General CPT codes

Bone graft harvested from the iliac crest and transferred to a recipient site using microvascular anastomosis to restore the graft's blood supply.

Harvest and transfer of a vascularized fibula bone graft using microvascular technique, including anastomosis of the accompanying blood supply to the recipient site.

Radical resection of a soft tissue tumor of the abdominal wall measuring 5 cm or greater, typically performed for malignant neoplasms such as sarcoma.

Radical resection of a soft tissue tumor (e.g., sarcoma) of the abdominal wall measuring less than 5 cm, including excision of surrounding tissue and any involved anatomical structures beyond the tumor margin.

Secondary closure of an extensively dehisced or complicated surgical wound, requiring reopening, debridement of non-viable tissue, and layered repair.

Surgical harvest and placement of a composite graft composed of dermis, fat, fascia, or a combination of those tissue layers from a donor site to a recipient site.

Application of a uniplane, unilateral external fixation system using pins or wires configured in a single plane on one side of the body.

Surgical removal of a subfascial (intramuscular) soft tissue tumor of the abdominal wall measuring less than 5 cm, with specimen sent for pathologic analysis.

Percutaneous ablation of one or more bone tumors using radiofrequency energy, including treatment of adjacent soft tissue involved by tumor extension, with imaging guidance when performed.

Open harvesting of a fascia lata graft by incision and area exposure, complex or sheet graft technique

Percutaneous cryoablation of one or more bone tumors, including destruction of adjacent soft tissue involved by tumor extension, with imaging guidance bundled into the code when performed.

Excisional debridement at an open fracture or dislocation site extending through skin, subcutaneous tissue, muscle fascia, muscle, and bone — the most extensive tier of the 11010–11012 series.

Surgical harvest of a tendon from a distant anatomical site — such as the palmaris longus, plantaris, or toe extensor — for use as a graft in reconstruction elsewhere.

Autologous soft tissue grafting harvested by direct excision — a block of fat, dermis, fascia, or similar tissue cut from a donor site and transferred to fill a defect in the same patient during the same operative session.

Surgical removal of a subcutaneous soft tissue tumor from the abdominal wall measuring 3 cm or greater in greatest diameter plus required margin.

Needle placement into muscle or soft tissue for radiation therapy treatment field localization or targeting purposes.

Surgical removal of a deeply embedded fixation implant — such as a buried screw, plate, rod, nail, wire, or metal band — requiring a deep incision typically below the muscle layer.

Excision of a nerve lesion (tumor or mass) arising from a cutaneous somatic nerve — the nerve supply to a defined skin region.

Harvesting of fascia lata or other fascia from the patient for use as an autograft in a separate reconstructive procedure.

Intermediate repair of wounds on the scalp, axillae, trunk, or extremities (excluding hands and feet) exceeding 30.0 cm in total length, requiring layered closure of subcutaneous tissue and/or superficial fascia in addition to skin closure.

Harvesting of a major or large autogenous bone graft from any donor site, performed through a separate skin incision not included in the primary procedure code.

Excision of a subcutaneous soft tissue tumor of the abdominal wall measuring less than 3 cm, including the tumor plus the margin required for complete removal.

Removal of an external fixation system performed under anesthesia, reported when the complexity of fixator removal requires an anesthetic beyond local infiltration.

Intermediate repair of wounds on the scalp, axillae, trunk, or extremities (excluding hands and feet), measuring 20.1 to 30 cm in total length.

Debridement of skin and subcutaneous tissue, including removal of foreign material, at the site of an open fracture or open dislocation.

Surgical exploration of a penetrating traumatic wound located in the abdomen, flank, or back to assess depth and damage to underlying structures.

Add-on code for implanting a biologic material — such as acellular dermal matrix — into breast or trunk tissue to provide structural reinforcement during a primary reconstructive or repair procedure.

New patient office or outpatient visit requiring high-complexity medical decision making, or 60–74 minutes of total time on the date of encounter.

Surgical removal of a deep or complicated foreign body lodged within muscle tissue or a tendon sheath, requiring incision and dissection to access and extract the object.

Intermediate repair of wounds on the scalp, axillae, trunk, or extremities (excluding hands and feet), measuring 12.6 to 20.0 cm in total length.

Surgical collection of bone marrow from a patient's own body for autologous transplantation use.

Skin substitute graft application to the trunk, arms, or legs in pediatric patients, covering the first 100 sq cm of wound surface area when total wound surface area is 100 sq cm or greater.

Minor autogenous bone harvest from a separate donor-site incision — a dowel, button, or similarly small graft quantity.

Highest-level office or outpatient E/M visit for an established patient, qualifying via high-complexity medical decision making or 40–54 minutes of total provider time on the date of service.

New patient office or outpatient visit requiring moderate medical decision making, or 45–59 minutes of total provider time on the date of the encounter.

Surgical implantation of an electrical stimulation device at a fracture or fusion site to promote bone healing from within.

Open surgical biopsy of a superficial bone, such as the ilium, sternum, spinous process, rib, or femoral trochanter, performed through a skin incision to obtain tissue for diagnosis.

Manual preparation and insertion of a drug-delivery device into the intramedullary canal of a bone, reported as an add-on to the primary procedure.

Percutaneous bone biopsy using a trocar or needle targeting deep skeletal structures such as the vertebral body or femur.

Surgical biopsy of deep muscle tissue located below the fascia or beneath adjacent muscles or bone structures.

Aspiration and injection procedure to treat a bone cyst — fluid is drawn out and a therapeutic agent is injected to promote healing.

Insertion of a wire or pin into bone with application of skeletal traction, including subsequent removal of the traction device.

Removal of an intra-articular drug delivery device from a joint, reported as an add-on to the primary procedure code.

Therapeutic apheresis procedure targeting platelet depletion (plateletpheresis) in a patient with a pathologic excess of circulating platelets.

Destruction of a peripheral nerve or branch using a neurolytic agent — chemical, thermal, electrical, or radiofrequency — for pain relief.

Office visit for an established patient requiring moderate-complexity medical decision making (MDM), or 30–39 minutes of total provider time on the date of service.

Surgical removal of a foreign body (such as a splinter, thorn, bullet fragment, or gravel) lodged in a muscle or tendon sheath, performed through a skin incision — simple complexity.

Removal of an intramedullary drug delivery device from the bone marrow canal, reported as an add-on to the primary procedure code.

Computer-based motion analysis using video recording and 3D kinematic capture to objectively evaluate gait and movement patterns.

Removal of a superficial implant such as a buried wire, pin, or rod through a small incision without layered closure

Percutaneous bone biopsy of a superficial bone using a trocar or needle, yielding tissue for diagnostic analysis.

New patient office or outpatient visit requiring a medically appropriate history and/or examination with low-complexity medical decision-making, or 30–44 minutes of total provider time on the date of the encounter.

High-complexity physical therapy evaluation requiring documentation of three or more personal factors or comorbidities affecting the plan of care, examination of four or more body system elements using standardized tests and measures, and an unstable or unpredictable clinical presentation — typically 45 minutes face-to-face.

Moderate-complexity physical therapy evaluation requiring documented history with one to two comorbidities or personal factors, examination of three or more body system elements with measurable findings, and moderate clinical decision-making for an evolving presentation — typically 30 minutes face-to-face.

Low-complexity occupational therapy evaluation, typically 30 minutes face-to-face, for patients with no comorbidities affecting occupational performance and a limited set of treatment options.

Occupational therapy initial evaluation at high complexity, involving extensive history review, assessment of five or more performance deficits, and high-analytic-complexity clinical decision-making — typically 60 minutes face-to-face.

Low-complexity physical therapy evaluation covering a history with no or minimal comorbidities affecting the plan of care, examination of 1–2 elements (body structures/functions, activity limitations, and/or participation restrictions), a stable and uncomplicated clinical presentation, and low-complexity clinical decision-making. Typically 20 minutes face-to-face.

Manual preparation and deep insertion of a drug-delivery device into subfascial tissue, reported as an add-on to the primary procedure.

Surgical removal of a tissue sample from a superficial muscle — tissue located just below the skin surface or just beneath the muscle fascia — for diagnostic laboratory analysis.

MRI of the lower extremity (excluding joint) performed without contrast material