2019-2020 Commercial Outpatient Benefit Preauthorization ...

2020 Commercial Outpatient Benefit Preauthorization Procedure Code List

This list includes Current Procedural Terminology (CPT?) and/or Healthcare Common Procedure Coding System (HCPCS) codes related to services/categories for which benefit preauthorization may be required as of January 1, 2020 for commercial plans/networks, such as those listed below: - PPO (PPO) - Blue Choice Preferred PPOSM (BCE) - Blue Choice PPOSM (BCS) - Blue OptionsSM/Blue Choice OptionsSM (BCO)

This is not an exhaustive listing of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply. Benefit preauthorization for some services/categories must be obtained through Blue Cross and Blue Shield of Illinois (BCBSIL). Benefit preauthorization for other services/categories must be obtained through a utilization management vendor.

It is imperative that providers check eligibility and benefits for each patient prior to rendering services to confirm benefits, benefit preauthorization/pre-notification requirements and utilization management vendors that must be used, if applicable. Providers may submit online eligibility and benefits inquiries (electronic 270 transactions) via the Availity? Provider Portal () or other preferred web vendor portal. Services performed without benefit preauthorization, if required, will be denied for payment and providers may not seek reimbursement from BCBSIL members. Obtaining benefit preauthorization/pre-notification is not a substitute for confirming eligibility and benefits.

Procedure Code Service/ Category

Description

Medical Policy Number

Medical Policy Title

2020 Updates

15824 15826 19316 19318 20930 20931

20936

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Joint, Spine Surgery

Joint, Spine Surgery

Joint, Spine Surgery

RHYTIDECTOMY; FOREHEAD

RHYTIDECTOMY; GLABELLAR FROWN LINES

MASTOPEXY

REDUCTION MAMMAPLASTY

Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)

SUR712.031 SUR712.031 SUR716.010

Surgical Deactivation of Headache Trigger Sites Surgical Deactivation of Headache Trigger Sites

Mastopexy

SUR716.012

Reduction Mammaplasty

eviCore Guidelines

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20937

Joint, Spine Surgery

Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

eviCore Guidelines

20938

Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or Joint, Spine Surgery tricortical (through separate skin or fascial incision) (List separately in addition to code for

primary procedure)

eviCore Guidelines

June 2020

Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

20974

Joint, Spine Surgery Electrical stimulation to aid bone healing; noninvasive (non-operative)

eviCore Guidelines

20975 21085 21110 21125 21127 21141 21142 21143 21145 21146

21147 21150 21151 21154 21155 21159

21160 21188 21193 21194 21195 21196

Joint, Spine Surgery Electrical stimulation to aid bone healing; noninvasive (operative)

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IMPRESSION AND CUSTOM PREPARATION; ORAL SURGICAL SPLINT

APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN FRACTURE OR DISLOCATION, INCLUDES REMOVAL

AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL

AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED UNILATERAL ALVEOLAR CLEFT) RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCL OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILAT ALVEOLAR CLEFT OR MULT OSTEOTOMIES) RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYNDROME) RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, "C", OR "L" OSTEOTOMY; WITHOUT BONE GRAFT RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL, "C", OR "L" OSTEOTOMY; WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION RECONSTRUCTION OF MANDIBULAR RAMUS AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION

eviCore Guidelines

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030

Orthognathic Surgery

SUR705.030 SUR705.030 SUR705.030 SUR705.030 SUR705.030 SUR705.030

Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery

SUR705.030

SUR705.030 SUR705.030 SUR705.030 SUR705.030 SUR705.030

Orthognathic Surgery

Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery

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21198 21199 21206 21208 21209 21210 21215 21230 22510 22511

22512

22513

22514

22515

22526 22527 22533 22534

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OSTEOTOMY, MANDIBLE, SEGMENTAL

OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT

OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD) OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT) OSTEOPLASTY, FACIAL BONES; REDUCTION

GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT)

GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR (INCLUDES OBTAINING GRAFT)

Joint, Spine Surgery

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

SUR705.030 SUR705.030 SUR705.030 SUR705.030 SUR705.030 SUR705.030 SUR705.030 SUR705.030

Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery Orthognathic Surgery

eviCore Guidelines

Joint, Spine Surgery

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral

Joint, Spine Surgery

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone Joint, Spine Surgery biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body,

unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

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Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone Joint, Spine Surgery biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body,

unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

eviCore Guidelines

Joint, Spine Surgery

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

Pain Management Pain Management Joint, Spine Surgery

Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; once or more additional levels (list separately in addition to code for primary procedure) Arthrodesis, lateral eXtracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare Joint, Spine Surgery interspace (other than for decompression); thoracic or lumbar, each additional vertebral

segment (List separately in addition to code for primary procedure)

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22551

Joint, Spine Surgery

Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2

22552

22554 22558 22585 22595

Arthrodesis, anterior interbody, including disc space preparation, discectomy, Joint, Spine Surgery osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2,

each additional interspace (List separately in addition to code for separate procedure)

Joint, Spine Surgery Joint, Spine Surgery Joint, Spine Surgery

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

Joint, Spine Surgery Arthrodesis, posterior technique, atlas-axis (C1-C2)

22600 22612 22614

Joint, Spine Surgery Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment

Joint, Spine Surgery

Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)

Joint, Spine Surgery

Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

22630

Joint, Spine Surgery

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

22632

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to Joint, Spine Surgery prepare interspace (other than for decompression), single interspace; each additional

interspace (List separately in addition to code for primary procedure)

22633

Arthrodesis, combined posterior or posterolateral technique with posterior interbody Joint, Spine Surgery technique including laminectomy and/or discectomy sufficient to prepare interspace (other

than for decompression), single interspace and segment; lumbar

22634

Joint, Spine Surgery

Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

22840

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation Joint, Spine Surgery across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet

screw fixation) (List separately in addition to code for primary procedure)

22841 22842 22843

Joint, Spine Surgery Joint, Spine Surgery Joint, Spine Surgery

Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)

Updated September 2020

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22844 22845 22846 22847 22848

22853

22854

22856 22857 22858

22859 22861 22862 22867 22868

Joint, Spine Surgery Joint, Spine Surgery Joint, Spine Surgery Joint, Spine Surgery

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)

Joint, Spine Surgery

Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)

Joint, Spine Surgery

Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when conjunction with interbody arthrodesis, each interspace (List performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)

Joint, Spine Surgery

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate Joint, Spine Surgery preparation (includes osteophytectomy for nerve root or spinal cord decompression and

microdissection); single interspace, cervical

Joint, Spine Surgery

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

Joint, Spine Surgery

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, Joint, Spine Surgery methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody

arthrodesis, each contiguous efect (List separately in addition to code for primary procedure)

Joint, Spine Surgery Joint, Spine Surgery

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

Joint, Spine Surgery

Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level

Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, Joint, Spine Surgery including image guidance when performed, with open decompression, lumbar; second level

(List separately in addition to code for primary procedure)

Updated September 2020

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22869

Joint, Spine Surgery

Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level

22870

Insertion of interlaminar/interspinous process stabilization/distraction device, without open Joint, Spine Surgery decompression or fusion, including image guidance when performed, lumbar; second level

(List separately in addition to code for primary procedure)

23000

Joint, Spine Surgery Removal of subdeltoid calcareous deposits, open

23020

Joint, Spine Surgery Capsular contracture release (eg, Sever type procedure)

23120

Joint, Spine Surgery Claviculectomy; partial

23130

Joint, Spine Surgery Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release

23410

Joint, Spine Surgery Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute

23412

Joint, Spine Surgery Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

23415

Joint, Spine Surgery Coracoacromial ligament release, with or without acromioplasty

23420

Joint, Spine Surgery Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

23430

Joint, Spine Surgery Tenodesis of long tendon of biceps

23440

Joint, Spine Surgery Resection or transplantation of long tendon of biceps

23450

Joint, Spine Surgery Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation

23455

Joint, Spine Surgery Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)

23460

Joint, Spine Surgery Capsulorrhaphy, anterior, any type; with bone block

23462

Joint, Spine Surgery Capsulorrhaphy, anterior, any type; with coracoid process transfer

23465

Joint, Spine Surgery Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block

23466

Joint, Spine Surgery Capsulorrhaphy, glenohumeral joint, any type multi-directional instability

23470 23472 23473 23474 27096 27125

Joint, Spine Surgery Arthroplasty, glenohumeral joint; hemiarthroplasty

Joint, Spine Surgery Joint, Spine Surgery Joint, Spine Surgery Pain Management

Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

Joint, Spine Surgery Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)

Updated September 2020

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27130 27132 27134 27137 27138

27279

27280 27332

Joint, Spine Surgery Joint, Spine Surgery

Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft

Joint, Spine Surgery Revision of total hip arthroplasty; both components, with or without autograft or allograft

Joint, Spine Surgery

Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

Joint, Spine Surgery Revision of total hip arthroplasty; femoral component only, with or without allograft

Joint, Spine Surgery Joint, Spine Surgery

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed

Joint, Spine Surgery Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral

27333

Joint, Spine Surgery Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral

27334

Joint, Spine Surgery Arthrotomy, with synovectomy, knee; anterior OR posterior

27335

Joint, Spine Surgery Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area

27403

Joint, Spine Surgery Arthrotomy with meniscus repair, knee

27412

Joint, Spine Surgery Autologous chondrocyte implantation, knee

27415

Joint, Spine Surgery Osteochondral allograft, knee, open

27416

Joint, Spine Surgery Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])

27418

Joint, Spine Surgery Anterior tibial tubercleplasty (eg, Maquet type procedure)

27420 27422 27424

Joint, Spine Surgery Reconstruction of dislocating patella; (eg, Hauser type procedure)

Joint, Spine Surgery

Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure)

Joint, Spine Surgery Reconstruction of dislocating patella; with patellectomy

27425

Joint, Spine Surgery Lateral retinacular release, open

27427

Joint, Spine Surgery Ligamentous reconstruction (augmentation), knee; extra-articular

27428

Joint, Spine Surgery Ligamentous reconstruction (augmentation), knee; intra-articular (open)

27429

Joint, Spine Surgery Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular

27430

Joint, Spine Surgery Quadricepsplasty (eg, Bennett or Thompson type)

27438

Joint, Spine Surgery Arthroplasty, patella; with prosthesis

Updated September 2020

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27440

Joint, Spine Surgery Arthroplasty, knee, tibial plateau;

27441

Joint, Spine Surgery Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy

27442 27443 27446 27447 27486 27487 30120 30124 30130 30140 30400 30410 30420 30430 30435 30450 30465 30520 30999 31296 31297 31299 36516

Joint, Spine Surgery Arthroplasty, femoral condyles or tibial plateau(s), knee;

Joint, Spine Surgery

Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy

Joint, Spine Surgery Arthroplasty, knee, condyle and plateau; medial OR lateral compartment

Joint, Spine Surgery

Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)

Joint, Spine Surgery Revision of total knee arthroplasty, with or without allograft; 1 component

Joint, Spine Surgery

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Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR RHINOPHYMA

EXCISION DERMOID CYST, NOSE; SIMPLE, SKIN, SUBCUTANEOUS

EXCISION TURBINATE, PARTIAL OR COMPLETE, ANY METHOD

SUBMUCOUS RESECTION TURBINATE, PARTIAL OR COMPLETE, ANY METHOD

RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR

RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL TIP WORK)

RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES)

RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES) REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION) SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT UNLISTED PROCEDURE, NOSE NASAL, SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF FRONTAL SINUS OSTIUM (EG, BALLOON DILATION) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF SPHENOID SINUS OSTIUM (EG, BALLOON DILATION) UNLISTED PROCEDURE, ACCESSORY SINUSES THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL SELECTIVE ADSORPTION OR SELECTIVE FILTRATION AND PLASMA REINFUSION

Updated September 2020

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SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

Multiple

SUR706.001, SUR712.031

Multiple

SUR706.001, SUR712.031

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

Multiple

SUR706.001, SUR712.031

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

SUR706.001

Nasal and Sinus Surgery

THE802.003

Lipid Apheresis

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