| | | | |
| Inpatient Only Code | 00176 | Anesth pharyngeal surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00192 | Anesth facial bone surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00211 | Anesth cran surg hemotoma | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00214 | Anesth skull drainage | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00215 | Anesth skull repair/fract | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00474 | Anesth surgery of rib | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00524 | Anesth chest drainage | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00540 | Anesth chest surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00542 | Anesthesia removal pleura | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00546 | Anesth lung chest wall surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00560 | Anesth heart surg w/o pump | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00561 | Anesth heart surg <1 yr | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00562 | Anesth hrt surg w/pmp age 1+ | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00567 | Anesth cabg w/pump | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00580 | Anesth heart/lung transplnt | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00604 | Anesth sitting procedure | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00632 | Anesth removal of nerves | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00792 | Anesth hemorr/excise liver | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00794 | Anesth pancreas removal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00796 | Anesth for liver transplant | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00844 | Anesth pelvis surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00846 | Anesth hysterectomy | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00848 | Anesth pelvic organ surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00864 | Anesth removal of bladder | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00866 | Anesth removal of adrenal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00868 | Anesth kidney transplant | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00882 | Anesth major vein ligation | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00904 | Anesth perineal surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00908 | Anesth removal of prostate | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00932 | Anesth amputation of penis | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00934 | Anesth penis nodes removal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 00936 | Anesth penis nodes removal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01140 | Anesth amputation at pelvis | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01150 | Anesth pelvic tumor surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01212 | Anesth hip disarticulation | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01232 | Anesth amputation of femur | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01234 | Anesth radical femur surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01272 | Anesth femoral artery surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01274 | Anesth femoral embolectomy | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01404 | Anesth amputation at knee | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01442 | Anesth knee artery surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01444 | Anesth knee artery repair | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01502 | Anesth lwr leg embolectomy | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01634 | Anesth shoulder joint amput | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01636 | Anesth forequarter amput | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01652 | Anesth shoulder vessel surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01654 | Anesth shoulder vessel surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01656 | Anesth arm-leg vessel surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01756 | Anesth radical humerus surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 01990 | Support for organ donor | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 11004 | Debride genitalia & perineum | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 11005 | Debride abdom wall | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 11006 | Debride genit/per/abdom wall | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 11008 | Remove mesh from abd wall | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| 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 | |
| Cosmetic & Reconstructive | 15820 | REVISION OF LOWER EYELID | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| 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 | 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 | 15100 | SKIN SPLT GRFT TRNK/ARM/LEG | | |
| Other Services | 15120 | SKN SPLT A-GRFT FAC/NCK/HF/G | | |
| 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 2023 | |
| Inpatient Only Code | 15757 | Free skin flap microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 15758 | Free fascial flap microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Other Services | 15770 | DERMA-FAT-FASCIA GRAFT | | |
| Other Services | 15775 | HAIR TRNSPL 1-15 PUNCH GRFTS | | |
| Other Services | 15776 | HAIR TRNSPL >15 PUNCH GRAFTS | | |
| Inpatient Only Code | 15778 | Impl absrb msh/prsth dly cls | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| 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 | 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. | |
| Cosmetic & Reconstructive | 15877 | Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Reconstructive procedures that either treat a medical condition or improve or restore physiologic function | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 15878 | Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Reconstructive procedures that either treat a medical condition or improve or restore physiologic function | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 15879 | Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Reconstructive procedures that either treat a medical condition or improve or restore physiologic function | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Inpatient Only Code | 16036 | Escharotomy addl incision | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| 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. | |
| Cosmetic & Reconstructive | 17999 | SKIN TISSUE PROCEDURE | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| 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 2023 | |
| Inpatient Only Code | 19306 | Mast rad urban type | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| 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 | |
| Inpatient Only Code | 20956 | Iliac bone graft microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20957 | Mt bone graft microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| 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 | 19324 | ENLARGE BREAST | | |
| 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 | |
| Breast Reconstruction | 19330 | REMOVAL OF IMPLANT MATERIAL | 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 | 19340 | IMMEDIATE BREAST PROSTHESIS | 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 | 19342 | DELAYED BREAST PROSTHESIS | 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 | 19350 | BREAST RECONSTRUCTION | 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 | 19357 | BREAST RECONSTRUCTION | 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 | |
| Inpatient Only Code | 19361 | Brst rcnstj latsms drsi flap | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 19364 | Brst rcnstj free flap | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 19367 | Brst rcnstj 1 pdcl tram flap | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 19368 | Brst rcnstj 1pdcl tram anast | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 19369 | Brst rcnstj 2 pdcl tram flap | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Breast Reconstruction | 19370 | SURGERY OF BREAST CAPSULE | 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 | |
| Inpatient Only Code | 20962 | Other bone graft microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20969 | Bone/skin graft microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Breast Reconstruction | 19371 | REMOVAL OF BREAST CAPSULE | 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 | 19380 | REVISE BREAST RECONSTRUCTION | 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 | 19396 | DESIGN CUSTOM 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 | |
| Other Services | 20205 | DEEP MUSCLE BIOPSY | | |
| Other Services | 20206 | NEEDLE BIOPSY MUSCLE | | |
| Other Services | 20220 | BONE BIOPSY TROCAR/NEEDLE | | |
| Other Services | 20240 | BONE BIOPSY OPEN SUPERFICIAL | | |
| Other Services | 20245 | BONE BIOPSY OPEN DEEP | | |
| Inpatient Only Code | 20661 | Application of head brace | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20664 | Application of halo | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20802 | Replantation arm complete | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20805 | Replant forearm complete | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20808 | Replantation hand complete | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20816 | Replantation digit complete | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20824 | Replantation thumb complete | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20827 | Replantation thumb complete | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20838 | Replantation foot complete | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Other Services | 20930 | SP BONE ALGRFT MORSEL ADD-ON | | |
| Other Services | 20931 | SP BONE ALGRFT STRUCT ADD-ON | | |
| Spine Surgery | 20939 | | | |
| Inpatient Only Code | 20955 | Fibula bone graft microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 20970 | Bone/skin graft iliac crest | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Other Services | 20974 | ELECTRICAL BONE STIMULATION | | |
| Other Services | 21040 | EXCISE MANDIBLE LESION | | |
| Inpatient Only Code | 21045 | Extensive jaw surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Other Services | 21120 | RECONSTRUCTION OF CHIN | | |
| Other Services | 21121 | RECONSTRUCTION OF CHIN | | |
| Other Services | 21122 | RECONSTRUCTION OF CHIN | | |
| Other Services | 21123 | RECONSTRUCTION OF CHIN | | |
| Other Services | 21125 | AUGMENTATION LOWER JAW BONE | | |
| Other Services | 21127 | AUGMENTATION LOWER JAW BONE | | |
| Inpatient Only Code | 21145 | Lefort i-1 piece w/ graft | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21146 | Lefort i-2 piece w/ graft | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21147 | Lefort i-3/> piece w/ graft | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Other Services | 21150 | LEFORT II ANTERIOR INTRUSION | | |
| Inpatient Only Code | 21151 | Lefort ii w/bone grafts | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21154 | Lefort iii w/o lefort i | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21155 | Lefort iii w/ lefort i | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21159 | Lefort iii w/fhdw/o lefort i | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21160 | Lefort iii w/fhd w/ lefort i | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic & Reconstructive | 21172 | RECONSTRUCT ORBIT/FOREHEAD | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 21175 | RECONSTRUCT ORBIT/FOREHEAD | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Inpatient Only Code | 21179 | Reconstruct entire forehead | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21180 | Reconstruct entire forehead | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic & Reconstructive | 21181 | CONTOUR CRANIAL BONE LESION | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Inpatient Only Code | 21182 | Reconstruct cranial bone | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21183 | Reconstruct cranial bone | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21184 | Reconstruct cranial bone | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 21188 | Reconstruction of midface | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Other Services | 21193 | RECONST LWR JAW W/O GRAFT | | |
| Other Services | 21195 | RECONST LWR JAW W/O FIXATION | | |
| Other Services | 21198 | RECONSTR LWR JAW SEGMENT | | |
| Other Services | 21199 | RECONSTR LWR JAW W/ADVANCE | | |
| Other Services | 21206 | RECONSTRUCT UPPER JAW BONE | | |
| Other Services | 21210 | FACE BONE GRAFT | | |
| Other Services | 21215 | LOWER JAW BONE GRAFT | | |
| Cosmetic & Reconstructive | 21230 | RIB CARTILAGE GRAFT | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 21235 | EAR CARTILAGE GRAFT | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Other Services | 21240 | RECONSTRUCTION OF JAW JOINT | | |
| Other Services | 21242 | RECONSTRUCTION OF JAW JOINT | | |
| Other Services | 21244 | RECONSTRUCTION OF LOWER JAW | | |
| Other Services | 21245 | RECONSTRUCTION OF JAW | | |
| Other Services | 21246 | RECONSTRUCTION OF JAW | | |
| Inpatient Only Code | 21247 | Reconstruct lower jaw bone | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic & Reconstructive | 21248 | RECONSTRUCTION OF JAW | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 21249 | RECONSTRUCTION OF JAW | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic & Reconstructive | 21256 | RECONSTRUCTION OF ORBIT | Preauth required for such services whether scheduled as inpatient or outpatient. | |
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