-
CPT Code Short Description Long Description Authorization
Required? PA Group
PA for Code in Group Applies to All Codes within Specific
Group UM Review Type SAD CPT Code Indicator 00100 ANESTH
SALIVARY GLAND ANESTHESIA SALIVARY GLANDS WITH
BIOPSYNo Auth Required
00102 ANESTH REPAIR OF CLEFT LIP ANESTHESIA CLEFT LIP INVOLVING
PLASTIC REPAIR
No Auth Required
00103 ANESTH BLEPHAROPLASTY ANESTHESIA EYELID RECONSTRUCTIVE
PROCEDURE
No Auth Required
00104 ANESTH ELECTROSHOCK ANESTHESIA ELECTROCONVULSIVE
THERAPY
No Auth Required
00120 ANESTH EAR SURGERY ANESTHESIA EXTERNAL MIDDLE & INNER
EAR W/BX NOS
No Auth Required
00124 ANESTH EAR EXAM ANES EXTERNAL MIDDLE & INNER EAR W/BX
OTOSCOPY
No Auth Required
00126 ANESTH TYMPANOTOMY ANES XTRNL MID & INNER EAR W/BX
TYMPANOTOMY
No Auth Required
00140 ANESTH PROCEDURES ON EYE ANESTHESIA EYE NOT OTHERWISE
SPECIFIED
No Auth Required
00142 ANESTH LENS SURGERY ANESTHESIA EYE LENS SURGERY No Auth
Required00144 ANESTH CORNEAL TRANSPLANT ANESTHESIA EYE CORNEAL
TRANSPLANT No Auth Required00145 ANESTH VITREORETINAL SURG
ANESTHESIA EYE VITREORETINAL SURGERY No Auth Required
00147 ANESTH IRIDECTOMY ANESTHESIA EYE IRIDECTOMY No Auth
Required00148 ANESTH EYE EXAM ANESTHESIA EYE OPHTHALMOSCOPY No Auth
Required00160 ANESTH NOSE/SINUS SURGERY ANESTHESIA NOSE &
ACCESSORY SINUSES
NOSNo Auth Required
00162 ANESTH NOSE/SINUS SURGERY ANES NOSE & ACCESSORY
SINUSES RADICAL SURGERY
No Auth Required
00164 ANESTH BIOPSY OF NOSE ANES NOSE & ACCESSORY SINUSES
BIOPSY SOFT TISSUE
No Auth Required
00170 ANESTH PROCEDURE ON MOUTH ANESTHESIA INTRAORAL WITH BIOPSY
NOS No Auth Required
00172 ANESTH CLEFT PALATE REPAIR ANES INTRAORAL W/BIOPSY REPAIR
CLEFT PALATE
No Auth Required
00174 ANESTH PHARYNGEAL SURGERY ANES INTRAORAL W/BX EXC
RETROPHARYNGEAL TUMOR
No Auth Required
00176 ANESTH PHARYNGEAL SURGERY ANESTHESIA INTRAORAL W/BIOPSY
RADICAL SURGERY
No Auth Required
00190 ANESTH FACE/SKULL BONE SURG ANESTHESIA FACIAL BONES OR
SKULL NOS No Auth Required
00192 ANESTH FACIAL BONE SURGERY ANES FACIAL BONES/SKULL RAD
SURG W/PROGNATHISM
No Auth Required
00210 ANESTH CRANIAL SURG NOS ANESTHESIA INTRACRANIAL PROCEDURE
NOS
No Auth Required
00211 ANESTH CRAN SURG HEMOTOMA ANES INTRACRANIAL
CRANIOTOMY/CRANIECTOMY HMTMA
No Auth Required
00212 ANESTH SKULL DRAINAGE ANESTHESIA INTRACRANIAL PROCEDURE
SUBDURAL TAPS
No Auth Required
00214 ANESTH SKULL DRAINAGE ANES INTRACRANIAL BURR HOLES
W/VENTRICULOGRAPHY
No Auth Required
00215 ANESTH SKULL REPAIR/FRACT ANES INTRACRANIAL/ELEVATION
DEPRSD SKULL FX XDRL
No Auth Required
00216 ANESTH HEAD VESSEL SURGERY ANESTHESIA INTRACRANIAL
VASCULAR PROCEDURE
No Auth Required
00218 ANESTH SPECIAL HEAD SURGERY ANES INTRACRANIAL PROCEDURE IN
SITTING POSITION
No Auth Required
00220 ANESTH INTRCRN NERVE ANES INTRACRANIAL CEREBROSPINAL FLUID
SHUNTING
No Auth Required
00222 ANESTH HEAD NERVE SURGERY ANES INTRACRANIAL
ELECTROCOAGULATION ICRA NERVE
No Auth Required
00300 ANESTH HEAD/NECK/PTRUNK ANES INTEG MUSC & NRV HEAD
NECK&POSTERIOR TRUNK
No Auth Required
00320 ANESTH NECK ORGAN 1YR/> ANES ESOPH THYRD LARYNX TRACH
& LYMPH NECK 1YR
No Auth Required
00322 ANESTH BIOPSY OF THYROID ANES ESOPH THYRD LARX TRACH &
LYMPH NCK BX THYRD
No Auth Required
00326 ANESTH LARYNX/TRACH < 1 YR ANESTHESIA LARYNX &
TRACHEA CHILDREN
-
00537 ANESTH CARDIAC ELECTROPHYS ANES CARDIAC ELECTROPHYSIOL
STDY W/RF ABLATION
No Auth Required
00539 ANESTH TRACH-BRONCH RECONST ANESTHESIA TRACHEOBRONCHIAL
RECONSTRUCTION
No Auth Required
00540 ANESTH CHEST SURGERY ANES THORACOTOMY & THORACOSCOPY
NOS
No Auth Required
00541 ANESTH ONE LUNG VENTILATION ANES THORACOTOMY &
THORACOSCOPY W/1 LUNG VNTJ
No Auth Required
00542 ANESTHESIA REMOVAL PLEURA ANES THORACOTOMY &
THORACOSCOPY DECORTICATION
No Auth Required
00546 ANESTH LUNG CHEST WALL SURG ANES THORACOTOMY &
THORACOSCOPY PULMONARY RESC
No Auth Required
00548 ANESTH TRACHEA BRONCHI SURG ANES THORACOTOMY
&THORACSCOPY TRACHEA & BRONCHI
No Auth Required
00550 ANESTH STERNAL DEBRIDEMENT ANESTHESIA FOR STERNAL
DEBRIDEMENT No Auth Required00560 ANESTH HEART SURG W/O PUMP ANES
HRT PERICARDIAL SAC& GRT VESLS
W/O PMP OXTNo Auth Required
00561 ANESTH HEART SURG
-
00868 ANESTH KIDNEY TRANSPLANT ANES XTRPRTL LWR ABD W/URIN TRACT
RENAL TRANSPL
No Auth Required
00870 ANESTH BLADDER STONE SURG ANES XTRPRTL LWR ABD W/URIN
TRACT CSTOLITHOTOMY
No Auth Required
00872 ANESTH KIDNEY STONE DESTRUCT ANES LITHOTRP XTRCORP SHOCK
WAVE W/WATER BATH
No Auth Required
00873 ANESTH KIDNEY STONE DESTRUCT ANES LITHOTRP XTRCORP SHOCK
WAVE W/O WATER BATH
No Auth Required
00880 ANESTH ABDOMEN VESSEL SURG ANESTHESIA MAJOR LOWER
ABDOMINAL VESSELS NOS
No Auth Required
00882 ANESTH MAJOR VEIN LIGATION ANES MAJOR LOWER ABDOMINAL
VESSELS IVC LIGATION
No Auth Required
00902 ANESTH ANORECTAL SURGERY ANESTHESIA ANORECTAL PROCEDURE No
Auth Required00904 ANESTH PERINEAL SURGERY ANESTHESIA RADICAL
PERINEAL
PROCEDURENo Auth Required
00906 ANESTH REMOVAL OF VULVA ANESTHESIA VULVECTOMY No Auth
Required00908 ANESTH REMOVAL OF PROSTATE ANESTHESIA PERINEAL
PROSTATECTOMY No Auth Required00910 ANESTH BLADDER SURGERY ANES
TRANSURETHRAL
W/URETHROCYSTOSCOPY NOSNo Auth Required
00912 ANESTH BLADDER TUMOR SURG ANES TRANSURETHRAL RESECTION OF
BLADDER TUMOR
No Auth Required
00914 ANESTH REMOVAL OF PROSTATE ANESTHESIA TRANSURETHRAL
RESECTION OF PROSTATE
No Auth Required
00916 ANESTH BLEEDING CONTROL ANES TRURL POST-TRURL RESECTION
BLEEDING
No Auth Required
00918 ANESTH STONE REMOVAL ANES TRURL FRAGMNTJ MANJ&/RMVL
URETERAL CALCULUS
No Auth Required
00920 ANESTH GENITALIA SURGERY ANESTHESIA MALE GENITALIA INCL
OPEN URETHRAL PX
No Auth Required
00921 ANESTH VASECTOMY ANES VASECTOMY UNI/BI INCL OPEN URETHRAL
PX
No Auth Required
00922 ANESTH SPERM DUCT SURGERY ANES SEMINAL VESICLES INCL OPEN
URETHRAL PX
No Auth Required
00924 ANESTH TESTIS EXPLORATION ANES UNDSCND TESTIS UNI/BI INCL
OPEN URTL PX
No Auth Required
00926 ANESTH REMOVAL OF TESTIS ANES RAD ORCHIECTOMY INGUN INCL
OPEN URTL PX
No Auth Required
00928 ANESTH REMOVAL OF TESTIS ANES RAD ORCHIECTOMY ABDOMINAL
INCL OPN URTL
No Auth Required
00930 ANESTH TESTIS SUSPENSION ANES ORCHIOPEXY UNI/BI INCL OPEN
URETHRAL PX
No Auth Required
00932 ANESTH AMPUTATION OF PENIS ANES COMPLETE AMPUTATION PENIS
INCL OPEN URTL
No Auth Required
00934 ANESTH PENIS NODES REMOVAL ANES RAD AMP PENIS W/BI
INGUINAL LYMPH NODE RMVL
No Auth Required
00936 ANESTH PENIS NODES REMOVAL ANES RAD AMP PENIS W/BI
INGUNL&ILIAC LYMPH RMOVL
No Auth Required
00938 ANESTH INSERT PENIS DEVICE ANES INSJ PENILE PROSTH PRNL
INCL OPEN URTL
No Auth Required
00940 ANESTH VAGINAL PROCEDURES ANESTHESIA VAGINAL PROCEDURE
W/BIOPSY NOS
No Auth Required
00942 ANESTH SURG ON VAG/URETHRAL ANES COLPTMY VAGNC COLPRPHY
INCL BX W/OPN URTL
No Auth Required
00944 ANESTH VAGINAL HYSTERECTOMY ANESTHESIA VAGINAL
HYSTERECTOMY INCL BIOPSY
No Auth Required
00948 ANESTH REPAIR OF CERVIX ANESTHESIA CERVICAL CERCLAGE
INCLUDING BIOPSY
No Auth Required
00950 ANESTH VAGINAL ENDOSCOPY ANESTHESIA CULDOSCOPY INCLUDING
BIOPSY
No Auth Required
00952 ANESTH HYSTEROSCOPE/GRAPH ANES
HYSTEROSCOPY&/HYSTEROSALPINGOGRAPHY W/BX
No Auth Required
01112 ANESTH BONE ASPIRATE/BX ANES BONE MARROW ASPIR&/BX
ANT/PST ILIAC CREST
No Auth Required
01120 ANESTH PELVIS SURGERY ANESTHESIA ON BONY PELVIS No Auth
Required01130 ANESTH BODY CAST PROCEDURE ANESTHESIA BODY CAST
APPLICATION OR
REVISIONNo Auth Required
01140 ANESTH AMPUTATION AT PELVIS ANESTHESIA INTERPELVI
ABDOMINAL AMPUTATION
No Auth Required
01150 ANESTH PELVIC TUMOR SURGERY ANES RADICAL TUMOR PELVIS XCP
HINDQUARTER AMP
No Auth Required
01160 ANESTH PELVIS PROCEDURE ANES CLOSED SYMPHYSIS
PUBIS/SACROILIAC JOINT
No Auth Required
01170 ANESTH PELVIS SURGERY ANES OPEN SYMPHYSIS PUBIS/SACROILIAC
JOINT
No Auth Required
01173 ANESTH FX REPAIR PELVIS ANES OPN RPR DISRPJ PELVIS/COLUMN
FX ACETABULUM
No Auth Required
01200 ANESTH HIP JOINT PROCEDURE ANESTHESIA CLOSED HIP JOINT
PROCEDURE
No Auth Required
01202 ANESTH ARTHROSCOPY OF HIP ANESTHESIA ARTHROSCOPIC HIP
JOINT PROCEDURE
No Auth Required
01210 ANESTH HIP JOINT SURGERY ANESTHESIA OPEN HIP JOINT
PROCEDURE NOS
No Auth Required
01212 ANESTH HIP DISARTICULATION ANESTHESIA OPEN HIP JOINT
DISARTICULATION
No Auth Required
01214 ANESTH HIP ARTHROPLASTY ANESTHESIA OPEN TOTAL HIP
ARTHROPLASTY
No Auth Required
01215 ANESTH REVISE HIP REPAIR ANESTHESIA OPEN REVISION TOTAL
HIP ARTHROPLASTY
No Auth Required
01220 ANESTH PROCEDURE ON FEMUR ANESTHESIA CLOSED PROCEDURES
UPPER 2/3 FEMUR
No Auth Required
01230 ANESTH SURGERY OF FEMUR ANESTHESIA OPEN PROCEDURES UPPER
2/3 FEMUR NOS
No Auth Required
01232 ANESTH AMPUTATION OF FEMUR ANESTHESIA UPPER 2/3 FEMUR
AMPUTATION
No Auth Required
01234 ANESTH RADICAL FEMUR SURG ANES UPPER 2/3 FEMUR RADICAL
RESCECTION
No Auth Required
01250 ANESTH UPPER LEG SURGERY ANES NERVE MUSC TENDON FASCIA
& BURSAE UPPER LEG
No Auth Required
01260 ANESTH UPPER LEG VEINS SURG ANES VEINS OF UPPER LEG
INCLUDING EXPLORATION
No Auth Required
01270 ANESTH THIGH ARTERIES SURG ANESTHESIA ARTERIES UPPER LEG
INCL BYPASS GRAFT
No Auth Required
01272 ANESTH FEMORAL ARTERY SURG ANES ART UPPER LEG W/BYPASS
GRAFT FEM ART LIG
No Auth Required
01274 ANESTH FEMORAL EMBOLECTOMY ANES UPPER LEG W/BYPASS GRFT
FEM ART EMBOLECTOMY
No Auth Required
01320 ANESTH KNEE AREA SURGERY ANES NERVE MUSC TENDON
FASCIA&BURSA KNEE&/POPLT
No Auth Required
01340 ANESTH KNEE AREA PROCEDURE ANESTHESIA CLOSED PROCEDURES
LOWER 1/3 FEMUR
No Auth Required
01360 ANESTH KNEE AREA SURGERY ANESTHESIA OPEN PROCEDURES LOWER
1/3 FEMUR
No Auth Required
01380 ANESTH KNEE JOINT PROCEDURE ANESTHESIA CLOSED PROCEDURES
KNEE JOINT
No Auth Required
01382 ANESTH DX KNEE ARTHROSCOPY ANESTH DIAGNOSTIC ARTHROSCOPIC
PROC KNEE JOINT
No Auth Required
01390 ANESTH KNEE AREA PROCEDURE ANES CLOSED PROC UPPER END
TIBIA FIBULA/PATELLA
No Auth Required
-
01392 ANESTH KNEE AREA SURGERY ANES OPEN PROC UPPER ENDS TIBIA
FIBULA&/PATELLA
No Auth Required
01400 ANESTH KNEE JOINT SURGERY ANES OPEN/SURG ARTHROSCOPIC PROC
KNEE JOINT NOS
No Auth Required
01402 ANESTH KNEE ARTHROPLASTY ANESTH OPEN/SURG ARTHRS TOTAL
KNEE ARTHROPLASTY
No Auth Required
01404 ANESTH AMPUTATION AT KNEE ANESTH OPEN/SURG ARTHRS KNEE
DISARTICULATION
No Auth Required
01420 ANESTH KNEE JOINT CASTING ANES CAST APPLICATION
REMOVAL/REPAIR KNEE JOINT
No Auth Required
01430 ANESTH KNEE VEINS SURGERY ANESTHESIA VEINS KNEE &
POPLITEAL AREA NOS
No Auth Required
01432 ANESTH KNEE VESSEL SURG ANES KNEE & POPLITEAL ARTERY
VEIN FISTULA NOS
No Auth Required
01440 ANESTH KNEE ARTERIES SURG ANES ARTERIES OF KNEE &
POPLITEAL AREA NOS
No Auth Required
01442 ANESTH KNEE ARTERY SURG ANES ART KNEE POPLITEAL TEAEC W/WO
PATCH GRAFT
No Auth Required
01444 ANESTH KNEE ARTERY REPAIR ANES ART KNEE POPLITEAL
EXC&GRF/RPR OCCLS/ARYS
No Auth Required
01462 ANESTH LOWER LEG PROCEDURE ANESTHESIA CLOSED PROC LOWER
LEG ANKLE & FOOT
No Auth Required
01464 ANESTH ANKLE/FT ARTHROSCOPY ANESTHESIA ARTHROSCOPIC
PROCEDURE ANKLE & FOOT
No Auth Required
01470 ANESTH LOWER LEG SURGERY ANES NRV/MUS/TND/FASC LOWER
LEG/ANKLE/FOOT NOS
No Auth Required
01472 ANESTH ACHILLES TENDON SURG ANES RPR RUPTURED ACHILLES
TENDON W/WO GRAFT
No Auth Required
01474 ANESTH LOWER LEG SURGERY ANESTHESIA GASTROCNEMIUS
RECESSION No Auth Required
01480 ANESTH LOWER LEG BONE SURG ANES OPEN PROC BONES LOWER
LEG/ANKLE/FOOT NOS
No Auth Required
01482 ANESTH RADICAL LEG SURGERY ANES RADICAL RESECJ INCL BELOW
KNEE AMPUTATION
No Auth Required
01484 ANESTH LOWER LEG REVISION ANES OPEN OSTEOTOMY/OSTEOPLASTY
TIBIA&/FIBULA
No Auth Required
01486 ANESTH ANKLE REPLACEMENT ANESTHESIA OPEN TOTAL ANKLE
REPLACEMENT
No Auth Required
01490 ANESTH LOWER LEG CASTING ANES LOWER LEG CAST APPLICATION
REMOVAL/REPAIR
No Auth Required
01500 ANESTH LEG ARTERIES SURG ANESTHESIA ARTERIES LOWER LEG
W/BYPASS GRAFT NOS
No Auth Required
01502 ANESTH LWR LEG EMBOLECTOMY ANES ART LOWER LEG W/BYP GRAFT
EMBLC DIR/W/CATH
No Auth Required
01520 ANESTH LOWER LEG VEIN SURG ANESTHESIA VEINS OF LOWER LEG
NOS No Auth Required01522 ANESTH LOWER LEG VEIN SURG ANES VEINS
LOWER LEG VENOUS THRMBC
DIR/W/CATHNo Auth Required
01610 ANESTH SURGERY OF SHOULDER ANES NRV MUSC TNDN FSCIA BURSA
SHOULDER & AXILLA
No Auth Required
01620 ANESTH SHOULDER PROCEDURE ANES CLOSED HUMRL H/N STRNCLAV
JOINT& SHO JOINT
No Auth Required
01622 ANES DX SHOULDER ARTHROSCOPY ANES DIAG ARTHROSCOPIC
SHOULDER JOINT PROC NOS
No Auth Required
01630 ANESTH SURGERY OF SHOULDER ANES ARTHRS HUMERAL H/N
STRNCLAV & SHOULDER NOS
No Auth Required
01634 ANESTH SHOULDER JOINT AMPUT ANESTHESIA ARTHROSCOPIC
SHOULDER DISARTICULATION
No Auth Required
01636 ANESTH FOREQUARTER AMPUT ANES ARTHRS INTERTHORACOSCAPULAR
AMPUTATION
No Auth Required
01638 ANESTH SHOULDER REPLACEMENT ANES ARTHROSCOPIC TOTAL
SHOULDER REPLACEMENT
No Auth Required
01650 ANESTH SHOULDER ARTERY SURG ANESTHESIA ARTERIES SHOULDER
& AXILLA NOS
No Auth Required
01652 ANESTH SHOULDER VESSEL SURG ANESTHESIA AXILLARY-BRACHIAL
ANEURYSM
No Auth Required
01654 ANESTH SHOULDER VESSEL SURG ANES ARTERIES SHOULDER &
AXILLA BYPASS GRAFT
No Auth Required
01656 ANESTH ARM-LEG VESSEL SURG ANESTHESIA AXILLARY-FEMORAL
BYPASS GRAFT
No Auth Required
01670 ANESTH SHOULDER VEIN SURG ANESTHESIA VEINS SHOULDER &
AXILLA No Auth Required01680 ANESTH SHOULDER CASTING ANES SHOULDER
CAST APPL
REMOVAL/REPAIR NOSNo Auth Required
01710 ANESTH ELBOW AREA SURGERY ANES NRV MUSC TDN FSCA&BRS
UPR ARM/ELBOW NOS
No Auth Required
01712 ANESTH UPPR ARM TENDON SURG ANESTHESIA OPEN TENOTOMY ELBOW
TO SHOULDER
No Auth Required
01714 ANESTH UPPR ARM TENDON SURG ANESTHESIA TENOPLASTY ELBOW TO
SHOULDER
No Auth Required
01716 ANESTH BICEPS TENDON REPAIR ANESTHESIA BICEPS TENODESIS
RUPTURE LONG TENDON
No Auth Required
01730 ANESTH UPPR ARM PROCEDURE ANESTHESIA CLOSED PROCEDURES
HUMERUS & ELBOW
No Auth Required
01732 ANESTH DX ELBOW ARTHROSCOPY ANESTHESIA ELBOW JOINT
DIAGNOSTIC ARTHROSCOPIC
No Auth Required
01740 ANESTH UPPER ARM SURGERY ANES OPEN/SURG ARTHROSCOPIC ELBOW
PROC NOS
No Auth Required
01742 ANESTH HUMERUS SURGERY ANESTHESIA OPEN/SURG ARTHRS
OSTEOTOMY HUMERUS
No Auth Required
01744 ANESTH HUMERUS REPAIR ANES OPEN/SURG ARTHRS REPRS
NON/MALUNION HUMERUS
No Auth Required
01756 ANESTH RADICAL HUMERUS SURG ANESTHESIA OPEN/SURG ARTHRS
RADICAL PROC ELBOW
No Auth Required
01758 ANESTH HUMERAL LESION SURG ANESTH OPEN/SURG ARTHRS EXC
CYST/TUMOR HUMERUS
No Auth Required
01760 ANESTH ELBOW REPLACEMENT ANESTH OPEN/SURG ARTHRS TOTAL
ELBOW REPLACEMENT
No Auth Required
01770 ANESTH UPPR ARM ARTERY SURG ANESTHESIA ARTERIES UPPER ARM
& ELBOW NOS
No Auth Required
01772 ANESTH UPPR ARM EMBOLECTOMY ANESTHESIA ARTERIES UPPER
ARM&ELBOW EMBOLECTOM
No Auth Required
01780 ANESTH UPPER ARM VEIN SURG ANESTHESIA VEINS UPPER ARM
& ELBOW NOS
No Auth Required
01782 ANESTH UPPR ARM VEIN REPAIR ANESTHESIA VEINS UPPER ARM
& ELBOW PHLEBORRHAPHY
No Auth Required
01810 ANESTH LOWER ARM SURGERY ANES NERVE MUSCLE TDN
FASCIA&BURSA FOREARM WRIST
No Auth Required
01820 ANESTH LOWER ARM PROCEDURE ANES RADIUS ULNA WRIST/HAND
BONES CLOSED PX
No Auth Required
01829 ANESTH DX WRIST ARTHROSCOPY ANESTHESIA DIAGNOSTIC
ARTHROSCOPIC PROC WRIST
No Auth Required
01830 ANESTH LOWER ARM SURGERY ANES ARTHRS/ENDSCPY DSTL RADIUS
ULNA/WRIST/HAND
No Auth Required
01832 ANESTH WRIST REPLACEMENT ANESTHESIA ARTHRS/ENDOSCPIC TOTAL
WRIST REPLCMT
No Auth Required
01840 ANESTH LWR ARM ARTERY SURG ANESTHESIA ARTERIES FOREARM
WRIST & HAND NOS
No Auth Required
01842 ANESTH LWR ARM EMBOLECTOMY ANES ARTERIES FOREARM WRIST
& HAND EMBOLECTOMY
No Auth Required
-
01844 ANESTH VASCULAR SHUNT SURG ANESTHESIA VASCULAR SHUNT/SHUNT
REVISION
No Auth Required
01850 ANESTH LOWER ARM VEIN SURG ANESTHESIA VEINS FOREARM WRIST
& HAND NOS
No Auth Required
01852 ANESTH LWR ARM VEIN REPAIR ANES VEINS FOREARM WRIST &
HAND PHLEBORRHAPHY
No Auth Required
01860 ANESTH LOWER ARM CASTING ANES FOREARM WRIST/HAND CAST APPL
RMVL/REPAIR
No Auth Required
01916 ANESTH DX ARTERIOGRAPHY ANESTHESIA DIAGNOSTIC
ARTERIOGRAPHY/VENOGRAPH
No Auth Required
01920 ANESTH CATHETERIZE HEART ANES C-CATHJ W/C ANGIOGRAPHY
& VENTRICULOGRAPHY
No Auth Required
01922 ANESTH CAT OR MRI SCAN ANES NON-INVASIVE IMAGING/RADIATION
THERAPY
No Auth Required
01924 ANES THER INTERVEN RAD ARTRL ANESTHESIA THER IVNTL
RADIOLOGICAL ARTERIAL
No Auth Required
01925 ANES THER INTERVEN RAD CARD ANESTHESIA CAROTID/CORONARY
THER IVNTL RAD
No Auth Required
01926 ANES TX INTERV RAD HRT/CRAN ANES ICRA ICAR/AORTIC THER
IVNTL RAD ARTL
No Auth Required
01930 ANES THER INTERVEN RAD VEIN ANES VENOUS/LYMPHATIC NOS THER
IVNTL RAD NOS
No Auth Required
01931 ANES THER INTERVEN RAD TIPS ANESTHESIA INTRAHEPATIC/PORTAL
THER IVNTL RAD
No Auth Required
01932 ANES TX INTERV RAD TH VEIN ANESTHESIA
INTRATHORACIC/JUGULAR THER IVNTL RAD
No Auth Required
01933 ANES TX INTERV RAD CRAN VEIN ANES INTRACRANIAL THER IVNTL
RAD VENS/LYMPHTC
No Auth Required
01935 ANESTH PERC IMG DX SP PROC ANESTHESIA PERQ IMAGE GUIDED
SPINE DIAGNOSTIC
No Auth Required
01936 ANESTH PERC IMG TX SP PROC ANESTHESIA PERQ IMAGE GUIDED
SPINE THERAPEUTIC
No Auth Required
01951 ANESTH BURN LESS 4 PERCENT ANES 2/3 DGR BRN EXC/DBRDMT
W/WO GRFT 4 % TBSA
No Auth Required
01952 ANESTH BURN 4-9 PERCENT ANES 2/3 DGR BRN EXC/DBRDMT W/WO
GRFT 4-9 % TBSA
No Auth Required
01953 ANESTH BURN EACH 9 PERCENT ANES 2/3 DGR BRN EXC/DBRDMT
W/WO GRF EA 9% TBS
No Auth Required
01958 ANESTH ANTEPARTUM MANIPUL ANESTHESIA EXTERNAL CEPHALIC
VERSION No Auth Required
01960 ANESTH VAGINAL DELIVERY ANESTHESIA VAGINAL DELIVERY ONLY
No Auth Required01961 ANESTH CS DELIVERY ANESTHESIA CESAREAN
DELIVERY ONLY No Auth Required01962 ANESTH EMER HYSTERECTOMY ANES
URGENT HYSTERECTOMY
FOLLOWING DELIVERYNo Auth Required
01963 ANESTH CS HYSTERECTOMY ANESTHESIA C HYST W/O ANY LABOR
ANALG/ANES CARE
No Auth Required
01965 ANESTH INC/MISSED AB PROC ANESTHESIA INCOMPLETE/MISSED
ABORTION
No Auth Required
01966 ANESTH INDUCED AB PROCEDURE ANESTHESIA INDUCED ABORTION No
Auth Required01967 ANESTH/ANALG VAG DELIVERY NEURAXIAL LABOR
ANALG/ANES PLND
VAGINAL DELIVERYNo Auth Required
01968 ANES/ANALG CS DELIVER ADD-ON ANES CESARN DLVR FLWG
NEURAXIAL LABOR ANALG/ANES
No Auth Required
01969 ANESTH/ANALG CS HYST ADD-ON ANES CESARN HYST FLWG
NEURAXIAL LABOR ANALG/ANES
No Auth Required
01990 SUPPORT FOR ORGAN DONOR PHYSIOL SUPPORT HARVEST ORGAN FROM
BRAIN-DEAD PT
No Auth Required
01991 ANESTH NERVE BLOCK/INJ ANES DX/THER NRV BLK/NJX OTH/THN
PRONE POS
No Auth Required
01992 ANESTH N BLOCK/INJ PRONE ANES DX/THER NERVE
BLOCK/INJECTION PRONE POS
No Auth Required
01996 HOSP MANAGE CONT DRUG ADMIN DAILY HOSP MGMT EDRL/SARACH
CONT DRUG ADMN
No Auth Required
01999 UNLISTED ANESTH PROCEDURE UNLISTED ANESTHESIA PROCEDURE
Authorization Required General Medicine - other services and
procedures
Full Clinical Review
10004 FNA BX W/O IMG GDN EA ADDL FINE NEEDLE ASPIRATION BX W/O
IMG GDN EA ADDL
No Auth Required
10005 FNA BX W/US GDN 1ST LES FINE NEEDLE ASPIRATION BX W/US GDN
1ST LESION
No Auth Required
10006 FNA BX W/US GDN EA ADDL FINE NEEDLE ASPIRATION BX W/US GDN
EA ADDL
No Auth Required
10007 FNA BX W/FLUOR GDN 1ST LES FINE NEEDLE ASPIRATION BX
W/FLUOR GDN 1ST LESION
No Auth Required Surgery
10008 FNA BX W/FLUOR GDN EA ADDL FINE NEEDLE ASPIRATION BX
W/FLUOR GDN EA ADDL
No Auth Required Surgery
10009 FNA BX W/CT GDN 1ST LES FINE NEEDLE ASPIRATION BX W/CT GDN
1ST LESION
No Auth Required Surgery
10010 FNA BX W/CT GDN EA ADDL FINE NEEDLE ASPIRATION BX W/CT GDN
EA ADDL
No Auth Required Surgery
10011 FNA BX W/MR GDN 1ST LES FINE NEEDLE ASPIRATION BX W/MR GDN
1ST LESION
No Auth Required Surgery
10012 FNA BX W/MR GDN EA ADDL FINE NEEDLE ASPIRATION BX W/MR GDN
EA ADDL
No Auth Required Surgery
10021 FNA BX W/O IMG GDN 1ST LES FINE NEEDLE ASPIRATION BX W/O
IMG GDN 1ST LESION
No Auth Required Surgery
10030 GUIDE CATHET FLUID DRAINAGE IMAGE-GUIDED CATHETER FLUID
COLLECTION DRAINAGE
No Auth Required Surgery
10035 PERQ DEV SOFT TISS 1ST IMAG PERQ SFT TISS LOC DEVICE PLMT
1ST LES W/GDNCE
No Auth Required Surgery
10036 PERQ DEV SOFT TISS ADD IMAG PERQ SFT TISS LOC DEVICE PLMT
ADD LES W/GDNCE
No Auth Required Surgery
10040 ACNE SURGERY ACNE SURGERY Authorization Required Surgery
of integumentary system Full Clinical Review10060 DRAINAGE OF SKIN
ABSCESS INCISION & DRAINAGE ABSCESS
SIMPLE/SINGLENo Auth Required Surgery of integumentary
system
10061 DRAINAGE OF SKIN ABSCESS INCISION & DRAINAGE ABSCESS
COMPLICATED/MULTIPLE
No Auth Required Surgery of integumentary system
10080 DRAINAGE OF PILONIDAL CYST INCISION & DRAINAGE
PILONIDAL CYST SIMPLE
No Auth Required
10081 DRAINAGE OF PILONIDAL CYST INCISION & DRAINAGE
PILONIDAL CYST COMPLICATED
Authorization Required Surgery of integumentary system Full
Clinical Review
10120 REMOVE FOREIGN BODY INCISION & REMOVAL FOREIGN BODY
SUBQ TISS SIMPLE
No Auth Required
10121 REMOVE FOREIGN BODY INCISION & REMOVAL FOREIGN BODY
SUBQ TISS COMPL
Authorization Required Surgery of integumentary system Full
Clinical Review
10140 DRAINAGE OF HEMATOMA/FLUID I&D HEMATOMA SEROMA/FLUID
COLLECTION
Authorization Required Surgery of integumentary system Full
Clinical Review
10160 PUNCTURE DRAINAGE OF LESION PUNCTURE ASPIRATION ABSCESS
HEMATOMA BULLA/CYST
Authorization Required Surgery of integumentary system Full
Clinical Review
10180 COMPLEX DRAINAGE WOUND INCISION & DRAINAGE COMPLEX PO
WOUND INFECTION
Authorization Required Surgery of integumentary system Full
Clinical Review
11000 DEBRIDE INFECTED SKIN DBRDMT EXTENSV ECZEMA/INFECT SKN UP
10% BDY SURF
Authorization Required Surgery of integumentary system Full
Clinical Review
11001 DEBRIDE INFECTED SKIN ADD-ON DBRDMT EXTNSVE ECZEMA/INFECT
SKN EA 10% BDY SURF
Authorization Required Surgery of integumentary system Full
Clinical Review
11004 DEBRIDE GENITALIA & PERINEUM DBRDMT SKN SUBQ T/M/F
NECRO INFCTJ GENT&PR
Authorization Required Surgery of integumentary system Full
Clinical Review
11005 DEBRIDE ABDOM WALL DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL
WALL
Authorization Required Surgery of integumentary system Full
Clinical Review
-
11006 DEBRIDE GENIT/PER/ABDOM WALL DBRDMT SKN SUBQ T/M/F NECRO
INFCTJ GENT/ABDL
Authorization Required Surgery of integumentary system Full
Clinical Review
11008 REMOVE MESH FROM ABD WALL REMOVAL PROSTHETIC MATRL ABDL
WALL FOR INFECTION
Authorization Required Surgery of integumentary system Full
Clinical Review
11010 DEBRIDE SKIN AT FX SITE DBRDMT W/RMVL FM FX&/DISLC
SKIN&SUBQ TISSUS
Authorization Required Surgery of integumentary system Full
Clinical Review
11011 DEBRIDE SKIN MUSC AT FX SITE DBRDMT W/RMVL FM
FX&/DISLC SKN SUBQ T/M/F MUSC
Authorization Required Surgery of integumentary system Full
Clinical Review
11012 DEB SKIN BONE AT FX SITE DBRDMT FX&/DISLC SUBQ T/M/F
BONE Authorization Required Surgery of integumentary system Full
Clinical Review11042 DEB SUBQ TISSUE 20 SQ CM/< DEBRIDEMENT
SUBCUTANEOUS TISSUE 20
SQ CM/<Authorization Required Surgery of integumentary system
Full Clinical Review
11043 DEB MUSC/FASCIA 20 SQ CM/< DEBRIDEMENT MUSCLE &
FASCIA 20 SQ CM/<
Authorization Required Surgery of integumentary system Full
Clinical Review
11044 DEB BONE 20 SQ CM/< DEBRIDEMENT BONE MUSCLE
&/FASCIA 20 SQ CM/<
Authorization Required Surgery of integumentary system Full
Clinical Review
11045 DEB SUBQ TISSUE ADD-ON DBRDMT SUBCUTANEOUS TISSUE EA ADDL
20 SQ CM
Authorization Required Surgery of integumentary system Full
Clinical Review
11046 DEB MUSC/FASCIA ADD-ON DEBRIDEMENT MUSCLE &/FASCIA EA
ADDL 20 SQ CM
Authorization Required Surgery of integumentary system Full
Clinical Review
11047 DEB BONE ADD-ON DEBRIDEMENT BONE EACH ADDITIONAL 20 SQ
CM
Authorization Required Surgery of integumentary system Full
Clinical Review
11055 TRIM SKIN LESION PARING/CUTTING BENIGN HYPERKERATOTIC
LESION 1
Authorization Required Surgery of integumentary system Full
Clinical Review
11056 TRIM SKIN LESIONS 2 TO 4 PARING/CUTTING BENIGN
HYPERKERATOTIC LESION 2-4
Authorization Required Surgery of integumentary system Full
Clinical Review
11057 TRIM SKIN LESIONS OVER 4 PARING/CUTTING BENIGN
HYPERKERATOTIC LESION >4
Authorization Required Surgery of integumentary system Full
Clinical Review
11102 TANGNTL BX SKIN SINGLE LES TANGENTIAL BIOPSY SKIN SINGLE
LESION No Auth Required11103 TANGNTL BX SKIN EA SEP/ADDL TANGENTIAL
BIOPSY SKIN EA
SEP/ADDITIONAL LESIONNo Auth Required
11104 PUNCH BX SKIN SINGLE LESION PUNCH BIOPSY SKIN SINGLE
LESION No Auth Required11105 PUNCH BX SKIN EA SEP/ADDL PUNCH BIOPSY
SKIN EA SEP/ADDITIONAL
LESIONNo Auth Required
11106 INCAL BX SKN SINGLE LES INCISIONAL BIOPSY SKIN SINGLE
LESION No Auth Required11107 INCAL BX SKN EA SEP/ADDL INCISIONAL
BIOPSY SKIN EA
SEP/ADDITIONAL LESIONNo Auth Required
11200 REMOVAL OF SKIN TAGS 2.0 CM SHVG SKIN LESION 1
TRUNK/ARM/LEG DIAM >2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11305 SHAVE SKIN LESION 0.5 CM/< SHAVING SKIN LESION 1
S/N/H/F/G DIAM 0.5 CM/<
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11306 SHAVE SKIN LESION 0.6-1.0 CM SHAVING SKIN LESION 1
S/N/H/F/G DIAM 0.6-1.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11307 SHAVE SKIN LESION 1.1-2.0 CM SHAVING SKIN LESION 1
S/N/H/F/G DIAM 1.1-2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11308 SHAVE SKIN LESION >2.0 CM SHAVING SKIN LESION 1
S/N/H/F/G DIAM >2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11310 SHAVE SKIN LESION 0.5 CM/< SHAVING SKIN LESION 1
F/E/E/N/L/M DIAM 0.5 CM/<
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11311 SHAVE SKIN LESION 0.6-1.0 CM SHVG SKIN LESION 1
F/E/E/N/L/M DIAM 0.6-1.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11312 SHAVE SKIN LESION 1.1-2.0 CM SHVG SKIN LESION 1
F/E/E/N/L/M DIAM 1.1-2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11313 SHAVE SKIN LESION >2.0 CM SHAVING SKIN LESION 1
F/E/E/N/L/M DIAM >2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11400 EXC TR-EXT B9+MARG 0.5 CM< EXC B9 LESION MRGN XCP SK TG
T/A/L 0.5 CM/<
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11401 EXC TR-EXT B9+MARG 0.6-1 CM EXC B9 LESION MRGN XCP SK TG
T/A/L 0.6-1.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11402 EXC TR-EXT B9+MARG 1.1-2 CM EXC B9 LESION MRGN XCP SK TG
T/A/L 1.1-2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11403 EXC TR-EXT B9+MARG 2.1-3CM EXC B9 LESION MRGN XCP SK TG
T/A/L 2.1-3.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11404 EXC TR-EXT B9+MARG 3.1-4 CM EXC B9 LESION MRGN XCP SK TG
T/A/L 3.1-4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11406 EXC TR-EXT B9+MARG >4.0 CM EXC B9 LESION MRGN XCP SK TG
T/A/L >4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11420 EXC H-F-NK-SP B9+MARG 0.5/< EXC B9 LESION MRGN XCP SK
TG S/N/H/F/G 0.5 CM/<
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11421 EXC H-F-NK-SP B9+MARG 0.6-1 EXC B9 LESION MRGN XCP SK TG
S/N/H/F/G 0.6-1.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11422 EXC H-F-NK-SP B9+MARG 1.1-2 EXC B9 LESION MRGN XCP SK TG
S/N/H/F/G 1.1-2.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11423 EXC H-F-NK-SP B9+MARG 2.1-3 EXC B9 LESION MRGN XCP SK TG
S/N/H/F/G 2.1-3.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11424 EXC H-F-NK-SP B9+MARG 3.1-4 EXC B9 LESION MRGN XCP SK TG
S/N/H/F/G 3.1-4.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11426 EXC H-F-NK-SP B9+MARG >4 CM EXC B9 LESION MRGN XCP SK
TG S/N/H/F/G > 4.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11440 EXC FACE-MM B9+MARG 0.5 CM/< EXC B9 LESION MRGN XCP SK
TG F/E/E/N/L/M 0.5CM/<
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11441 EXC FACE-MM B9+MARG 0.6-1 CM EXC B9 LES MRGN XCP SK TG
F/E/E/N/L/M 0.6-1.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
-
11442 EXC FACE-MM B9+MARG 1.1-2 CM EXC B9 LES MRGN XCP SK TG
F/E/E/N/L/M 1.1-2.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11443 EXC FACE-MM B9+MARG 2.1-3 CM EXC B9 LES MRGN XCP SK TG
F/E/E/N/L/M 2.1-3.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11444 EXC FACE-MM B9+MARG 3.1-4 CM EXC B9 LES MRGN XCP SK TG
F/E/E/N/L/M 3.1-4.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11446 EXC FACE-MM B9+MARG >4 CM EXC B9 LESION MRGN XCP SK TG
F/E/E/N/L/M > 4.0CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11450 REMOVAL SWEAT GLAND LESION EXCISION HIDRADENITIS AXILLARY
SMPL/INTRM RPR
No Auth Required Surgery of integumentary system
11451 REMOVAL SWEAT GLAND LESION EXCISION HIDRADENITIS AXILLARY
COMPLEX REPAIR
No Auth Required Surgery of integumentary system
11462 REMOVAL SWEAT GLAND LESION EXCISION HIDRADENITIS INGUINAL
SMPL/INTRM RPR
No Auth Required Surgery of integumentary system
11463 REMOVAL SWEAT GLAND LESION EXCISION HIDRADENITIS INGUINAL
COMPLEX REPAIR
No Auth Required Surgery of integumentary system
11470 REMOVAL SWEAT GLAND LESION EXCISION H/P/P/U
SIMPLE/INTERMEDIATE REPAIR
No Auth Required Surgery of integumentary system
11471 REMOVAL SWEAT GLAND LESION EXCISION H/P/P/U COMPLEX REPAIR
No Auth Required Surgery of integumentary system11600 EXC TR-EXT
MAL+MARG 0.5 CM/< EXCISION MAL LESION TRUNK/ARM/LEG
0.5 CM/<No Auth Required Removal of Dermal Lesions PA for
Code in Group Applies to
All Codes within Specific Group
11601 EXC TR-EXT MAL+MARG 0.6-1 CM EXCISION MAL LESION
TRUNK/ARM/LEG 0.6-1.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11602 EXC TR-EXT MAL+MARG 1.1-2 CM EXCISION MAL LESION
TRUNK/ARM/LEG 1.1-2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11603 EXC TR-EXT MAL+MARG 2.1-3 CM EXCISION MAL LESION
TRUNK/ARM/LEG 2.1-3.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11604 EXC TR-EXT MAL+MARG 3.1-4 CM EXCISION MAL LESION
TRUNK/ARM/LEG 3.1-4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11606 EXC TR-EXT MAL+MARG >4 CM EXCISION MALIGNANT LESION
TRUNK/ARM/LEG > 4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11620 EXC H-F-NK-SP MAL+MARG 0.5/< EXCISION MALIGNANT LESION
S/N/H/F/G 0.5 CM/<
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11621 EXC S/N/H/F/G MAL+MRG 0.6-1 EXCISION MALIGNANT LESION
S/N/H/F/G 0.6-1.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11622 EXC S/N/H/F/G MAL+MRG 1.1-2 EXCISION MALIGNANT LESION
S/N/H/F/G 1.1-2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11623 EXC S/N/H/F/G MAL+MRG 2.1-3 EXCISION MALIGNANT LESION
S/N/H/F/G 2.1-3.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11624 EXC S/N/H/F/G MAL+MRG 3.1-4 EXCISION MALIGNANT LESION
S/N/H/F/G 3.1-4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11626 EXC S/N/H/F/G MAL+MRG >4 CM EXCISION MALIGNANT LESION
S/N/H/F/G >4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11640 EXC F/E/E/N/L MAL+MRG 0.5CM< EXCISION MALIGNANT LESION
F/E/E/N/L 0.5 CM/<
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11641 EXC F/E/E/N/L MAL+MRG 0.6-1 EXCISION MALIGNANT LESION
F/E/E/N/L 0.6-1.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11642 EXC F/E/E/N/L MAL+MRG 1.1-2 EXCISION MALIGNANT LESION
F/E/E/N/L 1.1-2.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11643 EXC F/E/E/N/L MAL+MRG 2.1-3 EXCISION MALIGNANT LESION
F/E/E/N/L 2.1-3.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11644 EXC F/E/E/N/L MAL+MRG 3.1-4 EXCISION MALIGNANT LESION
F/E/E/N/L 3.1-4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11646 EXC F/E/E/N/L MAL+MRG >4 CM EXCISION MALIGNANT LESION
F/E/E/N/L >4.0 CM
No Auth Required Removal of Dermal Lesions PA for Code in Group
Applies to All Codes within Specific Group
11719 TRIM NAIL(S) ANY NUMBER TRIMMING NONDYSTROPHIC NAILS ANY
NUMBER
No Auth Required Surgery of integumentary system
11720 DEBRIDE NAIL 1-5 DEBRIDEMENT NAIL ANY METHOD 1-5 No Auth
Required Surgery of integumentary system11721 DEBRIDE NAIL 6 OR
MORE DEBRIDEMENT NAIL ANY METHOD 6/> No Auth Required Surgery of
integumentary system11730 REMOVAL OF NAIL PLATE AVULSION NAIL PLATE
PARTIAL/COMPLETE
SIMPLE 1No Auth Required Surgery of integumentary system
11732 REMOVE NAIL PLATE ADD-ON AVULSION NAIL PLATE PARTIAL/COMP
SIMPLE EA ADDL
No Auth Required Surgery of integumentary system
11740 DRAIN BLOOD FROM UNDER NAIL EVACUATION SUBUNGUAL HEMATOMA
No Auth Required11750 REMOVAL OF NAIL BED EXCISION NAIL MATRIX
PERMANENT
REMOVALNo Auth Required
11755 BIOPSY NAIL UNIT BIOPSY NAIL UNIT SEPARATE PROCEDURE No
Auth Required Surgery of integumentary system11760 REPAIR OF NAIL
BED REPAIR NAIL BED No Auth Required11762 RECONSTRUCTION OF NAIL
BED RECONSTRUCTION NAIL BED W/GRAFT No Auth Required Surgery of
integumentary system11765 EXCISION OF NAIL FOLD TOE WEDGE EXCISION
SKIN NAIL FOLD No Auth Required Surgery of integumentary
system11770 REMOVE PILONIDAL CYST SIMPLE EXCISION PILONIDAL
CYST/SINUS SIMPLE No Auth Required11771 REMOVE PILONIDAL CYST EXTEN
EXCISION PILONIDAL CYST/SINUS
EXTENSIVENo Auth Required Surgery of integumentary system
11772 REMOVE PILONIDAL CYST COMPL EXCISION PILONIDAL CYST/SINUS
COMPLICATED
No Auth Required Surgery of integumentary system
11900 INJECT SKIN LESIONS 7 INJECTION INTRALESIONAL >7
LESIONS No Auth Required Surgery of integumentary system11920
CORRECT SKIN COLOR 6.0 CM/< TATTOOING INCL MICROPIGMENTATION
6.0 CM/<No Auth Required Surgery of integumentary system
11921 CORRECT SKN COLOR 6.1-20.0CM TATTOOING INCL
MICROPIGMENTATION 6.1-20.0 CM
No Auth Required Surgery of integumentary system
11922 CORRECT SKIN COLOR EA 20.0CM TATTOOING INCL
MICROPIGMENTATION EA 20.0 CM
No Auth Required Surgery of integumentary system
11950 TX CONTOUR DEFECTS 1 CC/< SUBCUTANEOUS INJECTION
FILLING MATERIAL 1 CC/<
No Auth Required Surgery of integumentary system
11951 TX CONTOUR DEFECTS 1.1-5.0CC SUBCUTANEOUS INJECTION
FILLING MATRL 1.1-5.0 CC
No Auth Required Surgery of integumentary system
11952 TX CONTOUR DEFECTS 5.1-10CC SUBCUTANEOUS INJECTION FILLING
MATRL 5.1-10.0CC
No Auth Required Surgery of integumentary system
11954 TX CONTOUR DEFECTS >10.0 CC SUBCUTANEOUS INJECTION
FILLING MATRL >10.0 CC
No Auth Required Surgery of integumentary system
11960 INSERT TISSUE EXPANDER(S) INSERTION TISSUE EXPANDER INCL
SBSQ XPNSJ
No Auth Required Surgery of integumentary system
11970 REPLACE TISSUE EXPANDER REPLACEMENT TISS EXPANDER
PERMANENT PROSTHESIS
Authorization Required Surgery of integumentary system Full
Clinical Review
-
11971 REMOVE TISSUE EXPANDER(S) REMOVAL TISS EXPANDER W/O
INSERTION PROSTHESIS
Authorization Required Surgery of integumentary system Full
Clinical Review
11976 REMOVE CONTRACEPTIVE CAPSULE REMOVAL IMPLANTABLE
CONTRACEPTIVE CAPSULES
No Auth Required
11980 IMPLANT HORMONE PELLET(S) SUBCUTANEOUS HORMONE PELLET
IMPLANTATION
No Auth Required Surgery of integumentary system
11981 INSERT DRUG IMPLANT DEVICE INSJ NON-BIODEGRADABLE DRUG
DELIVERY IMPLANT
No Auth Required Surgery of integumentary system
11982 REMOVE DRUG IMPLANT DEVICE REMOVAL NON-BIODEGRADABLE DRUG
DELIVERY IMPLANT
No Auth Required Surgery of integumentary system
11983 REMOVE/INSERT DRUG IMPLANT RMVL W/RINSJ NON-BIODEGRADABLE
DRUG DLVR IMPLT
No Auth Required
12001 RPR S/N/AX/GEN/TRNK 2.5CM/< SIMPLE REPAIR
SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<
No Auth Required
12002 RPR S/N/AX/GEN/TRNK2.6-7.5CM SMPL REPAIR
SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM
No Auth Required
12004 RPR S/N/AX/GEN/TRK7.6-12.5CM SIMPLE RPR
SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12005 RPR S/N/A/GEN/TRK12.6-20.0CM SMPL RPR
SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12006 RPR S/N/A/GEN/TRK20.1-30.0CM SMPL RPR
SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12007 RPR S/N/AX/GEN/TRNK >30.0 CM SIMPLE REPAIR
SCALP/NECK/AX/GENIT/TRUNK >30.0CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12011 RPR F/E/E/N/L/M 2.5 CM/< SIMPLE REPAIR F/E/E/N/L/M
2.5CM/< No Auth Required12013 RPR F/E/E/N/L/M 2.6-5.0 CM SIMPLE
REPAIR F/E/E/N/L/M 2.6CM-5.0 CM No Auth Required
12014 RPR F/E/E/N/L/M 5.1-7.5 CM SIMPLE REPAIR F/E/E/N/L/M
5.1CM-7.5 CM No Auth Required Wound Repair PA for Code in Group
Applies to All Codes within Specific Group
12015 RPR F/E/E/N/L/M 7.6-12.5 CM SIMPLE REPAIR F/E/E/N/L/M
7.6CM-12.5 CM
No Auth Required
12016 RPR FE/E/EN/L/M 12.6-20.0 CM SIMPLE REPAIR F/E/E/N/L/M
12.6CM-20.0 CM
No Auth Required
12017 RPR FE/E/EN/L/M 20.1-30.0 CM SIMPLE REPAIR F/E/E/N/L/M
20.1CM-30.0 CM
No Auth Required
12018 RPR F/E/E/N/L/M >30.0 CM SIMPLE REPAIR F/E/E/N/L/M
>30.0 CM No Auth Required12020 CLOSURE OF SPLIT WOUND TX
SUPERFICIAL WOUND DEHISCENCE
SIMPLE CLOSURENo Auth Required Surgery of integumentary
system
12021 CLOSURE OF SPLIT WOUND TX SUPERFICIAL WOUND DEHISCENCE
W/PACKING
No Auth Required Surgery of integumentary system
12031 INTMD RPR S/A/T/EXT 2.5 CM/< REPAIR INTERMEDIATE
S/A/T/E 2.5 CM/< No Auth Required Wound Repair PA for Code in
Group Applies to All Codes within Specific Group
12032 INTMD RPR S/A/T/EXT 2.6-7.5 REPAIR INTERMEDIATE S/A/T/E
2.6-7.5 CM No Auth Required Wound Repair PA for Code in Group
Applies to All Codes within Specific Group
12034 INTMD RPR S/TR/EXT 7.6-12.5 REPAIR INTERMEDIATE S/A/T/E
7.6-12.5 CM No Auth Required Wound Repair PA for Code in Group
Applies to All Codes within Specific Group
12035 INTMD RPR S/A/T/EXT 12.6-20 REPAIR INTERMEDIATE S/A/T/E
12.6-20.0CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12036 INTMD RPR S/A/T/EXT 20.1-30 REPAIR INTERMEDIATE S/A/T/E
20.1-30.0 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12037 INTMD RPR S/TR/EXT >30.0 CM REPAIR INTERMEDIATE S/A/T/E
>30.0 CM No Auth Required Wound Repair PA for Code in Group
Applies to All Codes within Specific Group
12041 INTMD RPR N-HF/GENIT 2.5CM/< REPAIR INTERMEDIATE
N/H/F/XTRNL GENT 2.5CM/<
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12042 INTMD RPR N-HF/GENIT2.6-7.5 REPAIR INTERMEDIATE
N/H/F/XTRNL GENT 2.6-7.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12044 INTMD RPR N-HF/GENIT7.6-12.5 REPAIR INTERMEDIATE
N/H/F/XTRNL GENT 7.6-12.5CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12045 INTMD RPR N-HF/GENIT12.6-20 REPAIR INTERMEDIATE
N/H/F/XTRNL GENT 12.6-20 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12046 INTMD RPR N-HF/GENIT20.1-30 RPR INTERMEDIATE N/H/F/XTRNL
GENT 20.1-30.0 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12047 INTMD RPR N-HF/GENIT >30.0CM REPAIR INTERMEDIATE
N/H/F/XTRNL GENT >30.0 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12051 INTMD RPR FACE/MM 2.5 CM/< REPAIR INTERMEDIATE
F/E/E/N/L&/MUC 2.5 CM/<
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12052 INTMD RPR FACE/MM 2.6-5.0 CM REPAIR INTERMEDIATE
F/E/E/N/L&/MUC 2.6-5.0 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12053 INTMD RPR FACE/MM 5.1-7.5 CM REPAIR INTERMEDIATE
F/E/E/N/L&/MUC 5.1-7.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12054 INTMD RPR FACE/MM 7.6-12.5CM REPAIR INTERMEDIATE
F/E/E/N/L&/MUC 7.6-12.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12055 INTMD RPR FACE/MM 12.6-20 CM REPAIR INTERMEDIATE
F/E/E/N/L&/MUC 12.6-20.0CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12056 INTMD RPR FACE/MM 20.1-30.0 REPAIR INTERMEDIATE
F/E/E/N/L&/MUC 20.1-30.0CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
12057 INTMD RPR FACE/MM >30.0 CM REPAIR INTERMEDIATE
F/E/E/N/L&/MUC >30.0 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13100 CMPLX RPR TRUNK 1.1-2.5 CM REPAIR COMPLEX TRUNK 1.1-2.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to All
Codes within Specific Group
13101 CMPLX RPR TRUNK 2.6-7.5 CM REPAIR COMPLEX TRUNK 2.6-7.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to All
Codes within Specific Group
13102 CMPLX RPR TRUNK ADDL 5CM/< REPAIR COMPLEX TRUNK EACH
ADDITIONAL 5 CM/<
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13120 CMPLX RPR S/A/L 1.1-2.5 CM REPAIR COMPLEX SCALP/ARM/LEG
1.1-2.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13121 CMPLX RPR S/A/L 2.6-7.5 CM REPAIR COMPLEX SCALP/ARM/LEG
2.6-7.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
-
13122 CMPLX RPR S/A/L ADDL 5 CM/> REPAIR COMPLEX
SCALP/ARM/LEG EA ADDL 5 CM/<
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13131 CMPLX RPR F/C/C/M/N/AX/G/H/F REPAIR COMPLEX
F/C/C/M/N/AX/G/H/F 1.1-2.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13132 CMPLX RPR F/C/C/M/N/AX/G/H/F REPAIR COMPLEX
F/C/C/M/N/AX/G/H/F 2.6-7.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13133 CMPLX RPR F/C/C/M/N/AX/G/H/F REPAIR COMPLEX
F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13151 CMPLX RPR E/N/E/L 1.1-2.5 CM REPAIR COMPLEX
EYELID/NOSE/EAR/LIP 1.1-2.5 CM
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13152 CMPLX RPR E/N/E/L 2.6-7.5 CM REPAIR COMPLEX
EYELID/NOSE/EAR/LIP 2.6-7.5 CM
Authorization Required Wound Repair PA for Code in Group Applies
to All Codes within Specific Group
Network Validation
13153 CMPLX RPR E/N/E/L ADDL 5CM/< REPAIR COMPLX
EYELID/NOSE/EAR/LIP EA ADDL 5 CM/<
No Auth Required Wound Repair PA for Code in Group Applies to
All Codes within Specific Group
13160 LATE CLOSURE OF WOUND SECONDARY CLOSURE SURG WOUND/DEHSN
EXTSV/COMPLIC
No Auth Required Surgery of integumentary system
14000 TIS TRNFR TRUNK 10 SQ CM/< ADJACENT TISSUE
TRANSFER/REARGMT TRUNK 10 SQCM/<
Authorization Required Surgery of integumentary system Network
Validation
14001 TIS TRNFR TRUNK 10.1-30SQCM ADJNT TIS TRANSFR/REARRANGE
TRUNK 10.1-30.0 SQCM
No Auth Required Surgery of integumentary system
14020 TIS TRNFR S/A/L 10 SQ CM/< ADJT TIS TRNSFR/REARGMT
SCALP/ARM/LEG 10 SQ CM/<
No Auth Required Surgery of integumentary system
14021 TIS TRNFR S/A/L 10.1-30 SQCM ADJT/REARRGMT SCALP/ARM/LEG
10.1-30.0 SQ CM
No Auth Required Surgery of integumentary system
14040 TIS TRNFR F/C/C/M/N/A/G/H/F ADJT TIS TRNS/REARGMT
F/C/C/M/N/A/G/H/F 10SQCM/<
Authorization Required Surgery of integumentary system Network
Validation
14041 TIS TRNFR F/C/C/M/N/A/G/H/F ADJT/REARGMT
F/C/C/M/N/AX/G/H/F 10.1-30.0 SQ CM
Authorization Required Surgery of integumentary system Network
Validation
14060 TIS TRNFR E/N/E/L 10 SQ CM/< ADJT TIS TRNSFR/REARRGMT
E/N/E/L DFCT 10 SQ CM/<
No Auth Required Surgery of integumentary system
14061 TIS TRNFR E/N/E/L10.1-30SQCM ADJT TIS REARGMT
EYE/NOSE/EAR/LIP 10.1-30.0 SQCM
No Auth Required Surgery of integumentary system
14301 TIS TRNFR ANY 30.1-60 SQ CM ADJNT TIS TRNSFR/REARGMT ANY
AREA 30.1-60 SQ CM
Authorization Required Surgery of integumentary system Network
Validation
14302 TIS TRNFR ADDL 30 SQ CM ADJT TIS TRNSFR/REARGMT DEFEC EA
ADDL 30 SQCM
No Auth Required Surgery of integumentary system
14350 FILLETED FINGER/TOE FLAP FILLETED FINGER/TOE FLAP W/PREPJ
RECIPIENT SITE
No Auth Required Surgery of integumentary system
15002 WOUND PREP TRK/ARM/LEG PREP SITE TRUNK/ARM/LEG 1ST 100 SQ
CM/1PCT
No Auth Required Surgery of integumentary system
15003 WOUND PREP ADDL 100 CM PREP SITE TRUNK/ARM/LEG ADDL 100 SQ
CM/1PCT
No Auth Required Surgery of integumentary system
15004 WOUND PREP F/N/HF/G PREP SITE F/S/N/H/F/G/M/D GT 1ST 100
SQ CM/1PCT
No Auth Required Surgery of integumentary system
15005 WND PREP F/N/HF/G ADDL CM PREP SITE F/S/N/H/F/G/M/D GT
ADDL 100 SQ CM/1PCT
No Auth Required Surgery of integumentary system
15040 HARVEST CULTURED SKIN GRAFT HARVEST SKIN TISSUE CLTR SKIN
AGRFT 100 CM/<
No Auth Required Surgery of integumentary system
15050 SKIN PINCH GRAFT PINCH GRAFT 1/MLT SM ULCER TIP/OTH AREA
2CM
No Auth Required Surgery of integumentary system
15100 SKIN SPLT GRFT TRNK/ARM/LEG SPLIT AGRFT T/A/L 1ST 100
CM/&/1% BDY INFT/CHLD
No Auth Required Surgery of integumentary system
15101 SKIN SPLT GRFT T/A/L ADD-ON SPLIT AGRFT T/A/L EA 100 CM/EA
1% BDY INFT/CHLD
No Auth Required Surgery of integumentary system
15110 EPIDRM AUTOGRFT TRNK/ARM/LEG EPIDRM AGRFT T/A/L 1ST 100
CM/&/1% BDY INFT/CHLD
No Auth Required Surgery of integumentary system
15111 EPIDRM AUTOGRFT T/A/L ADD-ON EPIDRM AGRFT T/A/L EA 100
CM/EA 1% BDY INFT/CHLD
No Auth Required Surgery of integumentary system
15115 EPIDRM A-GRFT FACE/NCK/HF/G EPIDERMAL AGRFT
F/S/N/H/F/G/M/D GT 1ST 100 CM/<
No Auth Required Surgery of integumentary system
15116 EPIDRM A-GRFT F/N/HF/G ADDL EPIDERMAL AGRFT
F/S/N/H/F/G/M/D GT EA 100 CM
No Auth Required Surgery of integumentary system
15120 SKN SPLT A-GRFT FAC/NCK/HF/G SPLIT AGRFT F/S/N/H/F/G/M/D
GT 1ST 100 CM/
-
15276 SKIN SUB GRAFT F/N/HF/G ADDL SUB GRFT F/S/N/H/F/G/M/D/=
100SCM 1ST 100SQ CM
No Auth Required Surgery of integumentary system
15278 SKN SUB GRFT F/N/HF/G CH ADD SUB GRFT F/S/N/H/F/G/M/D
>/= 100SCM ADL 100SQ CM
No Auth Required Surgery of integumentary system
15570 SKIN PEDICLE FLAP TRUNK FRMJ DIRECT/TUBED PEDICLE W/WO
TRANSFER TRUNK
No Auth Required Surgery of integumentary system
15572 SKIN PEDICLE FLAP ARMS/LEGS FRMJ DIRECT/TUBE PEDICLE W/WO
TR SCALP ARMS/LEGS
No Auth Required Surgery of integumentary system
15574 PEDCLE FH/CH/CH/M/N/AX/G/H/F FRMJ DIR/TUBE PEDCL W/WOTR
FH/CH/CH/M/N/AX/G/H/F
No Auth Required Surgery of integumentary system
15576 PEDICLE E/N/E/L/NTRORAL FRMJ DIRECT/TUBED PEDICLE W/WOTR
E/N/E/L/NTRORAL
No Auth Required Surgery of integumentary system
15600 DELAY FLAP TRUNK DELAY FLAP/SECTIONING FLAP TRUNK No Auth
Required Surgery of integumentary system15610 DELAY FLAP ARMS/LEGS
DELAY FLAP/SECTIONING FLAP SCALP
ARMS/LEGSNo Auth Required Surgery of integumentary system
15620 DELAY FLAP F/C/C/N/AX/G/H/F DELAY FLAP/SECTIONING FLAP
F/C/C/N/AX/G/H/F
No Auth Required Surgery of integumentary system
15630 DELAY FLAP EYE/NOS/EAR/LIP DELAY FLAP/SCTJ FLAP EYELIDS
NOSE EARS/LIPS
No Auth Required Surgery of integumentary system
15650 TRANSFER SKIN PEDICLE FLAP TRANSFER ANY PEDICLE FLAP ANY
LOCATION
No Auth Required Surgery of integumentary system
15730 MDFC FLAP W/PRSRV VASC PEDCL MIDFACE FLAP W/PRESERVATION
OF VASCULAR PEDICLES
No Auth Required Surgery of integumentary system
15731 FOREHEAD FLAP W/VASC PEDICLE FOREHEAD FLAP W/PRESERVATION
VASCULAR PEDICLE
No Auth Required Surgery of integumentary system
15733 MUSC MYOQ/FSCQ FLP H&N PEDCL MUSC MYOQ/FSCQ FLAP
HEAD&NECK W/NAMED VASC PEDCL
No Auth Required Surgery of integumentary system
15734 MUSCLE-SKIN GRAFT TRUNK MUSC MYOCUTANEOUS/FASCIOCUTANEOUS
FLAP TRUNK
Authorization Required Surgery of integumentary system Network
Validation
15736 MUSCLE-SKIN GRAFT ARM MUSC MYOCUTANEOUS/FASCIOCUTANEOUS
FLAP UXTR
No Auth Required Surgery of integumentary system
15738 MUSCLE-SKIN GRAFT LEG MUSC MYOCUTANEOUS/FASCIOCUTANEOUS
FLAP LXTR
No Auth Required Surgery of integumentary system
15740 ISLAND PEDICLE FLAP GRAFT FLAP ISLAND PEDICLE ANATOMIC
NAMED AXIAL ARTERY
No Auth Required Surgery of integumentary system
15750 NEUROVASCULAR PEDICLE FLAP FLAP NEUROVASCULAR PEDICLE No
Auth Required Surgery of integumentary system15756 FREE MYO/SKIN
FLAP MICROVASC FREE MUSCLE/MYOCUTANEOUS FLAP
W/MVASC ANASTNo Auth Required Surgery of integumentary
system
15757 FREE SKIN FLAP MICROVASC FREE SKIN FLAP W/MICROVASCULAR
ANASTOMOSIS
No Auth Required Surgery of integumentary system
15758 FREE FASCIAL FLAP MICROVASC FREE FASCIAL FLAP
W/MICROVASCULAR ANASTOMOSIS
No Auth Required Surgery of integumentary system
15760 COMPOSITE SKIN GRAFT GRAFT COMPOSITE W/PRIMARY CLOSURE
DONOR AREA
No Auth Required Surgery of integumentary system
15769 GRFG AUTOL SOFT TISS DIR EXC GRAFTING OF AUTOLOGOUS SOFT
TISS BY DIRECT EXC
No Auth Required
15770 DERMA-FAT-FASCIA GRAFT GRAFT DERMA-FAT-FASCIA No Auth
Required Surgery of integumentary system15771 GRFG AUTOL FAT LIPO
50 CC/< GRAFTING OF AUTOLOGOUS FAT BY LIPO
50 CC OR LESSNo Auth Required
15772 GRFG AUTOL FAT LIPO EA ADDL GRAFTING OF AUTOLOGOUS FAT BY
LIPO EA ADDL 50 CC
No Auth Required
15773 GRFG AUTOL FAT LIPO 25 CC/< GRAFTING OF AUTOLOGOUS FAT
BY LIPO 25 CC OR LESS
No Auth Required
15774 GFRG AUTOL FAT LIPO EA ADDL GRAFTING OF AUTOLOGOUS FAT BY
LIPO EA ADDL 25 CC
No Auth Required
15775 HAIR TRNSPL 1-15 PUNCH GRFTS PUNCH GRAFT HAIR TRANSPLANT
1-15 PUNCH GRAFTS
Authorization Required Surgery of integumentary system Full
Clinical Review
15776 HAIR TRNSPL >15 PUNCH GRAFTS PUNCH GRAFT HAIR
TRANSPLANT >15 PUNCH GRAFTS
Authorization Required Surgery of integumentary system Full
Clinical Review
15777 ACELLULAR DERM MATRIX IMPLT IMPLNT BIO IMPLNT FOR SOFT
TISSUE REINFORCEMENT
No Auth Required Surgery of integumentary system
15780 DERMABRASION TOTAL FACE DERMABRASION TOTAL FACE
Authorization Required Surgery of integumentary system Full
Clinical Review15781 DERMABRASION SEGMENTAL FACE DERMABRASION
SEGMENTAL FACE Authorization Required Surgery of integumentary
system Full Clinical Review15782 DERMABRASION OTHER THAN FACE
DERMABRASION REGIONAL OTHER THAN
FACEAuthorization Required Surgery of integumentary system Full
Clinical Review
15783 DERMABRASION SUPRFL ANY SITE DERMABRASION SUPERFICIAL ANY
SITE Authorization Required Surgery of integumentary system Full
Clinical Review15786 ABRASION LESION SINGLE ABRASION 1 LESION
Authorization Required Surgery of integumentary system Full
Clinical Review15787 ABRASION LESIONS ADD-ON ABRASION EACH
ADDITIONAL 4 LESIONS OR
LESSAuthorization Required Surgery of integumentary system Full
Clinical Review
15788 CHEMICAL PEEL FACE EPIDERM CHEMICAL PEEL FACIAL EPIDERMAL
Authorization Required Surgery of integumentary system Full
Clinical Review15789 CHEMICAL PEEL FACE DERMAL CHEMICAL PEEL FACIAL
DERMAL Authorization Required Surgery of integumentary system Full
Clinical Review15792 CHEMICAL PEEL NONFACIAL CHEMICAL PEEL
NONFACIAL EPIDERMAL Authorization Required Surgery of integumentary
system Full Clinical Review15793 CHEMICAL PEEL NONFACIAL CHEMICAL
PEEL NONFACIAL DERMAL Authorization Required Surgery of
integumentary system Full Clinical Review15819 PLASTIC SURGERY NECK
CERVICOPLASTY No Auth Required Surgery of integumentary system15820
REVISION OF LOWER EYELID BLEPHAROPLASTY LOWER EYELID Authorization
Required Surgery of integumentary system Full Clinical Review15821
REVISION OF LOWER EYELID BLEPHAROPLASTY LOWER EYELID
HERNIATED FAT PADAuthorization Required Surgery of integumentary
system Full Clinical Review
15822 REVISION OF UPPER EYELID BLEPHAROPLASTY UPPER EYELID
Authorization Required Surgery of integumentary system Full
Clinical Review15823 REVISION OF UPPER EYELID BLEPHAROPLASTY UPPER
EYELID
W/EXCESSIVE SKINAuthorization Required Surgery of integumentary
system Full Clinical Review
15824 REMOVAL OF FOREHEAD WRINKLES RHYTIDECTOMY FOREHEAD
Authorization Required Surgery of integumentary system Full
Clinical Review15825 REMOVAL OF NECK WRINKLES RHYTIDECTOMY NECK
W/PLATYSMAL
TIGHTENINGAuthorization Required Surgery of integumentary system
Full Clinical Review
15826 REMOVAL OF BROW WRINKLES RHYTIDECTOMY GLABELLAR FROWN
LINES Authorization Required Surgery of integumentary system Full
Clinical Review
15828 REMOVAL OF FACE WRINKLES RHYTIDECTOMY CHEEK CHIN &
NECK Authorization Required Surgery of integumentary system Full
Clinical Review15829 REMOVAL OF SKIN WRINKLES RHYTIDECTOMY SMAS
FLAP Authorization Required Surgery of integumentary system Full
Clinical Review15830 EXC SKIN ABD EXCISION SKIN ABD
INFRAUMBILICAL
PANNICULECTOMYAuthorization Required Surgery of integumentary
system Full Clinical Review
15832 EXCISE EXCESSIVE SKIN THIGH EXCISION EXCESSIVE SKIN &
SUBQ TISSUE THIGH
Authorization Required Surgery of integumentary system Full
Clinical Review
15833 EXCISE EXCESSIVE SKIN LEG EXCISION EXCESSIVE SKIN &
SUBQ TISSUE LEG
Authorization Required Surgery of integumentary system Full
Clinical Review
15834 EXCISE EXCESSIVE SKIN HIP EXCISION EXCESSIVE SKIN &
SUBQ TISSUE HIP
Authorization Required Surgery of integumentary system Full
Clinical Review
15835 EXCISE EXCESSIVE SKIN BUTTCK EXCISION EXCESSIVE SKIN &
SUBQ TISSUE BUTTOCK
Authorization Required Surgery of integumentary system Full
Clinical Review
15836 EXCISE EXCESSIVE SKIN ARM EXCISION EXCESSIVE SKIN &
SUBQ TISSUE ARM
Authorization Required Surgery of integumentary system Full
Clinical Review
15837 EXCISE EXCESS SKIN ARM/HAND EXC EXCESSIVE SKIN &SUBQ
TISSUE FOREARM/HAND
Authorization Required Surgery of integumentary system Full
Clinical Review
15838 EXCISE EXCESS SKIN FAT PAD EXC EXCSV SKIN & SUBQ
TISSUE SUBMENTAL FAT PAD
Authorization Required Surgery of integumentary system Full
Clinical Review
15839 EXCISE EXCESS SKIN & TISSUE EXCISION EXCESSIVE SKIN
& SUBQ TISSUE OTHER AREA
Authorization Required Surgery of integumentary system Full
Clinical Review
15840 NERVE PALSY FASCIAL GRAFT GRAFT FACIAL NERVE PARALYSIS
FREE FASCIAL GRAFT
No Auth Required Surgery of integumentary system
15841 NERVE PALSY MUSCLE GRAFT GRAFT FACIAL NERVE PARALYSIS FREE
MUSCLE GRAFT
No Auth Required Surgery of integumentary system
15842 NERVE PALSY MICROSURG GRAFT GRF FACIAL NRV PALYSS FR
MUSCLE FLAP MICROSURG
No Auth Required Surgery of integumentary system
15845 SKIN AND MUSCLE REPAIR FACE GRF FACIAL NERVE PARALYSIS
REGIONAL MUSCLE TR
No Auth Required Surgery of integumentary system
-
15847 EXC SKIN ABD ADD-ON EXCISION EXCESSIVE SKIN & SUBQ
TISSUE ABDOMEN
Authorization Required Surgery of integumentary system Full
Clinical Review
15850 REMOVE SUTURES SAME SURGEON REMOVAL SUTURES UNDER
ANESTHESIA SAME SURGEON
No Auth Required
15851 REMOVE SUTURES DIFF SURGEON REMOVAL SUTURES UNDER
ANESTHESIA OTHER SURGEON
No Auth Required
15852 DRESSING CHANGE NOT FOR BURN DRESSING CHANGE UNDER
ANESTHESIA No Auth Required15860 TEST FOR BLOOD FLOW IN GRAFT IV
INJECTION TEST VASCULAR FLOW
FLAP/GRAFTNo Auth Required Surgery of integumentary system
15876 SUCTION LIPECTOMY HEAD&NECK SUCTION ASSISTED LIPECTOMY
HEAD & NECK
Authorization Required Surgery of integumentary system Full
Clinical Review
15877 SUCTION LIPECTOMY TRUNK SUCTION ASSISTED LIPECTOMY TRUNK
Authorization Required Surgery of integumentary system Full
Clinical Review15878 SUCTION LIPECTOMY UPR EXTREM SUCTION ASSISTED
LIPECTOMY UPPER
EXTREMITYAuthorization Required Surgery of integumentary system
Full Clinical Review
15879 SUCTION LIPECTOMY LWR EXTREM SUCTION ASSISTED LIPECTOMY
LOWER EXTREMITY
Authorization Required Surgery of integumentary system Full
Clinical Review
15920 REMOVAL OF TAIL BONE ULCER EXC COCCYGEAL PR ULC
W/COCCYGECTOMY W/PRIM SUTR
No Auth Required Surgery of integumentary system
15922 REMOVAL OF TAIL BONE ULCER EXC COCCYGEAL PR ULC
W/COCCYGECTOMY W/FLAP CLSR
No Auth Required Surgery of integumentary system
15931 REMOVE SACRUM PRESSURE SORE EXCISION SACRAL PRESSURE ULCER
W/PRIMARY SUTURE
No Auth Required Surgery of integumentary system
15933 REMOVE SACRUM PRESSURE SORE EXC SACRAL PRESSURE ULC W/PRIM
SUTR W/OSTECTOMY
No Auth Required Surgery of integumentary system
15934 REMOVE SACRUM PRESSURE SORE EXCISION SACRAL PRESSURE ULCER
W/SKIN FLAP CLSR
No Auth Required Surgery of integumentary system
15935 REMOVE SACRUM PRESSURE SORE EXC SACRAL PR ULCER W/SKN FLAP
CLSR W/OSTECTOMY
No Auth Required Surgery of integumentary system
15936 REMOVE SACRUM PRESSURE SORE EXC SAC PR ULC PREPJ MUSC/MYOQ
FLAP/SKN GRF CLSR
No Auth Required Surgery of integumentary system
15937 REMOVE SACRUM PRESSURE SORE EXC SAC PR ULC PREPJ MUSC/MYOQ
FLAP/SKN GRF OSTC
No Auth Required Surgery of integumentary system
15940 REMOVE HIP PRESSURE SORE EXC ISCHIAL PRESSURE ULCER
W/PRIMARY SUTURE
No Auth Required Surgery of integumentary system
15941 REMOVE HIP PRESSURE SORE EXC ISCHIAL PR ULC W/PRIM SUTR
W/OSTC ISCHIECT
No Auth Required Surgery of integumentary system
15944 REMOVE HIP PRESSURE SORE EXC ISCHIAL PRESSURE ULCER W/SKIN
FLAP CLOSURE
No Auth Required Surgery of integumentary system
15945 REMOVE HIP PRESSURE SORE EXC ISCHIAL PR ULC W/SKN FLAP
CLSR W/OSTECTOMY
No Auth Required Surgery of integumentary system
15946 REMOVE HIP PRESSURE SORE EXC ISCHIAL PR ULCER W/OSTC
MUSC/MYOQ FLAP/SKIN
No Auth Required Surgery of integumentary system
15950 REMOVE THIGH PRESSURE SORE EXC TROCHANTERIC PRESSURE ULCER
W/PRIMARY SUTR
No Auth Required Surgery of integumentary system
15951 REMOVE THIGH PRESSURE SORE EXC TRCHNTRIC PR ULCER W/PRIM
SUTR W/OSTECTOMY
No Auth Required Surgery of integumentary system
15952 REMOVE THIGH PRESSURE SORE EXC TROCHANTERIC PR ULCER
W/SKIN FLAP CLOSURE
No Auth Required Surgery of integumentary system
15953 REMOVE THIGH PRESSURE SORE EXC TRCHNTRIC PR ULC W/SKN FLAP
CLSR W/OSTECTOMY
No Auth Required Surgery of integumentary system
15956 REMOVE THIGH PRESSURE SORE EXC TROCHANTERIC PR ULCER
MUSC/MYOQ FLAP/SKIN
No Auth Required Surgery of integumentary system
15958 REMOVE THIGH PRESSURE SORE EXC TRCHNTRIC PR ULC MUSC/MYOQ
FLAP/SKIN W/OSTC
No Auth Required Surgery of integumentary system
15999 REMOVAL OF PRESSURE SORE UNLISTED PROCEDURE EXCISION
PRESSURE ULCER
Authorization Required Surgery of integumentary system Full
Clinical Review
16000 INITIAL TREATMENT OF BURN(S) INITIAL TX 1ST DEGREE BURN
LOCAL TX No Auth Required Surgery of integumentary system16020
DRESS/DEBRID P-THICK BURN S DRS&/DBRDMT PRTL-THKNS BURNS
1ST/SBSQ SMALLNo Auth Required Surgery of integumentary
system
16025 DRESS/DEBRID P-THICK BURN M DRS&/DBRDMT PRTL-THKNS
BURNS 1ST/SBSQ MEDIUM
No Auth Required Surgery of integumentary system
16030 DRESS/DEBRID P-THICK BURN L DRS&/DBRDMT PRTL-THKNS
BURNS 1ST/SBSQ LARGE
No Auth Required Surgery of integumentary system
16035 INCISION OF BURN SCAB INITI ESCHAROTOMY FIRST INCISION No
Auth Required Surgery of integumentary system16036 ESCHAROTOMY ADDL
INCISION ESCHAROTOMY EACH ADDITIONAL
INCISIONNo Auth Required Surgery of integumentary system
17000 DESTRUCT PREMALG LESION DESTRUCTION PREMALIGNANT LESION
1ST No Auth Required
17003 DESTRUCT PREMALG LES 2-14 DESTRUCTION PREMALIGNANT LESION
2-14 EA
No Auth Required
17004 DESTROY PREMAL LESIONS 15/> DESTRUCTION PREMALIGNANT
LESION 15/>
No Auth Required
17106 DESTRUCTION OF SKIN LESIONS DESTRUCTION CUTANEOUS VASC
PROLIFERATIVE 50.0 SQ CM
Authorization Required Surgery of integumentary system Full
Clinical Review
17110 DESTRUCT B9 LESION 1-14 DESTRUCTION BENIGN LESIONS UP TO
14 No Auth Required17111 DESTRUCT LESION 15 OR MORE DESTRUCTION
BENIGN LESIONS 15/> No Auth Required17250 CHEM CAUT OF GRANLTJ
TISSUE CHEMICAL CAUTERIZATION OF
GRANULATION TISSUENo Auth Required Surgery of integumentary
system
17260 DESTRUCTION OF SKIN LESIONS DESTRUCTION MALIGNANT LESION
T/A/L 0.5 CM/<
No Auth Required Surgery of integumentary system
17261 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
TRUNK/ARM/LEG 0.6-1.0 CM
No Auth Required Surgery of integumentary system
17262 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
TRUNK/ARM/LEG 1.1-2.0CM
No Auth Required Surgery of integumentary system
17263 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
TRUNK/ARM/LEG 2.1-3.0CM
No Auth Required Surgery of integumentary system
17264 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
TRUNK/ARM/LEG 3.1-4.0CM
No Auth Required Surgery of integumentary system
17266 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
TRUNK/ARM/LEG > 4.0 CM
No Auth Required Surgery of integumentary system
17270 DESTRUCTION OF SKIN LESIONS DESTRUCTION MALIGNANT LESION
S/N/H/F/G 0.5 CM/>
No Auth Required Surgery of integumentary system
17271 DESTRUCTION OF SKIN LESIONS DESTRUCTION MALIGNANT LESION
S/N/H/F/G 0.6-1.0CM
No Auth Required Surgery of integumentary system
17272 DESTRUCTION OF SKIN LESIONS DESTRUCTION MALIGNANT LESION
S/N/H/F/G 1.1-2.0CM
No Auth Required Surgery of integumentary system
17273 DESTRUCTION OF SKIN LESIONS DESTRUCTION MALIGNANT LESION
S/N/H/F/G 2.1-3.0CM
No Auth Required Surgery of integumentary system
17274 DESTRUCTION OF SKIN LESIONS DESTRUCTION MALIGNANT LESION
S/N/H/F/G 3.1-4.0CM
No Auth Required Surgery of integumentary system
17276 DESTRUCTION OF SKIN LESIONS DSTRJ MAL LESION S/N/H/F/G
LESION DIAM > 4.0 CM
No Auth Required Surgery of integumentary system
17280 DESTRUCTION OF SKIN LESIONS DESTRUCTION MALIGNANT LESION
F/E/E/N/L/M 0.5CM/<
No Auth Required Surgery of integumentary system
17281 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
F/E/E/N/L/M 0.6-1.0CM
No Auth Required Surgery of integumentary system
17282 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
F/E/E/N/L/M 1.1-2.0CM
No Auth Required Surgery of integumentary system
17283 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
F/E/E/N/L/M 2.1-3.0CM
No Auth Required Surgery of integumentary system
17284 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
F/E/E/N/L/M 3.1-4.0CM
No Auth Required Surgery of integumentary system
17286 DESTRUCTION OF SKIN LESIONS DESTRUCTION MAL LESION
F/E/E/N/L/M >4.0 CM
No Auth Required Surgery of integumentary system
-
17311 MOHS 1 STAGE H/N/HF/G MOHS MICROGRAPHIC H/N/H/F/G 1ST
STAGE 5 BLOCKS
Authorization Required Mohs PA for Code in Group Applies to All
Codes within Specific Group
Network Validation
17312 MOHS ADDL STAGE MOHS MICROGRAPHIC H/N/H/F/G EACH ADDL
STAGE
Authorization Required Mohs PA for Code in Group Applies to All
Codes within Specific Group
Network Validation
17313 MOHS 1 STAGE T/A/L MOHS TRUNK/ARM/LEG 1ST STAGE 5
BLOCKS
No Auth Required Mohs PA for Code in Group Applies to All Codes
within Specific Group
17314 MOHS ADDL STAGE T/A/L MOHS TRUNK/ARM/LEG EA STAGE AFTER
1ST STAGE
No Auth Required Mohs PA for Code in Group Applies to All Codes
within Specific Group
17315 MOHS SURG ADDL BLOCK MOHS TRUNK/ARM/LEG EA ADDL BLOCK ANY
STAGE
No Auth Required Mohs PA for Code in Group Applies to All Codes
within Specific Group
17340 CRYOTHERAPY OF SKIN CRYOTHERAPY CO2 SLUSH LIQUID N2 ACNE
Authorization Required Reconstructive Full Clinical Review
17360 SKIN PEEL THERAPY CHEMICAL EXFOLIATION ACNE Authorization
Required Reconstructive Full Clinical Review17380 HAIR REMOVAL BY
ELECTROLYSIS ELECTROLYSIS EPILATION EACH 30
MINUTESAuthorization Required Reconstructive Full Clinical
Review
17999 SKIN TISSUE PROCEDURE UNLISTED PX SKIN MUC MEMBRANE &
SUBQ TISSUE
Authorization Required Surgery of integumentary system Full
Clinical Review
19000 DRAINAGE OF BREAST LESION PUNCTURE ASPIRATION CYST BREAST
No Auth Required Surgery of integumentary system19001 DRAIN BREAST
LESION ADD-ON PUNCTURE ASPIRATION BREAST EACH
ADDITIONAL CYSTNo Auth Required Surgery of integumentary
system
19020 INCISION OF BREAST LESION MASTOTOMY W/EXPLORATION/DRAINAGE
ABSCESS DEEP
No Auth Required Surgery of integumentary system
19030 INJECTION FOR BREAST X-RAY INJECTION MAMMARY
DUCTOGRAM/GALACTOGRAM
No Auth Required Surgery of integumentary system
19081 BX BREAST 1ST LESION STRTCTC BX BREAST W/DEVICE 1ST LESION
STEREOTACTIC GUID
No Auth Required Surgery of integumentary system
19082 BX BREAST ADD LESION STRTCTC BX BREAST W/DEVICE ADDL
LESION STEREOTACT GUID
No Auth Required Surgery of integumentary system
19083 BX BREAST 1ST LESION US IMAG BX BREAST W/DEVICE 1ST LESION
ULTRASOUND GUID
No Auth Required Surgery of integumentary system
19084 BX BREAST ADD LESION US IMAG BX BREAST W/DEVICE ADDL
LESION ULTRASOUND GUID
No Auth Required Surgery of integumentary system
19085 BX BREAST 1ST LESION MR IMAG BX BREAST W/DEVICE 1ST LESION
MAGNETIC RES GUID
No Auth Required Surgery of integumentary system
19086 BX BREAST ADD LESION MR IMAG BX BREAST W/DEVICE ADDL
LESION MAGNET RES GUID
No Auth Required Surgery of integumentary system
19100 BX BREAST PERCUT W/O IMAGE BX BREAST NEEDLE CORE W/O
IMAGING GUIDANCE SPX
No Auth Required Surgery of integumentary system
19101 BIOPSY OF BREAST OPEN BIOPSY BREAST OPEN INCISIONAL No
Auth Required Surgery of integumentary system19105 CRYOSURG ABLATE
FA EACH ABLTJ CRYOSURGICAL W/US GID EA
FIBROADENOMANo Auth Required Surgery of integumentary system
19110 NIPPLE EXPLORATION NIPPLE EXPLORATION No Auth Required
Surgery of integumentary system19112 EXCISE BREAST DUCT FISTULA
EXCISION LACTIFEROUS DUCT FISTULA No Auth Required Surgery of
integumentary system19120 REMOVAL OF BREAST LESION EXC
CYST/ABERRANT BREAST TISSUE OPEN
1/> LESIONNo Auth Required Surgery of integumentary
system
19125 EXCISION BREAST LESION EXC BREAST LES PREOP PLMT RAD
MARKER OPEN 1 LES
No Auth Required Surgery of integumentary system
19126 EXCISION ADDL BREAST LESION EXC BRST LES PREOP PLMT RAD
MARKER OPN EA ADDL
No Auth Required Surgery of integumentary system
19260 REMOVAL OF CHEST WALL LESION EXCISION CHEST WALL TUMOR
INCLUDING RIBS
No Auth Required Surgery of integumentary system
19271 REVISION OF CHEST WALL EXC CHEST TUMOR W/RCNSTJ W/O
MEDSTNL LMPHADEC
No Auth Required Surgery of integumentary system
19272 EXTENSIVE CHEST WALL SURGERY EXC CHEST TUMOR W/RCNSTJ
W/MEDSTNL LMPHADEC
No Auth Required Surgery of integumentary system
19281 PERQ DEVICE BREAST 1ST IMAG PERQ DEVICE PLACEMENT BREAST
LOC 1ST LES W/GDNCE
No Auth Required Surgery of integumentary system
19282 PERQ DEVICE BREAST EA IMAG PERQ DEVICE PLACEMT BREAST LOC
EA LESION W/GDNCE
No Auth Required Surgery of integumentary system
19283 PERQ DEV BREAST 1ST STRTCTC PERQ BREAST LOC DEVICE PLACEMT
1ST STRTCTC GDNCE
No Auth Required Surgery of integumentary system
19284 PERQ DEV BREAST ADD STRTCTC PERQ BREAST LOC DEVICE PLACEMT
EA LESION STRTCTC
No Auth Required Surgery of integumentary system
19285 PERQ DEV BREAST 1ST US IMAG PERQ BREAST LOC DEVICE PLACEMT
1ST LESIO US IMAG
No Auth Required Surgery of integumentary system
19286 PERQ DEV BREAST ADD US IMAG PERQ BREAST LOC DEVICE PLACEMT
EACH LES US IMAGE
No Auth Required Surgery of integumentary system
19287 PERQ DEV BREAST 1ST MR GUIDE PERQ BREAST LOC DEVICE
PLACEMT 1ST LESIO MR GUID
No Auth Required Surgery of integumentary system
19288 PERQ DEV BREAST ADD MR GUIDE PERQ BREAST LOC DEVICE
PLACEMT ADD LESIO MR GUID
No Auth Required Surgery of integumentary system
19294 PREP TUM CAV IORT PRTL MAST PREP TUMOR CAVITY IORT
W/PARTIAL MASTECTOMY
Authorization Required Radiation Therapy Full Clinical
Review
19296 PLACE PO BREAST CATH FOR RAD PLMT EXPANDABLE CATH BRST
FOLLOWING PRTL MAST
No Auth Required Surgery of integumentary system
19297 PLACE BREAST CATH FOR RAD PLMT EXPANDABLE CATH BRST
CONCURRENT PRTL MAST
No Auth Required Surgery of integumentary system
19298 PLACE BREAST RAD TUBE/CATHS PLMT RADTHX BRACHYTX BRST
FOLLOWING PRTL MAST
No Auth Required Surgery of integumentary system
19300 REMOVAL OF BREAST TISSUE MASTECTOMY GYNECOMASTIA
Authorization Required Surgery of integumentary system Full
Clinical Review19301 PARTIAL MASTECTOMY MASTECTOMY PARTIAL No Auth
Required Surgery of integumentary system19302 P-MASTECTOMY W/LN
REMOVAL MASTECTOMY PARTIAL W/AXILLARY
LYMPHADENECTOMYNo Auth Required Surgery of integumentary
system
19303 MAST SIMPLE COMPLETE MASTECTOMY SIMPLE COMPLETE No Auth
Required Surgery of integumentary system19304 MAST SUBQ MASTECTOMY
SUBCUTANEOUS No Auth Required Surgery of integumentary system19305
MAST RADICAL MAST RAD W/PECTORAL MUSCLES
AXILLARY LYMPH NODESNo Auth Required Surgery of integumentary
system
19306 MAST RAD URBAN TYPE MAST RAD W/PECTORAL MUSC AX INT MAM
LYMPH NODES
No Auth Required Surgery of integumentary system
19307 MAST MOD RAD MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS
MIN
No Auth Required Surgery of integumentary system
19316 SUSPENSION OF BREAST MASTOPEXY Authorization Required
Reconstructive Full Clinical Review19318 REDUCTION OF LARGE BREAST
REDUCTION MAMMAPLASTY Authorization Required Surgery of
integumentary system Full Clinical Review19324 ENLARGE BREAST
MAMMAPLASTY AUGMENTATION W/O
PROSTHETIC IMPLANTAuthorization Required Surgery of
integumentary system Full Clinical Review
19325 ENLARGE BREAST WITH IMPLANT MAMMAPLASTY AUGMENTATION
W/PROSTHETIC IMPLANT
Authorization Required Surgery of integumentary system Full
Clinical Review
19328 REMOVAL OF BREAST IMPLANT REMOVAL INTACT MAMMARY IMPLANT
Authorization Required Surgery of integumentary system Full
Clinical Review19330 REMOVAL OF IMPLANT MATERIAL REMOVAL MAMMARY
IMPLANT MATERIAL Authorization Required Surgery of integumentary
system Full Clinical Review
19340 IMMEDIATE BREAST PROSTHESIS IMMT INSJ BRST PROSTH FLWG
MASTOPEXY MAST/RCNSTJ
Authorization Required Surgery of integumentary system Full
Clinical Review
19342 DELAYED BREAST PROSTHESIS DLYD INSJ BRST PROSTH FLWG
MASTOPEXY MAST/RCNSTJ
Authorization Required Surgery of integumentary system Full
Clinical Review
19350 BREAST RECONSTRUCTION NIPPLE/AREOLA RECONSTRUCTION No Auth
Required Surgery of integumentary system19355 CORRECT INVERTED
NIPPLE(S) CORRECTION INVERTED NIPPLES Authorization Required
Reconstructive Full Clinical Review19357 BREAST RECONSTRUCTION BRST
RCNSTJ IMMT/DLYD W/TISS
EXPANDER SBSQ XPNSJNo Auth Required Surgery of integumentary
system
19361 BREAST RECONSTR W/LAT FLAP BRST RCNSTJ W/LATSMS D/SI FLAP
WO PRSTHC IMPL
No Auth Required Surgery of integumentary system
19364 BREAST RECONSTRUCTION BREAST RECONSTRUCTION FREE FLAP No
Auth Required Surgery of integumentary system19366 BREAST
RECONSTRUCTION BREAST RECONSTRUCTION OTHER
TECHNIQUENo Auth Required Surgery of integumentary system
-
19367 BREAST RECONSTRUCTION BREAST RECONSTRUCTION TRAM FLAP 1
PEDICLE
No Auth Required Surgery of integumentary system
19368 BREAST RECONSTRUCTION BREAST RECONSTRUCTION TRAM 1 PEDCL
MVASC ANAST
No Auth Required Surgery of integumentary system
19369 BREAST RECONSTRUCTION BREAST RECONSTRUCTION TRAM FLAP
DOUBLE PEDICLE
No Auth Required Surgery of integumentary system
19370 SURGERY OF BREAST CAPSULE OPEN PERIPROSTHETIC CAPSULOTOMY
BREAST
Authorization Required Surgery of integumentary system Full
Clinical Review
19371 REMOVAL OF BREAST CAPSULE PERIPROSTHETIC CAPSULECTOMY
BREAST Authorization Required Surgery of integumentary system Full
Clinical Review19380 REVISE BREAST RECONSTRUCTION REVISION
RECONSTRUCTED BREAST Authorization Required Surgery of
integumentary system Full Clinical Review19396 DESIGN CUSTOM BREAST
IMPLANT PREPARATION MOULAGE CUSTOM BREAST
IMPLANTAuthorization Required Surgery of integumentary system
Full Clinical Review
19499 BREAST SURGERY PROCEDURE UNLISTED PROCEDURE BREAST
Authorization Required Surgery of integumentary system Full
Clinical Review20100 EXPLORE WOUND NECK EXPLORATION PENETRATING
WOUND SPX
NECKNo Auth Required Surgery of musculoskeletal system
20101 EXPLORE WOUND CHEST EXPLORATION PENETRATING WOUND SPX
CHEST
No Auth Required Surgery of musculoskeletal system
20102 EXPLORE WOUND ABDOMEN EXPL PENETRATING WOUND SPX
ABDOMEN/FLANK/BACK
No Auth Required Surgery of musculoskeletal system
20103 EXPLORE WOUND EXTREMITY EXPLORATION PENETRATING WOUND SPX
EXTREMITY
No Auth Required Surgery of musculoskeletal system
20150 EXCISE EPIPHYSEAL BAR EXCISION EPIPHYSEAL BAR No Auth
Required Surgery of musculoskeletal system20200 MUSCLE BIOPSY
BIOPSY MUSCLE SUPERFICIAL No Auth Required Surgery of
musculoskeletal system20205 DEEP MUSCLE BIOPSY BIOPSY MUSCLE DEEP
No Auth Required Surgery of musculoskeletal system20206 NEEDLE
BIOPSY MUSCLE BIOPSY MUSCLE PERCUTANEOUS NEEDLE No Auth Required
Surgery of musculoskeletal system20220 BONE BIOPSY TROCAR/NEEDLE
BIOPSY BONE TROCAR/NEEDLE
SUPERFICIALNo Auth Required Surgery of musculoskeletal
system
20225 BONE BIOPSY TROCAR/NEEDLE BIOPSY BONE TROCAR/NEEDLE DEEP
No Auth Required Surgery of musculoskeletal system20240 BONE BIOPSY
OPEN SUPERFICIAL BIOPSY BONE OPEN SUPERFICIAL No Auth Required
Surgery of musculoskeletal system20245 BONE BIOPSY OPEN DEEP BIOPSY
BONE OPEN DEEP No Auth Required Surgery of musculoskeletal
system20250 OPEN BONE BIOPSY BIOPSY VERTEBRAL BODY OPEN THORACIC No
Auth Required Surgery of musculoskeletal system
20251 OPEN BONE BIOPSY BIOPSY VERTEBRAL BODY OPEN
LUMBAR/CERVICAL
No Auth Required Surgery of musculoskeletal system
20500 INJECTION OF SINUS TRACT INJECTION SINUS TRACT THERAPEUTIC
SEPARATE PROC
No Auth Required Surgery of musculoskeletal system
20501 INJECT SINUS TRACT FOR X-RAY INJECTION SINUS TRACT
DIAGNOSTIC No Auth Required Surgery of musculoskeletal system20520
REMOVAL OF FOREIGN BODY REMOVAL FOREIGN BODY
MUSCLE/TENDON SHEATH SIMPLENo Auth Required
20525 REMOVAL OF FOREIGN BODY RMVL FOREIGN BODY MUSCLE/TENDON
SHEATH DEEP/COMP
No Auth Required Surgery of musculoskeletal system
20526 THER INJECTION CARP TUNNEL INJECTION THERAPEUTIC CARPAL
TUNNEL No Auth Required Surgery of musculoskeletal system
20527 INJ DUPUYTREN CORD W/ENZYME INJECTION ENZYME PALMAR
FASCIAL CORD No Auth Required Surgery of musculoskeletal system
20550 INJ TENDON SHEATH/LIGAMENT INJECTION 1 TENDON
SHEATH/LIGAMENT APONEUROSIS
No Auth Required
20551 INJ TENDON ORIGIN/INSERTION INJECTION SINGLE TENDON
ORIGIN/INSERTION
No Auth Required Surgery of musculoskeletal system
20552 INJ TRIGGER POINT 1/2 MUSCL INJECTION SINGLE/MLT TRIGGER
POINT 1/2 MUSCLES
No Auth Required Spine Care relating to neck and back
conditions, including:
20553 INJECT TRIGGER POINTS 3/> INJECTION SINGLE/MLT TRIGGER
POINT 3/> MUSCLES
No Auth Required Spine Care relating to neck and back
conditions, including:
20555 PLACE NDL MUSC/TIS FOR RT PLACEMENT NEEDLES MUSCLE
SUBSEQUENT RADIOELEMENT
No Auth Required Surgery of musculoskeletal system
20560 NDL INSJ W/O NJX 1 OR 2 MUSC NEEDLE INSERTION W/O
INJECTION 1 OR 2 MUSCLES
No Auth Required
20561 NDL INSJ W/O NJX 3+ MUSC NEEDLE INSERTION W/O INJECTION 3
OR MORE MUSCLES
No Auth Required
20600 DRAIN/INJ JOINT/BURSA W/O US ARTHROCENTESIS ASPIR&/INJ
SMALL JT/BURSA W/O US
No Auth Required
20604 DRAIN/INJ JOINT/BURSA W/US ARTHROCNT ASPIR&/INJ SMALL
JT/BURSAW/US REC RPRT
No Auth Required
20605 DRAIN/INJ JOINT/BURSA W/O US ARTHROCENTESIS ASPIR&/INJ
INTERM JT/BURS W/O US
No Auth Required Joint
20606 DRAIN/INJ JOINT/BURSA W/US ARTHROCENTESIS ASPIR&/INJ
INTERM JT/BURS W/US
No Auth Required Joint
20610 DRAIN/INJ JOINT/BURSA W/O US ARTHROCENTESIS ASPIR&/INJ
MAJOR JT/BURSA W/O US
Authorization Required Joint Network Validation
20611 DRAIN/INJ JOINT/BURSA W/US ARTHROCENTESIS ASPIR&/INJ
MAJOR JT/BURSA W/US
Authorization Required Joint Network Validation
20612 ASPIRATE/INJ GANGLION CYST ASPIRATION&/INJECTION
GANGLION CYST ANY LOCATJ
No Auth Required Surgery of musculoskeletal system
20615 TREATMENT OF BONE CYST ASPIRATION & INJECTION
TREATMENT BONE CYST
No Auth Required Surgery of musculoskeletal system
20650 INSERT AND REMOVE BONE PIN INSERTION WIRE/PIN W/APPL
SKELETAL TRACTION SPX
No Auth Required Surgery of musculoskeletal system
20660 APPLY REM FIXATION DEVICE APPL CRANIAL TONG/STRTCTC FRAME
W/REMOVAL SPX
No Auth Required Surgery of musculoskeletal system
20661 APPLICATION OF HEAD BRACE APPLICATION HALO CRANIAL
INCLUDING REMOVAL
No Auth Required Surgery of musculoskeletal system
20662 APPLICATION OF PELVIS BRACE APPLICATION HALO PELVIC
INCLUDING REMOVAL
No Auth Required Surgery of musculoskeletal system
20663 APPLICATION OF THIGH BRACE APPLICATION HALO FEMORAL
INCLUDING REMOVAL
No Auth Required Surgery of musculoskeletal system
20664 APPLICATION OF HALO APPL HALO 6/> PINS THIN SKULL
OSTEOLOGY
No Auth Required Surgery of musculoskeletal system
20665 REMOVAL OF FIXATION DEVICE REMOVAL TONG/HALO APPLIED BY
ANOTHER INDIVIDUAL
No Auth Required Surgery of musculoskeletal system
20670 REMOVAL OF SUPPORT IMPLANT REMOVAL IMPLANT SUPERFICIAL
SEPARATE PROCEDURE
No Auth Required Surgery of musculoskeletal system
20680 REMOVAL OF SUPPORT IMPLANT REMOVAL IMPLANT DEEP
Authorization Required Surgery of musculoskeletal system Network
Validation20690 APPLY BONE FIXATION DEVICE APPLICATION UNIPLANE
EXTERNAL
FIXATION SYSTEMNo Auth Required Surgery of musculoskeletal
system
20692 APPLY BONE FIXATION DEVICE APPLICATION MULTIPLANE EXTERNAL
FIXATION SYSTEM
No Auth Required Surgery of musculoskeletal system
20693 ADJUST BONE FIXATION DEVICE ADJUSTMENT/REVJ XTRNL FIXATION
SYSTEM REQ ANES
No Auth Required Surgery of musculoskeletal system
20694 REMOVE BONE FIXATION DEVICE REMOVAL EXTERNAL FIXATION
SYSTEM UNDER ANES
No Auth Required Surgery of musculoskeletal system
20696 COMP MULTIPLANE EXT FIXATION XTRNL FIXJ W/STEREOTACTIC
ADJUSTMENT 1ST & SUBQ
No Auth Required Surgery of musculoskeletal system
20697 COMP EXT FIXATE STRUT CHANGE XTRNL FIXJ W/STRTCTC
ADJUSTMENT EXCHANGE STRUT
No Auth Required Surgery of musculoskeletal system
20700 MNL PREP&INSJ DP RX DLVR DEV MANUAL PREP AND INSERTION
DEEP DRUG DELIVERY DEV
No Auth Required
20701 RMVL DEEP RX DELIVERY DEVICE REMOVAL DEEP DRUG DELIVERY
DEVICE No Auth Required20702 MNL PREP&INSJ IMED RX DEV MANUAL
PREP&INSJ INTRAMEDULLARY
DRUG DLVR DEVICENo Auth Required
20703 RMVL IMED RX DELIVERY DEVICE REMOVAL INTRAMEDULLARY DRUG
DELIVERY DEVICE
No Auth Required
20704 MNL PREP&INSJ I-ARTIC RX DEV MANUAL PREP&INSJ
I-ARTIC DRUG DELIVERY DEVICE
No Auth Required
20705 RMVL I-ARTIC RX DELIVERY DEV REMOVAL INTRA-ARTICULAR DRUG
DELIVERY DEVICE
No Auth Required
20802 REPLANTATION ARM COMPLETE REPLANTATION ARM COMPLETE
AMPUTATION
No Auth Required Surgery of musculoskeletal system
20805 REPLANT FOREARM COMPLETE REPLANTATION FOREARM COMPLETE
AMPUTATION
No Auth Required Surgery of musculoskeletal system
-
20808 REPLANTATION HAND COMPLETE REPLANTATION HAND COMPLETE
AMPUTATION
No Auth Required Surgery of musculoskeletal system
20816 REPLANTATION DIGIT COMPLETE RPLJ DGT EXCEPT THMB
MTCARPHLNGL JT COMPL AMP
No Auth Required Surgery of musculoskeletal system
20822 REPLANTATION DIGIT COMPLETE RPLJ DGT EXCLUDING THMB
SUBLIMIS TDN COMPL AMP
No Auth Required Surgery of musculoskeletal system
20824 REPLANTATION THUMB COMPLETE RPLJ THMB CARP/MTCRPL JT MP JT
COMPL AMPUTATION
No Auth Required Surgery of musculoskeletal system
20827 REPLANTATION THUMB COMPLETE RPLJ THUMB DISTAL TIP MP JOINT
COMPL AMPUTATION
No Auth Required Surgery of musculoskeletal system
20838 REPLANTATION FOOT COMPLETE REPLANTATION FOOT COMPLETE
AMPUTATION
No Auth Required Surgery of musculoskeletal system
20900 REMOVAL OF BONE FOR GRAFT BONE GRAFT ANY DONOR AREA
MINOR/SMALL
No Auth Required Surgery of musculoskeletal system
20902 REMOVAL OF BONE FOR GRAFT BONE GRAFT ANY DONOR AREA
MAJOR/LARGE
No Auth Required Surgery of musculoskeletal system
20910 REMOVE CARTILAGE FOR GRAFT CARTILAGE GRAFT COSTOCHONDRAL
No Auth Required Surgery of musculoskeletal system20912 REMOVE
CARTILAGE FOR GRAFT CARTILAGE GRAFT NASAL SEPTUM No Auth Required
Surgery of musculoskeletal system20920 REMOVAL OF FASCIA FOR GRAFT
FASCIA LATA GRAFT BY STRIPPER No Auth Required Surgery of
musculoskeletal system20922 REMOVAL OF FASCIA FOR GRAFT FASCIA LATA
GRAFT INCISION & AREA
EXPOSURENo Auth Required Surgery of musculoskeletal system
20924 REMOVAL OF TENDON FOR GRAFT TENDON GRAFT FROM A DISTANCE
No Auth Required Surgery of musculoskeletal system20926 REMOVAL OF
TISSUE FOR GRAFT TISSUE GRAFTS OTHER No Auth Required Surgery of
musculoskeletal system20930 SP BONE ALGRFT MORSEL ADD-ON ALLOGRAFT
FOR SPINE SURGERY ONLY
MORSELIZEDAuthorization Required Surgery of musculoskeletal
system Full Clinical Review
20931 SP BONE ALGRFT STRUCT ADD-ON ALLOGRAFT FOR SPINE SURGERY
ONLY STRUCTURAL
Authorization Required Surgery of musculoskeletal system Full
Clinical Review
20932 OSTEOART ALGRFT W/SURF & B1 OSTEOARTICULAR ALLOGRAFT
W/ARTICULAR SURF & BONE
Authorization Required Surgery of musculoskeletal system Full
Clinical Review
20933 HEMICRT INTRCLRY
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