| | | | |
| 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 | 0075T | Perq stent/chest vert art | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0076T | S&i stent/chest vert art | 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 | 0095T | Rmvl artific disc addl crvcl | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0098T | Rev artific disc addl | 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 | 0164T | Remove lumb artif disc addl | 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 | 0165T | Revise lumb artif disc addl | 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 | |
| Site of Service (SOS) Outpatient Hospital | 0191T | ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR INT | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Inpatient Only Code | 01990 | Support for organ donor | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Potentially Unproven Services | 0200T | PERQ SAC AGMNTJ UNI W/WO BALO/MCHNL DEV 1/> NDL | | |
| Potentially Unproven Services | 0201T | PERQ SAC AGMNTJ BI W/WO BALO/MCHNL DEV 2/> NDLS | | |
| Inpatient Only Code | 0202T | Post vert arthrplst 1 lumbar | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0219T | Plmt post facet implt cerv | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0220T | Plmt post facet implt thor | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0235T | Trluml perip athrc visceral | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0345T | Transcath mtral vlve repair | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0483T | Tmvi percutaneous approach | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0484T | Tmvi transthoracic exposure | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0494T | Prep & cannulj cdvr don lung | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0495T | Mntr cdvr don lng 1st 2 hrs | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0496T | Mntr cdvr don lng ea addl hr | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Transplants | 0537T | CAR-T THERAPY HRVG BLD DRV T LMPHCYT PR DAY | Follow Transplant JA to determine if SWHR is delegated for transplants for UHC | |
| Transplants | 0538T | CAR-T THERAPY PREPJ BLD DRV T LMPHCYT F/TRNS | Follow Transplant JA to determine if SWHR is delegated for transplants for UHC | |
| Transplants | 0539T | CAR-T THERAPY RECEIPT & PREP CAR-T CELLS F/ADMN | Follow Transplant JA to determine if SWHR is delegated for transplants for UHC | |
| Transplants | 0540T | CAR-T THERAPY AUTOLOGOUS CELL ADMINISTRATION | Follow Transplant JA to determine if SWHR is delegated for transplants for UHC | |
| Inpatient Only Code | 0543T | Ta mv rpr w/artif chord tend | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0544T | Tcat mv annulus rcnstj | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0545T | Tcat tv annulus rcnstj | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0569T | Ttvr perq appr 1st prosth | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0570T | Ttvr perq ea addl prosth | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0584T | Perq islet cell transplant | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0585T | Laps islet cell transplant | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0586T | Open islet cell transplant | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cardiology | 0614T | RMVL&RPLCMT SUBSTERNAL IMPLTBL DEFIBRILLATOR PG | | |
| Inpatient Only Code | 0643T | Tcat l ventr rstrj dev implt | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0656T | Vrt bdy tethering ant <7 seg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0657T | Vrt bdy tethering ant 8+ seg | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Inpatient Only Code | 0659T | Tcat intra-c nfs supersat o2 | 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 | |
| Cosmetic and Reconstruction Procedures | 11960 | INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 11971 | REMOVAL TISSUE EXPANDER W/O INSERTION IMPLANT | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Gender Dysphoria Treatment | 14000 | ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 SQCM/< | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 14001 | ADJNT TIS TRANSFR/REARRANGE TRUNK 10.1-30.0 SQCM | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Site of Service (SOS) Outpatient Hospital | 14040 | ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/< | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Gender Dysphoria Treatment | 14041 | ADJT/REARGMT F/C/C/M/N/AX/G/H/F 10.1-30.0 SQ CM | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Site of Service (SOS) Outpatient Hospital | 14060 | ADJT TIS TRNSFR/REARRGMT E/N/E/L DFCT 10 SQ CM/< | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Site of Service (SOS) Outpatient Hospital | 14301 | ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Site of Service (SOS) Outpatient Hospital | 15100 | SPLIT AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Site of Service (SOS) Outpatient Hospital | 15120 | SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1 % | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Site of Service (SOS) Outpatient Hospital | 15220 | FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 CM/< | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Site of Service (SOS) Outpatient Hospital | 15240 | FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F 20 CM/< | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Site of Service (SOS) Outpatient Hospital | 15260 | FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 SQ CM/< | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Gender Dysphoria Treatment | 15734 | MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15738 | MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15750 | FLAP NEUROVASCULAR PEDICLE | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Inpatient Only Code | 15756 | Free myo/skin flap microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Gender Dysphoria Treatment | 15757 | FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS | 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 2023 | |
| Gender Dysphoria Treatment | 15758 | FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS | 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 2023 | |
| Gender Dysphoria Treatment | 15775 | PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15776 | PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Inpatient Only Code | 15778 | Impl absrb msh/prsth dly cls | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Gender Dysphoria Treatment | 15780 | DERMABRASION TOTAL FACE | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15781 | DERMABRASION SEGMENTAL FACE | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15782 | DERMABRASION REGIONAL OTHER THAN FACE | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15783 | DERMABRASION SUPERFICIAL ANY SITE | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15788 | CHEMICAL PEEL FACIAL EPIDERMAL | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15789 | CHEMICAL PEEL FACIAL DERMAL | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15792 | CHEMICAL PEEL NONFACIAL EPIDERMAL | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Gender Dysphoria Treatment | 15793 | CHEMICAL PEEL NONFACIAL DERMAL | This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890 | |
| Cosmetic and Reconstruction Procedures | 15820 | BLEPHAROPLASTY LOWER EYELID | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15821 | BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15822 | BLEPHAROPLASTY UPPER EYELID | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15823 | BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15830 | EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15847 | EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15877 | SUCTION ASSISTED LIPECTOMY TRUNK | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15878 | SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 15879 | SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY | 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 | |
| Cosmetic and Reconstruction Procedures | 17106 | DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 17107 | DSTRJ CUTANEOUS VASCULAR LESIONS 10.0-50.0 SQ CM | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 17108 | DSTRJ CUTANEOUS VASCULAR LESIONS >50.0 SQ CM | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 17999 | UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Site of Service (SOS) Outpatient Hospital | 19125 | EXC BREAST LES PREOP PLMT RAD MARKER OPEN 1 LES | Prior authorization is only required when requesting service in an outpatient hospital setting. Prior authorization is not required if performed at a participating Ambulatory Surgery Center (ASC) or in OFFICE | |
| Gender Dysphoria Treatment | 19303 | MASTECTOMY SIMPLE COMPLETE | 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 2023 | |
| Inpatient Only Code | 19306 | Mast rad urban type | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Breast Reconstruction - Non Mastectomy | 19316 | MASTOPEXY | Notification or Prior Authorization is not required for certain diagnosis codes: Please reference the UHC Breast Recon Dx Codes TAB | |
| Breast Reconstruction - Non Mastectomy | 19318 | BREAST REDUCTION | Notification or Prior Authorization is not required for certain diagnosis codes: Please reference the UHC Breast Recon Dx Codes TAB | |
| Breast Reconstruction - Non Mastectomy | 19325 | BREAST AUGMENTATION WITH IMPLANT | Notification or Prior Authorization is not required for certain diagnosis codes: Please reference the UHC Breast Recon Dx Codes TAB | |
| 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 | |
| Spine Surgery | 20930 | ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED | | |
| Spine Surgery | 20931 | ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL | | |
| Spine Surgery | 20939 | BONE MARROW ASPIRATION BONE GRFG SPI SURG ONLY | | |
| Inpatient Only Code | 20955 | Fibula bone graft microvasc | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| 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 | |
| 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 | |
| Inpatient Only Code | 20970 | Bone/skin graft iliac crest | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Bone Growth Stimulator | 20974 | ELECTRICAL STIMULATION BONE HEALING NONINVASIVE | | |
| Bone Growth Stimulator | 20975 | ELECTRICAL STIMULATION BONE HEALING INVASIVE | | |
| Bone Growth Stimulator | 20979 | LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE | | |
| Inpatient Only Code | 21045 | Extensive jaw surgery | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21120 | GENIOPLASTY AUGMENTATION | | |
| Orthognathic Surgery | 21121 | GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE | | |
| Orthognathic Surgery | 21122 | GENIOPLASTY 2/> SLIDING OSTEOTOMIES | | |
| Orthognathic Surgery | 21123 | GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS | | |
| Orthognathic Surgery | 21125 | AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL | | |
| Orthognathic Surgery | 21127 | AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL | | |
| Orthognathic Surgery | 21141 | RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT | | |
| Orthognathic Surgery | 21142 | RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT | | |
| Orthognathic Surgery | 21143 | RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT | | |
| Orthognathic Surgery | 21145 | RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21146 | RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21147 | RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21150 | RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION | | |
| Orthognathic Surgery | 21151 | RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21154 | RCNSTJ MIDFACE LEFORT III W/O LEFORT I | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21155 | RCNSTJ MIDFACE LEFORT III W/LEFORT I | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21159 | RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21160 | RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic and Reconstruction Procedures | 21172 | RCNSTJ SUPERIOR-LATERAL ORBITAL RIM & LOWER FHD | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 21175 | RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS & LWR FHD | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 21179 | RCNSTJ FOREHEAD &/ SUPRAORB RIMS W/ALGRF/PROSTC | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic and Reconstruction Procedures | 21180 | RCNSTJ FOREHEAD &/ SUPRAORBITAL RIMS W/AUTOGRAFT | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic and Reconstruction Procedures | 21181 | RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC | Preauth required for such services whether scheduled as inpatient or outpatient. | |
| Cosmetic and Reconstruction Procedures | 21182 | RCNSTJ ORBIT/FHD/NASETHMD EXCBONE TUM GRF<40SQCM | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic and Reconstruction Procedures | 21183 | RCNSTJ ORBIT/FHD/NASETHMD EXC BONE GRF>40 <80 | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Cosmetic and Reconstruction Procedures | 21184 | RCNSTJ ORBIT/FHD/NASETHMD EXC BONE TUM GRF>80SQ | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21188 | RCNSTJ MDFC OTH/THN LEFORT OSTEOT & BONE GRAFTS | HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023 | |
| Orthognathic Surgery | 21193 | RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF | | |
| Orthognathic Surgery | 21194 | RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT | | |
| Orthognathic Surgery | 21195 | RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD | | |
| Orthognathic Surgery | 21196 | RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI | | |
| Orthognathic Surgery | 21198 | OSTEOTOMY MANDIBLE SEGMENTAL | | |
| Orthognathic Surgery | 21199 | OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT | | |
| Orthognathic Surgery | 21206 | OSTEOTOMY MAXILLA SEGMENTAL | | |
| Orthognathic Surgery | 21210 | GRAFT BONE NASAL/MAXILLARY/MALAR AREAS | | |
| Orthognathic Surgery | 21215 | GRAFT BONE MANDIBLE | | |
| Cosmetic and Reconstruction Procedures | 21230 | GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR | Preauth required for such services whether scheduled as inpatient or outpatient. | |