GENERAL SURGERY PROCEDURE BUNDLES / CPT

(COLORECTAL, MINIMALLY INVASIVE SURGERY, BARIATRIC SURGERY,

SURGICAL ONCOLOGY, TRANSPLANT, TRAUMA/ACUTE CARE/CRITICAL
CARE SURGERY, THORACIC SURGERY, VASCULAR)

LEVEL I CORE PRIVILEGES CPT

EVALUATION AND CLINICAL CARE

Admit, Consult, H&P, Orders

BREAST
Incision & Drainage Breast Abscess 19020
Biopsy/Excision Breast Mass 19100 19126
Mastectomy 19300 19307
Fine Needle Aspir w/o Image 10021
I&D Abscess Cyst Simp Single 10060
Aspirate Abscess Hematoma Cyst 10160
Injection Procedure Only for Mammary Ductogram or Galactogram 19030
Excision Benign Lesions 11402-11404
Removal Tun CV Cath w/Pump 36590 remove mediport
Biopsy Lymph Node Superficial 38500
Biopsy Deep Axillary Node(s) 38525
Identification of Sentinel Node 38792

DIGESTIVE SYSTEM
Esophagus
Esophageal incision, FB removal, esophageal resection, endoscopy 43020 43235
Repair,Nissen(open)Manipulation 43300,43324,43450

Stomach
Incision,Excision, 43500-43641
Laparoscopy Diagnostic 49230
Other Gastrojejunostomy 43830
Repair Perforated Gastric / Duodenal Ulcer 43840
Splenectomy, Open 38100
Splenorrhaphy 38115
Repair Paraesophageal / Diaphragmatic hernia 39502
Esophageal Myotomy, Abdominal Approach 43330

Small Intestine/Colon/Rectum/Anus
Exploratory Laparotomy 49000
Enterolysis (Lysis of Adhesions) 44005
Reduction Intussusecption 44050
Excision Meckels Diverticulum 44800
Small Bowel Resection, 44120, 44125
Colectomy, Anastomosis 44140
Partial Colectomy, Colostomy (Hartmann) 44143
Creation Enterostomy (Jejunostomy or Ileostomy) 44310
Creation Colostomy 44320
Feeding Jejunostomy 44015
Repair Enterotomy 44602
Appendectomy 44950
Appendectomy, Drainage Abscess 44960
Debride or Excise Perineal Infection 11004
Excision Pilonidal Cyst / Sinus 11771
Drainage Intra-Abdominal Abscess (Not Appendiceal) 49020
Revised 11-22-10 (jms)
1 of 11
LEVEL I CORE PRIVILEGES CPT
Laparoscopy
Exploratory Laparoscopy with/without Biopsies 49321
Appendectomy, Laparoscopic 44970
Cholecystectomy, Laparoscopic 47562

Liver/Biliary/Pancreas
Biopsy of Liver 47100
Drainage Hepatic Abscess / Simple Cyst 47010
Drainage Hepatic Amoebic or Echinococcal Cyst / Abscess 47015
Repair Hepatic Laceration 47350
Cholecystectomy, Open 47600
Common Bile Duct Exploration 47420
Cholecystoenteric Anastomosis 47720
Choledochoenteric Anastomosis 47760
Excision of Choledochal Cyst 47715
Partial Pancreatectomy 48140
Pancreaticojejunostomy (Peustow) 48180
Drainage / Debride Infection 48005
Internal Drainage Pseudocyst 48520
External Drainage Pseudocyst 48510

HEAD AND NECK

Thyroid Lobectomy 60210
Total Thyroidectomy 60240
Parathyroidectomy 60500
Tracheostomy 31600

GENITOURINARY
Adrenalectomy, Open 60540
Cystotomy Cystostomy 51040
Cystectomy Partial 51550
Nephrectomy 50220
Closure Enterovesical Fistula 44661
Oophorectomy 58940
Salpingectomy 28700
Excision Ovarian Cyst 58940
Excision Urachal Cyst or Sinus 51500

HERNIA
Inguinal Adult 49505
Umbilical Adult 49585
Femoral 49550
Ventral Incisional Initial 49560
Ventral Incisional Recurrent 49565
Remove Infected Abdominal Mesh 11008

SKIN / SUBCUTANEOUS
Incision and Drainage, Debridement,
Excision of skin and subcutaneous lesions, 10021- 11646
Removal of Nails,Pilonidal Cysts 11719- 11771
Wound closure, laceration repair 12001 -13160
Skin Grafting 15002 - 15431
Burns Treatment 16000 -16036
Destruction of skin lesions 17000 -17286

Revised 11-22-10 (jms)

2 of 11
LEVEL I CORE PRIVILEGES CPT

THORACIC
Excision Esophageal Lesion, Primary Repair 43101
Cricopharyngeal Myotomy 43030
Heller Myotomy, Open (Thoracic Approach) 43331
Cervical Esophagostomy 43352
Esophageal Perforation Repair / Drainage 43415
Thoracentesis
Tube Thoracostomy
Pulmonary Descortication, Open 32320

VASCULAR
Repair Trauma / Injury Major Vessel 35226
Ligation Major Vessel 37618
Placement Hickman / Broviac Catheter 36558
Placement Implantable Port 36571
Remove Catheter / Implantable Port
Thromboembolectomy 34201
Lower Extremity Vein Stripping 37700
Amputation Digit Simple / Ray 28820
Amputation Transmetatarsal 28810
Amputation Below Knee 27880
Amputation Above Knee 27590
Amputation Guillotine 27882
Upper Extremity Fasciotomy 25024
Lower Extremity Fasciotomy 27602

ENDOSCOPY
Upper GI Endoscopy 43235 43273
Sigmoidoscopy
Colonoscopy
Bronchoscopy (Flexible/Rigid)

ADMINISTRATION OF SEDATION AND ANALGESIA

Revised 11-22-10 (jms)

3 of 11
LEVEL II ADVANCED PRIVILEGES CPT

COLORECTAL
Complex Anorectal Procedures
Stapled Hemorrhoidpexy (PPH) 46947
Repair Complex Anorectal Fistulae 46707, 46710, 46712, 46288,
46270, 46280, 46275, 45562, 45563 45825
Closure Rectovaginal Fistula Perineal Approach 57300
Closure Rectovaginal Fistula Abdominal Approach 57305
Operation for Incontinence/Constipation 44150
Open Transabdominal Operation for Rectal Prolapse 45540, 45541, 45550
Laparoscopic Transabdominal Operation for Rectal Prolapse 45400, 45402
Perineal Operation for Rectal Prolapse 45540, 45541, 45550
Transanal Resection for Tumor/Polyp 45171, 45172
Pelvic Exenteration 45126
Operations for Anal Cancer 45110, 45112, 45119
Presacral Masses/Cysts/Tumors 49215
Hidradenitis Excision 11470, 11471
Abdominal and Perineal Prolapse Repairs 45540, 45541, 45550
Sphincteroplasty, Artificial Sphincter Implantation, Sacral Nerve Stimulation 46750, 46751, 46760, 46761, 46762
Post Episiotomy Perineal Body Reconstruction 46744 - 46750
Total Abdominal Colectomy for Constipation 44150, 44151, 44155 - 44158

EUA/Acetic Acid Inspection, Local Fulguration 45990

Local Resection, APR 45110, 45112, 45119

Complex Colon Procedures

Colectomy with:
Low Anterior Resection (lateral stalk ligation) 44145, 44146
Coloanal Anastomosis 44145, 44146, 44155 thru 44158
Colonic Pouch/Coloplasty 45119
Abdominoperineal Resection 45110, 45112, 45119
Pelvic Exenteratoin/Posterior Exenteration 45126
Endorectal Pullthrough
IPAA 44120, 44121
Proctectomy 45110 - 45119

Laparoscopic Colon Procedures

All Laparoscopic colon procedures
(including lap assisted, hand assisted, regardless of diagnosis)
Ileocolectomy, TAC/Ileostomy/IRA, Sigmoid/Sleeve Resection, IPAA, etc. 44202, 44204, 44205, 44206, 44207, 44208, 44210,
44211, 44212, 44213, 44227, 45395, 45397, 45400,
45402

Revised 11-22-10 (jms)

4 of 11
LEVEL II ADVANCED PRIVILEGES CPT

ADVANCED LAPAROSCOPY/MINIMALLY INVASIVE SURGERY

Gastrointestinal (laparoscopically or endoscopically)
Gastrotomy 43500
Gastrojejunostomy 43820
Suture Repair Bleeding Ulcer 43501
Pyloromyotomy 43520
Gastric Wedge Resection 43610
Hemi-Gastrectomy without Vagotomy 43632
Hemi-Gastrectomy with Vagotomy 43632/43635
Total Gastrectomy 43621
Vagotomy and Pyloroplasty 43640
Highly Selective Vagotomy 43641
Nissen Fundoplication, Laparoscopic 43280
Heller Myotomy, Laparoscopic 43289
Repair Perforated Gastric / Duodenal Ulcer 43840
Repair Paraesophageal / Diaphragmatic hernia 39502
Esophageal Myotomy, Abdominal Approach 43330
Reduction Intussusecption 44050
Excision Meckels Diverticulum 44800
Small Bowel Resection, Anastomosis 44120
Small Bowel Resection, Enterostomy 44125
Partial Colectomy, Anastomosis 44140
Partial Colectomy, Colostomy (Hartmann) 44143
Total Colectomy, Anastomosis 44150
Total Abdominal Colectomy, Ileostomy 44150
Colectomy, Laparoscopic 44204
Total Proctocolectomy with Ileostomy 44155
Creation Enterostomy (Jejunostomy or Ileostomy) 44310
Creation Colostomy 44320
Revision Enterostomy 44312
Revision Colostomy 44340
Takedown Colostomy 44626
Takedown Ileostomy 44620
Feeding Jejunostomy 44015
Repair Enterotomy 44602
Abdominoperineal Resection 44147
Ileocecectomy 44160
Low Anterior Resection 44145

Liver/Pancreas/Biliary/Spleen (laparoscopically or endoscopically)

Splenectomy, 38100
Splenorrhaphy 38115
Biopsy of Liver 47100
Hepatic Resection 47120
Drainage Hepatic Abscess / Simple Cyst 47010
Drainage Hepatic Amoebic or Echinococcal Cyst / Abscess 47015
Repair Hepatic Laceration 47350
Common Bile Duct Exploration 47420
Cholecystoenteric Anastomosis 47720
Choledochoenteric Anastomosis 47760
Excision of Choledochal Cyst 47715
Partial Pancreatectomy 48140
Whipple Resection 48140
Total Pancreatectomy 48155
Pancreaticojejunostomy (Peustow) 48180
Internal Drainage Pseudocyst 48520
Revised 11-22-10 (jms)
5 of 11
LEVEL II ADVANCED PRIVILEGES CPT

ADVANCED LAPAROSCOPY/MINIMALLY INVASIVE SURGERY (CONTINUED)

Abdominal Wall (laparoscopically or endoscopically)
Inguinal Hernia, Laparoscopic Adult 49650
Umbilical Adult 49585
Femoral 49550
Ventral Incisional Initial 49560

Endocrine
Thyroid Lobectomy 60210
Total Thyroidectomy 60240
Parathyroidectomy 60500
Adrenalectomy

Genitourinary (laparoscopically or endoscopically)

Adrenalectomy 60540
Cystotomy Cystostomy 51040
Cystectomy Partial 51550
Nephrectomy 50220
Liver Donor Nephrectomy 50547

BARIATRIC SURGERY

Open / Laparoscopic/Endoscopic

Gastric Band
Roux-en-Y
Sleeve Gastrectomy
ROSE Procedure

Revised 11-22-10 (jms)

6 of 11
LEVEL II ADVANCED PRIVILEGES CPT

SURGICAL ONCOLOGY
Breast
Fine Needle Aspir w/Image 10022
Adjacent Tissue Transfer /Rearrangement 14301, 14302
Excision of Chest Wall Tumor Including Ribs 19260
Excision of Chest Wall Tumor Involving Ribs 19271
Preoperative Placement of Needle Localization Wire, Breast 19290
Preoperative Placement Each Additional Lesion 19291
Image Placement Metallic Clip, Percutaneoius, during Breast Biopsy 19295
Placement of Radiotherapy.. 19296, 19297
Ultra Guide/Needle Biopsy Sup & Interp 76942
Echography Breast Unilateral/Bilateral 76645
Intraoperative Ultrasound 76998
Nipple/Areola Reconstruction 19350
Sentinal Lymph Node Biopsy Procedure

Hepato/Pancreatico/Biliary
Hepatic Lobectomy
Total Pancreatectomy
Hepatico Jejunostomy
Choledocho Jejunostomy
Radio Frequency Ablation of Hepatic Tumors

Esophagus
Excision Esophageal Lesion, Primary Repair 43101
Esophagectomy, Thoracotomy 43121
Esophagectomy, Transhiatal 43107
Esophagogastrectomy 43117

Thoracic
?????

Soft Tissue/Melanoma
Excision of Extremity Soft Tissue Sarcoma
Sentinal Lymph Node Biopsy

Revised 11-22-10 (jms)

7 of 11
LEVEL II ADVANCED PRIVILEGES CPT

TRANSPLANT
Liver
Liver Transplant (cadaver or living) 47135/47136
Jump Graft Kidney 50327
Jump Graft Liver 47147
Live Donor Hepatectomies 47140//47141/47142
Major Liver Resections 47120/47122/47125/47130
Lap Liver Resections (unlisted) 47379
Lap & Open Radiofrequency Liver Ablations 47370/47371 (laparoscopic
47380 (open)
Portal Decompressive Procedure 36481
Split Liver Transplantation and Procurements.

Pancreas
Pancreas Transplant 48554
Pancreatic Lesion Excision 48120
Percutaneous Pancreas Biopsy

Kidney
Renal Transplant (cadaver or living) 50360
Lap Nephrectomy 50545 - 50548
Open Nephrectomy 50220 - 50240
Percutaneous Kidney Biopsy
Percutaneous Liver Biopsy
Adrenalectomy 60540/60545

Dialysis Access
Percutaneous
A-V Fistula Surgery
Peritoneal

Revised 11-22-10 (jms)

8 of 11
LEVEL II ADVANCED PRIVILEGES CPT

TRAUMA/ACUTE CARE/CRITICAL CARE SURGERY

Critical Care
Airway Maintenance Intubation 31500
including fiberoptic bronchoscopy 31622
and laryngoscopy 31575
Temporary Cardiac Pacemaker Insertion and Application 33210
Cardioversion 92960
Echocardiography and Electrocardiography Interpretation 93314, 93010
Esophagoscopy and Gastroscopy with PEG Insertion 43246
Insertion of Central Venous, Arterial and
Pulmonary Artery Balloon Flotation Catheters
Insertion of Hemodialysis and Peritoneal Dialysis Catheters 49420
Intracranial Pressure Monitoring 61210
Lumbar puncture 62270, 62272

Management of Anaphylaxis and Acute Allergic Reactions E&M

Management of life-threatening disorders in intensive care units including
but not limited to shock, coma, heart failure, trauma, respiratory arrest,
drug overdoses, massive bleeding, diabetic acidosis and kidney failure E&M
Needle and Tube Thoracostomy 32551
Paracentesis 49080
Percutaneous Tracheostomy/Cricothyrotomy Tube Placement 31605
Pericardiocentesis 33010
Peritoneal lavage 49080
Thoracentesis 32421
Tracheostomy 31600
Image Guided Procedures 76998
Ventilator management, including experience with various modes and
continuous positive airway pressure therapies (BiPAP and CPAP) 94002, 94003, 94660
Administration of Sedation and Analgesia 99144
Admit, evaluate, diagnose, and provide treatment or consultative services
to critically ill adult patients with postsurgical or post-traumatic multiple
organ dysfunction and in need of critical care for life threatening disorders.
Assess, stabilize, and determine disposition of patients with
emergent conditions consistent with medical staff policy
regarding emergency and consultative call services. E&M

Trauma
Evaluation and admission of all adult Level 1, 2, and 3 injured
patients with criteria specified by the Trauma Program Director
as reflected in hospital policy. E&M
Resuscitation and stabilization of adult injured patients using
evaluation modalities including, but not limited to, FAST ultrasound E&M

Assessment and treatment of injured patients requiring operative

intervention. Credentialed providers may provide emergency
care of all neck, thoracic, abdominal and vascular injuries proximal
to the knee or elbow with appropriate consultation. 99199

Revised 11-22-10 (jms)

9 of 11
LEVEL II ADVANCED PRIVILEGES CPT

THORACIC SURGERY
Thoracic/Esophagus/Diaphragm (laparoscopically or endoscopically)
Mediastinoscopy 39400
Mediastinotomy 39000
Excision Mediastinal Tumor 39220
Thymectomy 60520
Transthoracic Drainage Empyema 32036
Pulmonary Lobectomy 32480
Pulmonary Wedge Resection, Open 32500
Pulmonary Segmental Resection, Open 32484
Repair Tracheo-Esophageal Fistula 43312
Creation Pericardial Window 33025
Vagotomy, All 64752
Cricopharyngeal Myotomy 43030
Esophageal Perforation Repair / Drainage 43415

Thoracoscopy
Thoracoscopy 32601
Pleurodesis, Thoracoscopic 32650
Pulmonary Decortication, Thoracoscopic 32651
Pulmonary Wedge Resection, Thoracoscopic 32657
Pulmonary Segmental Resection, Thoracoscopic 32663
Exploratory Thoractomy 32100
Pneumonectomy 32440

Revised 11-22-10 (jms)

10 of 11
LEVEL II ADVANCED PRIVILEGES CPT

VASCULAR
Angiography, Carotid 75665
Angiography, Aorta 75600
Angiography, Extremity 75710
Angiography, Visceral 75726
Correction Thoracic Outlet Obstruction 32900
Excision Aneurysm, Upper Extremity 35011
Excision Aneurysm, Lower Extremity 35141
Repair Aneurysm Abdominal Aorta 35081
Excision False Aneurysm 35045
Carotid Endarterectomy 35301
Endarterectomy, Aortoiliofemoral 35363
Carotid Subclavian Bypass 35507
Axillo Femoral Bypass 35521
Aorto Iliac or Femoral Bypass 35546
Femoro Femoral Bypass 35558
Femoro Popliteal Bypass 35556
Femoro Tibial Bypass 35566
Renal Artery Revascularization 35450
Mesenteric Revascularization Procedures 35480
Insert IVC Filter 75940
Portosystemic Shunt 37140
Creation AV Fistula 36821
Placement AV Graft 36825
Removal Infected / Nonfunctional Graft
Iliac Angioplasty with or without Stent 35454
Fem Pop Angioplasty with or without Stent 35456
Tibial Angioplasty with or without Stent 35459
Endovascular AAA Repair (1 Limb) 34802
Endovascular AAA Repair (2 Limb) 34803
Pulse Thrombolysis 75896

LEVEL II ADVANCED PRIVILEGES

ROBOTIC(CONTACT PERIOPERATIVE SERVICES FOR ROBOTIC PRIVILEGING)

LEVEL II ADVANCED PRIVILEGES

LASER

Revised 11-22-10 (jms)

11 of 11