| | | | |
| Inpatient Only Code | 00176 | ANESTH PROCEDURE ON MOUTH | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00176 | Anesth pharyngeal surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00192 | Anesth facial bone surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00211 | Anesth cran surg hemotoma | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00214 | Anesth skull drainage | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00215 | Anesth skull repair/fract | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00474 | Anesth surgery of rib | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00524 | Anesth chest drainage | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00540 | Anesth chest surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00542 | Anesthesia removal pleura | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00546 | Anesth lung chest wall surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00560 | Anesth heart surg w/o pump | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00561 | Anesth heart surg <1 yr | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00562 | Anesth hrt surg w/pmp age 1+ | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00567 | Anesth cabg w/pump | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00580 | Anesth heart/lung transplnt | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00604 | Anesth sitting procedure | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00632 | Anesth removal of nerves | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00792 | Anesth hemorr/excise liver | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00794 | Anesth pancreas removal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00796 | Anesth for liver transplant | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00844 | Anesth pelvis surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00846 | Anesth hysterectomy | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00848 | Anesth pelvic organ surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00864 | Anesth removal of bladder | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00866 | Anesth removal of adrenal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00868 | Anesth kidney transplant | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00882 | Anesth major vein ligation | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00904 | Anesth perineal surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00908 | Anesth removal of prostate | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00932 | Anesth amputation of penis | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00934 | Anesth penis nodes removal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 00936 | Anesth penis nodes removal | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01140 | Anesth amputation at pelvis | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01150 | Anesth pelvic tumor surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01212 | Anesth hip disarticulation | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01232 | Anesth amputation of femur | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01234 | Anesth radical femur surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01272 | Anesth femoral artery surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01274 | Anesth femoral embolectomy | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01404 | Anesth amputation at knee | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01442 | Anesth knee artery surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01444 | Anesth knee artery repair | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01486 | Anesth ankle replacement | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01502 | Anesth lwr leg embolectomy | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01634 | Anesth shoulder joint amput | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01636 | Anesth forequarter amput | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01638 | Anesth shoulder replacement | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01652 | Anesth shoulder vessel surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01654 | Anesth shoulder vessel surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01656 | Anesth arm-leg vessel surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01756 | Anesth radical humerus surg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 01990 | Support for organ donor | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| 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 | |
| Inpatient Only Code | 15756 | Free myo/skin flap microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Gender Dysphoria Treatment | 15757 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Gender Dysphoria Treatment | 15758 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Gender Dysphoria Treatment | 15775 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Breast Reconstruction | 11920 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | 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 | 11971 | 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. | |
| Gender Dysphoria Treatment | 14000 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 14001 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 14041 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15734 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15738 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15750 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15776 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15780 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15781 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15782 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15783 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15788 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15789 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15792 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15793 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Cosmetic & Reconstructive | 15820 | 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 | 15821 | 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 | 15822 | 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 | 15823 | 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 | 15830 | 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 | 15847 | 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 2021 | |
| Cosmetic & Reconstructive | 17106 | 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. | |
| Orthognathic Surgery | 21246 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21247 | Treatment of maxillofacial (jaw) functional impairment | | |
| Cosmetic & Reconstructive | 17107 | 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 | 17108 | 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 | 17999 | 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. | |
| Gender Dysphoria Treatment | 19303 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| 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 | |
| Breast Reconstruction | 19316 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | 19325 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | |
| Orthopedic Surgeries | 22864 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22865 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22867 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22869 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22899 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 23470 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 23472 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 24360 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 24361 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 24362 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 24363 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 27120 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 27122 | Spine and Joint Surgeries | | |
| Breast Reconstruction | 19350 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 2021 | |
| Inpatient Only Code | 19364 | Brst rcnstj free flap | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 19367 | Brst rcnstj 1 pdcl tram flap | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 19368 | Brst rcnstj 1pdcl tram anast | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Inpatient Only Code | 19369 | Brst rcnstj 2 pdcl tram flap | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021 | |
| Breast Reconstruction | 19370 | Reconstruction of the breast or other than following mastectomy | 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 | 19371 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | Reconstruction of the breast or other than following mastectomy | 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 | |
| Bone Growth Stimulator | 20974 | Use of either electronic stimulation or ultrasound to heal fractures | | |
| Bone Growth Stimulator | 20975 | Use of either electronic stimulation or ultrasound to heal fractures | | |
| Bone Growth Stimulator | 20979 | Use of either electronic stimulation or ultrasound to heal fractures | | |
| Orthognathic Surgery | 21120 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21121 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21122 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21123 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21125 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21127 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21141 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21142 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21143 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21145 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21146 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21147 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21150 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21151 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21154 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21155 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21159 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21160 | Treatment of maxillofacial (jaw) functional impairment | | |
| Cosmetic & Reconstructive | 21172 | 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 | 21175 | 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 | 21179 | 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 | | |
| Cosmetic & Reconstructive | 21180 | 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 | | |
| Cosmetic & Reconstructive | 21181 | 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 | 21182 | 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 | | |
| Cosmetic & Reconstructive | 21183 | 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 | | |
| Cosmetic & Reconstructive | 21184 | 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 | | |
| Orthognathic Surgery | 21188 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21193 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21194 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21195 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21196 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21198 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21199 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21206 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21210 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21215 | Treatment of maxillofacial (jaw) functional impairment | | |
| Cosmetic & Reconstructive | 21230 | 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 | 21235 | 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. | |
| Orthognathic Surgery | 21240 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21242 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21244 | Treatment of maxillofacial (jaw) functional impairment | | |
| Orthognathic Surgery | 21245 | Treatment of maxillofacial (jaw) functional impairment | | |
| Cosmetic & Reconstructive | 21248 | 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 | 21249 | 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 | 21255 | 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 | | |
| Cosmetic & Reconstructive | 21256 | 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 | 21260 | 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 | 21261 | 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 | 21263 | 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 | 21267 | 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 | 21268 | 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 | 21275 | 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 | 21299 | 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. | |
| Sleep Apnea Procedures & Surgeries | 21685 | Applies to inpatient or outpatient, including but not limited to: Palatopharyngoplasty - oral pharyngeal reconstructive surgery includes laser-assisted uvulopalatoplasty (LAUP). Applies only for surgical sleep apnea procedures, not sleep studies. | | |
| Cosmetic & Reconstructive | 21740 | 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 | 21742 | 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 | 21743 | 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. | |
| Gender Dysphoria Treatment | 21899 | | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Orthopedic Surgeries | 22100 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22101 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22102 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22110 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22112 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22114 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22206 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22207 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22210 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22212 | Spine and Joint Surgeries | | |
| Orthopedic Surgeries | 22214 | Spine and Joint Surgeries | | |
 | Loading… |
Loading… |
|