Annex 10. List of Alternative Documents For Record of Operative or Surgical Technique

ANNEX 10.
LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL

TECHNIQUE
RVS CODE DESCRIPTION REQUIREMENT

none ; operating room and anesthesia
77401 Radiation treatment delivery (Linear Accelerator)
records are waived
77401 Radiation treatment delivery (Cobalt)
records are waived
Dialysis procedure other than hemodialysis (e.g. none ; operating room and anesthesia
90945
peritoneal, hemofiltration) records are waived
96408 Chemotherapy administration
records are waived
79000 Radiopharmaceutical (radioactive iodine) therapy
records are waived
Simple repair of superficial wounds of scalp, neck, axillae,
doctor's order and/or nurse's notes
12001 external genitalia, trunk and/or extremities (including
indicating performance of the procedure
hands and feet); 2.5 cm or less
hands and feet); 2.6 cm to 7.5 cm
hands and feet); over 30.0 cm
Simple repair of superficial wounds of face, ears, eyelids, doctor's order and/or nurse's notes
12011
nose, lips and/or mucous membranes; 2.5 cm or less indicating performance of the procedure
12013
nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm indicating performance of the procedure
12014
12015
Simple repair of superficial wounds of face, ears, eyelids,
12016 nose, lips and/or mucous membranes; 12.6 cm to 20.0
cm
Simple repair of superficial wounds of face, ears, eyelids,
12017 nose, lips and/or mucous membranes; 20.1 cm to 30.0
cm
12018
nose, lips and/or mucous membranes; over 30.0 cm indicating performance of the procedure
Page 1 of 14
ANNEX 10. LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL
TECHNIQUE

Layer closure of wounds of scalp, axillae, trunk, and/or doctor's order and/or nurse's notes
12031
extremities (excluding hands and feet); 2.5 cm or less indicating performance of the procedure
12032
extremities (excluding hands and feet); 2.6 cm to 7.5 cm indicating performance of the procedure
12034
extremities (excluding hands and feet); 7.6 cm to 12.5 cm indicating performance of the procedure
Layer closure of wounds of scalp, axillae, trunk, and/or
12035 extremities (excluding hands and feet); 12.6 cm to 20.0
cm
Layer closure of wounds of scalp, axillae, trunk, and/or
12036 extremities (excluding hands and feet); 20.1 cm to 30.0
cm
12037
extremities (excluding hands and feet); over 30.0 cm indicating performance of the procedure
Layer closure of wounds of neck, hands, feet and/or doctor's order and/or nurse's notes
12041
external genitalia; 2.5 cm or less indicating performance of the procedure
12042
external genitalia; 2.6 cm to 7.5 cm indicating performance of the procedure
12044
12045
12046
12047
external genitalia; over 30.0 cm indicating performance of the procedure
Layer closure of wounds of face, ears, eyelids, nose, lips doctor's order and/or nurse's notes
12051
and/or mucous membrances; 2.5 cm or less indicating performance of the procedure
12052
and/or mucous membrances; 2.6 cm to 5.0 cm indicating performance of the procedure
12053
12054
12055
12056
Page 2 of 14
TECHNIQUE

12057
and/or mucous membrances; over 30.0 cm indicating performance of the procedure

31600 Tracheostomy, planned ;

31601 Tracheostomy, planned ; under two years

31603 Tracheostomy, emergency procedure; transtracheal
Tracheostomy, emergency procedure; cricothyroid doctor's order and/or nurse's notes

31605
membrane indicating performance of the procedure

31610 Tracheostomy, fenestration procedure with skin flaps
Thoracentesis, puncture of pleural cavity for aspiration, doctor's order and/or nurse's notes
32000
initial or subsequent indicating performance of the procedure
Thoracentesis w/ insertion of tube w/ or w/o water seal doctor's order and/or nurse's notes
32002
(e.g., for pneumothorax) indicating performance of the procedure
Tube thoracostomy w/ or w/o water seal (e.g., for doctor's order and/or nurse's notes
32020
abscess, hemothorax, empyema) indicating performance of the procedure
Arterial catheterization for prolonged infusion therapy doctor's order and/or nurse's notes
36640
(chemotherapy), cutdown indicating performance of the procedure
Placement of central venous catheter (subclavian,
jugular, or other vein) (e.g., for central venous pressure, doctor's order and/or nurse's notes
36488
hyperalimentation, hemodialysis, or chemotherapy); indicating performance of the procedure
percutaneous or cutdown
38220 Bone marrow aspiration and/or biopsy
Peritoneocentesis, abdominal paracentesis, or peritoneal doctor's order and/or nurse's notes

49080
lavage (diagnostic or therapeutic) indicating performance of the procedure

62270 Spinal puncture, lumbar, diagnostic
31231 Nasal endoscopy, diagnostic, unilateral or bilateral official report
Nasal/sinus endoscopy, diagnostic w/ maxillary
31233 sinusoscopy (via inferior meatus or canine fossa official report
puncture)
Nasal/sinus endoscopy, diagnostic w/ sphenoid
31235 sinusoscopy (via puncture of sphenoidal face or official report
cannulation of ostium)
Nasal/sinus endoscopy, surgical; w/ biopsy, polypectomy
31237 official report
or debridement
31238 Nasal/sinus endoscopy, surgical; w/ control of epistaxis official report
Page 3 of 14
TECHNIQUE

Nasal/sinus endoscopy, surgical; w/
dacrylocystorhinostomy
Nasal/sinus endoscopy, surgical; w/ concha bullosa
resection
Nasal/sinus endoscopy, surgical; w/ ethmoidectomy,
partial (anterior)
Nasal/sinus endoscopy, surgical; w/ ethmoidectomy,
total (anterior and posterior)
31256 Nasal/sinus endoscopy, surgical, w/ maxillary antrostomy official report
Nasal/sinus endoscopy, surgical, w/ removal of tissue
from maxillary sinus
Nasal/sinus endoscopy, surgical w/ frontal sinus
31276 exploration, w/ or w/o removal of tissue from frontal official report
sinus
31287 Nasal/sinus endoscopy, surgical, w/ sphenoidotomy official report
Nasal/sinus endoscopy, surgical, w/ removal of tissure
from the sphenoid sinus
Nasal/sinus endoscopy, surgical, w/ repair of
cerebrospinal fluid leak; ethmoid region
31291 Nasal/sinus endoscopy, surgical, sphenoid region official report
Nasal/sinus endoscopy, surgical; w/ medial or inferior
orbital wall decompression
Nasal/sinus endoscopy, surgical; w/ medial orbital wall
and inferior orbital wall decompression
Nasal/sinus endoscopy, surgical; w/ optic nerve
decompression
Laryngoscopy direct, w/ or w/o tracheoscopy; for
aspiration
Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic,
newborn
except newborn
w/ operating microscope
Laryngoscopy direct, w/ or w/o tracheoscopy; w/
insertion of obturator
dilatation, initial
dilatation, subsequent
Laryngoscopy, direct, operative, w/ foreign body
removal;
Laryngoscopy, direct, operative, w/ foreign body
removal; w/ operating microscope
31535 Laryngoscopy, direct, operative, w/ biopsy; official report
Laryngoscopy, direct, operative, w/ biopsy; w/ operating
microscope
Laryngoscopy, direct, operative, w/ excision of tumor
and/or stripping of vocal cords or epiglottis;
Page 4 of 14
TECHNIQUE

Laryngoscopy, direct, operative, w/ excision of tumor
31541 and/or stripping of vocal cords or epiglottis; w/ operating official report
microscope
31560 Laryngoscopy, direct, operative, w/ arytenoidectomy; official report
Laryngoscopy, direct, operative, w/ arytenoidectomy; w/
operating microscope
Laryngoscopy, direct, w/ injection into vocal cord(s),
therapeutic;
Laryngoscopy, direct, w/ injection into vocal cord(s),
therapeutic; w/ operating microscope
31575 Laryngoscopy, flexible fiberoptic; diagnostic official report
31576 Laryngoscopy, flexible fiberoptic; w/ biopsy official report
Laryngoscopy, flexible fiberoptic; w/ removal of foreign
body
31578 Laryngoscopy, flexible fiberoptic; w/ removal of lesion official report
31579 Laryngoscopy, flexible or rigid fiberoptic, w/ stroboscopy official report

Bronchoscopy; diagnostic, (flexible or rigid), w/ or w/o
cell washing or brushing
31625 Bronchoscopy; w/ biopsy official report
Bronchoscopy; w/ transbronchial lung biopsy, w/ or w/o
fluoroscopic guidance
Bronchoscopy; w/ transbronchial needle aspiration
biopsy
Bronchoscopy; w/ tracheal or bronchial dilation or closed
reduction of fracture
Bronchoscopy; w/ tracheal dilation and placement of
tracheal stent
31635 Bronchoscopy; w/ removal of foreign body official report
Bronchoscopy; diagnostic, (flexible or rigid),w/ placement
of bronchial stents
31640 Bronchoscopy; w/ excision of tumor official report
Bronchoscopy; w/ destruction of tumor or relief of
stenosis by any method other than excision (e.g., laser)
Bronchoscopy; w/ placement of catheters for
intracavitary radioelement application
Bronchoscopy; w/ therapeutic aspiration of
tracheobronchial tree, (e.g., drainage of lung abscess)
Thoracoscopy, diagnostic ; lungs and pleural space, w/o
biopsy
Thoracoscopy, diagnostic ; lungs and pleural space, w/
biopsy
32603 Thoracoscopy, diagnostic ; pericardial sac, w/o biopsy official report
32604 Thoracoscopy, diagnostic ; pericardial sac, w/ biopsy official report
32605 Thoracoscopy, diagnostic ; mediastinal space, w/o biopsy official report
32606 Thoracoscopy, diagnostic ; mediastinal space, w/ biopsy official report
Page 5 of 14
TECHNIQUE

32650 Thoracoscopy, surgical; w/ pleurodesis, any method official report
Thoracoscopy, surgical; w/ partial pulmonary
decortication
Thoracoscopy, surgical; w/ total pulmonary
decortication, including intrapleural pneumonolysis
Thoracoscopy, surgical; w/ removal of intrapleural
foreign body or firbin deposit
Thoracoscopy, surgical; w/ control of traumatic
hemorrhage
Thoracoscopy, surgical; w/ excision-plication of bullae,
including any pleural procedure
32656 Thoracoscopy, surgical; w/ parietal pleurectomy official report
Thoracoscopy, surgical; w/ removal of clot or foreign
body from pericardial sac
Thoracoscopy, surgical; w/ creation of percardial window
or partial resection of pericardial sac for drainage
32660 Thoracoscopy, surgical; w/ total pericardiectomy official report
Thoracoscopy, surgical; w/ excision of pericardial cyst,
tumor, or mass
Thoracoscopy, surgical; w/ excision of mediastinal cyst,
tumor, or mass
32663 Thoracoscopy, surgical; w/ lobectomy, total or segmental official report
32664 Thoracoscopy, surgical; w/ thoracic sympathectomy official report
Thoracoscopy, surgical; w/ esophagomyotomy (Heller
type)
Esophagoscopy, rigid or flexible; diagnostic, w/ or w/o
collection of specimen(s) by brushing or washing
Esophagoscopy, rigid or flexible; w/ biopsy, single or
multiple
Esophagoscopy, rigid or flexible; w/ injection sclerosis of
esophageal varices
Esophagoscopy, rigid or flexible; w/ band ligation of
esophageal varices
Esophagoscopy, rigid or flexible; w/ removal of foreign
body
Esophagoscopy, rigid or flexible; w/ removal of tumor(s),
43216 polyp(s), or other lesion(s) by hot biopsy forceps or official report
bipolar cautery
Esophagoscopy, rigid or flexible; w/ removal of tumor(s),
polyp(s), or other lesion(s) by snare technique
Esophagoscopy, rigid or flexible; w/ insertion of plastic
tube or stent
Esophagoscopy, rigid or flexible; w/ balloon dilation (less
than 30 mm diameter)
Esophagoscopy, rigid or flexible; w/ insertion of guide
wire followed by dilation over guide wire
Esophagoscopy, rigid or flexible; w/ control of bleeding,
any method
Page 6 of 14
TECHNIQUE

Esophagoscopy, rigid or flexible; w/ ablation of tumor(s)
43228 polyp(s), or other lesion(s), not amenable to removal by official report
hot biopsy forceps, bipolar cautery or snare technique
Upper gastrointestinal endoscopy, simple primary

examination ( e.g. w/ small diameter flexible endoscope)
Upper gastrointestinal endoscopy including esophagus,

stomach, and either the duodenum and/or jejunum as
appropriate; diagnostic, w/ or w/o collection of
specimen(s) by brushing or washing

43239 stomach, and either the duodenum and/or jejunum as official report
appropriate; w/ biopsy, single or multiple
appropriate; w/ transendoscopic tube or catheter
placement
appropriate; w/ injection sclerosis of esophageal and/or
gastric varices
appropriate; w/ band ligation of esophageal and/or
gastric varices
appropriate; w/ dilation of gastric outlet for obstruction,
any method
appropriate; w/ directed placement of percutaneous
gastrostomy tube
appropriate; w/ removal or foreign body

appropriate; w/ insertion of guide wire followed by
dilation of esophagus over guide wire
appropriate; w/ ballon dilation of esophagus (less than 30
mm diameter)
Page 7 of 14
TECHNIQUE

appropriate; w/ removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery

appropriate; w/ removal of tumor(s), polyp(s), or other
lesion(s) by snare technique

appropriate; w/ control of bleeding, any method

43258 appropriate; w/ ablation of tumor(s), polyp(s), or other official report
lesion(s) not amenable to removal by hot biopsy forceps,
bipolar cautery or snare technique

appropriate; w/ endoscopic ultrasound examination
Small intestinal endoscopy, enteroscopy, beyond second

44360 portion of duodenum, not including ileum; diagnostic, w/ official report
or w/o collection of specimen(s) by brushing or washing
44361 portion of duodenum, not including ileum; w/ biopsy, official report
single or multiple
44363 portion of duodenum, not including ileum; w/ removal of official report
foreign body
44364 portion of duodenum, not including ileum; w/ removal of official report
tumor(s), polyp(s), or other lesions(s) by snare technique
portion of duodenum, not including ileum; w/ removal of
tumor(s), polyp(s), or other lesion(s) by hot biopsy
forceps or bipolar cautery
44366 portion of duodenum, not including ileum; w/ control of official report
bleeding, any method
portion of duodenum, not including ileum; w/ ablation of
44369 tumor(s), polyp(s), or other lesion(s) not amenable to official report
removal by hot biopsy forceps, bipolar cautery or snare
tenchnique
44372 portion of duodenum, not including ileum; w/ placement official report
of percutaneous jejunostomy tube
Page 8 of 14
TECHNIQUE

portion of duodenum, not including ileum; w/ conversion
of percutaneous gastrostomy tube to percutaneous
jejunostomy tube
Small intestinal endoscopy, enteroscopy beyond second
44376 portion of duodenum, including ileum; diagnostic, w/ or official report
w/o collection of specimen(s) by brushing or washing
44377 portion of duodenum, including ileum;w/ biopsy, single official report
or multiple
44378 portion of duodenum, including ileum;w/ control of official report
bleeding, any method
Ileoscopy, through stoma; diagnostic, w/ or w/o
44382 Ileoscopy, through stoma; w/ biopsy, single or multiple official report
Endoscopic evaluation of small intestinal (abdominal or
44385 pelvic) pouch; diagnostic, w/ or w/o collection of official report
Endoscopic evaluation of small intestinal (abdominal or
pelvic) pouch; w/ biopsy, single or multiple
Colonoscopy through stoma; diagnostic, w/ or w/o
44389 Colonoscopy through stoma; w/ biopsy, single or multiple official report
44390 Colonoscopy through stoma; w/ removal of foreign body official report

Colonoscopy through stoma; w/ control of bleeding, any
method
Colonoscopy through stoma; w/ removal of tumor(s),
44392 polyp(s), or other lesion(s) by hot biopsy forceps or official report
bipolar cautery
Colonoscopy through stoma; w/ ablation of tumor(s),
44393 polyp(s), or other lesion(s) not amenable to removal by official report
hot biopsy forceps, bipolar caurtery or snare technique
Colonoscopy through stoma; w/ removal of tumor(s),

polyp(s), or other lesion(s) by snare technique
Colonoscopy, rigid or flexible, transabdominal via
colotomy, single or multiple
Colonoscopy, flexible, proximal to splenic flexure;
45378 diagnostic, w/ or w/o collection of specimen(s) by official report
brushing or washing, w/ or w/o colon decompression
Colonoscopy, flexible, proximal to splenic flexure; w/
removal of foreign body
biopsy, single or multiple
control of bleeding, any method
Page 9 of 14
TECHNIQUE

ablation of tumor(s), polyp(s), or other lesion(s) not
amenable to removal by hot biopsy forceps, bipolar
cautery or snare technique
45384 removal of tumor(s), polyp(s), or other lesion(s) by hot official report
biopsy forceps or bipolar cautery
45385 removal of tumor(s), polyp(s), or other lesion(s) by snare official report
technique
Anoscopy; diagnostic, w/ or w/o collection of
46604 Anoscopy; w/ dilation, any method official report
46606 Anoscopy; w/ biopsy, single or multiple official report
46608 Anoscopy; w/ removal of foreign body official report
Anoscopy; w/ removal of single tumor, polyp, or other
lesion by hot biopsy forceps or bipolar cautery
Anoscopy; w/ removal of single tumor, polyp or other
lesion by snare technique
Anoscopy; w/ removal of multiple tumor, polyps, or
46612 other lesions by hot biopsy forceps, bipolar cautery or official report
snare technique
46614 Anoscopy; w/ control of bleeding, any method official report
Anoscopy; w/ ablation of tumor(s), polyp(s), or other
46615 lesion(s) not amenable to removal by hot biopsy forceps, official report
bipolar cautery or snare technique
Biliary endoscopy, percutaneous via T- tube or other
47552 tract; diagnostic, w/ or w/o collection of specimen(s) by official report
brushing and/or washing
tract; w/ biopsy, single or multiple
tract; w/ removal of stone(s)
tract; w/ dilation of biliary duct stricture(s) w/o stent
tract; w/ dilation of biliary duct stricture(s) w/ stent
Renal endoscopy through established nephrostomy or
50551 pyelostomy, w/ or w/o irrigation, instillation, or official report
ureteropyelography, exclusive of radiologic service;
pyelostomy, w/ or w/o irrigation, instillation, or
ureteropyelography, exclusive of radiologic service; w/
ureteral catheterization, w/ or w/o dilation of ureter
biopsy
Page 10 of 14
TECHNIQUE

fulguration and/or incision, w/ or w/o biopsy
50559 ureteropyelography, exclusive of radiologic service; w/ official report
insertion of radioactive substance w/ or w/out biopsy
and/or fulguration
removal of foreign body or calculus
Renal endoscopy through nephrotomy or pyelotomy, w/
50570 or w/o irrigation, instillation, or ureteropyelography, official report
exclusive of radiologic service;
or w/o irrigation, instillation, or ureteropyelography,
exclusive of radiologic service; w/ ureteral
catheterization, w/ or w/o dilation of ureter

50574 or w/o irrigation, instillation, or ureteropyelography, official report
exclusive of radiologic service; w/ biopsy

exclusive of radiologic service; w/ endopyelotomy
(includes cystoscopy, ureteroscopy, dilation of ureter and
ureteral pelvic junction, incision of ureteral pelvic
junction and insertion of endopyelotomy stent)
exclusive of radiologic service; w/ fulguration and/or
incision, w/ or w/o biopsy
exclusive of radiologic service; w/ insertion of radioactive
substance, w/ or w/o biopsy and/or fulguration
exclusive of radiologic service; w/ removal of foreign
body or calculus
Ureteral endoscopy through established ureterostomy,
50951 w/ or w/o irrigation, instillation, or ureteropyelography, official report
exclusive of radiologic service;
w/ or w/o irrigation, instillation, or ureteropyelography,
Page 11 of 14
TECHNIQUE

50959 exclusive of radiologic service; w/ insertion of radioactive official report
substance, w/ or w/o biopsy and/or fulguration (not
including provision of material)
body or calculus
Ureteral endoscopy through ureterotomy, w/ or w/o
50970 irrigation, instillation, or ureteropyelography, exclusive of official report
radiologic service;


50978 exclusive of radiologic service; w/ insertion of radioactive official report
substance, w/ or w/o biopsy and/or fulguration (not
including provision of material)
body or calculus
50590 Lithotripsy, extracorporeal shock wave official report
Destruction of lesion(s), anus (e.g., condyloma,
46917 papilloma, molluscum contagiosum, herpetic vesicle), official report
simple; laser surgery
Page 12 of 14
TECHNIQUE

Non-contact laser coagulation of prostate, including
control of postoperative bleeding, complete (vasectomy,
meatotomy, cystourethroscopy, urethral calibration
and/or dilation, and internal urethrotomy are included)
Contact laser vaporization w/ or w/o transurethral

resection of prostate, including control of postoperative
52648 bleeding, complete (vasectomy, meatotomy, official report
cystourethroscopy, urethral calibration and/or dilation,
and internal urethrotomy are included)
Trabeculoplasty by laser surgery, one or more sessions
(defined treatment series)
65860 Severing adhesions of anterior segment, laser technique official report
Iridotomy/iridectomy by laser surgery (e.g., for

glaucoma) ( one or more sessions)
Discission of secondary membranous cataract (opacified

66821 posterior lens capsule and/or anterior hyaloid) laser official report
surgery (e.g., YAG laser) (one or more stages)
66998 Release of scleral flap suture by laser suture lysis official report
Severing of vitreous strands, vitreous face adhesions,
67031 sheets, membranes or opacities, laser surgery (one or official report
more stages)
Vitrectomy, mechanical, pars plana approach; w/ focal
endolaser photocoagulation
Vitrectomy, mechanical, pars plana approach; w/
endolaser panretinal photocoagulation
Destruction by any method, including laser, w/ or w/o
surgical curettement, all benign facial lesions or
17000 premalignant lesions in any location, or benign lesions official report if laser specific surgery
other than cutaneous vascular proliferative lesions,
including local anesthesia; any number of lesions
Destruction by any method, including laser, of benign

skin lesions other than cutaneous vascular proliferative
17100 official report if laser specific surgery
lesions on any area other than the face, including local
anesthesia; any number of lesions
Destruction of cutaneous vascular proliferative lesions
(e.g., laser technique)
Excision or destruction, any method (including laser),
intranasal lesion; internal approach
Bronchoscopy; diagnostic, (flexible or rigid),w/ placement
31641 of bronchial stents w/ destruction of tumor or relief of official report if laser specific surgery
stenosis by any method other than excision (e.g., laser)
Page 13 of 14
TECHNIQUE

Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o
collection of specimen(s) by brushing or washing; w/
45320 ablation of tumor(s), polyp(s), or other lesion(s) not official report if laser specific surgery
amenable to removal by hot biopsy forceps, bipolar
cautery or snare technique (e.g., laser)
Cystourethroscopy, w/ fulguration (including cryosurgery
52214 or laser surgery) of trigone, bladder neck, prostatic fossa, official report if laser specific surgery
urethra, or periurethral glands
52224 or laser surgery) or treatment of MINOR (less than 0.5 official report if laser specific surgery
cm) lesion(s) w/ or w/o biopsy
52234 or laser surgery) and/or resection of; SMALL bladder official report if laser specific surgery
tumor(s) (0.5 cm to 2.0 cm)
Transurethral destruction of prostate tissue;by
radiofrequncy ablation i.e., Transurethral Needle
Ablation (TUNA), transurethral laser incision of the
prostate (TULIP)
Conization of cervix, w/ or w/o fulguration, w/ or w/o
57520 dilation and curettage, w/ or w/o repair; cold knife or official report if laser specific surgery
laser
Repair of retinal detachment; scleral buckling (such as

lamellar scleral dissection, imbrication or encircling
procedure), w/ or w/o implant, w/ or w/o cryotherapy,
photocoagulation, and drainage of subretinal fluid w/
vitrectomy, any method, w/ or w/o air or gas tamponade,
focal endolaser photocoagulation, cryotherapy, drainage
of subretinal fluid, scleral buckling, and/or removal of
lens by same technique
Destruction of localized lesion of retina (e.g.,

67210 maculopathy, choroidopathy, small tumors), one or official report if laser specific surgery
more sessions; photocoagulation (laser or xenon arc)
Destruction of localized lesion of choroid (e.g., choroidal

67220 neovascularization); photocoagulation (e.g., laser), one or official report if laser specific surgery
more sessions
Destruction of extensive or progressive retinopathy (e.g.,
67228 diabetic retinopathy), one or more sessions; official report if laser specific surgery
photocoagulation (laser or xenon arc)
Repair of trichiasis; by electroepilation, electrosurgery,
cryotherapy or laser surgery
Closure of the lacrimal punctum; by thermocauterization,
ligation, or laser surgery
Page 14 of 14

Annex 10. List of Alternative Documents For Record of Operative or Surgical Technique

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Annex 10. List of Alternative Documents For Record of Operative or Surgical Technique

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Formatos disponíveis

ANNEX 10.

LIST OF ALTERNATIVE DOCUMENTS FOR RECORD OF OPERATIVE OR SURGICAL

RVS CODE DESCRIPTION REQUIREMENT

RVS CODE DESCRIPTION REQUIREMENT

RVS CODE DESCRIPTION REQUIREMENT

doctor's order and/or nurse's notes

doctor's order and/or nurse's notes

doctor's order and/or nurse's notes

Tracheostomy, emergency procedure; cricothyroid doctor's order and/or nurse's notes

doctor's order and/or nurse's notes

Peritoneocentesis, abdominal paracentesis, or peritoneal doctor's order and/or nurse's notes

doctor's order and/or nurse's notes

RVS CODE DESCRIPTION REQUIREMENT

RVS CODE DESCRIPTION REQUIREMENT

31579 Laryngoscopy, flexible or rigid fiberoptic, w/ stroboscopy official report

32604 Thoracoscopy, diagnostic ; pericardial sac, w/ biopsy official report

32605 Thoracoscopy, diagnostic ; mediastinal space, w/o biopsy official report

32606 Thoracoscopy, diagnostic ; mediastinal space, w/ biopsy official report

RVS CODE DESCRIPTION REQUIREMENT

RVS CODE DESCRIPTION REQUIREMENT

Upper gastrointestinal endoscopy, simple primary

Upper gastrointestinal endoscopy including esophagus,

Upper gastrointestinal endoscopy including esophagus,

Upper gastrointestinal endoscopy including esophagus,

RVS CODE DESCRIPTION REQUIREMENT

Upper gastrointestinal endoscopy including esophagus,

Upper gastrointestinal endoscopy including esophagus,

Upper gastrointestinal endoscopy including esophagus,

Upper gastrointestinal endoscopy including esophagus,

Small intestinal endoscopy, enteroscopy, beyond second

RVS CODE DESCRIPTION REQUIREMENT

44390 Colonoscopy through stoma; w/ removal of foreign body official report

Colonoscopy through stoma; w/ removal of tumor(s),

RVS CODE DESCRIPTION REQUIREMENT

RVS CODE DESCRIPTION REQUIREMENT

Renal endoscopy through nephrotomy or pyelotomy, w/

Renal endoscopy through nephrotomy or pyelotomy, w/

RVS CODE DESCRIPTION REQUIREMENT

Ureteral endoscopy through established ureterostomy,

Ureteral endoscopy through established ureterostomy,

RVS CODE DESCRIPTION REQUIREMENT

Contact laser vaporization w/ or w/o transurethral

65860 Severing adhesions of anterior segment, laser technique official report

Iridotomy/iridectomy by laser surgery (e.g., for

Discission of secondary membranous cataract (opacified

Destruction by any method, including laser, of benign

RVS CODE DESCRIPTION REQUIREMENT

Repair of retinal detachment; scleral buckling (such as

Destruction of localized lesion of retina (e.g.,

Destruction of localized lesion of choroid (e.g., choroidal

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