OUTPATIENT SURGICAL PROCEDURES CPT/HCPCS CODES

[Pages:6]UnitedHealthcare? Community Plan Network Bulletin Appendix

OUTPATIENT SURGICAL PROCEDURES ? SITE OF SERVICE: CPT/HCPCS CODES

Effective Date: June 1, 2020 This list of codes applies to the policy titled Outpatient Surgical Procedures ? Site of Service.

SITE OF SERVICE REVIEW

We're expanding our notification/prior authorization requirements to include the procedure codes below in the following states. We'll only require notification/prior authorization if these procedure codes will be performed in an outpatient hospital setting.

Effective Date 11/01/2019 01/01/2020 03/01/2020 06/01/2020 07/01/2020 08/01/2020

Maryland, Rhode Island, Washington Michigan, Missouri, Ohio Arizona, New York Mississippi Texas Pennsylvania

State

Refer to the policy titled Outpatient Surgical Procedures ? Site of Service.

CPT/HCPCS Code 10121 11440 11450 11624 11770 13101 13121 13132 14040 14060 14301 15100 15120 15240 19020 19120 19125 20552 20553 20680 21012 21013

Codes Subject to Site of Service Review Description

Incision & removal foreign body subq tiss compl Exc b9 lesion mrgn xcp sk tg f/e/e/n/l/m 0.5cm/< Excision hidradenitis axillary smpl/intrm rpr Excision malignant lesion s/n/h/f/g 3.1 - 4.0 cm Excision pilonidal cyst/sinus simple Repair of wound or lesion Repair complex scalp/arm/leg 2.6 - 7.5 cm Repair of wound or lesion Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Split agrft t/a/l 1st 100 cm/&/1% bdy inft/chld Split agrft f/s/n/h/f/g/m/d gt 1st 100 cm/ lesion Exc breast les preop plmt rad marker open 1 les Injection single/mlt trigger point 1/2 muscles Injection single/mlt trigger point 3/> muscles Removal of support implant Excision tumor soft tiss face/scalp subq 2 cm/> Exc tumor soft tiss face&scalp subfascial

Exc tumor soft tissue neck/ant thorax subq

Exc tumor soft tissue foot/toe subfasc 1.5 cm/>

Fasciectomy plantar fascia partial spx

Excision interdigital morton neuroma single each

Exc lesion tendon sheath/capsule w/synvct foot

Exc/curtg bone cyst/b9 tumortarsal/metatarsal

Ostectomy prtl 5th metar head spx

Ostectomy calcaneus

Ostectomy calcaneus spur w/wo plntar fascial rls

Partical excision bone phalanx toe

Correction hammertoe

Hallux rigidus correct w/cheilectomy 1st mp jt

Keller/mcbride/mayo procedure

Corrj hallux valgus w/wo sesmdc w/metar osteot

Corrj hallux valgus w/wo sesmdc lapidus - typ px

Corrj hallux valgus w/wo sesmdc phalanx osteot

Corrj hallux valgus w/wo sesmdc 2 osteot

Arthroscopy shoulder surgical capsulorrhaphy

Arthroscopy shoulder surgical repair slap lesion

Arthroscopy shoulder surgical removal loose/fb

Arthroscopy shoulder surg debridement limited

Arthroscopy shoulder surg debridement extensive

Arthroscopy shoulder distal claviculectomy

Arthroscopy shoulder ahesiolysis w/wo manipj

Arthroscopy shoulder w/coracoacrm ligmnt release

Arthroscopy shoulder rotator cuff repair

Arthroscopy shoulder biceps tenodesis

Arthroscopy elbow surgical synovectomy partial

Outpatient Surgical Procedures ? Site of Service: CPT/HCPCS Codes

Page 2 of 6

UnitedHealthcare Community Plan Network Bulletin Appendix

Effective 06/01/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

CPT/HCPCS Code 29840 29845 29846 29848 29861 29875 29876 29877 29879 29880 29881 29882 29888 29893 29916 30140 30520 30802 30930 31240 31254 31255 31256 31267 31276 31287 31288 31525 31535 31536 31541 31624 36590 38500 38510 38525 42415 42440 42820 42821 42825 42826 42830 43200 43235 43236

Codes Subject to Site of Service Review Description

Arthroscopy wrist diag w/wo synovial biopsy spx Arthroscopy wrist surgical synovectomy complete Arthrs wrst exc&/rpr triang fibrocart&/joint Ndsc wrst surg w/rls transvrs carpl ligm Arthroscopy hip surgical w/removal loose/fb Arthroscopy knee synovectomy limited spx Arthroscopy knee synovectomy 2/>compartments Arthrs knee debridement/shaving artclr crtlg Arthrs knee abrasion arthrp/mlt drlg/microfx Arthrs knee w/meniscectomy med&lat w/shaving Arthrs kne surg w/meniscectomy med/lat w/shvg Arthroscopy knee w/meniscus rpr medial/lateral Arthrs aided ant cruciate ligm rpr/agmntj/rcnstj Endoscopic plantar fasciotomy Arthroscopy hip w/labral repair Removal of turbinate bones Repair of nasal septum Abltj sof tiss inf turbs uni/bi supfc intramural Fracture nasal inferior turbinate therapeutic Nasal/sinus endoscopy, surg Revision of ethmoid sinus Removal of ethmoid sinus Exploration maxillary sinus Endoscopy, maxillary sinus Sinus endoscopy, surgical Nasal/sinus endoscopy, surg Nasal/sinus endoscopy, surg Laryngoscopy w/wo tracheoscopy dx except newborn Laryngoscopy direct operative w/biopsy Laryngoscopy w/biopsy microscope/telescope Largsc exc tum&/strpg cords/epigl mcrscp/tlscp Brnchsc w/brncl alveolar lavage Rmvl tun ctr vad w/subq port/pmp ctr/prph insj - av astula revision. Open Bx/exc lymph node open superficial Bx/exc lymph node open deep cervical node Bx/exc lymph node open deep axillary node Exc prtd tum/prtd glnd lat dsj&prsrv facial nr Excision submandibular submaxillary gland Remove tonsils and adenoids Remove tonsils and adenoids Removal of tonsils Removal of tonsils Removal of adenoids Esophagoscopy flexible transoral diagnostic Uppr gi endoscopy diagnosis Esophagogastroduodenoscopy submucosal injection

Outpatient Surgical Procedures ? Site of Service: CPT/HCPCS Codes

Page 3 of 6

UnitedHealthcare Community Plan Network Bulletin Appendix

Effective 06/01/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

CPT/HCPCS Code 43237 43238 43239 43242 43245 43246 43247 43248 43249 43251 43254 43255 43259 44360 44361 45171 45334 45335 45378 45380 45381 45384 45385 45390 45990 46020 46040 46050 46200 46220 46221 46250 46255 46261 46270 46275 46288 46505 46750 46910 46946 47000 49505 49585 49587 49650

Codes Subject to Site of Service Review Description

Esophagogastroduodenoscopy us scope w/adj strxrs Egd intrmural us needle aspirate/biopsy esophags Upper gi endoscopy biopsy Egd intrmural needle aspir/biop altered anatomy Egd dilation gastric/duodenal stricture Egd percutaneous placement gastrostomy tube Egd flexible foreign body removal Egd insert guide wire dilator passage esophagus Esoph endoscopy, dilation Egd removal tumor polyp/other lesion snare tech Egd transoral endoscopic mucosal resection Egd transoral control bleeding any method Edg us exam surgical alter stom duodenum/jejunum Endoscopy upper small intestine Endoscopy upper small intestine w/biopsy Exc rct tum not incl muscularis propria Sigmoidoscopy flx control bleeding Sgmdsc flx dired sbmcsl njx any sbst Diagnostic colonoscopy Colonoscopy and biopsy Colsc flx with directed submucosal njx any sbst Lesion remove colonoscopy Lesion removal colonoscopy Colonoscopy flx w/endoscopic mucosal resection Anrct xm surg req anes general spi/edrl dx Placement seton I&d ischiorectal&/perirectal abscess spx I&d perianal abscess superficial Fissurectomy incl sphincterotomy when performed Excision single external papilla or tag anus Hemorrhoidectomy internal rubber band ligations Hemorrhoidectomy xtrnl 2/> column/group Hemorrhoidectomy ntrnl & xtrnl 1 column/group Hrhc ntrnl & xtrnl 2/> column/group w/fissu Surg tx anal fistula subq Surg tx anal fistula intersphincteric Clsr anal fstl w/rct advmnt flap Chemodenervation internal anal sphincter Sphnctrop anal incontinence/prolapse adult Dstrj lesion anus smpl eltrdsiccation Hrhc ntrnl lig oth than rbbr band 2/> col/grp Needle biopsy of liver Repair inguinal hernia Rpr umbil hern reduc > 5 yr Rpr umbil hern block > 5 yr Lap ing hernia repair init

Outpatient Surgical Procedures ? Site of Service: CPT/HCPCS Codes

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UnitedHealthcare Community Plan Network Bulletin Appendix

Effective 06/01/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

CPT/HCPCS Code 49651 49652 49653 49654 49655 50590 52000 52005 52204 52224 52234 52235 52260 52276 52281 52287 52310 52320 52332 52344 52351 52352 52353 52356 54161 54840 55040 55700 57240 57250 57288 57461 57520 57522 58353 58558 58561 58562 58563 58565 64561 64640 64721 65426 65710 65730

Codes Subject to Site of Service Review

Lap ing hernia repair recur

Description

Lap vent/abd hernia repair

Lap vent/abd hern proc comp

Lap inc hernia repair

Lap inc hern repair comp

Fragmenting of kidney stone

Cystoscopy

Cystoscopy & ureter catheter

Cystoscopy w/biopsy(s)

Cystoscopy and treatment

Cystoscopy and treatment

Cystoscopy and treatment

Cystoscopy and treatment

Cystourethroscopy w/internal urethrotomy male

Cystoscopy and treatment

Cystourethroscopy inj chemodenervation bladder

Cystoscopy and treatment

Cystourethroscopy w/rmvl ureteral calculus

Cystoscopy and treatment

Cysto w/urtroscopy w/tx ureteral stricture

Cystouretero & or pyeloscope

Cystouretero w/stone remove

Cystouretero w/lithotripsy

Cysto/uretero w/lithotripsy &indwell stent insrt

Circumcision

Excision spermatocele w/wo epididymectomy

Removal of hydrocele

Biopsy of prostate

Ant colporrhaphy cystocele w/wo rpr urethrocele

Post colporrhaphy rectocele w/wo perineorrhaphy

Repair bladder defect

Colposcopy cervix vag eltrd conization cervix

Conization cervix w/wo d&c rpr knife/laser

Conization of cervix

Endometr ablate thermal

Hysteroscopy biopsy

Hysteroscopy removal leiomyomata

Hysteroscopy removal impacted foreign body

Hysteroscopy ablation

Hysteroscopy sterilization

Prq impltj neurostim eltrd sacral nrve w/imaging

Dstrj neurolytic agent other peripheral nerve

Carpal tunnel surgery

Removal of eye lesion

Keratoplasty anterior lamellar

Corneal transplant

Outpatient Surgical Procedures ? Site of Service: CPT/HCPCS Codes

Page 5 of 6

UnitedHealthcare Community Plan Network Bulletin Appendix

Effective 06/01/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

CPT/HCPCS Code 65820 65855 66170 66250 66710 66711 66761 66821 66825

66982

66984

66986

66987

66988 67010 67028 67036 67040 67041 67042 67105 67108 67113 67228 67311 67312 67840 68110 68115 68320 68720 68815 69205 69436 69631 G0260

Codes Subject to Site of Service Review Description

Goniotomy Laser surgery of eye Glaucoma surgery Revj/rpr oprative wound anterior segment Ciliary body dstrj cyclophotocoag transsceral Ciliary body dstrj cyclophotocoag endoscopic Revision of iris After cataract laser surgery Repositioning IO lens prosthesis req inc spx Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique, complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation Exchange intraocular lens Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique, complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique; with endoscopic cyclophotocoagulation Rmvl vitreous ant appr subtot rmvl mech vitrect Injection eye drug Removal of inner eye fluid Laser treatment of retina Vitrectomy pars plana remove preretinal membrane Vitrectomy pars plana remove int memb retina Rpr retinal dtchmnt 1/> ses pc incl subreti drg Rpr retinal dtchmnt w/vitrectomy any meth Rpr complex retina detach vitrect &membrane peel Treatment of retinal lesion Revise eye muscle Revise two eye muscles Exc lesion eyelid w/o clsr/w/simple dir closure Excision lesion conjunctiva 1 cm Conjunctivoplasty w/grf/xtnsv rearrangement Dacryocstorhinostomy Probe nasolacrimal duct w/wo irrg insj tube/stnt Rmvl fb xtrnl auditory canal anes Create eardrum opening Repair eardrum structures Inj proc si jnt;anes steroid&/tx agt&arthrogrph

CPT? is a registered trademark of the American Medical Association

Outpatient Surgical Procedures ? Site of Service: CPT/HCPCS Codes

Page 6 of 6

UnitedHealthcare Community Plan Network Bulletin Appendix

Effective 06/01/2020

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

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