cpt
A
S
2017
current procedural terminology
E
L
P
M
®
Professional Edition
Jay T. Ahlman
Angela J. Boudreau
Judy Connelly
Rick A. Crosslin
Biljana Dimovski, MS, RHM, CDC
Martha Espronceda
Desiree D. Evans, AAS
Lauren M. Feldman
DeHandro Hayden, BS
Nadia Khalid, MJ, RHIA, RMM
Elizabeth Lumakovska, MPA, RHIT
Janette Meggs, RHIA
Marie L. Mindeman, BA, RHIT
Karen E. O’Hara, BS, CCS-P
Mary R. O’Heron, RHIA
Danielle Pavloski, BS, RHIT, CCS-P
Desiree Rozell, MPA
Nancy Spector, BSN, MSC
Lianne Stancik, RHIT
Ada Walker, CCA
Arletrice Watkins, MHA, RHIA
Rejina L. Young
Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . .11
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Office or Other Outpatient Services . . . . . . . . . . . . . . . . . .11
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Section Numbers and Their Sequences . . . . . . . . . . . . . . . xii
Instructions for Use of the CPT Codebook . . . . . . . . . . . . . xii
Format of the Terminology . . . . . . . . . . . . . . . . . . . . xiii
Requests to Update the CPT Nomenclature . . . . . . xiii
Hospital Observation Services . . . . . . . . . . . . . . . . . . . . . .13
Hospital Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . .15
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Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Emergency Department Services . . . . . . . . . . . . . . . . . . . .22
Critical Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
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Application Submission Requirements . . . . . . . . . xiii
General Criteria for Category I and Category III Codes . xiii
Category-Specific Requirements . . . . . . . . . . . . . . . xiv
Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Nursing Facility Services . . . . . . . . . . . . . . . . . . . . . . . . . .25
Domiciliary, Rest Home (eg, Boarding Home),
or Custodial Care Services . . . . . . . . . . . . . . . . . . . . . . . . .28
Domiciliary, Rest Home (eg, Assisted Living Facility),
or Home Care Plan Oversight Services . . . . . . . . . . . . . . .30
Add-on Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Home Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Prolonged Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
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Place of Service and Facility Reporting . . . . . . . . . . . xv
Unlisted Procedure or Service . . . . . . . . . . . . . . . . . . xv
Results, Testing, Interpretation, and Report . . . . . . . xv
Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Code Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi
Alphabetical Reference Index . . . . . . . . . . . . . . . . . xvi
CPT 2016 in Electronic Formats . . . . . . . . . . . . . . . xvi
References to AMA Resources . . . . . . . . . . . . . . . . xvi
Illustrated Anatomical and Procedural Review . . . . . . xvii
Prefixes, Suffixes, and Roots . . . . . . . . . . . . . . . . . . . . . . xvii
Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Directions and Positions . . . . . . . . . . . . . . . . . . . . xviii
Additional References . . . . . . . . . . . . . . . . . . . . . . . . . . xviii
Medical Dictionaries . . . . . . . . . . . . . . . . . . . . . . . xviii
Anatomy References . . . . . . . . . . . . . . . . . . . . . . . xviii
Lists of Illustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii
Anatomical Illustrations . . . . . . . . . . . . . . . . . . . . xviii
Procedural Illustrations . . . . . . . . . . . . . . . . . . . . . . xix
Evaluation and Management Tables . . . . . . . . . . . . . . . . xxii
Evaluation and Management (E/M) Services Guidelines . . 4
Classification of Evaluation and Management
(E/M) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Definitions of Commonly Used Terms . . . . . . . . . . . . . . . . .4
Unlisted Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Clinical Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Instructions for Selecting a Level of E/M Service . . . . . . . .9
 Contains new or revised text
Case Management Services . . . . . . . . . . . . . . . . . . . . . . . .35
Care Plan Oversight Services . . . . . . . . . . . . . . . . . . . . . . .36
Preventive Medicine Services . . . . . . . . . . . . . . . . . . . . . .37
Non-Face-to-Face Services . . . . . . . . . . . . . . . . . . . . . . . . .39
Special Evaluation and Management Services . . . . . . . . .41
Newborn Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Delivery/Birthing Room Attendance and
Resuscitation Services . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Inpatient Neonatal Intensive Care Services and
Pediatric and Neonatal Critical Care Services . . . . . . . . . .42
Care Management Services . . . . . . . . . . . . . . . . . . . . . . . .47
Transitional Care Management Services . . . . . . . . . . . . . .49
Advance Care Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Other Evaluation and Management Services . . . . . . . . . .51
Anesthesia Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Time Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Anesthesia Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Supplied Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Separate or Multiple Procedures . . . . . . . . . . . . . . . . . . . .54
Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Anesthesia Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Qualifying Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . .55
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Thorax (Chest Wall and Shoulder Girdle) . . . . . . . . . . . . . .56
Intrathoracic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Spine and Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Upper Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Lower Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Perineum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Pelvis (Except Hip) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
American Medical Association
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Contents
Upper Leg (Except Knee) . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .427
Knee and Popliteal Area . . . . . . . . . . . . . . . . . . . . . . . . . . .60
Supervision and Interpretation . . . . . . . . . . . . . . . . . . . . .427
Lower Leg (Below Knee, Includes Ankle and Foot) . . . . . .60
Administration of Contrast Material(s) . . . . . . . . . . . . . .427
Shoulder and Axilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60
Written Report(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .427
Upper Arm and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61
Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .428
Forearm, Wrist, and Hand . . . . . . . . . . . . . . . . . . . . . . . . .61
Radiological Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . .61
Burn Excisions or Debridement . . . . . . . . . . . . . . . . . . . . .62
Obstetric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62
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Diagnostic Radiology (Diagnostic Imaging) . . . . . . . . . . .428
Diagnostic Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . .447
Radiologic Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . .453
Breast, Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . .454
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Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62
Bone/Joint Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .455
Surgery Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
Radiation Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .456
Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .464
CPT Surgical Package Definition . . . . . . . . . . . . . . . . . . . .66
Follow-Up Care for Diagnostic Procedures . . . . . . . . . . . .66
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Follow-Up Care for Therapeutic Surgical Procedures . . . .66
Supplied Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
Reporting More Than One Procedure/Service . . . . . . . . . .66
Separate Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
Pathology and Laboratory Guidelines . . . . . . . . . . . . . . . .487
Services in Pathology and Laboratory . . . . . . . . . . . . . . .487
Separate or Multiple Procedures . . . . . . . . . . . . . . . . . . .487
Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . .487
Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .487
Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . . .67
Pathology and Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . .488
Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Organ or Disease-Oriented Panels . . . . . . . . . . . . . . . . . .488
Imaging Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Drug Assay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .490
Surgical Destruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
Therapeutic Drug Assays . . . . . . . . . . . . . . . . . . . . . . . . .498
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
Integumentary System . . . . . . . . . . . . . . . . . . . . . . . . . . . .71
Musculoskeletal System . . . . . . . . . . . . . . . . . . . . . . . . .104
Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
Cardiovascular System . . . . . . . . . . . . . . . . . . . . . . . . . . .193
Hemic and Lymphatic Systems . . . . . . . . . . . . . . . . . . . . .255
Mediastinum and Diaphragm . . . . . . . . . . . . . . . . . . . . . .259
Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
Urinary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .319
Male Genital System . . . . . . . . . . . . . . . . . . . . . . . . . . . .341
Reproductive System Procedures . . . . . . . . . . . . . . . . . . .347
Intersex Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .347
Female Genital System . . . . . . . . . . . . . . . . . . . . . . . . . . .351
Maternity Care and Delivery . . . . . . . . . . . . . . . . . . . . . .360
Endocrine System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .364
Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .370
Eye and Ocular Adnexa . . . . . . . . . . . . . . . . . . . . . . . . . . .403
Auditory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .418
Operating Microscope . . . . . . . . . . . . . . . . . . . . . . . . . . .422
Radiology Guidelines (Including Nuclear Medicine
and Diagnostic Ultrasound) . . . . . . . . . . . . . . . . . . . . . . . . .426
Subject Listings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .426
Separate Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . .426
Evocative/Suppression Testing . . . . . . . . . . . . . . . . . . . .500
Consultations (Clinical Pathology) . . . . . . . . . . . . . . . . . .502
Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .502
Molecular Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .502
Genomic Sequencing Procedures and Other Molecular
Multianalyte Assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . .527
Multianalyte Assays with Algorithmic Analyses . . . . . . .529
Chemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .531
Hematology and Coagulation . . . . . . . . . . . . . . . . . . . . . .542
Immunology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .545
Transfusion Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . .551
Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .552
Anatomic Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .560
Cytopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .560
Cytogenetic Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .562
Surgical Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .563
In Vivo (eg, Transcutaneous) Laboratory Procedures . . . .568
Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .569
Reproductive Medicine Procedures . . . . . . . . . . . . . . . . .569
Medicine Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .574
Add-on Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .574
Separate Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . .574
Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . .574
Special Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .575
Unlisted Service or Procedure . . . . . . . . . . . . . . . . . . . . .426
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Contents
CPT 2017
Contentsery
Imaging Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .575
Diagnostic/Screening Processes or Results . . . . . . . . . .673
Supplied Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .575
Therapeutic, Preventive, or Other Interventions . . . . . . .679
Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .576
Follow-up or Other Outcomes . . . . . . . . . . . . . . . . . . . . .685
Immune Globulins, Serum or Recombinant Products . . . .576
Immunization Administration for Vaccines/Toxoids . . . . .576
Vaccines, Toxoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .577
Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .685
Structural Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .686
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Nonmeasure Code Listing . . . . . . . . . . . . . . . . . . . . . . . .686
Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .582
Category III Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .687
Biofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .586
Appendix A—Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . .709
Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .586
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Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .589
Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .590
Special Otorhinolaryngologic Services . . . . . . . . . . . . . . .595
Cardiovascular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .600
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Noninvasive Vascular Diagnostic Studies . . . . . . . . . . . .626
Pulmonary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .629
Allergy and Clinical Immunology . . . . . . . . . . . . . . . . . . .632
Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .635
Neurology and Neuromuscular Procedures . . . . . . . . . . .635
Medical Genetics and Genetic Counseling Services . . . .646
Central Nervous System Assessments/Tests
(eg, Neuro-Cognitive, Mental Status, Speech Testing) . .646
Health and Behavior Assessment/Intervention . . . . . . . .648
Hydration, Therapeutic, Prophylactic, Diagnostic
Injections and Infusions, and Chemotherapy and
Other Highly Complex Drug or Highly Complex
Biologic Agent Administration . . . . . . . . . . . . . . . . . . . . .648
Photodynamic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . .654
Special Dermatological Procedures . . . . . . . . . . . . . . . . .654
Physical Medicine and Rehabilitation . . . . . . . . . . . . . . .655
Medical Nutrition Therapy . . . . . . . . . . . . . . . . . . . . . . . .658
Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .658
Osteopathic Manipulative Treatment . . . . . . . . . . . . . . . .659
Chiropractic Manipulative Treatment . . . . . . . . . . . . . . . .659
Appendix B—Summary of Additions,
Deletions, and Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . .715
Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .722
Clinical Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .722
Office or Other Outpatient Service . . . . . . . . . . . . . . . . . .722
Hospital Inpatient Services . . . . . . . . . . . . . . . . . . . . . . .732
Subsequent Hospital Care . . . . . . . . . . . . . . . . . . . . . . . .735
Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .739
Emergency Department Services . . . . . . . . . . . . . . . . . . .744
Critical Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . .745
Prolonged Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .745
Care Plan Oversight Services . . . . . . . . . . . . . . . . . . . . . .746
Prolonged Clinical Staff Services with Physician or Other
Qualified Health Care Professional Supervision . . . . . . .746
Inpatient Neonatal Intensive Care Service and
Pediatric and Neonatal Critical Care Services . . . . . . . . .746
Appendix D—Summary of CPT Add-on Codes . . . . . . . . .747
Appendix E—Summary of CPT Codes
Exempt from Modifier 51 . . . . . . . . . . . . . . . . . . . . . . . . . . . .748
Appendix F—Summary of CPT Codes
Exempt from Modifier 63 . . . . . . . . . . . . . . . . . . . . . . . . . . . .749
Appendix G—Summary of CPT Codes
That Include Moderate (Conscious) Sedation . . . . . . . . .750
Non-Face-to-Face Nonphysician Services . . . . . . . . . . . .660
Appendix H—Alphabetical Clinical Topics Listing
(AKA – Alphabetical Listing) . . . . . . . . . . . . . . . . . . . . . . . .752
Special Services, Procedures and Reports . . . . . . . . . . . .661
Appendix I—Genetic Testing Code Modifiers . . . . . . . . .752
Education and Training for Patient Self-Management . . .660
Qualifying Circumstances for Anesthesia . . . . . . . . . . . .663
Moderate (Conscious) Sedation . . . . . . . . . . . . . . . . . . . .663
Other Services and Procedures . . . . . . . . . . . . . . . . . . . .664
Home Health Procedures/Services . . . . . . . . . . . . . . . . .665
Appendix J—Electrodiagnostic Medicine Listing
of Sensory, Motor, and Mixed Nerves . . . . . . . . . . . . . . . .753
Appendix K—Product Pending FDA Approval . . . . . . . . .756
Medication Therapy Management Services . . . . . . . . . .666
Appendix L—Vascular Families . . . . . . . . . . . . . . . . . . . . .757
Category II Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .667
Appendix M—Renumbered CPT Codes–Citations
Crosswalk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .760
Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .668
Composite Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .668
Appendix N—Summary of Resequenced CPT Codes . . .766
Patient Management . . . . . . . . . . . . . . . . . . . . . . . . . . . .669
Patient History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .670
Appendix O—Multianalyte Assays with
Algorithmic Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .767
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . .672
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .772
 Contains new or revised text
American Medical Association
xi
Illustrated Anatomical and Procedural Review
Figure 1A
Body Planes — 3/4 View
Coronal (frontal)
plane
E
L
Sagittal plane
(at the body's median)
A
S
Figure 1B
Body Aspects — Side View
Superior (cranial) aspect
Posterior aspect
P
M
Horizontal or transverse plane
Figure 1C
Body Planes — Front View
Paramedian sagittal
plane
Anterior aspect
Median sagittal plane
Proximal end
of upper limb
Lateral border
upper limb
Dorsal surface of hand
Palmar surface of hand
Distal end
of upper limb
Ulnar side
of hand
Radial (thumb)
side of hand
Medial border
upper limb
Dorsal surface of foot
Plantar surface of foot
Inferior aspect
American Medical Association
xxi
Evaluation and
Tables
EVALUATION
ANDManagement
MANAGEMENT
TABLES
Office or Other
Outpatient Services
History and Exam (#1 and #2)
Detailed or Comprehensive
X
Comprehensive
X
Medical Decision Making (Complexity) (#3)
X
A
S
Low
X
Contributory Factors
Presenting Problem (Severity) (#1)
Self-limited or Minor
Low to Moderate
Moderate to High
X
X
X
Moderate
High
X
Counseling (#2)
See E/M Guidelines
X
Coordination of Care (#3)
X
See E/M Guidelines
X
Moderate
P
M
X
Contributory Factors
Presenting Problem (Severity) (#1)
X
X
High
X
X
Moderate
High
X
Moderate
X
Straightforward or
Low
X
Detailed
Low
Interval History and Exam (#1 and #2)
X
Medical Decision Making (Complexity) (#3)
X
Expanded ProblemFocused
Straightforward
Required Key Components
Comprehensive
X
Problem-Focused
X
X
Counseling (#2) See E/M Guidelines
Coordination of Care (#3) See E/M Guidelines
Bedside/Unit/Floor Time (#4)
Minutes
30
50
70
10
20
30
45
xxii
xxiv
10
X
15
25
35
Low
X
X
X
Problem-Focused
X
Expanded Problem-Focused
X
X
Straightforward or
Low
X
Moderate
X
Presenting Problem (Severity) (#1)
X
Moderate
Minutes
Code
Contributory Factors
X
30
Stable/Recovering/Improving
X
X
Responding Inadequately/ Minor
Complication
X
Unstable/Significant Complication/New Problem
Bedside/Unit/Floor Time (#4)
25
15
High
See E/M Guidelines
X
5
Counseling (#2) See E/M Guidelines
Coordination of Care (#3) See E/M Guidelines
Bedside/Unit/Floor Time (#4)
99233
X
Counseling (#2) See E/M Guidelines
Coordination of Care (#3) See E/M Guidelines
Typical Face-to-Face Time (#4)
Minutes
X
Moderate
Counseling (#2) See E/M Guidelines
Coordination of Care (#3)
X
X
X
Unstable/Significant Complication/Significant New Problem
Medical Decision Making (Complexity) (#3)
High
Moderate to High
X
Inadequate Response to
Therapy/ Minor Complication
Development
99232
Contributory Factors
Presenting Problem (Severity) (#1)
Low to Moderate
X
Stable/Recovering/Improving
99231
X
High
Contributory Factors
Presenting Problem (Severity) (#1)
Detailed
Contributory Factors
Presenting Problem (Severity) (#1)
X
Self-Limited or Minor
99223
X
Moderate
X
X
Straightforward or
Low
High
X
Minimal
99222
X
N/A
X
Medical Decision Making (Complexity) (#3)
X
Low
X
High
Interval History and Exam (#1 and #2)
X
Comprehensive
X
Medical Decision Making (Complexity) (#3)
Straightforward
99221
99215
99214
99213
99212
99211
X
Comprehensive
X
Moderate
Required Key Components
Detailed or Comprehensive
Detailed
X
Straightforward or
Low
Subsequent Hospital Care
History and Exam (#1 and #2)
History and Exam (#1 and #2)
Problem-Focused
Medical Decision Making (Complexity) (#3)
Patient: New or Established
Required Components: 2/3
Required Key Components
Required Key Components
Expanded ProblemFocused
X
Detailed
Initial Hospital Care
Patient: New or Established
Required Components: 3/3
Code
Patient: Established
Required Components: 2/3
N/A
X
Expanded Problem-Focused
60
Office or Other
Outpatient Services
Code
X
Problem-Focused
Minutes
Typical Face-to-Face Time (#4)
Minutes
99226
History and Exam (#1 and #2)
99225
99205
99204
99203
99202
99201
E
L
Required Key Components
Required Key Components
99224
Code
99220
Code
99219
Patient: New or Established
Required Components: 3/3
Patient: New or Established
Required Components: 2/3
99218
Patient: New
Required Components: 3/3
Code
Subsequent Observation Care
Initial Observation Care
50
70
Counseling (#2) See E/M Guidelines
Coordination of Care (#3)
See E/M Guidelines
Bedside/Unit/Floor Time (#4)
Minutes
15
25
35
40
Evaluation
Evaluationand
andManagement
ManagementTables
Tables
CPT
CPT 2017
2013
Evaluation/Management
Evaluation and Management (E/M)
Services Guidelines
In addition to the information presented in the
Introduction, several other items unique to this section
are defined or identified here.
Solely for the purposes of distinguishing between new
and established patients, professional services are those
face-to-face services rendered by physicians and other
qualified health care professionals who may report
evaluation and management services reported by a
specific CPT code(s). A new patient is one who has not
received any professional services from the physician/
qualified health care professional or another physician/
qualified health care professional of the exact same
specialty and subspecialty who belongs to the same
group practice, within the past three years.
P
M
Classification of Evaluation
and Management (E/M)
Services
A
S
E
L
New and Established Patient
The E/M section is divided into broad categories such as
office visits, hospital visits, and consultations. Most of the
categories are further divided into two or more
subcategories of E/M services. For example, there are two
subcategories of office visits (new patient and established
patient) and there are two subcategories of hospital visits
(initial and subsequent). The subcategories of E/M
services are further classified into levels of E/M services
that are identified by specific codes. This classification is
important because the nature of work varies by type of
service, place of service, and the patient’s status.
The basic format of the levels of E/M services is the same
for most categories. First, a unique code number is listed.
Second, the place and/or type of service is specified, eg,
office consultation. Third, the content of the service is
defined, eg, comprehensive history and comprehensive
examination. (See “Levels of E/M Services,” page 6, for
details on the content of E/M services.) Fourth, the
nature of the presenting problem(s) usually associated
with a given level is described. Fifth, the time typically
required to provide the service is specified. (A detailed
discussion of time is provided on page 7.)
Definitions of Commonly Used
Terms
An established patient is one who has received
professional services from the physician/qualified health
care professional or another physician/qualified health
care professional of the exact same specialty and
subspecialty who belongs to the same group practice,
within the past three years. See Decision Tree.
In the instance where a physician/qualified health care
professional is on call for or covering for another
physician/qualified health care professional, the patient’s
encounter will be classified as it would have been by the
physician/qualified health care professional who is not
available. When advanced practice nurses and physician
assistants are working with physicians they are considered
as working in the exact same specialty and exact same
subspecialties as the physician.
No distinction is made between new and established
patients in the emergency department. E/M services in
the emergency department category may be reported for
any new or established patient who presents for treatment
in the emergency department.
The decision tree on page 5 is provided to aid in
determining whether to report the E/M service provided
as a new or an established patient encounter.
Certain key words and phrases are used throughout the
E/M section. The following definitions are intended to
reduce the potential for differing interpretations and to
increase the consistency of reporting by physicians in
differing specialties. E/M services may also be reported by
other qualified health care professionals who are
authorized to perform such services within the scope of
their practice.
4
Moderate sedation ✚ Add-on code ~FDA approval pending #Resequenced code Recycled/reinstated code £££See p xvi for details
Evaluation and Management / Office or Other Outpatient Services
CPT 2017
99201—99203
Office or Other Outpatient
Services
New Patient
99201
The following codes are used to report evaluation and
management services provided in the office or in an
outpatient or other ambulatory facility. A patient is
considered an outpatient until inpatient admission to a
health care facility occurs.
j
A
S
j
Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are self limited or
minor. Typically, 10 minutes are spent face-to-face with
the patient and/or family.
£ CPT Changes: An Insider's View 2011, 2013
£ CPT Assistant Winter 91:11, Spring 92:13, 24, Summer 92:1, 24,
For services provided in the emergency department, see
99281-99285.
Spring 93:34, Summer 93:2, Fall 93:9, Spring 95:1, Summer 95:4,
Fall 95:9, Jul 98:9, Sep 98:5, Jun 99:8, Feb 00:3, 9, 11, Aug 01:2,
Oct 04:11, Mar 05:11, Apr 05:1, May 05:1, Jun 05:11, Dec 05:10,
Feb 06:14, May 06:1, Jun 06:1, Aug 06:12, Oct 06:15, Apr 07:11,
Sep 07:1, Nov 08:10, Mar 09:3, Aug 09:5, Dec 09:9, Jul 10:10,
Jan 11:3, Jan 12:5, Mar 12:4, 8, Apr 12:10, Jan 13:9, Jun 13:3,
Aug 13:13, 14, Aug 14:3, Oct 14:3, Nov 14:14, Jan 15:12
For observation or inpatient care services (including
admission and discharge services), see 99234-99236.
Coding Tip
Determination of Patient Status as New or Established
Patient
£ Clinical Examples in Radiology Winter 12:9
99202
Solely for the purposes of distinguishing between new and
established patients, professional services are those face-toface services rendered by physicians and other qualified health
care professionals who may report evaluation and
management services reported by a specific CPT code(s). A
new patient is one who has not received any professional
services from the physician/qualified health care professional
or another physician/qualified health care professional of the
exact same specialty and subspecialty who belongs to the
same group practice, within the past three years.
In the instance where a physician/qualified health care
professional is on call for or covering for another physician/
qualified health care professional, the patient’s encounter will
be classified as it would have been by the physician/qualified
health care professional who is not available. When advanced
practice nurses and physician assistants are working with
physicians they are considered as working in the exact same
specialty and exact same subspecialties as the physician.
Office or other outpatient visit for the evaluation and
management of a new patient, which requires these 3
key components:
j
j
j
Usually, the presenting problem(s) are of low to moderate
severity. Typically, 20 minutes are spent face-to-face with
the patient and/or family.
£ CPT Changes: An Insider's View 2013
£ CPT Assistant Winter 91:11, Spring 92:13, 24, Summer 92:1, 24,
Spring 93:34, Summer 93:2, Fall 93:9, Spring 95:1, Summer 95:4,
Fall 95:9, Jul 98:9, Sep 98:5, Feb 00:11, Aug 01:2, Apr 02:14,
Oct 04:10, Apr 05:1, 3, Jun 05:11, Dec 05:10, May 06:1, Jun 06:1,
Oct 06:15, Apr 07:11, Sep 07:1, Mar 09:3, Aug 09:5, Dec 09:9,
Jan 11:3, Mar 12:4, 8, Jan 13:9, Jun 13:3, Aug 13:13, 14,
Jan 15:12
£ Clinical Examples in Radiology Winter 12:9
99203
CPT Coding Guidelines, Evaluation and Management,
Definitions of Commonly Used Terms, New and Established
Patient
Office or other outpatient visit for the evaluation and
management of a new patient, which requires these 3
key components:
j
j
j
•New code
An expanded problem focused history;
An expanded problem focused examination;
Straightforward medical decision making.
Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs.
An established patient is one who has received professional
services from the physician/qualified health care professional
or another physician/qualified health care professional of the
exact same specialty and subspecialty who belongs to the same
group practice, within the past three years.
▲Revised code
A problem focused history;
A problem focused examination;
Straightforward medical decision making.
P
M
j
To report services provided to a patient who is admitted
to a hospital or nursing facility in the course of an
encounter in the office or other ambulatory facility, see
the notes for initial hospital inpatient care (page 15) or
initial nursing facility care (page 25).
For observation care, see 99217-99226.
E
L
Office or other outpatient visit for the evaluation and
management of a new patient, which requires these 3
key components:
 Contains new or revised text  Modifier 51 exempt
A detailed history;
A detailed examination;
Medical decision making of low complexity.
American Medical Association
11
Evaluation/Management
Evaluation and Management
Evaluation and Management / Office or Other Outpatient Services
CPT 2017
99201—99203
Office or Other Outpatient
Services
New Patient
99201
The following codes are used to report evaluation and
management services provided in the office or in an
outpatient or other ambulatory facility. A patient is
considered an outpatient until inpatient admission to a
health care facility occurs.
j
A
S
j
Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are self limited or
minor. Typically, 10 minutes are spent face-to-face with
the patient and/or family.
£ CPT Changes: An Insider's View 2011, 2013
£ CPT Assistant Winter 91:11, Spring 92:13, 24, Summer 92:1, 24,
For services provided in the emergency department, see
99281-99285.
Spring 93:34, Summer 93:2, Fall 93:9, Spring 95:1, Summer 95:4,
Fall 95:9, Jul 98:9, Sep 98:5, Jun 99:8, Feb 00:3, 9, 11, Aug 01:2,
Oct 04:11, Mar 05:11, Apr 05:1, May 05:1, Jun 05:11, Dec 05:10,
Feb 06:14, May 06:1, Jun 06:1, Aug 06:12, Oct 06:15, Apr 07:11,
Sep 07:1, Nov 08:10, Mar 09:3, Aug 09:5, Dec 09:9, Jul 10:10,
Jan 11:3, Jan 12:5, Mar 12:4, 8, Apr 12:10, Jan 13:9, Jun 13:3,
Aug 13:13, 14, Aug 14:3, Oct 14:3, Nov 14:14, Jan 15:12
For observation or inpatient care services (including
admission and discharge services), see 99234-99236.
Coding Tip
Determination of Patient Status as New or Established
Patient
£ Clinical Examples in Radiology Winter 12:9
99202
Solely for the purposes of distinguishing between new and
established patients, professional services are those face-toface services rendered by physicians and other qualified health
care professionals who may report evaluation and
management services reported by a specific CPT code(s). A
new patient is one who has not received any professional
services from the physician/qualified health care professional
or another physician/qualified health care professional of the
exact same specialty and subspecialty who belongs to the
same group practice, within the past three years.
In the instance where a physician/qualified health care
professional is on call for or covering for another physician/
qualified health care professional, the patient’s encounter will
be classified as it would have been by the physician/qualified
health care professional who is not available. When advanced
practice nurses and physician assistants are working with
physicians they are considered as working in the exact same
specialty and exact same subspecialties as the physician.
Office or other outpatient visit for the evaluation and
management of a new patient, which requires these 3
key components:
j
j
j
Usually, the presenting problem(s) are of low to moderate
severity. Typically, 20 minutes are spent face-to-face with
the patient and/or family.
£ CPT Changes: An Insider's View 2013
£ CPT Assistant Winter 91:11, Spring 92:13, 24, Summer 92:1, 24,
Spring 93:34, Summer 93:2, Fall 93:9, Spring 95:1, Summer 95:4,
Fall 95:9, Jul 98:9, Sep 98:5, Feb 00:11, Aug 01:2, Apr 02:14,
Oct 04:10, Apr 05:1, 3, Jun 05:11, Dec 05:10, May 06:1, Jun 06:1,
Oct 06:15, Apr 07:11, Sep 07:1, Mar 09:3, Aug 09:5, Dec 09:9,
Jan 11:3, Mar 12:4, 8, Jan 13:9, Jun 13:3, Aug 13:13, 14,
Jan 15:12
£ Clinical Examples in Radiology Winter 12:9
99203
CPT Coding Guidelines, Evaluation and Management,
Definitions of Commonly Used Terms, New and Established
Patient
Office or other outpatient visit for the evaluation and
management of a new patient, which requires these 3
key components:
j
j
j
•New code
An expanded problem focused history;
An expanded problem focused examination;
Straightforward medical decision making.
Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs.
An established patient is one who has received professional
services from the physician/qualified health care professional
or another physician/qualified health care professional of the
exact same specialty and subspecialty who belongs to the same
group practice, within the past three years.
▲Revised code
A problem focused history;
A problem focused examination;
Straightforward medical decision making.
P
M
j
To report services provided to a patient who is admitted
to a hospital or nursing facility in the course of an
encounter in the office or other ambulatory facility, see
the notes for initial hospital inpatient care (page 15) or
initial nursing facility care (page 25).
For observation care, see 99217-99226.
E
L
Office or other outpatient visit for the evaluation and
management of a new patient, which requires these 3
key components:
 Contains new or revised text  Modifier 51 exempt
A detailed history;
A detailed examination;
Medical decision making of low complexity.
American Medical Association
11
Evaluation/Management
Evaluation and Management
13160—14060
13160
Surgery / Integumentary System
Secondary closure of surgical wound or dehiscence,
extensive or complicated
£ CPT Assistant Sep 97:11, Dec 98:5, Apr 00:8, May 11:4, Dec 12:6
(For packing or simple secondary wound closure, see
12020, 12021)
Adjacent Tissue Transfer or
Rearrangement
CPT 2017
Adjacent
AdjacentTissue
TissueRepairs
Repairs
14000-14061
14000-14061
Repair of primary and secondary defects. Assign code based upon repair location and
Repair of primary
and secondary
defects requires
of a code based upon the
approximate
description
(as demonstrated
below) ofassignment
area repaired.
location and the approximate description (as demonstrated below) of the area required.
A. Advancement Flap
A. Advancement Flap
For full thickness repair of lip or eyelid, see respective
anatomical subsections.
Integumentary
Skin graft necessary to close secondary defect is
considered an additional procedure. For purposes of code
selection, the term “defect” includes the primary and
secondary defects. The primary defect resulting from the
excision and the secondary defect resulting from flap
design to perform the reconstruction are measured
together to determine the code.
14000
Adjacent tissue transfer or rearrangement, trunk; defect
10 sq cm or less
£ CPT Assistant Sep 96:11, Jul 99:3, Jul 00:10, Jan 06:47,
Dec 06:15, Jul 08:5, Mar 10:4, Apr 10:3, Jan 12:8, May 12:13,
Nov 12:13, Dec 12:6, Apr 14:10, Feb 15:10
14001
1.0 cm
2.0 cm
Secondary defect
(Area 2)
P
M
Codes 14000-14302 are used for excision (including
lesion) and/or repair by adjacent tissue transfer or
rearrangement (eg, Z-plasty, W-plasty, V-Y plasty,
rotation flap, random island flap, advancement flap).
When applied in repairing lacerations, the procedures
listed must be performed by the surgeon to accomplish
the repair. They do not apply to direct closure or
rearrangement of traumatic wounds incidentally resulting
in these configurations. Undermining alone of adjacent
tissues to achieve closure, without additional incisions,
does not constitute adjacent tissue transfer, see complex
repair codes 13100-13160. The excision of a benign
lesion (11400-11446) or a malignant lesion (1160011646) is not separately reportable with codes 1400014302.
A
S
E
L
Primary defect
(Area 1)
1.0 cm
Area 1: 1.0 cm x 1.0 cm = 1.0 sq cm
Area 2: 1.0 cm x 2.0 cm = 2.0 sq cm
(Area 1) + (Area 2) = 1.0 sq cm + 2.0 sq cm = 3.0 sq cm
B. Rotation Flap
B. Rotation Flap
Primary defect
(Area 1)
2.5 cm
1.0 cm
Secondary defect
(Area 2)
1.2 cm
1.0 cm
Area 1: 1.0 cm x 1.0 cm = 1.0 sq cm
Area 2: 2.5 cm x 1.2 cm = 3.0 sq cm
(Area 1) + (Area 2) = 1.0 sq cm + 3.0 sq cm = 4.0 sq cm
defect 10.1 sq cm to 30.0 sq cm
£ CPT Assistant Aug 96:8, Jul 99:3, Jan 06:47, Dec 06:15,
Jul 08:5, Mar 10:4, Jan 12:8, May 12:13, Nov 12:13,
Dec 12:6, Apr 14:10, Feb 15:10
14020
Adjacent tissue transfer or rearrangement, scalp, arms
and/or legs; defect 10 sq cm or less
£ CPT Assistant Jul 99:3, Jan 06:47, Dec 06:15, Jul 08:5, Mar 10:4,
Jan 12:8, May 12:13, Nov 12:13, Dec 12:6
14021
defect 10.1 sq cm to 30.0 sq cm
£ CPT Assistant Jul 99:3, Jan 06:47, Dec 06:15, Jul 08:5,
Mar 10:4, Jan 12:8, May 12:13, Nov 12:13, Dec 12:6
14040
Adjacent tissue transfer or rearrangement, forehead,
cheeks, chin, mouth, neck, axillae, genitalia, hands and/
or feet; defect 10 sq cm or less
£ CPT Assistant Jul 99:3, Jul 00:10, Jan 06:47, Dec 06:15, Jul 08:5,
Mar 10:4, Jan 12:8, May 12:13, Nov 12:13, Dec 12:6
14041
14060
Adjacent tissue transfer or rearrangement, eyelids, nose,
ears and/or lips; defect 10 sq cm or less
£ CPT Assistant Fall 93:7, Jul 99:3, Jan 06:47, Dec 06:15, Jul 08:5,
Mar 10:4, Jan 12:8, May 12:13, Aug 12:13, Nov 12:13, Dec 12:6
defect 10.1 sq cm to 30.0 sq cm
£ CPT Assistant Jul 99:3, Jan 06:47, Dec 06:15, Jul 08:5,
Mar 10:4, Jan 12:8, May 12:13, Nov 12:13, Dec 12:6
82
Moderate sedation : Add-on code ~FDA approval pending #Resequenced code Recycled/reinstated code £££See p xvi for details
Surgery / Integumentary System
CPT 2017
defect 10.1 sq cm to 30.0 sq cm
£ CPT Assistant Jul 99:3, Jan 06:47, Dec 06:15, Jul 08:5,
Mar 10:4, Jan 12:8, May 12:13, Nov 12:13, Dec 12:6
(For eyelid, full thickness, see 67961 et seq)
14301
: 14302
Adjacent tissue transfer or rearrangement, any area;
defect 30.1 sq cm to 60.0 sq cm
£ CPT Changes: An Insider's View 2010
£ CPT Assistant May 12:13, Nov 12:13, Dec 12:6
each additional 30.0 sq cm, or part thereof (List
separately in addition to code for primary procedure)
£ CPT Changes: An Insider's View 2010
£ CPT Assistant May 12:13, Nov 12:13, Dec 12:6
(Use 14302 in conjunction with 14301)
14350
A
S
Skin Replacement Surgery
Skin replacement surgery consists of surgical
preparation and topical placement of an autograft
(including tissue cultured autograft) or skin substitute
graft (ie, homograft, allograft, xenograft). The graft is
anchored using the individual's choice of fixation. When
services are performed in the office, routine dressing
supplies are not reported separately.
The following definition should be applied to those codes
that reference “100 sq cm or 1% of body area of infants
and children” when determining the involvement of body
size: The measurement of 100 sq cm is applicable to
adults and children 10 years of age and older; and
percentages of body surface area apply to infants and
children younger than 10 years of age. The measurements
apply to the size of the recipient area.
Procedures involving wrist and/or ankle are reported with
codes that include arm or leg in the descriptor.
When a primary procedure requires a skin substitute or
skin autograft for definitive skin closure (eg, orbitectomy,
radical mastectomy, deep tumor removal), use 1510015278 in conjunction with primary procedure.
For biological implant for soft tissue reinforcement, use
15777 in conjunction with primary procedure.
The supply of skin substitute graft(s) should be reported
separately in conjunction with 15271-15278.
Definitions
Surgical preparation codes 15002-15005 for skin
replacement surgery describe the initial services related to
preparing a clean and viable wound surface for placement
of an autograft, flap, skin substitute graft or for negative
pressure wound therapy. In some cases, closure may be
possible using adjacent tissue transfer (14000-14061) or
complex repair (13100-13153). In all cases, appreciable
▲Revised code
•New code
E
L
P
M
Filleted finger or toe flap, including preparation of
recipient site
£ CPT Assistant Jan 06:47, Jul 08:5, Mar 10:4, May 12:13,
Dec 12:6
nonviable tissue is removed to treat a burn, traumatic
wound or a necrotizing infection. The clean wound bed
may also be created by incisional release of a scar
contracture resulting in a surface defect from separation
of tissues. The intent is to heal the wound by primary
intention, or by the use of negative pressure wound
therapy. Patient conditions may require the closure or
application of graft, flap, or skin substitute to be delayed,
but in all cases the intent is to include these treatments or
negative pressure wound therapy to heal the wound. Do
not report 15002-15005 for removal of nonviable tissue/
debris in a chronic wound (eg, venous or diabetic) when
the wound is left to heal by secondary intention. See
active wound management codes (97597, 97598) and
debridement codes (11042-11047) for this service. For
necrotizing soft tissue infections in specific anatomic
locations, see 11004-11008.
Select the appropriate code from 15002-15005 based
upon location and size of the resultant defect. For
multiple wounds, sum the surface area of all wounds
from all anatomic sites that are grouped together into the
same code descriptor. For example, sum the surface area
of all wounds on the trunk and arms. Do not sum
wounds from different groupings of anatomic sites (eg,
face and arms). Use 15002 or 15004, as appropriate, for
excisions and incisional releases resulting in wounds up to
and including 100 sq cm of surface area. Use 15003 or
15005 for each additional 100 sq cm or part thereof. For
example: Surgical preparation of a 20 sq cm wound on
the right hand and a 15 sq cm wound on the left hand
would be reported with a single code, 15004. Surgical
preparation of a 75 sq cm wound on the right thigh and a
75 sq cm wound on the left thigh would be reported with
15002 for the first 100 sq cm and 15003 for the second
50 sq cm. If all four wounds required surgical preparation
on the same day, use modifier 59 with 15002, and 15004.
Autografts/tissue cultured autografts include the harvest
and/or application of an autologous skin graft. Repair of
donor site requiring skin graft or local flaps is reported
separately. Removal of current graft and/or simple
cleansing of the wound is included, when performed. Do
not report 97602. Debridement is considered a separate
procedure only when gross contamination requires
prolonged cleansing, when appreciable amounts of
devitalized or contaminated tissue are removed, or when
debridement is carried out separately without immediate
primary closure.
Select the appropriate code from 15040-15261 based
upon type of autograft and location and size of the defect.
The measurements apply to the size of the recipient area.
For multiple wounds, sum the surface area of all wounds
from all anatomic sites that are grouped together into the
same code descriptor. For example, sum the surface area
of all wounds on the trunk and arms. Do not sum
wounds from different groupings of anatomic sites (eg,
face and arms).
 Contains new or revised text  Modifier 51 exempt
American Medical Association
83
Integumentary
14061
14061—14350
Appendix L—Vascular Families
Appendix L
Assignment of branches to first, second, and third order
in this table makes the assumption that the starting point
is catheterization of the aorta. This categorization would
not be accurate, for instance, if a femoral or carotid artery
First Order
Innominate
Second Order Branch
A
S
L. common carotid
 R. common carotid


























 R. subclavian & axillary
E
L
were catheterized directly in an antegrade direction.
Arteries highlighted in bold are those more commonly
reported during arteriographic procedures.
P
M
 L. internal carotid








 L. external carotid

Appendix L
Vascular Families
Third Order Branch
 R. internal carotid










 R. external carotid
 R. vertebral

 R. internal thoracic
 (internal mammary)



 R. thyrocervical trunk



 R. costocervical trunk

 R. lateral thoracic

 R. thoracoacromial
 R. humeral circumflex (A/P)

 R. subscapular

 R. brachial




 R. deep brachial
Beyond Third Order Branches
 R. ophthalmic
 R. p. communicating
 R. middle cerebral

 R. a. cerebral











R. superior thyroid
R. ascending pharyngeal
R. facial
R. lingual
R. occipital
R. p. auricular
R. superficial temporal
R. internal maxillary
R. middle meningeal
Basilar

 R. inferior thyroid
 R. suprascapular

 R. transverse cervical
 R. highest intercostal
 R. deep cervical

R. circumflex scapular
 R. ulnar
 R. radial
 R. interosseous
 R. deep palmar arch
 R. superficial palmar arch

 R. metacarpals and digitals
 L. ophthalmic
 L. p. communicating
 L. middle cerebral

 L. a. cerebral
 L. superior thyroid
 L. ascending pharyngeal
 L. facial
 L. lingual

 L. occipital
 L. p. auricular
 L. superficial temporal


 L. internal maxillary
L. middle meningeal
R 5 right, L 5 left, A 5 anterior, P 5 posterior
American Medical Association
757