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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