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Inpatient Only Code00176ANESTH PROCEDURE ON MOUTHHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00176Anesth pharyngeal surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00192Anesth facial bone surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00211Anesth cran surg hemotomaHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00214Anesth skull drainageHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00215Anesth skull repair/fractHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00474Anesth surgery of ribHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00524Anesth chest drainageHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00540Anesth chest surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00542Anesthesia removal pleuraHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00546Anesth lung chest wall surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00560Anesth heart surg w/o pumpHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00561Anesth heart surg <1 yrHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00562Anesth hrt surg w/pmp age 1+HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00567Anesth cabg w/pumpHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00580Anesth heart/lung transplntHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00604Anesth sitting procedureHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00632Anesth removal of nervesHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00792Anesth hemorr/excise liverHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00794Anesth pancreas removalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00796Anesth for liver transplantHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00844Anesth pelvis surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00846Anesth hysterectomyHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00848Anesth pelvic organ surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00864Anesth removal of bladderHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00866Anesth removal of adrenalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00868Anesth kidney transplantHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00882Anesth major vein ligationHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00904Anesth perineal surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00908Anesth removal of prostateHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00932Anesth amputation of penisHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00934Anesth penis nodes removalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00936Anesth penis nodes removalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01140Anesth amputation at pelvisHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01150Anesth pelvic tumor surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01212Anesth hip disarticulationHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01232Anesth amputation of femurHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01234Anesth radical femur surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01272Anesth femoral artery surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01274Anesth femoral embolectomyHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01404Anesth amputation at kneeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01442Anesth knee artery surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01444Anesth knee artery repairHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01486Anesth ankle replacementHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01502Anesth lwr leg embolectomyHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01634Anesth shoulder joint amputHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01636Anesth forequarter amputHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01638Anesth shoulder replacementHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01652Anesth shoulder vessel surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01654Anesth shoulder vessel surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01656Anesth arm-leg vessel surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01756Anesth radical humerus surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01990Support for organ donorHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code11004Debride genitalia & perineumHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code11005Debride abdom wallHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code11006Debride genit/per/abdom wallHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code11008Remove mesh from abd wallHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code15756Free myo/skin flap microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Gender Dysphoria Treatment15757 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 Treatment15758 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 Treatment15775 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Breast Reconstruction11920Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction11921Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction11922Reconstruction of the breast or other than following mastectomyNotification 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 & Reconstructive11960Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive11971Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Gender Dysphoria Treatment14000 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment14001 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment14041 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15734 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15738 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15750 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15776 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15780 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15781 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15782 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15783 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15788 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15789 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15792 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Gender Dysphoria Treatment15793 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Cosmetic & Reconstructive15820Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15821Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15822Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15823Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15830Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15847Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Inpatient Only Code16036Escharotomy addl incisionHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Cosmetic & Reconstructive17106Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Orthognathic Surgery21246Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21247Treatment of maxillofacial (jaw) functional impairment 
Cosmetic & Reconstructive17107Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive17108Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive17999Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Gender Dysphoria Treatment19303 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Inpatient Only Code19305Mast radicalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code19306Mast rad urban typeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Breast Reconstruction19316Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19318Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19325Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19328Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19330Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19340Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19342Reconstruction of the breast or other than following mastectomyNotification 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 Surgeries22864Spine and Joint Surgeries 
Orthopedic Surgeries22865Spine and Joint Surgeries 
Orthopedic Surgeries22867Spine and Joint Surgeries 
Orthopedic Surgeries22869Spine and Joint Surgeries 
Orthopedic Surgeries22899Spine and Joint Surgeries 
Orthopedic Surgeries23470Spine and Joint Surgeries 
Orthopedic Surgeries23472Spine and Joint Surgeries 
Orthopedic Surgeries24360Spine and Joint Surgeries 
Orthopedic Surgeries24361Spine and Joint Surgeries 
Orthopedic Surgeries24362Spine and Joint Surgeries 
Orthopedic Surgeries24363Spine and Joint Surgeries 
Orthopedic Surgeries27120Spine and Joint Surgeries 
Orthopedic Surgeries27122Spine and Joint Surgeries 
Breast Reconstruction19350Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19357Reconstruction of the breast or other than following mastectomyNotification 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 Code19361Brst rcnstj latsms drsi flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code19364Brst rcnstj free flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code19367Brst rcnstj 1 pdcl tram flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code19368Brst rcnstj 1pdcl tram anastHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code19369Brst rcnstj 2 pdcl tram flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Breast Reconstruction19370Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19371Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19380Reconstruction of the breast or other than following mastectomyNotification 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 Reconstruction19396Reconstruction of the breast or other than following mastectomyNotification 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 Stimulator20974Use of either electronic stimulation or ultrasound to heal fractures 
Bone Growth Stimulator20975Use of either electronic stimulation or ultrasound to heal fractures 
Bone Growth Stimulator20979Use of either electronic stimulation or ultrasound to heal fractures 
Orthognathic Surgery21120Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21121Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21122Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21123Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21125Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21127Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21141Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21142Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21143Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21145Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21146Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21147Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21150Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21151Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21154Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21155Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21159Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21160Treatment of maxillofacial (jaw) functional impairment 
Cosmetic & Reconstructive21172Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21175Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21179Cosmetic 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 & Reconstructive21180Cosmetic 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 & Reconstructive21181Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21182Cosmetic 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 & Reconstructive21183Cosmetic 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 & Reconstructive21184Cosmetic 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 Surgery21188Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21193Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21194Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21195Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21196Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21198Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21199Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21206Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21210Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21215Treatment of maxillofacial (jaw) functional impairment 
Cosmetic & Reconstructive21230Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21235Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Orthognathic Surgery21240Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21242Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21244Treatment of maxillofacial (jaw) functional impairment 
Orthognathic Surgery21245Treatment of maxillofacial (jaw) functional impairment 
Cosmetic & Reconstructive21248Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21249Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21255Cosmetic 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 & Reconstructive21256Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21260Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21261Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21263Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21267Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21268Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21275Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21299Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Sleep Apnea Procedures & Surgeries21685Applies 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 & Reconstructive21740Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21742Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21743Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Gender Dysphoria Treatment21899 This surgical codes with the following DX codes: F64.0, F64.1,F64.2,F64.8,F64.9,Z87.890
Orthopedic Surgeries22100Spine and Joint Surgeries 
Orthopedic Surgeries22101Spine and Joint Surgeries 
Orthopedic Surgeries22102Spine and Joint Surgeries 
Orthopedic Surgeries22110Spine and Joint Surgeries 
Orthopedic Surgeries22112Spine and Joint Surgeries 
Orthopedic Surgeries22114Spine and Joint Surgeries 
Orthopedic Surgeries22206Spine and Joint Surgeries 
Orthopedic Surgeries22207Spine and Joint Surgeries 
Orthopedic Surgeries22210Spine and Joint Surgeries 
Orthopedic Surgeries22212Spine and Joint Surgeries 
Orthopedic Surgeries22214Spine and Joint Surgeries 
Last updated: February 10, 2021