w/o repair; cold knife or laser

52224

52234

53852

official report if laser specific surgery

57520

official report if laser specific surgery

67108

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/ 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., maculopathy, choroidopathy, small tumors), one or more sessions; photocoagulation (laser or xenon arc) Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc) Repair of trichiasis; by electroepilation, electrosurgery, cryotherapy or laser surgery Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery

67210

official report if laser specific surgery

67220

official report if laser specific surgery

67228 67825 68760

official report if laser specific surgery official report if laser specific surgery official report if laser specific surgery

Page 14 of 14