Review Committee for Otolaryngology Case Log Coding Recommendations

Transcription

1 Review Committee for Otolaryngology Case Log Coding Recommendations The following Case Log Coding Recommendations have been provided in an attempt to establish some degree of uniformity for all Otolaryngology residents for logging cases into the ACGME Case Log System. The Review Committee for Otolaryngology publicly thanks and credits the Harvard Otolaryngology Residency Program for drafting the initially proposed document which was utilized in the development of these recommendations, and the University of Michigan Program for the most recent revisions. Please note that these recommendations additionally provide role definitions for Resident Surgeon, Resident Assistant, and Resident Supervisor, and demarcate those procedural codes that define Key Indicator Cases (as indicated by red asterisks *). These cases constitute the 14 procedure categories identified by the RRC to be representative of Otolaryngology surgical training. Also included are instructions for the proper un-bundling of procedures (as indicated by blue text) for Case Log recording (but not billing) purposes. This document contains a linkable Table of Contents for electronic use, but is also designed to print in booklet form (pages 2-9). This document will be periodically updated by the Review Committee for Otolaryngology based on updates to key indicator cases and procedures. Program directors will be notified of such updates via the RRC News for Otolaryngology or other correspondence. Table of Contents GENERAL/ENDOSCOPY/RHINOLOGY... 2 Emergency Department Procedures... 2 Postoperative Complications... 2 Endoscopy: Airway and Foreign Body Procedures... 2 Sinus Surgery... 3 General/Pediatric... 3 PEDIATRIC OTOLARYNGOLOGY... 4 LARYNGOLOGY... 4 HEAD & NECK SURGERY... 4 Endocrine Surgery... 4 Neck Dissection... 4 Salivary Gland Procedures... 5 Oral Cavity/Oropharynx... 5 Laryngectomy... 5 Anterior Craniofacial Resection... 5 Maxillectomy... 6 Excision of Cutaneous Facial Lesion... 6 Head & Neck Ablative Procedures... 6 FACIAL PLASCTIC AND RECONSTRUCTIVE SURGERY... 6 Free/Pedicled Flaps... 6 Plastics/Trauma Procedures... 6 Microtia Repair... 8 OTOLOGY/NEUROTOLOGY... 8 Otology... 8 Ablative Otologic Procedures... 8 Reconstructive Otologic Procedures... 9 Appendix: Key Indicator Categories

2 *Asterisk by key indicator cases Rules for unbundling noted in blue Role Definitions: Resident surgeon: performs 50% of the operation with the attending physician or resident supervisor, including the key portions of the procedure Resident assistant: performs < 50% of the operation, or 50% of the operation but not the key portions of the procedure. Resident supervisor: instructs/assists a more junior resident during a procedure in which the junior resident performs 50% of the operation, including the key portions of the procedure; the attending physician acts as an assistant or observer. GENERAL/ENDOSCOPY/RHINOLOGY Emergency Department Procedures: Repair complex scalp laceration: cm: cm: Each additional 5cm (code separate): Repair complex forehead/face laceration: cm: cm: Each additional 5cm (code separate): Repair complex eyelid/ear/nose or lip laceration repair: <1.0 cm: cm: cm: Each additional 5cm (code separate): Open repair frontal sinus fracture: Depressed: Complicated: Oral vestibule laceration repair: 2.5cm: >2.5cm: FOM/Oral tongue laceration repair: 2.5cm: >2.5cm Flexible laryngoscopy, diagnostic: Flexible laryngoscopy, w/ biopsy: *Flexible laryngoscopy, FB removal: * Flexible laryngoscopy, lesion removal: Peritonsillar abscess drainage: Removal impacted cerumen: Removal foreign body from ear: Under GA (operative): Removal of foreign body from nose: Under GA (operative): Epistaxis Control Anterior epistaxis control (simple): Anterior epistaxis control (complex): Posterior packing placement: Revision posterior packing: Ethmoid artery ligation: Internal maxillary ligation, transantral: Endoscopic control, operative: Septal hematoma/abscess drainage: Auricle hematoma/abscess: Oral vestibule drainage of cyst, abscess, hematoma: Simple: Complicated Intraoral I&D abscess/cyst/hematoma: Lingual: Sublingual; superficial: Sublingual; deep: Submental: Submandibular space: Sublingual/Submaxillary: Masticator space: Extraoral I&D abscess/cyst/hematoma: Sublingual: Submental: Submandibular space: Masticator space: Parotid abscess I&D; simple: Parotid abscess I&D; complicated: Retropharyngeal/parapharyngeal abscess I&D; intraoral: Retropharyngeal/parapharyngeal abscess I&D; extraoral: Postoperative Complications: Neck exploration for hematoma: Postoperative tonsil bleed requiring OR: I&D superficial abscess: I&D deep space hematoma or abscess: Endoscopy: Airway / Foreign Body Procedures : DL, diagnostic: DL with biopsy: DL w/ arytenoidectomy: MicroDL w/ arytenoidectomy: Tracheoscopy or microlaryngoscopy with biopsy: *Bronchoscopy, diagnostic: *Bronchoscopy with BAL: *Bronchoscopy with biopsy: Awake fiberoptic intubation or emergency intubation: Cricoidotomy: Tracheotomy, planned: Tracheotomy, emergency: Tracheal repair:

3 *DL with FB removal: Micro DL, diagnostic: *Micro DL with FB removal: Removal FB pharynx: Esophagoscopy with FB removal: *Bronchoscopy with FB removal: DL w open reduction of fracture: *DL with dilation, initial: *subsequent: *Bronchoscopy with dilation: *Bronchoscopy with stent placement: *Revision *Bronchoscopy with tumor excision: *Bronchoscopy with tumor or stenosis laser ablation: *Tracheobronchoscopy through tracheostomy incision: Esophagoscopy, diagnostic: Esophagoscopy, w/ submucosal injection: w/ biopsy: w/ tumor removal w/ insertion of stent/tube w/ dilation over guidewire Esophageal dilation w/ balloon with bougie: over guidewire: retrograde: PEG/ G-tube placement: Nasopharyngeal biopsy: Zenker s: (endoscopic) (open) (open cricopharyngealmyotomy) Transcervical repair of esophageal wound/injury (open): Sinus Surgery (log each side separately): Insertion of nasal button: Removal of FB; lateral rhinotomy: Lysis of intranasal synechiae: Endo maxillary antrostomy: Endo maxillary antrostomy + tissue: Endo frontal +/- tissue: Endo sphenoid: Endo sphenoid + tissue: Endo biopsy or polyp or debridement: Endo concha bullosa: DCR: Endo Open/fistulization *Endo Ant ethmoid: *Endo total ethmoid: Endo diag., maxillary b inf meatus: Endo nasal: Endo CSF leak repair: Ethmoid region: Sphenoid region: CSF leak repair w/ graft: (code graft harvest separately) Endo orbital wall decompression: Medial or inferior wall: Medial and Inferior wall: Endo optic nerve decompression: Non-Endoscopic Sinus Surgery Sinusotomy; frontal: Trephine: Transorbital: Frontal sinusotomy; obliterative: Brow incision w/o osteoplastic flap: Coronal incision w/o osteoplastic flap: Brow incision w/ osteoplastic flap: Coronal incision w/ osteoplastic flap: Frontal sinusotomy; non-obliterative: Brow incision w/ osteoplastic flap: Coronal incision w/ osteoplastic flap: Lavage by canulation; maxillary: Lavage by canulation; sphenoid: Sinusotomy; maxillary antrostomy: Sinusotomy; Caldwell-Luc: Sinusotomy; Caldwell-Luc + polyps: Sinusotomy: sphenoid+/- biopsy: Sinusotomy: sphenoid + polypectomy: Ethmoidectomy; intranasal, anterior: Ethmoidectomy; intranasal, total: Ethmoidectomy; extranasal, total: General/Pediatric: Intranasal biopsy: Transnasal excision nasal polyp: Simple: Extensive: Excision of intranasal lesion: Internal: Lateral rhinotomy: Turbinate soft tissue ablation; Mucosal, any method: Submucosal, any method: Turbinate excision, any method: Fracture inferior turbinate: Turbinate, submucous resection: Turbinate injection: Septoplasty: Frenotomy: Frenuplasty; revision w/ Z-plasty: UPPP: Tongue base suspension: Uvulectomy: Chemical or thermal destruction of 3

4 palate or uvular lesion: Uvula procedure NOS: T&A: >12 yrs: <12 yrs: Tonsil alone > 12yrs: <12 yrs: Adenoid alone: > 12yrs: <12yrs: M&T: Myringotomy Myringotomy under GA Tube Tube under GA Removal of ear tube under GA: PEDIATRIC OTOLARYNGOLOGY Pediatric Airway and Neck See also above codes for Endoscopy: Airway and Foreign Body DL / tracheoscopy in pediatric patients: MicroDL/Supraglottoplasty: *Diagnostic DL of newborn: *Tracheotomy = <2y: *Cricoid split: *Laryngoplasty for web; 2 stage w/ keel insertion or removal: *LTR: Rib graft: CTR / Trach R+R: *Laryngoplasty, NOS *Resection nasal dermoid: *simple *complex *Excision of vascular anomaly; *w/o deep neurovascular dissection: *w/ deep neurovascular dissection: *Branchial cleft anomaly not cyst: *Branchial cleft cyst: *Thyroglossal duct cyst: *recurrent Choanal atresia repair: Intranasal: transpalatine: Drainage of RP or PPS abscess internal approach: external approach: Tongue fixation to lip for micrognathia: LARYNGOLOGY DL w/ tumor excision or stripping vocal cord or epiglottis: *MicroDL w/ arytenoidectomy: Suspension microlaryngoscopy (SML) with resection/stripping of polyp /tumor: *SML resection nodule/submucosal mass w/ local flap recon: *SML resection nodule/submucosal mass w/ graft recon: *SML with cordectomy: *SML with endoscopic hemi laryngectomy: antero-vertical: latero-vertical: antero-latero-vertical: VF injection / injection laryngoplasty: VF injection or injection laryngoplasty (with microsope/telescope): *Medialization thyroplasty: Triple procedure: Adduction arytenopexy: Medialization thyroplasty: Cricothyroid subluxation: Office-based PDL: Office-based injection laryngoplasty: Stroboscopy: Laryngeal EMG: *DL w/ insertion of obturator: *DL w/ dilation, initial: *DL w/ dilation, subsequent: HEAD & NECK SURGERY Endocrine Surgery: *Hemithyroidectomy: *Hemithyroid; partial contralateral: *Completion thyroidectomy: *Total thyroidectomy: *Total thyroidectomy with pre-tracheal/ prelaryngeal dissection: *Total thyroidectomy with radical neck dissection: *Completion total thyroidectomy: Code neck dissection separately. Thyroid case in which attending does most of the first lobe and you are surgeon on the other side: (Log two different case IDs for each hemi thyroid - one as resident assistant and one as resident surgeon) *Parathyroid auto-transplantation: *Parathyroidectomy: *Parathyroidectomy; re-exploration: Neck Dissection (log each side separately) *MRND/SLND/SOHND: *Radical ND: Submandibular gland excision: Deep cervical node biopsy/slnb: Dissection, jugular node(s): If you get into IJ/carotid and repair it: Excision soft tissue mass, neck:

5 Excision tumor, deep neck: Radical excision of malignant tumor, anterior neck/thorax; <5cm: Drainage of RP or PPS abscess via external approach: Resection parapharyngeal space tumor: Vessel exploration: Major vessel repair: Salivary Gland Procedures: *Superficial parotid with FN dissection: *Superficial parotid w/o FN dissection: *Total parotid with FN dissection: *Total parotid with FN sacrifice: If you graft the FN: If you do a parotid/neck, log one of the above codes and log the neck procedure separately If mass goes into parapharyngeal space, also log: If abdominal fat graft following parotid: Submandibular gland excision: Selective neck dissection (levels 1A-1B):38724 Sublingual gland excision: Ranula: Excision: Marsupialization: Closure salivary fistula: Dilation salivary duct: Dilation of salivary duct w/ catheter: Ligation salivary duct; intraoral: Sialodochoplasty; Primary or simple: Secondary or complicated: Parotid duct diversion: Lip/ Oral Cavity/ Oropharynx: Lip Biopsy: Vermillionectomy w/ advancement flap: Wedge excision; primary closure: Lip excision; >1/4 of lip: Lip excision; local flap repair: Lip excision; cross lip repair: OC FB removal (embedded): Simple: Complicated: Biopsy of oral tongue: Glossectomy to be coded without neck dissection to keep unbundled: *Partial glossectomy w/o primary closure: *Hemiglossectomy w/o primary closure: *Total glossectomy: Excision of oral tongue lesion without closure Excision tongue lesion w/ primary closure: (anterior 2/3) (posterior 1/3) *Excision tongue lesion w/ tongue flap: Excision of frenulum: Excision FOM lesion: *Resection of RMT or OP tumor *Excision mandible tumor: Log neck dissection or tracheostomy separately if jointly performed with oral cavity/op resection Tooth extraction: Oroantral fistula repair: Oromaxillary: Oronasal: Limited Pharygectomy: Laryngectomy: Laryngectomy (without neck dissection to keep unbundled): Hemilaryngectomy (horizontal): Hemilaryngectomy (laterovertical): Hemilaryngectomy (anterovertical): Hemilaryngectomy (anterolaterovertical):31382 Epiglotidectomy: Pharyngectomy: (when closed primarily) (if requires flap for closure) Unbundle for laryngopharyngectomy Supraglottic laryngectomy: If you close the pharynx primarily (pharyngoesophageal repair): *If you take total thyroid: *If you take hemithyroid: *If you do MRND or SLND: *If you do radical ND: *If you do rotational SCM flap: *If you assist in PIG (pharyngeal interposition graft): TEP and prosthesis: Laryngofissue: w/ tumor/laryngocele excision: diagnostic: Cricopharyngeal myotomy: Anterior Craniofacial Resection: Pterygomaxillary fossa surgery; any approach: Anterior craniofacial approach and tumor resection w/o anterior cranial fossa resection: Anterior craniofacial approach and tumor resection w/ anterior cranial fossa resection: Orbitocranial approach to ant cranial fossa (ACF): Bicoronal, transzygomatic or LeFort I osteotomy approach to ACF:

6 Resection/excision of ACF lesion: Extradural: Intradural +/- dural repair: Orbital exenteration: Infratemporal fossa approach to parapharyngeal space or middle cranial fossa: Infratemporal resection of tumor/mass: Transpetrous approach to skull base: Resection of midline skull base tumor/mass: If you put in a flap, code as under free/pedicled flaps category Maxillectomy: Maxillectomy (including total, inferior, or medial): If you take the eye: Placement of pin-borne prosthesis: Excision of cutaneous facial lesion: Malignant face/eyelid/nose lesion <0.5 cm: cm: cm: cm: cm: >4.0 cm: Benign face/eyelid/nose lesion <0.5 cm: cm: cm: cm: cm: >4.0 cm: Malignant Scalp/Neck Lesion <0.5 cm: cm: cm: cm: cm: >4.0 cm: Benign Scalp/Neck Lesion <0.5 cm: cm: cm: cm: cm: >4.0 cm: Sentinel lymph node Box / Exec: If you inject ethylene blue dye, add: Head & Neck Ablative Procedures: Diagnostic DL: DL with biopsy: Tracheotomy: If you explore neck for vessels (suprahyoid) neck dissection, log SLND see previous codes *Excision of FOM lesion: *Partial glossectomy: *Hemiglossectomy: *Composite resection of tongue/fom/mandible (unbundle from neck): *Mandible excision for: *ORN/benign tumor/cyst: *Malignant tumor : *Segmental mandibulectomy: Auriculectomy; complete: Auriculectomy; partial: Carotid body tumor excisions: Carotid sparing: Carotid sacrifice: FACIAL PLASTIC & RECONSTRUCTIVE SURGERY Free/Pedicled Flaps: *RFFF (log assist if you help with inset): *FFF (log assist if you help with inset): *ALT (log assist if you help with inset): *Pec Flap: *TPFF, or temporalis muscle flap, or SCM rotational flap: *Cervico-facial rotational/advancement flap: if <10 cm2: if cm2: if > 30cm2: *Paramedian forehead flap: *Takedown of paramedian forehead flap pedicle (2 nd stage) Free flap +/- vessel anastomosis: *Muscle or myocutaneous: *Cutaneous: *Fascia: *Osteocutaneous: *Iliac crest: If you scrub in only to close: -Close the arm: skin graft: arm wound: *Advancement closure of leg (ie: fibula, ALT): Close the chest (pec): Close the neck: Close the parotid: Facial-hypoglossal nerve repair: Plastics / Trauma Procedures: Repair complex scalp laceration: 6

7 cm: cm: Each additional 5cm (code separate): Repair complex forehead/face laceration: cm: cm: Each additional 5cm (code separate): Repair complex eyelid/ear/nose or lip laceration repair: <1.0 cm: cm: cm: Each additional 5cm (code separate): Open repair frontal sinus fracture: Depressed: Complicated: Closed reduction of nasal fracture: Without stabilization: With stabilization: *Open reduction of nasal fracture: (log this as closed rhinoplasty with bony work:) *ZMC/midface fracture: (If done with Ophth, log orbital fx as assist: and log canthotomy if done: *Closed alveolar fracture repair: *Open alveolar fracture repair: *Percutaneous mandibular fracture repair; external fixation: *Open mandibular fracture repair; external fixation: *Mandible fracture: (Log each aspect of case separately) MMF: ORIF mandible fx: OR w/o fixation: *Open condylar fracture repair: *LeFort I fracture: Closed repair: Simple open repair: Complex open repair: *LeFort II fracture: Closed repair: Simple open repair: Complex open repair: *LeFort III fracture: Closed repair: Simple open repair: Complex open repair: *Percutaneous malar/tripod fx repair: *Gilles approach to zygomatic arch fx: *Open zygomatic arch/tripod fx repair: *Orbital floor fracture repair: Caldwell-Luc approach: Periorbital approach: alloplastic or other implant: *Open rhinoplasty: Septoplasty: *Rhinoplasty: *Revision rhinoplasty: *Nasal valve repair: *Repair of nasal vestibule stenosis Cartilage graft: Septal cartilage graft: Costochondral: Bone graft: Small or minor: Large or major: Facial bone graft: Cleft lip repair: Primary: Secondary: Cleft palate repair: Palatoplasty: Palatoplasty w/ alveolar ridge: Major revision: Palatoplasty w/ pharyngeal flap: Palatoplasty w/ island flap: Rhytidectomy; forehead: Rhytidectomy: Rhytidectomy SMAS flap: Platysmectomy (platysmal tightening): Cervicoplasty: Facial plastics Botox inj. (not larynx) Blepharoplasty: (Log each eye and each site {upper or lower} separately) Upper blepharoplasty: Lower blepharoplasty: Repair of blepharoptosis: Frontalis muscle pexy: Levator resection/advancement: Sup. rectus technique: Fasanella-Servat technique: Revision for overcorrection: Correction of lid retraction: Ectropion repair; Suture: Cautery: Excision tarsal wedge: Tarsal strip: Canthoplasty: Otoplasty (protruding ear): Brow lift (any approach): Eyelid weight: Removal of eyelid weight: Vestibuloplasty: Anterior:

8 Posterior: Entire arch: Complex Gracilis free flap: Unbundle as appropriate Myogenous free flap for paralyzed face: Temporalis tendon transfer: Neurorrhaphy: Nerve graft harvest: 4cm graft: >4cm graft: Fascia lata graft: STSG to face (eyelids, nose, mouth, lips, ears,neck): Dermal graft; face or neck: Derma-fat-fascia graft: *FTSG (including closure of donor site, scalp, arms or legs): 20cm 2 : cm 2 or part thereof: *FTSG (including closure of donor site forehead, cheeks, chin, mouth, neck): 20cm 2 : cm 2 or part thereof: *FTSG (including closure of donor site to nose, ears, eyelids): 20cm 2 : cm 2 or part thereof: *Composite Graft (ie: full-thickness of external ear or including primary closure of donor site) Acellular dermal replacement: *Autologous Ear cartilage graft (to nose or ear): Liposuction of head and neck: Adjacent tissue transfer/rearrangement: Scalp; 10 sq cm: Scalp; >10 sq cm: Any site >30 sq cm: *Paramedian forehead flap: *Takedown paramedian forehead flap: Moh s reconstruction (tissue rearrangement, advancement, rotational flaps): *eyelids, nose, ear, lips <10 sq cm: sq cm: *forehead, cheek, chin, mouth, lips <10cm2: cm2: *takedown of melolabial flap pedicle: Scar contracture release: Microtia repair 1 st stage with rib graft: *2 nd stage lobule transposition: *3 rd stage elevation of auricle w/ STSG: STSG (code separately): Dermabrasion: Chemical peel: OTOLOGY/NEUROTOLOGY Otology *Stapes *Revision Stapes: *Stapes mobilization: ME Exploration (postauric or transcanal):69440 Cochlear Implant (two codes): Insertion: *Mastoidectomy: Replace BAHA: Implant BAHA: with STSG: Facial nerve decompression; partial: *Facial nerve decompression; total: Suture repair of intramastoid CN VII: (code decompression/mastoid and nerve graft harvest separately) Endolymphatic sac decomps + shunts (two codes): Sac Decompression: *Mastoidectomy: Glomus tumor excision: Transcanal: Transmastoid: Extended (extratemporal): (code neck approach separately) Eust Tube Catheter, transnasal: Ablative Otologic Procedures *** need to unbundle and log separately tympanoplasty, mastoidectomy, and/or OCR from a key indicator case recording standpoint *Simple mastoid: *Complete mastoid (CWU): *MR Mastoid (CWD stapes +/-malleus, incus intact): *Radical mastoid (CWD all ossicles taken): Mastoid bowl debridement; complex: *Petrous apicectomy: *Revise mastoid to complete: *Revise mastoid to Mod rad: *Revise mastoid to Rad: *Mastoid obliteration: Lateral TB resection: Excision of EAC lesion: Radical excision EAC lesion:

9 *Radical excision EAC lesion + neck dissection: (code neck dissection separately) Auriculectomy: CPA tumor: Suboccipital/Retrosig: *Translabyrinthine approach: *Middle cranial fossa approach: Resection of petrous apex lesion: Extradural: Intradural: Vestibular nerve section: Translabyrinthine approach: Transcranial approach: Endolymphatic sac decompression: w/ shunt: w/o shunt: Labyrinthectomy: Reconstructive otologic procedures: Meatoplasty: STSG: *Myringoplasty: Exostoses/Canalplasty: Canalplasty for atresia: *Tymp without OCR: *Tymp with OCR: autologous tissue TORP or PORP *Tymp with mastoid and OCR: (code tymp/ocr and mastoid separate) CSF leak dura repair w/ graft: (code graft separately) The following appendix contains the 14 current key indicator case categories and the complete list of constituent key indicator case codes 9

10 APPENDIX: Key Indicator Case Categories Congenital Neck Masses Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues: Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx: Excision dermoid cyst, nose; simple, skin, subcutaneous: Excision dermoid cyst, nose; complex, under bone or cartilage: Excision of vascular anomaly, axillary or cervical; without deep neurovascular dissection: Excision of vascular anomaly, axillary or cervical; with deep neurovascular dissection: Excision of thyroglossal duct cyst or sinus: Excision of thyroglossal duct cyst or sinus; recurrent: Bronchoscopy guidance; with brushing or protected brushings: guidance; with bronchial alveolar lavage: guidance; with bronchial or endobronchial biopsy(s), single or multiple sites: guidance; with tracheal/bronchial dilation or closed reduction of fracture: guidance; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required): guidance; with removal of foreign body: guidance; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus: guidance; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required): guidance; with excision of tumor: Bronchoscopy (rigid or flexible); with destruction of tumor or relief of stenosis by any method other than excision (e.g., laser therapy, cryotherapy): Bronchoscopy (rigid or flexible); with injection of contrast material for segmental bronchography (fiberscope only): Tracheobronchoscopy through established tracheostomy incision: guidance; diagnostic, with or without cell washing (separate procedure): Airway Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn: Laryngoscopy, flexible fiberoptic; with removal of foreign body: Laryngoscopy, flexible fiberoptic; with removal of lesion: Arytenoidectomy or arytenoidopexy, external approach: Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator: Laryngoscopy direct, with or without tracheoscopy; with dilation, initial: Laryngoscopy direct, with or without t racheoscopy; with dilation, subsequent: Laryngoscopy, direct, operative, with foreign body removal: Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or telescope: Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s): Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft): Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope or telescope: Laryngoscopy, direct, with injection into vocal cord(s), therapeutic:

11 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope: Unlisted procedure, larynx: Laryngoplasty; for laryngeal web, two stage, with keel insertion and removal: Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy: Laryngoplasty, cricoid split: Laryngoplasty, not otherwise specified (e.g. medialization laryngoplaty; for burns, reconstruction after partial laryngectomy): Ethmoid Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior): Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior): Ethmoidectomy; intranasal, anterior: Ethmoidectomy; intranasal, total: Ethmoidectomy; extranasal, total: Thyroid Parathyroidectomy or exploration of parathyroid(s): Parathyroidectomy or exploration of parathyroid(s); re-exploration: Parathyroid autotransplantation: Total thyroid lobectomy, unilateral; with or without isthmusectomy: Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy: Thyroidectomy, total or complete: Thyroidectomy, total or subtotal for malignancy; with limited neck dissection: Thyroidectomy, total or subtotal for malignancy; with radical neck dissection: Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid: Resection Oral Cavity Glossectomy; less than 1/2 tongue: Glossectomy; hemiglossectomy: Glossectomy; partial, with unilateral radical neck dissection: Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection: Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection: Excision of lesion of tongue with closure; posterior one-third: Excision of lesion of tongue with closure; with local tongue flap: Excision of malignant tumor of mandible: Excision of malignant tumor of mandible; radical resection: Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (e.g., locally aggressive or destructive lesion(s)): Glossectomy; composite procedure with resection floor of mouth and mandibular resection, without radical neck dissection: Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection: Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type): Neck Dissection Suprahyoid lymphadenectomy: Cervical lymphadenectomy (modified radical neck dissection): Cervical lymphadenectomy (complete/rnd): Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection: Thyroidectomy, total or subtotal for malignancy; with limited neck dissection: Laryngectomy; total, with radical neck dissection: Laryngectomy; subtotal supraglottic, with radical neck dissection:

12 Pharyngolaryngectomy, with radical neck dissection; without reconstruction: Pharyngolaryngectomy, with radical neck dissection; with reconstruction: Glossectomy; partial, with unilateral radical neck dissection: Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection: Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type): Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection: Thyroidectomy, total or subtotal for malignancy; with radical neck dissection: Radical excision external auditory canal lesion; with neck dissection: Parotid Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection: Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve: Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve: Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve: Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection: Mastoid Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy: Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including labyrinthectomy, decompression, with or without mobilization of facial nerve and/or petrous carotid artery: Transmastoid antrotomy (simple mastoidectomy): Mastoidectomy; complete: Mastoidectomy; modified radical: Mastoidectomy; radical: Petrous apicectomy including radical mastoidectomy: Revision mastoidectomy; resulting in complete mastoidectomy: Revision mastoidectomy; resulting in modified radical mastoidectomy: Revision mastoidectomy; resulting in radical mastoidectomy: Revision mastoidectomy; resulting in tympanoplasty: Revision mastoidectomy; with apicectomy: Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction: Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction: Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)): middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction: Mastoid obliteration (separate procedure): Total facial nerve decompression and/or repair 12

13 (may include graft): Stapedectomy/Ossicular Chain Reconstruction Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (e.g, postfenestration): Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)): Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction: Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (e.g, partial acicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)): middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction: Stapes mobilization: Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material: Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out: Revision of stapedectomy or stapedotomy: Tympanoplasty Revision mastoidectomy; resulting in tympanoplasty: Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch: Myringoplasty (surgery confined to drumhead and donor area): Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction: Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction ( e.g., postfenestration): Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)): Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction: Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction: Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (e. g, partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)): Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction: Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction: Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction: middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction:

14 middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction: Flaps Free muscle or myocutaneous flap with microvascular anastomosis: Free skin flap with microvascular anastomosis: Free fascial flap with microvascular anastomosis: Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe: Free osteocutaneous flap with microvascular anastomosis; iliac crest: Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less: Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm: Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less: Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm: Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less: Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm: Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area: Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs: Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet: Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral: Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs: Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet: Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips: Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap): Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae): Muscle, myocutaneous, or fasciocutaneous flap; trunk: FTSG, including direct closure of donor site, scalp, arms and/or legs 20 cm² or less: FTSG including direct closure of donor site, scalp, arms and/or legs; each additional 20 cm² or part thereof: FTSG including direct closure of donor site, forehead cheeks, chin, mouth, and neck 20 cm²: FTSG including direct closure of donor site, forehead cheeks, chin, mouth, and neck; each additional 20 cm² or part thereof: FTSG, including direct closure of donor site to nose ears eyelids and/or let's 20 cm² or less: FTSG, including direct closure of donor site to nose ears eyelids each additional 20 cm² apart thereof: Composite Graft (i.e. full-thickness of external ear or nasal ala, including primary closure donor area): Ear cartilage graft autogenous to nose or ear: Mandible/Maxilla Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure): Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure): Closed treatment of mandibular fracture; without manipulation: Closed treatment of mandibular fracture; with manipulation: Percutaneous treatment of mandibular fracture, with external fixation: Closed treatment of mandibular fracture with interdental fixation: Open treatment of mandibular fracture with external fixation: Open treatment of mandibular fracture; without interdental fixation:

15 Open treatment of mandibular fracture; with interdental fixation: Closed treatment of fracture of orbit, except blowout; with manipulation: Open treatment of mandibular condylar fracture: Open treatment of fracture of orbit, except blowout; without implant: Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints: Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint: Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation: Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches: Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft): Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation: Open treatment of depressed zygomatic arch fracture (e.g., Gillies approach): Open treatment of depressed malar fracture, including zygomatic arch and malar tripod: Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches: Open treatment of complicated (e.g., comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft): Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation): Open treatment of orbital floor blowout fracture; periorbital approach: Open treatment of orbital floor blowout fracture; combined approach: Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant: Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft): Closed treatment of fracture of orbit, except blowout; without manipulation: Open treatment of fracture of orbit, except blowout; with implant: Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft): Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint: Open treatment of palatal or maxillary fracture (LeFort I type): Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches: Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint: Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation: Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches: Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (e.g., head cap, halo device, and/or intermaxillary fixation): Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, w/ bone grafting (includes obtaining graft): Rhinoplasty Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip: Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip: Rhinoplasty, primary; including major septal repair: Rhinoplasty, secondary; minor revision (small amount of nasal tip work): Rhinoplasty, secondary; intermediate revision (bony work with osteotomies):

16 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies): Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only: Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies: Repair of nasal vestibule stenosis