By Report Procedures

HMSA considers the following CPT procedure codes to represent “by report” procedures. When submitting claims for these procedures, please include an operative report with the claim.

CPT Code Description
21088 Impression and custom preparation; facial prosthesis
24940 Cineplasty, upper extremity, complete procedure
32850 Donor pneumonectomy(ies) with preparation and maintenance of allograft (cadaver)
33930 Donor cardiectomy-pneumonectomy with preparation and maintenance of allograft
41820 Gingivectomy, excision gingiva, each quadrant
41821 Operculectomy, excision peri-coronal tissues
41850 Destruction of lesion (except excision), dentoalveolar structures
41870 Periodontal mucosal grafting
47133 Donor hepatectomy, with preparation and maintenance of allograft, from cadaver donor
48550 Pancreatectomy, with preparation and maintenance of allograft from cadaver donor with or without duodenal segment for transplantation
50300 Donor nephrectomy, with preparation and maintenance of allograft; from cadaver donor, unilateral or bilateral
54440 Plastic operation of penis for injury
69710 Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone
HCPCS Code Description
G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee.

Revision History

Date Nature of Revision
08/03/2026 Migrated to new platform.