Once-in-a-Lifetime Procedure Codes (once)

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Once-in-a-Lifetime Procedure Codes

Page updated: December 2021

The following is a list of various procedures the Department of Health Care Services (DHCS) considers to be once-in-a-lifetime. (For a full definition of these codes, please refer to the Physician's Current Procedural Terminology [CPT?] code book published by the American Medical Association).

Note: Claims submitted for any of these procedures a second time for the same recipient must include a full explanation and medical justification to avoid being denied.

Denied claims may be submitted for reconsideration through the normal claim inquiry process. (See the CIF Overview section in the Part 1 manual and the CIF Completion section in this manual for instructions).

For a complete list of Proprietary Laboratory Analyses (PLA) procedure codes with a frequency limit of once in a lifetime, refer to the Proprietary Laboratory Analyses (PLA) (prop lab) section in this manual.

Once-in-a-Lifetime HCPCS Procedure Codes

HCPCS Code

Description

J3399

Injection, onasemnogene abeparvovec-xioi

Q2053

Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Q2054

Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

S3620

Newborn metabolic screening panel

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Page updated: April 2021

CPT Code 15920 15922 27080 30160 31360 31365 31390 31395 31420 31560 31561 32440 38100 38102 38571 38572 38780 41010 41140 41145 41150 41153 41155 42140 42820 42821

Once-in-a-Lifetime CPT Procedure Codes Description

Removal of tail bone ulcer Removal of tail bone ulcer Coccygectomy, primary Removal of nose Removal of larynx Removal of larynx Removal of larynx & pharynx Reconstruct larynx & pharynx Epiglottidectomy Laryngoscopy with arytenoidectomy Laryngoscopy with arytenoidectomy; with operating microscope Pneumonectomy, total Removal of spleen, total Removal of spleen, total Laparoscopy Laparoscopy Retroperitoneal transabdominal lymphadenectomy, extensive Incision of lingual frenum (frenotomy) Removal of tongue Tongue removal; neck surgery Tongue, mouth, jaw surgery Tongue, mouth, neck surgery Tongue, jaw, & neck surgery Excision of uvula Tonsillectomy and adenoidectomy; under age 12 Tonsillectomy and adenoidectomy; age 12 or over

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Page updated: April 2021

CPT Code 42825 42826 42830 42831 42835 42836 43107 43108 43112 43113 43620 43621 43622 44150 44151 44155 44156 44157 44158 44800 44950 44955 44960 45110 45112

Once-in-a-Lifetime CPT Procedure Codes (continued) Description

Tonsillectomy, primary or secondary; under age 12 Tonsillectomy, primary or secondary; age 12 or over Adenoidectomy, primary; under age 12 Adenoidectomy, primary; age 12 or over Adenoidectomy, secondary; under age 12 Adenoidectomy, secondary; age 12 or over Esophagectomy Esophagectomy Esophagectomy Esophagectomy Removal of stomach Removal of stomach Removal of stomach Removal of colon Removal of colon/ileostomy Removal of colon Removal of colon/ileostomy Colectomy with ileoanal anastomosis Colectomy with ileoanal anastomosis Excision of bowel pouch Appendectomy Appendectomy Appendectomy Removal of rectum Removal of rectum

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Page updated: August 2020

CPT Code 45120 45121 45126 45395 45397 47125 47130 47600 47605 47610 47612 47620 48155 48160 51500 51570 51575 51580 51585 51590

Description

Removal of rectum Proctectomy, complete; with subtotal or total colectomy Pelvic extenteration Removal of rectum Removal of rectum Partial removal of liver Partial removal of liver Removal of gallbladder Removal of gallbladder Removal of gallbladder Removal of gallbladder Removal of gallbladder Removal of pancreas Pancreas removal, transplant Removal of bladder cyst Removal of bladder Removal of bladder & nodes Remove bladder; revise tract Removal of bladder & nodes Remove bladder; revise tract

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Page updated: August 2020

CPT Code 51595 51596 51597 51925 52601 53210 53215 54125 54130 54135 54161 54164 54861 55810 55812 55815 55840 55842 55845 55866 56625

Description

Remove bladder; revise tract Cystectomy, complete Removal of pelvic structures Hysterectomy/bladder repair Transurethral prostatectomy (TURP) Removal of urethra Removal of urethra Removal of penis Remove penis & nodes Remove penis & nodes Circumcision, older than 28 days of age Frenulotomy of penis Removal of epididymes Extensive prostate surgery Extensive prostate surgery Extensive prostate surgery Extensive prostate surgery Extensive prostate surgery Extensive prostate surgery Laparascopy, radical Removal of vulva

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Page updated: August 2020

CPT Code 56633 56634 56637 56640 57110 57120 57130 57530 57540 57545 57550 57555 57556 58150 58152 58180 58200 58210 58240 58260

Description

Vulvectomy, radical, complete Vulvectomy, radical, complete Vulvectomy, radical, complete Vulvectomy, radical, complete, with lymphadenectomy Remove vaginal wall, complete Colpocleisis, Le Fort type Excision of vaginal septum Removal of cervix Removal of cervical stump, abdominal approach Removal of cervical stump, repair pelvis Removal of residual cervical stump, vaginal approach Remove cervix, repair vagina Remove cervix, with repair of enterocele Total abdominal hysterectomy Total abdominal hysterectomy Partial abdominal hysterectomy Extensive abdominal hysterectomy Extensive abdominal hysterectomy Removal of pelvis contents Vaginal hysterectomy

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Page updated: December 2020

CPT Code 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292

58294 58541

58542

58543

58544

58548

Once-in-a-Lifetime CPT Procedure Codes (continued)

Description

Vaginal hysterectomy

Vaginal hysterectomy

Vaginal hysterectomy with urinary repair

Hysterectomy & enterocele repair

Hysterectomy, revise vagina

Hysterectomy, revise vagina

Extensive hysterectomy

Vaginal hysterectomy, complex

Vaginal hysterectomy, including tube(s) and/or ovary(s), complex

Vaginal hysterectomy, including tube(s) and/or ovary(s) and enterocele, complex

Vaginal hysterectomy, with enterocele, complex

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed

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Page updated: August 2020

CPT Code

Description

58550

Laparoscopy surgical, with vaginal hysterectomy

58552

Laparoscopy surgical, with vaginal hysterectomy, including tube(s) and/or ovary(s)

58553

Laparoscopy surgical, with vaginal hysterectomy, for uterus greater than 250 grams

58554

Laparoscopy surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)

58570

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less with removal of tube(s) and/or ovary(s)

58572

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58573

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g with removal of tube(s) and/or ovary(s

58575

Laparoscopy, surgical; total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed

58950

Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy

58951

Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy

58952

Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors

Part 2 ? Once-in-a-Lifetime Procedure Codes

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