Inpatient Procedure List - MVP Health Care
MVP Inpatient Surgical List
Effective January 1, 2018
Procedures not listed on the MVP Inpatient Surgery list are expected to be performed in the Outpatient or office setting. The in office procedure list still applies. If a procedure is not listed and is being requested to be done in the Inpatient setting, an authorization will be required if it requires a higher level of care.
Codes listed as Medicare Only will require Place of Service Requests for All other Lines of Business
Code Description
Debridement of Necrotizing Soft Tissue Infections - First Coast
Debridement of Necrotizing Soft Tissue Infections - First Coast
Debridement of Necrotizing Soft Tissue Infections - First Coast
Debridement of Necrotizing Soft Tissue Infections - First Coast
Free muscle or myocutaneous flap with microvascular anastomosis Free skin flap with microvascular anastomosis Breast Reconstruction with Autologous Tissue Reconstruction Breast Reconstruction with Autologous Tissue Reconstruction Breast Reconstruction with Autologous Tissue Reconstruction Breast Reconstruction with Autologous Tissue Reconstruction Breast Reconstruction with Autologous Tissue Reconstruction Breast Reconstruction with Autologous Tissue Reconstruction Breast Reconstruction with Autologous Tissue Reconstruction Breast Reconstruction with Autologous Tissue Reconstruction Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) Bone Graft and Implantable Stimulator, Fracture Nonunion Bone Graft and Implantable Stimulator, Fracture Nonunion Maxillectomy Discectomy, Temporomandibular Joint (TMJ) Osteotomy, LeFort I Osteotomy, LeFort I Osteotomy, LeFort I Osteotomy, LeFort I Osteotomy, LeFort I Osteotomy, LeFort I Osteotomy, Anterior Segment, Maxilla
CPT/HCPCs
11004
11005
11006
11008 15756 15757 19324 19361 19364 19366 19367 19368 19369 19396 20670
I/O
Inpatient
Inpatient
Inpatient
Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient
Coverage
Medicare Only
Medicare Only
Medicare Only
Medicare Only ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
ALL
20680
Inpatient
ALL
20955 20975 21026 21060 21141 21142 21143 21145 21146 21147 21188
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
1 Updated 10/24/2019
Procedures not listed on the MVP Inpatient Surgery list are expected to be performed in the Outpatient or office setting. The in office procedure list still applies. If a procedure is not listed and is being requested to be done in the Inpatient setting, an authorization will be required if it requires a higher level of care.
Codes listed as Medicare Only will require Place of Service Requests for All other Lines of Business
Code Description
Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy Osteotomy, Sagittal Split, Mandible Ramus Reconstruction, Temporomandibular Joint (TMJ) Osteotomy, Sagittal Split, Mandible Ramus Reconstruction, Temporomandibular Joint (TMJ) Osteotomy, Sagittal Split, Mandible Ramus Reconstruction, Temporomandibular Joint (TMJ) Osteotomy, Sagittal Split, Mandible Ramus Reconstruction, Temporomandibular Joint (TMJ) Arthroplasty, Temporomandibular Joint (TMJ) Arthroplasty, Temporomandibular Joint (TMJ) Arthroplasty, Temporomandibular Joint (TMJ) Reconstruction, Temporomandibular Joint (TMJ) Maxillectomy Reconstruction, Temporomandibular Joint (TMJ) Maxillectomy Reconstruction, Temporomandibular Joint (TMJ) Reconstruction, Temporomandibular Joint (TMJ) Maxillectomy Reconstruction, Temporomandibular Joint (TMJ) Maxillectomy Reconstruction, Temporomandibular Joint (TMJ) Reconstruction, Temporomandibular Joint (TMJ) Discectomy, Temporomandibular Joint (TMJ) Pectus Excavatum Repair (Pediatric) Pectus Excavatum Repair (Pediatric) Pectus Excavatum Repair (Pediatric)
Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic
CPT/HCPCs I/O Coverage
21188
Inpatient
ALL
21193
Inpatient
ALL
21193
Inpatient
ALL
21194
Inpatient
ALL
21194
Inpatient
ALL
21195
Inpatient
ALL
21195
Inpatient
ALL
21196
Inpatient
ALL
21196
Inpatient
ALL
21240
Inpatient
ALL
21242
Inpatient
ALL
21243
Inpatient
ALL
21244
Inpatient
ALL
21245
Inpatient
ALL
21245
Inpatient
ALL
21246
Inpatient
ALL
21246
Inpatient
ALL
21247
Inpatient
ALL
21248
Inpatient
ALL
21248
Inpatient
ALL
21249
Inpatient
ALL
21249
Inpatient
ALL
21255
Inpatient
ALL
21299
Inpatient
ALL
21740
Inpatient
ALL
21742
Inpatient
ALL
21743
Inpatient
ALL
22010
Inpatient
ALL
Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral
22015
Inpatient
ALL
Anterior Cervical Discectomy and Fusion (ACDF) Anterior Cervical Discectomy and Fusion (ACDF) Fusion, Thoracic Spine
22220 22226 22532
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
2 Updated 10/24/2019
Procedures not listed on the MVP Inpatient Surgery list are expected to be performed in the Outpatient or office setting. The in office procedure list still applies. If a procedure is not listed and is being requested to be done in the Inpatient setting, an authorization will be required if it requires a higher level of care.
Codes listed as Medicare Only will require Place of Service Requests for All other Lines of Business
Fusion, Lumbar Spine
Code Description
Fusion, Lumbar Spine
Fusion, Thoracic Spine
Fusion, Cervical Spine
Fusion, Thoracic Spine
Fusion, Lumbar Spine Fusion, Lumbar Spine
Fusion, Thoracic Spine
Fusion (with Laminectomy), Cervical
Fusion (with Laminectomy), Cervical
Fusion (with Laminectomy), Cervical
Fusion (with Laminectomy), Thoracic
Fusion, Thoracic Spine
Fusion (with Laminectomy), Lumbar
Fusion, Lumbar Spine
Fusion (with Laminectomy), Cervical
Fusion (with Laminectomy), Lumbar
Fusion, Lumbar Spine
Fusion (with Laminectomy), Lumbar
Fusion, Lumbar Spine
Fusion (with Laminectomy), Lumbar
Fusion, Lumbar Spine
Fusion, Lumbar Spine
Fusion, Lumbar Spine
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
CPT/HCPCs I/O Coverage
22533
Inpatient
ALL
22534
Inpatient
ALL
22534
Inpatient
ALL
22548
Inpatient
ALL
22556 22558 22585
Inpatient
ALL
Inpatient
ALL
Inpatient
ALL
22585
Inpatient
ALL
22590
Inpatient
ALL
22595
Inpatient
ALL
22600
Inpatient
ALL
22610
Inpatient
ALL
22610
Inpatient
ALL
22612
Inpatient
ALL
22612
Inpatient
ALL
22614
Inpatient
ALL
22614
Inpatient
ALL
22614
Inpatient
ALL
22630
Inpatient
ALL
22630
Inpatient
ALL
22632
Inpatient
ALL
22632
Inpatient
ALL
22633
Inpatient
ALL
22634
Inpatient
ALL
22800
Inpatient
ALL
22800
Inpatient
ALL
22800
Inpatient
ALL
22802
Inpatient
ALL
22802
Inpatient
ALL
22802
Inpatient
ALL
22804
Inpatient
ALL
22804
Inpatient
ALL
22804
Inpatient
ALL
22808
Inpatient
ALL
3 Updated 10/24/2019
Procedures not listed on the MVP Inpatient Surgery list are expected to be performed in the Outpatient or office setting. The in office procedure list still applies. If a procedure is not listed and is being requested to be done in the Inpatient setting, an authorization will be required if it requires a higher level of care.
Codes listed as Medicare Only will require Place of Service Requests for All other Lines of Business
Scoliosis Surgery
Code Description
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Exploration of spinal fusion
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Scoliosis Surgery
Scoliosis surgery (Pediatric)
CPT/HCPCs I/O Coverage
22808
Inpatient
ALL
22808
Inpatient
ALL
22810
Inpatient
ALL
22810
Inpatient
ALL
22810
Inpatient
ALL
22812
Inpatient
ALL
22812
Inpatient
ALL
22812
Inpatient
ALL
22818
Inpatient
ALL
22818
Inpatient
ALL
22819
Inpatient
ALL
22819
Inpatient
ALL
22830
Inpatient
ALL
22840
Inpatient
ALL
22840
Inpatient
ALL
22840
Inpatient
ALL
22841
Inpatient
ALL
22841
Inpatient
ALL
22841
Inpatient
ALL
22842
Inpatient
ALL
22842
Inpatient
ALL
22842
Inpatient
ALL
22843
Inpatient
ALL
22843
Inpatient
ALL
22843
Inpatient
ALL
22844
Inpatient
ALL
22844
Inpatient
ALL
22844
Inpatient
ALL
22845
Inpatient
ALL
22845
Inpatient
ALL
22846
Inpatient
ALL
22846
Inpatient
ALL
22847
Inpatient
ALL
22847
Inpatient
ALL
4 Updated 10/24/2019
Procedures not listed on the MVP Inpatient Surgery list are expected to be performed in the Outpatient or office setting. The in office procedure list still applies. If a procedure is not listed and is being requested to be done in the Inpatient setting, an authorization will be required if it requires a higher level of care.
Codes listed as Medicare Only will require Place of Service Requests for All other Lines of Business
Scoliosis Surgery
Code Description
Scoliosis surgery (Pediatric)
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Fusion, Lumbar Spine
Scoliosis Surgery
Scoliosis surgery (Pediatric)
Artificial Disc Replacement, Lumbar
Removal and Replacement, Total Joint Replacement (TJR), Shoulder
Removal and Replacement, Total Joint Replacement (TJR), Shoulder
Removal and Replacement, Total Joint Replacement (TJR), Shoulder
Removal and Replacement, Total Joint Replacement (TJR), Shoulder
Joint Replacement, Shoulder
Removal and Replacement, Total Joint Replacement (TJR), Shoulder
Joint Replacement, Shoulder
Removal and Replacement, Total Joint Replacement (TJR), Shoulder
Amputation of Digit or Extremity
Amputation of Digit or Extremity
Joint Replacement, Elbow
Joint Replacement, Elbow
Joint Replacement, Elbow
Joint Replacement, Elbow
Bone Graft and Implantable Stimulator, Fracture Nonunion
Amputation of Digit or Extremity
Amputation of Digit or Extremity
Amputation of Digit or Extremity
Amputation of Digit or Extremity
Joint Replacement, Wrist
Bone Graft and Implantable Stimulator, Fracture Nonunion
Bone Graft and Implantable Stimulator, Fracture Nonunion
Joint Replacement, Wrist
Joint Replacement, Wrist
CPT/HCPCs I/O Coverage
22848
Inpatient
ALL
22848
Inpatient
ALL
22849
Inpatient
ALL
22849
Inpatient
ALL
22850
Inpatient
ALL
22850
Inpatient
ALL
22851
Inpatient
ALL
22851
Inpatient
ALL
22851
Inpatient
ALL
22857
Inpatient
ALL
23330
Inpatient
ALL
23333
Inpatient
ALL
23334
Inpatient
ALL
23335
Inpatient
ALL
23470
Inpatient
ALL
23470
Inpatient
ALL
23472
Inpatient
ALL
23472
Inpatient
ALL
23900
Inpatient
ALL
23920
Inpatient
ALL
24360
Inpatient
ALL
24361
Inpatient
ALL
24362
Inpatient
ALL
24363
Inpatient
ALL
24435
Inpatient
ALL
24900
Inpatient
ALL
24920
Inpatient
ALL
24930
Inpatient
ALL
24931
Inpatient
ALL
25332
Inpatient
ALL
25405
Inpatient
ALL
25420
Inpatient
ALL
25441
Inpatient
ALL
25442
Inpatient
ALL
5 Updated 10/24/2019
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