OUTPATIENT SURGICAL PROCEDURES CPT/HCPCS CODES

[Pages:26]UnitedHealthcare? Commercial Network Bulletin Appendix

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

Effective Date: November 1, 2019

SITE OF SERVICE REVIEW

For dates of service on or after Nov. 1, 2019, we're expanding our notification/prior authorization requirements to include the procedures/CPT codes listed below. We'll only require notification/prior authorization if these procedures/ CPT codes will be performed in an outpatient hospital setting. This change will take effect on or after Dec. 1, 2019, for California, Connecticut, New Jersey and New York, on or after Jan. 1, 2020 for Colorado, Maryland and Rhode Island, and on or after March 1, 2020 for Georgia, Iowa, Kansas, Nebraska, New Hampshire, North Carolina, Maine, South Carolina and Vermont. States excluded from this requirement are Alaska, Kentucky, Massachusetts, Texas, Utah and Wisconsin. Refer to the policy titled Outpatient Surgical Procedures ? Site of Service.

CPT/HCPCS Code 0249T 10121 10180 11000 11010 11012 11440 11441 11443 11444 11446 11450 11451 11462 11463 11470 11471 11601 11602 11603 11604 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643

Ligation hemorrhoid bundle w/us

Description

Incision & removal foreign body subq tiss compl

Incision & drainage complex po wound infection

Dbrdmt extensv eczema/infect skn up 10% bdy surf

Dbrdmt w/rmvl fm fx&/dislc skin&subq tissus

Dbrdmt fx&/dislc subq t/m/f bone

Exc b9 lesion mrgn xcp sk tg f/e/e/n/l/m 0.5cm/<

Exc b9 les mrgn xcp sk tg f/e/e/n/l/m 0.6-1.0 cm

Exc b9 les mrgn xcp sk tg f/e/e/n/l/m 2.1-3.0 cm

Exc b9 les mrgn xcp sk tg f/e/e/n/l/m 3.1-4.0 cm

Exc b9 lesion mrgn xcp sk tg f/e/e/n/l/m > 4.0cm

Excision hidradenitis axillary smpl/intrm rpr

Excision hidradenitis axillary complex repair

Excision hidradenitis inguinal smpl/intrm rpr

Excision hidradenitis inguinal complex repair

Excision h/p/p/u simple/intermediate repair

Excision h/p/p/u complex repair

Excision mal lesion trunk/arm/leg 0.6-1.0 cm

Excision mal lesion trunk/arm/leg 1.1-2.0 cm

Excision mal lesion trunk/arm/leg 2.1-3.0 cm/<

Excision mal lesion trunk/arm/leg 3.1-4.0 cm

Excision malignant lesion s/n/h/f/g 0.5 cm/<

Excision malignant lesion s/n/h/f/g 0.6-1.0 cm

Excision malignant lesion s/n/h/f/g 1.1-2.0 cm

Excision malignant lesion s/n/h/f/g 2.1-3.0 cm/<

Excision malignant lesion s/n/h/f/g 3.1-4.0 cm

Excision malignant lesion s/n/h/f/g >4.0 cm

Excision malignant lesion f/e/e/n/l 0.5 cm/<

Excision malignant lesion f/e/e/n/l 0.6-1.0 cm

Excision malignant lesion f/e/e/n/l 1.1-2.0 cm

Excision malignant lesion f/e/e/n/l 2.1-3.0 cm

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

Page 1 of 26

UnitedHealthcare Network Bulletin Appendix

Effective 11/01/2019

Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.

CPT/HCPCS Code 11644 11646 11750 11755 11760 11770 11772 12031 12032 12034 12035 12037 12041 12042 12051 12052 13100 13101 13120 13121 13131

13132

13151 13152

14040

14060

14301 15100 15120 15220 15240 15260 15576 15760 15770 15850 17000 17004 17110 17111 17311 17313 19101 19110 19112

Description Excision malignant lesion f/e/e/n/l 3.1-4.0 cm Excision malignant lesion f/e/e/n/l >4.0 cm Excision nail matrix permanent removal Biopsy nail unit separate procedure Repair nail bed Excision pilonidal cyst/sinus simple Excision pilonidal cyst/sinus complicated Repair intermediate s/a/t/e 2.5 cm/< Repair intermediate s/a/t/e 2.6-7.5 cm Repair intermediate s/a/t/e 7.6-12.5 cm Repair intermediate s/a/t/e 12.6-20.0 cm Repair intermediate s/a/t/e >30.0 cm Repair intermediate n/h/f/xtrnl gent 2.5cm/< Repair intermediate n/h/f/xtrnl gent 2.6-7.5 cm Repair intermediate f/e/e/n/l&/muc 2.5 cm/< Repair intermediate f/e/e/n/l&/muc 2.6-5.0 cm Repair complex trunk 1.1-2.5 cm Repair, complex, trunk; 2.6 cm to 7.5 cm Repair complex scalp/arm/leg 1.1-2.5 cm Repair complex scalp/arm/leg 2.6-7.5 cm Repair complex f/c/c/m/n/ax/g/h/f 1.1-2.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm Repair complex eyelid/nose/ear/lip 1.1-2.5 cm Repair complex eyelid/nose/ear/lip 2.6-7.5 cm Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 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/ Destruction benign lesions up to 14 Destruction benign lesions 15/> Mohs micrographic h/n/h/f/g 1st stage 5 blocks Mohs trunk/arm/leg 1st stage 5 blocks Biopsy breast open incisional Nipple exploration Excision lactiferous duct fistula

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

Page 2 of 26

UnitedHealthcare Network Bulletin Appendix

Effective 11/01/2019

Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.

CPT/HCPCS Code 19120 19125 20200 20205 20220 20225 20240 20245 20520 20525 20526 20551 20552 20553 20600 20604 20605 20606 20610 20611 20612 20680 20693 20694 20912 21011 21012 21013 21014 21030 21031 21040 21046 21048 21315 21320 21325 21330 21335 21336 21337 21356 21365 21385 21390 21407 21550

Description Exc cyst/aberrant breast tissue open 1/> lesion Exc breast les preop plmt rad marker open 1 les Biopsy muscle superficial Biopsy muscle deep Biopsy bone trocar/needle superficial Biopsy bone trocar/needle deep Biopsy bone open superficial Biopsy bone open deep Removal foreign body muscle/tendon sheath simple Rmvl foreign body muscle/tendon sheath deep/comp Injection therapeutic carpal tunnel Injection single tendon origin/insertion Injection single/mlt trigger point 1/2 muscles Injection single/mlt trigger point 3/> muscles Arthrocentesis aspir&/inj small jt/bursa w/o us Arthrocnt aspir&/inj small jt/bursaw/us rec rprt Arthrocentesis aspir&/inj interm jt/burs w/o us Arthrocentesis aspir&/inj interm jt/burs w/us Arthrocentesis aspir&/inj major jt/bursa w/o us Arthrocentesis aspir&/inj major jt/bursa w/us Aspiration&/injection ganglion cyst any locatj Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate) Adjustment/revj xtrnl fixation system req anes Removal external fixation system under anes Cartilage graft nasal septum Excision tumor soft tiss face/scalp subq Exc tumor soft tiss face&scalp subfascial Exc benign tumor/cyst maxl/zygoma encl & curtg Excision torus mandibularis Excision benign tumor/cyst mandible encl & curt Exc benign tumor/cyst mndbl intra-oral osteot Exc benign tumor/cyst maxl intra-oral osteot Closed tx nasal fracture w/o stabilization Closed treatment of nasal bone fracture; with stabilization Open treatment nasal fracture uncomplicated Open tx nasal fx comp w/int&/xtrnl skeletal fi Open tx nasal fx w/concomitant optx fxd septum Open tx nasal septal fracture w/wo stabilization Closed tx nasal septal fract w/wo stabilization Open tx depressed zygomatic arch fracture Open tx comp fx malar w/internal fx&mult surg Open tx orbital floor blowout fx transantral Optx orb floor blwt fx pri/bital appr w/allplstc Open tx fx orbit except blowout w/implant Biopsy soft tissue neck/thorax

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

Page 3 of 26

UnitedHealthcare Network Bulletin Appendix

Effective 11/01/2019

Proprietary Information of UnitedHealthcare. Copyright 2019 United HealthCare Services, Inc.

CPT/HCPCS Code 21552 21554 21555 21556 21557 21920 21930 21931 21932 21933 22900 22901 22902 22903 23071 23075 23076 23140 23150 23405 23415 23430 23480 23615 23630 23700 24000 24006 24065 24066 24071 24073 24075 24076 24101 24102 24105 24110 24120 24130 24147 24200 24201 24300 24310 24340 24357

Description Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater Exc tumor soft tissue neck/thorax subfasc 5 cm/> Exc tumor soft tissue neck/ant thorax subq ................
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