| | | | |
| Inpatient Only Code | 00176 | ANESTH PROCEDURE ON MOUTH | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00192 | ANESTH PHARYNGEAL SURGERY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00211 | ANESTH FACE/SKULL BONE SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00214 | ANESTH CRANIAL SURG NOS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00215 | ANESTH CRAN SURG HEMOTOMA | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 00300 | ANESTH SPECIAL HEAD SURGERY | | |
| Inpatient Only Code | 00474 | ANESTH SURGERY OF SHOULDER | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00524 | ANESTH SURGERY OF RIB | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00540 | ANESTH PACEMAKER INSERTION | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00542 | ANESTH CARDIOVERTER/DEFIB | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00546 | ANESTH CARDIAC ELECTROPHYS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00560 | ANESTH ONE LUNG VENTILATION | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00561 | ANESTHESIA REMOVAL PLEURA | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00562 | ANESTH LUNG CHEST WALL SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00567 | ANESTH STERNAL DEBRIDEMENT | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00580 | BONE SRGRY CMPTR CT/MRI IMAG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00604 | ANESTH HEART SURG <1 YR | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 00630 | ANESTH CABG W/PUMP | | |
| Inpatient Only Code | 00632 | ANESTH HEART/LUNG TRANSPLNT | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 00731 | ANESTH SPINE CORD SURGERY | | |
| Inpatient Only Code | 00792 | US LEIOMYOMATA ABLATE >200 | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00794 | ANESTH ABDOMINAL WALL SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00796 | ANES UPR GI NDSC PX NOS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 00802 | ANESTH REPAIR OF HERNIA | | |
| Inpatient Only Code | 00844 | ANESTH ABDOMINAL WALL SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00846 | ANESTH FAT LAYER REMOVAL | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00848 | ANES LWR INTST NDSC NOS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00864 | ANESTH REPAIR OF HERNIA | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 00865 | ANESTH REPAIR OF HERNIA | | |
| Inpatient Only Code | 00866 | ANESTH HERNIA REPAIR < 1 YR | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00868 | ANESTH HERNIA REPAIR PREEMIE | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00882 | ANESTH PELVIC ORGAN SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00904 | BREATH TEST HEART REJECT | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00908 | ANESTH KIDNEY/URETER SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00932 | ANESTH REMOVAL OF PROSTATE | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00934 | ANESTH BLADDER SURGERY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00936 | ANESTH BLADDER TUMOR SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 00944 | ANESTH GENITALIA SURGERY | | |
| Inpatient Only Code | 01140 | ANESTH BODY CAST PROCEDURE | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01150 | ANESTH AMPUTATION AT PELVIS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01212 | ANESTH HIP JOINT SURGERY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 01214 | ANESTH HIP DISARTICULATION | | |
| Inpatient Only Code | 01232 | ANESTH SURGERY OF FEMUR | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01234 | ANESTH AMPUTATION OF FEMUR | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01272 | CHD RISK IMT STUDY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01274 | ANESTH THIGH ARTERIES SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01404 | ANESTH KNEE JOINT SURGERY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01442 | ANESTH KNEE VESSEL SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01444 | ANESTH KNEE ARTERIES SURG | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01486 | ANESTH RADICAL LEG SURGERY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01502 | ANESTH LOWER LEG CASTING | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01634 | ANES DX SHOULDER ARTHROSCOPY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01636 | ANESTH SURGERY OF SHOULDER | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01638 | ANESTH SHOULDER JOINT AMPUT | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01652 | ANESTH SHOULDER REPLACEMENT | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01654 | LUMB ARTIF DISKECTOMY ADDL | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01656 | REMOVE LUMB ARTIF DISC ADDL | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01756 | ANESTH UPPR ARM PROCEDURE | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 01916 | ANESTH WRIST REPLACEMENT | | |
| Other Services | 01922 | ANESTH LWR ARM EMBOLECTOMY | | |
| Other Services | 01924 | ANESTH VASCULAR SHUNT SURG | | |
| Other Services | 01930 | ANESTH LWR ARM VEIN REPAIR | | |
| Other Services | 01936 | ANESTH CAT OR MRI SCAN | | |
| Inpatient Only Code | 01990 | ANESTH VAGINAL DELIVERY | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 01992 | ANESTH EMER HYSTERECTOMY | | |
| Other Services | 10021 | FNA BX W/O IMG GDN 1ST LES | | |
| Other Services | 10030 | GUIDE CATHET FLUID DRAINAGE | | |
| Other Services | 10140 | DRAINAGE OF HEMATOMA/FLUID | | |
| Other Services | 10180 | COMPLEX DRAINAGE WOUND | | |
| Inpatient Only Code | 11004 | DEBRIDE GENITALIA & PERINEUM | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 11005 | DEBRIDE ABDOM WALL | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 11006 | DEBRIDE GENIT/PER/ABDOM WALL | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 11008 | REMOVE MESH FROM ABD WALL | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 11012 | DEB SKIN BONE AT FX SITE | | |
| Other Services | 11042 | DEB SUBQ TISSUE 20 SQ CM/< | | |
| Other Services | 11043 | DEB MUSC/FASCIA 20 SQ CM/< | | |
| Other Services | 11044 | DEB BONE 20 SQ CM/< | | |
| Other Services | 11045 | DEB SUBQ TISSUE ADD-ON | | |
| Other Services | 11055 | TRIM SKIN LESION | | |
| Other Services | 11102 | TANGNTL BX SKIN SINGLE LES | | |
| Other Services | 11106 | INCAL BX SKN SINGLE LES | | |
| Other Services | 11306 | SHAVE SKIN LESION 0.6-1.0 CM | | |
| Other Services | 11400 | EXC TR-EXT B9+MARG 0.5 CM< | | |
| Other Services | 11401 | EXC TR-EXT B9+MARG 0.6-1 CM | | |
| Other Services | 11402 | EXC TR-EXT B9+MARG 1.1-2 CM | | |
| Other Services | 11403 | EXC TR-EXT B9+MARG 2.1-3CM | | |
| Other Services | 11420 | EXC H-F-NK-SP B9+MARG 0.5/< | | |
| Other Services | 11421 | EXC H-F-NK-SP B9+MARG 0.6-1 | | |
| Other Services | 11422 | EXC H-F-NK-SP B9+MARG 1.1-2 | | |
| Other Services | 11423 | EXC H-F-NK-SP B9+MARG 2.1-3 | | |
| Other Services | 11426 | EXC H-F-NK-SP B9+MARG >4 CM | | |
| Other Services | 11620 | EXC H-F-NK-SP MAL+MARG 0.5/< | | |
| Other Services | 11721 | DEBRIDE NAIL 6 OR MORE | | |
| Other Services | 11770 | REMOVE PILONIDAL CYST SIMPLE | | |
| Breast Reconstruction | 11920 | CORRECT SKIN COLOR 6.0 CM/< | Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 | |
| Breast Reconstruction | 11921 | CORRECT SKN COLOR 6.1-20.0CM | Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 | |
| Breast Reconstruction | 11922 | CORRECT SKIN COLOR EA 20.0CM | Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 | |
| Cosmetic & Reconstructive | 11960 | INSERT TISSUE EXPANDER(S) | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Other Services | 11970 | REPLACE TISSUE EXPANDER | | |
| Cosmetic & Reconstructive | 11971 | REMOVE TISSUE EXPANDER(S) | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Other Services | 11980 | IMPLANT HORMONE PELLET(S) | | |
| Other Services | 11981 | INSERT DRUG IMPLANT DEVICE | | |
| Other Services | 12005 | RPR S/N/A/GEN/TRK12.6-20.0CM | | |
| Other Services | 12020 | CLOSURE OF SPLIT WOUND | | |
| Other Services | 12051 | INTMD RPR FACE/MM 2.5 CM/< | | |
| Other Services | 13100 | CMPLX RPR TRUNK 1.1-2.5 CM | | |
| Other Services | 13160 | LATE CLOSURE OF WOUND | | |
| Other Services | 14000 | TIS TRNFR TRUNK 10 SQ CM/< | | |
| Other Services | 14001 | TIS TRNFR TRUNK 10.1-30SQCM | | |
| Other Services | 14020 | TIS TRNFR S/A/L 10 SQ CM/< | | |
| Other Services | 14021 | TIS TRNFR S/A/L 10.1-30 SQCM | | |
| Other Services | 14040 | TIS TRNFR F/C/C/M/N/A/G/H/F | | |
| Other Services | 14041 | TIS TRNFR F/C/C/M/N/A/G/H/F | | |
| Other Services | 14060 | TIS TRNFR E/N/E/L 10 SQ CM/< | | |
| Other Services | 14061 | TIS TRNFR E/N/E/L10.1-30SQCM | | |
| Other Services | 14301 | TIS TRNFR ANY 30.1-60 SQ CM | | |
| Other Services | 14302 | TIS TRNFR ADDL 30 SQ CM | | |
| Other Services | 15002 | WOUND PREP TRK/ARM/LEG | | |
| Other Services | 15004 | WOUND PREP F/N/HF/G | | |
| Other Services | 15100 | SKIN SPLT GRFT TRNK/ARM/LEG | | |
| Other Services | 15120 | SKN SPLT A-GRFT FAC/NCK/HF/G | | |
| Other Services | 15220 | SKIN FULL GRAFT SCLP/ARM/LEG | | |
| Other Services | 15240 | SKIN FULL GRFT FACE/GENIT/HF | | |
| Other Services | 15260 | SKIN FULL GRAFT EEN & LIPS | | |
| Other Services | 15271 | SKIN SUB GRAFT TRNK/ARM/LEG | | |
| Other Services | 15272 | SKIN SUB GRAFT T/A/L ADD-ON | | |
| Other Services | 15275 | SKIN SUB GRAFT FACE/NK/HF/G | | |
| Other Services | 15572 | SKIN PEDICLE FLAP ARMS/LEGS | | |
| Other Services | 15574 | PEDCLE FH/CH/CH/M/N/AX/G/H/F | | |
| Other Services | 15576 | PEDICLE E/N/E/L/NTRORAL | | |
| Other Services | 15620 | DELAY FLAP F/C/C/N/AX/G/H/F | | |
| Other Services | 15630 | DELAY FLAP EYE/NOS/EAR/LIP | | |
| Other Services | 15650 | TRANSFER SKIN PEDICLE FLAP | | |
| Other Services | 15730 | MDFC FLAP W/PRSRV VASC PEDCL | | |
| Other Services | 15731 | FOREHEAD FLAP W/VASC PEDICLE | | |
| Other Services | 15733 | MUSC MYOQ/FSCQ FLP H&N PEDCL | | |
| Other Services | 15734 | MUSCLE-SKIN GRAFT TRUNK | | |
| Other Services | 15736 | MUSCLE-SKIN GRAFT ARM | | |
| Other Services | 15738 | MUSCLE-SKIN GRAFT LEG | | |
| Other Services | 15750 | NEUROVASCULAR PEDICLE FLAP | | |
| Inpatient Only Code | 15756 | FREE MYO/SKIN FLAP MICROVASC | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 15757 | FREE SKIN FLAP MICROVASC | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 15758 | FREE FASCIAL FLAP MICROVASC | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 15770 | DERMA-FAT-FASCIA GRAFT | | |
| Other Services | 15775 | HAIR TRNSPL 1-15 PUNCH GRFTS | | |
| Other Services | 15776 | HAIR TRNSPL >15 PUNCH GRAFTS | | |
| Other Services | 15780 | DERMABRASION TOTAL FACE | | |
| Other Services | 15781 | DERMABRASION SEGMENTAL FACE | | |
| Other Services | 15782 | DERMABRASION OTHER THAN FACE | | |
| Other Services | 15783 | DERMABRASION SUPRFL ANY SITE | | |
| Other Services | 15788 | CHEMICAL PEEL FACE EPIDERM | | |
| Other Services | 15789 | CHEMICAL PEEL FACE DERMAL | | |
| Other Services | 15792 | CHEMICAL PEEL NONFACIAL | | |
| Other Services | 15793 | CHEMICAL PEEL NONFACIAL | | |
| Cosmetic & Reconstructive | 15820 | REVISION OF LOWER EYELID | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 15821 | REVISION OF LOWER EYELID | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 15822 | REVISION OF UPPER EYELID | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 15823 | REVISION OF UPPER EYELID | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 15830 | EXC SKIN ABD | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 15847 | EXC SKIN ABD ADD-ON | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Other Services | 15946 | REMOVE HIP PRESSURE SORE | | |
| Inpatient Only Code | 16036 | ESCHAROTOMY ADDL INCISION | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 17000 | DESTRUCT PREMALG LESION | | |
| Other Services | 17003 | DESTRUCT PREMALG LES 2-14 | | |
| Other Services | 17004 | DESTROY PREMAL LESIONS 15/> | | |
| Cosmetic & Reconstructive | 17106 | DESTRUCTION OF SKIN LESIONS | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 17107 | DESTRUCTION OF SKIN LESIONS | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 17108 | DESTRUCTION OF SKIN LESIONS | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Other Services | 17110 | DESTRUCT B9 LESION 1-14 | | |
| Other Services | 17111 | DESTRUCT LESION 15 OR MORE | | |
| Other Services | 17262 | DESTRUCTION OF SKIN LESIONS | | |
| Other Services | 17263 | DESTRUCTION OF SKIN LESIONS | | |
| Other Services | 17273 | DESTRUCTION OF SKIN LESIONS | | |
| Other Services | 17281 | DESTRUCTION OF SKIN LESIONS | | |
| Other Services | 17282 | DESTRUCTION OF SKIN LESIONS | | |
| Other Services | 17311 | MOHS 1 STAGE H/N/HF/G | | |
| Other Services | 17312 | MOHS ADDL STAGE | | |
| Other Services | 17313 | MOHS 1 STAGE T/A/L | | |
| Other Services | 17314 | MOHS ADDL STAGE T/A/L | | |
| Other Services | 17315 | MOHS SURG ADDL BLOCK | | |
| Cosmetic & Reconstructive | 17999 | SKIN TISSUE PROCEDURE | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Other Services | 19020 | INCISION OF BREAST LESION | | |
| Other Services | 19281 | PERQ DEVICE BREAST 1ST IMAG | | |
| Other Services | 19303 | MAST SIMPLE COMPLETE | | |
| Inpatient Only Code | 19305 | MAST RADICAL | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 19306 | MAST RAD URBAN TYPE | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Other Services | 19307 | MAST MOD RAD | | |
| Breast Reconstruction | 19316 | SUSPENSION OF BREAST | Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 | |
| Breast Reconstruction | 19318 | REDUCTION OF LARGE BREAST | Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 | |
| Other Services | 21146 | LEFORT I-2 PIECE W/ GRAFT | | |
| Other Services | 21147 | LEFORT I-3/> PIECE W/ GRAFT | | |
| Other Services | 21150 | LEFORT II ANTERIOR INTRUSION | | |
| Other Services | 21151 | LEFORT II W/BONE GRAFTS | | |
| Other Services | 21154 | LEFORT III W/O LEFORT I | | |
| Other Services | 21155 | LEFORT III W/ LEFORT I | | |
| Other Services | 21159 | LEFORT III W/FHDW/O LEFORT I | | |
| Other Services | 21160 | LEFORT III W/FHD W/ LEFORT I | | |
| Cosmetic & Reconstructive | 21172 | RECONSTRUCT ORBIT/FOREHEAD | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Breast Reconstruction | 19325 | ENLARGE BREAST WITH IMPLANT | Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 | |
| Breast Reconstruction | 19328 | REMOVAL OF BREAST IMPLANT | Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1 | |