Crystal's MCW Coder HubSurgery Guidelines 10004-69990
Follow-Up Care for Diagnostic Procedures
Guidelines to direct general reporting of services are presented in the Introduction. Some of the commonalities are repeated here for the convenience of those referring to this section on Surgery. Other definitions and items unique to Surgery are also listed.
Follow-up care for diagnostic procedures (eg, endoscopy, arthroscopy, injection procedures for radiography) includes only that care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately.
Services
Services rendered in the office, home, or hospital, consultations, and other medical services are listed in the Evaluation and Management Services section (98000-98016, 99202-99499) beginning on page 15. “Special Services, Procedures and Reports” (99000-99082) are listed in the Medicine section.
Follow-Up Care for Therapeutic Surgical Procedures
CPT Surgical Package Definition
Follow-up care for therapeutic surgical procedures includes only that care which is usually a part of the surgical service. Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported.
By their very nature, the services to any patient are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services “included” in a given CPT surgical code, the following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included in addition to the operation per se:
Supplied Materials
Supplies and materials (eg, sterile trays/drugs), over and above those usually included with the procedure(s) rendered are reported separately. List drugs, trays, supplies, and materials provided. Identify as 99070 or specific supply code.
- Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)
Reporting More Than One Procedure/Service
- Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
Copying, photographing, or sharing this CPT® book violates AMA’s copyright.
- Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals
- Writing orders
When more than one procedure/service is performed on the same date, same session or during a post-operative period (subject to the “surgical package” concept), several CPT modifiers may apply (see Appendix A for definition).
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Evaluating the patient in the postanesthesia recovery area
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Typical postoperative follow-up care
Separate Procedure
Some of the procedures or services listed in the CPT codebook that are commonly carried out as an integral component of a total service or procedure have been identified by the inclusion of the term “separate procedure.” The codes designated as “separate procedure” should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.
| + = Audio-only | ♦ = Add-on code |
| ★ = Telemedicine | ♠ = Audio-only |
| ♣ = FDA approval pending | ♢ = Resequested code |
| ♠ = Modifier 51 exempted | ♠ = Modifier 51 exempted |
| ♠ = See p xx for details |
Surgery Guidelines
CPT 2026
| Code | Description |
|---|---|
| 15999 | Unlisted procedure, excision pressure ulcer |
| 17999 | Unlisted procedure, skin, mucous membrane and subcutaneous tissue |
| 19499 | Unlisted procedure, breast |
| 20999 | Unlisted procedure, musculoskeletal system, general |
| 21089 | Unlisted maxillofacial prosthetic procedure |
| 21299 | Unlisted craniofacial and maxillofacial procedure |
| 21499 | Unlisted musculoskeletal procedure, head |
| 21899 | Unlisted procedure, neck or thorax |
| 22899 | Unlisted procedure, spine |
| 22999 | Unlisted procedure, abdomen, musculoskeletal system |
| 23929 | Unlisted procedure, shoulder |
| 24999 | Unlisted procedure, humerus or elbow |
| 25999 | Unlisted procedure, forearm or wrist |
| 26989 | Unlisted procedure, hands or fingers |
| 27299 | Unlisted procedure, pelvis or hip joint |
| 27599 | Unlisted procedure, femur or knee |
| 27899 | Unlisted procedure, leg or ankle |
| 28899 | Unlisted procedure, foot or toes |
| 29799 | Unlisted procedure, casting or strapping |
| 29999 | Unlisted procedure, arthroscopy |
| 30999 | Unlisted procedure, nose |
| 31299 | Unlisted procedure, accessory sinuses |
| 31599 | Unlisted procedure, larynx |
| 31899 | Unlisted procedure, trachea, bronchi |
| 32999 | Unlisted procedure, lungs and pleura |
| 33999 | Unlisted procedure, cardiac surgery |
| 36299 | Unlisted procedure, vascular injection |
| 37501 | Unlisted vascular endoscopy procedure |
| 37799 | Unlisted procedure, vascular surgery |
| 38129 | Unlisted laparoscopy procedure, spleen |
| 38589 | Unlisted laparoscopy procedure, lymphatic system |
| 38999 | Unlisted procedure, hemic or lymphatic system |
| 39499 | Unlisted procedure, mediastinum |
| 39599 | Unlisted procedure, diaphragm |
| 40799 | Unlisted procedure, lips |
| 40899 | Unlisted procedure, vestibule of mouth |
| 41599 | Unlisted procedure, tongue, floor of mouth |
| 41899 | Unlisted procedure, dentoalveolar structures |
| 42299 | Unlisted procedure, palate, uvula |
| 42699 | Unlisted procedure, salivary glands or ducts |
| 42999 | Unlisted procedure, pharynx, adenoids, or tonsils |
| 43289 | Unlisted laparoscopy procedure, esophagus |
| 43499 | Unlisted procedure, esophagus |
| 43659 | Unlisted laparoscopy procedure, stomach |
| 43999 | Unlisted procedure, stomach |
| 44238 | Unlisted laparoscopy procedure, intestine (except rectum) |
| 44799 | Unlisted procedure, small intestine |
| 44899 | Unlisted procedure, Meckel’s diverticulum and the mesentery |
| 44979 | Unlisted laparoscopy procedure, appendix |
| 45399 | Unlisted procedure, colon |
| 45499 | Unlisted laparoscopy procedure, rectum |
| 45999 | Unlisted procedure, rectum |
| 46999 | Unlisted procedure, anus |
| 47379 | Unlisted laparoscopic procedure, liver |
| 47399 | Unlisted procedure, liver |
| 47579 | Unlisted laparoscopy procedure, biliary tract |
| 47999 | Unlisted procedure, biliary tract |
| 48999 | Unlisted procedure, pancreas |
| 49329 | Unlisted laparoscopy procedure, abdomen, peritoneum and omentum |
| 49659 | Unlisted laparoscopy procedure, herniorrhaphy, herniotomy |
| 49999 | Unlisted procedure, abdomen, peritoneum and omentum |
| 50549 | Unlisted laparoscopy procedure, renal |
Surgery Guidelines 1004-6990
Copying, photographing, or sharing this CP* book violates AMAs copyright law. ▲ = Revised code ■ = New code ▶ = Contains new or revised text * = Duplicate PLA test
CPT 2026
| Code | Description |
|---|---|
| 50949 | Unlisted laparoscopy procedure, ureter |
| 51999 | Unlisted laparoscopy procedure, bladder |
| 53899 | Unlisted procedure, urinary system |
| 54699 | Unlisted laparoscopy procedure, testis |
| 55559 | Unlisted laparoscopy procedure, spermatic cord |
| 55899 | Unlisted procedure, male genital system |
| 58578 | Unlisted laparoscopy procedure, uterus |
| 58579 | Unlisted hysteroscopy procedure, uterus |
| 58679 | Unlisted laparoscopy procedure, oviduct, ovary |
| 58999 | Unlisted procedure, female genital system (nonobstetrical) |
| 59897 | Unlisted fetal invasive procedure, including ultrasound guidance, when performed |
| 59898 | Unlisted laparoscopy procedure, maternity care and delivery |
| 59899 | Unlisted procedure, maternity care and delivery |
| 60659 | Unlisted laparoscopy procedure, endocrine system |
| 60699 | Unlisted procedure, endocrine system |
| 64999 | Unlisted procedure, nervous system |
| 66999 | Unlisted procedure, anterior segment of eye |
| 67299 | Unlisted procedure, posterior segment |
| 67399 | Unlisted procedure, extraocular muscle |
| 67599 | Unlisted procedure, orbit |
| 67999 | Unlisted procedure, eyelids |
| 68399 | Unlisted procedure, conjunctiva |
| 68899 | Unlisted procedure, lacrimal system |
| 69399 | Unlisted procedure, external ear |
| 69799 | Unlisted procedure, middle ear |
| 69949 | Unlisted procedure, inner ear |
| 69979 | Unlisted procedure, temporal bone, middle fossa approach |
Imaging Guidance
When imaging guidance or imaging supervision and interpretation is included in a surgical procedure, guidelines for image documentation and report, included in the guidelines for Radiology (Including Nuclear Medicine and Diagnostic Ultrasound), will apply.
Imaging guidance should not be reported for use of a nonimaging-guided tracking or localizing system (eg, radar signals, electromagnetic signals). Imaging guidance should only be reported when an imaging modality (eg, radiography, fluoroscopy, ultrasonography, magnetic resonance imaging, computed tomography, or nuclear medicine) is used and is appropriately documented.
Surgery Guidelines 1004-6990
Surgical Destruction
Surgical destruction is a part of a surgical procedure and different methods of destruction are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition. Exceptions under special circumstances are provided for by separate code numbers.
Foreign Body/Implant Definition
An object intentionally placed by a physician or other qualified health care professional for any purpose (eg, diagnostic or therapeutic) is considered an implant. An object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.
Graft Procurement
Special Report
▶Codes that include obtaining or harvesting a graft include the work of procuring the graft from the patient during the same operative session.◀
A service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service
| + = Audio-only | ♦ = Telemedicine |
| ♠ = Audio-on code | ♣ = Add-on code |
| ♢ = Telemedicine | ♠ = Audio-only |
| ♦ = Telesurgery | ♣ = FDA approval pending |
| ♣ = Modifier 51 exempt | ♠ = Resequence code |
| ♠ = Modifier 52 code | ♣ = See p xx for details |
Unlisted CPT codes are non-specific codes used as a last resort when no existing CPT or HCPCS Level II code accurately describes the procedure, service, or technology you provided. They act as placeholders for services that are too new, rare, or unusual to have their own permanent code.
Why Would I Use Them?
You use an unlisted code to maintain coding accuracy and avoid fraud. Selecting a specific code that is “close enough” but not accurate is considered a misrepresentation of services.
- New Technology/Procedures: Medical innovation often outpaces the annual CPT updates. If you are using a brand-new device or surgical technique that hasn’t been assigned a code yet, you must use an unlisted code.
- Rare/Unusual Services: Some procedures are so rare that the AMA has not created a specific code for them.
- Variable Services: Some services are highly variable in their extent and nature, making it difficult to define a standard code.
What You Need to Know When Using Them
Because unlisted codes (often ending in “99”) have no established value or description, using them requires extra effort to get paid:
- Manual Review Required: These claims cannot be processed automatically. A human payer must review them, which delays payment.
- Documentation is Mandatory: You must submit a “Special Report” or operative note that explains:
- Definition: A clear description of the nature, extent, and need for the procedure.
- Time/Effort: How long it took and the complexity involved.
- Equipment: Any special equipment used.
- Benchmarking: To help the payer determine a price, you should compare the unlisted procedure to a similar, existing CPT code (a “crosswalk” or “comparison code”). Explain how your service compares in terms of work, time, and difficulty (e.g., “This procedure was similar to code X but required 20% more time due to…”).
Common Unlisted Code Examples:
- 30999 - Unlisted procedure, nose
- 69399 - Unlisted procedure, external ear
- 29999 - Unlisted procedure, arthroscopy
Unlisted codes almost always end in “99” (or sometimes “89”). They are categorized by body system or section in the CPT book.
Here are more examples broken down by specialty to help you recognize them:
Surgery / Musculoskeletal
- 20999 - Unlisted procedure, musculoskeletal system, general
- Scenario: A surgeon performs a novel tendon transfer technique that isn’t described by any existing orthopedic code.
- 22899 - Unlisted procedure, spine
- Scenario: Used for a new type of minimally invasive spinal implant that doesn’t fit the descriptors for current instrumentation codes.
- 27599 - Unlisted procedure, femur or knee
- Scenario: You might use this for a complex revision of a knee surgery that utilizes a brand-new experimental approach.
Digestive System
- 43289 - Unlisted laparoscopy procedure, esophagus
- Scenario: A doctor performs a laparoscopic repair of the esophagus using a method that doesn’t match the specific “Nissen fundoplication” or hernia repair codes.
- 44799 - Unlisted procedure, intestine
- Scenario: Used for rare intestinal surgeries, such as extensive distinct rerouting of the small bowel not covered by standard resection/anastomosis codes.
- 47399 - Unlisted procedure, liver
- Scenario: Sometimes used for new types of liver tumor ablation technologies that don’t match existing radiofrequency or cryoablation codes.
Cardiovascular & Respiratory
- 33999 - Unlisted procedure, cardiac surgery
- Scenario: A cardiac surgeon performs a hybrid procedure involving both open heart surgery and a catheter-based intervention that has no combined code.
- 31299 - Unlisted procedure, accessory sinuses
- Scenario: Often used by ENTs for sinus surgeries using novel tools (like certain drug-eluting stents) if no specific “placement of stent” code exists for that sinus.
Radiology
- 76499 - Unlisted diagnostic radiographic procedure
- Scenario: Used for an X-ray study that uses a non-standard view or technique required for a rare deformity.
- 76999 - Unlisted ultrasound procedure
- Scenario: Could be used for a specialized ultrasound examination (e.g., of a specific foreign body) not covered by organ-specific ultrasound codes.
Pathology & Laboratory
- 81599 - Unlisted multianalyte assay with algorithmic analysis
- Scenario: Frequently used for new “gene expression profile” tests (cancer classifiers) that are proprietary and haven’t been assigned a specific CPT or PLA code yet.
- 84999 - Unlisted chemistry procedure
- Scenario: Used for a lab test measuring a rare substance in the blood for which no specific analyte code exists.
Medicine & Vaccines
- 90749 - Unlisted vaccine/toxoid
- Scenario: Used when a new vaccine is FDA-approved but the CPT code hasn’t been updated to include it yet (common during early release of new vaccines).
- 99199 - Unlisted special service, procedure, or report
- Scenario: A “catch-all” for general medical services that don’t fit anywhere else, often used for administrative or special reporting services required by a payer.
Quick Tip for Usage
When you use any of these, remember the “Equivalent Code” rule:
On your claim or in your notes, tell the insurance company: “This unlisted procedure (Code X) was performed. It required similar skill, time, and resources to Code Y (The Comparison Code), but differed in the following way…” This gives them a price anchor.
Specifically for my specialties:
Based on the provided sources, you should use unlisted procedure codes in Otolaryngology, Ophthalmology, and urology when a specific CPT or HCPCS code that accurately describes the service performed does not exist. It is inappropriate to report the “best fit” code that merely approximates the service; if the specific procedure is not listed, the unlisted code must be used.
Here are specific scenarios and guidelines for these specialties:
Otolaryngology (ENT)
- Turbinate Excision: Use unlisted code 30999 (Unlisted procedure, nose) when performing excisions of the superior or middle turbinates. The specific CPT code 30130 (Excision inferior turbinate, partial or complete) is strictly for the inferior turbinate.
- Sinus Surgery with Novel Tools: Use unlisted code 31299 (Unlisted procedure, accessory sinuses) for sinus surgeries utilizing novel technologies, such as certain drug-eluting stents, if no specific code exists for the placement of that stent in that sinus.
- External Ear Procedures: Use code 69399 (Unlisted procedure, external ear) for rare or unusual procedures on the external ear that do not have a defined code.
- Lacrimal System: Use code 68899 (Unlisted procedure, lacrimal system) for procedures on the lacrimal system not described by other codes.
Ophthalmology
- Anterior Segment Procedures: Use code 66999 (Unlisted procedure, anterior segment of eye) for procedures performed on the anterior segment of the eye that do not have a specific code.
- General Services: Use code 92499 (Unlisted ophthalmological service or procedure) for general ophthalmological services or procedures not listed elsewhere.
- Visual Fields: Use unlisted codes if an examination method does not fit the defined visual field examination codes (92081-92083).
Urology
- Laparoscopic Ureter Procedures: Use code 50949
- (Unlisted laparoscopy procedure, ureter) for laparoscopic procedures on the ureter that lack a specific code.
- Male Genital Procedures: Use code 55899 (Unlisted procedure, male genital system) for procedures on the male genital system not described by existing codes.
- Kidney Procedures: Use code 53899 (Unlisted procedure, urinary system) or other specific unlisted codes like 50549 (Unlisted laparoscopy procedure, renal) if the specific laparoscopic renal procedure is not defined.
General Rules for Using Unlisted Codes
- New Technology: Use unlisted codes for brand-new devices or surgical techniques that have not yet been assigned a permanent Category I or Category III code.
- Documentation Requirements: When submitting an unlisted code, you must typically provide a “Special Report” or operative note. This documentation should include:
- A clear definition of the nature, extent, and need for the procedure.
- The time, effort, and complexity involved.
- Any special equipment used.
- Benchmarking: To assist payers in determining reimbursement, you should compare the unlisted procedure to a similar, existing CPT code (a “crosswalk” code) and explain how the unlisted service compares in terms of work, time, and difficulty.
- NCCI Edits: Generally, the National Correct Coding Initiative (NCCI) does not include edits for unlisted codes because they cover a diverse group of services.