Revision Date (Medicare): 1/1/2022
I-12
monitoring, pulse oximetry, and ventilation management (e.g., 93000-93010, 93040-93042,
94760, 94761).
5. See Section A, Introduction.
6. Exposure and exploration of the surgical field is integral to an operative procedure
and is not separately reportable. For example, an exploratory laparotomy (CPT code 49000) is
not separately reportable with an intra-abdominal procedure. If exploration of the surgical field
results in additional procedures other than the primary procedure, the additional procedures may
generally be reported separately. However, a procedure designated by the CPT code descriptor as
a “separate procedure” is not separately reportable if performed in a region anatomically related
to the other procedure(s) through the same skin incision, orifice, or surgical approach.
7. If a definitive surgical procedure requires access through diseased tissue (e.g.,
necrotic skin, abscess, hematoma, seroma), a separate service for this access (e.g., debridement,
incision, and drainage) is not separately reportable. Types of procedures to which this principle
applies include, but are not limited to, -ectomy, -otomy, excision, resection, -plasty, insertion,
revision, replacement, relocation, removal, or closure. For example, debridement of skin and
subcutaneous tissue at the site of an abdominal incision made to perform an intra-abdominal
procedure is not separately reportable. (See Chapter IV, Section I (General Policy Statements),
Subsection 11 for guidance on reporting debridement with open fractures and dislocations.)
8. If removal, destruction, or other form of elimination of a lesion requires
coincidental elimination of other pathology, only the primary procedure may be reported. For
example, if an area of pilonidal disease contains an abscess, incision, and drainage of the abscess
during the procedure to excise the area of pilonidal disease is not separately reportable.
9. An excision and removal (-ectomy) includes the incision and opening (-otomy) of
the organ. A HCPCS/CPT code for an –otomy procedure shall not be reported with an –ectomy
code for the same organ.
10. Multiple approaches to the same procedure are mutually exclusive of one another
and shall not be reported separately. For example, both a vaginal hysterectomy and abdominal
hysterectomy shall not be reported separately.
11. If a procedure using one approach fails and is converted to a procedure using a
different approach, only the completed procedure may be reported. For example, if a
laparoscopic hysterectomy is converted to an open hysterectomy, only the open hysterectomy
procedure code may be reported.
12. If a laparoscopic procedure fails and is converted to an open procedure, the
physician shall not report a diagnostic laparoscopy in lieu of the failed laparoscopic procedure.
For example, if a laparoscopic cholecystectomy is converted to an open cholecystectomy, the
physician shall not report the failed laparoscopic cholecystectomy nor a diagnostic laparoscopy.